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CONTENTS Sommaire

ORIGINAL ARTICLES / ARTICLES ORIGINA UX 39

Organization and Delivery of the Trauma Care to the Wounded in Peacetim Explosions: Russian Perspective. By V. KHOMINETS, I. SAMOKHVALOV and I. KHOLIKOV. Russian Federation

Psychological Well-Being of Indian Peace keepers in South Sudan: A Cohort Study. By S. VENKATESH and S. N. CHATURVEDULA. India

Highly Toxic Ribosome-Inactivating Proteins as Chemical Warfare or Terrorist Agents. By J. PATOCKA. Czech Republic

Physical Fitness as a Predisposing Factor for Injuries and Excessive Stress Symptoms during Basic Military Training. By S. SAMMITO and L. MÜLLER-SCHILLING. Germany

Extraction of Victims of War or Mass Killings: From the Trojan War to the Victims’ Extraction Corridors. By C. ERNOUF, A. ALLONEA U, M. BIGNAND and M. RÜTTIMANN. France

Interdisciplinary Treatment of Spinal Injuries and Bone Metastases Using 3D Robotic Fluoroscopy. By K. NESTLER, B. V. BECKER, D. A. VEIT, E. KOLLIG and S. WALDECK. Germany

Physical Activity in the Armed Forces of the Czech Republic. By V. PAVLIK, P. LASAK, J. HORACEK and M. DLOUHY. Czech Republic

Knowledge, Attitudes and Practices of Healthcare Workers Towards their Own Health Promotion in an Urban Military Hospital in South Africa. By R. MA MABOE, A. C. TURNER and T. K. MADIBA. South Africa

Military Medicine - The Irish Birth of a New Speciality. By G. KERR. Ireland

International Humanitarian Law and Veterinary Services - “It depends”. By L. BUCHNER. Germany

Photo on the cover: French VAB-SAN (© EVDG) - Extraction of Victims of War or Mass Killings: From the Trojan War to the Victims’ Extraction Corridors By C. ERNOUF, A. ALLONNEAU, M. BIGNAND and M. RÜTTIMANN. France

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Views and opinions expressed in this Review are those of the authors and imply no relationship to author’s official authorities policy, present or future.

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Les idées et opinions exprimées dans cette Revue sont celles des auteurs et ne reflètent pas nécessairement la politique officielle, présente ou future des autorités dont relèvent les auteurs.

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A RT ICLES

Organization and Delivery of the Trauma Care to the Wounded in Peacetime Explosions: Russian Perspective. By V. KHOMINETS∑, I. SAMOKHVALOV∏ and I. KHOLIKOVπ. Russian Federation

Vladimir Vasilievich KHOMINETS Colonel Vladimir KHOMINETS, MD, PhD, Professor. Graduated from the Military Medical Academy (Saint Petersburg, Russia) in 1989. From 1989 to 1994 V. KHOMINETS served on various medical positions in the troops. From 1994 to 1997 he had post-graduate training at the Military Medical Academy and after successful thesis defense he continued his work at the Department of Military Traumatology and Orthopedics. Currently he is heading the Department of Military Traumatology and Orthopedics of the Military Medical Academy. PROFESSIONAL MEMBERSHIP AO Trauma from 2007. SICOT from 2001. AAOS from 2013. Russian National Faculty of AO Trauma, Member of SICOT and Aesculap Academy. S CIENTIFIC A CHIEVEMENTS PhD, Professor of Traumatology and Orthopedics Over 100 of scientific publications Author of 3 monographs and 5 textbooks on Traumatology and Orthopedics 5 patents.

RESUME Organisation et livraison des soins en traumatologie aux blessés par explosions en temps de paix : Perspective Russe. Contex te : Les blessures par explosion sont connues pour être les plus graves en temps de paix comme en temps de guerre. Ces blessures ne surviennent pas uniquement à l’occasion de conflits armés, mais de plus en plus souvent dans notre vie quotidienne. Obj ectifs : Explorer les modalités de prise en charge actuelles, en temps de paix, des p atients atteints de lésions dues au souffle à partir de l’expérience de trois actes terroristes survenus en Russie. Résultats : Cet article permet de décrire les circonstances de survenue de ces explosions de temps de paix, leurs principales caractéristiques et leurs conséquences sur les blessés. Différents aspects des soins de traumatologie apportés aux blessés sont discutés. Conclusion : Pour garantir des soins d’urgence efficaces, le système de santé p ublic doit être constamment prêt à se mobiliser en collaboration avec d’autres services de l’État, tels ceux du ministère de la Défense, de l’Intérieur ou du ministère des Situations d’urgence et de réponse aux catastrophes. Pour cela, des modalités uniques d’intervention et de soins en traumatologie devraient être mises au point dès le temps de paix, en même temps qu’une formation de tous les spécialistes suscep tibles d’avoir à intervenir.

KEYWORDS: Peacetime explosions, Terrorist attacks, Combined injuries, Triage, Evacuation, Trauma care Organization. MOTS -CLÉS : Explosions en temps de paix, Attaques terroristes, Blessures complexes, Triage, Evacuation, Organisation des soins en traumatologie.

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Fig . 1: Investigation of debris af ter exp losion of the living house on Kashirskoe highway (Moscow, 1999).

INTRODUCTION Blast injuries are known to be the most severe injuries of peacetime and wartime. Blast effects (high-pressure of the released gases, toxic debris, blast wave, primary and secondary missiles etc.) result in multiple and extensive injuries, characterized by the destruction of soft tissues, bones and joints. These injuries are generally characterized by the acute blood loss and wound shock; also, there is a high risk of generalized infectious complications and multiple organ failure. These injuries occur not only during armed conflicts, but more and more often in our everyday life. Violations in observance of safety rules, deterioration of industrial equipment and some other factors lead to increase of industrial accidents, which we saw in past years. In many cases these accidents are accompanied by huge explosions. Explosions of peacetime include terroristic acts increasingly occurring worldwide day by day.

Eighty accident-assistant squads, twenty-four emergency aid teams of the Emergency Medical Services Centre and eight rapid response teams of "Defense" All-Russian Center for Emergency Medicine of the Ministry of Health of the Russian Federation. General treatment and evacuative support was provided by the administration of the Moscow public health services.

MATERIAL AND METHODS This is a descriptive study of the main explosive events in Russia. Total number of the wounded in terrorist acts in Russia exceeds seven thousand people in 1996-2016. More than 800 people were reported dead for the last decade in number of regions of Russia. In Russia there is no unified specific register of mass casualties, that would include information about injury pattern and treatment details, so the authors analyzed their own experience of work in the Military Medical Service and, in particular, providing of medical care to victims of terroristic acts and other disasters. The necessary statistic data were collected from the State Statistical Service and analyzed using t-test by the “STATISTIKA” software package.

In order to collect the victims out of the debris and prepare them for the evacuation, 5 medical stations and gathering spots were organized, where the medical triage and first-aid measures were performed. After that, the wounded were taken to city hospitals by t he accident-assistant squads. At the stage of the first aid after the explosion at Kashirskoye Highway an operative-dressing unit of the field multipurpose hospital unit of the "Defense " AllRussian Center for Emergency Medicine was organized by sources of the mobile hospital in order to provide first-aid care combined with specialized medical care.

RESULTS A. Examples of peacetime explosions in Russia

It should also be noted that after the explosions a psychiatric care was needed for relatives of one third of the victims in order to arrest their psychosomatic responsiveness. Even greater work was performed by the forensic medicine crews supported by the personnel of the Ministry of Internal Affairs on the site, where dead people were found.

1. Explosions of the apartment houses in Moscow in September, 1999 Modern efficient management of medical care delivery to patients with blast injuries can be considered on the basis of examples of three terroristic acts that occurred in Moscow in 1999, in particular, explosions at the Manezhnaya Square and apartment houses located at Gurianova Street and Kashirskoye Highway (Fig. 1).

∑ Colonel Prof. Dr., MD, PhD Head of the Department of Military Traumatolaugy and Orthopedics of the Military Medical Academy

As a result of these terrorist acts, the total number of civilian victims was 408 people, among them 211 people were reported dead, while 197 people got different mechanical injuries and burns, 87 people needed an ambulatory care.

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∏ Colonel (ret.) Prof. Dr., MD, PhD, Head of War Surgery Department of Military Medical Academy. π Colonel (ret.) Prof., PhD Legal Advisor of the Secretary General of the ICMM, SO1 Medical Doctrine, Development Doctrine and Concepts Centre. Correspondence: Colonel Prof. Dr.Vladimir Vasilievich KHOMINETS, MD, PhD Head of the Department of Military Traumatology and Orthopedics of the Military Medical Academy Military Medical Academy n.a. S. M. Kirov 6, Lebeva str. RUS-194044 Saint-Petersburg, Russian Federation E-mail: Khominets_62@mail.ru

Accident-assistant squads arrived at explosion site together with the police and the fireguard brigades. Coordination of accident-assistant squads was performed by the dispatching department of municipal emergency stations under the supervision of their chief medical officers.

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2. The crash of the Nevsky Express train on November 27th, 2009

The total amount of victims was 103. 37 heavily and medially inj ured were hospitalized into 5 nearest trauma centers of the city. Out-patient care was provided to the remaining 55. 11 people died on site, one (with massive internal bleeding and inj uries incompatible with life) died during evacuation and two people died in trauma centers (one due to massive internal bleeding and inj uries incompatible with life, the other due to septic complications of severe combined inj uries).

In cases when the terrorist acts took place outside big cities, the situation was different. The crash of the Nevsky Express passenger train No. 166, travelling between Moscow and St. Petersburg, was a result of the terroristic act (bombing of the railways) occurred on 27 November 2009 in 21:34 near Erzovka station, an hour and a half after its departure from the Moscow Railway Station (Fig. 2). Two last coaches were derailed, disconnected and blown over near the town of Bologoye, located at the border of the Novgorod Region and the Tver Region. The third coach fell down to the side, the forth coach curved off the subgrade, but remained in normal position. Twenty-six people were reported as dead, ninety-five passengers of Nevsky Express suffered the injuries of a different severity. Most of the wounded received medical assistance only few hours after the explosion due to the night time and remoteness from medical facilities.

The transport problems during evacuation of victims from the place of the event, which resulted from temporary closing of subway stations, became the main problem for medical assistance organization. Another issue were difficulties with cell-phone communication in the zone of terrorist act due to overload, however the ambulances used the special line of communication, which functioned properly. During triage, evacuation and admission of injured to treatment establishments the unconscious patients and inadequate patients with self-identification difficulties presented major challenge.

Fig . 2: The collapse of the train "Nevsky Exp ress " af ter exp losion of the railway.

B. First aid delivery In general, well-timed actions of emergency medical service, emergency response groups and fire fighters, which were performed in response to different terrorist acts, were extremely important. It should be noted, however, that according to the reports there was no information on organization of medical aid to the wounded or, probably, the possibility of its provision by the professional emergency response groups or police officers, military officers and volunteers, involved in the management of the explosion. As it was mentioned above, most of the wounded after explosions had open injuries, mostly of soft tissues, in addition to different evidences of psychic trauma. Experience shows that simple measures (a tincture of iodine applied to wound edges, adjustment of aseptic dressings) are at the same time the best way of positive psychological impact. For major cases of minor injuries, a conversation with medical service representative (not necessarily a medical officer) along with adjustment of a dressing for a small wound are often considered as a final stage of medical aid. Since the wounded of this type can form most the victims, the described measures should be recognized as a procedure of a very high importance.

3. Explosion in the subway train in St Petersburg on April 3rd, 2017 Another terrorist act took place in St. Petersburg metropolitan on 3 April, 2017. The bomb exploded when the train was moving in the tunnel between two stations. The power of the explosion was equivalent to 300g in TNT equivalent. The device was filled with bolts and shrapnel, which became additional damaging factor. At the time of the explosion there were 100 passengers in the coach and almost each of them has got injuries. The fact that the conductor managed the train to the next station facilitated the delivery of the first aid.

Arrest of external hemorrhage.

Immediately the operators of emergency medical aid services were informed and officially announced the emergency regime getting the trauma centers of the city also informed. The first ambulance arrived to the site 8 minutes after the explosion and the first physician who came there took the management of the situation at the place of terrorist act. Within half an hour after the blast 50 ambulances arrived. Medical personnel performed triage of the victims, provided emergency medical aid and evacuated them from the site.

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One of the significant points in the list of first-aid procedures is the arrest of external hemorrhage. According to many authors, for many of the wounded, a temporary hemostasis in 80% of cases is achieved by the application of a compression band2, but as long as a part of the injured may have extremity avulsions or major contused wounds, in cases of blast injury in comparison with injuries of different type, it is more often recommended to apply a tourniquet. As a rule, cloth tourniquets or improvised tourniquets made of strong

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fabric or trouser belts are applied in the emergency situations. They all have low efficiency in bleeding control and lead to additional traumas of the adjacent tissues. Therefore, one of the tasks for the accidenceassistant squads should include a replacement of these improvised tourniquets with standard ones, together with an elimination of many inevitable errors (improperly placed tourniquet, inefficient hemost asis, absence of transport immobilization and recording of tourniquet time and etc.)

necessary to evacuate them to large hospitals for specialized medical care. But at the same time a great part of the wounded has only low-severity injuries, which do not need any complicated treatment. Proper triage at the explosion site is of a great significance; therefore, well-qualified specialists in primary health care and qualitative emergency medical care are needed. Triage and selecting of the wounded requiring an evacuation is performed at arriving of the accident-assistant squads along with the emergency medical procedures. The experience of the earthquake response in Armenia (1988) showed that in disaster conditions the triage should depend on the proj ected efficiency of medical aid, rather than the severity of the patientâ&#x20AC;&#x2122;s condition.

Fractures and transport immobilization. One of the requirements of the first aid in cases of bone fractures includes apply ing of transport immobilization with the improvised splints. It is beyond argument, that within the wartime, when it is well known that there will be the long-distance transportation, applying of splints is absolutely necessary. However, in conditions of peacetime, when all the measures for the reduction of the surgical wait time are taken, and evacuation is performed via normal roads, this necessity would rarely occur. Basing on our experience of assisting the wounded in wartime, it is well known, that standard hand frames provide an acceptable immobilization of nearly all fractures for the period of extricating the wounded, then apply ing of the splint could be neglected. Moreover, some specialists believe that transport immobilization is performed in strict accordance with the academic rules is not reasonable, as it results in delay in the transportation of the wounded that is absolutely unacceptable. Therefore, when providing first aid it is sufficient to tie the injured leg to other leg or to secure an injured arm to the body.

The more important factor that is directly relevant to blast injuries: a high frequency of the craniocerebral injuries often combined with the internal injuries and the most severe injuries of the extremities. Regarding all wounded people it includes about half of the patients needed a hospital treatment at this stage (a significant part of the wounded with minor injuries are not taken into account, as they could be treated on the outpatient basis). An immediate evacuation is recommended in the wounded with suspected ongoing internal hemorrhage, as well as the wounded with penetrating injuries of cranium and brain, eyes, evulsion and destruction of the extremities. Modern options of evacuation, in particular, wide usage of helicopters and planes allow to significantly advance the arrival of the wounded in the medical institutions (trauma centers of the III levels). It should be accepted as a rule to continue an anti-shock therapy initiated at the stage of first aid during the evacuation, in particular, a fluid administration.

First aid to critically wounded The most repeated measures of premedical care (first aid) in critically wounded should also be an arrest of external hemorrhage, adjustment of aseptic dressings, transport immobilization and (especially) correcting of inevitable mistakes, occurred during these basic procedures. An important aspect of premedical care (first aid) is an anesthetic administration as well as immediate evacuation to the injured assembly points.

C. Surgical care Blast inj ury In case of blast injury at the stage of admission of the wounded for the specialized surgical care to be provided, it is necessary to conduct a thorough and systematized examination. Based on the etiology, pathogenesis, clinical and morphological characteristics of the blast injuries, it can be considered a priori important to keep in mind the above formula of the most typical set of injuries ("total contusion + other injuries ") at the first receipt of the data from the history, or, if the wounded is unconscious, according to accompanying persons informing on the impact of the damaging factors of any explosion on the wounded.

There are noteworthy recommendations of the Russian and foreign specialists regarding the role of remaining of posture, which critically wounded have after the explosion3 . Such constrained posture provides the most advantageous body position, facilitating the remaining of homeostasis in case of life-threatening injuries. The efforts to settle the injured face up, unless it is strictly necessary, can be harmful and lead to more intensive internal bleeding. When remaining the posture of the injured (side-lying, facedown), it is important to provide a possibility for easy breathing. If the injured is unconscious, a side-lying stable posture is used, that prevents the dislocation asphyxia or aspirational asphyxia. VOL. 92/3

It is very important to find out the details of the circumstances of the blast injury, but given the predominantly critical condition of the wounded along with an acute lack of time in case of mass casualties, an excessive emphasis on it must be avoided, and the examination should be performed according to a certain pattern. In case of blast injury, which is characterized by multiple

Triage/Evacuation The first aid is provided by the accident-assistant squads. In order to save lives of critically wounded it is

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wounds and their diversified localization, it is recommended to immediately select a "main" or prevalent injury ("the most life-threatening now and requiring the primary care." It is necessary to carry out the examination simultaneously with the life-saving procedures (damage control resuscitation, emergency surgery related to internal bleeding, evulsion and destruction of the extremities). In all c ases, including the listed, it is required to establish the nature and severity of brain damage (bearing in mind that it should be present nearly always), as well as the damage to the eyes, ears, nose, throat and maxillofacial area, which are quite common (especially hemorrhages and ruptures of the eardrum).

(neurologist, neurosurgeon, urologist, and others). These specialists should mandatory examine the patients with blast injuries, as it is quite common when a comorbidity is detected, concealed due to the clearly manifested wounds or injuries. The characteristic of the examination of patients with blast injuries involves its continuation during the surgical treatment that can be performed after the stabilization of the main hemodynamic parameters. At this time the nature and extent of primary necrosis are revealed, as well as and the border of viable tissues in the areas directly affected by the explosion, and, when necessary, the distant lesions are detected.

DISCUSSION

A total body physical examination There is no doubt, that the diagnosis should be based on total body physical examination aimed at the identifying of all injuries. It begins with an assessment of the hemodynamics status (pulse, blood pressure, etc.) and sequentially includes a thorough inspection, palpation and other tests used in the diagnosis of the organ damage. Particular attention is paid to a clinical diagnosis of bone lesions. When required, even if there is only a suspicion of damage, a complete X-ray examination, including modern methods of radiological diagnostics such as CT-scan (for the wounded in a stable state) should be performed. According to specialists in treatment of the associated trauma, it is advisable to carry out an emergency survey radiography of the skull, spine, chest, pelvis and limbs according to indications, depending on the trauma origin and presence of clinical signs of the injuries4.

Characteristics of peacetime explosions According to Michael C. Reade1 the characteristics of peacetime explosions are as they are shown in Table 1. These figures provide clear evidence of a great importance of peacetime explosions; therefore, our healthcare system must be in a permanent alert in order to provide high-quality medical care. In many cases the success of medical assistance for mass casualties’ victims with blast injuries depends on well-timed and professional cooperation of all agencies participating in emergency response. To achieve this goal, it is very important to distinguish between peacetime explosions and wartime explosions. The main distinctive feature is that, in general, explosions of wartime are more predictable, since the military characteristics of the weapon used are well known. Military medical specialists have better knowledge and higher qualification in providing of medical care to patients with blast injuries. Also, they are able to plan which injuries are expected to be found at the battlefield, and to estimate the volume of medical work and medical resources depending on the level of military operations.

Immediate laboratory examination should include a clarification of the volume of blood loss: hemoglobin, hematocrit; when possible - a circulating blood volume, acidbase balance, etc., i.e. anemia indices and other basic characteristics of the presence and intensity of shock. A catheter should be inserted immediately into the bladder for continuous monitoring of the quality and quantity of urine, especially in severe cases. As the ECG data can objectively indicate not only the heart function, but also a homeostasis status in general, it is highly desirable to use a dynamic monitoring via heart rate monitor. This short list should also be supplemented and extended in accordance with the consultants' recommendations

In case of explosions of peacetime medical specialists can face nearly unlimited scenarios of the emergency scenarios, so there can be a great variety of blast injuries.

Table 1: Peacetime explosions characteristics.

Industrial or Home accidents

Terroristic Acts Homicide / Suicide VOL. 92/3

CIRCUMSTANCES

NUMBER OF WOUNDED

EXPLOSIVES TYPES

Violation of standard safety rules. Home accidents, in particular, in many cases are associated with drug or alcohol consumption

1-5

Weak explosive (liquefied natural gas)

Socially significant facility, being in the purview of mass media

50 - 500

High explosive (ammonium nitrate)

Victim knows the assaulter. An explosion is used as a method of injuring with no need to be close to the attacked person (s)

1-2

Home-made explosive device

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The wounded could be of a different sex and age, including pregnant women and children. Finally, it is obvious that civilian medical specialists are less qualified to deal with combat injuries. The injuries could be of a different severity depending on the proximity of the victim to the explosion epicenter. The spread of blast wave results in different types of injuries: soft tissues injuries, orthopedic traumas, internal injuries and secondary traumatic stress. Therefore, an accident picture can be different depending on the place and type of explosion. The explosion can result in single or mass casualties; different qualitative composition of the wounded is observed in cases of explosion inside the building or unconfined explosions. After the explosion there can be chemical or even radioactive contamination, which can lead to not only isolated orthopedic traumas, but also to different injuries combined with burns, chemical and radioactive poisoning.

The main features of treatment The treatment of the patients with blast injuries is conducted comprehensively, considering the general state and the local damage. After 30 years of discussion a well-known concept of traumatic disease (TD) was formulated, the dynamics of which is divided into 4 periods: the first period (up to 12 hours) - the acute disorders of vital functions; the second (12-48 hours) - a relative stabilization, corresponding to intensive care; the third period (3-10 days) - is also a period of intensive care, but with the greatest risk of complications. Occurrence of generalized infectious can increase its duration; the fourth period - the total stabilization of vital functions. Given the need for simultaneous treatment of all injuries at the early stages (the concept of the Golden Hour), with regard to the phase of traumatic disease when it is impossible to perform all surgeries in full, the domestic and foreign experts have formulated an idea to divide one surgery into three stages (so-called multistage surgical treatment tactics - a damage control). In the treatment of unstable fractures of the pelvis and long bones of the limbs, which are typically occurring in case of blast injury, this tactic is denoted as a damage control orthopedics. The latter includes three main stages: - the first stage (48 hours after injury, 1 and 2 TD periods) - involves an intensive care and temporary stabilization of fractures with the rod-type external fixation devices in order to prevent the development of lifethreatening complications and ensure the possibility of additional examination. - the second stage (10-15 days after injury, the 3 TD period) - is aimed at the normalization of homeostasis, a surgery during these periods is contraindicated due to a high risk of complications. - the third stage corresponds to 4 TD period when the scheduled reconstructive surgery is performed.

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The advanced intensive care of the first and second TD stages (or the 1st stage of the orthopedic damage control) is aimed at the prevention of acute respiratory distress syndrome, fat embolism, pulmonary thromboembolism and generalized fibrinolysis (DIC). The need for blood and fluid transfusion is normally defined by most specialists as follows: about three liters of blood and 3-4 liters of blood fluids for the first period, which often provides a replenishment of blood loss, hereinafter a transfusion of blood and liquids is defined by the state of the wounded and the success of the surgical treatment. Basing on our experience, it can be concluded that it is insufficient merely to determine the recovery of some hemodynamic parameters before the surgical intervention - it is also of a high importance to take into account the state of diuresis (a surgery can be started only with the unmistakable signs of recovery of the renal activity). The method of surgical interventions in case of blast injury (except the amputations in case of extremity avulsion, which differ from such interventions, for example in patients with arterial disease) has no specific features, but the sequence of these surgical interventions is crucial. The surgery aimed to avoid of asphyxia (in case of failure or inability to perform the tracheal intubation) and ongoing internal bleeding control is considered a priority. Even in case of the apparent life-threatening injuries and penetrating injuries of the skull and the eyeball the surgery is carried out when the patient is stabilized, and the abdominal surgery is pe rfo rmed. Of course, there can be a variety of tactical and technical nuances such as, for instance, blood reinfusion etc., but it is accepted as a rule to perform a constant monitoring of the general hemodynamics state and the start of renal function recovery (the surgery with no vital indications should not be performed until the volume of the urine output of 40-50ml per hour). The further selection of priority of the interventions - in eyes, skull, limbs - should be made «ex consilio», considering the state of the wounded and the possibility of medical evacuation. The main surgical intervention in the affected areas of the body - the primary surgical debridement (which in case of large blast injury is an initial stage of the reconstructive and restorative treatment, including several surgeries) can be started only after the sustainable stabilization of the wounded. The significant experience in the surgical treatment of such severe injuries as true blast injuries (i.e. multifactor damage in several locations associated with a general commotion and contusion syndrome) showed that such interventions include the sequential surgeries based on the indications: on the skull and the brain (in case of growing hematoma and compression), the eyes (penetrating wounds and destruction), the organs of upper respiratory tract (displaced fractures and damage of the respective organs), extremities (avulsion and destruction, open and closed fractures, penetrating injuries of major joints with the destruction of the joint surfaces, extensive soft tissue injury). The list given is different

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for each wounded, but it shows the objectives and the content of the reconstructive operations in almost all body zones for all main types of surgical pathology.

severe injuries of peacetime and wartime. These injuries occur not only during armed conflicts, but also more and more often in our everyday life.

The modern possibilities of high-tech surgery, including the intervention on vessels, nerves, tendons, investing tissues, including the use of microsurgical techniques, various kinds of internal minimally invasive stable functional osteosynthesis, as well as the external osteosynthesis using the compression/distraction devices, the reconstructive surgery on spine, pelvis, large joints provide the highest attainable standard of recovery from the blast injury damage.

Objective: To explore the modern efficient management of medical care delivery in patients with peace-time blast injuries based on examples of three terroristic acts that occurred in Russia. Results: The main features of peacetime explosions, their circumstances and consequences are described. Some examples of industrial, home and terrorist explosions in Russia are given. Different aspects of trauma care for wounded in peacetime explosions are discussed.

The comprehensive research carried out by the Department of War Surgery of Military Medical Academy (St. Petersburg, Russia) showed that the use of the «orthopedic damage control» tactics in the treatment of the wounded with polytrauma reduces the mortality from 23 to 15%, the incidence of complications from 42 to 19% (fat embolism - to 2.2%, thromboembolism - to 4.4%), the disability from 39 to 30%5.

Conclusion: In order to provide an efficient emergency care the civil healthcare system should be in a constant readiness to mobilization and collaboration with other state authorities, such as the Ministry of Defense, the Ministry of Internal Affairs and the Ministry for Emergencies and Disaster Response. For this purpose, a unified principle of trauma care delivery to the wounded in peacetime explosions should be developed along with the performance of corresponding training of all specialists.

CONCLUSION The system of medical care delivery in case of peacetime explosions in our country is constantly improving. In order to provide an efficient emergency care the civil healthcare system should be in a constant readiness to mobilization and collaboration with other state authorities, such as the Ministry of Defense, the Ministry of Internal Affairs and the Ministry for Emergencies and Disaster Response. For this purpose, a unified principle of trauma care delivery to the wounded in peacetime explosions should be developed alo ng with the performance of corresponding training of all specialists.

Acknowledgements.

NIL. Potential Conflict of Interest. No conflict of interest exists for any author. Privacy and confidentiality. No personal information has been divulged. REFERENCES 1. Michael C. READE. Blast Injury: What to expect in civilian vs. military contexts// ICU. - 2015. - Vol. 15. - p. 73–83.

It is necessary to perform a thorough synthesis and analysis of the experience of medical assistance to the wounded in massive disasters and terrorist acts that happened in the past with further publication of these results and information dissemination to the professional associations.

2. MICHAELSON M., TAITELMAN U., BSCHOUTY Z. Crush syndrome: experience from the Lebanon war, 1982// Isr. J. Med. Sci . - 1984. - Vol. 20, 23. - p. 305–309. 3. Eric R. FRYKBERG. Medical Management of Disasters and Mass Casualties From Terrorist Bombings: How Can We Cope?// J Trauma . - 2002. - 53. - p. 201–212.

An arrangement of regular trainings for the civil healthcare specialists within a principle of specialized trauma care delivery to the wounded in peacetime explosions mentioned above is also an essential component.

4. Dana C. COVEY, Christopher T. BORN. Blast Injuries: Mechanics and Wounding Patterns// J. of surgical orthopaedic advances. - 2010. - Vol. 19, 1.

SUMMARY

5. BYKOV I.Y., GUMANENKO E.K., SAMOKHVALOV I.M. and others . War Surgery. National Manual. – .: GEOTAR, 2009, p. 655–690.

Background: Blast injuries are known to be the most

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Psychological Well-Being of Indian Peace keepers in South Sudan: A Cohort Study.* By S. VENKATESH∑ and S. N. CHATURVEDULA∏. India

Srinivasan VENKATESH Lieutenant-Colonel Srinivasan V ENKATESH MD is an Aviation Medicine Specialist at the 9 (I) Recce & Observation Flight in Udhampur, India. His Professional qualifications and area of specialization are Aerospace Medicine. His key research interests are Human Engineering and Ergonomics. Lieutenant-Colonel S. VENKATESH is an Assistant Professor at the Raj iv Gandhi University of Health Sciences and he is an Associate Fellow of Indian Society of Aerospace Medicine. He developed interest on the psychological well-being of troops after observing them in multicultural and multiracial environment like UN peace keeping mission.

RESUME Bien-être psychologique du personnel militaire indien déployé pour le maintien de la paix au Sud-Soudan : Étude de cohorte. Introduction Les soldats de maintien de la paix sont exposés à des facteurs de stress qui diffèrent d’une mission à l’autre mais qui peuvent être classés en facteurs de stress basiques, cumulatifs, critiques et traumatiques. Tous peuvent être vécus à des degrés divers avant, pendant et après le déploiement lors d’opérations de maintien de la paix (OMP). Le but de cette étude de cohorte est donc de connaître les effets du déploiement sur le bien-être psychologique et le niveau de résilience du personnel militaire indien déployé pour l’opération de maintien de la paix effectuée au Sud-Soudan. L’étude a également pour obj ectif spécifique d’explorer la question du « décalage » entre ce qui est attendu et ce qui est réellement vécu sur la santé mentale et le bien-être des militaires. Matériel et méthode Une étude par questionnaire sur 50 soldats a été réalisée pour examiner les niveaux de résilience et de bien-être psychologique ainsi que les relations entre les deux. Des corrélations ont été établies pour étudier la relation entre les différentes variables recueillies dans l’étude. La résilience a été mesurée à l’aide de Connor Davidson ResilenceScale. L’épanouissement, qui est l’étalon or du bien-être psychologique, a été mesuré à l’aide du questionnaire PERMA-P. Résultats Le degré d’épanouissement obtenu se situait entre six et neuf sur l’échelle utilisée, ce qui indique un niveau de bien-être était supérieur à la moyenne pour la plupart des personnes testées. L’évaluation du niveau d’épanouissement indiquait des degrés de bien-être tant hédonique qu’eudémonique élevés. Les participants possédaient également une capacité de résilience supérieure à la moyenne. Discussion Le personnel indien a maintenu des niveaux relativement élevés de résilience et de bien-être psychologique pendant le déploiement malgré un stress élevé et des combats intenses. Cela indique que les j eunes recrues évaluées possédaient des capacités et des modalités d’adaptation positives. La santé mentale de ces personnels dépend beaucoup de la reconnaissance, par leur pays d’origine, de la difficulté de leur travail, de la gratification qui leur est faite pour le rôle pris pour la réussite de la mission et de la fierté qu’ils ont à servir leur pays.

KEYWORDS: Psychological well being, Peacekeeping Operations, Mismatch. MOTS -CLÉS : Bien-être psychologique, Opérations de maintien de la paix, Stress opérationnel.

INTRODUCTION VOL. 92/3

Psychological Consequences on the Peacekeeping Forces.

“Peacekeeping is not a soldier’s j ob, but only a soldier can do it.” Dag Hammarskj old, Former UN Secretary General

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Peacekeeping is undertaken by the United Nations Organisation to maintain peace across the world, especially

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in strife zones after the warring groups cease the conflict. Ironically, in order to maintain vigorous peacetime, it is inevitable to utilize forces at the tactical level with the consent of those involved in combat and the Security Council, as per UN-mandated Peace Keeping Operations (PKO) 1. The heavy emphasis on peace and security might lead one to presume that PKOs would involve less stress than traditional combat. However, many studies brought out that the very difference between PKOs and combat causes a specific and unique kind of stress which may be due to the differences in the nature of the operations 2-3 . The nature of PKOs can be described as ambiguous, dynamic and psychologically intricate. The stress responses may also vary and is based on various factors like type of mission, time duration of deployment, violence and destruction, magnitude of havoc on the ground, cooperation obtained from local public, degree of peace enforcement and day-to-day unrest due to splinter groups. The United Nations had categorised these stress factors into basic, cumulative, and critical traumatic stressors. Soldiers in PKOs are exposed to these stressors at the initial stages, during, and post deployment. Numerous studies have reported that as deployment length increases, personnel are more likely to report lower overall well-being. Further these studies have investigated some of the characteristics of the stressors such as adjustment and maladjustment thereof have been explored 4-10 . Buckman et al11 found that being deployed for more than 6 months away from family and friends, and having these periods unexpectedly extended, can have ill effects on personnel’s health and well-being, and also on the well-being of their families. These ill effects are even much greater for deployments lasting longer than a year. It is somewhat ironic that a soldier in PKOs have a greater likelihood of developing harmful stress reactions than they do of being fired upon. The negative stress responses include flame out, Peace Keeping Acute Stress Syndrome, survivor guilt syndrome, compassion fatigue, PTSD, culture change syndrome and Stockholm syndrome. Some latent aspects include impairments in concentration and memory, discipline and in cohesion, breach of discipline leading to misconducts and clumsiness 11-15. Likewise, many positive responses are reported by most PKO personnel (60-90%) which can be summarised as sense of fulfilment in serving people in distress, contributing to the good of other nations, ex perience of associating with armed forces of other nations, exposure to new equipment, undergoing a sense of effectiveness in working in alien culture and so on. Additionally, such varied experiences may bring feeling of competence and confidence. They feel enriched which consequently may lead to a new perspective of life and one’s role as a military person16-18 . Financial benefits and gratitude toward people and things back home are some of the other positives contributing to the Psychological Well-Being of the deployed personnel19-20 . A recent Irish study brought out that peace keepers generally perceived their peacekeeping deployments as an enriching experience21.

soldiers. The UN Peacekeeping Training Unit was formed in 1994 for this purpose. The UN Mission Readiness22 and the UN Stress Management Booklet4 offer guidelines for psychologically preparing the civilian and military peace keepers for PKO missions and managing varying stresses of pre-deployment, deployment and post-deployment stages. It is evident from the above studies that peacekeeping stress syndromes are inherent in PKOs. Nations acknowledge that these deployments can be counterproductive and have profound psychological consequences. India is a major contributor to peacekeeping activities for well over sixty years. The (soldiers) are being deployed across the globe with large contingents. However, research was not carried out in this regard on Indian peace keepers. The purpose of this study, therefore, is to investigate the effects of deployment upon Psychological WellBeing and resilience of Indian military personnel deployed for PKOs in South Sudan. The study also examined the issue of ‘mismatch’which is likely to have an impact on mental health and well-being of soldiers.

MATERIALS AND METHOD A cohort study was designed for this research to examine the levels of resilience and Psychological WellBeing (PWB). Further, relationship between resilience and PWB of Indian military soldiers undertaking PKOs in South Sudan was also studied. The cohort is the Indian soldiers (n = 50). It constituted soldiers as well as officers. The cohort was deployed and returned to India after a tenure of PKOs for 18 months. The mean age of the participants was 39 ±6.19 years and the mean length of service in the Indian armed forces was 17±6.08. the rank wise distribution is as shown in figure below. Figure 1: Rank wise distribution of the cohort (n=50). 6%

14% 28% 2% 6% 4%

40%

Lt. Col.

Major

Sgt.

Cpl.

Unknown

∑ Lieutenant Colonel, Classified Specialist (Aviation Medicine), India. ∏ Dr. Scientist ‘E’, HoD Aviation Psychology Correspondence: Dr CHATURVEDULA Sowgandhi Naganjani, Scientist ‘E’, HoD Aviation Psychology, Institute of Aerospace Medicine, Indian Air Force, Vimanapura Post, IND-560017 Bangalore, India

Purpose of the Study Major emphasis is given by nations to ensure effective PKOs and maximise positive affect among deployed

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Captain

* Presented at the 42nd ICMM World Congress on Military Medicine, New Delhi, India, 19-24 November 2017.

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strong negative life outcomes and have minimal feelings of loneliness. The cohort also demonstrated high levels of physical health.

An informed consent was obtained from the soldiers and they were asked to complete self-reported questionnaires. Completion of questionnaires along with a demographic inventory took approximately 20 minutes. Data were analysed using Microsoft Excel and IBM SPSS version 20.0. The descriptive statistics were computed and Pearson Product Moment Correlations were drawn to study the relationship between the variables under study.

The mean value obtained for resilience was (M = 80.54, SD = 10.64) with the lowest score being 50 and the maximum score obtained being 97. The maximum possible score that could be obtained was 100, thus indicating that the participants possessed an above average ability to be resilient.

Resilience was measured using Connor – Davidson Resilience Scale which has 25 items and is defined as the ability to overcome or adapt to extreme stress or adversity and maintain or recover high well-being. The reliability coefficient in the Indian context of the CD-RISC was 0.89 consistent with Connor and Davidson’s study (á = 0.89) and also Lamond et al. who observed á = 0.92. PE RMA-P Questionnaire- A Brief Measure of Flourishing was administered which indicates the experience of life going well. It is a combination of feeling good and functioning effectively. Flourishing in synonymous with a high level of psychological well-being, and it epitomizes mental health. The questionnaire gives the overall level of flourishing as well its five dimensions which are considered as the p illars for PWB. These dimensions are Positive Emotions (P), Engagement (E), Relationships (R), Meaning (M) and Achievement (A). The co-efficient of reliability obtained for this measure is.72.

DISCUSSION This study represents the first investigation, for over decades, into the PWB and resilience of Indian personnel deployed at South Sudan for PKOs. United Nations peacekeeping personnel face numerous stressors due to their challenging deployments. The current research found that the Indian personnel maintained relatively high levels of resilience and PWB during deployment despite high stress and intense combat. This indicates that the deployed soldiers/jawans have reported positive benefits and coping styles. Exposure to new environment, adequate training and supervision may have helped the deployed personnel in maintaining high levels of PWB16-18. The high levels of meaning and engagement dimensions of PWB of the present cohort reflect the positive functioning of the PKOs. The findings of previous studies also support the present research. ‘Peace keepers’ mental health consequences are associated with recognition (or lack thereof) by their home country, their gratification in their mission role and their pride in serving their country. These factors will likely also be related to the peace keepers’psychological resilience19. The findings of the current study further substantiate literature supporting the claim that peace keeper military officers have sufficient psychological resources for coping with the stressful situations implied in peacekeeping mission23.

RESULTS The descriptive statistics computed on the cohort are as shown in table 1. From the above table, it can be understood that the mean value obtained for Flourish was found to be (M = 7.97, SD =.61) with scores ranging from 6 to 9, indicating that most of the participants scored above average on well-being. The mean and SD values obtained for the flourish dimensions include Positive emotion (M = 8.2, SD =.97), Engagement (M = 8.2, SD = 1.1), Relationship (M = 8.8, SD =.97), Meaning (M = 8.6, SD =.76) and Achievement (M = 8.3, SD =.75) indicating high levels of hedonic and eudemonic well-being. The mean scores on negative emotion and loneliness are below average which indicate that the cohort group is able to cope up with

In the military milieu, there were many investigations on whether mental health screening will help to decrease the number of traumatised soldiers. An American study shows the effectiveness of pre-deployment mental health screening to reduce mental health issues, medical evacuations from the front line for mental

Table 1: Descriptive statistics of the study variables (n = 50).

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Flourish Positive Emotion Engagement Relationship Meaning Achievement Happy Loneliness Negative Emotion Health Resilience

RANGE

MINIMUM

MAXIMUM

MEAN

3 4 4 4 3 4 5 10 7 6 47.00

6 6 6 6 7 6 5 0 0 4 50.00

9 10 10 10 10 10 10 10 7 10 97.00

7.97 8.26 8.25 8.83 8.62 8.35 8.56 4.66 4.14 8.65 80.54

.617 .970 1.112 .974 .768 .751 1.215 2.967 1.778 1.093 10.64

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health reasons and suicidal ideation24. For peace keepers and their effective functioning, it will be beneficial to elucidate the relations between personnel selection, pre-deployment mental status, pre-deployment trauma exposure and post-deployment mental health. The study recommends that psychological screening may be carried out before the deployment of the jawans for PKOs in addition to medical check-up. The medical officers deployed for PKOs may be given a capsule training on resilience -building and gate-keeping to identify any early signs. Further, commanding officers and mental health professionals need to develop an apt attitude and be prepared for the operations of the peace kind. An important factor that emerged during this research is the ‘mis-match’ with regard to deployment tenure. The pe rsonnel were initially scheduled for deployment for a period of six months, but due to various reasons got extended by another 6 months. Thus, the personnel had to plan and take necessary measures for the comfortable stay of their family members in their absence for the next six months also. This long-deployed tenure could have created emotional turmoil, both due to personal commitments as well as lack of adequate planning for the extended period. Previous studies have found that extension of deployment length beyond six months to significantly affect the Well-Being of personnel11. Although numerous studies12-15 have putforth an increased risk of mental health concerns associated with length of deployment and intensity of combat exposure, the present study did not find any effect of mismatch on the psychological Well-Being of the cohort which could be attributed to training as well as constant supervision by the commanders.

the state of knowledge about the effects of deployment upon psychological well-being and resilience of Indian military personnel deployed for PKOs in South Sudan. The study also aims specifically to explore the issue of ‘mismatch’ between expected and actual deployment period on the mental health and well-being. Materials and Method A questionnaire study on 50 soldiers were carried out to examine levels of resilience and psychological wellbeing as well as relationship between them. Pearson product moment correlations were drawn to study relationship between the variables under study. Resilience was measured using Connor Davidson Resilience Scale. Flourishing which is the gold standard of psychological well-being is measured by using PERMA-P questionnaire. Results The mean value obtained for Flourish was found to range from six to nine indicating that most of the persons scored above average on well-being. The dimensions of flourish indicated high levels of hedonic and eudonic well-being. The participants also possessed an above average ability to be resilient. Discussion The Indian personnel maintained relatively high levels of resilience and Psychological well-being during deployment despite high stress and intense combat. This indicates that the deployed jawans have reported positive benefits and coping styles. There mental health consequences are a result of recognition of their hard work by their home country, their gratification in mission role and their pride in serving their country.

CONCLUSION The research here was carried out to provide an insight into the psychological well-being and resilience of Indian soldiers/ jawans deployed for PKOs in South Sudan. The study brings out that Indian soldiers/jawans sustain high levels of psychological well-being and resilience while being deployed. The results reinforce the fact that PKOs also have the potential to offer opportunities for growth and resilience and respond to stress in positive ways. It is, therefore, a responsibility of commanders to nurture, train and reinforce the positive behavior, enhance resilience of the troops with the help of psychological interventions before and during the deployment to achieve the mission objectives. Further deployment tenure has to be planned and executed meticulously as the mis-match in the tenure can affect one’s mental health.

SUMMARY Introduction The peace keeping soldiers are exposed to stressors which differs from mission to mission and can be categorised into basic, cumulative, and critical traumatic stressors. All of them can be experienced in varying degrees before, during, and after deployment in PKOs. The purpose of this cohort study, therefore, is to establish

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REFERENCES 11. New York, NY: UN Secretariat; 2008. UN Department of Peacekeeping operations. United Nations Peacekeeping Operations: Principles and Guidelines. 12. New York, NY 10017: UN Stress Management Booklet; 1995. UN Department of Peacekeeping operations. 13. WEISAETH L, SUND A. Psychiatric problems in UNIFIL and the UN-soldiers stress syndrome. International Review of the Armed Forces Medical Services.1982; 55: 109-116. 14. KOOPMAN R, VAN DYK GA. Peacekeeping operations and adjustment of soldiers in Sudan. Afr J Conflict Resolut. 2012; 12:53 – 76. 15. MIRFIN KA. New Zealand: Massey University; 2004. The Psychological Effects of Peacekeeping Service in Bosnia, Thesis. 16. ELKLIT A. UN soldiers serving in peacekeeping missions: A review of psychological after effects. Int Rev Armed Forces Med Serv. 1998. 17. MURPHY PJ. Australia: University of Adelaide; 2008. Readiness, Resilience and Readjustment in PKOs. Thesis. 18. MULLOY G. HUMSECT Project. Sarajevo: 2007. Oct 4-6, Adapting Militaries to Peacekeeping and Policing Roles.

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19. WALLER M, TRELOAR SA, SIIM MR, ALEXANDER C M, McGUIRE ACL, BLIER J, et al. Traumatic events and other operational stresses following peacekeeping and war like deployments. BMC Psychiatry . 2012; 12: 88 .

dimensions and operational readiness in US armed forces deployed in Kosovo. 17. SCHOK ML, KLEBER RJ, ELANDS M, WEERTS JM. Meaning as a mission: A review of empirical studies on appraisals of war and peacekeeping experiences. Clin Psychol Rev. 2008; 28: 357–65.

10. CONNORTON E, PERRY MJ, HEMENWAY D, MILLER M. Occupational trauma and mental illness – Combat, peacekeeping, or relief work and the national co-morbidity survey replication. J Occup Environ Med. 2011; 53: 1360–3.

18. PALMER I. The stress of peacekeeping Rwanda 1994. Psychiatr Bull. 1995; 19: 777–8.

11. BUCKMAN JE, SUNDIN J, GREENE T, et al. The impact of deployment length on the health and well-being of military personnel: a systematic review of the literature. Occup Environ Med . 2011 Jan; 68 (1): 69-76.

19. AHMED N, SAJID WB, MUHAMMAD Z, FAZAILA S. Psychiatric morbidity in Pakistani peacekeepers and their perception about deployment in Liberia. Pak Armed Forces Med J . 2010; 2: 204–208.

12. SAREEN J, COX BJ, AFIFI TO, STEIN MB, BELIK SL, MEADOWS G, et al. Combat and peacekeeping operations in relation to prevalence of mental disorders and perceived need for mental health care: Findings from a large representative sample of military personnel. Arch Gen Psychiatry . 2007; 64: 843–52.

20. THOMAS S, DANDEKER C, GREENBERG N, KELLY V, WESSELY S. Serving in Bosnia made me appreciate living in Bristol: Stressful experiences, attitudes, and psychological needs of members of the United Kingdom Armed Forces. Mil Med. 2006; 171: 376–80. 21. TOBIN J. Occupational stress and UN peacekeepers. Ir J Psychol Med . 2015 Jun; 32 (2): 205-208.

13. PEARN MG. The victor as victim: Stress syndromes of operational service. I: Acute syndromes. ADF Health . 1999; 1:31 – 2.

22. Mission Readiness and Stress Management Booklet. New York: UN Office of Human Resource Management; 1995. Un Office of Human Resource Management.

14. PEARN MG. The victor as victim: Stress syndromes of operational service. II: Chronic syndromes. ADF Health. 2000; 1: 85–7.

23. LOSCALZO Y, GIANNINI M, GORI A, FABIO AD. The Wellbeing of Italian Peacekeeper Military: Psychological Resources, Quality of Life and Internalizing Symptoms. Front Psychol . 2018 Feb 13; 9:103.

15. JOSHUA, ADLER AB. West Port, NJ: Paeger Publishers; 2003. The Psychology of the Peacekeeper: Lessons from the Field.

24. BARTONE PT. Toronto, Canada: Annual Convention American Psychological Association; 1996. Stress and Hardiness in US Peacekeeping Soldiers.

16. CASTRO CA, BIENVENU RV, HUFFMAN AH, ADLER AB. Hiedelberg, Germany: USAMRU-Europe; 1999. Soldier

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Extraction of Victims of War or Mass Killings: From the Trojan War to the Victims’ Extraction Corridors. By C. ERNOUF∑, A. ALLONNEAU∏, M. BIGNANDπ and M. RÜTTIMANN∫. France

Michel RÜTTIMANN Prof. Dr. (OF-6) Michel RÜTTIMANN is the Head of the Teaching Coordination Department in the Val-de-Grâce Medical School in Paris. He is an anesthesiologist and intensivist, associate professor in emergency medicine. He worked in the Paris Fire Brigade, in the French Military Hospital in Dj ibouti, in the Metz Military Teaching Hospital and in the NATO’s Emergency Medicine Working Group. He commanded a Forward Surgical Unit during 3 years with several missions in Africa and Afghanistan. He was more recently the Director of Instruction of the Military Medical Service Teaching Scholl in Libreville, Gabon and Head of the French Military Hospital in Djibouti before its closure in 2016. He is also (co) author of several publications in emergency military medicine and anesthesiology. The author recognizes that the proposed document has not been sent simultaneously to other journals or has not been recently published under the same title.

RESUME Extraction des blessés de guerre ou de tuerie de masse : de la Guerre de Troie vers couloirs d’extraction des victimes. La prise en charge des blessés de guerre est passée successivement de l’extraction des blessés du champ de bataille sous la protection des boucliers à l’absence complète de soins pendant les combats puis au ramassage par des brancardiers, par des chariots bâchés à cheval et enfin par des ambulances automobiles. La protection du ramassage a commencé dès le début de la 2 ème Guerre Mondiale avec des véhicules semi-chenillés allemands puis américains, l’utilisation ponctuelle de chars légers se résumant à de simples fonctions de porte-brancards. La guerre froide a vu la généralisation d’ambulances faiblement blindées, dérivées le p lus souvent des versions commandement des nombreux véhicules blindés de transport de troupes créés alors par la plupart des armées, que ce soient des véhicules chenillés ou à roues de type 4x4, 6x6 ou 8x8. La vulnérabilité de ces véhicules blindés, en particuliers aux engins explosifs improvisés de plus en plus utilisés, a conduit certaines armées à utiliser soit des ambulances blindées équipées de surblindage, soit des châssis de chars lourds transformés en ambulance, soit de véritables chars de bataille munis d’un compartiment arrière pouvant transporter deux blessés, soit enfin de nouvelles ambulances à roues protégées contre les mines et les embuscades. L’extraction des victimes en cas de tuerie de masse nécessite actuellement le recours à des groupes d’extraction spécialisés, munis d’équipement de protection balistique et placés sous la protection des forces de l’ordre qui peuvent dans certains cas avoir recours à des véhicules blindés.

KEYWORDS: War casualties’ extraction, Armoured ambulance, Mass killing victims’ extraction, Extraction corridor, Specialized Extraction Team. MOTS -CLÉS : Extraction de blessés de guerre, Ambulances blindées, Extraction de victimes de tuerie de masse, Couloir d’extraction, Groupe d'extraction spécialisé.

INTRODUCTION

The notion of ‘war casualties’extraction’is very different in war time, and in civil situations of mass killings.

Humanitarian laws ensure the safe transport of medicines and medical material to civilian populations, as well as that of essential food, clothes and vitamins; hence the notion of ‘’humanitarian corridor’’1. The civilian populations’ right to access humanitarian help has eventually been completed by evacuations.

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The evolution of the extraction of war casualties

HISTORICAL BACKGROUND In Antiquity, the medical care provided on the battlefields

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the PzKpfw I/A tank, to transport the wounded on their superstructures6; t hey did the same with the T38, their amphibious light Russian rescued tank7 . The German Army also recycled some Lorraine armoured vehicles called Sdkfz 135 (véhicule blindé de chasseurs portés, VBCP) for medical transport. The light wounded could be transported in their back compartment, and the stretches could be put in the tow8 . From 1940 the American Army used medical Half-Track M3, they were lightly armoured and weighed 9 tonnes. They also used light tanks M5A1 to extract the wounded from difficult terrains, inaccessible to ambulances, the stretches were put on the back armoured part of the vehicles 9 .

is well described in the Iliad in which we can read how the comrades of a wounded soldier come to his rescue, drag him out of the battle and take him back to their camp under shields protection2 . The notion of protection during the extraction appeared in this text, probably for the first time. Later, medical care on the battlefields was only given when the battles were over, until the Dominique Larrey’s flying ambulances (Picture 1), involving horse drawn wagons with two or four wheels, which would take the wounded to the nearby surgeons3. These horse drawn wagons, of course, could not shield the wounded from shots or explosions. During the First World War, the wounded were removed from the trenches by teams of stretcher-bearers, using improvised vehicles such as stretcher-carrying wheel barrows. They were then evacuated by horse drawn ambulances and the first car ambulances (Picture 2) witch could not yet protect their passengers4 .

After World War ll, most countries acquired armoured ambulances, usually former armoured vehicles, to transport troops or light weakly armoured tanks, either tracked vehicles such as the MT-LB M1970 ambulance (URSS), the M113 and M577 ambulances (USA), the field armoured medical vehicles (VAB SAN) 4x4 (France) (Picture 3), the Mowag Piranha IB 6x6 ambulances (Switzerland), the TPz Fuchs 6x6 (Germany)…These armoured ambulances weigh between 12 and 15 tonnes, except for the German Wiesel which weighs 4 tonnes and the British Samaritan, 9 tonnes, both being smaller.

Picture 1: Baron Larrey ’s Flying Ambulance (Amicale des amis du Baron Larrey). © EVDG

Picture 3: French VAB-SAN . © EVDG

Picture 2: Unarmored Car Ambulance 1914-1918. © EVDG

The French Army used a particular technique of protection involving pairs of armoured medical vehicles, for the collection of casualties in the former Yugoslavia, during shootings by snipers on civilians in Sarajevo. A first armoured medical vehicle would adopt a protected position perpendicular to the supposed trajectory of the shooting,

∑ Médecin en chef (OF-4), Paris Fire Brigade. ∏ Médecin principal (OF-3), Paris Fire Brigade. π Médecin en chef (OF-5), Paris Fire Brigade.

ARMOURED AMBULANCES

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∫ Médecin-chef des services (OF-6), Professeur agrégé du Val de Grâce.

The first armoured ambulances probably date from World War ll. As early as 1939, the German Army had weakly armoured semi tracked medical vehicles, the 8 tonneSdKfz 251/85 but only used their light medical tanks, the 6 tonne-SdKfz 265, derived from the Command version of

International Review of the Armed Forces Medical Services

Correspondence: Monsieur le médecin-chef des services M. RÜTTIMANN, Département de la coordination de la formation, Ecole du Val-de-Grâce. 1, place Alphonse Laveran, 75230 Paris cedex 05 (France). E-mail : michel.ruttimann@intradef.gouv.fr

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while a second assisted the wounded10. This technique was used during attacks on convoys in Afghanistan and is still used today in the Sahel-Saharan strip.

were created in 2018, during Operation Barkhane, to give medical care to a casualty from the back of the vehicles18.

Today, armoured ambulances are still adaptations of armoured vehicles designed to transport troops; they are increasingly heavy such as the type Stryker 8x8 MEV (USA) which weighs 17 tonnes, the tracked FV 510 Warrior (Great Britain), 25 tonnes, the Boxer ARTEC 8x8 (Germany, the Netherlands), 33 tonnes or the tracked Bradley M2A0 AMEV (USA), 33 tonnes. However, since the development of improvised explosive devices, elements of overblanking or V shaped chassis have progressively modified armoured ambulances. On the other hand, since 2007, armoured ambulances have also been replaced by a new generation of four-wheel ambulances which are heavier and designed to resist mines and ambuscades (Mine Resistant Armored Ambush-MRAP). The latter have a high centre of gravity which results in a high risk of overturning on difficult terrains and are not adapted to narrow mountain roads11.

The extraction of casualties in the case of mass killings The recent terrorist attacks in urban areas with mass killings make the question of early medical care in danger zones, a topical issue. The operational doctrine advocates a non secured exclusion zone (red), forbidden to traditional assistance means, reserved to the Police Force equipped with ballistic protections and suitable weapons. In this zone, only the Police Force can transport casualties to the extraction point located on the edge of the exclusion zone19. One of the proposed solutions to ensure faster medical care is to create extraction corridors20 in which first aid responders, organised in specialised extraction teams, protected by individual protective equipments (helmets and ballistic vests), ensure the initial medical care and the evacuation of the victims under the protection of the Police Force equipped with ballistic shields, as if we were back in the good old days of the Trojan War. Sic transit gloria mundi…

AMBULANCE TANKS During World War ll, the Germans created the first armoured ambulances from a real battle tank with the chassis of the T34 Russian tank, but without its turret. If the armoured vehicle body ensured a good protection, both the loading and transport of casualties were hindered by its small height and difficult access6.

Extractions on foot can be completed by armoured vehicles if necessary depending on distances and the nature of the risks. Such was the case in Pau in March 2017, when casualties were transported to police armoured vehicles during an exercise21. Those were small protected vehicles (petits véhicules protégés, PVP) in which one wounded person can lie down or three can be sited. Such a solution mentioned as early as January 201622 is rarely used in urban areas, except in open spaces such as big esplanades; the same applies to armoured ambulances with resuscitation units, as used in Israel. These armoured ambulances are part of a programme aimed at transporting rescue teams safely and at evacuating the wounded in case of terrorist attacks. Since January 2018, four new armoured Chevrolet ambulances resuscitation units were added to the three Israeli civilian emergency ambulances used near the frontier in Judea, Samaria and the Gaza strip23.

In the 1960’s, the Israelis used the Ambutank I which weighs 30 tonnes, derived from an American middle tank, the M4 Sherman, then from 1968, they switched to the Ambutank II also 30 tonnes, derived from the Super-Sherman M50, an Israeli version of the Sherman M4A3E8 HVSS12. In 1988, they transformed enemy tanks such as the T54/55 into heavy transport vehicles for troops like the Achzarit which weighs 44 tonnes; there also was an ambulance version13. In 2000, they adapted a battle tank, the Merkava III, which weighs 65 tonnes into a ‘Tankbulance’ thanks to its wide back compartment which could accommodate two stretchers and two medical personnel. The medical installation does not alter the power of the tank in battle (although it cannot carry as many shells)14. From 2008, another heavy armoured vehicle designed to transport troops, derived from the Merkava IV with a wider back door, the Namer, weighing 60 tonnes, could also evacuate one or two casualties in its ambulance version (Namerbulance)15. These ambulance tanks offered the best protection to the wounded, as they were removed from battle fields.

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CONCLUSION The medical care provided to victims of mass killings during terrorist attacks have benefitted from the experience of the medical care given today, to war casualties, in particular from the principles of combat rescue. Survival techniques cannot be separated from technical aspects to protect both the intervention of first help teams, and the evacuation of the victims.

In France, from 2023, the VAB-SAN will be replaced by the medical version of a Multi-role armoured vehicle, the Griffon, which weighs 25 tonnes. It will have a level 4 STANAG 4569 armoured protection which can be improved with a modular armoured kit16. A medical version of the light 4x4 Serval Multi-role armoured vehicles, weighing 15 tonnes, is also planned17. In the meantime, kits to medicalize infantry vehicles (VBCI and VAB Ultima)

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ABSTRACT The care of war casualties has evolved in stages from the extraction of the wounded from battlefields under the protection of shields, the complete lack of medical care during battles, to the evacuation of the wounded by stretcher bearers, by horse-drawn wagons and

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finally by car ambulances. The protection of the evacuation process began at the beginning of the 2nd World War with German and American semi-tracked vehicles, the occasional use of light tanks used as simple stretcher-holders. During the Cold War the use of weakly armored ambulances became widespread. They were generally derived from the command versions of the many armored personnel carriers then created by most armies, be they tracked or wheeled 4x4, 6x6 or 8x8. The vulnerability of these armored vehicles, especially against increasingly frequent improvised explosive devices, led some armies to use either armored ambulances equipped with overblanking, or heavy tank chassis transformed into ambulances, or real battle tanks equipped with a rear compartment that could carry two wounded, and finally new wheeled Mine-Resistant Ambush Protected type ambulances. The extraction of the victims in the event of mass killings now requires the use of specialized extraction units equipped with ballistic protection equipment and placed under the protection of the police, who may in certain cases, use armored vehicles. BIBLIOGRAPHICAL REFERENCES 11. Fourth Geneva Convention, article 23, 1949. 12. Histoire de la médecine aux armées, Tome 1. Lavauzelle, Paris, 1982, p. 60. 13. Histoire de la médecine aux armées, Tome 2. Lavauzelle, Paris, 1984, p. 28–29. 14. Histoire de la médecine aux armées, Tome 3. Lavauzelle, Paris, 1987. p. 11. 15. DAVID B. Sd. Kfz 251 Hanomag. http://www.tank-encyclopedia.com/ww2/nazi_germany/SdKfz-251_Hanomag.php, online on December 1st 2004, consulted on March 21st 2018. 16. Les engins blindés de premiers secours dans les unités de Panzer. Steel Master n°60, Histoire et Collections, décembre 2003. 17. SERRA M. T38 Soviet amphibious scout tank, case report. http://panzerserra.blogspot.com/2014/05/t-38-sovietamphibious-scout-tank-part.html, put online on May 3rd 2014, consulted on June 11th 2018. 18. BECK A. SdKfz 135 Ambulanz. http://www.materielsterrestres39-45.fr/fr/index.php/vehicules-de-capture/71-allemagne-vehicules-capture/beute-panzer-france/548-sd-kfz135-ambulanz, consulted on March 21st 2018. 19. ZALOGA SJ, GERRARD H. US Army Tank Crewman 19411945. Osprey Publishing, Londres, 2004, p. 45. 10. KOWALSKI JJ, Le GUEN A, BELLEOUD D, CHARROT F, BARTOLI JF, DESJEUX G. FORPRONU: Poste de secours du bataillon français d’infanterie. Médecine et Armées 1995; 23: 291-295.

11. MRAP ambulances provide protection, « Rolling ER’s ». https://www.army.mil/article/15552/mrap_ambulances_pr ovide_protection_rolling_ers, put online on January 5th 2009, consulted on June 11th 2018. 12. Ambutank (Sherman Armored Ambulance). http://www.israeli-weapons.com/weapons/vehicles/tanks/sherman/ambutank/Ambutank.html, consulted on March 21st 2018. 13. DAVID B. Achzarit APC. http://www.tanksencyclopedia.com/coldwar/Israel/Achzarit_APC. php, put online on March 16, 2015, consulted on March 21th 2018. 14. DAVID B. Merkava. http://www.tanksencyclopedia.com/modern/israel/Merkava.php, put online on December 1st 2014, consulted on March 21st 2018. 15. NAMER. http://www.israeliweapons.com/weapons/vehicles/armored_personnel_carriers/namera/Namera.html, consulted on March 21st 2018. 16. Griffon VBMR 6x6 véhicule blindé multirôle EBMR Scorpion. http://www.armyrecognition.com/vehicules_et_blindes_a_r oues_france_armee_army/griffon_vbmr_vehicule_blinde_a_ roues_6x6_multirole_ebmr_scorpion_fiche_technique_specifications_desc.html, mis en ligne le 12 février 2018, consulté le 11 juin 2018. 17. https://www.defense.gouv.fr/dga/actualite/signature-dun-contrat-pour-les-vbmr-legers, mis en ligne le 27 février 2018, consulté le 13 juin 2018. 18. Portail.sante.defense.gouv.fr/actualités/18-blessés/1736le-service-de-santé-des-armees-et-l-armee-de-terre-innovent-pour-la-protection-des-equipes-medicales-en-operations, consulté le 16 juillet 2018. 19. Note de doctrine opérationnelle DGSCGC/CAB/DSP/SDDRH/BDFE du 20 mars 2017 relative à la réponse opérationnelle des services d’incendie et de secours en cas de tuerie de masse. 20- ABRIAT A, BIGNAND M, ERNOUF C, TRAVERS S, TOURTIER J-P. Organisation des secours pré-hospitaliers en cas d’attaque terroriste. In: Pasquier P, Mérat S, Colas M-D eds. Le blessé par attentat terroriste. Arnette, Paris, 2017, p. 45– 55. 21. LAMARQUE S. Un exercice hors norme: un attentat au Zénith de Pau. http://www.larepubliquedespyrenees.fr/2017/03/08/exercice-hors-norme-un-attentat-au-zenith-de-pau, 2104173.php, mis en ligne le 3 mars 2017, consulté le 21 mars 2018. 22. BOSSER JP. L’Armée de terre, le territoire national et l’année 2015. Revue Défense Nationale; 2016: 786. 23. LEV T. Andelsons donate new armored ambulance for Judea, Samaria. http://www.israelnationalnews.com/News/News. aspx/240272, put online on January 4th 2018, consulted on June 8th 2018.

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International Review of the Armed Forces Medical Services

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A RT ICLES

Physical Activity in the Armed Forces of the Czech Republic.* By V. PAVLIK∑, P. LASAK∑, J. HORACEK∑ and M. DLOUHY∏. Czech Republic

Vladimir PAVLIK LTC Vladimír PAVLIK was born on 28 November 1969. EDUCATION 2018: Associate Professor in Preventive Medicine and Hygiene. 2008: Specialization in Hygiene and Nutrition. 2002: Ph.D. degree (Milit ary Hygiene). 2000: Specialization in Internal Medicine. 1998: Specialization in Hygiene and Preventive Medicine. 1997: Specialization in General Medicine. 1988 - 1994 Graduation from the Medical Faculty of Charles University in Hradec Králové (M.D.) At the same time graduation from the Purkyne Military Medical Academy in HK. J OB EXPERIENCE 2014 - present: Deputy Head of the Department of Military Internal Medicine and Military Hygiene, Faculty of Military Health Science, University of Defence. 2008: MEDOPS HQ ISAF Kabul, Afghanistan. 2003: Military Staff School, Compieg ne, France (in French). 2001: Canadian Language School, Montreal, Canada (in French). 1997 - 2014: Lecturer at the Department of Hygiene and Preventive Medicine, Faculty of Military Health Science, University of Defence, Hradec Králové.

RESUME L’activité physique dans les forces armées de la république Tchèque. Les auteurs décrivent les bienfaits d’une activité physique régulière comme prévention primaire des maladies cardiovasculaires. Ces aspects positifs sont décrits dans la première partie. La seconde partie traite des possibilités en termes de temps et de lieux disponibles pour ce type d’activité au sein des forces armées de la république Tchèque, les types d’entraînement militaire au sein des différentes unités et les tests d’évaluation de la condition physique. Ce travail souligne l’importance de la condition physique dans l’armée de la République Tchèque.

KEYWORDS: Army of the Czech Republic, Primary prevention, Regular physical activity, Physical training, Fitness. MOTS -CLÉS : Armée de la République Tchèque, Prévention primaire, Activité physique régulière, Entraînement physique, Aptitude.

energy expenditure and is important for maintaining good physical health and for prevention of cardiovascular diseases and type 2 diabetes mellitus. Physical activity has its importance in prevention of oncological and other cardiometabolic diseases as well(1, 2) . It has been repeatedly proved that regular physical activity reduces blood pressure, total body weight, total body fat percentage or waist circumference. Simultaneously, it increases tissue sensitivity to insulin and HDL cholesterol

IMPORTANCE OF PHYSICAL ACTIVITY Physical activity along with a rational diet is considered a basis for prevention of cardiovascular, metabolic or oncological diseases. VOL. 92/3

Any physical activity performed regularly and with adequate intensity has positive effects on the human organism. Physical act iv ity increases significant ly

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level(3, 4) . Apart from increasing tissue sensitivity to insulin, physical activity leads to decreasing the glycaemic levels in blood and to decreasing insulinemia on an empty stomach(5, 6, 7) . Regularly performed physical activity also influences positively mental health and well-being. It results in producing endorphins which have a favorable psychological effect and decrease medical conditions of anxiety and depression(4) . Due to a higher muscle mass the exercising individual also has more insulin receptors what results in decreasing insulin resistance.

development of military technologies the number of military professionals performing their work sitting is increasing. Each soldier in the ACR has to meet a lot of requirements and physical fitness and good health belong to them. Physical training (PT) is a mandatory form of professional physical education and it is part of military training. It is a professional activity and it is performed in the course of training or lessons. Its aim is to prepare soldiers, regarding physical fitness, to be able to solve all the tasks resulting from their military occupational classification.

For the body weight reduction a moderate-intensity dynamic aerobic excise is recommended for 30 to 40 minutes a day. If there are no medical contraindications, aerobic physical activities involving major muscle groups are recommended, e.g. running or speed-walking, hiking, cycling, swimming, walking, cross-country skiing, rowing, stairs climbing, or skating(8, 9, 10, 11) . These physical activities are common and feasible in the Czech Republic and they are also accessible in terms of money and time for most of the Czech population. Patients with very low physical fitness, or patients diagnosed with some of the chronic diseases should consider to start their physical exercises in some of the sports or rehabilitation centres. It is possible to reduce physical activity risks associated with a disease or low physical fitness in these individuals by starting exercises slowly and then gradually increase the intensity and duration of physical load (8) .

Physical training as a compulsory form of professional physical education is determined only for military professionals. In the ACR the physical training is divided into basic physical training (BPT) and special physical training (SPT). The aim of both is to prepare soldiers to fulfil the task and cope with the workload during the military service under any conditions. Physical training is organized for at least 4 hours a week and for professional pilots and military technical personnel for at least 6 hours a week. Basic physical training is focused on the development of general locomotor skills, that means strength, speed, agility and endurance. Its aim is to handle different entrylevel physical fitness in soldiers. The basic physical training includes physical activities to which belong both individual sports such as athletics, swimming, gymnastics, tennis, skiing etc., and team sports such as football, floorball, volleyball, basketball, football tennis, ice-hockey etc. The aim of special physical training is to develop special locomotor skills which soldiers use in their professional activities. To this group belong activities such as close combat, military climbing training, military swimming training, obstacle fitness training, throwing training, training in moving personnel and equipment, survival training(13, 14) .

The physical activity itself leeds to body weight reduction. The increase of energy expenditure caused by physical activity contributes in individuals with overweight or obesity to body weight reduction or maintenance of achieved body weight loss. Besides body weight decrease, there even occurs the improvement in biochemical markers of non-communicable diseases of mass incidence. Thus, the health of an individual has been improved as well. Generally, any physical activity increase is very beneficial for health, and even a little activity can be positive when performed repeatedly(10, 11, 12) .

PHYSICAL ACTIVITY IN THE ARMY OF THE CZECH REPUBLIC Soldiers of the ACR have reserved space for the professional physical training during their working hours and there is a wide range of sports activities they can choose from. These physical activities in the ACR are compulsory and they are led by professional PTI = Physical Training Instructors with military specialization who graduated from the Faculty of Physical Education and Sport at Charles University in Prague. These above mentioned facts can be considered as the main advantages.

The control activity is also included in the system of professional physical education. It is performed in the form of annual physical fitness testing (once a year) and professional physical fitness testing (once a year). All soldiers of the ACR have to pass this testing, except soldiers with restricted health conditions, or shortly before finishing their military service in the Army. Annual physical fitness testing is performed from 1st May to 30th June. In this period the dates of testing, in which the soldiers have to participate, are g iven by a commander. ∑ Department Military Internal Medicine and Military Hygiene, Faculty of Military Health Sciences, University of Defence, Brno, Czech Republic. ∏ Department of Physical Education, Faculty of Education, Charles University, Prague, Czech Republic. Correspondence: assoc. prof. Vladimír Pavlík, M.D., Ph.D. Department of Military Internal Medicine and Military Hygiene, Faculty of Military Health Sciences, University of Defence, Brno, Czech Republic Třebešská 1575 500 01 Hradec Králové, Czech Republic Phone: +420 973 253 176 E-mail: vladimir.pavlik@unob.cz

Regular physical activity, the cheapest and probably the most effective natural form of primary prevention in the terms of non-communicable diseases of mass incidence including obesity, offers a wide range of options in the Armed Forces of the Czech Republic. After finishing compulsory military service in 2005 and with the

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* With courtesy of Editor of Military Medical Science Letters (MMSL) . This article was published in full version and in the Czech language in Mil. Med. Sci. Lett. (Voj . Zdrav. Listy) , 2018, 87(3), 126-133.

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At this testing soldiers are assessed according to the age categories. The tests for testing of male soldiers are composed of strength exercises (push-ups, sit-downs) and a 12-minute run. Instead of these exercises the tested soldier can choose an alternative form of testing. As for strength exercises, soldiers can perform overhand pull-ups on a horizontal bar, or they can swim 300-metre freestyle. Female soldiers are primarily tested in sit-downs and a 12-minute run. There is also an alternative form for female soldiers, instead of sitdowns they can choose a flexed-arm hang as long as possible, or instead of a 12-minute run they can choose swimming 300-metre freestyle. Men over the age of 51 (women over the age of 46) are tested only in endurance disciplines. Age and gender are important factors of assessing results in annual physical fitness testing (Table 1– 2) .

In the military, there are possibilities how to modify or increase the effectiveness of professional phys ical training, purposefully change preventive rehabilitation or spa treatments, perform effective dispensarization in risk persons at the catchment areas of healthcare facilities or at the professional healthcare facilities such as military hospitals. There is also sports environment in most of the military facilities and units fulfilling needs of individual soldiers outside the scope of compulsory physical education such as gyms, fitness centres, multi-purpose sports stadiums, outdoor sports grounds etc. To ensure professional physical education, the ACR buys tickets to selected sports grounds, e.g. swimming pools, fitness centres and sports facilities, sports arenas etc. But sports opportunities and equipment of individual units are different. There is at least a possibility for terrain running and going to the fitness centre. A physical training professional is available in each larger military unit and he is fully-qualified to give advice concerning physical training, or choosing a suitable physical activity.

Professional physical fitness testing assess general locomotor skills and special skills in an individual and in parts of an organizational unit on the basis of tests and performance standards that differ according to the type of the organizational unit, specialty and systematized position. These organizational units or their parts are categorized into performance groups A, B, or C according to the requirements for their fitness levels. This testing is performed from 1st January to 31st December every year. Control tests are selected from a fixed test set to examine all locomotor skills of a soldier. There are used basic control test sets testing strength, speed, endurance and agility. This type of testing is more demanding because it does not consider age categories.

Programmes of preventive rehabilitations seem to be a great opportunity how to improve and maintain physical fitness in the ACR. Preventive rehabilitation with physical activity programmes are organized for soldiers in the Military Spa and Recreation Facilities. These programmes offer two-week stays with sports activities in selected military recreation and rehabilitation facilities during the whole year. As for sports possibilities, the military facility of Bedřichov in the centre of the Giant Mountains is one of the best equipped military facilities.

Table 1: Standards and assessment of annual Physical Fitness Tests in soldiers. MEN Assessment

SIT-UPS (60S) / PUSH-UPS (30S) Excellent

Age group

Good

Satisfactory

Excellent

Number

Good

RUN)

Satisfactory

Metres

I. up to 30

52/32

46/28

42/22

3 000

2 800

2 600

II. 31 - 35

51/30

45/27

39/22

2 950

2 700

2 500

III. 36 - 40

44/27

40/24

34/ 19

2 850

2 600

2 400

IV. 41 - 45

41/25

39/22

32/ 16

2 750

2 500

2 200

V. 46 - 50

38/23

34/ 19

29/ 13

2 650

2 300

2 000

2 400

2 100

1 800

VI. over 51

WOMEN Assessment

SIT-UPS (60S) Excellent

Age group

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COOPER TEST (12-MINUTES

Good

COOPER TEST (12-MINUTES Satisfactory

Excellent

Number

Good

RUN)

Satisfactory

Metres

I. up to 25

2 550

2 300

2 100

II. 26 - 30

2 400

2 200

2 000

III. 31 - 35

2 300

2 100

1 900

IV. 36 - 40

2 200

2 000

1 800

V. 41 - 45

2 100

1 900

1 600

1 900

1 800

1 500

VI. over 46

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Table 2: Standards and assessment of annual Physical Fitness Tests in soldiers - alternatives. MEN

PULL-UPS

Assessment

Excellent

Good

Age group

300-METRE SWIMMING Satisfactory

Excellent

Number

Good

Satisfactory

Minutes : seconds

I. up to 30

4:20

5:20

6:00

II. 31 - 35

4:30

5:30

6:20

III. 36 - 40

4:40

5:50

6:40

IV. 41 - 45

4:55

6:10

7:20

V. 46 - 50

5:10

6:30

7:50

5:20

6:50

9:00

VI. over 51 WOMEN

FLEXED-ARM HANG

Assessment

Excellent

Age group

Good

300-METRE SWIMMING

Satisfactory

Excellent

Minutes : seconds

Good

Satisfactory

Minutes : seconds

I. up to 25

0:50

0:30

0:10

4:50

5:50

6:20

II. 26 - 30

0:46

0:28

0:10

5:10

6:10

6:40

III. 31 - 35

0:34

0:22

0:08

5:20

6:50

7:20

IV. 36 - 40

0:20

0:14

0:07

5:40

7:20

8:00

V. 41 - 45

0:18

0:10

0:05

6:10

7:40

8:50

6:35

8:10

9:40

VI. over 46

Students pass physical fitness tests provided that they achieve at least 1 point in each test.

The Bedřichov Hotel situated in Špindlerův Mlýn is the only one with a 25-metre covered swimming pool. Thus, clients of this hotel have an opportunity to do sports activities the most recommended for body weight reduction: hiking, Nordic walking, cross-country skiing, swimming, cycling or riding a bike simulator (8, 9, 10).

The aim of all the advanced armies is to have a welltrained soldier with good physical fitness. In the ACR each soldier is responsible for his/her physical fitness. In the ACR there are professional training instructors with university education who control the physical training itself, create methodology for individual army branches, and training plans for individuals. Besides, there are trained physical education instructors in units who care for training according to specializations, e.g. self-defence, climbing, swimming, survival etc.

The level of physical fitness is also important when enlisting in the ACR. There are two options of physical fitness testing. The first one is through recruitment centres, the second one is via the application form to the University of Defence. Recruitment centres use physical fitness tests including sit-downs, push-ups (only men), standing broad jump, W 170 test assessing physical performance capacity at heart rate of 170 bpm (Table 3). Recruits pass physical fitness tests provided that they achieve minimum standards shown in the table. The University of Defence uses for entrance examinations tests including sit-downs and a 12-minute run (Table 4).

DISCUSSION AND CONCLUSION Adherence of the most population to a regular physical activity is due to a higher and higher automation of production and a sedentary job and lifestyle very low.

Table 3: Standards and assessment of Physical Fitness Tests in recruitss (minimun limit).

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MEN

SIT-DOWNS / 60S

PUSH-UPS / 30S

STANDING BROAD JUMP

W170 TEST

Age group

Number

Centimetres

W/kg

up to 30

182

1,8

over 31

173

1,6

WOMEN

SIT-DOWNS / 60S

PUSH-UPS / 30S

STANDING BROAD JUMP

W170 TEST

Age group

Number

Centimetres

W/kg

up to 30

Not applicable

144

1,3

over 31

Not applicable

134

1,1

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Table 4: Standards and assessment of Physical Fitness Tests in candidates to University of Defence. MEN

WOMEN

12-minute run

Sit-downs/ 60s

Points

Sit-downs/ 60s

12-minute run

3 000 m

2 550 m

2 850 m

2 500 m

2 700 m

2 450 m

2 600 m

2 400 m

2 500 m

2 300 m

2 400 m

2 200 m

2 300 m

2 100 m

2 200 m

2 000 m

˂ 2200 m

˂ 33

˂ 31

˂ 2000 m

Performing a regular physical activity is very important and participates in reducing the risk of cardiometabolic, oncological and other diseases. Consistent, long-term and regular physical activity forms the basis for primary prevention leading to decreasing prevalence of non-communicable diseases of mass incidence in the ACR. By decreasing the prevalence of cardiovascular and metabolic diseases, also the morbidity of professional soldiers is simultaneously decreasing, thus their deployment capability in combat operations is increasing. Decreasing morbidity related to decreasing sick leave in military professionals causes a decrease in expenditure on their health care including expenditure on pharmacotherapy in individual components of metabolic syndrome such as obesity, arterial hypertension, hyperlipoproteinemia, or diabetes mellitus(15, 16, 17, 18). It is predictable that the above mentioned regime measures are significantly cheaper than further therapeutic interventional procedures, based on pharmacotherapy, long-term hospitalization, or surgery or invasive cardiac surgery. The population lacks awareness of importance of regular physical activity in everyday life. There should be mentioned an irreplaceable role of general practitioner who can play a key role in primary education in civilian, or military sectors.

Benefits of individual cardiometabolic diseases resulting from regular physical activity are described in the first part of the work. The second part deals with possible amounts of space and time for physical activities in the Armed Forces of the Czech Republic, types of military physical training in individual units, and types of physical fitness testing. The work emphasizes the import ance of physical fitness in the Army of the Czech Republic (ACR).

To sum up, it is obvious that out of general requirements for the ACR professionals, physical fitness is considered to be the most important. On the other hand, military professionals have, differently from the civilian sector, very broad possibilities how to maintain their physical fitness, or how to increase it. Only physically well-trained soldier is ready to fulfil demanding tasks in domestic or foreign environment.

5. BOULE, NG. et al. Effects of exercice on glycemic control and body mass in type 2 diabetes mellitus: a metaanalysis of controlec clinical trials. JAMA. 2001, 286, 1218-1227.

REFERENCES 1. SVAČINOVÁ, H. Role of movement therapy and physical fitness in metabolic syndrome therapy. Vnitř. Lék. 2005, 51, 87-92 (in Czech). 2. ZLATOHLÁVEK L. Clinical dietiology and nutrition. Praha, Grada, 2016 (in Czech). 3. DOBRÝ, L. History of physical activity and healht benefits. Těl. Vých. Sport. Mlad. 2008, 74, 7-18 (in Czech). 4. STACKE, D. Health benefits of physical acivity. Hygiena. 2010, 55, 25-28.

6. COKER, R., KJAER, M. Glucoregulation during exercise. Sports. Med. 2005, 35, 575-683.

Acknowledgement

7. EKELUND, U., GRIFFIN, SG., WAREHAM, NJ. Physical activity and metabolic risk in individual with a family history of type 2 diabetes. Diab. Care. 2007, 30, 337-342.

The work was supported by the Long-term Organization Development Plan No. 1011.

8. FAIT, T., VRABLÍK, M., ČEŠKA, R. et al. Preventive medicine. Praha, Maxdorf, 2011 (in Czech).

Conflict of interests

ABSTRACT

9. STRANSKA, Z., MATOULEK, M., VILIKUS, Z., SVACINA, S., STRANSKY, P. Aerobic exercise has beneficial impact on atherogenic index of plasma in sedentary overweight and obese women. Neuro. Endocrinol. Lett. 2011, 12, 102-108.

The authors describe benefits of regular physical activity in primary prevention of cardiometabolic diseases.

10. SVAČINOVÁ, H., MATOULEK, M. Physical activity in the obesity treatment. Vnitr. Lek. 2010, 56, 1069-1073 (in Czech).

Authors state no conflict of interests.

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11. THOMPSON, PD., BUCHNER, D., PIŇA, OL., BALADY, GJ. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease. Circulation . 2003, 107, 3109-3116.

15. HOJGAARD, B., OLSEN, KR., SOGAARD, J. Economic costs of abdominal obesity. Obes Facts 2008, 1, 146-154. 16. RIEMENSCHNEIDER, F., REINHOLD, T., BERGHOFER, A. Health economic burden of obesity in Europe. Eur J of Epid 2008, 23, 499-509.

12. MARTIN, AD., BROWN, E. The effects of physical activity on the human skeleton. Top Geriatr Rehab. 1989, 4, 25-35.

17. KŘÍŽ, J. Prevention and the economy. Hygiena 2011, 3, 8995 (in Czech).

13. Act No. 219/ 1999 Coll., on Armed Forces of the Czech republic (in Czech).

18. HOFFMANN TC, MAHER CG, BRIFFA T. Prescribing exercise interventions for patients with chronic conditions. CMAJ 2016, 188, 510-518.

14. Act No. 221/ 1999 Coll., on professional soldiers (in Czech).

20 19 CALENDAR - AGENDA

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Regional Workshop on Military Medical Ethics. 2-3, Tehran, IRAN

9th International Course for Health Support in Saharan Environment. 4-8, Tozeur, TUNISIA

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Knowledge, Attitudes and Practices of Healthcare Workers Towards their Own Health Promotion in an Urban Military Hospital in South Africa. By R. MA MABOE∑, A. C. TURNER∏ and T. K. MADIBAπ. South Africa

Radineo MA MABOE Colonel (Dr) Radineo MA MABOE FORMAL QUALIFICATIONS 1. Bachelor of Medicine and Surgery (MB.ChB) Medical University of South Africa (MEDUNSA), 1984. 2. Post Graduate Diploma Occupational Health (PGDOH), Witwatersrand University (Wits), 2003. 3. Post Graduate Diploma Public Health (PGDPH), Witwatersrand University (Wits), 2007. 4. Master of Public Health (MPH), University of Pretoria (UP), 2016. WORK EXPERIENCE 1. South African Military Health Services (SAMHS), South Africa, March 2001 to present first as a Major, Principal Medical Officer and from 2007 as Staff Officer, Chief Medical Officer in Mpumalanga Province, South Africa. Appointed Military Medical Superintendent and Senior Staff Officer at 1 Military Hospital, Pretoria 2013 to date. 2. Self-employed in Private Practice in Pretoria, South Africa 1984 until February 2001. Founding Director of Mediclinic Legae Private Hospital, Pretoria, South Africa.

RESUME Connaissances, attitudes et pratiques du personnel de santé concernant la promotion de sa propre santé dans un hôpital militaire en Afrique du sud. L’organisation mondiale de la santé recommande la promotion de la santé pour le personnel hospitalier et fournit un ensemble de documents pour sa mise en œuvre. En Afrique du Sud comme dans le reste du continent il n’existe pas d’hôpitaux de promotion de la santé et l’impact des campagnes de promotion auprès du personnel n’a pas été évalué. L’obj ectif de cette étude était donc d’évaluer les connaissances, attitudes et pratiques du personnel de santé en ce qui concerne leur propre santé dans un hôpital militaire d’Afrique du Sud. Le choix s’est porté sur une recherche qualitative concernant du personnel de santé en service. Trois groupes de discussions thématiques et une interview en profondeur ont été pratiques en langue anglaise. Les interviews en profondeur ont été pratiquées dans deux écoles de cadres infirmiers et les groupes de discussion étaient composés de deux médecins et quatre infirmières. Les données ont été analysées en utilisant le programme ATLAS.TI. Les participants à cette étude avaient des connaissances limitées en ce qui concerne la promotion de leur santé et opposaient les soins dus au patient comme un obstacle à la promotion e leur propre santé. Leur attitude concernant leur santé était variable en fonction de leur niveau d’instruction, les meilleurs résultats étant obtenus chez ceux ayant le niveau le plus élevé. D’autre-part, les interviews en profondeur des cadres de santé ont montré une bonne connaissance des politiques et la conviction que l’environnement hospitalier allait dans le sens de la promotion de la santé. Les cadres de santé ont montré qu’ils ignoraient le ressenti, les problèmes et les attitudes des travailleurs eux-mêmes.

KEYWORDS: Attitudes, Knowledge, Practices, Military hospital, Healt hcare worker, Health promotion. MOTS -CLÉS : Attitudes, Connaissances, Pratiques, Hôpital militaire, Personnel de santé, Promotion de la santé.

INTRODUCTION Based on the construct that health is a positive concept,

International Review of the Armed Forces Medical Services

the World Health Organization (WHO) Bangkok Charter states that “health is created and lived by people within the settings of their everyday life”1.The health promoting

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hospitals (HPH) approach, launched in 1988, integrates health promotion (HP) into hospitals and health services beyond disease prevention and health education2, 3 . Currently HPH networks occur in 34 countries4 . There are no listed HPH elsewhere in Africa and the South African HPH in Limpopo has been delisted5. African countries like South Africa, Mauritius, Uganda, Guinea and Niger have been attempting to broaden their health promotion footprint through HPH with little success6 .

electronically to thirty (30) randomly selected HCWs to ensure the validity of the study feedback. These HCWs were then excluded from the study. Interventions: Three focus group discussions (FGDs) and, two in-depth key informant interviews were conducted to assess KAP regarding HP. The in-depth key informant interviews were conducted with two NSMs. Participants from on-duty roster schedules (excluding specialists and Nursing Services Managers) were selected. Each FGD comprised two doctors and four nurses. The FGDs were conducted over 21 days in a private room while the indepth interviews were conducted over 7 days to minimize disruption of services.

Creating a healthy work environment is one of the standards for inclusion in the HPH network. This is designed to improve the lifestyle and health of healthcare workers (HCWthrough performance assessments; continued professional education, seminars and surveys of HP skills; focussing on HP issues such as smoking cessation, alcohol, physical activity and substance abuse7 8 .

Interviews were conducted in English by one of the authors assisted by a trained facilitator. This research assistant audiotaped and fully transcribed the FGDs and the in-depth interviews. ATLAS. ti software was used for data analysis 11.

The HP approach to hospital care might assist in resuscitating South Africa’s ailing health system by improving working conditions and health of HCWs9 .

Knowledge regarding HP was assessed by asking questions about whether the participants were aware of an existing HP policy in the workplace, whether they were informed about their own HP during their orientation; whether there was a dedicated HP forum at the workplace, and whether the hospital regularly evaluated their health status with regards to smoking, chronic diseases, alcohol and substance abuse.

Apart from Delobelle’s work there are no other published studies relating to the HPH concept in South Africa and the status of it in health facilities5. The aim of this study was therefore to assess the knowledge, attitudes, and practice of HP of HCWs in an urban military hospital in South Africa as the first step towards assessment for accreditation.

METHODS

Attitudes were assessed by asking opinions on HCW own HP; whether they thought they had support to do it; their opinion of colleagues who did not practise HP activities and whether they would caution a colleague who is involved in high-risk behaviour to abstain from such behaviour.

Study design: A qualitative observational study based on Knowledge Attitudes and Practices (KAP) was conducted that purposively sampled on-duty HCWs 10 . Setting: The study was conducted at an urban military hospital in South Africa not classified as a Health Promoting hospital and had not applied to be one in 2016.

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The practices regarding personal HP, were assessed by asking whether participants exercised regularly; washed their hands or sanitised them after every patient and if they avoided risky lifestyle behaviours such as alcohol consumption, smoking, unprotected sex or using illicit narcotics.

Participants: Participants (24 HCW and 12 doctors) were randomly selected from the staff component of approximately 1500 staff. Doctors and nurses that worked in the Emergency Room, High Care/ Intensive Care and theatre were excluded from the study in order not to disturb these services that needed constant monitoring. For sampling purposes nurses or doctors that decided not to participate in the study were used as a starting point and counted until the next 20th nurse or 10th doctor was reached (these numbers were based on the premise that it would be sufficient to avoid choosing nurses or doctors working within a particular department). This continued until twenty-four (24) nurses and twelve (12) doctors were reached. Participants were sampled randomly into the three groups using numbers drawn from a hat (including a blank piece that indicated non-participation). These HCWs were invited to participate in the study. Two Nursing Senior Managers (NSMs) were selected randomly from a hat with 17 NSMs names on pieces of paper.

The in-depth interviews of the nursing managers covered four topics, which were HP policy in the hospital, Awareness of HP policy by health workers, HP needs assessment for HCWs and promotion of a healthy working place5. ∑ Colonel (Dr) MBChB, MPH, DOH, DPH, 1 Military Hospital. ∏ Dr MBChB, FCPHM (SA), MMed, Dip HIV (SA), University of Pretoria. π Dr B. Dent Ther, BDS, DHSM, MChD (Community Dentistry), University of Pretoria. Correspondence: Colonel (Dr) Radineo MA MABOE, MBChB, MPH, DOH, DPH, 1 Military Hospital 247 Rose Acres Estate 781 Enkeldoorn Avenue, Montana Ext 99 SA-0182 Pretoria, South Africa Email: radineo@gmail.com Cell: +27.082 554 0517 Tel: -27. 012 314 0001 Fax: +27. 086 512 0687

Prior to conducting the study, pilot questions were sent

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Consent was obtained from each participant, all data was kept confidential, and anonymity was ensured by not including any names. The University of Pretoria Research Ethics Committee approved the study. The institutional Research Ethics Committee also approved the study and Military Defence Intelligence Division of the South African National Defence force gave permission for the study to continue.

trained and they know about chronic diseases like HIV/AIDS, TB and all non-communicable diseases but they admitted their levels of knowledge differ depending whether they are nurses or medical practitioners. Some participants reported a lack of shower facilities, fear of contracting HIV/AIDS after injuries, lack of time for sports and fear of injury where reasons why they did not engage in own HP.

RESULTS

RESULTS FROM IN-DEPTH INTERVIEWS OF THE NURSING SERVICE MANAGERS

Results for the three FGDs are shown in Table 1.

Health Promotion policy in the hospital

ADDITIONAL RESULTS FROM FOCUS GROUP DISCUSSION

The NSMs reported that there are health policies in the hospital and there are copies in the file. One of them mentioned that they are not necessarily named health promotion policies. They also reported that in addition to the hospital policies they also make use of the South African Nursing acts and regulations. Infection control

In general, participants were aware of annual assessments and activities that were offered for HP but had not heard of policy reviews. The participants also reported that because they are health professionals they have been

Table 1: Participants' responses according to thematic analysis. THEMES

PARTICIPANTS RESPONSES ARE GIVEN AS QUOTATIONS

Awareness and knowledge of a HP policy at the institution

I do not have a copy of the HP policy. I have not seen the hospital Mission Statement. The Mission Statement does not allude to HP. HP is not part of the Business plan. I am not aware of any HP policy. No one actively promotes HP policy. HP policy documents are hidden from us. I was not inducted about HP policy but received induction on military etiquette. I don’t know about HP.Is it a policy for occupational health and safety? (Non-commissioned officers).

Views on promotion There are no cessation programmes for smoking on offer. of a healthy and Canteen mostly provides junk food; only poor choice food is available. safe workplace There are no designated eating areas except in the canteens. There is no blocked time to take meals and drinks…..(everything is) rush-rush-rush. Smoking signs are largely ignored. Only social workers mention alcohol and drugs prior to deployment. Dietitians never evaluate canteen food. Hospital is too open; people move as they please. There is little visible patrolling of security in the hospital grounds. Hospital is a dangerous place to work at. There is growing fear of being attacked and raped in the hospital. Cars are broken into and stolen very frequently, not safe at all. Only infection control nursing staff are active in promoting hand washing and general hygiene.

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Attitudes towards own HP

There is no time for my HP activities. Although I struggle with time I think I must create time for own HP activities so that I can be healthy. The problem is there is no time allowed for own sporting time other than allotted times. Narrow band of extra-curricular activities provided by the institution. Management is indifferent to plight of disabled workers and they are not catered for.

Career pathing

No structured career planning or career path set out for members leading to dead end jobs and depression. Culture of promoting members who are not diligent in their duties or flagrant nepotism and favouritism. Long periods in a post before one can be considered for promotion.

HCWs view of Managers role in HP

Management does not have our advancement at heart or our health, and are only interested in our labour and the welfare of patients. Management is not actively making the hospital to be a safe and pleasant workplace. Management is not increasing security on the premises and people are burdened with a feeling of impending doom. There is a critical shortage of doctors and nurses nationally, yet management refuses to hire locum staff to cover the gaps always citing the dwindling health rand. We often feel “drained” when we think of the problems almost to the point of depression.

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policies and Occupational Health and Safety (OHS) policies were reported to be in place. The mission statement of the hospital “alluded” to health promotion. It was reported that Health promotion was part of the business plan and it was budgeted for. Policies were reported to be reviewed regularly with the last review in the past year.

Awareness of HP policy by HCWs The NSMS reported that the staff was aware of health policies in the hospital and that they had a quality assurance department in the hospital to ensure that information was disseminated. They further reported that the hospital has seven staff members in the quality assurance committee and the infection control committee, representing all the departments in the hospital. As they are, a military hospital there is a regimental sergeant major who is responsible for orientation of the staff on military related requirements; ensuring that the nurses attend workshops on OHS, infection control and record keeping. Health promotion was reported to be part of the job description of staff with each having a copy in their personal files.

HP needs assessment for HCWs The hospital evaluates the health of military personnel once a year through a programme named concurrent health assessment (CHA). Military personnel are evaluated for diseases of the lungs, diabetes, hypertension, malnutrition and this assessment includes an x ray and ECG once personnel are over 40 years of age. Part of the evaluation included testing for HIV and any history of alcohol or substance abuse was recorded. The challenge that was mentioned was that this was not the same as HP in line with WHO suggestions, as it was for military personnel only and was used to assess suitability for deployment.

Promoting a healthy working place The NSMs reported that there was promotion of a healthy working environment because there were designated smoking areas. The canteen also offered a variety of foodstuffs that included sweets and chocolate as well as healthy foodstuffs like fruit, vegetable, muesli, yoghurt and health bread. There were guards at all entrances and a security department within the hospital with cameras to maintain a safe working environment for staff. The NSMs further reported that they felt safe within the hospital and reported that if there were major security risks the military police could also be called in. They also reported that each department had a representative to ensure compliance with healthy policies and that specific calendar days were designated for campaigns about specific disease prevention. There was a hypertension awareness day, staff members had their blood pressure measured; also a diabetes awareness day where blood glucose levels were tested. All these campaigns were advertised in advance with posters.

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DISCUSSION Most participants were unfamiliar with the HPH concept. The HCWs who had heard about the concept demonstrated a superficial grasp of HP in general. One of the reasons for this could be the two-week induction orientation programme for new employees, primarily concentrated on human resource issues and conduct expected from employees in a military setting12.One study blames poor HP knowledge on the asymmetrical emphasis on biomedical knowledge during the training of HCWs which does not take into account the social determinants of diseases13. Participants were educated regarding HP of patients, but not about their personal HP, which appeared to be confused with institutional HP. Institutional HP includes activities such as concurrent health assessment which all military staff members have to complete annually14. Fitness programmes such as Phakamisa, 1-hour long walks and 1-hour Tae-Bo, a dance exercise programme; were offered daily. Monthly weighing assessments evaluated targeted weight loss. All HCWs have access to Masibambisane, the SANDF HIV/AIDS programme. This covers education and prevention of HIV/AIDS including peer education, Counselling on high- risk behaviour, mass awareness programmes, condom distribution15. There were no common courses on HP offered during the Education, Training and Development (ETD) activities for Officers and NCOs. One author asserts that most HCWs were misinformed about HP and practiced what they knew minimally8. However, HCWs demonstrated good knowledge about HIV/AIDS and TB and other occupational and chronic diseases within their risk profile. This is not surprising as this is part of training of health workers16. The NCOs expressed a view that HP is a policy that governs the work environment and therefore equated it and confused it with Occupational Health and Safety policy. On the other hand the Commissioned officers knew the differences between the Occupational Health and Safety policy and HP though they also admitted never seeing any policies especially HP policies. On probing, the Commissioned officers expressed that they will now review their own HP to make positive improvements whereas the NCOs expressed uncertainty about own health promotion and blamed the lack of time to engage on own health promotion. The attitudes of officers who hold supervisory, management positions towards their own HP were more positive than the NCOs. According to Whitehead, lack of political will of HCWs impairs their initiatives to drive own HP8. The negative attitude toward one’s HP may be due to the military work environment that inhibits autonomous practising with strict command and control structures. Typically, like all hospitals, the urban military hospital in the present study practices a biomedical framework that perpetuates focus on physical health and well-

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being of patients above that of its HCWs HP needs. This has an effect on HCWs “being drained” or “feeling drained” to the point of depression as expressed by members of one FGD. This is equivalent to what one study found in depressive episodes of Chinese nurses17. The FGD participants avoided describing themselves as depressed possibly for fear of the limitations on their careers if clinically diagnosed with depression. HCWs recommended that senior and authoritative members needed to attend HP training in order to influence management on HP decision-making.

when there is partnership between general staff and hospital management. Management on the other have the position to create an organizational environment to facilitate this process and hence it is recommended that they take an active role. There is a need for managers to re-evaluate their interpretation of policies and strategies addressing own HP at the urban hospital and follow-up with staff allocated to make sure that it is realised. This is because the NSMs reported that all was well and that staff had policies in their personal files whist t hat was disputed by staff. A healthy working environment is essential for WHO HPH accreditation. Continuous assessment of staff HP needs and implementing strategies to meet those needs are a prerequisite for the urban hospital towards accreditation as a HPH. In view of these reality it is recommended that the hospital in this study strife towards accreditation as a Health Promoting Hospital

The Nursing senior managers demonstrated from the in depth interviews an impressive knowledge base of policies and practices of HP. They also reported that staff have a copy of HP policies in their personal files but their held views were found to be incongruent with those of their subordinates. The NSMs reported that they felt safe around the hospital while the FGD revealed that there were problems with security. The FGD found that some of the people do not remember seeing the policies.

Financial support and sponsorship None

Most participants had a resigned attitude towards not engaging in their own HP especially the NCOs. A lack of blocked time for HP activities, no showering facilities after physical activities, fear of contracting HIV/AIDS and/or TB during contact sports, fear of sustaining a sports injury were reasons given for not engaging in HP activities. Most HCWs believed that patient care supersedes their own HP, which to some extent inhibited them from taking advantage of offered institutional HP programmes.

Declaration of interest None Acknowledgements The authors would like to acknowledge the contribution of Prof Cheryl McCrindle, the late Dr Kirstie Rendall-Mkosi, Mrs Estelle Grobler, Dr Cheryl Tosh and Mr Thulani Zengele.

ABSTRACT

Participants felt that personal HP goals that they could set included the practice of safe and protected sex, avoidance of excessive alcohol consumption, eating regular balanced meals, exercising regularly and undertaking periods of self-reflection.

The World Health Organisation advocates health promotion for hospital staff and gives a set of guidelines for implementation. Africa, including South Africa, has no health promoting hospitals and the extent of health promotion for staff working in hospitals has not been investigated.

CONCLUSION

The objective the study was therefore to explore the knowledge, attitudes and practises of healthcare workers towards their own health promotion at an urban military hospital in South Africa.

Participants reported that the focus on patient care was a barrier to their own HP. Participants perceived management more only interested in their commitment to patient care than their own HP. The knowledge, attitudes and practices of healthcare workers at the military hospital of their own HP was inadequate. The differences between their own HP and institutional HP remain vague for HCWs at the institution The NSMs in-depth interview showed that the managers had adequate knowledge about different policies and reported that the HCWs had adequate knowledge. This knowledge was in stark contrast with what the HCWs knew and experienced. The participants felt that the environment in the hospital was not congruent with health promotion and felt unsafe whilst the managers projected a different picture. VOL. 92/3

Recommendations Promoting a healthy workplace can only be achieved

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A qualitative research design was used, which purposively sampled on-duty healthcare workers. Three focus group discussions and two in-depth key informant interviews were conducted in English. The in-depth interviews were conducted with two Nursing services managers whilst each Focus group was composed of two doctors and four nurses. The data was analysed using ATLAS.TI 7 software. Participants in this study had limited knowledge about their own health promotion and reported focus on patient care as a barrier to own health promotion. The attitude towards own health promotion varied depending on the level of education, with those of participants with better education positive towards own health promotion.

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On the other hand, the in-depth interviews on nursing managers showed adequate knowledge of policies and an opinion that the environment in the hospital was conducive to health promotion. The nursing managers displayed ignorance of the feelings, concerns and attitude of health workers under them.

18. WHITEHEAD D. Health promoting hospitals: the role and function of nursing. Journal of clinical nursing . 2005; 141: 20-27. doi: 10.1111/j.1365-2702.2004.01012.x 19. National Health Insurance for South Africa: towards universal health coverage. Friday, 1 December 2015. Government Printers Version 40 Government Gazette No. 39506.

REFERENCES

10. KILALE, A.M. (2016). A critical review of the use of Knowledge, Attitude and Practice (KAP) studies to guide health communication: Strengths and weaknesses. June 2016 DOI: 10.13140/ RG.2.1.3248.7922.

11. World Health Organization. Health promotion: The Ottawa Charter for Health Promotion 1986 [cited 21 June 2018]. Available from: http://www.who.int/ healthpromotion/conferences/ previous/ottawa/en/

11. Atlas. Ti version 7 software. (2016). [Cited 2017 October 15]. Available on https://atlasti.com/ product/v7-windows/

12. YAGHOUBI M, JAVADI M, BAHADORI M, RAVANGARD R. Health Promoting Hospitals Model in Iran. Iranian j ournal of public health . 2016; 45 (3): 362-369.

12. South African Military Health Service. Induction documents for I Military Hospital. [Cited 2016 October 15]. Available on http://www.mhs.mil.za: 800/ imh/ policies.htm

13. World Health Organization. The Budapest Declaration on health promoting hospitals. Copenhagen: World Health Organization. 1991.

13. DAHL BM, ANDREWS T, CLANCY A. Contradictory discourses of health promotion and disease prevention in the educational curriculum of Norwegian public health nursing: A critical discourse analysis. Scand J Public Health . 2014; 42 (1): 32-7.

14. World Health Organization. The International Network of Health Promoting Hospitals and Health Services: integrating health promotion into hospitals and health services: concept, framework and organization. 2007 [cited 21 June 2016. Available from http://www.euro.who.int/__ data/assets/pdf_file/0009/99801/ E90777.pdf

14. South African Military Health Service. (1994). Concurrent Health Assesment. doi: Available on http://www.mhs.mil.za: 800/ imh/Concurrent Health Assesment. htm.

15. DELOBELLE P, ONYA H, LANGA C, MASHAMBA J, DEPOORTER AM. Advances in health promotion in Africa: promoting health through hospitals. Global health promotion . 2010; 17 (2 suppl): 33-36.

15. South African Military Health Service. HIV/AIDS Management in the Department of Defence.. [Cited 2016 October 15]. Available on http://www.mhs.mil.za: 800/ imh/ policies.htm.

16. NYAMWAYA D. Health promotion in Africa: strategies, players, challenges and prospects. Oxford University Press; 2003.

16. LALKHEN H., MASH R. Multimorbidity in non-communicable diseases in South African primary healthcare. South African Medical Journal . 2015, 105 (2): 134-138.

17. World Health Organization. Health Promotion: Jakarta Declaration on Leading Health Promotion into the 21st Century 1997 [cited 21 June 2017]. Available from: http://www.who.int/ healthpromot ion/conferences/ previous/jakarta/declaration/en/

17. GAO YQ, PAN BC, SUN W, WU H, WANG JN, WANG L. Depressive symptoms among Chinese nurses: prevalence and the associated factors. J Adv Nurs. 2012; 68 (5): 1166-75.

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A RT ICLES

Highly Toxic Ribosome-Inactivating Proteins as Chemical Warfare or Terrorist Agents.* By J. PATOCKA∑ ∏. Czech Republic

Jiri PATOCKA Prof. RNDr. Jiri PATOCKA, DrSc. Academic title was obtained at Masaryk University in Brno, Czech Republic, Faculty of Chemistry (1962). Since 1964, a scientist at the Military Medical Academy in Hradec Králové. Currently a professor of toxicology at the University of South Bohemia in České Budějovice. He works in the field of molecular biochemistry, enzymology and toxicology of extremely toxic, synthetically prepared and natural substances. He is the author or co-author of more than 20 monographs and textbooks, including Military Toxicology (2004) or Nutrition Toxicology (2008). He has published over 400 scientific articles. It also deals systematically with the popularization of science. More than 3800 citations to SCI, Hirsch-index = 30, i10-index = 77, RG = 40.65.

RESUME Les protéines inhibitrices des ribosomes de haute toxicité utilisées comme agents de guerre chimique ou comme armes terroristes. Les armes biologiques comprennent les agents infectieux et les toxines. Les toxines sont des poisons fabriqués par des organismes vivants. Un important groupe de toxines est constitué par les protéines inhibitrices de ribosomes (RIPs) d’origine végétale ou microbienne qui inhibent la synthèse des protéines en inactivant les ribosomes. Les RIPs présentent un grand intérêt scientifique en raison de leur importance dans la santé humaine, à la fois comme agents pathogènes ou comme médicaments, mais aussi en raison de leur usage potentiel en guerre biologique et par le bioterrorisme. Les RIPs utilisables par le bioterrorisme sont principalement la ricine et l’abrine. La ricine est une protéine produite par les graines de ricin (Ricinus communis). L’abrine est quant à elle une protéine qui a été isolée des graines de Abrus precatorius. Les deux inactivent les ribosomes et leur toxicité est due à l’inhibition de la synthèse des protéines qui en résulte. L’abrine et la ricine sont des substances très toxiques pour l’homme quel que soit le mode d’administration, à l’exception de l’ingestion. Les symptômes rassemblent nausées, diarrhée, tachycardie, hypotension et pertes de connaissance. Le traitement est symptomatique et il n’existe pas d’antidotes.

KEYWORDS : Plant toxic proteins, Ribosome inactivating proteins (RIPs), Abrin, Ricin, Modeccin, Viscumin, volkensin, Warfare, Medicine. MOTS -CLÉS : Protéines toxiques d’origine végétale, Protéines inhibitrices de ribosomes (RIPs), Abrine, Ricine, Modeccine, Viscumine, Volkensine, Guerre biologique, Médicament.

INTRODUCTION

volkensin are also associated with these two proteins. Abrin, ricin, viscumin, modeccin, and volkensin are very potent toxins derived from plants (Patocka and Streda,). They are g lycoproteins composed of two polypeptide chains linked by a disulphide bridge. The A-chain is the enzymatic toxic moiety and B-chain is responsible for bonding to the target cell and internalization of toxin.

Many plants produce proteins that are today referred to as ribosome-inactivating proteins (RIPs) (Stirpe and Battelli, 2006). Some of these RIP-expressing plants are very toxic and their toxicity has been known since antiquity (Olsnes, 2004). Most commonly RIPs are single – chain proteins (type 1 RIPs), but some (type 2 RIPs) possess a galactose – s pecific lectin domain that binds to cell surfaces. The latter RIPs are potent toxins, the best known of which are abrin and ricin (Patocka, 2001). Because of their high toxicity, viscumin, modeccin and

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The A-chain is the enzymatic toxic moiety and B-chain is responsible for bonding to the target cell and internalization of toxin. The B-chain is a lectin-like peptide that has strong affinity for sugar moieties displayed on

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the surface of cells and helps promote translocation through the plasma membrane. The toxic part of the toxin molecule removes an adenine from a specific adenosine residue in ribosomal RNA and blocks proteosynthesis. That is the reason of extreme toxicity of these compounds and their capacity to be used as biological warfare agents or terrorist weapon (Anderson, 2012). Therefore all these compounds a re in the schedules of controlled biological agents and toxins. Contrariwise, plant ribosome-inactivating proteins are studied intensive as possible chemotherapeutic agents (Das et al., 2012). RIPs have antibacterial and antiviral activities, and, in a widespread application, can also be linked to antibodies or ligands to form immunotoxins or conjugates specifically toxic to a given type of cell (Rust et al., 2017).

for protein synthesis from mRNA and amino-acid subunits linked to tRNA. Ribosomes have two subunits, a large subunit, which contains an rRNA fragment known as the 60s fragment and a smaller subunit. The 60S fragment is made up of several pieces of RNA, one of which is the 28S rRNA. It is thought to be the RNA components that are most important in protein chain elongation catalysis (Larsson et al., 2002). The A-chain is an N-glycosidase, which removes bases from nucleic acids. It catalytically and irreversibly inactivates the 60S, large ribosomal subunit (M anske et al., 1989) so that modifies a base in the 28S rRNA fragment of the 60S RNA chain and thus halts protein synthesis. Figure 1: Mechanism of action of ricin.

MOLECULAR STRUCTURE OF TYPE 2 RIBOSOME-INACTIVTING PROTEINS (2 RIPS) The g lyco proteins like abrin, ricin, viscumin, volkensin and modeccin come under the group of toxic lectins of A- and B-chains. The A-chain is an enzyme whereas Bchain is a lectin. Most of the research and information on plant toxic proteins has been obtained from studies on ricin. Ricin is considered the first lectin to be discovered, and it is thus the prototypical lectin in this category (Cummimgs et al ., 2017). Chemical structure and the mechanism of toxic action all this ricin-related protein family are very similar (Olsnes et al. 1974). The resemblance of A- and B-chains of all RIPs is evident from the fact that they are interchangeable and hybrid toxin built-up from modeccin A-chain and ricin B-chain was prepared (Sundan et al. 1983).

TOXIC ACTION OF TYPE 2 RIPS The g ly co proteins ricin, abrin, viscumin, volkensin and modeccin are lectins composed of 2 chains, linked by a disulfide bond (Kozlov et al., 2006). A chain inhibits protein synthesis by irreversibly inactivating eukyryotic ribosomes through removal of a single adenin residue from the 28s ribosomal RNA loop and prevents chain elongation of polypeptides and leads to cell death. B chain binds to galactose-containing glycoproteins and glycolipids expressed on the surface of cells and facilitates the entry of toxin into cytosol (Shi et al., 2016). Part of the toxin bound to the cell surface undergoes receptor-mediated endocytosis (Manske et al., 1989) and by this way a RIP is internalized. As soon as the toxin molecule is internalized to vacuolar and tubovesicular portions of the endosomal system where most of it remains bound to the plasma membrane, protein is transported retrograde through the Golgi to the endoplasmic reticulum and the A-chain to bind to its target ribosome site and cause toxic effects in the cell. When the ricin A-chain is separated from the B-chain and administered parenterally to amnimals, its toxicity is diminished by > 1,000-fold compared with ricin holotoxin (Soler et al., 1992) . The mechanism of toxic action of ricin is schematically illustrated in Figure 1. VOL. 92/3

Ricin binds to glycoproteins of the plasma membrane and internalizes into the cell. A small number of ricin molecules are transported first to the Golgi netwok and then to the endoplasmatic reticulum. The disulphide bridge is reduced and the A-chain translocates to the cytosol by the endoplasmatic reticulum-associated degradation (ERAD) pathway. In the cytosol, the Achain cleaves an adenine residue (A4324) near the 3’end of 28S RNA in the 60S subunit. This inactivates ribosome function and blocks protein synthesis and cause cell death. ∑ University of South Bohemia České Budějovice, Faculty of Health and Social Studies, Institute of Radiology, Toxicology and Civil Protection, České Budějovice, Czech Republic. ∏ Biomedical Research Centre, University Hospital, Hradec Kralove, Czech Republic. Correspondence: Prof. RNDr. Jiri PATOCKA, DrSc. University of South Bohemia Ceské Budejovice, Faculty of Health and Social Studies, Institute of Radiology, Toxicology and Civil Protection, Jirovcova 24/ 1347 CZ-370 04 Ceské Budejovice, Czech Republic. E-mail: toxicology@toxicology.cz Web: https://orcid.org/0000-0002-1261-9703

Ribosomes are complex structures, composed of prote in and nucleic acid (rRNA) components. They are responsible

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* With courtesy of Editor of Military Medical Science Letters (MMSL) . This article was published in Military Medical Science Letters, 2018, 87(4), 158-168.

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CLINICAL COURSE OF POISONING Illness symptoms of all RIPs and the course of poisoning are very similar because the mechanism of toxic action of these toxic proteins is identical. Best known is poisoning of human by ricin (Lopez Nunez et al., 2017). People who have poisoned ricin are large numbers (Audi et al., 2005; From et al., 2015). Toxic effects of ricin have a latent period and take 2-24 hours to develop. After ingestion the primary symptoms are abdominal pain, vomiting and diarrhoea often with blood. The toxin causes haemorrhages in the intestine, mesenterium and omentum. It may also cause a diffuse nephritis, multiple necroses in the liver and kidneys with cytoplasmic vacuolation and pyknosis of the nuclei (Knight, 1979). In the myocardium the myofibrils undergo degeneration. Within several days there is severe dehydration, a decrease in urine, thirst, burning throat, headache and the patient may die from hypovolemic shock. The patients’ temperature decreases before death, and they often undergo a characteristic shivering. Death occurs in exhaustion or cramp (Bradberry et al., 2003). When administered paraenterally ricin is twice as toxic as cobra venom, and is probably the most toxic paraenteral substance in the plant kingdom. After paraenteral administration the patient may present with fever, leucocytosis, and then falling blood pressure and temperature. The primary target organs are the kidney, liver, and pancreas. Differences in toxicities of particular RIPs are not very distinct. From the literary data the most toxic is abrin (Patocka 2001).

poison management if dedicated toxicology laboratories are not an option. For the convenience of fast measurement in th e outdoor environment, a portable electrochemiluminescence biosensor with the screen-printed electrode as the reaction center was developed, which possesses the characteristics of high sensitivity, small scale, simplified operation and so on, and has been used for in situ detection of abrin (Liu et al., 2018).

PROTECTION The usually chemical protective masks are effective against inhaled ricin as well as against all other RIPs. Two types of tight-fitting masks may be used: 1) respirator with HEPA filters, or 2) respirator with charcoal filters (Audi et al., 2005). A protective mask is the best protection against inhalation. Future protection efforts are aimed at developing a vaccine against inhaled ricin and abrin. No approved vaccine or specific antidote is currently available for human use, but experimental, recombinant vaccines are under development (Pittman et al., 2015; Wang et al., 2015). If exposure to skin occurs, decontamination with soap and water is available. Also, hypochlorite solutions can be used to inactivate ricin (Kent, 2006). As a toxin, ricin and other RIPs acts directly on the individual exposed to it and is not reproduced within the individuals: it cannot be passed from person to person. Quarantine of affected individuals would be of no value.

PROPHYLAXIS Because RIPs are potential agents for bioterrorism an effective vaccine against RIPs poisoning is urgently required (Griffiths et al., 1995). At present, the potential for vaccine development against RIPs, particularly against abrin and ricin, has been intensively studied (Zhang et al., 2014). Recently, a recombinant vaccine consisting of the A subunits of abrin and its homolog Abrus precatorius agglutinin (APA) was demonstrated to protect mice from abrin lethality (Kumar and Karande, 2016). Abrin and ricin are highly potent toxins, and is classified as one of the most important biological warfare and bioterrorism agents. The development of an effective vaccine is important in the prevention of intoxication by abrin and ricin. There is currently no approved vaccine for therse RIPs.

DIAGNOSIS Like other potential intoxications on the unconventional battlefield, epidemiological findings will likely play a central role in diagnosis. The observation of multiple cases of very severe pulmonary distress in a population of previously healthy young soldiers, linked with a history of their having been at the same place and time during climatic conditions suitable for biological warfare attack, would be suggestive of ricin intoxication. Diagnosis of an aerosolized attack ricin is similar to that of an attack with staphylococcal enterotoxin B, exposure to pyrolysis by-products of organofluorine polymers (Patocka and Bajgar, 1998) or other organohalides, oxides of nitrogen, and phosgene. Laboratory findings are nonspecific but similar to other pulmonary irritants that cause pulmonary edema. Enzyme-linked immunosorbent assays in blood or other body fluids (Poli et al., 1994) or by radioimmunoassays (Godal et al., 1981) or immunohistochemical techniques may be useful in confirming abrin and/or ricin intoxication but identification in body fluids or tissues is difficult (Garber et al., 2010; Xu et al., 2015).

DECONTAMINATION Ricin may be inactivated with 0.5% hypochlorite (Kent, 2006). Since it is not dermal active and is involatile, decontamination may not be as critical as with certain other biological and chemical agents (Spivak and Hendrickson, 2005).

RIPS AS CHEMICAL WARFARE OR TERRORIST AGENTS

Recently a first of its kind portable, colorimetric detection system has been developed for the rapid diagnosis of abrin poisoning (Cho and Jaworski, 2014). This unique diagnostic test for abrin poisoning has demonstrated key benefits of portability and simple visual readout. These significant advantages can thus provide the potential for more rapid assessment and corresponding

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Toxins have properties of biological and chemical weapons and the same is true for RIPs, especially for ricin and abrin (Kuca and Pohanka. 2010; Anderson, 2012). Ricin is the only toxin to exist naturally in large quantities. It is a

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byproduct of castor oil production and ricin isolation is a simple and cheap separation. Easy preparation and low price might make this toxin attractive to poor country. Center of Disease Control and Prevention (CDC) recognized ricin as a biological weapon category B. The lethal dose of ricin toxin after parenteral administration is 0.1 µg/kg and after oral administration 0.2 mg/kg. The first symptoms of poisoning occur within a few hours after application of toxin as a nausea, vomiting and abdominal pain. In the final stage there are observed: cardiac arrhythmia, collapse and symptoms suggestive of involvement of the central nervous system (Patocka and Streda, 2006). Stage immediately preceding death is a state of coma (From and Płusa, 2015). The ricin toxin is still the substance against which action has no optimal antidote. At the end of the First World War, US initiated a research program with ricin named compound W as a potential replacement of phosgene and during the Second World War, US produced, together with Canada, United Kingdom and France, 1,700 kg of ricin. United Kingdom designed a 500 pounds’bomb with ricin but never used it (Diac et al., 2017). The former Soviet Union was the first to really use ricin as a bioweapon in the cases described before. Even though they tried to develop a bomb, the costs of protecting the toxin from thermal effect was too high incorporate in artillery projectiles but the results were disastrous and the project abandoned. In the last century, at least 30 incidents related to the criminal use of ricin were registered, but in only half of these the toxin was actually identified. Al Qaeda attempted seed extraction of ricin by following methods described in US paramilitary publications but the ricin content of the extract was less than 1%, unsuitable for mass poisoning (Pearson, 1999). Ricin’s significance as a potential biological warfare toxin relates in part to its wide availability. Worldwide, one million tons of castor beans are processed annually in the production of castor oil and in the waste is five percent ricin by weight. The toxin is also quite stable and extremely toxic by several routes of exposure, including the respiratory route. Ricin is said to have been used in the assassination of Bulgarian exile Georgi Markov in London in 1978. Markov was attacked with a specially engineered weapon disguised as an umbrella which implanted a ricin-containing pellet into his body (Crompton and Gall, 1980; Papaloucas et al., 2008). The most likely scenarios in which ricin intoxication might be seen by military medical personnel are small-scale battlefield or terrorist delivery of an aerosol and parenteral administration of the toxin to an individual as an assassin’s tool (Madsen, 2001).

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Abrin may be considered to be an available toxin for weaponizing because its source, Abrus precatorius, may be easily cultivated and the preparation of the pure toxin is not complicated. For nations or terrorists who lack the money to spend on nuclear weapons and other high-tech killing instruments, toxin warfare offers horrific appeal: biological/toxin weapons are

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cheap, easy to make, and simple to conceal. Even small amounts, if effectively used, could cause massive injuries and make many suffer (Patocka et al., 2007).

ABRIN Abrin is a potent toxin that has been isolated from the seeds of Abrus precatorius (or Rosary pea). Its use as a tool for research was described in 1972 by Sharon and Lis (1972). Abrin exists in two forms, abrin a and abrin b. Both are composed of two chains, an A-chain and a B-chain. A disulfide bond between Cys247 of the Achain and Cys8 of the B-chain links the A and B chains. The A-chain is 251 residues and is divided into 3 folding domains. The A-chain catalytically inactivates 60S ribosomal subunits by removing adenine from positions 4 and 324 of 28S rRNA therefore inhibiting protein synthesis. The B-chain is a galactose-specific lectin that facilitates the binding of abrin to cell membranes (Olsnes and Pihl, 1976; Chen et al., 1992). The B-chain of both forms of abrin consist of 268 amino acid residues and share 256 identical residues (Kimura et al., 1993). Comparison of their sequences with that of the ricin’s B-chain shows that 60% of the residues of abrin’s Bchain are identical to those of the ricin’s B-chain and that two saccharide-binding sites in ricin B-chain identified by a crystallographic study are highly conserved in abrin B-chain (Kimura et al., 1993). The mechanism of toxic action of abrin is identical to that of ricin, but the toxicity of abrin in mice is 75 times that of ricin (0.04 µg/ kg for abrin compared to 3 µg/ kg for ricin.) The diagnosis, clinical features, treatment, protection, pro phy laxis and so on is also the same for both abrin and ricin intoxications (Olsnes et al., 1978). Published toxicity data for abrin are summarized in Table I.

RICIN Ricin was found by Stillmark in 1889 as the first plant lectin from the seeds of the castor plant, Ricinus communis . As with abrin, ricin is a lectin consisting of two polypeptide chains, the A-chain (30 kDa) and the Bchain (32 kDa), linked by a disulfide bond. It is one of a group of dichain ribosome-inactivating proteins, which are specific for the depurination of a single adenosine in ribosomal ribonucleic acid (Barbieri et al., 1993). The A-chain of ricin has the ability to modify catalytically the 28S subunit of ribosomes to block protein synthesis. The lectin subunit, B chain, of ricin plays an important role of binding to the cell surface g ly coconjugates of target cells and facilitates the internalization and translocation of the toxin to cytosol (Lord et al., 1994). The toxicity of castor beans has been known since ancient times, and more than 750 cases of intoxication in humans have been described (Rauber and Heard, 1985). There is a 100-fold variation in the lethal toxicity of ricin for various domestic and laboratory animals, per kilogram of body weight. Of animals tested, the chicken and frog are least sensitive, while the horse is the most sensitive (Balint, 1974). Toxicity of ricin also

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Table I: Published Toxicity Data for Abrin.

ORGANISM

TEST TYPEA

ROUTE

REPORT DOSE

REFERENCE

Mouse

LD50

Intraperitoneal

20 µg/kg

Lin et al., 1971

Mouse

LD50

Intraperitoneal

0,91 µg/kg

Chaturvedi et al., 2015B

Mouse

LD50

Intravenous

20 µg/kg

Berdy, 1982

Mouse

LD50

Unreported

20 µg/kg

Tung et al., 1975

Rat

LDLo

Oral

300 mg/kg

Anonymous, 1955

Rabbit

LDLo

Oral

21 mg/kg

Anonymous, 1955

Human

LDLo

Oral

7 µg/kg

Merck Index, 1989

LD50 = Acute Lethal Dose, LDLo = Lethal Dose Low.

The intraperitoneal LD50 value of purified abrin published by Chaturvedi et al. (2015) for mice was found to be 0.91 µg/kg of body weight. It is not clear why, but this value is much lower than the values published by Lin et al. (1971) and Berdy (1980), respectively. Indian authors (Chaturvedi et al. 2015) could have, for example, a much more purified abr in. B

varies with route of challenge. In laboratory mice, the approximate dose that is lethal to 50% of the exposed population (LD50) and time to death are, respectively, 3 to 5 µg/kg and 60 hours by inhalation, 5 µg/kg and 90 hours by intravenous injection, 22 µg/kg and 100 hours by intraperitoneal injection, 24 µg/kg and 100 hours by subcutaneous injection, and 20 mg/kg and 85 hours by peroral administration. Low oral toxicity reflects poor absorption of the toxin from the gastrointestinal tract. Published toxicity data for ricin are summarized in Table II.

VISCUMIN Viscumin (Mistletoe lectin I, ML I), inevitable to the family of RIPs, was identified in the late 1980s as the main pharmacologically-active ingredient of mistletoe (Viscum album) extract and is largely responsible for its toxicity (Krauspenhaar et al. 1999). Viscumin toxicity is high. The LD50 for mice with intraperitoneal administration is 2 µg/kg and is therefore comparable to ricin toxicity (Patocka et al. 2004) and acts by the same mechanism. Viscumin has a concentration-dependent activity profile unique to plant AB-toxins. It starts with lectin-dependent mitogenicity and then covers toxicity and cell agglutination, associated with shifts in the monomer/dimer equilibrium (Jiménez et al. 2006). When viscumin binds to its target cell, protein synthesis in that cell is interrupted as a result of the A-chain’s enzymatic activity, like a ricin. This interruption induces a cellular stress response, which triggers the release of cytokines by the target cell and, at high viscumin concentrations, apoptosis of the cell (Thies et al., 2005). Viscumin belongs to a group of selected substances, according to the Centers for Disease Control and Prevention, or the control of trade in dual-use products in the European Union (Duracova et al., 2018).

wt. 29,000) and of a B subunit (Mr 36,000) linked by disulfide and noncovalent bond (s) (Stirpe et al., 1985). The plant is a relatively unattractive and toxic succulent plant found in Africa that appears to be of little interest. However, it has proven useful as a research reagent in neurology because of its ability to be taken up and transported by certain types of nerve (Wiley and Stirpe, 1987). Although volkensin belongs to the same group of poisonous proteins as abrin or ricin, and its toxicity is comparable (LD50, intraperitoneal mice 1.38 µg/kg) with ricin and abrin (Barbieri et al. 1984), it seems to differ in some respects (Wiley and Stirpe, 1988). If it is injected in the rat dorsal hippocampus, volkensin is taken up by nerve terminals in the injected area of the brain and retrogradely transported to the cell bodies originating the projection, which are killed by the toxin (Contestabile et al., 1990). Volkensin-induced selective motoneuron death in the adult rat can be a useful experimental model for degenerative motoneuron disease (Nogradi and Vrbova, 1992). Experimental lesions and quantitative autoradiography were used to investigate the cellular distribution of neurotransmitter receptors in rats. Lesions were produced by intracortical injections of either volkensin or ricin. However, only volkensin is retrogradely transported and volkensin treatment causes significant loss of contralateral cortical pyramidal neurones. (Chessell et al., 1997).

MODECCIN Modeccin is a lectin from the roots of Adenia digitata an African succulent plant (Stirpe et al., 1977) that is comparable in toxicity to ricin (Olsnes et al. 1982) and acts by the same mechanism (Refsnes et al. 1977, Olsnes et al. 1978). The plant does not seem to have any significant uses, such as food or medicine and so is not available in quantities comparable to abrin, let alone ricin. However, the seed does seem to be readily available. The subunits were isolated of modeccin (subsequently referred to as modeccin 4B), purified from the roots of Adenia digitata by affinity chromatography on Sepharose 4B (Gasperi-Campani et al. 1978). They are

VOLKENSIN

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Volkensin is a lectin from Adena volkensii (the kilyambiti plant) that is comparable in toxicity to ricin and that acts by the same mechanism (Wu and Sun, 2012). The toxin is a glycoprotein (mol wt. 62,000, neutral sugar content 5.74%) consisting of an A subunit (mol

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Table II: Published Toxicity Data for Ricin.

ORGANISM

TEST TYPEA

ROUTE

REPORT DOSE

REFERENCE

MOUSE

LD50

Intraperitoneal

2 µg/kg

Creppy et al., 1980

MOUSE

LD50

Intravenous

2.2 µg/kg

NTIS, 2017

MOUSE

LD50

Subcutaneous

2.21 µg/kg

NTIS, 2017

MOUSE

LD50

Unreported

6.0 µg/kg

Gürtler and Horstmann, 1973

MOUSE

LDLo

Oral

30 mg/kg

Ishiguro et al., 1983

RAT

LD50

Intraperitoneal

1.5 µg/kg

Creppy et al., 1980

RAT

LD50

Unreported

5 µg/kg

NTIS, 2017

RAT

LD50

Parenteral

0.336 µg/kg

Strocchi et al., 1979

RAT

LD50

Unreported

4 µg/kg

NTIS, 2017

RAT

LDLo

Oral

30 mg/kg

Ishiguro et al., 1983

GUINEA PIG

LD50

Unreported

0.8 µg/kg

NTIS, 2017

GUINEA PIG

LDLo

Intraperitoneal

0.02 µg/kg

Mosher et al., 1964

RABBIT

LD50

Intratracheal

0.5 µg/kg

NTIS, 2017

RABBIT

LD50

Intravenous

0.54 µg/kg

Christiansen et al., 1994

RABBIT

LD50

Unreported

0.1 µg/kg

NTIS, 2017

RABBIT

LDLo

Oral

500 µg/kg

PCOC, 1966

CAT

LD50

Intratracheal

5 µg/kg

NTIS, 2017

CAT

LD50

Unreported

0.2 µg/kg

NTIS, 2017

DOG

LD50

Intramuscular

0.6 µg/kg

Marhold, 1986

DOG

LD50

Intratracheal

5 µg/kg

NTIS, 2017

DOG

LD50

Unreported

0.6 µg/kg

NTIS, 2017

DOG

LDLo

Unreported

1.6 µg/kg

Fodstad et al., 1979

DOG

LDLo

Intravenous

1.6 µg/kg

Fodstad et al., 1979

SHEEP

LD50

Unreported

0.8 µg/kg

NTIS, 2017

HUMAN

LDLo

Oral

2 mg/kg

PCOC, 1966

HUMAN

LDLo

Oral

0.3 mg/kg

NTIS, 2017

HUMAN

LDLo

Oral

0.9 mg/kg

Kopferschmitt et al., 1983

LD50 = Acute Lethal Dose, LDLo = Lethal Dose Low

an A subunit (mol.wt. 26 000), which inhibits protein synthesis, and a B subunit (mol.wt. 31 000), which binds to cells. Both subunits, as well as intact modeccin, gave single bands on sodium dodecyl sulphate/polyacrylamide-gel electrophoresis, but showed some heterogenity on isoelectric focusing and on polyacrylamide-gel electrophoresis at pH 9.5.

of protein synthesis in a lysate of rabbit reticulocytes, giving 50% inhibition at the concentration of 0.31 mg/ml (Barbieri et al. 1980).

CONCLUSIONS Ribosome-inactivating proteins (RIPs) abrin, ricin, viscumin, volkensin and modeccin are very potent toxins derived from plants. They are extremely toxic for all warm-blooded animals including human and represent potential biological warfare toxin and easy exploitable means for terroristic attack. Especially ricin for its easy availability is alluded as acute terrorist danger very often lately.

A second form of modeccin, not retained by Sepharose 4B, was purified by affinity chromatography on acidtreated Sepharose 6B: this form is subsequently termed modeccin 6B. Modeccin 6B has a molecular weight indistinguishable from that of modeccin 4B, and consists of two subunits of mol.wts. 27 000 and 31 000, joined by a disulphide bond. The subunits were not isolated because of their high insolubility in the absence of sodium dodecyl sulphate. As compared with modeccin 4B, modeccin 6B is slightly less toxic to animals, does not agglutinate erythrocytes, and is a more potent inhibitor

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COMPETING INTERESTS The authors declare that they have no competing interests.

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ACKNOWLEDGMENTS

11. CHEN YL, CHOW LP, TSUGITA A, LIN JY. The Complete Primary Structure of Abrin-a B Chain. FEBS Lett 1992, 309. 115-118.

This work was supported by the long-term organization development plan (University Hospital, Hradec Kralove, Czech Republic).

12. CHESSELL IP, PEARSON RC, HEATH PR, BOWN DM, FRANCIS PT. Selective loss of cholinergic receptors following unilateral intracortical injection of volkensin. Exp Neurol. 1997, 147 (1), 183-191.

SUMMARY

13. CHO H, JAWORSKI J. A portable and chromogenic enzyme-based sensor for detection of abrin poisoning. Biosens Bioelectron. 2014, 54, 667-673.

Biological weapons include infectious agents and toxins. Toxins are poisons produced by living organisms. An important group of toxins are ribosome inactivating proteins (RIPs) of plant or microbial origin that inhibit protein synthesis by inactivating ribosomes. RIPs have been of great scientific interest due to their importance in human health, as both pathogenic agents and therapeutics, but also due to their potential use in biological warfare and bioterrorism. RIPs relevant to bioterrorism include mainly ricin and abrin. Ricin is protein produced in the seeds of the castor oil plant (Ricinus communis). Abrin is protein that has been isolated from the seeds of Abrus precatorius. Both inactivate ribosomes, which results in toxicity because of the inhibition of protein synthesis. Abrin and ricin are substances very toxic to humans in all types of administration, with the exception of oral administration. Symptoms include nausea, diarrhea, tachycardia, hypotension, and seizures. Treatment is supportive, and no antidote exists.

14. CHRISTIANSEN VJ, HSU CH, DORMER KJ, ROBINSON CP. The cardiovascular effects of ricin in rabbits. Pharmacol Toxicol. 1994, 74 (3), 148-152. 15. CONTESTABILE A, FASOLO A, VIRGILI M, MIGANI P, VILLANI L, STIRPE F. Anatomical and neurochemical evidence for suicide transport of a toxic lectin, volkensin, injected in the rat dorsal hippocampus. Brain Res. 1990, 537 (1-2), 279-286. 16. CREPPY EE, LUGNIER AA, DIRHEIMER G. Isolation and properties of two toxic tryptic peptides from ricin, the toxin of Ricinus communis L. (castor bean) seeds. Toxicon. 1980, 18 (5-6), 649-660. 17. CROMPTON R, GALL D. Georgi Markov--death in a pellet. Med Leg J. 1980, 48 (2), 51-62. 18. CUMMINGS RD, L. SCHNAAR R. R-Type Lectins. In: Varki A, Cummings RD, Esko JD, Stanley P, Hart GW, Aebi M, Darvill AG, Kinoshita T, Packer NH, Prestegard JH, Schnaar RL, Seeberger PH, editors. Essentials of Glycobiology, 3rd edition. Cold Spring Harbor (NY): Cold Spring Harbor Laboratory Press; 2015-2017. Chapter 31, 2017.

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25. GASPERI-CAMPANI A, BARBIERI L, LORENZONI E, MONTANARO L, SPERTI S, BONETTI E, STIRPE F. Modeccin, the toxin of Adenia digitata. Purification, toxicity and inhibition of protein synthesis in vitro. Biochem J. 1978, 174 (2), 491-496.

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33. KOPFERSCHMITT J, FLESCH F, LUGNIER A, SAUDER P, JAEGER A, MANTZ JM. Acute voluntary intoxication by ricin. Hum Toxicol. 1983, 2 (2), 239-242.

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35. KRAUSPENHAAR R., S. ESCHENBURG, M. PERBANDT, V. KORNILOV, N. KONAREVA, I. MIKAILOVA, S. STOEVA, R. WACKER, T. MAIER, T. SINGH, A. MIKHAILOV, W. VOELTER, C. BETZEL: Crystal structure of mistletoe lectin I from Viscum album. Biochem. Biophys. Res. Commun. 1999, 257: 418–424.

52. OLSNES S. The history of ricin, abrin and related toxins. Toxicon 2004, 44, 361–370. 53. PAPALOUCAS M, PAPALOUCAS C, STERGIOULAS A. Ricin and the assassination of Georgi Markov. Pak J Biol Sci. 2008, 11 (19), 2370-2371.

36. KUCA K, POHANKA M. Chemical warfare agents. EXS. 2010, 100, 543-558.

54. PATOCKA J. Abrin and ricin - two dangerous poisonous proteins. ASA Newsletter 2001, 85, 205-208.

37. KUMAR MS, KARANDE AA. A monoclonal antibody to an abrin chimera recognizing a unique epitope on abrin Achain confers protection from abrin-induced lethality. Hum Vaccin Immunother. 2016, 12 (1). 124-131.

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38. LARSSON SL, SLOMA MS, NYGARD O. Conformational changes in the structure of domains II and V of 28S rRNA in ribosomes treated with the translational inhibitors ricin or alpha-sarcin. Biochem. Biophys. Acta 2002, 1577, 53– 62.

57. PATOCKA J, STREDA L. Plant toxic proteins and their current significance for warfare and medicine. J Appl Biomed. 2003, 1, 141-147.

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74. STIRPE F, GASPERI-CAMPANI A, BARBIERI L, LORENZONI E, MONTANARO L, SPERTI S, BONETTI E. Inhibition of protein synthesis by modeccin, the toxin of Modecca digitata. FEBS Lett. 1977, 85 (1), 65-67.

62. PITTMAN PR, REISLER RB, LINDSEY CY, GÜEREÑA F, RIVARD R, CLIZBE DP, CHAMBERS M, NORRIS S, SMITH LA. Safety and immunogenicity of ricin vaccine, RVEc™, in a Phase 1 clinical trial. Vaccine . 2015, 33 (51), 7299-7306.

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79. WANG J, GAO S, XIN W, KANG L, XU N, ZHANG T, LIU W, WANG J. A novel recombinant vaccine protecting mice against abrin intoxication. Hum Vaccin Immunother. 2015, 11 (6), 1361-1367.

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83. XU C, LI X, LIU G, XU C, XIA C, WU L, ZHANG H, YANG W. Development of ELISA and Colloidal Gold-PAb ConjugateBased Immunochromatographic Assay for Detection of Abrin-a. Monoclon Antib Immunodiagn Immunother. 2015, 34 (5), 341-345.

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A RT ICLES

Physical Fitness as a Predisposing Factor for Injuries and Excessive Stress Symptoms during Basic Military Training.* # By S. SAMMITO∑ ∏ and L. MÜLLER-SCHILLING∏ π. Germany

Stefan SAMMITO Lieutenant-Colonel (MC) Ass.- Prof. Dr. med. habil. Stefan SAMMITO, MD. Specialist for Occupational Medicine, General Medicine, additional specialisation in Emergency, Sport and Nutrition Medicine. He was born in 1978. 1998 - entering the navy. 1999-2005 - medicine studies at the Medical Universities at Düsseldorf and Bochum, Germany. 2005-2007 - Military Hospital Bad Zwischenahn, Internal Medicine and Anesthesia. 2007-2010 - Major Medical Clinic with Speciality Services Augustdorf, Physician in the 21th tank brigade. 2010-2012 - Bundeswehr Institute of Sport Medicine, Warendorf. 2012 - Central Institute of Medical Services German Armed Forces Koblenz, Department IV – Military Ergonomy and Exercise Physiology. 2012-2014 - Bundeswehr Medical Service Headquarters, Head of Section Military Medicine Research. 2014-2016 - Institute for Teacheręs Health at the Institute of Occupational, Social and Environmental Medicine at the University Medical Center of the Johannes Gutenberg University of Mainz. 2016-2019 - Bundeswehr Medical Service Headquarters, Head of Section Health Promotion, Sport and Nutrition Medicine. Since 02/2019 - Air Force Center of Aerospace Medicine, Department Research and Development. DEPLOYMENT 01-06/2008: Coy Commander SanEinsStff IV NRF 10, 07-09/2008: Emergency Doctor ISAF, 09/2009 – 01/2010: Commander of Military Hospital KFOR.

RESUME La condition physique étudiée comme facteur de prédisposition aux blessures et aux symptômes liés à une charge d’entraînement excessive au cours de l’entraînement militaire. Obj ectif : Le but de l’entraînement militaire initial (BMT) est de permettre aux recrues d’acquérir les savoirs militaires de base et de développer une forme physique adaptée. Cet entraînement s’accompagne d’une contrainte physique accrue et d’un risque de blessure et s = de symptômes liés à une charge d’entraînement excessive (I & ESS). L’obj ectif de cette étude était d’évaluer dans quelle mesure le niveau de condition physique existant au début de l’instruction militaire pouvait avoir une influence sur l’I & ESS et sur les exemptions de service qui en résultent. Méthodes : Les données concernant 774 suj ets mâles (âgés de 20,5 ± 2,2 ans) relevées dans 8 cantonnements voisins ont été analysées. Les diagnostics portés par les médecins d’unités au cours de leurs consultations ont été étudiés à la recherche d’I & ESS et les types de blessures ainsi que les arrêts de maladie prescrits ont été documentés. Le niveau de condition physique de chaque trimestre a été établi par le nombre de points obtenus lors du test standard d’évaluation (BFT). Cette catégorisation a été utilisée pour l’analyse du nombre de j ours perdus pour raisons physiques. Résultats : Au total, 255 des 774 suj ets (32,9 %) avaient consulté le médecin d’unité pour I & ESS. 60 % des blessures étaient aux membres inférieurs. Il y avait une augmentation significative du nombre de j ours d’inaptitude dans le groupe ayant la condition physique la moins bonne.

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Conclusions : L’étude a révélé que le niveau de condition physique existant au début du BMT a une influence significative sur la durée d’inaptitude liée à l’I & ESS. Le pourcentage élevé de blessures des membres inférieurs montre l’intérêt particulier qu’il y aurait à réduire les I & ESS pour éviter d’altérer le contenu de l’entraînement militaire initial.

KEYWORDS: Military, Injury, Training, Excessive stress symptoms, Physical fitness. MOTS -CLÉS : Militaire, Blessure, Entraînement, Symptômes liés à une charge excessive, Condition physique . International Review of the Armed Forces Medical Services

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Fig. 1: Results of a p revalence study of the US-Army 14 .

INTRODUCTION In some professions, a high level of physical fitness is a prerequisite for performing profession-related tasks. A work-related high level of physical fitness is a key component for meeting workplace demands especially in the police, fire brigade and armed forces3, 9, 16, 28, 29 . The demands, however, are of a complex nature, since soldiers must conduct task-specific activities (such as extinguishing a fire, handling a firearm safely) beside the purely physical component. Already about ten years ago, results obtained by the Department for Ergonomics and Exercise Physiology of the former Central Institute of the Bundeswehr Medical Service, Koblenz, revealed that apart from the physical demands to be met at different workplaces in the Army and medical units, the other demands are high and always complex23, 30, 31.

Using a model, the objective of BMT can be summarised in a simplified way in three factors: • Acquisition of general basic military skills; • Improvement of physical fitness and • Understanding of the military order.

In addition, the increasing lack of exercise among juveniles and young adults results in a reduction in physical resilience among potential first-time employees7, 11, 20 . Employees are especially unable to reliably perform complex activities like those mentioned above when they take up a new occupation. This is why first-time employees in the military initially undergo several months of BMT. Injuries and excessive stress symptoms (I&ESS) during BMT can reduce the time available for training and thus its overall quality significantly. American and Israeli studies have isolated various risk factors that influence the incidence of I&ESS during basic combat training (BCT) 1, 2, 4, 12, 17, 21, 22, 25, 26, 27 . Besides other risk factors, such as being female 17, 21 underweight or overweight4, 12, a smoker5, 17, 19, of a certain age12, 19 or belonging to a specific ethnic group5, 12, 19, 26, physical fitness at the beginning of the training period has been revealed to be a key predictor. Findings of the US armed forces show examples of how we can handle this modifiable risk factor in terms of a prevention strategy with, at the same time, better performance of course-related tasks. It was found out that US Army recruits were more likely to get hurt during Basic Combat Training (BCT), by a factor of 1.5 to 1.7, when they had not passed the initial Advanced Physical Fitness Test (APFT). Furthermore, the rate of recruits without passing initial APFT who finalised the BCT (52% to 59%) was lower than of those recruits who had passed the initial APFT (78% to 87%) 14 (see Figure 1). After the introduction of an eight-week prefitness training for recruits who had not passed the APFT with the overall objective of integrating them into BCT until the end of this pre-training, the risk of injury could be lowered significantly and, at the same time, the rate of recruits who successful finalised the BCT could be improved in an impressive way - from 59% to 83% with male recruits and from 52% to 69% with female recruits 14 .

The first two objectives especially increase the risk of I&ESS, which in turn as a negative feedback due to lost days have an adverse effect on the achievement of the BMT objectives (see Fig ure 2). The primary objective in this regard should be to plan and carry out training periods for the improvement of physical fitness and for the acquisition of general basic military skills in such a way that, on the one hand, the training objective can be reached, but, on the other hand, the strain on the recruits is such that the risk of I&ESS is reduced. Fig. 2: Modell f or higher risk f or inj ury and excessive stress symp toms and the negative f eedback to the goal of basic military training.

∑ Division VI, Preventive Medicine of the Bundeswehr Medical Service Headquarters. ∏ Otto-von-Guericke-University Magdeburg, Medical Faculty, Department of Occupational Medicine. π Bundeswehr Hospital Berlin. Correspondence: Lieutenant-Colonel Assistant Professor Dr. Stefan Sammito Air Force Center for Aerospace Medicine Flughafenstraße 11 D-51147 Köln, Germany. E-mail: stefansammito@bundeswehr.org

However, the first months of military training in the Bundeswehr and US armed forces are very different with regard to duration and kind of training. Even within the armed forces, BMT is different depending on the future assignment.

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* With courtesy of Editor of Wehrmedizinische Monatsschrift (WMM) . This article was published in Wehrmedizinische Monatsschrift, Vol. 2/2019. #

This study contains data and results from the doctoral thesis by Mrs Müller-Schilling at the Medical Faculty of Otto-von-Guericke-University Magdeburg.

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Table 1: Comparison of the anthrop ometric data of those who participated in the study and those who did not.

Unfortunately, the findings of the working group led by KNAPIK et al. cannot be directly applied due to the above-mentioned differences between the US armed forces and the Bundeswehr. However, the incidents that happened in summer 2017, especially in the officer candidate battalion in Munster, show the importance of a scientific discussion of this topic.

PARTICIPANTS

The objective of this study was therefore to determine the influence of the initial level of fitness of recruits on the incidence of I&ESS during BMT in the Bundeswehr.

NUMBER

774

383

AGE [YEARS]

20.5±2.2

20.6±3.2

0.883

HEIGHT [CM]

179.6±7.0

179.2±6.6

0.437

BODY WEIGHT [KG]

75.9±11.2

76.6±10.4

0.418

BMI [KG/ M2]

23.5±2.8

23.8±2.7

0.079

BODY

METHODOLOGY

NON PARTICIPANTS

Table 2: Allocation of participating recruits to the various quarters and training companies with the respective total numbers of all the recruits trained during this quarter, 5./203 = Tank Battalion 203 training company, 5./212 = Armoured Inf antry Battalion 212 training company.

During eight coherent training quarters (IV/2012 to III/2014), data on the Bundeswehr recruits who participated in the study was taken from their health files and from the standard Basis-Fitness-Test (BFT)6, 20 that they were put through at the start of their BMT. The recruits then underwent their basic training in the training companies of Tank Battalion 203 (5./203) or of Armoured Infantry Battalion 212 (5./212) which are based at the same barracks in Augustdorf, North RhineWestphalia, Germany (see Figure 3). Fig. 3: The method of this study.

QUARTER

5./203

5./212

IV/2012

53 / 105 (50%)

119 / 133 (89%)

I/2013

39 / 69 (56%)

71 / 81 (88%)

II/2013

51 / 65 (78%)

40 / 55 (73%)

III/2013

57 / 123 (46%)

37 / 56 (66%)

IV/2013

64 / 121 (53%)

66 / 94 (70%)

I/2014

53 / 74 (72%)

44 / 53 (83%)

II/2014

No BMT

29 / 58 (50%)

III/2014

51 / 70 (73%)

No BMT

TOTAL

368 / 627 (59%)

406 / 530 (87%)

BMT = Basis Military Training.

Two criteria for inclusion in the study were the successful completion of BMT and the issue of a written statement confirming that participation in the study was vo luntary. In total, 774 subjects (age 20.5 ± 2.2 years, body-mass index [BMI] 23.5 ± 2.8 kg/m²) were included in the study. This means that 67% of all the recruits undergoing their BMT during that period took part in it. There were no significant differences in the ages and body measurements of those who participated in the study and the recruits who did not participate (see Table 1). Table 2 shows the various quarters and training companies to which the participants were allocated.

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The medical data were reviewed for periods of absence from duty due to I&ESS, and the periods were documented. As a specific military feature, periods of full administrative leave were documented (in the civilian health system, such leave corresponds to a general inability to work) alongside periods of limited fitness for duty (e.g., exemption from outside duty activities, marching, physical training or field duty). Sub-analysis groups were defined for I&ESS that were

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/attributed to general military training in the field, obstacle course training, self-protection training in CBRN hazard situations, marksmanship training (all four categorised as general military training) and mandatory physical training. Acoustic trauma incurred during marksmanship training and blisters incurred during marches were excluded. The initial level of physical fitness was documented on the basis of the BFT results 6, 20 . This standard test consists of an 11 x 10-metre sprint, a flexed arm hang and a 1000-metre run and is always conducted at the beginning of BMT. Based on the BFT results of 719 recruits, fitness levels were categorised by quartiles, and the lost days due to I&ESS within each quarter were then analysed by means of ANOVA and a subsequent Dunnett-T post-hoc analysis. Furthermore, the I&ESS were analysed with regard to the body regions affected and their incidence during the various kinds of training. For the exposition analysis, the numbers of I&ESS were put into relation with the periods of exposure. The calculations of the perio ds of exposure were based on the number of hours for which each kind of training was scheduled to be conducted in the duty rosters, and lost days due to illness were factored in for each recruit.

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This study was approved by the ethics commission of Otto-von-Guericke-University Magdeburg (file no: 111/ 12).

7.6 hours for self-protection training in CBRN hazard situations, 7.0 hours for obstacle course training and 24.5 hours for mandatory physical training.

RESULTS

The analysis of I&ESS cases per 1,000 hours of specific training showed an incidence of 1.09 I&ESS/ 1,000 hours during general military training and 4.17 I&ESS/ 1,000 hours during mandatory physical training. A sub-analysis of the incidence of I&ESS during general military training, which comprised marksmanship training, CBRN defence training, obstacle course training and field training, revealed that a high number of I&ESS were incurred during obstacle course training, while no cases were incurred during marksmanship and CBRN defence training (see Figure 5). An increase in the number of I&ESS was also observed during the summer and winter quarters, especially as a result of field training and mandatory physical training.

255 subjects (32.9% of the total sample) reported to the unit physicians with 397 I&ESS during BMT. The average sick leave was 6.0 ± 7.9 days per recruit, and 60% of all the injuries were lower extremity injuries (see Figure 4). The trunk (22%), upper extremities (13%) and the head (4%) were clearly less affected. The majority of the I&ESS (57 were incurred during general military training. 10% of I&ESS were attributed to mandatory physical training, while the physicians documented no specific causes for the remaining 33%. During the study and in consideration of the fitness for duty of the participants, a total of 283,831.1 hours of general military training were conducted, the largest share of which was assigned to marksmanship training (138,082.3 hours) and field training (134,411.4 hours). Obstacle course training (5,446.1 hours) and CBRN defence training (5,891.3 hours) constituted only a minor share of the training time. Mandatory physical training, amounting to 18,959.8 hours, also only made up a rather small part of the total time for BMT. The time each recruit spent on training was 178.4 hours for marksmanship training, 173.7 hours for field training,

The ANOVA analysis revealed that physical fitness had a significant influence on the length of absence from duty in association with the total number of lost days due to I&ESS. The average number of lost days was significantly hig he r in the quartile with the lowest level of fitness than in the other quartiles. Fig . 5: Number of inj uries p er 1,000 hours of activity in total and f or the diff erent seasons, with red highlighted season with high risks.

Fig . 4: Distribution of inj uries by body regions, n = 397.

DISCUSSION AND OUTLOOK The present study shows that for Bundeswehr BMT, the initial level of physical fitness has a significant influence on lost days due to I&ESS. This was particularly the case for the quartile with the least fit recruits. Furthermore, an increase in lower extremity injuries and a seasonal increase in injuries in general were observed. Compared to data collected in 2008/924, BMT in its present form is estimated to cause substantially less injuries, since a decrease in the average number of injuries from 2.27/ 1,000 hours to 1.45/ 1,000 hours has been documented. This is probably largely due to the implementation of a new marksmanship training concept in BMT. This concept provides for a significantly higher number of training hours on the ranges, with the result

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that the number of hours set aside for field training has been reduced and reallocated for marksmanship training, during which particularly few injuries are caused and hence less I&ESS are incurred on the whole. This was also revealed by the data analysis. This study has shown that general military training was the main cause of injuries (57% of all injuries). Considering the high total number of training hours, however, the incidence of injuries per 1,000 hours, with the average being 1.09/1,000 hours, is rather low. Moreover, the division of general military training into four sub-categories reveals that there are training-specific differences involving varying risks of injury. Marksmanship and CBRN defence training have proved to cause particularly few injuries, with no I&ESS having been found to be incurred from it. In contrast, at more than 18 I&ESS/1,000 hours in the winter quarters, the very high injury rate for obstacle course training stands out. Measured against the low number of hours allocated for obstacle course training, however, the injuries incurred in winter carry considerably less weight in the overall analysis. Even if a reduction in the high injury rate makes sense from the preventive medicine point of view, the obstacle course is a particularly good form of training for various movement sequences that are specifically required in military operations. What is important in this context is to weigh the physiological advantages offered by the specific training against the high injury rate. Furthermore, an increase in I&ESS was noted during individual quarters. It is conceivable that this was due to the weather, as the influence of the weather on the surface conditions has already been identified as a cause of an increased injury rate during mandatory physical training in a study on injuries incurred during mandatory physical training at the same base8. Since general military training for the most part takes place outside, it is likely that (weather-related) changes in surface conditions in the winter months (due to snow and ice) and the summer months (highest precipitation rates of the year) may also be the reason for an increase in the risk of injury. The high number of I&ESS noted during the summer months can also be ascribed to other climatic conditions, such as the effects of higher temperatures on the body, which speed up the rate at which recruits become exhausted and increase the risk of injury, as found among recruits in the US military13.

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The analysis furthermore showed that the level of fitness of the recruits at the start of BMT had a significant influence on the incidence of I&ESS. The overall number of lost days for recruits with the lowest level of fitness was significantly higher than that for recruits with a higher level of fitness. The increase in the overall n umber of lost days also resulted in a loss of training time, and this clearly hampers the progress made in training by individual recruits. Moreover, lost days must be expected to lead to a further lowering of a recruit’s level of fitness (at that time) and, in turn, an increase in the risk of their incurring (additional) I&ESS. This can

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lead to a further rise in the difference in physical fitness betwe en recruits who incur injuries and others who do not lose days. This result tallies with the findings of the US armed forces 14, 17. To reduce the incidence of I&ESS, the level of fitness of recruits was raised by putting them through pre-training, and this significantly lowered the incidence of injuries during BCT14, 15. It can be assumed that this would also be the case with Bundeswehr recruits. A pilot project of the German Army aiming at an adjustment of BMT which was launched with the Training and Support Company of Armoured Infantry Battalion 401 in Hagenow in the summer of 2018 has already taken up certain aspects of this idea. Instead of introducing pre-training, however, the percentage of physical training has been increased and concentrated within the first six weeks of basic training. By dividing recruits into performance groups, their different levels of physical fitness are taken into account. The goal is for all recruits to reach a minimum grade of 4 in the BFT conducted after the first six weeks of training so that they can all embark on the next training phase, which has its focus on general military training. This pilot run was scientifically supported by the Bundeswehr Institute of Preventive Medicine. The results of the pilot phase support the approach pursued to date and they show how the physical fitness of recruits can be improved by adjusting the training10. The introduction of these new standards in all training facilities of the Bundeswehr Army18 is thus a logical and consistent step with a view to improving the physical fitness of recruits and reducing I&ESS at the same time. Conflicts of interest The authors declare that there are no conflicts of interest with regard to the guidelines of the International Committee of Medical Journal Editors.

ABSTRACT Objective: The purpose of basic military training (BMT) is to enable recruits to acquire basic military skills and develop the required physical fitness. This training is accompanied by increased physical strain and the risk of injury and excessive stress symptoms (I&ESS). The objective of this study was to examine the extent to which the level of physical fitness at the beginning of basic military training affects the incidence of I&ESS and resultant absences from duty. Method: The data of a total of 774 male subjects (age 20.5 ± 2.2 years) from 8 subsequent BMT quarters was analysed. The medical diagnoses made during the consulting hours of the unit physicians were reviewed for I&ESS and the kinds of injuries incurred as well as the sick leave pronounced were documented. The level of physical fitness per quarterly period was categorised by means of the total numbers of points achieved during the standard basic fitness test (BFT). This categorisation

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was finally used as a basis for an analysis of the lost days in relation to the level of physical fitness.

for physical activity promotion in German Children. Dtsch Z Sportmed 2012; 63: 94-101.

Results: In total, 255 of 774 subjects (32.9%) reported to the unit physicians with I&ESS. 60% of all the injuries were lower extremity injuries. There was a significant increase in the length of absence from duty among the group with the lowest level of physical fitness.

12. KNAPIK J, MONTAIN SJ, MCGRAW S, GRIER T, ELY M, JONES BH: Stress fracture risk factors in Basic Combat Training. Int J Sport Med 2012; 33: 940-946. 13. KNAPIK JJ, CANHAM-CHERVAK M, HAURET K, LAURIN MJ, HOEDE-BECKE E, CRAIG S, MONTAIN SJ: Seasonal variations in injury rates during US Army Basic Combat Training. Ann Occup Hyg 2002; 46: 15-23.

Conclusions: The analysis revealed that the level of physical fitness at the beginning of BMT has a significant influence on the length of absence from duty due to I&ESS. The high percentage of lower extremity injuries shows the specific relevance of a reduction of I&ESS to avoid limitations during BMT which otherwise may occur.

14. KNAPIK JJ, CANHAM-CHERVAK M, HOEDEBECKE E, HEWITSON WC, HAURET K, HELD C, SHARP MA: The fitness training unit in U.S. Army basic combat training: Physical fitness, training outcomes, and injuries. Mil Med 2001; 166: 356-361. 15. KNAPIK JJ, HAURET KG, ARNOLD S, CANHAM-CHERVAK M, MANSFIELD AJ, HOEDEBECKE EL, McMILLIAN D: Injury and fitness outcomes during implementation of physical readiness training. Int J Sports Med 2003; 24: 372-381.

REFERENCES 11. BECK TJ, RUFF CB, SHAFFER RA, BETSINDER K, TRONE DW, BRODINE SK: Stress fracture in military recruits: Gender differences in muscle and bone susceptibility factors. Bone 2000; 27: 437-444.

16. KNAPIK JJ, REYNOLDS KL, HARMAN E: Soldier Load Carriage: Historical, Physiological, Biomechanical and Medical Aspects. Mil Med 2004; 169: 45-56.

12. CAMERON KL, OWENS BD (eds): (2016, eds.) Musculoskeletal injuries in the military. New York: Springer, 2016.

17. KNAPIK JJ, SHARP MA, CNHAM-CHERVAK M, HAURET K, PATTON JF, JONES BH: Risk factors for training-related injuries among men and women in basic combat training. Med Sci Sports Exerc 2001; 33: 946-954.

13. ELSNER KL, KOLKHORST FW: Metabolic demands of simulated fire-fighting tasks. Ergonomics 2008; 51: 1418-1425.

18. Kommando Heer: Vorbefehl für die Umsetzung des neuen Ausbildungskonzeptes „Sport/KLF” in den GA Einheiten und Führungsnachwuchsbataillonen des Heeres in 2019. Strausberg, 5. November 2018.

14. FINESTONE A, MILGROM C, EVANS R, YANOVICH R, CONSTANTINI N, MORAN DS: Overuse injuries in female infantry recruits during low-intensity basic training. Med Sci Sports Exerc 2008; 40: S630-S635.

19. LAPPE JM, STEGMANN MR, RECKER RR: The impact of lifestyle factors on stress fractures in female Army recruits. Osteoporos Int 2001; 12: 35-42.

15. FRIEDL KE, NOUVO JA, PATIENCE TH, DETTORI JR: Factors associated with stress fracture in young army women: Indications for further research. Mil Med 1992; 157: 334-338.

20. LEYK D, ROHDE U, GORGES W et al.: Physical performance, body weight and BMI of young-adult in Germany 2000-2004: results of the Physical-Fitness-Test Study. Int J Sport Med 2006; 27: 642-647.

16. Generalinspekteur der Bundeswehr: Weisung zur Ausbildung, zum Erhalt der Individuellen Grundfertigkeiten und zur körperlichen Leistungsfähigkeit (Weisung IGF/KLF). Berlin, 2013.

21. MacLEOD MA, HOUSTON AS, SANDERS L, ANAGNOSTOPOULOS C: Incidence of trauma related stress fractures and shin splints in male and female army recruits: Retrospective case study. BMJ 199; 318: 29.

17. GRAF C, DORDEL S, KOCH B, PREDEL H-G: Bewegungsmangel und Übergewicht bei Kindern und Jugendlichen. Dtsch Z Sportmed 2006; 57: 220-225. 18. GUNDLACH N, SAMMITO S, BÖCKELMANN I: Prädisponierende Faktoren beim Dienstsport. In: Tagungsband zur 51. Wissenschaftlichen Jahrestagung der Deutschen Gesellschaft für Arbeitsmedizin und Umweltmedizin e. V. (DGAUM), 9.-12. März 2011 in Heidelberg: 413-416.

22. RAUH MJ, MACERA CA, TRONE DW, SHAFFER RA, BRODINE SK: Epidemiology of stress fracture and lowerextremity overuse injury in female recruits. Med Sci Sports Exerc 2006; 38: 1571-1577. 23. ROHDE U, ERLEY O, RÜTHER T, WUNDERLICH M, LEYK D: Leistungsanforderungen bei typischen soldatischen Einsatzbelastungen. Wehrmed Mschr 2007; 51: 138-142.

19. HOLMÉR I, GAVHED D: Classification of metabolic and respiratory demands in firefighting activity with extreme workloads. Appl Ergon 2007; 38: 45-52.

24. SAMMITO S: Risk of injury during combat training – Assessment of the relative rate of injuries during four successive basis training periods. Wehrmed Mschr 2011; 55: 90-93.

10. Institut für Präventivmedizin der Bundeswehr: „Steigerung der KLF vom ersten Tag an – Neustrukturierung der Grundausbildung”. Ergebnisbericht zu den Untersuchungen des Instituts für Präventivmedizin der Bundeswehr vom 13. November 2018.

25. SCHMIDT BRUDVIG TJ, GUDGER TD, OBERMEYER L: Stress fractures in 295 trainees: A one-year study of incidence as related to age, sex, and race. Mil Med 1983; 148: 666-667.

11. KETTNER S, WIRT T, FISCHBACH N, KOBEL S, KESZTYÜS D, SCHREIBER A, DRENOWATZ C, STEINACKER JM: Nesessity

26. SHAFFER RA, RAUH MJ, BRODINE SK, TRONE DW, MACERA CA: Predictors of stress fracture susceptibiliy in

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young female recruits. Amer J Sport Med 2006; 34: 108115. 27. TRONE DW, CIPRIANA DJ, RAMAN R, WINGARD DL, SHAFFER RA, MACERA CA: Self-reported smoking and musculoskeletal overuse injury among male and female U.S. Marine Corps Recruits. Mil Med 2014; 179: 735-743. 28. VON HEIMBURG ED, RASMUSSEN AKR, MEDBØ JI: Physiological responses of firefighters and performance predictors during a simulated rescue of hospital patients. Ergonomics 2006; 49: 111-126.

during simulated firefighting tasks in a high-rise structure. Special section: behavioural effects and drive-vehicle-environment modelling in modern automotive systems. Appl Ergon 2010; 41: 251-259. 30. WUNDERLICH M, MÖDL A, RÜTHER T, JACOB R, EGER T, LEYK D: Analyses of spine loads in medical occupations. New possibilities for prevention and ergonomics. Präv Gesundheitsf 2011; 6: 58-66. 31. W UNDERLICH M, RÜT HER T, ERLEY O, ERREN, T, PIEKARSKI C, LEYK D: Analyse von Wirbelsäulenverletzungen am Arbeitsplatz: Bewertung der Oberkörperhaltung von Hubschrauberpiloten. Arbeitsmed Sozialmed Umweltmed 2010; 45: 329.

29. WILLIAMS-BELL FM, BOISSEAU G, McGILL J, KOSTIUK A, HUGHSON RL: Air management and physiological responses

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Interdisciplinary Treatment of Spinal Injuries and Bone Metastases Using 3D Robotic Fluoroscopy.* By K. NESTLER∑, B. V. BECKER∑, D. A. VEIT∑, E. KOLLIG∏ and S. WALDECK∑. Germany

Kai NESTLER Kai NESTLER (1987) received his Dr. med. from the University of Bonn, Germany in 2015 and holds a Master in Health Economics (Master of Health Business Administration - University of Erlangen – Nuremberg). He is a physician at the Department of Radiology at the German Armed Forces Central Hospital, Koblenz, Germany and a senior research associate at the Bundeswehr Institute for Preventive Medicine, Koblenz, Germany.

RESUME Traitement Interdisciplinaire par fluoroscopie assistée par robot RD dans le traitement des blessures vertébrales et des métastases osseuses. Les progrès rapides des techniques radiologiques et de la robotique ouvrent des nouvelles perspectives de traitement interdisciplinaire dans des indications de médecine interne ou de chirurgie, qui restaient j usque-là du domaine de la spécialité. Deux cas d’atteintes vertébrales traités à l’hôpital central de la Bundeswehr de Coblence sont présentés pour illustrer cette utilisation interdisciplinaire de la radiologie assistée par robot. Les auteurs envisagent aussi l’applicabilité de ces techniques en opérations.

KEYWORDS: Percutaneous vertebroplasty, Kyphoplasty, Needle guidance, Dyna CT, Radiofrequency-targeted vertebral augmentation. MOTS -CLÉS : Vertebroplastie percutanée, Kyphoplastie, Guidage de l’aiguille, Dyna CT, Renforcement vertébral ciblé par radiofréquence.

INTRODUCTION

Interdisciplinary minimally invasive therapy, e.g. kyphoplasty or spinal fusion using fluoroscopic x-ray guidance, is increasingly being employed by physicians 2 . This is a result of the progress made in this therapeutic approach and the effectiveness of this low-risk treatment and is reflected in the increased number of operations.

The rapid progress in radiological technology opens up new opportunities for the interdisciplinary treatment of conditions that were previously managed by a single area of medical specialisation. A good example of this approach is the treatment of spinal conditions such as traumatic fractures and potential vertebral fractures caused by metastatic disease. Such conditions are now being managed by robot-assisted angiography at the Bundeswehr Central Hospital in Koblenz.

∑ Department of Radiology, of the Bundeswehr Central Hospital in Koblenz. ∏ Department of Trauma Surgery and Orthopaedics, of the Bundeswehr Central Hospital in Koblenz. Correspondence: Dr. Kai NESTLER Squadron Leader (MC) Bundeswehr Central Hospital, Koblenz Department of Radiology Rübenacher Str. 170, D-56072 Koblenz, Germany Email: kai1nestler@bundeswehr.org

Problem

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There is a high incidence of traumatic spinal injuries caused by high-energy blunt or penetrating impact 6 . Such injuries are seen in deployed settings following attacks on armoured vehicles5. Spinal metastatic disease occurs in 60-70% of patients with systemic cancer7 and is thus also found in soldiers.

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* With courtesy of the Editor of Wehrmedizinische Monatsschrift. This article was published in German in Wehrmedizinische Monatsschrift 2019; 63(2):86-88.

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Robot-assisted fluoroscopy expands previous treatment options and makes surgery more accurate with fewer complications. It does not involve the restrictions of intraoperative fluoroscopy using a conventional C-arm8 (Figure 1).

frequency is used to activate high-viscosity cement that then hardens. Combined with exact position control, this procedure reduces risks such as extraosseous cement leakage9 .

Figure 1: Robot-assisted ang iograp hy system.

This highly precise intervention also enables the targeted management of osseous metastases in order to prevent and treat pathological fractures in the spinal and pelvic areas. An interdisciplinary tumour board decides on the treatment, which is then conducted on a multidisciplinary basis. In this context, radiofrequency ablation increases the treatment options available, as a robot can assist with the exact placement of the probe.

CASE REPORTS We present the cases of two patients who received interdisciplinary treatment with minimally invasive technology and robot-assisted fluoroscopy. One patient had a traumatic vertebral body injury, the other one had painful osseous metastases that threatened the stability of the spine. Neither patient experienced complications. Peri-interventional Dyna CT made it possible to assess the outcome of treatment even before the intervention was completed.

Procedure Percutaneous vertebroplasty is a minimally invasive operation which uses fluoroscopic x-ray guidance to inject bone cement to stabilise vertebral bodies. With the patient in a prone position, a needle is advanced through the pedicle and into the vertebral body by radiologists and trauma surgeons/orthopaedists working in an interdisciplinary team. A robot-assisted flat panel detector angiography system makes possible peri-interventional 3D imaging, what is known as Dyna computed tomography (Dyna CT). Access can thus be planned in all dimensions and monitored during surgery. In addition to exactly showing the access route by CT, this system uses a laser to project the correct angulation at skin level (Figure 2). This allows the vertebral body to be punctured safely and exactly.

Case 1 Traumatic fracture of the 12th thoracic vertebral body Soldier, aged 37, after a fall Figure 3A shows an endplate trauma fracture of the anterior edge. A dual energy CT was used to visualise the new vertebral oedema (Figure 3B). A 3D reconstruction (Figure 3C) shows a wedge-shaped vertebral body with a wide base. Dyna CT was used for three-dimensional planning of the surgical access route. A trocar was inserted through the vertebral pedicle and into the vertebral body by means of fluoroscopic needle guidance (Figure 4A). Bone cement was then injected into the vertebral body, and the endplate was gradually raised (Figure 4B).

A probe is then used to prepare the vertebral body. The cavities created are filled by way of radiofrequency-targeted vertebral augmentation4 . In this procedure, radioFigure 2: Use of a laser to mark the surgical access route.

A 3D rotational data set was generated for a final assessment and showed that the vertebral body was sufficiently filled, the endplate was successfully raised, and the position of intravertebral cement was suitable (Figure 4C). ∑ Department of Radiology, of the Bundeswehr Central Hospital in Koblenz. ∏ Department of Trauma Surgery and Orthopaedics, of the Bundeswehr Central Hospital in Koblenz. Correspondence: Dr. Kai NESTLER Squadron Leader (MC) Bundeswehr Central Hospital, Koblenz Department of Radiology Rübenacher Str. 170, D-56072 Koblenz, Germany Email: kai1nestler@bundeswehr.org * With courtesy of the Editor of Wehrmedizinische Monatsschrift. This article was published in German in Wehrmedizinische Monatsschrift 2019; 63(2):86-88.

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Figure 3: A : Fracture of the 12th thoracic vertebral body. B: Dual energy CT scans with vertebral oedema. C: 3D visualisation by means of volume rendering .

Figure 5: A : Osteolytic metastasis of the right sacrum (arrow); treatment by means of radiof requency ablation. B-D: Radiof requency-targeted vertebral augmentation to f ill the aff ected area and to stabilise the p elvis by screw f ixation of the sacroiliac j oint.

Figure 4: A : Virtual marking of the surgical access route. B: Insertion of bone cement. C: Final assessment by Dyna CT shows suff icient f illing of the vertebral body and successf ul raising of the endp late.

Auxiliary systems such as needle guidance allow surgeons with less practical experience to perform safe surgery. In addition to their timely use in Bundeswehr hospitals after aeromedical evacuation, such systems could also be used in the future to expand treatment options in deployed settings.

ABSTRACT

Case 2

The rapid prog ress of radiological technology and robotics opens up new opportunities for the interdisciplinary treatment of surgical and internal medicine conditions that thus far have been managed by a single area of specialisation.

Osseous metastasis of the sacrum which may have compromised spinal stability Female patient, aged 58, with osteolytic bone metastases from non-small-cell lung cancer. Figure 5A shows painful osseous metastases on the right side of the sacrum which may have compromised spinal stability. The tumour board decided on multidisciplinary treatment.

Two case studies of vertebral body injuries in patients treated at the Bundeswehr Central Hospital in Koblenz are used to demonstrate the opportunities presented by the interdisciplinary use of robot-assisted radiological systems. The authors also discuss how this technology could be used to treat mission-related injuries.

To treat the lytic lesion, a probe was first placed using robot-assisted radiofrequency ablation. Radiofrequencytargeted vertebral augmentation was performed via a lateral access route to stabilise the affected area (Figure 5C). The pelvis was stabilised immediately afterwards by screw fixation of the sacroiliac joint via the lateral iliac bone (Figures 5B – D). Stabilisation and a substantial reduction in pain were achieved by the combined therapy.

LITERATURE 1. BAROUD G, CROOKSHANK M, BOHNER M: High-viscosity cement significantly enhances uniformity of cement filling in vertebroplasty: an experimental model and study on cement leakage. Spine 2006; 31 (22): 2562-2568. 2. Coronel EE, LIEN RJ, ORTIZ AO: Postoperative spine imaging in cancer patients. Neuroimaging Clinics 2014; 24 (2) : 327-335.

WAY AHEAD

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The treatment of complex conditions demands increased interdisciplinary cooperation, particularly on account of the rapid technical progress made in robotassisted fluoroscopic systems. The cases presented here show that low-risk operations with good outcomes are possible. Complications, particularly nerve and vascular injuries, and the risk of cement leakage are reduced 1. The interdisciplinary approach also broadens the range of treatment options and opens up additional opportunities for using osteosynthesis3 . Especially peri-interventional assessments by means of Dyna CT can lead to new uses in future.

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3. DOERFLER A, GÖLITZ P, ENGELHORN T, KLOSKA S, STRUFFERT T: Flat-panel computed tomography (DYNACT) in neuroradiology. from high-resolution imaging of implants to one-stop-shopping for acute stroke. Clinical neuroradiology 2015; 25 (2): 291-297. 4. PETERSEN A, HARTWIG E, KOCH EMW, WOLLNY M: Clinical comparison of postoperative results of balloon kyphoplasty (BKP) versus radiofrequency-targeted vertebral augmentation (RF-TVA): a prospective clinical study. European Journal of Orthopaedic Surgery & Traumatology 2016; 26 (1): 67-75.

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5. RAGEL BT, ALLRED CD, BREVARD S, DAVIS RT, FRANK EH: Fractures of the thoracolumbar spine sustained by soldiers in vehicles attacked by improvised explosive devices. Spine 2016; 34 (22): 2400-2405.

8. WALLACE MJ, KUO MD, GLAIBERMAN C, BINKERT CA, ORTH RC, SOULEZ G, Technology Assessment Committee of the Society of Interventional Radiology: Three-dimensional C-arm cone-beam CT: applications in the interventional suite.Journal of Vascular and Interventional Radiology 2008; 19 (6): 799-813.

6. SCHOENFELD AJ, NEWCOMB RL, PALLIS MP et al. : Characterization of spinal injuries sustained by American service members killed in Iraq and Afghanistan: a study of 2,089 instances of spine trauma. Journal of trauma and acute care surgery 2013; 74 (4): 1112-1118.

9. YANG PL, HE XJ, LI HP; ZANG QJ, WANG GY: Image-guided minimally invasive percutaneous treatment of spinal metastasis. Experimental and therapeutic medicine 2017; 13 (2): 705709.

7. SHAH LM, SALZMAN KL: Imaging of spinal metastatic disease. International j ournal of surgical oncology 2011; Article ID 769753 < http://dx.doi.org/ 10.1155/2011/ 769753>

10. ZHAN Y, JIANG J, LIAO H, TAN H, YANG K: Risk factors for cement leakage after vertebroplasty or kyphoplasty: a metaanalysis of published evidence. World neurosurgery 2017; 101: 633-642.

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The Jules Voncken Prize, for an amount of 2.000 €, will be awarded during the 44th ICMM World Congress on Military Medicine in Brussels, Belgium (September 20-24, 2021). This award will honor the best article published in the International Review of the Armed Forces Medical Services, between the 43rd and the 44th ICMM World Congress on Military Medicine (2019-2021).

www . cimm- i cmm . org For more information:

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Military Medicine - The Irish Birth of a New Specialty. By G. KERR. Ireland

Gerald KERR Colonel Gerald KERR joined the Defence Forces in 1986. He was appointed as Captain Medical Officer to 28th Infantry Battalion. Following promotion to Commandant, he was transferred to Collins Barracks, Cork as OC 1st Field Medical Company in 1996. Subsequently he served as Medical Company Commander 1 Logs Support Battalion before being promoted to Lt-Colonel appointed Brigade Medical Officer, 1st Southern Brigade. In 2010, he was promoted to Colonel and appointed as Director Medical Branch, an appointment in which he continues to serve. Colonel KERR holds the Membership of the Royal College of General Practitioners, as well as the Higher Diploma in Occupational Medicine. He is a Licentiate of the Faculty of Occupational Medicine of the Royal College of Physicians of Ireland (RCPI) and holds the Diploma in Tropical Medicine from the Royal College of Surgeons in Ireland (RCSI), as well as a Masters in Sports and Exercise Medicine from University College Cork. He is a Fellow of the Faculty of Sports & Exercise Medicine of Ireland. Currently he is Chairman of the Board of the Faculty of Military Medicine of Ireland and is entered on the Specialist Divisions of General Practice, Occupational Medicine, Sports and Exercise Medicine, and Military Medicine. He instructs on ATLS Provider and Instructor Courses and is also an Honorary Clinical Lecturer in RCSI.

RESUME La médecine militaire. Une nouvelle spécialité née en Irlande. Cet article détaille le raisonnement qui sous-tendait la campagne qui a eu lieu en Irlande, visant à faire reconnaître la médecine militaire comme une spécialité. Il présente un rapport chronologique des étapes qui ont conduit à cette reconnaissance et le programme d’enseignement en Médecine militaire. Il expose les interactions avec les différentes autorités médicales et statutaires.

KEYWORDS: Military medicine, Speciality, University, Training, Ireland. MOTS -CLÉS : Médecine militaire, Spécialité, Université, Irlande.

BACKGROUND HISTORY

Act of 1948 and withdrew from the British Commonwealth. In 1973 the Republic of Ireland joined the European Community. With a population of approximately 4.81 million, it has a Defence Force (Army, Naval Service and Air Corps) of 9,500 personnel. Traditionally it has adopted a neutral stance since the 1930s and is a member of the United Nations since 1955. It has participated in NATOs Partnership for Peace programme since December 1999. Ireland also contributes to the European Battle Group. Ireland has been a regular contributor of military personnel to United Nations missions since the 1960s and deployments have taken place to the Congo, Cyprus, and the Middle East including the Sinai. However, following bombings in both Dublin and Monaghan close to the

The island of Ireland is situated at the western periphery of continental Europe. It consists of the Republic of Ireland and Northern Ireland which is a constituent part of the United Kingdom. The 1920 Government of Ireland Act provided for the establishment of Home Rule in the six counties of Northern Ireland and led to the establishment of a parliament at Stormont. The Irish Free State was established in 1922 following the War of Independence (1919– 1921) and established a parliament in Dublin for the remaining twenty-six counties of Ireland. In 1949 the Irish Free State became a Republic under the terms of the Republic of Ireland

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Border with Northern Ireland, the Irish troops were withdrawn in 1974 from UN duties in order to secure the border with Northern Ireland. In 1978 UN peace keeping duties were resumed and Irish personnel are serving and have served in the Middle East and Africa.

analysis of this concern revealed that overseas service is viewed negatively when the deployment occurs repeatedly within short periods, and where the individual has complex domestic commitments. The obvious solution to such issues lay in increasing the panel of welltrained and young Medical Officers, for whom overseas deployment is seen as an exciting adventure at a time in their lives when domestic commitments are at a minimum; (viii) with increasing litigation and the growth in legal challenges to military medical doctors, it is necessary to establish to the satisfaction of the Courts that the experts in the application of medical principles in the military environment are military medical officers. However, such status would be dependent on recognition by the appropriate statutory body i.e. the Medical Council of Ireland.

MILITARY MEDICAL NEEDS The Defence Forces growing commitment to United Nations sanctioned military missions has increased the need, inter alia, for military medical personnel. Ironically, this coincided with a reduction in the number of applications from medical practitioners to join the Defence Forces. As an entirely voluntary body, the Defence Forces are totally dependent on volunteers. The failure to attract qualified personnel was most acutely felt among military medical officers. Many innovative solutions were explored, including short-term commissions, direct recruitment outside the State, contract renewal bonuses and engagement of civilian medicalemployment contractors. However, the overall number of serving Military Medical Officers continued to fall, reaching the lowest level of sixteen in 2012.

DECISION ON WAY FORWARD For the reasons outlined above from (i) to (viii), a decision was taken to seek specialty status for Military Medical Officers of the Defence Forces from the Medical Council. The Medical Council is the regulatory body for doctors. It has a statutory role in protecting the public by promoting the highest professional standards amongst doctors practising in the Republic of Ireland. The Council also sets the standards for medical education and training in Ireland. It oversees lifelong and learning and skills development throughout doctors' professional careers through its professional competence requirements. It is charged with promoting good medical practice. An ad hoc Steering Group was established on 12th March 2013 composed of Senior Medical Officers, retired Medical Officers, civilian Specialists with an interest in the military medical environment and Reserve Medical Officers. This Group began the application process and made an initial application to the Medical Council.

COMPREHENSIVE REVIEW

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While traditionally the accepted solution to any resource short fall was to use financial incentives to increase attractiveness. However, this was not an option at a time of economic recession and associated financial constraints. As a result, a more comprehensive review of incentives and disincentives associated with service by medical practitioners within the military was undertaken by the Director Medical Corps and commenced in 2010. The principle conclusions arising from this review were: (i) there was a major lack of understanding and knowledge of the activities of Military Medical Officers by civilian medical peers. In such circumstances, where there is ignorance of the role and function of any cohort, there is a tendency to dismiss the importance and extent of that role, especially where garrison walls impede access to non-military personnel. This indeed was the prevailing opinion of civilian medical practitioners about their military medical colleagues in their garrison role; (ii) there existed no specific forum for military medical continuing educational or military medical professional competence schemes; (iii) there were limited opportunities for specific medical training and even less for military medical training; (iv) military medical officers had no opportunities to contribute to medical academia in the civilian domain – this compounded the difficulties identified at (i) above; (v) military medical service did not enhance a medical practitioner’s curriculum vitae; (vi) given the falling numbers of military medical officers, even their military education and training (as opposed to their medical training) was suffering as the exclusive emphasis was on medical service delivery; (vii) one of the disincentives to military medical service among the currently serving medical officers identified was the frequency of overseas deployment. Further

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SPECIALTY APPLICATION PROCESS As a result of preliminary enquiries with the new Medical Council, it became evident that any application for recognition of a new specialty was required to undergo a twostage process. The first stage involved an internal review by the Education, Training and Professional Development Committee of the Council, and only if this review was successful could the application proceed to the second stage – a process involving a period of public, as well as external (international) consultation. From the outset it became clear that the establishment of a new and separate College with responsibility for training and governance of the new specialty was deemed not to be a realistic option. Therefore, the Ad Hoc Steering Group had to approach the existing institutions recognized by the Medical Council in the provision of postgraduate specialist training. While Correspondence: Colonel Gerald M. KERR Director Medical Corps, Defence Forces Headquarters, St. Bricins Hospital - Infirmary Road, Dublin 7 Ireland E-mail: gerald.kerr@defenceforces.ie

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these approaches were being made, the actual application process had to be put on hold because the outgoing Medical Council had completed its term of office, and further progress had to await the election and appointment of the incoming Council.

enriched curriculum vitae, they would also have the necessary qualification to engage in civilian general practice at the end of their military medical career.

MEDICAL EDUCATION AND TRAINING UNIT OF HSE

PLACEMENT OF MILITARY MEDICINE

In April 2014, preliminary discussions took place between representatives of the Ad Hoc Steering Group and the Medical Education and Training Unit of the Health Service Executive (HSE) in order to determine whether there would be support for the concept of a Specialty of Military Medicine and the associated training programme. The response was overwhelmingly positive.

The Steering Group examined the role of Medical Officers in the Defence Forces and acknowledged that the practice of medicine in the military environment of the Defence Forces was exclusively confined to the prehospital setting. Furthermore, given the size and resources of the Medical Corps of the Defence Forces, this was unlikely to change in the future. The Steering Group had to decide to which College it should align itself. Three Colleges were considered to be of relevance. The choice lay between: (i) The Royal College of Physicians of Ireland (RCPI) – the Faculty of Occupational Medicine was already a constituent Faculty of RCPI and a large element of the workload of the Medical Officer involved Occupational Medicine; (ii) The Royal College of Surgeons in Ireland (RCSI) – interestingly one of the foundation objectives of the RCSI when it was established in 1784 was to provide surgeons to the British Army. Today the RCSI has a much broader medical base including an undergraduate medical school, a Department of Tropical Medicine as well as being responsible for the roll-out of the Advanced Trauma and Life Support (ATLS) courses in Ireland; (iii) The Irish College of General Practitioners (ICGP) – primary care is an essential component of the practice of military medicine, both at home and abroad.

FACULTY OF MILITARY MEDICINE OF IRELAND On 19 June 2014 the Ad Hoc Steering Group became the Interim Board of the Faculty of Military Medicine of Ireland (FMMI) with its primary goal “to achieve specialist recognition for Military Medicine in Ireland and to deliver a programme of specialist training in the new discipline.” Articles of Association were formulated and adopted by the Interim Board.

FORMAL APPLICATION In November 2014, a 193-page document was lodged with the incoming Medical Council in which the case for recognition of Military Medicine was submitted. This document outlined the distinct nature of Military Medicine, the scientific foundation for the specialty, the professional base for the specialty in Ireland and the requirement to sustain educational activity in the area. The document also dealt with how the new specialty would impact on the effectiveness of healthcare within the military environment with improved health outcomes and tailored healthcare. It also considered the impact on existing specialties and the integration of military healthcare provision. It outlined the role and the activities of the Faculty of Military Medicine of Ireland as well as an early draft of a syllabus of training in Military Medicine. The document also outlined proposals for promoting, maintaining and improving standards in the new specialty. It demonstrated that the specific body of knowledge constituting military medicine was sufficiently complex and extensive as to require a distinct training programme. It proposed a set of characteristics which defined the role a medical officer and linked them to the eight domains of good professional practice as outlined by the Irish Medical Council. The distinct nature of the body of knowledge is outlined in the document and the rationale for the requirement of additional learning is notated. Issues surrounding the development of a trainer pool are discussed. The document also acknowledges the Faculty’s commitment to continuing professional development in the specialty. Finally, the submission to the Council discussed the burden of disease, as well as the various occupational hazards, to which military personnel are exposed, both at home and abroad, as well as how these could be positively influenced by a new Specialty of Military Medicine which had the support of the

Following a series of meetings between the Chairman of the Steering Group and the Presidents of the three Training Institutions which took place from April to August 2013, as well as robust debate at Steering Group level, the decision was taken that the most appropriate College or Training Institution for the new Specialty to align with was the Irish College of General Practitioners. Primary Care was the ‘sine qua non’of military medicine in the Irish context. While Primary Care was recognised as the single most important constituent of military medicine, it was equally accepted that a Specialty of Military Medicine would be a composite specialty. It would therefore include, in addition to Primary Care, other components such as Occupational Medicine, Sports and Exercise Medicine, Travel and Tropical Medicine, Aviation and Diving Medicine, Emergency Medicine, Public Health Medicine, Preventative Medicine as well as Conflict and Catastrophe Medicine.

DUAL SPECIALIST ENTRY Aligning with the Irish College of General Practitioner had the added value that graduation in the new Specialty of Military Medicine would entitle the graduate to entry on the Specialist Division in General Practice, as well as in Military Medicine. Thus, not alone would the successful graduate of the Specialty have an

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various stake-holders. Overall, the resource implications arising from the new Specialty could be more than compensated for by the benefits which would accrue to the community at large.

PROCEEDING FROM STAGE 1 TO STAGE 2 OF THE PROCESS On 21st May 2015, the Chairman of the Interim Board of the FMMI was informed that the application to the Medical Council for recognition of the Specialty of Military Medicine had successfully completed Stage 1 of the two-stage process. There followed a period of public consultation lasting several months during which submissions were invited from interested parties by the Council in relation to the proposed new specialty. In addition, the Medical Council approached several international military medical organisations for their opinions on the proposals including servic es including Austria, Israel, Luxemburg, Netherlands, New Zealand, Switzerland and the United Kingdom.

well as the architecture of training for Military Medicine. In addition, the nature of the assessments which candidates would undergo were described as well as the mechanism for subsequent entry onto the Specialist Division of the Medical Council’s Register in Military Medicine and arrangements for Continuous Professional Development. The second document was entitled “Medical Council Accreditation Standards for Postgraduate Medical Education and Training”. These Accreditation Standards considered the context of Education and Training, the outcomes of the Training Programme, the curriculum content as well as the associated assessment of learning, monitoring and evaluation of the curriculum as well as its implementation. The third, and largest, document was entitled “A Core Curriculum for Postgraduate Medical Education and Training in Military Medicine” and this document gave a detailed outline of the six military medical training modules. All these documents were submitted on behalf of the Faculty of Military Medicine of Ireland (FMMI) in August 2016.

ALIGNMENT WITH GENERAL PRACTICE TRAINING SCHEME

FORMAL RECOGNITION OF THE SPECIALTY OF MILITARY MEDICINE On 6th October 2015 the Minister for Health, Mr Leo Varadkar, consented to the recognition of Military Medicine as a Specialty in accordance with the provisions of Part 10, Section 89 (1) of the Medical Practitioners Act 2007. In a subsequent Press Release, the Minister stated “I think this measure makes a lot of sense. The new specialty will specifically address the medical requirements of the defence forces. It will lead to the development of a comprehensive and relevant training programme for medical practitioners, whether they serve at home or with the UN. The specialist skills will be a particular benefit to those involved in humanitarian assistance and disaster response. It will also provide a career path for military doctors when they completer their military career and return to general practice and civilian life.” The Minister for Defence, Mr Simon Coveney, commented that the new specialty “recognises the skillset which Medical Officers serving in the Defence Forces bring to be wear in their work at home and overseas.”

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On 21st October 2015 the Chairman of the Interim Board FMMI wrote to the Chairman of the Education, Training and Professional Development Committee of the Medical Council in order to advance the case for provisional accreditation for the Training programme of the new Specialty. This letter marked the start of an 18-month process in which very detailed documents were prepared for submission to the Medical Council. The first such document was entitled “Programme for Postgraduate Medical Education and Training in Military Medicine”. It outlined the context and content of Education and Training for the new specialty. It also dealt with the concept and organisation of training as

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In parallel with submission of documents to the Medical Council, the Trinity College Dublin/HSE Specialist Training Programme in General Practice committed in August 2016 to working with the FMMI in the future to deliver training to and support Military Medicine Trainees. On 04 November 2016, the Medical Council’s head of Education, Training and Professionalism confirmed to the Chairman of the Faculty of Military Medicine of Ireland that it was in order for the ICGP/FMMI to proceed with arrangements for a trainee intake for 2017. This resulted from a review by the Medical Council Executive of the documentation submitted by the FMMI and the conclusion that it was deemed to be ready for an accreditation team to consider.

ACCREDITATION SESSION The formal Accreditation Session took place on 31st January 2017 during which both National and International Assessors examined the submitted documentation and interviewed representatives of the FMMI and ICGP. The Accreditation Team’s remit was to assess the Programme of Specialist Training in Military Medicine against the ‘Medical Council Accreditation Standards for Postgraduate Medical Training and Education’ and to subsequently formulate a recommendation to the Medical Council’s Education, Training and Professional Development Committee. Topics covered included: The Military Medicine syllabus; training methods; formative and summative assessment tools; standards; outcome measures; workforce planning considerations (Initial Specialist Training, Higher Specialist Training and Specialist Practice); flexible training; learners in difficulty; mentorship, and lifelong learning including Continuous Professional Development. Discussions with the body were audio-recorded and documented through real-time stenography.

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ACCREDITATION APPLICATION OUTCOME

INDUCTION OF FIRST TRAINEES

On 14 June 2017, the Accreditation Manager, Education, Training and Professionalism wrote to the CEO of the ICGP announcing that the Medical Council approved, with conditions, (a) the Programme of Specialist Training in Military Medicine (the conditions were (i) that there be a written framework agreement in place between the Department of Health, the Health Service Exec utive (HSE), the National Doctors Training and Planning Unit of the HSE, and the Irish College of General Practitioners (ICGP) as to the scope of responsibility for each party and (ii) the first full training cycle must be completed leading to the award of a Certificate of Completion of Specialist Training to each successful graduate of the programme) and (b) the Irish College of General Practitioners should be approved by the Council as the body which may grant evidence of the satisfactory completion of Specialist Training in Military Medicine (the same two conditions outlined above were also attached). This approval, with conditions, was for a period of five years from the date of approval by the Council (29 March 2017). The letter from the Accreditation Manager also confirmed that Ministerial consent was received for this course of action.

The first trainees to the Military Medicine Training Scheme were commissioned and inducted in July 2017 when they commenced Initial Specialist Training (IST). This represented the successful culmination of a seven-year campaign to gain recognition for the Specialty of Military Medicine and gain accreditation for the associated Training Programme. The first trainees have now, with effect from July 2019, progressed on to Higher Specialist Training (HST) and are due to graduate as Military Medicine Specialists in June 2022.

SUMMARY The following article outlines the rationale behind the campaign to seek specialist recognition for Military Medicine in Ireland and gives a chronological account of the process which ultimately established the Specialty and the associated Training Programme in the Specialty of Military Medicine. It documents the interactions with the various civilian medical and statutory authorities.

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International Humanitarian Law and Veterinary Services – “ It depends”.* By L. BUCHNER∑. Germany

Leander BUCHNER Senior Colonel Dr. Leander BUCHNER was born in 1958 in Bavaria/Germany. He started his military career as a conscript in the German Air Force in 1978. Trained at the Air Force Officer School as an officer cadet, he began the study of Veterinary Medicine at the University of Munich in 1981. He was promoted to Captain (VC) in 1987 in Munich and specialized in Microbiology, Veterinary Public Health and Quality and Hygiene Management in the Food Sector. His thesis for the doctorate in veterinary medicine (1991) was concerned i.a. with the antimicrobial resistance of bacteria isolated from food and kitchen personnel. After several deployments in Germany and abroad like Cambodia (UNTAC, 1993), Afghanistan (ISAF, 2002), t he Balkans (SFOR 2001, KFOR 2003 and 2004) and the NATO Joint Force Command Naples (2004) he became the commander of the Bundeswehr School for Dog Handling and in 2013 the Senior Medical Officer of Veterinary Medicine of the Bundeswehr and Inspector General of Veterinary Medicine. He has been in charge as chairman of the Technical Commission for Veterinary Science the ICMM since 2015.

RESUME Droit humanitaire international et services vétérinaires : « Cela dépend ». Les missions des services vétérinaires au sein des forces armées ont fondamentalement changé au cours du siècle écoulé. A la place des soins aux chevaux et aux autres animaux de guerre qui assistaient les combattants ou leur conféraient la mobilité, la sécurité sanitaire de l’eau et des aliments et la prévention des zoonoses chez l’homme sont devenus l’essentiel pour la p lup art des services vétérinaires. Leur organisation a évolué en conséquence et la plupart de ce qui étaient des services vétérinaires indépendants ont été intégrés dans les services de santé avec toutes les protections conférées par le Droit humanitaire international sauf dans le cas où ils accompliraient des missions de soins au profit des animaux de guerre.

KEYWORDS: International Humanitarian Law, Veterinary Service. MOTS -CLÉS : Droit International Humanitaire, Service Vétérinaire.

DEFINITIONS

well as subsequent treaties, case law, and customary international law ". It defines the conduct and responsibilities of belligerent nations, neutral nations, and individuals engaged in warfare, in relation to each other and to protected persons, usually meaning noncombatants. It is designed to balance humanitarian

The International humanitarian law (IHL) is the law that regulates the conduct of war (jus in bello). It is that branch of international law which seeks to limit the effects of armed conflict by protecting persons who are not participating in hostilities, and by restricting and regulating the means and methods of warfare available to combatants. IHL is inspired by considerations of humanity and the mitigation of human suffering. "It comprises a set of rules, established by treaty or custom, that seeks to protect persons and property/objects that are (or may be) affected by armed conflict and limits the rights of parties to a conflict to use methods and means of warfare of their choice ". It includes "the Geneva Conventions and the Hague Conventions, as

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∑ Senior Colonel Dr., Bundeswehr Medical Service Headquarters. Correspondence: Senior Colonel Dr. Leander BUCHNER, Bundeswehr Medical Service Headquarters, Von-Kuhl-Straße 50, D-56070 Koblenz, Germany E-mail: lbuchner@cimm-icmm.org * Presented at the 5th ICMM Pan-European Congress on Military Medicine, Warsaw, Poland, 17-20 September 2018.

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The status of the veterinary officers has recently been raised at the Bundeswehr Medical Service HQ. It was commented that the Bundeswehr veterinary service personnel did not conform to the definition – and thus the status – of medical personnel that applies in the context of international humanitarian law.

concerns and military necessity, and subjects warfare to the rule of law by limiting its destructive effect and mitigating human suffering. Serious violations of international humanitarian law are called war crimes. International humanitarian law regulates the conduct of forces when engaged in war or armed conflict. It is distinct from jus ad bellum which regulates the conduct of engaging in war or armed conflict and includes crimes against peace and of war of aggression. Together the jus in bello and jus ad bellum comprise the two strands of the laws of war governing all aspects of international armed conflicts.

The veterinary service has not been mentioned in the Geneva Convention of 1864 and The Hague conventions. But the Geneva Convention of 1929 states in article 8, No. 4 the following: “A medical unit or establishment will not be deprived of the protection guaranteed to it if personnel and material of the veterinary service are found in the unit or establishment.”

HISTORICAL REVIEW The first Geneva Convention was signed in 1864 in Geneva by 12 states. It was a result of the suffering of the wounded soldiers of the Battle of Solferino, Italy in 1859 and pushed by Henry Dunant.

This view can only be explained from a historical perspective and can be traced back to the second Geneva Convention of 27 July 1929. The most important consequence of World War I for those aspects of international humanitarian law that are in the Geneva tradition was the “Convention relative to the Treatment of Prisoners of War”, which was negotiated in 1929. The fact that it ref ers to veterinarians is remarkable because the veterinary service used to be an independent specialist branch alongside the medical service in many armed forces at that time, including the German ones and still in the Indian Forces for example.

A second part of the IHL are The Hague Conventions I will not take in consideration here. Due to the experiences of World War I a broad revision of the Geneva was carried out and signed in 1929. And 20 years later, the 2nd Geneva Convention and The Hague Conventions were revised and edited in four parts. Part one deals with wounded and sick in the field, part two with wounded, sick and ship wrapped in marine operations, part three with prisoners of war and part four with civilians. The development of the Geneva Conventions is shown in figure 1.

The relevant section of the commentary on the resolutions of 1929 reads (Des Gouttes and Huber, 1930, p. 46–47; translated): “(4) The latter case is a complete novelty. It was introduced

Fig. 1: Development of the Geneva Conventions from 1864 to 1949.

FIRST GENEVA CONVENTION

1906 - GENEVA 1097 - THE HAGUE

REVISION

➪

1899 - THE HAGUE

➪

➪ 1864 - GENEVA

1929 - GENEVA

1949 - GENEVA

REVISION

REVISED AS GENEVA CONVENTION I Wounded and sick

HAGUE CONVENTION III

HAGUE CONVENTION X

ADAPTATION OF 1864 GENEVA CONVENTION TO MARITIME WARFARE

ADAPTATION OF 1906 GENEVA CONVENTION TO MARITIME WARFARE

NEW GENEVA CONVENTION II Wounded and sick and ship wracked

SECOND GENEVA CONVENTION HAGUE CONVENTION II

HAGUE CONVENTION IV

SECTION I (CHAPTER II) - POWS SECTION III - CIVILIANS

REVISED AS GENEVA CONVENTION III Prisoners of War

NEW GENEVA CONVENTION IV VOL. 92/3

Civilians

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by the American delegation due to the special organisational structure of their army. In the United States, veterinarians are not integrated into the medical service – but they follow its decisions and are under the command of the medical detachment. So it had to be ensured that units or establishments would not lose the protection guaranteed to them by the Convention in case veterinarians were present during a capture. What was easily accepted back then was the fundamental assumption that veterinarians are no combatants. For that very reason, the Conference was the birth-place of the idea of integrating the “service vétérinaire” into the health services (“service de santé”). This proposal was strongly supported by the Romanian delegation. One of their central arguments was that veterinarians provided direct and efficient support to health services through their bacteriological expertise. In the Romanian army, the argument continued, the veterinarians – who were regarded as specialised forces – would truly deserve being granted the privilege of this immunity. But this request for extended protection, which was not called for by the United States by the way, was deemed excessive and rejected by the Conference because it was thought to entail far-reaching problems. On the contrary, the Conference had always, and justifiably, been striving to draft an amendment to the Convention that would be acceptable to all governments, trying its hardest to avoid the ratification of a version less general than the previous one.”

There was general consensus, however, that the presence of veterinary service personnel and equipment at a protected medical unit was admissible, even without the veterinarians being an integral part of the medical unit in question. So it is understandable that this passage remained largely unchanged in the version of 1949 (then in article 22). It did not elaborate any further on the issue of combatant status. The origins of this debate go back to the task of taking care of the horse cavalry, whose last full-scale deployment had been the battle of Omdurman in Sudan in 1898(*, **), (figure 2). It can be assumed that a veterinary service of this kind, in its original meaning, is of limited relevance today and will only find application in a few very specific situations (such as mountain infantry units using pack animals). But whenever it does, such veterinary service activities will, in accordance with the Convention, not come under the protective shield of international humanitarian law. (Fleck et al., 1995). Generally, one can assume that the text passage in question has lost its significance – especially considering that modern armies were almost entirely motorised as early as in the 1950s (Pictet, 1952). Remarkable in this regard is the fact that the U.S. Army veterinary service personnel are still not protected by the Geneva Convention today. Said personnel is to be

Fig. 2: Battle of Omdurman (2 Sep tember 1898) “The Charge of the 21st Lancers at Omdurman ", by Richard C. Woodvill.

* At the Battle of Omdurman (2 September 1898), an army commanded by the British General Sir Herbert Kitchener defeated the army of Abdullah al-Taashi, the successor to the self-proclaimed Mahdi, Muhammad Ahmad. ** The battle of Krojanty was a Polish cavalry charge by the 18th Pomeranian Uhlans against German infantery. It occurred during the invasion of Poland on 1 September 1939 and delayed the German advance for several hours.

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Fig. 4: Off icer Unif orms of the indep endent German Veterinary Corps between 1919 and 1934 (Fontaine, 1939).

identified by means of a green cross, not a red one (Poppe, 2013). However, today’s Veterinary Corps is part of the U.S. Army Medical Department (http://veterinarycorps.amedd.army.mil/). Article 24 of Part one of the Geneva Convention (1949) in conjunction with article 8c of the first Additional Protocol (1977) specify the “medical personnel” (figure 3) that is to be respected and protected under all circumstances as those medical workers who are exclusively and permanently (as opposed to the “auxiliary personnel” described in article 25) engaged in the search for, or the collection, transport or treatment of the wounded or sick, or in the prevention of disease, or in the administration of medical units and establishments. Medical workers in this context are persons who are exclusively assigned by one conflict party to perform medical functions, manage medical units or operate or manage medical means of transportation. Said assignment may be permanent or temporary. The aforementioned medical functions in medical units also comprise disease prevention tasks performed in medical prevention centres and institutes. Disease prevention was first added to the list of medical functions at the Conference of 1949. Back then, the armed forces were already a modern organisation – hygienic and prophylactic disease prevention measures were play ing an increasingly significant role. Fig. 3: Medical Service Personnel ID Card.

Vaccinations, delousing and the disinfection of potable water were just some of the tasks performed by medical workers, and as such they were also mentioned there (Pictet, 1952). Some of these activities may be undertaken by veterinarians. The activities of veterinarians – even when they are members of the armed forces’ medical service – will, in principle, fall outside those listed in Article 24, particularly when they exclusively involve animal health care. Indeed, a veterinarian who, as a member of the armed forces, takes care of animals that are deployed to assist combat activities would, for example, be deemed a combatant. Historically, this has been the dominant paradigm. However, when a veterinarian engages exclusively in the protected activity of ‘prevention of disease’vis-à-vis human beings (figure 5), for example when inspecting the hygiene of food supplies for ablebodied combatants, as more and more veterinarians who are members of the armed forces do, this person qualifies to be ‘respected and protected’in the sense of Article 24. Fig. 5: Plasmid pattern of Salmonella Enteriditis strains causing f ood borne diseases isolated f rom diff erentf ood and human stool. (Buchner, Hans-Hartwig-Clasen-Award f or young medical off icers 1991).

SITUATION

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The holder of this card is protected by the Geneva conventions of 12 August 1949 and by the Protocol Additional to Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I) in his capacity as.

International Review of the Armed Forces Medical Services

If a country, such as the Federal Republic of Germany, integrates the veterinary service of its armed forces into the medical service of said forces, the veterinary service becomes a part of the medical service by governmental organisational decision. Consequently, in an armed conflict the veterinary service partakes in the functional protection that is due to the medical service because of the humanitarian tasks the latter is to perform, and its

Revue Internationale des Services de Santé des Forces Armées

members are permitted to wear the respective protective emblem and carry the special ID card. Should such personnel fall into the hands of the enemy, they may only be retained for as long as they are required for nursing and treating the wounded, sick and shipwrecked. Once their presence is no longer required, and if practically possible, they must be returned to their home country (even before the end of the armed conflict).

became a part of the medical services with all the privileges as protected personnel according the International Humanitarian Law except carrying out duties in the context of treating and taking care for war animals. LITERATURE 11. DES GOUTTES, Paul; HUBER, Max: La Convention de Genève pour l’amélioration du sort des blessés et des malades dans les armées en campagne du 27 juillet 1929: Commentaire. Genève: Comité internat. de la CroixRouge, 1930.

But if this veterinary personnel conducts tasks in regard with treating and taking care for duty animals such as pack animals or attack dogs that personnel is not protected by the Geneva Conventions. The status of veterinary personnel depends of the tasks carried out.

12. McCOUBREY, Hilaire: International humanitarian law: the regulation of armed conflicts. Aldershot: Dartmouth, 1990.

If a country decides differently, its veterinary service will not become a part of the armed forces' medical service but will have the status of combatant/fighter in armed conflicts instead. Consequently, its members do not enjoy protection in armed international conflict; rather, having combatant status, they will be regarded as prisoners of war if captured. And with this status, they will remain in captivity until the armed conflict ends.

13. FLECK Dieter; BOTHE Michael; et al.: The handbook of humanitarian law in armed conflicts. New York: Oxford University Press, 1995. 14. PICTET, Jean S.: The Geneva Conventions of 12 August 1949: 1: Geneva Convention for the amelioration of the condition of the wounded and sick in armed forces in the field. Geneva: International Committee of the Red Cross, 1952.

INTENTION

15. POPPE, John L., Brigadier General, US Army Deputy Chief of Staff for Sup-port US Army Medical Command and Chief, US Army Veterinary Corps. Personal communication, 2013.

What I can do is: I want to bring this situation in mind and want to advertise that veterinary services personnel will become protected as medical services personnel regardless they are engaged in prevention of human disease or in the search for, or the collection, transport or treatment of the wounded or sick animals.

SUMMARY The tasks of the veterinary services in armed forces changed fundamentally in the last century. While care and treatment of horses and other war animals that supported the combat troops or made them mobile food and water safety and prevention of human diseases like zoonosis turned to the focal point of the most veterinary services. Their organisational structure changed consequently and most of the former independent veterinary services

16. FONTAINE, H. 1939: Das Deutsche Heeresveterinärwesen – Seine Geschichte bis zum Jahre 1993. Verlag M. & H. Schaper, Hannover. 17. https://en.wikipedia.org/wiki/International_humanitarian_law 18. https://veterinarycorps.amedd.army.mil/ 19. https://en.wikipedia.org/wiki/Battle_of_Omdurman 10. https://en.wikipedia.org/wiki/Charge_at_Krojanty 11. https://upload.wikimedia.org/wikipedia/commons/1/12/RC WoodvilleJr_21Lancers_Omdurman.jpg

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International Review of the Armed Forces Medical Services

Revue Internationale des Services de Santé des Forces Armées

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