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CONTENTS Sommaire

ORIGINAL ARTICLES / ARTICLES ORIGINAUX 5

Réorganisation d’un service d’accueil des urgences d’un hôpital militaire face au COVID-19; se préparer à la vague épidémique. Par J.P. BOUDSOCQ, N. CHOUAKI, N. JUZAN, M. BELLETANTE, P.O. VIDAL, D. CLAESSENS, A. CHASTEL, E. JAVEL et E. DELMOND, France

Study of the Accuracy of Chest X-Ray in Blunt Trauma

Chest. By P. SHARMA, A. VATSA and M. LASKAR. India

Food Poisoning Outbreak in a Mexican Navy Unit: Epidemiological Approach of the Event. By B. LOOSE-ROJO, H. BENITES-VIRGEN and CG. SOLISHERNANDEZ. Mexico

Key Link Considerations for Conducting Timely and Efficient Aero Medical Evacuation in UN Field Mission: Lessons Learnt From South Lebanon. By Q-S. ZHANG, L. CHEN, G-Y. BI and Z-B. LI. China

The Development and Introduction of the United Nations Buddy First Aid Course. By MCM. BRICKNELL, C. BOOKER, A. TIWATHIA and J. FARMER. United Kingdom

Medical Management in Military Operations: Is there a Medical Command? By J-A. WEBER and G. CASSOURRET. France

A Review of the United States Innovative Readiness Training Program: Operation Healthy Delta 2017. By P.A. McWILLIAMS and A. KOSARAJU. U.S.A.

United States Department of Defense Global Health Engagement: Watering Plastic Flowers in the Hopes That they Will Grow? By D.J. LICINA. U.S.A.

Etude descriptive des caractéristiques de la population de patients militaires présentant un trouble de l’usage de l’alcool et consultant dans le service de psychiatrie d’un Hôpital d’Instruction des Armées. Par E. SAGUIN, A. DAVID, F. SAUVET, C. GUILLAUME, A. EON et B. LAHUTTE. France

Photo on the cover: Medical Management in Military Operations: Is there a Medical Command? - By J-A WEBER and G. CASSOURRET, France (© M.Vallé/armée de l'Air).

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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.

International Review of the Armed Forces Medical Services

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

Réorganisation d'un service d'accueil des urgences d'un hôpital militaire face au COVID-19; se préparer à la vague épidémique. Par J.P. BOUDSOCQ∑, N. CHOUAKI∏, N. JUZAN∑, M. BELLETANTE∑, P.O. VIDAL∑, D. CLAESSEN∑, A. CHASTEL∑, E. JAVELLE∑ et E. DELMOND∑. France

Jean-Paul BOUDSOCQ Après sa formation à l’Ecole Santé Navale de Bordeaux, le Médecin en Chef BOUDSOCQ Jean-Paul effectue son internat au sein de l’Hôpital d’Instruction des Armées (HIA) Laveran à Marseille jusqu’en 2007. Sa carrière est marquée de 2008 à 2019 par des affectations en tant que médecin au 35ème Régiment d’infanterie de Belfort, au 3ème Régiment étranger d’infanterie de Kourou en Guyane et au Bataillon de marins-pompiers de Marseille et des missions notamment en Afghanistan (PAMIR), aux Emirats-arabes-unis (au CENZDEA U) et en Guyane (Harpie). Il est actuellement urgentiste au Service d’accueil des urgences de l’HIA Laveran et référent de suivi de cursus pour les internes. Il est titulaire du Doctorat et du Diplôme d’études spécialisées de médecine générale, de la Capacité de médecine d’urgence, de la Capacité de médecine de catastrophe, du Diplôme interuniversitaire d’aide médicale urgente en mer et de l’Advanced trauma life support.

SUMMARY Reorganization of an emergency department of a military hospital facing COVID-19; preparing for the epidemic wave. The COVID- 19 outbreak forced all emergency departments to reorganize to deal with an influx of potentially serious patients. The Marseille military hospital, Alphonse Laveran, was no exception. By taking the example of an experience of patient triage largely acquired in operational missions, the Emergency Department has profoundly changed the way it operates. Based on the principles of anticipation and staff availability, the organization set up meets local needs.

MOTS-CLÉS : Hôpital militaire, Services hospitaliers d'urgence, Infection à coronavirus, COVID-19. KEYWORDS: Military hospital, Emergency hospital services, Coronavirus infection, COVID- 19.

INTRODUCTION

règle. Au début de cette épidémie de coronavirus SARS CoV2, de nombreux services d’urgences ont dû anticiper une réorganisation spécifique. D’une réflexion commune entre les urgentistes, les biologistes et les infectiologues de l’HIA a découlé une profonde adaptation

Une épidémie de maladie COVID-19 (Coronavirus disease 2019), dont l’origine provient de la ville de Wuhan en Chine, frappe actuellement la France depuis quelques semaines. Malgré les mesures barrières de protection et le confinement de la population, les services d’urgences doivent faire face à une augmentation de patients présentant des symptômes de cette maladie qui vont de la toux au syndrome de détresse respiratoire aiguë entraînant le décès. Le service d’accueil des urgences de l’hôpital d’instruction des armées (HIA) Laveran, qui est implanté dans le 13ème arrondissement de Marseille dont il a la responsabilité sectorielle pour l’ensemble des urgences adultes, n’échappe pas à cette

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∑ Hôpital militaire « Alphonse Laveran » de Marseille. ∏ Université Aix-Marseille, Faculté de Médecine. Correspondance: Dr Jean-Paul BOUDSOCQ, Hôpital d’Instruction des Armées « Alphonse Laveran », CS 50 004, boulevard Alphonse Laveran, 13384 Marseille Cedex 13 (France) Tél : 06.48.39.80.05 E-mail : jeanpaul.boudsocq@gmail.com

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du service d’accueil des urgences (SAU) tant sur le plan structurel que des ressources humaines. C’est cette organisation qui est présentée dans cet article.

un médecin, un interne, une IDE, appuyés par une équipe de réanimation et le cas échéant par un chirurgien, de prendre en charge un patient conformément aux directives sanitaires régionales. Deux zones de déchoquages constituent la SAUV.

LE FONCTIONNEMENT NORMAL DU SAU LAVERAN

Pendant la garde de nuit et de week-end, un médecin, deux internes, trois IDE et deux AS permettent le fonctionnement du service.

Le service d’accueil des urgences de l’HIA Laveran est implanté depuis de nombreuses années dans le bassin des quartiers nord de Marseille et plus spécifiquement dans le 13ème arrondissement, une partie du 12ème et du 14ème arrondissement et les communes d’Allauch et de Plan de Cuques pour lesquelles il est hôpital de secteur au profit des populations civiles.

ORGANISATION PENDANT L’ÉPIDÉMIE DE COVID-19 Une profonde réorganisation de l’HIA pour accueillir le flux des patients suspectés d’avoir contracté le Covid-19 s’est soldée par la déprogrammation de nombreuses activités comme les chirurgies réglées et certaines consultations, la création d’un secteur « suspicions COVID » et un secteur « COVID confirmés », sous la responsabilité des infectiologues, implantés dans les étages et servants d’aval aux urgences. L’augmentation des capacités d’accueil en réanimation de ces patients a été prise en compte par la transformation de l’unité de soins continus (USC) en unité de réanimation COVID et la création de lits dans la salle de surveillance post-interventionnelle. Le SAU, épicentre de l’accueil des patients, a pu bénéficier de renforts nécessaires à sa nouvelle réorganisation interne (Fig. 1-3).

Dans son fonctionnement normal, les patients autonomes sont accueillis via une esplanade par une salle d’attente dans lequel se trouve le secrétariat d’accueil et d’enregistrement avec 1 à 3 secrétaires en fonction des horaires. Un sas pour les véhicules sanitaires permet d’accueillir les patients allongés via une entrée spécifique. L’infirmière organisatrice de l’accueil (IOA) est un poste encadré par un référentiel précis1. Elle est en charge habituellement de la répartition des patients vers les filières internes au SAU en effectuant un premier bilan d’interrogatoire et de prises de constantes du patient en s’aidant de la collecte des informations de l’équipe qui a effectué le transport. Il n’existe pas de poste de médecin d’accueil et d’orientation (MAO) au sein du SAU Laveran. L’IOA peut s’appuyer chaque fois que nécessaire sur un médecin du service pour orienter au mieux un patient.

1. Salles d’attente : Une tente a été implantée sur le parvis extérieur des urgences et divisée en deux parties : Une salle d’attente « Respiratoire » et une salle d’attente « Autres » dans lesquels les patients se présentant de manière autonome se répartissent d’eux-mêmes sous la vigilance d’un personnel de la sécurité, espacés de 1 m selon les recommandations en vigueur2 . Concernant les patients en véhicules sanitaires, l’entrée spécifique a été fermée, remplacée par un cheminement spécial leur permettant de se présenter sur le parvis des urgences.

L’intérieur du SAU est organisé comme suit : - Une « filière courte » : armée d’un médecin sénior, d’un interne aux heures ouvrables et d’un médecin généraliste regroupé en association « SUMO » aux heures non ouvrables (20h00 à 00h00 en semaine, 12h00 à 00h00 le samedi et 8h00 à 00h00 le dimanche), cette filière à la charge des pathologies médicales et traumatiques légères. Les locaux sont constitués de deux cabinets de consultation, de deux boxes à sutures et d’une salle de plâtres.

Une deuxième tente a été installée dans le but d’accueillir les familles et les accompagnants. Figure 1 : Schéma simp lif ié du SA U en temps de crise du COVID-19.

- Une « filière longue » : armée par un médecin senior 24h/24 et deux internes, deux infirmiers diplômés d’état (IDE), deux aides-soignants (AS), cette filière accueille les patients nécessitant un bilan complémentaire et dont l’état est susceptible de requérir une prise en charge spécialisée et une hospitalisation. Cette zone est constituée de 6 boxes individuels d’examen, d’une zone d’attente à 6 emplacements pour brancards.

Tente Salle d’attente Filière non respiratoire non COVID-19 Secteur court

- Une unité d’hospitalisation de courte durée (UHCD) sous la responsabilité d’un médecin senior dédié aux heures ouvrables, d’un IDE et d’un AS et comporte 10 chambres.

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SAUV

UHCD

- La salle d’accueil des urgences vitales (SAUV) n’est pas en permanence armée par un médecin mais sur appel du SAMU 13 ou en cas d’arrivée imprévue d’un traumatisé sévère, une procédure spécifique permet à

International Review of the Armed Forces Medical Services

Filière respiratoire COVID-19

Zone de triage

Secteur long

Zone Respiratoire COVID-19

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Figure 2 : Armement RH du SAU aux heures ouvrables. HEURES OUVRABLES : ARMEMENT DU SAU PAR POSTE - PHASE 3 DU COVID-19 Ancienne localisation

Filière Longue SAU : FL

Filière Courte SAU : FC

UHCD

Renfort SAU

HDJ puis UNACOVID

Nouvelle localisation

Idem : FL

Idem : FC

Longue Respiratoire : LR

Nouvelle UHCD : NU

MOA : Médecin d’Orientation et d’Accueil

Médecins en zones de soins

Internes Internes de chirurgie de garde IDE du SAU (IOA non armé) IDE de renfort (autre service) AS du SAU AS de renfort (autre service)

Triage en salle d’attente principale : armement par un sénior de chirurgie en 12h 1 MED du SAU

1 MED du SAU

1 ou 2 MED du SAU

1 MED du SAU

1 MED des étages : liste 1

ou 1 MED de renfort du CMA 8h30 - 19h

ou 1 MED de renfort du CMA 9h30 - 18h30

1 MED : 8h - 19h

TNC et soins cliniques si afflux

5 gastro + 4 MPR + 2 INT

+/- 1 MED : 12h - 19h

10h - 18h

8h - 19h

de MPR

2 1 interne : 8h - 19h

12h - 20h

1 seul interne ou 2 internes (relève à 16h) : 8h - 00h

A disposition du SAU en dehors du bloc ou d’une activité de service impérative

1 ou 2

0 ou 1

1 ou 2 1

Figure 3 : Armement RH SAU aux heures non ouvrables. HEURES NON OUVRABLES : ARMEMENT DU SAU PAR POSTE - PHASE 3 DU COVID-19 Ancienne localisation

Filière Longue SAU : FL

Filière Courte SAU : FC

UHCD

HDJ puis UNACOVID

M. Régulation Urgences

Nouvelle localisation

Idem : FL

Idem : FC

Longue Respiratoire : LR

Nouvelle UHCD : NU

idem : MRU

MOA : Médecin d’Orientation et d’Accueil

Triage en salle d’attente principale : armement par un sénior de chirurgie en 12h

NUITS Médecins en zones de soins

1 seul URG pour FL et LR

SUMO

1 seul URG pour FL et LR 1 MED des étages : liste 1 1 MED des étages : liste 2

8h30 - 19h

Sem : 20h - 00h

8h - 19h

18h30 - 8h

1 Internes Internes de chirurgie de garde

18h30 - 8h

3 gastro + 3 MPR + MED p2016

Gastro + MPR + Pneumo + PIT-MIT + INT de spé

1+0,5 1 seul interne ou 2 internes (relève à 16h) : 8h - 00h

A disposition du SAU en dehors du bloc ou d’une activité de service impérative

WEJF EN JOURNÉE 1 MED du SAU Médecins en zones de soins

SUMO

1 MED du SAU

Sam : 12h - 20h 8h - 20h

1 interne : 8h - 20h

IDE du SAU (IOA non armé)

1 interne : 8h - 20h 1 seul interne ou 2 internes (relève à 16h) : 8h - 00h

A disposition du SAU en dehors du bloc ou d’une activité de service impérative

1 ou 2

IDE de renfort (autre service) AS du SAU

Gastro + MPR + Pneumo + PIT-MIT + INT de spé

1 interne : 12h - 20h Internes de chirurgie de garde

3 gastro + 3 MPR + MED p2016

8h - 20h

Dim JF : 8h - 20h

2 Internes

1 MED des étages : liste 1 1 MED des étages : liste 2

AS de renfort (autre service)

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2. Zone de triage :

- vers un secteur ambulatoire extérieur ou « SUMO », en présence de facteurs de fragilité pouvant nécessiter des consultations de contrôle, - vers un secteur pédiatrique ou obstétrique, - en « filière respiratoire », - ou en « filière non respiratoire ».

La salle d’attente a été transformée en zone de tri, passage obligatoire pour tous les patients. Cette pièce a pu être mise en extraction d’air exclusive vers l’extérieur, comme l’ensemble du SAU. La particularité de notre système de triage est qu’il est réalisé par un chirurgien des armées. En effet, l’histoire ancienne du triage médico-chirurgical dans le milieu de la santé militaire, la déprogrammation des activités chirurgicales réglées et la réduction des pathologies chirurgicales liées au confinement font que les chirurgiens, rodés à cet exercice, sont les praticiens qui ont été choisis. Il était important de faire bénéficier aux patients de cette organisation éprouvée dans de nombreuses opérations. Un interne en chirurgie, un externe des armées et un à trois secrétaires complètent l’armement de cette zone. Le port des équipements de protection individuelle est la règle. Le secrétariat d’entrée et la zone de tri sont colocalisés pour accélérer l’accueil à la manière d’un poste médical avancé en médecine de catastrophe. Les procédures internes de triage des patients, dest inées à harmoniser les pratiques, suivent les recommandations édictées par le ministère de la santé, les autorités sanitaires et les sociétés savantes mais également les retours d’expérience de nos confrères français, italiens et chinois3-7 . Afin de faciliter la visualisation des patients suspects COVID sur le logiciel T-urgences™ et donc contribuer à la protection des soignants, une couleur spécifique connue de tous a été déterminée.

Dans le SAU les cheminements pour chaque filière sont identifiés et différentiés au moyen de deux cheminements non croisés (figure 4).

3. Filière respiratoire : Ainsi nommée devant la prépondérance des symptômes respiratoires liés au COVID-19 cette filière regroupe : - un box d’examen qui permet d’examiner un patient qui relèverait du milieu ambulatoire, par un médecin sénior, un interne ou par un médecin généraliste de l’association « SUMO ». - une zone COVID-19 en lieu et place de l’UHCD habituelle

La zone COVID- 19 du SA U : Composée de 10 boxes individuels, ce secteur est entièrement protégé par des parois en polyane et identifié par des affiches de mise en garde. Cette zone est en pression négative. Chaque box est équipé d’un portique d’isolement avec les équipements de protection individuelle (EPI) recommandés et un rappel des procédures d’habillage et déshabillage est affiché sur chaque porte. La traçabilité des contacts avec les patients est assurée un registre de contact enregistrant le temps d’exposition. Cette zone a une place stratégique puisqu’elle est située à proximité immédiate du scanner dédié aux suspicions COVID-19 et a un accès direct par

A l’issue du triage le patient est orienté soit : - vers son domicile avec des consignes et un traitement symptomatique pour les patients sans facteurs de fragilité ou de gravité,

Figure 4 : Procédure de triage aux urgences de l ’HIA Laveran.

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ascenseur spécifique au secteur de réanimation dédié aux malades du SRAS CoV2. Le parti a été pris de ne pas créer une SAUV dédiée dans ce secteur car tout malade infecté peut dégrader ses constantes vitales. C’est le matériel de réanimation qui se déplace auprès du patient qui le nécessite via un chariot. En l’absence de zone tampon avant hospitalisation4, l’accès en secteur d’hospitalisation des suspicions COVID-19 est facilité par un itinéraire spécifique afin d’éviter la surcharge du SAU. Ce secteur est armé en journée d’un sénior dédié, 1 médecin de renfort, de 2 internes, de 2 IDE et de 2 AS.

La zone courte non respiratoire : Cette filière habituelle a été maintenue et est armée par un médecin sénior du SAU ou un médecin extérieur de renfort en journée ou par le médecin de l’association SUMO et le médecin de garde pendant les heures non ouvrables.

Cas particulier des examens complémentaires :

La zone longue non respiratoire :

L’HIA Laveran possède deux scanners. Vue la place importante qu’occupe le scanner du thorax dans le diagnostic, il a donc été décidé que le scanner des urgences serait dédié aux suspicions de COVID-19.

La filière longue a été maintenue dans les conditions habituelles et est armée par un sénior, un médecin de renfort et deux internes. Ce secteur étant également en pression négative, il a été cependant admis que tout patient ayant été orienté dans cette filière et présentant secondairement une suspicion de COVID-19 resterait dans le box qui lui a été attribué, avec la mise en place de mesures d’isolement afin d’éviter la surcharge de travail du personnel paramédical en termes de transferts et de bio nettoyage tout en minimisant les risques de contamination.

Le laboratoire de biologie de l’HIA est en mesure de fournir trois fois par 24 heures des résultats de RT-PCR COVID-19, permettant associé au scanner d’affiner les diagnostics. Les résultats sont rendus en 3 à 4 h.

4. Filière non respiratoire : Le confinement des personnes à leur domicile et les modalités de triage étant susceptible de réduire les admissions au sein du SAU, il était cependant important de maintenir un secteur classique, avec un accès spécifique, pour prendre en charge les patients, en l’absence de suspicion de contamination par le SARS CoV2. Ainsi dans la filière non respiratoire, la surcharge de travail imposé par les EPI, le bio nettoyage, l’allongement global du temps de passage au SAU, les procédures spécifiques des examens complémentaires se ressentent beaucoup moins par l’équipe des soignants. Cette filière est constituée de :

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La zone courte non respiratoire, La zone longue non respiratoire, La SAUV, Le nouvel UHCD, plus à distance.

La SA UV : La SAUV étant localisée au sein de la filière non respiratoire il a été actuellement décidé de n’y admettre que les patients non suspects de COVID-19.

La nouvelle UHCD : Cette unité d’hospitalisation a été transférée, à 50 m du SAU, au sein de l’hôpital de jour de l’HIA et comporte en cette période de crise six lits. Une nouvelle ligne de

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changé son mode de fonctionnement. Basée sur les principes d'anticipation, d’adaptabilité et de disponibilité du personnel, l'organisation mise en place permet de répondre aux besoins locaux.

garde a permis son armement par des médecins nonurgentistes, spécialistes de l’hôpital et par du personnel paramédical (1IDE et 1AS) extérieur au SAU. En cas de dépassement des capacités d’accueil de la filière respiratoire COVID-19 et de l’impossibilité immédiate d’admettre les patients en secteur d’hospitalisation « suspicion COVID » il est bien évidemment prévu d’admettre les patients dans les boxes de la zone longue « non respiratoire » avec les mesures de d’isolement virale.

Déclaration de liens d’intérêts : Les auteurs déclarent ne pas avoir de liens d’intérêts. RÉFÉRENCES 1. Infirmière organisatrice de l’accueil, référentiel SFMU (01-48), 2004.

CONCLUSION

2. gouvernement.fr/info-coronavirus [Internet]. Paris : gouvernement.fr; [mis à jour le 27/03/2020; consulté le 27/03/2020]. Information coronavirus. Disponible sur : https://www.gouvernement.fr/info-coronavirus.

La crise sanitaire liée au SARS CoV2 a imposé aux hôpitaux une réorganisation profonde de leurs activités en se recentrant sur les malades atteints du COVID-19. Grâce aux mesures de confinement du peuple français et à la régulation du centre 15 qui a freiné l’activité classique du service d’urgence, au soutien des services médicaux, chirurgicaux et médicaux techniques (laboratoire et imagerie médicale), mais également à la grande disponibilité des personnels soignants, une organisation cohérente du SAU Laveran pour faire face à cette épidémie a été possible. S’inspirant de la médecine de catastrophe afin de pouvoir faire face à un afflux de patients dans un contexte biologique, le triage, la catégorisation et la création d’une filière spécifique pour les patients COVID-19 susceptibles d’être hospitalisés, doivent permettre l’optimisation de la prise en charge des malades tout en assurant la protection des soignants.

3. Recommandations d’experts portant sur la prise en charge en réanimation des patients en période d’épidémie à SARS-CoV2 Version 2. SRLF-SFAR-SFMU-GFRUPSPILF. 2020. 4. Prise en charge des patients COVID-19, ou suspects, en structures d’urgence, mars 2020 Recommandations fiche mémo. SFMU et SPILF. 2020. 5. EB Medicine [Internet]. Norcross : EB Medicine; [mis à jour le 23/03/2020; consulté le 26/03/2020]. Novel 2019 Coronavirus SARS-CoV-2 (COVID-19) : An Updated Overview for Emergency Clinicians - 03-23-20. Disponible sur : https://www.ebmedicine.net/topics/infectiousdisease/COVID-19.

RÉSUMÉ

6. Handbook of COVID-19 Prevention an Treatment. Zhejlang University School of Medicine. 2020.

L'épidémie de COVID-19 a imposé la réorganisation d’une partie des services d’urgence en France pour faire face à un afflux de patients potentiellement graves. L'hôpital militaire de Marseille, Alphonse Laveran, n'a pas fait exception. En se basant sur l’expérience du triage des malades acquise lors de missions opérationnelles dans les hôpitaux militaires de campagne, le service des urgences de l’Hôpital Laveran a profondément

7. sfmu.org [Internet]. Paris : Société française de médecine d’urgence; [mis à jour le 20/03/2020; consulté le 20/03/2020]. Webinar - COVID-19 retours d’expérience. Disponible sur : https://www.sfmu.org/fr/busdossier/dos_id/115.

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International Review of the Armed Forces Medical Service

Revue Internationale des Services de Santé des Forces Armées

A RT ICLES

Study of the Accuracy of Chest X-Ray in Blunt Trauma Chest.* By P. SHARMA∑, A. VATSA∏ and M. LASKARπ. India

Pawan SHARMA Professor (Dr) Pawan SHARMA (1972) is a medical graduate and post graduate from Armed Forced Medical College, Pune (University of Pune), India. He holds a Post Doctoral Fellowship in Trauma and Critical Care Surgery from All India Institute of Medical Sciences, New Delhi (2014). He is an ACS-CoT recognized ATLS Course Director (2015) and specializes in Trauma training and Trauma Education. Presently, he is Professor and Instructor at Armed Forces Medical College, Pune and trains undergraduates and post graduates in General Surgery. He is an expert in Combat and battlefield Trauma Surgery.

RESUME Sensibilité de la radiographie thoracique face à un traumatisme thoracique contondant. Contexte : Les traumatismes thoraciques sont une cause importante de morbidité et de mortalité chez les soldats comme chez leurs personnes à charge, ceci quelle que soit la tranche d’âge. Une identification précise des lésions est essentielle et la radiographie pulmonaire est la première étape de l’évaluation et du traitement de ces patients. L’étude présentée a été réalisée pour évaluer si la radiographie pulmonaire seule, effectuée au cours de l’examen initial, était un outil suffisamment fiable pour l’évaluation diagnostique d’un traumatisme contondant thoracique et si les données complémentaires fournies par une tomodensitométrie thoracique avaient un réel impact sur les décisions thérapeutiques. L’étude visait donc à évaluer si une tomodensitométrie thoracique devait être effectuée et incluse systématiquement dans le protocole d’investigation de tous les cas de traumatismes thoraciques contondants hémodynamiquement stables. Méthode : Il s’agit d’une étude prospective d’observation et d’évaluation diagnostique menée sur 100 patients ayant présenté un traumatisme thoracique contondant. Cette étude s’est déroulée sur une période de deux ans dans un hôpital de soins tertiaires des Forces armées indiennes. Les analyses descriptives ont été effectuées sur la base de paramètres quantitatifs exprimés sous forme de moyennes et d’écart type. Les données catégorielles ont été exprimées en nombre absolu et en pourcentage. Une évaluation diagnostique détaillée a été réalisée pour distinguer les résultats de la radiographie de ceux de la tomodensitométrie. Cela a permis de présenter des tableaux grâce à l’utilisation du test du X2 . Les résultats des découvertes de la tomodensitométrie thoracique ont été considérés comme étalons vis-à-vis de ceux obtenus par la radiographie. Une valeur de p < 0,05 a été considérée comme statistiquement significative. La version 24.0 du logiciel SPSS a été utilisée pour l’analyse statistique. Résultats : Tous les patients hémodynamiquement stables inclus dans cette étude ont subi une radiographie et un scanner thoracique non contrasté. Il a été démontré que la sensibilité de la radiographie pulmonaire dans la détection d’un hémothorax, d’un pneumothorax ou d’autres blessures (contusion pulmonaire, fractures vertébrales thoraco lombaires, lésions diaphragmatiques, emphysème chirurgical et pneumomédiastin) était significativement plus faible que concernant la détection des fractures des côtes. Chez 71 % des patients, la tomodensitométrie thoracique a identifié des lésions intrathoraciques importantes que la radiographie thoracique n’avait pas permis de repérer. Une différence statistiquement significative a été observée dans les cas d’hémothorax (p = 0,004), de pneumothorax (p < 0,0001) et d’autres blessures comme la contusion pulmonaire, les fractures vertébrales thoraco lombaires et les lésions diaphragmatiques (p = 0,016). VOL. 93/2

Conclusion : Cette étude a permis de conclure que la radiographie pulmonaire effectuée seule à l’occasion de l’examen initial d’un traumatisme thoracique contondant n’était pas un outil suffisamment fiable pour évaluer la gravité du traumatisme en raison de sa faible sensibilité et de sa faible valeur prédictive négative.

International Review of the Armed Forces Medical Services

Revue Internationale des Services de Santé des Forces Armées

Des informations supplémentaires obtenues avec la tomodensitométrie thoracique influencent les décisions thérapeutiques et les interventions ultérieures pour la prise en charge précoce des patients souffrant de traumatisme contondant. Les conséquences thérapeutiques sont importantes et impactent de façon significative le devenir de ces patients.

KEYWORDS: Blunt Trauma Chest, Chest X-Ray, NCCT Chest. MOTS-CLÉS : Traumatisme thoracique contondant, Radiographie thoracique, Tomodensitométrie thoracique.

INTRODUCTION

from the Institutional ethical committee prior to the commencement of the study.

Trauma is one of the leading causes of mortality and permanent disability worldwide. As per WHO Global Health Observatory Data, more than 1.25 million people die due to road traffic accidents each year and an additional 20 to 50 million are injured or disabled1. In India, there is one death every four minutes due to road traffic accidents and 16 children die on Indian roads every day2.

Population for the study was 100 military personnel and their dependents with history of blunt trauma chest following dangerous mechanism of injury as described in ATLS manual 9th edition like fall from a height of more than 3 meters, death of a co passenger, eviction from the vehicle, rollover of the vehicle, frontal vehicular indentation of more than 30 inches after collision, recreational and contact sports injuries etc.

Chest trauma constitutes 10-15% of all injuries and is a significant cause of mortality amongst combatants and their dependents (25% of all fatalities due to trauma). Rib fractures are the most common (up to 25%) injuries resulting from chest trauma3. Minor blunt chest trauma with Injury Severity Score (ISS) of less than 15 is the most common form of blunt chest trauma and comprises more than half of the rib fractures without any significant intrathoracic injuries. Hence, accurate identification of soldiers at high risk for major chest trauma (ISS > 15) is essential and CXR is the first step in diagnosis and treatment of these patients. A quick primary survey can reveal usually expected and clinically apparent injuries like rib fractures, massive pneumothorax or a large hemothorax, but certain potentially life threatening injuries such as pulmonary contusion, occult pneumothorax, small to moderate hemothorax, mediastinal and diaphragmatic injuries, and thoracolumbar vertebral fractures may be missed on chest radiography during primary survey3.

All victims reporting to our Trauma Centre following such injuries who were hemodynamically stable (SBP >90mmHg, HR <100/min, capillary refill <2 seconds, urine output >1ml/kg/hr) after primary survey were included in the study, whereas, children (age <12 years), pregnant women and women of child bearing age group (15-45 years) were excluded from the study in view of potential radiation hazards. The analysis included profiling of patients on different demographic, clinical, laboratory and radiological findings. Descriptive analyses of quantitative parameters were expressed as means and standard deviation. Categorical data were expressed as absolute number and percentage. The analysis included the estimation of proportion with 95% confidence interval. Detailed diagnostic test evaluation was performed for Chest XRay with respect to NCCT chest according to findings. Cross tables were generated and Chi square test was used for testing of significance for association. Results

Chest computed tomography scan is the gold standard imaging tool for chest trauma and can diagnose pulmonary contusion, hemothorax, pneumothorax, rib fractures and thoracic spinal injuries with high sensitivity4. Yet, chest X-Ray is still considered a useful bedside and cost effective modality providing valuable information in the initial evaluation of trauma patients.

∑ Colonel Dr., Department of Trauma, Emergency and Critical Care, Command Hospital, Northern Command. ∏ Colonel, Department of Trauma, Emergency and Critical Care, Command Hospital, Northern Command. π Squadron Leader, Command Hospital, Northern Command.

MATERIALS AND METHODS

Correspondence: Colonel Dr. Pawan SHARMA MS, DNB, FACS, FICS, FCLS, MNAMS, Department of Trauma, Emergency and Critical Care, Command Hospital, Northern Command, Raghunathpura, IND-182101 Udhampur, Jammu and Kashmir, India. E-mail: drpawansharma55@gmail.com

This was a prospective observational and a diagnostic accuracy study that was conducted from December 2016 to November 2018 in a tertiary care hospital of the Indian Armed Forces in the department of Trauma Surgery. Ethical clearance for the study was obtained

International Review of the Armed Forces Medical Services

* Presented at the 43rd ICMM World Congress on Military Medicine, Basel, Switzerland, 19-24 May 2019.

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of the NCCT chest findings were considered as the gold standard for Chest X-Ray findings. For the Chest X-Ray findings sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio positive, likelihood ratio negative and accuracy were calculated by standard methods. P value <0.05 is considered statistically significant. SPSS software Version 24.0 was used for statistical analysis. Patients were followed up at the end of 1 month and 3 months from the date of injury for morbidities/ mortality.

morbidity and mortality were also seen in these 26% patients . NISS was observed to be a better predictor of major trauma (71% with NISS >15) as compared to ISS (only 24% with ISS >15). These 71% patients with NISS >15 required some form of intervention. Hence, NISS was observed to be a good indicator of overall morbidity and mortality. In this study, ISS (≥50) was a better indicator of mortality but ISS lacked in predicting morbidity. ISS was found to be a better predictor of duration of hospital stay as compared to NISS. NISS, on the other hand, was a better indicator of major trauma, and a better predictor of need for intervention and requirement of ICU care. (Fig. 2).

RESULTS A total of 100 patients with a mean age of 38.9 years (standard deviation of 18.1) with history of blunt trauma chest were included. Of these 100 patients, 63 were males and 37 females. As the leading cause of blunt trauma chest was road traffic accidents, 47% of the cases were seen in the age group 21-40 years.

Fig. 2: Trauma scoring: Inj ury Severity Score (ISS), New Inj ury Severity Score (NISS). 100,0% 90,0% 80,0% 76,0%

During the primary survey of the patients, all the patients had a positive chest compression test and 24% had a respiratory rate of more than 16 per minute. On auscultation, 67% had decreased breath sounds. The 24% patients who had a respiratory ratemore than 16 per minute were also found to have flail segments and decreased breath sounds on clinical examination. Of these 24 patients, 5 were found to have an SpO2 between 90 and 94% and the remaining 19 patients had an SpO2 less than 90%. (Fig. 1).

70,0% 60,0% 45,0%

50,0% 40,0%

29,0%

30,0% 14,0%

20,0% 10,0%

26,0%

10,0%

0,0%

Fig . 1: Findings during p rimary survey : Pulse, Resp iratory rate, Sp O2 .

≤15

16-49

50-75

≤15

16-32

ISS

>32

NISS

100,0% 90,0% 80,0%

78,0%

76,0%

All hemodynamically stable patients underwent an XRay chest and an NCCT chest. It was found that Chest XRay had a sensitivity of 94% (95% CI: 87.40% to 97.77%) in detecting rib fractures with a positive predictive value of 100%, positive likelihood ratio of 0.94 and accuracy of 94% (95% CI: 87.40% to 97.77%). However, the sensitivity of Chest X-Ray in detecting hemothorax, pneumothorax and other injuries (lung contusion, thoracolumbar vertebra fractures, diaphragmatic injuries, surgical emphysema and pneumomediastinum) was significantly lower. (Table 1).

76,0%

70,0% 60,0% 50,0% 40,0% 30,0%

24,0%

22,0%

19,0%

20,0% 10,0%

5,0%

Table 1: Comparison of f indings on Chest X-Ray and NCCT chest.

0,0% 60-90

>90

Pulse (Rate/ min.)

12-16

>16

>94

Resp Rate (per min.)

90-94

<90

SpO2 (%)

FINDINGS

Trauma scoring as per Injury Severity Score (ISS) and New Injury Severity Score (NISS) was done for all the patients. It was observed that 24% patients had an ISS >15 (ISS 16-49 in 14% patients, ISS 50-74 in 10% patients). These patients had a longer duration of hospital stay (>30 days). Further, 10% patients who had an ISS ≥50 had poor outcome and did not survive. VOL. 93/2

Out of the 100 patients in the study, 26% patients who had an NISS >32 required admission in ICU. Residual

International Review of the Armed Forces Medical Services

CHEST X-RAY NCCT CHEST

P VALUE

Rib Fractures

100

0.32

Hemothorax

0.004

Pneumothorax

0.0001

Other injuries: Lung, contusion, thoracolumbar vertabral injuries, surgical emphysema, diaphragmatic injuries

0.016

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Blood samples of all the patients were sent for complete hemogram and ABG analysis. The reports revealed that 26% had a HB of less than 10g/dl and a PCV of less than 37%. ABG analysis revealed that 22% had acidosis (pH <7.35). All the patients were scored as per ISS and NISS (Fig. 2). It was observed that 22% patients with ISS >15, NISS >32, pH <7.35, HB <10g/dl and PCV <37% required intubation.

79.85%). Chest X-Ray had an accuracy of 78.00% (95%CI: 68.61% to 85.67%) in detecting such injuries. NCCT chest was significantly more likely to detect these injuries (p = 0.016) as compared to X-Ray chest. In 71% patients, NCCT chest identified significant chest injury intricacies that were missed on Chest XRay. These findings were small to moderate hemothorax (n = 49), occult pneumothorax (n = 19), lung contusion (n = 12), thoracolumbar vertebral injuries (n = 4), surgical emphysema (n = 4), and diaphragmatic injuries (n = 2). NCCT Chest was fundamentally more compelling than routine Chest X-Ray in distinguishing lung injuries. Statistically significant difference was seen in cases of hemothorax (p = 0.004), pneumothorax (p <0.0001), and other injuries like lung contusion, thoracolumbar vertebral fractures, surgical emphysema and diaphragmatic injuries (p = 0.016).

X-Ray chest was found to have a sensitivity of 68.75% (95% CI: 58.48% to 77.82%) in detecting hemothorax with a specificity and a positive predictive value of 100%. It had a negative likelihood ratio of 0.31 (95% CI: 0.23 to 0.42), a negative predictive value of 11.76% (95% CI: 9.02% to 15.21%) and an accuracy of 70% (95%CI: 60.02% to 78.76%). NCCT chest was significantly more effective than chest X-Ray in detecting hemothorax (p = 0.004). X-Ray chest had a sensitivity of 71.64% (95% CI: 59.31% to 81.99%) in detecting pneumothorax. It had a specificity and positive predictive value of 100% for pneumothorax. The negative likelihood ratio was 0.28 (95% CI: 0.19 to 0.41) and the negative predictive value was 63.46% (95% CI: 54.28% to 71.76%). The accuracy of chest X-Ray was 81.00% (95% CI: 71.93% to 88.16%) in detecting pneumothorax. (Table 2).

Of all the 100 patients, 29% did not need any form of intervention and were managed with analgesics and incentive spirometry. Intercostal drain placement was sufficient for management of 65% patients. The remaining 6% underwent Video Assisted Thoracoscopic Surgery (VATS) for retained hemothorax and diaphragmatic injuries. In this study, the observation of additional NCCT Chest findings in 41% patients (occult pneumothorax in 19%, lung contusion in 12%, thoracolumbar vertebral injuries in 4%, surgical emphysema in 4% and diaphragmatic injuries in 2%) brought about a difference in treatment in these patients in the form of chest tube placement, chest tube adjustment of pneumothoraces or huge hemothoraces, VATS, ICU care and change in mode of ventilation and respiratory care.

X-Ray chest had a very low sensitivity of 15.38% (95% CI: 4.36% to 34.87%) in detecting injuries like lung contusion, thoracolumbar vertebral injuries, surgical emphysema and diaphragmatic injuries. The specificity and positive predictive value of chest X-Ray was 100% for these injuries. The negative likelihood ratio was found to be 0.85 (95% CI: 0.72 to 1.00) and the negative predictive value was 77.08% (95% CI: 74.06% to

Table 2: Diagnostic evaluation of Chest X-Ray in comparison to NCCT chest for various chest injuries. RIB FRACTURES

STATISTICAL PARAMETER

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HEMOTHORAX

PNEUMOTHORAX

OTHER INJURIES

VALUE

95% CI

VALUE

95% CI

VALUE

95% CI

VALUE

95% CI

Sensitivity

94%

87.40% to 97.77%

68.75%

58.48% to 77.82%

71.64%

59.31% to 81.99%

15.38%

4.36% to 34.87%

Specificity

100%

39.76% to 100%

100%

89.42% to 100%

100%

95.14% to 100%

Positive Predictive Value

100%

Negative Predictive Value

11.76%

9.02% to 15.21%

63.46%

54.28% to 71.76%

77.08%

74.06% to 79.85%

Accuracy

94%

87.40% to 97.77%

70%

60.02% to 78.76%

81%

71.93% to 88.16%

78.00%

68.61% to 85.67%

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Revue Internationale des Services de SantĂŠ des Forces ArmĂŠes

Fig . 5: Bilateral p osterior basal lung contusions with a small right sided pneumothorax apparent on NCCT chest whereas CXR of the same patient app ears normal.

All 24 patients with flail chest required ICU admission and had a high mortality or morbidity after a follow up period of 3 months in the form of pain at the site of fractures. Out of these 24 patients, 22 patients needed intubation and mechanical ventilation. Mortality was high (10 out of 22 patients) in this subgroup of patients with flail chest who needed mechanical ventilation. Six patients including one with traumatic diaphragmatic hernia and five with organized hemothoraces underwent VATS. All these six patients had residual morbidity in the form of post op pain and atelectasis requiring bronchoscopy during the initial follow up period of 1 month. However, patients who were operated for organized hemothorax had a complete recovery in their follow up after three months. The patient with traumatic diaphragmatic hernia had residual pain at the operated site in the follow up visit after three months. Fig . 3: Patient Outcome. Morbidity: 16%

Mortality: 10%

DISCUSSION Chest X-Ray continues to be an important adjunct during primary survey of a trauma victim, especially in those with suspected thoracic injuries. In view of limited information provided by CXR in such a scenario, NCCT is being increasingly used for early evaluation and possible interventions of intrathoracic chest injuries which otherwise are missed on a CXR in those who are hemodynamically stable. Based on the findings of the present study, CXR was found to have significantly low sensitivity and negative predictive value in diagnosing traumatic intrathoracic injuries compared to chest NCCT scan. The screening characteristics of CXR are less than 72% in all pathologies except rib fractures (94%). Carrying out a physical examination and CXR are considered as the first step in diagnosing traumatic chest injuries. El Wakeel et al. in their study of 100 blunt chest trauma patients showed a higher sensitivity of CT scan compared to CXR in detection of intrathoracic injuries13 .

Recovered: 74%

Out of all the 100 patients included in the study, 74% recovered uneventfully after a follow up period of 3 months. The remaining 26% patients who were admitted in ICU had residual morbidity or mortality. Morbidity was seen in 16 patients in the form of pain at the site of fractured ribs, scapula, and thoracolumbar vertebrae. The overall mortality was 10%. These 10% patients also had associated injuries (head injuries, cervical spine injuries, intra-abdominal solid organ injuries) and an ISS ≥ 50. Fig . 4: Apparently normal app earing chest radiograph (Lef t) missed a signif icant lef t sided Hemopneumothorax p icked up on NCCT (Right).

International Review of the Armed Forces Medical Services

In another study, Eckstein et al. estimated the sensitivity of CXR to be 42% in diagnosis of pneumothorax 19 . They also concluded that the diagnosis of hemothorax with CXR is difficult due to various reasons. Improper preparation of the patient and inability to be in an upright position before radiography were the most important of these reasons. In our study, sensitivity and specificity of CXR in diagnosis of pulmonary contusion were estimated to be 15.38% and 100%, respectively as compared to 40% and 100% observed by Eckstein et al17 . CT scan continues to be the gold standard investigation for blunt thoracic trauma cases which can diagnose rib fracture, hemothorax, pneumothorax, pulmonary contusion, diaphragmatic injuries and thoracolumbar vertebral injuries with high sensitivity 11, 15, 17, 18, 19 . Chardoli et al. conducted a study on 200 patients to detect the accuracy of CXR and CT scan of chest in hemodynamically stable patients with blunt chest trauma. The sensitivity of CXR for hemothorax, thoracolumbar vertebra fractures and rib fractures were 20%, 49% and 49%, respectively. The authors concluded that applying CT scan as the first-line diagnostic modality in hemodynamically stable patients with blunt chest trauma can detect pathologies which may change management and outcome15.

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In our study, NCCT chest distinguished significant chest injury details in 71% patients that were missed on CXR. These findings were small to moderate hemothorax, occult pneumothorax, lung contusion, thoracolumbar vertebral injuries, surgical emphysema and diaphragmatic injuries. Further, additional NCCT Chest findings in 41% patients (occult pneumothorax in 19%, lung contusion in 12%, thoracolumbar vertebral injuries in 4%, surgical emphysema in 4% and diaphragmatic injuries in 2%) brought about a difference in management in the form of chest tube placement, chest tube adjustment for pneumothoraces or large hemothoraces, Video Assisted Thoracoscopic Surgery (VATS), ICU care, change in mode of ventilation and respiratory care. This difference ultimately had an impact in the patient outcome. These finding correspond to observations in a similar study by Trupka A et al. conducted on 103 patients16.

years at a tertiary care hospital of the Indian Armed Forces. Descriptive analyses of quantitative parameters were expressed as means and standard deviation. Categorical data were expressed as absolute number and percentage. Detailed diagnostic test evaluation was performed for CXR with respect to NCCT chest according to findings. Cross tables were generated and chi square test was used as test of significance for association. Results of the NCCT chest findings were considered as the gold standard for CXR findings. P value < 0.05 was considered statistically significant. SPSS software Version 24.0 was used for statistical analysis. Results: All hemodynamically stable patients underwent CXR and a Non Contrast CT (NCCT) scan of chest. It was found that the sensitivity of CXR in detecting hemothorax, pneumothorax and other injuries (lung contusion, thoracolumbar vertebral fractures, diaphragmatic injuries, surgical emphysema and pneumomediastinum) were significantly lower as compared to detection of rib fractures. In 71% patients, NCCT chest identified significant intrathoracic chest injuries which were missed on Chest X-Ray. Statistically significant difference was seen in cases of hemothorax (p = 0.004), pneumothorax (p <0.0001), and other injuries like lung contusion, thoracolumbar vertebral fractures and diaphragmatic injuries (p = 0.016).

CONCLUSION From our study it was concluded that the sensitivity and negative predictive value of chest X-Ray was significantly low for hemothorax, pneumothorax, pulmonary contusions, thoracolumbar vertebral injuries, diaphragmatic injuries and subcutaneous emphysema despite its higher specificity and positive predictive value in diagnosing these injuries in blunt trauma chest. Further, it was observed that chest X-Ray performed alone during primary survey is not a reliable tool for evaluation of blunt trauma chest due to its low sensitivity and low negative predictive value. Additional information obtained with NCCT chest influences subsequent therapeutic decisions for early management of blunt trauma chest patients and also leads to a significant change in their outcome. Therefore, it is strongly recommended that NCCT scan of chest should be performed and included as a protocol in all hemodynamically stable cases of blunt trauma chest and availability of a CT scanner in military medical establishments wherever feasible, will go a long way in minimizing morbidity and mortality consequent to missed thoracic injuries amongst our combatants and their dependents.

Conclusion: It was concluded from the study that the CXR alone performed during primary survey is not a reliable tool for evaluation of blunt trauma chest due to its low sensitivity and low negative predictive value. Additional information obtained with chest CT scan influences subsequent therapeutic decisions and interventions for early management of blunt trauma chest patients which in turn, leads to a significant change in outcome of such patients. Conflict of interests: None REFERENCES 11. WHO Global Health Observatory data – May 2017. http://www.who.int/mediacentre/factsheets/ fs358/en/

ABSTRACT Rationale: Chest trauma is a significant cause of morbidity and mortality amongst soldiers and their dependents across all age groups. Accurate identification of such patients is essential and chest X-Ray (CXR) is the first step in evaluation and treatment of such patients. The study was carried out to evaluate whether CXR alone performed during primary survey is a reliable tool for evaluation of blunt trauma chest and whether additional information obtained with chest computed tomography scan (CT scan) influences subsequent therapeutic decisions. The study also aimed to assess whether CT scan of chest should be performed and included as a protocol in all hemodynamically stable cases of blunt trauma chest. VOL. 93/2

12. Tackling the Challenges of Unsafe Vehicles on Indian Roads by Indians for Road Safety. https://en.wikipedia.org/wiki/Traffic collisions in India. 13. PINKI KUMARI. Comparative analysis of efficacy of chest X-Ray and Chest CT scan in-patient with chest trauma: A retrospective study. International Journal of Contemporary Medicine Surgery and Radiology. 2017; 2 (2): 62-64. 14. TURK F, KURT AB, SAGLAM S. Evaluation by ultrasound of traumatic rib fractures missed by radiography. Emerg Radiol. 2010; 17: 473. 15. ATLS® Student Course Manual 9th Edition. 16. SCAGLIONE M, PINTO A, PEDROSA I, SPARANO A, ROMANO L. Multi-detector row computed tomography and blunt chest trauma. European journal of radiology. 2008; 65 (3): 377-88.

Methods: This was a prospective observational and diagnostic accuracy study that was conducted on 100 patients of blunt trauma chest over a period of two

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17. G.P. SANGSTER, A. GONZÁLEZ-BEICOS, A.I. CARBO et al., “Blunt traumatic injuries of the lung parenchyma, pleura, thoracic wall, and intrathoracic airways: multi-detector computer tomography imaging findings,” Emergency Radiology , vol. 14, no. 5, pp. 297–310, 2007. 1 18. LIVINGSTON DH, SHOGAN B, JOHN P, LAVERY RF. CT diagnosis of rib fractures and the prediction of acute respiratory failure. Journal of Trauma and Acute Care Surgery . 2008; 64 (4): 905-11.

14. TRAUB M, STEVENSON M, McEVOY S, et al. The use of chest computed tomography versus chest X-Ray in patients with major blunt trauma. Inj ury . 2007; 38 (1): 43-7. 15. CHARDOLI M, HASAN-GHALIAEE T, AKBARI H, RAHIMIMOVAGHAR V. Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma. Chinese Journal of Traumatology . 2013; 16 (6): 351-4.

19. BRINK M, KOOL D, DEKKER H, et al . Predictors of abnormal chest CT after blunt trauma: a critical appraisal of the literature. Clinical radiology. 2009; 64 (3): 272-83.

16. TRUPKA A, WAYDHAS C, HALLFELDT KK, NAST-KOLB D, PFEIFER KJ, SCHWEIBERER L. Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study. J Trauma. 1997; 43: 405-11.

10. EXADAKTYLOS A, BENNEKER L, JEGER V, et al. Total-body digital X-Ray in trauma: an experience report on the first operational full body scanner in Europe and its possible role in ATLS. Inj ury. 2008; 39 (5): 525-9.

17. ECKSTEIN M, HENDERSON SO. Thoracic Trauma in Rosen’s Emergency Medicine. Philadelphia: Mosby Elsevier; 2010.

11. KAEWLAI R, AVERY LL, ASRANI AV, NOVELLINE RA. Multidetector CT of Blunt Thoracic Trauma1. Radiographics . 2008; 28 (6): 1555-70.

18. GUERRERO-LÓPEZ F, VÁZQUEZ-MATA G, ALCÁZA R-ROMERO PP, FERNÁNDEZ-MONDÉJAR E, AGUAYO-HOYOS E, LINDEVALVERDE CM. Evaluation of the utility of computed tomography in the initial assessment of the critical care patient with chest trauma. Critical care medicine. 2000; 28 (5): 1370–5.

12. MAYBERRY JC. Imaging in thoracic trauma: the trauma surgeon’s perspective. Journal of thoracicimaging . 2000; 15 (2): 76-86.

19. RENTON J, KINCAID S, EHRLICH P. Should helical CT scanning of the thoracic cavity replace the conventional chest X-Ray as a primary assessment tool in pediatric trauma? An efficacy and cost analysis. Journal of pediatric surgery . 2003; 38 (5): 793–7.

13. EL WAKEEL MA, ABDULLAH SM, EL KHALEK RSA. Role of computed tomography in detection of complications of blunt chest trauma. Menoufia Medical Journal. 2015; 28 (2): 483.

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The Development and Introduction of the United Nations Buddy First Aid Course. By MCM. BRICKNELL∑, C. BOOKER∏, A. TIWATHIAπ and J. FARMER∫. United Kingdom

Martin CM BRICKNELL Professor BRICKNELL took up his appointment as Professor in Conflict, Health and Military Medicine at King’s College London in April 2019. Prior to his he served 34 years in the UK Defence Medical Services, culminating his service as the Surgeon General of the UK Armed Forces. He undertook operational tours in Afghanistan, Iraq, and the Balkans w ith mult iple addit ional overseas assignments. In 2010 and 2006, he held senior Medical Adviser appointments in the NATO ISAF mission. He commanded 22 Field Hospital in 1999-2002. He has trained as a general practitioner and is an accredited specialist in both Public Health and Occupational Medicine. He holds two doctorates and 3 masters degrees. He has published over 100 academic papers across military medical subjects. He is especially interested in how organisations learn, care pathways in military healthcare, and the political economy of health in conflict. He was awarded the Companion of the Order of Bath, the Order of St John and the US Bronze Star during his military service.

RESUME Développement et introduction du cours de premier secours des Nations Unies pour les camarades de combat. Cet article décrit le développement du cours de premiers secours des Nations Unies qui deviendra la norme minimale pour les premiers secours du personnel militaire et policier au sein des opérations de maintien de la paix (OMP) des Nations Unies. Cet article expose également les raisons de la révision du système de soutien médical pour les OMP des Nations Unies et les principales activités du programme d’amélioration médicale. L’élaboration du programme d’étude et du système de formation du cours de premiers secours des Nations Unies est basée sur les meilleures pratiques internationales. Ce programme a été expérimenté dans le cadre d’une série de cours de « formation des formateurs » auxquels ont participé des représentants des pays contributeurs de troupes des Nations Unies. Le cours de premiers secours des Nations Unies sera diffusé dans le courant de l’année 2020.

KEYWORDS: First aid, United Nations, Emergency medicine. MOTS -CLÉS : Premiers soins, Premiers secours, Nations Unies, Médecine d’urgence.

INTRODUCTION

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trauma at the point of injury; specifically, the life-saving re-introduction of a focus on stopping catastrophic bleeding through direct pressure and tourniquets2, 3, 4 . This is part of the package of basic first aid skills to be taught to all military personnel.

This paper describes the introduction of the United Nations Buddy First Aid Course (UN BFAC) in the context of a wider programme to improve the medical support arrangements for United Nations Peacekeeping Operations (UN PKO). This programme reflects the advances in military medical care that have occurred in the context of other coalition or allied military operations1. In particular, the UN BFAC is designed to adopt the innovations that have occurred in the immediate treatment of conflict-related

International Review of the Armed Forces Medical Services

IMPROVING THE FRAMEWORK FOR MEDICAL SUPPORT TO UN PEACEKEEPING OPERATIONS The nature of United Nations peacekeeping missions has changed, with more intra-state rather than inter-state

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DEVELOPMENT OF THE UN BFAC

conflict, a new generation of weapons being used, and peacekeepers being explicitly targeted by the parties to conflict5. There have been 3,868 fatalities on UN PKO of which 189 occurred over the period 2013-20176. Concerns about the cost and effectiveness of UN PKO resulted in a review of the conduct of UN PKO by the High-level Independent Panel on UN Peace-keeping Operations (HIPPO)7. The report was far-reaching and included the following observation ‘missions must deploy with the necessary military and medical capabilities and security procedures to deal with emergencies upon arrival’. It recommended that ‘measurable, effectsbased and performance-focused standards are required for the future, with a particular focus on developing performance standards for specialized capabilities such as medical capabilities’. This recommendation increased the responsibility of the United Nations Headquarters for ensuring medical support arrangements to United Nations field missions. International collaboration was enhanced by the development of a ‘medical group of friends’by supportive nations in 2017.

The UN BFAC curriculum was developed with the assistance of the United Nations Mine Action Program. After a thorough review of available Member State programs, the curriculum was adapted from the “Life Saver” program developed by the State of Israel for their first aiders. It uses the MARCH mnemonic (M-massive bleeding, R-respiration, C-circulation, H-heat/cold) that originated from the US Tactical Field Care drills within the Tactical Combat Casualty Care framework12. There are 9 modules of competency: first aid and the medical evacuation chain, general scene and primary assessment, tourniquets for extremity haemorrhage, wound packing for limb injuries not amenable to tourniquet application, airway management, chest injuries, emergency pressure bandages, heat disorders, casualty movement techniques. The legend for the UN BFAC graphics is shown in Figure 1. This curriculum was developed into a teaching course that was supported by graphics and teaching material that could be delivered in any language and with lowcost audio-visual support (posters and printed material rather than PowerPoint presentations). The intended training environment was expected to be highly flexible, including outdoor recreational or training areas normally used for other military activities.

The programme to improve medical support for UNPKO is based on a ‘chain of care’comprising 5 steps: buddy first aid, field medic assistant, casualty evacuation (CASEVAC), level 1 field clinics, and hospital care (level I +, II and III). It uses the planning timeline of 010 minutes for first aid and medic care, 0-1 hour to level 1 clinic resuscitation, and 0-2 hours to hospital care. A medical project plan was developed that contained the following 8 streams: development and implementation of a United Nations Buddy First Aid Course (UN BFAC) for all military and police personnel; development and implementation of a Field Medic Assistant training package; development and implementation of a CASEVAC Policy; standardisation of Health Care Quality and Patient safety in Level I Facilities; standardisation of Health Care Quality and Patient safety in Level I +/II/III Facilities; implementation of a Health Risk Assessment in all missions; development of standards for an Aero Medical Evacuation Team (AMET); and formation of a dedicated United Nations Medical Centre of Expertise. Medical arrangements on UNPKO came under further scrutiny through the publication of the Cruz Report8. This report observed that ‘to save lives after attacks occur, improving the quality and availability of first aid and Level 1 hospitals is crucial’. It strongly endorsed this medical project plan. UN Policy for Casualty Evacuation in the Field was published in March 20189 and was recently revised after stress testing was conducted in 4 high risk missions (MALI, Central African Republic, DRC and South Sudan). The United Nations published a Declaration of Shared Commitments on UNPKO in September 2018 that has been endorsed by 150 nations. This includes the provision of well-trained and equipped personnel and the obligation on the United Nations to provide training materials and standards that match operational requirements10. The formal United Nations request for uniformed capability requirements published in May 2019 included a specific request for support in first aid training (using the United Nations standard) to troop contributing nations11.

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The pilot course for the UN BFAC took place in Entebbe, Uganda in February 2018, delivering UN BFAC training to 24 students representing 15 UN Member states. This was designed to test and evaluate the draft training material and the ‘train-the-trainer’material. This pilot demonstrated the validity of the curriculum and teaching material for the UN BFAC course.

IMPLEMENTATION AND ROLLOUT OF THE UN BFAC It was clear that the United Nations could not deliver UN BFAC training to all personnel on UNPKO, indeed it is a national responsibility to provide their contingents to UN PKO missions trained for their role. Therefore, it was decided that the United Nations should train ‘mastertrainers’for Member States deploying troops to UN PKO. These Master Trainers would cascade the training in their ∑ Professor, Conflict, Health and Military Medicine. ∏ Squadron Leader RAF, HQ Joint Medical Group. π Dr, Senior Medical Officer, Clinical Governance Section, Division of Healthcare Management and Occupational Safety and Health. ∫ Dr, United Nations Medical Director Division of Healthcare Management and Occupational Safety and Health. Correspondence: Lt Gen (Rtd) Professor Martin CM BRICKNELL Professor of Conflict, Health and Military Medicine Conflict and Health Research Group School of Security Studies King’s College London K7.26 Kings Building London, WC2R 2LS E-mail: martin.bricknell@kcl.ac.uk

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Figure 1: UN BFAC Legend Card.

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In December 2018, the UN BFAC Master Trainer course was piloted at the United Nations Global Service Centre (UNGSC), Brindisi. This course comprised a UN BFAC course and an Instructional Techniques course. The latter course covered: roles and responsibilities, student engagement, planning and preparing a lesson, lesson structure, skills analysis, delivering training, selection and use of training aids, and confirmation of learning. Following the didactic phase, students were then required to teach back lessons and scenarios based upon the UN BFAC syllabus.

own countries by conducting Train the Trainer programmes within their national armed services to implement UN BFAC as the minimum requirement within their training systems. They would also provide oversight to the implementation of United Nations BFAC into the training pathway for their UN PKO contingents. This mirrors the cascade arrangements that many nations already use to teach point-of-injury first aid to their own military personnel. UN BFAC would be the United Nations training standard and contingents deployed in UNPKO would be assessed against this skill set. In the future, the UN BFAC material would also be made available to nations who provide training support as part of bilateral capacity-building programmes to support nations who are preparing contingents for UNPKO. This model is also applicable within the pre-deployment training pathway for police personnel assigned to UN PKO.

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The instructional staff reviewed the performance of the participants. Over the course of the week it became apparent there was variation in their initial knowledge and instructional skills. Unfortunately, some were unable to successfully pass the UN BFAC at their first attempt, let alone reach the level of a certified UN BFAC Master Trainer. This was an important insight into the variance in the nominations of candidates made by the Member States and the outcomes of the course. It

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was agreed that the participants would be awarded one of the following 4 levels: certified as a UN Master Trainer and able to train trainers, certified as a Trainer to deliver UN BFAC to students, certified as having passed the UNBFAC training and certified as an attendee of the UNBFAC Master Trainer Course. Overall, the UN BFAC Master Trainer Pilot Course was deemed successful; 22 students attended the course and 15 nations were represented. Over 70% of students attending achieved trainer status; with 50% being accredited as UN BFAC Master Trainers. Further courses have taken place in Renmore Barracks in Galway (Ireland, March 2019), within the United Nations Multidimensional Integrated Stabilization Mission in Mali (MINUSMA, April 2019) and in Salvador City, Brazil (September 2019). A photograph from one of the courses is shown at Figure 2. The concept of the cascade training was tested by having these Master Trainers and Trainers send their training dates and names of the trainees, s igned by their Senior Officers to the Division of Healthcare Management and Occupational Safety and Health at the UN, where a database is being maintained. Figure 2: UN BFAC Master-Trainer Course showing students f rom India and Ghana at the Irish UN Training Centre, Galway.

UNBFAC performance will be provided to United Nations missions to support training and missionrehearsal of military contingents’ incident response capabilities.

CONCLUSIONS This paper has provided a summary of the development of the United Nations Buddy First Aid Course within a wider prog ramme that aims to improve the performance of the medical support system within United Nations peace-keeping operations. It has described how the curriculum was developed and then the design of the cascade system for implementation. The importance of ‘master-trainers’to the whole project has been emphasised alongside the method for dissemination of reference material and instructional aides. We hope that the military medical community will embrace these developments and either introduce the United Nations BFAC within their own armed forces or collaborate with the United Nations to agree reciprocal recognition of their national military point-of-injury first aid training. Acknowledgement The following nations contributed funds, personnel or hosted training in support of this proj ect: Australia, Brazil, the People’s Republic of China, Denmark, France, Germany, Ireland, the State of Israel, Japan, Luxembourg, Republic of Mauritius, the Kingdom of the Netherlands, Nigeria, Norway, Sweden, United Kingdom of Great Britain and Northern Ireland and the United States of America. The views expressed herein are those of the authors and do not necessarily reflect the views of the United Nations.

ABSTRACT

It is expected that the UNBFAC will move into “business as usual” after promulgation in 2020, when a critical mass of Troop Contributing Countries master trainers will allow delegated certification of national training centres. The course material will be made available electronically to nations in both English and French. The material is also supported by a UN BFAC app, for both the Android and Apple platforms, which individual personnel are able to download to their personal electronic devices. This acts as both an aide-memoire for use before embarking on a patrol, during an incident, and also as reference source to maintain their knowledge. Finally, a standardised system of assessment of

International Review of the Armed Forces Medical Services

This paper describes the development of the United Nations Buddy First Aid Course (UN BFAC) that will become the minimum standard for first aid performance for military and police personnel on United Nations Peacekeeping Operations (UN PKO). It explains the rationale for the review of the medical support system for UN PKO and the key activities within the medical improvement programme. The development of the UN BFAC curriculum and training system is based on international best practice. This has been piloted through a series of ‘train-the-trainer’courses that were attended by representatives of UN troop contributing nations. The UN BFAC will be promulgated during 2020. REFERENCES 11. Inter Allied Confederation of Medical Reserve Officers. Combat Casualty Care Resource Page. Available at: https://ciomr.org/3c-resources/#1548613872780-ac6ffa043f1b 12. KRAGH JF, DUBICK MA. Battlefield Tourniquets: Lessons Learned in Moving Current Care Toward Best Care in an

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Army Medical Department at War. US Army Med Dep J. 2016 Apr-Sep; (2-16): 29-36.

18. Improving security of UN Peacekeepers. (Cruz Report) United Nations 19 Dec 2017. Available at: https:// peacekeeping.un.org/sites/default/files/ improving_security_of_ united_nations_peacekeepers_report.pdf.

13. BRODIE S, HODGETTS TJ, OLLERTON J, et al Tourniquet Use in Combat Trauma: UK Military Experience Journal of the Royal Army Medical Corps 2007; 153: 310-313.

19. Casualty Evacuation in the Field. Policy. United Nations Department of Peacekeeping Operations. Ref 2018.02 dated 01 Mar 2018. Available: http://dag.un.org/ handle/ 11176/400762.

14. SHLAIFER A 1, YITZHAK A, BARUCH EN, SHINA A, SATANOVSKY A, SHOVALI A, ALMOG O, GLASSBERG E.J. Point of injury tourniquet application during Operation Protective Edge-What do we learn? Trauma Acute Care 2017 Aug; 83 (2): 278-28 3. doi: Surg . 10.1097/TA.0000000000001403.

10. Action for Peacekeeping. Declaration of shared commitments on UN peacekeeping operations. United Nations. Available at: https:// peacekeeping.un.org/sites/default/files/a4p-declaration-en.pdf

15. Action 4 Peacekeeping (A4P) Factsheet ‘Challenges’. Available at: https:// peacekeeping.un.org/sites/default/files/a4p-factsheet-challenges.pdf Accessed 20 Oct 2019.

11. Current and Emerging Uniformed Capability Requirements for United Nations Peacekeeping. UN Department of Peace Operations. Dated May 19. Available at: https:// peacekeeping.un.org/sites/default/files/ uniformedcapability-requirements-un-peacekeeping_ may-2019.pdf accessed 20 Oct 2019.

16. United Nations Peacekeeping. Fatalities. Available at: https:// peacekeeping.un.org/en/fatalities 17. Report of the High-level Independent Panel on Peace Operations on uniting our strengths for peace: politics, partnership and people. (HIPPO Report) United Nations. A/70/95 – S/2015/446 dated 15 Jun 2015. Available at: https://www.un.org/en/ga/search/view_doc.asp?symbol=S/ 2015/446.

12. BUTLER FK. Two Decades of Saving Lives on the Battlefield: Tactical Combat Casualty Care Turns 20. Military Medicine. 2017; 182: e1563– e1568. https://doi.org/ 10.7205/ MILMED-D-16-00214

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Medical Management in Military Operations: Is there a Medical Command?* By J-A WEBER∑ and G. CASSOURRET∏. France

Julie-Anne WEBER Médecin-en-chef (OF-4) Julie-Anne WEBER is a medical doctor in the French Military Health Service. After her medical degree, she served five years supporting an armoured cavalry battalion. During that period, she obtained a specialization in emergency medicine and another one in sports medicine and was deployed twice in Afghanistan and in Central African Republic. After one year as Medical Operation Officer in Eurocorps, she joined the Operations Division at the Surgeon General Office. Then, she attended the Ecole de Guerre, the French Joint Military College. She is currently posted at the French Permanent Joint Headquarters.

RESUME Le management médical dans les opérations militaires : peut-on parler de commandement médical ? Une chaîne de commandement unique garantit la cohérence et l’efficacité des opérations militaires, par nature complexes. Néanmoins, au sein de nombreuses armées, le soutien médical relève d’une direction médicale qui représente une autorité technique et qui est intégrée à la chaîne de commandement interarmées. Dans les armées françaises, la chaîne de commandement médical s’est construite progressivement. Elle est maintenant forte et robuste garantissant aux soldats malades et blessés de bénéficier du meilleur traitement possible, au meilleur moment et au meilleur endroit compte tenu de la situation opérationnelle. En pouvant déléguer la planification et la conduite du soutien médical à un expert légitime, le commandement se voit renforcé.

KEYWORDS: Medical command and control, Medical leadership, Medical command, Management, Military operations.

MOTS -CLÉS : ‘Command and Control’ médical, Direction médicale, Commandement médical, Management, Opérations militaires.

This article is based on the lecture made by the first author the 23th of May 2019 during the plenary session 4, Leadership in Medicine and Lean Medical Management, at the 43rd ICMM World Congress on Military Medicine.

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∑ Médecin-en-chef (OF-4), French Military Health Service. ∏ Médecin-principal (OF-3), French Military Health Service. Correspondence: Médecin-en-chef Julie-Anne WEBER, Ministère des armées, Direction centrale du service de santé des armées, 60, boulevard du général Martial Valin, CS 21623. 75 509 Paris Cedex 15 E-mail: julie-anne.weber@intradef.gouv.fr

Medical practice in a military operation has many specific characteristics. The need for an effective organization is definitely one of the most preeminent. Maurice Druon, thus prefaced a book on the history of military medicine: « Where does a man need to be rescued with the most speed and certainty in the medical act than on

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* Presented at the 43rd ICMM World Congress on Military Medicine, Basel, Switzerland, 19-24 May 2019.

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« MEDICAL COMMAND », AN INACCURATE TERM

the battlefield? (…) Where does medicine need a more rigorous organization and more ardent research to be as effective as possible than in the armed forces? »1.

The necessary coherence in space and time of military action, as a whole, enshrines the notion of unity of command. The unity of command integrates every action of all the military components within the complexity of the operational situation. This ensures the effectiveness of the military action.

The question of a medical command has remained quite complex. However, referring to the main principles of the operational command may help to solve the equation between medical practice, in the field, operational command, as an overall system and medical leadership, which has proven to be essential for the management of medical resources.

We can illustrate this complexity with the example of medical evacuation in operation, referring to NATO doctrine. The Patient Evacuation Coordination Cell (PECC) is medical staff part of the Joint Operational Center (JOC)2, coordinating forward and tactical medical evacuation. Sending medical evacuation assets, on the proposal of the PECC remains the decision of the JOC. JOC duty officer is the only one to have an overall operational picture, which is critical to articulate the different on-going military actions. This integrated system is clearly an asset for military organizations, ensuring the effectiveness of all the components.

DEFINING « COMMAND », A PREREQUISITE BEFORE ADDRESSING « MEDICAL COMMAND » The military command refers to two concepts. First, command is the authority that a person in the military service lawfully exercises over subordinates, by virtue of their rank and assignment. It is also based on the principle of legitimacy - essential for the recognition of this authority - and on the principle of persuasion, which helps to generate adherence. This directly refers to the concept of leadership. Leadership and command are definitely the keystones of military institutions. Command and management are sometimes opposed, but they certainly have several common characteristics: - the military commander leads men and women; - their authority allows them to guide the efforts of the soldiers; - they set common objectives; - and finally, they give a guideline for the action.

The involvement of medical staff within the joint command, at the strategic level, the operative level and the tactical level ensures the proper use of medical capabilities and the continuum of care. The military physician is not only a caregiver, he also advises the command and manages integrated healthcare. It is not strictly a specific command but an ‘embedded’expert at each level, operative and strategic, within the military command.

THE GRADUAL ESTABLISHMENT OF THE MEDICAL COMMAND AND CONTROL

The main difference between military command and management is that military command leaves little room for personal initiative. It is appropriate for crisis management and thus for military operation management. Military command remains a characteristic of military medical practice, and has proven to be one of its main assets. It endows the military physician to lead their team throughout the care of the wounded, sometimes in isolation and in nonpermissive environments.

With regard to the French Military Health Service, challenges has historically raised from the lack of medical leadership. During the First World War, the blatant failure of the health support during the « Chemin des Dames » battle in Picardy led to a major reorganization of the military health services. Until then, medical doctors were confined to a technical role, and line officers were in charge of coordinating medical evacuations from the front to the rear. 29,000 soldiers died. From 16 to 20 April 1917, 40,000 soldiers were wounded in the front. It led to an influx of wounded soldiers, highlighting the failure of triage and the lack of capability to absorb the flow of moderately injured. The medical staff requested the most seriously wounded to be evacuated to Paris in order to relieve overworked surgical teams. However, medical trains initially evacuated only the slightly injured and not the most seriously wounded. After this dramatic episode, the Under-Secretary of State for the Military Health Service, obtained, in May 1917, the assignment of military physicians at various decision-making levels. They were in charge of evacuation and hospitalization strategies. For the first time, medical doctors were assigned to headquarters. With a fine knowledge of the operational plans, they could anticipate the best position for medical capacities and appropriately dispatch medical evacuation services. From then, the need for a

Describing a more modern concept, command represents a complex activity that combines the interaction of three components: command organization, command systems and command processes. Since the 1970s, have heard been described several stages of the concept of command: C2 (Command and Control), C3I (Command, Control, Communications and Intelligence) and now C4I2 (Command, Control, Communications, Computer, Intelligence and Interoperability). This evolution reflects the increasingly complexity of the concept of command. The three components are brought together in a system that is coherent in space and time to ensure the effectiveness of the military action. Its purpose is to plan, design, conduct and control operations, which gives a leader the authority to direct forces at different levels with coherence and effectiveness.

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medical expertise to ensure the coherence in the care of the war wounded was obvious. Much later, during the first Gulf War of 1990-1991, the significant medical contingent, and the complexity of the medical chain, led the office of the Surgeon General to structure a medical chain of command. It created a theatre-level Medical Director, and an Operational Cell at the strategic level dedicated to conduct medical support. Since then, the medical command and control has become stronger and more robust, and always integrated within the overall operational command3 .

able to analyze a situation, to prioritize the actions, to design and plan medical support, to coordinate the action of the medical units, and then to control orders enforcement, to lead medical technical activities, and to evaluate the achieved impact. A Medical Director is designated as the authority responsible for timely medical planning and coordination. The term « Medical Director » and not « Medical Commander » was intentionally chosen to designate this medical authority. In the current situation, a fair balance has to be found between the operational command and the medical direction. The concept of Medical Control (MEDCON) sometimes emerges from workshops, establishing a strengthened authority on the medical assets and challenging the medical command. Some argue that MEDCON could guarantee greater flexibility in the use of medical assets. However, there is no consensus about this concept. It may be refined in the future depending on the evolution that will affect the battlefield and the medical doctrine.

Integration of the medical direction in the French op erational chain of command.

THE BENEFIT OF MEDICAL STAFF INTEGRATED TO THE COMMAND STRUCTURE During the 2000s, in Afghanistan, the vision of the different NATO medical services converged. The effectiveness of a strong medical command and control system, covering the entire medical support chain was highlighted. Today, it does not seem controversial that a medical leadership in a functional and end-to-end logic should coordinate medical capabilities. Interestingly, it is enshrined in the doctrine of many countries. The NATO doctrine mentions: « for app rop riate planning, coordinating, directing, supporting and auditing of all medical support related functions, commanders need the support of a dedicated medical staff integral to the combined j oint operations staff and sufficient in number, training and experience. »4 . In other words, a dedicated and structured command is essential for an efficient medical support. This system should be supported by a reliable and secure communication and information management system. This emphasizes the medical responsibility in the « health maneuver ». At every level, the medical C2 is

Referring to civilian medical concepts, a manager is not a clinical expert. Therefore, it is legitimate to ask whether medical officers, and sometimes-even physicians, need to be involved to ensure the performance of the medical support in military operations. First, the management of wounded, injured and sick during a military commitment requires the implementation of a « therapeutic tactic ». A skilled person can only carry it out: the medical management should indeed consider the injury, such as abdominal wounds or maxillofacial injury, and take into consideration the « health tactics », which comprises factors such as the position of the medical treatment facilities, the availability of MEDEVAC assets, or the deployment of specialized care teams. Military medicine in operation is not apply ing concepts and standards a priori, or acting within a given and rigid organization. Its purpose is to focus on the needs, always providing care in a patientcentered design. In other words, it is necessary to ensure the coherence of the medical support within a specific space-time framework and to consider both technical and tactical requirements.

French chain of medical supp ort of the op erations. © BCISSA .

Moreover, the continuum of patient care, from the point of injury to the final-treatment hospital and rehabilitation, requires the presence of medical officers, at each level of command, able to advise and to assess the most appropriate course of action for the care, considering the available capabilities. Some nations, due to their culture and national health regulations, give a large part of these responsibilities to physicians, considering that they enhance the performance as experts. France, is one of this nation, and most of the officers in the medical command are physicians, pharmacists or veterinarians. VOL. 93/2

The PECC is one of the examples of the integration of medical staff in a command structure. It is part of the

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medical command but is fully integrated in the JOC. Medical evacuation is a formalized process that theoretically does not require any coordinating action. The unit on the ground expresses the theoretical evacuation urgency needed, according to both the injury assessment and the doctrine. However, from a practical point of view, it is often necessary to dispatch the transport of the wounded due to different factors: - the multiple and simultaneous operational actions; - the areas of operation that extend over vast territories; - the limited resources of airborne vectors. The physician, who masters the technical concerns, has fully their place in this medical management system. © M .Vallé/armée de l'A ir.

Then, the commanders need to rely on legitimate and skilled officers who know the intricacies of highly technical care, and who master the principles of medical support. The casualty care process implies an initial planning phase. Then, during the operation, medical support requires constant adaptations. Particularly at the operative and strategic level, great expertise is required to ensure effective decision-making. The involvement of medical experts in order to provide highly technical medical support is then particularly important when soldiers’ lives are at stake. Who, more than a medical expert could shoulder this responsibility?

requires a lot of training and the development of specific personal qualities. This autonomy is a great asset but can be a challenge for the commander. This is particularly the case when the commander needs to interfere in a medical decision, due to operational constraints, or even when he has to form their own opinion. The Medical Director then plays its role of technical authority, as a military and medical expert who knows and masters the specific issues related to the management of patients and the typical operational consequences. He can assist the commander to understand some tactical issues, which participate to its legitimacy. This overall legitimacy seems fundamental from the point of view of the commander.

Conclusion Considering the necessary unity of the command to ensure the success of the military operations, an integrated system of medical command has constantly been developed over time, supporting the operational command. This medical command has to follow the adaptation of both the operational command and the medical support. It also has to integrate innovations, particularly in the field of information technology. These are the conditions to ensure an effective medical support, serving the injured, wounded and sick. Medicine is taught at university. Specificities of military medical practice are usually taught during specific courses, led by the military medical services. The organization of medical support and leadership should benefit during education from the same consideration, all along the military career. Furthermore, in the era of performance and digital transformation, medical command and control, and more broadly medical management, must benefit from research and evaluation, similar to clinical research. Different evidence-based management concepts have been effectively transposed to medical management. Programs and research on medical leadership and management in operation would benefit from being promoted by our medical services. © Jérémy BESSAT/armée de Terre/Déf ense.

The third point is the regulation of the medical, the pharmaceutical and the veterinarian activities. If duly justified operational factors can exceptionally lead to marginal overrules of some regulations, this cannot be the norm. As described, depending on national regulations, specific prerogatives must be held under the responsibility of some profession. In France, for example, the dispatch of emergency medical services is a medical liability, and some medical supply falls under the responsibility of a pharmacist. Furthermore, armed forces must strictly comply with medical confidentiality and strictly follow ethical obligations, should they be specific to military operations. An entitled professional is therefore necessary to advise the authority and protect the legal and ethical interests of the patients. Lastly, medical practice in the field requires an essential degree of autonomy. Decisions are specific to each patient but also influenced by the tactical situation at the time. This type of medical practice is extremely technical, and

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SUMMARY Military operations are, by nature, complex. This is why a single chain of command must allow an efficient and coherent military action flow. However, in many

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countries, medical support is under the responsibility of a medical command, which represents a technical authority integrated in the joint command. In the French armed forces, the medical command has built up gradually over decades. It is now strong and robust, giving a clear benefit when it provides the best possible treatment to the sick and injured soldiers, at the right time and in the right place, according to the tactical situation. Delegating the medical support to a legitimate expert has strongly strengthened the role and capabilities of the Force commander.

de 1914 à nos jours, Paris, Lavauzelle, 1987, 421 p., préface. 2. Allied Joint Doctrine for Medical Support, AJP-4.10, Edition C, Version 1, September 2019, 2-3, 2-17, 3-20. 3. WEBER JA., Un siècle d’évolution de la chaîne médicale de prise en charge des blessés en opération, Direction Centrale du Service de Santé des Armées, 2019, 89 p. 4. Allied Joint Doctrine for Medical Support, AJP-4.10, Edition C, Version 1, September 2019, 2-1. 5. WEBER JA., CARENZO B., et al., Commandant de Centre médical des armées, un nouveau métier : médecin et manager, Médecine et armées, 2017, 45, 2, 113-120.

BIBLIOGRAPHY 1. LEFEBVRE P., Histoire de la médecine aux armées, tome 3,

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International Review of the Armed Forces Medical Services

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A RT ICLES

i l of the United States Innovative Readiness : A Review Training Program: I i l Operation Healthy Delta 2017. BBy P.A. McWILLIAMSd∑ and C SA.OKOSARAJU . Fr∏. U.S.A.

li Prescott A. McWILLIAMS nd Captain i Prescotf A. FM - c)WILiLI-A MS is a CE o mprehensivi e lDentistr w i itth the 52ch ilitar Squadron lt S atr Sipangdahlem . Dental Air Base, Germany. He is responsible for dental care fohr the acticvael dutgyr an,d family memiber popuslation.r i r r lr li n. uri g at r sh i s iali i in r i i e graduated Franklin and was aCaptain McW ILLIAMS i rts i from i d s and e l Marshall ic College i f in 2011 i in commission e tral ied in the Aliir Force through the Health Professions Scholarship Program in 2012. He graduated fro School f mrthe University ar as of Pen i nslylvania erati n ofi Dental r i Medicine r s,and entered i e active dutyr itn 2015. s iHe vi icomptleted ther Air Force 2-year in General Dentistry residency in 2018, statiol ned. in the l Advanced ic . e Education , e l , r n and J inthas been li UneitedcStates by the American Board of General rr t, lthe R s epublic at of Koreca, and Germnatny. He is baoard-certified rt rs Dentistry and a member of the American Dental Association.

E RESUME

a i ld sl r i il ir : utrl t dic l Présentation du programme de formation préparatoire innovante des Etats Unis : l’opération "Healthy îne e n ent i l et ’ i i op at lt i s nat r pl . Delta 2017".

ns a no br ar , e te al el ’ i i c l i se te ne t t t i et: Lei défi st i maj t eur del chaque c î eservice c médical a ent i test de maintenir . l ses s forces ée correctement f i , l ch aî c prêtes anà fournir ent Introduction militaire entraînées, i al s’médicaux t tr lors i de r tout r idéploiement . l etstquel ai que soit t l’environnement. ort t gar nt le ss passé, nt solservices s a s blmilitaires s des soins Dans les médicaux i ier leurs illeur tr t grâce à différentes i l , le o ontt et l eur leurs lim i ictes. Le programme det formation o ér ion el . entraînaient personnels méthodes, qui toutes montré préparatoire p l prog a if cati unique l qui entend i souti é icàl un à umode expde tdéploiemen é it e lt simulé, an e t innovante (« IRT é») est un ramme contribuer, grâce à un entraînement renfor militaire tout en offrant des soins à des patients des collectivités nationales. L’Opération Healthy Delta (OHD) 2017 est un exemple de formation préparatoire effectuée dans un environnement domestique. E : i c n l, i ll a i , ical d, a t, ilitar Situation et mission : Lors du OHD 2017, deux cliniques ont été installées dans deux villes du sud-est du Missouri. Les obj ectifs du r ti s. OHD étaient quadruples : fournir un entraînement pratique, des services médicaux, dentaires et optiques, p romouvoir l’intégration totale des forces ’ communautaire. i , i i , e é ic l, , : et développer la participation

ili cliniques . OHD ont été opérationnelles pendant neuf j ours, accueillant un total de 2 251 patients, générant 4 546 Résultatsi : Les deux consultations et représentant 15 887 procédures d’une valeur de 1 4 11 208 US Dollars. L’entraînement dans sa totalité a nécessité 10 196 heures effectuées à partir de 202 cours préparés et présentés par le personnel affecté au sein des unités déployées. Discussion : Les différents aspects de ce proj et ont permis de développer l’ensemble des compétences nécessaires au déploiement opérationnel. Des traitements médicaux, dentaires et d’optométrie ont été assurés grâce à l'« IRT » qui est l’un des rares environnements qui permette aux services médicaux militaires américains de superposer les trois aspects de la force totale. De plus il a contribué à une collaboration fructueuse entre les organismes communautaires et le personnel militaire. Conclusions : Le programme « IRT », illustré par l’OHD 2017, permet à l’armée américaine de préparer ses forces pour d’éventuelles missions tout en intégrant opérationnalité et préparation médicale avec des partenaires civils et un engagement communautaire. Le programme « IRT » est un programme modèle pour tout le service médical militaire.

KEYWORDS: Military, Medical, Readiness, Training, Deployment, Air force, IRT. MisOTSar-CLÉS Préparation, Entraînement, Déploiement, Force aérienne, « IRT ». i l i: Militaire, Médical, l ture a e f s th 3t of 2 i i i in a d rl n

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ical ic i a ilitar p rati as s ifi is ics ee f a fecti a izati n i d i i ly oINTRODUCTION t s i . a ri , s ist r ii r h ici c:h«a llenge A emajor of each military medical service is ito st s properly trained i t i toc provide t maintain forces ready

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environment. The different challenges include being current on medical * re en d atadapti t e 3 Ing to dep rld Con re s on ilitary i i , utilizing procedures, loyed environments, Ba l, S it rlan , 19 24 ay 2 . deployable medical equipment, logistical and supply rd

Revuee Inteernattioonalle des Serrv iccess de Sannt é dess Foorcees A rméess

provide medical care to underserved populations, in this case within the US state of Missouri. It embodies the medical aspect of IRT by fostering interaction between local, state, and federal healthcare levels. These clinics are manned by USANG (United States Air National Guard) and USNR (United States Navy Reserve) service members. In OHD 2017, two field clinics were erected in a Missouri county for medical, optometry, and dental care. As further innovation on this specific operation, the Active Duty components of the United States Air Force (USAF) and United States Navy (USN) were incorporated with the Guard and Reserve components6. The USAF and USN members included dental residents and supervisors, allowing further clinical experience and training for deployed situations. The purpose of this article is to discuss the Innovative Readiness Training Mission Operation Healthy Delta as an example of readiness training in a domestic environment.

issues, and being able to provide medical treatment in a non-traditional medical setting with limited supplies, equipment, and manpower. Depending on the military conflict, medical services may also encounter mass casualty situations that could overwhelm available medical resources, requiring familiarity with prioritization and triage skills. The development of a training platform to leverage all of these components is essential to prepare a ready medical service for deployed environments. In the past, military medical services provided this readiness training through different methods, all of which have inherent limitations. The daily treatment of routine patients provides a certain level of training but does not simulate the challenges during a deployment. Medical services have developed readiness training centers with mobile hospitals and simulated mass casualty or patient treatment scenarios. The United States Air Force Medical Service utilizes a military medical training center that provides deployment and readiness training in a controlled atmosphere without the benefit of live patients1. Another program that was developed was the Center for the Sustainment of Trauma and Readiness Skills (C-STARS) program, partnership that allows medics to train in civilian trauma center to maintain readiness and clinical currency skills. This training provides live patient treatment but lacked the experience of a deployed environment where the equipment and environment would not be ideal2. Overseas humanitarian missions provide difficulties that may simulate the environmental and logistical challenges of a deployment, but lack military rigor and infrastructure3.

SITUATION AND MISSION This readiness operation is made possible as a collaboration between the Office of the Secretary of Defense for Manpower and Personnel Affairs and the Delta Regional Authority (DRA), a federally-sponsored community organization to promote civilian welfare for counties of several states along the Mississippi River. In OHD 2017, clinics were set up in the US state of Missouri between neighboring cities. This area of Missouri has the highest levels of individuals in poverty (21%), adults older than 25 lacking high school education (78%), mortality (950/10,000), and life expectancy (75.2 years), along with limited health insurance coverage compared to the rest of the state7.

The Innovative Readiness Training Program (IRT) is a unique program that seeks to provide military readiness training through providing patient care to domestic communities in a simulated deployment environment. Responding to President Clinton’s call in 1992 to “Rebuild America,” the US federal government developed a program to leverage military readiness training requirements while also providing benefit to local communities4. IRT is an initiative of the US Office of the Secretary of Defense, with the mission “to produce mission-ready forces through military training opportunities that provide key services for American communities.”5 Just as the American citizens have invested in and supported military members, this program allows military members to return that support to American communities in need. In these community settings, military service members treat local needs (healthcare, infrastructure, etc…) while preparing readiness skills, developing innovative resource management, and strengthening the bond with civilian communities5. These operations are not limited to any particular service, with opportunities for all components, joint forces, multinational forces, and civilian society. Particularly in the medical service, readiness skills can be developed by treating civilian populations of need, while simulating a deployed environment setting for the service members.

The goals of OHD were fourfold: to provide hands-on readiness training, to provide medical, dental, and optical services, to promote total force integration, and to develop community involvement. Equipment used in this venture was obtained from McGuire AFB and shipped by truck to Missouri, and was similar to that which would be used in a medical contingency scenario. Personnel were quartered in local churches at Charleston and Caruthersville, with treatment conducted at each site in church classrooms and common areas. Services were provided from 0800 to 1700 each day and included examinations, dental extractions and fillings, pharmaceutical and eyeglass prescriptions, and were rendered at no cost to the patient. In addition to rendering care, all personnel were able to receive comprehensive medical readiness training (CMRP) in both ∑ Captain, DMD, MS, USAF 52nd Medical Group, Spangdahlem Air Base, United States Air Force, Germany ∏ Colonel, DMD, MSed, MS, USAF, 11th Medical Group, Joint Base Andrews, United States Air Force, Maryland, USA. Correspondence: Captain Prescott A. McWilliams, DMD, MS, ABGD, USAF, DC Comprehensive Dentist, 52nd Dental Squadron Spangdahlem AB, Germany DSN: (314) 452-8193 Email: prescott.a.mcwilliams.mil@mail.mil

Operation Healthy Delta (OHD) is one such mission to

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didactic and hands-on settings. Adding to the innovative nature of this program, active duty personnel were added to the mission to increase familiarization with readiness skills and increase the amount of care provided by the mission. As guests in the community, personnel were invited to and participated in social events, to build community resiliency and foster military-civilian relationships.

prescription writing as appro priate, and preventative medical counseling in the outpatient setting, as can be seen in Figure 1. Dental treatment started with oral evaluations and subsequent cleanings, restorations with amalgam or composite, or extractions as needed, as can be seen in Figures 2 and 3. Optometry patients were evaluated and applicable patients were fitted for spectacles, as can be seen in Figure 4. Not all patients received every aspect of available care, as the amount and type of care received depended on patient factors and clinic availability.

RESULTS The two OHD clinics operated for nine days, seeing a combined total of 2,251 patients. These patients generated 4,546 patient encounters (as some patients were seen by multiple specialties), accounting for 15,887 procedures at a value of $1,411,208 as can be seen in Table 1.

The IRT is one of few environments in the US military medical services that allows superimposition of all three aspects of the total force. In addition to the diurnal patient care, the close living quarters, evening training sessions, and recreational and community events fostered a closer interaction between the active duty, guard, and reserve personnel. The mission design allowed the guard and reserve personnel to meet annual training requirements, developed and reinforced active duty member skills, and provided a unifying sense of esprit des corps for the total force.

Table 1: Patient Treatment Statistics f or OHD 2017. SPECIALTY

PATIENT ENCOUNTERS

PROCEDURES

PRODUCTION

Medical

1787

2345

$199,447

Optometry

1524

4236

$312,203

Dental

1235

9306

$899,558

Total

4546

15887

$1,411,208

Figure 1: OHD 2017 service member collecting vital sign inf ormation on a patient. Photo credit: Senior Master Sergeant Mary-Dale Amison.

Total training amounted to 10,196 hours, from 202 classes developed and presented by attached personnel within the units. These trainings covered job-specific skills, basic life support, advance cardiac life support, CMRP skills, and upgrade trainings.

DISCUSSION The OHD 2017 mission accomplished four key objectives: hands-on readiness training, delive ry of medical care to an underserved population, total force integration, and community resilience development. Nearly every aspect of this venture developed the readiness skillset. The equipment used was of a model foreign to most participants, as may be the case on a deployment. For example, digital dental radiography was accomplished on this mission using a NOMAD (KaVo) portable x-ray source and digital sensor, both components likely to be used in a deployed setting but not in routine use at a typical AF clinic. The process of learning to set up, utilize, and repair this unfamiliar equipment developed skills invaluable should these personnel be placed in a medical contingency environment. A simulated deployed environment was created as personnel were restricted to premises and had limited outside communication (due to a damaged local cell tower). Didactic and hands-on training was conducted at both sites each evening in the residences and workspaces, allowing members to provide higher levels of care and be more prepared for deployment needs. VOL. 93/2

Figure 2: OHD 2017 p ersonnel review handheld digital radiography system. Credit: Cap tain Prescott McWilliams.

Various treatments were offered in each clinic. Medical services covered wellness visits, smoking cessation,

International Review of the Armed Forces Medical Services

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Figure 3: OHD 2017 dental p ersonnel p erf orming restorative dentistry. Credit: Cap tain Prescott McWilliams.

Figure 4: OHD 2017 op tometric p ersonnel p erf orming eye exams. Photo credit: Senior Master Sergeant Mary-Dale Amison.

CONCLUSIONS Every military service faces the challenge to maintain forces that are ready and prepared to deploy and provide medical treatment. Though multiple methods are available through service training programs, overseas missions, and civilian partnerships, each method is limited in its ability to provide the scope and depth of care in a deployed environment. The Innovate Readiness Training program, exemplified by Operation Healthy Delta 2017, provides the ability for the US military to produce mission-ready forces by combining readiness and medical preparedness with civilian partnerships and community engagement, and is a model program for a military medical service. This domestic engagement not only prepares the military for wartime contingencies, but also strengthens the bond with the home front they will defend. Disclaimer: The views expressed are solely those of the authors and do not reflect the official policy or position of the United States Air Force, the Department of Defense, or the United States Government. The authors have no financial conflicts of interest to disclose. Acknowledgement: None.

ABSTRACT

IRT missions are organized at the request of the community, and a collaborative relationship was developed between the community organizations and the military personnel. Over the course of the mission, members of the community invited service members to sports games, cookouts, and expressed their gratitude in daily events. Such interactions help to develop community resiliency and foster trust with the armed services, key elements of the IRT mission. The cornerstone of a military medical unit is the ability to treat members in wartime and return them to the fight. However, this mission can be difficult to simulate in peacetime. To address this challenge, milita ry medical services have found modalities to simulate deployment conditions and medical situations. IRT programs present a unique opportunity to not only develop comfort with austere conditions and medical procedures, but also produce goodwill in local communities and treat underserved populations. Missions such as the IRT to Missouri will allow better preparedness for military medical services in the event of war, but will also achieve immediate effects in educational training and community service.

International Review of the Armed Forces Medical Services

Introduction: A major challenge of each military medical service is to maintain properly trained forces ready to provide medical treatment in a deployed environment. In the past, military medical services provided this readiness training through different methods, all of which have inherent limitations. The Innovative Readiness Training Program (IRT) is a unique prog ram that seeks to provide military readiness training through providing patient care to domestic communities in a simulated deployment environment. Operation Healthy Delta (OHD) 2017 is an example of readiness training in a domestic environment. Situation and Mission: In OHD 2017, two clinics were set up in two southeastern Missouri cities. The goals of OHD were fourfold: to provide hands-on readiness training, to provide medical, dental, and optical services, to promote total force integration, and to develop community involvement. Results: The two OHD clinics operated for nine days, seeing a combined total of 2,251 patients, generating 4,546 patient encounters, and accounting for 15,887 procedures at a value of $1,411,208. Total training amounted to 10,196 hours, from 202 classes developed and presented by attached personnel within the units. Discussion: Nearly every aspect of this venture developed the readiness skillset. Medical, dental, and optometry treatments were offered, and the IRT is one of few environments in the US military medical services that allows superimposition of all three aspects of the total force. Further, a collaborative relationship was developed between the community organizations and the military personnel.

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p s ré. és ltat: re d sa e: holi est r es pl ti es vaila le t tp: / .i . / pu li ti s d/ i x/ osa . t l r I e_ 23 ; acc e ril, 2019.

Conclusions: 3. i is re deThe l IRT pro . g ram, tr exemplified by OHD 2017, provides the ability for the US to de produce d 27 ars 2012 lati ux iti military d’ it s mission-ready forces by integ r ating readiness veill édi le du pers nel lé à ar ici r and aux ca ’es is ’ îne re medical pnes re paredness with civilian partnerships and des r h s ph rés. and is a model program for a community engagement, military medical service.

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, HE IN S, BB I, B S , CE F, L , C I , . C rac ri i f novel BC "sil " ll le: p i CITATIONS ti (p. l204 sp) ses l ss ctivi y an rol ed SKELTONi P,set al. EMEDs Teams. Care ap t iuand . SPEARR 2014; 9:Critical e101552. Nursing Clinics of North America . 2003; 15 (2): 201-12. L I E . i l li es rase JOHNSON sGRIMM r ct r ,J and c ion, ic K.ri Saint s, isLouis ry Center se i tfor e Sustainment Skills: A Collaborative clini , an of Trauma i l tandraReadiness ti . har l h Air Force 2015; 1 –: Civilian -46. Trauma Skills Training Program. Journal of Emergency Nursing. 2016; 42 (2): 104-7. SS P, LUS EKI S .E of cat l ti i cMEADger i s The Importance hosph rus ent . Che i K, et al. of Medical Readiness 1 ; : Maintaining 1 . ITraining act Exercises: Medical Readiness in a

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8. LOCKRIDGE O NORGREN RB JR, JOHNSON RC, BLAKE TA. at r ll ccur in eneti iant of ac lc olies rase and tyr lch li ter ir ot ial i pac the risk toxi i fr ch li ster i i is. ; 29: 1381- . oxi Low-Volume Combat Casualty Flow Era. Military . Medicine R , . 2017; 182 J .(7): ff e1734-e1737. csi f antic li tec nd s in i l l s on fl ri4. United Congress, History 102-484: a . States, 19 ; : Legislative . i nvest National Defense Authorization Act FY 1993; Public Law Admtiinistration . 102-484. I FR,1993. R General. Services cti ility c Cong li ress. teinhi ite ri i . ic l pl 5. Innovative Training, Office of the Deputy ; : 1. r l 1Readiness Assistant Secretary of Defense for Reserve Integration, .I I 1. irt.defense.gov/ I R, ,B P GE I P. tilisati e l lines se pl ati e i ica6. AMISON,l’Mary-Dale. in High i io Military i s Dentists i id s or ano Demand at. Health Missouri. Guard, 1 Air ; National : . r esCare l Initiative di r in si elle US 29 Sept. 2017, www.ang.af.mil/ Media/Article. Display/Art: icle/r 1335183/ op smilitary-dentistss. : ro in-high-demandi iir : i i ions i et is ues ssi ls, at-health-care-initiative-in-missouri/ . 11 . ited st d , illet JP Paris Es 2007. 7. Missouri Department of Health and Senior Services. 2013, . Missouri H , Health Assessment, ER SC S health.mo.gov/data/ J, LLER SPR mohealIT HE , RE F,pdf/assessment.pdf. I N , . l ri is i thassess/ i S ia : r i verifi i n i in int ional l tor r . r ; : 1- . c ic .

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The Jules Voncken Prize, for an amount of 2.000 €, will be awarded during the 44 ICMM World Congress on Military Medicine in Brussels, Belgium (September 20-24, 2021). th

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-icmm.org For more information:

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Food Poisoning Outbreak in a Mexican Navy Unit: Epidemiological Approach of the Event. By B. LOOSE-ROJO, H. BENITES-VIRGEN and CG. SOLIS-HERNANDEZ. Mexico

Bernardo LOOSE-ROJO Corvette Lieutenant Bernardo LOOSE-ROJO graduated as a General Practitioner from “Universidad Autónoma de Guadalajara” in 2010; his medical internship was done at the Military Regional Hospital in Guadalajara He became a Diving Medical Officer in 2013 after receiving training by the Argentinian Navy at the “Escuela de Submarinos y Buceo” in Mar del Plata. From 2015 to 2017 he was commissioned to the “Escuela Militar de Graduados de Sanidad” by the Navy University, acquiring a Master in Public Health.` Lieutenant LOOSE-ROJO joined the Mexican Navy in 2011 as a General Physician appointed to the Guaymas Navy Hospital, later being assigned to the Hyperbaric Medicine Unit of the same hospital; currently he serves as the head of the Preventive Medicine & Public Health Department at the Mazatlan Regional Navy Hospital. Among other things, he participated in the UNITAS 53-2012 operation on board the PO-151 “ARM Durango” and was also part of the Mexican Naval relief force sent to Cabo San Lucas (Baja California Sur) after Hurricane “Odile” in 2014, up to this day he has served as medical officer in many other lesser social-assistance missions.

RESUME Épidémie d'intoxication alimentaire dans une unité de la marine mexicaine : approche épidémiologique de l'événement. Obj ectif : Cet article vise à souligner l'importance, pour toute force armée, d'un approvisionnement alimentaire et en eau sécurisé. Il présente à cet effet l'approche épidémiologique d'un cas d'intoxication alimentaire collective au sein d'une unité de la marine mexicaine. Méthodes : Compte tenu de la situation, l'ensemble des personnels de l'unité touchée a pu être interrogé sans nécessité d'avoir recours à un échantillon représentatif. Les données ont été traitées en utilisant l'outil STATA 12.0 avec un intervalle de confiance de 95 %. Une valeur « p » de 0,05 a été considérée statistiquement significative. Cela a permis de calculer le risque relatif des divers aliments ingérés afin de trouver la cause de l'intoxication présumée.

Résultats : Pour les différents repas suspectés, les risques relatifs (RR) des différents repas suspectés ont ainsi été retrouvés : petit-déj euner RR = 1,44 (IC : 0,66-3, 11; Chi2 : 0,35), déj euner RR = 3, 16 (IC : 0,82-12, 18; Chi2 : 0,04) et dîner RR = 0,75 (IC : 0,25-2, 11; Chi2 : 0,55). Concernant les menus du déj euner de cette j ournée le RR était : « Pozole Guerrerense » RR = 3,36 (CI : 0,86-13,00; Chi2 : 0,03), chili farci au thon RR = 1,45 (CI : 0,69-3,05; Chi2 : 0,32), fromage frais RR = 2, 17 (IC : 0,82-5,72; Chi2 : 0,08), tacos frits RR = 1,74 (IC : 0,72-4, 19), couenne de porc RR = 1,54 (IC : 0,68-3,51; Chi2 : 0,28), citron RR = 1, 11 (IC : 0,52-2,34; Chi2 : 0,78), tortillas RR = 0,38 (IC : 0, 10-1,43; Chi2 : 0,09). Quant à la boisson, il s 'agissait d'eau naturelle RR = 0,47 (IC : 0,07-2,85; Chi2 : 0,34) et / ou hibiscus-eau RR = 1,08 (IC : 049-2,36; Chi2 : 0,83).

Conclusions : Une épidémie est touj ours une situation très délicate à gérer au sein d'une unité militaire. Dans le cas présenté, la cause la plus probable est apparue être celle d'un Pozole servi pendant l'heure du déj euner. Grâce à la prise en charge effectuée par les services d'urgence, aucun décès n'a été signalé et tous les marins ont repris le service peu de temps après. Des mesures appropriées ont également été prises pour éviter toute complication.

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Le personnel médical des forces armées se doit d'avoir une compréhension épidémiologique de base en plus d'une connaissance clinique très approfondie, afin de mieux comprendre et conseiller le commandement dans de telles situations.

KEYWORDS: Mexican navy, Food poisoning, Epidemiological approach, Epidemic. MOTS -CLÉS : Marine mexicaine, Intoxication alimentaire, Approche épidémiologique, Epidémie.

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Figure 1: Military units are in greater risk of an outbreak than normal p op ulation, due to the close working and living environment, esp ecially naval units.

INTRODUCTION “An army marches on its stomach”; a quote attributed to the French general Napoleon Bonaparte or to the Prussian king Frederick the Great 1, in any case both are considered by many military academics among the best strategists in history. This highlights the importance that any military force without regular and safe food provision is doomed to fail, the moral drops and its fighting capabilities are diminished. Nutrition plays a very important role in the performance of a combatant, not only physically but also at a psychological level; trough history there is ample evidence that success in military operations depends as much on weapons and manpower as in the logistics for safe food and water2, 3 .

Figure 2: Mazatlán Regional Navy Hosp ital, is the ref erence hosp ital f or Northwest Pacif ic coast f or the Mexican Navy Health system.

The aim of the present case report is not to focus on the case of an isolated patient, but to show to medical officers of different armed forces all the interest of an epidemiological approach to an outbreak4 in order to recognize its most probable cause and be able to take the proper steps in accordance to the information at hand for detection, alarm, alert, acceptability, implementation of countermeasures or not 5. An outbreak of “Food Poisoning” (FP) usually involves a large number of persons affected with similar symptoms and signs -mainly gastrointestinal- related to the intake of a common meal. In military settings every meal is a common one and therefore identifying the cause of a foodborne disease is not always a matter of simple evidence6 .

A HISTORY OF FOODBORNE ILLNESS

Figure 3: Entrance to the Emergency Room (ER) of the Mazatlán Regional Navy Hosp ital.

As mentioned before, military personnel, usually, by the mere fact of their profession hold, already, two of the three characteristics needed to turn any event in to an epidemiological affair, being: place and person, lacking only time (Figure 1)7 . The present outbreak was first suspected by the medical officer in charge of the “Hospitalization & Emergency Department” at the Mazatlán Regional Navy Hospital (Figure 2, 3), who not ified the Preventive Medicine & Public Health Department of an atypical number of patients requesting emergency attention due to gastrointestinal symptoms. After an evaluation of the cases, it was evident that we were in an outbreak situation since all the sick belonged to the same navy unit, and therefore, an epidemiological investigation must be instructed.

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METHODS The “case” was defined as: any personnel that presented, within the last 24 hours, abdominal or digestive system symptoms, and was part of the crewbelonging to the afflicted unit. Due to the evolution of the illness the suspected etiology was FP by preformed toxins and patients were treated as such8, 9, 10 . Given the importance of the

The protocol designed for these events was implemented, including among other things the quarantine of the affected unit until further notice. All the military health officials in the territorial command were alerted, and for security reasons, civil authorities too when more information was available). The menu of the afflicted unit was requested, and the kitchen closed for exhaustive cleaning.

International Review of the Armed Forces Medical Services

Correspondence: Corvette Lieutenant Bernardo LOOSE-ROJO Hospital Regional Naval de Mazatlán Calle Armada de México S/ N, Mazatlán Sinaloa, México. Col. Sembradores de la Amistad C.P. 82416 E-mail: loose.bernardo@gmail.com

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event and the possibility of interviewing all the personnel involved, it was decided that there was no need for a sample and that the whole universe complete crew was going to be considered in the investigation. A retrospective cohort study was considered the best approach for the present problem and therefore the whole crew was interviewed trough a written questionnaire (Figure 4) regardless of the presence or not of symptoms11, 12, 13. All the information gathered by the survey was turned into a database and statistically processed using STATA 12.0. A 95% Confidence Interval (CI) with a “p” of 0.05 was considered for significance, no special treatment of missing data was performed14 . General descriptive measures were obtained as well as risk ratio -relative risk-(RR) for each meal, as well as for every food item in the menu of 24 hours prior to the event, in order to assess its association with the “cases”15, 16, 17. Figure 4: Written questionnaire designed sp ecif ically f or interviewing the crew of the aff licted naval unit (in Spanish). 43051678&9:;13278&27<78&=:&>7?768@2 0AB=19:CC1D2&>E=1C7 F:!76A97&=:&753G3&>E=1C3 0:9<1C13&=:&>:=1C127&59:<:261<7&G&078A=&5HB81C7

!"#$%&'(&%()*$+'(%&'(&,"+(%"&-."%"/ G"#JB(B6%/6(c-2) !"#$%&'() !"#$%&'(&,"%-"%&-$+&I+&-J%I-.$&."&%()*I()K"&-$%%(-K"L&*I('(&,"%-"%&,M)&'(&I+"&%()*I()K"&*$%& *%(NI+K"/ *"#+%,-) $%.%/0/1(2&340/5"#7d(6Q<%2%/@(B-6.-4%2@0(26(WB-.0/(4%2eB0H%2@0C(2: 01 23 5"!"#678394%2: ;0(<<%( =(32%(

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Further strengthening of the suspected etiology was obtained in discovering that of the 8 sailors that were on guard duty the prior day, 6 were “cases” which meant an RR = 2.81 (CI: 1.50-5.27; Chi2 :0.01) (Table 2), that is because personnel on guard duty are not allowed to go outside the premises of the unit or disembark during the 24 hour period of their watch and therefore most likely had only eaten onboard. The second step of the epidemiological approach was to calculate the RR for each meal, obtaining the following data: breakfast RR = 1.44 (CI: 0.66-3.11; Chi2 :0.35), lunch RR = 3.16 (CI: 0.82-12.18; Chi2 :0.04), and dinner RR = 0.75 (CI: 0.25-2.11; Chi2 : 0.55) (Table 3). The menu of the day for lunch was “Pozole Guerrerense” (a traditional Mexican stew 18) RR = 3.36 (CI: 0.86-13.00; Chi2 :0.03), stuffed chile with tuna RR = 1.45 (CI: 0.69-3.05; Chi2 :0.32), fresh cheese RR = 2.17 (CI: 0.82-5.72; Chi2 : 0.08), fried tacos RR = 1.74 (CI: 0.72-4.19), pork rind RR = 1.54 (CI: 0.68-3.51; Chi2 : 0.28), lemon RR = 1.11 (CI: 0.52-2.34; Chi2 :0.78), tortillas RR = 0.38 (CI: 0.10-1.43; Chi2 : 0.09) and for drinking there was natural-water RR = 0.47 (CI: 0.07-2.85; Chi2 : 0 .34) and/o r hibiscus-w ate r RR = 1.08 (CI: 049-2.36; Chi2 :0.83) (Table 4).

DISCUSSION An outbreak is a nightmare in any tightly packed group of people like the navy (or any other military force). In the present scenario medical treatment at the Mazatlán Regional Navy Hospital was impeccable and

T"#;%2.-/@(/B-6B%6H3(<B0() 01 23 D"#X%2Q%&@-6(64-26(40.%/@-26B%46B_(6B%6(E%<) D"!"#;%2E3/-) 01 D"!"!"#67F(2?632@%B6(6B%2(E3/(<: D"!"G"#6783946B%64-2620H30%/@%26(40.%/@-260/H0<0-632@%B: D"!"G"!#6$<3@( D"!"G"G"#68%<%(4 D"!"G"*"#6L%&'% D"!"G"5"#6O3<<0@-26B%6&'-<0P-6&-/6Q(Q( D"!"G"T"#6$<0U-4 D"G#8-.0B() 01 D"G"!"#67F(2-632@%B6(6&-.%<: D"G"G"#6783946B%64-2620H30%/@%26(40.%/@-260/H0<0-632@%B: D"G"G"!"#6F-P-4%6V3%<<%<%/2% D"G"G"G"#68'04%6X%44%/D"G"G"*"#6[3%2-6K<%2&D"G"G"5"#6Z(&-6;-<(BD"G"G"T"#68'0&'(<<-/ D"G"G"D"#6L0.-/ D"G"G"I"#6X(W(/D"G"G"M"#6J/2(4(B(6B%64%&'3H( D"*#8%/() 01 D"*"!"#67F(2-632@%B6(6&%/(<: D"*"G"#6783946B%64-2620H30%/@%26(40.%/@-260/H0<0-632@%B: D"*"G"!"#6+-Q%26B%6.(<4_/ D"*"G"G"#6[3%2D"*"G"*"#68<%.( D"*"G"5"#6L%&'3H( D"*"G"T"#6`(/('-<0(

Table 1: Socio-economical inf ormation of the aff licted naval unit. GENDER

23 D"!"G"D"#6+(42( D"!"G"I"#6J/2(4(B(6K<%2&( D"!"G"M"#68(KN D"!"G""R"#6SH3(

Female

Male

34 (57%)

26 (43%)

Mean (Min-Max)

Std. Dev.

38.16 yrs (22-53)

± 8.23

AGE

23 D"G"G"R"#6+(42(6B%6&'04%6B%6(<W-4 D"G"G"!Y"#6Z-<@044(2 D"G"G"!!"#6Z-2@(B(2 D"G"G"!G"#6O(<<(6B%6J/2(4(B(6\%2Q0/(&(] D"G"G"!*"#6SH3(6B%6^(.(0&( D"G"G"!5"#6SH3(6=(@3<(4 D"G"G"!T"#6^0&(.(

Table 2: Ep idemiological table f or the sailors on duty the day p rior.* ON DUTY THE DAY

23 D"*"G"D"#6F%Q0/D"*"G"I"#68(4BD"*"G"M"#6+(42( D"*"G"R"#6SH3(6/(@3<4( D"*"G"!Y"#68(KN

RESULTS The naval unit under epidemiological investigation had a muster roll of 60. All were present at the time when the interviewing took place, of whom 34 (57%) were female and the rest were masculine. With a mean age of 38.16 years (Std. Dev ± 8.23) the youngest being 22 and the oldest 53 (Table 1). Due to the small size of the unit and in order to keep anonymity no further socioeconomical information was requested (eg. military rank, schooling, etc.).

International Review of the Armed Forces Medical Services

PRIOR

Exposed

Unexposed

Total

Cases

Noncases

Total!

Risk

0.75

0.26

0.34

Point Estimate

Conf. Interval (95%)

Risk diff.

0.48

0.15

0.81

Risk ratio

2.81

1.50

5.27

chi2 = 7.08

Pr >chi2 = 0.01

* Missing values were not considered, therefore the total number may not meet the total of muster roll.

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Table 3: Relative risk (RR) f or every meal given at the aff ected navy unit by the Food Poisoning Outbreak. MEAL

Breakfast

1.44

066-3.11

0.35

Lunch

3.16

0.82-12.18

0.04

Dinner

0.75

0.25-2.11

0.55

Figure 6: Assigned p ersonnel to the Preventive Medicine & Public Health Service at the Mazatlan Regional Navy Hosp ital, team work among the diff erent hosp ital services is essential in any susp ected medical outbreak.

* ‘’p’’ <0.05 was considered for statiscal significante.

Table 4: Menu of the day f or lunch and the Relative Risk (RR) f or each f ood item. FOOD ITEM

Pozole Guerrerense

3.36

0.86-13.00

0.03

Stuffed chile

1.45

0.69-3.05

0.32

Fresh cheese

2.17

0.82-5.72

0.08

Fried tacos

1.74

0.72-4.19

0.19

Pork rind

1.54

0.68-3.51

0.28

Lemon

1.11

0.52-2.34

0.78

Tortilla

0.38

0.10-1.43

0.09

Natural-water

0.47

0.07-2.58

0.34

Hibiscus-water

1.08

0.49-2.36

0.83

Figure 7: In the p resent outbreak all patients had a good resp onse to hydration and symp tomatic treatment, f urther supp orting the p resumed etiology.

* ‘’p’’ <0.05 was considered for statiscal significante.

therefore no deaths were reported, and all sick sailors were fine by the next day (Figure 5). In this situation team work was essential as evidence shows in the excellent outcome for the patients, and once the medical emergency was taken care of, it is essential to design an epidemiological investigation with the aim of establishing the most likely cause (Fig ure 6). In this case the etiology was presumed from the start as FP by preformed toxins, and further support for that theory was the evolution (rapid onset and good response to hydration and symptomatic treatment) 10 (Figure 7) and the fact that sailors on guard duty the prior day turned out to have a risk 2.81 times higher of being sick (6 out of 8 sailors) than the rest of the crew. The most likely cause was the “Pozole Guerrerense” Figure 5: Assigned p ersonnel to the Emergency Service at the Mazatlán Regional Navy Hosp ital, timely and correct treatment allowed a no-death toll in the p resent outbreak.

served at lunch, as determined by a statistically significant RR of 3.36 times higher among those who eat the stew against those who didn’t. The supplier of the meat for the “Pozole Guerrerense” was visited at his shop and asked to produce copies of permits and supervisions by the corresponding authorities, as well as to inform him that the FP was linked with his product in order to strengthen the quality control in his shop. The authorities also were informed so they could take the proper measures in their field of competence19 .

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Continual education of the pe rso nnel involved in food preparation was strengthen with seminars and practical cases (Figure 8), also awareness was made to the commanding officers in the different navy units of the importance to maintain adequate storage for food items and a safe water source.

Figure 8: Mexican Navy f ood-handlers are in constant training, this was strengthen by organizing seminars and p ractical cases f or the p ersonnel involved in f ood p reparation.

CONCLUSION The medical profession is generally very much oriented towards an individual clinic. Thus, most health workers, since their training, tend not to consider epidemiology at its true value and do not give this area of medicine all the interest they should. This relative lack of knowledge is clearly reported in the literature20, 21, 22, 23, 24 . and this can be particularly harmful in the military environment. The present FP case is an excellent example of the practical importance of epidemiology for the field doctor, especially in a military setting, where medical personnel have a wide range of functions ranging from disease prevention, to treatment sick personnel, to rehabilitate the soldiers. If in this particular case, the use of stats, once the data was collected, was very useful, having basic statistical knowledge and the necessary will can solve many problems like the one presented here.

ETHICS STATEMENT, CONFLICT OF INTEREST & FUNDING

SUMMARY Objective: This article aims to emphasize the importance, for any armed force, of a secure food and water supply. To this end, he presents the epidemiological approach to a case of collective food poisoning within a unit of the Mexican Navy. Methods: Given the situation, all the staff of the affected unit could be interviewed without the need to use a representative sample. The data were processed using the STATA 12.0 tool with a 95% confidence interval. A "p" value of 0.05 was considered statistically significant. This made it possible to calculate the relative risk of the various foods ingested in order to find the cause of the suspected intoxication. Results: For the different suspected meals, the relative risks (RR) of the different suspected meals were thus found: breakfast RR = 1.44 (CI: 0.66-3.11; Chi2 : 0.35), lunch RR = 3.16 (CI: 0.82-12.18; Chi2 : 0.04) and dinner RR = 0.75 (CI: 0.25-2.11; Chi2 : 0.55). Regarding the lunch menu for this day the RR was: "Pozole Guerrerense " RR = 3.36 (CI: 0.86-13.00; Chi2 : 0.03), chili stuffed with tuna RR = 1.45 (CI: 0.69-3.05; Chi2 : 0.32), fresh cheese RR = 2.17 (CI: 0.82-5.72; Chi2 : 0.08), fried tacos RR = 1.74 (CI: 0.72-4.19), pork rind RR = 1.54 (CI: 0 .68-3.51; Chi2 : 0.28), lemon RR = 1.11 (CI: 0.52-2, 34; Chi2 : 0.78), tortillas RR = 0.38 (CI: 0.10-1.43; Chi2 : 0.09) As for the drink, it was natural water RR = 0.47 (CI: 0.07-2.85; Chi2 : 0.34) and / or hibiscus-water RR = 1.08 (CI: 049 -2.36; Chi2 : 0.83). Conclusions: An epidemic is always a very delicate situation to manage within a military unit. In the case presented, the most likely cause appeared to be that of a Pozole served during lunch time. Thanks to the care provided by the emergency services, no deaths were reported and all the sailors returned to the service shortly after. Appropriate measures have also been taken to avoid complications. The medical personnel of the armed forces must have a basic epidemiological understanding in addition to a very thorough clinical knowledge, in order to better understand and advise the command in such situations. REFERENCES

At all times anonymity was protected in accordance to national and international standards.25,26 The authors state no conflict of interest; no funding was requested for this research.

11. Oxford University. The Oxford Dictionary of Phrase and Fable http://www.oxfordreference.com/view/ 10.1093/oi/authority.20110803095425331. 12. HIDALGO-GARCÍA MDM. Las nuevas tendencias en la alimentación y su repercusión en la defensa. Documento de Análisis. Instituto Español de Estudios Estrategicos; 2017; (6)76-91

Acknowledgements

The authors wish to thank the staff of the Navy Hospital at Mazatlán for their support in the management of the FP and for sharing their time and data. Special mention must be made of those in the emergency service for their quick response and assessment of the situation, as well as the enlisted men and women of the afflicted unit who participated in the investigati.

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13. MIHAI-BOGDAN A, DANIEL-SORIN C, MARIUS M. Managerial Elements Specific to Military Logistics. In International Conference Knowlege-Based Organization; 2018; 24(2) 10-17. 1 14. CASTILLO-SALGADO C, MUJICA O, LOYOLA E, CANELA J. Módulos de Principios Epidemiológicos para el Control de

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las Enfermedades. 2nd ed. Pacheco L, editor. Brasilia: PanAmerican Health Organization; 2011.

for Health Research: A Practical Guide to Epidemiology and Statistics. 2nd ed. Oxford: John Wiley & Sons Ltd; 2018.

15. TEXIER YB. From outbreak detection to anticipation. Revue d'Épidémiologie et de Santé Publique. 2010 Dec; 58(6) 425-433.

17. MANTEROLA C, OTZEN T. Valoración Clínica del Riesgo, Interpretación y Utilidad Práctica. Int. J. Morph. 2015; 33(3) 842-849.

16. KUMAR MK BVRS. Food poisoning outbreak in a training establishment: A retrospective cohort study. J Mar Med Soc. 2017; 19(1) 28.

18. Wikipedia. Pozole. https://en.wikipedia.org/wiki/Pozole 19. Comisión Federal para la Protección contra Riesgos Sanitarios. NOM-251-SSA1-2009 Practicas de higiene para el proceso de alimentos, bebidas o suplementos alimenticios. Ciudad de México: Secretaría de Salud; 2009.

17. CASTILLO-SALGADO C, MUJICA O, LOYOLA E, CANELA J. Módulos de Principios de Epidemiología para el Control de Enfermedades. 2nd ed. Pacheco L, editor. Washington DC: Pan American Health Organization; 2001; 31(1) 394. 18. PINILLOS MA, GÓMEZ J, ELIZALDE J, DUEÑAS A. Intoxicación por Alimentos, Plantas y Setas. ANALES Sis San Navarra. 2003; 26(Supl 1) 243-263.

20. TORALES J, BARRIOS I, VIVEROS-FILARTIGA D, GIMÉNEZLEGAL E, SAMUDIO M, AQUINO S, et al. Conocimiento sobre métodos básicos de estadística, epidemiologia e investigación en médicos residentes de la Universidad Nacional de Asunción, Paraguay. Educ Med. 2017; 18(4) 226-232.

19. National Health Service. Food poisoning. Queenęs Printer and Controller of HMSO, Department of Health and Social Care; 2008.

21. AL-ZAHRANI S, AL-KHAIL B. Resident physicianęs knowledge and attitudes toward biostatistics and research methods concepts. Saudi Med J. 2015; 36(10) 1236.

10. LARRY-JAMESON J, FAUCI AS, KASPER DL, HAUSER SL, LONGO DL, LOSCALZO J. HARRISON. Principios de Medicina Interna. 20th ed. Ciudad de México: McGraw-Hill Education; 2018.

22. NOVACK L ea. Evidence-based medicine: assessment of knowledge of basic epidemiological and research methods among medical doctors. Postgraduate medical journal. 2006; 82(974) 817-822.

11. VILLASIS-KEEVER MA. El protocolo de investigación II: los diseños de estudio para la investigación clínica. Rev Alerg Mex. 2016; 63(1) 80-90.

23. GODWIN M, SEGUIN R. Critical appraisal skills of family physicians in Ontario Canada. BMC medical education. 2003; 3(1) 10.

12. PG C. Diseño de estudios cuantitativos: Diseños descriptivos. Enfermería en cardiología. 2016; 23(69) 23-29.

24. YOUNG J, GLASZIOU P, WARD J. General practitioners selfratings of skills in evidence based medicine: validation study. BMJ. 2002; 324(7343) 950-951.

13. VERA M. Los diseños de la investigación en áreas de la salud. Medicina Interna. 2014; 30(3).

25. NORMA Oficial Mexicana NOM-012-SSA3-2012, Que establece los criterios para la ejecución de proyectos de investigación para la salud en seres humanos. Secretaria de Salud; 2012.

14. RODERIK JL ea. The Prevention and Treatment of Missing Data in Clinical Trial. N Engl J Med. 2012; 367(14) 13551360.

26. LOPEZ-PACHECO M, PIMENTEL-HERNÁNDEZ C, RIVASMIRELLES E, ARREDONDO-GARCÍA J. Normatividad que rige la investigación clínica en seres humanos y requisitos que debe cumplir un centro de investigación para participar en un estudio clínico en México. Acta pediatr Mex. 2016; 37(3) 175-182.

15. MORENO-ALTAMIRANO A LMSCBA. Principales medidas en epidemiología. Salud Publica de México. 2000; 42(4) 337-348. 16. BRUCE N, POPE D, STANISTREET D. Quantitative Methods

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Key Link Considerations for Conducting Timely and Efficient Aero-Medical Evacuation in UN Field Mission: Lessons Learnt From South Lebanon. By Q-S. ZHANG∑ E, L. CHENπ E, G-Y BI∏ and Z-B LI∏. China

Qiu-Shi ZHANG Lieutenant Colonel Qiu-Shi ZHANG graduated from the Fourth Military MedicalUniversity, Peo ple's Liberation Army, China. With post graduate qualification in Biomedical Engineering, I have served 21 years in the army as a medical engineer. Following my Master Degree in Biomedical Engineering, I worked as a medical staff officer since 2014 with a major rank and promoted as Lieutenant Colonel in 2017. As a member of the preparatory group, I participated in the organization of the China-Germany Combined-Aid 2016 Joint Military Exercise in Chongqing, China. As a team leader, I implemented several military aid activities to Nepa l, Maldives, Ecuador and Argentina. I deployed as Force Medical Officer Operations in the headquarter of United Nations Interim Force In Lebanon (UNIFIL) from October 2018 to October 2019, responsible for the peacekeeping troops medical evacuation and medical exercise conducting. I was awarded United Nations Medal of Peace and Letter of Appreciation by the UNIFIL force commander.

RESUME Points clés pour des évacuations aéromédicales rapides et efficientes lors des opérations menées par les Nations Unies : leçons tirées de l’expérience acquise au Sud-Liban. Une évacuation aéromédicale (EAM) s’impose parfois face au niveau d’urgence de l’état de santé d’un patient. Dans les opérations de maintien de la paix (OMP) des Nations Unies, les capacités du disp ositif à la prise en charge et à l’évacuation rapide des personnels sont d’importance cruciales. Pour les soldats de la paix, il est cependant très difficile de procéder à une évacuation médicale qui réponde aux exigences de temps édictées par le manuel des services médicaux des nations unies. Cet article expose l'intérêt d’une mise à plat des différents aspects du processus d’évacuation MEDEVAC afin d’en augmenter l’efficience en raccourcissant les différents temps de prise en compte de l’urgence, de traitement de l’information, de prise de décision, de communication et de coordination des différents intervenants. Certaines considérations pratiques sont évoquées à partir des enseignements issus des retours d’expérience de missions au SudLiban. Cet article peut contribuer à l’amélioration des procédures d’évacuations médicales effectuées dans le cadre des missions de maintien de la paix menées par les Nations Unies.

KEYWORDS: Military, Peacekeeping, Medical support, Evacuation. MOTS -CLÉS : Militaire, Maintien de la paix, Soutien médical, Evacuation sanitaire.

INTRODUCTION

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Aero-Medical Evacuation (AME) undoubtedly proved to be an essential component of the medical support that enabled the prompt transportation of casualties from point of injury (POI) to closest medical facilities in field mission area1.

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United Nations (UN) field missions are typically conducted in austere and challenging operating condition. It is obvious that timely evacuation will largely enhance survival rate for those suffering from trauma injury and those with sudden onset, acute life-threatening conditions requiring immediate expert medical intervention. In order to ensure the health and well-being of the personnel in

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the field, medical support guidelines are designed to balance clinical demand against operational constraints. The guideline adopted in the UN system is the “10-1-2” timeline concept2, which requires access to immediate life saving measures (bleeding and airway control for the most severely injured casualties) within 10 minutes of the point of injury or the onset of symptoms; advanced life support by medical personnel within 1 hour of wounding/onset; and access to damage control surgery no later than 2 hours after wounding/onset. AME should be supported by a responsive air transport assets involving fully equipped ambulances, rotary or fixed wing air facilities, well trained and equipped Aero Medical Evacuation Teams (AMETs) and a well-functioning communication network linkage for rapid medical response.

operations in the field. Chapter 3 in this manual briefly mentions the function of casualty/medical evacuation, how to develop an evacuation plan in UN field mission and what kind of assets are required to meet the evacuation demands. Chapter 10 in this manual describes the medical evacuation policies and procedures in UN missions. Some factors needed to be considered when drawing up a mission evacuation plan and how to conduct out-of-mission evacuation, are included in this chapter. Apart from the Medical Support Manual, the first standard operating procedures (SOP) regarding casualty evacuation in the field was issued in 2018. This document provides policy direction on the management of casualty evacuation. It elaborates the related parties involved in operation and their responsibilities. The capabilities required for building a field casualty evacuation system are articulated, such as first response capability, command & control capability, deployment capability and damage control surgery capability. It is noted that the general process of conducting a field medical evacuation was not mentioned in this document. This kind of document is being reviewed continuously and updated year by year. The latest version of UN casualty evacuation SOP is being revised since 2019 and expected to be issued in 2020.

This article will deal with the key links that must be considered in conducting a timely and efficient AME. To illustrate these important considerations, the author briefly presented the general requirements of each step during AME operation, and then focused on how to quickly and effectively implement evacuation by putting forward some detailed notes based on his own work experience of South Lebanon peacekeeping operations.

CONTEXT

In line with the Medical Support Manual and the UN evacuation SOP in the field mentioned above, it is necessary to study in depth how to effectively reduce the medical evacuation time in practical operation. Numerous studies and writings focus on AME implementation from different perspectives. Joshi et al3 discussed in details of the common problems experienced in flight (Increased altitude, forces of acceleration, noise, vibration and decreased humidity), relative contraindications and patient preparation checklist. The textbook “Aeromedical Evacuation: Management of Acute and Stabilized Patients” (as the first modern book describing the medical aspects of aeromedical evacuation (AE) published by Springer-Verlag in 2003) provided invaluable information that captures rich operational experiences and collective wisdom on AME implementation skills, such as aircraft considerations for AME, AME triage support, preflight medical clearance, patient flight physiology, nursing care in flight and trauma management skills, etc.4. Apart from patient care skills during evacuation, appropriate coordination procedure framework is also vital to shorten evacuation time and to ensure a timely and efficient AME. The procedure framework covers emergency response, reporting & communication, information processing and decision making, and coordination between related sectors & partners involved. Efficient AME operations require immediate and coordinated actions between all stakeholders.

The UN Mission in Lebanon (United Nations Interim Force In Lebanon, UNIFIL) commenced in 1978 to confirm Israeli withdrawal from Lebanon and help ensure humanitarian access to civilian population with over 10,000 contingent troops deployed from more than 40 countries. The author was deployed as the medical officer operations in the Force Medical Section, UNIFIL Headquarter, from October 2018 to October 2019. The medical section is committed to improving the quality of care for peacekeepers continuously by overseeing the operation and maintenance of health services for the entire force based on the UN medical support manual. UNIFIL is deployed in an area of responsibility (AOR) of 1026 of km2, with the largest span of 64 kilometers from east to west and 40 kilometers from north to south. Even in such a small mission area, it is still very challenging to conduct evacuation of the wounded within 2 hours. According to the statistics in the mission from February 2018 to July 2019, 8 of the total 55 medical evacuation cases were not made within the required 2 hours. Moreover, from December 2018 to October 2019 when the author got on board participating in coordination of AME, all 7 cases of air medical evacuation failed to meet the 2 hours’ timeline strictly as the starting time was calculated from when the wounded evacuation report was received, instead of when the evacuation was initiated to be launched in the operation center.

∑ General Station for Drug & Instrument Supervision and Control, PLA, Beijing, China. ∏ Joint Service Academy, National Defence University of PLA, Beijing, China.

THE MEDICAL SUPPORT GUIDELINES FOR UNITED NATIONS FIELD MISSIONS.

π Directorate of Medical Services, Logistic Support Department, CMC, PLA, Beijing, China. Correspondence: Corresponding Author Email: guofangdaxuelzb@126.com

The Medical Support Manual for United Nations Field Missions (3rd Edition, 2015) serves as a standard reference document on medical support aspects of UN peacekeeping

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E Qiu-Shi ZHANG and Lin CHEN contributed equally to this work.

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STAKEHOLDERS INVOLVED: ROLES AND RESPONSIBILITIES

the helipad within a required timeframe and has the command and control in medical care for the whole journey until handover to the referred hospital medical team. During the air evacuation, AMET should keep CMO/FMO or his/her designated staff informed and updated of the patient condition. To meet the demanding timeframe, the philosophy of "ownership at the highest level and execution at the lowest level" is more workable in practice. This means that the execution staff in real situation do not always wait till seeking and obtaining permission from the highest level leaders.

Two kinds of personnel are involved in conducting AME: medical and non-medical. The Head of Mission is responsible for the entire AME system and can give delegated authority to a headquarter staff with situational awareness, who would normally be the Director of Mission Support (DMS) or Force Commander (FC). As figure 1 shows, Chief Aviation Officer (CAO) in the mission is accountable to the DMS in the terms of ensuring the availability of air assets in support of AME. The Chief Medical Officer (CMO) is the principle staff officer responsible for the overall medical strategy ensuring the implementation of all delegated roles to conduct AME in the mission. In the CMO office, a civilian nurse is often the focal point for liaising with the military or contracted civilian hospital for receiving patients; Force Medical Officer (FMO) and medical officer operations are the designated officers of CMO in coordinating the evacuation. The Aero-Medical Evacuation Team (AMET) is a highly mobile medical unit which is responsible for providing medical care for the casualty suffering from serious trauma injuries during air evacuation. After receiving the evacuation order, AMET should proceed to

KEY POINTS OF A MEDICAL EVACUATION SYSTEM AME Operations are conducted mostly in a time compressed mode with involved stakeholders expected to execute their job as swiftly as possible. This type of operational environment presents a number of hazardous situations with elevated levels of risk in terms of injuries, loss of life or damage to property and assets. Therefore, the whole process of AME operation should be well organized and coordinated. Every step that failed to respond efficiently may have a serious impact on the progress of the whole operation. The following actions are critical in AME conduction.

Figure 1: Organization diagram f or the stakeholders involved AME op eration (SMO: Senior Medical Off icer in the sector).

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a) First response to health emergency The first response includes the earliest time first-aid and prompt alert to forewarn an AME. Immediate lifesaving measures in the POI are critical to prevent a fatality. Injured person should be given immediate first aid by means of self-aid and/or buddy-aid within 10 minutes after accident happens. UNIFIL Medical Section urges every senior medical officer in the battalion to conduct first aid training targeted on each soldier every quarter for these life-saving skills. Every vehicle should be equipped with first aid kit and radio tool during patrol operations. In some locations where first responder program is identified as needed, first responders can be appointed to provide extended field medical care. First responders are individual non-medical personnel trained in advanced first aid who are able to stabilize a casualty at the POI for an extended period before emergency care personnel arrive. After the timely life-saving action, an evacuation alert would be compiled and sent to mission operation center using proper communication tool provided.

Thoughts for improving the process. It should be clarified that first-aid action should be prioritized to take compared with sending out evacuation alert message. In view of grasping basic level skills, all contingent personnel and military officers in headquarter should receive pre-deployment first aid and basic life support skills training. UNIFIL medical section provides continuous training to all contingent senior medical officers on basic first aid skills focusing on stopping the bleeding and securing the airway. All of these senior medical officers are responsible for training their own personnel. After first aid, the first alert message is to be sent to the operation center, which provides the basic information for decision makers to take further actions.

b) Alert Message Alert message is the first hand signal for activating AME. Anyone in the scene, such as the casualty itself or other witnesses, is able to transmit this message to mission operation center to initiate an evacuation response. At least five pieces of information should be covered in the alert message: the incident location and call sign, what happened (incident details), how many casualties/patients needed to be evacuated, actions currently taken and special resources required regarding casualties/patients condition. In UNIFIL, this message should be transmitted using radio casualty evacuation (CASEVAC) channel and directly to Joint Operation Center (JOC) although the Sector Tactical Operation Center (STOC) should be informed as soon as reasonably practical. Receipt of the alert message by the mission operation center must trigger a speedy evacuation response.

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Sometimes the medical personnel at the scene can call CMO/FMO directly to transmit an alert message verbally.

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Although this sounds very easily to act, even medics will be overwhelmed in real situations due to dizziness. Example When a car accident happened in sector east in UNIFIL on 4th October 2019, the medical officer in JOC tried to contact the medics at the scene for more than 20 minutes before obtaining the information required. Even worse is that only one seriously back injured soldier was reported to require an AME, but there are actually two casualties and the second one was suffering from an open fracture in his right leg, which was not reported at the beginning. This second casualty was sent to level 2 hospital at first time and then had to be evacuated by helicopter from level 2 to a contracted level 3 hospital due to the casualty's serious condition. Inappropriate alert message at the scene will result in delay to make fully informed judgement about the situation and put the casualties/patients at risk. According to some related research, early surgery will improve the survival rate and save an extra 10% of the casualties/patients5, 6. In addition, it is well noted that the 9-line message format used in UNIFIL helped greatly in transferring essential information for mass casualty situation or major incident that occurred7. Its purpose is to inform the medical duty officer, CMO's designated for coordination of medical evacuation in operation center, of the status of the casualty, which is usually compiled by first responders who must be trained and equipped to provide the information required. The medical duty officer is to transmit all relevant clinical information to the receiving medical facilities and AMET en-route including the number of casualties expected to receive and estimated time of arrival. However, a complete 9-line message should not be a prerequisite for initiating AME. It is a good reference for all personnel to know what kind of information is needed, and its hard copy can be submitted as soon as possible after the casualties/patients condition is stable. It is the verbal alert message, not the 9-line message, is prioritized in order to make an AME decision promptly. Transmission efficiency is the key element of alert message, which means that even if not all data is available, the personnel at the scene should be sending this message as soon as possible. What is important is the number and severity of casualties.

c) Decision Making In real-time operation, the principal of "ownership at the highest level and execution at the lowest level" seems working better in view of meeting the demanding timeframe of an efficient AME. It means the authority to launch AME operations should be flexible to delegate to the lower practical level with no precondition of seeking permission from the "ownership level" during the emergency happens. In UNIFIL, the head of mission is responsible for the whole AME system. The Director of Mission Support is tasked to provide essential resources for conducting AME. The two

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Thoughts for improving the process.

people belong to the "ownership level". However, when an accident or serious incident occurs, the three key decision makers for AME execution are CMO, Chief of Mission Air Operation Center (MAOC) and Chief of JOC, who belong to the "lower practical level". They are to make the medical, aviation and security assessment in order to develop a AME plan. Decision is then transmitted to the DMS by JOC for review and approval for using mission resources and asset. During the decision making process, CMO decides the choice of referral hospital. The aviation unit is to initiate the risk assessment to define the level of risk involved in the operation. A log of all the activities and decisions is made by operation center, which is also responsible for monitoring the entire operations until it is completed. The whole decision making process requires high levels of trust between senior leaders and those subordinates executing actual operations.

In general, there are two chains of communication and coordination for conducting an AME, one is operational and the other is medical. JOC is the highest operational point of contact for operational information when an AME is in progress. CMO or his/her designated will be the medical focal point in JOC to monitor the patient status and provide medical advices for every stakeholder to make a proper decision. The sector duty officer will report directly to JOC and the sector medical officer to the medical duty officer in JOC. In order to make information transmission prompt and smooth, it is recommended that alert message be sent directly to JOC after an accident takes place instead of through various channels. Example During the AME operation for a soldier who got heart attack in UNIFIL HQ in 2019, it took more than one hour in setting up smooth communication chain after the alert message was sent. In real situation, medical personnel at the scene usually received non-stop calls from different parties which also prevents him/her from focusing on the timely report and information collection.

Thoughts for improving the process. If, for any reason, the Chief of JOC and Chief of MAOC cannot rapidly obtain medical advice from CMO or his/her designated, they have the authority to initiate preparation for an AME. When the helipad planned for conducting evacuation at the beginning is not suitable for landing due to the weather condition, the risk assessment for another nearest helipad should be selected immediately and the whole evacuation plan shall be formulated as soon as possible. In that case, the medical team at the scene should be informed and the ambulance should be used to send the casualties/patients to be the new helipad as adjusted. The referred hospital selected to receive patient can also be informed by JOC to deal with emergency situation.

In this situation, people who are not in JOC should also refrain from calling the duty officers frequently, which will influence them collecting information and make decision as promptly as possible. Another lesson learnt is about timely medical updates by the level 2 hospital receiving the patient. While focusing on stabilizing the casualty, the hospital should report properly and keep CMO/FMO updated about the condition of the patient, so that CMO is in the position to make timely judgement and assess for further evacuation as needed.

d) Coordination and Deployment In real situation, all parties have to react accordingly to advance the whole operation process. When the JOC receives alert message from the sector operation center or POI, sometimes from CMO who is informed by the medics at the scene, JOC notifies all the related parties to activate AME including the MAOC and AMET. At the same time, JOC is also responsible for coordinating approval seeking from the high level leaders, although this approval can be completed afterwards. During the operation, CMO or his/her designated keeps focus on monitoring the patient condition via senior medical officer in the sector or the medics at the scene, and keep AMET informed and updated. The air operation center will alert the aircrew and AMET team regarding the destination landing sites and patient status, and assess landing feasibility, prepare flight plan, perform proper aviation risk management and keep its supervisor duly informed. The medical and flight information sharing and coordination between medical duty officer and air operation center, is vital for the whole operation. Medical report from the medical treatment facility should be sent directly to the CMO promptly after the casualty's arrival. The report informs the mission leadership of the status of the casualty and forms the basis for a decision on possible further evacuation.

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CONCLUSIONS & DISCUSSIONS As a key component in the field medical support chain, AME involves not only the transportation of the sick/injured to the nearest medical facility, but also the entire continuum of medical treatment and rehabilitation. The whole process is driven by the dictum of UN medical timeline principle. Each field mission has its own standard operation procedure on medical evacuation. Most of the procedures only describe general procedures for evacuation and cannot cover many details. Responsible personnel who perform evacuation tasks need to continuously accumulate work experience from practice in order to implement medical evacuation in a more smooth and efficient way. In developing and updating SOP on casualty evacuation, more concrete steps and related instructions are advised to be covered in view of helping involving parties better understand the procedures and conduct the evacuation effectively.

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Some considerations in practice are highlighted for every key step during AME operations based on the lessons learnt in South Lebanon. This article can provide a reference for the development of medical evacuation standard operation procedure (SOP) in the field, which is expected to give some insight into the field AME operation and be conducive to the pilot implementation of UN Casualty Evacuation Policy in UN field missions.

- Firstly, all the stakeholders involved must be clear about their roles and responsibilities, such as with clear elaboration of who is to initiate the operation, who is to implement and who is to announce its completion. - Secondly, all parties must work closely together to advance each stage at the fastest speed. The first responder who sends out alert message is vital, and his/her role should be clearly elaborated in the standard operation procedure. The use of advance orders is also helpful in making preparation for rapid response to emergency evacuation.

Acknowledgement The authors would give special thanks to Lt.Col Roberto CIARDELLA, the MAOC Chief in South Lebanon, UNIFIL, for his technical assistance in conducting air medical evacuation, and to Sr.Col. Rui LI, who served as Chief Medical Officer in UN & AU Planning Team for AMISOM in 2007 and Senior Medical Officer, MSS, UNHQ from 2010 to 2012, for her comments and suggestions to this paper.

- The last but not the least, information communication and sharing need to be given sufficient attention since the person in charge of the command needs to make decisions based on the information provided by the medical staff. In the terms of conducting a timely and efficient AME, an effective communication & information management system, a smooth coordination between different sectors and team mobilization are the cores to achieve an expected goal. Every stakeholder should act promptly and correctly to reach this goal. It is cherished that through the close coordination between operations, medical and aviation staffs, we manage to provide the best quality care during the evacuation and transfer the casualties to the tertiary care facilities the earliest time.

1. ASSA A, LANDAU DA, BARENBOIM E, GOLDSTEIN L. Role of Air-Medical Evacuation in Mass-Casualty Incidents—A Train Collision Experience. Prehospital and Disaster Medicine. 2008; 24(3):271–276.

ABSTRACT

3. JOSHI MC, SHARMA RM. Aero-medical Considerations in Casualty Air Evacuation (CASAEVAC). Mil Med. MJAFI 2010; 66: 63-65.

REFERENCES

2. Medical Support Manual For United Nations Field Missions, 3rd version, chapter 3, sess A.

Air-Medical Evacuation (AME) shall be required if the condition of the patient/casualty is endangered by the level of emergency. It plays a vital role in United Nations (UN) peacekeeping field mission to provide capabilities for timely evacuation and treatment of its personnel. Nevertheless, it is very challenging in UN field missions to conduct timely and efficient medical evacuation in accordance with timeline requirement outlined in the Medical Service Manual for UN field missions. This article discusses how to smooth the whole evacuation process and shorten evacuation time to ensure a timely and efficient AME in the terms of emergency response, communications, information processing & decision making and coordination among all stakeholders.

4. WILLIAM WH, JOHN GJ. Aeromedical Evacuation: Management of Acute and Stabilized Patients. New York: Springer-Verlag; 2003. 5. BELLAMY RF. The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med. 1984; 149:55-62. 6. TAI N, HILL P, KAY A, PARKER PJ. Forward trauma surgery in Afghanistan: Lessons learnt and surgical skills needed for the asymmetric modern battlefield. Submitted JRAMC 12/07. 7. Standard Operating Procedure for Medical, United Nations Interim Force in Lebanon. 2011; chapter 5, sess B.

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References Ref-1: Huang C et al: Lancet 2020; 395: 497–506 Ref-2: Guan W. et al., NEJM 28 Feb 2020, https://www.nejm.org/doi/full/10.1056/NEJMoa2002032 Ref-3: Zhou et al., Lancet , March 9, 2020 , https:// doi.org/10.1016/S0140-6736(20)30566-3 Ref-4: Chen N. et al., Lancet 2020; 395: 507–13 Ref-5: Xiao-Wei, X. et al., BMJ (Online); London 2020, 368 (Feb 19, 2020).DOI:10.1136/bmj .m606 Ref-6: Huang Y et al., medRxiv preprint 2020, doi: https://doi.org/10.1101/2020.02.27.20029009 Ref-7: Schuetz P. et al., Exp. Rev Anti-infect. Ther., 2018, 16:7, 555-564, DOI: 10.1080/14787210.2018.1496331

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A RT ICLES

United States Department of Defense Global Health Engagement: Watering Plastic Flowers in the Hopes That They Will Grow? By D. J. LICINA∑, E. AMSPACHER∏ and C. FRANCISCOπ. U.S.A.

Derek Joseph LICINA Derek Joseph LICINA, DrPH, MPH, CPH, retired after nearly 24 years of service in November 2019 as a Colonel in the US Army Medical Service Corps and currently serves as a Defense Advisor to the consulting firm Kearney. His last assignment was as the Chief of Medical Security Cooperation, US Central Command. Prior to this assignment, he served as the Chief of Global Health Engagements for Regional Health Command – Pacific based out of Honolulu, HI. Derek’s interests revolve around the U.S. Government employment of health as part of foreign policy which includes humanitarian assistance, disaster response and health capacity building efforts. Derek served in both installation and deployable medical organizations in the Department of Defense from the tactical to strategic level in positions ranging from Medical Platoon Leader, General’s Aide to International Health Policy Advisor in the Office of the Secretary of Defense for Stability Operations. He was assigned to both Conventional and Special Operations units and deployed to combat with each community. Derek holds a Doctorate in Public Health, with a focus on global health, from the George Washington University.

RESUME L'engagement du Département de la Défense des Etats Unis pour la "santé globale". Le domaine de la santé globale occupe une place de plus en plus importante. Dans un effort de normalisation de ce domaine d'activité, le département de la défense des Etats Unis a décidé en 2017 d'une véritable une stratégie de mise en œuvre en attribuant des responsabilités et en prescrivant les procédures nécessaires. Malgré la publication de l'instruction destinée à cette mise en œuvre de la santé globale, celle-ci n'est pas véritablement app liquée au niveau du département de la défense. Les exigences requises ne sont donc pas satisfaites et cela ne permet donc pas d'avancer vers les obj ectifs fixés par les États-Unis et les pays partenaires. La publication d'un document d'orientation à destination des équipes, le renforcement de services spécifiques au sein de la direction de l'A gence de santé de la défense, la mise en poste de personnels dédiés, la réaffirmation de la place de la santé globale pour le département de la défense et le déploiement des fonds nécessaires doivent permettre d'améliorer sa mise en œuvre.

KEYWORDS: Global health, Global Health Engagement (GHE), Department of Defense (DoD) USA, Medical cooperation, National security. MOTS -CLÉS : Santé globale, Engagement dans la santé globale, Département de la Défense, Coopération médicale, Sécurité nationale.

GHE as an interaction that supports strategic endstates like achieving interoperability and operational objectives such as developing medical capability and enhancing capacity. During the same year, the Office of the Secretary of Defense for Personnel and Readiness (Health Affairs) facilitated a GHE capabilities based assessment (CBA). This analytical method is used to identify needed capabilities and their associated gaps that are transformed into DoD requirements. The CBA

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The role of the international military sector in global health is growing1, 2 . In an effort to codify these activities, the United States Department of Defense (DoD) established policy, assigned responsibilities, and prescribed procedures for the conduct of Global Health Engagement (GHE) in 2017 thro ug h the Department of Defense Instruction (DoDI) 2000.303 . The policy defines

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was facilitated by a professional consulting firm over a period of twelve months and informed by technical experts and leaders in GHE representing various organizations within and outside of the DoD. Findings of this effort eventually led to a doctrine, organization, training, materiel, leadership, personnel, facilities and policy (DOTMLPF-P) Change Recommendation (DCR) endorsed by the Joint Requirements Oversight Council (JROC) of the Joint Staff in February 2019. The JROC acknowledged the DCR identifies numerous shortfalls within the Joint Force that constrain effective and efficient GHE support to the Geographic Combatant Commands (GCCs) as well as potential solutions.

PERSONNEL REQUIREMENTS The Conceptual Framework for the spectrum of DoD GHE activities depicted in Figure 1 of DoDI 2000.30 is composed of four major categories to include building partner capacity and humanitarian assistance among others. Within the categories are twenty-two separate activities. These activities range from the International Global Health Security Agenda to the Defense Threat Reduction Cooperative Biological Engagement Program with the GCCs as one of the primary customers. Despite GHE residing at the nexus of the DoDI Conceptual Framework, the number of dedicated GHE personnel committed to supporting implementation across the GCCs and Military Departments is small and variable.

Despite these significant achievements, DoD is frantically peddling a GHE bicycle without any handlebars. Currently there is no formal GHE guidance document that translates the DoDI from the strategic to operational level nor full time dedicated GHE personnel to implement the specified and implied responsibilities. Further confounding effective implementation is the lack of dedicated GHE resourcing which is captured in the literature elsewhere4. The few temporarily assigned personnel (e.g. Air Force International Health Specialists) and the Commands they support are left to develop their own guidance and procedures for implementing the DoD policy and compete for funding such as Title 10, United States Code, to execute medical security cooperation which is a key GHE activity. The following three sections describe the GHE guidance shortfall, personnel challenges and concludes with recommendations on how to close these gaps.

For example, the US Central Command (USCENTCOM) has no permanently assigned GHE professionals. Rather, borrowed manpower is provided from some Services to support implementation of the nine GCC responsibilities outlined in DoDI 2000.30. The two borrowed personnel supporting USCENTCOM serve four Service Components, one Theater Special Operations Command and two Joint Task Forces. Across these seven headquarters, there are only four dedicated positions supporting GHE – all International Health Specialists (IHS) belonging to US Air Forces Central Command with duty location split between the Air Component and GCC. Unfortunately, as of writing this article, only two of the four IHS positions are filled. Other GCCs have a similarly inadequate number of permanently assigned GHE personnel responsible for implementing the DoDI policy of “conducting activities that build the capacity of partner nation government to maintain a level of health care conducive to a healthy population, bolstering the civilian population’s confidence in PN governance, and lowering the PN’s susceptibility to destabilizing influences.” To accomplish the daunting list of DoDI tasks for just one GCC would take all GHE personnel in the DoD.

IMPLEMENTING GUIDANCE The DoDI 2000.30 states the GCCs are given the responsibility to “ensure GHE activities… conform to U.S. policy guidelines and principles by establishing appropriate polices and procedures for component commands and offices of security cooperation.” Some GCCs have developed their own policies and procedures based on the strategic guidance of the DoDI and their respective Theater Campaign Plans (TCP). However, there is a significant leap between the Office of the Secretary of Defense GHE policy and GCC implementation procedures – excluding the Joint Staff entirely. Furthermore, assessment, monitoring and evaluation requirements are difficult to achieve due to variance between the GCCs in their approach to GHE. Some GCCs use regional approaches, other emphasize bilateral efforts. Civilian institutions such as Ministries of Health may be prioritized over Ministries of Defense. How the GCCs engage also varies whereby some use joint doctrinal medical functional areas while others leverage civilian sector models. Practioners of GHE acknowledge the need for flexibility in determining who to engage (e.g. military vs civilian sectors) and how using the various authorities available to meet unique TCP objectives. However, in the absence of a standard approach to implementation across the GCCs, aggregating data to inform senior leaders of the Services, Joint Staff and Office of the Secretary of Defense regarding the impact of GHE is significantly lacking.

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There are winners in this space such as the US Indo-Asia Pacific Command where eight IHS personnel are assigned to the US Pacific Air Forces Command and another seven personnel working GHE implementation efforts in other Service Components and the GCC Headquarters. Although one could argue this disparity in assignment of Air Force IHS personnel across the GCCs is warranted based on the 2019 National Defense Strategy, the imbalance does bring into question if the risk is worth the reward. Bearing this in mind, the GCCs are grateful for the leadership provided by the Air Force in assigning personnel to implement the DoDI. The Navy is working to do the ∑ Colonel, U.S. Army, Chief, Medical Security Cooperation ∏ Maj, Nurse Corps, U.S. Air Force 1 π MSgt, Enlisted Corps, U.S. Air Force 1 Correspondence: Colonel Derek LICINA Chief, Medical Security Cooperation, US Central Command Surgeon, 7115 South Boundary Blvd., MacDill AFB, FL 33621-5101, U.S.A. E-mail: licinaj@gwmail.gwu.edu

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Figure 1: D oDI 2000.30.

same with establishing a Health Security Cooperation Officer capability while it remains unclear what role the Army will play in the GHE space as they neither have dedicated GHE personnel nor an additional skill identifier. The individual Army professionals attempting to work in the GHE space lean on the other Services for guidance and support.

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art referral facility for ongoing operations, and increases flexibility to support future contingency operations. Despite these successes, USCENTCOM is not able to meet current GHE demand and is declining future partner nation engagement requests based on limited GHE personnel capacity. This is ironic as GHE is intended to enhance the capacity of our partner nations. However, the DoDI has not done the same for the GCCs attempting to implement the requirements. It is possible the DoDI assists in streamlining existing GHE capability thereby enhancing capacity, but that is a tenuous statement at best for those working at the GCC level and below. As an organization, DoD continues to pour water on plastic GHE flowers in the hopes that they will grow.

Notwithstanding the dearth of dedicated GHE personnel in USCENTCOM, the command leverages these experts to support Country Security Cooperation Plans (CSCP) and TCP objectives through medical security cooperation. These engagements improve bi- and multi-lateral interstate relations and advance U.S. national priorities. Since 2014, USCENTCOM conducted 169 GHEs in the region, 9% of the total security cooperation engagements, at a cost of less than 1% of the GCC security cooperation budget. The percentage of GHE increased to over 12% in 2018 and demand from partner nations is growing. These exchanges included rehabilitative medicine with Iraq, disease surveillance with Jordan, and trauma medicine with Uzbekistan. The USCENTCOM GHE team also developed a multi-million US dollar trauma, burn and rehabilitative medicine foreign military sales case in direct support of a Secretary of Defense initiative with a key partner nation. This effort, fully funded by the partner nation, enhances partner nation capacity in these critical areas, supports interoperability, provides the US military a venue to enhance wartime surgical skills, creates a possible in-theater state of the

International Review of the Armed Forces Medical Services

POTENTIAL SOLUTIONS Fortunately, there are practical solutions that can be implemented in the near term to resolve these ongoing challenges. Specific guidance from the Office of the Joint Staff Surgeon to standardize GHE implementation would improve execution and increase the GCCs and DoDs ability to “measure effectiveness and evaluate the outcomes of command GHE operations….”5. Using a joint doct rine medical functional area approach for implementation is pro posed6, 7 . Leveraging medical functional areas based on how the Services are organized, trained and equipped enhances

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the ability to task and support GHE activities. This approach would support both military and civilian institutions as it enhances health service support and force health protection capacity. Outlining this approach in a Joint Staff guidance document, possibly a Chairman’s Memorandum, would enable DoD and our partner nations to streamline what GHE activities are offered and requested as well as track progress toward achieving established objectives. Closing the personnel gap remains a challenge. However, as the Defense Health Agency (DHA) assumes its legally mandated joint military health system (MHS) and combat support agency (CSA) roles, GHE will be its responsibility8. A solution in line with the broader National Defense Authorization Act mandates may be to dissolve existing Service GHE Offices and establish a unified office under DHA. This suggestion becomes feasible after DHA assumes all MHS responsibilities, platforms and personnel. Current responsibilities assigned to the Military Departments should be transferred to DHA during the next DoDI 2000.30 review. Emerging GCC GHE opportunities could then be routed by the Joint Staff Surgeon to the Defense Health Agency for action, or directly from the GCCs which is the informal process employed today. This approach would liberate the Joint Staff and or the GCCs from coordinating requirements with different Services, who implement GHE in disparate ways according to their own policies and customs. The newly established DHA GHE Office could work with the Defense Security Cooperation Agency and Assistant Secretary of Defense for Legislative Affairs to develop a GHE authorization and corresponding appropriation to implement the DoDI. This effort would replicate the means by which the Defense Threat Reduction Agency, a similar CSA, implements a Counter Threat Reduction portfolio that includes biological threats. The GHE authorization and appropriation would enable DHA organizations such as the Joint Trauma System and Psychological Health Center of Excellence to more effectively support the DoDI in the near term while providing the GCCs and their component commands the funding necessary to conduct persistent engagement with partner nations using health to support TCP objectives. The DHA GHE Office could also support the GCCs and implementing partners by consolidating defense health research funding and capabilities in support of GHE requirements. This would include the alignment of Service research priorities with GCC operational requirements. The Joint Staff and GCCs currently spend a significant amount of time and effort trying to synchronize these disparate efforts and this leadership role from DHA would be a welcomed change.

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The Uniformed Services University could serve as the unified academic organization that consolidates entities that train US forces such as the Defense Medical Readiness Training Institute, Military Medical Education and Training Center and those that execute international training such as the Defense Institute for Medical Operations. Integrating similar organizations would assist in preparing DoD personnel to implement the DoDI, as well as

International Review of the Armed Forces Medical Services

supporting the development of standardized products (e.g. medical functional area playbooks) to deliver GHE. This consolidation and streamlining of DoD GHE capabilities should be explored to see where efficiencies can be gained to offset personnel shortfalls. Consideration should be given to reassessing who is best positioned to serve as GHE proponent for the Under Secretary of Defense for Policy. Since the Assistant Secretary of Defense (ASD) for Special Operations and Low-Intensity Conflict only supports one of the four major categories in the GHE Conceptual Framework, the community of interest may be better served if the ASD Strategy, Plans, and Capabilities assumes responsibility. Collocated with “GHE” at the center of the Conceptual Framework Venn diagram is “security cooperation.” The Deputy Assistant Secretary of Defense (DASD) for Security Cooperation works for this office and would be a good policy fit. With support from the ASD Health Affairs, Joint Staff Surgeon and the Director of the DHA, this restructure would further enhance implementation of the DoDI. Additionally, the GCCs require the leadership and support of the Global Health Engagement Council to review the current allocation of GHE professionals in support of the GCCs and Service Components. The analysis and ensuing recommendations would ensure staffing is commensurate with requirements. There is no question Phase 0 shaping operations leveraging GHE are important in permissive environments. However, they are even more important in semi and non-permissive areas, such as predominate in USCENTCOM, as a risk mitigation strategy for regional and international insecurity. The GHE Council should ensure DoD has the right balance in terms of GHE capability to DoDI requirements as there is an overemphasis in the IndoAsia Pacific Command Area of Responsibility at the expense of all other GCCs. Appropriate GHE expert staffing at the GCCs and the unification of Service GHE capabilities at the DHA will position DoD to establish an improved forum to coordinate and collaborate with our international partners. Definitive GHE wins through published guidance, consolidated capabilities and dedicated personnel ensures the DoD community of interest has the means necessary to accomplish the requirements outlined in the DoDI 2000.30. As GHE leadership roles are refined, we look to ASD Strategy, Plans, and Capabilities and the Director of DHA to be the change agents so desperately need to pull out the plastic GHE flowers from the pot and put down real seeds that will grow in the future.

SUMMARY The role of the international military sector in global health is growing. In an effort to codify these activities, the United States Department of Defense established policy, assigned responsibilities, and prescribed procedures for the conduct of Global Health Engagement in 2017 through the Department of Defense Instruction 2000.30.

Revue Internationale des Services de Santé des Forces Armées

Despite publication of the Instruction, systematic implementation across the Department is lacking. This shortfall impedes the ability to meet the specified requirements and track prog ress toward achieving United States and Partner Nation objectives over time. Publishing a Joint Staff guidance document, consolidating Service Global Health Engagement offices under the Defense Health Agency, developing a dedicated profession, reassigning Global Health Engagement leadership within DoD, and establishing a dedicated funding appropriation will enhance implementation.

4. Derek LICINA, Brad COGSWELL, Richard PAZ, “Establishing a Predictable Military Global Health Engagement Funding Authority: Supporting Theater Security Cooperation Objectives and Generating Military Medical Readiness,” Military Medicine, 2016, Vol 181, 1397-8, available at: https://academic.oup.com/milmed/article/ 181/ 11-12/ 1397/4158606

REFERENCES

6. Bertram PROV IDENCE, Derek LICINA, Andrew LEIENDECKER, “Increasing Partner Nations Capacity Through Global Health Engagement and Global Health,” Joint Forces Quarterly , 2017, Vol 87, 64-8, available at: https:// ndupress.ndu.edu/ Portals/ 68/ Documents/jfq/jfq87/jfq87_64-68_Providence-Licina-Leiendecker.pdf?ver=201709-28-092007-493

5. US Department of Defense Instruction 5132.14, “Assessment, Monitoring, and Evaluation Policy for the Security Cooperation Enterprise,” 2017, available at: https://www.esd.whs.mil/Portals/54/Documents/DD/issuances /dodi/513214_dodi_2017.pdf

1. Josh MICHAUD, Kellie MOSS, Derek LICINA, et al, “Militaries and Global Health: Peace, Conflict, and Disaster Response,” The Lancet, 2019, Vol 393, 276-86, available at: https://www.thelancet.com/journals/ lancet/article/PIIS0140 -6736(18)32838-1fulltext

7. Matthew LEVINE, Eric LUTZ, Derek LICINA, “Increasing Partner Nations Capacity Through Global Health Engagement and Global Health Engagement Playbooks: Aligning Tactics with Strategy Using Standardized Engagement Packages,” Military Medicine 2018 Vol 9/ 10, 181-3, htt ps://academic.oup.com/ milmed/article/ 193/910/ 181/45036727

2. Derek LICINA, “The Military Sector’s Role in Global Health: Historical Context and Future Direction,” Global Health Governance, 2012, Vol 6, no. 1, 1-30, available at: http:// blogs.shu.edu/ghg/fils/2012/ 12/VOLUME-VI-ISSUE-1FA LL-2012-The- Military-Sector’s-Role-in-Global-HealthHistorical-Context-and-Future-Direction.pdf 3. US Department of Defense Instruction 2000.30, “Global Health Engagement Activities,” 2017, available at: https://www.esd.whs.mil/Portals/54/Documents/DD/issuances /dodi/200030_dodi_2017.pdf

8. National Defense Authorization Act, January 17, 2019, available at: https://www.govinfo.gov/content/ pkg/CRPT115hrpt874/ pdf/CRPT-115hrpt874.pdf

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International Review of the Armed Forces Medical Services

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A RT ICLES

Etude descriptive des caractéristiques de la population de patients militaires présentant un trouble de l’usage de l’alcool et consultant dans le service de psychiatrie d’un Hôpital d’Instruction des Armées. Par E. SAGUIN∑ ∫, A. DAVID∏, F. SAUVET π ∫, C. GUILLAUME∑, A. EON∑ et B. LAHUTTE∑. France

Emeric SAGUIN Admis à l’Ecole du Service de Santé des Armées en 2007, le Médecin Emeric SAGUIN (OF-2) a entamé un cursus de spécialisation en Psychiatrie en 2014. Titulaire d’un master 2 en Neurosciences (2016), d’un DES de Psychiatrie (2018), d’un DESC d’addictologie (2019), il poursuit actuellement son cursus de formation par une thèse de Neurosciences. Ses principales thématiques de travail sont le traumatisme psychique et la pharmacogénétique. Depuis 2016, il est affecté dans le service de Psychiatrie de l’Hôpital d’Instruction des Armées Bégin où il exerce une activité clinique au profit des patients militaires et civils. Il a participé à une première Opération Extérieure (Barkhane) en 2020.

SUMMARY Descriptive study of military inpatients and outpatients with alcohol use disorder (AUD) treated in psychiatric department of a military hospital. Introduction: The prevalence of alcohol use disorder (A UD) is higher in the military than in the civilian population. To our knowledge, there is currently no study about the treatment of A UD among an active military population. The obj ective of this study is to improve the characterization of this population. Method: We carried out a retrospective study, focusing on the biographical and clinical features of military inpatients and outpatients presenting an AUD and being treated in the psychiatric department of the Val-de-Grâce hospital between 2009 and 2015. Results: In our patient register the prevalence of A UD was 19.99%. Data was obtained from 109 out of 28 1 patients treated for an A UD. Care was very rarely asked by the patient himself; therefore, the first complain was not the A UD but depression. Traumatic event was found among 32. 10% of our patients and a p ost-traumatic stress disorder was effective in 16.50% of cases. On one hand, this population was characterized by a few somatic consequences of the A UD; on the other, we found a significant socio-professional impact. Conclusion: Our study outlines, under a new perspective, the peculiarities of the clinical profile of soldiers consulting in a military hospital for an A UD.

MOTS-CLÉS : Trouble de l’usage de l’alcool, TUA, Militaire, HIA . KEYWORDS: Alcohol Use Disorder, SUD, Military, Army medical center.

INTRODUCTION

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des décès). Ceci inclut 16 000 décès par cancers, 9 900 décès par maladies cardiovasculaires, 6 800 par maladies digestives, 5 400 par accidents ou suicides et plus de 3 000 pour une autre cause (dont les maladies mentales et les troubles du comportement)2 .

L’alcool est de très loin la substance psychoactive la plus consommée en France, du fait notamment d’aspects culturels suscitant de nombreuses controverses 1. Cette consommation n’est pas sans incidence en termes de santé publique puisqu’on estime à 41 000 le nombre de décès attribuables à l’alcool en 2015 (soit environ 7 %

International Review of the Armed Forces Medical Services

En cela, la consommation d’alcool constitue un enjeu de santé publique du fait des complications médicales

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dans un climat conflictuel – peut s’incarner à la manière d’une déchéance qui n’épargne l’individu ni sur le plan psychique (sentiment de honte, d’indignité pouvant s’inscrire dans un épisode dépressif caractérisé), ni sur le plan somatique (perte des capacités physiques nécessaires à la projection opérationnelle voire apparition de pathologies physiques résultant de la consommation)13.

aiguës et chroniques mais aussi du coût social et économique pour la société que cette substance est susceptible d’induire1. Dans le champ de la santé mentale, le trouble de l’usage de l’alcool (TUA) est classiquement défini comme correspondant aux formes symptomatiques de l’usage, c’est-à-dire qui ont des conséquences visibles sur le plan social, psychologique ou médical3.

Enfin, de nombreuses données suggèrent que le TUA persiste au moment de la sortie de l’Institution voire s’aggrave notamment si la transition professionnelle dans le milieu civil s’avère compliquée14.

Différentes études nationales et internationales tendent à montrer que la prévalence du TUA est plus importante dans la population militaire que dans la population générale4. Cependant, la consommation d’alcool dans les armées est difficile à appréhender de manière globale, notamment car il existe de fortes disparités selon les modalités d’emploi. Des différentes enquêtes menées au sein des forces armées, il en ressort une prévalence de l’usage régulier d’alcool de 48,4 % avec des variations importantes selon l’armée d’appartenance (58,8 % dans la Marine Nationale où la consommation quotidienne d’alcool est estimée à 17,6 g soit entre une et deux Unités d’Alcool par jour). 21,2 % des militaires déclaraient avoir eu au moins une ivresse alcoolique au cours du dernier mois (57,3 % dans la Marine Nationale). Concernant la dépendance à la substance (évaluée par un test DETA >2), la prévalence était de 13,8 % et ne différait pas selon les armées d’appartenance5, 6.

Dans l’armée, de manière relativement similaire à ce qui s’observe dans la population générale, le TUA est une comorbidité très fréquente de l’ensemble des maladies mentales, en particulier le trouble panique, la dépression, les idées suicidaires et l’Etat de Stress PostTraumatique (ESPT)15, 16. La prévalence des troubles de la personnalité chez les soldats présentant un TUA est estimée à 17,5 %17. Dans cette population, la comorbidité du TUA et de l’ESPT est particulièrement étudiée. Ainsi, dans la population de vétérans suivis pour un ESPT, on estime la prévalence du TUA est comprise entre 45 % et 79 %16, 18. Si la physiopathologie de cette comorbidité reste mal comprise, il est cependant généralement admis que le TUA s’inscrit systématiquement dans une dynamique complexe entre déterminants biologiques et fonctionnement subjectif19.

Pour autant, la consommation d’alcool n’est pas linéaire au cours de la vie d’un militaire. En premier lieu, l’engagement dans l’Institution est susceptible de venir accroître une consommation d’alcool préexistante. En effet, il existe un effet d’entraînement au sein du groupe militaire, l’alcool étant souvent utilisé comme un moyen de créer un sentiment de cohésion7, 8. Ainsi, une étude réalisée dans la Marine Nationale montrait que 38,9 % des marins décrivaient une augmentation de leur consommation d’alcool après leur engagement5. De surcroît, en opération, la consommation d’alcool peut s’inscrire comme un moyen de tromper l’ennui, de créer un contexte favorisant les échanges sociaux, de produire une anxiolyse dans un environnement qui maintient parfois une tension psychologique quasiconstante avec la potentialité d’une confrontation à des évènements psychotraumatiques ou encore s’inscrire dans le cadre d’une consommation chronique9. De la même manière, les TUA ont tendance à s’aggraver au retour d’un déploiement en Opération Extérieure (OpEx)10. Il est bien établi que les séjours outre-mer, la mise à disposition de l’alcool détaxé, la « fréquence des pots », l’isolement géographique ou affectif et les déceptions professionnelles constituent des facteurs de risque d’une augmentation de la consommation d’alcool chez le militaire11, 12.

Au total, le TUA a un impact bien identifié sur la santé physique, psychique, la vie sociale et la performance au travail20. Néanmoins, certaines spécificités du métier du militaire (port d’arme, conduites d’engins spéciaux, pilotage d’aéronefs, opérations intérieures (OpInt) et extérieures (OpEx)) imposent une préoccupation toute particulière vis-à-vis de la population militaire21, 22. C’est pourquoi le Service de Santé des Armées (SSA) a développé très précocement une réflexion addictologique, prenant en compte les particularités du milieu militaire, afin de pouvoir proposer des interventions davantage ciblées1. L’action du SSA est organisée d’une part autour d’actions de prévention, principalement à la charge des médecins d’unité (médecins généralistes) répartis au sein d’un maillage territorial efficace et d’autre part, autour de structures de soins addictologiques en milieu civil ou au sein des Hôpitaux d’Instruction des Armées (HIA). ∑ Service de Psychiatrie, HIA Bégin. 69, avenue de Paris. 94 160. Saint-Mandé. ∏ Service de Psychiatrie, HIA Percy. 1, rue du Lieutenant Raoul Batany. 92 190. Clamart. π Unité fatigue et vigilance, Institut de recherche biomédicale des armées, 1 place du Médecin général Valérie André, 91 223 Brétigny sur Orge.

Si la consommation d’alcool peut passer inaperçue dans un premier temps, voire constituer un facteur renforçant certains liens sociaux, l’aggravation de l’alcoolodépendance est susceptible de venir majorer les conflits entre le soldat et sa hiérarchie et d’amener à une exclusion du groupe. Cette désadaptation progressive du soldat vis-à-vis du milieu militaire – qui se fait très souvent

International Review of the Armed Forces Medical Services

∫ EA 7330 VIFASOM, Hôtel Dieu, Paris, Université Paris Descartes. Correspondance : Médecin des Armées Emeric SAGUIN HIA Bégin, Service de Psychiatrie 69, avenue de Paris. 94 160. Saint-Mandé. Tél. : 01.43.98.54.40. E-mail : emeric.saguin@intradef.gouv.fr

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Dans les HIA, les psychiatres ont une expertise de la psychiatrie générale et prennent en compte la dimension addictologique pour l’organisation des soins. Les services de psychiatrie des HIA accueillent les patients militaires selon différentes modalités. En premier lieu, le mode de rencontre avec les soins le plus fréquent est une orientation décidée par le médecin d’unité afin que le patient puisse bénéficier de soins spécialisés en milieu hospitalier. Viennent ensuite les rencontres sur le mode de l’urgence : soit du fait d’une présentation spontanée ou non du patient aux urgences de l’HIA, soit du fait d’une hospitalisation dans le service hospitalier au décours d’un rapatriement sanitaire depuis un théâtre d’opérations. Enfin, le psychiatre militaire, sollicité en sa qualité d’expert ou de sapiteur pour statuer sur l’aptitude du militaire et sa position médico-statutaire, est susceptible de proposer et d’organiser les soins à partir de cette rencontre initiale. Ce dernier aspect revêt une importance particulière puisque les problématiques addictives convoquent en plein les médecins des armées dans leur responsabilité d’expertise. Effectivement, outre les développements intrinsèques ou comorbides des TUA et la manière dont l’usage de substances est susceptible de venir catalyser certains troubles du comportement, les différentes modalités d’usage posent en elle-même des questions d’aptitude médico-professionnelles.

En pratique courante, les armées utilisent la classification internationale des maladies (CIM-10) afin de côter les pathologies présentées par les patients. Il a été décidé de procéder à une extraction informatisée de l’ensemble des patients qui avaient reçu une cotation F10 (Troubles mentaux et du comportement liés à l’utilisation d’alcool) et qui ont bénéficié d’un suivi dans le service de psychiatrie de l’HIA du Val-de-Grâce entre 2009 et 2015. La catégorie F10 comprend de multiples sous catégories qui permettent l’exploration de troubles liés à une consommation d’alcool active ou non24. Les patients pouvaient avoir reçu cette cotation diagnostique aussi bien en tant que diagnostic principal ou tant que diagnostic associé à une autre pathologie psychiatrique. A partir, de cette liste de patients, une base de données a été créée. Par la suite, plusieurs réunions avec les praticiens du service de psychiatrie de l’HIA du Val-deGrâce ont permis de déterminer un formulaire de recueil d’informations (Annexe 1) que chaque médecin référent a eu à remplir pour les patients dont il assurait le suivi. L’accent a été mis sur des données qui nous sont apparues pertinentes non seulement d’un point de vue épidémiologique (âge, corps d’armée, grade) mais également d’un point de vue clinique (mode de consommation, conséquences de la consommation d’alcool, traitements mis en œuvre…). Ce format d’étude, type « enquête auprès des thérapeutes » nous a semblé le plus à même pour rendre compte de la réalité clinique de nos interventions addictologiques.

JUSTIFICATION DE L’ÉTUDE A notre connaissance, la seule étude évaluant la consommation d’alcool chez les patients consultants dans les services de psychiatrie des HIA remonte à 2000 et prenait uniquement en compte les patients hospitalisés. Cette étude retrouvait que 34,5 % des patients hospitalisés dans les services de psychiatrie des HIA avaient une consommation excessive (DETA >2)23.

Les nuages de mots ont été regroupés en catégories sémantiques selon une méthode d’analyse des contenus. Il s’agissait de regrouper les mots choisis par les praticiens en fonction de leur ressemblance thématique. Toutes les variables ont été saisies sur Excel. Nous avons ensuite procédé à une analyse statistique à partir du logiciel SPSS (IBM, Armonk, North Castle).

Les limites de cette étude étaient la population étudiée (les patients hospitalisés représentent une fraction minoritaire de l’ensemble des patients reçus dans nos services) et son caractère purement épidémiologique.

Les statistiques descriptives sont présentées sous la forme suivante : effectif (N) et proportion (%). Les analyses de corrélation, comparent les sous-types de population en utilisant un test du Khi2 de Pearson (Très significatif : p <0,01; significatif : p <0,05; ddl : degré de liberté en rapport avec le nombre de variables).

Il nous a néanmoins semblé que l’obtention d’informations cliniques complémentaires, nécessaires pour caractériser plus spécifiquement cette population de patients militaires présentant un TUA, pouvait être utile afin d’améliorer notre dispositif de soins.

L’étude complète des associations statistiques entre les différents facteurs fera l’objet d’une seconde publication.

Nous avons par conséquent proposé de réaliser une étude rétrospective sur la population de patients consultant dans le service de psychiatrie de notre HIA et présentant un TUA. Cette étude a fait l’objet d’un financement en tant que Petit Projet de Recherche Clinique (PPRC) et d’une promotion par la Direction Centrale du Service de Santé des Armées (DCSSA).

RÉSULTATS Sur la file active des 1 406 patients régulièrement suivis par un psychiatre dans le service de psychiatrie de l’HIA du Val-de-Grâce, 281 (soit 19,99 %) patients avaient une cotation diagnostique comprenant le code F10 (TUA). Les psychiatres référents ont pu renseigner les données du questionnaire pour 109 des 281 patients initiaux soit un taux de réponse à 38,79 %. Ces patients ont été inclus dans notre étude (Figure 1). Parmi les 109 patients nous retrouvions majoritairement des hommes (91 %). Les patients étaient répartis équitablement entre 3 classes

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L’objectif de ce travail est d’évaluer la prévalence du TUA dans la population de militaires consultant en HIA et de préciser les caractéristiques biographiques et cliniques de ces patients.

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Figure 1 : Inclusion des patients présentant un trouble de l’usage de l’alcool.

demande du commandement dans 29,40 % des cas, à la demande du médecin d’unité au décours d’une visite médicale périodique (VMP) dans 23,9 % des cas et dans 42,2 % des cas du fait d’un rapatriement sanitaire.

Patients ayant bénéficié d’un suivi psychiatrique à l’HIA du Val-de-Grâce entre 2009 et 2015

Plusieurs motifs de soins, le plus souvent intriqués, motivaient la demande et l’initiation de la prise en charge hospitalière. Ainsi, nous retrouvions dans 62,4 % des cas la description d’un syndrome dépressif, et seulement dans 50,5 % des cas une consommation d’alcool pathologique. Les troubles du comportement étaient, eux aussi, fortement représentés (22 %).

1406 Extraction Codage CIM Patients présentant un trouble de l’usage de l’alcool 281 (20%) Recherche des données cliniques

A noter que lors de l’évaluation psychiatrique, les troubles de la personnalité étaient au-devant de la scène dans 55 % des cas et les conséquences de la consommation d’alcool dans 42,2 % des cas. Le déni, paramètre clinique souvent décrit dans cette population, portait ici majoritairement sur les conséquences des consommations (19,30 %) ainsi que sur la quantité consommée (17,4 %).

Formulaires remplis 109 (taux de réponse : 39%)

d’âge : 25-35 ans (31,20 %), 35-45 ans (31,10 %), plus de 45 ans (31,20 %). On retrouvait une surreprésentation de l’Armée de Terre (65,10 %) et une majorité de militaires du rang (56 %).

L’analyse des modes de consommation révélait une consommation continue dans le cadre d’une dépendance (F1025) dans 33 % des cas, une utilisation actuelle dans 15,60 % des cas (F1024) et une consommation sur le mode épisodique et massif (F1026) dans 38 % des cas. Au moment de l’étude 11,90 % des patients étaient parvenus à l’abstinence (F1020).

Les caractéristiques de la population sont précisées dans le Tableau 1.

PRESENTATION CLINIQUE DES PATIENTS PRESENTANT UN TUA

Les patients décrivaient une consommation d’alcool lorsqu’ils étaient seuls dans 77,10 % des cas. Selon les données recueillies, les patients lui attribuaient une fonction anxiolytique dans 51,40 % des cas, une fonction sociale et festive dans 33 % des cas, rapportaient consommer par ennui dans 15,60 % des cas et à visée hypnotique dans 9,20 % des situations. Ces catégories sémantiques ont été obtenues par l’analyse et le regroupement des mots utilisés par les psychiatres pour la fonction de la consommation d’alcool pour leurs patients.

L’ensemble des caractéristiques cliniques est détaillé dans le Tableau 2. Le recueil des informations cliniques a pu mettre en évidence le contexte de rencontre particulier avec les soins chez ces patients présentant un TUA. Ainsi, ils étaient seulement 21 % à initier spontanément une demande de soins. A l’opposé, l’orientation vers l’HIA s’était faite à l’initiative de l’entourage dans 22 % des cas, à la

Tableau 1 : Caractéristiques générales de la population. NR = information non renseignée. ELÉMENTS BIOGRAPHIQUES Sexe

Age

Homme

Femme <25 ans 25-35 ans

N = 99

N = 10

N=6

91%

9,20%

5,50%

Statut marital

Enfants

35-45 ans

>45 ans

Seul

En couple

Oui

Non

N = 34

N = 35

N = 34

N = 45

N = 62

N=2

N = 51

N = 45

N = 13

31,20%

32,10%

31,20%

41,30%

56,90%

1,80%

46,80%

41,30% 11,90%

PARCOURS MILITAIRE Corps d’Armée Armée de Terre

Gendarmerie Nationale

Marine Nationale

Armée de l’air

Catégorie BSPP

Légion étrangère

Autre

N = 71

N = 13

N=8

N=7

N=4

N=2

N = 61

N = 39

65,10%

11,90%

7,30%

6,40%

3,70%

1,80%

56,00%

35,80% 8,30%

Caractéristiques du poste

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Militaire SousOfficier du rang officier

Modalité d’engagement

Vigilance Monotonie / / stress attente

Sans particularité

Poste isolé

N = 78

N=1

N = 21

71,60%

0,90%

19,30%

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N=9

Sous contrat >3 ans

Sous contrat <3 ans

De carrière

N=8

N=1

N = 52

N = 15

N = 41

N=1

7,30%

0,90%

47,70%

13,80%

37,60% 0,90%

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Tableau 2 : Aspects cliniques. Pour chaque sous-groupe, plusieurs réponses étaient possibles. ASPECTS CLINIQUES Modalités d’entrée dans les soins VMP

Rapatriement sanitaire

Demande spontanée du patient

Demande de Demande du l’entourage commandement

N = 26

N = 46

N = 23

N = 24

N = 32

N=6

23,90%

42,20%

21,10%

22,00%

29,40%

5,50%

Motif des soins

Adressé par médecin civil

Manifestation clinique au-devant de la scène Autre toxique

Aptitude

Alcool

Trouble de la personnalité

Alcool

Dépression

Troubles du comportement

N = 55

N = 68

N = 24

N = 14

N = 16

N = 46

N = 60

50,50%

62,40%

22,00%

12,80%

14,70%

42,20%

55,00%

Les conséquences / la gravité

Dépendance utilisation continue

Caractéristique du trouble de l’usage de l’alcool

Déni concernant : L’existence de la consommation

La quantité consommée

Utilisation actuelle

Consommation épisodique

Abstinents

N = 12

N = 19

N = 21

N = 36

N = 17

N = 42

N = 13

11,00%

17,40%

19,30%

33,00%

15,60%

38,50%

11,90%

Mode de consommation

Fonction attribuée à l’alcool

Seul

En groupe

Dipsomanie

Anxiolyse

Hypnotique

Festif

Rien

N = 84

N = 42

N = 11

N = 56

N = 10

N = 36

N = 17

77,10%

38,50%

10,10%

51,40%

9,20%

33,00%

15,60%

Clinique en lien avec le milieu militaire Si oui, augmentation Si oui, mission Départ antérieur compliquée du de la consommation au en OpEx retour de mission ? fait de l’alcool

Evènement traumatique

ESPT caractérisé

N = 57

N = 22

N = 16

N = 35

N = 18

52,30%

38,60% (20,20% de l’effectif total)

28% (14,70% de l’effectif total)

32,10%

16,50%

les psychiatres avaient orienté le patient vers une psychologue en vue de mettre en place une psychothérapie complémentaire dans 51,40 % des cas. Les patients bénéficiaient d’une prise en charge dans un CSAPA dans 17,40 % des cas. Seulement 3,70 % avaient pu rencontrer une association de patients. Les données relatives aux traitements utilisés sont résumées dans le Tableau 3.

Concernant plus spécifiquement le milieu militaire, 52,30 % des patients étaient déjà partis en OpEx. Parmi cette sous-population de patients partis en OpEx, la consommation d’alcool avait pu compliquer la mission dans 38,60 % des cas. Une augmentation des prises au retour de mission était décrite dans 28 % des cas. Sur le plan psychique, il existait un impact opérationnel direct puisque 32,10 % des patients avaient vécu un ou plusieurs évènements traumatiques et 16,50 % présentaient un tableau d’ESPT caractérisé.

COMPLICATIONS SOMATIQUES, PSYCHIATRIQUES, SOCIALES ET PROFESSIONNELLES CHEZ LES PATIENTS PRESENTANT UN TUA

USAGE DES THERAPEUTIQUES MEDICAMENTEUSES ET NON-MEDICAMENTEUSES

Ces données sont présentées dans le Tableau 4. L’évaluation des conséquences de la consommation d’alcool relevait, sur le plan des pathologies somatiques chroniques que 5,50 % des patients souffraient d’insuffisance hépato-cellulaire, 7,30 % présentaient des complications neurologiques et 7,30 % présentaient une autre complication somatique non spécifiée attribuable à la consommation d’alcool. Dans un registre plus aigu, la consommation était responsable d’ivresses à répétition dans 74,30 % des cas, d’alcoolisations pathologiques (alcoolisations massives, sans forcément de sentiment

Les traitements addictolytiques spécifiques du TUA avaient été utilisés dans 32,10 % des cas au cours de la thérapie, les antidépresseurs dans 55 % des cas, les antipsychotiques dans 62 % des cas et les thymorégulateurs (hors antipsychotiques) dans 23,90 % des cas. 100 % des patients avaient reçu des benzodiazépines au cours de leur prise en charge, 50,50 % pour une indication spécifique en lien avec la problématique alcoolique. Concernant les thérapeutiques complémentaires,

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Tableau 3 : Thérapeutiques mises en oeuvre. THÉRAPEUTIQUES MISES EN OEUVRE (ACTUELLES ET ANTÉRIEURES) Addictolytique

Antidépresseur

Antipsychotique

Thymorégulateur autre

N = 35

N = 60

N = 67

N = 26

32,10%

55,00%

62,00%

23,90%

Benzodiazépines

En lien avec le trouble de l’usage de l’alcool

Pour une autre indication

Non renseigné

N = 109

N = 55

N = 48

N=6

100%

50,50%

44,00%

5,50%

Recours psychologue

CSAPA

Post-cure

Association de parents

N = 56

N = 19

N = 14

N=4

51,40%

17,40%

12,80%

3,70%

Tableau 4 : Complications des consommations. COMPLICATIONS ASSOCIÉES À LA CONSOMMATION Complications somatiques chroniques Insuffisance hépatocellulaire

Complications neurologiques

Complications somatiques autres

N=6

N=8

5,50%

7,30%

Complications somatiques aiguës Ivresses à répétition

Alcoolisations pathologiques

Complications de sevrage

Accidentalité

N = 81

N = 29

N = 12

N = 26

74,30%

26,60%

11,00%

23,90%

Complications psychiatriques associées à la consommation d’alcool Dépression

Trouble anxieux

Conduites auto-agressives

Trouble social / ordre public

N = 51

N = 28

N = 18

N = 40

46,80%

25,70%

16,50%

36,70%

Conséquences professionnelles Arrêt maladie

CLDM

Inaptitude temporaire à l’emploi

Réforme / Radiation

Punition

101

92,70%

48,60%

78,90%

29,40%

26,60%

Stabilité conjugale

Désertion

Autres conséquences AVP

Judiciaires

Financière

N = 13

N = 16

N = 24

N = 56

N=2

11,90%

14,70%

22,00%

51,40%

1,80%

Les conséquences professionnelles étaient importantes avec dans 92,70 % des cas un arrêt maladie, un Congé Longue Durée pour Maladie (CLDM pour une période d’au moins 6 mois) dans 48,60 % des cas, une décision d’inaptitude temporaire dans 78,90 % des cas, une sortie de l’Institution par réforme ou radiation dans 29,40 % des cas. Les consommations d’alcool avaient été responsables d’une sanction disciplinaire dans 26,60 % des situations.

d’ivresse mais associée à des troubles des conduites ou de l’humeur) dans 26,60 % des situations, de complications de sevrage pour 11 % des patients. A noter un taux d’accidentalité important attribuable à la consommation : 23,90 %.

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Sur le plan clinique, les psychiatres estimaient que la consommation d’alcool associée à la dépression dans 46,80 % des cas, à un trouble anxieux dans 25,70 % des cas, à des conduites auto-agressives dans 16,50 % des cas et à un trouble des conduites sociales ou trouble de l’ordre public dans 36,70 % des cas.

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Nous noterons sur le plan social une répercussion de la consommation sur la stabilité conjugale dans 51,40 %

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qu’aux patients hospitalisés, donc a priori à des patients dans un moment plus aigu de leur pathologie et de fait, potentiellement avec une problématique alcoolique surajoutée.

des cas, un impact financier pour 22 % des patients et des conséquences judiciaires dans 14,70 % des cas.

ANALYSES MULTIVARIÉES : PATIENTS PRESENTANT UN ETAT DE STRESS POST-TRAUMATIQUE CARACTÉRISÉ ET CONTEXTE OPERATIONNEL

La surreprésentation de l’Armée de Terre peut s’expliquer par le fait que ses personnels sont plus nombreux que ceux des autres Armées (environ 110 000 personnels pour l’Armée de Terre contre 215 000 personnels pour toutes les armées confondues)25. Également, la localisation de notre hôpital (à proximité de plusieurs unités de l’armée de Terre) et son rôle dans l’accueil des patients rapatriés sanitaires (l’armée de Terre est majoritairement projetée sur les théâtres de guerre) peut donner des éléments de compréhension sur la prédominance de l’armée de Terre dans notre échantillon.

Notre analyse statistique centrée sur la sous-population de patients présentant un ESPT caractérisé retrouvait une association très significative avec les caractéristiques du poste (p = 0,001; Khi2 = 26,06; ddl = 8). Effectivement, ils étaient 61,1 % à avoir un poste les exposant un état de vigilance et de stress. Assez logiquement, 100 % des patients ESPT avaient vécu un évènement traumatique (association très significative, p = 0,00; Khi2 = 117,18; ddl = 4). Il existait une association très significative avec l’augmentation de la consommation au retour de mission et le diagnostic d’ESPT (p = <0,01; Khi2 = 42,15; ddl = 4). Le diagnostic d’ESPT était très significativement corrélé au placement en CLDM (p = 0,002; Khi2 = 17,10; ddl = 4).

Cette étude a permis de mettre en lumière les particularités des modes de rencontre avec les soins pour les patients militaires présentant un TUA. En effet, le milieu militaire amène les psychiatres à rencontrer et à suivre au long cours des patients qui n’ont pas initialement de demande de soins spontanée en rapport avec leur TUA (soit 79 % des patients de notre étude). Cette population que l’on pourrait qualifier de « captive », est bien souvent accompagnée dans la rencontre avec les soins que ce soit sur le mode disciplinaire par l’intermédiaire du commandement, du fait des préoccupations de l’entourage, au décours d’une visite systématique avec le médecin d’unité et surtout, dans plus de 40 % des cas, du fait d’un rapatriement sanitaire depuis un théâtre d’opérations extérieures. Ce taux important nous montre le retentissement opérationnel que peut avoir un TUA non repéré avant le départ avec un coût financier et humain pour les forces armées. Cela impose des stratégies de prise en charge globales, ne ciblant pas systématiquement en premier lieu l’addiction mais prenant en compte la dynamique psychique du sujet.

ANALYSES MULTIVARIÉES : CARACTERISTIQUES DU TUA ET CONSEQUENCES DE LA CONSOMMATION Une analyse de corrélations de survenue des complications, montrait différents profils selon que le patient avait une consommation chronique continue, une consommation actuelle (souvent davantage réactionnelle à un contexte particulier), une consommation épisodique, ou était sevré. Ainsi, les complications somatiques étaient statistiquement corrélées à une consommation continue s’intégrant dans une dépendance (association significative entre le diagnostic F1025 et l’insuffisance hépato-cellulaire [p = 0,01; 100 % (N = 6)] ainsi qu’avec les complications neurologiques [p = 0,02; 87,5 % (N = 7)]). Également, il existe une association très significative entre les autres complications somatiques et le diagnostic F1025 [p = 0,002; 100 % (N = 8)].

A noter également dans ce contexte particulier que l’alcool n’était pas le symptôme le plus fréquemment responsable de la rencontre avec les soins mais qu’il s’agissait de la dépression dans plus de 60 % des cas. Ce chiffre est supérieur à celui concernant la population générale suivie pour TUA pour laquelle la comorbidité avec la dépression est estimée à 45 %26. Cette statistique nous indique la forte intrication entre TUA et dépression mais également le caractère souvent moins évident de considérer la consommation comme pathologique avant l’apparition d’altérations de l’humeur. De plus, cela nous engage à davantage rechercher des éléments en faveur d’un TUA face à un patient dépressif.

On retrouve une association significative entre la consommation continue s’intégrant dans une dépendance (F1025) et les complications de sevrage [p = 0,02; 66,7 % (N = 8)]. La réforme et les problèmes judiciaires étaient significativement corrélés à une consommation épisodique (F1026) (réforme : (p = 0,04); 46,9 % (N = 15); problèmes judiciaires : (p = 0,04); 37,5 % (N = 6)).

Les taux relativement faibles de complications somatiques dans notre échantillon s’expliquent probablement principalement par le suivi médical rigoureux organisé au profit des militaires d’active par les médecins d’unité. De manière intéressante, il apparaît qu’une consommation continue d’alcool s’intégrant dans un syndrome de dépendance soit davantage pourvoyeuse de complications somatiques chroniques et de syndrome de sevrage. En parallèle les consommations épisodiques qui comprennent des alcoolisations massives

DISCUSSION En premier lieu, notre étude a pu mettre en évidence une prévalence du TUA de 19,99 % dans notre population de militaires consultant dans le service de psychiatrie de l’HIA du Val-de-Grâce. Ce chiffre est en deçà des 34,5 % retrouvés par une autre étude23. Cela est cohérent puisque cette précédente étude ne s’intéressait

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sur le mode du binge drinking et des consommations plus « réactionnelles » à un moment précis de la trajectoire de vie, sont statistiquement corrélées à plus de conséquences socio-professionnelles.

coûteux sur le plan des ressources adaptatives, et surtout l’augmentation de la consommation au retour de mission chez ces patients. Néanmoins, nous retenons également la grande variabilité des tableaux psychiatriques des patients militaires que nous recevons et qui présentent un TUA puisque, dans plus de 70 % des cas, les évènements traumatiques n’apparaissent pas en cause dans la consommation d’alcool.

Une statistique qui nous interpelle est la fréquence importante des alcoolisations lorsque le patient est seul (77,10 %). Cela va à l’encontre de l’image très répandue de la fonction sociale de la consommation d’alcool dans le milieu militaire. On peut supposer que ce taux très haut de « consommations en solitaire » s’explique par la dynamique à l’œuvre chez ces patients psychiatriques. Effectivement, ces patients qui consultent en HIA sont très souvent dans un moment de décompensation vis-à-vis d’un état préalablement stable. Autrement dit, une transformation du mode de consommation, passant d’une consommation dite sociale, organisée autour d’un phénomène de groupe, à une consommation en solitaire constituerait un signe de gravité du TUA puisque allant de pair avec la nécessité d’organiser des soins spécialisés. D’autres études sont nécessaires afin de pouvoir obtenir une vision dynamique au cours du temps de l’évolution des modes de consommation des militaires.

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Les prises en charge psychiatriques de ces patients s’inscrivaient au long cours car si 92,70 % des patients ont bénéficié d’un arrêt maladie, 48,60 % n’ont pas pu reprendre le travail à l’issue des 180 jours d’arrêt maladie réglementaires et sont passés en CLDM. Cela résulte probablement, d’une part de la désadaptation progressive au milieu militaire engendrée par l’alcool et d’autre part de la difficulté de récupérer une aptitude au service (78,90 % d’inaptitudes au moins temporaires dans notre échantillon) chez des patients dont l’évolution clinique est très souvent instable, marquée par une alternance de périodes de sevrage et de périodes de rechute. Ces statistiques nous engagent à mettre en œuvre rapidement la prise en charge la plus efficace possible.

Conformément à ce que nous avons pu décrire dans notre analyse des données de la littérature, l’OpEx constitue une période particulièrement vulnérante visà-vis de la consommation d’alcool. Comme cela a été décrit précédemment, nous retrouvons une augmentation importante de la consommation après la mission10. Un chiffre très indicatif, dans notre étude est le taux important de situations au cours desquelles l’alcool est venu compliquer la mission : 38,60 %. Le contexte opérationnel est susceptible d’induire un climat particulièrement anxiogène en privant l’individu de ses étayages habituels comme par exemple le soutien de ses proches, et en l’exposant à une alternance entre des situations de combat angoissantes et des périodes plus calmes ou un sentiment d’ennui est très souvent décrit. Par ailleurs, en opération, il existe un fonctionnement spécifique du groupe, les habitudes venant rythmer les périodes d’inactivité ce qui est susceptible d’induire une consommation dite d’entraînement (« alcoolite »)27. Dans ce contexte, l’alcool, « anxiolytique » facilement accessible, constitue un palliatif qui va cependant provoquer chez certains individus un retentissement sur leur aptitude à mener à bien leur mission comme l’atteste le taux important de rapatriements sanitaires.

Or, nous relevons le taux très faible de l’usage des groupes et associations de patients. L’utilité de tels groupes de parole en tant que stratégie thérapeutique complémentaire, notamment pour les militaires, est particulièrement mise en valeur dans la littérature28, 29. En l’occurrence dans notre étude, le faible recours aux groupes de parole s’explique par l’absence de « groupe alcool » organisé au profit des militaires à l’HIA du Valde-Grâce. Depuis 2015, la situation a évolué et de tels groupes sont soit déjà fonctionnels, soit en cours de mise en place dans les différents HIA.

Notre échantillon relève dans plus de 30 % des cas une exposition à des évènements traumatiques et dans 16,50 % des cas un tableau constitué d’ESPT. Ce taux très important confirme l’adage ayant cours dans les HIA selon lequel « tout militaire qui boit est susceptible de souffrir d’un état de stress post-traumatique jusqu’à preuve du contraire ». Cette formulation certes quelque peu abrupte engage cependant à ne pas s’arrêter aux manifestations symptomatiques les plus évidentes mais à la prise en compte psychodynamique du trouble. L’étude d’association a permis de mettre en évidence la forte intrication entre l’ESPT, les postes particulièrement

Sur le plan méthodologique, l’extraction du codage CIM contribue probablement à sous-estimer le nombre de patients présentant un TUA. En effet, cette modalité de recueil des données est basée sur la qualité des cotations des pathologies, très variable en fonction du praticien. De la même manière, il est difficile d’évaluer si ce sont uniquement les tableaux de dépendance qui ont été pris en compte ou si les mésusages ont également été évalués.

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LIMITES Une des limites importantes de notre étude est le manque d’information relative à d’éventuelles co-addictions. La consommation de tabac – facteur reconnu comme important car intimement lié à la consommation d’alcool5 – n’a pas pu être évaluée car les données chiffrées n’avaient pas été retranscrites dans les dossiers médicaux par les médecins. Pour les mêmes raisons, nous n’avons pas pu obtenir d’information sur les consommations de drogues à l’instar du cannabis, facteur intimement associé à la consommation d’alcool en milieu militaire21.

Enfin, le mode de recueil des informations – une enquête soumise aux psychiatres – peut conduire à

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d’important biais, notamment car cette méthodologie repose sur la bonne mémoire des praticiens. Cependant, cette méthode nous a semblé la plus propice afin d’obtenir des informations cliniques précises sur cette population, ce qui se vérifie par le caractère inédit de certains de nos résultats. Quelques données telles que l'évaluation de la personnalité n'ont pas pu être exploitées au vu des résultats obtenus; les psychiatres ont le plus souvent répondu en attribuant un type de personnalité à chaque patient plus à la manière d’un diagnostic « de fonctionnement » que comme un trouble de la personnalité tel que défini dans la nomenclature. Cette question du fonctionnement psychique des patients présentant un TUA mériterait d’être étudiée sous un autre angle dans un prochain travail.

obtenu les données relatives à 109 patients sur les 281 suivis pour un TUA. Le mode d’entrée dans les soins était très rarement à l’initiative du patient et très souvent le motif d’entrée dans les soins n’était pas le TUA mais la dépression. On retrouvait la notion d’évènement traumatique dans 32,10 % des situations et un tableau d’Etat de Stress Post-Traumatique constitué dans 16,50 % des cas. Cette population se caractérisait par relativement peu de conséquences somatiques du TUA mais par un impact socio-professionnel important. Conclusion : Notre étude a permis de mettre en évidence de manière inédite les particularités du profil clinique des militaires consultant dans un HIA pour un TUA. Remerciements :

Au total, il nous semble nécessaire de compléter cette étude par une démarche prospective, avec l’utilisation de questionnaires d’évaluation cliniques validés. Cette seconde étude pourrait permettre d’étudier plus précisément notre population et de confronter les perceptions des patients et des psychiatres vis-à-vis des TUA.

Les auteurs remercient l’ensemble de l’équipe médicale et paramédicale du service de psychiatrie du Val-deGrâce sans le concours de laquelle ce travail n’aurait pu voir le jour. Nous remercions particulièrement les MP DUZAN, MP MARION, PSYCN WROBLEWSKI et PSYCN BRETON pour avoir contribué activement au recueil des informations cliniques.

CONCLUSION

Les auteurs ne déclarent pas de conflit d’intérêts concernant les données présentées dans cet article.

En conclusion, cette étude observationnelle, rétrospective et monocentrique a permis de mettre en lumière une proportion importante de patients présentant un TUA et suivis dans le service de psychiatrie de l’HIA du Val-de-Grâce. Il ressort également de cette étude que le milieu militaire impose des particularités tant du fait du contexte de la rencontre avec ces patients que de la possible intrication entre leur consommation d’alcool et les caractéristiques de leurs emplois et/ou missions. Le TUA constitue un important facteur de rupture avec le groupe militaire et conduit très souvent à des arrêts maladie prolongés. En cela, la double casquette du psychiatre militaire, à la fois expert et soignant, lui permet d’apporter des soins spécialisés et dans le même temps, d’assurer la sécurité des missions des forces armées du fait de sa bonne connaissance du milieu et d’une culture militaire partagée.

BIBLIOGRAPHIE 11. DE MONTLEAU F. Besoins de prévention des militaires d’active. Les risques liés à l’alcool en milieu militaire. Médecine et Armées. 2010; 38 (1) : 37-48. 12. Santé Publique France. Consommation d’alcool, comportements et conséquences pour la santé. Bulletin épidémiologique hebdomadaire. 2019; 5-6. 13. American Psychiatric Association. DSM-5, Manuel diagnostique et statistique des troubles mentaux (« Diagnostic and Statistical Manual of Mental Disorders »). 2013. 14. GOODWIN L, NORTON S, FEAR NT, JONES M, HULL L, WESSELY S, et al. Trajectories of alcohol use in the UK military and associations with mental health. Addictive behaviors. 2017; 75 : 130-7.

RÉSUMÉ

15. RAFFRAY P, RONDIER J, DE MONTLEAU F. Les risques liés à la consommation de l’alcool dans la population militaire : revue de la littérature. Médecine et Armées. 2009; 37 (5) : 411-7.

Introduction : La prévalence du trouble de l’usage de l’alcool (TUA) est plus importante dans la population militaire que dans la population civile. A notre connaissance, il n’existe pas à ce jour d’étude s’intéressant à la population de militaires d’active consultant dans un service de psychiatrie d’un Hôpital d’Instruction des Armées (HIA) pour la prise en charge d’un TUA. L’objectif de la présente étude est de mieux caractériser cette population.

16. DIA A, QUEYRIAUX B, et al. Enquête Consommations et Santé - Enquête pour évaluer les conduites addictives dans les unités opérationnelles de la Marine. Doc. n° 399/IMTSSA/DESP/06. 17. MARIMOUTOU C, QUEYRIAUX B, et al. Enquête Consommations et Santé - Evaluation des conduites addictives dans les unités métropolitaines de l’armée de Terre. Doc. N°417/IMTSSA/DESP/07.

Méthode : Nous avons réalisé une étude rétrospective, s’intéressant aux caractéristiques biographiques et cliniques des patients militaires présentant un TUA et suivis dans le service de psychiatrie de l’HIA du Val-deGrâce entre 2009 et 2015.

18. JONES E, FEAR NT. Alcohol use and misuse within the military : a review. International review of psychiatry (Abingdon, England). 2011; 23 (2) : 166-72.

Résultats : Au sein de la file active de nos patients, la prévalence du TUA était de 19,99 %. Nous avons

International Review of the Armed Forces Medical Services

19. PRÉVOT E. Alcool et sociabilité militaire : de la cohésion

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au contrôle, de l'intégration à l'exclusion. Travailler. 2007; 18 (2) : 159-81.

de jouissance. L'information psychiatrique. 2014; 90 (6) : 471-6.

10. FEAR NT, JONES M, MURPHY D, HULL L, IVERSEN AC, COKER B, et al. What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces ? A cohort study. Lancet (London, England). 2010; 375 (9728) : 1783-97.

20. REYNAUD M. Traité d'addictologie : Flammarion; 2006. 21. MAYET A, MARIMOUTOU C, HAUS-CHEYMOL R, VERRET C, OLLIVIER L, BERGER F, et al. État des lieux des conduites addictives dans les armées françaises : une méta-analyse des enquêtes de prévalence conduites entre 2005 et 2009. Médecine et Armées. 2014; 42 (2) : 113-22.

11. ROUÉ R, LARROQUE P, BARBU ML, FAVRE J, MANSOUR C, CRISTAU P. Causes et motivations de l’alcoolisme en milieu militaire. Alcoologie et Forces Armées. La documentation française, Paris. 1981.

22. OTTO J, O’DONNELL F, FORD S, RITSCHARD H. Selected Mental Health Disorders Among Active Component Members, U.S. Armed Forces, 2007-2010. MSMR. 2010; 17:2-5.

12. FOSTER E. Deployment and the citizen soldier : need and resilience. Med Care. 2011; 49 (301) : 12.

23. ARVERS P, MOULIA-PELAT J-P, FAVRE J-D, AUZANNEAU G, BRUNOT J, DELOLME H. Prévalence des conduites addictives chez les patients hospitalisés – Enquête multicentrique effectuée un jour donné dans les hôpitaux d'instruction des armées en 1999. Bulletin épidémiologique hebdomadaire. 2000; 15.

13. LEBIGOT F. L’alcoolique et l’armée : le malentendu. Alcoologie. 1995; 17 (4) : 315-9. 14. MURPHY D, TURGOOSE D. Exploring patterns of alcohol misuse in treatment-seeking UK veterans : A cross-sectional study. Addictive behaviors. 2019; 92 : 14-9.

24. Available from : httpsq ://www.aideaucodage.fr/cim-f10 15. STEIN MB, CAMPBELL-SILLS L, GELERNTER J, HE F, HEERINGA SG, NOCK MK, et al. Alcohol Misuse and CoOccurring Mental Disorders Among New Soldiers in the U.S. Army. Alcoholism, clinical and experimental research. 2017; 41 (1) : 139-48.

25. RAE 2014, Observatoire économique de la défense. 26. SHANTNA K, CHAUDHURY S, VERMA AN, SINGH AR. Comorbid psychiatric disorders in substance dependence patients : A control study. Industrial Psychiatry Journal. 2009; 18 (2) : 84-7.

16. HEAD M, GOODWIN L, DEBELL F, GREENBERG N, WESSELY S, FEAR NT. Post-traumatic stress disorder and alcohol misuse : comorbidity in UK military personnel. Social Psychiatry and Psychiatric Epidemiology. 2016; 51 (8) : 1171-80.

27. BAZOT M. Rapport introductif, le traitement et la réinsertion sociale du personnel civil et militaire alcoolo-dépendants - In : Colloque International : Alcoologie et Forces Armées. Les colloques et congrès du haut comité. La documentation française. 1981.

17. BOURGEOIS JA, NELSON JL, SLACK MB, INGRAM M. Comorbid affective disorders and personality traits in alcohol abuse inpatients at an Air Force Medical Center. Military medicine. 1999; 164 (2) : 103-6.

28. CLAUDON M, GRESLE C. Chapitre 22. Psychothérapie de groupe et groupes d’entraide en addictologie - In : Lejoyeux M, Adès J, Aubin HJ, Auriacombe M, BalesterMouret S, Batel P, et al. Addictologie. Paris : Elsevier Masson; 2009. p. 302-6.

18. BREMNER JD, SOUTHWICK SM, DARNELL A, CHARNEY DS. Chronic PTSD in Vietnam combat veterans : course of illness and substance abuse. The American journal of psychiatry. 1996; 153 (3) : 369-75.

29. SHARBAFCHI MR, HEYDARI M. Management of Substance Use Disorder in Military Services : A Comprehensive Approach. Advanced Biomedical Research. 2017; 6 : 122.

19. DAUDIN M, RONDIER J-P. Traumatisme de guerre, conduites addictives : une illustration du concept lacanien

ANNEXE 1

➻ VOL. 93/2

International Review of the Armed Forces Medical Service

Revue Internationale des Services de Santé des Forces Armées

ANNEXES Annexe 1 : Questionnaire QUESTIONNAIRE TROUBLE DE L’USAGE DE L’ALCOOL EN POPULATION MILITAIRE

Date de saisie

Numéro de dossier

A- LES CARACTERISTIQUES DU PATIENT Identification • Sexe o Masculin o Féminin • Année de naissance Vie familiale • En couple • Seul • Enfant Situation militaire • Corps d’Armée o Terre o Gendarmerie o Air o Marine o SSA o Légion o BSPP o Divers •

•

Catégorie o Militaires du rang o Sous-officiers o Officiers Statut militaire o Sous contrat depuis moins de 3 ans o Sous contrat depuis 3 ans et plus o Carrière Caractéristiques du poste o Maintien de la vigilance, facteurs de stress répétés aigus ou continus o Monotonie de la tache ou périodes d’attente/inactivité prolongée o Isolement dans le poste o Sans plainte sur le poste

Classification diagnostique lors de l’entrée dans les soins • L’alcoolodépendance : o F10.20 actuellement abstinent o F10.21 idem mais dans environnement protégé o F10.22 suit actuellement régime de maintenance/substitution sous surveillance médicale o F10.23 abstinent mais avec traitement aversif/bloquant o F10.24 utilise l’alcool actuellement o F10.25 utilisation alcool continue o F10.26 utilisation alcool épisodique •

Trouble de la personnalité o F60.0 paranoïaque o F60.1 schizoïde o F60.2 dyssociale o F60.3 émotionnellement labile

•

Autre (précisez) : …………......……….........................................................…………………….

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B- L’ENTREE DANS LES SOINS Modalité de rencontre avec les soins psychiatriques • VMP (découverte fortuite du médecin d’unité) • Rapatriement sanitaire • Médecin civil • Demande du patient • Demande de l’entourage • Demande du commandement

oui oui oui oui oui oui

non non non non non non

Motif de soins • Alcool • Autre o Dépression ou angoisse ou autre trouble psy o Trouble du comportement ou prob disciplinaire o Prise d’un autre toxique o Question sur aptitude

oui oui oui oui oui oui

non non no non non non

C- LA CLINIQUE Y a-t-il un déni (sur la quantité d’alcool consommé voir sur la consommation d’alcool en elle-même) : oui non • Si oui (sur quoi porte le déni ?) o ➺ sur l’existence de la consommation : oui non o ➺ sur la quantité consommée oui non o ➺ sur la gravité des conséquences oui non Manifestation au « devant de la scène » : • OH • Trouble de la personnalité En milieu militaire • •

Implication dans des évènements potentiellement traumatique ESPT caractérisé

• Le sujet a-t-il été en OPEX ? Si oui : o Prise d’alcool a-t-elle compliqué la mission ? o Y a-t-il eu majoration de la prise d’alcool après l’OPEX

oui oui

non non

oui

non

oui oui

non non

Habitus quant à l’alcool • Seul • En groupe • Dipsomanie/binge drinking « Fonction » de l’alcool (nuage de mots) : .................................................................................................................................................................................. ..................................................................................................................................................................................

D- LES CARACTERISTIQUES DU TRAITEMENT (actuel ou antérieur)

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Médicaments • Traitement spécifique à l’alcool (aotal/revia/esperal/selincro/baclofene) • Benzodiazépines o En lien avec l’alcoolodépendance o Autre indication • Traitement psychotrope additionnel o Neuroleptique o Antidépresseur o Thymorégulateur

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oui

non

oui oui

non non

oui oui oui

non non non

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Thérapeutique additionnelle non médicamenteuse • CSAPA oui • Séjour en postcure oui • Psychothérapie avec psychologue oui • Association d’entraide oui

non non non non

E- LES COMPLICATIONS Complications somatiques chroniques • Cancer • Insuffisance hépatocellulaire/varices œsophagienne, … • Complications neurologiques (névrites, démence, encéphalopathie) • Autre

oui oui oui oui

non non non non

Complications aigues • Ivresses répétées • « Alcoolisations pathologiques » • Complication de sevrage (préDT ou DT) • Accidentalité (AVP, accident domestique, blessure physique)

oui oui oui oui

non non non non

Complications psychiatriques • Dépression F32 • Trouble anxieux organisé F41 • Trouble des conduites : autoagressives • Trouble des conduites : sociales

oui oui oui oui

non non non non

Conséquences militaires o Rapatriement sanitaire o Arrêt maladie o CLDM o Inaptitudes temporaires o Réforme/radiation o Punition

oui oui oui oui oui oui

non non non non non non

Conséquences autres • AVP • Problème judiciaire • Finance/dettes • Sur la stabilité conjugale • Désertion

oui oui oui oui oui

non non non non non

(QUESTION DU CODAGE) Pour ce patient : le codage a-t-il évolué au cours de la prise en charge ? oui

non

Ce patient figurait il initialement dans les dossiers codés alcool ? oui

non

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