Defence Medical Services’ REBOA training course

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) enables temporary haemorrhage control and physiological stabilisation. This article describes the bespoke Defence Medical Services (DMS) training package for effectively using REBOA. The article covers how the course was designed, how the key learning objectives are taught, participant feedback and the authors’ perceptions of future training challenges and opportunities. Since the inaugural training course in April 2019, the authors have delivered six courses, training over 100 clinicians. For the first time in the UK DMS, we designed and delivered a robust specialist endovascular training programme, with demonstrable, significant increases in confidence and competence. As a result of this course, the first DMS REBOA-equipped forward surgical teams deployed in June 2019. Looking to the future, there is a requirement to develop an assessment of skill retention and the potential need for revalidation.

Doron medicum—the gift of medicine: How a rare 17th century medical translation positively impacted the community and predicted current analgesic techniques

In 1683, a self-proclaimed apothecary physician and London professor of physick by the name of Guilelmus (William) Salmon authored a pharmacopoeia titled Doron medicum, the ‘gift of medicine’ (Greek/Latin translation). This text formulates an English supplement to the Latin Materia medica (16th century), discussing internal and external compound medicines of the late 17th century. This pharmacopoeia enabled those incapable of reading Latin to provide medical care to a challenging post-plague community. Opiology, mercury, dragon’s blood, willow bark, animal preparations and therapies now considered obscure, provide insight into therapies at the time. Early critical care treatments in haemorrhage control and pain management are described. Doron medicum preceded the controversial opening by the College of Physicians of the first London Dispensary in 1698, and was published in a maturing period of medical governance and healthcare establishment in London. During the 17th century, great competition and debate existed between the Royal College of Physicians and the apothecaries. Throughout such debates, William Salmon advocated for access to medical care for the poor and recognition of an allied approach to healthcare. This paper discusses Salmon’s contribution to medicine, which has been poorly transcribed in medical history. A selection of opiate-based analgesic therapies, early critical care strategies and animal preparations are revisited. A small chronicle of William Salmon’s life and professional achievements will be reviewed. Debate surrounding the opening of the first London Dispensary will be discussed in relation to William Salmon’s contribution, echoing ongoing contemporary challenges in healthcare over 300 years later.

Balloons on the battlefield: REBOA implementation in the UK Defence Medical Services

Established in 2018, the Defence Endovascular Resuscitation (DefER) group recognised that resuscitative endovascular balloon occlusion of the aorta (REBOA) offered an option to improve survival in battle casualties dying from haemorrhage, particularly in remote and austere surgical settings. Following a successful jHub opportunity assessment, DefER purchased training and operational kit at pace. By 1 April 2019, the first forward surgical group undertook a bespoke endovascular training and assessment package. Results of the pilot were presented back to a jHub 4* Innovation Board, which initially awarded £500 000 to fund the project to full implementation. Med Op Cap provided a solution to establish REBOA as a core capability on to the 370 modules. REBOA catheters and arterial access kit are now available to deployed Role 2 facilities across defence as an adjunct to damage control resuscitation in specific circumstances. REBOA has, from a standing start, gained pan-Defence Medical Services (DMS) endorsement and has been integrated into deployed damage control resuscitation. To establish a new resuscitation capability across all Role 2 platforms within 15 months of inception represents implementation at pace. This agility was unlocked by empowering clinicians to develop the platform in conjunction with commercial procurement. This article describes how this innovative pathway facilitated the rapid introduction of a lifesaving haemorrhage control technique to equip DMS clinicians.

The way to a man’s heart is through his stomach: a case of myocardial infarction mimic and pseudo-tamponade in a polytrauma patient

Background There exists a therapeutic conflict between haemorrhage control and prevention of thromboembolic events following polytrauma and complications are not uncommon. Such opposing therapies can result in unexpected pathophysiology and there is a real risk of misdiagnosis resulting in harm. This case presents a previously unreported complication of prevention and management of thromboembolism- STEMI (ST elevation myocardial infarction) and tamponade mimic secondary to retroperitoneal haematoma. Case presentation We present a 50-year-old male polytrauma patient who following treatment for presumed pulmonary embolus demonstrated classical clinical findings of myocardial infarction and pericardial tamponade secondary to a retroperitoneal haematoma. This is an event not previously reported in the literature. The risk of adverse outcome by management along the standard lines of STEMI (ST elevation myocardial infarction) was averted through awareness for alternative aetiology via a multi-team approach which resulted in percutaneous drainage of the haematoma and complete resolution of symptoms. Conclusions This manuscript highlights the therapeutic conflict between haemorrhage control and prevention of thromboembolic events in critically injured, the importance of high index of suspicion in this patient cohort and the benefits of multidisciplinary decision making in the complex patient through a not previously published pathophysiologic phenomenon.

Multiple trauma management in mountain environments - a scoping review

Background Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. Objective To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. Eligibility criteria All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. Sources of evidence PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. Charting methods Evidence was searched according to clinically relevant topics and PICO questions. Results Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. Conclusions Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.

Transcatheter arterial embolisation is efficient and safe for paediatric blunt torso trauma: a case-control study

Background It remains unclear whether transcatheter arterial embolisation (TAE) is as safe and effective for paediatric patients with blunt torso trauma as it is for adults in Japan, owing to few trauma cases and sporadic case reports. The study aimed to compare the efficacy and safety of TAE performed in paediatric (age ≤ 15 years) and adult patients with blunt torso trauma. Methods This was a single-centre, retrospective chart review study that included blunt torso trauma patients who underwent TAE in the trauma centre from 2012 to 2017. The comparative study was carried out between a ‘paediatric patient group’ and an ‘adult patient group’. The outcome measures for TAE were the success of haemorrhage control and complications and standardised mortality ratio (SMR). Results A total of 504 patients with blunt torso trauma were transported to the trauma centre, out of which 23% (N = 114) with blunt torso trauma underwent TAE, including 15 paediatric and 99 adult patients. There was no significant difference between the use of TAE in paediatric and adult patients with blunt torso trauma (29% vs 22%, P = .221). The paediatric patients’ median age was 11 years (interquartile ranges 7–14). The predicted mortality rate and SMR for paediatric patients were lower than those for adult patients (18.3% vs 25.9%, P = .026, and 0.37 vs 0.54). The rate of effective haemorrhage control without repeated TAE or additional surgical intervention was 93% in paediatric patients, which was similar to that in adult patients (88%). There were no complications in paediatric patients at our centre. There were no significant differences in the proportion of paediatric patients who underwent surgery before TAE or urgent blood transfusion (33% vs 26%, P = .566, or 67% vs 85%, P = .084). Conclusions It is possible to provide an equal level of care related to TAE for paediatric and adult patients as it relates to TAE for blunt torso trauma with haemorrhage in the trauma centre. Alternative haemorrhage control procedures should be established as soon as possible whenever the patients reach a haemodynamically unstable state.