Clinical quality management in the combat zone: the good, the bad, and the unintended consequences

Clinical quality management (CQM) is a fixture of modern U.S. healthcare to include fixed military medical treatment facilities. CQM is now being applied to the battlefield. In a related fashion, standards of care have been proposed in the context of combat medicine. The overall goal is to improve the medical care of casualties. Despite good intentions, the concepts and execution of CQM and standards of care are neither well-described in the literature nor established in official military doctrine and regulation. This has resulted in variable and haphazard applications that range from the positive and supportive to the negative and counterproductive. This article outlines the use of CQM in combat operations and asserts that a deliberate analysis of the benefits and risks is needed before its continued use. Future directions should focus on the impact of CQM on mission, doctrine, training, staffing, and unit organization. Rigorous adherence to evidence of effectiveness is essential before applying CQM in the combat zone.     

U.S. Army disease and nonbattle injury model, refined in Afghanistan and Iraq

Previous analysis of Operation Desert Shield/Operation Desert Storm data yielded a disease and nonbattle injury (DNBI) model using distinct 95th percentile daily admission rates during the three phases of a war-fighting operation to predict medical requirements. This study refines the model with data from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Inpatient health care records of U.S. Army soldiers deployed to OEF and OIF who were admitted with DNBI diagnoses were analyzed. DNBI admission rates for OEF and OIF were compared with rates for Operation Desert Shield/Operation Desert Storm. DNBI admission rates for OEF and OIF were lower than those for Operation Desert Shield/Operation Desert Storm. Rates among the phases of OIF were distinctly different. DNBI admission rates have been reduced during recent deployments. The concepts of the original model based on Operation Desert Shield/Operation Desert Storm data were validated by experiences during OEF and OIF. Continuous surveillance of DNBI admission rates is recommended.     

A cluster of septic olecranon bursitis in association with infantry training

Septic olecranon bursitis (OB) is caused primarily by Staphylococcus aureus (SA) usually in association with occupations involving trauma to the elbows. An outbreak of septic OB was identified in an infantry platoon. The severity of the injury to the skin overlying the elbows was scored and compared to a parallel platoon of the same unit. All soldiers were tested for SA carriage and pulse field gel electrophoresis (PFGE) was performed on available isolates. Nine cases of septic OB were identified only in platoon A. The significant risk factor for septic OB was a moderately or severely injured elbow (RR = 3.86). SA was isolated from the anterior nares and elbows of 29/36 (80.6%) of the soldiers in the unit (platoons A + B); however, this did not account for the difference in morbidity between the two platoons. This is the first report of a cluster of septic OB in association with intense infantry training.     

The greatest organizer of military medicine and health service E.I.Smirnov about N.I.Pirogov

E.I.Smirnov's views of the role and place of organizational aspects of the greatest Russian surgeon N.I.Pirogov in development of modern medical supply system are covered on the basis of vast historiographical data. From the perspectives of historism and objectivism a degree of realization Pirogov's ideas during creation of the consistent military-medicine doctrine and organization of medical-evacuational measures during the Great Patriotic War 1941-1945 is analyzed.     

Problems with claims that sanctity leads to 'pro-life' law, and reasons for doubting it to be a convincing 'middle way'

This paper focuses on the idea of pro-life arguments and the sanctity of life doctrine in the context of debates on end-of-life law. Advocates of the sanctity doctrine are often thought of as being pro-life, which has potentially troublesome implications in policy debate. I explore what it means to be pro-life, and consider sanctity's relation to this. I question the coherence and appeal of truly pro-life law, and law that is premised on the sanctity doctrine. The analysis allows me to examine and reject the idea that the sanctity doctrine is reasonably described as a 'middle way' that we should enshrine in policy and practice.     

Health service support in Operations Desert Shield and Desert Storm.

Operations Desert Shield and Desert Storm have brought into focus a number of difficulties with the medical support of U.S. Army tactical forces. These difficulties include inadequate preparation of Medical Corps officers for command, inadequate medical training of field medical unit personnel, and problems utilizing available equipment to support Operation Desert Storm tactical operations. This paper will discuss these difficulties, potential solutions for these difficulties, and some unresolved issues created by or despite these potential solutions.     

Some medical aspects of Long Range Penetration. Regimental Medical Officer, 4th Battalion, The Border Regiment (September 1944)

Editor's note: The following notes were intended as a help to platoon commanders operating with LRP troops and were the result of observations made on six months LRP training and fifteen weeks operations with a column of 23rd British Infantry Brigade in the Naga Hills. The operations, particularly from the point of view of treatment and evacuation of casualties, differed from those of the Brigades who were operating inside Burma itself owing to the nature of the terrain, but the basic problems, particularly from the platoon commander's point of view, were the same. The author's views may still be of interest today after more than 40 years.     

Controversy, alternatives, and decisions in complying with the legal doctrine of informed consent.

The complexities involved in conforming with the legal doctrine of informed consent at present are seemingly limitless. This communication is designed to acquaint the physician attempting to comply with this legal doctrine with an experience gained during the last four years. The major points are aimed at the most frequently asked questions and decisions involved in its implementation. An alternative approach to the question of how and whom to inform is provided, which may make the task easier for those seeking to inform their patients.     

Dynamics of returning the injured and ill to military and work responsibilities in wartime]

Returning of the injured and diseased to military and working duties in war have been trained and tested in the final training of members of the School of Reserve Medical Officers of the Military Medical Academy in the period 1985-1989. The time of returning of the injured and diseased members of the armed forces depends directly on the organization of the military medical and public health service, and especially of the preparedness of health personnel, well equipped military medical units and health institutions and the consistent application of the unique military doctrine.     

Legal values as tools for promoting harmony

The doctrine of informed consent has the effect of allowing the mentally competent adult patient to exercise individual choice in any proposed medical treatment. The ethical principles primarily inherent in this doctrine would be the principles of autonomy and beneficence. However, it is argued in this essay that the concept and meaning of autonomy might be vastly different between western and eastern communities. Consequently the doctrine of informed consent will lead to a different meaning in these different societies. The essay also raises the implication of transplanting legal doctrines into societies which might not be fully prepared to implement the ideal contained in the doctrine of informed consent.     

Preparations for war in a Saudi Arabian host nation hospital.

This paper describes how the King Fahad National Guard Hospital in Riyadh, The Kingdom of Saudi Arabia, integrated United States Army (USA) medical units and prepared the hospital to receive war casualties during Operation Desert Storm. In particular, preparation of the hospital, the staff, and military systems are reviewed. The report will also discuss operations at the hospital during Operation Desert Storm and the major lessons learned. Comment is provided by the host nation hospital regarding the impact of the experience with the USA medical units and their personnel.     

The doctrine of “Reasonable Doctor” in medical negligence: Need to be more reasonable

The model of a ‘reasonable doctor’ has been quite successfully used to deliver justice in disputes involving medical negligence. However, many a times a doctor is held guilty of negligence when viewed through the narrow lens of an ideal ‘reasonable doctor’ and without looking into the circumstances under which he was working which could have actually led to the alleged act of negligence. This short write-up highlights the importance of applying this doctrine more reasonably in the best interest of all stake holders and the drawbacks of the doctrine of ‘reasonable doctor’ in adjudicating medical negligence cases with few international case laws.     

Aeromedical evacuation: remembering the past, bridging to the future

Operations Desert Shield/Desert Storm saw the largest mobilization of aeromedical evacuation (AE) assets since the Vietnam War. Ultimately, more than 1,950 AE personnel were deployed to support the medical airlift of personnel. With aircrews based at 17 locations in the region, at its peak the system could move up to 3,600 intratheater and 2,500 intertheater casualties per day. Fortunately, the demand for AE fell far short of predictions. During the period from August 12, 1990, to March 31, 1991, more than 12,500 patients were successfully airlifted using converted cargo aircraft, a concept originally validated in World War II. The authors describe the Operations Desert Shield/Desert Storm AE system and identify the efforts underway to construct a new aeromedical evacuation system capable of meeting the needs of the battlefield of the 21st century.     

Respiratory illnesses in relation to military assignments in the Mojave Desert: retrospective surveillance over a 10-year period

Military training exercises are conducted routinely in the Mojave Desert. To determine whether assignment in this desert environment increases risk of respiratory illnesses, hospitalization rates were compared between two matched cohorts of soldiers during three intervals of follow-up during a 10-year surveillance period. The exposed cohort (N = 21,543) included all soldiers who were ever assigned to the Mojave Desert during the surveillance period. The control cohort (N = 86,172) included soldiers matched on demographic characteristics who were never assigned to the Mojave Desert during the surveillance period. Three follow-up intervals ("before," "during," "after") were defined relative to times when exposed soldiers were assigned to the desert. Rates of respiratory hospitalizations were similar between the cohorts for the "before" and "during" intervals but were higher in the exposed cohort for the "after" interval (rate ratio, 1.30; 95% confidence interval, 1.07-1.59). This difference was largely attributable to excess pneumonia and influenza hospitalizations in the exposed cohort. Healthy, young adults may have increased susceptibility to respiratory infectious illnesses after prolonged exposures to desert environments.     

The third era of human rights: global accountability

This article argues that the trend in the current protection of human rights may be seen as a revival of an old idea: governments are accountable for their actions. The protection of human rights has gone through three eras. In the first era, the Catholic Church in the Middle Ages claimed to rule from a divine mandate. This principle of natural law was a unifying factor in western Europe because it created a standard system of morality. The second era, beginning in the seventeenth century with the doctrine of state sovereignty, rejected that natural law. Rulers wanted to run their own territories and not be subject to foreign influence. Laws were created by the 'national sovereign' (king, queen, president, parliament, congress and so on). This legal doctrine survived for about three centuries, but the excesses of leaders such as Hitler in the middle of last century forced a re-think. Although the term 'natural law' is not used, there has been a revival of its essential meaning: that governments have to be answerable to a higher authority for their behaviour.     

Informed consent, informed refusal, informed choice--what is it that makes a patient's medical treatment decisions informed?

Informed consent is the fundamental ethical and legal doctrine that protects the patient's rights of personal autonomy and bodily self-determination. An adjunct to the doctrine of informed consent advanced by some is the notion of informed refusal. According to advocates of this concept, incoherent, unconscious, or otherwise incapacitated patients cannot make informed treatment choices because such patients cannot receive a full and current explanation of their health problems and treatment options. This, in turn, raises serious questions about what it is that makes a patient's treatment decisions--whether consents or refusals--informed. Is current, detailed information about the patient's medical condition and treatment options an ethical and legal prerequisite? Can non-medical values and concerns of the patient ever suffice to make the patient's treatment choices informed? How does the concept of informed refusal affect the use of health-care advance directives? This paper will address these important questions.     

A brief survey of chemical defense, crew rest, and heat stress/physical training issues related to Operation Desert Storm.

A brief questionnaire was administered to 148 soldiers, over two-thirds of whom were aviators, at the conclusion of Desert Storm. Questions were asked about chemical defense, work/rest schedules, an aspect of pharmacological support, and heat stress/physical training during Operations Desert Shield and Desert Storm. Follow-up face-to-face interviews also were conducted with some respondents. Some of the most noteworthy findings concerned (1) training issues and side effects related to pyridostigmine bromide, (2) problems with chemical defense clothing, (3) suggestions for improving crew rest, and (4) facts about the ways in which heat-related difficulties were minimized.     

Role of the independent duty corpsman on the USNS Comfort (T-AH 20): the Operation Desert Shield/Desert Storm experience.

Independent duty corpsmen (IDCs) have a significant role in providing health care on the USNS Comfort (T-AH 20). The IDCs are responsible for staffing sick call, emergency response teams, and resuscitation/stabilization teams. IDCs are trained in advanced patient care and in medical administrative and logistical duties. During peacetime, their function often focuses on primary care to the decrement of skills necessary to perform in medical emergencies. The Operation Desert Shield/Desert Storm mobilization has emphasized the need for Navy medicine to continue its support of IDC training so that they are kept in a state of preparedness to competently deliver the full spectrum of care that is expected of them.     

Application of thorium-normalized airborne radiospectrometric survey data of Wadi Araba area, North-eastern Desert, Egypt, as a guide to the recognition of probable subsurface petroleum accumulations.

A new exploration method has been developed by Saunders et al. (Geophysics 58(10) (1993) 1417) using surface and aerial gamma-ray spectral measurements in prospecting for petroleum in stratigraphic and structural traps. Wadi Araba area, North-eastern Desert, Egypt, was selected to apply this method on its recorded aerial gamma-ray spectrometric survey data, due to its distinct stratigraphic and structural setting as well as its situation in close connection with the Gulf of Suez, which represents one of the important sites of oil production in Egypt. The three variables (eU, eTh, and K) registered for the whole study area, in the form of three contour maps, were digitized along the flight paths every 1.0 km. The DRAD arithmetic means plus three standard deviations for the data set were computed. Any single profile value greater than this quantity should have a probability of 99.87% that it represents a valid anomaly and is not caused by random variations in the background values. The use of these criteria has identified one flight line which has a valid anomaly that is not caused by random variations in the background values. This might indicate a prospective possibility for petroleum accumulation in the Wadi Araba area. North-eastern Desert, Egypt.