Development of a deployment course for graduating military internal medicine residents

Graduates of military internal medicine residency programs are required to have the necessary knowledge and skills to function as internists, military physicians, and military medical leaders. The global war on terrorism has increased the role internists are playing in combat theaters as they fill multiple different military medical positions including battalion, brigade, and division surgeons as well as physicians in echelon I, II, and III medical facilities. Along with general internists, internal medicine subspecialists, pediatricians, and family physicians also fill these roles. Although internal medicine training provides a broad-based knowledge to care for adults, it does not provide significant training in combat casualty care, detainee health care, or environmental health. To overcome many of these perceived shortfalls, we developed the 3-day deployment course for graduating internal medicine residents outlined in this article. Through a combination of didactic and hands-on training, militarily relevant medical knowledge and skills necessary to function at echelon I and II levels of care were provided. Residents uniformly accepted the course with measurable increase in their fund of knowledge at the completion of the course.     

Quality assessment of primary health care in a military setting

PURPOSE: The aim of this study was to analyze the quality of primary care in Israeli Defense Forces primary care clinics and physicians (PCPs) and to test the hypotheses that: (1) the quality of primary care provided in battalions is higher than that provided by other primary care providers and (2) the evaluation of a specific PCP within the framework of the quality assessment program results in an improved score during a second evaluation. METHODS: Teams of two physicians carried out the control process. Each primary care clinic is evaluated in a standardized manner by filling a prospectively established form. Five parameters are examined: (1) direct inspection of the PCP, (2) medical record audit, (3) high-risk patients' management evaluation, (4) evaluation of secondary health care characteristics, and (5) medical staff guidance evaluation. The various clinics and physicians evaluated were classified as: battalion clinics, division and brigade clinics, training center clinics, and home-front clinics. RESULTS: Between the years 1999 and 2001, 149 primary care clinics and 250 PCPs were evaluated. Seventy-four PCPs (29.6%) were evaluated twice. Battalion clinics scored higher than the other clinics. PCPs evaluated twice had significantly better quality assessment results at the second encounter. CONCLUSIONS: Quality of primary health care is the highest in battalion troops clinics. We interpret the increase in quality assessment scores from one examination to the other as an index of improvement resulting from the feedback given to the providers.     

The medical evacuation procedures in slight gunshot wounds]

The article makes a detailed analysis concerning the results of treatment of minimally wounded who were stationed at the separate medical battalion. All the wounded were returned to the ranks in first 55 days from the moment of wounding, and after being examined by the Main Medical Commission. There is a direct dependency between the terms of treatment, number of surgical interventions, development of complications on the one hand, and the size of wound on the other hand. The article stresses that actually the duration of treatment of minor wounded at the separate medical battalion is limited by 10 days. The authors make a conclusion that the possible increase of these terms could return the wounded to their duties without further evacuation to the other medical establishments. There are indications for primary surgical management of gunshot wounds and for further evacuation of this category of wounded from separate medical battalion.     

Hand injuries sustained during jungle training

During the initial six week period of deployment and jungle training in Belize, a 634 man strong infantry battalion group sustained twenty-three machete hand injuries. Eighteen were treated at battalion level, while five required hospital treatment. The management of these injuries is considered.     

About the history of creation and development of the system for rendering skilled surgical care in the troop region

Practice of rendering the elements of skilled surgical care to the wounded in Russian Army during the wars of first half of the XIX century has coincided with introduction of evacuation system into medical support of troops' military operations. With improvement of the last. advantages of medical-and-biologic science, military skills the battery sick quarters, dressing detachments providing the work of main dressing stations, the medical care main stations were subsequently included into the kit of medical service means of the formations. In December 1935 this process was ended with creation of division medical-and-sanitary battalion (deployed by the division medical station) that took an active part in rendering skilled surgical care to the wounded during the subsequent local military conflicts and wars.     

The beneficial relationship of the colocation of orthopedics and physical therapy in a deployed setting: Operation Iraqi Freedom

In a deployment setting, orthopedic and musculoskeletal injuries represent the majority of both combat-related and noncombat-related injuries. To expeditiously and efficiently manage the large influx of patients, our experience revealed the tremendous benefits of having physical therapy colocated with an orthopedic surgeon in a level III combat support hospital. A physical therapist, working in a physician extender role, can treat the majority of nonsurgical orthopedic patients, thus allowing the orthopedic surgeon to focus his or her skills and time on surgical interventions. This physician extender role, although often overlooked during peacetime, becomes essential during wartime, when critically injured patients are abundant and physicians are in short supply. The lessons learned support the continued colocation of physical therapy and orthopedics in a deployment setting and recognize the need to have more physical therapists placed at level I and II echelons of care.     

Medical support of the personnel of check and observation posts in the zone of Georgian-Abkhazian conflict

During the operations for peace support by collective forces it is necessary to deploy check (CP) and observation (OP) posts usually at a distance of dozens kilometers from each other and from the battalion base camp. Depending on CP and OP dislocation place, problems they should solve the number of servicemen in the posts can vary from 12 to 50. For rendering medical care the company base post has the permanent medical instructor of the company and in the other CPs and Ops--supernumerary medical instructors of the posts from the number of the trained servicemen. The experience of medical support of collective forces for peace support in the zone of Georgian-and-Abkhazian conflict allowed to summarize and outline some ways of its improvement which first of all are directed to more effective work of medical instructors.     

Survey of personal protection measures against mosquitoes among Australian defense force personnel deployed to East Timor

A questionnaire was completed by 955 Australian Defense Force soldiers from two battalion groups to determine their usage of mosquito repellents and bed nets during peacekeeping duties in East Timor. The survey showed that most soldiers (84%) used repellents, but only 19% used them daily. The soldiers used a number of repellent formulations; however, few soldiers used the Australian Defense Force deet (diethyl methylbenzamide) formulation containing 35% deet in a gel. Most soldiers preferred several commercial formulations, which contained 7 to 80% deet. The occurrence of mosquito-borne disease in soldiers was not affected by repellent usage, as the use of repellents was comparable between infected and noninfected individuals. The overall frequency of bed net usage differed in the two battalion groups. The occurrence of malaria in soldiers from one battalion group who did not sleep under a bed net every night of their deployment was significantly (p = 0.007) higher than those who did.     

"Tip of the spear" physical therapy during a 6-month deployment to the Persian Gulf: a preliminary report.

When a U.S. Navy aircraft carrier battle group deploys overseas, the ship's medical department is responsible for more than 10,000 personnel and their numerous musculoskeletal injuries. This paper reviews the effectiveness of having a U.S. Navy physical therapist and physical therapy technician onboard the USS Carl Vinson during its most recent deployment to the Persian Gulf. Physical therapy had 3,373 patient visits during the ship's 1998-1999 Western Pacific deployment. Having physical therapy personnel onboard resulted in fewer patient visits to sick call for musculoskeletal problems and fewer evacuations compared with other similar carrier deployments. Providing physical therapy at the "tip of the spear" is an effective, beneficial, and cost-saving landmark improvement in providing quality medical care to the fleet. The lessons learned from this experience will assist in clarifying the role of physical therapy in future military support operations and sustained deployments.     

HMS Illustrious, OCEAN WAVE 97 and the medical branch.

As can be seen from the statistics, the challenges to all medical staff involved in OW97 were considerable. It is to the combined credit of all RN and RFA medical staff that a high standard of medical care was provided throughout the deployment. All operational casualties were treated correctly and without delay and most have made full recovery. Moreover, the varied general naval experience, foreign travel, new colleagues and friends gained from Global deployments such as this is something to be recommended. The authors wish to extend their thanks to all medical staff involved in OW97. Their support and hard work contributed significantly to make the medical aspects of the deployment such a success.     

The Ranger medic

The Ranger medic (military occupational specialty 91B) provides advanced trauma management across the operational spectrum in which the 75th Ranger Regiment is employed. Ranger medic duties, both in combat environments and in training, medical training, professional progression, and medical assets in the Ranger battalion are detailed. Ranger medic training management tools and techniques are discussed and illustrated. The role of the combat lifesaver, force modernization, and interoperability issues facing the medical team are discussed. The Ranger medic is a capable special operations tactical medic.     

Expanding the role of the nurse practitioner in the deployed setting

Today's military is experiencing rapid advances in technology and in manpower utilization. The Army Medical Department is redesigning the structure and function of deployable hospital systems as part of this effort. The transformation of deployable hospital systems requires that a critical analysis of manpower utilization be undertaken to optimize the employment of soldier-medics. The objective of this article was to describe the use of nurse practitioners as primary care providers during deployment. The lived experiences of five nurse practitioners deployed to Operation Iraqi Freedom are presented. Data gathered during the deployment and an analysis of the literature clearly support expanded and legitimized roles for these health care professionals in future conflicts and peacekeeping operations.     

The effectiveness of the parachutist ankle brace in reducing ankle injuries in an airborne ranger battalion

The purpose of this study was to determine if the parachutist ankle brace (PAB) decreases the number and severity of ankle injuries in an airborne Ranger battalion. A retrospective study was performed covering a 38-month period. A computer database was used to track all jump injuries with a diagnosis of ankle pain, sprain, or fracture. The frequency was calculated for ankle injuries per 1,000 jumps and the average length of medically restricted duty per ankle injury. A total of 13,782 static line parachute jumps were conducted during the study period. Without the PAB, 35 ankle injuries were seen (4.5/1,000 jumps), with 9 fractures and 316 days of medical restriction per 1,000 jumps. Using the PAB, 9 ankle injuries were seen (1.5/1,000 jumps), with 3 fractures and 71 days of medical restriction per 1,000 jumps. The correct use of the PAB appeared to significantly decrease the incidence of ankle injuries in this battalion.     

Physical medicine and rehabilitation in the military: Operation Iraqi Freedom

This article describes the role of a physical medicine and rehabilitation (physiatry) physician (physiatrist) as a general medical officer within a forward support battalion during the invasion and nation-building phases of Operation Iraqi Freedom. Between March 10 and May 3, 2003 (invasion phase), 364 patients were evaluated. Thirty-two percent had musculoskeletal noncombat injuries, 9% had combat-related traumatic injuries, and the remaining 59% had nontrauma/nonmusculoskeletal conditions. Between May 4 and July 25, 2003 (nation-building phase), 1,387 patients were evaluated. Of these, 19% had musculoskeletal injuries, 1% had combat-related traumatic injuries, and the remaining 80% had nontrauma/nonmusculoskeletal conditions. During this nation-building phase, the musculoskeletal workload seen at the division-level combat support hospital was 4 times the workload seen in the forward support battalion. This experience underscores the role of physiatry in wartime casualty management and profiles the combat support hospital as the most suitable place for the physiatrist during wartime. Interventions focused on acute management and rehabilitation counseling for all musculoskeletal injuries, as well as consultation services to the combat support hospital and local civilian hospitals for the evaluation of complex neuromusculoskeletal trauma cases.     

A review of the surgical treatment options for the obstructive sleep apnea/hypopnea syndrome patient

Obstructive sleep apnea/hypopnea syndrome (OSAHS) is a medical condition that has received significant attention within the medical community and mainstream media due to its potentially serious physiological consequences and relatively frequent occurrence within the general population. From the military perspective, the impact on individual readiness for deployment, and the potential degradation of performance in critically important military duties, often results in tremendous expenditures of training resources, time, and expertise to replace the military member with a suitable substitute or release of the individual from active duty. This article reviews common surgical techniques for clinical management of OSAHS patients in a presentation format for primary care and sleep medicine specialists, as well as surgeons interested in the philosophies of surgical management of sleep disordered breathing. Presentation of risks and benefits of surgical treatment are discussed in a manner to facilitate communication between patient and health care provider.     

Patient-centered medical home: an emerging primary care model and the military health system

The patient-centered medical home (PCMH) is a primary care model that aims to provide quality care that is coordinated, comprehensive, and cost-effective. PCMH is hinged upon building a strong patient-provider relationship and using a team-based approach to care to increase continuity and access. It is anticipated that PCMH can curb the growth of health care costs through better preventative medicine and lower utilization of services. The Navy, Air Force, and Army are implementing versions of PCMH, which includes the use of technologies for improved documentation, better disease management, improved communication between the care teams and patients, and increased access to care. This article examines PCMH in the Military Health System by providing examples of the transition from each of the branches. The authors argue that the military must overcome unique challenges to implement and sustain PCMH that civilian providers may not face because of the deployment of patients and staff, the military's mission of readiness, and the use of both on-base and off-base care by beneficiaries. Our objective is to lay out these considerations and to provide ways that they have been or can be addressed within the transition from traditional primary care to PCMH.     

Evaluation of a novel protective gas mask during medical unit activity.

Evaluation of a battalion medical unit drill in a chemical warfare environment was carried out by comparing two respiratory protective devices: a new protective device (the Chemical Team Respirator) and the mask currently used in the Israel Defense Forces (the M-15). After a medical deployment drill conducted with 24 participants and 14 inspectors, comfort, communication, and various aspects of activity were evaluated by structured questionnaires. The new device, consisting of a hood, nose cup, and air blower system, was found to be preferable to the M-15 mask for physical and respiratory comfort, quality of visual field, and performance. The communication capabilities of the unit members, on the other hand, were severely limited by the hearing reduction caused by the hood of the new protective device. We conclude that the new device proved superior to the current mask by facilitating better performance of the team at the drill. Interference with hearing must be dealt with technically or bypassed by modifications in the unit's mode of communication.     

Primary closure of battle wounds of the colon: is it an option for the military surgeon?

The management of battle wounds of the colon has been safely established for many years, with primary closure of the wounds being discouraged. More recent work, involving large numbers of patients from civilian trauma centres, has challenged this. The appropriateness of these conclusions for the battle situation is discussed, including the nature of injury, the medical logistics and the combat scenario. Parameters are indicated and guide lines given, incorporating battle-proven military surgical principles and modern trauma experience. This includes damage control and possible primary closure of selected wounds. In this way the military surgeon can take an informed decision in providing optimal care for patients with battle wounds of the colon.     

Explosive ordinance disposal team equipment and its use in diagnosing extremity trauma

A 31-year-old man presented to the Rakkasan battalion aid station, located at the Qandahar Airport, Afghanistan, with complaints and physical findings consistent with those that would either support a grade III ankle sprain or fracture. The battalion aid station is an echelon I level of care. This facility does not have radiographic capabilities. With the closest radiology facility located in Seeb, Oman the 710th Explosive Ordinance Disposal team, which was operating in the area, was contacted. This unit was able to perform radiographs in a timely manner to help aid in correctly diagnosing the injury.     

The use of the principles of military field surgery in rendering medical care to the victims during catastrophes]

Despite the existing differences in medical care of war and catastrophe casualties it is possible to apply a variety of organizational and management principles of military medicine for the disaster medicine. The authors express the opinion that in case of big catastrophes the medical service could operate by means of rapid deployment units formed on the basis of territorial principle.