Journal of the Royal Army Medical Corps
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Pneumorrhachis or intraspinal air is an increasingly encountered phenomenon in the management of severe trauma. The case of a 23-year-old soldier, who sustained a gunshot wound to the chest, is presented and the subsequent discussion illustrates that while often benign this phenomenon may indicate serious occult injury.
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Compartment syndrome of the foot is a rare complication of injury to the foot. Treatment by decompression of the compartments is debatable. The debate surrounding decompression stems from the rarity of the condition, the lack of consensus regarding the anatomy of the foot compartments and whether to accept the inevitable contractures by not decompressing. The aim of this paper is two fold; firstly to sample current military orthopaedic experience and secondly establish if there exists a consensus of opinion in how and if to perform fasciotomy of the foot thereby providing guidance to other clinicians. ⋯ DMS clinicians need to remain vigilant to compartment syndrome of the foot and especially in cases of crush or blast injury or of multiple fractures. If diagnosed or even if an impending compartment syndrome is suspected then, in line with the current weight of expert opinion, the foot should be decompressed and the deployed orthopaedic surgeon should be capable of performing it. Evidence concerning their battlefield use is limited. Extensive UK military trials are ongoing and the results of which are expected to clarify questions regarding complication rate and efficacy.
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Anaesthetists in the Defence Medical Services (DMS) are currently dealing with casualties who have an increased prevalence of injuries due to blast, fragmentation and gunshot wounds. Despite guidelines already existing for unanticipated difficult tracheal intubation these have been designed for a civilian population and might not be relevant for the anticipated difficult airway experienced in the deployed field hospital. ⋯ There are certain key principles that should be considered in all cases and these are considered. Potential pitfalls are discussed and our initial proposed guidelines for use in the deployed field hospital are presented.
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Simulation in healthcare has come a long way since it's beginnings in the 1960s. Not only has the sophistication of simulator design increased, but the educational concepts of simulation have become much clearer. One particularly important area is that of non-technical skills (NTS) which has been developed from similar concepts in the aviation and nuclear industries. ⋯ Uses of simulation include pre-deployment training of hospital teams as well as Medical Emergency Response Team (MERT) and Critical Care Air Support Team (CCAST) staff. Future projects include developing Role 1 pre-deployment training. There is enormous scope for development in this important growth area of education and training.
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The primary brain insult that occurs at the time of head injury, is determined by the degree of neuronal damage or death and so cannot be influenced by further treatment. The focus of immediate and ongoing care from the point of wounding to intensive care management at Role 4 should be to reduce or prevent any secondary brain injury. ⋯ Concurrent injuries must also be managed appropriately. Attention to detail at every stage of the evacuation chain should allow the head-injured patient the best chance of recovery.