Chapter 2 Family not to be informed?

What are the ethics that shape or should shape engagement with historical medical data, particularly archives containing patient voices? This question has come to the fore through the ‘Men, Women and Care’ project, a European Research Council-funded project creating a database of information drawn from the PIN 26 personal pension award records from the First World War. Held by the National Archives, London, these records contain a wealth of personal information, including potentially sensitive details of medical conditions and diagnoses, as well as material concerning stigmatising social situations, such as domestic violence, prostitution and illegitimacy. Using material drawn from ‘Men, Women and Care’, this chapter considers the opportunities presented and challenges posed by this material as sources for historical analysis. It considers issues of both disciplinary practice and theoretical framing to explore the position of the historian in relation to analysing and disseminating the historical patient voice. In doing so, it asks what use historians can and should make of this information and what steps the historical community might consider taking to articulate a code of ethics around practice that is sensitive both to family feeling and academic enquiry

The medical management of casualties in a chemical contaminated environment : a start for the CBRNE defence research program for clinicians

The main objective of this research program was to assess the status of clinical knowledge and evidence-based practice in the medical management of mass casualties, contaminated by exposure to a chemical weapon, during a medical evacuation, which is defined as from the incident site of a contaminated environment up-to a clean zone. First, in our published systematic review, we assessed past medical responses during a chemical attack. The lack of clinical data and intervention-related information, such as protection and decontamination capabilities, stresses not only the need to study acute or prehospital settings, but also a set of integrated competences in the contaminated environment (i.e.: protection, decontamination and clinical interventions) (Prospero registered CRD42019104473). Second, a method paper which presents an ongoing international retro-prospective observational study on the medical responses during a chemical attack has been submitted for publication. The goal of this study is to describe the acute clinical management of patients in the contaminated zone (1970-2036; US Clinical trial registered NCT05026645). Data gathering is currently ongoing with the use of a comprehensive online registry programmed by the Quebec Respiratory Health Research Network. In the third and fourth, we started the development of two technological innovations to improve the medical management of mass casualties, caused by a chemical weapon, in contaminated environments. The first is the creation of a mobile laboratory for the continuity of our work in both indoor and outdoor settings. The other is the launch of a research program, named VIMY Multi-System, which includes: (1) An electronic casualty card system integrating the United Kingdom National Early Warning System; (2) a forward-deployable telemedicine capability prototype – currently undergoing integration testing – that incorporates drone technology to monitor patients being clinically managed in a simulated chemically contaminated environment. Our fifth published paper, on the methods of oxygen conservation with an automated titration system (n= 60; US Clinical trial registered NCT02782936 and NCT02809807), showed that such an automated system may constitute a viable medical solution for interventions in a contaminated environment and also constitutes one of the possible solutions to improve therapeutic interventions. The system studied allows the maintenance of adequate oxygenation while reducing the use of oxygen in patients, making it possible to extend their treatment duration even under conditions of limited logistical resources in oxygen. The oxygen flow provided by the automated system allows a mean reduction in administered oxygen quantities of more than six-fold when decreasing the prescribed SpO2 target from 98 to 90% (5 L/min to1 L/min, p <0.001) in hospitalized patients with respiratory disorders. The comparison was conducted on the basis of conservative flow rate targets reported in the literature (2.5, 5.0, 10.0 and 15.0 l/min). When it comes to the automated correction of a hypoxemic condition in sick patients and healthy subjects wearing a gas mask, the prescribed SpO2 target resulted in maximum administered oxygen flow rates of 0.2 L/min and 2.9 L/min respectively. These results show a possible logistic and therapeutic optimization in the use of oxygen. Finally, these initial advances will be integrated as our research work progresses in order to improve clinical evidence-based practices in contaminated environments due to the use of chemical weapons.L’objectif principal de cette recherche était d’évaluer l’état des connaissances et le savoir-faire de la pratique clinique dans la gestion d’un grand nombre de blessés, contaminés des suites d’une exposition à l’arme chimique, pendant leur évacuation médicale depuis le site de l’incident dans un environnement contaminé jusqu’à la zone propre. Premièrement, dans une revue systématique que nous avons publiée, nous avons évalué les réponses médicales passées lors d’attaques chimiques. Le manque de données cliniques et d’autres informations liées à l’intervention, tel que les capacités de protection et de décontamination, souligne non seulement la nécessité d’étudier l’environnement préhospitalier, mais aussi la gamme de compétences interdépendantes en milieu contaminé (c.-à-d. : protection, décontamination et interventions cliniques) (Prospero CRD42019104473). Deuxièmement, nous avons soumis pour publication la méthodologie d’une étude rétroprospective observationnelle internationale s’intéressant aux réponses médicales lors d’une attaque chimique. Le but consiste à décrire la gestion clinique en soins aigus des blessés dans la zone contaminée (1970-2036) (ClinicalTrials.gov NCT05026645). L’acquisition de données est en cours à l’aide d’un registre de données intégral en ligne qui a été programmé par le Réseau de recherche en santé respiratoire du Québec. En troisième et quatrième lieu, nous avons entrepris le développement de deux innovations technologiques afin d’améliorer la prise en charge médicale des patients en milieu contaminé à la suite de l’utilisation de l’arme chimique. L’un est la création d’un laboratoire mobile pour poursuivre nos travaux tant à l’intérieur qu’à l’extérieur. L’autre est la mise sur pied d’un programme de recherche, nommé VIMY Multi-Systèmes, qui inclut : (1) un système de carte de blessés électronique intégrant le système national d’alerte précoce du Royaume-Uni, (2) les premiers tests d’intégration d’un prototype d’une capacité de télémédecine de déploiement avancé, incluant la technologie du drone, pour une surveillance clinique globale des patients pris en charge en milieu contaminé chimique simulé. Notre cinquième publication, qui porte sur les méthodes de maintien de l’oxygénation par titrage automatisée (n=60 ; ClinicalTrials.gov NCT02782936 et NCT02809807), nous a permis de démontrer qu’un système automatisé peut constituer une solution médicale intéressante qui serait applicable dans les interventions en milieu contaminé et de surcroît comme une solution pour améliorer les actions thérapeutiques. Le système que nous avons étudié permet de maintenir une oxygénation adéquate tout en limitant la consommation d’oxygène des patients, prolongeant ainsi leur durée de traitement, notamment en cas de ressources en oxygène limitées. D’une part, le débit de l’oxygène fourni par le système automatisé a permis une réduction moyenne des quantités administrées de l’ordre de plus de six fois lors de la diminution de la cible de saturation en oxygène (SpO2) prescrite de 98 à 90 % (5 L/min à 1 L/min, p < 0,001) chez les patients hospitalisés atteints de maladies respiratoires. La comparaison s’est faite par rapport à des débits conservateurs rapportés dans la littérature (2,5, 5,0, 10,0 et 15,0 L/min). D’autre part, la correction automatisée d’une condition hypoxémique chez les patients malades et les sujets sains portant le masque à gaz, la cible SpO2 a engendré des débits maximaux d’oxygènes administrés de 2,5 et 2,9 L/min respectivement. Ainsi, nous avons démontré une optimalisation logistique et thérapeutique de la consommation de l’oxygène. Finalement, ces premières avancées seront intégrées au fur et à mesure de l’avancement de nos recherches afin d’améliorer le processus de soins en milieu contaminé issu de l’utilisation de l’arme chimique

Personal defense sprays: Effects and management of exposure

Background: Defense sprays have become quite popular for both police use and personal protection. Officers in more than 2000 law enforcement agencies now carry sprays, and the public spends millions of dollars per year on them. As more and more people carry sprays, it is inevitable that optometrists will be called upon to treat the ocular consequences of accidental or intentional exposure. Types of Sprays: Most defense sprays contain o-chlorobenzylidene malononitrile (CS), co-chloroacetophenone (CN), oleoresin capsicum (OC), or a combination of these ingredients as the active agent. In addition, they contain propellants such as isobutane and/or propane, along with carriers such as isopropyl alcohol, hydrocarbons, or water. Management of Exposure: All of the sprays cause significant ocular irritation, lacrimation, conjunctivitis, and blepharospasm. Initial management of spray victims involves a determination that there is no significant systemic distress, followed by ocular irrigation and decontamination. Recovery from the acute effects of the sprays typically takes 30 to 60 minutes; significant consequences of uncomplicated spray exposures are rare. Effects of Sprays on Contact Lenses: Based on reports from police trainers, rigid gas permeable lenses can be cleaned and reworn after spray exposure. However, decontamination of soft lenses is more problematic. Gas chromatography and mass spectroscopy revealed residual capsaicin in lenses that had been cleaned two times after exposure to a spray containing OC. Therefore, it is recommended that exposed soft lenses be discarded. Summary: The ocular consequences of exposure to defense sprays typically resolve without complications, and can usually be managed either by a telephone consultation or an in-office evaluation

The blast pelvis

Decreasing the human cost of war is a vital role within the Ministry of Defence, and the Defence Medical Services. With the considerable improvements in care, from point of wounding to rehabilitation, it is possible that we have reached the ceiling of optimal management with available, deployed resources. Injury prevention or mitigation may therefore have a more important role than ever in improving survival rates. The current character of conflict, and certainly the recent conflicts in Iraq and Afghanistan have seen the Improvised Explosive Device used to devastating effect to personnel. These devices cause multisystem injuries, and have a high fatality. The lower extremity was most often affected in these recent conflicts, and many fatalities occurred. A greater understanding of lower extremity trauma biomechanics is likely to be key to preventing future fatalities due to injuries in this body region. This thesis focusses on lower extremity blast injury, performs a review of current understanding, and undertakes a casualty data analysis to further understand injury patterns and the cause of fatal wounding. This analysis finds that haemorrhage secondary to pelvic fracture is the key factor in fatal lower extremity injuries, and therefore an area of considerable research interest. Pelvic injury patterns were therefore analysed using measurement techniques to qualify injury patterns and understand the link between injury patterns and the presence of vascular injury. Subsequent physical and computational testing provided a platform to apply different loading conditions to the pelvis to replicate a blast injury, and understand the behaviour of the bony structures under high rate axial loading. This thesis concludes that the anterior pelvic ring at the pubic symphysis is key to pelvic integrity at high rates of loading. Disruption of the anterior pelvis can lead to subsequent posterior ligamentous rupture which, due to the proximity to major vessels, can lead to major haemorrhage and death. Preventing lateral disruption may be the key to maintaining pelvic integrity at these high loading rates, and preventing vascular compromise and fatality from lower extremity blast injuries.Open Acces

Operational leadership : Relationship with swift trust, moral stress, and adaptability

Forutsetningene for krigføring og militær ledelse har endret seg dramatisk de siste tiårene. Raske teknologiske fremskritt og et nytt geopolitisk landskap innebærer en rekke nye krav og utfordringer for militære ledere. Denne avhandlingenfokuserer på den enkelte militære leder fra et psykologisk perspektiv. Det overordnede målet med dette doktorgradsprosjektet var å gi en større forståelse av hvordan rask tillit til midlertidige grupper, moralsk stress og tilpasningsevne er relatert til operativ ledelse blant hærledere på lavere nivå. Studie 1 hadde som mål å belyse faktorer som gagner, eller ikke gagner, utviklingen av rask tillit til ledere i midlertidige militærgrupper. Totalt deltok 581 norske og svenske kadetter og offiserer og en kombinasjon av kvalitativ metode og ikke-parametrisk statistikk ble brukt. En hierarkisk modell av faktorer som bidrar til rask tillit til ledere av midlertidige grupper dukket opp. Modellen består av to kategorier på høyt nivå – individuelle kjennetegn og relasjonsrelaterte kjennetegn, som begge omfatter flere underordnede kategorier. Studie 2 hadde som mål å identifisere og få en dypere forståelse av miljø-, organisasjons- og gruppeforhold, og ledelsesrelaterte spørsmål spesielt, rapportert som viktige i alvorlig stressende situasjoner som involverer en moralsk stressor som militær- og politifolk står overfor. Studiegruppen besto av 16 militærkadetter og offiserer og 10 politifolk (alle svenske). Det ble gjennomført dybdeintervjuer og analysert ved hjelp av en fundert teoritilnærming. Den nye modellen består av et hierarkisk system av innbyrdes beslektede koder og kategorier av aspekter rapportert som viktige i alvorlig stressende situasjoner som involverer en moralsk stressor. Kategoriene var følgende (hver er underbygget av flere koder): Miljø, Organisasjon, Ledelse og Gruppe. Studie 3, til slutt, besto av en innledende kvalitativ studie (studie 3A), etterfulgt av en kvantitativ studie (studie 3B). Målet med studie 3A var å oppnå en dypere forståelse av følgende spørsmål: hva kjennetegner vellykket og mislykket militær ledelse på et lavere hierarkisk nivå, når tilpasningsevne er nødvendig for å håndtere en uventet truende hendelse under et fredsbevarende eller fredshåndhevelsesoppdrag i et miljø preget ved irregulær krigføring? Siden kvalitative studier har lav generaliserbarhet, ble de oppnådde resultatene operasjonalisert til et spørreskjema (studie 3B) for å fastslå om en kvantitativ studie ville validere resultatene eller ikke. Intervjuer ble gjennomført med 16 svenske soldater og offiserer i studie 3A, og svar innhentet fra 193 svenske soldater og offiserer i studie 3B. En prosessmodell som beskriver forhold som påvirker tilpasningsevnen når man møter en uventet hendelse ble utviklet i studie 3A. Modellen ble testet i studie 3B. Regresjonsanalyser viste høye til moderat høye justerte R²-koeffisienter. Imidlertid ga en moderasjonsanalyse et ikke-signifikant resultat og en baneanalyse resulterte i en dårlig modelltilpasning. Hovedbidragene til avhandlingen er de tre utviklede teoretiske modellene, og ved tilpasningsevne, den kvantitative testen av modellen. Person-for-situasjon-paradigmet ble brukt som rammeverk i den generelle diskusjonen av alle tre studiene. Til sammen utvider funnene den nåværende forståelsen av operativ ledelse blant militære ledere på lavere nivå.The conditions for warfare and military leadership have changed dramatically in the last few decades. Rapid technological advancements and a new geopolitical landscape imply an array of new demands and challenges for military leaders. This thesis focuses on the individual military leader from a psychological perspective. The overall aim of this thesis was to provide a greater understanding how swift trust in temporary groups, moral stress and adaptability are related to operational leadership among lower-level army leaders. Study 1 aimed to illuminate factors that benefit, or do not benefit, the development of swift trust towards leaders in temporary military groups. A total of 581 Norwegian and Swedish cadets and officers participated and a combination of qualitative clustering and non-parametric statistics was used. A hierarchical model of factors contributing to swift trust in leaders of temporary groups emerged. The model consists of two high-level categories—Individual-related characteristics and Relationship-related characteristics, both of which comprise several subordinate categories. Study 2 aimed to identify and gain a deeper understanding of environmental, organizational, and group conditions, and leadership-related issues in particular, reported as being important in severely stressful situations involving a moral stressor faced by military and police officers. The study group consisted of 16 military cadets and officers and 10 police officers (all Swedish). In-depth interviews were conducted and analyzed using a grounded theory-approach. The emerging model consists of a hierarchical system of interrelated codes and categories of aspects reported as being important in severely stressful situations involving a moral stressor. The categories were the following (each being underpinned by several codes): Environment, Organization, Leadership, and Group. Study 3, finally, consisted of an initial qualitative study (study 3A), followed by a quantitative study (study 3B). The aim of study 3A was to obtain a deeper understanding regarding the following question: what characterizes successful and unsuccessful military leadership at a lower hierarchical level, when adaptability is needed to handle an unexpected threatening event during a peacekeeping or peace enforcement mission in an environment characterized by irregular warfare? Since qualitative studies have low generalizability, the obtained results were operationalized into a questionnaire (study 3B) in order to ascertain whether a quantitative study would validate the results or not. Interviews were conducted with 16 Swedish soldiers and officers in study 3A, and responses obtained from 193 Swedish soldiers and officers in study 3B. A process model describing conditions that affect adaptability when encountering an unexpected event was developed in study 3A. The model was tested in study 3B. Regression analyses showed high to moderately high adjusted R² coefficients. However, a moderation analysis yielded a non-significant result and a path-analysis resulted in a poor model fit. The main contributions of the thesis are the three developed theoretical models, and in the case of adaptability, the quantitative test of the model. The person-by-situation paradigm was used as a framework in the general discussion of all three studies. Taken together, the findings broaden the current understanding of operational leadership among lower-level military leaders.Doktorgradsavhandlin

Medical planning for military operations other then [i.e. than] war: Is a paradigm shift required?

Military operations other than war are increasing in frequency and, as one might surmise present unique challenges to the operational commander and the medical planner. Over time and by necessity the U.S. military has developed a logistical support system with unprecedented capability. This logistical system includes a medical system that is increasingly called upon to provide care to people outside the normal scope. Increased participation means Navy assets will be tasked to provide care to U.S. troops, U.N. troops, multinational troops, NGO personnel, and the civilians that precipitated the need for intervention in the first place. The current planning paradigm is rightfully focused on combat support. This thesis will investigate the necessity of breaking away from that paradigm when planning MOOTW.http://archive.org/details/medicalplanningf109459791Lieutenant, United States NavyApproved for public release; distribution is unlimited

Happiness is a Warm Gun: Militarized Mourning and Ceremonial Vengeance

Towards a Psychological Theory of Combat and Manhood in America

Improving pre-hospital care at mass gathering events: Applying military intelligence methodology to the St John ambulance WA event health operations

With the growth of the mass gathering event domain and its ever constant place within the contemporary Australian lifestyle, the number of patrons who attend these events that require medical assistance rises (Zeitz et al., 2007, p. 23; Zeitz, Zeitz, & Arbon, 2005, p. 164; Zeitz, Zeitz, & Kadow-Griffin, 2012). This increased demand and inherited risk to the event organiser, the patrons attending and the pre-hospital care or first aid provider creates a need for the investigation into enhancements to the medical care operations at these events. The provision of pre-hospital care at mass gathering events in Western Australia is a vital service to the health of the community members in attendance and requires in depth planning, resourcing and staff to ensure that the risk of permanent injury or death to patrons is mitigated or reduced. This study aimed to examine the viability of the introduction of the military intelligence methodology, Intelligence Preparation for the Battle Space (IPB), to the St John Ambulance WA Ltd planning process to improve the decision making ability within all levels and at the planning and operational stages of a mass gathering event. Through the utilisation of a case study and documentary analysis methodological processes, supported by a constructivist framework, the existing knowledge base was examined and the integration of intelligence based concepts was introduced. The study has concluded that, utilising the Big Day Out Perth 2009 contextual setting and case study variable comparisons, that the introduction of IPB or a variation of its intelligence based methodological concepts is a viable and beneficial undertaking. The study has demonstrated that this would allow for the enhanced examination of potential clinical presentations and the identification of required physical, human and information resources as a result of an event’s unique planning variables, risk inputs and their casual relationships within an event’s contextual setting. Though theoretically possible, the study highlights that further research is required to refine and explore the utilisation of the proposed model to other event types and/or organisations in order to validate its result

Defining and rectifying the gaps in our ability to record and measure eye injuries internationally.

Eye injuries and the resulting vision loss are a significant contributor to monocular vision loss worldwide.(1) Eye injuries can result in immediate and devastating vision loss and are quoted as being 90% avoidable.(2) Whilst eye injury data is available from many countries, the terms, definitions and methods of collection are not uniform and low-and-middle-income countries are underrepresented in the published literature as highlighted in Chapter 1. The capacity to reduce ocular mortality and morbidity requires systematic and aligned data internationally. A systematic review of ocular trauma registries, past and present is provided in Chapter 2. A system for recording ophthalmic trauma data to be used internationally, the International Globe and Adnexal Trauma Epidemiology Study (IGATES) methodology, is presented in Chapter 3. To validate IGATES, a point incidence study was undertaken to examine the impact of fireworks at key festivals, such as Devali and New Year’s Eve. The data for fireworks-related eye injuries is presented in Chapter 4. Based on the need for a consensus-based approach to the terms and definitions associated with ophthalmic (eye and adnexal) trauma was used to provide more the basis for uniform data collection, analysis and informed interventions internationally a survey was conducted. The results of a Delphi survey conducted to achieve consensus on terms and classifications for ophthalmic trauma are presented in Chapter 5. Chapter 6 provides the concluding remarks including aims and implications for future research in the area of ocular trauma