A revolutionary approach to improving combat casualty care

Background: Military medicine has historically advanced in war. Advances in concepts, technology, organisation and operational processes have occurred during the contemporary conflicts of the last decade. Aims: To determine whether the advances constitute a ‘Revolution in Military Medical Affairs (RM2A)’; to demonstrate my role within a revolutionary transformation; and to introduce new theory to determine if advances have been appropriately matched to clinical need. Definition: An RM2A is defined here as a radical change in the character or practice of military medicine. Methods: 20 papers are selected (15 first author; 5 second author) that describe the changes in modern combat casualty care. These are clustered into conceptual (doctrine) innovation; changes to organisational structure and operational processes; and advances in technology. These are analysed against Lambeth’s (1997) criteria for a Revolution in Military Affairs (RMA); Cohen’s (2009) three tests for an RMA, but adapted for an RM2A; and Toffler’s (1993) criteria for a ‘true revolution’. The null hypothesis for the novel theory (Homunculus Casualty Theorem) states that the concept, training, equipment and practice changes within the RM2A are not correspondingly or proportionately matched in importance to the immediately life-threatening injuries and physiology of contemporary combat trauma. Results: The creation of new concepts (ABC, DCR) and doctrine (MIMMS, 1st Aid) are demonstrated, incorporating a raft of novel heuristics. Developments in trauma governance are described that have provided both the evidence to drive change and the proof of effect of change. Specific evidence for avoidable in-hospital cardiac arrest is presented, together with an organisational solution for prevention that highlights the NHS barriers to innovation adoption. The results of system transformation are demonstrated as a cohort of 75 unexpected survivors of critical combat injury; traumatic cardiac arrest survival of 24% is unexpectedly high. Conclusions: An RM2A is proven that meets the sentinel criteria. The scope of advances in combat casualty care has appropriately reflected clinical need particularly for the rapid and effective treatment of haemorrhage, although battlefield analgesia has failed to advance. Most importantly, it is asserted that the proven RM2A is responsible for the unexpected positive outcomes following critical combat injury. There is evidence I have played a central role in this transformation of military medicine. Effort to transfer the learning into NHS practice has begu

Innovation strategies for defence: the successful case of Defence Medical Services

Over the past 20 years, the Defence Medical Services (DMS, the umbrella organisation for medical provision within the British armed forces) has been innovating consistently and at pace within the Ministry of Defence. The result of this sustained effort has led to progressive improvement in the outcomes of the critically injured. Separately, it has also led to global transformational innovation in support of the response to the Ebola epidemic in Sierra Leone. Through planned and orchestrated interventions across the entire organisation, from leadership to technology, medical practices to training and organisational design, the DMS can legitimately claim to have achieved a ‘Revolution in Military Medical Affairs’. Matthew Ford, Timothy Hodgetts and David Williams examine the innovation lifecycle within the DMS as it defines its response to the challenges of the changing character of conflict and consider the way defence medicine is an example to the wider military

A revolutionary approach to improving combat casualty care

Background: Military medicine has historically advanced in war. Advances in concepts, technology, organisation and operational processes have occurred during the contemporary conflicts of the last decade. Aims: To determine whether the advances constitute a ‘Revolution in Military Medical Affairs (RM2A)’; to demonstrate my role within a revolutionary transformation; and to introduce new theory to determine if advances have been appropriately matched to clinical need. Definition: An RM2A is defined here as a radical change in the character or practice of military medicine. Methods: 20 papers are selected (15 first author; 5 second author) that describe the changes in modern combat casualty care. These are clustered into conceptual (doctrine) innovation; changes to organisational structure and operational processes; and advances in technology. These are analysed against Lambeth’s (1997) criteria for a Revolution in Military Affairs (RMA); Cohen’s (2009) three tests for an RMA, but adapted for an RM2A; and Toffler’s (1993) criteria for a ‘true revolution’. The null hypothesis for the novel theory (Homunculus Casualty Theorem) states that the concept, training, equipment and practice changes within the RM2A are not correspondingly or proportionately matched in importance to the immediately life-threatening injuries and physiology of contemporary combat trauma. Results: The creation of new concepts (ABC, DCR) and doctrine (MIMMS, 1st Aid) are demonstrated, incorporating a raft of novel heuristics. Developments in trauma governance are described that have provided both the evidence to drive change and the proof of effect of change. Specific evidence for avoidable in-hospital cardiac arrest is presented, together with an organisational solution for prevention that highlights the NHS barriers to innovation adoption. The results of system transformation are demonstrated as a cohort of 75 unexpected survivors of critical combat injury; traumatic cardiac arrest survival of 24% is unexpectedly high. Conclusions: An RM2A is proven that meets the sentinel criteria. The scope of advances in combat casualty care has appropriately reflected clinical need particularly for the rapid and effective treatment of haemorrhage, although battlefield analgesia has failed to advance. Most importantly, it is asserted that the proven RM2A is responsible for the unexpected positive outcomes following critical combat injury. There is evidence I have played a central role in this transformation of military medicine. Effort to transfer the learning into NHS practice has begunEThOS - Electronic Theses Online ServiceGBUnited Kingdo

Effects of publication bias on conservation planning

Conservation planning needs reliable information on spatial patterns of biodiversity. However, existing data sets are skewed: some habitats, taxa, and locations are under-represented. Here, we map geographic publication density at the sub-national scale of individual 'provinces'. We query the Web of Science catalogues SCI and SSCI for biodiversity-related publications including country and province names (for the period 1993-2016). We combine these data with other provincial-scale factors hypothesised to affect research (i.e. economic development, human presence, infrastructure and remoteness). We show that sites that appear to be understudied, compared with the biodiversity expected from their bioclimatic conditions, are likely to have been inaccessible to researchers for a diversity of reasons amongst which current or recent armed conflicts are notable. Finally, we create a priority list of provinces where geographic publication bias is of most concern, and discuss how our provincial-scale model can assist in adjusting for publication biases in conservation planning.Comment: 10 pages; 3 figures; 1 table;R code on https://github.com/raffael-hickisch; data at https://zenodo.org/record/998889; interactive at http://bit.ly/publication_density_ma

The BCD Triage Sieve outperforms all existing major incident triage tools:comparative analysis using the UK national trauma registry population

BACKGROUND: Natural disasters, conflict, and terrorism are major global causes of death and disability. Central to the healthcare response is triage, vital to ensure the right care is provided to the right patient at the right time. The ideal triage tool has high sensitivity for the highest priority (P1) patients with acceptably low over-triage. This study compared the performance of major incident triage tools in predicting P1 casualty status in adults in the prospective UK Trauma Audit and Research Network (TARN) registry. METHODS: TARN patients aged 16+ years (January 2008-December 2017) were included. Ten existing triage tools were applied using patients’ first recorded pre-hospital physiology. Patients were subsequently assigned triage categories (P1, P2, P3, Expectant or Dead) based on pre-defined, intervention-based criteria. Tool performance was assessed by comparing tool-predicted and intervention-based priority status. FINDINGS: 195,709 patients were included; mortality was 7·0% (n=13,601); median Injury Severity Score (ISS) was 9 (IQR 9–17); 97·1% sustained blunt injuries. 22,144 (11·3%) patients fulfilled intervention-based criteria for P1 status, exhibiting higher mortality (12·8% vs. 5·0%, p<0.001), increased intensive care requirement (52·4% vs 5·0%, p<0.001), and more severe injuries (median ISS 21 vs 9, p<0.001) compared with P2 patients. In 16–64 year olds, the highest performing tool was the Battlefield Casualty Drills (BCD) Triage Sieve (Prediction of P1 status: 70·4% sensitivity, over-triage 70·9%, area under the receiver operating curve (AUC) 0·068 [95%CI 0·676–0·684]). The UK National Ambulance Resilience Unit (NARU) Triage Sieve had sensitivity of 44·9%; over-triage 56·4%; AUC 0·666 (95%CI 0·662–0·670). All tools performed poorly amongst the elderly (65+ years). INTERPRETATION: The BCD Triage Sieve performed best in this nationally representative population; we recommend it supersede the NARU Triage Sieve as the UK primary major incident triage tool. Validated triage category definitions are recommended for appraising future major incidents. FUNDING: This study is funded by the National Institute for Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre. GVG also acknowledges support from the MRC Heath Data Research UK (HDRUK/CFC/01). The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care, or the Ministry of Defence

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Enacting connectivity: woodland mammal conservation practices in England &amp; Wales

In recent years ideas about connectivity have become increasingly influential in theories pertaining to wildlife conservation. These ideas range from concerns with spatial habitat linkages or species' movements, to the forms of connection existing between 'people' and 'nature'. This thesis is concerned with how these various forms of connectivity are enacted in wildlife conservation through varied spatial practices. Following Mol (2002), I suggest that these modes of connectivity are enacted not separately but as a multiple. Indeed, through tracing how connectivity is enacted in a series of conservation situations relating to woodland mammals in England and Wales (red squirrels, pine martens, and wild/feral boar), I suggest that these multiple spatial practices of connectivity shape the biopolitical possibilities for living with non-human life. Since the connectivity multiple is composed, following Latour (2010) I further argue that it can be recomposed. Thus, I make the normative suggestion that contemporary trends in conservation policy (towards larger-scale action, process-based objectives, and neoliberal modes of governance) might be rethought and differently articulated through a conceptual and practical approach I term revitalizing conservation. This thesis thus makes several important contributions to geographic literatures. Following a widespread (re)affirmation of nonhuman agency in social science (e.g. Latour, 2005; Callon et al, 2009; Braun &amp; Whatmore, 2010), and particularly the agential capacities of animals (Wolch &amp; Emel, 1998; Philo &amp; Wilbert, 2000), it foregrounds the role of woodland mammals in enacting connectivity through developing the concept of animal mobilities. Furthermore, it engages with existing work tracing affirmative possibilities for conservation (bio)politics (Whatmore, 2002; Lulka, 2009; Hinchliffe et al, 2005; Hinchliffe, 2008; J.Lorimer, 2010, 2012, 2015), by illuminating the intersection of spatial practices of connectivity, and the potential these offer for alternative modes of 'living with' more-than-human lives

Orang-utans as issue animals: how flagship species are implicated in rallying actors around conservation issues

Within human cultures, animals often come to symbolize the environmental controversies in which they are entangled; yet the roles played by such animals go far beyond mute signification. This paper critically engages with ‘flagship species’ theory from the field of conservation, to trace an account of the ways in which animals become implicated in the rallying of various actors (and objects) around conservation issues. It introduces the term “issue-animals” to describe the under-explored practice where flagships are proposed, accepted, and implicated as representatives for particular issues facing habitats or ecosystems. Drawing heavily on the insights of relational-material perspectives within contemporary human geography, it develops an animal-centric epistemological approach with which to interrogate the attachment of a particular animal and issue: the orang-utan and palm oil-led deforestation in south-east Asia. Orang-utans are found to be implicated in the rallying of both publics and of conservation actors, but the agency of orang-utans as issue-animals affects and interacts with these actor types in different ways. Through illuminating the various processes involved in this context, a tentative step towards a more general account of issue-animals is subsequently proposed

Orang-utans as Issue Animals: How flagship species are implicated in rallying actors around conservation issues

Within human cultures, animals often come to symbolize the environmental controversies in which they are entangled; yet the roles played by such animals go far beyond mute signification. This paper critically engages with ‘flagship species’ theory from the field of conservation, to trace an account of the ways in which animals become implicated in the rallying of various actors (and objects) around conservation issues. It introduces the term “issue-animals” to describe the under-explored practice where flagships are proposed, accepted, and implicated as representatives for particular issues facing habitats or ecosystems. Drawing heavily on the insights of relational-material perspectives within contemporary human geography, it develops an animal-centric epistemological approach with which to interrogate the attachment of a particular animal and issue: the orang-utan and palm oil-led deforestation in south-east Asia. Orang-utans are found to be implicated in the rallying of both publics and of conservation actors, but the agency of orang-utans as issue-animals affects and interacts with these actor types in different ways. Through illuminating the various processes involved in this context, a tentative step towards a more general account of issue-animals is subsequently proposed