The Journal of the Royal Army Medical Corps (JRAMC) is published with the aim of propagating current knowledge and expertise while also acting as institutional memory for the practice of medicine within the military. This work aimed to examine how the interests of the JRAMC, and by inference the Army Medical Services, have changed over time as reflected by the articles published in the journal. A text mining analysis of the titles of all published articles in the JRAMC between 1903 and 2019 was performed. The most commonly used terms were identified and their relative frequency over the decades analysed to identify trends. Article content and contemporary events were compared with the observed trends to identify explanatory events and themes of interest. Medical topics of interest centred around specific infectious diseases, particularly during the early/mid-20th century, and trauma and battle injury. The medical specialties of surgery, anaesthetics and mental health were all well represented in nearly all decades, while primary care only came to prominence as a named specialty from the 1960s onwards. India, France, Egypt and wider Africa were the most commonly cited geographical regions, although there were spikes of interest associated with specific conflicts in the Falklands, Bosnia, Afghanistan and Iraq. The interests of the JRAMC have changed considerably over the years primarily driven by the geopolitical interests of Britain-in particular its colonial interests and the conflicts it has been involved in, but also by medical advances seen in contemporary society.
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This article describes the evolution of first aid in the British Army from the Crimean War to the present day in order to interpret the processes of innovation, implementation, and diffusion of ideas to improve the clinical outcomes for military casualties. The article is an analysis of policy and practice for training in first aid published in King's/Queen's Regulations for the Army, the Field Service Pocket Book, or generic military training policy. This is complimented by a review of medical training manuals and a search of articles in the Journal of the Royal Army Medical Corps (RAMC). Most sources have been accessed from the Museum of Military of Medicine and the Wellcome RAMC Muniments Collection. The narrative summarizes the evolution of clinical concepts in first aid and their translation for Army personnel; starting with RAMC stretcher bearers, extended to soldiers assigned to medical duties at unit level, and finally simplified into first aid training to be taught to all soldiers. Alongside this story of training is a secondary story of the development of field first aid equipment, principally dressings, tourniquets, and analgesia. The final part of the story is the transfer of knowledge from military first aid training into the civilian, community setting. The following themes were identified: the reality of conflict wounds, battlefield first aid is different from civilian first aid, progressive transfer of training from medics to soldiers, transfer of knowledge to civilian sector and internationally, and specific clinical innovations: first field dressings, tourniquets, and prehospital analgesia. The current generation of soldiers are at the highest ever standard of first aid training and equipment. This must be maintained through gathering of evidence in effectiveness and outcomes in prehospital emergency care in both military and civilian settings.
General Practice training in the civilian and military environments follows a common training pathway, yet the scope of practice of a military General Practitioner (GP) varies significantly. A level of care for the acutely unwell and traumatically injured patients is frequently provided in austere environments remotely located from definitive medical care. This qualitative service needs evaluation scopes current level of trauma and acute care training and requirement for further training within military GPs and GP trainees. The transition to contingency operations increases the likelihood of medical officers being deployed to remote, austere locations, and it remains important to be fully skilled to manage any acute medical or trauma situation. The aim of this project is to identify how to maintain skills in prehospital and acute care within the military general practice. The specific objectives are (1) to assess the current level of training and experience across military GPs and military GP trainees in the domain of prehospital and acute competencies; (2) to assess satisfaction with the current level of training in these domains; (3) to assess the current deficiencies in training in this domain; and (4) to suggest possible changes or enhancements to the current military GP training pathway. Qualitative data was collected using a combination of focus groups and semistructured interviews. An initial focus group gathered codes and concepts. A topic guide generated from the initial focus group informed six semistructured interviews. A final focus group was used for validation purposes. Data were analysed using the constructivist grounded theory approach. Concurrent observational data were also collected from military and civilian courses pertinent to the research topic. Focus groups (n=2, total participants=14) and semistructured interviews (n=6) suggest that military GPs and trainees feel their level of trauma and acute care training generally diminishes over time, with significant interservice variation, and is of generally a lower level than desired. Qualified GPs suggest that maintaining clinical currency in prehospital emergency care (PHEC) for short-notice deployments is difficult. Modification to the current military GP training programme and easier access to training courses are suggested as potential solutions to the perceived shortfall in training in these areas. Prehospital care and care of the acutely unwell patient remain an area of significant anxiety within military primary care doctors. While most military GPs may not want or choose to spend much of their time exclusively managing trauma and acute care, it is accepted that there is a professional requirement to provide this level of care on a frequent basis. The study suggests that there is an appetite for a higher level of training, both within the military GP specialist training pathway and postqualification. Suggested solutions to this challenge include (1) modification of the current military general practice specialty trainee residential course and (2) modification of military GPs' terms of reference to include PHEC experience during the working week.
The Department of Communication and Applied Behavioural Science is one of the three departments in the academic faculty at the Royal Military Academy Sandhurst. The aim of the Department is to equip officer cadets with the skills, knowledge and personal qualities in order for them to develop their own potential, as both individuals and leaders in the British Army. The members of the Department have a range of backgrounds, with most having served in various capacities across UK Defence, both in uniformed and/or civilian crown servant contexts. Several members of the faculty are qualified psychologists, while others have related academic and professional backgrounds. The academic and applied discipline of psychology is the fundamental thread that runs through the various courses and projects delivered by the Department. This paper provides a brief overview of the activities undertaken by the Department, with a specific focus on the psychology components of the academic and applied activities. Although mainly serving in academic teaching roles, this paper illustrates the work of the psychologists outside the classroom, such as via field exercises and deployments overseas. It also touches on the importance of the outreach undertaken by the psychologists in the Department, which supports their ongoing research.
The long-standing debate on medical complicity in torture has overlooked the complicity of cognitive scientists-psychologists, psychiatrists and neuroscientists-in the practice of torture as a distinct phenomenon. In this paper, we identify the risk of the re-emergence of torture as a practice in the USA, and the complicity of cognitive scientists in these practices. We review arguments for physician complicity in torture. We argue that these defences fail to defend the complicity of cognitive scientists. We address objections to our account, and then provide recommendations for professional associations in resisting complicity in torture. Arguments for cognitive scientist complicity in torture fail when those actions stem from the same reasons as physician complicity. Cognitive scientist involvement in the torture programme has, from the outset, been focused on the outcomes of interrogation rather than supportive care. Any possibility of a therapeutic relationship between cognitive therapists and detainees is fatally undermined by therapists' complicity with torture. Professional associations ought to strengthen their commitment to refraining from engaging in any aspect of torture. They should also move to protect whistle-blowers against torture programmes who are members of their association. If the political institutions that are supposed to prevent the practice of torture are not strengthened, cognitive scientists should take collective action to compel intelligence agencies to refrain from torture.
The extent of the French forces' territory in the Sahel band generates long medical evacuations. In case of many victims, to respect the golden hour rule, first-line sorting is essential. Through simulation situations, the aim of our study was to assess whether the use of ultrasound was useful to military doctors. In combat-like exercise conditions, we provided trainees with a pocket-size ultrasound. Every patient for whom the trainees chose to perform ultrasound in role 1 was included. An extended focused assessment with sonography for trauma (E-FAST) was performed with six basic sonographic views. We evaluated whether these reference views were obtained or not. Once obtained by the trainees, pathological views corresponding to the scenario were shown to assess whether the trainees modified their therapeutic management strategy and their priorities. 168 patients were treated by 15 different trainee doctors. Of these 168 patients, ultrasound (E-FAST or point-of-care ultrasound) was performed on 44 (26%) of them. In 51% (n=20/39) of the situations, the practitioners considered that the realisation of ultrasound had a significant impact in terms of therapeutic and evacuation priorities. More specifically, it changed therapeutic decisions in 67% of time (n=26/39) and evacuation priorities in 72% of time (n=28/39). This original work showed that ultrasound on the battlefield was possible and useful. To confirm these results, ultrasound needs to be democratised and assessed in a real operational environment.
Moral theory should be practically useful, but without oversight from the philosophical community, the practical application of ethics by other institutions such as the military may drift into forms that are not theoretically robust. Ethical approaches that drift in this way run the risk of becoming 'cargo cults': simulations that will never properly fulfil their intended purpose. The four quadrant approach, a systematic method of ethical analysis that applies moral principles to clinical cases, has gained popularity in the last 10 years in a variety of medical contexts, especially the military. This paper considers whether the four quadrant approach is a cargo cult or whether it has theoretical value, with particular reference to the more popular four principles approach. This analysis concludes that the four quadrant approach has theoretical advantages over the four principles approach, if used in the right way (namely, with all four quadrants being used). The principal advantage is that the four quadrant approach leaves more room for clinical judgement, and thus avoids the charge of being too algorithmic, which has been levelled at the four principles approach. I suggest that it is the fourth quadrant, which invites the user to consider wider, contextual features of the case, which gives the approach this key advantage. Finally, I make a more general proposal that theoretical ethicists should work closely with those practitioners who apply ethics in the world, and I call for a symbiotic relationship between these two camps.
This paper considers the manifestation and treatment of psychological trauma in the military. The article describes how military psychologists conceptualise psychological trauma within the culture of the Armed Forces (AF), which is reflected in the process of acquiring what has been referred to as cultural competency. Psychologists in this context acquire an understanding of the manner in which the psychological and organisational systems and culture of the military affect the presentation of psychological trauma, including post-traumatic stress disorder (PTSD). The paper outlines core psychological features of military life, including some of the ways in which the AF functions effectively as an adaptable fighting force. This highlights, for example, the potential for stigma within and between military personnel who experience mental health difficulties. The article proceeds to examine aspects of help-seeking in military mental healthcare, how symptoms can present at different stages in a deployment process, and the consequences that such problems can cause for military conduct and performance. Psychological care in the military is structured within an occupational mental health ethos, in which psychologists fulfil a range of clinical, organisational and leadership roles. These dynamics are explored with examples of care pathways and clarity on evidence-based interventions for trauma and PTSD in those experiencing military-related psychological injuries. Two vignettes are then offered to illustrate how some of these interventions can be used psychotherapeutically in addressing symptoms pertaining to hyperarousal, hypervigilance, guilt and shame.
Despite all local authorities in England signing up to the Armed Forces Covenant, only a small proportion of Joint Strategic Needs Assessments (JSNAs) include detailed consideration of the health of the local ex-military population. This article supports improvements to JSNAs by systematically reviewing published research for evidence of differences in health between the ex-military population and the general public. Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology for qualitative synthesis of mixed study designs. SCOPUS, PubMed and Google Scholar were searched for published research on health outcomes among UK ex-military populations. All study designs were included. 43 studies met the inclusion criteria. Rates of mental illness and hearing loss are higher among ex-military populations compared with the general public, while rates of cancer among ex-military personnel born after 1960 are lower. Despite high rates of hazardous drinking among serving personnel, rates of alcohol-related harm among ex-military populations are no higher than the general public. There is a subpopulation at increased risk of a range of adverse outcomes. This group is variously identified as younger, male, less educated, more likely to have served in a combat role and/or left service early. This review found evidence of areas of increased and reduced disease burden among ex-military populations. More detailed information on the make-up of the local ex-service population would support more meaningful needs assessments. The Ministry of Defence and local authorities and service providers should work together to support early identification and targeted support for those at the highest risk of adverse outcomes.
This paper describes the first ever analysis of health data to report influenza vaccine uptake and the effectiveness of the vaccine in preventing general practice presentations for influenza-like illness (ILI) in the UK Armed Forces (UK AF). This was undertaken during the 2017-2018 influenza season. Clinical Read codes for ILI and influenza vaccinations were used to generate reports for the period from September 2017 to April 2018. Using a methodology adapted from Public Health England's (PHE) in hours syndromic surveillance, the ILI rate for the UK AF was calculated. Subsequent analysis explored vaccination uptake in target groups and compared the relative risk (RR) of ILI in vaccinated versus unvaccinated Service Personnel (SP). 4234 SPs had a record of ILI between September 2017 and April 2018, with a peak rate of 216 cases per 100 000 PAR. The absolute risk reduction for reporting ILI in vaccinated versus unvaccinated SP was 0.4% (p=0.0031), and the RR was statistically significant at 15% (95% CI 5% to 23 %) lower than in the non-vaccinated PAR. The number needed to vaccinate (NNV) to prevent one presentation of ILI was 241 (95% CI 145 to 714). The 8153 vaccinations recorded for the untrained strength equate to approximately 38% of overall training throughput and 65% of all Army SP recorded as being in phase 1 training at some point during this period. The relative risk reduction (RRR) for vaccinated personnel was modest and lower than reported elsewhere, but closely compares with ILI rates included in a 2018 Cochrane review. The small RRR and large NNV do not support widening the population of UK AF eligible to receive influenza vaccine. Regimental Medical Officers (RMOs) seeking advice on whether to vaccinate other groups of SP should be aware that this approach offers questionable clinical benefit. The ILI surveillance methodology used in this work could be adapted for syndromic surveillance of other infectious diseases.
Psychologists first became prominent within the Armed Forces largely as a result of their contributions to military systems, operations and personnel during the First and Second World Wars. In the early years of the 20th century, as psychology was becoming a profession in its own right, its association with the military arose within the emerging concept of 'shell shock' during World War I and supporting selection activities in World War II. There are approximately 25 occupational psychologists currently employed within the Ministry of Defence (MoD), operating across all branches of the MoD, within the department of the Chief of Defence Personnel, the UK Defence Academy and a small number at the Defence Science and Technology Laboratory. The aim of this paper is to discuss the history and current application of occupational psychology within the UK MoD.
UK Ministry of Defence (MOD) policy and strategy recommend the use of a 'Defence MODified' version of the Health and Safety Executive Management Standards Indicator Tool to help managers identify risks of work-related stress among Defence personnel. The Defence MODified Tool ('Stress Indicator Survey') asks personnel to rate their perceptions of eight working conditions known to be significantly associated with work-related stress. MOD psychologists are developing a Defence norm group against which future survey scores can be compared. This article describes the use of the Stress Indicator Survey in MOD and gives an overview of findings from 2016 to 2018. MOD psychologists conducted 27 Stress Indicator Surveys in 2016-2018. Data were collated from 6227 personnel for the Defence norm group and comparisons were conducted between Service personnel and MOD civil servants, and between Services (Royal Navy/Royal Marines (RN/RM), Army and Royal Air Force (RAF)). Service personnel had significantly more favourable perceptions than MOD civil servants of most working conditions. The RN/RM had significantly more favourable perceptions than either the Army or the RAF of all working conditions. These findings indicate differential risks of work-related stress in different groups of personnel. Possible explanations for the observed differences in risk of work-related stress are discussed, including the nature of military life and planned changes to Defence civilian headcount. Examples of managerial actions to improve working conditions based on individual survey findings are given.
Using a major ethics crisis as a methodological approach to study secret science environments, part II examines the origins and organisation of the Applied Biology Committee (ABC), the first independent research ethics committee (REC) at Porton Down, Britain's biological and chemical warfare establishment since the First World War. Although working in great secrecy, the UK military, and Porton in particular, did not operate in a social, political and legal vacuum. Paradigm shifts in civilian medical ethics, or public controversy about atomic, chemical and biological weapons, could thus influence Porton's self-perception and the conduct of its research. The paper argues that the creation of the first REC at Porton in 1965, that is, the ABC, as the ' father confessor ' inside the UK's military research establishment reflected a broader paradigm shift in the field of human research ethics in the mid-1960s.
The Defence Clinical Psychology Service (DCPS) is the professional clinical psychology service and community of clinical psychology practice within UK Ministry of Defence (MoD). The DCPS provides professional clinical care, consultation and research in support of the UK Armed Forces. Regulated by the Health and Care Professions Council, DCPS psychologists are employed as Crown (Civil) Servants within the MoD. Serving as assets of Joint Forces Command within the Defence Primary Healthcare organisation, the professional leadership for such personnel is provided by the office of the Defence Consultant Advisor (DCA) for clinical psychology. The following paper offers an overview of the history, service context, training and mission of the DCPS. Areas for future development are also considered.
Military physicians can experience ethical tensions and encounter important dilemmas when acting at the same time as healers, soldiers and humanitarians. In the literature, these are often presented as the result of pressures, real or perceived, from the military institution or role and obligation conflicts that can divert physicians from their primary duty towards their patients. In this article, I present the ethical experiences of 14 Canadian military physicians who participated in operational missions, particularly in Afghanistan. Interestingly, although some dilemmas discussed in the academic literature were raised by Canadian physicians, ethical tensions were less frequent and numerous than what might have been expected. Instead, what emerged were distinctions between the ethical experiences of physicians: generalists experienced more frequent and different ethical challenges than specialists, and these also varied by context, that is, garrison versus on deployment. The main dilemmas during deployment were similar to those encountered by humanitarian physicians and concerned inequalities in the provision of care between coalition soldiers and Afghans (soldiers and civilians), as well as the lack of resources. Surprisingly, participants were evenly divided with regards to how they perceived their professional identity: one group clearly prioritised the medical profession (ie, doctor first and foremost), while the other group identified themselves as military physicians, but without prioritising one profession over the other.
Poor mental health in the perinatal period is associated with a number of adverse outcomes for the individual and the wider family. The unique circumstances in which military spouses/partners live may leave them particularly vulnerable to developing perinatal mental health (PMH) problems. A scoping review was carried out to review the literature pertaining to PMH in military spouses/partners using the methodology outlined by Arksey and O'Malley (2005). Databases searched included EBSCO, Gale Cengage Academic OneFile, ProQuest and SAGE. Thirteen papers fulfilled the inclusion criteria, all from the USA, which looked a PMH or well-being in military spouses. There was a strong focus on spousal deployment as a risk factor for depressive symptoms and psychological stress during the perinatal period. Other risk factors included a lack of social/emotional support and increased family-related stressors. Interventions for pregnant military spouses included those that help them develop internal coping strategies and external social support. US literature suggests that military spouses are particularly at risk of PMH problems during deployment of their serving partner and highlights the protective nature of social support during this time. Further consideration needs to be made to apply the findings to UK military spouses/partners due to differences in the structure and nature of the UK and US military and healthcare models. Further UK research is needed, which would provide military and healthcare providers with an understanding of the needs of this population allowing effective planning and strategies to be commissioned and implemented.
Operation RUMAN was the British government's combined military and humanitarian operations in September 2017 to provide relief to the British Overseas Territories in the Caribbean affected by Hurricane Irma. The Ministry of Defence (MoD), in conjunction with the Department for International Development, produced a tangible effect by the delivery of healthcare and a response to a humanitarian disaster with very little time for planning. The rescue element was accomplished within days but this was followed swiftly by a recovery phase requiring a 'whole force approach', with additional assets from non-governmental organisations and the private sector. The aim of this article is to provide information on the role of the Defence Medical Services on behalf of the MoD, and other departmental organisations in achieving the mission of providing medical and logistical support for these British Overseas Territories.
The 700+ Caribbean islands present a vast area of operations (AO) with challenges providing healthcare to the local population and deployed personnel. Predisaster host nation medical care relied on casevac for basic primary and secondary healthcare, with medivac by air for advanced medical treatment. Disruption to facilities and transport links by Hurricane Irma rendered the native healthcare system on its knees. During Op RUMAN, the Royal Air Force Medical Services (RAFMS) provided expertise in prehospital emergency care and critical care aeromed to enable emergency treatment and access to definitive care for local nationals and our own personnel. The ability to provide independent, safe aeromedical care across a variety of aviation platforms is unique to the RAFMS. The AO did not fit any current doctrine; an adaptable, functional unit concept was adopted to enable care to the walking wounded through to critical care along prolonged timelines.