Report on the CIOR/CIOMR

The official opening of the congress in the “Luns” auditorium of the NATO HQ featured two outstanding guest speakers: Mr. Pieter de Crem, Deputy Prime Minister and Minister of Defense of Belgium, and the Supreme Allied Commander Europe (SACEUR) and US Europe Commander (EUCOM), General Philip M. Breedlove.

General Breedlove reminded the audience of the prominent role reservists play in the modern Armies. In particular he mentioned the contribution of the military medical reservists to deployments.

Minister de Crem insisted on the active part played by reservists in today’s armed forces and particularly in the medical field. He reaffirmed the necessity to enhance co-operation in defense matters at all levels between the allies and their partners.  

During the Executive Committee the request of the Committee of Chiefs of Medical Services in NATO (COMEDS) to CIOMR was discussed. COMEDS has asked CIOMR for a report “on the global contribution of the medical reserve in the NATO countries available for medical support in missions”. The Executive Committee turned out to be most willing have such a report produced and to present it to COMEDS. 

The Scientific meeting took place on February 7, in the “Luns” auditorium.

“Stress and burn-out in the military; the personal approach is the next challenge

Colonel MC (R) ret. BEL A  Alexander Van Acker, MD.

The armed forces, in general, generate a lot of “exterior” stress. These are objective stressors on missions: the alien geography and climate, lack of comfort and sleep, insecurity and hostilities, fights and battles. However the main invalidating psychological factor happens to be the subjective “interior” stress. These are the problems, the painful memories and dysfunctional mental strategies an individual joins the unit with. The challenge for the unit is to detect and help those individuals because that would be really preventive! Of course it is a more complicated way but it is worth the investment. It is a fallacy to think that a certain level of stress is good. A stress reaction is a physical adaptation reaction and there is no life without stress, but stress can cumulate and lead to a burn out. Military thinking about stress carries four pitfalls: selection on external features, the idea that “stress is good for you”, the “Rambo” syndrome and general morale boosters meant to take stress away. Anti-stress measures ought to be general and specific. General measures are realistic training at home which helps to develop routines to avoid shock, an experienced staff and common activities to keep the unit aware of its military nature and give a sense of unity. Specific measures are continuous selection based on stress detection and prevention.                                                                                     

As stress is mainly an individual problem it is more realistic to asses and select people according to their actual stress state. This can be done at buddy level, by non-commissioned-officers (NCOs) and petty officers, and at command level. Continuous stress prevention can be done on individual and unit level or at individual level by training people in individual stress prevention. After learning to identify one’s stress level, different relaxation techniques are possible, like sports and gymnastics. At unit level it has to be explained what is going to happen, rituals have to be used, mind and body have to be occupied in a positive way and finally: “Rest & Recreation” as the old classic. 

Concluding: a lot of teaching has to be done: soldiers have to recognize stress in themselves and in those around them, the staff has to keep an eye on morale, food and ammunition, personnel has to learn individual awareness of stress and has to develop ways of coping with it.

“UK Military Medical Reserve Contribution to Cross-Border Emergency and Humanitarian Planning between Northern Ireland and the Irish Republic, 2006-2013”                                                                                                                                                     

Lt. Col. MC (R) GBR A Alan Moore, MBE, TD, DL, BSc(Hons), FRICS, RAMC(V).

For this lecture, some knowledge about the Irish history is worthwhile because “Cross-Border” activities, particularly in this region, could be rather “burdened”. The origin of this collaboration dates back to 1998 in the aftermath of the tragedy that became known as the “Omagh Bombing”. This explosion, caused by a car-bomb through the Provisional Irish Republican Army, killed 29 people and wounded 220. Emergency medical services became close to being overwhelmed and recognized that medical response between both jurisdictions could have been more effective.                                                    

The value of the Military Medical Reserves is demonstrated by their contribution to emergency and humanitarian training but also by their capacity to exploit their civilian roles and influence to further the aims of the Medical Reserves. Especially in these cross-border activities the Military Medical Reserves have the potential to contribute to Defense Diplomacy.                                                             

In 2006 it was agreed to sponsor joint Mass Incident Medical Management Systems (MIMMS) training for the two ambulance services. The UK Military Medical Reserve was seen as the most appropriate organization to deliver this specialist training. The success of the MIMMS course prompted opportunities to exercise medical response skills on a cross border basis. The proposal carried some challenges for the UK and Irish militaries but the exercise was viewed as being politically acceptable. Therefore the exercise was called “Medical Bridge” and the response included ground and air evacuation to a number of hospitals. Both “Medical Bridge” and the MIMMS course were repeated on two further occasions. The success of this co-operation led to an agreement to undertake a Battlefield Advanced Trauma Life Support (BATLS) course in the Irish Republic on a cross border basis. As the end of military operations in Afghanistan has prompted focus on using medical reservists in Disaster Response and Humanitarian Relief operations, it was desired to extend the UK/Irish collaboration through a cross border Disaster Assistance Course (DAC).

It was concluded that there is a value of Military Medical Reserves in contributing to emergency and humanitarian training and support on a cross border basis. As the Medical Bridge program allowed opportunities for a greater dialogue between the militaries of North and South Ireland, it was demonstrated that there is a potential in the Military Medical Reserves to contribute to Defense Diplomacy as well.

“Disaster Victim Identification (DVI) in Mass ­Casualty ­Situations”                                                                                                             

 Surg. Cdr. MC (R) DNK N Peter Knudsen, Royal Danish Naval Reserve

When the rescue work is over, the main preoccupation will be the identification of the deceased (DVI). To give an example: after the Tsunami in Thailand rescuers were confronted with 1200 corpses, wrapped in plastic, at an environmental temperature of 28°C!                                                                                

DVI is based on the fact that a given body or body parts are part of a given person. This work is led by the police, but the forensic pathologist has a key role working with fellow experts such as forensic dentists, -geneticists and -anthropologists. The main stumbling block for this kind of work is the logistics, the co-operation with the local authorities and locating ante-mortem information. Obstructive to DVI are lawyers, the press and the weather. The victims are the deceased ànd their relatives. DVI proceeds according to a fixed pattern: autopsy, comparison of fingerprints, dental identification and DNA sampling. Though a military medical background is not a necessity, it can be very useful when dealing with those situations. Officers are used to work with hierarchical organizations and medical officers know the intricacies of the medical world everybody is dependent upon for a successful identification. Staffing for a DVI operation is a problem and the military, including the military reserves, are obvious sources. Among the “do’s and the don’ts” are that you have to make sure that they want you and to know what to do when something goes wrong! Among the lessons learned are that staffing must be sufficient. When confronted with circumstances beyond one’s control, it is better to deliver 8 hours of good work than 12 hours of bad work. After two weeks a DVI team has to be relieved.   

“Canadian Armed Forces Territorial Battalion Groups. Operation LENTUS”                                                                                     

Major MC (R) CAN A William Patton, MD, 41 Canadian Brigade Group Surgeon, RCAMC Reserve, CAN.

Operation LENTUS 2013 was a supportive operation in connection with the flooding in Southern Alberta, CAN. The army took part in this operation with 2300 soldiers, including 400 reservists from the Primary Reserve List. Approximately half of the Canadian army consists of reservists and they are tasked with home defence.  With the exception of the arctic area, Canada has 10 battalions to co-ordinate territorial support. For the arctic area there is the Arctic Response Company Group (ARCG) and this group is fully involved in a region bigger than the whole of Europe. Reservists are deployed for several natural disasters like the Swiss air crash, the Quebec ice storm, the Pine Lake tornado, the British Colombia fires, the Northern Ontario fires, the Manitoba floods, the Resolute Bay crash and the Southern Alberta flooding (Calgary, High River and Canmore). By the way, “High River” happens to be the native Indian name for a river that is regularly overflowing! The means available for these battalions are air evacuation, reconnaissance and the introduction of a command structure. What they have learned from these interventions is that battalions need a flexible structure, the relationships need to be maintained, local knowledge need to be used, the material has to be properly serviced and operational readiness needs to be maintained by training.   

“Rapid deployment of a surgical unit in natural ­disaster zones in Haiti, January 2010”                                                                                        

Lt. Col. MC FRA A Philippe May, MD, PhD, Armed Forces Biomedical Research Institute (IRBA), BP73, Bretigny-sur-Orge, Cedex, FRA

The massive earthquake of January 12, 2010, struck the Caribbean nation of Haiti. The French President decided to send rescue and medical teams from the Civil Defense Military Unit. Already on January 18, a field hospital, called ESCRIM (Fast Civil Defense Medical Unit) was fully operational. This unit consisted of one advanced medical post, a hospitalization sector, a surgery room and a living zone. Initially, the hospital activity used 140 persons including one surgeon and one anesthetist to allow surgical activity to happen. One week later an airborne surgical unit reinforced this set up. In one month 2300 consultations, 1554 hospitalizations, 216 surgeries, 1 birth and 43 airborne transfers were performed. 8 deaths were to be deplored. In fact, this was a tremendous humani­tarian mission with a maximum intensity during the first week. Other activities of this unit were the production and ­distribution of clean water and sanitation. Four mobile water purifying installations were deployed for this reason. Also food logistics and telecommunication had to be organized and emergency shelters were built. Chaos management included emotional management and handling of the media, who were omnipresent. The French rescue and medical teams demonstrated their ability to rapidly deploy into disaster areas and to develop good relationships with the population in order to optimize medical treatment and psychological support. 

“Panama Medical Readiness Training Exercise (MEDRETTE)”                                                                                                                               

Major (R) USA AF Marissa Marquez, NC, United States Air Force Reserves.

MEDRETTE means Medical Readiness Training Exercise and is part of the International Health Specialist (IHS) mission. The Air Force’s IHS program focuses on building medical partnerships with other countries in peacetime and before they need assistance. HIS members are educated in the language, culture and politics of their specific areas of responsibility. The HIS teams support theatre engagement plans, create partnerships with medical colleagues from nations within their region, facilitate military-to-military and military-to-civilian interactions and support medical planning operations plus deployment. The main focus of IHS is to promote the “Total Force” concept and therefore training plus exercises are identified that will combine Air National Guard Reserve and active duty efforts.                                                                                                                                            

The Panama MEDRETTE operation was to provide medical service to Panamanian residents who have little access to medical care and to allow Airmen the opportunity to use their skills in an environment outside the military. In August 2012, nine days of civic assistance projects were performed that provided medical, dental and optometry care to communities most in need. The Panamanian Ministry of Health advertised to residents that there would be medical services available and after that, word of mouth helped deliver the message to residents in extremely rural areas. As a result over 9.400 local citizens received medical, optometry and dental care, which is quite a lot in nine days! Also health education was given about women’s health, nutrition and infection control. Immunizations were performed and professional relationships with Panamanian Ministry Health providers were established.                                                                                                                            

The “lessons learned” were that pre-planning is important: the needs of the population to serve ought to be identified, training and medical needs planned and a co-ordination established between the Host nation and the US embassy. Basic needs of the team have to be taken care of as well like: hydration, repellants and taking breaks. Flexibility and team building are important and a daily debrief plus progress report ought to be established. Cultural awareness and communication should be encouraged by research information regarding the country’s “Guide for communication and culture awareness”.  

“Introduction to Post Traumatic Stress – A Family affair” Brigadier General (R) ret. USA AF Gerald Griffin, 

MD, Pharm.D., FACFM.

Post Traumatic Stress (PTS) is introduced from a “patient & family” perspective. PTS is a long term condition that may be recurrent or simply go away over time. Speaker does not look upon PTS as being a disease but as a condition. There are even indications that PTS leads to minor brain damage indicating an anatomical substrate for the condition. PTS may be worsened by lack of treatment. On the other hand treatment may not be available, simply ignored or refused.                                                             

Families can also be victims of PTS and need treatment along with the soldiers and veterans.  For example: in Iraq, speaker was on the telephone with his wife when a mortar attack erupted. He ended the conversation abruptly shouting: “we are under attack, I have to rush to the bunker”. What would you think of the effect of this on his wife, in far away America?                                                                                                     The fact that PTS carries a divorce percentage of 80% ought to be food for the brain! Resilience training is supposed to be preventive and has priority in the US.   

“ISAF support to Health Care Services in Afghanistan”                                                                                                                                             Wing Commander MC (R) GBR AF Colin Mathieson, AE, FCMI, RAuxAF.

The International Security and Assistance Force (ISAF) regards the positioning of military NATO units in Afghanistan. The speaker was deployed to Afghanistan for seven months in the role of Medical Liaison Officer within the Helmand Provincial Reconstruction Team (PRT). A PRT is an international, joint ­­civil-military multi-agency organization working to support the ­stabilization, transition and sustainability of the Islamic Republic of Afghanistan. Actual at the moment is the situation after the reduction or withdrawal of NATO military forces. The Medical Liaison Officer has the responsibility to visit each of the districts within Helmand, to assess existing Health ­facilities’ capability and infrastructure. Based on this ­assessment, he has to offer key recommendations for future development of healthcare provision and for the establishment of sustainable community education programs. The role requires extensive Key Leader engagement between Afghan Ministries, District Councils, Healthcare Professionals, Non Government Organizations (NGO’s) and both US and UK military and civilian District Stabilization Teams to ensure plans are agreed, supported and implemented. As a result of his achievements during this tour the speaker was nominated for Outstanding Reservist of the Year during The National Military Awards 2011. 

“Department of Defense/Food and Drug Administration Shelf Life Extension Program (SLEP)”                                                                               Commander MC USA N Brandon Hardin, PharmD, MSC. 

As program manager the speaker presented a teleconference. SLEP is a key component of the Medical Readiness Strategic Plan (MRSP) and is subordinate to the Defense Health Agency (DHA). It is developed to defer drug replacement costs for date sensitive prepositioned stocks by extending their useful life. On the other hand, SLEP assures that only safe and effective drugs are provided to personnel during war or other contingencies. Every item has to be approved by the Food and Drug Administration (FDA) and test protocols have to be submitted. Selected drug products are tested using the U.S. Pharmacopeia or New Drug Application methodology to determine if their shelf life can be extended past the labeled expiration date. So far no biological e.g. vaccines or medical devices are tested. SLEP assures that only safe and effective drugs are kept in ready reserve.                          

The results are promising because to date SLEP has deferred $ 2.980B in pharmaceutical replacement costs for the U.S. Government as a whole. Historically, DoD deferred $ 140 for every dollar spent on SLEP testing!                                                                                                                                                       

The Strategic National Stockpile (SNS) is a key component of preparation to defend against natural or manmade events (e.g., terrorist attack, flu outbreak, and earthquake). For every country there is a need for SLEP in order to reduce the expense of maintaining an SNS. However creating a joint SNS for the EU is facing fiscal and political difficulties.                                                                                                   

The Israeli experience is brought forward as an example for SLEP. Ciprofloxacin is a component of the Israeli National Stockpile. By extending the shelf life from 3 to 5 years roughly $ 17M were deferred. Concluding it was stated that purchasing medical supplies against an unknown agent or event can be expensive and therefore difficult to justify. A well regulated SLEP can lead to significant cost reductions while maintaining the desired state of readiness.              

“The benefits of UK Reserve Medical Services to the National Health Service”                                                                      

Wing Commander MC (R) GBR AF Marie Noelle Orzell, OBE, 4626 AES, Qvrm RAuxAF

The Speaker is assigned to the no. 4626 (Aero Medical Evacuation) Squadron that takes care of military medical evacuation from the battlefield in Afghanistan to the UK, delivering a unique application of clinical knowledge and leadership at 30.000 feet.                                                                                       

The UK has recently brought out a white paper about the Future Reserves for 2020, a committee has reviewed the Defense Medical Services and all this has led to the idea that the numbers of regulars have to be reduced and those of reservists have to be increased. However, the National Health Service (NHS) is having problems to supply those reservists. The economic climate has worsened and savings of £ 20 billion are required. This has led to an increase in performance targets in the Emergency Departments (ED) and in the elective treatment of care. Finally there happens to be a shortage in key medical and nursing specialties for the ED. In order to provide the NHS with arguments in favor of a further civil-military co-operation, the benefits of medical reserves are outlined. One main benefit is a unique clinical training provided by the military and directly beneficial to the NHS. The military medical reservists are trained in MIMMS, BATLS, aero medical evacuation, and medical operations, they receive specialist courses plus training dependent on their role. This leads to transferable skills like communication, decision making, clinical subject matter expertise, autonomy in the air, flexibility, advanced skills and scope of practice, finally leading to continued professional development. It is figured out that on average a GBR reservist receives the equivalent of £ 8.327 worth of military training every year, also all to the benefit of the NHS!

“Extended storage of blood platelets in a phase of hibernation induced by a chemical bioregulator”      

Commander (R) NLD N Stef Stienstra.

As the use of “frozen packed cells” has extended the tenableness of erythrocytes, the search is now for shelf life extension of blood components. As freezing is dangerous for living cells, because of the formation of tissue damaging ice crystals, researchers look for “artificial hibernation”. The idea behind it is that following cooling down, normal functions are restored after rewarming. During hibernation mammalian tissue and blood cells ought to be protected against oxidative stress damage as the metabolism changes towards minimal need for oxygen and nutrition.                                                                                                         

For blood platelets a compound is used for prolonged storage of platelets at 4°C. and this compound is called a bioregulator. The compound has to be tested for toxicity beforehand and to be washed away afterwards. The research is still in an experimental stage but the idea is to extend the life time of platelets up to 80%.                                                                                                                               

Platelet activation is the process in which they start their coagulation process. Remarkable is the fact that in non-hibernating mammals platelets suffer activation on cooling down under 12°C, which is irreversible and leading to storage lesion. Hibernating mammals do not suffer cold induced activation of platelets and these platelets are functional after rewarming. As man belongs to the species of non-hibernating mammals, this finding seems a bit controversial with this presentation.  

“Health Services Support to the Arctic Response Company Groups (ARCG)”                                                                                                                                           

Captain (R) CAN A Renee Gordon, 23 Field Ambulance, Canadian Health Services Primary Reserves. 

In response to the growing strategic importance of Canada’s Arctic region, the Canada First Defence Strategy mandates a significant Canadian Forces presence in the Arctic. The ARCG is the Canadian Armed Forces approach to land based Arctic Response capabilities and is assigned to the Canadian Rangers. The Rangers are deployed for 30 days in the arctic and ought to be able to support themselves for at least 21 days. The ARCG concept focuses on domestic and expeditionary operations and has been tasked to the Canadian Army Reserve for force generation and implementation. Northern domestic emergencies included air plane crashes, flooding and forest fires. In this presentation the structural concept of Health Services Support to the ARCG was outlined highlighting five key operational considerations specific to the provision of adequate medical support to arctic operations by the Canadian Health Services Primary Reserves. These considerations include: force generation of personnel, appropriate training, adequate equipment and supplies, the expanse of time and space with limited infrastructure, furthermore, types of injuries sustained and planning for casualty management together with the chain of evacuation during arctic operations. It should not be forgotten that Canada’s Arctic region is bigger than the whole of Europe and that Combat Casualty Care at minus 70°C certainly is a challenge! The old Lee Enfield SMLE No4 MkI is used for personal protection (polar bears!) because of its reliability at low temperatures.

The congress ended on Saturday February 8, 2014.

The Summer Congress CIOR/CIOMR/NRFC 2014 will take place from August 4 to 8, in Fulda, DEU. The theme for the Scientific Meetings will be: “Long term effects of deployment to reservists: rehabilitation, mental problems, resilience training, provider fatigue, burn out and suicide”. n

Editor’s Special Remark:

For many years, Prof. Dr. Olaf Penn has provided MCIF with concise and highly informative reports not only on CIOR/CIRMR meetings and congresses but also on other international military medical conventions. His precise yet appealing style of writing and his competence in balancing essential detail and required brevity have inspired not only the editorial staff but also numerous readers of MCIF. I personally want to thank Prof. Penn for his many precious contributions to this publication.

Dr. Buettner, Editor-in-Chief

Date: 02/24/2014

Source: MCIF 1-14