Very Model of Modern Military Medicine
Thursday, 11 January 2018
Dr Douglas Kennedy, Consultant Oral and Maxillofacial Surgeon, Dundee.
Douglas Kennedy qualified in both dentistry and medicine at the University of Dundee, followed by surgical training in Dundee, Glasgow and South Wales.
He is a Consultant Oral and Maxillofacial Surgeon at Ninewells Hospital, with extensive experience in the full range of Maxillofacial surgery including trauma, salivary gland surgery and surgery for facial skin cancer..
He is a Colonel in the Territorial Army and has served as a Maxillofacial Surgeon in military hospitals in the conflicts in Iraq and Afghanistan.
This talk will discuss some of the principles used for preparing a Field Hospital for deployment and how we ensure that what we deliver will be care of the highest order.
Team building will be discussed as will some of the ways we train to ensure readiness.
Note of Meeting of 11th January 2018
The President welcomed the audience and passed on good wishes from the Council for the year ahead. He commented on the great success of the Heritage Group event in December, again acknowledging Dr Marion White’s major role in its organisation. He announced that Council is looking to appoint a new Buildings Officer now following Dr Foster’s move to Qatar and to find a replacement as Honorary Secretary for Dr McHardy who will demit office at the end of the current session; expressions of interest from members in relation to either role were invited. The President also thanked Professor Maggie Cruickshank for undertaking to represent the Society on the Suttie Users’ Group in place of Dr Foster. The audience was reminded that places are still available for the joint Burns event with the Aberdeen University Medical Society on 26th January. The President also gave details of the developing arrangements for the spring ceilidh to be held at the RNUC on 24th March, where consensus favoured a lower price ticket with guests making their own provisions for buying wine. Finally, members were encouraged to remember the intention to hold the Famous for Five Minutes Charity event on Saturday 12th May with recruitment of acts to proceed shortly.
Attention then turned to the main speaker for the evening, Douglas Kennedy and his talk entitled ‘The Very Model of Modern Military Medicine’. Mr Kennedy told of his ‘regular’ job as Consultant maxillo-facial Surgeon in Dundee, specialising in oncology then went on to tell of his other role as a Colonel and Army Reservist. Having been a medical military reservist for 25 years, he is currently Commanding Officer of 205 Scottish Field Hospital. He explained that a recent embargo on use of clinical slides – that may possibly identify the victims of warfare and their injuries – had limited his use of illustrated anecdotes. He would therefore focus on strategic and operational aspects of preparing for, and when necessary deploying, a military field hospital.
Mr Kennedy began by describing his own origins as a medical reservist, explaining that this had more than a little to do with the traditional model of training in maxillo-facial surgery. He had initially done a dental degree and was earning money as a dental practitioner when his chosen career path meant he had to go back to being an impoverished student working towards a second primary degree, this time as a medic. For a 26 year old who had completed his dental studies, then earned a reasonable living and was now faced with another 5 years at University, the financial lure of becoming a commissioned officer in the Army Medical Reserve was a great attraction. This was to prove an excellent decision for him, far beyond the financial remuneration for he enjoyed the work, learned a great deal and, to this day, feels that the Military invested greatly in developing the professional and life skills of their young officers.
He then said something of the prevailing global concerns of the British Forces at that stage, in the early 1990s. The prevalent threat, over previous decades, of Soviet invasion was receding. Accordingly, the expectations of his predecessors that deployment would involve establishing a field hospital in West Germany to support those repelling a Soviet advance had also faded. There had been minimal involvement of reservists in the troubles in Northern Ireland, or in the Falklands. However, during the first Gulf War in the early 90s, 205 had mobilised a full unit to Riyadh in Saudi Arabia. Small numbers of reservists with various specialised skills were deployed in the Balkan wars. In 2003, however, a sea change in the utilisation of reservists was seen in major deployments in Iraq and later Afghanistan. It was also the case that another reservist unit, 22 Field Hospital, had been deployed to Sierra Leone to help during the Ebola virus crisis; some are currently part of a United Nations mission in South Sudan.
Greater emphasis in recent years on the so-called ‘Whole Force Concept’ has seen a reduction in the perceived barriers between regular and reservist members of the Armed Forces with the latter having grown to a total of some 30k personnel. On this background, Mr Kennedy’s mission, in respect of his reservist function, is to develop and prepare for comprehensive deployed hospital care – whether by taking over an existing medical facility in an appropriate area of the world, or establishing a new, temporary hospital near a region of military conflict. He suggested that an important component of this role was in the selection and preparation of reservists from across the full spectrum of medical, nursing and allied health professionals who could be trained to provide excellent care in potentially austere environments. Recruits to this service would need to be team players, show leadership skills, apply clinical governance standards, display sound clinical skills and work to NHS-equivalent standards in respect of appraisal, disclosure and learning lessons from practice.
Mr Kennedy went on to explain the important differences between so-called ‘enduring’ and ‘contingency’ operations. ‘Enduring’ operations involve the field hospital taking over an existing hospital facility which is therefore in a known location, has an established staff and equipment and a predefined set of current functional capabilities. Recent operations like this have taken place in Camp Bastion in Afghanistan, and in Sierra Leone.
With enduring operations, the layout of the facility to be taken over is already known and therefore medical reservist training, such as occurs in a large warehouse-type building in York, can be more precisely focussed. The inside of the York building was, for example, remodelled to the layout of Camp Bastion so that training allowed personnel to practise in an environment that would already be familiar on deployment. A video produced in conjunction with the Royal College of Nursing was shown which illustrated medical reservist teams training in the York facility. Sound bites from some of the nurses in the video described benefits in terms of confidence, adaptability and professional development resulting from involvement as a medical reservist, and making reference to how this was also of great benefit to their customary, civilian practice and patients. The exercises cover a full range of clinical, and associated administrative, processes and a senior panel of experts are involved throughout in overseeing, coaching and mentoring.
‘Contingency’ operations involve the establishment of a hospital facility in an unestablished medical site. ‘Precision training’, as described above, is not therefore feasible. Contingency operations involve a great deal of military and medical planning to define the scale of the initial and the follow-on facilities with complex inventories developed that provide absolutely everything that may be needed. Such facilities are usually constructed of movable units of variable sizes and a medical complex will require the improvised provision of roads, accommodation, water and drainage, etc.
Illustrative images of a facility set up in Iraq in 2003 showed the complexity of such operations. A further video clip was shown describing the smaller facility set up more recently to support the operations of the Royal Engineers in South Sudan. The clip showed the sequence of emergency bays, operating theatre, intensive care beds and ward area which in this case could be formulated as a ‘220.127.116.11 facility’. Adaptations such as a collapsible operating table, on which the patient is laid on a stretcher, were explained with the consequence that this is only used for lifesaving emergency procedures. The range of realistic facilities will vary with size of facility but will typically include anaesthetic administration, ventilation and HDU-standard monitoring.
A further illustrative operation concerned the Role 3 hospital in Kandahar in 2007, constructed partly of portakabins, surrounded by blast protection outer walls. This facility was unusual in that it had a landing area for helicopter delivery of casualties. (It was explained that such could only ever be the case when there was a strictly enforced no-fly zone for enemy aircraft.) The operating theatre was ‘containerised’ but still used only for life and limb saving surgery. As an aside, the matter of standard issue surgical equipment was mentioned, meaning that a surgeon’s personal preferences and operative idiosyncrasies cannot be catered for! Overall, and as anticipated, more general skills are needed by personnel working in such environments. Units are often constructed with provision to enlarge capacity if necessary. The ready access to a CT scanner, radiographers and a radiologist were hailed as major advantages despite the limited overall facilities available.
Certain aspects of what may be called ‘advanced team working’ were highlighted in response to a major incident being called in such a facility. All of the teams on site would be called in and whatever the mixture of first language and professional skills, all would be working to the same protocols! An additional example of facultative improvisation came with the description of a situation with two general surgeons of whom one would be in charge of theatre at any given time; the other then went round the patients performing abdominal ultrasound examinations to look for any cases of occult intra-abdominal haemorrhage.
The need for adherence to standardised methods and practices – despite the unpredictability of what the next case may be, and what improvisation may be necessary in management - was again alluded to in summarising some of the ‘established principles’. Importance is accorded to prevention - including the appropriate use of body armour, prompt and judicious use of tourniquets (in the use of which all military personnel are trained), so-called ‘damage control’ surgery and resuscitation, early use of blood products, and the appreciation that major haemorrhage regularly requires the promotion of ‘C’ to lead position in the standard ‘ABCDE’ of resuscitation.
Mr Kennedy concluded with some comments on the people who comprise the type of team player needed for medical reservist operations. He said the team members must be able to get along; there can be no ‘prima donnas’, but there must be sound leadership when required. They must be able to interact quickly and constructively in making difficult decisions in difficult circumstances. They must show resilience and endurance, for example, sleeping in overcrowded accommodation before getting up and getting on with the job again.
In closing Mr Kennedy said the military reservists are needed – because in today’s world, one never knows what is coming next.
There followed a lively question and answer session addressing topics including regimental aid posts, the current complement of the Royal Army Medical Corps and the relationship between regular and reservist military medics, the involvement of orthopaedic as well as general surgeons , the need to accommodate civilian casualties - and especially children - in medical facilities in war zones, the possibility of incorporating more of the military’s corporate adherence to standard policy in NHS management, the improbability of the NHS having stand-by capacity like military reservists, the need for appropriate support and debriefing of personnel having to handle appalling casualties, the potential tensions of simultaneous roles as a military officer and a medical practitioner, and the preservation of separate medical contingents within each of the three main military services.
The President gave a vote of thanks and closed the meeting with a reminder of the next meeting where the speaker will be Professor Sir Iain Torrance.