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New Developments
“Head and Neck Trauma, Prevention, Treatment and Long Term Care”
The Interallied Confederation of Medical Reserve
Officers (CIOMR) organizes yearly a summer congress together with the
Interallied Confederation of Reserve Officers (CIOR) and the National
Reserve Forces Committee (NRFC).
The official opening took place in the Tivoli Congress Centre of
Copenhagen and was performed by the active reserve officer HRH Prince
Joachim of Denmark.Thirteen countries participated in this CIOMR summer congress and the program consisted of a scientific program provided by the host country, a scientific program taken care of by the Scientific Committee, a meeting of the Executive Committee and a transfer of the Presidency CIOMR from Germany to The Netherlands, for the period from 2012 to 2014.
The “Combat Casualty Care Competition (3C-Competition)” is part of the Military Competition (MILCOM) and took place on Tuesday July, 31, 2012, in the barracks of the “Royal Lifeguards” in Høvelte. This competition is organized by the “Operational Medicine Committee (OMC )” of CIOMR and (para)medics train and judge the participating military reservists. The scenario consisted this time of a group of six wounded soldiers after an explosion. Two of these were T1 and four were T3. The meaning of this 3C Competition is to judge the competitors on security and safety, medical care and evacuation.
The scientific program
The scientific meetings were held in the Tivoli Congress Centre and were accredited by the American organization for “Continuous Medical Education (CME)” for 12 points.
The scientific program from the host country was presented on Wednesday, August 1, and carried the theme: “Human aspects of Danish International Military Missions - the sick, the sad, the living and the dead”.
This program was opened by the Surgeon General of Denmark, major general E. Darre, MD, who lectured about “Danish Armed Forces in an active foreign policy – medical aspects”. The Danish Armed Forces have a personnel structure of 25.000 people and has as mission statement “By being able to fight and win, Danish service men and women promote peaceful and democratic development in the world and a secure society in Denmark”. For the Medical Corps a new approach in physical training is applied that is focused on core stability and strength. A military physical training team is enlisted to coach the Danish Medical Corps to train as they fight.
The overall medical responsibility for the soldiers is provided by the National Health System and there exists an official support organization for veterans. In Afghanistan the Danish Armed Forces have lost 36 soldiers and 205 were wounded. In 18 soldiers 25 amputations were performed with the objective of redeployment. Fortunately, with only 41 cases, the percentage for suicide is low in Denmark.
Major F. Warburg, MD, Copenhagen University Hospital “Rigshospitalet”, DNK, was responsible for the “University hospital treatment of the wounded soldiers”. The “Rigshospitalet” is assigned to the treatment of wounded soldiers and received 63 casualties in the period from 2006 till 2010. The causes of the injury were gunshots, rocket propelled grenades (RPG) and mines. The treatment included Intensive Care Treatment (ICU), debridement, vascular grafts, simple osteosynthesis and hyperbaric oxygen. Hyperbaric oxygen was applied to fight infection and to improve healing of tissues. A liberal use of morphia was noted. With regards to prostheses, they work hard on myo-electrical ones. A remarkable development is the application of “Pilates” training for revalidation. The Royal Danish Ballet has spontaneously offered this kind of training for the invalid soldiers and, after 1200 hours, with good results.
Surgeon Commander (R) P. Knudsen, MD, Defense Health Service Institute of Forensic Medicine, Odense, DNK, lectured about “Military autopsies – lessons learned”. Autopsies are compulsory in Denmark for military personnel and are meant to evaluate the first aid, the role 1 medical first aid, the field hospital treatment (role 2 and 3), the protective equipment and to be able to brief the relatives. 52 soldiers, sailors and airmen died during international operations from 2002 to 2010. 39 were combat injuries, including 3 from friendly fire, 10 were accidents, one was suicide and there were two deaths from natural causes. The main cause of injury was explosions and the main causes of death were multi-traumas, exsanguinations and head injuries. Medical treatment and protective equipment were found to be sufficient.
M. Bertelsen, MD, PhD, Danish Veteran Centre, DNK, investigated the “Psychological health in a group of 610 Danish soldiers deployed to Afghanistan – a prospective study”. Effective planning and tailoring of treatment of Post Traumatic Stress Disorder (PTSD) and other stress related disorders depend on large scale prospective studies on long term incidence and development of these disorders. This study investigated the development of PTSD symptoms and outlined to what degree delayed onset of PTSD can be expected up to 2,5 years after exposure. 610 Danish soldiers deployed in Helmand, AFG, from February to August 2009 were included in the study. The study was carried out in six waves and soldiers had been assessed before, during and four times after homecoming. Primary outcomes were PTSD (22,5 %), depression and anxiety (82 %) and substance abuse (11 %). The most vulnerable group proved to be young, poorly educated people, with violence in their upbringing.
C. Olsen, Physiotherapist, R. Oland, Sports Manager and J. Manuel, Staff Sergeant and war casualty, had a combined presentation about “Rehabilitation through physiotherapy and sports – the struggle back”. The physiotherapy for wounded soldiers with its organizations and actions was explained as was the introduction to sports and paralympic disciplines with its difficulties, benefits and challenges. Finally the soldiers view was emphasized by the way from wounded in Afghanistan to living with a disability in Denmark.
“Head and neck trauma, prevention, treatment and long term care”.
Squadron leader E. Larkin, MD, 612 Squadron, Royal (Auxiliary) Air Force, University of Edinburgh, School of Medicine, Royal College of Defense Medicine, Birmingham, GBR, lectured on “Mortality and Morbidity of Combat Neck Injury”. The neck is vulnerable for accerelation/deceleration trauma and mortality of an explosive wound to the neck was 41 %. The vasculature is very vulnerable (78 %) while esophagus and trachea are less offended. 11 % of battle injured from UK service personnel incurred neck wounds and this relatively high incidence was not shared by US soldiers. It was considered that inadequate and poorly designed neck protection and reluctance to wear it, was responsible. It was concluded that there existed an urgent need for operational requirement to redesign neck protection.
Colonel K. Biesold, MD, Military Hospital Hamburg, DEU, was putting the question if “Mild Traumatic Brain Injury (mTBI) is the Shell shock of the 21th Century? Concussion or Somatoform Stress Reaction?”. The change of terminology for a general affection of the nervous system following traumatic effects over the years leaves the same question intact: is it easier to accept the diagnosis to suffer from brain disease than from stress reaction? The unexplained somatoform symptoms as headache, nausea, vomiting, dizziness/balance problems, fatigue, insomnia/sleep disturbances, drowsiness, sensitivity to light/noise, blurred vision, disturbances in remembering and/or concentrating on something can be seen as stress reaction but also as being symptomatic for traumatic brain injuries.
P. Blondeel, MD, PhD, dept. of Plastic, Reconstructive and Aesthetic Surgery, University Hospital Gent, BEL, emphasized “The importance of 3D-modeling in the pre-operative planning of complex facial reconstruction by a Vascularized Composite Tissue Allotransplantation (VCTA) of the face”. Extreme trauma to the central part of the face is difficult to reconstruct with traditional autologous pedicled or free flaps. The only way to restore vital facial functions in one single procedure is to perform a VCTA. Digital 3D imaging was used to recreate the 3D model of the missing bone. In a 20 hours surgical procedure the largest amount of bone ever was transplanted together with the soft tissues of the entire lower 2/3rd of the face. The first VCTA face transplant in BEL was successful and in the meantime 25 cases are performed all over the world, with a mortality of 8 %.
Squadron leader E. Larkin, MD, 612 Squadron, Royal (Auxiliary) Air Force, University of Edinburgh, School of Medicine, Royal College of Defense Medicine, Birmingham, GBR, is using the “Deep circumflex iliac artery free flap reconstruction of the mandible”. Vascularised bone free flap reconstruction is the technique of choice for significant defects of the mandible. They have chosen for the “arteria circumflexa ilium profunda” to create a large volume of vascularised bone for reconstruction.
Commander(R) P. Felmer, MD, PhD, dept. of General-, Transplant-, Thoracic-, and Vascular Surgery, University Hospital Leipzig, DEU, explained about traumatic vessel injury of the neck – Treatment and Outcome”. Traumatic injury to the cervical vessels is a rare event but with a high mortality and therefore the education of Medical Officers should focus on alternative education. The neck is to be divided in three regions: I low, II mid and III high. Trauma to region I needs surgical exploration. Lesions to region II are most common and can be treated expectative. In case of instability surgical exploration is indicated for all regions. Diagnostic investigation can be executed by angiography, duplex ultrasound and Magnetic Resonance Imaging (MRI).
Lieutenant-colonel J. Kosel, Military Medical Directorate, DEU, gave “A brief overview of the Standardization Agreement (STANAG) on military forensic dental identification”. The Dental Services Expert Panel (EP-DS) within the COMEDS structure is staffing doctrine and procedures on techniques, on tasks and on the interchange of information for all aspects of dental and maxillofacial care in the operational environment. One example of current EP-DS topics/activities is STANAG 2464 on military forensic dental identification.
Colonel M. Kossowski, MD, dept. of Ear-Nose and Throat (ENT) Surgery, Percy Military Hospital, Clamart, FRA, presented an “Evaluation of the Role of ENT Surgeon in a theatre operation: experience of the French KAIA Role 3”. Because of an increase with 40 % of injuries of head and neck, French ENT surgeons are deployed to the Kabul International Airport (KAIA) role 3 hospital since October 2011. Ever since they have been treating 35 craniofacial- and cervical injuries, 70 % of which in locals. Damage control by general surgeons in craniofacial injuries is difficult and in laryngeal injuries it is not sufficient. Therefore the presence of an ENT surgeon in theatre is a necessity.
Colonel prof. U. Kunz, MD, dept. of Neurosurgery, Military Hospital Ulm, DEU, related to the “Experience from International Security Assistance Force (ISAF) mission in Neurosurgical Practice”. Because of the low fighting activity in the North Region the necessity of the presence of a neurosurgeon was questionable. However from 2009, 190 surgeries were performed of which 26,3 % were acute procedures, conducted to save lives or preserve neurological function. In addition 24,7 % were urgent and 49 % elective. 30,5 % were cranial surgeries, 59.5 % were spinal injuries and 5,8 % were peripheral nerve surgeries. 81,6 % of the surgical treatment was in civilians, 11,6 % for Afghan National Forces and 6,8 % for ISAF soldiers. Question marks were placed at the used helmet since fragments were able to make lacerations in the posterior fossa after blast injuries.
2nd Lieutenant MC (R) M. Dutor, Dental Surgeon, ESP, explained the “Therapeutic potential of Plasma Rich Growth Factors (PRGF) in regenerative medicine. Use in oral surgery”. PRGF are platelet proteins obtained from the patients own blood. The application accelerates the repair and regeneration mechanisms of various tissues. It is widely used in oral surgery for bone augmentation, regeneration of soft tissue and fracture healing (but in the meantime in other surgical specialties as well).
Squadron leader MC (R) B. Larkin, 612 Squadron, Royal (Auxiliary) Air Force, University of Edinburgh, Royal College of Defense Medicine, Birmingham, GBR, investigated a “Design validation of military ballistic cervical protection through development of a novel numerical injury model”. A review of all injured UK soldiers over the last 6 years revealed that 11% had neck wounds. The incidence in US soldiers over this period has been 3%. The difference is explained by the uptake of neck protection. Characterization of neck injury from explosive fragments requires post mortem and clinical evaluation of mortality and morbidity, surface wound mapping of fragment entry site and explosive fragment analysis of mass, velocity and shape. It is concluded that there is an urgent operational requirement to redesign neck protection for UK personnel. CIOMR would be a useful forum to enable design ideas to be better coordinated between nations.
E. Bernard, Military Hospital “Queen Astrid”, Brussels, BEL, presented his work on “The joint position sense of the cervical spine in patients with unilateral neck-shoulder-arm pain of radicular origin”. The restoration of proprioception and motor control is a prerequisite in the musculoskeletal rehabilitation prior to the start of strengthening and conditioning exercises. Impaired Joint Position Sense (JPS) has been demonstrated in chronic neck pain and whiplash associated disorders. 16 patients were investigated with unilateral neck-shoulder-arm pain of radicular origin. 75 % of the patients showed a greater repositioning error on the involved side.
Colonel MC (R) D. Di Duca, Military Medical Directorate, BEL, explained about the “Prise en charge d’un traumatisme de la colonne cervical au sein du détachement médical Belge en role-0 ou role-1”. Based on the experiences of a Belgian detachment deployed in Lebanon from 2006 to 2008 and in Afghanistan from 2010 till 2011, the use of the immobilizing collar is indicated for protection of the cervical spine under all circumstances, when possible.
Major general R. Kasulke, MD, Commanding General, Army Reserve Medical Command, USA, emphasized on the “Advancement in the treatment of abdominal injuries sustained on the battlefield, lessons learned in surgical techniques, resuscitation and post operative care”. Numerous medical- and surgical lessons have been learned in a decade’s long experience with treating those who have been wounded on the battlefield. Some of the conclusions are that there is no civilian equivalent to major combat trauma, that the definition of conservative treatment has to be revised because non-operative management is radical and that damage control is naval term for control the hole. At the moment the rule of thumb for emergency measures is: make them naked, roll them over and perform a chest X-ray. The abdominal compartment syndrome is dangerous because of the development of intra-abdominal hypertension. Therefore the abdomen has to be closed over gauzes and surgical foil. Details have to be written on the dressing.
Free paper session
Captain E. French, CD, RN, BSc, Canadian Field Hospital Detachment, Canadian Forces Health Services, CAN, presented “Co-morbid Traumatic Brain Injury (TBI) and Operational Stress Injuries (OSI), the role of the Mental Health Clinician in a Multidisciplinary Deployed setting”. The recent opening of the “Warrior Recovery Centre” at the Kandahar Air Field (KAF), AFG, may be seen as the birth of the comprehensive approach to assessing and treating soldiers who have been injured in combat. Such injuries can include mild traumatic brain injury (mTBI) and Operational Stress Injuries (OSI) which can coexist in an overlapping manner that may be confusing when establishing a diagnosis and a treatment plan. Post-deployment statistics show that greater that one third of veterans who have suffered from mTBI also suffer from PTSD. The inclusion of a mental health clinician can improve both short and long-term patient outcomes. Improved outcomes and reduced costs is the aim of improved acute care.
Brigadier general G. Griffin, MD, PhD, US Army Medical Corps, USA, lectured on “Of mice and men: Stroke, Brain Trauma, Infection: Use Beta Blockers: Connecting the Dots”. The etiology of infection in stroke and brain injury is reviewed, with focus on the immune system response. Antibiotic therapy is examined and compared with the use of additional beta-blockade. It was noticed that beta blocker therapy in stroke patients was leading to a decrease in the amount of pneumonias with 50 %.
Squadron leader B. Lange, MD, Royal Danish Air Force, DNK, investigated the “Effect of targeted strength, endurance and coordination exercise on neck pain among Danish F-16 pilots: a randomized controlled trial”. Objectives of the study were to determine the prevalence and intensity of neck pain among F-16 pilots and explore the effectiveness of a 24 weeks three-times-a-week training program. Flight helmets weigh 6 kg at 1G but 54 kg at 9 G which leads to neck pain and asks for measures like training of the deep neck muscles. Training revealed a significant decrease in neck pain in high performance jet aircraft pilots.
Squadron leader B. Larkin, MD, 612 Squadron, Royal (Auxiliary) Air Force, University of Edinburgh, Royal College of Defense Medicine, Birmingham, GBR, questioned about “Percutaneous Endoscopic Gastrostomy (PEG) – an essential skill for the military surgeon?”. Assisted enteral feeding is an integral part of the management of the trauma patient but in head injury, significant maxillofacial trauma and neck injuries there is often little other option. PEG placement is a minimal access, maximally invasive procedure but it is essentially safe and within the potential skills framework of all competent surgeons. Therefore it should be added to the core abilities of the military surgeon.
Posters
Two posters were presented and the poster price was awarded to lieutenant-colonel S. Neuling, PhD, for her poster about “Veterinary public health in Germany”. Veterinary public health is an essential part of public health and includes various types of cooperation between disciplines.
Mid Winter Meeting CIOMR 2013
The Mid Winter Meeting CIOMR will take place in the NATO HQ in Brussels (Evere) BEL, from Tuesday, January 31 till Saturday, February 2, 2013. The theme for the Scientific Meeting will be “Frontline Medicine: resuscitation, evacuation and stabilization of battlefield casualties”.
Authors: Colonel MC (R) Prof. Olaf Penn, MD, PhD (President CIOMR), Captain MC (R) Rob Favié, MD (National Vice-President NLD CIOMR), Major MC (R) Christine Vermeulen, MD, PhD (International Vice-President CIOMR).
Another article about the keyword:
CIOMR *κάντε κλίκ στη λέξη CIOMR για να μεταβείτε στην σελίδα της Διεθνους Ενωσης Εφέδρων Αξκων του Ιατρικού ΣώματοςExperiences
African Trypanosomiasis: A Unique Experience at UN Mission in Liberia
African Trypanosomiasis is a serious public
health problem in certain regions of Africa. Many cases remain
undiagnosed due to lack of diagnostic facilities. The disease is
curable; fatal if untreated. We report a middle aged African individual
with nonspecific symptoms diagnosed as a case of African
Trypanosomiasis.
IntroductionAfrican Trypanosomiasis (sleeping sickness) is caused by Trypanosoma brucei, a hemoflagellate protozoan parasite, transmitted to human by an insect vector Tsetse fly (Glossina spp) found in some parts of rural Africa. Two subspecies are responsible for human disease; T. brucei rhodensiense in East Africa and T. brucei gambiense in West Africa. Morphologically, both are indistinguishable but differ in clinical course and geographic distribution, the East African species causing a more rapidly progressive disease as compared to West African sleeping sickness. The disease is reasonably well controlled at present, with about 10,000 cases occurring annually with over 95 % cases from Congo, Angola, Sudan, Chad, Central African Republic and northern Uganda1. Still, most cases remain undiagnosed and unreported due to lack of proper laboratory facilities and technical expertise.
A 56-years-old man, resident of Maryland county-Harper, Liberia, businessman by profession, presented at the medical reception centre of Pak-Field level II hospital, Harper with complaints of headache, body aches, intermittent fever and night time sleep disturbance for the last month. There was no history of flee bite, boil, ulcer, skin rash or itching. He was not diabetic or hypertensive. History revealed extensive traveling to other African countries including Ghana, Cote De Ivoire and Guinea during the last three years. He has previously been treated as a case of typhoid fever at a local hospital.
On examination, he was looking weak but well oriented in time, place and person. He was afebrile with pulse 70 /min, blood pressure 140/100 mmHg and respiratory rate 18 breaths/min. There were no visible boil, ulcer or enlarged lymph nodes. Examination of chest, heart, abdomen and CNS was unremarkable. Blood complete picture revealed haemoglobin 11.3 gm/dL, other indices were within normal limits, ESR was 40 mm at the end of 1st hour. Urine routine examination, chest X-ray, ultrasonography of abdomen and pelvis did not reveal any abnormality. On site typhoid IgG/IgM rapid test and thick and thin blood films for malaria parasite were also negative. Serum Widal test revealed a titre of < 1/20 for each of TO, TH, AO, BO antibodies.
Keeping in view the endemicity, a peripheral blood film for Trypanosoma was prepared using concentration technique (centrifugation and preparation of blood film from buffy coat). The Leishmain stain of blood film revealed the trypomastigote form of Trypanosoma brucei showing a long cylinder body, central nucleus and undulating membrane with long flagellum arising from the kinetoplast located at the posterior end (Fig 1).
To rule out central nervous involvement, lumbar puncture was performed. CSF examination did not reveal a trypomastigote form or an increase in cell count or proteins. With fianal diagnosis of African Trypanosomiasis (1st stage), patient was given injections of Pentamidine (Lomidine) 4 mg/kg/d intramuscularly for ten days. Follow up blood films were negative for Trypomastigote form. He was discharged with advice for regular follow ups of blood films at six monthly intervals for up to two year to rule out any relapse.
Awareness lectures / presentations regarding the disease and its prevention were regularly delivered to locals and especially troops for prevention.
Discussion
Over 35 million people occupying the “Tsetse fly belt” of Africa are at risk of developing sleeping sickness2,3. The causative agent, found in mammalian blood as elongated trypomastigote, evades host antibody response by developing series of genetically controlled surface coats resulting in successive waves of parasite each with a different coat4. The clinical course has two stages: in the first, the parasite is found in the peripheral circulation while in the second stage, it invades the central nervous system. After an infective bite, most patients develop fever, headache, muscle/joint aches and enlarged lymph nodes within one to two weeks. Some patients may also develop rash or a large sore at the site of bite. CNS involvement results in ‘sleeping sickness syndrome’ comprising changes in personality, increased day time sleepiness with disturbed night sleep, and progressive confusion, coma and death if untreated5. East African sleeping sickness is a rapidly progressive disease causing mental deterioration, neurological problems and death within months. While West African sleeping sickness is a slowly progressive disease, CNS involvement occurs in 1 – 2 years and death usually occurs within three years, but this period may be prolonged for up to 6 – 7 years.
Definitive diagnosis depends upon demonstration of trypomastigotes in the blood, lymph node/primary lesion aspirate, bone marrow or CSF. Gimesa/Leishmain’s stain of thick/ thin blood films and buffy coat concentration method are recommended for parasite detection2. Multiple slides should be prepared with multiple blood examinations to rule out trypanosomiasis. We were successful in our very first attempt in identifying the organism; following proper technique was the main reason. All patients must undergo CSF examination to determine CNS involvement as trypomastigotes can be demonstrated in centrifuged sediments. The WHO criteria for CNS involvement includes increased protein in CSF and white cell count of > 51. Serologic techniques like Card agglutination trypanosomiasis test, ELISA, IHA and IFA are available but have not proven to be useful for routine diagnosis, as local population already showelevated levels due to exposure to non-infectious animal trypanosomes.
For T. brucei rhodensiense, Suramin 1 g intravenously on day 1, 3, 5, 14 and 21, is a drug of choice in the haemolymphatic stage, while Melarsoprol 2 - 3.6 mg/ kg/day for three days (3 courses; 7 days apart) is suggested for CNS disease. For T. brucei gambiense, Pentamidine 4 mg/kg/d intramuscular or intravenous, for 7-10 days in the haemolymphatic stage and Eflornithine 400 mg/kg/d in 4 doses for 14 days is recommended in patients with CNS involvement5,6. In our case, timely diagnosis followed by petamidine treatment for ten days proved effective.
Patients should be followed up every six month for two years to detect any relapse. As there is no prophylactic vaccine or drug, prevention and control mainly depends upon decreasing the reservoir; searching for, isolating and treating patients with the disease; controlling the tsetse fly vector by traps or screens, usage of insecticides and insect repellents, avoiding contact with bushes, wearing long sleeved shirts and pants.
To conclude, most cases of African Trypanosomiasis remain undiagnosed and unreported not only due to lack of diagnostic facilities but also due to non specific symptoms early in the disease. Therefore, the disease should always be kept in mind for differential diagnosis in endemic areas not only to reduce mortality but also to decrease reservoirs, helping prevention and control.
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