TY - JOUR
AU1 - Kaiser, Eric
AU2 - Kenane, Nadia
AU3 - Montcriol, Ambroise
AU4 - Palmier, Bruno
AB - ABSTRACT The French army is often engaged in stability and support operations in Africa, and its military health service has gained much experience. The goal of this article is to present our military medical management strategies during the two main phases of military action. These situations most often begin with an initial combat phase, with combat casualty care. This consists of first aid, i.e., treatment of bleeding points, followed by battlefield forward medical care, damage control surgery, and resuscitation in forward surgical units. The quieter second phase of peacekeeping operations is dominated by the management of tropical diseases and their prevention, essential for the preservation of the military strength. Introduction The French army is often engaged in stability and support operations in Africa, which usually follow a standard two-phase pattern. Missions are nominally peacekeeping, but there are often early combat casualties in the initial phase. During the second phase, military activity is relatively quiet and the population is favorably disposed toward the troops. Thus, the health service has gained great experience of combining the care of combat casualties with the management of tropical diseases. During the year 2004, a total of approximately 20.000 French soldiers were present in five African countries: Ivory Coast, Chad, Central Africa, Cameroon, and the Democratic Republic of Congo. These troop deployments were associated with a large number of military caregivers: 138 general physicians, 45 surgeons, 17 anesthesiologists, and 639 nurses, supporting approximately 30 battalion aid stations and 4 forward surgical units. The purpose of this article is to present French military medical management strategies for these two main aspects: initial combat casualty management with particular emphasis on hemorrhage control and, later on, the prevention of tropical diseases. Combat Casualty Management Location of Injuries The recent introduction of a new type of Kevlar bulletproof jacket in the army has affected the pattern of combat injuries. It is efficient, but leaves the face, limbs, and the side of the trunk exposed. Table I compares the location of injuries seen in forward surgical units by two French forces.1,2 Wearing the new bulletproof jacket produced more injuries to the limbs, head, and neck, but fewer to the thorax and abdomen, and thus fewer wounds were classified as absolute emergencies (necessitating surgery in <6 hours) and there was a slight reduction in mortality. The mortality rate was similar to that of the American troops in Afghanistan and Iraq from 2001 to 2004.3 TABLE I LOCATION OF INJURIES, ABSOLUTE EMERGENCY RATE, AND MORTALITY FROM WOUNDS OF SOLDIERS ACCORDING TO THE TYPE OF BODY ARMOR (INCLUDED MULTIPLE INJURIES, HENCE THE TOTAL EXCEEDS 100%)   Previous Protective Devicea 1992-1996 (n= 499 WIA)c  Current Protective Deviceb 2002-2004 (n= 73 WIA)  Location of injuries         Limbs  69%  100%     Cephalic  11%    27%     Thorax  19%      8%     Abdomen  26%      0%  Absolute emergency (<6 hours)  44%    19%  Died from wounds  10%      7%    Previous Protective Devicea 1992-1996 (n= 499 WIA)c  Current Protective Deviceb 2002-2004 (n= 73 WIA)  Location of injuries         Limbs  69%  100%     Cephalic  11%    27%     Thorax  19%      8%     Abdomen  26%      0%  Absolute emergency (<6 hours)  44%    19%  Died from wounds  10%      7%  a Sarajevo. b Ivory Coast, Afghanistan, Kosovo. c WIA, wounded in action. View Large TABLE I LOCATION OF INJURIES, ABSOLUTE EMERGENCY RATE, AND MORTALITY FROM WOUNDS OF SOLDIERS ACCORDING TO THE TYPE OF BODY ARMOR (INCLUDED MULTIPLE INJURIES, HENCE THE TOTAL EXCEEDS 100%)   Previous Protective Devicea 1992-1996 (n= 499 WIA)c  Current Protective Deviceb 2002-2004 (n= 73 WIA)  Location of injuries         Limbs  69%  100%     Cephalic  11%    27%     Thorax  19%      8%     Abdomen  26%      0%  Absolute emergency (<6 hours)  44%    19%  Died from wounds  10%      7%    Previous Protective Devicea 1992-1996 (n= 499 WIA)c  Current Protective Deviceb 2002-2004 (n= 73 WIA)  Location of injuries         Limbs  69%  100%     Cephalic  11%    27%     Thorax  19%      8%     Abdomen  26%      0%  Absolute emergency (<6 hours)  44%    19%  Died from wounds  10%      7%  a Sarajevo. b Ivory Coast, Afghanistan, Kosovo. c WIA, wounded in action. View Large Organization of the French Military Health Service on the Battlefield The level of care, location, responsibilities, and personnel of each French medical echelon are presented in Figure 1. The two main characteristics of service on the battlefield are forward medical care and the staging of surgery through the evacuation process. The injured soldier receives first aid from a buddy and quick evacuation to the nearest secure zone. Although still on the battlefield, the soldier can receive medical care from one general physician provided for each battlefield company (150– 200 soldiers), assisted by one certified nurse and five first aid stretcher bearers. This medical team support one advanced battalion aid station. (The profession of paramedic does not exist in France.) Lifesaving medical care is thus within 5 to 20 minutes. Next, the injured soldier is taken to the advanced battalion aid station, a light tent structure in which more sophisticated care can be performed: better control of hemorrhage, oxygen, intubation, and ventilation. Evacuation of less severely wounded to the main battalion aid station or the forward surgical team is via an armored medically equipped ambulance or helicopter. The helicopter crew includes a flying surgeon and one nurse specialized in medical care in aircraft. Fig. 1 View largeDownload slide Level of care, responsibilities, location, and personnel of each medical echelon. Fig. 1 View largeDownload slide Level of care, responsibilities, location, and personnel of each medical echelon. The forward surgical unit is a light mobile structure consisting of two tents with their own electrical power. It permits anesthesia, intensive care, and damage control surgery and is manned by one general and one orthopedic surgeon, one anesthesiologist, and nine nurses and stretcher bearers. They are capable of performing 10 lifesaving operations per day during a 2- to 4-day period, according to need. Unlike the above units, this one can offer blood transfusion; it has a stock of 25 red blood cell packs and desiccated plasma. To supplement this, autotransfusion is frequently used via a cell-saver device (centrifugation plus washing) or with special kits for autotransfusion of hemothorax. Whenever combat conditions permit, e.g., when the front is relatively stationary, the forward surgical team is strengthened into a modular surgical unit. Rigid shelters deployed from special trucks can be connected together to provide a preequipped operating room, intensive care unit of six beds, a laboratory, and in some places such as the Ivory Coast, computer tomography. This modular unit is less transportable, but provides more specialists such as an internist, tropicalist, laboratory doctor, and radiologist. After initial surgical treatment, casualties are evacuated to the mobile field hospital, or more frequently nowadays back to France, where definitive surgery is performed. Treatment of Civilians During quiet periods, the military health workers treat the local population of the country. This is an old tradition, but this mission was officially bestowed upon the French military health service and funded by ministerial decree in 1999. It allows the treatment of pathologies not seen in developed countries, and thus maintains a degree of medical and surgical competence that could not otherwise be achieved. Medical Skills for Trauma Resuscitation Training Table II describes trauma resuscitation at the various levels of care. The medical skills for combat casualty care are taught to military medical students studying for the forward medicine certificate in three phases. Initial teaching, in the military medical universities of Bordeaux and Lyon, consists of theory and practice on manikins. It is completed during the last year in the school of instruction in Paris in addition to a 1-week field training exercise. All general physicians have to complete continuous training courses every 3 years in the military teaching hospitals, consisting of 1 week of practice in the operating rooms, emergency unit, and intensive care unit. Finally, just before deployment, all nurses and physicians spend 2 days in Lyon at a specialized preparation center for overseas operations. They are informed about the local military situation and about the specific tropical diseases they may encounter. TABLE II TRAUMA RESUSCITATION AT THE VARIOUS STAGES OF CARE IN THE FIELD Role 1: Forward Livesaving Medical Care  Role 2: Forward Resuscitation and Surgery Surgical Team  First Aid in the Field  Battalion Aid Station    Buddy  As before plus  As before plus     First aid, including tourniquet and analgesia  Chest drainage  Cell saver    Hemothorax autotransfusion  Homologous blood transfusion  Medical team  Mechanical ventilation  Dried plasma     Hemorrhage control  Analgesia  Fresh whole blood        Pressure dressing    Recombinant activated factor VII        Tourniquet    Oxygen concentrator        Intravenous line    Turbine-powered ventilator        Bone perfusion    Anesthesia        Fluid infusion    Damage control surgery     Respiratory distress    Intensive care unit        Exsufflation of pneumothorax    Laboratory        Closure of open-chest wound    Computer tomography        Oropharyngeal cannula            Manual ventilation            Tracheal intubation            Oxygen cylinder      Role 1: Forward Livesaving Medical Care  Role 2: Forward Resuscitation and Surgery Surgical Team  First Aid in the Field  Battalion Aid Station    Buddy  As before plus  As before plus     First aid, including tourniquet and analgesia  Chest drainage  Cell saver    Hemothorax autotransfusion  Homologous blood transfusion  Medical team  Mechanical ventilation  Dried plasma     Hemorrhage control  Analgesia  Fresh whole blood        Pressure dressing    Recombinant activated factor VII        Tourniquet    Oxygen concentrator        Intravenous line    Turbine-powered ventilator        Bone perfusion    Anesthesia        Fluid infusion    Damage control surgery     Respiratory distress    Intensive care unit        Exsufflation of pneumothorax    Laboratory        Closure of open-chest wound    Computer tomography        Oropharyngeal cannula            Manual ventilation            Tracheal intubation            Oxygen cylinder      View Large TABLE II TRAUMA RESUSCITATION AT THE VARIOUS STAGES OF CARE IN THE FIELD Role 1: Forward Livesaving Medical Care  Role 2: Forward Resuscitation and Surgery Surgical Team  First Aid in the Field  Battalion Aid Station    Buddy  As before plus  As before plus     First aid, including tourniquet and analgesia  Chest drainage  Cell saver    Hemothorax autotransfusion  Homologous blood transfusion  Medical team  Mechanical ventilation  Dried plasma     Hemorrhage control  Analgesia  Fresh whole blood        Pressure dressing    Recombinant activated factor VII        Tourniquet    Oxygen concentrator        Intravenous line    Turbine-powered ventilator        Bone perfusion    Anesthesia        Fluid infusion    Damage control surgery     Respiratory distress    Intensive care unit        Exsufflation of pneumothorax    Laboratory        Closure of open-chest wound    Computer tomography        Oropharyngeal cannula            Manual ventilation            Tracheal intubation            Oxygen cylinder      Role 1: Forward Livesaving Medical Care  Role 2: Forward Resuscitation and Surgery Surgical Team  First Aid in the Field  Battalion Aid Station    Buddy  As before plus  As before plus     First aid, including tourniquet and analgesia  Chest drainage  Cell saver    Hemothorax autotransfusion  Homologous blood transfusion  Medical team  Mechanical ventilation  Dried plasma     Hemorrhage control  Analgesia  Fresh whole blood        Pressure dressing    Recombinant activated factor VII        Tourniquet    Oxygen concentrator        Intravenous line    Turbine-powered ventilator        Bone perfusion    Anesthesia        Fluid infusion    Damage control surgery     Respiratory distress    Intensive care unit        Exsufflation of pneumothorax    Laboratory        Closure of open-chest wound    Computer tomography        Oropharyngeal cannula            Manual ventilation            Tracheal intubation            Oxygen cylinder      View Large Hemorrhagic Shock Hemorrhage is considered as the most frequent preventable cause of death during combat. For this reason, the doctrine of treating hemorrhage in the field has been recently reassessed. Hemostasis as soon as possible should be the first priority of first aid by the buddy, to avoid early unnecessary death from bleeding. If immediate pressure application is unsuccessful, the buddy applies a tourniquet; a soldier can die very quickly from massive bleeding from a peripheral wound, whereas a physician will quickly be able to decide whenever the tourniquet is necessary or not and possibly remove it. Nurses and physicians can insert intravenous lines but this may not be practicable in hemorrhagic shock, and after two unsuccessful intravenous attempts, they perform tibial bone perfusion via a Mallarme trocar to give isotonic crystalloids and colloids or hypertonic saline combined with ethilstarch. The infusion is maintained to achieve a radial pulse, assuming that the arterial systolic blood pressure is approximately 80 mm Hg, sufficient to maintain the life of a young soldier until hemostatic surgery can be performed; the goal is to operate in < 1 hour. Thus, the Anglo-Saxon concept of scoop and run has been adapted to the French military health service, but after early correct control of the bleeding whenever possible. Hemostatic agents for local use4 are not currently available in the French army. At the forward surgical unit, hemorrhage is treated by damage control surgery and resuscitation. The goal is to stop the bleeding as early as possible with a simple, rapid, and standardized technique to avoid the lethal triad of hypothermia, acidosis, and coagulation disorders. A technical handbook for blood transfusion in exceptional situations was edited in 2004 by the French military transfusion center, with the intention that transfusion should be performed in conditions as close as possible to those applying in peacetime. In the first place, the blood group stated on the dog tag is used. If the blood bank is empty, the anesthesiologist will collect fresh whole blood from volunteer healthy preselected soldier colleagues. Recombinant activated factor VII is now provided for the forward surgical team to reduce the use of red blood cells, because large transfusions are detrimental for trauma patients.5 A prospective randomized double-blind multicenter international study evaluated recombinant factor VII activated vs. placebo in bleeding trauma patients.6 This study (which was performed in a highly sophisticated civilian hospital environment, where the conditions are far from that of an isolated forward surgical team with restricted access to red blood cells) showed a mean reduction of two transfused red blood cell packs in blunt trauma and fewer massive transfusions (>20 red blood cell packs transfused) in the same group. For penetrating trauma, there was a nonsignificant trend toward a less bleeding. Respiratory Distress Respiratory distress is not common on the battlefield. Chest drainage is not performed in the field, but tension pneumothorax is treated by needle exsufflation, and an open wound is treated by occlusive dressing. Chest tubes connected to a self-sealing valve are available at the battalion aid station, where nurses and physicians can perform manual ventilation and intubation. The use of oxygen concentrators is preferred in the forward surgical team, since cylinders of oxygen are not always available. They can be connected to turbine-powered ventilators7 to treat severe respiratory distress. Tropical Diseases Figure 2presents the results of a retrospective epidemiological survey of an average of 4,500 French soldiers present each day in the Ivory Coast (with permission8). Analyzed documents from September 2002 to September 2005 showed there were 3,883 medical consultations. Three main causes accounted for >80% of the consultations: 1.590 diarrhea (40.9%), 925 malaria (23.8%), and 626 sexual exposure at risk for human immunodeficiency virus (HIV) contamination (16.1%). Every French soldier receives a routine preventive briefing about infectious risks during initial training, in the week before being sent overseas, and whenever possible just after deployment in an attempt to decrease these disease rates. Fig. 2 View largeDownload slide Reasons for medical consultations of French soldiers in the Ivory Coast between September 2002 and September 2005 (numbers and percent).8 Fig. 2 View largeDownload slide Reasons for medical consultations of French soldiers in the Ivory Coast between September 2002 and September 2005 (numbers and percent).8 Diarrhea is due to a lack of hygiene and clean water. Lavatories, field showers, and washbasins are provided, and 3 L or more of drinkable bottled water are provided each day for combatants. Where there is insufficient clean water, chlorine tablets are available in the meal ready-to-eat rations to decontaminate local water before drinking. In the larger medical units, water treatment stations can produce large amounts of drinkable water. Recently introduced kits permit bacterial and chemical analysis of the water directly on the battlefield. However, most of the troops also eat food from the local economy to supplement the meal ready-to-eat rations, which may explain this result. Malaria has always been an important problem for French troops in Africa. Figure 3 presents the evolution of the incidence rate for 1,000 soldiers per month of malaria in the Ivory Coast from 2002 to 2005 (8 with permission). The beginning of the operation in year 2002 was marked by an epidemic: in some squads more than one-half of the soldiers were out of action. Several factors may explain this fact. Malaria prevention consists of wearing long garments during the night, mosquito nets impregnated with repellent, the use of skin repellents to avoid mosquito bites, and chemical prophylaxis. In some places, the intensity of the initial combat may not allow the soldiers to sleep under mosquito nets. The initial chemical prophylaxis was a chloroquine-proguanil association, to which it seems that Plasmodium falciparum has become resistant to that in the Ivory Coast. For this reason, daily oral 200 mg doxycycline was secondarily introduced and is currently efficacious. The most frequent adverse effect of doxycycline is a photosensitivity resulting in a moderate rash; the alternative treatment is the chloroquine-proguanil combination. Compulsory application of these preventative measures and reinforcement of the educational briefings resulted in a progressive improvement in the epidemic (Fig. 3). Malaria is confirmed in the field by a simple rapid P. falciparum-specific antigen histidine-rich protein 2 detection test (Core Malaria Pan/Pv/Pf; CORE Diagnostics, Birmingham, United Kingdom). Each test is packed in a metallic waterproof cover and is stable in the wet and hot environment of the Ivory Coast. It has a 2-year shelf-life if stored between +4°C and +30°C. Other laboratory tests are only available in the laboratories at the modular surgical unit and at the regular base camp (quantitative buffy coat test and blood smear). Malaria is initially treated on the field with quinine, orally in moderate cases and intravenously for more severe attacks. Fig. 3 View largeDownload slide Incidence of malaria per 1,000 soldiers per month, Ivory Coast from September 2002 to September 2005.8 Fig. 3 View largeDownload slide Incidence of malaria per 1,000 soldiers per month, Ivory Coast from September 2002 to September 2005.8 Prevention of HIV contamination is performed by systematic education regarding sexual behaviors and by supplying condoms. Nonprotected sexual relations with a local partner of unknown HIV serological status is considered a risk for HIV contamination. The French guidelines for postsexual exposure prophylaxis for HIV are applied to informed and willing patients with a special kit supplied by the military health service, including triple therapy (nelfinavir, lamivudine, zidovudine). However, soldiers are not systematically screened for HIV before and after deployment except by individual request, and none of the exposed soldiers have actually converted their HIV serology. Fifty-nine other cases of sexually transmitted diseases were also treated. Acute respiratory tract infections were classified in the “other illness” groups. They were less frequent than previously reported in a U.S. army forward unit during Operation Desert Shield,9 probably because of the continuously wet and hot climate of the Ivory Coast. Conclusions The African experience of the French military health service has provided new concepts for the management of combat casualties and tropical diseases. Early arrest of hemorrhage is the first aid priority, in addition to forward medical care in the battlefield. Prevention of tropical diseases is the key to the preservation of the military strength. References 1. Versier G, Le Marec J, Rouffi J Four years of war surgery at the French surgical facility in Sarajevo—July 1992–August 1996. Médecine et Armées  1998; 26: 213– 8. 2. Peytel E, Le Marec C, Versier G, Saissy JM Incidence des effets de protection sur les caractéristiques et la mortalité des blessures de guerre. Ann Fr Anesth Reanim  2000; 19(Suppl 1): 316. Google Scholar PubMed  3. Gawande A Casualties of war–military care for the wounded from Iraq and Afghanistan. N Engl J Med  2004; 351: 2471– 5. Google Scholar CrossRef Search ADS PubMed  4. Alam HB, Burris D, DaCorta JA, Rhee P Hemorrhage control in the battlefield: role of new hemostatic agents. Milit Med  2005; 170: 63– 9. Google Scholar CrossRef Search ADS   5. Malone DL, Dunne J, Tracy JK, Putnam AT, Scalea TM, Napolitano LM Blood transfusion, independent of shock severity, is associated with worse outcome in trauma. J Trauma  2003; 54: 898– 905. Google Scholar CrossRef Search ADS PubMed  6. Boffard KD, Riou B, Warren B, et al.   Recombinant factor VIIa as adjunctive therapy for bleeding control in severely injured trauma patients: two parallel randomized, placebo-controlled, double-blind clinical trials. J Trauma  2005; 59: 8– 15. Google Scholar CrossRef Search ADS PubMed  7. Kaiser E, Pernod G, Meaudre E, Boret H, Palmier B Oxygen concentrations delivered by LTV 1000TM supplied with low pressure oxygen. Eur J Emerg  2005; 18: 149– 53. 8. Migliani R Medical supervision of French military forces in operations: the example of Ivory-Costa. In: Medicine and Health in the Tropics, September 11 , 2005, Marseille. France. 9. Wasserman GM, Martin BL, Hyams KC, Merrill BR, Oaks HG, McAdoo HA A survey of outpatient visits in a United States Army forward unit during Operation Desert Shield. Milit Med  1997; 162: 374– 9. Footnotes 1 Presented at the Combat Casualty Care Conference, March 9–10, 2006, London, U.K. Reprint & Copyright © Association of Military Surgeons of the U.S.
TI - Expeditionary Medicine in Africa: The French Experience
JF - Military Medicine
DO - 10.7205/MILMED.172.7.708
DA - 2007-07-01
UR - https://www.deepdyve.com/lp/oxford-university-press/expeditionary-medicine-in-africa-the-french-experience-0r4O3ZPRpS
SP - 708
EP - 712
VL - 172
IS - 7
DP - DeepDyve
ER -