French Military Health Service Research Articles

Training for a Mass Casualty Incident: Conception, Development and Implementation of a Crew-Resource Management Course for Forward Surgical Teams.

The purpose of this article is to describe the development of a crew resource management (CRM) training course dedicated for the forward surgical teams (FSTs) of the French Military Health Service. Since 2021, the predeployment training of French FSTs has included a simulation-based curriculum consisting of organizational and human factors. It combines lectures, laboratory exercises, and situational training exercises to consider four fundamental "nontechnical" (cognitive and social) skills for effective and safe combat casualty care: (a) leadership, (b) decision-making, (c) coordination, and (d) situational awareness. The approach was based on three steps: (1) establishment of a conceptual framework of FSTs deployment; (2) development and implementation of an aircrew-like CRM training dedicated to combat casualty care; and (3) assessment of FSTs' CRM skills using an audio/video recording of a simulated mass-casualty incident. To ensure complete and high-quality predeployment training, French FSTs undergo a high-quality training that takes into account both technical and non-technical skills to maintain quality of combat care during mass-casualty incidents.

Use of Instant Messaging Applications by General Practitioners During Overseas Deployment: A Survey of the French Military Health Service

ABSTRACT Introduction Instant messaging applications (MAs) represent a major component of modern telecommunications for data transmission. During overseas deployments, military doctors increasingly rely on MAs due to their availability and the urgent need to obtain advice from specialists for optimal patient management. In this study, we aimed to describe and analyze the context and usage characteristics of these MAs for transmitting medical data by military general practitioners (GPs) during overseas missions. Materials and Methods This observational study was conducted between June 2020 and December 2020, based on a survey sent to GPs from the French Military Health Service who had been deployed overseas in military operations between 2010 and 2020. Results We received 233 surveys of which 215 were analyzed. Among these, 141 military GPs used instant MAs to transmit medical data during deployment. Notably, WhatsApp was used by 97% of the participants. The military GPs mainly used these applications for the speed of exchanges (45%) and their ease of use (28%). The physician specialties predominantly involved in data sharing were trauma and orthopedic surgery (38%) and dermatology (31%). The correspondents were mainly military specialist physicians from French military teaching hospitals (85%). A response time of less than 1 h was reported in 78% of the cases. Additionally, 72 doctors (51%) undertook their last deployment in an isolated post. Conclusion MAs were extensively utilized communication tools among GPs during their overseas deployments. Although the use of these applications seems essential in telemedicine, it raises several legal and ethical questions. Thus, we recommend employing these tools while ensuring medical and military confidentiality.

Nine years of surgical activity in the deployed French military role 2 medical treatment facility in Mali

IntroductionIn January 2013, France launched a military operation in Mali, which ended in August 2022. This study aimed to analyse the global activity performed by a surgical team within the...

French Military Neurosurgery: At Home and Abroad.

The origins of military neurosurgery are closely linked to those of neurosurgery in France and more particularly in Paris. The history of the field starts with its origins by 2 men, Thierry de Martel and Clovis Vincent. The first note about the creation of military neurosurgery was in 1942, when Marcel David was reassigned from the Sainte Anne Hospital to practice at the Val-de-Grâce Military Hospital. David trained the first military neurosurgeon. The field of military neurosurgery was subsequently developed at the Val-de-Grâce Military Hospital, at Sainte Anne Military Teaching Hospital in Toulon in 1990 and then at Percy Military Teaching Hospital in 1996. Over 29 military neurosurgeons were trained in these institutions. Since 2000, French military neurosurgeons have been deployed from France in the Mobile Neurosurgical Unit. This Mobile Neurosurgical Unit represents 12% of all medical evacuation of casualties categorized as the high dependency level. Neurosurgeons were able to adapt to asymmetrical wars, such as in the Afghanistan campaign where they were deployed in the Role 3 medical treatment facility, and more recently in sub-Saharan conflicts where they were deployed in forward surgical roles. To manage the increasing craniocerebral war casualties in the forward surgical team, the French Military Health Service Academy established a training course referred to as the "Advanced Course for Deployment Surgery" providing neurosurgical damage control skills to general surgeons. Finally, military neurosurgery is reinventing itself to adapt to future conflicts through the enhancement of surgical practices via the addition of head, face, and neck surgeons.

Extremity injuries in the Sahelian conflict: lessons learned from a French Forward Surgical Team deployed in Gao, Mali.

This study aimed to analyse extremity combat-related injuries (CRIs) and non-combat related injuries (NCRIs) treated in the French Forward Surgical Team deployed in Gao, Mali. A retrospective study was conducted using the French surgical database OpEX (French Military Health Service) from January 2013 to August 2022. Patients operated on for an extremity injury less than one month old were included. During this period, 418 patients with a median age of 28years [range 23-31years] were included and totalized 525 extremity injuries. Among them, 190 (45.5%) sustained CRIs and 218 (54.5%) sustained NCRIs. Multiple upper extremity injuries and associated injuries were significantly more common in the CRIs group. The majority of NCRIs involved the hand. Debridement was the most common procedure in both groups. External fixation, primary amputation, debridement, delayed primary closure, vascular repair and fasciotomy were significantly predominant in the CRIs group. Internal fracture fixation and reduction under anaesthesia were statistically more frequent in the NCRIs group. The overall number of procedures and the overall number of surgical episodes were significantly higher in the CRIs group. CRIs were the most severe injuries and did not involve the upper and lower limbs separately. A sequential management was required with application of damage control orthopaedics followed by several procedures for reconstruction. NCRIs were predominant and mostly involved the hand among the French soldiers. This review supports the fact that any deployed orthopaedic surgeon should be trained in basic hand surgery and preferably have microsurgical skills. The management of local patients requires the execution of reconstructive surgery and therefore imposes the presence of adequate equipment.

The intranasal route for ketamine administration may be a simple way to improve battlefield analgesia.

1171th Armed forces medical center, Quartier LCL Normand, 82160, Caylus, France. [email protected], ORCID: 0000-0002-1274-677X 2Department of anesthesiology and intensive care, Percy Military Training Hospital, Clamart, France., [email protected], ORCID: 0000-0003-4526-3720 34th Specialized Medical Unit, Bayonne, France. [email protected] Corresponding author: Romain Montagnon, Email: [email protected], Tel : +33 4 83 16 25 51, 171th Armed forces medical center, Quartier LCL Normand, 82160 Caylus, France, ORCID: 0000-0002-1274-677X Disclosure: The opinions or assertions expressed herein are the private views of the authors and are not to be considered as reflecting the views of the French Military Health Service. Financial disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose. Acknowledgements: The authors would like to thank all participants for their time and interest. This work is dedicated to all deployed military healthcare personnel. Author contributions: Drafting of manuscript (MR, NP); revision of manuscript (DC); All authors read and approved the final manuscript.

Exertional Heatstroke Support at the Acute Phase: Assessment of Professional Practices in the French Military Forces.

Exertional heatstroke (EHS) is defined as a disturbance in consciousness, ranging from confusion to coma, with hyperthermia typically higher than 40 °C that occurs during intense physical activity. It is a life-threatening pathology that has been observed in the military since antiquity. Recent research has changed the understanding of the pathophysiology of EHS and led to the development of gold-standard treatment, which includes intrarectal temperature monitoring and cooling the patient as quickly as possible. The objective of this study was to describe the theoretical knowledge of French military unit practitioners regarding the latest recommendations for the treatment of EHS and their management of this condition in practice. We conducted a web-based survey from August 2 to December 31, 2020, including all French military practitioners. The questionnaire, sent via email, aimed to describe practitioners' theoretical knowledge of EHS and its practical management. Practitioners who had a local management protocol were asked to include it with their responses to analyze and determine if protocols complied with the latest recommendations. The responses were collected by name, anonymized, and analyzed by a single investigator. This observational study was exempted from ethics board approval by the French Military Health Service's research department. Of the questionnaires sent, 84 practitioners responded, describing their theoretical knowledge of EHS. Of the respondents, 42 had experience managing EHS and described their practical management of EHS in the field. In addition, 15 local protocols were analyzed. Intrarectal temperature measurement was recommended by 71 physicians (84.5%), and cooling was preferably achieved by immersion in cold water by 65 practitioners (77.4%). If this method was unavailable, only 36.9% (24/65) of practitioners submerged patients in water at room temperature. Nine practitioners (10.7%) had perfect theoretical knowledge, and 36 (42.9%) knew the optimal management of EHS. There was no difference in the frequency of perfect theoretical knowledge between practitioners who had experience with EHS (9/36) and those who did not (12/48; P = 1). Practitioners who had experience with EHS had better optimal management knowledge than those who did not (61.1% vs.29.1%; P = .03). In practice, 21 (50%) cases had intrarectal temperature monitoring, and only 6 (14.3%) were immersed in cold water. Logistical challenges prevented optimal cooling methods in 29 (90.6%) cases. Concerning the other aspects of management, four (26.7%) practitioners recommended tympanic temperature measurement, two (20%) did not indicate immersion for cooling, and one (6.7%) administered paracetamol. French military practitioners' theoretical knowledge of EHS is insufficient for a lethal pathology that is common in the military. Thus, improvements must be made in training and disseminating up-to-date knowledge. In practice, a lack of adequate logistics and the fact that first responders are rarely practitioners increase the suboptimal care of EHS. First responders should be equipped with valid and adapted protocols and adequate logistical means to manage this condition. By establishing a cohort of well-treated patients, we will be able to develop evidence-based recommendations for when to cease cooling and identify intrinsic susceptibility to EHS.

Wartime upper-extremity injuries in the Sahelian strip: Experience from a French Forward Surgical Team deployed in Mali

This study aimed to analyze upper-extremity combat-related injuries (CRIs) and non-combat-related injuries (NCRIs) treated in the French Forward Surgical Team currently deployed in Gao, Mali. A retrospective study was conducted using the French Military Health Service OpEX surgical database from February 2013 to March 2020. All patients operated on for upper-extremity injury were included: 224 patients, with a mean age of 28.15 years, for 249 upper-extremity injuries. Seventy-six (33.9%) sustained CRIs and 148 (66.1%) NCRIs. Multiple upper-extremity injuries and associated injuries were significantly more common in the CRI group. The majority of NCRIs involved the hand. Debridement and wound care was the most common procedure in both groups. External fixation and fasciotomy were significantly more frequent in the CRI group, and internal fracture fixation in the NCRI group. The overall number of procedures was significantly higher in the CRI group. Due to the high frequency of upper-extremity injury in current theaters of operations, deployed orthopedic surgeons should be trained in basic hand surgery so as to optimally manage both CRIs and NCRIs.

Prolonged tactical tourniquet application for extremity combat injuries during war against terrorism in the Sahelian strip.

This study reports on complications following extended tourniquet application in patients with combat extremity injuries treated by the French Military Health Service in the Sahelian strip. A retrospective review was performed in a French forward medical treatment facility deployed in Gao, Mali, between 2015 and 2020. All patients treated for an extremity injury with the application of at least one tourniquet for a minimum of 3h were included. Prehospital data were injury pattern, associated shock, tourniquet location, and duration. Subsequent complications and surgical procedures performed were analyzed. Eleven patients with a mean age of 27.4years (range 21-35years) were included. They represented 39% of all patients in whom a tourniquet was applied. They had gunshot wounds (n = 7) or multiple blast injuries (n = 4) and totaled 14 extremity injuries requiring tourniquet application. The median ISS was 13 (interquartile range: 13). Tourniquets were mostly applied proximally on the limb for a mean duration of 268min (range 180-360min). Rhabdomyolysis was present in all cases. The damage control surgeries included debridement, external fixation, vascular repair, and primary amputation. Ten injuries were complicated by compartment syndrome requiring leg or thigh fasciotomy in the field or after repatriation. Two severely injured patients died of their wounds, but the others had a favorable outcome even though secondary amputation was sometimes required. Extended and proximal tourniquet applications led to significant morbidity related to compartment syndrome and rhabdomyolysis. Hemorrhagic shock, mass casualty incident, and tactical constraints often precluded revising the temporary tourniquet applied under fire.

2020, Mulhouse, Covid-19 : une leçon d’histoire, d’Europe, de résilience

In March 2020, Covid-19, caused by the severe acute respiratory syndrome coronavirus 2, struck the Haut-Rhin region with extreme violence, overwhelming hospitals and requiring the massive opening of new resuscitation beds. The military resuscitation element of the French military health service was deployed for the first time in Mulhouse (68), in eastern France. Alsace-Lorraine, a European crossroads and the birthplace of European institutions, was once again at the heart of history. Perspectives.

Small but nimble: measures taken to face the COVID-19 pandemic in small French military hospitals.

To describe a complete panel of actions of the Service de Santé des Armées (SSA) (ie, French Military Health Service) that together contributed to prevent French health system saturation during the coronavirus disease 2019 (COVID-19) pandemic. Observational retrospective study. Actions taken by military practitioners in the Parisian military hospitals, which contained 500 beds, to fight COVID-19 were listed and described. The Parisian military hospitals were fully reorganized to offer 147% more intensive care unit beds and took care of 665 inpatients with COVID-19 while continuing their core mission of war-wounded military care. A strategy to prioritize the use of medicine and medical devices was designed to avoid shortages. Field intensive care unit deployment and airborne collective medical evacuation by the SSA's MoRPHEE system avoided hospital saturation. Key facets of this achievement were interunit collaboration, esprit de corps, and health workers' adaptability. Small hospitals can provide a coherent answer to the COVID-19 pandemic, as long as they organize and prioritize the patients' care.

Combat Casualty Care Training: Implementation of a Simulation-Based Program in a Cross-Cultural Setting: Experience of the French Military Health Service in West Africa

In the French army, combat casualty care (CCC) training involves the use of simulation. The application of this pedagogic method in a cross-cultural environment has not previously been described. In this report, we explore the challenges highlighted by multiple training sessions for foreign medical providers in West Africa.We collected the data from six 2-week courses held in Libreville, Gabon. Our main objective was to describe the course; our secondary objective was to assess our trainees' progress in their knowledge of CCC.The first week involved lectures, technical workshops, and single-patient simulations. The second part emphasized multiple-victim simulations and interactions with combatants and was held in the Gabonese rainforest. Sixty- two trainees undertook the six sessions. Their knowledge improved during the course, from a median score of 4 (of a maximum of 40) before to 9.5 after (p < .05).Our study is the first to describe medical-level CCC training in a cross-cultural environment. Challenges are numerous, notably differences in the expected roles of instructors and trainees. Mitigating those difficulties is possible through cultural awareness and self-awareness. Our results are limited by the absence of evaluation of improvement in the actual management of patients.CCC training using medical simulation is feasible in a cross-cultural environment.

Oxygen Management During Collective Aeromedical Evacuation of 36 COVID-19 Patients With ARDS.

ObjectiveThe ongoing coronavirus disease-2019 pandemic leads to the saturation of critical care facilities worldwide. Collective aeromedical evacuations (MEDEVACS) might help rebalance the demand and supply of health care. If interhospital transport of patients suffering from ARDS is relatively common, little is known about the specific challenges of collective medevac. Oxygen management in such context is crucial. We describe our experience with a focus on this resource.MethodsWe retrospectively analyzed the first six collective medevac performed during the coronavirus disease-2019 pandemic by the French Military Health Service from March 17 to April 3, 2020. Oxygen management was compliant with international guidelines as well as aeronautical constraints and monitored throughout the flights. Presumed high O2 consumers were scheduled to board the last and disembark the first.ResultsThirty-six mechanically ventilated patients were successfully transported within Europe. The duration of onboard ventilation was 185 minutes (145-198.5 minutes), including the flight, the boarding and disembarking periods. Oxygen intake was 1,650 L per patient per flight (1,350-1,950 L patient per flight) and 564 L per patient per hour (482-675 L per patient−1 per hour) and surpassed our anticipation. As anticipated, presumed high O2 consumers had a reduced ventilation duration onboard. The estimations of oxygen consumptions were frequently overshot, and only two hypoxemia episodes occurred.ConclusionOxygen consumption was higher than expected, despite anticipation and predefined oxygen management measures, and encourages to a great caution in the processing of such collective medevac missions.

Medical and surgical management of lower extremity war-related injuries. Experience of the French Military Health Service (FMHS)

Lower extremity war wounds are characterized by high-energy trauma occasioning loss of complex and pluritissular substances. The support pipeline put into place by the French defense health service (SSA) is designed to rapidly evacuate the injured person from the scene of injury to mainland France, following initial surgery in the framework of a sequential tactic known as "Damage Control Surgery". This strategy is aimed at stabilizing the traumatized individual and enabling his evacuation. Patients are subsequently treated in a restorative surgery unit in a Hôpital d'Instruction des Armées (HIA), a level 1 trauma center (HIA Percy, HIA Saint-Anne) Cooperation between the plastic and orthopedic surgery specialties is essential insofar as it allows for surgical optimization aimed at saving the limb while restoring function to the greatest possible extent. Notwithstanding painstaking application of this common strategy, septic pseudoarthrosis remains the principal and most feared complication, at times rendering impossible any therapeutic solution other than amputation. Whether prosthetic or non-prosthetic, the rehabilitation provided by doctor/physiotherapists is conducive to patients' social and professional reintegration. The nation's duty to assist its wounded veterans is carried out with determination by the French defense ministry. As concerns lower extremity war wounds, the authors detail the reconstruction doctrine based on the 6/7/8/9 rule, in accordance with which strategies for repair of soft tissue and reconstruction of the lost bone substance have been developed.

Review of Scorpion Stings and Snakebites Treated by the French Military Health Service During Overseas Operations Between 2015 and 2017

Depending on their theatre of operation, French soldiers may potentially be exposed to scorpion stings and snakebites. Following the recommendations of a French military health service (FMHS) technical committee for envenomation, the FMHS provides antivenoms appropriate to each deployment. This work aimed to evaluate this risk of envenomation and to assess the antivenoms used by the FMHS in operational theatres since the creation of this committee in 2015. Cases were identified based on a review of temporary authorization of use application forms for the use of antivenom. Data were collected retrospectively from these forms, and prescribing physicians were contacted for any missing data. Between 2015 and 2017, 28 requests for temporary authorization of use were identified: 19 for Scorpifav (Sanofi-Pasteur, Lyon, France) and 9 for Fav-Afrique (Sanofi-Pasteur). The FMHS treated 15 soldiers and 4 civilians for scorpion envenomation with Scorpifav: 15 in Mali, 3 in Chad, and 1 in Niger. Systemic signs were observed in 7 patients. Two soldiers and 7 civilians were treated with Fav-Afrique for ophidian envenomation: 5 in Djibouti, 3 in Mali, and 1 in the Republic of Côte d'Ivoire. These 28 patients were treated without sequelae. Other than moderate erythema that resolved with an antihistamine, no adverse effects were reported. Medical evacuation to France was unnecessary. This study shows that the risk of envenomation for soldiers on deployment is low but real. Antivenoms used by the FMHS were efficient and well tolerated, preserving the operational capacity of deployed troops.

Blast injury of the hand related to warfare explosive devices: experience from the French Military Health Service

IntroductionThe objective was to report on the experience of the French Army Health Service in the management of blast injury of the hands related to warfare explosive devices.MethodsA retrospective study...

Rational and design of the T-STORHM Study: A prospective randomized trial comparing fresh whole blood to blood components for acutely bleeding trauma patients.

Massive hemorrhage remains the main cause of preventable death in combat settings and is also the main cause of year loss in developing countries. The management of these patients relies on blood transfusion and surgery. Time is a key factor, related to survival. Recent events highlight the need to be more efficient in the transfusion supply during terror attacks or mass casualties in civilian settings. Blood components therapy with a 1:1:1 ratio is associated with a decrease of mortality but encounters many logistic issues in those circumstances. Whole blood provides in one bag all the blood components in physiologic proportions with minimal amount of additive solution. Whole blood has been implemented in military as well as civilian settings worldwide. However, direct comparisons with component therapy in prospective clinical trials are scarce. Here we present the rational and the design of the T-STORHM (Trauma-Sang TOtal dans les Hémorragies Massives) trial. This prospective randomized multicentric clinical trial will test low titer group O whole blood to components therapy in the in-hospital management of trauma patients with massive hemorrhage. Sample size calculation, primary and secondary endpoints as trial blood products preparations are discussed. The trial is expected to start in 2019 in 6 civilians and military trauma centers. The French Military Health Service is promoting the study in collaboration with the French transfusion public service (Établissementfrançaisdusang).

Five years of prolonged field care: prehospital challenges during recent French military operations.

French military operations in the Sahel conducted since 2013 over more than 5 million square kilometers have challenged the French Military Health Service with specific problems in prolonged field care. To describe these challenges, we retrospectively analyzed the prehospital data from the first 5 years of these operations within a delimited area. One hundred eighty-three servicemen of different nationalities were evacuated, mainly as a result of explosions (73.2%) or gunshots (21.9%). Their mean number evacuation was 2.2 (minimum, 1; maximum, 8) per medical evacuation with a direct evacuation from the field to a Role 2 medical treatment facility (MTF) for 62% of them. For the highest-priority casualties (N = 46), the median time [interquartile range] from injury to a Role 2 MTF was 130 minutes [70 minutes to 252 minutes], exceeding 120 minutes in 57% of cases and 240 minutes in 26%. The most frequent out-of-hospital medical interventions were external hemostasis, airway and hemopneumothorax management, hypotensive resuscitation, analgesia, immobilization, and antibiotic administration. Prehospital transfusion (RBCs and/or lyophilized plasma) was started three times in the field, two times during helicopter medical evacuation, and five times in tactical fixed wing medical aircraft. Lyophilized plasma was confirmed to be particularly suitable in these settings. One of the specific issues involved in lengthy prehospital time was the importance to reassess and convert tourniquets prior to Role 2 MTF admission. Main challenges identified include reducing evacuation times as much as possible, preserving ground deployment of sufficiently trained medics and medical teams, optimization of transfusion strategies, and strengthening specific prolonged field care equipment and training.

Contribution of the French army health service in support of expertise and research in infectiology in Africa.

Historically, infectious diseases have caused more casualties than battle. The French military health service therefore developed a range of research on vector-borne diseases such as malaria and arboviruses, antibiotic resistance, infectious agents that can be used as biological weapons and vaccines. The main objective is to control naturally acquired or provoked infectious diseases and limit their impact on armed forces as well as on civilian populations in France or abroad, particularly in Africa and anywhere French armies may be deployed. The expertise of the military health service teams in manipulating agents requiring high level of biosafety precautions and in organizing and providing medical care in unnatural conditions, including the battlefield, associated with complementarity staff experience (physicians, biologists, epidemiologists, researchers, pharmacists, logisticians), has been used in the management of the Ebola outbreak in Guinea.

Has Current French Training for Military Orthopedic Surgeons Deployed in External Operations Been Appropriately Adapted?

The current evolution of surgical practices is increasingly trending toward hyper-specialization. For military surgeons, their practice in France does not differ from their civilian counterparts. In contrast, in external operations, they have to deal with specific war injuries in austere conditions. They are also required to take care of local populations. Therefore, specific training is necessary, and the French Military Health Service Academy (Ecole du Val-de-Grâce) Paris has set up a specific training called Advanced Course for Deployment Surgery (ACDS) in 2007. The aim of this study is to assess the relevance of this teaching regarding pathologies encountered during current conflicts. The activity of deploying orthopedic surgeons during the three recent major external operations (Afghanistan, Mali, and Central African Republic) has been retrospectively recorded in terms of global volume, types of trauma, status of patients who had been operated on, and indications. These data have been compared with teaching during the ACDS. Our study found a high variability in terms of operating volume, types of trauma, patients' statuses, and types of operations performed depending on the operation theaters. The volume of surgical activity carried out within Role 3 is much more important than that in Role 2 with more than half of the surgeries performed as scheduled surgery to the benefit of the local population. Within advanced Role 2 surgical structures deployed in Mali and Central Africa, more than 70% of the activity was performed as emergencies. Surgical indications were varied, ranging from emergency surgery to limb reconstructive surgery. A lot of non-orthopedic procedures such as vascular repairs and decompressive craniotomies were also performed. All of the encountered pathologies were taught during ACDS. The large variety and technical nature of the performed operations requires the training of highly qualified military orthopedic surgeons with both experience in war surgery and management of after-effects and complications. Orthopedists are also required to carry out procedures dealing with neurosurgery, general, and/or vascular surgery on missions. These data highlight the complexity of military surgeons' training along with the hyper-specialization of the civilian medical world. For more than 10 yr, French military surgeons have benefited from a training program called ACDS to meet these objectives. This initial training seems to be appropriated adapted in view of the managed pathologies.