Lessons from the battlefield: human factors in Defence Anaesthesia

Abstract

Anaesthetists in the Defence Medical Services spend most of their clinical time in the National Health Service and deploy
on military operations every 6–18 months. The deployed operational environment has a number of key differences particularly
as there is more severe trauma than an average UK hospital and injury patterns are mainly due to blast or ballistics. Equipment
may also be unfamiliar and there is an expectation to be conversant with specific standard operating procedures. Anaesthetists
must be ready to arrive and work in an established team and effective non-technical skills (or human factors) are important
to ensure success. This article looks at some of the ways that the Department of Military Anaesthesia, Pain and Critical Care
prepares Defence Anaesthetists to work in the deployed environment and focuses on the importance of human factors. This includes
current work in the field hospital in Afghanistan and also preparing to work for the Royal Air Force and Royal Navy. We highlight
the importance of human factors with reference to the type of case mix seen in the field hospital. We also detail the current
pre-deployment training package, which employs multiple educational tools including high-fidelity simulation.

Full text

REVIEW ARTICLES
Lessons from the battlefield: human factors in defence
anaesthesia
S. J. Mercer1*, C. L. Whittle 2and P. F. Mahoney3
1
Royal Navy, Royal Liverpool University Hospital, Liverpool, UK
2
Royal Air Force, Frenchay Hospital, North Bristol, UK
3
Royal Army Medical Corps, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Birmingham, UK
* Corresponding author. E-mail: simonjmercer@hotmail.com
Key points
†Defence Anaesthetists deal
with unfamiliar trauma very
different to routine NHS
practice.
†They work with different
standard operating procedures
(SOPs) and equipment in an
unfamiliar environment.
†Human Factors are essential to
ensuring success in the field
hospital team.
†Pre-deployment training offers
an opportunity to familiarize
with equipment, SOPs and the
deployed environment.
Summary. Anaesthetists in the Defence Medical Services spend most of their clinical time in
the National Health Service and deploy on military operations every 6–18 months. The
deployed operational environment has a number of key differences particularly as there
is more severe trauma than an average UK hospital and injury patterns are mainly due
to blast or ballistics. Equipment may also be unfamiliar and there is an expectation to be
conversant with specific standard operating procedures. Anaesthetists must be ready to
arrive and work in an established team and effective non-technical skills (or human
factors) are important to ensure success. This article looks at some of the ways that
the Department of Military Anaesthesia, Pain and Critical Care prepares Defence
Anaesthetists to work in the deployed environment and focuses on the importance of
human factors. This includes current work in the field hospital in Afghanistan and also
preparing to work for the Royal Air Force and Royal Navy. We highlight the importance of
human factors with reference to the type of case mix seen in the field hospital. We also
detail the current pre-deployment training package, which employs multiple educational
tools including high-fidelity simulation.
Keywords: education; military anaesthesia; training
The majority of Anaesthetists in the Defence Medical Ser-
vices (DMS) spend most of their clinical time in the National
Health Service (NHS) and deploy on military operations
every 6–18 months, depending on their role. Other clinical
staff are in a similar position and, despite having vast
experience in civilian hospitals, will find that the deployed
operational environment has a number of key differences.
These need to be addressed for the individual in pre-
deployment training.
The military hospital previously in Iraq and currently in
Afghanistan manages much more severe trauma than an
average UK hospital.
1
As a consequence, the injury patterns
seen with military trauma (mainly blast and ballistic injury)
are different from the blunt trauma that predominates in
UK civilian practice
2–4
(the exception to this is when explo-
sive attacks take place in the civilian environment).
5
In
order to ensure best evidence practice is adhered to, Clinical
Guidelines for Operations (CGOs)
6
have been devised for use
in the deployed environment. Summaries of some of the
pathways for ballistic, blast, and blunt trauma from CGOs
are shown in Figures 1–4.
Military clinical treatment protocols may well be
unfamiliar to the clinician who has not deployed before.
7
These include early and rapid use of blood and blood
products within an overall construct of ‘Damage Control
Resuscitation’ (DCR).
89
In addition, specialist anaesthetic
and surgical equipment comes as a standardized ‘module’
within a field hospital. It is highly likely that this will not be
the same as that used by a clinician on a daily basis in
their NHS environment. In essence, the individual will face
unfamiliar trauma, need to understand unfamiliar protocols,
and work with unfamiliar equipment. In addition, medical
units tend to change over at 3 or 6 months intervals.
Within this period, individual clinicians will be ‘trickle
posted’ in and out of the deployed unit for periods of 8–12
weeks. This means that the whole medical system needs to
be prepared to work in the deployed environment and
rapidly integrate individuals into the team when they
arrive. Human factors play an important role in this unique
clinical environment and some of those that need to be
addressed in the field hospital are described with illustrative
clinical cases in Tables 1–4. (These cases are not based on
any particular individual but do represent the type of injuries
and decisions faced by the deployed clinicians.)
Despite the above complexities, the clinical care and
effect delivered on operations has recently been reviewed
by the Healthcare Commission and found to be excep-
tional.
10
The training pathway to get the individual in tune
British Journal of Anaesthesia 105 (1): 9–20 (2010)
doi:10.1093/bja/aeq110
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with the environment, the clinician ready for the specific
casualty types, and the system ready to work in a complex
environment is key to achieving this. Specific pre-deployment
training courses allow individuals the opportunity to become
fully immersed in their new environment and allow familiar-
ization before arriving on operation.
Owing to the very busy schedule in the deployed environ-
ment, it is important from a human factors perspective that
individuals are comfortable with the unfamiliar equipment
and the environment.
11
First-rate human factors or non-
technical skills (NTS) have been shown to be important in a
busy operating theatre with the more effective clinician
Ballistic: Role 1
Pathways 1
Interventions
<c> ABCDE approach
Limbs
Haemorrhage control
Go to Sec 3
If appropriate to
re-examine wounds prior
to surgery, redress with
iodine-soaked gauze and
secure with crepe bandage
2
Treatment
guidelines
Go to Sec 3 3
1
Treatment
guidelines
Go to Sec 3 3e
Treatment
guidelines
Go to Sec 3 5a–c
Treatment
guidelines
Go to Sec 3 11i
Treatment
guidelines
Go to Sec 3 6a
Treatment
guidelines
Splint long bone injuries
Analgesia
Antibiotics
Fluid resuscitation
Benzylpenicillin 1.2 g i.v./i.m.
Pathways
Penetrating head injury
Low GCS = airway at risk:
Lateralizing signs = need
surgical assessment.
Antibiotics
Benzylpenicillin 1.2 g i.v./i.m.
Airway injury
Above cricothyroid membrane
think cricothyroidotomy:
Below cricothyroid membrane
think tracheostomy and
evacuate to surgeon
Chest
Antibiotics
Benzylpenicillin 1.2 g i.v./i.m.
Antibiotics
Abdomen
Internal bleeding?
Evacuate for surgery.
Consider need for NG tube.
Benzylpenicillin 1.2 g i.v./i.m.
Caveats
Check front and back
of casualty
Bullets and fragments
cross-cavities
Pneumothorax?
Haemothorax?
Critical decisions
Identify time-critical injuries
(non-compressible haemorrhage)
requiring urgent evacuation for surgery
C-collar is not required for penetrating
neck injury unless there are signs of
abnormal neurology
Fig 1 Ballistic trauma pathway: Role 1.
BJA Mercer et al.
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using them well as part of their working routine.
12
In a con-
flict environment, an alarm bell ringing may signify the need
to drop down flat on the floor (‘on your belt buckle’) to
protect you from an incoming mortar attack. This is different
from NHS where it might signify a fire alarm or the cardiac
arrest bleep.
Training to prepare for the operational environment is pro-
vided at a number of levels, with the aim to provide scenarios
Ballistic: Roles 2 and 3
Pathways 1 (Cont’d)
Penetrating head injury
Follow guidelines for Role 1
Plus consider RSI:
Obtain CT unless expectant (T4)
Antibiotics: cefotaxime 1
g i.v.;
add metronidazole 500
mg i.v.
if air sinus or middle ear
clinically breached
Airway injury
Above cricothyroid membrane
think cricothyroidotomy:
Below cricothyroid membrane
think tracheostomy:
Chest
move to emergency surgery.
Follow guidelines for Role 1
Plus antibiotics
Co-amoxiclav 1.2
g i.v.
(instead of benzylpenicillin)
Internal bleeding?
Confirm with FAST USS or DPL
Antibiotics
Co-amoxiclav 1.2
g i.v.
(instead of benzylpenicillin)
Abdomen
Interventions
<c> ABCDE approach
Penicillin allergy
Clindamycin 600
mg i.v. qds
or alternatively
Limbs
cefuroxime 1.5
g i.v. for fractures
+ metronidazole 500
mg i.v. for
complex compound fracture
with soft tissue injury
Fluid resuscitation
Tetanus prophylaxis
for the non-immune
Urinary catheter
with hourly measurement
for critical patients
Co-amoxiclav 1.2
g i.v.
(instead of benzylpenicillin)
Follow guidance for Role 1
plus antibiotics:
Go to Sec 3 6a
Treatment
guidelines
Go to Sec 3 3c
Treatment
guidelines
Go to Sec 3 3e
Treatment
guidelines
Investigations
FBC
Critical decisions
Consider absikute requirement for surgery
at Role 2 Enhanced, or whether transfer
to Role 3 is more appropriate
Decision must be tempered by casualty’s
condition, timeline to next Role, and
anticipation of further casualties inbound
Cross-match blood
Blood gases (I-STAT)
for critical patients
Urea and electrolytes
where indicated
Plain radiology/USS/Ct
where indicated
Fig 2 Ballistic trauma pathway: Roles 2 and 3.
Human factors in defence anaesthesia BJA
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that are as real as possible using simulation, where appropri-
ate. Simulation allows us to deliver facilitated learning and
set our own training agenda with pre-defined learning objec-
tives and instant feedback in a safe environment.
13
The
different levels of training understandably overlap and are
described below.
General training: individual based
In order to ensure that individuals are up to date with the
ever-changing operational environment, a service-specific
intensive pre-deployment package is mandatory before
deployment. It is important to realize that individuals are
Blast
1–2
Pathways
Perforated ear drums
Pattern 3
Pattern 2
Associated ballistic
injury?
Associated blunt
injury?
Associated burn?
Multiple fragments from mine
triggered near casualty
Injuries to face, head, chest,
abdomen, and limbs
In suicide IED consider
blood sample for
Hep B immunoglobin/
immunisation
HIV PEP
From handling mines: deminers
removing mines or children
playing with them. Severe
head, face, eye injuries
Pathways 2
Source: BMJ 1991;303:1509–12
ICRC (International
Committee of the
Red Cross) describe
3 injury patterns for
an antipersonnel mine.
Management
<c> ABCDE approach
Go to Sec 3 2d
Treatment
guidelines
Go to 1
Pathways
Go to 3
Pathways
Go to 4
Pathways
Blast lung
Is uncommon in survivors
who reach hospital
May develop over
24–48
h
Consider rFVlla
Pattern 1
Usually from standing on
buried mine
Usually sustain traumatic
amputation of foot of leg
Other leg often affected
Perforated TMs are not
a reliable indicator that
blast lung will develop
Hearing loss and/or
balance disorder requires
urgent ENT assessment
One or both legs may need
amputation
Injuries to genitalia are
common
Have a high index of suspicion for bowel
injury—clinical diagnosis, ultrasound
and CT can be inconclusive: diagnostic
peritoneal lavage may reveal vegetable
matter and raised amylase/white count
Fig 3 Blast trauma pathways.
BJA Mercer et al.
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not only deploying as clinicians, but also as members of the
armed forces and there is, in effect, no room to ‘carry passen-
gers’. Personnel have a responsibility to ensure that they are
physically and mentally fit enough to work and look after
themselves and their colleagues in a conflict zone. The
generic pre-deployment package is summarized in Table 5.
Professional training
There are differences in the way a deployed field hospital
functions compared with a typical NHS hospital. As stated
above, the clinical workload is also different. To ensure that
clinicians are more confident in dealing with these situations,
Blunt trauma
Pathways 3
Blunt head injury
Low GCS = airway at risk:
surgical assessment.
Lateralising signs = need
Fractured base of skull
CSF leak/panda eyes/
bruised mastoid
NP airway can be used
In head injury
Airway (basic)
Airway injury
C-spine
Collor + head blacks
If suspect spine injury
Spinal injury
Loss of motor power?
Loss of sensation?
Record level
Evacuate with full
immobilisation
Pelvic injury
Improvise a binder
Ex fix unstable injuries
Limbs
Haemorrhage control
Splint long bone injuries
Analgesia
Antibiotics
Fluid resuscitation
For compound fractures
If appropriate to
re-examine wounds prior
to surgery, redress with
iodine soaked gauze and
secure with crepe bandage
Interventions
<c> ABCDE approach
Go to Sec 3 2
Treatment
guidelines
Go to Sec 3 11i
Treatment
guidelines
Go to Sec 3 6a
Treatment
guidelines
Go to Sec 3 3
Treatment
guidelines
Go to Sec 3 3f
Treatment
guidelines
Go to Sec 3 3a
Treatment
guidelines
Go to Sec 3 5a–c
Treatment
guidelines
Go to Sec 1 Contents
Preparation
Above cricothyroid membrane
think cricothyroidotomy:
Below cricothyroid membrane
think tracheostomy:
move to emergency surgery.
Chest
Pneumothorax?
Haemothorax?
Flail chest?
Internal bleeding? Evacuate
for FAST USS +/– surgery
Consider need for NG tube.
Abdomen
Caveats
Critical decisions
Trauma Team Acttvation
Criteria and Roles
Check front and
back of casualty
Log roll
Fig 4 Blunt trauma pathways.
Human factors in defence anaesthesia BJA
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there are several professional courses that they are expected
to attend in the build up to their deployment. Elements of
these overlap and cover aspects of team training.
Battlefield Advanced Trauma Life Support Course
14
This course historically takes its roots from the Advanced
Trauma Life Support Course
15
and has been continuously
updated to take into account best evidence and clinical experi-
ence. The most common cause of preventable death on the
battlefield is external haemorrhage. This has led to the tra-
ditional ABC approach to trauma resuscitation being revisited
for the ballistic environment and presented as a new paradigm:
,C.ABC (where ,C.represents the need to control cata-
strophic haemorrhage as the over-riding priority).
7
There are
four discrete levels of care covered on the course, all of which
require human factors training. This is summarized in Table 6.
There is an interactive emphasis on teaching using
part-task trainers and low-fidelity manikins in addition to
interactive case-based workshops. Reinforcement of the key
principles such as ,C.ABC and practice using the specific
standard operating procedures
6
is encouraged to promote
communication and teamwork during trauma moulages.
Specific communication with external bodies (such as acti-
vating the transfer team) is also rehearsed using the military
communication tool the ‘9 liner’
16
that may be unfamiliar to
some course participants.
Tri-Service Anaesthetic Apparatus Simulation Course
This is a 1-day course held at Cheshire & Mersey Simulation
Centre (under contract to the MoD) and concentrates on
the familiarization and use of the Tri-Service Anaesthetic
Apparatus (TSAA) in crisis situations. This is a piece of anaes-
thetic equipment that has served the military well since it
was formally described in the early 1980s.
17
It is no longer
available to use in the NHS as it has no CE Mark. Although
the current field hospital in Afghanistan uses modern
Table 1 A casualty with multiple injuries
Scenario Decisions Key human factor elements
A 22-yr-old soldier arrives at the field
hospital via the Medical Emergency
Response Team (MERT).
29 30
He has been
injured by an improvised explosive device
(IED) and has multiple injuries
This patient will need to go to theatre in the
very near future for exploration and
debridement of wounds. The timing of all
these procedures needs to be decided
Assemble trauma team as per hospital protocol
†A balance must be reached in calling the
trauma team, who may be asleep and have a
busy workload the next day. There is no
European Working Time Directive or shift
system in place, so if people are continually
woken up fatigue will result.
†Reported severity of injury in the ‘9 liner’
often does not eventually warrant a trauma
team call
16
Should the patient remain in the emergency
department or move directly into theatre?
Mobilize resources
†Radiographer to prepare CT Scanner
†Laboratory staff to deal with the possibility of
a massive transfusion requirement
All team members must be aware of their
environment
†Team composition (Fig. 5)
†Individual roles
†Equipment
†Standard operating procedures
Cross-check and double-check
11
†Primary and secondary survey as per BATLS
14
†Communicate findings to team
Cognitive aids
†Local SOPs
†Clinical Guidelines for Operations
6
†Surgeon General Policy Letters
Careful anticipation and planning ensure that
equipment is in the correct location and is
functioning
Leadership change if patient is transferred to
theatre
BJA Mercer et al.
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anaesthetic machines, there are instances where anaes-
thetics may be required to be delivered using the TSAA
such as commando or air assault deployments. Training
scenarios are designed to allow candidates to get use to
this piece of equipment, as familiarization is also important
for effective NTS.
11
Performance of anaesthetists in dealing
with emergencies has been shown to improve with this
type of simulation training.
18
If this is incorporated with a
focused debrief, technical skills have also been shown to
improve.
19
A recent survey of UK military anaesthetists has
provided evidence of general support for simulation in pre-
deployment training.
20
Field surgical team
Military Operational Surgery Course
This course takes place in the Simulation Suite at the Royal
College of Surgeons and allows scenarios to be rehearsed
Table 2 Multiply injured patient arriving in theatre with cardiopulmonary resuscitation ongoing.
a
‘Right Turn Resuscitation’. This is a local term that reflects the layout of the hospital in Bastion. From the front entrance, a right turn takes the
patient directly into the operating theatre. A left turn moves them into the emergency department.
b
‘RoTEM’ stands for ‘rotation thromboelastometry’ and is an enhancement of classical thromboelastography
Scenario Decisions Human factor elements
A 24 yr old is involved in a vehicle explosion from
an IED. He arrives via the Medical Emergency
Response Team (MERT) and has multiple injures
Whether to proceed with a thoracotomy
or manage the patient solely by rapid i.v.
infusion
A common scenario in the current Military theatre
environment (45 ‘right turn resuscitations’ in the
period of July–October 2009)
31
†Prior rehearsal
†Acquisition of preformed mental models built
up from prior experience
†Continuous practice and refinement has led to
much success
32
†Individuals are tuned into to their
environment, knowing their roles,
theatre-specific equipment and
communication issues
CPR is in progress Where to place i.v. lines as patient may
have lost limbs and skin and soft tissues
may be damaged by blast or thermal
injury
Cognitive aids (one such SOP has recently been
published)
33
A decision has already been made so that the
patient makes a ‘right turn resuscitation’
a
(Fig. 6)
and by-passes the emergency department
turning right and straight into theatre
Early assembly of the trauma team. In addition, the
anaesthetic team will have a person responsible for
†Leading the team
†Airway management
†Intravenous catheter insertion
The trauma team is assembled in theatre If there is a high index of suspicion that a casualty
may require ‘right hand turn into theatre’ equipment
such as the level one rapid infuser and central line
kit will be set up ready to go in both locations
The most likely reason for his severe state is
hypovolaemic shock
Decisions made quickly but with discussions
between the anaesthetic and the surgical team
†Anaesthetist aware of the stage of the
resuscitation
†Surgeon focused on thoracotomy
Communication with surgeons and anaesthetists is
vital during damage control surgery
8
as bleeding
can be due to a cause amenable to surgery or due to
derangement of clotting that could be corrected as
guided by the RoTEM
b
There is an element of ‘crowd control’ that requires
effective leadership
Priorities are set dynamically and the situation is
constantly re-evaluated
Additional communication with
†Laboratory staff
†Intensive care
Human factors in defence anaesthesia BJA
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with surgeons, anaesthetists, and operating department
practitioners. It is intended to involve emergency depart-
ment physicians, and other professions allied to healthcare,
as the course develops to allow a truly multidisciplinary
approach to patient management. Scenarios have been
designed to reflect current practice in the field hospital in
Afghanistan with the input of subject matter experts who
have recently returned from the conflict. They concentrate
on a number of important issues such as DCR
8
and burns
management. The availability of the wireless manikin,
Table 3 A multiply injured patient is anaesthetized in the operating theatre
Scenario Decisions Human factor elements
Multiply injured patient anaesthetized in
the operating theatre for damage
control surgery
Sequence of surgical procedures
depending on the priority
Clinical situation that does not frequently occur in routine NHS
practice
There may be multiple surgical teams The time spent in theatre is limited
when performing damage control
surgery
34
Pre-deployment training
†Familiarization with environment
†Familiarization with equipment
Need to return to CT after
thoracotomy
SOPs
6
to encourage teamwork and communication, effective
leadership and followership
Is a laparotomy required? Leader must
†Communicate with the surgical teams when to operate and
when to pause depending on the patient’s physiology and
the stage of the resuscitation
†Coordinate the anaesthetist responsible for vascular access
†Coordinate the anaesthetist responsible for airway
management
†Coordinate OPDs running the ‘level one’ infusion device
†Maintain situational awareness—crucial to success, as
anticipation and planning for frequent changes in condition
will be necessary
The process of achieving vascular
control in damaged limbs
Patient’s condition and management are constantly re-evaluated
in case changes need to be made to the original plan
Decision to halt surgery to allow a
period of physiological stability on
ITU
Additional communication with
†Laboratory
†ITU—decision can be made if evacuation to Role 4 (Royal
Centre for Defence Medicine) is required and the CCAST
team needs to be mobilized from RAF Lyneham
Table 4 A multiply injured patient anaesthetized and receiving large-volume fluid replacement
Scenario Decisions Human factor elements
Multiply injured patient is anaesthetized in
the operating theatre and receiving a
large-volume fluid replacement
Where to site IV access (current practice
is a subclavian CVP line). Will be
influenced by site of injury
Ongoing experience of dealing with damage control
resuscitation has allowed the practice and refinement of
this process based on that experience
Type of fluid to administer? Priority is to
give blood and blood products
It is important that all members of the team are ‘singing
from the same hymn sheet’ (working in a coordinated
manner, with shared goals and common procedures)
The rate of fluid administration? The use of SOPs
33
to improve teamwork and
communication
The clinical parameters that are being
chased
Communication
†With the team controlling the ‘level one infuser’—
when to start
†Laboratory staff
†Intensive care
†Hospital Management Cell (HMC)
Monitoring and management of
hyperkalaemia and hypocalcaemia
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SimMan 3G
w
(Laerdal Medical Ltd, Orpington, UK), has
allowed scenarios to begin with a warning call from the
MERT en route with a patient to the emergency department.
Simulation provides the opportunity to bridge any edu-
cational gaps, particularly for team training in DCR.
8
This course is constantly evolving, and in order to provide
the highest fidelity, efforts have been made to recreate the
field hospital operating theatre or emergency department
including all the equipment that would be available. This is
particularly important as candidates are given the opportunity
to acquaint themselves with the environment they will be
working with on deployment, again key to effective NTS.
11
The manikin is also ‘mocked up’ depending on the injuries
received including burnt military uniform (CS95-Desert), and
simulated gunshot wounds. Diesel fumes in the air of the
simulation suite simulate the smell of aviation fuel familiar
to those who have deployed. All scenarios are video recorded
and are followed by a focused debrief concentrating on correct
patient management with an emphasis on human factors. An
experienced faculty is present and it is important to have cred-
ible subject matter experts present to facilitate the debriefing
of technical skills. Recently, a military trainee has been able to
undertake a clinical fellowship in simulation in healthcare to
gain experience in running such courses.
21
The hospital exercise ‘HOSPEX’
This is held at Army Medical Services Training Centre
(AMSTC) near York and is in effect a macro-simulation that
Table 5 Generic pre-deployment package
Pre-deployment element Key features
Operational briefings Introduction to the environment in
terms of
†Climate
†Language
†Culture
†History
†Political background
†Aims of the operation
Familiarization with
theatre-specific equipment
Personal protective equipment
(e.g. combat body armour) worn
for periods of time to allow
familiarity
Weapons handling test Issue of SA-80 rifle
Demonstration of safe operation,
maintenance and disassembly
Weapon firing test
Field craft Additional field craft is depending
on deployment
Practice in field environment Foot patrolling
Actions on ambush in a vehicle
Actions on land mine discovery
Fitness test Mandatory (parameters depend on
their age and gender)
Trauma team roles and positions
Preparation 4
Airway
Specialist
Airway
Assistant
Radlographer
Nurse
1
Nurse
2
Specialists
Trauma Team
Leader
Scribe
(Nurse/Medic)
Doctor
1
Doctor
2
Fig 5 Trauma team roles and positions.
Table 6 Levels of care rehearsed on BATLS Course
Level of care What is involved
Care under fire Treatment is delivered in a non-permissive
environment. The clinician is actually treating
and evacuating their casualty while under
enemy attack
Tactical field care Treatment is delivered at the point of
wounding in a permissive or semi-permissive
environment
This process not only introduces the very
dangerous and hazardous environment, but
also allows rehearsal of key non-technical
skills such as leadership, communication, and
team working. Other members of the team
are encouraged to adopt effective
followership
Field
resuscitation
Care is conducted at what is essentially a field
dressing station (usually denoted Role 1).
Equipment issues play a strong role, as does
communication with the field hospital and
Medical Emergency Response Team (MERT)
The team available is not necessarily all of a
medical background, with chefs and gunners
being required to hold fluids and act as
runners to obtain equipment
Advanced
resuscitation
This is team-based and consultant-directed
resuscitation in a field hospital (usually
denoted Role 3)
Human factors in defence anaesthesia BJA
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involves the whole of the deploying field hospital.
22
An air-
craft hanger has been ‘mocked up’ to represent the exact
outline of the field hospital with all the available equipment
and personnel being present. In order to provide a fully
immersive experience, candidates dress in the same cloth-
ing that they will wear on deployment, including body
armour, CS95 clothing, and desert boots. This exercise pro-
vides an opportunity for teams who are deploying together
to practice simulated scenarios and rehearse how they
would work together in the field hospital. The NHS operating
theatre has been described as a highly complex environ-
ment similar to an airplane cockpit
23
and this is not differ-
ent in the field hospital emergency department or theatre
where human factors play an important role in patient
safety and clinical outcome.
In order that HOSPEX be successful, it is important that
the entire multidisciplinary team be present including admin-
istrative medical commanders. This ensures that admission
and discharge processes can be tested and real-time leader-
ship, communication, decision-making, and other crisis man-
agement skills practiced. HOSPEX uses real-life scenarios that
have been devised by subject matter experts to ensure that
the exercise is as realistic as possible and are constantly
updated based on current operational experience. Simulation
can provide an additional means to explore any potential
vulnerability that exists in healthcare delivery,
24
particularly
Background
‘Right turn’ refers simply to the layout of the field hospital in Camp Bastion:
It is a left turn into Resuscitation Bay 1, but a right turn into the operating theatre
(directly opposite Resuscitation Bay 1). The term is applied to a casualty who moves
directly into the operating theatre on arrival. It has emerged as an increasingly useful
process in the resuscitation of combat casualties who are at the very edge of their
physiological envelope. This protocol does not by-pass Emergency Department care
as such, as the ED team moves into the operating theatre for the multidisciplinary
resuscitation.
Which patients?
Decision points
A decision to ‘right turn’ can occur at two points:
• Receipt of the advance pre-hospital information (JCHAT)
• Ambulance bay triage
Note: an earlier decision is preferred so that the team can pre-position itself.
Actions
(a) ED Team operating theatre
• Team Leader
• Nurse Level 1 Blood Warmer Teams
(b) Team leadership starts with the Consultant Emergency Medicine (positioned
at the foot end) and is passed on to the Consultant Anaesthetist (at the head end)
once rapid infusion lines are secured, fluid resuscitation with blood products has
started, the patient is anaesthetized, and the initial imaging is complete (e.g. FAST
scan and/or critical plain films.
(c) Anaesthetists
• Manage: ‘A’ and central access
• Massive Transfusion Protocol
(d) Surgeons
• Surgical intervention will start immediately in cardiac arrest or peri-arrest, if
thoracotomy and aortic cross-clampin
g
is indicated.
Surgical time critical
• Traumatic cardiac arrest with CPR in progress
• Limb trauma
• Torso trauma With signs of critical hypovolaemia
Æ
Fig 6 Right turn resuscitation.
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as all aspects of the field hospital team are exercised
together.
Aviation environment
Since the mid-1990s, the RAF’s ‘Critical Care Air Support
Team’ (CCAST) aims to provide UK standard levels of critical
care to ventilated patients requiring repatriation. Over the
last decade, CCAST has moved 464 priority 1 and 2 critical
care patients. The team is prepared to operate in extreme,
unusual, tiring, and often-unpredictable circumstances for
up to 48 h. Maintaining high clinical standards requires
exceptional teamwork and this is achieved through a strin-
gent training schedule.
The CCAST team is composed as a minimum of a Consult-
ant Anaesthetist, Intensive Care Nurse, Flight Nursing Assist-
ant, and a Medical Equipment technician. More recently, the
team has been reinforced by a second Intensive Care Nurse
and wherever possible, a senior anaesthetic trainee. The
team spends a month on ‘6 hours notice to move’ and by
the time the CCAST first meets their patient, they may have
been travelling for up to 16 h. On average, a single complete
aero-medical mission can take up to 36 h from first activation.
Close interaction with the aircrew is required while simul-
taneously providing clinical care. This is considerably more
challenging due to the environmental stressors including
additional noise, vibration, changes in ambient light, temp-
erature, pressure, humidity, and acceleration forces and
these have been shown to affect human performance.
25
In
addition to the difficulties of caring for a patient during
flight, the CCAST team will experience disturbed biological
rhythms, related to sleep disturbance as a consequence of
increased speed and trans-meridian travel.
Every member of the team undergoes regular equipment
training and this is refreshed on the CCAST(E) course (Equip-
ment). Training starts with regular familiarization flights to
allow new members to acclimatize to the aviation
environment stressors before having to focus on their clinical
roles. Simulated environments such as a ‘Hercules Rear Crew
Trainer’ and ‘Chinook Simulator’ allow team training to take
place with immediate focused human factors debrief. An
understanding of the requirements of the aircrew is also
essential, so that both the clinical and aviation teams can
interact effectively in the decision-making processes.
Maritime environment
Deploying as an anaesthetist on a maritime platform for the
Royal Navy may involve working on one of the aircraft car-
riers HMS Illustrious or HMS Ark Royal, which have surgical
capability, an amphibious ship such as HMS Ocean or the
Primary Casualty Receiving Ship (PCRS), RFA Argus. This pro-
vides the opportunity to work with a theatre team in
another unique and different environment. Environmental
and equipment familiarization is vital and is an ongoing
process that begins on joining the Royal Navy. Doctors,
regardless of their career path, undergo an intensive New
Entry Medical Officers Course (NEMO Course). Not only does
this introduce candidates to the military requirements to
serve at sea, but also it involves a number for short
courses. The initial and pre-deployment training is summar-
ized in Table 7.
Anaesthetic trainees
Currently, operations are at a high tempo, but we must
prepare to train junior anaesthetists to deploy even in
times of relative peace. Recently, a military training module
has been approved by the Royal College of Anaesthetists
and simulation has been suggested as a means of delivering
some of its components.
26
The syllabus includes leadership,
communication, and team-working skills.
Table 7 Maritime initial and pre-deployment training
Combat Casualty Care Course Based onboard a warship berthed in a training establishment. Opportunity to get to grips with
basic ships knowledge in the context of treating and transferring simulated casualties. Key
decision-making and leadership skills are rehearsed. Communication is important not only
with the clinical team but also with the crew who are driving the ship
Fire-fighting Training Rehearsal practicing as part of the fire-fighting team. Using real equipment
Chemical, Biological, Radiological, Nuclear and
Damage (CBRN) Control Course
CBRN background. Rehearsal treating casualties with the fully protective clothing.
Demonstrates the difficulties of working in this environment and the additional stresses
provided by the protective clothing
Damage Repair Instructional Unit (DRIU) Damage control simulator based at the Phoenix NBCD School at HMS Excellent. Experience
flood damage in a moving ship in scenarios involving ship grounding and damage from enemy
fire
Candidates perform damage control tasks such as hammering wooden blocks into holes in the
ship’s hull in freezing cold water, with smoke and noise from flood alarms. In essence, this is
the most realistic mock-up of a ship about to sink
Basic Sea Survival Course Introduction to the process of abandoning a sinking vessel including manning a life craft and
protective clothing
Helicopter Ditching Escape Training (Dunker) Ensures familiarity with the layout out a helicopter cabin and the procedures if it were to ditch
over water
Human factors in defence anaesthesia BJA
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The future
Data on all major trauma casualties treated by the DMS are
collected by Trauma Nurse Coordinators and returned to
the Joint Theatre Trauma Registry at RCDM.
27
This is analysed
for emerging injury patterns and to look for clinical issues
that have been done well or could be improved upon.
These lessons are used to feedback to the deployed teams
at the weekly Joint Theatre Clinical Case Conference
28
(JTCCC) and into the training courses described above.
Specific clinical issues may also be worked through with
the Combat Casualty Care Group at DSTL Porton Down to
identify areas that need urgent research. Results from this
research are in turn fed back into the training and develop-
ment pathway for those about to deploy.
Conflict of interest
This article represents opinion of authors and not necessarily
that of the Ministry of Defence. This article has been security
cleared by the Ministry of Defence for publication in the
British Journal of Anaesthesia. All figures are crown copyright
and permission to include them in this article has been
granted.
Funding
No funding was received for writing this article. The authors
have no commercial interests to declare but are involved in
the design and delivery of pre-deployment training to
Defence Anaesthetists.
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