Share and share alike…
How to share best practice, civilian and military, was the theme for the joint
conference held 14 June 2013 for the RCN Critical Care and In-flight Nursing Forum
and Defence Nursing Forum. Here we showcase the speaker abstracts that best
demonstrate the military contribution to ‘sharing best practice’ with our civilian
colleagues. DNF Chair Maj Chris Carter QARANC writes.
Keynote speech: how will the future look?
Col Bates D L/QARANC, Defence Nurse Adviser, SG Department
The support to personnel injured on operations is of an excellent standard because all Armed
Forces personnel are supported by dedicated and comprehensive medical services, including
mental health support (Care Quality Commission 2011). This must be ensured and assured
post-2014 when combat operations will have ceased in Afghanistan.
The Development, Concept and Doctrine Centre’s Strategic trends programme: global
strategic trends out to 2040 (UK Ministry of Defence (MoD) 2012), assesses that the UK will
continue to have a global influence in a world that is threatened with environmental disasters
as well as those caused by humankind, including war, for which the Defence Medical Service
(DMS) and its nurses need to be prepared.
Individuals and teams will be training for smaller, more frequent, difficult and possibly
distant missions. These missions are likely to be conducted by all three services (joint), by
military coalitions (combined) and other government departments, international organisations
and non-governmental organisations, including contractors (integrated). This approach
presents opportunities such as sharing best practice, economic leverage and gearing capability
but also challenges, in particular, governance across organisations (Bullivant 2011).
The Defence Nursing Vision and Intent, as part of the DMS Sub-Strategy (MoD 2012),
recognises this future need and the need to research and invest in improvements to remain a
world leader. It is preferable to do this in partnership rather than competition but is difficult
to be convincing in an age of austerity.
The one constant will always be people and any health and care delivery system needs to
ensure and assure that people’s needs are prioritised and appropriately resourced.
The paper is intended to provoke discussion within the critical care, in-flight and defence
nursing communities, which will contribute to the future delivery of nursing effect to people
and patients.
Recommended reading
 John Bullivant (2011), Integrated governance II – governance between organisations.
Available at: http://good-governance.org.uk/Products/integrated-governance-II
GBO.htm (Accessed 4 June 2013) (Web).
 Ministry of Defence Development, Concepts and Doctrine Centre (2012) Strategic
trends programme: global strategic trends out to 2040, Shrivenham: MoD.
Catastrophic haemorrhage
Dr Emrys Kirkman, Principle Scientist, DSTL Porton Down
Haemorrhage is the leading cause of military battlefield deaths and the second leading cause
of death in civilian patients after trauma. Addressing problems associated with severe blood
loss is the subject of intense research by a number of groups worldwide. A variety of
techniques have been developed to help control catastrophic haemorrhage, which is the first
priority in seriously injured patients. Once the bleeding has been controlled and immediate
issues such as ensuring a patent airway and adequate breathing have been achieved, several
pathophysiological problems need to be addressed. Sufficient tissue oxygen delivery needs to
be maintained to sustain life and, if possible, limit physiological deterioration during the
evacuation to hospital. Competing challenges include ensuring adequate tissue blood flow
whilst minimising the risk of iatrogenic re-bleeding.
In collaboration with the Royal Centre for Defence Medicine we have developed a
resuscitation strategy called ‘Novel Hybrid’ (NH) to address this issue during prolonged
evacuation, especially if there is concomitant lung damage e.g. blast lung after explosive
injuries. NH involves early hypotensive resuscitation, followed after approximately one hour
by a revision of the target blood pressure to normotensive levels. This has been shown to
improve survival after combined blast and haemorrhage and reduce physiological
deterioration after haemorrhage, even in the absence of blast. A related problem involves the
development of acute trauma coagulopathy, which affects 3040% of seriously injured
casualties. The pathophysiology of this condition is currently being examined. Significant
clinical advances include early, proactive, use of blood products (for example, fresh frozen
plasma) in addition to packed red cells.
Finally, haemorrhagic shock and the reperfusion associated with resuscitation leads to
ischaemia-reperfusion injury and systemic inflammatory responses. A range of adjuncts
(drugs) have been proposed as potential treatments to ameliorate this condition and future
advances have seen some of these incorporated into early resuscitation strategies.
Intended learning outcomes
At the end of this session, participants should be able to:
 discuss strengths and weaknesses of pre-hospital fluid resuscitation strategies
 explain potential causes of acute trauma coagulopathy
 identify potential adjuncts to reduce secondary organ damage after haemorrhage and
resuscitation.
Recommended reading
 Brohi K et al. (2007) Acute traumatic coagulopathy: initiated by hypoperfusion.
Modulated through the protein C pathway? Annals of Surgery, 245, pp.812–8.
 Kirkman E et al. (2011) Blast injury research models. Philos Trans R Soc Lond B Biol
Sci, 366, pp.144–59.
 Watts S (2013) Military trauma research at Porton Down – a view from the benches.
Journal of the Association of Surgeons of Great Britain and Ireland, 39, pp.29–31.
Military patient pathway
Sgt K Scott, Intensive Care Nurse, 16 Medical Regiment and FS W Hughes,
Intensive Care Nurse, Royal Centre for Defence Medicine
Injuries sustained within the operational environment present unique triage, diagnostic and
management challenges. The clinical treatment along the various stages of the evacuation
chain back to Role 4 is paramount. This presentation will outline the journey of a British
soldier injured in Afghanistan and aims to focus on the pathway from point of wounding on
the battlefield through to their discharge from hospital and further rehabilitation.
Initial treatment upon wounding is delivered by medics on the ground. This care continues
during the evacuation by the medical emergency response team (MERT). The evacuation is
by helicopter to the UK Field Hospital (Role 3), Helmand Province, Afghanistan, located at
Camp Bastion. Upon arrival at Role 3 the patient is assessed, operated upon as required and
transferred to critical care. Here, the patient will await aeromedical evacuation (AE) back to
the UK by the critical care air support team (CCAST). Once in the UK the patient is admitted
into Role 4. The patient will receive treatment from various specialities within the Queen
Elizabeth Hospital and the Royal Centre for Defence Medicine (RCDM). The extensive
welfare support network within RCDM will then support the patient and their family.
Intended learning outcomes
By the end of this session, participants should be able to:
 identify key areas of treatment to wounded soldiers
 describe the various stages involved in the patient journey
 understand the roles involved within the patient journey.
Field Intensive Care
SSgt J Sessions, Intensive Care Nurse, 16 Medical Regiment
This presentation looks at the development of critical care nursing within the military field
hospital. It highlights some of the treatments service personnel receive whilst on the
battlefield through to the evacuation phase back to the UK. A historical review of conflicts
shows that there have been advances that are now being seen in civilian practice. Finally it
takes a look at the challenges faced with nursing in austere environments and how the
military train prior to deployment.
Intended learning outcomes
By the end of this session, participants should be able to:
 learn how military field hospitals have evolved through various conflicts
 understand the role of critical care within the military field hospital
 understand the transition of practice from military to the NHS.
Recommended reading
 Henning JD et. al (2009) Military intensive care part 1 – a historical review. Journal
of the Royal Army Medical Corps, 153 (4), pp.283–5.
 Thompson J (2011) Caring for critically injured soldiers. Nursing Times. 107. (1),
p.11.
Maritime intensive care
CPONN C Maguire
The aim of this presentation will be to give an overview of maritime nursing, with specific
reference to the critical care capability. An outline of the Role 1–4 patient journey will then
go on to concentrate on looking at the teams involved at each stage.
The main content of the presentation will concentrate on the role of the primary care
receiving facility and the role of the deployed critical care nurses on Role 2 afloat.
Intended learning outcomes
By the end of this session, participants should be able to:
 understand the joining procedures of the QARNNS and how to become a critical care
specialist nurse in the Royal Navy
 identify the key features and facilities onboard the Primary Casualty Receiving
Facility, RFA Argus
 understand the role of the critical care nurse when deployed as part of the Role 2
afloat team.
Recommended reading
 Joint Doctrine Publication 4-30, Medical support to joint operations (2nd ed).
Massive transfusion and rotational thromboelastometry (ROTEM)
Sgt A Coull, Intensive Care Nurse, Royal Centre for Defence Medicine
The presentation will briefly look at the overarching principles of treatment for battlefield
casualties requiring massive transfusion from point of wounding to critical care. Initial
management of these casualties will be described.
Goal directed resuscitation using rotational thromboelastometry to guide correction of
coagulopathy will be discussed in detail. The role of the critical care nurse in addressing the
lethal triad of trauma will also be examined.
Intended learning outcomes
By the end of this session, participants should be able to:
 state the lethal triad
 correctly identify transfusion requirements based on ROTEM
 describe the critical care nurses role in management of coagulopathy in the trauma
patient.
Recommended reading
 Dorna C et. al (2010) Feasibility of using rotational thromboelastometry to assess
coagulation status of combat casualties in a deployed setting. The Journal of Trauma,
69 (Suppl 1), S.40–48.
 Jansen J et. al (2009) Damage control resuscitation for patients with major trauma.
British Medical Journal, 338, pp.1436–40.
 Tieu H et. al (2007) Coagulopathy: its pathophysiology and treatment in the injured
patient. World Journal of Surgery, 31, pp.1055–64.
Military ethics
Capt JP Nola, 256 (V) Field Hospital
This presentation will examine the ethical framework within which all nurses work and
examine specifically how this applies to the defence nursing context. Specific issues
including consent and capacity, the treatment of detainees and scope of practice will be
considered. The tools and guidance available to guide defence nursing in their decision
making will be outlined.
Intended learning outcomes
By the end of this session, participants should be able to:
 understand the ethical framework within which nurses registered with the UK NMS
work within
 understand the Defence Operational Nursing Competencies (DONC) core competency
related to ethical decision making
 be able to use the high-level principles for ethical decision making.
Recommended reading
 BMA: Armed forces decision making tool kit
 the Geneva Conventions
 Values and standards of the British Army.
‘It’s not all about the trauma!’
Capt Carter C, Intensive Care Nurse, 16 Medical Regiment
The majority of admissions to military critical care units will be due to battlefield trauma,
however a small proportion will be due to non-traumatic injuries, termed disease and nonbattle injuries (DNBI). These patients potentially provide challenges for the deployed nursing
teams due to the variety and types of DNBI conditions exposed to deploying personnel. There
is very little published on this patient group within the professional arena, therefore this
presentation will explore military critical care case mix and discuss the needs of the nontrauma patient in the military critical care unit.
Intended learning outcomes
At the end of this session, participants should be able to:
 explain the term ‘disease and non-battle injury’
 explore the impact of DNBI patients within the deployed critical care unit by using
examples and case studies
 explain military critical care practices.
Recommended reading
 DCDC (2011) Joint Medical Doctrine. JDP 4-03. 3rd Ed.
 Delacour H et. al (2010) Norovirus: a challenge for military forces. Journal of the
Royal Army Medical Corps, 156 (4), pp.251–4.
 Porter D et. al (2009) Medical conditions requiring intensive care. Journal of the
Royal Army Medical Corps. 155 (2), 1220124.
Conclusion
Overall the event was well evaluated, and the RCN DNF and Critical Care and In-Flight
Nursing (CCIF) steering committees would like to thank everyone’s contribution to this
event. Plans have already begun for the next DNF Conference, which will be held on 19–20
March 2014 at RCN HQ in London. The theme of this conference will be ‘Contingency
operations – are we ready?’ and will focus on all specialities within defence. A call for poster
abstracts has begun and details of this conference and the DNF can be found at
www.rcn.org.uk.
chris.carter946@mod.uk
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