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Abstract
Introduction During previous deployments of the British Armed Forces, a significant proportion of aeromedical evacuations were accounted for with recurrent symptoms from a known disease that had often triggered occupational medical downgrading. Many servicemen and women had deployed inappropriately, and by doing so became a burden on the deployed medical facilities. Commanders performing systematic medical risk assessments prior to departure might have prevented these individuals from deploying. This study was designed to assess the avoidable burden from recurrent disease during the current Afghanistan operation.
Methods A cross-sectional study reviewing the hospital and computerised primary care medical records of consecutive patients admitted under the General Physicians to the Role 3 Hospital in Camp Bastion over 9 months from April 2011. The occupational medical grading, diagnosis, disposal and whether the disease was recurrent were recorded.
Results Of 270 patients admitted, 14 (5.2%) were medically downgraded. The computerised records were unavailable for 31 (11.5%) patients. All those patients who were medically downgraded were graded ‘Medically Limited Deployable’. In the downgraded group, only one patient presented with recurrent symptoms from their pre-existing condition (Crohn's disease). In the non-downgraded group, two patients presented with symptoms relating to their previous diagnoses. One presented with a second heat illness and should have been medically downgraded and not have been deployed, while the other patient had previously been investigated for recurrent syncope and was upgraded 6 months prior to deploying. All three patients underwent aeromedical evacuation but only two of these were considered to have been avoidable.
Discussion The number of general medical admissions to the Role 3 Hospital due to a pre-existing disease is very low.
- INTERNAL MEDICINE
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Key messages
Historically deployed patients have frequently been admitted to the field hospital due to a known chronic disease.
These diseases might have been detected at the commanders’ medical risk assessment prior to deployment.
A review of General Internal Medicine admissions to the hospital in Camp Bastion was undertaken, showing relatively few admissions due to a known chronic disease.
These findings are in contrast to previous deployments and may reflect the effect of lessons successfully learned over a decade of continuous operations.
Introduction
A key factor in maintaining the morale and fighting capability of an armed force is the minimisation of casualties. To achieve this aim, medical support arms use a number of strategies, including careful predeployment preparation, environmental and public health planning and the timely and effective care of casualties when they occur. This study was designed to examine specifically one aspect of the predeployment selection of the UK Armed Forces prior to service in Afghanistan. The presentation of individuals with previously identified chronic disease to the field hospital has been perceived as an important and avoidable burden on the secondary care medical facilities. In many cases, these conditions need treatment and subsequent evacuation from the operational theatre.1 In addition to putting a strain on the local medical resources, which being remote from the UK are limited and costly to maintain, there is an avoidable military cost in terms of absent manpower in the field and the monetary expense of the serviceperson's training, care and transportation. This burden can, in most cases, be avoided through a timely occupational medical assessment, to inform the commanders’ medical risk assessment (MRA) prior to deployment.
All military personnel in the UK Armed Forces have an occupational health grading, comprising a PULHHEEMS grade and a Joint Medical Employment Standard (JMES). The PULHHEEMS system provides a coding for the medical assessment of the functional ability of personnel, from which is determined their fitness for service.1 It is an occupational medical assessment intended to record the presence or absence of a medical condition or physical limitation that may affect employment, providing an overall ‘P’ grade (indicating the individual's overall physical and mental capability), which is influenced by the other qualities in the PULHHEEMS profile (namely Upper limb, Locomotion, Hearing, Eyesight, Mental capacity and emotional Stability). The P grades, compatible with work, that may be awarded are given as follows:
P2—medically fit for unrestricted service worldwide.
P3—medically fit for duty with minor employment limitations.
P4—medically fit for duty within the limitations of pregnancy.
P7—medically fit for duty with major employment limitations.
These P grades are only visible to the medical staff; however, they give rise to an associated JMES, which is the grading used to inform commanders of the employability and deployability of their personnel. The Medical Deployment Standard (MDS) describes the medical capacity for deployment and is determined by the P grade. An MDS of Medically Fully Deployable (MFD) is awarded when the P grade is P2; Medically Limited Deployable (MLD) when the P grade is P3 or, exceptionally P7; and Medically Non Deployable (MND) when the P grade is P4 or P7. The Medical Employment Standard (MES) relates the individual's PULHHEEMS profile to their trade or employment branch requirements, and grades within four functional areas, denoted A, L, M and E, to signify fitness for duty in the Air, Land and Maritime environments, and any requirements for medical and Environmental support. While the allocation of JMES codes is a medical responsibility, the decisions on employability and deployability of downgraded personnel rest with the chain of command, who owns the risk. This risk assessment should be informed by the MRA,1 which the chain of command must raise for all personnel deploying in a grade of MLD or below.
The fact that British servicemen and women have deployed inappropriately into operational theatres in the past is well known. An audit of aeromedically evacuated patients from the operation to liberate Kuwait in 1992 demonstrated a small number of individuals, presenting with conditions known prior to deployment that included insulin-dependent diabetes, planned pregnancy, asthma and grand-mal seizures.2 Four years later, during the British military operation in the Former Republic of Yugoslavia, 41% of individuals awaiting aeromedical evacuation were suffering from previously recognised chronic conditions.3 Of these patients, 13% had been appropriately downgraded and in spite of this had gone on to be deployed. The situation was relatively unchanged during the most recent study undertaken during the invasion of Iraq in 2003 where approximately a third of admissions to two field hospitals presented with chronic illness. In 20% of cases, asthma was the presenting condition.4
The period since 2003 has been a busy one for the British Armed Forces with continuous operations in several theatres culminating in the recent high-tempo combat operations seen in Helmand Province, Afghanistan. The medical forces of all three services have undergone numerous developments as a result of the lessons learned during this period. This study was designed to investigate the current state of predeployment selection of servicemen and women at the unit level.
The Role 3 Hospital in Camp Bastion was established to support International Security Assistance Force (ISAF) operations in Helmand Province, Afghanistan. During the study, its form was of a semi-permanent building to where patients could be admitted and treated to the same or better standard than they would receive in a British District General Hospital. The hospital is manned mainly by British and American staff, although other allied nations also contribute. Casualties from ISAF and other eligible groups, including some civilian contractors and local nationals, are treated by the hospital but the majority of admissions under the General Internal Medicine (GIM) team were from the British Armed Forces.
The hypothesis to be tested by this study was that there was a burden of avoidable admissions under the GIM team to the Role 3 Hospital in Camp Bastion by individuals who had deployed to Afghanistan in spite of known disease. The GIM team at the time consisted of one consultant physician and one GIM trainee.
Methods
Cross-sectional admission details were collected for consecutive British servicemen and women admitted under the GIM team commencing in April 2011 for a 9-month period. Only patients serving in the UK Armed Forces were eligible for the study. Data were prospectively collected by successive GIM trainees. Patient details recorded included gender, rank, age, length of stay, discharge diagnosis and disposal. This was later matched with each individual's Electronic Integrated Health Record (known as the Defence Medical Information Capability Programme, DMICP) following which a review was made of their occupational medical grading. An individual was recorded as downgraded if they had a JMES of either MLD or MND. When the admission was due to a potentially chronic cause, but the individual was not already downgraded for this, an assessment of their health immediately prior to their deployment was also reviewed in order to investigate whether symptoms following occupational medical review, but prior to deployment, failed to produce an appropriate downgrading. Previous symptoms related to potentially chronic disease were also reviewed to see whether opportunities to downgrade individuals were missed in their less recent past. Information on symptoms was restricted to the DMICP record and no formal questionnaire or other retrospective recollection of symptoms was sought. The purpose of restricting the study to the DMICP record was to simulate the information available to the patient's Medical Officer prior to deployment. This study was not designed to summarise the range of presenting symptoms or discharge diagnoses. However, in a few discrete cases of individual or collective interest we have highlighted specific diagnoses.
The findings are presented in the graphical and descriptive form. Statistical analysis was carried out by using commercially available software (SPSS PASW Statistics Release V.18.0.0). Quartile–quartile plots and the Kolmogorov–Smirnov and Shapiro–Wilk tests were used to assess distribution normality. Significance testing was performed using the Student's t test, the Mann–Whitney test or Fisher's exact test. A two-tailed value of p<0.05 was considered significant.
The authorisation for this study was obtained from the Research Directorate at the Royal Centre for Defence Medicine as two separate protocols: a first study collecting patient admission details from the hospital (Protocol: RCDM/Res/Audit/1036/12/0305) and for the additional data collection using DMICP (Protocol: RCDM/Res/Audit/1036/12/0322).
Results
A total of 270 UK Armed Forces personnel were admitted under the care the GIM team to the Role 3 Hospital between the 17 April 2011 and 10 February 2012. Of these patients, 31 (11.5%) individuals had subsequently left the Armed Forces and their records were unavailable for analysis on DMICP. None of these individuals were discharged on medical grounds. The remaining 239 records were examined and 14 (5.9%) were found to be medically downgraded prior to their deployment to Afghanistan and subsequent admission to the hospital.
The characteristics of the three groups are outlined in Table 1 and Figure 1A–C. The medically downgraded groups were older than those MFD groups (p=0.005). There was no difference in age between either the MFD and ‘grading unknown’ groups (p=0.244) or the downgraded and ‘grading unknown’ groups (p=0.134). There was no difference in the length of hospital stay between the downgraded and non-downgraded groups (p=0.404) or the non-downgraded and ‘grading unknown’ groups (p=0.367). Similarly, there was no significant difference in the proportions of women between downgraded and MFD groups (p=0.194) or ‘grading unknown’ and MFD groups (p=1.00).
Summary of the patient characteristics
Downgrading study: (A) non-downgraded patients, (B) downgraded patients and (C) patients with unknown gradings.
The spectrum of disease diagnoses was broadly the same between the three groups with the majority of diagnoses newly acquired and likely to be the first presentation of these diagnoses in these individuals. Although more patients presented with acquired non-infectious disease than acquired infectious disease in the downgraded group, there was no significant difference between the groups (p=0.1733).
The ultimate disposal was predominantly ‘returned to unit’ (RTU) in the MFD group (85.8%) but significantly more were aeromedically evacuated back to the UK in both the downgraded group (50%, p=0.019) and the group whose DMICP records were not available (61.3%, p=0.039).
All those patients who were downgraded were assessed as MLD and were P3 rather than P7. None of those patients who were admitted were found to have been MND patients. Just over half of the MLD patients (8 of 14, 57.1%) were downgraded due to musculoskeletal injuries. The remainder resulted from hearing loss, gynaecological disease, asthma, inflammatory bowel disease and non-freezing cold injury. Of the downgraded patients, one (7.1%) was found to present to Camp Bastion hospital with symptoms related to their previous downgrading diagnosis of Crohn's Disease. The other downgraded patients presented with a heat-related illness, a pulmonary embolism: two with detached retinas and the remainder with acquired infections.
Of the serviceman graded MFD patients, one patient had previously experienced a heat-related illness and was admitted to the hospital with the same diagnosis. The investigators felt that prior to deployment this individual fell within the disease severity requiring medical downgrading and further investigation, as defined by current military policy.5 This was the only patient identified in the study as being inappropriately graded MFD. The two patients diagnosed with recurrent heat illness and Crohn's disease were both aeromedically evacuated.
A further individual had previously suffered from several episodes of syncope that she had been downgraded for. Following extensive cardiac investigation and a prolonged asymptomatic period, she was upgraded to MFD 6 months prior to the deployment. Unfortunately, she was then admitted twice with recurrent symptoms over only a few days and was aeromedically evacuated as a result. The investigators felt that a risk assessment had been performed in her case and the outcome, while unfortunate, could not have been foreseen. She was ultimately discharged from the Armed Forces on medical grounds relating to these syncopal episodes.
A single person who was not downgraded was found to have a L2 marker in their JMES. This marker indicates that the service person is fit for unrestricted military duty in the land environment, but with a medical risk marker. This allows them to deploy in an MFD capacity but signals to their medical support that they may require some medical surveillance while deploying or returning to firm base.
Discussion
This study shows that most people admitted under the GIM team received novel diagnoses for them and that only a small percentage of them were downgraded from MFD. The vast majority of those patients who were admitted to hospital were deemed fully fit for deployment. Of those who were medically downgraded, most were due to musculoskeletal conditions and injuries rather than a GIM diagnosis. Given that only one patient was admitted for symptoms for which they had a current downgrading, this study indicates that the risk assessments that occur prior to deployment of medically downgraded personnel appear to be mostly effective in reducing the burden of avoidable admissions under the hospital GIM team. It certainly appears that the risk assessment, for GIM complaints particularly, prior to deployment into the mature and continuing operation in Afghanistan is better than the rushed predeployment risk assessment seen during the invasion of Iraq.4
By putting these results into the context of the known admission patterns on operations, another perspective of these data can be taken. Historically, a high proportion of the burden of ‘disease and non-battle injuries’, during recent military deployments, are due to diarrhoeal disease or heat-related illness.6 ,7 This pattern was seen in this study where high levels of infectious disease were noted. Therefore, the low proportion of positive links between a previous medical condition and admission to hospital could be due to the low number of cases being swamped by acute infectious illness. This study was designed to look only at the burden of recurrent disease on the GIM team and within this context it is successful. However, it is impossible from these data to calculate the overall operational burden due to a recurrent disease and even if this were known it would not be entirely informative without knowing how many personnel were excluded from deployment due to a chronic disease and how many eventually deployed into theatre despite a known disease, without encountering any problems.
The retrospective and selective nature of this study limits the interpretability of these data. To get a fuller understanding of the burden caused by a recurrent illness, different study cohorts would benefit from investigation. Review of the medical discharge statistics for the Armed Forces demonstrates that the majority of individuals discharged from service on medical grounds do so as a result of a musculoskeletal injury.8 We do not know if the high incidence of musculoskeletal injury in the general military population translates to more individuals deployed with chronic musculoskeletal injury, but if this was the case these patients may be more likely to present to the deployed primary care service with symptoms relating to their injury, than they are to be admitted to the hospital. While these patients are not going to fill hospital beds, which may be needed in the event of a major incident, they are going to be the cause of reduced manning on the front line, an increased burden on deployed rehabilitation services and the increased use of aeromedical evacuation flights. Interesting follow-on studies would be to investigate those patients managed by all the deployed medical services.
Ultimately, the gold-standard investigation would be a review of the personnel due to their arrival in theatre prior to their predeployment medical with different outcomes recorded. The DMICP record could be studied at the point where medical officers initiate their medical force preparation to identify chronic disease and grading status. The end-points would be whether they deployed or not and if deployed whether they used the deployed medical services because of their chronic condition. If this audit was performed without the knowledge of the Medical Officers involved, this would provide accurate data on medical downgrading and deployment rates and outcome data on operational morbidity. Often Medical Officers are attached to a deploying unit immediately prior to the deployment. In this situation, the focus is on reviewing patients already downgraded in order to determine whether any can be returned to MFD or deployed with appropriate limitations. In extreme circumstances, the force preparation could be even more limited to ensuring unit vaccinations and audio assessments are complete. If it were discovered that the MRAs were not being adequately performed, then bringing forward the attachment of medical officers to units, to allow the time to perform a full unit MRA, could improve the situation.
It should be noted that there is also a limitation with this study. Of the 273 UK service personnel admitted during the period, 11.3% had left the army before their primary healthcare records could be accessed. This arose due to a delay for operational reasons between collecting the data in Afghanistan and reviewing the DMICP record. Although we know that none of these patients were discharged on medical grounds, we can only hypothesise about their occupational medical grading status and medical history. It could be argued that personnel more seriously unwell or impaired by a prior condition would be included in that lost cohort and that the results may be skewed in favour of more mild disease as a result. The worst case scenario would be that they were all downgraded, though this seems unlikely as the pattern of disease was broadly similar between the groups and approximately two-thirds were discharged back to their units. The maximum duration between admission to hospital and review of the DMICP records was 10 months and for the majority considerably less. Most of the servicemen and women leave their service due to some personal reasons, depending on the duration of their contract,9 and so, on balance, it is unlikely that many of the patients in this group would have presented with symptoms of a recurrent disease and we can be fairly certain that the burden of the recurrent disease on the GIM hospital team is low.
Conclusion
Most admissions to the hospital in Camp Bastion under the GIM team were of patients not identified with any previous medical conditions. For those who were medically downgraded, the reason for downgrading was only rarely related to their reason for admission to the hospital and an appropriate risk assessment prior to deployment had usually been performed by their chain of command. Patients admitted to hospital under the GIM team for symptoms relating to a known disease do not present a significant strain on the hospital resources. Given the imminent ending of British operations in Afghanistan, it is important that the lessons learned over the past decade are not forgotten as the UK Armed Forces return to their non-deployed role.
Acknowledgments
The authors are grateful for the assistance of the following: Maj Kevin Bailey, Surg Lt Cdr Matthew O'Shea, Maj Julian Lentaigne, Maj Jason Biswas, Maj Thomas Fletcher, Sqn Ldr Joanne Rimmer and Maj Samuel White.
Footnotes
Contributors TDL and ATC contributed equally to this study. ATC and LT devised the project. ATC and TDL designed the protocol. ATC, TDL, KB and MS collected and analysed the data. SS and DW advised on methodology. All authors contributed to writing the manuscript.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.