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Impact of military medicine on civilian medical practice in the UK from 2009 to 2020
  1. Katherine France1 and
  2. C Handford2
  1. 1 General Surgery, James Cook University Hospital, Middlesbrough, UK
  2. 2 Orthopaedics, Queen Elizabeth Hospital, Birmingham, UK
  1. Correspondence to Maj Katherine France, General Surgery, James Cook University Hospital, Middlesbrough TS4 3BW, UK; Katherine.france3{at}nhs.net

Abstract

Introduction The positive impact of advances in military medicine and the influence these have had on civilian medical practice have been well documented throughout history: this review will be looking specifically between 2009 and 2020.

Aims Review of innovations that have been implemented or have influenced civilian practice within the areas of trauma, disease outbreak management and civilian systems between 2009 and 2020. This review will also aim to explore the impact that working with or within the military can have on individuals within civilian healthcare systems and the future challenges we face to maintain skills.

Results Using a narrative approach to this review, we found that there have been numerous changes to trauma management within the UK, based on military practice and research during conflict, which have improved survival outcomes. In addition, the use of niche military skills as part of a coordinated response, during both internal and international disease outbreaks, are thought to have supported civilian systems enabling an efficient and prolonged response. Furthermore, adaptation of military concepts and their application to the NHS through consultant-led prehospital teams, centralisation of specialties in the form of major trauma centres and the introduction of guidelines to manage 'major incidents and mass casualty events' in 2018 have improved patient outcomes.

Conclusion From 2009 to 2020, lessons learnt from the British and other nations’ militaries have been integrated into UK practice and have likely contributed to improved outcomes in the management of major incidents both nationally and internationally.

  • trauma management
  • international health services
  • accident & emergency medicine
  • education & training (see medical education & training)
  • organisational development
  • organisation of health services

Data availability statement

Data sharing is not applicable as no datasets were generated and/or analysed for this study. N/A.

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Key messages

  • Within the last decade, lessons learnt from military deployments and research have been integrated into civilian practice, with a positive impact on survival rates when managing trauma.

  • The inclusion of military aid to civil authorities (MACA) to the National Security Strategy and Strategic Defence Review in 2015 has enabled a structured contribution of niche capabilities from the military in response to all types of emergencies.

  • Awareness that we need to make a conscious effort to maintain skills during periods of low kinetic activity by investing in regular training opportunities and ensuring the appropriate deployment of military consultants to major trauma centres.

Introduction

The positive impact of advances in military medicine and innovation on civilian medical practice have been well documented throughout history: from the French introducing the concept of triage during World War I, the storage and mobilisation of blood products in World War II, to the invention of the one-handed Combat Application Tourniquet (C.A.T) in 2002.1 All of these innovations are still in use today and have been integrated into civilian practice to reduce mortality from trauma.

This review will be looking specifically at the advances made within military medicine between 2009 and 2020 and how these innovations have been implemented or have influenced civilian practice. In the last 10 years, the British Military have moved away from conventional war fighting to subthreshold competition and a ‘protect–engage–constrain’ mentality, with conventional conflict as the far right of the arc. In addition to this, the military has supported defence engagement deployments using short-term training teams with objectives that would not traditionally be considered as ‘high risk’. As a result of this change in traditional engagement, the numbers of UK casualties have reduced over the last decade, with only two deaths having been recorded as a result of hostile action since 2014.2 One may expect this to have had a negative effect on the impact that military medicine could have on influencing civilian practice. However, with an increasing effort not to forget lessons learnt and an ambition to continue to develop and improve the care that can be provided in increasingly austere environments, the military has strived to maintain its positive contribution to the civilian healthcare sector. This essay explores these contributions in the areas of trauma, systems, disease outbreak management, the impact that working with or within the military can have on individuals within civilian healthcare systems and the future challenges we face to maintain skills.

Trauma management

War is the only proper school for a surgeon. (Hippocrates, c. 460–370 BC)

Conflict has always been synonymous with disease and injury. As technology progressed and spears and swords were replaced by guns and bombs, the pattern of injury changed and the numbers of casualties increased. Throughout history, war has forced innovation in trauma management, and our recent conflicts in Iraq and Afghanistan have been no different. Many of the advances during this time were not new ideas but were evolved and improved to provide better point of care management and a more coordinated approach to casualty management throughout the evacuation chain. An example of this is the use of the tourniquet: in 2002, the traditional tourniquet was reinvented to enable one-handed self-application, allowing soldiers to treat their own upper limb extravasation1; in addition to this, there was a shift in the training paradigm to prioritise control of major haemorrhage in the Battlefield Advanced Trauma Life Support (BATLS) protocol,3 ensuring that all personnel involved in casualty management were checking and looking for the application of tourniquets; this has been further developed in 2018 when the ‘Catastrophic Haemorrhage, Airway, Breathing, Circulation’ algorithm was published in the civilian guide to the management of major incidents and mass casualty protocol when dealing with blast injuries.4 This single intervention, its development, application and coordinated use have been shown to reduce deaths significantly due to peripheral-extremity haemorrhage and, if applied prior to the onset of shock, has been shown to increase survival from 10% to 90%.5

In 2015, a 10 year review of casualties conducted by the US Military (2001–2011) found that 90.9% of deaths were due to haemorrhage,5 with 63.7% of lethal haemorrhage being due to a truncal site of extravasation.6 This highlighted a need for innovation in managing these casualties more effectively and finding a way of providing haemostasis in an austere environment, where a limited operating capacity might delay laparotomy or thoracotomy for aortic cross clamping and proximal control of bleeding. First described on the battlefield in 1954, resuscitative endovascular balloon occlusion of the aorta provides a rapid, effective solution to exsanguinating haemorrhage from pelvic and non-compressible torso haemorrhage.7 This technique of gaining proximal control of truncal haemorrhage has been demonstrated to be a viable alternative to resuscitative thoracotomy8 and can be used as a temporary anatomical and physiological stabilising tool in a deployed environment, when access to theatre and other resuscitative products may be limited. The use of this technique is gaining some interest in a prehospital and combat setting, as a bridging method of haemorrhage control. Due to this, in 2019, the American colleges published a comprehensive set of guidelines for its use within civilian trauma systems, based on a literature review with representation from the US Military.9

Innovation in trauma management, whether military or civilian, is continually developing: many advances made prior to 2009 have had a positive impact through their incorporation into civilian medical practice over the last decade (Table 1).

Table 1

Summary of innovations in trauma management

In addition to evolving the way trauma is managed, the military has invested in finding ways to prevent or minimise traumatic injury. An example of this is the development of personal body armour. From analysis of the data coming out of the recent conflicts in the Middle East, it was identified that the critical structures that need to be protected were the heart, great vessels, liver and spleen.10 In addition, further anthropometric studies were done to assess coverage of the protective plates used. These established that the use of surface landmarks was a more accurate measurement for body armour plate sizing than stature.11 The UK Home Office Body Armour Standard Guidelines, published in 2017, reflects this research in the recommendations for the minimum protective qualities of individual body armour used by police in the UK.12 With the number of incidents in which police firearms were discharged in England and Wales rising, from 4 reported in 2011 to 13 incidents in 2019,13 it is thought that this innovation in personal protective body armour will save lives, within both the military and civilian services.

Systems

The management of trauma and of major medical incidents is commonplace within the military; they are concepts that are regularly trained for through table top exercises, trauma courses and Hospital Exercise (HOSPEX) moulage training. While the BATLS course and the Military Operational Surgical Training course provide individuals with skills training to manage trauma, the table top and HOSPEXs enable healthcare providers to work as a team to triage, manage and evacuate trauma casualties. In addition, they must think about the larger operational picture with regard to resource and capacity management and how these factors will affect the capability of a treatment facility.

These concepts were trialled and tested during conflicts in Afghanistan and Iraq and saw the evolution of a consultant-led evacuation team to speed things up and to enable senior clinical decision making that would influence immediate treatment as well as evacuation planning.3 This resulted in better use of assets and a sustained capability to manage a large number of trauma casualties. These concepts have been adapted and transferred to the National Health Service through the development of major trauma centres (MTCs), the use of Major Incident Medical Management and Support course and the development of guidelines in 2018 for major incidents and mass casualty events. All of these tools help to save lives by streamlining resource and personnel management and by standardising our approach to trauma care.

Before 2012, the emergency care system in England had been based on geography: from point of injury to the nearest accident and emergency department regardless of that treatment facility’s resuscitation or surgical capability. The National Confidential Enquiry into Perioperative Deaths 2007 report suggested that almost 60% of major trauma patients received a substandard level of care, with avoidable deaths.14 This report led to a recommendation from the National Audit Office to reassess and reorganise the system for trauma management in England.15 Following this recommendation, a major trauma network was developed based on models used in other countries, such as the USA,16 17 which showed improved trauma care when care for a region is provided by a network of hospitals with MTCs at the hub.18 This concept was finally realised in England in 2012 with the reorganisation of our trauma system and the development of 27 designated MTCs. The Defence Medical Services (DMS) support these MTCs and, where possible, post military personnel to these locations to ensure maintenance of skills and continuity of military training and to enable transfer of knowledge: from lessons learnt during conflict to the civilian management of trauma. A still developing part of England’s trauma system is the forward placement of consultants on prehospital platforms. This alteration in the trauma pathway was shown, during conflicts in Afghanistan and Iraq, to increase survival and, when compared with the paramedic-led platform used by the US Airforce, was shown to have a lower mortality rate.19 Although not commonplace, a consultant-led service was adopted by the London Air Ambulance in 2017 and may have a place in other regions that have a high incidence of trauma with Injury Severity Scores of >20.3

In addition to innovation in prehospital care and MTC management of patients, the DMS have been able to use their wealth of experience in definitive surgery and rehabilitation for blast, blunt and penetrating trauma: in 2011, the National Institute of Health Research Centre for Surgical Reconstruction and Microbiology opened at the Queen Elizabeth Hospital in Birmingham. This brought together both civilian and military trauma surgeons and scientists to continue innovation in the care of trauma patients and used battlefield experience to benefit NHS patients at an early stage of injury. This was reflected in 2017, when the Manchester Arena bombings took place. The military aid to civil authorities (MACA) enabled the DMS to share their knowledge and experience with their NHS colleagues, influencing patient care and having a positive impact on patient outcomes. In addition to clinical advice, the DMS was also able to offer forensic pathology support, which enabled swift understanding of the major incident’s forensic picture and promoted a multidisciplinary approach to forensic autopsy that improved accuracy and specificity of forensic recovery. The paper by Bowley et al 20 that reviewed this collaboration concluded that the use of MACA to incorporate lessons learnt from a military perspective was invaluable and should become a standard operating procedure for such events in future. In addition, it was felt that applying this system to support the NHS made a positive contribution to the morale of NHS workers and had a positive impact on extending resilience of the workforce and their ability to adjust psychologically to the magnitude of such events.

Disease outbreak

International

The United Nations Inter-Agency Standing Committee Definition of Civil-military Coordination promotes essential dialogue and interaction between civilian and military actors in humanitarian emergencies. This is necessary to protect and promote humanitarian principals, avoid competition, minimise inconsistency and, when appropriate, pursue common goals. Basic strategies range from coexistence, cooperation and coordination. Shared responsibility was facilitated by liaison and common training.

The UK’s humanitarian policy has three main goals:

  1. To improve the effectiveness of the humanitarian response.

  2. To be a better donor.

  3. To reduce risk and extreme vulnerability.21

The military has a useful role in providing advice and assets for a response in order for the UK to achieve these goals. However, it is important that there are safeguards on the involvement of the military. The Oslo Guidelines state that ‘military assets should be seen as a tool complementing existing relief mechanisms in order to provide specific support to specific requirements’ and that ‘foreign military assets should be requested only where there is no comparable civilian alternative’.22

The outbreak of the Ebola virus disease (EVD) in West Africa in 2014 was a major threat, both regionally and globally. Due to the severity and nature of this disaster, non-governmental organisations (NGOs) were unable to gain sufficient numbers of volunteers with sufficient expertise to manage this crisis. They had to request foreign military support as there was no civilian alternative that could rapidly deliver the support required. The UK military involvement in the global response to this disease outbreak was one of logistical support, healthcare delivery, security and training. The multidisciplinary force of the UK military enabled effective collaboration with NGOs to build treatment centres, to provide training for over 4000 locals in infection prevention and control measures, to coordinate the cold chain of equipment delivery, and to provide security to civilians and healthcare workers during this time.23 In addition to this response, the Royal Navy RFA Argus provided an offshore medical facility for any non-EVD disease/injury.

The deployment of military forces to aid the EVD outbreak was initiated by a request made to the United Nations by Medical Sans Frontier (MSF). The use of military forces in a humanitarian crisis was controversial, but MSF felt that the deployment of foreign militaries was the only way to provide the numbers of personnel needed to stabilise the situation in a short time frame.24 Reflection on the usefulness of military involvement and their impact on civilian practice is varied, as there was no common framework under which different nations’ militaries were to work.25 An article in the Lancet on ‘Civil-Military Cooperation in Ebola and Beyond’ praised the UK for its use and adherence to the Oslo Guidelines and for working in support of the civilian-led Department for International Development, ensuring that the UK military was deployed in a supporting role and did not assume leadership of the UK’s overall response.26 This global humanitarian crisis highlighted to civilian organisations that the military can offer a rapid, skilled and organised work force to assist in humanitarian crises. In addition, the UK military has the expertise to offer advice and a deployable workforce to manage health-related disasters of disease outbreak. The international military response to EVD has had a significant impact on civilian practice: it has fuelled conversation and engendered a review of policies and a critical analysis of the military’s role and how it can be improved and used by civilian organisations in these ever more frequent disasters.27

Internal

At the end of 2019, a pneumonia of unknown cause was declared in Wuhan province of the People’s Republic of China. This was identified as COVID-19 and was further characterised as SARS-CoV-2.28 This viral disease has become a global pandemic with significant impact on healthcare systems and global economies. Sorbello et al identified the requirement to activate military support in the construction of field hospitals with biocontainment capabilities,29 and in considering the socioeconomic effects of COVID-19, Nicola et al identified the need for a robust system to support the staffing of emergency sector jobs and COVID-19 testing stations to facilitate the return of a functional economy.30 In the UK, MACA coordinated this response, codenamed Op RESCRIPT, using the Armed Forces to provide public health advice from a military perspective, research on the stability of COVID-19 in the air, from the Defence Science and Technology Laboratory, and aid in the logistical tasks of setting up testing stations and emergency field hospitals (the Nightingale hospitals) while ensuring that the majority of defence personnel remained embedded within the NHS trusts in which they worked to ensure the continued stability of these facilities.

It is too early to draw conclusions about the effect that this operation has had on the UK’s response to the COVID-19 pandemic. However, MACA’s decision to use the military in a predominantly logistical and structural capacity in support of civilian services, rather than withdrawing military medical personnel in an attempt to cohort a military medical response, may have prevented a collapse in infrastructure and enabled a supported and coordinated civilian response to the pandemic.

Individuals

Serving in the UK military as a medical professional offers a unique opportunity to develop leadership and team working skills in addition to medical training. It is the experience gained and developed from exercises and deployments outside of an NHS setting that enables military personnel to offer an alternative perspective when returning to their NHS job roles. Positive contributions to these roles can be seen in a number of categories: leadership and management on the ward or within a specialty effective prioritisation of tasks, keeping calm to enable effective decision making in times of stress and clinical experience from situations not easily replicated within an NHS setting. These attributes have been recognised on numerous occasions by NHS trusts and have been more recently verbalised by the Chief Executive of Blackpool Teaching Hospitals NHS Foundation Trust who said ‘We recognise and value the skills and experience leavers and serving reservists bring to the workplace’.31

Future challenges

It is challenging to develop and maintain skills while not engaged in a deployed kinetic operational setting, as the patterns of injury seen are difficult to replicate on any kind of scale within the UK. Another complex challenge is in maintaining and learning the appropriate skills for deployed surgical care; small deployment teams mean that a broad range of trauma skills are required by relatively few individuals, which is difficult to obtain in an NHS training pathway directed towards subspecialty competencies. A recent paper by Breeze et al 32 explored these challenges and concluded that there were three main factors in mitigating against loss of skills and in provision of appropriate training: military-tailored fellowships, to provide opportunities to develop the extended competencies required in training, regular training courses to revise and review these competencies, and restriction of military consultants to work only at level 1/MTCs.

Conclusion

Within the UK and globally, the military approach, experience and response to challenges have influenced the development of civilian practice. From 2009 to 2020, lessons learnt from the British and other nations’ militaries have been integrated into UK practice: the reorganisation of the NHS to incorporate MTCs, areas of the UK with high trauma providing consultant-led prehospital care and the development of MACA, to advise and support the NHS in all aspects of the casualty chain when dealing with major incidents or high-energy trauma. Traditionally, these innovations have been associated with high-casualty numbers, political interest and financial investment. As the UK moves forward into a period of defence engagement and an ever-changing geopolitical environment, there needs to be a conscious effort to maintain skills, to remember corporate experience and to remain agile in order to maximise the learning opportunities of future challenges as they present.

Data availability statement

Data sharing is not applicable as no datasets were generated and/or analysed for this study. N/A.

Ethics statements

Acknowledgments

This article is an expansion and development of an essay entitled ‘The impact of military medicine on civilian medical practice in the last decade has been substantial’, which was awarded first place for the Royal Society of Medicine Military Council essay prize, awarded by the Colt Foundation in 2019. The authors also like thank formally Lieutenant Colonel J Breeze RAMC for his guidance and support in preparing this article for publication.

References

Footnotes

  • Contributors The title for this article was provided by the Royal Society of Medicine Military Council essay prize awarded by the Colt Foundation in 2019. KF and CH both planned, researched and produced the work. Both KF and CH reviewed the submitted final article and were responsible for the overall content of the piece.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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