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Abstract
In response to an Urgent Operational Requirement, the UK Ministry of Defence (MoD) investigated, designed, developed, trialled and subsequently fielded a Tiered Pelvic Protection System to service personnel deployed on Operation HERRICK in Afghanistan. An Urgent Statement of User Requirement (USUR) was drafted in order to equip service personnel with protection for the groin, perineum, buttocks and upper thigh areas from the effects of buried Improvised Explosive Devices (IEDs). Injuries to the groin and pelvic area from buried IEDs can have severe physiological and psychological impact; therefore the aim of the pelvic protection was to reduce the number and severity of such injuries and to improve the outcome, both in terms of quality of life of the survivors and increase the chances of survival. The aim of this paper is to outline some of the research and development that contributed to the design(s) of the Tiered Pelvic Protection System; describe the components of, and report the medical success of, the Tiered Pelvic Protection System.
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Introduction
On Operation HERRICK in Afghanistan, injuries to the groin and pelvic area are common from buried Improvised Explosive Devices (IEDs). Collaborative investigations between the Deployed Medical Staff in the UK Role 3 Hospital in Camp Bastion, Afghanistan, The Academic Department of Military Emergency Medicine (ADMEM) at the Royal Centre for Defence Medicine (RCDM), Defence Equipment and Support (DE&S) and the Defence Science and Technology Laboratory (DSTL) revealed a defined trend in the groin and pelvic injuries as the use of IEDs changed. The injuries can have both severe physiological and long term psychological impacts. An Urgent Operational Requirement (UOR) was raised in order to field a protective system with the aim of reducing the number and severity of such injuries to the groin area to improve the outcome, both in terms of quality of life of the survivors and to increase the chances of survival.
The Urgent Statement of User Requirement (USUR) defined a requirement for the adoption of a tiered approach, which initially focused on the fielding of the first tier of protection (Tier 1 Pelvic Protection) in order to equip service personnel on Op HERRICK 13. Tier 1 was aimed at daily wear and was intended to replace the standard issue underwear. The subsequent tiers of protection (Tier 2 and 3) each offer an incremental increase in the level of protection. They are to be worn in conjunction with Tier 1 and when the risk is perceived to be increased and subsequently removed/not worn when in low risk scenarios. This was the first time that a scheduled tiered approach to protection would be produced for general service personnel on operations.
Methods
In order to develop protection for the pelvic region, the Defence Clothing (DC) and Personal Combat Equipment (PCE) Teams in DE&S worked with DSTL to determine the nature of the threats to the pelvic region and to assess the casualty data in order to determine which areas to protect and prioritise. A Commercial Off The Shelf (COTS) assessment was carried out in order to establish if any systems existed that met the requirement; but the work concluded that at the time of the review, no COTS items were available to fulfil the requirement. Therefore prototype systems were developed in order to meet the requirement (Tier 1 prototypes were developed by DC Team and DSTL and Tier 2 and Tier 3 prototypes developed by PCE Team). These prototypes were narrowed down through advice on the coverage requirements from military trauma specialists, extensive ballistic assessments, human factors integration assessments and through military user assessment trials at the Infantry Trials and Development Unit (ITDU).
Tier 1 Pelvic Protection
In September 2010, Tier 1 Pelvic Protection was fielded to UK Service Personnel deployed in Afghanistan. Tier 1 Pelvic Protection was introduced to mitigate the effects of dust, grit, dirt and debris and other secondary fragmentation emanating from a buried IED. An undergarment, the Tier 1 Pelvic Protection is constructed from a jersey-type material with two layers of high performance knitted silk protection stitched to the outside to cover the vulnerable areas as defined by casualty analysis and expert medical opinion (Figure 1). The area of coverage is identical on the front and the rear of the garment. Knitted silk was selected as the protective material as it provided the best compromise between ballistic performance against small fragments, flexibility, comfort, breathability and stretch (of the material). Other materials (such as Aramid felts) were also evaluated and were found to meet the ballistic requirement, but were discounted due to their stiffness and bulk, which added to the discomfort and perceived burden of the garment. As well as providing protection against secondary fragmentation, Tier 1 Pelvic Protection contains antimicrobial properties. It was initially issued in a unisex version to all service personnel serving in Afghanistan to replace the issued underwear.
Tier 1 Pelvic Protection.
Subsequent to the initial fielding of Tier 1 Pelvic Protection, an analysis was conducted by the Deputy Scientific Advisor (DSCIAD) based in Task Force Helmand to determine initial feedback on the use of the newly issued Tier 1 Protection. A questionnaire was designed and issued across all Areas of Operation (AOs) targetting a statistically significant sample of service personnel. The analysis demonstrated that the Tier 1 Protection received very positive feedback for comfort, fit, function and durability and in terms of the positive psychological effect of protecting the groin area when compared to the standard issue underwear. Out of over 500 questionnaire respondents, over three quarters deemed Tier 1 Pelvic Protection as ‘comfortable’ or ‘very comfortable’. In addition, when asked how the Tier 1 Protection compared to the issued underwear; over a third responded with ‘no difference’, and two thirds responded with ‘significantly better’ or ‘better’.
The first medical success of Tier 1 Pelvic Protection was anecdotally reported very soon after its initial issue to Afghanistan, whereby the ‘lack of skin damage to the upper thigh and perineal area’ to an IED casualty was deemed ‘remarkable’ by the attending plastic surgeon, and the newly issued Pelvic Protection ‘appearing to have made significant reductions in the ingress of debris’.
Tier 1 Pelvic Protection is available in five sizes, and is compatible with male and female service personnel requirements. Male and female derivatives have been developed and the female derivative is compatible with the issued ‘she wee’ to allow discrete urination when out in the field.
Tier 2 pelvic protection
Tier 2 Pelvic Protection was fielded to Afghanistan in February 2011 after a period of design, evaluation, human factor trials and military assessment at ITDU. It is a protective overgarment designed to be worn in conjunction with Tier 1 Pelvic Protection. Its level of protection is commensurate with the textile armour component of the OSPREY body armour system; therefore providing a significantly higher level of protection compared to the Tier 1 Pelvic Protection. The design covers the groin and buttocks area and offers some protection to the inner thigh. Tier 2 Pelvic Protection is worn over the combat trouser, whereas the Tier 1 Pelvic Protection is worn underneath the combat trouser, (Figure 2), and is intended to be worn for higher risk and shorter duration tasks and stowed on the rear of the belt of the combat trousers (Figure 3) in low risk scenarios.
Tier 2 Pelvic Protection as worn outside of the combat trousers.
Tier 2 Pelvic Protection stowed on the rear of the belt.
An analysis was conducted by DSCIAD to determine the initial feedback to the use of Tier 2 Pelvic Protection. Over 350 service personnel from all AOs responded to a questionnaire; whereby nearly half of respondents rated the Tier 2 Pelvic Protection as ‘very comfortable’ or ‘comfortable’ and the other half thought it was either ‘uncomfortable’ or ‘very uncomfortable’. However, when asked if Tier 2 Pelvic Protection was beneficial, three quarters of the service personnel responded ‘yes’, an attitude which was reinforced by the positive comments received from Bastion Role 3 Hospital on the benefits of wearing the protection ‘Tier1/2 pelvic protection was instrumental in saving Soldier X's life, had he not he may not have survived. Not only did this protect his genitalia, but also prevented further lacerations and the subsequent loss of blood’.
Tier 2 was initially issued in one size in February 2011, but feedback from deployed service personnel and from the Military Genitourinary Group (MGUG) suggested that a range of sizes would not only cater for the very small to the very large but would also provide an enhanced area of coverage to further mitigate secondary fragmentation. From March 2012, Tier 2 Pelvic Protection was issued in five sizes.
Tier 3 Pelvic Protection
Tier 3 Pelvic Protection (Figure 4) was designed and developed by PCE and DC Teams in DE&S and was issued to service personnel in Afghanistan in September 2011. It was designed for more intense high risk and short duration tasks conducted by Counter-IED (C-IED) operators and dismounted soldiers conducting C-IED drills. The Tier 3 Pelvic Protection is worn over the combat trousers (Figures 4 and 5) and is designed to integrate with both Tier 2 (which can be worn over or under the Tier 3) and Tier 1 (which is worn under the combat trousers). Tier 3 Pelvic Protection provides enhanced protection by covering the upper leg, wider abdominal regions and the femoral artery. The level of protection provided by the Tier 3 Pelvic Protection is commensurate with the textile armour component of the OSPREY body armour system and is provided in five standard sizes.
Donning Tier 3 Pelvic Protection over the combat trousers.
Wearing Tier 3 Pelvic Protection with Tier 2 Pelvic Protection.
Tier 1 and Tier 2 analysis
In July 2011, DSTL were tasked by PCE to evaluate the effect of Tier 1 and Tier 2 Pelvic Protection upon casualty patterns. The analysis of returned Pelvic Protection (from casualties) as well as a review of casualties demonstrated the positive effect of wearing the protection. Overall, the number and severity of injuries to the groin, perinea and genitals since the introduction of the Pelvic Protection had reduced, and this was directly attributable to wearing the Pelvic Protection.
Discussion
The design of any protective system will inevitably be a compromise between coverage, performance and user acceptability; and in this case, particularly in the assessment of the added burden versus psychological impact.
The success of the Tiered Pelvic Protection system in reducing the physiological and psychological impact of IED injuries has been demonstrated through UK reviews and questionnaires. This has been achieved through a multidisciplinary approach taking advice from science, technology and medical experts to consider all lines of development and produce a system that maximises the balance between protection and acceptance. Its benefits have also been recognised worldwide, with our International Allies either directly purchasing the UK systems through International Memorandums of Understanding or by fielding very similar systems to protect the pelvic areas of their service personnel. This has further reinforced the status of the UK as a world leader and an innovator in the provision of personal protective armour systems to deployed service personnel.
Conclusions
Whilst the Pelvic Protection System has demonstrated a significant benefit in the overall reduction in the number and severity of urogenital injuries, it is continually evolving as it is monitored, assessed and modified (when required) to ensure that UK deployed service personnel receive the best possible personal protective equipment to mitigate the ever present buried IED threat.
Acknowledgments
The authors wish to acknowledge the input of individuals from, and affiliated to Cap GM, PCE Team and DC Team DE&S, DSTL, ITDU & MGUG. The continued success of the Pelvic Protection System is a multidisciplinary and multi organisation effort.
Footnotes
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.