En Route Critical Care Transfer From a Role 2 to a Role 3 Medical Treatment Facility in Afghanistan

BACKGROUND En route care is the transfer of patients requiring combat casualty care within the US military evacuation system. No reports have been published about en route care of patients during transfer from a forward surgical facility (role 2) to a combat support hospital (role 3) for comprehensive care. OBJECTIVE To describe patients transferred from a role 2 to a role 3 US military treatment facility in Afghanistan. METHODS A retrospective review of data from the Joint Trauma System Role 2 Database was conducted. Patient characteristics were described by en route care medical attendants. RESULTS More than one-fourth of patients were intubated at transfer (26.9%), although at transfer fewer than 10% of patients had a base deficit of more than 5 (3.5%), a pH of less than 7.3 (5.2%), an international normalized ratio of more than 2 (0.8%), or temporary abdominal or chest closure (7.4%). The en route care medical attendant was most often a nurse (35.5%), followed by technicians (14.1%) and physicians (10.0%). Most patients (75.3%) were transported by medical evacuation (on rotary-wing aircraft). CONCLUSION This is the first comprehensive review of patients transported from a forward surgical facility to a more robust combat support hospital in Afghanistan. Understanding the epidemiology of these patients will inform provider training and the appropriate skill mix for the transfer of postsurgical patients within a combat setting.

Establishment and Dissent in Nineteenth-Century Medicine: An Exploration of some Correspondence and Connections Between Religious and Medical Belief-Systems in Early Industrial England

I know the historical sociology of religion only as an outsider; as an historian of medicine helped by that literature to a better understanding of early industrial society and perhaps to a clearer vision of what the social history of medicine ought to be. To read a recent review of the social history of religion, such as A. D. Gilbert’s Religion and Society in Industrial England, Church, Chapel and Social Change, 1740-1914, is to recognise how underdeveloped by comparison is the social history of medicine. Historians of medicine have the equivalent of church histories, of histories of theology and, of course, biographies of divines, but we lack the quantitative and comprehensive surveys of the chronological and geographical patterns in lay attendance and membership, and in professional recruitment and modes of work. For as long as medicine was generally only a transaction between an individual and his medical attendant, few statistics were produced and there is little national data. Yet there are very few local studies of how diseases were handled and how the various kinds of practitioner interacted with each other and with their various publics, so it will be some time before we shall be able to generalise on such matters.

OVERDOSING WITH OPIUM, A SERIOUS PEDIATRIC PROBLEM IN ENGLAND A CENTURY AND A HALF AGO

Early nineteenth-century physicians commonly believed Sydenham's panegyric about opium—that it was a donum Dei and that the "art of physic would be defective and imperfect without it."1 Opium preparations, such as Godfrey's Cordial, a nineteenth century English proprietary preparation, contained 1¼ grain of opium in each ounce of liquid. It was readily available without prescription in England and America, and was given to infants for a variety of complaints. The severity of the problem caused by misuse of opium given to children in Nottingham, England, in 1840 is evident in the following quotation.2 The very great number of deaths amongst children, resulting from overdoses of opium, or its preparations, and from doses thereof given in mistake for other medicines, cannot fail to excite attention .... Most of the children poisoned in this way, lost their lives owing to the ignorance, carelessness, or presumption of their mothers. It cannot be too generally known, that narcotic, and anodyne drugs, powerful though they be in the adult, act with infinitely greater energy upon the more sensitive nervous system of the infant: so that even experienced medical men never administer remedies of this class to the very young, without exerting the utmost caution, and making the most accurate calculation. Two drops of laudanum have been known to kill an infant. Nay we have heard of a case in which one drop stole away the life of a newborn babe. It is evident that mothers and nurses should never dare to administer medicines of the narcotic kind, except under the immediate direction of the medical attendant.

Diet Treatment of Obese Hypertensives

1. The management of hypertension in overweight subjects has been studied. 2. Sixty-three patients were randomly allocated into a ‘dietary management’ or ‘treatment’ group; the sixty-four controls were told of their hypertension and instructed to seek advice from their usual medical attendant. Reassessment was at 1 year. 3. Treated patients consumed a 700 calorie, 1 g NaCl diet daily. 4. Weight loss was greater in the ‘treated’ group. 5. The average fall of blood pressure was slightly greater in the ‘treated’ group.

A Flaw in the English Lunacy Law

The following case shows the necessity for reform in the legal procedure connected with the admission of private patients:—E. E. S—, a lady patient, was admitted on October 26th last, upon the order of a justice of the peace who had not seen her, and upon the medical certificate of her regular medical attendant, and the second certificate of a neighbouring practitioner. Within the statutory period after admission she signed a request to be seen and examined by a judicial authority, under 53 and 54 Vict., cap. 5, sec. 8 (2). On November 2nd I made a return to the Commissioners in Lunacy stating—“She was insane, suffering from melancholia; had a dejected appearance and nervous manner, with delusions of unworthiness; said ‘God would never forgive her her sins’; was agitated, restless, and dissatisfied,” etc. On November 5th she was seen and examined by a local county justice of the peace, who, in the face of these three certificates, and a note in the case book by Dr. Patterson, reported that he did not consider the patient insane. In consequence of this report she was removed by her brother on November 26th, the Commissioners in Lunacy, who apparently, under 53 and 54 Vict., cap. 5. sec. 8 (3), had no option in the matter, having requested him to take this step. I may add we considered her probably suicidal, and when she left I wrote her ordinary medical attendant advising him to watch her, and have her placed under fresh certificates, but she declined to see him again. On the night of December 9th (that is, less than fourteen days after leaving the asylum) E. E. S— committed suicide on the permanent way of the Great Northern Railway in North London. Thus a report by a young and inexperienced justice of the peace outweighs the opinions of two experts, the family medical attendant, who had watched the case for months, and a fourth medical man, who signed the second certificate on admission. Surely this life was sacrificed through a defect in lunacy law!