Military Medicine in Operations - New Psychological Constraints

Case of doctors in charge of medical evacuations by air

MP Virginie Vautier, service de psychiatrie – HIA Sainte-Anne

84th Aerospace Medical Association Congress - San Diego – 2014

Combat Casualty Care

•  Improved aircraft performance

•  Advances in prehospital care

•  New constraints for French military doctors

Operational Stress

•  This relates to all soldiers

•  And doctors too…

•  Adaptive resources are not unlimited

Our Study

•  Semi-structured interviews lasting 1½ hrs

•  Questions revolving around experiences, feelings and subjective aspects

•  The literature refers to quantitative assessments, but rarely to carer stress

Reality of the Field

•  Initial idealization of the mission

•  Hostile character of the theatre of operations

•  A fragile balance based on trust

The Solitude of Doctors in Charge of Evacuations

•  Expressed by all interviewees

•  Aircraft adaptation process

•  Solitude during and after the mission

•  Closure of the decompression chamber

•  No thought given to doctors’ homecoming on an institutional level

Technical Constraints

•  Aeromedical coordination • Doctor / Crew synergy • MEDEVAC / Doctors on ground synergy

•  Tactical combat casualty care • Multiple gunshot wounds • Head and neck wounds

• Hemorrhaging and clotting disorders

Training & Specialization

•  An issue referred to by all interviewees

•  Very limited number of competent and trained doctors

Insecurity of Theatres of Operation

•  The Afghan experience marked a whole generation of doctors

•  Absence of sanctuaries

•  Emergency vehicles targeted

•  Commonest defense mechanisms •  Minimization of danger •  Trivialization •  Superstition

"Armoured Personnel Carriers explode more often than choppers"

"IEDs are for APCs"

Operational Fatigue

•  Exhaustion of adaptive resources

•  One mission: 40 to 50 medical evacuations

•  No relief

New Care Requirements for Each Mission

•  Afghanistan: implementation of a modus operandi for medical care

•  PECC

•  NINE LINE

•  2009: cohesion camps - systematic attendance prior to projection

Psychological Impact

•  Casualty care

•  But also: relief of ground troops

•  Conviction of the usefulness and necessity of the mission is a powerful protective factor - For doctors…

Adaptation Disorders

•  Psychopathological disorders •  Inability to express suffering experienced in the theatre of

operations •  Somatoform variations: conversion disorders, somatization,

physical pain…

•  The dual constraint of support and implication

•  Cognitive and sleeping disorders

•  Loneliness upon returning home = Risk factors/ Psychiatric disorders

•  Impact on care

The Literature

•  Publications on this topic are few and far between

•  Quantitative and operational approach to mental suffering

  Bordes, Meaudre, Drouin. Accueil et traitement d’un afflux de blessés dans une formation hospitalière de campagne. Urgences 2013, chapitre 83.

  Lauzu, Periolle, Maillet. Intervention de l’hélicoptère de l’ALAT. Rev Corps et Santé 1970, 11, 6, 785-8   Boisseaux H. Le stress au sein de la population militaire. Médecine et Armées, 2010, 38, 1, 29 – 36.   Knezevic B. Stress at work among military doctors. Acta Med Croatica, 2006, 60, 4, 309-14.   Colas MD et Daudin M. Le stress opérationnel des PN, Journée Pierre Deniker, 14février 2013, Toulon.

Conclusion

•  Carers are exposed to specific operational stress

•  Homecoming involves complex challenges

•  Carers have special needs in terms of support, screening for psychological disorders and recognition