Medi-Solfen^® has the potential to have a major role in military and mass casualty trauma situations

Military

The recent wars in Iraq and Afghanistan have helped to shape the modern Defence Medical Services. Over the course of these conflicts there were a number of incremental innovations and improvements in clinical techniques and attitudes that contributed to the overall effect of reducing the mortality from combat injury. Significant resources were allocated to prepare for and deliver a coherent plan for deployed trauma care. The medical advances during the recent conflicts in these parts of the world have also included advances in anaesthesia and analgesia, but to a lesser extent than in other areas. The priority has so far been on improving survival rates. The humanitarian and physiological consequences of analgesia have featured less highly on the priority list.

Presently, with the level of small arms and fragment protection that is issued to Armed Forces, the survival rate following combat trauma is approximately 98%; however, there has been an increase in the number of extremity, groin, and facial wounds, as these are areas that are not as well shielded by individual combat armour¹. Many of the concerns and obstacles faced by early anaesthesia providers continue to exist today. The needs for safety, rapid application to surface injuries, mobility and availability of logistical resupply are all concerns for military anaesthesia providers.

The ideal analgesic for military use should have a predictable action, no side effects, a long duration of action, a readily available antidote, be easily administered and be easily stored and transported².

A Combat Medic will typically carry a backpack styled bag known as a “Unit One Pack”. Aid bags are available from many different manufacturers, in many different styles. Depending on the unit and their standard operating procedures, the Medic may have to follow a strict packing list, or may have the liberty of choosing their kit depending on the mission at hand. In terms of analgesics a typical aid bag will include: Morphine, Naproxen and some OTC products such as Acetaminophen and Ibuprofen³. Depending on the injury pain control may involve a combination of simple measures and different drugs. Morphine auto-injectors are issued to many countries’ armed forces on operations. All UK soldiers receive ample training on the use of the morphine auto-injector. Confidence in using the device is high and generally knowledge is good⁴. Unwanted side effects associated with Morphine use include respiratory depression, constipation and constriction of the pupils of the eye all of which may affect overall performance in combat situations. The goal in a casualty with mild-to- moderate pain is to provide pain relief that does not affect their sensorium. This allows them to either continue to facilitate their mission set or to help facilitate their own medical care and evacuation, depending on circumstances. In the wilderness setting, this would, in particular, apply to the casualties being able to facilitate their own evacuation⁵. The respiratory depression that is associated with opiate administration may result in the casualty requiring airway support, greatly complicating any movement.

Wound infection following combat injury is a cause of significant morbidity and occasional mortality⁶. Combat injury is often filthy, with ingrained dirt containing many troublesome microbes, both bacterial and fungal. These sow the seed for problems which may continue for many years after the injury⁷. Currently there is no provision for the delivery of any topical antimicrobial agents prior to the arrival of the patient at the Field Hospital.

Now that the survival rate has significantly improved following combat injury, perhaps now is the time to concentrate more effort into the humanitarian and other physiological effects of better anaesthesia, as well as ways of reducing the wound infection rate.

Medi-Solfen® offers the potential for a safe, effective replacement for Morphine that can both be easily and quickly applied and have immediate effect. It is important that delivery of these multi-modal anaesthetics has minimal psychoactive effects so that patients can continue to assist in their own care, evacuation and defence. An additional major benefit offered is that these drugs would act only at the wound site and not systemically. The inclusion of adrenaline into the overall formulation could also have a beneficial effect in controlling surface bleeding. Compared with opiates, which are Controlled Substances and Accountable Items, it would be relatively easy to envisage every soldier carrying an application of Medi-Solfen® in his first aid kit. Cost is also a factor in what medications are carried and utilized. Generic non-prescription medications such as Acetaminophen and Ibuprofen are available at minimal cost, whereas morphine injectors are much more expensive. There is also much less potential for criminal abuse of an item such as Medi-Solfen, unlike opiates. The logistics of the issuing of Medi-Solfen should therefore be much less onerous. The individual provider will need to decide which analgesics he or she should carry based on cost as well as regulatory and standard care pathway considerations.

Mass Casualty

In addition to military conflicts disaster situations, such as earthquakes, floods, conflicts, might happen in areas where access to a regular hospital or treatment centres might be hours away or not available at all. The provision of effective analgesia for mass casualties needs to be simple in its scope and application, supporting the principle of providing the greatest good for the greatest number in the safest way. The care of wounded victims, and the building or rebuilding of medical and first-aid facilities falls to the role of humanitarian assistance and disaster relief agencies such as the United Nations, Medecins Sans Frontieres and the IRC. These agencies are funded by donations and/or government funding and grants. Similar to the military, all of these agencies source and supply basic medical necessities to their Field Officers for the management of wounded victims and for the setting up of basic medical facilities. A product like Medi-Solfen® has the potential to become a critical component of the basic medicines supplied. It is ideally suited to such applications because it is cheap, portable and able to be applied immediately by rapidly trained lay personnel. It would provide a means of promptly treating wounds that otherwise may remain untended for prolonged periods of time particularly in war-torn or third-world countries. Indeed in many cases such wounds may not receive any other anaesthetic. The monitoring of such casualties may need to rely on minimally trained personnel using simple clinical parameters. When casualties present in large numbers with minor injuries resulting in breakdown of the skin Medi-Solfen can provide an effective rapid solution to pain relief during potential long waits for initial triage or allow casualties to return for later treatment if not in imminent danger. The benefits of having a cheap, simple to use product to relieve pain, minimise bleeding and protect against infection in these circumstances are considerable. Medi-Solfen® has the potential to act as the ‘front line’ pain relief for topical wound care product for victims of trauma throughout the world.

References

1. Jeffery SLA. Advanced wound therapies in the management of severe military lower limb trauma: a new perspective. Eplasty 2009; 21: e28
2. Battlefield Advanced Training Life Support. Chapter 14 Analgesia. JR Army Med Corps (2003); 149: 297-302
3. Equipment of a combat medic https://www.google.co.uk/search?q=morphine+in+soldiers+combat+back+packs&rlz
   =1C1GCEA_enGB784GB784&oq=morphine&aqs=chrome.1.69i57j35i39j0l4.5917j0j8 &sourceid=chrome&ie=UTF-8
4. Nelson SC and Wedgwood JT (2015.) How much do soldiers know about the morphine they carry on operations? A questionnaire study of knowledge and understanding of the morphine auto-injector on Op HERRICK 17. J R Army Corps; 161(1): 27-31
5. Wedmore IS and Butler FK Jr (2017) Battlefield analgesia in Tactical Combat Casualty Care. Wilderness and Environmental medicine;28: S109-S116
6. Taylor C, Jeffery SLA. Management of military wounds in the modern era. Wounds UK 2009; 5: 50-58.
7. Jeffery SL. The Management of Combat Wounds: The British Military Experience. Adv Wound Care 2016 Oct 1; 5(10): 464-473.

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