The Canadian Forces trauma care system

According to the Trauma Association of Canada, a trauma system is a preplanned, organized and coordinated injury-control effort in a defined geographic area. An effective trauma system engages in comprehensive injury surveillance and prevention programs; delivers trauma care from the time of injury to recovery; engages in research, training and performance improvement; and establishes linkages with an all-hazards emergency preparedness program. To support Canada's combat mission in Afghanistan, the Canadian Forces (CF) developed a comprehensive trauma system based around its trauma hospital--the Role 3 Multinational Medical Unit (R3MMU) at Kandahar Airfield. This article reviews the essential components of a modern trauma system, outlines the evidence that trauma systems improve care to injury victims and describes how the current CF trauma system was developed.

Introduction to the Canadian Forces supplement on war surgery

Improvements in trauma care have been inextricably linked to wars. Surgical techniques and trauma systems have been refined in successive conflicts. Ambroise Paré, perhaps the first modern trauma surgeon, pioneered the use of antiseptic ointments for the treatment of gunshot wounds and the use of ligature, instead of cauterization, to control arterial bleeding. Dominique-Jean Larrey, Napoleon’s surgeon, addressed trauma from a systematic and organizational standpoint by introducing the concept of the “flying ambulance,” the sole purpose of which was to provide rapid removal of wounded soldiers from the battlefield. From his own World War II experiences, Michael DeBakey noted that wars have always promoted advances in trauma care because of the concentrated exposure of military hospitals to large numbers of injured people. Furthermore, DeBakey felt that this wartime medical experience fostered a fundamental desire to improve outcomes by im prov ing practice. In July 2011, Canada ended its combat mission in Af ghan istan. During our 9 years in Afghanistan, we have accomplished much, but at a significant cost. A total of 157 Canadian Forces (CF) personnel have died in the war since 2002 — the largest number for any single Canadian military mission since the Korean War. Among the dead were 8 CF medical technicians, who always accompan ied our combat troops on patrol “outside the wire” and who were killed in action while providing medical support to them. On Remembrance Day, we reflect on the sacrifices made by CF members in this most recent and other previous conflicts. As first-hand witnesses to the sacrifices made by our brothersand sisters-in-arms, members of the Canadian Forces Health Services (CFHS) are also remind ed of our solemn responsibility to care for our wounded. Our sense of responsibility continues to be our fundamental motivation to improve practice in order to improve outcomes for those who serve. Compared with past conflicts, this current conflict has seen a dramatic reduction in the number of soldiers killed from combat wounds: the current case fatality rate is 8.8%, whereas the rate during World War II was 22.8%. Better body and vehicle armour, technology and tactics all likely contributed substantially to this improved survival rate. However, advances in prehospitaland hospital-based trauma care have also improved survival. In addition, comprehensive rehabilitative and mental health care have improved the quality of life of our wounded soldiers after they return to Canada. As this Remembrance Day passes, members of the CFHS have contributed their reflections on lessons learned during the war in Afghanistan to this supplement of the CanadianJournal ofSurgery. We hope that our wartime experiences and lessons will be the starting point for future health care innovation that helps us continue to sustain and shield our fighting forces when they deploy on future military missions.

Introduction au supplément sur les Forces canadiennes et la chirurgie en temps de guerre

L’amélioration des soins en traumatologie est inextricablement liée aux guerres. Les techniques chirurgicales et les systèmes de traumatologie ont été per fectionnés au fil des conflits. Ambroise Paré, considéré comme le père de la chirurgie moderne en traumatologie, fût le premier à utiliser les pommades antiseptiques pour traiter les blessures par balle et à avoir recours à la ligature, au lieu de la cautérisation, pour contrôler les saignements artériels. Dominique-Jean Larrey, chirurgien de Napoléon, envisagea la traumatologie d’un point de vue systématique et organisationnel. Il créa le concept de « l’ambulance chirurgicale mobile », dont le seul but était d’évacuer rapidement du champ de bataille les soldats blessés. Fort de ses propres expériences durant la Seconde Guerre mondiale, Michael DeBakey a fait remarquer que les guerres ont toujours favorisé les progrès en traumatologie, le personnel médical étant exposé à un grand nombre de blessés dans les hôpitaux militaires. DeBakey estimait en outre que cette expérience médicale en temps de guerre alimentait un désir fondamental d’améliorer les résultats en améliorant les pratiques. En juillet 2011, le Canada mettait fin à sa mission de combat en Afghanistan. Au cours de ces 9 années en Af ghan istan, nous avons beaucoup accompli, mais au prix de grands sacrifices. Au total, cette mission aura coûté la vie à 157 membres des Forces canadiennes (FC) depuis 2002 — le plus grand nombre de morts, toutes missions militaires du Canada confondues, depuis la guerre de Corée. Parmi les morts figurent 8 techniciens médicaux des FC qui accompagnaient toujours nos troupes de combat en pa trouille « à l’extérieur des barbelés » et qui ont été tués dans le feu de l’action alors qu’ils fournissaient ce soutien médical. Le jour du Souvenir, nous nous recueillons en mémoire de ces hommes et de ces femmes qui ont perdu la vie au cours de ce récent conflit et de conflits antérieurs. En tant que témoins de première ligne des sacrifices consentis par nos frères et sœurs d’armes, les membres des Services de santé des Forces canadiennes (SSFC) n’oublient pas leur responsabilité solennelle de prendre soin de nos blessés. Notre sens des responsabilités continue d’être notre motivation fondamentale pour perfectionner la pratique afin d’améliorer les résultats pour ceux et celles qui servent notre pays. Comparativement aux conflits passés, on note, pour ce conflit, une réduction considérable du nombre de soldats morts des suites de blessures. En effet, le taux de mortalité est de 8,8 %, alors qu’il s’élevait à 22,8 % lors de la Seconde Guerre mondiale. Un équipement de protection personnelle amélioré et un meilleur blindage des véhicules, ainsi que le perfectionnement des techniques et des tactiques, ont fort probablement contribué beaucoup à cette amélioration. Les progrès des soins préhospitaliers et hospitaliers en traumatologie ont toutefois apporté aussi leur contribution. En outre, les soins complets de réadaptation et de santé mentale ont amélioré la qualité de vie de nos soldats blessés de retour au Canada. À l’approche de ce jour du Souvenir, des membres des SSFC ont couché sur papier dans ce supplément du Journal canadiende chirurgie leurs réflexions sur les enseignements tirés de la guerre en Afghanistan. Nous espérons que nos expériences de guerre et les leçons tirées serviront de tremplin à des innovations en soins de santé afin de continuer à appuyer et à protéger nos forces de combat quand elles seront déployées sur le terrain lors de futures missions militaires.

Innovation as the core strategy for the future success of academic health centres

Tough economic times pose challenges for all sectors of the economy, and academic health centres are no exception.1 Health care reform in the United States will also pose additional challenges for academic medicine.2 What is the future role for academic health centres? Innovation, productivity and prosperity (particularly in the health sector, which includes health care, education, research and industry) are important contributions not only to the health status of the population but also to the well-being of society.3 We propose that innovation should be a core strategy for academic health science centres (AHSCs) and propose strategies to enhance that historical strength. What is needed in order for AHSCs to develop that strength? The AHSCs or teaching hospitals have a tripartite mission of research, education and clinical care.4 Through research, AHSCs aim to develop new and better methods of caring for patients and improve the health care outcomes of the broader population; we, like many others, would argue that AHSCs have an imperative or social responsibility to do so. Thus, innovation is an implicit goal of every AHSC and is essential to fulfilling their academic mission. Whereas attention has been focused on improving research innovation, little attention has been directed to the development and evaluation of specific strategies to promote innovation in the academic health sector. The AHSCs should consider turning to the private sector if they want to implement tactics that have been shown to promote and sustain a culture of innovation.5 Although some might question the relevance of the private sector to academic centres, many of the strategies merit attention, testing and even implementation. Whereas AHSCs strive to generate Nobel prize–worthy discoveries, this lofty goal cannot be the only driver of innovation within the organization. The need for innovation has spread beyond research to many areas, including the education of health professionals and patients through new technologies, such as e-health, e-learning or simulation. Innovative methods for managing institutions and increasing efficiency have also become essential for effective and financially viable AHSCs. Leadership has a key role to play in promoting innovation.5 Innovation needs to be explicitly integrated in 1 or more of the institutional vision, mission or values. However, while explicit statements by leaders about the importance of innovation are essential, alone they are insufficient. Rather than focusing exclusively on research, the promotion of innovation should occur in all spheres of activity, including clinical services, support services, educational activities and administration. Leaders also need to create the necessary structures, processes and reward systems. For example, leaders play a unique role in developing a workplace where staff members feel comfortable bringing forward and testing new ideas and investing resources to promote innovation. Although this does entail an element of risk in that new innovations may not succeed or may not be more cost effective than current approaches, this should not curtail the innovation imperative of leading AHSCs. How people are organized may also have a substantial influence on creativity and innovation. The traditional departmental organizational structure provides comfort in groupings of like disciplines and allows administrative simplicity for performance management and fiscal accountability, but has the potential to create institutional silos that may constrain interactions and potentially create competitiveness that stifles creativity. Alternative models of organization that focus on integration, such as interdepartmental units, centres of excellence or institutes, bring multiple disciplines together around a single theme, such as the heart or nervous system, but may replace one silo by another. Matrix organizations create overlapping or intersecting organizational designs. For example, a surgeon may belong to a university or hospital department of surgery but may also be a member of a centre or institute focused on an organ, such as the heart, or another discipline, such as transplantation or regenerative medicine. Because matrices will be more complicated to administer, institutions will need to create clear lines of accountability and financial responsibility. They will also need to ensure that the matrix approach enables interdisciplinary and interprofessional creativity. The skills and attitudes of people working in AHSCs will affect performance, culture, direction and willingness to change. While people who innovate tend to be independent, think more expansively, combine concepts and more willingly take risks,5 an organization that rewards only such high-octane risk-takers would not derive the full value of the innovation chain across the skill mix of its staff complement. Multidisciplinary approaches are needed to create new approaches to problems.6 Thus, the ability to work collaboratively and share ideas is likely to foster creativity. Creating a climate that encourages brainstorming and welcomes ideas will tend to bring out innovative ideas from most but will require identification of formal roles for individuals or groups of individuals to generate, discuss, test and disseminate ideas. Newer generations will have different attitudes toward interaction and collaboration, evidenced by a high degree of comfort with the Internet and social networking, which has the potential to bring broad input from large numbers of individuals, particularly over dispersed geographic areas, and minimize social constraints and hierarchy. The organization must find ways to recognize and reward innovation across all activities — research, clinical, educational or administrative.5 Such rewards need not be financial or only financial, but should include celebration of innovation, more protected time or time to pursue professional development. Furthermore, recognition should include both small and large innovations and reward both groups and individuals. Keeping in mind that results may be slow in coming, reward should be targeted toward creativity rather than production goals. Equally important as appropriate rewards is avoidance of criticism of failed attempts at innovation, since some, if not many, of the ideas or initiatives will not be successful. Clinical innovations pose unique challenges. Specifically, “failed” innovation can adversely impact patient outcomes with associated liability risks. Encouraging clinical innovation will require processes for introducing innovations in a way that does not jeopardize patient safety.7 Innovation requires support.8 First and foremost, individuals require time to be creative. A fully committed day with stressed individuals is almost certainly not going to lead to creativity. Finding the appropriate balance between work and creative time is not straightforward in a for-profit, competitive market or in a constrained publicly funded model. A separate stream of dedicated time may also address the potential tension between the discipline of quality improvement based on standardization and the disruptive nature of innovation.8 Developing and evaluating innovative ideas will often benefit from seed money or innovation funds. An enduring theme of research is that physical colocality — placing offices of individuals or groups of researchers together — strongly influences the probability of collaboration. “Who to place where” should be a key feature in designing work spaces. Physical design also needs to consider the use of open spaces and types of common areas. Open spaces provide more opportunity for interchange but pose challenges for personnel privacy and security of health information. Industries that value creativity create informal common areas to encourage creative thought through casual interaction. This later concept, the equivalent of a modern “water cooler,” should influence the placement of major equipment and eating and working areas. In summary, the time is ripe for innovation as a key strategy to preserve and enhance the clinical and academic mission of teaching hospitals. While yet to be tried in the academic setting, the private sector has tested and implemented many strategies that have direct relevance to AHSCs. Teaching hospitals will be challenged to grapple with complex issues, including measuring innovation and developing methods to evaluate promotion strategies. However, the current climate provides an opportunity and mandate to exploit the implicit strength of AHSCs to innovate.

Creating a university technology commercialisation programme: confronting conflicts between learning, discovery and commercialisation goals

Our knowledge-based society is pressing universities to transform from monastic scholarly enclaves into producers of new technologies and incubators of start-up firms. However, converting scientists' curiosity-driven discoveries into commercially viable innovations has proven so difficult that observers liken the journey to crossing a 'Valley of Death'. We conceptualise the challenges of commercialising university inventions in terms of three gaps: the technology discovery gap, the commercialisation gap, and the venture launch gap. We chronicle the inception and evolution of a technology commercialisation programme at the University of Oregon, relating how the university confronted and dealt with the three gaps, and describing the intra-organisational partnerships developed to address them. We find that negotiating the gaps requires assimilation of a technology commercialisation mission into the traditional academic missions of education and scientific discovery. To do this, universities must confront fundamental contradictions between learning, discovery, and commercialisation.

Enhancement of industry initiative through the Zero-energy Mass Custom Home Mission to Japan experience towards commercialisation

In response to growing global warming issues and increasing energy prices, house-builders today are becoming keener on the delivery of zero energy sustainable homes than ever. Nevertheless, their business operation still tends to develop into routine in view of their close system mode of operation. In 2006, to stimulate the industry, knowledge transfer study visits to Japanese net zero energy cost mass custom housing manufacturers were initiated. The educational event was later called 'Zero-energy Mass Custom Home Mission to Japan' and was resumed in 2007, 2008 and 2010. Consequently, three industry participants were transformed successfully from conventional housing suppliers to early adopters of net zero energy/carbon-emission homebuilders in their local contexts. This study demonstrates the gravity of the mission's execution that was aimed at putting the theory of organisational buying behaviour into practice in order to develop a way to change the nature of the homebuilding industry towards the delivery of zero energy mass custom homes of the future.

Extracorporeal membrane oxygenator rescue and airborne transportation of patients with influenza A (H1N1) acute respiratory distress syndrome in a Mediterranean underserved area

Adult respiratory distress syndrome (ARDS) secondary to H1N1 viral infection has been a worldwide medical and organizational challenge. We report our experience with extracorporeal membrane oxygenator (ECMO) rescue and transportation of patients with H1N1 ARDS within an insular and rural Mediterranean area of seven million inhabitants. A 24/7 on-call ECMO team was organized including one anesthesiologist, one cardiac surgeon, and one perfusionist. To limit missions' time to and from peripheral hospitals, airborne transportation with helicopter was the first choice. From November 2009 to January 2010, we performed 10 missions. Eight patients (80%) were placed on ECMO and transferred either on helicopter (70%) or with standard ambulance (10%). Average mission duration was nine hours (6-16 h). No complications secondary to the transportation means or to the ECMO were reported. Delivery of advanced medical technology can be achieved even in remote and underserved areas presenting geographical barriers. A multidisciplinary mobile ECMO team coordinated with adequate means of transportation could be routinely employed to rescue patients affected with other forms of severe acute hemodynamic and/or respiratory impairment.

Les voies/voix de la vengeance à l'opéra au XIXe siècle

" [...] ici chacun se venge ", proclame Ruy Blas au denouement, sanglant, du drame de Victor Hugo. La declaration vengeresse pourrait s'appliquer au champ lyrique, dans son extension historique, culturelle et esthetique tant les mots " vengeance ", " vendetta ", " Rache " ou " revenge " ponctuent, amplifies par l'hyperbolisation du chant, duos, airs ou finales d'operas. " Poursuivons jusqu'au trepas l'ennemi qui nous offense ", decrete Armide chez Quinault et Lully en 1686 (acte I, scene IV). " Der Holle Rache kocht in meinem Herzen ", chante la Reine de la Nuit chez Mozart en 1791 (" Mon cœur est tout brulant de vengeance infernale ", acte II, scene VIII). " Si, vendetta, tremenda vendetta / Di quest'anima e solo desio ", martelle Rigoletto chez Verdi, d'apres Hugo, en 1851 (" Oui, vengeance, terrible vengeance, / C'est le seul desir de mon âme ", acte II, scene VIII). " Here my tragedy began, here revenge begins ", declame sur un mode hypnotique Miss Jessel, dans The Turn of the screw, Le Tour d'ecrou de Benjamin Britten, d'apres Henry James, en 1954 (" Ici a commence ma tragedie, ici commence ma vengeance "). C'est comme si l'opera s'etait donne pour mission d'explorer les zones obscures du dechainement passionnel et de baliser les territoires archaiques des cultures humaines, un monde d'avant la retenue imposee au sujet ou au clan par la morale du pardon ou par l'institution de la justice - du moins serait-ce la lecon delivree par une approche anthropologique. Sans doute la vengeance possede-t-elle, comme sujet et comme donnee dramatique, - selon cette fois une approche dramaturgique - une charge spectaculaire auquel les enchantements lyriques, pas plus que la fable tragique, ne sauraient renoncer. Sans doute aussi la vengeance trouve-t-elle une voie d'expression privilegiee dans le chant, dont l'expressivite (hauteur de son, intensite, couleur, accents) transcende la communication commune pour laisser entendre, stylisee ou metaphorisee par la musique vocale, la brutalite quintessenciee des affects qu'aucune civilite ni socialite ne controleraient plus.

Mission Acronyms

Very sophisticated? Mission und Ausbreitung des Christentums in der Welt der Zweiten Sophistik