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War is changing; modern conflicts appear likely to be fought in urban or remote environments, producing different wounding patterns and placing non-combatants in the line of fire. Military medical skills training and available resources must reflect these fundamental changes in preparation for future conflicts.

HighlightsEVD is associated with life-threatening electrolyte imbalance and organ dysfunction.Clinical staging/early warning scores can be useful EVD prognostic indicators.Enhanced protocolized care is a blueprint for future treatment in low-resource settings.

The early use of CVCs in Ebola virus disease is safe, effective and facilitates patient care. It should be considered a feasible additional route of venous access, where physician expertise and resources allow.

Ballistic fractures remain a challenge for trauma surgeons in times of war and still have a poor prognosis. Further work is required to determine the optimal treatment of these injuries during conflicts. In addition, there still seems to be a continued need to re-learn the principles of war surgery in order to minimise complications and optimise functional recovery.

Ann R Coll Surg Engl 2009; 91: 417-419 417The General Surgical Syllabus of the Intercollegiate Surgical Curriculum (ISCP, August 2007) sets out the knowledge, clinical and technical skills expected of general surgical trainees in the management of emergency trauma at each of the three key stages of training -initial, intermediate and final.1 The syllabus includes the technical skill of trauma laparotomy at the initial stage, the management of penetrating and blunt abdominal and thoracic trauma at intermediate stage and the performance of thoracotomy, trauma laparotomy and the surgical management of specific organ injury at the final stage.In 2002, a postal questionnaire was undertaken of the experience, training and recent exposure to trauma of all general surgical consultant and specialist registrars in the UK.2 This demonstrated that UK general surgeons have limited experience in the management of severe trauma and that general surgical specialist registrars (SpRs) have limited exposure to general surgical trauma during their training. There is a paucity of technical hands-on experience with SpRs being involved with a median of only two blunt and one penetrating trauma laparotomies per annum and the majority will not see, or be involved in, an emergency thoracotomy throughout the 5 years of their training. These figures sit in direct contrast to the requirements for training in emergency trauma set out in the ISCP General Surgical Syllabus. Previous work has shown that trainees are involved in only two blunt and one penetrating trauma laparotomies per annum. During their training, nearly half of trainees will not be involved in the surgical management of liver injury, 20% will not undertake a trauma splenectomy and only a quarter will see a trauma thoracotomy. Military general surgical trainees require training in, and exposure to, the surgical management of trauma and specifically military wounding patterns that is not available in the UK. The objective of this study was to determine whether operative workload in the sole British surgical unit in Helmand Province, Afghanistan (Operation HERRICK) would provide a training opportunity for military general surgical trainees. PATIENTS AND METHODS A retrospective theatre log-book review of all surgical cases performed at the Role 2 (Enhanced) treatment facility at Camp Bastion, Helmand Province on Operation HERRICK between October 2006 and October 2007, inclusive. Operative cases were analysed for general surgical trauma, laparotomy, thoracotomy, vascular trauma and specific organ injury management where available. RESULTS A total of 968 operative cases were performed during the study period. General surgical procedures included 51 laparotomies, 17 thoracotomies and 11 vascular repairs. There were a further 70 debridements of general surgical wounds. Specific organ management included five cases of liver packing for trauma, five trauma splenectomies and four nephrectomies. CONCLUSIONS A training opportunity currently exists on Operation HERRICK for military general...

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