Peacekeeping Safety and Security

The Development and Introduction of the United Nations Buddy First Aid Course

By MCM. BRICKNELL , C. BOOKER , A. TIWATHIA and J. FARMER. United Kingdom

Martin CM BRICKNELL

Professor BRICKNELL took up his appointment as Professor in Conflict, Health and Military Medicine at King’s College London in April 2019. Priorto his he served 34 years in the UK Defence Medical Services, culminating his service as the Surgeon General of the UK Armed Forces. He undertook operational tours in Afghanistan, Iraq, and the Balkans with multiple additional overseas assignments. In 2010 and 2006, he held senior Medical Adviser appointments in the NATO ISAF mission. He commanded 22 Field Hospital in 1999-2002. He has trained as a general practitioner and is an accredited specialist in both Public Health and Occupational Medicine. He holds two doctorates and 3 masters degrees. He has published over 100 academic papers across military medical subjects. He is especially interested in how organisations learn, care pathways in military healthcare, and the political economy of health in conflict. He was awarded the Companion of the Order of Bath, the Order of St John and the US Bronze Star during his military service.

INTRODUCTION

This paper describes the introduction of the United Nations Buddy First Aid Course (UN BFAC) in the context of a wider programme to improve the medical support arrangements for United Nations Peacekeeping Operations (UN PKO). This programme reflects the advances in military medical care that have occurred in the context of other coalition or allied military operations. In particular, the UN BFAC is designed to adopt the innovations that have occurred in the immediate treatment of conflict-related trauma at the point of injury; specifically, the life-saving re-introduction of a focus on stopping catastrophic bleeding through direct pressure and tourniquets. This is part of the package of basic first aid skills to be taught to all military personnel.

IMPROVING THE FRAMEWORK FOR MEDICAL SUPPORT TO UN PEACEKEEPING OPERATIONS

Figure 1: UN BFAC Legend Card

The nature of United Nations peacekeeping missions has changed, with more intra-state rather than inter-state conflict, a new generation of weapons being used, and peacekeepers being explicitly targeted by the parties to conflict. There have been 3,868 fatalities on UN PKO of which 189 occurred over the period 2013-2017. Concerns about the cost and effectiveness of UN PKO resulted in a review of the conduct of UN PKO by the High-level Independent Panel on UN Peace keeping Operations (HIPPO). The report was far-reaching and included the following observation 'missions must deploy with the necessary military and medical capabilities and security procedures to deal with emergencies upon arrival'. It recommended that 'measurable, effects-based and performance-focused standards are required for the future, with a particular focus on developing performance standards for specialized capabilities such as medical capabilities. This recommendation increased the responsibility of the United Nations Headquarters for ensuring medical support arrangements to United Nations field missions. International collaboration was enhanced by the development of a 'medical group of friends' by supportive nations in 2017.

The programme to improve medical support for UNPKO is based on a 'chain of care' comprising 5 steps: buddy first aid, field medic assistant, casualty evacuation (CASEVAC), level 1 field clinics, and hospital care (level I II and III). It uses the planning timeline of 0- 10 minutes for first aid and medic care, 0-1 hour to level 1 clinic resuscitation, and 0-2 hours to hospital care. A medical project plan was developed that contained the following 8 streams: development and implementation of a United Nations Buddy First Aid Course (UN BFAC) for all military and police personnel; development and implementation of a Field Medic Assistant training package; development and implementation of a CASFVAC Policy; standardisation of Health Care Quality and Patient safety in level I Facilities; standar-disation of Health Care Quality and Patient safety in Level I+/II/III Facilities; implementation of a Health Risk Assessment in all missions; development of standards for an Aero Medical Evacuation Team (AMP); and formation of a dedicated United Nations Medical Centre of Expertise. Medical arrangements on UNPKO came under further scrutiny through the publication of the Cruz Report. This report observed that 'to save lives after attacks occur, improving the quality and availability of first aid and Level 1 hospitals is crucial’. It strongly endorsed this medical project plan. UN Policy for Casualty Evacuation in the Field was published in March 2018 and was recently revised after stress testing was conducted in 4 high risk missions (MALI, Central African Republic, DRC and South Sudan). The United Nations published a Declaration of Shared Commitments on UNPKO in September 2018 that has been endorsed by 150 nations. This includes the provision of well-trained and equipped personnel and the obligation on the United Nations to provide training materials and standards that match operational requirements. The formal United Nations request for uniformed capability requirements published in May 2019 included a specific request for support in first aid training (using the United Nations standard) to troop contributing nations.

DEVELOPMENT OF THE UN BFAC

The UN BFAC curriculum was developed with the assistance of the United Nations Mine Action Program. After a thorough review of available Member State programs, the curriculum was adapted from the “Life Saver” program developed by the State of Israel for their first aiders. It uses the MARCH mnemonic (M-massive bleeding, R-respiration, C-circulation, H-heat/cold) that originated from the US Tactical Field Care drills within the Tactical Combat Casualty Care framework. There are 9 modules of competency: first aid and the medical evacuation chain, general scene and primary assessment, tourniquets for extremity haemorrhage, wound packing for limb injuries not amenable to tourniquet application, airway management, chest injuries, emergency pressure bandages, heat disorders, casualty movement techniques. The legend for the UN BFAC graphics is shown in Figure 1.

This curriculum was developed into a teaching course that was supported by graphics and teaching material that could be delivered in any language and with low-cost audio-visual support (posters and printed material rather than PowerPoint presentations). The intended training environment was expected to be highly flexible, including outdoor recreational or training areas normally used for other military activities.

The pilot course for the UN BFAC took place in Entebbe, Uganda in February 2018, delivering UN BFAC training to 24 students representing 15 UN Member states. This was designed to test and evaluate the draft training material and the ‘train-the-trainer’ material. This pilot demonstrated the validity of the curriculum and teaching material for the UN BFAC course.

IMPLEMENTATION AND ROLLOUT OF THE UN BFAC

It was clear that the United Nations could not deliver UN BFAC training to all personnel on UNPKO, indeed it is a national responsibility to provide their contingents to UN PKO missions trained for their role. Therefore, it was decided that the United Nations should train ‘master trainers ’for Member States deploying troops to UN PKO. These Master Trainers would cascade the training in their own countries by conducting Train the Trainer programmes within their national armed services to implement UN BFAC as the minimum requirement within their training systems. They would also provide oversight to the implementation of United Nations BFAC into the training pathway for their UN PKO contingents. This mirrors the cascade arrangements that many nations already use to teach point-of-injury first aid to their on military personnel. UN BFAC would be the United Nations training standard and contingents deployed in UNPKO would be assessed against this skill set. In the future, the UN BFAC material would also be made available to nations who provide training support as part of bilateral capacity-building programmes to support nations who are preparing contingents for UNPKO. This model is also applicable within the pre-deployment training pathway for police personnel assigned to UN PKO.

In December 2018, the UN BFAC Master Trainer course was piloted at the United Nations Global Service Centre (UNGSC), Brindisi. This course comprised a UN BFAC course and an Instructional Techniques course. The latter course covered: roles and responsibilities, student engagement, planning and preparing a lesson, lesson structure, skills analysis, delivering training, selection and use of training aids, and confirmation of learning. Following the didactic phase, students were then required to teach back lessons and scenarios based upon the UN BFAC syllabus.

Figure 2: UN BFAC Master-Trainer Course showing students f rom India and Ghana at the Irish UN Training Centre, Galway.

The instructional staff reviewed the performance of the participants. Over the course of the week it became apparent there was variation in their initial knowledge and instructional skills. Unfortunately, some were unable to successfully pass the UN BFAC at their first attempt let alone reach the level of a certified UN BFAC Master Trainer. This was an important insight into the variance in the nominations of candidates made by the Member States and the outcomes of the course. It was agreed that the participants would be awarded one of the following 4 levels: certified as a UN Master Trainer and able to train trainers, certified as a Trainer to deliver UN BFAC to students, certified as having passed the UNBFAC training and certified as an attendee of the UNBFAC Master Trainer Course. Overall, the UN BFAC Master Trainer Pilot Course was deemed successful; 22 students attended the course and 15 nations were represented. Over 70% of students attending achieved trainer status; with 50% being accredited as UN BFAC Master Trainers. Further courses have taken place in Renmore Barracks in Galway (Ireland, March 2019), within the United Nations Multidimensional Integrated Stabilization Mission in Mali (MINUSNIA, April 2019) and in Salvador City, Brazil (September 2019). A photograph from one of the courses b shown at Figure 2. The concept of the cascade training was tested by having these Master Trainers and Trainers send their training dates and names of the trainees, signed by their Senior Officers to the Division of Healthcare Management and Occupational Safety and Health at the UN, where a database is being maintained.

It is expected that the UNBFAC will move into "business as usual" after promulgation in 2020, when a critical mass of Troop Contributing Countries master trainers will allow delegated certification of national training centres. The course material will be made available electronically to nations in both English and French. The material is also supported by a UN BFAC app, for both the Android and Apple platforms, which individual personnel are able to download to their personal electronic devices. This acts as both an aide-memoire for use before embarking on a patrol, during an incident, and also as reference source to maintain their knowledge. Finally, a standardised system of assessment of UNBFAC performance will be provided to United Nations missions to support training and mission-rehearsal of military contingents’ incident response capabilities.

CONCLUSIONS

This paper has provided a summary of the development of the United Nations Buddy First Aid Course within a wider programme that aims to improve the performance of the medical support system within United Nations peacekeeping operations. It has described how the curriculum was developed and then the design of the cascade system for implementation_ The importance of 'master-trainers’ to the whole project has been emphasised alongside the method for dissemination of reference material and instructional aides. We hope that the military medical community will embrace these developments and either introduce the United Nations BFAC within their own armed forces or collaborate with the United Nations to agree reciprocal recognition of their national military point-of-injury first aid training.

Acknowledgement

The following nations contributed funds, personnel or hosted training in support of this project Australia, Brazil, the People's Republic of China, Denmark, France, German, Ireland, the State of Israel, Japan, Luxembourg, Republic of Mauritius, the Kingdom of the Netherlands, Nigeria, Norway, Sweden, United Kingdom of Great Britain and Northern Ireland and the United States of America.

The views expressed herein are those of the authors and do not necessarily reflect the views of the United Nations.

Abstract

This paper describes the development of the United Nations Buddy First Aid Course (UN BFAC) that will become the minimum standard for first aid performance for military and police personnel on United Nations Peacekeeping Operations (UN PKO). It explains the rationale for the review of the medical support system for UN PKO and the key activities within the medical improvement programme. The development of the UN BFAC curriculum and training system is based on international best practice. This has been piloted through a series of ‘train-the-trainer- courses that were attended by representatives of UN troop contributing nations. The UN BFAC will be promulgated during 2020.

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