Pharmacy practice in the Armed Forces


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Did you know that the Ministry of Defence employs over 30 pharmacists and 80 pharmacy technicians? Not all are in uniform, but they do all support the work of the Armed Forces both in the UK and overseas. Maintaining the health and fitness of military personnel is vital and the role of pharmacy in supporting this is becoming increasingly recognised.

The Defence Medical Services provide healthcare to Royal Navy, Army and Royal Air Force personnel both in the UK and overseas. Military medical centres in the UK provide primary healthcare (PHC) to Service personnel and, in some larger garrisons, to their dependants as well. Overseas medical centres support permanent bases such as Germany and Cyprus or smaller training bases, such as those in Kenya and Canada. DMS staff also work in affiliated NHS hospitals where military personnel are provided with secondary healthcare. This twoway arrangement enables medical staff to maintain their clinical skills for operations, whilst contributing to the NHS at the same time.

Where pharmacy fits in

So where does pharmacy fit into all this? There are a number of different ways that pharmacists and technicians are employed by the MOD. Large UKbased medical centres will have a dispensary, which is usually technician-led and is broadly based on a ‘dispensing doctor’ model. Smaller medical centres will have their prescriptions dispensed through a contracted high street pharmacy. Pharmacists oversee these services, and each pharmacist will have approximately 15 medical centres (including those without a dispensary) to support. They will provide advice to the technicians, other healthcare professionals, liaise with the contracted pharmacies and generally manage the pharmacy services for their area of responsibility. PHC pharmacy staff are a mixture of civilian and military professionals. The RN and RAF only have one pharmacist each, both of whom are civilians who work closely with RN, RAF and civilian technicians.

A small number of military pharmacists are based in those NHS hospitals with Ministry of Defence Hospital Units attached. These include hospitals in Plymouth, Frimley Park and Birmingham. This enables them to develop and maintain the clinical skills they require to support a Field Hospital on operations.

In addition to these posts, there are pharmacists and technicians working in the Defence Medical Services Training Group where they train non-pharmacy staff such as Combat Medical Technicians. The Defence supplies organisation employs civilian pharmacists to procure pharmaceuticals and provide regulatory advice such as that surrounding the military Wholesale Dealers Licenses and unlicensed medicines. Uniformed pharmacists work in logistic roles in Cyprus and Wiltshire, where they learn the skills required to manage the supply and issue of medical supplies on operations.

The operational role

Perhaps the most unusual aspect of military pharmacy is the operational role, which varies depending on circumstances, but can broadly be broken down into Medical Logistics and Clinical. Only the Army employ and deploy uniformed pharmacists, who are commissioned officers in the Royal Army Medical Corps. They are supported by military pharmacy technicians from all three Services. Most tours are around three months long and a pharmacist can expect to deploy twice in three years, technicians less frequently.

In the initial stages of an operation, the main focus will be on making sure that the correct supplies reach theatre, that they are transported and stored properly, that the cold chain is maintained and that the accounting procedures for future issues and audit are in place. Casualty numbers are usually expected to be low and most of the clinical pharmacy work will be at a PHC level. Army pharmacists will be based within the logistics chain, working alongside Royal Logistic Corps colleagues (RLC), and within the Field Hospitals, where there will often be a PHC medical facility attached. As the operation matures, so does the level of clinical input. Pharmacists will then find themselves carrying out a greater level of ward based clinical pharmacy, which is predominantly trauma-based. Military personnel are generally young and fit and therefore medical conditions are less common. However, there are still unexpected diabetic episodes, asthma attacks and infectious diseases to deal with. This requires the deploying pharmacist to be a ‘generalist’ rather than a specialist in any one area.

The nuances of an operational tour are probably best illustrated by providing some examples. Logistic challenges are not to be underestimated and throw up scenarios that could not be imagined in the UK. Whilst I was deployed for the first time in Bosnia in the 1990s, a serious helicopter crash resulted in a rapid depletion of oxygen supplies at the Field Hospital in Sipovo. There was an urgent requirement for replacement oxygen cylinders (no piped gas facilities existed) from the warehouse I managed in Croatia. As I was very new to the Service I had a number of questions to ask: How many cylinders can a Sea King helicopter carry? Are they even allowed to carry this dangerous air cargo? I contacted the pilots for advice, arranged for a helicopter to be requisitioned and the oxygen arrived in time. In Kosovo a few years later, we were having to manage warehouse stocks where external temperatures were as low as -25oC, with limited temperature controlled storage. In Iraq a colleague had to quickly re-locate stocks when the power supply to a refrigerated storage area was struck by a mortar. It could have been a lot worse had it landed a few feet away on the oxygen storage facilities…

The operational PHC role, in many ways, reflects that of a community pharmacist in the UK. Patients are prescribed medicine against a formulary, which reduces the risk of a supply problem. A non-formulary drug can take over two weeks to receive and so prescribers do stick to the formulary whenever possible. There are a small number of locally employed civilians who are entitled to medical care, and recently operations have taken place in Muslim countries where the Ramadan fasting has to be taken into account, with interpreters assisting in the medication counselling and other visual aids used. No different, really, to the UK. However, it is the non-routine matters that generate the biggest challenges. Aircrew, for example, may have illnesses that restrict their flying and are unable to take certain medications due to the risk of side effects. Serious rhinitis in one pilot nearly grounded an entire helicopter crew in Bosnia as he was unable to use the antihistamine that was held in stock. There was no alternative he could use. We had to ensure he got his medicine as soon as possible and that such a situation did not arise again in future. Pharmacists get questions from a number of sources, and my favourite is still the veterinary technician asking if it was true that loss of smell could be a side effect with doxycycline. The question would not have been so worrying had the ‘patient’ not been an explosives sniffer dog!

The operational pharmacist is also required to provide a ward-based service in addition to their PHC role. Usually patients are routine trauma cases, but it is often the medical conditions that throw up the biggest challenges, not least because it is not possible to hold drugs for every eventuality. In the last few months my colleague in Afghanistan had to deal with supplies for a hypertensive emergency. This required him to identify a NATO ally that held stocks of sodium nitroprusside and then liaise with a US Field Hospital to arrange for the injection to be flown in by helicopter.

Non-operational duties

When not deployed, most military pharmacists work from an office, Monday to Friday. Only those based in medical or logistic regiments will need to attend routine inspection parades. The weapons we carry on operations are locked away in the armoury and can only be drawn for training or field exercises. Uniformed personnel are required to undertake annual training covering navigation, weapon handling, fitness, values and standards, and battlefield first aid, and these are tested. Unsurprisingly there is a heavy emphasis on fitness and adventurous training exercises provide opportunities for a number of sports such as sailing, skydiving, skiing and mountaineering.

Professionally, questions on legislation, supply problems, governance and such like are probably very similar to those in any civilian organisation. We do get some interesting variations, such as one from the Royal Navy asking if captured pirates apprehended in the Horn of Africa are allowed to keep their khat. There is also a lot of emphasis on travel-related medicine due to the geographical spread of postings, exercises and operations.

A recent report from Afghanistan

Nov 2011: A major medical incident following a suicide bomber resulted in a large number of injuries, including 20 walking wounded casualties, who all arrived by helicopter at the UK Field Hospital within 40 minutes of each other. To manage these patients additional resuscitation bays were created on the ward to receive the injured personnel. The pharmacist, together with a nurse, managed the drugs area on the ward and assisted in drawing up IV drugs and maintaining a log of all CD issues.

Thinking of joining up?

Pharmacists registered (or eligible to be) with the General Pharmaceutical Council can apply to join the regular Army up to the age of 34, and the Territorial Army up to the age of 45. There are a limited number of cadetships available to students who already have a place at pharmacy school. More information can be found through the army careers website, recruiting offices or from RAMC Recruiting, FASC, RMAS Sandhurst, Camberley GU15 4NP.

Registered Pharmacy Technicians may join the RN, Army or RAF as direct entrants. Those interested in training to be a pharmacy technician can do so through all three Services. Entrance criteria vary and more details can be found on the relevant career websites:

www.royalnavy.mod.uk/careers

www.army.mod.uk/army-medical-services/ramc/15867.aspx

www.raf.mod.uk/careers

A number of civilian pharmacists and pharmacy technicians work for the MOD in the UK and overseas. When vacancies for these jobs arise they are usually advertised through relevant professional journals.

Further information

This article has concentrated on the operational role of pharmacy, but civilian pharmacists and technicians are vital in supporting this. They provide expertise in areas such as prescribing, training and procurement, and often fill the gaps left when colleagues deploy. Anyone interested in knowing more about working in the MOD can find information on one of the websites listed in the panel, or from your local Armed Forces career offices. Alternatively, contact Lieutenant Colonel Williams via ellie.williams664@mod.uk.

Lieutenant Colonel Ellie Williams is Head of Pharmacy at the Surgeon General’s Headquarters

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