All of the scenarios in the garrison healthcare suit should be considered from the perspective of a healthcare professional working in a military garrison healthcare centre with responsibility for the clinical care of patients and management of the healthcare centre. The primary supporting reference for this suit is the World Medical Association International Code of Medical Ethics (WMA Code) at: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/ . You should also consider your national professional ethical codes and relevant military law or guidance

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: You have received an x-ray report that identifies a serious pelvic stress fracture in a young recruit. You had been treating them for over 6 months with painkillers and physiotherapy, and only arranged the x-ray after her insistence. What do you do?
• List the Issues that arise from the scenario.
• Identify Critical Information required and Assumptions to be made:

This scenario covers the ethics and law regarding potential mistakes and medical negligence. You should note that this is a female patient, and the risk of pelvic stress fractures in female military recruits is well recognised.

Step 2 – ANALYSE

Patient: the patient has a right to expect competent medical care. It might be considered that the diagnosis has been unreasonably delayed in this case. In the UK you have a ‘duty of candour’. Honesty protects the clinician-patient relationship. In many nations, professional ethics would demand that you inform the patient of the delay as soon as reasonable after you become aware of it. Different nations will have different routes through which to enable this notification.

Clinical: you should decide whether it is appropriate for you to continue to care for this patient given the delay in diagnosis, and you might arrange transfer of care to another clinician.

Legal: This case has the potential for a medical negligence claim. You should not change the medical record, though you may wish to ensure that everything is correctly and completely recorded.

Societal/Military: The patient may already be on restricted duties, you should review all other aspects of their management as a recruit to give her the best chance of a favourable outcome – including completion of training/or medical discharge.

Step 3 – FUSE

• Summarise conclusions
• Insert citations to key reference sources for your analysis
• Determine the exact Decision(s) to be made

This scenario could be interpreted as an unreasonably delayed diagnosis for a recognised clinical condition. You should ensure that everything possible is done to give the patient the best chance of recovery.

Step 4 – DECIDE

• What is your Decision?
• Why (can you justify it)?
• Residual uncertainly, need for review?

You need to treat the patient according to any clinical guidelines or best practice for the management of pelvic stress fractures. You may wish to discuss the case with her physiotherapist as well. You might need to declare the case as part of any professional review or appraisal process; you might also want to discuss it with a senior clinician and your professional indemnity insurers.

Contributors – Brigadier (Rtd) Charles Beardmore MBBS MRCGP MFOM MA MSc MBA LLM. Charlie is a qualified General Practitioner with 32 years of military service that culminated in the role of Head of Defence Primary Healthcare in the UK. He is studying for a PhD on the topics of military healthcare ethics. Brigadier Phil Carter MBChB MRCGP MPH MA. Phil is a qualified General Practitioner with 28 years of military service, He recently served as Commander of Defence Primary Healthcare in the UK and Chief Medical of a multinational operational headquarters in the Middle East.