Experience of the Air Medical Evacuation Team of Serbian Armed Forces in the United Nations Mission in the Democratic Republic of Congo – Deployment stress and psychological adaptation

Background/Aim. Wars of the nineties in former Yugoslavia, Somalia, Rwanda imposed new tasks to the United Nations (UN) forces, such as providing humanitarian aid, protection of civilians, peacekeeping, and in many instances providing armed enforcement of peace. The aim of this study was an observational analysis of Serbian participation in the UNs Mission in the Democratic Republic of Congo with the emphasis on stress and coping techniques. Methods. Serbian contribution in this mission dates back to April 2003 till the present days with a military contingent consisting of six members as a part of Air Medical Evacuation Team. The observed stressogenous factors acted before arrival to the mission area and in the mission area. In this paper we analysed ways to overcome them. Results. The productive ways of overwhelming stress used in this mission were: honesty and openness in interpersonal communications, dedication to work, maintaining discipline and order, strict following of appropriate regime of work, diet, rest and recreation; regular communication with family and organizing and participation in various social, cultural and sports manifestations. Conclusion. This analysis indicates that out of all the observed factors, the most important is appropriate selection of personnel.


Introduction
Wars of the nineties in former Yugoslavia, Somalia, Rwanda, have imposed new tasks to the United Nations (UN) forces, such as providing humanitarian aid, protection of civilians, peacekeeping, and in many instances providing armed enforcement of peace.These changes caused the increase in response to stress [1][2][3] .Factors that affect stress in peacekeeping operations are: individually conditioned factors, separation factors and factors of the mission 4,5  gree of stress significantly correlated with mood, psychiatric symptoms and poor morale [6][7][8][9][10] .The most important dimensions of stress in soldier adaptation are: isolation, ambiguity, powerlessness, boredom, and threat [11][12][13] .Maladjustment can be viewed chronologically 14 , from early up to late maladaptation reactions, and cyclically throughout the duration of deployment 15 .

Air Medical Evacuation Team
Serbian participation in the United Nations (UN) Mission in the Democratic Republic of Congo (DRC) dates back to April 2003 up to the present days, with a military contingent consisting of six members -two doctors and four paramedics, as a part of Air Medical Evacuation Team (AMET), who are trained and equipped to set up two fully autonomous aeromedical evacuations.AMET has several tasks, the primary one being expert escort, monitoring vital signs, diagnosing and treatment of diseases during medical evacuation, casualty evacuation and medical repatriation by air and by land.The second task is provision of medical support during visits of official delegations and various military, political and cultural events.Also very important tasks are to secure logistical preconditions (repair of devices, procurement of new devices and procurement of expendables) for noninterrupted and continuous functioning and pleasant stay of a contingent in specific terms of the mission area, and, finally, regular, everyday communication and correspondence with the command in the mission and in country and performing numerous regular and ad hoc complex administrative duties.
The aim of this article was to illustrate deployment stress and psychological adaptation, as observed from the period of preparation up to the return home.

Methods
All data presented in this paper were obtained during the author's (DJ) involvement in the Serbian AMET mission as a member, where he participated twice, in 2005 and 2007.All the subjects were participants of AMET, six per term, totally 12.The shift took six months.AMET members were employed in the Serbian Armed Forces, and chosen for this mission.The data were collected through the author's observation of stressogenous factors, stress reactions and coping techniques in this mission, before arrival to the mission area (during a one-month preparation period), and during the whole stay in the mission area.The uniqueness of this article is that it talks about the first time in a 20-year history of Serbian participation in the UN Missions to deal with these issues.Table 1 shows some basic demographic data on the Serbian AMET.

Stressogenous factors
Stressogenous factors were numerous and can be divided into two groups: stressogenous factors before arrival to the mission area and stressogenous factors during the whole stay in the mission area (Table 2).

Stress reactions
Stress reactions in the mission were individually conditioned and therefore diverse.They include: emotions, somatic manifestations, interpersonal relationships, behavioral manifestations, as described by Logan 15 (Table 3).

Coping techniques
Productive ways of coping with stress, by the author's personal experience, were: honesty and openness in interpersonal communication, respect and fairness in the superiorsubordinate relationship, smoothing misunderstandings, dedication to working for achievement of personal and mutual progress and well-being, professional execution of duties, maintaining discipline and order, strict adherence to the corresponding regime of work, nutrition, rest and recreation, regular communication with family, organizing and participating in various social, cultural and sports activities.His experience was in accordance with data from the literature and confirms that "only members with a high level of mental health will make success in peacekeeping operations in Africa" 16 .

Recommendations
Although this engagement was specific, there were no substantial differences in deployment stress and psychological adaptation already described in the literature concerning the participation of medical personnel, in general.Factors that influenced deployment stress reactions and coping tech- niques were very similar for both teams.The author was the member of both teams, as well as the nurse.The author's experience is that the best way around this mission showed younger, unmarried, children less, male doctors, officers, and middle-aged, married, with children, female, paramedics, military employees.The recommendations for stress prevention in this mission besides crucial factors are selection of personnel, also adequate training, equipping with necessary devices, then improvemеnt of communication capabilities with command and families and improvement of living and working conditions, and, finally, maintaining exemplary dis-cipline with correct interpersonal relationships and designing constructive leisure activities.

Conclusion
Appropriate selection of mentally stable, mature personality, open minded, without prejudice, communicative, resourceful, wise, brave, courageous, devoted and motivated, persistent, competent, skilled and welltrained persons is a guarantee for successful adaptation to the Serbian AMET mission.

Table 2 Stressogenous factors before arrival and during the stay in the mission area
Stressogenous factors before arrival to the mission areaStressogenous factors during the stay in the mission area