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Navy Revives Idea to Beef Up Trauma Surgery at Sea

U.S. Navy Fleet Surgical Team – 3 (FST-3) and USS Essex (LHD 2) medical department personnel triage a simulated casualty as part of a casualty evacuation drill between the Essex and the USS Rushmore (LSD 47) during Exercise Dawn Blitz, Oct. 22, 2017. Navy Medicine, in concert with Exercise Dawn Blitz, is experimenting with placing Role 2 capabilities across the amphibious force. US Marine Corps photo.

The Navy is experimenting with operating a specialized medical team on a smaller amphibious ship to provide more front-line trauma care at sea, filling a capability gap that arises when deployed ships are operating apart from their larger strike groups.

The seven-member Navy Adaptive Trauma Team (NATT), operating on dock landing ship USS Rushmore (LSD-47) during amphibious exercise Dawn Blitz, is a “proof of concept” test that Navy and Marine Corps officials believe may save more lives by putting more surgical resuscitation aboard ships that lack operating rooms and surgical teams – and closer to the fight. Officials say that need has grown as more deployed amphibious ships, almost always carrying combat-ready Marines, operate away from big-deck amphibs, which have larger and more capable medical departments.

“Smaller amphibs such as an LPD and LSD have their organic medical staff headed by a general medical officer, with no capability to do surgery or major resuscitation,” Cmdr. Robert Staten, Expeditionary Strike Group-3 command surgeon and officer in charge of Fleet Surgical Team 9, told USNI News via email from amphibious assault ship USS Essex (LHD-2). Rushmore and other LSDs “are not equipped with [operating rooms] or associated gear and instruments, so the addition of the NATT provided a significant plus-up in capability.”

The new trauma team provides what is called “Role 2” care. In the four echelons of care, it’s the first denoting surgical capability by a surgeon on a patient.

The Navy has three “Role 2” surgical teams participating in the biennial Dawn Blitz amphibious task force exercise: Fleet Surgical Team 3 on Essex, Fleet Surgical Team 9 on amphibious transport dock USS Anchorage (LPD-23), and Navy Adaptive Trauma Team 1 on Rushmore. The three amphibs formed Amphibious Force 3 for the exercise, which ran Oct. 20 to 29 off southern California.

NATT-1 is considered “role 2 light maneuver,” or R2LM, denoting its light footprint and mobility in providing that level of surgical care. The team has been training in recent months, including a three-week-long pilot course at Surface Warfare Medical Institute East in Norfolk, Va., according to a July 28 Navy Medicine Operational Training Center news release.

“With our basic set, we can perform four surgeries and resuscitate up to six non-surgical patients and hold them for at least four further hours while awaiting” medical evacuation, Cmdr. Michael Johnston, NATT-1’s officer-in-charge, said via email from Rushmore.

“Placing the NATT on an LSD for Dawn Blitz represents a proof of concept,” Johnston said.
“The LSD can indeed disaggregate and sail away on its own to deliver Marines and special (operations) forces to the beachhead and then standby to receive casualties for whom it can now provide role 2 care.”

When San Antonio-class amphibious transport docks (LPD-17) disaggregate from the amphibious ready group (ARG), they take with them a medical space with two operating rooms, two dozen hospital beds and room for a hundred more if overflow space were used in an emergency. If an LSD disaggregates from the ARG, though, it takes no operating rooms and only a handful of hospital beds for patient isolation.

Along with the new team on Rushmore, the addition of the fleet surgical team on Anchorage enables its medical department to provide greater surgical and resuscitative care.

An FST has about 16 members, including a surgeon, operating room nurse, critical care nurse, two surgical technicians, psychiatrist, family medicine physician, two laboratory technicians, respiratory therapist, X-ray technician and two general duty corpsmen, Staten said. Each FST is headed by an officer-in-charge and may include a medical regulating control officer to handle administration and patient movement.

Adding extra surgical capability isn’t a new idea, and this latest experiment renews a recent effort that fell flat despite broad support within the Navy and the Marine Corps.

Last year, a Navy Expeditionary Forward Resuscitative Surgical System, or ERSS – which included trauma, surgical and en-route care teams – participated in the International Mine Countermeasures Exercise aboard expeditionary fast transport ship USNS Choctaw County (T-EPF-2) in the Persian Gulf. The Navy’s first demonstration of ERSS came a year earlier in U.S. 7th Fleet, during the initial trial in 2015 when a San Diego-based medical team rehearsed the concept on USS Germantown (LSD-42) and guided-missile destroyer USS Fitzgerald (DDG-62) in Yokosuka, Japan.

The concept for this iteration of the Fleet Surgical Team “is built on the previous Expeditionary Resuscitative Surgical System (ERSS) and Damage Control Surgery (DCS) teams that the Navy has used for the past decade or so to provide damage control surgery capabilities on ships (in the case of ERSS) and on shore (in the case of DCS),” Johnston said.
“Unfortunately, neither ERSS or DCS were official programs of record and both went through primarily Army training, which is no longer available due to constraints on the Army side.”

So the Navy is breathing new life into the idea “to build a pure-Navy program of record to provide an R2LM capability to the battle-space,” he said. “This is extremely important, as the demand signal for mobile role 2 care has only risen over the past decade, both from our friends on the special operations side and from our amphibious ready groups that more and more operate in a disaggregated state.”

During disaggregated operations, the smaller ships are hundreds of miles away from the big-deck ship “and therefore can’t rely on the LHD for surgical support,” Staten said. Having surgical capability on each ship will ensure more timely care to treat injured and ill patients, and it “extends the battle-space by broadening ‘golden hour’ coverage, particularly when the LSD sails alone in a disaggregated state.”

The experiment also is testing the use of a secure, 4G LTE network to support medical consults and telemedicine, Staten said. At one point, “this technology allowed a surgeon from an ashore facility to visualize and remotely ‘coach’ a shipboard physician through a simulated surgical procedure (cricothyroidotomy) in real time using the high-quality video link.” The procedure, involving an incision to clear an airway, is “believed to be first procedure performed of this type,” he said.

While the new trauma team is also capable of providing surgical care ashore, that capability wasn’t included in the proof-of-concept test during Dawn Blitz, officials said. Marine landing forces have an embedded Shock Trauma Platoon and Forward Resuscitative Surgical System, which receives and treats casualties close to front-line units.

  • DaSaint

    Makes sense. However, I’m wondering if this changes some of the specifications for the LX(R), as info I’ve seen on Huntington Ingalls website relating to LPD Flight II/LX(R) indicates that compared to the Baseline LPD-17, they’re reducing the operating rooms from 2 to 1, and reducing the hospital bed surge capacity from 124 to 8, (which hopefully is a typo). If they’re serious about the flexibility of disaggregated activities, hopefully the LX(R) will retain at least 1 OR, and have a surge capability of at least 60 beds.

    There’s long been conversation regarding the overall dissatisfaction with the Mercy-class Hospital Ships, due to their large size, slow speed, and most importantly, difficulty in moving patients around on the vessel, including the fact that they can only come aboard via 1 helicopter landing spot. At one time there was a report of consideration of either conversion of a soon-to-be-retired Harpers Ferry/Whidbey Island-class LSD, or even using the basic hull-form of the LPD-17/San Antonio class for a new Hospital Ship. Since we’re now transitioning to the cheaper LX(R), an option exists to consider a new-build version. All would add the important option of bringing patients aboard via landing craft through the well deck, significantly increasing the number of patients that can be brought aboard at one time. Chances are however, it may make more sense to use a retired LSD, saving the acquisition cost, and doing a conversion, and trying to squeeze 20 additional years out of them.

  • RunningBear

    Two additional LPD-17s (reconfigured as hospitals) should be built to replace the two Mercy hospital ships. The ORs required for the LPD/ LX(R) should be determined by the ; 1- Corp for the troop count assigned on board (or supported), 2- (provided by not continually staffed) based on separate duty assignments away from the LHA/D ARG. This provides the helicopter capability as well as the surface connector capacity for transfer and resupply.

    • DaSaint

      Maybe they can be built with 50/50 funding contributions from Department of Homeland Security as well as the Navy, as they will certainly be used for domestic disaster relief duties. This reduces the strain on naval shipbuilding budgets. This model has actually worked several times in Europe (France & Italy come to mind), where some vessels are paid for by naval and non-naval budgets, as they are intended to be multi-use ships.

      • wilkinak

        I’d go for 70/30 with DHS picking up most of the tab. The hospital ships have treated far more civilian than military patients over the years.

        • Secundius

          There was a reason why in WWII the US Military put Wounded into “Full Body Casts”!/? To Keep Them Immobile until THEY (the Wounded) could be Safely Transported to Receive Medical Treatment in a Safe “Controlled” Location…

        • DaSaint

          Agree with both points. And the likelihood of DHS footing that much of the bill is minimal.

          • Secundius

            But then again, IT’S good “PR” for Both the US Navy and the United States…

          • DaSaint

            You know, now that I think of it, make it a Coast Guard ship, run it with a Coast Guard crew, staff it with Navy and Marine Corps medical staff, and fully justify a DHS/DOD cost-sharing.

  • Ed L

    Much needed. While in the early 80’s on an AO we had a crew member get seriously injured and required surgery. Our Dr had limited surgery experience but with help of our Dentist, Independent duty trained Corpsman plus one of the other Corpsman has experience in operating rooms. Our man survived but according to the Doctor he was lucky to have skilled people to help him in surgery. I know people will say “a dentist?” That was the 2nd time I know of a dentist helping save a life while in the Navy. To the people I have Block and don’t understand that Dentist are Doctors (MD) before they become Dentist (DMD)

    • DaSaint

      One day in the distant future, each ship will have a surgically trained doctor, a nurse and/or corpsman, and a fully-equipped OR and ward for up to 8 patients.

      • Secundius

        Either that or an A.I. AutoDoc…

        • DaSaint

          Beam me up.

          • Secundius

            There’s a Website called “Medgadgets”, where New Innovations in Medical Science and Technologies are Discussed. Including Remote and A.I. Telepresence Surgery and A.I. AutoDocs, Also BioReactors for Making Skin and Limb Replacements, as well as 3-D Medical Printers for Virtually Anything Plausible that can be 3-D Printed for Everyday Medical Usage. Including Prescription Medications…

    • publius_maximus_III

      Ed, I’ve always addressed my dentist as “Doctor.”

  • publius_maximus_III

    OK, Hawkeye, instead of a M*A*S*H unit, maybe this would be called a W*A*S*H unit? Help me out here with an acronym-in-reverse: WAterborne Surgical Hospital?

    • Secundius

      For an Medical LCS or JHSV, how about Medical Ambulance Ship Hospital, or High Speed Ambulance Medical or High Speed Ambulance Watercraft, or Ambulance Ship, or just plain Light Medical Frigate (Fast)…

  • Navy Doc

    This is the perpetuation of some really dumb forward surgical support ideas that have been tried and rejected in the past. Someone must be taking LSD (not the ship-type) to think that watered-down trauma care in a compromised location on a small combat ship (operating room table was to be in the officers mess!) represents the best medical care for our sailors and Marines. Do you want your sailor or
    Marine taken care of by someone who hasn’t seen a trauma patient in months – while riding around the world on basically unarmed ships that can barely propel themselves?

    The Marines have bought and paid for 15 anesthesia billets – yet I do not see any of 1) an anesthesiologist, 2) a nurse anesthetist or 3) even a dentist who is anesthesia-capable even on the FST list. Who will provide the anesthesia care on these further dumbed-down surgical platforms? Who else will man these “disaggregated” vessels? As Navy ships have now accelerated their forward deployment cycles, how will all these operating room personnel maintain their clinical skills and training requirements? Where will the trained bodies come from? MFTs, FMF, Reserves….Will they be ship’s company – or rent-a-riders who only board when the ship approaches some hostile environment. Operating room personnel are in short supply in the Navy – to the point that major MTFs have had to stand down elective surgery due to shortages – OR nurses, surgical techs, etc. In all, this idea of half-assed medical care is very discouraging.

    It would make more sense to consider deploying dedicated, concentrated medical assets as part of any logistical combat package. Converting one or more of the existing LHD’s into true hospital ships capable of high-capacity helicopter access (lacking on Comfort and Mercy), twin shaft/turbine configuration (lacking on C&M), and with a trained, dedicated crew (also lacking on C&M) makes far more sense that creating these dispersed, poorly considered surgical assets. It is an irony that civilian medicine is moving quickly towards “centers of excellence” (concentrated resources) rather than a cats-and-rats surgical resource approach. Quality of outcome studies strongly support concentrated care.