Communications and Medical Training
The explosion's force created a 20-foot-by-40-foot port-side hole and knocked out power in most of the ship, disabling the 1MC public address system and the ship's capabilities for long-distance communications. Walkie-talkies remained operable only in the aft portion of the ship, compelling each member of the medical department to operate mostly independently and limiting central triage opportunities. Time spent attending to the wounded prevented taking time to write treatment details on each patient's standard NATO triage cards.
The aft battle dressing station and amidships areas were primary triage areas until personnel were moved to the flight deck. The crew provided self and buddy aid immediately. Command policy wisely had mandated a full day of first-aid training during indoctrination for each new crewmember. This was critical as, like most ships, the Cole experienced an annual crew turnover of about one-third. Training emphasized the "Gitmo Eight" skills (treating extremity fractures, abdominal evisceration, electrical shock, amputation, smoke inhalation, sucking chest wound, jaw fracture, and burns). 1 Drills using moulaged "patients" (including fake blood and simulated wound make-up, for example) and moving crewmembers during patient transport stretcher carries added realism.
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Crewmembers universally felt the Gitmo Eight training should be emphasized. Each assigned stretcher bearer, with more extensive first-aid training, had worked with a team for three months or more. Their assignment stability made it possible for them to stabilize and transport the wounded expeditiously after the blast. A training concern expressed by all members of the department was their lack of any mass-casualty training during Hospital Corpsman Class A School and IDC schools. Career corpsmen are more likely to go to sea than most medical officers, yet one of the corpsmen noted that during his assignment to a clinic, only the officers had the opportunity to practice triage during mass-casualty drills; corpsmen were restricted to obtaining vital signs and other such tasks.
- Require every sailor and officer not already extensively trained in first aid to undergo a full day of first-aid training, with emphasis on the Gitmo Eight.
- Continue extensive medical training of stretcher bearers, search-and-rescue swimmers, and rescue personnel.
- Practice first-aid training with moulaged, simulated patients; practice patient transport using sailors when this can be conducted safely.
- Ensure stable assignment of designated stretcher bearers so each serves continuously for at least six months.
- Equip each medical general-quarters station with a wireless internal communications system (WICS) unit.
- Provide medical team members with WICS units that have commercial off-the-shelf headsets so they can communicate while treating patients as well as record patient information.
- Incorporate mass-casualty triage training into both corpsman A and IDC schools.
After fleet review of the curricula of both submarine and surface IDC schools, the Navy's Bureau of Medicine and Surgery (BuMed) approved enhancement of trauma training starting in fiscal year 2003.
- Ensure corpsmen are involved more directly in conducting triage of simulated patients during mass-casualty drills at military treatment facilities.
Reporting and Patient Tracking
Limited communications made it significantly harder for the medical department to tally and classify casualties and to liaise with and thereby optimally prepare medical and support staffs at follow-on locations. The only means of off-ship communications was the commanding officer's cellular telephone, kept powered by a battery rotation. Continental U.S. commands, such as type commanders (TyCom), commanders-in-chief (CinCs), and Naval Military Personnel Command (BuPers), had limited visibility of the wounded (e.g., exact locations, follow-on care and transport plans, intended time lines, injuries, individual case prognosis).
Media coverage shortened the time before families heard reports on Cole casualties. After seeing television images of loved ones, or those who looked like them, families pressed the Navy for information on patient status. Navy health-care providers and managers, with limited patient information, were unable to answer rapidly many family inquiries, unable to confirm officially what appeared obvious to families. In addition, the communications vacuum limited and delayed the medical staff's ability to provide accurate information to chaplains, ombudspersons, fleet and family services staffs, and the Special Psychiatric Rapid Intervention Team (SPRINT). For those outside the theater, obtaining factual information often required numerous telephone calls to reach individuals in the theater.
While some of those within the Washington, D.C., Beltway had a much clearer idea of what was going on, the CinCs and TyComs directly involved with families and with decisions regarding distribution of personnel and resources received limited information. A critical tool that helped the families was Surface Forces Atlantic's (SurfLant) rapid establishment of a central crisis and information center at Norfolk Naval Air Station's bachelor officers' quarters, Ely Hall. Numerous commands provided volunteers to supplement the SurfLant line staff. Force and area chaplains, the force surgeon, fleet and family services counselors, Naval Medical Center Portsmouth staff, SPRINT members, and others staffed and volunteered extensively. Base generosity was unmatched: free rooms were provided to many relatives of the missing, deceased, and wounded, along with food, beverages, e-mail terminals, and defense switched network phone lines.
- Equip every deploying ship with at least two cellular telephones and sufficient batteries to enable communications throughout the supported CinC's area of responsibility. Cell phone availability and use must be regulated closely.
- Provide deployers with transceivers capable of operating on battery or hand-crank generators without ship's power. Military transceivers with encryption capability should have at least the transmission capabilities of commercially available ham radios. Special Forces uses high-speed, low-drag, secure communication devices, including satellite communications, which may fit this requirement handily.
- BuMed should develop standardized templates with patient information, working with the line for intratheater resources to "push" information as soon as feasible, and thereafter regularly, to BuPers, TyComs, and CinCs. This would minimize requests for information sent from those outside the area of responsibility. It also would help to provide information to family members.
With the Cole alongside a refueling dolphin, it took substantial time, along with a large number of personnel, to move and rig the ship's accommodation ladder. During the interim, a wooden ladder was leaned against the ship and used as a makeshift slide to lower several litter patients to the dolphin. Transferring all the patients ashore took 99 minutes from the time of the explosion.
- Explore the development of inflatable, commercial aircraft-type escape slides capable of evacuating both ambulatory and litter patients. Any device should enable personnel to climb back onto the ship and provide a floating landing point to transfer patients to small boats.
Medical Equipment and Supply
The explosion immediately taxed patient transportation assets. Eleven standard Stokes basket-type litters and two search-and-rescue litters were the primary methods of transport. Miller body boards, the standard backboards carried on all ships, were condemned by both medical and nonmedical personnel as unable to provide sufficient stability, particularly for larger patients. Rapid evacuation of patients minimized the amount of intravenous fluid used. Larger quantities would have been necessary for any significant transit.
Crewmembers used fire axes to access caches of medical supplies because the portable medical lockers were padlocked. Controlled medicines, including morphine sulfate, are kept at two separate sites on the ship, one that houses a working stock and the other housing bulk stock. HMC Moser fortuitously had opened the working stock safe not long prior to the attack, and thus did not have to wrestle with the combination lock. He and others felt it would have been nearly impossible to access the bulk safe because of passageway damage.
Standard battle lanterns provided limited light for a limited number of hours, speaking to the need for a better light source. Used for both sanitary and casualty recovery purposes, the supply of disposable patient examination gloves ran out quickly. FBI and other forensic experts went through the ship's supplies of oil of wintergreen and eugenol to block the scent of decomposition. Because the crew spent most of its time topside after the attack, sunscreen was used up in the first few days. While only a few casualties were transported with small D-size compressed-oxygen cylinders, the regulators (placed on top of each cylinder to reduce oxygen pressure delivered to the patient) were exhausted quickly.
- Keep Stokes litters in the inventory to provide transportation of larger-frame personnel. Remove Miller body boards.
Fleet action removed Miller body boards from all authorized minimal medical allowance lists (AMMALs) and replaced them with a new full-length backboard litter, the Reeves Sleeve II, which easily allows patient movement in any situation.
- Secure portable medical lockers with plastic tamperproof seals instead of padlocks, and put their supplies in flexible-material, zippered containers with shoulder straps and carrying handles to facilitate moving through scuttles.
Fleet action revised the contents of the portable medical locker and redesignated it as a mass-casualty box (MCB). Previously located on the damage control deck, MCBs will be located in areas designated as primary triage areas.
- Do not separate the bulk custodial supply of medicines from the working stock, and distribute the working stock among the different battle dressing stations in key-opened rather than combination-opened safes. Pertinent instructions require that controlled medicinals be kept in a three-combination safe.
Surface TyComs now permit replacement of standard dial-type locks with key-pad entry devices.
- Develop or purchase a battle lantern that provides more light for a longer time than the current design. Provide medical personnel with miner-type headlamps with a standard-size battery, enabling them to use both hands while directing light on wounds.
Fleet action placed battery-powered headlamps (similar to those used by climbers and spelunkers) on the AMMALs.
- Increase stocks of nonsterile, disposable examination gloves prior to any deployment.
Fleet action changed the amount and type of nonsterile gloves carried on the AMMALs to match the heavier-gauge gloves used by civilian emergency medical personnel.
- Increase quantities of higher-SPF lotions for deployments, with SPF 30 the minimum.
- Stock more oil of wintergreen.
- Increase the AMMAL to ensure each small D cylinder of oxygen can be transported with a regulator.
Fleet action changed the number of D cylinders on the battle dressing station AMMAL from two to four, and a change has been submitted to place an equal number of regulators on the AMMAL.
Augmented Care and Counseling
The Naval Forces, U.S. Central Command (NavCent) staff's previous contacts with French military medical personnel in Djibouti facilitated the air transport, with a surgical team, of 11 of the most seriously wounded to Djibouti within nine hours of the attack. A physician and nurse from the U.S. embassy in Saana, Aden, helped out at the hospitals and then came to the ship on the evening of the attack. Fortunately, the USS Camden (AOE-2), USS Hawes (FFG-53), and USS Donald Cook (DDG-75) arrived in the days after the attack and boosted morale by providing Cole crewmembers with showers, hot meals, laundry facilities, and the like.
Chaplains from NavCent arrived within the first 24 hours to provide spiritual and psychological support. The squadron chaplain came a week later to provide an ongoing spiritual presence for the crew. A Sigonella-based special intervention response team arrived in the area the second day after the attack. 2 Led by a psychiatrist, the team was staffed with a Medical Service Corps administrator, a psychiatric technician, a substance abuse counselor, and five primary medical care providers trained in critical-incident stress management (CISM). The team established contact with the commanding officer, executive officer, and command master chief and provided command consultation on initial stress management. The psychiatrist assessed approximately one dozen referrals for acute stress reactions, managing all but one with support, rest, and prompt return to duty aboard ship.
The team saw about 35 to 40 sailors who reported insomnia during the week after the attack. On days four, five, and six, the team provided one-to-one support to large numbers of the crew and conducted onboard debriefings emphasizing stress reduction, mission focus, and command cohesion. The team was well received and maintained a supportive presence throughout the evolution, intervening more actively as requested and offering, in conjunction with the chaplains, opportunities for sailors to share the trauma of their experiences. Additional IDCs from the Navy's clinic in Bahrain and the U.S. Marine Corps fleet antiterrorist security team also assisted the crew.
One problem encountered was that SPRINT teams from different Navy hospitals were at varying levels of deployment preparedness. Despite a potential worldwide support mission, there was no BuMed requirement for team members to have valid passports or travel funding. This reduced the commands' ability to call on SPRINT personnel to deploy rapidly.
- BuMed should develop a standardized instruction for funding and passport-readiness requirements for SPRINT teams. All SPRINT teams should be trained in crisis intervention, command consultation, and combat stress control. They should be taught debriefing-based methods such as CISM and follow-on interventions.
- The Department of Defense (DoD) and the individual armed services should have Web sites detailing the mission of psychiatric support teams in each service, the areas to which they are available to deploy, and points of contact. Joint training could help provide CinCs with a wider range of tools to deal with similar situations.
- DoD should establish an annual meeting for leaders of SPRINT teams and similar groups from other services (for example, Air Force CISM teams and Army combat stress control teams) to share knowledge and to facilitate future field operations.
- Those in charge in any postdisaster scenario should maximize opportunities for assistance from those well known to and having rapport with the crew.
- CinCs and fleet commanders should continue to expand contacts with allied medical personnel within their areas of responsibility to prepare and maintain contingency medical evacuation and care plans. CinCs and fleet commanders need to have ready access to, and provide to deploying commands, detailed maps of foreign cities with aerial photographs, global positioning system data, latitude and longitude, address, and strip map guides that show the locations of hospitals, airports, potential rotary-wing landing sites, and other key sites.
- CinCs and fleet commanders should be more familiar with counseling and mental health resources, including at least brief training on combat stress and its management.
- Training exercises should incorporate scenarios involving management of these issues.
Public Health and Industrial Hygiene
Daily temperatures on the weather decks exceeded 110 deg. F., with significantly higher temperatures internally. Initial blast damage eliminated any capability to produce potable water using the ship's evaporators, or to halogenate water. Increased water requirements were met partly by bottled water previously taken aboard, though a handful of sailors still presented with dehydration. High internal temperatures, disruption of spaces, fear of another attack, and safety concerns led many crewmembers to sleep on the weather decks. A large amount of refrigerated provisions quickly spoiled. Some personnel used surgical masks wetted with eugenol and oil of wintergreen to mask odors. The crew was started on malaria chemoprophylaxis because of concerns over potential malaria vector exposure.
The CHT (waste disposal) system was intact but inoperative. Only a single commode, on the pier/refueling dolphin, was available to serve the crew. The lack of hygiene resources and facilities was followed within two days by about a dozen cases of nonbloody diarrhea, with 70 cases reported within the first five days. These were treated with ciprofloxacin hydrochloride, using up the ship's supply. The disease risk might have been compounded by the inability to regulate the temperature of foods prepared by hotels in Aden during their transport to the ship.
- Provide antibacterial "prep towels" or waterless antibacterial solutions for hand washing when water supplies are interrupted or secured. As an alternative, provide gravity-feed lister bags (duffel bag-size canvas water containers with a spigot, typically used in the field) for hand washing in case power is lost for the potable water system.
Fleet action added antibacterial towelettes to the AMMALs.
- Provide a means to desalinate water in case shipboard evaporators are inoperative.
- Increase antibiotic supplies for treating enteric bacteria.
An increase in the amount of ciprofloxacin carried is being reviewed.
- Consider providing standard marine portable toilets, or keep field-design 55-gallon barrel drums to prepare burnout latrines if shipboard commodes are unusable.
Distribution of Lessons Learned
The consensus of the medical team and debriefers, based on efforts to obtain hard copy of medical lessons learned from U.S. Navy shipboard disasters from the medical chain of command, was that there is little in-depth information immediately available. Lessons learned from prior disasters and attacks on Navy ships were not taught to medical team members in corps school, during the IDC training pipeline, or during refresher training. As of this writing, more than 20 months after the attack, there have been only rare requests from outside the unrestricted line community for hard copies of the medical lessons learned from the USS Cole experience. We are concerned that there is no systemic plan to ensure that the medical lessons learned will be passed on to those who could most benefit from them to save lives in a potential future attack. As the lessons learned have been used by fleet medical staffs to develop policy and supply changes, this material could be more broadly applied.
- BuMed should ensure copies of the medical lessons learned from the attack on the Cole (and from other mass-casualty events) are provided to members of the Navy medical department and others who may go in harm's way, and should train those who will manage the consequences of any attack.
- Provide a permanent record of the lessons learned and the experiences of the medical team from the Cole using formats that can be presented readily during military medical training evolutions. This will ensure information is passed on long after the principals have transferred.
- BuMed should develop format guidelines so that lessons learned from future events can be captured systemically for analysis and incorporation as appropriate into training for members of the Navy medical department.
The response to the attack on the Cole by the ship's medical department, along with the actions of virtually every member of the crew who came in contact with one of the wounded, provides us with a number of lessons. We owe it to those 17 whose futures were taken from them to take onboard the lessons they paid such a dear price to learn.
Captain Hayashi was Force Surgeon, Commander Naval Surface Forces Atlantic, from August 1997 to September 2001, and is now a preventive medicine officer at Navy Environmental and Preventive Medicine Unit Six, Pearl Harbor. Master Chief Bailey has been assigned to Commander Naval Surface Forces Atlantic since November 1997 and will retire this year after 30 years of service. Chief Moser is assigned to the Boone Clinic, Virginia Beach, Virginia; at the time of the attack on the USS Cole , he had 18 years of naval service. Admiral Potter is fleet surgeon, U.S. Atlantic Fleet Command; Command Surgeon, U.S. Joint Forces Command; and medical advisor, Supreme Allied Commander Atlantic. The authors acknowledge the assistance of Lieutenant Commander Chris Peterschmidt, Captain Mike Miller, Master Chief James Parlier, Lieutenant Commander John Kennedy, Lieutenant Commander Ed Simmer, Captain Marty Snyder, and many of the men and women of the Cole .
1. The "Gitmo Eight" is named after medical treatment drills evaluated when refresher training was conducted for Atlantic Fleet ships at Guantanamo Bay, Cuba. In 1995, the training became regional but the drills still are referred to as Gitmo wounds. back to article
2. The team, and other Naval Forces Europe teams like it, now carries the name of its stateside counterpart: Special Psychiatric Rapid Intervention Team (SPRINT). back to article