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By Captain Arthur M. Smith, Medical Corps, U.S. Naval Reserve
r'ne Corps. “The professional knows how easily 411 operation can founder Without these naval support elements.” These
‘t . .
support” considerations uhimately determine the 0fder of battle and the tactics employed, as well as the sustainability of deployed forces.
Since the end of World )^ar II, U.S. security pol- lcy has required sustained Worldwide deployment of naval forces. Even today,
^spite the end of the Cold War and massive Eductions in defense pending, combined elements of the U.S. Navy and Ma- r'le Corps are positioned around the world, at the sites of Potential military flash points. Establishing and maintaining ari infrastructure to support these long-term overseas deployments—plus any military contingencies—is critical.
Preparations for treating wounded and diseased per- s°nnel are critical planning factors for any military oper- ahon. Effective military health care ultimately depends uPon adequate numbers of trained and competent per- ^onnel, reliable equipment, and dependable logistical replenishment. Gaps in any of these components diminishes amount and quality of health care available. If com- °at cotnmanders ignore realistic medical care planning, °Perattmal flexibility and mobility will diminish because ()1 the fee Emulation of sick and wounded. From a
U.S. NAVY (P. WINTER)
Korea. Similar doctrine was implemented in the early 1980s during Operation Urgent Fury (Grenada) and following the landings of the U.S. Marines at the Beirut airport. During Desert Shield/Storm, similar preparations existed: the augmented health-care facilities of an amphibious task force of 31 ships were linked together for the care of 34,000 embarked Navy and Marine Corps personnel.
A Rude Awakening
Medical assets in the amphibious Navy ttiay look impressive—here, mock casualties are moved to the triage area on the hangar deck of the New Orleans (LPH-11)—but a realistic assessment of their capabilities uncovers some sobering limitations.
As Operations Desert Shield and Desert Storm demonstrated, logistics—including medical care— is integral to the sustainability of deployed forces. They are often overlooked when novices discuss amphibious operations,” noted General P. X. Kelley, former Commandant of the Ma- agement perspective, it would have been less costly to minimize the risk of health-care attrition prior to combat.
History has demonstrated that the highest casualty rates are incurred during “opposed over-water assaults.” Nevertheless, during large-scale amphibious training evolutions, such as Operation Tandem Thrust—a recent joint service combat exercise off the coast of California—Navy and Marine Corps commanders are not challenged to contend with the formidable and inevitable degradation of personnel assets through combat injury. Because of this, a highly unrealistic dimension is interjected into the command-and-control preparation of the involved Navy line and Marine Corps officers. This deviation from reality presented no challenges to amphibious medical assets
either. They were never obligated to rise above the “business as usual” implementation of fleet medical support practices to address their contingency role during realtime amphibious warfare operations.
During amphibious operations, the healthcare facilities of the amphibious task force are the major source of support for the organic medical elements of the Marine Corps landing force. This was true during World War II and again in the landings at Inchon,
Despite conscientious planning, gaps in operatiomj ical support occur. For example, a mfedical officer i the pr ncipal casualty recovery ship < >f thfc amphibic force lurpig Urgent 1 uJ/\n 1983, n >tec,TWe wer f A.,,, f ii
boa
whelmed, and the word was not out that we were. It was almost as if the casualties were obliged to ‘take a number’ and wait their turn.”
Indeed, on the first day of Urgent Fury, 37 casualties were admitted on board the Guam (LPH-9). The Guam's blood-bank inventory of 50 units was inadequate and was replaced three times via crew donors. In peacetime, blood from donors is laboratory tested to determine its compatibility with recipients. On this occasion, uncrossmatched type “O” (universal donor) blood was administered to the combat injured, and on one occasion was being transfused as fast as it could be collected and typed. A medical officer stated, “At one point things got so desperate that I merely matched the blood types from dog tags and drew blood from one donor and immediately transfused it, warm, into one of our patients.” Fortunately, the Independence (CV-62) responded by tapping their walking blood bank of crew members, though there was much concern that it would not arrive fast enough. The after-action report from the Guam also noted, “Consumables were being depleted at a very rapid and unexpected rate. For example, [the] Guam went through 23 cases of Ringers lactate solution [the principal fluid given intravenously to combat injured] in day one of the operation.”
The Guam’s medical report continued, “Most casualties arrived untriaged, not having been examined by any type of medical personnel on the beach.” One observer noted that an Army helicopter pilot, unfamiliar with amphibious vessels, even landed a critically injured patient on the secondary casualty receiving ship, the Trenton (LPD-10), which was not adequately equipped to manage such grave injuries.
Casualty overload is a potential problem for any amphibious task group. After the terrorist bombing of the battalion landing team headquarters in Beirut on 23 OcT tober 1983, the Iwo Jima (LPH-2) received 61 stretcher patients within 90 minutes.
Bringing Expectations Into Focus
Misperceptions concerning afloat medical capabilities can adversely influence operational planning and execution. For example, should an operational commander equate the capability of the deployed medical personnel and medical assets on board an LHD (despite its 6 operating rooms, 17 intensive care beds, 47 ward beds, and 536-bed overflow capacity) with a similarly equipped land- based civilian trauma care facility? In reality, despite an apparently equivalent endowment of assets, the capabilities and limitations of sea-based trauma care facilities are substantially different.
A large urban 300-500 bed trauma care hospital is extremely resource dependent. The requirements for supporting the initial reception, surgery, and postoperative care of a single trauma victim easily can overwhelm a hospital not specifically prepared for such patients. Providing 24-hour staffing of operating rooms, intensive- ^are units, laboratories, X-ray, and blood bank facilities squires an extensive roster of highly trained technicians ndjmedical and nursing personnel. It also derp^nds an
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extensive support network, including such allied specialists as respiratory therapists and specially trained pharmacists. The availability of competent personnel— especially professional nursing staff—has a significant impact on the level of services available in any healthcare facility.
Blood bank, anesthesia, pharmacy, and nursing requirements also demand an extensive logistical support network—from supply procurement to equipment maintenance. Combined with personnel costs, these requirements easily may generate costs in the millions of dollars per year. The fact that the Navy cannot afford to maintain a single accredited major trauma center at any of its shore-based hospitals speaks to the enormous commitment of resources required by such activities.
Medical Assets of the Amphibious Ready Group
The amphibious ready group—a deployed naval task force operating with a Marine Expeditionary Unit—contains an integrated matrix of medical capability. There is an extensive commitment of both physical resources and space to health-care operations, but can the functional capabilities of such facilities match the investment in hardware?
The naval task force supporting amphibious ready groups generally consists of a five-ship combination of tank-landing ships (LSTs), dock-landing ships (LSDs), amphibious cargo ships (LKAs), amphibious transport docks (LPDs), and amphibious assault helicopter carriers (LPHs). If the larger and more versatile amphibious assault ships—LHAs or LHDs—are deployed, the amphibious group may require fewer ships.
Since the Korean War, the helicopter has been the predominant mechanism for casualty evacuation during amphibious operations. But, in the absence of air superiority in combat, or during poor flying conditions, surface evacuation would assume greater importance. The LPH, however, is not designed to receive casualties directly from surface evacuation craft. Casualties evacuated via displacement-hulled surface landing craft, such as the LCU or LCM, can only be safely moved to ships with ballasted well decks.
The medical facility assets of a notional amphibious ready group are noted in Table 1. During peacetime deployments, the medical personnel and facilities on board the larger LPHs, LHAs, or LHDs—the Primary Casualty Receiving and Treatment Ships (PCRTSs)—generally are augmented by a designated fleet surgical team. During wartime they may be augmented by active duty personnel from naval hospitals. Surgical team personnel are noted in Table 2.
Depending upon their facilities, manning, and geographical location, other ships of the amphibious task force may be designated Secondary Casualty Receiving and Treatment Ships (SCRTSs). '
Primary Casualty Receiving and Treatment* Vessels
Tbe LPH: M ostiin their thiVd decade of si LPHs
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--- vj -
Proceeding/ October 1992
supp
are designed for receiving only helicopter transfers of casualties. Medically, they have not enjoyed a comfortable existence. Some comments from the Urgent Fury medical after-action report are illustrative:
- “Separating primary triage in the hangar bay and the secondary survey/definitive care in the Medical Annex is a pole litter hoist mechanism. This greatly hampers patient care for those requiring CPR and medically assisted breathing, as there is no room for an attendant to ride up the hoist with the patient.”
- “There was no ventilation system in the main O.R. and temperatures were between 90° and 95°.”
- “Doors were too small to negotiate sharp angle turns with litters. One paralyzed patient had to be turned on his side and strapped to a back board in order to get into the ICU.”
- “The LPH class ships have too few O.R.s, ward, and ICU beds, and too few physicians!”
The LHA: These are now in their second decade of service. With flight-deck and well-deck facilities, the LHA can receive patients by air or via displacement-hulled landing craft. However, large numbers of vehicles and combat equipment awaiting offloading can hinder the transfer of casualties on board from the well deck.
This congestion can complicate initial triage and litter transfers on board. Casualties from the well deck also must be carried by hand litter up several high-grade inclines to sick bay. At the flight deck triage reception area, however, a large, dedicated medical elevator facilitates transfer of patients and their attendants directly into the main medical spaces.
The medical department of an LHA is noteworthy tor its large, unencumbered triage area—capable ot managing 12-24 litter patients simultaneously—with dedicated overhead surgical lights, oxygen, suction, and compressed air outlets for each station. There also are two minor surgery rooms and four full-size operating rooms with piped in oxygen, anesthesia gas, suction, and compressed air. In addition, medical spaces include a dedicated blood bank, frozen-blood freezers, X-ray, laboratory, pharmacy, and a' jation medicine examination and physical therapy comp; rtnients. An 18-bed intensive care unit, a 48-^d Ward, jntlcasualty overflow capacity for 300 are alsp^n\;
^ -------------------
Proceedings / October vided. Distributed elsewhere on the ship are battle dressing stations and dedicated refrigerated mortuary facilities.
The LHD: This is the newest class of multipurpose amphibious assault ships. Capable of receiving casualties within its ample well deck, the LHD also can accommodate casualty transfer on its flight deck. A dedicated medical elevator, from a marginally equipped, Spartan flight deck triage area, allows patients to be transferred directly to the main sick bay. Unfortunately, the ample main
medical department triage area characteristic of the older LHA class has been replaced by a smaller modernistic preoperation area. With this reduced patient holding capacity, back-up to access triage areas is predictable.
The LHD also has a modern, well-equipped, six-room surgical suite and dental operating facilities, supported by blood bank, frozen-blood freezers, laboratory, X-ray, physical therapy, a 17-bed ICU, a 47-bed ward, and 536-bed casualty overflow facilities. Refrigerated mortuary facilities also are provided.
Secondary Casualty Receiving and Treatment Vessels
The physical facilities and staffing of the SCRTSs also are noted in Table 1. Ideally, such ships could be used to manage the less critically wounded in the event of casualty overload on board the PCRTSs.
Because of its functional attributes—a flight deck, well deck, and good tactical communications facilities—the LPD has often been designated the principal SCRTS. As such, it would be expected to substitute for the PCRTS in the event of casualty overload. Realistically, even if temporarily augmented by physicians from the embarked Marine Corps units, the medical “back-up” provided by these vessels is marginal. This generally is because of limited logistics and space, as well as grossly encumbered paths for litter bearing between casualty reception and sick bay.
The newer Whidbey Island-class LSD has easier casualty access to sick bay, and a designated operating roorri which contain! a modem-ap|eari^g anesthelia Aa- chin4 Major gaps ill sdrgical equipment and ana|th/s\a within yiefr tmthorized medical equipment aN
USS Saginaw (LST-1188) | USS Portland (LSD-37) | USS El Paso (LKA-117) | USS Trenton (LPD-14) | USS two Jima (LPH-2) | TOTAL |
| |
Ward Beds | 4 | 9 | 12 | 9 | 12-20 | 54 |
|
Overflow Beds | - | 50 | - | 75 | 125 | 250 |
|
Isolation Beds | - | - | 4 | 2 | 4 | 10 |
|
Intensive Care | |||||||
Beds | - | - | - | - | 2 | 2 |
|
Operating Rooms | |||||||
Minor | 0 | 1 | 0 | 1 | 0 | 2 |
|
Major | 0 | 0 | 1 | 0 | 2 | 3 |
|
Personnel Independent Duty | |||||||
Corpsmen | 1 | 1 | - | - | - | 2 |
|
Hospital | |||||||
Corpsmen | 2-3 | 3 | 6 | 6 | 10 | 28 |
|
General Medical Officer | - | - | 1 | 1 | 1 | 3 |
|
Table 2: Personnel Components of a Notional Fleet Surgical Team Augmenting a Deployed Amphibious Ready Group
Notional Fleet Surgical Team
* Added following Desert Shield/Storm
CATF Surgeon (Amphibious Task Force Staff) General Surgeon (1)
Family Practice Medical Officer (1)
Nurse Anesthetist/Anesthesiologist (1)
Nursing Care Supervisor (1)
Operating Room Nurse Supervisor (1)
MSC Medical Regulating Officer (1)
Operating Room Technicians (2)
General Service Corpsmen (5)
Respiratory Therapy Technician (1)*
Advanced Laboratory Technician (1)*
lubes. Consequently, many radical functions necessary
not exekcisrd until
lowance, however, basically render these craft ill-suited for such functions.
During World War II and the Korean War, certain LSTs also were used for medical purposes. Designated LST(H)s, they were beached at critical invasion shorelines and reconfigured for use by surgical teams to stabilize the wounded. Others were outfitted as floating blood banks or medical command-and-control stations.
Functional Limitations of Afloat Medical Assets fortunately, the grandiose scale of modem afloat am- us medical facilities may lead to erroneouftexpec- tations concerning their role in the medical continuum of care. Despite their size, afloat medical facilities of an amphibious task force ultimately are incapable of functioning as definitive-care hospitals. Such ships are only capable of serving as a single forward echelon within the chain of evacuation.
Combat surgical care, in contrast to civilian trauma surgery, generally is rendered through echelons of increasing sophistication. Each echelon does only as much as is necessary to either return the patient to duty or prepare him for safe evacuation to the next echelon. Any attempts at providing more definitive and reparative surgical care within afloat locations only adds to the logistic burden borne by the facility. Furthermore, administering definitive care to complex combat wounds requires time, which can limit the availability of operating rooms and patient care beds. This could place later-arriving casualties at a disadvantage and could become a heavy drain on staff time and endurance.
Personnel skills, uneven reliability of equipment, and uncertain logistic adequacy also can have a significant impact upon the operational efficiency of amphibious ships.
► Personnel Considerations. Ship’s company medical personnel on board the larger amphibious assault ships typically includes a general medical officer, an administrative officer, and a contingent of enlisted Hospital Corps personnel. The medical facility does not assume “hospital-type” responsibilities until the ship is deployed and a fleet surgical team is embarked. In port, ship’s- company medical personnel merely provide routine sick call and perform fundamental medical housekeeping
ational Perso ' \ dardL
"HWliai IVYWI v/l UIl --------------------- *
Persormelphould be upgraded to and maintained at a stab- for a£ lP'
Following deployment on board an LHA in 1984, a surgical team critique noted that the ship’s-company corps- men lacked “practical experience in their specialties.” In 1989, on board the same ship, the situation was unchanged. This was especially noteworthy among the operating room technicians, who seldom had the opportunity to function in a surgical setting on board ship.
For the LHA laboratory technician assigned to blood banking duties, including the processing of frozen blood, this issue is critical. In Vietnam, 10% of all wounded required blood transfusions. The average amount transfused was seven units per patient; about 12% received 11 or more units, and some received up to 90 units. In the event of combat casualty reception on board ship, large volumes of blood will need to be processed efficiently and effectively within quality control standards and within the narrow time constraints mandated by the critical nature of most wounds. This can limit the extent of surgery that is available to casualties.
As one observer noted, “Reconstituting frozen blood to a quality fit for transfusion is not the same as mixing Kool- Aid. This critical skill should have a credentialing requirement.” Indeed, following Desert Storm, the director of the Armed Services Blood Program Office readily acknowledged that military blood-bank technicians in general were not prepared to process frozen blood in support of the war. As a result, he noted, none of the 7,000 units of frozen blood sent to the Middle East was ever transfused.
Surgical and X-ray technicians also require continuing professional training and practical implementation within a hospital setting. Without practice and experience, the effectiveness of casualty care will be drastically degraded when their services are truly needed.
The 1984 surgical team on board the LHA continued, “Most ward personnel had limited or no prior experience as ward corpsmen in a Navy Hospital. A 17-bed intensive care unit, or a 45-bed acute care ward, cannot be staffed by personnel lacking hospital ward experience. Since a fleet surgical team includes only one supervising ward nurse, this gap can degrade the patient-care services of the ship. Regularly scheduled patient-care and ward administrative procedure training in a Navy hospital should be mandatory. .
Following Desert Storm, amphibious task force physicians identified shortages in ICU nurses and inhalation therapists on board their ships. In terms of modern medical practices, the services of these professionals are mandatory for supporting critically injured personnel.
How can large numbers of casualties be stabilized in triage areas while awaiting surgery without assistance from personnel trained in advanced resuscitation techniques? Most ships attempt to educate the ship s company through lectures and occasional makeshift hands-on sessions. These generally vary in content and quality, however, and they are highly influenced by the specific interests of the ship s general medical officers. For this class of ship, the oper- peiformance level of all assigned enlisted medical
al emcrgi
specific and fairly precarious medical mission of this class of ship, this capability for all corpsmen is necessary for true operational readiness.
>• Reliable Equipment Resources. It has been estimated that there are more than 225 “medically unique” types of equipment in an LHA’s medical department during peacetime steaming. There is an even greater quantity of sophisticated equipment within specialized contingency supply blocks. Does an adequate level of maintenance capability exist for all this equipment to ensure materiel readiness for casualty support?
The 1984 report of the surgical team on board an LHA stated, “The ship’s central oxygen supply system was inoperable throughout the deployment. According to the ship’s medical officer, this condition has existed for several years, necessitating the use of small portable cylinder containers of gas in lieu of the ‘piped in’ system. Calculations, using the numbers of cylinders in the Authorized Medical Allowance List, reveal that if two patients had to have their breathing controlled by a respirator for more than 48 hours [commonplace in wartime], the oxygen supply would be inadequate.” In 1989, the same central oxygen supply system remained inoperative because of a malfunctioning pressure control mechanism, the control panel of which is welded to the bulkhead and cannot be repaired by ship’s company personnel. On board another LHA in 1992, the identical system was inoperative.
On board the same ship in 1989, the control panel governing the piping of anesthesia gas into the operating rooms was inoperative. (Similar problems were noted on board another LHA in 1992.) The browning, dust-covered gauges were leaking glycerin, reflecting a long period of maintenance neglect and non-use. Likewise, the control system for pressurized air—used for running equipment such as respirators—was not reliable. Suggested repairs apparently were disregarded during a past overhaul period.
Frozen blood freezers, capable of holding hundreds of units of frozen blood for many years, had been placed on board the same amphibious assault ship. Unfortunately, there was limited shipboard expertise available for repairing or maintaining the equipment, and the ship carried no spare parts inventory. Centrifuges designed for reconstituting frozen blood remained fallow and covered with dust, never having been tested for effectiveness. (Reports several years previously described the efforts of a special blood bank team that deployed with the ship to test the equipment. Although the team had expertise in maintaining the centrifuges, it was plagued for months by lack of repair parts for them.)
The 1984 report continued, “One of the new X-ray units was inoperative throughout the six-month deployment.... Major maintenance work such as this needs to be planned for completion well in advance of deployment.” In 1989, certain X-ray equipment was again inoperative, because of protracted delays in obtaining repair parts.
In the context of operational readiness, medical t tg,the same] function batdnljy
Integrated Logistics Support in Navy Medicine
Lieutenant Commander Stephen L. Koenig, Supply Corps, U.S. Navy
What would you do if your car broke down and the service station told you, “Sorry, we can’t fix it because we don’t have the necessary technical manuals,” “We can’t identify the parts,” or “We don’t have the spare parts?” You probably would never deal with that service department again. That same scenario has been played out numerous times over the past years with shipboard medical and dental equipment. Too often the Navy has procured equipment without comprehensive technical manuals, provisioning technical data, adequate spare part support, or maintenance material management (3M) documentation. The reasons for this seemingly haphazard procurement include rapid changes in technology, expediency, and our routine selection of the lowest-priced model.
The Bureau of Medicine and Surgery’s (BuMed) primary mission is to provide the highest quality medical and dental care to all Navy and Marine Corps operating forces. To meet this objective, Navy doctors and dentists serving on board ship or ashore with the Marines must have equipment that is well designed, logistically supportable throughout its life cycle, and able to withstand the unique rigors of shipboard and combat operating environments. We can obtain quality equipment that is logistically supportable by adhering to the basic principles of the Navy’s Integrated Logistic Support (ILS) Program. In
U.S. AIR FORCE (D. MCMICHAEL)
To provide the highest quality medical and dental care to the fleet, Navy doctors and dentists must have equipment that is well designed, logistically supportable, and able to withstand the rigors of shipboard and combat environments. The first step is adherence to the Navy’s Integrated Logistic Support Program.
the last two years, Navy Medical Logistics has embarked on a rigorous program to bring fleet medical and dental equipment within standard Navy ILS doctrine.
Navy medicine’s journey into ILS was precipitated by three events.
The first was the Chief of Naval Operations August 1990 message that cited examples of ILS deficiencies for new ships and systems being introduced into the fleet. It directed the fleet commanders to introduce new equipment only when proper support was in place. Less than full adherence to ILS and lifecycle management policies resulted in reduced reliability, maintainability, and readiness. Second, a letter from the President, Board of Inspections and Survey to Chief, BuMed, reported numerous examples of shipboard medical equipment not performing satisfactorily. The letter noted two reasons for equipment degradation: equipment design that was incompatible with the dynamics of ship’s motion and poor or nonexistent proprietary specific consumable and repair parts support. Last, but most important, was the dissatisfaction and frustration of fleet medical and dental personnel over the poor reliability and maintainability of their equipment.
BuMed launched its ILS campaign by hosting a Fleet Medical and Dental Logistics Conference on 7 March 1991. For the first time, the conference brought together all the key logistic activities to discuss support of afloat medical and dental equipment. The primary objective
munications center. Medical equipment must be able to adapt to the motions, vibrations, and environmental uniqueness of shipboard existence. Personnel who are qualified to operate and maintain the equipment also are essential.
Furthermore, an inventory of key spare parts should accompany such equipment. Medical spare parts inventories on board ships need to be coordinated by a central authority and constantly matched against a medical equipment casualty reporting system. Such information must be integrated into the development of medical parts inventories. In addition, a planned maintenance schedule for each piece of equipment should be designed prior to its placement on a ship and monitored at intervals by knowledge- e personnel. At best, medical systems assessment teams logically should inspect the competence level of those
who operate and maintain this equipment.
The functional integrity of medical equipment must be monitored continuously. It cannot be considered operationally ready unless subjected to periodic use. Unfortunately, much of the equipment on board CRTSs lies fallow, except for limited use during deployments. If unused during in-port and routine cruising conditions, it will deteriorate. On the other hand, operation of some medical equipment can be very expensive. As one shipboard medical officer noted, while commenting upon a blood chemistry analyzer in his laboratory, “If I ran that machine for any length of time, it would totally consume all of my [operations target] funds.”
It is also evident that the types agd models if medical e^uipipent vary {rorjh.ship to snip, \yith time,[$oi]pq may
/\__ . 1/v , ^ \J U
The CoSAL is a technical document to the extent that equipment, components and parts, nomenclature, operating characteristics, and technical manuals are described. It is also a supply document, as it lists the items required to achieve maximum selfsupporting capability for an extended period of time.
The nuts and bolts of the CoSAL are its APLs, therefore, BuMed has concentrated its efforts in their development. NavMedLogCom, NavSea, Ships Parts Control Center, and Naval Supply Systems Command combined efforts to produce 618 APLs. These documents have in turn been loaded to the Navy’s central configuration data base, consisting of the Weapons System File and Ships Logistic Support Information System. A CoSAL update for medical and dental equipment was distributed to applicable fleet units in July 1992.
While the medical, supply, and engineering communities have accomplished a great deal in a short period of time, ILS is an evolving process we must continue to improve. It will help ensure that the fleet has the best designed, most reliable, and fully supportable equipment available.
Lieutenant Commander Koenig is Director, Logistics Division, at the Bureau of Medicine and Surgery. Prevous tours include assistant Material Director at NSC Jacksonville; supply officer for Mine Group Two; and on board the Independence (CV-62), Maritime Prepositioned Group One, the Jesse L. Brown (FF-1089), the Wainwrighr (CG-28), and the Illusive (MSO-448).
ment will significantly reduce overhead and life-cycle costs.
Maintenance and Material Management
The 3M program provides a means of managing maintenance and maintenance support in a manner that will ensure maximum equipment operational readiness. It also provides a means to report corrective maintenance actions. This information is used for analyzing maintenance and logistic support problems. To enhance 3M coverage on medical and dental equipment, BuMed and the Naval Sea Center Atlantic have worked to ensure all equipment has planned maintenance system coverage or is certified not maintenance significant. In the last three years, Naval Sea Center Atlantic and NavMedLogCom have combined to develop 95 new maintenance index pages and 268 maintenance requirement cards. Additionally, 2,468 technical feedback reports have been processed.
Coordinated Shipboard Allowance Lists/Allowance Parts Lists
The heart of the ILS process is the coordinated shipboard allowance list (CoSAL). It is the key fleet configuration management tool developed from the Weapons System File. It is both a technical and supply document that, when properly maintained, will provide an accurate picture of an individual ship’s configuration.
Standardization of equipment across hulls is one way to achieve significant savings in life-cycle costs. Navy Medical Logistics Command (NavMedLogCom), BuMed’s equipment program manager, and Naval Sea Systems (NavSea) attacked the standardization problem from several directions. Essential characteristics standards have been revised to more tightly define acceptable equipment performance criteria. New or replacement equipment being purchased must have a shipboard performance history or be subject to Navy test and evaluation before introduction into the fleet. Additionally, medical and dental equipment lists for all initial construction outfitting must be forwarded to BuMed/NavMedLogCom for review and final approval.
NavMedLogCom has made extensive use of requirement contracts with an indefinite delivery schedule from single manufacturers for purchase of replacement equipment. Reprocurement of exiting equip
was to identify the status of the ILS process. The conference proved extremely successful and the attendees identified specific items that required immediate attention. Areas identified included: equipment standardization, development of allowance parts lists (APLs), increased 3M coverage, and the necessity for close cooperation between the engineering, supply, and medical communities.
Equipment Standardization
have become outmoded, but were retained for budgetary reasons. In their reports, previous surgical teams declared the anesthesia equipment on one LHA to be archaic and recommended replacement (a recommendation that was never implemented). Of interest is the fact that the new Wasp (LHD-1) and some LHAs have reverted back to the simplified and compact field hospital anesthesia machines—in sharp contrast to their sleek and modernistic
operating rooms. . .
The repair, maintenance, and replacement policies tor ntedical equipment on the differing classes ot ships also rnay uary between commands. Such variabilities make it difficult to maintain system-wide parts inventories and define rlpatr priorities. It also is evident that a lone Ftp- rnedic»l Jquipment Repair Technician cannot diagj(o\e and repair each and every malfunction within the large number of unique pieces of medical equipment on any given ship.
Further Logistic Considerations____________________
In the event that major casualty surgical care is required, “surgical blocks” of supplies assembled by Navy medical logistics facilities generally are placed on board each ship prior to the deployment of a fleet surgical team or surgical augmentation group. For each surgical team added, another 36 or more pallets of supplies weighing sii-seven tons jnust be placed bn board to sijppo£ their initial «Jt- * nepds. A
ikular cone ;jti i\. Desert $tc ^ I Ml
reiilating. Many medical augmentees were unfamiliar with thacogtents of the surgical supply blocks and were unable
ery that logistical support ships accompanying the amphibious task force did not carry an adequate resupply inventory of expendable combat surgical supplies, pharmaceuticals, blood, oxygen, and other medical gases. If casualty flow had been heavy, the need for forward supply dumps, either on land or sea, would have become imperative. Unfortunately, the Navy’s principal medical logistics liaison officer at the Army-run medical logistics facility in Saudi Arabia noted, “Difficulty with communicating requisitions, preparing supplies for [vertical replenishment] to ships, and transportation to staging sites, made support to afloat units ineffective.”
It has been estimated that the average amphibious assault ship in peacetime possesses less than its designated authorized medical allowance list because of the costs involved. Consequently, critically deficient supplies are often shared, transferred from one ship to another prior to deployment. For example, routine noncombat surgical problems often arise during deployments. Operative attention by the embarked surgical team would be desirable, because it reduces the need for continuous medevac and provides essential training and skills maintenance for the operating teams. Nevertheless, this requires the consumption of supplies. Can an adequate supply of these materials be assured without tapping contingency supply blocks?
Some Additional Desert Shield/Storm Issues
Within the expanded amphibious task force—which included two LHAs, five LPHs, six LSDs, eight LPDs, and eight LSTs— were many medical augmentees
from Navy hospital staffs. They included medical specialists from 20 distinct disciplines, accompanied by nursing and technical staff. Most had no prior seagoing expe- to acquaint themselves with these materials prior to any projected amphibious invasion. Anecdotal feedback, from those occasions when some were inspected, indicated that physicians often challenged the accuracy of the inventories, as well as the utility of some equipment in terms of contemporary standards of good patient care.
Few medical personnel had any training in the care of chemical casualties, and the ships themselves had no doctrinal plans for the decontamination of any evacuated casualties. Also, because of a lack of adequate chemical-bacteriological-radiological protective features, many crews would have been unable to make their ships airtight in the event of chemical attack. In some ships the exhaust vents in decontamination (DeCon) areas are located near the air intake vents. Plumbing from DeCon stations is connected to common sewer lines instead of to a dedicated line running to a holding tank or piped off of the ship, thereby increasing the risk to the crew of exposure to chemical agents.
For five months during Desert Shield/Storm, amphibious ships with patient-care responsibilities operated in remote areas more than 500 miles from the nearest higher level shore-based medical facility. Yet, doctrine to facilitate periodic offloading of stabilized casualties for more definitive treatment at higher echelons—freeing afloat facilities for subsequent casualties— was not clearly defined.
The extensive wounds of war always have borne a high complication rate. For example, most casualties from Vietnam, after initial treatment in-country, stopped at either Clark Air Force
Base or in Japan on their way to the United States. In one analysis of 128 casualties—most about four days after wounding—arriving at Clark, more than half required rehospitalization. Ultimately, a total of
or am-
Win $1,500
phibious ship. If casualties are not moved expeditiously through an echeloned medical chain, possibly one third of surgically treated casualties will require additional, complex reoperation. Because of this reality, logistics and nursing care requirements escalate exponentially.
It should be noted that during the Falklands Conflict, the British Navy used three converted survey vessels as “ambulance ships” to convey casualties previously treated on the hospital ship Uganda to a neutral medevac staging point on land 420 miles away. This helped keep beds open for future combat contingencies.
Communications with hospital ships in the Persian Gulf were difficult as well, because Geneva Convention protections prevent these ships from receiving ciphered messages. In the Falklands Conflict, communications with the neutral hospital ship were via transmission stations ashore, which received coded messages and then retransmitted them to the ship “in the clear.”
Conclusions
During war, medical assets of the amphibious task force will have even broader responsibilities. The U.S. Navy possesses a limited number of hospital ships, which are costly to staff and operate. Aircraft carriers, another potential source of afloat medical care, generally will not be available because of their heavily committed offensive role. In reality, the medical facilities of the amphibious ships provide, potentially, the greatest concentration of contingency medical assets available to the fleet. They
The United States Naval Institute and the Vincent Astor Foundation take pleasure in announcing the Nineteenth Annual Vincent Astor Memorial Leadership Essay Contest for Junior Officers and Officer Trainees of the U.S. Navy, Marine Corps, and Coast Guard. The contest is designed to promote research, thinking, and wnting on topics of leadership in the U.S. Navy, Marine Corps, and Coast Guard.
FIRST PRIZE: $1,500, a Naval Institute Gold Medal, and a Life Membership in the Naval Institute.
FIRST HONORABLE MENTION: $1,000 and a Naval Institute Silver Medal.
SECOND HONORABLE MENTION: (two to be awarded) $500 and a Naval Institute Bronze Medal. The first prize essay will be published in the U.S. Nava Institute Proceedings. The Institute’s Editorial Board may elect to publish any or all of the honorable mention essays in any given year, but is not obligated to do so. The Editorial Board may, from time to time, publish collections of the award winning essays and other essays in book or pamphlet form.
The contest is open to:
- Commissioned officers, regular and reserve, in the U.S. Navy, Marine Coips, and Coast Guard in pay grades 0-1,0-2, and 0-3 (ensign/2nd lieutenant; lieutenant (junior grade)/1st lieutenant; and lieutenant/captain) at the time the essay is submitted.
- U.S. Navy, Marine Corps, and Coast Guard officer trainees within one year of receiving their commission.
are, in essence, the Navy’s only “tactical hospital ships.” Consequently, their projected role in service to the fleet extends far more widely than that of amphibious operations alone.
We must reassess the role of the casualty receiving and treatment facilities on board our amphibious ships. Following a sober determination of the limits of our medical capabilities afloat, we should reorder our future training and medical logistical priorities. It ultimately devolves upon the line sponsors of our afloat assets, however, to determine just how much medical care they are willing to provide and pay for within the realities of current defense cutbacks. It behooves us to seek greater efficiency, to maximize the potential for saving lives when called into a combat support role.
Walter E. Williams, a nationally syndicated columnist, once wrote, “War and other hostilities require heart-rending, tough decisions that the average person would not want to make. But, the fact is: Hard decisions must be made, and we hope that the people in charge have the guts to make them.” From the important perspective of fleet medical support, some tough decisions will have to be made in the Gator Navy as well.
Captain Smith, a frequent visitor to the amphibious fleet as a Navy reservist, is clinical professor in both the Departments of Surgery and Military Medicine at the Uniformed Services University of the Health Sciences in Bethesda. He also is professor of surgery (urology) at the Medical College of Georgia in Augusta. In 1989, he was designated as the Proceedings Author of the Year.
ENTRY RULES
- Essays must be original and may not exceed 4,000 words.
- All entries should be directed to: Executive Director (VAMLEC), U.S. Naval Institute, 118 Maryland Avenue, Annapolis, Maiyland 214025035.
- Essays must be postmarked on or before 15 February 1993.
- The name of the author shall not appear on the essay. Each author shall assign a motto in addition to a title to the essay. This motto shall appear (a) on the tile page of the essay, with the title, in lieu of the author's name and (b) by itself on the outside of an accompanying sealed envelope. This sealed envelope should contain a typed sheet giving the name, rank, branch of service, biographical sketch, social security number, address, and office and home phone numbers (if applicable) of the essayist, along with the title of the essay and the motto. The identity of the essayist will not be known of the judging members of the Editorial Board until they have made their selections.
- The awards will be made known and presented to the successful competitors during the graduation awards ceremonies at their respective schools, if appropriate, or at other official ceremonies. Mrs. Astor or her personal representative will be invited to present the first prize each year.
- Essays must be typewritten, double spaced, on paper approximately 8J? x 11". Submit two complete copies.
- Essays will be judged by the Naval Institute's Editorial Board for depth of research, analytical and interpretive qualities, and original thinking on the topic of leadership. Essays should not be merely expositions or personal narratives.
DEADLINE: 15 FEBRUARY 1993
VINCENT ASTOR MEMORIAL
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UNITED STATES NAVAL INSTITUTE, 118 Maryland Avenue, Annapolis, Maryland 21402-5035 (410)268-6110