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“The new Navy strategy notes with pride that our warships have a healthy self-sufficiency, that they can remain on station for extended periods, and that they can sustain support for long term operations,” noted a medical veteran of naval operations. “That’s all true ... until the first bloodied body goes by!”
/\ t the outset of Operation Restore Hope, the Joint Chiefs of Staff declined to order the deployment hfVAof our hospital ships in support of early military insertions into Somalia. Their decision conveyed a message: Despite annual taxpayer expenditure of $6.2 million per ship to maintain a high state of readiness for treating combat casualties, sailing orders for these platforms bear significant economic and political implications, as well as military ones.
During Desert Shield and Desert Storm, activation of these afloat medical resources required a major personnel augmentation, drawn primarily from shore-based Navy medical facilities. Consequently, mobilizing these vessels does imply large financial expenditure—primarily to cover the patient-care responsibilities vacated by the health-care augmentees. Furthermore, getting these white sanctuaries under way sends a clear message to the American public: Military leadership acknowledges and anticipates the possibility of large numbers of major casualties.
If our leadership will use these personnel support assets only in major strategic conflicts, how will we provide medical support for our new naval strategy, “. . .From the Sea?”
will be directed toward involvement and intervention Third World regional crises. Mobile, joint power proj
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Our New Naval Strategy in the Contemporary World
As demonstrated by the Gulf War and more recently by security actions in Somalia, the employment of U.S.
tion forces will be the standard, with particular early eti> phasis upon maritime assets.
To sustain a Third World power projection capabil1■ 1 in these times of budget austerity, however, tradition^ naval deployments will be undertaken only as required f regional deterrence and stability. Situational presence ^ regional crisis-response missions now receive primacy ‘ our new strategy. Flexible maritime forces will be 1 watchword of our new naval expeditionary orientation’.
Less costly ways of fulfilling the traditional roles carrier battle groups have been suggested. Proposed ternatives include splitting the groups into smaller c° y figurations and dispersing them over larger areas to Pr
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Vlde more extensive regional coverage. These smaller groupings are to be built around surface combatants (surface action groups) and amphibious assault ships (amphibious ready groups).
All this creative deployment planning, however, is overlooking something vitally important.
CQsiicilties on Ships Come in Large Clusters
h As a previous General Accounting Office report noted, The low-intensity threat is not necessarily a low-tech- lology threat.” It is no longer axiomatic that we can exPect to face unsophisticated armaments when deploying military forces to local conflicts. Many players around the w°rld now have at their disposal weapons of mass deduction and the means to deliver them. These include allistic and cruise missiles, sophisticated littoral mining technologies, chemical and biological weapons, and, in a few cases, nuclear weapons. Other countries' abilities to 'Srupt our surveillance, electronic intelligence collection, and early warning capabilities also are expected to incase. Consequently, when we develop a concept for outing our Navy’s role in future military conflict, we cannot exclude the inevitability of combat-related Casualties.
Unfortunately, naval warfare always will be an exCeedingly dangerous activity, whether ships are operating ln blue or littoral waters. The potential for catastrophic casualties in ships at sea is related both to the availabil- ’fy of modern, accurate, and powerful ordnance and to the pr°Pensity for secondary explosions and shipboard fires, as several historical examples demonstrate:
In May 1941, an armor-piercing shell penetrated the der magazine of HMS Hood. A secondary explosion tore e ship in two, and she sank within 90 seconds. There dre three survivors from a crew of 1,800.
In March 1945, two Japanese armor-piercing bombs penetrated the flight deck of the USS Franklin (CV-13) and exploded on the hangar deck. The resulting secondary ^plosions and fires destroyed a substantial portion of the s ’P, resulting in nearly 1,000 casualties out of 3,300 crew X’embers, 800 of whom died.
During the Falklands Conflict, a single missile pene- (rated HMS Sheffield but failed to explode. Nevertheless, ■ e searing heat generated by its passage through the uh and into the forward engine room set fire to paint and s ^er flammable materials, filling the ship with acrid within seconds. Twenty died in this incident and ^ "'ere seriously wounded.
d The USS Forrestal (CV-59) experienced a major con- agration following the accidental firing of a Zuni rocket a the flight deck while in the Gulf of Tonkin. The ex- Osi°n and flames killed 134 men and injured 162 thers.
h is difficult to predict specific injury rates to Navy bl rS°nnel at sea, even from such recognized causes as s^ast overpressures, fragment penetrations, underwater • °ck motion, fire injury, and smoke inhalation. Even profited battle-casualty estimates for separate classes of U.S. avy ships vary, given the nature of the various studies used and their differing databases. Nevertheless, a thread of continuity runs through all of them: Large numbers of personnel can be killed or wounded by a relatively small number of successfully targeted and delivered munitions.1
Medical Support Capabilities at Sea
Within an independently steaming carrier battle group, amphibious ready group, or surface action group, where would casualties be treated? The carrier, heavily involved in flight-deck operations, hardly can afford to stand by for continuous reception of casualties via sea or air lift. The ships of the amphibious task force, although theoretically capable of assuming responsibility for casualty care, remain basically untested—with the exception of the aging amphibious assault helicopter ships (LPHs) in the task forces that supported U.S. operations off Grenada and Lebanon.
During these operations, the USS Guam (LPH-9), steaming off the coast of Grenada, was overwhelmed by the near-simultaneous receipt of 36 casualties. Off the coast of Beirut in October 1983, the USS Iwo Jima (LPH-2) served primarily as a staging point for the evacuation of a large number of the living casualties after the bombing of the Marine headquarters. Indeed, 61 stretcher patients were received on board the hvo Jima within one and a half hours. Fortunately, many of the seriously wounded had been sorted out by triage teams at the Beirut explosion site and were transported to other facilities. Most of the stabilized evacuees were transferred from the hvo Jima within the day.
Even in today’s Navy, fleet commanders are gravely mistaken if they equate the capability of our deployed afloat medical assets with land-based facilities of equivalent size. For example, despite its 6 operating rooms, 17 intensive care beds, 47 ward beds, and 536-bed overflow capacity, the USS Wasp (LHD-1) cannot be compared with a land-based civilian medical trauma care facility with the same number of patient care units. The capabilities and limitations of these facilities are substantially different. Misconceptions that ignore the logistical shortcomings and personnel limitations of afloat medical facilities ultimately could impact adversely upon operational planning and execution.2
A comparably sized land-based trauma hospital is extremely resource-dependent. It requires an extensive roster of highly trained technicians and many professional medical and nursing personnel. Around-the-clock staffing of operating rooms, intensive care units, laboratories. X-ray rooms, and blood bank facilities, as well as essential support services from respiratory therapists and specially trained pharmacists, are critical for ensuring the survival of injured patients. They also demand an extensive logistical support network, ranging from supply procurement to equipment maintenance. The basic operation of a hospital-based trauma intensive care unit equivalent in size to that found on an LHA or LHD, for example, commonly uses the services of one registered nurse per patient, per shift, to optimize the opportunity for patient recovery.
*10
Where within a surface action group could the number of potential casualties caused by a well-placed cruise missile be treated? In reality, no naval ship in a battle mode— except perhaps a fully outfitted and staffed hospital ship— can afford to manage the casualty load that can be expected in future naval engagements. Afloat medical facilities on other larger ships may be used for stabilizing casualties and performing forward echelon initial medical care only. For any sizable number of casualties, further echelons of medical care must be available well beyond the afloat battle group. Even a hospital ship would be heavily taxed if more than a small portion of the injuries were critical.
Expeditionary Forces and Land-based Medical Support
Afloat medical support services do not exist in a vacuum. There is an inextricable relationship between events at sea and those on land. Land frequently will determine whether a navy has the overseas infrastructure—including medical logistic support bases—to undergird its deployments. During the Falklands Conflict, for example, the number of British shipboard casualties at times exceeded casualties ashore. Serious shipboard casualties occasionally required evacuation to the combat zone hospital ashore, for initial stabilization. For example, assume a repetition of the 179 casualties generated by the air attack on HMS Sir Galahad. Could an underway battle group continue to function and still be able to deal with the sudden generation of so many casualties? Fortunately, many of Sir Galahad's, casualties could be transferred quickly to medical facility ashore for initial care. In addition, tb£ British Navy acquired a neutral land' based staging point in Montevideo' Uruguay, to transfer 593 casualty from the task force. This allowed med' ical facilities afloat to prepare for th£ arrival of new casualties.
From the medical perspective, ad' vanced facilities on land are critical10 support of naval warfare. Fleet hosp[1]' tals, for example, have served as on* such arm of support. In the matur^ theater of operations that existed duf ing the latter stages of World War ft large numbers of mobile, base, afl“ fleet hospitals were located oversea*[2] Their value to the fleet was high' lighted during the invasion of Ok1' nawa, when kamikaze attacks on tb* casualties among the forces afloat. F°: continuity of naval operations, s1' hospital ship transports were requif^ for evacuating the mounting shipbo^ casualties to Navy hospitals in Gua[3] During Desert Shield and Dese(l Storm, three large fleet hospitals vvef‘ erected in-theater, to support bo111 land- and sea-based operations. Lest we forget, howevd' there will be few similar wars in terms of uncontestf" buildup of forces, virtually unlimited local fuel, and tl*® unrestricted use of modern seaport and airfield facility Political considerations also may dictate the availab1* ity of medical staging sites ashore. When a situation lS considered politically unfavorable, even our friends ma' refuse to help. France and Spain, for example, refuse overflight rights to U.S. F-l 11 aircraft during U.S. attack upon Libya in 1986, because they considered such opef ations contrary to their national interests.
Medical Support of Amphibious Operations .
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ICal assault phase of an amphibious operation. Unfortunately, this also is when the medical service has a mininumber of medical personnel and facilities ashore, taher than the support provided by medical personnel or- j=an‘c to combat units, the options for medical care are 'rnited. Large numbers of casualties ashore—combined ^'th the need for initial care and making the best dispo- s,tion of the wounded in the face of inadequate facilities an<l other unforeseen difficulties—may impede and even efeat an operational undertaking. The need for organized
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[jj ro§rade evacuation to casualty reception facilities within '■float expeditionary task force, and a sophisticated ca- ty regulation network. If not, a huge logistical burden inay ■Materialize for the landing force, as the dead and JUred accumulate ashore, with inevitable adverse impact P°n morale.
^ 'eet support is further complicated by the fact that new aP°ns and communications technology and new forms phfault vehicles may well favor over-the-horizon am- gening weapons of potential adversaries, while si- ^aneously providing greater tactical latitude for land-8 f°rces. It recognizes the 250-nautical-mile range of ship cruise missiles, as well as the extensive shales"' and deep-water mining capacity out to the 100-fathom both developed by Soviet technology and sold %h • ide’ Similarly> the ballistic threat from infantry by vehicles introduced into the world arms market qUe former Eastern Bloc cannot be ignored. Conse- nt’y. support ships may be required to stand out many
miles from shore, presenting a significant challenge to earlier systems for evacuating sick and wounded members of the assault force back to the amphibious task force.
Will ready evacuation of casualties by air be assured? Since the Korean War, the helicopter has been the predominant mechanism for casualty evacuation during amphibious operations. In the face of modern antiaircraft defenses—including highly effective light shoulder-fired heat-seeking missiles—the survivability of helicopters on the modern battlefield certainly is not guaranteed. Furthermore, in the absence of total air superiority in combat or during poor flying conditions, surface evacuation of casualties back to the task force would assume greater importance.
Unfortunately, neither the LPHs nor the large deck carriers are designed to receive casualties directly from surface evacuation craft. Even our modem hospital ships primarily are designed to accept casualties by air transfer. Waterborne transfer of casualties to such vessels, when they are not at anchor, will be extremely difficult and of limited use.3 In addition, other amphibious ships that have surface evacuation capabilities, such as the LPD (amphibious transport dock) and LSD (landing ship dock) classes, as currently outfitted and configured, would provide a limited and dangerous setting for the injured if challenged with major casualty care responsibilities.
The Importance of Innovation
FLAG OFFICER AND PORT ADMIRAL, GIBRALTER ROYAL 1
and adaptive thinking of those on the scene or those left holding direct responsibility on major staffs. In such settings, the Navy’s line leadership should encourage dynamic problem-solving efforts among medical combat support services. Following Operation Desert Storm, for example, when describing the medical evacuation system available to his ground troops, then-Lieutenant General Walter Boomer, U.S. Marine Corps, noted, “It was a relic of World War II ... . The concept of an orderly evacuation sequence is nonsense .... It hasn’t kept up with the times!”
Examples of past innovations are instructive:
► During World War II amphibious operations—as well as subsequent landings at Inchon, Korea—the tank landing ship (LST) was converted into an important component of the medical care system. LSTs modified for surgical support, although of limited capacity, were reconfigured for use by surgical teams to stabilize the wounded. Given the intensity of the warfare and the lack of hospital ships, the use of LSTs in this role became es-
As the Navy implements the new strategy outlined in .. From the Sea,” it also must consider adaptive and innovative ways to provide casualty support. One example of such innovation is the Royal Navy’s conversion of commercial ships for casualty care during the Falklands Conflict—here, the SS Uganda, a cruise liner, after being converted to a hospital ship.
sential in providing the wounded quick, early, life-saving treatment in forward locations.
► During the landings at Leyte Gulf in 1944, the benefit of having surgical team LSTs beached after unloading was demonstrated. Planners saw the value of holding one or two surgical LSTs in reserve, awaiting demand either at beaches overwhelmed with casualties or at those left without medical facilities. During the operation at Lingayen Gulf in January 1945, six LSTs with embarked surgical teams were beached to provide casualty care.
► At Normandy, all LSTs were equipped to handle returning casualties, and 54 were outfitted to perform surgery. Others subsequently were equipped to serve as casualty-control ships, regulating the retrograde flow of the wounded to rear facilities afloat and ashore. One was even outfitted as a floating blood bank. Such hospital LSTs, able to provide sophisticated surgical care in a relatively safe environment close to shore, received their successful test under fire at Iwo Jima and Okinawa.
► At the inception of the British campaign to retake the Falkland Islands in 1982, in anticipation of the expected casualties, two commercial cruise ships were requisitioned and refitted for casualty care. Three ocean survey veS' sels also were converted to serve as ambulance ships, i
The SS Uganda, for example, an educational cruisi| liner, was converted to a hospital ship in Gibraltar with'1 60 hours. A helicopter pad was fitted, and a ramp was if stalled to allow rapid transfer of patients to the main hof pital on the promenade deck. Other sections of the shif were converted to an operating room suite, an intense care ward, and a high-dependency skilled nursing uni' A separate burn unit was established in the ship’s orig' nal hospital. Further space conversions allowed low-d£ pendency wards, an eye department, and X-ray, labors tory, and dental facilities. Two desalination plan1’ eventually were installed en route to overcome fresh wat£l limitations. Ultimately, 730 combat patients were adrn'1 ted on board the Uganda, and 500 operations wefl performed.4
The three ocean survey vessels, converted to ambulant ships, each evacuated between 60 and 100 casualties o" every run from the Uganda to Montevideo, Uruguay. The)
transported a total of 593 casualties, clearing room new casualties on board the hospital ship.5 >■ During the prelude to the Gulf War in September 19^ with an increasing number of United Kingdom mariti1111 forces in the Persian Gulf, a surgical support team ^ placed on board the Royal Navy ammunition ship F0< Grange, to supply forward-located emergency stabilize surgery to injured fleet personnel. A group of ship’s col" pany volunteers also was successfully trained in basic nub ing skills. .
Because Fort Grange, with her hazardous cargo, coal“ not be sent too far forward—where the casualties most likely to occur—medical assistance had to go f°f ward to the casualties. A forward-deployment team, si**1 ilar to the new U.S. Army forward surgical team, instituted. In concept, the team was to go forward cad) ing its own gear, resuscitate and stabilize casualties board a damaged ship, and then transfer them, acting a'!’1 as escorts to undertake continuing care.6 > During Desert Shield and Desert Storm, Royal NaV| casualty estimates indicated the need for a minimum 0 100 beds in a hospital facility, with the capacity to hal1
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*e mass casualties of all types, initiate their management, and hold them for up to six days. HMS Argus, the air Gaining ship of the Royal Navy, was designated as the Platform.
The flight deck of Argus, with five helicopter landing ?P°ts and two large aircraft elevators, was considered an 'deal platform for the movement of casualties. Feasibility studies analyzed the possibility of building a “tactical °spital facility” within the ship, and specifically whether ae ship’s services could cope with the vastly increased requirements that would be imposed. Ultimately, plans VVere drawn to convert the forward hangar of Argus into a two-story 100-bed hospital in airtight collective protec- l0|h leaving the other three hangars for the air department
0 Maintain and operate their aircraft.
a three-week period prior to deployment, the hospi- a Was designed, built, equipped, and staffed. Using the "jodular construction components of the Portakabin Du- Pex Building System, the exoskeleton of the hospital was
1 ted onto the flight deck in sections, then fitted together ar|d moved into position. A forward located decontami- nadon portakabin also was added.
, Ultimately, Argus arrived in the Gulf with a 100-bed °spital in a citadel independent of the superstructure of ship. It included a 10-bed intensive care unit, a 14- Ie<^ high-dependency skilled nursing care unit, a 76-bed w'dependency unit, plus four operating tables in two operating rooms with full support services. The hospital . as staffed by a medical team of 136 men and women, deluding surgical, orthopedic, burn, dental, and ophthal- , 0|°gy specialists, as well as nurses, X-ray, laboratory, nh other technical specialists. The hospital also was sup- 0Ped by the air department of Argus, with four desig- ^>ted casualty evacuation Sea King helicopters, as well s woyal Navy support and liaison personnel, p Uver the 16-day transit period, the medical augmenta- s°n staff, many of whom had never previously been to : a' developed and implemented training protocols. Civil- n casualty training techniques were adapted to the re- lrements of combat casualties in a shipboard environ- ent- crew members were trained in first aid and
e handling of stretchers and in understanding the man- frCment and decontamination of contaminated casualties, implementation of this afloat tactical medical support ncept allowed a significant shortening of potential ca- ^ ahy transit time from frontline, at-risk maritime units, ^ecause it could operate in a gray hull in forward areas ^ .h unrestricted communications. In the eyes of all, the |4ish fleet in the Gulf was fully and closely medically
PPorted.7
bottom Line [4][5] clearing, or even the interpositioning of ships to prevent intervention by another power in local disputes affecting our interests. In each setting, the sudden massive generation of U.S. casualties is a distinct possibility that must be considered.
Dedicated hospital ships will not be readily available to every task force that enters into dangerous waters. Furthermore, in light of modem over-the-horizon missile warfare, reliance upon Geneva Convention protection for hospital ships may be unrealistic. Nevertheless, wounded naval personnel still must receive initial far-forward care, often at sea, if they are to survive the immediately destabilizing impact of injury and then tolerate a sometimes tortuous journey to a higher echelon definitive care facility ashore.
For example, the naval strategy outlined in “. . . From the Sea" requires maintaining the sustainability of relatively isolated ships, which ordinarily are dangerous locations for treating and holding casualties. Hostage rescue efforts at sea previously have used specially trained medical personnel—placed on board targeted ships via helicopter through direct landings, rope drops, or other ingenious methods—for the early treatment of casualties. Rather than splitting a task force medical team among a dispersed task group or attempting dangerous ambulance mercy flights from affected ships, the Navy must consider such innovative means for bringing specially trained operational medical teams to the scene.
As our new naval strategy is implemented, a more realistic assessment of adaptive casualty support mechanisms within the fleet must be undertaken prior to any expeditionary deployment. A can-do, problem-solving mind set for implementing innovative modifications of casualty care doctrine—successfully demonstrated by the Royal Navy—should be incorporated into such deliberations. U.S. military strategists and tacticians must be no less sensitive to these realities than they are in seeking offensive advantages during battle.
'Capt. Arthur M. Smith, MC, USNR, “Can We Effectively Control Human Costs During War at Sea?” Naval War College Review 45: 9-24, Winter 1992.
•’Capt. Arthur M. Smith, MC, USNR, “Gator Aid.” U.S. Naval Institute Proceedings, October 1992, p. 67.
‘Capt. Arthur M. Smith, MC, USNR, and Craig H. Llewellyn, “Tactical and Logistical Compromise in the Management of Combat Casualties: There is No Free Lunch,” Naval War College Review 43: 53-66, Winter 1990.
JR.J. Leicester, “Conversion of SS Uganda to a Hospital Ship,” Journal of the Royal Naval Medical Service 69: 10-16. Spring 1983; and J.G. Williams, F.R. Wilkes, P.J. Shouter, and P. Jones, “Assessment of Ships Taken Up From Trade and Other Ships for Use as Emergency Facilities in Wartime," Journal of the Royal Naval Medical Sendee 69: 17-20, Spring 1983.
5M.C. Newman, “Medical Officer’s Journal - HMS Hecla," Journal of the Royal Naval Medical Sendee 69: 26-31, Spring 1983.
hM.A. Farquharson-Roberts, “Naval Party 1026 (SE)—First In - First Out,” Journal of the Royal Naval Medical Sendee 78: 53-54, Summer 1992.
7E.P. Dewar, “Primary Casualty Reception Ship: The Hospital Within—Operation Granby,” Journal of the Royal Naval Medical Sendee 78: 55-64, Summer 1992.
Captain Smith, a frequent visitor to the amphibious fleet as a Navy Reservist, is a clinical professor in both the Departments of Surgery and Military and Emergency 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.
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An amphibious assault, launched by any naval exp^1 tionary force against a stubborn, well-entrenched ad'?er. sary, inevitably will produce a large number of casual^ among the landing force. In fact, amphibious operatic1^ of the many forms of combat assault, historically have s'1 fered the highest casualty rates. Tactical activity prom of U.S. Army and Marine Corps divisions in World ^ j
[2] for example, demonstrated that the highest rates, wounding occurred in opposed overwater assaults des1? nated as beachhead operations. The average wounding r‘*, of 11.04 men per 1,000 men per day was seven times j average rate for a division in combat and more than tW1
the average for virtually all other types of action. Casw rates as high as 25% of landing force personnel have curred in such heavily opposed amphibious actions as 76-hour invasion of Tarawa in 1943.
The highest casualty rates usually occur during the cl
Providing medical support amid the rapidly changing events of expeditionary missions has proved quite difficult. Solutions to the obstacles imposed upon medical support services must evolve from the creativity, versatility,
^ n the future, U.S. naval expeditionary task forces
[5] be called upon to perform numerous functions. These fQ u include evacuation of U.S. personnel, insertion of g0^es’ protection of U.S. property, resupply of friendly tjQernments involved in crises, patrol and escort operate ns f°r friendly shipping, combat against coastal navies