The urgent call came from Commander, Seventh Fleet to U.S. Naval Hospital Okinawa on an autumn afternoon in November 2002. A surgical team along with an operating room and ten units of blood were needed in three hours aboard a destroyer to deploy—destination, mission, and expected casualties unknown—in support of a top secret mission in the Global War on Terrorism. The only catch: the Navy had no surgical team with an operating room ready to deploy within three hours in the Western Pacific, or anywhere else for that matter. However, through the efforts of a small group of Navy personnel, a surgical team with an array of equipment and supplies boarded a small combatant ship having no inherent surgical capability within three hours after the initial call. The team set up a functioning operating suite, provided the Joint Task Force Commander the needed flexibility to carry out his mission, and successfully performed emergency surgery at sea. The Mobile Shipboard Surgical Suite (MSSS) was born.
Mission Defined by a New Type of War
The war on terrorism is driven by perishable intelligence and has required a change in tactics for all services, with greater emphasis placed on special operations missions that are limited in personnel and brief in duration. Such operations are typically executed far from traditional surgical support. All services have developed land-based mobile forward surgical units that are potentially deployable in support of special operations. The Army's Forward Surgical Team, the Air Force's Mobile Field Surgical Team and the Marine Corps' Forward Resuscitative Surgical System all represent efforts to provide early surgical intervention for forward personnel. In the maritime, and especially the coastal arenas, the suite adds surgical support to ships that possess tactical superiority for covert littoral-based special operations but have no organic surgical capability.
The MSSS was conceived out of necessity rather than through the lengthy process of planning, funding, and procurement that occurs at higher headquarters. There are advantages and disadvantages to this unconventional development pathway. On one hand, Operation Enduring Freedom mission commanders get what they need now; on the other, the MSSS is something of an orphan since its conception and development were driven by real-world contingencies and not the usual agencies. Regardless, its simple mission is unique in the Navy: quickly convert a small space on almost any Navy platform (with no inherent surgical capability) into a functional operating room to provide life-and limb-saving surgery. The mobile suite is a lightweight package of personnel and equipment that can deploy on several hours' notice, perform up to 15 surgeries, and then care for these patients for up to 48 hours until they can be evacuated. Today, the only system that can do this is the MSSS at Okinawa.
Those who have deployed and treated wounded sailors and Marines have equipped this system from an operator's perspective. The MSSS is characterized by off-the-shelf equipment that is similar or identical to that routinely used by Navy surgical personnel in their day-to-day hospital duties. This includes monitors, anesthesia equipment, surgical instruments, and consumable supplies. It contains cutting edge equipment in small packages such as the SonoSite ultrasound machine for diagnosis of abdominal trauma, the Uni-Vent for mechanical ventilatory support, the compact Narkomed M anesthesia machine, the i-Stat handheld laboratory analyzer, and the Rapid Response Orthopaedic Care Kit that contains the essentials for emergency treatment of orthopaedic injuries, which alone account for 70% of all war wounds.1 It also has a uniquely identifiable Advanced Trauma Life Support breakout module that can be hand-carried to the site of injured personnel. The price tag for the 550 items that comprise this system is $289,000—a real bargain considering the capability it provides.
Tested in the Global War on Terrorism
The MSSS has now successfully deployed four times with Joint Task Forces (JTF) 572 and 515 to support classified counter-terrorism missions, and with JTF 58 to provide a surgical support platform for President Bush's visit to Asia. Each mission has provided further validation of forward deployed shipboard surgical support on platforms that have ranged from a destroyer to a utility landing craft. Perhaps more importantly, each of the completed missions has provided valuable lessons in equipment and employment that have been incorporated into the latest mobile suite iteration.
Potential Employment
The advent of this capability brings surgical support to the far edges of the fleet, shifting shipboard surgical capabilities from platform-centric to task-centric to support virtually any mission. The mobile suite concept is well suited to a number of missions such as special operations, combat search-and-rescue, maritime interception operations, and visit, board, search, and seizure on a wide array of ship types. Scenarios for employment of the surgical suite are many and might range from augmentation of an aircraft carrier's surgical capabilities during a humanitarian mission to establishing a stand-alone suite on a small amphibious ship in support of a forward-deployed SEAL unit at the beachhead. The small, light load-out of the suite (1,650 pounds.; 151 cubic feet) allows it to be transported on one U.S. Air Force pallet or broken down into four warehouse pallets that can be deployed to any area by ground, sea, or air. Given that many current missions are driven by perishable intelligence, there will be an expanding role for the rapidly deployable MSSS aboard nontraditional Primary Casualty Treatment and Receiving Ships.
The Way Ahead
At the grass roots level, there are ongoing discussions concerning how the Navy should deploy its surgical assets in a global war that is ever-changing, where fast-moving developments require surgical support on station within hours-not days or weeks. After the Persian Gulf War, recommendations were made to make Navy surgical assets lighter and more quickly deployable,2 and there has been a gradual evolution in that direction through downsizing of large fleet hospitals and development of smaller expeditionary medical units. However, for many contingency or designer deployments, a definite wave of the future, these systems fall short of the mark. September 2001 was a watershed for the way our military will do business in the fore seeable future, but the real turning point for Navy surgical support occurred in November 2002. This sea change will apply in a broader context to Navy medicine in all theaters.
The mobile shipboard surgical suite has revolutionized surgical support in the Western Pacific from ship-centric to mission-centric. The suite is inexpensive, compact, simple to operate, deployable within several hours, and has earned its stripes during Operation Enduring Freedom counter-insurgency operations. There are still obstacles to overcome, including the fact that the MSSS is not subsidized and located only at Okinawa. It should be centrally funded and pre-positioned at strategic locations worldwide to provide leading edge support for those fighting the war on terrorism.
1 CAPT D. C. Covey, MC, U.S. Navy, "Blast and Fragment Injuries of the Musculoskeletal System," The Journal of Bone and Joint Surgerv. 84-A (2002), pp. 1221-1234.
2 LCDR D. C. Covey, MC, USNR, "Fleet Hospitals Could be Better," U.S. Naval Institute Proceedings, June 1992, pp. 60-63.
Captain Covey is the Navy's Orthopaedic Surgery Specialty Leader/Consultant to the Surgeon General at the Naval Medical Center in San Diego, California. He has made numerous field and shipboard deployments in support of varied wartime and other operational contingencies, including Operation Iraqi Freedom. Commander Hancock is currently with the Emergency Medicine Department, Naval Medical Center, Portsmouth, Virginia. Commander Plurad is with the Los Angeles County/University of Southern California Division of Trauma/Surgical Critical.