The casualty care system on USNS Comfort (T-AH-20) works. That was the consensus of those returning from the hospital ship's 2003 deployment to Operation Iraqi Freedom, where the ship successfully treated more than 360 battle casualties in 37 days-a rate comparable to that of the hospital ship USS Sanctuary (AH-17) during the Vietnam war.
But these facts are more than just a reflection on Comfort and her crew. The lessons of this experience should be applied to our other afloat surgical platforms: the LHDs and LHAs, which are configured differently, and in some ways not as effectively, for handling the wounded of war.
Effective casualty care involves four distinct phases, each of which requires dedicated beds and equipment:
* Triage—Separate the walking wounded from those needing urgent resuscitation.
* Resuscitation—Airway breathing and blood pressure must be stabilized, external bleeding controlled, wounds examined, and an order established for surgery.
* Surgery—The wounds are definitively repaired in the operating room.
* Intensive Care—The postoperative patient is carefully monitored during the immediate recovery phase.
In an ideal situation, epitomized by Comfort, patients move swiftly and smoothly through these phases. The number of patients through the operating room in 24 hours (which on Comfort was sometimes 50 per day) determines a ship's effectiveness as a surgical platform.
Here is how Comfort's, internal configuration achieved this result. Wounded were brought from the flight deck in a dedicated elevator to a triage area containing 6 to 10 stretchers. After brief evaluation by a triage officer, they were transferred to either urgent or nonurgent bays in the resuscitation area. This was on a grand scale, comprising upward of 50 beds in bays of 4 to 6 beds apiece. Each bay was manned by several physicians and nurses, and at least six corpsmen. The beds had standard equipment such as oxygen, wound care trays, and IVs. As noted previously, intensive resuscitation, X-rays, and examination of wounds occurred in this area. Surgeons circulated among the beds, then huddled and determined an order for surgery. The patients were transferred in this order to the operating room (OR) area, which contained 11 individual ORs.
Finally, after surgery, they were moved to the intensive care units, which contained more than 60 fully-equipped beds and mustered several hundred nurses and corpsmen. Patient flow was always fore-to-aft, which increased order and efficiency. This was a highly capable system with an estimated capacity of 100 to 200 surgical cases per day. It worked so well that on one occasion, when 54 casualties were received at once, the resuscitation area was empty three hours later.
Clearly, no greyhull can approach this capability—nor should it. But our current primary casualty receiving ships are not Comforts on a smaller scale. Their medical spaces have significant configuration problems that limit their utility in casualty care.
The medical spaces on USS Iwo Jima (LHD-7), our newest primary casualty receiving ship, begin with a triage area linked to the flight deck by a medical elevator, as on Comfort. But here, the similarities end. The triage area, which measures 18 x 28 feet, is too small for effective use (this area is somewhat larger on LHAs). More seriously, there is no resuscitation zone. The six operating rooms are separated by bulkheads, and they are not equipped to serve as resuscitation beds. Moreover, the six ORs are redundant: because of a chronic Navywide shortage of anesthesia providers, there is no likely scenario in which more than three operating rooms will be in use at once-nor has that ever happened on any LHD or LHA.
In practice, the excess ORs are used as storage rooms, audiogram rooms, or sick call spaces for embarked Marines. In our current configuration, triage is carried out on the flight deck level, while resuscitation is clumsily performed on litters staged in the designated triage area.
The result is a very limited facility, with serious bottlenecks to patient flow. During our internal drills on Iwo Jima, we found that we could treat a maximum of ten patients before backup occurred due to lack of resuscitation beds. This is even more disconcerting because, with the standard augmentation of one surgeon, advanced care may need to be given during resuscitation, while patients wait for the attention of the single surgical team on board. The LHD's intensive care ward and blood-bank units, on the other hand, are good facilities that can do the job.
On Iwo Jima, we modified our unit to address these issues. The chief action was to convert three of the ORs into resuscitation rooms. If a hospital gurney is added, each room can accommodate two patients. A bulkhead-mounted plate holds essential resuscitation supplies, with equipment for airway management, breathing support, and support of circulation arranged in three color-coded zones. Color-coded carts provide overflow supplies for each zone.
This reflects the arrangements on Comfort and on the Royal Navy's RFA Argus, another successful model for casualty care. The rooms so configured serve as resuscitation beds, yet they can be swiftly converted back to OR beds if required. Triage is still done on the flight deck level, but the bottleneck in resuscitation beds has been eliminated. Subsequent drills increased our casualty-receiving capacity, from 10 to 20 to 30 in the first few hours.
How might an LHD approach a Comfort level of efficiency, albeit on a smaller scale? One answer lies in a rearrangement of current medical spaces on Iwo Jima. An expanded triage area (formed by sacrificing two office spaces), opens on to a pair of four-bed resuscitation bays that replace three ORs. A waist-high portal is cut in the structural bulkhead separating the two to facilitate communication between these areas. The three remaining ORs are turned 90°, increasing their size; this allows a second surgery to be conducted in each room, using a movable OR table, in the event of mass casualties. These plans respect key structural features such as bent frames (a key factor in modification of current LHD design), and leave the overall size of the medical spaces unchanged.
A novel yet important addition is the inclusion of a computerized tomography (CT) scanning unit, using a 44.5 x 15 foot area now occupied by X-ray and the lab (these are shifted into current blood bank and storage spaces). CT scanning is a long overdue upgrade. The importance of the scanner on Comfort was demonstrated during Operation Iraqi Freedom. Outside of simple extremity injuries, it provided important information on nearly all patients; it was essential in head, neck, and abdominal cases. The device on Comfort proved durable and reliable in the operational setting. The Royal Navy, which installed CT on its greyhull aviation training ship/casualty care ship HMS Argus, has had a similar experience.
The area indicated is sufficient for a CT (it requires 50 x 13 feet on Comfort, 27 x 13 feet on Argus). Certain support items (450 volts of electricity with a 125-amp circuit breaker; deck support for the 1.5-ton device; and extra refrigeration lines) must be considered. The procurement costs (counting spare parts and maintenance) are close to $900,000 and the billeted X-ray technician will need to be trained in CT, but these are not insuperable obstacles. The savings in MedEvac costs alone will likely justify this investment. Even at sea, CT scanners are now essential to the minimum standard of surgical care, and they should be installed in our primary casualty receiving ship without delay.
The principles of rapid evacuation and speedy surgical care have hardly changed over the years, yet the design of medical facilities may have a profound effect on the outcome of these endeavors. The success of the Comfort model shows many ways in which our existing afloat medical facilities can be improved. As always, heeding the lessons of war will have the greatest effect on the fortunes of our sailors and Marines.
Captain Foote served at sea from 2003 to 2005 in USS Iwo Jima. His previous sea duty includes service in USS Gunston Hall (LSD-44) and USNS Comfort. He is currently staff neurologist at Naval Medical Center, Portsmouth, Virginia.