Contentious debate on the function of the Navy’s Role-3 hospital ship highlights the uncertainty of its future.1 The Navy has two hospital ships with 1,000 hospital beds, 100 intensive-care beds, and a broad range of medical capability, designed to provide medical support for U.S. forces in conflict. The ships are massive—894-foot-long, slow, deep-draft vessels with transient medical crews, limited embarkation for shipboard medical training, and limited personnel platform familiarity. The hospital ship’s primary mission is supporting military contingency operations; however, in the past two decades, the Navy has increasingly used hospital ships for humanitarian efforts and global health engagements.
This mission detracts from the anticipated maritime medical needs in a western Pacific conflict over vast distances while the Navy conducts distributed maritime operations (DMO). With the Mercy-class hospital ships now beyond their initial service lives and operating on a service-life extension through the mid-2030s, the Navy is implementing new Role-2 light maneuver capabilities and emplacing new medical resources on board expeditionary fast transport (T-EPF) vessels. However, continual training and preparation to fulfill the primary mission of Mercy-class hospital ships remains an ongoing imperative. The USNS Mercy (T-AH-19) recently participated in Pacific Partnership, the largest annual multinational humanitarian assistance and disaster relief (HADR) preparedness mission in the Indo-Pacific. During Pacific Partnership 2022, the Mercy was staffed with medical personnel to support an immediately deployable 250-bed augmentation in Readiness State III (capable of responding with humanitarian support to civil authorities). While HADR missions support theater security cooperation, they cannot provide the full range of mass casualty care training necessary for warfighting in a DMO setting. To support high-end warfighting at sea, several aspects of the hospital ship must be improved.
Up-Echelon Healthcare Delivery and DMO
The current Navy medical up-echelon healthcare delivery system is separated into three tiers afloat, with the goal of optimizing patient care and rapidly returning injured service members to the fight. Role-1 facilities provide basic first aid, triage, and immediate life-saving care (medical care as found on board small combatants). Role-2 facilities provide damage-control surgical intervention (found on board large combatants such as amphibious assault ships) to stabilize patients in anticipation of up-echelon evacuation. Role-3 facilities (including hospital ships) have both surgical and specialty care and can hold patients for an extended time until they can return to duty. Role-4 facilities are shore-based clinics and hospitals and provide definitive care outside the theater of operations.
For a hospital ship to be effective in DMO, many supporting services will be necessary to safely transport patients from the point of injury to the ship and then to the next level of care or specialty service. Patient evacuation was a major challenge in World War II, and the ability of hospital ships to operate close to beachheads was crucial.2 The current port infrastructure of most Pacific Island nations, for example, will not support the draft of the Mercy-class hospital ships. In addition, experts predict that hospital ships, which are a large target for adversaries, would need to be geographically distanced from Role-1– and -2–capable ships in the Pacific.3 While some smaller vessels can support damage-control resuscitation, they are not equipped for prolonged casualty care.4 Ideally, the Role-3 medical facility afloat will maintain a strategic position in the theater and minimize patient theater evacuation. Those with minor injuries and illnesses who can fully recover on board the hospital ship will be rapidly returned to the fight, saving money, time, and resources while supporting force generation. Hospital ships should, therefore, augment a medically ready fleet maintaining a forward presence.
Preparation for Mass Casualties at Sea
The DMO concept requires extensive repair, resupply, and sustainment during conflict. Hospital ships must therefore be prepared for any event that overwhelms available medical resources at the scene of battle. A hospital ship crew should prepare for mass casualties the same way a warship crew prepares to fight the ship at general quarters. A hospital ship must train to provide shipboard care for wounded trauma patients—even during peacetime and alongside global health engagements—since shipboard emergencies, environmental disasters, or foreign aggression cannot be predicted. A hospital ship always prepared to handle mass casualties adheres to former Chief of Naval Operations Admiral Michael Gilday’s guidance to field the most lethal force by sustaining a ready and relevant fleet.5
However, Navy Medicine’s current training methodology inadequately prepares medical-treatment personnel for mass casualties, a complex operation requiring significant resources, time, and manpower.6 Aspects such as communications, documentation, and patient flow must be included in drills. And for drills to be effective, a dedicated training team should oversee mass casualty training, similar to how warship crews use integrated team trainers ashore before embarking training teams. This will require resources, including simulation equipment and consumables for high-fidelity training. A walking blood bank activation is particularly important, as historical reporting depicts lengthy preparation and rapid depletion of traditional blood bank resources.7
A shore-based medical treatment facility, which regularly manages patients, is accustomed to the flow of patients through the operating room to the intensive-care unit, medical-surgical wards, and on to discharge. Sea-based mass-casualty training, however, typically includes the first stage of care from casualty receiving through the operating room and recovery, but often neglects training on the care needed after arrival to the intensive-care unit or medical-surgical ward.
This follow-on care delivery in the intensive-care unit or medical-surgical ward is not well practiced during peacetime, as a hospital ship often lacks direct patient care. Gurneys that have been secured for sea need to be mobilized. Moving patients via ramps and litters is different from moving patients via elevators. At times, certain shipboard elevators may not function, and afloat personnel need to practice alternate routes for patient movement. Patient movement also needs to occur while underway vice pierside, recognizing potential mobilization difficulties during heavy sea states. Often, patient movement is not isolated to the patient themselves, but also includes vital signs machines, IV pumps, wound vacuums, chest tube atria, and other devices attached to the patient. Familiarity with this follow-on care delivery is imperative as a hospital ship is expected to receive up to 300 patients on the first day of conflict and 100–200 a day thereafter.
In addition, corpsmen should learn to “fight the ship” while receiving casualties. When the ship is attacked, medical and nonmedical personnel must be prepared to modify aspects of patient receiving, triage, and movement. They should train for multiple roles in the event personnel are injured during a shipboard emergency.
Finally, consistent resupply is unlikely in a DMO environment. Current U.S. medical practices consume a considerable amount of resources for a single patient. This may portend better shore-based outcomes, but in the face of a large number of critically wounded patients and limited supplies, rapid supply depletion would likely worsen expeditionary outcomes. Resource conservation unique to combat operations must also be part of the training. Given all these issues, afloat mass-casualty training must therefore be a prolonged evolution with patients simulated through all stages of care to identify areas for improvement.
Watch Quarter Station Bill
Hospital ships should apply the watch quarter station bill (WQSB) concept to training and preparing for mass-casualty events. Critical roles should be assigned to clinicians with the appropriate expertise to optimize patient care outcomes. For example, a trauma surgeon or emergency medicine physician should fill the role of mass-casualty director. A WQSB would facilitate training for all the ship’s crew to ensure readiness to perform the duties and responsibilities of their primary assignments, as well as any secondary and tertiary assignments.
Another advantage of using a WQSB is the ability to flex additional staff to critical and over-stressed areas. During a mass-casualty drill on a recent mission, the casualty receiving department quickly became overwhelmed. With the WQSB, nurses and appropriately trained corpsmen can be redirected to casualty receiving to assist with initial patient influx and stabilization. And as patients move out of casualty receiving, the team may be flexed to other patient care areas as needed.
As the Navy continues to train for DMO, Navy Medicine must enhance its forward-deployed medical capabilities while still attending to the preparedness of its current infrastructure. Hospital ships play a critical role in theater operations, but recent experiences exposed several weaknesses. Navy Medicine should adopt some key fleet training concepts, such as integrated team training, to enhance the readiness of Role-3 care afloat. Support to the warfighter must always be Navy Medicine’s top priority.
The authors thank Captains Jeffrey Feinberg and Mark Lenart for their assistance on this article.
1. RADM Michael S. Baker, MC, USN (Ret.), Jacob B. Baker, and CAPT Frederick M. Burkle, MC, USN (Ret.), “The Hospital Ship as a Strategic Asset in 21st Century Foreign Policy and Global Health Crises,” Military Medicine 187, no. 910 (September–October 2022): e1176–e1181; RADM Bruce Gillingham, USN, et al., “A Commentary,” Military Medicine 187, no. 910 (September–October 2022): 281–283.
2. CAPT Matthew D. Tadlock, USN, et al., “Between the Devil and the Deep Blue Sea: A Review of 25 Modern Naval Mass Casualty Incidents with Implications for Future Distributed Maritime Operations,” The Journal of Trauma and Acute Care Surgery 91 (August 2021): s46–s55.
3. William G. Day et al., “Prolonged Stabilization during a Mass Casualty Incident at Sea in the Era of Distributed Maritime Operations,” Military Medicine 185, no. 11–12 (December 2020): 2192–97.
4. Benjamin T. Miller et al., “Red Tides: Mass Casualty and Whole Blood at Sea,” The Journal of Trauma and Acute Care Surgery 85 (July 2018): s134–s139.
5. ADM Michael Gilday, USN, Advantage at Sea: Prevailing with Integrated All-Domain Naval Power (Washington, DC: December 2020).
6. Miller et al., “Red Tides: Mass Casualty and Whole Blood at Sea.”
7. Patricia H. Netzer and Tara Zieber, “Historic Review of Naval Theater Hospitals: World War I to the Vietnam War,” Center for Naval Analyses (March 2022).
