Monthly Archives: October 2017

Navy Medicine in Araby (Episode 7)

I’m posting this episode a day or two early because I’ll be away from my PC for the next several days to attend the annual Congress of the Naval Order of the United States, this year in Jacksonville, FL.

The Naval Order is the oldest Naval historical organization in the country, founded in 1890. It Mission is to preserve, promote and support research in the history of our maritime uniformed services (Navy, Marine Corps, Coast Guard, Public Health Service and NOAA). One of my favorite features of our Congresses is that the local organizers try to highlight the military history of their locale. So in Jacksonville this week, we’ll have talks on “Rising Seas in Naval Cities”; “Doolittle’s Raiders”; “History of Florida in World War II”; “Maritime History of Jacksonville”; “Sinking of the Gulf America”; “”A History and Future of ASW in the Atlantic”; and “St John’s Bar Pilots”. You can see that there’s a broad sweep here, and likely something of interest to almost everyone in attendance.

Now, “Navy Medicine in Araby”, Episode 7 of 8.

In 2006, when the war in Afghanistan was being run by NATO, the Canadian Forces Health Services stood up a combat casualty facility at the Kandahar air base in southern Afghanistan. Initially an Echelon 2 facility – limited to one operating room and very basic radiology and laboratory – the facility was expanded physically and by capability so that by the time it was turned over to U.S. Navy command in 2009, it boasted of 2 CT scanners, a robust blood bank and concomitant surgical capabilities. By the time the Canadians turned over command, the hospital and staff had performed more than 6700 procedures for more than 4100 patients. The mission of the hospital, from its beginning was three-fold; to treat coalition soldiers, to treat civilians injured as a result of the conflict, and to treat any civilians who presented with any life- limb- or eye-threatening medical problems.[1] The U.S. Navy retains overall command of the facility, though the staff is multinational.

The value of putting surgical assets very close to the area of combat became fully established during World War II, but as often happens, this idea was lost in time, especially as helicopter and other evacuation techniques came on line. Adding wartime experience and modern medical understanding has led to the system of echelons of care described earlier. Based on the notion of the “Golden Hour” – the critical time required for the best chances for successful combat casualty management – Forward Surgical Teams now accompany troops to positions very close to active combat – being placed in tents or other “shelters of opportunity”[2]so casualties can receive skilled stabilization and life-saving “damage-control” surgery at least theoretically within minutes of injury. Casualties are then evacuated in a stepwise fashion to more sophisticated levels of care, ultimately, when necessary, arriving in high-level specialty, research and teaching hospitals in the U.S.[3] Brooke Army Burn Center in San Antonio is a key example of this: all warriors – Army, Navy or Marine – who suffer significant burns receive the most advanced available care in this high level specialty, research and teaching hospital.

[1] Can J Surg. 2011 Dec; 54(6 Suppl): S124–S129

[2] Frosolone, op. cit.

[3] Frosolone, op. cit.

Navy Medicine in Araby (Episode 6)

Gina and I have been away, culminating a 6 month-long celebration of our 50th wedding Anniversary, this time with a couple of couple-friends. We cruised the Seine to Normandy, where we walked the long flat beaches and appreciated what our men faced as they came ashore. The American Cemetery is a quietly majestic reminder of the sacrifices made there. We also visited Giverny, the living memorial to Claude Monet, and then later, the l’Orangerie museum that houses 8 very large Monet renderings of his famous water lillies. They brought tears to my eyes.

Now, back to part 6 of my 8 part series on Navy medicine in the middle east.

As a result of past experience and from learning in our middle east combat zones, the system of levels of care has evolved as follows: Level 1 is the simplest and most basic care; our soldiers and Marines each carry a tourniquet with them, and are taught how to apply it to stop bleeding from injured extremities. Level 2 facilities, located as close to the combat zone as is safe, offer basic capabilities to provide what is referred to as “damage-control” surgery. Level 3 facilities are fully capable hospitals with most major specialties, ICUs, and specialized nursing care. Level 4 facilities are specialized hospitals, research facilities and teaching hospitals with the highest levels of sophistication of care and facilities available.[1]


Medical facilities aboard U.S. ships range from simple sick bays in Destroyers and  Frigates that have nothing more than an examining table, rudimentary instrument sets and an autoclave for sterilizing dressings and instruments. With perhaps two navy corpsmen aboard, medical capabilities in these smaller ships is limited to simple surgical procedures, routine care of simple medical problems like upper respiratory infections, and first aid – echelon 1 level care – for more serious industrial-type and combat injuries. Patients in these ships would need to be evacuated by helicopter or boat to larger, more capable ships or facilities ashore. Our aircraft carriers and amphibious landing ships can offer, when fully staffed, Echelon 2+ to Echelon 3 levels of care. They have complete surgical teams aboard, in the instance of U.S.S. Nimitz, 2 General Medical Officers, a General Surgeon, 2 Registered Nurses (one trained in intensive care, one an anesthetist), a psychologist, physical therapist, 20 corpsmen and a dental department. [2] Patients treated there would need transport to higher levels of care only if their recovery time exceeds the time permitted by local so-called evacuation policy, or if they have suffered massive injuries that will require prompt advanced surgical and medical management.

The U.S. has two hospital ships in active service. USNS Comfort, homeported in Baltimore at the outset of the wars in the Middle East, but now in Norfolk; and the USNS Mercy, homeported then in Oakland, and now in San Diego. Each has a bed capacity of 1000, both have 12 operating rooms and a radiology suite including CT scanners. They are kept in custodial status with skeleton crews, but can be activated on a five-day schedule, their medical staffs brought together from military hospitals throughout the U.S. Both ships deployed to the Persian Gulf during Operation Desert Storm / Shield. Between them, they admitted nearly 1400 patients and performed over 600 surgeries during their 6 month deployments. Comfort again deployed in 2003 to support Operation Iraqi Freedom. In her 56 days in the Persian Gulf, she cared for 700 patients, performing 590 surgeries and administering 600 units of blood. Her medical staff also cared for nearly 200 Iraqi civilians and POWs. These floating hospitals are capable of Echelon 3 level care.


Navy Fleet Hospitals began during WW II as tent hospitals set up on remote Pacific Islands to provide definitive care for injured and sick warriors in theater. The fleet hospital concept grew as medical care became more sophisticated, and Fleet Hospitals became large, heavy hospitals-in-shipping-containers that could be prepositioned, then moved to places of need. In August 1991, FHs 3, 5 and 15, each with 500 beds, were mobilized to support Operations Desert Shield / Storm. By the time they were demobilized eight or nine months later, the medical people assigned to them had cared for more than 32,000 patients, most importantly providing top level combat casualty care.[3]

By 2003, the Fleet Hospital concept had evolved to smaller, more easily transportable modular hospitals that could be configured for specific missions. Between April and July 2003, Four Fleet Hospitals were stood up to support Operation Iraqi Freedom. Fleet Hospital 3, designated an Expeditionary Medical Facility of 116 beds, was the first such Echelon 3 hospital to be set up in a theater of combat, in southern Iraq. Within two weeks of its opening, its 300 personnel had already cared for 500 patients and performed more than 280 surgical operations.[4] A second Expeditionary Medical Facility, FH 8, was located in Rota Spain to provide Echelon 3 care as well. Later expanded to a 250 bed Fleet Hospital, its medical personnel cared for 1400 patients and performed around 250 surgical operations in support of Operations Enduring Freedom and Iraqi Freedom.[5]

[1] Pruitt, Basil A, Combat Casualty Care and Surgical Progress, Ann. Surg., 2006, Jun; 243 (6): 715-729.

[2] Frosolone, Charles A, General Surgery in the United States Navy, slide show presentation,, no date, accessed 27 September 2016.

[3]Navy Expeditionary Medical Support Command, Williamsburg, VA, Command History, Fleet Hospitals – the Beginning,, accessed 30 September 2016.

[4] Website “America’s Navy”, Fleet Hospital 3 – Best Care in Iraq,, accessed 30 September 2016

[5] Website “America’s Navy”, Ten Year After – Fleet Hospital 8 Returned Home to Naval Hospital Bremerton,, accessed 30 September 2016.