PEs (Physiological Events) in Navy Jets

On 5 April 2017 Navy authorities grounded its fleet of T-45 training jets, after instructor pilots vigorously expressed concerns about an apparent rise in the number of PEs (“Physiological Episodes”) experienced in that fleet of aircraft.

It turns out that the Navy has experienced a “sharp increase in hypoxia-like physiological events in the last decade” in its entire combat fleet of airplanes and T-45s, according to an article in Aviation Week’s Aerospace Weekly online. These episodes appear to take two forms: those mimicking true hypoxia – “oxygen starvation” or decreased oxygen in the blood – euphoria and loss of judgement, headache, nausea, light-headedness or dizziness, paresthesias (pins-and-needles sensations), breathlessness; and decompression sickness – from exposure to low barometric pressure, in aviation typically the result of loss of cabin pressure, which results in formation of tiny nitrogen bubbles in tissues (think what happens when you pop the top off a bottle of ginger ale) – joint pain in shoulders, elbows, knees or ankles (“the bends”), headache, confusion, dizziness, nausea, breathlessness and chest pain, paresthesias. Except for the bends, the similarity of symptoms of hypoxia and decompression sickness is striking.

Most recent data for the Navy’s operational aircraft fleet report 101.42 PEs per 100,000 flight hours in F/A-18AD aircraft, 66.52 (down from 90.83 a year earlier) in EA-19Gs and 30.37 in F/A-18EF series planes. Pilots of F-35s (from all services), the new “joint fighter”, have reported 27 PEs since the aircraft began entering service in 2011. I couldn’t find statistics for the T-45s. Since 2010, four aviator deaths have been attributed to PEs.

The Navy (and the Air Force and NASA, and Boeing, manufacturer of the F/A-18 series) are vigorously studying the matter using what’s described in a 5 April Navy release as an “unconstrained resources” approach. Investigators include aviation medicine types, flight physiologists and, of course, a plethora of engineers. It appears that, in the F/A-18 series, 75% of PEs are decompression sickness episodes are caused by the aircrafts’ Environmental Control System (“ECS”) while the remainder are hypoxia episodes attributed to the On Board Oxygen Generating System (“OBOGS”).

Finding the causes and solving the problems have not been easy, in part because of the very complicated interrelatedness of onboard aircraft systems – themselves being intricate – and the human pilot’s physiology and psychology. Slowly, however, the problems are being teased out, and they are multiple and often interrelated.

Regarding the ECS, NASA researchers think the problem – especially in the older F/A-18 AB series aircraft – is due to the fact that the system is designed to “service” the avionics, radars and other electronic systems preferentially. The amount of electronics has increased markedly over the years while key components including even the ductwork and the software haven’t really changed since the 1980s. Because the ECS is programmed to feed the electronics first, the OBOGS gets fed with air last. And that is the system that generates oxygen for the pilots.

NAVAIR is installing modifications to the equipment and software with urgency as causes are identified. So far, this has produced the previously noted short drop in PEs in the especially electronics-heavy EA-18G series. Results in the others remains to be seen. Says RADM Sarah Joyner, who heads up the PE team, “PEs are not going to go away, but we are going to try to do our best to mitigate them and make them milder in nature as best we can”.

This doesn’t sound very optimistic. Stand by for future reports.

Hat tip to my high school classmate Price Bingham, Lt Col, USAF, Retired, who has been keeping abreast of news on OBOGS and EXS.

Articles I consulted, thanks to Lt Col Bingham, include:

https://aviationweek.com/awindefense/us-navy-turning-corner-fa-18-hypoxia-crisis

http://www.navy.mil/submit/display.asp?story_id=99760

https://breakingdefense.com/2017/09/jpo-fixing-f-35-oxygen-carrier-landing-software-glitches-vadm-winter/

https://www.faa.gov/pilots/safety/pilotsafetybrochures/media/dcs.pdf

https://www.faa.gov/pilots/safety/pilotsafetybrochures/media/hypoxia.pdf

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Health / Medical Diplomacy and Navy Medicine

We are quite used to seeing big white ships festooned with large red crosses much in evidence after natural disasters. Our Navy’s hospital ships Comfort and Mercy, and the Chinese ship Peace Ark create very dramatic visual representations of their nations’ outreach to provide humanitarian assistance and to help build local medical infrastructure through advice and training.

Building international goodwill through medical assistance is a relatively new arrival in diplomacy, which started out as efforts to manage interdynastic or international communication. The earliest “diplomats” likely were relatives of monarchs sent to foreign capitals as hostages to assure honest fulfillment of treaty agreements. Because such hostages were of high social station, they likely had ready access to their “host”‘s leadership, and thus could report to the folks back home on a variety of matters of interest. From this simple expediency evolved the system of information gathering, representation and negotiation by state-designated agents (and non-state actors, too) that we call diplomacy today. There is evidence of such (City) State – to (City) State representation as early as the Sumerian civilization around 2400 BCE.

“Diplomacy” around health matters no doubt accompanied the health policies instituted by Mediterranean states in the 14th century, as commercial ships and their crews were held in quarantine, sometimes for weeks, without compensation. As international trade and travel increased, quarantine and other local policies failed to prevent the rapid spread of diseases. The mid-19th century saw the institution of a wave of international sanitary conferences that sought to create synchronized policies for the control of diseases like cholera, yellow fever and plague and to regulate trade and traffic in alcohol and drugs. These efforts were supplanted in the 20th century first by the League of Nations Health Office, and later by the World Health Organization. Other health-oriented organizations like the Pan American Health Organization also were created by governments to promote policy synchronization and technical interchange on a more regional basis.

The current status of health diplomacy is captured in this graphic from the National Defense University Press:

This document categorizes various types of “medical engagement” according to their benefit to local populations. In a tone of realpolitik, it also attempts to assess “U.S. Gains” from said engagements.

So, what are some examples of each “Mission Type”; and in particular, what roles has U.S. Navy medicine played?

As I mentioned at the top, very visible examples of Types I & 2 missions include big white ship (and other large naval unit) participation in efforts of humanitarian relief, training and technical exchanges. According to Navy publicity, the most recent international deployments of Mercy and Comfort, in Pacific Partnership and Continuing Promise operations respectively, saw visits throughout the Indo-Asia-Pacific and Central- & South-America and the Caribbean over the past several years. In 20 port visits the ships’ medical staffs cared for more than 140,000 patients and performed nearly 2000 surgical operations. Medical personnel of this joint operation also provided disaster relief trainings, and offered such technical assistance as monitoring for mosquito larvae near schools. The most recent purely international disaster response that I could find was the very visible attendance of Comfort to provide humanitarian relief after the devastating Haitian earthquake in 2010. Immediately upon arriving her medical staff of 300 began caring for the sickest and most severely injured earthquake victims.

According to a 20 November 2017 China Daily article, the People’s Liberation Army Navy’s sole purpose-built big white ship (and one only 4 or five hospital ships in the world), Peace Ark most recently participated in a multinational medical mission in Africa. The ship’s 115 medical workers, “mostly from the Naval Medical University” provided “carry out free medical services, humanitarian assistance, and conduct medical training to consolidate and promote friendly relations and deepen professional exchanges between China and (several nations on both coasts of the African continent).” Peace Ark carried out a similar mission in 2015.

Such short term endeavors seem to me to have great humanitarian merit, but as “diplomacy”, I think they miss the mark, because they by and large fail the definition of diplomacy I offered at the top: information gathering, representation and negotiation. Certainly, except for temporary “feel good” relationships, it’s hard to imagine many meaningful nation-to-nation policy changes emerging from Mission Types I & II. Think of it this way: do you remember the name of the doctor who set your child’s broken bone 20 years ago? Did you even remember that she broke her arm? Apply that thought to people who benefit from temporary humanitarian relief and one-week medical visits to rural communities.

The U.S. Navy has long been engaged in Type III missions. Navy medical historian André Sobocinski has pointed out that the Navy was fortunate to have a world class expert in tropical diseases – Edward Stitt, MD – in its ranks at the turn of the 19th to 20th centuries. His interest was piqued by the “new” medical problems he saw as a result of our Navy’s engagement during and after the Spanish American War (1898) and our resulting acquisition of tropical territories in the Pacific and Caribbean. Under the leadership of Stitt and others, Navy doctors, corpsmen and nurses soon were engaged in research, diagnosis, treatment and prevention of diseases exotic and common in those areas. Between 1911 and 1918 Navy nurses established schools in American Samoa, Guam and Haiti to teach basic health knowledge and skills to native women. Navy personnel vaccinated the people of American Samoa and Guam against the scourge of smallpox in the early years of the 20th century. In the 1940s, Navy experts stood up a series of Navy Medical Research Units in places like Addis Ababa, Ethiopia and Jakarta, Indonesia. Today, NAMRUs in Cairo, Egypt, Lima, Peru and Honolulu continue their missions of monitoring disease activity, performing ongoing research (with particular emphasis on infectious diseases), and – medical diplomacy.

in 2012, Public Health England, the UK’s public health agency responded to requests for assistance during a cholera outbreak in Sierra Leone by sending a microbiologist with special skills in identifying enteric pathogens to work with local personnel to set up a national enteric bacteria diagnostic and reference lab. While there, he trained four local staff members on cholera identification and on laboratory safety and quality assurance. This Type III Mission also has Type IV (see below) implications, as the laboratory was to become part of Sierra Leone’s national cholera control program.

As can be seen by these example, Type III medical missions add a new element to medical diplomatic missions, the element of time. U.S. NAMRUs have been deployed for decades, and in the British example, direct involvement lasted for several weeks. The time element offers opportunity for plenty of professional-to-professional interaction that provides for education, and conceivably over time, will have international policy impact. Certainly the longer term goodwill created by these interactions can have a salutary effect on nation-to-nation relations.

While the U.S. Navy created physical and human infrastructure (Type IV missions) in territories “adopted” after the Spanish American War and World War I, such efforts are quite limited today. Interestingly, Cuba has become a major force in this form of medical diplomacy – especially in developing human infrastructure throughout the developing world. Originally an initiative of Che Guevara, himself medically trained, Cuba has sent more that 130,000 medical personnel to the world’s poorest areas to treat the sick and educate local providers. Even in today’s economic hard times in Cuba, something like 37,000 Cubans provide care in rural Venezuela; in return, Venezuela sends oil to Cuba. That’s medical diplomacy with a nice quid pro quo.

China provides another example of long term medical commitment to care, training and infrastructure. She started sending medical missions overseas in the late 1960s. Since then, in Africa alone, she has established a long term medical presence in 25 nations. China has constructed more than 100 hospitals worldwide, 54 of which are in Africa. She runs or participates in several medical training programs. When I visited my son in Mozambique a couple of years ago, the lovely 1950s Portuguese-built Central Hospital Of Maputo was undergoing renovations sponsored by the Chinese (they are not just putting up new structures). And they’ve built pharmaceutical production facilities in 3 countries abroad.

With Type IV missions – infrastructure building – the longer term political and diplomatic benefits become more clearly discernible. There are two reasons for this. First, the longer term person-to-person relationships that develop can produce, as the people involved move up in their national medical establishments, meaningful impacts on nations’ health and international policies. Second, the infrastructures developed – both human and and especially physical (hospitals, clinics, labs, schools) – provide a continuing remainder of the medical missions for the citizens of recipient nations. Generation after generation of goodwill and support can result. Think of it this way: if you’ve developed a good relationship with your GP, or your therapist, now, 20 years on, office visits are more likely to be taken up with conversations about the now adult kids in your families, or about politics… Thus it might be with populations, and especially thought leaders who’ve developed long term relationships with medical workers from abroad.

The National Defense University source for this post’s graphic gives no specific examples of Type V medical diplomacy missions. Perhaps examples of this level of medical diplomacy would include G7 and G20 health ministers meetings and other minister-level interactions and engagements. Besides producing high-sounding declarations of principle, they must provide “top down” direction for ongoing international health policy cooperation and execution.

One final note. I did a word search (“medical” and “health”) in the new National Security Strategy document released by President Trump in December 2017. I found no instance where either term was conjoined with “diplomacy”, and but one instance where “health” was used in an international context: “REDUCE HUMAN SUFFERING: The United States will continue to lead the world in humanitarian assistance. Even as we expect others to share responsibility, the United States will continue to catalyze international responses to man-made and natural disasters and provide our expertise and capabilities to those in need. We will support food security and health [italics mine] programs that save lives and address the root cause of hunger and disease. We will support displaced people close to their homes to help meet their needs until they can safely and voluntarily return.” But American medical diplomacy is not quiescent. HHS announced in December (the document was signed by Ambassador Deborah L Birx, MD) [bolding mine] that PEPFAR (George W Bush’s “President’s Emergency Plan for AIDS Relief” has seen remarkable success in controlling that scourge in Africa. (During my Mozambique visit, mentioned above, I met a Maputo-based Brazilian infectious disease specialist at an American 4th of July party. He told me that when he first came to the country, he saw people dying in the streets of AIDS / complications. “Today,” he said, “I see none of that. PEPFAR is a miracle for these people. President Bush is a revered hero because of it.”) The HHS announcement stated that President Trump had committed his support of the program, “noting both its importance and it as an example of doing more each year by finding more efficiencies and ensuring we continue to drive forward with impact and clear value for each dollar invested.”


Here are the sources I used for this post (in no particular order). I accessed all of them during the period of preparation for this post: 11 – 16 January 2018. I did not write at the weekend.

https://www.scribd.com/document/125263073/Black-j-2010-a-History-of-Diplomacy

http://ndupress.ndu.edu/Media/News/Article/577539/medical-diplomacy-in-achieving-us-global-strategic-objectives/

https://thediplomat.com/2016/04/chinas-medical-diplomacy/

https://csis-prod.s3.amazonaws.com/s3fs-public/legacy_files/files/publication/111122_Freeman_ChinaEmergingGlobalHealth_Web.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5331141/#!po=4.16667 I didn’t actually use any material from this article, but it’s quirky comparison of doctors and diplomats is enlightening and informative.

http://summit.sfu.ca/system/files/iritems1/10865/ghg-ghd-lee-smith-12-07-11.pdf

http://navymedicine.navylive.dodlive.mil/archives/3881

http://www.who.int/bulletin/archives/79(9)842.pdf

https://pdfs.semanticscholar.org/96a9/2f8d24383480e0a1f90842a4734972c0a535.pdf

https://health.mil/News/Articles/2018/01/11/Joint-efforts-in-search-of-a-cure-for-tropical-diseases

http://www.paho.org/hq/index.php?option=com_content&view=article&id=91

https://www.navy.com/about/equipment/vessels/hospital-ships.html

http://navylive.dodlive.mil/2015/10/01/by-the-numbers-pacific-partnership-and-continuing-promise/

http://www.chinadaily.com.cn/world/2017-11/20/content_34757172.htm

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/354156/Global_Health_Strategy_final_version_for_publication_12_09_14.pdf

http://www.coha.org/cuban-medical-diplomacy-a-developmental-paradox/

https://www.ft.com/content/debaad0c-5d6e-11df-8373-00144feab49a

https://www.scribd.com/document/8057665/Medical-Diplomacy-a-Brief-Outline “Medical Diplomacy – A Brief Outline” from Aesisgroup.com was a late find. It offers a different “system” for considering this topic, and carefully differentiates between “medical diplomacy” (by which medical resources are used to encourage positive relations between nations and / or to exchange specific benefits between nations) and “health diplomacy” (diplomatic efforts to enact international health measures). Aesis is a “network for advancing and evaluating the societal impact of science” – http://aesisnet.com/

http://www.g7italy.it/sites/default/files/documents/FINAL_G7_Health_Communiqu%C3%A8_Milan_2017_0.pdf Eric Hargan took office as Acting Secretary of Health and Human Services on 10 October 2017. I could not identify his face in the photo of ministers attending this November 2017 meeting. The HHS website is similarly unrevealing.

https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/G/G20-Gesundheitsministertreffen/G20_Health_Ministers_Declaration_engl.pdf I think I can identify then-HHS Secretary Tom Price at this May 2017 meeting.

https://www.whitehouse.gov/wp-content/uploads/2017/12/NSS-Final-12-18-2017-0905-2.pdf

https://www.whitehouse.gov/articles/american-leadership-brink-controlling-aids/

(c)2018 Thomas L Snyder

Happy New Year!

To my readers, I know there’s been a drought of my scribblings over the past some time. But now I’ve passed most of my Naval Order responsibilities off to an energetic and capable successor, and already this ancient brain is beginning to swirl with ideas for new posts. Let’s hope some mental alchemy yields nuggets of gold from the lead that’s been mouldering in the depths and is just now getting some agitation!

My older son James gave me as a holiday gift Admiral Jim Stavridis’s 2017 book, Sea Power (New York, Penguin Press). In what I see as the Admiral’s combination memoir and strategic reflection, I encountered (for the first time in my consciousness) the term “medical diplomacy”.

Bingo! The subject of my next post – in a few days.

For now, my standard New Years mantra: may 2018 meet or exceed your expectations!

Thanksgiving 2012

I wrote this greeting 5 years ago. I still like it. Best wishes to my historical friends.

Of Ships & Surgeons

The cornucopia – horn of plenty – symbolizing the abundance of a good harvest, comes down to us from the ancient Romans. Americans have traditionally associated the symbol with Thanksgiving.

We have the great good fortune to live in a nation that is wealthy enough to be able to support a robust historical establishment. University programs and fellowships produce their own cornucopiae of newly minted historians each year. Many if not most cities and communities sponsor or at least encourage local historians to accession and preserve their communities’ stories. Some corporations have historians on staff (I retired from Kaiser-Permanente, a company that does this). Even our popular culture embraces – and purchases – the works of excellent historians who have plumbed the far reaches, and the nooks and crannies of our national history. The instant popularity of Jon Meacham’s biography of Thomas Jefferson is but the most recent example of this.

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Navy Medicine in Araby (Episode 8, the Final)

In seven previous episodes, I’ve told the story of combat casualty and general medical care given our sailors in conflicts in “Araby”, starting with 19th century battles against the Barbary States and finishing with our current military activities in Iraq and Afghanistan. Herewith is the final episode, in which I describe the truly innovative aerial ICUs of the U.S. Air Force.

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The final 21st century iteration of an earlier concept is the Air Force’s Critical Care Air Transport Team. The first reported aeromedical evacuation was during the Franco-Prussian War of 1870-71, when 160 French casualties were evacuated by observation balloons from Paris, then under siege. Fixed wing aircraft soon followed, and by the end of WW I, the British were using aircraft specifically modified for medical applications. The United States Army Air Corps created Medical Air Ambulance Squadrons starting in 1942, and by the end of WW II more than a million patients from both theaters of war had been evacuated by these means. The concept of critical care evacuation – that is, transporting medically unstable patients requiring such support as respirators and intensive physiological support (IVs, transfusions and blood pressure sustaining drugs and the like) – evolved quickly after Operation Desert Storm, when it was discovered that such a capability simply did not exist. This lack of capability at the time forced the Army and Navy to utilize huge and semi-permanent Field Hospitals in or near the theater of operations. Prior to 1994, aeromedical transport teams typically consisted of two or more nurses, sometimes with critical care training, and several medical technicians. In 1994, the Air Force launched a formal Critical Care Air Transport Team program. These teams include critical care physicians, critical care nurses, respiratory therapists and the required medical supplies to support what are essentially flying ICUs. This concept has permitted medical planners to reduce the size of in-theater medical facilities while enhancing their flexibility and mobility to keep them as close as possible to zones of combat. [1],[2] Once wounded warriors receive emergency stabilizing surgeries, they can be rapidly evacuated to more definitive care settings in Kandahar & Bagram in Afghanistan, or to Landstuhl Germany or even to the specialty care facilities like the Brooke in San Antonio.

flying ICU.jpg

Intensive Care Unit in an Airplane (Credit: http://www.dodlive.mil)

In conclusion, there really is no comparison between the medical care offered our sailors in the Barbary Wars and that provided today. Hippocrates, the Greek father of western medicine wrote in ‘On the Surgery”, “He who desires to practice surgery must go to war”, and it is cliché’ nowadays to say that the surgical art and science advance with every war. The evolution of that art is clearly seen in this story of Navy medicine across three centuries. From bleeding and purging to antibiotics and transfusions, from amputations in the cockpit to damage control surgery in the field and intensive care in airplanes, the sophistication of knowledge and the resources brought to bear for the care of combat casualties are beyond comparison.

The one common thread throughout this story, however, is the dedication of medical people to the care of their sick and wounded military compatriots.

[1] Air Transport of the Critical Care Patient, http://www.cs.amedd.army.mil/FileDownloadpublic.aspx?docid=57ab806b-df57-42d7-85b4-5f96907faf92, accessed 5 October 2016.

[2] U.S. Air Force Website, Gulf War Created Need for Better Critical Care, http://www.af.mil/News/ArticleDisplay/tabid/223/Article/643126/gulf-war-created-need-for-better-critical-care.aspx?source=GovD, accessed 5 October 2016.

Veterans’ Day Greeting

Today, I wrote this to Naval Order Companions of the San Francisco and Continental Commanderies, and the members of the Albany Medical College – Military Affinity Group. I send the greeting now to followers of Of Ships and Surgeons, with my best wishes:

Inline image 1
 
The word “service” comes to us from the Latin servus / servitium, meaning “slave” and “slavery”. By the 13th century, the old French servise had come to mean “labor undertaken for or at the direction of another”. The Roman and “Scholastic” notion of work with body or hands as dishonorable servitude underwent further modification under the influence of the Enlightenment so by the early 1700s, the association of “service” with military duty, at least for higher ranks, was seen as completely honorable. The need for larger “citizen” militaries probably completed the transition to a view of “honorable” service being performed by all ranks.
 
Let us salute each other on this day set aside especially to honor the service and sacrifice of the Veterans among us. 
Very Respectfully,
Tom S
Tom Snyder MD ’69

Captain, Medical Corps, US Navy (Ret​.​)
Commander, San Francisco and Continental Commanderies,
Naval Order of the United States
Founder / Coordinator
Albany Medical College – Military Affinity Group

 

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, http://washington.providence.org/~/media/files/providence/hospitals/wa/phc/conference%20handouts/general%20surgery%20in%20the%20us%20navy.pdf/, no date, accessed 27 September 2016.

[3]Navy Expeditionary Medical Support Command, Williamsburg, VA, Command History, Fleet Hospitals – the Beginning, http://www.med.navy.mil/sites/nemscom/CommandInfo/Pages/history.aspx, accessed 30 September 2016.

[4] Website “America’s Navy”, Fleet Hospital 3 – Best Care in Iraq, http://www.navy.mil/submit/display.asp?story_id=7056, accessed 30 September 2016

[5] Website “America’s Navy”, Ten Year After – Fleet Hospital 8 Returned Home to Naval Hospital Bremerton, http://www.navy.mil/submit/display.asp?story_id=75648, accessed 30 September 2016.

Navy Medicine in Araby (Episode 5)

This is instalment 5 of a series of 7, wherein I endeavor to contrast medical care of sailors of the 19th century with that of today.

Before I discuss our Navy’s medical assets, I must discuss the concept of Levels, Echelons or Roles of Care in today’s combat casualty care environment. Combat casualty care has evolved significantly since the Barbary Wars. The Napoleonic surgeon Larrey made a significant first step toward modernity when he established a system of horse-drawn “flying ambulances” to move casualties – who heretofore may have lain for days in the field without care, food or water – to facilities where prompt care of their wounds could be given. Modern combat casualty care started in the U.S. Army during the Civil War as a result of a series of reforms brought forth by the Lincoln-appointed Sanitary Commission led by Frederick Olmstead. Basing many of its recommendation on learnings from the Crimean War, the Commission and the Army built hospitals, established a system of evaluation of prospective Army doctors (the Navy already had such a system in place) and provided supplies and equipment. Under this system, Army Surgeon Jonathan Letterman established an ambulance corps to effect prompt evacuation of field casualties to facilities in the rear; he also established an early system of echelons of care with field dressing stations on the battlefield, field hospitals for definitive surgery located in nearby homes, churches or barns, and larger hospitals in the rear for longer term treatment. While more advanced surgical technique and evacuation by ambulance were utilized in World War I, it wasn’t until World War II that an appreciation of the need for rapid surgical intervention in injured soldiers was institutionalized with the development of mobile surgical teams attached to division level field hospitals. Shortly after our entry into the war, it became clear that transfusion of flood was an essential element in the resuscitation and ongoing management of men who suffered extensive wounding, and the robust system of blood collection that I described earlier was implemented. In the Korean War, an emphasis on the treatment of shock with IV fluids and transfusions saved many additional lives, and the forward care surgical facilities referred to as MASH units plus the use of helicopters for casualty movement further improved outcomes for injured warriors. During the Vietnam war, emphasis was put on shortening the time from injury to surgical care by keeping medical facilities close to the area of combat and by using helicopter transport.

©2016, 2017 Thomas L Snyder

Navy Medicine in Araby (Episode 4)

This is instalment 4 of a 7 segment article comparing combat casualty care in the Navy of the 19th century with that of the 21st.

My original intent here was to compare and contrast Navy medical care between the 19th and the 21st centuries. However, it soon became clear to me that there really is no comparison, only contrast. So much has changed, at so many levels of endeavor, to have changed Navy medicine almost completely. First is the matter of physical diagnosis – the interpretation of symptoms (what the patient reports) and signs (what the physician observes) to diagnose illness. The system of physical diagnosis began with the 1760 discovery of percussion – the tapping of certain body parts, say the chest, to determine if fluid is where it doesn’t belong. Next came the stethoscope in 1816; this permitted physicians to listen for abnormal sounds in the lungs, the heart and vessels, and the abdomen, and to interpret them. The inventor, Laennec, was also the first to correlate his physical findings with autopsy examinations, thereby beginning a system of thought about disease processes and their diagnosis. The so-called German School of the mid-to-late 19th century added laboratory examinations to the diagnostic set. The ophthalmoscope (1850) permitted physicians to peer into the eye, called the window to the body because many illnesses cause changes that can be seen there. The thermometer was invented in 1871, and all understand the importance of that device. Conrad Roentgen discovered x-rays in 1895, and immediately appreciated their implications for medical diagnosis. Just three years later, American surgeons used the x-ray apparatus extensively for localizing bullets in wounded soldiers during the Spanish-American War.[1] Radiologic diagnosis took a major leap forward with the introduction of CT scanning in the mid-1970s; the technique creates essentially 3-d views of the inside of the body, permitting much more precise diagnosis in most cases.

The role of bacteria in causing wound infections was elucidated by Pasteur and others from about 1861. This work prompted the German army to adopt antibacterial surgical techniques, the effectiveness of which to reduce wound infection rates was proven in the Franco-Prussian War. The bacterial theory of disease was advanced throughout the early 20th century, and the role of viruses in causing such diseases as smallpox, poliomyelitis and yellow fever was worked out the 1920s and 1930s. Public health and preventative medicine – for example the role of immunizations against epidemic diseases – played a huge role in reducing morbidity and mortality in military organizations thereby keeping more soldiers on the battlefield more of the time. Once again, the Germans led the way with mandatory vaccination: in the Franco-Prussian War, the immunized Germans suffered 4835 cases of smallpox with a mortality rate of 0.5%, compared with the unimmunized French POWs who experienced 14,178 cases with a mortality rate of nearly 14%.[2]

The notion of replacing blood lost as a result of wounding and injury gained credibility only after a system of blood typing was worked out by Karl Landsteiner in 1901. While transfusions from one man to another had been tried before (transfusions from animals had been tried, too) – all with disastrous results – it was only after transfusion of matching blood became possible that the procedure could be safely carried out. Transfusion was used during World War I, British surgeons commonly using the man-to-man technique in the early part of the war. The American Army physician Oswald Paterson came up with the idea of banking blood during the war. This played a major role in combat casualty care, but only after technical problems- such as keeping collected blood from clotting, preserving it, and of practical transfusion set-ups – were solved. Transfusion of banked blood became commonplace near the end of the war. The technical and practical approaches to the handling and banking of blood were refined in the inter-war period, so by the outbreak of WW II, mass collection, banking and transport of blood to theaters of war were instituted. Some elements of the German army had their members’ blood type tatooed on them; these men became part of a walking blood bank – men, who as in World War I, could be called upon to give blood on the spot, when needed. Our Navy still uses the walking blood bank concept today, as a supplement to the blood banking system, but without that particular type of tatoo. Finally, the advent of anesthesia permitting major surgical operations without pain came in the 1870s. This single advance permitted a vast refinement in surgical techniques that are applied to this day. Compare the image of the sole ship’s surgeon and his assistants, with no anesthesia, working in a dark cockpit with modern combat casualty care where two or more surgical teams are working on a patient while the anesthetist is responsible not just for administering the anesthesia, but also administering blood and blood products, fluids and a multitude of drugs to support a patient who has been gravely injured.

[1] Gabriel, Richard A. and Karen S. Metz, A History of Military Medicine, Vol II, New York, Greenwood Press, 1992, pp 221, 222.

[2] Gabriel and Metz, op. cit., pp 108, 109.

©2016, 2017 Thomas L Snyder