Between the devil and the deep blue sea: A review of 25 modern naval mass casualty incidents with implications for future Distributed Maritime Operations.

ABSTRACT: In the future, United States Navy Role 1 and Role 2 shipboard medical departments will be caring for patients during Distributed Maritime Operations in both contested and noncontested austere environments; likely for prolonged periods of time. This literature review examines 25 modern naval mass casualty incidents over a 40-year period representative of naval warfare, routine naval operations, and ship-based health service support of air and land operations. Challenges, lessons learned, and injury patterns are identified to prepare afloat medical departments for the future fight. LEVEL OF EVIDENCE: Literature Review, level V.

Shipboard Global Health Engagement Missions: Essential Lessons for Military Healthcare Personnel.

INTRODUCTION: Global health engagement missions are conducted to improve and protect the health of populations worldwide. Recognizing the strong link between health and security, the Armed Forces have increased the number of global health engagement missions over the last decade to support force health protection, medical readiness, enhance interoperability, improve host nation capacity building, combat global health threats (i.e., emerging infectious diseases), support humanitarian assistance and disaster relief efforts, as well as build trust and deepen professional medical relationships worldwide. These missions additionally support the US Global Health Security Agenda, US National Security Strategy, US National Defense Strategy and National Military Strategy.Although global health engagement missions are conducted by armed forces with numerous military units and geographical locations, military healthcare personnel assigned to US Naval hospital ships also perform a wide range of these missions. These missions comprise some of the largest global health engagement missions conducted, encompassing hundreds of subject matter expert exchanges, community health exchanges, medical symposiums, and side-by-side partnered healthcare in countries around the world. Military healthcare personnel who have completed past missions possess valuable knowledge related to ship-based global health engagement missions. Capturing and transferring this knowledge to future deployed personnel is important for future successful missions, but has remained a significant challenge. The purpose of this study was to capture and examine first-person accounts of experiential learning among active duty physicians, nurses, and hospital corpsmen who had participated in recent hospital ship-based global heath engagement missions. MATERIALS AND METHODS: We used the interpretive, ethnographic method of interviewing and data analysis described by Benner. Interviews elicited detailed, narrative examples of experiences from military health care personnel who had participated in previous global health engagement missions aboard hospital ships (N = 141). Our approach to gaining meaning from these narratives was guided by three central strategies: (1) identify paradigm cases, (2) identify themes within and across participant narratives of meaningful patterns, and (3) identify exemplars to represent common patterns of meaning and common situations. Additionally, we collected demographic information. RESULTS: Our findings provide firsthand descriptions of five essential elements to prepare military healthcare personnel for shipboard global health engagement missions. These essential elements are mission clarity, preparedness, experiential knowledge, lessons learned, and flexibility/adaptability. CONCLUSIONS: Widespread dissemination of the lessons learned from military global health engagement missions is crucial to shaping forces that operate effectively in a rapidly changing global environment. Sharing lessons learned increases efficiency, adaptability, and agility, while decreasing variance in processes and the need to relearn mission-specific lessons.

A review of the physiological and psychological health and wellbeing of naval service personnel and the modalities used for monitoring.

Naval cohorts rely heavily on personnel to ensure the efficient running of naval organisations. As such, the wellbeing of personnel is essential. In an occupational setting, naval service personnel experience a variety of physiological and psychological stressors. Most naval services arrange annual physical fitness and body composition tests to ensure the physical readiness of personnel. However, these tests only evaluate a small amount of physiological capabilities. Components such as aerobic and strength capabilities are assessed, however, other components of physical fitness such as speed, agility, anaerobic capacity and flexibility are not. In addition to the physical capabilities, personnel are impacted by fatigue, nutrition and psychological stressors such as copping in stressful situations or dealing with time away from family and friends. This review will discuss the physiological and psychological factors that affect personnel's wellbeing. In addition to this, it will also evaluate the methods that are used to assess both physiological and psychological wellbeing.

[Delivery of surgical care on naval ships: formation, development, and current stage].

Acute surgical diseases were and remain one of the most important problems of the organization of medical care and treatment of patients in the conditions of long distant sea voyage, when there is no possibility for medical evacuation. We analyzed the positive experience of surgical care in the sea, gained by Soviet and then and by Russian Navy physicians. As we haven't registered significant changes in morbidity of Navy crewmembers, we think that studying and creative application of this experience will have the positive effect.

[Status and development prospects of radiological health in the Navy].

More than 7.5 thousands of people work as military and civilian personnel and have an access to a lot of sources of ionizing radiation on ships and vessels, at coastal units and institutions of the Navy. This fact determines the importance of radiation safety and medical preventive measures on naval fleets. The article analyses the state of radiation-hygienic measures, outlines the conceptual basis for the development of radiation hygiene in the Navy. Substantiated reconstruction tasks effectiveness of health control and state sanitary and epidemiological supervision of radiation safety, provides information about the optimal set of instruments for radiation monitoring equipment radiobiological laboratories and centres of state sanitary and epidemiological supervision at various levels.

[Aspects of development of surgical service of modem Navy].

The article is devoted to the aspects of a current state of surgical service in the Navy, prospects of development of professianl training for navy surgeons, formation of modern training comlex, united electronic library, containig the issues about combat surgical trauma, software technologies, realizing of the application methodology during the process of training and practical activity for the development of the training system for surgeons of Navy and improvement of effectiveness. Formation of normative technical documents, regulating activity of navy surgians is also among the expectations. The authors also touched on the issues of development of modern technologies in bone grafting with the help of domestic implants based on the osteoinductive nanostructured nonorganic matrices (titanium) with defined structure and composition. Department of navy and hospital surgery participate in this debelopment. Due to increased amount of oncologic patients, it was decided to establish the Cancer Center of the Ministry of Defense based on department of navy and hospital surgery of the Kirov Military Medical Academy. It makes possible to perform the following procedures: canser surgery; surgical repair; plastic repair of major vessels, bone and soft tissue grafting, removal of residual cancer cells with the help of loco-regional methods of hyperthermic intracavitary and intravascular chemoperfusion; diagnostics and treatment of recurrent tumors (surgical and radiation treatment, systemic chemotherapy, loco-regional chemoembolization. Each of the given methods help to develop and improve the innovation technologies.

[Improvement of the supply norms for ships carrying combat missions in peace-time].

The authors developed the projects of norms of supplying of ships of Northern Fleet by medical reinforcement groups. Norms are added by the medicals which are in the log-book of pharmaceuticals and necessary for the sudden problems. The third norm is added by the traumatologic set. Modern diagnostic equipment is also added to the norms. The authors came to conclusion that the forehanded planning of requirement of medical supply for medical reinforcement groups allows to create an adequate norms of supplying of medical reinforcement groups in the Northern Fleet.

The need for international seafarer medical fitness standards.

The text of this paper is based on a presentation at the First International Congress of Maritime, Tropical, and Hyperbaric Medicine, 4th July 2009, Gdynia, Poland. The assessment of fitness to work at sea is an important aspect of maritime risk management. The risks in the industry, the approaches used for assessment, and the evidence on which they are based have changed over time. The transition from an industry in which the nationality of seafarers and the ships on which they worked were the same to one in which ownership and crewing have become global means that, as is true for most other aspects of maritime risk management, compatible international criteria for decisions regarding fitness to work are required. Many parties, including flag states, employers and their insurers, and seafarers and their trade unions, are involved in agreeing international medical fitness criteria. While all have a common interest in improved health and safety at sea, each has their own more detailed agenda of sectional interests. The scope for development of agreed standards and the role of the parties involved is reviewed, and the current arrangements for taking this process forward are discussed. Contributions from maritime health professionals and other medical and scientific experts are essential to the development of rational and valid criteria, but the decisions on the level of authority to be given to these and the means adopted for ensuring compliance with them are essentially political issues where the voice of those with subject knowledge is only one among many in the processes for adoption and implementation of any new arrangements.

Primer y segundo escalones navales. El BAC Patiño como paradigma en la operación Libertad Duradera / First and second naval steps. The Ship Patiño as a paradigm in the Endurance Freedom Operative

Los acontecimientos posteriores a los trágicos sucesos del 11 de septiembre han acarreado un nuevo ámbito de actuación dentro del seno de las FAS y concretamente de la Armada. El motivo del presente artículo es hacer una presentación de las actividades sanitarias navales realizadas durante la operación Libertad Duradera (LD) utilizando el BAC Patiño como paradigma debido a su implicación como primer y segundo escalón sanitario naval, lo que nos permite analizar muchas de las actividades y acciones comunes y específicas de la sanidad naval. De todo ello extraeremos reflexiones críticas de las posibles mejoras y acciones a llevar a cabo en próximas misiones navales en Oriente Medio y costas africanas, estableciéndose además un referente práctico a tener en cuenta para oficiales destinados en primer y segundo escalón (AU)

: The subsequent events following the tragic attemts of the september 11th, have derived to a new operative system into the AF,s and specially in the Navy. The reason for the present paper is to introduce the naval health activities done, during the Endurance Freedom (EF) operative, considering the warship Patiño as a paradigm, being a result of its implication as a naval first and second sanitary step, analysing many of the common and specific activities and actions of the naval health service. From all of these, we must make critical reflexions about the possible improvements and realizations to develop along the next naval operatives in Middle East and african coasts, also establishing a practical reference to the health officers from the first and second step (AU)