Ambulatory surgery in a Navy Fleet Hospital Training Set

Military Medicine, Jun 2003 by Covey, Dana C

A series of 51 active duty patients who elected to undergo ambulatory surgery in a Navy Fleet Hospital Training Set (a modified field hospital) over a 2-year period were followed prospectively for perioperative complications. All patients were active duty personnel, ranging in grade from E1 to O5, who voluntarily gave specific informed consent to have their surgery performed in the training set. Patients were offered surgery in the training set only if attending surgeons were confident that the surgery could be done safely and with the same expected outcome as if performed in the hospital. Their entire surgical experience was contained within this tent-based field facility from admission to discharge. There were 12 orthopedic surgery, 4 general surgery, 3 otolaryngology, 2 urology, 1 ophthalmology, and 29 oral and maxillofacial surgery cases. General, regional, or local anesthesia or intravenous conscious sedation were used as indicated. No patients developed wound infections, and there were no anesthetic, bleeding, or other significant perioperative complications. Selected ambulatory surgical procedures can be safely performed on appropriate patients in this field hospital assemblage.

Introduction

One of the continual challenges facing military medicine is how to incorporate operationally relevant training into a system that is primarily hospital based. In the case of Navy medicine, readiness has long been a top strategic goal, but competing priorities, the most pressing of which is to provide day-to-day beneficiary care in its medical treatment facilities, has at times been at odds with preparing personnel for combat or other contingency missions.

Considering lessons learned from the deployment of fleet hospitals during the Persian Gulf War, in 1992 an initial recommendation was made that training of personnel should include actual patient care in a fleet hospital setting.1 Four years later, the Navy's Bureau of Medicine and Surgery committed $36 million for deployable medical systems training at designated Navy hospitals as part of the Medical Readiness Omnibus Training Initiative. Under this plan, excess fleet (field) hospital tent-age, International Standards Organization shelters, and varied equipment would be provided to designated hospitals to use for readiness training. Soon thereafter, a concept of operations was written for local deployable medical systems training programs, and staffing plans were established for six active duty fleet hospitals at: Naval Medical Center, Portsmouth and Naval Hospitals Jacksonville, Camp Pendleton, Camp Lejeune, Bremerton, and Pensacola. It was envisioned that these tent-based facilities would be used not only for drills but also for actual clinical and surgical care in an environment, and with the equipment medical personnel would use in an actual fleet hospital deployment.2

Experience during overseas deployments of fleet hospitals has shown that major surgical cases can be successfully performed with a low infection rate in a field environment. Fleet Hospital 5 had a clean wound infection rate of 0.125% during its deployment to Saudi Arabia during Operations Desert Shield and Desert Storm from 1990 to 1991 (G. Parker, personal communication). During the deployment of Fleet Hospital 6 to the former Yugoslavia in 1994, the incidence of wound infections for 277 total surgical cases was 0.36% (Fleet Hospital 6 After Action Report and Patient Statistics, August 30, 1994). During the deployment of Fleet Hospital 5 to the Republic of Haiti in 1997, for 224 total cases, there was an infection incidence of 0.89% (Fleet Hospital 5 after Action Report and Patient Statistics, August 12, 1997).

The present study was undertaken to ascertain the feasibility of safely performing routine outpatient surgery within a Navy Fleet Hospital Training Set using the equipment and in an environment that would simulate an actual fleet hospital deployment.

Materials and Methods

Patients

From December 1998 to December 2000, 51 patients who underwent ambulatory surgery in the Naval Hospital (Bremerton, Washington), Fleet Hospital Training Set comprised a prospective case series. There were 43 males and 8 females and the mean age was 26 years (range, 18-43 years). All patients were active duty personnel ranging in grade from E1 to O5 who elected to have their surgery performed in the training set. Selected patients would be American Society of Anesthesiologists physical class 1 or 2.3 Anesthesia personnel would use equipment and use techniques that could be used in field conditions that were also appropriate to the clinical scenario and the patient's choice.

Perioperative care was entirely self-contained within the training set from the time of patient check-in until the time of discharge to home or quarters. Fleet hospital pharmacy, laboratory, and X-ray departments were staffed to provide ancillary support and to enhance technician expertise with procedures and equipment in the field setting. Depending upon the type of surgery and anesthetic criteria, patients received general, regional, or local anesthesia or intravenous conscious sedation as indicated. Categories of cases included general, orthopedic, urology, otolaryngology, ophthalmology, and oral and maxillofacial surgery.