Anesthesia Services Aboard USNS COMFORT (T-AH-20) during Operation Iraqi Freedom

Military Medicine, Jun 2005 by Paine, Gregory F, Bonnema, Craig L, Stambaugh, Terry A, Capacchione, John F, Sipe, Patrick S

USNS COMFORT (T-AH-20), the only U.S. hospital ship to be deployed in support of combat operations during Operation Iraqi Freedom, sailed from Baltimore, Maryland, on January 6, 2003, and returned on June 12, 2003. During the course of her deployment, 648 anesthetic procedures were performed. We describe the anesthesia services provided, lessons learned, and recommendations for future concepts of employment.

Introduction

The USNS COMFORT is one of two hospital ships operated by the United States. She is home-ported in Baltimore, Maryland, and is assigned to the Military Sealift Command. COMFORT is the second ship of the MERCY Class and was delivered on December 1, 1987. Her sister ship, USNS MERCY (T-AH-19), is home-ported in San Diego, California. These ships were former SAN CLEMENTE Class supertankers that were extensively modified to their present configuration. This is the third hospital ship with the name COMFORT; her predecessors were AH-3 and AH-6 of World War I and World War II, respectively. During World War II, COMFORT was staffed with U.S. Army physicians and was struck by a Japanese kamikaze aircraft on April 28, 1945, which killed 30 and wounded 48.1

The current COMFORT was previously deployed in support of Operations Desert Shield and Desert Storm, providing medical support to U.S. and Coalition forces as well as numerous humanitarian missions. In full operating status, 61 civilian mariners staff the ship and 1,214 military personnel staff the medical treatment facility (MTF).

The MTF's commanding officer, Captain Charles Blankenship, MC USN, was the surgery department head aboard the COMFORT during Operations Desert Shield and Desert Storm and provided continuity based on his previous experience. The concept of operations regarding casualty management has changed little since 1991 and is eloquently explained in an article he coauthored.2 In brief, the ship is capable of providing 1,000 hospital beds, including a 50-bed casualty receiving (CASREC) area, anywhere the U.S. Navy deploys. The primary mission of the MTF is ". . . to provide rapid, flexible, and mobile acute medical care to support Marine Corps Air/Ground Task Forces deployed ashore. Army and Air Force units deployed ashore, and naval amphibious task forces and battle forces afloat. Operations are governed by the principles of the 'Geneva Convention for the Amelioration of the Condition of Wounded, Sick, and Shipwrecked Members of the Armed Forces at Sea' of 12August 1949."3

Additional afloat medical assets in the area of operations during Operation Iraqi Freedom included numerous Amphibious Ready Group casualty receiving and treatment ships and two Coalition ships that functioned as hospital ships. These were the SSPS GALICIA from Spain and the RFA ARGUS from Great Britain. GALICLA had two operating rooms and a 50-bed medical facility on board and was responsible for delivering humanitarian supplies to the Iraq city of Umm Qasr on April 9, 2003.4ARGUS had four operating rooms and a 100-bed medical facility and treated 67 casualties before returning to Devonport Naval Base in Plymouth, after a 4-month deployment, on May 28, 2003.5 The COMFORT received patients from both of these vessels.

Composition of Department

One anesthesiologist, one certified registered nurse anesthetist (CRNA), and one anesthesia technician reported aboard 1 day before ship's movement and were charged with ensuring that all anesthesia equipment and supplies were ready for immediate use upon arrival at the theater of operations. Additional personnel, representing the main body, joined the ship in Bahrain and brought staffing up to a total of 22 personnel (12 anesthesiologists and 10 CRNAs) from six different commands. This staffing was six less than the full operating status billets for 28 anesthesia providers. Among the anesthesiologists, 11 were board certified; three were fellowship trained, one in intensive care and two in pain management. The department was divided into four duty sections, with five or six personnel in each section. This organization allowed for continual use of four operating rooms at all times, with the ability to surge in the event of mass casualties. During the third week of April, additional anesthesia assets were added to COMFORT, in anticipation of an increased patient load, and included two anesthesiologists and one CRNA. An additional anesthesiologist arrived to augment the intensive care staff.

Equipment

The COMFORT has 12 operating rooms, one of which is a dedicated angiography suite. Two procedure rooms in the dental department were also equipped with anesthesia machines. The anesthesia machines were Ohmeda Excel 210 series (GE Medical Systems, Waukesha, Wisconsin), with 7000 series ventilators, Hewlett Packard monitors (Hewlett Packard, PaIo Alto, California), and Datex Ohmeda 5250 RGM gas analyzers (GE Medical Systems). The ship was equipped with both isoflurane and halothane vaporizers and had a large amount of sevoflurane but no vaporizers. However, 13 Tec 7 sevoflurane vaporizers (GE Medical Systems) were obtained en route to the theater of operations and were available for use before receipt of patients. Each operating room was equipped with a hotLine fluid warmer (Smiths Medical, Keene, New Hampshire) and either a Polarair total temperature management system or a Bair Hugger warming unit, model 505 (Arizant Healthcare, Eden Prairie, Minnesota). In addition, four Level One rapid infusers (Smiths Medical) were available and another four arrived before cessation of major combat operations. The ship is configured with two lowpressure, oxygen production plants (GEECO, Milford, Connecticut) capable of producing 20 gallons per hour of liquid oxygen, which is transferred to a 500-gallon storage tank. Liquid oxygen is then converted to a high-pressure/high-temperature gas for charging of oxygen cylinders. Oxygen is piped from the storage tanks to 168 connections throughout the ship, which are primarily located in CASREC, the intensive care units, and the main operating room. Initially, there was not a supply of nitrous oxide aboard. However, approximately 180 H cylinders and 80 D cylinders were ordered and obtained en route. Airway carts were available in both CASREC and the main operating room suite. A regional block cart, malignant hyperthermia cart, and intravenous line cart were available in the main operating room suite.