Expeditionary Surgery at Sea: A Practical Approach

Disclaimer
Foreword
Preface
Preface
Expeditionary Surgery at Sea: Top 10 Lessons Learned
Contents
Part I: Maritime Surgery Overview
	Chapter 1: Overview of Current Maritime Surgical Platforms and Operational Environments: Part 1—United States Navy and Marine Corps
		Introduction
		Continuum of Care
			Role 1 (First Responder Care)
			Role 2 (Forward Resuscitative Care)
			Role 3 (Theater Hospitalization Capability)
			Role 4 (Definitive Care)
			Patient Movement and En Route Care (ERC) Capability
		Maritime Surgical Platforms
		Aircraft Carrier (CVN)
		Fleet Surgical Team (FST)
		Expeditionary Resuscitative Surgical System (ERSS)
		Hospital Ship (T-AH)
		United States Marine Corps (USMC) Surgical Platoon
		The Future Is Now: Distributed Maritime Operations (DMO) and Expeditionary Advanced Base Operations (EABO)
		Maritime Single-Surgeon Team Limitations
		Conclusion
		References
	Chapter 2: Overview of Current Maritime Surgical Platforms and Operational Environments Part 2: United Kingdom and The Royal Navy
		Introduction
		Operational Patient Care Pathway (OPCP)
		Role 2 Afloat (R2A)
		Maritime Role 3 (MR3)
		Commando Forces Surgical Group (CFSG)
		Platforms
		Conclusion
		References
	Chapter 3: The Ship’s Surgeon and Surgery at Sea: A Brief History
		Introduction
		The Age of Manpower (~800 bc to ad 1450)
			Ancient Greece (~800–322 bc)
			The Imperial Roman Navy (~27 bc to ad 180)
			The Middle Ages (ad ~476–1453)
		The Age of Discovery (~1450–1600)
			British Sea Power
			The Father of Sea Surgery
		The Age of Sail (~1600–1850)
			The American Revolutionary War
		The Age of Steam and Iron (~1850–1915)
			The American Civil War
			Battleships and Blood Transfusions
		World War II (1939–1945)
			Normandy
			Iwo Jima
		Korean (1950–1953) and Vietnam (1955–1975) Wars
		Women Surgeons at Sea
		Conclusion
		References
	Chapter 4: Mechanisms of Injury During Modern Naval Operations
		Introduction
		Non-flight Deck Injuries
		Flight Deck Injuries
		Injuries During Naval Warfare
		Conclusion
		References
	Chapter 5: I’m Deploying on a Ship, Now What?
		Introduction
		Preparation: Ship/Surgical
			Credentials/Privileges
			Inventory, Supply, and Maintenance
			Identify Resources
			Establish Capabilities
		Preparation: Shore/Surgical
			USAISR Burn Center
		Preparation: Ship/Nonsurgical
			Checking in/Sponsor
			Warfare Qualifications
			Goals
		Preparation: Shore/Nonsurgical
			Professional Requirements
			Expectations for Loved Ones
			Affairs in Order
			Packing
		Conclusion
		Further Reading
	Chapter 6: Leadership and Communication 101
		Introduction
		In Depth: Aircraft Carrier (CVN) Ship’s Surgeon
			Team Personnel
			Preoperative Communication
			Postoperative Communication
			MEDEVAC/CASEVAC
			Trauma and Mass Casualty (MASCAL)
			Closing Thoughts
		In Depth: Fleet Surgical Team (FST) Staff Surgeon
			Team Personnel
			Chain of Command (COC)
			Perioperative Communication
			MASCAL
			Closing Thoughts
		In Depth: Expeditionary Resuscitative Surgical System (ERSS) OIC
			Team Personnel
			Perioperative Communication and MASCAL
			Closing Thoughts
		In Depth: Forward Resuscitative Surgical System (FRSS) Staff Surgeon
			Team Personnel
			Perioperative Communication and MASCAL
			MEDEVAC/CASEVAC
			Team Training
			Closing Thoughts: A Senior Surgeon’s Perspective
		Conclusion
		Further Reading
Part II: Before the Operating Room
	Chapter 7: Shipboard Triage and Mass Casualty
		Introduction
		Initial Triage
		Immediate/Delayed Treatment Areas
		Special Considerations for Shipboard Triage: Limited Resources
		Communication
			“What Do I Know? Who Needs to Know? Have I Told Them?”
		Training and Drills
		Conclusion
		References
			Further Reading
	Chapter 8: Shipboard Diagnostics: Laboratory and Radiology
		Introduction
		Shipboard Laboratory: Historical Perspective
		Shipboard Laboratory: Current Overview
			Laboratory Suite
			Regulation
		Shipboard Laboratory: Common Technology and Tests
			Hematology
			Chemistry
			Blood Gases
			Additional Tests
		Shipboard Radiology: Historical Perspective
		Shipboard Radiology: Current Overview and Technology
			Radiology Suite
			Radiography Technology Advances
			Shipboard Ultrasound
		Shipboard Radiology: Common Exams
		Conclusion
	Chapter 9: Principles of Shipboard Ultrasound
		Introduction
		Extended Focused Assessment with Sonography in Trauma (eFAST)
			Introduction and Indications
			Technique
			Subxiphoid Cardiac Views (Fig. 9.1)
			Right Upper Quadrant (RUQ) Views (Fig. 9.2)
			Left Upper Quadrant (LUQ) Views (Fig. 9.3)
			Pelvic/Bladder Views (Figs. 9.4 and 9.5)
			Anterior Right and Left Chest Views
			Keys to Success
		Limited Echocardiography
			Introduction and Indications
			Technique
			Parasternal Long Axis (PLAX) View (Fig. 9.9)
			Parasternal Short Axis (PSAX) View (Fig. 9.10)
			Apical 4 Chamber (A4Ch) View (Fig. 9.11)
			Subxiphoid View
			Inferior Vena Cava (IVC) View (Fig. 9.12)
			Cardiac Tamponade
			Right Heart Strain
			Cardiac Contractility and Ejection Fraction (EF) Estimation
			Cardiac Arrest
			Keys to Success
		Right Upper Quadrant (RUQ) Ultrasound
			Introduction and Indications
			Technique
			Keys to Success
		Appendicitis
			Introduction and Indications
			Technique
			Keys to Success
		Testicular Torsion
			Introduction and Indications
			Technique
			Keys to Success
		Lower Extremity Deep Vein Thrombosis (DVT)
			Introduction and Indications
			Technique
			Keys to Success
		Pregnancy
			Introduction and Indications
			Technique
			Keys to Success
		Ovarian Torsion
			Introduction and Indications
			Technique
			Keys to Success
		Central Venous Catheter (CVC) Placement
			Introduction and Indications
			Technique
			Keys to Success
		Conclusion
		References
	Chapter 10: Practical Nursing Principles Afloat
		Introduction
		Aircraft Carrier (CVN) Nursing
			Nursing Supervisor and Medical Training Team (MTT) Leader
			Aircraft Carrier (CVN) Medical and Surgical Capabilities
			Medical Evacuation (MEDEVAC)
			Clinical Pearls
		Fleet Surgical Team (FST) Nursing
			Certified Registered Nurse Anesthetist (CRNA)
			Critical Care Registered Nurse (CCRN)
			Certified Perioperative Nurse (CNOR)
		Expeditionary Resuscitative Surgical System (ERSS) Nursing
			Preoperative: Trauma Resuscitation
			Intraoperative: Operating Room (OR)
			Postoperative: Intensive Care Unit (ICU) & Medical Evacuation (MEDEVAC)
		General Practical Tips
		Conclusion
		Further Reading
	Chapter 11: Alone and Unafraid: The Independent Duty Corpsman at Sea
		Introduction
			Clinical Vignette 11.1
			Clinical Vignette 11.2
		Being Prepared with Medical Knowledge
		Training Your Junior Corpsmen
		Safe Patient Movement Throughout the Ship
		Building a Relationship of Trust and Mutual Respect with Your Commanding Officer (CO)
		Principles of Medical Evacuation (MEDEVAC)
		Working with Your Physician Supervisor
		Administration at Sea
		Conclusion
Part III: Elective and Emergency Surgical Care
	Chapter 12: Mess Deck, Hangar Bay, or Operating Room? The Shipboard Operating Theater
		Introduction
		Surgical Team Members (Table 12.1)
			CVN
			FST
			ERSS
		Equipment/Sets/Inspections
			FST
			ERSS
		Supply
			CVN/FST
			ERSS
		Maintenance
			CVN/FST
			ERSS
		Decontamination, Sterile Processing, and Storage
			CVN/FST
			ERSS
		OR Capabilities Outside of Primary OR
			CVN
			FST
			ERSS
		Conclusion
		Further Reading
	Chapter 13: Principles of Maritime Expeditionary Anesthesiology
		Introduction
		Pre-deployment Considerations
			Leadership and Administration
			Logistics and Preparation
		Deployment Considerations
			Mechanism of Injury
			Prehospital Treatment (i.e., Tactical Combat Casualty Care (TCCC))
			Triage/Receiving Casualties
		Resuscitation
			Intravenous (IV) Access
			Blood Products
			Hemostatic Pharmacologic Adjuncts
			The Lethal Triad
		Airway Management
			Non-surgical Airway Management
			Surgical Airway Management
		Anesthesia in the Deployed Setting
			General Anesthesia
			Regional Anesthesia
		Prolonged Patient Holding and Austere Critical Care
		Platform-Based Considerations for Maritime Expeditionary Anesthesia
			CVN
			Fleet Surgical Team (FST)
			Expeditionary Resuscitative Surgical System (ERSS) or Role 2 Light Maneuver (R2LM)
		Conclusion
		References
	Chapter 14: Elective and Emergency Surgery: Operate, Observe, or Transfer? (If You Can)
		Introduction
		Operate, Observe, or Transfer: Factors to Consider
			Communication and Mission
			Quality of Life/Quality of Work
			Training
			Pathology
			Inactivity
			Nearby Ships
			Ancillary Studies (Laboratory and Radiology)
			Timing
			A Captive Audience for Observation
		General Surgery Emergencies
			Nephrolithiasis
			Appendicitis
			Diverticulitis
			Small Bowel Obstruction (SBO)
			Peptic Ulcer Disease (PUD)
			Upper Gastrointestinal Bleeding (UGIB)
			Lower Gastrointestinal Bleeding (LGIB)
			Inflammatory Bowel Disease (IBD)
			Foreign Bodies
		Non-general Surgery Emergencies
			Vascular
			Pneumothorax
			Ophthalmologic Emergencies
			Otolaryngology (ENT)
			Testicular Mass
		Elective/Non-urgent
			Hernias
			Biliary Disease
			Benign Anorectal Disease
			Pilonidal Disease
			Breast Disease
			Urologic Elective Procedures
		Conclusion
		References
	Chapter 15: The Tyranny of Distance and the Difficult Gallbladder
		Introduction
		Diagnosis
		Management
		Complications
			Filling Defects on Intraoperative Cholangiogram (IOC)
			Common Bile Duct injury (CBDI)
			Intraoperative or Postoperative bleeding
		Management of Other Acute Biliary Diseases
			Gallstone Pancreatitis
			Mirizzi Syndrome
			Bouveret’s Syndrome and Gallstone Ileus
		Conclusion
		References
	Chapter 16: Infectious Disease Pearls for Maritime Surgical Teams
		Introduction
		Diagnostic Tools at Hand
		The Maritime Pharmacy
		Neurological Infections
			Penetrating Central Nervous System (CNS) Trauma
			Meningitis
			Encephalitis
		Infections of the Head and Neck
			Facial Trauma
			Peritonsillar Cellulitis and Abscess
			Submandibular Abscess and Ludwig’s Angina
		Pulmonary Infections
			Penetrating Thoracic Trauma
			Pneumonia
			Tuberculosis (TB)
			Coronavirus Disease 2019 (COVID-19)
		Gastrointestinal Infections
			Penetrating Abdominal Trauma
			Common Surgical Diagnoses
			Diarrhea in the Returning Traveler
		Ophthalmologic Injuries
		Skin Injuries and Infections
			Burns
			Lacerations
			Necrotizing Soft Tissue Infections (NSTI)
		Vector-Borne Infections
		Conclusion
		References
	Chapter 17: But…I’m a General Surgeon! Obstetric, Gynecologic, and Urologic Emergencies
		Introduction
		Female Reproductive Anatomy
		Pregnancy at Sea
			Spontaneous Vaginal Delivery
			Perineal Laceration Repair
			Breech Presentations
			Postpartum Hemorrhage (PPH)
			Delayed Placental Removal or Avulsed Cord
			Cesarean Delivery
		Gynecologic Emergencies
			Ectopic Pregnancy
			Ovarian Torsion and Ruptured Hemorrhagic Cysts
			Straddle Injuries/Vaginal Lacerations
			Bartholin’s Cyst and Abscess
		Male Genital Emergencies
			Testicular Torsion
			Testicular Injury
			Urethral Injury
		Conclusion
		References
			Further Reading
	Chapter 18: Haze, Gray, and Endoscopy Underway
		Introduction
		Endoscopy Equipment
			The “Equipment Tower”
			Endoscopes
			Electrocautery Unit and Argon Plasma Coagulation (APC)
			Preparing Equipment for a Case
			Equipment Set-Up
			Endoscopic Instruments
		Risks of Esophagogastroduodenoscopy (EGD) and Colonoscopy
			Moderate Sedation/Monitored Anesthesia Care (MAC)
		Techniques for Performing Esophagogastroduodenoscopy (EGD) and Colonoscopy
			Esophagogastroduodenoscopy (EGD)
			Colonoscopy
		Common Pathologies: Dysphagia and Odynophagia
			Esophageal Foreign Body
			Eosinophilic Esophagitis (EoE)
			Drug-Induced Esophagitis
			Infectious Esophagitis
			Erosive Esophagitis
		Common Pathologies: Gastrointestinal (GI) Bleeding
			Peptic Ulcer Disease (PUD)
			Dieulafoy Lesion
			Angiodysplasia (AD)
			Colonic Ischemia
			Diverticulosis
			Inflammatory Bowel Disease (IBD)
			Internal Hemorrhoids
		Incidental Findings
			Gastric Inlet Patch
			Barrett’s Esophagus
			Schatzki Ring
			Pancreatic Rest
			Polyp
			Lipoma
		Colorectal Cancer (CRC) Screening
		Conclusion
		References
	Chapter 19: Of Hatches and Hands: Management of Hand Injuries
		Introduction
		Basic Anatomy and Terminology
		Management of Urgent/Emergent Hand Injuries
			Hatch Hand: Urgent/Emergent Hand Injuries: Likely Medical Evacuation (MEDEVAC)
			Lacerations and Tendon Injuries: Likely Medical Evacuation (MEDEVAC)
			Digital Nerve Injury: Likely Medical Evacuation (MEDEVAC)
			Amputations: Likely Medical Evacuation (MEDEVAC)
			Dysvascular or Crushed Limbs: Likely Medical Evacuation (MEDEVAC)
			High-Pressure Injection, Burns, and Degloving Injuries: Likely Medical Evacuation (MEDEVAC)
			A Word on Damage Control Orthopedics (DCO)
		Management of Lower Acuity Hand Injuries
			Carpal, Metacarpal, and Phalangeal Fractures: Likely Nonoperative Management
			Carpal Fractures: Likely Nonoperative Management Versus Routine Medical Evacuation (MEDEVAC)
			Metacarpal Fractures: Likely Nonoperative Management Versus Routine Medical Evacuation (MEDEVAC)
			Phalangeal Fractures and Dislocations: Likely Shipboard Nonoperative Management
			Fingertip Injuries: Likely Shipboard Nonoperative Management
		Supplies and Prevention
		Conclusion
		References
			Further Reading
Part IV: Critical Care, Trauma, and Burn Management
	Chapter 20: The Floating Intensive Care Unit: Capabilities and Limitations
		Introduction
		Staff, Space, and Supplies
			Staff
			Space
			Supplies
		Medical Evacuation (MEDEVAC)
		Critical Care Emergencies at Sea
			Sepsis
			Acute Coronary Syndromes (ACS)
			Hypertensive Crisis
			Hyperglycemic Crisis
			Nonsurgical Neurologic Emergencies
			Venous Thromboembolism (VTE)
			Gastrointestinal (GI) Bleeding
			Anaphylaxis
		Conclusion
		References
			Further Reading
	Chapter 21: Acute Respiratory Failure and Ventilator Management Afloat
		Introduction
		Respiratory Failure in the Operational Environment
		Diagnosis of Respiratory Failure with Limited Equipment
			Laboratory and Monitoring
			Diagnostic Imaging
		Airway and Ventilator Management in the Operational Theater or Deployed Unit
		Acute Hypoxemic Respiratory Failure
			Pathophysiology of Hypoxemia
			Acute Respiratory Distress Syndrome (ARDS)
		Treatment of Acute Hypoxemic Respiratory Failure
			Low Tidal Volume (LTV) Ventilation
			Proning
			Dexamethasone
			Aggressive Euvolemia
		Hypercapnic and Mixed Respiratory Failure
			Pathophysiology of Hypercapnia
		Treatment of Acute Hypercapnic Respiratory Failure
		Conclusion
		References
	Chapter 22: Damage Control Surgery at Sea
		Introduction
		“Damage Control Zero” and Advanced Resuscitative Care Afloat
		Indications for Damage Control Surgery (DCS)
			Hypothermia
			Acidosis
			Coagulopathy
		Abdominal Damage Control Surgery (DCS)
		Vascular Damage Control Surgery (DCS)
		Damage Control Resuscitation (DCR)
		Definitive Surgical Repairs
		Aircraft Carrier (CVN) Considerations
		Large Deck Amphibious Assault Ship Considerations
		Austere Resuscitative Surgical Team Considerations
		Conclusion
		References
	Chapter 23: Damage Control Resuscitation and the Walking Blood Bank
		Introduction
		Damage Control Resuscitation (DCR)
		Platform-Specific Capabilities
			Aircraft Carrier (CVN)
			Fleet Surgical Team (FST)
			Expeditionary Resuscitative Surgery System (ERSS)
		Frozen Blood Product Capabilities
			FWB: Fresh Whole Blood; PRBC: Packed Red Blood Cells; FFP: Fresh Frozen Plasma
		Walking Blood Bank (WBB)
			Preparation
			Activation/Screening
			Delivery
			Post-delivery
		Special Considerations for Austere Role 2 Surgical Teams
		Conclusion
		References
	Chapter 24: Orthopaedic Damage Control at Sea
		Introduction
		Fracture Care
			Extremity Fractures
			Pelvic Fractures
		Infection Control
		Acute Compartment Syndrome (ACS)
			Pathophysiology
			Associated Conditions
			Signs and Symptoms
			Treatment
		Dislocations
			Shoulder
			Ankle
		Conclusion
		References
	Chapter 25: Austere Neurosurgical Emergencies
		Introduction
		Traumatic Brain Injury (TBI) Pathophysiology
			Intracranial Dynamics
			Primary and Secondary Brain Injury
		Neurocritical Care
			Evaluation
			Medical Management
			Neurological Exam
			Anti-epileptic Drugs (AEDs)
			Elevated Intracranial Pressure (ICP)
			Hyperosmolar Therapy
		Surgical Management
			External Ventricular Drain (EVD) and Intracranial Pressure (ICP) Monitor Placement
			Decompressive Hemicraniectomy
		Conclusion
		References
	Chapter 26: Burn, Inhalation, and Electrical Injuries
		Introduction
		Mechanism of Injury
		Severity of Burn Injury
			Anatomy
			Depth of Burn Injury and Corresponding Treatment Modalities
			Total Body Surface Area (TBSA) of Burn Injury
		Phases of Burn Care
			Stop the Burning and Initial First Aid “Buddy Care” in the Field
			Initial Evaluation and Management at a Medical Facility
				Evaluation
				Airway
				The Difficult Surgical Airway
				Resuscitation
			Burn Wound Care
				Clean
				Reassess
				Antibiotics
				Bandaging
				Pain Management
		Preparation for Transport
			Securing Endotracheal Tube (ETT)
		Burn Wound Healing
			First Degree: Superficial Burns
			Second Degree: Superficial Partial-Thickness Burns
			Second Degree: Deep Partial-Thickness Burns
			Third Degree: Full-Thickness Burns
			Fourth Degree: Burns Involving Structures Deep to the Skin Including Soft Tissue and Bone
		Burn Pathophysiology
			Local Tissue Damage
			Systemic Capillary Leak
			Burn Shock
		Burn Wound Infections
			Burn Wound Cellulitis
			Burn Wound Infection
			Burn Wound Sepsis
		Types of Burn Injury
			Inhalation Injury
			Scald Injury
			Steam Injury
			Flame Injury
			Contact/Conduction Injury
			Friction Injury
			Electrical Injury
			Chemical Injury
			Radiation Injury
		Elevated Compartment Pressures and Compartment Syndromes
			Escharotomy
			Lateral Orbital Canthotomy Release
		Technical Procedures Used in Burn Care
			Equipment
			Excision of the Burn Wound
			Harvesting Donor Skin Graft
			Hemostasis
			Skin Grafting Technique
			Bandaging Postoperative Autografts and Donor Sites
		Conclusion
		Further Reading
	Chapter 27: Management of the Drowned Patient
		Introduction
		Drowning
			Definition of Drowning
			Process of Drowning
			Shallow Water Drowning
			Morbidity/Mortality/Complications
		Management
			First Responder Care
			Initial Management
			In-Hospital Airway Management
			Ventilator Management
		Considerations in Fresh, Salt, and Contaminated Water
			Fresh Water
			Salt Water
			Contaminated Water
			Atypical Organisms
		Cold Water
		Conclusion
		References
			Further Reading
	Chapter 28: Management of Hypothermia and Immersion Injuries
		Introduction
		Hypothermia
			Pathophysiology
			Staging and Symptoms
			Field Passive Rewarming
			Field Active External Rewarming
			General Treatment Strategies
			Cardiopulmonary Resuscitation (CPR) in Hypothermia
		Cold Water Immersion
			Pathophysiology
			General Treatment Strategies
			Swimming-Induced Pulmonary Edema (SIPE)
		Frostbite
			Pathophysiology
			Staging and Symptoms
			General Treatment Strategies
			Chilblains
			Cold Urticaria
		Non-Freezing Cold Injuries (NFCI)
			Pathophysiology
			General Treatment Strategies
			Warm Water Immersion Foot (WWIF)
		Conclusion
		Further Reading
	Chapter 29: Acute Management of Chemical, Biological, Radiological, and Nuclear Exposure at Sea
		Introduction
		Operation Tomodachi
		Chemical and Biologic Agent Exposure
			Prevention and Planning
			Containment and Decontamination
			Management
		Radiation and Nuclear Agent Exposure
			Prevention
			Containment and Decontamination
			Management
		Conclusion
		Further Reading
	Chapter 30: Maritime Prolonged Casualty Care
		Introduction
		Prolonged Casualty Care (PCC) Mindset
		PCC Limitations
			Staffing
			Training
			Equipment
		Core Skill Sets
			Minimum/Better/Best
			Diagnostics/Monitoring
			Resuscitation
			Airway
			Ventilator
			Sedation/Analgesia
		Common Situations
			Infections/Sepsis
			Cardiovascular/Thromboembolic Disease
			Burn/Trauma
		Brilliance in the Basics
		Preparation for Medical Evacuation (MEDEVAC)
		Conclusion
	Chapter 31: En Route Care: Shore to Ship, Ship to Ship, and Ship to Shore
		Outline Placeholder
		En Route Care (ERC) Patient Preparation
		En Route Care (ERC) Mission Planning
		ERC Mission Execution
		Transport Planning Concerns
			Patient Access and Packaging
			Packaging Pearls
			Equipment Organization
			Organization Pearls
			Transportation Safety
			Safety Pearls
		Conclusion
		References
Part V: Humanitarian and Disaster Relief Missions
	Chapter 32: Principles of Elective Navy Humanitarian Missions
		Introduction
		Objectives of U.S. Navy Humanitarian and Civic Assistance (HCA) Missions
		Small- and Medium-Scale HCA Missions
			Understanding Host Nation Capabilities
			Working with State and International Agencies or Organizations
		Large-Scale HCA Missions
			Medical Capabilities of U.S. Navy Hospital Ships
			The Humanitarian Assistance Survey Team (HAST)
			The Advanced Echelon or Advanced Liaison (ADVON) Teams
			Providing Surgical Care
			Other Aspects of Large-Scale HCA Missions
		Challenges of HCA Missions
		Deployment Considerations
			Capabilities of the Surgical Team
			Screening Criteria for Surgery
			Surgical and Medical Civil Action Programs (SURGCAPS and MEDCAPS)
			Subject Matter Expert Exchanges (SMEE)
		Post-deployment
			Lessons Learned
			After Action Reports
		Conclusions
		References
			Further Reading
	Chapter 33: Disaster Relief: Lessons Learned
		Introduction
		The Earthquake Heard Around the World: Haiti 2010
			Medical Capability Limitations of a US Aircraft Carrier
			Walking Blood Bank (WBB) Activation
			Translation Challenges
			Absence of Training Requirements for Leaders
			Supply Reconnaissance
		The “Apocalyptic [12]” Aftermath of Hurricane Maria: Puerto Rico 2017
			Humanitarian Assistance Versus Disaster Relief
			Intensive Care Unit (ICU) Care in a Unique Environment
		Beware the Ides of March: The USNS Comfort Augments New York’s Medical Care During the COVID-19 Pandemic
			Activation Without Known Mission Causes Manning Shortages
			Medical Capability Limitations of a Hospital Ship
			Just-In-Time Supply Limitations
			Ongoing Mission Execution Adaptations and Limitations
		Conclusions
		References
	Chapter 34: Children in an Operational Environment: Forward Surgical Teams Caring for Pediatric Patients
		Introduction
		Clinical Vignettes
		Intravenous Access
		Common Medication Doses
		Fluid and Blood Resuscitation
		Pediatric Vitals
		Anatomical Considerations
			Differences in Airway
			Other Key Anatomic Differences
		Trauma in Pediatric Patients
			Primary and Secondary Survey in Pediatric Patients
			Traumatic Brain Injury (TBI) and Pediatric Glasgow Coma Scale (GCS)
			Additional Trauma Surgery Considerations
		Management of the Malnourished Pediatric Patient
		Abdominal Surgical Incisions
		Chest Tubes, Drains, Foleys
		Any Special Equipment to Bring on the Ship that Is Not in the AMAL Just in Case?
		Common Surgical Procedures
			Inguinal Hernia
			Umbilical Hernia
			Incision and Drainage Abscess
			Appendectomy
			Malrotation/Volvulus
		Conclusion
		References
	Chapter 35: Avast! Acute Medical Emergencies of Detained Pirates or Local Nationals
		Introduction
		Ethics and Level of Care
		Standard Operating Procedures (SOP)
		Training
		Specific Medical Situations
			Tuberculosis (TB)
			Coronavirus Disease 2019 (COVID-19) and Other Communicable Diseases
			Dehydration and Malnutrition
			Dental Health
			Mental Health
			Chronic Medical Conditions
		Provider and Crew Safety
		Conclusion
		References
	Chapter 36: Practical Bioethical Principles in the Deployed Maritime Environment
		Introduction
		Justice
		Autonomy
		Nonmaleficence
		Beneficence
		Ethics Curriculum and Training
		Conclusion
		References
Appendix A: MacGyver or Tactically Acquire? Maritime “Alternate” Equipment
	MacGyver or Tactically Acquire?
	MacGyver
	Tactically Acquire
	References
Appendix B: Sample Packing List for Maritime Deployment
	General
	Uniforms
	Clothing
	Technology
	Medical/Surgical
	Paperwork/Administrative
	Hygiene/Toiletries
	Berthing/Stateroom
	Leisure Time
Appendix C: Glossary of Common Nautical Terms
	References
Appendix D: Common Acronyms and References
	Common Acronyms
	Common References and Resources Relevant to Combat Trauma and Expeditionary Surgery
Index