With the first light of dawn, the arid coast of Somalia comes into view from the sea. A new day begins aboard the Spanish Navy's F-82 frigate "Victoria", for four months the command ship of the EU-sponsored "Operation Atalanta". Two hundred and twenty-nine men and women from 7 countries make up the crew and the embarked staff (in the latter, English is considered the official language). The mission is to contribute to the deterrence, prevention and repression of acts of piracy and to protect the vessels of the global food programme and other vulnerable shipping in this African area. The grouping has other warships, maritime patrol aircraft and several special operations teams in the area.1
The ship's medical capability is supported by a first medical echelon (ROLE 1) composed of a medical officer, a nursing officer and a doctor who perform preventive, care and advisory duties to the command. The surgical team of ROLE 2 F (F: Forward), which recently embarked for the first time on this type of ship, is made up of three specialist military doctors (general surgeon, traumatologist and anaesthesiologist) and a military nurse with a medical-surgical speciality in operations. Its primary function is to perform advanced damage control resuscitation, on a naval platform, with limited means and allowing the casualty to be stabilised for 24−48 h, put in a state of evacuation and provide an adequate transfer to another ship or hospital on shore with more capabilities and resources. This recent surgical capability is independent of whether or not the Spanish frigate is a command ship.
All members of the surgical team must pass a medical examination prior to deployment, meet the minimum technical requirements (in the case of the anaesthesiologist, they are required to spend the last year on rotations in all surgical specialties and resuscitation areas, with at least 4 duty shifts per month in their military hospital), pass the 5-day advanced life support in combat course of the Escuela Militar de Sanidad and have received the annual course on surgery in war and major disasters given at the “Gómez Ulla” Central Defence Hospital (ROLE 4) in Madrid. In this theoretical-practical meeting, knowledge of combat surgery is updated, clinical cases of wounded treated in different deployments are reviewed, health lessons identified in the military field are recalled and practices are carried out in the experimental surgery centre of the Armed Forces. In addition, in order to familiarise themselves with all the drugs, equipment and devices available on board and to increase group cohesion, the members of the surgical team are stationed on the warship for several days before the international deployment.
This system of preparation and readiness is like that used in other allied military health facilities. Smaller, more flexible surgical teams are now being used to treat casualties from special operations teams, compared to those used in the early years of the Iraq/Afghanistan conflict.2 This change represents a real paradigm shift. The "golden hour" rule with immediate surgical capability at the cutting edge is prioritised over the more robust and complex medical treatment facilities common in the past decade.
The anaesthetic equipment on board is adequate to perform damage control resuscitation procedures and follows national standards while preserving the Helsinki recommendations for patient safety in the perioperative environment. Equipment is available for airway management (laryngoscope, laryngeal mask and tubes, Airtraq®, Frova® and cricotomy set), massive haemorrhage (packed red blood cells (4 from group 0+ and 4 from group 0-), fibrinogen, prothrombin complex - Octaplex®, Octapharma AG, Lachen, Switzerland -, tranexamic acid and calcium chloride), and for regional anaesthesia (needles for intradural, epidural, combined and nerve plexus block anaesthesia, as well as an ultrasound scanner with linear probe). There is a Dräguer Fabius® Tiro anaesthesia tower, Qnox® hypnosis and analgesia monitor, Alaris® infusion pumps, electrocardiograph, defibrillator, several transport ventilators, 6 oxygen cylinders from 50 L to 200 bars and an oxygen concentrator. The medication available in the frigate's operating theatre is similar to that can be found in any anaesthesia trolley in an operating theatre in Spain. Finally, the telemedicine capability allows real-time connection with any specialist doctor in our military reference hospital (Fig. 1).
A) Spanish Navy frigate F-82 "Victoria". B) Anaesthesia tower and anaesthetic medication. C) Infirmary-operating room of the frigate. D) Airway control equipment available on board. E) Acute haemorrhage control equipment. F) Telemedicine connection with the “Gómez Ulla” Central Defence Hospital in Madrid.
The peculiarities of the military environment, such as isolation, limited resources, limited space and abbreviated surgical capacity (a non-definitive procedure aimed at stabilising a wounded person, allowing subsequent evacuation, usually by air, and ensuring that he/she arrives alive to a hospital where the complete treatment will be performed) are variables that are not normally analysed in the civilian environment and require specific anaesthesiological procedures to be performed.3,4 From the authors' point of view, total intravenous anaesthesia is prioritised over inhalation anaesthesia in order to reduce the logistical footprint (need for resources such as electricity, number of devices, complexity of supplying or replenishment time of the material…). Regional anaesthesia is considered a good option for most surgical procedures and as an analgesic technique prior to an operation in the only operating theatre available in a situation with a large number of wounded, contingency plans are considered for a wounded person with massive haemorrhaging, such as blood products at tactical level or whole blood transfusion, and finally, the necessary tactical and medical resources are assessed to carry out aero-evacuation of the critically wounded in the naval helicopter.5,6 Throughout our maritime deployment, only locoregional anaesthesia techniques with sedation have been performed for minor surgical procedures.
Despite it being November, the day is peaceful on board, possibly because we are in the inter-monsoon period. The Spanish Navy's special operations team has returned to the ship without incident. The comradeship and sense of duty remain unchanged among the crew. In the officers' quarters, I randomly open a volume of Don Quixote, which reads "to be prepared is half the victory". A harbinger of our current mission as a naval ROLE-2 F surgical team.
FundingThe authors declare that they have not received any funding for this study.
Our thanks to the members of the Military Health Corps of the Frigate Victoria.
