One of four intensive care units aboard the Comfort.

he USNS Comfort (T-AH-20) and USNS Mercy (T-AH-19) are two hospital ships operated by the United States and assigned to the Military Sealift Command. Comfort is home-ported in Baltimore, Maryland, while the Mercy is located in San Diego, California. Both ships are former San Clemente Class supertankers that were extensively modified to their present configurations. At full operating status, a crew on one of these ships consists of approximately 60 civilian maritime personnel and 1,200 military personnel to include a full complement of medical and surgical subspecialties.

In recent years, these ships have deployed to provide humanitarian relief after 9/11 in New York City, the tsunami in Southeast Asia and Hurricane Katrina in New Orleans. The primary mission of these hospital ships, however, 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 12 August 1949.”¹ In support of this mission, Comfort was the only Level III medical facility in the area of operations at the outbreak of hostilities for Operation Iraqi Freedom (OIF). As a result, Navy anesthesia and Comfort have played pivotal roles in OIF.

The Comfort passes the Statue of Liberty enroute to Manhattan to provide assistance to victims of the September 11 terrorist attack on the World Trade Center. U.S. Navy Photo by Journalist 1st Class Preston Keres.

The Comfort is capable of providing 1,000 hospital beds to include 80 intensive care unit beds and 50 beds in the casualty receiving area. The 12 operating rooms are equipped with Ohmeda Excel 210 series anesthesia machines (GE Medical Systems, Waukesha, Wisconsin) with 7000 series ventilators, Hewlett Packard monitors (Hewlett Packard, Palo Alto, California), Datex Ohmeda 5250 RGM gas analyzers (GE Medical Systems), isoflurane and sevoflurane vaporizers, Hotline fluid warmers (Smiths Medical, Keene, New Hampshire) and model 505 Bair Hugger warmer units (Arizant Healthcare, Eden Prairie, Minnesota). Additionally eight Level One rapid infusers (Smiths Medical) are available. The ship is configured with two low-pressure oxygen production plants (GEECO, Milford, Connecticut) capable of producing 20 gallons of liquid oxygen per hour, 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 located primarily in the casualty receiving area, intensive care units and the main operating room.²

At the beginning of OIF in March 2003, Comfort had on board a total of 135 units of packed red blood cells, 147 units of fresh frozen plasma and more than 1,000 units of frozen packed red blood cells, the majority of which were class D. Class D blood is greater than 10 years old and has not been tested for the p24 antigen associated with human immunodeficiency virus. The Navy has a waiver from the Food and Drug Administration to use this type of blood only during wartime; fortunately, none was required.³ Class A, B and C frozen blood also was available. Twelve deglycing units were available, but the use of frozen blood was never required. Platelets were not available due to problems with their short shelf life and timely resupply at sea. If platelets are needed for forward-deployed casualties, the military activates the “walking blood bank,” whereby predesignated donors have been typed and cross-matched for the transfusion of fresh whole blood. During the two months of major hostilities between March 20 and May 6, 2003, Comfort received three separate replenishments of approximately 200 units each of packed red blood cells, and more than 600 units were transfused.

Comfort at Work
During those 48 days of major conflict, more than 600 patients were treated, including 330 inpatient admissions, 196 of which were enemy prisoners of war (EPWs) or Iraqi civilians. A total of 630 anesthetic procedures were performed, with the greatest number of combat casualty cases (31) occurring on April 11, 2003. Of the 630 wartime cases, 560 (89 percent) were combat-related, and the remaining 70 (11 percent) were noncombat-related. A total of 127 anesthetic and surgical procedures were provided for U.S./coalition forces, representing 20 percent of the wartime caseload. The remaining 503 procedures (80 percent) were performed for Iraqi nationals, 383 (61 percent) for presumed EPWs and 120 (19 percent) for presumed Iraqi civilians (women and children). A total of 45 procedures were performed for pediatric patients (<18 years of age), the youngest being 3 years of age. Two patients were pregnant on admission, one of whom spontaneously aborted, and the other delivered a viable baby on transfer from Comfort. Seventy-seven percent of all cases were treated by either orthopedics (41 percent) or general surgery (36 percent). For many of the multiple-trauma combat casualties, more than one surgical service was involved. The primary anesthetic technique was general anesthesia (83 percent). Regional anesthesia had limited utility due mainly to the large proportion of Iraqi patients and difficulty with the language barrier.²

One of the major lessons learned during OIF is the appropriate clarification of the ship’s capacity. Comfort is listed as a 1,000-bed hospital ship; however, those 1,000 beds are subcategorized into 500 limited self-care beds, 120 light-care beds, 280 intermediate-care beds, 80 intensive care unit beds and 20 postanesthesia care unit beds. It also was discovered that each 20-bed intensive care unit could accommodate only 15 patients requiring mechanical ventilation, thus reducing the advertised intensive care unit capabilities.

The Comfort's halls are as wide and long as a shore-based hospital, which makes it easy to transport patients to different areas of the ship. U.S. Navy photo by Photographer's Mate 1st Class Shane T. McCoy.

Comfort for All
OIF marked the first time that large numbers of EPWs and foreign nationals were treated aboard Comfort. Care was provided for Iraqis that was unavailable in their own country and prohibited aboard combatant ships in the Persian Gulf. Disposition for the Iraqi casualties was problematic as there was no plan in place for them to receive follow-up or rehabilitative care in their own country, and other Arabic nations were unwilling to accept them into their countries.

Initially only two translators were available onboard; however, this did not present a major obstacle in providing anesthesia care. Many patients were transferred from lower-echelon medical treatment facilities and had medical records of their care. Patients undergoing repeat surgical procedures aboard Comfort had previous preanesthetic evaluations in their records. Anesthetic consent for EPWs was implied, although efforts were made to obtain a verbal indication of patient understanding. Translators were most helpful with pediatric patients, providing reassurance to the child and answering questions if a family member was present. With rare exceptions, most of the Iraqi patients appeared to be grateful for the care they were receiving and cooperated readily.

At the beginning of OIF, it was the goal and the plan for Comfort to fulfill its written mission of supporting our U.S. military troops. Due to the rapid pace and early coalition successes, land-based level III facilities were not available when needed. Comfort was able to bridge that gap until the land-based facilities became available. Furthermore the mission evolved to include the treatment of EPWs and adult and pediatric foreign nationals.

As a result, Comfort did and will continue to provide American goodwill wherever there is human suffering.

References:
1. U.S. Navy Department: Required Operational Capabilities and Projected Operational Environment (ROC/POE) for T-AH-19 (MERCY) Class Hospital Ships, OPNAVINST 3501.16C. Washington, D.C., U.S. Navy Department, 1997.
2. Paine GF, Bonnema CL, Stambaugh TA, Capacchione JF, Sipe PS. Anesthesia services aboard USNS COMFORT (T-AH-20) during Operation Iraqi Freedom. Military Medicine. 2005; 170(6):476.
3. U.S. Navy Department, Bureau of Medicine and Surgery: Ltr 6530/2 Ser 273/0059, Washington, D.C., U.S. Navy Department, 2001.

John F. Capacchione, M.D., is Assistant Professor of Anesthesiology, Uniformed Services University of the Health Sciences, Walter Reed Army Medical Center, Washington, D.C.