J Royal Naval Medical Service 2014, Vol 100.2 205

Operational Op Patwin Part 2: HMS Illustrious’ medical response to

Surg Cdr A Dew

Abstract

Operation PATWIN was the ’s (UK) response to the disaster caused by Typhoon Haiyan. The UK deployed a force including HMS DARING and HMS ILLUSTRIOUS and this article describes the medical response including the deployment of a Role 2 medical team and the hosting of a UK civilian medical team UK Med. The deployment followed humanitarian guidelines in UK doctrine and contained in the guidelines, but demonstrated a unique example of a civilian team supported by the military.

Background Typhoon Op PATWIN was the UK military response to the disaster At 2040L on 7 Nov 13 Typhoon Haiyan (known locally as caused by Typhoon Haiyan. The UK deployed a force Yolanda) made landfall on the Philippine Islands; Haiyan was the strongest recorded at landfall and the deadliest including HMS DARING and HMS ILLUSTRIOUS to hit the Philippines with over 6,000 people killed (2). and this article is the second of two articles describing The typhoon followed a north-westerly course across the the Maritime contribution to OP PATWIN; the first was Philippines weakening slightly as it went. Its effect varied published in the previous issue of this journal (1). according to local conditions such as height above sea level and shelter from headland, but the greatest damage was HMS ILLUSTRIOUS (LUST) is a CVS (Carrier Vessel caused by the storm surge striking low-lying communities. Support) now re-roled as an LPH (Landing Platform Helicopter). She deployed for COUGAR 13, the annual Response Force Task Group deployment, on 10 Aug 2013. After participating in Exercise ALBANIAN LION she passed through the on 10 Sep to conduct exercises with Middle Eastern navies and in early November 2013 was off the coast of Somalia participating in counter- piracy operations. As the R2 (Readiness State 2) LPH she was at five days’ notice to respond to any incident and had conducted Flag Officer Sea Training earlier in the year that included a disaster relief exercise. She was due to return to the UK in early December 2013.

Figure 1: The path of Typhoon Haiyan (Yolanda) through the The medical department consisted of 11 staff with a Philippines. General Duties Medical Officer (GDMO) embarked for the deployment. The Role 2 Afloat (R2A) capability, equipped One of the hardest hit areas was Tacloban, capital of Leyte to provide damage control surgery within two hours of province, and the first population centre that the typhoon wounding, had been exercised in COUGAR 12, but the hit. As the international media became aware of the disaster this area became the focus of the international response, planned embarkation for COUGAR 13 was cancelled when not least because it was most accessible to the American Exercise DJIBOUTIAN LION was cancelled. As one of the contingent approaching from the east. R2A platforms LUST holds all the Role 2 equipment at 48 hrs notice, but anticipates the R2A team to deploy with or at The international response tended to follow the course of the the same time as blood products to complete the capability. typhoon, with aid agencies arriving in the western islands 206 Operational

much later than the eastern parts. The aid agencies were also on 11 Dec. LUST departed the Philippines on 12 Dec, challenged by the dispersed nature of the eastern islands (or coinciding with the end of Op PATWIN, in order to return Visayas) and their relative inaccessibility except by sea or to the UK and regenerate for COUGAR 14. air. Conversely, they were attracted to Tacloban and Cebu by their relative accessibility by air with established airports. International Medical Response This meant that HMS DARING and LUST, approaching There was a robust international medical response and from the west by sea, and with air assets, were ideally the different teams formed clusters consisting of Foreign placed to contribute to the aid effort in the eastern Visayas. Medical Teams of varying capability. Many of those on The (RAF) dispatched a C130 to Cebu outlying areas were equivalent to Role 1 (i.e. small medical and assisted both the international effort and the movement teams able to provide immediate life saving treatment and of some supplies and people for DARING and LUST; pre-hospital care with some primary care) but there were exchange officers were sent to Roxas, Cebu and Manila quite sophisticated field hospitals in Tacloban and Cebu. with Joint Force Logistics Command (JFLogC) establishing The UK dispatched a civilian medical team called UK Med. a one-star headquarters in Manila to co-ordinate the British Initially they split into a surgical team that went to Tacloban response. The Canadian military established themselves in and a pre-hospital team that went to HMS DARING. On Roxas on Panay island, co-ordinated the aid effort in that the handover to LUST the pre-hospital team changed and region and worked closely with LUST during her mission. a new team joined LUST. Both ship’s movements were co-ordinated by DfID working from Manila and by the LUST Canadian team co-ordination team working in Roxas. The Five days after the storm hit, HMS ILLUSTRIOUS was medical effort was co-ordinated by the health clusters that released from COUGAR 13, operating off Somaliland, to were content to allow LUST to move freely and deploy deploy at best speed for Relief operations in support of medical teams as necessary, while reporting back to the DfID (Department for International Development). A brief, health clusters. but intensive, logistics stop in Singapore enabled a seamless handover with HMS DARING on 25 Nov and subsequent Handover from DARING provision of humanitarian aid, primarily to the point of need The handover from DARING consisted of an afternoon of in more remote islands of the central Philippines. The 36- briefing in which the Medical Officer (MO) from DARING hour logistic stop in Singapore was key to the success of the presented to the Command Team of LUST and separately to operation and involved the embarkation of large quantities the medical team whilst a combined LUST and DARING of disaster relief stores and a few augmentees, including team were ashore conducting a Humanitarian Assistance to embarkation of Role 2 personnel and blood products. Disaster Relief (HADR) task. This enabled the LUST team Besides the Role 2 personnel the medical department to continue the work the DARING had started. The main required very little additional equipment or supplies, but difference between the two platforms was the increased used the opportunity to embark typhoid vaccines (after a capacity of LUST with its extra helicopters and personnel, period in which vaccination had been suspended because of which enabled LUST to send seven teams ashore and so a shortage of the vaccine) and a tropical medicine module. serve several islands or baranguays at once, where DARING had sent one team. LUST relieved DARING in North East Panay on 25 Nov and then spent six days delivering aid to the dispersed island Force Protection group to the east of Panay. There were up to seven teams The Command Estimate highlighted that the highest risk deployed ashore at any one time delivering humanitarian to personnel ashore would be medical. This included heat aid or helping with reconstruction. The ship was then tasked illness, biting insects, diarrhoeal disease and the risk of with assessing the need in islands to the west of Panay, trauma. Medical timelines were prolonged because of the and moved between several island groups deploying small lack of reliable host nation facilities and concern about assessment teams ashore. The need for aid was much less the transit time to them. The JFLogC Medical Estimate than in East Panay but the completed assessments allowed concluded it would take two hours from Point of Wounding the UN effort to focus efforts elsewhere. LUST then to definitive care; this was based on a rapid transit by Merlin moved back to East Panay to continue aid delivery, this helicopter to Manila where transport times to hospital can time working much more closely with Non-Governmental be extended by traffic congestion. To enable freedom of Organisations (NGOs) who had moved in to the area, before manoeuvre and remain self-reliant, deployment of Role 2 sailing for Manila to offload a residual amount of stores and was recommended by ILLUSTRIOUS and independently conduct Defence Engagement. agreed by Navy Command Headquarters, Permanent Joint Headquarters, and HQ Surgeon General (SG). Role 1 DfID tasking was completed on 10 Dec, prior to a high- medics ensured that immediate aid was always available profile Defence Engagement and logistics stop in Manila to teams ashore thus obviating the need for a designated J Royal Naval Medical Service 2014, Vol 100.2 207

CASEVAC helicopter (although one was always available The following is a quote from one of the MAs onboard: within an hour). “All the MAs on board had been trained to provide Role 1 humanitarian aid in Flag Officer Sea Training serials but With augmentation of LUST by Role 2 the Principal never thought we would have to actually do it. Once we Medical Officer assessed that he could support up to seven got told we were apprehensive about what was expected teams ashore with a BATLS (Battlefield Advanced Trauma of us as MAs, whether it was to provide aid to the locals Life Support) trained medic. This allowed a reserve of or to provide medical cover for the teams ashore. Once we trained personnel in case of an emergency, but required found out that we were to provide medical cover for the augmentation by the Medical Assistant (MA) from the Role teams ashore we were more focused on the task at hand. 2 team and, on occasion, an Emergency Medicine (EM) Once ashore we found that we were more use as a spare nurse. All of the MAs who went ashore were integrated in set of hands within the teams ashore as we could provide to the Aid Teams and were an additional asset for the team med cover whilst helping the teams. Predominately it was leaders. helping to re-roof community buildings such as schools or churches, which we achieved quite well and got the locals involved with the teams. The teams seemed quite relieved to know that they had a member of the ship’s company medical department within them (even though we didn’t really have to do anything we went for).”

Role 2 A complete Role 2 team including physician and MDSS technician embarked, who were all familiar with their role onboard with the exception of In-Transit Care (ITC). This was successfully provided by an EM nurse who received local training on aircraft types. The capability was only deployed to enable freedom of manoeuvre within medical timelines and therefore to provide force protection to UK personnel. There was no direction to provide Role 2 care to Philippines nationals, although it was clear that if somebody was in need of urgent care not available close by then the team would be used. The capability was activated for one casualty with heat illness. Members of Role 2 were occasionally used to augment the Role 1 team who were heavily engaged in supporting teams ashore with two EM nurses and the ITC MA all deploying with Humanitarian and Disaster Relief teams. Role 2, therefore, enabled freedom of manoeuvre for LUST and enhanced the Role 1 team’s ability to support operations ashore.

UK Med UK-Med is a NGO which provides medical staff to disasters. Its members are maintained on a register and are on a roster to respond to incidents. They have previously responded Figure 2. A member of MHS Illustrious’ Medical Team assisting on to disasters in Chile, China, Haiti and Pakistan. A team of the ground as part of the Aid Teams. six civilian doctors, nurses and paramedics from UK Med, sponsored by DfID, embarked on LUST and these personnel were used to provide medical aid ashore. Assessment teams would be used to identify islands (baranguays) that required aid and the UK Med team would be then be sent to that area for up to a day to provide clinics. They saw 280 patients, the majority of whom had chronic disease or new problems since the typhoon, but were not able to access the Philippines health service which was disrupted by the Typhoon. LUST’s team built upon the success of the team on HMS DARING, 208 Operational

although UK Med services were less required as time went Environmental Health by and as other NGOs with medical teams moved into the An Environmental Health Officer deployed with the Role more remote islands. 2 team and an Environmental Health Technician was part of 24 Royal Electrical and Mechanical Engineers The teams were sent ashore with a LUST medic and a Regiment. These individuals provided two functions: signaller if not co-located with other teams. The LUST advice to command via the PMO on force protection issues medic provided logistical support to the clinic and liaison (especially the risk of tropical diseases), and assessment of with the ship but also gained valuable experience of environmental issues especially water sources on the islands, conducting aid clinics. testing 24 wells. They brought an enormous amount of experience and knowledge about the environmental threat, which was hugely valuable, as ships do not regularly deploy to the Philippines. They were very frequently sent ashore with assessment teams to evaluate the environmental threat to both the ship’s teams and to locals and were especially useful if a team had been established on the ground in a ‘camp’ or if water sources or sanitation had been disrupted by the typhoon.

The Environment Health Officer reported: “From a Medical Force Protection aspect the Operation was a resounding success with no significant increase in morbidity amongst the ships company. From the outset it was clear that the biggest risk to health came from having to carry out physically demanding work in hot and humid conditions. This combined with a host of other hazards from flora and fauna presented a real challenge. However, the Assistance Teams were fully briefed before leaving the ship and the risks were well managed.”

As with most Disaster Relief Operations, basic advice can have a profound effect on the health of the affected population. Examples included a simple test for saltwater contamination of a water source, provision of emergency Figure 3. Medical care being delivered on the ground by HMS latrines and measures to remove mosquito breeding sites. Illustrious medical staff. Unless these basic issues are addressed at an early stage conditions can deteriorate rapidly. The early deployment The use of the UK Med team was continued after DARING of Environmental Health to HADR operations is hugely left and was a novel example of a civilian (charity- beneficial and they should be involved in all stages of sponsored) team being assisted and hosted by the military planning, as they are better able to identify and mitigate to deliver aid soon after a disaster. medical risks.

The concurrent deployment of a highly experienced Discussion military Role 2 team and a similarly qualified civilian team Joint Doctrine Publication 3-52 refers to UN guidance with a focus on HADR was mutually beneficial and enabled including the ‘Oslo Guidelines’ for the involvement of a valuable exchange of experience and knowledge. A replenishment at sea serial afforded a quiet day in the middle the military in disaster relief operations (3). In these, the of Op PATWIN and so a conference was held in which Role military should “be seen as a tool complementing existing 2 presented the military’s experience of trauma over the last relief mechanisms in order to provide specific support to ten years and UK Med gave a presentation on the work they specific requirements, in response to the acknowledged had done in earthquakes in Pakistan and Haiti. A MA from humanitarian gap between the disaster needs that the relief LUST gave a moving presentation on the role of an MA community is being asked to satisfy and the resources both in Afghanistan and afloat. available to meet them.”(4) J Royal Naval Medical Service 2014, Vol 100.2 209

LUST provided a unique capability able to quickly move JFLogC and an RAF C130 detachment. It demonstrated between island groups and assess need, providing aid the unique versatility of the and the maritime where required. From a medical perspective LUST was environment and was an example of the military providing a able to facilitate the deployment of a civilian medical unique capability during the early phases of a disaster relief team much better able to provide humanitarian assistance operation. The medical effort comprised a Role 2 team than the organic medical team. The UK Med team were for Force Protection and a civilian medical team whose accommodated and supported through the use of internet deployment was facilitated by the UK military. access, shared information and transport to and from their tasks, as well as being given a military escort and signaller References whilst conducting clinics. This use of a hybrid structure of 1. Butterworth SJ. Operation PATWIN: HMS DARING’s military staff directly supporting civilian teams was unique experience of providing humanitarian disaster relief and is a model for future operations. following super-Typhoon Haiyan. J Roy Nav Med Serv 2014;100.1:81-7. 2. http://reliefweb.int/sites/reliefweb.int/files/resources/ The deployment of the Role 2 team was subject to NDRRMC%20Update%20re%20Sit%20Rep%2092%20 much debate, both before and since the operation. From Effects%20of%20%20TY%20%20YOLANDA.pdf. LUST’s perspective they brought an essential part of the Accessed 28 Jan 14. force protection and the ability to move freely around 3. Ministry of Defence. Joint Doctrine Publication 3-52. the Philippines without concern about where the nearest Disaster Relief Operations. 2nd ed. hospital would be. In its execution LUST was sent to far 4. United Nations Office for the Coordination of Humanitarian more remote islands than had been anticipated in the initial Affairs. Oslo Guidelines - Guidelines on the use of foreign Command Estimate and so the medical timelines used in the military and Civil Defence Assets in Disaster Relief. https:// docs.unocha.org/sites/dms/Documents/Oslo%20 original planning were significantly extended. Guidelines%20ENGLISH%20(November%202007).pdf. Accessed 14 Apr 14. Conclusions Op PATWIN was a contingent Disaster Relief operation conducted by HMS DARING, HMS ILLUSTRIOUS,

Author Surgeon Commander A Dew MBBCh MRCGP MA RN.

Formerly PMO HMS Illustrious Currently SO1 Med Force Generation RN Navy Command Headquarters, Whale Island,

Correspondence [email protected]