J Royal Naval Medical Service 2011, 97.1 21-27

General Sailing new waters - role two afloat medical facility Enhanced counter operations September – December 2010

A L Day, D A Newman, R M Heames, J E Risdall

Introduction predominantly on the East coast of Somalia in In Autumn 2010, a Role Two Afloat Medical the Somali Basin [Figure 1]. The aim of Team (R2A), deployed onboard RFA Fort counter piracy operations was to deter and Victoria (FTVR), initially as part of the UK disrupt pirate activity through a show of Enhanced Counter Piracy (ECP) operation, Maritime Force using the assets on board initially Operation Capri under CTF 151 (with FTVR, namely the airpower of the embarked HMS Northumberland) and subsequently Merlin, and the Royal Marine boarding teams under NATO command (CTF 508) on and boats. Operation Ocean Shield with HMS Montrose. This article sets out the background to the The area of operation spanned the North West history of piracy in the Somali Basin and how region of the Indian Ocean, focusing the R2A developed its role on the ship and integrated itself with the other Embarked Military Forces (EMF) to provide support to the anti-piracy operations.

Political Background Since 2008, piracy of commercial shipping within the Somali region has escalated, finally coming to a head by the taking of the super tanker MV Sirius Star captured November 2008, 450 miles south-east of Mombasa, . Once taken it was sailed to an anchorage close to Hobyo, Somalia, a well known pirate camp area. This incident was of international concern especially as the Sirius Star (with 2 UK citizens in the crew) contained a quarter of ’s daily output of oil and resulted in its price jumping to more than $1 a barrel. The Rail Transport and Maritime Union (RMT) called for increased patrolling to prevent further incidents and ensure the safety of merchant vessels and their crews. The British government agreed there was a Figure 1 Map of the Somali Basin growing problem in the region and agreed to

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support the NATO response of counter piracy international naval counter piracy operations. operations. This has provoked global interest Pressure for resolving the problems in the and disrupted any image of government region was also being applied by international stability within the region. shipping operations, with some refusing to Colloquially known as Sea Bandits (Burcad transit the Suez Canal until the situation badeed), piracy had initially been envisaged as improved. This has been influenced by a heroic act, protecting valuable local fishing increased insurance for vessels operating in waters from foreign interest and ships laden this area, with some even employing armed with toxic cargos. In the 1990s, initial pirate security teams. gangs were formed from impoverished and remote communities, who felt that their Maritime Background fishing livelihood was being depleted through In 2009 the commenced counter irresponsible over-fishing by larger foreign piracy operations in the Indian Ocean and Gulf vessels. A typical pirate gang consisted of of Aden. Royal Marine Boarding Teams, from S young Somali men with whalers and skiffs Squadron, Force Protection Group (FPGRM) fitted with large engines. These boats were and the newly formed P Squadron, were often filled to capacity with drums of fuel, a trained to conduct boardings of various vessel number of climbing ladders, and armed with types [Figure 2]. The different levels of assault rifles and rocket propelled grenades boarding are described in Table 1. In support of (RPG’s). boarding operations at Level 3 or above, the The Somali Government attempted to presence of Role 2 Medical was required to resolve this issue by training ex-militiamen as a deal with the medical planning estimates of T1 National Coast Guard and directing them to and T2 casualties being sustained during target foreign trawlers involved in illegal fishing operations. The R2A had to provide support acts and impose ‘fines’. This involved crews within predetermined medical timelines as laid being held aboard their vessels in discrete down in doctrine(1,2). Descriptions of the anchorages until these ‘fines’ were paid. current medical timelines and medical facilities These boarding and detention methods were available at each role can be viewed in Table 2. subsequently adopted for use in criminal Following a capability review in 2009(3) operations, netting tens of thousands of dollars current operations within the Maritime, Littoral annually. The Majerten Pirate Barons who and Land environments were reviewed and initially funded these boardings, facilitated the brought up to UK clinical standards and levels development of well-organised, highly adaptive of clinical practice. Defence Planning crime syndicates with broad international Assumptions were utilised in considering the connections, involving bankers, negotiators, detailed operational requirements and ship valuations and money laundering to determined that the new enhanced R2A support these piracy operations. Alarm was expressed by European Governments following suggestions that the pirates were receiving sensitive shipping intelligence to aid their boarding operations, along with allegations that piracy was being financed and initiated from within Western Nations. Following recent escalations of piracy, the African Nations sought approval from the United Nations to try and resolve the problems in Somalia. The International Community was approached, with a view to deploying ground troops and the generation of a naval blockade, in addition to the current Figure 2 Level 2 Boarding Sailing new waters - role two afloat medical facility 23

Table 1: Boarding Levels

Boarding Level Situation Conducted By

Level 1 Simple vessel, open deck, Most RN Vessels with dedicated compliant Pirates. boarding teams, consisting of a Pacific RIB, 6 Man boarding party and preferable helicopter air cover. Level 2 Simple vessel, open deck, Most RN Vessels with dedicated non- compliant Pirates. boarding teams, consisting of a Pacific RIB, 6 Man boarding party and preferable helicopter air cover. Level 3 Complex vessel, closed decks, Requires 4 specialist (FPGRM) trained non-compliant Pirates. 6 man RM Boarding Teams. Ideally two helicopters with Maritime Sniper Teams and Role 2 Afloat Medical Teams. Level 3+ Complex vessel, closed decks, **Requires 4 specialist (FPGRM) trained opposed by pirates, with crew 6 man RM Boarding Teams. Two isolated in secure safe area on board. helicopters with Maritime Sniper Teams and Role 2 Afloat Medical Teams. Level 4 As for level 3+ but with crew held **Boarding involving Special Forces. as hostages.

** Requires Ministerial approval.

Table 2: Medical Roles and Capabilities

Medical Facility Capability Time Line

Role 1 Primary Health Care Specialised Embedded Role 1 with boarding teams First Aid, Casualty Triage, (almost immediate). Initial Rhesus and Stabilisation. Role 2 Consultant-led resuscitation, 1 hour to Resus Team and 2 hours to Damage control surgery and get to Damage Control Surgery. stabilisation, X-Ray. Role 3 Enhanced medical capability, wider Normally 24 hours but extended to 36 range of specialist capability, hours for this Operation due to distance including the ability to hold patients from operating area to Role 3 location of all levels of dependency until and endurance of Merlin Helicopter. further evacuation. Role 4 Care in UK operations is delivered Approximately 48 hours back to Queen by the NHS, for all British casualties Elizabeth Hospital, Birmingham. who require specialist or prolonged in patient care. 24 J Royal Naval Medical Service 2011, Vol 97.1

capability was needed to meet the casualty operationally. This R2A capability parallels the estimate. The nearest Role 3 facilities deemed level of Role 2 care already in place on other appropriate and suitable, were at Djibouti, UK military operations (e.g. Operation Herrick). Salalah (Oman), Mombasa (Kenya) and the Initial treatment at point of wounding Seychelles. The distances to these Role 3 would be delivered by the BATLS trained hospitals were sufficiently far from the MA/CMT embedded as a part of the Boarding operational area that permission was Team. This could then be supplemented by requested to extend the clinical timelines the MERT (Medical Emergency Response beyond those in standard doctrine to 48 hours. Team), consisting of an Emergency Nurse In its present form the current R2A provided Practitioner and Medical Assistant, depending emergency resuscitation, damage control on the severity and stability of the casualty. surgery and post-operative critical care until a An enhanced capability, MERT-E, which safe transfer to a Role 3/4 facility could be included an anaesthetist, would be available in effected, with the team embedded on the the event of a prolonged evacuation of a same platform as the Level 3 boarding casualty or one requiring critical care support capability. at the scene. After arrival at the R2A facility resuscitation Medical Organisation and initial trauma management would be carried Although Role 2 Medical Teams have been out in the Emergency Department (ED), under deployed on maritime operations and exercises the direction of the Emergency Medicine before, Operation Capri 2010 was the first consultant and two Emergency Care Trauma opportunity for the enhanced 18 strong multi- specialist nurses [Figure 3]. The ED was disciplinary team of specialists to deploy supported by a radiographer with a DRagon x-ray

Figure 3 Emergency Department Mission Rehearsal Sailing new waters - role two afloat medical facility 25

and FAST Scan capability and the laboratory can should be based on the 370 module series(4) provide basic haematology and biochemistry as and the MERT module, currently in use in land well as cross-matched blood and fresh frozen operations. At the time of the deployment, plasma. Rapid transfusion, if required, could be the principle of employing the extant 370 delivered via the Level One Rapid Infuser. The module for maritime use had been accepted in presence of two consultant anaesthetists meant principle but had not been fully funded and that ventilatory support could also be managed was not due to be so until December 2011. within the ED prior to transfer to theatre or the The R2A 370 equipment was not therefore intensive care unit (ICU). appropriated in the normal manner through The operating theatre was staffed by Medical Stores at Donnington, but was consultant general and orthopaedic surgeons, acquired and assembled in a small warehouse a consultant anaesthetist, a peri-operative in Portsmouth Dockyard. The initial specialist nurse and two operating department assessment was that, whilst not ideal, there practitioners. The focus of the operating were no deficiencies that would prevent the theatre team was to conduct life-saving, R2A declaring operational capability and damage control surgery. The expected number readiness. of procedures (and hence the stores held) was Operationally there was a requirement to pre-determined from the casualty estimate. generate Standing Operating Procedures The ICU, staffed by the two consultant (SOPs) across the clinical environment. These anaesthetist/intensivists and three specialist drew on both operational experience from ICU nurses, was resourced to provide critical other theatres and the lessons learned in care support for two patients for up to 36 multiple training serials conducted onboard. hours. Safe onward transfer with continuation These scenarios also facilitated the clinical of care to the nearest appropriate Role 3 integration of the R2A team with both the RFA facility required the formation of a Critical Care Standing Sea First Aid Party and medical Transfer Team, consisting of an intensivist and personnel from other EMFs. The resulting specialist nurse drawn from the ICU staff. SOPs have been submitted to Naval Command They would accompany the patient to the Headquarters to be adapted for use by future receiving hospital or the point of handover to R2A teams. the RAF Critical Care Air Support Team for Once the SOPs were completed the R2A onward transfer to the UK. team was in a position to identify relevant Risks and Issues and develop appropriate R2A Development Structure registers according to Health Care Assurance As this was the first maritime deployment of and Clinical Governance guidelines. Monthly the enhanced R2A, various tasks were clinical governance meetings were held and undertaken by the team to develop the the relevant returns submitted. A separate facility’s capability and operational function. record of Lessons Identified was generated at Each task was effectively a novel evolution and the start of the deployment and updated had to be planned and undertaken from throughout. scratch. Several key issues had to be Structured training, SOPs and the addressed during the deployment. operational requirement highlighted the need The first task was to unpack and audit all for certain amendments to the supplied 370 the stores provided and highlight any critical module. The Officer Commanding the R2A deficiencies to Fleet. This allowed the was asked to conduct a review of the 370 submission of stores demands to rectify these module. This review highlighted operational deficiencies and bring the R2A to full differences between the maritime and land capability. Nonetheless, there were only environments, it identified obsolete equipment limited opportunities to receive these stores and practices which had the potential to during the deployment. It had previously been compromise standards of governance and it recommended that the R2A scale of stores identified equipment that had been omitted. 26 J Royal Naval Medical Service 2011, Vol 97.1

Figure 4 Remembrance Day Service at Sea

The subsequent report was supported by hosting the ceremony. Statements of Requirement for additional The Remembrance Day service was also equipment to amend or enhance that supplied organised by members of the team. The in the 370 module, and emphasised the need service was led by the three senior officers on for a role-specific maritime variant of the 370 board representing the RFA, RN and RM module or 370(Maritime). [Figure 4]. A wreath was laid by the most junior RN rate and the Colour Sergeant from The Lighter Side of R2A FPGRM read the names of those RM In addition to the daily organisation and routine Personnel who had fallen in the past 12 of the R2A, the team became involved with months making this a very poignant event. the organisation of numerous events involving the entire Ship’s Company, including Crossing Conclusion the Line Ceremony, Remembrance Sunday, Although not tested clinically, this inaugural and Flight Deck barbecues. All these events R2A deployment has demonstrated how a were greatly appreciated by the Ship’s small, specialised clinical team can be and crew and raised funds for respected embedded into a ship to support embarked charity organisations (Poppy Appeal, Troop Aide forces. The key element of the R2A capability and Fallen Comrades of 40 Commando). is its versatility and ability to deploy onto The Crossing the Line Ceremony was appropriate maritime platforms and provide conducted as the ship came off task, heading high standards of clinical support to south to the Seychelles for re-supply. The operations. evolution was undertaken and executed within This initial deployment has laid the four days, identifying the numerous personnel groundwork for future R2A deployments. Risk on board who had previously failed to meet and Issues have been identified and codified in King Neptune. This included a member of the appropriate registers to support staff actions to RN who reputedly had been an able rate in correct or mitigate them. Recommendations Lord Nelson’s time. Members of the R2A, have been provided for a bespoke who had previously taken King Neptune’s 370(Maritime) module of stores and SOPs medicine, played key roles in setting up and have been developed that can be adapted by Sailing new waters - role two afloat medical facility 27

teams deploying in the future. G Hill Royal Navy for granting The operational use of the R2A and the permission to write this article and for his time spent looking at the structure and support and guidance as OC R2A during Op equipment within the maritime environment Capri/ Op Ocean Shield 2010. has generated further concepts for the development of this role in subsequent References operations. Seen as the future of medical 1. JDP 4-03.1 Clinical Guidelines for Operations operations afloat, significant lessons have been (Change 1) May 2010 identified which will enhance this capability 2. JDP 4-30 2nd Ed Medical Support to Joint and allow the provision of robust medical Operations. support to maritime and littoral warfare. 3. NCHQ/MEDOPCAP/Capability Review Role 2 Afloat Dated 05 Oct 2009 Thanks 4. NCHQ/MEDOPCAP/Capability Review Role 2 The authors would like to thank Surgeon Afloat Dated 05 Oct 2009

Angelika L Day BSc(Hons)Adult Nursing, BSc Specialist Practice Urgent Emergency Care Leading Naval Nurse, Emergency Care Specialist Nurse, MDHU Portsmouth

Darryl A Newman DipHERN(A), BSc(Hons) Specialist Practice Emergency Care Petty Officer Naval Nurse, Emergency Care Specialist Nurse, MDHU Derriford

Richard M Heames FRCA, Surgeon Commander Royal Navy Consultant Anaesthetist, Southampton University Hospitals NHS Trust

Jane E Risdall MA(Cantab), MA(Lond), FFARCSI, Surgeon Commander Royal Navy Consultant Anaesthetist, Honorary Visiting Specialist, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust. Foundation Senior Lecturer, Department of Military Anaesthesia and Critical Care, Royal Centre of Defence Medicine, Birmingham

Correspondence to: [email protected]