Operational 159 Operation RUMAN: Role 2 Afloat delivering Humanitarian Aid and Disaster Relief operations in the J J Matthews

Abstract

In the autumn of 2017, two Category 5 hurricanes caused extensive damage in the Caribbean. This resulted in the activation of two Role 2 Afloat (R2A) teams in support of Operation RUMAN, the military response to provide Humanitarian Aid and Dis- aster Relief (HADR) to the affected area. This paper documents the deployment of the R2A capability during Op RUMAN and outlines the main lessons identified in the delivery of HADR in the maritime environment.

Matthews J J. J R Nav Med Serv 2018;104(3):159–164

Introduction Narrative Op RUMAN saw the short notice activation of two Role 2 On 6 September 2017, Irma hit the Caribbean as a Category Afloat (R2A) teams in support of Humanitarian Aid and Disaster 5 hurricane with winds of up to 185mph. MNTS had been in Relief (HADR) operations after Hurricanes Irma and Maria in the Caribbean since July 2017 in preparation for the hurricane the autumn of 2017. A full (20-person) team, with the capability season. The ship carries a specialist disaster relief team and was of providing two resuscitation beds, an operating table and able to deliver six tonnes of emergency aid to the day two critical care beds,1 was deployed to RFA MOUNTS BAY after the hurricane devastated the island. MNTS is a nominated (MNTS), which was already stationed in the Caribbean. This R2A platform and is equipped for a full 2-1-2 R2A team. Prior team was supplemented by the addition of a consultant physician to MNTS sailing to the Caribbean, the 370(Aft) module had due to the nature of the HADR tasking. A smaller seven-person been removed with only the fixed items (steriliser, operating R2A (light) team joined HMS OCEAN (OCEA) in , table and lights) remaining. On 8 September, R2A Team 1 was and then sailed for the Caribbean, arriving 11 days later to activated to deploy to MNTS along with a 370(Aft) module to supplement the R2A capability already in theatre on MNTS. establish a R2A 2-1-2 MTF to support the HADR activities of Op This team was able to provide a limited surgical capability (one RUMAN. Once the Action Order had arrived on 8 September, operating table and one critical care bed) supported by the R2A a 370(Aft) module was sourced from RFA ARGUS (ARGU). custodians already embarked on OCEA.2 The module was packed overnight and then transferred to RAF Brize Norton (BZZ) prior to onward transit to the Caribbean. Op RUMAN was the military response in support of the Department for International Development (DFID) and the The team, minus the biomedical scientist (BMS) and one of Foreign and Commonwealth Office (FCO) following the the Medical Assistants (MAs), flew from BZZ to Barbados on Category 5 hurricanes Irma and Maria, which caused extensive 11 September. The 370 (Aft) module and blood were flown damage in Anguilla, Dominica, and in later that day accompanied by the BMS and another MA. the (BVI). On arrival in Barbados, the R2A team was transferred to Camp Paragon for in-theatre briefings. The plan emerged for This complex and extended archipelago created a joint the R2A team and equipment to be flown on to the US Virgin operational area (JOA) spanning 1000 miles, causing significant Islands (USVI) prior to transfer onto MNTS. The full team challenges in communications and patient movement. The R2A and equipment were reunited later that day to await onward team joining MNTS was activated at short notice, experiencing transfer and, after some delays, were flown to the USVI on a prolonged and austere deployment into theatre. The R2A 13 September, finally transferring onto MNTS during the Medical Treatment Facility (MTF) on MNTS was the lead morning of 14 September. R2 theatre asset, supporting a population at risk of over 2500 military and civil service personnel deployed to assist with the On sailing, the main effort was to establish the R2A MTF and HADR operations. In addition, the R2A facility was used to tactically pack (and account for) the stores, ensuring that R2A provide medical assistance to a number of entitled, vulnerable did not impact on the Role 1 capability on board but could be British nationals and locals as required. The Defence Medical established as quickly as possible. MNTS was due to arrive Services provided a significant contribution to Op RUMAN in the Turks and Caicos Islands on 16 September, so initial with 48 medical personnel deployed at its height. operating capability (IOC) needed to be established before 160 Journal of the Royal Naval Medical Service 2018; 104(3)

Figure 1: Hurricane damage, British Virgin Islands. arrival. A full inventory of the module was completed and key Items previously identified as key deficiencies arrived once deficiencies were identified. An IOC of 2-1-1 was declared on MNTS arrived in BVI, enabling the declaration of full 16 September, within 36 hours of the team’s arrival on MNTS. operational capability (FOC) of 2-1-2 on 21 September. A A key deficiency of ventilator tubing meant that the critical visit to Pebbles Hospital in Roadtown, BVI, was conducted care provision was limited to one bed, with the solution being by the deployed Clinical Director (CD) and MNTS Medical to use the anaesthetic machine in the operating theatre to Technician, and valuable medical stores were delivered. From ventilate any patients in need of critical care support. 25-28 September, MNTS conducted a port visit to Martinique for crew changes and to pick up stores. Whilst conducting HADR operations in the Turks and Caicos Islands it became obvious that a second potentially catastrophic HMS OCEAN (OCEA) had arrived in the JOA on 22 hurricane, Maria, was sweeping towards the British Overseas September. The decision was made to supplement this team Territories already battered by two weeks with personnel from MNTS to ensure that a full 2-1-2 R2A previously. With also reaching Category 5 MTF remained to support the continuing HADR operations; status, MNTS sailed from the Turks and Caicos Islands and seven personnel cross-decked to OCEA via boat transfer on put herself in a position of safety, 150 miles out to sea, whilst 23 September. OCEA conducted HADR operations in the BVI preparing to provide aid to the BVI after the storm had passed. and then sailed to support similar activities in Dominica. On 27 September, the R2A team was tested when a short-notice Whilst on passage, the R2A team conducted on-going training Non-Combatant Evacuation Operation (NEO) was activated to ensure the MTF was in the best possible state to deliver involving 37 vulnerable persons. deployed R2 hospital care once MNTS was back on station in the BVI after Hurricane Maria. This was effected through These were British entitled persons and included a number table-top discussions and recurrent escalating casualty of children and elderly with a variety of chronic medical management scenarios. conditions as well as some acute injuries and illnesses. At the same time, an elderly patient was transferred from the On 21 September, the R2A MTF dealt with three patients from hospital in Dominica, which had been extensively damaged a successful search and rescue operation conducted by MNTS by Hurricane Maria. The patient was critically unwell with and its Wildcat helicopter, involving the Ferrel, a 133-foot sepsis. He required pre-hospital intubation and ventilation former survey ship which had capsized when she was caught before being transferred by the Maritime Medical Emergency in Hurricane Maria off the storm-ravaged Puerto Rican island Response Team (MMERT) onto OCEA. The patient remained of Vieques. intubated and ventilated in one of the R2A MTF critical care Journal of the Royal Naval Medical Service 2018; 104(3) 161

Figure 2: Non-combatant Evacuation Operation (NEO), HMS OCEAN.

Figure 3: Rearward evacuation of critical care patient utilising Merlin helicopter. beds overnight before rearward evacuation to a hospital in worked well, delivering life-saving critical care without any Barbados via Merlin helicopter. unforeseen problems.

This was the first time an intubated, critically ill patient When MNTS returned to the JOA, and took over HADR had been admitted to a deployed R2A MTF; the facility operations around Dominica from OCEA on 28 September, 162 Journal of the Royal Naval Medical Service 2018; 104(3) the members of the MNTS R2A team on OCEA returned to Equipment MNTS to re-establish the full 2-1-2 capability once again. The pre-deployment of 370 Afloat modules on strategically On arrival in Barbados the R2A MTF on MNTS was stood located platforms should remain the gold standard. The down. custodian team (comprising a Leading MA and an Operating Department Practitioner) has been shown to be a robust way Key lessons identified of managing the 370 Afloat module, ensuring that the drugs and electro-medical equipment are appropriately maintained. Manpower This allows the R2A team to be mobilised to the platforms as Previous operational R2A deployments have highlighted required and achieve FOC in the shortest time possible. This the lack of executive support to R2A both when deployed deployment has shown that the combined deployment of the and on standby commitments. The creation of the Maritime R2A 2-1-2 team with a full 370 Afloat module is possible even Deployed Hospital Care (MDHC) team has helped to address in the extreme circumstances of a developing logistics chain this issue, although the exact structure and configuration of during a natural disaster. However, this should be exceptional this team remains under development. Op RUMAN was the practice, and normal practice should continue to be the use of first time a Medical Services Officer (MSO) was deployed dormant facilities with a custodial team prepared to receive operationally on a R2A platform. He was able to provide high a R2A team as operational tasking dictates. If the module is quality executive support to the R2A team, managing several maintained on board then FOC should be possible within 6 logistical issues and ensuring constant feedback to Joint hours of the R2A team embarking. Forces Headquarters (HQ) and Navy Command HQ with daily Medical Assessment Reports. The MSO’s experience This operation once again highlights the possibility that working within Permanent Joint HQ and medical planning deployed MTFs will see paediatric patients, and a review of allowed him to improve the executive set-up of the deployed the paediatric equipment and capability on R2A should be R2A team on this tasking. This allowed the deployed CD to undertaken. concentrate on clinical issues and patient care, safe in the knowledge that the appropriate reports and administration vital The 370 Afloat module is primarily equipped for damage to the daily running of the R2A MTF were being completed. control resuscitation and surgery. Consideration needs to be Going forward, this deployment has clearly shown that the given to the need for additional equipment, personnel and deployment of an MSO within the R2A team has worked well stores to allow the R2A team to deliver a ‘small hospital’ and should continue in the future; the standard 2-1-2 R2A function rather than its primary Damage Control Resuscitation team is now supplemented by the addition of a MSO when role in HADR taskings. deployed. The MSO should take on the role of the Operations Officer responsible for executive support to the deployed Training R2A MTF. The requirement for a secondary retrieval capability (i.e. On this occasion, the decision was made to supplement the rearward transfer from the R2A to a Role 3 medical treatment standard 2-1-2 R2A MTF team with a general physician to facility) highlights the need for appropriately trained personnel increase the medical capability offered, in addition to the to undertake such a task. On this occasion, an anaesthetist standard damage control resuscitation capability normally with critical care transfer experience and an Intensive Care provided by the R2A team. This decision was completely Unit (ICU) nurse undertook the necessary transfer, but this vindicated, as a significant proportion of the patients treated highlights the need for deployed ICU nurses to be familiar had medical rather than surgical morbidities. However, with, and trained for this role. An annual training day for flight although the deployment of a physician in HADR taskings familiarisation with various aircraft might give the opportunity supported by R2A is valid, it would be sensible to supplement for ICU teams to train with kit prior to or during nomination the diagnostic capability of the R2A MTF to reflect the subject on the R2A capability. matter expertise the physician brings to the team. Information 3 Doctrine within MMERT continues to evolve. The maritime MMERT policy is under development, with an evolving environment presents unique challenges for MMERT, which directive on team composition, roles and responsibilities and needs to be task-specific and extremely adaptable. Particularly clinical Standard Operating Procedures. Corporate knowledge with HADR taskings, MMERT may be called upon to move and experience were used on Op RUMAN to mitigate the risk patients with a wide variety of morbidities ranging from minor incurred by the policy’s developmental status. injuries and chronic medical conditions (as seen during the Non-combatant Evacuation Operation (NEO) carried out in Sustainability Dominica), to critically ill septic patients as well as trauma casualties. As such, a full review of the MMERT manning The Bay Class platform provided the R2A team with an is being undertaken, taking into account the huge variety of excellent facility in which to operate. The team was able to potential patients which may need to be dealt with and also the utilise a large day cabin with audio-visual facilities, which was various limitations of airframes that may be used. invaluable as a ‘hospital office’. Journal of the Royal Naval Medical Service 2018; 104(3) 163

During high intensity operations with long evacuation times the patient on the ground prior to transfer is more limited, the and multiple assets, the addition of a MMERT Medical Officer optimal airframe for MMERT forward retrieval is the Merlin. should be considered. Currently, the MMERT personnel are taken from R2A manpower, which reduces the R2A capability. Summary Alternatively, certain taskings may require deployment of a separate MMERT team to support the R2A MTF especially Op RUMAN was the first time a R2A medical team deployed where there are multiple medical assets and a large area of on a Bay Class ship in support of a HADR tasking. Also, it operations. Op RUMAN used several RAF-led MERT and was the first time that a 2-1-2 R2A team had deployed at short tactical Critical Care Air Support Teams (CCAST) located notice with a full 370 Afloat module to set up a MTF on a ashore, deployed by the Prehospital Evacuation Coordinating platform with no embarked R2 custodian team or equipment Cell (PECC) to support patient movements throughout beyond the kit integral to the ship’s superstructure. The the JOA. Experience from MNTS 16 and Op RUMAN has establishment of a R2A MTF within 36 hours of the team provided evidence to support the use of stand-alone MERT and equipment having embarked on MNTS was a significant and tactical CCAST to support R2A MTFs. MMERT must achievement and reflected the experience, adaptability and maintain a high level of adaptability and flexibility to reflect hard work of the deployed R2A team. the huge variability in taskings particularly in R2A support to contingency operations. This should be reflected in MMERT Once the logistical challenges were overcome, the team doctrine as it develops. became an integral part of the operation, able to project influence and provide a reassuring presence to the personnel at The Wildcat airframe can be used for MMERT operations but risk both on board and ashore. The flexibility and adaptability has limitations. Due to space constraints, each MMERT is of the R2A team was proven. limited to two personnel with one stretchered casualty. In the permissive environment, the Wildcat can be used for MMERT The 18-person 2-1-2 R2A team should be considered to be forward patient retrieval as any patient treatment can be done the standard configuration deployed to support contingency on the ground prior to flying. Complex interventions would operations on platforms able to accommodate this team, due be difficult in the Wildcat due to space constraints. Inthe to the unpredictability of workload, especially in HADR non-permissive environment, where the opportunity to treat taskings.

Figure 4: Combined HMS OCEAN / RFA MOUNTS BAY Role 2 Afloat team. 164 Journal of the Royal Naval Medical Service 2018; 104(3)

This deployment has generated a number of valuable lessons provide deployed hospital care afloat to HADR contingency for the support of HADR contingency operations by R2A. operations to a high standard. However, Op RUMAN has shown that a R2A MTF can

References

1. Matthews JJ, Mercer SJ, Khan MA, Hillman CM, Robin J, Scott TE. Establishing and maintaining a robust Role 2 Afloat organisation within the Royal Naval Medical Services. J R Nav Med Serv 2017;103(1):10–3. 2. Hudson J, Mercer S. The Role 2 Afloat custodian.J R Nav Med Serv 2017;103(1):14-6. 3. Mercer SJ, Khan MA, Hillman CM, Robin J, Matthews JJ. The Maritime Medical Emergency Response Team: what do we really need? J R Nav Med Serv 2017;103(1):17-20.

Author

Surgeon Commander Jon Matthews Clinical Director, Role 2 Afloat and Consultant, Royal Cornwall Hospitals Trust [email protected] / [email protected]