J Royal Naval Medical Service 2011, 97.1 21-27 General Sailing new waters - role two afloat medical facility Enhanced counter piracy 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, Kenya. 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 Saudi Arabia’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 21 22 J Royal Naval Medical Service 2011, Vol 97.1 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 Royal Navy 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