Operational 159 Operation RUMAN: Role 2 Afloat delivering Humanitarian Aid and Disaster Relief operations in the Caribbean 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 Anguilla 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 Gibraltar, 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, Turks and Caicos Islands and in later that day accompanied by the BMS and another MA. the British Virgin Islands (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 Hurricane Irma two weeks with personnel from MNTS to ensure that a full 2-1-2 R2A previously. With Hurricane Maria 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.