T-AH(X) / T-AH Future
Navy Medicine provides medical care to the Navy and Marine Corps during wartime and other operational contingencies. Its two largest platforms are the hospital ships (two) and fleet hospitals (ten). USNS Mercy and USNS Comfort were 30 years old in 2008. It is likely that both will be retired in the following 10-15 years. Many US Navy leaders are asking whether it would be a good idea to replicate the current hospital ships.
Both hospital ships are San Clemente-class tankers that were converted for medical purposes in the mid-1980s; each is equipped with 12 operating rooms, 80 intensive-care beds, and the capability to care for up to 1,000 patients. They are among the largest ships in the Navy-almost 900 feet long; they have one helicopter pad each and steam at about 17 knots. One hospital ship is stationed in San Diego, and the other is in Baltimore. in Operation Desert Storm, USNS Comfort arrived on station, operational with 500 beds in 28 days, and USNS Mercy arrived on station, operational with 500 beds 37 days.
A fleet hospital is a "tent medical center" designed to support the medical needs of the personnel on the ground. It arrives simultaneously with CINC-delivered supplies that can sustain it for up to 60 days. Each of the 10 fleet hospitals worldwide has 6 operating rooms and 500 beds. A fully deployed fleet hospital can require 28 to 35 acres, and takes a considerable amount of labor and equipment to construct on a new site. Fleet hospitals are in containers on Maritime Prepositioning Force (MPF) ships, as well as prepositioned in containers in strategic areas of the world. Once delivered in theater, the fleet hospitals are charged with being fully operational with 500 beds in 10 days. Operation Desert Storm showed that Navy medical assets, including hospital ships and prepositioned fleet hospitals, arrived in theater and were fully operational within 35 days.
Navy Medicine's hospital ships and fleet hospitals are capable of supplying the large number of beds needed in the event of two nearly simultaneous Major Theater Wars (MTWs). But past military humanitarian assistance operations demonstrated that military medicine generally did not have the right type of facilities needed to treat pediatric, OB/GYN, or geriatric conditions. Hospital ships have not always been able to easily deal with humanitarian operations because they aren't configured to handle communicable diseases. To conduct humanitarian operations, they need to have more than one method of getting patients on and off the ship, and more than one major pathway to move patients once on board. In addition, they must have medical compartments that are physically separate and have separate ventilation from the rest of the ship.
The concept of casualty care supporting Operational Maneuver From The Sea [OMFTS] is dramatically different from the traditional approach. Within the generic scenario of an over-the-horizon insertion of forces deep into hostile terrain distant from supporting facilities and with no initial lodgment ashore, the provision of far forward medical support can be hampered by small unit isolation, obstacles to tactical radio communication, the dispersion of combatants and casualties, and greatly limited utility of vehicular transportation. The new lightness and mobility of assault forces with their downsized and reconfigured supporting units implies greater dependence upon afloat resources with the expectation of rapid evacuation of sick and wounded to these offshore assets.
This was described in Marine Corps Combat Development Command's 1997 "A Concept of Casualty Care for Operational Maneuver from the Sea (Working Draft)," [Marine Corps Combat Development Command, Quantico, Va., and Naval Doctrine Command, Norfolk, Va.]. The concept places emphasis on early trauma care on the battlefield; rapid tactical aeromedical evacuation to a casualty-receiving and casualty-care facility (in most cases an amphibious assault ship); minimum, essential care and hospitalization in-theater; and rapid evacuation of casualties from the theater. Although the large amphibious assault ships have excellent casualty-care capabilities, they have little critical-patient holding space. To ensure that the ship does not become a bottleneck in the care system, the flow of casualties to more appropriate facilities must be maintained. Once emergency care has been provided, patients must be moved from the ships to hospitals that can continue the care. Current ship-capable aircraft, including the V-22, lack suitable en route care capabilities for long, medical evacuation flights; in-theater hospital care, a hospital ship, or transfer to strategic medical evacuation must be readily available.
In the sea-base concept, the large-deck amphibious assault ships within the expeditionary strike groups (ESGs), of the LHA and LHD types, and presumably the forthcoming LHA replacement or LHA) containing Level II medical facilities and limited surgical capabilities for stabilizing injuries, will no doubt be designated as "casualty receiving and treatment ships." In reality, as currently outfitted, these large-deck amphibious ships could offer only limited surgical capabilities for stabilizing injuries. The primary mission of these ships is to facilitate combat operations; the logistic, space, and mobility demands of casualty care cannot realistically be expected to outweigh their combat and combat service imperatives.
Sea-based operations have been called a critical future capability for the United States military. Sea-based operations will greatly diminish the logistical footprint of combat service support elements, including health services support (HSS). In order to provide combat casualty care from a seabase, as of 2004 Navy Medicine had developed or was developing Forward Resuscitative Surgical Systems (FRSS), En Route Care Systems (ERCS), and Level III medical treatment facilities (MTFs) aboard future Maritime Prepositioning Force MPF(F) ships.
Captain Arthur M. Smith, Medical Corps, U.S. Naval Reserve, Retired, suggested in 1999 ["Care Delayed Is Care Denied! Casualty Handling in Littoral Operations" Naval War College Review, Autumn 1999, Vol. LII, No. 4] "The future U.S. armamentarium will need smaller hospital ships, capable of responding to the needs of littoral warfare as well as disaster relief and humanitarian assistance. Three to five ships of fairly shallow draft, each with about one hundred beds, should be developed, with emphasis upon primary care and basic surgical services. Design considerations should include operation in unimproved ports; physical dimensions allowing more use of piers than is possible now; ability to receive and transfer casualties by surface craft; and access by helicopter and MV-22. Whether such a hospital ship can claim Geneva Convention protection needs to be addressed; the fact that it would be served by "unprotected" combat-evacuation vehicles may violate its own neutral status."
The debate on the future of the Mercy-class hospital ships continued in the Winter 2005 edition of the Naval War College Review. Professor Richard Grunawalt's is entitled, Hospital Ships on the War on Terror: Sanctuaries or Targets, (Newport, Rhode Island: Naval War College Review, Winter 2005, Volume 58, Number 1, pp.98-119). Among the many ideas Grunawalt postulated is the essence of international law that a hospital ship does not necessarily have to be painted white, just clearly identified as a humanitarian platform. This distinction is important in dealing with adversaries who are not principled and would attack a hospital ship in the same fashion as the USS Cole or the French tanker Limburg. Yet, according to the essay, the hospital ship as it is configured today is a valued symbol of America's humanity and a potent moral force.
The author also argued that it is time for the United States to encrypt communications aboard hospital ships. Grunawalt goes a step further applauding the January 2003 decision to provide USNS Comfort with this capability but wants the Navy to reaffirm its adherence to the humanitarian purpose of the platform and provide the right of a principled adversary to board and inspect the hospital ship in the presence of a neutral observer. The issue of encryption also touches on the means by which patient information is exchanged between ships and military treatment facilities via e-mail and ways in which encryption protects a patient's privacy.
The series of Round Tables convened by the International Institute of Humanitarian Law of San Remo, Italy, from 1988 to 1994, was intended to provide a contemporary restatement of international law applicable in armed conflicts at sea. The San Remo Manual on International Law Applicable to Armed Conflicts at Sea that resulted from the deliberations of the Round Tables was not envisaged as a draft convention but was viewed by participants in the Round Tables as a modern equivalent of the Oxford Manual on the Laws of Naval War Governing the Relations between Belligerents adopted by the Institute of International Law at Oxford in 1913.
Richard Grunawalt argued for arming hospital ships with robust defensive capabilities and a clearer definition of the San Remo's Manual that governs "deflective means of defense" for hospital ships. The author proposes that hospital ships be equipped with Close-in Weapons Systems (CIWS), a fully automated Gatling gun that shreds an incoming missile or plane within several hundred yards. CIWS or Phalanx is a warship's last line of defense. Grunawalt also argues that the San Remo Manual needs to be updated and disagrees with its classification of anti-aircraft guns being offensive in nature.
Specific requirements vary according to the type of operation. Large amphibious assaults require a large number of beds. OMFTS requires that communication capabilities between casualty origination and deployed platforms be expanded, both day and night operations. OMFTS also emphasizes the mobility and survivability needs of future sea-based medical platforms. Biological/ chemical warfare adds the requirement to have special ventilation systems and control of the ship's internal environment. Multiple entry points (sea and air) are especially important in such a biological/ chemical environment. Homeland defense puts particular emphasis on the degree to which a deployable platform can be "tailored" in size to different types of contingencies.
The Mercy-class hospital ship is quite large, which is both good and bad. The primary benefit of its size is that it can accommodate 1,000 beds and can receive up to 200 patients per day. Because of its size, round-shaped hullform, and high block-coefficient, it is a stable platform that is suitable for performing most surgical procedures in various sea conditions. These physical characteristics make it somewhat slow, with a maximum speed of just over 17 knots. Also, the large ship is not easily or quickly deployed or docked. Its size gives it a substantial radar signature that, combined with its lack of maneuverability, makes it vulnerable to attack. The Mercy class is much larger (in terms of medical capacity) than is needed for most military operations. Perhaps one of the ship's weakest features is its lack of flexibility in patient movement. It has one helicopter pad for receiving patients and no ability to receive patients from the sea.
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