The USNS Mercy is a Military Sealift Command hospital ship and may be described as a floating level-I trauma center (Fig. 1). Her primary mission is to provide rapid, flexible, and mobile acute medical and surgical services to support Marine Corps, Army, and Air Force units ashore and Navy forces afloat. Her secondary mission is to provide mobile surgical service during disaster or humanitarian relief operations13. The ship is 894 ft (272.5 m) in length and has a 1000-bed capacity, which includes an eighty-bed intensive-care unit, twelve operating theaters, and a twenty-bed recovery ward. Departments and facilities include casualty reception, radiographic services (including a computed tomography scanner, an angiography suite, echocardiography, Doppler ultrasound, two fluoroscopy suites, and three portable c-arm fluoroscopy units), central sterile receiving, biomedical repair, pharmacy, physical therapy, burn care, dental services, optometry services/lens laboratory, histopathology, laboratory, and blood bank services. Additionally, the Mercy has a flight deck capable of launching and landing large military transport helicopters. Civilian mariners maintain the day-to-day operations of the ship, and Navy personnel staff the hospital components of the ship.
Prior to December 26, 2004, the Mercy had been deployed only twice. In 1987, she conducted a humanitarian assistance mission in the Philippines and the South Pacific. In 1990, she was activated to support multinational allied forces during Operation Desert Storm. After the Gulf War, the Mercy remained stationed in San Diego and was used primarily for training exercises. Although she had not deployed on a major mission in over thirteen years, within days of the tsunami the ship was rapidly activated and set sail for Southeast Asia in support of Operation United Assistance. The initial surgical team included the following specialties: orthopaedic surgery (two surgeons), obstetrics/gynecology (two), head and neck surgery (one), oral/maxillofacial surgery (one), general and burn surgery (four), vascular surgery (one), urology (one), dental surgery (two), and plastic surgery (one). Anesthesia support initially included a team of anesthesiologists (three) and one registered nurse anesthetist who could routinely support three or four operating rooms per day. The initial orthopaedic team consisted of one military orthopaedist with a subspecialty in knee surgery and joint reconstruction and one civilian orthopaedist with a subspecialty in trauma and adult reconstruction. Over the course of the mission, three other general orthopaedists (two civilian and one military) rotated and replaced the position vacated by the first civilian orthopaedic surgeon.
Before patients were brought aboard the hospital ship, they were evaluated and triaged ashore by a forward team of Mercy health-care providers. This crucial task of deciding which patients would be brought onto the ship was executed daily by a core group of personnel that included an internist (the military Director of Medical Operations for Operation Unified Assistance), a family-practice physician, a registered nurse practitioner, and multiple other rotating military and civilian providers of varying specialties depending on the requests made by the host nation and health-care providers ashore. Because of the extensive damage and flooding that remained along the Indonesian coastlines, all patients, visitors, and crew were transported to and from the Mercy by helicopter.
Of seventy-five orthopaedic patients referred for evaluation aboard ship, forty were managed surgically. Injuries from the tsunami or earthquake were typically neglected fractures and dislocations (twenty-five) and soft-tissue wounds (twenty) presenting at a mean of fifty-four days after the tsunami (Banda Aceh) and eighteen days after the earthquake (Nias Island). A total of 120 orthopaedic procedures were performed at sea; these included fifty wound débridements, twenty-one open reduction and internal fixation procedures, seventeen intramedullary nail insertions, seven amputations, and five closed reductions (Table I). Management of the orthopaedic patients was challenging at every level. From a clinical standpoint, many patients were deconditioned and/or in poor physical health. The injuries and patient conditions were chronic and often complex. In addition to the orthopaedic evaluations, comprehensive medical screenings by Navy and civilian internal medicine specialists were crucial to optimize surgical treatment, as those specialists often discovered numerous comorbidities, including malnutrition, anemia, tuberculosis, hypertension, coronary artery disease, diabetes mellitus, and deep venous thrombosis. Medical management and optimization of patients was routinely conducted prior to all orthopaedic operations. Fortunately, despite the delayed presentation of numerous patients with tsunami-related long-bone injuries, deep venous thrombosis was an uncommon finding. Given the impracticality of conventional treatment with prolonged use of anticoagulation therapy and follow-up surveillance, we treated the twelve acute deep venous thromboses that we encountered with preoperative placement of an inferior vena cava filter.
Another challenge of managing the orthopaedic patients was the limited time allotted for the mission in each location. Most orthopaedic care plans were necessarily concentrated to achieve a desired result within a very short time-frame. Also, because we could not rely on timely follow-up by physicians with orthopaedic expertise in the post-disaster region, orthopaedic care aboard the Mercy was designed to be as definitive as possible.
Perhaps the single greatest challenge faced by the crew of caregivers was the day-to-day task of communication with our patients and their families. Even with interpreters from the host nation, some of whom were Indonesian medical students, language and cultural barriers presented difficulties in gathering an accurate history, obtaining informed consent, and communicating postoperative expectations and plans for continued care. For example, in a region where broken femora are most commonly treated by application of herbs, splinting, and months of rest, the Western ideal of intramedullary nail fixation proved difficult for many patients to comprehend and accept.
Other challenges worth noting relate to operating on a ship at sea and in an area remote from supply depots. Although heavy seas were not a problem when the Mercy was anchored off the coast of Sumatra, storms had been encountered on the voyage across the Pacific. In transit from San Diego to Sumatra, one of two fracture tables was irreparably damaged after it careened into a wall on rough seas just west of Pearl Harbor. Although weather conditions did not affect delivery of surgical care, they were a major factor for helicopter pilots charged with transporting patients to and from the Mercy. Also, needed surgical supplies were lacking while the Mercy was at sea; commercially available vacuum dressings and pumps as well as a larger supply of antibiotic-impregnated methylmethacrylate would have simplified our management of open fractures and soft-tissue infections. Although our intramedullary nail inventory became depleted of some of the shorter lengths, the locking capacity of the implants allowed us to utilize the remaining nails quite effectively while awaiting resupply. The need for a very long dynamic compression plate that was not available on ship was met by contacting Massachusetts General Hospital and arranging for the plate to be hand-carried by an incoming civilian volunteer in time for use in a staged repair of a femoral nonunion complicated by infection (described in Case 2).
Four cases are presented to demonstrate the spectrum of patients encountered during Operation Unified Assistance. These reports include treatment of a tibial fracture associated with a soft-tissue deficit and an infection, a femoral nonunion and infection following failed open reduction and internal fixation, an acute open ankle fracture-dislocation with a soft-tissue deficit, and a chronic deep spine infection with retained instrumentation. These cases illustrate the typical orthopaedic workload during Operation Unified Assistance as well as the challenges of providing care in the setting of a natural disaster despite the availability of a sophisticated hospital ship and professional expertise.
Case 1. On February 12, 2005, a forty-year-old man was referred to the USNS Mercy orthopaedic team by the Australian military field hospital. This patient had sustained a tsunami-related open tibial fracture when he was swept from his motorcycle. At the time of transfer to the Mercy, no surgical débridement or fracture stabilization had been performed. Our evaluation confirmed an open diaphyseal tibial fracture with a large proximal soft-tissue deficit and a deep infection (Figs. 2-A through 2-D). Also, medical screening revealed moderately elevated blood glucose levels consistent with type-II diabetes.
A strategy for definitive limb salvage was devised. Medical management was also optimized. Over the course of two weeks, the patient underwent a series of four operations. On February 13, débridement of all infected and devitalized tissues with placement of cement beads impregnated with tobramycin and vancomycin was performed. Deep wound specimens were obtained for culture. Tibial stability was maintained with a long leg splint. Initially, the patient was treated with broad-spectrum antibiotics (ceftriaxone, ticarcillin-clavulanate, and vancomycin) until culture data confirmed polymicrobial infection with coagulase-negative Staphylococcus species, Streptococcus species, and Pseudomonas species. Accordingly, a course of appropriate antibiotics (ceftazidime and ciprofloxacin) was initiated. On February 16, the second débridement was performed in conjunction with a medial gastrocnemius flap. Two days later, the flap was inspected and found to be viable, and a split-thickness skin graft was applied. On February 22, the fourth and final surgery was reamed intramedullary nailing with a statically locked device to stabilize the fracture. The nail was inserted proximal to the rotation flap, which remained healthy and intact.
Within two weeks after the final surgery, the Mercy concluded its mission and the patient was discharged to home. At that time, the patient was walking well and bearing weight as tolerated, the wounds were healed, and he had completed a one-month course of intravenous antibiotics. He was provided with a six-week supply of oral ciprofloxacin and Augmentin (amoxicillin). Early follow-up evaluations were arranged with volunteer surgeons of the International Red Cross in Banda Aceh. Although follow-up by Mercy orthopaedists was attempted seventeen months later, the patient could not be located.
Case 2. On February 18, 2005, a twenty-three-year-old man who had had an open reduction and internal fixation of the right femur presented to the USNS Mercy orthopaedic team during its visit to the International Red Cross Hospital in Banda Aceh. According to the patient, he had sustained a gunshot wound to the right thigh in 2002 and had undergone surgical fixation later that same year. Now, he reported chronic thigh pain, an inability to bear weight, and episodic purulent drainage from medial and lateral thigh wounds. Because he also had sustained a traumatic forequarter amputation of the left upper extremity in 2000, his mobility was substantially compromised as he could use only a single crutch under his right arm.
The patient was transferred to the Mercy hospital for further evaluation. Examination of the right lower extremity revealed a 7-cm limb-length discrepancy and medial and lateral thigh incisions that were mostly well healed but had multiple small draining fistulous tracts. Knee motion was from 0° to 120°, but it was limited by pain. Neurovascular examination revealed normal findings. Radiographs of the right lower limb showed shrapnel remnants as well as osseous fragments in the soft tissues of the thigh. The femur had segmental diaphyseal bone loss and a retained dynamic compression plate that was bowed, with one of the screws broken (Figs. 3-A, 3-B, and 3-C).
Over the course of three and one-half weeks, the patient underwent a series of five surgical procedures to treat the infected femoral diaphyseal nonunion site. On February 19, wound débridement and hardware removal were performed. The débrided osseous defect measured approximately 5 cm. Deep wound specimens were obtained for culture. Cement beads augmented with antibiotics were placed in the wound prior to closure. Femoral stability was maintained by application of an external fixator outside the zone of injury. The patient was treated with an empiric regimen of broad-spectrum antibiotics until cultures confirmed polymicrobial infection with Klebsiella species, Staphylococcus species, and Streptococcus. Thereafter, appropriate antibiotics (imipenem and gentamicin) were given.
Additional débridements were performed approximately every five days. On March 8, the fifth and final surgery included removal of the external fixator, application of a plate to the femur, and grafting with autologous bone from the iliac crest. Within one week after the final surgery, the Mercy concluded its mission and the patient returned to the International Red Cross Hospital. At the time of discharge, the patient and his caregivers were provided with a plan of care, dressing supplies, and enough intravenous antibiotics to complete a six-week course. We also facilitated follow-up with Handicap International, a non-governmental organization, to fit him with a shoe-lift to compensate for the persistent limb-length discrepancy and a prosthesis for the left upper extremity.
In July 2006, the USNS Mercy returned to Banda Aceh. This patient was located and reexamined. He was in excellent condition. He reported no substantial thigh, hip, or knee pain. He walked without assistance, with a non-antalgic but short-legged gait. The gait was improved by a 4-cm sole-augment of the right shoe provided by Handicap International. Examination of the thigh revealed well-healed surgical wounds. The ranges of motion of the hip and knee were excellent and essentially symmetric with the contralateral side. The patient was brought aboard the Mercy for radiographs of the right femur, which confirmed osseous union with 100% incorporation of the autologous bone graft (Fig. 3-B).
Case 3. On February 11, 2005, a nineteen-year-old woman presented to the USNS Mercy team during their visit to the Australian military field hospital on the campus of Zainoel Abidin Hospital in Banda Aceh. The patient was known to have an open fracture-dislocation of the right ankle with a medial full-thickness soft-tissue deficit (Figs. 4-A and 4-B), sustained in a moped crash one day earlier. Australian surgeons had performed a preliminary irrigation and débridement and applied a posterior splint. The patient was transferred to the USNS Mercy for further care.
Aboard the Mercy, a staged surgical approach was planned. Over the next two weeks, the patient underwent a series of five surgical procedures. On February 12, 2005, débridement of the medial wound and open reduction and internal fixation of the fracture were performed, and a vacuum dressing was applied to the medial wound. Although the USNS Mercy did not stock commercially available vacuum-dressing equipment, the raw materials were available to fabricate a negative pressure dressing. We packed the wound with sterile soap-free surgical sponges retrieved from single-use scrub brushes (Scrub Care; Cardinal Health, McGaw Park, Illinois). Next, sterile suction tubing (fenestrated by hand with a number-15 scalpel) was placed atop the sponges. Finally, the sponges and suction tubing were carefully sealed to the wound with sterile plastic adhesive (Ioban antimicrobial incise drape; 3M, St. Paul, Minnesota) and connected to continuous wall suction at 125 mm Hg (Figs. 5-A, 5-B, and 5-C). Prophylactic antibiotic coverage was administered perioperatively. Over the next two weeks, the patient was returned to the operating room at regular intervals for wound irrigation and débridement with a change of the vacuum dressing. The improvised vacuum-dressing regimen kept the wound clean and rapidly promoted granulation tissue sufficient to accept a split-thickness skin graft after only eleven days. On February 23, a split-thickness skin graft was applied, and 100% acceptance of the graft was confirmed at one week. At this time, the patient was discharged to home with follow-up care through Abidin Hospital.
In July 2006, the USNS Mercy returned to Banda Aceh. This patient was located and reexamined. She was in excellent condition and had learned to speak fluent English. She reported no extremity pain, and she walked with a normal gait. Examination of the ankle revealed well-healed surgical wounds and skin graft and donor sites (Fig. 6-A). Ankle strength and range of motion were symmetric with the contralateral side. Radiographs of the right ankle made aboard the Mercy confirmed osseous union with stable positioning of the hardware (Fig. 6-B).
Case 4. On February 27, 2005, physicians from the Kesdam TNI Military Hospital consulted Mercy orthopaedists regarding an inpatient with a complex spine condition. The patient was a thirty-three-year-old woman with paraplegia related to an old spinal cord injury; she had had a posterior spinal fusion in 1997. She had done reasonably well until December 26, 2004. During the tsunami, she was swept from her wheelchair and sustained new back trauma. Over the subsequent months, she noted the insidious onset of low-back and bilateral lower-limb pain. By late February, she had become systemically ill and a draining back wound with exposed spinal instrumentation had developed.
On March 1, the patient was transported to the Mercy with a preliminary diagnosis of deep spinal infection with retained hardware. Over the next forty-eight hours, comprehensive medical evaluation and resuscitation with intravenous fluid and antibiotic therapy were performed by Navy and civilian internal medicine specialists. Preoperative cultures of specimens from the wound revealed methicillin-resistant Staphylococcus aureus infection. Imaging with conventional radiography as well as computed tomography showed intact hardware from T12 to L3 with prominent posterior wires (Fig. 7-A) and a large paraspinal fluid collection. With no orthopaedic spine specialists aboard, details of the case as well as images were forwarded by electronic mail to U.S. experts in Boston and Minneapolis for additional consultation and recommendations for management. Experts provided preferred protocols for management as well as technical advice.
On March 4, débridement with removal of instrumentation was performed. The wound was left open and was covered with an improvised vacuum dressing (identical to that described in Case 3). Intravenous vancomycin was administered postoperatively. After three days, the sepsis had completely resolved and the patient was returned to the operating room for repeat débridement and delayed primary closure of the wound. Afterward, preparations were made for the transfer of the patient's care to doctors ashore. Surgeons from the Kesdam TNI Military Hospital were brought aboard to participate in the patient's postoperative care. Our infectious disease specialists devised a regimen of vancomycin that could be safely administered for a six-week period without the absolute need for monitoring peaks and troughs. Additionally, our nursing staff educated the patient and her husband about how to administer the vancomycin at home.
When the USNS Mercy returned to Banda Aceh in the summer of 2006, the patient was located and reexamined at the outpatient clinic of Zainoel Abidin Hospital. Although she remained in stable condition neurologically, she reported persistent back pain that was exacerbated by sitting. Examination of her back revealed intact skin and a well-healed surgical wound without evidence of infection. New radiographs of the thoracolumbar spine, however, showed vertebral collapse and an increased kyphosis when compared with the appearance on radiographs made early after the débridement (Fig. 7-B). Unfortunately, the time constraints of the mission did not allow further medical evaluation and/or surgical management aboard the Mercy.
Managing orthopaedic patients as a visiting surgeon in a post-natural disaster environment presents enormous challenges. Available facilities do not typically include a well-equipped operating room, and what resources are available are more properly directed toward providing basic needs for food, water, shelter, and lifesaving care. In the early days following December 26, 2004, orthopaedic care was largely limited to external fixation, amputations, and débridements—initially because they were the most urgently needed procedures, but later because there was no local facility with the capacity to perform more complex procedures. Within weeks, the need for more sophisticated orthopaedic care became apparent. Tsunami victims with neglected and/or partially treated fractures were languishing in the few available hospital beds, and their numbers were increasing daily as a result of acute trauma admissions related to falls and motor-vehicle accidents as life in Banda Aceh returned toward normal. During Operation Unified Assistance, Navy and Project HOPE orthopaedic surgeons aboard the USNS Mercy met the need for complex orthopaedic care and complemented the work of preexisting medical teams in the region. Working in cooperation with the Zainoel Abidin Hospital, the Kesdam TNI Military Hospital, the International Red Cross, Gunung Sitoli Hospital in Nias, and numerous international non-governmental organizations and military personnel, seventy-five patients were transferred to the ship for evaluation and treatment that were not otherwise available. As we had the resources of a U.S. hospital ship, the treatment challenges that we encountered were not as often medical as they were logistical. The constraints imposed by a time-limited mission required that staged treatments be accelerated beyond the usual norms and that we discharge some patients sooner than we would have preferred. Additionally, several orthopaedic patients whom we wanted to bring aboard were identified too late to have had their treatment completed by the date established for conclusion of the mission.
This small case series highlights the hospital ship as a platform uniquely suited to export medical and surgical expertise, especially to developing nations or to an environment where the civil and medical infrastructures are limited or compromised. Furthermore, these cases illustrate the challenges of treating complex conditions with limited time and uncertain access to follow-up care. In all cases, management was predicated on a comprehensive initial work-up; adherence to a well-defined care plan; application of sound orthopaedic principles; accessing the multidisciplinary support provided by our level-I trauma capabilities (i.e., anesthesiology, critical care, infectious disease specialists, nursing, a blood bank, a microbiology laboratory, a main laboratory, and physical therapists); and, when necessary, maximizing hospital resources through innovation (e.g., use of improvised vacuum dressings). Another major resource that contributed substantially to our success aboard the Mercy was electronic mail. E-mail allowed instant communication with our physician-colleagues in the U.S. Digital radiographic images and clinical photographs were transmitted and advice was received in cases in which our own expertise was limited. This practice proved to be of particular value in managing our spine and oncology patients. E-mail also facilitated our communication with referring facilities during and after the mission.
Despite an intensive effort to find and follow patients in 2006, only four could be located. Three of these four cases are detailed in this report. Although limited by the inherent difficulties of locating patients treated in the wake of a natural catastrophe, the follow-up that we have presented offers some insight into what may be accomplished by orthopaedic surgeons on disaster relief missions in which a hospital ship is deployed. Importantly, at least one of these cases (Case 4) shows how imperfect management strategies during humanitarian aid and disaster relief missions may lead to temporarily improved but ultimately imperfect outcomes.
Finally, the unprecedented collaboration between Project HOPE and the U.S. Navy during Operation Unified Assistance deserves recognition. In an era of severe strain on military medical resources, the combined civilian/military medical team successfully utilized the full capacities of the Mercy and provided a valuable resource to disaster victims. It is a confirmation of that success that continued joint civilian/military humanitarian operations in both hemispheres have followed in the two years since the 2004 Asian tsunami27,28. 