2024 General Surgery/Global Health Engagement/Quality Improvement Presentations

Sophia M Schermerhorn, MD; Jonathan R Gower, MD; Kathleen A Cannon, MD; Katherine A Wrenn-Maresh, MD; Matthew D Tadlock, MD; Naval Medical Center San Diego

Objectives: Surgical teams embarked on US Navy warships routinely manage traumatic injuries as well as elective and emergency surgical conditions. While the tenants of surgery are universal regardless of setting, some aspects are unique to the austere maritime environment. As a process improvement (PI) initiative, we retrospectively reviewed surgical care performed at sea to identify common operative case types, best practices, and opportunities for improvement.

Methods: Surgical case logs and post-deployment After-Action Reports (AARs) provided by Fleet Surgical Teams (FST) embarked on amphibious warships and aircraft carrier surgical teams (CVN) Cruise Reports (CR) completed between 2006-2020 were identified, compiled, and systematically reviewed categorizing data into 3 categories: (1) Pre-Deployment Training (2) Equipment (3) Surgical Care Provided.

Results: Upon review of 21 AARs/CRs and case logs, 727 operations were identified over 24 deployments on 13 warships (5 CVN, 7 FST); 534 (73.5%) performed on CVNs and 106 (26.5%) on FSTs. Two deployments described Mass Casualty Events (MCE); a CVN responding to the 2010 Haiti Earthquake, and an FST response to a Tilt-rotor mishap. Average number of cases performed per week of deployment was similar between CVN and FST platforms at 0.98 and 0.73 cases/week respectively (p=0.48). (1) 92% of AARs addressing training identified the need for improved standardized pre-deployment training. (2) Equipment: 65% of teams pointed to missing equipment, delays in receiving equipment, or a need to independently source equipment from the Military Treatment Facilities. (3) Excluding MCE, 30 operation types were identified including gynecologic, urologic, and orthopedic emergencies not routinely managed by general surgeons; 2.4% required evacuation off the ship. The 5 most common procedures performed included Vasectomy (129), Lipoma/Cyst Excision (94); Abdominal Wall Hernia Repair (93), Appendectomy (91), and Hand/Finger Injury Operative Management (72). Other high-acuity, less frequent cases identified included Laparoscopic Cholecystectomy (13), Diagnostic Laparoscopy (5), Orchiopexy (4), and Exploratory Laparotomy. Tracking of operative volume and complications was highly variable.

Conclusions: Post-deployment AAR/CRs by ship-based surgical teams provide critical insight into areas for surgical care improvement in the austere maritime environment. Gaps identified include a lack of standardized pre-deployment training and a lack of standardized operative tracking and PI initiatives—a significant quality issue as team members typically rotate annually, resulting in teams “re-inventing the wheel” with each deployment. As a result of this initiative, the Maritime Surgery Quality Improvement program was developed to standardize maritime operative reporting, share best practices, and improve surgical care in the maritime environment.