Page 81 - JSOM Winter 2025

for non-indexed articles and grey literature with the same be trained in self-rescue techniques, water safety, and, in some
keywords. Titles were initially screened for relevance and the cases, underwater navigation. Military medical protocols for
potential to fulfill the objectives of the paper. The selected ar- drowning include airway management, supplemental oxygen,
ticles were thereafter read in full before a final decision on and the treatment of hypoxia and hypothermia. 12
inclusion. Key papers were also hand searched for additional
unidentified references. From the initial set of articles, a core Trauma Care in Confined and Moving Spaces
for the current paper was written focusing on major themes. Trauma management in maritime environments is challenging
A subsequent search was conducted on December 12, 2024, due to confined spaces, low light, and constant motion. Nar-
using keywords relevant to each sub-section of the article to row alleyways, gangways, and bulkheads restrict movement,
further enrich the discussion. The search was done for English requiring patients to be carried rather than dragged. Some
language articles from 2005-01-01until 2024-12-12. Article compartments resemble confined space rescues, demanding
inclusion was determined by author consensus (FG and DT) specialized techniques. Standard trauma protocols must adapt
based on relevance to the objectives. Inclusion of data from to limited mobility, scarce medical supplies, and the need for
websites retrieved during the Google search was determined rapid stabilization before evacuation. Training and mission
by author consensus (FG and DT). planning should include flexible extrication methods, with
teams maintaining proficiency in rope and technical rescue
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skills for safe patient evacuation in these complex settings. It
Discussion is also essential to incorporate the use of various illumination
devices and night vision goggles into training protocols and
Key Medical Challenges in Maritime Operations clinical practice. 14,15 Common injuries depend on the current
Hypothermia and Cold-Water Immersion mission, but planning should at least include gunshot wounds,
Hypothermia is one of the most immediate medical threats burn/blast injuries, and blunt trauma from collisions with
in maritime operations, as exposure to cold water rapidly de- structures or equipment on vessels. 16
creases body temperature, impairing physical and cognitive
5,6
functions. Even in relatively warm water, prolonged expo- Trauma Care on Multiple Decks
sure can lead to hypothermia, reducing physical performance The size of vessels and their multi-deck layouts can pose sig-
and compromising mission effectiveness. To manage this risk, nificant challenges for triage, patient care, and evacuation,
medical teams must assess the water temperature, mission du- particularly in dynamic environments with ongoing threats.
ration, and exposure levels to determine appropriate thermal This was evident in the lessons learned from the Mavi Mar-
protection measures. SOF and SWAT personnel may use in- mara mass casualty incident. During this event, Israel Defense
sulated wetsuits or dry suits designed to minimize heat loss. Forces (IDF) commandos boarded the vessel, and the resulting
Teams should also consider specific rewarming medical equip- confrontation created a highly volatile and dangerous mass
ment to be used during casualty care. 7 casualty situation that presented the medical team with un-
precedented challenges. 13
Hypothermia and Dexterity
Maintaining manual dexterity is crucial for military SOF per- Respiratory Issues and Marine Environmental Hazards
sonnel, as their tasks often require fine motor skills in challeng- Maritime environments present unique challenges to respira-
ing environments. Cold exposure significantly impairs dexterity, tory health, including risks from saltwater aspiration, chemical
which can compromise mission success. Studies show that even exposure, and smoke inhalation during vessel fires. Saltwater
short-term cold-water immersion can reduce both fine and gross aspiration, often resulting from prolonged immersion or expo-
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motor skills. For example, one study showed that recruits ex- sure to high waves, can lead to pulmonary edema and respira-
perienced a 250% increase in time to assemble a nut, bolt, and tory distress. Chemical hazards, such as fuel spills, smoke from
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washer after a long swim in cold water. This could seriously fires or explosions, and exposure to toxic substances, further
impair a soldier’s capacity to perform mission-critical tasks, compromise respiratory function. 17
such as using weapons or operating emergency equipment. Fur-
thermore, reduced dexterity can be exacerbated by decreased During fires on vessels or offshore platforms, materials com-
handgrip strength. Maintaining adequate hand and finger tem- monly release significant quantities of hydrogen cyanide
peratures is vital for preserving dexterity. Indirect hand heating, (HCN), particularly under thermal decomposition at high tem-
which involves heating the torso to increase blood flow to the peratures and low oxygen levels. The recycling of combustion
hands, can be more effective than direct hand heating (elec- byproducts in confined spaces exacerbates HCN production,
trically heated gloves) or passive insulation (mitts or gloves). with reduced ventilation increasing its concentration by six to
9
Therefore, effective strategies for maintaining dexterity, includ- ten times. Consequently, having oxygen supplies and appropri-
ing appropriate clothing and heating methods, are essential to ate antidotes (like hydroxocobalamin) readily available is criti-
ensure the operational effectiveness of SOF personnel. cal for managing life-threatening exposures. 18,19

Drowning and Near-Drowning Incidents Respiratory complications like swimming-induced pulmonary
Maritime operators face the constant risk of drowning due edema (SIPE) frequently occur during United States Navy
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to rough waters, unexpected immersion, or combat scenarios Special Warfare (NSW) training. SIPE is a potentially life-
that impair breathing. Even elite swimmers can experience threatening condition that can affect Special Forces Operators,
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severe problems particularly in combat when injuries, exhaus- and it is characterized by the accumulation of fluid in the lungs
tion, or equipment entanglement limit mobility. A recent event during or immediately after strenuous water immersion. It is
highlighting this risk is the drowning of two US Navy SEALs a form of non-cardiogenic pulmonary edema, distinct from
during a counter terrorism mission off the coast of Somalia in aspiration, and is marked by rapid symptom resolution with
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January 2024. Most advanced SWAT and SOF teams should supportive care. Typical symptoms include dyspnea, cough,
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