Page 66 - JSOM Summer 2018

Surgery at Sea

The Effect of Simulated High Sea States on Surgical Performance

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Eric Pierce, MS ; Renato Rapada *; Penelope Anne Herder ; Anthony J. LaPorta, MD ;
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Tuan Hoang, MD ; Matthew Pena, MD ; Jeff Blankenship, MS ; Jeff Kiser ; Sarah Ashley Catlin, MS 9
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ABSTRACT
Background: The US Navy initiated design concepts for a may indicate a coping response to the increased stress of the
Medical Mission Module Support Container (M3SC), a mo- motion setting. Procedure and team dynamic were the stron-
bile operating room capable of rapid installation aboard ma- gest predictors of overall performance, suggesting a learning
neuverable ships within proximity of active combat units. The curve exists and that added focus on training should be en-
M3SC provides an alternative echelon of care in the current forced. Conclusion: Based on data collected in this study, sim-
trauma system by decreasing the time between point of injury, ilar surgical procedures should be implemented aboard these
arrival, and surgical intervention. The mobile ships used as classes of ships. By doing so, injured military personnel would
M3SC platforms, however, are more susceptible to oceanic have more timely access to care. Surgical team members were
conditions that can induce detrimental physiologic motion aware of craft motion, used compensatory measures, and ex-
sickness in medical personnel and patients aboard the vessels. hibited some physiological response.
This study investigated the effects of different sea-state motion
conditions on the performance of surgical teams. Methods: Six Keywords: sea medicine; operational medicine; tactical med-
four-person surgical teams performed 144 procedures in an icine; remote damage control surgery; motion sickness; sea
M3SC aboard a Stewart motion table that simulated motion sickness; surgical simulation; trauma; exsanguination
profiles of sea states 0, 3, and 4. A modified human-worn par-
tial-task surgical simulator was used as a surgical surrogate
to simulate the four most common, wartime, improvised ex- Introduction
plosive device injuries in the past 10 years. Electroencephalo-
graphs and heart rate variability (HRV) data were collected Today’s dynamic operational environments warrant the con-
from surgeons and surgical technologists during each proce- sideration of newer mobile health-care facility options that
dure to assess real-time physiologic responses to motion. Two can respond faster to unpredictable enemy threats. Although
postprocedure surveys, a Surgical Task Load Index and a Mo- trauma care delivery has significantly improved patient out-
tion Sickness Assessment Questionnaire, were given to assess comes in our recent deployed conflicts, most battlefield deaths
subjective responses of workload stress and motion-induced still occur before a casualty ever reaches a military treatment
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kinetosis. Surgical subject matter experts quantified surgical facility. Recognizing the need to develop improved medical
performance after each procedure by measuring blood loss response elements, the US Navy initiated design concepts
and orthopedic pin placement to evaluate each intervention. for a Medical Mission Module Support Container (M3SC).
Results: Motion did not significantly influence overall perfor- An M3SC is similar in concept to the Forward Resuscitative
mance (p = .002). Surgical procedure was the strongest pre- Surgical System. It would be capable of rapid installation
dictor of performance. HRV was used to measure stress and aboard smaller, high-speed ships of opportunity, providing the
was increased in surgical technologists; however, HRV was de- positional advantage to maneuver near active combat units.
creased for surgeons and technologists in motion. There was Integration of this mobile health-care platform into the cur-
a significant interaction between role and motion (p = .002): rent continuum of trauma care could significantly decrease
Surgeons had higher workloads than did surgical technologists the interval between combat injury and arrival at surgical
and neither demonstrated differences between motion and no intervention.
motion. Surgeons demonstrated significantly decreased work-
loads under motion conditions (p = 0.002); however, surgeons Smaller ships, however, can be more susceptible to turbulence
perceived their workload to be higher. We attribute this to in high sea states. Sea states, which are varying states of ag-
their increased critical thinking and physical execution of pro- itation of the sea resulting from factors such as wind, swell,
cedures. Surgeons and surgical technologists showed a trend and current, have the potential to provoke motion-induced
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toward HRV suppression within the motion conditions. This physiological symptoms in the medical personnel and patients
*Correspondence to Renato.Rapada@rvu.edu
1 Mr Pierce is with the US Navy Human Systems Integration Team, Test and Evaluation Branch, Naval Surface Warfare Center Panama City
Division, Panama City, FL. 2LT Rapada, USA, is at Rocky Vista University College of Osteopathic Medicine, Parker, CO. 2d LT Herder,
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USAF, is at Rocky Vista University College of Osteopathic Medicine. COL (Ret) LaPorta, USA, is at Rocky Vista University College of Osteo-
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pathic Medicine. CAPT Hoang, USN, is with the Medical Corps, United States Navy. Dr Pena is at University of California, Davis, CA. Mr
Blankenship is with the US Navy Human Systems Integration Team, Test and Evaluation Branch, Naval Surface Warfare Center Panama City
Division. Mr Kiser is with the US Navy Human Systems Integration Team, Test and Evaluation Branch, Naval Surface Warfare Center Panama
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City Division. Ms Catlin is with the US Navy Human Systems Integration Team, Test and Evaluation Branch, Naval Surface Warfare Center
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Panama City Division.
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