Expeditionary Surgery at Sea: A Practical Approach

Description

Currently, no comprehensive practical surgical textbook or other reference exists for the management of injured and other surgical patients at sea.  This text focuses on the increasingly important field of medical and surgical management of patients in the modern expeditionary maritime environment.  The editors and contributors to this new handbook are a group of physicians, nurses, and corpsmen with extensive experience in caring for patients in the expeditionary maritime environment, designing and implementing current doctrine and policy, and publishing peer-reviewed articles focused on these topics. This handbook takes the approach of a "how to" manual for the management of combat or disaster victims, beginning at the point of injury and proceeding through each stage of care until they leave the maritime environment.  This includes sections on prehospital care, triage, en-route care, and maritime mass casualty management, as well as additional chapters covering unique aspects of maritime platforms, capabilities, and missions.  The bulk of the book focuses on the initial patient evaluation and resuscitation as well as the operative and perioperative phases of care including prolonged casualty care.  The primary focus throughout the book is on simple, practical, and proven practices that can be easily understood and implemented by physicians and independent providers of any experience level who may find themselves in similar situations. For the clinical chapters, each begins with a clinical vignette relevant to the chapter based on actual patients or maritime scenarios experienced by the authors demonstrating the various challenges that can occur caring for injured and surgical patients at sea while deployed on maritime and amphibious platforms. When appropriate, each clinical chapter will conclude by describing the recommended management and outcome of the patient(s) presented in the vignette that opened the chapter. The style is plain and direct language, avoiding scientific jargon and unnecessary complexity whenever possible. Each chapter begins with 5 to 10 bullet points that summarize the key information or “BLUF” (bottom line up front) from that chapter and conclude with common tips and pitfalls, as well as recommended high-yield resources for the entire maritime surgical team. Disclaimer Foreword Preface Preface Expeditionary Surgery at Sea: Top 10 Lessons Learned Contents Part I: Maritime Surgery Overview Chapter 1: Overview of Current Maritime Surgical Platforms and Operational Environments: Part 1—United States Navy and Marine Corps Introduction Continuum of Care Role 1 (First Responder Care) Role 2 (Forward Resuscitative Care) Role 3 (Theater Hospitalization Capability) Role 4 (Definitive Care) Patient Movement and En Route Care (ERC) Capability Maritime Surgical Platforms Aircraft Carrier (CVN) Fleet Surgical Team (FST) Expeditionary Resuscitative Surgical System (ERSS) Hospital Ship (T-AH) United States Marine Corps (USMC) Surgical Platoon The Future Is Now: Distributed Maritime Operations (DMO) and Expeditionary Advanced Base Operations (EABO) Maritime Single-Surgeon Team Limitations Conclusion References Chapter 2: Overview of Current Maritime Surgical Platforms and Operational Environments Part 2: United Kingdom and The Royal Navy Introduction Operational Patient Care Pathway (OPCP) Role 2 Afloat (R2A) Maritime Role 3 (MR3) Commando Forces Surgical Group (CFSG) Platforms Conclusion References Chapter 3: The Ship’s Surgeon and Surgery at Sea: A Brief History Introduction The Age of Manpower (~800 bc to ad 1450) Ancient Greece (~800–322 bc) The Imperial Roman Navy (~27 bc to ad 180) The Middle Ages (ad ~476–1453) The Age of Discovery (~1450–1600) British Sea Power The Father of Sea Surgery The Age of Sail (~1600–1850) The American Revolutionary War The Age of Steam and Iron (~1850–1915) The American Civil War Battleships and Blood Transfusions World War II (1939–1945) Normandy Iwo Jima Korean (1950–1953) and Vietnam (1955–1975) Wars Women Surgeons at Sea Conclusion References Chapter 4: Mechanisms of Injury During Modern Naval Operations Introduction Non-flight Deck Injuries Flight Deck Injuries Injuries During Naval Warfare Conclusion References Chapter 5: I’m Deploying on a Ship, Now What? Introduction Preparation: Ship/Surgical Credentials/Privileges Inventory, Supply, and Maintenance Identify Resources Establish Capabilities Preparation: Shore/Surgical USAISR Burn Center Preparation: Ship/Nonsurgical Checking in/Sponsor Warfare Qualifications Goals Preparation: Shore/Nonsurgical Professional Requirements Expectations for Loved Ones Affairs in Order Packing Conclusion Further Reading Chapter 6: Leadership and Communication 101 Introduction In Depth: Aircraft Carrier (CVN) Ship’s Surgeon Team Personnel Preoperative Communication Postoperative Communication MEDEVAC/CASEVAC Trauma and Mass Casualty (MASCAL) Closing Thoughts In Depth: Fleet Surgical Team (FST) Staff Surgeon Team Personnel Chain of Command (COC) Perioperative Communication MASCAL Closing Thoughts In Depth: Expeditionary Resuscitative Surgical System (ERSS) OIC Team Personnel Perioperative Communication and MASCAL Closing Thoughts In Depth: Forward Resuscitative Surgical System (FRSS) Staff Surgeon Team Personnel Perioperative Communication and MASCAL MEDEVAC/CASEVAC Team Training Closing Thoughts: A Senior Surgeon’s Perspective Conclusion Further Reading Part II: Before the Operating Room Chapter 7: Shipboard Triage and Mass Casualty Introduction Initial Triage Immediate/Delayed Treatment Areas Special Considerations for Shipboard Triage: Limited Resources Communication “What Do I Know? Who Needs to Know? Have I Told Them?” Training and Drills Conclusion References Further Reading Chapter 8: Shipboard Diagnostics: Laboratory and Radiology Introduction Shipboard Laboratory: Historical Perspective Shipboard Laboratory: Current Overview Laboratory Suite Regulation Shipboard Laboratory: Common Technology and Tests Hematology Chemistry Blood Gases Additional Tests Shipboard Radiology: Historical Perspective Shipboard Radiology: Current Overview and Technology Radiology Suite Radiography Technology Advances Shipboard Ultrasound Shipboard Radiology: Common Exams Conclusion Chapter 9: Principles of Shipboard Ultrasound Introduction Extended Focused Assessment with Sonography in Trauma (eFAST) Introduction and Indications Technique Subxiphoid Cardiac Views (Fig. 9.1) Right Upper Quadrant (RUQ) Views (Fig. 9.2) Left Upper Quadrant (LUQ) Views (Fig. 9.3) Pelvic/Bladder Views (Figs. 9.4 and 9.5) Anterior Right and Left Chest Views Keys to Success Limited Echocardiography Introduction and Indications Technique Parasternal Long Axis (PLAX) View (Fig. 9.9) Parasternal Short Axis (PSAX) View (Fig. 9.10) Apical 4 Chamber (A4Ch) View (Fig. 9.11) Subxiphoid View Inferior Vena Cava (IVC) View (Fig. 9.12) Cardiac Tamponade Right Heart Strain Cardiac Contractility and Ejection Fraction (EF) Estimation Cardiac Arrest Keys to Success Right Upper Quadrant (RUQ) Ultrasound Introduction and Indications Technique Keys to Success Appendicitis Introduction and Indications Technique Keys to Success Testicular Torsion Introduction and Indications Technique Keys to Success Lower Extremity Deep Vein Thrombosis (DVT) Introduction and Indications Technique Keys to Success Pregnancy Introduction and Indications Technique Keys to Success Ovarian Torsion Introduction and Indications Technique Keys to Success Central Venous Catheter (CVC) Placement Introduction and Indications Technique Keys to Success Conclusion References Chapter 10: Practical Nursing Principles Afloat Introduction Aircraft Carrier (CVN) Nursing Nursing Supervisor and Medical Training Team (MTT) Leader Aircraft Carrier (CVN) Medical and Surgical Capabilities Medical Evacuation (MEDEVAC) Clinical Pearls Fleet Surgical Team (FST) Nursing Certified Registered Nurse Anesthetist (CRNA) Critical Care Registered Nurse (CCRN) Certified Perioperative Nurse (CNOR) Expeditionary Resuscitative Surgical System (ERSS) Nursing Preoperative: Trauma Resuscitation Intraoperative: Operating Room (OR) Postoperative: Intensive Care Unit (ICU) & Medical Evacuation (MEDEVAC) General Practical Tips Conclusion Further Reading Chapter 11: Alone and Unafraid: The Independent Duty Corpsman at Sea Introduction Clinical Vignette 11.1 Clinical Vignette 11.2 Being Prepared with Medical Knowledge Training Your Junior Corpsmen Safe Patient Movement Throughout the Ship Building a Relationship of Trust and Mutual Respect with Your Commanding Officer (CO) Principles of Medical Evacuation (MEDEVAC) Working with Your Physician Supervisor Administration at Sea Conclusion Part III: Elective and Emergency Surgical Care Chapter 12: Mess Deck, Hangar Bay, or Operating Room? The Shipboard Operating Theater Introduction Surgical Team Members (Table 12.1) CVN FST ERSS Equipment/Sets/Inspections FST ERSS Supply CVN/FST ERSS Maintenance CVN/FST ERSS Decontamination, Sterile Processing, and Storage CVN/FST ERSS OR Capabilities Outside of Primary OR CVN FST ERSS Conclusion Further Reading Chapter 13: Principles of Maritime Expeditionary Anesthesiology Introduction Pre-deployment Considerations Leadership and Administration Logistics and Preparation Deployment Considerations Mechanism of Injury Prehospital Treatment (i.e., Tactical Combat Casualty Care (TCCC)) Triage/Receiving Casualties Resuscitation Intravenous (IV) Access Blood Products Hemostatic Pharmacologic Adjuncts The Lethal Triad Airway Management Non-surgical Airway Management Surgical Airway Management Anesthesia in the Deployed Setting General Anesthesia Regional Anesthesia Prolonged Patient Holding and Austere Critical Care Platform-Based Considerations for Maritime Expeditionary Anesthesia CVN Fleet Surgical Team (FST) Expeditionary Resuscitative Surgical System (ERSS) or Role 2 Light Maneuver (R2LM) Conclusion References Chapter 14: Elective and Emergency Surgery: Operate, Observe, or Transfer? (If You Can) Introduction Operate, Observe, or Transfer: Factors to Consider Communication and Mission Quality of Life/Quality of Work Training Pathology Inactivity Nearby Ships Ancillary Studies (Laboratory and Radiology) Timing A Captive Audience for Observation General Surgery Emergencies Nephrolithiasis Appendicitis Diverticulitis Small Bowel Obstruction (SBO) Peptic Ulcer Disease (PUD) Upper Gastrointestinal Bleeding (UGIB) Lower Gastrointestinal Bleeding (LGIB) Inflammatory Bowel Disease (IBD) Foreign Bodies Non-general Surgery Emergencies Vascular Pneumothorax Ophthalmologic Emergencies Otolaryngology (ENT) Testicular Mass Elective/Non-urgent Hernias Biliary Disease Benign Anorectal Disease Pilonidal Disease Breast Disease Urologic Elective Procedures Conclusion References Chapter 15: The Tyranny of Distance and the Difficult Gallbladder Introduction Diagnosis Management Complications Filling Defects on Intraoperative Cholangiogram (IOC) Common Bile Duct injury (CBDI) Intraoperative or Postoperative bleeding Management of Other Acute Biliary Diseases Gallstone Pancreatitis Mirizzi Syndrome Bouveret’s Syndrome and Gallstone Ileus Conclusion References Chapter 16: Infectious Disease Pearls for Maritime Surgical Teams Introduction Diagnostic Tools at Hand The Maritime Pharmacy Neurological Infections Penetrating Central Nervous System (CNS) Trauma Meningitis Encephalitis Infections of the Head and Neck Facial Trauma Peritonsillar Cellulitis and Abscess Submandibular Abscess and Ludwig’s Angina Pulmonary Infections Penetrating Thoracic Trauma Pneumonia Tuberculosis (TB) Coronavirus Disease 2019 (COVID-19) Gastrointestinal Infections Penetrating Abdominal Trauma Common Surgical Diagnoses Diarrhea in the Returning Traveler Ophthalmologic Injuries Skin Injuries and Infections Burns Lacerations Necrotizing Soft Tissue Infections (NSTI) Vector-Borne Infections Conclusion References Chapter 17: But…I’m a General Surgeon! Obstetric, Gynecologic, and Urologic Emergencies Introduction Female Reproductive Anatomy Pregnancy at Sea Spontaneous Vaginal Delivery Perineal Laceration Repair Breech Presentations Postpartum Hemorrhage (PPH) Delayed Placental Removal or Avulsed Cord Cesarean Delivery Gynecologic Emergencies Ectopic Pregnancy Ovarian Torsion and Ruptured Hemorrhagic Cysts Straddle Injuries/Vaginal Lacerations Bartholin’s Cyst and Abscess Male Genital Emergencies Testicular Torsion Testicular Injury Urethral Injury Conclusion References Further Reading Chapter 18: Haze, Gray, and Endoscopy Underway Introduction Endoscopy Equipment The “Equipment Tower” Endoscopes Electrocautery Unit and Argon Plasma Coagulation (APC) Preparing Equipment for a Case Equipment Set-Up Endoscopic Instruments Risks of Esophagogastroduodenoscopy (EGD) and Colonoscopy Moderate Sedation/Monitored Anesthesia Care (MAC) Techniques for Performing Esophagogastroduodenoscopy (EGD) and Colonoscopy Esophagogastroduodenoscopy (EGD) Colonoscopy Common Pathologies: Dysphagia and Odynophagia Esophageal Foreign Body Eosinophilic Esophagitis (EoE) Drug-Induced Esophagitis Infectious Esophagitis Erosive Esophagitis Common Pathologies: Gastrointestinal (GI) Bleeding Peptic Ulcer Disease (PUD) Dieulafoy Lesion Angiodysplasia (AD) Colonic Ischemia Diverticulosis Inflammatory Bowel Disease (IBD) Internal Hemorrhoids Incidental Findings Gastric Inlet Patch Barrett’s Esophagus Schatzki Ring Pancreatic Rest Polyp Lipoma Colorectal Cancer (CRC) Screening Conclusion References Chapter 19: Of Hatches and Hands: Management of Hand Injuries Introduction Basic Anatomy and Terminology Management of Urgent/Emergent Hand Injuries Hatch Hand: Urgent/Emergent Hand Injuries: Likely Medical Evacuation (MEDEVAC) Lacerations and Tendon Injuries: Likely Medical Evacuation (MEDEVAC) Digital Nerve Injury: Likely Medical Evacuation (MEDEVAC) Amputations: Likely Medical Evacuation (MEDEVAC) Dysvascular or Crushed Limbs: Likely Medical Evacuation (MEDEVAC) High-Pressure Injection, Burns, and Degloving Injuries: Likely Medical Evacuation (MEDEVAC) A Word on Damage Control Orthopedics (DCO) Management of Lower Acuity Hand Injuries Carpal, Metacarpal, and Phalangeal Fractures: Likely Nonoperative Management Carpal Fractures: Likely Nonoperative Management Versus Routine Medical Evacuation (MEDEVAC) Metacarpal Fractures: Likely Nonoperative Management Versus Routine Medical Evacuation (MEDEVAC) Phalangeal Fractures and Dislocations: Likely Shipboard Nonoperative Management Fingertip Injuries: Likely Shipboard Nonoperative Management Supplies and Prevention Conclusion References Further Reading Part IV: Critical Care, Trauma, and Burn Management Chapter 20: The Floating Intensive Care Unit: Capabilities and Limitations Introduction Staff, Space, and Supplies Staff Space Supplies Medical Evacuation (MEDEVAC) Critical Care Emergencies at Sea Sepsis Acute Coronary Syndromes (ACS) Hypertensive Crisis Hyperglycemic Crisis Nonsurgical Neurologic Emergencies Venous Thromboembolism (VTE) Gastrointestinal (GI) Bleeding Anaphylaxis Conclusion References Further Reading Chapter 21: Acute Respiratory Failure and Ventilator Management Afloat Introduction Respiratory Failure in the Operational Environment Diagnosis of Respiratory Failure with Limited Equipment Laboratory and Monitoring Diagnostic Imaging Airway and Ventilator Management in the Operational Theater or Deployed Unit Acute Hypoxemic Respiratory Failure Pathophysiology of Hypoxemia Acute Respiratory Distress Syndrome (ARDS) Treatment of Acute Hypoxemic Respiratory Failure Low Tidal Volume (LTV) Ventilation Proning Dexamethasone Aggressive Euvolemia Hypercapnic and Mixed Respiratory Failure Pathophysiology of Hypercapnia Treatment of Acute Hypercapnic Respiratory Failure Conclusion References Chapter 22: Damage Control Surgery at Sea Introduction “Damage Control Zero” and Advanced Resuscitative Care Afloat Indications for Damage Control Surgery (DCS) Hypothermia Acidosis Coagulopathy Abdominal Damage Control Surgery (DCS) Vascular Damage Control Surgery (DCS) Damage Control Resuscitation (DCR) Definitive Surgical Repairs Aircraft Carrier (CVN) Considerations Large Deck Amphibious Assault Ship Considerations Austere Resuscitative Surgical Team Considerations Conclusion References Chapter 23: Damage Control Resuscitation and the Walking Blood Bank Introduction Damage Control Resuscitation (DCR) Platform-Specific Capabilities Aircraft Carrier (CVN) Fleet Surgical Team (FST) Expeditionary Resuscitative Surgery System (ERSS) Frozen Blood Product Capabilities FWB: Fresh Whole Blood; PRBC: Packed Red Blood Cells; FFP: Fresh Frozen Plasma Walking Blood Bank (WBB) Preparation Activation/Screening Delivery Post-delivery Special Considerations for Austere Role 2 Surgical Teams Conclusion References Chapter 24: Orthopaedic Damage Control at Sea Introduction Fracture Care Extremity Fractures Pelvic Fractures Infection Control Acute Compartment Syndrome (ACS) Pathophysiology Associated Conditions Signs and Symptoms Treatment Dislocations Shoulder Ankle Conclusion References Chapter 25: Austere Neurosurgical Emergencies Introduction Traumatic Brain Injury (TBI) Pathophysiology Intracranial Dynamics Primary and Secondary Brain Injury Neurocritical Care Evaluation Medical Management Neurological Exam Anti-epileptic Drugs (AEDs) Elevated Intracranial Pressure (ICP) Hyperosmolar Therapy Surgical Management External Ventricular Drain (EVD) and Intracranial Pressure (ICP) Monitor Placement Decompressive Hemicraniectomy Conclusion References Chapter 26: Burn, Inhalation, and Electrical Injuries Introduction Mechanism of Injury Severity of Burn Injury Anatomy Depth of Burn Injury and Corresponding Treatment Modalities Total Body Surface Area (TBSA) of Burn Injury Phases of Burn Care Stop the Burning and Initial First Aid “Buddy Care” in the Field Initial Evaluation and Management at a Medical Facility Evaluation Airway The Difficult Surgical Airway Resuscitation Burn Wound Care Clean Reassess Antibiotics Bandaging Pain Management Preparation for Transport Securing Endotracheal Tube (ETT) Burn Wound Healing First Degree: Superficial Burns Second Degree: Superficial Partial-Thickness Burns Second Degree: Deep Partial-Thickness Burns Third Degree: Full-Thickness Burns Fourth Degree: Burns Involving Structures Deep to the Skin Including Soft Tissue and Bone Burn Pathophysiology Local Tissue Damage Systemic Capillary Leak Burn Shock Burn Wound Infections Burn Wound Cellulitis Burn Wound Infection Burn Wound Sepsis Types of Burn Injury Inhalation Injury Scald Injury Steam Injury Flame Injury Contact/Conduction Injury Friction Injury Electrical Injury Chemical Injury Radiation Injury Elevated Compartment Pressures and Compartment Syndromes Escharotomy Lateral Orbital Canthotomy Release Technical Procedures Used in Burn Care Equipment Excision of the Burn Wound Harvesting Donor Skin Graft Hemostasis Skin Grafting Technique Bandaging Postoperative Autografts and Donor Sites Conclusion Further Reading Chapter 27: Management of the Drowned Patient Introduction Drowning Definition of Drowning Process of Drowning Shallow Water Drowning Morbidity/Mortality/Complications Management First Responder Care Initial Management In-Hospital Airway Management Ventilator Management Considerations in Fresh, Salt, and Contaminated Water Fresh Water Salt Water Contaminated Water Atypical Organisms Cold Water Conclusion References Further Reading Chapter 28: Management of Hypothermia and Immersion Injuries Introduction Hypothermia Pathophysiology Staging and Symptoms Field Passive Rewarming Field Active External Rewarming General Treatment Strategies Cardiopulmonary Resuscitation (CPR) in Hypothermia Cold Water Immersion Pathophysiology General Treatment Strategies Swimming-Induced Pulmonary Edema (SIPE) Frostbite Pathophysiology Staging and Symptoms General Treatment Strategies Chilblains Cold Urticaria Non-Freezing Cold Injuries (NFCI) Pathophysiology General Treatment Strategies Warm Water Immersion Foot (WWIF) Conclusion Further Reading Chapter 29: Acute Management of Chemical, Biological, Radiological, and Nuclear Exposure at Sea Introduction Operation Tomodachi Chemical and Biologic Agent Exposure Prevention and Planning Containment and Decontamination Management Radiation and Nuclear Agent Exposure Prevention Containment and Decontamination Management Conclusion Further Reading Chapter 30: Maritime Prolonged Casualty Care Introduction Prolonged Casualty Care (PCC) Mindset PCC Limitations Staffing Training Equipment Core Skill Sets Minimum/Better/Best Diagnostics/Monitoring Resuscitation Airway Ventilator Sedation/Analgesia Common Situations Infections/Sepsis Cardiovascular/Thromboembolic Disease Burn/Trauma Brilliance in the Basics Preparation for Medical Evacuation (MEDEVAC) Conclusion Chapter 31: En Route Care: Shore to Ship, Ship to Ship, and Ship to Shore Outline Placeholder En Route Care (ERC) Patient Preparation En Route Care (ERC) Mission Planning ERC Mission Execution Transport Planning Concerns Patient Access and Packaging Packaging Pearls Equipment Organization Organization Pearls Transportation Safety Safety Pearls Conclusion References Part V: Humanitarian and Disaster Relief Missions Chapter 32: Principles of Elective Navy Humanitarian Missions Introduction Objectives of U.S. Navy Humanitarian and Civic Assistance (HCA) Missions Small- and Medium-Scale HCA Missions Understanding Host Nation Capabilities Working with State and International Agencies or Organizations Large-Scale HCA Missions Medical Capabilities of U.S. Navy Hospital Ships The Humanitarian Assistance Survey Team (HAST) The Advanced Echelon or Advanced Liaison (ADVON) Teams Providing Surgical Care Other Aspects of Large-Scale HCA Missions Challenges of HCA Missions Deployment Considerations Capabilities of the Surgical Team Screening Criteria for Surgery Surgical and Medical Civil Action Programs (SURGCAPS and MEDCAPS) Subject Matter Expert Exchanges (SMEE) Post-deployment Lessons Learned After Action Reports Conclusions References Further Reading Chapter 33: Disaster Relief: Lessons Learned Introduction The Earthquake Heard Around the World: Haiti 2010 Medical Capability Limitations of a US Aircraft Carrier Walking Blood Bank (WBB) Activation Translation Challenges Absence of Training Requirements for Leaders Supply Reconnaissance The “Apocalyptic [12]” Aftermath of Hurricane Maria: Puerto Rico 2017 Humanitarian Assistance Versus Disaster Relief Intensive Care Unit (ICU) Care in a Unique Environment Beware the Ides of March: The USNS Comfort Augments New York’s Medical Care During the COVID-19 Pandemic Activation Without Known Mission Causes Manning Shortages Medical Capability Limitations of a Hospital Ship Just-In-Time Supply Limitations Ongoing Mission Execution Adaptations and Limitations Conclusions References Chapter 34: Children in an Operational Environment: Forward Surgical Teams Caring for Pediatric Patients Introduction Clinical Vignettes Intravenous Access Common Medication Doses Fluid and Blood Resuscitation Pediatric Vitals Anatomical Considerations Differences in Airway Other Key Anatomic Differences Trauma in Pediatric Patients Primary and Secondary Survey in Pediatric Patients Traumatic Brain Injury (TBI) and Pediatric Glasgow Coma Scale (GCS) Additional Trauma Surgery Considerations Management of the Malnourished Pediatric Patient Abdominal Surgical Incisions Chest Tubes, Drains, Foleys Any Special Equipment to Bring on the Ship that Is Not in the AMAL Just in Case? Common Surgical Procedures Inguinal Hernia Umbilical Hernia Incision and Drainage Abscess Appendectomy Malrotation/Volvulus Conclusion References Chapter 35: Avast! Acute Medical Emergencies of Detained Pirates or Local Nationals Introduction Ethics and Level of Care Standard Operating Procedures (SOP) Training Specific Medical Situations Tuberculosis (TB) Coronavirus Disease 2019 (COVID-19) and Other Communicable Diseases Dehydration and Malnutrition Dental Health Mental Health Chronic Medical Conditions Provider and Crew Safety Conclusion References Chapter 36: Practical Bioethical Principles in the Deployed Maritime Environment Introduction Justice Autonomy Nonmaleficence Beneficence Ethics Curriculum and Training Conclusion References Appendix A: MacGyver or Tactically Acquire? Maritime “Alternate” Equipment MacGyver or Tactically Acquire? MacGyver Tactically Acquire References Appendix B: Sample Packing List for Maritime Deployment General Uniforms Clothing Technology Medical/Surgical Paperwork/Administrative Hygiene/Toiletries Berthing/Stateroom Leisure Time Appendix C: Glossary of Common Nautical Terms References Appendix D: Common Acronyms and References Common Acronyms Common References and Resources Relevant to Combat Trauma and Expeditionary Surgery Index