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7/7/2003

Pharmacists Play Vital Role on USNS Comfort

Donna Young

Maintaining a sufficient supply of narcotic pain medications and antimicrobial agents—particularly when treating severe wounds and patients infected with Acinetobacter baumannii, an organism that is resistant to many antimicrobials—was the greatest challenge for military pharmacists serving aboard the Navy hospital ship USNS Comfort T-AH 20 during Operation Iraqi Freedom, said Lieutenant Gary West, pharmacy division officer.

The Comfort, one of the Navy’s two hospital ships, returned to its home port in Baltimore, Maryland, on June 12 after completing a five-month mission in the Persian Gulf.

Comfort

Sister ship USNS Mercy T-AH 19, based in San Diego, California, was not activated for the operation.

Both ships participated in Operation Desert Storm in 1991.

Comfort and Mercy are layberthed, a term used by the Navy’s Military Sealift Command (MSC) to describe when ships are maintained by a skeleton crew in reduced-operating status, until they receive orders to sail again.

West and more than 300 military medical and support personnel—predominantly from the National Naval Medical Center in Bethesda, Maryland—and about 60 MSC civil service mariner crew, departed January 6 to support troops in Iraq.

In March, about 1000 military health care workers, who were deployed from various United States military medical treatment installations, were transported from Bahrain to the Comfort by helicopter, according to the Navy.

During the military operation, Comfort’s health care team treated more than 650 patients, including about 200 Iraqi civilians and prisoners of war in the ship’s 1000-bed medical treatment facility, according to a Navy statement.

Three pharmacists, 15 pharmacy technicians, and a chief petty officer in charge of administrative issues and technician training, served on the ship during Iraqi Freedom, said West in an e-mail response from the Comfort.

The pharmacy prepared thousands of i.v. medications—mostly antimicrobials and morphine, he added.

Resistant bacteria. When Comfort's physicians discovered that several patients aboard the ship were infected with A. baumannii, patients were prescribed imipenem–cilastatin and tobramycin to treat the infection, West said.

wound

The bacteria, he noted, were resistant to gentamicin.

Lieutenant Fazi Sabi, staff obstetrician and gynecologist at National Naval Medical Center, said A. baumannii was difficult to identify at first and presented one of the most frustrating challenges for Comfort's health care staff.

When the organism contaminated a patient’s open wound, she said, it caused cellulitis, a serious skin infection that can spread to lymph nodes and the bloodstream, and is life-threatening if left untreated.

Sabi, who assisted in numerous surgical operations performed aboard the Comfort, said skin graft procedures would fail when a patient’s wound was infected with the bacteria.

Health care workers isolated patients infected with A. baumannii to keep the organism from spreading and infecting other patients, she noted.

“The bacteria was very difficult to get rid of, and you had to scrub your hands and be very careful not to spread it around,” she said.

“Pharmacists played a huge role” in ensuring that patients were provided with needed medications, especially with the unexpected presence of A. baumannii on the ship, Sabi said.

Inventory control. Lieutenant Elizabeth L. Hearin, pharmacy outpatient division officer at the Navy’s medical center in Bethesda, said that, because imipenem–cilastatin were not agents generally stocked in large quantities on the Comfort, the ship’s pharmacy had to closely track its supply of the products.

“It became very clear that monitoring medication use was required for success,” West added.

The pharmacy provided daily lists of patients receiving imipenem–cilastatin to the ship’s infectious disease physician, who would verify how many days a patient was expected to continue taking the medication, Hearin said.

“We came close to running out, but we made it through,” she said.

Military medical treatment facilities use a procurement system in which drug products are delivered within 24 hours after placing an order, West said.

When delivery or availability problems interfere with the receipt of an order, a military installation pharmacy can borrow needed products from another nearby facility, he added.

But for a pharmacy at sea in a combat environment, West said, turnaround for delivery of supplies was “unpredictable, and there was very little chance of borrowing.”

“The pharmacy developed a very good relationship with the ship’s supply department,” he said. “When it appeared that essential medications would become depleted we would notify supply and they would find ways to obtain the medication in a more timely fashion.”

Pharmacy at sea. The ship’s formulary, West noted, included some manufactured items in unit dose packages, adding that Comfort's pharmacy had equipment for repackaging medications in unit dose containers when needed.

Since some of the patients aboard the ship included Iraqi children, Hearin said, Comfort's pharmacists and pharmacy technicians compounded several pediatric doses of medications.

The ship’s pharmacy has an i.v. preparation room containing two laminar-airflow hoods and a large compounding area, and three storage areas, West said.

Pharmacy technicians, under the guidance of a pharmacist, were responsible for most of the dispensing process, he noted.

More than dispensing. Pharmacists on the ship served as troubleshooters in a more clinical role than practiced in a typical hospital environment, West said.

The pharmacy had a workspace in the ship’s casualty receiving (CASREC), a triage area similar to a hospital emergency room where patients first arrive after being transported by helicopter to the ship, he said.

Pharmacists working in CASREC aided physicians in determining which therapy to prescribe and helped administer i.v. medications, Hearin said.

Pharmacists and technicians also assisted in changing patients’ wound dressings and consoled patients who had severe gunshot or burn wounds, she added.

“We were right there in CASREC making i.v.’s, assisting [in] dosing, and being an integral part of the team during one of the most critical phases of our patients’ care,” West said.

The CASREC pharmacy stocked medications used in trauma situations, such as i.v. pain medications, vasopressors, burn treatments, and antimicrobials, West said.

If a physician ordered a medication that was not maintained in the CASREC pharmacy, he said, pharmacists used Microsoft NetMeeting, a real-time messaging program, to request delivery of a medication from the ship’s main pharmacy.

“This allowed for a much faster delivery time to CASREC, which in turn allowed for the patient to be ready for transport in a more timely fashion,” West said.

Petty Officer Eric Watson, a pharmacy technician based in Bethesda, served in a unique role on Comfort.

He is part of the Chemical Biological Radiological Defense (CBRD) team and trained Comfort's military staff in using Mission-Oriented Protective Postures (MOPP) gear—protective equipment such as gas masks and chemical suits—and administering nerve-agent antidotes via autoinjectors containing atropine sulfate and pralidoxime chloride.

Each military person aboard the Comfort is provided three kits, called MARK I kits, that contain the autoinjectors, Watson said.

Other missions. Comfort has participated in many worldwide missions since it was delivered to the Navy on December 1, 1987, according to the Navy.

When terrorists attacked the United States on September 11, 2001, Comfort was activated and directed to New York City where the ship’s crew and medical staff provided sleeping quarters, meals, laundry services, and medical treatment to relief workers.

Hearin served aboard the Comfort in June 2002 when the ship was activated to participate in Rescuer/MEDCEUR (Medical Exercise Central Europe) 02, a six-week exercise that provided training in rescue, humanitarian assistance, disaster relief, and joint medical operations.

The exercise involved 3500 people from Latvia, Estonia, Poland, Germany, Sweden, and the United States, according to the Navy.

During the mission, Hearin and other military health care professionals helped train and educate health care workers from the Baltic nations about United States regulatory agencies, such as the Centers for Disease Control and Prevention, FDA, and the Centers for Medicare & Medicaid Services.

Hearin also discussed with foreign health care workers the effects of overusing antimicrobials.