Wheat Googling #6

How do I turn a ship's sick bay into a proper field hospital?

Hello!

Over the last few letters, I’ve been trying to work out what the crew of my fictional ship will need in order to be happy. Today, I want to focus on medical care. Of the five negative feelings listed on the World Happiness Report, four of them are stress, anxiety, sadness and pain. A robust healthcare system capable of keeping people alive who have been badly hurt, and of dealing with chronic pain, would obviously massively help with all of these.

So in this letter I am going to decide on the changes I’ll need to make to the traditional 19th Century naval sick bay.

What did the British Navy really do?

Well. Usually, the sick bay was under the forecastle: right at the front of the ship, under only one deck. Comparatively light and airy. But that was a pretty dangerous place to be if people were firing cannons at you, so during battle, the sick bay was moved to the cockpit, in the orlop. That was at least a couple of decks down, below the waterline. Much safer, but also with zero natural light, and no fresh air. Sailors would bring their injured mates down to be laid out on the Midshipmen’s sea chests for beds, and the surgeon, his two mates, and the loblolly boy (not a boy, a sort of untrained nurse) would do their best to stop them dying. This involved pulling out bullets, removing splinters, and occasionally hacking off limbs that were too damaged to save.

The Death of Nelson by Arthur William Devis

How did that work out for them?

On the Victory during the Battle of Trafalgar, 102 of the 832 people aboard were injured, and I was surprised to learn that almost all of them lived! The Victory’s surgeon, Beatty, reported that he lost five patients, and a further fifteen had to be left at various hospitals or were still convalescing, but the other 82 made full recoveries (though not necessarily with the same number of limbs they started with). With a medical team of probably four. Amazing.

What do modern field hospitals do?

I started by looking at what the Royal Navy does now, which is usually to have one Medical Officer (who must have completed medical school, among other more specialised training) and two Medical Assistants (requires GCSEs but no other starting qualifications) if they are going far from home or into battle. But this actually isn’t a great analogue, because a modern frigate is only expected to look after people for a maximum of 48 hours until they can be airlifted to a proper hospital. Strictly emergency surgery only, for example. My ship will be nowhere near any support.

So I’ve been looking at the WHO guidelines for Foreign Medical Teams (FMT) providing emergency care for Sudden Onset Disasters. Both SODs and naval battles require very efficient triage for a sudden influx of injured people with limited medical personnel.

The smallest FMT, Type 1, can provide emergency care for up to 100 outpatients per day and has three doctors and nine nurses. Type 2, the next one up, has to do everything Type 1 can do, plus have the facilities for 20 inpatients and one single-bed operating theatre, and the ability to do 7 major and 15 minor procedures every day for two weeks. They should also be able to triage 200 cases daily.

They need:

• One surgeon
• One anaesthetist
• One internist (an internal medicine physician - kind of like a holistic doctor who looks at a range of different conditions in the same patient and makes connections)
• One general physician
• One dentist
• One hygiene officer
• One pharmacist
• One head nurse
• Two intensive care nurses
• Two OT assistants
• Ten nurses/paramedics
• One radiology assistant
• One lab technician
• One dental assistant
• Two ambulance drivers
• Eight support staff

Crunching some numbers

10% of the sailors on the British side at the battle of Trafalgar got killed or wounded. On the Victory, 57 were killed and 102 wounded. In the absence of better data, and because ‘killed or wounded’ is usually listed together in the records, I’m going to assume that the ratio of killed to wounded is about 1:2. About 6.6% wounded, then.

The losing side at the Battle of Trafalgar had about 30% killed or wounded, so we’ll call it 20% wounded.

What shall I do?

The navy in my story wants to give its sailors the best. That means preparing for a worst case scenario in which 20% of the crew - about 17 people - are badly injured during one battle.

Luckily, I don’t need the full 33 staff members of a Type 2 field hospital because a lot of those jobs literally don’t exist in my world. No anesthetist, hygiene officer, radiology assistant, lab technician or ambulance drivers. They will also be triaging a maximum of perhaps 20 people rather than 200, so they should manage with the WHO recommended minimum of one nurse per eight hospital beds.

But they do still have to work within the physical limitations of the ship. I can’t make the ship bigger without losing maneuverability or speed, and I can’t increase the size of the crew I’m cramming into it without reducing quality of life. So I have a maximum crew of 87 to work with, and 60 of those have to be the actual people making the ship go. Of the remaining 27, some are officers, or officers-in-training, but most are what’s known as ‘idlers’ - crew with specific, technical expertise that makes it a waste of resources to have them standing around on deck for four hours. They don’t stand a watch, so they’re idle! These are the surgeon’s mates, carpenter’s mates, gunner’s mates, and so on. I’ll have to draw my medical team from that 27, but I also have to leave enough spaces for the other essential ‘idler’ roles.

This is what I can spare the sickbay:

• One fully qualified doctor specialised in surgery (drawn from my pool of officers).
• One newly qualified, inexperienced doctor (also drawn from the officers’ pool).
• One nurse with a specialism in practical dentistry (the game is inspired by the Napoleonic Wars - I don’t think they know enough dentistry to warrant a whole job). Drawn from the Idlers.
• One nurse with a specialism in pain management and apothecary (this will cover pharmaceuticals and OT). Drawn from the idlers.
• One trainee doctor (drawn from the officers-in-training).

That’s my core team. Five medics to look after a realistic maximum of 20 people. I am also going to make it a rule that every idler has to be trained in basic first aid, and that their job during battle is to look after the injured. This is taken from what the real navy does now, in which 10-15% of the crew are deployed in this way. I’m imagining them as kind of on-foot paramedics. Another incredibly logical thing the navy does now is split its medics into a fore station and an aft station in order to make it much less likely that the entire medical team gets wiped out in a single hit. So I’m definitely writing that in too.

It’s funny how quickly I abandon my high ideals, even in this thought experiment. I started this letter assuming I would be able to provide my crew with full hospital care, then swiftly discovered this would be literally impossible. The entire concept of this ship is that despite being a ship of war, it is built around making the crew feel as happy and safe as possible, but despite that, I am still having to compromise based on simple physical limitations. It makes me feel a little bit more understanding of the people who actually have to make these kinds of decisions - and don’t have impossibly large imaginary budgets to work with.

Enjoy the rest of your day!

Grace xx

PS: What do you think of my compromises? Would you do anything differently?

Next time

I have massively reduced the crew of my frigate, but I still need to fill all the essential technical roles with enough left over to actually make the ship go. Next time, I want to work out how to make that possible.

This week’s interesting link

Royal Museums Greenwich account of the painting above

Very short, but with interesting details about the painting.

Right now, the project for which I am doing most of my wheat googling is a choose your own adventure IF game I’ve been commissioned to write for Choice of Games. You can find out all about it, and play the 60K word demo, here.