Medicine at sea: On board the USS Dwight D. Eisenhower

Under normal circumstances, it might seem like a grievous lapse of medical ethics.

One man lay wounded, crying out in pain from a badly fractured leg and third-degree burns. At least two others nearby were unconscious with severe injuries. And although numerous medically trained personnel were on the scene and able to provide aid immediately, they all continued to fight the fire for another 15 minutes or so before the first rescuer turned his attention to the wounded men.

"Seems pretty cold, doesn't it?" said Capt. Ted Williams, observing the scene. "I have to fight the fire before I can treat the man. If I save three people but lose the ship, then we've lost 3,000 people."

Thankfully, the episode was only a drill. Williams is the executive officer of the USS Dwight D. Eisenhower (CVN 69), nicknamed IKE, one of 10 Nimitz-class nuclear-powered aircraft carriers in active service for the U.S. Navy. When the simulated explosion and ensuing fire occurred in its massive hangar bay on Nov. 18, 2008, the roughly 100,000-ton ship was under way in the Western Atlantic off the coast of North Carolina, training for a scheduled February deployment.

The simulated emergency highlighted the unique challenges facing the roughly 40 medical personnel and 20 dental personnel on the ship. They are entrusted with protecting the health of more than 3,000 sailors and officers -- closer to 5,000 when the full carrier air wing is aboard. But the primary task of the ship is to deliver crucial air support during military operations in Iraq, Afghanistan or anywhere it is needed.

"In a freestanding hospital, the patients are the mission," said Cmdr. Richard Knittig, MD, an ob-gyn and the carrier's senior medical officer. "We support the mission of the ship."

That means the ship's surgeon might request that the carrier head into calmer seas when a surgery is imminent, but that request might be denied if the crew must continue launching F/A-18 fighter aircraft off the deck. More complex patients can be transported to land-based facilities by Seahawk helicopter, but not if the carrier is in the middle of the Atlantic or deployed too far away from a friendly base.

If those options are unavailable, the medical staff treat the patient as best they can in an operating room where the table is bolted to the deck so it won't shift when the ship does. Every sailor and officer is taught self-aid and buddy care so he or she can help stabilize patients if the ship itself is vulnerable and medical staff cannot reach them beyond sealed watertight hatches.

IKE is an inherently dangerous place to live and work on deployments that typically last six months or more. Nearly everything is made of solid steel, and ubiquitous narrow hatches and steep ladders enhance the possibilities of falls and other traumas. The threat of fire, explosions and radiation leaks is always present.

"Nowhere else in the world would you have bombs sitting next to a nuclear reactor," said Lt. Cmdr. David Sheppard, the ship's nurse anesthetist.

A little more than a month before the hangar bay emergency drill, a sailor working on the flight deck was killed instantly when he was struck by an aircraft as it catapulted off the carrier. Although the doctors could do nothing for him, the tragedy underscored the potential for serious injury and death, an awareness of which is constantly drilled into all of the servicemen and servicewomen aboard.

Most of the time, however, the medical staff has its hands full providing preventive care, tending to the typical acute care issues of patients with an average age just older than 20 and curtailing communicable diseases that can thrive in such cramped quarters. The ship has everything it needs to handle anything from the smallest mole removal to the most complex open-chest surgery.

Because the Navy is getting young men and women at an early time in their lives, the physicians, nurses, dentists and corpsmen work to instill healthy behaviors, Sheppard said. Such services as routine health screenings, full dental care, physical therapy and smoking cessation treatment are available to all on board.

Despite the dangers of the job, the relatively low pay and the stresses of being away from loved ones for months at a time, many of the physicians and other medical personnel on board say they wouldn't be anywhere else. They take great pride in the top-notch training and experience that are not available in the civilian world, Dr. Knittig said.

Civilian medicine owes much to lessons learned from those who treat wounded warriors aboard aircraft carriers and at other points along what the military calls the tip of the spear, said Cmdr. Mark Day, a trauma nurse on IKE who has also served the Navy in Iraqi combat zones. "We're doing things out here and on the ground that you will see in civilian emergency departments soon," he said. "If you're looking to be on the cutting edge of medicine, this is it."