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AANS Neurosurgeon | Volume 28, Number 4, 2019


The Surfacing Evolution

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The views expressed in this presentation do not represent the official policy or opinion of the United States Navy, Defense Health Agency, Department of Defense, or the United States Government.

“Diving officer, submerge the ship, make your depth one five zero feet.”

“Submerge the ship, make my depth one five zero feet, aye sir,” replied the diving officer of the watch, who just happened to be the saltiest submarine-qualified Master Chief that I have ever had the privilege to serve with in the Navy. A veteran of the old school diesel-boat submarine force, his keen sense of weight and ballast made him the ideal senior enlisted leader on the ship’s control party for that hazardous evolution. Yet, this was but another routine dive into the deep Atlantic green off the waters of New England, pushing our readiness on the way to hone our edge against all adversaries and sustain our tactical advantage in the underwater world.  Little did I know that the lessons onboard this vessel during my first junior officer tour would give me the foundation for a career that was not stealthily moving beneath the blue, but striving each day to get all those who do back into the fight. The privilege of serving in the military was the natural scaffolding for service as a neurosurgeon.

Thus began my voyage towards medicine, eventually finding harbor in neurosurgery after serving my initial commitment from the Naval Academy and then attending medical school at the Uniformed Services University. Opportunity took me to a civilian neurosurgery residency in Rochester, New York, and then again to Bethesda, Maryland, to serve the ‘tuition’ of time mortgaged to the Navy for their support of my family during the eleven years of education and residency.

Rochester was the ideal balance to my service-based college and medical school years, I probably only wore my uniform a handful of times over those years other than when I had to report for the mandatory semi-annual physical fitness training. In this way, I was able to immerse myself into residency, much like that initial dive, in order to surface at the end ready to practice independently anywhere in the world. Little did I know that “anywhere” was exactly where I was about to be sent.

Landstuhl Regional Medical Center, in the Rhine Valley near Ramstein Air Base, is the receiving hospital for all the casualties coming back from the wars in Afghanistan, Iraq and other hot spots around the world. Soon after I reported back to Bethesda as a young attending, I took an assignment to Landstuhl for what turned out to be a six-month solo tour without my family.  The time spent there was central to my development as an attending, as I had to manage both staff and patients through an absolute solo practice perspective. I was far from the assistance of residents or other neurosurgical staff.

My solo practice experience repeated itself during a recent deployment to Afghanistan, where I was the only neurosurgeon in the southern part of the country during the heavy casualty summer of 2012. Once again, I found that the independence forged in the operating room (OR) by my mentors in Rochester was uniquely coupled to the unsupported nature of my attack submarine heritage. I found that this fusion gave me the skills to make unfettered decisions while having the stamina to stand the watch for the duration of the deployment. 

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No doubt, the formality of communications in the submarine force established a framework for heightened patient safety in the medical setting. Within surgery, the tenets of verbatim repeat-back and procedural compliance, the baseline for operating a submarine at sea, are beginning to gain traction in our patient safety culture. In many ways, I conduct myself in the OR today the same way I did on watch underwater, whether in the reactor control room or on the bridge of the ship. The lessons of reactor safety, which my senior officers made so clear to me as part of the junior officer cadre onboard the submarine, can nearly all be translated into patient safety correlates. If I was to replace the word ‘reactor’ or ‘ship’ in nearly any Navy technical manual or doctrine from the submarine force with the word ‘patient,’ the principles of each would be aligned. Safety of ship is patient safety, and a recent Naval Proceedings article by Captain Howard Warner (one of my classmates from the Naval Academy and submarine training) and orthopedic surgeon Rear Admiral Bruce Gillingham (one of the Navy’s senior Medical Corps Officers) highlights how the Navy Medical Corps is bringing fleet practices to the practice of medicine in pursuit of higher reliability.1

Within the overlap of these seemingly disparate environments of nuclear power and surgical care, the element of independent practice, a culture of safety and a dedication to fellow crew members are directed towards a single purpose – the safe completion of every patient encounter. Clearly, the commitment to the critical concept of patient safety informs every part of my service to patients suffering from neurosurgical problems.

Photos courtesy of Philip Medbery.


1. Gillingham, B., Cobridge, J., Warner, H., Shaub, C., & Hoffman, D. (2016, October). Fleet practices are driving better health care. Proceedings Magazine.



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Bri Goslin | July 15, 2019 at 11:37 pm

Hi Dr. Tomlin,

Thank you for you service and for speaking at the Neurotrauma Society.

I’m interested in completing a Neuro PhD program where I might conduct research and write a dissertation on biochemical/nutritional tberapy for TBI. Would you have any particular programs you might recommend where there are mentors researching TBI and a program that would encourage these efforts?

Thank you!