Mass casualties are defined by insufficiency of existing support to cope
with the number and severity of casualties. It is therefore necessary to
transport support teams from other areas, usually overseas, to the crisis
area. The unpredictability of these crises implies that when preparations
for deployment begin, the clock is already ticking. Construction of a
field hospital requires large amounts of sophisticated equipment. The
speed with which the hospital must be put together and transported so as
to be efficient and the basic conditions of a field hospital dictate
specific considerations regarding medical auxiliary equipment. In the
Turkish earthquake crisis, Israel was one of the many states to deploy a
field hospital to the crisis site. This was set up in Adapazari, The
second city with regard to the amount of damage. We present here the
considerations in choosing equipment, problems encountered during
installation, and recommendations for the future.
Introduction
Mass casualties, where there are hundreds or thousands of casualties are
frequently complicated by complete collapse of all local support systems
[1]. This can be due to different reasons including war or guerilla
activity industrial accident and natural event. The case of a massive
earthquake is probably the most destroying, since underground facilities,
including electricity, communications, water and sewage are crushed [1].
This set-up dictates that for a field hospital to be most effective, it
must be able to set itself up completely independently of the local
infrastructure. Several factors contribute to the delay of arrival of
field hospitals on the site, usually making their arrival between 36 and
72 hours after the incident. These are the unpredictable nature of these
events, their diversity, the delay in transfer of information regarding
the extent of the crisis and the time taken for political decisions about
deployment. The logistics involved in erecting an independent functioning
field hospital with advanced capabilities are immense. The personnel
involved in preparing the delegation are not necessarily trained or
knowledgeable regarding the peculiarities of this sort of mission (the
serious problem of effective backup) [2-4]. It is therefore necessary to
carefully study the developing experience of the various teams, create a
general body of knowledge, and prepare drawer programs for the deployment
of a field hospital to a mass casualty site. The purpose of this paper is
to discuss the experience of the Israeli field hospital team regarding the
auxiliary medical equipment, so that others can learn, without repeating
those mistakes. This was the fifth medical delegation sent from Israel to
crisis areas, and it is important to state that even though no crisis is
similar to another, the Israel Defense Forces Medical Corps are
continually learning and improving the technique of organizing the
delegations.
Methods
The mission definition of the IDF field hospital was to set up a field
hospital capable filling in the vacuum created by the damage to the city
hospitals of Adapazari. The hospital was to be able to receive patients
within 24 hours of deployment. The demanded capabilities were: triage,
resuscitation, life saving surgery including laparotomy and other major
surgery, intensive care treatment and monitoring (5 beds) and general
hospital admission and treatment (80 beds including internal medicine,
obstetrics and gynecology, surgery and orthopedics, and pediatrics
including neonates).
The laboratory equipment was chosen to be lightweight table top models,
easily installed, without the need of a technician. As fully automated
equipment for running all tests customarily provide in a general hospital
by 5-10 different laboratories was obviously not feasible, and as for
staff economy only one laboratory technician was to be deployed, the time
consummation factor regarding various tests was of critical importance.
CBC and electrolytes (Na+/K+) were to be freely accessible with results
without delay. This was for general survey and predicting that there might
be electrolyte imbalance due to crush injuries or from an outbreak of
diarrhea. The CBC was provided by the Micros 60 of ABX, France, with the
ability to test 18 functions (WBC, LYM, MON, GRA, RBC, HGb, Hct, MCV, MCH,
MCHC, RDW, PLT, MPV, PDW, PCT and percentages). The analysis takes about
1.5 minutes. Electrolyte analysis was provided by the Ilyte Na+ K+ Ca++ pH
System of Instrumentation Laboratory USA. It uses ion selective electrodes
and can analyze serum and urine. We didn't think that it would be
necessary to analyze urine electrolytes and therefore didn't take the
urine buffer. Following coagulation and 5 minutes centrifugation, the
analysis takes about 1.5 minutes.
Bearing in mind possible DIC after crush injuries or major trauma, the MCL
2 Coagulation Analyzer from Instrumentation Laboratories USA. This
analyzer uses photo-optical clot detection, and is capable of measuring
PT, aPTT, fibrinogen assays, and quantitative assay of specific factors.
We took kits for PT and aPTT only.
Shock patients, surgical patients and ICU patients depend on arterial
blood gas analyses for respirator parameters. The OPTI 1 pH/Blood Gas
Analyzer of AVL Scientific Corporation, Georgia USA measures pH, PO2 &
PCO2 by luminescence with optical electrodes. It was chosen for its
compactness and the fact that the sample cassettes could be stored at room
temperature.
For the remaining biochemistry tests, the BT 224 Photometer of biotecnica
instruments spa, Italy, was chosen. This is a programmable photometer with
the basic ability to perform almost any test. We took kits for glucose,
urea, creatinine, CK, GPT, amylase and bilirubin. Because the glucose test
is an end-point reaction test, it takes about 30 minutes and was reserved
for special cases. Routinely, glucose tests were performed using Acutrend
glucometers, which were dispensed to the departments. Urea testing, using
a kinetic reaction, taking only 2 minutes, and was therefore less time
consuming.
Microbiology equipment included a standard laboratory microscope,
equipment for Gram staining, culture plates with: blood agar for standard
cultures, chrome agar for gram negative bacteria, MacKonkey and SS agar
for fecal culture, agar tubes for biochemical identification and Muller
Hinton and XLD plates for sensitivity identification. Incubation was
performed in an Imperial III incubator, Lab Line, at 37(C. Standard
urinalysis sticks were chosen to include blood, glucose, nitrates,
ketones, pH, bilirubin, and specifically leukocytes. They also were
dispensed to the departments.
Minimal blood bank services were provided: Rh typing of mothers to decide
whether anti D immunoglobulin was necessary. AB typing was performed for
cases where fresh blood donation was considered necessary, and type
specific blood was given without cross matching. This was achieved with a
standard typing set including anti-A, anti-B, anti- D and anti human
globulin.
Additional equipment included 2 desktop centrifuges, a standard household
refrigerator and automatic pipettes. The tubes necessary for these tests
were plain (serum), EDTA (CBC) and sodium citrate (coagulation). Equipment
not mentioned, but requiring detailed preparation would include slides,
gloves, tubing etc. etc.
Radiology equipment included a porta ray inc. 9000a series x-ray generator
(Deer park, NY) able to generate up to 100kV. Films were developed with
evamatic60 Agfa Gevaert, developer (Germany), capable of developing a film
in about 4 minute. A specially designed developing tent, insulated from
light (standard in Israeli field hospitals) was constructed by the
radiology tent.
Results
With this equipment, the hospital was able to provide services comparable
to a fully equipped modern hospital. 1205 patients were treated over a
period of 1 week. 148 patients were X-rayed, and some 350 lab tests were
performed. As both the laboratory and radiology were manned by only one
technician each, there services were limited to working hours (08:00-
22:00) and life-saving cases overnight. It was necessary to train the
physicians on the auxiliary services available and their utilization so as
to enable smooth functioning. Minor problems installing the laboratory
equipment were encountered, solvable by the engineer in the team.
The radiology equipment was damaged by a surge of 380 volts from the
generator. This necessitated transport of new equipment from Israel.
Luckily the local radiology department was back functioning (including CT
scan) within 5 days of the earthquake, so patients were referred. Damage
to the films from wet weather was also solved, but better packing is
required in future. Another problem encountered was that the instrument
designed to hold the X-ray cassettes was to tall for the tent (an Italian
tent provided by the local authorities. The team did not take tents,
planning to set up within a the building of the local forestry ministry,
localized by the scout mission, and cleared by the city engineer. Due to
frequent after shocks, the building, was evacuated). A known problem with
this evamatic60 Agfa Gevaert developer was overheating on the warmer days
which caused melting of the silicone wheel. This was solved by replacement
and simply lowering the thermostat to minimum.
Conclusions
Setting up a field hospital with advanced auxiliary medical services is a
feasible mission. The above equipment enabled smooth and professional
work, with the ability to diagnose and treat most of the anticipated
problems, and stabilize most others prior to evacuation.
Accurate planning of the service to be provided and the equipment is
necessary. Minor modifications of the list above might include a different
cassette holder and spare X-ray equipment. Had there been cases of
suspected DIC, the kit for fibrinogen would have been useful. Training the
physicians regarding the need to use auxiliary services sparingly is an
important part of running a field hospital.
Acknowledgements
We are indebted to all the physicians, nurses, paramedics, medics and
logistic team who participated in the mission. We also wish to express our
gratitude for the help of all the Turkish physicians, translators and
coordinators working in common with us in the field hospital. This article
is devoted to the 1205 families to whom we had the opportunity to give
medical aid in the field hospital in Adapazari.
References
1. Nakamura H , Overview of the Hanshin-Awaji earthquake disaster. Acta
Paediatr Jpn, 1995; 37: 713-6.
2. Heyman SN, Eldad A, Wiener M, Airborne field hospital in disaster
area: lessons from Armenia (1988) and Rwanda (1944). Prehospital Disaster
Med, 1998; 13: 21-28.
3. Henderson AK, Lillibridge SR, Salinas C, Graves RW, Roth PB, Noji EK,
Disaster medical assistance teams: providing health care to a community
struck by Hurricane Iniki. Ann Emerg Med, 1994; 23: 726-730.
4. Kunii O, Wakai S, Honda T, Tsujimoto K, Role of external medical
volunteers after disasters. Lancet, 1996; 347: 1411.
Competing interests:
No competing interests
13 September 1999
A S Finestone
Department of Orthopedic Surgery
Y Wolf, Y Bar-Dayan, Y Zieda, Y Tearosh, M Stein, D Mankuta
Rapid Response:
Medical Auxiliary Equipment in a Field Hospital
Medical Auxiliary Equipment in a Field Hospital: Experience from the
Israeli Delegation to the Site of the Turkish Earthquake
AS Finestone, Y Wolf, Y Bar-Dayan, Y Zieda, Y Tearosh, M Stein, D
Mankuta,
A Eldad, & P Benedek.
IDF field hospital mission team, IDF Medical Corps, Israel
Keywords: mass casualty, field hospital, laboratory equipment,
radiology equipment
Address for correspondence: Aharon Finestone MD,
Department of Orthopedic Surgery,
IDF Field Hospital Mission Team, Adapazari
IDF Medical Corps
Phone:00-972-8-9262254
Fax: 00-972-8-9266716
Email: asff@internet-zahav.net
Abstract
Mass casualties are defined by insufficiency of existing support to cope
with the number and severity of casualties. It is therefore necessary to
transport support teams from other areas, usually overseas, to the crisis
area. The unpredictability of these crises implies that when preparations
for deployment begin, the clock is already ticking. Construction of a
field hospital requires large amounts of sophisticated equipment. The
speed with which the hospital must be put together and transported so as
to be efficient and the basic conditions of a field hospital dictate
specific considerations regarding medical auxiliary equipment. In the
Turkish earthquake crisis, Israel was one of the many states to deploy a
field hospital to the crisis site. This was set up in Adapazari, The
second city with regard to the amount of damage. We present here the
considerations in choosing equipment, problems encountered during
installation, and recommendations for the future.
Introduction
Mass casualties, where there are hundreds or thousands of casualties are
frequently complicated by complete collapse of all local support systems
[1]. This can be due to different reasons including war or guerilla
activity industrial accident and natural event. The case of a massive
earthquake is probably the most destroying, since underground facilities,
including electricity, communications, water and sewage are crushed [1].
This set-up dictates that for a field hospital to be most effective, it
must be able to set itself up completely independently of the local
infrastructure. Several factors contribute to the delay of arrival of
field hospitals on the site, usually making their arrival between 36 and
72 hours after the incident. These are the unpredictable nature of these
events, their diversity, the delay in transfer of information regarding
the extent of the crisis and the time taken for political decisions about
deployment. The logistics involved in erecting an independent functioning
field hospital with advanced capabilities are immense. The personnel
involved in preparing the delegation are not necessarily trained or
knowledgeable regarding the peculiarities of this sort of mission (the
serious problem of effective backup) [2-4]. It is therefore necessary to
carefully study the developing experience of the various teams, create a
general body of knowledge, and prepare drawer programs for the deployment
of a field hospital to a mass casualty site. The purpose of this paper is
to discuss the experience of the Israeli field hospital team regarding the
auxiliary medical equipment, so that others can learn, without repeating
those mistakes. This was the fifth medical delegation sent from Israel to
crisis areas, and it is important to state that even though no crisis is
similar to another, the Israel Defense Forces Medical Corps are
continually learning and improving the technique of organizing the
delegations.
Methods
The mission definition of the IDF field hospital was to set up a field
hospital capable filling in the vacuum created by the damage to the city
hospitals of Adapazari. The hospital was to be able to receive patients
within 24 hours of deployment. The demanded capabilities were: triage,
resuscitation, life saving surgery including laparotomy and other major
surgery, intensive care treatment and monitoring (5 beds) and general
hospital admission and treatment (80 beds including internal medicine,
obstetrics and gynecology, surgery and orthopedics, and pediatrics
including neonates).
The laboratory equipment was chosen to be lightweight table top models,
easily installed, without the need of a technician. As fully automated
equipment for running all tests customarily provide in a general hospital
by 5-10 different laboratories was obviously not feasible, and as for
staff economy only one laboratory technician was to be deployed, the time
consummation factor regarding various tests was of critical importance.
CBC and electrolytes (Na+/K+) were to be freely accessible with results
without delay. This was for general survey and predicting that there might
be electrolyte imbalance due to crush injuries or from an outbreak of
diarrhea. The CBC was provided by the Micros 60 of ABX, France, with the
ability to test 18 functions (WBC, LYM, MON, GRA, RBC, HGb, Hct, MCV, MCH,
MCHC, RDW, PLT, MPV, PDW, PCT and percentages). The analysis takes about
1.5 minutes. Electrolyte analysis was provided by the Ilyte Na+ K+ Ca++ pH
System of Instrumentation Laboratory USA. It uses ion selective electrodes
and can analyze serum and urine. We didn't think that it would be
necessary to analyze urine electrolytes and therefore didn't take the
urine buffer. Following coagulation and 5 minutes centrifugation, the
analysis takes about 1.5 minutes.
Bearing in mind possible DIC after crush injuries or major trauma, the MCL
2 Coagulation Analyzer from Instrumentation Laboratories USA. This
analyzer uses photo-optical clot detection, and is capable of measuring
PT, aPTT, fibrinogen assays, and quantitative assay of specific factors.
We took kits for PT and aPTT only.
Shock patients, surgical patients and ICU patients depend on arterial
blood gas analyses for respirator parameters. The OPTI 1 pH/Blood Gas
Analyzer of AVL Scientific Corporation, Georgia USA measures pH, PO2 &
PCO2 by luminescence with optical electrodes. It was chosen for its
compactness and the fact that the sample cassettes could be stored at room
temperature.
For the remaining biochemistry tests, the BT 224 Photometer of biotecnica
instruments spa, Italy, was chosen. This is a programmable photometer with
the basic ability to perform almost any test. We took kits for glucose,
urea, creatinine, CK, GPT, amylase and bilirubin. Because the glucose test
is an end-point reaction test, it takes about 30 minutes and was reserved
for special cases. Routinely, glucose tests were performed using Acutrend
glucometers, which were dispensed to the departments. Urea testing, using
a kinetic reaction, taking only 2 minutes, and was therefore less time
consuming.
Microbiology equipment included a standard laboratory microscope,
equipment for Gram staining, culture plates with: blood agar for standard
cultures, chrome agar for gram negative bacteria, MacKonkey and SS agar
for fecal culture, agar tubes for biochemical identification and Muller
Hinton and XLD plates for sensitivity identification. Incubation was
performed in an Imperial III incubator, Lab Line, at 37(C. Standard
urinalysis sticks were chosen to include blood, glucose, nitrates,
ketones, pH, bilirubin, and specifically leukocytes. They also were
dispensed to the departments.
Minimal blood bank services were provided: Rh typing of mothers to decide
whether anti D immunoglobulin was necessary. AB typing was performed for
cases where fresh blood donation was considered necessary, and type
specific blood was given without cross matching. This was achieved with a
standard typing set including anti-A, anti-B, anti- D and anti human
globulin.
Additional equipment included 2 desktop centrifuges, a standard household
refrigerator and automatic pipettes. The tubes necessary for these tests
were plain (serum), EDTA (CBC) and sodium citrate (coagulation). Equipment
not mentioned, but requiring detailed preparation would include slides,
gloves, tubing etc. etc.
Radiology equipment included a porta ray inc. 9000a series x-ray generator
(Deer park, NY) able to generate up to 100kV. Films were developed with
evamatic60 Agfa Gevaert, developer (Germany), capable of developing a film
in about 4 minute. A specially designed developing tent, insulated from
light (standard in Israeli field hospitals) was constructed by the
radiology tent.
Results
With this equipment, the hospital was able to provide services comparable
to a fully equipped modern hospital. 1205 patients were treated over a
period of 1 week. 148 patients were X-rayed, and some 350 lab tests were
performed. As both the laboratory and radiology were manned by only one
technician each, there services were limited to working hours (08:00-
22:00) and life-saving cases overnight. It was necessary to train the
physicians on the auxiliary services available and their utilization so as
to enable smooth functioning. Minor problems installing the laboratory
equipment were encountered, solvable by the engineer in the team.
The radiology equipment was damaged by a surge of 380 volts from the
generator. This necessitated transport of new equipment from Israel.
Luckily the local radiology department was back functioning (including CT
scan) within 5 days of the earthquake, so patients were referred. Damage
to the films from wet weather was also solved, but better packing is
required in future. Another problem encountered was that the instrument
designed to hold the X-ray cassettes was to tall for the tent (an Italian
tent provided by the local authorities. The team did not take tents,
planning to set up within a the building of the local forestry ministry,
localized by the scout mission, and cleared by the city engineer. Due to
frequent after shocks, the building, was evacuated). A known problem with
this evamatic60 Agfa Gevaert developer was overheating on the warmer days
which caused melting of the silicone wheel. This was solved by replacement
and simply lowering the thermostat to minimum.
Conclusions
Setting up a field hospital with advanced auxiliary medical services is a
feasible mission. The above equipment enabled smooth and professional
work, with the ability to diagnose and treat most of the anticipated
problems, and stabilize most others prior to evacuation.
Accurate planning of the service to be provided and the equipment is
necessary. Minor modifications of the list above might include a different
cassette holder and spare X-ray equipment. Had there been cases of
suspected DIC, the kit for fibrinogen would have been useful. Training the
physicians regarding the need to use auxiliary services sparingly is an
important part of running a field hospital.
Acknowledgements
We are indebted to all the physicians, nurses, paramedics, medics and
logistic team who participated in the mission. We also wish to express our
gratitude for the help of all the Turkish physicians, translators and
coordinators working in common with us in the field hospital. This article
is devoted to the 1205 families to whom we had the opportunity to give
medical aid in the field hospital in Adapazari.
References
1. Nakamura H , Overview of the Hanshin-Awaji earthquake disaster. Acta
Paediatr Jpn, 1995; 37: 713-6.
2. Heyman SN, Eldad A, Wiener M, Airborne field hospital in disaster
area: lessons from Armenia (1988) and Rwanda (1944). Prehospital Disaster
Med, 1998; 13: 21-28.
3. Henderson AK, Lillibridge SR, Salinas C, Graves RW, Roth PB, Noji EK,
Disaster medical assistance teams: providing health care to a community
struck by Hurricane Iniki. Ann Emerg Med, 1994; 23: 726-730.
4. Kunii O, Wakai S, Honda T, Tsujimoto K, Role of external medical
volunteers after disasters. Lancet, 1996; 347: 1411.
Competing interests: No competing interests