Abstract
Field hospitals are a vital element in providing as many medical services as possible to a stricken population in times of disaster. Setting up a field hospital with advanced auxiliary medical services is possible as long as there is comprehensive and careful planning, training, and preparation done ahead of time. The main objective of the AMS department is to organize and assist in establishing the field hospital, ensure its smooth and efficient operation throughout the stay, and, at the close of a mission to disassemble the equipment for its return journey and then ensure it is in optimum working order for the next call up. The department is responsible for maintaining all medical devices in perfect working order with the focus being on safety compliance and patient welfare. The four core services provided by the department cover medical engineering, medical equipment and pharmacy, diagnostic imaging, and the clinical laboratory. All these services operate according to a predetermined workflow and clear working guidelines. In keeping with the goals of the humanitarian mission, the medical engineering service will handle the acquisition and maintenance of equipment capable of functioning in an electricity free environment. They will verify that all devices are robust and capable of operating under extreme weather conditions and comply with any specifications mandated by the different countries. The pharmacy service plays a vital role in ensuring medicine and its accompanying information is handled efficiently and safely. Data is accrued over the span of a mission to assist with ever more accurate future planning. The diagnostic imaging service must be able to provide both investigative and diagnostic examinations. This service is agile and can be provided in an imaging department tent, a dedicated container unit or bedside for patients who are not to be moved. The clinical laboratory service performs a full array of tests that facilitate in diagnosis and treatment of the patient. The services provided by the laboratory include biochemistry, hematology, and microbiology. The laboratory diagnoses the pathogens in infectious diseases and identifies the type of bacteria and its susceptibility to various antibiotics.
Introduction
Setting up a field hospital with advanced auxiliary medical services (AMS) is a feasible mission. The chosen equipment and workforce enable smooth and professional work, with the ability to diagnose and treat most of the anticipated problems, and to stabilize most others prior to evacuation. Accurate planning of the service to be provided and the equipment is necessary. Training the medical staff regarding the need to use auxiliary services sparingly is an important part of running a field hospital.
The work of all the AMS departments begins well before a disaster occurs and continues well after it ends. Their work is of importance even during routine times, long before the outbreak of a disaster, and involves purchasing and equipping medical devices and instruments suited for work in the field, with an emphasis on the mobility of the equipment and its ability to function without electricity (at least for several hours until the hospital connects to the electricity grid). Given certain disaster scenarios, consideration must be given to the equipment’s ability to operate under extreme weather conditions and, of course, it must correspond to the specifications as defined by the medical professionals of the different disciplines.
Following the occurrence of a disaster/incident, as much information as possible is collected on the given scenario, the size of the disaster, the estimated number of casualties, and the type of injuries, as well as the treatment required on scene.
Based on this information, the goals of the humanitarian mission are determined, with the field hospital a part of the mission. At this point, the departments and medical capabilities the field hospital will have are decided, which are determined by the hospital’s commander and senior medical personnel who will head the hospital’s planned departments.
At this planning stage, the department of AMS is incorporated into the hospital structure so that a list of equipment and accessories can be made in preparation for establishing the hospital and recruiting professional staff (Figure 11.1).
Figure 11.1 The structure and organization of the AMS department
The functions and tasks of the AMS department are to:
prepare and plan for the mission within the given time constraints
assist in preparing the required equipment for shipping to the country of destination
organize and assist in establishing the field hospital as quickly as possible in the country of destination
ensure regular, continuous activity of all the field hospital’s departments by providing maintenance of the equipment, running the obligatory testing of the equipment, and enforcing safety and security requirements
assist and take part in preparing the equipment for its return journey home at the end of a mission
ensure the equipment is maintained in good working order in between missions
take part in the debriefing sessions that are held throughout the mission and at its closing
Medical Engineering
Background
The work of a medical engineering department begins well before a disaster occurs and continues long after it is over. Medical engineering deals with the acquisition of equipment suitable for work in the field, with emphasis on the equipment’s mobility and ability to operate without an electricity source (at least for several hours until the hospital connects to the electricity grid), the ability to operate under extreme weather conditions, and of course, it must correspond to the specifications as defined by the medical professionals of the different disciplines.
When the field hospital is at the planning stage, the medical engineering department is incorporated into the hospital structure so that a list of equipment and accessories can be made in preparation for establishing the hospital and recruiting professional staff.
The Role of a Field-Hospital Medical Engineering Department
The department is responsible for providing maintenance services: repairing and ensuring the smooth running of all the field hospital’s medical devices, including all the various gas systems. They must be able to guarantee the competency of all devices throughout the hospital’s various departments, while maintaining the safety of both patients and caregivers. Only standard medical devices are allowed, in order to avoid exposing patients and caregivers to any danger. Those operating the equipment must receive appropriate training.
The role of the medical engineering department remains the same no matter what type of disaster the field hospital is attending. The only difference will be the nature of the equipment, the quantities, and the personnel (the qualifications required and the number of people needed for the specific mission: more detail on this is in the section on personnel later in the text).
The Required Core Competencies
installation of all the field hospital’s medical equipment
provision of the training and technical support for operating the equipment, including the gas systems
Repair of the medical equipment and medical gas systems
In a field hospital, there is no option to send a piece of equipment for repair off campus (i.e., sending faulty devices, which cannot be repaired in-house, to an external workshop/supplier). Due to the nature of the missions and the distance from home, the department should use all the means at its disposal to maintain the medical equipment to the highest standard. This ensures the hospital has maximum independence as there is no option of receiving a repair service from external suppliers. The medical engineering department is, in fact, called on to use all its professional skills to keep everything in working order.
This is also true in between missions, where the medical engineering department is responsible for storing and preserving the functionality of the equipment. Before embarking on a mission, they must conduct test runs. Charging the batteries of equipment that includes rechargeable batteries is critical and important.
Personnel
Division of Labor
The objective is to maintain the physical strength and availability of technicians throughout all working hours of the field hospital, including nighttime. If necessary, night shifts should be implemented to provide a seamless response to service calls from the operating rooms and to provide technical support for faulty medical devices during these hours. Devices that do not urgently need to be fixed at night can be repaired during normal working hours.
For the morning shift (when the hospital opens for activity and starts receiving patients), there will be at least two technicians present who will conduct a daily round of all the hospital departments; checking in with the head of each department regarding the condition of their medical devices, whether any devices need fixing or changing, the condition of the oxygen system, and whether oxygen cylinders are needed.
For the night shift, there will be one technician on call every night. If the field hospital has three technicians, the night-shift technician will rest during the day, not performing daytime activities to be alert for the night work. If there are only two technicians, the night-shift technician will perform minimum duties throughout the day (depending on the hospital’s workload) to better provide optimal response throughout the night.
Essential Equipment
Main Functions and Tasks
provide support in all aspects of deploying medical equipment and gas systems
maintain all medical devices; both proactive checks and repairs
repair medical equipment, including the gas systems installed in the hospital
train and provide technical support to those operating the medical devices
manage the inventory of spare parts, technical rotation, and testing of the medical devices
Department Action Required Prior to Deployment
Collaborate with the heads of department to prepare the list of medical equipment needed that is specific to the mission.
Prepare a second list (based on the above) of all the spare parts, disposables, accessories, tools, and testing equipment needed, as well as professional technical literature, including user and maintenance manuals.
Raise funds and join forces with other hospitals/ nongovernmental organizations (NGOs) to recruit specialist or fragile equipment, or equipment that is not in frequent use (such as that for newborns, infants, and children).
Test all equipment prior to packing it. Charge all devices with rechargeable batteries and replace all faulty equipment before departure. In between missions, conduct routine maintenance checks to catch any faulty equipment ahead of time. This routine will ensure equipment is kept in good condition and will leave just the batteries to be recharged as a precaution prior to a swift departure.
Actively participate in packing the equipment, with emphasis on marking the boxes that hold spare parts, disposables, tools, and testing equipment. Boxes should be grouped according to department and clearly labeled.
Unique and important testing equipment, as well as expensive and important items, should be packed together with the technician’s personal luggage.
Action Required at Deployment
Take part in establishing and organizing the field hospital.
Distribute the medical equipment among the various departments and connect them to electricity. Ensure the devices are in working order and were not damaged during transport.
Establish the infrastructure for medical gases and ensure it is working and is up to standard.
Instruct the medical teams on how to work and operate the equipment.
Routine Action Required in a Functioning Field Hospital
Accurately list all equipment by department. This register is important for keeping track of the equipment when the field hospital is dismantled and packed for the return journey.
Maintain a list of all equipment that has been repaired or replaced and ensure the list is always up to date.
Proactively conduct tours at the various departments, both in the morning and evening, to check the status of all medical devices.
Repair broken or faulty devices.
Replenish the disposables.
An appliance that the department is not able to repair will be replaced or exchanged (depending on availability and inventory). Any device found to be deficient/dangerous, which cannot be repaired, should be removed from circulation. Patient and team-member safety is paramount.
Instruct users on using all the field hospital’s medical equipment and provide technical support.
Manage the inventory of spare parts, disposables, and technical rotation of medical equipment, and replace medical equipment if necessary.
Manage purchasing requests and orders for spare parts, disposables, and accessories
Register and manage the inventory of medical devices by department and note the status of any device being repaired.
Dispatch a daily report on the competence of all medical devices.
Pharmacy Services
Background
If the pharmacy and the role of the pharmacist in a field hospital is considered prior to deployment, there are many benefits to the field hospital. The pharmacist is involved in many predeployment projects and is an integral part of ensuring medicines and medicine information are handled efficiently in country. At the end of a deployment, the pharmacist will assist in hospital operation during the mission and implementing changes.
Field Hospitals: Rules
The World Health Organization (WHO) lists minimum standards that need to be met with regards to medicine supply within the emergency medical team (EMT) framework according to the type of deployment[1].
The medication requirements as set out by WHO can be seen in Table 11.1. Medicines should align with the latest version of the WHO essential medicines list (EML), which is updated every two years[2,3]. The EML outlines medicines that should be available to satisfy the priority health needs of a population. This considers the medicines’ efficacy, safety, public health relevance, and cost-effectiveness. Most countries use the WHO EML to develop their own local EML. Medicines in field hospitals should, wherever possible, align with the host country’s EML. Field hospitals need to be able to manage cold chain safely and carry vaccines including tetanus and pediatric hepatitis B vaccine. The medicine requirements increase as the complexity of the hospital increases.
Table 11.1 Medication requirements according to EMT type
| EMT type | Medication requirements |
|---|---|
| 1 | Outpatient drug supply to treat for the EMT’s declared capacity for two weeks, the WHO essential medicines list or equivalent, and tetanus prophylaxis |
| 2 | Inpatient and outpatient drug supply, including surgical and anesthetic drugs, and enhanced essential drug list |
| 3 | Intensive-care-level drug pharmacopeia |
All medicines that are carried and used within the hospital must be of a quality that could be used in the hospital’s home country. They should also meet the WHO guidelines for medicine donations[4]:
medicines must have a remaining shelf life of at least one year
medicines must have instructions written in a language that is understood in the host country and contain the international nonproprietary name
medicines should appear on the host country EML
medicines should come from a quality-assured source and comply with quality standards in both the donor and host countries
medicines cannot have been returned by patients or be free samples
Medicines Licensing and Legislation
Every country has their own rules around the exportation and importation of medicines. In most countries, some medicines need approval in the form of a license before they can be imported or exported. These licenses generally need to be applied for in advance to allow processing. It is worthwhile contacting the licensing body to determine whether they will allow a multiple-use annual license. A license will also be needed for the host country. Assistance of host-country embassy staff may expedite this process.
The field hospital must maintain the pharmacy according to local host-country legislation and the legislation governing medicines in the team’s country of origin. This includes medicine storage requirements, documentation requirements, and the pharmacist’s scope of practice.
All practitioners within the field hospital need to have a valid “authority to practice” in the host country. They must also work only within their usual scope of practice and within the scope of practice of the profession in the host country. For example, if the pharmacist does not administer vaccines as a part of their normal scope of practice, it would be inappropriate to administer vaccines in the field hospital. In addition, if vaccine administration is part of the pharmacist’s usual work in their home country, but not a permitted role of pharmacists in the host country, then their “authority to practice” will not cover this service and it should not be offered.
Australian Experience
The Australian government requires 30 days’ notice to issue an import/export license, which is not feasible if you are to be deployed at short notice. The Australian Medical Assistance Team (AUSMAT) applies for a multiple import/export license from Australian customs at the start of each year listing the maximum amount of medicines an AUSMAT may take. The Australian government is not concerned if fewer are taken. AUSMAT does not apply for licenses to every possible host country for a deployment; rather, it relies on the Australian government’s assistance in acquiring a permit at short notice. As we do not go without an invitation from the host country, this has been successful in the past.
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 7 – Personnel
Chapter 15 – Pediatrics in a Field Hospital
Chapter 18 – Orthopedics in a Field Hospital
Chapter 25 – Infectious Diseases and Public Health in a Field Hospital
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