Abstract
The medical contingent of the field hospital has different roles to play as the deployment continues, due to the changing case load and breakdown of patients and disease. If deployment occurs more than a few days from the event, the need for medical (as opposed to surgical) personnel will increase. This is due to the need to treat chronic medical conditions- due to the collapse of local medical services- and to treat infectious disease (wound infections) and to prevent and treat disease outbreaks.
Preparation for the mission will ultimately determine its success, due to the very short interval between the decision to deploy and deployment. Team preparation should ideally form a vaccinated group who will form the basis of those deployed.
The team must be self-sufficient in most aspects, taking only the minimum from the community: this will require requisition of many items and training in their use.
Infectious diseases personnel will not only guide treatment of patients but also be responsible for the health of the team and disease prevention.
The laboratory is an essential part of the team: microbiology capacity will enable guiding of treatment decisions by identifying antibiotic resistance.
Introduction
Even though most of the disaster situations in which international help was needed were related to trauma events (earthquakes, floods, and so on), all the missions that were deployed have shown a need for the deployment of a nonsurgical (i.e., medical) ward and medical staff. This is due to several reasons:
1. A high rate of wound infections among the casualties due to delay in treatment and lack of working hospitals, leading to treatment in suboptimal conditions. Treatment of these infections requires specialists in surgery, infectious diseases, and in wound care.
2. Within a short time, the team will have to deal with routine medical problems of the local population who will turn to them for help. On many occasions the international team has replaced local medical facilities, which, even before the event, were only able to provide a basic level of treatment. Thus, any treatment started must be sustainable after the departure of the mission.
3. These events usually occur in resource-poor countries where there is a high risk of the international team itself being infected by endemic diseases. Outbreaks of infectious diseases are liable to occur in the aftermath of the disaster due to the breakdown of the existing medical infrastructure and damage to homes necessitating transfer of the population to refugee centers.
Preparing the Team
Caring for the caregivers is highly important and should include vaccinations tailored to the area and conditions of deployment, together with lectures on relevant medical recommendations. These should cover at least the following areas and should be part of pretravel briefings[1]:
Food and Water Precautions
Ideally, the team should be self-sufficient, carrying supplies of food and water for the first 48–72 hours with capacity for food preparation from local supplies or continuous resupply from abroad.
A ready supply of potable water is a major priority to be addressed by the advance team. Clean, nonpotable water (for personal hygiene and so on) must be requisitioned from local sources, often requiring disinfection by team personnel.
Kitchen managers must be well versed in all aspects of setting up and operating food services under extreme conditions. Food and water will be purchased as available, often from unregulated suppliers. Food must be prepared according to strictest hygiene standards. Local kitchen workers, if employed, should be constantly supervised especially as to personal and hand hygiene. The manager must head a team including not only cooks but also hygiene specialists as food safety is critical for the continuing functioning of the whole unit. The level of functioning of foreign medical teams (FMTs) is notoriously prone to be affected by gastroenteritis caused by noncompliance of team members with simple guidelines followed by all travelers.
In some situations, the team may be allowed to experience local cuisine. In this case, the team members must observe the basic rules of travelers’ hygiene (“boil it, cook it, peel it, or forget it”).
Arthropod-Borne Diseases
Mosquito- and other vector-borne diseases are widespread. The field hospital team will rarely be working in an air-conditioned environment, and available sleeping accommodation will often preclude use of efficient mosquito nets. Mosquito and bug repellents must often be continuously applied.
Since different mosquitoes have different feeding times (Table 14.1), the team has to be instructed according to their destination. Aedes-related diseases (such as yellow fever, dengue, West Nile, Zika, and others) are widely spread around the globe, requiring daytime preventive measures. Anopheline mosquitoes carrying malaria are night feeders and therefore applying nighttime repellent and sleeping under mosquito nets are important for prevention of disease. If required, malaria prophylaxis must be taken starting before departure using one of the available regimens tailored to local conditions and Plasmodium resistance.
Table 14.1 Common arthropod-borne infections and their time of activity
| Vector | Activity time | Common diseases transmitted |
|---|---|---|
| Anopheline mosquitoes | Dusk to dawn | Malaria |
| Culex mosquitoes | Dusk to dawn | West Nile fever, Rift-Valley fever, lymphatic filariasis |
| Aedes mosquitoes | Daytime (mainly early morning and before dusk) | Dengue, Zika, yellow fever, chikungunya |
| Sandflies | Dusk to dawn | Leishmania (cutaneous and visceral) |
Animal Bites
Historically, field hospitals have been deployed in areas endemic for rabies, and this is the scenario expected in the future. The team should be aware that the risk is not only from dogs and that, in these regions, most of the mammals are not vaccinated, and therefore contact must be avoided. Since rabies preexposure vaccine takes three to four weeks before deployment, in most scenarios the team will not have been vaccinated. This will require not only designated personnel to ensure the hospital is free of animals but also the transport of passive and active vaccination to enable treatment of team members, and, if possible, of locals exposed to animal bites.
Exposure to Human Body Fluids
All members of the team must be fully vaccinated against hepatitis B. HIV postexposure prophylaxis has to be carried by the infectious disease members.
Vaccines
Vaccines are a highly important measure in protecting the team, but in some instances the operation timeline does not allow the proper time recommended by the vaccine schedule; in others vaccine recommendations require a repeat dose after few weeks’ interval, which does not always exist. In any case, last-moment vaccination is preferable to no vaccine.
Ideally, team members should have received basic travel vaccinations in advance, with additional specific vaccines (such as meningococcal and cholera) available for relevant destinations.
Vaccines before departure must include hepatitis A vaccine as this is the most common vaccine-preventable disease in most of these countries. Since the team often originates from highly industrialized countries, their chance of having natural immunity is very low.
Typhoid vaccine should be considered, especially when the target destination is in a highly endemic area for typhoid such as the Indian subcontinent. The current typhoid vaccine gives protection mainly against Salmonella typhi infection and does not cover Salmonella paratyphi infection, which has a similar clinical course.
To update tetanus toxoid, using diphtheria, tetanus, and acellular pertussis (dTaP) is recommended. For team members who last received the vaccine more than five years previously, a booster dose is advisable; tetanus exposure during the operation will not require a further dose during deployment.
Hepatitis B is indicated for all members of the medical team; a booster dose should be administered to all those without evidence of adequate cover.
Recommended Vaccines
Predeparture Vaccine
hepatitis A (highly recommended for all missions; on-call personnel should be vaccinated)
yellow fever (a must for missions in sub-Saharan Africa and South America)
dTaP (recommended after five years from last dose)
typhoid (for missions in endemic countries)
meningococcal vaccine, preferably conjugate; consider group B vaccine
cholera (in specific settings)
Japanese encephalitis vaccine (to be considered in missions to South and East Asia)
tick-borne encephalitis (in specific settings)
Carry-on Vaccines
These might be needed for the team and for local demands:
tetanus vaccine
tetanus immune globulin (TIG)
rabies vaccine
human rabies immune globulin
Vaccines must be transported under refrigeration and refrigerators must be available immediately on arrival.
Medicine During the Field Hospital Mission
The role of the nonsurgical side of the field hospital depends not only on the setting where the hospital is deployed but also the time of the deployment relative to the catastrophic event. Hospitals deployed into purely trauma events (such as earthquakes) find that the emphasis of treatment moves from emergency and urgent surgery to dealing with the medical requirements of surgical patients, but within a matter of days the balance again changes with the nonsurgical personnel being called to treat unknown and uncontrolled medical conditions by virtue of the field hospital hosting the only available medical services[2,3,4]. At this time, although only days after the defining event, the flow of patients requiring urgent surgery slows to a trickle. Most of those presenting at the hospital gates will at this stage require ambulatory care, with only a minority needing admission for overnight treatment and monitoring[3,5].
Thus, the role of the medical team in these situations can be grossly divided into two aspects:
1. Shoulder to shoulder with the surgical team – especially at the peak of surgical/orthopedic admissions – performing all nonsurgical tasks to free the surgeons to operate, then performing ambulatory follow-up together with the surgical team
2. A purely medical mission
Backing Up the Surgical Team and Treating Infections Associated With the Trauma Event
The medical ward, or more correctly the inpatient ward, will be mainly occupied at the early stage of the situation by postsurgery/post-trauma patients. Nonsurgeons will staff the ward, performing rounds together with a senior surgeon. In the first days, those hospitalized will be those requiring postoperative care, treatment of the nonoperable results of trauma, and those with conditions treated and stabilized in the operating room; some requiring further surgery. Most of the first wave of patients will be discharged within days, leaving those with severe infections, those requiring a second operation and those with other conditions such as crush injuries to be treated on a longer-term basis[4]. Pediatric patients show a similar pattern: inpatients comprising those with earthquake-caused injuries together with children suffering from nontrauma-caused infections [3,6].
In this setting, daily rounds must be done by the collaborative teams of the surgery and medical teams; the changing composition reflecting the lowering of the surgical burden and increase in medical inpatients and ambulatory workload.
One of the responsibilities of the nonsurgical team is treatment of infections. Antimicrobial treatment must be tailored to the individual patient, requiring daily refining, preferably by infectious disease specialists. Microbiology capacity as part of the hospital laboratory is often limited, but even limited data can be invaluable in identifying the local pathogens and antibiotic resistance. The circumstances of major traumatic events create conditions unlike any that physicians are likely to have met during regular hospital work, so the inclusion of physicians with experience of these scenarios is to be encouraged.
Even though wound infections complicate most injuries, it is not possible to treat empirically using nondisaster guidelines. These presume infection with Gram-positive species, which typically cause skin and soft tissue injuries in nonhospitalized patients. Pathogens causing wound infections are indeed traditionally considered to be Gram positive, but all those reporting culture results taken from infected wounds in the field have found that most are Gram negative. This fact must be taken into consideration when deciding which antimicrobials to use as empirical therapy, and which to include in the procurement list (Table 14.2).
Table 14.2 The breakdown of bacterial isolates from victims of various disasters[7]
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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