Introduction

A mobile hospital or field hospital, when activated in a disaster scenario, is generally guided by the principle of doing the greatest good for the greatest number[1]. This notion puts into question the allocation of a large amount of material and human resources to the treatment of a few critically injured patients.

Answering such a question must take into consideration the complexity of modern critical-care medicine. The development of the current concept of intensive care units (ICUs) has allowed the survival of patients with advanced illness and injury, although at a cost of substantial infrastructure. Since this discipline involves maximal lifesaving procedures and interventions, in the daily practice of the health system, it was usually not provided by most field hospitals deployed to disaster areas.

The capability to provide medical care to critically ill patients has evolved considerably since the 1970s. ICUs were developed where special expertise and equipment could be used to treat extremely complicated patients. Data suggesting that the presence of ICU staffing alone can affect a change in overall patient outcome (hospital mortality, length of stay) for the critically ill population, lends credence to the importance of adequate and aggressive ICU care, even in austere conditions[2]. As the field of critical care has developed, it has become clear not only that ICUs are effective tools for resuscitation and stabilization of the critically ill but also that the timing with which the treatment is initiated have lasting effects on the overall hospital course of the patient. A modern ICU represents a delicate assembly of skilled personnel and physical infrastructure. This infrastructure must include space to support patients and staff; temperature control; secure oxygen, electricity, water, and vacuum sources; medical supplies; pharmaceutical agents; and equipment. ICUs must also have ready access to surgical, radiographic, blood bank, and laboratory capabilities. Understanding the complex infrastructure elements needed for the practice of critical-care medicine, and advanced monitoring and life-support technologies, enabled modern medicine to push forward ICU capabilities to austere situations. This can be a significant “pro” in the equation of “pros and cons” when considering the ICU integration in a deployed field hospital to a disaster area. Another aspect used in this equation of “pros and cons” is the modern approach to the concept of end-of-life decisions and limitation of care, practiced today more commonly in most modern critical care units in the Western world[3,4]. Combining these two aspects can offer a new notion to guide the ICU integration in a disaster event setting: providing a limited number of predetermined critical care interventions to as many casualties as possible, rather than maximal critical care to fewer patients.

Supportive elements for the decision whether to operate a critical care unit in a disaster scenario can be the nature of the disaster itself. Based on extent and severity of injuries, the literature classifies casualty level in disaster scenarios into two types: “mass-casualty event” versus “multiple-casualty event.” These two types differ with respect to the balance between the scope and intensity of medical care required, and the numbers injured and their medical requirements[5]. In a “mass-casualty event,” the medical system, which is supposed to provide medical services, is overwhelmed by the extent of the disaster and the number of casualties. In such a situation – for example, chemical-weapons attack or catastrophic nuclear event with mass radiation exposure – clear distinction is made between the walking wounded and casualties not able to move by themselves. Under such circumstances, medical resources should be directed to the walking wounded only, while other casualties receive minimal medical attention. Here, the strict guiding principle is to give the best possible treatment to the largest number of patients. Therefore, the individual patient requiring intensive care, including multisystem support, will not receive any treatment as this may divert treatment resources away from a wide group of more minor casualties having an acceptable outcome and a better prognosis. In this scenario, operation of an ICU should not be considered. In contrast, in a “multiple-casualty event,” where the medical system is functional and its resources do meet the casualties’ medical needs, high-quality medical care becomes possible and there should be aspiration to reaching the best available predefined standards of modern critical-care medicine. There is obviously a need for casualty triage and construction of an order of therapeutic priorities, but in this type of event, most casualties will receive medical attention, and establishment of an ICU within the framework of a deployed field hospital for such a scenario is completely indicated.

The medical response to recent disasters illustrates different ways in which critical care was provided during such events. A major earthquake struck western Turkey in August 1999, resulting in thousands of casualties and major damage to the region’s medical infrastructure. The IDF deployed a field hospital to the city of Adapazarı, where 2627 people died and 5084 were wounded. This hospital included an ICU which was staffed with three physicians, three nurses, and five paramedics. Over the course of two weeks, this team managed a range of medical, trauma, and postsurgical patients[6]. To enhance their sustainability, they successfully integrated with the local medical system to augment their equipment and supplies.

In June 2001, Houston, Texas was struck by a tropical storm, causing major flooding. This resulted in compromise in emergency and critical care in the city. The US Air Force deployed a 25-bed portable field hospital, which, during an 11-day stay, successfully cared for 1036 patients, including 33 ICU patients[7]. This event validated the model of military response with a portable hospital/ICU for disasters within the USA.

In December 2003, an earthquake struck Bam, Iran, causing many thousands of casualties and disabling the city’s medical system. An Iranian army-based team reported on their experience operating a portable field hospital with an ICU in the disaster area[8]. The authors faced a range of casualties from those suffering acute trauma to delayed complications (tissue infection, compartment syndrome, and rhabdomyolysis), as well as exacerbation of chronic illness. They emphasize the role of casualty evacuation outside of the disaster area as a key for proper activation of a field hospital and especially the ICU.

In April 2015, a major earthquake hit Nepal, causing thousands of casualties. The field hospital of the IDF was deployed to the city of Kathmandu, where it was positioned beside the Nepalese military hospital, which was heavily damaged[9,10]. This deployment was unique since the field hospital was equipped for the first time with a full-scale critical-care unit. This added medical component allowed the teams to provide treatment to the most severe casualties, and allowed the surgical patients state-of-the-art postoperative care. After this deployment, numerous lessons regarding activation of a critical-care unit in such circumstances were learned. This chapter will review and summarize them.

Information Before Deployment

As discussed earlier, specific disaster event characteristics are to be assessed and analyzed to come up with a plan of action. Having this information prior to deployment of the critical-care unit can aid in defining three major elements, essential for the clinical activity of the unit: the nature of injuries and casualties to be anticipated, the scope and extent of treatment to be provided, and end-of-life decisions and limitations of treatment to be decided on. These three elements are, in turn, translated to the following variables:

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  medical staff: training, seniority, and availability

  
  
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  training and availability of nursing and other medical staff operating the unit

  
  
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  extent of medical equipment available for operation within the framework of the unit

The “Donabedian model” for quality of care defines three domains: structure, process, and outcome[11]. In our case, structure of care specifies ICU infrastructure, equipment, and human resources. Process of care measures and monitors the process in which medical care is being delivered (daily rounds, bundles of care, and adherence to evidence-based guidelines). Outcome specifies the mortality and long-term morbidity of the patients being treated. In this chapter, we will focus on the structural component of the “Donabedian model.” Our perception of ICU structure is based on a “module of four” ICU beds: this basic module can be extended as needed.

ICU Team

Building a field ICU team and delivering the appropriate level of care are challenged by two main issues. The first is the difficulty in practice arising from the lack of medical data available in a regular hospital ICU. The second is the fact that a field ICU team, based on the reserve forces (as in the IDF Medical Corps), is gathered from a few different-acting ICUs of regular hospitals. Bridging those two aspects is mandatory for a proper operation of a field ICU.

Medical Staff: Seniority, Diversity and Decision-Making in a Poor Evidence Environment

Patient medical data available in a critical-care unit operating in a field hospital are relatively limited. When compared to the continuous flow of information on patient history, lab results, or imaging studies results in a regular hospital setting, the field ICU is lacking a lot of data elements essential for numerous, daily, clinical decision-making processes. Under these circumstances, there is an inherent difficulty in undertaking therapeutic decisions. A team of senior physicians with a wealth of clinical experience and diverse expertise may compensate for the information deficit and enable modification of the well-established guidelines in such a way that assures best medical practice. A well-recognized notion in building an ICU team is that diversity in training of the medical staff is of great importance[12,13]. ICU capabilities of providing care to complex multiorgan-failure patients, the ability to support and stabilize life-threatening injuries, and deliver extracorporeal life support (ventilation or renal replacement therapy) are very well enhanced by recruiting critical-care specialists with different backgrounds. A variation of trained staff is likely to increase the efficiency of the ICU. Critical-care physicians with a specialty in anesthesia, pulmonology, surgery, and internal medicine can create a synergy within the ICU team. In addition, skills in performing abdominal and lung sonography and echocardiography, or in conducting regional nerve blocks, are of great importance. The basic “model of four” IDF field hospital’s ICU in Kathmandu, Nepal, consisted of three ICU attendings (practicing in daily life as unit directors in three different facilities in Israel), one having a surgical background and two having anesthesiology backgrounds. This versatile team had the capability of making empirical decisions regarding delivery of maximal care, despite the scarcity of medical data. Therapeutic plans were continuously discussed, modified, and updated in accordance with the patient’s changing clinical condition and flow of medical information. Clinical discussions must be conducted by professional medical staff, but other parties external to the unit, such as hospital directors or ethical authorities, can be involved regarding relevant issues as they arise. This empiric decision-making should drive the practice in which no admission request will be limited by clinical severity of the casualty presented. Only if the preadmission evaluation of the patient’s severity, combined with the limitation of resources, leads to an estimate of nil survival chances, will patient admission be refused. During the deployment of the IDF field hospital in Kathmandu, only one incident of this type occurred. All the other patients were hospitalized “empirically.” The scope of treatment administered was maximal without any technical limitations. “Treatment limitation” was put into effect only after comprehensive discussion: the staff’s impression was that the patient would not survive. This occurred for one patient who presented with irreversible multiorgan failure.

Another aspect of the medical staff seniority is the presence of an attending physician 24 hours a day, 7 days a week, as all shifts are done by senior physicians (in contrast to regular critical-care practices, where shifts are done by residents). This allows safely shortening the time for medical procedures performed, like ventilation weaning or tracheostomy tube decannulation, since the ability to immediately and effectively address any procedural mishaps is present. In addition, it can offer the “pushing forward of medical conditions”: rapid advancement of a patient’s care plan, shortening of ICU stays, and faster discharge to the general wards, allowing for better utilization of the ICU beds. To be able to provide such high-level patient care for an uncertain amount of time, and preserve team capabilities in the long term, medical staff should start working in 12-hour shifts as soon as possible. Shifts should be started immediately with the initiation of field-hospital operation; usually within 12 hours of arrival on the scene.

Tasks that must be fulfilled by medical ICU physicians, apart from managing the most critical patients, also include consulting in the emergency room, the ORs, and the regular wards of the field hospital. The medical team must be versatile enough to support the pediatric ward in managing their most critical casualties. Other tasks to be covered by the team are the administrative aspects, military activities, and communication with the large framework of the field hospital. The core of three ICU attendings are essential for the basic “model-of-four” operability. In the chapter authors’ experience, for every extension beyond four stations, another physician (not necessarily an ICU attending, but a general practitioner or a resident) should be added to the team.

Nursing Staff: Building-up, Routine Establishment, and Working Atmosphere

The wellbeing of the nursing-team is critical for the proper function of every ICU, especially in the extremes of operating in the framework of a field hospital[14,15]. The nursing team in the regular ICU is unified, well integrated, and highly skilled at working according to predefined protocols and routines. As with the physicians, the nursing team is based on reserve personnel who in everyday life work in various military and civilian facilities with different daily practices and routines. Unifying these in the short time available until the field ICU is fully operational is challenging. In the chapter authors’ experience, protocol modifications were done rapidly, by the hour, and from shift-to-shift, until they were shaped into their final configuration. The team must be aware of patient safety issues during the first hour after unit activation. More medical and therapeutic mishaps can happen, and safety-related incidents may arise more frequently. Risk management should be a high concern, and preventive actions must be instituted until working routines and protocols are fully established.

The nursing team needed for the basic “model of four” comprises six nurses, all with a strong background of daily practice in taking care of critical patients. The nursing shifts should be eight hours – versus the 12-hour shifts for physicians – for better continuity of care. The nursing staff must be divided into three defined teams, with each team constituting a fixed organic unit. Only limited flexibility is allowed in terms of “switching” between teams. Each organic team is composed of two critical-care nurses and two additional nurse practitioners who can be replaced by paramedics if unavailable. The inclusion of nonregistered nurses, such as paramedics, mandates strict nursing and physician supervision. Their responsibilities and duties must be clearly defined, since in stressful moments – a frequent occurrence in the field ICU setting – they have to have full perception of what is strictly forbidden for them to do. Therefore, “two plus two” nursing personnel per shift are needed for activation of the “model-of-four” station’s ICU.

There will always be an influx of volunteers with varying nursing experience offering assistance. These must be managed in an organized fashion and can only assist after strict evaluation of their credentials and capabilities. Tasks to be covered by the nursing team, aside from those in the critical-care unit, include supporting the emergency medicine department trauma bays, supporting the operating theaters with postoperative care in the recovery room, and the transportation of critical patients to and from the unit. This large workload places a huge burden of responsibility on the professional nursing team and can in turn lead to early burnout and fatigue. All factors potentially underlying staff burnout should be continuously searched for and, when identified, be resolved efficiently to avoid safety incidents and complications[14]. The main points to be anticipated are shown in Table 24.1.

Preventive measures should be planned, and action should be taken from day one of operation with frequent team meetings and multiple discussions:

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  an opportunity to discuss subjects related to the establishment of medical procedures as rapidly as possible

  
  
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  a forum for personal expression and venting

  
  
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  daily multidisciplinary clinical discussions

As the team members may come from different backgrounds, the nursing staff daily schedule should be constructed from a synthesis of practice made by the various team members. A suggestion for an established daily schedule is as described in Table 24.2.

A method of coping with the expected physical and emotional load is to lead active team involvement in building an atmosphere of excellence, uniqueness, and precedent setting[14,15]. In the chapter authors’ practice, this plan was extremely successful as the team was united within a short time, and a culture of mutual dependence was developed. It allowed maximal professional achievement by our small nursing team.

Other Professional Staff Training: Need and Utilization

The paramedic: The paramedic profession is becoming more centralized in the military medical corps, with new positions and tasks being carried out by paramedics. Positioning paramedics in the ICU of the field hospital is questionable since paramedic skills are distinct from those of a registered nurse. When considering the wide knowledge and expertise required to become a critical-care nurse, paramedic skills may seem even less applicable. As discussed earlier, the “model of four” comprises two registered critical-care nurses aided by two nurse practitioners. Paramedics can be used as alternatives to nurse practitioners[16,17]. Authorizations and tasks must be strictly defined prior to deployment to avoid, or at least minimize, uncertainty and confusion. Every nursing team has to define a “nurse in charge” for each paramedic. These organic pairs are essential for facilitation of the paramedic’s training on unfamiliar issues. A significant task more suitable for a paramedic is the transporting of patients into and out of the ICU. This will be further discussed later.

The emergency medical team (EMT): EMT skills are even more remote from critical care nursing than those of the paramedic. The EMT profession is not appropriate for a significant clinical role in a field critical-care unit. EMTs can assist with medical equipment and devices, as shown in Table 24.3. As with the paramedic, defining the role’s requirements and areas of responsibilities is crucial for optimum utilization of the available personnel and avoiding patient risks.

The medical equipment technician (MET): For every operative ICU, METs are essential for daily practice. METs are particularly needed in the field ICU, where backup equipment may not exist and, in most cases, units are supposed to handle their own malfunctioning devices. Therefore, METs should be constantly available. Ideally, two MET personnel should be present to maintain equipment and address the unit’s requirements.

The social worker: Social workers in the ICU are uniquely qualified to assess and address many of the complex psychosocial circumstances that arise in the intense settings of every critical-care unit. These skills are extremely important in a field ICU setting deployed to a disaster area, where cultural differences and language barriers are significant obstacles. Social workers can clarify potential misunderstandings, and improve communication between patients, their families, and medical team members. This can not only help improve the quality of life for very sick and dying patients in the ICU and their families but may also reduce the likelihood of decision-making conflicts arising. As well as supporting patients and their families, the social worker must monitor the working atmosphere and stress among the ICU team[18]. Although the personnel restraints of a field hospital will not enable having a social worker dedicated to the ICU, these issues should be addressed within the psychosocial service of the hospital.

Building a field hospital ICU is challenging. To maintain it is even more demanding. The leadership team must ensure periodic training sessions and social meetings for team consolidation are undertaken, as well as practice of procedures.