Introduction

Events like high-magnitude earthquakes or floods may cause humanitarian disasters especially in remote, poor, and underserved areas. In these areas, the predisaster health-care human resources and facilities are scarce. The constructions of public and private buildings as well as infrastructure are underdeveloped or poor and unable to give immediate as well as long-term services.

The ambulatory and primary-care units on scene may act as small outreach units that start their action as soon as international first-aid services are available. They may act for long periods with rotating volunteers and local health-care staff. Another mode of operation is as part of a larger body such as a field hospital. The deployment as well as the end of action on scene will depend in these scenarios on the aims and mission of the field hospital while the primary-care and ambulatory unit will act as an annex to the field hospital, receiving missions and responsibilities as a directive from the field hospital manager.

We aim to describe the primary care and ambulatory unit (PCAU) of such a field hospital in a disaster area.

Epidemiology

In a natural disaster there may be thousands of people who will die and many more will be injured, left homeless, and otherwise adversely affected by the loss of infrastructure. People displaced by structural damage to their homes or those afraid to return to their homes for fear of damage tend to go and live in tent camps, which spring up spontaneously or are organized by local authorities or international nongovernmental organizations (NGOs). Displaced people, especially those without adequate shelter and without access to sanitation and other services, are at particular risk for immediate as well as long-term health problems.

In the hours and days immediately following a high-magnitude earthquake, it has been well demonstrated that injuries such as acute orthopedic injuries, head injuries, and crush injuries with subsequent rhabdomyolysis contribute to significant mortality. Illnesses resulting from poor shelter and lack of access to fuel, clean water, and sanitation will appear later.

Fernald and colleagues had been deployed with their MASH unit in response to the 2005 earthquake in Pakistan[1]. More than 20000 patients received care during a four-month period. An initially high surgical workload decreased in about two weeks while the volume of primary-care patients increased, eventually accounting for 90% of the total patient visits. They estimated that 15% were < 5 years of age and about 50% of patients were < 18 years of age. A similar trend had been documented by one of the authors (Shlomo Vinker) in 2010 at Port-au-Prince, Haiti[2]. Figure 26.1 describes the relative workload in the ambulatory unit during the deployment of the Israeli field hospital in Port-au-Prince, Haiti.

Figure 26.1 Visits to the Israeli field hospital in Port-au-Prince, Haiti – the relative workload in the ambulatory unit according to the date since deployment

Broach and colleagues collected data regarding the epidemiology in the tent camps of Port-au-Prince, Haiti on days 15–18 after the earthquake in 2010[3]. They note a preponderance of pediatric illness, with 53% of cases being patients younger than 20 years old and 25% younger than 5 years old. The most common complaints noted by category were respiratory (24.6%), gastrointestinal (16.9%), and genitourinary (10.9%). They also observed a high incidence of malnutrition among pediatric patients, noting that only a small number of cases of traumatic injuries were identified (less than 5%).

Operating Ambulatory Service in the Field Hospital or as an Outreach Mobile Unit

Service can be delivered as a department in the field hospital or by outreach to tent camps. It must be coordinated with the local health-care authorities and/or other international bodies active in the arena.

The clinic should contain a triage area, an area for patient consultations, and a pharmacy area with medications to distribute.

Usually the PCAU should work in one shift in daylight and there is no need for night or afterhours shifts. The PCAU should work seven days a week. The workload is markedly decreased in local major holidays[1], and shifts and staff scheduling should take this into account.

Triage

Triage can be active – being performed by providers in the refugee camps – or passive, at the entrance to the field hospital. Triage medical officers may include family physicians or qualified nurses. Local translators should accompany all staff members, but are especially critical in the triage group.

The criteria for triage include factors such as age, nature of illness, and clinical appearance. The principle is to select those people who could most benefit from care while minimizing triage examinations.

Consultations and Treatment

After the triage, each patient should carry a medical record with his or her name, age, and chief complaint. The patient is then moved to wait in another area, separated from the triage area, where a provider will make a brief clinical note on each patient, including the symptoms, diagnosis, and treatment. In the pharmacy, medications will be provided free of charge.

The number of patients seen every day, the duration of time for which medications will be supplied, and scheduling of follow-up visits all depend on the capacity of the PCAU in terms of staff, medications, and dressings supply.

It is recommended to give tetanus toxoid to each injured patient no matter what his or her vaccination status is.

An average consultation unit, which includes a family physician, a qualified nurse, and a translator, can treat 30–50 patients in a working day.

What Skills and Equipment Are Required by Physicians?

During routine operation, family physicians encounter complex medical, psychological, and social problems daily. These problems are intensified during disasters. As disaster responders, they face the unknown. The physician can be in an isolated, unfamiliar area with limited resources and patients with complex medical problems: acute, traumatic, and chronic illnesses.

Even in the most catastrophic event, the need for primary-care physicians in conjunction with trauma specialists is high since the local medical system is overwhelmed, especially in low-income countries[4]. The contribution of a family physician is crucial.

Health-care workers need some skills to cope with the consequences of devastating natural disasters and to provide successful intervention. Firstly, a health-care worker should prepare him- or herself to work long hours, usually in twelve-hour shifts. Teamwork ability is extremely important. And the physician should be ready to be exposed to suffering and agony. The level of suffering can be overwhelming.

The chapter authors’ experience indicates that, during the first week, trauma injuries are predominant. Up to 80% of the patients have trauma injuries[2]. Primary-care physicians should therefore be skilled in emergency medicine and should be trained in basic and advanced trauma life support, especially first evaluation of severe traumatic injuries and treatment of minor trauma (closed fractures, wounds, and so on)[5,6]. Severe trauma will be treated by surgeons, orthopedic surgeons, and emergency-medicine specialists, but the triage and primary evaluation is often performed by the family physicians in the team.

Health-care teams should be prepared to treat infectious diseases[3], especially routine infections such as upper respiratory tract infections, gastrointestinal infections, and genitourinary tract infections. They should be familiar with the prevalence of different pathogens and their antibiotic resistance. It is very important to know what the endemic common medical problems are, and to learn about them before reaching the arena. For example, tropical diseases such as typhoid fever or malaria can be extremely rare in the daily clinic in high-income countries, but can be very common in the disaster area and physicians should be familiar with the signs, symptoms, and management of such diseases. It is recommended to consult an infectious diseases specialist about common infections in the disaster area. Another way to learn about the local infectious diseases is by using the Centers for Disease Control and Prevention (CDC) website: www.cdc.gov

One of the most crucial obstacles in treatment is communication with the local population. In the IDF field-hospital mission in Nepal after the earthquake in 2015, local medical students offered translation services. Translation services were also used in the field hospital of the refugee camp in Kosovo in 1999[7]. Every physician was accompanied by a medical student who helped to understand the medical problem and local cultural beliefs, and to explain the medical recommendations to the patients. The translation by medical staff facilitated the treatment and the stream of patients in the ambulatory clinic. Translation can be done by local medical staff like students or nurses, as well as local English teachers or other teachers or students.

The medical staff should be familiar with the local health care as well as public and religious facilities and with local approved medications. For example, in low-income countries, beta blockers are sometimes the first-choice treatment for hypertension because of their low cost. In such a scenario, prescribing an angiotensin converting enzyme (ACE) inhibitor would be worthless, since the patient cannot afford to buy the medication. Recommendation for hemodialysis for chronic renal failure patient will be useless if the nearest dialysis unit is hundreds of kilometers away. Even simple recommendations such as drinking warm liquids or storing antibiotic syrups in a cold place can be unachievable to a patient who is discharged to a tent in a refugee camp.

There is a high risk of psychological problems such as acute stress disorder, depression, and anxiety after a disaster. The family physician should be familiar with assessment tools and brief interventions for mental problems to identify and treat patients at risk for mental problems[8].