In what types of situations would you need to improvise medical equipment and procedures? Experience demonstrates that physicians in the most-developed countries are most likely to need improvisation when their usual procedures fail or their equipment does not function. That is not the case outside these privileged medical practice arenas:

Throughout the world, clinicians must practice medicine while making do with minimal resources. Material and equipment scarcity often overwhelms health care professionals, whether they are the sole medical provider at a localized event who lacks the materials to treat one or more patients, groups at a more widespread calamity that affects an entire community or region, or teams at a long-lasting degradation of care spanning entire countries. This resource scarcity may last from only minutes to many days or even weeks. Or, they may be chronic conditions. Limited-resource situations may be due to physical isolation (e.g., prisoner of war [POW] camp, airplane, ship), being in a remote area (e.g., wilderness, rural highway), being in a least-developed country with a chronic lack of health care resources, or being in a disaster/post-disaster setting.

These situations, especially when they occur in settings where resources are usually plentiful, often result in degraded levels of treatment (Fig. 2-1). But, if clinicians use their ingenuity, this need not be the case. Good medical treatment can often be provided using limited resources if clinicians willingly alter their approach and techniques to fit the circumstances.

Resource-poor situations are logically grouped into simple, extended, and complex disasters, depending on how long they are likely to last, how much help is required, and the degradation of health care and the social order (riots and unrest) that may occur.¹

Throughout this book, methods that can and should be used in all four circumstances are discussed interchangeably. The focus in many sections is on the chronically resource-poor situations found in the least-developed countries, although these methods may be used anywhere. Each of the main limited-resource settings is briefly described later in this chapter.

Simple disasters last a short time and usually require only local resources. Examples include a multi-casualty motor vehicle crash, an apartment building collapse, a multi-casualty fire, a landslide, and a tornado going through a trailer park. The needed support systems include emergency medical services (EMS), fire services, medical services, and law enforcement. Social order generally remains intact.

Extended disasters include widespread flooding, devastating hurricanes or tsunamis, massive heat waves, and major earthquakes. In these cases, the necessary support system also includes outside assistance to augment surviving local EMS, fire services, medical services, and law enforcement. The social order may be unstable.

Complex disasters are those chronic situations, usually in the least-developed countries, that often are the result of a major drought, famine, or war. A major nuclear incident would also fall into this category. Societal and social support systems are normally disrupted.

Isolated settings are remote, without an immediate way to gather resources that are not already available. The classic isolated setting is in an internment camp, such as the World War II POW camps. However, isolated settings may also occur on a boat or an airplane or, the ultimate isolation, in space. One of the best-documented physician histories from a POW camp is that of Capt. Thomas H. Hewlett (Surgeon, US Army Medical Corps). He wrote,

Remote locations classically include wilderness settings, such as deserts, mountains, caves, forests, and jungles. More commonly, even in the most-developed countries, it means coming across (“on-siding”) a personal injury crash or medical emergency far from a source of help. Be prepared by carrying basic materials (see Appendix 2) and being ready to improvise.

Even organized and experienced search and rescue (SAR) teams who carry equipment into the field may have to improvise. While rescuing a patient deep in a cave shaft with a back injury, our SAR team found that we could not maneuver a backboard into the narrow space where she lay. After several hours of working in the hot, humid, cramped, and relatively dark area, we improvised an immobilizer and extricated her from the cave.

Chronic shortages are the norm in the least-developed countries. Health care workers know they must make-do with whatever supplies and equipment are available and functioning. As a nurse practitioner student on a medical mission to the rural Philippines wrote, “the challenge of the lack of equipment and medications taught me that we sometimes have to deal with the resources at hand and that there are ways to improvise in order to obtain the same results.”⁴

An emergency physician working at a Latin American general hospital (used by the poorest people) found that only two or three vials of medication were available for resuscitation, and only 8-mm endotracheal (ET) tubes were available. The medications would change weekly, as would the ET tube sizes. The medical team made-do with available supplies when they could; when they couldn’t, patients died. Improvisation was the norm.

The key features of disasters are “threat, urgency and uncertainty, which affect not only the victims themselves, but also the organizations that have to respond.”⁵ Disasters can be from man-made (e.g., multivictim vehicle crashes, terrorism, radiation leaks, and war) or natural (e.g., tsunamis, earthquakes, and epidemics) forces. Both often lead to resource-poor situations. The assistance provided varies greatly, depending on a host of factors.