Abstract
According to the World Heath Organization’s (WHO) EMT initiative, teams must meet an agreed set of standards, both clinically and logistically. EMTs must be self-sustainable and not create a burden on the already stretched resources of a host nation.
The technical demands of field hospitals require logistical personnel with specialist skills, which ensures a field hospital can continue to function when all around them has been destroyed. They must be multiskilled to fulfill multiple roles within the team.
A collection of tents does not constitute a field hospital: methodical planning around safety and security, patient flow, and overall functionality is a necessity. Field hospitals require large volumes of clean water that meets or exceeds the WHO standards of potable water; consequently, EMTs must understand the requirements of self sustainability, water quality, and quantities for the delivery of services they are offering. WASH requires an expertise and the capacity and capability to deliver high levels of WASH irrespective of the circumstances. Leading by example in health care to other health-care personnel and facilities is a essential criteria of an EMT: technical logistics is key to achieving this.
Introduction
Building a hospital in a developed and well-resourced country is a difficult task and can take years. Replicating key functions and elements of that same hospital in a disaster area within days is challenging to say the least. Health facilities are an essential pillar of all communities and a building block for disaster recovery, and health professionals are expected to lead by example. Demonstrating this leadership in areas such as hygiene and sanitation by health responders should always be a key consideration of logistics personnel. Deployable self-sustaining field hospitals take meticulous planning, resourcing, education, training, and exercising to get it right.
This chapter will discuss key elements that differentiate a generic humanitarian camp to a field hospital and it is those very key elements, whether you are a leader, clinician, or technical logistics team member, which will illustrate the complexities surrounding the practicalities of preparing and responding with a self-sustaining field hospital to disasters.
Field hospitals have been deploying to disasters for many years and, while it would be arrogant to think there are no more lessons to be learned, we must be mindful that with the experience, information, and technology that are now available there are very few excuses to arrive at a disaster unprepared.
Self-Sustaining Field Hospitals
A self-sustaining field hospital is a facility that can lead, manage, and fundamentally look after itself for predetermined periods without being a burden on affected communities or health systems, and, importantly, without compromising health care or the safety and security of its personnel and patients.
It also should be understood that field hospitals sometimes cannot transport all the necessities to operate a health-care facility, such as water or fuel. In those cases, careful planning needs to be in place and the communication of those needs to the hosts is essential well prior to any mobilization.
While water and fuel are two obvious elements to consider, the intricacies and contingencies of a functioning field hospital are vast.
Can you incinerate biological waste?
Do you have enough laundry detergent for surgical scrubs?
Do you have a second washing machine for contaminated clothing?
Do you have enough clinical waste bags and what do you do with them when full?
Can you repair the autoclave in the field?
Can you secure your shelters on soft and hard ground?
Can you transition from trauma to an outbreak emergency?
Can you manage a fire or hazardous material spill in your facility?
Technical Logistics Personnel
The term “logistics” is broad and generically covers many areas of warehousing, stock movement, and stores management. While the freight movement of a field hospital may be a standard task, it is the complexities of building a field hospital, and then ensuring it continues to function, which demand a more technical role.
Medical on-site ground support demands a specialist skill set supported by a capability and capacity to ensure health professionals can deliver uninterrupted patient care within hours of arriving and for the duration of the deployment. Disaster zones are chaotic and the ability to function without contributing to the chaos is essential.
Personnel with particular skillsets are a necessity and those with multiple skills are highly desirable: cross training where practicable is essential.
Typical base skill sets include:
electrical
mechanical
construction/building trades
electronics and communications
emergency management
safety and security
environmental health: water, hygiene, sanitation, and vector control
medical waste management
Specific training for repairs and maintenance is required relative to the equipment being deployed; for example:
autoclaves
X-ray
incinerators
morgues
IT and communication systems
oxygen and associated devices
monitoring devices
surgical equipment
toilets/showers
isolation wards
laboratory equipment
cold chain
vehicles
Having the skills to build and run a field hospital is only one part: ensuring the technical logistic personnel have the necessary tools and equipment to perform their roles is also important. Spare parts and servicing equipment are a must. A low-cost autoclave part or fan belt for a generator could bring a surgical mission to a standstill.
It is not uncommon for emergency medical teams (EMTs) to surge technical logistics personnel in the build phase and scale back during normal operations and again surge for demobilization.
In the context of logistics, it should not be overlooked that clinical needs planning may sometimes unintentionally overshadow or compromise the welfare of health responders. While appreciating working in disasters is hard, uncomfortable, and testing, occasionally important elements of team welfare can get overlooked. Tunnel vision in emergency management can be a common problem; this can be exacerbated when key logistic personnel are not present during planning and decision-making processes. A proper leadership structure with logistics personnel included can mitigate many issues.
EMT Personnel
EMT personnel are a critical asset to mission objectives: this must be considered and reflected when conducting risk assessments.
Health-care personnel working in disaster areas are expected to perform high-functioning tasks for long periods in extremely testing conditions, which will obviously test their mental and physical fitness. For example, for a nurse, working a 14-hour night shift and then expected to sleep between shifts in a nylon tent on the ground in stifling heat over a 4- to 14-day rotation is undoubtedly problematic to their well-being, which will ultimately impact on team and clinical performance. While acknowledging the practicalities, the positives of looking after your personnel are significant.
Typically, planning for personnel begins with a knife-and-fork approach, which in turn leads to many questions:
Do they have a knife and fork to eat with (or chopsticks)?
Do they have a plate?
What are they going to put on the plate?
How do they heat their food?
How do they wash their hands before they eat from the plate?
Where does the dirty water go?
Where do they sit?
Do they have a table?
Is the table out of the weather?
Is there a light?
What do they do with food scraps?
Who empties the rubbish?
Where does the rubbish go?
Where do they wash the knife, fork, and plate?
How do they dry the knife, fork, and plate?
Health-care personnel should be well presented to patients and the community: EMT personnel should wear an identifiable uniform with the basic principle of one on, one dirty, and one clean. The following questions need to be considered:
Does the uniform protect them from:
work hazards?
climate?
vectors?
How do the team wash and dry their uniforms?
Do they use handwash?
Do they machine wash?
Do you have laundry soap?
Do you have enough?
Where does the water go?
Does the EMT have procedures around contaminated clothing?
Who supplies footwear?
Who sets the standard in foot care?
Where does the team sleep?
Do they have climate appropriate bedding?
Do they have mosquito netting?
Do they have a stretcher to get them off the ground?
Are they in individual tents or dorm living?
Where do they sleep between night shifts?
Is the accommodation secure?
Do you have evacuation plans and key muster points?
Health personnel need to wash/bathe regularly:
Do they have the facilities to have a regular shower?
Do they have hot or cold water?
Do they have soap?
Do they have shampoo?
Do they have a towel?
Do they have privacy?
Do they have security?
So, from the above examples, it is clear to see how easy it is to overlook necessities and unfortunately increase the likelihood of heading down the “lessons learned” path in regard to caring for EMT personnel.
As discussed previously, the benefit of caring for EMT personnel is a positive for the team and ultimately the patients you are there to assist.
The Facilities
There are a wide variety of shelters for EMTs: a health facility can be compartmentalized, incorporating different shelter types. These types may range from a simple quick erect triage shelter and outpatients through to a complex surgical theater and logistical areas such as:
mess/kitchen
medical stores
food stores
logistic stores
shower/washing areas
toilets
disabled toilets and showers
water treatment area
accommodation
While not exhaustive, the following fundamentals of a shelter system should be considered:
Climate-specific: a shelter system needs to be climate matched to the region of operation. Shelters designed for the European winter will be challenged in the tropics and vice versa.
Weight: shelter systems need to be manageable when no heavy lift equipment is available.
Water rating: shelters must be waterproof to protect the patients, staff, and electrical equipment from inundation.
Wind and snow rating: from a safety perspective, shelters with high wind and snow ratings should be considered. This should also include fixings for both hard and soft surfaces. The constant noise from wind and rain on lightweight shelters should also be considered.
Configuration: shelter systems should be configurable to a variety of layouts: areas of allocation may not be symmetrical such as car parks, streets, and hospital grounds.
Size: shelters need to be fit for purpose and ergonomic for staff and patients. Staff cannot walk around bent over for days, and patient spacing needs to be appropriate.
Layout
Once functionality, safety, and security have been considered, the field hospital should be laid out with patient flow, security, and functionality as key priorities. This typically begins with waiting areas and triage through to outpatients, emergency, wards, and advanced treatment areas such as surgical. Field hospitals that incorporate staff facilities should have clear segregation between the hospital and staff areas.
The layout of a field hospital should consider climate and geography; for example, shelters erected in areas prone to rain should be positioned in such a way that water runoff will not create problems. A shelter with a roof area of 100 m2 that receives 10 mm of rain may have a runoff of up to 1000 L; erection at right angles to a downward slope will be problematic for other parallel running shelters: if you consider two or more parallel shelters, the issue should be obvious.
With consideration given to patient flow and positioning, ingress and egress for emergency vehicles and freight must also be planned. Trucks delivering water, fuel, and stores, or removing waste, need ample room to access and exit critical areas. Ambulances or patient transport vehicles will require turnaround points.
The placement of critical areas and their compatibility with other functional areas is a crucial consideration; examples include fuel dumps next to wards or incinerators, waste-collection points near kitchens or mess facilities, and waste or incinerators near the accommodation.
Facilities such as toilets and showers should be located within an easy walking distance of accommodation and wards: no further than 50 m in well-lit and secure areas.
Understanding the layout, footprint, and variable configuration is essential to selecting, or more so articulating, your requirements to a host nation, which is critical to getting a suitable and adequate deployment site. Geospatial information systems should be used to view and measure sites before deployment; this will consequently reduce on-site assessment time and mistakes.
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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