Training Prior to Selection for Deployment

Some organizations, including the author’s[5], have a training and orientation program prior to going forward to the adaptation training in step 2. This can provide participants with sufficient, reliable information to enable them to make an informed decision about whether they are ready for this work, and for the selection committee to consider if they are likely to be able to deploy to a field hospital EMT, and if so, in what capacity.

The essential elements include imparting an understanding of the background to humanitarian responses, the UN system, the cluster system, the major international nongovernmental organizations (NGOs), international organizations such as the International Committee of the Red Cross (ICRC)and the International Federation of Red Cross and Red Crescent Societies (IFRC), government organizations, and major donors.

Understanding the context in which they will work, with a realistic appreciation of the risks and benefits of deploying to a SOD, is an important outcome of this predeployment training. This should include an introduction to working practices and cultures that will be different to their own. It is important, both to those who may deploy and those who are responsible for those who do deploy, to ensure the level of risk involved has been properly and fairly communicated, alongside how those risks may be mitigated. Included in this analysis of risk should be the risk to one’s mental and physical health. If there are any conditions that automatically preclude deployment, then they should be flagged up at this stage.

Adaptation Training

Before giving care to others, team members need to understand the risks to their own health and how to mitigate them. If they are sick or injured, then they are adding to the disease burden while reducing the strength of the team. The risk of illness and injury cannot be fully mitigated, even in the best prepared and run teams, but it can be reduced. A good understanding of disease profiles of commonly affected countries and the common risks to aid workers is essential for safe deployment. Malaria prophylaxis, compulsory seat belt use, no night driving, and adherence to safety and security standard operating procedures (SOPs) must be high on the list.

Clinicians must understand what is required to deliver and maintain background essential emergency health care, both during and after a SOD. This is in addition to recognizing the patterns of illness and injury after different types of SOD. For, while each type of SOD brings its own direct medical and surgical issues, the “everyday” emergencies continue and must be managed. Therefore, in addition to training in the approach to injury management and acute emergencies directly consequent on the disaster, training must also include the approach to nondisaster-related emergencies, which will inevitably continue to present to the same facility. In what may be the only functioning health-care facility, at least in the region and perhaps for a while, team members must also understand the approach to the management of nonurgent, chronic diseases, which will almost inevitably find their way into a field-hospital setting.

The adaptation of clinical practice to the limitations of a field hospital and a large number of casualties will inevitably raise ethical dilemmas, and training is required in how to predict and deal with these, for both individuals and the team. A particular issue is the appropriateness and scope of resuscitation – if/when to start; if/when to stop – when the prolonged ventilation of the one patient will limit, or maybe even prevent, the mechanical ventilation of many more patients during surgery.

When the next SOD may strike cannot be known for sure, but we know where they are most common. Therefore, we can prepare for working in these countries, learn more about their demographics and topography, and identify where certain conditions/diseases are more prevalent than in other countries and that are essential for incoming teams to know how to manage. Foremost in this list of diseases is malaria. Not only must teams know how to recognize and manage an acute presentation but they must also understand and be aware of how it presents alongside other acute and chronic conditions.

The impact of HIV/AIDS is similarly important to appreciate, and, of course, surgical and maternity teams especially must be made aware of its significance and how to mitigate its risk to other patients and health-care workers.

Tuberculosis, dengue fever, and now Zika virus must be included in training on infectious diseases. The management of diarrheal disease, particularly typhoid and cholera, is an important element in the preparation for deployment, but must include also specific training in safe working practices and the isolation of infectious patients. This will then lead into the recognition and management of suspected viral hemorrhagic fevers, the use of personal protective equipment, and liaison in country with the ministry of health (MoH) and WHO when there is a potential danger of outbreak.

Included in this broader health-care training program should be the management of stings and envenomation. The risk of animal bites must be emphasized, their management explained, and the rabies protocol for the team expanded on and understood; and similarly, the tetanus prevention, management, and treatment protocols.

The special needs of women and children must be addressed, emphasizing the risks of measles outbreak in camps and overcrowded environments, and the recognition and management of malnutrition in children.

How to recognize gender-based violence, including female genital mutilation, must be taught, and the protocol for its onward management explained to the team.

Finally, when discussing the provision of essential emergency health care in a humanitarian context, the team must understand and be able to safely transfer and/or discharge patients within the systems established/supported by the national MoH and WHO.

Specialist Training for the Austere Environment

It is important that those with technical skills are trained prior to deployment in how to adapt those skills to a field-hospital environment. This involves an understanding and mastery of those surgical techniques that are quick, safe, and effective when dealing with large numbers of casualties presenting within a short space of time. The course must also teach consistency of technique and practice to ensure a safe, continuous treatment pathway between surgeons in the same team as they change shifts, and between teams as they rotate through the periods of deployment. Included in this training program must be the techniques of essential emergency surgery to ensure the surgical team can enter all body cavities and carry out damage control/limitation and/or lifesaving surgery. The highly specialized nature of modern surgical training means that most surgeons’ day-to-day practice will involve a fairly narrow spread of case presentation and surgical techniques, usually confined to one part of the body or system. It is essential that surgeons in a field hospital can deal with all, or as many as possible, of the cases that may present. These will range from trauma – usually blunt in nature – post-earthquake and SOD, to penetrating in these circumstances. They will also need to deal with the consequences of violence, including gunshot wounds, blast injury, and stabbings. These will continue to occur, even in the aftermath of a SOD; those countries vulnerable enough to need and request outside help may also be fragile more generally and therefore suffer a higher incidence of background violence. Obviously, if the deployment is to a conflict or a peri-conflict area, a firm understanding of the principles of war surgery is required. Finally, irrespective of the background to the deployment, surgical emergencies will continue to occur. Incarcerated hernias, perforated ulcers, and so on; and importantly, pregnant women will continue to present to health facilities. The team must have the knowledge and equipment to deal with obstetric emergencies, including emergency caesarian section.

The training process must be based on, and use, the equipment that will be available in the field hospital itself. Individual surgeons often have their own preferred instrumentation, but it is impractical to cater for a wide variety of options in a field hospital. Surgeons must accept, and be trained in using, a defined set of instruments and equipment which will be available to them in the field, and become expert in their use prior to deployment.

There are two options to secure a spread of surgical expertise. One is for each individual surgeon to be trained and become competent in all aspects of emergency and trauma surgery; including thoracic, abdominal, vascular, and general surgery, as well as the management of limb injuries, including fractures, and the management of head injuries. Included in this skill set must also be the management of obstetric emergencies. Modern surgical training makes the accumulation of such a broad range of skills difficult to secure, although there are countries that train surgeons more broadly as “trauma” surgeons, and military surgeons may have acquired these skills. However, this may not be the case for many surgeons in civilian practice unless working for a large humanitarian organization such as Médecins Sans Frontières (MSF) or the ICRC. The team may therefore look to broaden the training for its individual surgeons to ensure that each individual has this broader skill set. Alternatively, they may choose to include in the team a broader range of individual specialist surgeons, including obstetricians, each of whom has also had extra training in the management of a wider range of conditions. Another option is simply to run the field hospital with the range of specialist surgeons we would find in everyday practice. This may, however, limit the capacity of the field hospital, as specific surgical expertise is “parceled up” in an individual surgeon and patients queue to be allotted to one, rather than across several, potential clinicians. If the surgeons have been more broadly trained and extended their skills, there will be more surgeons available to work simultaneously across numerous patients. Whatever approach is taken, it is imperative to accept and understand that surgeons, like all other medical practitioners who respond to these emergencies, must only practice within their usual competencies, which can, however, be legitimately extended by appropriate training by an accredited body (such as the Royal College of Surgeons in the UK, for example). However, as stated at the outset, these emergencies are not simply opportunities for surgeons to gain new surgical skills or experience, but rather an opportunity to bring the skills and experience they have already gained to the benefit of those in need.

There are a few courses that address these issues, but the most comprehensive in the author’s experience is that run by the Royal College of Surgeons in the UK under the directorship of Dr. David Nott and in collaboration with the ICRC, MSF, and the military[6]. An important feature of this course is that the training is carried out on unembalmed cadavers, allowing for the most realistic skills-based training.

Anesthetists also need to adapt their skills to the austere environment. Oxygen supplies, whether piped or in cylinders, will be restricted, if indeed available at all; so, supplemental oxygen will usually be from oxygen concentrators. The supply of oxygen will be a determinant of the depth and duration of general anesthesia and thereby potentially the type and duration of surgery. Anesthetic gases may also be limited, so alternative methods need to be understood and employed (although much can be achieved with continuous intravenous anesthesia; for example, ketamine +/− propofol).

Training should emphasize that “what can be done under local anesthesia, is done under local anesthesia,” with local, regional, and spinal blocks demonstrated and candidates’ competencies tested and confirmed.

As gas-powered ventilation may be at a premium, the principles and practice of “draw-over” anesthesia may be required to be taught and mastered.