Dr. Brandon Horne
Dr. Benjamin Kam, LtCol, AF
Dr. Benjamin Kam, LtCol, AF
E. Demonstrate the ability to determine extremity care logistical needs for a health care operation
I. Introduction
A. Logistical needs for extremity care run gamut from surgical supplies for extremity trauma to inpatient musculoskeletal nursing and therapy to outpatient clinic supplies and durable medical equipment to prostheses
B. Depending on situation, level of host nation/local healthcare available, and transport, logistical needs may be minimal (local, modern healthcare available) to total (no local care and full spectrum logistical support needed)
C. Needs are dynamic, as balance between supply and demand changes based on casualty volume and time course from disaster or initial event
II. Surgical Needs
A. Adequate anesthesia services
B. Adequate sterilization system
C. Adequate nursing and surgical technician support
D. Supplies for common musculoskeletal operations
1. irrigation and debridement/fasciotomy/escharotomy/amputation
a. sterile irrigation fluids
b. low pressure irrigation tubing
c. basic orthopedic instruments set
d. Gigli saw
e. tourniquet
f. assortment of surgical drains
g. sterile dressings
h. braided and monofilament sutures
2. external fixation of long bone fractures
a. external fixation instrumentation
b. hand or power drill with Jacobs chuck
c. radiographic imaging
3. percutaneous or internal fixation of small bone fractures
a. basic orthopedic instruments set
b. small fragment set
c. K-wire set
d. power drill with chuck/wire drivers
e. 20 gauge wire
f. radiographic imaging
4. shunting of concomitant vascular injury
a. basic surgical instruments set
b. atraumatic vascular clamps
c. vascular loops
d. Fogarty catheters
e. shunts of various sizes
f. vessel Doppler
III. Inpatient Needs
A. Skilled nursing staff
B. Skilled physical therapy staff
C. Radiologic services
D. Laboratory services
E. Oxygen delivery
F. Sterile supplies
G. Walker/crutches/bedside commode
H. IV medications to include narcotics and antibiotics
I. Overhead trapeze, traction assembly
J. Negative pressure dressing therapy
IV. Outpatient Needs
A. Radiographic services
B. Laboratory services
C. Orthotic/bracing services
D. Durable medical equipment products (wheelchair/walker/crutches/cane)
E. Casting/splinting capability
1. plaster rolls and splints
2. fiberglass rolls
3. cotton/synthetic webril padding and stockinette
4. Ace/elastic bandages
5. cast saw
6. cast spreader
7. tape (various)
F. Injectable supplies
1. syringes/needles/alcohol preparation/gauze/Band-Aids
2. local anesthetic (1% lidocaine)
3. corticosteroids
G. Prosthetic services
V. Guide to Assessment of Local Facilities1
A. Assessment should be done first, in order to plan appropriately for what care can be provided at any given facility and what will be needed for sustainment
B. General
1. name of hospital
2. assessment done by
3. date
4. country
5. town
C. Key questions
1. type (ministry of public health, private, missionary, non-government organization, others)
2. catchment population
3. assistance from others than authority in charge
4. level of reference (rural, district, regional)
5. if rural or district hospital, number of primary facilities served (first aid posts, dispensaries, health centers)
6. possibilities of further referral
7. transport system for patients (in and out)
8. reputation of hospital (indicate source of information)
9. bed capacity, effective number of beds (breakdown by department)
10. present bed occupancy
11. activities including specialties (surgery, medicine, pediatric, obstetric, specialized services, etc.)
12. security (is area safe? Is hospital secured?, i.e., clearly marked, fenced, watchmen present, absence of arms inside hospital compound?)
13. endemic diseases and epidemic risk in region
D. Management and Administration
1. general management
a. set-up (management team/board)
b. how are decisions taken and implemented?
2. human resources management
a. who is in charge?
b. does staff receive salary/incentives?
c. total number of personnel/breakdown by function (MD, medical assistants, nurses, students, etc.)
d. is there a roster system in place in hospital?
3. financial management
a. management of finance (is there a budget? how is hospital financed?)
b. is there any cost participation, “cost recovery system”? do destitute have access to care?
4. statistics
a. management of statistics and reporting
b. are statistics available?
c. is there an annual report?
d. are people specifically in charge of collecting data?
5. infrastructure and utilities (general condition of)
a. wall and roof
b. water (running water, wells, safety of water supply, etc.)
c. sanitation (type of toilets, etc.)
d. electricity and/or generator (number of hours per day, fuel supply, etc.)
e. heating/fans/air-conditioning
f. maintenance team (number, composition, etc.) is there a maintenance schedule?
g. is there a functioning workshop?
6. waste disposal
a. waste management systems (including toxics such as X-ray developer/fixator, etc.)
b. incinerator (type, condition, etc.)
7. non-medical support services
a. kitchen (staff, nutritionist, origin of food, number of meals served per day, special diets, etc.)
b. laundry (staff, washing by hand, machine, supplies, etc.)
c. tailor (staff, supplies, etc.)
d. cleaning and hygiene (system, staff, supplies, etc.)
e. morgue (infrastructure, management, etc.)
E. Medical support services
1. pharmacy
a. pharmacy staff and management
b. is there a standard list of medicines?
c. are stock cards used?
d. where do drugs and medical equipment come from (regular supplier, local market, donations, etc.)?
e. is there a reliable system of communication between pharmacy and wards (request forms, delivery forms, etc.)?
f. did the pharmacy run out of basic drugs last month (penicillin, anti-malaria, paracetamol, oral rehydration salts)?
g. is medical equipment regularly maintained and serviced?
2. laboratory
a. laboratory staff and management
b. tests available (hematology, chemistry, parasitology, bacteriology, serology, etc.)
c. source of supplies
d. is there reliable system of communication between laboratory and wards (request and results forms)
e. quality of working relationship between clinical and laboratory staff
3. blood transfusion
a. staff and management
b. policy of blood sampling and transfusion; HIV/AIDS policy?
c. indications for blood transfusion/average number of requests
d. how are blood units kept? is there functioning refrigerator to store blood?
e. testing process and quality control
4. imaging (X-ray and ultrasound)
a. staff and management
b. average number of X-rays per day
c. type and quality of machine
d. are there guidelines for prescription of X-rays?
e. is more sophisticated imaging equipment available?
5. other diagnostic services (electrocardiograms (ECG), electroencephalograms (EEG), etc.)
F. Clinical services
1. outpatient department (OPD)
2. admission/emergency department
a. number of beds
b. is there a team on duty 24 hours/day? composition of team?
c. is there an on-call system in place?
d. is there an admission book or regular procedure for admitting and registering patients?
e. is there a regular procedure to send patients to appropriate wards or to operating theater (OT)?
f. number and type of emergencies per day?
g. are basic supplies and equipment available?
3. operating theater (OT)
a. staff and roster
b. hygiene of OT
c. is there an accurate operation book? if yes, number of surgical operations in last month
d. what kind of surgery is performed?
e. what kind of instruments and sets are available (laparotomy, caesarean section, debridement, skeletal traction sets, etc.)?
f. number of operating rooms, tables
g. surgical linen (availability and source of provision)
h. functioning surgical equipment (lamps, suction, diathermy, oxygen, etc.)
i. source of materials and consumables
4. sterilization
a. staff and roster
b. equipment (autoclaves, dry ovens)
c. protocols in place?
5. anesthesia
a. staff and roster (MD and/or anesthetist nurses)
b. is a laparotomy performed safely with full muscle relaxation (including endotracheal intubation) by a trained anesthetist?
i. role of the outpatient department (consultation, follow-up of patients, admission, emergency)
ii. are there specialized outpatient departments?
iii. are there criteria to admit patient to outpatient department?
iv. is there a register with data about all patients seen every day?
v. average number of cases seen every day (medicine, pediatric, surgery, obstetric, etc.)
vi. personnel in charge (MD, medical assistants, nurses)
vii. is there clear roster? opening days and hours
c. main pathologies
i. common anesthesia (gas, ketamine, spinal, local)
ii. type of anesthesia machines
iii. availability of other equipment (pulse oximeters, oxygen supply, etc.)
6. nursing care
a. is there 24-hour nursing supervision in wards?
b. are patient records complete?
c. is nursing handover book used properly?
d. are drugs administered on time?
e. is laparotomy performed safely with patient supervised (vital signs) for 24 hours post-operatively in room with light and where he or she receives intravenous fluids and antibiotics?
f. what do dressings look like (clean, smelly, etc.)?
g. are bedsores a problem?
h. are relatives involved with patient care?
7. frequently asked questions
a. availability of mosquito nets for all beds
b. is there an admission book or regular procedure for admitting and registering patients in ward? if yes, number of admissions to ward in last month?
c. is there person in admissions/ER and wards who controls system whereby patients are assessed and then go to operating theater or receive treatment?
d. are new admissions systematically seen by senior surgeon/MD and within what timeframe?
e. are there regular rounds in wards and/or regular meetings to discuss cases?
f. are diagnosis and treatment clearly formulated in patients’ files and treatment copied to patients’ charts?
8. surgical care
a. main pathologies present in wards (fractures, burns, chest, abdomen, etc.)
b. management of ward/hygiene
c. human resources (number, composition, roster)
d. infrastructure and beds
e. is laparotomy performed safely? patients seen few days after operation with healing wound and eating normally?
f. can five or more laparotomies be performed in 24 hours under good conditions including anesthesia? if not, why?
g. what type of orthopedic treatment is present in surgical wards (pin site care, skeletal traction, external or internal fixation)?
h. what do wounds present in ward look like (clean, dirty, smelly, pus)?
9. physiotherapy unit
a. are patients walking on crutches in wards? if not, why?
b. management of physiotherapy department
c. human resources
G. Conclusion
1. first general impression (cleanliness/hygiene, staff, presence of patients)
2. main positive findings
3. main negative findings
4. capacity to cope with mass influx of wounded
5. emergency/contingency plan
6. proposals
7. next step
Reference
1. Giannou C. War Surgery, vol. 1. International Committee of the Red Cross, IRC. May 2010, annex 6a, pp 140-145.
The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of Defense or the U.S. Government.
Materials and support for The Disaster Preparedness Toolbox is provided by Lt Col. Ky Kobayashi, MD and Col. Benjamin Kam, MD.