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INTRODUCTION

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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:

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The mother’s blank stare and hurried manner reveals that she knows how sick the child is that she carries into the emergency department at a rural sub-Saharan district hospital. Still swaddled in a colorful cloth, the child stares unseeing from eyes with white palpebral conjunctivae; there’s barely a grimace when she’s stimulated. A nursing assistant quickly puts her ear to the child’s chest to listen for a heartbeat and then applies a venous tourniquet in a vain attempt at finding an extremity IV site. The nurse wants to apply oxygen, but they used the last of it on the night shift; the oxygen concentrator promised for two years has never arrived. She then fashions a scalp tourniquet from a disposable glove and the physician uses an injection needle to place an IO line. The first blood sample is rushed to the lab along with the mother-donor, since the blood bank has no blood; the lab reports that the child’s Hgb is < 4 g/dL. More fluid is needed, so the physician starts an intraperitoneal infusion. Even with the mother as donor, the blood is not forthcoming, since the lab has run out of reagents and is having to use a coagulation test to check for compatibility.

The child’s respirations become labored and, using a makeshift fit with an adult mask, they assist her breathing. They improvise an endotracheal tube and prepare to intubate. They give IV quinine using aluminum foil to control the flow and IM ceftriaxone using a resterilized single-use syringe. Blood arrives; it’s still warm. They begin transfusing. The child is doing a little better and the nursing aide steadfastly keeps monitoring the femoral pulse, since that’s all that is available. It’s going to be a long night.

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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.

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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.

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