Preface to the Second Edition

This second edition developed from the marked increase in published innovations applicable to medical improvisation. Clinicians throughout the world who dared to stretch their imaginations beyond the tight confines of medical conformity have produced marvelous innovations, generally stemming from the necessity to provide treatment in situations of acute or chronic shortages. Increasingly, clinicians have also recognized that the use of improvised techniques, equipment, and knowledge may be necessary not only in remote settings and in the developing world, but also in large medical centers and sophisticated emergency medical service (EMS) systems when confronted by medication and equipment shortages, localized crises, and major disasters. I am grateful for these clinicians' experiences and their support for Improvised Medicine, clearly an outlier from the staid teachings and guidelines of traditional practice.

This book is divided into several sections, beginning with introductory chapters that describe resource-poor situations that may require medical improvisation. Subsequent sections discuss Basic Needs, Patient Assessment/Stabilization, Surgical Interventions, and Nonsurgical Interventions. The Appendices provide useful information about preparing a hospital disaster plan and assembling medical kits for different activities.

The Basic Needs section begins with communication alternatives, because difficult communication is the most frequently cited problem in resource-poor situations. Improvised methods for preventive medicine/public health come next, because supplying clean drinking water and suitable waste facilities saves more lives (in a non-dramatic way) than all the interventional medical treatments combined. After that, I discuss improvised basic equipment for health care. However, only a fraction of the book's improvised equipment is discussed in this first section: Most is described in the chapter appropriate for its use.

The final topic in Basic Needs is methods for cleaning and reusing medical equipment under resource-poor conditions. Reusing medical equipment is, rightfully, a controversial subject, because inadequate cleaning, disinfection, and sterilization lead to passing diseases from one patient to another. The best available information has been used to provide guidance about when to avoid reusing supplies and when certain cleaning methods are suboptimal.

The Patient Assessment/Stabilization section describes methods and improvised equipment to assess vital signs and to manage airways, breathing, circulation, and dehydration/rehydration (vital to saving children's lives). Also included are improvisations and alternatives for medications and medication delivery, imaging, laboratory testing, and patient movement/evacuation. Four chapters describe improvisations for analgesia, local and regional anesthesia, and general anesthesia. The Sedation and General Anesthesia chapter includes techniques for both non-anesthesiologists and anesthesiologists. The Ketamine, Ether, and Halothane chapter describes the most common anesthetics used in developing countries, including unique administration methods. Younger anesthesiologists, as well as other practitioners who may be called upon to give ketamine or ether, may be unfamiliar with these medications or alternative administration techniques.

While not everything in the Surgical Interventions section is strictly surgical (e.g., there is a chapter on Neurology/Neurosurgery), dividing the chapters in this way provides a convenient method to quickly locate information. The two Dental chapters and the Orthopedics chapter occupy significant space, because health care professionals often need to apply these skills in resource-poor environments even if they have little training in these areas. All chapters in the Surgical Interventions section describe improvised equipment and techniques that can save lives. For instance, the Otolaryngology chapter describes the old, very basic, technique of placing posterior nasal packs, whereas the Obstetrics/Gynecology chapter describes balloon tamponade for peripartum and other vaginal bleeding.

All chapters in the Nonsurgical Interventions section include improvisations that can be used in traditional medical areas (e.g., gastroenterology, infectious diseases, pediatrics/neonatal, and psychiatry), as well as other areas in which health care professionals may need to be involved when resources are limited: recognizing and treating malnutrition, assisting with rehabilitation, and doing death notification, forensic investigation, and body management.

The Appendices provide a disaster plan and suggestions for what to include in medical kits for several resource-poor situations. Although some have questioned including a disaster plan, my experience shows that it helps to have a structure to guide clinicians and others in what may be the most significant improvised situation of their career.

Hopefully, Improvised Medicine's contents will help you provide excellent medical care to your patients in resource-poor settings. This information has already proven valuable when I had to provide care in such settings. My experience has convinced me that medical improvisation is both possible and highly useful.