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Preface: How the Book Is Organized

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 Non-Surgical 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, since difficult communication is the most frequently cited problem in resource-poor situations. Improvised methods for preventive medicine/public health come next, since supplying clean drinking water and suitable waste facilities saves more lives (in a non-dramatic way) than all the interventional medical treatments combined. Finally, I discuss improvised basic equipment for health care and methods for cleaning and reusing medical equipment under resource-poor conditions.

Not all improvised equipment is discussed in this section, since most equipment improvisations are described in the chapter appropriate for their use. Reusing medical equipment is, rightfully, a controversial subject, since inadequate cleaning, disinfection, and sterilization lead to passing diseases from one patient to another. The best available information has been used to provide guidance for when supplies and 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 of locating information. The two Dental and the Orthopedics chapters occupy significant space, since 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 Intervention 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, while the Obstetrics/Gynecology chapter describes balloon tamponade for peripartum and other vaginal bleeding.

The Non-Surgical Interventions chapters include improvisations that can be used both 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 for hospitals that includes transparent markers and clear actions for each progressive disaster level, and also suggest what to include in medical kits for several resource-poor situations.

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.

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