Chapter 1. What Is Improvised Medicine?

Improvised medicine, as described in this book, encompasses a spectrum of ad hoc equipment and special methods and knowledge for advanced health care practitioners who already work capably within their own areas of expertise. Use Improvised Medicine when, due to the circumstances, you must reach beyond your comfort level and provide medical care usually provided by other specialists—or without the medications, equipment, and milieu to which you have become accustomed.

In the context of a disaster or a resource-poor environment, frustration may be defined as understanding what can be done, what needs to be done, and how to do it, but not having the necessary tools. Unlike paramedics, who are trained to expect the unexpected, most health care professionals (including physicians, dentists, podiatrists, physician assistants, and nurse practitioners) who work in high-tech health care systems don't expect that the power will fail, a fire will ignite, the computer system will crash, a facility will flood, or an epidemic will erupt. Yet these events occur on a routine basis and, given the state of the world, it is likely they will occur more frequently in the future.

How do you practice medicine in a disaster when you are confronted by increased numbers of patients, the need to extend your scope of practice beyond your comfort level, and the need to work with limited or alternative methods, equipment, and staff in unusual, often makeshift, locales? When a disaster's scope is regional or national, knowing what to do and how to improvise becomes even more crucial. For a health care provider to innovate, work, and provide leadership in resource-poor environments, especially when others are panicking, often requires superior knowledge and greater understanding. Improvised Medicine provides this.

In selecting material for this book, I have tried to anticipate both short-term and long-term resource deficiencies. Therefore, some improvised techniques in the book can be used immediately in sudden critical situations; others are long-term solutions for use when equipment and facilities will be lacking for some time. The most mundane, everyday occurrences include the lack of necessary equipment and difficulty with procedures (e.g., airway, IV). If this book's improvised methods help in these situations, great; but the real emphasis is on opening your mind to ways of solving problems in a crisis and providing options for you (and your patients) when alternatives seem limited or nonexistent.

Farley wrote in 1938 that "original ideas for improvising equipment have been pretty well exhausted."1

This book is essentially an argument against Farley's thinking. Improvised Medicine represents both exploration and discovery. My adventure took the form of a search through the world's medical literature, both past and current, for procedures that can be used and equipment that can be improvised in resource-poor situations. Many techniques were tested to see if they actually work; some that exist in medical lore did not work when tested. Three major techniques that, initially, seemed like good ideas were the much-published auscultation for fractures, the use of papier-mâché (paper-maché) for casts, and the use of ham or portable radios for intra-hospital communication. I won't bore you with the details, but trust me, these methods don't work. (Thanks to my very patient wife for acting as the subject for the casting tests, and to Scott Clemans and Mykle Raymond of the Southern Arizona Rescue Association for helping with the radio tests—multiple times.)

New techniques and equipment in the book include a lightbulb beaker, two types of improvised saline locks, simplified vertical mattress sutures, makeshift medication atomizers (with and without pressurized gas), improvised stethoscope earpieces, a scalpel fashioned from a disposable razor, a nasal speculum made from a clothes hanger, and a number of other items that, while developed for this book, may have been previously improvised. These methods and equipment were tested in clinical practice. I learned and tested the simple and rapid method for vertically (down the stairs) evacuating patients from hospitals during a Disaster Medical Assistance Team exercise, although it does not seem to have been published before. Rapid-admixture blood warming, the amobarbital interview for conversion reactions, and hypnosis for fracture-dislocation reduction are not new. (Although either I originally published the technique [rapid blood warming] or my publications on the subject are among the most recent.) New mnemonics (like PAIN for tooth pain) are included to assist in remembering these important details. This book also rescues many techniques that were buried in dusty books or little-known publications. While some cynics and critics might contend that these techniques should remain in obscurity, I'm convinced that lives may be saved by resurrecting them.

There is no one-size-fits-all in situations with limited resources. Circumstances will vary: in one, necessary equipment may be unavailable; in another, medications will be lacking; and in yet others, there will be no way to transport patients safely and quickly. Whatever the problem, the individuals making key decisions—and often the entire medical team—need to participate in fashioning the best medical treatment for their patients in that situation. However, as Dr. Maurice King wrote, "Failure to improvise, where this is at all possible, is never an adequate reason for not doing something."2

Nearly all the chapters contain material that is familiar to specialists in that field. The difficult balance has been to include enough information so that those not familiar with the field can perform adequately without a wealth of equipment or expert assistance. The idea is for any advanced clinician to be able to use the appropriate techniques in this book.

Naturally, a huge emphasis is placed on using improvised methods in less-developed countries, remote areas, and other resource-poor environments. My hope is that, while most clinicians will know many of these techniques, they will find new material that can be used to help their patients. Every effort has been made to supply enough information to perform the techniques or to make the equipment, even if the original sources lacked the details.

Ultimately, this book suggests ideas that should prod you into a How can I do this? mind-set. Problem solving is only part of the solution. The real issues are motivation and attitude. Your motivation is to help your patient; your attitude is "The difficult we do immediately. The impossible takes a little longer."3

Improvised Medicine is intended to help you and your health care team to problem-solve and find a workable solution. As the old medical adage about stethoscopes says, "It's not what goes in the ears, but what's between the ears that matters." A modern update, based on military medicine, says that while "technology is important, … the best instruments on the battlefield are your hands, fingers, and brain, trained for optimal use. They seldom break, they are hard to misplace, they can be upgraded continuously, and frequently invent new solutions."4 In austere medical situations, it is the combination of the knowledge and skills of the entire team, not just of one individual, that may save the day. Note the following story:

One very basic (and recent) example of improvisation occurred while I was considering what to include in this introduction. I had to drain an ischemic priapism in an austere situation and discovered that no large-bore butterfly needle was available. (The butterfly tubing permits movement of the needle without dislodging it during the drainage/irrigation/medication instillation process.) Once the team decided to go ahead with the procedure and not use a less-than-optimal piece of equipment (e.g., small-bore butterfly or fixed needle), a workable substitute was quickly devised using a large-bore hypodermic needle attached to a short piece of extension tubing.

This book can only supply ideas about how to "make do" when dealing with shortages. Problem-solving skills will take you the rest of the way when you are faced with missing equipment, personnel, or facilities. As is typical in medicine—and in life, generally—once we recognize that something can be done, we find ways to do it better. Over time, the hot air balloon evolved into a rocket ship, a daguerreotype into a digital video movie, an abacus into a computer, and the ancients' signal fires into the Internet. Many of the techniques and much of the equipment described in this book are either retrieved from our predecessors, essentially "lost knowledge," or innovations that colleagues have developed. Nearly all can be improved upon; it only takes more people thinking about how to do it better. That is where you come in. If you develop an improvement on the techniques or equipment described in this book, please forward it to me so it can be included (with credit to you or the originator, of course) in the next edition. Mail them to me c/o Galen Press Ltd., PO Box 64400-IM, Tucson, AZ, 85728-4400 USA; or e-mail me: kvi@galenpress.com.