Chapter 2. What Are Resource-Poor Situations?

In what types of situations would you need to improvise medical equipment and procedures? Experience demonstrates that the most likely scenario for physicians in the most-developed countries is when their usual procedures fail or equipment does not function. That is not the case outside these privileged medical practice arenas:

The mother's blank stare and hurried manner reveals that she knows how sick the child, that she carries into the emergency department at a rural sub-Saharan district hospital, is. 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; the blood bank has no blood and the child's findings show that her Hgb is <4 g/dL. More fluid is needed, so the physician starts an intraperitoneal infusion. 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.

Throughout the world, clinicians must practice medicine while having to make-do with minimal resources. Acute situations of scarcity often overwhelm the individuals immediately available to respond to them. These may be a local event where the sole medical provider lacks the materials to treat one or more patients, a more widespread calamity that influences an entire community or region, or a long-lasting degradation of care spanning entire countries. Situations of 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.

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.

Resource-poor situations are logically grouped into simple, extended, and complex disasters, depending on how long they are likely to last, how much help is required, and the degradation of health care and the social order (riots and unrest) that may occur.1

Throughout this book, methods that can and should be used in all four circumstances are discussed interchangeably. The focus in many sections is on the chronically resource-poor situations found in the least-developed countries, although these methods may be used anywhere. Each of the main limited-resource settings is briefly described later in this chapter.

Simple disasters last a short time and usually require only local resources. Examples include a multi-casualty motor vehicle crash, an apartment building collapse, a multi-casualty fire, a landslide, and a tornado going through a trailer park. The needed support systems include emergency medical services (EMS), fire services, medical services, and law enforcement. Social order generally remains intact.

Extended disasters include widespread flooding, devastating hurricanes or tsunamis, massive heat waves, and major earthquakes. In these cases, the necessary support system also includes outside assistance to augment surviving local EMS, fire services, medical services, and law enforcement. The social order may or may not be partially intact.

Complex disasters are those chronic situations, usually in the least-developed countries, that often are the result of a major drought, famine, or war. A major nuclear incident would also fall into this category. Societal and social support systems are normally disrupted.

Isolated settings are remote, without an immediate way to gather resources that are not already available. The classic isolated setting is in an internment camp, such as the World War II POW camps. However, isolated settings may also occur on a boat or an airplane or, the ultimate isolation, in space. One of the best-documented physician histories from a POW camp is that of Capt. Thomas H. Hewlett (Surgeon, US Army Medical Corps). He wrote,

[In the camp,] our only available anesthesia consisted of several vials of dental Novocain tablets. Two of these tablets dissolved in a small amount of the patient's spinal fluid, and injected into the spine gave about forty-five minutes of anesthesia, giving us time to perform most operations that had to be done …. Dutch torpedo technicians were able to make surgical knives out of old British table silver-ware …. We treated fractures without x-rays …. We operated bare handed, [sic] the fingernails of the surgical team stayed black as a result of our using bichloride of mercury and 7% iodine in preparing our hands before surgery …. [However,] our infection rate in surgical patients never exceeded 3% …. Sharpened bicycle spokes were used as traction wires in the treatment of hip and leg fractures. Plaster of Paris was never available.3

Remote locations classically include wilderness settings, such as deserts, mountains, caves, forests, and jungles. More commonly, even in the most-developed countries, it means coming across ("on-siding") a personal injury crash or medical emergency far from a source of help. Be prepared by carrying basic materials (see Appendix 2) and being ready to improvise.

Even organized and experienced search and rescue (SAR) teams who carry equipment into the field may have to improvise. While rescuing a patient deep in a cave shaft with a back injury, the SAR team found that no backboard could be maneuvered into the narrow space where she lay. After several hours of working in the hot, humid, cramped, and relatively dark area, they improvised an immobilizer and extricated her from the cave.

Chronic shortages are the norm in the least-developed countries. Health care workers know they must make-do with whatever supplies and equipment are available and functioning. As a nurse practitioner student on a medical mission to the rural Philippines wrote, "The challenge of the lack of equipment and medications taught me that we sometimes have to deal with the resources at hand and that there are ways to improvise in order to obtain the same results."4

An emergency physician working at a Latin American general hospital (used by the poorest people) found that only two or three vials of medication were available for resuscitation, and only 8-mm endotracheal (ET) tubes were available. The medications would change weekly, as would the ET tube sizes. The medical team made-do with available supplies when they could; when they couldn't, patients died. Improvisation was the norm.

The key features of disasters are "threat, urgency and uncertainty, which affect not only the victims themselves, but also the organizations that have to respond."5 Disasters can be from man-made (e.g., multivictim vehicle crashes, terrorism, radiation leaks, and war) or natural (e.g., tsunamis, earthquakes, and epidemics) forces. Both often lead to resource-poor situations. The assistance provided varies greatly, depending on a host of factors.

The vagaries of war can overwhelm what seem to be adequate medical facilities. For example, during the Spanish-American War, three-fourths of all casualties came from the assault on San Juan Hill: "A temporary hospital at Siboney, established to care for only 200 men, was overwhelmed by so many injured that soldiers slept naked on the ground until tents could be set up for them …. For five straight days, doctors treated the wounded."6

Terrorist attacks have become common in many areas of the world. Immediate improvisation is often required until organized EMS and medical teams take control. Dr. Wesley Shum worked in "a surreal scene" at a makeshift hospital setup close to Ground Zero immediately after 9/11. We lacked "basic medical supplies like bandages and painkillers … [I] was forced to use cut-up cardboard boxes and strapping tape to make makeshift casts for [my] patients."7 All of his patients were firefighters injured when the Twin Towers collapsed.

Specific problems associated with different natural disasters are listed in Table 2-1.

Presenting their own mini-disaster, health care facilities may be suddenly struck by an unexpected flood, water or power outage, computer crash, epidemic, or other occurrence that diminishes or overwhelms their capacity to treat patients. For example, when Tropical Storm Allison flooded Houston's Memorial Hermann Children's Hospital in June 1991, the facility lost all but its emergency power. As some nurses described it,

We had no air-conditioning; garbage and medical supplies filled the hallways. Generators provided electricity as water was pumped out of the building, and the parking lot served as a cafeteria. We had only bottled water and portable toilets. The scene bordered on catastrophe. [The next day] the ground floor was under 4 feet of water; the basement was completely submerged …. We climbed the seven flights of stairs to the NICU in the dark and were immediately hit by hot, humid air and pitch-black darkness. The usual noises were strikingly absent: none of the cardiopulmonary monitors, ventilators, radiant warmers, or incubators worked. Every baby was covered with blankets to contain warmth.8

As Jeff Arnold wrote, "At least one thing has become predictable about disasters in recent years—once a disaster begins to unfold, an outbreak of disaster mythology is likely to ensue."9 The persistence of such myths is attested to by David Alexander,

This reaction is particularly tragic in response to disasters, in which incorrect beliefs often are the basis for misguided actions that lead to avoidable casualties and suffering …. One of the most troublesome aspects of present-day responses to disasters is the crushing inevitability of the mistakes that are made, the myths that are propagated, and the inefficiencies that plague their management. For the people who live through them, disasters are times of accelerated learning …. Disaster myths are robust enough to survive Herculean attempts to debunk them.10

Many people, even experienced disaster workers, have trouble not believing all the myths in Table 2-2.

While it may seem obvious in the aftermath, making the decision that a significant resource-poor situation is developing into a disaster may, at the time, be difficult, bureaucratic, financially burdensome, and ethically charged. Specific, measurable, and widely known "triggers" must be in place so that an on-site individual can declare a disaster. This allows the mobilization of resources while they can still be most effective. (See Appendix 1, Hospital Disaster Plan, for a generic all-hazards approach to identifying and responding to localized or larger disasters.)

Two excellent, free, online disaster resources are available: The World Health Organization's Health Library for Disasters (http://www.helid.desastres.net/) is available in English, French, and Spanish. Three short videos (in English and in Spanish) describing the method behind and the ethics of allocating scarce resources in disaster situations can be found at www.crestaznm.org.