Gowns, Gloves, Masks, Booties, and Goggles
Standard, or universal, precautions start with protecting oneself against the microbes, fluids, and detritus that haunt the health care environment. The basic equipment is protective gear. In an austere environment, this paraphernalia often must be made, rather than purchased.
The simplest gown that is waterproof is a plastic garbage bag with head and arm holes cut out. Arm pieces can also be cut from another bag and stapled on. Note this also works well as a raincoat, although if used for that purpose, the arm connections should be folded over and secured so that they do not leak.
While not waterproof and probably better for patient use than as medical equipment, a sheet cut like a poncho will also work. Fold a flat sheet so that one-third is doubled over to form the arms. In the center of the folded edge, cut out a hole large enough for your head to pass through. The sleeve is fashioned by cutting slits on both sides of the sheet, midway down the folded section. The slits should extend to the approximate site of the axilla (Figs. 5-17, 5-18, and 5-19). Once the person dons the gown, the arms can be secured with safety pins, staples, or tape (Fig. 5-20). Wrap the large pieces around the back under the arms, and use the flap on the back as a tie for the gown.28 (Depending upon the person's girth, the tie may also need to be pinned.)
Improvised surgical/patient gown, Step 1. (Reproduced from Olson.28)
Improvised surgical/patient gown, Step 2.
Improvised surgical/patient gown, Step 3.
Improvised surgical/patient gown, completed. (Reproduced from Olson.28)
Sometimes, you cope as best you can, as one disaster response team discovered. "Sterile gowns are bulky and consume precious space; therefore, the team considered other options, such as wearing one gown and changing gloves between each case, or wearing disposable aprons, sleeves, and gloves. [We] finally decided to use aprons over street clothes and boots covered with disposable covers."5
Masks are useful to protect both you and your patients against dust and particulate matter (i.e., inhaling ash is what often kills people after a volcanic explosion), virulent organisms that they or you carry, and nauseating smells, especially when working around decomposing bodies or opening feculent abscesses. Put some tincture of benzoin on your mask to disguise the smell. Caps protect the head and hair from any nasty stuff. They are also useful for protecting the patients' wounds from contamination by your hair.
The most basic masks are towels or cloth held to the mouth and nose, either with your hand or tied in place.
An improvised surgical mask and cap can be made using a piece of cloth about 18 × 12 inches (46 × 31 cm). Cut a 4-inch (10-cm) narrow oval to fit over the eyes, about 5 inches (12.5 cm) from one end. Be certain that you can breathe as easily through the cloth as through a normal surgical mask. Attach a long piece of tape that extends over the edges of the material, at both sides of the slit. Also, attach a long piece of tape to the bottom of the short end. The wearer can adjust the slit over the eyes, flip the long piece of material over the head for a cap, and then tie both pieces of the tape behind the neck (Fig. 5-21).
Make a simple cap by covering the head with a long cloth or towel (Fig. 5-22) and pinning or taping it to the nape of the neck.
Improvised cap. (Reproduced from Olson.29)
Wearing eyeglasses helps to protect the eyes from splattering blood and fluids. If your glasses are small or if the splatter is expected to be large, put tape around their edges. Goggles (such as for skiing, woodworking, etc.) also work and can often be worn over eyeglasses. Another option is to purchase a cheap pair of plain glass or plastic (no refraction) glasses with big lenses.
To conserve exam gloves, cut the fingers off a glove and use each one as a finger cot for digital rectal exams, instead of the whole glove. That allows you to do five exams with one glove.
Digital Impaction/Obstetric Gloves
Elbow-length gloves should be used for bimanual compression of the uterus, manual placental extraction, vaginal childbirth, disimpactions, and similar procedures where there is a great chance of contamination. When they are not available, you can make them from two pairs of standard surgical gloves. Cut the four fingers (not the thumb) off one pair of gloves just below the point where the finger portion of the glove begins (Fig. 5-23). If you are doing this sterilely, such as in the OR, or using the gloves for a disimpaction, then use the pieces as described below. Otherwise, for obstetric cases, sterilize or high-level disinfect those pieces along with a standard pair of uncut gloves. When ready to use the elbow-length gloves, first pull a fingerless piece of glove over your hand and up to the elbow. Do the same on the other arm. Then put on the surgical gloves so that the wrist portion overlaps the pieces already on the arm (Fig. 5-24). The overlapping section can be sealed with cyanoacrylate, although this is not usually necessary.30 Rather than making long gloves, standard long kitchen or lightweight household gloves can also be used.
Improvised long gloves, Step 1.
Improvised long gloves, Step 2.
To fashion waterproof booties, cut a large plastic garbage bag open so that it lays flat. From that piece, cut out a portion that is as long as the distance from your foot to your knee and as wide as three lengths of your foot. Use larger dimensions if you need longer booties, such as in a bloody procedure or trauma. Secure them on your foot with duct tape. Do not make it too tight—you may be wearing them a while. One caveat: Take care when wearing these plastic boots; they can become very slippery on a wet or tiled surface.
Dressings are the materials that go on the wound. They can be adherent or non-adherent, wet or dry, and absorbent or non-absorbent. Dressings are usually sterile and can be occlusive (airtight). Bandages cover dressings, and can be adherent (such as tape) or impermeable. Bandages can also be used to place pressure on the wound. Most clean fabric can be used as a dressing or a bandage. Avoid paper products such as tissues and paper towels, since they disintegrate when wet and leave fibers in the wound.
To make life simpler, consider not putting a dressing on the wound! Sound like sacrilege? It's not. You do not have to put a dressing on every wound. Most clean closed wounds do not need them. Not applying a dressing allows easy inspection for infection or dehiscence. It also does not form a moist, possibly anaerobic, space in which the wound can macerate and increase the likelihood of infection.
Not applying a dressing also makes it much easier to keep the wound clean. Forget the voodoo about keeping it dry for 24 hours. (You think they don't sweat for that time either?) After a few hours, let patients shower or swim. Have them keep the wound clean with soap and water.
Even so, some wounds do better, at least initially, if dressed. A dressing helps absorb any serosanguineous drainage, keeps the wound moist (good initially for small plastic closures), protects them from further injury, and may lessen pain by keeping the air off open wounds (e.g., paper cuts always hurt less when covered).
Any absorbent material may be used as a dressing. If a highly absorbent dressing is needed, such as for wounds with lots of exudate, use a menstrual pad. Otherwise, use the more-absorbent cotton fabrics, rather than synthetics, which absorb less. In a pinch, use moss, especially sphagnum (peat) moss that many cultures traditionally use as an absorbent dressing.
Make non-adherent dressings from sheer synthetic materials, such as parachute cloth or nylon stockings. Occlusive dressings, such as those used over open-chest wounds, can be made from any clean piece of plastic sheeting, such as a plastic bag. If possible, first place a sterile dressing against the open wound.
One concern with dressings is their sterility. However, "provided the material used for dressings is clean, in most cases this will have very little impact on the incidence of infection."31 If you need a sterile dressing—or need to sterilize dressings to reuse on other patients, the procedure is described under "Dressings and Other Textiles" in Chapter 6.
The purpose of a bandage is to hold a dressing in place. If you need a bandage, the easiest and most available option is to use a piece of cloth that is expendable. Remember the damsel in old movies ripping up her petticoat to make bandages? She had the right idea. Another simple method is spirally cutting a shirt. If you prepackage bandages, be sure to label the package so you know what is inside.
If no cloth bandage is available, use duct tape to secure a dressing. Shave the area first, since when the tape comes off, it can hurt. Shaving can also help tape stick, which is a problem if the person's skin is wet. Poking holes in the tape (especially thick tape, like duct tape) helps by allowing fluids and sweat to escape. Clean the skin with soap and water, acetone, or alcohol to remove oils. Prepare the skin with tincture of benzoin to enhance "stickiness." To make an adhesive dressing, cover a small square of dressing with a piece of tape.
If you need to see the wound, but still want it covered, a clear bandage (like the standard steri-drape) can be fashioned from clear plastic wrap (e.g., Saran Wrap) or a piece of clear plastic bag. In both cases, affix the edges to the skin with tape or cyanoacrylate glue.
A pressure bandage over dressings, used when there is significant seepage or concern about hematoma development, is most easily constructed from an elastic bandage, a bungee cord (use only over fabric stiff enough to distribute the cord's force), or the elastic from a piece of clothing or equipment.
Sharps containers are often in shorter supply than needles, especially after disaster-mandated immunization clinics or in the homes of patients needing routine injections, such as for insulin. These are easily improvised.
For large volumes of sharps, use a large container such as a 5-gallon water bottle. Empty the container and tape a fitted piece of cardboard or thin plastic over the top. Cut an X-shaped slit in the cardboard to form a "one-way" opening. When it is full, tape the slits and dispose of it with other biohazardous waste. An alternative is to use a heavy cardboard box. Seal it completely and then cut a 3-inch "X" in one side. Push the sharps through the hole. Discard the box when it is full.
For clinic or patient use, get a large, empty coffee can with a plastic lid and clean and dry it. Then make two slits at 90-degree angles to each other in the center of the plastic lid. Securely tape the lid to the can. Put a syringe and needle through the opening, and then check to make sure that it can be easily pushed through the slits, but that a small child's fingers cannot get through. When the coffee can is full, tape the slits shut and dispose of it.
Use a piece of IV tubing as a tourniquet for drawing blood or placing IVs. A rubber glove (sterile or unsterile, but "stretchy") works well as a venous tourniquet when starting intravenous lines or drawing blood. Cutting between the fourth and fifth fingers and onto the wrist part of the glove produces a nice tourniquet. Even better, cut the wrist portion off a surgical glove and slip it over the arm, as suggested by Daniel Tsze, MD, from Brown University (written communication, June 5, 2007). This is very effective as a tourniquet to locate an infant's scalp vein.
Needles used for injection also can be used as IV needles, although they may be more difficult to thread into a vein, since the injection needle will tend to puncture the vein, rather than slide in as the plastic-coated needle on a catheter does. Also, since they have a tendency to perforate the vessel, take extra care when securing them, and always check that they cannot be jostled or moved; use an arm board or generous bandaging, if needed.
Should you reuse needles in austere situations? If so, how do you sterilize them? The answers are in Chapter 6, Cleaning and Reusing Equipment. How to make surgical needles and suture is discussed in Chapter 21, Surgery/Trauma.
Make an excellent, inexpensive saline lock easily by slipping the rubber end of the plunger from a 2- or 3-mL disposable syringe over the end of an IV catheter (Fig. 5-25). This also works on a straight needle, if that needs to be used as an IV catheter. Simply fill the catheter with saline (or heparin) as would normally be done.
Make an improvised saline lock by attaching a small syringe (either empty or with a small amount of saline) to the end of the IV catheter. To prevent the plunger from moving, which would allow blood to enter the catheter, fix a rubber band or tight adhesive tape over the barrel's end, or put a drop of cyanoacrylate cement at the juncture of the plunger and barrel. The smallest-size syringe on which a rubber band fits well is 3 cc, but adhesive tape or cyanoacrylate also can be used with a tuberculosis (TB) or an insulin syringe (Fig. 5-26).
Improvised saline lock, alternative method.
One method for adjusting an IV flow rate is to wrap a small piece of malleable metal (e.g., heavy aluminum foil) around the tubing. The flow rate is determined by how tightly it is wrapped on the tubing. Count the drops to get the desired rate.
There are multiple ways to increase the external pressure on IV or blood bags. These include inflating a blood pressure cuff around them and wrapping them with an elastic bandage, a belt ("stretchy" if possible), nylon stockings, a rope, or similar materials.
If external pressure is applied to an IV bag, it does not have to be hung. Rather, the pressurized IV bag can simply lie on, or next to, the patient. This facilitates transporting the patient. If the bag is placed under an adult patient, the pressure exerted by the body keeps the IV flowing. This is particularly useful when transporting a patient in the field.
To speed the flow of IV fluid running out of a plastic bottle, once it is hanging, insert a hypodermic needle into its uppermost part. This also helps to more accurately gauge the amount of delivered fluid, since without the needle to release the vacuum, the plastic deforms and gives a false reading on the quantity markers on the bottle's side.
With glass bottles, increase flow by inserting a needle into the stopper or end of the IV bottle to speed the flow by "venting," allowing air to enter as the fluid drips out. You can also "strip" the IV tubing by using your fingers to compress the tubing and continually running them down both sides of the IV tubing. This is marginally useful and very time consuming, but it is better than doing nothing.
If the IV pole will not accommodate the IV bag or bottle's "hanger," use a loop of IV tubing to connect the bottle's hanger to the pole or other available elevated hook.
Use clear plastic bins to store clinical equipment. Israeli emergency physicians ask why everyone else seems to persist in "beautifying" their resuscitation rooms by storing critical equipment in opaque containers. They use clear plastic bins that contain only the most commonly used equipment and sizes at the bedside; the rest is stored across the room for use when needed. They also position most bins between adjacent beds, so that they can slide the bins open to either side—doubling their usability and conserving space.
How many uses can you think of for the common clothespin? It works well as a tubing clamp for urethral catheters and IVs: Double the tubing over and clamp it with a clothespin. It also works great as a wire/tubing organizer (Fig. 5-27): Gather up a number of wires and tubes and secure them with a clothespin. This is particularly helpful when patients are transported since it keeps the extraneous equipment from becoming entangled with ambulance or helicopter equipment. Of course, these clips can also be used to attach triage tags and medical records to patients' clothing.
Clothespins holding wires out of the way.
Lubricants (for Rectal/Pelvic Exams and Nasal Packing)
Nearly any nontoxic lubricant works for rectal exams, if standard water-based lubricants are not available. Try vegetable oil, lard, cold cream, salad oil, sweet cream, unsalted butter, or sweet oil.32
For endotracheal tubes, you normally do not need lubricant unless you are doing an awake intubation or a nasotracheal intubation. In those cases, use a sterile, water-based lubricant. Similarly, it does not help much to put a little lubricant on an NG tube. It is better to apply some local anesthetic and wet the tube before insertion. Likewise, use warm water to lubricate a vaginal speculum. Sterile water is the safest, least-toxic substance.
Cyanoacrylate, duct or other tape, sutures, or surgical wire can be used to quickly secure, repair and construct medical equipment. A method to securely fix tapes and leads on a patient is to use tincture of benzoin. Absent that, the same effect can be achieved by saturating alcohol gauze with Betadine. As the alcohol evaporates, "you're left with the same residue as tincture of benzoin. It's convenient and readily applied without using extra 4 × 4s" (Darrell G. Looney, MD, personal written communication to author, received June 5, 2007).
There are several ways to make ice packs, but all require something cold to fill them. The easiest is to simply fill a plastic bag with a cold source, which can be ice, frozen food, cold drinks, or snow. Be certain to put a cloth between the cold source and the skin. Without a portable cold source, an option is to put an affected extremity into cold water. Alternatively, use evaporative cooling in a warm, dry climate by putting a wet cloth over the area and exposing it to a hot breeze. It will cool quickly.
When you have significant facilities and want to prepare ice packs in advance, fill 1-gallon plastic bags that can be securely closed with 4½ cups of water and 1½ cups of 70% isopropyl alcohol. To prevent leaks, put each bag inside another securely locking plastic bag. Place the bags in a freezer for about 4 to 6 hours.33
Heat packs are a bit easier to make, although, of course, you need a heat source. To make a "Wheat Pillow" hot-pack,
Use dry long-grain rice or wheat grain (e.g., bird food) as the filler.
Put it into a heavy, wool sock or, if you want to make a larger pack, a piece of strong, breathable fabric that can be put in a microwave. Tie the end closed with a string.
Put it in a microwave on high for 1 to 2 minutes; use a longer heating time if the microwave is less powerful. You can also put it in an oven at low heat.
If the smell is bothersome, add some potpourri.
This heating pad works for 8 to 10 minutes and can be reheated and reused.
See also "Heating the Bed," above, for more ideas.
It may seem mundane, but being able to supply plates and cups becomes vital, especially when a horde of patients descends on a facility after a disaster. Metal cans of various sizes can be cut down, if necessary, for use as cups, plates, pots, storage containers, and a wide variety of other items. The only caveat is that whenever cans are cut down for use, their edges must be folded inward or otherwise dulled, since they are very sharp. While most cans are used to store food, it is safest to both clean and sterilize them before using them for eating. What if you need forks, knives, and spoons? In a pinch, hands work great. Emily Post is not looking, but do wash your hands before eating!