Chapter 5. Basic Equipment

Basic medical equipment may not be available when needed. In developing countries, for example, even some of the largest hospitals lack basic medical equipment.1 Louis Pasteur reportedly said, "Chance favors the prepared mind." Be prepared to improvise. This book supplies ideas about how to make-do when faced with shortages. Problem-solving skills will take you the rest of the way.

"When improvising medical equipment, consider whether it (A) Will accomplish the purpose for which it is intended? (B) Is practical? and (C) May cause an accident or increase danger to the patient or clinician?"2

Health care resources, whether purchased, donated, or improvised, should be matched with the skills of the practitioners and the type of facility in which they are to be used. Table 5-1 describes the spectrum of health care facilities worldwide and is the basis for the "Essentials" tables in this chapter (Table 5-2) and elsewhere in the book.

Improvised (Safe) Medical Structures/Modification of Existing Structures

Any available site may be used to provide immediate health care when local facilities are overwhelmed. Generally, these will be buildings of convenience. Optimally, such buildings will be selected in advance and assigned a specific use (ambulatory care, hospital or nursing home overflow, minor acute hospitalization). Control (who runs and is responsible for it) and funding (who pays) for the facility, as well as the required supplies and equipment, should be predetermined. In most cases, a contingency contract with the building's owners will be necessary.

The following elements are necessary for any health care facility to function. They may need to be improvised at alternative sites, and even at regular health care facilities in disaster or austere situations.

Access

Identification as a Health Care Facility

Making the public aware of the availability of a makeshift medical facility is an often overlooked task. Workers assume that once they have set up shop, people will know where they are located. Not true! If possible, make easily visible signs with identifiable symbols (e.g., Red Cross, Red Crescent, Mogen David Adom, or Disaster Medical Assistance Team [DMAT]). Also, ask patients and others who visit the site to spread the word.

Ramps

If the facility you use has stairs at the entryway or inside the building between patient care areas, build ramps so that non-ambulatory patients and those with difficulty walking have easy access.

When elevators are not functional, use pulley systems to help get stretchers up ramps with steep inclines. Such pulley systems, similar to search and rescue haul systems, can be set up and operated by fire department/rescue teams.

Light Sources

Health care facilities must have ambient lighting and specialized task lighting for workers to perform examinations and procedures. Since electrical power may be limited or nonexistent, you may need to improvise.

Sunlight

Sunlight (or even a bright moon) can provide excellent general lighting. During the US Civil War, for example, surgeons often performed operations outside. This provided them with much better light than they could get inside the hospital tent. It also was safer, since there was no need to have an open flame that could ignite the flammable anesthetic they were using.4

When using sunlight for illumination, it helps to know how much time you have until sunset. Hold your palm out flat toward the Western horizon. One fingerbreadth from the horizon to the bottom of the sun = 15 minutes until the sun sets.

Headlamps/Flashlights

Powerful illumination is, of course, necessary in the operating room (OR). It is also needed for many diagnostic and therapeutic procedures, including intra-oral and gynecological procedures. Even at major medical centers during normal conditions, extra light may be needed. Carrying a powerful, small, battery-powered, and hands-free headlamp literally "saves the day" by providing sufficient light to examine patients and do procedures when the power fails or the existing light is insufficient.5

When choosing a headlamp, check the brightness and the focus at the distance you will need to perform procedures. Also, be sure it is comfortable to wear for several hours (or an entire shift) and that you can get extra batteries for it. (Rechargeable batteries are useless if the power is out.)

Very small flashlights, such as the penlights that health care professionals commonly carry, can be tucked into an elastic athletic headband or an elastic bandage wrapped around the head to make a headlamp. Laryngoscopes have been used for light when ORs unexpectedly lost power.

Room Lighting

Solar-powered garden lights work well as room lighting (if charged). They last for several hours and work best if put into an empty 2-L soda bottle (with a hole cut in the side). They can be carried around, and the plastic helps diffuse the light, like luminarias (paper bags half-filled with sand in which a candle sits). Just remember to put them in the sun to recharge.

Automobile Headlamp

One group successfully used an automobile headlamp as a light for the OR. They wrote that

The halogen headlamp is preferable to an incandescent lamp because of greater light intensity. A 12-volt automobile battery serves as the power source …. A disadvantage is the periodic need to recharge the battery. The battery may remain in a vehicle (a mobile eye unit's Land Rover, operating on a 12-volt electrical system, for example) and a constant charge maintained with the engine running. The battery leads for the operating lamp are passed into the operating theatre through a window. The halogen lamp is affixed with a small metal hinge to a 10 × 20 × 2 cm section of wood with 4 drilled holes, one in each corner. Sturdy cord passed through these holes and to an IV pole will attach and elevate the lamp above the surgical field for an excellent surgical light source. The portable operating theatre light may be used as a back-up light source for eye surgery in communities where power shortages are frequent. It is also reliable for mobile eye work and surgery in rural areas where electricity is unavailable.6

Flaming Light

You may need to make a fire for light. More commonly, you can use one or more candles. For a short burst of light (or as a fire starter), petrolatum (Xeroform) gauze works well, as does an alcohol swab. The swab's flame lasts only seconds, but is especially useful for warming ENT mirrors. Always be careful when using open flames as there is always danger of igniting nearby objects (such as clothing) or combustible gases.

Patient Records

To make medical records and radiographs more accessible and less likely to "walk away," tie them to the end of the patient's bed or chair. Alternatively, radiographs and the patient's bedside chart (containing vital signs and intake/output) can be placed in a holder made from cloth or old x-ray film and taped to the head of the bed or wall.

If no other method is available, especially when there are large numbers of patients during a disaster or when transferring patients to another medical unit or facility, clip or pin patients' records and imaging studies to their clothing.

Refrigeration

The ability to keep laboratory reagents and medications cool is usually taken for granted. When there is no power, some type of system must be devised to keep them cool. It is important to remember that refrigeration is vital for vaccines, as well as for some other medications (e.g., epoetin alfa, total parenteral nutrition, some antibiotic IV solutions, and suppositories). Four types of refrigeration units can be improvised (described below). Note that storing blood requires a relatively constant temperature of 4°C: this cannot be achieved using the methods mentioned below.

Use Refrigerators Normally Used for Other Purposes

If you have electricity, but not a standard refrigerator, try to find an alternative. The best way to store refrigerated medical supplies is in a unit with a transparent door so that the contents are visible. Only commercial-product refrigerators, such as those used to dispense soda pop and cold water, have these. Some hospitals have appropriated them for use when necessary. Of course, they put a lock on them to avoid pilferage.

Refrigeration Using Ice7

To make an "icebox," use a 5- or 10-gallon can or jar with a cover. Place it in the center of a wooden box or barrel. Surround the can with chopped ice mixed with sawdust, bran, flaxseed, hay, straw, or similar material. Cover the entire box with newspapers or an old raincoat, robe, or quilt. Place the material to be cooled in the can. Do not let it remain uncovered for long when you retrieve the contents.

Alternatively, you can make an "in-ground" icebox. Dig a hole in the ground big enough for a large sealed can or jar plus a 1-foot space between the can and the sides of the hole. Put the can in the center and pack cakes of ice (as big as will fit) around it. Pack crevices with sawdust, leaving a generous covering on top of the ice. Put on another covering of hay or straw, followed by a thick layer of heavy mud. Leave about 8 inches of the container above ground for easy access; cover this part to protect it from the sun. Place the articles inside the can to cool. Take special care to close the cover tightly after opening the icebox.

Refrigeration Using Cool Outside Temperature

During cold weather, a "cold box" built into a window will keep items cold. Fit a wooden or metal box to the outside of a window with a vertical sash (the pane slides up). Raise the window to access the cold box. This still allows light to enter the upper half of the window. Extend the windowsill with a shelf supported by brackets. The cold box rests on the windowsill and the extended shelf, and is fastened to the window casing by screws or nails near the top and bottom of each side of the box. The box should have a sloping top to shed rain. Cut holes for ventilation in the ends of the box and cover with screen. Shelves in the box may be made of heavy screening, poultry netting, or wood. They rest on cleats fastened to the sides of the box (Fig. 5-1). Cover anything placed in the box to protect it from dust.7

Refrigeration Using Evaporative Cooling

This iceless refrigerator is excellent for high-temperature, low-humidity conditions. It costs little to build and nothing to operate. Make a wooden frame 42 × 16 × 14 inches and cover it with screen wire, preferably rust-resistant. It should have a solid floor, but cover the top with wire screening. Attach the door with brass hinges and fit tightly; fasten it with a wooden latch. Wooden shelves or sheets of galvanized metal rest on side braces that can be spaced as needed. Place a 14 × 16-inch baking pan on the top and rest the frame in a 17 × 18-inch pan. Paint the wood, the shelves, and the pans with two coats of white paint and one or two coats of white enamel. Also paint the wire screen to prevent rusting.7

Make a cover of flannel, burlap, or canvas to fit the frame; this requires about 3 yards of material. Put the smooth side out if flannel is used. Secure this cover around the top of the frame and down the two sides and back, using buttons, hooks and eyes, safety pins, or similar easy-to-remove methods. On the front, arrange the hooks on the top of the door, instead of on the frame, and fasten the cover along the latch side of the door, allowing a wide hem of the material to overlap where the door closes. This allows the door to be opened without unbuttoning the cover. The bottom of the cover should extend down into the lower pan. Sew four double strips, which taper to 8 or 10 inches in width, to the upper part of the cover. These strips form wicks for the water to drip down the sides from the upper pan (Fig. 5-2).

Lowering the temperature inside the refrigerator depends upon the evaporation of water. Keep the upper pan filled with water. The water is drawn by capillary attraction through the wicks and drips onto the cover, saturating it. Capillary action starts more readily if the cover is dampened with water. The greater the rate of evaporation, the lower the temperature; therefore, the refrigerator works best with rapid evaporation. Place the refrigerator in a shady spot with a strong, preferably warm and dry, breeze. Evaporation takes place continuously, and the temperature inside the refrigerator may get as low as 50°F under ideal conditions. It works less well in damp or cool conditions. Clean and dry the refrigerator regularly. If possible, make a second cover, so the first can be removed for cleaning and thoroughly dried.

Beds and Amenities

Fixing a Sagging Mattress

Sagging mattresses and poor bedsprings are a universal problem in health care facilities, as well as in other sleeping accommodations. To fix this, place two smooth boards across the bed, between the mattress and the springs. Place the first about one-third of the way down from the head and the other one-third of the way up from the foot.8 You can also put one big piece of plywood under the entire mattress, if you have lots of wood.

Protecting Mattresses

Patient mattresses can still be protected from soiling, even if rubber, plastic, or similar impermeable materials are not available. Use heavy paper such as butcher's paper or newspapers stapled together (about 10-layer thick) to protect the mattress. Smooth them out, if necessary, by sewing or stapling them to heavy cloth, which may be tucked under the mattress.8 Pieces of old raincoats, tents, or tarps can also be used.9

Heating the Bed

Heating a patient's bed or sleeping bag when the external temperature is low makes them feel better and may stave off hypothermia. Just remember to wrap hot objects to avoid burning the patient. Heat bricks or smooth stones, wrap in newspapers or old cloth, and place them in the bed. Sand, salt, sawdust, bran, oats, or wheat can be heated and then placed in bags, or just placed in bags or old cotton socks and then heated. (Turn filled bags frequently so they don't burn.) You can also make "hot-water bottles" using plastic bottles or bags, canteens, or similar items filled with hot water.10,11

Backrest for Patient Bed

On basic beds and stretchers, the head end cannot be raised. To elevate a patient's head, use a chair placed with its legs against the headboard and the seat facing the mattress. Pad it by putting pillows under the patient's head (Fig. 5-3).

A Cradle to Support Bed Linen over the Body or an Extremity

Cradles to support bed sheets over sensitive areas, such as for burn patients, can be made by tying two or more wire hangers together. Put the ends of the hangers under the mattress or other support (Fig. 5-4). (See also Fig. 22-10, Improvised cradle over a burn patient.) Several supports should be used, depending upon the length needed. Another method is to string wire or twine the length of the bed above the patient and hang the sheet over the wire(s) (Fig. 5-5).12

Bedside Table/Tray

Construct temporary tables for meals by placing a board, supported on both ends by chairs, across the patient. Alternatively, use piles of books to support the corners of a square piece of wood or metal.9

Bed Screen

To screen one patient from another in multi-bed rooms, including in the emergency department, tape together bed sheets or newspapers and suspend them from string or wire, or from hooks in the ceiling. For more substantial and portable screens, make two or three lightweight wood frames that are tall enough to provide privacy (at least 6 feet). Each should be about 3-feet-wide. Put three hinges between the frames, one set going each way. Stretch a sheet or piece of cloth across the frames, and nail or staple it in place. When using this screen, angle the pieces slightly at the points where they are hinged, to give it stability. If desired, put small wheels on the bottom so that it can be moved.

Waste Basket

A "newspaper bag" pinned to the bedside will hold refuse and tissues. Fold a newspaper into a basket, with or without staples or adhesive, and attach it to the side of the patient's bed using safety pins or clothespins (Fig. 5-6).13

Bedpans/Urinals/Commodes

Bedpan

To improvise a bedpan, place a board (for the patient to sit on) across one end of a wide baking pan.14 At the Nakom Paton Japanese prison camp during World War II, Allied medical personnel made bedpans from giant bamboo.15 One disaster team lined bedpans with a plastic bag that, after use, was tied closed and put into a large red biohazard bag. The waste was incinerated on a daily basis.5

Commodes

The camp toilet for the same disaster team was a bucket lined with plastic. It had a padded toilet seat attached. Each team member was responsible for removing their bag and depositing it in the larger biohazard bag.5

A bedside commode or toilet also can be fashioned by cutting a hole in the seat of an old kitchen chair and then putting padding and a plastic cover on it. Place the chair over a bucket at the patient's bedside. To hide the bucket, tack a piece of heavy cloth around the chair legs (Fig. 5-7). Similarly, you can put wheels on the legs of a chair that has a hole cut into the seat, and use it over a standard toilet or a bucket. This can also double as a wheelchair to take a non-ambulatory patient to the bathroom (Fig. 5-8).16 Attaching legs to a standard toilet seat or to a padded piece of wood with a hole cut into it works, either over a bucket or as a movable seat over a pit latrine (Fig. 5-9).

Urinals

As every trucker knows, any waterproof container can be used as a urinal. For patients, a plastic bottle or carton, cut such that the diameter of the container's mouth is at least 2 inches (5 cm), serves as an adequate urinal. One nurse described a very usable urinal made from a bleach bottle with a large oval hole cut out opposite the bottle's large handle.17

A urine bag for an infant can be constructed from a small plastic sandwich bag, several pieces of tape, and a small straw or piece of IV tubing. Waxed paper can be used to store it until needed. To make this urine bag (Fig. 5-10), follow these directions18:

1. Make a hole in the plastic sandwich bag using radial cuts (A). The hole should be about the size of a small child's penis for a boy or, for a girl, large enough for the urethral opening.

2. With the holes lined up, attach a piece of adhesive tape with the same-size hole (B) (adhesive side out) to the outside of the bag with two smaller pieces of tape.

3. Insert the straw or a small piece of IV tubing into the bag, and fold the top piece of tape over the top of the bag to seal it closed (C). Fold the radial cuts out and stick them to the adhesive tape.

4. Then, take a smaller piece of adhesive with a slightly smaller hole (D), line the holes up, place it adhesive-to-adhesive, and fold its sides inward to form a smooth opening (E).

5. Cover the bag's exposed adhesive piece with wax paper if it is not being used immediately. Multiple bags can be made at one time and stored. They can also be sterilized using ultraviolet irradiation, such as is available in most laboratories and ORs.

The World Health Organization (WHO) lists what they consider the essential basic equipment for patient diagnosis and monitoring worldwide (Table 5-2). This is in addition to the "Essentials" listed in other chapters, and varies with four levels of hospital capabilities shown in Table 5-1.19

Stethoscope

Ear to Patient

Before Laennec invented the stethoscope, direct auscultation—placing the physician's ear directly on the patient's chest—was an established practice.20 If no other option is available, you can still put your ear directly against the chest, heart, or abdomen. The clarity of the sounds will not be as good as through a stethoscope (you probably cannot hear a murmur unless the murmur is also palpable), but you can get a general idea of cardiac rhythm, chest clarity, and bowel sounds (Fig. 5-11). As noted in Chapter 7, Vital Signs, Measurements, and Triage, directly listening to an infant's chest is the fastest and most accurate method for assessing the presence of cardiac activity.

Improvised Standard Stethoscopes

Stethoscopes can easily be fashioned by following Laennec's original method. As first described, Laennec used his original stethoscope on a young woman "because her age and sex did not allow him to directly place his ear on her chest. ‘In 1816, I was consulted by a young woman presenting general symptoms of disease of the heart. Taking a sheaf of paper, I rolled it into a very tight roll, one end of which I placed over the praecordial [sic] region, while I put my ear to the other.’ "20

To make a basic Laennec-type stethoscope, use a hollow wooden tube such as bamboo, or the cardboard tube from toilet paper or paper towels. Place one end on a person's chest and your ear at the other end; you can hear the heartbeat clearly, depending upon ambient noise and the person's habitus. Nearly any hollow tube can be (and has been) used as a monaural stethoscope. These include short lengths of garden hose, ivory or wood tubes, and metal pipes.

A slightly more sophisticated stethoscope can be made by attaching a funnel to two pieces of tubing. Use T-tubing scrounged from any source (including a juncture of IV tubing) to connect two long pieces of rubber tubing to a piece of short rubber tubing. Connect the short piece to the funnel. Put the tubing directly in your ears, or fashion earpieces as described in "Stethoscope Earpiece" below.

Precordial Stethoscope

One of the most useful anesthetic monitors is a precordial stethoscope taped to the patient's chest. It gives the anesthetist a continuous assessment of the patient's heart rate and rhythm and breath sounds. Only one earpiece is normally used, so that the anesthetist can also monitor everything else in the OR.21 For infants, it is best to tape the stethoscope to the left chest, so that both the heartbeat and breath sounds can be heard.22 In adults, it can be placed over the midsternum, in the suprasternal notch, in the paralaryngeal area, or in the axilla. If in the suprasternal notch or paralaryngeal areas, it facilitates recognizing the presence of vomitus in the hypopharynx.23

Several improvised methods will produce a workable precordial stethoscope that can also be used as a regular stethoscope. The basic method is to attach a piece of rubber tubing to the top of a screw-top plastic bottle that has a narrow, tapered opening, such as a ketchup/mayonnaise dispenser. Another way is to cut off the tapered end of a rubber bulb suction syringe and connect it to a piece of rubber tubing that runs to the ear.24 If a stethoscope head is available, make an improvised precordial stethoscope by attaching about 1 meter of IV tubing to the stethoscope head.21

Some California anesthesiologists produced an excellent, easily constructed precordial stethoscope when they forgot theirs at home while on a medical mission (Fig. 5-12, A-E). They cut a 20-mL syringe 1 inch (2.54 cm) from the infusion end (A). They then smoothed the edges with a file and placed adhesive tape around the syringe's cut end to further smooth it. Next, they removed the rubber sealer from the plunger (B) and cut a large hole in its center (C). They then inserted the rubber piece into the small piece they cut off the syringe barrel (D). After securing this to a 3-way stopcock, they connected the stopcock to IV tubing (or other tubing) and then to an earpiece (E).25

Esophageal Stethoscope

Breathing and cardiac rhythm can be monitored with a tube passed into the esophagus—the esophageal stethoscope. To make an esophageal stethoscope, you need a rubber glove, a nasogastric (NG) tube, a suture, and a regular stethoscope. Cut a finger off the glove and tie the finger over the end of an NG tube (Fig. 5-13). Remove the head from the stethoscope. Pass the NG tube approximately halfway down the esophagus and connect the proximal end to the end of the stethoscope. The NG tube can also be passed through the nose (Fig. 5-14). In the OR, this stethoscope is often used with only one earpiece, so that the anesthetist can hear the rest of the surgical team.26

Hearing Aid

A stethoscope can be a substitute for a patient's hearing aid during an exam. You simply use the stethoscope in reverse by putting the earpieces in the patient's ears and talking into the diaphragm (Fig. 5-15). Unfortunately, experience shows that it only works for patients with specific types of hearing loss (but so do hearing aids).

Stethoscope Earpiece

When the earpieces for a stethoscope have been lost (a very uncomfortable situation), use the nipple from a baby bottle or a "binky" (pacifier) (Fig. 5-16). Make the normal pinhole opening in the nipple slightly larger, and tie the nipple in place on the stethoscope. So you don't look ridiculous, cut the nipple so only the distal 1 to 2 cm of the rubber piece is used, rather than the entire nipple and the flange that holds it in the bottle cap. The rubber part (bulb) of a medicine- or eye-dropper can also be used in a similar fashion. Be sure to cut a hole to allow the sound to flow through it.

Sphygmomanometer

If you have a BP cuff, ideally it is accurate. However, aneroid devices (those without fluid) are easily damaged and can go out of calibration without it being detected. The most common problems with these devices are that they leak, do not "zero," or go out of calibration.

"If a leak develops in the system, wrap the cuff around itself and secure the end. Inflate the cuff to 250 mm Hg; watch the pointer. If it slowly drops, there is a leak—it is most likely to be in the cuff or inflation bulb. It is fairly rare for a leak to occur in the gauge itself. A small pointed brush with soapy water on it will help find the smallest leak."27

If the gauge does not return to zero after the cuff has been deflated, "the easiest method of adjusting it is by removing the glass from the front of the gauge and carefully taking off the pointer and replacing it in the correct position. The pointer can usually be taken off using your finger and thumbnails. If this is not successful, find two very small screwdrivers or thin flat pieces of metal and lever the pointer upward using one on each side."27

Aneroid systems may go out of calibration, especially if dropped. Check them on a regular basis for accuracy against a mercury sphygmomanometer. To do this, "connect the gauges together with a plastic T-piece and connect the third arm to an inflation bulb. Inflate the bulb slowly and note the readings showing on each instrument" at intervals of about 20 mm Hg. "If the readings are within a few millimeters of mercury throughout the scale this is acceptable for clinical use."27 Someone who has experience with aneroid blood pressure machines should calibrate them.

One other common problem is that the glass breaks on the pressure gauge. Either get a watch repair person to fix it or make a cover from a thin plastic sheet.27

Mercury sphygmomanometers work longer and more consistently than do aneroid systems. However, if the mercury is not clean or if it continues to rise slowly after you have stopped inflating the cuff, it may need repair. Mercury is toxic. Find a reputable, qualified person to fix it.

Infant Spinal Tap Needle

If a standard infant lumbar puncture (LP) needle is not available, use a 22-gauge butterfly needle with the tubing cut short. It works as well as, or better than, the standard LP needle—as long as the little one is not too chunky.

Gowns, Gloves, Masks, Booties, and Goggles

Standard Precautions

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.

Gowns

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.)

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

Caps and Masks

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.

Eye Protection

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.

Gloves

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.

Booties

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 and Bandages

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.

No Dressing

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.

Dressing Material

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.

Bandages

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.

Syringes and Needles

Sharps Containers

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.

IV Fluids and Equipment

Venipuncture Tourniquet

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.

IV Needles

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.

Saline Locks?

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).

IV Tubing

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.

IV Bottles/Bags

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.

Resuscitation/Equipment Cart

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.

Tubing Clamp/Organizer

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.

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.

Adhesives

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).

Ice/Heat Packs

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,

1. Use dry long-grain rice or wheat grain (e.g., bird food) as the filler.

2. 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.

3. 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.

4. If the smell is bothersome, add some potpourri.

5. This heating pad works for 8 to 10 minutes and can be reheated and reused.

See also "Heating the Bed," above, for more ideas.

Dinnerware

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!

Transportation Within Health Care Facilities

Patients must be transported within health care facilities, once they arrive. How they arrive is discussed in Chapter 20, Patient Transportation/Evacuation.

Cushions for Wheelchairs, Exam Tables, Stretchers, Chairs

Any patient surface that will be used for a prolonged period should be cushioned. There are three ways to make cushions: (a) Stuff a bag with soft, quiet (feathers, cotton, etc.) materials—but use torn newspaper, if necessary—and sew up the open end. (b) Tie bicycle tire tubes or similar tubes together in an "S" pattern. Thin pieces of the tubing can be used to bind the tube together. If larger pieces are needed, such as to cover a gurney or a bed, use the tube strips to tie multiple "S" pieces together (Fig. 5-28). (c) Glue together multiple pieces of thick cardboard. Wet the cardboard and have someone sit on it to mold it. Then let it dry and varnish it. If rubber is available, use a 1-inch-thick piece to pad it.34

Wheels for Gurneys, Wheelchairs, or Other Equipment

Simple wheels can be made from circular pieces of wood at least 2 inches thick and with a diameter to fit the equipment on which it is to be used. If this thickness of wood is not available, glue one or more pieces together. The wood grain should run across, rather than through, the wheel. Cut a hole just large enough to fit the axle. Then cover the wheel rim by either gluing or nailing on a piece of rubber from an old car tire or inner tube. Or, cut a piece along the circumference of the wheel from a bicycle tire. Cutting notches in the side of the tire allows it to conform to the wooden wheel and prevents the nails from loosening.35

Safety

Safety after Flooding

Many disasters result from flooding. Rather than simply beginning to use equipment that may have been damaged in a flood, take the following steps:

1. Check all power cords and batteries to make sure they are not wet or damaged by water. If electrical circuits and electrical equipment have gotten wet, turn off the power at the main breaker.

2. Make sure you check for water before plugging in your device. Do not plug in a power cord if the cord, the device, or the outlet is wet.

3. If there was a power outage, when the power is restored, check to make sure the settings on your medical device have not changed (often these devices reset to a default mode when power is interrupted).36

Generator Safety

Generators are the common source of electricity in austere circumstances. The problem is that they generate carbon monoxide. To be safe, never run a generator, pressure washer, or any gasoline-powered engine outside an open window or door where exhaust can vent into an enclosed area. Also, do not run them inside a basement, garage, or other enclosed structure, even if the doors or windows are open, unless the equipment has been professionally installed and the area properly vented.36

Maintenance

Heat and Humidity

Heat and humidity affect equipment anywhere, especially when electricity no longer powers air conditioning. In moist environments, frequently examine all equipment—including ophthalmoscopes, otoscopes, microscopes, tonometers, and endoscopes—for mildew. In addition, the US FDA offers these suggestions to protect medical devices from heat and humidity:

1. Use a dry cloth to wipe off devices regularly.

2. Keep devices out of direct sunlight.

3. Enclose medical products in plastic containers to keep them dry.

4. Do not use ice if there is a danger of water contamination; use dry ice or instant cold packs to keep your device cool.

5. Do not use disposable devices that are wet.36

Anesthesia Hoses

Black (antistatic) anesthetic breathing hoses, used with ether anesthesia, deteriorate rapidly in high humidity. After use, they will be wet inside from the water vapor in the patient's breath. After use, hang them vertically to allow them to dry. Inspect them regularly for cracks, especially between the corrugations, where they most often develop leaks. The normal polyethylene anesthetic hoses do not deteriorate as rapidly.37

In austere situations, you use what is available. That may include catheters, tubes, and needles sized in a system with which you are unfamiliar. This conversion chart (Table 5-3) can help you decide the appropriately sized equipment for the situation. Other measurement equivalents are listed in Chapter 19, Laboratory. For volume and length conversions, see Chapter 7, Vital Signs, Measurements, and Triage.