in the field
During a deployment you will probably be living and working in field conditions. Disaster areas usually are without power, food & water, sewage, garbage removal, comfortable shelter and heating & air conditioning. That's why they call them disasters. In order to properly pack and secure yourself and your gear, you will have to anticipate the time of year, the location to which your traveling and the environmental conditions you may expect during the deployment. There are a number of ways you can prepare and things to bring with you that will make your deployment more comfortable and thus improve your productivity in the treatment and care of the disaster victims. Remember that your first priority in any deployment is for your own physical well being and safety. Without that, you will be distracted from providing quality care in the austere field environment. A disabled or injured rescuer is of no use and complements the problem rather than reducing it.
When you are packing your bag, consider that you may be separated from it for a time during travel. DMAT travel can tend to be frustrating and slow. There is a saying, "If you have time to spare, fly military air". You may find yourself and your gear sitting in the middle of some airport for a period of time. Not only will your bags get thrown about, but occasionally during travel, your bags may be left exposed to the elements. It will be of great importance that you pack your bags so that everything remains inside, and everything inside remains dry. The best way to do this is by utilizing smaller ziplock or water tight bags within your big bag. You can place an entire change of clothes, shirt, pants, socks and underwear in a single large ziplock. You can place a large sweater in a ziplock, suck the air out and seal it, and the sweater takes up much less space than it did before. Everything in your bag should be compartmentalized in these smaller, water tight bags. This will protect your gear from the elements and assure that after standing in the rain for 6 hours, you will have a clean, dry change of clothes. You will also find things quicker in your bag and can even label each smaller bag with tape and a marker.
You should have a good boot or shoe. Puncture wounds of the foot have shown to be a frequent injury in the post disaster environment. Make sure the shoe has ankle protection, a non-slip tread and thick soles. Do not take a brand new boot or shoe on a deployment. Make sure you have tested it and broken it in for comfort! It is appropriate to bring along a strong pair of work boots that should be worn to the point of departure. Also bring along a more comfortable pair of sneakers in your pack to change in to during off duty time or if the deployment site warrants it. Your boots and shoes should be sprayed prior to deployment with a commercial water repellent such as Scotch-Guard. If you can afford the more expensive breathable shoes, they are worth the money. If not, plan on bringing extra socks as you will probably have to change them more often.
Depending on what phase of the disaster you are deployed during, you may have the opportunity to do some laundry on the deployment. Otherwise, you can always do your laundry utilizing the "bucket method". When doing field laundry, do it away from the living or working areas, and down hill to prevent drainage from seeping back into the DMAT living area. You should pack a few items just in case you must do your laundry in the field. You will need a couple of large strong bags. Don't skimp on cheap brand names (The red contaminated waste bags you have in the hospital are perfect... and some peoples laundry may warrant these bags). The bags will function as your washing machine. You should also bring some liquid laundry soap (powder may not dissolve as easily in cold water). You will also need a couple dozen feet of clothes line cord. Follow these steps to wash your clothes: 1) Place your clothing in one bag, about 1 change of clothes at a time. 2) Add water to the bag until the clothes are wet and there is also some loose water in the bag. 3) Add the soap sparingly as some laundry soap is hard to rinse from clothing and soap left in the clothing may cause irritation when wearing it. If you are prone to be allergic to soaps, consider a hypo-allergenic laundry soap. 4) Close the bag in a way that you can get it open again (i.e. twist ties or a bag clip). 5) Agitate the bag for about 5-10 minutes. 6) Remove your clothes from the soap bag, wring them out into the bag and then place them in the second bag. 7) Add a couple of gallons of water to the rinse bag and agitate it for another 5-10 minutes. 8) Lastly, wring your clothing out and hang to dry as soon as possible. When you choose your clothing, consider cloth that dries quickly such as cotton. This will facilitate your doing laundry in the field. The team may also have a few 5 gallon buckets set aside for members to do laundry. Five Gallon buckets with lids work well when half full of clothing and water and shaken. Buckets also will allow about 5-6 loads to be done without changing the water.
Paying attention to your own personal hygiene is the best preventative medicine for disallowing yourself to get ill during a deployment. Washing your clothing, bathing, hand washing, repelling insects, foot care and other individual protective measures will make your deployment more successful. Keep your feet clean and dry them well after bathing. Use foot powder if you are prone to sweaty feet. Change your socks at least daily or when wet. Shower as often as possible to avoid skin disease. If unable to bathe, at least wash your face, underarms and groin, etc. daily your tent mates will thank you for it. When water is not readily available for washing, consider packing in your gear a box of baby-wipes. These anti-bacterial wipes will provide you with some refreshment and assist in keeping the bacteria level down and your skin clean. Always wash your hands after using the latrine and before eating. Even if you don't do this when not on a deployment! While taking care of patients, wash your hands between every patient.
There are a number of ways to handle human waste. If no bathrooms or portable toilets are available, the easiest method is the bucket latrine. This system may also be of use for patients in the treatment tents. The bucket system is much simpler than it appears and is actually a lot easier than the old burial system. The items necessary include, two 5 gallon paint buckets, a plastic toilet seat, large, heavy duty plastic bags (#15 trash compactor bags work well), deodorant chemical (septic-mate, aqua-chem, chlorine bleach, quick lime, etc. You can obtain organic and biodegradable type from your local RV supply store, follow directions on the container), toilet paper, 1 gallon hand washing bucket and liquid soap, rubber gloves and scissors. The system is set up as follows: One of the 5 gallon buckets serves as the actual toilet container, the second 5 gallon bucket serves to hold all of the supplies. First line the bucket with two of the heavy duty plastic bags. Fold the excess bag around the top edge. Pour the deodorant into the open bag top and place the toilet seat on top of the bucket. The toilet is now ready to use. The hand washing bucket and liquid soap can be placed close by. Used toilet paper and articles particular to feminine hygiene (tampons and sanitary napkins) can be placed directly into the toilet. After each deposit, the toilet is covered with a large plastic bag, thus discouraging flies. When 1/2 full it takes only a few minutes to remove the contents and make the toilet ready for the next use. Put on your rubber gloves, squeeze the excess air out of the bag and tie it off. This portion of the job should be done by the person with the highest HAZMAT training on the team. Tie the first bag and place the bag containing the feces into a second bag if you have not already done so. This is a security measure against leakage. The second bag is then tied off securely and the whole thing of disposed of in an appropriate place away from the DMAT site. The amount of chemical used per day depends on the type used and the amount of people using each toilet. With liquid deodorant, a few ounces at the bottom of the bag is sufficient for six or seven people per day (follow directions on the container). If you are using bleach, more is required, approximately double. Quick lime should be sprinkled over feces after each use (in place of flushing). The deodorant reduces bacterial growth in the feces and the production of methane gas. Wash hands thoroughly after handling the toilet.
More than likely, portable toilets will be available for the teams use. These toilets have a chemical added to the holding tank that will deodorize and enzymatically degenerate bodily wastes. Chemical toilets should be located downhill and down wind from the Field Hospital and DMAT Living site. They should be emptied as necessary and should not be used to the point of overfilling. It is probably desirable to locate a couple of portable toilets closer to the Field Hospital site and mark them for "patient-only" use. It is also a good idea to set up a hand-washing station outside every portable toilet.
One should expect that any deployment will grant strong physical demands on a DMAT member. In a warm weather deployment, physical labor increases the potential for heat injuries as well as decreases your overall productivity. Some of the basic tenets to cold weather clothing will hold true with the hot weather environment. Wear loose clothing to allow for maximum cooling and evaporation of perspiration. Remember, evaporation can be your friend in the hot weather environment. Tight clothing prevents perspiration from leaving your clothing. Darker clothes will absorb the energy of the sun and increase your body temperature due to conduction with the warm clothes. Cotton and cotton blends are the best fabric for clothing in hot weather. They allow air to pass through them and are absorbent. As you perspire, the clothing absorbs your perspiration. Air currents over the clothing promote evaporation which will help to cool the body. You will probably also need to keep in mind some additional survival tips for warm weather deployments. Wear sunscreen and re-apply it often. If you are wearing short sleeves and short pants, wear insect repellent. Wear a hat to protect your head from the sun. Dark hair can absorb the heat from the sun just as dark clothing would. Fluid replacement is a must.
There are some specific details to keep in mind when you deploy in cold weather. The body attempts to maintain homeostasis. The extremities are used to dissipate heat from the body. When you are hot, your peripheral blood vessels dilate and allow more blood to flow to the skin surfaces allowing for heat loss. When your cold, these same vessels constrict. This is why your hands and feet get numb when cold and become more vulnerable to frostbite. The biggest loss of body heat (about 55%) is through exposed skin. Your brain needs oxygen to function, so your body can't decrease the blood flow to your head. Consequently, your head and neck are a major source of heat loss. Conduction and convection will also increase heat loss. When you are exposed to cold, wet objects or have tight, wet clothing you can lose up to 15% of your body heat. Evaporation of those wet clothes can supplement that heat loss up to another 21%. Heat can also be lost from the wind blowing away heat from body surfaces, and to a lesser degree by respiration, that can account for up to 9% of your heat loss. Not enough to recommend you stop breathing in cold weather though.
It's difficult to appreciate the effect of living 24 hours in the outdoor environment in cold weather. Most of us only experience the mad dash to our car in the early morning to go to work. Not enough time to really realize the impact on productivity and comfort that living, working and sleeping in those conditions will have on us. Cold weather deployments offer a tremendous challenge to the DMAT. As of the writing of this manual, NDMS has been fortunate to not have been required to deploy in these conditions, however, a large earthquake in January on the New Madras Fault would necessitate many teams suddenly becoming experts in cold weather medical care.
One can remember the word COLD to help keep in mind the primary personal objectives of a cold weather deployment. Keep yourself and your clothes Clean, avoid Overheating, wear clothes in Layers, and keep Dry. Additionally, remember that when wearing rain gear, which doesn't breath well and allow perspiration to exit, change your clothes more often. The same goes for your socks when wearing rubber boots. Wear a stocking or other warm hat that covers the ears and neck area. When choosing your clothing for a cold weather deployment, utilize fabrics that maintain their effectiveness when wet. Wool, flannel, cotton and most woven materials are good insulators even when wet. Nylon, plastics and vinyl are poor insulators both wet and dry.
When sleeping in cold environments, make sure your sleeping bag is kept dry. Most synthetic insulating materials lose their properties when wet. Do not sleep with your head under the covers as it will increase the humidity in the bag and make it damp, instead, wear a stocking cap to bed. Insulate yourself from the ground as much as possible, and if on a cot, insulate yourself from the cold area between the cot and the ground. Increase your activity just before bedding down as this will generate more body heat and warm your bag quicker when you climb in. Remove your clothes before bedding down and put on a clean dry pair. In the morning, before you get out of bed, bring your clothes you plan to wear into the bag to warm them and make them more comfortable to put on. Lastly, between deployments, hang your sleeping bag out so the insulation will not be compressed
More than likely, you will be sleeping on military style cots. These come in aluminum or wood frames with a canvas or nylon material as the bed. They fold to about 2 1/2 feet by 6 inches in diameter. When unfolding the cot, be careful not to pinch your fingers in the hinge. After unfolding the cot, place it on the ground and put some weight on the middle of the bed to stretch it out somewhat and make it easier to place the end poles. There are two end poles that should be in the cot bundle. Slide these into the sleeve at the end of the cot and put the pin of the cot frame into the open hole of the end pole. On the aluminum frame cots there are two different types of holes in the end pole. One is just a hole, the other has a gray plastic spacer of about 1/4" that forms the hole. When you first assemble the cot, you use the hole without the spacer. As you lie on the cot, and you feel the bed getting loose you can rotate the end poles to the holes with the spacer; first one, then the other to keep the bed tight and compensate for the material stretching. You may find it difficult to put the second of the two end poles into the pin of the cot frame. If this occurs, you can use another cots end poles or a tent stake to lever the end pole on one side into place. Be vary careful while doing this not to pinch your finger or damage the cot. If you are in an insect prone area, you can put deet on the legs of the cot to prevent insects from climbing up the cot legs.
It is preferable for DMAT leadership to try to designate sleeping areas so that each DMAT member has a cot and a personal space. This will allow individuals to place their gear under the cot and hang a gear hammock or clothesline near the cot. Some people may wish to sling mosquito netting and otherwise personalize their space. Although it may seem trivial to designate a personal space for each team member, and a cot to sleep on, this will provide a higher piece-of-mind and make the camp feel more like home. This can have a strong stress management effect and make the individual more productive.
When possible, do not use the same cot for patient and staff use. Designate some sleeping cots for team personnel and not patient use and designate some cots just for patients. Try to keep one tent for team sleeping and another tent for treatment. Don't try to house patients and staff in the same tent. There are infectious disease and health risks and in most cases the cots are not cleaned like a hospital bed between patient use.
Lastly, the night crew needs some special arrangements for sleeping. Their tent should be located at the far end of camp, away from daytime activity that may disturb their sleep. If necessary, post a guard to maintain quite around the area. Assure those who are working nights get adequate sleep. With lack of sleep comes an increase in the effects of stresses that may lead to a degradation in performance.