Page 37 - JSOM Summer 2020

The following subsets may require separate and deliberate lo- Instrument Sterilization
gistical planning. There are three principal methods to sterilize instruments:
autoclave or steam sterilization, exposure to dry heat, and
• Mission Critical, consumable: There simply are not chemical antiseptics. Boiling is regarded as unreliable. Me-
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ways to improvise shortfalls of a few things (e.g., chanical- or steam-sterilizing devices are large, require high
blood products, citrate bags, IV calcium, key anesthetic power input, and require several hours to clean, dry, and cool
medications). instruments. If sterilization devices are not available on site,
• Mission Critical, durable with lifespan: replacement in- instrument sets may be autoclaved or steam sterilized at a base
struments, litters, replacement medical electronics, such of operations and turned over between missions. Careful plan-
as ventilators, monitors, ultrasound, Doppler probe, ning should be used in packaging instrument sets so not all
suction. instruments are opened and contaminated at once. The min-
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• Frequent high use: may be improvised: laparotomy imum standard for instrument decontamination is application
sponges, TCCC equipment, operating room towels and of enzymatic cleaner followed by disinfection with an antisep-
drapes, dressings, flushes, syringes, IV catheters, IV tub- tic, which can be achieved solutions such as formaldehyde,
ing, HPMKs, suture, lines, tubes, pain medications, an- glutaraldehyde (Cidex ; Johnson & Johnson, https://www
®
tibiotics, and so forth .jnj.com/), or chlorhexidine. Refer to the manufacturer’s stan-
dards for time of solution contact and other considerations.
A best practice is to plan with the supported unit’s logistical To preserve resources, certain disposable items such as surgical
support personnel to increase available assets for resupply and staplers, clip appliers, or cautery pencils may be disinfected
shorten the time required to execute. Educate the supported in chemical solution. Cautery grounding pads may be cleaned
unit on movement requirements and limitations of critical sup- and reused with germicidal wipes; although not ideal, this is
plies to facilitate timely and accurate decisions if a medical the reality of the ARSC environment.
representative is not available at the higher level of command.
Establish push-and-pull rapid-resupply packages, often called Power Requirements
“speed balls,” at the resupply base with focus on medications The medical team must communicate power requirements to
and expendables rather than durable equipment. Establish and the supported element. Medical electronics and blood stor-
practice supporting procedures for resupply to function well, age require power. Planning considerations include the size of
and maintain abundant medical supply stocks for unexpected the generator, voltage output (i.e., 110V versus 220V), max-
requirements. Depending on the mission, consider incorporat- imum ampere load, optimal and maximum wattage operat-
ing non-US resupply resources into medical logistics planning, ing ranges, type of fuel used, amount of fuel required for the
including intergovernmental organizations, nongovernmental mission, and maintenance plans. Other considerations include
organizations, and host-nation facilities and services. Such the total power required for all electrical equipment, the daily
schemes may optimize coalition or advise, assist, and accom- fuel consumption, and the capacity in amperes of the largest
pany missions where the population at risk may be primarily available circuit breaker needed to power a heating element
host or foreign country nationals. or other high energy device. Power outputs and devices (110V
versus 220V) must be carefully matched to provide adequate
Specific Logistical Concerns power to medical equipment and prevent destruction of crit-
ical electronic equipment. Be careful to maintain an ample
Surgical Sets supply of fuses for important electronic equipment. Note that
Traditional Role 2 surgical sets are bulky, difficult to access, each piece of equipment has unique and specific fuses that are
and redundant. 3,83 Surgeons and surgical technologists should not universal to each other and are prohibitively difficult to
work together to design sets that support their specific mission. find on the local economy in most deployed locations. Table 3
In general, hold and evacuation times are directly proportional lists mission-critical tasks and equipment that require power.
to the degree of care to be rendered and, subsequently, the
amount of equipment required. See Appendix A for packing Medical Waste Disposal
considerations organized by the Ruck-Truck-House model. The estimated field-hospital medical waste per patient per day
averages 1.5 to 3 kg. ARSC planners should anticipate con-
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Anesthesia Equipment siderably more waste in the ARSC setting, given the critical na-
Equipment should be mobile and adaptable to a variety of ture of patients with wartime injuries. Team members should
surgical cases. TIVA and regional anesthetic strategies are mo- be sensitive to local religious customs when disposing of an-
bile and light. In addition, regional anesthetics will decrease atomic waste. The World Health Organization recommends
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requirements for systemic pain medication and lessen the appropriate disposal of potentially infectious biological waste
concern for airway compromise and management. The use of by either steam sterilization or high temperature incineration.
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regional anesthesia in patients at risk for compartment syn- Burying waste is an option, but consideration should be given
drome is controversial; although the data are sparse, there is to avoid pollution of the environment and water sources. 85,86
no evidence that peripheral nerve blocks delay the diagnosis. 84 Establish a safe system to dispose of sharps. The International
Committee of Red Cross Manual of Medical Waste Manage-
Nursing Equipment ment is an excellent resource and provides specific guidance. 86
Nursing equipment is often single use, disposable, and re-
quires frequent resupply (e.g., IV catheters, IV tubing, sy- Documentation
ringes). Careful reuse of nursing items for the same patient will
minimize waste. Long-term nursing supplies are not necessary, Accurate and complete documentation promotes patient
because the ARSC teams do not have holding capacity and safety and facilitates patient transfer, handover, and continuity
rely heavily on expeditious transport to the next level of care. of care. Documentation is required at all levels of care and can

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