**5. Discussion**

Although each and every disaster presents unique challenges for aid teams, numerous lessons can be derived from the ten IDF missions over the last three decades. After each mission, a rigorous post-mission comprehensive review was held in order to derive lessons about decisions regarding how to improve cooperation with local healthcare providers and foreign delegations.

In general, Israel policy has been to send a large delegation and allow both local and foreign medical personal to join its team [34, 35]. For example, in the IDF field hospital in Armenia, local medical staff that could not operate the destroyed local medical facilities was incorporated in the IDF FFH, enhancing efficacy, translating, utilizing available local facilities, such as sonography and laboratory equipment, and particularly by bridging cultural and professional gaps. Local logistic systems provided warmed housing, transportation and technical aid at the site of action. In Kosovo (1999), young Albanian students volunteered to provide translations, while in Haiti (2010) eight Columbian doctors and nurses joined the surgical teams, enabling around the clock surgeries at 3–4 operating tables.

At the IDF hospital in Rwanda [36], hired locals were used as translators, in preparing local food and in feeding patients, in the preparation of oral rehydration solutions, and in additional maintenance and logistic tasks. Locals were hired in Haiti, Nepal, and the Philippines as well. This help was especially important as the numbers of hospitalized patients increased over time. Incorporating a Dutch Medical Corps company that operated a rehabilitation/convalescence department for severely debilitated patients further expanded overall capacity to about 200 beds. In meetings held at the UNHCR headquarters, representatives of the

**67**

*Healthcare Military Logistics at Disaster Regions around the World: Insights from Ten Field…*

various medical relief missions were briefed by CDC experts regarding epidemiology and susceptibility of prominent pathogens, exchanged clinical data and developed a working network of collaboration. Few examples are the conversion of the IDF FFH into a referral center for other medical facilities, the creation of an outflow tract for convalescing children without families in orphanages, a major contribution of a French Army Microbiology laboratory in the diagnosis and management of infectious diseases such as meningitis, and a help by various agencies in supple-

Intact domestic third level medical facilities at the perimeter of the disaster settings enabled transfer of treated patients. This option occasionally offered stabilized critically wounded patients better critical care than in the field conditions. For instance, in Armenia (1988), a patient with ruptured viscera, shock and hypothermia was transported by a Russian Army helicopter, escorted by Israeli and local anesthesiologists to Yerevan, following a lifesaving urgent control of internal bleeding. Air transport of treated and stabilized patients to Macedonian hospitals in the Kosovo mission (1999), and to major hospitals in Ankara and Istanbul in the Turkish earthquake disasters (1999) helped maintaining the operating capacity of the FFH at the disaster settings. Similar cooperative pattern was adopted following the disaster in Nepal (2015), with the IDF FFH in Kathmandu working in collaboration with the Nepalese Birenda Army Hospital. In Bhuj, India (2001), an IDF Hercules airplane remained at hand, providing airlift of treated casualties to remote hospitals in India. In Haiti (2010), such patients were transferred to local primary care facilities to continue with postoperative care, facilitating coping with the never-ending stream of newly admitted patients. The best way to facilitate such cooperation among medical centers is through a centralized system such as the United Nations Disaster Assessment in this event, or the UNHCR headquarters in

A totally different type of collaboration might be the incorporation of the FFH medical staff within an overwhelmed and injured local medical facility. This approach was adopted in the FFH mission to the Philippines (2013) where it was decided to combine efforts with the local facility, creating one integrated medical infrastructure [37]. The IDF delegation was integrated with the Severo Verallo memorial district hospital, an urban healthcare facility with approximately 80 beds, which was understaffed and had limited resources. The IDF 25 physicians representing most medical subspecialties, with the additional medical personnel worked under the medical and administrative direction of the local health care directors, while the logistic staff assisted the repair of the local hospital, restoring electricity, and providing much-needed supplies and equipment such as a mobile X-ray machine and an autoclave. Open discussions, held to establish clear lines of responsibility and co-sharing of tasks, helped in building trust and cooperation [38]. The mission's termination timing depended on the resolution of the disastrous event, for instance the termination of influx of patients removed from ruins in earthquake Turkish disasters, or the control of diarrheal epidemics among Rwandan refugees by the installation of appropriate water and food supplies and sanitation. Another important factor is the restoration of local health systems, as occurred in Armenia or the Philippines, or the establishment of appropriate long-lasting substitute services such as a Norwegian field hospital that settled at Goma, Zair, or the arrival of the USNS Comfort floating hospital, and other medical facilities operated by the Red cross and the University of Miami in the Haitian disaster. In such settings a handing over procedure of hospitalized patients was carried out, with their available medical data. Some convalescing but fully incapacitated patients were handed over to other non-medical local humanitarian facilities such as monasteries and orphanages. The termination of mission was coordinated with and orchestrated

*DOI: http://dx.doi.org/10.5772/intechopen.88214*

humanitarian aid to refugees.

menting medical supplies and equipment at shortage.

#### *Healthcare Military Logistics at Disaster Regions around the World: Insights from Ten Field… DOI: http://dx.doi.org/10.5772/intechopen.88214*

various medical relief missions were briefed by CDC experts regarding epidemiology and susceptibility of prominent pathogens, exchanged clinical data and developed a working network of collaboration. Few examples are the conversion of the IDF FFH into a referral center for other medical facilities, the creation of an outflow tract for convalescing children without families in orphanages, a major contribution of a French Army Microbiology laboratory in the diagnosis and management of infectious diseases such as meningitis, and a help by various agencies in supplementing medical supplies and equipment at shortage.

Intact domestic third level medical facilities at the perimeter of the disaster settings enabled transfer of treated patients. This option occasionally offered stabilized critically wounded patients better critical care than in the field conditions. For instance, in Armenia (1988), a patient with ruptured viscera, shock and hypothermia was transported by a Russian Army helicopter, escorted by Israeli and local anesthesiologists to Yerevan, following a lifesaving urgent control of internal bleeding. Air transport of treated and stabilized patients to Macedonian hospitals in the Kosovo mission (1999), and to major hospitals in Ankara and Istanbul in the Turkish earthquake disasters (1999) helped maintaining the operating capacity of the FFH at the disaster settings. Similar cooperative pattern was adopted following the disaster in Nepal (2015), with the IDF FFH in Kathmandu working in collaboration with the Nepalese Birenda Army Hospital. In Bhuj, India (2001), an IDF Hercules airplane remained at hand, providing airlift of treated casualties to remote hospitals in India. In Haiti (2010), such patients were transferred to local primary care facilities to continue with postoperative care, facilitating coping with the never-ending stream of newly admitted patients. The best way to facilitate such cooperation among medical centers is through a centralized system such as the United Nations Disaster Assessment in this event, or the UNHCR headquarters in humanitarian aid to refugees.

A totally different type of collaboration might be the incorporation of the FFH medical staff within an overwhelmed and injured local medical facility. This approach was adopted in the FFH mission to the Philippines (2013) where it was decided to combine efforts with the local facility, creating one integrated medical infrastructure [37]. The IDF delegation was integrated with the Severo Verallo memorial district hospital, an urban healthcare facility with approximately 80 beds, which was understaffed and had limited resources. The IDF 25 physicians representing most medical subspecialties, with the additional medical personnel worked under the medical and administrative direction of the local health care directors, while the logistic staff assisted the repair of the local hospital, restoring electricity, and providing much-needed supplies and equipment such as a mobile X-ray machine and an autoclave. Open discussions, held to establish clear lines of responsibility and co-sharing of tasks, helped in building trust and cooperation [38].

The mission's termination timing depended on the resolution of the disastrous event, for instance the termination of influx of patients removed from ruins in earthquake Turkish disasters, or the control of diarrheal epidemics among Rwandan refugees by the installation of appropriate water and food supplies and sanitation. Another important factor is the restoration of local health systems, as occurred in Armenia or the Philippines, or the establishment of appropriate long-lasting substitute services such as a Norwegian field hospital that settled at Goma, Zair, or the arrival of the USNS Comfort floating hospital, and other medical facilities operated by the Red cross and the University of Miami in the Haitian disaster. In such settings a handing over procedure of hospitalized patients was carried out, with their available medical data. Some convalescing but fully incapacitated patients were handed over to other non-medical local humanitarian facilities such as monasteries and orphanages. The termination of mission was coordinated with and orchestrated

*Military Engineering*

recovery from anesthesia [30].

in open fractures fixation in the Haiti mission.

tion with local healthcare providers and foreign delegations.

enabling around the clock surgeries at 3–4 operating tables.

**5. Discussion**

screening of blood products. Powered plasma, used for instance in Nepal, helped compensating for the limited storage capacity for blood products [29], and the use of ultrasound-guided nerve blocks for limb surgery saved turnover time and

An important result highlighted during the analysis was the ingredient of creativity needed in all missions with the variety of injuries and diseases they faced (disaster and non-disaster related). Crush injuries and traumatology in missions deployed to earthquake scenarios, epidemics in Rwanda, and later in Haiti, malnutrition and endemic diseases in both missions and in Kosovo, etc. In the mission to Philippines surgical interventions were considered in FFH for therapeutic, palliative, and diagnostic purposes of head and neck tumors [31]. Similarly, another example of improvisation during IDF mission to Philippines occurred when a child with a suspected brain abscess was successfully diagnosed and properly treated [32]. This complex heterogeneity required adaptations in equipment and supplies, not always foreseen, especially with altering clinical challenges. Other improvisations were the extended use of local or regional anesthesia over general anesthesia to shorten recovery periods, the primary abdominal closure with plastic infusion bags due to inflamed Shigella-related necrotizing enterocolitis requiring intestinal resection, blood donation by medical personnel to avoid HIV transmission to recipients in hyperendemic population in Rwanda and Haiti, or the use of protracted (days) ventilation with Ambu bag by hired personnel, in the case of continuous use of all available respirators. Another example of creativity is the self-production of orthopedic hardware, for instance the conversion of Steinman pins into Scentz screws with the aid of a local blacksmith and an engraving machine [33]. These screws underwent standard autoclave sterilization and proved effective

Although each and every disaster presents unique challenges for aid teams, numerous lessons can be derived from the ten IDF missions over the last three decades. After each mission, a rigorous post-mission comprehensive review was held in order to derive lessons about decisions regarding how to improve coopera-

In general, Israel policy has been to send a large delegation and allow both local and foreign medical personal to join its team [34, 35]. For example, in the IDF field hospital in Armenia, local medical staff that could not operate the destroyed local medical facilities was incorporated in the IDF FFH, enhancing efficacy, translating, utilizing available local facilities, such as sonography and laboratory equipment, and particularly by bridging cultural and professional gaps. Local logistic systems provided warmed housing, transportation and technical aid at the site of action. In Kosovo (1999), young Albanian students volunteered to provide translations, while in Haiti (2010) eight Columbian doctors and nurses joined the surgical teams,

At the IDF hospital in Rwanda [36], hired locals were used as translators, in preparing local food and in feeding patients, in the preparation of oral rehydration solutions, and in additional maintenance and logistic tasks. Locals were hired in Haiti, Nepal, and the Philippines as well. This help was especially important as the numbers of hospitalized patients increased over time. Incorporating a Dutch Medical Corps company that operated a rehabilitation/convalescence department for severely debilitated patients further expanded overall capacity to about 200 beds. In meetings held at the UNHCR headquarters, representatives of the

**66**

#### *Military Engineering*

by the local health authorities in order to ensure continuity of operations by local medical staff or newly arrived substitutes. In most cases, supplies and equipment were handed over to local health systems under the direction of local authorities.

While the selection and incorporation of drafted highly qualified medical personnel within the military framework, characteristic for the Israeli FFH model, provides excellent medical performance customized for the specific mission, this restricts the longevity of the mission, as drafted personnel are expected to resume their civil work within a relatively short period of time. Thus, most missions lasted 2–3 weeks, only. Nevertheless, as happened in the Rwandan disaster, and in other missions addressing disasters in Cambodia and in Ethiopia, substituting teams of medical experts and additional personnel were created with changing operative shifts at 2–4 weeks intervals [39]. This enabled protracted mission activity, as required.
