**4. Results**

Our case studies cover a variety of field hospitals deployed by the IDF. Descriptive information of the missions is described in **Table 1** and statistics is presented in **Table 2**. The studied disasters vary in their type, size, and number of casualties, addressing different types of required medical services.

All earthquakes in our case studies had a magnitude of higher than 7 on the Richter scale, associated with mass casualties and damage to local health facilities, requiring foreign assistance. FFH can confront various levels of acuity. If the number of casualties is extremely high (Haiti), one may expect confronting severely wounded patients. If the damage is mainly to the infrastructure (Nepal), one will confront more chronic conditions. It depends on the number of injured people seeking medical care, number of other FFH, how fast the team arrives, the baseline standard of care, damage to local facilities, etc.

For example, in the missions to Armenia or India, most treated casualties in the FFH were principally survivors with minor or intermediate injuries and patients with a variety of acute and chronic medical conditions seeking substitute for the non-functioning local health systems. In some cases, as in Haiti, the FFH served as a tertiary medical center, in the absence of domestic alternatives until the establishment of an appropriate substitute, in this case the floating hospital USNS Comfort [21, 22]. In the two missions to Turkey, the FFH served as a buffer and regional second echelon, relieving pressure from nearby functional local health systems [23, 24]. In Japan, due to the rather late arrival and efficient local medical and evacuation systems, the team work took the form of a primary care service.

Our study also reviews missions addressing medical needs of displaced and crowded refugees in two other countries: Kosovo, and Rwanda [25]. While the Kosovo mission addressed anticipated ongoing medical needs of such a population, the relief operation to Goma, one of many heterogeneous medical relief missions orchestrated by the UNHCR, faced overwhelming outbreak of lethal diarrheal epidemics that exceeded any reasonable capacity [26]. In addition to treating such patients this mission became a referral center for complicated patients transferred from other health facilities.

The evolution of IDF humanitarian operations started by deploying mobile clinics to disaster areas, the first time in Kefalonia (1953), and subsequently in Skopje (1963), or by joining international relief operations such as a Red Cross hospital for Cambodian refugees in Thailand in 1979 [27]. Later, it developed into the adaptable structure of FFHs where the scale was tailored to the disaster arena. The first full scale FFH was in Armenia and later in Turkey, and subsequent missions.

**63**

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

Armenia In December 1988, a 7.1 magnitude earthquake occurred in Kirovakan, Soviet Armenia.

gynecology-obstetrics, and a few acute general surgical cases.

Rwanda In July 1994, IDF deployed 3 teams sequentially for 6 weeks to Goma, Zaire, following a

Kosovo The conflict in Kosovo in the 90s escalated in 1999, causing more than one million people

The IDF medical corps deployed a field hospital to Kirovakan. The FFH team included general and orthopedic surgeons, anesthesiologists, experts in rehabilitation, internal and emergency medicine, nephrology, and pediatrics. The medical relief operation was originally designed to serve as a pediatric rehabilitation center combined with dialysis facilities, as requested by the Soviet authorities but eventually provided primary care. The majority of patients received ambulatory treatment, but there were additional trauma cases,

tribal strife in Rwanda with consequently displaced population subjected to large scale epidemics (principally cholera and dysentery) and famine. The length of the operation requiring team substitution every 2 weeks, with replacements and supplies arriving by subsequent cargo airplanes, enabling continuous prolonged operation. In each team there were experts in internal medicine and pediatrics with subspecialties, clinical microbiology/ tropical medicine, critical care, anesthesiology and neonatology, general and orthopedic surgeons, and gynecologists. The FFH comprehensive multi-disciplinary facilities provided primary and secondary care. The FFH composed of a triage unit, pediatric, medical and

from Kosovo to flee from their country to the neighboring countries of Macedonia and Albania. In April 1999, the IDF provided medical services to the refugees. The structure of the hospital was composed of several wards: emergency room, internal medicine, obstetrics and gynecology, pediatric and neonatology, delivery, pharmacy, laboratory x-ray, and security. Twenty hours after arriving in Macedonia, the FFH became functional in the Brazda camp. The IDF field hospital became the referral center for all others primary medical teams. Most of the patients were treated for infections (because of poor sanitary conditions in the refugee camps), exhaustion, and chronic illness (heart disease,

On August 17, 1999, a major earthquake (7.4 Richter) occurred in western Turkey. The city of Adapazari was severely hit. The Israeli field hospital was sent by the Israel Defense Force (IDF) command. The IDF field hospital located in Adapazari provided advanced surgical and medical services; it included trauma care and life saving surgeries and was ready to accept patients in 24 h after arrival on site. The site included 5 beds for intensive care treatment and 80 beds for general hospital admission including internal medicine, obstetrics and gynecology, and surgery. The hospital staff was overall composed of 102

In Nov 1999, an earthquake of 7.2 magnitude struck Turkey, this time in the region of Duzce. The IDF medical corps Field hospital was sent 3 days after the disaster. It functioned for 9 days, aiming to substitute for a part of the damaged medical facilities. It acted as a secondary referral center providing specialized and surgical care The hospital structure included seven clinical branches: emergency room (triage), operation room (OR), surgical intensive care unit, internal medicine, orthopedics, pediatrics, obstetrics, and gynecology. The Israeli Field hospital managed to fill the gap in the local medical system, and during its peak operation, its capacity was 300 patients per day. The field hospital focus was on secondary

in the city of Bhuj. The IDF-led relief activity in India departed within 84 h after recruiting personnel from both regular army and reserve units and initiated hospital activity at site on day six. The field hospital had a fully self-sufficient tent enactment with 30 beds and included auxiliary services units such as radiology, laboratory and medical supplies, and a logistical support unit. The total number of personnel deployed for the India operations

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

Sources: [7, 18, 17].

Sources: [7, 18, 25, 36].

diabetes, etc.). Sources: [26].

Sources: [24].

was 97. Sources: [8].

Adapazari, Turkey

Duzce, Turkey

surgical wards, and diagnostic facilities.

personnel acting as a secondary referral center.

medical care rather than primary and urgent care.

Bhuj, India On January 26, 2001, a 7.7 Richter earthquake occurred in India, with the epicenter located

Sources: [6, 16, 19, 20, 23, 28]

**Country Description of FFH**

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


*Military Engineering*

were readjusted.

**4. Results**

care service.

from other health facilities.

in the operative mode of the FFH.

rescue period, the hospital principally provided first aid and primary care for the nearby population, as the number of patients with acute and chronic medical, pediatric and neonatal conditions exceeded that of traumatic cases [20]. The heterogeneous mixture of medical staff enabled the transformations that took place

Our case studies cover a variety of field hospitals deployed by the

casualties, addressing different types of required medical services.

standard of care, damage to local facilities, etc.

IDF. Descriptive information of the missions is described in **Table 1** and statistics is presented in **Table 2**. The studied disasters vary in their type, size, and number of

All earthquakes in our case studies had a magnitude of higher than 7 on the Richter scale, associated with mass casualties and damage to local health facilities, requiring foreign assistance. FFH can confront various levels of acuity. If the number of casualties is extremely high (Haiti), one may expect confronting severely wounded patients. If the damage is mainly to the infrastructure (Nepal), one will confront more chronic conditions. It depends on the number of injured people seeking medical care, number of other FFH, how fast the team arrives, the baseline

For example, in the missions to Armenia or India, most treated casualties in the FFH were principally survivors with minor or intermediate injuries and patients with a variety of acute and chronic medical conditions seeking substitute for the non-functioning local health systems. In some cases, as in Haiti, the FFH served as a tertiary medical center, in the absence of domestic alternatives until the establishment of an appropriate substitute, in this case the floating hospital USNS Comfort [21, 22]. In the two missions to Turkey, the FFH served as a buffer and regional second echelon, relieving pressure from nearby functional local health systems [23, 24]. In Japan, due to the rather late arrival and efficient local medical and evacuation systems, the team work took the form of a primary

Our study also reviews missions addressing medical needs of displaced and crowded refugees in two other countries: Kosovo, and Rwanda [25]. While the Kosovo mission addressed anticipated ongoing medical needs of such a population, the relief operation to Goma, one of many heterogeneous medical relief missions orchestrated by the UNHCR, faced overwhelming outbreak of lethal diarrheal epidemics that exceeded any reasonable capacity [26]. In addition to treating such patients this mission became a referral center for complicated patients transferred

The evolution of IDF humanitarian operations started by deploying mobile clinics to disaster areas, the first time in Kefalonia (1953), and subsequently in Skopje (1963), or by joining international relief operations such as a Red Cross hospital for Cambodian refugees in Thailand in 1979 [27]. Later, it developed into the adaptable structure of FFHs where the scale was tailored to the disaster arena. The first full scale FFH was in Armenia and later in Turkey, and subse-

In the same way, the Haiti mission coped in the first days with injuries caused directly by the earthquake, with very busy orthopedic and surgical units, doubling the surgical capacity by cross-over mixed teams concomitantly addressing needs for various surgical disciplines. A few days later, when patients with less urgent medical needs arrived, staff assignments, organization of unites, and hospitalization policy

**62**

quent missions.


#### **Table 1.**

*Description of IDF disaster relief missions.*

All missions were self-sufficient in terms of means of transportation, fuel, drinking water and food supplies, generators and electrical supply, communication systems, tents, kitchen and laundry accessories, and equipment for mechanical maintenance, as well as with means of physical security and preventive medicine. Medical equipment and supplies were based on standard gear of field hospitals stored in military warehouses, supplemented with specific items, medications and supplies tailored for specific mission characteristics [28]. All missions were equipped with standard units for field operations, with ventilators, monitors, and defibrillators, with oxygen supply, with X-ray and ultrasound machines and with a basic diagnostic laboratory (for blood counts, urinary chemistry analysis, microbiology cultures, blood smear staining, coagulation profile, blood gases analysis, serology, and with complementary facilities as needed, such as kits for HIV detection following accidental needle sticks by personnel. There was a limited supply and storage capacity for blood products and with the means for on-site collection, and

**65**

**Country** Date (month, year)

Type of disaster

Time until initiation of FFH Duration of deployment

Number of casualties

Number of injured

Number of beds in FFH

Total number of patients

Total personnel

Physicians

Nurses Paramedics and medics

Pharmacists Radiology technicians

Laboratory technicians

**Table 2.** *Data on relief missions.*

1

1

1

1

1

1

1

1

1

1

7 1

2

1

1

4

2

18

19

2400

34 20

3

21

7

10

13

18

15

21

21

110

76

102

100

97

100

45 27 21

2 2 3

2

1

1

1

1

1

1

1

1

7

14

25

45

29

55

147

126

6000

1560

1205

2230

1223

1111

400

2686

1668

25

50

35

80

30

72

80

60

19,000

Hundreds of thousands

25,000

Hundreds of thousands

13 days

6 weeks

16 days

1 week

2627 5084

3500

166,812

250,000

2800

28,000

23,000

705

20,005

230,000

28,000

6300

9000

9 days

10 days

10 days

2 weeks

10 days

11 days

12 days

6.8 Richter earthquake

Rwandan refugees

Albanian refugees

4 days

24–36 h

63 h

6 days

89 h

2 weeks

5 days

82 h

7.6 Richter earthquake

7.2 Richter earthquake

7.7 Richter earthquake

7 Richter earthquake

9.0 Richter earthquake

Dec-88

Jul-94

Apr-99

Aug-99

Nov-99

Jan-01

Jan-10

Mar-11

Nov-13 Typhoon

7.8 Richter earthquake

Apr-15

**Armenia**

**Rwanda**

**Kosovo**

**Turkey (Adapazari)**

**Turkey (Duzce)**

**India**

**Haiti**

**Japan**

**Philippines**

**Nepal**

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

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


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

**Table 2.** *Data on relief missions.*

*Military Engineering*

Port au Prince, Haiti

**Country Description of FFH**

beds, which could be expanded to 72. Sources: [5, 6, 9, 10, 21, 22, 35, 42]

wireless services. Sources: [6, 15, 42]

care administrators. Sources: [31, 32, 37, 38]

Sources: [29, 30, 43]

*Description of IDF disaster relief missions.*

orthopedic, and imaging facility.

Japan An earthquake of 9.0 on the Richter scale struck Japan on March 11, 2011. It caused a

Philippines The typhoon Haiyan struck the Philippines on November 8, 2013. Five days after the event,

Nepal A 7.8 Richter magnitude earthquake struck Nepal on April 25, 2015. The IDF mission that

**64**

**Table 1.**

All missions were self-sufficient in terms of means of transportation, fuel, drinking water and food supplies, generators and electrical supply, communication systems, tents, kitchen and laundry accessories, and equipment for mechanical maintenance, as well as with means of physical security and preventive medicine. Medical equipment and supplies were based on standard gear of field hospitals stored in military warehouses, supplemented with specific items, medications and supplies tailored for specific mission characteristics [28]. All missions were equipped with standard units for field operations, with ventilators, monitors, and defibrillators, with oxygen supply, with X-ray and ultrasound machines and with a basic diagnostic laboratory (for blood counts, urinary chemistry analysis, microbiology cultures, blood smear staining, coagulation profile, blood gases analysis, serology, and with complementary facilities as needed, such as kits for HIV detection following accidental needle sticks by personnel. There was a limited supply and storage capacity for blood products and with the means for on-site collection, and

A 7.2 Richter magnitude earthquake struck Haiti on January 2010. The Israel Defense Medical Corps Field Hospital was on site and operational 89 h after the earthquake and provided medical care to many patients during its 10 days of operation. The hospital brought all required supplies in order to stay independent and provide fast deployment, including medical requirements such as antibiotics, imaging machines and lab facilities, and energy sources and accommodations. The Field Hospital consisted on 121 hospital staff members, divided in different units, including medical, surgical, pediatric, orthopedic, gynecologic, ambulatory and auxiliary. The capacity of the Field hospital was 60 inpatient

Tsunami that washed away 250 miles at northeast Honshu. The IDF send a delegation to build a small scale FFH in the format of clinic. Its clinic was located on the east coast in the town of Minami-Sanriku. It served mainly as a referral unit for diagnostic and medical treatment. It was staffed with 55 personnel. The structure of the FFH consisted of several wards: registration-triage and discharge, gynecology, internal medicine, laboratory, surgery, pediatrics, surgery, pharmacy, laboratory and imaging, and a logistics command center. Also, a team of 8 translators helped the FFH crew. In addition, there were an imaging crew equipped with ultrasound and X-ray, a hematology-microbiology-chemistry laboratory, and

an IDF team from Israel was assigned by the Philippines government to provide medical assistance to the city of Bogo, where a local hospital that serves more than 250,000 people was operating at partial capacity. The FFH team in the Philippines decided to combine its physical setup with the local structure and support the local medical staff with its experienced medical group, to provide maximum benefit and thereby create one integrated medical infrastructure. Although the IDF team had 25 physicians representing most medical subspecialties and first-class logistics support, they decided to relinquish sole decisionmaking authority and improvised to establish a model of cooperation with the local health

established a field hospital in Kathmandu on April 29 consisted of 126 personnel including 45 physicians. They arrived with 100 tons of equipment and supplies, and capacity to treat 200 patients per day. It was largest IDF mission deployed overseas. Its wards included 2 operating rooms, 8-bed intensive care unit, trauma, obstetrics, gynecology, surgical,

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 recovery from anesthesia [30].

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 in open fractures fixation in the Haiti mission.
