RESUPPLY

Resupply should be categorized as Mission Critical, Mission Essential, and Mission Enhancing for planning and communicating purposes. The category of medical supply or equipment items may change depending on the mission.

- Mission Critical: There is high risk of mission failure without these items.
- Mission Essential: There may still be significant impact but less risk of mission failure if lacking these items.
- Mission Enhancing: There is low risk of mission failure if lacking these items.

The following subsets may require separate and deliberate logistical planning.

- Mission Critical, consumable: there simply are not ways to improvise shortfalls on a few things (i.e. blood products, citrate bags, IV calcium, key anesthetic medications)
- Mission Critical, durable with lifespan: replacement instruments, litters, replacement medical electronics such as ventilators, monitors, ultrasound, Doppler probe, suction, etc.

Frequent high use. May be improvised: laparotomy sponges, TCCC equipment, OR towels and drapes, dressings, flushes, syringes, IV catheters, IV tubing, HPMKs, suture, lines, tubes, pain medications, antibiotics, etc.

A best practice is to plan with the supported unit’s logistical support personnel in order to increase available assets for resupply and shorten the time required to execute. Educate the supported unit on movement requirements and limitations of critical supplies in order to facilitate timely and accurate decisions if a medical representative is not available at the higher level of command. Establish push and pull rapid resupply packages, often called “speed balls,” at the resupply base with focus on medications and expendables rather than durable equipment. Establish and practice supporting procedures in order for resupply to function well, and maintain abundant medical supply stocks for unexpected requirements. Depending on the mission, consider incorporating non-U.S. resupply resources into medical logistics planning including intergovernmental organizations, non-governmental organizations, and host nation facilities and services. Such schemes may optimize coalition or advise, assist, and accompany missions where the population at risk may be primarily host or foreign country nationals.

SPECIFIC LOGISTICAL CONCERNS

Surgical Sets

Traditional Role 2 surgical sets are bulky, difficult to access, and redundant.3,83 Surgeons and surgical technologists should work together to design sets that support their specific mission. In general, hold and evacuation times are directly proportional to the degree of care to be rendered, and subsequently, the amount of equipment required. See Appendix A for packing considerations organized by the Ruck-Truck-House model.

Anesthesia Equipment

Equipment should be mobile and adaptable to a variety of surgical cases. TIVA and regional anesthetic strategies are mobile and light. Additionally, regional anesthetics will decrease requirements for systemic pain medication and lessen the concern for airway compromise and management. The use of regional anesthesia in patients at risk for compartment syndrome is controversial; although the data is sparse, there is no evidence that peripheral nerve blocks delay the diagnosis.84

Nursing Equipment

Nursing equipment is often single use, disposable and requires frequent resupply (i.e. IV catheters, IV tubing, syringes). Careful reuse of nursing items for the same patient will minimize waste. Long term nursing supplies are not necessary since the ARSC teams do not have holding capacity and rely heavily on expeditious transport to the next level of care.

Instrument Sterilization

There are three principal methods to sterilize instruments including autoclave or steam sterilization, exposure to dry heat, and chemical antiseptics. Boiling is regarded as unreliable.85 Mechanical or steam sterilizing devices are large, require high power input, and require several hours to clean, dry, and cool instruments. If sterilization devices are not available on site, instrument sets may be autoclaved or steam sterilized at a base of operations and turned over between missions. Careful planning should be used in packaging instrument sets so that not all instruments are opened and contaminated at once.83 The minimum standard for instrument decontamination is application of enzymatic cleaner followed by disinfection with an antiseptic, which can be achieved with a number of solutions including formaldehyde, glutaraldehyde (Cidex®), or chlorhexidine. Refer to the manufacturer’s standards for time of solution contact and other considerations. In order to preserve resources, certain disposable items such as surgical staplers, clip appliers, or cautery pencils may be disinfected in chemical solution. Cautery grounding pads may be cleaned and reused with germidical wipes; while not ideal, this is the reality of the ARSC environment.

Power Requirements

The medical team must communicate power requirements to the supported element. Medical electronics and blood storage require power. Planning considerations include the size of the generator, voltage output (i.e. 110V vs 220V), maximum ampere load, optimal and maximum wattage operating ranges, type of fuel used, amount of fuel required for the mission, and maintenance plans. Other considerations include the total power required for all electrical equipment, the daily fuel consumption, and the capacity in amperes of the largest available circuit breaker needed to power a heating element or other high energy device. 110V vs 220V power outputs and devices must be carefully matched to provide adequate power to medical equipment and prevent destruction of critical electronic equipment. Be careful to maintain an ample supply of fuses for important electronic equipment. Note that each piece of equipment has unique and specific fuses that are not universal to each other and are prohibitively difficult to find on the local economy in most deployed locations. See Table 3 below for mission critical tasks and equipment that require power.

Medical Waste Disposal

Field hospital medical waste has been estimated to be an average of 1.5 to 3 kg of waste per patient per day.86 ARSC planners should anticipate considerably more waste in the ARSC setting given the critical nature of patients with wartime injuries. Team members should be sensitive to local religious customs when disposing of anatomic waste.86 The World Health Organization (WHO) recommends appropriate disposal of potentially infectious biological waste by either steam sterilization or high temperature incineration.85 Burying waste is an option but consideration should be given to avoid pollution of the environment and water sources.85-86 Establish a safe system to dispose of sharps. The International Committee of Red Cross Manual of Medical Waste Management is an excellent resource and provides specific guidance.86

Table 3: Mission critical tasks and equipment that may require power