The following post on self-defense and medical preparedness is third in a series by Pete Farmer, who holds advanced degrees in research biology and history, and is also an RN and EMT.
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For this, the third installment of our look at self-defense and medical preparedness, we will examine some of the specific issues and problems pertaining to securing a clinic or other fixed facility during a crisis, such as in the aftermath of a natural disaster, during wartime or civil unrest, or under other atypical conditions. Rather than consider each and every possible scenario or situation that you, your colleagues, or community may face – which is beyond the scope of this series – our purpose is to think about some of the most likely problems you and your fellow health care providers may face, and stimulate additional thought on these concerns. As always, readers with specific expertise and/or experience in this subject are encouraged to contribute comments, corrections, observations, etc. as appropriate.
Whether you are a medical professional practicing your craft (doctor, nurse, pharmacist, paramedic, physical therapist, etc.) or a layperson doing your best in the absence of formally trained professionals, many of the security issues you will face operating a clinic or aid station will be similar if not identical. Let’s look at some of them…
Location: Where your clinic or aid station is sited or will be sited. Apart from the normal considerations of locating a clinic near reliable sources of power, sewerage, and clean water, other considerations enter into play quickly.
Does your building or other dwelling sit above the floodplain? Is it protected from high winds? These are important considerations when siting a clinic in the aftermath of a natural disaster.
If conditions of violence – war or civil unrest or rampant crime – pertain, how well-protected is your clinic from gunfire, shrapnel or other damage? If your facility is on or near a battlefield, it should be sited in a protected yet accessible location – far-enough from the fighting to be reasonably safe, but not so far away that your patients cannot reach you in time. The military uses the echelon system to locate medical care from the battlefield backward into the interior – primary, secondary, tertiary, and quaternary levels of care, for example. The battlefield medic or corpsman is the first echelon of care, the first responder to attend to the wounded soldier or other casualty. The casualty (exceptions may be made depending on type and severity of the case) is then typically evacuated to a battalion aid station or BAS, which delivers more sophisticated care, generally not including full surgical care. (Forward surgical teams are an exception, but will not be discussed here). Once stabilized, the casualty moves from the BAS rearward to a mobile hospital or other more comprehensive facility, such as a fixed base medical center. In general, the further forward the care is delivered, the less complex it is – there are exceptions – but the more mobile the caregivers are. As one moves rearward, the care given is generally more complex and definitive in nature. The implied trade-off is between mobility and complexity of care, although with today’s technology, such trade-offs are rarer than they once were.
For our purposes, we will need to decide what kind of care we wish to deliver, and the best place in which to deliver it. If your clinic is set up to handle trauma, and you are in a war zone, you may wish to site it closer to the action than you might if your concern is primary care.
If your clinic or aid station is operating under wartime or near-wartime conditions, an important consideration is the proximity to the enemy. Specifically, you should consider the relative likelihood of being overrun or captured. In conflicts like the Second World War, in the ETO (European Theater of Operations), Allied and Axis medical stations near the front were sometimes overrun or captured, but only rarely were their occupants harmed. Both sides usually honored the Geneva Conventions, and respected the non-combatant status of medics and their patients. In the Pacific Theater in WWII and in more recent conflicts and civil wars, however, these rules have not always been observed. Medical personnel have been targeted, and there have been fatalities and atrocities committed. Civilian medical providers are not immune; physicians with “Doctors without Borders” and other NGOs operate in at-risk areas of Africa and elsewhere, and have to be briefed on how to avoid being victimized.
Another location consideration involves operations during an epidemic or under quarantine conditions. Does your clinic need to be separated from the general population in order to quarantine certain patients? If you are providing in-patient care of the chronically ill or non-ambulatory sick, this may be a factor with conditions such as influenza or other high-communicable diseases.
Is your clinic or aid station accessible to your patients, using locally-available transportation?
If your operation is intent upon handling large numbers of patients, you will need to think about providing one or more security personnel, just as modern hospitals do, and also about crowd control and handling the flow of people in and out of your facility. Controlling access to certain parts of your clinic is probably going to be a necessity; drugs, instruments, first aid supplies etc. are all valuable targets of thieves and addicts. Moreover, just as in modern clinics and hospitals, doctors and others performing complex tasks need to be able to focus on the job at hand without worrying about unexpected interlopers barging into the examination room, treatment area, or operating room.
If you plan to have in-patient and skilled nursing care, that involves planning also. Most hospitals limit access to patients at least part of the day, per visiting hours, to allow staff members to do their work, and also to allow patients to rest. Access may be controlled depending on whether a patient has compromised immunity, a drug-resistant infection such as MRSA (Methicillin-resistant Staphylococcus aureus) or has a highly-communicable disease such as tuberculosis. Quarantine may be in effect. These factors will likely be exacerbated in a crisis, especially if refugees or displaced persons are present. If you fail to plan for this contingency, your facility can be overwhelmed quickly.
And don’t forget that your patients have friends and relatives who care about them – they will need a waiting room or similar provision. If yours is a clinic or aid station serving only a family or perhaps a small number of families, these considerations still apply.
In addition to your primary location, it is a good idea to select a secondary location in case you need to “bug out,” or leave your existing base of operations. This is in case the floodwaters rise, the earth quake has aftershocks, or the bad guys get too near your clinic.
Visibility: How visible is your clinic or aid station? How visible do you want it to be? The answer depends on what you are trying to accomplish, and the conditions under which you are operating.
If you are operating in a post-disaster scenario, such as in the aftermath of a flood or earthquake, you may wish your operation to be as visible as possible. That means putting up signage; one or more prominently displayed “red crosses” and similar measures. Directions can be posted, written in whatever the local language(s) happen to be.
If your clinic or aid station is operating in a dangerous or hostile environment, discretion may be called for as a means of lessening signs of your presence. Location becomes all the more important in such circumstances; consider also whether or not you wish to camouflage your presence so that you are less-visible from the air or from a distance on the ground. Learn the military terms cover and concealment. The former is protection against hostile fire; the latter is being hidden from observation and fire by your enemy. Ideally, you want both cover and concealment for your site. If natural or man-made concealment isn’t available, then consider using naturally-occurring or fabricated camouflage.
One fundamental way of lessening your profile is to locate your aid station behind or within a natural feature of the landscape; select a site that does not stand out against the sky. By setting up in a draw or behind a terrain feature such as a hill or under forest cover, you can take yourself out of the line of fire of direct-fire weapons with a flat trajectory, if not high-angle weapons such as mortar and indirect-fire artillery. If you have to set up on a hill, do not select a site on the top or crest, instead go just below it on the side opposite your enemy – this is called the military crest.
The point is to use sound tactical thinking; if you do not know how to do this, ask someone who does. Ideally, you want a site that permits you to do your job, but allows your security personnel or guards to do theirs – and of course you must be accessible to patients. On operations, the military often sites the aid station near headquarters, and in close proximity to communications, supply, and other necessities. Whether this model suits your needs is up to you.
In conclusion, it is in your best interest and that of your patients, to do some thinking and planning about operational security. Location and visibility are two of the critical factors involved; we will consider more of them in coming installments.
Copyright © 2012 Peter Farmer