Protection of Hospitals

[Protection of Hospitals]
[From the U.S. Government Publishing Office, www.gpo.gov]

Medical Division
Bulletin No, 3

PROTECTION OF HOSPITALS

United States Office of Civilian Defense Washington, D. C.

Prepared by a joint committee of the council on hospital

PLANNING OF THE AMERICAN HOSPITAL ASSOCIATION AND THE

U. S. OFFICE OF CIVILIAN DEFENSE

PROTECTION OF HOSPITALS

CONTENTS

Foreword.
Section I.—Protection of Building
Fabric, Patients, and Personnel.
Sandbagging.
Protection of Basements.
Protection of First Floor.
Section II.-—Protection of Glass.
Partial Obstruction of Window Openings.
Glass in Skylights and Domes.
Adhesive Treatments for the Protection of Glass.
Section III.—Ventilation.
Section IV.—Protection Against Fire.
Fire Organization Within the Hospital.
Storage of Combustible Materials.
Protection of the Roof and Upper Floors.
Auxiliary Fire Equipment Recommended.
Incendiary Bombs and Their Control.
Magnesium Alloy Bombs.
Thermit Bombs.
Phosphorus Bombs.
Oil Bombs.
Multiple-Effect Bombs.
Fire and Evacuation Drills.
Section V.—Rescue Squad.
Section VI.—Air Raid Shelters.
Provision To Be Made for Selected Groups.
Care of Bed Patients.
Sites Suitable for Shelter Within Buildings.
Section VII.—Blackout.
Materials Suitable for Blackout.
Methods.
Curtains.
Use of Shades and Blinds.
Light Locks.
Light-Weight Screens.
Lighting Within the Hospital.
Removal of Unnecessary Bulbs.
Use of Lights of Low Intensity.
Group Control Points.

Section VIII.—Utilities.
Protection.
Organization of an Emergency Repair Squad.
Mapping Distribution of Utility Services.
Communications.
Electricity.
Water.
Heat.
Sewage.
Garbage.

Section IX.—Facilities for the Care of Patients.
Hospital Entrances.
Reception Room.
Decontamination Rooms.
Operating Rooms.
Mortuary.
Laundry.

Section X.—Distribution of Patients to Wards.

Section XI.—Unit System and Reserve Stocks.
Beds.
Linens.
Blankets.
Food.
Fuel.
Drugs and Biologicals.
Other Supplies.
Stretchers.
Radium.

Section XII.—Morale.

Section XIII.—The Ambulance
Entrance.

Appendix.

PROTECTION OF HOSPITALS

FOREWORD This publication has been pre-■ vHkilUHM pared by a joint committee of the Council on Hospital Planning, of the American Hospital Association and the U. S. Office of Civilian Defense. The committee included Dr. Robin C. Buerki, Philadelphia, and Dr. Asabel J. Hockett, New Orleans, co-chairmen; Dr. Willard C. Rappleye, New York, Dr. Anthony J. J. Rourke, San Francisco, Dr. Joseph Turner, New York, Dr. Huntington Williams, Baltimore. Dr. James M. Mackintosh, former chief medical officer of the Department of Health for Scotland, served as consultant. The protective measures recommended are presented for consideration by hospital executives. Revisions of these recommendations may be issued from time to time as new developments make them necessary.
The attention of hospital administrators and chiefs of staff is directed to the fact that all hospitals in cities exposed to enemy action are part of the Emergency Medical Service of the local and State Defense Councils and participate in the Civilian Defense program under the direction of the chief of Emergency Medical Service as integral segments of a comprehensive plan for the care of casualties. Hospital administrators should therefore acquaint themselves with the contents of Medical Division Bulletins Nos. 1 and 2 on “Emergency Medical Service for Civilian Defense” and “Equipment and Operation of Emergency Medical Field Units.”
The installation of protective devices in hospitals is essential because the damage to unprotected hospitals caused by air raids combined with a heavy casualty load might result in the collapse of the medical services. In a recent letter Maj. Gen. L. D. Gasser, U. S. Army, War Department member of the Board for Civilian Protection, said:
“From a practical standpoint, the installation of expensive protection procedures should not be undertaken except under conditions where frequent or continuous bombing can be expected.
“The military situation today does not justify any such contingency. This does not preclude the desirability in the-interest of preparedness of preparing plans so that they could be placed into operation very promptly and in an orderly manner in case of need.”
The instructions within this publication cover the general principles of procedure to be observed in planning for the protection of hospitals. Regional civilian defense authorities in all parts of the country are in close touch with corps area commanders with reference to the military situation and will apprise the local civilian defense authorities concerning the need for immediate installation of these protective measures
To integrate the activities of the various protective services, a central administrative unit called the Control Center has been established. Large cities and metropolitan areas are divided into districts and the administrative responsibili

ties of the Control Center have been decentralized by the creation of district Control Centers to govern activities within their respective zones.
The protective services are set up to function as follows:
1. The military aircraft warning service notifies a District Warning Center which in turn relays the information to the Control Center of the approach of hostile aircraft. The Control Center relays this information to the district Control Centers.
2. The district Control Center makes the necessary arrangements to introduce the blackout and places the various units of the protective service on the alert.
3. If bombs fall the Air Raid Warden notifies the district Control Center of the exact place and approximate extent of damage, and the approximate number of casualties.
4. The district Control Center directs an appropriate number of Rescue Squads and Emergency Medical Field Units (and other units as necessary, such as Demolition Squads, Fire Fighting Units, etc.), to proceed to the scene of the incident to carry out their functions.
5. Casualties, with severe injuries, following emergency care at the scene, will be dispatched to hospitals designated by the Control Center.
6. When a hospital has received a load of casualties approaching its capacity the director of the hospital will inform the Control Center of this fact. The Control Center will then direct the first aid posts and casualty stations to route casualties to other hospitals which have not yet received their quotas.
7. When all of the hospitals within or assigned to a district are approaching their full load the district Control Center will communicate this fact to the main Control Center, which will direct that casualties be routed to specific hospitals in some other district.
8. All other protective services will act similarly ; so long as the district is self sufficient it will operate as a separate unit, but assistance may be obtained from other districts when necessary by calling upon the main Control Center.
In order that movements of the various units of the Protective Services may be controlled by a single administrative authority, it is important that the operating integration of the services be worked out by frequent field drills. It is therefore urged that Emergency Medical Field Units participate in such exercises as frequently as possible.

PROTECTION OF HOSPITALS

Section I.—PROTECTION OF BUILDING FABRIC, PATIENTS, AND PERSONNEL

In estimating the possibility of damage to a hospital, the industrial, military, transportation, and administration centers near it must be taken into consideration, as well as the number of searchlights, anti-aircraft guns and other defensive

FIGURE 1.—SANDBAG BARRICADE.

weapons in the immediate vicinity. Apart from the question of damage, the extent to which the facilities of a hospital may be employed during an incident demands a careful appraisal of such factors as the population density of the area and the convenience of access to the hospital.
It is not practical to install in hospital buildings protective devices which would withstand the effects of a direct hit by a high-explosive bomb. However, considerable protection may be provided in some types of buildings without resorting to major structural change. Buildings in which the frames are built with a continuity of structure are least likely to be damaged. Steel frame

buildings are most resistant to blast and in addition are very resistant to splinters and fragments. In buildings of reinforced concrete, damage due to high-explosive bombs is usually localized, and such buildings are especially safe from a standpoint of

fire resistance. Wooden buildings are moderately resistant to blast but provide little protection from splinters and are unsafe because they cannot be made fire resistant. Buildings carried on walls of brick and concrete blocks cannot be made safe except by major structural changes. No hospital building should be abandoned for structural reasons unless it is built entirely of wood, and is a hazard even in peacetime.
If services can be concentrated on the third floor or above, there will be considerable protection against splinters from high-explosive bombs striking the ground nearby, and the danger of contamination by poison gas is reduced to a minimum.

PROTECTION OF HOSPITALS

There should be at least two floors above the point of concentration of essential services to provide protection should explosive or incendiary bombs land on the roof. In less towering institutions where the number of floors is insufficient for adequate protection, a moderate amount of safety for the housing of essential services without major structural changes may be obtained on lower floors in well-framed buildings. Sandbagging when properly carried out gives substantial protection (fig. 1), but the expense of upkeep is considerable. This measure should be regarded as a temporary expedient to be replaced as soon as possible by more permanent reinforcement.
Much can be done to protect basements and even ground floors. The greatest danger is collapse of the building or the fall of heavy debris through the floors. It is generally necessary to strengthen the ceilings of basements (and ground floors if feasible) to support debris loads that may fall upon them. British and German specifications require strengthening in masonry buildings sufficient to carry a load from 200 to 400 pounds per square foot. This is commonly achieved by the installation of tubular steel or timber struts to carry the additional weight.
In hospitals of less than three stories in height, the essential services should be set up in the basement. Basements offer the greatest protection from blast and splinters, but are very susceptible to earth shock. To minimize the danger of transmission of earth shock a barricade should

be built a foot away from the basement wall to keep personnel and equipment from contact with the wall. Such a barricade can be made of chicken wire. Basements are further liable to the risks of flooding from fractured sewers or water mains and the accumulation of war gases. The risks of fracture of steam, water, and gas pipes which traverse most hospital basements are obvious.
Protection against blast and splinters is best secured in basements by removing windows and blocking up their openings by brick work. Forced ventilation and adequate lighting must be provided.
Because of its exposed position, the ground floor cannot be completely protected against blast and splinters. It is recommended that windows be permanently occluded to a height of 6 feet 6 inches from the floor (fig. 2). The window pane above this level may be protected by lowering the window below the point of permanent occlusion or by replacing the glass with a glass substitute. It may be partially protected by wooden shutters 2 to 3 inches thick which reduce the danger from blast but will not prevent damage by bomb splinters.
On the other floors of a hospital there are two principal protection problems:
(a) Fire prevention—which will be dealt with in a later section;
(6) Protection of patients against the dangers of shattered glass.

Section II.—PROTECTION OF GLASS

The only really safe way to avoid the risk of shattered glass is to remove windows and other glass structures. This is feasible in some places and to a limited extent in others. Cubicle walls made of glass should be removed and replaced by screens. Glass structures in other obviously dangerous positions should be replaced where possible by wood or plywood.
As previously indicated, windows on lower floors can be protected by obstructing the openings to a height of 6 feet 6 inches and by inserting a glass substitute in the upper part of the sash ( fig. 2). Permanent obscuration in patients’ rooms and wards is contra-indicated because of the special need for good light.
It is important that all glass should be removed from skylights and domes. Occasionally this involves a major structural change and cannot be

carried out at a reasonable cost. In such cases the well leading to the dome should be boarded over in such a way as to minimize the danger of falling glass. In addition, to protect against the elements, the glass should receive the fabricbitumen treatment discussed later. It is impracticable to protect large plate-glass windows. The glass may be removed and the opening closed with wood in which is incorporated one or more small windows of glass or a glass substitute according to the lighting requirements.
Most of the plans suggested for preventing the splintering of glass have been found unsatisfactory for use in hospitals. Criss-crossing glass with strips of paper, tape, or gauze; or covering the entire pane with transparent paper or cellophane will not prevent shattering.
Although the fracture of glass cannot be prevented, various means can be adopted to reduce the danger of flying splinters. One effective

method consists of glueing a sheet of muslin or pieces of net curtains to the inside surface of the pane. The net or muslin should be large enough and so applied that its edges extend well beyond the pane on all sides and are firmly adherent to the sash. The materials should be pasted on with colorless glue, or flour paste with 5 percent glycerine added, and subsequently varnished. The varnish needs renewal every 3 months.

FIGURE 2—FILLED CONCRETE BLOCK BARRICADE.

Glass should be further protected by chicken wire, mesh not larger than one-half inch, to prevent flying splinters. The mesh should be installed as close as possible to the inside surface of the glass. If attached to the window frame the wire will prevent cleaning or reapplication of the treatments outlined above. The netting is, therefore, best attached to a separate frame fitted snugly against the window.
When windows have been broken by blast or projectiles, they may be replaced temporarily by light-weight screens of plywood, building paper, or wall board, which will serve to maintain the blackout and protect against the elements. The

PROTECTION OF HOSPITALS

insertion of a glass substitute to replace fractured windows will give the best permanent results. Where this is not feasible, part of the window may be replaced by glass and the remainder filled with wood. The darkening of windows has a bad psychological effect on patients, and it is therefore important to plan methods of glass protection that will permit windows in wards and patients’ rooms to be unobscured during daylight.

Bitumen-treated fabrics.—Where permanent obscuration is feasible, bitumen-treated fabrics applied to the OUTSIDE of windows or skylights will maintain obscuration in the event the glazing is fractured and will, in addition, prevent the scattering of glass fragments (except for small flakes). When used with wired glass or in conjunction with wire mesh close to the inside surface of the glass or with wood or metal battens touching the glass, weather protection is permanent. Application of bitumen-treated fabrics to skylights is equally effective. The method of application and specifications for materials are given in the appendix.

PROTECTION OF HOSPITALS

FIGURE 3—LIGHT TRAPS FOR WINDOWS.

Section III—VENTILATION

Adequate ventilation during the whole 24 hours of the day must be secured by some means. In the obscuration or replacement of windows careful thought must be given to this problem. Ordinarily, the air volume on the hospital ward should be changed at least six times an hour, and more frequently in hot weather.

In figure 3, suitable types of light traps windows are shown. These can be used whether glass is retained or replaced by a substitute. In a large ward, however, it is probable that natural ventilation will be insufficient to maintain the correct number of air changes. Some restriction of flow, probably as much as 50 percent, is unavoidable, for ventilators of this kind lose a great deal by friction and give rise to eddy currents.
The simplest and most satisfactory method of obtaining additional ventilation is to install a

large electric exhaust fan in one of the window openings from which the glass has been removed. The opening for the exhaust fan must be protected with a light lock designed so as not to render the fan ineffective because of friction.
In basements where windows have to be blocked up entirely, mechanical means alone must be relied upon to provide adequate ventilation. For specially constructed operating rooms the installation of an air conditioning apparatus should be considered.

Section IV.—PROTECTION AGAINST FIRE

Each hospital should develop an organization of fire watchers and auxiliary firemen which would be competent to deal with any emergency except a major conflagration. Such a group should be organized and trained to work not only as a unit but also as individuals so that separate fires may be attacked as soon as discovered. Local fire officials, many of whom have received training in fighting fires caused by incendiary bombs, should be consulted in the preparation of

organization and training plans for the hospital’s fire fighting staff.
A group leader should be responsible for the training and activities of the hospital auxiliary fire force. The leader should receive thorough training from the local fire department in methods of combating incipient fires. He in turn will train the auxiliary force of the hospital and select the stations to which its members are to report at the sounding of an air-raid alarm. Fire watchers’ posts should be established in such numbers and positions that all sections of the

PROTECTION OF HOSPITALS

hospital are under observation and will have adequate first-aid fire protection. Particular attention should be given to the attic or loft areas. The unit leader should instruct all employees as to the fire alarm system and evacuation drill. The leader should instruct members of the fire fighting force in the methods of handling a hose line. Where chemical extinguishers are employed, their care and use should be explained and drills in their use conducted. The leader should make regular inspection of attics, basements, wards, and storage places to see that unnecessary accumulations of combustibles are removed and that exits are kept open.
Hospital records, though valuable, are a source of danger from the fire standpoint. They should be transferred to a place of storage away from the building, especially if they occupy space in the

basement which is needed during wartime for other purposes. X-ray films are inflammable, though they may not support combustion. Those not needed should be destroyed and the remainder removed to a place of storage at a safe distance from other buildings. Storage of gasoline, ether, alcohol, and other highly inflammable chemicals requires special attention.
The woodwork of attics and upper floors of the hospital building should be made as fire resistant as possible. Several noncombustible materials have been tested for resistance against burning and heat from incendiary bombs. These can be used in loose or granular form to cover existing wood flooring or in sheet form to cover or replace it. Materials giving protection against burning by the 2-pound magnesium incendiary bomb are listed as follows:

MATERIAL MINIMUM WEIGHT PER
LAYER SQUARE FOOT
Inches Pounds
Dry sand ________ . _ ____ ____ ___ _______ .. 1% 13. 5
Brick dust____________________________________________________ ___________________ - __________ 1/2 9. 5
Slate dust______________ --- _________________ __ _ ___________ . . __ ____ ____ 1# 5. 0
Foamed slag (ground) „ --- _________ __ -__________________ . _ ____________________ 2 5. 5
Boilerhouse ash_________________ __________________________________________ __________________ 1% 6. 0
Limestone* screenings (passing %-inch screen)_________ ___ _ ______ _____________ _ 1J4 10. 0
Concrete (including cinder concrete)____________________________________________________________ 1 12 or less

’Carbonates stimulate the burning of magnesium and are not suitable for use in a removal bucket. They can, however, be used as a prot ective layer.

These substances may be spread over the attic floor or joist area and a layer of ordinary chicken wire on a frame placed above the material. Whatever material is used, care should be taken to insure that the building will stand the added weight. Interior parts of the roof structure, walls and joists may be covered with a fire-resistant plaster as an added precaution. A coat of whitewash is of value. If the building will stand the additional weight, a 2-inch layer of sand or other material should be put on the roof if the roof is flat. It should be remembered that these loose materials will blow or wash away and tend to increase in weight from the absorption of water.
All roofs and other areas where incendiary bombs may have to be combated should be made readily accessible. There should be two or more means of access to attics and to roofs on which small incendiary bombs might come to rest. This applies particularly to flat roofs, or sloped roofs with parapet walls against which a bomb deflected by the roof might lodge. Doors or passageways should be cut through all blind partitions to allow access to every square foot of the

roof and attic area. Where partitions serve as fire cutoffs such openings should be protected by fire-resistant doors.
If it is necessary to store material in the upper floors of the building, a clear aisle sufficiently wide to allow the passage of portable fire fighting equipment should extend the length of the building with numerous cross passages or transverse aisles.
The hospital should supply itself with fire fighting equipment, which should be frequently inspected to insure its constant readiness for use. The following items of equipment are recommended:
1. 12-quart buckets of water and sand and strong paper bags containing sand to be distributed throughout the hospital at each fire watcher post and each station for auxiliary firemen.
2. Pump-can tank type water extinguishers (fig. 4) also should be placed at each fire watcher station and post for auxiliary firemen. These pump-tank extinguishers should be equipped with at

PROTECTION OF HOSPITALS

least 12 feet of hose and a nozzle that will provide both a spray and a solid stream.
3. A garden hose equipped with quick-coupling connectors to fit domestic faucets should be located at stations near faucet outlets.
4. A long-han'dled, square-nosed shovel should be placed at each fire watcher station and at a majority of the auxiliary fire fighter posts.

5. While not absolutely essential, it is desirable to provide each fire watcher and each auxiliary fire fighter with heavy gloves and some type of face protector or protective goggles.
6. Each fire watcher should be furnished with a flashlight.
7. Fire axes should be placed at readily accessible points throughout the hospital and especially at fire watcher stations on the roof.

FIGURE 4.—BACK-PACK TYPE WATER-PUMP CAN.

Reports of British experience indicate that sprinkler systems are effective in dealing with fires started by incendiary bombs. If a sprinkler system has been installed it should be maintained in good condition but should not be relied upon to the exclusion of other methods of fire fighting.

Incendiary Bombs,

1. Magnesium Alloy Bombs.
The magnesium alloy type of incendiary consists of a magnesium-aluminum alloy case which contains a priming mixture, usually thermit. The priming mixture melts and ignites the magnesium case, which burns at a temperature of about 2,400 degrees F. The bombs vary in size from about 2 to 50 pounds. The 2-pound bombs have been most commonly used. They are designed to ignite upon impact. Each bomb is about 9 inches long and 2 inches in diameter.

Because of the limited power of penetration of smaller sized magnesium alloy bombs, they tend to lodge on the roofs or upper floors of buildings. They rapidly burn through a floor, because of the intense heat generated, and drop to the floor below. To control the fire and limit its spread, prompt action must be taken. The heat prevents the fire fighter from approaching the bomb closely. To do so is dangerous, especially during the first minute when the priming mixture burns with such violence that a mass of sparks and molten metal may scatter for as much as 20 feet around the bomb. After the priming mixture has burned, the bomb can be dealt with. The fire fighter should hold a table, chair, or similar shield in front of him while fighting the incendiary.
At least two persons are needed to handle an incendiary bomb by using a pump tank ex

PROTECTION OF HOSPITALS

tinguisher—one to use the hose and one to work the pump. It is a great advantage to have a third helper to carry buckets of water. Two persons can manage, however, and even one person alone if he tackles the job soon enough.
The fire fighter must decide in each case whether to deal first with the fire or the bomb itself. If the fire has gained considerable headway, it should be brought under control first. If it has not progressed appreciably the bomb should receive first attention. In the presence of large amounts of smoke, the fire fighter should keep

FIGURE 5.—MAGNESIUM INCENDIARY BOMB.

his head as close to the floor as possible. It will usually take from 5 to 6 gallons of water to deal with the bomb alone, so that at least 10 gallons of water should be available to control the bomb and the fire it has started. A solid stream of water should be used to control the fire around the bomb, but not against the bomb itself.
On the bomb itself, a fine spray of water is used. This does not extinguish the bomb, but causes it to burn more rapidly. The 2-pound bomb will normally burn from 10 to 15 minutes, but when it is sprayed with water the burning time is reduced to 2 or 3 minutes. When water is added to a burning magnesium bomb hydrogen is formed. This burns harmlessly if the water is added slowly in the form of a spray,

but if a solid stream is used, the hydrogen is formed in such quantities that an explosion may occur.
Dry sand or earth in pails may also be used in combating magnesium alloy bombs. The bomb should not be attacked until after the first minute, during which time the priming mixture burns itself out. A protecting screen, a chair, table, or other suitable object, is held in front of the fire fighter, who goes as close to the bomb as he can and throws the sand over it. He uses a long-handled shovel to raise the bomb on the bed of sand if he can approach near enough. The sand over and around the bomb reduces the amount of heat given off and shields the dazzling glare of the burning metal. A bomb thus covered is not extinguished and will burn through the floor in a few minutes unless removed. Using the shovel, the fighter may be able to scoop up the bomb and place it in the sand pail. This bucket should have in it a 4-inch layer of sand to prevent the bomb from burning through the bottom before it can be removed from the building.
Chemical extinguishers: Carbon tetrachloride extinguishers should never be used on thermit, or magnesium bombs, as phosgene may be formed by reaction with the molten metal. Soda acid and foam type extinguishers are effective but no more so than water alone. Since it requires 5 or 6 gallons of water to deal with a single 2-pound bomb, several 2 ^-gallon hand extinguishers would be required. Carbon dioxide extinguishers have been found ineffective.

2. Thermit Bombs.
Thermit consists principally of a mixture of powdered aluminum and iron oxide. This mixture when ignited reacts chemically to form molten iron, which acts as the incendiary in igniting adjacent combustible material. The chemical reaction is very rapid and violent. As a direct incendiary agent, thermit is not as effective as magnesium alloy. A 10-pound thermit bomb expends itself in slightly less than a minute. The mass of molten iron set free burns through floors and ceilings very rapidly. Water is useless against burning thermit, which obtains oxygen from the iron oxide of the mixture. It burns itself out when ignited. The fire fighter should attack the fire with a regular hose stream and call the local fire department if necessary.

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3. Phosphorus Bombs.
A small explosive charge is usually incorporated in phosphorus bombs to scatter the incendiary agent, starting small fires simultaneously in a number of places. White phosphorus ignites spontaneously on exposure to air. The pellets have a low combustion temperature and may set fire to easily combustible material, but are ineffective on planks or heavy wood construction. Burning phosphorus may be extinguished with plain water, or it may be sprayed with a copper sulphate solution, which causes a thin coat of copper phosphide to be deposited over the pellets. Whether extinguished by water or chemical, all the pellets must be removed and disposed of by burning. If a pellet treated with copper is not removed, it may be stepped upon or otherwise abraded so that it will cause another fire. Care should be exercised in dealing with phosphorus because painful burns will result if it comes in contact with the skin and also because systemic absorption is harmful. The intense white smoke produced by burning phosphorus may prove slightly irritating to the nose and throat, but it is harmless.

4. Oil Bombs.
Oil bombs are usually composed of a solid inflammable oil such as aluminum stearate mixed with a highly combustible material such as gasoline or kerosene. The oils may be ignited by a small incendiary unit. Finely divided metallic sodium or potassium may be added to reignite the oil in case it comes in contact with water. Oil bombs are usually reserved for military objectives. Fires caused by oil bombs present the same problem as the ordinary oil fire. The burning oil must be smothered with some noncombustible material such as steam, fine water spray, or foam, while the fire beyond the limits of the oil is either smothered or extinguished with water. An oil bomb containing metallic sodium or potassium may be encountered. The best method of dealing with such a bomb is to smother it with sand or let it burn itself out while keeping the surrounding area wet but allowing no water to reach the bomb.

5. Multiple-Effect Bombs.,
This is usually a large bomb containing many small incendiary units with the interstices between the units filled with phosphorus or oil. The large bomb usually penetrates the building after

which the case is ruptured by an explosive charge which ignites and scatters the smaller incendiary units and materials. Each unit must be dealt with individually as previously described.

Eire and Evacuation Drills.

Every hospital should institute at once a system of fire and evacuation drills with practices held at frequent intervals. Certain considerations deserve special attention:
1. Patients must not [be upset by frequent alarms and drills.
2. The hospital staff changes every 8 or 12 hours and there must be trained forces for each shift of duty.
The disturbing noise of alarms should be avoided as far as possible by having an alarm system so designed that the ’signals will sound only in departmental offices, engine room, auxiliary fire fighting stations, and other important central locations.
All exits from the hospital must be inspected. The doors should open outward and several exits should be available lest some be blocked by debris. Additional exits may be provided by removing windows at convenient points and replacing them with shutters. All exit openings must be large enough to take stretchers and even mattresses, if patients are moved in this way.
In anticipation of the possible need for evacuation of a hospital, ambulatory and convalescent patients should be housed as far as possible on upper floors, the lower floors being reserved for wheel chair and stretcher patients.
During the evacuation drill ambulatory patients put on dressing gowns and slippers, pick up their blankets, and leave the building accompanied by a few attendants. Patients in wheel chairs follow and patients on stretchers leave the hospital last. Wheel chair and stretcher patients should be accompanied by a suitable number of attendants.
A nurse, orderly, or ambulatory patient should be assigned to each bed occupied by a wheel chair patient to help patients from their beds to wheel chairs. Sufficient help must be provided to move stretcher patients. If frequent and sustained bombing is anticipated stretcher patients should be nursed with canvas stretchers under the bottom sheet or four or five strong canvas loops may be attached to the mattress so that it may be used as a stretcher.

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No specific directions have been given in this section on the details of hospital evacuation and fire drills because such details depend upon the structural characteristics of the individual hospital.

Section V. —RESCUE SQUAD

A rescue squad should be organized within the hospital along the lines recommended in the Handbook for Rescue Squads, a copy of which may be procured from your local or State Defense Council. The rescue squad is responsible for the extrication of persons from points of special danger. The members should also notify the police of the location of unexploded bombs, rope off the danger area, and notify the telephone switchboard. The squad should be composed of a leader and four or five members, all of whom should be from the service department and should understand utilities and construction. The utility repair squad discussed in a later section may also act as a rescue squad.

Section VI. —AIR RAID SHELTERS

The provision of complete protection for all patients and members of staff is seldom possible. Certain measures of protection have already been suggested, but actual shelter provision should be confined to the following groups:
(a) Those who are performing essential services on which the functioning of the hospital depends, e. g., telephone operators, emergency operatingroom staff, and certain key administrative officers, air raid wardens, etc.
(b) Nursing and domestic staff who are off duty.
(c) A limited number of ambulant patients who can easily be transferred to shelter.
Bed patients should be moved into corridors away from the immediate vicinity of windows and covered as far as possible with bed clothes, bed tables, and other materials that offer protection against splinters.
Shelters within buildings are readily accessible, can be made comfortable, and can be provided with the usual services.
The sites previously discussed as being suitable for the housing of essential services within the hospital are also suitable for air raid shelters.
Shelters within buildings should be well isolated from light and elevator shafts, Several small

shelters are preferable to a single large one and not more than fifty persons should be assigned to any single shelter.
If an air conditioning system is not installed, ventilation must be provided in some other way. The inlet for such a system should be not less than twenty-five feet above the ground or other horizontal surface which might become contaminated by gas. Steam, gas, and water pipes and those carrying refrigerants should not traverse or enter the shelter because of the danger of fracture. The ideal heating system is electrical. If steam or hot water must be used to heat the shelter, valves should be so labeled that a patient could manipulate them. If space is limited, shelves can be built around the wall to hold bassinets for babies and bunks with sides for small children. A barricade of chicken wire should be placed six inches from the wall to prevent the transmission of shock from the wall. Some provision should be made for hot drinks and emergency feeding. Drugs and dressings to be used in an emergency should be kept in the shelter under lock and key.

Section VIL—BLACKOUT

The blackout introduces the problem of preventing the egress of light, no matter how small and faint, which might be seen from the outside, and at the same time maintaining sufficient light for the performance of essential services within the hospital.
As already described, skylights and domes should be boarded over with timbers which have been fireproofed, or the glass should be protected by the bitumen-fabric treatment.
Shades and curtains already in use are not likely to be satisfactory for blackout purposes, since for a successful blackout they must extend at least six inches beyond the frames on each side and at the top and bottom. Any sort of black cloth which is opaque to light can be used, and this property should be tested not by daylight but by holding the cloth against a strong electric bulb to make certain that no light whatever shines through it. In addition to its property of opacity, the material should possess durability, permanence of dye, mechanical strength, resis-

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tance to heat and dampness, and should preferably be noninflammable. The best kind of curtain is made in a single piece. It is hung on one side of the window in such a way that it can be drawn across from side to side without a parting in the middle. The free end can be fixed to the wall by snap fasteners. The other side is fixed permanently to the wall with a thin strip of wood. The upper edge is supported on a piece of picture wire.
Very large windows can be covered with strips of carpet stitched together and attached to a strong roller. If new shades or blinds are procured, they should be large enough to overlap the whole window opening by 6 inches on each side or be enclosed in box fittings. Tarpaulins should be kept in reserve as temporary covers to prevent exposure of light in the event that the existing arrangements are destroyed during a raid.
An additional blackout precaution is to paint an area about 12 inches wide around the window frame with matt black paint to minimize the reflection of light. A simple light trap can be constructed by using strips of beaver board or similar material 4 to 6 inches wide in the form of a box to guard against the escape of light through cracks above or around shades or curtains (fig. 6).

For rooms in constant use for administrative purposes it will often be more economical in the long run to provide well-fitting light-weight screens which can be put aside in the hours of daylight (fig. 7).
Doors opening to the outside must be protected against the escape of light. While the use of double windowless dbors is sometimes feasible, the provision of a light lock is generally much more satisfactory. The examples illustrated in figure 8 are easily constructed, using either canvas or wood. Light locks through which patients are admitted must, of course, be large enough to take stretchers easily.

Lighting Within the Hospital.

The interior of the hospital should be examined by night in order to determine what lights can be entirely eliminated without loss of efficiency. Unnecessary bulbs should then be removed. Lights of reduced candlepower can be substituted for bright lights in corridors and other places where good lighting is not a necessity. The use of small bulbs screwed into baseboards should also be considered, and lights which can be dimmed by the use of resistance coils can be installed in wards and siderooms, Reduced in

FIGURE 6—TEMPORARY IMPROVISED SCREEN BLIND (WINDOW SHADE).

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tensity lights protected by louvers to deflect radiation downward are commercially available for blackout for use inside or outside of buildings.
Cylindrical tubing of tin or cardboard, cut to the proper size, can be placed over unprotected bulbs to throw light downward in a circle and prevent the rays from spreading. Desk lights should be equipped with opaque shades.
In accident rooms, where good light is essential, the blackout arrangements should be carried out with scrupulous care. Entrances—which should be provided with light locks—can be indicated by white incandescent bulbs of low intensity properly hooded or by signs as illustrated in figure 9. Direction signs can be marked by broad, heavily painted white stripes a few inches above the floor or street level.
It is desirable that lights be connected to group control switches distributed throughout the hospital so that they can be extinguished instantly in the event of damage to the premises causing exposure of lighting. On the receipt of an air raid warning, all lights except those essential for the operation of the hospital should be extinguished as soon as the precautions for protection, evacuation to shelters, etc., have been carried out. The work required to complete blackout arrangements in a hospital is difficult and time consuming. Hospitals should be in a position to complete their lighting restriction measures on a few hours’ notice. The preparation of equipment cannot be deferred until lighting restrictions take effect.
When lighting restrictions have been introduced, every window, transom, and door should be individually inspected, to be certain that the blackout is complete. The inspection should be carried on outside the building by competent, reliable observers, who preferably have had nothing to do with the installation of blackout devices. The inspection must be carried out routinely and repeatedly, to be certain that precautions are not being relaxed. These tests made by the hospitals themselves are in addition to the surveys which will be carried out under the jurisdiction of air raid wardens.
The State and local defense councils will provide the general rules for blackout. These should be posted in conspicuous places throughout the hospital, and should be supplemented by such rules as the hospital authorities may make for the behavior of patients and staff.

FIGURE 7.
INEXPENSIVE FORM OF LIGHT-WEIGHT SCREEN

Section VIII.—UTILITIES

1. Protection,

Although the maintenance of essential services, including the telephone, is the joint responsibility of utility companies and the State and local defense authorities, the hospital must also play [its part. The hospital should organize an emergency repair squad whose duties should include shutting off illuminating gas, refrigerant, steam, and non-essential electric lines and making such emergency repairs as may be required to limit damage or loss. The dispatch of this crew should be handled by the control office within the hospital. The crew should be composed of a foreman and four or five men selected from personnel normally performing the repair work of the hospital. This same group may serve as a rescue squad, the functions of which have already been discussed.
Most hospitals already have plans showing the distribution of their essential services, such as electricity, heat, water, telephone and sewage.

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FIGURE 8—EXTERNAL REMOVABLE LIGHT LOCKS.

If plans do not already exist, they should be made promptly. Important valves, flanges, switches, etc., should be identified by special colors, preferably corresponding to the code of the American Society of Mechanical Engineers. The plans, code colors, and other essential data should be available in several parts of the hospital and there should be in the hospital at all times, day and night, at least one person who knows where they are and how to interpret them.
In the event of a break-down of the essential utilities within the hospital, every effort should be made to restore service as quickly as possible. Reinforcement of the walls and roofs housing the engine room, sandbagging the points of entrance and exit of pipes, drains, and cables is of value. Pipes should be valved at their point of entrance to the building. The telephone switchboard, which is especially sensitive to earth shock, should be placed well away from walls which might transmit the shock and on the second or third floors of buildings of 5 or more stories.

2. Communications,

The private branch exchange, such as is used in most hospitals, is often powered with batteries, but the entire telephone system within the hospital may be disrupted or destroyed. Special messengers may be needed for communications both inside and outside the hospital, and arrangements for their services should be made through the communications officer at the Control Center.

3. Electricity.

The estimated peak demand of one-half kilowatt per bed per day, half of which is for laundry purposes, may far exceed the amount of electric current which can be furnished in an emergency. If a power generator is to be procured it should provide sufficient current to supply:
1. Lighting for emergency operating rooms, essential corridors, control office, telephone exchange, and reception rooms.
2. At least one elevator.
Small power plants are adequate to maintain services of this extent for short periods of time. Be-

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FIGURE 9.—DIRECTION AND LOCATION SIGNS.

cause of the amount of power required it is rarely practical to operate the X-ray department if the public electric supply is interrupted. Auxiliary electric systems should be tested out once a week or at least once a month to ascertain whether they are in proper condition.
Provision for lighting at essential points should be made in case the auxiliary system is destroyed. Portable operating-room lights powered by indi-

vidual batteries have proved satisfactory and many hospitals already possess them. Dry cell batteries deteriorate after a time, and British experience would indicate that the accumulator type of battery is to be favored. Open flame illumination by candles, lamps, etc., is dangerous and should not be used except as a last resort. Employees should be supplied with flashlights, the condition of which should be checked periodically. The use of flashlights must conform to regulations of the blackout.

4. Water.

Hospital administrators should request the advice of municipal water departments as to how their water supply can best be protected and be supplemented by auxiliary supplies. In some instances this may be accomplished by tapping additional water mains. Steps to provide auxiliary water supplies for drinking or fire protection should be undertaken only under supervision and with approval of State and local health departments.
Hospitals should make plans for the conservation of water in event of emergency. Emergency

water rations for use in shelters and wards can be stored in bottles. Static water storage on the premises in tanks and other reservoirs that can be made available for fire protection and other purposes should be utilized as far as possible.

5. Heat.

Failure of the central heating system will require the temporary use of improvised heaters, such as gas jets and kerosene or gasoline stoves or lamps. All windows may be closed to conserve heat. This closing of windows, combined with the often inadequate ventilation resulting from blackout, creates a definite hazard from the possible formation of toxic concentrations of carbon monoxide when such direct combustion heaters are used. The danger of fire from careless handling of such heating devices should not be overlooked.

6. Sewage.

If the water supply is interrupted, the water-carried waste disposal system will not function. Consequently every hospital should, with the assistance of the State and local health depart

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ments, plan and develop emergency collection by pail service. If buckets are used, at least one for each 50 patients should be provided.; Prearranged plans for disposal should be agreed upon with the proper public officials.
Broken sewer pipes will not in general require special action by hospital officials except in cases where drainage is involved, with flooding of basements and contamination of water or food. Details of dealing with such a situation cannot be given here as they will be peculiar to each incident. When drainage is not interrupted, the water-carried waste disposal system will generally be used regardless of the condition of the sewer.

7. Garbage.

In emergency conditions an interruption of garbage collections may be anticipated. Garbage suitable for swine may be accumulated for their use subject to the regulations of the sanitary code. What remains should be incinerated. Hospitals which do not already have an incinerator should consider the advisability of securing one. Incineration must be carried out in such a way that it does not violate the regulations of the blackout. It is advisable to consult the local or State health department in regard to emergency disposal of garbage. Burying and hauling are possibilities.

Section IX.—FACILITIES FOR THE CARE OF PATIENTS

Hospitals intended for the immediate treatment of air raid casualties should organize facilities so as to provide the following:

1. Hospital Entrances.

Entrances and routes for walking cases, stretcher cases, and casualties contaminated with gas should be clearly marked.
Wherever it is possible separate entrances and approaches to the hospital should be provided for stretcher cases, ambulatory patients, and those suffering from the effects of gas. Gatemen posted before the hospital should direct the patients to their proper entrance. Where only one entrance is available the three types of casualties must be directed to separate admitting rooms, one for gas contaminated cases, one for

walking injured, and one for stretcher cases. If it is impossible to provide more than two admitting rooms, stretcher and ambulatory cases can be assigned' to one and gas cases to the other. If only one admitting room is possible, no person contaminated with persistent gas should be permitted to enter unless the hospital is reserved for the care of those injured by persistent gases, in which case other casualties should be refused admission.
The admitting entrance to the hospital should be wide enough to admit an ambulance easily. To assist ambulance drivers working under the conditions of the blackout, the following markings should be applied with white paint to indicate the route to the admitting entrance:
(a) Interrupted lines in lengths of 1 foot with 1-foot gaps on vertical objects such as trees and corners of buildings; and on horizontal faces of curbs at intersections, corners, and places where road widths alter abruptly.
(6) A continuous white line down the middle of the drive. Arrows or other suitable markings should be used to indicate points at which ambulances are to stop and back to the reception platform. Similar white arrows should be used to direct ambulances to the exit.
Such devices, though suitable for lighted vehicles, will not serve to give directions to walking cases. Illuminated signs equipped with approved hoods should be used to indicate both the main entrance to the hospital and the entrances to be used for walking wounded and contaminated cases.

2. Reception Room.

In the event of an air raid it should be anticipated that patients will be brought to the hospital in large numbers. The reception room must, therefore, be commodious and so arranged that members of the staff can keep all the patients in it under continuous observation. In larger hospitals it may be more efficient to provide separate rooms for males and females, but in small units this increases the number of staff required to handle patients to such an extent as to interfere with the operation of the hospital as a whole. In such cases separation by screens is sufficient if separate toilet accommodations are provided.
The reception room serves three main purposes:

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(a) As a waiting and observation room before distribution of patients to operating rooms, wards, etc.
(6) For making and checking records.
(c) For the continuous supervision and sorting of cases requiring resuscitation or other forms of urgent treatment. This function must be carried out by an experienced physician.
Because of the nature of the work for which the reception room is to be used, it should be closely related to the resuscitation and transfusion rooms and to the minor surgery room.

3. Decontamination Dooms,

The subject of chemical warfare is discussed extensively in “First Aid in the Prevention and Treatment of Chemical Casualties” and “Protection Against Gas,” published by the U. S. Office of Civilian Defense, copies of which may be secured from State Defense Councils. Only the arrangement and not the operation of the decontamination rooms will be discussed here.
Decontamination stations for walking cases are most efficient when separated from the hospital. Seriously injured patients may be brought to the hospital in a contaminated state, however, and it is necessary for hospitals to arrange to accommodate them. The arrangements of the decontamination station are portrayed in a diagram in “First Aid in the Prevention and Treatment of Chemical Casualties.”
The arrangement of the decontamination station need not be elaborate, but certain essential features must be provided. These include a room in which contaminated clothing may be removed and stored in bins, a second room where the cleansing is carried out, and a third room where patients can be reclothed and temporary dressings applied to wounds. From this point patients should be sent to the minor surgery clinic, to the resuscitation room, directly to a hospital ward, or elsewhere as indicated.
Attendants in the gas decontamination room wear masks, special gasproof gloves and clothing. Ordinary rubber gloves are not gasproof. Gasproof clothing is awkward to work in, and repeated rehearsals are necessary. Also, it is liable to deteriorate, and must be inspected at regular intervals. The Army gas mask furnishes effective

protection to the lungs and eyes against every type of gas likely to be used by the enemy.
Bandage scissors provided for the decontamination room must have unusually large finger holes, to permit their use with the type of gloves which must be worn.
The ventilation of the decontamination room must be adequate to prevent the accumulation of gases. After use, the room must be scrubbed with chloride of lime; the walls and floors must be hosed, and the room left open to the air for 24 hours or more.
Methods have been devised by which those in the field can be taught to recognize and distinguish gases by their odors and general characteristics. The clinician far away from the field of activity, however, will frequently be confronted with the need for differential diagnosis on the basis of signs alone. It is essential that differential diagnostic criteria be understood so that contaminated patients will not be admitted to the hospital and so that persons suffering from the effects of nonpersistent gases will not be subjected to decontamination procedures which might jeopardize their lives.
A rule of thumb diagnosis may be made on the following bases:
1. Is the patient wearing a mask?
2. Is the patient breathing easily? (Patients wearing a mask will be breathing easily. Patients suffering from lungdamaging gas cannot stand the restriction of respiration caused by a mask.)
3. Is there any sign of cyanosis?
If the patient is breathing easily, and has no cyanosis, treat for persistent gas. If the patient is breathing with difficulty treat for phosgene.

4. Operating Dooms.

Operating rooms situated on the top floor with large windows and skylights are obviously unsuitable for use during air raids. It will be necessary to plan alternative rooms for use in the event of an emergency. Such rooms should be on the protected lower floors or in the basement. They should be as convenient as possible to the reception room. Taking into consideration the number of staff men who will be available to man them, the number of rooms provided should be in proportion to the number of casualties which may be expected. If it is anticipated that the period of

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emergency may be prolonged it may be worthwhile to consider the installation of an air conditioner. In any case proper ventilation should be provided. The emergency operating rooms should be large enough to hold two tables at a time. One anaesthetist can then handle two cases. The number of nurses required is likewise proportionately reduced.
Because of the high percentage of fracture cases among air raid casualties, special provision should be made for them. This may mean adding to the number of fracture tables and fracture beds already in the possession of the hospital. If the closed treatment of wounds is to be used, plaster equipment will be required.

5. Mortuary.

Experience in air raids has indicated that the death rate may be 30 to 50 percent of all casualties. While many of the victims may be pronounced dead at the scene of the incident and taken directly to the public morgue, some will reach the hospital in a moribund state and others may die after admission.
Those who die en route to the hospital should be removed immediately to the mortuary, both to spare the feelings of the living and to make room for those for whom something can be done. Because of the need for all available space to accommodate the injured, the mortuary should be in a separate building adjacent to the hospital if possible. Identification should, if possible, be made before the victim is transferred to the mortuary.
The importance of securing additional staff for mortuary work should be stressed. Nurses, whose services should be devoted entirely to the care of the living, should not be used to attend the dead. The work of identification, even on the wards, should be carried out by trained lay workers. Bodies should be properly prepared before being shown to relatives or friends.
The importance of postmortem examinations should not be forgotten and permission should be sought in all feasible cases.

6. Laundry,

Usually it will not be practical to expand the existing laundry facilities of the hospital because of the expense involved and the difficulty in procuring the needed equipment. As it is difficult to determine the extent to which expansion of

facilities may be required, it is usually more economical to utilize the services of commercial laundries. The capacity of the existing hospital laundries can be expanded by shortening the washing formula, though this should not be carried beyond the point of safety.

Section X.—DISTRIBUTION OF PATIENTS TO WARDS

Patients should be distributed to the various wards by the admitting officer. To lessen the strain on the nursing staff, severely injured patients should be evenly distributed over several wards. It is particularly’unwise to assign many burn cases to a single ward because of the nursing demands of such cases. For psychological reasons a special ward should be reserved for obviously moribund patients.

Section XI.—UNIT SYSTEM AND RESERVE STOCKS

The various departments of the hospital must anticipate the possibility that part or all of their working supplies may be destroyed or otherwise rendered unusable through accident. This applies to the pharmacy, emergency operating rooms, reception room, delivery rooms, etc. A plan should be prepared whereby activities could be carried out at some other location should the original quarters or equipment of any department be destroyed.
Such a plan would necessitate the maintenance of reserve stocks of essential items. Before additional supplies and equipment for this purpose are purchased, a careful survey should be conducted to determine what equipment and supplies are on hand and what could serve as substitutes. Purchases should not exceed the anticipated demands of the hospital. It would be advisable to plan a program of this nature on a long-range basis, with purchases systematically spaced as funds are available.
Hospitals in the same community could profitably undertake such a program as a joint project, since it is unlikely that all of the hospitals of a community would be seriously damaged in an air raid. Stores should include folding beds, mattresses,

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linens, blankets and drugs, which should be placed in a central depository and drawn upon as needed by the various members of the pool.

I. Beds»

An adequate number of folding beds should be on hand so that they may be put up in the places selected at the time of the survey of the hospital. They should not be set up permanently until required, but rehearsals should be carried out so that the procedure can be expedited when the need arises. Because of the number of fracture cases which can be expected among air raid casualties, it would be wise to increase the number of fracture beds.

2. Linens»

The amount of bed linen to be laid in should be sufficient to supply the increased bed capacity of the hospital and for the expanded reception and operating-room facilities.

3» Blankets»

There is a very high incidence of shock among air raid victims, and the stocks of blankets should therefore be increased. An adequate number should be on hand to meet the demands of the increased bed capacity, the work in the reception and operating rooms and the ambulance transport.

4» Food»

A supply of nonperishable foods should be laid away in a special larder, preferably in a safe place in the hospital. The food in this larder should not be used except in emergency. As boxed or canned foods are used up they should be replaced systematic ally.
On account of the danger of contamination of food by chemical warfare agents, stores of food should not be kept in the open. If stored in warehouses, they should be placed on the upper floors where gas is least likely to reach them. Meat in cold storage is generally regarded as safe from contamination by gas. If it is suspected that food has been contaminated, samples should be submitted to the health department for investigation.

5. Fuel»

Supplies of fuel should be accumulated to meet the demands of a possible emergency, taking into consideration the space for storage.

3» Drugs and Biologicals.

Many drugs now in common use are likely to become scarce because the source of supply has been or may be cut off. Although the justifiable use of drugs should not be curtailed, unnecessary use should be avoided so as to conserve our limited supply.
Drugs which are likely to be needed in large quantities include the sulphonamides, morphine, tannic acid, gentian violet, sera of various types (particularly for tetanus and gas gangrene), oxygen, and the intravenous solutions, glucose and saline.
The need for blood for transfusion (both whole blood and plasma or serum) raises the question of establishing a blood bank within the hospital. It may be practical in some instances for a single hospital to serve as the collecting and distributing agent for a number of neighboring institutions. In any case, each hospital must have facilities for the storage of blood or plasma for transfusion purposes.

7» Other Supplies»

The incidence of shock in air raid victims emphasizes the importance of having an adequate supply of hot water bottles and heat cradles.
Because wounds in air raid victims are extensive and often multiple it will generally be necessary to increase the equipment needed to sterilize dressings, the number of dressing carts and the * supply of dressings on hand.
To care for the large lacerated wounds of the extremities so common in air raid victims, an unusually large store of plaster of paris bandages and splints should be provided. Additional oiled silk may be needed for the treatment of burns, depending on the form of treatment to be followed.
Provision of special instruments for the operating room should be held to the minimum. Surgeons should be encouraged to improvise or to get along with less complex and more easily procured equipment.
Other equipment which will probably be needed in excess of peacetime demands includes nasal catheters (for oxygen), BLB or similar masks, and blood pressure cuffs. It will generally not be necessary to purchase any extra sphygmomanometers although an additional supply of cuffs is needed; these can be left in place on patients under observation and plugged into the sphygmomanometer gauge as needed.

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A reserve of parts which are likely to break down in electrical or plumbing equipment should be available.
Supplies of cigarettes and hard candy should be on hand in the part of the building to be used as an air raid shelter.
A number of large city hospitals carry a considerable quantity of apparatus and equipment which in time of war would be difficult to replace. Such hospitals may be obliged to reduce their bed capacity and perhaps abandon operating rooms because of their exposed position. To conserve valuable supplies it is suggested that they be transferred to safe areas or loaned to base hospitals affiliated with the central unit. Such equipment might include portable X-ray apparatus, microscopes, incubators, centrifuges, etc.

0. Stretchers,

A large number of stretchers will be required for patients brought to the hospital and for a reserve supply so that ambulances need not be delayed while stretchers brought in by them are unloaded. Stretchers should combine the features of durability, comfort, and low cost.

9. Radium.

Special consideration must be given to the protection of radium, not only because of its financial and therapeutic value, but also because it is dangerous if dispersed. The amount of radium possessed by any institution is usually small, and the containers in which it is kept are also small. The blast of high-explosive bombs may hurl the containers to great distances, making location difficult, or a container may be broken and its contents dispersed. In that event, the buildings and sites of dispersal would be unsafe for many years unless cleared by specially protected workers. Until then it would probably be safer to abandon them, for prolonged exposure to even small amounts of radium is dangerous.
The first step in safeguarding the supply of radium is to make a census of the amount in each hospital. In wartime it is safer to use radium in the form of radon, which can be prepared in an extra-urban area.
Radium element may be employed if some one is designated to remove it immediately in

the event of an air raid and place it in storage. If night attacks are frequent, it should be used only during daylight hours.
Opinions differ as to how radium should be stored. Concrete buildings and bulletproof safes, with walls at least three inches thick, have been proposed but are not practical. Some hospitals in London have wells thirty to fifty feet deep, into which the radium is lowered and from which it is raised in a specially built, protected bucket. Whatever plan is employed, the radium should be kept in some place in which the risk of a direct hit is minimal. An underground storage place is best. Radium should be assigned to the custody of two or more persons properly instructed in the risks of its exposure and dispersion.

Section XII.—MORALE

Possibly the most important single need in a hospital during wartime is to make the entire staff comprehend that preparations must be made on the basis that an emergency is positively going to occur rather than that it is likely to occur. No opportunity must be lost of convincing the staff and the general personnel of the seriousness of the emergency which may arise even though there is no present evidence of it, and of the importance of the preparations which must be made to combat it. Overtime work and the sacrifice of personal comforts are universal during an actual emergency, but the maintenance of morale is always difficult during a period of inactivity.
A well trained, conscientious staff makes for calm patients and averts the risk of panic in an emergency. Therefore discipline must be strict and unremitting at all times, and no laxity of any sort must be permitted.
Regular rehearsals must be carried out in every department. They should include the driving, loading and unloading of ambulances in a blackout, stretcher bearing, fire drills and the evacuation of wards, working in the operating room and elsewhere in gas masks, working in the hospital generally in blackout conditions. Mobilization of Emergency Medical Field Units and field drills should be carried out weekly in association with extra-mural Reserve Medical Squads, Rescue Squads and fire auxiliaries. These rehearsals should be serious from start to finish.

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Section XIII.—THE AMBULANCE ENTRANCE

As previously indicated, separate entrances should be provided for the admission of walking wounded, stretcher cases, and gas cases. The ambulance drive should be so arranged that unnecessary turns are eliminated and ambulances may enter by one route and leave by another. Unnecessary turns at the admitting platform can be eliminated if the path of entrance and discharge approaches that illustrated in figure 10. The ambulance enters at the Gate A, goes forward to the point B which is indicated by a sign, backs to the reception platform C, goes forward from that point so as to leave by exit D.
A barricade should be erected on two sides of the reception platform according to the plan illustrated in figure 2. The barricade must extend at least to the top of the door to the reception room. The barricade not only serves to protect those working on the platform but will also prevent direct access of blast to the reception room.

A cover of heavy canvas extending from the hospital building to the top of the barricade will maintain blackout and permit sufficient light for unloading operations. Having discharged its load, the ambulance should be furnished with a fresh supply of blankets and stretchers. Time should not be lost in transferring patients from stretchers brought by the ambulance to hospital stretchers.
As stretcher cases are brought into the reception room they should be placed as far as possible from the door to provide space for those to follow. Stretchers can be placed on saw horses of such height (36 inches) as will make them serviceable examining and dressing tables.
The ambulance used for the transportation of persons injured with persistent types of gas should be so constructed that the entire interior can be washed with a strong solution of chlorinated lime. If the patient’s compartment communicates with the driver’s compartment, the latter must be subjected to the same treatment.

FIG. 10—SUGGESTIVE SKETCH FOR LAYOUT OF AMBULANCE ENTRANCE.

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APPENDIX

Bitumen-Fabric Treatment of Glass—Methods and Specifications

The treatment is applied as follows:
1. Glass is washed as clean as possible and scoured where necessary.
2. A first coat of bituminous emulsion is applied by brush.
3. Within 10 to 15 minutes the fabric is laid and pressed into the coating.
4. After about 30 minutes a second coat of emulsion is applied, being well brushed through the meshes to bond with the first coat.
5. After not less than 24 hours a third (final) coat is applied.
The properties required in the bituminous emulsion are similar to those found in many, though not in all, materials of this type used in the building industry. It is necessary that the bond between the emulsion and the glass should not be readily destroyed by water, and this requires a restriction on the presence of free alkali as emulsifier. The amount of filler present is also restricted. The emulsion must be sufficiently stable to be applied by brush. It must on drying give a film which provides adequate obscuration to interior lighting, which is sufficiently hard to hold the shattered glass in warm weather, and which does not deteriorate on weathering. Bituminous emulsions of the type used for road work normally give a film which is too soft and lacks adequate obscuration power. The following test requirements should be met:
(a) Drying time: The first coat when applied to a glass plate under atmospheric conditions of a temperature of 60° to 68° F. and relative humidity of 60% to 70% should become tacky within 15 minutes.
(b) The thickness of the first coat should correspond to an application of not less than 1 gallon to 8 square yards. Sealing and final coats should become appreciably dry to touch within 4 hours.
(c) Alkalinity: A drop of emulsion, diluted with an equal volume of distilled water, should be placed on a white glazed tile, with a glass rod. One side of this drop should then be touched with a rod dipped into a phenolphthalein solution (1% in absolute alcohol). There should be no red coloration.
(d) Filler content: The amount of filler present should not be greater than 12 percent by weight of the nonaqueous part of the emulsion.

(e) Softening point of dried film: The softening point (ring and ball method) of the bituminous material left in a dried film should not be less than 125° F.
The fabric recommended for use is oznaburg (cotton) weighing not less than 3 ounces per square yard. It should permit ready penetration of the emulsion. The fabric should be rot-proofed by a suitable copper treatment. If the material shrinks appreciably on wetting, it should, before use, be wetted with water or diluted emulsion and applied in a damp condition.
In applying the fabric: Lay the fabric in full width down the panels, carrying it over the glazing bars and the sides of the sash and sticking it to them. Adjacent sheets should be overlapped 4 inches.
While the bitumen-fabric treatment of glass in skylights and domes will usually be sufficient to hold the glass in place at the instant of explosion, there will be a subsequent tendency for broken fragments gradually to become detached and fall into the building. This effect will be most serious in warm weather when the fall of glass may occur within a few days. To prevent this it is desirable that additional support should be given to the glass on the under side.
Supports should preferably take the form of cross-bars fitted between the glazing bars. They should touch the glass and be reasonably rigid, spaced not more than two feet apart. Supports should not impose any excessive side thrust on the glazing bars.
Wired glass which is treated with fabric and bituminous emulsion will, when cracked, have a considerable measure of support from the imbedded wire mesh. With other types of glass, however, wire netting (one-half inch chicken wire) should be provided beneath the whole area of glass in the dome or skylight in addition to the supporting cross bars. It will usually be convenient to fix the wire netting between the cross bars and the glass so that it is held in close contact with the glass. Special care must be taken to secure the netting at the top and bottom of each sheet of glass.
Roof glazing treated as described and supported by cross bars and wire netting underneath, or with cross bars only, in the case of wired glass, is likely to remain effective for weather exclusion and obscuration for many months with the glass fractured.

16—269581-1

GPO