Medical Care During Extended Shelter-in-Place

When armed conflict surrounds your shelter and medical services are unavailable, every person in your group may be called upon to provide medical care. The injuries caused by conflict — blast trauma, penetrating ballistic wounds, burns, and psychological crisis — are among the most severe that civilians can face. You will not be able to provide hospital-level care. What you can provide is life-preserving intervention: stopping catastrophic haemorrhage, managing airways, reducing infection risk, and maintaining the group's psychological cohesion.

This guide prepares you for the medical realities of extended conflict shelter, with practical interventions that are within the capability of a non-medical person with basic preparation.

Blast and Ballistic Injuries: The Most Likely Threats

Modern conflict kills and injures civilians primarily through four mechanisms:

Mechanism	Primary Injury Type	Immediate Risk
Blast wave (overpressure)	Blast lung (pulmonary haemorrhage), tympanic membrane rupture, bowel perforation	Respiratory failure, internal haemorrhage
Primary fragmentation (shell casing, debris)	Penetrating wounds, lacerations, eye injuries	Haemorrhage, pneumothorax
Secondary fragmentation (glass, building material)	Lacerations, penetrating wounds	Haemorrhage, infection
Ballistic (direct gunshot)	Penetrating wound — bone fracture, organ damage, major vessel injury	Haemorrhage, tension pneumothorax

The most preventable cause of death from these injuries is uncontrolled haemorrhage — bleeding to death. It accounts for the majority of preventable trauma deaths in conflict settings. Learning to stop severe bleeding is the single most impactful medical skill you can develop.

Controlling Catastrophic Haemorrhage

Severe bleeding from extremity wounds (arms and legs) can cause death within minutes. The intervention is a tourniquet.

Tourniquet application (improvised):

1. The wound must be on a limb (arm or leg)
2. Place the tourniquet 5–7cm above the wound (between the wound and the heart)
3. Use a strip of material at least 4cm wide — narrower materials cut into tissue and are less effective
4. Wrap twice around the limb
5. Tie in a half-knot; place a stick, pen, or rigid object on the knot; tie a full knot over it
6. Twist the stick until bleeding stops — this typically requires significant force
7. Secure the stick so it cannot unwind
8. Write the time of application on the person's skin or clothing with a marker
9. Do not remove the tourniquet — removal before surgical intervention can cause sudden cardiovascular collapse
10. Seek surgical care as soon as safely possible — a tourniquet applied correctly is limb-threatening beyond 6 hours

For wounds where tourniquet cannot be applied (groin, armpit, neck): Use wound packing. If haemostatic dressing (QuikClot, Celox) is available:

1. Clear blood from wound so you can see it
2. Pack the haemostatic dressing tightly into the wound using your fingers — push deep into the wound
3. Apply firm, sustained direct pressure for 3–5 minutes without releasing
4. Apply a pressure dressing over the top to maintain pressure

Without haemostatic dressing: Use clean gauze or the cleanest fabric available. Pack tightly into the wound and apply firm pressure for a minimum of 5–10 minutes without releasing. Releasing pressure prematurely disrupts the forming clot.

Penetrating Chest Wounds — Sucking Chest Wound

A penetrating wound to the chest (from bullet, shrapnel, or sharp debris) can create an opening that allows air to enter the chest cavity with each breath. This is called an open pneumothorax. It is life-threatening and requires immediate intervention.

Signs:

• Visible hole or wound in the chest wall
• Sucking or gurgling sound from the wound when breathing
• Increasing breathing difficulty
• Blood or bubbling at the wound site

Improvised management:

1. Cover the wound with a commercially vented chest seal if available
2. Without a commercial chest seal: use any non-porous material (plastic packaging, food wrap) to cover the wound
3. Tape three sides of the covering, leaving one side unsealed — this creates a flutter valve that allows air out but not in (a fully sealed wound can convert to a tension pneumothorax, which is more dangerous)
4. Position the patient: semi-upright if breathing, on the injured side if unconscious
5. Monitor breathing closely — if breathing deteriorates significantly despite the seal, briefly lift the covering to release pressure, then reseal

⚠️ Blast lung — internal pulmonary haemorrhage caused by the blast wave alone — presents as increasing respiratory difficulty and blood-tinged sputum, but with no external wound. There is no effective field treatment. Keep the patient calm, semi-upright, and minimise exertion. Evacuation for medical care is the only intervention.

Burns

Burns are common in conflict from fires in bombed buildings, vehicle explosions, and incendiary weapons.

Burn first aid:

1. Remove the casualty from the heat source (ensuring your own safety)
2. Remove clothing and jewellery from the burn area if not stuck to the skin
3. Cool the burn with cool (not cold or icy) water for 20 minutes; this stops the burning process and provides pain relief
4. Do not use ice — ice causes additional tissue damage
5. Cover with clean, non-fluffy material (cling film or a clean plastic bag works well; do not use cotton wool or anything that sticks)
6. Do not burst blisters
7. Do not apply toothpaste, butter, oil, or any home remedy — these increase infection risk and complicate medical assessment

Assessing severity: Burns affecting large areas of the body (rule of nines: arm = 9%, leg = 18%, front torso = 18%) cause fluid loss and are immediately life-threatening. Burns to the face, hands, genitals, or involving inhalation injury (singed eyebrows, hoarse voice, soot in mouth/nose) require urgent medical attention.

Infection Prevention and Wound Care

In conflict settings where medical care is unavailable, wound infection becomes the principal cause of secondary death. All wounds — even apparently minor lacerations — must be treated aggressively to prevent infection.

Wound cleaning protocol:

1. Irrigate the wound with clean water under pressure — a syringe, squeeze bottle, or pour from height creates useful irrigation pressure. Use at least 100ml per wound.
2. Do not probe or explore the wound
3. Remove obvious surface debris; do not attempt to extract deeply embedded fragments
4. Apply antiseptic (iodine solution, chlorhexidine, or saline if nothing else is available)
5. Cover with clean dressings; change daily or when soaked
6. Monitor for infection signs: increasing redness, warmth, swelling, pus, red streaking from wound, fever — these require immediate escalation

Embedded fragments: Do not attempt to remove shrapnel, bullets, or deeply embedded glass. Removal of embedded objects in field conditions risks worsening haemorrhage, causing tissue damage, and introducing further contamination. Cover, immobilise, and seek medical care.

Managing Chronic Conditions Without Pharmacy Access

People in shelter-in-place situations frequently have pre-existing medical conditions that require regular medication. When pharmacy and medical services are unavailable, managing these conditions is critical.

Condition	Primary Risk of Medication Interruption	Management Without Full Supply
Type 1 Diabetes	Diabetic ketoacidosis — life-threatening	Ration insulin; reduce carbohydrate intake to lower dose requirement; test blood glucose if meters available
Type 2 Diabetes (medication-controlled)	Hyperglycaemia — serious but more gradual	Restrict sugar and carbohydrate; exercise if possible; closely monitor symptoms
Hypertension	Hypertensive crisis, stroke risk	Stress reduction; reduce salt intake; rest; if very high readings (>200/120), prioritise medical evacuation
Epilepsy / seizure disorder	Breakthrough seizures	Never abruptly stop anti-seizure medication; ration carefully; manage stress and sleep deprivation (both are seizure triggers)
Asthma	Acute severe asthma attack	Conserve reliever inhaler for attacks; reduce exertion; minimise dust and smoke exposure; keep preventer regimen going
Mental health (antidepressants, antipsychotics)	Withdrawal syndrome, psychiatric crisis	Most antidepressants should not be stopped abruptly; if supply is ending, taper dose gradually if possible; monitor closely

Psychological First Aid for a Confined Group

Extended shelter-in-place creates profound psychological stress. The combination of physical danger, immobility, uncertainty, and loss erodes psychological resilience. Psychological First Aid (PFA) is a set of actions that you can take to support the mental health of your group without professional training.

Core PFA principles:

1. Safety: Ensure people feel as physically safe as possible. Reinforce the protections in place.
2. Calming: Help people in acute distress use grounding techniques — slow breathing (4 counts in, 4 hold, 4 out), focusing on physical sensations (feet on floor, back against wall).
3. Connectedness: Keep people together. Isolation during crisis amplifies distress. Encourage conversation, shared activities, mutual support.
4. Self-efficacy: Give people tasks and agency. Even small tasks (tracking water use, maintaining a schedule, teaching others) restore a sense of control.
5. Hope: Realistic, not false, hope. Discuss what you know about the situation; share reliable information; avoid catastrophising.

Managing acute distress reactions:

• Trembling, crying, hyperventilation, confusion after a traumatic event are normal acute stress responses
• Do not tell someone to "calm down" or "stop" — acknowledge what they experienced
• Use calm, quiet, direct speech: "You are safe right now. I am here. Take a slow breath with me."
• Physical contact (hand on shoulder, guided breathing together) is often helpful for people in acute distress
• Give the person a simple, concrete task as soon as they are able: "Can you help me do X?"

When Someone Needs Evacuation Despite Danger

There are medical conditions that become life-threatening if not treated and cannot be managed in a shelter environment:

• Active internal haemorrhage (abdomen or chest)
• Appendicitis (begins as right lower abdominal pain, fever, worsening over 12–24 hours)
• Perforated bowel (severe abdominal pain and rigidity after blast)
• Difficulty breathing that does not respond to positioning
• Stroke symptoms (FAST: Face drooping, Arm weakness, Speech difficulty, Time to act)
• Diabetic ketoacidosis (fruity breath, vomiting, confusion, rapid breathing in a diabetic patient)
• Childbirth complications (haemorrhage, prolonged obstructed labour)
• High fever with altered consciousness (potentially meningitis, severe infection)

In these cases, the risk of not moving must be weighed against the risk of movement. Contact the ICRC hotline or MSF/Red Cross emergency lines if communications allow — they can sometimes facilitate medical evacuation or provide guidance remotely.

ICRC general enquiries and family tracing: +41 22 734 6001 MSF emergency operations: +32 2 474 7474

Quick Reference

Situation	Action
Severe limb bleeding	Tourniquet 5–7cm above wound; twist until bleeding stops; note time
Wound in groin, armpit, or neck	Pack tightly with haemostatic dressing; firm sustained pressure for 3–5 minutes
Sucking chest wound	Three-sided seal with non-porous material; tape three sides; leave one side open
Blast lung suspected (no external wound but breathing difficulty)	Semi-upright; calm; minimise exertion; evacuation priority
Burns	Cool water for 20 minutes; clean cover; no home remedies; no ice
Wound showing infection signs	Irrigate; clean dressing; if antibiotics available, begin course; prioritise medical evacuation
Someone in acute psychological distress	Calm voice; grounding techniques; physical presence; give a small task
Chronic medication running out	Ration carefully; do not stop abruptly; reduce contributing factors; prioritise evacuation if life-critical