Evacuation of Hospitals during Disaster , Establishment of a Field Hospital , and Communication

The buildings, working personnel, and patients and their relatives may directly or indirectly be affected by the disasters. Here we will discuss evacuation, establishing a field hospital, communication, the role of the media in disasters, and defending against sabotage. The affected individuals should be evacuated and transferred to secure zones safely and rapidly. How the decision for evacuation should be made and how the evacuation triage should be performed are important issues. Field hospitals should be established within the bounds of possibility for continuation of the treatments of evacuated people. The standards for the field hospitals and its sections that may be created according to the needs will be explained. Undoubtedly, since one of the most important subjects in disasters is communication, the types of communication in disasters and their significance will be mentioned. How the relationships with the media should be an aspect of communication and how they can be beneficially used will also be mentioned. As in all organizations and institutions, sabotage attempts may also be present concerning health facilities. For this reason, during the preparation of the hospital disaster plan, defending against sabotage will be discussed, and what should be done at that stage will be mentioned.

days. The medical files and laboratory and imaging results should be sent along with the patients who have been referred to other centers. After completion of the evacuation processes, the hospital is checked, and whether any section of the hospital can be taken into service following the event is decided [1][2][3].
The types of evacuation: 1) Internal (Partial) Evacuation: It is the evacuation of only the affected section in situations where the hospital was partially affected; this can be performed in two ways, vertical and horizontal. The transfer from the lower floor to one or more floors up in situations such as flood and similar events, or the transfer to the lower floor in cases where the roof and top floor are damaged is called a vertical evacuation. The type of evacuation that is performed simultaneously on several floors or in the entire block in a situation such as fire, explosion, or collapse, where a section of the hospital has been affected but has been taken under control is called a horizontal evacuation [3]. 2) External (Complete) Evacuation: It is the transfer of patients to pre-determined suitable hospitals in a situation where the hospital has been completely damaged and become unusable or the threat is continuing for the hospital [3]. The evacuation priorities for the transfer of patients are as follows: • 1 st row: Small children and babies, patients who are not connected to machines and can walk (For rapid evacuation of patients who can walk, a group leader can provide the exit of patients to an appropriate area by shouting "All people who can walk should follow me!") • 2 nd row: Patients who can move using a wheelchair or walker • 3 rd row: Patients for whom a stretcher is required for transport • 4 th row: All patients in the intensive care unit • 5 th row: Patients with the least probability of living The place outside the area where the incident has occurred, is not affected by the disaster, and is considered to be safe for patients and their relatives and workers, is called the safe zone. In the safe zone, an emergency case should be present. The supplies that should be kept in this emergency case are as follows: • Rechargeable aspirator • Full O 2 tubes, with their regulatorhoods ready to use • Sterile clothing and sets • Light source • Sufficient amount of blankets The decision-making for evacuation should be made as shown in Figure 1, and the evacuation triage and categorization should be done as shown in Figure 2, 3.

Field Hospital
The hospitals may become unusable during disasters. The field hospitals are the hospitals that are constituted following the disasters for the purpose of providing safe health care services to disaster victims and continuation of treatment of hospitalized patients temporarily in pre-determined, safe regions close to the hospitals. According to the World Health Organization (WHO), the field hospitals are units consisting of containers, tents, and inflatable or containerized modules, having at least ten beds, one operating room, one basic laboratory and mobile X-ray equipment [4]. WHO does not propose to establish a field hospital if the hospital is still functioning during the disaster and is well-equipped and the teams are available because supporting the permanent health system is less costly and the local resources of the institution are used more efficiently [5].  The area where the field hospital will be established should be investigated and determined beforehand, and when required, protocols should be signed with related organizations. This area should be away from the structures that are in danger of collapse and in a safe location not prone to floods, landslides, fire, and contamination. While this field hospital may be established in secure buildings, unharmed by the disaster (e.g., the substantial parts of a hospital, school, mosque, sports hall, and cultural center), it can be installed with portable hardware such as tents, inflatable modules, prefabricated structures, and trailer or ship containers. Among these, the usage of tents is easier and cheaper compared to the other kinds of hardware. Tents can be installed easily and quickly, can be easily transferred to another site, are easily repairable, and can be used multiple times. The materials that can be used in constituting the field hospital vary depending on the magnitude of the disaster and the financial resources of the nation and the hospital. Portable ventilator devices, together with accumulators, batteries, generators, and oxygen condensation equipment required for the operation of these devices should be kept ready and checked periodically. If the materials, generators, drugs, and medical supplies that will be used in disasters are kept ready for use in warehouses, they should be checked and updated at regular intervals. If they are not stored, protocols should be signed with the related companies beforehand [5][6][7].
The field hospital also has a modular structure as in HDP. This modular structure consists of five main sections: administrative unit, hospital admission, operational unit, logistic section, and humanitarian services. These sections and the sub-sections of each section can be enlarged, downsized, or excluded from the plan completely depending on the circumstances during the disaster. Besides, during disasters, the field hospitals can be forced to undertake duties other than patient care, such as providing food aid and shelter to people affected by the disaster. Therefore, the presence of nutrition and sheltering units in the field hospital plan would be appropriate [8].
The sections of the field hospital are as follows [8,9]

Communication in Disasters and the Media
Although communication and coordination are critical in disasters, the communication systems usually do not function properly during a catastrophe. This situation is one of the most significant problems concerning disasters. It becomes even a greater problem if communication and coordination with necessary institutions have not been established ahead of a catastrophe. Conflicts occur between institutions or even between units of the same institution, and they cannot be solved during the disaster. In this way, some institutions or units are excluded and the information and resources cannot be used effectively. This situation leads to further increase in chaos. In-house and inter-institutional training and drills should be performed, responsibilities and jurisdictions of the individuals should be determined, and it should be known whether the person who will be contacted is legally authorized, reliable and competent to prevent the chaos that occurs during a disaster [10][11][12].
As for all circumstances in the hospital, the communication may also be adversely affected by the disasters. Various methods should be developed for recalling the hospital personnel and previously trained volunteers and using them at the time of disaster, considering these adverse circumstances. The contact information of these people should be recorded and updated at regular intervals. An active communication channel should be established among these individuals before the disaster. The employees can be called one by one during a catastrophe. They can be informed by a computer-aided automated paging system; if no system is functioning, they can be notified by the courier system. The required infrastructure should be established for radio communication with the Governor' s Crisis Management Center, the Provincial Directorate of Health, the fire department, the security forces, and 112 Emergency Medical Services, because one hospital may not be able to manage the patient load during disasters. The patient load is shared via the inter-institutional communication, and therefore, less turmoil is encountered [17,18].
In disasters, another significant tool of communication is the media. All events that have occurred may be addressed to the nation and the world in a short period through the media, and the necessary assistance may be requested. Even small-scale disasters may receive a response through the social media at the national or international level. In this way, extensive numbers of volunteers and many materials can be received by the hospital and the disaster area. Good relationships should be constituted considering the benefits of the media, and speculations should not be allowed by giving the necessary information regularly and quickly [19]. The loss of life and property can be reduced by establishing a logical, effective, and constructive relationship with the media, informing the public correctly about the magnitude and duration of the disaster, the affected area, and things needed to be done [20,21]. A media center should be set up, and the media should be informed directly by the public relations authority from a single center. The probability of sensational and speculative news should be reduced by providing trained and knowledgeable individuals for working in this center. Additionally, since the media will use its own resources for making news, preparations should be done against inappropriate news [22]. The media center should give the most reliable and detailed information to the press at the shortest time by developing an appropriate strategy. Thus, the majority of the media will be directed to a place that may make an official, true, and timely press statement. By the help of this center, coordination with the media and news is acquired, announcement of which is dangerous regarding security can be put on hold. Furthermore, by explaining the names and places of the people who are alive and/ or injured, the influx of people worrying about their relatives is reduced [23]. In situations that the communication systems are harmed, necessary assistance can be provided by establishing communication through the media. Disaster training may be performed by converting the interviews with the experts about the disaster to educational essays and publishing them periodically. Moreover, awareness should be raised in the public by including any faulty application of the local and government authorities, if there is any, in the educational essays, and also including their timely and correct applications about the disaster [24,25].
When appropriate communication cannot be established with the media, or sometimes when the media exaggerates the events with the purpose of rating, the sensational news is issued, even if its official or not. This ungrounded news leads to panic and turmoil in the community. Besides, by exerting pressure on the authorities to get information and shoot on location, they may slow down the execution of the workflow. The pressure to make statements on many topics that are impossible to know or predict at the early phase of a disaster leads to misconceptions about the authorities in the community. Giving estimated answers or stating that it is still early for answers raises conflicts about the competence of the institution [12,26].
To be more successful in relationships with the media, the following points should be considered [27]: • appropriate planning • training the media about disasters • introduction of the disaster plan to the press • ensuring the participation of local broadcasting organizations • conducting the planning within the knowledge of the media • setting up the press and broadcast center • taking the crowdedness of broadcasting organizations under control is important

Plan for Defending Against Sabotage
Sabotage is derived from the French word "sabot. " It means disastrous, deep, and intentional. The aggressive and destructive activities performed for temporarily disabling all kinds of transportation and communication, and personnel and administrative structure entirely or partially is called sabotage.
The necessary precautions to protect the organizations and institutions against sabotages, expose the persons or the groups who perform or might perform sabotage activities and make them ineffective by taking necessary measures, and eliminate sabotage activities are called defending against sabotage [28,29].
Through which doors and at which days the visitors of the patients in hospital can enter and exit should be pre-determined to prevent a sabotage activity. While entering, the equipment and belongings that are allowed by the hospital administration should be permitted to pass. To which sections or units the personnel, patients, and visitors have entry permits should be pre-determined. Unauthorized people should not be permitted to enter. The parking places of the personnel and visitors should be predetermined, and the entry-exit should be kept under control. The interiors and exteriors of the hospital should be lighted against a sabotage action that can be performed at night, and the malfunctions should be immediately repaired.
Security should be maintained for 24 hours by the security personnel standing sentinel and patrolling and camera system. When required, law-enforcement officers should be called. The fuel, oxygen, and nitrogen tanks, bought for using in the hospital, should be stored away from the hospital and their security should be ensured. With the purpose of protecting the work order and functionality of the hospital, to raise the morale of the personnel against defeatist actions, and to prevent conflict within the personnel, training should be done and planning should be carried out on the psychological defense-related issues.