- 1 - Survival and Austere Medicine: An Introduction Survival and Austere Medicine: An introduction Second Edition Written and Edited by The Remote, Austere, Wilderness and Third World Medicine Discussion Board Moderators April 2005 - 2 - Survival and Austere Medicine: An Introduction Copyright 2005: Excluding contributions attributed to specific individuals, all material is copyrighted to the authors and all rights are reserved. This work may be copied and distributed freely as long as the entire text and all disclaimers and copyright notices remain intact. This material may not be distributed for financial gain or included in any commercial collections or compilations. Any constructive comments and debate are welcome. We welcome correction in any errors of fact. We apologise for any errors of grammar or spelling they are entirely ours. We have tried to avoid detailing specific managements (although we haven’t been entirely successful) for various conditions as we do not consider this to be an appropriate forum for that sort of detail and we suggest you consult the references. Contributors and Editors: This book is a combined effort. The primary chapter writers are credited, but there have been many contributions within chapters from others. We have also had editorial assistance and constructive comment from a number of others whose efforts we greatly appreciate. BCE. MD (BCE) A Grey Man. Lab Tech (GM) Goatlady. Herbalist (GL) Reasonable Rascal. RN/Paramedic (RR) Swedeglocker. Medic (SG) Tangent. EMT (TG) Resqdoc. MD (RQD) - 3 - Survival and Austere Medicine: An Introduction READ THIS FIRST ! Disclaimer: The editors and authors accept no responsibility for the use or misuse of this information. The practice of medicine is something that should only be undertaken by trained professionals. If you start administering medical or surgical treatments without the appropriate skills you will kill someone. Even in emergency situations often no action is better than uninformed and untrained action. Any practice of survival medicine should be backed up with appropriate training. Much of this information is offered to give you perspective of what may be possible in a long term catastrophic disaster or when working in an austere or remote environment without access to organised or trained medical care – we in no way endorse practicing these techniques except in such a situation. This information is offered as personal opinions and should not be taken to represent a professional opinion or to reflect any views widely held within the medical community. Appropriate additional references should be consulted to confirm and validate the information contained in this book. - 4 - Survival and Austere Medicine: An Introduction Contents Page Disclaimer Background 7 Chapter 1 Introduction 9 Chapter 2 What do I need to know & how do I learn it? (BCE) 12 Formal training Informal training Chapter 3 Organisation (BCE) 18 Chapter 4 Medical kits (BCE) 21 Obtaining medical suplies Storage and rotation How much? Specific medical kits Surgical instruments Chapter 5 Antibiotics (BCE) 39 Bacteria Antibiotics Chapter 6 Sterilisation and disinfection (TG) 44 Chapter 7 The basic laboratory (GM) 51 Urine testing Blod counts Blod grouping Cros matching Gram staining Pregnancy tests Glucose testing Chapter 8 Herbal and Botanical medicine (GL) 65 Preparation of botanicals and herbs for storage Medicinal botanical preparation methods Specific botanicals and herbs - 5 - Survival and Austere Medicine: An Introduction Chapter 9 Other alternative medicine (BCE) 80 General points Coloidal Silver “The Placebo efect” Chapter 10 Medical aspects of shelter living (BCE) 83 Psychological problems Infectious disease Light Exercise Nutrition Chapter 11 Long-term survival medicine (BCE) 89 Introduction Education/Knowledge Lifestyle/Public health Patient asesment Treatment/Therapies Chapter 12 Woman’s Health Issues (BCE) 109 Contraception Childbirth Abortion Breastfeding Chapter 13 Medical aspects of NBC warfare (SG) 117 Nuclear Biological Chemical Chapter 14 Wound closure and suturing (BCE) 127 Chapter 15 Austere Dental care (BCE/RQD) 131 Preventive dentistry Scaling and cleaning Driling and filing Dental trauma Extractions Prosthetics - 6 - Survival and Austere Medicine: An Introduction Chapter 16 Nursing care in an austere environment (RR) 143 Chapter 17 Frequently asked questions (BCE) 169 What is Ketamine? How do I debride a wound? Can I give resuscitation fluids rectally? How do I amputate a leg? Can I use Superglue to close a wound? How do I know if someone is dead? Why is diarhoea important? How likely is an infectious disease like SARS or a new strain of influenza to cause a major disaster? What is influenza? What is “Bird flu”? Will Tamiflu save me from the Pandemic? How do I use maggots to clean a wound? Can I use sugar to treat an infected wound? How do I “set” a broken bone? How do I recognise and treat a heart attack in an austere situation? Do I need Quickclot or Traumadex to control bleeding? What is the most useful antibiotic? What do I do if I’m allergic to penicillin? When should I stop using antibiotics? Chapter 18 Reference books (RR) 183 First tier references Second tier references Third tier references Chapter 19 Austere medicine sound bites 193 Chapter 20 Survival Medicine Fiction 194 Amputation The aprentice Apendix 1 Equipment supliers 209 - 7 - Survival and Austere Medicine: An Introduction Background This book is a major revision of the Survival Medicine FAQ’s (Frequently Asked Questions) originally written for the misc. survivalism Usenet newsgroup in 1997. It was written in response to recurring posts asking the same questions and the fact that many answers were often wrong and occasionally dangerous. It hasn’t undergone any changes or revisions since then. While the original content remains valid we thought it was time it underwent an update. This is a significant revision – most sections have been re-written and a number of new sections added. We hope you will find it useful. It is offered in good faith but the content should be validated and confirmed from other sources before being relied on even in an emergency situation. There are very few books aimed at the “Practicing Medicine after the End of the World As We Know It” market – which is hardly surprising! So we hope this book fills a void. We also hope it will be useful for those people delivering health care in remote or austere environments. It is not designed as a “how to do x” reference – although there is some of that. There are plenty of books which tell you how to practice medicine. It is designed to provide some answers to commonly asked questions relating to survival/preparedness medicine and to provide relevant information not commonly found in traditional texts or direct you to that information. We have tried to minimise technical language, but at times this has not been possible, if you come across unfamiliar terms – please consult a medical dictionary. It has taken two years, and a lot of stopping, and starting but here it is. The authors and editors are passionately committed to helping people develop their medical knowledge and skills for major disasters. We hope you find it useful. Web Site: F or questions and comments the authors can all be contacted via posting at the f ollowing website: “The Remote, Austere, Wilderness and Third world Medicine Forum” http://medtech.syrene.net/forum/ - 8 - Survival and Austere Medicine: An Introduction Medicine at the End of the World “With no antibiotics there would be no treatment for bacterial infections; pneumonia or a simple cut could kill again, contagious diseases (including those sexually transmitted) would make a come back, and high mortality rates would be associated with any surgery. Poor hygiene and disrupted water supplies would lead to an increase in diseases such as typhoid and cholera. Without vaccines there would be a progressive return in infectious diseases such as polio, tetanus, whooping cough, diphtheria, mumps, etc. especially among children. People suffering from chronic illnesses such as asthma, diabetes, or epilepsy would be severely affected with many dying (especially insulin-dependent diabetics). There would be no anaesthetic agents resulting in return to tortuous surgical procedures with the patient awake or if they were lucky drunk or stoned. The same would apply to painkillers; a broken leg would be agony, and dying of cancer would be distressing for the patient and their family. Without reliable oral contraceptives or condoms the pregnancy rate would rise and with it the maternal and neonatal death rates, women would die during pregnancy and delivery again, and premature babies would die. Women would still seek abortions, and without proper instruments or antibiotics death from septic abortion would be common again. In the absence of proper dental care teeth would rot, and painful extractions would have to be performed. What limited medical supplies available would have to be recycled, resulting in increasing risks of hepatitis and HIV infection.” - 9 - Survival and Austere Medicine: An Introduction Chapter 1 Introduction What is preparedness/survival medicine? Our definition is: "The practice of medicine in an environment or situation where standard medical care and facilities are unavailable, often by persons with no formal medical training". This includes medical care while trekking in third world countries, deep-water ocean sailing, isolated tramping and trekking, and following a large natural disaster or other catastrophe. The basic assumption is that trained doctors and hospital care will be unavailable for a prolonged period of time, and that in addition to providing first aid - definitive medical care and rehabilitation (if required) will need to be provided. Also the basics of personal and public hygiene will also need to be considered. Austere medicine is the provision of medical care without access to modern investigations or technology. As is the case with any aspects of preparedness you need to decide what you are preparing for and plan accordingly. For some it will only be a 72-hour crisis, for others it will be a major long-term event, and for yet others a multiple generation scenario. Your medical preparations will need to reflect your own risk assessments in terms of what knowledge and skills you develop and what supplies/equipment/medicines you store. This book is more slanted towards preparation for medium to longer term disasters. But most of the included information is applicable to shorter situations as well. A recent Internet survey asking about medical risk assessments in a major disaster came up with the following results: “What do you see as the most likely common source of medical problems? Batlefield injuries 5 % Lack of surgical care 36 % Environmental related 8 % Infectious disease (naturally occurring) 64 % Infectious disease (biological warfare) 20 % Nuclear conflict (radiation, blast, burns) 4 % ” (Frugal’s forum 1/04 with permission. http://www.frugalsquirrels.com) What you may have to deal with will depend on what happens. Obviously a nuclear war will produce a different set of problems than a pandemic. However, regardless of whatever the initial triggering event after the initial wave of injuries or illness associated with it the majority of medical problems that happen will be common, and mundane, and not nearly as interesting as the above survey results suggests. - 10 - Survival and Austere Medicine: An Introduction Below are the results of one author’s experience in the provision of health care in various remote and austere locations (some third world, some first world) to nearly two thousand people over a cumulative 15-month period (spread over 10 years). The record keeping was a bit unreliable at times, but the following summary is reasonably accurate. The Top 20 presentations: 1. Minor musculoskeletal injuries (ankle sprains most common) 2. Upper respiratory tract infections 3. Allergic reactions/Hay fever/Anaphylactic reactions/Rashes 4. Minor open wounds 5. Gastroenteritis/Vomiting/Diarrhoea 6. Sexual health/Contraceptive problems 7. Skin infections/Cellulitis 8. Mental health problems 9. Dental problems 10. Abdominal pain (2 confirmed acute appendix + 1 gangrenous gall bladder; no cause found. Renal or biliary colic were most common) 11. Flu/Viral illness 12. Chest infections 13. Major musculoskeletal injuries (fractures/dislocations) 14. Asthma 15. Ear infections 16. Urinary tract infections 17. Chest pain 18. Syncope/Collapse/Faints 19. Early pregnancy problems 20. Burns Top 12 prescribed drugs: 1. Paracetamol (Acetaminophen) 2. Loratadine (and other assorted antihistamines) 3. Diclofenac (and other assorted antiinflammatories) 4. Combined oral contraceptive 5. Flucloxacillin 6. Throat lozenges 7. Augmentin 8. Loperamide 9. Nystatin (and other antifungals) 10. Hydrocortisone cream 11. Ventolin inhalers 12. Morphine The above gives you a variety of insights into what medical problems might occur and what medications are likely to be required. Most of it relatively mundane and not life threatening. Truly catastrophic problems in medicine are fortunately rare. You should