Medical FAQ V2.00

Feb 2006, compiled few cogent first aid articles, linked to each other.

Medical FAQ by Craig Ellis

Medical FAQ by Craig Ellis   .pdf   38 pages

Basic First Aid, from Maine Farm Safety  .pdf  6 Pages

First Aid, Field Sanitation from the Navy SeaBee Manual  .pdf   44 pages

A guide to natural survival if lost in the wilderness

Wilderness First Aid- Dvorchak. pdf  7 Pages

Wound Care  (from scrapes to sutures)  By George E. Dvorchak Jr. M.A., M.D.   .txt

Wound Care  (from scrapes to sutures)  By George E. Dvorchak Jr. M.A., M.D.    .pdf  4 pages


Version 2.00
Created September 1997
Supersedes Version 1.00

Medical FAQ
By Craig Ellis

Excluding contributions attributed to specific individuals, all material is copyrighted to the author 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, unless my prior permission is obtained. This FAQ may not be distributed for financial gain, included in any commercial collections or compilations or included as any part of a wed site without the permission of the author.

(Copyright.(c) Craig Ellis 1997)

Thanks to Richard DeCastro, Diana and Alan Hagan and Pat Turner for comments and suggestions.

All views in this FAQ reflect only my opinions and is not to be considered in any way a professional opinion or advice.

Craig Ellis loucr@globe.co.nz

Any constructive comments and debate are welcome. I welcome correction in any errors of fact. I apologise for any errors of grammar or spelling they are entirely mine. I've tried to avoid detailing specific managements for various conditions as I do not consider this to be an appropriate forum. I will, however, respond to specific questions, with suitable references on request.

[Alan's note: Craig is in New Zealand and many of his words use the British spelling.]

Disclaimer: The author accepts no responsibility for the use or misuse of this information. The practice of medicine is something that should only be practiced 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. This information is offered as my personal opinion and should not be taken to represent a professional opinion or to reflect any views widely held from the medical community.

CONTENTS

BEFORE I START, THE MOST IMPORTANT THING ABOUT
MEDICINE, SURVIVAL OR OTHERWISE, IS
***WASH YOUR HANDS***

1.0 Survival Medicine:

2.0 What do you need to know?

3.0 Training

The most important aspect of survival medicine is to obtain knowledge and the skills related to it. Medicine is dangerous and uninformed decisions and actions will kill people. But, having said that, a lot of medicine is common sense. Anyone with a bit of intelligence, a good anatomy and physiology book, and a good medical text can easily learn the basics. Although, I have to stress: There is no alternative to a trained health care professional; anything else is taking risks. Obviously in survival situation any informed medical care is better than no medical care. Notice I said informed, if you really don't have a clue what you are doing, you will be very dangerous.

3.1 Formal training

3.2 Informal Training

3.3 Volunteering

4.0 Organisation

5.0 Reference Books

6.0 Medical Kits

7.0 . Medications

This section contains a significant amount of technical information. It is intended as a very brief overview and introduction of the subject area. I accept no responsibility for the accuracy or otherwise of this material. A suggested books section gives more specific references for these topics:

7.1 Storage and Rotation of Medications

Medications can be one of the more expensive items in your storage inventory and there can be a reluctance to rotate them due to this cost issue and also due to difficulties in obtaining new stock.

Unfortunately, drugs do have limited shelf life. It is a requirement for medications sold in the US (and most other first world countries) to display an expiration date. It is my experience that these are usually very easy to follow, without the confusing codes sometimes found on food products, e.g. -- Exp. 12/00=December 2000.

I cannot endorse using medications which have expired. But having said that it is my understanding that the majority of medications are safe for at least 12 months following their expiration date. A colleague recently did some aid work in the Solomon islands and a local pharmaceutical warehouse gave him a number of expired drugs. They stated that the drugs were safe to use for at least another 18 months. As with food the main problem with expired medicines is not that they become dangerous, but that they lose potency over time, and the manufacturer will no longer guarantee the dose/response effects of the drug. The important exception to this rule is the tetracycline group of antibiotics, which can become toxic with time, there may be others that I am unaware of but it is very difficult to obtain this information. Let the buyer beware, the expiry dates are there for a reason.

In addition, I recommend that if you are acquiring medications on a doctor's prescription that when you have the prescription filled you explain the medications are for storage (you don't need to say exactly what for), and request recently manufactured stock with distant expiration dates.

The ideal storage conditions for most medications is in a cool, dark, dry environment. These conditions will optimise the shelf life of the drugs. A small number of drugs require refrigeration to avoid loss of potency. These include insulin, ergometrine, oxytocin and some muscle relaxants. Others such as Diazepam rapidly lose potency if exposed to the light.

7.2 Antibiotics

7.2.1 Antibiotic Recommendations

In some cases access to antibiotics may be very limited. The following is my preferred list of antibiotics. If your limited in what you can get, I suggest you purchase and expand in this order. All are good broad spectrum antibiotics and have different strengths and weakness. I suggest you purchase an antibiotic guide, most medical book shops have small pocket guides for junior doctors detailing which drug to use for which bug and outlining sensitivities.

If allergic to Penicillin, I would advise A Quinolone as a first choice with some Metronidazole as a anerobe back-up. Alternative would be Erythromycin.

7.2.2 Antibiotic Summary

The Bugs:

A basic understanding of how bugs (read bacteria) cause infections is required to appropriately use antibiotics. I will not discuss viral or other infective agents here. This is not the forum for a proper discussion, so consider this a brief introduction. There are HUNDREDS of bacteria, I will only discuss common disease causing ones in man.

Four Classes of Bacteria

Gram positive bacteria stain blue and gram negative bacteria stain pink, when subjected to a gram staining test. It is related to the presence or absence of a coating in the cell wall of the bacteria. Anaerobic bacteria are ones which require no oxygen to grow. Bacteria are also described by their shape (cocci = round, bacilli = oval) and how they are grouped together (chains, clusters, pairs)

Gram Positive Bacteria ( Gram +ve)

Gram Negative Bacteria ( Gram -ve )

Anaerobes

Others

The Drugs:

Penicillins - These act by preventing replicating bacteria from producing a cell wall. A number of bacteria produce a enzyme which inactivates the penicillins ( B-lactamase).

A number of varieties:

Cephalosporins - Same method of action as penicillins. Developed in three generations (now four, but not widely available). The third generation e.g., Cefotaxime (Claforan, IV only) and Ceftriaxone (Rocephin, IV only) have the most broad spectrum. They are effective against most gram positives and negatives and some variable anaerobic cover. The second generation e.g., Cefuroxime (Zinacef, oral and IV) and Cefaclor (Ceclor, oral only) also have good general cover, but are not as effective against some gram negative bacilli. This loss of gram negative cover expands to most gram -ve cocci and bacilli in the first generation cephalosporins e.g., Cephalexin (Keflex, oral only) and Cephazolin (Kefzol, IV only). The third generation is ideal for use in those with very severe generalised infection, meningitis or intra-abdominal sepsis (e.g., penetrating abdo wound or appendicitis, with metronidazole added in) and the second generation offer a good broad spectrum antibiotic for general use in skin, wound, urinary and chest infections.

Quinolones - Acts by inhibiting DNA replication in the nucleus of the replicating bacteria. New generation of antibiotics. Most common is Ciprofloxacin. Very broad spectrum cover, except anaerobes. Excellent survival AB, but my second choice due to amoxycillin + clavulanic acids better cover of anaerobes. Effective for most types of infections except intra-abdominal sepsis and gangrene.

Macrolides - Acts by inhibiting protein synthesis in the replicating bacteria. Includes Erythromycin and the newer Roxithromycin and Clarithromycin. Often used in people with a penicillin allergy, however it does have a reduced spectrum (esp. with Gram negatives), but is an alternative to tetracycline in Chlamydia. First choice in atypical pneumonias e.g., with Mycoplasma pneumonia.

Co-Trimoxazole - Acts by interfering with folate metabolism in the replicating bacteria. Previously a very broad spectrum antibiotic, now has a much more variable response rate due to resistance. Still useful for urinary and, mild chest infections.

Metronidazole - Acts by directly damaging the structure of the DNA of the bacteria/protozoa. Drug of choice for anaerobic infection. Should be used with another broad spectrum AB in any one with possible faecal contamination of a wound or intra-abdominal sepsis (such as severe appendicitis). Also the drug of choice for parasitic infections such as Giardia.

Others - There are many other antibiotics available. I have only discussed the common ones above. For further information I refer you to any Antibiotic guide, of which there are many.

NOTES

In pregnancy Penicillins and Cephalosporins are safe. Many others are not (or only during certain parts of the pregnancy). You should always check if any drug you are using is safe, before using in pregnancy and breast feeding. The PDR will tell you. If you want a specific reference try "Drugs in Pregnancy", Ed D.F Hawkins.

7.3 Suggested books

Antibiotics

8.0 The Basic Laboratory

This section contains a significant amount of technical information. It is intended as a very brief overview and introduction of the subject area. I accept no responsibility for the accuracy or otherwise of this material. A suggested books section gives more specific references for these topics:

8.1 The basics of a diagnosis can generally be reached by a careful history and physical examination. Modern medicine relies heavily on laboratory investigations. In a survival situation these will not be available. However there are some simple laboratory tests which can be performed with very little equipment or chemicals. The problem is that even basic tests require some equipment. Ranging from simple test strips to a microscope and a few chemicals. Obviously what you are preparing for will dictate what tests you may want to be able to perform.

8.2 Urine Testing: Urine is easily tested with multi-function dip stix. These can test for the presence of protein, glucose, ketones, nitrates, red blood cells and white blood cells. The test strip is dipped in a specimen of clean catch urine ( i.e. you start to pee in the toilet, stop, then start again into the specimen container, stop, and continue into the toilet) and panels containing the test reagents change colour depending on the presence and concentrations of the substance being tested for The colour changes are compared to a table supplied with the strips. Can be used to diagnose urinary infections, toxaemia in pregnancy, dehydration, diabetes (outside pregnancy) and renal stones/colic.

The following is a quote on analysing urine from a book to be published on the practice of medicine under relatively primitive conditions.

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From . Roberts, S. D.; A Guide to the Practice of Medicine Under Austere Conditions (Revised Ed.), 1997, to be published.

Urinalysis

Of the various bodily fluids, urine is the most easily obtained. It is possible to perform a number of tests on urine with little or no equipment. Visual and olfactory examination of a urine sample alone can provide considerable information. Urine which is pink, red, or red-orange may contain blood, although it is important to remember that these colors may also be seen in those who have eaten certain foods, such as beets, blackberries, or rhubarb. Urine which is green or blue- green, or which takes on these hues on standing, may indicate diseases of the liver or gall bladder. Bright yellow or yellow-orange urine is indicative of kidney dysfunction (if there is no reason for the urine to be concentrated and if the color is maintained for several days). Cloudy urine may result from abnormally high levels of phosphates or carbonates in the urine, and may be a precursor of kidney stones. Cloudy urine may also indicate the presence of an infection, particularly if the fresh urine has an odor of ammonia or other disagreeable odor (note that urine will develop an ammoniacal odor on standing).

It is possible to approximately localize an infection that is producing cloudy urine by using the three glass test. This test requires three clean containers (glasses), of which at least one (the second used) will need a capacity of at least 500 ml. In this test, the first 5 ml is voided into the first container, the second container is used until the patient is almost done, and then the third container is used to collect the last 5 ml. If the urine in the first container is the most cloudy, with decreasing cloudiness in the remaining containers, a urethral infection is the most likely cause. If the urine in the first container is less cloudy than either of the following two, a kidney, bladder, or prostate infection is indicated as the cause, while, if the urine in the third container is the cloudiest, the prostate is the likely site of the infection.

The odor of maple syrup associated with fresh urine is, of course, the classic sign of maple syrup urine disease. The urine may also have characteristic odors which are associated with other genetic disorders: the "mousy" odor associated with phenylketonuria, for instance. The presence of glucose in urine has long been recognized as an indication of diabetes, and its detection has been assigned a high degree of importance by the general public. While its presence was at one time detected by taste, a more aesthetically acceptable method (which is also less likely to transmit infection) is to heat the urine and observe the odor. If the scent of burning sugar or caramel is detected, there is an excessive amount of sugar present.

Proteins, or carbonates and phosphates, in urine may be detected by filling a test tube three- fourths full of urine and boiling the upper portion. Any cloudiness produced by this may arise from either the presence of carbonates and phosphates (which may be normal) or from the presence of proteins. These two causes may be differentiated by adding a small amount of acetic acid (3-5 drops of 10% acetic acid) to the tube: if the cloudiness vanishes, carbonates and phosphates were the cause; if the cloudiness persists (or becomes apparent only after the acid is added), proteins are present.

The iodine ring test is a simple test which can detect the presence of bile in the urine before color changes or jaundice make its' presence obvious. In this test, the appearance of a green ring after layering a 10% alcoholic iodine solution over the urine in a test tube indicates the presence of bile.

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8.3 Blood Counts: There is no easy way to do blood counts without some basic equipment. You require a microscope and a graded slide. A graded slide is a microscope slide which has very small squares etched onto its surface. Using a standardised technique a smear of blood is placed on the slide. Now using the microscope the number of different types of blood cells in a square on the slide is counted, this is then repeated several times and then averaged. This technique will give you:

8.4 Blood Grouping: The simplest thing to do is have your group or expedition blood typed prior to your expedition or TEOTWAWKI. However provided you have several basic chemicals a cross match is a simple test. But due to its potential fatal complications if done incorrectly I will not describe the procedure here. It is well described in any basic laboratory medicine textbook. Also see 'Lucifer's Hammer" quote in section 12.0.

8.5 Pregnancy Tests: The ability to accurately diagnose pregnancy may be important, both for psychological reasons and for the practical reasons. Currently available pregnancy test kits test urine for the presence of the hormone Human chorionic gonadothrophin (HCG). They require only a small amount of urine, and are accurate from 10-14 days from conception.

8.6 Blood Glucose test strips: Also known as BM stix, after a common brand. This can be used to diagnose diabetes (in a survival situation), both generally and during pregnancy, also it can detect low or high blood sugars in other severe illnesses. A finger or toe is pricked and a drop of capillary blood is collected onto a test strip. It's allowed to sit for 30 seconds, then is wiped off, and a further 90 seconds, then the colour of the test strip is compared to a control chart to give a blood glucose level.

8.7 Gram Staining: This is a technique for approximate identification of bacteria in urine, pus, sputum, cerebral spinal fluid (csf) and from bacterial cultures. Although not highly accurate in species identification, combined with a knowledge of the clinical situation, it enables a good guess to be made for the appropriate antibiotic. It requires a microscope and also several chemical solutions. This is a very standard microbiological procedure and can be learned very easily at any entry level microbiology course.

The basic technique is:

(1) the infected area or fluid is swabbed and the swab smeared onto a slide and dried and fixed.

(2) It is then washed with crystal violet for 1 min, rinsed, washed grams iodine for 1 min, long rinse, washed safranin 30 seconds, washed again then dried. It is then examined down the microscope. The bacteria will stain certain colours and appear certain shapes depending on species, this aids in identification as discussed already.

8.8 Suggested books

Microbiology

Laboratory Medicine
No ideal book in this section, but these are a couple of suggestions.

9.0 Simple Medical Tips

9.1 * Rectal Fluid Resuscitation

9.2 * Death

9.3 * Gastroenteritis and Dehydration

9.4 Sterilisation:

10.0 Alternative Therapies

11.0 Common Sense Medical Phrases

There are hundreds of little sayings within medicine about dozens of topics. At first some of them sound extremely basic or stupid, but the all have a basis in fact. Medicine is made up of common sense. Here's a selection. I welcome additions.

12.0 Quotes and Final Comments

I've included these quotes because one accurately describes a primitive medical technique, giving an example of how a life saving procedure such as cross matching blood can be done under primitive conditions and the second and third summarises several key realities of a long term TEOTWAWKI situation. Obviously I do not recommend using this procedure.

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When Maureen reached the hospital, Leonilla Malik took her and led her firmly into a front room.

"I came to help, "Maureen said, "But I wanted to talk to the wounded. One of the Tallifsen Boys was in my group and he-". "He's dead.", Leonilla said. There was no emotion in her voice. "I could use some help. Did you ever use a microscope?" "Not since college biology class" "You don't forget how" Leonilla said. "First I want a blood sample. Please sit down here." She took a hypodermic needle from a pressure cooker. "My autoclave" she said. "Not very pretty but it works." Maureen had wondered what had happened to the pressure cookers from the ranch house. She winced as the needle went into her arm. It was dull. Leonilla drew out the blood sample and carefully squirted it into a test tube which had come from a child's chemistry set. The tube went into a sock: a piece of parachute cord was attached to the sock, and Leonilla used that to whirl the test tube around and around her head. "Centrifuging" she said. "I show you how to do this and then you can do some of the work. We need more help here in the lab". She continued to swing the test tube. "There", she said. "We have separated the cells from the fluid. Now we draw off the fluid and wash the cells with saline." She worked rapidly. "Here on the shelf we have cells and fluid from the patients who need blood. I will test yours against theirs." "Don't you want to know my blood type?", Maureen asked. "Yes. In a moment. But I must make the tests anyway. I do not know the patients blood types and I have no way to find out, and this is more certain. It is merely very inconvenient."

The room had been an office. The walls had been painted not long ago and were well scrubbed. The office table where Leonilla worked was formica, and very clean. "Now", Leonilla said, "I put samples of your cells into a sample of the patient's serum, and the patient's cells in yours, so, and we look in the microscope."

The microscope had also come from a child's collection. Someone had burned the local high school before Hardy had thought to send an expedition for its science equipment. "This is very difficult to work with.", Leonilla said, "But it will work. You must be careful with the focus." She peered into the microscope. "Ah, Rouleaux cells. You cannot be a donor for this patient. Look so that you will know."

Maureen looked in the microscope. At first she saw nothing, but she worked the focus, the feel of it coming back to her fingers. Leonilla was right, she thought. You don't really forget how. She remembered that you weren't supposed to close the other eye, but she did anyway. When the instrument was properly focused she saw blood cells. "You mean the little stacks like poker chips?", she asked.

"Poker chips?"

"Like saucers-"

"Yes. Those are Rouleaux formations. They indicate clumping. Now what is your blood type?"

"A" Maureen said.

"Good. I will mark that down. We must use these file cards one for every person. I note on your card that your blood clumps that of Jacob Vinge, and note the same on his card. Now we try yours with others." She went through the same procedure again, and once more. "Ah. You can be a donor for Bill Darden. I will note that on your card and his."

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"We have no way to store whole blood, except as now - in the donor".

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"No, we must learn to live without penicillin." She grimaced. "Which means a simple cut untreated can be a death sentence. People must be made to understand that. We cannot ignore hygiene and first aid. Wash all cuts."

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12.2 For a fictional account I recommend James Wesley Rawles "TEOTWAWKI". This contains accounts of survival medicine in practice (in addition much other excellent material) with detailed descriptions of several surgical procedures and childbirth in a post-collapse society. Although there is some dramatisation to it I feel this accurately reflects some of the medical situations which will need to be faced.

12.3 These are some final thoughts about the medical situation post a severe TEOTWAWKI. I've included this just to stimulate some thoughts and discussions:

With no antibiotics there would be no treatment for bacterial infections, pneumonia and a cut would 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 effected with many dying (especially insulin dependent diabetics). There would be no anesthetic agents resulting in a 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, woman 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 were available would have to be recycled, resulting in increases risks of hepatitis and HIV infection.

THE MOST IMPORTANT THING TO REMEMBER IS THAT GOOD HYGIENE CAN PREVENT MANY PROBLEMS.

WASH YOUR HANDS AND BOIL YOUR WATER!

Any comments or suggestions welcomed. I plan to periodically update this FAQ with any recurring questions from misc.survivalism and also


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