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When considering the question of appendicitis at TEOTWAWKI the most important questions are these:
1.     What is the cause?
2.     How can it be recognized?
3.     Who is most at risk?
4.     Is it always fatal?
5.     Can it be treated non-surgically?
6.     Should it be removed before TEOTWAWKI?
Appendicitis is caused by a blockage of the appendix, which varies according to age.  In children and young adults this is usually due to infection.  In the elderly it is usually due to hardened feces.  In developing countries appendicitis may be caused by parasites.  In people with an inflamed bowel it can be due to swollen lymphoid tissue, which can also occur with stomach flu, viral respiratory infections, measles, or mononucleosis.
Once the blockage has occurred, the appendix swells due to continued production and trapping of secretions, causing the appendix to enlarge like a water balloon until it bursts, spewing the contents into the abdomen (peritoneal cavity), leading to sepsis (overwhelming infection), and death.  The inflammation also draws white blood cells to the area, which produces pus and additional pressure.
Also, once the pressure within the appendix rises too high, this acts like a tourniquet, cutting off the circulation to the appendix.  This injures the lining of the appendix, which allows infection to invade the wall of the appendix, and may lead to gangrene of the appendix and/or perforation (a hole in, or bursting of, the appendix). 

What symptoms does this lead to?  As S.M.G. describes, the classic history is one of loss of appetite associated with pain around the navel, followed by nausea and right lower abdominal pain.  Unfortunately, no single symptom or test is completely accurate in diagnosing appendicitis.  Only 50% of patients have vomiting.  Because the location of the appendix varies, the location of the pain may vary.  Even with modern medicine, 20% of cases of appendicitis are misdiagnosed as something else.  Though surgeons hope to be 100% accurate, even now up to 40% of patients who undergo emergency appendectomy are found to have a normal appendix.  When someone claims that they have cured appendicitis at the painful and nauseous state by administering a purgative, I question the accuracy of the diagnosis.

The classic signs described above occur only half the time in true appendicitis (diagnosed with surgery and pathological examination of the appendix).  Nausea and loss of appetite occur most but not all the time, and at the same rate that occur with other causes of abdominal pain. Vomiting that follows onset of pain is more typical of appendicitis than vomiting that precedes abdominal pain.  Diarrhea or constipation may occur with appendicitis, and the diagnosis of either as a cause for abdominal pain does not rule out appendicitis.

Abdominal pain is the most consistent symptom of appendicitis.  The migration of the pain from one location to another increases the likelihood of a correct diagnosis of appendicitis.  Fever is not usually present early on.  Appendicitis can be confused with bladder infection, kidney stones, endometriosis, ovarian cysts, diverticulitis, gallbladder disease, intestinal virus or other infection, or duodenal ulcers.   
If this is the case now, what will it be at TEOTWAWKI?  Will diagnostic accuracy improve in a scenario without blood testing or internal imaging (CAT scans, MRI, ultrasounds).  Not likely.   No doubt cases of appendicitis will not be diagnosed as such, possibly leading to fatality.  Other causes of abdominal pain will be mistaken as appendicitis, sometimes leading to treatments being mistaken as cures.

Since a person can live a completely normal life without an appendix, should it then be removed to prevent a life-threatening emergency at TEOTWAWKI?  The current incidence of appendicitis in the U.S. is about 1 per 1,000 people per year, with a 7% lifetime risk.  (This is less than the incidence of breast cancer.  Should women have prophylactic mastectomies before TEOTWAWKI as well?  Just a thought.)  No doctor is likely to perform such a surgery unless you have a documented genetic predisposition to appendicitis (and insurance is not likely to pay either). 
The incidence of appendicitis is less in undeveloped countries where the intake of dietary fiber is much higher, and is actually decreasing in developed countries where dietary intake of fiber has increased.  Dietary fiber draws water into the stool, making feces softer and less likely to form fecaliths (stone-like feces) which may obstruct the bowel or appendix.

The best answer for prevention of appendicitis is a high fiber diet, high enough to keep the stools on the softer side.  A bowel movement that has the consistency of a soft banana is about right.      

Without treatment is appendicitis always fatal?  The standard answer is “yes,” though the truth is “not always.”  If an obstruction is relieved, the inflammation may resolve without treatment.  I have seen a few cases of recurrent appendicitis which were not recognized as such until the appendix was eventually removed.  At times the body will wall off the infection resulting in a local abscess which prevents bacteria from entering the blood stream.    
Can antibiotics help?  An interesting study by Eriksson (BR J Surg. 1995; 82(2):166-9) compared antibiotic therapy alone to surgery.  Their conclusion was that IV antibiotic treatment (followed by oral antibiotics) was as effective for acute appendicitis as was surgery, though 7 of 20 patients who took antibiotic therapy alone had recurrent symptoms within a year (and underwent subsequent appendectomy).

Can appendicitis be treated with oral antibiotics alone?  While I have never tried this, if surgery were not an option, I would treat acute appendicitis much as I have treated acute diverticulitis, a fairly common illness in the middle-aged and elderly.  For diverticulitis I commonly prescribe either ciprofloxacin plus metronidazole, or Levaquin plus metronidazole.  Other possibilities might be amoxicillin-clavulanate plus metronidazole or trimethoprim-sulfamethoxazole plus metronidazole.  It generally takes two antibiotics used in combination to kill intestinal bacteria (aerobic and anaerobic bacteria).   
If you believe you or your loved one is suffering from appendicitis, go to the nearest emergency room.  However, at TEOTWAWKI, if no surgeon is available, administering the above antibiotics may be life-saving.  It will not cure everyone, and the likelihood of recurrence is high.  Still, it is a much better answer than doing nothing at all, and gives the patient at least a fighting chance of survival. 

About the Author: Dr. Cynthia J. Koelker is SurvivalBlog’s Medical Editor. Her web site is: www.ArmageddonMedicine.net 

Sir:
I am an Emergency Room physician in Arizona and a preparist.  When I treat people with Type 1 diabetes I routinely mention the need to stockpile and safeguard insulin and diabetes supplies.  When the patient is agreeable I write prescriptions for extra supplies on the spot.  One of my patients told me about Wal-Mart’s ReliOn brand of regular insulin, which is about half the price of other U-100s.  Those SB readers who are physicians and other healthcare providers have an obligation to their patients to inform them and help them obtain the medication and supplies they will need when TSHTF. – Dr. John in in Arizona

JWR:
First, many thanks to AERC for a very well-written article on Type 1 diabetics in SHTF situations. It was greatly appreciated and well written.

My youngest son (now 7) was diagnosed as a Type 1 diabetic about 2 months after I read [the novel] One Second After by William R. Forstchen (the daughter of the main character is a Type 1 diabetic), and along with getting used to our “new normal” lifestyle, I have also been trying to get prepped over the past 18 months in case SHTF. We are stocking up on insulin, test strips and other supplies, but I felt more was needed. My biggest concerns are 1) refrigeration for medications, and 2) protecting vital equipment from EMP/solar flare bursts.

My solution to refrigeration has been to begin testing a small “six-pack” refrigerator with a battery connection, which my father-in-law found at a swap meet. (I’ve also seen “battery powered coolers” for sale elsewhere.) This refrigerator is big enough to hold a few dozen vials of insulin and requires much less power than any other refrigerator. To keep it going long-term, I plan to rotate several car/deep cell batteries with a solar trickle charger for the duration of the emergency. Based on AERC’s article, I’ll also be looking at other alternatives as well. [JWR Adds: With a couple of 40 watt photovoltaic panels and a charge controller, you should be able to keep a refrigerator running for up to eight years. (The limiting factor is the sulfation of lead-acid batteries.]

For protection against EMP and solar flares, I intend to build a Faraday cage for extra diabetes electronic equipment such as an extra blood glucose test kit (along with radios, laptop, etc.). One possibility I will be trying is a 2-drawer filing cabinet conversion; the instructions are at Instructables. There are other possibilities I’m researching now for small, easy-to-build Faraday cages.

Even with a prepper mentality, along with a parent’s acquired nerves of steel….I still haven’t been able to pick up and read One Second After again since my son’s diagnosis. Just can’t do it. But articles like this one give me hope that, with proper planning, we can weather almost anything as a family. Thanks again. – Z. from Arizona

Dear JWR:
Another option not mentioned in the article is a DC refrigerator, batteries, charge controller, and a few solar panels.  There are other uses for this setup as well. One brand of compact refrigerators to consider is Sundanzer. – S.B., MD

About five years ago, my husband started worrying about many things happening to our country and the world in general.  Bird flu, inflation, resource grabbing, bank bail outs, government policies, Peak Oil… and more provided fuel for his concern.  As I listened to him talk about what was happening in the world, I began to think about what to do in a situation that would dramatically alter our “way of life”.  We already had goats, sheep, pigs, rabbits and chickens.  We already had a nice sized garden and I already canned what we didn’t eat fresh, but it wasn’t done with a plan to store anything for more than a few months.    We started working on our food storage and stockpiling animal feed until we hit a huge wall:  How would I deal with having diabetes if I couldn’t get my monthly insulin and blood checking strip refills? 

I have been a diabetic since the age of 6 – so about 40 years.  I became diabetic when all insulin was derived from pork or beef pancreases.  Blood checking machines weren’t even available until I turned 14.  Back then, I had to collect urine and use an eye dropper to put a certain number of drops of urine and add a reagent to see if I was spilling sugar in my urine.  Unfortunately this is one of the least accurate methods of checking how the body is processing food and if the person needs more insulin which is why I would need to go into the hospital for a finger prick and blood test once a week.  As a child, my blood sugars would vary from 200mg/dl to 350mg/dl and higher (normal is around 70).  Control was very difficult to achieve, particularly in a young person who is growing and going through hormone changes. 

Today, we are fortunate in that we can buy blood checking machines in several different brands and blood checking strips to go with them.  These wonderful devices give a result in 5 seconds and tell the person what is going on in their body right now (taking blood from a finger actually shows what happened 10-15 minutes prior, but it is the most accurate result that is available at home).  We also have different kinds of insulin available, from insulin that will react within a couple minutes to insulin that will last 24 hours.  All insulin available in the US right now is human insulin (it is human derived insulin which is grown in the laboratory using e-coli bacteria that is genetically modified to make insulin that is virtually identical to the insulin made by human pancreases) We also have insulin pumps that can include a device to give up to date blood sugar readings.  A diabetic has so many options that they can have extremely tight control and can live very normal lives with few complications. 

Unfortunately, all of the supplies needed to keep a diabetic under control would soon run out if anything interrupts the system needed to run the laboratory that makes this lifesaving hormone and all of the paraphernalia a person with diabetes needs to keep good control.  Sure, pharmacies keep a supply of insulin on hand, but it needs to be refrigerated and even then, has a relatively short shelf life.  So what can a diabetic do if they are confronted with a widespread grid down situation or even a long term break down of “normal” operations? 

The following is not to be used as medical advice.  I am not a doctor and even if I were, what you take from this article is meant to give you some suggestions based on my experiences.  Make sure that you talk to your regular medical professional and take their advice and make informed decisions.

The diabetic confronts some serious issues in a SHTF situation.  They may not be able to obtain insulin.  They may not be able to keep the insulin they have cool.  They may not be able to check their blood sugar.  They may be able to obtain one kind of insulin but not their usual insulin.  They may be on more than one kind of insulin but only be able to obtain one of them.  They may not have enough blood checking strips.  Their blood checking machines may no longer work (in an EMP situation).  They may not have batteries for their machines.  Their pumps may no longer work.  They may not be able to get the pump components.  Diabetics on Ace inhibitors may not be able to get their pills.  Diabetics who are experiencing complications from their disease may not be able to obtain dialysis or other vital treatments.  The problems facing a person with diabetes seem almost endless.

As a diabetic, I had to take a hard look at what I could be facing if I were not able to get my supplies.  I pondered the problem for a long time.  I did lots of research and came up with all kinds of conflicting information on storing diabetic supplies.  All of the official sites talked about how open vials of insulin should be thrown away on day 28 (because it degrades at room temperature). Syringes were to be used once and tossed.   Insulin was no good after the expiration date.  So, I decided to use myself as a guinea pig.  First I began reusing syringes.  I would keep my bottle of insulin on the refrigerator shelf and put the syringe beside it. Amazingly, I did not get any infections.  I also continued using both kinds of insulin after the 28 day mark.  Here again, I didn’t experience any issues with the insulin degrading past the 28 day mark.  I decided to talk to my doctor about what I had found.  My doctor was not the “prepper” type and was a bit dismayed at my using my insulin differently than before, but knew that not only was I stubborn, but I was also extremely well controlled (HA1C of 6.5).  She told me that if she noticed a spike in my HA1C readings she would take issue with my new way of doing things.  Of course, I check my blood sugars a minimum of 10 times a day before meals, after meals, before bed and during the night so if I had a spike or drop in blood sugar I could immediately correct it.  A little background to explain what an HA1C is; Hemoglobin A1C (HA1C) is a component of hemoglobin that glucose binds to.  Doctors use this measurement to give a broader picture of diabetic control.  This means that it is an average of the blood sugars for the previous three or four months.  A “normal” person’s HA1C should be between 4.5 and 6. 

See:

What Is What Is A1C And What Does It Measure?

and,

The Hemoglobin A1c (HbA1c) Test for Diabetes (at WebMD)

Prior to my experimenting, I had been using the insulin pump but had stopped for a period of time.  I didn’t like the pump because I was prone to getting infections at the injection site.  I talked to my doctor and came up with a Lantus/Humalog combination that worked for me and kept my blood sugars under control.  I then decided I would start stockpiling insulin, but how was I going to overcome the expiration date issue?  I talked to my doctor and mentioned that I was concerned about issues that would cause problems with being able to get diabetes supplies and she gave me a prescription for double my monthly prescriptions. So every month, I used a bottle and saved a bottle.  Of course I rotated my stock but occasionally, a bottle would get overlooked and near its expiration date.  I decided to perform an experiment and leave a couple bottles and use them past the expiration date.  The first bottle I used was 6 months past the expiration date and it worked like one that was brand new so I let another bottle go a year past the expiration date and again, no problems.  Right now, I am using insulin a couple years past its expiration date and it still works.  Of course, my bottles of insulin are kept very cold in a very good refrigerator which might be a reason they haven’t degraded, but they still work as normal.  I think we can conclude that if insulin is kept at optimal temperature, which is around 40 degrees Fahrenheit it doesn’t degrade like insulin kept at improper temperatures which might shorten its storage ability.  As an aside, pork and beef derived insulin is available internationally and might be able to be stored longer due to it being pure insulin and not chemically manufactured.  Keep in mind that using any other kind of insulin other than what your doctor prescribes carries with it a risk.  You need to make sure you are discussing this with your doctor and getting his or her suggestions as far as boluses and times.   If you do decide to go back to using animal derived insulin you are in good company.  I know many diabetics who feel that the genetically modified insulin has made them feel “unhealthy”.  Do your research and decide for yourself with the help of your doctor.

The first concern a person with diabetes should have is how to ensure their insulin is kept cold in a grid down situation.  There are several ways to keep things cool.  The first is a root cellar.  Root cellars which are dug deeply enough and insulated well can maintain a year round temperature of about 40F.  The most important thing to remember is that a thermometer needs to be kept inside the cellar to keep track of the temperature.  If the goal is to create an environment to keep insulin at a constant temperature this needs to be a priority.  A second method of refrigeration could be a “Servel” LP Gas refrigerator.  Unfortunately, long term LP might be a bit iffy, but it is definitely an option which should be considered.  [JWR Adds: There are still a number of brands of LP refrigerators being made. Most of these are made for the RV market and hence are fairly small and thrifty to use. A couple of SurvivalBlog advertisers sell them. Also keep in mind that almost any LP freezer can be run at its lowest flame setting to have it work as a refrigerator, with an interior temperature in the low 40s.] I have heard that this refrigerator is no longer being manufactured in the US due to issues with leakage, but I have used them and as long as they are kept in an outbuilding, and they are monitored for malfunction, they should work just fine.  I have seen them on CraigsList as well.  

Another method that can keep insulin cold is a “pot-in-pot” which uses a large earthenware pot with a smaller pot set inside of it.  Wet sand is put in between the two pots.  The moisture in the sand evaporates and cools the contents of the smaller pot.  The sand needs to be kept wet, but this could be an emergency way of keeping insulin cold. The fourth is to put the insulin in a waterproof container and an insulated cooler (the cooler is to add an extra layer of protection against fluctuating temperatures) and immerse the entire contraption into cold water such as a lake or a stream.  Before doing so however, the temperature of the water must be measured over a period of time to determine if it is an appropriate temperature for the insulin.  However, even if it isn’t, as long as the temperature is not at or below freezing, and it is cooler than ambient temperature, it can help to prolong the life of insulin.  I have heard some medical professionals mention that an additive has been put in human insulin to make it “shelf stable”.  Regardless of this, I still keep my insulin refrigerated.  If only to ensure that I can store it for the longest period of time possible.

The second concern for the diabetic is to find ways to check blood sugars and ketones.   A dangerous problem that diabetics who have prolonged high blood sugar can experience is ketoacidosis.  This is when the body doesn’t have enough insulin to digest food that is ingested and instead starts to break down fat and muscle for fuel.  The waste product created is called ketones.   Now everybody has heard of protein diets and how they cause ketones which in turn cause weight loss.  In a diabetic who is experiencing ketoacidosis, they not only have ketones but they also have high blood sugar.  The biggest problem is that the body has no way to deal with high blood sugar other than insulin and if a person is diabetic, their pancreas does not make any, so a vicious cycle is entered into.   Both ketones and sugar are excreted by the kidneys and can cause kidney damage as well as further complications due to dehydration.  If a person has high blood sugar and ketones for more than 24 hours and this situation is not corrected with insulin, the diabetic will enter into diabetic coma and ultimately die.   

Because of this, diabetics should stockpile Ketostix which is a urine test that can show if the diabetic is spilling ketones.  If they are, checking blood sugars would be the first thing to do.  The easiest way to check blood sugars is to use a blood checking machine.  There are many excellent brands on the market.  I have purchased several of the same brand and keep many months of blood checking strips and batteries.  Blood checking strips can be purchased over the counter but many insurance companies will cover them.  I have a very good relationship with my doctor and routinely ask for about 100 strips more than I use a month.  Of course strips also have an expiration date but I vac pac them to keep moisture out which is the biggest no-no for the reagent strip.  But, what if there is something that causes a problem for the machine?  The best thing to do is to have back up strips that can give a visual reading.  Unfortunately these are not available in the US but BetaChek.com will ship them worldwide.   The key to avoiding ketoacidosis is to make sure to check blood sugars regularly and correct high blood sugar.  This issue needs to be discussed thoroughly with your doctor and a sliding scale of bolus insulin should be charted.  This is vital. 

Many diabetics today use one of the insulin pump models available on the market today.  These devices have helped many people with diabetes achieve very tight control.  Unfortunately the pump components may not be available if we experience an interruption in modern services.  Make sure to store extra batteries for the pump, extra pump sets and reservoirs, extra sterile pads, extra glucose monitoring supplies if you use “continuous glucose monitoring” and/or any other things needed to keep the pump operational.  Additionally, make sure to store plenty of extra insulin.  Not only the fast acting insulin used in the pump, but also long acting insulin for a pump failure.  Prepare for a SHTF situation by having a discussion about what injectable insulin to use with your doctor. 

Many doctors will put their patients on several different medications that will lower blood pressure, protect kidneys or lower cholesterol.  It goes without saying that the most important thing a prepper can do is to make lifestyle changes that will protect the circulatory system, but it is vital that a diabetic who is on these medications stockpile them as well.  It is crucial that the diabetic speak with his or her doctor and ask for double prescriptions.  This is easier to do than most people think.  If the diabetic is on a 50mg pill once a day, ask for a prescription that is 50mg twice a day or 100mg once a day and split the pills.  This way the person can put the extra away every month.  It might be a good idea to look outside of the US to purchase additional stock of these medications.  These meds can often prolong a person’s health and are an important addition to a diabetic’s medical stockpile.    Again, discuss this with your doctor.  Some pills can’t be split without it affecting the medication delivery.  These choices should not be attempted without thorough research and medical advice.

Unfortunately there are diabetics that have had additional complications that have compromised their eyesight or kidneys (or other organs).  It can’t be stressed enough that the person with these complications be completely forthright with their doctor with concerns about the future.  Discuss options that can be done at home.  A good way to get your medical professional on your side is to talk to them about the aftermath of Katrina, Sandy and the weather issues that have caused blackouts and power failures.  Talk to them about how you can deal with this.  This is particularly important if you are on dialysis or suffer from infections that aren’t healing.  Talk to them about how to manage these problems if you can’t go into the clinic.  Ask them what medications to use and ask them for additional supplies “just in case”.  Talk to your medical professional about alternative dialysis procedures, and if you are a candidate for these.  If you have already had transplant surgery, make sure you discuss what you should be doing for your immune system and how you can get additional anti-rejection medication as well as the shelf life of these necessary drugs. 

Something that needs to be discussed is pregnancy in diabetics.  In a long term SHTF situation, pregnancy must be avoided.  A diabetic pregnancy is very high risk now when we have modern conveniences available.  If they are interrupted long term, the repercussions could be terrible for a diabetic.  I have had three children and my last was the most difficult.  My blood sugars were perfect throughout my pregnancy but diabetes affects the entire system.  My daughter was born 6 weeks early because of placental insufficiency.  In a SHTF situation both she and I would have died.  Make sure to store condoms, birth control pills, and/or anything else to prevent pregnancy. 

The last part of this is dealing with reality.  I know that if systems are interrupted long term that I most likely won’t survive.  Yes, I feel as if I can stockpile my medications for years, but ultimately they will lose their effectiveness over time.  If I am unable to get more, I need to prepare for the inevitable.  I don’t want to think that way, but just because I don’t like it doesn’t mean I shouldn’t prepare for it.  We do the best we can for as long we can but a diabetic has an organ that no longer works.  If insulin is no longer available it won’t take long before the diabetic goes into ketoacidosis, coma and death.  This conversation should be had with all family members so all can prepare for this eventuality.  I hope and pray that if we do experience a SHTF scenario that we can rebuild before my stockpiles run out, but if not, I want my heart, soul and family to be ready for the end.

There are 25.8 million diabetics in the US and about 371 million worldwide. Most of these are Type II diabetes but for those of us who are Type I, we need to think ahead.  Most Type II diabetics can control their disease with diet and exercise, but not all.  For those of us who need insulin and other medication, we need to plan.  I hope that this will help a person who has diabetes as well as their family prepare for a SHTF situation.  Do your research.  Decide what the best approach is for you and talk to your medical professional.  Find a doctor that is willing to work with you and help you prepare.  I have included some links at the bottom of this article that can help give some suggestions about the different types of insulin available.  Look at the links that are included in the article as well as those at the bottom.  Learn as much as you can about your condition and prepare, prepare, prepare. 

Further Reading:

http://care.diabetesjournals.org/content/25/suppl_1/s112.full
http://www.iddt.org/wp-content/uploads/2011/05/JDN15-1pg32-6.pdf
http://www.iddtindia.org/whichinsulin.asp
https://secure.pharmacytimes.com/lessons/200510-03.asp
http://www.diabeticconnect.com/discussions/5892-pork-insulin-what-i-have-learned
http://www.idf.org/about-insulin-0
http://care.diabetesjournals.org/content/4/2/180