Two Letters Re: Beyond First Aid–Where to Learn Medical Skills

It’s funny how life gets in the way. I was in the process of writing a fairly long (I stopped at 15 pages) discussion of pandemics and medical care at home when the report in Chest came out. Suffice it to say that the wind was somewhat taken from my sails. And my take-home messages would have been 1) Hospitals are terrible places to be in a pandemic so stay away (I plan to), 2) Since you’re not going to the hospital, people at home better learn how to do basic nursing care (so finding older nursing textbooks and patient care equipment like bedpans is a good idea), and 3) despite what all of medical science can, and cannot do, think about what to do when your family member succumbs to the disease.

I’m also pleased to see the various good points offered by others with regard to medical care. The Western Rifle Shooters Association course looks particularly good. Almost all of the various suggestions are good, but there are a couple of things that need to be emphasized:

For example, having antibiotics and administering them can be very good – but, you have to use the right antibiotic for the organism in question. Using an antibiotic that is effective against (say) Gram-positive organisms when the patient has a Gram-negative infection is not ‘almost as good’ or ‘close enough’, it’s not only not at all helpful, it can make the patient much worse (not to mention using up valuable resources that are not easily replaced). There is a reason there are lots of different antibiotics, and there is no one magic bullet that works on everything.

Starting an IV is sometimes necessary, but usually not – we use them in the hospital to keep a route open for drug administration right away, should it be needed, and to provide fluids. However, the current Tactical Casualty Care Guidelines (used by military medics in combat, and limited in applicability to that sort of trauma, only) call for IV fluids to be withheld until hemorrhage (bleeding) is stopped. Not only is it wasteful of scarce resources (in combat, you only have what you have, not unlike a TEOTWAWKI situation), but adding more fluids to drain out onto the ground is actually dangerous to the patient (IV fluids don’t carry oxygen, and washing out red blood cells is a bad idea). So, stopping the bleeding (if any) comes first.

In a medical (the patient is sick, not hurt) situation, keeping the patient hydrated is important, but giving too much fluids via IV can be just as harmful – especially in a respiratory infection kind of pandemic: The fluid has to go somewhere, and can build up in the lungs causing pulmonary edema and eventually heart failure. In fact, this is one of the modalities that people died from during the 1918 influenza pandemic. IVs too, can cause harm if used with gusto by people who don’t fully understand the physiology of the body.

Also, being able to apply a cast is great – but, if the fracture is not reduced (straightened) first, the person will be left with a life-long disability. If the blood vessels are compromised (either by the fracture, or the treatment) the persons limb will certainly be put at significant risk, and their life very much potentially so. It’s not a matter of simply applying a cast. And should a person need a wet plaster cast applied to a leg (for example), it will be several days at least before the cast will be strong enough to be moved, so the patient will require bed rest and care for that time – and as you and others have said, they will require a wheel chair and crutches for several months while the leg heals – a big plaster cast is heavy. And care must be taken to not apply the cast too tightly, to monitor the cast and limb for swelling and be ready to cut it open (bivalve it) if swelling is present, and the right amount of padding must be used since the plaster gets pretty hot while it is curing.

And finally, there are few (if any) reasons why a wound must be sutured in the field. All wounds will heal, eventually, and it’s often better to leave a wound that is contaminated with foreign matter open than to close it. All wounds must be cleaned out, and while we will use sterile water or saline solution plain clean water is just fine. Using a 30cc syringe with a 22 gauge angiocath (a flexible needle used for IV administration) will provide about the ideal pressure, but using a plastic bag with a small hole poked in it will work adequately. The important thing is to get the wound cleaned out – dirt, leaves, blood clots, and anything else not viable – including dead and dying tissue, which must be removed surgically (we call that debriding). Then, the body is made in layers, and when you’re sewing it up it each layer has to be sewn separately, with each layer using a particular kind of suture material, a particular needle, and a particular kind of stitches. Even closing a ‘simple’ skin laceration can cause problems if the edges of the wound are pulled too tightly – blood flow is compromised, the tissue dies, and infection sets in leading to sepsis and gangrene.
After all, the first rule of medicine is “First, do no harm”. – Flighter


Chuck Fenwick at Medical Corps runs a fine operation, but there are other ways to learn to suture. Chuck does have great surgical equipment and suture material for sale at very good prices.
First download Ethicon’s book on wound closure, or buy a printed copy from, among other places.

This is the same book (in a newer edition, of course) that I was taught with back in the early 1960s in my summer job as an ortho tech while in college.
Then get the necessary instruments (needle-holder, surgical scissors, etc.), including a package or two of suture with an atraumatic needle (needle attached) or separate curved needles. Don’t worry about sterile technique at this point. You’re learning technique and to tie knots.

Next, order a fresh ham (not smoked) from your butcher or the local grocer. This will be your “patient”. Now make a small incision through the skin of the ham, maybe 4″ long. Suture the incision following the directions in the manual. Then make another incision and suture it closed. Continue this until you can close an incision at a reasonable speed with a nice neat row of stitches. This is how I learned to suture, at the kitchen table at home.

Finally, remove all the sutures, bake the ham, and serve with red cabbage and sweet potatoes for Sunday dinner. I hope this is of help to your readers. – Jonas P.

JWR Adds: Keep in mind that most wounds do not require suturing–although failing to do so will likely result in the formation of some extra scar tissue. But remember that we are talking about TEOTWAWKI here–not a beauty contest. Also, don’t be in a hurry to suture! In most cases wounds should indeed be allowed to drain extensively, and premature closure could actually increase the risk of sepsis.