Post-SHTF Anesthetic Medicine Options

[Introductory Note from JWR: The following article is presented for educational purposes only. As previously discussed in SurvivalBlog, using vinyl ether for anesthesia can be very tricky. Not only are its vapors highly flammable, but it can can induce deep levels of sedation much more quickly than desired. Thus, at a minimum can can compromise the patient’s airway, and thereby very possibly kill the patient. So unless you have both the equipment and the regularly-practiced expertise to safely intubate and extubate your patient, then do not use ether!]

Pain is not my friend!  In some circumstances, it is useful, perhaps to help guide workout intensity or to let you know that something is wrong.  As an emergency physician I frequently perform painful procedures on my patients. The last 10 years or so have seen major strides in our ability to sedate patients using [dissociative] agents like ketamine and propofol. This makes my job much easier, to say nothing of making life more pleasant for the patients who have to undergo procedures like drainage of abscesses, repositioning of fractured limbs and dislocated joints, spinal taps and repair of complex lacerations.

Luckily, to make it easier on them, and frankly possible for me, we have drugs.  Gone, for the time being, are the days of biting the bullet after a shot (or more) of whiskey, then having a few friends hold you down.  Before the invention of anesthesia, surgeons were often lauded for speed:  doing the fastest amputation was a plus for a surgeon’s career, for example. Now, we have loads of options for sedation, pain control and anesthesia.  I love giving ketamine!  It works great, and is generally very safe.  There are others, too, but obviously they all have potential drawbacks in a Schumeresque situation.

I started thinking about this when my wife, pregnant with twins, jokingly asked me late in term to “do a C-section on the kitchen table.”  Being a disaster planner at my local hospital, I inwardly cringed:  what would I do if we got hit with EMP or a coronal mass ejection (if she couldn’t deliver the old-fashioned way) to keep her and our babies from dying? 

A number of recent novels like“Patriots” and “One Second After” describe various post-crash scenes of severe infrastructure disruption that impair delivery of routine medical care. Many of these books also illustrate excellent preparedness on the part of some of their characters, who stockpiled ketamine and other medications in advance to have them available. Lidocaine, Novocaine and other local anesthetics can be used for nerve blocks and other “regional anesthesia” techniques, good to know if you are serious, but demanding of practice and subject to the same logistical concerns. 

This wonderful concept might not be realistic in some cases:  many useful medications are only available by prescription, and you may not have a sympathetic physician willing to prescribe them to you.  This applies especially to mood-altering drugs that are prone to abuse. How do you get hold of these controlled substances without a nocturnal visit from your local DEA special agents?  Sure:  you could grown your own, but poppies give an impure hodgepodge of drugs, and the druggies may be attracted to your garden as much as the cops.  Your doctor will prescribe them, you say?  Well, supposing you find someone willing to prescribe them, these medications may simply not be available:  even with prescriptions, you must figure out how to afford and store these medicines.

“Special K” is but one of many street names for ketamine, and propofol was recently made famous as a drug of abuse courtesy of Michael Jackson. What happens after TSHTF?  Count on your friendly pimps, dealers and druggies to know where this stuff is used and stored. They will surely take advantage of the lack of LEOs to gobble up as much as they can. With significant damage to the grid, we can envision stressed people resorting to violence or breaking and entering to obtain drugs of abuse. Keep in mind these are the same people who roam around the dumpsters over at the local nursing home looking for discarded narcotic fentanyl patches. They chop these up and use them to make tea, and also have been known to place them as rectal suppositories to get their high. (I’m not joking about this.)

Under these circumstances, you may not have access to anesthetic medications, and you may not choose to go looking for them, either.  For any grid crash scenario, you must have alternatives, like using “old” tools when nothing else is available.   This might include using a medication that can be produced from materials at hand to provide sedation for painful procedures.  Luckily, a few smart guys used just such a drug as an anesthetic after learning about its use as a recreational drug:  Yep, they were “huffing” in the 19th Century! Of course I am talking about ether, or more correctly diethyl ether.  You may have poured starter fluid into your carburetor in the past.  Many brands are mostly ether.  In a pinch, you can make pure ether yourself. 

All the usual kitchen chemistry safety caveats apply:  Make sure you know what you’re doing, as this is explosive stuff.  It is highly flammable, and since its vapor is denser than air, ether fumes may travel along the ground, creating the conditions for distant explosion or fire. Ether attacks plastic and rubber. Because of all this, it poses a serious fire risk when you are making or using it.  You should try to find a person knowledgeable about chemistry and preferably volatile/explosive chemicals for your intentionally chosen prepper community if you have any thoughts about doing this!!! 

Ether has a number of advantages.  Like ketamine, it stimulates respiration and doesn’t lower blood pressure, so it is good for patients in shock.  When too much ether is given, respiration becomes depressed, and the patient breaths in less, potentially self-correcting the problem.  It causes bronchodilation, so it doesn’t worsen asthma. It is a good pain reliever, so you don’t have to have other drugs, and it gives good muscle relaxation. It is especially useful for caesarean section (because the baby tolerates it and the uterus contracts well after delivery.)  Overall, it is considered medically to be a safe agent for high-risk cases (using lower doses) and is the agent of choice when general anesthesia is needed but oxygen isn’t available.

Ether anesthesia was largely abandoned due to its explosive risk. Its flammability means you should not use open flames or filaments (like cautery) with this agent nearby.  To minimize risk, keep at least 40 inches between electrical equipment and ether; vent the space naturally or with a fan.  Don’t use any electrical appliances, live plugs or sockets lower than 18 inches above the ground in the area you are using ether.  Watch out for static electricity; consider using only cotton drapes and clothes for patient and staff.  You probably will be doing many of these things by the same circumstances of TEOTWAWKI that force you to make and use ether. 

Ether has some disadvantages besides its aforementioned volatile nature.  Its effects begin and end slowly, and it may cause coughing. Finally, it causes a lot of secretions, and most folks have postoperative nausea and vomiting after ether. The main benefit, of course, is that you could make ether with simple materials that are widely scavengable, or that you can make from other simple materials.  Just to show that this is not a hypothetical suggestion, the proof is in the experience of Allied POWs during World War II who made ether in captivity. One prisoner (a surgeon) needed to tie off an aneurysm on one of his fellow POWs, digging deeply around his shoulder to do so.  His hosts, unfortunately, neglected to provide any medications to allow the procedure.

The surgeon turned to another prisoner and asked him for help.  The chemist (as pharmacists were known then) demanded two simple materials:  ethanol and sulfuric acid.  He got the ethanol from sake that some [camp guard] NCOs were making illicitly in their hut from burnt rice, and sulfuric acid stolen from batteries in the Japanese auto shop some prisoners staffed.  Two weeks later, they had brewed enough ether to do over 40 surgical procedures!  

Ether has drawbacks, no question, but if it’s all you got, you could make it and use it.  Consider, for example, that ether is still used in parts of the third world to provide anesthesia.  With some tools we have now that weren’t available to earlier anesthetists, we might be able to make it better and safer.

If you think you might use ether, you should have a few other things and more importantly, some knowledge, prior to using ether.  You should know basic airway support like chin-lift or jaw-thrust, plus use of Sellick’s maneuver to reduce aspiration, placement of oral airways, and bag-valve-mask ventilation.  Ideally, knowledge and supplies for more advanced airway management like intubation are good to have as well.  You should have atropine or glycopyrrolate (to decrease secretions) and an anti-emetic (like zofran, for nausea) when using ether as an anesthetic agent.  Suction and oropharyngeal airways will help increase the safety of ether as well. 

Use a portable pulse oximeter to monitor heart rate and oxygen level.  Nonin sells a nice portable model that gives you an audible pulse and cues you to a drop in oxygen saturation in the patient’s blood. (Obviously a pulse oximeter has many other applications in medical aid, like deciding when a pneumonia patient is sick enough to need some of the precious antibiotic you’ve stored up.)  
Your patient should have an IV for administration of fluids and medicines.  If you have ketamine, you can give one dose of this agent to make the patient sleepy, and begin having them breath in ether.  By the time the ketamine wears off, the ether will have taken effect. 

 The World Health Organization web site has a free downloadable book on austere surgery, with a good description of the techniques for using ether anesthesia.   In a pinch, you could do it the way the non-physician anesthetists use ether in many places even today:  dripping it into a piece of gauze using an ether mask like the Schimmelbusch mask, which you can improvise out of a regular medical facemask, or sometimes find on eBay.

The old style “open drop method” is to place a towel over the patient’s eyes, then drip some ether onto 10-to-12 layers of gauze held by the mask.  The mask is held a few inches above the towel and gradually lowered to cover the patient’s nose and mouth as they fall asleep.  The pupils dilate with etherization, and the muscles relax.  When the pupils dilate, you should place an oropharyngeal airway.  Further ether can then be dripped slowly onto the gauze as needed to keep the patient under. 

Stop giving ether about 20 minute prior to the end of the procedure, and assist patient respirations with a bag-valve mask to wash out the drug and speed awakening.  This may mean you put the patient out then stop giving ether, doing the procedure while the patient “emerges” from anesthesia, for short procedures. 

If you have all the know-how, all the stuff, and can safely make your own ether, you could use it for a lot of painful procedures like caesareans sections, wound care, chest tubes, fracture manipulation and the like. You may not choose to do (or even be able to do) a lot of complex surgeries, but those are probably unrealistic under the conditions where you’d want to make your own ether anyway. As always, what you can do is so much more important than what you have.