Trauma School, by John M.

Little shoots of green grass are peeking up in my part of the unnamed western state due to the unseasonably warm weather we’ve been having. Hope the sun is shining wherever you are today as well. My desire today is to share some knowledge and tidbits I’ve picked up at my job in the medical field. I hope these notes will be of benefit to you in the days ahead and that you can use them when I’m no longer coming in to work to help good folks like you because I’m at home guarding my food storage and family from the “unprepared and unprincipled”. The standard warnings apply, if you do this stuff at home pre-TEOTWAWKI, you may kill yourself or someone you love, but when there’s no other choice when the SHTF, well, you’ll have to decide for yourself. So, without further adieu…

Let’s say that you find yourself in a situation like some character in JWR’s “Patriots: A Novel of Survival in the Coming Collapse”. Living in northern Idaho, you’re a member of the resistance that is fighting back against the UN intrusion. As part of a three-member cell, you are often sent on missions for either reconnaissance or to show the opposing forces a little “Idaho welcome” with your heavily modified potato guns. Inevitably, one of your two companions suffers a fractured femur after falling from a lookout post. As they lay writhing on the ground, you instinctively know that by applying traction to the broken extremity, the muscle spasms will subside, giving your friend much relief. Take any piece of straight, rigid material you have with you, such as a branch from a tree, a walking stick, a ski pole, tent poles (doubled or tripled up and lashed together), etc., and lay them along the broken leg. Apply heavy padding to the inside of the groin and around the ankle in the form of folded t-shirts, etc. Now, use any form of rope or webbing available to tie two loops, one around the thigh high in the groin, and the other around the ankle, over the padding you just applied. Again, make sure they are well padded or you will cause more discomfort and risk interfering with circulation. They shouldn’t be loose, but don’t need to be overly tight, just enough to slip a finger or two under. Now with your remaining rope or webbing, attach the groin loop to the top tip of your straight, rigid pole. Do the same with the ankle loop, except make a simple pulley loop running from the bottom tip of the pole up through the ankle loop and back down to the tip again. In this way you can increase the amount of traction on the leg as necessary to relieve as much pain as possible. Furthermore, your rope/webbing/twine around the ankle, groin, and pole may relax with time, so you can simply unknot the pulley, pull tighter, and re-knot to keep the traction effective. When finished, lash the pole to the affected leg around the ankle and mid-calf for greater stability. One commercial option I’ve used is the Kendrick Traction Device (KTD) if you have the funds, but it is definitely not necessary. I would recommend watching a YouTube video of applying a KTD just in case you have questions about any of my instructions above, as obviously a video is worth 10,000 words.

Now that you have traction applied and your accomplice is happily enjoying a fentanyl lollypop for pain control, you need a litter to evacuate. Litters are made in all shapes and sizes. I’ll give you a couple examples, but the guiding principle here is to use your imagination and whatever is available to create a gurney-like device that you and your non-injured friend can use to haul your injured ally back to home base. The simplest option is to lay a square tarp down (maybe your tent footprint) and tie a knot in one corner to create a pocket where the injured individual’s feet will go. Then simply lay him diagonal on the tarp with his feet in the pocket, fold the tarp over top (he can even help hold it closed) and then drag him home from the head end of the tarp. In this way, one person can evacuate another without any help, but if you had some help they could lift the foot end so the injured didn’t get such a jarring ride. Obviously, don’t drag from just the foot end because it would be like being pulled down a flight of stairs by your feet. If he didn’t have a brain injury before, then he surely would after bouncing his noggin down the trail being towed by you.

The next variation on the litter just takes it a step further by adding rigidity. Lay your tarp down and run two of those rigid poles (like the ones we talked about earlier, a straight branch, a walking stick, NOT your M1A because you’re still under attack) down the center about two feet apart. Fold one straight side of the tarp over one pole, and then the opposite straight side over the other pole. Both sides are folded towards the center so they end up overlapping each other somewhere between the poles. Lay the injured between the poles on the tarp, and with one person at the head and one at the feet, lift and carry. If you don’t have a tarp handy, lay down two coats, vests, or heavy shirts (zipped or buttoned up), top to bottom or bottom to bottom, turn the arms inside out (turned into the body of the garment), and run the poles through the inverted arm holes and out the bottoms. Load the injured between the poles on the coats and carry him to help.

There are endless variations of litters, and I’ll wrap up this section with one of the most ingenious I’ve ever seen constructed. Take a long length of rope and lay it on the ground in a back and forth fashion like a snake (imagine a radio wave with high frequency and high amplitude) leaving yourself a coil of at least a third of the rope at one end. Each wave’s “amplitude” should be about three feet wide from bend to bend and the “frequency” should be about a foot apart. Next, lay the tarp down on top of the rope, adding a blanket if it’s cold out. Now you can add poles or an empty backpack for rigidity. Lay the injured on top and wrap him in the blanket and tarp like a burrito. Now with your leftover coils, start lacing the package together by “sewing” the amplitude waves over the tarp, back and forth, back and forth, until you get back to the other end. Go back through and pull out all the slack you can to really tighten it down, but save the tightening till you’ve laced all the way through or it may throw off your waves. You now have a very secure (and warm!) litter that many people can help carry, each grabbing a piece of the rope on opposite sides of the injured. Eight of us once used this litter to carry a rather heavy individual and it made the trip much easier. This also makes a great straight jacket for your friends experiencing TEOTWAWKI psychosis until they can calm down a bit.

While carrying your pal out of enemy territory, you’re probably going to be shot at and possibly even take a bullet or two. Assuming you don’t get shot anywhere really bad like the guts, heart, lungs, brain, spine, etc., you may live! Bring out those fish antibiotics and open wide, friends. I’m not going to cover the “sucking chest wound” or anything that would require a wound vac, a chest tube with suction, or any other heroic medical measures, because it is a very precarious situation to find yourself in a level one trauma hospital, let alone TEOTWAWKI. I’ll just say that if you get shot in the arm or leg or whatever and you don’t exsanguinate, then clean the wound very well with a mixture of half hydrogen peroxide and half normal saline, pack gently with iodoform gauze using a sterile cotton-tipped applicator (or anything sterile), and cover with sterile gauze and tape. Iodoform gauze comes in many widths, I personally like the ¼ or ½ inch varieties because they get in the crevices better. Take the dressing off every day, rinse with the ½ hydrogen peroxide ½ saline, and pack again with new iodoform gauze (using strict sterile technique!) and cover. Eventually (this may take a long time) the wound will begin to granulate and it will fill in. Keep feeding this person protein! I have personally taken care of people that either got shot or suffered some other penetrating injury through the legs, abdomen, flank, and arms who eventually recovered with this course of treatment. As far as antibiotics, I’ll leave that to Dr. Bob, but basically just keep taking whatever you have and keep the wound as clean and sterile as possible. Since I know you really want me to say some names to satisfy your cravings, my favorite antibiotics for this type of wound seem to be trimethoprim/sulfamethoxazole (Bactrim) by mouth and of course cephazolin (Ancef) one or two grams every eight to twelve hours if you have IV capabilities.

On the topic of antibiotics, no one ever mentions the side effects. If you are on antibiotics for a few days or more, you may get a nasty little red rash in your privates and some super funky white growth in your mouth. That is fungus growing in your moist bits. There is a natural war happening all the time between your bacteria and your fungi (who knew you were such a “fun-guy”). When you load up on the antibiotics, it gives the fungi the go ahead to take over those moist, dark places of your body. You need an anti-fungal such as nystatin or miconazole, but in a serious pinch I would try some crushed garlic, citronella oil, coconut oil, iodine, tea tree oil, or some of the other alternatives you can find cruising the web. I am not an infectious disease expert! I have just always had nystatin and it has always worked. Keep as dry as you can with baby powder and clean those areas scrupulously and often.

When your team mate fell off that lookout and broke his femur, he may or may not think about his dislocated kneecap until a bit later. Dislocations can happen in all the joints- shoulders, knees, fingers, etc. Each is put back into place a bit differently, but the principle is always the same, slow steady traction. In some Hollywood movie, a character dislocates his shoulder, and to reduce it (the medical term for putting it back in place) he rams his shoulder full steam into a wall or something. That’s Hollywood for you. In the real world, every time I’ve dislocated my shoulder, the doc applies slow steady traction until the muscles fatigue and stop their spasms and the joint will pop back in almost on it’s own. Man, I can’t tell you how good it feels when it does that. Don’t be surprised by the sound, I promise it is a relief, but be prepared for weak-stomached onlookers to faint when they hear it.

The how-to of reducing dislocations is a topic in itself, but just in case you ever find yourself alone in TEOTWAWKI with a dislocated shoulder, here is what I would do. Find a flat place to lay face down where you can hang your arm over the side, a kitchen table is ideal. Place something heavy on the floor, a five or ten pound dumbbell or ammo can. Lay face down on the table with the affected arm hanging over the side and gently pick up the weight and hold it just off the floor, with your arm hanging straight down, then try and relax and think some happy thoughts. After a while, your shoulder muscles will tire from the traction of weight, and they will allow the head of the humerus to slip back into the labrum (the ball back into the socket). You’ll know when it happens, I promise. Warning- do not dislocate your shoulder more than you have to, it will become so loose that it slips out in your sleep, quiet a weird experience to wake up to. After TEOTWAWKI, you won’t be able to get your orthopedic surgeon neighbor to do the surgery you need quite as readily.

Knees and hips follow the same principle, but you need another person to help. For knees, lay the “patient” flat on the table with the affected knee bent at 90 degrees, wrap your elbow around the back of the lower leg at the top of the calf muscle, and apply traction away from the pelvis. You’ll probably need someone holding the patient’s shoulders so you don’t pull them off the table while you’re holding traction. The top of the tibia will eventually slip back into connection with the condyles of the femur. Hips are essentially the same positioning (person laying on back, knee bent at 90 degrees, the “doctor’s” elbow wrapped under the knee to provide traction) except they require rotation (abduction) of the leg to the outside to get the trochanter (top of the femur) moved out of the way and back into the socket. Again, this is a topic that requires a little more than a paragraph. Your local paramedic or emergency room doctor can lead you aright, but YouTube is always a great place to start if you don’t have time to volunteer on Friday nights at your local emergency department. All the standard warnings apply, if you do this at home pre-TEOTWAWKI, you risk nerve impingement or circulatory disruption and you could lose the function of your extremity at the least and eventually die from any number of possible sequelae.

Since we’ve covered dislocations, we should quickly cover ligaments. Ligaments are those awesome pieces of 550 paracord that God put in and around our joints to hold them together and keep them moving in the right fashion. If your friend who fell off his LP/OP is complaining of pain in the knee, you can examine the four knee ligaments to determine if he has a tear. With him laying on his back and the knee flexed at 90 degrees, gently attempt to move the tibia forwards and backwards at the joint. You can practice this right now where you’re sitting if your knee is bent. With your hand resting over your kneecap, use your other arm to push and pull your lower leg (the top of your tibia) towards and away from your pelvis by pushing at the top of the calf muscle in the back and just below the kneecap in the front. You may feel slight movement, but more than slight movement or intense pain while doing this following an injury is indicative of a tear. The other two ligaments are tested by attempting to angle the lower leg inward and outward (adducting and abducting) while holding the thigh still. If you get movement or pain, your in trouble. Rest, ice, elevation, compression, ibuprofen, and a good knee brace will be the TEOTWAWKI prescription for healing, since you won’t be getting any tendon repair surgery post-SHTF.

At this point I’m going to slip in a quick note about the spine. When your buddy hit the ground and commenced his injured state, there’s a high likelihood he also suffered a spinal injury of one level or another. The most frequently injured portion is from the base of the skull down through the neck, the cervical or “c-spine” area. Think of those videos of motor vehicle crash test dummies. When they hit the wall, their neck flexes down till their chin touches their sternum and then extends back up in a whiplash movement. That’s a c-spine injury. One of the first things paramedics do when they reach the scene of the crash is to immobilize the c-spine with a hard collar. At my facility we use the Aspen brand, but you can buy any number of hard cervical collars. After the wreck, people are so focused on their other injuries that they sometimes don’t notice the aching neck, or they think it’s just an ache and shrug it off. Unless you’ve squirreled away a CT scanner and neurosurgeon at your retreat (hey, it could happen), leave that collar on for six weeks! You’ve got a much better chance of decreasing the subsequent neurological impairment by keeping the neck immobilized, as well as decreasing further injury when the injury swells. You’ll know you’ve got a problem when you can’t move or feel an arm, but I’ve seen people walk in with three column vertebral fractures, not knowing that if they broke that fourth column they’d sever their spinal cord and become an instant quadriplegic. Under the current guidelines, we leave the collar on for three to four days till the other injuries subside, then get flexion/extension films of the c-spine before removing the collar. Post-TEOTWAWKI, six weeks of a hard collar is going to be a lot better than any amount of nerve impairment that reduces motor control or sensation. Lastly, the collar should be snug! Loose collars are as useless as not having one on at all.

To conduct a TEOTWAWKI neuro exam, have the “patient” flex, extend, abduct, and adduct his arms, hands, legs, and feet against resistance. Any focal weakness, numbness, tingling, or pain is indicative of nerve impairment. If any member of my group showed such signs, they’d likely be relegated to bed rest with bedside commode privileges for six weeks. Obviously they’re going to get stiff and weak and grumpy, but better than losing the ability to walk because of a thoracic or lumbar fracture that got worse because of too much activity. The hardest part is learning to get out of bed correctly. Learning the log roll can really help. Flex the knee 90 degrees opposite the side of the bed you plan to get out of. Reach the ipsilateral (same side) arm across your chest and grab the side of the bed. Pull yourself onto your side with that arm and by pushing with your flexed leg. Focus on keeping your hips and shoulders square to each other to prevent twisting in your spine. You are now on your side close to the edge of the bed you’ll be getting out on. As you drop your legs over the side of the bed, push yourself to a sitting position using the hand you pulled yourself over with and the elbow you rolled onto. That’s the log roll, and it will save your back a ton of straining and stress if you have a fracture or some pulled muscles. Some Flexeril, Soma, or Valium will help those muscles relax and quit their spasms, but you’re going to look like a druggie if you go ask your doc for them. Try alternating ice packs with heat packs, and stay on top of the pain meds.

Speaking of pain, I keep waiting to read a “how-to acupuncture” article on SurvivalBlog, but until then will just have to keep stockpiling the acetaminophen, aspirin, ibuprofen, and naproxen. Pain is a topic unto itself, but for the moment suffice it to say I would direct the reader to an excellent presentation called “Pain Management in the Wilderness” by Casey Turner and Patrick Zimmerman of Wilderness Medicine of Utah. It gives the topic of pain a thorough but easily understandable examination. For further reading I recommend “Wilderness Medicine” by Paul S. Auerbach, MD, and “Pain Management in the Wilderness and Operational Setting” by Col. Ian Wedmore, MD. Since reading up on wilderness medicine is basically the same as SHTF medicine, you cannot go wrong with the Wilderness Medical Society, the Wilderness Medicine Institute, or the Wilderness and Environmental Medicine Journal. I take no responsibility if you learn how to do a peripheral nerve block or employ herbs in any manner.

One final thought- if your friend doesn’t die from the initial impact, the lack of modern medical care, or the innumerable complications that we haven’t discussed, it sure would be pitiful for him to expire from a bowel blockage after he lays around for weeks and sucks down your narcotic supply like a kid in a candy store. Bowel movements are close to, if not the number one reason people spend an extra day in the hospital after surgery. All those pain pills put your bowels to sleep, and coupled with long hours in bed, you’ve got a recipe for constipation turned deadly. You better have some senna, docusate sodium (Colace), biscodyl suppositories, and Fleet enemas stockpiled. Give the senna and Colace one or two times a day starting immediately, and mandate a suppository or enema or both on day two or three post injury if no bowel movement.. They may not feel like eating or drinking, but fiber and liquids are a must and should be encouraged. If you have done all of the above but cannot produce a bowel movement and cannot hear bowel tones when listening to the abdomen with your stethoscope, the person will presumably be vomiting foul smelling bile and it’s time to start digging if you don’t have access to a nasogastric tube and intermittent suction.

Well friends, that’s about all I have to say for now. Here’s to us all being well versed and well prepared for a coming day in the future when the ER has been ransacked and the grocery stores are empty. Maybe we’ll meet and trade some junk silver for some .22 LR, or you could trade some of your new-found medical knowledge to someone in desperate need in exchange for a mansion in our Father’s Kingdom. May God’s blessings rest upon you and yours.