Practical Medicine, by S.S.

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This is the first in what I hope will be several articles discussing field medicine in a TEOTWAWKI scenario. The information contained is for informational purposes only and is not meant to replace a call to 911 when that service is available. It also does not replace prompt attention from a medical provider. There are many areas where I purposely “gloss” over the worst-case scenario, so as to more effectively instruct the new first responder on proper mindset. This is not to say that the worst can’t happen; only, honestly if it does, then no amount of Internet training will be able to assist you. That being said, there are a lot of garden-variety “emergencies” that the general public CAN and SHOULD be able to handle on their own with just a little bit of knowledge!

Emergency Medical Services (EMS) have come a long way in the last few decades. Even though the scope of our practice is inherently limited to a few life and limb saving procedures and medications, for the uninitiated, the basics of EMS can seem daunting. As a relatively new provider myself, I sometimes look at what I am “authorized” to do and try to imagine it from the point of view of the public– “Wow, those guys are like doctors!”

Here is a little about me. I am a certified Emergency Medical Technician Intermediate. This is the bridge certification between an Emergency Medical Technician Basic and a full Paramedic. In practice (in my state/locality), I am authorized to perform nearly every procedure and medication administration that a paramedic does. I perform these tasks per protocol (without a specific doctor’s order) under my own initiative. There are plenty that have been doing this longer than me, but I feel it important to share a few things that could benefit anyone in a post-SHTF situation.

Let’s say you are working outside on your farm and you hear a call for help. This call originates from your son who has tripped and fallen into a furrow. A number of things flash through your mind, such as how to help him when there is no doctor? Call 911? Oh wait…..

First Responder

So for now put on your EMT helmet and step back for a moment and approach this problem like a seasoned first responder.

  1. Scene Safety: This is not a “check the box” item. Is it truly answering is it safe for you to render care? Is there a big dog nearby who might be unhappy with you for “helping” its owner? Is there an undesirable with a gun? Is there a downed power line nearby? All of these and more are myriad hazards that first responders would consider before even opening the door. Adrenalin is not your friend. Today you are a clinician. Today you must think clearly. I admonish you to stop and take your own pulse. Remember: If you become injured, then you are a patient too, and you will be of less use to those you love.
  2. Overall presentation: This is the 1000-foot view. Do they look sick or not sick? To follow with our example of a seemingly-simple trip-and-fall, does the patient appear to be in acute distress from pain or merely inconvenienced? This important piece of information will inform your next steps and the urgency in which you do them.
  3. Control life-threats:
    1. Circulation: Are there any major bleeds? Correcting this ASAP is a top priority. There are many tricks a medic can use to increase blood “volume”, but once oxygen carrying stuff is outside the body it doesn’t go back in.
    2. Airway: Is the patient in a position where they can breathe on their own? Sometimes people land in such a way that their own body collapses the airway. The patient could be choking on a foreign object, such as food or vomit. Clear this carefully. (There is more on this later.)
    3. Breathing: Some people are tempted to place this first. This is simply not the best practice. The realistic situation is that the body can operate on the oxygen stored in your blood (unless the blood is leaking out!) for a short period of time. This means that while making sure the person is breathing is vital, it is not more important than securing circulatory status. It also certainly cannot be more important than making sure the mechanisms for breathing (clear airway) are intact.
  4. Vital signs: I have no expectation that you will sit there with a blood pressure cuff and take careful notes of the patient’s hemodynamic stability. What I will say is that you should allow your view of the overall presentation to flow into a more detailed look at how effectively the patient is moving blood around the body.
    1. Mental status: Are they awake? Are they alert? Are they oriented to person/place/time/recent events? Ascertain this by talking to the patient. If they seem “with it”, that’s excellent. If they do not, then they are less stable.
    2. Skin color/temperature/moisture. A patient who is pale/cool/sweaty is less stable than one who is “pink, warm, and dry”.
    3. Radial pulse. This is one of the more “clinical” things I will ask you to do. A radial pulse is very helpful tool as it tells a clinician a lot about how effectively the heart is pumping blood. Consider that the radial artery is located pretty far from the heart. Logically then a strong, regular radial pulse shows that the patient’s heart is maintaining enough blood pressure to perfuse most of the body. This is important as it establishes a baseline minimum blood pressure of 70 systolic. (Systolic is the top number of the blood pressure statement.)

      To obtain a radial pulse, move your first and second finger (index and middle finger) to the inside of your patient’s wrist. Position your fingers such that they are towards the upper part of the wrist. With very gentle pressure you should feel a rhythmic pulsing. Count the number of pulses you feel for one minute. This is the patient’s heart rate. Practice this on yourself and family members. It is a very important clinical skill.

Congratulations. By completing the above you have actually assessed the initial condition of your patient effectively. Let’s assume the following about our trip-and-fall from earlier:

  1. You arrive to the location of the patient and find no immediate life-threats.
  2. The patient is noted to be a 17 year old male (your son). Initially, the patient seems to be in pain, but he is “dealing” with it okay.
  3. The patient is talking to you. This allows you to comfortably assume a pulse, since dead people don’t talk outside of movies; a clear airway; and breathing adequate to sustain life.
  4. Vitals: Since you left your sphygmomanometer (blood pressure cuff) at home, you do some basic checks. The patient is able to relay to you that while weeding he slipped and fell. The patient reports feeling a twisting motion in his ankle and hearing/feeling a popping sound/sensation. The patient’s skin is noted to be pink, warm, and dry. The patient has a radial pulse of 72.

This is the picture of what would “normally” be an injury of inconvenience and not necessarily a death sentence. Maybe your regional medical facility is still functioning on some level. If so, his prognosis is excellent! Even if it is not, there is something you can do for the patient.

Focused Physical Exam:

In this case we have an isolated injury to the ankle. Clinicians are very interested in the status of areas distal to or past the injury. In this case, we will examine the foot first.

  1. Pulse: Does blood flow past the injury? Find the pedal pulse. This pulse point is located on the top of the foot near the middle. If this is your first time finding this pulse point, find it on yourself using the same technique as the radial pulse, just in a new spot. Once you have the knack of it, try it on your patient. Pulses distal to the injury are indicative of good circulation. Absent pulses may mean that the patient has a pinched artery.
  2. Motor function: Can the patient wiggle their toes? Yes, it will hurt. Do it once, briefly, anyway.
  3. Sensation: Can the patient feel you touching their toes?

Assuming that we have intact pulse, motor function, and sensation (PMS), we can now examine the injury site. Is there evidence of a compound fracture (bone ends sticking out of the skin)? Is there obvious swelling or deformity?

There most likely will be swelling, at a minimum, with this type of injury. If the patient does in fact have a compound fracture, this will require the immediate attention of a doctor. The same is true for a pulseless extremity. There is a possibility that realignment will restore pulses, but this is something that must be done very carefully and is outside the scope of this article. In all of these scenarios though, I encourage you to take the time to do what you can before moving the patient. This will keep the patient comfortable and reduce the chance you make the injury worse.

Splinting:

On to the treatment! You may not have the latest in self-hardening splinting material, but you can still effectively immobilize the area with some common items. I break this down into the “hard” stuff and the “wrapping” stuff.

Hard stuff:

  1. Cardboard: This works very well for short-term splints, when secured properly.
  2. Chicken wire: Some commercial splints are just plain old chicken wire (with the ends carefully folded down so that they don’t stab your patient).
  3. Sheet metal: Not my favorite, but it will work.

All of the above should be cut to approximately three-foot lengths and three to four inches wide.

Wrapping Stuff:

  1. Ace wrap: This is my favorite wrap. It will add an element of compression, which may help with swelling.
  2. Gauze: Even unprepared people seem to have this laying around.
  3. Old t-shirt: Cut this into strips of cloth.

Gingerly take your hard splinting material and place the strip along the bottom of the patient’s injured foot and run it up the back of the leg. The material needs to go from the toes to approximately mid-calf. You will have extra, but that’s okay. Fold it back so that it goes back down the leg or cut it off. Secure the hard material with your wrapping material of choice. Wrap from the bottom of the splint (by the toes) to the top.

Reassess your patient!

Recheck PMS. If something changed, note it and expedite high levels of care. Splinting is a pain-relieving process. It genuinely helps make people more comfortable.

Overview: This article focused heavily on performing a modified EMT-style assessment. Quickly ascertaining the level of injury and the extent of the damage is crucial to making good decisions about care. A good assessment should buy you the information you need to make confident, informed decisions about care. This is less important today with an ER or an urgent care on every corner, but it will be more so in a post-SHTF scenario, when the closest medical treatment may be four hours away! If this article was interesting to you, I encourage you to seek out more medical training via an EMT-Basic course. These courses are generally not very long and can impart a lot of knowledge about the human body in a short amount of time.

Remember, you may be the only “clinician” available. That doesn’t mean you are a doctor or that you know everything. Please utilize local medical resources for serious injuries.