Perhaps you are a civilian EMT, paramedic or RN that has found interest in preparedness, or you are an established prepper who has taken an EMT class or a Wilderness EMT class, but are having some difficulty with bridge to the world that has no power grid, no Internet and lacks a certain social cohesion. Even military medics will be challenged in this situation, as they are currently accustomed to having modern equipment, restock and a means of patient evacuation (in most cases). Either way you bring essential experience and knowledge to your preparedness group as the medical specialist, but lack in certain areas. This article will help to begin the adaptation of your knowledge and skill set to the world without modern medicine.
The austere environment is one in which evacuation to definitive care is extremely delayed or non-existent. Without power modern electronic diagnostic and treatment options will be very limited or not possible. Many medicines will be unusable and re-supply of medical equipment will not occur. In addition, running (and potable water) and modern sanitation will not be available, nor will the assistance of law enforcement. Think post-Katrina or Haiti and extend that indefinitely.
If you are a current practitioner, ask yourself how much of your EMS or nursing education covered care in this environment. Maybe it was alluded to in the MCI chapters if you were lucky. The mental context that you currently practice in will be a hindrance in the austere environment. Or, if you are a prepper whose chosen profession was not medicine, having a collection of disparate skills and knowledge has limited usefulness without knowing how to triage and prioritize your care.
Now before you run off scared and think that this is impossible and that you will be stuck in a Civil War- era medical setting, stop and reflect. Regardless of what event caused the modern tools of medicine to be limited, it did not drain away your knowledge base, experience and common sense that got you this far in your career or preparedness. Your ability to assess, diagnose and adapt were the foundation of your practice and abilities before the event, and will be afterwards.
I have been a paramedic, supervisor and educator in various capacities in public safety for over 20 yrs. I have also done some wilderness medicine and participated in several long- term disaster responses. My wife (who is an RN and worked in the same capacities) and I have been actively prepping for awhile now and have a good grasp on preparedness thanks in large part to Rawlesian philosophy and other selected experts. I firmly believe that preparedness must be embraced by the medical community and that their contributions to society must be extended into whatever challenging environments that we may face as society.
There are four main differences in your practice that will be very different in the austere environment that must be understood. First, you may need to defer treatment and walk away from patients that you would currently treat aggressively. Second, you will need to get out of the mindset of transport or referral to definitive care. Third, will be the need for improvisation in supplies. Finally, you will need to develop or expand your knowledge of preventative medicine. The overall goal will be to treat what you can, given what you have, and keep minor to moderate medical/trauma conditions from worsening, or better yet, not occurring. It will truly be a mix of modern medicine, public health, wilderness medicine and elements of combat medicine.
Your triage, initial assessment and ABCs will be the same as they are now. In a MASCAL setting patients are triaged into the Red category for life threats; Yellow for moderate and delayed; and Green for minor conditions. The difference will come when you encounter a life threatening condition. Whether it is a patient triaged as a red tag patient; or a single, critical medical or trauma patient; a determination will need to be made on, “Can we definitively fix this”, and/or how many people will be needed. Secondarily, you must ask, “Do we have the supplies to do this”, and/or will others suffer from a lack of supplies if expended on this potentially mortal patient.
If you cannot definitively treat the patient’s life threat and/or, others with less severe conditions will become emergent without the supplies at hand, then the patient must be secondarily triaged as Expectant. These are patients that are critical but will die despite all interventions. This category is rarely used outside of large MASCAL incidents. The idea is to treat those with the best chance of survival and do the most good for the most people.
Major trauma such as head injuries with increasing intracranial pressure; internal hemorrhage; spinal injuries; and chest trauma will all likely be placed in the expectant category. Yes, you can perform needle decompression for a GSW to the chest, but then what? Jerry-rig a Pleura-Vac with a chest tube? What about surgical intervention and the dedicated personnel for continuing care of this patient? Even if the first 1-2 hours of care can be accomplished, the definitive and continuing advanced care will not be possible.
On the other hand, if your assessment revealed an obstructed airway (foreign body or positional) or an external hemorrhage’ then these conditions could be corrected, and definitively cared for in an austere environment and should be given the needed attention.
Obviously medical patients that would receive critical care as definitive care, such as heart attacks, strokes and those in need of resuscitation, would be unable to receive it without functioning hospitals so their triage category would also be expectant. Some very limited cardiac care could be done for those not needing invasive procedures but it would depend on the availability of specific medicine and electric power.
However, some chronic medical conditions, that can be life threatening in specific circumstances, could be successfully treated even in the austere environment. Allergic reactions and anaphylaxis; asthma; hypoglycemic diabetics; seizures (from epilepsy); and dehydration could all be treated with the judicious use of medicine and IV fluids. Long term management of these conditions could prove the most challenging due to the inability to maintain a supply of needed medications (i.e. insulin, antihistamines or adrenalin).
We currently live in an area of medical specialization and few providers care for a patient from beginning to end. In the austere environment the complete opposite will be true. If you are a willing medical provider you will be the initial and definitive care. This will be similar to rural primary care without the capability of consults, transport or referral. This fact will also impact many other aspects of life in a post-collapse world.
Except for selected life threats as described above, your main focus will be on minor to moderate conditions, such as lacerations, extremity fractures, minor infections, heat exposure/dehydration and pain management. Your scope of practice will necessarily change out of circumstance. Remember, good treatment of minor conditions will prevent a deterioration of them into a condition that is untreatable.
If you are an RN that does not currently perform wound debridement and closure; if you are a paramedic that does not commonly participate in long term care (bed sore prevention, long term pain management, etc); or you are a physician that does not commonly handle fracture realignment, you will need to get the training to achieve a baseline competency in these procedures at a minimum.
Although no complete course in austere care currently exists, there are some courses that can be adapted to the austere environment. Wilderness medicine courses are good for expanding a provider’s knowledge of improvisation. These courses also put you in an austere setting for realism. AMEDD combat medic (68W) or Special Operations Combat Medic (18D) certified medics are superior resources for trauma care and preventative medicine. (Most who have this background are willing to teach and show what they know to other professionals). Doctors Without Borders also is an excellent organization that can provide experience that could approximate the conditions that you could face if society implodes. SurvivalBlog also has published articles, and references to other resources for elements of this type of training.
No matter how well you prepare and stockpile medical supplies, eventually you will run out, need replacements and reach expiration dates. Some preplanning for this eventuality will avoid having to ask the infamous question, “Now what?” Care outside of a hospital has always had a degree of improvisation to it, especially in the wilderness. Every Wilderness medicine text will have no less than three ways to create a traction splint, but few providers have had the need to find alternative supplies and methods to practice definitive care. What follows is a sampling of some possibilities. It will take ingenuity in order to be safe and successful. Several archived articles on Survivalblog address this issue as well.
Wound Closure
Silk thread that has not been dyed and unwaxed dental floss, as well as the thinnest gauge fishing line, could be used to suture lacerations. Scalp lacerations can be temporarily closed by twisting the hairs on each edge of the wound into braids; tying off the distal end of each braid; and then tying the braids into a small knot cinching the laceration closed (Auerbach).
Oral Rehydration
A simple electrolyte solution can be made from everyday cooking supplies. Crushed multivitamins can also be added to the solution. To 1 liter of fresh, potable water add: ½ tsp salt (3.5 G); ¼ tsp salt substitute (KCl- 1.5 G); ½ tsp baking soda (bicarbonate-2.5 G); and 2-3 Tbsp of sugar or honey (sucrose- 20G). Pedialyte can be roughly approximated by cutting the additive amounts in half.
Sterilization
A turkey fryer outfit (unused for cooking) can be used to boil water to a sufficient temperature to kill anything but some bacterial spores. Aluminum is a perfect material and many fryers come with baskets that can hold smaller instruments and needles. The long ladles are also practical for removing sterilized supplies. Time should be for 30 minutes and a smaller stock pot will work faster. Adding 2% sodium carbonate solution will increase effectiveness in a 10:1 ratio to water
Urine Sample Assessment
Litmus paper used for pool water can give a rough estimation of the pH of urine. Other non-medical chemical test strips could be used in a similar manner. A urine sample left outdoors for 24 hours which is covered in ants can accurately diagnose high blood sugar and diabetes.
Physical Examination Techniques
Without x-rays, CAT scans and MRIs, providers will need to re-discover the older techniques of actually touching their patients for assessment. The use of percussion to assess for air-filled or fluid-filled body cavities can be used to diagnose various pathologies. Palpation of the left lower abdominal quadrant eliciting rebound pain on the right lower quadrant can help diagnose appendicitis (McBurney’s sign). Kernig’s sign (touching the patient’s chin to chest eliciting neck pain) can help diagnose meningitis if present with fever, malaise and aseptic meningitis syndrome (AMS).
Many take modern medical care for granted and as a result prevention is disregarded, or at best, an afterthought. In the medical literature and texts it is a topic that gets limited emphasis and the least time devoted to it. In the austere environment, due to the limited supplies and lack of definitive care, prevention will be essential. There are three main areas of prevention that will be your focus: injury prevention, infection control and nutrition.
Injury prevention is a topic that is glossed over in medical curriculums at any level of training. Although important in modern society, it will take on a much higher importance when the ability to treat trauma is limited. This area may not be directly supervised by medical personnel, but ensuring that some prevention controls are in place will be important. Training in the proper use of tools (especially farm equipment) and firearms will be key to preventing unnecessary injuries. Likewise, the use of protective equipment (from ballistic vests to work gloves) will be another focus.
Infection control will need to be a watchword due to the limited supply of antibiotics in the austere environment. Proper wound debridement, cleansing and closure will be essential skills for all medical personnel. Medical specialists will also likely be responsible for disinfection of medical treatment areas; bleach preparation; and overseeing food and water preparation/storage.
Nutrition will be challenging for several reasons in post-collapse world. Although our dependence on fast food will come to end, and improve our diet, the selection of healthy foods that are available in the modern world will greatly decline. Without a balanced diet of carbs, fats and protein people will develop deficiencies and be more prone to infectious disease. The average male, working at the laborious tasks of survival for 8 hours a day, needs approximately 3,500 calories per day to avoid weight loss and general health decline. Accordingly, the medical specialist may be called on for advice on meal plans, crop selection and supplementation depending on the expertise in the group.
As you prepare to be the medical specialist for your retreat group, or for your family, keep these concepts in mind and let them guide you as you stockpile supplies; recruit new members and get more medical assistance; and continue your training. Many of the older methods of assessment and treatment will have to be re-discovered if the conveniences of modern medicine are no longer available. But the difference between us and our predecessors will be that we have that body of knowledge to fall back on, and as society reorders itself, we will be able to re-establish modern medicine.
Reference: Auerbach, Paul. Wilderness Medicine. Mosby: 2008.