As a reformed Christian and novice “prepper”, I am so glad to have found your blog and all the informative material that it contains. With your help, I am becoming prepared for the hard times that I believe are imminent. I am a general surgeon practicing in the southeast. Your writings have caused me to think a lot about the logistical vulnerabilities that exist in our health care system and how drastically surgery would change if/when Schumer hits the fan.
The Coming Instrument Shortages
Many instruments and most of the supplies that we use for routine operations are disposable. Hospitals typically keep no more than one or two weeks worth of surgical supplies on hand. Any interruption would be devastating to the continued provision of surgical care. Surgeries that require general anesthesia would be very problematic if not impossible. In such a scenario, Haiti and Zambia may be better positioned to provide basic surgical services than our “advanced” US hospitals because they already live by the principle of “use it up, wear it out, make do or do without.” In the third world, they routinely re-use things like surgical gloves, drapes, and suturing needles (after properly cleaning and re-sterilizing them.) In America, we have far too many government regulations and trial lawyers for us to re-use anything. Most things here go to the landfill after a single use. It seems that Haiti and Zambia are poor countries while we are “rich and increased with goods” (Revelation 3:14-19). We have no need to be frugal in the US. There is no monetary crisis coming, no unsustainable deficits, no federal Ponzi schemes ready to burst. No, no. Nothing to see here.
Having read several articles on various web sites regarding medical preparedness and wound care that are unrealistic, if not harmful, I was prompted to send a few comments regarding the virtues of “wet to dry dressings.” In managing a traumatic wound in a TEOTWAWKI scenario, your readers should keep in mind that most wounds can be left open without causing any problems whatsoever. A fresh wound is one that is 1-2 hours old. The longer the time between wound creation and closure, the more bacteria the wound is exposed to, the greater the chance of infection if closure is attempted. Right now with health care functioning fairly well, I never close a wound that is more than 6 hours old no matter how clean it appears as the risk of infection is prohibitive. If a wound is simple (a clean cut rather than frayed skin edges), fresh, and free from gross contamination, it can be copiously irrigated with saline (do a web search and print the recipe) or clean water, numbed with lidocaine injections, and sutured up. If there is any doubt, then leave it open and start a wet to dry dressing using gauze moistened with saline. Wounds with gross contamination such as the presence of dirt, leaves, or feces should always be left open even after cleaning them thoroughly. All bite wounds should be left open, especially human bite wounds as these are perhaps the dirtiest. Nearly all wounds in the body can be safely managed this way. The chief advantage of suturing a wound closed is that the scar will be more cosmetically appealing than the scar that will be left if the wound closes slowly over time with wet to dry dressings. Closing the wound will also obviate the need for painful daily wound packing (the dressing changes stop hurting after about a week). Suturing the wound can make you look like a hero, but the patient may be placed at unnecessary risk by doing so. Don’t hesitate to leave it open and pack it with gauze. Nobody will care what the scar looks like if the grid is down. If a wound is sutured and later becomes infected, cut the sutures out, open the wound with a clean (preferably gloved) finger to its depths, and begin wet to dry dressing changes. It will usually heal fine once you let the pus out.
Large abdominal wounds that go down through the muscle and fascia would be difficult to close without general anesthesia. Anyone trying to close such an abdominal wound would risk injury to the underlying bowel, creating a bigger and smellier problem. Leave it open and do wet to dry dressings. This may result in a hernia forming, but the hernia can be fixed years later when order is restored. Extremity wounds involving muscle, fascia, and tendons can safely be left open. Muscle and facial injuries almost always heal without functional deficits. Tendon repairs can prevent functional deficits, but are probably beyond the ability of non-surgeons. Most tendons can be repaired at a later date. “Sucking chest wounds” which go down into the chest cavity exposing the lung would likely be fatal in a TEOTWAWKI scenario so I will not elaborate on the three sided dressing that ATLS recommends. Open skull fractures would be un-survivable without a functioning hospital.
Gastrointestinal (GI) surgical cases such as colon cancer resections necessarily cause limited contamination of the incision resulting in frequent post-operative wound infections in spite of antibiotics. If the incision becomes infected a week after surgery, we remove the sutures, open the wound widely with a finger, and start wet to dry dressings. In operations done for ruptured appendicitis or diverticulitis where there is gross fecal contamination, we leave the incision open from the start and begin wet to dry dressing changes immediately. I have seen thousands of wounds close using this method. The wounds typically heal in 3-6 weeks, usually without incident. The wound should be packed to its depths daily with plain gauze moistened (not dripping) with saline solution. This provides an ideal environment for healing resulting in granulation tissue formation. Any devitalized or infected tissue sticks to the gauze as it begins to dry and is removed when the packing is changed. Granulation tissue fills the wound causing it to get shallower over time. Each day the wound requires less gauze. The skin edges begin to close from the sides. The depths fill in, the edges draw together, and the wound closes leaving a wide scar. It may sound fictitious, but I have seen wounds close in this fashion that were big enough to hold a 25 pound sack of rice. Leaving the wound open and performing wet to dry dressing changes greatly diminishes the risk of infection. Antibiotics are unnecessary in treating most wounds that are left open. Necrotizing (so called “flesh-eating”) bacterial wound infections will be fatal in TEOTWAWKI. Leaving wounds open will greatly reduce the chances of necrotizing fasciitis.
Contrary to some things I have read, gauze sponges do not stop bleeding. We could not live many days without a functioning clotting system. It is the clotting system that stops almost all bleeding vessels. Large veins or arteries may not stop on their own. Direct pressure with a finger or two can stop bleeding from almost any vessel outside of the abdominal or chest cavity where direct pressure cannot be held. Hold pressure for 20 minutes by the clock (no peeking) and most small and medium sized bleeders will stop. Large vessels (bigger around than a pencil) may take an hour. Once the bleeding is controlled, get the patient to a surgeon (or get a surgeon to the patient) when feasible as a large vessel has a high risk of re-bleeding in the subsequent hours/days. If none is available, two weeks of complete rest, a snug ace wrap, and a gentle dressing change each day is the best that you can do. Penetrating wounds to the abdomen or chest cavity with associated large vessel injury would be fatal.
Ligating (dividing and tying off) injured blood vessels is doable, but attempting it without a lot of previous experience can make the bleeding worse. It should be attempted only if direct pressure for an hour has failed to stop the bleeding. If the vessel is visible in the wound, clamp it with hemostats above and below the bleeding point, divide the vessel with something clean and sharp, and tie off both ends with suture (easier said than done). Sometimes a torn vessel retracts into the surrounding tissue making it difficult to find for ligation. A figure of 8 suture can be done in such a circumstance. Imagine a square postage stamp with the retracted bleeder at its center. Insert the needle at the top left corner of the stamp. The needle should travel in an arc deep through the tissue and exit at the bottom left corner of the stamp. Pull extra suture through such that the tails are long enough for tying. Next, insert the needle at the top right corner of the postage stamp passing it deep through the tissue such that it exits at the bottom right. When the knots are tied the suture will cinch down around the hidden vessel and stop it from bleeding. I recommend that you do a web search on “figure of eight suture” to see a diagram or video to make this technique clear to you. (One video shows this technique used for skin closure. I’m describing a figure of eight suture down in the wound under the skin where the bleeder is.) It can be a very useful technique in a pinch.
Trying to repair or reconstruct an injured blood vessel would be unnecessary and dangerous even for a surgeon in TEOTWAWKI except in rare circumstances. The redundancy [of “dual supply”] that God gave our bodies makes it possible to ligate most blood vessels (even large ones) with few if any adverse consequences. We should learn from our Designer (Romans 1:19-20). A tourniquet can be used briefly to stop major vessel bleeding as a bridge to surgery, but a finger usually works better if you can spare a person to hold pressure. Tourniquets are necessary in badly mangled extremities as there would be more bleeders than available fingers, but such a severe injury would likely be fatal in TEOTWAWKI. Keep in mind that limb amputation in the 1800s performed by the best surgeons of the time had a 50-90% mortality rate. Also consider the fact that a surgeon in the 1800s was far better prepared than a modern surgeon would be in a societal collapse.
Your readers will do well if they stock up on lots of 4″x 4″ and 2″ x 2″ gauze sponges as well as rolls of Kerlex gauze. Remember that gauze is woven cotton thread, not the stretchy, synthetic stuff that some manufacturers call “gauze.” Wide tape such as 3″ Medipore works well for most wound dressings. ABD pads come in handy as they are very absorbent and are used to cover the wet to dry dressing before taping it down. Make sure to get some 4″ Ace brand (or similar) wraps. Get the ones with Velcro strips on the end. These elastic wraps can be used instead of tape on an extremity to hold the dressing in place. They can be useful in bleeding extremity wounds to tightly wrap the arm or leg to help with stubborn oozing after the dressing is applied.
I recommend getting some Vaseline impregnated gauze or Xeroform which are non-stick dressings good for superficial abrasions (scrapes) and burns. Each family needs a gallon of 4% Chlorhexidine gluconate (Hibiclens or other brand) in case community acquired MRSA infections continue to plague us. It can be used as skin preparation for wound closure, but may be more useful as treatment for MRSA colonization and infections. Finally, make sure that you and your kids are current on tetanus shots, hepatitis, and other vaccines. Hopefully, by leaving all but the cleanest and freshest wounds open and pre-forming wet to dry dressing changes, more of your readers will be spared the risk of a serious wound infection in TEOTWAWKI.