I am a peace officer by trade, but I am also a paramedic. This article will have five sections to it, based on experiences, thoughts, and training that I have seen and done on a few topics that I think may benefit the readers. The daily sections will be:
- Certifications/Training Options
- Tactical Combat Casualty Care Lessons/Training
- Canine ALS/TCCC
- Selection of Gear Carried
- Training Tips
A lot of this will be geared towards the retreat group that already has some medical training and for the medical coordinator, but it is applicable to someone looking to start somewhere.
First, let me share a little background on me. I am based in the western U.S. I can’t speak for the east coast, but in the west, it is common for the Forest Service to contract with local law enforcement to patrol and handle calls for service within the National Forest that fall within those local jurisdictional boundaries. USFS LEO’s are tasked primarily with resource protection, so this approach lets them focus on that while not neglecting the public’s needs for peace keeping. My current assignment is in this role. There are currently 20 of us in the division. My squad consists of five, and we have a little over 1000 square miles of patrol area. We range from a hundred degrees in the summer to snow in winters, with over 7000 feet of elevation change. There are a few rivers and lakes in the area. We have very few full-time residents in the area, and those that are full-time residents tend to introduce themselves with the ranch they ride for at the end of their name. There are some very popular recreation areas in our beat, so we deal with a lot of campers, hunters, fishermen, ATV riders, and day trippers that find misfortune.
I am a state and nationally-certified paramedic, and I was an EMT before that. I am a Wildlife First Responder and am Canine ALS trained. I am a NAEMT instructor, EMT instructor, and Tactical Combat Casualty Care/Trauma First Responder/ Law Enforcement First Responder instructor as well. I am the liaison between our department and our medical volunteer group. I have other law enforcement certifications as well, but they don’t pertain to this article.
This duty post is a very interesting look into mini-SHTF situations that the general public encounters. We (myself, a squad mate or two, and the patient/patient’s party) are often very isolated, with whatever gear we have on scene. We are often times assisted by whoever is in the victim’s group; this help has ranged from EMT’s, nurses, and doctors to good Samaritans. I have had the opportunity to witness all levels of people provide care in the field– some great, some awful. There are some interesting trends with each. While we see a few medical calls (medical as in difficulty breathing or stomach pain), most of our calls are trauma based– vehicle/ATV accidents, shootings, stabbings, falls, fights, prop cuts from boats, et cetera. In addition, I end up acting as the default care provider for my co-workers, for everything from cuts and scrapes, deep splinters, allergic reactions, and dehydration to infections that were left untreated too long and pulled muscles. (Why go to town and fill out paperwork when I can get this solved here?) I share duties for coordinating medical training for my division as well as for our volunteers. Nothing in this article is legal or medical advice. It is merely my observations and experiences from these unique situations that I’ve chronicled for the benefit of others, with an eye towards practicing medicine under austere conditions. I will talk about different certification levels. Many of the skills discussed may be outside of your scope of practice, and this is no way an endorsement for you to perform them. However, there may come a day when your knowledge and skill in them may save a life.
If you are looking into advanced medical training for yourself or group, it is often a daunting task. In addition to time away from work, there is often a large cost associated with any training available. Can you get by on a weekend course? Should you go longer? Should your group sponsor a member to go through something bigger and then re-teach it to the others? Is it worth it to get certified?
Common training avenues include pre-hospital options (like CPR/first aid, EMT, paramedic, and the Wilderness First Aid series) and nursing. I am not going to delve into NP, PA, MD, or DO. These deserve a separate article. Hopefully, this run down may help you plan for your retreat’s medical needs. Medical systems will change greatly at TEOTWAWKI, and the training options need to be looked at in this light.
At a minimum, CPR and basic first aid should be learned by all group members. My agency puts on free classes for the public, and most communities offer them free as well. This is bare bones stuff, covering basic wound care and splinting, RICE, et cetera. It is a very low cost, low time investment. Everyone above age ten (or younger, depending on the individual) should be certified.
As mentioned above, first aid training is usually broken up into two schools– EMS and hospital or nursing.
EMT or BLS (Basic Life Support) is usually considered the next step up from first aid. It is taught at local community colleges, or through special EMS schools. The EMT idea was devised by the National Highway Transportation Safety Administration in the 1960’s as a way to deal with the increase in vehicular trauma. Trauma is what EMT is about. EMT covers basic anatomy and physiology, recognition and treatment of shock, recognizing and treating basic problems with the ABC’s, and basic wound care. It is first aid on steroids. This is not a knock. It is the basics, but the basics with a very high level of comfort and skill. A good EMT can do amazing things. Once you have your EMT certification, most communities offer free continuing education (CE) classes to meet annual requirements. EMT’s have limited pharmacology, and a few systems allow them to start IV’s and carry limited medications.
In the same way the EMT idea was designed to deal with vehicular trauma, paramedics or ALS (advanced life support) were designed to deal with cardiac events. Paramedic is usually a 12-24 month certification. Besides EMT skills, medics have extensive cardiology training, pharmacology, pathophysiology, and other advanced skills, such as intubation and needle decompression. Paramedics carry a cardiac monitor and a drug box. A vast majority of it is still basic stuff, but with an even higher level of comfort. As an example, EMTs and medics are both trained in child birth. In EMT, it is covered in class. In paramedic, in addition to class, you have to assist with a certain number of births to pass.
EMT and paramedic are both considered pre-hospital level care. Both operate under a doctor’s license at their base hospital. You have “offline” and “online” protocols for patient care. Offline protocols are written orders that your doctor allows you to perform on any patient meeting the stated criteria. For example, I can give Benadryl or epinephrine to a patient having an allergic reaction without having to call in first. Online protocols or a ”patch” is where you call the base hospital and speak directly to a doctor for orders, usually for a complicated situation or for something outside of your protocols. For example, if I’m allowed to give a certain amount of morphine, but a patient with a high opiate tolerance and a compound fracture needs more to control the pain, I can patch through to a doctor, explain the situation, and seek permission to go outside of the normal protocols.
Both EMT and medic are exceptional with dealing with emergency scenes and immediate life saving care. Neither of these certifications includes any long-term patient care training, and this is a huge downside of EMS training in a SHTF world. The ”golden hour” is the standard of care for EMS systems. It is the goal of getting a patient from the time of accident to the hospital within one hour. EMS is designed to stabilize and go. Even with a critical care paramedic, such as a flight medic, you are stabilizing them to get them to surgery. So, you can intubate the unresponsive patient with massive head trauma to keep them alive to get them to the hospital, but what if the hospital is gone? EMS training is also hindered by the relatively short transport time. If the hospital is 30 minutes away, a doctor is not going to allow anything risky to be done in the field. Wounds are covered and transported, not cleaned, washed, and dressed on scene. Why waste ten minutes on scene trying to do a thorough cleaning of a wound when the hospital is ten minutes away, and they are going to re-clean and dress the wound anyway? Broken bones or dislocations are not set or reduced, unless a pulse is missing in the extremity. Even with a weak pulse, a reduction in blood flow, and nerve transmission will not tend to have long lasting effects, so why risk causing more harm? With this in mind, the limitations of EMS training come into view. The care is designed for minutes and hours, not days and weeks.
The wilderness series of certifications was designed to address some of the lack of long-term patient care training and the reduced availability of equipment for first responders, EMTs, and medics operating in remote back country areas. Think about your back country hunting guide or remote search and rescue team. Instead of an hour by the patient’s side before you reach higher care, think more in the 2-5 day range of time. In addition to the entire EMS curriculum, Wilderness teaches some additional skill sets. A few of these include reducing dislocations, bandaging/infection care, and clearing C-spine in the field. A lot of it is scouting basics, such as field expedient splinting and bandaging materials. Imagine you are on day three of a five day hike. Your hiking partner slips and rolls down a hill, dislocating his shoulder and opening up a nasty gash on his arm. In the three days it will take to hike out, infection will set in if not properly cleaned. If the dislocation is not reduced, lifelong deficits could develop. If you can’t clear C-spine in the field, you have to leave him there and go get help. These are not realistic options, so Wilderness Protocols were developed. As stated above with online and offline protocols, Wilderness Protocols are a set of guidelines for patient care when traditional EMS is not available.
I am a huge fan and supporter of the wilderness series of EMS. Our current protocols are a blend of traditional and wilderness ones. Our usual patient care time to transfer is from 30 minutes to four hours, but 8-12 hour time frames occur on a monthly basis. (Think rappelling to a patient and having to do a helicopter long line extraction), and we have been on scene for over 24 hours before, in extreme cases. A large portion of our patrol area is accessible only by boat, helicopter, or foot. We are blessed with a very good base hospital and a doctor who has taken the time to get to know us, our limitations, and the area we work in. Our pre-hospital coordinator is also in charge of emergency preparedness, and they are both realists. We have very liberal medication policies, due to the lack of radio reception in many areas, and we can clear some c-spine in the field among other things. Our hospital would rather have well-trained people capable of making independent decisions in the field, if needed, knowing we may not be able to patch, and then explain why we did what we did later. There is a huge responsibility with this, but it can be and is addressed with training. This is the basis of the mindset for Wilderness first aid, and should be the basis for your group’s planning.
As much of a supporter of the Wilderness Series as I am, it still has some limitations. It contains no patient rehab or long-term care. It covers hours to a few days but not weeks. As a side note, I have also seen that for some reason when someone is trained in Wilderness first aid, they have a hard time correctly applying it. People do not rise to the occasion; they sink to their level of training. So rather than treat the broken arm and shoulder injury by just safety pinning the bottom of the patient’s shirt to the collar in a make shift triangular bandage sling or some other simple fix, they feel a need to whittle a splint from birch bark and use natural grasses to tie it all up. I’m not joking. This is a consistent theme. I’ve seen people with paracord bracelets and all sorts of usable quality medical gear (including large first aid kits!) feel a need to use the most rudimentary option they can devise, just because they are surrounded by trees. I blame the approach to training. For the most part, people that take those classes are outdoorsy types, and they get caught up in the chance to play survivor man. I think most don’t have any other medical training, so they lose sight of the overall goal of patient care and get fixated on that cool thing they saw in class. Also, if you are Wilderness certified as an EMT but operating in the ”city”, wilderness protocols do not apply.
In the same way EMS was designed to stabilize and get the patient to a hospital for treatment, nursing came about as its namesake; it is about nursing people back to health. Nurses originally took over after the doctor provided initial treatment, and they provided all aspects of recovery care. As hospitals have modernized (read as cut budgets and staffing) nurses have branched out into many other aspects of patient care, because in a nut shell, they cost less than doctors do. If you go to the ER, you will be triaged by a nurse, assessed by a nurse, a doctor will see you for a few minutes, then a nurse will provide the care the doctor prescribed. If you have surgery, it is very likely a Nurse Anesthetist will be the one putting you to sleep, not the anesthesiologist. Like EMS providers, nurses have patient care protocols. There are certain interventions they can perform, but they need a doctor’s orders for most care or medication administration. Nursing is usually broken up into CNA, LPN, and RN/BSN. (I’m sorry if I left any specialties out).
CNA is a 6-week course that is pretty much taking vitals, basic first aid, and changing bed sheets and bed pans. It’s the jobs in the hospital no one wants to do.
LPN is a year to 18 months, and includes all of the fun of CNA, plus a few more patient care aspects, phlebotomy, and some medication. They go over assessments, triage, et cetera.
RN is a two year program, and BSN is a four year program with a Bachelor of Nursing at the end. These are the real deal nurses people think of when they picture a nurse. There is extensive training in all of the above, including bandaging, dressing, rehabs, pharmacology, anatomy, pathophysiology, some advanced interventions, et cetera. (As a side note, if someone wants to join your group and presents themselves as a nurse, it would be beneficial to find out what type they are!)
As EMS was designed for seconds to a few days, nursing was designed for seconds to months, and every aspect of patient care. I am a huge believer in the usefulness of nursing post-SHTF. This may be a bit pessimistic and basic, but I think most injuries post-SHTF will either kill you or require a long rehab. You won’t have the surgical option to save those in between cases. During this rehab, nurses will shine.
Where nursing does not shine is in pre-hospital emergency field care. I know many critical care flight nurses that are patient care wizards in any condition, along with some top notch ER nurses. Their skill was learned on the job and in that specific field, not in the process of obtaining the basic certification. Nursing is not designed for this, so it’s not a knock against nurses. It’s the nature of the job. Nurses tend to be active types, so I run into a fair number of them on calls. Nurses are great at assessment and triage in the field, but not interventions. A lot of nurses are used to having the supplies of a hospital on hand, so they do not carry first aid kits afield. Many also have a difficult time prioritizing injuries in the field. For example, I’ll leave a broken arm alone until we take care of other things, because broken arms don’t kill right away. One thing nurses are excellent at is doing something rather than just standing by and waiting.
I have also seen doctors perform field care, which has been a mixed bag. From chiropractors to trauma surgeons to family practitioners, along the same lines as others, you must realize what your limitations are and work to fix them. Everyone loses skills if they do not use them. Just ask a doctor to start an IV sometime! Don’t rest on your laurels and be content with your current experience. Expand your training.
Before I start a firestorm of angry letters from doctors, medics and nurses, please understand what I am saying: Our modern medical system is an integrated one with different providers playing different roles. Because each of these roles and accompanying certifications play only a part, they do not receive comprehensive training. People struggle when you take them out of their comfort zone. So what is the solution, besides becoming a Wilderness paramedic, marrying a nurse, and going to Cynthia Koelker’s Survival Medicine class, or recruiting a trauma surgeon? First, realize the limitations of your current training. Then address them. If you are an EMT, get training on bandaging, infection control, rehab, suturing, dentistry, et cetera. If you are a nurse, look into getting EMT trained or buy and read a EMS text. Most states will let a nurse challenge the test and test out. Like Mary Gray in Patriots, think about the skills you may need (for example blood transfusions or suturing) and then seek out training in them. I have a cousin in the Peace Corps. I have used this to start all sorts of conversations with doctors I come across to ask questions about medicine in austere conditions.
If you have no medical training at all, I highly recommend Wilderness EMT. It is a great starting point, it carries national certification, and it lets you start to volunteer in your local community. It is also a low cost, low time commitment option. Note that it is only a starting point. (Go buy and read a nursing text book too!) You know what it is lacking, so plan on learning those topics as well. Nurses and EMS all require CE hours. These can be found for free. Go to them. If you are a nurse, go to EMS CE’s. If you are a medic, go to nursing CE’s. A lot of these apply to TEOTWAWKI. One I attended recently had a lecture on a recent increase of infant seizures. They ended up being caused by electrolyte imbalance from caregivers thinning out formula with water at the end of the month before the first of the month (and the money) came. This is absolutely a problem that will exit with TEOTWAWKI. You never know what you will find out. I also highly recommend Tactical Combat Casualty Care for any provider. (There is more on this later in this article.) I work with many volunteer EMT’s. Some of the best, as far as overall ability to manage a patient, are current or ex-nurses who became EMTs as well. They are well rounded and have addressed the weak points in each of their skill sets. The above is meant as simply a generic observation and is not a limitation on anyone. Use it to help direct your future training.
After getting your basic training, USE IT! Volunteer with a local fire service. There is no substitute for experience, and this will get you an ”in” to many EMS opportunities and trainings. You can often diagnose things by feel after a certain point. Anaphylaxis is a great example of this. After seeing anaphylaxis versus allergic reactions, you can almost tell by the restlessness of the patient which way it is going to go. Make your mistakes now when you have the benefit of others to help you learn from them. Improve your skills. You don’t want the first IV you try to give to be on your dehydrated eight year old who has had diarrhea for a week from bad food and now has collapsed veins. Get better training and experience now when the cost of a mistake is still low. There was a recent letter to the blog regarding the use of body armor. The author stated that although he attended a survival medicine class, he was unsure he could treat a gunshot wound. This is a common feeling that people go through. A little training makes you realize how much you don’t know, because your eyes are opened a little bit more. Training is designed to expose you to new ideas, so that you can learn them to proficiency later. Practice is what cements those ideas in. Let it spark a fire, not discourage you. There will be a day when whether you think you can or can’t won’t matter. You will have to, because no one else will be there to do it.
Realize that whatever level of training you have, you will be the ”doctor” for your family/group. Get training now and round out your skills. Go to a survival medicine class. (I still recommend having baseline medical training, as a starting point for a frame of reference and experience – see the above example.) Practice now. Treat your family. At a minimum, if your spouse has to go to the doctor for an infection or something, diagnose them first. Assess, decide what antibiotics you would give, what dose, length of time, et cetera, and compare them to the doctor’s prescription. If someone gets a horrible case of the flu, try giving them an IV at home. I get ear infections, and my wife made ear drops that work wonders by experimenting. Take vital signs. Listen to lung sounds. Even if you don’t know the names of the sounds, you will learn what normal is and recognize when something is different.
If you are on a strict budget, you could buy an EMS text, nursing text, and Armageddon Medicine, but you still need to read them and put them into practice. My medic teacher loved the analogy of medicine as cooking. Anyone can follow the instructions on a box of hamburger helper. However, a chef can look at a few ingredients and come up with a great meal. Your goal for medical training is to become a chef, not just a cook. The more you understand and learn about disease processes, physiology, and so forth, the better problem solver you will become. Rounding out your education and skills is critical to this. Leonid Rogozov was able to perform a self-appendectomy in Antarctica by being able to apply his skills and knowledge.
I will also encourage anyone in the medical field to start to instruct and teach. In addition to giving back, you will learn the subject in a way you never had imagined. Students ask some amazing questions, and keep you on your toes. It helps keep you up to date with the newest advancements in the topic. I think that medical instruction post-SHTF will be in high demand as a skill, as well as a community asset. (In the Expatriates book before the ambush is planned in Tangerine, imagine the benefit of giving a hasty class to the ambushers on gunshot care or the like.)