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JWR’s book “How to Survive the End of the World as We Know It” has motivated me to add a little more light for those who may be in a situation where a physician is not available, but caring for someone needing sophisticated medical care.

I am an Internist, and have been working in an urgent care setting for 20 years. Before that, I had a number of years experience working in several Emergency Rooms (ERs), and a trauma center. Since I am not formally trained in ER work, I have concentrated more on stabilizing patients to get them to more specialized care. I have no experience in battlefield injuries, like arms and legs blown off, or eviscerations, so I will not venture there.

My previous article focused on the common types of infections one is likely to encounter, and the most appropriate antibiotic. Please read the recent SurvivalBlog article for common infection treatment.

This article will go further into the weeds with antibiotic use.

This article is only for general medical information and should not be used for specific treatment. Always seek expert help for medical problems whenever possible.

Early in our medical training, medical students are taught the following principles of medical care,

1. Murphy’s Law
“Everything that can go wrong, will go wrong.”

2. Sutton’s Law
Willie Sutton was a famous bank robber. When asked why he robbed banks, he retorted, “That’s where the money is.” Sutton’s law is, “Go where the money is.” [In emergency medicine] you don’t mess around with treatments that might work, or do tests that might give you the answer. You go for the money the first time, because you might not get a second chance.

3. Hippocratic Oath and Principle
“First and foremost, do no harm.” This is in the Hippocratic oath. If there is ever a question that you may cause more harm than good, you do not do it.

One of the first things medical students are taught is that all medications have “good” actions, which we call “therapeutic,” and “bad” actions, we call “side effects,” or allergic reactions.

Allergic reactions to medications are very common. Every G.O.O.D. bag should include benadryl. Take it immediately if you start itching after taking a medication. It might save your life. [In an emergency] if you have trouble breathing or swallowing [which are symptoms of anaphylactic shock], I would take benadryl, but I would also seek medical attention if possible. Adrenaline is called for here.

For the advanced student, choosing the correct antibiotic for an infection is critical. Choose the wrong antibiotic, and if the infection worsens, you are in a heap of trouble. My previous article was intended make the choice for the use of antibiotics as simple as I could, because most people have very little training in medicine. So my thinking was to make it as simple as possible. For those with some medical training, I will go a little deeper into the weeds.

Most infections are the result of some breakdown in our defense system, coupled with exposure to an infective organism. If we lived in a sterile bubble, we would never get an infection. But even with the exposure we have every day to zillions of virus’ and bacteria, we still rarely become infected because we have complex systems to protect us from becoming infected. The first line of resistance is our skin. If it is in good shape, and intact, infections are rare. So pay attention to your skin. If it is dry, use moisturizing cream to keep it supple. If you are standing in water all day, take off your shoes and socks several times daily and air dry your feet. If you sweat a lot, air dry twice daily the areas that stay wet all the time to keep the skin in good condition.

Respiratory infections are best prevented by limiting exposure. If you are coughing, you should cover up when coughing, and wear a surgical mask. Most authorities believe that if you remain 6-8 feet from others, you are unlikely to spread a respiratory infection. You should also wear a surgical mask. These are not proven effective, but will capture large droplets if you cough or sneeze.

If someone is ill around you, you should be wearing an N-95 mask. The N-95 mask should be in everyone’s survival plans. These masks really work to prevent contracting respiratory infections. They must fit snugly, and they are difficult to wear for extended periods of time, but they do work. They are inexpensive if you stock up in a non emergency situation. During the last flu epidemic they disappeared from the shelves, so stock up now. Make sure they are clearly labeled certified by OSHA as N-95.

For those interested in going deeper into the weeds for the use of antibiotics in TEOTWAWKI, I will discuss how MDs decide on the use of antibiotics. I am only discussing treatment of adults. This does not apply to children. Children are very different than adults. As a wise Pediatrician once told me, “Children are not small adults. They are biologically very different.”

First some definitions:
1. Symptoms are those things the patient feels and describes to the doctor. Symptomatic treatment is treating the symptoms, not the underlying illness. So, taking Tylenol for fever is symptomatic treatment.
2. Signs are those things the doctor sees in his exam.
3. Malaise means just plain feeling lousy.
4. Virus. A virus is an odd creature, not able to live or reproduce on it’s own. It causes disease by attaching to your cells, drilling a hole in your cell, and injecting it’s DNA (or RNA) into your cell. It then takes over your cell mechanism, reproduces hundreds of copies of itself, ruptures your cell to spill the copies of itself into your body, and the process begins again. Antibiotics are worthless against them. There are a few anti-virals that work for herpes, influenza, chicken pox, and shingles.
5. Bacteria are fully living creatures which cause disease by growing and invading the tissue of your body. Antibiotics are highly effective if correctly targeted against the particular bacterium.
6. Prions are like creatures from the black lagoon. They are crooked proteins that will make all similar proteins crooked when they come in contact, and are very deadly. I know you have heard of Mad Cow disease [the common name of Bovine Spongiform Encephalopathy (BSE)] , and that it is caused by a virus. Actually, it is caused by a prion.

The first decision to be made is whether you are dealing with a viral infection, or a bacterial infection. This is usually fairly easy for a physician, as we see thousands of cases of each over our years of medical practice, and can tell pretty quickly with a brief history and physical examination. These are the things that usually differentiate viral and bacterial infections. None of the points are 100%, but if you look at all the differentiating features, you can make a pretty good judgment.

And why does it matter? It matters because viral illnesses are almost always self limited illnesses (they go away by themselves), so we treat them symptomatically. We do not use antibiotics as antibiotics are worthless in treating viral illnesses, and may cause harm (see the Hippocratic Oath above). However if it is a bacterial infection, it is important to use antibiotics promptly to avoid complications, even death.

There are exceptions, but typically viral illnesses will not be accompanied by a fever above 100.5 F. Usually there will not be swollen glands (infectious mononucleosis is one exception). There are usually systemic symptoms like achiness, fatigue, malaise. Bacterial infections are usually accompanied by fever over 100.5, may include swollen glands, and usually do not include the systemic symptoms.

Let me begin by describing the typical “viral syndrome.” The most common viral illness is the common cold. It usually consists of a runny nose, nasal congestion, sore throat, and cough. There is usually not a fever over 100.5, and usually not any significant swollen glands in the neck. This is the classic viral syndrome, and although there are many virus’ that can cause similar symptoms,

Another typical viral syndrome is Viral Gastroenteritis. This is very common. Some people think it is the “flu,” and call it the “stomach flu,” but it has nothing to do with “flu.” It typically is an acute, sudden onset of nausea, vomiting, and watery diarrhea. There may be some cramping, maybe even a low grade fever of 100.5, rarely any higher. People usually feel terrible. Fortunately it usually only lasts a day or two. Food poisoning will do the same thing. If the diarrhea is bloody, or the cramping is severe, or the fever is above 100.5, or it lasts more than two days, then I would suspect a possible bacterial infection.

We often see patients with a sore throat concerned they have “strep throat.” Strep throat is a bacterial infection of the throat. Patients with strep will typically have a sore throat, fever over 101, and swollen glands. Those with a cold will have a sore throat, runny nose, achiness, fatigue, and cough. Fever, and swollen glands will be absent.

Bronchitis is another viral syndrome. Unless you are a smoker, or have emphysema or some other chronic lung disease, bronchitis is almost 100% a viral illness. It is usually just a nasty cough without a fever. It is usually non-productive, and often becomes productive of clear sputum, which becomes discolored to yellow and green toward the end of the illness. Leave it alone. It will go away by itself.

Influenza is a little different. It is a viral infection, and is a little unusual in that it is accompanied by high fever, up to 103-104 even. Experienced MDs can tell easily though, because of the extreme fatigue associated with influenza, and the typical “viral syndrome” symptoms of cough, runny nose, sore throat, nasal congestion which accompany the illness Extreme fatigue is a hallmark of illnesses. Patients have difficulty getting out of bed to come to the doctor. And it has an abrupt onset. Within an hour or so, victims go from feeling fine, to feeling terrible with aches, extreme fatigue, followed by the fever and other symptoms.

With these viral syndromes understood, it becomes easier to recognize bacterial infections.

Pneumonia is a bacterial lung infection. Since it is a lung infection, you would expect a cough. Since it is a bacterial infection, you would expect a fever of 101 or higher. Since it is not viral you would not expect “viral syndrome” symptoms of runny nose, nasal congestion, sore throat. An important caveat for pneumonia is that it often develops as a complication of a cold because your resistance is down, then later the pneumonia sets in. Typically, a patient develops a “cold” with the usual runny nose, nasal congestion, sore throat, and cough without a fever. Then a week or so into the illness, suddenly a fever over 101 develops, the cough worsens, and becomes productive, sometimes blood tinged. This is the onset of pneumonia complicating a viral illness. (So you thought being a doctor was easy?)

Bacterial enteritis. This is a bacterial infection of the intestines. It is very similar to viral gastroenteritis, but is usually more severe, often accompanied by a fever over 101, and may include blood tinged diarrhea. There is usually a history of travel, and uncooked food eaten, or possibly contaminated water from a well or stream. If someone has viral gastroenteritis which is not getting better in 2-3 days, start thinking about a bacterial infection.

Clostridium difficile. This is a good time to mention this disease. This disease is one of many reasons doctors try to limit the use of antibiotics. It is a potentially serious complication of antibiotic use. Sometimes when taking an antibiotic, the normal bowel bacteria are killed off allowing this nasty bacteria to grow out. So if someone gets the typical diarrhea, cramps, sometimes low grade fever after taking antibiotics, it is probably clostridium difficile. This is treated with metronidazole.

Strep throat is a bacterial infection of the throat. So we would expect a sore throat, fever over 101, and swollen glands. If the patient has viral symptoms like cough, runny nose, nasal congestion, and does not have a fever, the odds are 20-1 or more it is a cold. Treat it symptomatically.

I discussed the treatment of these bacterial infections in my previous article.

OTC medications for symptoms.

1. Diarrhea: Imodium
2. Runny nose: antihistamines, Benadryl
3. Congestion: Sudafed
4. Fever: Advil, Tylenol
5. Sore throat: Cepastat lozenges, Advil, Tylenol
6. Cough: Robitussin, Dextromethorphan (in Robitussin DM)
7. Nausea: Benadryl
8. Heartburn: Maalox, Prilosec

Dear Mr. Rawles:
I recently read through the cluster of articles regarding preparation measures for antibiotic storage and use on your blog, starting with A Doctor’s Thoughts on Antibiotics, Expiration Dates, and TEOTWAWKI, by Dr. Bones. As the medic for my family resilient survival group and an EMT paramedic, I have learned of some resources relevant to this discussion that will be useful to your readers.

The first is the Sanford Guide. This is a book used daily by physicians and other healthcare providers worldwide to assist with empiric antibiotic treatment of infectious diseases. Empiric therapy means that you’re not sure exactly which bug is causing the disease, but based on the location of the infection and other characteristics (like patient age and other illnesses), you can make an educated guess about what antibiotic you should choose. This is akin to going hunting and not knowing exactly which guns to use, but since you are in a farmer’s field or marsh, for example you might expect to run into birds instead of deer and so you bring a shotgun with birdshot instead of a slug gun or rifle. 

There is a similar book published by Emergency Medicine Residents Association but this is expensive and hard to find.  I have found Sanford Guides in used bookstores in bigger cities.  The knowledge in these books changes slowly, so a copy that is two or three years out of date will probably be fine for most purposes. You can also web-search “empiric antibiotic therapy” and surf away.    

This brings up the issue of the meds Dr. Bones lists (Z-packs, Amoxicillin or Keflex.) These are not great for diarrhea, but are narrow spectrum drugs that may help some skin and respiratory infections.  If you are going to the trouble to get antibiotics and keep them on hand, consider that you either need a big stable of “narrow spectrum” drugs or a smaller, appropriate group of a few “broad-spectrum” drugs.

Mel Tappan wrote a lot about the need for having a selection of useful guns that are relatively specific to given tasks.  You could think of antibiotics in the same manner, having a drug for each type of infection.  Getting adequate coverage for a wide range of diseases would be more logistically challenging and terribly costly than a few broad-spectrum drugs.  You might instead choose to have a “formulary” of a few drugs that should cover most of your needs.  Unfortunately, some of the antibiotics recommended by Doc Bones and others seem limited in their utility for serious infections.

The formulary approach was suggested in a recent book entitled “When There Is No Doctor”.  I would make one change to this author’s list, adding moxifloxacin in place of levaquin;  I base this on the fact that “moxi” (brand name Avelox) has been put in the “combat pill pack” of front-line combat troops in the Sandbox:  they are told take a moxi pill (which covers gut bugs, skin bugs, MRSA etc.) for any open wound while waiting for evac.  It is absorbed almost as well as an IV dose.  In short, moxi covers a broader spectrum than levaquin and cipro, which are in the same family. 

Regarding obtaining and choosing antibiotics, another resource is the “Orange Book”. Published by the FDA, this book is really the only source I could find that talks about the effectiveness and safety of generic formulations. It has been mentioned in a prior post in SurvivalBlog, and allows you to search by drug name, ingredient or maker. 

Basically, when you find a generic drug, you can check in the Orange Book to see if the generic manufacturer’s formulation tests like the more expensive brand formulation.  The tests are not too sophisticated, and the FDA is hoping that looking at how a drug looks and behaves (in simple tests like dissolving in water) compared to the brand-name drug it is copying.  Bare bones, but I’m told other testing would be way to expensive. 

I would almost never use medicines made for animals on humans, and I think you should look very seriously into the safety of this. As an example, I can’t find the “fish-mox” nor any of the other fish drugs Doc Bones mentions in the Orange Book by its manufacturer, which I consider the minimal safety check.  I do this check when thinking of getting drugs from overseas, too.  Dr. Doyle covers some of the other safety concerns in these alternative approaches to obtaining medicines in the book mentioned above. 

Start, within the limits of OPSEC, with your own doctor, dentist, Nurse Practitioner (NP) or Physician’s Assistant (PA).  Be aware, though, that if you ask your doctor for specific medications by name, he/she will (a) wonder what you’re up to and (b) likely be less willing to do this.  If you are honest, and aren’t asking for narcotics, you might stand a better chance.  Disaster prep is coming more into vogue, at least among many of the docs I work with in the ER now, anyway, because of the recent H1N1 ramp-up.

Finally, I heartily concur with the suggestion of getting as much training as you can. I worked with a surgeon who stated he could train a monkey how to operate in two years, but it takes much longer to train people when to operate.  Having a few fish tank drugs won’t do a lot for some conditions, and you need to know what you’re treating.  More importantly, you need to know when to expend your precious resources, especially when re-supply may not be coming anytime soon.

One last resource to help with deciding when to treat is the CDC antibiotic usage guidelines, published for things like upper respiratory infections, sore throats and bronchitis.  We all love to leave the doc’s office with a prescription but after TSHTF we need to be much more realistic. 

Medical Corps and other courses are good for this kind of training, although I hope to attend a physician assistant school in the future. I’m too old and have too many family commitments for medical school, but being trained in two years as a PA will allow me access to much of the same basic knowledge while being afforded the opportunity to learn on actual sick and injured patients rather than just “book learnin’” the theory. Regards, – Ron L.

James,
Antibiotics can also be purchased on the internet. While I am no attorney, the Wikipedia article about online pharmacies provides some info on the legalities of ordering prescription grade antibiotics from Canada. While I’m certainly not advising anyone to break the law and order antibiotics or any other prescription grade drugs on line, it seems a like a real grey area for the Government to crack down on Americans that do order prescription drugs on line. Maybe another reader with some legal expertise can clarify what the Government enforces when it comes to ordering prescription drugs on line? Thanks, – W. J.