Four Letters Re: Extended Care of the Chronically Ill in TEOTWAWKI

Wednesday, Dec 12, 2007

Mr. Rawles:
Every once in a while, at topic comes up that I feel somewhat qualified to comment on. I'll offer some miscellaneous comments on Dave T's letter and your thoughts on medicine WTSHTF, as posted on SurvivalBlog. This is not meant to be exhaustive, and of course may not apply to your particular situation. Since I can't see you, its hard for me to diagnose you or give you specific advice. Disclaimers all 'round.

Chronic renal failure: It may be worth learning to do peritoneal dialysis if you may have to help someone deal with this condition in a grid-down situation. It is not as effective as hemodialysis, but it is much simpler. The risk of infection would be significant, especially in less than optimal hygienic conditions. It might, however, be a useful technique, especially as a 'bridge' for use until hemodialysis can
(hopefully) be arranged. Dialysate is introduced into the abdominal cavity and later removed (or exchanged continuously). Another thing to consider is renal transplant, if that's reasonable for the patient, but that has its own perils.

Diabetes: The key here, as many will realize, is the type of diabetes. Diabetes Mellitus ("DM") Type 2 is the most common. WTSHTF, it may be self-treating, as it can often be eliminated by weight loss. DM Type 1 is treated with insulin. Living on the edge of starvation is a brutal but somewhat effective treatment, if insulin can't be had. Islet cell transplants (often in the context of a kidney transplant) can lead to years of no insulin requirement (they make insulin), but you have to be on (often expensive, toxic, and obscure) immunosuppressants. Might be better to stock up on insulin. Be careful with Lantus (long acting glargine insulin). Potency decreases by about half , six weeks after the bottle is opened. Are you dedicated enough to learn how to *make* insulin, and confident enough to use insulin you made yourself? I did biochemistry for a while, and I'm not confident I could do so. Diabetes insipidus is fairly rare, and not what most people think of when 'diabetes' is mentioned.

Lung disease: By far, most lung disease is self inflicted. Don't smoke. Some, obviously, is not. Move lower, where there is 'more air in the air', is sound advice. If you have asthma, learn what your triggers are, and avoid them (this goes for many 'episodic' chronic illnesses). Stimulants such as caffeine can often help at least a little with an acute asthma attack. CFC-propellent inhalers are nearly gone, and the newer versions (such as Proventil-HFC) are often in short supply; plan ahead.
If someone requires oxygen, again, moving to a lower elevation may make sense. Small oxygen concentrators are a common home health item; they require electrical power but do not require a supply of oxygen from the medical supply company. Most welding oxygen is generated on exactly the same equipment as medical oxygen, but is not certified for medical use. Diving gas?

Coronary artery disease: Do you need bypass surgery? Can you arrange to get a 'cadillac' surgery with both a right and left internal mammary artery graft instead of just a left, and a bunch of venous grafts?

Other miscellaneous chronic medical conditions: these run the gamut. If your doctor put you on Toprol-XL and Diovan because your blood pressure was running 150/90 all the time, and you are sedentary and overweight, you can probably bring the blood pressure down by losing weight and exercising. It may not come down to normal, and you may still have an increased risk of heart attack and stroke, but your life expectancy won't be reduced by much compared to the reduction that would accompany socioeconomic collapse. If you need to choose between blood pressure medicine and insulin for your type-1 diabetic son (who can otherwise pull his weight and then some), I'd probably go for a little extra insulin.
You might also try to change from these top-shelf meds to generic metoprolol (which has to be taken more often, but costs a lot less) and lisinopril (which might or might not make you cough, and costs a lot less). If your doctor has you on five different drugs for blood pressure and you still run 150/90, even though you're 10 pounds under actuarial ideal weight, well, you may need those medications to keep from dying from a stroke in the short term.

Alternative medicine: I have to expose my bias here. I have been practicing medicine for 10 years, and my wife worked for a 'nutriceutical' company while I was in graduate and medical school, keeping tabs on clinical studies on alternative treatments. 'Alternative' is often code for 'expensive placebo'. This is a many billion dollar a year business. Most alternative treatments, if they worked, would have been studied and would be accepted for use as medical treatments. There are no (governmental, whether good or bad) controls on what actually goes into these 'treatments'; if, for instance, a particular flower was effective, the companies could put in the stems and the leaves, and leave the flower out. Also, 'natural' does not mean 'safe and effective'. Curare is natural (and the basis for all the paralytics that are used in surgery and anesthesia). Foxglove is natural (and deadly, and the basis for the anti-arrhythmic medicines digoxin and digitoxin). Uranium (including U-235) is natural. There are water wells in north-central New Mexico that would almost qualify as uranium mines (but rarely does anyone test for it). The usual response to this is 'well, it works for me'. The fallacy here is, of course, mistaking correlation for causality. You would have gotten better anyway (or with another placebo).

Veterinary medicines: Most come from the same factories as the human equivalent. I am told by my veterinary friends that meds intended for horses may be higher purity than those intended for dogs and cats. One of our geldings, Jack, had a pretty bad, dirty laceration on his hip. Our vet sold us equine trimethoprim/sulfamethoxizole (bactrim or septra are brand names in the human medical world) -- the pills were marked exactly the same as the ones I prescribe. We put 15 of them into a syringe with some water and injected the paste into Jack's mouth, twice a day. That's a 7.5 day course for an adult human in one dose for a horse.

Expiration dates: I have heard of (not personally read) military studies that suggested most (dry) medicines would lose less than half their potency after 10 years storage in the cool and dry. I can't confirm this myself, but it has the ring of truth to it.

Dentistry: This is a black art to me, as it is to many medical doctors. There is a product called Cavit-G that dentists have recommended to me as temporary 'patch' material... I don't know how long you can stretch out its use. Oil of cloves (does that count as alternative?) is a fairly effective oral topical anesthetic for short-term use.

Eye surgery: my PRK is settling even further. I started at -5.5 and -6.0 diopters; I am now at 0 and -0.5 diopters, which works well for me. I do get some "haloing" around lights at night, and I think my contrast discrimination is slightly reduced. Now I wear glasses primarily to protect my eyes, rather than correct them. Everything is a trade off, but if my glasses get crushed, I will not be nearly as crippled as I would have prior to surgery.

Appendicitis: It is not uncommon for folks planning travel ["over-winter"] in Antarctica to undergo elective laparoscopic appendectomy. If you develop appendicitis in the back country in Colorado, you apologize to your traveling companions (for inconveniencing them). If you develop appendicitis in Antarctica, your friends may well be apologizing to you (because you're going to die). Post-SHTF, things start to look like Antarctica. Are you going to have your aching gallbladder removed? Ask your surgeon to take out your appendix at the same time. If not, maybe ask a different surgeon.

Antibiotics: Most readers will be attracted to the idea of having at least a small stockpile of antibiotics. These can indeed be lifesavers, however they are over prescribed in the extreme. Common reasons for giving antibiotics are 'bronchitis' (almost always viral, and thus unaffected by antibacterials), 'pneumonia' without any abnormal physical findings or even an abnormal chest x-ray (usually this is the same thing, a viral upper respiratory infection), 'strep throat' which may be viral pharyngitis masquerading as a bacterial infection. Some bacterial infections don't really need to be treated with antibiotics: a lot of folks come to the ER with a 'spider bite', without ever having noticed any spider. These are often abscesses caused by Methicillin-Resistant Staphylococcus Aureus [MRSA], which can be cured by incision and drainage, but will be unaffected by most of the commonly prescribed antibiotics. Even urinary infections will often clear (in females) with large volumes of fluid and acidification of the urine (i.e, cranberry juice). Expert advice both on when to use an antibiotic and which one to use can be helpful! It ain't rocket surgery, but it ain't always intuitively obvious either. (I am fond of saying that, as a doctor, I don't give orders, I just sell advice).

Another thing a lot of folks don't consider is actually talking to your doctor about your concerns. The knee-jerk liberal AMA does not represent the attitudes of all physicians. The American Academy of Pediatrics' position that guns and children should not coexist on the same planet does not represent the opinion of all physicians. You can open the discussion with your doctor with questions like 'what if there was a hurricane Katrina here' (insert the natural disaster most likely to occur in your geographic area); what would I do about my medications/conditions? If your doc looks at you and blinks, then suggests a good [psycho]therapist, maybe you should find a new doctor. If he starts telling you about cheaper alternatives so you can afford a year's supply without the insurance company's help, or talks to you about sizing your solar panels and backup diesel genset to run your medical equipment, you may have found someone worth knowing outside the doctor-patient relationship.
Apologies for the length of this letter, but perhaps there are some useful tidbits in there. - Simple Country Doctor


Dear James,
In response to the medical supplies listed on your blog, I would also add that it would be a good idea to stock up on the following:
1. Over the Counter Meds: imodium (for diarrhea), laxatives (for constipation), gatorade/pedialyte for dehydration, Tylenol, ibuprofen (and children's tylenol/ibuprofen), cough and cold medicines,
benadryl, vaseline.

2. Prescription Meds: pain medication such as T3's, percocet, or hydrocodone, anti-virals such as Tamiflu or Relenza (note that there has been some recent controversy about these drugs recently with reports of psychiatric conditions and suicide amongst Japanese children on Tamiflu), Sambucol (a herbal remedy for the flu), nitroglycerin (for angina/heart disease), blood pressure meds, and very importantly, antibiotics. For skin and soft tissue infections (impetigo, diabetic ulcers, human or animal bites, etc) amoxicillin-clavulanate, 500 mg po ["by mouth"] tid ["three times a day"] for 10 days, for post nail puncture of the foot,
ciprofloxacin 750 mg po bid for 2 weeks, for most upper respiratory tract infections I would use amoxicillin 500 mg po tid for 10 days. Erythromycin is also a good antibiotic to have on hand for community acquired pneumonia (500 mg po qid ["four times a day"] for 10 days). For gastroenteritis and traveller's diarrhea I would use ciprofloxacin 500 mg po bid ["twice a day"] for 5 days. Urinary tract infections can also be treated with ciprofloxacin. Make sure to speak with your physician about any of these as this does not represent medical advice.

3. Palliative Care medication: in the event of a long term grid down situation there will be many people dying and in distress, not only from trauma but also from end stage cancer, heart disease, etc. Three of the worst symptoms to be faced with when dying are pain, nausea, and shortness of breath. Having morphine on hand can be very valuable as this can help with pain and shortness of breath. Other good narcotics include dilaudid and fentanyl. For nausea it is a good idea to have phenargen or compazine as well as zofran or kytril. These medications can be very expensive, so again, plan accordingly and prioritize. Find yourself a good family doctor that is willing to work with you.

4.Anaphylactic reactions: whether from bee stings or other sources, you must be prepared to deal with an anaphylactic reaction. Having an Epi-pen on hand can save someone's life. Also, have lots of benadryl and if possible some prednisone. (Benadryl is over the counter).

5. Burns - You will want to store up on sterile NaCl as well as silvadene and lots of gauze. If you need to sedate someone to perform any kind of debridement, versed and ativan are useful as well as morphine for pain.
Hope this helps. - KLK

With regard to your suggestion that the Big Island of Hawaii might be a good place for people needing kidney dialysis, let me add a little local knowledge. The Big Island has a good percentage of alternative energy sources (wind farms, geothermal, hydropower and small scale solar) which would allow our local power company (HELCO) to direct power to a home or facility pre-designated as being for "emergency use", so in that respect, you're right.

However, the diesel powered generators that still make up the bulk of power provided have very little on-island storage (fuel trucks make the run from the port of Hilo to Kona virtually every day) and there are no projected plans to increase storage capacity in any significant way. Earthquake damages to bridges or tsunami damage to the port could literally limit or shut most of the power off for an extended length of time. As serious as that problem is, a much greater negative is the status of medical facilities on the Big Island. The hospitals are quite small and so inadequate for major medical emergencies that patients with serious injuries or conditions are routinely flown to Oahu (300 miles away) via air ambulance. It is often said (by local doctors) that the hospitals on-island are limited to an equivalent of "third-world" care, which is something that has to be seriously stressed with regards to chronic care.

This is not to say that it would be the wrong choice for everyone. In the case of CPAP machines (for sleep apnea), it could be a very good possibility, but when it comes to machines that require extensive supply replacements and constant thorough cleaning (such as dialysis machines), one might be better off looking elsewhere. The availability of emergency electricity is only one factor of the equation and when the necessity of ongoing sophisticated medical treatment (which is normally required for chronic care) is added in, the Big Island loses some of its luster as a survival retreat possibility. - Hawaiian K.


I found it interesting that your comments about Hawaiian Electric essentially concede, without explicitly saying so, that in some situations, the chronically ill are doomed to die without medical care provided by the Establishment. This is, of course, true (unless you have unfathomable financial resources at your disposal to proactively re-create a private, parallel medical infrastructure).

Without insulin, diabetics will eventually die; without dialysis, so will kidney patients; without oxygen, so will those who need assisted breathing. These are just facts. Let me suggest that for those who are in the unfortunate situation of having to care for a loved one with a chronic condition, contingency planning needs to be broken into short- and long-term time horizons.

In the short term, all of your points are well taken re: stockpiling supplies. The plan here is to hold out on your own for as long as you can, and hope that things eventually go back to normal (e.g., Hurricane Katrina). I would add that many insurers will fill a 90-day supply of medicines, provided that you’re willing to use a mail-in service, and generic substitutes are available. If finances are tight, look into this route—it will give you an additional 60 days of stockpile for the same co-pay.

One thing you sort of skipped over was medical knowledge. All the supplies in the world won’t do you a lick of good if you don’t know how to use them. So take the time when things are good to amass a reasonable medical library. Like I mentioned in a previous letter, I own a copy of "Medicine for the Outdoors" for acute care issues, and obviously as a new parent, I own pediatric references too. But it would probably be a good idea to add books like the PDR to have information about drug interactions; a slightly out-of-date edition might be available on ebay. I’m sure real doctors out there could make recommendations.

In terms of longer-term planning, it’s going to come back to relying on the Establishment for drugs, life-saving chronic therapies, etc. My view is that if things go to hell, they may or may not go to hell all at once and everywhere. Cities will get worse before the countryside; collapse may be local before it is national. So use this time, when the internet still works, to do research. For example, how much could it hurt for a dialysis patient to have a list of every public and private dialysis center within 200 miles? The hope would be that if your locale turned ugly, an operating medical establishment could be found somewhere nearby.

The rest of your post dealt with preventative care: elective surgeries, dental care, physical fitness. I’m in wild agreement with everything you said (but now we’re far afield from the original question about chronic care, notice). I’d add that I’m a post-Lasik patient myself, and recommend it highly. I can understand budgetary constraints, but these days Lasik is no longer nearly as expensive as it used to be. Depending on the amount of correction you need, the surgery can be obtained for the cost two handguns, or one good rifle, and is probably worth more to you in a SHTF situation than another firearm in the arsenal, or an extra 1,000 rounds of .308 Winchester.

Keep up the great thinking and writing. - DCs


JWR Replies: I'd be reluctant to consider Oahu, since its population density is so high that it could not be self-sufficient in the event of an economic collapse and the likelihood of rioting and looting seems much, much higher than on the Big Island. There are at least three dialysis centers extant on the Big Island (One on the Kona coast, one in Hilo--both operated by Liberty Medical--as well as another in Hilo at the Hilo Medical Center. OBTW, I've also read that a large, new dialysis center was just recently opened on Maui.

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