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Three Letters Re: Advanced Medical Care and Transport After TEOTWAWKI

James,

[Regarding the letter from DS in Wisconsin:] Maybe and I mean maybe there would be someone to care for a injured or sick member of your retreat group or a doctor or nurse to look at them, probably not. If you have the gas to get them there. If you can leave enough security at the retreat and enough security to take with you. Remember, this is The End of the World as we Know It (TEOTWAWKI). There are several books that should be in a medical library you might already have them: Where There is No Doctor, Where There is No Dentist, and Emergency War Surgery. There are more, but to me these are the first books that I would choose. Your training would be one of the best barter jobs I can think of. You can't call it practicing medicine without a license. You would be a Healer or Doctor for your area. Remember this is not the world as it was. I don’t think enough people put enough emphasis on medical [training and supplies] for there preparations. I truly don’t mean the foregoing to sound mean. - Lee (Once a Marine, always a Marine)

Dear JWR:
I felt (along with protracted pushing from my wife) that a response to the honest and logical questions raised by DS in Wisconsin was warranted. This is coming from a long term preparer who is a practicing anesthesiologist with internal medicine training and the husband of a “retired” ER/ICU RN. If we are talking about a scenario where transportation is problematic, one needs to look in the mirror and determine if you are able and willing to do what needs to be done. While training and experience are crucial, the idea of limiting one’s actions based on whether or not it is within an individual’s “licensed” scope of practice is problematic. In a survival situation, one should do what he/she is capable of doing and let the legal dust settle out later (i.e. Good Samaritan Laws, etc.). I can honestly say that in the absence of a fully stocked and staffed Operating Room (OR), anybody with a little training, and preferably a little experience, could perform 90+% of the “medical” interventions I could perform.

During the American Civil War, a good example of an era prior to “modern” medicine with large displaced populations, the vast majority of deaths (including military units) was from infections and communicable diseases. Actual combat deaths were a significant minority. Above all else, sanitation alone, has contributed the most to increasing the life expectancy of humans. This is where I have a major problem with the idea promoted in the article by Keith in Minnesota (The Home Chicken Flock for Self-Reliance) where he suggests building immunity by constant exposure to pathogens. You do not need an MD or RN license to practice good sanitation or isolation from communicable diseases.

In the same vein as sanitation, preventive medicine is a strong contributor to life expectancy, and is more crucial now before TEOTWAWKI. If you have a gallbladder which is acting up or a problematic tooth, you should get those things addressed now while “licensed” professionals have fully stocked offices and ORs. Given the upcoming elections (and global conditions such as food shortages), your time frame for addressing these issues should likely be within 9-to-12 months.

Finally, let me address the core issue raised by DS in Wisconsin, namely the occurrence of major injury or illness in bad times. This is where a crucial paradigm shift in thought has to occur in people with medical/nursing training and/or experience. Most people in the health care community see a major injury and immediately think “ship it” to somebody or someplace else to deal with the problem. In the OR (frequently the “final common pathway” for these problems), for better or worse, we have a very fatalistic viewpoint imposed on us. Some injuries and illnesses are simply not survivable and we have accepted the fact that there will be some losses. This is a very hard thing to come to grips with while maintaining stable mental health. In my own personal case, I find comfort in the fact that I can (usually) say that I did everything I was capable of doing in the situation. Hindsight and after-action evaluation may find some deficiency, but this process should be viewed as a learning tool rather than finger pointing. Pathologic depression and protracted feelings of guilt take a major toll on healthcare providers in “critical care” areas such as ER, ICU and OR. It is difficult to explain, but there is a particular serenity in being able to accept that despite the fact that mistakes were made, one did the best he could in the heat of battle. This paradigm shift will be very difficult for many in the healthcare field. I think it would be difficult to accept that my efforts were not optimal because of some self imposed limitation such as “scope of practice”, but others may find comfort in this view. I would simply implore you to try and do everything you are capable of doing.

In the case of major injury or illness, the largest improvement in survivability will come from stopping bleeding and replacing lost intravascular volume. If major organ damage is done (such as liver, heart or brain), one has to accept that death is a likely outcome, even in the best of times (with fully stocked and staffed ORs). The problem is that there is nobody to “ship it” to, and the implications that has on the mental health of the person providing care. Apart from this, it is the rare injury, where bleeding has been stopped and intravascular fluids replaced, where immediate survival is not possible. In the case of a self limited illness like Salmonella poisoning, continued supportive care with fluid replacement will likely be all that is possible, and probably all that is necessary. For wounds and other injuries, limiting infection and supportive care will again likely be all that is possible (and likely all that is necessary). Keeping a wound clean and removing devitalized tissue is something any person (healthcare provider or not) should be capable of doing with training. One does not need to go digging for the bullet (as in Hollywood lore). In the OR, bullet removal is usually incidental to following the tract of the bullet to repair damage, not specifically to find it.

As far as material preparation, as a healthcare provider, I would suggest a stock of items which will help with these two critical areas, namely stopping bleeding and replacing lost intravascular fluid. Clean bandage material with or without a pro-coagulant (such as Quick Clot) applied with pressure will likely be all that is necessary (or possible) to stop most bleeding. An ability to provide intravascular fluid resuscitation such as an IV catheter and tubing with IV fluid (either prepackaged or home made) would put you in the top tier of being able to provide emergency medical care in a crisis. A simple battlefield surgical kit (although common household items such as scissors and tweezers will suffice) will provide the ability to keep a wound clean. If your neighbor knows that you have an RN or MD after your name, I promise you that people will come seeking help in bad times. It will be up to you to decide if you can provide it or turn them away. For your own mental health, I suggest you think about this prior to a time of crisis. - NC Bluedog

Dear JWR,
If I am interpreting D. in Wisconsin's questions correctly, then they need to be addressed separately:
The first question is being posed as a licensed healthcare provider. Are you exempt from legal liability in TEOTWAWKI situations for intervening in a person’s emergent situation to render healthcare or aid and/or transporting them to a facility as the books that are referenced suggest to do? The current Good Samaritan laws, (see definition), and their facts lie in which state of the US or Canadian province you are practicing in. Notice that I said practicing in. If you are visiting or vacationing another state or country, you had best look up this law’s application for where you’re going. In October/2000, the Cardiac Arrest Survival Act (CASA) was added to the Federal Good Samaritan Law. It requires an Automated External Defibrillator (AED) to be located in all Federal buildings. There is no comprehensive US Federal Good Samaritan Law as of yet which details a reciprocity for your healthcare actions or coverage in your rendering licensed assistance to a victim of injury or accident. See this site for a detailed list of the US States and their individual Good Samaritan Law. Study it carefully. Each different state has its own standards, limitations and exceptions. One consistent issue however, that is often confusing in it’s liability of risk, is whether or not you have been a previous or ongoing provider of this person’s healthcare. Meaning, if you are their routine Physician Assistant, Nurse Practitioner or MD, that perhaps you best consider the diagnosis of why you are intervening on an emergent basis and expecting the Good Samaritan Law to provide you with protection? Is it for a different diagnosis? Like an electrocution or lake drowning or cardiac arrest or gunshot wound? Hopefully, however, even if it is for the recurrent diagnoses but with a new emergent reason, like a diabetic crisis, or a difficult child birthing, that you’ve treated before in the past that you will still make the decision to intervene and treat them for the condition, based on your scope of experience and practice skills. Don’t rely on the Good Samaritan Law to be your decision basis to help. Only you as an individual can make that difficult decision for yourself. In the TEOTWAWKI scenarios in some very rural areas or seasons, if you are the accessible to transport to “medical person”, then you are it!

The second question that is asked is specifically about transport issues. This has been a test case scenario for lawyers of Hurricane Katrina victims requiring emergency intervention in Louisiana and Mississippi . Since that lesson, there is still no proposed Federal intervention of the Good Samaritan Law. I say that we do not need to federalize good moral practice. If more people will just do what must be done in obvious emergencies or accidents and stop looking for the government or the lawyers to decide for them what is best, then we’ll be able to truly practice what is best for them and for our medical professions. Look up the bible’s definition of what it means of being a Good Samaritan. Ask yourself, Why would you in a TEOTWAWKI situation, transport that emergent someone who needs assistance immediately, and is the intervention needed either not possible to do, or not wise to do, because it’s over your head and experience and skill level. However, even after you consider all of these answers, if you are the best or only one that is available, then it’s you! You’re it. Do your honest best and pray and be willing to accept some losses and your own human weaknesses.

In summary, get your medical certifications up to date, if you’re retired, consider reallocating your license to volunteer practice status. You should already know current CPR practices, which according to the AMA have recently been revised to advocate no more mouth to mouth required for arrest cases and know how to use an AED. But, the true moral to this whole story is, “Nosce te ipsum!” Know Thyself! Know your limitations. Now, not later is the time to acquire the skills and supplies and medications you will need to be the best you can be to offer medical assistance in a TEOTWAWKI situation for your family, friends, community, or if you chose to hang that shingle out of your retreat as the “Doctor is In”. And if you chose to assist as a licensed medical person, it is your personal responsibility to have the qualifications to back your actions! I hope this information helps us all when the time arises, and it will. - KBF

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