Introductory Proviso from JWR: The following article is intended for educational purposes only. DO NOT attempt to administer anesthesia without the proper training. There is a very fine line between unconsciousness and death, and this path should be tread only by a trained specialist. This is a very delicate art (and science) that requires advanced training, constant practice, and some advanced monitoring equipment. All vital signs must be closely monitored closely. Even for someone with an "MD" after their name, it is EXCEEDINGLY EASY to mess up, and the consequences of doing so are tremendous. (In short: If you are untrained and inexperienced and try to anesthetize a patient with diethyl ether or chloroform, then the odds are high that you will be more lethal to the patient than the trauma that you are attempting to repair!
Survival medicine requires thought given to pain relief and anesthesia. It
is all well and good to have sutures and skin staplers in the SHTF kit, along
with instruments for debriding wounds sustained when the nearest doctor is
buried under 50 tons of rubble. But how can we do minor surgical procedures
without effective anesthesia? If a survival group member sustains a bad fracture,
how can we relieve their pain with only aspirin and head off stress ulcers?
We can just put on our hearing protection, give the patient a thick stick to
bite down on, and set that bone or debride that wound, while hardening our
heart to their cries of agony. This way we save some expense and eliminate
the need for several hours of extra intense study by the group's designated
medic, and maintain a very low profile. But few would forgo stocking tools
which can reduce the suffering of a wounded comrade.
We can, of course, talk our friendly family doctor into writing us prescriptions
for local anesthetics, morphine, and for ketamine. The local anesthetics will
probably be fairly easy to get obtain if we can show our doctor that we can
competently utilize the agents. But the DEA will probably want a word with
you and your doctor after you fill those prescriptions for morphine and ketamine
both of which are DEA Scheduled drugs.
But what if our doctor is scared of the DEA, and refuses to help your group
obtain any of the above agents? You can read this article and find alternative
anesthesia and pain relief medications
that are either “over the counter” (OTC)
or non-Scheduled drugs.
So what can we easily stock for pain control and basic anesthesia? I have some
ideas, based on my eighteen years as a chronic pain patient as well as some
training as a dental assistant and EMT, including some specialized anesthesia
training.
What follows is a simple “anesthesia module” for a group survival
medical kit that can be put together with minimal legal difficulties and for
modest cost. It will enable the user to deal with acute and chronic pain issues
such that the patient can be well cared for. It will also allow one to provide
good analgesia/anesthesia when perform basic minor surgery procedures such
as wound closure, wound debridement, or bone setting. Even, in extremis, used
to facilitate care for a gunshot wound as described in"Patriots"
This article will certainly not enable a layperson to become a skilled anesthesiologist.
What it will do is point out possible solutions, possible agents and references
to learn more about this subject. It will provide a list of agents which will
facilitate providing simple anesthetic care to injured group members who require
minor surgery or who have sustained significant, painful injuries.
This article will cover basic anesthesia definitions. “OTC” agents,
divided into chemicals/meds and herbs, will be covered for both oral and inhaled
use. Then a few relatively easy to obtain prescription agents will be described.
An annotated bibliography follows the article.
For the purposes of this article, anesthesia is defined as a state in which
the patient does not react to surgical activities in a significant physiological
way, has amnesia for the procedure, and feels no pain or “touch” sensations
during the procedure. Analgesia is defined as a state of reduced to no awareness
of the sensation of pain, though awareness of pressure and stretch may remain.
The state of anesthesia is traditionally divided into four Stages. The agents,
with few exceptions, described in this article enable putting our wounded comrade
into only Stages 1,2, and the 1st Plane of Stage 3. This is fine, as our concern
as survivalists will mainly be with performing minor surgery . The 1st level
of plane 3 equals light surgical anesthesia; deep enough to enable us to safely
and comfortably perform these minor procedures for our injured companion, light
enough to avoid significant respiratory or circulatory problems from the agents
used.
The first Stage is analgesia and amnesia; it lasts from the start of relative
pain relief and drowsiness to the loss of consciousness and loss of the eyelid
reflex. The second Stage is excitement, marked by delirium, breath holding,
and, likely, regurgitation. The third Stage is surgical anesthesia. It consists
of three Planes. We will only be working with the 1st Plane, light surgical
anesthesia. Note that at this Plane, our patient may move in response to surgical
manipulation and their heart/respiratory rate may change, though they will
not have any memory of the procedure. The 3rd Plane is the level needed for
major surgery, such as abdominal surgery. The fourth Stage is the time from
complete paralysis of the chest muscles until the time of shutdown of the circulation.
Anesthesia requires some basic tools and capabilities. Suction must be available
to keep the airway clear, especially if any of the ethers are used. Manual
powered units are widely available from such suppliers as Moore Medical. Oxygen
is very useful and should be considered along with the masks and tubing necessary.
Oxygen can make a great difference in the outcome for patients and is relatively
inexpensive, so consider adding an oxygen rig to your group kit.
Masks for administering inhaled agents and simple vaporizers must be bought
or locally fabricated. The absolute minimum for patient monitoring is: precordial
stethoscope and a BP cuff. Having a pulse oximeter is recommended though the
precordial
stethoscope will give more “advanced warning” of breathing issues.
The oximeter would be most useful when used with an oxygen rig to track improvement
in oxygen saturation.
One must be able to recognize developing severe allergic reactions, bronchospasm
and other medical emergencies and have the meds and skills necessary to save
the day. Study of respiratory and circulatory systems, coupled with a good
grasp of the basic principles of pain control and anesthesia will enable the
designated medic to use these drugs and equipment to improve the patient's
situation, and not generate additional medical problems. Only then can one
put together a useful anesthesia kit for Survivalist Field Hospital.
OTC Agents
We start with the classics here. Aspirin, , ibuprofen and naproxyn will see
us through most needs for pain control and reduction of inflammation from sprains,
tears, or arthritis. All are non-steroidal anti inflammatory drugs (NSAIDs)
and work very well. For pulled muscles or arthritis pain, we can also add in
such roll-on or “smear on” agents as Biofreeze, a very versatile,
herb-based agent which works surprisingly well for arthritis pain, or use such
venerable creams as Icy Hot or Ben Gay.
A few cautions with these. Avoid giving the patient multiple NSAIDs at the
same time as chance of side effects such as bleeding tendencies, slowed blood
clotting, and stomach damage increases greatly. Also, beware of using other
salicylate-containing meds, such as Ben Gay cream or Pepto-Bismol along with
an NSAID as overdose can result easily.
Other OTC pain relievers include Tylenol, which will lower fever and relieve
pain. But it will not reduce inflammation . Tylenol is very toxic to the liver
and kidneys so it is vital to not exceed the maximum 24 hour dosage. Menthol,
applied topically, is useful for relief of the pain . Biofreeze is a good menthol-based
product which can currently be obtained from physical therapists, sports medicine
clinics and the like.
What if our companion needs a dislocation reduced? How can we ease the process
by relaxing muscle spasm? We could use standardized, to 0.8% valerenic acids,
valerian root capsules or liquid extract. Valerenic acids are mild sedatives
and skeletal muscle relaxants. Valerenic acids will not be anywhere as effective
as giving the patient Valium or other benzodiazepines to facilitate the reduction.
But valerian root is OTC, while benzodiazepines are Scheduled drugs.
A quick note on alcohol for pain relief and anesthesia. Alcohol provides pain
relief in the same way a punch to the jaw can assist one in going to sleep,
by deranging the brain's functions. Only in Hollywood can a patient be anesthetized
with alcohol for the simple reason that alcohol is a very weak anesthetic such
that the anesthesia dose is functionally equivalent to the fatal dose.
All the agents below can cause some nausea so don't forget to include some
Benadryl or Dramamine in your medical kit. Either will help reduce the nausea
and also provide some sedation for the patient. Dramamine will also help reduce
the copious secretions that occur especially with usage of diethyl ethers.
We now get into our OTC anesthetic agents. All three are relatively common
chemicals which can be used in simple inhalers, such as drip masks or simple
vaporizers. All are general anesthetics which means they can be used to put
the patient “completely under”. Note that it is vital to do the
necessary study before using any of these agents as there is always the potential
for death or serious problems when using general anesthetics. In addition,
none of these three agents should be allowed to contact the skin as they can
cause bad dermatitis.
There are three “OTC” inhaled anesthetics available that fit our
needs; for safety, for efficacy, and for ease of use. Diethyl ether (DEE),
is the safest inhaled anesthetic for “lay usage” as it has a very
slow onset, with very clearly defined “descent” through the Stages
of anesthesia. Divinyl ether, DVE, has a shorter induction time and less incidence
of post-operative nausea and vomiting (PONV) than DEE. It is also less irritating
to the throat and lungs than diethyl ether. Trilene, TCE (trichloroethylene),
provides excellent analgesia at low doses, is non irritating to the airway,
and is non flammable . Careful monitoring of anesthesia depth for more extensive
procedures is critical with usage of trilene. All three of these agents were
widely used up until the 1950s, even the 1960s for trilene and diethyl ether.
These three agents are not equal in capability. Trilene can only be used for
such things as debriding wounds, suturing, or tooth extraction as it is a very
potent agent that sensitizes the heart to stress . This could result in heart
problems if Trilene was used for a long or extensive procedure or the patient
was given epinephrine. Trilene provides anesthesia only to Stage 3 Plane 1,
light surgical anesthesia, because it cannot be vaporized to a high enough
dose for extensive procedures. TCE must not be used with a closed circuit system
as it forms phosgene, a war gas, when it contacts soda lime.
It has the great advantage of quick recovery time when only used for short
procedures. One surgeon mentioned that his patient was [by observation only]
fully recovered 10 minutes after surgery. It was successfully used for wound
repair, bone setting (some reports), childbirth (the most common usage), and
dental procedures. It is “tailor made” for “self-administered” anesthesia
and is associated with less incidence of PONV than with the two ethers.
On the downside; it is a known teratogenic and carcinogenic chemical. It also
cannot be used in simple “drip masks” as it doesn't vaporize well
below body temperature. But a trilene vaporizer can be made by any handy person
with a basic grasp of how carburetors work.
Divinyl ether is only for short procedures, though it does provide good surgical
anesthesia (up to 2nd Plane of 3rd Stage), as it is toxic to the kidneys and
liver if used for long procedures. Induction doses and recovery time will be
a little less with DVE than with DEE.
On the downside; it requires very careful storage, away from light and moisture,
or else it will polymerize easily into [literally] a useless lump. DVE is fabulously
expensive, up to 30+ fold the cost of the other two agents.
Diethyl ether is usable for procedures of any length, provides excellent analgesia
at low doses, muscle relaxation, and anesthesia to 3rd Plane of Stage 3-and beyond
if you aren't paying attention! It also improves cardiac efficiency and stimulates
breathing so it is useful in the shocky patient. Theoretically it is the ideal
anesthetic for our use.
DEE administration does elicit heavy secretions and coughing so it is makes more
work for the “survivalist anesthesiologist” and her assistant than
Trilene does. It is highly flammable and can cause explosions, so all sources
of ignition must be far from the surgery. It must be stored in the dark, with
moisture absorbers, and preferably with oxygen absorbers. Recovery times for
the patient will be long, over 6 hours. Diethyl ether and Trilene are roughly
the same low cost (ca $34/500ml).
Chloroform is not even considered here even though it seems to be an ideal
agent for our use at first glance. Sure; it is not flammable, it doesn't induce
the
heavy secretions and coughing that the ethers above do, and it is a potent
agent. But it has serious disadvantages. First, it has a very narrow margin
of safety
and requires a true expert in anesthesia to use it safely. Second, it strongly
sensitizes the heart to stress, so if the anesthesia is too light and the operator
starts the incision, the patient could go into nearly instant cardiac arrest--something
we will not be able to treat.
Herbs
The herbs described below are widely available in most jurisdictions and can
be used for pain relief and the induction of light anesthesia in survival situations.
However, they are also “evil” in the eyes of the DEA and the like.
Some fools have used these herbs irresponsibly and ruined it for legitimate
researchers and survivalists. I strongly encourage those who use these to use
them responsibly,
otherwise we give our friends at the DEA more targets.
These herbs are psychedelics, some call them hallucinogens or even entheogens.
They provide pain relief and [very] light anesthesia by two mechanisms: making
all sensory input “equal” so that pain becomes no more important
than the fact that the sun is shining and these agents facilitate a disassociative
state in which the patient's interpretation of pain or pressure signals can
be radically altered by simple measures such as playing music, reading of Bible
verses or the like.
Extensive research in the 1950s and 1960s on LSD, for example, found that the
drug provided much better [for disassociative] pain relief than morphine, with
few, if any, side effects. The few formal studies done on salvia, the second
agent
below,
found
that it
also offered strong, albeit short-lived pain relief and has the potential to
be used as a general anesthetic.
In using these herbs, one must pay special attention to two vital factors; set
and setting. Set refers to the state and focus of the patient's mind; a relaxed
patient who is focused on positive thoughts will be unlikely to experience an
anxiety attack whether given one of these herbs, ketamine, or morphine. Setting
refers to how pleasant, or at least non-chaotic the treatment or convalescence
area is. Operating in a quiet, clean room will help allay patient anxiety and
thus reduce the need for additional meds during the procedure.
The first herb might be as available as your garden; morning glory seeds, preferably
Heavenly Blue or Flying Saucers. Yes, these are the real names. But the truth
is that the active agent in the seeds, lysergic acid amide, is a strong analgesic
that can provide six or more hours of pain relief with a single dose of roughly
150 seeds that are chewed thoroughly and swallowed. The downside is that tolerance,
of about three days duration, develops quickly. So that a second dose given
for pain control 10 hours after the initial dose must be roughly twice as large
and
so on. The total effects last for upwards of 12 hours. The seeds must either
be non-treated or must be washed free of the arsenical which is commonly used
on the seeds.
The taste is vile and tends to induce moderate nausea and vomiting, treatable
with mild anti emetics such as Benadryl, so the patient will probably never
want to repeat the psychedelic trip. This agent will
permit wound debridement or closure as long as the patient's attention is captured
by music, art, or a deep discussion about whatever interests
them at that millisecond. It would provide good relief of pain for bone setting
but careful monitoring of the patient's blood pressure and heart rate would
be required because this agent is a poor anesthetic and provides little, if
any
amelioration of the patient's body's response to the surgery. Used in conjunction
with one of the strong pain killers described in this article and/or one of
the inhaled agents, then bone setting becomes possible.
Salvia divinorum, a member of the sage family, is an herb which could be useful
in Survivalist Hospital for pain relief and in easing the pain and discomfort
associated with minor surgical procedures. In terms of the Stages of anesthesia,
salvia enables Stage 1 (analgesia). At very high doses, it produces a profound
disassociative state, coupled with a stormy Stage 2 of anesthesia that barely
reaches Plane 1 of Stage 3. It could be used when setting bones when combined
with an inhaled agent. Salvia frequently produces a calmness and “afterglow” for
up to a few days post-usage that will help greatly in reducing post-op pain
and anxiety.
It also produces a slowed reaction time and coordination side effects so the
patient should not operate the retreat's armored car or tractor for several
hours after salvia dosage. Since it acts on the kappa-opiod receptor in the
brain,
rather than the mu-receptor affected by morphine and the like, salvinorin A
is highly unlikely to turn the patient into a raving, addicted, member of the
Army
of Darkness. Euphoria is very uncommon with salvia use, indeed people do not
tend to ever take it for “kicks”. It also has potential for treatment
of addiction as the kappa-opiod receptor is key in addictive behavior.
Overdose will not kill per se, but it will result in a dangerous agitation of
the patient though of short, under 30 minutes, duration. The patient can leap
up and charge about, resulting in secondary injury. Salvia is usable for our
purposes only if the operator pays very close attention to dosage, using only
enough to enable the surgical procedure, but not so much that the operation suddenly
becomes catch-the-delirious-staggering-patient!
My personal experience with salvia has been with use for relief of chronic and
acute pain. It has reliably relieved pain of level 8 (roughly the pain from a
leg being shattered in a bike wreck) completely for 1.5 hours, and kept said
pain at endurable levels for three hours or more from a single salvia dose. Tolerance
does not develop so analgesic doses of salvia can be given consecutively.
A salvia researcher, Daniel Siebert, has published a good on line guide to
salvia which includes his model of “planes of the salvia experience”. As “survivalist
anesthesiologists”, we will be getting our patients to Siebert's “plane” 4
(vivid visionary state-with eyes closed, outside world is “gone”)
to 6 (amnesiac state, also high movement potential!).
Salvia can be purchased as a live plant which grows very well in the Northwest
USA as an indoor plant. It is also available as dried leaves. Dried leaves are
only marginally usable for our purposed though. It is also available as a crude
5x or 10x concentrate, or as a standardized extract. The standardized form is
obviously the best choice for our purposes.
It can be administered by mouth, by chewing 15-20 fresh leaves and holding
the chewed leaves in the cheek for 15 minutes. The effects then last about
45 minutes.
Ingesting the leaves or concentrate is useless as the agent is inactivated
by stomach acid. Or it can be "smoked", (inhaled as a vapor).
Vaporization allows the best titration
to effect, it also is associated with a high “failure rate” as
it is very technique sensitive. When vaporizing salvia concentrate, it is vital
that the concentrate be heated as much as possible, the smoke drawn deeply
into
the lungs, and held there as long as possible. Throat and lung irritation can
happen when using the vaporization method . I have asthma; salvia vapor does
not induce bronchospasm for me, but “your mileage may vary”.
The active agent, salvinorin A is extremely potent, being effective at 200-500mcg
for an inhaled/vaporized dose. Its effects begin in under 30 seconds which makes
titrating an analgesic dose fairly easy. It provides good analgesia, being about
as potent as morphine, though it only provides, at best, two hours of strong
pain relief. After inhalation, drug effects begin to fade within 3-5 minutes
of dosing.
At higher doses of 500-1,000mcg, it provides relative disassociative anesthesia
for about 5 to 7 minutes. However, at these doses the drug causes severe “motor
hyperactivity”. Think a PCP zombie who also drank three double espressos!
Titrating the dose to true disassociative effect, Siebert's “plane” 6,
without the patient lashing about and injuring herself can be tricky.
If used for just relieving the pain of simple wound debridement, having the
patient “smoke” small
amounts of concentrate until they report no sensation when the intact skin
is pricked with a sterile needle . If possible, capture the patient's attention
while the wound is cared for. Patient will probably still be somewhat aware
of
pressure and stretch sensation, thus the need to capture their attention elsewhere.
If a bone must be set or extensive wound debridement is required, then a higher
dose of salvia must be used, preferably along with one of the inhaled agents
listed above. This will mean a brief excursion back to pre-19th Century surgical
practice; the use of sturdy assistants to hold the patient in place. The purpose
here is to keep the patient from moving about and injuring themselves or facilitating
a horrible surgical disaster.
By Prescription:
There are some useful prescription pain killers that are not on DEA lists and
should be fairly easy to obtain. All have the potential for significant side
effects so thorough study is required before using these drugs.
Toradol (ketorolac) is the strongest drug in the NSAID class and is available
in pill , eye drops , and injectable forms. It provides excellent relief of
post-operative pain. It is also an anti coagulant so any bleeding must be under
good control
before giving Toradol. It also can cause serious liver or kidney problems.
Because of these “side properties”, Toradol cannot be used for
more than 2 days of continuous dosing for injection or 5 days of oral dosing
Tramadol is a pain killer which works well for moderate to moderately severe
pain. Or in layperson's terms, it will do for pain relief for most of the common
injuries the survivalist might deal with . It is available as both a pill and
in an injectable form. It does not elicit as much nausea as other opiods such
as morphine and unlike morphine, will not completely shut down the drive to
breathe at high doses. Another bright spot is that Tramadol is rarely associated
with
addiction as it relieves pain without euphoria. If needed, it can also be used
for your dogs or cats.
On the downside, it does lower the seizure threshold so it is a poor choice if
the patient has a history of seizures or is taking other drugs which lower the
seizure threshold.
Nubain® (nalbuphine) is a very strong pain reliever
that is only available in an injectable form. It is incompatible with ketorolac
and is an “opiod
effect reverser”. This means that giving Nubain to someone who is addicted
to opiods will result in withdrawal symptoms. I was told by an Army medic,
who had completed the US Army Field Anesthesia course, that Nubain is ineffective
for bad war wounds.
There are a few prescription “para anesthesia” drugs which should
be stocked. For reversal of overdoses of opiods, stock Narcan (naloxone). It
has significant side effects, be aware, be proactive.
Murphy's Law says that the group member who requires emergency surgical care will have a full stomach, risking aspiration of vomitus, a serious complication. Reglan (metoclopramide) is an anti-nausea/vomiting drug and it accelerates stomach emptying. But do not rely solely on Reglan in the patient who ate or drank within a few hours pre-surgical need. Phenergan (promethazine) is a venerable anti emetic and sedative that also helps dry up secretions. It is available in both pill and injectable forms. If injecting it, dilute and give slowly and carefully as it can cause tissue damage and pain on injection.
Anesthesia and pain control must be factored into planning a survival medical
kit. I hope this article has helped point you in a useful direction. With the
items described in this article, you can provide better, more comfortable medical
care to your group members in a crisis environment. In a 96 hour crisis, you
will have the ability to perform exigent minor surgery. In a TEOTWAWKI scenario,
you will have a solid base for providing general anesthesia care to your group
members.
Bibliography:
Introduction
to Anesthesia
[Textbook of Military Medicine] Anesthesia and Perioperative Care of the Combat
Casualty; edited by: Brigadier General Zajtchuk, Russ and Grande, Christopher
M., M.D.; GPO; 1995. Thorough coverage of the practice of anesthesia in a military
setting. If you need to know how to handle the anesthesia for a wounded comrade,
this is the book. Slanted toward more “high tech” care than usual
survivalist group can deliver but good for its explanations of procedures and
caveats. Also
available online, as free PDFs.
U.S.
Army Special Forces Medical Handbook
Internet Resources:
New York
School of Regional Anesthesia. How to do regional blocks if you have local anesthetic
agents in your kit. Thorough, with very good illustrations.
Several Power Point
lectures on various basic anesthesia procedures as well as presentations on wound care,
orthopedics, and womens' issues.
All the volumes of Textbook
of Military Medicine are available online; for download as [free]
PDFs or as hardcover books for purchase. Lots of useful information for Survivalist
Hospital on anesthesia and wound care, care of environmental injuries, NBC issues, etc. A very informative site
that deals with psychoactive chemicals and herbs. It can be a good research
tool for the survival anesthesiologist. Use the site for research, and be responsible.
