Health, Hygiene, Fitness and Medical Care in a Coming Collapse, by RangerDoc

Friday, May 8, 2009

Spiritual Fitness
Let us start this discussion by confronting a stark fact of life: very few of us, living the life of North American citizens, are fit to survive for a generation in an austere, off the grid, world. First of all, few of us have the philosophical orientation to be survivors. I know in my bones that without God’s help, my family’s ability to survive in a prolonged state of austerity is worse than questionable. As an evangelical Christian, I understand that my own commitment to preparedness is a function of my ongoing submission to God’s will. It could have been otherwise. He could have willed me to pursue other ventures: sacrificing my own survival for the benefit of others as I helped them “escape the storm”. Is this not the philosophical basis of soldiering and of the missionary? Self-sacrifice, even to the point of death. That was Jesus’ example of discipleship. So I diverge from that example only by virtue of an ongoing conversation with my Lord and Master, and He urges me to prepare for the worst, so that my family and my “retreat posse” will survive. I know not His particular purpose in this endeavor, but I trust His will implicitly. It is my personal belief that the Lord calls all family leaders to provide deeply for the sustenance and well being of their families. But unless you have had this conversation with the Author of life, you may not be philosophically and spiritually “fit” for the challenging times to come. And God may have a different path for you to pursue, in the service of His Kingdom. Remember that Jesus has called us all to Himself and He wants you to trust Him today! Preparedness is not a hobby- it is a calling. In this vein also, I do not condone the “secret squirrel” approach to preparedness. Being discreet about the specifics of our preparedness plans is a wise tactic in these dangerous times, but failing to share our wisdom, insight and knowledge with others who could effectively use this information for good is, in my estimation, downright sinful. So much for my personal philosophical bias.

Physical Fitness

Second of all, few of us have the physical fitness level required to be 19th century farmer-builder-warriors, which is what we may be called to become. Example: Thirty five years ago, I was a carpenter and gardener: climbing, lifting, sawing, digging, hammering. I joined the US Army to become a Ranger. And, boy, did I find out how poor my aerobic fitness was. Fast forward ten years: I was then a medical student and an avid, competitive triathlete. I visited my buddy’s place (Yeah, he’s in the “posse”) and helped him cut, stack and split firewood for a day. Well, my “designer body” ala swim-bike-run was exquisitely fit aerobically, but that episode of real labor left my body an aching mess for the next three days! Now I am a 60 year old surgeon who mixes aerobic exercise with gardening, light carpentry, resistance training, hiking with the Boy Scouts, woodcutting, et cetera, so that I can be at least minimally fit for the challenging lifestyle that would be required in a TEOTWAWKI world. If you are overweight, smoking and sedentary, you are engaged in a futile fantasy to think that you will survive in a post-apocalyptic world, surrounded by your storage food, guns and ammo. These are mere possessions that will swiftly be taken from you by the ravenously hungry horde of healthy young men who have heard about your stash. Start your physical preparedness plan with physical fitness.

Preventative Medicine
Next issue: public health measures. For many years I taught and practiced medical and surgical care in austere environments. In the late 1990s I was the chief of the medical special response teams for the US Army, Pacific, and taught disaster planning and medical care in austere environments around the world as a Department of Defense consultant. If I had to choose between having access to modern medical care and having a sound public sanitation system and clean water, it would be a no-brainer. The clean water and hygienic handling of human waste as first perfected in the twentieth century have saved many more lives than have antibiotics and modern surgery. Hepatitis, polio, typhoid fever, dysentery and other waste and waterborne diseases have defeated far more armies throughout history than have poor tactics and strategy. Witness [German General Erwin] Rommel’s own struggle with hepatitis during the North Africa campaign of WWII, which he roundly lost, in spite of his brilliance as a military tactician. If you have a retreat, please remember this simple principle: keep you food and water supply as far as possible from latrine sites. Controlling mosquitoes may be important in some areas, to avoid epidemics of West Nile Virus, malaria and yellow fever. The current H1N1 flu pandemic should remind us all that we need to protect ourselves from infectious disease. There is much more to learn about field sanitation and hygiene, so please consider reviewing this comprehensive resource.

Now you have arrived at the next step. You are right with God and your body has been worked into a lean, mean, diggin’, buildin’ and fightin’ machine. You have an ample and reliable source of potable water and your latrines are at least 100 yards downhill from your water supply. You have a half ton of lime ($30-40 worth) to sprinkle in the latrine. Your food is stored securely and safely away from vermin, fungus and other pests. After 2-3 years of experimenting, your food growing skills and garden are adequate. You have established sound and reliable defense and OPSEC measures, to include perimeter defense, adequate weapons capability, mastering of small unit operations and tactics and adequate familiarization with improvised weapons and tactics and redundant communications systems. Whew!! That was a lot of work! Now, and only now, should you plan your strategy for medical, dental and surgical care.

Medical Care in Austere Environments

Number one principle: avoid injuries and illness. In practical terms that means maintaining sound health and hygiene, as above noted. It includes scrupulous avoidance of horseplay, as well. What a tragedy to break your ankle playing Ultimate Frisbee during planting season, when every able body will be needed to secure your frugal harvest for the year. Without the availability of operative orthopedic care, many of our ancestors became lifelong cripples from simple injuries such as this. Skiing and mountain biking will be absolute no-no’s unless truly necessary for operational reasons. Sorry, but fun activities are way low on the list of gotta-do’s in a survival environment.

Next: eat to survive, not for fun. No one will care what you prefer in your diet, least of all your retreat cook, who is tasked with cobbling together a nutritious meal from whatever is on hand. (As an aside, when my very wise wife and I developed the list of friends that we would invite into our “retreat posse”, the overarching selection criteria, following a Judeo-Christian moral orientation, could be characterized as “high skill, low maintenance” personality traits). Multivitamins will be most helpful, but probably can be stretched to one every other day or even two per week, if there is a shortage. Include adequate fiber in your diet. In our stores, we have large containers of Metamucil, for instance, to avoid constipation. When encountering this problem, the French Maquis (WWII resistance fighters) would ask a local farmer for some butter or lard and eat 2-3 tablespoons…like grease through a goose! We also have a simple formula for an oral rehydration solution to treat dehydration following diarrheal illnesses, heat injury, or trauma- induced hypovolemia. Please copy the data on this site of the Rehydration Project (http://rehydrate.org/solutions/homemade.htm) for an excellent and simple description of homemade rehydration remedies.

Take scrupulous care of your teeth! Floss at least three times per week and brush at least twice daily. Toothpaste is nice, but not necessary. Baking soda works almost as well and it is not only cheap, but has many other uses. Buy 20 pounds of baking soda. I strongly urge all to get a copy of Where There Is No Dentist by Murray Dickson. It is available from Ready Made Resources. This is an excellent and authoritative manual that is easy to put to use by someone with at least a modicum of medical training, for example an EMT.

Now the fun part you were all waiting for: interventional health care, i.e., the practice of medicine and surgery in an austere environment. To start with, I strongly recommend getting a copy of the list of $4 prescription medications available at Wal-Mart pharmacies. The array of inexpensive medications is astounding. Antibiotics, antihypertensives, hormone replacements, topical medications, eye and ear preparations- they are all on this list. Ten to fifteen years ago, most of these items were very expensive “designer drugs”. If you need antihypertensives, see if your doctor will prescribe drugs off this list and then get him to write you a 6-12 month prescription. Also ask him to write you prescriptions for the antibiotics that I recommend below. You should also get several bottles of eye and ear antibiotic drops. Admittedly, this may be an uphill battle. Hopefully you can educate your physician about the importance of preparedness and make him an ally. Tell the Wal-Mart pharmacist that you are going on a mission trip to a distant land without access to pharmaceuticals. This would not really be a lie, would it?! Don’t worry about your cholesterol- it will drop on your new diet…but then, my guess is that the survival lifestyle will also “cure” most hypertension and non-insulin dependent diabetes. But, please, try to get to that level of lean fitness prior to encountering the “SHTF” dilemma. I recommend a stockpile of four antibiotics that will treat most conditions that will really require them: pneumonia, anthrax, urinary tract infections, skin infections, and wound infections: Cephalexin 500 mg, Ciprofloxacin 500 mg, Doxycycline 100 mg, and Septra DS (SMZ/TMP DS). These can all be taken by folks with penicillin allergies, with the possible exception of the cephalexin. The number of tablets that you need will be based on the size of your group. All of these are dosed for adults but can be split or crushed for children. Echoing the advice of Jim Rawles, having a retreat member with significant medical experience, e.g., an advance practice RN, a PA or, ideally a practicing physician, will enable you to utilize these medications optimally. In my humble estimation, about 30-40% of antibiotic prescriptions currently doled out by my colleagues are unnecessary, and often done to placate demanding “health care consumers” because it is often too frustrating and time consuming to educate folks in the office. Although these medications are inexpensive now, when you have a limited supply that must last months or years, they will become precious allies in your fight for survival that must only be used when life or limb are at risk. The expiration dates on the bottles of meds that you receive at the pharmacy are really made up, since no pharmaceutical company really studies the time-related efficacy and safety of these drugs carefully. The expiration dates are always much earlier than the true degradation dates, except for liquid and injectable medications. Almost all medications are probably still safe and effective for at least 1-2 years after the printed expiration date. Almost every doctor friend of mine gives his/her family expired medications from their sample shelves! If you live within 200 miles of a nuclear power plant, a large military base or a major urban center, it is prudent to stockpile a 1 month supply of iodine supplements for each member of you family, to avoid the long term carcinogenic effects of a nuclear fallout emergency. These are really cheap, have long shelf lives, and can be purchased from several of the advertisers on this web site.

Wound and Trauma Care
Let’s start by making life simple: any soap with water works as an adequate antiseptic for scratches and scrapes, and good ol’ Vaseline works nearly as well as a wound dressing as the expensive antibiotic ointments. Large second or third degree burns are another story, however. Having worked in the developing world as both a military doc and as a medical missionary, I have observed for myself the well known fact that flame injuries are a major cause of death and disability in primitive cultures. Open fires are often used for heating and cooking, resulting in frequent flame injuries, especially to children. Children are neither wise nor well coordinated, and they fall into fires. Get several large jars of Silvadene cream for extensive burn use only. Keep it refrigerated, or even frozen as long as possible to extend its shelf life. This stuff is somewhat expensive, but not easily replaced. OTC topical antibiotics like bacitracin ointment could be substituted in a pinch. Extensive burns (larger than the palm of your hand) should be cleaned with soap and water and dressed with antibiotic ointment and sterile gauze reapplied daily until fully healed. When you run out of Silvadene, use Vaseline (get 50 lbs of it- it has many, many practical uses).

I currently teach advanced tactical medics for the US Army, SWAT teams and the U.S. Border Patrol. We teach them suturing techniques. But, unless you can really clean a wound within 12-24 hours of its occurrence and close it surgically with a truly aseptic technique- sterile gloves, drapes, sutures and instruments- it should be left open to heal by itself. Otherwise it will likely get grossly infected, pus out, and require you to take out your precious suture material and use your precious antibiotics to treat the now deep wound infection. Soap and Water will take care of this wound better, along with copious irrigation with previously boiled water (allowed to cool, of course). “The solution to pollution is dilution!” Clean the wound with a 50/50 mix of hydrogen peroxide and sterile water if it gets crusty or develops a thick discharge and change the dressing daily. If large vessels, tendons, nerves or bones are exposed, the wound will require suturing, but only after extensive cleaning and irrigation, followed by several days of sterile dressing changes and the administration of oral cephalexin three times each day, and then only with the cleanest, sterile technique.

Orthopedic Injuries
Basic first aid techniques are most important to acquire for all preppers. This is especially true for injuries to bone, joint and spine. The first aid techniques that I learned as a Boy Scout almost 50 years ago are still relevant today. Taking a Red Cross First Aid course is really important as the minimum medical training for anyone seriously facing a survival situation. However, when there is no doctor available, you will be required to go several steps further. Fractures must be set into their normal , functional positions and then casted or splinted effectively when you are the final medical authority. Additionally, if the fracture is open, i.e., there is a break in the skin where the bone had poked through, this wound must be thoroughly washed and irrigated, dressed with a sterile dressing and antibiotic ointment, and broad spectrum antibiotics given for a week. Serious spinal injuries may be a death sentence in this situation, invoking the principle of expectant care (see “Triage principles” below).

Pain Relief and Anesthesia
Okay, so this part comes easy to me. Not only is my wife a former marathon runner, triathlete, and cross country cyclist, she is also a total Christian babe. And an anesthesiologist. She has taught me how to perform total IV anesthesia, using relatively inexpensive drugs given by injection, thereby not requiring the use of inhalational agents. Most of the procedures that can be done outside of the hospital are short- under one hour in duration. In the austere environment, the group surgeon would ideally be prepared and equipped to perform the following major surgical procedures: Debridement of dirty wounds; open ligation of major bleeding vessels; appendectomy; cholecystectomy (removal of a diseased gall bladder); cesarean section. Although endotracheal intubation may be required, the presence of a ventilator and oxygen can be circumvented. A bag-valve device will be necessary for manual ventilation. Intravenous equipment and fluids are required. Again, the amounts of each will depend upon your situation, but I would recommend having at least four liters of normal saline IV solution for each member of your group. Ignore the expiration dates: salt water does not degrade. Avoid using this precious resource for routine causes of dehydration. Use the rehydration solutions instead. Put up an ample supply of Tylenol, Motrin and Aleve. If possible, store a supply of stronger narcotic pain medications, such as Vicodin.

Triage Principles
Triage is the function of rationing medical care in the context of limited availability. This may mean a limitation in supplies, time, facilities, transportation or professional medical providers. In a TEOTWAWKI scenario, all of these factors may be in short supply.
The four triage categories are as follows:
1. IMMEDIATE: These victims have life threatening conditions that will a) result in death if not promptly addressed and b) can be remediated with the judicious use of assets on hand. An example would be a deep laceration to the groin with arterial bleeding from the femoral artery. The immediate application of pressure or, if necessary, a tourniquet, will save a life. This could then be treated with definitive surgery later.
2. DELAYED: This describes serious conditions that are not immediately life threatening, but that will require medical attention in hours to days to avoid serious disability or even death. An appropriate example would be a humerus fracture sustained while having piggy back chicken fights in the back yard (you’ve already forgotten: no horseplay!)
3. MINIMAL: This category includes illnesses and injuries that are self limiting: small lacerations, a non-displaced finger fracture, a short episode of diarrheal illness, etc. These folks need to keep working!
4. EXPECTANT: When medical resources are severely limited, they must be used to derive the greatest survival benefit for the community. That means that using a lot of medications, supplies and manpower in attempts to resuscitate profoundly ill or injured patients is unethical. These unfortunate folks will be unlikely to survive regardless of your best efforts. They are triaged as expectant, meaning that they are likely to die. Examples include severe shock, quadriplegic injuries, or multiple gunshot wounds to vital organs. They should be treated for pain if possible, and given comfort and affection until their demise. This will save resources for those who are salvageable and can continue to contribute to the group’s survival.

Medicolegal disclaimer: Please do not use any of the above advised techniques or methods unless you have no possible access to professional medical care. This advice is not at all applicable, and may in some instances be harmful, if you have access to professional medical care. - RangerDoc, MD, FACS


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