Doom and Bloom: Active Shooters In The New Norm

The Altons at Doom and Bloom Medical write about Active Shooters in the New Norm and training and first aid for the same.

On March 23rd, 2021, a man thought to be mentally disturbed entered a Boulder, Colorado grocery store and began a shooting rampage. 21-year-old Al Aliwi Alissa, born in Syria but living in the United States since the age of three, managed to kill 10 people, including a police officer, before disrobing and surrendering to authorities. It’s thought that the gunman has a long history of anger issues and may have paranoid tendencies.

The shooting follows an incident where another 21-year-old killed 8 people in Georgia at local massage parlors, which he saw as a form of temptation for what is described as a “sex addiction.” The recent shootings in diverse settings follow a lull during the 2020 COVID-19 pandemic.

In the last few years, shooting events by the disaffected, disturbed, and disgruntled have occurred on a regular basis.  Schools, churches, places of business, and other public venues are now fair game for those with bad intentions. Armed not only with weapons but with a blueprint from previous incidents, gunmen can identify soft targets easily and are more “successful” in achieving their goal of creating mass casualties.

Like COVID-19, have these events become part of the “New Normal”? Should we just get used to them?

You might think that the “successes” achieved by active shooters occur at random. The increase in the sheer number of casualties, however, reveal a strategy that is being refined to deadly effect.

The selection of soft targets is becoming a science and is leading to higher numbers of deaths and injuries. In the 2018 South Florida high school shooting, for example, the gunman activated the fire alarm to make sure there would be lots of targets in the hall. To create confusion, he tossed smoke bombs (but prudently wore a gas mask).

If the ill-intentioned are now that much better at creating mayhem, it stands to reason that our society must become better at thwarting those intentions. Here are ways that would, in my opinion, decrease the number of shooter incidents and the deaths caused by them:

Improve security in areas at risk. I would define an “area at risk” as just about anywhere where a crowd of people would gather. Better protection at malls or grocery stores may just be a matter of hiring more security personnel. Given the loss of so many jobs during the pandemic, it’s not a bad idea to train and hire workers specifically to keep an eye out for those with bad intentions. If the money isn’t there, establishing and training a volunteer safety team in places like churches, schools, or workplaces can increase the level of vigilance and identify threats early.

Although the recent attacks occurred in cities, rural areas aren’t immune. Establish volunteer safety officers in small towns where there may not be law enforcement and emergency medical personnel just around the corner. These persons should have training in security, firearms, and first aid for bleeding wounds. If there are volunteer fire departments, while not trained volunteer safety departments?

Instill a culture of situational awareness in our society. Situational awareness is a state of calm, relaxed observation of factors that might indicate a threat. These are called “anomalies”; learning to recognize them can identify suspicious individuals and save lives.

Situational awareness involves always having a plan of action when a threat occurs, even if it’s as simple as making a note of the nearest exit in whatever building you’re in. Seems like common sense, but in these days of smartphone distractions, many are oblivious of their surroundings.

Identify persons of interest through their social media posts. Some active shooter candidates are vocal about their intentions. You might be concerned about “big brother” monitoring our public conversations on social media. It concerns me also, but you must answer this question:  How many deaths are you willing to accept in your community due to a lack of vigilance?

We must always be on the lookout for signs of trouble. Even if this drives some potential gunmen underground, it might identify others in time to abort their mission.

In the case of Alissa, his sister-in-law felt compelled to take a gun away from him when he was acting erratically. In some states, it is possible for family members or police to ask the court to order the temporary removal of firearms from someone who may present a danger to others or themselves. A judge makes the determination to issue the order based on statements made and actions of the person in question. Controversial? Yes, but it could save lives.

Each municipality must set a mechanism (and an earlier trigger) for the authorities to apprehend and interrogate suspicious characters. Indeed, Ali Aliwi Alissa was a known person of interest to authorities before the attack.

Learn how to stop bleeding in wounds
Learn how to stop bleeding in emergencies

Learn how to stop bleeding in emergencies: Teach our citizens to avoid the natural paralysis that occurs in an unexpected event. This paralysis occurs as a result of “normalcy bias”, the tendency to discount risks because most days proceed in a certain standard manner; we usually assume that today will be the same.

By teaching simple courses of action such as the Department of Homeland Security’s “Run, Hide, Fight” triad, the decision-making process may be more intuitive and more rapidly implemented. This is more effectively taught and ingrained at a young age. Make sure it’s a part of every child’s education.

We should also teach our students simple first aid strategies to stop bleeding, the most likely cause of death in these scenarios. Rapid action by bystanders is thought to decrease the number of deaths from hemorrhage. Add “Reduce” hemorrhage to “Reading, ‘Riting, and ‘Rithmetic” as part of school curriculum, and lives might be saved.

Provide first aid kits for bleeding in public venues. In the last few years, bleeding kits have been packed into fire extinguisher wall cabinets in many public venues and can be accessed by those at the scene. Unfortunately, in most places, there isn’t a sign that indicates their presence. With supplies, the Good Samaritan will be more likely to save a life. I predicted, years ago, that these kits will be fixtures everywhere one day. It’s good that they’re there, but let the public know they are.

Our response as a nation has been to do little to correct the problem. I say that era must end. Let’s stop being “soft” targets. We must forsake the notion that shootings are just part and parcel of the New Normal and begin the process by which we change our attitude and level of vigilance, not in isolated cases, but as a society.

The above recommendations wouldn’t affect the average (sane) citizen’s right to bear arms. It would mean more situational awareness so that people can be more ready to “Run, Hide, Fight”.  

If it means more surveillance, we should realize how much there is already. Watching people who publicly threaten violence more closely makes sense; so does increasing access to mental health resources to, perhaps, prevent someone from going off the rails.

The New Normal is an angry, dangerous place. The American identity has been replaced by many tribal ones; Most seem to hate each other. It’s a recipe for disaster that’s likely to get worse if we don’t reverse course, but that takes fortitude and determination on the part of all parties.

You don’t have to be a Department of Homeland Security official to know that there are more active shooter events on the horizon.  Watch for anomalies in behavior and always have a plan of action. A prepared nation wouldn’t be invulnerable to attacks, but its citizens would have a better chance to survive them.

Joe Alton MD

Doom and Bloom: Double Masking

The Altons at Doom and Bloom Medical have a post talking about the most recent recommendation for Double Masking. The mask mandate has been one of the worst handled public health campaigns that I have ever witnessed. The messaging from government health agencies at all levels has ranged from incorrect lies at worst and incompetent at best. Putting aside the deliberate prevarications at the beginning the ongoing failures are manifold:

(1) I have yet to see a campaign at any level on the proper procedure for donning and removing a mask. I should be seeing PSAs as YouTube ads, on TV, and maybe even in regular mail. Medical journal articles on the inefficacies of mask mandates often cite the lay person’s inability to wear a mask correctly, but no one has tried to remedy this.

(2) All masks are not equal. No effort has been made to educate people on this front either. Presumably government health agencies at the beginning of the crisis though something like, “There aren’t enough N95 masks to go around. How do we protect people? We can’t. Let’s just tell them to slap anything over their face.” Like unarmed national guard soldiers at airports are for security theater, we can think of this failure as health theater. Different masks and different materials offer differing levels of protection to different parties. An N95 mask is far superior than a homemade cloth mask. If any air can be sucked in around the edges of your mask, then your mask only serves to protect other people from your breath, and it is not protecting you very much if at all.

(3) Related to taking off and putting on your mask, but different, people need to be taught what to do and not do with their masks while they are on. Sucking on your mask is bad. Wearing your mask below your nose is bad. Touching the front of your mask with your hands is bad. All of those either reduce or negate the effectiveness of your mask or contaminate other body parts.

Luckily private parties before and after the pandemic started have produced videos on proper mask wearing.

Both the CDC and the Mandalorian say “This is the Way

After a year of wearing masks, the Centers for Disease Control and Prevention has decided that wearing two masks on your face is really what you should do if you want to avoid COVID-19.

Recent studies using mechanical devices that simulate breathing and generate “cough droplets” gave the alarming result that you receive only 42% protection wearing a standard surgical mask and 44% wearing a cloth mask. The researchers used 3-ply masks for the experiment. Therefore, they recommend double masking: a disposable medical mask under a cloth mask.

I have been saying all along that I felt cloth masks were not enough to provide the protection needed to avoid getting the virus. I have also said that standard surgical masks are not enough either, at least compared to the well-known N95. Still, I was surprised to see a protection rate in the low forties for both cloth and surgical masks, since the Wake Forest Institute of Regenerative Medicine published data in April 2020 suggesting that these masks gave protection rates in the 62-79 percent range.

N95 masks are supposed to give at least 95% protection against particles 3 microns in size or more. The SARS-CoV2 virus is actually smaller than that, though, so how can I say that wearing an N95 is the way to go? Is it better than the other options? Wouldn’t those tiny particles just go right through even N95s?

Studies were performed using medical workers dealing with the related (and similarly-sized) MERS virus in 2012. Results showed that those who used the N95 had less incidence of infection than those wearing lesser protection. The researchers stated that “policymakers might prefer to err on the side of caution and support recommendations for full protective equipment, including the use of N95 masks for MERS-CoV, an emerging novel respiratory virus.”

Well, in the 2020s, there’s a new novel respiratory virus (not so novel now), but the CDC has given mixed and confusing signals about mask wear since the pandemic began. They said not to buy N95 masks so that medical workers could have them.  This was in the face of a scarce supply of these masks in the Strategic National Stockpile.

Mask production has ramped up since then, but the FDA.gov website still publishes this statement: “The Centers for Disease Control and Prevention (CDC) does not recommend that the general public wear N95 respirators to protect themselves from respiratory diseases, including coronavirus (COVID-19).”

They cite the importance of availability to health workers (certainly true), but then, the CDC endorsed home care for mild-moderate cases of COVID-19, cases that won’t kill you but certainly make you contagious. That made the average family caregiver a “health care worker” at risk too. The unavailability of quality masks, however, led to most people using cloth coverings or standard surgical masks.

The problem with these masks is that it’s hard to get a tight fit. The grand majority of procedure masks are fluid-resistant “melt blown” fabric secured with ear loops. They’re produced according to American Society of Testing and Materials (ASTM International) standards and designed to protect from splashes and prevent aerosol particles from getting into the air. They don’t offer a perfect seal and tend to have openings where microbes can go in or out. Not a good thing, if you’re dealing with a virus that’s airborne.

N95 masks, however, are manufactured according to standards set by another body, NIOSH (The National Institute for Occupational Safety and Health). NIOSH testing considers a “worst-case” scenario as the testing conditions are the most severe likely to be experienced by the wearer.

On top of discouraging N95 usage, the FDA issued an Emergency Use Authorization on April 18th, 2020, allowing for the production of medical face masks without fluid resistance. These may be manufactured from materials other than melt blown fabric, such as cloth. This began the cottage industry in cloth coverings encouraged by the government.

N95 mask with elastic straps

The problem with these masks is that it’s hard to get a tight fit with ear loops.  All N95 “respirator” masks are equipped with elastic straps which hold the mask tightly to the users face. The recently-reported low percentage of protection from cloth coverings and standard procedure masks could possibly be improved with training in proper mask fitting.

standard surgical mask with ear loops tied together and tucked for better fit

A good mask fit forms a seal between the mask and the person’s face, decreasing the chance of infection. One recent recommendation is to tie a knot in each ear loop as close to their attachment to the mask itself as possible, in the hopes of getting a better seal. This involves modifying each mask, and making sure to tie it properly. It’s very important to tuck in material that may represent a hole in your defenses. This method, the government says, is almost as good as wearing two masks.

Poorly tucked, a surgical mask gives poor protection even if ear loops are tied together

Also important is training on how to properly remove masks so as not to contaminate one’s hands. The front of the mask should be considered at risk for contamination and shouldn’t be touched if possible. To learn how to get a proper fit and seal for different masks, and how to properly remove them to avoid contamination, see my video from January of 2020, at the very beginning of the pandemic, where I originally discussed the importance of correct mask techniques. Click below:

Truth is, there is nothing like having the right medical equipment in normal times as well as pandemic times. If you can find N95 masks, you should invest in a supply. If you don’t have the best mask, you end up wearing two or modifying a less protective one. Next month’s CDC recommendations? Use the contact form to let me know what you think.

Doom and Bloom: Labor and Delivery in Austere Settings

The Altons at Doom and Bloom Medical have an article on Labor and Deliver in Austere Settings. Given the topic, it is a longer article with more diagrams and visual aids than usual. Below is an abbreviated excerpt, so please click through the link to read the entire article with visual aids.

Pregnancy and childbirth are usually considered a blessing in modern times. Off the grid, however, the family medic/midwife will be thrown back to the 19th century, when childbirth was associated with a much higher rate of complications than now.

Even if the group has no women of childbearing age at present, at one point or another the medic may be called upon to attend a delivery without the benefits of a modern medical system. This article will focus on a pregnancy at term, classically defined as one that has reached 37-42 weeks from the first day of the last menstrual period. More articles on pregnancy diagnosis, care, and complications can be found at doomandbloom.net.

(Note: I am an actively-licensed Life Fellow of the College of Ob/Gyn and my wife is an actively licensed Certified Nurse Midwife.)

As the woman approaches her due date, several things happen. The fetus begins to “drop”, assuming a position deep in the pelvis. The patient’s abdomen may look different, or the “fundus” (the top of the uterus) may appear lower. As the neck of the uterus (the cervix) relaxes, the patient may notice a mucus-like discharge mixed with a little blood. This is referred to as the “bloody show” and is usually a sign that labor will occur soon, anywhere from the next few hours to a week or so.

If you examine your patient vaginally by gently inserting two fingers of a gloved hand, you’ll notice the cervix is firm like your nose when it is not ripe, but becomes soft like your lips when the due date is approaching. This softening and thinning out of the cervix is called “effacement”

Effacement is measured in percentages. When 50% effaced, the cervix is half its normal thickness and length. At 100% effacement (“completely effaced”), the cervix is paper-thin. Effacement usually occurs before any significant opening of the cervix (also called “dilation”).

Contractions will start becoming more frequent. To identify a contraction, feel the skin on the soft area of your cheek, and then touch your forehead. A contraction will feel like your forehead. False labor, Braxton-Hicks contractions, will be irregular and will go away with bed rest (especially on the left side) and hydration. If contractions are coming faster and more furious even with bed rest and hydration, it’s likely the real thing!

A gush of watery fluid from the vagina will often signify “breaking the water”, and is also a sign of impending labor and delivery. The timing will be highly variable, however, and sometimes urine leakage may confuse the situation. A product called “nitrazine paper” will turn a bright blue when it touches amniotic fluid due to its high Ph. A bright blue result (nitrazine positive) usually verifies that the bag of water is broken. If you have a microscope in the hospital tent, a little amniotic fluid on a slide will reveal fern-like crystals. This is called “ferning” and is more solid proof of membrane rupture than nitrazine positive tests.

There are three stages of labor:

FIRST STAGE (LATENT PHASE)

Latent phase

The first stage is the longest part of labor: lasting up to 20 hours or more. It begins when your cervix starts to dilate and efface, and is separated into a latent phase and an active phase. The first stage is considered complete when the cervix reaches 10 centimeters and is so effaced that you can barely identify it.

The latent phase is when labor begins. False labor has been ruled out and contractions are becoming stronger, more regularly, and in greater frequency. They may also last longer (60-90 seconds). The contractions cause your cervix to dilate and efface. In latent phase, dilation to about 4 centimeters or so often progresses slowly.

The mother should be given as much freedom to walk, sit, practice breathing techniques, or do other activities as she can handle. Keeping her occupied and moving is a good way to move the process along. A soak in a warm tub or shower is helpful if the water hasn’t broken. Oral hydration and small meals are also acceptable.

Once the cervix reaches 4 centimeters of dilation, a vaginal exam will allow you to place two (normal-sized) fingertips in the cervix. You’ll feel something firm; this is the baby’s head. In general, however, vaginal exams are invasive and shouldn’t be performed more often than, perhaps, every two hours.

FIRST STAGE (ACTIVE PHASE)

When the cervix reaches 5 centimeters or so of dilation, labor enters the active phase. Contractions get even stronger and spacing becomes closer. As the baby’s head descends, the mother may notice back pressure and bloody vaginal discharge. If the water membrane hasn’t ruptured, it will likely happen during this time.

Cervical dilation in active phase speeds up to about a centimeter an hour, although women who have had children may go much faster. Breathing techniques may be needed to manage discomfort during contractions (you won’t have epidural anesthesia or strong pain meds off the grid). Other strategies include:

-Changing positions. Some women prefer being on hands and knees to improve back pain.

-Walking between contractions with a helper.

-Emptying the bladder often.

-Gently massaging the mother’s back.

It may help to remind the mother that each contraction brings her closer to having a baby in her arms. Despite that, don’t encourage her to push until the cervix is completely dilated and the baby’s head has descended into the pelvis.

SECOND STAGE

Various position to help with contractions

The second stage of labor begins when the cervix is fully dilated and ends when the baby is born. This stage is usually completed within two hours, but is dependent on the strength and frequency of contractions. First-time mothers take longer than those who have had children.  Those who have delivered several children may proceed through this stage very quickly.

At this point, the mother will likely feel a strong urge to push. Encourage rest between contractions. When pushing, different positions may work for different mothers. Try squatting, lying on their side with a leg raised, or even hands and knees. The body should “curl into” the push as much as possible, almost exactly like have a bowel movement.

The delivery of a baby is best accomplished with the help of an experienced midwife or obstetrician, but those professionals will be hard to find in survival settings. If there is no chance of accessing modern medical care, you must prepare to perform the delivery…(continues)

Doom and Bloom: Anemia

The Altons at Doom and Bloom Medical talk about Anemia and how to recognize and deal with it in survival situations.

In survival scenarios, there are plenty of occasions where the medic will encounter a group member suffering from anemia. Anemia is a condition in which you lack enough healthy red blood cells in your circulation. Red blood cells are what make your blood, well, red; their job is to carry oxygen to your body’s tissues and carbon dioxide away. If you don’t have enough of these tiny, disc-shaped cells, it can have major effects on your health.

Red cells primarily consist of a protein made in bone marrow called hemoglobin. In men, anemia is typically defined as a hemoglobin level of less than 13.5 gram/100 ml and in women as hemoglobin of less than 12.0 gram/100 ml.

Anemia happens for different reasons. Survivors in a prolonged disaster setting are unaccustomed to being off the grid, and could easily injure themselves and bleed heavily from a wound. This is the most sudden cause of severe anemia, but it can also occur from lack of production due to malnutrition or medical conditions that destroy red blood cells or shortens their life span (normally, about 115-120 days).

Depending on the cause, signs and symptoms of anemia may vary.  If your patient’s case is mild and they’ve had it for a while, their body may have accommodated to the extent that they might not have symptoms. If they do occur, they might include:

  • Fatigue
  • Weakness
  • Headache
  • Pale or yellowish skin
  • Cold hands and feet
pale inner eyelid seen in anemia

Simple blood tests could identify the problem, but won’t be available off the grid. Just checking under the lower eyelid, however, may reveal a hemoglobin deficiency. Normally, the inside of the eyelid is light red or pink; in anemia, it’s very pale or yellow. Worse cases can cause major symptoms:

  • Irregular or fast heart rates
  • Shortness of breath
  • Dizziness or lightheadedness
  • Chest pain

The worse the anemia, the less productive your group member will be, so it’s important to do everything possible to treat it and increase the hemoglobin level.

Iron deficiency is the most common cause of anemia. It’s often seen in women who are or were recently pregnant.  Heavy periods will also cause iron-deficiency anemia. Treatment usually involves oral supplements like ferrous sulfate or ferrous gluconate. The usual dose is 325 mg (65 mg of elemental iron) three times a day. Some complain of intestinal issues at that dose: dark stools, constipation, nausea, and cramps. This can take a lot out of a person, so consider a lower dose or every other day dosing in those afflicted. Be aware that caffeinated beverages may delay iron absorption, while vitamin C at 500 mg promotes it.

In addition to iron, your body needs folate (vitamin B9) and vitamin B12 to produce enough healthy red blood cells. A diet lacking in these and vitamin C can impair the production of red cells. Some people get enough B12 but can’t absorb it due to an autoimmune reaction, causing a condition called “pernicious anemia”.  Special B12 injections are given for this and other conditions.

Anemia can also be related to inflammation. Certain diseases, such as cancers like leukemia and lymphoma, AIDS, rheumatoid arthritis, kidney disease, Crohn’s disease and other inflammatory ailments can lower production of red blood cells or destroy them. For these, you have to treat the main problem, a major challenge for the off-grid medic.

Another group of anemias are known as “hemolytic” (blood disintegraters). They develop when red blood cells are destroyed faster than bone marrow can replace them. You can inherit a hemolytic anemia, or you can develop it later in life.

Sickle cell anemia (sometimes called “sick-as-hell” anemia) is a type of hemolytic anemia. It’s caused by a defective form of hemoglobin that forces red blood cells to assume an abnormal (sickle) shape instead of a disc. These irregular blood cells die prematurely, resulting in a chronic shortage. Patients, often African Americans, go into what we call “crises” that can be very painful when these abnormally shaped cells clog small blood vessels.

Hemolytic anemias can also be caused by certain drugs, which can cause the immune system to mistake your own red blood cells for foreign substances. The body responds by making antibodies to attack and destroy its own cells. Make sure your healthcare provider knows if you take any of these medicines:

  • Cephalosporins like Keflex
  • Fluoroquinolones like Levaquin
  • Penicillins
  • Nitrofurantoin (Macrodantin) and phenazopyridine (Pyridium; used for bladder infections)
  • Levodopa for Parkinson’s disease
  • Dapsone for skin disease
  • Quinidine for irregular heartbeats
  • Methyldopa for high blood pressure
  • Aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs

Dietary sources of iron may be helpful, so adjust your food storage and survival garden goals accordingly. Eating a diet high in meats, especially red meats, may help. Nonmeat iron sources include:

  • Spinach and other dark green leafy vegetables
  • Peas and certain other legumes like chickpeas
  • Beans
  • Dried fruits, such as prunes, raisins, and apricots

Some foods are Iron-fortified, like certain cereals and breads. Many also have B12 added, as well. Other food sources of B12 are:

  • Meats, such as liver, beef, fish, and poultry
  • Eggs
  • Dairy products

For folic acid:

  • Spinach and other dark green leafy vegetables
  • Black-eyed peas and other dried beans
  • Beef liver
  • Eggs
  • Bananas, oranges, and related fruits and juices

As mentioned earlier, vitamin C is a tool to help absorb iron. Good sources of vitamin C can be found in many fruits as well. Fresh and frozen fruits, vegetables, and juices usually have more vitamin C than canned ones.  Vegetables rich in vitamin C include tomatoes, peppers, broccoli, brussels sprouts, potatoes, and spinach.

Joe Alton MD

Doom and Bloom: The Case for Fish Antibiotics

The Altons at Doom and Bloom Medical talk about The Case for Fish Antibiotics and their viability for human use in emergency cases when there is no medical system to which to resort.

More than a decade ago, I was the first physician to advocate for the storing of antibiotics marketed for tropical fish and pet birds as a potential tool for the medic in long-term survival settings. Although I never recommended them for use in situations where there is a functioning medical infrastructure, I believe, despite criticism, that having a supply of these on hand will save lives, otherwise lost from bacterial infections, in a prolonged off-grid disaster scenario.

Accumulating over-the-counter drugs for the medic’s storage may be a simple enterprise, but not prescription medicines. Even with a sympathetic physician, the ability to obtain the quantity needed to be an effective caregiver for a survival community is limited, at best. Antibiotics are one example of life-saving medications that would be in short supply off the grid.

The inability to have antibiotics at hand may cost some poorly prepared individuals their lives in a survival situation. There will be a much larger incidence of infection when people have to fend for themselves and are injured as a result. Any strenuous activities performed that aren’t routine in normal times can lead to injuries that break the skin. These wounds will, very likely, be dirty. Within a relatively short time, they might begin to show signs of infection in the form of redness, heat, and swelling.

Treatment of such infections at an early stage improves the chance they will heal quickly and completely. However, many rugged individualists are likely to “tough it out” until their condition worsens and the infection spreads to their blood. If the medic has ready access to antibiotics, the problem can be nipped in the bud before a tragic outcome occurs.

Some solutions for medical issues off the grid without medical help, like fish antibiotics, may save lives

The following is contrary to standard medical practice; it’s a strategy that is appropriate only when help is not on the way. If there are modern medical resources available to you, seek them out.

Antibiotic Options

Small quantities of antibiotics can be obtained by anyone willing to tell their doctor that they are going out of the country and would like to avoid “Travelers’ Diarrhea” or other infections common at their destination. Likewise, asking for medications that must be taken early in an infection, like oseltamivir (Tamiflu) for influenza, is a reasonable strategy; after all, not everyone can get in to see their doctor right away, and the antiviral Tamiflu is most effective in the first 48 hours after symptoms begin.

(Note: Tamiflu is an anti-viral and only works against influenza (and not COVID-19. Antibiotics have no effect against viruses at all.)

This approach is fine for one or two courses of therapy, but a long-term alternative is required for the survival caregiver to have enough antibiotics to protect a family or survival group. In the aftermath of a disaster, some deaths may be unavoidable, but bacterial-related deaths are unacceptable. This concern led us to what we believe is a viable option: aquarium and avian antibiotics.

Betta splendens

For many years, we have kept tropical fish in aquaria and tilapia in ponds. We also have parrots as pets. After years of using aquatic medicines on fish and avian medicines on birds, we decided to evaluate these drugs for their potential use off the grid. They seemed to be good candidates: All were widely available, available in different varieties, and didn’t require a medical license or prescription.

A close inspection of a number of these products found exactly one ingredient: the drug itself, identical to those obtained by prescription at the local pharmacy. A bottle labeled aquatic amoxicillin, for example, had as its sole ingredient amoxicillin, which is an antibiotic commonly used in humans. Unless they’re listed on the bottle, there are no additional chemicals to makes your scales shinier or your feathers more colorful.

Any reasonable person might be skeptical about considering the use of aquarium antibiotics for humans, even in disaster settings. Those things are for fish, aren’t they? Yet, a number of them only come in dosages that correspond to pediatric or adult human dosages.

The question became: Why should a one-inch guppy require the same dosage of, say, amoxicillin as a 180-pound adult human? We were told that it was due to the dilution of the drug in water. However, at the time, there were few instructions that tell you how much to put in a ½ gallon fishbowl as opposed to a 200-gallon aquarium (they have them now, however).

Finally, the “acid test” was to look at the pills or capsules themselves. The aquatic or avian drug had to be identical to that found in bottles of the corresponding human medicine. For example, when (in 2010) we opened a bottle of FISH-MOX FORTE 500 mg distributed by Thomas Labs and a bottle of Human Amoxicillin 500mg (DAVA pharmaceuticals), we found:

human amoxicillin by DAVA pharmaceuticals

Human Amoxicillin:         Red and Pink Capsule, with the letters and numbers WC 731 on it.

Fish amoxicillin (the brand is now defunct)

FISH-MOX FORTE: Red and Pink Capsule with the letters and numbers WC 731 on it.

There are still a number of examples today, including:

fish versions of different antibiotics
Appearance of same antibiotics made by human pharmaceutical companies

Logically, then, it makes sense to believe that they are essentially identical, manufactured in the same way that human antibiotics are. Further, it is our opinion that they are probably from the same batches; some go to human pharmacies and some go to veterinary pharmacies or bottling companies. Over the years, readers in the human and veterinary pharmacy fields have confirmed this.

This is not to imply that all antibiotic medications met the criteria. Many cat, dog, and livestock antibiotics contain additives that might cause ill effects on a human being. Look only for those veterinary drugs that have the antibiotic as the sole ingredient.

There has been significant controversy regarding these medicines as some have chosen to use them in normal times against our recommendations, which only apply to long-term survival scenarios. As a result, the original distributor of these drugs, Thomas Labs, eventually stopped production in response to political pressure.  For now, other brands with names like FISH-AID and others have, at the time of this writing, filled the void by offering a number of veterinary equivalents online. Expect volatility in terms of availability as a number of these drugs are placed under increasing government control in the future.

VETERINARY “EQUIVALENTS”

Having antibiotics in quantity will help the medic save lives in survival scenarios

Here is a list of antibiotics that are commercially available in aquatic or avian form as of the writing of this article:

AMOXICILLIN,  (Amoxicillin 250 mg and 500 mg)

AMPICILLIN 500 MG

PENICILLIN 250 mg and 500 mg

CEPHALEXIN 250 mg and 500 mg

METRONIDAZOLE 250 mg and 500 mg

CIPROFLOXACIN 250 mg and 500 mg

CLINDAMYCIN 150 mg

AZITHROMYCIN 250 mg

LEVOFLOXACIN 500 mg

SULFAMETHOXAZOLE/TRIMETHOPRIM 400 mg/80 mg and 800 mg/160 mg

DOXYCYCLINE 100 mg

MINOCYCLINE 50 mg and 100 mg

FLUCONAZOLE (anti-fungal) 100 mg

Most of the above come in lots of 30 to 100 tablets which can be bought in multiples. This makes them eligible for the survival medic to stockpile for prolonged disaster events. As recently as December 2020, we were able to purchase several without a prescription.

Antibiotics are not candy; they must be used judiciously in survival scenarios

Of course, anyone could be allergic to one or another of these antibiotics, but it would be a very rare individual who would be allergic to all of them. It should be noted that there’s a 10% cross-reactivity between Penicillin drugs and cephalexin (Keflex). If you are allergic to penicillin, you could also be allergic to Keflex. For those who can’t take penicillin, there are suitable safe alternatives. Any of the antibiotics below should not cause a reaction in a patient allergic to Penicillin-family drugs:

  • Doxycycline
  • Metronidazole
  • Tetracycline
  • Ciprofloxacin
  • Clindamycin
  • Sulfamethoxazole/Trimethoprim
  • Levofloxacin
  • Minocycline

This one additional fact: We have personally used some (not all) of these antibiotics as veterinary equivalents on our own persons without any ill effects. Whenever we have used them, their effects have been indistinguishable from human antibiotics.

Having said this, we recommend against self-treatment in any circumstance that does not involve the complete long-term loss of access to modern medical care. This is a strategy to save lives in a post-calamity scenario only.

Finding Out More

Although you might think that any antibiotic will work to cure any disease, specific antibiotics are used at specific doses for specific illnesses. The exact dosage of each and every medication in existence for each and every disease is well beyond the scope of this article. It’s important, however, to have as much information as possible about medications that you plan to store.

This information is available in a number of drug reference manuals (with images) in both print and digital form. Online sources such as drugs.com or rxlist.com are other useful sources, but we recommend a hard copy for your medical library in case a disaster affects the internet.

Your manual should list medications that require prescriptions as well as those that do not. Under each medicine, you will find the “indications”, which are the medical conditions that the drug is used for. Also listed will be the dosages, risks, side effects, and even how the medicine works in the body. It’s okay to obtain a book that isn’t the latest edition, as information about common drugs doesn’t often change a great deal from one year to the next. Try to obtain a recent copy, though, as occasional changes do occur.

For those skeptical of our opinion on this topic, we ask you to imagine this circumstance: A disaster has occurred that has knocked you off the grid and sent you on the road. Your family is performing activities of daily survival like chopping wood for fuel, something they’ve never done before. Your son or daughter cuts themselves and, in a day or so, the wound becomes red, hot, and swollen. There may be the beginnings of a fever. You only have a bottle of “fish” amoxicillin. Would you use it? We’ll let you decide.

Joe Alton MD

Doom and Bloom: When a Person Faints

The Altons at Doom and Bloom Medical have an article about what to do When a Person Faints. I once fainted while standing in early morning PT formation in the Army, probably from a combination of low blood sugar and low hydration. Well, I vomited and then fainted, so I hit at least one of the warning signs which the Altons mention. I think I also hit “momentary lack of attention.” After questions from a medic and a drink of water, I was able to continue with PT as usual with no further issues. Anyone can faint, but sometimes more rest is better.

Even 6’4″ military men may experience fainting

We often write about medical strategies when a society collapses, but, sometimes, an individual may collapse as a result of fainting (also called “syncope”). It usually occurs when a drop in blood pressure (“hypotension”) doesn’t allow enough oxygenated blood to reach the brain.

Someone who has fainted must be differentiated from the person who has “seized” from epilepsy. Fainters won’t exhibit jerky movements as in a Grand Mal seizure or stare into space as in a Petit Mal seizure. Also, a person who has had a seizure tends to be difficult to rouse for a period of time. This is called a “post-ictal” state and may last for 30 minutes or so before it resolves on its own. Most people who have only fainted will regain alertness relatively soon after the episode.

(Note: Grand Mal and Petit Mal are no longer used in the latest nomenclature of seizures. They changed the whole system in 2017, but most people still know them by these names.)

There are a few signs that a person is close to fainting:

  • Cold, clammy skin
  • Nausea or vomiting
  • Complaints of feeling lightheaded or weak
  • A sensation of spinning
  • Tunnel vision or blurriness
  • Yawning
  • Slow pulse
  • Momentary lack of attention

(Note: More than once, I’ve had a surgical intern or other assistant faint dead away during a grueling and long surgical procedure.)

Survival scenarios almost guarantee the medic will be confronted with a person who has fainted at one point or another. Simple activities of survival, such as long hikes to retreats, work sessions in hot weather, and hiding out in hot shelters without climate control, can make certain group members prone to syncope. In addition, skipped meals and dehydration will put many of your people at risk.

Low blood sugar and various other medical conditions can cause fainting. Good hydration and appropriate dietary intake will prevent most episodes. Glucose or honey packets, for example, can help raise a person’s blood sugar that has gone dangerously low. Have some in your kit. Others may pass out due to irregular heart rhythms, extreme stress, or even pregnancy.

If someone feels as if they are about to collapse, they should sit down and put their head down between their knees to increase blood flow to the brain. If you see someone who is fainting from a standing position, hold and gently lower them to the ground on their back. In normal times, of course, you would have someone call emergency medical services as soon as possible.

If help isn’t coming, it’s up to you to quickly evaluate the victim. If the patient fell to the floor, there is always the possibility of a head injury. Evaluate for obvious wounds and rule out concussion.

A person who has had a simple fainting spell will usually be breathing normally and have a steady, regular pulse. Raise their legs about 12 inches off the ground and above the level of their heart and head. This position will help increase blood flow to the brain. Assess the patient for evidence of trauma, bleeding, or signs of a seizure. If bleeding, apply direct pressure to the wound. If no pulse or breathing, begin CPR.

(Seizure disorders are discussed on this website here.)

After the first few seconds, you have determined that the victim is breathing, has a pulse, and is not bleeding. Tap on their shoulder (some say to gently shake) and ask in a clear voice “Can you hear me?” or “Are you OK?”. Loosen any constricting clothing and make sure that they are getting lots of fresh air by keeping the area around them clear of crowds. Look for a medical alert bracelet that may give clues as to their health issues. If you are in an area that is hot, fan the patient or carefully carry them to a cooler area. Cool compresses may be helpful.

If you are successful in arousing the patient, ask them if they have any pre-existing medical conditions such as diabetes, heart disease or epilepsy. Stay calm and speak in a reassuring manner. People oftentimes are embarrassed and want to brush off the incident, but be aware they are still at risk for another fall.

Once the victim is awake and alert (Do they know their name? Do they know where they are? What year it is?), you may have the patient sit up slowly if they are not otherwise injured. Don’t let them get up for 15 minutes or so, even if they say that they are fine. If you are not in an austere setting, emergency medical personnel are on the way; wait until they arrive before having the patient stand up. Off the grid, however, you will have to make a judgment as to whether and when the victim is capable of returning to normal activities. A period of observation would be wise.

As dehydration and low blood sugar are possible causes, some oral intake may be helpful during recovery. This is appropriate only if it is clear that they are completely conscious, alert, and able to function. Test their strength by having them raise their knees against the pressure of your hands. If they are weak, they should continue to rest. Close monitoring of the patient will be very important, as some internal injuries may not manifest for hours.

Doom and Bloom: Asthma in Survival

The Altons at Doom and Medical have an article about Asthma in Survival.

Asthma is a chronic condition that limits your ability to breathe. It affects the tubes that transport air to your lungs, collectively known as the “airways”. Asthma affects 20 million Americans and is the most common cause of chronic illness in children. Off the grid, increased stress and exposure to new substances will only makes things worse. The family medic must know how to recognize and treat symptoms with limited supplies.

When people with asthma are exposed to a substance to which they are allergic (an “allergen”), airways become swollen, constricted, and filled with mucus. As a result, air can’t pass through to reach the part of the lungs that absorbs oxygen (the “alveoli”).

During an episode of asthma, you will develop shortness of breath, tightness in your chest, and start to wheeze and cough. This is referred to as an “asthma attack”. In rare situations, the airways can become so constricted that a person could suffocate from lack of air.

Here are common allergens that trigger an asthmatic attack:

  • Pet or wild animal dander
  • Dust or the excrement of dust mites
  • Mold and mildew
  • Smoke
  • Pollen
  • Severe stress
  • Pollutants in the air
  • Some medicines
  • Exercise

Yes, you can trigger an asthmatic attack with exercise. This doesn’t mean you shouldn’t stay in shape. Exercise strengthens lungs, which helps improve asthma control.

There are many other myths associated with asthma; the below are just some:

Asthma is contagious. (False)

You will grow out of it. (False; it might become dormant for a time but you are always at risk for it re-emerging.)

It’s all in your mind. (False; although may trigger it, it’s very real.)

If you move to a new area, your asthma will go away. (False; it may go away for a while, but eventually you will become sensitized to something else and it will likely return.)

Asthma should only be treated when an episode occurs. (False; asthma is best treated with constant medication to reduce frequency and severity of attacks. Encourage your asthmatic group members to stockpile meds.)

You will become addicted to your asthma meds. (False; inhalers and oral asthma drugs aren’t addictive. It’s safe to use them on a regular basis.)

Here’s are two “true” myths: Asthma is, indeed, hereditary. If both parents have asthma, you have a 70% chance of developing it compared to only 6% if neither parent has it. Also, asthma does have the potential to be fatal, especially if you are over 65 years old.

(Note: In the 1980s, I treated a pregnant patient who had the worse type of asthma attack, called “status asthmaticus.” Once she improved somewhat, she insisted on going home against my advice  to care for her other children. She returned that night in an irreversible state of oxygen loss. Both mother and baby perished.)

PHYSICAL SIGNS AND SYMPTOMS OF ASTHMA

Asthmatic symptoms may be different from attack to attack and from individual to individual. Some of the symptoms are also seen in heart conditions and other respiratory illnesses, so it’s important to make the right diagnosis. Symptoms may include:

  • Cough
  • Shortness of Breath
  • Wheezing (usually of sudden onset)
  • Chest tightness (sometimes confused with coronary artery spasms/heart attack)
  • Rapid pulse rate and respiration rate
  • Anxiety

Besides these main symptoms, there are others that are signals of a life-threatening episode. If you notice that your patient has become “cyanotic”, they are in trouble. Someone with cyanosis will have a blue/gray color to their lips, fingertips, and face.

Cyanosis

You might also notice that it takes longer for an asthmatic to exhale than to inhale. As an asthma attack worsens, wheezing may take on a higher pitch. As the attack worsens, the patient suffers a lack of oxygen that makes them confused and drowsy; they may possibly lose consciousness.

Asthma vs Heart Attack

As an asthma attack may resemble a heart attack, the medic should know how to tell the difference. For Asthma is usually improved by using fast-acting inhalers, a strategy that doesn’t offer relief from a heart attack or other cardiac events. Cardiac patients often have swelling of the lower legs, also called “edema.” This is rarely seen with asthma. Asthmatic also don’t have arm and jaw pain that is often seen with heart attacks. Those with a history of cardiac chest pain improve with the angina drug nitroglycerin.

Although both may be associated with shortness of breath, few will confuse the symptoms of COVID-19 with asthma, but suffice it to say that COVID-19 is associated with fever and loss of taste or smell.

DIAGNOSING ASTHMA

On physical exam, use your stethoscope to listen to the lungs on both sides. Make sure that you listen closely to the bottom, middle, and top lung areas as described in the section on physical exams.

In a mild asthmatic attack, you will hear relatively loud, musical noises when the patient breathes. As the asthma worsens, less air is passing through the airways and the pitch of the wheezes will be higher and perhaps not as loud. If no air is passing through, you will hear nothing, not even when you ask the patient to inhale forcibly. This person may become cyanotic.

typical peak flow meter

Sometimes a person might become so anxious (a “panic attack”) that they become short of breath and may think they are having an asthma attack. To resolve this question, you can measure how open the airways are with a simple diagnostic instrument known as a peak flow meter. A peak flow meter measures the ability of your lungs to expel air, a major problem for an asthmatic. It can help you identify if a patient’s cough is part of an asthma attack or whether they are, instead, having a panic attack or other issue.

To determine what is normal for a member of your group, you should first document a peak flow measurement when they are feeling well. Have your patient purse their lips over the mouthpiece of the peak flow meter and forcefully exhale into it. Now you know their baseline measurement. If they develop shortness of breath, have them blow into it again and compare readings.

In moderate asthma, peak flow will be reduced 20-40%. Greater than 50% is a sign of a severe episode. In a non-asthma related cough or upper respiratory infection, peak flow measurements will be close to normal. The same goes for a panic attack; even though you may feel short of breath, your peak flow measurement is still about normal.

TREATMENT OF ASTHMA

Asthma bronchodilator in inhaler

The cornerstones of asthma treatment are the avoidance of “trigger” allergens, as mentioned previously, and the maintenance of open airways. Medications come in one of two forms: drugs that give quick relief from an attack and drugs that control the frequency of asthmatic episodes over time. In panic attacks, however, these medicines are ineffective; treatment for anxiety is discussed elsewhere in this book.

Quick relief asthma drugs include “bronchodilators” that open airways, such as Albuterol (Ventolin, Proventil), levalbuterol (Xopenex HFA), among others. These drugs should open airways in a very short period of time and give significant relief. These drugs are sometimes useful for people going into a situation where they know they will exposed to a trigger, such as before strenuous exercise. Don’t be surprised if you notice a rapid heart rate on these medications; it’s a common side effect.

If you find yourself using quick-relief asthmatic medications more than twice a week, you are a candidate for daily control therapy. These drugs work, when taken daily, to decrease the number of episodes and are usually some form of inhaled steroid. There are long-acting bronchodilators as well, such as ipratropium bromide (Atrovent HFA). Another family of drugs known as Leukotriene modifiers prevents airway swelling before an asthma attack even begins. These are usually in pill form and may make sense for storage purposes. The most popular is Montelukast (Singulair).

Often, medications will be used in combination, and you might find multiple medications in the same inhaler. The U.S. pharmaceutical Advair, for example, contains both a steroid and an airway dilator. Remember that inhalers lose potency over time. Expired inhalers, unlike many drugs in pill or capsule form, have less effect than fresh ones. Physicians are usually sympathetic to requests for extra prescriptions from their asthmatic patients.

NATURAL TREATMENT OF ASTHMA

Ginger

In mild to moderate cases of asthma, you might consider the use of natural remedies. Some involve breathing exercises:

Pursed-lip breathing: This slows your breathing and helps your lungs work better. Breathe in slowly through your nose for two seconds. Then position you lips as if you were whistling, and breathe out slowly through your mouth for four seconds.

Abdominal breathing: Similar to pursed-lip breathing but focuses on using the diaphragm more effectively. With your hands on your belly, breathe as if you were filling it with air like a balloon. Press down lightly on the belly as you slowly exhale.

There are also a number of substances that have been reported to be helpful:

Ginger: A study published in the American Journal of Respiratory Cell and Molecular Biology indicates that ginger is instrumental in inhibiting chemicals that constrict airways. Animal tests find that extracts of ginger help ease asthmatic symptoms in rodents. Use as a tea or extract twice a day.

Ginger and Garlic Tea: Add three or four minced garlic cloves in some ginger tea while it’s hot. Cool it down and drink twice a day. Some report a benefits from just the garlic.

Other herbal teas are thought to help: Ephedra, Coltsfoot, Codonopsis, Butterbur, Nettle, Chamomile, and Rosemary all have been used in the past to relieve asthmatic attacks.

Caffeine: Black unsweetened coffee and other caffeine-containing drinks may help open airways.  Don’t drink more than 12 ounces at a time, as coffee can dehydrate you. Interestingly, coffee is somewhat similar in chemical structure to the asthma drug Theophylline.

Eucalyptus: Essential oil of eucalyptus, used in a steam or direct inhalation, may be helpful to open airways. Rub a few drops of oil between your hands and breathe in deeply. Alternatively, a few drops in some steaming water will be good respiratory therapy.

Honey: Honey was used in the 19th century to treat asthmatic attacks. Breathe deeply from a jar of honey and look for improvement in a few minutes. To decrease the frequency of attacks, stir one teaspoon of honey in a twelve-ounce glass of water and drink it three times daily.

Turmeric: Take one teaspoon of turmeric powder in 6-8 ounces of warm water three times a day.

Mustard Oil Rub: Mix mustard oil with camphor and rub it on your chest and back. There are claims that it gives instant relief in some cases.

Gingko Biloba leaf extract: Thought to decrease hypersensitivity in the lungs; not for people who are taking aspirin or ibuprofen daily, or anticoagulants like warfarin (Coumadin).

Lobelia: Native Americans actually smoked(!) this herb as a treatment for asthma. Instead of smoking, try mixing tincture of lobelia with tincture of cayenne in a 3:1 ratio. Put 1 milliliter (about 20 drops) of this mixture in water at the start of an attack and repeat every thirty minutes or so

Further research is necessary to determine the effectiveness that some of the above remedies have on severe asthma, so take standard medications if your peak flow reading is 60% or less than normal.

Don’t underestimate the effect of diet on the course of asthma. Asthmatics should:

  • Replace animal proteins with plant proteins.
  • Increase intake of Omega-3 fatty acids and vitamin D.
  • Eliminate milk and other dairy products.
  • Eat organically whenever possible.
  • Eliminate trans-fats; use extra-virgin olive oil as your main cooking oil.
  • Always stay well-hydrated; more fluids will make your lung secretions less viscous.

Finally, various relaxation methods, such as taught in Yoga classes, are thought to help promote well-being and control the panic response seen in asthmatic attacks. Acupuncture is thought by some to have some promise as well.

I’m sure you have your own home remedy that might work to help asthmatics. If so, let us know!

Joe Alton MD

Doom and Bloom: Hypothermia in Austere Settings

The Altons at Doom and Bloom Medical have an article on Hypothermia in Austere Settings.

As we head into the colder part of the year, I thought I’d talk about the dangers of exposure to cold. On or off the grid, if you don’t take environmental conditions into account, you have made Mother Nature your enemy, and she is a formidable one, indeed.

Hypothermia is a condition in which body core temperature drops below the temperature necessary for normal body function and metabolism. The normal body core temperature is defined as between 97.5-99.5 degrees Fahrenheit (36.0-37.5 degrees Celsius). Symptoms related to cold exposure occur once the core temperature dips below 95 degrees (35 degrees Celsius).

HOW THE BODY LOSES HEAT

Besides simply breathing out warm air, the body loses heat in various ways:

Image by JEMS

Evaporation: The body perspires (sweats), which releases heat from the core. Heat loss through evaporation increases in dry, windy weather conditions.

Radiation: While the body makes efforts to maintain normal body temperatures, the body loses heat to the environment when the ambient (surrounding) temperature is lower than about 68 degrees F. Much lower temperatures cause heat loss more quickly.

Conduction: The body loses heat when its surface is in direct contact with cold temperatures, as in the case of someone falling from a boat into frigid water. Water, being denser than air, removes heat from the body much faster.

Convection: Heat loss where, for instance, a cooler object is in motion against the body core. The air next to the skin is heated and then removed, which requires the body to use energy to re-heat. Wind Chill is one example of air convection: If the ambient temperature is 32 degrees F but the wind chill factor is at 5 degrees F, you lose heat from your body as if it were actually 5 degrees F.

A surprising amount of heat is lost from the head area, due to its large surface area and tendency to be uncovered. Direct contact with anything cold, especially over a large area of your body, will cause rapid cooling of your body core temperature. When the Titanic sank in 1912, hundreds of people fell into near-freezing water. Within 15 minutes, they were probably beyond medical help.

GENERAL SYMPTOMS OF HYPOTHERMIA

The body, when it is exposed to cold, kicks into action to produce heat once the core cools down below 95 degrees F. The main mechanism to produce heat is shivering. Muscles shiver to produce heat, and this will be the first symptom you’re likely to see. As hypothermia worsens, more symptoms will become apparent if the patient is not warmed.

The diagnosis of hypothermia may be difficult to make with a standard glass thermometer because it doesn’t register below 94 degrees Fahrenheit. Unless you have a thermometer that can measure low ranges, it may be difficult to know for certain that you’re dealing with this problem.  You should assume that anyone with altered mental status encountered in cold weather is hypothermic until proven otherwise.

Aside from shivering, the most noticeable symptoms of hypothermia will be related to mental status. The victim may appear confused and uncoordinated. As the condition worsens, speech may become slurred. The patient will appear apathetic, lethargic, and uninterested in helping themselves; they may fall asleep. This occurs due to the effect of cooling temperatures on the brain; the colder the body core gets, the slower the brain works. Brain function is supposed to cease at a body temperature of about 68 degrees Fahrenheit, although there have been exceptional cases where people (usually children) survived even lower temperatures.

To learn about hypothermia in dogs, click here.

LEVELS OF HYPOTHERMIA

Some sources differentiate different levels of hypothermia body temperature:

MILD: (93-97 degrees F; 33.9-36.1 degrees C)

A person with mild hypothermia will usually still be awake and alert, but shivering. Hands and feet will be cold, and they may complain of pain or numbness in the extremities. Loss of dexterity is often noted.

MODERATE: (90-93 degrees F; 32.2-33.9 degrees C)

In moderate hypothermia, you’ll see all of the above, but mental status begins to alter and efforts to produce heat by shivering may decrease or even stop.

SEVERE HYPOTHERMIA: (82-90 degrees F; 27.8-32.2 degrees C)

The severely hypothermic person will stop shivering and mental status changes become clearly apparent. Expect to see confusion, lethargy, and memory loss. The victim’s muscles appear less flexible; they will be uncoordinated and speech will be slurred. An unusual apathy or denial regarding the seriousness of the situation is often noted.

CRITICAL HYPOTHERMIA (less than 82 degrees F (27.8° C))

Once less than 82 degrees F, the victim will likely be unconscious. Respirations will be impaired and the pulse slow and difficult to feel. Skin will be cold and cyanotic (blue) and muscles will be rigid. Pupils may be dilated.

Individual cases may vary somewhat.

TREATING HYPOTHERMIA

Immediate action must be taken to 1) prevent further heat loss and 2) reverse the ill effects of hypothermia. Important measures to take are:

Get the person out of the cold. Transport as soon as possible to a warm, dry location. If you’re unable to move the person out of the cold, shield them as much as possible. Be sure to place a barrier between them and the cold ground.

Exercise to produce heat in mild cases: In alert victims who can move without difficulty, mild exercise can help raise body temperature (as long as they stay dry). Avoid exertion in those with moderate hypothermia or worse, however, and in anyone with altered mental status.

Monitor breathing. A person with severe hypothermia may be unconscious. Verify that the patient is breathing and check for a pulse. If none, still assume the patient is revivable and begin CPR. Elevate the feet as you would for anyone in shock.

Take off wet clothing. If the person is wearing wet clothing, remove them gently. Ignore pleas of “leave me alone!” Cover them with layers of dry blankets, including the head, but leave the face clear (see image above).

Share body heat. There may be circumstances when it’s necessary to warm the person’s body by removing your clothing and making skin-to-skin contact. Then, cover both of your bodies with blankets. Some people may cringe at this notion, but it’s important to remember that you are trying to save a life. Gentle massage or rubbing may be helpful, but vigorous movements may cause unnecessary trauma.

Give warm oral fluids. If the affected person is alert and able to swallow, provide a warm, non-caffeinated beverage to help warm the body. Despite the image of St. Bernards saving alpine mountaineers with casks of brandy around their necks, alcohol is a bad idea. Alcohol may give you a “warm” feeling, but it actually causes your blood vessels to expand; this results in more rapid heat loss from the surface of your body and negates the body’s efforts to stay warm. Alcohol and recreational drugs also cause impaired judgment: Those under the influence might clothe inadequately for cold weather.

Use warm, dry compresses. First-aid “shake and break” warm compresses or warm (not hot) water in a plastic bottle will effectively apply heat to the body core if placed on the neck, chest wall or groin. Don’t use hot water, a heating pad or a heating lamp directly on the person. The extreme heat can damage the skin, cause strain on the heart, or even lead to cardiac arrest.

PREVENTION OF HYPOTHERMIA

An ounce of prevention is worth a pound of cure. To prevent hypothermia, you must anticipate the climate that you will be traveling through, including wind conditions and wet weather. Condition yourself physically to be fit for the challenge. Travel with a partner if at all possible, and have enough food and water available for the entire trip.

It may be useful to remember the simple acronym C.O.L.D. This stands for:  Cover, Overexertion, Layering, and Dry.

Cover: Protect your head by wearing a hat. This will prevent body heat from escaping from your head. Instead of using gloves to cover your hands, use mittens. Mittens are more helpful than gloves because they keep your fingers in contact with one another, conserving heat.

Overexertion:  Avoid activities that cause you to sweat a lot. Cold weather causes you to lose body heat quickly; wet, sweaty clothing accelerates the process. Rest when necessary; use rest periods to self-assess for cold-related changes. Pay careful attention to the status of your elderly or juvenile group members. Diabetics are also at high risk.

Layering: Loose-fitting, lightweight clothing in layers do the best job of insulating you against the cold. Use tightly woven, water-repellent material for wind protection. Wool or silk inner layers hold body heat better than cotton does. Some synthetic materials, like Gore-Tex, Primaloft, and Thinsulate, work well also. Especially cover the head, neck, hands and feet.

Dry: Keep as dry as you can. Get out of wet clothing as soon as possible. It’s very easy for snow to get into gloves and boots, so pay particular attention to your hands and feet.

If left untreated, hypothermia leads to complete failure of various organ systems and death.  People who develop hypothermia due to cold exposure are also vulnerable to other cold-related injuries, such as frostbite and immersion foot. We’ll discuss those and some specific clothing strategies in the near future.

Joe Alton MD

Doom and Bloom: Soft Tissue Infections

The Altons at Doom and Bloom Medical write about Soft Tissue Infections. More pictures are in the original article.

All injuries carry a risk of infection. When the skin is breached, various microbes can invade and cause damage. Inflammation in soft tissues known as “cellulitis” may develop when bacteria enter through a crack or break in your skin. Fortunately, infections from minor wounds are relatively easy to treat today due to the availability of antibiotics. Without them, any bacteria may become life-threatening if it enters the circulation.

If germs invade the soft tissues below the superficial level of the skin (the “epidermis”), they can rapidly infect the main layers of soft tissue below. These include the deep layer of the skin (the “dermis”), the subcutaneous fat, the muscle layers, and various blood vessels and nerves.

image by Cerevisae 

Cellulitis may be easy to deal with in normal times, but it will be an epidemic in the aftermath of a major disaster. This is not because it’s contagious; it isn’t unless you have an open wound yourself or exchange bodily fluids. Expect cases simply because of the sheer number of injuries incurred from performing activities of daily survival in less than sanitary conditions.

Without antibiotics, infections can spread to lymph nodes and the bloodstream, rapidly becoming life-threatening. The end result might affect the entire body, referred to as “sepsis.” Once sepsis develops, inflammation of deep structures like the spinal cord (“meningitis”) or bone marrow (“osteomyelitis”) can further complicate the situation. In the past, sepsis was usually fatal.

The bacteria that can cause cellulitis are on your skin right now. Normal inhabitants of the surface of your skin include Staphylococcus and Group A Streptococcus. They do no harm until the skin is broken and they enter deeper tissues where they don’t belong. In recent years, a resistant bacterium called MRSA (Methicillin-Resistant Staphylococcus Aureus) has arisen which causes cellulitis resistant to the usual antibiotics.

As an aside, Cellulitis has nothing to do with the dimpling on the skin called “cellulite”. The suffix “-itis” simply means “inflammation”, so cellul-itis simply means “inflammation of the cells.”

The signs and symptoms of cellulitis must be recognized as early as possible. They include:

  • Discomfort in the area of infection
  • Fever and Chills
  • Exhaustion (fatigue)
  • General ill feeling (malaise)
  • Muscle aches (myalgia)
  • Heat in the area of the infection compared to non-affected areas
  • Redness, usually spreading towards torso
  • Swelling in the area of infection (often appearing shiny and causing a sensation of tightness)
  • Drainage of pus or cloudy fluid from the area of the infection
  • Foul odor coming from the area of infection
  • Hair loss at the site of infection (less common)
  • Joint stiffness caused by swelling of the tissue over it (less common)

Cellulitis commonly occurs in an extremity, such as a leg. In these cases, it’s helpful to keep the limb elevated. Other strategies include warm or cool compresses or soaks to the affected area, and the use of ibuprofen (Advil) or acetaminophen (Tylenol) to decrease pain, discomfort, and fever.

Although the body can sometimes resolve cellulitis on its own, treatment usually includes the use of antibiotics. These can be topical, oral, or intravenous. Topical therapy helps more to prevent infection than cure it.

As most cases of cellulitis are caused by bacteria, they should improve and disappear during a 7-14-day course of therapy with medications in the Penicillin, Erythromycin, or Cephalosporin (Keflex) families. Amoxicillin and ampicillin are particularly popular. MRSA cellulitis can be treated with clindamycin and the sulfa drug combination of sulfamethoxazole/trimethoprim (SMX-TMP). It’s important to complete the full course of therapy.

Adult dosing:

-Penicillin, amoxicillin, cephalexin, or ampicillin 250-500 mg orally four times a day for 7-14 days (Amoxicillin also comes in 875 mg).

-Clindamycin 150-300 mg orally three times a day for 7-10 days.

-SMX 800 mg-TMX 160 mg orally twice a day for 7-10 days.

Those allergic to penicillins can still take clindamycin or SMX-TMP. It should be noted that not all sources will recommend the same dosage, frequency, and duration of therapy for a particular drug. In resistant infections like MRSA, combination therapy with SMX/TMP and Cephalexin 500 mg orally four times a day for 7-14 days may be necessary.

As with all medications, the longer the therapy and the higher the dose, the more likelihood that adverse reactions may occur. A much more comprehensive discussion of antibiotics can be found in Alton’s Antibiotics and Infectious Disease: The Layman’s Guide, or online at drugs.com and rxlist.com.

All the drugs mentioned above are available in veterinary equivalents (at least at present). In a survival situation, however, antibiotics will be precious commodities. You, as medic, should dispense them only when absolutely necessary. The misuse of antibiotics, along with their excessive use in livestock, is part of the reason that we’re seeing an epidemic of antibiotic resistance in this country.

 

Doom and Bloom: Tonsillitis In Austere Settings

The Altons at Doom and Bloom Medical have a short article on Tonsillitis in Austere Settings.

Your tonsils are glands on each side of the back of the throat. Their job is to help trap bacteria and other germs that cause infections. Sometimes, however, they can become infected themselves, a condition known as “tonsillitis“. Most cases of tonsillitis are caused by viruses, but bacteria may also be the culprit. The average age is between 5 and 15 years old.

Once, tonsils were commonly removed (known as “tonsillectomy”) in young children at the first sign of infection. In the 21st century, the procedure is much less common. Recurrent bacterial infections or severe symptoms may still require removal, a simple procedure (see link) in the hands of an experienced provider, but difficult for the family medic. The best option, therefore, in austere settings is identifying and treating as early as possible.

(Note: I had my tonsils removed at age 5. At least they gave me some ice cream afterwards! Joe Alton, MD)

whitish-yellow patches may be seen on exam

Use of a tongue depressor helps visualize the area. Common signs and symptoms of tonsillitis include:

•             Red, swollen tonsils

•             White or yellow coating or patches on the tonsils

•             Sore throat

•             Difficult or painful swallowing

•             Fever

•             Enlarged, tender glands (lymph nodes) in the neck

•             A scratchy, muffled or throaty voice

•             Bad breath

Since tonsillitis is often seen in children too young to give a good history, look for:

  • Loss of appetite
  • Irritability
  • difficult or painful swallowing
  • Drooling or difficulty breathing (signs of a severe case)

Treating someone with tonsillitis can include some of the following:

  • bedrest
  • hydration
  • A soft diet
  • Humidifiers
  • Saltwater gargles
  • Throat lozenges
  • Acetaminophen or ibuprofen is helpful for pain, but aspirin should be avoided in children due to Reye’s Syndrome.
Antibiotics may nip a bacterial tonsillitis in the bud

Although viral tonsillitis isn’t improved with antibiotics, Penicillin or amoxicillin works for bacterial infections if taken by mouth for ten days.  If Penicillin is not an option due to allergy, azithromycin may be substituted. These drugs are available in veterinary equivalents at fishmoxfishflex.com.

Adult doses:

  • Amoxicillin 500-875 mg orally twice a day or 250-500 mg orally every 8 hours for 10 days
  • Penicillin V 500 mg orally twice a day for 10 days or 250 mg orally four times a day for 10 days
  • Azithromycin 500 mg orally once a day for 5 days

Pediatric doses:

  • Penicillin V 25-50 mg/kg/day divided by four and given every 6 hours for 10 days
  • Amoxicillin 50 mg/kg/day orally in 2 or 3 divided doses for 10 days
  • Azithromycin 12 mg/kg orally once daily for 5d

Joe Alton MD

Doom and Bloom: Cyclospora Infection (Food Contamination)

The Altons at Doom and Bloom Medical have an article up on Cyclospora Infection.

Food contamination is a constant concern in the United States, especially from imported produce. In normal times, U.S. citizens take for granted the ability to buy bananas in Montana in February. As long as we import food, we must be especially careful to eliminate subtropical and tropical pathogens from our food.

A number of different disease-causing organisms especially put humans at risk; one of these is Cyclospora cayetanensis. From May to late August, 2020, more than 1100 laboratory-confirmed cases of food contamination due to Cyclospora (known as cyclosporiasis) were reported in 34 states. In most cases, fresh imported produce, especially greens and vegetables, were identified as likely origins.

Cyclospora is a one-celled parasite that is a natural inhabitant of the tropics and subtropics, where it seems to cause outbreaks that are seasonal in nature. The U.S. cases, however, occurred in people who had not recently visited the tropics before symptoms began.

THE LIFE CYCLE OF CYCLOSPORA

Cyclospora is spread by people ingesting food or water contaminated with feces containing Cyclospora oocysts (essentially a thick-walled fertilized ovum). Unlike some similar parasites, however, the oocyst needs time (usually, at least 1–2 weeks) after being passed in a bowel movement to become infectious. Therefore, it’s unlikely that Cyclospora can be passed directly from one person to another. More likely, the oocysts contaminate crops or water sources.

SYMPTOMS OF CYCLOSPORIASIS

Exactly how food and water becomes contaminated with Cyclospora oocysts isn’t  fully understood but, once the oocysts “hatch” in the human body, the microbes enter the intestinal wall. Some symptoms then begin to manifest. They start an average of 7 days after ingestion of the infective version of the oocyst and can include the following:

  • Watery diarrhea (most common)
  • Loss of appetite
  • Low-grade fever
  • Weight loss
  • Cramping
  • Bloating, increased gas
  • Nausea and vomiting
  • Fatigue

A typical case would cause watery diarrhea, with frequent, sometimes explosive, bowel movements. Vomiting, body aches, headache, fever, and other flu-like symptoms may be noted. Interestingly, some people infected with Cyclospora have no symptoms at all.

If untreated, the illness endures for a few days, but some cases last a month. Some victims experience improvement and then relapse several times during the progress of the infection. Although not life-threatening, long-term fatigue and other problems are a possibility.

The Complex Life Cycle of Cyclospora

TREATMENT

Once the organism is identified in a stool sample, cyclosporiasis can be effectively treated with the combination sulfa drug trimethoprim-sulfamethoxazole (TMP-SMX). The usual regimen for adults is trimethoprim (TMP) 160 mg plus sulfamethoxazole (SMX) 800 mg (one double-strength tablet) twice daily for 7–10 days. The veterinary equivalent is FISH-SULFA FORTE. No effective alternatives have been identified yet for those allergic to sulfa drugs. In this case, most immune-competent people will recover without treatment and with good hydration.

 

PREVENTION

Avoiding any food or water that might be contaminated with feces is the best way to prevent infection.  Routine chemical disinfection is less effective for Cyclospora than for most other bacteria or parasites.

Fruit and vegetable handling basics include:

1)Washing hands with soap and warm water after touching fruits and vegetables. Also, be sure to clean cutting boards, dishes, utensils, and counter tops between the preparation of meat, poultry, and seafood and fruits and vegetables.

2)Preparing all fruits and vegetables thoroughly under running water before eating, cutting, or cooking. Remove any damaged or bruised areas on fruits and vegetables. Firm items like cucumbers or melons should be scrubbed with a clean brush dedicated to the purpose.

3)Storing properly by refrigerating cut, peeled, or cooked fruits and vegetables within two hours (preferable sooner). Separate the storage of fruits and vegetables and raw meat, poultry, and seafood.

It should be noted that routine chemical disinfection is less effective for Cyclospora than for most other bacteria or parasites. No vaccine exists and immunity isn’t long-term: Recurrence of infection is not uncommon if re-exposed.

(Note: The U.S. Food and Drug Administration’s (FDA) Center for Food Safety and Applied Nutrition (CFSAN) has a special advisory called: Guide to Minimize Microbial Food Safety Hazards for Fresh Fruits and Vegetables.

Joe Alton MD

Doom and Bloom: Heat-Related Emergencies

The Altons at Doom and Bloom Medical have a post up on Heat-Related Emergencies for the summer heat.

  • noaa heat index chart

    Summer is here with a vengeance and parts of the Midwest and Southern U.S. are experiencing record high temperatures in major heat waves. Officials predict a high-risk situation for 200 million citizens as places as far north as Buffalo, NY hit 90 degrees Fahrenheit for a week straight, while Pheonix, Arizona will have multiple days in the 110s. The air temperature in Death Valley, California may reach as high as 125 degrees.

    Even in places where the air temperature isn’t as high, the “heat index” is surpassing the 90s, 100s, and the 110s. The heat index is a measure of the effects of air temperature combined with high humidity.  Above 60% relative humidity, loss of heat by perspiration is impaired and exposure to full sun increases the reported heat index by as much as 10-15 degrees F. All this increases the chances of heat-related illness such as heat stroke and heat exhaustion.

    In the next few weeks, we can expect the power grid to be challenged by tens of millions of air conditioning units set on “high”. Major health issues may arise if the electricity goes out and people have to fight the heat with hand fans, like they did in the “good old days”.

    HEAT ISLANDS

    graph of temperatures from urban to rural

    Things are even worse in the city. Buildings and roads replace open land and vegetation. Concrete and asphalt surfaces in the sun become much hotter than air temperature, resulting in a “heat island” effect in large populated areas. Rural areas are more moist and cool, leading to less heat-related emergencies.

    Another factor may increase the risk of heat-related emergencies. Homes without air conditioning will not only become sweatboxes, but many people cooped up in closed environments are a recipe to increase the number of COVID-19 cases (so much for the summer giving us a break from the pandemic).

    HEAT WAVES ARE NATURAL DISASTERS

    man,it’s hot!

    You might not consider a heat wave to be a natural disaster, but it most certainly is. Heat waves can cause mass casualties, as it did in Europe when tens of thousands died of exposure (not in the Middle Ages, but in 2003). India, Pakistan, and other underdeveloped tropical countries experience thousands of heat-related deaths yearly.

    HOW HEAT KILLS

    So how exactly does heat kill a person? Your body core regulates its temperature for optimal organ function. When core body temperature rises excessively (known as “hyperthermia”), inflammation occurs, cells die, and toxins leak. Fatalities can occur very quickly without rapid intervention. Even with modern technology, hyperthermia carries a 10% death rate, mostly in the elderly and infirm. Those who are physically fit, however, are not immune.

    HEAT EXHAUSTION AND HEAT STROKE

    The ill effects due to overheating are called “heat exhaustion” if mild to moderate; if severe, these effects are referred to as “heat stroke”. Heat exhaustion usually does not result in permanent damage, but heat stroke does; indeed, it can permanently disable or even kill its victim.  It’s a medical emergency that must be diagnosed and treated promptly.

    Simply having muscle cramps or a fainting spell doesn’t necessarily signify an imminent heat-related medical emergency. You will see “heat cramps” often in children that have been running around on a hot day.  Getting them out of the sun, massaging the affected muscles, and providing hydration will usually resolve the problem.

    Heat exhaustion’s signs and symptoms include:

    • Confusion
    • Rapid pulse
    • Profuse sweating
    • Flushing
    • Nausea and vomiting
    • Headache
    • Temperature elevation up to 105 degrees F

    If no action is taken to cool the victim, they could easily progress to heat stroke. In addition to all the possible signs and symptoms of heat exhaustion, heat stroke will manifest as loss of consciousness, seizures or even bleeding (seen in the urine or vomit).  Breathing becomes rapid and shallow. Shock and organ malfunction may ensue, possibly leading to death.

    heat exhaustion (left) vs heat stroke (right)

    In heat stroke, the skin is likely to be red and hot to the touch, but dry; sweating might be absent.  Once the body core hits 105 degrees or more (it varies from person to person), thermoregulation breaks down and the body’s ability to use sweating as a natural temperature regulator fails. In heat stroke, the body core can rise as high as 110 degrees Fahrenheit or more.

    (Aside: The highest body temperature ever recorded was 115 degrees: On July 10, 1980, 52-year-old heatstroke victim Willie Jones of Atlanta was admitted to the hospital with a temperature of 115 degrees Fahrenheit. He spent 24 days in the hospital and recovered.)

    In some circumstances, the victim’s skin may actually seem cool. Despite feeling “clammy” to the touch, it’s important to realize that it is the body core temperature that’s elevated. You could be misled unless you take readings with a thermometer to reveal the patient’s true status.

    Avoid giving fluids unless the victim is awake and fully oriented

    When overheated patients are no longer able to cool themselves, it is up to their rescuers to do the job. If hyperthermia is suspected, the victim should immediately:

    • Be removed from the heat source (for example, out of the sun).
    • Have their clothing removed.
    • Be drenched in cool water (with ice, if available)
    • Have their legs elevated above the level of their heart (the shock position)
    • Be fanned or otherwise ventilated to help with heat evaporation
    • Have moist cold compresses placed in the neck, armpit and groin areas

    Why the neck, armpit and groin? Major blood vessels pass close to the skin in these areas, and cold packs will more efficiently cool the body core. Recent studies by the military suggest that cold packs to feet and hands are also helpful.

    Oral rehydration is useful to replace fluids lost, but only if the patient is awake and alert. If your patient has altered mental status, he or she might “swallow” the fluid into their airways; this is known as “aspiration” and causes damage to the lungs.

    Heat stroke is preventable in many cases. The Arizona department of health recommends the following:

    • Drink at least 2 liters (about a half-gallon) of water per day if you are mostly indoors and 1 to 2 additional liters for every hour of outdoor time. Drink before you feel thirsty, and avoid alcohol and caffeine.
    • Wear lightweight, light-colored clothing and use a sun hat or an umbrella to deflect the sun’s rays. Use sunscreen if available.
    • Eat smaller, more frequent meals instead of large ones.
    • Avoid strenuous activity.
    • Stay indoors as much as possible.
    • Take regular breaks if you exert yourself on warm days.

    In a heat wave, it’s important to check on the elderly, the very young, and the infirm regularly and often. These people have more difficulty seeking help, and you might just save a life if you’re vigilant. You can bet there’ll be more than one heat wave this summer, so know the warning signs and how to help those with hyperthermia.

Doom and Bloom: Suture Basics For The Off-Grid Medic: Needles

Continuing their earlier article on suturing, the Altons at Doom and Bloom Medical followup with an article devoted to suture needles in Suture Basics For The Off-Grid Medic: Needles.

Basic diagram of a suture (by medscape.com)

In my recent article “Suture Basics For The Off-Grid Medic “,  I gave some thoughts on suture materials, especially as they apply to closing skin lacerations. Your skin is your armor, and anything that breaches it can cause a life-threatening infection.

Although the decision to close a wound should never be automatic, simple skin lacerations can often be cleaned and closed successfully by the off-grid medic. Sutures are just one of a number of ways to accomplish this goal and allow acceleration of the healing process. Today, we’ll discuss the qualities of suture needles.

(Note: This article is for educational purposes only. If the medical system in your area is intact, seek it out to treat lacerations or other medical issues!)

Suture needles are made of a corrosion-resistant stainless steel alloy that is sometimes coated with silicone to permit easier tissue penetration.

Basic diagram of a suture (medscape.com )

A suture needle has three sections: the point, the midportion or body, and the swage. The swage is the “end” of the needle and is where the thread is attached. The midportion is usually curved at an arc, and the point is, well, pointy.

SWAGING

Before about 1920, suture needles had “eyes” and string was separate; the surgeon had to thread the eye of the needle. Since then, sutures became a single continuous unit. This process of connecting suture needle and string is called “swaging”.

Swaging dealt with a number of disadvantages associated with using separate needles and thread. In the old method, two lengths of string were formed on either side of the eye. Passage of a double strand of suture through tissue led to more tissue trauma and, perhaps, a higher risk of infection. Also, the suture string was more likely to become unthreaded or frayed.

THE IDEAL SUTURE NEEDLE

Suture needles perform based on a number of qualities, including strength and sharpness. The strength of a needle refers to its resistance to deformation during use, limiting the amount of trauma to tissue. Sharpness measures the ease of penetration into tissue and is dependent on factors involving not only the point, but the shape of the body of the needle.

Just as suture thread has ideal characteristics, the effective suture needle would be:

  • Made of high-quality stainless steel
  • The smallest diameter possible
  • Stable in the grasp of the needle holder
  • Capable of running suture material through tissue with minimal trauma
  • Sharp enough to penetrate tissue with minimal resistance
  • Sterile and corrosion-resistant to prevent introduction of microorganisms or foreign materials into the wound
  • Rigid enough to go through tissue, but flexible enough to bend before breaking

Not all suture needles meet the above criteria, but will suffice for the basic needs of the medic.

NEEDLE TYPES

There are a number of different needle types variations at the point, body, and swaged end:

Common needle types with cross sections at midportion and point (ethicon.com)

Cutting Needles: The shape of the suture needle on cross-section may vary dependent on the particular need. The point of this shape to have more cutting edges. On cross section, it appears triangular. These needles are effective in penetrating thick, firm tissue, like skin.

There are two common types of cutting needles. “conventional” and “reverse”. Conventional cutting needles have the third edge of the “triangle” on the inner surface of the needle. Reverse cutting needles have the third edge of the triangle on the outer surface of the needle’s arc. The reverse edge is even stronger and able to penetrate tendons and other tough tissues, while decreasing the amount of trauma during the procedure.

Tapered Needles: These needles are round on cross-section and can pass through tissue by stretching more than cutting. A sharp tip at the point becomes round, oval, or square shape as you approach the swage. The taper-point needle minimizes trauma in delicate and easily-penetrated tissues such as organs or intestinal lining.

Blunt Needles: These don’t come to a sharp point, but are rounded at the end. These are best used for suturing liver, kidney, and other delicate organ tissue without causing excessive bleeding.

BODY SHAPES

Suture comes in many shapes, but 3/8 circle and 1/2 circle are most commonly used for learning

The body of a needle is important for interaction with the needle holder instrument and the ability to easily transfer penetrating force to the skin. A needle must be stable in the jaws of the needle holder to give maximum control and prevent bending.

The midportion comprises most of the needle’s length and is commonly curved into a 3/8 circle arc for skin or 1/2 circle for close spaces. Of course, other curvatures are available. Straight needles may be used if dealing with easy-to-reach tissues such as certain types of skin closures.

Next time, we’ll discuss the instruments you’ll use when closing a laceration with sutures.

Doom and Bloom: Covid Fatigue and the Second Wave

The Altons at Doom and Bloom Medical have an article up about Covid Fatigue and the Second Wave. A second spike in cases is coming.

COVID-19 cases may again be on the rise as a second wave of infections coincide with the reopening of many businesses throughout the United States.

Perhaps the first thing I should mention is that a second wave is going to occur as society reopened. I repeat: Regardless of the timing or the measures taken, at one point or another there is going to be a second spike in cases. This is to be expected; It’s what many pandemics do. Health officials and political policies can do little to stop it.

If we look at previous infectious disease outbreaks, like the Spanish Flu of a century ago, it’s clear that there were, not two, but three waves in Spring and Fall of 1918 and winter of 1918-19. Each wave claimed its share of victims.

Most health officials have long stated that more cases are expected. Social distancing, face coverings, and other important measures to prevent spread of infection may be breaking down. In some cases, it’s because of what I call “COVID fatigue”. People are weary of staying home, donning personal protection equipment, and avoiding the restaurants, movie theaters, malls, and other staples of normal American society. The New Normal compares poorly to the “good old days”.

Not an example of social distancing

Even for those who have adjusted to pandemic prevention guidelines, current headlines have sparked nationwide mass protests which are spilling over internationally. As you can imagine, large demonstrations don’t follow the rules of social distancing and hamper efforts to stop the spread of infection.

Public policy may also play a part. Reopening too quickly due to COVID fatigue-fueled anger may cause large numbers of new cases, while staying in semi-permanent lockdown must eventually throw the nation into a major economic depression. The balance is so delicate that a perfect solution is almost impossible to achieve. Either option is fraught with risk.

All of the above factors make it more likely that a second wave will be significant, but how significant? Will we see just a ripple in the pond or a massive tidal wave?

One expert, Dr. Lawrence Kleinman of Rutgers University, says: “I think people mistake the idea of society reopening with the idea that society is safer, but things are no safer today than they were weeks ago when we were in full lockdown,” said Dr. Lawrence Kleinman, MD MPH of Rutgers University. He goes on to say that the recipe for personal safety doesn’t change even as society opens up.

Others aren’t as pessimistic.  Columbia University virologist Dr. Vincent Racaniello said, “I’m hoping we can continue our lives without having to go back into quarantine in the fall, because we’ve learned that distancing and face masks can really make a difference.”

Indeed, we have learned much about SARS-CoV2, the virus behind the COVID-19 pandemic. Besides social distancing, we have come to realize the importance of mass testing, and keeping close track of contacts. With a contagious disease, we have to know who is capable of spreading it. With workplaces beginning to reopen, this information becomes essential.

We have also realized the importance of having personal protection items in our medical kits. Surgical and N95 masks are considered to be for medical workers only, leaving the average citizens with a limited array of less-effective cloth coverings. These were endorsed by health officials, but only because of the lack of standard supplies.

Yet, many folks ended up becoming “medical workers” when someone in the family came down with a mild to moderate case of COVID-19. You can bet that there will be more face masks to go around in future outbreaks; many of these will be made in the U.S.A…(continues)

Doom and Bloom: Suture Basics for the Off Grid Medic

The Altons at Doom and Bloom Medical have an article on Some Suture Basics for the Off-Grid Medic. More photos at article.

suture basics

Many animals, (insects, spiders, shrimp, crabs) have an exoskeleton as a protective covering. Humans have their skeleton on the inside, so we depend on the largest organ of the body, our skin, instead.

Skin represents the armor that protects the body from invasion by debris and microbes. A breach in that armor increases the chance of infection that may spread throughout (called “sepsis”) and become life-threatening.

As such, there are circumstances where a break in the skin should be closed with materials known as sutures. The decision to close skin should not be automatic and depends on many factors (discussed in previous articles on this site). Once that decision is made, however, the correct choice of suture material impacts the strength and effectiveness of the healing process.

THE IDEAL SUTURE

All wound closure methods have their advantages and disadvantages. Your choice should depend on the careful evaluation of the wound, as well as an understanding of the properties of a given suture material.

The optimal suture should be:

·           Sterile

·           Easy to use

·           Strong enough to hold wound edges together

·           Able to retain strength for the time needed to heal

·           Unlikely to cause infection, tissue reaction, or significant scarring

·           Reliable in its everyday use with every type of wound

It’s difficult to find a single suture type that meets all of the above criteria, but there are many that will do if chosen properly.

TISSUE HEALING

The time needed for healing should impact the choice of suture materials. The interval it takes for a tissue to no longer require support from sutures will vary depending on tissue type:

Days: Muscle, subcutaneous tissue like fat, and skin

Subcutaneous tissue is sometimes called the “hypoderm”. It’s connected to the deep layer of skin (the “dermis”). The skin and muscle in many areas of the body are separated by a layer of subcutaneous fat. Fat will appear as yellowish globules below the whitish dermis.

Weeks to Months:  Fascia or tendons

Fascia is connective tissue beneath the skin that attaches, covers, stabilizes, and compartmentalizes muscles and other internal organs. A tendon is connective tissue attaching a muscle to a bone.

CATEGORIZING SUTURE DIAMETERS

Around a century ago, the average suture consisted of a needle through which a separate string was threaded. This method was used for thousands of years until the process of swaging was invented. A swaged suture has the thread built into the blunt end of the needle, making surgical sutures a single unit for the first time.

In the United States and many other countries, a standard classification of sutures has been in place since the 1930s.  This classification identifies stitches by type of material and size of the “thread”.

The first manufactured sutures were given sizes from #1 (thinnest) to #6 (thickest). #4 suture would approximate the string on a tennis racquet.

As technology advanced, even thinner sutures were produced that were titled beginning at 0 (pronounced “oh”). Just like double-ought buckshot is bigger than triple-ought, 2-0 (pronounced “two-oh”) suture is thicker than 3-0 (pronounced “three-oh”). If you are doing microsurgery, you’re going down all the way to 8-0, 9-0, or 10-0. Size 7-0 is about the diameter of a human hair.

The suture thread used should be the smallest size which will give adequate tensile strength to keep skin together. Finer sutures have less tissue reaction but are more difficult to handle for the inexperienced. The off-grid medic should consider using somewhat thicker sutures that can be more easily handled.

ABSORBABLE SUTURES

Absorbable chromic gut suture

In addition to diameters, sutures are classified as absorbable and non-absorbable.  An absorbable suture is one that will break down spontaneously over time (but not before the tissue has mostly healed).

Absorbable sutures have the advantage of not requiring removal.  They can be used in a number of deep layers, such as muscle, fat, organs, etc.  A classic example of this is “catgut”, actually made from the intestines of cows or sheep. Since these sutures are made from multiple fibers, they remain extremely strong in the first few days of healing.

plain “catgut”

Catgut is usually found in “plain” and “chromic” varieties. Plain gut absorbs very quickly but has a tendency to cause tissue inflammation. When dipped in a chromic salt solution, catgut retains tensile strength in the body longer and causes less of a reaction, while still remaining absorbable.

Gut sutures are used today to close tissue that heals rapidly, such as vaginal lacerations from childbirth or in the oral cavity.

Newer absorbables are synthetic. These include:

  • PDS (polydiaxonone)
  • Monocryl (poliglecaprone 25)
  • Vicryl (polyglactin)
  • Maxon (polyglyconate)
  • Dexon (polyglycolic acid)

These sutures retain their tensile strength for varying lengths of time. They cause less tissue inflammation due to an absorption process different than that of gut.

Vicryl sutures are used for approximating muscle or fat layers, as well as lower layers of skin. Maxon and Monocryl can also be used for soft tissue as well as for cosmetic procedures where visible sutures aren’t desired. PDS is used to stitch muscle and fascia tissue.

Besides the classic synthetic sutures, new subtypes such as Vicryl Rapide, Vicryl Plus and PDS II exist. These may take less or more time to dissolve than the originals.

(Aside: Every physician has their own preference for sutures that relate to their experience, schooling, and other factors. For example, it is considered old-fashioned by many to use stitches for closing surgical incisions on skin, as most close skin wounds with staples. A randomized, clinical trial, however, found that women who had C-sections with dissolvable stitches were 57% less likely to have wound complications than those whose wounds were closed with staples. I used this method (known as a “subcuticular” closure) with good results for 20 years.)

NONABSORBABLE SUTURES

Nonabsorbable sutures are those that stay in the body indefinitely or, at least, for a very long time. Normally. They are best used in skin closures or situations that require prolonged tensile strength.

Nonabsorbable sutures can be used in deep layers in certain situations. They cause less tissue reaction, although a small remnant may be felt where the body’s immune system walled it off (known as a “granuloma” or “encapsulation”).

Nonabsorbable sutures can be separated into synthetic single-stranded monofilaments and braided natural or synthetic multifilaments.

Single-stranded monofilaments include Ethilon (nylon) and Prolene (polypropylene). Braided natural multifilaments include braided surgical silk or cotton. Ethibond is the most commonly-used synthetic multifilament.

Nylon monofilament suture

Monofilaments like Nylon are slightly less likely to harbor bacteria, whereas braided multifilaments have tiny nooks and crannies which may serve as hideouts for microbes. The difference in infection rate is very small, however.

Monofilaments also glide more easily through tissue, but may require more knots to stay in place than a braided multifilament like silk. While multifilamentous thread tends to come out straight, monofilaments retain the same S-shape in which they were packaged. This is more an annoyance for the inexperienced than anything else.

Braided surgical silk suture

Braided surgical silk is easier to handle than nylon, especially for novices, and is often used for teaching purposes. 2-0 and 3-0 are sizes considered too thick by many surgeons, but are useful for teaching aspiring off-grid medics to learn surgical knot-tying. Although scarring may be more noticeable, this is a secondary issue in survival scenarios.

The off-grid medic must know skills ordinarily not taught to the average citizen. Wound closure is one of these skills, but must be combined with a working knowledge of when closure is appropriate and when it isn’t. We’ll discuss these issues in future articles.