Doom and Bloom: Tetanus

The Altons at Doom and Bloom Medical have an article up about tetanus and its causes and treatment. More photos in their original article. Go there and read more about emergency and off-grid medical care.

The destruction caused by hurricane Ian in Florida recently was widespread and devastating. Flood waters teeming with contaminants and debris posed a hazard to all who ventured out after the storm. You can bet that there was a run on tetanus shots after citizens had a painful encounter with the proverbial “rusty nail” and other objects. In off-grid settings, tetanus is an ever-present risk. The family medic should have knowledge of risks, symptoms, treatment, and prevention.

What is Tetanus?

Tetanus (from the Greek word tetanos, meaning tight)  is an infection caused by the bacteria Clostridium tetani.  The bacteria produces spores (inactive bacteria-to-be) that primarily live in soil or the feces of animals. These spores are capable of laying dormant for years and are resistant to extremes in temperature.

Tetanus is relatively rare in the United States, with about 50 reported cases a year.  Worldwide, however, there are more than 500,000 cases a year. Most are seen in developing countries in Africa and Asia.  Still, we should realize that developed countries may be thrown into third world status in the aftermath of a mega-catastrophe.  There’ll be many more cases that could be your responsibility as medic to identify and treat.

Causes of Tetanus

Most tetanus infections occur when a person has experienced a break in the skin.  The skin is the most important barrier to infection, and any breach in the armor leaves a person open to infection. The most common cause is some type of puncture wound, such as an insect or animal bite, a splinter, or even that rusty nail.  This is because the bacteria is anaerobic (doesn’t like oxygen); deep, narrow wounds are exposed to less O2, providing a favorable environment for C. tetani. Any injury that compromises the skin, however, is eligible: Burns, crush injuries, and lacerations can also be entryways for tetanus bacteria.

Tetanus spores

When a wound becomes contaminated with Tetanus spores, the spores become full-fledged bacterium and reproduce rapidly.  Damage to the victim comes as a result of a strong toxin excreted by the organism known as tetanospasmin.  This toxin specifically targets nerves that serve muscle tissue.

Tetanospasmin binds to motor nerves, causing “misfires” that lead to involuntary contraction of the affected areas.  This neural damage could be localized or can affect the entire body. You would possibly see the classical symptom of “lockjaw”, where the jaw muscle is taut; any muscle group, however, is susceptible to the contractions if affected by the toxin.  This includes the respiratory musculature, which can inhibit normal breathing and become life-threatening.

The most severe cases seem to occur at extremes of age, with newborns and those over 65 most likely to succumb to the disease. Death rates from generalized Tetanus hover around 25-50%, higher in newborns.

You will be on the lookout for the following early symptoms:

  • Sore muscles (especially near the site of injury)
  • Weakness
  • Irritability
  • Difficulty swallowing
  • Lockjaw (also called “trismus”; facial muscles are often the first affected)

Initial symptoms may not present themselves for one to two weeks. As the disease progresses, you may see:

  • Progressively worsening muscle spasms (may start locally and become generalized over time)
  • Involuntary arching of the back (sometimes so strong that bones may break or dislocations may occur!)
  • Fever
  • Respiratory distress
  • High blood pressure
  • Irregular heartbeats

Complications of untreated tetanus can lead to a fatal outcome in one out of four people. The death rate for newborns is even higher. 

Treating Tetanus

The first thing that the survival medic should understand is that, although an infectious disease, tetanus is not contagious. You can feel confident treating a tetanus victim safely, as long as you wear gloves and observe standard clean technique.  Begin by washing your hands and putting on your gloves.  Then, wash the wound thoroughly with soap and water, using an irrigation syringe with 3% hydrogen peroxide to repeatedly flush out any debris.  This will, hopefully, limit growth of the bacteria and, as a result, decrease toxin production.

You will want to administer antibiotics to kill off the rest of the tetanus bacteria in the system.  Although not used as prevention, antibiotics will decrease the toxin load and speed recovery. Metronidazole (Aqua-zole, Flagyl) 500mg 4 times a day or Penicillin 500 mg 4 times a day are among some of the drugs known to be effective.  Muscle relaxants like tizanidine and cyclobenzaprine are used to treat spasms, but are unlikely to be available to the off-grid caregiver.

Additional strategies include IV hydration, if available, and keeping the patient as comfortable as possible in a quiet and dimly-lit environment.

Late stage Tetanus is difficult to treat without modern technology. For this reason, it’s important for the survival medic to monitor anyone who has sustained a wound for the early symptoms mentioned earlier.

As medic, you must obtain a detailed medical history from anyone that you might be responsible for in times of trouble.  This includes immunization histories where possible.  Has the injured individual been immunized against tetanus? Most people born in the U.S. will have gone through a series of immunizations against diptheria, tetanus, and whooping cough early in their childhood. Booster injections for tetanus are usually given every 10 years (or if 5 years have passed in a person with a fresh wound, sometimes along with tetanus Immunoglobulin antitoxin).

Tetanus vaccine is not without its risks; severe complications such as seizures or brain damage occur in rare cases (less than one in a million).  Milder side effects such as fatigue, fever, nausea and vomiting, headache, and inflammation in the injection site are more common.

Given the life-threatening nature of the disease, though, this is one vaccine that you should encourage your people to receive, regardless of your feelings about vaccines in general. If not caught early, there may be little you, the off-grid medic, can do to treat your patient without all the bells and whistles of modern medicine.

Joe Alton MD

Doom and Bloom: Noroviruses

In this article, Dr. Alton at Doom and Bloom Medical talks about Norovirus symptoms, treatment, and prevention.

Many of us have heard of the “stomach flu” but not the actual virus that causes it: Norovirus. Norovirus has been in the news lately when a long-term outbreak occurred among more than 220 rafters and hikers in the Grand Canyon National Park from April to mid-June of this year. Less well known is 448 norovirus cases reported in the U.S. from Aug 2021 to March of this year. That was six times the number of cases reported during the same time the year before.

We personally an experience with the virus a few years ago when my wife sampled “The World’s Best Hot Dog” at a street stand in New York City while visiting our daughter. Believe me, it’s no fun, and considering that norovirus can be found everywhere from the Big Apple to the Grand Canyon, the family medic should know about it.

ABOUT NOROVIRUSES

The National Foundation for infectious diseases reports that noroviruses are the most common cause of acute stomach and intestinal infections in the United States, The U.S. reports 19 million to 21 million cases a year. Humans are, apparently,  the only hosts of the virus. It affects people of all ages, but it’s particularly dangerous in the elderly, the very young, and those with weakened immune systems. Except for this year, winter is the most common time for outbreaks.

The virus was formerly known as the Norwalk virus because the first known outbreak took place at an elementary school in Norwalk, Ohio. Scientists identified the virus in 1972 from stool samples and renamed it “norovirus.” Since then, it’s been identified everywhere from cruise ships to nursing homes.

Norovirus is very contagious (just 5-20 viral particles can cause illness) and is easily transmitted through contaminated food or water, close personal contact, and even by air droplets from vomit, contaminated kitchen counters, and even toilet flushes. Infection can be passed from person to person for a time even after apparent recovery.

Here’s how contagious the norovirus is: In one outbreak reported in 1998, 126 people were dining at a restaurant when one person vomited onto the floor. Despite a rapid cleanup, 52 customers fell ill within three days. More than 90% of the people who later dined at the same table reported symptoms. More than 70% of the diners at a nearby table got sick; at a table on the other side of the restaurant, the rate was still 25%.

Norovirus is a hardy microbe, and is known to survive for long periods outside a human host. It can live for weeks on countertops and up to twelve days on clothes. It can survive for months in still water. Disinfectants containing chlorine, however, like bleach will quickly eliminate it, as will sufficient heat.

SYMPTOMS OF “STOMACH FLU”

The symptoms of the stomach flu include nausea and vomiting, watery diarrhea, and (sometimes severe) abdominal pain, usually within 12 to 48 hours of exposure. Along with this, muscle aches, headache, and fever may be seen. Luckily, life-threatening illness is rare, with dehydration being the main danger in those infected with the virus. Symptoms may last several days before eventually subsiding.

Unlike some viruses, immunity to norovirus is only temporary. Antibodies against the virus at thought to last up to six months after recovery. Also, there are various types of noroviruses, getting one doesn’t protect you against others.

Outbreaks of norovirus infection often occur in closed spaces such as cruise ships, nursing homes, schools, camps, and prisons. Shellfish, such as oysters, and salad ingredients are the foods most often implicated in norovirus outbreaks (except, of course, “the World’s Best Hot Dog”).

TREATING NOROVIRUS

As is the case with most viruses, there is no known cure for norovirus infection. Antibiotics will not be effective, as they are meant to kill bacteria, not viruses. Treatment involves staying well-hydrated. Suspect dehydration if you see these signs and symptoms:

·        Dry mouth

·        Decrease in quantity or dark color of urine

·        Dizziness when standing up

·        Decreased elasticity of skin (it “tents” when pulled)

·        No tears when crying or unusual irritability in infants

Using antidiarrheal meds like loperamide (Imodium) and anti-vomiting drugs like Ondansetron (Zofran) may also help.

PREVENTING NOROVIRUS

A cure may not be available but prevention is another issue. To decrease the chance of norovirus infection:

·        Wash your hands frequently with soap and water (norovirus is relatively resistant to alcohol), especially after using the restroom or handling food. Be especially sure to do this for 2 weeks after becoming infected (yes, you can be contagious for that long).

·        Wash food before cooking; cook shellfish thoroughly.

·        Frequently disinfect contaminated surfaces with a bleach solution (the EPA recommends 5-25 drops of bleach per gallon).

·        Keep sick individuals away from food preparation areas.

·        Avoid close contact with others when you are sick, and don’t share utensils or other items.

·        Wear disposable gloves while handling soiled items.

·        Immediately remove and wash clothes that may be contaminated with vomit or feces. Machine dry if possible.

It may be difficult to completely eliminate the risk of norovirus infection, but careful attention to hand and food hygiene will go a long way towards avoiding the stomach flu.

Joe Alton MD

Doom and Bloom: Burns

The Altons at Doom and Bloom Medical have a couple of articles on burns. The first is on First and Second Degree Burns, while the third covers Third Degree Burns. Here’s an excerpt from the first of the articles, as always, more pictures in the original article:

A wide variety of situations, both in normal times and disaster settings, put us in proximity with high levels of heat. If we’re knocked off the grid, it won’t be unusual to cook food over a fire of our own making, something very few do on a regular basis. As such, the survival medic will often be faced with burn injuries. Having the materials and knowledge to treat burns will be absolutely necessary in times of trouble.

Burns can be caused by contact with sources other than flames, including:

•             Scalds due to contact with hot water or steam.

•             Contact with electricity associated with lightning or another source.

•             Friction burns due to contact with hard surfaces such as roads (“road rash”), carpets, or hard flooring.

•             Skin exposure to extreme cold and winds. Yes, extreme cold can cause burns.

•             Chemical spills.

•             Radiation due to contact with energy emitted by x-rays and other medical testing or treatment, “dirty bombs,” or thermonuclear explosions.

In general, the different types of burns are treated similarly, although some burns, like those caused by electricity or radiation, may cause internal damage without destroying the skin. Inhalation of superheated air may cause damage to lung tissue. Off the grid, the lack of advanced care will make these cases a challenge for the medic.

The severity of a burn injury and resulting chance of death or disability depends, in part, on the percentage of the total body surface involved, as measured by the “rule of nines.”

Assessing the percentage of body surface area burned is standard practice and helpful in modern medicine. It may, however, have less practical benefit in austere settings where transport isn’t an option. In any case, knowing the “rule of nines” may give the medic an idea of the chances of recovery for a burn victim.

Burns to the face, feet, hands, genitals, and lungs are considered the most problematic. Burns that go completely around a body part, say, an arm, cause constriction that may affect circulation. Areas with a lot of scar tissue may have limited mobility.

BURN DEGREES

Besides total surface area involved, an important factor is the amount of penetration of the burn. This is usually measured in degrees.

First-Degree Burns

Most burns you’ll see will be due to excessive exposure to the sun. A majority of cases will be “first-degree burns.” In first-degree burns, the patient may be red as a lobster, but only the superficial layer of the skin (the “epidermis”) is injured.

A first-degree burn will appear red, warm, and dry. It will be painful to the touch, especially when large areas of skin are involved. Fortunately, major complications are rare unless other symptoms such as nausea and vomiting appear. Treatment is simply focused on relieving discomfort.

Immersion in a cool bath will be helpful; at the very least, run cool water over the injury. A cool moist cloth on the burn for 20 minutes will give some relief. So will anti-inflammatory medicines such as Ibuprofen. Aloe vera, zinc oxide, and benzocaine sprays are effective alternatives. Expect the discomfort to improve after 24 hours. Until then, avoid constrictive, tight clothing and wear light fabrics, such as cotton.

Prevention, of course, is worth a pound of cure. To avoid this type of sunburn:

•             Don’t “sunbathe” (a tan is not healthy).

•             Avoid the peak sun hours for the time of year and latitude.

•             Wear long pants and sleeves, hats, and sunglasses.

•             Spend time in the shade whenever possible.

If extended exposure to sunlight is unavoidable, be certain to use a sunblock. Apply 15 minutes prior to going outside and re-apply frequently throughout the day. Even water-resistant sunscreens should be reapplied every one to two hours. Most people fail to put enough on, so be sure to use plenty.

As an aside, sunblock and sunscreen are not the same thing. Sunblocks contain tiny particles that “block” and reflect UV light. A sunscreen contains substances that absorb UV light, thus preventing it from penetrating the skin below. Many commercial products contain both. Sunblocks and sunscreens should be an integral part of your medical storage.

The SPF (Sun Protection Factor) rating system was developed in 1962 to measure the capacity of a product to protect against UV radiation. It measures the length of exposure to the sun before you burn. A SPF (sun protection factor) of at least 15 is recommended. It takes about 20 minutes without sunscreen for your skin to start turning red. SPF 15 blocks 94 percent of the sun’s rays, SPF 30 blocks 97 percent, and SPF 45 98 percent. The higher the number, the longer it takes for the skin to burn.

Although the increase in protection may seem small, higher SPF numbers are especially beneficial to those with fair skin. They offer better protection against long-term skin damage leading to cancer.

Besides the sun, first-degree injuries will most likely be related to cooking or campfires. Using hand protection will prevent many of these burns, as will careful supervision of children near campfires and food preparation areas.

Second-Degree Burns

Second-degree burns are deeper injuries that penetrate through the superficial epidermis and partially through the deeper layer of the skin (the “dermis”). Thus, they’re often called “partial thickness burns.” While first-degree burns may cover a large percentage of surface area without becoming life-threatening (but are painful), a relatively small percentage of the body covered with significant second-degree burns may require serious medical intervention.

Unlike first-degree burns, which appear dry, second-degree burns will be moist and often have blisters with reddened bases. The area will have a tendency to weep clear or whitish fluid. Second degree burns will cause swelling as well, so it’s important to remove rings and bracelets.

To treat second degrees burns:

Remove the victim from the heat source immediately. Run cool water over the injury for 10-15 minutes (avoid ice, which will traumatize already-damaged skin). After washing and running water over the wound, pat the area dry. The next step is to apply moist skin dressings such as Xeroform, Spenco Second Skin or non-stick dressings (Telfa pads) with thin layers of products like aloe vera or Aquaphor. Be sure to replace regularly and review the progress of healing. Other actions should include:

•             Removing jewelry like rings and bracelets (swelling may cause painful constriction).

•             Elevating burned extremities.

•             Applying cool compresses.

•             Giving oral pain relief such as Ibuprofen (Advil).

•             Applying anesthetic creams such as benzocaine or lidocaine.

•             Avoidance of “peeling” burned skin, which sometimes comes off in sheets.

•             Protecting adjacent burned fingers and toes with a dry barrier in-between.

•             Encouraging hydration.

•             Using a “tenting” method to keep sheets above extensive burns.

We’re often asked whether to pop blisters associated with second-degree burns. It’s wisest to avoid the lancing of blisters, if possible, unless they’re infected and filled with pus. Some very large blisters will, however, break with the slightest pressure and may benefit from controlled drainage. If this is the case, use a sterilized needle or scalpel blade to pierce the side of the blister near the base. The roof of the blister is often retained to provide additional protection to the healing base.

It’s important to avoid the use of lard or butter on burns: They tend to keep in heat and may worsen the injury. Egg whites and toothpaste, long considered to be home remedies, may increase the risk of infection. It’s better to use sterile saline solutions to keep the burn area and (non-stick) dressing moist, especially in severe burns.

In part 2 of this series, we’ll discuss third-degree burns. Is there anything the survival medic can do if confronted with this life-threatening issue?

Doom and Bloom: Bleeding Management, Part 2 – Stab Wounds

Stab Wounds is the second part of Doom and Bloom Medical’s bleeding management series. See the original article at Doom and Bloom Medical for more photos related to the article. See part one of the series here.

Any disaster can put your people at risk for injury. Many of those injuries cause bleeding, and, depending on the area damaged, a few can be life-threatening. In survival, a lot of activities involve the use of sharp objects. In this article, we’ll discuss how to deal with hemorrhage from knife wounds.

You could define a classic stab wound as a laceration where the puncture on the skin is smaller than the depth of penetration into the body. This is in contrast to a slash injury, which is generally longer on the skin than  deep. Stab wounds tend to enter in line with the long axis of the knife, while slashes don’t.

These types of wounds are a type of penetrating trauma, which is further divided into two types: perforating and non-perforating.  A perforating wound is one in which the object causing the damage goes in one side of the body and then exits through the other side.  A wound from a .223 round or NATO .556 would be a good example of perforating trauma.

Stab wounds are an example of a non-perforating wound:  the projectile causing the damage enters the body and either stays there or exits where it entered. There are some sharp instruments that could possibly do perforate: A crossbow bolt, for example, or a spearhead, but let’s assume these will be less common than knife wounds, even in a survival setting.

Bullets and other high-speed projectiles cause damage not only from the act of penetration, but also the shock wave produced as the bullet passes through the body at high speed. Low speed projectiles such as knives don’t produce much of a shock wave, so your concerns are mostly related to the area of entry and the structures located directly in the path of the offending instrument.

With stab wounds, blood loss will be the major issue.  Your immediate action upon encountering a victim with a wound from a sharp instrument may save their life. The heart takes less than one minute to pump blood to the entire body; if the circulatory system is breached, arterial blood loss can become life-threatening very quickly.

Average-sized adult males have approximately 9-10 pints (about 5 liters) of blood in their body. Athletes and those living at very high altitudes may have more. You can’t afford to lose more than 40% of total blood volume without needing major resuscitation.  To get an idea of how much blood this is, empty a 2-liter bottle of any liquid on the floor.  It’s an eye opener. Imagine how much of your supply of bandages might be expended from just one major bleed.

HOW TO HANDLE A STAB WOUND

If you’re attending to an actively bleeding wound from a sharp object, you’ll need a level head and quick action. In normal times, of course, contact emergency services immediately.

 In the meantime, follow these steps:

-Assess the safety of the situation.  Make sure there is no active threat. it makes no sense for you to become the next casualty.

-Put on gloves if possible.  Your hands are full of bacteria and you’ll reduce the risk of infection by doing so. If no gloves are available, any barrier or, at least, hand sanitizers will be useful if you have to touch the wound with bare hands (let’s face it, though;  you might not have the time if the bleeding is that heavy).

-Verify the victim’s breathing and mental status.  Clear airways if obstructed. Determine if the person is   alert enough to follow commands.

-In a non-combat setting, remove clothing or otherwise fully expose the area and identify other injuries.  Make sure that you have a bandage scissors or EMT shears in your medical pack.

-Apply pressure with some type of dressing, even your shirt if that’s all you have.  Most non-arterial bleeding will stop with firm direct pressure on the wound. If the sharp instrument is still in place in the victim and help is on the way, place pressure down on either side towards the blade to prevent it from slipping out.  The knife may actually be providing pressure on damaged vessels.  Stabilize the wound with the weapon in place with ample dressings on either side and gauze or elastic rolls to secure. An example is seen below.

Knife in place secured with dressing and bandage materials

-If one dressing doesn’t work and you don’t have specialized blood-clotting materials (called “hemostatics”), place additional dressings on top of the first.

-Elevate the feet above the level of the heart and head (the “shock position”) to increase blood flow to the heart and brain. If the wound is to the abdomen, however, bend the knees instead.

-Lift an injured extremity above the level of the heart. Make it more difficult to pump blood out of the body.

-If direct pressure fails, apply a tourniquet to stop the bleeding.  Our experience in Iraq and Afghanistan shows that tourniquets save lives in cases of severe or arterial hemorrhage. As a matter of fact, if the bleeding is obviously arterial (bright red blood spurting out of the wound), using a tourniquet  should be your FIRST course of action.

-If you’re transporting a patient to a modern medical facility, make sure you mark a “T” on the victim’s forehead or otherwise notify emergency personnel of the location and length of time that the tourniquet’s been in place.

Image of Hemostatic Gauzes
Different hemostatic gauze options shown: ChitoSam, QuikClot and Celox

-I mentioned hemostatics earlier. In cases of heavy bleeding, the use of special blood clotting materials such as Quikclot, Celox, or ChitoSam is a life saver. We put these products in all our medical packs, even the smaller individual first aid kits. In this case, you would remove the blood-soaked bandages and place a hemostatic gauze directly on the bleeding vessel with pressure for 3 full minutes.

-Secure everything with a pressure dressing, of which there are various on the market.  The Israeli Battle Dressing, known as The Emergency Bandage in the U.S., can apply up to 30 pounds of pressure if used properly.

Hemostatic dressing and pressure bandage in place

-Keep the victim warm: Throw a mylar blanket or other cover over them.  If help is coming, keep them as still and calm as possible to avoid further bleeding.  Monitor breathing, pulses, and mental status. An unconscious patient should be placed, if possible, in the “recovery position”.  This will, among other things, allow fluid to drain from airways and help them breathe.

Let’s say you placed a tourniquet successfully and there’s no help coming.  Ever. You’re the end of the line when it comes to medical care for this victim. If a tourniquet is on, should you loosen it from time to time? You may be tempted to do this, but don’t: It can cause further bleeding.

That doesn’t mean you can leave the victim, now your patient, with a tourniquet on and a knife sticking out of them forever. Carefully transport them to a more controlled setting where you have the bulk of your medical supplies and remove the knife. Yes, I said remove the knife, there’s no hospital, no trauma surgeon, just you. You may have to place a second tourniquet above the first one if bleeding returns. You goal is to transition the patient from the tourniquet within, say, 2 hours or so, to a hemostatic gauze and a pressure bandage.

Once the bleeding is under control, clean the wound thoroughly and dress it.  Remove hemostatic materials within 24 hours. Wound closure may be an option in some cases, but most back-country stab wounds will be dirty and should be left open. You’ll find daily wound care described in other articles on this website.

All of the above may not be necessary if you practice preventative measures.  In other words, insist your people wear hand and eye protection when using sharp instruments, and don’t run with scissors.  With some foresight, you may be able to avoid a mishap that could turn into a tragedy.

Joe Alton MD

Doom and Bloom: What To Do About Baby Formula Shortages

The Altons at Doom and Bloom Medical have an article up on What to Do About Baby Formula Shortages.

A large survey of 11,000 stores have found that fully 43% are sold out of baby formula. More mothers are breast-feeding their babies these days, but most still find themselves using baby formula at one point or another in their child’s first six months of life. A formula shortage panic is part and parcel of a society that is unprepared for shortages in the face of disasters and other upheavals.

In this case, the formula shortage is thought to be due to a major recall by one of the three companies that make the product: Abbott labs. Recently, several infants were hospitalized with cronobacter sakazakii, a bacterium that was identified in the company’s Michigan plant. One of the babies is reported to have died. Supply chain issues may also be a factor in the current crisis.

If you have Abbott products in your pantry, the Food and Drug Administration (FDA) asks that you check to see if it might be at risk for contamination. Recalled lots can be identified. Check to see if the first two digits of the product code are 22 through 37, the code contains K8, SH, or Z2, and has an expiration date later than April 1, 2022. Abbott’s website has a search feature that allows you to plug in your lot numbers to see if it’s part of the recall.

Baby formula is meant to be as close to human breast milk as possible, making an acceptable substitute difficult to find. What to do? You should first consult with your pediatrician, of course, about the issue. Some pediatricians say that Pedialyte is an option for a day or so to keep the baby hydrated. Others say that toddler formula will do for a few days while you’re hunting for the right stuff. Infants over one year of age on formula can slowly transition to whole milk. A few say small amounts of cow’s milk can even be given in babies 6 month of age or over for a short time.

The brands removed from supermarket shelves include popular brands like Similac, Alimentum, and Elecare. Pediatricians from Prisma Health are reported in South Carolina’s Greenville News as suggesting the following substitutes for recalled products:

Similac 360 Total Care/Advance substitutions: Gerber Good Start Gentle, Enfamil Infant, Enfamil NeuroPro, Enfamil Enspire, Up&Up Advantage/Infant, Parent’s Choice Advantage/Infant

Similac Soy Isomil substitutions: Gerber Good Start Soy, Enfamil Plant Based, Up&Up Soy, Parent’s Choice Soy

Similac Neosure substitutions: Enfamil Enfacare

Similac Sensitive/360 Total Care Sensitive substitutions: Gerber Good Start Soothe, Enfamil Gentlease, Up& Up Sensitivity, Parent’s Choice Sensitivity

Similac for Spit-up substitutions: Enfamil AR, Parent’s Choice Added Rice Starch

Similac Total Comfort substitutions: Enfamil Reguline, Up&Up Advantage Complete Comfort, Parent’s Choice Tender

Similac Alimentum substitutions: Gerber Good Start Extensive HA, Enfamil Nutramigen, Up&Up Hypoallergenic, Parent’s Choice Hypoallergenic

Similac Elecare substitutions: Nutricia Neocate Infant, Enfamil Puramino, Nestle Alfamino

If these options are not available, there isn’t a lot of advice that the government or the pediatric establishment give as alternatives. They recommend continuing to breastfeed or returning to breastfeeding if the infant was recently weaned. Another suggestion is to search for it in places other than supermarkets: pharmacies, for example. Look in areas where the infant population is low (such as senior communities), you may find more available there. Of course, if you can find your baby’s formula online from a trusted source, use that avenue.

If you do find a supply, though, the government says not to get more than a month’s worth (because that’s just greedy). Needless to say, advice like this goes against the grain for preparedness folk.

It’s possible that an infant could transition to solid food. A baby that’s ready should be able to:

  • remain stable in a sitting position.
  • hold their head steady while sitting up.
  • have sufficient coordination so they can look at food, pick it up, and put it in their mouth by themselves.
  • swallow food easily without frequently spitting up.

Other behaviors could be mistaken as ready for solids. Chewing fists and wanting extra formula are not indications to switch over.

The opinion of the FDA, CDC, and almost all pediatricians is that no formula shortage should result in using cow’s milk in young infants, plant milks like soy or almond, watering down existing formula, or making your own. They explain that all these options are dangerous and can overload an infant’s kidneys or cause electrolyte imbalances that can lead to seizures. The CDC states that homemade formula recipes you’ll find online can contain harmful ingredients or be contaminated.  They recommend you ignore those “mommy blogger” recipes.

Unfortunately, solutions to the problem are scarce. Some websites actually advise mothers to borrow a can of formula from a neighbor as a strategy. Not exactly a long-term answer.

Of course, families with infants should listen to their pediatricians, but what happens when the approved commercial substitutes are sold out? What if a disaster knocks out formula manufacturing altogether? In the old days, there were nursemaids, but that doesn’t seem like a popular career path today. Up until the 1960s, some mothers were even sent home with homemade formula recipes.

If the formula shortage continues, you might have little choice but to buck the pediatric establishment and make your own. I’m not a pediatrician and haven’t been in a situation where I needed formula and there was none to be had. Having said that, you have to do something if you can’t find formula and your baby needs to eat. Here are a number of links to various “mommy blogger” homemade recipes (none of which, I have to admit, I’ve tested myself):

https://wehavekids.com/parenting/Emergency-Baby-Formula

https://dustyoldthing.com/1950s-homemade-formula-recipes/

Formula – Homemade Baby Formula – The Weston A. Price Foundation

https://wellnessmama.com/wprm_print/203435

It should be noted that no formula recipe using honey is safe for infants, due to the risk of botulism.

For now, it may take a little searching to find the formula you need, but be sure to consider what you’d do if there was none to be found. That’s part of being prepared; if we all had a plan of action for every contingency, we’d be a nation that could weather any shortage.

(Addendum: There’s a program called “Healthy Mothers Healthy Babies” that has formula stockpiles in various parts of the country. Worth checking into.)

Doom and Bloom Medical: Bleeding Wound Management, Part. I

The Altons at Doom and Bloom Medical have part one of an article on bleeding wound management.

In a destabilized society, traumatic wounds may be commonplace is scenarios where there is a desperate population and no rule of law. Even routine activities of daily survival may cause injuries that could become life-threatening. Therefore, the family or group medic must always be prepared to deal with bleeding wounds. Some of these, especially those in the abdomen and chest, are likely to be fatal without advanced medical care. In this article, let’s commemorate National Stop The Bleed Month (I’m a certified instructor through the American College of Surgeons) by concentrating on those hemorrhages that are survivable.

Cuts in the skin can be minor or catastrophic, superficial or deep, clean or infected. Significant cuts (also called “lacerations”) penetrate both layers of the skin (dermis and epidermis) and are associated with bleeding, the amount of which depends on the blood vessels disrupted. Knowing how to manage hemorrhagic wounds quickly and effectively will be of paramount importance for the survival medic.

In studies of casualties in recent wars, 50 percent of those killed in action died of blood loss. 25 percent died within the first “golden hour” after being wounded. The golden hour is the time after which a victim’s chance of survival diminishes significantly if untreated, with a threefold increase in death rate for every 30 minutes without care thereafter.

If there is active bleeding and the wrong artery is severed, however, it could take just a few minutes for a person to “bleed out” and be beyond medical help. A severed femoral artery can lose more than a pint of blood a minute. With hemorrhage, the reality should, perhaps, be called the “platinum five minutes” instead.

Venous bleeding manifests as dark red blood that drains steadily from the wound, while arterial bleeding is bright red (due to higher oxygen content) and comes out in spurts that correspond to the pulse of the patient. As the vein and artery usually run together, a serious laceration can have both.

Once below the level of the skin, large blood vessels, muscles, and nerves may be involved. You’ll identify more problems with vessel and nerve damage in deep lacerations and crush injuries. In any case, bleeding control must be achieved.

In response to fatalities due to bleeding in recent military conflicts, the U.S. instituted Tactical Combat Casualty Care (TCCC) guidelines. It is thought that up to one in five deaths from hemorrhage in the field may be prevented with quick action by those at the scene. Civilian and law enforcement authorities have established similar strategies in response to the hard lessons learned by our soldiers; so should the family medic.

BLOOD BASICS

It’s worthwhile for the medic who may be dealing with bleeding wounds to know some basics about blood. Blood is a specialized fluid that comprises about 7-8 percent of a person’s total weight. It’s involved in:

•             Delivering oxygen to the body from the lungs and eliminating carbon dioxide (a process called “gas exchange”).

•             Forming clots that stop hemorrhages.

•             Transporting substances that fight infections and disease.

•             Delivering waste products to the kidneys and liver.

•             Helping to regulate body temperature.

There are four main components to blood:

Red blood cells (RBCs): RBCs are the cells that carry oxygen to body tissues, thanks to a special iron-containing protein called “hemoglobin.” Red cells account for 40-45 percent of total blood volume. They start as immature cells in the bone marrow that mature and are released into the bloodstream. The average lifespan of a red blood cell is about 120 days.

White blood cells (WBCs): These cells account for only about one percent of total blood volume, but are extremely important for fighting infection and disease.  There are several types, including short-lived cells deployed for immediate response and longer-lived ones that regulate the function of immune cells, make antibodies, and directly attack infected cells and tumors.

Platelets and other clotting factors: These are small cell fragments that allow bleeding to stop by gathering at the wound site and helping to form a clot. Like RBCs and WBCs, they originate in the bone marrow.

Plasma: A yellow liquid that transports all of the above throughout the body.

Together, these components are referred to as “whole blood.”

PHYSICAL EFFECTS OF BLOOD LOSS

Evaluating blood loss is an important aspect of dealing with wounds. An average size human adult has about 10 pints (4.73 liters or 4730 ml) of blood. The effect on the body caused by blood loss varies with the amount incurred. The American College of Surgeons recognizes four classes of acute hemorrhage, along with expected signs and symptoms:

Class I:  Hemorrhage is less or equal to 15 percent of blood volume (1.5 pints/750 ml) in an average adult male. 750 ml is the amount in a bottle of wine. A person donating 1 pint of blood is giving slightly less than 500 ml. At this level there are almost no signs or symptoms, although some may have a slightly rapid pulse and feel vaguely faint or anxious.

Class II:  Hemorrhage is 15 to 30% loss of total blood volume (1.5-3 pints/750-1500 ml).  The body’s efforts to compensate for less red blood cells at this point results in a faster heartbeat and breathing rate to speed oxygen to tissues.  This patient will appear pale and skin will be cool.  They’ll feel shaky, weak, and anxious. Blood pressure remains, for now, within normal range. Urine production begins to slow down in order to retain fluid volume.

Class III: Hemorrhage is 30 to 40% loss of blood (3-4 pints/1500-2000 ml).  At this point, the heart will be beating very quickly and breathing very fast as the body encounters difficulty getting enough oxygen to tissues.  Blood pressure drops. Smaller blood vessels in extremities constrict to keep the body core circulation going. This patient will be confused, pale, and in hypovolemic (low blood volume) shock. Urine decreases significantly. In normal times, blood transfusion is usually necessary. 

Class IV:  Hemorrhage is more than 40% of total blood volume (greater than 4 pints/2000 ml). The heart can no longer maintain blood pressure and circulation.  All parameters are well outside normal range and the patient becomes lethargic due to lack of oxygen and circulation to the brain. Without major resuscitative help at this point, organs like the kidneys fail. The patient loses consciousness. Heart rate and respiration slows and eventually ceases as the patient dies.

ABCDE VS. CABDE

The traditional initial field assessment of a victim usually involves the acronym ABCDE. Although ABCDE may mean different things to different people, one interpretation goes as follows…(continues)

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