Doom and Bloom: Asthma in Survival

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

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

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

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

Here are common allergens that trigger an asthmatic attack:

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

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

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

Asthma is contagious. (False)

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

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

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

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

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

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

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

PHYSICAL SIGNS AND SYMPTOMS OF ASTHMA

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

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

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

Cyanosis

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

Asthma vs Heart Attack

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

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

DIAGNOSING ASTHMA

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

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

typical peak flow meter

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

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

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

TREATMENT OF ASTHMA

Asthma bronchodilator in inhaler

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

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

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

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

NATURAL TREATMENT OF ASTHMA

Ginger

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Joe Alton MD

Doom and Bloom: Hypothermia in Austere Settings

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

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

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

HOW THE BODY LOSES HEAT

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

Image by JEMS

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

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

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

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

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

GENERAL SYMPTOMS OF HYPOTHERMIA

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

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

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

To learn about hypothermia in dogs, click here.

LEVELS OF HYPOTHERMIA

Some sources differentiate different levels of hypothermia body temperature:

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

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

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

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

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

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

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

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

Individual cases may vary somewhat.

TREATING HYPOTHERMIA

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

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

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

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

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

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

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

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

PREVENTION OF HYPOTHERMIA

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

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

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

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

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

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

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

Joe Alton MD

Doom and Bloom: Soft Tissue Infections

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

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

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

image by Cerevisae 

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

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

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

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

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

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

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

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

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

Adult dosing:

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

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

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

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

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

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

 

Spotter Up: The EDC Tourniquet

Eugene Nielsen at Spotter Up has a pretty comprehensive article on The EDC Tourniquet.

According to published research, reported in the October 2017 issue of the Journal of the American Medical Association (JAMA)), the average response time in the US from the time of a 911 call to arrival of EMS on scene was seven minutes. This increased to more than 14 minutes in rural settings. A person can bleed out from a severed femoral artery in less than five minutes. You do the math.

By the time EMS arrives it may be too late. You need to be your own first responder.. Photo: Public Domain.

In an active shooter or terrorist incident, emergency personnel won’t reach victims until the threat has been neutralized. During the Paris attacks on 13 November 2015, it was over 160 minutes from the time the terrorists fired the first shots in the Bataclan theater until the responding emergency personnel were able to reach those inside the venue.

The reality is that you’re going to be your own first responder. Bystanders will always be first on the scene, whether it be terrorism or other criminal act or an accident. In the Boston Marathon bombing on 15 April 2013, bystanders employed improvised tourniquets to save lives. Time consuming and inefficient, but it was all that they had. Don’t plan to improvise if the need arises. Always have a real tourniquet.

Data from the Boston Marathon Bombing found that six of the rubber and improvised type tourniquets had to be subsequently replaced with C-A-T® tourniquets. Additionally, the most common EMS tourniquet on scene consisted of rubber tubing and a Kelly clamp.

Roughly 80% of combat deaths and 50% of civilian trauma deaths are attributable to hemorrhage. It’s the most preventable cause of death in compressible injuries. The proper use of tourniquets saves lives.

Hypovolemic Shock

Time is of the essence. Hypovolemic shock occurs where there is an acute fluid or blood loss in the body. It’s a life-threatening emergency. Hypovolemic shock is most often secondary to rapid blood loss (hemorrhagic shock). It causes inability of the heart to pump the essential blood needed to the body, resulting in multiple organ failure due to inadequate cellular oxygenation. There are four stages of hypovolemic shock.

No, it’s not an ancient torture device, although Roman soldiers may have begged to differ. It’s a Roman thigh tourniquet circa199 BCE to 500 CE. It’s made from bronze. Photo: Welcome Collection. Licensed under the Creative Commons Attribution 4.0 License.

Stopping the blood loss before patient goes into Stage II shock, ie., blood volume loss up to 15% (~750 mL), keeps survivability at around 94%. If blood loss continues and the patient is in Stage II (30% or ~1500 ml) or greater, the survivability goes down to 14%, without any blood being administered. These figures are based on a US Army Institute of Surgical Research (USAISR) study conducted in 2006 and 2007.

Tourniquets

While I recommend that everyone carry a trauma kit, a tourniquet (and gloves) needs to become part of your everyday carry (EDC) at the at the very minimum. Tourniquets have emerged as the standard of care in the tactical environment due to their ease of use, rapid application, and complete stoppage of blood loss. Current protocol considers the tourniquet an initial lifesaving intervention to control massive hemorrhage from an extremity.

The old dogma of “save a life, lose a limb” has been proven to be false. A tourniquet can safely remain in place for up to two hours. Thousands of combat veterans are walking around today with all their limbs because their lives were saved by tourniquet use.

The use of tourniquets on the battlefield isn’t new. As far back as Alexander the Great’s military campaigns in the fourth century BC, tourniquets were used to staunch the bleeding of wounded soldiers. The term “tourniquet” dates from the 17th century and originated from the French “tourner” meaning “to turn”. .

Tourniquets have emerged as the standard of care in the tactical environment. Combat Application Tourniquet (C-A-T) is recommended by CoTCCC and standard issue to the US military. First responders and others are most likely to have trained with the C-A-T. Photo: North American Rescue.

Tourniquets lost popularity after the US Civil War, having been blamed for complications that resulted in amputation. This misunderstanding has unfortunately persisted, especially as it pertains to tourniquet use in civilian settings.

Although there have been several studies in the past that have looked at tourniquet use in civilian settings, the survival benefit for patients has been unclear. However, new research shows that for civilian patients with peripheral vascular injury, prehospital tourniquet use is associated with dramatically improved odds of survival.

The study, titled “Civilian Prehospital Tourniquet Use Is Associated with Improved Survival in Patients with Peripheral Vascular Injury,” was published 29 March 2018 and reported in the May 2018 issue of the Journal of the American College of Surgeons (JACS). This study was a multi-institutional retrospective review of all patients sustaining peripheral vascular injuries admitted to all 11 urban Level I trauma centers in the state of Texas from January 2011 to December 2016.

The study found that “Although still underused, civilian prehospital tourniquet application was independently associated with a 6-fold mortality reduction in patients with peripheral vascular injuries. More aggressive prehospital application of extremity tourniquets in civilian trauma patients with extremity hemorrhage and traumatic amputation is warranted.” Simply put, tourniquets save lives.

Popular commercial tourniquets include the Combat Application Tourniquet® (C-A-T®), SOF® Tourniquet, RevMedx® TX® Series Ratcheting Medical Tourniquet -Tactical™ (RMT-T™), SAM Extremity Tourniquet (SAM-XT™), Tactical Mechanical Tourniquet™ (TMT™), SWAT-T® and Rapid Application Tourniquet System®® (R.A.T.S.®) / Rapid Tourniquet. Each has its pros and cons. All are capable of occluding blood flow when properly applied.

No longer a last resort, a tourniquet is now considered an initial lifesaving intervention to control massive hemorrhage from an extremity. SWAT-T is a versatile tourniquet that has proven effective in studies and has been successfully fielded in combat. Photo: H&H Medical.

As of this writing, the C-A-T, RMT-T, SAM-XT, SOF Tourniquet (SOFTT-W), TMT and TX Series (TX2 and TX3) are  the only US military Committee on Tactical Combat Casualty Care (CoTCCC) recommended non-pneumatic limb tourniquets. It’s important to keep in mind that the CoTCCC, a division of the DoD Joint Trauma System, is looking at tourniquets for use on adults in combat by trained military personnel. not for use by civilians with limited training or for use on children.

The C-A-T, RMT-T, SAM-XT, SOF Tourniquet, TMT and TX Series are windless/ratcheting tourniquets. The SWAT-T (Stretch, Wrap and Tuck Tourniquet®) and R.A.T.S. are elastic wrap tourniquets.

A plus to elastic wrap tourniquets is that they pack down into a significantly smaller size, making them easier to carry. They’re also considerably less expensive than windless/ratcheting tourniquets. On the downside, elastic wrap tourniquets require a wider range of motion to apply. The latter can make self-application more difficult.

The SWAT-T and R.A.T.S. can be be employed for higher axillary and groin applications than windless tourniquets. They may also be employed for pediatric and K-9 applications, where standard windlass tourniquets cannot. A study of commercial tourniquets conducted in Israel, and reported in a paper submitted to the 2018 NAEMSP Scientific Assembly, found that the SWAT-T and R.A.T.S. were the best tourniquets for use on children.

It should be noted that North American Rescue states that the C-A-T has been shown to be effective on limbs as small as five inches in circumference. It should also be noted that the TX Series ratcheting tourniquet is available in a pediatric model designed specifically for children.

The SWAT-T is a versatile medical multi-tool that may be employed not only as a tourniquet, but also as pressure dressing, occlusive device, elastic bandage, sling and swathe, used to secure a splint, and more. If the SWAT-T is employed as a pressure bandage or dressing, it’s important to check for a distal pulse after application. Although not a CoTCCC-recommended tourniquet, the SWAT-T has been the subject of several studies which demonstrated it’s efficacy.

PHLster Flatpack is a great way to EDC a windlass tourniquet. Flatpack is shown with SOF Tourniquet (SOFTT-W). Photo: PHLster Holsters.

PHLster Flatpack Tourniquet Carrier

No tourniquet does you any good if you don’t have it with you when you need it. I have found the PHLster Flatpack® Tourniquet Carrier from PHLster Holsters to be a great, low-profile way to EDC a windlass tourniquet for easy, one-hand deployment. Designed for versatility, it allows you to carry a folded and staged windlass tourniquet on your belt, in a pocket or with MALICE CLIPS® for MOLLE/PALS mounting..

Training

Having the necessary tools is only part of the equation. Equipment is only as good as your training. Basic emergency medical training should cover the entire spectrum of lifesaving skills. And like shooting, they’re perishable skills.

Emergency medical training should be part of the basic skill sets of every firearms owner. In fact, it should be part of the basic skill sets of everyone. The time to learn isn’t when someone is bleeding out.

The National Association of Emergency Medical Technicians (NAEMT) and STOP THE BLEED® are excellent resources that can direct you to courses in your area. Dark Angel Medical offers a free online introductory course designed to teach the basics of bleeding control.

Kerry Davis of Dark Angel Medical discussing hemorrhagic injury management and tourniquet placement with two students in Direct Action Response Training (D.A.R.T.) course. Hemorrhage is the most preventable cause of death in compressible injuries. It accounts for approximately 80% of battlefield deaths and 50% of civilian trauma deaths.

Dark Angel Medical also offers an outstanding two-day Direct Action Response Training (D.A.R.T.) course at various locations around the country. All participants receive BCON (Bleeding Control) certification from the American College of Surgeons. It also provides 16 hours of CEU’s, per CECBEMS, to NREMT EMT-Basics/Advanced and Paramedics. I have taken the D.A.R.T. course and highly recommend it. Dark Angel Medical is also a great source for trauma kits and components. I have taken the course and highly recommend it. Idid an article on the D.A.R.T. course recently for Spotter Up.

The online learning platform Deployed Medicine is also valuable resource. It’s used by the Defense Health Agency (DHA) “to trial new innovative learning models aimed at improving readiness and performance of deployed military medical personnel.” Learning assets include the standardized Tactical Combat Casualty Care All Service Members (TCCC ASM) Course curriculum developed by the Joint Trauma System, which is part of the DHA. You don’t have to be a member of the military to take advantage of its resources.

Some Final Thoughts

Preparedness requires the proper mindset, training, and tools. It doesn’t just happen. It’s a way of life and takes some effort. And it’s about preparing for possibilities, not just probabilities.

Carry a proven tourniquet. Not all tourniquets are created equal. I recommend carrying at least two tourniquets. This will leverage your capability. I carry a C-A-T as my primary EDC tourniquet and a SWAT-T as my secondary/backup tourniquet

Buy from a reputable source. If you try to save a few bucks you may wind up with poorly made counterfeit. Counterfeit tourniquets are a growing problem. They can cost lives. The life you save may be your own or that of a loved one.

Practice with the tourniquet in situations that are similar you may encounter. Get a spare/training tourniquet for this purpose. Don’t use the actual tourniquet that you will be counting on in an emergency. Practice both strong and support side applications.

The Medic Shack: Amputation – First Aid and Post Aid

Chuck at The Medic Shack talks about amputating injuries, first aid for them, and post aid while using photos from his son’s recent injury. So be warned of finger amputation photos through the link.

This post is on Amputation. What first aid and also post aid needs to be done.

NOTE: Some of the images at the end of this are graphic. They are of my son’s finger and the wound. 

This site contains affiliate links to products. We may receive a commission for purchases made through these links. This does NOT increase the price of the product you may purchase.

Background

Normally when I write a blog post its from current events, past experiences both civilian and or military. This time I am using my youngest son as our topic. This past week (Tuesday the 4th of August) he had a pretty normal day at work. He works at a motorcycle accessory shop. Sells gear and he is about the most requested tire man in the city.

People bring him tires to mount that they bought from all over. From the store he works at to mail order The reason he is so requested is he cares for the customer and the motorcycle. Never scratches or damages a rim. He recently did a set of tires that the rims cost 2 grand each. Personally requested by the bike owner. Not bad for a 19 year old young man. Today’s post ties in to one from may on one we did years ago on Emergencies 

Where did my finger go?

He and his manager were moving out the old tire machine for the brand new one the store bough. As they were lifting it on the pallet the old one came on, the bead breaker slipped out of position, dropped down and amputated his lift index finger between the 3rd knuckle and the nail bed. (Knuckles are counted from nearest to the hand to the finger tip. Think of drawing and angle from the cuticle backwards from that point at a 45 degree angle to the 1st knuckle. If folks have taken my classes or shooting classes from some of my friends, you have heard me say that a traumatic injury is not a painful as it looks. For a while at least.

According to Ryan it felt like he pinched his finger. Not to bad. He went to keep lifting and he looked down and saw the blood covering the floor and tire machine. His mechanic glove was torn and the end of it was missing. The body has amazing self preservation tools. I’ve know gunshot victims who were shot, walked down a flight of stairs with a suspect in custody, put them in the patrol car and then died.

First Aid

STOP THE BLEEDING! This cannot be stressed enough STOP THE BLEEDING. Even an injury like my son Ryan has can be dangerous if the bleeding is not stopped. When blood is spilled on the floor it looks 5 times as much as it is.

The blood loss Ryan had was about ¼ a cup 60 cc more or less. It looked like more. MUCH more. 2 fluid ounces is not much in the grand scale of the body. An adult will have approximately 1.2-1.5 gallons (or 10 units) of blood in their body. The average us 1.2 gallons or 5 liters

Now the scary part. The ½ cup of blood he lost was in the first minute! And it was not pure arterial flow. It was a mixed flow. The finger tips do not have large arteries in them The vessels are about 1/32nd of an inch in diameter (.79 mm). DIRECT PRESSURE.

Ryan has been trained extensively in first aid. Well he HIS my and his mom’s son. Growing up in a medical family has advantages. He squeezed below the wound and yelled he needed something to help hold it. His manager and the vendor grabbed shop towels and put pressure on it. Sat him down with his hand higher than his heart and called 911.

If at all possible retrieve the amputated part, wrap in clean cloth or sterile bandage material, place in a baggie, and place that baggie into one containing ice. This gives the surgeons the best chance of re-attachment.

To tourniquet or to not tourniquet.

There is a sorted history on the tourniquet. Lets go back to the 1980’s As an old medic, when we had a wound that needed a tourniquet, we put it on, marked a “T” on the patients forehead with date and time of application. If your patient was going to be with you for a few hours, every hour or so we would loosen the tourniquet for a short time to allow blood to the part below the tourniquet. The reapply it.

This did not work as well as expected. For a tourniquet to work it has to be tight. TIGHT. When it is applied correctly. Tissues will be damaged. When tissue is damaged there is swelling. We call it edema. So when we let off the tourniquet, let some blood down, then re applied it, the bleeding would stop and all was good in the world. Until the patient bled out. What happened was when the tourniquet was re-applied, it compressed the edema, and stopped the flow. But once the edema had been moved, the tourniquet was now loose…(continues)

Click here to read the entire article at The Medic Shack.

The Human Path: Herbal First Aid Kit

Sam Coffman, author of The Herbal Medic, at The Human Path has this video about The Herbal First Aid Kit.

Sam Coffman from The Human Path (an herbalism and survival school in Austin and San Antonio, Texas) explains the most fundamental concepts around creating and using your own herbal first aid kit. Sam’s experience as a former Special Forces Medic, while blending that world with herbalism, gave him some unique insights into making and using herbal first aid kits that are highly effective in a variety of situations. He uses the herbal first aid kit that The Human Path sells, as the starting point for talking about the packs, the containers, the herbs, the practicality of what works and what doesn’t, and why you would want to use an herbal first aid kit in the first place.

https://www.youtube.com/watch?v=PIhXY1q2cv4

Doom and Bloom: Heat-Related Emergencies

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

  • noaa heat index chart

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

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

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

    HEAT ISLANDS

    graph of temperatures from urban to rural

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

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

    HEAT WAVES ARE NATURAL DISASTERS

    man,it’s hot!

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

    HOW HEAT KILLS

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

    HEAT EXHAUSTION AND HEAT STROKE

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

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

    Heat exhaustion’s signs and symptoms include:

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

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

    heat exhaustion (left) vs heat stroke (right)

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

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

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

    Avoid giving fluids unless the victim is awake and fully oriented

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

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

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

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

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

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

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

Practical Self Reliance: 50+ Ways to Use Yarrow

An earlier post on elderflower mentioned its use in combination with yarrow and mint to fight fevers. Yarrow grows prolifically in our garden, filling in the edges and between rows. In damp conditions, it makes for a pretty soft ground cover — enough so that the kids want a yarrow yard. In this post from Practical Self Reliance, Ashley Adamant discusses many more uses for yarrow – 50+ Ways to Use Yarrow.

Yarrow is a common wild herb that’s useful in both the kitchen and medicine cabinet.  This list of yarrow uses covers everything from biscuits and beer to salves, soaps, and tinctures.

Yarrow uses

Yarrow’s always seemed magical to me, and I remember lounging in my room as a teenager, reading through 16th-century herbals and dreaming of the day I’d spot it in real life.  (Yes really, that’s actually how I spent my free time as a teenager.  I know, I’m such a nerd.)

The problem is, while yarrow grows ALMOST everywhere, I happened to grow up in one of the very few places outside of yarrow’s range…the Mojave Desert.  Now on my homestead in Vermont, it grows in every untended nook and cranny.  We’ll see our first yarrow blooms in early summer, and it’ll keep right on producing through fall, meaning I have a virtually unlimited supply of yarrow (even leaving plenty for the bees).

Yarrow Identification

Though yarrow is incredibly common, so are its look-alikes.  Once you’ve actually spotted yarrow, you’ll agree that the look-alikes aren’t really all that close.  There are lots of low growing herbs with white flower clusters, but yarrow really stands out in a crowd.

Start with the flowers.  They’re white, but not really.  If you were looking at paint samples, they’d have the name “Victorian white” or some other fancy title, because in reality, they’re a muted off white color.

Yarrow leaves are also distinctive, and there’s a reason its species name is “millefolium” or thousands of leaves.  The leaves are feathery, as opposed to the more distinct leaves of Queen Anne’s Lace and other white flowering herbs.

Identifying Yarrow by the feathery leaves and distinct white flower clusters

Make sure you’re 100% certain on your identification, as there are white-flowering plants within its range that are deadly toxic (namely, Water Hemlock).  To my eye, they don’t look anything alike, but as an optimistic teenager desperate to find yarrow in some stray ditch…I may well have made that mistake.

Read this guide to Yarrow Identification for more information.

Benefits of Yarrow

So why is yarrow so magical?  Many reasons!

A wide geographic distribution means yarrow made it into the traditional pharmacopeias in Asia, Europe and the new world.  Yarrow is used in everything from food and drink, to salves and tinctures, to ritual divination and ceremony.

This quick list will give you some ideas, but is by no means comprehensive:

  • Stops Bleeding
  • Skin Toner & Astringent
  • Bitter Tonic
  • Treats Cold and Flu
  • Lowers Blood Pressure
  • Improves Circulation
  • Induces Sweating
  • Reduces Fever

Be aware that while it’s generally considered safe, individual reactions are always possible.  It’s also contraindicated for pregnant women, as it can induce menstrual flow and possibly increase the risk of miscarriage.

Recipes for Cooking with Yarrow

While yarrow is perhaps best known for its uses as a medicinal, both internally and externally, it’s also a tasty culinary herb.  It’s not the only one of course, and many culinary herbs (thyme, sage, rosemary, and more) are potent medicinals, taken in the right dosage at the right time.

These yarrow recipes incorporate a small amount of yarrow, just enough to flavor the dish without reaching a “medicinal” dosage.

Recipes for Yarrow Beverages

Believe it or not, hops are actually a relatively recent brewing ingredient.  Before hops became common in beer, herbal beers, or gruits, were all the rage.  Yarrow was one of the most common brewing ingredients, and it was known to create an extremely intoxicating brew.

While hops are a sedative, that dulls the senses and slows the sex drive, yarrow based brews do just the opposite.  There’s a reason yarrow beers (and meads) were popular historically because they lifted you up and sent you home ready to put a few buns in the oven (if you catch my drift).

Our own homemade yarrow beer

Our own homemade yarrow beer

If you’re interested in learning to brew with herbs, specifically yarrow, I’d highly recommend the book Sacred and Herbal Healing Beers, which takes you through literally thousands of years of herbal brewing tradition (with recipes for each herb discussed).

The Wildcrafting Brewer likewise includes recipes for yarrow brews and approaches the subject more from a foraging perspective (rather than a historical one).

While the traditions have but been forgotten, a few brewers keep the traditions alive.  Here are a few yarrow beverage recipes to wet your whistle, both alcoholic and non.

Harvesting Flowering Tops for Yarrow Tincture

Harvesting Flowering Tops

Yarrow Uses for First Aid

My most common use of yarrow is as a first-aid treatment for bleeding.  Yarrow tincture in a spray bottle is a powerful astringent, and I’ve watched it pucker closed wounds in seconds.

I always keep a small spray bottle on hand just in case, and it’s worked wonders on all manner of small (but persistent) topical injuries.  It’s also made into styptic powder and DIY quick clot, for similar purposes.

Homemade Yarrow Tincture (Alcohol extract of yarrow)

Over the longer term, something like a yarrow salve is wonderful for treating injuries and promoting healing.  It’s also commonly employed as an itch remedy topically.

Making a yarrow salve is no different than making any herbal healing salve, and it comes together quickly with just a few ingredients.

Yarrow has been used for millenia to stop bleeding and treat minor wounds. A healing salve helps preserve the herb, and ensures that it's on hand when needed.

Yarrow has been used for millennia to stop bleeding and treat minor wounds. A healing salve helps preserve the herb, and ensures that it’s on hand when needed.

More yarrow uses for first aid:

Yarrow Herbal Remedies

Beyond yarrows use as a topical first aid remedy, it’s also commonly used in preventative remedies and internal medicine…

 

Continue reading at Practical Self Reliance.

 

 

 

 

 

 

 

See also this video from Cat Ellis, the Herbal Prepper:

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

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

Basic diagram of a suture (by medscape.com)

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

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

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

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

Basic diagram of a suture (medscape.com )

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

SWAGING

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

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

THE IDEAL SUTURE NEEDLE

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

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

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

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

NEEDLE TYPES

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

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

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

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

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

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

BODY SHAPES

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

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

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

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

The Medic Shack: Less Than Lethal Rounds. Are They?

Chuck at The Medic Shack has an article about Less Than Lethal Rounds, what damage they do and how to treat the wounds in the field. If you’re particularly squeamish to wound pictures, there are a couple of photos in the article which may disturb you.

Last time we were here, we talked about Chemical Defense. The week we move to things that can make a hole in you. This week its all about Less than lethal rounds.

What is the Rubber Bullet

The so called rubber bullet is not non lethal. It is a less lethal bullet. It has and will cause death if not used correctly or with malice.

A rubber bullet (LL round) is normally blunt to a flat tip. When it hits think of getting hit with a golf ball at close range. It will hurt like hell. Also it will cause massive bruising around the area of impact.

 

 

If fired at close range it will penetrate and act like a low velocity pistol bullet. It’s wound channel is wide and can cause severe damage to tissue, tendons, nerves and blood vessels.

If a person is taking blood thinners rubber bullets can cause severe bleeding under the skin which can be dangerous.

In 2016 a study was performed on the damage caused by rubber bullets. The results were eye opening to say the least. All images in this section are taken from the study

Pattern of rubber bullet injuries in the lower limbs: A report from Kashmir 

One thing noticed was when a LL round was fired at close range its wound channel was much larger than the bullet diameter. It was found that on impact a large portion of these rounds skewed sideways and a few tumbled a few times after impact…

As seen in the above image the wound is oblong, not round as one would expect. This tissue damage is seen though the wound channel.

Should You Remove a Rubber Bullet? Disclaimer

Before we go any further…

Use of the information on this site is AT YOUR OWN RISK, intended solely for self-help, in times of emergency, when medical help is not available, and does not create a doctor-patient relationship. We here can not diagnose, prescribe medication or treatments. We are not doctors, NP’s or PA’s

The information on this site is meant to be used only during times when improvisational, last-ditch efforts are all that is possible. When writing posts, the author often assumes that if anyone uses the advice, the person will have no access to regular medical equipment or supplies. This author always assumes that the person will not have access to professional medical care. DO NOT USE THIS INFORMATION WHEN YOU CAN GET MORE TRADITIONAL OR PROFESSIONAL CARE.

First off, see the disclaimer above. /\

Problems with Removing a Rubber Bullet

With that out of the way, the big question is, “Do I or Do I NOT remove the rubber bullet?”

Blindly probing around in a wound is dangerous. You can cause extreme bleeding by dissecting and/or damaging a blood vessel, such as an artery or a large vein. This can cause your patient to bleed out. It doesn’t take long.

You can also cause permanent and crippling damage to the person.

In the modern world when a bullet is removed, we take X-rays and CT scans. Ultrasound is also used to guide the surgeon to the object. It is NOT the toss the Bowie Knife on the fire and take a slug of whiskey and start digging.

Even in the worst of times I would usually clean the wound and then pack and dress it and let the docs with a MD degree or who came out of Ft. Sam Houston take out the bullet.

BUT…….

An old friend and mentor of mine who passed away about 15 years ago from pancreatic cancer taught me a lot about surgery. He told me that the best surgical instrument ever made was the index finger. He also said that the sharpest object one should ever put in the human body is, you guessed it, your index finger.

There were (and will be) times when a DUSTOFF was unable to come, or it was not in our best interests to go to a civilian hospital. If it was not in a dangerous area, I would remove one. Notice, I said I would remove one. I was trained in the best facility on the planet for combat medicine. The United States Army Medical Department and School, Fort Sam Houston Texas. as a 91B40.

However that is something that is too involved to cover safely and responsibly in a blog post. You really want to learn? Let’s get a class together and I’ll do a live, in person one. It is dangerous to do. And, without the proper training, you’d be a menace to your patient.

What we will go over is the first aid needed to treat these in the field and let the professionals do the fixing.

Treating a Rubber Round Injury In the Field

In a SHTF situation, the treatment of this is flushing the wound with copious amounts of saline. Water can be used, but an isotonic saline solutionis much more effectiveand a bit less painful than water. As a combat medic, I would flush a wound like this with a mixture of 500cc ( ½ quart) of saline and 30 cc ( 1 ounce) of Betadine. Using a 60 cc syringe or a turkey baster style bulb syringe

This is from a advanced class I taught on gunshot wounds, showing how I flushed the wound track in the tissue, (pork shoulder).

 

Let’s look at some real life wounds from the Kashmir report, linked to above…

LL rounds are NASTY. They HURT, and a lot of people after being shot with one refuse advanced medical care.

So lets talk about GSW care, MINUS the removal.

First you will need a REAL first aid kit. No not the 5.99 one from Walmart. A true blow out kit. These are a 1 time use kit that has only the items you need to stop the bleeding of a GSW (Gun Shot Wound).

This Kit, Everlit Emergency Trauma Kit is a decent kit.  It has everything you need to treat a variety of traumas. This stuff is not cheap. The trauma kit with chest seal will set you back  70 bucks or so. And, it is a one time use.

Yes, there are cheaper. And, there are much more expensive. This set up is a mid-range kit that fills your needs. You will see kits with many different style of tourniquets. This one comes with the industry standard. the Combat Action Tourniquet (CAT). In my opinion there is none better.

Train with Your Kit

So you have this kit. Pop Quiz Medic. What do you do with it?

Grab the Israeli bandage from the kit, or this 6 inch Israeli compression bandage. Open it and practice putting it on.

The kits come with a CAT tourniquet, and it is reusable. But, having 2 is better (remember, 2 is 1 and 1 is none). Here’s an extra CAT Tourniquet.  Practice putting one on…

 

Doom and Bloom: Suture Basics for the Off Grid Medic

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

suture basics

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

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

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

THE IDEAL SUTURE

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

The optimal suture should be:

·           Sterile

·           Easy to use

·           Strong enough to hold wound edges together

·           Able to retain strength for the time needed to heal

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

·           Reliable in its everyday use with every type of wound

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

TISSUE HEALING

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

Days: Muscle, subcutaneous tissue like fat, and skin

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

Weeks to Months:  Fascia or tendons

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

CATEGORIZING SUTURE DIAMETERS

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

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

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

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

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

ABSORBABLE SUTURES

Absorbable chromic gut suture

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

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

plain “catgut”

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

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

Newer absorbables are synthetic. These include:

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

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

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

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

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

NONABSORBABLE SUTURES

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

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

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

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

Nylon monofilament suture

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

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

Braided surgical silk suture

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

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

The Medic Shack: Triage

Chuck at The Medic Shack has an article introducing people to the concept of Triage.

Triage. An introduction to combat medicine.

Welcome to the next level of preparedness. Trauma. Trauma can come from many sources. A slip with an knife in the kitchen. A smashed thumb in the workshop. A terrible cut from a chainsaw. Being at the wrong place at the wrong time and caught up in a riot. Now add in those same injuries, but multiply times 10. You now have a MCE. Pick the scenario. It can happen. Learning how to prioritize, delegate, investigate, assess and treat are skills anyone can learn.

Applying them with out emotion is a different beast altogether. It is doable. One of the hardest things to master in triage is seeing the injuries, and not getting personal with them. Another is being able to itemize the injuries, almost coldly and place them in the order of severity, and the order of treatment.

This is a HUGE deviation from the basic first aid that we talk about. With the fast moving changes sweeping the country and the world, Cat from The Herbal Prepper and I decided that we need to change up some of our topics and delve into more advanced lifesaving.

A word of warning and disclaimer. We are not doctors. We can not diagnose, prescribe or treat injury nor illness outside of a SHTF situations. This blog post is for informational use only. Pagan Preparedness, nor the owners, operators, instructors or author’s claim any responsibility for people using this information in any manner.

Glossary of terms

MOI= Method Of Injury

LOC=Level Of Consciousness

LOR = Loss of Resistance

MCE Mass Casualty Event

Triage= The process of sorting people based on their need for immediate medical treatment as compared to their chance of benefiting from such care.

The military triage flow sheet.

This is the method I used as a combat medic. There are terms here that people may be uncomfortable with. Items like balancing resources that you have now, to what you may have to what benefit it will give the patient, AND what loss/benefit of the expending those supplies will have on the group

Triage Decision Flowchart

Triage Decision Flowchart, showing the five steps in the triage process.

Step 1: Remove GREEN patients. Get help, you can’t do it all yourself

ASSESS:

2: MOI

3: LOC

4: Breathing.

 

Always remember. There are many more patients than rescuers.

Triage is designed to separate patients into categories according to their injuries, level of consciousness , and yes even if they are alive. It is important to do the examination quickly but be very complete with it. Lives depend on it. This is one the things that gives us medics bad dreams. At the triage station you may have to make a decision on if someone lives or dies.

The triage that we’ll go over here, is slightly different than what one will see in the local emergency room. The basics are the same, but the application of a hostile or dangerous environment adds a new level of difficulty,

An example of the difference between combat and civilian triage is the Boston Marathon bombing. The civilian medics on site risked their lives and rushed to the aid of the victims. And treated them where they fell. There also was a detachment of Army Medics to support the Army team running. They risked their lives and rushed to the aid of the victims AND SNATCHED THEM UP AND BROUGHT THEM TO SAFETY BEFORE TREATING THEM. The civilian medics triage and treated on site. Military medics, train to if at all possible get the victim to a safe or at least safer area before triage or treating…(continues)

Human Path: Making your own Herbal Medic First Aid Kit – Online Course, Aug. 2020

The Human Path is hosting an eight hour, online course on Making your own Herbal Medic First Aid Kit Aug. 3 – 16, 2020 for $100 ($65 if you register by July 13).

Making your own Herbal Medic First Aid Kit

Building your own first aid kit can be a daunting task – trying to find the best pack to hold your gear, keep the weight manageable and have all the equipment you need in one place..

It even becomes more complicated when you want to add herbal remedies to your first aid kit.

Do you know the essential equipment you must have in your kit?

Do you know the best type of packs to use for small, medium and large first aid kits?

What are the most important herbal first aid preparations to include in every kit and why?

Do you know how to improvise bandages, splits, packs and kitchen first aid herbs?

This is an 8-hour course that includes lectures, videos and resources on:

FIRST AID KIT CONTAINERS

  •  The top three items every kit MUST haves
  • Improvisation – making a great herbal first aid kit from containers EVERY household has
  • How a kit opens and why this is important
  • Compartmentalizing: containers within containers
  • Sizing and weight
  • Car kits, work kits, go bags and mini (every day carry) kits

ESSENTIAL TRAUMA FIRST AID SUPPLIES

  • Necessary bandaging equipment from minor to life-threatening
  • Wound & burn management
  • Sharps from A to Z
  • Hydration, nutrition and recovery
  • First aid improvisation: using materials on hand for your kit (and in emergencies when you have no kit)

MUST-HAVE HERBAL PREPARATIONS

  • Infection control for respiratory, UTI, Gut and Skin
  • Nervines/Adaptogens for anxiety and trauma
  • Immune supportive herbs for medical emergencies
  • Venomous bites and stings
  • Salves and powders (which to use, when and contraindications)
  • Working with herbs you probably have in your kitchen

The Herbal Medic First Aid Kit Course will include eight hours of video lectures, resources for supplies and materials, slideshows and handouts.  Students will also receive access to ‘The Top 25 herbs for the end of the world’ pdf and the ‘Building Your Own Herbal First Aid Guide’ pdf for download. 

In addition, students will be mailed two full-size glossy 11”x17” posters:  “First Aid Kit Essentials” and “Herbs for Emergency First Aid”. One of these posters includes an organized and visual layout to help you understand what to pack in your first aid kit and how to organize it, whether you know nothing about first aid or you are a medical doctor. The other poster includes an organized structure that will help you pick the most essential herbs you need for your kit, with over 50 herbs spanning multiple health care issues from acute to chronic!

This incredible online course will open on August 3rd with 60 days access. All course materials can be downloaded for personal future reference and use, and the posters will ship out on receipt of tuition.

Dates: The online classroom access will open on August 3rd, 2020, with materials made available for download.

Live Session TBA.

Registration will remain open until August 16th, 2020.

Location: This is an online class – you do not have to be in our area to participate! You only need access to the internet to take this class.

Click here for the class info and registration page.

Columbia Safety Holding Classes Again

Medical skills trainer Columbia Safety of Kennewick, WA is holding classes again. You can check out their calendar of classes here. Retired St. Louis police captain David Dorn was murdered earlier this week, shot by looters breaking into a friend of Dorn’s pawn shop. Some of the incident had been posted as video to Facebook. I watched a good portion of the video. He was conscious and while he was verbally encouraged to stay alive, he didn’t appear to have received any first aid. While I don’t know if rapid first aid would have saved his life, it is a good reminder that 20% of people who have died from traumatic injuries could have survived with quick bleeding control. Please take a Stop the Bleed or first aid course!

Some courses coming up:

Red Cross Adult and Pediatric FA/CPR/AED – Sat, June 13, 9:00am – 3:30pm

Stop The Bleed – Mon, June 15, 6pm – 9pm

Red Cross Adult FA/CPR/AED Hybrid – Tue, June 23, 1:00pm – 2:30pm

Stop The Bleed – Wed, July 15, 6pm – 9pm