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.

Survivopedia: The Beginner’s Guide To Essential Oils

From Survivopedia, The Beginner’s Guide To Essential Oils

Throughout history, people have used essential oils for a variety of applications.

In Ancient Egypt, they were used for religious ceremonies. The Greeks and Romans used them aromatically. And ever since, they’ve been integrated into society.

Today many people use essential oils daily, for several different purposes. Let’s take a quick look at what essential oils are, which ones are good for beginners, and how you can use them.

What Are Essential Oils?

Essential oils come from plants. After harvesting, the plant material is distilled down, creating a pure compound. It’s very aromatic and powerful. These oils are then bottled, so you can store them for use.  They evaporate quickly, so always make sure your lids are on tight.

Want to make your own essential oils from herbs you grow? Check out this post for step-by-step directions.

Because essential oils are so concentrated, they need to be diluted before using. This means the tiny bottles you purchase end up lasting quite a while. You only use a few drops at a time.

Top 10 Essential Oils for Beginners

Name a plant, and you can probably find essential oil from it. There are so many types available. You can also mix your oils, to create combinations.

It’s best to start small. If you are new to essential oils, don’t feel like you must buy them all at once. Pick a couple you think you can get the most benefit from. Then slowly add to your collection.

Here are the top ten essential oils I recommend for beginners. These are the ones that are in my cupboard, and the ones I frequently use. I list the common name and the scientific name for each of them.

I also share a couple of benefits of each. This is not even close to being an inclusive list, just a quick guide to get you started.

Finally, you’ll find a link to one scientific study for each of the oils I recommend. You can dive into the research on your own and see just how beneficial essential oils can be.

1. Peppermint (Mentha x piperita)

Peppermint is revitalizing! It helps improve exercise performance[1]. This essential oil has been shown to help with nerve pain, stomachaches, and bruising.

2. Sweet Orange (Citrus sinensis)

The sweet smell of orange is calming. Sweet orange essential oil is used to reduce anxiety[2], reduce inflammation, and provide antiseptic properties.

3. Lemon (Citrus limonum)

Lemon essential oil helps relieve stress[3]. It also supports the digestive system and is thought to improve circulation.

4. Eucalyptus (Eucalyptus globulus)

This oil has a unique, almost woodsy scent. It’s very strong. Eucalyptus has been used as a natural antibiotic[4] throughout history. Many people use it for respiratory problems, and to relieve pain from arthritis.

5. Tea Tree (Melaleuca alternifolia)

You can use tea tree oil to help treat head lice[5]. It’s also thought to fight bacteria and help relieve shock.

6. Lavender (Lavandola angustifolia)

One of the most popular essential oils, lavender has many therapeutic uses. It’s soothing and can help relieve stress.  It’s thought to help relieve migraines[6] and stabilize moods. Lavender also has antimicrobial properties.

7. Oregano (Origanum heracleoticum)

Oil of oregano is used to treat wounds[7]. It has anti-inflammatory properties, making it a good choice for skincare products. It also is an immune booster.

8Clary Sage (Salvia sclarea)

Clary sage is a natural antimicrobial agent[8]. It can help lift the spirits and reduce stress. Many women use it to help with menstrual cramps.

9. Rosemary (Rosmarinus officinalis)

You can use rosemary essential oil to boost your memory. It’s shown beneficial as part of a treatment plan for patients with Alzheimer’s[9]. Additionally, rosemary is thought to relieve pain and improve circulation.

10. Ginger (Zingiber officinale)

Ginger helps relieve inflammation in the body. It helps alleviate nausea[10] and can be used to help digestion.

Where to Buy Essential Oils

There are different qualities of essential oils. You always want to read the ingredients before you purchase, and make sure you are happy with what’s in the bottle you’re purchasing. You don’t want any fillers or artificial oils added to them.

You can find decent essential oils on Amazon. There are several beginner packages that are a good place to start. I do recommend going with organic essential oils.

Alternatively, you can purchase from a direct sales company. There are several of those.

I’m not going to tell you which kind to buy. Find one you like and go with it. You can always change later.

How to Use Essential Oils

Once you have your essential oils, what can you do with them? Let me show you some of my favorite ways to use them.

Inhale

Perhaps the easiest way to get some benefits from your essential oils is to simply unscrew the cap and breathe deeply. You can add a drop or two to a cotton ball and keep in your pocket. Then whenever you need a mental boost, you can pull it out and inhale.

Add to a Bath

You can add a few drops of essential oil to a warm bath.

Diffuse

Looking for a simple way to experience some benefits of essential oils? Pick up a diffuser and select an oil. Let the diffuser release the scent into the air and take a deep breath…(continues)

Click here to read the entire article at Survivopedia.

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

Survivopedia: Are We Looking At The Wrong Numbers?

Bill White at Survivopedia writes about some of the numbers that aren’t being talked about much related to the current coronavirus pandemic – people with permanent damage who didn’t die – Are We Looking At The Wrong Numbers?

As the second wave of COVID-19 continues sweeping the nation, it is becoming even more politically polarized than ever before.

This is sad to me, that we can’t unite over something that is really not a partisan issue but is affecting us all. Our focus, all of us, should be on doing what is best for the people of our county; and that includes both protecting their health and protecting their ability to provide for their needs, financially speaking. The two are not mutually exclusive.

But that’s not what’s happening. Those on the political left are trying to use the pandemic to make Trump and Republican governors look bad, focusing on the rise in cases, as we wade through the second surge. It doesn’t matter that this second surge was part of the plan all along, as the original lockdowns were just about flattening the curve, in their narrative, the surge has to be because of some grave error in judgment on the part of their political enemies.

Then we’ve got the political right, many of whom are focusing on how the left-leaning media is overreacting and overstating the danger of the current situation. Sadly, they aren’t serving us any better, when they’re saying that we shouldn’t have to be wearing masks. Yes, I understand their position that the government is infringing on our liberty, but at the same time, I’ve got to say that there’s enough evidence that masks help save lives, that it makes sense to do so.

The argument that’s being used is that only one percent of the people die of COVID-19. But just what do they mean by “one percent?” If they’re talking 1% of the people who come down with it, the numbers don’t jive. We’ve had 4,170,000 people come down with the disease and 147,342 deaths as of this writing. That works out to 3.53% of total cases ending up in death.

But we need to realize that 3.53% is a low number. Even if nobody else comes down with the disease, some of the 2,042,559 active cases will result in death. We just don’t know how many. If we divide the number of people who have died by the total number of closed cases, we get 6.9%. That’s probably too high. When all is said and done, the death toll will probably end up being somewhere between those two percentages; we just don’t know where.

On the other hand, if they’re talking about one percent of the total population dying from COVID-19, then we’re talking 3.31 million people. Since we have no idea of how many total people are going to come down with the disease, that number is not outside the realm of possibility. I personally don’t think it will get that bad, but I can’t discount the possibility…

o start with, for every person who dies of COVID-19, there are 19 others who require hospitalization. That’s a hard number, which can be substantiated by hospital records. So the 147,342 people who have died become 2.8 million who have been hospitalized. Unfortunately, I can’t find any data to substantiate that; as everyone is reporting hospitalizations on a weekly basis, not a cumulative total; and I can’t just add those up, because we don’t know how long any of those people have been in the hospital.

So let’s use that 2.8 million number for now. Supposedly for every person who dies of COVID-19:

  • 18 people will have to live with permanent heart damage
  • 10 people will have to live with permanent lung damage
  • 3 people will end up having strokes
  • 2 people will have to live with chronic weakness and loss of coordination due to neurological damage
  • 2 people will have to live with a loss of cognitive function due to neurological damage

Granted, I’m sure these numbers are preliminary and they will be modified in the future, as our medical community gains more information. But we’re talking about the potential for all of those 2.8 million people having to live with some sort of permanent or semi-permanent disability. And that number is only going to go up, as we’re nowhere near the end of this pandemic if an end actually even exists.

If we take the viewpoint that one percent of the population is going to die of COVID-19, as some are saying, then we’re looking at a total of:

  • 3,311,000 dead
  • 59,598,000 with permanent heart damage
  • 33,110,000 with permanent lung damage
  • 9,933,000 who have strokes
  • 6,622,000 with permanent weakness and lack of coordination
  • 6,622,000 with permanent loss of cognitive function

Obviously, we can’t afford that as a nation. While I’m sure that there will be a considerable amount of overlap, with people having more than one of those symptoms, that just means that those who do have long-term effects will be in that much worse shape. And before you say it will just be old people, I know people in their 20s who have come down with COVID and are still battling these sorts of long-term symptoms two to three months later.

When I say we can’t afford that, I’m referring to the loss in our labor force. While a large percentage of the people who have serious problems with COVID-19 and die are elderly people with underlying health problems, more and more younger people are having serious problems with the disease. Are those young people going to become disabled and end up needing public assistance their whole lives? (continues)

Click here to read the entire article at Survivopedia.

Organic Prepper: What It’s Really Like to Work in a COVID Ward

Chuck Hudson, a friend of Daisy Luther of The Organic Prepper, who works at Roper St. Francis Healthcare, Roper Hospital in South Carolina takes time to write about what it is like to work in a COVID ward there. Because some people still believe that COVID-19 is entirely a hoax without any patients or full hospitals, Daisy had to preface with the article with her statement about Chuck being a personal friend of hers, so that people don’t think it’s some kind of planted fake story.

Editor’s Note: This article was written by a personal friend of mine. This isn’t some stranger who wrote to me to share some story that may or may not be true. This is a man I’ve known for years who has dedicated his entire career to caring for the health of others. In this essay, he shares an average day in the COVID ward of the hospital where he works. ~ Daisy

COVID virus has turned the world upside down. From the economy of the planet to pitting neighbor against neighbor and friend against friend. Never mind the violence destroying our cities. We are all dealing with this virus with totally unbelievable numbers, huge numbers of infected people, and a rising death toll.

Yet, I look out my living room window and see green grass, flowers blooming and some kids down the street playing basketball.

And then, I go to work.

The area where our day patients come in is called 2HVT. All 14 rooms of 2HVT are now negative pressure rooms. (Also called isolation rooms, negative pressure rooms help prevent airborne diseases from escaping the room and infecting others.) All the rooms of the old Cardiac ICU, which is attached to our cath lab by a short hall, are now negative pressure rooms. 4 South on the 4th floor is now a COVID unit. 6 south, an old Ortho ward, and 5 South have been converted as well. All these conversions are in the downtown hospital alone. All patient areas of the 3, newer hospitals in the system have been converted to handle COVID patients.

Watching the news here in my new home state of South Carolina, no matter the station, it is the same thing: doom and gloom. More and more infected people from testing, talking heads pointing the finger of blame, and numbers being sensationalized. After all, “If it bleeds it leads.” It’s gotten so bad that I turn on the news just long enough to catch the weather and traffic for the morning drive from Summerville to Charleston.

But enough of that. Let me tell you what it is really like in the COVID step-down unit. This unit is for people not sick enough to need high flow O2 or intubation, yet too sick to go to a “regular” floor. (Like there is a regular COVID floor!) As with any floor, the “permanent “ nurses and techs get morning reports from their night shift counterparts. After getting the reports we start our rounds with the patients.

Wait…no, we don’t just walk into a COVID room.

It takes about 3-5 minutes to gear up before entering a room.

Step 1 put on a set of gloves.

Step 2 Put on impermeable gown.

Step 3 Put on N95 mask.

Step 4 Put on face shield. ( We 3D print the frames for these. And use pieces of acetate we get from Staples. )

Step 6 Put on 2nd set of gloves.

Step 7 Triple check that everything is sealed and in order.

Now…we can go in the room.

We try to allow only 1 person at a time in the room, unless something demands that 2 people are needed. The nurse or tech who goes in the room does not leave the room until they have completed all tasks. If the nurse or techs needs something this is where I come in. If I am not assigned a patient, I run and get things. We are runners. We run and get whatever is needed.

What about emergencies?

Same procedure.

We have Mayday bags stapled to the wall in front of each room. Each of these Mayday bags contains the following:

  • 2 N95’s: small and regular
  • “Bunny Suit”
  • Face shield (We 3D print face shields in-house)
  • 6 pairs of separately bagged gloves (sm, med, lg)
  • Bouffant hat

All of this must be put on prior to entering a room. It is mandatory. Even if the patient is dying.

Very little is talked about…so much to tell.

Even the little things that the patients and the staff endure take a huge toll on us.

A majority of our patients have lost their sense of taste and smell. Some can only sense texture and temperature. This makes it difficult and frustrating for our patients and staff. The food delivered to our COVID patients is left at the “Airlock”. In normal rooms, insulated containers can be used for the food, keeping it hot. However, food in the COVID areas must be served using only paper plates, paper cups, paper serving trays and plastic ware. We have to use a microwave to heat the food just before it goes in the room.

In normal rooms a tech, nurse or CNA brings the food to the patients. In our world, only the assigned nurse or tech brings the food. And it may be a LONG wait due to having to microwave the food just prior to going in. We have to coordinate routine care to keep the number of times a room is entered to a minimum. (I have become an expert at microwaving paper plates of hospital grade food!)

One thing the virus does that many people outside of the medical field don’t know is it interferes with the blood clotting cascade. Believe you me, as a former Medical Lab Tech (MLT) I would LOVE to go over in mind-numbing detail the 12 steps of clotting. The intrinsic and extrinsic pathway that lead to a fibrin strand…”OUCH!” (My wife just tossed a crafts magazine at me. I started describing the steps. In detail.)

So, in addition to damaging the lungs, COVID can cause deep vein thrombosis. It also causes DIC (Disseminated Intravascular Coagulation.) Post mortem exams have revealed up to 30% of early COVID patients had elevated D-Dimer, C-reactive protein and lactate dehydrogenase. All markers for clotting system problems, which has led to death by stroke, even in young people.

Some patients are in denial until the last moment.

Recently, I was helping to discharge a fairly young patient, about the mid to late 40s. As I was getting his history and gathering information on his experience, I asked how he ended up in ICU and then in my area.

He told me he thought he had a summer cold. He thought the whole virus was a hoax and refused to wear a mask. When his wife brought him in he thought it was a bad cold AND an ulcer. He complained of stomach pain, severe diarrhea, and shortness of breath. He was admitted to our COVID floor, still in denial. What he had believed was a stuffed up nose was actually him losing his sense of smell. Then he crashed.

The anesthesiologist did what is called rapid sequence intubation. The patient is given sedative and paralytic drugs. That’s it. Once they are intubated, they are put out.

He told me when they jerked his head back and he saw that the young doctor looking scared though his protective gear he knew then it wasn’t a hoax.

Good news: we ARE saving more than we lose.

Here in Charleston where I work, our average patient stay is 4 days. If they go to the ICU their stay is about double that. In the last 3 weeks we have dropped from 44% to 31% of our inpatients being in for COVID. Our percentage of positive COVID tests is at about 21%. We test EVERY PATIENT that comes in the hospital.

We have a game plan:

  • Remdesivir
  • Lovanox
  • Plasma antibodies from COVID survivors
  • Intervene and intubate
  • ECMO: Extracorporeal membrane oxygenation (to treat some patients)

We have a long way to go. We still have shortages of protective gear, but we improvise, adapt and overcome. Up to 170 or so of our teammates, young and not so young,  have been out with COVID. Some ended up in the ICU. Our hospital is finding ways to use senior management. A large group of nurses that haven’t been bedside in years are filling in as runners, housekeepers, and patient transport.

This is part of a corporate email from this past week. (Patient sensitive information has been removed.)

Roper St. Francis Healthcare has tested and confirmed that 46 more patients since Tuesday have COVID-19, bringing our total to 3,806 since the beginning of the pandemic. 

Once each week, we will provide additional information about our testing and which segments of the population are most affected by the virus.

In the past seven days, 19 percent of our 3,014 COVID-19 tests have been positive, which is down from our 22 percent positive rate during the past 14 days. Our overall positive rate since we started COVID-19 testing is 15 percent. We have 949 tests pending.

Of those testing positive in the past seven days,

– 19 percent are under 29 years old

– 15 percent are 30-39 years old

– 12 percent are 40-49 years old

– 17 percent are 50-59 years old

– 16 percent are 60-69 years old

– 20 percent are over 70 years old

Thirty four percent of those patients have been white, 44 percent have been Black, 5 percent have been Latino and 16 percent have been other.

The areas where we’ve seen the largest number of new cases are North Charleston, Charleston and Summerville.

There have been 3,882,167 cases nationally with a total of 141,677 deaths, according to the federal Centers for Disease Control and Prevention. South Carolina has had 73,101 confirmed cases and 1,203 deaths.

Hero’s? Nah…We signed up for this because we wanted to help.

I’m not going to berate, belittle, or bully anyone over their choice when it comes to personal protective equipment. I am going to ask that you be careful. You do not want someone like me or my old Ranger bud Johnny doing CPR on you. You will end up with damaged ribs.

I’m pretty blessed to be working at Roper St. Francis Healthcare, Roper Hospital. We show up to work each day to care for our patients, and we go home to rest up a little before doing it again the next day. Some of us, myself included, don’t care much for the term “hero”. It is MY job to take care of YOU if you end up in OUR hospital. It is YOUR job to stay healthy, be careful, and be smart about this virus.

Doom and Bloom: Heat-Related Emergencies

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

  • noaa heat index chart

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

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

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

    HEAT ISLANDS

    graph of temperatures from urban to rural

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

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

    HEAT WAVES ARE NATURAL DISASTERS

    man,it’s hot!

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

    HOW HEAT KILLS

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

    HEAT EXHAUSTION AND HEAT STROKE

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

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

    Heat exhaustion’s signs and symptoms include:

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

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

    heat exhaustion (left) vs heat stroke (right)

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

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

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

    Avoid giving fluids unless the victim is awake and fully oriented

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

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

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

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

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

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

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

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

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

Basic diagram of a suture (by medscape.com)

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

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

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

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

Basic diagram of a suture (medscape.com )

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

SWAGING

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

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

THE IDEAL SUTURE NEEDLE

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

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

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

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

NEEDLE TYPES

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

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

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

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

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

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

BODY SHAPES

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

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

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

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

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: Covid Fatigue and the Second Wave

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

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

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

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

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

Not an example of social distancing

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

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

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

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

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

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

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

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

Doom and Bloom: Suture Basics for the Off Grid Medic

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

suture basics

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

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

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

THE IDEAL SUTURE

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

The optimal suture should be:

·           Sterile

·           Easy to use

·           Strong enough to hold wound edges together

·           Able to retain strength for the time needed to heal

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

·           Reliable in its everyday use with every type of wound

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

TISSUE HEALING

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

Days: Muscle, subcutaneous tissue like fat, and skin

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

Weeks to Months:  Fascia or tendons

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

CATEGORIZING SUTURE DIAMETERS

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

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

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

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

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

ABSORBABLE SUTURES

Absorbable chromic gut suture

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

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

plain “catgut”

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

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

Newer absorbables are synthetic. These include:

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

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

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

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

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

NONABSORBABLE SUTURES

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

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

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

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

Nylon monofilament suture

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

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

Braided surgical silk suture

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

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

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