Thursday, January 31, 2013

Casualty/Trauma Care & Supplies In Austere Conditions

Per a request to MDs and SF 18Ds (of which I am neither, being instead a trauma nurse of some years' experience) on John Mosby's "mountain guerrilla" blog, I offer my two cents:

Under the heading of “What would you want to pre-stock/cache to care for casualties with moderate to severe trauma under semi-austere conditions?”

Rather than go all Pollyanna, I’m going to be blunt: The first thing you’re going to need, to quote Col. Trautman from “First Blood”, is “A large supply of body bags.”
Major trauma and gunshot wounds (GSWs), under field conditions, have a much higher likelihood of turning live people into dead ones, despite all your efforts. It’s not a certainty, but the likelihood is much greater, so let’s deal with worst things first. You absolutely need, along with the mental and emotional toughness to deal with this fact, the physical ability to properly bag and tag the remains, and inter them without creating a pandemic among caregivers and survivors. Plague, cholera, typhoid, and a host of other medieval ailments await humanity if you can’t accommodate this eventuality. So casualty bags, a place to bury them, and a crew of people to do it, will have to be provided for. Both Korean War M.A.S.H. hospitals and their modern 21st century equivalent have a Graves Registration Unit, for good reason. You also need to record the deaths, and mark the graves – overtly or covertly – so that next of kin might have some opportunity to recover the remains in better times.

That leads to a need for chaplain(s) or equivalent, to perform the associated rites and rituals. They serve dual duty for those not imminently leaving this world for whatever might come afterward, and such care can have a great impact on casualty recovery. I don’t care if you’re personally an atheist, literal piles of documented peer-reviewed studies underline the point that physical casualties need spiritual care. Do not neglect this aspect if you want optimum outcomes.
You’re undoubtedly going to have personal effects, as well as weapons and gear from said casualties, so you’ll absolutely need to have the people and space to deal with, store, inventory, and be accountable for safeguarding and/or passing along such items, with absolute integrity.

Then there are the casualties themselves, and their care, which was certainly the main reason for the query.
Once you move beyond primary care for injuries and wounds during the first hours or day, your patients’ concerns balloon from mere initial treatment to the full range of human survival: you now have to deal with hydration, nutrition, elimination, cleanliness and personal hygiene, as well as continued medical management, wound care, infection control, and other therapies.

In short you’re now looking at creating a hospital, at minimum, however primitive, and at most essentially re-creating an entire healthcare system continuum, whether you meant to or not. The alternative is to shoot your wounded.
Hospital Rule One: Cleanliness Is Next To Godliness. As was demonstrated in the Crimea by Florence Nightengale, or the American Civil War by Clara Barton, and every conflict before or since, clean patients and wards heal, and dirty ones kill.

So immediate needs: Betadine, bleach, Bactine, hydrogen peroxide, isopropyl alcohol, Lysol, Cavicide disinfectant (or equivalents). Sterile dressings and clean bandages (dressings are what you put on the open wound, bandages hold the dressing in place, thus the latter only need to be clean, while the former need to be sterile). Silk, plastic, and paper adhesive tape. Q-tips. Penrose wound drains. Ace wraps, Iodoform gauze, sterile surgical gloves, drapes, and sponges. Clean exam gloves, patient gowns, slippers, sheets, blankets, towels, washcloths, basins, bedpans, urinals, commodes, sponges, toothbrushes, combs, disposable razors, soap, shampoo, lotion, water pitchers, cups, meal trays, dishes and utensils. Enema supplies, sterile urinary catheters in a range of sizes and collection bags.

{Edit addition: And lest we forget - like I did - you need a means of disposing of poo, pee, dirty diapers, gowns, sheets, bloody and pus-filled bandages, and all other assorted nastiness, far from patients, food, water supplies, and anyone you have any regard for. "Red bags" for biohazardous waste are only the beginning of solving your problem, not the ultimate solution. Just as in Rawlesian survival, think systems, not just a list of stuff.}
BP cuffs, thermometers, stethoscopes, and at least a basic drugstore pulse oximeter. Ideally otoscope and laryngoscope, plus disposable speculums and tongue blades.

A host of over-the-counter (OTC) meds. IV fluids, poles and hooks to hang them, administration kits, tubing, catheters, etc. (Most of which is Rx.) All the oral antibiotics you can lay hands on. Other Rx meds if you can get them legally and store them safely.*
You’ll need “holy water”. Q.: How do nuns make holy water? A.: they boil the hell out of it.

So a water supply, the equipment/capability to boil water, do piles of laundry, sterilize instruments and equipment, wash hands, and bathe, cook for, and feed a patient/patients for days or weeks.
Food stores, and the ability to heat/cook/prepare them. Vitamins, both multi and individual types. Supplemental and homeopathic remedies.

Splinting and casting materials, crutches, slings, braces,  post-op shoes.
Surgical instruments (both reusable and disposable), a full range of sterile suture materials.

Higher-end: Laboratory-quality microscope, test tubes, slides, centrifuge, and associated lab equipment. Refrigeration capability, and blood collection/storage/transfusion equipment.
Top-drawer: Cardiac and/or vital signs (VS) monitor/defibrillator, and some X-ray/ultrasound capability (dream list, and a tad pricey, but doable, and since you asked…).

And hopefully a surgeon and/or ER doc, physician assistant, nurse(s), orthopedist/physical therapist, pharmacist, homeopath, nutritionist, etc. to help you take advantage of all of it, as well as the cooks, laundry, orderlies, and associated minions who do the grunt work. Even if it’s just one or two people, but obviously, the more people you can staff, the better you’ll do. And all the notebooks, paper, pens/pencils, and index cards you can get to keep charts on your patients. At a minimum, so that the person who takes over the next 12 hour shift for you while you or the doctor sleeps knows what’s going on with the patient, what to do/not do, and so you do too when you take over again after them.**
I didn’t go into quantities for any of the above, because whether you acquire 2 or 200 of something depends upon resources, storage space, etc.

Lest this sound extreme, it can be readily accommodated bare-bones in an average two-bedroom house if it were a dedicated care station, and it’s pretty much the range of supplies/equipment I’ve had at my disposal in ERs ranging from basic 2-bed units, up to world-class 60+ bed Level I ER/trauma centers. Imagine a widow/er in a large house with 2-3 spare bedrooms and ideally a full basement with an empty garage (let alone farmhouse/ranch with a bunkhouse and full barn with basic indoor plumbing! Happy day!), and you or I could set up a full-on clinic/mini-ER/surgery/recovery ward for as long as food, water, and expendable supplies and medicine held out, sufficient to care for a battalion of troops and/or a town from 500-1000 people pretty easily. All it takes is space and money, just like pretty much everything else in life. You could do it as small as one dedicated treatment room in a large bedroom, but there are economies of scale, and trying to do everything in a space the size of a 20’ Conex container is barely possible, but it’s a distant third choice, IMHO. I think it’s kind of geometric: If you allot 2x the resources compared to a medic with a cot and an aidbag, you can probably do 4x as well. If you allot 5x the space/equipment, you can do 25x as well, and so on.
Some quality references are the “Special Operations Forces Medical Handbook, 1st or 2d Ed., ca. 2008” (not to be confused with the ubiquitous, somewhat helpful, but woefully obsolete and outdated SF Medical Handbook ST 31-91B from ca. 1982 or so), and “Survival Nurse”, by Ragnar Benson, which is a decent if minimal overview on setting up a basic casualty care mini-facility in rugged conditions. An especially ideal one specifically for this topic is "Improvised Medicine: Providing Care in Extreme Environments " by Iserson, 2012, which is precisely geared towards pulling a hospital out of your back pocket in crappy locales or after disasters and other extreme events. And at least one comprehensive textbook of standard nursing practice by Mosby, Lippincott, etc. Along with all the CURRENT physician/medical references you can acquire, from textbooks to periodicals, hard copy, CD, digitized, and any videos/DVDs/BDs of care, procedures, etc. The obvious step beyond setting up such a capability is to make it, so much as possible, a “teaching” facility, so that you can start multiplying and disseminating the knowledge to as many people as possible, both to better care for your patients now, and to ensure the capability isn’t lost. “Two is one, and one is none” works for hospitals, doctors, nurses, etc. just as well as it does for shovels and bug-out bags.

*Meds, which are probably 50% of modern Western medicine, are another huge issue, especially regarding pain control. I realize we’re talking about operating in an insurgent or post-zombie apocalypse environment, but in preparing for worst cases, it’s worth noting that an illegal stockpile of minor narcotic pain relievers stored with one firearm, now, could get you enough federal enhancements at sentencing to pretty much screw the rest of your life and twenty other peoples’. Due diligence and common sense are called for.

** I’m not, at this point, going into all the specialty items for care regarding eyes, ears, nose, and throat concerns, or dental injuries, or burn care, or amputation care/prosthetics, all of which are likely co-components of wounds from penetrating and blast trauma after association with getting shot, stabbed, fragmented, and blown up, and nearly killed. Mainly because it would be an encyclopedia, a pitifully sketchy one at that, and there are numerous textbooks on the subject.


Shorty said...

Excellent. I've stocked very small quantities of betadine, H2O2, and Isopropyl Alcohol, but not on a scale of keeping only one small operating area sanitary. Great list.

One question: one of my employees is a 68W and mentioned patients with allergies to iodine/betadine. Is 91% Isopropyl an appropeiate substitute for area sterilization or is there another product that would be better suited for use?

Aesop said...


Your employee has correctly identified the chief Achilles heel to iodine/betadine: personal allergies.

Isopropyl is NOT a good substitute.
It's better than rubbing dog crap on a wound, but it's sub-optimal for the following reasons:
A) It stings like hell on open wounds - use it only on people you don't like, and remember to duck
B) It takes up to 10 minutes to kill the nasty germs.
C) The reason it stings like hell is because it's also killing/harming healthy/vital tissue, which decreases healing, and thus increases the time it takes.
D) It's a fire/ignition hazard. Setting your patient's open wound, the treating personnel, yourself, and/or the bedding and clothes on fire during treatment is generally frowned upon in medical circles, not to mention flailing patients with actively flaming wounds are harder to suture or bandage. So obviously, heaven forbid you have a patient allergic to iodine, with for example a fragment of embedded white phosphorous, and disinfected with rubbing alcohol. Think Polynesian flame dancer on crack. Potentially still armed with his personal firearms.
E) Did I mention it stings like hell?
Therefore it's best used for things like thermometers, instruments, etc, that you can drop in a glass or tray of it, and leave for a half hour or so, with a cover over the container.

Hydrogen peroxide has similar drawbacks, minus the flammability, but it loses potency under increased heat & light, and it only kills germs (very slowly, slower than alcohol) on the germs it actually touches. Deep lacerations/punctures -like GSWs - it doesn't reliably get deep enough. Which sets patient up for a massive infection and sepsis. Again, it's better than rubbing dirt on a wound, and it's okay on really small or superficial cuts/scrapes but it's a very poor substitute for betadine, or just sterilized water.

Your go-to substitute is chlorohexadine and similar, usually under trade names like Chloroprep, which can be had in sealed individual use skin prep scrub wipes, swabs, etc. You don't want to be pouring it into wounds. Make sure anything you select is listed as okay for skin use, and check about whether it's approved for open wound cleansing, or merely for surface prep.

When all else fails, the medical maxim is "The solution to pollution is dilution." I.e. wash with sterile water, then repeat, then repeat, then repeat.

As a fresh young EMT before nursing school, I watched a well-meaning nurse (from the early Pliestocene era) "care" for a runner in the L.A. Marathon who'd fallen at mile 2, and been trampled by the following pack. At mile 20, he limped into our aid station with two huge bloody roadrash scrapes to both knees. Nursey, per her training when Hoover was president,reached for two big wads of gauze, dunked them in isopropyl alcohol, and as I was just the volunteer non-licensed chart recorder, I turned away from the inevitable reaction as alcohol hit hamburger knees.

The guy's scream made me feel his pain, and cops a block away turn around to see what was going on; our patient levitated vertically about 5 feet straight up from being seated in a chair, and after some quick dressings were applied, he just about flew out of the station, running the last 6 miles on pure pain, adrenaline, and guts.

I deduced then that when my instructors said "Don't use isopropyl on open wounds" they knew their business.

Exl said...

Aesop - You and I have crossed swords in the past but I am in awe at your experience as a Nurse, you have my utmost respect for taking that job. I'd like to ask you your opinion on the "Where There Is No X" series available I know they are not the be all and end all series of books but I'd like an opinion before I add them to my library.



Aesop said...


That's easy. I have both "Where There Is No Doctor" and "Where There Is No Dentist" in my personal reference library. I cannot speak to the utility of the other guides they publish, but the two I have are both solid B+ ratings in my opinion.

"Where There Is No Doctor" is the better of the two. If you can imagine a medical guide for layman,living under Third World medical conditions (travellers, sailboat tourists, foreign contractors, teachers, archaeological expeditions, missionaries, etc.) written from the perspective of birkenstock-wearing tree-huuging Peace Corps volunteers, that's what it is. Given that in any serious U.S. catastrophe/societal collapse, we'll HAVE lots of layman trying to cope with Third World medical conditions, it fills a very worthwhile niche. And at the time it was published, "Where There Is No Dentist" covered one of the most neglected aspects of care (at the time) for those in similar circumstances. I've recommended WTIND specifically to nurses going overseas on medical short-term missions to places like Haiti and Central America, and was told it came in very helpful in both instances, both for prep and planning, and while working on scene.

Anonymous said...

Just a brief comment on water, specifically, holy water. You may have just been purposely flippant but correctly speaking, nuns cannot make real holy water. This can only be done by a priest, using special prayers for that purpose. Next best thing, as you say, is sterile water. Holy water does indeed have special benefits for believers. Always include if available. Water with special blessing, such as from Lourdes in France, would be highly desirable.

Aesop said...

Actually, it's an old Catholic joke, told to me by an old Catholic, in this case, a nun. Who was also one great nurse.
It has become shorthand in many situations, as one can frequently tell somebody with austere/wilderness medical training that "I need some holy water" and they know you mean boil the hell out it without further explanation. I think God has a sense of humor, and no blasphemy is intended nor implied.