Wednesday, February 17, 2021

Sorry, But Just...No


To set up this Tinker-to-Evers-to-Chance triple play, WRSA linked to an American Partisan article posted by NC Scout, the gist of which was a link to an SF article on prolonged casualty care, and the "guerrilla hospital".

Presumably in the context of people thinking of some sort of grid-down problem, long- or short-term, anywhere in a spectrum from between post-Katrina ugliness all the way to full flaming Zombpocalypse, including in the intermediate range, moderate to severe civil unrest/guerrilla warfare in CONUS.

Probably 95% or more of casual readers who follow that will be thinking, "Yessirree, we're gonna need us one of them there go-rilla hospitals!"

Sorry, kids, you won't be having any of that.

The article in the OP was concerned with actual SF medics, with access to modern drugs, satellite communications, air drops, a logistical tail that reaches any point on the globe, given enough time, and ultimately the entire US military's medical behemoth for back-up, sooner or later.

You. Won't. Have. Any. Of. That.

You might could handle a clinic, or convalescent hospital, by which I mean a place to get well or die. That you could manage to pull off, from 1 bed and up, and I've suggested a bare bones framework on how you might think about doing that. But it will not be anything like what you know as a hospital, from any time since 1960 or so, and it won't be even as modest as the "guerrilla hospital" Col. Farr is talking about in the linked article.

Here's what you won't need, and what you won't have, hence what you won't be doing to save anyone's life.

You won't have anesthesia. You won't have analgesia, except moonshine or weed, in all likelihood. So without those two things, you won't have surgery of any type other than "Civil War v1.0"-type. Complete with bone saws, sepsis, and spurting arteries after amputations.

You won't have cardiac code drugs. Nor supplemental oxygen in metric f**ktons. (A re-purposed O2 concentrator running up to 6 lpm? Maybe. Putting people on ventilators at 15-100 lpm? NFW. Not happening.) So you don't need protected airways, defibrillators, ventilators (large nor portable version), nor any other such nonsense. Forget CPR. Waste of time and energy.

Thus any cessation of heartbeat or respiration will go by what medical professionals quaintly refer to as "Death".

You're unlikely to have the ability to transfuse blood products, let alone type and screen donors and recipients.

You might cobble together enough antibiotic doses to save a couple/three folks from serious wounds, if they aren't liable to bleed to death first. But when those are gone, your only antibiotics will be mold on bread, which isn't the same thing as penicillin. 

So what are you going to need? In the immortal words of one famous Special Forces operator:

No, really.

Plan on one body bag per person, double that for random others, and hope you haven't sold it short. And learn how to safely dispose of bodies without contaminating yourself or your water supply.

Calvin Coolidge Jr., son of the sitting president, played tennis with his older brother John on the White House tennis court without socks in 1924, got a blister, which became septic, and he died within a week. No antibiotics. Just like you won't have.

Should you gather medical supplies, and get CPR and medical training?

Hell YES! It ain't the Zombpocalypse yet, and that stuff and the know-how is always handy to have. And you should absolutely do as much as you possibly can, or can prepare for.

But get a better grip on what you will and won't be able to do. (And, no, that doesn't include shooting the wounded.)

When Ebola got here the first time, I lost track of how many people I tried to tell "You aren't going to "treat" this. You're either going to isolate, or die from it if you don't."

"But I can't abandon my family members! I'd HAFTA try!"

Said every one of 50,000 dead family members in Liberia, Guinea, and Sierra Leone that same year who tried that. Suture self.

Now, with a year of weak-ass COVID under your belts, many of you who contracted it infected by other family members, you can see what a year on your own is like, to a very small degree, and that's with a virus with, at worst, a 3% fatality rate. (Like we told you.)

Look up casualties in WWI and/or the Civil War, for either side, and get back to me.

That's the level of medical care you'd be looking at providing/accessing in any serious "problem", over the long run.

So expect similar death rates when you revert to medical expertise last seen from 1860-1940.

Some few of you maybe might have a doctor, P.A., etc. handy.

D'ya know what you call a cardiologist or internal medicine specialist without a hospital around him, 98% of the time?


Because that's what you've got with no labs, no pharmacies, no imaging, and minimal facilities.

Don't believe me; ask them yourself, and see how fast they laugh at the idea of modern health care without anything that differentiates it from 19th century medicine, other than a bit more insight into certain things.

Then go back and read ,Rawles' HTSTEOTWAWKI, and find the part where he mentions the great "Die Off".

Now you can imagine why it's so.

Absolutely prepare as much as you can for anything and everything that concerns you.

But FFS, have some realistic expectations of what you can and cannot do with your two hands, and whatever bag of goodies you cobble together for bad times. Reality is going to be harsh enough in any bad situation without the double sting of shock because you thought it was going to be a picnic.

UPDATE (3/6/21): Grenadier1 disagrees at WRSA radio.

My reply to that is in Comments.


FredLewers said...

It will be a quickly cascading collapse of the logistics channels that overwhelms most.
An ounce of prevention will be worth a hell of a lot more than a pound of cure.
After seeing the first person or three die from sepsis; common sense, critical thinking and forethought will become highly desirable character traits again.

Chuck Pergiel said...


David Hamel said...

Sadly true Aesop. I love the line about "Steve" ! I'm a retired emergency medicine PA and will sorely miss the access to good anaesthetics (big fan of ketamine) and analgesics (especially morphine). Amputation and death by hangnail-induced sepsis will again be a "thing".

Mark said...

Being a student of the American Civil War (and former re-enactor) I can tell you that two thirds of the deaths were from disease (including infections). Survive the wound be get an infection? Die. Get pneumonia? Probably die. Ditto dysentery, smallpox, malaria.

We have one SMALL leg up on them, in that we know that germs exist and how to kill them. So even in less-than-idea conditions your Dr Steve isn't going to go from one wounded person to another without washing his hands in between (and Hell, I made soap on my High School chemistry class, it can be done). You're not going to put your latrine next to the stream you get your water from. You're not going to let the corpses pile up and attract flies. We're going to put up mosquito netting because we know malaria isn't caused by breathing the swamp miasma.

I recall reading a fantasy story years ago where a modern guy was transported to a primitive society (might not even have been an Earth society). He had some sort of cut, and the healer came in to fix him up, bringing with him obviously soiled bandages. He was told the bandages were excellent, they'd already healed six people. Hilarity ensued.

Mark D

Michael said...

Mostly I agree with you Aesop.

However IF manage to keep sanitation up, establish safe drinking water (given Superstorm Sandy-Katrina reports not guaranteed) maintain handwashing and knowledge of prevention of infections with soap and water (Something Coolidge FAILED at) a lot less useful lives will be lost. All the above wasn't so assured during the American Civil war. Dysentery killed FAR more than Bullets friends, even up into WW1 with civilians the worst off.

I have basic tooth extraction tools and skills along with Tooth ache plants in my medical garden. It DOES Numb the tooth-gum and cheek I can assure you, like lidocaine. I have a fair bit of ditch medicine skills from various 3rd world adventures so somethings can be done. A toothache can kill you. I can make colloidal silver with is pretty useful.

Other than clearing the airway-doing the shock positioning to see if respirations are restored CPR is mostly useless with out the 911 system as you said.

Diabetics and such will suffer and die unless so minor that diet and exercise can "cure it". A of of morbidly obese folks *Still* produce insulin BUT their massive bodies NEED MOAR.

If you think folks are nutty NOW wait until the estimated 30% some percent of Americans that take Mood-altering LEGAL Drugs to deal with the Craziness NOW RUN OUT in about 30 days or so.

A lot or triage will be done to preserve the resources for those you can REALLY Help. A sucking chest wound is easier to deal with than a bowel wound. Proper use of bleeding controls *might* help a lot but Gilligan's with Tourniquets SCARE ME.

Proper disposal of bodies only begins with sanitation as I've SEEN how wild folks can get when you CANNOT HELP Grandma who was clearly dead before they showed up at my ER. Even in Recent history America Doctors and such were murdered by angry relatives for essentially doing proper Triage.

90% die off *might* be optimistic given the near total lack of sanitation-safe water procedures in general knowledge.

Rhea said...

Regarding your comments about Ebola, you are 120% correct. If it had become/ becomes a pandemic here, there would/will be nothing I can do for any family members that may catch it, beyond palliative care that will end up giving me Ebola, too. I thought about that a lot back when Obama was doing everything in his power to give the country an Ebola pandemic. I don't know how I would have reacted had it happened(no one ever does, I think, until reality hits head-on), but I planned to stay and care for them, as much as I could.

And yes, I was aware at the time that such an action would be for all practical purposes, sentencing myself to death, but I couldn't think of any way I could live with myself if I abandoned the people I loved.

Sometimes all you can do is pick which hill you plan to die on.


Charlie said...

Your last paragraph is what we need to be drumming into people's heads again and again.

Also why tribe helps, if you can gather one!

Stealth Spaniel said...

For those of us who grew up in Stepfordland......also known as Hollywood, this is why the latest Ashley Judd story rings so false. This is the one where she was in Deepest, Darkest Africa....alone, except for 4 natives and the local WitchDoctor. She was shooting a movie with her GoPro, I guess. Most actresses view "roughing it" as wearing cute poplin pants with a skin tight T-shirt so your tiXXies show really well, (Got to get in that advertisement for Dr. LiftEmtotheStars to keep the discount), and wearing no make up. Yes-this is what reality in Stepfordland for most females. Then! She snaps her leg in 3/4 places, while crossing a river. The leg-fully defurred thanks to that new expilatory from Kim Kardashian- is precisely set without anesthesia. Then Ashley is carried in a makeshift sling for MILES before reaching civilization and being air lifted to South Africa. Right. African Queen anyone? (Hepburn was a much better actress.) As a medical professional, you're telling me that when CW2 kicks in, I won't be able to expect such treatment? Now where is the Justice and Fairness??

Matt Bracken said...

If and when, the survivors will probably welcome the ChiCom CCP in to rescue us. Starting with the west coast ports and spreading out from there.

Phelps said...

If you want a hospital, the one thing you need before everything else is an MD.

Get an MD, and the rest (with the limitations above) will follow.

Good luck.

Aesop said...


Germ Theory was well-known and disseminated by 1924. It was the total dearth on anything antibiotic that killed Coolidge Jr. Soap and water wouldn't have helped, as the germs had already moved from outside to inside. Like they do.

That's the brave new world of grid-down medicine that most people want to ward off with amulets and incantations. When your only tool is a hammer...

Phelps said...

I'm a retired emergency medicine PA and will sorely miss the access to good anaesthetics (big fan of ketamine) and analgesics (especially morphine).

I think that you will find it astonishingly easy for a guerilla to obtain ketamine and heroin (as your morphine substitute). Dosing could be a little more difficult for the heroin since the purity might be all over the place.

Also, make friends with a veterinarian. You can find virtually everything trauma related in a hospital pharmacy is also in a vet pharmacy, and the only difference is that the production line splits into differently labeled boxes. The tablets even have the same markings.

Steve H said...

I don't have grand fantasies of being able to do much effective treatment if things go south for me or one of mine. Preventive care and common sense will hopefully help to limit risks and injury/sickness. I will still prepare with supplies and knowledge though. But at the end of the day, I want something on hand to ease the pain and suffering of the dying after coming to grips with the fact that they are beyond recovery.

Night driver said...

Wait a minute.
Some of my best doc friends are DOs.

Judd's description is pretty damn close.
Been in those environments.
She be lucky and strong batch.
And no, really, all she needed was to be PROPERLY splinted with appropriate traction.
Y'all should see what care looks like up hill from Askoli in Pakistan. Yeah that would be uphill from the end of the jeep track.

Night driver.

Aesop said...


1) Vet med supply lines will run out for the same reason human ones will. No delivery, no toys.

2) Yes, you will find heroin, and carfentanil.
And without Narcan reversal agents, and because of dubious purity and sterility issues, you'll kill more people using it than not, between ODs and hepatitis. People won't miss the FDA until they no longer have it.
Caveat emptor.
If the intention is euthanasia for those dying anyways, however...

Colombo said...

Chloroform and ether, both easy to cook up now. Vet antibiotics cheap and available now. Spend your time and fiat as you see fit. I recommend learning and training, stock and stash.

Charlie said...

Oddly enough, there is really not much to do about what is coming, not medically anyway.

Whether it all falls apart or not, most here are guilty of wrongthink and will get no state of the art medical care.

Kinda makes me think of my weekly safety meetings at work. Go thru a pre-prepared checklist of topics, end with DON'T GET HURT.

Pretty much sums up what is coming.

Jester said...

Hey I'll just say that the VA hospital system while pretty well off is saying don't use sterile products where possible to conserve the supply BECUASE THE ENTIRE FUCKING SYSTEM is a just in time 30 days or less supply on hand. For those of you in the outside world that means you fuckers too. And they hit up frequently that everyone IN THE FUCKING WORLD is drawing off the same supplies. My thoughts aside about the intelligence of such things this means that at best AT FUCKING BEST any hospital might if your fucking lucky have about 30 days supplies of basic things like sterile gloves and gowns. Simple shit like that that have to be disposed of after every single victem. This does not go in to things beyond those nice sterile wipes to things like ya know.. antibiotics, medicines ((Double points for you ding dongs that think this stuff is not sourced for basic ingredients in the US or other westeren countries like England, France etc.) Indo-China region is where a lot of the physical non medicine supplies come from, if not nearly all of them. I wonder the chances of even getting a box of non sterile gloves are when shit hits the fan from across the Pacific? Anyone want to guess that one?

Aesop said...


Hey, you're about 373 days behind the curve there, pard.
That material was covered.

Virginia Granny said...

Dear Aesop,

I don't think I ever posted here before, but I read you every day. I have learned a lot from you, including acronyms I otherwise would never have heard of.... If you lived close enough to us for me to hug you, I would adopt you and welcome you wholeheartedly into our Clan.

I am 70 and live on a farm, raising livestock. The dogs and cats are "employees" who get food, housing, free health care. I have learned about medical treatments and death the hard way. I have put too many rounds into the heads of some of my best friends to ease their suffering.

As a child in the early 30s, my mother burned her leg on the kitchen cookstove. The scar (when healed) was 7 inches long and about a half-inch deep. The doctor came every day to the house to rip off the scab and pour alcohol directly on the wound. There were no anti-biotics available and this was the only hope she had. She screamed a lot, but she recovered. My Grandfather died of "blood poisoning" in 1955 from a small cut he got at work. There were some anti-biotics, but no one thought a simple nick would cause sepsis so quickly. He died on Christmas Eve.

Anyone who thinks you are overstating your warning has his head up his butt. You couldn't be more correct.

You mention the use of street drugs for euthanasia. Personally, I think a well-placed bullet is equally/more effective, but harder to do when it is someone you love. One of the things we all need to get our heads into is the probability that, with TEOTWAWKI surely coming, we will have to make horrible decisions regarding the unavailability of medical care. Most of us won't have MSF-trained members in our group. Stockpiles of supplies run out. Accidents and infection NEVER do.

I have told my 40-something children and DH never to even consider sending me to an ER unless they can't stop the bleeding or there are bones sticking out. I want to end my life in my own home, even if it's on the floor of the barn. I've said it so many times that they can almost see DNR tattooed on my forehead. I've considered having one really tattooed on my chest, but I'd probably get an infection from that. LOL.

I told my doctor that he spends too much time worrying about me dying. I spend more time worrying that I won't and someone else is going to have to deal with me....

I know I can pull the trigger for someone else. It hurts me to the soul to even put a cat down, but I bought my .38 for several reasons. Self-defense was one.

I hope your readers give some thought to the real end-problem of no modern medical care. And then look around at the faces of the people they love.

Mark said...

Supply chain issues go FAR beyond mere manufacture of the drugs/medical supplies themselves. Suppose, just for the sake of supposing, all drugs and medical supplies (with ALL their precursors) were now manufactured in the continental US, with export limited to the excess after domestic needs are provided for.

How about the boxes/bottles/vials they come in?

How about the forklifts (with replacement parts) that load them onto the trucks for shipment?

How about those trucks, and THEIR replacement parts?

How about the fuel they both require?

How about the PVC pipe the hospital needs to keep the toilets flushing? Toilet paper (we ALL learned far too much about THAT topic over the last year).

Gas the doctors/nurses need to get TO the hospital? Replacement parts for THOSE cars, and the vehicle (ambulance or personal) that gets YOU there?

My point is, if one part of it crashes, the WHOLE thing comes down. Sure, you may have metric fucktons of domestically-manufactured antibiotics sitting on the loading dock at the factory, where they'll do you precisely zero good should you get a boo-boo that gets infected.

Are we too late to keep it from crashing? Dunno. What I do know is that the best way to survive an accident is not to be IN one. We need to both plan for the crash, and do what we can to prevent it, because if/when it comes down it'll make The Road look like Pollyanna.

Mark D

Brian E. said...

The surviving sheep will, and I fear - far too many sheepdogs that have lost loved ones and are none too well themselves, or that severely underestimated just how SOLITARY, POOR, NASTY, BRUTISH, AND SHORT life is when the modern world falls over.

Being prepared isn’t just having a warehouse full of supplies and enough guns and ammo to defend it.

It is learning how to survive WITHOUT modernity (especially medical, farming, and food preservation advances), and the value in a good tribe.

And equally important is the need to have the proper headspace: a complete understanding that no one is coming to save you.

Those ChiCom CCP folks - they’re just coming to ‘salvage’ anyone that might be a useful slave/subject of the new Peoples Republic of North America. Nothing more.

David Klassen said...

Truth bomb. Without a supply line We are well and mightily fugged. I can keep people alive in the OR and ICU with equipment, supplies and trained help. Can’t do it by myself, without supplies and equipment very long or very well. No one is going to run an OR or ICU in their house for longer than 24 hours.
Hey I can make ether and chloroform! I can start an IV! I can intubate! I can suture!

The stupid. It hurts.

Jester said...

I was commenting about it a year ago too, still remains valid and worthy of repeating for the slow folks out there just catching on.

Aesop said...

Absolutely true.

thepatientlife said...

Paging all organic chemistry graduates who learned how to synthesize sulfa drugs in undergrad.

Toirdhealbheach Beucail said...

Supply Chain is critical, as is the availability of materials. I work in the larger biopharmaceutical industry and The Plague has almost completely consumed manufacturing capacity at third party fillers as well as consumables and certain excipients. And this is just a single issue. I cannot imagine if we were to have two significant medical pandemics at a single moment. One would get prioritized over the other.

Aesop said...

Grenadier1 at WRSA Radio thinks I overstated things.
My response:

You either didn't notice what I wrote, or didn't read the whole thing very well.
From 2/3rds of the way through:

"Should you gather medical supplies, and get CPR and medical training?

Hell YES! It ain't the Zombpocalypse yet, and that stuff and the know-how is always handy to have. And you should absolutely do as much as you possibly can, or can prepare for.

But get a better grip on what you will and won't be able to do.

You also evidently didn't click on the links I provided, in my reply, as to what to get your hands on, and set up for doing what you can:

Raconteur Report: Equipping The Disaster Clinic: The Space

Raconteur Report: Equipping the Disaster Clinic: The Basic Stuff

None of that will include shooting the wounded.

Raconteur Report: "We'll Shoot The Wounded"

But the article linked was in a very specific context of the US military, with near-unlimited medical resources, supporting unconventional warfare anywhere in Creation, by putting trauma surgeons and mini-MASH hospitals as far forward as they can.

Call me when you have a catalog of unlimited medical resources to do that, for any value of anyone.

That will be 0% of the world. Ever.

The whole point of the original article was that even US Special Operations Forces, with no limit on what they could do if they chose, and functionally limitless personnel to do it, doesn't have this capability.

The Pentagon budget last year was $721.5B.

The median American's annual salary is $50K.

So when your group gets to 14,400,000 adult members (the population roughly of ), and they sign all of their salary over to you, you're at parity with DoD.

But you don't need stealth bombers and aircraft carriers? Okay. Let's get it to local level: It costs about $2M/yr per bed for non-trauma hospitals.

That would be 100% of the annual income from 40 people.

Aesop said...

If you can cough that up, including at least 1 MD, you could acquire the capability to treat everybody you could, in a 1-bed hospital, for a year. (In the example hospital I looked up, that would be 3-4 patient visits/day, and 1 admission per week.)

Got less resources, and 2 serious patients come in at once? Pick the one who lives, because the other one is probably going to die. Maybe not in Week 1, but by Week 10 or so. Welcome to my world, if you take away my resources. And after that, every day, forever, even if you had enough stuff to begin with.

Standard course of antibiotic for 1 GSW is 2-3 antibiotics, 1-3X/day, for a week or more. So, you've got all nine of those IV bags? Nine sets of admin tubing? two dozen IV bags of fluid, and IV sets for those too? refrigeration for all of them? Medication to treat an unexpected anaphylactic reaction if your patient turns out to be allergic to one of them? The alternate antibiotic because now you can't use the first one? Doses of tetanus? Enough sponges and drains and IVs to change dressings and admin sites as often as needed? No??? Nice try, but your patient died anyways. And sometimes, they die even if you had all that stuff, but you still had to use it on them, so it's still not there for the next one. We haven't even talked about feeding your patient, cleaning clothes and bedding, repeating lab work, physical therapy, or any dozen other things. And we've assumed no complications, or repeat surgeries, despite that even under ideal conditions, that happens 10% of the time. That's where that $2M goes, even if all your staff works for just 3 hots and a cot.

And if you had it all socked away, you might could do it grid-down, for awhile.

But without that, and no re-supply, you can gather all the professionals you want, including the entire staff at a trauma hospital, and most seriously injured trauma patients are going to die, because exactly as noted, no anesthesia, no analgesia, no antibiotics, no oxygen, mo lab, no imaging, no pharmacy, and medicines limited to what you could get by filling a pillowcase at WalMart with OTCs.

Knowing germ theory does nothing about penetrating wound sepsis, and you won't fix that with hand sanitizer and Tylenol.

Anybody that cannot grasp that, doesn't know what they don't know.

Do what you can with what you've got, sure. Please do! I'm begging you.

But understand what you won't do, which is most of what you think of when you hear the phrase "modern medicine". You won't have that.

But that's trench medicine from WWI, minus the surgery, which, if it happens at all, will be purely on Civil War terms: "Have a slug of whiskey, and bite on this leather strap, while I saw your leg off!"

Look at the casualty rates in 1918, or 1865, and get familiar with that level of care making a comeback.

Out of pocket, I can run a disaster clinic/aid station, probably for a full month, with just what I've got squirreled away. I've seen me do it, in actual emergencies.

But a trauma hospital? Fuggedaboudit.
Change my mind. Gainsaying reality doesn't count.