THE STATUS ASSESSMENT
The first thing that the survival medic should perform in preparation for a collapse situation is a status assessment. The questions below must be asked and answered.
What Will Your Responsibilities Be?
It goes without saying that, as medic, you will be responsible for the medical well-being of your survival community. But what does that mean? It means that, as well as being the chief medical officer, you will take on the following roles:
Chief sanitation officer
It will be your duty to make sure that sanitary conditions at your camp or retreat don’t cause the spread of disease among the members. This will be a major issue in an austere setting.
Some of your responsibilities will relate to latrine placement and construction; others will relate to the supervision of appropriate filtering and sterilization of water. Ensurance of proper cleaning of food preparation surfaces will also be very important, as will be the maintenance of good personal and group hygiene.
Chief dental officer
Medical personnel in wartime or in remote locations report that patients arriving at sick call complained of dental problems as much as medical problems. Anyone who has had a bad toothache knows that it affects concentration and, certainly, work efficiency. You will need to know how to deal with dental issues (toothaches, broken teeth, lost fillings) if you are going to be an effective medic.
It goes without saying that any societal collapse would wreak havoc with people’s mindsets. You will have to know how to deal with depression and anxiety as well as cuts and broken bones. You will have to sharpen your communication skills as much as your medical skills.
You’ve accumulated medical and dental supplies, but when do you break them out and use them? When will you dispense your limited supply of antibiotics? In a survival setting, these items may no longer be manufactured. Careful monitoring of supply stock and usage will give you an idea of your readiness to handle medical emergencies for the long term.
You are in charge of archiving the medical histories of the people in your group. This record will be useful in remembering all the medical conditions that your people have, their allergies, and medications that they might be taking. If your community is large, it would be almost impossible to memorize all of this information.
Also, your histories of the treatments you have performed on each patient are important to put into writing. One day, you might not be there to render care; your archives will be a valuable resource to the person who is in charge when you’re not available.
Medical education resource
You can’t be in two places at once, and you will have to make sure that those in your group have some basic medical education. It’s important that they can care for injuries or illness while you’re away.
These responsibilities are many but may be modified somewhat by the makeup of your group. If you have a pastor or other clergy in your group, they can take some of the burden of counseling away from you. Take whatever help you can get.
How Many People Will You Be Responsible For?
Your store of medical supplies should correlate well with the number of people you will be responsible for. If you have stockpiled five treatment courses of antibiotics, it might be enough for a couple or a sole individual, but it will go fast if you are taking care of twenty people.
Remember that most of those people will be out performing tasks that they aren’t used to doing. They will be making campfires, chopping wood and toting gallons of water. You’ll see more injuries like sprains and strains, fractures, lacerations, and burns among those people as they perform activities of daily survival.
It only makes sense to accumulate as many supplies as you possibly can. You might wind up dealing with more survivors than you expected; in reality, you almost certainly will. The biggest mistake that the survival medic is likely to make is the underestimation of the number of people who will appear on their doorstep in times of trouble.
Don’t be concerned that you have too much stored away. Any “excess” items will always be highly sought after for barter purposes. Food and medical items will be more valuable than silver and gold in hard times. Don’t become complacent just because you have a closet full of bandages; they will be used more quickly than you think. Always have more medical items on hand than you think are sufficient for the number of people in your group.
What Special Needs Will You Have to Care For?
The special issues you will deal with depend on who is in your group. The medical needs of children or the elderly are different from an average adult. Women have different health problems than men. You will have to know if group members have a chronic condition, such as asthma or diabetes. Failure to take things like this into account could be catastrophic. For example, would you be prepared if you found out a group member required adult diapers after a calamity occurs?
These variables will modify the supplies and medical knowledge you must obtain. Encourage those with special needs to stockpile materials they’ll routinely need. Encourage them to have a frank discussion with their physician and obtain extra drug prescriptions in case of emergency (filled in advance).
What Physical Environment Will You Live In?
Is your retreat in a cold climate? If so, you will need to know how to keep people warm and how to treat hypothermia. If you’re located in a hot climate, you will need to know how to treat heat stroke. Is your environment wet and humid? People who are chronically wet don’t stay healthy, so you will have to have a strategy to keep your group members dry. Are you in a dry, desertlike environment? If you are, you will have to have strategies for providing lots of clean water.
Some people live in areas where all of the above conditions exist at one point or another during the year. These considerations might even factor into where you choose to live if a collapse is imminent.
How Long Do You Expect to Be the Sole Medical Resource?
Some catastrophes, such as major damage from tornadoes or hurricanes, may limit access to medical care for a relatively short period of time. Other events could precipitate a long-term collapse.
The longer you will be the healthcare resource for your group, the more supplies you will have to stockpile and the more varied those supplies should be. If the catastrophe means a few weeks without medical care, you probably can get away without, for example, equipment to extract a diseased tooth. If it’s a true collapse, however, that equipment will be quite important. Remember to plan for issues that may occur further down the road, such as birth control for a daughter who has not yet reached puberty.
How Do You Get the Information You Will Need to Be an Effective Healthcare Provider?
A good library of medical, dental, survival, and nutritional books will give you the tools to be an effective medic. Even if you were already a doctor—let’s say a general practitioner—you would need various references to learn how to perform surgical procedures that you ordinarily would send to the local surgeon.
Although printed matter is more important off the grid, don’t ignore online sources of information. Take advantage of websites with quality medical information. By collecting information you believe will be helpful to your specific situation, you will have a unique store of knowledge that fits your particular needs.
Sites like YouTube.com have thousands of medically oriented videos on just about every topic. They range from suturing wounds to setting a fractured bone to extracting a damaged tooth. To us, seeing things done in real time is always better than just looking at pictures.
How Do You Obtain Medical Training?
There are various ways to get practical training. Almost every municipality gives you access to various courses that would help you function as an effective healthcare provider.
These programs are based around delivering the patient to a hospital as an end result. As medical facilities may not be accessible in the aftermath of a disaster, these classes may not be perfect for a long-term survival situation; nevertheless, you will still learn a lot of useful information.
Although EMT courses are excellent, most of us will not have the time and resources to commit to such intensive training. For most of us, a Red Cross first responder or community emergency response team (CERT) course is the ticket. These programs cover a lot of the same subjects and would certainly represent a good start. The usual course length is 40–80 hours.
Of course, the Red Cross and others provide standard cardio-pulmonary resuscitation (CPR) courses, which everyone should take, whether or not they will have medical responsibility in times of trouble.
Use your spare time to volunteer at the local emergency room. You’ll desensitize yourself to seeing blood and injuries and will pick up useful knowledge just by observing.
LIKELY MEDICAL ISSUES YOU WILL FACE
It is important to tailor your education and training to the probable medical issues you will have to treat. By looking at the experience of caregivers in remote settings, you can determine what medical supplies will be needed and prepare yourself for the most likely medical issues.
It wouldn’t be unusual to see the following:
• Minor musculoskeletal injuries (sprains and strains)
• Minor trauma (cuts, scrapes)
• Major traumatic injury (fractures, occasional knife or gunshot wounds)
• Burn injuries (all degrees)
• Respiratory infections (pneumonia, bronchitis, influenza, common colds)
• Diarrheal disease (sometimes in epidemic proportions)
• Infected wounds
• Minor infections (urinary infections, “pinkeye”)
• Sexually transmitted diseases
• Lice, ticks, mosquitoes, and the diseases they carry
• Minor (for example, bites or stings from insects)
• Major (anaphylactic shock)
• Broken or knocked-out teeth
• Loss of fillings
• Loose crowns or other dental work
• Birth control
Pregnancy is relatively safe these days, but there was a time in the not too distant past where the announcement of a pregnancy was met as much with concern as joy. Complications—such as miscarriage, bleeding, and infection—took their toll on women, and you must seriously plan to prevent pregnancies, at least until things stabilize.
MEDICAL SKILLS YOU WILL WANT TO LEARN
A very reasonable question for an aspiring medic to ask is “What will I need to know?” The answer is “As much as you’re willing to learn!” Using the previous list of likely medical issues will give you a good idea of what skills you’ll need. You can expect to deal with lots of ankle sprains, colds, cuts, rashes, and other common medical issues that affect you today. However, you should know how to deal with more significant problems, such as a leg fracture or other traumatic injury. You’ll also need to know what medical supplies will be required and how to use them. The effective medic will have learned the following:
• How to take vital signs, such as pulses, respiration rates and blood pressures.
• How to place wraps and bandages on injuries.
• How to clean and monitor an open wound.
• How to treat varying degrees of burns.
• The indications for use of various drugs and herbal remedies as well as the dosages, frequency of administration, and side effects of those substances. You can’t do this on your own; you’ll need resources such as the Physicians’ Desk Reference. This is a weighty volume that comes out yearly and has all the information you’ll need to use for both prescription and nonprescription drugs.
• How to perform a normal delivery of a baby and placenta.
• How to splint, pad, and wrap a sprain, dislocation, or fracture.
• How to identify bacterial infectious diseases (such as strep throat).
• How to identify viral infectious diseases (such as influenza).
• How to identify parasitic and protozoal infectious diseases (such as giardiasis).
• How to identify and treat head, pubic, and body lice, as well as insect bites and stings.
• How to identify venomous snakes and treat the effects of their bites, as well as the bites from other animals.
• How to identify and treat various causes of abdominal, pelvic, and chest pain.
• How to treat allergic reactions and anaphylactic shock.
• How to identify and treat sexually transmitted diseases.
• How to evaluate and treat dental disease (such as replace fillings, treat abscesses and perform extractions).
• How to identify and treat skin disease and rashes.
• How to care for the bedridden patient (such as treating bedsores, transport considerations).
• Basic hygiene, nutrition, and sanitary practices. (This couldn’t be more important.)
• How to counsel the depressed or anxious patient (common in times of trouble).
• How to insert an intravenous line (IV) line. (EMT classes teach this.)
• How to close a wound.
Actually, more important than knowing how to close a wound is when to do so. Most wounds incurred in the outdoors will be dirty wounds, and closing such an injury can lead to bacteria being locked into the tissues, causing infection.
Perhaps the most important skill to obtain is how to prevent injuries and illnesses. Observe simple things, such as whether your people are appropriately dressed for the weather. Make certain to enforce the use of hand and eye protection during work sessions. Learn to recognize situations that place those you are medically responsible for at risk, and you will avoid many injuries and illnesses.
Don’t feel that learning all this information is impossible, or that you can’t be of benefit if you only learn some of the above. The important thing to do is to learn at least enough to treat some of the more common medical issues.
Properly caring for the medical needs of others requires having the right equipment. Imagine a carpenter having to use a steak knife as a saw, or a hunter using a pea shooter instead of a rifle. The same goes for the medic.
It’s important to note that the value of many medical supplies depends largely on the knowledge and skill that the user has obtained through study and practice. A blood pressure cuff isn’t very useful to someone who doesn’t know how to take a blood pressure. Concentrate on first obtaining items that you can use effectively, and then purchase more advanced equipment as your skills advance.
Don’t forget that many items can be improvised; a bandanna may serve as a sling, an ironing board as a stretcher, or thin fishing line and a sewing needle might be useful in sewing up a wound. A careful inspection of your own home would probably turn up things that can be adapted to medical use. Look with a creative eye, and you’ll be surprised at the medical issues you are already equipped to deal with.
Sterile vs. Clean
A significant factor in the quality of medical care given in a survival situation is the level of cleanliness of the equipment used.
From a medical standpoint, “sterility” means the complete absence of microbes. Sterile technique involves hand washing with special solutions and the use of sterile instruments, towels, and dressings. When used on a patient, the area immediately around these items is referred to as a “sterile field.” The sterile field is closely guarded to prevent contact with anything that could enable microorganisms to invade it.
To guarantee the elimination of all organisms, an autoclave—a type of pressure cooker—is used for instruments, towels, and other items that could come in contact with the patient. All hospitals, clinics, and medical offices clean their equipment with this device. Having a pressure cooker as part of your supplies will enable your instruments to approach the level of sterility required for minor surgical procedures.
Of course, it may be very difficult to achieve a sterile field if you are in an austere environment. In this case, we may only be able to keep things “clean.” Techniques for achieving this concentrate on reducing the number of microorganisms that could be transferred from one person to another by medical instruments. Thorough hand washing with soap and hot water is the cornerstone of a clean field.
To maintain a clean area, certain disinfectants are used. Disinfectants are chemical substances that are applied to nonliving objects to destroy microbes. This would include surfaces where you would treat patients or prepare food. Disinfection does not necessarily kill all bugs and, as such, is not as effective as sterilization. An example of a disinfectant would be bleach.
Disinfection removes bacteria, viruses, and other bugs and is sometimes considered the same as decontamination. Decontamination, however, may also include the removal of noxious toxins and could pertain to the elimination of chemicals or radiation. The removal of nonliving toxins, such as radiation, from a surface would, therefore, be decontamination but not disinfection.
It’s useful to know the difference between a disinfectant, an antibiotic, and an antiseptic. While disinfectants kill bacteria and viruses on the surface of nonliving tissue, antiseptics kill microbes on living tissue surfaces. Examples of antiseptics include BetadineTM, chlorhexidine (Hibiclens), iodine, and benzalkonium chloride (BZK).
Antibiotics are able to destroy microorganisms that live inside the human body. These include drugs such as amoxicillin, doxycycline, metronidazole, and many others. We’ll discuss these in detail later in the book.
Most commercial first-aid kits are fine for the family picnic or a day at the beach, but we discuss serious medical stockpiles here. There are three levels of medical kits that we identify below. The first is a personal-carry or individual first-aid kit, sometimes called an IFAK. Every member of a group can carry this lightweight kit. It enables treatment of some common medical problems encountered in the wilderness or during travel.
The second kit listed below is the family kit, which is mobile, with the items fitting in a standard large backpack. It will suffice as a medical “bug-out” (travel) bag for a couple and their children. It is, in our opinion, the minimum amount of equipment that a head of household would need to handle common emergencies in a long-term survival situation.
The third kit is the community clinic, or everything that a skillful medic will have stockpiled for long-term care of his or her survival family or group.
Don’t feel intimidated by the sheer volume of supplies in the clinic version; it would be enough to serve as a reasonably well-equipped field hospital. Few of us have the resources or skills to purchase and effectively use every single item. If you can put together a good family kit, you will have accomplished quite a bit.
The list of items could go on and on, but the important thing is to accumulate supplies and equipment that you will feel competent using in the event of an illness or an injury. Some supplies, such as stretchers and tourniquets, can be improvised using common household items.
It should be noted that many of the advanced items are probably useful only in the hands of an experienced surgeon and could be very dangerous otherwise. In addition, some of the supplies would be more successful in their purpose with an intact power grid. These items represent a wish list of what I would want if I were taking care of an entire community.
You should not feel that the more advanced supply lists are your responsibility to accumulate alone. Your entire group should contribute to stockpiling medical stores, under the medic’s coordination. The same goes for all the medical skills that I’ve listed. To learn everything would be a lifetime of study; more than even most formally trained physicians can accomplish. Concentrate on the items that you are most likely to use regularly.
IFAK or Personal Carry Kit
1 cold pack or hot pack
1 ACETM wrap (4 inches)
1 Israeli bandage or other compression bandage (6 inches)
1 CeloxTM hemostatic agent (stops bleeding)
2 eye pads
1 pack (2 sheets) Steri-StripsTM
1 nail scissors
1 straight hemostat clamp (5 inches)
1 nylon suture (size 2–0)
1 Super GlueTM or medical glue packet
1 LED penlight
1 stainless steel bandage scissors (7.25 inches)
20 adhesive bandages (1 inch by 3 inches)
10 adhesive bandages (2 inches by 3 inches)
2 sterile dressings (5 inches by 9 inches)
5 pairs large nitrile gloves
20 nonsterile gauze pads (4 inches by 4 inches)
10 sterile gauze pads (4 inches by 4 inches)
5 nonstick sterile dressings (3 inches by 4 inches)
1 rollgauze sterile dressing
1 MylarTM solar blanket
1 cloth medical tape (1 inch by 10 yards)
1 duct tape (2 inches by 5 yards)
1 triangular bandage with safety pins
1 tube of triple antibiotic ointment
10 alcohol wipes
10 povidone-iodine (Betadine) wipes
6 BZK antimicrobial wipes
2 packets burn gel
6 sting relief towelettes
1 hand sanitizer
Note: Quantities will depend on the number of people for which you are medically responsible.
First-aid reference book
Antibacterial soap and hand sanitizers
Antiseptic and alcohol wipes
Gauze dressing (various sizes—sterile and nonsterile)
Gauze rolls (Kerlix, etc.)
Nonstick pads (Telfa)
Triangular bandages or bandannas
Safety pins (large)
Israeli battle dressings or other compression bandage
Adhesive Band-AidsTM (various sizes and shapes)
Large absorbent pads (ABD, etc.)
Medical tape (Elastoplast, silk, paper varieties; 1 inch and 2 inches)
Moleskin or Spenco 2nd SkinTM blister kit
Cold packs, heat packs, hot water bottle (reusable if possible)
Cotton eye pads, patches
Eye wash, eye pads
Cotton swabs (Q-tipsTM), cotton balls
Disposable nitrile gloves (hypoallergenic)
Face masks (surgical and n95)
Bandage scissors (all-metal are best)
Headlamp or penlight
Blood pressure cuff
Irrigation syringe (60–100 cc)
Kelly clamp (straight and curved)
Nylon or silk sutures (sizes 2–0, 4–0) and/or stapler kit
Scalpel or field knife
Hemostatic agents (Celox or QuikClotTM powder)
Saline solution (liter bottle or smaller)
Steri-Strips or butterfly closures, thin and thick sizes
Tincture of benzoin (glue to hold Steri-Strips in place long-term)
Survival sheet/solar blanket
Antiseptic solutions (Betadine, Hibiclens, etc.)
Hydrogen peroxide (3 percent)
Benzalkonium chloride wipes
Hydrocortisone cream (1 percent)
Lidocaine cream (2.5 percent; local anesthetic)
Diphenhydramine (BenadrylTM) or loratadine (ClaritinTM)
Bismuth Subsalicylate (Pepto-BismolTM)
RIDTM Lice Killing Shampoo, Fels-Naptha, or Zanfel soap
Soap for general use
Oral rehydration packs (or make them from scratch)
Water purification filter or tablets
Gold Bond foot powder
SilvadeneTM cream (for burns)
Epinephrine (EpiPenTM, a prescription injection for severe allergic reactions)
Zofran (for nausea and vomiting-prescription)
Birth control accessories (condoms, birth control pills, etc.)
Herbal teas, tinctures, salves, and essential oils
Raw, unprocessed honey
Cotton pellets and rolls
Dental scraper, toothpicks
Clove bud oil
Commercial dental kits (Dentemp, CavitTM)
Chromic suture (size 4–0)
ActCelTM oral hemostatic agent (stops dental bleeding)
Extraction equipment (forceps and elevators)
Gloves, masks, and eye protection
Community Clinic Supply List
For a long-term care center
Obtain all of the above in larger quantities, plus the following:
Extensive medical library
Plaster of Paris cast kits (4–6 inches)
Naso-oropharyngeal airway tubes
Resuscitation facemask with one-way valve
Resuscitation bag (AmbuTM bag)
Endotracheal tube/laryngoscope (enables you to breathe for patient)
Blood pressure cuff
Otoscope and ophthalmoscope
Urine test strips
Pregnancy test kits
Scrub suits, goggles, or face shields
Paracord (various uses)
Triage tags (for mass casualty incidents)
• Normal saline solution bags
• Dextrose and normal saline (50 percent) IV solution bags
• IV tubing sets
• Syringes (2, 5, 10, and 20 ml)
• Needles (gauges 20–24)
• IV kits (gauges 16–24)
• Paper tape (½ inch and 1 inch)
• IV stands
• Saline solution for irrigation (can be made at home as well)
Penrose drains (to allow blood and pus to drain from wounds)
Foley urinary catheters (sizes 18, 20)
Urine bags and enema bags
Nasogastric tubes (to pump a stomach)
Pressure cooker (to sterilize instruments, etc.)
Medrol dose packs
Antibiotic and anesthetic eye and ear drops
Oral contraceptive pills
Morphine sulfate or DemerolTM
There are many issues that are best handled with the support of the latest technology and modern equipment and facilities. Sure enough, I’ve just spent the last chapter telling you to stock up on all sorts of high-tech items (even defibrillators!) and, indeed, many of these things are indispensable when it comes to dealing with certain medical conditions.
Unfortunately, you probably will not have the resources needed to stockpile a massive medical arsenal. Even if you are able to do so, your supplies will last only a certain amount of time. You may be shocked at the rapidity with which precious medications and other items are used up.
One solution is to grossly overstock on commonly used medical supplies, but even large stockpiles will eventually dry up when dealing with the common issues you’ll encounter. Therefore, you will need a way to produce substances that will have a medical benefit. The plants in your own backyard or nearby woods would be the best place to start.
Physicians have occupied different niches in society over the ages, from priests during the time of the pharaohs, to slaves and barbers in imperial Rome and the Dark Ages, and artists during the Renaissance. All of these ancient healers used different methods, but they had one thing in common: They understood the importance of natural products for medicinal purposes. If they needed more of a particular plant than occurred in their native environment, they cultivated it. They learned to make teas, tinctures, and salves containing these products and how best to use them to treat illness. If modern medical care is no longer available one day, we will have to take advantage of their experience.
An example is salicin, a natural pain reliever found in the under bark of willows, poplar, and aspen trees. In the nineteenth century, we first developed a process to commercially produce aspirin (salicylic acid) from these trees.
Natural remedies should be integrated into the medical toolbox of anyone willing to take responsibility for the well-being of others. Why not use all the tools that are available to you? At one point or another, the medicinal herbs and plants you grow in your garden may be all you have.
Natural substances can be used in “home remedies” through several methods, including the following:
Teas: a hot drink made by infusing the dried, crushed leaves of a plant in boiling water.
Tinctures: plant extracts made by soaking herbs in a liquid (such as water, grain alcohol, or vinegar) for a specified length of time, then straining and discarding the plant material (also known as a “decoction”).
Essential oils: liquids comprised of highly concentrated aromatic mixtures of natural compounds obtained from plants. These are typically made by a process called “distillation”; most have long shelf lives.
Salves: highly viscous or semisolid substances used on the skin (also known as an ointment, unguent, or balm).
Some of these products may also be ingested directly or diluted in solutions. A major benefit of home remedies is that they usually have fewer side effects than commercially produced drugs. It is the obligation of the group medic to obtain a working knowledge of how to use and, yes, grow these plants. For more detailed information on individual herbs, see the latest edition of our comprehensive book The Survival Medicine Handbook.
Another alternative therapy thought by some to boost immune systems and treat illness is colloidal silver. Colloidal silver products are made of tiny silver particles, silver ions, or silver combined with protein, all suspended in a liquid. Silver compounds were used to treat infections before the development of antibiotics.
Colloidal silver products are usually marketed as dietary supplements that are taken by mouth. They also come in forms that can be applied to the skin, where they are thought to improve healing by preventing infection. It should be noted that long-term ingestion of silver may result in a condition known as argyria. This rare condition is mostly a cosmetic, causing skin to turn blue.
Ionic silver (Ag+) and silver particles in concentration have been shown to have an antimicrobial effect in certain laboratory studies. Physicians use wound dressings containing silver sulfadiazine (Silvadene) to help prevent infection. Wound dressings containing silver are being used more and more often because of the increase in bacterial resistance to antibiotics.
You should know that the US Food and Drug Administration (FDA) has banned colloidal silver sellers from claiming any therapeutic or preventive value. As a result, it cannot be marketed as preventing or treating any illness. More evidence is warranted before silver becomes a standard part of the medical arsenal.
THE PHYSICAL EXAM
By reading this book, you have made the decision to take responsibility for the medical well-being of your family in the aftermath of a disaster. Therefore, it will be necessary to build a store of knowledge of how to evaluate a patient and make a diagnosis.
You will have to put your (gloved) hands on them and be able to look for physical signs of illness or evaluate wounds in a systematic manner. Sometimes the problem is obvious in seconds; other times, you will have to examine the entire body to determine the problem. During an exam, always communicate to your patient who you are, what you are doing, and why. Remain calm and be very careful about forcing them to move or perform an action that is beyond their capability.
The most basic information is obtained by checking the vital signs. This includes the following:
Pulse rate. This can be taken by using two fingers to press on the side of the neck or the inside of the wrist (by the base of the thumb). A normal pulse rate at rest is 60–100 beats per minute. You may choose to feel the pulse for, say, 15 seconds and multiply the number you get by 4 to get beats per minute. A full minute would be more accurate, however. You will find that most people who are agitated from having suffered an injury will have a high pulse rate (tachycardia).
Respiration rate. This is best evaluated for 1 full minute to get an accurate reading. The normal adult rate at rest is 12–18 breaths per minute, somewhat more for children. Note any unusual aspects, such as wheezing or gurgling noises. A respiration rate of more than 20 breaths per minute is a sign of a person in distress and is known as tachypnea.
Blood pressure. Blood pressure is a measure of the work the heart has to do to pump blood throughout the body. You’re looking for a pressure of less than 140/90 at rest. Blood pressure may be high after extreme physical exertion but goes back down after a short while. Of course, some people have high blood pressure as a chronic condition. A very low blood pressure may be seen in a person who has hemorrhaged or is in shock. Instructions on how to take a blood pressure can be found in the high blood pressure section of the book.
Mental status. You want to know that your patient is alert and, therefore, can respond to questions and commands. Ask your patient what happened. If they seem disoriented, ask simple questions like their name, where they are, or what year it is. Note whether the patient appears lethargic or agitated. Some patients may appear unconscious but respond to a spoken command, for example, “Hey! Open your eyes!” If no response, see if the patient reacts to a stimulus, such as gentle pressure on their breastbone. If they don’t, something very serious is going on.
Body temperature. Take the patient’s temperature to verify that they don’t have a fever. A normal temperature will range from 97.5 to 99.0 degrees. (Note: All degrees of temperature in this book are expressed in Fahrenheit. To convert to Celsius, use the following formula: multiply by 1.8 and add 32.) A significant fever is defined as a temperature above 100.4 degrees). Very low temperatures (less than 95 degrees may indicate cold-related illness, also known as hypothermia. On the opposite hand is heat stroke (hyperthermia), where the temperature may rise above 105 degrees.
Once you’ve taken the vital signs and determined that there is no obvious injury, perform a general exam from head to toe in an organized fashion. Touch the patient’s skin. Is it hot or cold, moist or dry? Is there redness, or is the patient pale? Examine the head area and work your way down. Are there any bumps on the head; are they bleeding from the nose, mouth, or ears? Evaluate the eyes and see if they are reddened. Use a light source to see if the pupils respond equally to light.
Have the patient open their mouth and check for redness, sores, or dental issues with a light source and a tongue depressor. Check the neck for evidence of injury, and feel the back of the head and neck, especially the neck bones (vertebrae).
Take your stethoscope and listen to the chest, which is called “auscultation.” Do you hear the patient breathing as you place the instrument over different areas of each lung? Are there noises that shouldn’t be there? Practice listening on healthy people to get a good idea of what clear lungs should sound like. Abnormal sounds would include wheezing, gurgles, and crackles.
Listen to the heart and see if the heartbeat is regular or irregular in rhythm. Check along the ribs for rough areas that might signify a fracture. Check the armpits (also known as the axilla) for masses. Perform a breast exam by moving your fingers in a circular motion over the breast tissue, starting from the periphery near the axilla and ending at the nipple.
Palpate the abdomen, which means press on the abdomen with your open hand. Is there pain? Is the belly soft, or is it rigid and swollen? Do you feel any masses? Use your stethoscope to listen to the gurgling of bowel sounds. Lack of bowel sounds may indicate lack of intestinal motility; excessive bowel sounds may be seen in some diarrheal disease. Place your open hand on the different quadrants of the abdomen and tap on your middle finger. This is called “percussion.” The abdomen will sound hollow normally, but dull where there might be a mass. Press down on the right side below the rib cage to determine if the liver is enlarged (you won’t feel it if it isn’t). An enlarged spleen will appear as a mass on the left side under the bottom of the rib cage.
Check along the patient’s spine for evidence of pain or injury. Pound lightly with a closed hand on each side of the back below the last rib, where the kidneys are; injury or infection would cause this action to be very painful to the patient.
Check each extremity by feeling the muscle groups for pain or decreased range of motion. Make sure the patient’s circulation is good by checking the color on the tips of the fingers and toes. Poor circulation will make these areas white or blue in color. Check for sensation by lightly tapping with a safety pin. Place your hands on the patient’s thighs and ask them to lift up, to check for normal strength and tone. Ask them to grasp your fingers with each hand; then, try to pull your hand away. If you can’t, that’s good.
If you draw a line vertically down the length of the human body, each side is essentially the same (with a few internal exceptions). This means that, if you are uncertain whether a limb is injured or deformed, you can compare it with the other side. The strength on each side should be about equal.
These are just some basics. Certainly, there’s a lot more to a physical exam than we just described, but practicing exams on others will give you experience. As time goes by, you’ll get the feel of what is normal and what isn’t.
THE MASS CASUALTY INCIDENT
You’ve just read about performing a physical exam. Most of these exams will be unhurried and routine, but, occasionally, you will have to make some quick decisions. For major trauma, it is important to take note of the “golden hour”—the first hour after the victim’s injury, when his or her chance of survival is highest. A victim’s chance of survival decreases significantly if not treated within that hour. It then worsens with every thirty minutes that pass without care.
Usually, the healthcare provider will be dealing with one ill or injured individual at a time. There may be a day, however, when you find yourself confronted with an emergency scenario in which multiple people are injured. This is referred to as a mass casualty incident (MCI).
A mass casualty incident is any event in which your medical resources are inadequate for the number and severity of injuries incurred. MCIs can be quite variable in their presentation and can include any of the following:
• Doomsday scenario events, such as nuclear weapon detonations
• Terrorist acts, such as occurred on 9/11 or in Oklahoma City
• Consequences of a storm, such as a tornado or hurricane
• Consequences of civil unrest
• A mass transit mishap (train derailment, plane crash, etc.)
• A car accident with, for example, three people significantly injured and only one ambulance
The effective medical management of any of the events listed above requires rapid and accurate triage. Triage, which comes from the French word trier (“to sort”), is the process by which medical personnel can rapidly assess and prioritize a number of injured individuals, thereby doing the most good for the most people. Note that I didn’t say, “Give the best possible care to each individual victim.”
Evaluating an MCI Scene
Your initial actions at the scene of an MCI may determine the outcome of the emergency response. The following constitute the five S’s of evaluating an MCI scene:
• Sizing up
• Sending for help
• Setup of areas
• Simple triage and rapid treatment (START), a term used in triage
1. Safety assessment. In the Middle East, an insidious strategy on the part of terrorists is the use of primary and secondary bombs. The main bomb causes the most casualties, and the second bomb is timed to go off or is triggered just as the medical and security personnel arrive.
Many medical professionals wince when I talk about not approaching the injured in a hostile setting. Remember that your primary goal as medic is your own self-preservation; keeping the medical personnel alive is likely to save more lives down the road.
As you arrive on the scene, be as certain as possible that there is no ongoing threat. Do not rush in there until it is clear that you and your helpers are safe.
2. Sizing up the scene. Ask yourself the following questions:
• What’s the situation? Is this a mass-transit crash? Did a building on fire collapse?
• How many injuries and how severe? Are there a few victims or dozens? Are there others who can help?
• Are the victims all together or spread out over a wide area?
• What are possible nearby areas for transport and treatment of the injured?
• Are there areas open enough for vehicles to come through to help transport victims?
3. Sending for help. If modern medical care is available, call 911 and say (for example), “I am calling to report a mass casualty incident involving a multivehicle auto accident at the intersection of Hollywood and Vine. At least seven people are injured and will require medical attention. There may be people trapped in their cars, and one vehicle is on fire.”
In three sentences, you have informed the authorities that a mass casualty event has occurred, what type of event it was, where it occurred, an approximate number of patients that may need care, and the types of care or equipment that may be needed.
If you are the only one there, get your phone or other communication device and notify others of the situation and what you’ll need in terms of personnel and supplies. If you are not medically trained, contact the person who is the group medic. The most experienced medical person is the incident commander.
4. Setup. Determine likely areas for victims of various levels of illness (see below) to be further evaluated and treated. Also, determine the appropriate entry and exit points for victims that need immediate transport to medical facilities, if they exist.
5. START. The first round of triage, known as “primary triage,” should be fast (30 seconds per patient, if possible) and does not involve extensive treatment of injuries. It should be focused on identifying the triage level of each patient. Evaluation in primary triage consists mostly of quick evaluation of respiration (or the lack thereof), perfusion (adequacy of circulation), and mental status. Other than controlling massive bleeding and clearing airways, very little treatment is performed in primary triage.
Although there is no international standard for this, triage levels are usually determined by color:
Immediate (red tag) – The victim needs immediate medical care and will not survive without rapid treatment (for example, a major hemorrhagic wound or internal bleeding). This person has top priority.
Delayed (yellow tag) – The victim needs medical care within 2–4 hours. Injuries may become life threatening if ignored (for example, open fracture of femur without major hemorrhage) but can wait until patients with red tags are treated.
Minimal (green tag)—Generally stable and ambulatory (“walking wounded”) but may need some medical care (for example, broken fingers, sprained wrist).
Expectant (black tag)—The victim is either deceased or is not expected to live (for example, open skull fracture with brain damage, or multiple penetrating chest wounds).
Knowing this patient marking system easily enables a caregiver to understand the urgency of a patient’s situation. It should go without saying that, in a power-down situation without modern medical care, a lot of red tags and even some yellow tags will become black tags. It will be difficult to save someone with major internal bleeding without surgical intervention.
Let’s go through an example of a mass casualty incident and discuss how triage duties should be performed.
Primary Triage: MCI Scenario
Here’s our hypothetical scenario: You are walking down the street when you hear an explosion. You are the first one to arrive at the scene, and you are alone. There are about twenty people down, and there is blood everywhere. What do you do?
Referring back to the five S’s, let’s assume that you have already determined the safety of the current situation and sized-up the scene. There appears to have been a bomb that exploded. There are no hostiles nearby, as far as you can tell, and there is no evidence of incoming ordnance. Therefore, you believe that you and other responders are not in danger. The injuries are significant, and the victims are all in one area.
The incident occurred on a main thoroughfare, so there are ways in and out. You have sent a call for help and described the scene, and have received replies from several group members, including a former intensive care unit (ICU) nurse who is contacting everyone else with medical experience. The area is relatively open, so you can set up areas for various triage categories. Now you can START.
You will call out as loudly as possible: “I’m here to help, everyone who can get up and walk and needs medical attention, get up and move to the sound of my voice. If you are uninjured and can help, follow me.”
You’re lucky, thirteen of the twenty, mostly from the periphery of the blast, sit up, or at least try to. Ten can stand, and eight go to the area you designated for walking wounded. These people have cuts and scrapes, and a couple of them are limping; one has obviously broken an arm. Two bruised but sturdy individuals join you. By communicating, you have made your job as temporary incident commander easier by identifying the walking wounded (green tags) and getting some immediate help. You still have ten victims down.
You then go to the closest victim on the ground. Start right where you are and go to the next nearest victim in turn. In this way, you will triage faster and more effectively than trying to figure out who needs help the most from a distance or going in a haphazard pattern.
Let’s cheat just a little and say that you happen to have what are known as “SMART” tags in your pack. SMART tags are handy tickets that enable you to mark a particular triage level on a patient. Once you identify a victim’s triage level, you remove a portion of the end of the tag until you reach the appropriate color and place it around the patient’s wrist.
You could, instead, use colored markers or numbers placed on the victims’ foreheads. If you use numbers, follow this coding:
• Priority 1—immediate/red
• Priority 2—delayed/yellow
• Priority 3—minimal/green
• Priority 4—dead or expectant/black
It is important to remember that you are triaging, not treating. The only treatments in START will be stopping massive bleeding, opening airways, and elevating the legs in case of shock. As you go from patient to patient, stay calm, and identify who you are and that you’re there to help. Your goal is to find out who will need help most urgently (red tags). You will be assessing respiration, perfusion, and mental status (RPM).
Respiration: Is your patient breathing? If not, tilt the head back or insert an oral airway if available. (Note: In modern emergency care, the neck is not moved unless a cervical spine injury has been ruled out; in an MCI triage situation, the rule is temporarily suspended.) If you have an open airway and no breathing, that victim is tagged black. If the victim breathes once an airway is restored or is breathing more than 30 times a minute, tag red. If the victim is breathing normally, move to perfusion.
Perfusion: Determine how normal the blood flow or circulation is. Check for a (wrist or neck) pulse. Alternatively, press on the nail bed or pad of a finger firmly and quickly remove. It will go from white to normal color in less than 2 seconds if there is good perfusion. This is referred to as the capillary refill time (CRT). If there is no pulse, or it takes longer than 2 seconds for the color to return to pink, tag red. If a pulse is present and CRT is normal, move on to checking mental status.
Mental status: Can the patient follow simple commands (“open your eyes,” “what’s your name?”)? If the patient is breathing and has normal perfusion but is unconscious or disoriented, tag red. Tag patients yellow if they can understand you and follow commands but can’t get up, green if they can. Remember that, as a consequence of the explosion, some victims may not be able to hear you well.
It might be easier to remember all this by just thinking “30–2–Can Do”: 30 (respirations), 2 (CRT), Can Do (Commands).
If there is any doubt as to the category, always tag the highest priority triage level—red. Once you have identified someone as triage level red, tag them and move immediately to the next patient unless you have major bleeding to stop. Any one RPM check that does not meet the 30–2–Can Do rule tags the victim as red. For example, if someone wasn’t breathing but began breathing once you repositioned the airway, tag red, and stop further evaluation if the person is not hemorrhaging. Elevate the legs if you suspect shock, then move to the next patient.
Now, let’s return to our mass casualty event. You have identified eight walking wounded and moved them to a designated area. Your two uninjured helpers are an able-bodied man and woman. The woman knows how to take a pulse. Let’s say you have no medical equipment with you other than some oral airways and triage tags to work with. We describe below how to triage your ten victims, starting with the closest.
Victim 1. Male in his thirties, complains of pain in his left leg (obviously fractured), respirations are 24 times per minute, pulse strong, CRT is 1 second, no excessive bleeding.
Respirations are within acceptable range (fewer than 30); pulse and CRT is normal. The patient complains of pain and is communicating where it hurts, so mental status is probably normal. This patient is tagged yellow: needs care but will not die if there is a reasonable (2–4 hour) delay. Move on.
Victim 2. Female in her fifties, bleeding from nose, ears, and mouth. Trying to sit up but can’t, respirations are 20, pulse is present, CRT is 1 second, not responding to your commands.
This victim has a significant head injury but is stable from the standpoint of respirations and perfusion. As her mental status is impaired, tag red (immediate). Move on.
Victim 3. Teenage girl bleeding heavily from her right thigh, respirations are 32, pulse is thready, CRT is 2.5 seconds, follows commands.
This victim is seriously hemorrhaging, one of the reasons to treat during triage. Respirations are elevated and perfusion is impaired. You have your unskilled male helper place his hands on the bleeding and apply pressure, preferably using his shirt or bandanna as a dressing. Tag red. As the patient is already tagged red, you don’t really have to assess mental status. You and your female helper move on.
Victim 4. Another teenage girl, small laceration on forehead, says she can’t move her legs. Respirations are 20, pulse is strong, CRT is 1 second.
Probable spinal injury but otherwise stable and can communicate. Tag yellow. Move on.
Victim 5. Male in his twenties, head wound, respirations absent. Airway repositioned, still no breathing.
If he is not breathing, you will reposition his head and place an airway. This fails to restart his breathing. This patient is deceased for all intents and purposes. Tag black and move on.
Victim 6. Male in his forties, burns on face, chest, and arms. Respirations are 22, pulse is 100, CRT is 1.5 seconds, follows commands.
This victim has significant burns over large areas of his body, but is breathing well and has normal perfusion. Mental status is unimpaired, so you tag yellow and move on.
Victim 7. Teenage boy, multiple cuts and abrasions but not hemorrhaging, says he can’t breathe, respirations are 34, radial pulse (the pulse of the radial artery palpated at the wrist) is present, CRT is 2.5 seconds.
This victim doesn’t look too bad but is having trouble breathing and has questionable perfusion. Mental status is unimpaired, but he likely has other issues, perhaps internal bleeding. You tag red (due to respirations greater than 30 and impaired perfusion). Move on.
Victim 8. Female in her twenties, burns on neck and face, respirations are 22, pulse is present, CRT is 1 second, asks to get up and can walk, although with a limp.
Obviously injured, this young woman is otherwise stable and communicating. With assistance, she is able to stand up, and can walk by herself. She becomes another of the walking wounded: tag green. Point her to the other green victims and move on.
Victim 9. Elderly woman, bleeding profusely from an amputated right arm (level of forearm), respirations are 36, pulse on other wrist is absent, CRT is 3 seconds, unresponsive.
The victims is obviously in dire straits, so you use your shirt as a tourniquet and have your helper apply pressure on the bleeding area. Tag red and move on.
Victim 10. Male child, multiple penetrating injuries, no respirations. Airway repositioned, starts breathing. Radial pulse is absent, CRT is 2 seconds, unresponsive.
You initially think this child is deceased, but you follow protocol and reposition his airway by tilting his head back. In normal circumstances you would be very reluctant to do this because of the possibility of a neck injury. An MCI is one of the few circumstances where you don’t worry about cervical spine injuries in making your assessment. To your surprise, he starts breathing even without an oral airway, so you tag him red. If he is bleeding heavily from his injuries, you apply pressure and wait for the additional help you originally requested to arrive.
You have just performed triage on twenty victims, including the walking wounded, in ten minutes or less. Help begins to arrive, including the ICU nurse that you contacted initially. You are no longer the most experienced medical resource at the scene, and you are relieved of incident command. The nurse begins the process of assigning areas where secondary triage and treatment can occur for victims with yellow, red, and black tags.
There is still much to do, but you have identified those victims who need the most urgent care. In a normal situation, modern medical facilities will already have ambulances and trained personnel with lots of equipment on the scene. In an off-grid setting, however, the prognosis for many of the victims is grave. Go over our list of victims and see who you think would survive if modern medical care is not available. Many of the red tags and even some of the yellow tags would be in serious danger of dying from their wounds.
Before deciding whether to move a patient, stabilize them as much as possible. This means stopping all bleeding, splinting, orthopedic injuries, and verifying that the person is breathing normally. If you cannot ensure this, consider having a group member get the supplies needed to support the patient before you move them. Have as many helpers available to assist you as you can. The most important thing to remember is that you want to carry out the evacuation with the least trauma to your patient and yourself.
An important medical supply to have in this circumstance is a stretcher. Many good commercially produced stretchers are available, but improvised stretchers can be put together without too much effort. Even an ironing board can become an effective transport device. A person with a spinal injury should be rolled onto a stretcher without bending their neck or back, if at all possible.
Other options include taking two long sticks or poles and inserting coats or shirts through them to handle the weight of the victim. If the rescuer grasps both poles, a helper could pull their coat off. This automatically moves the coat onto the poles. Lengths of paracord or rope can also be crisscrossed to form an effective stretcher.
If you must pull a person to safety, grasp their coat or shirt at the shoulders with both hands, allowing their head to rest on your forearms. You could also place a blanket under the patient, and grasp the end of the blanket near their head and pull. Again, if you are uncertain about the extent of any spinal injuries, do your best to avoid bending the body or neck during transport.
If your patient can be carried, there are various methods available. The “fireman’s carry” is effective and keeps the victim’s torso relatively level and stable. If the patient is unconscious, this process is easier if they are carefully positioned so as to lie on their stomach. You can lift by “hugging” the victim under their arms and putting your dominant leg between their bent legs for support. You would then grasp the person’s right wrist with your left hand and place it over your right shoulder. Keeping your back straight, place your right hand between their legs and around the right thigh. Using your leg muscles to lift, rising up; you should end up with their torso over your back and their right thigh resting over your right shoulder. Their left arm and leg will hang behind your back if you have done it correctly. Adjust their weight so as to cause the least strain.
Another option is the “pack-strap carry.” With your patient behind you, grasp both arms and cross them on the front of your chest. If squatting, keep your back straight and use your legs and back muscles to lift the victim. Bend slightly so that the person’s weight is on your hips and lift them off the ground.
If you have the luxury of an assistant, you might consider placing your patient, if conscious, on a chair and carrying them using their front legs and the back of the chair. This constitutes a sitting “stretcher.” Another two-person carry involves one rescuer wrapping their arms around the victim’s chest from behind while the second rescuer (facing away from the patient) grabs the patient’s legs behind each knee. This is done in a squatting position, using the leg muscles to lift the patient.
It’s important to remember this simple acronym when pulling or carrying a person: B.A.C.K, which stands for the following:
Back straight. Muscles and discs can handle more weight safely when the back is straight.
Avoid twisting. Joints can be damaged when twisting.
Close to body. Avoid reaching to pick up a load, as it causes more strain on muscles and joints.
Keep stable. The more rotation and jerking, the more pressure on the discs and muscles.