HYGIENE-RELATED MEDICAL PROBLEMS
In nature, many animals make specific efforts to preen and groom themselves. Their instinctual tendency to stay clean keeps them healthy. Time and effort spent in remaining clean translates into resistance to disease. When humans are under stress, attention to hygiene suffers because all available energy must be directed to activities of daily survival.
As the medic, you will have some control over the likelihood that your family or group will be exposed to unsanitary conditions. Indeed, your diligence in this matter is one of the major factors that will determine your success as a caregiver. Strict enforcement of good sanitation and hygiene policies will do more to keep your family healthy than anything that any medical doctor can do.
In a situation where there is no access to common cleansing items, such as soap or laundry detergent, the goal of staying clean is difficult to achieve, even with the best of intentions. Therefore, accumulation of these items in quantity is in your best interest.
Cleanliness issues extend to many areas, such as dental care and foot care. The dirtier and wetter we get, the more prone we are to problems such as infections or infestations. With careful attention to hygiene, we can avoid many medical issues, as we discuss in this section.
LICE AND TICKS
A common health problem pertaining to poor hygiene is louse infestation, also known as “pediculosis.” Lice are wingless insects that are found on many species. On humans, there are three types: head, body, and pubic. Lice serve as a vehicle to transmit some diseases, causing major implications for entire families. Sometimes itching caused by lice leads to breaks in the skin, which enables other infections to develop.
Although it is thought that human lice evolved from organisms on gorillas and chimpanzees, they are, generally speaking, species specific. That means that you cannot get lice from your dog, like you could get fleas. You get them only from other humans.
Lice spread rapidly in crowded, unsanitary conditions or where close personal contact is unavoidable. These conditions occur, for example, in many schools where children come into contact with each other during the course of the day (head lice, mostly). The sharing of personal items can also lead to louse infestations; combs, articles of clothing, pillows, and towels that are used by multiple individuals are common ways that lice are spread.
Adult head lice (Pediculus humanus capitis) are greyish-white and can reach the size of a small sesame seed. Infestation with head lice can cause itching and, sometimes, a rash. However, this type of lice is not a carrier of any other disease. Even in developed countries, head lice are relatively common, with 6–12 million cases a year in the United States, mostly among young children.
With their less developed immune systems, kids sometimes don’t even know they have them; adults are usually kept scratching and irritated unless treated.
The diagnosis is made by identifying the presence of the louse or its “nits” (eggs). Nits look like small bits of dandruff that are stuck to hairs. A fine-tooth comb run through the hair is a good method to find adult lice and nits. Special combs are used to remove as many lice as possible before treatment and to check for them afterwards. Many prefer the metal nit combs sold at pet stores to plastic ones sold at pharmacies.
You will find that the nits are firmly attached to the hair shaft about one-quarter inch from the scalp. Nits will generally appear as yellow or white and oval-shaped. Nits may be easier to remove by applying olive oil to the comb.
Body lice (Pediculus humanus corporis) are latecomers compared with head lice, probably appearing with the advent of humans wearing clothes. As the concept of cleaning clothes occurred quite later, the constant contact with dirty garb caused frequent infestations.
This may be a common issue with the homeless today but will likely be an epidemic in a survival situation when regular bathing and clothes washing becomes problematic. Body lice are slightly larger than head lice; they also differ in that they live on clothes, using the body only to feed. They are sturdier than their cousins and can live without human contact for thirty days or so.
Removal and, preferably, destruction of the infested clothing is the appropriate strategy here. Using medication is sometimes unnecessary, as the lice have left with the clothes (don’t bet on it, however). Body lice, unlike head lice, are associated with infectious diseases such as typhus, trench fever, and epidemic relapsing fever. Continuous exposure to body lice may lead to areas on the skin that are hardened and deeply pigmented.
Pubic infestations may be caused by either lice or mites. Pubic lice (Pthirus pubis), also known as “crabs,” usually start in the pubic region but may eventually extend anywhere there is hair, even the eyelashes. They are most commonly passed by sexual contact. Severe itching is the main symptom and can involve the axillary (armpit) hair or even the eyelashes.
Although they are sometimes seen in a patient as a sexually transmitted disease because they are usually transferred from one person to another through sexual activity, pubic lice do not actually transmit other illnesses. It should be noted that pubic lice constitute one of the few “sexually transmitted diseases”TM that is not prevented by the use of a condom.
Scabies is different from crabs and is caused by tiny eight-legged organisms called mites (Sarcoptes scabiei), not lice. The mites burrow through the skin, forming small, raised, red bumps. Itching is noted and is most intense at night. Scabies can affect skin folds, even those with few hairs, such as the folds of the wrists, elbows, or between the fingers or toes.
These types of infestation are killed by medications called “pediculocides,” which include the following:
• NixTM lotion (1 percent permethrin)
• RID shampoo (pyrethrin)
• Kwell shampoo (lindane)
• Malathion 5 percent in isopropanol
Nix lotion (permethrin) will kill both the lice and their eggs. RID shampoo will kill the lice, but not their eggs. Be certain to repeat the shampoo treatment seven days later. This may not be a bad strategy with the lotion, as well. Ask your physician for a prescription for Kwell shampoo to stockpile. It is a much stronger treatment for resistant cases. It may cause neurological side effects in children, so avoid using this medicine on them. Use these products as follows:
1. Start with dry hair. If you use hair conditioners, stop for a few days before using the medicine. This will enable the medicine to have the most effect on the hair shaft.
2. Apply the medicine to the hair and scalp.
3. Rinse off after 10 minutes or so.
4. Check for lice and nits in 8–12 hours.
5. Repeat the process in 7 days.
6. Wash all linens that you don’t throw away in hot water (at least 120 degrees). Unwashable items, such as stuffed animals, that you cannot bring yourself to throw out should be placed in plastic bags for 2–5 weeks (to kill off any remaining head and body lice), then opened to air outside. Combs and brushes should be placed in alcohol or very hot water. Clothes should be changed frequently, if possible.
Natural remedies for lice have existed for thousands of years. Even commercial medications such as RID shampoo use pyrethrin, which is extracted from the chrysanthemum flower. Another favorite antilice product is ClearLiceTM, a natural product containing peppermint, among other things, and is thought by many to be superior to standard treatments.
Another good treatment for lice is a combination of tea tree and neem (a tree in the mahogany family) oils. For external use only, mix a blend of salt, vinegar, tea tree oil, and neem oil and apply daily for 21 days. Alternatively, witch hazel and tea tree oil applied after showering daily for 21 days has been reported to be effective against hair lice.
A triple blend of tea tree, lavender, and neem oil applied to the pubic region for 21 days may also be effective in eliminating scabies, as might witch hazel and tea tree oil. Some have advocated bathing with ½ cup of Borax and ½ cup of hydrogen peroxide daily for 21 days.
Ticks are not as clearly associated with poor hygiene as lice. Although they are commonly thought of as insects, they are actually arachnids like scorpions and spiders. The American dog tick carries pathogens (disease-causing organisms) for Rocky Mountain spotted fever; and the blacklegged tick, also known as the deer tick, carries the microscopic parasite that’s responsible for Lyme disease. Some tick-borne illness is similar to influenza with regards to symptoms, and so is often missed by the physician. Lyme disease sometimes has a telltale “bull’s-eye” rash, but other tick-related diseases may not.
Most Lyme disease is caused by the larval or juvenile stages of the deer tick. These are sometimes tough to spot because they’re not much bigger than a pinhead. Each larval stage feeds only once and very slowly, usually over several days. The larval ticks are most active in summer. Although most common in the northeastern United States, they seem to be making their way farther west every year.
Ticks don’t jump like fleas do; they don’t fly like flies, and they don’t drop from trees like your average spider. The larvae like to live in leaf litter, and they latch onto your lower leg as you pass by. Adults live in shrubs along game trails, hence the name deer tick. In inhabited areas, you might find them in woodpiles (especially in shade).
Many people don’t think to protect themselves outdoors from exposure to ticks and other such potentially harmful animals, or plants, such as poison ivy. Anyone spending the day in the fresh air should take some precautions:
• Don’t leave skin exposed below the knee.
• Wear thick socks (tuck your pants into them).
• Wear high-top boots.
• Use insect repellant.
A good bug repellant is going to improve your chances of avoiding bites. Citronella can be found naturally in some areas and is related to plants such as lemon grass; just rub the leaves on your skin. Oil from soybeans or eucalyptus will also work. Consider including these in your medicinal garden, if your climate is suitable.
It is important to know that the risk of contracting Lyme disease, or other tick-borne illness, increases with the length of time it feeds on someone. The good news is that there is generally no transmission of disease in the first 24 hours. The chance of infection is highest after 48 hours, so it pays to remove that tick as soon as possible. Ticks sometimes don’t latch onto a person’s skin for a few hours, so showering or bathing after a wilderness outing may simply wash them off. This is where good hygiene pays off.
To remove a tick, take the finest set of tweezers you have and try to grab the tick as close to the skin as you can. Pull the tick straight up; this will give you the best chance of removing it intact. If removed at an angle, the mouthparts sometimes remain in the skin, which might cause an inflammation at the site of the bite. Fortunately, it won’t increase the chances of getting Lyme disease.
Afterwards, disinfect the area with Betadine or what is known as “triple antibiotic” ointment. Although other methods of tick removal, such as smothering it with petroleum jelly or lighting it on fire, are often tried, no method is more effective than pulling it out with tweezers.
Luckily, only about 20 percent of deer ticks carry Lyme or another parasitical disease. A rash that appears like a bull’s-eye occurs in about half of patients. Anyone getting a rash along with flu-like symptoms that are resistant to medicines will need further treatment.
Oral antibiotics will be useful to treat early stages. Amoxicillin (500 mg 3 times a day for 14 days) or doxycycline (100 mg 2 times a day for 14 days) should work to treat the illness. These can be obtained without a prescription in certain veterinary medications (discussed later in this book). Don’t be surprised if your patient still experiences muscle aches and fatigue for a time after treatment.
Many of our readers are often surprised that a book on survival medicine devotes a portion of its pages to dental issues. History, however, tells us that problems with teeth take up a significant portion of the medic’s patient load. During the Vietnam War, medical personnel noted that half of all sick call patients presented with dental complaints.
To be clear, neither of us is a dentist, and it’s illegal and punishable by law to practice dentistry without a license. The lack of formal training or experience in dentistry may cause complications that are much worse than a bum tooth. If you have access to modern dental care, seek it out.
Anyone who has had to perform a task while simultaneously dealing with a bad toothache can attest to the decrease in work efficiency caused by the problem. Therefore, it only makes sense that you must learn basic dental care and procedures to handle common dental emergencies.
A survival medic’s philosophy should be that an ounce of prevention is worth a pound of cure. This thinking is especially apt when it comes to your teeth. By enforcing a regimen of good dental hygiene, you will save your loved ones from a lot of pain (and yourself from a lot of headaches).
The anatomy of the tooth is relatively simple for such an important part of our body and is worth reviewing. The part of the tooth that you see above the gum line is the “crown.” Below it is the “root.” The bony socket that the tooth resides in is the “alveolus.” Teeth are anchored to the alveolar bone with ligaments, just like you have ligaments holding together your ankle or shoulder.
The tooth is composed of several materials:
Enamel—the hard, white external covering of the tooth crown
Dentin—the bony yellowish material under the enamel and surrounding the pulp
Pulp—connective tissue with blood vessels and nerve endings in the central portion of the tooth
Most dental disease is caused by bacteria. Your mouth is chock full of them, so anything that decreases the amount of bacteria there will reduce the chances of developing problems.
A daily brushing routine is essential, but at one point or another you will run out of toothbrushes. As an alternative, you can use your finger with a little toothpaste in a circular motion. A piece of cloth can also be used for this purpose.
Another option is to chew on the end of a twig until it gets fibrous and use that to clean your teeth. Any bendable twig (that is, live wood) will serve the purpose. This twig can serve dual purposes in that you could use the other end as a toothpick.
At one point or another, commercially made toothpaste will no longer be available. Consider baking soda as an inexpensive alternative. It’s less abrasive to dental enamel than manufactured silica-based toothpaste.
Every time you eat a meal and, especially, before going to bed, you should brush your teeth or at least rinse your mouth. This will decrease inflammation in the gums and the risk of infection.
An effective and inexpensive option would be to use a solution made of ½ water and ½ hydrogen peroxide (3 percent). Swish it around in your mouth for 1–2 minutes to obtain the full effect. Most people don’t include mouth rinses as part of their survival storage, but this is a great way to prevent tooth issues. Beware of higher concentrations of hydrogen peroxide, as these could burn the inside of your mouth.
Another method of preventing tooth decay is faithful flossing. It may be inconvenient for some, but a lot of bacteria accumulate between your teeth. You can prove this by flossing and then smelling the floss. Unless you’re flossing regularly, it will have a foul odor due to the large amounts of bacteria you have just dislodged. Dental floss is also useful for removing foreign objects, such as food particles, from between teeth.
It’s important to understand how bacteria causes tooth disease. Bacteria live in your mouth and colonize your teeth. Usually, they accumulate in the crevices on your molars and at the level where the teeth and gums meet. These colonies form a thick, irregular film on the base of your enamel known as tartar or plaque. The more tartar you have, the less healthy your gums and teeth are.
When you eat, these bacterial colonies also have a meal; they digest the sugars you take in and produce a toxic acid. This acid has the effect of slowly dissolving the enamel of your teeth.
Once the enamel has broken down, a “cavity” is created. When the cavity becomes deep enough to invade the soft inner part of the tooth (the pulp), the process speeds up and, because you have living nerves in each tooth, starts to cause pain. If the cavity isn’t dealt with, it can lead to infection once the bacteria dig deep enough into the nerve or the surrounding gum tissue.
Inflamed gums have a distinctive appearance: They’ll appear red and swollen; they’ll bleed when you brush your teeth. Known as gingivitis, this is very common in adults. As the condition worsens, it can easily lead to infection. If it affects the gums, it may spread to the roots of teeth or even the bony socket.
Once the root of the tooth is involved, you could develop a particularly severe infection (abscess). This is an accumulation of pus and inflammatory fluid that causes gum swelling and can be quite painful. Once you have an abscess, you will need antibiotic therapy and, perhaps, a procedure to drain the pus that has accumulated. The tooth will likely be unsalvageable at this point.
Treatment of a toothache starts with finding the bad tooth. Have your patient open his or her mouth so that you can investigate the area. A dental mirror and dental pick are good tools to start with. First, you will carefully look around for any obvious cavity or fracture. If there is nothing that you can see, however, you may still have serious decay between teeth or below the gums.
So how do you tell which tooth is the problem if you don’t see anything obvious? Touch the teeth in the area of the toothache with something cold. The bad tooth will be very sensitive to cold. Now, touch it with something hot. If there is no sensitivity to heat, the tooth is probably salvageable.
A tooth that is probably beyond hope will cause significant pain when you touch it with something hot (only touch the tooth). It will continue to hurt for ten seconds or so after you remove the heat source. This is because the nerve has been irreversibly damaged. Once the nerve is damaged at the level of the root, you might not feel either hot or cold. It will, however, be painful to even the slightest touch.
The goal of modern dentistry is to save every tooth, if at all possible. In the old days (as recently as fifty years ago), the main treatment for a diseased tooth was extraction. In a survival setting, we may have to return to that strategy.
If you delay extracting a severely decayed tooth, it will likely get worse. Decay could spread to other teeth or cause septicemia, an infection that could spread to your bloodstream and cause major damage.
The important thing to know is this: 90 percent of all dental emergencies can be treated by extracting the tooth.
Besides a dental pick and mirror, what else needs to be in the medic’s dental kit?
Medical Dental Kit
• Dental floss, toothbrushes.
• Dental or orthodontic wax as used for braces; even a candle will do in a pinch. Wax can be used to splint a loose tooth to its neighbors.
• A rubber bite block to keep the mouth open. This will help you see the dentition and prevent yourself from getting bitten. One of those large pink erasers would serve the purpose just fine.
• Cotton pellets, Q-tips, gauze sponges (cut into small squares).
• Temporary filling material, such as Tempanol, Cavit or DentempTM.
• Oil of cloves (eugenol), a natural anesthetic. It’s important to know that eugenol burns the tongue, so never touch anything but teeth with it.
• Zinc oxide powder; mixed with two drops of clove oil, it will harden into temporary filling cement or may help fasten loose crowns.
• Dental tweezers, dental mirrors, and a dental pick.
• Extraction forceps. These are like pliers with curved ends. They come in versions specific to upper and lower teeth. Although there are many types of dental extractors, you should at least have two: number 151 or 79N for lower teeth and number 150A or 150 for upper teeth; number 23 is useful for some molar extractions.
• Elevators—one small, one medium. These are thin, chisel-like instruments that help loosen teeth by separating ligaments that hold teeth in their sockets. (Some parts of a Swiss army knife might work in a pinch.)
• A dental scaler and dental pick to remove tartar.
• Pain medication and antibiotics.
Common dental issues will include lost fillings or loose crowns. These can be repaired, at least temporarily, by making a mixture that will harden quickly and provide a reasonable seal.
Take two drops of clove oil and mix it with zinc oxide powder to form a paste. Roll this into a ball and apply this to the area. It will harden, relieving pain at the same time.
Use your dental pick to scrape out black decay, especially at the edges of the cavity. Your paste should cover the entire area previously occupied by the original filling. Scrape off excess so that the person can close their teeth normally when they bite. You can use carbon paper or paper that you have rubbed a pencil on to identify areas where you have placed excess cement. Have your patient bite down; the carbon will stain the excess filling material dark.
It should be noted that these methods are temporary measures. Unless modern dentistry becomes available again, you will likely have to repeat the filling process multiple times.
Dental trauma may appear in various forms. After an injury to the oral cavity, a person may have any of the following:
Dental fracture—portion of a tooth chipped or broken off
Dental subluxation—a loose tooth
Dental avulsion—a tooth knocked out completely
When a portion of a tooth is broken off, it is categorized on the basis of the number of layers of the tooth that are exposed. Dentists generally refer to these as Ellis class I, II, or III fractures:
Ellis I fracture: This is where only the enamel has been broken and no dentin or pulp is exposed. This is only a problem if there is a sharp edge to the tooth. You can consider filing the edge smooth or using a mixture of oil of cloves (eugenol) and zinc oxide powder as temporary cement.
Ellis II fracture: These fractures show yellow or beige dentin under the enamel. This area may be sensitive and should be covered if possible. The composition of dentin is different than enamel, and bacteria may enter and infect the tooth.
Ellis III fracture: Here the pulp and dentin are both exposed, and Ellis III fractures can be quite uncomfortable. If the pulp is exposed, it may bleed. Protective coverings will be most necessary here, and the risks of permanent damage most likely.
When you identify a fracture of a tooth, you should evaluate the patient for associated damage, such as to the face, inside of the cheek, tongue, and jaw. On occasion, a tooth fragment may be lodged in the soft tissues and must be removed with instruments.
Blood is likely to be present because of the trauma, so thoroughly rinse out the inside of the mouth so you can fully assess the situation. Then, using your gloved hand or a cotton applicator, lightly touch the injured tooth to see if it is loose. Don’t forget your bite block.
For sensitive Ellis II fractures of dentin, cover the exposed surface with a calcium hydroxide composition (commercially sold as DycalTM), a fluoride varnish, clear nail polish, or a medical adhesive, such as DERMABONDTM(medical super glue) to decrease sensitivity. Provide pain medications, and instruct the patient to avoid hot and cold food or drink.
Ellis III fractures into pulp are trouble, due to the risk of infection, among other reasons. Calcium hydroxide on the pulp surface coupled with additional temporary cement can be used as coverings. Provide analgesics and antibiotics, such as penicillin or doxycycline, are acceptable options. Despite all this, the prognosis is not favorable without modern dental intervention.
A particularly difficult dental fracture involves the root. Sometimes, it is not until the gum is peeled back that a fracture in the root is identified. If this is the case, the tooth is likely unsalvageable (especially in vertical fractures) and usually needs extraction.
Dental Subluxations and Avulsions
A subluxation is a tooth that is knocked loose but not out of its alveolar socket. Lightly pressing the tooth with your gloved hand or a cotton applicator should identify if it is loose and how much. Minimal trauma may require no major intervention.
If a tooth is loose, it should be pressed back into the alveolus (socket) and “splinted” to neighboring teeth for stability. Dentists use wire or special materials for this purpose, but you might find yourself having to use soft wax if professional help is not at hand. If you can, use enough wax to anchor the loose tooth to neighboring teeth both in front and in back. Prevent further trauma by placing the patient on a diet of liquids and soft foods (juices, gelatin, pudding, etc.) for a time, until the tooth appears well anchored.
The most favorable situation when a tooth is completely knocked out (an avulsion) is that it came out in one piece, down to its root and ligaments. In this circumstance, time is an important factor in possible treatment success. If the tooth is not replaced or at least placed in a preservation solution, the success of reimplantation drops 1 percent every minute the tooth is not in its socket. Note: Don’t attempt to replace baby teeth.
A good preservation liquid for teeth that have been knocked out is Hanks’ solution. It helps protect raw ligament fibers for a time. This solution is available commercially as Save-a-ToothTM.
If a tooth is knocked out, do the following:
Find the tooth.
Pick it up by the crown, avoid touching the root, as it will damage the already damaged ligament fibers.
Flush the tooth clean of dirt and debris with water or saline solution. Don’t scrub it, as it will damage the ligament further.
If you don’t have preservation solution, place the tooth in milk, saline solution, or saliva (put it between your cheek and gum, or under your tongue). This will keep your ligament cells alive longer than plain water will.
If the tooth has been out for less than 15 minutes, you may attempt to reimplant it. Flush the tooth and the empty socket with Hanks’ solution (Save-a-Tooth), replace it, and cover it with cotton or gauze. Then, have the patient bite down firmly to keep it in place. Splint it with soft wax to the neighboring teeth and place your patient on a liquid diet. Antibiotics such as penicillin (veterinary equivalent: Fish Pen) or doxycycline (Bird Biotic) will be helpful to prevent infection.
You may have to soak the tooth for a half hour or so in Hanks’ solution before you replace it, if it has been out for more than 15 minutes. The longer you wait to replace the tooth, the more painful it will likely be to replace, so make sure you have pain relief meds in your supplies.
After a couple of hours of being out, the ligament fibers dry out and die, and the tooth is for most intents and purposes dead. Replacing it at this point is problematic, as the pulp will decay like all dead soft tissue does. The dead tooth (which may turn dark in color) then scars down into its bony socket, acting like a dental implant. This is called “ankylosis.”
It’s important to know that, in mature permanent teeth, the pulp doesn’t survive the injury even if the ligament does. As such, without the availability of modern dental care to remove dead tissue, even your best efforts may be unsuccessful. Serious infection in the dead pulp often ensues, and your patient may be in a worse situation than just missing a tooth.
Life with dentists may be unpleasant sometimes, but life without dentists will leave us with few options in most dental emergencies. In such circumstances, we may have to return to tooth extraction as the treatment of choice.
You, as medic, may eventually find yourself in a situation where you have to remove a diseased tooth. Tooth extraction is not an enjoyable experience as it exists today, and will be less so in a long-term survival situation with no power and limited supplies. Unlike baby teeth, a permanent tooth is unlikely to be removed simply by wiggling it out with your (gloved) hand or tying a string from it to the nearest doorknob and slamming. Knowledge of the procedure, however, will be important for anyone expecting to be the medical caregiver in the aftermath of a major disaster.
Proper positioning will help you perform the procedure more easily. The patient should be tipped at a 60-degree angle to the floor for an upper extraction (also called a maxillary extraction). The patient’s mouth should be at the level of the medic’s elbow. For a lower extraction (also called a mandibular extraction), the patient should be sitting upright with the mouth lower than the elbow of the medic. For right-handed medics, stand to the right of the patient; for left-handers, stand to the left. For uppers and most front lower extractions, it is best to position yourself in front of the patient. For lower molars, some prefer to position themselves behind the patient.
To begin with, wash your hands and put on gloves, a face mask, and some eye protection. You will want to keep the area around the tooth as dry as possible, so that you can see what you’re doing. Some bleeding will occur, so you might want to place cotton balls or rolled gauze squares around the tooth to be removed and replace as needed.
The teeth are held in place in their sockets by ligaments, which are fibrous connective tissue. These ligaments must be severed to loosen the tooth. This is accomplished with an elevator, which looks like a small-headed flathead screwdriver or chisel.
Dental extractors and elevator
Go between the tooth in question and the gum on all sides and apply a small amount of pressure to get down to the root area. This should loosen the tooth. Expect some bleeding.
Take your extraction forceps and grasp the tooth as far down the root as possible. This will give you the best chance of removing the tooth in its entirety the first time. For front teeth (which have one root), exert pressure straight downward for upper teeth and straight upward for lower teeth, after first loosening the tooth with your elevator. For teeth with more than one root, such as molars, a rocking motion will help loosen the tooth further as you extract. Once loose, avoid damage to neighboring teeth by extracting towards the cheek (or lip, for front teeth) rather than towards the tongue. This is best for all but the lower molars that are furthest back (wisdom teeth).
Use your other hand to support the mandible (lower jaw) in the case of lower extractions. If the tooth breaks during extraction (this is not uncommon), you will have to remove the remaining root. Use your elevator to further loosen the root and help push it outward.
Afterwards, place some gauze on the bleeding socket and have the patient bite down. A product known as ActCel hemostatic gauze is helpful to slow excessive bleeding; cut the gauze into small moistened squares and place directly on the bleeding area. It should form a gel which can be rinsed away with water in 24 hours.
Occasionally, a suture may be required if bleeding is heavy. Use 4–0 chromic catgut absorbable suture material in this case. In a recent Cuban study, what is known as veterinary “super glue” (N-butyl-2-cyanoacrylate) was used in more than one hundred patients with good success in controlling both bleeding and pain. DERMABOND glue has been used in some cases in US emergency rooms for temporary relief. Hot liquids and hard foods should be avoided for 24–72 hours.
Expect some swelling, bruising, and pain over the next few days. Cold packs will decrease swelling for the first 24–48 hours; afterwards, use warm compresses to help with jaw stiffness. Also, consider antibiotics, as infection is a possible complication. The patient should be put on a diet of liquids and soft foods to decrease trauma to the area.
Use acetaminophen (TylenolTM) or nonsteroidal anti-inflammatory medicine, such as ibuprofen, for pain (or stronger meds, if you have them). Stay away from aspirin, as it may hinder blood clotting in the socket. The blood clot is your friend, so make sure not to smoke, spit, or even use straws; the pressure effect might dislodge it, which could cause a painful condition called alveolar osteitis or “dry socket.”
In this case, you will notice that the clot is gone and you may notice a foul odor in the person’s breath. Antibiotics and warm saltwater gargles are useful here, and a solution of water with a small amount of clove oil may serve to decrease the pain. Don’t use too much of the oil, as it could burn the mouth.
In a long-term survival situation, difficult decisions will have to be made. If modern dentistry is gone because of a mega-catastrophe, the survival medic will have to take on that role as well as that of medical caregiver. Never perform a dental procedure on someone if you have modern dental care available to you.
Even with today’s modern medical technology, most of us can’t avoid the occasional respiratory infection. Without strict adherence to sanitary protocol, it would be very easy in a major disaster for your entire community to come down with colds, sinusitis, influenza, or even pneumonia. Common colds may be caused by any of 200 different viruses. Influenza comes from viruses in the Influenza A, B, and C categories (mostly A). Over the course of history, influenza outbreaks have killed more than 100 million people.
Most of the deaths associated with influenza are not caused by the virus itself, but instead by bacterial pneumonia, a secondary infection that invades a virus-weakened immune system.
In general, most respiratory infections are spread by viral particles, and many organisms that cause these infections can live for up to 48 hours on common household surfaces, such as kitchen counters and doorknobs. Contagious viral particles can easily travel 4–6 feet when a person sneezes.
Respiratory issues are usually divided into upper and lower respiratory infections. The upper respiratory tract is considered to be anything at the level of the vocal cords (larynx) or above. The diagnosis often will be related to the affected part of the upper respiratory system. Here’s how it works:
• voice box—laryngitis
• ear canal—otitis
The lower respiratory tract includes the lower windpipe, the airways (taken together, called “bronchi”), and the lungs themselves. Respiratory infections, such as bronchitis and pneumonia, are the most common cause of infectious disease in developed countries.
Typical N95 mask
Symptoms of the common cold can include fever, cough, sore throat, runny nose, nasal congestion, headaches, and sneezing. Symptoms of lower respiratory infections (pneumonia and some bronchitis) include cough (with phlegm, a “productive” cough), high fever, shortness of breath, weakness, and fatigue. Most respiratory infections start showing symptoms 1–3 days after exposure to the causative organism. They can be expected to last 7–10 days if upper and somewhat longer if lower.
Colds vs. Influenza
There are differences between the common cold and influenza that are helpful to know in making a diagnosis. The symptoms are similar but differ in frequency and severity. Consult the list below to identify what you’re most likely dealing with:
Aches and pains
For influenza, the administration of antiviral medications such as oseltamivir (TamifluTM) will shorten the course of the infection if taken in the first 48 hours after symptoms appear. After the first 48 hours, antivirals have less medicinal effect.
For colds, concentrate your treatment on the area involved: nasal congestion medication for runny noses or sore throat lozenges for pharyngitis, for example. Ibuprofen or acetaminophen will alleviate muscle aches and fevers. Steam inhalation and good hydration also give some symptomatic relief. Various natural remedies are also useful to relieve symptoms, which we discuss in the next section of this book.
Although most upper respiratory infections are caused by viruses, some sore throats may be caused by a bacterium called beta Streptococcus (strep throat). These patients will often have small white spots on the back of their throat, tonsils, or both and are candidates for antibiotics. Amoxicillin (veterinary equivalent: Fish Mox) or Keflex (Fish Flex) are included among the drugs of choice in those not allergic to penicillin drugs. Erythromycin (Fish Mycin) family drugs are helpful in those who are penicillin-allergic.
In most cases, however, it is not appropriate to use antibacterial agents such as antibiotics for upper respiratory infections. Antibiotics have been overused in treating these problems, and this has led to resistance on the part of some organisms to the more common drugs. Resistance has rendered some of the older antibiotics almost useless in the treatment of many illnesses.
Lower respiratory infections, such as pneumonia, are the most common cause of death from infectious disease in developed countries. These can be caused by viruses or bacteria. The more serious nature of these infections leads many practitioners to use antibiotics more often to treat the condition. Most bronchitis is caused by viruses, however, and will not be affected by antibiotics. Antibiotics may be appropriate for those with a lower respiratory infection that hasn’t improved after several days of treatment with the usual medications for upper respiratory infections.
The patients who are at risk will appear to have worsening shortness of breath or thicker phlegm over the course of time despite the usual therapy.
Both upper and lower respiratory infections are different from asthma, a condition where the airways become constricted in a type of spasm when exposed to a substance. This causes a particularly vocal kind of breathing (wheeze). Asthma may occur as an allergic response, or may be associated with some respiratory infections, such as childhood “croup.” The treatment of asthma involves different medicines not used with colds or flus, such as airway “openers” and epinephrine.
Good respiratory hygiene is important to prevent patients with respiratory infections from transmitting their infection to others. This is not only a good strategy for you and your family, but demonstrates social responsibility. Use the protocols below to prevent the spread of respiratory infection.
• Cover mouth and nose with tissues and dispose of those tissues safely.
• Use a mask if coughing often. Although others caring for the sick individual may wear masks (N95 masks are best for healthcare providers), it is most important for the afflicted person to wear one.
• Keep at least 4 feet away from other persons (the average distance droplets will spread), if possible.
• Perform rigorous hand hygiene before and after contact. Wash soiled hands with soap and warm water for 15 seconds or clean hands with alcohol-based hand sanitizers.
• Wash down all possibly contaminated surfaces, such as kitchen counters or doorknobs, with an appropriate disinfectant (dilute bleach solution will do).
• Isolate the sick individual in a specific quarantine area, especially if he/she has a high fever.
• Wear gloves at all times when treating the patient.
• Don’t self-medicate, especially with antibiotics, unless modern medical care is not accessible.
Many of the strategies and treatments described above will deal with respiratory infections quite well, but what if modern pharmaceuticals are not available or are no longer produced because of a major catastrophe? In that circumstance, we must look to our own backyard and, if we planned wisely, our medicinal garden. We will have to consider natural substances that might help alleviate various respiratory symptoms and strengthen the body’s immune response.
Vitamin C, Vitamin E, and other antioxidants, taken regularly, are supposed to decrease the frequency and severity of respiratory infections. Many studies confirm their usefulness, although the duration of symptoms due to respiratory viruses per year was only decreased 1 day in one study. Despite this, antioxidant support for the immune system is important and should be part of any approach to survival food storage.
Most natural remedies are meant to target individual symptoms, such as nasal congestion or fever. There are, however, a number of alternative treatments for various respiratory infections that are reported to help stimulate the entire immune system. Consider the following essential oils:
• Clove Bud
• Tea tree
To use these oils, you would follow a procedure called direct inhalation therapy. Place 2–3 drops on the palm of your hand. Warm the oil by rubbing your hands together, and then bring your hands to your nose and mouth. Breathe 3–5 times slowly and deeply. Relax and breathe normally for two minutes, then repeat the process. Wipe any excess oil onto the throat and chest.
Many herbs may be helpful when used internally as a tea. Popular ones for general respiratory support are elderberry, Echinacea, licorice root, goldenseal, chamomile, peppermint, and ginseng. Antibacterial action has been also found in garlic and onion oil, fresh cinnamon, and powdered cayenne pepper. Other options include raw unprocessed honey, lemon, and apple cider vinegar, which are often added to one of the herbal teas mentioned above.
Other than general treatments, there are several good remedies to treat specific symptoms associated with colds and flu. To treat fever, for example, consider teas made from the following herbs:
• Licorice root
• Lemon balm
The underbark of willow, poplar, and aspen trees is known to be a source of salicin, the essential ingredient in aspirin. Strip off the outer bark, and take several strips of the green underbark and make a tea out of it. It should work as aspirin does to decrease fever.
To deal with the congestion that goes along with most respiratory infections, consider using direct inhalation therapy (described above) or salves with the following essential oils:
• Tea tree
Another inhalation method of delivering the above herbs or even traditional medications involves the use of steam. Steam inhalation is beneficial for many respiratory ailments and is easy to implement. Just place a few drops of essential oil into steaming water and lower your face to inhale the vapors. Cover the back of your head with a towel to concentrate the steam.
Herbal teas made from the following relieve congestion:
• Stinging nettle
• Licorice root
• Cayenne pepper
Mix with honey and drink 3–4 times per day as needed. Fresh horseradish is used to open airways by taking ¼ teaspoon orally 3 times a day. Plain sterile saline solution (via nasal spray or in a “neti pot”) is also used by both traditional and alternative healers.
For aches and pains due to colds, try using salves consisting of the following essential oils:
• St. John’s wort
• Arnica (dilute)
Teas made from the following are thought to relieve muscle ache:
• Valerian root
• Willow underbark
Drink the tea warm with raw honey 3–4 times a day.
For the occasional sore throat, time-honored remedies include honey and garlic “syrups,” and ginger, tilden flower, or sage teas. These should be drunk warm with honey and perhaps lemon several times a day. Gargling with warm saltwater will also bring relief. Licorice root and honey lozenges are also helpful to decrease painful swallowing.
Although the herbs described in this book have all been known to be helpful, it is important to remember that individual response to a particular herbal product differs from person to person. Also, the quality of an essential oil may differ depending on various factors, including rainfall, soil conditions, and the time of harvest.
Guide to Protective Masks
Throughout history, infectious diseases have been part and parcel of the human experience. Ever since the Middle Ages, it has been clear that some infections have the capacity of passing from person to person through the air or by contact with bodily fluids. As such, medical personnel have used masks to prevent exposure.
This makes sense from more than a selfish standpoint: In survival situations, there will be few medically trained individuals to serve a group or community. In the countries affected by the 2014 Ebola epidemic, there were only two doctors per 100,000 people. The medic, therefore, is a valuable resource. It would be a disservice to those who depend upon them if they became ill.
The basic surgical mask hasn’t changed much in general appearance in the last 100 years. No doubt, you’ve seen photos of people wearing them in areas where there is an epidemic. In Asia, especially, it is considered socially responsible to wear them if you have a cold or flu and are going out in public. Face masks have the added advantage of reminding people to keep their hands away from their nose and mouth, a major source of the spread of infection.
If you will be taking care of your family in situations where modern medical care is unavailable, you will want a good supply of masks (and gloves) in your medical storage. Without these items, an infectious disease could possibly affect every member, including you.
Standard “medical masks” have a wide range of protection based on fit and barrier quality; three-ply masks (the most common version) are more “breathable,” as you can imagine, than six-ply masks, which likely present more of a barrier. A tight fit is imperative in providing a barrier to infectious droplets.
An upgrade to the basic mask is the N95 respirator mask. N95 masks are a class of disposable respirators that have at least 95 percent efficiency against particulates larger than 0.5 microns. These are useful against many contaminants but are not 100 percent protective. There are higher level masks—N99 masks (99 percent) and N100 masks (99.7 percent)—but they are more expensive. The N stands for non-oil-resistant; there are also R95 (oil-resistant) and P95 (oil-proof) masks; these are used mostly for industrial and agricultural work.
Many of these masks have a square or round “exhalation valve” in the middle, which helps with breathability. They do not cover the eyes, however, and do not protect against gases such as chlorine. For this, you would need a “gas mask,” although even these do not prevent contamination from substances absorbed through the skin.
So what would be a reasonable strategy? You’ll need both standard and N95 masks as part of your medical supplies. I would recommend a significant number of each, because the masks will be contaminated once worn and should be discarded. In cases of extremely deadly diseases, such as Ebola, face shields and hoods should be added.
There are no absolute standards with regards to who wears what in the sickroom. I would recommend using the standard masks for those who are ill, to prevent contagion from coughing or sneezing (which can send air droplets several feet). Reserve the N95 masks for the caregivers. In this fashion, you will give maximum protection to those at highest risk for exposure. Remember, your highest priority is to protect yourself and the healthy members of your group. Isolate those who might be contagious, have plenty of masks, along with gloves, aprons, eye wear, and antiseptics, and pay careful attention to every aspect of hygiene.
THE EFFECTIVE SICKROOM
In normal times, we have the luxury of modern medical facilities and advanced techniques to isolate a sick patient from healthy people. If we ever find ourselves off the grid because of a disaster, most of these advantages will go the way of the dinosaur, and we will be placed in, essentially, the same medical environment we experienced in the nineteenth century.
We have the benefit, however, of knowing about sterilization and the way contagious diseases are spread, so we have a head start on our ancestors. Using this knowledge, it should be possible for the medically prepared to put together a “sickroom” or “hospital tent.” This will minimize the chance of infectious diseases running rampant.
Plans for an area to care for the sick and injured should be in place whether you are at home or on the trail. If you’re staying in place, designate a sickroom in your home. It should be at one end of the house, have a window or two to allow light and ventilation, and a door that can be closed. If you are in the wilderness, choose a hospital tent and place it on the periphery of your camp. Making a plan before a major disaster is important, as you will inevitably be kicking someone out of their room or tent if you don’t. As a result, you can expect resentment at a time when everyone needs to pull together to survive.
If you don’t have a spare room or tent, you’ll have to erect a makeshift barrier, such as a sheet of plastic, to separate the sick from the healthy. Even if you have a dedicated sickroom, this might make sense to hang over the door as added protection. You’ll want to keep those with injuries separate from those with infectious diseases, such as influenza or pneumonia, if at all possible.
Air-conditioning ducts will be close to useless in a power-down scenario, and could pose a major risk to the rest of your group. Cover them. Keep windows or vent flaps open except in particularly inclement weather to decrease the concentration of airborne pathogens.
Furnishings should be minimal, with a work surface, an exam area, and bed spaces. Cloth surfaces, such as on sofas and carpets can harbor germs and therefore should be avoided. Even bedding for the contagious might best be covered in plastic. The more areas that can be wiped down or disinfected easily, the better. (Try to do that daily with a carpet!) It’s important to have a way to eliminate waste products from your bedridden patients, even if it’s just a 5-gallon bucket of bleach solution. Have closed containers available for used sickroom items.
A station near the entrance of the room or tent with masks, gloves, gowns, and disinfectants would be very helpful. You’ll need a basin with water, soap, or other disinfectant, and towels that should be kept for exclusive use by the caregiver. There should only be one person involved in caring for those with possibly contagious illnesses.
For supplies, get plenty of masks and gloves; gowns can be commercially made, can be plastic coveralls, or even full-body aprons. Many people consider medical supplies to consist of gauze, tourniquets, and battle dressings, but you must also dedicate sets of sheets, towels, pillows, and other items to be used in the sickroom. Keep these items separate from the bedding, bathing, and eating materials of the healthy members of your family.
Cleaning supplies should also be considered medical preparedness items. You’ll want to clean the sickroom on a daily basis. Clean surfaces that may have germs on them with soap and water, or use other disinfectants. Bleach diluted in water 1:10 would be effective for this purpose. Areas to disinfect include doorknobs, tables, sinks, toilets, counters, and even toys. Wash bedsheets and towels frequently; boil them if there is no other option. Consider patient bedding and clothes to be infected, and wash or otherwise disinfect your hands right after touching them. The same goes for plates, cups, and anything else used in caring for the patient. Any medical supplies brought into the sickroom should stay there.
One additional item is important for sickroom patients: Give them a noisemaker of some sort that will enable them to alert you when they need help. This will decrease anxiety and give them confidence that you will know when they are in trouble.
FOOD-BORNE AND WATER-BORNE ILLNESS
Modern water-treatment practices and disinfectant techniques have made drinking water and eating food a lot safer than in the past. Contaminated water was the source of many deaths in olden times, and still causes epidemics of infectious disease in developing countries. It just makes common sense, therefore, that we can expect sanitation issues in the aftermath of a disaster.
Any water that has not been sterilized or any food that hasn’t been properly cleaned and cooked could place an entire community at risk. As the medic, your duty will be to ensure that water is drinkable and that food-preparation areas are disinfected.
Water can be contaminated by floods, disruptions in water service, and a number of other random events. A dead raccoon upstream from where you collect your water supplies could be a source of deadly bacteria.
Even the clearest mountain brook could be a source of parasites, called protozoa, that can cause disease. A parasite is an organism that, once it is in your body, sets up shop and causes you harm. Common parasites that cause illness include those in the Giardia and Entamoeba genera; they can affect hikers in the deepest wilderness settings.
If you’re starting with cloudy water, it is because there are many small particles of debris in it. There are many excellent commercial filters of various sizes on the market that deal with this effectively. You could also make your own particulate filter by using a length of 4-inch-wide PVC pipe and inserting two or three layers of gravel, sand, zeolite, or activated charcoal, with each layer separated by pieces of cloth or cotton. Once flushed out and ready to go, you can run cloudy water through it and see clear water coming out the other side.
This type of filter, with or without activated charcoal, will get rid of particulate matter but will not kill bacteria and other pathogens. It’s important to have several ways available to sterilize your water to get rid of organisms, including the following:
• Boiling. Use a heat source to get your water to a roiling boil. There are bacteria that may survive high heat, but they are in the minority. Using a pressure cooker would be even more thorough.
• Chlorine. Household bleach sold for use in laundering clothes is a 3–8 percent solution of sodium hypochlorite. Bleach has an excellent track record of eliminating bacteria, and 8–10 drops in a gallon of water will do the trick. If you’re used to drinking city-treated water, you probably won’t notice any difference in taste.
• Tincture of Iodine (2 percent). Add 12–16 drops per gallon of water. An eyedropper is useful for this purpose. You should wait 30 minutes before drinking water sterilized by iodine or bleach.
• Ultraviolet Radiation. Exposure to sunlight will kill bacteria! 6–8 hours in direct sunlight (even better on a reflective surface) will do the trick. Fill your clear gallon bottle and shake vigorously for 20 seconds. The oxygen released from the water molecules will help the process along and even improves the taste.
Anyone who has eaten food that has been left out for too long has probably experienced an occasion when they have regretted it. Properly cleaning food and food-preparation surfaces is a key to preventing disease.
Your hands are a food-preparation surface. Wash your hands thoroughly before preparing your food. Other food-preparation surfaces, such as countertops, cutting boards, dishes, and utensils, should also be cleaned with water and soap or a dilute bleach solution before using them. Soap may not kill all germs, but it helps to dislodge them from surfaces.
Wash your fruits and vegetables under running water before eating them. Food that comes from plants grown in soil may have disease-causing organisms, and that’s without taking into account fertilizers, such as manure. You’re not protected if the fruit has a rind; the organisms on the rind will get on your hand and will be transferred to the fruit once you peel it.
Raw meats are notorious for having their juices contaminate food. Prepare meats separately from your fruits and vegetables. Ensure that meats reach an appropriate safe temperature and remain consistently at that temperature until cooked, which varies by the type of meat. A meat thermometer is useful in ensuring this. Below is the safe cooking temperature for various meats.
Sauces and gravy:
Soups with meat:
DIARRHEAL DISEASE AND DEHYDRATION
With worsening sanitation and hygiene, there will likely be an increase in infectious disease, none of which will be more common than diarrhea. Diarrhea is defined as an increased frequency of loose bowel movements. If a person has three liquid stools in a row, it is a red flag that tells you to watch for signs of dehydration. Dehydration is the loss of water from the body. If severe, it can cause a series of chemical imbalances that can be life-threatening.
Diarrhea is a common ailment that may go away on its own simply by restricting your patient to clear fluids and avoiding solid food for 12 hours. However, the following symptoms that may present in association with diarrhea can be a sign of something more serious:
• Fever equal to or greater than 101 degrees
• Blood or mucus in the stool
• Black or grey-white stool
• Severe vomiting
• Major abdominal distension and pain
• Moderate to severe dehydration
• Diarrhea lasting more than 3 days
All of these symptoms may be signs of serious infection, intestinal bleeding, liver dysfunction, or even conditions that require surgery, such as appendicitis. These symptoms will also increase the likelihood that the person affected won’t be able to regulate his or her fluid balance.
Epidemics caused by organisms that cause diarrhea have been a part of the human experience since before recorded history. Cholera is one particularly dangerous disease that was epidemic in the past and may be once again in the uncertain future. This infection will produce a profuse watery diarrhea with abdominal pain.
Typhoid fever is another very dangerous illness caused by contaminated food or drink. It is characterized by bloody diarrhea and pain and, like cholera, has been the cause of deadly outbreaks over the centuries. In typhoid cases, fever rises daily and, after a week or more, you may see a splotchy rash and spontaneous nosebleeds. The patient’s condition deteriorates from there.
The end result (and most common cause of death) of untreated diarrheal illness is dehydration. By weight, the body is 75 percent water; the average adult requires 2–3 liters of fluid per day to remain in balance. Children become dehydrated more easily than adults: 4 million children die every year in underdeveloped countries from dehydration due to diarrhea and other causes.
Fluid replacement is the treatment for dehydration. Oral rehydration is the first line of treatment, but if this fails, fluid introduced intravenously may be needed, which requires special equipment and skills. Always start by giving your patient small amounts of clear fluids. Clear fluids are easier for the body to absorb; examples include water, clear broth, gelatin, GatoradeTM, and PedialyteTM.
Oral rehydration packets are commercially available, but you can produce your own homemade rehydration fluid very easily: Add the following to 1 liter of water:
6–8 teaspoons of sugar (sucrose)
1 teaspoon of salt (sodium chloride)
½ teaspoon of salt substitute (potassium chloride)
A pinch of baking soda (sodium bicarbonate)
For children, use 2 liters of water.
As the patient shows an ability to tolerate these fluids, advance the diet to juices, puddings and thin cereals, such as grits or cream of wheat. It is wise to avoid milk, as some people are lactose intolerant. Once the patient can keep down thin cereals, you may start giving them solid food.
A popular strategy for rapid recovery from dehydration is the BRAT diet, used commonly in children. This diet consists of the following:
Toast (plain, or crackers)
The advantage of this strategy is that these food items are bland and easily tolerated. They also slow down intestinal motility (the rapidity of movement of food and fluids through your system), which in turn slows down water loss.
Of course, there are medicines that can help. Pepto-BismolTM and Imodium (loperamide) will help diarrhea. They don’t cure infections, but they will slow down the number of bowel movements and conserve water. These are over-the-counter medicines, and are easy to obtain. In tablet form, they will last for years if properly stored.
A good prescription medicine for vomiting is ZofranTM (ondansetron). Doctors will usually have no qualms about writing this prescription, especially for patients traveling out of the country. Of course, ibuprofen or acetaminophen is good to treat fevers. The higher the fever, the more water is lost. Therefore, anything that reduces fever will help a person’s hydration status.
Various natural substances have been reported to be helpful in these situations. Herbal remedies include the following:
• Blackberry leaf
• Raspberry leaf
Make a tea with the leaves and drink a cup every 2–3 hours.
Half a clove of crushed garlic and 1 teaspoon of raw honey 4 times a day is thought to exert an antibacterial effect in some cases of diarrhea. Ginger tea is a time-honored method of decreasing abdominal cramps.
As a last resort to treat dehydration from diarrhea (especially if there is also a high fever), you can try antibiotics or antiparasitic drugs. Ciprofloxacin, doxycycline and metronidazole are good choices, twice a day, until the stools are less watery. Some of these are available in veterinary form without a prescription (discussed later in this book). These medicines should be used only as a last resort, as the main side effect is usually . . . diarrhea.