Tag Archives: Dr. Bones

Triage For The Non-Medical Responder

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‘Who Goes First and Why’
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I wanted to write today’s post with the goal of familiarizing a non-medical professional with the process of triaging. This would apply if you’re the first person to arrive–accidentally, or on purpose–at a multi-casualty trauma scene whether that happens in our current world, or after a collapse. Triaging is the same, you determine which patients need priority in transport and treatment. What changes after a collapse is the lack of resources available to care for the patients.

I felt I was very qualified to write this post. As a former military medic and civilian paramedic I have been involved in several actual Mass Casualty Incidents (MCIs) and many simulated MCI drills.

As I was doing research for this post I remembered that Dr. Bones, of Doom and Bloom, had recently written on this topic. At the time I had skimmed the information, feeling relatively confident in my ability to handle an MCI if needed. As I went back to review them for this post I realized anything I say would be redundant. Dr. Bones wrote three excellent and very detailed posts on triaging. They are complete with examples and are directed toward the non-medical responder. As I always say, Dr. Bones and Nurse Amy are my definite collapse medicine specialists (I reviewed their book The Doom and Bloom Survival Medicine Handbook a few months ago).

So instead of trying to reinvent the wheel I am reposting Dr. Bones first triage post:

The Mass Casualty Incident: Triage, Part 1

The responsibilities of a medic in times of trouble will usually be one-to-one; that is, the healthcare provider will be dealing with one ill or injured individual at a time.  If you have dedicated yourself to medical preparedness, you will have accumulated significant stores of supplies and some knowledge. Therefore, your encounter with any one person should be, with any luck, within your expertise and resources.  There may be a day, however, when you find yourself confronted with a 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.  Mass Casualty Incidents (we’ll call them “MCIs”) can be quite variable in their presentation.

They might be:

  • 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 or battlefield injuries
  • Mass transit mishap (train derailment, plane crash, etc.)
  • A car accident with, say, three people significantly injured (and only one ambulance)
  • Many others

The effective medical management of any of the above events required rapid and accurate triage.  Triage comes from the French word “to sort” (“Trier”) and is the process by which medical personnel (like you, survival medic!) can rapidly assess and prioritize a number of injured individuals and do the most good for the most people. Note that I didn’t say: “Do the best possible care for each individual victim”.

Let’s assume that you are in a marketplace in the Middle East somewhere, or perhaps in your survival village near the border with another (hostile) group.  You hear an explosion.  You are the first one to arrive at the scene, and you are alone.  There are twenty people on the ground, some moaning in pain.  There were probably more, but only twenty are, for the most part, in one piece.  The scene is horrific.  As the first to respond to the scene, medic, you are Incident Commander until someone with more medical expertise arrives on the scene.  What do you do?

Your initial actions may determine the outcome of the emergency response in this situation.  This will involve what we refer to as the 5 S’s of evaluating a MCI scene:

  • Safety
  • Sizing up
  • Sending for help
  • Set-up of areas
  • START – Simple Triage And Rapid Treatment

1. Safety Assessment:  Our friend Joshua Wander (the Jewish Prepper of blogspot fame)  relates to us an insidious strategy on the part of terrorists in Israel:  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/security personnel arrive.  This may not sound right to you, but your primary goal as medic is your own self-preservation, because keeping the medical personnel alive is likely to save more lives down the road.  Therefore, you do your family and community a disservice by becoming the next casualty.

As you arrive, be as certain as you can that there is no ongoing threat.  Do not rush in there until you’re sure that the damage has been done and you and your helpers are safe entering the area.  In the immediate aftermath of the Oklahoma City bombing, various medical personnel rushed in to aid the many victims.  One of them was a heroic 37 year old Licensed Practical Nurse who, as she entered the area, was struck by a falling piece of concrete.  She sustained a head injury and died five 5 days later.

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?  Was there a car bomb?
  • How many injuries and how severe?  Are there a few victims or dozens? Are most victims dead or are there any uninjured that could assist you?
  • Are they all together or spread out over a wide area?
  • What are possible nearby areas for treatment/transport purposes?
  • 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 multi-vehicle auto accident at the intersection of Hollywood and Vine (location).  At least 7 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 numbers of patients that may need care, and the types of care (burns) or equipment (jaws of life) that may be needed.  I’m sure you could do even better than I did above, but you want to inform the emergency medical services without much delay.

If the you-know-what has hit the fan and you are the medical resource, get your walkie-talkie or handie-talkie and notify base camp of whatever the situation is and what you’ll need in terms of personnel and supplies.  If you are not the medical resource, contact the person who is; the most experienced medical person who arrives then becomes Incident Commander.

4.  Set-Up:  Determine likely areas for various triage levels (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.  If you are blessed with lots of help at the scene, determine triage, treatment, and transport team leaders.

5. S.T.A.R.T.:  Triage uses the acronym S.T.A.R.T., which stands for Simple Triage and Rapid Treatment.

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 respirations (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 if not treated quickly.  (for example, a major hemorrhagic wound/internal bleeding) Top priority for treatment.

Delayed (Yellow tag): The victim needs medical care within 2-4 hours. Injuries may become life-threatening if ignored, but can wait until Red tags are treated. (for example, open fracture of femur without major hemorrhage)

Minimal (Green tag): Generally stable and ambulatory (“walking wounded”) but may need some medical care. (for  example, 2 broken fingers, sprained wrist)

Expectant (Black tag): The victim is either deceased or is not expected to live.  (for example, open fracture of cranium with brain damage, multiple penetrating chest wounds)

Knowledge of this system allows a patient marking system that easily allows 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 a major internal bleeding episode without surgical intervention.

In the next part of this series, we will go through a typical mass casualty incident with 20 victims, and show how to proceed so as to provide the most benefit for the most people.

Dr. Bones

Links to Doom and Bloom follow-up posts:
Mass Casualty Incident: Triage, Part 2
Mass Casualty Incident: Triage, Part 3

(Friday: What We Did This Week To Prep)

What I Did This Week To Prep 2/3/12

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Reading, and writing my review of, The Doom and Bloom Survival Medicine Handbook this week took a lot of my time, so not as much other stuff got done.

Sarah and I did do a fair amount behind the scenes on the the blog site itself. Sarah does the technical side and I handle the personal networking aspects. Is this a prepper topic though? I believe it is – especially since our blog is about prepping. But any blog you write allows you to teach and learn; it also may have the potential to develop into a business and/or give you more personal independence. Sarah upgraded us from WordPress.COM to WordPress.ORG. WordPress.org is the WordPress software that must be self-hosted (we went with Host Gator for that) but allows for greater flexibility and expansion potential. I’ve been corresponding more with people in the online prepper community; strengthening relationships and starting new ones. We’re also bringing on a new monthly contributor to our blog (more on her next week). Along those same lines, we’re considering having a (different) guest blogger write a post for us each month. So if you–or anyone you know–are interested, send me an email or facebook message (my contact information can be found on the About Trace page).

Last month I wrote a post on the Gerber EAB Lite Utility Knife. There has been discussion on TSP Forum where several people complained about the clip easily breaking off the knife. I’ve carried mine, clipped to my pocket everyday, for several months now without any issues. But just to do some follow-up, I contacted Gerber’s Warranty Department (by email). I told them we have several EABs and expressed my concern about the clip weakness, and asked them for a couple extra clips to keep on hand. They, no questions or hassles, sent me three replacement clips – no charge for shipping or anything. In summary, it’s a good little knife, good customer service experience, and I haven’t had any issues with the clip.

Finally, after reading the Doom and Bloom book, I decided we need to continue actively working on our medical preps. Because of my background, knowledge, and willingness, I’m sure one of my primary roles in a collapse will be as the medic. I believe I need to do as much as I can now to prepare for that role. So, coincidentally, last week on the Doom and Bloom blog, Dr. Bones wrote, Over The Counter Drugs When You’re the Doctor, that included a thorough list of OTC drugs to stock up on. This week he wrote, Must Have Antibiotics, Antifungals, and Antivirals. So, we’ve earmarked some money for additional fish antibiotics (Antibiotics In Your Preps) and are going to stock up on more OTC meds when we go to Costco. How much is too much? Tough call. But they store for a long, long time (Expired, or Not Expired… That is the Question), they’re relatively cheap, they don’t take too much space to store and–in a collapse–they’re irreplaceable.

What did you do?

(Monday: Book Review: Where There Is No Doctor)

Having Your Fire Extinguisher Ready

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Only Seconds to React
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Fire is neither good nor bad, it just is. When the right combination of fuel, oxygen, and an ignition source combine there will be fire. It can be a lifesaving asset providing light, cooking, and heat – or it can be property and life destroying.

Though fire safety has many aspects* today we’re going to discuss fire extinguishers. As preppers we should build in redundancies and safety. If the power goes out, we start up the generator and cook over propane; if those fail, we light lanterns and cook over a small fire. But most of us aren’t use to using fire on a routine basis; we can get complacent or careless and accidents can happen. To mitigate those risks, and keep you loved ones and home safe, consider keeping a fire extinguisher within arms reach of an open flame. No one means to knock over the kerosene lantern, but if suddenly the counter is engulfed in flame you have seconds to make decision.

In that situation, if the fire is small and not spreading, grab the extinguisher. Start with your back to the exit, making sure the fire does not block your escape route. Stand about six feet away from the fire. Then, as fire departments teach, use the PASS word:

  • Pull the pin to unlock the fire extinguisher
  • Aim at the base (bottom) of the fire
  • Squeeze the lever to discharge the agent
  • Sweep the spray from left to right until the flames are totally extinguished

A typical fire extinguisher contains ten seconds of extinguishing power. You cannot use fire extinguishers more than once, they must be replaced or refilled if used.

For home use, there are typically two categories of extinguishers: 1) a less expensive, plastic top, disposable type and 2) a metal top, rechargeable type. Professionals recommend the rechargeable ones; they initially cost more, but are far more reliable, can be serviced, and have a longer shelf-life.

There are no laws regarding home fire extinguisher inspections, however it is recommended that twice a year you inspect your extinguisher. You should check:

  • the pressure gauge arrow to be sure it’s full (straight up on the gauge in the green area).
  • the hose and nozzle for cracks, tears or blockage.
  • the pin and tamper seal to ensure they are intact.
  • that the handle-locking device is in place.
  • for dents, leaks, rust, chemical deposits and/or other signs of abuse or wear.

At the end of your inspection turn the extinguisher upside down and hit the bottom sharply with your hand, then shake it well. This will prevent the dry chemical powder from settling or packing down in the cylinder, making it ineffective.

Most rechargeable dry chemical fire extinguishers, if properly handled and maintained, have a lifespan of 5 – 15 years. If your extinguisher is 5 years old bring it in to a local service center and have it inspected (costs about $20). If your extinguisher is over 12 years old, it needs to be hydrostatically tested and recharged by a qualified service technician (they’ll probably just swap you for one that’s been recently tested).

Remember fire doesn’t care, so you need to.

(Friday: What I Did This Week To Prep)

*Dr. Bones, of the Doom & Bloom Show, recently wrote posts on Smoke Inhalation and Natural Burn Treatments. Both of these topics are huge fire safety aspects; these posts  contain good information and are definitely worth reading.

Expired, or Not Expired… Can You Store Medications Long Term?

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What medications* do we keep in our preps? We store: 1) over-the-counter (OTC) drugs: ibuprofen (Motrin), acetaminophen (Tylenol), aspirin, diphenhydramine (Benadryl), pseudoephedrine (Sudafed), loratadine (Claritin), guaifenesin (Mucinex), and 2) antibiotics (that I recently posted about): amoxicillin, cephalexin, ciprofloxacin, doxycycline, metronidazole.

How long can they be stored? They have expiration dates, does that mean they go bad?

Let’s start with what do drug expiration dates mean? Required since 1979, the expiration date is the last date that the pharmaceutical company will guarantee 100% potency (some sources state at least 90% potency). So then we ask, how long does it take a drug to lose it’s beneficial effects?

That is the question that the Department of Defense (DOD) asked the Food and Drug Administration (FDA) in 1985 (the military had over a billion dollars worth of medication stored). So in response, in 1986, the DOD and the FDA began the Shelf Life Extension Program (SLEP).

The SLEP program is documented in the Wall Street Journal article, Many Medicines Are Potent Years Past Expiration Dates, by Laurie P. Cohen, March 28, 2000. The military submitted, and the FDA has evaluated, over 100 drugs – prescription and OTC. The results showed that about 90% of them were safe and effective well past their expiration dates, some for 10 years or longer. Joel Davis, a former FDA expiration-date compliance chief, said that with a handful of exceptions – notably nitroglycerin, insulin and some liquid antibiotics – most expired drugs are probably effective.

In light of these results, a former [FDA] director of the testing program, Francis Flaherty, says he has concluded that expiration dates put on by manufacturers typically have no bearing on whether a drug is usable for longer.

Mr. Flaherty notes that a drug maker is required to prove only that a drug is still good on whatever expiration date the company chooses to set. The expiration date doesn’t mean, or even suggest, that the drug will stop being effective after that, nor that it will become harmful.

“Manufacturers put expiration dates on for marketing, rather than scientific, reasons,” said Mr. Flaherty, a pharmacist at the FDA until his retirement in 1999. “It’s not profitable for them to have products on a shelf for 10 years. They want turnover.”

The Harvard Medical School Family Health Guide, in Drug Expiration Dates – Do They Mean Anything?, notes that, with rare exceptions, “it’s true the effectiveness of a drug may decrease over time, but much of the original potency still remains even a decade after the expiration date”.

Where and how medications are stored is an important factor in minimizing their degradation. Storing in a cool, dry, dark place will maximize their lifespan; when possible keep sealed in their original container until ready to use. Medications stored in bathroom cabinets or shelves could have effectiveness significantly reduced. Be sure to discard any pills that become discolored, turn powdery, or smell overly strong; any liquids that appear cloudy or filmy; or any tubes of cream that are hardened or cracked.

Dr. Bones, from The Doom and Bloom Show, states in his blog post, The Truth About Expiration Dates, “I put forth to you this recommendation: Do not throw away medications that are in pill or capsule form after their expiration dates if you are stockpiling for a collapse. Even if a small amount of potency is lost after time, they will be of use when we no longer have the ability to mass-produce these medicines. I’m aware that this is against the conventional medical wisdom, but we may find ourselves in a situation one day where something is better than nothing.”

(Friday: What I Did This Week To Prep)

* The terms medications and drugs (referring to legal drugs) are used interchangeably.

Post Script: Dealing With The ‘Tetracycline Becomes Toxic’ Myth

There has long been a belief that the antibiotic tetracycline becomes toxic once it has past it’s expiration date.

In Medscape Today’s article, Do Medications Really Expire?, they discusses the original case, “A contested example of a rare exception [of expired drugs possibly becoming toxic] is a case of renal tubular damage purportedly caused by expired tetracycline (reported by G. W. Frimpter and colleagues in JAMA, 1963;184:111). This outcome (disputed by other scientists) was supposedly caused by a chemical transformation of the active ingredient.”

The case was thoroughly evaluated in the 1978 article, Tetracycline in a Renal Insufficiency: Resolution of a Therapeutic Dilemma, it states, “”Old” and degraded tetracyclines have previously been demonstrated to have direct toxic effects on the renal proximal tubule, but because of changes in manufacturing techniques this is no longer a real problem.” It also states, “It has often been stated that the tetracyclines should be avoided in patients with severe renal disease, but, as we shall see, doxycycline represents an important exception to the rule”.

In Cohen’s article on the Shelf Life Extension Program, Many Medicines Are Potent Years Past Expiration Dates, it goes on to state, “Only one report known to the medical community linked an old drug to human toxicity. A 1963 Journal of the American Medical Association article said degraded tetracycline caused kidney damage. Even this study, though, has been challenged by other scientists. Mr. Flaherty says the Shelf Life program encountered no toxicity with tetracycline”.

Dr. Bones and Nurse Amy, from The Doom and Bloom Show, when interviewed on TSP, clearly state that tetracycline past it’s expiration date is safe (episode 736, beginning at 43:45). Nurse Amy concludes the topic with “. . . if they can just get that in their heads that tetracycline isn’t going to kill you when it’s past expiration”.

Medical evidence supports that tetracycline, past it’s expiration date–especially in the form of doxycycline–is as safe as any other expired antibiotic.

Can You Store Antibiotics In Your Preps?

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“The first rule of antibiotics is try not to use them, and the second rule is try not to use too many of them.” – Paul Marino The ICU Book 2007

Cellulitis

Last week in Soap and Water I posted about the risk, in a collapse situation, of an infection–from minor cuts and scrapes–known as cellulitis. I linked to Dr. Bones Doom and Bloom blog post, Cellulitis: An Epidemic in a Collapse. Here’s another good article by Dr. Bones, A Doctor’s Thoughts on Antibiotics, Expiration Dates, and TEOTWAWKI. For additional perspective about antibiotics before and during a collapse I recommend comments by Dr. ‘Walker’ on TSP forum. Additional, non-prepper/collapse, antibiotic information can be found at eMedicineHealth.com.

I need to state, though I was previously certified and worked as a paramedic for almost ten years, I am currently not a medical professional of any type; thus I am not giving any professional medical advice. All the information in this post is from open internet sources. As Dr. Bones states “. . . [these] are hypothetical strategies for a post-apocalyptic setting. They are not meant to replace standard care and advice when modern medical technology and resources are available.” And always remember, the practice of medicine or dentistry without a license is illegal and punishable by law.

So with all the caveats stated:

Antibiotics refer to a substance that kills, slows or disrupts the growth of:

  • bacterial infections: caused by a pathogenic (a ‘germ’/microorganism that causes disease) bacteria
  • protozoan infections: caused by a parasitic disease, i.e. giardia which occurs through ingestion of infected fecal contaminated water or food

Antibiotics do not fight infections caused by viruses, such as: colds, flu, most coughs, and most sore throats (unless caused by strep).

Much of my information comes from Dr. Bones. I trust his advice. I applaud him; he is a medical doctor who is willing to say what he believes will save lives in a collapse situation. But as he clearly states, “[This] advice is contrary to standard medical practice, and is a strategy that is appropriate only in the event of societal collapse. If there are modern medical resources available to you, seek them out.”

As discussed in Soap and Water, describing a collapse situation, there are several things that will aggravate the chances of getting an infection: 1) We will be doing more ‘dirty’ jobs, 2) We will be doing a lot more manual labor and other activities that can easily lead to cuts and scrapes, and 3) Clean water and basic hygiene will not be as accessible or convenient. So a relatively minor wound that is ignored while you continue working gets more contaminated; then the wound isn’t thoroughly washed out because clean water is saved for drinking. In a short period of time that wound can develop a serious infection.

Dr. Bones states in Fish Antibiotics in a Collapse, “These injuries can begin to show infection, in the form of redness, heat and swelling, within a relatively short time. Treatment of such infections, called “cellulitis”, at an early stage improves the chance that they will heal quickly and completely.  However, many rugged individualists are most likely to “tough it out” until their condition worsens and spreads to their blood.  This causes a condition known as sepsis; fever ensues as well as other problems that could eventually be life-threatening. The availability of antibiotics would allow the possibility of dealing with the issue safely and effectively.”

Having antibiotics available in a collapse situation will be very important, even lifesaving. The question is how can we as preppers obtain a stockpile to be used if other ‘medical resources’ are no longer available?

Dr. Bones continues, “After years of using [antibiotics] on fish, I decided to evaluate these drugs for their potential use in collapse situations. A close inspection of the bottles revealed that the only ingredient was the drug itself, identical to those obtained by prescription at the local pharmacy. If the bottle says FISH-MOX, for example, the sole ingredient is Amoxicillin, which is an antibiotic commonly used in humans.  There are no additional chemicals . . .”

So it seems that fish antibiotics are the same drugs as used in human antibiotics. I believe that adding fish antibiotics to my preps is a sound strategy. They are available, without a prescription, through many fish supply websites. I have purchased, or plan to purchase, the following:

  • Fish-Mox Forte (amoxicillin 500mg): used to treat infections of the ears, nose, throat, urinary tract, skin, pneumonia, and gonorrhea
  • Fish-Flex Forte (cephalexin 500mg): used to treat infections of the bone, ear, skin, urinary tract, and pneumonia; it has very low side effects, (it is typically safe for those with penicillin allergies)
  • Fish-Flox Forte (ciprofloxacin 500mg): used to treat infections of bones and joints, sinuses, skin, urinary tract, gastroenteritis (stomach ‘flu’), typhoid, plague, and anthrax
  • Aqua-Doxy (doxycycline 100mg): used to treat infections of the sinus and respiratory tract, skin (staph), urinary tract, intestines, chlamydia, anthrax, Rickettsia, Lyme disease, plague, and cholera
  • *Fish-Zole (metronidazole (Flagyl) 250mg): as an antiprotozoal, used to treat giardia and dysentery

For any medication you choose to stock (antibiotics or otherwise) print out the entire drug card and keep that information stored with the drug; a good online source of drug information is the U.S. National Library of Medicine. Also it’s always best to store them in the original package and, like food storage, keep in a dry, dark, cool place.

If you choose to add antibiotics to your preps it is your responsibility to be thoroughly educated about their usages, contradictions, doses, and side effects. This is something you can’t just buy and figure you have it if you need it. Obtain additional medical publications such as the Physicians Desk Reference (PDR) or Delmar Nurse’s Drug Handbook*. Antibiotics are drugs, taking an antibiotic is a medical treatment, do not take this lightly. When I was going through my Army medic training one of my instructors said, “Every medicine you put into the body is a toxin, be sure the benefits outweigh the risks.”

(Wednesday: Expired, or Not Expired; That Is The Question)

* There are many other good references available, these are just two examples. There is no reason to buy a current edition; older editions are much cheaper and have essentially all the information a layperson would ever need.