Extended Medical Care w/ No Chance of Re-Supply

[tangent]

jagdkampf
Advanced First Aider

Joined: Dec 23, 2001
Posts: 21 Posted: 2002-02-04 01:19
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One other possibility is renewable resources. Modern hospital use a very high percentage of non renewable resources, i.e. disposable syringes, needles, iv solutions, etc, etc. The most basic of IV fluids are either .9% NACL or D5W, both of which can be easily manufactured and sterilized. Glass syringes and needles without plastic hubs can also be sterilized. Instrumentation can be readily resterilized as well. Suture materials can be obtained from some other unorthodox sources. Probably the most difficult thing to come by would be medications. We certainly overuse antibiotics in the modern world but they also don't have an easy replacement. Aseptic technique and sterility goes a long way along with good hygenic measures in preventing infection and disease but we will never be able to replicate a modern hospital in the worst case scenario and a higher mortality rate is inevitable. Perhaps we should talk more about how to invest in renewable supplies and how to make IV solutions.
JAG

[tangent]

I have to agree wholeheartedly w/ JAG!

lets look at the 3 areas Craig brought up; antibiotics, pain meds (and meds in general) and fluids, then consider some other areas.

antibiotics are a hard one - with the exception of penicillin, they are hard to make. Granted, there are thousands of antibiotics, or rather materials with antibiotic properties, but few are used, as most are not strong enough. This is one area where stocking up on an expendable pays!

there are alternatives: asepsis, sugar therapy, maggot therapy, maintaining a healthy immune system, various herbal/botanical items, for example Carica, an enzyme from papaya, aids healing and aids the removal of necrotic tissue. A commercial ointment based on this, mixed w/ urea (the urea is supposed to help the process) is available. In the case of pneumonia, Dr. Gene Lam wrote in some USAF Survival Medicine notes based on his experience in Korea the following:

You will encounter diseases and your resistance to them will be low. Pneumonia is probably the most common, especially in winter and it makes you extremely sick. You will have no penicillin, no terramycin, not even old fashioned sulfa. (In Korea I had 250 sulfanilamide tablets for more than 2,000 men.)

When a man has pneumonia, in primitive circumstances, there is only one thing you can do for him, even though it is not in any medical book - keep him on his feet. You should not keep a sick man on his feet 24 hours a day, but don't let him lie in a corner, pull something over his head, and roll over to face the wall. If he does this, he will die. You must keep him alert and interested, or he will not live.

Some men with severe cases of pneumonia lived because of this treatment and their own will. Others with bad colds got frightened, laid down, gave up and died within 24 hours.

OK - this doesn't work really well for patients w/ GSW's, but the point is that antibiotics are not always necessary. Penicillin and sulfa drugs can be made, as can others - some native American pultices(sp?) had antibiotic properties and there are other treatment options, as well.

anesthetics - I know you think ketamine is the cats meow! it is also the drug of choice for your "walk in" surgical patient, with a full stomach. This seems to be a good time to talk about "phasing in" less than ideal treatment options.

Most people have an attitude of: "I'll use the good stuff till it runs out, then I'll fall back to the less than ideal stuff". - WHY? - when you do this with food, going from a refined diet to one of whole grains, overnight, you not only have a very steep learning curve, but you get sick! Why should medicine be any different? Wouldn't it be better to phase your preparations and improvisations in slowly? I the case of ketamine, it excels at the rapid induction of anesthesia for the patient that is not NPO. But you will have cases where surgery can be more planned, and the patient can be NPO. Doesn't ether make more sense here? saving the ketamine for the cases where it really is the best drug? (I'm using this as a hypothetical example - I personally have no experience w/ general anesthesia or major surgery). What I'm getting at is a 3 pronged approach:

1) pre-disaster: when resupply is a given, use the good materials - don't risk the "make do" approach.

2) post disaster: use the make do approach whenever possible, saving the "big guns" or drug of choice for those cases when you really need it.

3) hedge your bets on a middle ground: a limited form of re-supply is probably possible. Know any: pharmacists, veterinarians, ranchers, tropical fish hobbyists, people working in ranch supply shops, herbalists, chemists or microbiologists? for the latter 2, some pre-planning in the form of research and stocking of materials and equipment will probably be necessary, the same as if you are going to make IV fluids at home. Do you have the necessary ingredients or can you obtain them? can you make the ingredients of the ingredients? For the former, we're either talking about botanicals (and don't forget that roughly 25% of modern medicines are based on botanicals and can be extracted from them if you have the seeds and know how to grow them and how to do the extractions. Some medicines can be made chemically, fairly easily. Otherwise, we're talking about using veterinary products or being on good terms w/ a pharmacist who you could supply with an "end of the world wish list" of things you would like pulled from his shelves and brought to you, in exchange for taking him or her in... I'm not being that optimistic - resupply is a possibility. In the case of growing things, it will take months to a year, depending on the season, and setting up production is certainly a possibility. Stockpiling the less expensive vet meds yourself, in bulk is also a possibility. especially for antibiotics.

For chemistry and botanical extractions, many of the processes are little more than extractions, recrystalisations and solvent recovery - none of these processes are particularly hard to learn and require minimal equipment to perform.

some good books to act as a starting point include (from the sci-chem FAQ):

11.9 Where can I find pharmaceutical chemistry information?
Pharmaceutical research often is initially reported in patent literature, consequently patent searching is a good place to start. The Merck Index is focused on pharmaceuticals, and also provides excellent leads to the research literature. There are several pharmaceutical chemistry books, such as Goodman and Gilman53, and "Essentials of Medicinal Chemistry"54, that provide overviews of the field. The Journal of Pharmaceutical Chemistry is a good source for research articles. Details of chemicals appearing in formulated products can be found in the "Handbook of Pharmaceutical Excipients"55.

53] Refer 6.8
[8] The Pharmacological Basis of Therapeutics - 9th edition
J.G.Hardman, A.G.Gilman et al (editors)
McGraw Hill (1995)

[54] Essentials of Medicinal Chemistry - 2nd edition
A.Korolkovas (editor)
John Wiley (1988)

[55] Handbook of Pharmaceutical Excipients - 3rd edition
A.Wade and P.J.Weller
American Pharmaceutical Assoc. (November, 1999) ISBN 091733096X

[13] Martindale : The complete drug reference - 32nd edition
K.Parfitt (editor)
Pharmaceutical Press (April 1999) ISBN 085369429X

others:
Medical Botany by Lewis and Lewis

I'll add a few more later...

what about fluids - is this for rehydration or as a means of administering drugs? For the latter, if you are relying having a lifeline, re-examine what you are doing. ACLS is very hard to pull off, for most things, in the austere environment. For anesthesia, or administration of, say antibiotics over a longer period, perhaps a different approach (solid dosage form) should be considered.

Lets look at rehydration. Of the administration routes that allow high volumes, but demand sterile fluids there are IV and IO. Please refer to the the article on making IV fluids in the pharmacy.

Of the types that are more forgiving as to types of fluids you can administer and their sterility we have: oral, NG tube and rectal, the latter being the only one that is really limited as to how much you can administer at once.

In the middle is SQ. This one is limited to 500cc's per injection sight, preferably less. Water boiled for 15-20 minutes and made into a 5% saline solution is adequately sterile (ref: advanced first aid of all outdoors). a boiled canteen, cork, tubing and needle is all that is needed.

As to modes of drug administration, IV and OS are great. The others may be somewhat lacking. Rectal holds promise for solid dosage forums - quoting from a post on Frugals:

"almost all meds that are given by mouth can be given in the rectum if the patient is unable to swallow. The exception is enteric coated or time release meds which require an acidic environment. Make sure stool is evacuated prior to inserting meds Use KY or a water based lubricant, place multiple pills in a gel capsule if available (unlikely if TSHTF), and place against the rectal wall within 6" of the anus. If the rectal tissue is dry, instill about 10cc of warm water first. Liquid medicine can also be inserted in the rectum, but try to keep volume less than 60cc, best if less than 25cc."

as an alternative means of administering meds, how about dermal? Like the nicotine patch, it is possible for a solvent to penetrate the skin and carry with it another substance. From my understanding of this, the substance being carried must have a lower molecular weight then the solvent and depending on it's chemical configuration, may change into something else, unexpected, when exposed to the solvent or refuse to let go of the solvent, once inside the body. In other words, this might not work as expected in many cases. Still, it works for nicotine and DMSO carries lemon juice, perfectly... anyone know more about this? again, some info from the sci.chem FAQ:

31.18 How fast do solvents pass through human skin?
It obviously depends on the solvents, and traditional measurements have been made using dead skin, but some recent work has provided a simple comparison of individual solvents. It must be emphasized that mixtures of solvents may have significantly different rates29.
Solvent Permeability Constants in g/m2h
Average Standard Deviation
Dimethylsulfoxide 176 42
N-Methyl-2-pyrrolidone 171 59
Dimethylacetimide 107 19
Dimethylformamide 98 1.1
Methyl ethyl ketone 53 29
Methylene chloride 24 8.4
Water [3H radiolabelled] 14.8 0.1
Ethanol 11.3 0.5
Butyl acetate 1.6 0.1
gamma butyrolactone 1.1 0.1
Toluene 0.8 0.7
Propylene carbonate 0.7 0.4
Sulfolane 0.2

[29] Permeability of Commercial Solvents Through Living Human Skin
C.Ursin, C.M.Hansen, J.W.Van Dyk, P.Jensen, I.J.Christensen, J.Ebbehoej.
Am.Ind.Hyg.Assoc.J. v.56 p.651-660 (1995)



what about other things? I've taken to looking over my supplies and wish lists and asking about each item: "can I re-use this?" and "How long will this last?". Most medical kits are long on throw-always, and short on reusable. It's hard to get good reusable supplies these days. There are lure lock needles, made for autoclaving and re-sharpening. Plastic syringes and rubber ET tubes made for autoclaving. They are not easy to find. Bandaging is a big area where it's 100% throw away. Surgical towels (about 50 cents each from RR) and ACE wrap will satisfy most of your needs and can be washed and reused. strips of cloth can be sterilized and used. If you must invest in gauze, wonderful as it is, use it when resupply is a given and stockpile a box or two of the sterile type for packing wounds and using as drains - applications where it goes in or directly on a wound. Forget about it's common, throw away use.

Get an autoclave or pressure cooker. Glass syringes are great, but a waste of money if you can't sterilize them. Even then, a WHO study found they were able to grow bacterial cultures off 40% of "sterilized" glass syringes and needles due to poor sterilization practices. You need to learn to do it right!

many items that were never made to be sterilized, are, in third world countries. Dental floss has been used as suture, pliers as dental extraction forceps, etc. improvisation is the word of the day.

sanitary napkins are plentiful and cheap and make great blood sopper-uppers... don't expect this abundant supply to last, they are a potential source of supply, though disposable.

enough for now - feedback?

[Reasonable Rascal]

I never cease to be amazed at the durable medical technology that has been abandoned by current practices in favor of the disposable route. Case in point:

This week-end I made a shopping foray to a medical supply warehouse. I ran across an interesting item, the nasal douche. A simple if odd looking glass device used to cleanse the sinuses with warm saline. Eye cups are another old device. Add these to the glass syringes, reusable needles (for which ideally you have the proper size cleaning wire as well), glass an rubber atomizers, urinometers and more. When is the last time you saw metal bedpans and urinals.

There is a company - name presently unknown to me but I'm hunting down the issue of Forbes magazine that had the article - who collects disposable goods from hospitals, re-santizes and sterilizes them and resells them back at a significant cost savings to the institutions. We are talking about plastic and latex goods here. I presume they use chemical means.

More ideas here please!

RR

[jagdkampf]

A good example of what we can do with rudimentary supplies is the civil war. Most casualties in the civil war were not a direct result of trauma. Most morbidity and mortality were due to disease and infection. Asepsis and good hygiene are the most important medical factors in surviving trauma and illness in austere circumstances so let me approach that first. During the civil war sterility and asepsis were virtually unknown and still many people survived. The first items to stockpile are antiseptics: Soap-any kind but preferably an anti-bacterial type, several reusable, sterilizable scrub brushes. Betadine/iodine are nice but has a limited shelf life, in my opinion, chlorine bleach is better. A 10-15% solution is very good for disinfecting surface. It probably shouldn't be used on skin but would work in a pinch, just rinse it off with sterile water as soon as possible. A large pressure cooker makes an excellent autoclave. Many items can be sterilized in it from IV solutions (just like canning) to bandages and instruments. Alcohol is another good possibility and it doesn't have to be isopropyl. It can be of the ethyl variety, the same stuff you drink. A still can be made to obtain alcohol with a little ingenuity and copper tubing and can be produced from an fementable source. Alcohol is also very handy for making elixirs. I won't go into all the details of making alcohol but it's not rocket science.
Another aspect of good hygiene is compartmentilization. Any one suspected of carrying a contagious disease must be isolated and quarantined. In austere circumstances there is no other way. This is no place for political correctness. For the good of the community, they must be separated until they become better of die. Secondarily, everyone should have a textbook on communicable diseases and learn to recognize the S+S and incubation/ communicability periods. All contact with an infected individual should be handled by trained people and all reusables decontaminated and sterilized before reuse. Absolute good handwashing and hygiene techniques are a must with any patient.
Well, that's my 2 cents worth on what I consider to be a basic. Any other ideas?
JAG