WRSA Sends: The Grid Down Hospital

Re-Post from MDT

Stressing that you get as much first aid and patient care training and info before SHTF, cannot be over emphasized.

_________________________________________________________________

Grid Down Hospital – Part I

red-cross-flag

Grid Down Hospital
Introduction

Welcome to the first of what I hope will be many (or at least a few) articles on running a Grid Down Hospital.

For the purposes of these articles, I will use the term Grid Down Hospital to refer to any medical care facility put into service when normal facilities and services, for whatever reason, are not available. Hopefully, such care facilities will be established and staffed by medical professionals, but one can never be certain.

Some of this information will not be useful for you. Some will. Take what you can use, and leave the rest. If you have any specific questions, or concerns, please let me know and I’ll do my best to answer your concerns.

Be forewarned: I am not a traditional kind of physician. I have my own opinions about what works and how things should be done. I also don’t tolerate any ‘woo’ – that is ‘alternative medicine’ that has no basis in science. I may say things you don’t like. You may say things I don’t like. That’s called a discussion.

Right now, I have some articles that I wrote for another website, that hasn’t been updated in more than a year. These include Hygiene and Sanitation, the Grid Down Hospital Library, Medical School (medical education), Grid Down Hospital Central Supply, Grid Down Hospital Pharmacy, Basic tools for the Grid Down Hospital Staff, and the Grid Down Hospital Lab. I have already planned a couple of articles on equipment and techniques for the pre Grid Down Hospital care provider.

If there are any other topics you would like to see covered, please let me know.

Grid Down Hospital – Part II: Hygiene & Sanitation

Editor’s Note: Apologies to FlightERDoc and the readership for erroneously truncating the content in this post. Take two…

The next in a continuing series:

Trauma is cool…

Patching bullet holes can be exciting.

But this will be a very small part of what you need to prepare for. Grid down, more lives will be saved by the application of basic sanitation steps than all the CLS bags in the world. Being able to find clean water, disinfect or sterilize it, treat sewage and infectious waste (or at least keep it away from anything that will spread it) is far more important in the long term.

In fact, garbage collection and clean water supplies have done more to keep society healthy than all the doctors and hospitals in the world, and for far less cost. Disease, rather than trauma is what kills most people, grid up or down. If you can minimize disease you will have done more to save lives than treating a bullet wound or broken bone.

Clean Water

How to sterilize water? Simple:

You don’t need to ‘sterilize’ water.  Sterilization is the destruction of all microorganisms in, on and around an object.  What is needed, assuming the water has no other chemical pollutants in it, is disinfection (killing of pathogenic (disease causing) organisms). If the water is polluted with chemicals, you have a very serious problem on your hands.

Disinfection can be done many ways, including filtration, heat, ozonation, and chemical disinfection.  

Despite many stories to the contrary, simply boiling water will disinfect it.  At any elevation you’re likely be at the boiling point of water is high enough to kill (or denature) anything in the water.  You don’t need to boil it for any particular length of time, just get it boiling at a good rolling boil.

Filtration is a good method, you should use a filter that has an absolute rating of 0.2 micron diameter or LESS (0.1 micron).  Personally, I use iodine crystals (Polar Pure™) first, then filter the water.

Chemical disinfection is the use of various chemicals (usually a halide like chlorine or iodine) in the water.  It’s usually a quick, economical and effective method.

Here is a summary of water disinfection chemical usage based on theWilderness Medical Society Practice Guidelines 2nd Edition, edited by William Forgey MD (page 63):

For chemical disinfection, the key is the concentration of halogens (halogens are a group of elements like Chlorine, Bromine or Iodine), in parts per million (halogen to water):

screen-shot-2016-10-06-at-11-34-46-pm

How to get the desired concentration of halogens, for various products:

Iodine tablets, also known as: tetraglycine hydroperiodide; EDWGT (emergency drinking water germicidal tablets); USGI water purification tablets; Potable Aqua (trade name); Globaline (trade name):

4 ppm – ½ tablet per liter of water 8 ppm – 1 tablet per liter of water.

NOTE: These tablets should be gunmetal gray in color when used – if rust colored, they are useless:

The free iodine has combined with atmospheric moisture. The bottles should be kept well sealed and replaced often. Checking the tablets in the bottle just exposes them to moisture in the air.

For 2% iodine (tincture of Iodine) (gtts=drops)

4 ppm – 0.2 ml (5 gtts) 8 ppm – 0.4 ml (10 gtts)

NOTE: Tincture of Iodine should NOT be used as a wound treatment, so this is not a good option for a ‘dual use’ item.

10% povidone-iodine solution (Betadine™)

NOTE: Solution only, NOT SCRUB – Scrub has soap in it

4 ppm – 0.35 ml (8 gtts) 8 ppm – 0.7ml (16 gtts)

Saturated (in water) Iodine crystals (Polar Pure™)

4 ppm – 13 ml 8 ppm – 26 ml

Iodine crystals in alcohol

0.1 ml / 5 ppm 0.2 ml / 10 ppm

Halazone tablets (Monodichloroaminobenzoic acid)

4 ppm – 2 tabs 8 ppm – 4 tabs

NOTE: The old Vietnam era chlorine tabs are decades out of date. Chlorine tabs decay even more rapidly than iodine tabs. Not recommended.

Household bleach (Clorox™)

4 ppm – 0.1 ml (2 gtts) 8 ppm – 0.2 ml (4 gtts)

Note: Bleach offers a relatively economical method of treating large (gallons) of water at a time. 4 liters is approximately 1 gallon.

For very cold water contact time should be increased.

If drinking this water after disinfection, flavoring agents (drink mixes, etc) can be added: This must be done AFTER the period allocated for disinfection (the disinfecting agent will bind to the organic material and not work).

Bleach offers the easiest and most economical method of disinfecting water, especially in large quantities. Unfortunately, liquid bleach does not store well, and will lose potency over a relatively short time (months to year).

It is possible to make ‘bleach’ from products that are more stable…in particular calcium hypochlorite, also known as ‘pool shock’ or ‘HTH’ (which stands for “high test hypochlorite”). You can buy 1 lb plastic bags for a couple of dollars, and make thousands of gallons of water from it.

Unfortunately, the plastic bags it normally is sold in are not well suited for long term storage. I keep mine in 2 liter Nalgene™ lab flasks similar to these:

http://www.amazon.com/Nalgene-HDPE-Mouth-Round-Container/dp/B001OPMG52/ref=sr_1_1?s=industrial&ie=UTF8&qid=1434985816&sr=1-1 (retrieved 22 June 2015)

which I then keep in 5 gallon sealed buckets. I then keep this bucket well away from anything that may react to it, including metal, brake fluid or water.

Directions for calculating how much HTH to use can be found here:

https://www.scribd.com/doc/266122449/2006-09-14-Faq-Fs-Emergency-disinfection-drinkingwater-2006 (retrieved 1 October 2016) or here:

http://www.who.int/water_sanitation_health/hygiene/emergencies/fs2_19.pdf(retrieved 22 June 2015)

General guidelines on water and handwashing:

Boiling Water

http://www.who.int/water_sanitation_health/dwq/Boiling_water_01_15.pdf
(Accessed 16 May 2015)

Guidelines for Drinking Water

http://www.who.int/water_sanitation_health/publications/2011/dwq_guidelines/en/

(Accessed 16 May 2015)

Handwashing

http://www.who.int/gpsc/5may/tools/9789241597906/en/

(Accessed 16 May 2015)

Sterilization of Medical Supplies

Face it, disposables won’t be, but they have to be sterile. Here is some guidance on how to sterilize medical instruments in an austere environment

http://www.moljinar.com/page6/files/Sterilization%20v1-2.pdfAccessed 23 June 2015

Sanitation

Everyone goes, and we need to deal with it. If you’re out of cities, there is a good chance your home is on a septic system, which is great! When was the last time you had it pumped out (not everything is processed in it) and inspected to make sure the leach field is in good shape? It’s easier to fix it now than later.

If you need to dig a hole and build an outhouse, here is a compendium of information:

http://inspectapedia.com/septic/Outhouse_Latrine_Construction.phpAccessed 23 June 2015

http://www.marines.mil/Portals/59/Publications/MCRP%204-11.1D%20Field%20Hygiene%20and%20Sanitation.pdf

Accessed 23 June 2015

http://www.weblife.org/humanure/pdf/humanure_handbook_third_edition.pdf(retrieved 22 June 2015)

Medical waste

Medical waste needs to be handled differently than regular garbage, since it is oftentimes more infectious and is always ‘ickier’.

Method for incineration of medical waste:https://www.icrc.org/eng/assets/files/publications/icrc-002-4032.pdf retrieved 22 June 2015

Burial

Unfortunately, it will be necessary to deal with the dead. Here are some guidelines:

https://www.icrc.org/eng/assets/files/other/icrc-002-0880.pdf Accessed 23 June 2015

More On Sanitation

From a like-minded Doc:

MSF Public Health Engineering In Precarious Situations

screen-shot-2016-10-08-at-11-22-42-am

You are printing hard copy of all of this material, right?

Tempus fugit.

Grid Down Hospital: Part III – Tools

 

Flighterdoc sends:

Basic Tools

Certain basic tools are needed to perform medicine. While all are not needed on every patient, some are and are needed to properly perform an exam and diagnose patients.

Stethoscope – A cheap stethoscope is good for taking blood pressures in a quiet room and not much more. A good stethoscope can cost several hundred dollars, without getting into electronic ‘scopes. Good brands include 3-M Littman, Welch-Allyn and Hewlett-Packard, ADC is a mid-range brand. It is possible to find good stethoscopes at reasonable prices. Be careful with “Sprague-Rappaport” (a style and not a brand) dual tube scopes, if the tubes rub against each other you get noise. If that’s all you have, tape the two tubes together. Sources include Amazon, Ebay, and Allheart.com, among others.

BP Cuff set – Actually called an aneroid sphygmomanometer, these are the common things that get wrapped around your arm and pumped up. You should have a kit with different sized cuffs, a cuff that is too small for the arm will read high, and too large for the arm will read low. Automated home BP units are nearly worthless – they are expensive, use power, and are frequently quite inaccurate. If you should happen on a mercury sphygmomanometer that is still intact, great – they are fairly accurate over the long haul, and as long as the glass doesn’t break, safe enough.

Headlamp – Preferably a bright and adjustable output LED version. Actually, you should have several. This can be one you use for camping, it doesn’t have to be a medical version. I keep one in my locker at work and occasionally use it in day to day work in my ED.

LED lights have pretty well changed flashlights in the last few years. LED’s are typically whiter, can be brighter and certainly uses less battery power. A headlamp can be used to perform minor or major surgical procedures, work on patients at night, and just is a handy thing to have. They can be purchased almost anywhere, including Amazon or even Wal-Mart for $10-15 or less. Combined with a small solar battery charger and rechargeable batteries, you should be able to have light for quite some time.

Thermometer, normal range, oral – Get a digital version and a bunch of the plastic sleeves for it, and just replace it yearly (it’s cheaper than trying to find the battery and replacing it). Wal-Mart, your local drug store, or Amazon.

For when you can’t replace the digital battery, get (several) glass medical thermometers – oral and rectal, (the only real difference is the taste) and a small dish or tray to disinfect them in. You will also need a program or policy to clean them between different patients: I suggest having one for each admitted patient and do a thorough sterilization between patients, don’t use them across patients. You can use the same sleeves as for the digital thermometers on them to make hygiene a bit easier.

Thermometer, hypothermia – This is a lower than normal reading thermometer. Most of the same comments for regular thermometers apply, with the exception of finding them at Wal-Mart, and they are a bit more expensive. Handy when treating a suspected hypothermia patient.

Tuning fork, 128 Hz and 256 Hz – Refer tohttp://griddownmed.com/2015/02/13/tuning-fork-and-a-stethoscope-poor-mans-xray/ for reasons. (Accessed 1 Oct 2016)

Oto-Ophthalmoscope – This is the tool that doctors use to look at your eyes, and in your ears. While it is two different tools, they are usually combined with a common handle/battery pack. Of the two, the otoscope is probably the most useful, and the least expensive: You can get them at Wal-mart for less than $10, while a professional tool is several hundreds. They require batteries.

Pulse Oximeter – A small device that usually clips onto a fingertip and provides a reading on the amount of oxygen in the blood (showing how well oxygen is getting to the rest of the body) and usually the pulse. These can be purchased from Amazon and the usual sources for around $25 and up, and require battery power.

Watch with second hand, wind-up – This can be a simple and inexpensive watch, if you don’t already have a wind-up look for an old Timex at a swap meet, pawn broker or online. You should have a wind-up for when you can’t get a replacement battery, and the sweep second hand makes it easier to time things like respirations.

Patient Charts -There’s a saying in medicine – if you didn’t write it down, you didn’t do it. So, some sort of charting for your patients is in order. The government, of course, has all sorts of forms for this, some of which are actually useful. You can download government forms from http://www.gsa.gov/portal/forms/type/SF
(Accessed 1 October 2016).

Some of the more useful ones include SF 88, SF 93, and some of the 500-series forms. You can download and print them out if they will be useful for you. You could also make your own if you want, on plain paper. You will need clip boards, pens, 3-ring binders, large envelopes and file folders. Some post-it notes might be useful as well as 3×5 and 4×6 index cards, all of which are commonly available. Don’t forget pens and pencils.

Tool and Supply Sources

As mentioned, many tools are commonly available at Wal-Mart, your local drug store, online at Amazon, Ebay, etc.

Other sources include some of the following online stores – I’ve purchased from them all. (All accessed on 16 May 2015).

http://www.Allheart.com

http://www.Chinookmed.com

http://www.Mooremedical.com

http://www.boundtree.com

http://www.life-assist.com

http://www.dixieems.com

Government Surplus

Sometimes, if you know what you’re looking for you can buy US Government surplus. Generally the government isn’t getting rid of equipment that works well, that is complete, or is even safe to use so extreme caution is necessary.

The website is http://www.govliquidation.com/

Refer to the upcoming “Grid Down Hospital: Central Supply” for more tools and storage.

We will talk about what to do with this stuff in another article.

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Grid Down Hospital: Part IV – Medical Books For Your Hospital Library

 

Flighterdoc sends:

Medical Books

Where to get these books

Obviously, if you have the interest and budget, the easiest place to get these is from Amazon.com. Since you don’t need the latest editions of most of them, buying used books from Amazon, or from Half.com is perfectly adequate. You can also check Ebay, local bookstores (new or used) or most any other source. Public libraries probably won’t have a good collection of this level of medical books, and you can’t keep the books indefinitely. Some may be available as electronic books (legitimately or pirated). If you go this route then print them out. It may be much less expensive to just buy them, then pay for ink to print out a several hundred page book.

The time to get and study these books is before you need the knowledge in them. And since the quality of electronic versions can be spotty, plus electronic readers can fail, get the paper copies even though many of these textbooks (and others) are available

Medical textbooks are normally referred to by the primary authors’ name, and most of these books are listed that way. They are all listed with sufficient information that they can be identified on Amazon or whatever. Many are also available as illegal downloads, as well.

Generally, you don’t have to have the latest version of a medical textbook – but you don’t want one that is decades out of date, either.

Medical science does change, and things that were considered appropriate treatment even ten years ago are now known to be dangerous, or vice-versa, so try and use the most current books available and review several different books for a consensus for treatment.

Before you start

Medical Terminology

Chabner, Medical Terminology: A short course

Medicine has its own language, and words mean very specific things. You need to understand this language.

Medical Dictionary (Professional level). Any of the following dictionaries are fine, preference for one or another is purely personal.

Stedman’s Medical Dictionary
Dorland’s Illustrated Medical Dictionary
Taber’s Cyclopedic Medical Dictionary

Laypersons level

Merriam-Websters Medical Dictionary

English Dictionary

Sometimes you have to get to basics to understand the topic.

Basic Medical Texts: Common textbooks used in current Medical School curriculums, and following a more or less typical progression of courses. These give you the fundamental knowledge to be able to effectively use the specialty books and pocket guides mentioned later.

Anatomy – How the body is put together in a general sense. Keep in mind that nobody is exactly like the pictures, there is no such thing as ‘normal’ when talking about people – just ‘normal range’.

Netter (Drawings of how the body is supposed to look)
Rohen (Photos of how embalmed bodies actually look. Live people, and unembalmbed bodies, don’t look at all like these pictures.)

Gray’s Anatomy – The various commemorative reprints of early editions are not only wrong, they are in some cases dangerous. Avoid them as a reference source and only use a modern version which can be hard to determine since the commemorative reprints have current print dates….it might be better to skip this one for the others.

Embryology (How the fetus develops) Included for completeness, not a lot you can do about the process.

Langmans’s Medical Embryology

Histology (The anatomy and purpose of individual types of cells) If you have access to a good microscope and various stains, you might be able to differentiate cells to good purpose. At the very least understand that the body is made of different kinds of cells, which have specific purposes.

Junqueira’s Basic Histology
Wheater’s Functional Histology: Atlas

Medical Research, Epidemiology and Biostatistics – Being able to interpret reports is critical – aside from the baseline knowledge there is a skill to reading and extracting information from the reports, and understanding what they say and what they don’t say and why. The short version is that popular media reports are usually 100% wrong, and even the executive summary of actual studies sometimes are partially wrong.

Riegelman, Studying the Study and Testing the Test
Clinical Biostatistics and Epidemiology Made Ridiculously Simple

Psychiatry

Kaplan and Sadock’s Synopsis of Psychiatry

Biochemistry (What makes the different ‘machines’ in the body work. Understanding biochemistry and physiology is essential to understanding HOW to fix things, not just a checklist approach.)

Lippincott, Review of Biochemistry
Lehninger, Principles of Biochemistry

Physiology (how the different parts of the body are supposed to work)

Guyton and Hall, Physiology

These next two are only useful if you actually have the ability to monitor EKGs. An AED will NOT give you that capability.

Dubin, Rapid Interpretation of EKG’s
Garcia, 12-Lead ECG: The Art of Interpretation

Genetics

While this is taught in med school, it’s probably useless grid-down (it’s not terribly useful now, except in understanding and explaining what has gone wrong). Genetics is a rapidly expanding field, however, and the technology is becoming more available.

Microbiology

Understanding microbiology allows one to determine what illness a person may have, and which of the many different antibiotics are appropriate (if any) to treat that illness.

Pathology: What goes wrong in how things work in the body

Robbins, Principals of Pathology (any edition after the 5th, and any version except the pocket book).
Goljan, Rapid Review Pathology

Neuroscience (How the brain and central nervous system is built). While working on the brain grid down is probably a losing proposition, understanding the nervous system, especially the spine, is useful.

Snell, Neuroanatomy
Haines, Neuroanatomy in Clinical Context

Pharmacology

Katzung, Basic and Clinical Pharmacology
Pharmacology, Lippincott Illustrated Review

Clinical Skills, Physical Exam

Bates Guide to Physical Exam and History Taking: (Kind of basic, Barbara Bates was a nurse who wrote these books for nursing students, but a good intro). Get the big book, and then the pocket book as a memory aid.

Bates Videos: There are some truly boring videos that go with the Bates Guide. You can find them on Youtube.

Swartz, Textbook of Physical Diagnosis: History and Examination (better for PE)
DeGowin’s Diagnostic Examination (My personal favorite for PE)

Generally, STAY AWAY from the following:

The Dummies Series….your patients don’t need any dummies, and these books are just too basic.
Board Review Series (or similar) books – these are for cramming before medical board tests, and expect you to already have a grasp of the fundamentals. The “First Aid” series (First aid for the boards, First Aid for Surgery, etc) is also a book to stay away from unless you’re cramming for the medical boards.

Not quite Medical school level books that might be useful

These books are commonly community-college or EMT/Paramedic level training

Tortora, Principals of Anatomy and Physiology
Costanza, Physiology

Emergency Care and Transportation of the Sick and Injured – the classic book for training EMT basics
Prehospital Trauma Life Support

Medical Specialty Books

These are commonly used in the third and fourth year of medical school when students are exposed to the various specialties of medicine, and patients, and are also the basic books (there are many more) for each specialty.

Surgery

Schwartz, Principals of Surgery
Skandalakis, Surgical Anatomy and Technique
Giddings, Surgical Knots and Suturing Techniques: While I generally don’t recommend laypeople suturing, this is a good primer on how to.

Internal Medicine

Harrison’s Internal Medicine
Kelley, Textbook of Internal Medicine

Family Medicine

Taylor Manual of Family Practice
Singleton Primary Care
Rakel, Textbook of Family Practice

Emergency Medicine

Rosen’s Emergency Medicine
Tintinalli’s Emergency Medicine
Ma, Emergency Medicine Manual
Buttaraviolli, Minor Emergencies – Splinters to Fractures

Pediatrics (Kids are not just small adults)

The Harriet Lane Handbook of Pediatrics
Nelson, Textbook of Pediatrics

Obstetrics / Gynecology

Beckman, Obstetrics and Gynecology

Orthopedics

McRae, Practical Fracture Treatment
Hull and Bacon, Introduction to Dislocations
Chapman, Orthopedic Surgery

Dentistry

Halestrap, Simple Dental Care for Rural Hospitals
Nara, How to become dentally self sufficient
Oxford Handbook of Dental Patient Care

Disaster Medicine

Koening, Disaster Medicine
Ciottone, Disaster Medicine
Antosia, Handbook of Bioterrorism and Disaster Medicine

Ophthalmology

The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology
The Wills Eye Manual

Anesthesia

Brown, Atlas of Regional Anesthesia
Anesthesia, Longnecker
Miller, Anesthesia

Frequently Handy Books

Merck Manual of Diagnosis and Therapy– From the last 20 years or so

Gomella Scut Monkeys Guide

Tarascon Pharmacopia – Any edition from the last 5 years or so should be fine

Sanford Guide to Antimicrobial Therapy – Any edition from the last 5 years or so should be fine

Giddings and Giddings, Surgical Knots and Suturing Techniques, any edition is good

Trott, Wounds and Lacerations

Special Operations Forces Medical Handbook, 2nd Ed,

Physicians Desk Reference – one from the last 5 year or so should be fine, you can often get them for free from your physician or pharmacist. The pictures are most useful for identifying pills.

Book Series that may be useful; additional (not primary) sources:

Lippincots Illustrated Reviews Series

Medmaster Made Ridiculously Simple Series

The Washington Manual Series

The Oxford Medical Book Series

The Pocket Medicine Series

Current Diagnosis and Treatment Series

The 5-Minute Clinical Consult Series

The Ships Medical Chest and Medical Care at Sea

Auerbach, Wilderness Medicine and the Field Guide

Iserson, Improvised Medicine: Medical Care in Resource Poor Situations

Special Operations Forces Medical Handbook, 2nd Ed,

Ranger Medical Handbook

Special Forces Medical Handbook, ST31-91B This book is useful ONLY for the ideas on austere camp setups and veterinary medicine. The human medical information in it is of extremely poor quality, and consists mostly of war stories and old wives tales that were written down and put into a book. Be very careful with this one.

Buttaravoli, Minor Emergencies: Splinters to Fractures

Oxford Handbook: Acute Medicine

Oxford Handbook: Tropical Medicine

Oxford Handbook: Emergency Medicine

Coffee, Ditch Medicine

Issac, Wilderness and Rescue Medicine

Wilkerson, Medicine for Mountaineering

Flint’s Emergency Treatment & Management, 7th edition (out of print x 20 years, many around, the single best black bag book ever, covers camel bites – ‘Nair’ poisoning – and a million other things found nowhere else)

Medical Training and Education

There are a number of ways the layperson can get medical training. There is a sort of hierarchy to basic first aid training, usually named something like:
Standard First Aid – a one or two day class from the Red Cross
Advanced First Aid –
Emergency Medical Responder / First Responder
Emergency Medical Technician, I or Basic
Emergency Medical Technician, Advanced
Paramedic / Emergency Medical Technician-Paramedic
https://en.wikipedia.org/wiki/Emergency_medical_technician#United_States

Just because a person is an EMT-Advanced, or Paramedic, they don’t usually have any special authority when they are not actually on duty, and under the control of a medical doctor. Some states have scopes of practice for off-duty EMT’s…it pays to check out your local policies.

Wilderness Training

There are several wilderness first aid programs – such as Wilderness First Aid, Wilderness Advanced First Aid, Wilderness EMR, etc…

Except in Colorado, there is no actual official recognition of this level of training. That doesn’t mean you shouldn’t get it, on the contrary I recommend these sorts of classes to anyone who wants to learn more.

Wilderness first aid has to treat people with fewer resources, and fewer people, and often in difficult conditions (terrain, weather), and for longer periods. Unfortunately, the regular pre-hospital training programs all assume that more help (paramedics, hospital, etc) are nearby.

It is possible to get wilderness add-on ratings for existing EMR or EMT ratings, or take wilderness first aid classes. They usually take a few days more than a standard class, and involve a lot of practical field experience. From time to time other organizations (American Red Cross, Scouting USA, various wilderness adventure training programs) offer wilderness medical training. If they don’t provide certification from one of the following, I’d pass them by – you are investing some time and money in a course that may be quite good, or quite bad.

Wilderness Training Providers

Wilderness Medical Associates https://www.wildmed.com/wilderness-medical-courses/
National Outdoor Leadership Courses (NOLS)http://www.nols.edu/wmi/courses/
SOLO Schools http://soloschools.com/
From time to time other organizations may offer wilderness courses, if they are not certified to one of the above organizations standards I’d pass them by.

Online (Free) courses

Actual university (not really graduate) level courses in various medically related topics – free for the taking
Coursera https://www.coursera.org/
Accessed 15 May 2015

EdX https://www.edx.org/
Accessed 15 May 2015

Online Resources

These do not replace the knowledge above, they supplement it. Print the .pdf’s out while you can.

Ethicon Wound Closure: http://www.ethicon.com/healthcare-professionals/products/wound-closure
Accessed 15 May 2015

Ethicon wound closure manual: http://media.xn--benersttning-lcb.se/2012/04/Ethicon-wound-closure-manual.pdf
Accessed 15 May 2015

Stewart and Stewart, Austere Medical Sterilizationhttp://www.moljinar.com/page6/files/Sterilization%20v1-2.pdf
Accessed 1 Oct 2016

World Health Organization

Surgical Care at the District Hospital
http://www.who.int/entity/surgery/publications/en/SCDH.pdf?ua=1
Accessed 15 May 2015

Integrated Management for Emergency and Essential Surgical Care (IMEESC) toolkit
http://www.who.int/surgery/publications/imeesc/en/
Accessed 15 May 2015

International Medical Guide for Ships: Including the Ship’s Medicine Chest
http://apps.who.int/bookorders/anglais/detart1.jsp?codlan=1&codcol=15&codcch=3078
Accessed 15 May 2015

Basic Hospital Equipment
http://www.who.int/medical_devices/innovation/core_equipment/en/#
Accessed 16 May 2015

Global Help

Basics of Wound Care http://global-help.org/products/basics_of_wounds_care/
Accessed 15 May 2015

Practical Plastic Surgery for Non Surgeons http://www.global-help.org/publications/books/help_practicalplasticsurgery.pdf
Accessed 15 May 2015

And many others:

US Army Medical Department Borden Institute
http://www.cs.amedd.army.mil/borden/Portlet.aspx?id=aef88463-dc77-415a-8919-2ae436bd4b30
Accessed 15 May 2015
Many different specialties, all free for the download.

Hesperian Health Guides

http://hesperian.org/books-and-resources/
Accessed 15 May 2015

Home of Where there is no Doctor, Where there is no Dentist, and others geared strictly towards very basic laypeople

Epidemiology and prevention of vaccine-preventable disease
http://www.cdc.gov/vaccines/pubs/pinkbook/index.html
Accessed 15 May 2015

The Medical Aspects of Radiation Incidents
http://orise.orau.gov/reacts/resources/radiation-accident-management.aspxAccessed 15 May 2015

FEMA / DHS publications:
These were written by AMR, the largest private ambulance company in the US…I’d recommend downloading them as soon as possible and then printing them out.

https://www.amr.net/solutions/federal-disaster-response-team/references-and-resources

Available titles include (accessed 9 October 2016)

MASS MEDICAL CARE WITH SCARCE RESOURCES

ALTERED STANDARDS OF CARE IN MASS CASUALTY EVENTS

FEMA – DESIGNING A NATIONAL EMERGENCY RESPONDER CREDENTIALING SYSTEM

FEMA EMS TYPED RESOURCE DEFINITIONS

PARATRANSIT UTILIZATION GUIDE

DISABILITY EVACUATION GUIDELINES

72 HOUR GO KIT RECOMMENDED PACKING LIST

REQUIRED GROUND AMBULANCE EQUIPMENT LIST FOR FEDERAL RESPONSE

EMS SCOPE OF PRACTICE FOR AMR-FEMA FEDERAL DISASTER DEPLOYMENTS

DHS AUSTERE EMS FIELD GUIDE

DHS TACTICAL EMS GUIDE

DHS FEMA ALS AND BLS PROTOCOLS

AMR/FEMA DEPLOYMENT HANDBOOK

CRISIS STANDARDS OF CARE

________________________________________________

Grid Down Hospital: Part VI – Patient Assessment Overview

 

The latest from the team:

Patient Assessment Overview

Entire medical text volumes have been written about a full patient assessment, and what it should encompass. This will not be one of them, but it will serve as a reasonable overview for your efforts.

The type of assessment you perform is entirely based on time and resources devoted, which dictates the scope.

The first, and largely ignored, is the Eyeball Assessment. What you see in the first few to twenty seconds of contact with your patient.

Are they conscious? Alert? Oriented to person, place, time, and events?

Breathing? Normally?

Bleeding?

Do they have any Stevie Wonder fractures, i.e. obvious deformities?

What color is their skin, as in normal nail-bed pink, or pale, jaundiced, etc.?

In short, can they walk, talk, and basically function normally?

This is a Go/No Go evaluation, and determines the likely severity of their situation, and the scope of your further efforts.

The second, usually deployed in the Mass Casualty Event (a Mass Casualty is ANY event when demands exceeds immediate resources, and could be as little as one patient), is known in the biz as the START assessment, for Simple Triage And Rapid Treatment.

A picture being worth 1000 words, here it is:

gdh-startadulttriagealgorithm

The algorithm above embiggens. Learn it, love it, live it.

Use of this algorithm enables one person, with a handful of triage tags with four color choices (which determine rather exactly your medical future) to triage multiple patients in a few seconds apiece, and then get back to focusing on the worst first without wasting resources on those who died or soon will.

There are multiple videos on YouTube covering START Triage which explain this process. A quick survey showed that they’re all bad (in being poor quality, lousy presenters, boring as f***, but..), but pick one and follow along, because they cover the information, while unfortunately being largely unwatchable.

The next level of patient assessment is used for most contacts – the Primary Assessment.

The list is a little more involved, and from this point onwards, all assessments need to be seen as only one data point. This means while true, they don’t tell you much by themselves; the key is to do multiple assessments, and note the trend, over time. That’s where they gain their true value.

This requires adequate documentation each and every time, and completeness, each and every time, at least of the pertinent items.

You want the following:

Baseline mental ability: awake, alert, oriented times four items?
Body Temperature?
(Note that even lacking a thermometer – which you shouldn’t but…- hot/warm/cold to touch is still clinically useful.)
And skin color and moisture: pink/dry is normal. Pale/diaphoretic(sweaty) is not.
(Note also that if lacking medical terminology, plain English will suffice.)
Pulse: regularity (or not), rate (beats per minute), and quality (weak/strong/bounding).
Respirations: regularity (or not), rate, including chest symmetry, and any further medical description of the respirations (which requires more than laymen-level instruction), if appropriate.
Blood pressure: With a cuff, and where (on the patient’s body) taken.
Pulse oxygenation, if you have the capability.

The above is standard from field and ER triage desks to surgical anesthesiology, and will stand you in good stead if you equip for it, learn it, and do it. Practice now, and on patients from infants to the elderly, any time the opportunity presents itself.

Ancillary equipment in any of those environments can get you more information, but you can’t suffice with less, in most instances, nor should you try.

I repeat: Documentation, Accuracy, and Trend Over Time.

Lastly is the Secondary Assessment. It is a complete review of the body from head to toe.

I can do a pretty thorough one in two to five minutes on a prone patient, even if they’re unconscious. The checklist runs to two or three pages. (Flighterdoc, I , or some other author may devote a separate essay to same in the future.) As this is where patient assessment and other medical texts come in handy, the short summary is that you look at and palpate (touch and feel) everything from the top of the scalp to the soles of the feet, which you have to be able to get to and see – which is why the doctor always wants you in that annoying loose gown first, and why paramedics cut your clothes to ribbons nine times out of ten at an accident scene. Jeans and boots are replaceable, death is not.

You are looking for obvious deformities, bleeding and/or other fluid leaks, bruising, other wounds, skin color, movement, nerve sensation, circulation, intactness of bones, normality of reflexes, or any and all deficits in the above. Head, neck, torso, abdomen, groin, arms to the fingertips, and legs to the toes, including rolling on the side to inspect everything, particularly the spinal column, from head to tailpipe, inclusive.

If the patient is awake and responsive, it also includes hearing, eye movements, and verbal expression checks, because these give you cranial nerve function times twelve (you should look these up) without a CT scan, in about a minute.

After that, you progress to things like laboratory blood, urine and fluid tests, and diagnostic imagery (Xrays, Ultrasounds, CTs, MRIs) which probably are – but need not necessarily be – beyond your scope. For one example, you can get a bedside ultrasound machine for about the price of a thermal weapon scope. One can pick out a target at 1500 yards, and the other can diagnose internal bleeding or appendicitis. You decide whether either of those things are important, and devote your resources appropriately.

You can also, even in degraded conditions, do blood laboratory work and cultures of specimens to detect infection, if you have the equipment, training, and resources. SF 18Ds are expected to meet that standard, and did so in sandbag hooches in SEAsia amidst a war. You get what you pay and train for, and your people will bless or curse you, depending on your abilities and their outcomes.

_________________________________________________________________

JCD

 

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