A Surgeons Advice to Preppers

8/6/2019 A Surgeons Advice to Preppers

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A Surgeon's Advice to Preppers, by Swampfox, M.D.Permalink

As a reformed Christian and novice "prepper", I am so glad to have found your blog and all the informativematerial that it contains. With your help, I am becoming prepared for the hard times that I believe areimminent. I am a general surgeon practicing in the southeast. Your writings have caused me to think a lotabout the logistical vulnerabilities that exist in our health care system and how drastically surgery wouldchange if/when Schumer hits the fan.

The Coming Instrument ShortagesMany instruments and most of the supplies that we use for routine operations are disposable. Hospitalstypically keep no more than one or two weeks worth of surgical supplies on hand. Any interruption wouldbe devastating to the continued provision of surgical care. Surgeries that require general anesthesiawould be very problematic if not impossible. In such a scenario, Haiti and Zambia may be betterpositioned to provide basic surgical services than our "advanced" US hospitals because they already live bythe principle of "use it up, wear it out, make do or do without." In the third world, they routinely re-usethings like surgical gloves, drapes, and suturing needles (after properly cleaning and re-sterilizingthem.) In America, we have far too many government regulations and trial lawyers for us to re-useanything. Most things here go to the landfill after a single use. It seems that Haiti and Zambia are poorcountries while we are "rich and increased with goods" (Revelation 3:14-19). We have no need to befrugal in the US. There is no monetary crisis coming, no unsustainable deficits, no federal Ponzi schemesready to burst. No, no. Nothing to see here.

Wound ClosureHaving read several articles on various web sites regarding medical preparedness and wound care that areunrealistic, if not harmful, I was prompted to send a few comments regarding the virtues of "wet to drydressings." In managing a traumatic wound in a TEOTWAWKI scenario, your readers should keep in mindthat most wounds can be left open without causing any problems whatsoever. A fresh wound is one thatis 1-2 hours old. The longer the time between wound creation and closure, the more bacteria the woundis exposed to, the greater the chance of infection if closure is attempted. Right now with health carefunctioning fairly well, I never close a wound that is more than 6 hours old no matter how clean itappears as the risk of infection is prohibitive. If a wound is simple (a clean cut rather than frayed skinedges), fresh, and free from gross contamination, it can be copiously irrigated with saline (do a websearch and print the recipe) or clean water, numbed with lidocaine injections, and sutured up. If there isany doubt, then leave it open and start a wet to dry dressing using gauze moistened with saline. Woundswith gross contamination such as the presence of dirt, leaves, or feces should always be left open evenafter cleaning them thoroughly. All bite wounds should be left open, especially human bite wounds asthese are perhaps the dirtiest. Nearly all wounds in the body can be safely managed this way. The chief

advantage of suturing a wound closed is that the scar will be more cosmetically appealing than the scarthat will be left if the wound closes slowly over time with wet to dry dressings. Closing the wound willalso obviate the need for painful daily wound packing (the dressing changes stop hurting after about aweek). Suturing the wound can make you look like a hero, but the patient may be placed at unnecessaryrisk by doing so. Don't hesitate to leave it open and pack it with gauze. Nobody will care what the scarlooks like if the grid is down. If a wound is sutured and later becomes infected, cut the sutures out, openthe wound with a clean (preferably gloved) finger to its depths, and begin wet to dry dressing changes. Itwill usually heal fine once you let the pus out.Large abdominal wounds that go down through the muscle and fascia would be difficult to close withoutgeneral anesthesia. Anyone trying to close such an abdominal wound would risk injury to the underlyingbowel, creating a bigger and smellier problem. Leave it open and do wet to dry dressings. This mayresult in a hernia forming, but the hernia can be fixed years later when order is restored. Extremitywounds involving muscle, fascia, and tendons can safely be left open. Muscle and facial injuries almostalways heal without functional deficits. Tendon repairs can prevent functional deficits, but are probably

beyond the ability of non-surgeons. Most tendons can be repaired at a later date. "Sucking chest wounds"which go down into the chest cavity exposing the lung would likely be fatal in a TEOTWAWKI scenario so Iwill not elaborate on the three sided dressing that ATLS recommends. Open skull fractures would be un-survivable without a functioning hospital.Gastrointestinal (GI) surgical cases such as colon cancer resections necessarily cause limitedcontamination of the incision resulting in frequent post-operative wound infections in spite ofantibiotics. If the incision becomes infected a week after surgery, we remove the sutures, open thewound widely with a finger, and start wet to dry dressings. In operations done for ruptured appendicitisor diverticulitis where there is gross fecal contamination, we leave the incision open from the start andbegin wet to dry dressing changes immediately. I have seen thousands of wounds close using thismethod. The wounds typically heal in 3-6 weeks, usually without incident. The wound should be packedto its depths daily with plain gauze moistened (not dripping) with saline solution. This provides an idealenvironment for healing resulting in granulation tissue formation. Any devitalized or infected tissue sticksto the gauze as it begins to dry and is removed when the packing is changed. Granulation tissue fills the

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wound causing it to get shallower over time. Each day the wound requires less gauze. The skin edgesbegin to close from the sides. The depths fill in, the edges draw together, and the wound closes leaving awide scar. It may sound fictitious, but I have seen wounds close in this fashion that were big enough tohold a 25 pound sack of rice. Leaving the wound open and performing wet to dry dressing changes greatlydiminishes the risk of infection. Antibiotics are unnecessary in treating most wounds that are leftopen. Necrotizing (so called "flesh-eating") bacterial wound infections will be fatal inTEOTWAWKI. Leaving wounds open will greatly reduce the chances of necrotizing fasciitis.Contrary to some things I have read, gauze sponges do not stop bleeding. We could not live many dayswithout a functioning clotting system. It is the clotting system that stops almost all bleedingvessels. Large veins or arteries may not stop on their own. Direct pressure with a finger or two can stopbleeding from almost any vessel outside of the abdominal or chest cavity where direct pressure cannot be

held. Hold pressure for 20 minutes by the clock (no peeking) and most small and medium sized bleederswill stop. Large vessels (bigger around than a pencil) may take an hour. Once the bleeding iscontrolled, get the patient to a surgeon (or get a surgeon to the patient) when feasible as a large vesselhas a high risk of re-bleeding in the subsequent hours/days. If none is available, two weeks of completerest, a snug ace wrap, and a gentle dressing change each day is the best that you can do. Penetratingwounds to the abdomen or chest cavity with associated large vessel injury would be fatal.Ligating (dividing and tying off) injured blood vessels is doable, but attempting it without a lot of previousexperience can make the bleeding worse. It should be attempted only if direct pressure for an hour hasfailed to stop the bleeding. If the vessel is visible in the wound, clamp it with hemostats above andbelow the bleeding point, divide the vessel with something clean and sharp, and tie off both ends withsuture (easier said than done). Sometimes a torn vessel retracts into the surrounding tissue making itdifficult to find for ligation. A figure of 8 suture can be done in such a circumstance. Imagine a squarepostage stamp with the retracted bleeder at its center. Insert the needle at the top left corner of thestamp. The needle should travel in an arc deep through the tissue and exit at the bottom left corner of

the stamp. Pull extra suture through such that the tails are long enough for tying. Next, insert theneedle at the top right corner of the postage stamp passing it deep through the tissue such that it exits atthe bottom right. When the knots are tied the suture will cinch down around the hidden vessel and stopit from bleeding. I recommend that you do a web search on "figure of eight suture" to see a diagram orvideo to make this technique clear to you. (One video shows this technique used for skin closure. I'mdescribing a figure of eight suture down in the wound under the skin where the bleeder is.) It can be avery useful technique in a pinch.Trying to repair or reconstruct an injured blood vessel would be unnecessary and dangerous even for asurgeon in TEOTWAWKI except in rare circumstances. The redundancy [of "dual supply"] that God gaveour bodies makes it possible to ligate most blood vessels (even large ones) with few if any adverseconsequences. We should learn from our Designer (Romans 1:19-20). A tourniquet can be used briefly tostop major vessel bleeding as a bridge to surgery, but a finger usually works better if you can spare aperson to hold pressure. Tourniquets are necessary in badly mangled extremities as there would be morebleeders than available fingers, but such a severe injury would likely be fatal in TEOTWAWKI. Keep inmind that limb amputation in the 1800s performed by the best surgeons of the time had a 50-90%

mortality rate. Also consider the fact that a surgeon in the 1800s was far better prepared than a modernsurgeon would be in a societal collapse.Your readers will do well if they stock up on lots of 4"x 4" and 2" x 2" gauze sponges as well as rolls ofKerlex gauze. Remember that gauze is woven cotton thread, not the stretchy, synthetic stuff that somemanufacturers call "gauze." Wide tape such as 3" Medipore works well for most wound dressings. ABDpads come in handy as they are very absorbent and are used to cover the wet to dry dressing beforetaping it down. Make sure to get some 4" Ace brand (or similar) wraps. Get the ones with Velcro strips onthe end. These elastic wraps can be used instead of tape on an extremity to hold the dressing inplace. They can be useful in bleeding extremity wounds to tightly wrap the arm or leg to help withstubborn oozing after the dressing is applied.I recommend getting some Vaseline impregnated gauze or Xeroform which are non-stick dressings good forsuperficial abrasions (scrapes) and burns. Each family needs a gallon of 4% Chlorhexidine gluconate(Hibiclens or other brand) in case community acquired MRSA infections continue to plague us. It can beused as skin preparation for wound closure, but may be more useful as treatment for MRSA colonization

and infections. Finally, make sure that you and your kids are current on tetanus shots, hepatitis, andother vaccines. Hopefully, by leaving all but the cleanest and freshest wounds open and pre-forming wetto dry dressing changes, more of your readers will be spared the risk of a serious wound infection inTEOTWAWKI.

Wednesday, February 23, 2011Letter Re: Antibiotics for Serious WoundsPermalink

A reader wrote to ask: "Dr. Koelker, you explained what each of the antibiotics is good for, but one majorconcern was unaddressed. In a TEOTWAWKI situation we may be faced with having to treat gunshotwounds. And just as likely, if not more so, we may need to treat serious lacerations, such as accidentswith sharp, dirty tools. I think, as am I, the readers of this blog might be interested to know whichantibiotics are the most effective in preventing infections if/when we sustain such wounds."Doctor Koelker Replies: As usual, such answers come in a short and a long form. At the moment I wont



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address details of wound cleansing, closing, cauterizing, likelihood of infection or fatality, etc., etc.

Here is the short answer: The microbes that are likely to have been introduced into a wound determinethe choice of both prophylactic and/or treatment antibiotics. When antibiotics are given before a visibleinfection is apparent, the assumption is that the wound still contains bacteria in low numbers (most ofwhich have hopefully been washed away by appropriate cleansing). Killing off these remaining microbesshould prevent infection in most cases although prophylactic treatment is not always effective.Where do these germs come from? This depends on the body part that was penetrated, the environment,and the source of the projectile.Injuries that pierce the skin carry the risk of contamination from common skin microbes, primarily staphand strep germs. When orthopedic surgeons place pins and screws in bones, they pierce the skin. Despitecareful antisepsis, perhaps a few bacteria might still be introduced into a bone, where infection canfester, causing permanent damage, limb loss, or even death. Though in a surgical setting the risk ofinfection is low, the potential consequences of infection are so high that prophylactic antibiotics arestandard one dose before surgery, and one to several doses after surgery. The intravenous antibioticAncef is most commonly employed (which is most similar to cephalexin, see below).Of the available oral antibiotics previously discussed, the best choices would be cephalexin, Augmentin,Avelox or Levaquin. Less potent alternatives, if the former are unavailable, would include theerythromycins (including clarithromycin and azithromycin), tetracyclines (including doxycycline), ortrimethoprim-sulfamethoxazole (TMP-SMX). Amoxicillin, penicillin, and ciprofloxacin are much less likelyto be effective. Normally IV antibiotics are preferred due to their immediate bioavailability and highblood concentration. If oral antibiotics are used pre-op, they should be given on an empty stomach withwater only, about two hours prior to surgery.The other large class of potential contaminants is that of intestinal bacteria, especially gram-negativebacteria and anaerobes. If the source of contamination is external, as an explosion in a cesspool, a

person might live without surgery. If the source is perforation of ones internal organs, death is likelywithout emergency surgery.But say surgery is an option, or youve cut your hand deeply while cleaning out a septic tank youllprobably need a combination of antibiotics to avoid or treat infection. The first should be eitherciprofloxacin, Levaquin, or Avelox, whichever is available (ciprofloxacin is the only inexpensive generic inthis class). Second line alternatives for these would be Augmentin or TMP-SMX. Additionally,metronidazole should be added to cover anaerobic bacteria. Basically, the same antibiotics useful fordiverticulitis or other intra-abdominal infection are indicated for intra-abdominal wounds.Lastly, we seldom think of tetanus except to get vaccinated when were injured. If you havent beenimmunized in the last five years, then do so now. The new TDAP vaccine includes immunization againstdiphtheria and pertussis as well. If a wound is deep or contaminated with rust, treating withmetronidazole (or penicillin) may decrease the number of tetanus-toxin producing Clostridium tetanibacteria, but these antibiotics do nothing to counter the toxin that has been produced, and which maycause muscle spasms that constrict the airway. Without immunization, risk of death is veryhigh. (Doctor Koelker is SurvivalBlog's Medical Editor. She is also the editor ofArmageddonMedicine.net. )

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A Surgeons Advice to Preppers