Hogwarts: “And of course with that shiny new airway, you’re going to need some accessories…”

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You, your S-4, and your medical officer are planning covert convalescent care, right?

No, really – you are doing so, right?

33 responses to “Hogwarts: “And of course with that shiny new airway, you’re going to need some accessories…”

  1. Marlo Stanfield

    Visiting an elderly relative in a average rehab place I have noticed that if one is clean and polite you can come and go at will as long as someone you know is there. Most old people in places like that have no visitors. If they have family they don’t come around and have simply left them to fend for themselves. This is going on while the juice and 911 are on in America. Younger CNAs and such stay around long enough to build up some seniority and move on. These places are wide open for honest people to come in do volunteer work and even go to  school and get jobs in these places. No reason not to form your own church, lots of empty buildings and start offering your time. Most people are scared to go around old people so its a wide chance to ingrain your self with the medical staff and the patients. The equipment is already there and in time of real emergencies a shortage of qualified staff. Same thing at these assisted care places where some but not all can take care of themselves. Hopefully you have many years to put such a network into place before ever needing it. It has been rumored that the mob has places for their higher ups to go to. How many retired doctors and nurses out there that do work for the outfit? Or work at a medical place that handles the illegals? You just need to know the staff well ahead of time. This is from Breaking Bad.  Gus has an emergency tent already set up.      https://www.youtube.com/watch?v=TjXEy_dL-Xk       Breaking Bad, Season 4, episode 11.    

    • We’ll be getting right on that, soon as we are done launching our surveillance bird, building our A10 from parts on Amazon and …

      Sorry but you have two three options if you need this level of medical care:

      Surrender to OPFOR and hope the get you well enough to walk to the electric chair.

      Have roots in the community that will allow you to be treated in-cognito

      Die

      Some little town in Ohio just had a botulisim outbreak, 12 people needed vents, 10 were airlifted to columbus and that took up 30% of the long term vents available in an 8 county area.

  2. Hope this isn’t too much of a shocker but there will be no convalescent care in my AO unless someone I am not aware of is taking care of that. When it gets bad, it will be worst for those who are sick or injured. Unless something changes between then and now… they will be dead and dying. Harsh reality.

  3. Unless you are filthy rich you simply cannot afford to acquire and stockpile meaningful levels of supplies for truly serious medical conditions….it would be hard to have enough of the proper supplies and people to cope with ONE serious GSW. When you start talking open conflict the number of wounded will quickly overwhelm small bands of people.

    • agree. For quite some time, anyone wounded will be left a weapon, some ammo, and told to delay the pursuers as long as possible

      • Jimmy the Saint

        Yeah, that will build a sense of unity among your troops. One or two might opt for martyrdom, but you can bet your ass that whoever you’re fighting against will soon figure out that offering your wounded care will yield all sorts of valuable intel about your group.

        • OK. So we’ll just do it up Wild Bunch style –

          “Mr. Bishop…I can…..I can’t…see……finish it, Mr. Bishop…”

          BANG!

  4. Grenadier1

    Really awesome info. I think the focus for those of us outside of the medical world is to keep people alive until they can get to the covert hospitals that need to be set up. Those set ups will have to be done by people like the good Docs at Hogwarts. the rest of us need to learn how to be good EMT’s and figure out the transportation.

  5. flighterdoc

    The serious problem with prepper/patriot medical planning is that having TCCC training, or a combat lifesaver bag, will not heal a patient.

    They work well enough when you have the entire resources of the US Military to provide battlefield evacuation, front-line stabilization and in theater surgical care followed by evac to CONUS and rehab, but by themselves are useless.

    So, what to do? Better have a plan.

    And yes, medical care takes a metric shit-ton of gear, in warehouse lots, and it has a relatively short shelf life in some cases. The hardware used these days (like vents) are expensive and power hogs, and require constant maintenance, as do things like oxygen concentrators.

    I have a plan, for me and my group – we are medical professionals, who understand that care post SHTF (for whatever reason) will not be the same as care today, but we will try our very best. We have supplies stockpiled, skilled people, and plans on how to make things to make due.

    And yes, we will expect those around us to provide security, fuel, and food, as needed. So we can save lives.

  6. anonymous

    In case of shtf and 4gw, I think things will look like the civil war medical care at best. And I believe tptb have past laws to make it that way. The higher the death toll the better for them. And proper medical care along with food and water can be used by tptb to get sheeple to side with them.

  7. Ed Grouch, MD

    I read, some time ago, an opinion from an ER doc. He was asked, what supplies should we stock up on for a true, grid-down, end-of-the world scenario? He replied: body bags.

    I’m not quite that cynical (although he is, technically speaking, correct). I think, in a catastrophic event, one of the most important things will be to manage our expectations. The things I see in my ICU will be “death, uncontested” in those scenarios. Yet I refuse to give up hope.

    CA, I owe you a apology. You had requested an article on covert convalescent care quite some time ago, and I think we have become distracted. We will bump that up the priority list. It’s a nasty, tricksy topic, however–if there are any specific things you want, let us know.

    Flighterdoc, agree 100%. Also, email sent your way.

    DJ, the hope is to get the creative wheels turning. Fabbersmith, in a comment on the post on our site, indicates “Any rigid tube could be improvised into a low pressure single stage compressor, and with a stepper or servo for power, volume given is easy.” Not that I am an engineer (except in genetics) but it seems those with skills can improvise if needed.
    There are many designs for vents (and suction, and whatnot) available for free online, the Google patent search is quite fruitful.

    As you correctly point out, prepping is easier if you have Bill Gate’s bankroll. Most if not all medical equipment is wildly overpriced, typically at least a 200% profit margin and in some cases many times that. Having all the gear means nothing, however, if you don’t know how to use it. Examples of surgery in austere environments abound, with not much more equipment than soap, injectable local anesthesia, a knife, and some needle & thread. Outcomes sucked compared to grid-up, western-style medicine, but that is to be expected. See, for example, here:

    http://www.ncbi.nlm.nih.gov/pubmed/17563965

    DocDeath, your comment reminded of this, which occurred during my fellowship training. What is not mentioned in this article is that they fermented the prison moonshine in the toilet. Moral of the story: don’t drink from a prison toilet.

    http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6139a2.htm

    Finally, I would add: Got Tribe? Cause you’re gonna need them. Ain’t no way you’ll get through almost any true medical problem alive without help.

    • Doc:

      No worries; it’s not like the Hogwarts faculty has been drinking Volcanos at the swim-up pool bar.

      My primary question is what gear (in some level of detail) should the…ahem, brave American liberators liberate from the enemy medical facility they just overran in their triumphant advance on Berlin….or Detroit….or some such.

      Mucho gracias.

      • Ed Grouch, MD

        All of it. 🙂
        I’ll try to summon up a less flippant answer here over the next few days.

        • Good to know that my “salvage” instinct was correct.

          😉

          • Jim Klein

            Ha, scrap. That’s all the good ever was, turning nothing into something. The bad—I once watched a lot full of vans sit and rust over the years in Detroit. “Weatherization” they were, lol.

            Thanks, docs. You say you have to know how to use that stuff, eh?

            • Ed Grouch, MD

              At the very least, figure out which end you stick in the patient…
              🙂

    • Thanks for the mention. Something else I was thinking about was materials. While i dont know enough to comment competently on just what the profit margins are, aside from low production volumes a big reason for the expense of medical equipment is the materials. At a certain point cleanliness and other factors take over on a level far eyond even food production, and paperwork takes even more time.

      My rigid tube wou’d most likely be a piece of PVC pipe. Should work well enough, im sure you’d want to filter your air though, but would a vacuum cleaner HEPA filter work, or would you really need something much more robust? If you make parts on a 3D printer, you have to consider cleanliness since an FDM machine leaves tiny ridges unless post treated, and most prints are hollow to some extent and tiny cracks can let fluid in to stay inside.

      It might be nice to put on the list some less-than-obvious considerations for makers looking to improvise this stuff. Porosity a day surface finish can be rather obvious, but things like what kind of HEPA filter to use for a respiration machine take some consideration.

      There are several sites that host wikis, and software exists for private hosting. Have you guys considered such for storing this kind of info?

      • Ed Grouch, MD

        The materials themselves aren’t as spendy as you might think. Medical, just like military, goes to the low bidder. The process may be more costly, and certainly no hidden ridges or whatnot can be allowed. Also, cleaning all that stuff is important. The FDA just ruled that any equipment that touches a patient, must be either disposable, or autoclavable. (unless you have one of the prion diseases, then you just have to throw it away).

        Only in specific instances are the materials highly specialized, such as the sintered titanium surfaces on the inside of LVADs. Or the magnetic bearings that allow the spindle to rotate without touching any surfaces. See here for an example:
        http://www.heartware.com/

        The paperwork is a cast-iron dirty whore chasing you with a HIV covered bloody knife. On a good day.

        Any HEPA filter should do.

        I have been thinking about trying to impart more understanding from a physiology point of view, so that folks would understand what was needed and improvise. I’d not considered that from a manufacturing perspective. Good call on your part. I’m not sure I’ve the experience to lay that down, but, as they say, I know people who know people.

  8. all this discussion just brought to mind a section in F.W. Deakins’ THE EMBATTLED MOUNTAIN. D. was a Brit liason officer with Tito’s Red partisans, fighting the Italo-Germans & Chetniks and etc. in Serbo-Croatia, 1943-44. During one especially intense, prolonged fight they had a large number of wounded and couldn’t bring them along during the usual evasion…partisan doctors and nurses (some 200 in #) elected to, & were allowed to stay behind with the wounded, in the expectation that, given the large #’s involved, they’d get decent treatment from the enemy. Nope. 7th SS Mt. Div. troops killed them all. That’s how it’ll be here. On all sides

    • anonymous

      Haxo, I was thinking something like this the other day. In my A.O. I have no place for a prison camp. Let alone the people to guard prisoners or feed them and care for their medical needs. And letting the enemy go so I can fight him again tomorrow ain’t happening. The death toll is truly going to be staggering. GOD help us.

  9. A couple of thoughts on the topic from years past:
    http://raconteurreport.blogspot.com/2013/01/casualtytrauma-care-supplies-in-austere.html
    http://raconteurreport.blogspot.com/2013/03/equipping-disaster-clinic-space.html
    http://raconteurreport.blogspot.com/2013/03/equipping-disaster-clinic-basic-stuff.html

    Knock yourselves out.

    And btw, you could put together your own 1-bed ER/trauma clinic, complete and first-world capable right now, for far less than the price of a Hyundai. Probably even less than that. So if you have twenty-plus guns in the safe, don’t bitch that it’s out of your price range. It’s not.
    (What it probably is, is out of your experience range, which is both understandable, and fixable.)
    The highest single-item draw would be a solid patient monitor, at around $3K, give or take. (You can live without that, but doing all vital signs by hand forever gets old fast.) Most of the other stuff can be had in case lots and gobbled up for <$100, and contrary to myth, about 99% of it goes bad only after about 50 years or so.
    And there are workarounds for most of the other 1%.

    With about 4 20' conex shipping containers, you could set up a 2-bed clinic/ER/OR (20'x36'ish) that would do everything your local 500 bed hospital can do except CT scans, and save one helluva lotta lives with a staff of <10 people, while treating up to 50 cases/day for as long as your backstock held out, including the occasional major trauma case, IF you had the correct staff for that.

    This is not the rocket science many assume. Those of us in the trade know better. But you have to have some people committed to doing it, which includes getting training now, while such is do-able, and not just having only the stuff or the space. Supplies without skills are deadweight. So are people without either.

    Just for one point of historical reference, the average EMT today with a high school diploma possesses more (and more precise, if they pay attention) medical knowledge than the average physician had from as recently as about 1900, as a general rule.
    And that same EMT with a circa 2015 first-line medical reference library and a few like-minded individuals would be better than any medical school before about 1950, in short order. Even grid-down, we aren’t going back to the stone age. More like the steam age.

  10. NightWatcher

    I think I can comment intelligently on this subject.

    We need to remember that “breathing” consists of three inter-related systems:

    1) Ventilatory Drive or the impetus to breath. This is a complex system but suffice it to say that it resides in a very primitive part of the brain (even statists manage it).

    2) Gas Exchange or in other words, putting circulating blood in proximity to air so diffusion can occur.

    3) Ventilation or the mass movement of gas from an internal space to ambient. This includes the mechanics and plumbing necessary.

    In an austere environment, disorders which affect #1 & #2 will essentially be fatal with few exceptions. #1, because if the brain is damaged to the point that even the Reptilian parts don’t function, the patient is likely Tango Uniform. #2, because if gas exchange can’t occur (think massive pulmonary edema or ARDS), the level of care will far exceed what is available.

    That leaves us with item #3 to concentrate on. Typical examples of such injuries are facial trauma and pneumothorax. These will possibly require immediate intervention (i.e. tracheotomy/cricothyroidotomy or pleural decompression), but will be highly unlikely to require ventilatory support once the mechanical failure has been resolved/circumvented.

    An exception would be bilateral flail chest, but that is getting pretty far into the weeds so to speak.

    In an austere environment, if appropriate intervention with an “Ambu bag” (think drowning) doesn’t resolve the crisis, we should probably be calling the Chaplain, rather than for a ventilator.

  11. NightWatcher

    Some additional thoughts:

    In an austere environment, we in the medical profession need to concentrate on “helping people to help themselves”. This is not some “new age” or “community organizer” idea. The point is to get the casualty from a state of crisis into a state where natural healing can occur.

    In a sense, we can consider ourselves plumbers. Primarily, we need to fix leaks and open up blocked pipes (sometimes, a little straightening may help as well). Then we need to concentrate on filling up the tanks (but not before the leaks are fixed).

    IMHO, the best asset we could provide after initial stabilization is the ability to provide IV fluid appropriately. This would require either a large stockpile of IV fluids, catheters and tubing, or the ability to make the former and re-use the latter.

    Afterward, the critical requirement is a safe protected environment where basic needs can be met while the natural healing process occurs. It will be the nursing (which can be performed by MD’s as well) which will determine survival. Despite our egos (MD’s), it has always been this way.

    It is the basics or survival: Air, Food, Water, Shelter and Security. With some basic supplies and a few trained people, it could be done almost anywhere. Instead of ventilators, I would want bedpans. Instead of a pulse-ox and capnometer, I would want clean sheets and sterile dressings.

    NightWatcher

    • TexasCRNA

      Could not agree more with NightWatcher..
      The posts and comments by Aesop, Doc Grouch and others are EXECELLENT!
      My opinion, though, mirrors that of NightWatcher- dressings, betadine, and linens.
      I’m not discounting any of the fantastic work Aesop, Doc Grouch and the others have contributed, not even a little. I’d bet that each of them are smarter than I am.
      I just can’t see myself managing a vent and hemodynamics grid down, simply from a resource management point of view.

  12. flighterdoc

    Wow, Aesop….thats some good stuff there. Did you ever finish the posts you mentioned?

    • No, those were as far as I got, and that was before Doc Grouch, IvyMike, and I were introduced. (And before my employment hiccup sidelined my contributions to Hogwarts.) Their input on the missing sections would be noteworthy.
      My point at the time was that there isn’t much rocket science going on at the E.D. outside of the radiology suite (X-ray, ultrasound, and CT.) The former two of which could be purchased for use right now off the shelf at prices similar to those for high-end battle rifles.
      Most of the critical lab work requires only a tech, a glass slide, and a microscope, in a pinch.
      But what saves lives (in the short run) is the medicine itself, and knowing which one to use for what.
      In the long run, we’ll save 100 lives through public health (primarily vaccination, sanitation, and clean drinking water) to every 1 life saved with the rest of the medical arts. We (un)knowingly save more lives with tetanus boosters every week than the career total of Code Blue/CPR saves since forever.
      In descending order, the pyramid of what saves lives most is probably
      public health
      nursing
      pharmacology
      surgery
      the rest of medicine
      trauma medicine.
      One can quibble about the details, but the most bang for the buck is at the least expensive end of the scale, and the most expensive end provides the smallest return on investment.
      But if you’re the one with the sucking chest wound, that pointy end matters a great deal.
      And the investment to get a decent return isn’t nearly as steep as most folks (who don’t know any different) imagine, even for trauma medicine.

  13. Ed Grouch, MD

    As this site has greater reach:
    Any physical therapist, occupational therapist, or specialist wound care folks out there? If any of the above would want to contribute to a post in convalescent care, please drop a line to the Hogwarts email address.

  14. Bill Harzia

    What happens to second generation equipment that still works? They don’t just shitcan it, do they? Is it sold as surplus, donated to charities, etc? I can’t believe they just scrap it.

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  16. Ed Grouch, MD

    Nightwatcher, Aesop:
    Agree that public health rules all. And IV fluids would indeed be a critical component. In my conversations with the docs who have worked the Ebola treatment facilities, lack of appropriate IV fluids is the number 1 cause of death. And the list of things that some IV fluids can fix is fairly long.

    Nightwatcher, I don’t know your level of medical training but the phrasing of your comment suggests a very high level. I agree with your 3 interrelated systems (obviously, ’cause that’s the truth) but am forced to acknowledge some grey area within the black or white you present.
    Perhaps someone has just enough lung injury that they need, say, support for a day or two, on 45% O2, and then will be ok?
    If they need more than the bootleg O2 concentrator can provide, are they SOL then? What if it’s the old man in your tribe that knows how to raise food, or fix the radio, or your gunsmith, but has not yet passed on the info? Hard to say when to call for a vent or a chaplain. It would be nice to have options, should you really, desparately need that particular patient to stay alive.

    Of course, it may be that it’s only my own foolish imagination that paints the future world this way. Perhaps it will be more the way you see it. I don’t know. And I hope not to find out, honestly.

  17. Apparently (and mostly anecdotally to date), a substantial reason that the African death rate from Ebola is 60-90%, and the Western death rate (in single-digit outbreaks) is <10%, is specifically because intense hydration early on and continuously allows your immune system to catch up to the virus and eventually kick its ass.
    Dehydration and concentration of viral load in dehydrated patients is essentially a death sentence from multi-system organ failure.

    And I defer to specialists, but my understanding is that hyperbaric oxygen therapy (think large dive compression chamber) heals a host of things better than 1ATM medical treatment does. But we can't even afford to do that now, for most patients. Grid down, fuggedaboudit.

    My other point with my articles was to demonstrate that the overwhelming majority of current standards of medical care are maintainable even in extreme societal distress, with a rather modest amount of forethought, planning, and investment.
    (Which TPTB right now didn't do with Ebola, and aren't doing, even here in Califrutopia at Ground Zero, for earthquakes). The SOP seems to be wait until disaster crashes down around their heads, muddle through – devil take the hindmost – then hold AARs, where they identify what they should have done, and promptly don't do it the next time either. Lather, rinse, repeat.
    I've watched them eff up Ebola response by the numbers. Before that, it was ignoring any capability to deal with chemical agents. Before that and continuously, it's ignoring preparation for earthquakes. And on and on.

    Anyone seriously interested in surviving tougher times could do one helluva lot better than the so-called experts, simply by doing something, which would automatically put them miles ahead of anyone’s local disaster planners. When thing go seriously to crap, any tribe that can maintain 21st century health care and sanitation will simply outlive the ones who can’t.
    The first region that can get pharmaceutical production back up will become the regional power through simple demographics. Digging a well and growing food, vital as they are, is technology from 10,000 B.C.
    Producing medical grade sterile normal saline, tetanus prophylaxis, and 1st/2d/3rd line antibiotics is technology from the 1960s. I would sooner choose to live in the latter civilization than the former.

    Everything you can stockpile to tide you and your tribe over until things come back up improves your chances.

    And as Doc Grouch, Ivy Mike and I discussed back-channel in discussing getting Hogwarts up, the cheapest public health program is to get your fat ass out and PT, eat right, etc. Diabetes, digestive issues, heart disease, and COPD (look up the top killers, annually) virtually disappear if you don’t smoke, and aren’t 50 pounds overweight, and a host of cancers shrink in incidence as well.

    Total prep cost of not smoking, and not packing your face until your ass is too big to fit in an average airline seat: $0.