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 the Wilderness 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):


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: (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: (retrieved 1 October 2016) or here: (retrieved 22 June 2015)

General guidelines on water and handwashing:

Boiling Water
(Accessed 16 May 2015)

Guidelines for Drinking Water

(Accessed 16 May 2015)


(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 Accessed 23 June 2015


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: Accessed 23 June 2015

Accessed 23 June 2015 (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: retrieved 22 June 2015


Unfortunately, it will be necessary to deal with the dead. Here are some guidelines: Accessed 23 June 2015

12 responses to “Grid Down Hospital – Part II: Hygiene & Sanitation

  1. Thanks for the write-up and the links, much more thorough now.

    Might be beneficial to stock some chlorhexidine solution ( for the hospital, both for use as a topical antiseptic and a surface/floor disinfectant. Would appreciate the Doc’s thoughts on this, or better alternatives, considering that hot water for cleaning may not be as readily available (and more costly in terms of fuel use) grid down.

    And in case anyone missed it, the FDA banned the antibacterial triclosan for consumer liquid soap products last month.

    Manufacturers have one year to phase it out, so if you want some better get it soon. Apparently it’s unsafe for consumer use, except in toothpaste(?). Counter argument here:

  2. Keep this coming. Getting too old to be the point of the spear but I damn sure can be logistics and support.

  3. Stocking antiseptics and disinfectants is always a good idea. Betadine and Hibiclens are always handy – but if you are going to stock them, stock them in SMALL bottles…..Hibiclens is a chlorhexidine gluconate product. As with Betadine, it comes in both a solution and a scrub version, the scrub has soap in it.

    Lots of folks think that they’ll buy a gallon jug of whatever and call it done. I can understand the rationale – they save a bit of money, The problem with that idea is that all your whatever is one jug. If it springs a leak, you’re done. If you contaminate it, you’re done. If you need it in two places, you have a problem. And once you open it the first time, it will deteriorate much more quickly.

    A gallon (total) may not be a bad quantity, but I prefer to have it in small (say, 8 oz or at most 16 oz) bottles. I can have several different in use at a time, I can accidentally spill a bottle and not lose it all, and if one springs a leak….just clean it up. A small bottle will usually be more than an individual use requires but if more is needed it won’t be more than one more. And finally, with a small bottle I can work on someone and then give them some bandages and the remaining bottle and let them deal with it at home.

  4. Note on the Humanure Handbook — You eliminate into a bucket and then cover it with sawdust. The system requires you to have a store of sawdust, so this is something to consider as you go about cutting firewood or other wood.
    I have used the system and sawdust *does* eliminate the smell, as long as you use enough.

  5. Pingback: WRSA Sends: The Grid Down Hospital – Mason Dixon Tactical

  6. Absolutely.
    A flat of 4 or 8 oz. bottles of Betadine is vastly preferable to a couple of gallon jugs.

    FYI, Clorox (and the EPA) has updated the gtt. quantities in reference to their new, and slightly more potent formulation of household bleach, 6 gtts/gallon.
    They also note once opened, a bottle of their bleach is good for 4 months.

  7. Guilty, gallon of PVP-I scrub and a gallon of chlorhexidine is the bulk of the stored stuff set aside for grid down use. That’s at least two beers I owe ya now Doc, thanks.

  8. And since it was purged in the re-post of the full text of this installment, I repeat the comment that the 2000 edition of FM 21-10 is a pamphlet/handbook, compared to the more detailed 1970 or 1988 versions of same.
    1970 edition pdf:

    You’ll have to dig for a 1988 edition pdf. In their haste to update, most sites purged the longer manual for the newer, low-attention-span version.

    You shouldn’t choose either/or, but rather both, since they’re yours for mouseclicks, ink, and a ream of printer paper.

  9. Good to know.. Everyone, make a note.

  10. I posted this a while back in some other thread.
    “Thieves” Oil consists of @ these mixes:
    4 parts – Clove essential oil
    3.5 parts – Lemon essential oil
    3 parts – Cinnamon essential oil
    2 parts – Eucalyptus essential oil
    1 part – Rosemary essential oil

  11. Alfred E. Neuman

    Reblogged this on ETC., ETC., & ETC..