Sunday, May 31, 2015

Emergency Preparedness: First Aid

This week I participated in an Emergency Preparedness Fair held at the North Augusta LDS Church.  During the event there were presenters that talked on numerous preparedness topics such as: 72-hour kits, planting fruit trees, canning and preserving, food storage, bread making, and first aid. I covered the first aid topic.

2 Disaster Categories
When it comes to emergency preparedness, there are 2 general classes of disasters: local short-term vs. national or global long-term.  Short-term local disasters include events such as: ice storm, flood, dam break, tornado, hurricane, earthquake, nuclear accident, chemical spill, power outage, etc. National long-term disasters include infectious disease pandemic (flu or ebola), EMP strike, WW3 nuclear first-strike, economic collapse, etc.

Disruption of Services
The reason to differentiate these 2 types of disasters is to understand the extent of disruption to public services and the kinds of preparation needed. In the more common short-term disasters, all or at least some of the area hospitals are usually still in operation. The most likely disruption would be to EMS services.  We are accustomed to calling 911 and having an ambulance show up within 10-15 minutes.  However, during any disaster, EMS services may be disrupted because EMS are overextended with too many calls, no phone service, and/or road inaccessibility.

First Aid Goal
In a short-term local disaster, the first thing to realize is that at least some of the hospitals will be operational.  The goal is not to take it upon yourself to diagnose and perform an emergent appendectomy on your neighbor in the aftermath of a hurricane. When I go camping and hiking with the scouts, I don't take a huge pack filled with every sort of medical device with a plan to perform advanced procedures in the backcountry. The goal in any short-term local disaster is to understand and be able to perform basic first-aid and EMS skills and possibly transport  the injured person yourself to the hospital while keeping them alive.

In the event of any disaster, and even without a widespread disaster, it is critical that eveyone understand and can perform basic first aid.  In many instances, waiting 10-15 minutes for EMS to arrive can be too long. The brain cannot survive 15 minutes without circulating blood, and a bleeding patient can exsanguinate is only a few minutes.  Taking and making a few simple acts can make the difference between life and death.

When it comes to disaster preparedness or any preparedness, an ounce of prevention is worth a pound of cure. If you live in an area with tornados, make sure your home has a basement shelter, cellar, or safe room.  Also, if you can help it, pick a home that isn't in a flood plain, or right next to railroad tracks or a chemical plant.

Avoid needing medical services during a disaster buy adopting a healthy lifestyle.  exercise, maintain a healthy diet, lose weight, and quite smoking.  If you are dependant on pain or heart medications, try and liberate yourself from these if possible (as directed by your doctor) through diet, exercise and physical therapy.  If you are otherwise dependant on a med, make sure you have some meds saved up in reserve.  Most pharmacies allow patients to buy their meds 3-months or more at a time.

Safety and Sanitation:
Many health issues can be avoided through proper safety and sanitation. In any emergecy, don't forget to continue to wash your hands, dispose of waste and garbage, store and be able to purify water, and use proper eye and protective clothing when using tools and other equipment.

Water Storage
An easy way to maintain proper cleanliness during a disaster is to store clean water.  You can purchase used 60-gallon blue water barrels for relatively cheap as well as 275-gallon caged water IBC Totes.  These IBC Totes stack very well also. 

Cleanliness can be maintained by storing basic soap and water but also having a box of wet wipes, and a bottle of hand sanitizer. Using wet wipes after the toilet can decrease the amount of toilet paper needed.  Simple household bleach is cheap and can be used to disinfect any surface.

Water Purification
Water can be purified in several ways. It is important to be able to purify water by boiling, filtering, and chemical treatment.  To boil water, you will need to fuel.  Propane for use with a camp stove is both easy and cheap. You can also build a simple paint can gassifier stove and boil water using pine cones.  Water can be easily filtered using a camping pump-action water purifier or Big Berkey ceramic filter. The cheapest way to chemically treat water is to buy a tub of Pool Shock. You then can create a chlorinated concentrate by adding 1 tsp pool shock to 1 gal water and then treating water using the concentrate in a 1:100 ratio.  Household bleach purifies 8 drops per gallon for 30 minutes.  Vitamin C or letting the water sit open overnight will eliminate most of the chlorine taste.

Dry Toilet
Human waste disposal is often overlooked. It takes over 1 gallon of water to flush a typical toilet.  If water pressure is affected, if you let the waste build up, toilets can becomes clogged and become a serious health hazzard in addition to generating very unpleasant odors.  A dry toilet works under the same principles as kitty litter. You can buy toilet lid seats that snap on to the top of any 5-gallon bucket. You line the bucket with a plastic bag and lay out sone dry saw dust, leaves, grass or sand in the bottom.  After you make your solid waste deposite, you cover the waste with a scoop of lime or wood ashes.  The lime and wood ash is basic and will desiccate, kill bacteria, neutralize odors, and allowing fungus to break down the material.  You do not urinate in a dry toilet.  Urine should be kept separate.  Solid waste should be later buried or burned.

ABCD First Aid Skills:
After you have taken all the necessary preventative measures, accidents can and will still happen. That is when basic first aid skills are essential.  However, no one need be intimidated.  First Aid is really as easy as ABC. First Aid really comes down to a few basic elements: A- Access, Airway, B- Breathing, Bleeding, C- Chest Compressions, Circulation, D- Deformity. 

When you come across an unconscious person, you need to access the situation quickly? What do you see around the patient? Is there empty pill bottles? Is there signs of a fall or trauma?  Did the person clutch their throat (choking) or chest (heart attack) before collapsing? These are all clues to what is going on with the individual. 

An unresponsive person could just be asleep, or alcohol intoxicated or both.  The first step is to call out and lightly tap them on the shoulder and say several times "Are you alright?  Are you alright?".  If you don't get a response, you yell, "Help, call 911" and ideally direct a specific person to call 911.  Point at the specific person you want to make the call. If you are alone, you will have to call yourself, but do not leave the patient.

Next you kneel at the head of the victim and look, listen, and feel for signs of breathing.  Do you see chest rise?  Do you hear breathing or feel exhaled breaths againat your cheek? Do their lips appear white, pale, or blue?  After looking for signs of breathing, feel around the anterior lateral sides of the base of the neck for a pulse. This assessment should take less than 30 seconds to perform.  If the victim doesn't have a pulse, you skip A and B and jump down to C for Chest Compressions. 

When some people lose consciousness for whatever reason: seizure, concussion, overdose, etc, they can obstruct their airway. The unconsious person may be overweight or in a contorted position that restricts their ability to breath.  You can usually tell this if they are snoring loudly, and especially if their lips turn white, pale or blue.  The easiest way to help someone breath is to roll them flat on their back, or on their side if vomiting.  Do not stick anything in the mouth. If they are gaving a seizure and they are biting their tongue, let them bite it even if its bleeding.  Roll them on their back or side and clear away objects from around them. 

After rolling a person on their back or side (if vomiting), is to lift their chin slightly into the "sniffing position", and from the head of the person performing a jaw thrust by placing light pressure behind both sides of the jaw just below their ears.  In many cases, an unconscious, but spontaneously breathing person who appears cyanotic (blue) will pink up with these 3 simple maneuvers. 

1. Roll on Back (or side)
2. Chin Lift to Sniffing Position
3. Jaw Thrust

If a person is choking, if the person is making some sounds, do nothing but call 911.  If they are making gasping or gagging or stridor sounds they are only  partially obstructed and doing something can make it worse and not better.  If they are clutching their throat and not making any sound, then you perform the Heimlich Maneuver standing behind them with you arms wrapped around the person, making a fist with one hand and placing it in the top of the stomach. You then clasp your fist (base of thumb into the stomach) tightly with your other hand and forcefully thrust your fist into their stomach repetitively in an abrupt inward and upward movement.  If they have gone unconscious, then you straddle the victim, looking up their nostrils, lock your fingers and push up against their stomach with the heel of your hand pushing up in repetitive forceful thrusts and perform several rescue breaths.

B- Breathing
Mouth-to-mouth resuscitation can be perfomed if the person is not breathing starting with 2 initial rescue breaths.  It is important to pinch the nose closed while you give breaths so the air fills the lungs and doesn't just leak out the nose.  A plastic barrier device, face mask, or Ambu bag will help. Ambu bags are very bulky but collapsible pocket face masks are small, lightweight and work very well. Also, these face masks ($10) have a filter and valve to prevent exposure to body fluids and they seal around both the mouth and nose so pinching the nose closed is not necessary. (Google: CPR Face Mask)

Another simple airway device that isrelatively inexpensive but really works to help open the airway is a nasal trumpet device. These are flexible tubes of different lengths made of latex rubber or non-latex that can be inserted into a nostrile to aid in breathing or giving rescue breaths in combination with the CPR face mask.  A set of nasal trumpets cost about $15-$25.  (Google: Nasal Trumpet) You measure the correct size of nasal trumpet by measuring the distance from the nostrile to the ear lobe. 

Most bleeding can be controlled with direct pressure.  It amazes me how many people come into the Emergency Department with a gun shot wound to the shoulder or leg and look much worse they they are because no one bothered to just hold pessure on the bleeding wound.  Paramedics are guilty many times of not holding effective direct pressure.  Many times they will take a lot of thick bandages and extensively wrap the wound.  But inevitably, the thick dressings quickly just become saturated with blood.  Don't use a pile of dressings when a couple 4x4 gauze and 2 finger pin-point pressure will do.  

In cases where direct pressure is not working, tourniquets can be very effective. Wrapping cloth or elastic material around the extremity above the injury can work very well to control bleeding.  A manual blood pressure cuff works well also.  You don't need to tie the tourniquet so tight the extremity turns white or you cause nerve damage.  You are just looking to slow down the bleeding in comblination with 2-finger direct pressure on the wound.   You also, do not need to untie the tourniquet.  Arms and legs can go several hours without blood without permanent damage.  As long as you are on your way to a hospital, you can leave the tourniquet in place. 

C- Chest Compresions
If you come across someone who turns diaphoretic, short of breath, clutches their chest and then collapses, that person is having a heart attack, and their heart has gone into ventricular fibrillation and has stopped beating.  That person will be unconscious, and they will have no pulse and no blood flowing to their brain. If the victim does not receive chest compressions, they will become brain dead in less than 10 minutes. The latest recommendations is for bystanders to perform chest compression-only CPR until EMS arrives.  You can check for a pulse in the neck when you first assess the victim, but if you think the person's heart is stopped, and they are not breathing or are having a few agonal respirations, you don't feel a pulse, and they are unresponsive, they need compressions.  

You don't have to worry about breathing for these patients, only chest compressions.  The heart will not start beating again until the person is defibrillated using an AED, but doing chest compressions without interruption, will keep the blood following until EMS arrives or someone can bring an AED device.  If you are performing chest compressions on someone, do not stop to check for a pulse, and do not stop to perform breathing. Just keep on doing the chest compressions with minimal interruption.  If there is another person assisting, they can give some rescue breaths, but do not stop compressions to allow the breaths. Stopping and starting chest compressions makes them ineffective. It takes nearly 15-20 compessions to get the blood to begin to circulate at all, if you are stopping every 15 or 30 compressions to give breaths, you really are not circulating any blood. 

Many EMS do very poor chest compressions. Doing good CPR can make all the difference.  Kneel beside the patient or straddle the patient looking up their nostriles.  Place the palm of your hand against their sternum, 2 fingers above their xyphoid process, lock your fingers together with your other hand and lock your elbows straight and compress forcefully giving about 100 compressions a minute. You should perform compressions while thinking of the song "stay'n alive".  Don't worry about breaking ribs or feeling pops in the chest as you do compressions. Remember to keep your elbows locked as you do compressions.  Use your back, shoulder, and even hip and thigh muscles to do compressions and not your arm muscles. If you are perfoming compressions on a child, you will use the palm of one hand.  If you are doing CPR on a baby, you use 2 fingers. 

The last major skill that EMS perform is to stabilize the neck and back and any broken arms or legs. When you come across an unconscious victim, you need to assume that they may have suffered some sort of trauma and could have a neck or back fracture. If you move them without stabilizing their neck, then they could suffer a spinal cord injury and become paralzyed. 

The key to stabilizing the neck is to use a plastic hard collar that just makes sure the head stays midline with the shoulders and doesn't flop around to the right or left or back or forwards.  If you don't have a plastic c-collar, you can use rolled up towels and tape to wrap around the base of the neck.

The key to stabilizing the back is to have the person remain flat on their back. If they have to be moved onto their side, then they need to be "log rolled" onto their side by moving their neck and back together in one motion, like a log.  The victim should not be made to sit up, or be bent over or to the side in any manner. If the victim is being moved, then the c-collar should be placed first, and someone should hold the head and neck straight between their forearms, while another person rolls them up on their side pulling from their hip and shoulder. 

Arms and leg fractures can be stabilized by using SAM splints or various poles or sticks or handles. SAM splints can be purchased for under $10. You position the rigid splint on either side of the fracture and then wrap and ACE bandage, or cloth, or tape around the splint so it doesn't move or slip and stabilizes the extremity from painfully flopping around. 

Total Social Collapse
If EMS cannot get to you, then you will have to perfrom the function of EMS and transport the victim to the hospital.  However, in the event of a nation-wide disaster, hospital services may also be disrupted. In this "Without Rule of Law" or "Feathers Hit the Fan" situation, survival will involve additional preparation including long term storage of water, food, gardening, etc. 

Additional medical procedures that would be useful would be the ability to suture a laceration.  Disinfect wounds and surrounding skin with high-pressure water irrigation (clean but not sterile) using a syringe and iodine and clorhexidine surgical wash.  Fishing line and sewing needle can be used as suture.  Superglue can be used as skin glue. However, skin glue only works on simple linear lacerations that are not gaping and the skin edges come together easily on their own after all bleeding has stopped. If the wound is bleeding and even oozing, adding super glue to blood will create a big mess. In the case of persistent bleeing, suturing the edges together with fishing line will help stop the bleeding. 

Useful Medications:
Ibuprophen- pain reliever, and fever reducer.
Aspirin- pain reliever, fever reducer, blood thinner. 
Reglan- nausea, migraines.
Imodium/Lomotil- diarrhea
Antibiotics- various infections
Magnesium Sulfate- constipation, diabetes, inflammatory illnesses, asthma
Decadron- inflammation, asthma, bronchitis
Antifungal- fungal skin rashes
Doxepin- super powerful antihistamine
Epi-Pen- severe anaphylactic allergic reactions
Albuterol- asthma, you can connect tubing and nebulizer reservoir to any tire pump to create a nebulizer.

WHO ORT fluid is 6 tsp sugar and 0.5 tsp salt in 1 liter fluid. An alternative to giving fluid orally, or even IV, is to give fluid rectally via an enema catheter and bag.  The colon's main function is absorb water.

Useful Herbs
Mustard: antibiotic, antifungal
Pine needles: antiviral, vitamin C
Sweetgum: antiviral
Salt gargle/honey/zinc tab- sore throat

First Aid Kit
1. CPR Resuscitation Mask
2. Nasal Trumpet Airways
3. SAM splints
4. ACE wraps
5. 4x4 gauze
6. tape
7. trauma scissors 
8. scalpel
9. hemostat clamps
10. forceps tweezers 
11. Bandaids (various sizes)
12. Iodine wash
13. Clorhexidine wash
14. Afrin nasal spray and nose clamp
15. Bulb syringe
16. Enema bag and tube
17. O2 Pulse Ox sensor
18. Neck Brace/C-Collar
19. Epi-Pen
20. Albuterol Inhaler, Spacer
21. Other Useful medicine
22. Light
23. N95 Masks
24. Nitrile Gloves
25. Mole Skin
25. Fishing line and needles
26. Superglue
27. Lidocaine with needle and syringe

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