Survival

Survival

Anaphylaxis can be a scary encounter even when 911 is a few minutes away. In Austere medicine, where patient evacuation is delayed, not on it's way, or you are the medical professional sitting on this patient, a serious situation just became worse. When you give your initial intramuscular injection for anaphylaxis, there is about a 20% chance you patient may need another dose, but you only had one Epi-pen... What now?

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A consideration for austere management of anaphylaxis

  Anaphylaxis can be a scary encounter even when 911 is a few minutes away. In Austere medicine, where patient evacuation is delayed, not on it's way, or you are the medical professional sitting on this patient, a serious situation just became worse. When you give your initial intramuscular injection for anaphylaxis, there is about a 20% chance you patient may need another dose, but you only had one Epi-pen... What now?

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  There is enough for around 3-4 doses in the epi-pen still left. I'm going to show you a step by step process in basic terms to be used in emergency situations only. For Medical Professionals and Providers, before you throw out the expired epi-pens, it's free training to take one apart and see how it's done. IMG_9768SAFETYOFF1stDOSE

Step 1.) Loosening the shell.

  We're starting from the point where you've already removed the blue safety and administered the first dose. Your clinical judgement has led you to decide you need to administer another dose. You can use a knife, multi-tool, pliers or what you have on hand to loosen/pry the four corners around the core, as you keep the orange tip away from you to prevent accidental 'stick' with the used needle.   You are loosening the transparent case from the white core for the next step.

Step 2.)   Pulling the white core out of the transparent sheathe

  Now that the outside is loosened, pulling the internal parts of the Epi-pen out will be easier. It may take a couple minutes and some wriggling back and forth. When on it's way out, the spring may cause the white core you're grabbing to spring out. To avoid parts going all over the place you can pull down with the orange tip facing up. After the spring comes out, the only thing left inside should be the syringe of epi and it's needle. [gallery size="medium" ids="1747,1749,1750"]

Step 3.)   Identify and prepare needle and syringe:

  The only thing left inside the epi-pen should be the syringe and needle. You can see for yourself how many doses are left.  It's important to note that the needle is covered in a gray sheathe and to avoid sticking yourself. You will want to remove the gray sheathe carefully. The 'plunger' is opposite the needle and will be used to draw air into the vial of epi as well as push more epinephrine into the anaphylaxis patient in the next step. [gallery size="medium" ids="1752,1753,1758"]

Step 4.)  Administering a dose:

  The plunger should come already pushed down to the stopper due to the initial dose given to the patient.   Point the needle up in the air and draw air into the needle until the rubber part of the plunger is near the back of the vial that holds the epinephrine. CAUTION,  if you pull the rubber part of the plunger back too far, you could pull the plunger out of the vial and leak the precious epinephrine out of the back!   Once you have air drawn in to the syringe, you will administer the second intramuscular dose to the patient. The air is mainly to replace pressure, because the plunger has the stopper and can not be depressed past that point, so you need to draw the air in, in order to push more epinephrine out. This can be repeated 3-4 more times depending on how you measure it.

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  Don't worry about a small amount of air getting into your patient, contrary to popular belief, you need a lot of air directly into a blood vessel to begin to risk that. It's especially negligible when we're talking about the tangible danger of anaphylaxis and anaphylactic shock. [caption id="attachment_1758" align="aligncenter" width="400"]IMG_9804INJECTIONSIMULATION Pushing the epinephrine out is easy. After each dose, the needle will become more dull and possibly increase the pain of the insertion.[/caption]   Between doses when you need to move the casualty for patient transport, as well as when all the doses are used up, place the syringe and needle back in the case for safe transport. Continue evacuation, as mentioned in the article: The Scary Reality of Casualty Evacuation to a higher level of care
References: Epi-pens Website, Reference and Videos - https://www.epipen.com/en/hcp/about-epipen/dosage-and-administration Biphasic Anaphylaxis - http://www.medscape.org/viewarticle/583328_7

  [caption id="attachment_981" align="aligncenter" width="640"]Firearms, Tactical & Defense Training Firearms, Tactical & Defense Training[/caption]

Preparing for medical intervention can range from a band-aid in the medicine cabinet to extensive medical kits. Deciding on medical equipment when expecting to be in an austere, survival, disaster or other situation depends on what you know how to use as well as how much you can carry on foot. For situations that involve a vehicle or close to home, the weight and bulk is not as much of an issue. On that basis I will address the variations of medical kits in a tiered system from small first aid kits and everyday carries, to Aid bags, to large Truck bags or cases in the house. 1.) Basics - Every Day Carry, Minimalist, Clandestine Medical Supplies: This is the easiest level for all skill and financial levels, with little to no weight, while offering some medical capability in any and all situations. In a former article we discuss Every Day Carry of a tourniquet added for extremity bleeding.  A hemostatic gauze could also be added to account for non-compressible hemorrhage, or areas where tourniquets can't control the bleeding. For those at risk of a severe allergic reaction, an Epi-pen is a must ( link article) 2.) First Aid Kits (IFAK) and Pouches: The next step up, an IFAK or medical pouch on yourself or nearby means being able to handle more during your Trauma Patient Assessment (MARCH-E). This moves on from just tourniquets and gauze to Nasopharyngeal Airways, Vented or Occlusive Chest Seal(s) , 14G Needle's for Needle Chest Decompression, and a few other items your situation may warrant. Epi-pens, Gloves and a few others items can easily be added to the kit, as well as duplicates of the basics. The C.A.G. Tier 1 MedPack offers all the essentials to care for an emergency. 3.) Aid Bags - The Aid Bags go multiple different ways. You must tailor it to your situation, which may change. For examples I will list the different roles battlefield medics fulfill. No two medics are alike, even if their job is the same. If your aid bag will be in a truck or vehicle nearby, it can be filled to the brim and you can enjoy more medical capabilities. If you are wearing your aid bag, whatever you have on your back is what you and your Emergency Action Group have. If you are staying out for extended periods of time, you need to bring a lot with you to account for everything that may go wrong when you can't seek medical help. If you plan on going through urban situations or in tight spaces after a disaster, you'll want a bag with a small silhouette and to add some high visibility markings, panels, chemlights and maybe whistle. Tips:
  • "Hot-wire" your Aid-Bag to save time. Placing Labels provides easier access. Putting tape where the openings of medical equipment are save time when motor skills are impaired by adrenaline.
  • You should train your Emergency Action Group on where everything is in your bag. If they need to grab it for you, or get something inside, perhaps even treating you, you'll be thankful that they are not lost in the many pouches an Aid bag can have.

This article will be addressing the "R" in MARCH-E. Massive Bleeding Airway Respirations Circulation Hypothermia / Head Injury Evacuation
  1. Before we know what we're doing, we should know "Why"      (Basic anatomy)
  2. How-to exam and what you're looking for
  3. Injuries and how to treat (flail chest, pneumo/hemo, etc.)
(Insert occlusive vs vented article) Video of a Needle Chest Decompression from the inside: ( Note during the video expansion of the lung before needle entry and after) [youtube https://www.youtube.com/watch?v=co9_RLN78IY&w=560&h=315]

I'm a practical guy and I like practical solutions. I was thinking about my often neglected apartment dweller readers recently. I was trying to figure out a way for them to produce their own meat when I recalled a conversation that I had with a retired Green Beret and Delta Force operator that was an instructor with me in the 18 Delta course. We had many conversations about farming, survival and austerity. He had mentioned to me that he was going to raise guinea pigs (aka cavi or cuya) on his quarter acre property in downtown Fayetteville North Carolina. Initially I laughed and thought the idea was crazy. At the time I was raising pot belly pigs, chickens and goats in a subdivision on 2 acres, what could be crazier than that?Pet's Fer dinner!?!
I'm a practical guy and I like practical solutions. I was thinking about my often neglected apartment dweller readers recently. I was trying to figure out a way for them to produce their own meat when I recalled a conversation that I had with a retired Green Beret and Delta Force operator that was an instructor with me in the 18 Delta course. We had many conversations about farming, survival and austerity. He had mentioned to me that he was going to raise guinea pigs (aka cavi or cuya) on his quarter acre property in downtown Fayetteville North Carolina. Initially I laughed and thought the idea was crazy. At the time I was raising pot belly pigs, chickens and goats in a subdivision on 2 acres, what could be crazier than that? He explained the process to me and how they were common food in South America.

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As I pondered this article, I considered that many folks already have guinea pigs in their apartments. Once you get over the social bias that we have in America towards eating what we consider pets, it seems like a logical idea. In a small amount of apartment space you can grow wheat grass like many folks do for their backyard chickens. This and scrap vegetables can provide you a sustainable food source for your guinea pigs. Some things they cannot eat like mustard, parsley, and potato peels. You can raise them and harvest them with no one knowing. You could use their droppings and litter to provide much-needed nutrients for your apartment vegetable garden. You could use the skins to produce clothing.

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The cavi could provide someone looking to grow their own food in a confined space, or to have a survival food source, an excellent renewable source of protein. Not to mention a nice break from canned spam in a SHTF scenario. At 21% protein and 8% fat, the cavi has less cholesterol and more protein than beef pork and chicken.There are many restaurants on both the east and west coast that are catering to an Andean expat crowd. This is opening the door to make "cuyas" not so taboo.

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Amazingly they can out breed rabbits. With just two males and 20 females, a family of 4 can provide all of their protein requirements for a year. That is about 200 guinea pigs per year. Check your local laws if you happen to live in one of those ever controlling places like New York City or California, as it is illegal to eat guinea pig. However, if you do decide to give it a try, like rabbits, a blow to the back of the head will render them unconscious then quickly cut the jugular and hang them up to drain. Afterwards, drop them in boiling water for a few seconds and the hair will easily pull away from the skin. Cut the carcass from anus to nose without cutting the intestines and remove the contents as you would any other animal. Now it can be roasted or deep fried or cooked however you see fit. I hear there are always free guinea pigs on Craigslist. Try one for free!

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Don't get hung up on the medical words, but we'll have you understanding how to and why you treat a gunshot wound to from Neck to Naval in no timeSuckingChestWound

A Consideration for Austere Management of Sucking Chest Wounds

     Today we are going over one of the leading preventable causes of death on the battlefield: Tension Pneumothorax. Don't get hung up on the medical words,  we'll have you understanding how to and why you treat a gunshot wound from Neck to Naval in no time. The battlefield sets the example for first line care because we learn from our mistakes and translate them into the civilian care. The front line medics are expected to uphold the standard in Austere Medicine where they don't have an ambulance but just the supplies on their back. However, not just the Combat Medics on the battlefield are trained, but non-medical professionals are being taught how and why to save lives in first aid.  This is where the Austere Medical provider comes in, when 911 is not coming and you have to treat and get them to the next level of care by yourself or with the assistance of your Emergency Action Group. Before we can go over how to treat, we must understand "why" we are treating: pneumothorax

 "What is a pneumothorax?"

   As the picture above demonstrates, you have a wound from you neck to your naval, letting air go out of the hole(s) instead of out of your mouth, which is not good. You won't get quality oxygen where you need it and pressure may build up putting pressure on the lungs and heart until failure.

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"Why should I be worried about a pneumothorax?"

    From hunting accidents, negligent discharges on the range, to active shooter and self-defense situations, we may get injured ourselves and that is just including gun shot wounds.  In addition, if Tension Pneumothorax is the second most preventable cause of death in the battlefield where we wear body armor, it's even more likely in an austere situation where we likely don't have body armor. Some medics do not see chest wounds progress from open to tension pneumothorax due to it taking awhile to build up but we have short evacuation times in Iraq/Afghanistan. When it often takes less time to get a bird overseas than it does to get a bird or ambulance in the states, this is another reason to consider this injury a priority where 911 is not coming and this injury has more time to manifest.
" So how do I treat it? I see Vented and Non-Vented Chest Seals." [caption width="300" id="attachment_1484" align="aligncenter"]sucking-chest-wound4 Taping three sides and leaving a corner to vent is an outdated method.[/caption]   If you look around you'll see many variations of the chest seal over the last decade. Occlusive Dressings, Taping on three sides, burp valves and other vents. I'm here to make sure you have an educated decision. This is not a guessing game on what might work, these chest seals are all rigorously tested both on and off the battlefield from U.S. Army Institute of Surgical Research (USAISR) to Committee on Tactical Combat Casualty  Care (CoTCCC). They came out with some new updates, which is important because just because you take a medical class in 2006 does not mean you are "set" and never have to take one again. Doctors take continual classes every year to stay on top of what is current, so when it comes to First Line Care, you should have the same mentality that what is best changes. An emergency is not the time to attempt outdated care or try to save a few bucks by getting a knock off or older chest seal. Using what you have available as a contingency and preparing ahead of time are two different aspects; you know if it was you that was wounded, you would want a superior product: [caption width="300" id="attachment_1483" align="alignleft"]Hyfin Vent Chest Seal in Use Hyfin Vent Chest Seal in Use[/caption]   We have been using occlusive (non-vented) dressings which would trap in the air and increase pressure in the chest cavity AKA Tension Pneumothorax translated simply to "Pressure from Air in Thoracic Cavity." By using a fully occlusive dressing you could take a bad situation like an open pneumothorax and make it into a more lethal Tension Pneumothorax. Instead of letting air escape out of the wounds hole, you are now trapping the air inside, inflating the lungs cavity much like a tire. With a vent you let out enough air to avoid the tension while still assisting proper ventilation through the windpipe.    The CoTCCC guidelines quote, " All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. "

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   Occlusive Seals are proven to work, for those who are trained and ready to recognize when to do a Needle Chest Decompression (NCD). If you use an occlusive dressing, be prepared to perform a needle chest decompression. For someone unprepared to perform an NCD, I recommend getting the Hyfin Vent Two-Pack Instead. If you're dressing has a "burp" such as an Asherman or Bolin, I'd recommend switching to the more reliable Hyfin Vent as well due to the three-vents offering more redundancy when it comes to getting clogged up by debris or blood. If two of the vents are completely occluded, the third can still function enough to work. Final Tips: No matter which chest seal you use,  Petrolatum Gauze ($3.99) , HALO XL, Hyfins, or any other method,  I have a bit of advice:
  •   Prepare your site! Use your sleeves, gauze or clothing to dry the sweat or blood from where you are about to place it. If the patient is hairy, you definitely need to dry it because the hair can make it even more difficult to get on and stay on.  Don't throw it on there in the heat of the moment and cause your intervention to fail. Take  deep breath, take a second and properly dry your site with whatever you have available.
  •   When you find the sucking chest wound during your Trauma Patient Assessment (Click here to see how) , you can use the back of your hand, not palm to cover the wound with your gloved hand. This frees up your fingers to help open the packaging while you prepare your supplies while having the added benefit of making it less likely bear weight on that arm and 'push down' on your patients wound if you have to reach or lean across them.
  •  You've run out of chest seals, had a mass casualty, or your original came off during transport. What now? Use the package it came in as an improvised occlusive dressing and tape it down.
  •   As always, the equipment is only as good as the training. You can use tape and the packaging to practice covering a chest seal for the low-cost of tape. "Dry Firing" isn't only for Combat Marksmanship , It's for Medicine, too!
[caption width="400" id="attachment_1488" align="aligncenter"]Crisis Application Group's Hyfin Vents: 2 for Crisis Application Groups Hyfin Vents: 2 for $14.99. (Click the picture)[/caption]