Practical Question and Answer series
For more questions and answers see the
Q&A Index.
9) [How can I get] Medical
supplies?
I've been sitting on this one for a little while giving some thought.
It's a big topic, an important topic, and a difficult topic. While
I was thinking about this I spent a few days at the local hospital
observing in the Operating Room and the Emergency Room trying
to get a better idea of what kinds of day to day medical supplies
are used right now in a hospital setting. I already know what
is used in a ambulance setting from my paramedic training. In
general, medical environments depend on plenty of plastics and
disposable items which require a lot of energy to produce and
also produce leave plenty of waste.
I'm going to break this one down into categories like I usually
do. And then I'll discuss them each in turn in light of the four
strategies I outlined in Strategies
for Shortages: stocking up and conservation, substitution
and relocalization, improvisation, and restructuring. I encourage
you to read that quickly if you haven't already, because the following
will make a lot more sense. (And to make it clear, the difference
between substitution and relocalization and improvisation is that
in substitution you make something yourself from local "resources",
but in improvisation you modify something that someone else has
made.) For the restructuring strategy in general, it's worth referring
to several of Jason Godesky's Thirty
Theses including "Civilization
makes us sick" and "Civilization
has no monopoly on medicine".
This is going to be one of the answers that will get expanded
significantly over time as I come across new information and people
write in with suggestions.
First of all, here are seven general categories of medical supplies:
A. Bandaging and Dressing Supplies
B. Splinting and Immobilization Supplies
C. Medicines
D. Personal Protective Equipment
E. Diagnostic Devices
F. Tools and Instruments
G. Specialized Instruments and Equipment
The following discussion is not a substitute for any
kind of medical training. The notes about treatment are simply
to give you a better idea of the applications of different medical
supplies or to supplement your existing knowledge. I heartily
encourage you and people in your community to take medical training
available to you.
There are a number of excellent books available on medical skills
to use when you don't have access to hospitals or doctors. There
are many good books
on this subject published by the Hesperian
Foundation. They are designed for areas or communities with
limited access to medical professionals, and include Where
There Is No Doctor, its companion volume Where
There Is No Dentist, as well as the woman-focused Where
Women Have No Doctor, and A
Book For Midwives.
Books on wilderness medicine are also well suited
for this area of study. The "bible" of wilderness medicine
is Wilderness
Medicine: Management of Wilderness and Environmental Emergencies
by Paul S. Auerbach. At a hefty 2000 pages is has tremendous detail
on every aspect of wilderness medicine. The downside is that the
book is quite expensive, and that it is written for doctors and
other medical professionals so you'll need medical training and/or
an excellent medical vocabulary to make good use of it. Auerbach
has a shorter and less expensive book called the Field
Guide to Wilderness Medicine. For an comprehensive text directed
at the lay-person, you can refer to Outdoor
Emergency Care: Comprehensive Care for Nonurban Settings by
Warren Bowman. For a shorter and less expensive primer, see Basic
Essentials: Wilderness First Aid by William Forgey.
For general historical reference for the subject of medical supply,
the medical
items most often in short supply in World War II were surgical
dressings, blood plasma, surgical instruments, penicillin, atabrine
(an anti-malarial), spectacles, artificial eyes, hearing aids,
orthopedic equipment and supplies (including prosthetics), and
various books and journals.
A. Bandaging and Dressing Supplies:
General: Bandages and dressings are two different
things. A dressing is a material which is in direct contact with
a wound, whereas a bandage is a material placed or wrapped over
top of the dressing to keep it in place and absorb fluids. A wound
is any damage to the body that cuts, punctures, tears or otherwise
damages the skin. That could include open wounds like lacerations
or closed wounds like bruises.
A dressing can have multiple purposes to keep in mind, although
not all of the following apply to any given dressing. These purposes
include:
- The maintenance of high humidity where the dressing meets
the wound. A dry environment can cause dehydration and cell
death at the wound site. A moist environment causes wounds to
heal three to five times more quickly, and also less painfully.
- The removal of excess fluids coming from the wound, including
blood.
- The movement of air around the wound.
- The provision of thermal insulation.
- Impermeability to bacteria. Infection, local or systemic,
can delay or impede healing. The most common complication to
wound healing is infection, and hemorrhage is the most serious.
- Freedom from particles and toxic wound contaminants, so a
dressing which sheds particles or fibres into the wound would
not be very suitable.
- Removal without causing trauma (such as by tearing) since
trauma will worsen the wound and delay healing.
For more information on these points, and in caring for wounds
in general, see The
Care of Wounds: A Guide for Nurses by Carol Dealey. (For the
purposes of writing this I've also referred to Clinical
Guide: Wound Care by Cathy Thomas Hess, though I wouldn't
recommend buying that particular book because it is largely about
commercially available wound care products.) There are also good
wound care primers online, including this wound
care primer from McKinley Health Center.
Generally speaking almost clean fabric can be used as a dressing
or bandage in a pinch, including towels, bed sheets or clothing.
Things like paper towels, toilet paper, or paper in general are
not suitable for dressings because they tend to fall
apart when wet and will leave particles and fibres in the wound.
You can categorize dressings in terms of sterile / non-sterile,
absorbent / non-absorbent, occlusive / non-occlusive, adherent
/ non-adherent, and wet / dry.
A sterile dressing is free of microorganisms
and is placed in direct contact with a wound, while non-sterile
dressings are used as bulk layers above to absorb fluid. It's
difficult to improvise a completely sterile dressing. However,
you can kill almost all microorganisms by boiling a dressing in
water for 15 minutes or saturating it with a disinfecting
solution of alcohol. (It can also be important to apply disinfectants
directly to an open wound.) The main issue is that the dressing
can become recontaminated after sterilization, so do not touch
the side of the dressing you are going to place on the wound.
However, if you want to truly sterilize something and kill all
possible microbial spores you have to heat it at a temperature
significantly above 100 degrees celsius. For general information
on this topic see this Biosafety
Manual. One way that you can truly sterilize dressings is
to put them in a pressure cooker. You'll need to steam them (such
as in a vegetable steaming basket) and place them loosely so that
steam can circulate around them. Your pressure cooker will have
to reach at least 15 psi and a minimum of 121 degrees C (250 degrees
F) for a period of at least thirty minutes, followed by fifteen
minutes of drying under residual heat.
An absorbent dressing is used to soak up a lot
of blood or other fluids. This is useful for bleeding wounds.
In cases of wounds that are bleeding profusely you can also improvise
a highly absorbent layer by using a regular disposal menstrual
pad, which contains extremely absorbent materials (like sodium
polyacrylate). However, in any situation where someone is bleeding
profusely or for a long time you should get proper medical attention.
Almost any clean absorbent fabric or material can be used as an
absorbent layer, although fabrics like cotton tend to be much
more absorbent than synthetic fabrics. Many mosses, especially
sphagnum
moss, are incredibly absorbent. Sphagnum moss is twice as
absorbent as cotton. The use of sphagnum moss to treat wounds
is an ancient practice in many cultures. You may be able to use
mosses local to your area. (Unfortunately, industrial scale moss
harvesting from the wild for garden uses is currently causing
serious ecological damage in some places.) Non-absorbent dressings
are used when a barrier to leakage is desired.
An occlusive dressing is essentially a plastic
barrier that prevents the passage of air or fluids. It is used,
for example, in deep lacerations to neck or penetrating chest
wounds to prevent air from entering the bloodstream or chest cavity.
You can improvise an occlusive dressing from any clean, plastic
membrane (which is currently done by Emergency Medical Services
personnel). It's preferable to put a sterile dressing underneath
the non-sterile plastic, and then tape the edges of the plastic
down. (In the case of a pentrating chest wound you would only
tape three sides of a square dressing.) Most dressings are not
occlusive.
An adherent dressing is generally made of untreated
cotton or similar fibrous pads which stick to leaking blood and
fluids. This helps clot formation to stop bleeding more quickly.
However, because they stick to the wound their removal can be
painful and tear the scab, causing the wound to bleed again. Most
wounds are best covered by a non-adherent dressing, especially
burns. A dressing with many fibres hanging off will be more adherent
than a "sheer" one. The inner layer of most commercial
cotton dressings is chemically treated to be non-adherent, but
some sources suggest using a sheer synthetic material like parachute
cloth or other nylon fabrics as a non-adherent dressing.
A wet dressing is sometimes used on specific
kinds of wounds including burns and eviscerations. One problem
with wet dressings is that the water can allow infectious microorganisms
to move into the wound. The usual fluid used to wet dressings
is sterile normal saline. You can make normal saline by adding
two teaspoons of salt (9 grams) to 1 litre of potable water. Sterilizing
can be done by boiling, but as above the main problem is with
recontamination. In cases of minor burns or skin irritation, Aloe
vera gel is an effective substance to improve healing, and you
can easy grow it yourself indoors. Refer to wound care sources
for more information about the use of wet dressings.
Different dressings are suitable for different kinds of wounds,
and for different stages of wound healing.
Bandages in general are simple to improvise. Bandages for absorbing
blood and fluid simply need to be absorbent and clean. Bandages
may also be used to hold lower layers of dressings and bandages
in place, such as triangular bandages which you can cut from a
larger piece of fabric, which simply have to be reasonably strong
(and which won't shrink when wet or drying). Many decent cotton
fabrics can be used for either of these, but really whatever you
have available will work in a pinch.
With regard to stocking up and conservation:
There are a wide variety of wound dressing types even beyond those
discussed above. Perhaps the three things in this category of
supplies that are the hardest to make or improvise are medical
tape, non-adherent dressings, and totally sterile dressings, so
you could consider stocking up on those. In general, a well-stocked
first aid kit is still useful because it is handy to have easy
supplies at hand.
You can actually use tapes other than medical tape as long as
they are sticky and waterproof. Duct tape can be quite effective.
If you wish you use duct tape on someone's skin to help close
a wound or keep a dressing in place there are several ways to
improve "sticking". First, poke holes numerous small
holes in the tape with a pin to allow fluids like sweat to get
out. Second, wipe the area of skin you are going to tape with
a solvent (like acetone) or simply wash with soap and water to
remove oils. Thirdly, you can apply a tincture of benzoin, commonly
found in first aid kits, to the area of skin to improve stickiness.
There are a number of fairly standard bandaging supplies. These
include the self-adherent roller bandage, sometimes called "Kling"
or "Kerlex", which wraps around a dressings and clings
to itself while stretching slightly. It is very handy and quick
to use. A gauze bandage can also come in a roll but does not stretch
or stick to itself, so you have to tuck it in to itself or otherwise
keep it from unravelling. Triangular bandages (sometimes called
cravats), and "Ace" elastic bandages can be very handy.
Safety pins are useful for a great number of purposes, including
affixing bandages.
Substitution and relocalization: Since infection
is the most serious and common complication after initial bleeding
has been dealt with, you will want to do whatever you can to reduce
that risk. There are various anti-microbial substances that you
can make or gather, as described below in anti-microbial
medicines. [See part two when posted.] Absorbent mosses can
be grown in many places, and a wide variety of plants and herbs
are of great use in wound care and other medicine.
Improvisation: For bandages you can use any
clean fabric that you can wrap around the dressing and the appropriate
part of the body. But avoid anything strongly elastic (like rubber
bands) or tying the bandage to tightly, since that can cut off
circulation to part of the body and cause tissue damage.
This improvisation doesn't need to be complicated. You can make
a simple "bandaid" by placing a small square of gauze
in the middle of a strip of medical tape.
And as discussed above most dressings and bandages can be improvised
with some basic knowledge.
Restructuring: For all healing, good diet and
nutrition are important for the body to deal with stresses and
grow new tissues. So ensuring that people in your community have
good nutrition is one step.
Minor wounds like scrapes and cuts are common across cultures,
civilized or not. You can take steps to reduce the likelihood
of wounds by removing hazards (like broken glass) from your environment
and by using sharp tools as safely as possible. But wounds will
happen anyway, so the best you can do is to give prompt care to
any wound, clean it and remove contamination and watch for signs
of infection.
The continuation of this answer will be posted early next week.
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