The Preppers Medical Handbook by William Forgey

THE PREPPER’S
MEDICAL
HANDBOOK
How to provide medical care when
you can’t rely on anyone but yourself
WILLIAM W. FORG E Y, MD
Guilford, Connecticut
This book is dedicated to my good friends Eric Wan Clement
and his wife Taylor, without whose help these past several
years it could not have been accomplished.
I further reach out to my good friend Justin Van Ouse

and his wife Malgorzata and their lovely children
Zofia, Madeline, and Katherine.
Preppers all and great friends.
An imprint of The Rowman & Littlefield Publishing Group, Inc.

4501 Forbes Blvd., Ste. 200
Lanham, MD 20706
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Distributed by NATIONAL BOOK NETWORK
Copyright © 2020 William W. Forgey, MD

Illustrations by Robert L. Prince
All rights reserved. No part of this book may be reproduced in any form or by any electronic or
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from the publisher, except by a reviewer who may quote passages in a review.
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ISBN 978-1-4930-4694-2 (paperback)

ISBN 978-1-4930-4695-9 (e-book)
The paper used in this publication meets the minimum requirements of American National
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Z39.48-1992.
CO NTENTS
Chapter 1: How to Prepare for Medical Care Off the Grid . . . . . 1

Off-Grid versus No-Grid Medical Prepping . . . . . . . . . . . . . . . . . 1
How to Use This Book. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Chapter 2: Assessment and Stabilization . . . . . . . . . . . . . . . . . 4

Assessment and Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Initial Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Survey the Scene • Check the Airway and Breathing •
Check Circulation • Check for Severe Bleeding •
Check the Cervical Spine
Focused Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
The Physical Exam
Vital Signs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Level of Responsiveness • Pulse • Respirations • Skin Signs •
Blood Pressure • Temperature • Oxygen Saturation
Medical History and Physical Examination. . . . . . . . . . . . . . . . . 12
Head • Neck • Chest • Abdomen • Back • Pelvis/Hip •
Legs • Shoulders and Arms
Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Difficult Respirations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Foreign Body Airway Obstruction. . . . . . . . . . . . . . . . . . . . . . . . 16
Adult One-Rescuer Cardiopulmonary Resuscitation (CPR) . . . . 17
Adult Two-Rescuer CPR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Rapid Breathing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Cardiac Evaluation and Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Heart Attack (Myocardial Infarction)
Rapid Heart Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Tachycardia
Slow Heart Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Bradycardia
iv CONTENTS
Chapter 3: Body System Symptoms and Management . . . . . 27

Symptom Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Fever/Chills • Lethargy • Pain • Itch • Hiccups • Headache
Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Eye Patch and Bandaging Techniques •
Foreign Body Eye Injury • Contact Lenses • Eye Abrasion •
Snow Blindness or Ultraviolet Eye Injury • Conjunctivitis •
Iritis • Allergic Conjunctivitis • Sties and Chalazia •
Spontaneous Subconjunctival Hemorrhage •
Blunt Trauma to the Eye • Glaucoma
Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Nasal Congestion • Foreign Body Nose Injury • Nosebleed •
Nose Fracture
Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Earache • Outer Ear Infection • Middle Ear Infection •
Foreign Body Ear Injury • Ruptured Eardrum •
Temporomandibular Joint (TMJ) Syndrome
Mouth and Throat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Sore Throat • Infectious Mononucleosis • Mouth Sores
Chest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Bronchitis/Pneumonia • Pneumothorax • Pulmonary Embolus
Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Abdominal Pain • Gall Bladder Problems and Appendicitis •
Vomiting • Motion Sickness • Diarrhea • Constipation •
Hemorrhoids • Hernia • Bladder Infection
Reproductive Organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Venereal Diseases • Vaginal Discharge and Itching •
Menstrual Problems • Spontaneous Abortion •
Ectopic Pregnancy • Pregnancy • Painful Testicle
Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Plant or Food Poisoning • Petroleum Products Poisoning •
Ciguatera Poisoning • Scombroid Poisoning •
Puffer Fish Poisoning • Paralytic Shellfish Poisoning
Managing Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Water and Waste. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Oral Fluid Replacement Therapy • Water Purification •
Human Waste Disposal
CONTENTS v
Chapter 4: Radiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Units of Radiation Measurement • Diagnosis and
Management of Radiation Exposure and Illness
Chapter 5: Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Gum Pain or Swelling • Mouth Lacerations • Dental Pain •
Lost Filling • Cavity • Loose or Dislodged Tooth •
Pulling a Tooth
Chapter 6: Soft Tissue Care and Trauma Management . . . . . 116

The Bleeding Wound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Stop the Bleeding • Clean the Wound • Antibiotic Guidelines
Wound Closure Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Tape Closure Techniques • Stapling • Suturing
Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Shaving the Wound Area • Bleeding from Suture or Staple Use •
Scalp Wounds • Eyebrow and Lip Closure •
Mouth and Tongue Lacerations • Control of Pain • Dressings
Other Types of Wounds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Abrasions • Puncture Wounds • Splinter Removal •
Fishhook Removal • Friction Blisters • Thermal Burns •
Human Bites • Animal Bites
Finger and Toe Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Ingrown Nail • Paronychia (Nail Base Infection) • Felon •
Blood under the Nail
Wound Infection and Inflammation. . . . . . . . . . . . . . . . . . . . . 147
Abscess • Cellulitis
Skin Rash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Fungal Infection • Allergic Dermatitis • Bacterial Skin Rash •
Seabather’s Eruption
Chapter 7: Orthopedics—Bone and Joint Pain and Injury . . . 154

Management Off the Grid. . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Concepts of Orthopedic Care. . . . . . . . . . . . . . . . . . . . . . . . . . 155
Muscle Pain—No Acute Injury • Muscle Pain—Acute Injury •
Joint Pain—No Acute Injury • Joint Pain—Acute Injury •
Fractures
vi CONTENTS
Diagnosis and Care Protocols. . . . . . . . . . . . . . . . . . . . . . . . . . 164

Head • Neck • Spine • Collarbone • Shoulder • Shoulder Blade •
Upper Arm Fractures (Near the Shoulder) • Upper Arm Fractures
(Below the Shoulder) • Elbow Trauma • Forearm Fractures •
Wrist Fractures and Dislocations • Thumb Sprains and Fractures •
Hand Fractures • Finger Fractures and Sprains •
Hip Dislocation and Fracture • Thigh Fractures •
Kneecap Dislocation • Knee Sprains, Dislocations, and Fractures •
Ankle Sprains, Dislocations, and Fractures • Foot Injuries •
Chest Injuries
Chapter 8: Bites and Stings . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Venemous Stings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Anaphylactic Shock
Snakebites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Identifying Common North American Poisonous Snakes •
Signs and Symptoms of Pit Viper Bite •
Treatment of Pit Viper Bite • Neurotoxic Snakebites •
Treatment of Coral Snake Bites
Insect Bites and Stings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Spider Bites • Ticks • Caterpillar Reactions •
Millipede Reactions • Centipede Bites • Mosquitoes •
Black Flies • No-See-Ums and Biting Gnats •
Scorpion Stings • Ants/Fire Ants
Aquatic Stings, Cuts, and Rashes. . . . . . . . . . . . . . . . . . . . . . . 208
Sea Urchin • Jellyfish • Coral Stings •
Coral and Barnacle Cuts • Stingray • Catfish •
Scorpion Fish • Sponge Rash
Chapter 9: Bioterrorism and Infectious Disease . . . . . . . . . . 212

Managing Infectious Diseases in North America
and Potential Off-Grid Travel Destinations. . . . . . . . . . . . . . . 218
Anaplasmosis • Babesiosis • Blastomycosis • Chikungunya Fever •
Cholera • Coccidioidomycosis • Colorado Tick Fever • Dengue •
Echinococcus • Ehrlichiosis• Encephalitis • Giardiasis •
Hantavirus • Hepatitis A • Hepatitis B • Hepatitis C •
Hepatitis D • Hepatitis E • Hepatitis G • Leptospirosis •
Lyme Disease • Malaria • Measles (Rubeola) •
CONTENTS vii
Meningococcal Meningitis • Mumps • Plague • Rabies •

Relapsing Fever • Rocky Mountain Spotted Fever •
Rubella (German Measles, 3-Day Measles) • Schistosomiasis
• STARI • Tapeworms • Tetanus • Tick Paralysis • Trichinosis
• Trypanosomiasis, African (African Sleeping Sickness) •
Trypanosomiasis, American (Chagas Disease) • Tuberculosis •
Tularemia • Typhoid Fever • Endemic Typhus, Flea-Borne •
Epidemic Typhus, Louse Borne • West Nile Virus •
Yellow Fever • Zika Virus
Chapter 10: Environmental Injuries . . . . . . . . . . . . . . . . . . . . . 246

Hypothermia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Chronic Hypothermia • Acute Hypothermia •
Cold Water Submersion
Cold-Stress Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Frostnip • Frostbite • Cold-Induced Bronchospasm •
Immersion Foot • Chilblains
Heat-Stress Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Dilutional Hyponatremia • Heat Cramps • Heat Exhaustion •
Heat Stroke • Prickly Heat
Lightning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
High Altitude Illnesses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Acute Mountain Sickness (AMS) • High Altitude Pulmonary
Edema (HAPE) • High Altitude Cerebral Edema (HACE)
Chapter 11: The Off-Grid Medical Kit . . . . . . . . . . . . . . . . . . . . 269

Alternative and Herbal Therapy . . . . . . . . . . . . . . . . . . . . . . . . 269
Topical Bandaging Module • Non-Rx Oral Medication
Module • Rx Oral/Topical Medication Module • Rx Injectable
Medication Module • Cardiac Medication Module
Replacement Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
Prepper’s Medical Resource Bookshelf . . . . . . . . . . . . . . . . . 298

Clinical Reference Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
CHAPTER 1
HOW TO PREPARE FOR
MEDICAL CARE OFF THE GRID
OFF-GRID VERSUS NO-GRID

MEDICAL PREPPING
The basis of adequate prepping is being prepared for both common
and dire events that may occur under the worst of all possible circum-
stances. These circumstances might include the breakdown in normal
emergency support services (such as 911), the lack of the ability to
obtain additional supplies, and the probability that you will not be able
to rely on anyone but members of your immediate group or yourself.
Obviously, prepping requires forethought with regard to food,
water supplies, power, and protection—all areas of significant techni-
cal preparation requiring skill sets and supplies. Self-reliant medical
care is no exception. Even advanced first aid classes such as Wil-
derness First Responder and Tactical Combat Casualty Care rely
eventually on evacuation as part of the treatment protocol. Under the
situation of impractical or impossible evacuation, a means of provid-
ing a plan for long-term management must be available.
This book provides the basis of prevention, identification, and
long-term management of survivable medical conditions and can
be performed with minimal training. It helps you identify sources of
materials you will need and should stockpile, discusses storage issues,
and directs you to sources for more-complex procedures requiring
advanced concepts of field-expedient techniques that could be of use
to trained medical persons such as surgeons, anesthesiologists, den-
tists, and midwives.
2 THE PREPPER’S MEDICAL HANDBOOK
Two critical components of medical prepping is the concept of

“off grid” versus “no grid.” This book is structured around this concept.
You will be advised how to manage most problems with no outside
assistance, that is, without contact with the grid. However, it is also
important to know when it is important to rely on grid support, when
a patient should be seen by an advanced care provider. But then back
to the other issues: What if there is no grid or it is impossible for you
to return to the grid for whatever reason? Then you must also know
how to provide management under a TEOTWAWKI (the end of the
world as we know it) event, when the grid simply will not be available
to you.
While this book is based upon my book Wilderness Medicine, 7th
edition (Falcon, 2017), numerous modifications have been made to
address the uniquely different aspect of prepper medical care from
the experiences facing wilderness expeditions into remote areas. Liv-
ing in a remote cabin in northern Manitoba for a winter does qualify
as a sort of “prepping”; this book is also based upon over forty years
of experience with such activities. Providing medical care on dozens
of medical service projects in remote areas of Haiti and elsewhere
also provides the basis of my experience to write the ultimate prep-
per’s medical handbook. But the greatest inspiration for my prepper
instincts comes from my thirty months in Vietnam as a young infan-
try officer and the training I had in preparation for my military expe-
riences. I have never stopped training, preparing, and experiencing
the activities required to help others survive their environment and
their medical situation. With this book I pass on this knowledge to
you so that you can prepare and then act to manage medical problems
in the ultimate austere environment, the one in which you must be
fully self-dependent for even emergent medical care without any help
from “the grid.”
HOW TO USE THIS BOOK

There are four ways to rapidly identify where in this book to find the
information you need.
HOW TO PREPARE FOR MEDICAL CARE OFF THE GRID 3
First
A quick glance through the contents can lead you to the proper chap-
ter and subject.
Second
The Initial Assessment (pages 6–8) and the Focused Assessment
(pages 8–9) not only describe how to perform a physical examination
and what to look for, but these sections also refer you to the page of
the book that tells you what to do if something is wrong.
Third
Throughout the book various sections have diagnostic tables with
references to further evaluate or explain treatment options. For prob-
lems that fall into these categories, you can refer directly to the tables
indicated in the list below
List of Diagnostic Tables/References

Abdominal Problems Table 3-6
Bites and Stings page 193
Ear Problems Table 3-5
Environmental Injuries page 246
Eye Problems Table 3-4
Infectious Diseases Tables 9-1 and 9-2
Orthopedic Injuries page 159
Shock page 13
Soft Tissue Care page 116
Symptom Management Table 3-1
Fourth
The Clinical Reference Index at the end of the book provides a com-
prehensive cross-reference between symptoms, conditions, and treat-
ments. Subjects are listed using both medical jargon and vernacular
descriptions.
CHAPTER 2
ASSESSMENT AND
STABILIZATION
ASSESSMENT AND CARE

The technique of providing aid to an injured person is similar to giv-
ing appropriate treatment to someone who complains of sickness or
sudden pain from a noninjury cause. Proper care can result only if
several basic steps are performed correctly. The basics are straightfor-
ward, and you should not be intimidated by this process. The problem
with medicine in general is that there are so many possible diagnoses
and treatments that the whole thing can seem overwhelming. It is
not, however, if you follow certain logical steps.
These logical steps form the basis of starting the decision tree
that will lead almost automatically to a correct course of action. They
simplify the process into a much less scary proposition. The initial
phase is assessment, the second phase is stabilization, and the third
phase is treatment. While the first aid approach only includes assess-
ment, this book is concerned with developing approaches to defini-
tive treatment that could be reasonably performed in remote areas by
relatively untrained (and undoubtedly very concerned) friends of the
suddenly impaired.
Trauma assessment is divided into two phases called the initial
assessment and focused assessment. What good is an assessment if
you don’t know what to do with the information? During rescue oper-
ations, what you do with the information is record it. This recorded
information, which includes periodic reassessment data, can be valuable
ASSESSMENT AND STABILIZATION 5
to physicians at treatment centers, as it indicates either a stable or a

deteriorating patient and helps direct the future course of action. For
those of us stuck with caring for the patient in a remote area, this data
can be used to begin a decision tree that will help determine our best
course of action. Sometimes this will be definitive treatment; other
times it will amount to minimizing the damage and striving to keep
the victim as functional as possible, or sometimes just alive.
Assessment and Care 4

Initial Assessment 6
Survey the Scene 6
Check the Airway and Breathing 6
Check Circulation 7
Check for Severe Bleeding 7
Check the Cervical Spine 7
Focused Assessment 8
The Physical Exam 8
Vital Signs 9
Level of Responsiveness 10
Pulse 10
Respirations 10
Skin Signs 10
Blood Pressure 11
Temperature 11
Oxygen saturation 11
Medical History and Physical Examination 12
Head 12
Neck 12
Chest 12
Abdomen 13
Back 13
Pelvis/Hip 13
Legs 13
Shoulders and Arms 13
Shock 13
Difficult Respirations 16
Foreign Body Airway Obstruction 16
Adult One-Rescuer Cardiopulmonary Resuscitation (CPR) 17

Adult Two-Rescuer CPR 20
Rapid Breathing 21
Cardiac Evaluation and Care 22
Heart Attack—Myocardial Infarction 22
Rapid Heart Rate 25
Tachycardia 25
Slow Heart Rate 25
Bradycardia 25
INITIAL ASSESSMENT
Survey the Scene

Before assessing the patient, assess the scene! Accidents tend to
multiply. Make sure the scene is safe for the rescuers and the vic-
tim. Ensure that the situation does not become worse. This step can
include such diverse aspects as avoiding further avalanches or rock-
falls and ensuring adequate clothing and food supplies for rescuers.
Initially, however, scene assessment should consist of looking for
immediate hazards that might result in more casualties among the
group attempting to help the victim.
Check the Airway and Breathing

Check the airway. If the victim can talk, his airway is functioning. In
an unconscious patient, place your ear next to his nose/mouth and
your hand on his chest and look, listen, and feel for air movement.
No air movement: Check to see whether the tongue is blocking
the airway by pushing down on the forehead while lifting the chin.
In case of possible neck injury, the airway can be opened by lift-
ing the jaw without moving the neck. Open the victim’s mouth and
visually inspect, removing any objects you can see.
Still no air movement: Pinch his nose, seal your mouth over his,
and try to breathe air into his lungs. If the first attempt to breathe air
into the victim fails, you should reposition the victim’s head and try
again.
Still no air movement: Perform chest thrusts, similar to the com-

pressions of cardiopulmonary resuscitation (CPR); see page 17.
Perform 30 compressions followed by attempts to breathe in air as
directed above.
Once you are able to establish air movement, continue com-
pressions until the victim’s heart is
beating and no longer requires com-
pressions and he is breathing on his
own. See one-person and two-person
CPR on pages 17-20.
Check Circulation
Check circulation by placing sev-
eral of your fingertips lightly into
the hollow below the angle of the
Figure 2-1.
patient’s jaw. See figure 2-1. Position of fingers to check for
1-1
No pulse: Start CPR; see page 17. the carotid artery pulse
Check for Severe Bleeding

Check quickly for severe blood loss. Check visually and with your
hands. Slide your hand under the victim to ensure that blood is not
leaking into the ground or snow, and check inside bulky garments for
hidden blood loss.
Severe bleeding: Use direct pressure and/or a tourniquet; see page 118.
Check the Cervical Spine

During the primary assessment, keep the head and neck as still as
possible if there is any suspicion of a cervical spine injury. This may
certainly be the case if the patient is unconscious or suffering from an
accident such as a steep fall, a sudden stop, or significant blows to the
head. See treatment of spine injuries, page 168.
In their excellent book Medicine for the Backcountry (Globe Pequot
Press, 1999), Buck Tilton and Frank Hubbell state, “Do not let fear
of spinal cord injury blind you to more immediate threats to life. If
the scene is not safe, the patient may need to be carefully moved. If
the airway is not open, grasp the sides of your patient’s head firmly,
and pull with steady, gentle traction, and attempt to align the head
and neck with the rest of the body. Gentle traction should be main-
tained until mechanical stabilization can be improvised.” See spinal
cord management, page 167.
FOCUSED ASSESSMENT
The Physical Exam

While the purpose of the initial assessment (formerly called the pri-
mary or hasty survey) is to rapidly find and correct life-threatening
conditions, the focused assessment (formerly identified as the sec-
ondary survey) is an attempt to identify all of the medical problems
that the patient might have. This requires a thorough examination
because sometimes an obvious injury can be distracting: A broken
bone may cause both you and the victim not to notice a less painful
but potentially more serious injury elsewhere.
The only way to perform a focused assessment is to do it thor-
oughly, using both your vision and sense of touch, asking simple
questions, and being methodical in the approach. Sense of touch
is important. Sliding your hand under the victim might find areas
of tenderness or even considerable blood loss that would otherwise
be unnoticed. It is surprising how much blood can be absorbed into
snow or sand under a wounded victim and not even be noticed until
your hand encounters it.
The mission of the focused assessment is not only to discover
various medical problems but also to record and keep track of them
during periodic reassessments. The reassessment information is even
more important than the first set of information taken during the
initial focused assessment. How often the focused assessment needs
to be repeated and how extensive it needs to be depend primarily on
the history of the event. Very serious-appearing events could initially
require total body reassessment every 15 minutes. There can be no
hard and fast rule concerning how often to repeat reassessments and
how extensive they must be. There is no escaping the use of com-
mon sense. Eventually reassessment every few hours, even discontin-
uing this process, will become proper. This is particularly appropriate
when the examination is unchanged and stable, the patient is alert,

and you obviously have effectively dealt with the injuries. The scheme
for recording this information is in the form of a SOAP note, which
stands for Subjective, Objective, Assessment, Plan.
The most significant difference between off-grid and standard
urban first aid is that the focused assessment when you are off the
grid must also lead to treatment protocols. This methodical examina-
tion should generally start at the head and work its way to the feet.
The exception could be children, where you might want to alleviate
their apprehension by starting with their legs before examining their
heads. Generally starting at the head is best. Some ethnic groups
demand this. For example, Romani find it insulting to be touched
above the waist directly after being touched below the waist. This is
good to know if you are coexisting with Romani.
General Principles of the Focused Physical Assessment:

1. Start at the top and work your way down.
2. Move the patient as little as possible and try not to aggravate known
injuries while looking for others.
3. Constantly communicate with the patient during the examination,
even if she seems unconscious.
4. Look for damage, even cutting away clothing if necessary to
visualize suspected injuries.
5. Ask about pain, discomfort, and abnormal sensations constantly
during the exam.
6. Gently feel all relevant body parts for abnormalities.
VITAL SIGNS
While even accurate measurements of the body’s functions may not
indicate what is wrong with a patient, the second and subsequent
measurements indicate how well the patient is doing. You will need
to use common sense to determine how often the signs are taken, but
certainly close monitoring of the patient should be continued until
she is “out of the woods,” either literally or figuratively.
Vital signs consist of several elements: level of responsiveness,

pulse, respirations, skin signs, blood pressure, and temperature.
Level of Responsiveness
Is the patient alert, or does she respond only to verbal or painful stim-
ulus? Or is she unresponsive? She should know who she is, where
she is, what happened to her, and about what time of the day it is.
Responsiveness ranges from alert to verbal (responsive to spoken
contact) to pain (not responsive to verbal contact but responsive to
being pinched or rubbed on the shin) to unresponsive.
Pulse
Check and record rate, rhythm, and quality (weak, normal, or strong)
of the pulse. If an injury has been sustained by a limb, check pulses on
both injured and uninjured limbs, and compare.
Shock, see page 13.
Deformed fracture causing a decreased pulse, see page 178.
Respirations
Note the rate, rhythm, and quality of respirations (labored, with pain,
flaring of nostrils, or noise such as snores, squeaks, gurgles, or gasps).
An adult normally breathes 12 to 18 times per minute, while children
breathe faster.
Respiratory difficulties, see page 16.
Skin Signs
Check skin color, particularly in the nonpigmented areas of the body,
and note whether skin is hot/cold and moist/dry.
Hot, fever, see page 11.
Heat stress, see page 255.
Cold, shock, see page 13.
Hypothermia, see page 246.
Yellow skin, jaundice, see page 225.
Anemia, see page 31.
Blood Pressure
Blood pressure can be measured with a stethoscope and blood pres-
sure cuff or by estimating. If you can feel a pulse in the radial artery
at the wrist, the top (systolic) pressure is probably at least 80 mm
Hg. If you can feel the femoral pulse only in the groin, the pres-
sure is no lower than 70 mm Hg. When only the carotid pulse in
the neck is palpable, the systolic is probably at least 60 mm. Normal
systolic blood pressures range from 100 to 140. Low upper blood
pressures with normal pulses (70 to 85 beats per minute) are safe. But
an increased pulse rate with a low pressure is an indication of shock.
Temperature
Oral thermometers will give the most accurate field temperatures
unless the ambient temperature is close to the room temperature of
a Ritz-Carlton resort, in which case forehead infrared or ear tem-
perature thermometers are convenient, until their batteries wear out.
Plastic direct-contact thermometers also require a similar ambient
temperature range for accuracy. An estimation of fever can be made
if the person’s normal resting pulse rate is known. Each degree Fahr-
enheit will generally result in a 10-beats-per-minute pulse increase.
There are exceptions, such as typhoid fever, when there is a relatively
slow heart rate for a high fever (see page 242).
Oxygen Saturation
I have not included a pulse oximeter in the Off-Grid Medical Kit.
If you have anyone in your group with a lung problem, you need to
consider an oxygen concentrator and a renewable power supply. This
is very reasonable equipment to manage, both acquisition cost and
weight. A pulse oximeter is only $30 and available over the counter at
most pharmacies. Portable oxygen concentrators do not require pre-
scriptions and power units—and power units are a mainstay of any
prepper project, so no need for me to belabor the topic here.
MEDICAL HISTORY AND

PHYSICAL EXAMINATION
Taking a medical history allows you to factor in your patient’s pre-
vious or current illnesses as they may relate to the situation at hand.
Before or during your actual physical examination, if the patient is
not in an acute stage, ask about any allergies, medications that your
patient is taking, health history, last food or drink, and about the
events that led up to the accident. If he is in pain, ask what provokes
it, what action (if any) decreases its intensity, whether it radiates, how
severe it is, what type it is (burning, sharp, dull), and when it started.
Head
Look for damage, discoloration, and blood or fluid draining from
ears, nose, and mouth. Ask about loss of consciousness, pain, or any
abnormal sensations. Feel for lumps or other deformities.
Losses of consciousness, see page 165.
Headache, see page 36.
Ear trauma, see page 54.
Eye trauma, see page 37.
Nose trauma, see page 53.
Mouth trauma, see page 131.
Neck
Look for obvious damage or deviation of the windpipe (trachea). Ask
about pain and discomfort. Feel along the cervical spine for a pain
response.
Cervical spine trauma, see page 167.
Chest
Compress the ribs from both sides, as if squeezing a birdcage, keeping
your hands wide to prevent the possibility of too much direct pressure
on fractures. Look for damage or deformities. Ask about pain. Feel
for instability.
Chest trauma, see page 191.
Difficulty breathing, see page 16.
Abdomen
With hands spread wide, press gently on the abdomen. Look for
damage. Ask about pain and discomfort. Feel for rigidity, distention,
or muscle spasms.
Abdominal pain, see page 65.
Back
Slide your hands under the patient, palpating as much of the spine
as possible.
Spine trauma, see page 168.
Pelvis/Hip
Place your hands on the top front of the pelvis on both sides (the iliac
crests), pressing gently down and pulling toward the midline of the
body. Ask about pain. Feel for instability.
Hip or pelvis pain, see page 185.
Legs
One at a time, with your hands surrounding the leg, run your hands
from the groin down to the toes, squeezing as you go. Note espe-
cially if there is a lack of circulation, sensation, or motion in the toes.
Repeat for the other leg.
Bone injury, see page 154.
Shoulders and Arms

One at a time, with hands wide, squeeze the shoulder, and run your
hands down the arms to the fingers. Check for circulation, sensation,
and motion in the fingers. Repeat for the other shoulder.
Shoulder trauma, see page 172.
Joint trauma, see page 158.
Broken bone, see page 161.
SHOCK
Shock is a deficiency in oxygen supply reaching the brain and other
tissues as a result of decreased circulation. An important aspect in
the correction of shock is to identify and treat the underlying cause.
Shock can be caused by burns, electrocution, hypothermia, bites,

stings, bleeding, fractures, pain, hyperthermia, high altitude cerebral
edema, illness, rough handling, allergic reaction (anaphylaxis), dam-
age or excitement to the central nervous system, dehydration from
sweating, vomiting, or diarrhea, or loss of adequate heart strength.
Each of these underlying causes is discussed separately in this text.
Shock can progress through several stages before death results.
The first phase is called the compensatory stage, during which the
body attempts to counter the damage by increasing its activity level.
Arteries constrict and the pulse rate increases, thus maintaining the
blood pressure. The next phase is called the progressive stage (or
decompensatory stage), when suddenly the blood pressure drops and
the patient worsens, often swiftly. When he has reached the irrevers-
ible stage, vital organs have suffered from loss of oxygen so profoundly
that death occurs even with aggressive treatment.
Consider the possibility of shock in any victim of an accident or
when significant illness develops. Ensure that an adequate airway is
established (see further discussion under Adult One-Rescuer CPR,
page 17). Assess the cardiovascular status. Place your hand over the
carotid artery (figure 2-1) to obtain the pulse. In compensatory shock
the patient will have a weak, rapid pulse. In adults the rate will be over
140; in children, 180 beats per minute. If there is doubt about a pulse
being present, listen to the bare chest. If cardiac standstill is present,
begin one-person or two-person CPR (see pages 17–20). Elevate the
legs 45 degrees to obtain a better return of venous blood to the heart
and head. However, if there has been a severe head injury, keep the
person flat. If he has trouble breathing, elevate the chest and head to a
comfortable position. Protect the patient from the environment with
insulation underneath and shelter above. Strive to make him com-
fortable. Watch your spoken and body language. Reassure without
patronizing, and let nothing that you say or do cause him increased
distress.
Attempt to treat the underlying cause of the shock. The pri-
mary or secondary assessment and history may well elicit the cause
of shock, and appropriate treatment can be devised from the field-
expedient methods listed in this book.
Shock due to severe allergic reactions is called anaphylactic shock

and is discussed on page 193.
Vasovagal syncope is a common form of shock. Sometimes called
fainting, the clue is a very slow heartbeat in the patient. Generally
something has happened to the patient that precipitates this reaction,
such as witnessing blood loss in herself or another person, receiving an
injection (or even witnessing someone else receiving one), or perhaps
attending one of my medical lectures. (See slow heart rate, page 25.)
Decision/Care Table
If no breathing is present—from whatever cause—
see Adult One-Rescuer CPR, page 17.
If no heartbeat is present—from whatever cause—
see Adult One-Rescuer CPR, page 17.
If associated with high altitude (above 6,500 feet),
see High Altitude Illnesses, page 265.
If associated with cold conditions,
see Hypothermia, page 247.
If body temperature is over 100°F with cough,
see Bronchitis/Pneumonia, page 63.
If body temperature is over 100°F without cough,
see Fever/Chills, page 29.
If severe pain, sudden onset after trauma,
see Chest Injuries, page 191.
If severe pain, sudden onset, no trauma,
see Pneumothorax, page 63
see Pulmonary Embolus, page 64
see Cardiac Evaluation and Care, page 22.
If associated with hysterical reaction,
see Rapid Breathing, page 21.
If associated with choking,
see Foreign Body Airway Obstruction, page 16.
If associated with dull ache in middle of chest,
see Cardiac Evaluation and Care, page 22.
DIFFICULT RESPIRATIONS
It has been stated that you can live three minutes without air, three
days without water, three weeks without food, and three months
without love. While some feel that they may stretch any of these time
limits to four, others feel they could survive only the shorter periods.
Without any question, adequate respirations are the most significant
demand of the living creature. When respiratory difficulties start, it’s
urgent to find the reason and alleviate it. When breathing stops, rees-
tablishing airflow is critical.
FOREIGN BODY AIRWAY OBSTRUCTION

If a conscious adult seems to be experiencing distressed breathing, ask,
“Are you choking?” A choking victim cannot talk but may be mak-
ing a high-pitched sound during
attempts to breathe. He or she
will rapidly become a bluish color
and unconscious if the blockage
is total. If the victim is apparently
choking, perform an abdominal
thrust to relieve foreign body air-
way obstruction. If the victim is
standing or sitting, stand behind
and wrap your arms around the
patient, proceeding as follows:
Make a fist with one hand. Place
the thumb side of the fist against
the victim’s abdomen, in the mid-
line slightly above the navel and
well below the breastbone. Grasp
your fist with the other hand. Lift
your elbows away from the vic-
tim’s body and press your fist into
the victim’s abdomen with a quick
upward thrust. Each new thrust Figure 2-2.
should be a separate and distinct The abdominal thrust, formerly
1-2
movement. It may be necessary to called the Heimlich maneuver
repeat the thrust multiple times to clear the airway. If the person is
obese or pregnant, use chest thrusts in the same manner as described,
but place your arms around the lower chest and your fists on the cen-
ter of the victim’s sternum.
If the victim becomes unconscious and is on the ground, she
should be placed on her back, face up. In civilization and on the
grid, you would activate the emergency medical services (EMS) sys-
tem by calling 911. Perform a tongue-jaw lift, open the mouth, and
remove any visible objects. With the airway open, try to ventilate. If
still obstructed, reposition the head and try to ventilate again. If still
obstructed, give 30 chest thrusts, followed by 2 attempts to ventilate
as described above. Each time you open the mouth to ventilate the
victim, check for a visible obstruction and remove it if you see one.
Repeat these steps until effective.
ADULT ONE-RESCUER CARDIOPULMONARY

RESUSCITATION (CPR)
Note: This brief presentation of the basics of CPR reflects research
indicating the importance of immediately reestablishing circulation
via chest compressions. If you are without training in rescue breath-
ing, you may choose to perform hands-only CPR.
To establish unresponsiveness, first try talking—clearly and
loudly—to the victim, asking questions such as “Are you OK? Can
you hear me?” If there is no response to your verbal contact, make
gentle physical contact by touching the victim’s shoulder and repeat-
ing your questions. If gentle contact fails, apply a painful stimulus,
such as a pinch to the back of the arm. If the patient remains unre-
sponsive, in civilization, activate the EMS system (call 911) prior to
attempting CPR. Off the grid immediately proceed with the follow-
ing steps.
Check for signs of circulation that include coughing, breathing,
or movement. If you have been trained, you may also check for a
carotid pulse. This is found by placing your hand on the voice box
(larynx). Slip the tips of your fingers into the groove beside the voice
box and feel for the pulse (see figure 2-1). Check for circulation for a
maximum of 10 seconds.
If the victim is unresponsive with no signs of circulation, start

chest compressions.
Chest compressions are performed by the rescuer kneeling at the
victim’s side, near his chest. Place the heel of one hand on the center
of the sternum. Place the other hand on top of the one that is in posi-
tion on the sternum (see figure 2-3). Be sure to keep your fingers off
the ribs. The easiest way to prevent this is to interlock your fingers,
thus keeping them confined to the sternum. With your shoulders
directly over the victim’s sternum, compress downward, keeping your
arms straight. Depress the sternum at least 2 inches. Relax the pres-
sure completely, keeping your hands in contact with the sternum at
all times, but allowing the sternum to return to its normal position
between compressions. Both compression and relaxation should be of
equal duration.
Perform 30 external chest compressions at a rate of at least 100
per minute. Push down hard, and push down fast.
Open the airway using the head-tilt/chin-lift or jaw-thrust tech-
nique (see figure 2-4). Place one hand on the victim’s forehead and
apply firm backward pressure with the palm to tilt the head back.
Place the fingers of the other hand under the bony part of the lower
(A) (B)
Figure 2-3.
1-4
(A) Position of hands, (B) position of rescuer
jaw near the chin and lift to bring the chin forward and the teeth
almost shut, thus supporting the jaw and helping to tilt the head back,
as indicated in figure 2-4. In case of a suspected neck injury, use the
chin-lift without the head-tilt technique. The nose is pinched shut by
using the thumb and index finger of the hand on the forehead.
The chin-lift method will place tension on the tongue and throat
structures to ensure that the air passage will open.
If breathing is absent, give 2 slow breaths (about 1 second per
breath), watching the chest rise, then allow for exhalation between
breaths. The breathing rate should be once about every 6 seconds.
Using slow breaths reduces the amount of air that tends to enter the
stomach and cause gastric distention.
After 5 cycles of 30:2 compressions and ventilations (lasting
about 2 minutes), reevaluate the patient. Check for the return of cir-
culation. If it is absent, resume CPR with 30 compressions followed
by 2 breaths, as indicated above. If it is present, continue to the next
step. Check breathing. If present, monitor breathing and pulse closely.
If absent, perform rescue breathing at 1 breath about every 6 seconds
and monitor pulse closely.
If CPR is continued, do not interrupt CPR for more than 5 sec-
onds except in special circumstances. Once CPR is started, it should
be maintained until professional assistance can take over the respon-
sibility, or until a physician declares the patient dead. If CPR has
Figure 2-4.
The head-tilt/chin-lift method of opening the airway in an unconscious person
been continued for 30 minutes without regaining cardiac function,

and the eyes are fixed and nonreactive to light, the patient can be
presumed dead. The exceptions would be hypothermia (see page 247)
and lightning injuries (page 261). In these circumstances, if profes-
sional help does not intervene, CPR should be continued until the
rescuers are exhausted.
Some authorities in remote-area rescues feel that the survival rate
is very low without defibrillation within 4 minutes by paramedics,
and that CPR should not be started when cardiac standstill is due to
a heart attack. It certainly should not be started or maintained under
these conditions when its performance might endanger the lives of
members of the rescue party. Regardless, CPR is an important skill
that every person should master. The only way to learn this technique
is to take a CPR course—it cannot be properly self-taught.
ADULT TWO-RESCUER CPR

The two-rescuer technique differs in that Rescuer One will take a
position by the head and Rescuer Two assumes the position as
described under one-rescuer CPR (page 17).
After establishing unresponsiveness (and activating the EMS
system if in civilization) and finding no signs of circulation, Rescuer
Two begins chest compressions with his hands on the center of the
patient’s sternum, at a rate of at least 100 compressions per minute,
and compressing the chest at least 2 inches with each compression.
After 30 compressions, Rescuer One opens the airway (head-
tilt/chin-lift or jaw-thrust), takes a quick look for obstructions and
removes any that are visible, and then gives 2 breaths of about 1 sec-
ond each. After 5 cycles of 30:2, the two rescuers may switch places if
one rescuer is experiencing fatigue.
Two-person CPR is not generally taught to the public in basic
courses to avoid confusion. However, off the grid where prolonged
CPR might be necessary, being familiar with this technique can help
alleviate the tremendous fatigue that CPR induces in rescuers.
RAPID BREATHING
Rapid breathing (hyperventilation syndrome or tachypnea) can either
represent a serious medical condition or be the result of a harmless
panic attack. This symptom in a diabetic is extremely dangerous, as
it represents a very high blood sugar level, but it can be prevented
by proper diabetic management. High-altitude stress can result in
hyperventilation (see page 265).
The feeling of panic that results in very shallow breathing causes
the victim to lose excessive amounts of carbon dioxide from the
bloodstream. The resulting change in the acid-base balance of the
blood (respiratory alkalosis) will cause a numb feeling around the
mouth and in the extremities, and if the breathing pattern persists, it
can even lead to violent spasms of the hands and feet. This form of
hysteria can appear in teenagers and healthy young adults. It would be
helpful for victims to rebreathe their air from a stuff sack to increase
the carbon dioxide level in the bloodstream. They need to be reas-
sured and told to slow down the breathing. It is fine for them to draw
long, deep breaths, as it is the rapid breathing that causes the loss of
so much carbon dioxide.
If necessary, from the Non-Rx Oral Medication Module give
Percogesic, 2 tablets, or from the Rx Oral/Topical Medication Mod-
ule, give hydroxyzine hydrochloride, 25 mg, 2 tablets. From the Rx
Injectable Medication Module, hydroxyzine hydrochloride, 50 mg
intramuscular (IM), is also helpful in treating hyperventilation. These
drugs are being used in this instance as antianxiety drugs. Brand
names for hydroxyzine hydrochloride are Atarax (oral) and Vistaril
(injectable).
Diabetics must have access to a glucometer to check their blood
sugar levels, even if they do not use insulin. A high sugar reading
causing rapid breathing is a medical emergency requiring rapid evac-
uation. The management of diabetes is beyond the scope of this book,
but it must be well understood by diabetics going off the grid.
CARDIAC EVALUATION AND CARE
Heart Attack (Myocardial Infarction)

The following symptoms are fairly classic for a person having an
inadequate oxygen supply to the heart: chest heaviness or pain with
exertion; pain or ache radiating into the neck or into the arms; sweat-
ing; clammy, pale appearance; shortness of breath. The pain is called
angina and results from the heart muscle starving for oxygen. If the
blockage is profound, heart muscle will die. This is called a myocar-
dial infarction, and it means heart attack and damaged muscle. The
cause of death is frequently a profound irregular heartbeat caused by
electrical irritation in the damaged muscle. Another cause of death
is loss of adequate power to pump blood from weakened heart mus-
cle. A delayed cause of death can be from the sudden rupture of the
weakened heart wall.
The most important thing for an individual on the grid with these
symptoms is rest, which minimizes the oxygen requirement of the
heart. Position the victim for optimum comfort, generally with his
head elevated about 45 degrees (see figure 2-5). In some cases, even
with an electrocardiogram, it is impossible for a trained physician to
determine whether an individual is having a cardiac problem. When
in doubt, rest the patient and try to evacuate without having him do
any of the work. Treat him as a total invalid.
Physical rest is preferred, but if air evacuation or litter transport is
impossible, the quickest route to the hospital is the best route, even if
the victim must walk at a slow pace. Reperfusion therapy (i.e., open-
ing the coronary arteries with medications or mechanical means),
even up to 36 hours post-infarction, reduces long-term mortality and
complications.
Oral therapy can reduce infarction size and improve mortal-
ity (see Wilderness Medical Society Practice Guidelines for Wilderness
Emergency Care, 5th edition, edited by William Forgey, MD, Falcon
Guides, 2005).
1. Immediately give the patient 4 chewable baby aspirin (81
mg each), then 1 daily afterward. Check to see if the victim
Figure 2-5.
A heart attack victim can usually breathe better sitting up.
1-5
is carrying any prescription heart medications and note

usage instructions on the bottle.
2. Give sublingual glycerin if anyone in the party is carrying
it. If you are carrying the Rx Cardiac Medication Module,
you will have nitroglycerin spray. Do not give it, however, if
the systolic blood pressure (BP) is below 100 mmHg. If no
BP cuff is available, administer it if the pulse is palpable in
sitting position and there are no signs of hypotension. Do
not give if the pulse is below 60 beats per minute. Do not
repeat if syncope (fainting) develops after the initial dose.
One tablet, followed by an additional tablet at 10-minute
intervals, is appropriate. When using the spray, the dose is
1 or 2 sprays under the tongue, repeating as per the above
schedule.
3. Give Plavix (clopidogrel), 300 mg, loading the dose

immediately, then continue with 75 mg daily. Obese patients
may require 600 mg loading dose for complete platelet
inhibition.
4. Administer metoprolol or atenolol (25 mg) every 6 hours,
beginning 30 minutes after onset of chest pain, and repeat
every 6 hours even if pain improves. Wait 30 minutes after
onset of chest pain to identify patients with severe shock,
bradycardia (slow heart rate), or acute pulmonary edema; in
other words, do not give if the patient’s heart rate is below
60 beats per minute or systolic BP is below 100 mmHg, or
if the patient complains of severe shortness of breath or is
wheezing.
5. You may give the victim medication adequate to relieve
pain (see page 31). From the Rx Oral Module, give Atarax
(hydroxyzine), 25 mg orally, or from the Rx Injectable
Module, give Vistaril (hydroxyzine), 25 mg IM, if needed, to
treat nausea or to help sedate the victim. You may repeat the
pain medication and the nausea/sedation medication every 4
hours as needed.
Observe respirations and pulse rate. You will note the comment
in the section under Adult One-Rescuer CPR (page 17) that provid-
ing CPR to a heart attack victim who cannot be defibrillated within
4 minutes is a lost cause. The only significant reason for starting CPR,
if the person becomes pulseless, is to placate the onlookers. Due to
the virtual zero salvage rate, you are treating yourself and the others
watching who, after perhaps half an hour, will consider that every-
thing possible has been done. This may be a very important part of
the emotional support required by individual group members as they
reflect upon the event.
RAPID HEART RATE
Tachycardia
A rapid heart rate after trauma or other stress may signify impending
shock. The underlying cause should be treated. This may require fluid
replacement or pain medication. Body temperature elevations cause
an increase in heart rate of 10 beats per minute for each degree above
normal. At elevations above 8,000 feet (2,500 meters), a pulse rate
of 120 or greater per minute after a 20-minute rest is an early sign
of pulmonary edema (see page 266). A sudden onset of rapid heart
rate with sharp chest pain can indicate a pulmonary embolism or
pneumothorax. Treat with pain medication and have the patient sit
propped up for ease in breathing.
A very rapid rate of 140 to 220 beats per minute may be encoun-
tered suddenly and without warning in very healthy individuals.
This PAT (paroxysmal atrial tachycardia) frequently has, as its first
symptom, a feeling of profound weakness. The victim generally stops
what she is doing and feels better sitting down. These attacks are
self-limited, but they can be aborted by one of several maneuvers that
stimulate the vagus nerve, which in turn slows down the pulse rate.
These maneuvers include holding one’s breath and bearing down very
hard, closing one’s eyes and pressing firmly on one of the eyeballs,
inducing vomiting with a finger down the throat, or feeling for the
carotid pulse in the neck and gently pressing on the enlarged portion
of this artery, one side at a time. Another effective maneuver is to take
a deep breath and plunge one’s face into ice water. Frequently, how-
ever, the victim must just wait for the attack to pass. This arrhythmia
will sometimes come on after a spate of activity. No medication is
generally required.
SLOW HEART RATE
Bradycardia
A slow heart rate is important in two instances: when someone passes
out or and when it accompanies a high fever. Generally, fainting or
shock is associated with a rapid pulse rate (see compensatory shock,
page 14), an attempt by the body to maintain blood pressure. A safety

mechanism, which the body employs to prevent blood pressure from
elevating too high, is a sensor system in each carotid artery in the
neck, called the carotid bodies. If these sensors are stimulated by an
elevated blood pressure, a reflex mechanism that relaxes and opens
blood vessels throughout the body and lowers the heart rate is gen-
erated via impulses from the carotid bodies through the vagus nerve,
which can at times be fooled into inappropriately initiating this reflex
mechanism. A person watching an accident scene, or even thinking
about such an episode, can stimulate the vagus nerve through its con-
nection with the frontal lobe. The resulting slow pulse and relaxed
arteries can result in the person passing out (fainting).
As mentioned above, the pulse usually increases as the body tem-
perature rises. It also falls as the core temperature lowers into a hypo-
thermia state (see page 247). Several diseases are notable in that the
pulse rate is lower than would be expected for the elevated body tem-
perature caused by the disease. Typhoid fever (page 242) is the classic
example of this phenomenon.
CHAPTER 3
BODY SYSTEM SYMPTOMS
AND MANAGEMENT
SYMPTOM MANAGEMENT
Symptoms are indicators of problems. Fever, pain, and itch can some-
times aid you in determining exactly what is wrong with the patient.
The various decision tables in this book use one or more symptoms to
help identify a diagnosis and plan a treatment.
It is also useful to know how to minimize some of these symp-
toms. Why itch when you can treat it? The cause of an itch may vary
from poison plant dermatitis to an insect bite to liver disease. Regard-
less of the cause, what can you do to alleviate it?
The best method for reducing symptoms is to successfully treat
the underlying problem. Sometimes definitive treatment cannot be
accomplished. At other times, the symptom remains after the injury
is past, and the symptom becomes the greatest part of the problem.
Table 3-1 provides a guide to general symptom care.
Table 3-1. General Symptom Care Guide

Breathing Difficulties 16
Cough 29
Diarrhea 29
Fever/Chills 29
Heart Rate, Too Fast 25
Heart Rate, Too Slow 25
Hiccups 35
Itch 33
Lethargy 30
Nausea/Vomiting 70
Pain 31
Rash 149
For a discussion of symptoms localized to a particular body part,

refer to table 3-2 for the anatomical or body location and symptom
cross-referenced in the Clinical Reference Index, starting on page
300.
Table 3-2. General Anatomical Location Guide

Eye 36
Nose 51
Ear 53
Mouth and Throat 59
Chest 62
Abdomen 65
Reproductive organs 77
Evaluation and management of symptoms relating to injuries

and environmental exposure can also be found through the Clinical
Reference Index on page 300.
BODY SYSTEM SYMPTOMS AND MANAGEMENT 29
Fever/Chills
The average oral temperature of a resting individual is 98.6°F (37°C);
in active individuals, it is 101°F (38°C). Rectal temperatures are 0.5
to 1.5°F higher. A tympanic temperature (taken by an infrared sen-
sor placed in the ear) will range from equaling to being 0.5 to 1°F
higher than an oral temperature. An axillary (armpit) reading ranges
from 0.5 to 1°F lower than oral. Forehead or temporal readings are,
in my opinion, all over the map, depending on ambient temperature,
sweating, technique, and expense/accuracy of the device, but they are
generally considered equal to oral. Certainly, they are useful when
checking a large number of persons rapidly and provide a good esti-
mate. A 1°F temperature rise above normal in a human will result in
the heart rate increasing 10 beats per minute over the patient’s nor-
mal resting heart rate. This is a useful field method of judging tem-
perature, if everyone knows what his resting pulse is. Some diseases
cause a peculiar drop in heart rate, even in the face of an obviously
high temperature. The most notable of these are typhoid fever (see
page 242) and yellow fever (see page 244).
Although injury and exposure can cause elevated body tempera-
ture, fever is usually the result of infection. The cause of the fever
should be sought and treated. If pain or infection is located in the ear,
throat, or elsewhere, refer to the appropriate anatomical area listed in
the Clinical Reference Index on page 300.
If other symptoms beside fever are present (diarrhea, cough, etc.),
see the cross-references listing for these symptoms in the Clinical
Reference Index to provide treatment to alleviate the suffering due
to these conditions. This may diagnose the underlying disease, which
will have a specific treatment indicated in the text.
The prepper approach to therapy may be quite different from
that used in clinical medicine. When off the grid and in doubt about
whether a fever is due to viral, bacterial, or other infectious causes,
treat for a bacterial infection with an antibiotic from your Rx Medi-
cation Modules. Initially give the patient Levaquin 500 mg, 1 tablet
daily, and continue until the fever has broken for an additional 3 days.
This will conserve medication while providing adequate antibiotic
coverage for a suspected bacterial infection.
If it is possible that the patient has a strep throat, give Zithro-

max rather than Levaquin, as described on page 285. If you are not
carrying the Rx kit, then treat the symptoms using the medications
described in your non-Rx Medication Modules. In either case, rest is
important until the patient is again free of fever and has a sense of
well-being.
Chills are a kind of shivering, accompanied by a feeling of coldness
(not related to hypothermia; see page 247). Chills, also called rigors,
usually occur when the body temperature is 102°F (38.9°C) or the
person has had a sudden rise in body temperature. Chills frequently
indicate the onset of a bacterial infection, which should be treated
with an antibiotic as described above. In tropical countries, serious
infections such as malaria must be considered (see page 229). People
tolerate fevers quite well, and it is possible that elevated temperatures
enhance the immune response to infections. However, persons with
a history of febrile seizures or a history of heart problems should
certainly be treated to lower an elevated temperature. Generally, it is
best to use Tylenol (acetaminophen), but usually ibuprofen and aspi-
rin are safe. Aspirin should be avoided in children with chicken pox
or other viral illness due to an increase in Reye’s syndrome (a disease
of progressive liver failure and brain deterioration) with its use. The
Non-Rx Oral Medication Module contains three products useful
in treating fever: ibuprofen, aspirin, and Percogesic. As these are all
over-the-counter products, the dosage will be listed on the product
containers. The Rx Oral/Topical Medication Module contains the
nonsteroidal anti-inflammatory drug (NSAID) meloxicam, and its
use is described in that section (see page 284).
Lethargy
Lethargy, or prolonged tiredness or malaise, is a non-localizing symp-
tom such as fever or muscle aches (myalgia). Pain, however, is a local-
izing symptom that points to the organ system that may be the cause
of such things as lethargy, fever, or a general ill feeling. Frequently
after a few days of lethargy—or at times even hours—localizing
symptoms develop, and the cause of the lethargy can be determined
to be an infection of the throat, ear, or elsewhere.
Sometimes a chronic condition is the source of the lethargy, such

as anemia, leukemia, low thyroid function, occult or low-grade infec-
tion, mental depression, or even physical exhaustion. The latter we
would expect to be obvious from the history of the preceding level of
activity, and strength should return within a few days.
Anemia can be present due to chronic blood loss from ulcers,
menstrual problems, inadequate formation of iron, leukemia, or other
cancers in the bone marrow, and so on. Chronic anemia can be iden-
tified by looking at the color of the skin inside the lower eyelids.
Pull the lower lid down, look at it, and compare to another person.
Normally this thin skin is very orange colored, even if the cheeks are
pale. If the color is a blanched white, anemia is very likely. Another
good indication of anemia is an increase in the pulse rate of more
than 30 beats per minute in the standing position when compared to
a recumbent position.
Malaise or lethargy can be a presenting complaint of acute
mountain sickness, but this would be unusual below 6,000 feet (1,800
meters). If other symptoms are present, such as nausea, one must
think of hepatitis (see page 225) or, if preceded by a severe sore throat,
infectious mononucleosis (see page 60).
Lethargy is one of the most common presenting complaints that
I see in my office. An accurate diagnosis requires careful evaluation,
sometimes aided by laboratory tests. If the problem is not depression,
then regardless of the cause, the person needs rest, proper nutrition,
and adequate shelter.
Pain
Adequate pain management can involve a mixture of proper medica-
tion and attitude—the attitudes of both the victim and the medic are
crucial. A calm, professional approach to problems will lessen anxiety,
panic, and pain. Pain is an important symptom that tells you some-
thing is wrong. It generally “localizes” or points to the exact cause of
the trouble, so that pain in various parts of the body will be your clue
that a problem exists, and that specific treatment may be required to
eliminate it. Refer to the Clinical Reference Index (page 300) under
specific areas of the body (such as ear, abdomen, etc.) to read about
diagnoses and specific treatments of the causes of pain.
An application of cold water or ice can frequently relieve pain.
This is very important in burns, orthopedic injuries, and skin irrita-
tions. Cold can sometimes relieve muscle spasm. Gentle massage and
local hot compresses are also effective treatments for muscle spasm.
The alleviation of pain with medication calls for a step-wise
increase in medication strength until relief is obtained. Throughout
this book you will be referred to this section for adequate pain man-
agement. Use discretion in providing adequate medication to do the
job, without overdosing the patient. Remember that a pill takes about
20 minutes to begin working and is at maximum therapeutic strength
in about 1 hour. If possible, wait an hour to see how effective the
medication has been. But use common sense. If the injury is severe,
give a respectable initial dose.
MILD PAIN
For mild pain, from the Non-Rx Oral Medication Module, pro-
vide the victim with ibuprofen, 200 mg, 1 or 2 tablets every 4 hours.
Meloxicam in the prescription kit is particularly good for orthopedic
injuries, or whenever muscle sprains and contusions are encountered.
It is also ideal for menstrual cramps and tension headache, and it is
relatively safe to use in head injuries. It can also be used for the mus-
cle aches and fever from viral and bacterial infections.
Meloxicam, ibuprofen, and aspirin have anti- inflammatory
actions that make them ideal for treatment of tendinitis, bursitis, or
arthritic pain.
SEVERE PAIN
For severe pain you may have to rely on providing the maximal dose
of ibuprofen (800 mg every 6 hours) or meloxicam 15 mg once daily.
This can be augmented by giving the victim 1 or 2 Atarax 25 mg tab-
lets every 4 to 6 hours. This medication helps eliminate any associated
nausea, and from my experience also potentiates the pain medication
so that it works more effectively.
The Rx Oral/Topical Medication Module also contains nasally

inhaled Stadol (butorphanol tartrate). This very powerful pain medi-
cation is about ten times stronger per milligram than morphine. It is
taken as a spray up one nostril, followed by another spray in the other
nostril 5 to 20 minutes later, if necessary. This may be repeated every
3 to 4 hours. This medication is as powerful as any injectable product
available. (See a full discussion of this medication on page 289.) Its
rate of onset is rapid; within 5 minutes relief should start, reaching its
maximum effect within 20 minutes. As there are no needles required
to administer this drug, it should be easier to take on foreign trips
than injectable medications. You might consider keeping it with your
toothpaste until across the border. At least I do.
If you are carrying the Rx Injectable Medication Module, severe
pain can be treated with an injection of 10 mg of Nubain (nalbu-
phine). This amounts to 0.5 ml of the strength listed in the kit. This
can be potentiated with Vistaril (hydroxyzine), 25 mg or 50 mg, also
by injection. These two drugs can be mixed in the same syringe. They
both sting upon injection.
Local pain can be eliminated or eased with cold compresses or
ice, as mentioned above. Applying dibucaine 1% ointment will help
skin surface pain, such as from sunburn and abrasions. Applying a
cover of Spenco 2nd Skin dressing provides cooling relief due to the
evaporative action of the water from this safe-to-use gel pad. Deep
cuts and painful puncture wounds can be injected with lidocaine
1% from the Rx Injectable Medication Module. This technique is
described on page 292.
Itch
As itch is a sensation that is transmitted by pain fibers, all pain med-
ications can be used in alleviating itch sensations. Itch also indicates
that something is awry and may require specific treatment. The most
common causes are local allergic reactions, such as poisonous plants,
fungal infections, and insect bites or infestations (or look under spe-
cific causes in the index). General principles of treatment include
further avoidance of the offending substance (not so easy in the case
of mosquitoes). Avoid applying heat to an itchy area, as this makes
it flare up worse. Avoid scratching or rubbing; this also increases the

reaction. If weeping blisters have formed, apply wet soaks with a clean
cloth or gauze. While plain water soaks will help, making a solution
with regular table salt will help dry the lesions and alleviate some of
the itch. Make a solution approximately 10% weight to volume of
water. Cream-based preparations work well on moist lesions, while
ointments are more effective on dry, scaly ones. The Topical Bandag-
ing Module contains 1% hydrocortisone cream, which, while safe to
use, is generally not very effective against severe allergic dermatitis.
For best results, one should apply it 4 times daily and then cover
the area with an occlusive dressing, such as cellophane or a piece of
plastic bag. The Rx Oral/Topical Medication Module contains Top-
icort (desoximetasone) 0.25% ointment, which is strong enough to
adequately treat allergic dermatitis with light coats applied twice
daily. Athlete’s foot and skin rashes in the groin or in skin folds are
generally fungal and should not be treated with these creams. They
may seem to provide temporary relief, but they can worsen fungal
infections. For possible fungal infections, apply clotrimazole cream
1% twice daily from the Topical Bandaging Module.
Oral medications are frequently required to treat severe skin
reactions and itch. The Non-Rx Oral Medication Module contains
Benadryl (diphenhydramine), 25 mg. Take 1 or 2 capsules every 6
hours. It is one of the most effective antihistamines made, but there
are less sedating ones now sold without prescription, such as Claritin,
Zyrtec, and Allegra. The Rx Oral Topical Medication Module con-
tains Atarax (hydroxyzine), 25 mg. It is very effective both in treating
the symptom of itch and as an antihistamine. Take 1 or 2 tablets every
6 hours. These medications are safe to use on all sorts of itch prob-
lems. If one is suffering from an asthma attack, however, they should
not be used, as they tend to dry out the lung secretions and potentially
make the illness worse. Patients with a history of asthma should use
the newer antihistamines mentioned above.
HIVES
Hives are the result of a severe allergic reaction. Commonly called
welts, these raised red blotches develop rapidly and frequently have a
red border around a clearer skin area in the center, sometimes referred
to as an annular lesion. As these can and do appear over large surfaces
of the skin, treatment with a cream is of little help. Use the diphen-
hydramine or hydroxyzine as indicated above. Extensive urticaria
or allergic dermatitis lesions frequently need to be treated with an
oral steroid. The Rx Oral/Topical Medication Module has Decadron
(dexamethasone) 4 mg tablets; 1 tablet should be taken twice daily
after meals.
It should be noted that the Vistaril recommended for the Rx
Injectable Module is also hydroxyzine, as is the oral Atarax. This same
module also has an injectable form of the dexamethasone. For treat-
ment of rash, the oral medications should suffice.
In case of a concurrent asthmatic condition or the development
of shock, treat as for anaphylactic shock (see page 193). In case of
suspected tick bite, an annular or circular lesion may be a sign of
Lyme disease (page 228). If fever is present, one must consider that
a rash and itch have resulted from an infection. A diagnosis may be
impossible in the bush, so treatment with an antibiotic is appropriate
on expeditions expected to last longer than several more days. Use
doxycycline, 100 mg twice daily, from the Rx Oral/Topical Medica-
tion Module as a field-expedient solution to the problem. Treat fever
as described on page 29.
Hiccups
Hiccups can start from a variety of causes and are generally self-
limited. Persistent hiccups can be a medically important symp-
tom requiring professional evaluation and help to control. Several
approaches to their control when off-grid may be tried. Have the
victim hold his breath for as long as possible or rebreathe air from a
paper sack. These maneuvers raise the carbon dioxide level and help
stop the hiccup reflex mechanism. Drinking 5 to 6 ounces of ice
water fast sometimes works; one may also close one’s eyes and press
firmly on the eyeballs to stimulate the vagal blockage of the hiccup.
The other vagus nerve stimulation maneuvers described under Rapid
Heart Rate (page 25) can be tried.
If these maneuvers do not work, from the Non-Rx Oral Medi-

cation Module, you may give diphenhydramine, 25 mg, or from the
Rx Oral/Topical Medication Module you may give Atarax, 25 mg, 2
tablets. The Rx Injectable Medication Module includes Vistaril, the
injectable form of Atarax. This medication may be given in a dose
of 50 mg IM. These doses may be repeated every 4 hours. Let the
patient rest and try to avoid bothering him until bedtime. If still
symptomatic at that point, have him rebreathe the air from inside a
sleeping bag to raise the carbon dioxide level in his bloodstream and,
if nothing else, to muffle the sounds.
Headache
A variety of situations can cause a headache; refer to table 3-3. Too
much sun exposure, dehydration, withdrawal from caffeine, stress,
high altitude illness, dental or eye problems—the list is almost end-
less. Be sure to consider the possible underlying problems mentioned
above as they are the most common.
Table 3-3. Causes of Headache

Dental 109
TMJ (temporomandibular joint ) 59
High altitude 265
Heat 255
Sun exposure 260
EYE
Pain and irritation of the eye can be devastating. Many causes are
listed in table 3-4.
Table 3-4. Symptoms and Signs of Eye Pathology

VISION PAIN RED DRAINAGE TISSUE
LOSS SWELLING
Trauma (49) l n n l l
Foreign Body (38) n n n
Infection
Bacterial (45) n n l
Viral (45) n l l
Sty (48) n n
Allergy (47) n l
Corneal Ulcers (42) l
Snow Blindness (44) l n n l
Strain l
Glaucoma (50) n l
Spontaneous
Subconjunctival n
Hemorrhage (49)
Legend n A frequent or intense symptom

l Common, less intense symptom
Blank Less likely to produce this symptom
Note: The page numbers are in parentheses.
Eye Patch and Bandaging Techniques

In case of evidence of infection, do not use an eye patch or splint, but
have the patient wear dark glasses or a wide-brimmed hat, or take
other measures to decrease light exposure. Wash the eye with clean
water by dabbing with wet, clean cloth every 2 hours to remove pus
and excess secretions. Apply antibiotics as indicated under Conjunc-
tivitis, page 45.
Eye patch techniques must allow for gentle closure of the eyelid
and retard blinking activity. Sometimes both eyes must be patched for
this to succeed, but this obviously is a hardship for the patient. Simple
strips of tape holding the eyelids shut may suffice. In case of trauma,
an annular ring of cloth may be constructed to pad the eye without
pressure over the eyeball. A simple eye patch with oversize gauze or
cloth may work fine, as the bone of the orbital rim around the eye acts
to protect the eyeball, which is recessed.
Serious injury requires patching both eyes, as movement in the
injured eye will decrease if movement in the unaffected eye is also
controlled. It generally helps to have the victim kept at rest with her
head elevated 30 degrees. A severe blow to one eye may cause tem-
porary blindness in both eyes, which can resolve in hours to days.
Obviously, a person with loss of vision should be treated by a physi-
cian if possible. Eye dressings must be removed, or at least changed,
in 24 hours.
If a foreign object has been removed from the eye or the victim
has suffered a corneal abrasion, the best splint is the tension patch.
Start by placing 2 gauze pads over the shut eye, requesting the patient
keep his eyes closed until the bandaging is completed. The patient
may help hold the gauze in place. Three pieces of 1-inch-wide tape
are ideal, long enough to extend from the center of the forehead to
just below the cheekbone. Fasten the first piece of tape to the center
of the forehead, extending the tape diagonally downward across the
eye patch. The second and third strips are applied parallel to the first
strip, one above and the other below. This dressing will result in firm
splinting of the bandaged eye.
Foreign Body Eye Injury

The most common eye problems outdoors are from a foreign body,
abrasion, snow blindness, and infection (conjunctivitis). Therapy for
these problems is virtually the same, except that it is very important
to remove any foreign body that may be present.
The initial step in examining the painful eye is to remove the
foreign object. One of the lessons drilled into medical students is to
never ever write a prescription for eye anesthesia agents (such as the
tetracaine ophthalmic solution that I recommend for the Rx Oral/

Topical Medication Module). The reason is the patient may use it,
obtain relief, and then not have the eye carefully examined for a for-
eign body. Eventually this foreign body may cause an ulcer to form in
the cornea, doing profound damage.
When using the tetracaine, remember that it is very important to
find and remove any foreign body. Pull down on the lower lid and use
1 drop. If the patient is unable to open her eye due to pain, place 1 or
2 drops in the inner corner of the eye while she is lying face up. Have
her blink once or twice to allow the liquid to cover the eyeball. This
medication burns when initially placed in the eye. This will increase
the level of pain for a brief period until the medication takes effect.
After the patient has calmed down, have her open the eye and look
straight ahead. Very carefully shine a pen light at the cornea from one
side to see if a minute speck becomes visible. By moving the light
back and forth, one might see movement of a shadow on the iris of
the eye and thus confirm the presence of a foreign body. Mucus can
give a gooey appearance to the cornea that may mimic a foreign body.
Have the victim blink to move any mucus around. A point that con-
sistently stays put with blinking is probably a foreign body.
In making the foreign body examination, also be sure to check
under the eyelids. Evert the upper lid over a Q-tip stick, thus exam-
ining not only the eyeball but also the undersurface of the eyelid. This
surface may be gently brushed with the cotton applicator to elimi-
nate any minute particles. Always use a fresh Q-tip when touching
the eye or eyelid each additional time. Some foreign bodies can be
removed easily. Have the patient place his face under water and blink.
Water turbulence from underwater blinking or from directing run-
ning water in a fast-moving stream or poured from a cup may wash
the problem away.
When a foreign body has been found embedded in the cornea,
take a sterile, or at least a clean, Q-tip and approach the foreign body
from the side. Gently prod it with the Q-tip handle until it is loos-
ened. The surface of the eye will indent under the pressure of this
scraping action. Indeed, the surface of the cornea will be scratched
in the maneuver, but it will quickly heal. Once the foreign body has
been dislodged, if it does not stick to the wooden or plastic handle

but slides loose along the corneal surface, use the cotton portion to
touch it for removal.
A stoic individual, particularly one accustomed to contact lenses,
might be able to undergo an uncomplicated foreign body removal
without the use of tetracaine 0.5% ophthalmic drops, but using an
anesthetic makes the patient more comfortable and cuts down on
interference from the blink reflex.
Foreign bodies stuck in the cornea can be very stubborn and resist
removal. At times it is necessary to pick them loose with the sharp
point of a #11 scalpel blade or the tip of a needle (I frequently use
an 18-gauge needle). Anesthesia with tetracaine will be necessary for
this procedure. Scraping with these instruments will cause a more
significant scratch to the corneal surface, but under these circum-
stances it may have to be accepted. I would leave stubborn foreign
bodies for removal by a physician in all but the most desperate cir-
cumstances. If you have a difficult time removing an obvious foreign
body from the surface of the cornea, waiting 2 to 3 days may allow the
cornea to ulcerate slightly so that removal with the Q-tip stick may
be much easier. Deeply lodged foreign bodies will have to be left for
surgical removal.
A painless foreign body may not be a foreign body. It could be a
rust ring left behind after a bit of ferrous, or iron-containing, material
has fallen out of the eye after having been lodged for a short time. If
what you see is painless, ignore it in the off-grid setting.
The history that involves striking an object should alert you to
the fact that the injury may have penetrated much more deeply than
you would expect from blowing debris hitting the eye. While blowing
debris can lodge in the eye surface, a foreign body slamming into the
eye due to someone striking an object (say, a hammer against a rock)
might have penetrated very deeply into the eyeball. Penetrating inju-
ries are a disaster!
A puncture wound of the eyelid mandates careful examination of
the cornea surface for evidence of a penetrating foreign body. These
injuries must be seen by a physician for surgical care. Evacuation is
necessary. If this is impossible, the eye must be patched, examined
for infection twice daily, and treated with antibiotics both orally and
topically.
After removal of a foreign body, or even after scraping the eye
while attempting to remove one, apply some antibiotic. The prescrip-
tion kit should contain Tobradex ophthalmic drops. There are no non-
prescription eye antibiotics. Brand-name Neosporin and Polysporin
ointments in 15-gram tubes are nonprescription antibiotics that can
be used in the eye. However, the manufacturer cannot recommend
the use of these over-the-counter products for this purpose.
While the tetracaine will provide local pain relief, its continued
use may hinder the natural healing process and disguise a significant
injury or the presence of an additional foreign body. Pain relief is best
attempted by protecting the eye from sunlight using sunglasses, pro-
viding a damp cloth for evaporative cooling, and oral pain medication.
There is no evidence that patching an eye with a corneal abrasion is
useful. Percogesic or ibuprofen, 200 mg, from the Non-Rx Oral Med-
ication Module, both given in a dose of 2 tablets every 4 to 6 hours,
may be provided for pain. The prescription analgesic Norco 10/325, 1
tablet every 4 to 6 hours, would provide significant pain relief.
Contact Lenses
The increased popularity of contact lenses means that several prob-
lems associated with their use have also increased. The lenses are of
two basic types: the hard or rigid lens, which generally is smaller and
does not extend beyond the iris, and the soft lens, which does extend
beyond the iris onto the white of the eye. Soft lenses have been
designed for extended wear. Hard lens use requires frequent removal,
as the delicate cornea of the eye obtains oxygen from the environ-
ment and nutrients from eye secretions. These lenses interfere with
this process and therefore are detrimental to the cornea.
Examine the eyes of all unconscious persons for the existence of
hard lenses and remove them if found. It is probably best to remove
soft lenses as well, as some are not designed for extended use and
may also damage the eye. If you expect that you may go off the grid
for an extended time, you may want to rethink using contact lenses
altogether. Also obtain the proper eyeglass prescription and keep a

pair in your bug-out bag!
Leaving most hard contact lenses in the eyes longer than 12 hours
can result in corneal ulceration. While not serious, this can be a very
painful experience. At times, even iritis (see page 47) may result. This
condition almost always resolves on its own within a day. The history
is the major clue that the diagnosis is correct. If the condition fails to
clear within 24 hours, other problems should be looked into, such as
corneal laceration, foreign body, or eye infection.
After removal of the contact lenses, place cool cloths or ice packs
on the eyes. The patient should be evaluated by a physician to con-
firm the diagnosis. Provide protection from sunlight, using sunglasses
during the day. Give aspirin or other pain medication if available. The
patient may have pain from the migration of the lens into one of the
recesses of the under to upper or lower eyelid, or possibly note only
a loss of refractive correction. At times the complaint is a sudden
“I have lost my contact lens!” Never forget to look in the eye as the
possible hiding spot for the lens. Examine the eye as described in the
section on foreign bodies in the eye (see page 38). When dealing with
a hard lens, use topical anesthesia as described, if necessary and avail-
able. If the lens is loose, slide it over the pupil and allow the patient
to remove it as she usually does. If the lens is adherent, rinse with eye
irrigation solution or clean water and try again. If a corneal abrasion
exists, patch as indicated above after the lens is removed.
The soft lens may generally be squeezed between the fingers and
literally “popped” off. A special rubber pincer is sold that can aid in
this maneuver. Hard lenses may also be removed with a special rubber
suction cup device.
If the patient is unconscious, the hard lenses will have to be
removed. Lacking the suction cup device, two different maneuvers
may be employed. One is the vertical technique. In this method,
move the lens to the center of the eye over the pupil. Then press
down on the lower lid, over the lower edge of the contact lens. Next
squeeze the eyelids together, thus popping the lens out between them
as indicated in figure 3-1. In the horizontal technique, slide the lens
to the outside corner of the eye. Tug on the facial skin near the eye
in a downward and outward direction; the lens can pop over the skin
edge and be easily removed. See figure 3-2.
The unconscious patient should have antibiotic salve placed in
her eye and the lids taped or patched shut to prevent drying. These
patches should be removed when needed for neurological checks and
certainly upon regaining consciousness.
If removal of the lenses must be prolonged, safe storage will have
to be provided. Regarding hard lenses, the ideal would be marked
2-1 containers that pad the lenses so that they do not rattle around or
otherwise become scratched. Small vials, labeled R and L, filled with
a fluff of clean material, taped together, and placed in a safe location,
2-1
Figure 3-1.
Contact lens removal—vertical technique
2-2
Figure 3-2.
Contact lens removal—horizontal technique
2-2
would be ideal. Soft contact lenses must be protected from dehydra-

tion. It is always proper to store them in normal saline. This solution
can be prepared by adding 11/2 ounces of table salt to 1 pint of water.
Of course, if the patient has a special solution for her lenses in her
possession, use it.
Eye Abrasion
Abrasions may be caused by a glancing blow from a wood chip, a
swinging branch, or even from blowing dirt, embers, ice, or snow. The
involved eye should be anesthetized with prescription tetracaine and
protected with Tobradex ophthalmic drops. Make sure that a foreign
body has not been overlooked.
In cold wind be sure to protect your eyes from the effects of both
blowing particles of ice and the wind itself. Grey Owl, in his inter-
esting book Tales of an Empty Cabin, tells how he was walking along
a windswept frozen lake on one of his long trips through the back-
woods when suddenly he lost sight of the tree line. He felt that he
must be in a whiteout, so he turned perpendicular to the wind and
hiked toward the shore. Suddenly he bumped into a tree and realized
that he was blind! He saved himself only by digging a snow cave and
staying put for three days. He wondered how many good woodsmen
were lost on their trap lines by a similar incident, apparently, a tem-
porary opacification of the cornea from the cold wind or ice crystal
abrasions.
Snow Blindness or Ultraviolet Eye Injury

Snow blindness is a severely painful condition primarily caused by
ultraviolet B rays of the sun, which are considerably reflected by snow
(85%), water (10–100%), and sand (17%). Thin cloud layers allow the
transmission of these rays, while filtering out infrared (heat) rays of
the sun. Thus, it is possible on a rather cool, overcast day with bright
snow conditions to become sunburned or snow blind.
Properly approved American National Standards Institute
(ANSI) sunglasses will block 99.8% of the ultraviolet B rays. Suitable
glasses should be tagged as meeting these standards. Nonprescrip-
tion glasses must fit properly and ideally provide side protection. A
suitable retention strap must be worn, as I finally learned while raft-

ing on the Green River in Colorado. And for those of us who must
learn these things more than once, a second pair of glasses—particu-
larly if prescription lenses are worn—is essential. Lacking sunglasses,
any field-expedient method of eliminating glare, such as slit glasses
made from wood or any material at hand, including the ubiquitous
bandanna, will help. An important characteristic of snow blindness is
the delayed onset of symptoms. The pain and loss of vision may not
be evident until after damaging exposure has been sustained.
Besides snow blindness, either direct or reflected ultraviolet
exposure can result in headache or sometimes activate herpes simplex
sores on the lips (see page 62). The headache can be treated with pain
medication (see page 31), or look for other underlying causes (see
page 165).
Snow blindness is a self-limiting affliction. However, not only
is the loss of vision a problem, but so is the terrible pain, usually
described as feeling like red hot pokers were massaging the eye sock-
ets. Lacking any first aid supplies, the treatment would be gentle
eye patches, avoiding pressure on the eyes, and the application of
cold packs as needed for pain relief. Generally, both eyes are equally
affected, with a virtual total loss of vision.
The prescription tetracaine ophthalmic drops will help ease the
pain, but long-term use will delay eye surface healing. Oral pain med-
ication will be helpful and should be used. The severe pain can last
from hours to several days. In case a drainage of pus or crusting of the
eyelids occurs, start antibiotic ophthalmic ointment applications as
indicated in the following section on conjunctivitis.
Conjunctivitis
Conjunctivitis, an infection or inflammation of the eye surface, will
be heralded by a scratchy feeling, almost indistinguishable from a for-
eign body in the eye. The sclera (white of the eye) will be reddened.
Usually the eye will be matted shut in the morning with pus or
granular matter.
Infections are generally caused by bacteria, but viral infections
also occur. Viral infections tend to have a blotchy red appearance over
the white of the eye, while bacterial infections have a generalized red
appearance. The drainage in bacterial infections tends to be pus, while
viral infections usually cause a watery discharge.
Allergic conjunctivitis will result in a faint pink coloration and a
clear drainage. There are frequently other symptoms of allergy such
as runny nose, no fever, and no lymph node enlargement. With either
viral or bacterial conjunctivitis, look for fever and possibly lymph
node enlargement in the neck. Runny nose and sinus infection are
frequently present as well. Be sure that a foreign body is not the cause
of the reddish eye and infection. If so, it must be removed (see page
38).
Rinse the eye with clean water frequently during the day. Eye
infections such as common bacterial conjunctivitis, the most com-
mon infection, are self-limiting and will generally clear themselves
within 2 weeks. They can become much worse, however, so medical
attention should be sought. Do not patch the eyes but protect them
from sunlight. When one eye is infected, treat both eyes, as the infec-
tion spreads easily to the uninfected eye.
There is no suitable nonprescription medication, but note the dis-
cussion concerning the use of non-Rx Neosporin or Polysporin in the
section on foreign body eye injury (page 38). From the Rx supplies,
one could use the Tobradex ophthalmic drops 3 times a day for 5 to
7 days. If the infection fails to show improvement within 48 hours,
the antibiotic will probably not be effective. Reasons for antibiotic
failure include a missed foreign body; allergy to the antibiotic or to
something else, such as pollen; or resistance of an infectious germ
to the antibiotic being used. Switch medications in the case of no
improvement after 48 hours. When no other antibiotic ointment is
available, use an oral antibiotic such as doxycycline 100 mg, 1 cap-
sule twice daily, or the alternative antibiotics suggested for the Rx
Oral/Topical Medication Module (page 284). If the eye is improving,
continue use as indicated above, continuing for a full 24 hours after
symptoms have ceased.
Iritis
Iritis is an inflammatory disease of the eye having the general appear-
ance of conjunctivitis, but while in the latter the reddish color fades to
white near the iris of the eye (the colored part), with iritis the rim of
sclera (white of the eye) around the iris is more inflamed or reddened
than the white portion farther out. The pupil will not constrict when
light is shined at it.
Provide sun protection. Give aspirin or other pain medication if
available. This patient requires urgent evacuation to a specialist. The
non-Rx treatment will consist of giving the patient ibuprofen, 800
mg every 6 hours, or meloxicam, 15 mg daily. Instill Tobradex oph-
thalmic drops 4 times a day.
As iritis progresses, the red blush near the iris will become more
pronounced and a spasm of the muscle used in the operation of the
iris will cause the pupil to become irregular. With further progres-
sion, it is possible for the pupil (anterior chamber) to become cloudy,
for cataracts and glaucoma to develop, and for serious scarring of
eye tissues to occur. Sometimes a profound conjunctivitis or corneal
abrasion will cause an iritis that will clear as the problem resolves.
Some cases of mild iritis can be cleared with agents that dilate the
pupil without steroid use. All cases of iritis require treatment by an
ophthalmologist.
Allergic Conjunctivitis
Common causes of allergic conjunctivitis are sensitivity to inhaled
pollens and irritation from wood smoke. This problem is usually asso-
ciated with a runny nose (rhinitis) and at times swelling of the eyelids.
Rarely there will be a generalized skin itching and the appearance of
welts (urticaria). In severe cases there can be considerable swelling
of the conjunctival covering of the white of the eye (sclera), forming
what appears as fluid-filled sacs over the sclera of the eye (but not
covering the cornea). This puffy tissue generally has a light pink tinge
to it. While this can look terrible, it is not serious and will resolve on
its own within 48 hours, after further exposure to the causative agent
ceases.
From the non-Rx supplies give Percogesic, 1 tablet 4 times a day,

and use the Opcon-A eye drops, 1 drop in each eye every 3 or 4 hours
as needed. Percogesic is used for its decongestant actions, and it will
also treat the itchy discomfort of this condition.
Sties and Chalazia

The infections of the eyelid called sties and chalazia can cause scratch-
ing of the cornea surface. Often the victim thinks that something is in
the eye when, in fact, one of these small pimples is forming. The sty is
an infection along a hair follicle on the eyelid margin. The chalazion
is an infection of an oil gland on the inner lid margin. The patient will
have redness, pain, and swelling along the edge of the upper or lower
eyelid. At times the eye will be red with evidence of infection, or
conjunctivitis. An eyelid may be swollen, without the pimple forma-
tion, when this problem first develops. There should not be extensive
swelling around the eye. That could represent a periorbital cellulitis,
which is a serious infection requiring treatment with injectable anti-
biotics and urgent evacuation.
Make sure that a foreign body is not causing the symptoms.
Check the eye and eyelids as indicated (see page 38). While check-
ing, ascertain if a pimple formation confirms the diagnosis. If it is on
the upper lid and it is scratching the eye while blinking, patch the eye
and send the patient to a physician for treatment. If no medical care
is available, have the patient place warm compresses on the eye for
20 minutes every 2 hours to cause the sty to come to a head. When
it does, it may spontaneously break and drain. If it does not drain
within 2 days, open it with a flick of a sharp blade or needle that has
been sterilized. Continue the warm compresses and provide medica-
tion as below.
If Rx supplies are available, instill Tobradex ophthalmic drops 3
times a day. (Also note discussion concerning the use of over-the-
counter antibiotic ointment in the eye on page 41.) If the lid is quite
swollen, give the patient doxycycline, 100 mg twice daily, or Leva-
quin, 500 mg once daily. Once the infection is localized and draining,
the oral antibiotic will not be necessary.
Spontaneous Subconjunctival Hemorrhage

This condition, an amazingly common problem, presents as bright
bleeding over a portion of the white of the eye. (Actually, a hem-
orrhage has occurred between the white of the eye and the mucous
membrane covering it.) It spreads out over a period of 12 to 48 hours,
then reabsorbs slowly over the next 7 to 21 days, next turning the
conjunctiva yellowish as the blood is reabsorbed. There should not
be any pain with this condition, although some people may report a
vague “full” feeling in the eye. It normally occurs without cause, but
can appear after blunt trauma or violent coughing, sneezing, or vom-
iting. No treatment is necessary. Evacuation is not required unless
associated with trauma.
Blunt Trauma to the Eye

The immediate treatment is to immobilize the injured eye as soon
as possible by patching both eyes and moving the patient only by
litter. Double vision could mean that there has been a fracture of the
skull near the eye or that a problem has developed within the central
nervous system. Double vision is sometimes caused by swelling of
tissue behind the eyelid. A hyphema, a collection of blood in the
front or anterior chamber of the eye, may appear. The blood settles
in front of the pupil and behind the cornea, and can develop a dis-
tinct blood fluid level easily noticed simply by looking carefully at
the pupil and iris.
Patch as indicated in the section on eye patch and bandaging
techniques (page 37). Patients with a hyphema and serious blunt
trauma should be evacuated to a physician for care. Have the patient
sit with head up from 45 to 90 degrees, to allow blood to pool at
the lower edge of the anterior chamber. Check the eye twice daily
for drainage, which might indicate infection. If infection develops,
treat with an oral antibiotic such as the doxycycline 100 mg twice
daily. The Tobradex ophthalmic drops may be instilled 3 times daily.
Treat with oral pain medication. Give Atarax, 25 mg, 4 times daily as
needed to potentiate the pain medication and help alleviate nausea,
or 50 mg 4 times daily if required to calm the patient.
Provide the strongest pain medication required to prevent the

injured patient from grimacing and squeezing the injured eye so as
not to compromise the eye contents even more. Small corneal or
scleral lacerations may require no treatment at all, but these should
be seen and evaluated by a physician if at all possible. Note that severe
injury to one eye may even cause blindness to develop in the other
eye due to “sympathetic ophthalmia,” which is probably an allergic
response to eye pigment from the injured eye entering the victim’s
bloodstream.
Glaucoma
Glaucoma is the rise of pressure within the eyeball (intraocular pres-
sure increase). The most common form (open angle glaucoma) gen-
erally is not encountered before the age of 40. The patient notes halos
around lights, mild headaches, loss of vision to the sides (peripheral
field cuts), and loss of ability to see well at night. The external eye
usually appears normal. Glaucoma frequently affects both eyes. This
condition is generally of gradual onset, so the patient can consult a
physician upon returning from the bush.
Initial treatment is with a prescription drug, 1 drop of 0.5% pilo-
carpine. It would not be necessary to carry this medication, except to
treat this condition. This problem should be detected by the pre-trip
physical examination. Everyone over the age of 40 should check their
intraocular pressure periodically as part of their on-the-grid periodic
health assessment.
Acute glaucoma (narrow angle glaucoma) is much less common
than open angle glaucoma but is much more spectacular in onset.
Acute glaucoma is characterized by a rapid rise in pressure of the
fluid within the eyeball, causing blurred vision, severe pain in the eye,
and even abdominal distress from vagal nerve stimulation. An acute
attack can sometimes be broken with pilocarpine, but it often needs
emergency surgery. A thorough eye examination should be done
before the trip to discover those eyes with narrow angles that could
result in acute glaucoma. In eyes likely to develop acute glaucoma,
a laser iridectomy can be done as an outpatient to prevent an acute
narrow angle glaucoma attack.
Events that might precipitate an acute glaucoma attack can

include the use of certain medications, such as decongestants. If any-
one develops severe eye pain while taking a decongestant or other
nonessential medication, have them stop taking it immediately.
Severe eye pain from any cause is a reason for urgent evacuation of
the patient.
NOSE
Nasal Congestion
Nasal congestion is caused by an allergic reaction to pollen, dust, or
other allergens, and viral or bacterial upper respiratory infections.
Bacterial infections can be cured with antibiotics, but otherwise all
are treated similarly for symptomatic relief. Use Percogesic, 1 tablet
every 6 hours as needed, for nasal congestion or discomfort. Drink
lots of liquid to prevent the mucus from becoming too thick. Thick
mucus will not drain well and can pack the sinus cavities with increas-
ingly painful pressure.
If the patient has no fever, do not give an antibiotic. A low-grade
temperature is probably viral and still does not warrant an antibiotic.
If a temperature greater than 101°F (38°C) is present, treat with an
antibiotic such as doxycycline, 100 mg twice daily, or Zithromax, as
indicated on page 285.
Foreign Body Nose Injury

Foul drainage from one nostril may well indicate a foreign body. In
adults, the history of something being placed up the nose would, of
course, help in the diagnosis. In a child, drainage from one nostril
must be considered to be the result of a foreign body until ruled out.
Have the patient try to blow his nose to remove the foreign body.
With an infant it may be possible for a parent to gently puff into the
baby’s mouth to force the object out of the nose.
While having a nasal speculum would be ideal, any instrument
that can be used to spread the nostrils open will work; for example,
the pliers on your Swiss Army knife or Leatherman tool. Spread the
tips apart after placing them just inside the nostril. The nostril can
stretch quite extensively without causing pain. Shine a light into the
nostril passage and attempt to spot the foreign body. Try to grasp
the object with forceps or another instrument. If the foreign material
is loose debris—such as a capsule that broke in the patient’s mouth
and was sneezed into the nostrils—it is best to irrigate this mate-
rial out rather than attempting to cleanse with a Q-tip or other tool.
Place a bulb or irrigation syringe in the clear nostril. With the patient
repeating an “eng” sound, flush water and, hopefully, the debris out
the opposite nostril.
After removing a foreign body, be sure to check the nostril again
for an additional one. Try not to push a foreign body down the back
of the patient’s throat, where he may choke on it. If this is unavoid-
able, have the patient bend over, face down, to decrease the chance of
choking. After pushing the object farther into the nose and the upper
part of the pharynx, hopefully the victim can cough the object out. If
you are using this technique, first read the sections on nosebleed (see
below) and foreign body airway obstruction (page 16).
Nosebleed
If nose bleeding (epistaxis) is caused by a contusion to the nose, the
bleeding can be impressive but is usually self-limited. Bleeding that
starts without trauma is generally more difficult to stop. Most bleed-
ing is from small arteries located near the front of the nose partition,
or nasal septum. The best treatment is direct pressure. Have the victim
squeeze the nose between her fingers for 10 minutes by the clock (a
very long time when there is no clock to watch). If this fails, squeeze
another 10 minutes. Do not blow the nose, for this will dislodge clots
and start the bleeding all over again. If the bleeding is severe, have the
victim sit up to prevent choking on blood and to aid in the reduction
of the blood pressure in the nose. Cold compresses can provide a
slight amount of help.
Continued bleeding can result in shock. This will, in turn, decrease
the bleeding. The sitting position is mandatory to prevent choking on
blood from a severe bleed and, as indicated above, will aid in the
reduction of blood pressure in the nose. Taken to the extreme degree,
this position aids in allowing shock to occur.
Another technique that can be tried is to wet a gauze strip thor-

oughly with the epinephrine from the syringe in the Rx Injectable
Medication Module. The epinephrine can act as a vasoconstrictor to
decrease the blood flow and allow clotting.
Those having only nonprescription medical supplies will have to
use the Opcon-A eye drops, which will not be as powerful in blood-
vessel constriction. First clear the nose of blood clots so the gauze can
be in direct contact with the nasal membranes. Have the victim blow
his nose gently or use the irrigation syringe. Place the epinephrine-
soaked gauze in the nose and apply pinching pressure for 10-min-
ute increments. The gauze may be removed after the bleeding has
stopped.
Nose Fracture
A direct blow causing a nasal fracture (broken nose) is associated
with pain, swelling, and nasal bleeding. The pain is usually point ten-
der, which means a very light touch elicits pain, indicating a fracture
has occurred at that location. While the bleeding from trauma to the
nose can initially be intense, it seldom lasts more than a few minutes.
Apply a cold compress or a damp cloth that can cool by evaporative
cooling. Allow the patient to pinch his nose to help reduce bleeding.
If the nose is laterally displaced (shoved to one side), push it back
into place. More of these fractures have been treated by coaches on
the playing field than by doctors. If it is a depressed fracture, a spe-
cialist will have to properly elevate the fragments. As soon as the
person returns from the bush, have him seen by a physician, but this
is not a reason for expensive urgent evacuation. Provide pain medica-
tion, which should be necessary for only a few doses. It is rare to need
to pack a bleeding nose due to trauma, and this should be avoided, if
possible, due to the increased pain it would cause.
EAR
Problems with the ear involve pain, loss of hearing, or drainage.
Traumas involving the ear could include lacerations, blunt trauma
and hemorrhage (bleeding) in the outer ear tissue, and damage from
pressure changes to the eardrum (barotrauma) from diving or high
altitude, explosions, or direct blows to the ear. See table 3-5 for signs
and symptoms.
Table 3-5. Symptoms and Signs of Ear Pathology

HEARING PAIN HEAD FEVER
LOSS CONGESTION
Drainage Trauma n n
Foreign Body l
Infection
Inner Ear n n n n
Outer Ear l l n l
Allergy l l n
Dental Source n
TMJ Source l l
Lymph Node Source l
Legend n A frequent or intense symptom

l Common, less intense symptom
Blank Less likely to produce this symptom
Only if the eardrum ruptures will drainage occur in an inner ear infection.
After the rupture the pain decreases remarkably.
Earache
Pain in the ear can be associated with a number of sources, as indi-
cated in table 3-5. The history of trauma will be an obvious source of
pain, as mentioned. Most ear pain is due to an otitis media infection
behind the eardrum (tympanic membrane), or to otitis externa infec-
tion in the outer ear canal (auditory canal). It can also be caused by
infection elsewhere (generally a dental infection, infected tonsil, or
lymph node in the neck near the ear). Allergy can result in pressure
behind the eardrum and is also a common source of ear pain.
A simple physical examination and additional medical history will

readily (and generally accurately) distinguish the difference between
an otitis media or otitis externa infection, as well as sources of pain
beyond the ear. Pushing on the knob at the front of the ear (the tra-
gus) or pulling on the earlobe will elicit pain with otitis externa. This
will not hurt if the patient has otitis media. The history of head con-
gestion favors otitis media.
A swollen, tender nodule in the neck near the ear would be an
infected lymph node. If the skin above the swelling is red, the patient
probably has an infected skin abscess. The pain from an abscess is so
localized that confusion with an ear infection is seldom a problem.
One or more tender lymph nodes can hurt to the extent that the exact
source of the pain may be in doubt. Swollen, tender lymph nodes in
the neck are usually associated with pharyngitis (sore throat), severe
otitis externa, or infections of the skin in the scalp. The latter should
be readily noted by examination—palpate the scalp for infected cysts
or abscesses.
Dental caries, or cavities, can hurt to the extent that the pain
seems to come from the ear. They can ordinarily be identified during
a careful examination of the mouth. If an obvious cavity is not visual-
ized with a light, try tapping on each tooth to see if pain is suddenly
elicited (see Dental Pain, page 109.)
Outer Ear Infection

Outer ear infection of the auditory canal (otitis externa), the part of
the ear that opens to the outside, is commonly called swimmer’s ear.
The external auditory canal generally becomes inflamed from con-
ditions of high humidity, accumulation of ear wax, or contact with
contaminated water. Scratching the ear after picking the nose or
scratching elsewhere may also be a source of this common infection.
Prevent cold air from blowing against the ear. Warm packs against
the ear or instilling comfortably warm sweet oil or even cooking oil
can help. Provide pain medication. Obtain professional help if the
patient develops a fever, the pain becomes severe, or lymph nodes or
adjacent neck tissues start swelling. Significant tissue swelling will
require antibiotic treatment. At times a topical ointment will suffice,
but with fever or swollen lymph or skin structures, an oral antibiotic

will be required.
Triple antibiotic ointment with pramoxine from the Topical Ban-
daging Module will work fine for outer ear infections. This is not
approved by the FDA for this use, as ear infections are serious, and it
is not intended that nonphysicians treat this condition without med-
ical help. From the Rx kit, one could use the Tobradex ophthalmic
drops. These medications should be applied with the ear facing up
and, in the case of the ointment, allowed to melt by body temperature.
This may take 5 minutes per ear. Place cotton in the ear to hold the
medication in place. Instill medication 4 times daily and treat for 14
days. If the canal is swollen shut, a steroid ointment may also be used
in between applications of the other ointments. From the Topical
Bandaging Module, use the hydrocortisone 1% cream in addition to
the triple antibiotic ointment. Tobradex contains enough steroid to
be adequate for these purposes.
Swollen tissue and/or fever also require an oral antibiotic. From
the Rx Oral/Topical Medication Module, use doxycycline, 100 mg
twice daily, or Levaquin, 500 mg daily. Provide the best pain medica-
tion that you can. From your Non-Rx Oral Medication Module, use
1 or 2 Percogesic tablets every 4 hours.
Middle Ear Infection

Middle ear infection (otitis media) presents in a person who has sinus
congestion and possibly drainage from allergy or infection. The ear
pain can be excruciating. Fever will frequently be intermittent, nor-
mal at one moment and over 103°F (39°C) at other times. Fever indi-
cates bacterial infection of the fluid trapped behind the eardrum. If
the eardrum ruptures, the pain will cease immediately and the fever
will drop. This drainage allows the body to cure the infection, but will
result in at least temporary damage to the eardrum and decreased
hearing until it heals.
There is no increased pain when pulling on the earlobe or pushing
on the tragus (the knob in front of the ear) in this condition, unless an
outer ear infection is also present. If you were to look at the eardrum
with an otoscope, it would be red and bulging out from pressure or

sucked back by a vacuum in the middle ear.
You do not need an otoscope to diagnose this condition. Many
people will complain of hearing loss and think they have wax or a
foreign body in the ear canal, when they actually have fluid accumu-
lation behind the eardrum. Consequently, ear drops and washing the
ear will not help improve this condition. Beside pain, the key to the
diagnosis is head congestion and fever.
There is little that can be accomplished without medication. Pro-
tect the ear from cold, position the head so that the ear is directed
upward, and provide warm packs to the ear. While drops do not help
cure this problem, some pain relief may be obtained with drops of
warmed sweet oil (or even cooking oil) in the ear.
Treatment will consist of providing decongestant, pain medica-
tion, and oral antibiotic. A good decongestant and pain reliever from
the Non-Rx Oral Medication Module is Percogesic, 2 tablets 4 times
daily. Rx pain medication is given as needed, as indicated in the pre-
vious section. Only the Rx Oral/Topical Module has the proper anti-
biotics to treat this condition. Use doxycycline, 1 tablet twice daily, or
Levaquin, 500 mg daily, generally for 5 to 7 days.
If the pressure causes the eardrum to rupture, the pain and fever
will cease, but there will be a bloody drainage from the ear. Hearing
is always decreased with the infection and will remain decreased for
some time due to the ruptured eardrum. This generally heals itself
quite well, but treat with decongestant to decrease the drainage and
allow the eardrum to heal. Avoid placing drops or ointments in the
ear canal if there is a chance that the eardrum has ruptured, as many
medications are damaging to the inner ear mechanisms.
Foreign Body Ear Injury

These are generally of three types: accumulation of wax plugs (ceru-
men), foreign objects, and living insects. Wax plugs can usually be
softened with gently warmed oil. This may have to be placed in the
ear canal repeatedly over many days. Irrigating with room tempera-
ture water may be attempted with a bulb syringe, such as the one rec-
ommended for wound irrigation in the Topical Bandaging Module.
If a wax-plugged ear becomes painful, treat as indicated in the section

on otitis externa (Outer Ear Infection, page 55).
The danger in trying to remove inanimate objects is the tendency
to shove them farther into the ear canal or to damage the delicate
ear canal lining, thus adding bleeding to your troubles. Of course,
rupturing the eardrum by shoving against it would be an unnecessary
disaster. Attempt to grasp a foreign body with a pair of tweezers if
you can see it. Do not poke blindly with anything. Irrigation may be
attempted as indicated above.
A popular method of aiding in the management of insects in the
ear canal is the instillation of lidocaine to kill the bug instantly, prior
to attempting removal. There are reports of lidocaine making a person
very dizzy, especially if it leaks through a hole in the eardrum into the
inner ear. This dizziness is very distressing and may result in profound
vomiting and discomfort. It is self-limiting, however, and should not
last more than a day if it does transpire. An alternative method is to
drown the bug with cooking or other oil, then attempt removal. Oil
seems to kill bugs quicker than water. The fewer struggles, the less
chance for stinging, biting, or other trauma to the delicate ear canal
and eardrum. Tilt the ear downward, thus hoping to slide the dead
bug toward the entrance, where it can be grasped. Shining a light at
the ear to coax a bug out is probably futile.
Ruptured Eardrum
Rupture of the eardrum (tympanic membrane perforation) can result
from direct puncture, from explosions, and from the barotrauma of
diving deep or rapid ascent to high altitude. Being smacked on the
ear can also rupture the eardrum, an event that can easily happen
during horseplay.
If suffering from sinus congestion, avoid diving or rapid ascents
of altitude in vehicles or airplanes. Congestion can lead to blockage of
the eustachian tube. Failure to equilibrate pressure through this tube
between the middle ear and the throat, and thus the outside world,
can result in damage to the eardrum. In case of congestion, take a
decongestant and pain medication combination such as Percogesic, 2
tablets every 4 hours, until clear. Cancel any diving plans if congested.
Also, if a gradual pressure squeeze is causing pain while diving, the

dive should be terminated.
When flying, blocked eustachian tubes will cause more pain
upon descent than ascent. When going up, the pressure in the inner
ear will increase and blow out through the eustachian tube. When
coming down, increased outer atmospheric pressure is much less apt
to clear the plugged tube, and a squeeze of air against the eardrum
will result. Try to equalize this pressure by pinching the nose shut
and gently increasing the pressure in your mouth and throat against
closed lips. This will generally clear the eustachian tube and relieve
the air squeeze on the eardrum. Do not overdo this; that can also be
painful. If barotrauma results in eardrum rupture, the pain should
instantly cease. There may be bloody drainage from the ear canal. Do
not place drops in the ear canal, but gently wipe away any drainage or
frequently change cotton plugs used to catch the bloody fluid.
Temporomandibular Joint (TMJ) Syndrome

TMJ syndrome is actually a problem of the jaw, but the pain radiates
into the ear so often that we will consider it primarily as a source of
ear pain. The temporomandibular joint is the hinge joint of the jaw,
located just in front of the ear. You can easily feel it move if you place
a fingertip into your ear canal. When this joint becomes inflamed, it
will frequently cause ear pain. It will then be painful to apply fingertip
pressure directly on the joint. No swelling should be noted. Tender-
ness is increased with chewing, and pain and popping or locking may
be noted when opening the jaw widely. The pain radiates into the
temple area, and when severe, the entire head hurts.
Treatment is with local heat. The use of ibuprofen or Percogesic
can be very helpful. Do not eat foods that are hard to chew or that
require opening the mouth widely.
MOUTH AND THROAT
Sore Throat
The most common cause of a sore throat, or pharyngitis, is a viral
infection. While uncomfortable, this malady requires no antibiotic
treatment—in fact, antibiotics will do no good whatsoever. Strictly

speaking, the only sore throat that needs to be treated is the one
caused by a specific bacteria (beta hemolytic streptococcus, Lance-
field group A), as it has been found that antibiotic treatment for 10
days will avoid the dreaded complication of rheumatic fever, which
may occur in 1 to 3% of people who contract this particular infec-
tion. Many purists in the medical profession feel that no antibiotics
should be used until the results of a throat culture or antibody screen
that prove this particular infection have been returned from the lab.
On a short trip the victim can be taken to a doctor for a strep culture
to determine if the sore throat was indeed strep. When off the grid
longer than 2 weeks, it would be best to commit the patient to a full
course of antibiotic therapy, realizing that the symptoms will soon
pass and the patient seem well, but that it is essential to continue
the medication for the full treatment regimen. The number of days
of treatment differs depending upon which antibiotic is being used.
There are textbook differences in the general appearance of a viral
and strep sore throat. The lymph nodes in the neck are swollen in
both cases; they are more tender with bacterial infections, but peo-
ple with a low pain threshold will complain bitterly about soreness
regardless of the source of infection. The throat will be quite red in
bacterial infections, and a white splotchy coating over the red tonsils
or the back portion of the throat generally means a strep infection—
at least these classic indications are present 20% of the time. Sore
throats caused by some viral infections (namely infectious mononu-
cleosis and adenovirus) may mimic all the above. From the Rx Oral/
Topical Medication Module, use Zithromax 500 mg as described.
The 3-tablet dose provides a therapeutic blood level for 10 days.
Infectious Mononucleosis
Infectious mononucleosis, a disease of young adults (teens through
30 years of age), generally presents as a terrible sore throat, swollen
lymph nodes (normally at the back of the neck and not as tender
as with strep infection), and a profound feeling of fatigue. It is self-
limited, with total recovery to be expected after 2 weeks for most
victims—some, unfortunately are bedridden for weeks and lethargic
for up to 6 months. Spleen enlargement is common. The most serious

aspect of this disease is the possibility of splenic rupture, but this is
rare. Avoid palpating the spleen (shoving on the left upper quadrant
of the abdomen) and let the victim rest (no hiking, etc.) until the ill-
ness and feeling of lethargy has passed. The first 5 days are the worst,
with fever and excruciating sore throat being the major complaints.
Continued physical activity in persons with this disease can contrib-
ute to a prolonged convalescent period.
Treatment is symptomatic, with medication for fever and pain
such as the non-Rx Percogesic or ibuprofen, each given 1 or 2 tablets
every 4 to 6 hours. A mild form of hepatitis frequently occurs with
mononucleosis that causes nausea and loss of appetite. This requires
no specific treatment other than rest. If severe ear pain begins, add a
decongestant (or just use the Percogesic), 2 tablets every 6 hours, to
promote relief of eustachian tube pressure. Due to the uncertainty of
diagnosis, treat the severe sore throat as if it were a strep infection,
with an antibiotic for 10 days or with Zithromax as indicated above
(see Sore Throat on page 59).
Mouth Sores
When mouth sores develop, patients frequently believe they either
have cancer or infection, especially herpes. A common reason for a
lesion is the sore called a papilloma, caused from rubbing against a
sharp tooth or dental work. They may look serious but are not. They
are raised and normally orange in color. One can usually find an obvi-
ous rough area causing the irritation. Treatment is to avoid chewing
at the lesion and to apply 1% hydrocortisone cream from the Topical
Bandaging Module every 3 hours. If the Rx Oral/Topical Medication
Module is available, use the Topicort 0.25% ointment every 4 hours.
An alternative therapy, which can be used simultaneously, is to apply
oil of cloves (eugenol).
A canker sore, also called an aphthous ulcer, can appear anywhere
in the mouth and be any size. It has the distinctive appearance of a
white crater with a red, swollen border. Treatment is as above.
If there is generalized tissue swelling, possibly with drainage
or whitish cover on the gums, foul-smelling breath, and gums and
mouth tissue that bleed easily when scraped, it is possible that the vic-
tim has trench mouth, or Vincent’s infection. This is caused by poor
hygiene, which is unfortunately common on long expeditions under
adverse circumstances. If the white exudate is located over the tonsils,
one has to be concerned about strep throat (see page 30), infectious
mononucleosis (page 60), and diphtheria. Treat trench mouth with
warm water rinses, swishing the crud off as much as possible. If the
Rx Oral/Topical Module is available, give the full dose regimen of
Zithromax 500 mg tablets for 3 days, or treat with Levaquin, 500 mg,
once daily for 5 days.
The mouth lesions of herpes simplex begin as small blisters and
leave a raw area once they have broken open. The ulceration from
herpes is red rather than the white of the canker sore. They are very
painful. From the Rx Oral/Topical Module, apply the Denavir cream
every 2 hours. This is not approved for use inside of the mouth, but it
is perfectly safe and it works.
Fever blisters are sores that break out on the vermilion border of
the lips, generally as a result of herpes simplex virus eruptions. These
lesions can be activated by fevers (hence the name “fever blister”)
or other trauma, even mental stress. Ultraviolet (UV) light will fre-
quently cause flares of fever blisters. This can be a common problem
of mountain travel due to the more intense UV radiation encountered
at higher altitudes. Treat as above for the herpes simplex inner mouth
lesions. These lesions can be prevented with adequate sunscreen and/
or by taking an antiviral prescription medication.
Gum Pain or Swelling, Tooth Issues, see chapter 5, Dental Care
(page 109).
CHEST
One of the most common reasons for a visit to a physician’s office or
emergency department is a problem with the chest. Chest pain and
shortness of breath can be symptoms of serious disorders and can-
not be taken lightly. Fortunately, most times the chest pain is benign,
generally due to muscle spasm or chest wall inflammation. It can be
very difficult to evaluate, even at the emergency department. Chest
problems are best evaluated by a physician, but in a remote area, try to
sort out your options with the table on page 5. In case of trauma, the
patient may have suffered torn muscles between the ribs or broken
ribs (see page 191).
Bronchitis/Pneumonia
Infection of the airways in the lung (bronchitis) or infection in the air
sacks of the lung (pneumonia) will cause very high fever, persistent
cough that frequently produces phlegm stained with blood, and pros-
tration of the victim. From the Non-Rx Oral Medication Module
treat the fever with Percogesic, 2 tablets every 4 hours, or ibuprofen
200 mg, 2 tablets every 4 hours, and the cough with diphenhydr-
amine 25 mg every 4 hours.
Cool the fever with a wet cloth over the forehead as needed. Do
not bundle the patient with a very high fever, as this will only drive
the temperature higher. The shivering cold feeling that the patient
has is only proof that his thermal control mechanism is out of adjust-
ment; trust the thermometer or the back of your hand to follow the
patient’s temperature. Encourage the patient to drink fluids, as fever
and coughing lead to dehydration. This causes the mucus in the bron-
chioles to become thick and tenacious. Force fluid to prevent this
sputum from plugging up sections of the lung.
Provide antibiotic: From the Rx Oral/Topical Medication Mod-
ule, give the Levaquin 500 mg daily until the fever is broken and then
for an additional 4 days. Alternately give the Zithromax as directed
on page 285. Or from the Rx Injectable Medication Module, you may
give Rocephin, 500 mg twice daily.
Prepare a sheltered camp for the victim as best as circumstances
permit. Until the fever is broken, rest is essential with or without the
availability of antibiotic. Encourage the patient to eat. Even though
they are very ill, people lose their appetites.
Pneumothorax
Even in very healthy young adults and teenagers, it is possible for
an air cell in the lung to break for no apparent reason and fill a por-
tion of the chest cavity with air, thus collapsing part of one lung. A
minor pneumothorax will spontaneously take care of itself, with the
air being reabsorbed and the lung re-expanding over 3 to 5 days. The
classic sign of decreased breath sounds over the area of the collapse
will be very difficult for an examiner to detect, even with a stetho-
scope. But listen first to one side of the chest and then the other to
see if there is a difference. Part of the difficulty lies in the fact that
patients with chest pain do not breathe deeply, and thus all breath
sounds are decreased. Other parts of the physical exam are even more
subtle. In unexplained severe chest pain in an otherwise healthy indi-
vidual, pneumothorax might be the cause.
Severe pneumothorax will have to be treated by a physician or
trained medic with removal of the trapped air with a large syringe
or flutter valve, or by other methods currently employed in a hospital
setting. If pain is severe and breathing difficult, the only choice is
evacuation of the victim.
From the Non-Rx Oral Medication Module, you may give 2 Per-
cogesic for pain every 4 hours, or 2 to 4 ibuprofen 200 mg tablets
every 6 hours. This can be augmented with Atarax, 25 mg every 6
hours. It is possible for the pain to be so severe that the use of inject-
able Nubain or inhaled Stadol will be necessary (see page 289).
Pulmonary Embolus
A pulmonary embolus is a blood clot breaking loose from its point
of origin, normally from a leg or pelvic vein, and then lodging in the
lung after passing through the heart. When serious, this condition
appears as shortness of breath and rapid breathing, with a dull sub-
sternal chest pain. There may be cough, bloody sputum, fever, and
sharp chest pain. A pulmonary embolus can mimic pneumonia (page
63) and high-altitude pulmonary edema (page 266). It can be fatal
if an embolus large enough to block off more than 50% of the lung
circulation occurs at once. This condition generally resolves within a
matter of days. Increased risk is found in older people who have been
sitting a long time (such as on plane flights) or anyone immobilized
after injury.
The only medication in the suggested Off-Grid Medical Kit
that would be of any help is ibuprofen, 200 mg given 4 times daily.
Stronger doses of this product (up to 800 mg given 4 times daily) or
additional pain medication can be given to help with the discomfort.

The use of Plavix from the Rx Cardiac Medication Module is not
supported by the literature, but giving a loading dose of 300 mg, and
then 75 mg daily, is a possible field technique. Due to the uncer-
tainty of the diagnosis, treat with an antibiotic such as Zithromax, as
described on page 285, or Levaquin, 500 mg once daily, until the pain
and/or fever resolves, and then continue for an additional 4 days. This
would not help a pulmonary embolus, but it would properly treat
pneumonia.
ABDOMEN
Even for professionals with years of clinical experience and unlim-
ited laboratory and X-ray facilities, abdominal pain can be a diagnos-
tic dilemma. How serious is it? Should evacuation start, or can it be
waited out or safely treated off the grid? Or what treatment protocol
can be followed when there is no grid?
Abdominal Pain
Any abdominal pain that lasts longer than 24 hours is a cause for
concern, and professional help should be sought if possible. Diag-
nosis will be determined from the history (type and severity of pain,
location, radiation, when it started), as well as certain aspects of the
physical examination and the clinical course that develops. Some of
these aspects are summarized in Table 3-6 and in the discussion that
follows.
A burning sensation in the middle of the upper part of the abdo-
men (mid-epigastrium) is probably gastritis, or stomach irritation.
If allowed to persist, this can develop into an ulcer, a crater eaten
into the stomach or duodenal wall. In the latter case the pain may be
most notable in the right upper quadrant. For some reason, ulcers will
occasionally feel better if you press against them with your hand. This
supposedly was why Napoleon is seen with his hand inside his jacket
in his favorite pose—he was pressing against his abdomen to relieve
the pain of an ulcer.
Severe, persistent mid-epigastric pain that is also frequently burn-
ing in nature can be pancreatitis, an inflammation of the pancreas.
This is a serious problem but rare. Alcohol consumption can cause

pancreatitis, as well as gastritis and ulcer formation. Avoid alcohol if
pain in this area develops. In fact, any food that seems to increase the
symptoms should be avoided. Reflux of stomach acid up the esoph-
agus, caused by a hiatal hernia—protrusion of a part of the stom-
ach through a hole in the diaphragm through which the esophagus
passes—will cause the same symptoms. The reflux also causes the
burning pain to radiate up the center of the chest.
Treatment for all of the above is aggressive antacid therapy. These
conditions can be made worse by eating spicy food, tomato products,
and other foods high in acid content. Milk may temporarily help the
burning of an ulcer or gastritis but may increase the burning sensa-
tion later. Avoid any medications containing aspirin and ibuprofen.
Acid suppression medication such as Tagamet, Zantac, Pepcid, Axid,
Prevacid, Nexium, AcipHex, Dexilant, and Prilosec help greatly, and
anyone with a history of these disorders should consider adding such
items to the medical kit. There is a concern that these medications
can make the user more vulnerable to traveler’s diarrhea, cholera, and
other infectious disease from which a normal or high stomach acid
level might otherwise provide some protection. A safer medication
for persons afflicted with heartburn not responsive to antacids, who
must travel in a third-world situation, would be Carafate taken 1
gram 4 times daily. This is a prescription medication.
Mild nausea may be associated with the above problems, but
intense nausea could indicate gastroenteritis, food poisoning (gen-
erally these also cause significant diarrhea), hepatitis, or gall bladder
disorder.
Table 3-6. Symptoms and Signs of Abdominal Pathology

FOOD
BURNING NAUSEA* RELATED DIARRHEA FEVER
Gastritis/Ulcer (page 65) n l n

Pancreatitis (page 65) n l l l
Hiatal Hernia (page 66) n l
Gall Bladder (page 67) n n l
Appendicitis (page 67) l l
Gastroenteritis (page 70) n l n l
Diverticulitis (page 72) l l l
Colitis (page 72) n
Hepatitis (page 225) n l l
Food Poisoning (page 84) n n l
Legend n Frequent or intense

l Usual or less intense
Blank Less likely to be associated
*See also Vomiting, page 70.
Gall Bladder Problems and Appendicitis

Nausea associated with pain in the right upper quadrant of the abdo-
men may be from a gall bladder problem. No burning is associated
with gall bladder pain, and this discomfort is typically made worse by
eating and sometimes even by smelling greasy foods. While drinking
cream or milk would initially help the pain of gastritis or an ulcer,
it causes an immediate increase in symptoms if the gall bladder is
involved. Treatment is avoidance of fatty foods. Nausea and vomiting
can be treated as indicated on page 70. Treat for pain as described on
page 31.
The onset of fever is an important indication of infection of the

blocked gall bladder. This is a surgical emergency. Treat with the
strongest antibiotic available. If the Rx Injectable Medication Mod-
ule is available, give Rocephin, 500 mg, 2 doses, IM immediately;
repeat with 2 doses every 12 hours. Lacking that medication, give
Levaquin, 500 mg, daily. Continue to treat the pain and nausea as
required for relief. Offer as much fluid as the patient can tolerate.
Gall bladder disease is more common in overweight people over
the age of 30. It is also more common in women.
The possibility of appendicitis is a major concern, as it can occur
in any age group, and that includes healthy individuals. It is fortu-
nately rare. While surgery is the treatment of choice, probably as
many as 70% of people not treated with surgery or antibiotics can
survive this problem. The survival rate is over 80% with appropriate
IV therapy. Of course, timely surgery provides 100% survival. A 2018
Finnish study confirmed the above statement; unfortunately, it also
showed that within 5 years 40% of those not having surgery will have
a recurrence.
The classic presentation of this illness is a vague feeling of dis-
comfort around the umbilicus (navel). Temperature may be low grade,
99.6 to 100°F (or 37°C) at first. Within 12 hours the discomfort turns
to pain and localizes in the right lower quadrant, most frequently at
a point two-thirds of the way between the navel and the very top of
the right pelvic bone (anterior-superior iliac crest). Ask the patient
two questions: Where did you first start hurting? (Belly button.)
Now where do you hurt? (Right lower quadrant as described.) Those
answers mean appendicitis until it is ruled out.
It is possible but unusual to have diarrhea with appendicitis.
Diarrhea usually means that the patient does not have appendicitis.
I find it helpful to ask the patient to walk and watch how he does it.
A person with appendicitis will walk with rather careful, short steps,
bent slightly forward in pain. They certainly do not bounce off the
examining table and walk down the hall to the bathroom. Anyone
with springy steps most likely does not have appendicitis.
Sometimes full laboratory and X-ray facilities can do no better in
making this diagnosis. The ultimate answer will come from surgical
exploration. If a surgeon has doubts, he might wait, with the patient

safely in a hospital or at home under close supervision. But the patient
with those symptoms should certainly be taken to a surgeon as soon
as possible.
In the examination of the painful abdomen, several maneuvers
can indicate the seriousness of the situation. The first is to determine
how guarded the area is to palpation. If the patient’s stomach is rigid
to gentle pushing, this can mean that extreme tenderness and irri-
tation of the peritoneum, or abdominal wall lining, exists. Use only
gentle pushing. If there is an area of the abdomen where it does not
hurt to push, apply pressure rather deeply. Now, suddenly take your
hand away! If pain flares over the area of suspect tenderness, this is
called referred rebound tenderness and means that the irritation has
reached an advanced stage. This person should be evacuated to surgi-
cal help at once.
What can you do if you are in the deep bush, say the Back River
of Canada, without the faintest hope of evacuating the patient? Move
the patient as little as possible. No further prodding of the abdo-
men should be done, as her only hope is that the appendix will form
an abscess that will be walled-off by the bodily defense mechanisms.
Give no food. Provide small amounts of water, Gatorade, or fruit
drinks as tolerated. With advanced disease the intestines will stop
working and the patient will vomit any excess. This will obviously
cause a disturbance to the gut and possibly rupture the appendix or
the abscess.
Treat for pain, nausea, and with antibiotics as indicated in the
section on gall bladder infection.
The abscess should form 24 to 72 hours following onset of the
illness. Many surgeons would elect to open and drain this abscess as
soon as the patient is brought to them. Other surgeons feel it is best
to leave the patient alone at this time and allow the abscess to con-
tinue the walling-off process. They feel there is so much inflamma-
tion present that surgery only complicates the situation further. Even
without surgery, within 2 to 3 weeks the patient may be able to move
with minimal discomfort.
One form of therapy never to be employed when there is a suspi-

cion of appendicitis is a laxative. The action of the laxative may cause
disruption of the appendix abscess with resultant generalized perito-
nitis (massive abdominal infection).
It is currently thought that there is no justification for the prophy-
lactic removal of an appendix in an individual, unless he is planning
to move to a very remote area without medical help for an extended
period of time and it is known from X-ray that he has a fecalith (or
stone) in the colon at the mouth of the appendix. Otherwise, the
possible later complications of surgical adhesions may well outweigh
the “benefit” of such a procedure.
Vomiting
Nausea and vomiting are frequently caused by infections known as
gastroenteritis. Many times these are viral, so antibiotics are of no
value. These infections will usually resolve without treatment in 24
to 48 hours. Fever is seldom high but may briefly increase in some
cases. Fever should not persist above 100°F (38°C) longer than 12
hours. Nausea may be treated with diphenhydramine, 25 mg every 8
hours, from the Non-Rx Oral Medication Module, or with Atarax,
25 mg every 6 hours, from the Rx Oral/Topical Medication Module.
If the Rx Injectable Medication Module is available, severe nausea
and vomiting may be treated with Vistaril, 25 to 50 mg every 6 hours
given intramuscularly. Vomiting without diarrhea will not require the
use of an antibiotic. If the vomiting is caused by severe illness, such
as an ear infection, then use of an antibiotic to treat the underlying
cause is justified.
Nausea induced by high altitude, see page 265.
Nausea associated with jaundice, see hepatitis, pages 225–227.
Nausea from ingestion of seafood, see paralytic shellfish poison-
ing, page 86; scombroid poisoning, page 85; and ciguatera poisoning,
page 85.
See also plant or food poisoning, page 84, and petroleum prod-
ucts poisoning, page 84.
Motion Sickness
Motion in any vehicle can induce nausea, hence the many etiologies
of this disorder, such as sea sickness, air sickness, and the dreaded
“tilt-a-whirl”-induced vomiting at the amusement park. After being
exposed to motion for many days—for example, a long nautical trip
or train ride—some people become nauseated when the motion sud-
denly stops and they are on terra firma. The natural method for pre-
venting motion sickness is to look at a point on the horizon, thus
minimizing the motion exaggeration. On a large plane, stare at a dis-
tant cloud, or if you’re stuck in a center seat, look as far forward in
the plane as possible. Reading tends to increase the symptoms. Avoid
alcohol and greasy foods on bouncy trips. With repeated exposure to
the same sort of motion over many days, you may become adapted
and experience less discomfort.
To medically prevent and treat motion sickness, a very useful
medication in the Non-Rx Oral Medication Module is diphenhydr-
amine, 25 mg taken 1 hour prior to departure and repeated every 6
hours as needed. This is not an indicated use for this medication, and
treatment or prevention of nausea will not be noted on the package.
But it works, although drowsiness may be a problem for some (see
page 282).
Transderm Scop, a patch containing scopolamine, has been devel-
oped for prevention of motion sickness and post-operative nausea
and vomiting, but it requires a prescription. Each patch may be worn
behind the ear for 3 days. It is fairly expensive but very worthwhile if
you are prone to this malady. There tends to be a higher frequency of
side effects in elderly people with this medication, consisting of visual
problems, confusion, and loss of temperature regulation. It is unlikely
that this medicated patch would tolerate long periods of storage.
A valuable drug to prevent and treat motion sickness is Atarax, 25
mg every 4 hours as needed, from the Rx Oral/Topical Medication
Module, or Vistaril, 25 mg IM every 4 hours as needed, from the Rx
Injectable Medication Module.
Diarrhea
Diarrhea is the expulsion of watery stool. This malady is usually
self-limited but can be a threat to life, depending upon its cause and
extent. Diarrhea can be the result of bowel disorders such as diver-
ticulitis or colitis; infectious diseases such as cholera, campylobacter,
shigella, or salmonella; and the presence of many other creatures hid-
ing in contaminated food or water; it is seen rarely with appendicitis
and gall bladder disease. The serious infectious disease malaria can
have diarrhea as a presenting complaint. Obviously, diagnosing the
cause of diarrhea can be of importance both in regard to treating and
in estimating the danger to the patient.
Diverticulitis is usually found in people over the age of 40 and is
generally a condition only of the elderly. Diverticula are little pouches
that form on the large intestine, or colon, from a weakness that devel-
ops over time in the muscles of its wall. These are of no trouble unless
they become infected. Infection causes diarrhea, fever, and painful
cramping. Pain is usually located along the left side of the abdomen.
It tends to be at a constant location, unlike many conditions with
diarrhea where the pain migrates. Appendicitis pain is in the right
lower quadrant of the abdomen (see page 67). Treatment for divertic-
ulitis is with antibiotics such as Levaquin, 500 mg daily, or Rocephin,
500 mg given by injection twice daily.
Colitis and other inflammations of the bowel cause repeated
bouts of diarrhea. At times a fever may be present. These cases are
chronic, and like diverticulitis, the diagnosis must be made with CT
scan using contrast or colonoscopy. If in doubt, treat with antibiot-
ics as indicated under diverticulitis. Both conditions require specific
drugs for treatment, such as the steroids included with the Rx Oral/
Topical and Injectable Medication Modules, but unless the person
has a prior history of these diseases, the use of such drugs off the grid
is inappropriate.
Traveler’s diarrhea is caused by infections, so prevention seems an
appropriate priority. Prevention equates to staying alert. Water sources
must be known to be pure or should be treated, as indicated on pages
89–94. Once dehydrated or freeze-dried food has been reconstituted,
it should be stored as carefully as any fresh, unprocessed food. Certain
animal products are tainted in various parts of the world, particularly

at specific times of the year. Know the flora and fauna from local
sources that you can utilize for survival! The primary prevention that
has been classically stressed concerning food safety is “Peel it, boil
it, or forget it,” but this has not been proven to be practical or even
accurate. The recognized method of reducing diarrhea in travelers has
been to improve the hygiene of food handlers preparing the food.
Simple measures such as washing hands appropriately, using clean
utensils, and reasonable food-preparation techniques apply critically
when off the grid as well.
Diarrhea is diagnosed when an individual has 2 or 3 times the
number of customary bowel movements for that individual. These
stools can be either soft, meaning that they will take the shape of a
container, or watery, meaning that they can be poured. By definition
at least one associated symptom of fever, chills, abdominal cramps,
nausea, or vomiting must be present. This will generally mean 4
unformed stools in a day or 3 unformed stools in an 8-hour period
accompanied by at least one other symptom listed above.
While the disease is generally self-limiting, lasting 2 to 3 days,
this illness can result in chronic bowel problems in many patients.
Initially, as many as 75% of people will have abdominal pain and
cramps, 50% will have nausea, and 25% will have vomiting and fever.
An acute onset of watery diarrhea usually means that an enterotoxi-
genic E. coli is the cause, but shigellosis will also first present in this
manner. Symptoms of bloody diarrhea or mucoid stools are frequently
seen with invasive pathogens such as shigella, campylobacter, or sal-
monella. The presence of chronic diarrhea with malabsorption and
gas indicates possible giardia. Rotavirus disease starts with vomiting
in 80% of cases.
In a study of US students in Mexico, the cause of diarrhea was
found to be enterotoxigenic E. coli 40%; enteroadherent E. coli 5%;
Giardia lamblia and Entamoeba histolytica 2%; rotavirus 10%; aero-
monas 1%; shigella 15%; salmonella 7%; campylobacter 3%; and
unknown 17%. Studies of traveler’s diarrhea show different frequen-
cies from the above in various other locations of the world, but the
cause is always due to infection.
Various medications have been shown effective in preventing trav-

eler’s diarrhea, but experts discourage their use due to cost, exposing
people to drug side effects, and the possible development of resistant
germs due to antibiotic overuse. Pepto-Bismol, 2 ounces (4 table-
spoons) or 2 tablets taken 4 times daily, can prevent this problem.
Ugh! About 8 aspirin tablets worth of salicylate are in that quantity
of Pepto-Bismol. Prevention with antibiotics is effective, although
not usually indicated. Prevention of diarrhea-causing illness is best
accomplished in a survival situation with good hygiene.
Treating diarrhea with Pepto-Bismol requires 2 tablespoons every
30 minutes for 8 doses. As most diarrhea in developing countries is
from bacterial causes, the use of antibiotics can be very effective. A
single dose of the antibiotic Levaquin, 500 mg, can eliminate diar-
rhea instantly. Loperamide, 2 mg, from the Non-Rx Oral Medica-
tion Module, may not be required if you have access to Levaquin. A
dose of loperamide may be given simultaneously with the Levaquin.
When using loperamide, give 2 tablets at once, followed by 1 tablet
after each loose stool, with a maximum adult dose of 8 tablets per
day. One tablet of the pain medication Norco 10/325 can also stop
diarrhea, but it would be best to use the loperamide and/or Levaquin
if they are available. In parts of the world where Levaquin is losing
its effectiveness, such as the Indian subcontinent, Southeast Asia, and
Africa, Zithromax is a better choice. Since diarrhea in North Amer-
ica is seldom caused by bacteria, antibiotics should be used there only
after stool cultures.
Constipation
One of the popular wilderness medical texts has instructions on how
to break up a fecal impaction digitally, that is, using your finger to
break up a hard stool stuck in the rectum. Don’t let it get that far.
In healthy young adults (especially teenagers), there may be a reluc-
tance to defecate due to the unusual surroundings, lack of a toilet,
and perhaps swarms of insects or freezing cold. It is the group leader’s
responsibility to make sure that a trip member does not fecal hoard
by failing to defecate in a reasonable length of time. Certainly, one
should be concerned after 3 days without a bowel movement.
To prevent this problem, I always include a stewed fruit at break-

fast on menus. The use of hot and cold food and water in the morning
will frequently wake up the “gastric-colic reflex” and get things mov-
ing perfectly well.
If the 5-day mark is approaching, especially if the patient—and
the person has become a patient at about this point—is obviously
uncomfortable, it will become necessary to use a laxative. From the
Non-Rx Oral Medication Module, give 15 mg bisacodyl laxative tab-
let at bedtime. If that fails, the next morning take 2 tablets. Under
winter conditions, when getting up in subzero weather might prove
abominable, or under heavy insect conditions, take these tablets in
the morning, rather than at bedtime, to preclude this massive incon-
venience occurring in the middle of the night. Any laxative will cause
abdominal cramping, depending upon how strong it is. Expect this.
Hemorrhoids
Also called piles, this painful swelling is a cluster of varicose veins
around the rectum. External hemorrhoids are small, rounded, pur-
plish masses that enlarge when straining at stool. Unless a clot forms
in them, they are soft and not tender. When clots form, they can
become very painful, actually excruciating. Hemorrhoids are the
most common cause of rectal bleeding, with blood also appearing on
the toilet tissue. The condition can be very painful for about 5 days,
after which the clots start to absorb, the pain decreases, and the mass
regresses, leaving only small skin tags.
Provide the patient with the OTC pain medication Percogesic,
2 tablets every 4 hours. The application of heat is helpful during the
acute phase. Heat a cloth in water and apply for 15 minutes 4 times
a day if possible. Avoid constipation, as mentioned above in that sec-
tion. If you are carrying the Rx Oral/Topical Medication Module,
Topicort 0.25% ointment will provide the anti-inflammation ability
of a steroid and some local pain relief.
Hernia
The most common hernia in a male is the inguinal hernia, an out-
pouching of the intestines through a weak area in the abdominal wall
located above and on either side of the groin. It is through this area
that the spermatic cord connects the testes to the back of the penis.
A hernia can be produced while straining or lifting, even coughing or
sneezing, when the bowel pushes along the spermatic cord. There will
be a sharp pain at the location of the hernia and the patient will note
a bulge. This bulge may disappear when he lies on his back and relaxes
(i.e., the hernia has reduced).
If the intestine in the hernia is squeezed by the abdominal wall to
the point that the blood supply is cut off, the hernia is termed a stran-
gulated hernia. This is a medical emergency, as the loop of gut in the
hernia will die, turn gangrenous, and lead to a generalized peritonitis
or abdominal infection (peritonitis is discussed under Gall Bladder
Problems and Appendicitis, page 67). This condition is much worse
than appendicitis, and death will result if it is not treated surgically.
The hernia that fails to reduce or disappear when the victim
relaxes in a recumbent position is termed incarcerated. While this
may turn into an emergency, it is not one at that point.
Most hernias caused by straining in adults will not strangulate.
Further straining should be avoided. If lifting items is necessary, or
coughing cannot be prevented, etc., the victim should protect him-
self from further tissue damage by pressing against the area with one
hand, thus holding the hernia in reduction.
Bladder Infection
The hallmarks of bladder infection (cystitis) are the urge to urinate
frequently, burning upon urination, small amounts of urine being
voided with each passage, and discomfort in the suprapubic region—
the lowest area of the abdomen. Frequently the victim has fever, with
its attendant chills and muscle aches. In fact, people can become quite
ill with a generalized infection caused by numerous bacteria enter-
ing their bloodstream. At times the urine becomes cloudy and even
bloody. Cloudy urine without the above symptoms does not mean
an infection is present and is frequently normal. The infection can
extend to the kidney, at which time the patient also has considerable
flank pain, centered at the bottom edge of the ribs along the lat-
eral aspect of the back on the involved side (often both sides). While
bladder infections are more common in women than men, they are
not an uncommon problem in either sex. One suffering from recur-
rent infections should be thoroughly evaluated by a physician prior to
having to leave the grid.
Many drugs have been developed for treating infections of the
genitourinary system. Doxycycline, 100 mg, 1 tablet taken twice daily,
is very effective. Levaquin, 500 mg tablet once daily, is ideal to use
if the doxycycline seems ineffective. Generally, 3 days is a sufficient
length of time for treatment, unless flank pain is involved, in which
case provide 10 days of antibiotic. Symptoms should disappear within
24 to 48 hours, or it may mean that the bacteria are resistant to one
antibiotic and the other should be substituted.
For severe infections with high fever that have not responded
within 48 hours to oral antibiotic use, the injectable Rocephin, 500
mg IM given twice daily, provided in place of the oral antibiotic
would be a superior choice.
Additional treatment should consist of drinking copious amounts
of fluid, at least 8 quarts per day! At times this simple rinsing action
may even cure cystitis, but I wouldn’t count on it. Use an antibiotic,
if it is available. Percogesic or ibuprofen may be needed to treat the
fever and pain that accompany such problems prior to the start of the
antibiotic and during the early stages of therapy.
REPRODUCTIVE ORGANS
Venereal Diseases
Venereal infections are totally preventable by abstention; any other
technique falls short of being foolproof. Most venereal infections
cause symptoms in the male but frequently do not in the female.
Either may note increased discomfort with urination, the develop-
ment of sores or unusual growths around the genitalia, and discharge
from the portions of the anatomy used in sex (pharynx, penis, vagina,
anus). Some venereal diseases can be very difficult to detect, such as
syphilis, hepatitis B, and AIDS. Hepatitis B is rampant in many parts
of the world, with high carrier rates in local population groups. It can
be prevented with a vaccine.These are no vaccines against the other

venereal diseases except human papillomavirus (HPV).
Gonorrhea is common and easy to detect in the male. Symptoms
appear between 2 and 8 days from time of contact and basically con-
sist of a copious greenish-yellow discharge. The female will frequently
not have symptoms. From the Rx Oral/Topical Medical Module pro-
vide doxycycline, 100 mg twice daily for 15 days, to ensure adequate
treatment of syphilis, which may have been caught at the same time.
Also give Zithromax, 1 gram at once (4 of the 250 mg tablets), to cure
chlamydia, which frequently is a coinfection.
Syphilis has an incubation period of 2 to 6 weeks before the char-
acteristic sore appears. The development of a painless ulcer (1/4 to 1/2
inch, or 0.6 to 1.2 centimeters in size), generally with enlarged, non-
tender lymph nodes in the region, is a hallmark of this disease. A
painful ulcer formation is more characteristic of herpes simplex. The
lesion may not appear in a syphilis victim, making the early detection
of this disease very difficult. A second stage consisting of a generalized
skin rash (which usually does not itch, does not produce blisters, and
frequently appears on the soles of the feet and palms of the hands)
appears about 6 weeks after the lesions mentioned above. The third
phase of the disease may develop in several years, during which nearly
any organ system in the body may be affected. The overall study of
syphilis is so complicated that a great medical instructor (Sir Wil-
liam Osler) once said, “To know syphilis is to know medicine.” Treat-
ment of primary-stage syphilis is 15 days of antibiotics, as mentioned
above. Development of a clear, scanty discharge in the male may be
due to chlamydia or other nonspecific urethral infections. Symptoms
appear 7 to 28 days after contact. Women may have no symptoms.
Treat with doxycycline, 100 mg twice daily, for 15 days. Blood tests
for syphilis should be performed now (ideally) and again in 3 months.
Since 20% of victims with nonspecific urethritis will have a relapse,
adequate medical follow-up after the trip is essential.
Herpes lesions can respond to Denavir 1% cream applied fre-
quently during the day until they disappear in 8 to 10 days. Famvir
capsules, 250 mg taken 3 times daily for 7 to 10 days, are effective
during the acute phase, when the symptoms first manifest.
Upon returning home, members who may have experienced

symptoms of a sexually transmitted disease should be seen by their
physician for serology tests for syphilis, hepatitis B tests, chlamydia
smears, gonorrheal cultures, herpes simplex titers, and possibly HIV
studies. Lesions or growths should be examined as possible mollus-
cum contagiosum, and venereal warts should be treated.
Vaginal Discharge and Itching

Vaginal discharge and/or itching are often not indicators for vene-
real disease. The most common cause is a fungal or monilia (can-
dida) infection. This condition is more common in conditions of
high humidity or with the wearing of tight clothes such as pants or
pantyhose.
A typical monilia infection has a copious white discharge with
curds like cottage cheese. From the Non-Rx Oral Medication Mod-
ule, one can use the clotrimazole 1% cream. This formulation has
been designed for foot and other skin fungal problems, but it will
work vaginally as well. From the Rx Oral Medication Module, also
use 1 Diflucan 150 mg tablet for treatment.
A frothy, greenish-yellow, irritating discharge may be due to
trichomonas infection. This can be spread by sexual encounters. The
male infected with this organism generally has no symptoms, or per-
haps a slight mucoid discharge early in the morning, noted before
urinating. The treatment of choice is Flagyl (metronidazole), 250 mg
capsule 3 times a day for 10 days, or 8 capsules given as 1 dose. This
drug cannot be taken with alcohol. Sexual abstention is important
until medication is finished and a cure is evident clinically. Generic
Flagyl is frequently available in third-world countries at pharmacies
without a prescription.
A copious yellow-green discharge may indicate gonorrhea. Any
irritating discharge that is not thick and white is best treated with
Levaquin, 500 mg once daily. If sexual contact may have been the
source of the problem, treat for 15 days to also kill any syphilis that
may have been contracted simultaneously. A douche of very dilute
Hibiclens surgical scrub, or very dilute detergent solution, can be
prepared and may be helpful; very dilute is better than too strong.
Frequent douching is not required, but it may be done for a few days
as required for comfort and hygiene.
Menstrual Problems
On the move, menstrual flow is best contained with a vaginally inserted
tampon, but be sure to have experience with the chosen product prior
to heading into the backcountry. A resealable plastic bag, with per-
haps a paper bag liner, should be carried if it is necessary to pack out
discarded pads. Many find the use of a vaginal cup is the best solu-
tion. An excellent blog article that provides pre-trip advice is “Girl
Talk: How to Handle Your Period in the Backcountry” (blog.rei.com/
hike/girl-talk-part-2-handling-your-period-in-the-backcountry/).
Rolling several Nu- Gauze pads from the Topical Bandaging
Module will substitute as an outer sanitary napkin if none is available.
Menstrual cramping can generally be controlled with ibuprofen, 200
mg, 1 or 2 tablets every 4 to 6 hours, from the Non-Rx Oral Medi-
cation Module. While this medication is generally used as an anti-
arthritic, its anti-prostaglandin activities make it an ideal medication
for the treatment of menstrual pain.
Menorrhagia, either excessive flow or long period of flowage,
should be evaluated by a physician to determine if there is an under-
lying pathology that could or should be corrected. If the problem is
simply one of hormone imbalance, this can frequently be corrected
by the use of birth control pills with higher amounts of estrogen and
lower progestogen content. Consult a physician well in advance of a
trip, as it takes a least three cycles of the “correct” hormone dose to
comfortably predict adequate management.
Spontaneous Abortion
Bleeding during pregnancy is not unusual—20 to 30% of women
bleed or cramp during the first 20 weeks of their pregnancies. This
is termed threatened abortion and is treated with bed rest, since this
usually decreases the bleeding and cramping. However, 10 to 15% of
pregnant women will go on to abort. As long as all products of the
abortion pass—a “complete abortion”—the bleeding and pain will
stop and the uterus shrinks back to its normal size.
An incomplete abortion—the expulsion of only a portion of the

fetus or the rupture of only the membranes—will often require a
surgeon’s care to perform a D&C (dilation and curettage). However,
urgent evacuation is always mandatory. Watch for signs of sepsis,
such as elevated temperature, and start an antibiotic if possible. Give
Rocephin, 1 gram IM, followed by 500 mg IM every 12 hours. The
best oral antibiotic recommended from your Rx Oral/Topical Med-
ication Module would be Levaquin, 500 mg given daily. Give pain
medication as necessary.
Ectopic Pregnancy
In an ectopic pregnancy, spotting and cramping usually begin shortly
after the first missed period. If a pregnancy test is positive and the
woman has severe lower abdominal pain lasting more than 24 hours,
you probably have a surgical emergency on your hands. A rupture of
the uterine tube usually occurs at 6 to 8 weeks of pregnancy, while a
rupture of a cornual pregnancy occurs at 12 to 16 weeks. The rupture
causes massive blood loss with a rapid onset of shock and death when
it occurs.
While other causes of spotting during pregnancy are possible,
you are in no position to handle any of them off the grid. Evacuate
this woman immediately.
If a woman is having spotting and lower abdominal pain, and the
pregnancy test is negative, you are in no position to bet her life that
she is not pregnant. Ectopic pregnancies have lower blood levels of
ß subunit HCG hormone to detect, and the test may, therefore, be
falsely negative.
Pregnancy
If you are approaching a potential off-grid situation and a member of
your team is in advanced pregnancy, you will need to have the sup-
plies and basic knowledge of delivery. During the second trimester
she should receive an additional 340 kcal (kilocalorie) and during the
third trimester 450 additional kcal of food per day. She should also
have a multivitamin that includes 400 to 600 mcg folic acid, 400 IU
vitamin D, 300 mg calcium, 70 mg vitamin C, 3 mg thiamine, 2 mg
riboflavin, 20 mg niacin, 6 mg vitamin B-12, 290 mcg iodine (but not

more than a total daily amount of 1,100 mcg), and trace amounts of
zinc and copper.
Over 94% of deliveries are uncomplicated, but about 10 to 20%
of pregnancies end with a spontaneous abortion before the 20th
week; this might be much higher as many miscarriages occur so early
in pregnancy that the woman might not realize she was even preg-
nant. Once pregnancy is advanced and obvious (generally beyond
the 12th to 16th week), care must be taken to make sure that the
woman’s diet is appropriate as mentioned above and that she does
not develop hypertension (not usual before week 20). This hyperten-
sion is best controlled with reduced sodium intake and the possible
use of a diuretic blood pressure medication. Gestational diabetes can
occur between weeks 24 and 28, and one should ideally check blood
sugars at that time. If the person develops signs of diabetes (fre-
quency of urination matched with thirst), diet and exercise usually
manage 80% of these cases, while some women will require insulin.
Frequency and burning while urinating small amounts may mean
a urinary tract infection. Obstetricians would treat a urinary tract
infection usually with nitrofurantoin, 100 mg twice daily, but the
Rx Oral/Topical Medication Module suggestion of levofloxacin, 500
mg once daily for 3 days, is safe. Edema in late pregnancy is a seri-
ous sign of a condition called preeclampsia (hypertension, protein in
urine, and edema). It must be treated as a medical emergency. Return
to the grid if possible—otherwise, bed rest, salt restriction, diuretic.
On the grid, the baby is frequently delivered early to prevent this
condition from progressing, which can otherwise lead to the death
of both the mother and child. Seizures from eclampsia are difficult to
treat and are rare in places like the United States but relatively com-
mon in areas where I volunteer like Haiti. This is a deadly situation
without help.
In general, delivery progresses through various stages without dan-
ger to mother or child. However, even basic training for the birthing
assistant will provide a safer birth and management of the newborn
and will identify issues requiring sometimes very basic maneuvers, or
some very desperate ones, to save lives in the 10% of situations that
require help. There is an ideal chapter on birthing in Buck Tilton’s

book Wilderness First Responder (Falcon Guides, 2010) covering basic
principles in detail, including immediate care of the newborn.
Survival mode off the grid will require maintaining the mother
on her prenatal vitamins and encouraging breastfeeding exclusively
for 6 months, then continue combined with solid food for 2 years.
Painful Testicle
If pain is severe, provide support by having the victim lie on the insu-
lated ground with a cloth draped over both thighs, forming a sling
or cradle on which the painful scrotum may rest. If ambulatory, pro-
vide support to prevent movement of the scrotum. Cold packs would
help initially, and providing adequate pain and nausea medication as
available is certainly appropriate. An antibiotic is not required unless
a fever ensues.
Spontaneous pain in the scrotum, with enlargement of a testicle,
can be due to an infection of the testicle (orchitis) or more commonly
to an infection of the sperm-collecting system called the epididymis
(epididymitis). Treatment of choice would be to provide an antibiotic
such as doxycycline, 100 mg, 1 tablet twice daily, or Levaquin, 500 mg
once daily. Pain medication should be provided as necessary.
The problem may not be due to an infection at all. It is possible
for the testicle to become twisted, due to a slight congenital defect,
with severe pain resulting. This testicular torsion, as it is called, is a
surgical emergency. It can be almost impossible to distinguish from
orchitis. In a suspected case of torsion, it is helpful to try to reduce
the torsion. Since the testicle always seems to rotate “inward,” one
need only rotate the affected testicle “outward.” This will often result
in immediate relief of the pain. If you cannot achieve this, or if you
are dealing with orchitis, no harm is done; but if it is a torsion, you
have saved the testicle and the trip. A person with severe testicular
pain should be evacuated as soon as possible, as infection or torsion
can result in sterility of the involved side. An unreduced testicu-
lar torsion can become gangrenous, with life-threatening infection
resulting.
POISONING
Plant or Food Poisoning

The ideal treatment after poison plant ingestion is to give the patient
activated charcoal. If that isn’t possible, induce vomiting by gagging
the throat with a finger or spoon. This latter technique may well be
the only method available while in the bush.
Petroleum Products Poisoning

The danger from accidentally drinking various petroleum products—
for example, while siphoning gas from one container to another—is
the possibility of accidentally inhaling or aspirating this liquid into
the lungs. That will kill. The substances are not toxic enough in the
gastrointestinal (GI) tract to warrant the danger of inducing vomit-
ing. Do not worry about swallowing several mouthfuls of any petro-
leum product. If the person vomits, there is nothing you can do about
it, except position him so that there is less chance of aspiration into
the lungs—sitting while bending forward is probably ideal. The more
volatile the substance, the more the danger of aspiration. In other
words, kerosene is less dangerous than Coleman fuel.
If organic phosphorous pesticides are dissolved in the fuel, you
have a more complex problem. These substances are potentially toxic
and must be removed. In the emergency room this would be accom-
plished by gastric lavage, or stomach pumping. In the bush, if you
cannot evacuate the person within 12 hours, you will have to take
a chance of inducing vomiting, with possible lethal aspiration—to
eliminate the poison. Treat by inducing gagging as described above
under Plant or Food Poisoning. After vomiting, administer a slurry
of activated charcoal, if available. This helps bind non-regurgitated
toxins. Charcoal powder, to which you add water to form a slurry, is
available at pharmacies. In the field you might consider tearing apart
a charcoal water filter and crushing the charcoal granules. Or you can
make the slurry from the blackened, partially burnt portions of logs
from a campfire.
Ciguatera Poisoning
Ciguatera poisoning is caused by a toxin released by a small ocean
organism called a dinoflagellate. As various species of fish eat this
small plant, they acquire the toxin. Larger fish that in turn prey on
the smaller fish acquire larger and larger amounts of the toxin, thus
resulting in more severe cases of ciguatera toxin poisoning in humans
if these larger fish are consumed. Over 400 species of fish from the
tropical reefs of Florida, the West Indies, and the Pacific have been
implicated, but most often it has been barracuda, grouper, and amber-
jack that are contaminated. No deep-sea fish, such as tuna, dolphin,
or wahoo, have been found contaminated.
There is no way to detect contamination—no change in flavor,
texture, or color of the fish flesh. Worse yet, no method of preserving,
cooking, or treating fish can destroy this toxin. One must rely on local
knowledge to avoid potentially polluted species.
Symptoms usually start with numbness and tingling of the lips
and tongue, and then progress to dry mouth, abdominal cramping,
vomiting, and diarrhea that lasts 6 to 17 hours. Muscle and joint
pain, muscle weakness, facial pain, and unusual sensory phenomena
such as reversal of hot and cold sensations develop. Occasionally low
blood pressure, respiratory depression, and coma can result. Neuro-
logical symptoms are made worse by alcohol and exercise. Start rescue
breathing if necessary (see page 17). This type of poisoning does not
result in death.
See also Scombroid Poisoning (below) and Paralytic Shellfish
Poisoning (page 86).
Scombroid Poisoning
The flesh of dark-meat fish, such as tuna, mackerel, albacore, bonito,
amberjack, and mahi-mahi (dolphin), contain large amounts of histi-
dine. Improper storage after catching these fish allows bacterial enzy-
matic changes to this meat, releasing large amounts of histamine and
other toxic by-products that are not destroyed by cooking.
Symptoms of scombroid poisoning include flushing, dizziness,
headache, burning of the mouth and throat, nausea, vomiting, and
diarrhea. Severe poisoning can cause significant respiratory distress.
Diphenhydramine has been reported to cause an increase in symp-

toms at times, which is surprising since it is an excellent antihistamine.
Ranitidine (Zantac) 150 mg, from the Non-Rx Oral Medication
Module, may block the effects of scombroid poisoning; give two 150
mg tablets every 12 hours. While normally a prescription product at
300 mg dosage used to control stomach acid formation, ranitidine’s
mode of action is known as a histamine-2 receptor blocker.
Puffer Fish Poisoning

Incorrectly prepared puffer fish (fugu) contain tetrodotoxin, which
can be lethal as it leads to respiratory failure and cardiac collapse.
Symptoms may be slow in onset. Provide CPR as necessary (see page
17). Probably more people are killed by ingesting poisonous marine
creatures than are killed by any other type of encounter, such as
trauma from biting, stinging, or shocking.
Paralytic Shellfish Poisoning

Mussels, clams, oysters, and scallops may ingest the poison saxitoxin
from dinoflagellates found in “red tide,” which occurs from June
to October along the New England and Pacific coasts. Numbness
around the mouth may occur between 5 and 30 minutes after eating.
Other symptoms are similar to ciguatera poisoning (page 85). These
include gastrointestinal illness, loss of coordination, and paralysis
progressing to complete respiratory paralysis with 12 hours in 8% of
cases. No specific treatments or antidotes are available, but purging of
stomach contents should be encouraged. Artificial support of respira-
tion is potentially lifesaving.
MANAGING DIABETES
Diabetic children and adults can have an active off-grid life, but
learning to control their diabetes must first be worked on with their
physicians. The increased caloric requirement of significant exercise
may range above an extra 2,000 calories per day, yet insulin dosage
requirements may drop as much as 50%. The diabetic, as well as the
trip partners, must be able to identify the signs of low blood sugar
(hypoglycemia)—staggering gait, slurred speech, moist skin, clumsy

movements—and know the proper treatment, for example, oral car-
bohydrates or sugar candies and, if the patient becomes unconscious,
the use of injectable glucagon. The urine of diabetic outdoor trav-
elers should be tested twice daily to confirm control of sugar. This
testing should preclude a gradual accumulation of too much blood
sugar, which can result in unconsciousness in its advanced stage. This
gradual accumulation would have resulted in massive sugar spill in
the urine and finally the spill of ketone bodies, providing the patient
ample opportunity to increase insulin dosage to prevent hyperglyce-
mia (too high of a blood sugar level). Battery-powered, point-of-care
blood sugar test devices (glucometers) must be included in the per-
sonal property of anyone taking insulin.
Storage of insulin off the grid, where it forgoes recommended
refrigeration, is not a major problem as long as the supply is fresh
and direct sunlight and excessive heat are avoided. Unopened insu-
lin usually has an expiration date of one year. With proper storage
this might be extended several years, but there is an unknown finite
point when it will not be viable. Biologicals such as insulin will not
have long, extended storage times. Syringes, alcohol prep pads, Keto-
Diastix urine test strips, insulin, and glucagon are light additions to
the Off-Grid Medical Kit. Persons who are insulin dependent will
not be able to survive without grid contact. Adults whose diabetes
started later in life might do adequately with oral medications, but
they need to have an ideal body mass index and eat no more calo-
ries than they are expending. I recommend persons with diabetes
who experience elevating blood sugars should readily accept start-
ing insulin. Lifestyle changes, weight loss, and healthy diet choices
might allow control to be reestablished and diabetes medications
reduced, or even stopped altogether. It is all a matter of results. Ele-
vated blood sugars require more aggressive medication management.
But just because you start insulin does not mean you will always have
to be on it. Start it sooner than later, and try to modify your life so
you can live without insulin. If the grid collapses, you may have to
get by without it.
WATER AND WASTE
Oral Fluid Replacement Therapy

Replacement of fluid loss is required for three different circum-
stances: diarrhea, heat stress sweat formation, and insensible moisture
loss from breathing and skin respiration (yes, skin must breathe also).
The ideal fluid replacement for each of these losses differs in electro-
lyte and sugar content. In general, diarrhea replacement fluids should
not have a sugar content greater than 2.5%, as a higher concentration
might cause additional diarrhea. (A higher sugar concentration is not
a problem in a person who is not ill.) Sweat replacement solutions
should not have a sugar concentration greater than 8.5%; this slows
the emptying of the fluid from the stomach. The uptake of water by
the body is decreased, as this occurs in the intestines and not the
stomach. The ideal electrolyte composition for these circumstances
also differs dramatically.
Profound diarrhea from any source may cause severe dehydration
and electrolyte imbalance. The non-vomiting patient must receive
adequate fluid replacement, equaling his stool loss plus about 2 liters
(2 quarts) per day. For a couple of days, an adult can replace these
losses by drinking enough plain water. A child or less healthy adult
will require electrolyte replacement in addition to the water. The
Centers for Disease Control and Prevention (CDC) recommends the
oral replacement cocktails for fluid losses caused by profound diar-
rhea seen in table 3-7. Drink alternately from each glass. Supplement
with carbonated beverages, or water and tea made with boiled or car-
bonated water as desired. Avoid solid foods and milk until recovery.
Throughout the world, the United Nations International Chil-
dren’s Emergency Fund (UNICEF) and World Health Organization
(WHO) distribute an electrolyte replacement product called Oralyte.
It must be reconstituted with adequately purified water.
If the patient is maintaining fluid balance with an effective oral
rehydration therapy, such as with the packets as indicated above, the
additional glass of carbonated or bicarbonate water is not necessary.
Other products that are considered safe for rehydration due to diarrheal
losses are NaturaLyte, Pedialyte, Enfalyte, and Pediatric. Gatorade is
too high in carbohydrate and too low in sodium, potassium, and base
to be considered a safe substitute, even with modification.
Table 3-7. Oral Replacement Cocktails

Prepare two separate glasses of the following:
Glass 1 Orange, apple, or other fruit juice
(rich in potassium). . . . . . . . . . . . . . . . . . . . . . . . . 8 ounces
Honey or corn syrup (glucose necessary for
absorption of essential salts). . . . . . . . . . . . . 1⁄2 teaspoon
Salt, table (rich in sodium and chloride). . . . . . . . 1 pinch
Glass 2 Water (carbonated or boiled). . . . . . . . . . . . . . . 8 ounces
Soda, baking (sodium bicarbonate) . . . . . . . 1⁄4 teaspoon
Water Purification
Water can be purified adequately for drinking by mechanical, physi-
cal, and chemical means.
The clearest water possible should be chosen or attempts made
to clarify the water prior to starting any disinfectant process. Water
with high particulate counts of clay or organic debris allows high
bacterial counts and tends to be more heavily contaminated. In pre-
paring potable, or drinkable, water, we are attempting to lower the
germ counts to the point that the body can defend itself against the
remaining numbers. We are not trying to produce sterile water; that
would generally be impractical.
The use of chlorine-based systems has been effectively used by
municipal water supply systems for years. There are two forms of
chlorine readily available to the outdoors traveler. One is liquid chlo-
rine laundry bleach, and the other is halazone tablets.
Laundry bleach that is 4 to 6% sodium hypochlorite can make
clear water safe to drink if 2 drops are added to 1 quart of water. Avoid
brands of bleach that contain soap or surfactant. Mix this water thor-
oughly and let it stand for 30 minutes before drinking. The resulting
blend should have a slight chlorine odor. If not, the original laundry
bleach may have lost some of its strength, and you should repeat the
dose and let it stand an additional 15 minutes prior to drinking.
Halazone tablets from Abbott Laboratories are also effective.

They are quite stable, with a shelf life of 5 years, even when occasion-
ally exposed to temperatures over 100°F (38°C). Recent articles in
outdoor literature have stated that halazone has a short shelf life and
that it loses 75% of its activity when exposed to air for 2 days. Abbott
Labs refutes this and has proven the efficacy of halazone sufficiently
to receive FDA approval. A clue to the stability of the tablets is that
they turn yellow and have an objectionable odor when they decom-
pose. Check for this before use. Add 5 tablets to a quart of clear water
for adequate chlorination.
Chlorine-based systems are very effective against viruses and
bacteria. They work best in neutral or slightly acid waters. As the
active form of the chlorine, namely hypochlorous acid (HClO), read-
ily reacts with nitrogen-containing compounds such as ammonia,
high levels of organic debris decrease its effectiveness. The amount of
chlorine bleach or halazone added must be increased if the water is
alkaline or contaminated with organic debris.
Iodine is a fairly effective agent against protozoan contamination
such as Giardia lamblia and Entamoeba histolytica, both of which tend
to be resistant to chlorine. Further, iodine is not as reactive to ammo-
nia or other organic debris, thus working better in cloudy water. It is
relatively ineffective against cryptosporidia, which must be destroyed
by either filtration or heat (see page 92). Tincture of iodine, as found
in the home medicine chest, may be used as the source of the iodine.
Using the commonly available 2% solution, 5 drops should be added
to clear water or 10 drops to cloudy water, and the resultant mix
should be allowed to stand 30 minutes prior to drinking.
An elemental iodine concentration of 3 to 5 ppm (parts per
million) is necessary to kill amoeba and their cysts, algae, bacteria
and their spores, and enterovirus. Crystals of iodine can also be used
to prepare a saturated iodine water solution for use in disinfecting
drinking water. In a 1-ounce (30 ml) glass bottle, place 4 to 8 grams
of USP-grade iodine crystals. Water added to this bottle will dissolve
varying amounts of iodine, based upon the water temperature. This
saturated iodine water solution is then added to a quart of water. The
amount added to produce a final concentration of 4 ppm will vary

according to temperature, as indicated in table 3-8.
This water should be stored for 15 minutes before drinking. If the
water is turbid or otherwise contaminated, the amounts of saturated
iodine solution indicated in table 3-8 should be doubled and the
resultant water stored 20 minutes before using. This product is now
commercially available as Polar Pure through many outdoor stores
and catalog houses.
Mechanical filtration methods are also useful in preparing drink-
ing water. They normally consist of a screen with sizes down to 6
microns, which are useful in removing tapeworm eggs (25 microns) or
Giardia lamblia (7 to 15 microns). These screens enclose an activated
charcoal filter element, which removes many disagreeable tastes. As
most bacteria have a diameter smaller than 1 micron, bacteria and the
even smaller viral species are not removed by filtration using these
units. For water to be safe after using one of these devices, it must
be pretreated with chlorine or iodine exactly as indicated above prior
to passage through the device. While these filters remove clay and
organic debris, they will plug easily if the water is very turbid. A con-
cern with the charcoal filter usage is that the filters may become con-
taminated with bacteria when they are used the next time. Pretreating
the water helps prevent this. I have frequently used a charcoal filter
system to ensure safe, good-tasting water after chemical treatment.
Another filtration method is perhaps one of the oldest, namely
filtering through unglazed ceramic material. This was done in large
crocks, a slow filtration method popular in tropical countries many
years ago. A modern version of this old system is the development
of a pressurized pump method. Made in Switzerland, the Katadyn
Pocket filter has a ceramic core enclosed in a tough plastic hous-
ing, fitted with an aluminum pump. The built-in pump forces water
through the ceramic filter at a rate of approximately 3/4 quart (750 ml)
per minute. Turbid water will plug the filter, but a brush is provided
to easily restore full flow rates. This filter has a 0.2-micron size, which
eliminates all bacteria and larger pathogens. Pretreating of the water
is not required. There is evidence that viral particles are also killed
by this unit, as the ceramic material is silver-impregnated, which
appears to denature viruses as they pass through the filter. The Euro-
pean Union did not approve this claim; as a result, the manufacturer
no longer makes this statement in their literature. I have worked with
many groups using this device, however, and they have had many
favorable comments. These units are not cheap, costing about $370
retail. They weigh 23 ounces. There are several less expensive ceramic
units now available, but be sure to pretreat the water chemically when
using these systems, as they may be ineffective against viral disease
without the silver impregnation.
Using the same technology as kidney dialysis systems, Sawyer
Products produces a microtubule filter with a 0.1-micron absolute
size (see figure 3-3). Normally a filter with such a small diameter
would be very difficult to pump water through, but the microtubules
have an effective large surface area allowing one to suck water or to
gravity-feed water through the system easily. I prefer the Sawyer per-
sonal water bottle filter, as the oral opening is protected by a closing
flap mechanism. In dusty areas, especially those with possible fecal
contamination, such as trails in developing countries, this is ideal.
Sawyer also makes an attachment using this filter system that screws
into common commercial disposable water bottles.
If it not only removes particles but has an absorption mechanism
to remove chemicals, a quality water filter eliminates viruses and bac-
teria, as well as protects against chemical contaminants and water-
borne parasites. It may require prefiltering to remove large particles,
charcoal or similar filtering to remove chemicals, and a microfilter to
remove bacteria. Sawyer also produces a microtubule system with an
absolute pore size of 0.02 microns, thus also effective against hepatitis
C virus particles.
SteriPEN and similar devices use ultraviolet C rays to kill viral,
bacterial, and protozoan cysts. The water should be prefiltered if it is
turbid, as shadows from particles in the water potentially shield these
germs from destruction. Of course, agitation or swirling the wand in
the water helps overcome this problem, and the light must stay on
longer. Loss of battery power ends the device’s usefulness.
Another method of water purification has been with us a long
time, namely using our old friend fire. Bringing water to a boil will
Figure 3-3.
Cutaway photograph of the Sawyer microtubule system. The microtubules are
folded into the filter apparatus that effectively gives this filter a large surface
area through which water can drain with minimal squeezing pressure or sucking
vacuum.
effectively kill pathogens and make water safe to drink. One reads
variously to boil water 5, 10, or even 20 minutes, but simply bring-
ing the water temperature to 150°F (65.5°C) is adequate to kill the
pathogens discussed above and all others besides. At high altitude the
boiling point of water is reduced. For example, at 25,000 feet (7,600
meters) the boiling point of water is 185°F (85°C). Bringing water to
a boil is the minimal safe time for preparation. At times fuel or water
may be in short supply and this minimal time must be used.
It will never be necessary to boil water longer than 5 minutes, and
the shortest time mentioned (just bringing the water to a boil) will
suffice for a safe drinking water. This water will not be sterile, but it
will be safe to drink.
Water may be obtained by squeezing any freshwater fish and
some plants. A solar still can be prepared for reprocessing urine,
water from debris, or any moist material, as indicated in figure 3-4.
In water-poor areas, catching rainwater may be an essential part of
routine survival. Be careful, however, of melting ice; treat all meltwa-
ter as indicated above. There is a very strong chance of contamina-
tion in ice deposits. Surprisingly, it is possible to survive quite a long
time drinking only urine. Seawater is problematic, as the surface
water has varying amounts of salt concentrations, depending upon
currents, melting ice, and even river influxes, which are sometimes
hundreds of miles away.
Table 3-8. Iodine Concentrations for Water Disinfection

TEMPERATURE VOLUME CAPFULS
37°F 20.0cc 8
(3°C)
68°F 13.0cc 5+
(20°C)
77°F 12.5cc 5
(25°C)
104°F 10.0cc 4
(40°C)
*Assuming 2.5cc capacity for a standard 1-ounce glass bottle cap
Figure 3-4.
Solar still condensing drinkable water from vegetation or contaminated sources.
A solar still is very slow and produces 2-3
minimal amounts of water.
Human Waste Disposal

This is a matter not only of aesthetics but of primary preventative
medicine. Improper waste disposal on the wagon trains heading
west in the 1840s and 1850s caused vast epidemics of cholera in the
trains that followed. Unbelievable numbers of people were killed.
Even in our wilderness areas, it is widely acknowledged that the
cleanest-looking streams should still be suspected of human or ani-
mal contamination.
Most official campsites in the national park system have toilets.

These should always be used. Otherwise, human defecation should be
buried at least 200 feet (60 meters) from a lakeshore or stream. Waste
should be buried in a shallow pit, as this promotes rapid decomposi-
tion. Disinfecting waste by adding undiluted bleach or solid bleach
powder is a viable alternative. In very dry and seldom traveled areas,
using the smear technique to dispose of feces is advocated. In some
ecosystems all solid waste, including feces, must be carried out. Gen-
eral guidelines are available for different ecosystems and various lev-
els of human usage. The Leave No Trace Foundation curriculum is
taught by many outdoor groups interested in conservation.
CHAPTER 4
RADIATION
Four possible events can trigger significant radiation exposure (beside

natural background and medical testing):
1. Nuclear bomb
2. Nuclear power plant disaster
3. Terrorist dirty bomb
4. Accident in transport or storage of nuclear material
When selecting a possible survival retreat, it should be possible
to avoid being at a ground-zero location for any of the above. The
issue then becomes how to minimize the effects of radiation spread-
ing from one of those locations. It is obvious that many metropolitan
areas could be targets for intercontinental ballistic missile attack, and
if they are, they would probably receive multiple hits due to redun-
dant targeting. The locations of nuclear power plants are well-known,
and the greatest danger from them is a natural disaster that causes a
plant malfunction, or terrorist destruction of an individual plant or
mass attack via hacking controls. We need to evaluate the extent of
the plume danger, including its potential distance and contents, and
develop strategies to counter this danger. Bomb plumes are one thing;
continuing plumes from a malfunctioning nuclear plant are another.
A dirty bomb, consisting probably of an enriched nuclear material
detonated by a conventional explosion, will have a different isotope
danger, with intense local long-lasting radiation, but a minimal dis-
tance to its plume. Transport accidents will be localized along a rail
or road corridor, will have a specific isotope release, and will probably
RADIATION 97
be an isolated incident that will bring the grid authorities scrambling

to clean up and cordon off the area, with localized plume and runoff
contamination from surface water.
The isotope release and plume from nuclear bombs has been
extensively studied with regard to bomb construction, yield, and burst
height, including subsurface, ground, and water detonations. The
lethality and injury estimates have also been extensively predicted for
various distances from ground zero for ground and air blasts of vari-
ous yields from nuclear detonations.
A nuclear device detonation releases 40 to 50% of its total energy
as blast overpressure, 30 to 40% as thermal heat radiation, 5% as ion-
izing radiation (more in a neutron bomb, which has much less blast
energy), and 5 to 10% remains as residual radiation.
For those victims too close to ground zero, the rates of death
and survivable injuries will be related to blast and heat injury, but if
we have chosen our retreat location well, we will have avoided those
immediate injuries, and the concern for most preppers will be the
immediate fallout radiation from the plume and then managing long-
term residual contamination. But if you are caught near a detonation
location, the chance for survival increases dramatically by using the
1950s technique of “duck and cover” immediately upon the bright
light flash, by not looking in the direction of the blast, and by shel-
tering. The shock wave will cause immense physical damage directly
and from flying debris. To survive and minimize the blast energy and
the thermal heat and to minimize the ionizing radiation, stay put in
the nearest building for 2 to 24 hours. The length of time to safely
leave and evacuate depends upon the ionizing radiation release and
the protective value of the shelter. During the height of the cold war,
buildings were graded by a protective factor up to R20, the ideal pro-
tective covering for the ionizing radiation phase of the blast, but most
buildings provide at least some protection, and one should evacuate
to a more obviously protective shelter only when the withering initial
ionizing irradiation period has passed or decreased so that increasing
one’s outside exposure briefly to move to an R20 level building is
worth it.
There are different antidotes for the various isotopes, and length of
administration depends upon exposure characteristics. We will focus
on minimizing these dangers and radiation illness in this chapter.
The topics we need to study therefore include the following:
1. Units of radiation measurement
2. Measuring and estimating safe exposure limits
3. Neutralizing immediate fallout and decontamination of
residual contamination
4. Managing long-term radiation exposure
5. Treating radiation sickness
If someone is caught near a blast location, minimizing damage
from overpressure trauma, flying debris, direct radiation, and thermal
burn must be done by finding immediate physical barrier protection
and, if wounded, treating burns (page 139), orthopedic injuries (page
154), lacerations (page 116), injury from foreign bodies (page 38),
and eye injuries (page 36). Radiation sickness prevention and treat-
ment follows.
UNITS OF RADIATION MEASUREMENT

Roentgen is the unit of actual exposure, defined as ionizations per
unit volume of air (measured by Geiger counters and ionization
chambers). The rad is the amount of radiation energy absorbed per
unit of mass. Neutron radiation causes more damage than gamma
or X-ray radiation. A conversion is made by this degree of damage
to form a unit called the rem, or roentgen equivalent in humans. The
international system outside of the United States makes the follow-
ing substitution: Rad is replaced by the gray (Gy), and rem is replaced
by the sievert (Sv).
1 Gy = 100 rad
1 Sv = 100 rem
The quantity of radioactivity is expressed as the number of nuclear
disintegrations per second. One disintegration per second is called 1
becquerel (Bq) in the international system. In the United States one
curie is 37 billion Bq.
RADIATION 99
When describing X-ray, beta, or gamma radiation, the rad and

rem (and Gy and Sv) are essentially the same.
Ionizing radiation damage (the rem or Sv) is accumulative. When
worn continuously, dosimeters can provide insight into this accu-
mulative dose or, with modern electronic systems, can indicate dose
accumulations by various time frames so that workers in radiation-
exposed occupations can be kept below an acceptable accumulative
risk (see figure 4-1). A Geiger counter measures radioactive emissions,
mostly beta and gamma rays, in becquerels, and can be used to iden-
tify points of contamination. Other devices can measure accumulated
Figure 4-1.
Graphical Comparison of Electronic Personal Dosimeters
Rate range (minimum and maximum): The range of exposure rate that the prod-
uct can measure within an accuracy of ±30%. All quantities in this table are
expressed in units of Roentgen (i.e., of Milliroentgens per hour and Roentgens
per hour) to simplify product comparisons. Quantities have been converted by
using the approximation 1 R ≈ 1 rem ≈ 1 rad. Specifications in Sv were first multi-
plied by 100 to convert Sv to rem. Note: 1,000 mR/h = 1 R/h
Source: Radiation for Response and Recovery Market Survey Report. US Department of
Homeland Security, June 2016. https://www.dhs.gov/sites/default/files/publications/(1)
Radiation-Dosimeters-Response-Recovery-MSR_0616-508_0.pdf.
or current dose, and identify the isotope source and type of radiation.
The effect of radiation on people depends upon the intensity of the
dose, how focused it is, and the duration of exposure. A whole-body
dose of 4.5 Gy (450 rad) delivered in minutes to hours will cause
significant illness and possible death, while 10 Gy (1,000 rad) deliv-
ered to a focused area over a long period of time (such as in radiation
therapy) might be well tolerated. Thus, while we tolerate easily a nor-
mal daily exposure of 0.6 rads, mild symptoms will occur at a sudden
exposure to about 30 rads; between 30 and 200 rads, the person may
become ill; from 200 to 1,000 rads the person will become seriously
ill; and above 1,000 rads the dose will be fatal.
If people can protect themselves from the immediate irradiation
from the detonation, they next must deal with fallout and radiation
from contamination, which may be external or internal.
Severe local fallout, extending way beyond the blast and thermal
effects, is increased by larger yield and a near surface burst that will
suck up vast amounts of particulate matter. This irradiated material
starts to fall in a downdraft even as the cloud rises, but the obvious
smaller particles form the classic oval fallout pattern, mostly down-
wind from the blast center.
The low yield atomic (fission) bombs used in the Trinity (19 kt),
Hiroshima (12.5 kt), and Nagasaki (2 kt) blasts did not produce siz-
able fallout. The damage was all due to blast and immediate radiation
effects. Larger tests such as those at the Bikini Atoll and virtually all
of the Chinese above-ground tests have produced sizable fallout.
The explosive energy of any fission bomb is about 90% of the
actual total yield, leaving 10% as residual radiation composed mostly
of fission products. A fusion (hydrogen) bomb will release 95% of its
explosive energy. There are no known biological effects of the electro-
magnetic pulse generated by the bomb, but this can induce long cables
to generate high voltages, destroy unshielded electronic devices, and
cause a short period of radio and radar blackout. Electronics can be
shielded by wrapping them completely in conductive materials such
as aluminum foil.
With surface or near-surface bursts, the fission products of the
bomb are incorporated into materials scoured from the earth. About
RADIATION 101
200 different radioactive substances are formed by fission, with

additional ones created by neutron irradiation of weapon parts, soil,
and other material drafted into the explosion. These materials will
emit beta and gamma radiation with various half-lives, meaning the
length of radioactive decay and danger will differ. Much of this is
carried high into the atmosphere by large fireballs, with the fallout
spreading in a downwind oval pattern. Leftover fissionable material
from the bomb will be negligible and found only in the immediate
vicinity of the blast downdraft where harm from the heat and previ-
ous blast effect will be of much greater concern. A homemade dirty
bomb, simply a conventional explosion of radioactive material, will
have a very dirty immediate-vicinity effect but a minimal plume.
In a large, properly detonated nuclear bomb, there is no immediate
vicinity left.
Even hundreds of bombs going off in Europe, Asia, and North
America will not be the end of the world. A 5-megaton bomb surface
burst would carry aloft about 2 million tons of other materials in the
stem and mushroom cloud. The material that returns to earth over the
next ten years is almost entirely soil with a concentration of radioac-
tive material of less than one-tenth part per million. Surviving the
blast, our job as survivalists is to make sure we increase our chances of
dealing with fallout, and here is how we will do it.
An accurate estimator of radioactive decay of mixed fission prod-
ucts is the “7-10 rule.” Radiation intensity will decrease tenfold for
each sevenfold passage of time. In other words, fallout radiation mea-
sured 4 hours after the blast will be one-tenth that reading at 28
hours after the blast. The fission radiation is a component of initial
radiation during the first minute. At one hour after the blast, the
radioactivity of the fission-product mixture is about 125 times less
than it was at one minute.
The heavier particles that fall to the earth in a manner of hours
contain most of the radioactivity produced by the explosion, but luck-
ily much of this is locked within glassy particles, shielding or contain-
erizing some of the radiation.
A peak dose of 0.5 R/hr, the accepted level above which a fall-
out threat is recognized, extends from a distance of 210 to 310 miles
downwind from this 5-megaton bomb surface burst (a very dirty

explosion with the most immediately dangerous fallout) with a 15
mph wind (figure 4-2).
Distance in miles
Contours in roentgens per hour
Vertical showing peak time after detonation
Fission yield 50%
Figure 4-2.
Peak Dose-Rate Pattern (5 MT surface burst)
Source: DCPA Attack Environmental Manual, chapter 6, panel 11. Defense Civil
Preparedness Agency, US Department of Defense, June 1973. https://www.hsdl
.org/?abstract&did=34719.
The protection factor is the degree of decreasing radiation expo-

sure offered by various substances and buildings. Figure 4-3 illus-
trates the various levels of protection within a metropolitan building.
And why is this important?
RADIATION 103
Figure 4-3.
Levels of Protection
Note: Areas near windows and at street level have less protection than inner
areas; even basements of frame houses provide between 10 and 20 protection
factor (PF). This means that a twentyfold decrease in radiation from outside
exposure would be encountered in that position. It is not hard to develop a
simple construction that can increase the PF to 100, even higher (see chapter 6,
DCPA Attack Environmental Manual, Defense Civil Preparedness Agency, US
Dept. of Defense, June 1973). Single-story homes with average basement wall
exposure aboveground of less than 2 feet will provide PF 20 throughout the
basement. Homes with two or more stories and a basement with no more than 2
feet exposure will provide at least PF 40 throughout the basement.
Source: DCPA Attack Environmental Manual, chap. 6, panel 18. Defense Civil Preparedness
Agency, US Department of Defense, June 1973. https://www.hsdl.org/?abstract&did=34719.
Table 4-1. Dose Penalty Table

Acute Roentgen Exposure 1 Week 1 Month 4 Months
Effects Dose in Any
Medical Care Not Needed 150 200 300
Some Need Medical Care 250 350 500
Few if Any Deaths
Most Need Medical Care 450 600 *
50% + Deaths
*Little or no practical consideration
The accumulative doses of radiation indicated in table 4-1 are a guide

to how much danger the exposed patient will experience. As can be
seen, the damage from radiation is sustained by both the rate at which
exposure occurs and the total accumulative dose.
Table 4-2. Doses at 30 Miles Downwind

5-MT surface burst; 15 MPH wind
Time In Open In Shelter 46 In Shelter 76
1 Week 11,400 248 150
1 Month 13,500 294 178
4 Months 15,000 326 197
The shelter with a 46 protective factor shows the one-week

calculated dose to be 248 R, just short of the 250 R shown in the
dose-penalty table, so few if any deaths would be expected. At one
month the dose would be 294 R and that person would have 56 R
“to spare.” Since the dose outside would be nearly 2 R/hour at one
month, not much time could be spent outside without exceeding
the body’s repair capability (see table 4-2). In certain circumstances,
it might be wiser to use the “spare” dose during the second week
to move out of the heavy fallout area. If equipped with measuring
equipment one could calculate the real exposure risks allowing for
safer evacuation timing. Improve the protective factor of the location
RADIATION 105
by preventing dust from settling inside or rinsing it away. Removing

dust-covered clothing and footwear and rinsing dust from the skin
and hair will reduce this radiation by 90%. Dust will accumulate
beneath belts and waistbands, neck and shirt openings, and on foot-
wear and exposed skin anywhere. Removing this dust reduces the
radiation by another 5%.
Beta burns occur only if fallout is deposited on skin during the
first day or two following detonation; otherwise the decay of this
form of radiation is so rapid as not to cause issues. These beta burns
would appear about 2 weeks after the exposure and will generally heal
well when treated as described on page 139 (burn care).
Of the many residual radioactive components of fallout from a
nuclear blast, the most serious are radioactive iodine (131I), strontium
(89Sr, 90Sr), and cesium (137Cs). Due to its short half-life, radioactive
iodine could exist as a hazard for at most a month. It is particularly
hazardous to children whose thyroid is much more vulnerable to
this exposure than in adults. Radioactive iodine is a major concern
of nuclear power plant meltdowns due to the ease by which iodine
vaporizes and can escape the reactor and auxiliary buildings, unlike the
majority of the other heavier isotopes that remained primarily con-
tained, unlike with a bomb. (See https://www.nap.edu/read/10868/,
especially Appendix B for a full isotope hazard list).
DIAGNOSIS AND MANAGEMENT OF

RADIATION EXPOSURE AND ILLNESS
Clearance of iodine is age dependent and proceeds based upon two
biological half-lives: one of 6 hours (elimination of the whole body
fraction, about 70%) and one of 100 days (elimination of the thyroid
fraction, about 30%); 80% of this excretion is via urine. As of 2018,
the World Health Organization (WHO) states that risk over 1 cGy
(1 rad) is appropriate to initiate iodine blocking treatment, while the
FDA feels it should be 5 cGy (5 rad) from their evaluation of the
Chernobyl data. Treatment of radioactive iodine exposure consists of
loading the thyroid with stable iodine as quickly as possible.
WHO’s recommended dose is 130 mg of potassium iodide,
65 mg for children ages 3 to 12 years (FDA states 65 mg for all
school-age children), 25 mg for infants and children ages 1 month

to 3 years, and 12.5 mg for neonates from birth to 1 month. If using
iodine-potassium iodide solution (Lugol’s solution) 1%, adults need
80 drops, children 3 to 12 require 40 drops, children less than 3 years
old use 20 drops. The highest priorities for treating are newborn
babies, breastfeeding mothers, and children. Dosing before the expo-
sure (immediately after the incident and prior to the arrival of the
radioactive contamination) does the most good. A single administra-
tion of stable iodine is usually sufficient.
Treatment more than 24 hours after exposure may do more harm
than good by prolonging the excretion of the radioactive iodine
already absorbed by the thyroid. Similarly, continued dosing does less
good than an adequate dose pre-exposure (before the plume hits),
as a fully saturated thyroid will not absorb much additional iodine
unless a very large additional supply is offered to it. And even that
additional supply of protective iodine will dislodge what is already
there and sweep some of the radioactive material in with it. Iodine
transfer into the thyroid takes place via complex sodium/iodine sym-
porters, or transmembrane glycoproteins that act as a carrier, trans-
porting the iodine across the basolateral membrane of the thyroid.
The rare exception to requiring additional iodine would be in the case
of continuous high-iodine plume exposure from a melting reactor
(not bombs during the first few days of attack)—an unlikely scenario
that would have to find you just sitting there, not evacuating, and
one causing much more difficulty than radioactive iodine isotopes,
requiring emergency evacuation regardless. You do not need a pre-
scription to obtain potassium iodide pills (sold under brands names
such Iostat, ThyroSafe, ThyroShield), but please note the dosing I dis-
cussed as opposed to what you read in much of the prepper literature.
Also, the storage life is virtually unlimited, not 5 to 7 years.
Ingestion or inhalation of particulate fallout material is particu-
larly difficult to treat, so masks sufficient to filter out fine dust during
the fallout plume phase are essential, even wads of cloth wrapped
around the face as necessary.
Insoluble Prussian blue is a compound that can remove radioactive
cesium and thallium from the body, effectively reducing the biological
RADIATION 107
half-life by binding to these compounds and allowing them to be

defecated. Take 3 grams by mouth 3 times a day for 30 days (minimal
dose). The total duration of therapy would ideally depend upon mea-
suring residual radiation. It is important to be on a high-fiber diet
to prevent constipation while on this product, and the tablets can be
taken with food. It can also lead to low potassium levels.
Tritium (radioactive hydrogen) is removed internally by increas-
ing the intake of water, 3 to 4 liters per day. This can reduce the effec-
tive half-life from 10 days to 2.4 days, and the increased water intake
does not need to extend beyond a week. See page 258 about the issue
regarding overhydration and hyponatremia.
Uranium is chemically toxic to the kidney by itself, but when irra-
diated, the radiation risk prevails. Uranium speeds through the body
fairly quickly, and this can be increased by the use of sodium bicar-
bonate, 2 tablets every 4 hours until the urine reaches a pH between
8 and 9, or one acetazolamide 250 mg tablet. Urine pH can be eval-
uated by common urine test strips, or simply give these tablets every
4 hours for 2 days.
GI tract contamination for americium (241Am), cobalt (57,59,60Co),
plutonium (238,239,249Pu), and polonium (210Po) is complementarily
treated with aluminum hydroxide 10 mL with 1.2 g, 60 to 100 mL
orally or barium sulphate 100 to 300 g in a single oral dose in 250
mL of water.
Strontium (85,89,90Sr) requires very rapid early treatment with
ammonium chloride 0.5 g, 4 tablets every 8 hours. Ten grams of mag-
nesium sulfate speeds up digestive tract transit and reduces absorp-
tion. Radioactive barium and calcium are striated similarly, with
immediate blockage of absorption and inducing diarrhea to prevent
absorption of ingested particles.
The above are adjunctive treatments for decontamination, but
additional intravenous medications would normally be given also,
such as trisodium calcium diethylenetriamine- pentaacetate (Ca-
DTPA) in advanced treatment centers. Obviously, anyone with access
to professional help during a nuclear emergency would seek it, but
the above synopsis of decontamination techniques—of which the
most important is the replacement of clothing, the washing of hair
and exposed skin and to take actions to prevent inhalation and inges-
tion of radioactive particles and gas—may be all that a prepper has
available.
When suspecting contamination, the entire body should be sur-
veyed using a thin window Gieger-Müller probe attached to a survey
meter. Lacking any of the appropriate equipment, the prepper may
have to evaluate the amount of illness by patient symptoms.
There are several symptom phases possible. An exposure range
of 1 to 2 Gy (100 to 200 rad) may have nausea and vomiting onset
within 2 to 6 hours, which lasts less than 1 day, no diarrhea, slight
headache, no fever, maybe some fatigue and weakness. An onset to
vomiting of 1 to 2 hours will occur in 50 to 100% of people exposed
to 2 to 6 Gy, and it will last 24 to 48 hours; they may develop bruises
and hemorrhage and infection about 3 weeks after exposure. Expo-
sure to 3 Gy will result in hair loss in about 3 weeks. While death
may occur in 5 to 50% of these people within 4 to 6 weeks, this means
that most in this exposure range will survive. Above 5 Gy (500 rad) of
sudden exposure, survival without advanced care to provide white cell
stimulation medications and appropriate IV fluids is unlikely.
Then what do you do? You return to the basics of what we always
do in a remote area, practicing medicine in an austere environment.
It’s basically down to supportive care.
Nausea/vomiting/gastritis treatment as per protocols, see page 70.
Diarrhea as per protocols, see page 72.
Fever as per protocols, see page 29.
Even when developing these symptoms, including infections
from temporary suppression of the white blood cell counts, these
people may survive for many years in good health once through this
rough beginning. Receiving advanced medical care, including injec-
tions of medications that stimulate blood formation, would, of course,
be performed in advanced treatment centers. As with any terrible
tragedy, the focus is on supportive care, not making things worse, and
not giving up.
CHAPTER 5
DENTAL CARE
If your potential time off the grid may be substantial, then planning
for dental emergencies is critical. Keep preventative dental care up
to date. Then when off the grid, brush twice daily. If you run out
of toothpaste, use baking soda or salt as a substitute. Flossing and
brushing can prevent needless pain and suffering.
GUM PAIN OR SWELLING

Pain with swelling high on the gum at the base of the tooth usually
indicates an infection and a tooth that may require extraction, or root
canal therapy, if a dentist can be consulted who has brought a lot
more than just his fly rod with him on the trip. Attempting to treat
without either option, have the patient use warm-water mouth rinses.
Start the victim on antibiotics as indicated in the previous section.
If a bulging area can be identified in the mouth, an incision into the
swollen gum made with a sharp blade may promote drainage. If the
pain is severe and not relieved with any pain medication that you
have, the tooth may have to be pulled.
Swelling at the gum line, rather than at the base of the tooth, may
indicate a periodontal abscess. The gingiva (or gum) is red, swollen,
foul smelling, and oozing. Frequently this represents food particle
entrapment and abscess formation along the surface of the tooth and
the gums, the so-called gingival cuff. Considerable relief can often be
obtained by probing directly into the abscess area through the gin-
gival cuff using any thin, blunt instrument. Probe along the length
of the tooth to break up and drain the abscess. Have the patient use
frequent hot-water mouth rinses to continue the drainage process. If
a foreign object, such as a piece of food, is causing the swelling, irri-

gate with a warm salt solution or warm water, using sufficient force to
dislodge the particle. Probe it loose if necessary. Dental floss may be
very helpful. Acute pain and swelling of the tissue behind the third
molar usually is caused by an erupting wisdom tooth; technically this
is called pericoronitis. A little flap of tissue called the operculum lies
over the erupting wisdom tooth, and biting on this causes it to swell,
and it becomes much easier to bite on it again and again. The result
is considerable pain. This can be relieved by surgically removing the
operculum. If local anesthetic is available, such as lidocaine, inject it
directly into the operculum, and then cut it out with a sharp blade
using the outline of the erupting tooth as a guideline. The bleed-
ing can soon be stopped by biting down on a gauze or other cloth
after the procedure is over. Stitching this wound is not required. If no
lidocaine is available, swab the area with alcohol, as this helps pro-
vide some slight anesthesia. Application of powder from a crushed
diphenhydramine tablet from the Non-Rx Oral Medication Module
might provide some anesthesia.
Swelling of the entire side of the face will occur with dental infec-
tions that spread. This condition should ideally be treated in a hospital
with intravenous antibiotics. In the bush apply warm compresses to
the face. Do not lance the infection from the skin side, but a peaked,
bulging area on the inside of the mouth may be lanced to promote
drainage. Abscess extension into surrounding facial tissues generally
means that lancing will do little good. This patient is very ill and rest
is mandatory. Provide antibiotic coverage from the Rx Oral/Topical
Medication Module, with levofloxacin, 500 mg once daily, Zithro-
max as indicated on page 285, or, from the Rx Injectable Medication
Module, Rocephin, giving 500 mg by intramuscular injection every
12 hours. Urgent evacuation is mandatory.
MOUTH LACERATIONS
Any significant trauma to the mouth causes considerable bleeding
and concern. The bleeding initially always seems worse than it is.
Rinse the mouth with warm water to clear away the clots so that you
can identify the source of the bleeding.
DENTAL CARE 111
Laceration of the piece of tissue that seems to join the bottom lip
or upper lip to the gum line, called the labial frenum, is a common
result of trauma to the mouth and need not be repaired, even though
it initially looks horrible and may bleed considerably. Simply stuff
some gauze into the area until the bleeding stops.
A laceration of the tongue will not require stitching (suturing)
unless an edge is deeply involved. Fairly deep cuts along the top sur-
face and the bottom can be ignored when off the grid. If suturing is
to be accomplished and you have injectable lidocaine from the Rx
Injectable Medication Module, inject into the lower gum behind the
teeth on the side of the gum facing the tongue. Technically this area
is called the median raphe distal to the posterior teeth. This will block
the side of the tongue and be much less painful than directly injecting
into the tongue. Use the 3-0 gut sutures. These sutures will dissolve
within a few days. Sutures in the tongue frequently come out within
a few hours, even when they are well tied, much to the victim’s and
surgeon’s annoyance. If this happens and the tongue is not bleeding
badly, just leave it alone. Minor cuts along the edge of the tongue can
also be ignored.
Make sure that cuts on the inside of the mouth do not have for-
eign bodies, such as pieces of tooth, inside of them. These must be
removed. Inject a small amount of lidocaine into the wound before
probing if you have the Rx Injectable Medication Module, then irri-
gate thoroughly with water. Even without the lidocaine, the inside
of the mouth can be stitched with minimal pain. Use the 3-0 gut
sutures, removing them in 4 days if they have not fallen out already.
Refer to page 130 for discussion of suturing the face and the outside
portion of the lips.
DENTAL PAIN
Cavities may be identified by visual examination of the mouth in
most cases. At times the pain is so severe that the patient cannot tell
exactly which tooth is the offender. It helps to know that a painful
tooth will not refer pain to the opposite side of the mouth and painful
back teeth normally do not refer pain to front teeth and vice versa.
With the painful area narrowed down, look for an obvious cavity.
If none is found, tap each tooth in turn until the offending one is
reached—a tap on it will elicit strong pain.
For years, oil of cloves, or eugenol, has been used to deaden den-
tal pain. Avoid trying to apply an aspirin directly to a painful tooth;
it will only make a worse mess of things. Many excellent dental kits
that contain topical anesthetic agents and temporary fillings are now
available without prescription. A daub of topical anesthetic will work.
In your Topical Bandaging Module, you have triple antibiotic with
pramoxine that you can use. It’s the pramoxine component that pro-
vides the pain relief. Before applying the anesthetic, dry the tooth
and try to clean out any cavity you may find. From the Non-Rx Oral
Medication Module, give Percogesic, 2 tablets every 4 hours, or ibu-
profen, 200 mg, 2 to 4 tablets every 6 hours, for pain. When off the
grid and a toothache begins, I would also start treating with an anti-
biotic if the Rx Oral/Topical Medication Module is available. While
not the first choice usually in civilization, use Levaquin, 500 mg once
daily, until swelling or pain resolves, which indicates the infection is
under control.
LOST FILLING
This could turn into a real disaster. An old-fashioned remedy uses
powdered zinc oxide (not the ointment) and eugenol. Start with the
two in equal parts and mix until a putty is formed by adding more
zinc oxide powder as necessary. This always takes considerably more
of the zinc oxide than at first would seem necessary. Pack this putty
into the cavity and allow it to set over the next 24 hours.
The Cavit dental filling paste in the Rx Oral/Topical Medication
Module provides a strong temporary filling. Dry the cavity bed thor-
oughly with a gauze square. Place several drops of anesthetic, such as
oil of cloves (eugenol), to deaden the nerve endings and kill bacteria.
The triple antibiotic with pramoxine ointment from the Non-Rx
Oral Medication Module can also be used for this purpose (plain
triple antibiotic ointment will not work). You will have to pack the
ointment into the cavity area and allow it to melt. Dry the cavity
carefully once again. The Cavit paste should be applied to the dry
cavity and packed firmly into place. Obviously avoid biting on the
DENTAL CARE 113
side of the filling, regardless of the materials used to make your tem-
porary filling. The loss of a filling may indicate extension of decay in
the underlying tooth and an underlying cavity.
CAVITY
In the event a tooth becomes painful, you may note the formation
of a cavity. While in normal dental practice the cavity area would be
drilled out, in your situation off the grid, you may be able to handle
this problem quite well without drilling. Using a dental spoon, you
can scrape the edges of the decay area clean. Be careful not to go too
deep as you will hit the nerve in the pulp at the core of the tooth. As
long as you seal the area with your filling, you should prevent further
decay. Of course, if an abscess has formed, it is too late to fill the tooth
and it should be extracted. Fill with a temporary filling as mentioned
above under lost filling. A more permanent filling can be achieved
with a glass ionomer compound (an Rx item in the US that requires
mixing just before using, it hardens to an appropriate stiffness) or
something like Prevest DenPro’s Fusion Flo nano hybrid composite,
which is available without a prescription but requires an ultraviolet
light to cure or harden it; the UV source can be a blue cobalt penlight.
When placing a permanent filling, you have to be particular about
your technique. After scraping the decay out of the cavity, dry out the
hole or the cement will not stick. Practice with the cement to achieve
the right consistency prior to inserting it or in managing the UV
light to harden the material when it is in place. If the cavity extends
to the side of the tooth, protect the space between the teeth by plac-
ing something thin between them, such as a tooth from a comb. It is
also critical to remove extra cement from around the tooth and from
between the tooth, and to make sure that the filling does not extend
so high that the tooth biting down on it comes into contact with the
filling.
An excellent description of performing this procedure using the
glass ionomer is found in Where There Is No Dentist by Murray Dick-
son (2018). You will find it much easier to use the UV-cured nano
hybrid. You can purchase a simple dental tool kit online, in addition
to any of the products previously mentioned in this section.
LOOSE OR DISLODGED TOOTH

When you examine a traumatized mouth and find a tooth that is
rotated or dislocated in any direction, do not push the tooth back into
place. Further movement may disrupt the tooth’s blood and nerve
supply. If the tooth is at all secure, leave it alone. The musculature of
the lips and tongue will generally gently push the tooth back into
place and keep it there.
A fractured tooth with an exposed pink substance that is bleeding
is showing the exposed nerve. This tooth will need protection with
eugenol and temporary filling as indicated above. This is actually a
dental emergency that should be treated by a dentist immediately.
If a tooth is knocked out, replace it into the socket immediately.
If this cannot be done, have the victim hold the tooth under their
tongue or in their lower lip until it can be implanted. In any case,
speed is a matter of great importance. A tooth left out too long will
be rejected by the body as a foreign substance.
All of the above problems mean a soft diet and avoidance of
chewing with the affected tooth for many days will be necessary. Off
the grid, start the patient on an antibiotic such as doxycycline, 100 mg
daily, for any of the above problems.
Trauma that can cause any of the above may also result in frac-
tures of the tooth below the gum line and of the alveolar ridge affect-
ing several teeth. If this is suspected, start the patient on an antibiotic
as mentioned in the paragraph above. Oral surgical help must be
obtained as soon as possible. A soft diet is essential until healing takes
place, possibly a matter of 6 to 8 weeks.
PULLING A TOOTH
It is best not to pull a tooth from an infected gum, as this might
spread the infection. If an abscess is forming, place the patient on an
antibiotic such as Levaquin, 500 mg daily, or doxycycline, 100 mg
twice daily, and use warm-water mouth rinses to promote drainage.
After the infection has subsided, it is safer to pull the tooth. Opening
the abscess as described under Gum Pain or Swelling (page 109) will
be helpful at times. If it appears necessary to pull an infected tooth,
DENTAL CARE 115
give the patient an antibiotic pill about 2 hours before pulling the
tooth to provide some protection against spreading the infection.
Pull a tooth by obtaining a secure hold with either a dental for-
ceps or, even better, a side-cutting bone rongeur. You will have to
obtain one from a surgical supply house or a friendly orthopedic sur-
geon. Slowly apply pressure in a back-and-forth, side-to-side motion
to rock the tooth free. This loosens the tooth in its socket and will
permit its removal. Avoid jerking or pulling the tooth with a straight
outward force; it can resist all of the strength that you have in this
direction. Jerking may break off the root. The rongeur will grip the
tooth surface by cutting into the enamel, holding better than even
dental extraction forceps. The Murray Dickson book described above
also indicates an alternative method of dental extraction using differ-
ent equipment.
If the root breaks off, you may leave it alone rather than trying to
dig it out. If the root section is obviously loose, then you can pick it
out with a suitable instrument. Thin fragments of bone may fracture
off during the extraction. These will work their way to the surface
during healing. Do not attempt to replace them, but pick them free
as they surface.
If you do not have the side-cutting dental rongeur or dental for-
ceps, it is best not to attempt to pull the tooth with another instru-
ment. Pliers may crush the tooth and the tooth can slip in your grasp.
However, even a large, solid tooth can be removed by using your fin-
ger to rock it back and forth. This may take days to accomplish, but it
will eventually loosen sufficiently to remove.
CHAPTER 6
SOFT TISSUE CARE AND
TRAUMA MANAGEMENT
Probably no issue will distress the prepper more than worrying about
managing wounds—and with good reason. It is estimated that the
rate of home accident lacerations requiring hospitalization is approx-
imately 24.9 per 100,000 persons.
Table 6-1.
A quick review of table 6-1 can help you plan the relative risk
of various common non-fatal injuries that you as a prepper should
SOFT TISSUE CARE AND TRAUMA MANAGEMENT 117
be prepared to handle. This chapter will provide guidance in your

approach to managing these conditions. Bites and stings are covered
in chapter 8, orthopedics in chapter 7, poisoning symptoms in chap-
ter 3, and overexertion in chapter 10.
Skin Injuries and Ailments

The Bleeding Wound 118
Stop the Bleeding 118
Clean the Wound 122
Antibiotic Guidelines 125
Wound Closure Techniques 126
• Tape Closure Techniques 126
• Stapling 126
• Suturing 127
Special Considerations 130
• Shaving the Wound Area 130
• Bleeding from Suture or Staple Use 130
• Scalp Wounds 131
• Eyebrow and Lip Closure 131
• Mouth and Tongue Lacerations 131
• Control of Pain 132
• Dressings 132
Other Types of Wounds 133
• Abrasions 133
• Puncture Wounds 133
• Splinter Removal 134
• Fishhook Removal 135
• Friction Blisters 138
• Thermal Burns 139
• Human Bites 143
• Animal Bites 143
Finger and Toe Problems 144
• Ingrown Nail 144
• Paronychia (Nail Base Infection) 145
• Felon 145
• Blood under the Nail 146
Wound Infection and Inflammation 147

• Abscess 147
• Cellulitis 148
Skin Rash 149
• Fungal Infection 150
• Allergic Dermatitis 151
• Bacterial Skin Rash 152
• Seabather’s Eruption 152
THE BLEEDING WOUND

The first aid approach to a bleeding wound is to stop the bleeding,
treat for shock, and transport the victim (with appropriate assess-
ments) for definitive care. Off the grid it will be very appropriate for
the party to provide its own definitive care.
Stop the Bleeding

Wound care, whether on or off grid, can be broken into chronological
phases. The first phase consists of saving the victim’s life—by stopping
the bleeding and treating for shock. Even if the victim is not bleeding,
you will want to treat for shock. Shock has many medical definitions,
but bottom line, it amounts to an inadequate oxygenated blood sup-
ply getting to the brain. Lie the patient down, elevate feet above the
head, and provide protection from the environment—from both the
ground and the atmosphere. Grab anything that you can find for this
at first—use jackets, pack frames, unrolled tents, whatever. Eventually
you will be able to pitch a tent, put up a rain fly or sun shield, and
prepare materials for further wound care. (See also Shock, page 13.)
Direct pressure is the best method to stop bleeding. In fact, pres-
sure alone can stop bleeding from some amputated limbs! When the
accident first occurs, you may even have to use your bare hand to
stem the flow of blood. Ideally, you will have something to protect
yourself from direct contact with blood and to protect the wound
from your dirty hand. The best item to carry would be a pair of nitrile
gloves. These can withstand long-term storage, as well as heat and
cold, better than latex gloves. In their absence, grab a piece of cloth
(bandanna, clothing article) or other barrier substance (plastic food
wrapper) and press. My book Basic Illustrated Wilderness First Aid,

2nd edition (Falcon Guide, 2016) describes the various glove mate-
rials and their suitability for long-term storage. In general, nitrile
gloves will prove to be the best solution.
Control of blood loss is a priority. This makes the “tourniquet
first” approach appropriate if blood loss cannot be controlled by direct
pressure on an extremity wound. The military has approved two com-
mercial strap and windlass-style tourniquets: the Combat Action
Tourniquet (CAT) and the Special Operations Forces Tactical Tour-
niquet Wide (SOFTT-W ).
The Special Operations Forces Tactical Tourniquet Wide
(SOFTT-W ) pictured in figure 6-1a is the latest model, specially
constructed to give a true 11/2-inch circumference without pinching
when tightened using the windlass.
Due to the interest in the national “Stop the Bleed” awareness
programs precipitated in the United States by active shooter inci-
dents, the American Red Cross is also co-marketing the SOFT-T
tourniquet.
Once applied, keep the tourniquet in place until definitive care
has been reached. A careful exception might be made for a remote
situation. To quote from the current Boy Scouts of America Wilder-
ness First Aid (BSA WFA) doctrine:
In a very remote area where care might not be reached for days,
continuous application will result in loss of the limb. It is more
important to save a life than a limb. In all situations, it is better
to apply a tourniquet prior to seeing the signs and symptoms of
shock. A rule of thumb is to leave a tourniquet on an extremity
with severe arterial bleeding, not venous bleeding, no longer than
2 hours, and attempt to transition to wound packing and a pres-
sure dressing to control severe bleeding. If a tourniquet is left on
an extremity longer than 6 hours then it is recommended to leave
on until definitive care can be reached. Tourniquets should not
be released periodically just to resupply the limb with blood. The
control of blood loss is a critical step in a remote care situation.
Only remove the tourniquet if it seems feasible to apply adequate
direct pressure to fully control the bleeding.
Figures 6-1a and 6-1b.

The Combat Action Tourniquet (CAT) and the Special Operations Forces Tactical
Tourniquet Wide (SOFTT-W).
HEMOSTATIC DRESSINGS
There are now three hemostatic dressings approved by the military.
Since the addition of Combat Gauze (ZMedica LLC, Wallingford,
CT, USA; www.quikclot.com) in April 2008 to the Tactical Com-
bat Casualty Care (TCCC) guidelines, based on recent analyses of
battlefield results in hemostatic dressings used in Afghanistan and
Iraq as well as other special operations combat areas, Celox Gauze
(Medtrade Products Ltd., Crewe, UK; www.celoxmedical.com)

and ChitoGauze (HemCon Medical Technologies, Portland, OR,
USA; www.tricolbiomedical.com) have been added. To use, place
the gauze on the wound on top of the bleeding vessel—not on top
of other bandage material. Direct pressure must be applied contin-
uously for a minimum of 5 minutes or as per the manufacturer’s
recommendation.
If direct pressure does not stop the bleeding, immediately apply
a tourniquet. Extensive military experience has indicated that even
temporary removal of a tourniquet results in a higher loss of life.
Additionally, placement of an effective tourniquet can be difficult.
Ineffective placement allows continued bleeding. Continue applying
direct pressure while the tourniquet is on to facilitate the clotting
process. If an inadequate result is obtained, immediately place a sec-
ond tourniquet about an inch proximal from the first one.
If the patient has lost a massive amount of blood, do not attempt
to remove the tourniquet. Sometimes bleeding control with direct
pressure may require hours of direct pressure, but this is unusual.
There are three main lessons to remember concerning a tourni-
quet: First, applying it sooner rather than later is critical; if bleeding
is not controlled by pressure on an extremity, apply the tourniquet
immediately. Second, a wide tourniquet is better than a narrow one.
Third, don’t remove the tourniquet.
Improvising an adequate tourniquet is difficult to achieve. Belts
seldom work; cords and surgical tubing will not adequately stop bleed-
ing, and an appropriate fastening technique is not easy to maintain.
The minimum width for a tourniquet is 11/2 inches. Tie a short stick
or another rigid object into the tourniquet material to create a wind-
lass technique and twist it, tightening the tourniquet until bleeding
stops—and no more. Attach the stick to the windlass by incorporat-
ing it into the knot and fasten one end of the windlass when it has
been adequately tightened by tying a square knot over it and the limb.
In areas where a tourniquet cannot be applied, plunge two fingers
into the bleeding wound. This always stops bleeding and works any-
where on the body, shy of a massive explosive injury. Use your index
and middle finger held together. This is the technique used over and
over again during surgery when something cuts loose and blood wells
up in the surgical field.
A third technique is an internal pressure packing using a moist
piece of sterile or clean cloth. Wet the cloth with sterile or at least
drinkable water, wringing it out until it’s practically dry. Then stuff
this cloth into the wound firmly, continuing to pack more cloth into
the wound until the bleeding is stopped by the tamponade, or com-
pression. If bleeding continues, do not remove the material, but firmly
stuff in more. Cover this dressing with a dry, clean cloth. It should be
replaced in 24 hours.
With the bleeding stopped, even using your hand, and the victim
on the ground in the shock treatment position, the actual emergency
is over. Her life is safe. And you have bought time to gather together
various items you need to perform the definitive job of caring for this
wound. You have also treated for psychogenic shock—the shock of
fear.
In the first aid management of this wound, the next step is simply
bandaging and then transporting the victim to professional medical
care. For those who are isolated and must provide long-term care for
wounds, further management will go through several more phases:
cleaning, closing, dressing, and treating the possible complications of
infection.
Clean the Wound

Adequate cleansing is the most important aspect of wound manage-
ment. Especially when in an isolated or survival situation, the preven-
tion of infection is of critical importance and can only be assured by
aggressive irrigation techniques.
There is an adage in nature: “The solution to pollution is dilution.”
In wound care this means copious irrigation. The whole purpose of
scrubbing a wound is to reduce the total number of potentially harm-
ful bacteria. You won’t get ’em all out, but if the total number is suffi-
ciently small, the body’s own defense mechanisms can take over and
finish the job for the patient.
To best provide water for irrigation, prepare sterile water. This can
be done by boiling the water for 5 minutes. Lacking the ability to do
that, try to use water that is fit for drinking (see page 89–94 for tech-
niques of water purification). In a pinch, clean water from a stream or
lake can be used as long as you are not downstream from the sewage
pipe of a third-world village, or the bloated, rotting carcass of a moose.
To provide adequate force to the irrigation stream, there are two
items of potential importance. One is the bulb syringe (see figure
6-2). The 1-ounce model is adequate for most wounds. The other
approach is to use a syringe (10 to 35 ml size) with a device attached
called a Zerowet Supershield (see figure 6-3). With either technique
one can increase the velocity of the water to aid in dislodging debris
and those all-important germs.
Forceful water irrigation is the mainstay of wound cleaning. The
use of a bota bag, a squeezable plastic water cube, or simply a ziplock
plastic bag with a small hole poked in it to bring a stream of water
to the wound is very helpful, but the stream generated using them is
not fully adequate to provide the irrigation force required. Adding
mild surgical scrub solution to the initial batch of irrigation water is
a good step but does not make up for the lack of adequate forceful
irrigation. Adding mechanical abrasion can be helpful and probably is
the only hope of adequate wound cleansing. Several products can be
particularly useful for this technique. The most effective is Hibiclens
surgical scrub. Another is povidone iodine (Betadine) diluted to a 1%
solution (the stock solution is 10%). Another approach is to use a very
dilute soap solution. Err on the side of making the soap solution too
weak, because strong soap solutions can damage healthy tissue. Make
the solution weak enough that you could drink it without purging
yourself.
Many cleaning techniques and compounds should not be used:
Tincture of iodine, Mercurochrome, and alcohol are very harsh, and
hydrogen peroxide destroys good flesh as well as germs. Red-hot
branding irons and pouring gun powder into a wound and lighting
it, while effective in killing germs and among Rambo’s favorite tech-
niques, also destroy good tissue. And destroyed tissue is not some-
thing you want when you are off the grid.
When stuck with a weak irrigation stream, perhaps being able
to pour water into the wound only from a container, the mechanical
abrasion technique saves the day. Besides irrigation, a technique of

cleaning used by physicians in the operating room is called debride-
ment. This amounts to cutting away destroyed tissue. Of course, there
is no way a person can do this in the bush—especially with inadequate
lighting, equipment, and training. But we can safely approximate it
by vigorously rubbing the area with a piece of sterile gauze or clean
cloth. The rigorous scrubbing action will remove blood clots, torn bits
of tissue, pieces of foreign bodies—all items that generally result in
higher bacteria counts or foci for bacterial growth. This scrubbing
process has to be accomplished quickly—it is painful and the victim
will not tolerate it for long. Have everything ready: clean, dry dress-
ing to apply afterward; the water supply; an instrument to spread the
wound open (a pair of tweezers or the needle holder are ideal); and
sterile gauze to use for scrubbing this wound.
To sterilize cloth and any instruments, boil for 5 minutes, if nec-
essary in the water you are preparing to use for irrigation. While hav-
ing adequate sterile dressings would be ideal, you may find yourself
slicing and dicing your wool shirt or Polarguard jacket into bandag-
ing material. A rough cloth works better at wound cleaning than a
smooth cloth, such as cotton.
Once everything is ready and assistance is at hand (perhaps
someone to squirt the jet of water into the wound and another to
assist shooing the black flies away or comforting the victim), go to it!
If this job is performed well, the final outcome will be great. This part
of wound care is far more important than wound closure technique.
It will be messy. And it will hurt. But spread the wound apart, blast
that water in there the best you can, and scrub briskly with the gauze
pad. This whole process will have to be completed in 20 to 30 seconds.
In the operating room, or under local anesthesia in the emergency
room, we might take 15 minutes or longer. You won’t be able to take
that much time, but you must be thorough and vigorous. You should
use at least 1 cup of water for a very small wound and 1 quart (1 liter)
for most other wounds. When in doubt, do more—if the patient can
tolerate it within reason.
Once the irrigation is completed, the wound will bleed vigorously
again, since the blood clots were knocked off during the cleansing
Figure 6-2. Figure 6-3.

The irrigating bulb syringe The Zerowet Splashield attached to a
3-1 syringe
3-2 as long as
process. Apply a sterile dressing and use direct pressure
necessary to stop bleeding; 5 to 10 minutes usually suffice, but if an
hour or more is required, keep at it or use the pressure dressing tech-
nique described above. If you fail to adequately clean a wound, the
resulting infection could cost the patient his life. It would simply be a
slower and more painful demise than bleeding to death.
Antibiotic Guidelines
It is always tempting to place a person on antibiotics after a lacera-
tion, but I would advise against doing this unless the wound was from
an animal or human bite (see pages 143–144), the wound occurred
in contaminated water, or there was an open fracture (see page 163).
Bacteria are jealous creatures and do not like to share their food source
with other species. If an infection develops, it will generally be a pure
culture, the other species originally contaminating the wound having
been killed off by the body’s defense mechanisms and the winning
bacterium. If the patient is on an antibiotic from the beginning, the
winning bacterium is guaranteed to resist your medication. If no anti-
biotic is used initially, there is hope that the emergent bacterium will
be sensitive to the antibiotic that you are about to employ.
If it is necessary to start a prophylactic antibiotic, from the Rx

Oral/Topical Medication Module use Levaquin, 500 mg once daily
for 3 days. In case of infection, see page 147.
WOUND CLOSURE TECHNIQUES

With direct pressure still applied, dry around the wound. We are now
ready to enter the wound-closure phase of wound care. Perhaps more
worry and concern exist about this phase of wound care than the oth-
ers, but it is really the easiest—and much less important than the first
two phases just discussed.
Tape Closure Techniques

If the laceration can be held together with tape, then by all means
use tape as the definitive treatment. Butterfly bandages are univer-
sally available and generally work very well. The commercial but-
terflies are superior to homemade in that they are packaged sterile
with a no-stick center portion. They can be made in the field by
cutting and folding in the center edges to cover the adhesive in the
very center of short tape strips, thus avoiding adhesive contact with
the wound. Of course, such homemade strips will not be sterile, but
in general they will be very adequate. Steri-Strips and their generic
equivalents are now commercially available in neighborhood phar-
macies. The ideal wound closures, they are lightweight, inexpensive,
and easy to apply.
When using a tape method of closure, adhere the strips next to
each other to opposite sides of the wound, then use them to pull the
wound together as you proceed down the wound length, closing it
as you go. Even with very sticky tape, there may be times when they
cannot hold a wound closed and the wound will have to be stapled or
sutured (stitched).
Stapling
A fast, strong method of holding skin edges together is with the use
of stainless-steel staples. A special disposable device will contain a
certain number of sterile staples that rapidly staple the wound edges
while pinching the wound together. This obviously stings while being
Figure 6-4.
The 3M Precise Five-Shot Skin Stapler and its companion staple extraction
device 3-3
used, but the pain is brief and the wound is securely closed. A very
useful device is the Precise Five-Shot Skin Stapler by 3M, which
obviously contains five staples. A special disposable staple remover is
very handy for removing staples virtually painlessly. The skin stapler
and staple remover are nonprescription and shown in figure 6-4. They
come packaged in sterile, waterproof containers.
Suturing
Suture (stitching) material is available in many forms and with many
types of needles. For the expedition medical kit, I would recommend
using 3-0 nylon suture with a curved pre-attached needle, shown in
figure 6-5. This comes in a sterile packet ready for use. It will be nec-
essary to use a needle holder to properly hold the suture. The nee-
dle holder looks like a pair of scissors, but it has a flat surface with
grooves that grab the needle and a lock device that holds the needle
firmly. Hold it as illustrated to steady the hand. All fly-tying stores
sell needle holders.
Apply pressure in the direction of the needle, twisting your wrist
in such a manner that the needle will pass directly into the skin and
cleanly penetrate, following through with the motion to allow the
needle to curve through the subcutaneous tissue and sweep upward
and through the skin on the other side of the wound; see figure 6-6.
3-4 3-5
Figure 6-5.
3-4 decreases hand tremor.
Grasping the needle holder; this technique
3-5
Figure 6-6.
Proper placement of suture,
showing passage of the suture
material at an equal depth on
both sides of the cut
Figure 6-7.
Improper placement of suture, showing that different depths of penetration result
in tissue puckering
DEPTH OF SUTURES
Suture through the skin surface only and avoid important structures
underneath. If tendon or nerve damage has occurred, irrigate the
wound thoroughly as described previously under “Clean the Wound”
and repair the skin either with tape or sutures as necessary. The ten-
don or other structures can be repaired by a surgeon upon return to
the outside—weeks later if necessary.
It is important to have the needle enter both sides of the wound

at the same depth or the wound will not pull together evenly, and
there will be a pucker if the needle took a deep bite on one side and a
shallow bite on the other; see figure 6-7.
A square knot is tied with the use of the needle holder in a very
easy manner, as in figure 6-8. Frankly, a knot tied in any fashion will
do perfectly well.
1 2 3
4 5 6
7 8 9
Figure 6-8. How to tie a square knot

Loop the suture around the needle holder once, using the long end of the
thread.
3-7
Grasp the short end and pull the wound together.
Loop the long end around the needle holder again the opposite way. This will
form a square knot.
Repeat this process a third time in the original direction to ensure a firm knot. Do
not pull too tightly, as this will pucker the skin; just an approximation is required.
SPACING OF STAPLES AND SUTURES

The stitches should not be placed too closely together. Usually, on the
limbs and body, 4 stitches per inch will suffice. On the face, however,
use 6 per inch; here it is best to use 5-0 nylon, as it will minimize scar
formation from the needle and suture. I use a 6-0 suture on the face,
but it is considerably more difficult to use than the 5-0.
These stitches can be combined with tape strips or butterfly ban-
dages to help hold the wound together and to cut down on the num-
ber of stitches required.
Once they are in, leave stitches in the limbs for 10 days, in the
trunk and scalp for 7 days, and in the face for 4 days. A wound that
tends to break open due to tension, such as over the knee, can be sta-
bilized by splinting the joint so that it cannot move while the wound
is healing.
SPECIAL CONSIDERATIONS
Shaving the Wound Area

It has been found that shaving an area actually increases the chance of
wound infection. Scalp lacerations are hard to suture when unshaven
due to the matting of hair with blood and accidental incorporation
of hair into the wound. However, catching hair in the wound is not
detrimental. Just pull it loose from the wound with a pair of forceps
or tweezers when you are through suturing.
Bleeding from Suture or Staple Use

You will note that entrance and exit points of the needle punc-
ture anywhere on the body will bleed quite freely. A little pressure
always stops the bleeding—it is not necessary to delay your sewing
to even worry about it. Just complete stitching the wound, then
apply pressure until the bleeding from the needle punctures stops,
cleanse the skin when you are done to remove dried blood, and
dress the wound.
Scalp Wounds
Scalp wounds bleed excessively—expect this. Spurting blood vessels
can be clamped with the needle holder and tied off with a piece of the
3-0 gut suture from the Topical Bandaging Module. To tie, simply
place a knot in the flesh to fall beneath the tip of the needle holder.
Someone may have to remove the needle holder while you are cinch-
ing the first loop of the knot. Or you may simply suture the scalp
wound closed and apply pressure between each suture to minimize
intraoperative bleeding. Apply firm direct pressure after suturing to
minimize hematoma (blood pocket formation) from bleeding within
the wound.
I have read many times that a scalp laceration can be closed by
tying the hair on either side into a knot, thus holding the wound
together. I have sutured a lot of scalp lacerations, and I doubt this
technique would work very well. A scalp laceration bleeds so pro-
fusely, blood is so sticky and slippery at the same time, and the hair
would have to be long enough and of the right texture. See the dis-
cussion on head injuries on page 165.
Eyebrow and Lip Closure

If sewing an eyebrow or the vermilion border of the lip, approximate
the edges first with a suture before sewing the ends or other por-
tion of the laceration. Never shave an eyebrow. Use 5-0 nylon suture
on the face and remove these sutures in 4 days, replacing them with
strips of tape at that time.
Mouth and Tongue Lacerations

When sewing the inside of the mouth, use the 3-0 gut suture. These
sutures tend to unwind very easily, especially if the patient cannot
resist touching them with his tongue. When making the knot, tie it
over and over. The mouth heals rapidly, and even if the sutures come
out within a day, the laceration has generally stopped bleeding and
may heal without further help. These mouth sutures will generally
dissolve on their own, but any remaining ones can be removed within
4 days.
Lacerations on the tongue can almost always be left alone. The

wound may appear ugly for a few days, but within a week or two there
will be remarkable healing. Infections in the tongue or mouth from
cuts are very rare. If the edge of the tongue is badly lacerated, so that
the tongue is cut one-quarter of the way across or more, sewing the
edge together is warranted. Use the 3-0 gut suture.
Control of Pain
For anesthesia you will require a prescription to obtain injectable
lidocaine 1% and a syringe with needle. Inject into the wound, just
under the skin on both sides of the cut. Cleansing and suturing soon
after a cut may help minimize the pain, due to tissue “shock” in the
immediate post-trauma period. Ice applied to the wound area can
help numb the pain, but local topical anesthetic agents are of no help
in pain control. Two Percogesic or 2 or 3 ibuprofen, 200 mg, given
about 1 hour prior to surgery may help minimize pain.
Dressings
Most sutured lacerations leak a little blood during the first 24 hours.
Increased pain or apparent swelling is a reason to remove the dressing
to check for signs of infection (see page 147). The dressing should be
removed, and replaced, when it is time to remove staples or sutures
as indicated above. When using a hydrogel dressing system, it is not
necessary to remove the dressing, as it facilitates more rapid healing
and provides protection from the environment while in place. There
are many brands of these dressings at local drug stores. Look for a
bandage that has a gel pad construction.
Alternative dressings in the Topical Bandaging Module are the
Nu Gauze pads and the Tegaderm and Spenco 2nd Skin dressings.
An initial covering that can soak up leaking wounds is the Nu Gauze
pad. After the wound becomes dry, the Tegaderm dressing will keep
the sutures visible and the wound protected even if it must be sub-
mersed in water. Wounds that continue to leak considerable serum
and/or blood should be covered by Spenco 2nd Skin and managed as
discussed above.
OTHER TYPES OF WOUNDS
Abrasions
An abrasion is the loss of surface skin due to a scraping injury. The
best treatment is cleansing with Hibiclens surgical scrub, applica-
tion of triple antibiotic ointment, and the use of gel pad dressing, all
components of the Topical Bandaging Module. This type of wound
leaks profusely, but the above bandaging allows rapid healing, excel-
lent protection, and considerable pain relief. Avoid the use of alcohol
on these wounds as it tends to damage the tissue, to say nothing of
causing excessive pain. Lacking first aid supplies, cleanse the wound
gently with mild detergent and protect it from dirt, bugs, and other
contaminants the best that you can. Tetanus immunization should
have been within 10 years; see discussion in chapter 9.
A significant question on the mind of the victim and the medic
is how aggressively ground-in cinder and dirt should be removed
from a road rash. Having raced bicycles for several years on a cinder
track (Indiana University’s Little 500), I have had personal experi-
ence with this—which perhaps clouds my perspective. Before I raced,
I aggressively cleaned these wounds with a wire brush. During my
racing years my approach changed to simply coating the wound with
a layer of the antibiotic ointment and allowing the resultant scab
formation to lift the cinders out of the wound when it fell off. A
recent publication has shown that antibiotic salve, if applied within
3 hours of a surface wound, significantly decreases wound infection
in animal studies. I have not experienced problems with cinder tat-
toos or wound infection using a gentle scrub (e.g., Hibiclens) with a
soft cloth, removing deeply embedded debris carefully with tweezers,
and liberally coating triple antibiotic ointment, reapplied daily or as
necessary until the wound heals. I like to avoid a bandage, leaving the
wound open to the air, or using a gel pad dressing when a covering is
required over the ointment.
Puncture Wounds
Briefly allow a puncture wound to bleed, thus hoping to effect some
irrigation of bacteria from the wound. Cleanse the wound area with
surgical scrub or soapy water and apply triple antibiotic ointment to

the surrounding skin surface. Do not tape it shut, but rather apply a
warm compress for 20 minutes every 2 hours for the next 1 to 2 days,
or until it is apparent that no subsurface infection has started. These
soaks should be as warm as the patient can tolerate without danger
of burning the skin. Larger pieces of cloth, such as undershirts, work
best for compresses, as they hold the heat longer. Infection can be
prevented or treated with antibiotics as described in the section on
cellulitis (page 148). Dress with a clean cloth. If sterile items are in
short supply, they need not be used on this type of wound. Tetanus
immunization should be current (see chapter 9).
Splinter Removal
Wash the wound with Hibiclens surgical scrub or another solution
that does not discolor the skin. Minute splinters are hard to see. If the
splinter is shallow, or the point buried, use a sharp blade to tease the
tissue over the splinter to remove this top layer. The splinter can then
be pried out more easily.
It is best to be aggressive in removing this top layer and obtaining
a substantial bite on the splinter with the tweezers, rather than nib-
bling off the end when making futile attempts to remove it with inad-
equate exposure. When using tweezers, grasp the instrument between
the thumb and forefinger, resting the instrument on the middle fin-
ger and further resting the entire hand against the victim’s skin, if
necessary, to prevent tremor. Approach the splinter from the side, if
exposed, grasping it as low as possible; see figure 6-9. Apply triple
antibiotic ointment after removal.
Figure 6-9.
Hold tweezers parallel
to the skin surface and
grasp only after obtain-
ing adequate exposure
of the splinter.
3-8
Tetanus immunization should be current (see chapter 9). If the

wound was dirty, scrub it afterward with Hibiclens or soapy water. If
deep, treat as indicated above for Puncture Wounds, with hot soaks
and antibiotics.
Fishhook Removal
The first aid approach to an impaled fishhook is to tape it in place
and not try to remove it if there is any danger of causing damage to
nearby or underlying structures, or if the patient is uncooperative.
Cut the fish line off the hook. Destroy triple hooks, but do not cut
the hook close to the skin with your wire cutters. This makes subse-
quent manipulation by the surgeon more difficult. Anyone fishing
with barbed hooks needs to include side-cutting wire cutters in their
tackle equipment.
If you will be more than 2 days from help, it is important to
remove any impaled object, including a fishhook, as such objects are
a high risk for infection. And, since fishhooks are relatively easy to
remove anyway, you may wish to do it yourself to prevent a long trip
back to town and the doctor’s waiting room.
There are three basic methods for removing a fishhook, which I
refer to as “the good, the bad, and the ugly” techniques. I will let you
decide which is which:
Push through, snip off method: While the technique seems straight for-
ward, consider a few points:
1. Pushing the hook should not endanger underlying or adja-
cent structures. This limits the technique’s usefulness, but it
frequently is still an easy, quick method to employ.
2. Skin is not easy to push through; it is very elastic and will
tent up over the barb as you try. Place the side-cutting wire
cutters, with jaws spread apart, over the point on the surface
where you expect the hook point to punch through to
hold the skin down while the barbed point punches to the
surface.
3. This is a painful process and skin hurts when being poked

from the bottom up, as much as from the top down.
Once committed, finish the push-through portion of this
technique as quickly as you can.
4. This adds a second puncture wound to the victim’s anatomy.
Cleanse the skin at the anticipated penetration site before
shoving the hook through, using soap or a surgical scrub.
5. When snipping off the protruding point, cover the wound
area with your free hand to protect yourself and others from
the flying hook point. Otherwise you may need to refer to
the section on removing foreign bodies from the eye on
page 38.
The steps are simple:
1. Push the hook through.
2. Snip it off.
3. Back the barbless hook out.
4. Treat the puncture wounds. If you do not have wire cutters,
you may still use this technique, but be able to crush the
barb flat enough that you will be able to back the hook out.
The string jerk method: This is the most elegant of the methods.
Fingers are loaded with fibrous tissue that tends to hinder a
smooth hook removal. This technique works best for the back of
the head, the shoulder, and most aspects of the torso, arms, and legs.
It is highly useful and can be virtually painless, causing minimal
trauma.
See figure 6-10: (A) Loop a line, such as the fish line, around
the hook, ensuring that this line is held flush against the skin. Push-
ing down on the eye portion of the hook helps disengage the hook
barb, so that the quick pull (B) will jerk the hook free with minimal
trauma. Many times a victim will ask, “When are you going to pull it
out?” after the job has been completed.
(A)
(B)
Figure 6-10.
Press the shank of the hook against the skin surface. Vigorously jerk the hook
along the skin surface.
3-9
The dissection method: At times it just seems we are not as lucky, and
we must resort to what will probably be a difficult experience for the
victim and surgeon alike.
This is the case with embedded triple hooks, a hook near the eye,
or other situations when the above methods cannot be used. No per-
son in his right mind would attempt this on his own if evacuation to
a physician’s office was at all possible. It is tedious and, without a local
anesthetic, such as injectable lidocaine, extremely painful.
The technique employs the use of either a sharp, thin blade or an
18-gauge or larger bore hypodermic needle. Examine a hook similar
to the one that is embedded in the victim to note the bend in the
shank and the location of the barb. You will need to slide the blade
along the hook shank, cutting the strands of connective tissue so that
the hook can be backed out. If using the needle, you will have to slide
it along the hook and attempt to cover the barb with a hollow tube,
thus shielding connective tissue strands from the barb, allowing the
hook to be similarly backed out. This is an elegant method and can

result in minimal tissue damage, with only the entry hole left. But
it can take time and, without local anesthesia, the victim has to be
stoic. If available, inject a little 1% lidocaine from the Rx Injectable
Medication Module. Practice this technique using a piece of closed-
cell foam sleeping pad, rather than human skin, prior to your trip in
the bush.
Friction Blisters
Blisters can be prevented if immediate care is taken of any hot spot as
soon as it develops. Generally, a simple piece of tape placed directly
over the hot spot will eliminate any friction causing the problem.
An easily obtainable substance has revolutionized the prevention and
care of friction blisters: Spenco 2nd Skin, available at most athletic
supply and drug stores. Made from an inert, breathable gel consisting
of 4% polyethylene oxide and 96% water, it has the feel and consis-
tency of, well, most people would say, snot. It comes in various-size
sheets and is sterile and sealed in watertight packages. It is very cool
to the touch; in fact, large sheets are sold to cover infants to reduce
a fever. Three valuable properties make it so useful: It will remove all
friction between two moving surfaces (hence its use in prevention); it
cleans and deodorizes wounds by absorbing blood, serum, or pus; and
its cooling effect is very soothing, which aids in pain relief.
2nd Skin comes between two sheets of cellophane. It must be
held against the wound, and for that purpose the same company
produces an adhesive knit bandage. For prevention, 2nd Skin can be
applied with the cellophane attached and secured with the knit ban-
daging. For treatment of a hot spot, remove the cellophane from one
side and apply this gooey side against the wound, again securing it
with the knit bandaging.
If a friction blister has developed, it will have to be lanced. Cleanse
it with soap or surgical scrub and open it along an edge with a sharp
blade. There is no advantage to making a small hole as opposed to a
wide incision. Allow the skin covering to collapse by expressing the
fluid, and then apply a fully stripped piece of 2nd Skin. This is best
done by removing the cellophane from one side, then applying it to
the wound. Once it adheres to the skin surface, remove the cellophane
from the outside edge. Over this you will need to place the adhesive
knit. The bandage must be kept moist with clean water. The 2nd Skin
should be replaced daily. If the skin cover is still covering the wound,
it should be cut off after 2 days, as the skin underneath is now less
raw and the dead skin will start to decompose. Until you use it on a
friction blister, you’ll find it hard to believe how well 2nd Skin works!
It makes good sense to coat all open blisters with triple antibiotic
ointment. This acts as a barrier to prevent infection.
The old blister-care technique using rings of moleskin is seldom
effective. Moleskin should be relegated to the dark ages of medicine.
But it is cheap, and for that reason most commercial first aid kits
include it rather than Spenco 2nd Skin.
Thermal Burns
As soon as possible remove the source of the burn. Quick immer-
sion into cool water will help eliminate additional heat from scalding
water or burning fuels and clothing. Do not overcool the victim and
cause hypothermia. If water is not available, suffocate the flames with
clothing, sand, or other flame suffocating materia. Do not allow a
victim to panic and run, as this will fan the flames and increase the
injury.
Treatment of burns depends upon the extent (percent of the
body covered) and the severity (degree) of the injury. The percent of
the body covered is estimated by referring to the “rule of nines,” as
indicated in figure 6-11. An entire arm equals 9% of the body sur-
face area; therefore, the burn of just one side of the forearm would
equal about 2%. The chest and back equal 18%, and the abdomen and
back equal 18%. The proportions are slightly different for small chil-
dren, the head representing a larger percentage (18%) and the legs a
smaller percentage (13.5%). Severity of burns is indicated by degree.
First degree (superficial) will be red, dry, and painful. Second degree
(partial skin thickness) will be moist and painful, and have blister
formation with reddened bases. Third degree (deep) involves the full
thickness of the skin and extends into the subcutaneous tissue with
char, loss of tissue, or discoloration.
For purposes of field management, victims can be divided into

three groups depending upon a combination of the extent and sever-
ity of the burn.
First-degree burns, regardless of the extent, rarely require evac-
uation. The severe pain initially encountered in a first-degree burn
usually disappears within 24 hours. The patient’s requirement for pain
medication can range from ibuprofen, 200 mg, 4 tablets every 4 to 6
hours, to Percogesic, 2 tablets every 3 to 4 hours. After a few doses,
further pain medication is generally not required. Surface dressings
13.5 13.5
Figure 6-11.
The “rule of nines” burn chart helps determine the percentage of a body cov-
ered by burns. Note the differences3-10
between an adult and an infant.
are not indicated, but soothing relief of small burns can be obtained
by either applying a Spenco 2nd Skin dressing or a damp cloth.
Second-degree burns covering less than 15% and third-degree
burns covering less than 10% of the body surface area do not require
rapid evacuation, but they should receive professional care. Pro-
vide pain medication as above. Cleanse the area with either a gen-
tly applied surgical scrub or nonmedicated soap. Do not attempt to
remove debris that is stuck to the burn site. Gently pat it dry. The
general consensus is to remove skin from blisters that have ruptured
or that are blood filled. I find it best to initially leave the skin covering
the blister, removing it after 3 days. People generally feel better when
you open turgid blisters with a long cut using a sharp blade. Apply
Spenco 2nd Skin dressing and change it twice daily. Second-degree
burns will slough off the skin after 3 to 4 days. An unopened or cov-
ered blister surface will turn white in 3 days, and frequently an ooze
of pus may develop in the underlying blister fluid. If the underlying
skin does not become red and swollen, this is a normal development.
White, moist, dead skin should be cut away. If you have no ointment
or dressings, leave a second- or third-degree burn alone. The surface
of the blister, if it is drained, will dry out and slough off on its own.
Either way, healing will take place in 2 weeks or less for a second-
degree burn. A third-degree burn greater than 1/2 square inch will
require a skin graft to heal. Red swollen skin under and around the
burn site probably indicates an infection. If this develops, provide
antibiotics from the Rx Oral/Topical Medication Module, such as
Levaquin, 500 mg once daily, or from the Rx Injectable Module give
Rocephin, 500 mg by intramuscular injection twice daily. Elevate the
burned area to minimize the swelling.
A third-degree burn greater than 10% and second-degree burn
greater than 15% of the total body surface area, any serious burn to
the face, and any third-degree burn of hands, feet, or genitals require
urgent evacuation of the patient. Wound management is the least
important part of the care of these patients. Burn wounds are sterile
for the first 24 to 48 hours. Burn management is aimed at keeping the
wound clean, reducing pain, and treating for shock.
An important aspect of treating for shock will be maintaining

adequate fluid replacement. Generally patients with less than 20%
of their body surface area burned can tolerate oral fluids very well. If
they are not vomiting, those with between 20 and 30% of their body
surface area involved can be resuscitated by drinking adequate fluids.
This individual will be prone to go into shock. If the victim is vomit-
ing, he will fall behind in fluid replacement.
The replacement fluid should initially consist of Gatorade
diluted 1:1 with water, or a mixture consisting of 1/3 teaspoon salt
and 1/3 teaspoon baking soda in 1 quart (1 liter) of flavored, lightly
sweetened water. Avoid the use of potassium-rich solutions (orange
juice, apple juice), as serum potassium can rise to high levels during
the first 24 hours. During the second day the oral fluids should
be diluted Gatorade and lightly sweetened, flavored water (such
as Wyler’s dried fruit crystals or dilute Tang). Push as much fluid
during these 2 days as the patient can tolerate without becoming
nauseous. Attempt to keep urine flow at 12/3 to 31/3 ounces (50 to
100 ml) per hour. Nausea can be suppressed with adequate pain
management and the use of Atarax, 25 to 50 mg every 6 hours,
from the Rx Oral/Topical Medication Module, or Vistaril, 25 to
50 mg by intramuscular injection every 4 hours as needed, from the
Rx Injectable Module. Pain relief will require Nubain, 10 to 20 mg
intramuscular, the nasally inhaled Stadol (see page 289), or the oral
medications as tolerated. Patients who lapse into a coma during the
first 48 hours will require intravenous fluids to save their lives. Phy-
sicians equipped with IV fluids are aware of the massive doses that
are required to succeed at this point.
Starting on the third day, the patient should be given a moder-
ately high carbohydrate diet, rich in protein. Approximately 200 mg
of vitamin C and substantial vitamin-B complex should be started
daily. This would equal about 4 each One-A-Day multiple vitamin
(Miles Laboratories) or equivalent. Continue to push fluids.
Spenco 2nd Skin is the ideal dressing for these severe burns. It
provides a breathable cover that is sterile and will exclude bacteria
from the environment. It is also easily removed with whirlpool or
gentle cleansing. Otherwise, apply a topical dressing such as triple
antibiotic ointment. Occlusive dressings must not be used. The oint-

ment may be placed on thick gauze dressings that are then held
against the wound with a single layer of gauze roll dressing. The
wound should be cleaned daily, removing obviously dead tissue. This
can be done with gentle scraping using a sterile gauze and clean water
with a little Hibiclens surgical scrub added, about 30 minutes after
proper pain medication has been provided. Lacking Hibiclens, use a
very dilute soap solution. Elevate the burned area, if practical. Have
the victim gently and regularly move the burned area as much as pos-
sible to minimize contraction of burn tissue across joints. This will be
a concern only with long-term care lasting many weeks.
Avoid the use of oral or injectable antibiotics to prevent wound
infection. If you suspect an infection has developed because the
underlying tissue is becoming red and swollen, red streaks are travel-
ing from the burn toward the heart, or the burn was grossly contami-
nated (such as from an explosion), use antibiotics as described above.
Human Bites
Unless group discipline has really degenerated, human bites are due
to accidents such as falling and puncturing flesh with teeth. Bites
within the victim’s own mouth seldom become infected and are dis-
cussed in the section on mouth lacerations (see page 110). Human
bites to any other location of the body have the highest infection rate
of any wound. Scrub vigorously with Hibiclens surgical scrub, soapy
water, or any other antiseptic that you can find. Pick out broken teeth
or other debris. Coat the wound area with triple antibiotic ointment.
Start the application of hot, wet compresses as described under Punc-
ture Wounds (page 133). Start antibiotics with Rocephin, 500 mg IM
every 12 hours, or from the Rx Oral/Topical Module use Levaquin,
500 mg once daily. Bite wounds to the hand are extremely serious and
should be seen by a qualified hand surgeon as soon as possible.
Animal Bites
Animal bites tend to be either tearing or crushing injuries. Animal
bite lacerations must be vigorously cleaned, but hot soaks need not
be started initially. Some authorities state that bite lacerations should
not be taped or sutured closed due to an increased incidence of wound

infection. This has not been my personal experience, nor that of many
ER physicians with whom I have discussed this problem. After vigor-
ous wound cleansing I would close gaping wounds as described under
Wound Closure Techniques (page 126). Only gaping wounds should
be closed—not puncture wounds. Start antibiotic coverage immedi-
ately, as described in the preceding section on human bites.
The massive lacerations from a large animal bite, such as bear
or puma injuries, are another matter. The entire goal of treatment is
to stop the bleeding, treat for shock, and evacuate. You may need to
close these massive lacerations to help control bleeding.
If an infection seems to start, treat as indicated in the section on
wound infection (page 147) by removing the closures and starting hot
soaks and antibiotics.
Treat crush injuries with cold packs and compressive dressings.
Large lacerations can also be treated with compressive dressings. The
ideal item would be a 6-inch elastic bandage. Cold sources can be
chemical cold packs or the coldest water available, safely packaged in
poly bottles or similar containers.
Refer to Rabies, page 233.
FINGER AND TOE PROBLEMS
Ingrown Nail
This painful infection along the edge of a nail can, at times, be relieved
with warm soaks. There are several maneuvers that can hasten heal-
ing, however. One technique is a taping procedure, shown in figure
6-12. A piece of strong tape (such as waterproof tape) is taped to the
inflamed skin edge next to—but not touching—the nail. The tape is
fastened tightly to this skin edge with gentle but firm pressure. By
running the tape under the toe or finger, the skin edge can be tugged
away from the painful nail and thus relieve the pressure.
Another method is to shave the top of the nail by scraping it
with a sharp blade until it is thin enough that it buckles upward. This
“breaks the arch” of the nail and allows the ingrown edge to be forced
out of the inflamed groove along the side.
Figure 6-12.
Apply tape to the skin edge
next to the nail and tug the
skin away from the nail, fas-
tening the tape down under
the toe or finger.
The above techniques should be implemented at the first sign of

irritation rather than once infection has developed, though even then
they are effective. Provide antibiotics such as doxycycline, 100 mg
twice daily, or Levaquin,
3-11500 mg once daily.
Paronychia (Nail Base Infection)

Paronychia, an infection of the nail base, is a very painful condition
that should initially be treated with warm soaks, 15 minutes every
2 hours, and the use of oral antibiotics such as doxycycline, 100 mg
twice daily, or Levaquin, 500 mg daily. Oral pain medication will also
be necessary. If the lesion does not respond within 2 days, or if it
seems to be getting dramatically
worse, an aggressive incision with
a sharp blade will be necessary, as
shown in figure 6-13. This wound
will bleed freely; allow it to do
so. Change bandages as neces-
sary, and continue the soaks and Figure 6-13.
medications as described under Paronychia, showing the incision
Abscess (page 147). required to3-12
drain the abscess
Felon
A deep infection of a fingertip is called a felon. It results in a tense,
tender finger pad. Soaking a felon prior to surgery, unlike other infec-
tions, does not help and only increases the pain. Treatment is effected
Figure 6-14.
Felon, showing the incision required to drain the abscess
3-13
by a very aggressive incision, called a fish-mouth incision, made along
the tip of the finger from one side to the other and extending deep to
the bone; see figure 6-14.
An alternate incision is a through-and-through stab wound going
under the finger bone, from one side to the other. A gauze or sterile
plastic strip is then inserted through the wound to promote drainage
of the pus from the felon.
The pain is severe and not helped by local injection of lidocaine.
But relief is quick as pressure from the pus buildup is alleviated. Allow
this wound to bleed freely. Soak in warm water for 15 minutes every
2 hours until drainage ceases (about 3 days). Give pain medication
about 1 hour prior to your surgical procedure, using the strongest that
you have in your kit. Simultaneously start the victim on an antibi-
otic such as Levaquin, 500 mg once daily; doxycycline, 100 mg twice
daily; or Rocephin, 500 mg IM twice daily.
Blood under the Nail

Blood under a fingernail or toenail, called subungual hematoma, is
generally caused by a blow to the digit involved. The accumulation
of blood under a nail can be very painful. Relieve this pressure by
twirling the sharp point of a blade through the nail (using the lightest
pressure possible) until a hole is produced and draining effected. This

is a painless procedure and the tip of the blade should not enter the
nail bed, only the pocket of blood under the nail. Soak in cool water
to promote continual drainage of this blood. The finger may still hurt
from the contusion, however, so additional pain treatment with Per-
cogesic, 1 or 2 tablets every 4 hours, or Norco 10/325, 1 tablet every 4
to 6 hours, may also be useful. Antibiotic use is not necessary.
WOUND INFECTION AND INFLAMMATION

Lacerations that have been cleaned and either sutured, taped, or sta-
pled together will generally become slightly inflamed. Inflammation
is part of the healing process and does not indicate infection, yet
the appearance is similar; it’s a matter of degree. Inflammation has
slight swelling and red color. The hallmarks of infection are swelling,
warmth to touch, reddish color, and pain. Pus oozing out of a wound
is another clue. If the cut has a red swelling that extends beyond 1/4
inch from the wound edge, infection has probably started.
The method of treatment of wound infection is quite simple.
Remove some of the tapes, sutures, or staples and allow the wound to
open and drain. Apply warm, moist compresses for 15 to 20 minutes
every 2 hours. This will promote drainage of the wound and increase
the local circulation, thus bringing large numbers of friendly white
blood cells and fibroblasts into the area. The fibroblast tries to wall
off the infection and prevent the further spread of germs. Once an
infection has obviously started, the use of an antibiotic will be helpful
but is not always essential. From the Rx Oral/Topical Medication
Module, use evaquin, 500 mg once daily. If the Rx Injectable Medi-
cation Module is available, use Rocephin, 500 mg twice daily IM or
1,000 mg once daily IM.
Abscess
An abscess (boil or furuncle) is a pocket of pus (white blood cells),
germs, and red blood cells that have been contained by an envelope
of scar tissue produced by fibroblasts. This protects the body from the
further spread of germs. It is part of the body’s strong natural defense
against invasion by bacteria. Conversely, many antibiotics cannot
penetrate into the abscess cavity very well. The cure for an abscess is
surgical. It must be opened and drained.
There are two basic ways in which this can happen. First, moist
warm soaks will not only aid in abscess formation but will also aid
in bringing the infection to the surface and cause the infection to
“ripen,” even open and drain on its own. An abscess can be very pain-
ful and this opening period very prolonged. Once the abscess is on
the surface, it is generally better to open it using a technique called
incision and drainage, or I&D. The ideal instrument for I&D is a
thin, sharp blade. Use the blade to penetrate the surface skin and
open the cavity with minimal pressure on the wound.
Abscesses are very painful, primarily because of the pressure
within them. A person coming into a doctor’s office with a painful
abscess would expect to have it anesthetized before opening. Injec-
tions into these areas only add to the pain. The best anesthesia is to
cool the wound area. In the field an ice cube or application of an
instant cold pack will help provide some anesthesia. A person with a
painful abscess will usually let you try the knife, as they can become
desperate for pain relief. The relief that they get when the pressure is
removed is immediate, even without cooling.
Coat the skin surface around the abscess with triple antibiotic
ointment from the Topical Bandaging Module to protect the skin
from the bacteria that are draining from the wound. Spread of infec-
tion from these bacteria is unlikely, however, unless the skin is abraded
or otherwise broken.
Cellulitis
Cellulitis is a very dangerous and rapidly progressive skin infection
that results in red, painful swelling of the skin without pus or blis-
ter formation. The lesion spreads by the hour, with streaks of red
progressing toward the heart ahead of the swelling. This represents
the travel of infection along the lymphatic system and is frequently
called blood poisoning in the vernacular. While lymphatic spread is
not strictly blood poisoning, cellulitis does frequently lead to general-
ized blood poisoning (septicemia) and can cause the development of
chills, fever, and other symptoms of generalized profound infection,
such as lethargy and even shock. Very dangerous and virulent germs
are responsible. Strong antibiotics are necessary, and the application
of local heat is very helpful.
Old-time remedies included the use of various “drawing salves,”
but nothing works better than local hot compresses. Local heat
increases the circulation of blood into the infected area, bringing
white cells that will kill the bacteria directly and produce antibodies
to aid in killing the germs. The infection fighters, and the walling-off
process of the fibroblasts, will hopefully contain and destroy the infec-
tion. When this walling off process succeeds, an abscess is formed
(see preceding section). If the Rx Injectable Medication Module is
available, give Rocephin, 500 mg IM twice daily. Or, if only the Rx
Oral/Topical Medication Module is available, give doxycycline, 100
mg twice daily, or Levaquin, 500 mg once daily.
SKIN RASH
A rash is a frequent outdoor problem. At times a rash is associated
with certain diseases and can help in the diagnosis. If the patient is
feverish or obviously ill, review the sections on Lyme disease, Rocky
Mountain spotted fever, typhoid fever, syphilis, meningococcal men-
ingitis, strep throat, measles, and mononucleosis in chapter 9.
Many infections that cause rash are viral and will not respond
to antibiotics. But, with no professional medical help available, rash
associated with symptoms of illness, particularly fever and aching,
should be empirically treated with an antibiotic such as doxycycline,
100 mg twice daily, for at least 2 days beyond the defervescence (loss
of fever). Some of the above infections require longer antibiotic treat-
ment, so it should be continued as indicated if there is a probability
that you are dealing with one of them.
Localized rashes without fever are usually due to superficial skin
infections, fungal infections, or allergic reactions. Itch can be treated
with antihistamine or any pain medication. The Non-Rx Oral Med-
ication Module has diphenhydramine, 25 mg, as an antihistamine.
One capsule (2 in severe cases) every 6 hours will help with itch from
nearly any cause.
As itch travels over the same nerves that carry the sensation of
pain, any pain medication can also help with itch. Warm soaks gen-
erally make itch and rash worse and should be avoided, unless there
is evidence of deep infection (see Abscess and Cellulitis above). It
is hard to do better than diphenhydramine with regard to oral anti-
histamine effect, but it should be noted that Atarax (in the Rx Oral/
Topical Medication Module), and the same medication in injectable
form, Vistaril (in the Rx Medication Injectable Module), also have
antihistamine action and can be used for itch. Also soothing to either
a non-weeping lesion or a blistered and weeping lesion is the appli-
cation of a piece of Spenco 2nd Skin from the Topical Bandaging
Module. Cool compresses will also soothe a rash.
For a moist, weeping lesion (this includes poison ivy, poison oak,
and poison sumac), wet soaks of dilute Epsom salts, boric acid, or
even table salt will help dry it. If it is a dry, scaly rash, an ointment
works best, much better than a gel, lotion, or cream. Blistered rashes
are treated best with creams, lotions, or gels. Specific types of rashes
require specific types of topical medications, however.
Fungal Infection
A fungal infection is commonly encountered in the groin, in the arm-
pit, in skin folds, on the scrotum, under a woman’s breasts, and around
the rectum. Rashes can range from bright red to almost colorless but
are generally at least dull red, and frequently have small satellite spots
near the major portion of confluent rash. Fungal infections are very
slow in spreading, with the lesions becoming larger over a period of
weeks to months. Body ringworm is a circular rash with a less intense
center area (caution: see Lyme Disease, page 228).
Fungal rashes should be treated with a specific antifungal, such as
clotrimazole 2% cream from the Topical Bandaging Module. Apply
a thin coat twice daily. Good results should be obtained within 2
weeks for jock itch, but athlete’s foot and body ringworm may take
4 weeks and need to have continued treatment until all evidence of
rash is gone, then treatment continued once daily for an additional
3 weeks. If no improvement has been made, the diagnosis may have
been wrong, or the fungus is refractory to your medication. From the

Rx Oral Medication Module, Diflucan, 150 mg, daily will destroy
most body surface fungal infections, but it is included in only a small
quantity for primary use in the treatment of vaginitis.
Allergic Dermatitis
The hallmarks of allergic dermatitis are vesicles, or small blisters, on
red, swollen, and very itchy skin. A line of these blisters clinches the
diagnosis of allergic, or contact, dermatitis. The most common cul-
prits are poison ivy, poison sumac, and poison oak. Contact with cat-
erpillars, millipedes, and many plants—even such innocent species as
various evergreens—can also induce allergic or toxic skin reactions.
A toxic reaction to a noxious substance, such as from certain
insects and plants, is treated like an allergic dermatitis. First aid treat-
ment is a thorough cleansing with soap and water. Further treatment
is with diphenhydramine, 25 mg every 6 hours, from the Non-Rx
Oral Medication Module, and twice daily applications of hydro-
cortisone cream 1% from the Topical Bandaging Module. Weeping
lesions can be treated with wet soaks as mentioned above. An occlu-
sive plastic dressing will allow the rather weak 1% hydrocortisone to
work much better.
The Rx Oral/Topical Medication Module has two very effective
medications to treat this problem. Continue use of the diphenhydr-
amine, but add Decadron, 4 mg tablet, 1 daily for 5 to 7 days, and
apply Topicort 0.25% ointment in place of the hydrocortisone cream.
A thin coat twice daily without an occlusive plastic dressing should
work rapidly.
Stinging nettle causes a severe irritation that can be instantly
eliminated by the application of “GI jungle juice,” a mixture of 75%
DEET insect repellent and 25% isopropyl (rubbing) alcohol. I dis-
covered this neat trick the hard way (accidentally) while camping in
fields of the stuff along the Cape Fear River in North Carolina. Since
mentioning this in the first edition of my book Wilderness Medicine
in 1979, many others in contact with this plant have confirmed the
treatment’s instantaneous effectiveness.
Bacterial Skin Rash

A common bacterial superficial skin infection causing a rash is
impetigo. The normal appearance of this condition is reddish areas
around pus-filled blisters, which are frequently crusty and scabbed.
The lesions spread rapidly over a period of days. The skin is generally
not swollen underneath the lesions. It often starts around the nose
and on the buttocks, spreads rapidly from scratching, and can soon
appear anywhere on the body. Early lesions appear as small pimples,
which form crusts within 12 to 24 hours. Lesions should be cleaned
with surgical soap (or hydrogen peroxide) and then covered with an
application of triple antibiotic ointment. Avoid placing bandages on
these lesions, as the germs can spread under the tape.
Bacterial skin infections generally must be treated with prescrip-
tion antibiotics. From the Rx Oral/Topical Medication Module, give
Levaquin 500 mg once daily. The Rx Injectable Medication Module
contains Rocephin, which would be ideal for this condition; give 500
mg IM once daily.
Treatment of abscess and cellulitis, forms of deep skin infections,
are discussed on pages 147 and 148.
See pages 61–62 for treatment of cold sores and lip or mouth
lesions.
Seabather’s Eruption
Seabather’s eruption is the term used for the sudden onset of a very
itchy rash associated with swimming. In south Florida and the Carib-
bean, it is caused by larvae of the thimble jellyfish (Linuche unguicu-
lata) or by the larvae of the sea anemone (Edwardsiella lineata). The
latter was shown to be responsible for thousands of cases on Long
Island, New York. Global warming will probably cause this condition
to become a problem much farther north than that.
Welts (urticaria) or a fine red or pimply rash appears within 24
hours of exposure to ocean water, normally in areas covered by bath-
ing suits. The tiny larvae are trapped next to the skin within the bath-
ing suit and discharge nematocysts that cause the disease. Additional
symptoms frequently associated with this rash include fever, chills,
weakness, and headache, as the larvae penetrate the skin and cause
illness. In south Florida the occurrence is from March to August,

with a peak of outbreaks in May. In Long Island waters the outbreaks
occur from mid-August until the end of the swimming season in
early September. These outbreaks are episodic, with very few cases
some years and thousands of cases during peak years.
Treatment consists of topical corticosteroid (1% hydrocortisone
cream from the Topical Bandaging Module applied 4 times daily,
or 0.25% Topicort ointment from the Rx Oral/Topical Medication
Module applied twice daily) and antihistamine (diphenhydramine,
25 mg) from the Non-Rx Oral Medication Module taken 4 times
a day. Swimmers should remove bathing suits and shower as soon
as possible after leaving the water. And swimming at a nude beach
doesn’t protect you just because you are not wearing a bathing suit.
CHAPTER 7
ORTHOPEDICS – BONE AND
JOINT PAIN AND INJURY
MANAGEMENT OFF THE GRID

Orthopedics includes the study of bone, joint, and muscle function
and disorders. This section establishes basic protocols for the assess-
ment and care of orthopedic disorders. General concepts of care will
be followed by a systematic evaluation by anatomical region with sug-
gested care plans. No condition can be more debilitating or restrict
operations more than an injury or simply the development of pain
that interferes with your ability to survive or function in the challeng-
ing circumstances of living off the grid.
While diagnosis and management can be complex, this chapter
will provide an approach to caring for these concerns in a reasonable
and often definitive manner, even in the case of a nonexistent grid!
The following chart refers you to general management principles
and to diagnosis and treatment plans by anatomical region.
Diagnosis and Treatment Plans

Concepts of Orthopedic Care
• Muscle Pain—No Acute Injury 155
• Muscle Pain—Acute Injury 156
• Joint Pain—No Acute Injury 158
• Joint Pain—Acute Injury 159
• Fractures 161
• Open Fracture 163
ORTHOPEDICS – BONE AND JOINT PAIN AND INJURY 155
Diagnosis and Care Protocols 164

• Head 165
• Neck 167
• Spine 168
• Collarbone 170
• Shoulder 172
• Shoulder Blade 174
• Upper Arm Fractures (Near the Shoulder) 174
• Upper Arm Fractures (Below the Shoulder) 175
• Elbow Trauma 177
• Forearm Fractures 178
• Wrist Fractures and Dislocations 180
• Thumb Sprains and Fractures 182
• Hand Fractures 183
• Finger Fractures and Sprains 183
• Hip Dislocation and Fracture 185
• Thigh Fractures 187
• Kneecap Dislocation 188
• Knee Sprains, Dislocations, and Fractures 189
• Ankle Sprains, Dislocations, and Fractures 190
• Foot Injuries 191
• Chest Injuries 191
CONCEPTS OF ORTHOPEDIC CARE
Muscle Pain—No Acute Injury

Muscle aches can arise from chronic inflammation disorders such
as lupus and fibromyalgia, but the discussion here will be limited to
those conditions that might reasonably arise when performing stren-
uous or repetitive activities.
When associated with a fever, consider an infectious basis for the
pain. Without a reasonable method of diagnosis, it would be best
to treat with both an antibiotic and appropriate pain medication.
Even in North America, several serious conditions can present in this
manner that require antibiotic treatment, such as Rocky Mountain
spotted fever. Regardless of cause, it is appropriate to start ibuprofen,

200 mg tablets with 2 to 4 tablets each dose, repeated every 6 hours,
for fever and muscle aches.
While it’s best to have a physician see the patient and to draw
the appropriate lab tests before commencing antibiotics (when you
are on the grid and can obtain tests), if the pain is localized to a spe-
cific area and accompanied by swelling, redness, and especially fever,
start doxycycline, 100 mg twice daily. If you might be treating Lyme
disease, this treatment will need to be continued for at least 2 weeks
(see page 228).
Under conditions of heat stress, heavy exertion causing sweating,
or diarrhea and vomiting, or the use of diuretics causing increased
urine output, muscle cramping may be caused by the resulting elec-
trolyte abnormality. Appropriate fluid and electrolyte replacement is
necessary, as discussed on page 88.
Overuse syndromes cause pain in muscles that go beyond the
mild ache you are accustomed to feeling after a workout at the gym.
While it is possible to suddenly tear muscles with sudden movements,
significant pain that starts gradually or soon after the exercise is over
could be tendinitis, spasm caused by a pinched nerve, or significant
inflammation in the muscle. The treatment for these conditions is
the same as that employed for tendinitis, as described in that section
on page 158. Additionally, the use of a muscle relaxer is of benefit.
From the Non-Rx Oral Medication Module, take Percogesic, 2 tab-
lets every 6 hours, or from the Rx Oral/Topical Medication Module,
use Atarax, 25 mg every 6 hours. These medications can be used in
addition to the others prescribed for tendinitis, unless the condition is
relatively mild, when the use of ibuprofen alone should suffice.
Muscle Pain—Acute Injury

Pain occurs immediately after a significant muscle injury, a contusion
or strain being the general cause. RICE is the acronym that applies
here: rest, immobilize, cold, elevate or, more classically, rest, ice, com-
press, and elevate. An elastic bandage, cold stream water, elevation of
a limb, and rest may not all be possible, but they comprise the initial
treatment. The application of cold is most important as it decreases
tissue bleeding from constricting blood vessels, though be careful not

to cause freezing injury. Compression can provide stability as well as
accomplishing much the same benefit.
Contusions cause bleeding into the surrounding muscle tissue
through the rupture of small blood vessels. Using the RICE tech-
nique will minimize the bleeding and local swelling. Strains on mus-
cles result in either microscopic muscle fiber tears or muscle mass
tears. These are classified from grade I (microscopic) to grade IV (total
tear of a muscle). Grades II and III are partial tears of a muscle mass.
A total tear would require surgical repair. All will be treated similarly
in an off-grid situation: Initially use RICE, as indicated above. If sig-
nificant swelling of the muscle occurs, consider that you are dealing
with a grade III or IV tear and continue RICE for 2 days. Otherwise
use RICE for the first 24 hours.
The next step in treating significant muscle injury is to apply local
heat. In the case of minor injuries, apply it the next day. For more
serious injuries, delay the use of heat for 2 days. Continue the use of
the compression dressing. Splint or sling as necessary for comfort.
Decrease activity to a level where the pain is tolerable.
A full rupture of a muscle body will generally result in a bulging
of the muscle mass and a loss of strength during the late recovery
period. This may not be noticeable at first, as the swelling would ini-
tially be attributed to local bleeding and pain would restrict use. Once
the pain is gone, continued swelling, especially after several weeks
have passed, is probably due to a significant muscle tear or a ruptured
tendon. This should be repaired when possible, but do not despair
if it is not, as this is a tolerable injury. The acute pain of a muscle
belly tear will subside within a few weeks, noticeable discomfort after
6 weeks, and then scar tissue forms and the body will replace the
primary actions of the torn muscle (if fully torn) by using accessory
muscles to the extent that it can and the injured individual will have
to subsequently adapt to the weakened condition that will result. It
is amazing how well we can perform with some of these injuries, one
of the most common being total tear of the biceps muscle or tendon.
The muscle contracts, which means that it will bulge, but its major
action, that of pronation (e.g., turning a screwdriver), will be greatly
weakened. Fortunately, accessory muscles will aid in most function of

the upper arm, such as flexion of the elbow.
Joint Pain—No Acute Injury

Pain in the joint without history of injury is generally due to arthri-
tis, bursitis, or tendinitis. Without a history of previous arthritis, the
latter two are the more likely diagnosis, but the treatment is the same
for all three. The most common reason for tendon or joint inflamma-
tion is overuse. French trappers frequently complained of Achilles
tendinitis while snowshoeing, which they appropriately termed mal
de raquette. Persons hammering, chopping wood, or playing tennis are
familiar with “tennis elbow” (epicondylitis of the elbow). Tendinitis
can occur in the thumb and wrist—in fact, any tendon in the body
can become inflamed with overuse. Joints similarly become inflamed
with repetitious activity or even unusual compression. Bricklayers and
others who must work kneeling will, on occasion, encounter a patellar
bursitis of the knee (called commonly housemaid’s knee). Many peo-
ple form bursitis flare-ups in a shoulder after repetitive arm actions
or in the forearm due to the overuse of flexor tendons of the wrist.
Treatment of these conditions must include adjusting the tech-
nique for the activity that seems to have caused it. By changing a grip
on an axe or hoe, using the tool with a different pitch to the blades,
or altering a movement in any fashion to avoid generating additional
pain, the victim can try to alleviate the discomfort and avoid inflam-
ing it more. Prior to an activity, the application of heat to the sore area
helps with prevention. Immediately after aggravating the condition,
applying cold is of benefit. Within an hour, return to a local heat
application and continue this during the evenings.
Applying a cream such as Aspercreme (other brand names are
Myoflex and Mobisyl) with a dry heat might help a tendinitis, as the
active ingredient (trolamine salicylate 10% concentration) penetrates
the skin and provides local anti-inflammatory action. Sports creams
that feel warm, such as Icy Hot, simply irritate the skin surface to
cause an increased blood flow and thus provide warmth to the area.
They do not have an anti-inflammatory effect, nor do they provide
any benefit over the application of heat. This does not mean that these
creams do not have a potentially valuable role here. It is very difficult

to apply hot soaks sometimes, and these creams can serve the pur-
pose. Topical products containing diclofenac are now widely available
by prescription (brand names Voltaren 1% gel, Pennsaid, or Flector
1.3% patches). These are the most effective topical treatment possible,
but the onset of relief takes a few days of application.
If hot compresses seem to aggravate the pain, switch to a cold
compress. Avoid making any movements that seem to cause the most
pain for 5 to 7 days. Splinting may help during this period. Avoid
nonuse of the shoulder for longer than 2 weeks, as it is prone to adhe-
sion formation, and loss of function can result.
The best medication for chronic joint pain is ibuprofen from
the Non-Rx Oral Medication Module due to its anti-inflammatory
action; 4 tablets every 6 hours will help with joint and tendon pain.
From the Rx Oral/Topical Medication Module, one could use
Decadron, 4 mg, given once daily for 7 days for joint inflammation.
Note: See the warning in the discussion of the use of the antibiotic
Levaquin with regard to tendonitis and tendon rupture (page 286).
Joint Pain—Acute Injury

Immediately after a joint injury, we all want to evaluate the injury,
determine how serious it is, and figure out how or if the injury may
affect our whole group’s survival situation. Frankly, making a precise
diagnosis usually isn’t possible initially, so our approach to the acute
joint injury must be to look at methods of treatment and potential
long-term care. The discussion on orthopedic injuries in this book
considers the body by region, not by precise diagnosis of injury. Nev-
ertheless, we must try to have some understanding of what might have
happened, make an accurate prognosis early in the event, and mini-
mize the damage while keeping the victim as functional as possible.
Unusual stress across a joint can result in damage to supporting
ligaments. Ordinarily this is a temporary stretching damage, but in
severe cases rupture of ligaments or even fracture of bones or tears
of cartilage can result. These injuries are serious problems and may
require surgical repair. This is best done immediately but can be safely
delayed 3 weeks. Fractures entering the joint space may result in
long-term joint pain and subsequent arthritis. Cartilage tears do not

heal themselves, unlike ligament, tendon, and bone damage. These
frequently cause so much future pain and instability that surgical cor-
rection is required.
Proper care of joint injuries must be started immediately. RICE
(Rest, Ice, Compress, Elevate) forms the basis of good first aid man-
agement. Cold should be applied for the first 2 days as continuously
as possible. Then apply heat for 20 minutes or longer, 4 times daily.
Cold decreases the circulation, which lessens bleeding and swelling.
Heat increases the circulation, which then aids the healing process.
This technique applies to all injuries, including muscle contusions
and bruises.
Elevate the involved joint, if possible. Wrap with elastic bandage
or cloth tape to immobilize the joint and provide moderate support
once ambulation or use of the joint begins. Take care that the wrap-
pings are not so tightly applied that they cut off the circulation.
Use crutches or other supports to take enough weight off an
injured ankle or knee so that increased pain is not experienced. The
patient should not use an injured joint if it causes pain, as this indi-
cates further strain on the already stressed ligaments or fracture.
Conversely, if use of the injured part does not cause pain, additional
damage is not being done even if there is considerable swelling. If the
victim must walk on an injured ankle or knee, and doing so causes
considerable pain, then support it the best way possible (wrapping,
crutches, decreased carrying load, tight boot for ankle injury) and
realize that further damage is being done, but that, in your opinion,
the situation warrants such a sacrifice.
While compression is good for an acute injury, too much could
cut off circulation and must be avoided. If an ankle is injured, the boot
can provide needed compression, but remove it if the pain becomes
intolerable. A boot can always be put back on a swollen ankle by
undoing the laces and just wrapping them around the boot circum-
ference rather than using the eyelets.
Pain medications may be given as needed, but elevation and
decreased use will provide considerable pain relief. See also Fractures
below.
Fractures
A fracture is a medical term meaning a broken bone. It is not true that
“if you can move the part, it is not broken.” Pain will prevent some
movement, but this does not aid in the diagnosis between a fracture
and a contusion. Fractures may consist of a single crack in the bone and
be rather stable, or there may be many cracks and pieces, consequently
becoming very unstable. There may be no way of telling which is pres-
ent, or even if a fracture is there at all, without an X-ray. Deformity
indicates either a fracture or contusion causing swelling with soft tissue
bleeding if located in the middle of a long bone area, or a possible dis-
location or severe sprain with or without a fracture if located at a joint.
The hallmark of a fracture is point tenderness or pain to touch over the
site of the break. Swelling over the break site is further evidence of a
fracture. Another way to deduce the presence of a fracture is to apply
gentle torsion or longitudinal compression to the bone in question,
with either technique causing increased pain at the fracture site.
Each fracture has several critical aspects in its management to
consider: (1) correct loss of circulation or nerve damage due to defor-
mity of the fracture; (2) prevent the induction of infection if the skin
is broken at or near the fracture site; (3) prevent further soft tissue
damage; and (4) obtain reasonable alignment of bone fragments so
that adequate healing takes place. The nonskilled practitioner is lim-
ited to the first three management techniques.
The first aid approach to a fracture is to “splint them as they
lie.” This, however, is not an appropriate response in remote areas.
Straighten gross deformities of angulated fractures with gentle in-line
traction, as in figure 7-1. Before straightening, check and compare
the pulses beyond the fracture site on the left and right side of the
victim and check for any abnormality of sensation. After correcting
the angulation, circulation should improve. As arteries and veins are
hollow tubes, their lumens will stretch and narrow if they are forced
to bend around a corner, thus decreasing blood flow. When this bend
is eliminated, the vessel will return to its normal size and blood flow
will improve. As the person could be in shock, it might be difficult to
feel the pulses on either side. It is much more accurate to evaluate the
circulation by examination of both sides and comparing the results.
Figure 7-1.
Use in-line traction to straighten grossly angulated fractures. This technique is
not meant to perfectly align the bone ends; it is only meant to eliminate gross
deformity.
Grossly angulated fractures also allow sharps ends of bone to

project against the skin surface. Even with careful padding, jostling
along during an evacuation may cause one of these bone spicules to
penetrate the skin surface, causing an open fracture and increasing
the chance of serious wound and bone infection.
The chance of causing harm while straightening an angulated
fracture would be extremely low. It is possible for a blood vessel or
nerve to become trapped within the fracture site, but gentle reposi-
tioning into slight deformity should correct this.
Pad splints well to prevent skin damage. Pneumatic splints are

available from many outfitters. Fracture splinting is generally well
covered in first aid courses. Such a course should be taken before
any major expedition into the bush. Improvisation is the name of the
game in fracture immobilization, and having an adequate first aid
course provides one with information upon which to improvise. In
general, splint fractures to immobilize the joint above and below the
fracture site.
Any wound in the skin near a broken bone increases the chance
of a bone infection. Follow the principles of thorough wound cleans-
ing as indicated on page 122.
With proper splinting, the pain involved with a fracture will
decrease dramatically. Provide pain medication when possible. Pain
control is discussed on page 31. The Rx Atarax can be given to aid in
muscle spasm control. Mild sedation with diphenhydramine (Benad-
ryl) may help its sedating effects.
At times there will be uncertainty about whether a fracture exists.
When in doubt, splint and treat for pain, avoiding use of the involved
part. Within a few days the pain will have diminished and the crisis
may be over. If not, the suspicion of a fracture will loom even larger.
OPEN FRACTURE
Even a laceration or puncture wound near a broken bone is a cause for
alarm. Such a wound can allow bacteria into the fracture site, causing
a serious bone infection. This wound requires aggressive cleansing,
as indicated on page 123. The wound should not be closed, as this
increases the chance of infection. Wet dressings are best over an open
wound. Soak the sterile dressing in sterile water, and cover with a
clean, dry dressing. Change this dressing twice daily.
If a piece of bone is protruding from the skin, the break is called
an open fracture. The first aid approach is to splint in position and
cover with a sterile dressing. In a remote area this approach will not
work. This wound requires aggressive irrigation with surgical scrub or
soap as described on page 124.
The aggressiveness of this cleansing action should be done in
such a manner as not to cause further damage, but the area must be
free of foreign particulate matter and as antiseptic as possible. Cover

the wound with triple antibiotic ointment. Protect with sterile gauze
dressings, with only enough pressure to control bleeding. Straighten
the gross angulation of the fracture with gentle in-line traction (see
figure 7-1). This will cause the protruding bone to disappear under
the skin surface, unless the fragment is loose from the main bone;
allow this wound to remain open and dress as indicated above.
In all cases of a laceration or puncture wound near a fracture,
place the victim on oral antibiotics when available. From the Rx Oral/
Topical Medication Module, use Levaquin, 500 mg daily. However,
if the Rx Injectable Medication Module is carried, give Rocephin,
500 mg IM twice daily. Continue the medication until the patient is
evacuated or the medication runs out.
DIAGNOSIS AND CARE PROTOCOLS

The diagnosis of these injuries will be difficult due to lack of expe-
rience or the benefit of X-ray equipment. Uncertainties of diagnosis
will exist, and therefore a systematic approach to the evaluation and
treatment of the injured patient has to be developed that will handle
most common injuries appropriately.
The orthopedic evaluation is made easier because human beings
have equal sides that can be compared. Take the clothing off both the
injured and normal sides and compare, weather permitting. Look for
swelling or different configuration. When examining the injured side,
touch lightly. A fracture or sprain is very tender and will not require
hard poking to elicit obvious pain. Swelling results from localized
bleeding, which a fracture will almost always cause. Several days after
the injury, a bruise may appear near it or lower on the person. Gravity,
as well as various muscle groups and local anatomy, can cause this
spilled blood to migrate to a place at a different location from the
injury site. This does not mean that the injury is spreading; it just rep-
resents the displacement of blood and part of the reabsorption pro-
cess of healing. Don’t be concerned about the appearance of bruising
and its spread in the days after the injury.
Head
Lacerations of the scalp or face result in massive bleeding, the care
of which is discussed on page 131. Internal head injuries range from
insignificant to lethal. Check the level of reponsiveness as per page
10. Urgent evacuation is necessary for anyone who exhibits any of the
following:
• Unconsciousness for more than 2 minutes
• Debilitating headache
• Loss of coordination or garbled speech
• Persistent nausea and vomiting
• Bruising behind the ears (sign of skull fracture)
• Bruising around the eyes (sign of skull fracture)
• Decrease in vision
• Clear fluid draining from nose and/or ears (possible spinal fluid)
• Seizures
• Relapse into unconsciousness
Suspect a neck injury in anyone with a head injury. On most trips
it is prudent to seek medical care for anyone who has been knocked
unconscious for even a brief moment. The patient can walk and assist
in her own evacuation if there is no apparent spine injury. If the
patient is not thinking clearly or has any of the above signs, immobi-
lize the neck and entire spine. Initially this may have to be done on
the ground, with the patient lying down and using hand traction to
stabilize his head and neck.
A head-injured patient will frequently vomit. To avoid aspirat-
ing this into his lungs, place him face down with his face turned to
one side, or sit the patient up with his head elevated to 30 degrees.
This position may also decrease some of the headache associated with
head injury.
While the patient is kept awake for neurological assessments of
levels of responsiveness in civilization, if evacuation will take a long
time (several days), allow the person to fall asleep. While the person is
asleep the brain has its best chance to control its own swelling.
While the use of pain and anti-nausea medication might alter
the mental status and is avoided in urban first aid care, when you are
responsible off the grid for long-term care, it makes sense to use these
medications. It is best to use the mildest medication necessary for
relief. Refer to pain management (page 31) and nausea management
(page 24).
If you detect improvement in the symptoms over the next 2 days,
the prognosis is very good. If symptoms increase, rapidly return the
patient to the grid if possible. If there is no grid, most everything you
do will be of no additional help. In the past, large doses of steroid
were given (such as dexamethasone, 16 to 24 mg per day, from the Rx
Oral/Topical Medication Module). Recent studies indicate steroids
cause more harm than good, although if all you have to offer is death
in a deteriorating patient, going back to a widely used old protocol
is all you have. Improved results from that therapy may show within
1 day or take up to 8 days. When this high a dose of dexamethasone
is used, it will need to be gradually withdrawn (tapered) when con-
cluding the treatment period in order to allow the adrenal glands to
recover and produce the normal cortisol levels that have been sup-
pressed by this therapy. When using low-dose dexamethasone (4 mg
per day) less than 10 days, it can be stopped abruptly. But large doses
used as indicated above must be tapered no matter how long they are
used. Reduce high dose (16 to 24 mg) by halving the dose every few
days, until down to 2 mg, then reduce by 0.5 to 1 mg every 5 to 7
days. A standard method of treating increased intracranial pressure is
the use of hyperosmolar diuretics (such as mannitol) via intravenous
infusion. This item is not in your suggested Off-Grid Medical Kit,
but another item used is a “loop diuretic,” which is suggested. Use
furosemide, 40 mg daily until consciousness improves, at which time
it may be stopped abruptly. If only a milder diuretic is available, such
as the hydrochlorothiazide, use 50 mg per day. It also may be stopped
abruptly when symptoms improve. If the patient is conscious, you
will need to insert a Foley catheter.
Neck
Examination of the neck is critical to helping preserve the spinal cord
from injury if the neck is unstable. Without moving the neck, gently
palpate along the spinous process to elicit point tenderness in the
conscious patient. No point tenderness will generally mean no signif-
icant bone damage to the neck. In an unconscious patient with head
trauma, treat as if the neck is fractured. Splint carefully for maximal
immobilization. If the neck is at an odd angle, it should be straight-
ened with gentle in-line traction, by pulling steadily and slowly on
the head along the line in which you find the neck. Move the neck to
a neutral position in a line with the spine. This is a maneuver taught
by wilderness first aid classes. Practice before attempting.
Patients should not be allowed to move, nor should they be lifted
or transported without careful immobilization of the neck. The best
technique for initial cervical immobilization is gentle but firm control
by a person holding the patient’s head. Remind the victim to remain
still. Eventually this firm control might be replaced with a cervical
collar, or a rolled Ensolite pad or other soft material. The SAM Splint
can be molded into a cervical collar, as shown in figure 7-2.
Neck injuries, when serious as described above, are best treated
within the grid, but without the grid, you will need to move them onto
a comfortable bed. Elevate the head to 30 degrees. Pad the neck with
pillows on each side to discourage sideways movement and forward
or rearward bending of the neck. The greatest challenge to be man-
aged over the 8 weeks of healing is toilet activities. The neck must be
provided adequate padding to prevent movement when the patient’s
position must change. Treat for pain and muscle spasm (see page 31
for pain management). Numbness, radiating pain, loss of nerve or
muscle function possibly could have been prevented with surgery, but
lacking on-grid care, the only thing you can do now is to try to relieve
swelling around the spinal cord. Use the same treatments as indicated
above for head injury with regard to use of dexamethasone, furose-
mide, or hydrochlorothiazide.
To prevent neck injury, the cervical collar must be augmented with
total body immobilization. Current techniques are being promoted
Figure 7-2.
SAM Splint molded into a cervical collar. The vertical creases make the splint
rigid.
4-2 collars, as even attempting to

that would avoid the use of cervical
put them on can cause more neck trauma than they prevent. Most
cervical fractures are not unstable, so the collar adds to airway man-
agement difficulty and patient discomfort, and provides no benefit.
If no point tenderness is claimed by the conscious victim, but
generalized pain and spasm of the neck muscles are present, the vic-
tim may be suffering a severe sprain. A neck brace made from a towel
or other rolled cloth can help with the long-term treatment and pro-
vides adequate support. Local warmth will help relax these muscles.
Pain medication and muscle relaxants are useful in curing a neck
sprain and spasm. It can take weeks for this injury to cease hurting.
Spine
The neurological assessment of potential neck injury includes assess-
ment of the entire spine. For a neurological check, ask the patient
if there is numbness or tingling anywhere on the body. Assess grip
strength on both sides as well as the ability to wiggle toes and flex the
feet up and down. Check the entire spine by palpating along the spi-
nous processes, looking for any point tenderness. If the above exam-
ination is questionable, or even if the trauma seems severe, both neck
and spinal immobilization are in order. Having a rescuer maintain
firm hand control of the victim’s neck will be necessary until the
patient has been placed upon a suitable rigid stretcher. Rigid stretch-
ers are very difficult to improvise, and moving people upon them even
more difficult. While Buck Tilton’s Wilderness First Responder, 3rd
edition (Globe Pequot Press, 2010) goes into great detail in describ-
ing this technique, these skills require practice.
Ensure that the patient has been securely tied into the litter
before you secure the head. If the body shifts while the head is tied
down, any damage present in the neck could increase.
When on the grid, this is the end of the neck/spine story. The
patient remains fastened rigidly to a stretcher until the emergency
department physician has taken tests and made the determination
that she can be removed. This may take several agonizing hours. I say
agonizing because even a normal person will hurt like crazy when
attached to a rigid stretcher or backboard. It’s almost a self-fulfilling
prophecy. If patients don’t have back trouble before being fastened
down, they will now. A report in the Annals of Emergency Medicine
titled “The Effect of Spinal Immobilization on Healthy Volunteers”
placed 21 volunteers (who had never experienced any back problems)
in standard backboard immobilization for 30 minutes and found that
100% had pain during that period, with 55% grading it moderate to
severe, and after release 29% developed additional symptoms during
the following 48 hours.
Especially in a remote location, it is important to reassess the
spine to ensure that continued immobilization is necessary, which is
difficult even if healthy people develop back pain after a short time
on the board. You will have to use common sense. Inability to move
an extremity or loss of sensation, without an orthopedic injury in that
limb, must cause a high suspicion of spinal cord injury. But if these
signs and symptoms are not present and you become convinced that
you are only dealing with a sore muscle problem in the back, not a
broken or disrupted spine, then the spine may be cleared—a term
meaning let the patient out of the rigid support. Continued partial
support with a soft foam pad around the neck, or even a back brace
made of Ensolite foam wrapped around the patient, might make
sense. Then again, it might not. It’s a judgment call based upon the
severity of the injury and resulting symptoms and, in general, how far
off the grid you are.
Point tenderness encountered when carefully palpating the spine
indicates a possible fracture. If it is a fracture of the body of the ver-
tebrae, this very painful condition can heal with only rest, although
the healing process will take 8 weeks. This is a common fracture of
elderly people due to osteoporosis and is encountered when they sud-
denly place a compression on the spine, usually while falling. These
seldom are so bad that fragments compress the spinal cord. Fractures
of the vertebral process where muscles attach can be stretch injuries
or blows that can be very painful but not neurologically compromis-
ing. No numbness should result or endanger leg movement. Inju-
ries causing instability of the back can result in complete paralysis
below the injury. The only thing that can be done without proper
X-ray evaluation is to pad the patient and prevent movement. This
means feeding, toilet activities, and as much pain control as you can
provide. There is no need to discuss here how tragic this injury can
become without proper neurosurgical care. Eight weeks will tell the
tale. Some pain relief can be attempted with the addition of oral ste-
roid (decadron 4 mg twice daily) as discussed under head and neck
injuries above.
Collarbone
Evaluate for pain by palpation along the collarbone (clavicle). Sepa-
rations of the clavicle from the sternum (breastbone), fractures of the
clavicle, and separations of the shoulder can all be treated similarly
with a sling and swathe, shown in figure 7-3.
The clavicle frequently fractures in the midportion. Proper
reduction will occur if the shoulders are held back, like those of a
Marine at attention. A figure eight (figure 7-4) will maintain this
position. A stoop shoulder position will allow too much override of
the fracture parts.
A fracture of the clavicle at the end near the shoulder may be hard
to hold in proper position. In children there is a sleeve of tissue at
this location that aids in holding the proper alignment. In adults this
tissue is missing, and surgical pinning may be required for optimal
Figure 7-3.
A sling and swathe will protect the
injured shoulder and decrease pain in the
recently fractured clavicle. This system
can be duplicated by pinning the forearm
to the front of a shirt. Use a sling without
swathe if there is a danger of the person
slipping off a hill or falling into water.
4-3
Figure 7-4.
The figure-eight splint will hold a clavicle fracture in the proper position for heal-
ing. Add a sling for maximum pain control.4-4
healing. However, even in the adult this fracture may be treated ade-
quately, usually with a sling.
A fracture of the clavicle at the end near the breastbone (ster-
num) is best reduced and held in position with a figure-eight splint.
In any clavicle fracture the use of a sling will aid greatly in decreasing
pain. The sling can be eliminated in 2 weeks, but the figure-eight
splint should be kept on for 3 to 4 weeks, or until there is no pain over
the fracture site with free movement of the shoulder.
Shoulder
Shoulder separations are classified as grade I to grade III, depending
upon the severity. Grade I has tenderness over the acromioclavicular
joint, representing a strain of the ligaments but with no disruption or
tear. A grade II is a rupture of the two acromioclavicular ligaments,
while a grade III is disruption of both acromioclavicular ligaments as
well as the coracoclavicular ligament. The latter case will allow eleva-
tion of the clavicle, as the entire suspension of the shoulder has been
disrupted. There is no strong evidence that grade III separations do
better with surgery than without if the patient is willing to accept
slight deformity at the end of the clavicle. Functionally the patient
should do fine from treatment with an arm sling for 3 to 6 weeks for
comfort, with mobilization of the shoulder as early as possible and
return to activity.
Shoulder dislocations are separations of the humerus (the long
bone of the upper arm) from the shoulder and are classified as either
anterior or posterior. Anterior is by far the most common, at a ratio of
10:1. Fractures of the head, or top part, of the humerus may be asso-
ciated with dislocations. A replacement (reduction) of the dislocation
should be attempted as soon as possible. Muscle spasm and pain will
continue to increase the longer the dislocation is allowed to remain
untreated.
Anterior dislocations may be identified by comparison with the
opposite side. The normal, smooth, rounded contour of the shoulder,
which is convex on the lateral (outside) side, is lost. With anterior
displacement the lateral contour is sharply rectangular and the ante-
rior (or front) contour is unusually prominent. The arm is held away
Figure 7-5.
A person with an anterior shoul-
der dislocation holds the arm
away from the body and across
the chest. Note the steep shoul-
der contour.
from the body, and any attempted movement will cause considerable
pain. See figure 7–5.
A numb area located at the insertion of the deltoid4-5 muscle means
that the axillary nerve has been damaged. Numbness or tingling of
the little finger could mean ulnar nerve damage, while decreased sen-
sation to the thumb, index, and middle finger may mean the radial
nerve is injured. These findings increase the urgency of attempting
a reduction. The best method of reducing the anterior dislocation
of the shoulder is the Stimson method. While other methods exist,
this technique puts less force on the shoulder, which is particularly
important in case a fracture of the head of the humerus coexists with
the dislocation. The technique is illustrated in figure 7-6. After reduc-
tion has been obtained, the arm is placed in a sling and a swathe is
wrapped around the arm and chest to hold the arm against the body
for 3 weeks. Mobilization too soon after reduction will result in a
weak, unstable shoulder. In a young person this sling and swathe may
Figure 7-6.
The Stimson method of replacing a dislocated shoulder.
Using a wide cloth, wrap the forearm several times.
Attach this wrap to a bucket or bag filled with 10 to 15
pounds of rocks and allow gravity to do the rest. It will
take 20 minutes.
be maintained for 4 weeks prior to range-of-motion exercise. Hold-

ing the position longer than 4 weeks4-6will not reduce the chance of
recurrent dislocation, while holding it there longer may result in a
frozen shoulder.
Shoulder Blade
Fractures of the shoulder blade (scapula) are generally due to major
trauma, and the patient may also require treatment for multiple frac-
tures of the ribs, punctured lung (pneumothorax), or heart contusion.
A direct blow to the scapula may fracture it without these other inju-
ries. Diagnosis is difficult without an X-ray, but suspicion may be high
if there is point tenderness to palpation over the scapula, particularly
several days after the accident. An indication of scapular fracture is
Comolli’s sign, which is a triangular swelling corresponding to the
outline of the scapula. Treatment uses a sling and early mobilization
to prevent stiffening of the shoulder.
Upper Arm Fractures (Near the Shoulder)

The humerus is the upper bone of the arm. Fractures of the upper
part (or head) of the humerus are most common in elderly people.
Again, the shoulder will be very painful. The classification of these
fractures is made with X-rays, which indicate that not only has a frac-
ture occurred but also shows the number of pieces in the fracture and
whether angulation or displacement has transpired. Displacement
or severe angulation frequently requires surgical repair, but often
very conservative measures are followed by the orthopedic specialist.
Without access to X-ray or an orthopedic specialist, we have to treat
all injuries conservatively.
Fractures of the upper humerus are associated with swelling and
eventual bruising of the shoulder and upper arm, with gravity slowly
causing the swelling and bruising to appear lower and lower down
the arm. Severe pain will prevent normal movement of the shoulder,
but some movement is frequently possible. As fractures of the upper
part of the humerus occur through bone that mends itself readily
(cancellous bone), the final outcome is often more dependent upon
limiting the length of time of immobilization and starting proper
physical therapy than it is upon the number of pieces or the sepa-
ration and angulation. Conservative treatment will consist of a sling
and swathe (figure 7-3). It is important in older individuals to mobi-
lize the shoulder as soon as possible; otherwise adhesions form and
a frozen shoulder will result. An X-ray would help determine how
much time should be allowed in the sling. This would range from only
a few days to 4 or even 6 weeks for a four-part fracture with marked
displacement. If the patient is over 30, the best rule of thumb when
treating without an X-ray is to mobilize and start physical therapy
at 2 weeks. A youngster’s arm can be left in a sling for 4 weeks. The
therapy should consist of range-of-motion movements, such as circu-
lar elephant trunk motions while bending over and raising the arm in
front, to the side, and toward the rear. Effort should be made to move
the shoulder as if the patient were wiping his bottom. The patient
should do this on his own, without someone forcing his arm through
these motions.
Upper Arm Fractures (Below the Shoulder)

Fractures in the shaft beneath the head of the humerus will result
in muscle spasm, causing an overriding of the shafts of bone. This is
prevented by applying a hanging cast. This amounts to a weighted
cast applied to the forearm, with a loop of cloth supporting much of

the weight of the cast from around the victim’s neck. Mobilization
and physical therapy should be started in 2 weeks. It is not practical
in a setting without X-ray to properly design and follow the results
of a hanging cast. Pain and apparent fracture of the humerus at the
shoulder will probably have to be treated with a sling and swathe,
with early mobilization as mentioned above.
Humeral shaft fractures take 2 to 4 months to heal. Located
between the shoulder and the elbow, this type of fracture is best
splinted with a cast that orthopedic surgeons call a sugar tong splint.
It amounts to a U-shaped plaster extending from the armpit around
the elbow back up to the shoulder, molded to the arm after reduction,
and wrapped with an ace bandage. A SAM Splint can be used to
construct a sugar tong splint, as in figure 7-7.
Complete fractures of the shaft of the humerus will be very pain-
ful, making a crunching feel when the bone is gently stressed. Incom-
plete fractures will be exquisitely tender to touch. Several days after
the injury, swelling and bruising will appear at the elbow and forearm.
Humeral shaft fractures at a point one-third of the way up from the
Figure 7-7.
SAM Splint in sugar tong splint
for a humerus midshaft fracture
4-7
elbow may cause damage to the radial nerve, thus causing numbness
to the forearm, thumb, and index finger. This numbness generally lasts
from 3 to 6 months and will commonly resolve on its own. Usually
developing numbness is a serious consequence that reflects either a
tear or compression on a nerve. This is an area where the development
of such a numb feeling is less cause for panic.
Elbow Trauma
Fractures of the humerus above the elbow are very treacherous, as
bone fragments may seriously injure the nerves or blood vessels at
this location. Fractures of the elbow itself are similarly dangerous due
to the possible damage to nerve, blood vessel, or articular surfaces of
the bones in this joint. The immense swelling associated with frac-
tures or sprains at the elbow causes compression that frequently does
more damage than sharp pieces of broken bone.
Avoid splinting the elbow near a 90-degree angle. Allow the
elbow to droop in the sling with a posterior padding. Never wrap the
elbow joint at the front aspect—leave this area open to the air. It is
compression in the front of the elbow joint, an area called the antecu-
bital fossa, that frequently results in serious injury to the blood vessels
and nerves. Surgical intervention with X-ray assistance is required, so
back to the grid with you for this one to ensure normal elbow func-
tion. Allowing the injured elbow to freeze into a 120-degree position
may be the only treatment you can offer under long-term off-grid
conditions.
Dislocation of the elbow is most common in young adults. Frac-
tures of the tip of the elbow (the coronoid process) frequently are
involved but generally do not cause future problems.
Forearm Fractures
Forearm fractures in children can generally be treated by reducing
under X-ray and plaster casting, while in adults they frequently are
treated surgically. Neither option is available to the isolated wilder-
ness inhabitant if evacuation is not possible. The position of splinting
on forearm fractures differs depending upon the location along the
two bones, due to different forces upon these bones from tendon and
muscle attachments. This positioning can only be held properly with

tight-fitting plaster splints. Bone alignment can only be followed
through repeated X-rays. Therefore, it is obvious that a completely
fractured, unstable condyle can cause severe problems, as indicated
above, primarily due to compression from associated bleeding on the
neurovascular bundle. Reduction obviously should not be attempted
if there is a chance of being treated properly by an orthopedic spe-
cialist with X-ray equipment. The appearance of the dislocated elbow
is obvious when compared to that person’s other elbow. Some people
have a sharper-looking elbow tip than the average individual. How-
ever, swelling and a particularly prominent, hard point behind the
elbow would indicate that a dislocation has transpired.
Pain medication should be given to the victim to relax the mus-
cles prior to attempting to reduce the dislocation. Figure 7-8 demon-
strates the technique of reducing an elbow dislocation.
The ideal position after reduction of the elbow is at 90 degrees
with a posterior plaster splint. However a 90-degree position is
potentially dangerous, as swelling may compromise the circulation. If
the pulses at the wrist are decreased, then allow the elbow to droop as
necessary to relieve this compression, possibly to a 120-degree posi-
tion as described above. The reduction of a simple elbow dislocation is
Figure 7-8.
The Stimson method
for reducing a dislo-
cation of the elbow.
This dislocation
results when the ulna
is forced backward,
so that the tip (olec-
ranon) becomes very
prominent. Besides
traction on the wrist,
pushing on the olec-
ranon aids in the
reduction.
4-8
best maintained in the posterior splint for 3 weeks, then start range-
of-motion exercises. Soaking the elbow in warm water about 15 min-
utes prior to starting a gentle exercise program is helpful. If unusual
deformity has resulted, or if the elbow is frozen, this may have to
be accepted under survival conditions until definitive surgery can be
accomplished. Full and proper use of this elbow will probably never
again be reestablished; even after delayed surgery a fracture of the
forearm will very likely not heal properly when treated by crude tech-
niques in an off-grid setting.
Most fractures of the forearm are not complete and unstable,
however. They will heal nicely with protective splinting being the
only required therapy. A stable crack can be suspected from swell-
ing and point tenderness to gentle finger palpation by the examiner
along the radius and ulna, the two forearm bones. Under this cir-
cumstance a splint must be manufactured that will provide stability
so that this fracture can heal without danger of further trauma, as
in figure 7-9. The bone will weaken during the healing process and
additional trauma may turn this non-displaced fracture into an angu-
lated mess. Pad the splint well and provide a sling for at least 3 weeks.
Keep splinted for a total of 6 weeks, longer if point tenderness is still
present. If point tenderness disappears within a few days or at most 2
Figure 7-9.
Forearm splint technique with the SAM Splint
4-9
weeks, the injury was not a fracture, but simply a contusion, and the
splint may be safely removed at that time.
Fractures associated with deformity in the forearm provide the
physician with two challenges: first, reducing the fracture, and sec-
ond, maintaining its position with proper casting. Reduction of fore-
arm fractures is generally done by traction, increasing the angulation
to engage the fracture ends, then straightening the bones prior to
casting. This is done with anesthesia. The survivalist had best splint
deformed fractures of the forearm after straightening gross angula-
tion with in-line traction. The splinted position will have to be main-
tained for 8 weeks or longer, depending upon the disappearance of
local tenderness. A well-padded splint may generally be applied in
a firm manner, immobilizing the elbow and wrist joints. Corrective
surgery can be performed later. It is best to avoid a manipulation that
will be extremely painful and unstable anyway.
Wrist Fractures and Dislocations

Wrist fractures and dislocations are common in young adults who
extend their arms and hands to help break a fall. The three most com-
mon problems are fractures of the navicular (or scaphoid) bone, dis-
location of the lunate, and perilunate dislocation. (See wrist anatomy
in figure 7-10.) Navicular fractures frequently do not heal even with
appropriate casting.
Dislocations of the lunate or of the remaining carpals from the
lunate would ideally be reduced, but without X-ray, experience, or at
least local anesthesia, this is not possible. Symptoms of lunate dis-
location would be pain in the wrist and frequently numbness in the
thumb, index, and middle fingers.
There is pain with any attempt to move the wrist. An abnormal
knob on the palm side of the wrist at the crease, when compared
to the other wrist, should be obvious to palpation. The numbness
described indicates pressure on the median nerve from the dislocated
navicular bone, and an attempt at reduction should be made. As in
figure 7-11, with the wrist in extreme dorsiflexion, apply traction
while attempting to push the lump back into position. The reduction
often is accompanied by an obvious pop.
Capitate
Trapezoid Hamate
Trapezium Triquetral
Scaphoid Pisiform
Lunate
Radius Ulna
Figure 7-10.
Anatomy of the wrist bones
Perilunate dislocation will have similar symptoms and signs, with

pain on attempted movement of the 4-10
wrist and possible median nerve
compression causing thumb, index finger, and middle finger numb-
ness. The knob will not be present, but there will be a slight deformity
of the back side of the wrist, sometimes called a modified silver fork
deformity, or hump at the upper side (dorsum) of the wrist. The tech-
nique of reduction is similar; apply traction to the wrist and place
your thumb firmly over the location of the lunate bone (just beyond
the end of the ulna) to hold the lunate in position as the wrist is
then gradually flexed to bring the rest of the carpal bones down into
proper position with the lunate and the ends of the radius and ulna.
There is generally no snap when this occurs. The numb feeling should
wear off within the next hour if the pressure has been removed from
the median nerve.
Figure 7-11.
Extreme dorsiflexion
of the wrist. This is
the position of the
wrist used to aid in
the reduction of
lunate bone
dislocation.
Figure 7-12.
The thumb spica
wrap and a thumb
spica made with a
4-12 SAM Splint
4-11
Navicular (scaphoid) fractures will have pain on the thumb side
of the wrist, and while the entire wrist will be sore to palpation, it
will be particularly sore below the thumb at the wrist. This fracture
seldom dislocates, but it often doesn’t heal, even after being placed in
a tight plaster cast for several months.
After attempting to reduce a dislocation of the wrist or treat the
possible fracture of the navicular, splint the wrist and thumb so they
are as immobile as possible. While it is not a rigid dressing, a thick
wrap using a 2-inch Ace elastic bandage applied in the manner called
a thumb spica, as illustrated in figure 7-12, can do well. Under survival
conditions, fusion, arthritis, and even loss of median nerve function
may have to be accepted. This is a terrible loss that proper orthopedic
treatment can almost always avoid. The thumb spica wrap will also be
adequate for sprains of the wrist and thumb.
Thumb Sprains and Fractures

Injuries causing severe pain and swelling of the thumb may be sprains
or fractures. A severe sprain will cause loss of strength of the thumb
for many weeks, even months. Swelling can be substantial with either
injury. First aid management is splinting until treatment by a physi-

cian can be arranged. In an extended survival situation, reduce any
obvious deformity and hold in position with a thumb spica wrap, as
in figure 7-12. Severe sprains and all fractures will take 8 weeks to
heal. There is risk of arthritis and loss of function depending upon
the injury, patient’s age, adequacy of reduction, and suitability of your
splinting technique.
Hand Fractures
A hand fracture of the first metacarpal can be treated with a thumb
spica wrap (see figure 7-12) that immobilizes the entire wrist. The
fifth metacarpal is the most commonly broken bone in the hand. The
name given to this fracture, a “boxer’s fracture,” indicates its frequent
method of origin. Perfect reduction of this fracture is not required; in
fact, up to 30 degrees of angulation is acceptable. Only 5 to 10 degrees
of angulation is acceptable in the third and fourth metacarpals.
Measuring the amount of angulation will be impossible without
an X-ray. If you are used to seeing these fractures, before-and-after
X-rays become merely a legal maneuver and are not medically neces-
sary. In a survival situation one may be able to tell if too much angu-
lation has occurred by palpating the palm of the hand. If the nodular
head of the metacarpal is felt where it joins the finger, there may be
too much angulation. If too much angulation is allowed, a lump in
the palm of the hand will make holding tools and objects uncom-
fortable for the rest of the patient’s life. Unacceptable angulation will
have to be snapped back into place. Splinting should be maintained
in a position of function for 6 weeks.
Finger Fractures and Sprains

Gross lateral or sideways deviations of fingers should be corrected,
and the finger splinted in the position of function. These deviations
may be corrected by tugging and thus resetting the fracture, or by
placing a pencil or similar object between fingers and thus getting
leverage to snap a deviated finger shaft back into place. Deviations
at the joints probably represent dislocations, and generally these may
be easily reduced by the tugging technique. An alternate technique to
tugging is to place the dislocated joint into partial flexion; it will then
be easier to lever the joint into position.
Swelling associated with “jammed” fingers can become perma-
nent if use of the finger is allowed before adequate healing has taken
place. After the acute injury, splinting in the position of function is
always appropriate for at least 3 weeks, followed by “buddy splinting”
to the adjacent finger for another 2 to 3 weeks. Fingers should not be
splinted straight. Buddy splinting may be used initially if the victim
must use the hand immediately, as in gardening, wood cutting, or
chores that require all hands on deck.
Ruptured tendons can be repaired generally by splinting in a
position of function, with the exception of a rupture of the distal
extensor tendon of a finger. This injury is rather common and can be
caused by an object hitting the tip of the finger or catching the finger
in something (often in a sheet while making a bed). While making
beds may not be a problem you expect to encounter, this illustrates
how easily the injury may occur. Figure 7-13 illustrates the appear-
ance of this injury, commonly called a mallet finger deformity. The
splinting technique for this injury is not the position of function, but
as illustrated in figure 7-14.
Figure 7-13.
Mallet finger deformity from
ruptured distal extensor tendon
4-13
Figure 7-14.
Splint technique for the ruptured
distal extensor tendon
4-14
Hip Dislocation and Fracture

Hip injuries are very serious. Tremendous blood loss occurs internally.
Fractures of the hip cause pain in the anterior medial aspect (front
and side) of the thigh. Dislocations in younger people may be asso-
ciated with fractures; in older people fractures are very common and
are the probable cause of the deformity. See figure 7-15 for positions
of fracture and dislocation.
Posterior dislocation of the hip is more common in healthy
young adults compared to central fracture/dislocation and anterior
hip dislocation. All these injuries are infrequent when compared, for
instance, with dislocation of the shoulder. Posterior dislocations can
cause injury to the sciatic nerve, the main nerve of the leg. This can
cause shooting pains down the back of the leg and/or numbness of
the lower leg. It is most important that reduction of the disloca-
tion not be delayed longer than 24 hours. Muscle relaxants and pain
medication must be given. To reduce, place the victim on her back
with the knee and hip in a 90-degree position. The line of the femur
should point vertically upward. The thigh should be pulled steadily
upward while simultaneously rotating the femur externally, as shown
in figure 7-16.
If possible, evacuate this patient back to the grid. For evacuation
purposes, pad well and buddy splint to the other leg. This victim is
a litter case. Continued pressure on, or severe injury to, the sciatic
nerve will cause muscle wasting and loss of sensation to practically
the whole leg. This damage must be surgically repaired as soon as
possible. In the extreme case of survival without possible repair, brace
the affected leg to allow mobility by the victim and take care of numb
skin areas to prevent sores and infection.
Central fracture/dislocations result when the head of the femur is
driven through the socket into the pelvis. As in all orthopedic injuries,
an X-ray is almost essential for the diagnosis. If the fragments can be
replaced surgically, this is the treatment of choice. In the extreme
survival situation (when there is no hope of medical care for many
months), this injury can be left alone and still result in a stable and
relatively painless joint. Light traction can be applied to the lower
leg for comfort. After 3 weeks, ambulation with crutches, gradually
(A) (B) (C)
Figure 7-15.
(A) Typical appearance of a fractured hip, (B) typical appearance of a posterior
hip dislocation, and (C) typical appearance of an anterior hip dislocation
increasing weight, can be encouraged. Range-of-motion exercises

should be started from the beginning to help mold the healing frag-
ments into a relatively smoother joint surface. Sciatic nerve injury
should not occur with this injury, but an arthritic joint will result.
Anterior dislocation results from forceful injuries such as air-
plane crashes and motorcycle accidents. Examination of the lower leg
demonstrates considerable lateral rotation, or outward tilting, of the
foot when the victim is lying on his back. Reduction is as described
under posterior dislocation, with traction on the flexed limb but
(A) (B)
Figure 7-16.
Reduction of the posterior hip dislocation, providing upward
traction on the hip while flexed to 90 degrees (A) and rotating
externally (B)
4-16
combined with medial rotation, or rotating the limb inward rather
than outward.
Thigh Fractures
Fractures of the thigh (femur) can, of course, occur from the hip to
the knee. They are classified and treated by the orthopedic specialist
differently according to the location of the break.
First aid treatment consists of treating for shock and immobi-
lizing, initially using hand traction splinting. Start by providing pain
relief with gentle hands-on in-line traction. Traction splinting is
initially helpful, as spasms from the powerful muscles in this region
cause considerable overriding of bone fragments, increasing the
extent of the injury. Traction also reestablishes the normal length and
configuration of the musculature and tightens the membranes that
surround the muscle (the fascia), which very importantly decreases
the bleeding that occurs with this injury.
The amount of pull required is minimal due to Pascal’s law of

hydrodynamics. It indicates that any change in pressure applied at
any point in the fluid is transmitted undiminished throughout the
fluid. As the thigh is a closed cylinder, the massive bleeding that
occurs with a fractured femur will have a tamponade applied by
lengthening, ever so slightly, the sack of fascia or tissue covering the
muscle and broken bone. This elongation of a slight sphere into more
of a cylinder reduces the surface area of the sphere into that of a
cylinder, but the volume of blood inside remains the same. Thus,
through the magic of Pascal’s law, there is a significant increase in
the deep tamponade on the bleeding bone and muscle tissues with
even slight traction. Partial pain relief is the guide by which you will
generally know how much pull to exert. This traction is initially per-
formed by pulling on the ankle/foot gently in line, with the patient
lying on their back.
The patient should do quite well with simple buddy splinting to
the other leg during litter transport. The best traction method for
the person in a fixed camp situation is to have them on a throughly
padded and comfortable bed with a foot board rigged to accept a sash
tied around the ankle with an appropriate tug (about 2 pounds [1.6
kilograms] of tug). A person kept in bed with a traction splint will be
at a higher risk of developing leg blood clots (thrombophlebitis). Ini-
tially, bleeding into the leg muscle is your biggest concern. Coupled
with severe pain, this can lead to shock. After a few days, bleeding
is less of a concern, but developing a blood clot in an immobilized
patient is one. At that time, it is appropriate to start aspirin, 81 mg
per day. If you have the 325 mg aspirin, give one initially and then 1
every 2 days.
After the traction splinting period, buddy splint with non-weight-
bearing ambulation. A fractured femur will take 8 to 12 weeks to
firmly stabilize.
Kneecap Dislocation
The kneecap (patella) usually dislocates laterally, or to the outside of
the knee. This dislocation results in a locking of the knee with a bump
to one side, making the diagnosis obvious. Relocate the patella by
flexing the hip and the knee. When straightening the knee, the patella
usually snaps back into place by itself. If not, just push it back into
place while straightening the knee on the next try. Splint with a tube
splint (closed-cell foam sleeping pad) with the knee slightly flexed.
This patient should be able to walk to the base camp. No further care
will be necessary in an off-grid situation, except physical therapy per-
formed by attaching a light weight (4 pounds [1.8 kilograms]) to the
ankle and having the person sit with the leg dangling and repeatedly
extending the knee. This exercise strengthens the quadriceps muscle,
providing the chance for tightening the patella when under actual
use stress against the knee joint and allowing less laxity, decreasing
the chance of future dislocations. An on-grid orthopedic referral for
recurrent patella dislocations is appropriate to repair the torn capsule
for better ensured stability.
Knee Sprains, Dislocations, and Fractures

The initial care of sprains, or acute joint injuries, is described on page
159. If the pain in the knee is severe, several diagnoses are possi-
ble. There may be tears of ligaments, tendon, cartilage, or synovial
membranes. There may be associated dislocations or fractures. All you
really can assess is the amount of pain that the patient is experiencing,
and you have to take his word for that. You can visually assess the
amount of swelling or deformity and that might tell the tale, but the
most important aspect of care will be handling pain as the patient
interprets it.
Have the patient lie as comfortably as possible. Apply RICE (see
page 160) to the knee. In case of significant pain or swelling, remove
the boot (weather permitting) and check the pulse on top of the foot
(the dorsal pedal pulse); question the victim about sensation in the
feet. Check the dorsal pedal pulse on the opposite side for compari-
son. If the injury appears minor, this is not necessary.
Significant deformity means that a dislocation may have
occurred. Serious disruption of the blood vessels and nerve damage
can happen. Check the pulses and for sensation in the foot. If these
are all right, splint the knee as it lies. If not, have a helper hold the
lower thigh while you grip the ankle with one hand and the calf with
the other. Use in-line traction while you gently flex the knee to see
if you can reposition it better. If the pain is too great, you meet resis-
tance, or you cannot do it, splint in the most comfortable position
and evacuate as soon as possible back to the grid. If there is no grid
return possible, then you MUST succeed with reduction technique
just described.
Even without obvious deformity, an immediate complaint, or
continuing complaint, about significant pain means that you now
have a litter case, and you should make plans accordingly. If in 2
hours, the next morning, or 2 days later, the patient feels better and
wishes to walk on the knee, great! Let it happen. You had best remove
all weight from the patient’s shoulders and provide a cane to use on
the side opposite the injury. This places a more natural force vec-
tor on the injured joint. Continue the compressive dressing. After 2
days begin applying heat packs during rest stops and in the evenings.
The patient’s perception of pain should be the key to managing these
injuries, although this approach can be complicated by varying pain
thresholds, from macho to wimp.
Ankle Sprains, Dislocations, and Fractures

Generally, fractures of both sides of the ankle (a tibula-fibula fracture)
are associated with a dislocation. The severe pain associated with the
fracture is an early indication that this patient is a litter case. Splint
the ankle with a single SAM Splint, or form a trough of Ensolite
foam and tape it on. The latter is not a walking splint, but if the pain
is significant enough, the patient isn’t walking anyway. A flail ankle,
caused by complete disruption of the ankle ligaments, readily slops
back into position and can be held in place with a trough splint of
Ensolite padding.
Allow the patient to rest after the injury, before attempting to
walk on the ankle. If there is severe pain, it might be broken or badly
sprained. Either way, if the pain is too severe, the patient won’t be
walking—at least not until it quiets down. As with the knee, if the
pain diminishes enough that the victim can walk, allow him to do so
without carrying equipment but using a cane for added support and
decreased weight-bearing.
Foot Injuries
Stubbed toes can be buddy splinted to provide pain relief. If they have
been stubbed to the extent that they deviate at crazy angles sideways,
they should be repositioned before buddy taping. Place a pencil (or
a similar-width object) on the side opposite the bend, and use it as a
fulcrum to help snap the toe back into alignment. Blood under the
toenail can be treated as described on page 146.
Severe pain in the arch of the foot or in the metatarsals can repre-
sent fractures or sprains. Apply RICE as described for Knee Sprains,
Dislocations, and Fractures on page 189). Allowing a little time to
lapse before use might result in decreased pain in minor injuries, but
it would take weeks for a fracture to decrease in severity. Reduce the
patient’s weight load and provide a cane. If the foot swells to the
extent that the boot cannot be placed on the foot, consider cutting
it along the sides and taping the boot circumferentially around the
ankle to hold it on. This provides support for the foot, ankle, and the
patient’s favorite on-grid retailer.
Chest Injuries
Broken ribs may develop after a blow to the chest. Even a severe
cough or sneeze can crack ribs! Broken ribs have point tenderness or
exquisite pain with the lightest touch over the fracture site. The pain
at this site will be reproduced by squeezing the rib cage in such a
manner as to put a stress across the fracture site. Deep breathing will
also produce pain at that location.
It is not necessary to strap or band the chest, except that such a
band might prevent some rib movement and make the patient more
comfortable. It is very important for the patient to breathe and have
some cough reflex to aid in pulmonary hygiene, namely to prevent the
accumulation of fluid in the lungs, which can rapidly lead to pneu-
monia. For that reason, emergency departments do not discharge
patients with compression rib belts. However, if I fracture a rib, I will
definitely want one. Simply tying a large towel or undershirt around
the victim’s chest should suffice. A fractured rib takes 6 to 8 weeks to
heal. A similar pain may initially be present due to a tear of the inter-
costal muscles or separation of cartilage from the bone of the rib near
the sternum or breastbone. These problems are treated as above. They

heal much more quickly, generally in 3 to 5 weeks.
If several adjacent ribs are broken in more than one location, a
section of the chest wall is literally detached and held in place by
the muscles and skin. This section of the chest wall can bulge out
when the patient exhales instead of contracting as the chest would
normally do. It can also move in when the rest of the chest expands
during inhalation. This paradoxical motion of the chest wall is called
a flail chest. Treatment includes placing an adequately sized rolled
cloth against the flail portion to stabilize the motion. This cloth roll
will have to be bound in place.
Treat all of the above conditions with pain medication as described
on page 31. Avoid unnecessary movement. Have the patient hold his
hand or a soft object against his chest when coughing to prevent rib
movement and decrease the pain. Allow the patient to assume the
most comfortable position, which is usually sitting up. If a fever starts,
treat with an antibiotic such as Levaquin, 750 mg once daily.
Broken ribs usually heal well even though considerable move-
ment seems to occur due to breathing or even flailing of the chest.
They are always so painful that patients feel like they might puncture
a lung at any minute. This does not usually happen, but if it does, there
is a chance that air will leak into the chest cavity, causing a pneumo-
thorax. This can lead to significant respiratory distress, including cya-
nosis (blue discoloration of the skin due to inadequate oxygen in the
blood). Crepitation can form in the skin. This is a crackling sensation
that is very noticeable to the examiner when running the fingers over
the skin in the upper part of the chest. It is not painful, but it indi-
cates that air leakage and a pneumothorax have occurred. A pneumo-
thorax can resolve on its own or it can expand, causing death. There is
nothing you can do for this unless you are trained in its management.
Similarly, bleeding into lung tissue can result in a hemothorax, which
can either resolve on its own or progress to death. Cyanosis with dif-
ficult breathing may also result due to this condition.
CHAPTER 8
BITES AND STINGS
VENEMOUS STINGS
On grid or off grid, these things will find you. Stings from bees,
wasps, yellow jackets, hornets, and fire ants—all members of the order
Hymenoptera—produce lesions that hurt instantly, and the pain lin-
gers. The danger comes from the fact that some people are hyper-
sensitive to the venom and can go into immediate, life-threatening
anaphylactic shock.
The pain of the sting can be alleviated by almost anything applied
to the skin surface. Best choices are cold compresses, hydrocortisone
1% cream, or the triple antibiotic with pramoxine ointment from the
Topical Bandaging Module. Oral pain medication—OTC or Rx—
can be given as necessary. Delayed swelling can be prevented and
treated with oral antihistamines such as diphenhydramine, 25 mg
taken 4 times daily, from the Non-Rx Oral Medication Module.
A generalized rash, asthmatic attack, or shock occurring within
2 hours of a sting indicates anaphylaxis, which requires special
management.
Anaphylactic Shock
While most commonly due to insect stings, anaphylactic shock may
result from a serious allergic reaction to medications, shellfish, and
other foods—in fact, anything to which one has become profoundly
allergic. Some non-stinging insect bites can also produce anaphylac-
tic shock, like bites from the cone-nosed beetle (a member of the
Reduviidae family), which can be found in California and throughout
Central and South America. We are not born sensitive to these things
but become allergic with repeated exposure. Those developing ana-
phylaxis generally have warnings of their severe sensitivity in the
form of welts (urticaria) forming all over the body immediately after
exposure, the development of an asthmatic attack with respiratory
wheezing, or the onset of symptoms of shock.
While these symptoms normally develop within 2 hours and cer-
tainly before 12 hours, this deadly form of shock can begin within
seconds of exposure. It cannot be treated as indicated in the section
on “normal” shock on page 13. The antidote for anaphylactic shock
is a prescription drug called epinephrine. It is available for emer-
gency use in vials or the special automatic injectable syringe called
the EpiPen; see figure 8-1. Automatic injection syringes are quite
expensive. Vials of epinephrine are less expensive but will require an
accurate small-barrel (1 cc) syringe to properly measure and inject.
The normal dose for an adult is 0.3 cc of the 1:1000 epinephrine solu-
tion given IM. This is quite easy to do, and even if a dose larger than
0.3 cc is administered (even twice that dose), it will cause no harm in
either an anaphylaxis or asthma emergency. While it is not necessary
to treat the itchy, generalized rash, the epinephrine should be given
if the voice becomes husky (signifying swelling of the airway) and if
wheezing or shock occurs. This injection may have to be repeated in
15 to 20 minutes if the symptoms return. The EpiPen Jr is available
for use in patients weighing less than 66 pounds (30 kilograms) when
the dose is 0.15 cc of the same solution.
Antihistamines are of no value in treating the shock or asthmatic
component of anaphylaxis, but they can help prevent delayed allergic
reactions. If you have oral or injectable Decadron, give a 4 mg tablet
or 4 mg injection for long-term protection, as each dose of this med-
ication lasts approximately 12 hours.
On the grid evacuate anyone experiencing anaphylactic reactions
even though they have responded to the epinephrine. They are at risk
of the condition returning, and they should be monitored carefully
BITES AND STINGS 195
over the next 24 hours. People can die of anaphylaxis very quickly,
even in spite of receiving aggressive medical support in a hospital
emergency department. Beyond 24 hours they are no longer at risk
of an anaphylactic reaction. If the patient is still alive after that time,
vital signs are stable, and there is no manifestation of anaphylaxis, the
evacuation can be terminated.
USE OF EPIPEN
The EpiPen (figure 8-1) is an auto-injection system with two injec-
tion units available per box. It is available in adult and child doses.
Using the EpiPen involves three simple steps:
1. Pull off the blue safety cap.
2. Place the orange tip on the outer thigh, halfway between the
hip and knee (lateral side), preferably against the skin, but it
can be used through thin clothing.
3. Push the unit against the thigh until it clicks, and hold it in
place for a count of 10.
Due to the high cost of this device, I suggest your physician pre-
scribe vials of epinephrine and appropriate syringes for administra-
tion. Vials are sealed glass containers or rubber-stopper sealed vials.
The glass vial system will require etching the ampule neck with a glass
cutter and then snapping it off. Some glass vials are pre-etched and
require only a careful snap to open. I always snap these vials cuddled
in a thin towel. Draw the fluid up in a small-gauge needle and give
the shot IM.
Figure 8-1.
The EpiPen is used to treat severe allergic reactions.
5-1
SNAKEBITES
Identifying Common North American

Poisonous Snakes
With regard to the visual identification of the most common poi-
sonous snakes in North America, pit vipers take their name from the
deep pit, a heat-receptor organ, between each eye and nostril. Most of
them have triangular heads and catlike vertical elliptical pupils.
While not pit vipers, coral snakes (Micrurus fulvis, family Elap-
idae) also have vertical elliptical pupils. Some nonpoisonous snakes
do as well. Color variations in coral snakes make the old saying “red
on yellow can kill a fellow, red on black, venom lack” a very treach-
erous method of identification. This is particularly true in Central
and South America. Coral snake bites should be treated as described
below under Neurotoxic Snakebites.
The essential steps in treating snakebites are calm the victim,
cause no additional harm, decide about evacuation urgency, and
arrange for appropriate long-term wound care. The field first aid care
of snakebites differs for nonpoisonous snakes, pit vipers (including
rattlesnakes, cottonmouth/water moccasins, and copperheads—all in
the family Crotalidae), and neurotoxic snakes (coral snakes, cobras,
green mambas, kraits, and all poisonous Australian snakes, all the
family Elapidae). That being said, the actual first aid care is easy to
accomplish and will generally depend on where geographically the
snake bite occurs. Treat North American pit viper snakebites without
compression, and treat snakebites received elsewhere as neurotoxic
bites requiring compression and immobilization, as indicated below.
Regardless of the type of snakebite, the first step is to calm the
patient and treat for shock. How do you calm a person who has just
been bitten by a snake? Not surprisingly, just telling him to remain
calm won’t work. In a remote area when something terrible has hap-
pened, it’s only your actions and demeanor that will provide comfort.
Depending on the individual, you may need to treat for shock imme-
diately, as described on page 13.
All snakebites are puncture wounds, and nonpoisonous bites and
“dry” North American pit viper bites should be treated as indicated
in the puncture wound section on page 133. Studies indicate that

20% of eastern diamondback rattlesnake bites and 30% of cotton-
mouth/water moccasin bites are dry, which means no venom has been
injected into the victim.
Signs and Symptoms of Pit Viper Bite

What are the signs and symptoms of envenomation from pit vipers?
The first indication noted by many is a peculiar tingling in the mouth,
often associated with a rubbery or metallic taste. This symptom may
develop in minutes and long before any swelling occurs at the bite
site. Envenomation also may produce instant burning pain. Weakness,
sweating, nausea, and fainting may occur with either poisonous or
nonpoisonous snakebites, due simply to the trauma of being bitten. In
case of envenomation, within 1 hour there will generally be swelling,
pain, tingling, and/or numbness at the bite site. As several hours pass,
bruising (ecchymosis) and discoloration of the skin begin and become
progressively worse. Blisters may form, which are sometimes filled
with blood. Chills and fever may begin, followed by muscle tremor,
decrease in blood pressure, headache, blurred vision, and bulging eyes.
The surface blood vessels may fill with blood clots (thromboses), and
this can, in turn, lead to significant tissue damage after several days.
Treatment of Pit Viper Bite

For rattlesnakes, copperheads, and water moccasins, treat for shock
and calm the patient as indicated above. Remove any constricting
objects such as rings. Immobilize the injured part at heart level. And
evacuate if you can.
It has been said that the best snakebite kit is a set of car keys. The
reason is that envenomation can make a person very ill (on average
seven people die yearly in North America from these bites), and it
can cause serious tissue damage that is best treated with antivenin.
There is a golden hour and a half before North American pit viper
venom causes significant generalized effects that might make the
victim nonambulatory. You might want to start walking the victim
toward the nearest road to shorten the length of a litter evacuation,
which will become necessary if his condition deteriorates. This walk
out should be performed in a calm but urgent manner. Attempting to

carry any but a very light individual will excessively prolong it.
Do not apply compression or a tourniquet to the swelling asso-
ciated with this type of bite because the venom causes considerable
tissue damage from squeezing blood vessels, and further compression
makes this effect worse. Do not apply ice, as this results in increased
local tissue destruction. Avoid the use of a constricting band between
the bite site and the heart, as this has never been shown to be effective
and there is a real danger of it being applied too tightly, resulting in a
tourniquet effect that increases tissue destruction.
If no grid exists, treat as indicated above: immobilization with the
injured part at heart level. As most bites are dry bites or partial venom
loads, this may be all that one needs to do. If local swelling starts,
slightly elevate the limb to decrease pressure within it. Trunk and
facial bites, while rare, are even more of a challenge. Treat for shock,
prevent hypothermia, and provide Tylenol for pain, avoiding aspirin
and anti-inflammatory medications. While the use of steroids is not
required in an on-grid hospital setting, without access to care the
use of steroids (Decadron, 4 mg every 12 hours for 3 days) probably
reduces inflammation.
Neurotoxic Snakebites
Coral snakes, all Australian snakes, and most African, Indian, and
South American snakes are all capable of injecting neurotoxins into
their victim’s system with their bites. In 1979 Australia adopted
pressure and immobilization as the first aid treatment for the very
dangerous snakes found on that continent and dropped their yearly
death rate from snakebites to virtually zero. In Australia the wound is
not washed prior to wrapping, as special “snake venom detection kits”
are available at hospitals that can identify the snake from venom in
the wound. The wound is not manipulated in any way; instead, pres-
sure and immobilization is applied immediately as indicated in figure
8-2. The pressure dressing works to slow the venom from migrating
into the main body, allowing time for the antivenin to be acquired.
Without antivenin, treat the patient for shock (page 13) and try to
maintain breathing with respiration-assisted breathing (see page 19);
Figure 8-2.
How to apply pressure/immobilization for neurotoxic snakebites:
(A) Apply a broad pressure bandage over the bite site as soon as possible.
Do not take off clothing, as any movement helps the venom enter the
bloodstream. 5-2
(B) The elastic bandage should be as tight as you would apply to a sprained
ankle.
(C) Extend the bandage as high as possible, wrapping over clothing if
necessary.
(D) Apply a splint to the leg.
(E) Bind the splint to as much of the leg as possible.
(F) For bites on hands or forearms: 1. Bind to elbow with bandage. 2. Splint to
elbow. 3. Use sling.
there is not anything else you can do. If you are moving off the grid
into Australia, India, or South America, poisonous animal encoun-
ters add a whole level of risk. (Also read below concerning neurotoxic
venom).
Treatment of Coral Snake Bites

North American coral snakes envenomate by a slow chewing process,
so that a rapid withdrawal from the attack may result in no enven-
omation. For treatment: (1) treat for shock as necessary, (2) wash the
bitten area promptly to possibly remove some venom, (3) make no
incisions, (4) apply pressure/immobilization, and (5) evacuate to a
hospital if possible. Since, like the cobra, the coral snake is an Elapid
family of snake, signs and symptoms of envenomation take time to
develop, and deterioration then proceeds so rapidly that the antivenin
may be of no avail. Without the possibility of evacuation, after initial

care of the wound as above, allow the victim to rest with adequate
protection from the environment. Just leave the compression dressing
on, making sure that it is not acting as a tourniquet. If severe pul-
monary symptoms develop, see paragraph below. Provide breathing
assistance as long as possible.
Cobra, Russell’s viper, green mamba, and krait bites outside of
Australia result in thousands of deaths yearly. While many areas of
the world have a local source of antivenin for the species of snakes
that are of concern in that locale, often the antivenin may be inacces-
sible. The use of a class of compounds called anticholinesterases can
be lifesaving when dealing with neurotoxic envenomations if no anti-
venin is available. For physician use only, a suggested protocol is the
administration of 0.6 mg of atropine IV (0.05 mg/kg for children) to
control intestinal cramping, followed by 10 mg of Tensilon (0.25 mg/
kg for children). If there is improvement, further control of symptoms
can be obtained by titration of a dose of neostigmine, 0.025 mg/kg/hr
by IV injection or continuous infusion. Note: These medications are
not included in the recommended Rx Injectable Medication Module.
INSECT BITES AND STINGS
Spider Bites
Generally, spiders will make a solitary bite, not several. If you wake
with multiple bites, you have probably collided with some other
arthropod. While only some spiders are considered poisonous, all
spiders have venom that can cause local tissue inflammation and even
slight necrosis or destruction. Most spiders are unable to bite well
enough to inject the venom.
BLACK WIDOW SPIDER

The black widow (Latrodectus mactans) is usually glossy black with a
red hourglass mark on the abdomen. Sometimes the hourglass mark
is merely a red dot, the two parts of the hourglass do not connect,
or the coat is not shiny and it may contain white. The bite may be
only a pinprick, but generally a dull cramping pain begins at the
site within 15 minutes, which may spread gradually until it involves

the entire body. The muscles may go into spasms and the abdomen
becomes boardlike. Extreme restlessness is typical. The pain can be
excruciating. Nausea, vomiting, swelling of eyelids, weakness, anxiety
(naturally), and pain on breathing may all develop. A healthy adult
can usually survive, with the pain abating in several hours and the
remaining symptoms disappearing in several days.
An ice cube on the bite, if available, may reduce local pain. A
specific treatment for relieving muscle spasms is methocarbamol
(Robaxin), 100 mg given as a bolus into an IV line at 1 ml/min. After
the initial bolus, a constant infusion of 200 mg/hr IV, or 500 mg
by mouth every 6 hours, can be used. This medication has not been
included in the Off-Grid Medical Kit, but adequate pain relief can
be given by using medications from the Non-Rx Oral Medication
Module, or Norco 10/325.
Similar spiders are found throughout the world. The South
African knoppie, the New Zealand katipo, and the Australian red
black spider bites have the same symptoms and can all be treated as
described above. A specific antivenin is available in those countries.
BROWN RECLUSE SPIDER

A brown coat with a black violin marking on the cephalothorax, or
top part, identifies the brown recluse spider (Loxosceles reclusa). The
initial bite is mild and may be overlooked at the time. In an hour or
two, a slight redness may appear; by several hours a small bleb appears
at the bite site. Sometimes the wound appears as a bull’s eye with
several rings of red and blanched circles around the bite. The bleb
ruptures, forming a crust, which then sloughs off; a large necrotic
ulcer forms, gradually enlarging. Over the first 36 hours, vomiting,
fever, skin rash, and joint pain may develop, and hemolysis of the
blood may be massive.
Apply ice to the wound as soon as possible. Dapsone (a medica-
tion used in the treatment of leprosy), 100 mg twice daily, has been
used, but its effectiveness is unlikely. Dapsone, once thought to be
effective during the early stages of treatment to decrease the severity
of the inflammation, is not included as a routine component of the
Rx Oral/Topical Medication Module. Prophylactic use of antibiot-

ics does no good. Avoid the application of heat to this wound, even
though it is inflamed and necrotic.
Give ibuprofen, 200 mg, 4 tablets every 6 hours, to help with pain
and to reduce inflammation. From the Rx Oral/Topical Medication
Module give Decadron, 4 mg every 6 hours. It is doubtful that steroid
therapy is of benefit after 24 hours. Apply triple antibiotic ointment
from the Topical Bandaging Module and cover with gel dressing.
Ticks
More vector-borne diseases are transmitted in the United States by
ticks than by any other agent. Ticks must have blood meals to survive
their various transformations. It is during these meals that disease can
be transmitted to humans and other animals.Two families of ticks
can transmit disease to humans: Ixodidae, or hard ticks, and Argasi-
dae, or soft ticks. The life cycle of the hard tick takes two years to
complete: from the egg to the six-legged larva or seed tick, the eight-
legged immature nymph, and finally the eight-legged mature adult.
They must remain attached for hours to days while obtaining their
blood meal. Disease will not be transferred if the tick can be removed
before 24 hours. The soft ticks can live many years without food. They
have several nymphal stages and may take multiple blood meals. They
usually stay attached less than 30 minutes. Of the soft ticks, only the
genus Ornithodoros transmits disease in the United States, namely
relapsing fever. The 24-hour rule does not apply in this case.
Preventing attachment is the best defense against tick-borne
disease. DEET insect repellents are very effective against ticks (see
page 205). Permethrin 0.5% spray–treated clothing kills ticks upon
contact and remains active on clothing for 2 weeks. Then it’s prob-
ably about time to wash those camping clothes anyway and respray
them. The combination of permethrin on clothing and DEET on
skin is 100% effective against tick attachment. Insects are develop-
ing some resistance to permethrin and the best current alternative
is resmethrin, which is available for fogging, residual spraying, and
clothing application.
OK, so you didn’t follow my advice and you find a tick attached.
How do you remove it? A tried-and-true method is to grasp the skin
around the insertion of the tick (not the body) with a pair of fine-point
tweezers and pull straight outward, removing the tick and a chunk
of skin. For some reason this doesn’t hurt. A recent study has shown
the effectiveness of three tick-removal products on the market in the
United States, sold under the brand names of the Original Ticked Off,
the Pro-Tick Remedy, and the tick pliers, also sold under the name Tick
Nipper. Hot wires, matches, glue, fingernail polish, Vaseline—none of
them work. Burning the tick might cause it to vomit germs right into
the victim, yet it will not let go. Again, be careful not to grasp the tick
body—crushing it might cause germs to be injected into the victim.
Caterpillar Reactions
The puss caterpillar (Megalopyge opercularis) of the southern United
States and the gypsy moth caterpillar (Lymantria dispar) of the
Northeast have bristles that cause an almost immediate skin rash and
welt formation. Treatment includes patting the victim with a piece of
adhesive tape to remove the bristles. Further treatment is discussed
under Skin Rash on page 149.
Millipede Reactions
Millipedes do not bite, but contact can cause skin irritation. Cold
packs can reduce discomfort. Wash thoroughly and treat as indicated
on page 149.
Centipede Bites
Some larger centipedes can inflict a painful bite that causes local
swelling and a painful red lesion. Treatment with a cold pack is usually
sufficient. Some bites are severe, and regional lymph node enlarge-
ment may occur, which will be a swelling of the nodes generally at
the joints along the blood-flow pattern toward the heart from the
bite site. Swelling at the bite location may persist for weeks. Adequate
treatment consists of pain medication. Infiltration of the area with
lidocaine 1% from the Rx Injectable Medication Module provides
instant relief and is justified in severe cases.
Mosquitoes
Mosquitos “see” by three different mechanisms: chemical sensors,
visual spectrum, and infrared sensors. Countering these, we can use
three protective strategies to prevent their bites: behavior, barrier, and
chemical.
Behavior is the least known, yet very important. Humans pro-
duce a carbon dioxide plume that travels up to 150 feet, depending
upon the wind speed. If you can camp where the wind blows your
plume into a lake as opposed to the forest, you will decrease mosquito
bites. Once they pick up your plume, they will then use a visual spec-
trum to locate any brightly colored flower mimics. Avoid Hawaiian
shirts when camping! Wear white or light colors. The green of a Scout
uniform is OK. Wear long-sleeve shirts, long pants, and socks—all
treated with permethrin. Once closer to you, mosquitos activate their
chemical sensors to detect the by-product of your oil-gland secretions
that are being degraded by common skin bacteria. The highest bacte-
ria content on your skin is located in your armpits and on your feet.
Keeping clean decreases this smell and reduces bites significantly.
When very near to you, they turn on their infrared sensor and home
in on the juiciest place to successfully chomp and get that delicious
human blood meal. Sounds like a scary campfire story, but it is true.
You are surrounded by tiny insect vampires that want to turn you
into—if not the living dead—real dead people with one of the many
mosquito borne diseases of which there are many to choose. It has
been estimated that simply using the above techniques can decrease
mosquito bites by 85%.
And third, we come to what most people regard as their primary
means of suppressing insect bites: chemical. Treating your clothing
before a trip with 0.5% permethrin, a chrysanthemum derivative, is
100% effective in preventing tick bites. A tick crawls around on you
before attaching. Treating clothing, including socks and underwear,
solves tick disease problems. A single clothing treatment lasts for 6
weeks. Mosquitos, however, require additional skin protection for
bite prevention. Generally, this can be achieved with 20% picaridin or
DEET in concentrations of 30%, repeated as required. Lemon euca-
lyptus in 30% concentrations works almost as well. Other herbals,
wrist bands, and electronic devices do not match the effectiveness of

those products.
The best mosquito repellent invented to date has been DEET
(n,n diethyl-m-toluamide). This product has undergone a revolution
since it was developed in 1946, ranging from the earliest preparations
of 12% strength to numerous products marketing 100% DEET con-
centration. Between 10 and 15% of DEET applied to the skin surface
is excreted in the user’s urine. This fact, coupled with a few reports of
convulsions in children using DEET (generally when simultaneously
sunburned) indicates we should probably minimize the total amount
placed on the skin.
I never use 100% DEET except to soak either my head netting or
a “bug jacket.” Bug jackets are a very loose weave of cotton fabric that
soaks up DEET. The loose weave allows air circulation, which is a
real lifesaver during hot, mosquito-laden summer days. Buy one with
a hood. Avoid buying the tight “no-see-um-proof ” mosquito suits, as
you can sweat to death in them. Even during monstrous mosquito
moments, it is possible to be relatively comfortable in a treated bug
jacket. The hood can be pulled over your head when you are eating,
and your cup or bowl brought very near your face so that you can gulp
down food that is relatively free of mired insects (except for those
that fall into the pot during the cooking process). Treat the bug jacket
by pouring 100% DEET into a ziplock plastic bag and soaking the
jacket overnight. Rather than wearing tight-weave net pants, I find it
best to treat my trousers with permethrin, as indicated above, and my
ankles or exposed legs with the DEET.
Picaridin in 20% strength provides relatively good black-fly and
mosquito protection for up to 8 hours.
Adequate mosquito netting for the head and for the tent or cot
while sleeping is essential. Spraying netting and clothing with 0.5%
permethrin increases the effectiveness of the netting and decreases
bug bites enormously. Permethrin is an insecticide, not a repellent.
It kills mosquitoes, ticks, and black flies, and does not simply chase
them away. It will not work if applied to the skin, as an enzyme in the
skin destroys it. Not only is there no absorption through the skin, it is
safe to use on both natural and synthetic fibers.
Vitamin B-1 (thiamine) is not an effective preventative oral

agent. Electronic sound devices to repel these critters have never
dented mosquito buzzing or biting enthusiasm in the far north, in
my experience.
A considerable number of bites, or sensitivity to bites, may require
an antihistamine, such as diphenhydramine, 25 mg capsules every 6
hours, from the Non-Rx Oral Medication Module. Triple antibiotic
ointment with pramoxine applied every 6 hours can provide local
itch relief, but that is only due to the pramoxine component. Triple
antibiotic ointment by itself is of no value. From the Rx Oral/Topi-
cal Medication Module, use Topicort 0.25% ointment twice daily, or
Lanacane cream.
Black Flies
DEET compounds will work on black flies, but the concentration
must be 30% or greater, and even the pure formula will work for only
a short time. It is best to use a specific black-fly repellent.
For years Skin So Soft, a bath oil marketed by your local Avon
representative, has been mentioned as a black-fly repellent. It does
work, but only poorly, and it requires frequent applications, approxi-
mately every 15 minutes.
Netting and heavy clothes that can be sealed at the cuffs may be
required. All black-fly species like to land and crawl, worming their
way under and through protective clothing and netting. Spray cloth-
ing and netting with 0.5% permethrin as mentioned in the section on
mosquitoes.
Black-fly bites can result in nasty sores that are usually self-
limited, although at times slow healing. If infection is obvious, treat
as indicated in the section on skin infection on page 152. Treat symp-
toms as indicated under Mosquitoes above.
No-See-Ums and Biting Gnats

These two examples of insect life are the scourge of the north coun-
try, or any country in which they may be found. Many local people
refer to any small black fly as a “no-see-um,” but the true bug by that
name is indeed very hard to see. They usually come out on a hot,
sticky night. The attack is sudden and feels like fire over your entire
exposed body surface area. Under the careful examination of a flash-
light, you will notice an incredibly small gnat struggling with its head
down, merrily chomping away. Make that bug portion of the previous
sentence plural, please. You may need to resort to a strong product
of 35% DEET or greater. Immersion in cold water will help relieve
symptoms temporarily. One remedy for the sting, which I understand
works quite well but have never had it along to try, is an application
of Absorbine Jr.!
Gnats, on the other hand, are small black flies whose bite is sel-
dom felt. But these gentle biters leave behind red, pimple-like lesions
to remind you of their visit. A rash of these pimples around the neck
and ankles attests to their ability to sneak through protective cloth-
ing. Treat bites as described above under Mosquitoes. Without a head
net or treated hooded bug jacket, hordes of gnats can suffocate you.
Treat clothing with permethrin and a bug jacket with 100% DEET,
as described in the Mosquitoes section.
Scorpion Stings
Most North American scorpion stings are relatively harmless. Stings
usually cause only localized pain and slight swelling. The wound may
feel numb. Diphenhydramine, 25 mg 4 times daily, and Percogesic, 2
tablets every 4 hours, may be all that is required for treatment. A cold
pack will help relieve local pain.
The potentially lethal Centruroides sculpturatus is the exception to
this rule. This yellow-colored scorpion lives in Mexico, New Mexico,
Arizona, and on the California side of the Colorado River. The sting
causes immediate, severe pain with swelling and subsequent numb-
ness. The neurotoxin injected with this bite may cause respiratory
failure; respiratory assistance may be required (see page 19). Tapping
the wound lightly with your finger will cause the patient to withdraw
due to severe pain. This is an unusual reaction and does not occur
with most insect stings. A specific antivenin is available in Mexico
and is also produced by the Poisonous Animals Research Laboratory
at Arizona State University for local use.
In addition to the antivenin, atropine may be needed to reduce

muscle cramping, blurred vision, hypertension, respiratory difficulty,
and excessive salivation. Methocarbamol may be given, as described
in the section on black widow spider bites (page 200). Neither of
these medications is included in the Off-Grid Medical Kit. Avoid
narcotics such as Demerol and morphine, which can increase the tox-
icity. Percogesic from the Non-Rx Oral Medication Module may be
safely given.
Ants/Fire Ants
While many ants alert you to their presence with a burning bite, fire
ants can produce an intensely painful bite that pales the bite of any
other ant—and many other bugs—to insignificance. While holding
on tightly with a biting pincer and pivoting around, the fire ant stings
repeatedly in as many places as the stinger can reach, causing a cluster
of small, painful blisters to appear. These can take 8 to 10 days to heal.
Treatment is with cold packs and pain medication. Large local reac-
tions may require use of an antihistamine such as diphenhydramine,
25 mg, 2 capsules every 6 hours, or even Decadron, 4 mg twice daily.
Local application of Spenco 2nd Skin can provide some relief. Treat
with pain medication as required.
The greatest danger is to the hypersensitive individual who may
go into anaphylactic shock; see page 193.
AQUATIC STINGS, CUTS, AND RASHES
Sea Urchin
Punctures from sea urchin spines cause severe pain and burning.
Besides trauma from the sharp spines, some species inject venom. The
wound can appear red and swollen, or even blue to black from harm-
less dye that may be contained in the spines. Generalized symptoms
are rare but may include weakness, numbness, muscle cramps, nausea,
and occasionally shortness of breath.
The spines should be removed thoroughly, a very tedious pro-
cess. Very thin spines may be absorbed by the body without harm,
but some may form reactive tissue (granulomas) around them several
months later. Spines may migrate into joints and cause pain and
inhibit movement, or lodge against a nerve and cause extreme pain.
The discoloration of the dye causes no problems but may be mistaken
for a thin spine. Relief may be obtained by soaking in hot water (110
to 113°F or 43 to 45°C) for 20 to 30 minutes. Vinegar or acetic acid
soaks several times a day may help dissolve spines that are not found.
Evacuation and treatment by a physician is also advisable if the grid
is available.
Jellyfish
An extensive number of species of jellyfish in the world pose varying
degrees of danger to people. Jellyfish tentacles in contact with human
skin can cause mild pricking to burning, shooting, terrible pain. The
worst danger is shock and drowning.
Pouring vinegar on the wound (4 to 6% acetic acid) inhibits the
venom from being fired into the skin. Alcohol (or ideally formalin)
poured over the wound may also prevent the nematocysts from firing
more poison. Avoid the use of hot water in treating this injury, as
water of any temperature activates the nematocysts. Try to remove
the tentacles with gloved hands.
Dust the area with a dry powder such as flour or baking powder.
Gently scrape off the mess with a knife, clamshell, or other sharp
instrument, but avoid cutting the nematocysts with a sharp blade.
Apply hydrocortisone 1% cream 4 times daily from the Topical Ban-
daging Module, or Topicort 0.25% ointment twice daily from the
Rx Oral/Topical Medication Module for inflammation. Severe stings
can be treated with pressure/immobilization. Provide rescue breath-
ing as required.
Coral Stings
These injuries are treated as indicated above under Jellyfish.
Coral and Barnacle Cuts

Clean the wound thoroughly. Trivial wounds can later flare into real
disasters that may go on for years. Scour it thoroughly with a coarse
cloth or soft brush and surgical scrub or soapy water. Then apply
hydrogen peroxide to help bubble out fine particles and bacteria.

Apply triple antibiotic ointment from the Topical Bandaging Mod-
ule. Manage this wound as discussed in the section on the Bleeding
Wound (page 118). If an infection ensues, treat as indicated under
Cellulitis on page 148.
Stingray
The damage is done by the stingray’s barbed tail, which lacerates the
skin, embedding pieces of tail material and venom into the wound.
The wound bleeds heavily; pain increases over 90 minutes and takes
6 to 48 hours to abate.
Immediately rinse the wound with seawater and remove any par-
ticles of the tail sheath that are visible, as these particles continue to
release venom. Hot water is the treatment of choice, applied as soon
as possible and as hot as the patient can stand (110 to 113°F, or 43
or 45°C). The heat will destroy the toxin rapidly and remove the pain
that the patient is experiencing. After hot water has been applied
and all tail particles removed, the wound may be closed with taping
techniques (see page 126). Elevation of the wound is important. If it’s
particularly dirty, leave the wound open and continue to use intermit-
tent hot soaks as described on page 134.
Questionably dirty wounds should be treated with Levaquin, 750
mg daily, or doxycycline, 100 mg twice daily, from the Rx Oral/Top-
ical Medication Module. As these are nasty, painful wounds, treat for
shock from the onset (see page 13).
Catfish
Apply hot water as indicated above under Stingray. The wound,
caused by a puncture from spines in the fish’s dorsal and pectoral fins
protruding near its mouth, must be properly cleaned and irrigated
using surgical scrub, if available, or soap. Place the patient on oral
antibiotics for several days to decrease the chance of wound infec-
tion, which is common with this injury. Treat an infected wound as
described on page 147.
Scorpion Fish
Scorpion fish spines have poisonous venom located in their fins,
which usually cause wounds when unwary individuals step on them
or otherwise accidentally contact them with their hands. Use the
same treatment as above under Stingray.
Sponge Rash
Sponges handled directly from the ocean can cause an allergic reac-
tion that appears immediately. Fine spicules may also break off in the
outer layer of skin, causing inflammation. It will be difficult to tell
whether your victim is suffering from the allergic reaction or the spic-
ules, or both. Soak the affected skin by applying vinegar to a cloth and
covering it for 15 minutes. Dry the skin and pat with the adhesive
side of tape to remove any sponge spicules. Again, soak in vinegar for
5 minutes. An application of rubbing alcohol for 1 minute has been
suggested. Then apply hydrocortisone 1% cream 4 times a day from
the Topical Bandaging Module, or Topicort 0.25% ointment twice
daily from the Rx Oral/Topical Medication Module for several days,
until the inflammation subsides.
CHAPTER 9
BIOTERRORISM AND
INFECTIOUS DISEASE
While there are many reasons to leave the grid, there are also multi-
ple issues that might cause the grid to collapse right out from under
you. While we usually think of issues like economic collapse, con-
ventional or nuclear war, massive natural disasters from weather or
violent nature, a less considered potential is bioterrorism or natural
biological catastrophe.
Further, if you are moving into unfamiliar territory in your depar-
ture from your normal habitat, you may be moving into an area with
unusual environmental stress and very likely exposure to new endemic
(locally available) infectious diseases. Initially you will probably not
have immunity to these pathogens, and you must be prepared to pre-
vent and/or treat yourself for these dangers. Please study this section
carefully during your planning phase so you can enter your new home
base fully prepared to diagnose and treat, or better yet, prevent, what
may well be more dangerous than an attack by armed marauders. Of
all of the natural challenges, the environmental stress issues will be
the most dangerous, and they are covered in chapter 10. That is not
to say that bites, stings, and injuries are not potentially lethal, but
these issues are usually very apparent to the survivalist, much more so
than the plethora of tiny pathogens that can also prove debilitating
or lethal.
Diagnosing an illness can sometimes be made by noting the
time of symptom onset after being exposed to the illness in question.
This is most feasible when you first move into a completely foreign
BIOTERRORISM AND INFECTIOUS DISEASE 213
environment and an illness suddenly appears within your group. Oth-

erwise, after being in an area for more than several months, or when
dealing with indigenous people in that area, you are going to rely on
knowing what diseases are the most prevalent and evaluate symptoms
to work out a probability of what you are treating. Sir William Osler,
one of the greatest teachers of medicine, gave a lecture at the Harvard
Medical School in which he stated that of the three basic principles of
medicine, the most important was diagnosis. After the lecture he was
asked, “What are the other two principles?” he answered, “The first is
diagnosis, the second is diagnosis, and the third is diagnosis.” Putting
this into perspective, let us say that it is pitch black out and a fierce,
deadly enemy of unknown number is approaching our perimeter. We
would probably resort eventually to spreading a vast quantity of pow-
erful ammunition in his general direction. The more powerful our
ammunition, the greater the chance of our neutralizing this enemy.
We have ammunition when it comes to fighting infectious diseases.
We have antibiotics, antivirals, antiparasitics, and medications to treat
symptoms, all of which can be lifesaving. But the ammunition we
use is a two-edged sword: It will not work on the wrong target, side
effects can be more dangerous than some illnesses we are treating,
and we will always have a limited supply. Correctly identifying the
diagnosis is as critical as correctly identifying that target.
So, what is the approach to infectious disease?
Identify the potential geographic risk of the diseases; where are
they lurking? Let’s look at the vector that spreads the disease; how do
we block it from attacking us? If someone gets ill, how do we identify
the most likely cause and what is the best treatment available to us?
That is what this chapter is about, and you can see why it is important
in your planning, particularly if you are leaving the grid.
Tables summarize the diseases of North America (table 9-2) and
high-risk illnesses and diseases encountered in world travel (table
9-3) where you find yourself when leaving your normal habitat. The
individual sections of this chapter discuss these diseases in greater
detail, including treatments when using the items suggested for the
Off-Grid Medical Kit. Management of issues such as pain, fever, vec-
tor control, water purification, and other preventative measures are
covered elsewhere in this book and also must be considered import-

ant to preventing and managing these diseases.
Bioterrorism is when one of these diseases is brought to you.
Some of these illnesses are rarely seen in North America; others are
here but seldom encountered. Some diseases are returning in force
due to low immunization rates. The US government classifies poten-
tial bioterrorism agents/diseases into three categories:
Category A
1. Can be easily disseminated or transmitted from person to
person
2. Result in high mortality rates
3. Might cause public panic and social disruption
4. Require special action for public health preparation
Category B
1. Are moderately easy to disseminate
2. Result in moderate morbidity and mortality
3. Require special enhancements of CDC’s diagnostic capacity
and enhanced surveillance
Category C
1. Availability
2. Ease of production and dissemination
3. Potential for high morbidity and mortality rates and major
health impact
Diseases found naturally in North America that are considered
category A are plague (page 232) and tularemia (page 241), and in
category B are typhus fever (page 242) and various food and water-
borne diseases (pages 218–242). Other category A diseases such as
anthrax (the last case in the US was in 1976), botulism (caused by
poor food preservation), and smallpox (now extinct from the world
except in certain US and Russian laboratories), are not something
you will encounter unless there is a mass bioterrorism release. The
viral hemorrhagic fevers are also in this category (Ebola, Marburg,
Lassa, Machupo viruses). Category B agents encountered naturally

are brucellosis, glanders, melioidosis, psittacosis, and Q fever—again,
diseases that are so rare as to be insignificant in the normal experi-
ence of a prepper.
This takes us back to the issue of a mass terrorism release of the
rare diseases. Your greatest risk comes not from the weaponized dis-
persal of a disease, but from nature effectively accomplishing identical
results. Included in this group are the diseases listed in tables 9-1 and
9-2, below, and the childhood diseases that are reappearing because
decreased immunization rates have resulted in the loss of “herd
immunity,” the percent of a population that, when immune from an
illness, will interrupt the spread of that illness through the remaining,
even nonimmune, population. If a certain percentage of a group loses
its herd immunity, a single case can spread like wildfire through the
entire group, infecting even those who have some immunity due to
the overwhelming number of germs that a massive flare in the infec-
tion causes. Depending upon how virulent the germ is and how easily
it spreads, various levels of immunity must be present to prevent this
“wildfire” spread.
Table 9-1. Importance of Herd Immunity in Preventing

Disease Spread within a Group
Herd immunity
Transmission required
Measles Airborne 92–95%
Pertussis (whooping cough) Airborne droplet 92–94%
Diphtheria Saliva 83–86%
Rubella Airborne droplet 83–86%
Smallpox Airborne droplet 80–86%
Polio Fecal–oral route 80–86%
Mumps Airborne droplet 75–86%
SARS (severe acute Airborne droplet 50–80%
respiratory syndrome)
Ebola Bodily fluids direct contact 33–60%
Influenza Airborne droplet 33–44%
It is interesting that some of the most dangerous diseases have a

relatively low herd immunity required for the group protection from
disease acceleration. Ebola has a high case-fatality rate of 60 to 90%
in the case of the Zaire strain and 40 to 60% in the Sudan variety.
But for potential number of deaths on the planet, it is hard to beat
the danger of influenza. An aggressive strain of influenza could reach
a mortality rate of 2.5%, but as the disease spreads easily among non-
immune persons, where virtually everyone catches it (unlike Ebola,
which no one should catch with simple body fluid precautions), the
death toll can be astounding.
Sometimes herd immunity does not protect you from a disease
like tetanus, as you catch this from spores when they enter your body
via the skin from the environment and not from another person.
A bioterrorism release of a germ will not collapse the grid, but a
grid collapse frequently causes a massive infectious breakout of the
various waterborne diseases, including typhoid fever and cholera. If
the grid is intact during a bioterrorist release, it would require and can
rely on the expertise of the CDC and US Department of Homeland
Security to respond with appropriate guidance and treatment, includ-
ing specialized vaccine. In my opinion, the prepper needs to prevent
and manage the diseases listed in this book. Prevention is simple,
basic, and critical. It consists of proper hygiene (washing hands),
proper water sourcing, proper food preparation and storage, proper
insect protection, and proper immunizations. Beyond the commonly
recommended infant, childhood, and adult immunizations, the prep-
per should consider typhoid, as it commonly explodes during natural
disasters. The grid will withstand a bioterrorism attack but is vulnera-
ble to many natural and human-made events, including nuclear war-
fare (chapter 4), and it is those issues that the prepper must calculate
into the survival equation.
Table 9-2. Significant Diseases of North America

Illness Mode Page number
Anaplasmosis tick 218
Babesiosis tick 218
Blastomycosis soil 219
Coccidioidomycosis soil 220

Colorado tick fever tick 220
Echinococcus water 222
Ehrlichiosis tick 223
Giardiasis water 223
Hantavirus rodents/soil 224
Hepatitis A, E water, food 225–27
Hepatitis B, C, D, G blood, sex 225–27
Lyme disease tick 227
Meningococcal meningitis people 231
Plague rodents/fleas, people 232
Rabies mammals 233
Relapsing fever tick 234
Rocky Mountain spotted fever tick 235
STARI tick 236
Tetanus soil 237
Tick paralysis tick 238
Trichinosis food 238
Tuberculosis people 240
Tularemia tick, fly 241
Typhus, endemic fleas 242
West Nile virus mosquito 243
Note: This is not an all-inclusive list. Also, many of these diseases have world-
wide distribution.
Table 9-3. Significant Diseases of the World

Illness Mode Page number
Chikungunya fever mosquito 219
Cholera water 219
Dengue mosquito 221
Malaria mosquito 229
Schistosomiasis snail/water 236
Tapeworms food/water 237
Trypanosomiasis, African fly 239
Trypanosomiasis, American * 240
Typhoid fever water/food 242
Typhus, epidemic lice 243
Yellow fever mosquito 244
Zika mosquito 244
* See text for vector description.

MANAGING INFECTIOUS DISEASES

IN NORTH AMERICA AND POTENTIAL
OFF-GRID TRAVEL DESTINATIONS
Anaplasmosis
Caused by the bacterium Anaplasma phagocytophilum and previously
known as human granulocytic ehrlichiosis (HGE), this has more
recently been called human granulocytic anaplasmosis (HGA). It
is transmitted primarily from the black-legged tick (Ixodes scapu-
laris) and the western black-legged tick (Ixodes pacificus). Symptoms
including fever, headache, chills, and muscle aches occur within 1 to
2 weeks of a tick bite. Lab tests can eventually confirm the diagnosis,
but symptoms are similar to the other tick-borne diseases. The first-
line treatment for adults and children of all ages is doxycycline.
Babesiosis
First discovered in Yugoslavia in 1957 and detected in the United
States in 1968, this malaria-like illness is caused by a protozoan par-
asite that invades red blood cells. Two species have been identified,
Babesia microti in the northeastern United States, and B. equi in Cal-
ifornia. An unidentified species caused this disease in a patient in
Washington State. Of the approximately 2,000 cases reported in the
United States, 95% were reported in Connecticut, Massachusetts,
Minnesota, New Jersey, New York, Rhode Island, and Wisconsin.
Tick-borne transmission of Babesia parasites is well established in
these states.
Symptoms begin gradually 1 week after a tick bite with fatigue
and loss of appetite, giving way in several days to fever, drenching
sweats, muscle aches, and headache. The illness ranges from mild to
severe, with death occurring in about 10% of patients. Treatment is
available with oral quinine plus clindamycin (not included in the rec-
ommended medical kit). Protection from tick bites is best accom-
plished by treating clothing with permethrin (see page 202).
Blastomycosis
This infectious disease is caused by the fungus Blastomyces dermatitidis.
Outbreaks usually cluster, with multiple members of a party becom-
ing ill. It is found in the Mississippi River Valley and the southeastern
United States. It is also found in various parts of Africa. Wisconsin
may have the highest incidence of blastomycosis of any state, with
yearly rates ranging from 10 to 40 cases per 100,000 persons in some
northern counties. In the United States it has been associated with
beaver lodges and digging in contaminated soil. It can also result
from dog bites.
Onset of illness is slowly progressive, usually starting with a cough
and developing into pneumonia with fevers, shortness of breath, chest
pain, and drenching sweats. The symptoms generally present 3 weeks
to 3 months after breathing in the fungal spores.
Infected blood carries the fungus to the skin and other tissues.
Skin lesions enlarge with a collapsed center, purplish-red border, and
frequent ulcerations.
Treatment is with specific antifungal medications.
Chikungunya Fever
This viral infection is spread by the Aedes mosquito (see Mosquitoes,
page 204). Although not related to dengue fever, it is very similar
clinically, with particularly miserable, virtually crippling joint aches,
particularly of the ankles, wrists, and hands. Since it mimics dengue
and Zika virus, it is best to avoid treating with nonsteroidal anti-
inflammatory medications such as ibuprofen or aspirin, as there can
be bleeding complications with these diseases. Use Tylenol or Ultram
for pain management. The painful effects of this disease can last for
months.
Cholera
This intestinal infection, caused by the bacterium Vibrio cholerae, pro-
duces profuse, cramping diarrhea. Death can come from dehydration;
indeed, the death toll can reach the tens of thousands during an epi-
demic. Ingestion of water contaminated with the bacteria spreads the
disease. Humans are the only documented hosts for this disease.
The most important treatment is to use oral rehydration as indi-

cated on page 88. Antibiotics can reduce the shedding of cholera in
the stool and can reduce diarrhea volume and duration by 50% but
are not required for treatment, only adequate rehydration. A single
dose of 3 doxycycline 100 mg tablets from the Rx Oral/Topical Med-
ication Module is adequate to treat shedding.
Coccidioidomycosis
Also called San Joaquin fever or valley fever, coccidioidomycosis is a
fungal infection caused by Coccidiodes immitis. Found in the San Joa-
quin Valley of California and throughout the southwestern United
States, this disease is caught by inhaling the fungal spores in dust.
Symptoms can be delayed in travelers, appearing after leaving the
endemic area. The primary symptoms are those of an upper respira-
tory infection, bronchitis, or pneumonia. Incubation time varies and a
progressive form may occur weeks, months, or years after the original
infection in people with decreased immunity (e.g., AIDS patients,
people on steroids, or those receiving chemotherapy).
Treatment is not required for those with upper respiratory infec-
tion symptoms. The diagnosis should be made with special blood
tests to avoid missing other treatable pneumonia. Progressive disease
must be treated with intravenous antifungal medications.
Colorado Tick Fever

A viral disease spread by ixodid (hard-shelled) ticks, this disease is
twenty times more common in Colorado than Rocky Mountain
spotted fever. It is also found in the other states of the western Rocky
Mountains and in provinces of western Canada. It is most frequent
in April and May at low altitudes, and in June through July at high
altitudes. Onset is abrupt, with chills, fever of 100.4 to 104°F (38 to
40°C), muscle aches, headache, eye pain, and eye sensitivity to light
(photophobia). The patient feels weak and nauseated, but vomiting
is unusual. During the first 2 days, up to 12% of the victims develop
a rash. In half the cases the fever disappears after 2 to 3 days, and
the patient feels well for 2 days. Then a second bout of illness starts,
lasting intensely for 2 to 4 days. This second phase subsides, with the
patient feeling weak for 1 to 2 additional weeks.
This disease requires no treatment other than bed rest, fluids to
prevent dehydration, and medications to treat fever and aches. How-
ever, as the same ticks can also spread potentially dangerous Rocky
Mountain spotted fever, treatment with doxycycline (100 mg twice
daily), as described on page 235, should be started immediately and
continued for 14 days. Do not wait for the characteristic rash of
Rocky Mountain spotted fever or the fever pattern of Colorado tick
fever to develop, or for a firm diagnosis of either to be established by
a physician.
Dengue
Dengue—also called breakbone fever or dandy fever—is a viral infec-
tion caused by group B arbovirus or flavivirus and is spread by bites
from the Aedes aegypti mosquito. Dengue is endemic throughout the
tropics and subtropics and can be expected to work its way into the
southern United States due to the spread of the mosquito vector.
After an incubation period of 3 to 15 (usually 5 to 8) days, there
is a sudden onset of fever (104°F or 40°C), chills, headache, low back
ache, pain behind the eyes with movement of the eyes, and extreme
aching in the legs and joints. The eyes are red and a transient flushing
or pale pink rash occurs, mostly on the face. There is a relatively slow
pulse rate for the temperature (see page 29). The fever lasts 48 to 96
hours, followed by 24 hours of no fever and a sense of well-being. A
second rapid temperature increase occurs, but generally not as high as
the first. A bright rash spreads from the arms and legs to the trunk,
but generally not to the face. Palms and soles may be bright red and
swollen. There is a severe headache and other body aches as well. The
fever, rash, and headache constitute the “dengue triad.” The illness
lasts for weeks, but mortality is nil. Treatment is rest and the use of
pain and fever medication.
A condition called dengue hemorrhagic fever shock syndrome
is lethal, however, and usually occurs in patients younger than 10,
generally infants under 1 year of age. Dengue may be confused with
Colorado tick fever, typhus, yellow fever, or other hemorrhagic fevers

such as the Ebola virus or Rift Valley fever in Africa. This is a reaction
to having had a dengue infection in the past and developing a partial
immunity. A second infection of the disease (there are 4 serotypes
that are closely related) can result in an autoimmune reaction that
attacks the kidneys and causes other evidence of bleeding.
Echinococcus
Also called hydatid disease, the echinococcus infection is caused by
the larval stage of a tapeworm found in dogs (with sheep as an inter-
mediate host) or in wolves in wilderness areas (with moose as the
intermediate host). This disease is found worldwide but is most com-
monly a problem in Europe, Russia, Japan, Alaska, Canada, and the
continental United States, particularly Isle Royale in Lake Superior.
When ingested by sheep, moose, or humans, the eggs form embryos
that pass through the intestinal circulation into the liver and some-
times beyond into the lungs, brain, kidneys, and other tissue. There a
fluid-filled cyst forms, which contains scolices, brood capsules, and
second- generation (daughter) cysts containing infectious scolices.
The hydatid cysts maintain their presence, sometimes bursting and
spreading in a malignant fashion, causing destruction of liver, lung,
and other critical tissues. After remaining without symptoms for
decades, abdominal pain, jaundice, or chest pain and coughing may
commence.
If the intermediate host is eaten by a carnivore (dog, wolf, or man),
the infectious scolices are released into the gastrointestinal tract,
where they develop into adult worms, and the life cycle continues.
Most hydatid disease is from the tapeworm (Echinococcus granulo-
sis), but a rapidly progressive form develops when infection is caused
by the E. multilocularis tapeworm. This tapeworm is carried primarily
by foxes and domestic dogs and cats. Numerous small cysts form that
multiply rapidly. The result is often fatal. There is no adequate medical
treatment; attempts at surgical removal of multiple cysts are the only
reliable hope for cure.
Ehrlichiosis
Since its discovery in 1987, the incidence of ehrlichiosis has increased
to approximately 1,000 cases per year. In North America the time of
greatest risk is May through July. This is a rickettsial infection caused
by Ehrlichia chaffeensis that is spread by several species of ticks.
The incubation time ranges from 1 to 21 days (mean 7 days). It
presents with high fever and headache, with other common symp-
toms being tiredness, nausea, vomiting, muscle aches, and loss of
appetite. Twenty percent of victims develop a rash, but this rash is
seldom on the feet or hands. This disease can range from mild, flu-
like symptoms to its extreme, which can be fatal.
The drug of choice is doxycycline, 100 mg twice daily for at least
3 days, beyond fever detection and until evidence of clinical improve-
ment, typically 5 to 7 days total duration.
Encephalitis
Encephalitis from group A arbovirus (western equine encephalitis,
eastern equine encephalitis, Venezuelan equine encephalitis) in the
United States and Canada, and from group B arbovirus (St. Louis
encephalitis) in the United States can be prevented by liberal use
of repellent and covering exposed areas with netting or clothing to
prevent bites from infected mosquitoes. Symptoms of these illnesses
include high fever (104°F, or 40°C) and generally headache, stiff neck,
vomiting, and, at times, diarrhea. These cases can be fatal and require
evacuation to medical help.
Cool the patient with external means (cool water, fanning), and
the use of aspirin or Mobigesic. The disease occurs in epidemics;
be very careful with mosquito exposure when the disease becomes
prevalent.
Giardiasis
Intestinal infection by Giardia lamblia, a single-cell parasite that
causes giardiasis or beaver fever, is becoming a significant problem
in wilderness travel in the United States and is a very common cause
of traveler’s diarrhea. The stools of infected individuals contain the
infective cyst form of the parasite. These cysts can live in water for
longer than 3 months. Other mammalian vectors, such as the beaver,
are responsible for much of the spread of this disease.
In the active disease, the trophozoite form attaches itself to the
small bowel by means of a central sucker. Multiplication is by binary
fission, or division. Approximately 2 weeks after ingestion of the
cysts, there is either a gradual or abrupt onset of persistent watery
diarrhea, which usually resolves in 1 to 2 weeks, but may persist less
severely for several months. Abdominal pain, bloating, nausea, and
weight loss from malabsorption may occur. Giardiasis is often with-
out symptoms at all, and a chronic carrier state exists. In the United
States about 4% of stools submitted for parasitology examination
contain G. lamblia cysts.
Diagnosis is by finding cysts in stools, or trophozoites from gas-
tric suction, or the “string test” from the duodenum. This latter test
is performed by having the patient swallow a string, allowing the far
end to pass into the first part of the bowel, or duodenum. When
the string is pulled out, a microscopic examination may demonstrate
the presence of trophozoites. In active disease the cysts are routinely
secreted, but in the chronic carrier state, repeated stool examinations
(at least three) are required to provide a 95% accuracy of test results.
Treatment is with one of several drugs available in the United States,
the most commonly used being Flagyl (metronidazole), 250 mg 3
times daily for 5 days. A better drug is tinidazole, 2 grams taken as
a single dose. Prevention is by proper filtration of water, adequate
chemical treatment, or heating water to 150°F (66°C). See page 89
for a full discussion of water treatment.
Hantavirus
Hantavirus was the cause of death among members of the Navaho
Indian Nation in New Mexico in 1993. The virus has been identified
in serum samples from 690 people in twelve states, with the greatest
concentration in the western United States. It is caught by inhaling
dust contaminated with feces from an infected deer mouse (Peromys
cus maniculatus).
The onset of illness is a period of fever, muscle aches, and cough,

followed by an abrupt onset of acute respiratory distress. The mortal-
ity rate has been 60%! There is no specific treatment available. Avoid-
ing breathing dust that may contain the contaminated mouse feces is
the preventative measure. When cleaning out cabins, use a wet mop
and avoid sweeping dry debris.
Hepatitis A
A viral infection of the liver, hepatitis A (infectious hepatitis) has
worldwide distribution. It is transmitted by ingestion of infected
feces, in water supplies contaminated by human sewage, in food han-
dled by persons with poor hygiene, or in contaminated food such as
raw shellfish grown in impure water. Contaminated milk and even
infusion of infected blood products (see Hepatitis B, below) can
spread this disease.
From the time of exposure to the appearance of symptoms takes
15 to 50 days. The disease can range from minor flu-like symptoms to
fatal liver disease. Most cases resolve favorably within 6 to 12 weeks.
Symptoms start abruptly with fever, lethargy, and nausea. Occasion-
ally a rash develops. A characteristic loss of taste for cigarettes is fre-
quent. In 3 to 10 days the urine turns dark, followed by jaundice, with
yellowing of the whites of the eyes and the skin. The stool may turn
light colored. There is frequently itching and joint pain. The jaundice
peaks within 1 to 2 weeks and fades during the 2- to 4-week recovery
phase. The hepatitis A patient stops shedding virus in the stool prior
to the jaundice developing and is therefore not contagious by the
time the diagnosis is normally made. Personal hygiene helps prevent
spreading, but isolation of the patient is not strictly required.
In most cases no specific treatment is required. After a few days
to 2 weeks, appetite generally returns and bed confinement is no lon-
ger required, even though jaundice remains. The best guideline is the
disappearance of the lethargy and feeling of illness that appeared in
the first stages of the disease. Restrictions of diet have no value, but a
low-fat diet is generally more palatable.
If profound prostration occurs, the trip should be terminated for
the patient, and he should be placed under medical care. If possible,
unimmunized contacts should be immediately given the hepatitis A

shot, but the only practical solution is to immunize everyone against
hepatitis A prior to leaving the grid.
Hepatitis B
Another viral infection of the liver, hepatitis B (serum hepatitis) is
also worldwide in distribution. Transmission is primarily through
infusion of infected blood products, sexual contact, use of contami-
nated needles or syringes, or even sharing contaminated razor blades.
Dental procedures, acupuncture, and ear piercing and tattooing with
contaminated equipment will also spread this disease.
Incubation period from time of exposure to the development of
symptoms is longer than with hepatitis A, namely 30 to 180 days. The
symptoms are similar, but the onset is less abrupt, and the incidence
of fever is lower. There is a greater chance of developing chronic hep-
atitis (5 to 10% of cases). Mortality is higher, especially in elderly
patients, where it ranges from 10 to 15%.
Immunization is available and is very effective.
Hepatitis C
A form of hepatitis, with similar manifestations to hepatitis B, has
been designated as hepatitis C (formerly “non-A, non-B” since evi-
dence of exposure to those virus particles was not previously found
in blood tests). The transmission is probably the same as for hepati-
tis B. Incubation period is from less than 2 weeks to more than 25
weeks, with an average of 7 weeks for the development of clinical
disease. Immunization is available. Specific treatment is available for
this disease.
Hepatitis D
Hepatitis D, or the “delta agent,” can only infect a person who has hep-
atitis B. The presence of this mutated RNA particle causes the infec-
tion to be more fulminant. It spreads only by contaminated needle use.
No specific treatment exists. It is considered prudent in persons who
have this disease to immunize them with the only two vaccines now
available, injections of vaccines for Hepatitis A and Hepatitis B.
Hepatitis E
An epidemic form of hepatitis (that is not A or C) has been termed
hepatitis E. Spread by ingestion of contaminated food or water, the
incubation period from time of contact ranges from 2 to 9 weeks,
with a mean of 45 days. The disease mimics hepatitis A. The fatality
rate in pregnant women is highest, about 20%. Outbreaks have been
confirmed throughout developing areas of the Old World. There is no
immunization or specific treatment available.
Hepatitis G
A new virus has been identified as the hepatitis G virus. A member of
the family Flaviviridae, it can be spread by blood and sexual contact,
just as with hepatitis B. There is no immunization or specific treat-
ment available.
Leptospirosis
This disease is caused by a spirochete, genus Leptospira; a similar
organism causes syphilis and Lyme disease. Like those diseases, this
organism can attack virtually any organ system, yet 90% of those
infected have no symptoms. The organism can live in damp soil, veg-
etation, and mud, but dies almost instantly upon drying. It spreads
into the environment due to contaminated urine from ill animals.
This germ is located all over the world, including the northern United
States. Cuts and abrasions on the skin increase the risk of illness,
while wearing protective footwear or clothing decreases it.
The incubation period is 7 days, with a range of 2 to 29 days.
Initially it can present with high fever, headache, chills, muscle aches,
red eyes, abdominal pain, diarrhea, rash, and jaundice. It may occur
in two phases. Recurrent fevers of up to 102˚F (38.9°C). After the
first phase, the patient may recover, then relapse 6 to 12 days later
with similar symptoms. About 200 cases are identified in the United
States (50% in Hawaii), but this is considered the most widely spread
disease from an animal in the world. Between 1 and 5% of cases are
fatal. The most serious form is called Wiel’s disease, which includes
jaundice and severe lung, kidney, and bleeding disorders. It is treated
with doxycycline, 100 mg twice daily for 2 weeks, but recent studies
are unclear if antibiotics actually help. However, I subscribe to the old

adage: You should not die in the tropics unless you die on doxycycline.
Lyme Disease
Lyme disease is caused by the spirochete Borrelia burgdorferi. The dis-
ease lives in various mammals but is transmitted to humans by the
bite of several species of ticks. The disease is most common in the
Northeast, extending through Connecticut and Massachusetts down
to Maryland; in Wisconsin and Minnesota; throughout the states
of California and Oregon; and in various south Atlantic and south-
central states, with cases reported in 43 of the Lower 48 states. A map
showing the reported incidence of Lyme disease per county by state
within the United States is located at www.cdc.gov. It has been found
in the former Soviet Union, China, Australia, and Japan as well as
several European countries.
The disease goes through several phases. In stage one, after an
incubation of 3 days to a month, about 95% of victims develop a cir-
cular lesion in the area of the bite. It has a clear to pink center, raised
border, is painless, and ranges from 1 to 23 inches in diameter. There
are usually several such patches. The patient feels lethargic and has
headache, muscle and joint pain, and enlarged lymph nodes. In stage
two, 10 to 15% of patients can develop meningitis, and less than 10%
develop heart problems. Symptoms may last for months but are gen-
erally self-limited. Approximately 60% enter stage three, the devel-
opment of actual arthritis. Frequently a knee is involved. The swelling
can be impressive. Stage three can start abruptly several weeks to 2
years after the onset of the initial rash.
Treatment of stage one Lyme disease is a tetracycline, such as
doxycycline, 100 mg taken twice daily for 21 days. Alternate drugs are
penicillin and erythromycin. Treatment of choice for stage two and
three Lyme disease consists of Rocephin, 2 grams given intravenously
(IV) daily for 14 to 21 days.
For prevention of Lyme disease after a recognized tick bite,
routine use of antimicrobial prophylaxis or serologic testing is not
recommended. A single dose of doxycycline may be offered to adult
patients (200 mg) if (a) the attached tick can be reliably identified as
an adult or nymphal deer tick (Ixodes scapularis) that is estimated to

have been attached for more than 36 hours on the basis of the degree
of engorgement of the tick with blood or of certainty about the time
of exposure to the tick; (b) prophylaxis can be started within 72 hours
of the time that the tick was removed; (c) ecologic information indi-
cates that the local rate of infection of these ticks with B. burgdorferi is
more than 20%; and (d) doxycycline treatment is not contraindicated.
One manifestation of Lyme disease is the development of a facial
paralysis on one side, called Bell’s palsy. The involved side is expres-
sionless since the patient is unable to move the muscles of the fore-
head, around the eye and so on. While there are other causes of Bell’s
palsy, in North America this problem must be considered a result of
Lyme disease until ruled out by a physician. Treatment of Bell’s palsy
caused by Lyme disease is with oral antibiotic for 21 days.
Malaria
Human malaria is caused by five species of a protozoan: Plasmodium
falciparum, P. vivax, P. ovale, P. malariae, and, rarely, P. knowlesi in
Southeast Asia. The infection is acquired from the bite of an infected
female anopheles mosquito. It may also be spread by blood transfu-
sion. Falciparum malaria is the most serious. While all forms of this
disease make people ill and may be lethal, P. falciparum is the one
that kills.
Regions of the world where malaria may be acquired are sub-
Saharan Africa, parts of Mexico and Central America, Haiti, parts
of South America, the Middle East, the Indian subcontinent, and
Southeast Asia. Resistance to chloroquine by the deadly P. falciparum
has become widespread. For travelers in resistant areas, there are sev-
eral prophylactic medications that are currently used: Malarone, Lar-
iam, and doxycycline. To use Lariam (mefloquine), 250 mg, take 1
tablet weekly, starting 1 week prior to departure and continuing for
4 weeks after return. An alternate drug regimen, especially necessary
when P. falciparum has become resistant to mefloquine, is the use of
doxycycline, 100 mg to be taken once daily for prevention. This must
be started the day before exposure, continued daily and for 4 weeks
after exposure.
In areas with relapsing malaria (P. vivax and P. ovale), primaquine

should be taken 1 tablet daily during the last 2 weeks of chloroquine
therapy. This is usually appropriate for anyone faced with long expo-
sure in areas with a high concentration of these strains of malaria. The
International Association for Medical Assistance to Travellers (www
.iamat.org) provides the percentage of P. falciparum versus P. vivax
and P. ovale, as well as current information on resistance to chloro-
quine for each country.
If you are moving off the grid into an area with malaria, taking
a very long-term (multiple years) of an antimalarial drug, while safe,
may be impractical. Your best approach is strict mosquito protection
with permethrin treatment of clothing, bed netting, residual spraying
of building interiors, and skin protection—and the use of a treatment
dose of medication if someone comes down with possible malaria.
In children malaria frequently presents with diarrhea and abdomi-
nal pain, but in all expect severe fever with profuse sweating, head-
ache, nausea, and vomiting. This can lead to convulsions and death.
A good treatment is to use Malarone (250 mg atovaquone + 100 mg
proguanil) 4 tablets once daily (take with food or milk and the same
time each day, repeating the dose if patient vomits within 1 hour
of taking it). A pediatric treatment dose is also devised based upon
weight. The pediatric tablet is 62.5 mg atovaquone + 25 mg proguanil.
Table 9-4. Pediatric Treatment Dose of Malarone for

Malaria (Given for 3 Days)
Weight Tablets
11 to 18 pounds (5 to 8 kg) 2 pediatric tabs once daily
19 to 23 pounds (9 to 10 kg) 3 pediatric tabs once daily
24 to 44 pounds (11 to 20 kg) 1 adult tab once daily
45 to 66 pounds (21 to 30 kg) 2 adult tabs once daily
67 to 88 pounds (31 to 40 kg) 3 adult tabs once daily
Over 89 pounds (over 41 kg) 4 adult tabs once daily
Measles (Rubeola)
A viral disease, measles spreads easily by inhalation and is one of the
most contagious viral diseases; 90% of unimmunized persons who
are exposed catch it. Occurring 1 to 3 weeks after exposure, usually 2
weeks, onset is with a high fever 105°F (40.6°C) and typically con-
junctivitis, runny nose, and cough. Within 3 to 7 days after the fever,
a rash appears on the face, then covers the entire body, lasting for 4 to
7 days. It is contagious 4 days before and 4 days after the rash breaks.
One per 1,000 cases can develop deadly brain infections. It can
cause diarrhea, middle ear infections, and pneumonia, which can also
become fatal. Persons with ear infections, and pneumonia may have a
secondary bacterial infection as well due to their weakened condition,
and these can be treated with antibiotics, but an antibiotic will not
help if the cause is just from the measles. There is no specific treat-
ment. Only use acetaminophen (Tylenol) and not aspirin or NSAIDs
like ibuprofen when treating the fever. You can treat cough and runny
nose symptoms. Children who contract this disease should receive
200,000 units of vitamin A (50 units under 6 months; 100,000 units
for 6 to 11 months) with a repeat dose in 2 to 4 weeks. If this breaks
out in a group, any nonimmunized persons will catch it.
Immunization is protective and is provided by the measles-
mumps-rubella (MMR) vaccine.
Meningococcal Meningitis
This acute bacterial infection caused by Neisseria meningitidis results
in inflammation of the brain and central nervous system. Many cases
are without symptoms or consist of a mild upper respiratory illness.
Severe cases begin with sudden fever, sore throat, chills, headache,
stiff neck, nausea, and vomiting. Within 24 to 48 hours, the victim
becomes drowsy and mentally confused, followed by convulsions,
coma, and death. Immediate and appropriately large doses of the
proper antibiotic are critical to save the patient’s life; the medical kit
only has Rocephin, which must be given in large amounts: 1 gram IM
twice daily. The disease is spread by contact with the nasal secretions
of infected persons (sneezing and coughing).
While the disease is found worldwide, large epidemics are more

common in tropical countries, especially sub-Saharan Africa in the
dry season, New Delhi (India), and Nepal.
In 80% of healthy young adults, bacterial meningitis is caused by
the meningococcus bacteria discussed in this section or by a pneumo-
cocci bacterium. Vaccines are available against both organisms.
Mumps
This virus infection spreads by respiratory droplets either by inhala-
tion or touching them on surfaces. The incubation period is 16 to 18
days (range, 12 to 25). The disease starts with fever, headache, loss of
appetite, and muscle aches. The hallmark of the disease is swelling of
one or both parotid (salivary) glands. People are the most contagious
from a few days before illness until 5 days after the onset of parotid
gland swelling. The complications can be infections of the testicle,
hearing loss, meningitis, encephalitis, and pancreatitis. Treat the fever
with acetaminophen (Tylenol) and avoid aspirin.
Immunization is protective and is provided by the MMR vaccine.
Unfortunately, the mumps component of this shot is the least effec-
tive and provides only about 88% protection, which may gradually
decline and, in case of outbreaks, the MMR should be boosted.
Plague
Plague is caused by a bacterium (Yersinia pestis) that infects wild
rodents in many parts of the world, including the western United
States and parts of South America, Africa, and Asia. Epidemics
occur when domestic rats become infected and spread the disease to
humans. Bubonic plague is transmitted by infected fleas, while pneu-
monic plague is spread directly to other people by coughing. Plague
is accompanied by fever, enlarged lymph nodes (bubonic plague) and,
less commonly, pneumonia (pneumonic plague).
Treatment is with doxycycline, 100 mg twice daily. Treat fever as
necessary. Isolate the patient, particularly if coughing. Drainage of
abscesses (buboes) may be necessary (see page 147). Exposed persons
should be watched for 10 days, but incubation is usually 2 to 6 days.
Rabies
Rabies can be transmitted on the North American continent by sev-
eral species of mammals, namely skunk, bat, fox, coyote, raccoon, bob-
cat, and wolf. Obviously, if removing an animal from a trap, jogging
past an animal, separating mother from child, or taking food from a
critter causes an attack, the most likely cause of the attack is not from
a rabid animal, but a scared or angry one. An attack by a wounded
animal is cause for concern, as the animal may be wounded due to
loss of coordination from rabies. Any unprovoked attack by one of
these mammals should be considered an attack by a rabid animal.
Dogs and cats in the United States have a low incidence of rabies.
Information from local departments of health will indicate if rabies is
currently of concern in your area.
Animals whose bites have never caused rabies in humans in the
United States are livestock (cattle, sheep, horse), rabbits, gerbils, chip-
munks, squirrels, rats, and mice. A significant epidemic of raccoon
rabies has now extended from Florida to Connecticut, with isolated
reports from New Hampshire and Ohio showing an expansion of
this epidemic north and west. Hawaii is the only rabies-free state.
Canada’s rabies occurs mostly in foxes and skunks in the province of
Ontario.
The rabies vaccine available in the United States is very effective,
with low side effects. It is expensive, but much less expensive than
having to acquire post-exposure rabies immune globulin in addition
to the complete series of shots.
The incubation can be brief or take months. It is caused when
the virus is able to reach a peripheral nerve synapse, then penetrates
it and moves toward the brain at the rate of 4 inches (10 cm) per day!
Once the virus is in the nerve, the patient is doomed. Rabies is vicious,
virtually 100% fatal once it develops clinically. It is sometimes called
hydrophobia because the person appears to be afraid of water. They
will be very thirsty but will choke when trying to swallow. Spasms,
high fever, and terrible headache rapidly progress to death. Because
of this, there is generous use of rabies vaccine and rabies-specific
immune globulin to provide immediate, passive immunity until the
vaccine can take effect. Approximately 16,000 to 39,000 people are

vaccinated in the United States yearly to prevent this disease. Per-
sons having to work with potentially rabid animal populations can
be immunized with the vaccine and given yearly booster shots. It
is possible to obtain the disease by merely being contaminated with
the saliva or blood of an infected animal if it encounters a break in
the skin or mucous membranes, and possibly even by breathing in
dust infected with the virus. The first aid treatment will always be to
irrigate the wound area, especially with a virucidal material, such as a
saturated iodine water solution used for water purification (page 90),
soap and water, or the other methods indicated for wound cleansing
(page 122).
Relapsing Fever
This bacterial infection is caused by several species of Borrelia spi-
rochete and is spread by body lice in Asia, Africa, and Europe, or
by soft-bodied ticks in the Americas (including the western United
States), Asia, Africa, and Europe. Symptoms occur 3 to 11 days from
contact with the tick or louse vector and start with an abrupt onset
of chills, headache, muscular pains, and sometimes vomiting. A rash
may appear and small hemorrhages present under the skin surface.
The fever remains high from 3 to 5 days, then clears suddenly. After 1
to 2 weeks a somewhat milder relapse begins. Jaundice is more com-
mon during relapse. The illness again clears, but between 2 and 10
similar episodes reoccur at intervals of 1 to 2 weeks until immunity
fully develops.
Antibiotics are available for effective treatment. Mortality is low,
less than 5% in healthy adults. Treatment is with doxycycline, 100 mg
twice daily for 5 to 10 days. Personal hygiene is effective in preventing
louse-borne disease, while control of ticks with insect repellent and
frequent body checks and tick removal minimize the chance of tick-
borne disease. Unlike many tick-borne diseases that will not spread
to humans unless the tick has been attached for longer than 2 days,
relapsing fever can be caught soon after attachment.
Rocky Mountain Spotted Fever

This is an acute and serious infection caused by a microorganism
called Rickettsia rickettsii and transmitted by ixodid (hard-shelled)
ticks. It is most common in North Carolina, Virginia, Maryland, the
Rocky Mountain states, and the state of Washington. The peak inci-
dence of cases is from May to September. Onset of infection occurs
after a 3- to 12-day incubation period (average 7 days from the tick
bite). Fever reaches 103 to 104°F (40°C) within 2 days. There is con-
siderable headache, chills, and muscle pain at the onset. In 4 days a
rash appears on the wrists, ankles, soles, and palms and then spreads
to the trunk. Initially pink, this rash turns to dark blotches and even
ulcers in severe cases.
Any suspected case of Rocky Mountain spotted fever should be
considered a medical emergency. Do not wait for the rash to develop;
rather, start the patient on antibiotics from the Rx Oral/Topical
Medication Module. Give doxycycline, 100 mg, 1 tablet every 12
hours, and keep on this dosage schedule for 14 days. This is the drug
of choice, and its early use can cut the death rate from 20% to nearly
zero. Prevention is by the careful removal of ticks and the use of insect
repellent and protective clothing. Obviously, anyone suspected of
having this disease needs to be seen immediately by a physician.
Rubella (German Measles, 3-Day Measles)

A viral disease (unrelated to measles), this is highly contagious and
is spread by persons between 7 days before and 5 to 7 days after the
onset of the characteristic rash, which starts on the face and spreads
to the body. Frequently there are aching joints, especially in young
women. Incubation from exposure averages 14 days (range is 12 to 23
days). The illness may start with a low-grade fever and lymph node
enlargement. Some people will not have symptoms, but they will also
be contagious. It is extremely dangerous to a pregnant woman’s baby,
even more so than Zika virus.
There is no treatment. Avoid aspirin for fever and use acetamino-
phen (Tylenol). It is prevented with immunization using the measles-
mumps-rubella (MMR) vaccine.
Schistosomiasis
Blood trematodes or flukes are responsible for schistosomiasis (bil-
harziasis, safari fever). The eggs are deposited in freshwater and hatch
into motile miracidia, which infect snails. After developing in the
snails, active cercariae emerge, which can penetrate exposed human
skin. Swimming, wading, or drinking freshwater must be avoided in
infected areas.
Schistosoma mansoni is found in tropical Africa, part of Venezu-
ela, several Caribbean islands, the Guianas, Brazil, and the Middle
East. S. japonicum is encountered in China, Japan, the Philippines,
and Southeast Asia. S. haematobium is in Africa, the Middle East, and
small portions of India and islands in the Indian Ocean, all probably
pretty far off the grid. The former two species are excreted in the
stools, and the latter in urine. Shedding may occur for years. No isola-
tion is required of patients. Specific treatments for the various species
are available. Initial penetration of the skin causes an itchy rash. After
entry, the organism enters the bloodstream, migrates through the
lungs, and eventually lodges in the blood vessels draining either the
gut or the bladder, depending upon the species. While the worms are
maturing, the victim will have fever, lethargy, cough, rash, abdominal
pain, and often nausea. In acute infections caused by S. mansoni and
S. japonicum, victims develop a mucoid, bloody diarrhea and tender
liver enlargement. Chronic infection leads to fibrosis of the liver with
distension of the abdomen. In S. haematobium infections, the bladder
becomes inflamed and eventually fibrotic. Symptoms include painful
urination, urgency, blood in urine, and pelvic pain.
STARI
Southern tick-associated rash illness (STARI) develops around the
site of a lone star tick bite and develops within 7 days of the bite. It
can expand to a diameter of 3 inches (8 centimeters). Patients possi-
bly experience fatigue, headache, fever, and muscle pains. Lone star
tick bites almost always cause a local small inflamed area, but that by
itself is not an indication that a patient has STARI. Lone star ticks do
not carry Lyme disease. While the CDC does not recommend, at the
time of this writing, the use of antibiotics in treating STARI, since
the causative organism is not known, studies have shown taking an

antibiotic such as doxycycline clears the symptoms quicker.
Tapeworms
Three species of tapeworm infect humans: Taenia saginata larvae
found in beef, T. solium in pork, and Diphyllobothrium latum in fish.
In all three the human ingests undercooked flesh of the host animal,
acquiring the infective cysts.
The beef tapeworm can be huge, forming lengths of 10 to 30
feet inside the human host. It is common in Mexico, South America,
Eastern Europe, the Middle East, and Africa. Symptoms can include
stomach pain, weight loss, and diarrhea, but frequently the human
host has no clue of the infestation.
The pork tapeworm infects victims in South America, eastern
Europe, Russia, and Asia. Generally, it is without symptoms; at times
vague abdominal complaints are noted. A complication of this disease
is cysticercosis: The tapeworm larvae penetrate the human intestinal
wall—after the human drinks infected water—and invade body tis-
sues, frequently skeletal muscle and the brain. There they mature into
cystic masses. After several years the cysts degenerate and produce
local inflammatory reactions that can then cause convulsions, visual
problems, or mental disturbances. In this case the human replaces the
pig in the maturation cycle of the tapeworm, and it is the human flesh
that is contaminated by the tapeworm cyst. This is an unlucky break
for the involved human and any cannibals he might meet. Any water
filtration or purification system can prevent cysticercosis.
The fish tapeworm occurs worldwide but is a particular hazard
in Scandinavia and the Far East. A single tapeworm, usually with-
out symptoms, develops. The worm’s absorption of vitamin B-12 may
cause pernicious anemia in the host.
Tetanus
Although caused by a bacterium (Clostridium tetani) that is located
worldwide, most cases of tetanus occur from very minor wounds such
as a paper cut, rather than from rusty barbed wire, as so many people
think. In fact, a hiker on the Appalachian Trail got tetanus from a
blister on his heel and inadequate immunization. Onset is gradual,

with an incubation period of 2 to 50 (usually 5 to 10) days. The ear-
liest symptom is stiffness of the jaw, then sore throat, stiff muscles,
headache, low-grade fever, and muscle spasm. As the disease pro-
gresses, the patient is unable to open their jaw, and the facial muscles
may be fixed in a smile with elevated eyebrows. Painful generalized
spasms of muscles occur with minor disturbances such as drafts, noise,
or someone jarring the patient’s bed. Death from loss of respiratory
muscle function, or even unknown causes, may ensue. The disease is
frequently fatal. Prevention is obtained by adequate immunization.
Tick Paralysis
Five species of ticks in North America produce a neurotoxin in their
saliva that can paralyze their victims. Most cases are found in the
Pacific Northwest, Rocky Mountain states, and seven southern states,
as well as Australia. Spring and summer are the times of highest risk.
The toxin is usually carried by an engorged pregnant tick. Symptoms
begin 2 to 7 days after the tick begins feeding. Throughout the ordeal
the patient’s mental function is usually spared. Symptoms start as
weakness in the legs, which progressively ascends until the entire
body is paralyzed within several hours to days. At times the condition
presents as ataxia (loss of coordination) without muscle weakness.
The diagnosis is made by finding an embedded tick. After remov-
ing the tick, symptoms resolve in hours to days, rarely longer. Untreated
tick paralysis can be fatal, with mortality rates of 10 to 12%.
Trichinosis
Trichinosis is caused by eating improperly cooked meat infected with
the cysts of this parasite, the roundworm Trichinella spiralis. It is most
common in pigs, bears (particularly polar bears), and some marine
mammals. Nausea and diarrhea or intestinal cramping may appear
within 1 to 2 days, but it generally takes 7 days after digestion. Swell-
ing of the eyelids is very characteristic on the 11th day. After that,
muscle soreness, fever, pain in the eyes, and subconjunctival hemor-
rhage (see page 49) develop. If enough contaminated food is ingested,
this can be a fatal disease. Most symptoms disappear in 3 months.
Treatment is with pain medication (Percogesic from the Non-Rx

Oral Medication Module, or Norco 10/325 from the Rx Oral Med-
ication Module). The use of steroids such as Decadron (20 mg/day
for 3 or 4 days, followed by reduced dosage over the next 10 days) is
indicated in severe cases. Specific drugs are available for treatment of
this disease (albendazole and, when available, mebendazole). The best
prevention is cooking suspected meat at 150°F (66°C) for 30 minutes
for each pound of meat.
Trypanosomiasis, African (African Sleeping Sickness)

While it is very likely that you are not leaving the grid for Africa,
the African variety of trypanosomiasis is interesting as it is so dif-
ferent from the American variety, which you may encounter if you
are heading to Central America or South America. Two species of
trypanosomes cause African trypanosomiasis (African sleeping sick-
ness), which is transmitted by the bite of the tsetse fly. The severity
of the disease depends upon the species encountered. The infection
zone is confined to the area of Africa between 15 degrees north and
20 degrees south of the equator—the exact distribution of the tsetse
fly. Humans are the only reservoir of Trypanosoma gambiense found in
west and central Africa, while wild game is the principal reservoir of
the T. rhodesiense of east Africa.
T. gambiense infection starts with a nodule or a chancre that
appears briefly at the site of a tsetse fly bite. Generalized illness
appears months to years later and is characterized by lymph node
enlargement at the back of the neck and intermittent fever. Months
to years after this development, invasion of the central nervous sys-
tem may occur, noted by behavioral changes, headache, loss of appe-
tite, backache, hallucinations, delusions, and sleeping too much. In T.
rhodesiense infection the generalized illness begins 5 to 14 days after
the nodule or chancre develops. It is much more intense than the
Gambian variety and may include acute central nervous system and
cardiac symptoms, fever, and rapid weight loss. It has a high rate of
mortality. If untreated, death usually occurs within 1 year. Specific,
but frequently toxic, therapy is available.
Trypanosomiasis, American (Chagas Disease)

Chagas disease (American trypanosomiasis), caused by Trypanosoma
cruzi, a protozoan hemoflagellate, is transmitted through the feces of
a brown insect called the “kissing bug,” or the “assassin bug” in North
America. This bug is a member of the family Reduviidae. The bug’s
popular name in South America is vinchuca, derived from a word
which means “one who lets himself fall down.” These bugs live in
palm trees or the thatching in native huts and like to drop onto their
sleeping victim’s face or exposed arms. When biting victims, the bug
defecates. The itch of the wound causes bitten patients to scratch the
wound, rubbing the feces into the bite site, thus causing the inocu-
lation of the infectious agent. This disease is found in parts of South
and Central America, but the vector for the disease (the kissing bug)
is located in the southwestern United States. At first this disease may
have no symptoms. A chagoma, or red nodule, develops at the site of
the original infection. This area may then lose its pigmentation. After
1 to 2 weeks, a firm swelling of one eyelid occurs, known as Roma-
na’s sign. The swelling becomes purplish in color, and lymph node
swelling in front of the ear on the same side may occur. In a few days
a fever develops, with generalized lymph node swelling. Rapid heart
rate, spleen and liver enlargement, swelling of the legs, and meningitis
or encephalitis may occur. Serious conditions also can include acute
heart failure. In most cases, however, the illness subsides in about 3
months and the patient appears to live a normal life. The disease con-
tinues, however, slowly destroying the heart, until 10 to 20 years later,
chronic congestive heart failure becomes apparent. The underlying
cause may never be known, especially in a traveler who has left the
endemic area. In some areas of Brazil, the disease attacks the colon,
causing flaccid enlargement with profound constipation.
This disease is a leading cause of death in South America, gen-
erally due to heart failure. As many as 15 million people in South
America may be infected.
Tuberculosis
Tuberculosis (TB) is caused by one of two bacteria, Mycobacterium
tuberculosis or M. bovis. The infection results in a chronic illness that
can reactivate many years after it apparently has been killed. In the
United States there are 20,000 new cases, with 1,800 deaths, yearly.
Worldwide there are 8 to 10 million new cases, with 2 to 3 mil-
lion deaths annually. This disease is spread primarily by inhalation of
infected droplets. The disease also spreads by drinking infected milk
or eating infected dairy products such as butter. If milk cannot be
pasteurized, the animals from which it is sourced (cows, goats, etc.)
should be tuberculin-free. In my practice I once treated an elderly
lady from southern Indiana who had widespread tuberculosis, which
she had caught from drinking goat’s milk.
Active pulmonary disease usually develops within a year of con-
tact. The early symptoms of fever, night sweats, lethargy, and weight
loss can be so gradual that they are initially ignored. Tuberculosis usu-
ally infects the lungs, but it can spread throughout the body, causing
neurological damage, bone infections, and overwhelming infection.
Diagnosis is usually made with a chest X-ray.
Tularemia
Tularemia (rabbit fever, deerfly fever) can be contracted through
exposure to ticks, deerflies, or mosquitoes. Cuts can be infected when
working with rabbit pelts. Eating improperly cooked infected rabbits
can result in onset. Similarly, muskrats, foxes, squirrels, mice, and rats
can spread the disease via direct contact with their carcasses. Stream
water may become contaminated by these animals.
An ulcer appears when a wound is involved, and lymph nodes
become enlarged, first in nearby areas and then throughout the body.
Pneumonia normally develops. The disease lasts 4 weeks in untreated
cases. Mortality in treated cases is almost zero, while in untreated
cases it ranges from 6 to 30%.
Treatment of choice is streptomycin, but the doxycycline sug-
gested for the Rx Oral/Topical Medication Module works extremely
well. The average adult would require an initial dose of 2 tablets, fol-
lowed by 1 tablet every 12 hours. Continue therapy for 5 to 7 days
after the fever has broken.
Typhoid Fever
Caused by the bacterium Salmonella typhi, typhoid fever is spread
by contaminated food and dairy products. Prevention is proper food
storage, the thorough cooking of food, and avoidance of unrefriger-
ated dairy products.
The disease is characterized by headache, chills, loss of appetite,
backache, constipation, nosebleed, and tenderness of the abdomen
to palpation. The temperature rises daily for 7 to 10 days. The fever
is maintained at a high level for 7 to 19 more days, then drops over
the next 10 days. With typhoid fever, a pulse rate of only 84 may
occur with a temperature of 104°F (40°C), when one might otherwise
expect a pulse rate of over 120. Between the 7th and 10th days of the
illness, rose-colored splotches, which blanch when pressure is applied,
appear in 10% of patients.
The drug of choice for treating this illness is Rocephin, given
at 30 mg/kg of body weight/day IM in 2 divided doses per day for
2 weeks. An oral drug that can be used is Levaquin, 500 mg given
once daily. Diarrhea may be severe in the latter stages of this illness.
Replacement of fluids is especially important during the phases of
high fever or diarrhea (see page 88). Patients with relapses should be
given another 5-day course of the antibiotic. Immunization prior to
departure to endemic areas is useful in preventing or curtailing the
severity of this infection and should be taken by anyone traveling
to an endemic area. This disease is very common after mass disaster
situations, and while immunization is not usually indicated for living
in the US, it is a disease to be aware of if the grid collapses.
Endemic Typhus, Flea-Borne

This disease is also known as murine typhus, rat-flea typhus, New
World typhus, Malaya typhus, and urban typhus. It is one of several
diseases caused by rickettsia, which resemble both viral and bacterial
infections. Other diseases caused by this order are Rocky Mountain
spotted fever, Q fever, trench fever, and the various typhus diseases.
Endemic typhus is due to Rickettsia typhi, which is located world-
wide, including the southern Atlantic and Gulf Coast states of the
United States. It is spread to humans through infected rat flea feces.
After an incubation period of 6 to 18 days (mean 10 days), shak-

ing chills, fever, and headache develop. A rash forms, primarily on the
trunk, but fades fairly rapidly. The fever lasts about 12 days. This is a
mild disease and fatalities are rare. Antibiotic treatment with doxycy-
cline, 100 mg given twice daily, is very effective. Prevention is directed
toward vector (rat and flea) control.
Epidemic Typhus, Louse-Borne

This malady is also called classic typhus, European typhus, and jail
fever. It killed 3 million people during World War II. On the positive
side, no American traveler has contracted this disease since 1950. It
is most likely to be encountered in mountainous regions of Mexico,
Central and South America, the Balkans, eastern Europe, Africa, and
many countries of Asia. The causative agent is Rickettsia prowazekii,
which is transmitted by infected lice.
Following a 7- to 14-day incubation period, there is a sudden
onset of high fever (104°F, or 40°C), which remains at a high level,
with a usual morning decrease, for about 2 weeks. There is an intense
headache. A light pink rash appears on the 4th to 6th day, soon
becoming dark red. There is low blood pressure, pneumonia, mental
confusion, and bruising in severe cases. Mortality is rare in children
less than 10 years of age but may reach greater than 60% in those
over 50. Antibiotics, such as doxycycline, 100 mg twice daily, are very
effective if given early in the disease. Prevention is proper hygiene and
delousing when needed. A vaccine was formerly made in the United
States but is no longer available and is not needed due to the low
incidence observed.
West Nile Virus

This is an arbovirus that primarily infects birds, especially crows,
ravens, and robins. Mosquitoes then spread this virus to all mammals,
which unfortunately includes humans. A sign of local West Nile
virus activity can be dead birds, especially crows, ravens, and robins.
In North America the mosquito vector is the culex, which is unfor-
tunate as these mosquitoes do not usually announce their presence by
buzzing in your ears or leaving welts when they bite. They are silent,
stealth biters. If you are being buzzed and welt up, you don’t have to
worry about it being from a culex mosquito.
West Nile virus was first identified in the United States in 1999
and has presented in all states and in all provinces of Canada (with
rare exceptions). The disease is usually without symptoms, but when
more severe it results in fever, headache, stiff neck, nausea or vomit-
ing, muscle aches and weakness, and even coma and death. It does not
spread from person to person, except via blood transfusion. Support is
accomplished with adequate pain medication, evacuation if possible,
and generally helping with normal body functions.
Yellow Fever
An arbovirus, yellow fever is found in tropical areas of South and
Central America and Africa. This viral disease is contracted by the
bite of the Aedes aegypti mosquito (and other species). Onset, about
2 weeks after the bite, is sudden, with a fever of 102 to 104°F (40°C).
The pulse is usually rapid the first day, but becomes slow by the sec-
ond day. In mild cases the fever falls suddenly 2 to 5 days after onset.
This remission lasts for hours to several days. Next the fever returns,
but the pulse remains slow. Jaundice, vomiting of black blood, and
severe loss of protein in the urine (causing it to become foamy) occurs
during this stage. Hemorrhages may be noted in the mouth and skin
(petechiae). The patient is confused, and the senses are dulled. Delir-
ium, convulsions, and coma occur before death in approximately 10%
of cases. If the patient survives, this last febrile episode lasts from 3 to
9 days. With remission the patient is well, with no aftereffects from
the disease.
Immunization is available and required or recommended for
travel to many countries. It was once a common disease in the US,
and we have the mosquito here that can spread it again.
Zika Virus
This is a viral disease spread by a daytime biting mosquito that fre-
quently lives in human habitats, the Aedes alopictus. As the range of
this beast is well into the northern areas of the United States, and
it can also carry dengue, chikungunya, and West Nile virus, febrile
illness associated with muscle and joint pain, and at times rash and/
or eye irritation, could be any one of these diseases. Avoid the use
of aspirin or meloxicam, but treat instead with Tylenol or Ultram.
Due to possible birth defects from this disease, pregnant women will
need to have a careful specialist follow-up. Prevention is the use of
mosquito protection as indicated on page 204, and since this disease
can be spread sexually, use of condoms for at least 6 months after
exposure or illness. Persons traveling into a Zika-infested area should
continue to wear mosquito repellant at least 2 weeks after they leave
to prevent a mosquito in a disease-free area from biting and spreading
this illness into the community. Frequently the ache and other symp-
toms of Zika are very mild, and a person can contract it without even
knowing they have had it or are carrying it.
CHAPTER 10
ENVIRONMENTAL INJURIES
No matter where you go off the grid, while ankle sprains, blisters,
and diarrhea are the most common problems that may bother you,
environmental conditions pose the most likely threat to life. In fact,
most of prepping goes into preparing for environmental injuries. The
basic skills involving shelters and fire and energy production are all
meant to control environmental challenges. Foremost among these
dangers is hypothermia. Death from heat exposure is still the second-
leading cause of death among high school athletes (discounting the
highway). Unless you live right on the Pacific Coast, lightning can
do more than scare you. And for those of us forced to suddenly travel
vertically, high-altitude illnesses are potentially miserable, even lethal,
experiences. This chapter covers injuries that can occur depending on
environmental conditions.
Hypothermia 247
Chronic Hypothermia 247
Acute Hypothermia 250
Cold Water Submersion 251
Cold-Stress Injuries 252
Frostnip 252
Frostbite 252
Cold-Induced Bronchospasm 254
Immersion Foot 254
Chilblains 255
Heat-Stress Injuries 255
Dilutional Hyponatremia 258
Heat Cramps 259
ENVIRONMENTAL INJURIES 247
Heat Exhaustion 259

Heat Stroke 260
Prickly Heat 261
Lightning 261
High-Altitude Illnesses 265
Acute Mountain Sickness (AMS) 265
High-Altitude Pulmonary Edema (HAPE) 266
High-Altitude Cerebral Edema (HACE) 267
HYPOTHERMIA
The term hypothermia refers to the lowering of the body’s core tem-
perature to 95°F (35°C); profound hypothermia is a core tempera-
ture lower than 90°F (32°C). Another important point is that the
term hypothermia applies to two distinctly different diseases. Chronic
hypothermia is the slow onset of hypothermia in the outdoor traveler
who is exposed to conditions too cold to be protected by his equip-
ment. Acute hypothermia, or immersion hypothermia, is the rapid
onset of hypothermia in a person immersed in cold water.
In acute hypothermia—when the onset of cold core tempera-
ture takes less than 2 hours—the body cannot produce the complex
physiological responses that it is capable of when it has more time.
In chronic hypothermia—when body temperature takes 6 hours or
longer to arrive at the cold core—the responses are quite dramatic
and include profound dehydration, exhaustion, and complex chem-
ical changes in the blood. The ideal treatment is quite different in
the hospital setting; in the field our treatment options are reduced
to basic techniques of preventing further heat loss and some passive
reheating maneuvers.
Chronic Hypothermia
You do not have to be in a bitterly cold setting to die of hypothermia.
In fact, most chronic hypothermia deaths occur in the 30°F to 50°F
(0 to 10°C) range. This temperature range places almost all of North
America in a high-risk status year-round. To survive hypothermia,
be prepared to prevent it, recognize it if it occurs, and know how
to treat it. Dampness and wind are the most devastating factors to
be considered: Dampness can reduce the insulation of clothing and
cause evaporative heat loss, and the increased convection heat loss
caused by wind can readily strip away body energy—the so-called
windchill effect. Currently, many television weather forecasters dis-
cuss a “feels-like temperature” to indicate either a coolness noticeable
at cold temperatures from wind or a warmness felt at hot tempera-
tures with associated humidity. But windchill is an incredibly import-
ant concept in understanding the importance even a slight breeze has
with regard to stripping body heat away from you and in knowing to
immediately consider whatever shelter you can find—even a solitary
tree—to minimize this loss if clothing is inadequate. Once, while a
small group of us were waiting for a bus in freezing temperatures
in a remote area of Leningrad, we simply took turns hiding behind
each other as a windbreak. And many times, in a wilderness, I ducked
behind that solitary tree!
Factors important in preventing hypothermia are a high level
of physical conditioning, adequate nutritional and hydration status,
avoiding exhaustion, and availability of adequate insulation. There is
increased risk of “trauma hypothermia” in the case of injury, especially
shock. Even in mild temperatures, a person in shock can become
hypothermic. It is very important to insulate persons who are injured
from the environment, particularly by providing ground insulation.
An initial response to cold is vasoconstriction, or the clamping
down of surface blood vessels. This prevents heat from being con-
ducted to the surface by the blood, and effectively increases the thick-
ness of the mantle, or outer layer depth, for increased insulation.
Those who become profoundly hypothermic, with a core temperature
below 90°F (32.2°C), have concentrated their blood volume into a
smaller inner core. The amount of dehydration in these persons can
be profound, approaching 5.8 quarts (5.5 liters) in someone below
90°F, equivalent to the entire circulatory volume. This fluid loss comes
not only from the vascular space but also from fluid between the cells
and within the cells as the body slowly adjusts to the continuing heat
loss by shrinking blood circulation into the core and increasing the
thickness of the mantle layer. Cold diuresis, an increased urination,
is part of this response. At this point, rapid, sudden rewarming can

lead to rewarming shock. Hospital methods of rewarming must be
coupled with tight metabolic control by adjusting blood factors such
as clotting, electrolytes, and blood sugar levels.
In chronic hypothermia, rewarming shock and loss of metabolic
control are the causes of death, not the so-called afterdrop phenom-
enon. Afterdrop, or the further lowering of core temperature after
rewarming has started, is due to the combination of conduction
equilibration of heat and a circulation component. By far the most
important aspect is conduction equilibration. This physical property
of conduction results in an equilibration of thermal mass as the higher
warmth of the core leaches into the colder mantle layer. The amount
of afterdrop that occurs is primarily dependent upon the rate of cool-
ing prior to the rewarming process, not the method of rewarming!
The goal of treatment for the chronic hypothermic victim is to
prevent further loss of heat; this generally means providing shel-
ter and/or more adequate clothing. Persons who are cold may well
become hypothermic, and, if they are not exhausted, the best method
of warming is to continue exercise. If the victim is exhausted, she
will require rest and food. She is dehydrated and requires fluids. If
she can stand, a roaring fire can provide adequate, controlled heat.
Since chronic hypothermia victims are usually exhausted, however,
they will then not be able to exercise themselves to warmth. Exercise
is a method of generating heat, as is shivering, but when energy stores
are consumed, exhaustion commences and significant hypothermia
will begin unless further heat loss is stopped.
Deepening hypothermia will lead to a semicomatose state—and
worse. This victim needs to be evacuated and hospitalized. Obviously,
the real salvation of this situation is a warm shelter, but if you are
stuck in the elements, wrap to prevent further heat loss and transport
to warmth as soon as possible. Chemical heat packs and the like can
be added to the wrap to help offset further heat loss, but this will
not add enough heat to rewarm the patient, and thus having these
items in your survival kit is practically worthless. If you’re heating
bottles of water to provide external heat, care must be taken not to
burn the victim. If evacuation is not feasible, add heat slowly to avoid
rewarming shock. Huddling the victim between two rescuers in an

adequate sleeping bag may be the only alternative.
Acute Hypothermia
Afterdrop is, however, a real problem for the acute or immersion
hypothermic who has had a significant exposure to cold water. As a
rule of thumb, a person who has been in water of 50°F (10°C) or less
for a period of 20 minutes or longer is suffering from a severe amount
of heat loss. That individual’s thermal mass has been so reduced that
he is in potentially serious condition. He should not be allowed to
move around, as this will increase the blood flow to his very cold skin
and facilitate a profound circulatory-induced afterdrop—one so great
as to be potentially lethal. If this same person is simply wrapped in
a litter and not provided with outside heat, there is a real danger his
core temperature will cool down to a lethal level because of this pro-
found amount of heat loss.
The ideal treatment is rapid rewarming of the acute hypothermic
by placing him in hot water (110°F, or 43°C) to allow rapid replace-
ment of heat. The acute hypothermic may have an almost normal core
temperature initially, but it is destined to drop dramatically as his
body equilibrates his heat store from his core to his very cold mantle.
A roaring fire can be a lifesaver. If not available, huddling two rescuers
with the victim in a large sleeping bag may be the only answer—the
same therapy that might have to be employed in the field treatment
of chronic hypothermia under some conditions.
The person who has been immersed for less than 20 minutes in
cold water can do anything he wants to rewarm. He can run around
like crazy, stand by a fire, or just wrap up in warm, dry insulation. The
total body thermal mass is still high enough that the temperature
equilibration by both the conductive and circulatory components will
not reduce the core temperature to a dangerous level.
To review, the person who has been in cold water longer than 20
minutes has experienced such a profound heat loss that allowing him
to run around or even wrapping him without additional significant
heat will cause a tremendous drop in his core temperature—into a
lethal range. The person who is fished out of cold water after 2 hours
or longer must be considered as approaching chronic hypothermia.

He has survived long enough that his physiological protective mech-
anisms have resulted in dehydration and other changes that are so
complex that rapid rewarming can result in shock and death unless
he is carefully monitored in a hospital setting.
Cold Water Submersion

Cold water submersion is always associated with asphyxiation and
simultaneous hypothermia. Note that there is a distinct difference
between immersion and submersion: Submersion indicates that the
victim is entirely underwater; immersion means that the head is
above water.
Asphyxiation results in brain death, so prompt rescue and imme-
diate implementation of CPR (cardiopulmonary resuscitation) play
an important role in the survival of the victim. Total submersion in
cold water causes a rapid core cooling, which results in a lower oxy-
gen demand by the brain and other body tissues and increases the
chance of survival over that of a victim of warm water submersion.
Full recovery after 10 to 40 minutes of submersion can occur. CPR
must be continued until the body has been warmed to at least 86°F
(30°C). If still unresponsive at that temperature, the victim may be
considered dead. It may take several hours of CPR while the patient
is being properly rewarmed to make this determination.
The rewarming process for immersion victims should not be
attempted in the field. Hospital management of victims of cold water
submersion is very complex. They are best transferred to centers expe-
rienced with this problem, but they will never have a chance if rescu-
ers do not implement CPR immediately. In an off-the-grid situation,
the safest approach in rewarming any hypothermia victim is to place
them in a warm room, be patient, hydrate if and when they become
conscious, and know that there are stories of dead, hypothermic peo-
ple, waking up after being left for dead in a warm room.
COLD-STRESS INJURIES
Frostnip
Frostnip, or very light frostbite, can be readily treated in the field,
if recognized early enough. This term is usually reserved for a form
of superficial frostbite, but I am convinced there really is a separate
entity that should be considered frostnip: The skin turns pure white
in a small patch, generally the tip of the nose or ear edges. When
frostnip is detected, cup your hands and blow on the affected parts to
effect total rewarming.
Under identical exposure conditions, some people are more
prone to this than others. On one of my trips into subarctic Canada,
a companion almost constantly frostnipped his nose at rather mild
temperatures (20°F, or 7°C). We frequently had to warn him, as he
seemed oblivious to the fact that the tip of his nose would repeatedly
frost.
Frostbite
Frostbite is the freezing of skin tissue. The temperature of the skin
must be 24°F (4°C) before it will freeze. Risk for frostbite increases if
the victim is hypothermic, dehydrated, injured, wearing tight-fitting
clothing or boots, or is not removing boots and changing socks or
checking his feet for frozen tissue at least nightly.
Traditionally, several degrees of frostbite are recognized, but the
treatment for all is the same. The actual degree of severity will not
be known until after the patient has been treated. In the field, most
cases of frostbite are not identified until the area has already thawed
and the blue, discolored skin is found when finally changing socks or
actually looking at the area in question.
When superficial frostbite is suspected, thaw immediately so that
it does not become a more serious, deep frostbite. Warm hands by
withdrawing them into the parka through the sleeves—avoid opening
the front of the parka to minimize heat loss. Feet should be thawed
against a companion or cupped in your hands in a roomy sleeping bag
or other insulated environment.
The specific therapy for a deeply frozen extremity is rapid thaw-

ing in warm water (approximately 110°F or 43°C). This thawing may
take 20 to 30 minutes, but it should be continued until all paleness of
the tops of the fingers or toes has turned to pink or burgundy red, but
no longer. This will be very painful and will require pain medication
(Rx: Norco 10/325, 1 tablet; nasal Stadol; or injectable Nubain will
probably be required).
Avoid opening the blisters that form. Do not cut skin away but
allow the digits to autoamputate over the next 3 months. Blisters will
usually last 2 to 3 weeks and must be treated with care to prevent infec-
tions (best done in a hospital by gloved attendants; lacking that, this is
handled quite adequately using clean dressings to soak up the fluids).
A black carapace will form in severe frostbite. This is a form of
dry gangrene. The carapace will gradually fall off with amazingly
good healing beneath. Efforts to hasten the carapace removal gen-
erally results in infection, delay in healing, and increased tissue loss.
Leave these blackened areas alone. The black carapace separation can
take over 6 months, but it is worth the wait. Without surgical inter-
ference, most frostbite wounds heal in 6 months to a year. All persons
prior to leaving the grid already should have had their tetanus booster
(within the previous 10 years is ideal, but see the discussion under
immunizations, page 215). Treat for shock, with elevation of the feet
and lowering of the head, as shock will frequently occur when these
people enter a warm environment.
Once the victim has been thawed, very careful management of
the thawed part is required. Refreezing will result in substantial tis-
sue loss, and this must be avoided. The patient sometimes becomes a
stretcher case if the foot is involved, but not always. For that reason, it
may be necessary to leave the foot or leg(s) frozen and allow the victim
to walk back to the evacuation point or the facility where the thawing
will take place, realizing that the amount of damage is increasing the
longer the area remains frozen. Early, rapid thawing is essential to
minimize tissue loss. Do not allow the extremity to remain frozen
unless it is essential to preserve life. Peter Freuchen, the great Green-
land explorer, once walked days and miles keeping one leg frozen,
knowing that when the leg thawed, he would be helpless. He lost his
leg but saved his life. And that’s what can also happen to you: If you
leave it frozen, you will lose the frozen part.
If a frozen foot has thawed and the patient must be transported,
use cotton between toes (or fluff sterile gauze from the emergency kit
and place it between toes) and cover other areas with a loose bandage
to protect the skin during sleeping bag stretcher evacuation. The use
of Spenco 2nd Skin for blister care would be ideal; see page 274.
Cold-Induced Bronchospasm
Cold-induced bronchospasm, a form of asthma sometimes called
“frozen lung” or pulmonary chilling, occurs when breathing rapidly at
very low temperatures, generally below 20°F (29°C). There is burning
pain, sometimes coughing of blood, frequently asthmatic wheezing,
and, with irritation of the diaphragm, pain in the shoulder(s) and
upper stomach that may last for 1 to 2 weeks. The treatment is bed
rest, steam inhalations, drinking extra water, humidification of the liv-
ing area, and no smoking. Avoid this condition by using parka hoods,
face masks, or breathing through mufflers, which result in rebreathing
warm, humidified, expired air. The differential diagnosis must include
the possibility of pneumonia. Pneumonia patients will also have high
fevers (see page 63 for treatment).
Immersion Foot
Immersion foot results from wet, cool conditions with temperature
exposures from 68°F (20°C) down to freezing. This is an extremely
serious injury that can be worse than frostbite. There are two stages
to this problem. In the first stage the foot is cold, swollen, waxy, and
mottled with dark burgundy to blue splotches. This foot is resilient
to palpation, whereas the frozen foot is very hard. The skin is sodden
and friable. Loss of feeling makes walking difficult. The second stage
lasts from days to weeks. The feet are swollen, red, and hot; blisters
form; infection and gangrene are common.
To prevent this problem, avoid nonbreathing (rubber) footwear
when possible, dry the feet and change wool socks when they get
wet or sweaty (certainly every night), and periodically elevate, air, dry,
and massage the feet to promote circulation. Avoid tight, constricting
clothing. At a minimum remove boots and socks nightly, drying the

feet and warming them before sleeping.
Treatment differs from frostbite and hypothermia in the follow-
ing ways: (1) Give the patient 10 grains (650 mg) of aspirin every 6
hours to help decrease platelet adhesion and the clotting ability of the
blood; (2) give additional Norco 10/325 every 4 hours for pain, but
discontinue as soon as possible; (3) provide 1 ounce (30 ml) of hard
liquor every hour while awake and 2 ounces (60 ml) every 2 hours
during sleeping hours to vasodilate, or increase the flow of blood to
the feet. There is no data concerning the value of using Plavix as an
antiplatelet agent in treating immersion foot, but if you have it in
your cardiac kit, use it. If you are unsure whether you are dealing with
immersion foot or frostbite, or if the victim may have suffered both,
treat for frostbite.
Chilblains
Chilblains result from the exposure of dry skin to temperatures from
60°F (16°C) to freezing. The skin is red, swollen, frequently tender,
and itching. This is the mildest form of cold injury and no tissue loss
results. Treatment is the prevention of further exposure with protec-
tive clothing over bare skin and, if available, the use of ointments
such as A+D ointment or Vaseline (white petrolatum). The hydrocor-
tisone 1% cream from the Topical Bandaging Module will help when
applied 4 times daily.
HEAT-STRESS INJURIES
High environmental temperatures are frequently aggravated by stren-
uous work; humidity; reflection of heat from rock, sand, or other
structures (even snow!); and the lack of air movement. It takes a
human approximately 10 days to become heat acclimated. Once heat
stress adaptation takes place, there will be a decrease in the loss of
salt in the sweat produced to conserve electrolytes. Another major
change is the rapid production of sweat and the formation of larger
quantities of sweat. Thus, the body is able to start its efficient cooling
mechanism—sweating—more fully and with less electrolyte distur-
bance to the body.
Risk factors for heat-stress injuries include:

• High humidity
• Overweight
• Very young or very old
• Unaccustomed to heat
• Illness with fever or taking drugs such as antihistamines
• Clothing or equipment that interferes with heat loss (certain
helmets, too much or restrictive clothing)
• Dehydration (drinking to prevent thirst will keep dehydration
above 2%)
Salt lost in sweat during work can normally be replaced at meal-
times. An unacclimated man working an 8-hour shift would sweat
4 to 6 liters. The salt content is high, 3 to 5 grams per liter of sweat.
With acclimatization, salt concentration drops (1 to 2 grams per
liter). An acclimatized man might lose 6 to 16 grams of salt during an
8-hour shift in 6 to 8 liters of sweat. The unacclimated man could lose
18 to 30 grams of salt in 4 to 6 liters of sweat. The average American
diet contains 10 to 15 grams per day of salt. This means that an unac-
climated worker could suffer from a salt deficit of 3 to 20 grams per
day. In the 10 days that it would take his body to become conditioned
to heat stress, the total salt deficit could become substantial.
A concern in heat-illness prevention is that a heat-stressed indi-
vidual must obtain adequate fluid replacement. If we focus on salt
replacement to the exclusion of adequate water intake, the individual
may become salt loaded and accelerate his dehydration. Generally, an
excess of salt or water over actual needs is readily controlled by kidney
excretion.
Depletion of body salt can lead to progressive dehydration because
the body will attempt to maintain a balance between electrolyte con-
centrations in tissue fluids with that in the cells. Deficient salt intake,
with continued intake of water, tends to dilute tissue fluid. This sup-
presses the antidiuretic hormone (ADH; vasopressin) of the pituitary
gland, preventing the kidney from reabsorbing water. The kidney will
then excrete a large volume of very dilute urine. The salt concentra-
tion of body fluids will be maintained, but at the cost of increasing
the depletion of body water, with a rapid onset of dehydration. Under
heat stress, this can result in symptoms of heat exhaustion similar to
those resulting from water restriction, but with more severe signs of
circulatory insufficiency and notably little thirst. Absence of chloride
in the urine (less than 3 grams per liter) is diagnostic of salt defi-
ciency, a test not performable in the field.
An opposite defect in the regulation of ADH can lead to severe
loss of sodium by the body, resulting in hyponatremia. A deficiency
of ADH causes water retention by the kidney and hyponatremia with
rather low amounts of water ingestion. Another cause of hyponatre-
mia would be overhydrating, basically causing water intoxication. The
discovery of hyponatremia as a reason for the collapse of hikers in the
Grand Canyon has been blamed on overhydration. But it is hard to
imagine carrying that much water. Their condition may have resulted
from ADH deficiency. Military personnel during training have also
suffered from hyponatremia collapse, but in the case of an individ-
ual being allowed multiple breaks for water whenever he felt like it
(unrestricted access to limitless water), overhydration as the cause for
hyponatremia makes sense.
The ideal replacement fluid for the unacclimated worker in heat
would be lightly salted water (0.1%, or 1 teaspoon per gallon or 1
gram per liter) to prevent water or salt depletion. He needs 13 to
20 ounces (400 to 600 milliliters) of water before activity, and 3 to 6
ounces (90 to 180 milliliters) of water every 10 to 15 minutes during
an active period. Do not go longer than 30 minutes between drinks
of water. Replacement fluids should not contain sugar concentrations
greater than 6 grams per 100 milliliters, as higher concentrations slow
gastric emptying. Acclimatized subjects need only water as a replace-
ment fluid, but need 32 ounces (1 liter) per hour in activity during hot
weather. Thirst develops when a person is about 2% dehydrated, so
“drinking to thirst”—that is, drinking to satisfy thirst—is a safe way
to prevent dehydration and avoid overhydration.
With no water available, how long could a person expect to sur-
vive? The answer is generally dependent upon the temperature and the
amount of activity. At a temperature of 120°F (49°C) with no water

available, the victim would expect to survive about 2 days (regardless
of activity). This temperature is so high that survival would not be
increased beyond 2 days by even 4 quarts (3.7 liters) of water. Ten
quarts (9.5 liters) might provide an extra day. At 90°F (32°C) with no
water, the person could survive about 5 days if she walked during the
day, 7 days if travel was only at night or if no travel was undertaken
at all. With 4 quarts of water, survival would extend to 6.5 days with
day travel and to 10 days with only night travel. With 10 quarts,
days of survival would increase to 8 and 15 respectively. If the highest
temperature was 60°F (15.5°C) with no water, the active person could
expect to survive 8 days, the inactive person 10 days.
Recommendations for preventing heat illness include:
• Water to prevent thirst.
• Avoiding alcohol.
• Wearing baggy clothing that promotes evaporation of sweat.
• Covering the head and shading the face.
• Keeping physically fit and allowing time for heat
acclimatization.
• Avoiding exercise during the hottest time of the day.
Dilutional Hyponatremia
This is a condition in which the blood sodium level falls too low to
maintain normal body function, and is typically caused by drinking
too much water and not consuming adequate salt-containing food.
Drinking only to treat thirst can prevent overhydration.
Symptoms include headache, weakness, fatigue, lightheadedness,
muscle cramps, nausea with or without vomiting, sweaty skin, nor-
mal core temperature, normal or slightly elevated pulse and respi-
rations, and a rising level of anxiety. These patients appear to have
heat exhaustion or heat stroke since the signs and symptoms overlap.
Treating it like heat exhaustion by just adding water will harm the
hyponatremia patient, making it worse. Increased severity of hypo-
natremia includes disorientation, irritability, and combativeness,
which gives the problem a more common name: water intoxication.

Untreated, the ultimate result will be seizures, coma, and death.
Note that heat-exhausted patients have a typically low output
of yellowish to brown urine (urinating every 6 to 8 hours) combined
with thirst. Hyponatremia patients urinate a clear stream frequently.
Hyponatremia patients deny thirst and will admit to drinking lots of
water.
Patients with mild to moderate symptoms and a normal mental
status may be treated in the field: The treatment for this condition is
rest in shade with no fluid intake (even sports electrolyte drinks) and
a gradual intake of salty foods while the kidneys reestablish a sodium
balance. The ideal treatment fluid would be an approximately 9% salt
solution, which would be the equivalent of 3 to 4 bouillon cubes in
1/2 cup (100 ml) of water. Once a patient develops hunger and thirst
combined with normal urine output, the problem is solved. Restric-
tion of fluids for someone who is well hydrated, fortunately, is harm-
less. Patients with an altered mental status require rapid evacuation
to a medical facility.
Heat Cramps
Salt depletion can result in nausea, twitching of muscle groups, and
at times severe cramping of abdominal muscles, legs, or elsewhere.
Treatment of heat cramps consists of stretching the muscles involved
(avoid aggressive massage), resting in a cool environment, and replac-
ing salt losses. Generally, 10 to 15 grams of salt (a pinch per quart)
and drinking to satisfy thirst should be adequate treatment.
Heat Exhaustion
Heat exhaustion is a classic example of compensatory shock (see page
13) and is encountered while working in a hot environment. The body
has dilated the blood vessels in the skin to divert heat from the core to
the surface for cooling. However, this dilation is so pronounced, cou-
pled with profuse sweating and loss of fluid (also a part of the cooling
process), that the blood pressure to the entire system falls too low
to adequately supply the brain and the visceral organs. The patient
will have a rapid heart rate and other findings associated with the
compensatory stage of shock: pale color, nausea, dizziness, headache,

and a lightheaded feeling. Generally, the patient is sweating profusely,
but this may not always be the case. The temperature may be elevated
but often is not at all.
Treat as for shock. Have the patient lie down immediately, elevate
the feet to increase the blood supply to the head, and restrict direct
sunlight and the hot environment. Provide copious amounts of water,
a minimum of 1 to 2 quarts (0.9 to 1.8 liters); lightly salted water
would be best. Obviously, fluids can be administered only if con-
scious. If the patient is unconscious, elevate the feet 3 feet (1 meter)
above head level and protect from aspiration of vomit. Give water
when the patient awakens.
Heat Stroke
Heat stroke (sun stroke) represents the complete breakdown of the
heat control process (thermal regulation) in the human body. With
the loss of the ability to sweat, core temperatures rise over 105°F
(40°C) rapidly and soon exceed 107.6°F (42°C), resulting in death
if not treated aggressively. This is a true emergency. It is a progres-
sive stage of shock. The patient will be confused, very belligerent, and
uncooperative, and will rapidly become unconscious. Immediately
move into shade or erect a hasty barrier for shade. Spray with water
or other suitable fluid and fan vigorously to lower the core tempera-
ture through evaporative cooling. Lacking other available fluid, this is
the one time in medicine when it may be justifiable to urinate on your
patient. Massage the limbs to allow the cooler blood of the extrem-
ities to return to core circulation more readily, and fan to increase
evaporative heat loss. Carefully monitor the core temperature and
cease cooling when it lowers to 102°F (39°C). The temperature may
continue to fall or suddenly rise again.
The most significant finding in heat stroke is the altered mental
status of the victim. While heat exhaustion victims can be confused,
this should resolve rapidly when they are in the shock treatment posi-
tion (head down, feet up). The confusion and very often belligerent
behavior of heat stroke victims make them very hard to handle. While
their skin is normally dry and hot, this is not always the case. Suspect
heat stroke in anyone who becomes confused and erratic in behavior,

or unconscious, during exercise in a hot environment.
This person should be evacuated as soon as possible, since his
thermal regulation mechanism is quite unstable and will remain so
for an undeterminable length of time. He should be placed under
a physician’s care as soon as possible. Return to the grid if possible.
Otherwise, treat as above.
Prickly Heat
Prickly heat is a heat rash caused by the entrapment of sweat in
glands in the skin. This can result in skin irritation and frequently
severe itching. Treatment includes cooling and drying the involved
area and avoiding conditions that may induce sweating for a while.
Providing several hours in a cool, dry environment daily is the only
reliable treatment for prickly heat, but you may treat for itch as indi-
cated on page 149.
LIGHTNING
Other than being totally toasted, cardiopulmonary arrest is the most
significant lightning injury. People who can scream from fright or
pain after an electrical bolt has struck are already out of immediate
danger. Their wounds may be dressed later. Those who appear dead
must have immediate attention, as they may be saved. Normally,
when dealing with mass casualties, the wounded are cared for pref-
erentially while the dead are left alone. Not in this instance! The vic-
tim is highly unlikely to die unless cardiopulmonary arrest occurs.
If cardiopulmonary arrest does happen, 75% will die unless CPR is
performed. As the heart tends to restart itself due to its inherent abil-
ity (automaticity), the heartbeat may return spontaneously in a short
time. However, the respiratory system may be shut down for 5 to 6
hours before being able to resume its normal rhythm. Lack of oxygen
will cause a person whose heart has restarted spontaneously to die.
When administrating CPR, take precautions with the cervical
spine, as the explosion may have caused fractures of the neck or other
portions of the body. While CPR is being performed, check for the
pulse periodically. When the heart restarts, maintain ventilations for
the patient until respirations also resume. Attempt to continue this as

long as possible; a victim may be revived even after many hours with
no neurological defects—but only if CPR or respiration ventilation has
been properly performed. Remember, after a lightning strike the vic-
tim’s eyes may be fixed and dilated, respirations ceased, heart stopped,
blood pressure 0/0—all signs of clinical death. Pay no attention to
these findings and administer CPR as long as physically possible.
Lightning strike frequently causes vascular spasms in its victim.
This can result in faint, or even nonpalpable, pulses. When the vaso-
spasm clears, which it generally does within a few hours, the pulses
return.
Neurological defects are the second major consequence of light-
ning hits. Approximately 72% of victims suffer loss of consciousness,
and three-quarters of these people will have a cardiopulmonary arrest.
Direct damage to the brain can result, but frequently the neurological
defects, including seizure activity and abnormal brainwave studies,
eventually revert to normal. Two-thirds of victims will have neuro-
logical defects in the lower half of their bodies; one-third will suffer
from paralysis of the upper half. Amnesia and confusion of events
after the accident are common but are usually transient.
Most will have amnesia, confusion, and short-term memory loss
that may last from 2 to 5 days. These effects are similar to those expe-
rienced by electroconvulsive shock therapy patients. The person may
be able to talk intelligently but shortly thereafter not remember the
conversation had taken place.
Burns from lightning itself are generally not severe. Very high
voltage is carried over the surface of conductors; the high voltage of
lightning is similarly carried over the surface of the body with mini-
mal internal burn damage, the so-called flashover effect.
Direct electrical burn damage can occur, however, and when it
does it usually consists of one of several types. Linear burns start at
the head, progress down the chest, and split to continue down both
legs. These burns are usually 1/2 to 11/2 inches (1.3 cm to 3.8 cm) in
width, and are first and second degree. They follow areas of heavy
sweat concentration. Punctate burns look like a buckshot wound.
These are full thickness, third-degree burns that are discrete, round
wounds, measuring from a few millimeters to a centimeter (¼ inch

to ½ inch) in width. These seldom require grafting as the area is so
small. Feathering or ferning burns are diagnostic of lightning injury.
They fade within a few hours to days and require no treatment. This
phenomenon is not a true burn but the effect of electron showers
on the skin. They have a characteristic reddish fern appearance that
covers the skin surface—especially the trunk. Thermal burns also
result from vaporization of surface moisture, combustion of clothing,
heated metal buckles, and so on. Thermal burns are the most common
type of lightning-associated burn, and they can be first, second, or
third degree.
The flashover effect saves most victims from burn trauma. How-
ever, as noted, burns do occur. Persons with head burns are two and a
half times more likely to die than those without. Possibly more sur-
prising, persons with leg burns are five times more likely to die than
those who do not have them. This is probably related to a ground or
step current phenomenon.
The four mechanisms of direct lightning injury are: (1) direct
strike, (2) splash, (3) step current, and (4) blunt trauma. To minimize
the chance of lightning injury, the following should be noted about
these mechanisms:
1. Direct strikes are most likely to take place in the open,
especially if you carry metal or objects above shoulder level.
Shelter should be taken within the cone of safety, described
as a 45-degree angle down from a tall object, such as a tree
or cliff face. But that cone of safety ain’t all that safe. Being
too close to the tree or cliff face can result in increased
exposure to splash current or ground current; too near the
outer edge and the zone of safety simply fails and you have
increased exposure to direct strike.
2. Splash injuries are perhaps the most common mechanism
of lightning hit—the current strikes a tree or other object
and jumps to a person whose body has less resistance than
the object the lightning initially struck. Splash injuries
may occur from person to person, when several people are
standing close together. It has jumped from fences after

having struck the fence some distance away. It has splashed
to people from plumbing fixtures inside houses that were
struck. Avoid close proximity to walls, fences, plumbing, or
other items that could be struck.
3. Step current is also called stride voltage and ground current.
The lightning current spreads out in a wave along the
ground from the struck object, with the current strength
decreasing as the radius from the strike increases. If the
victim’s feet are at different distances from the point of
the strike, and the resistance in the ground is greater than
through his body, he will complete a circuit. Large groups
of people can be injured simultaneously in this manner.
Keeping feet and legs together, while squatting down,
minimizes the chances of step voltage injury.
4. Blunt trauma, or the sledgehammer effect, results from the
force of the lightning strike, or the explosive shock wave
that it produces. The victim may be forcibly knocked to
the ground. Over 50% of victims will have their eardrums
ruptured in one or both ears. This may result from direct
thermal damage, the thunder shock wave, or even skull
fractures from the blunt trauma. Barotrauma to the ears may
be reduced by keeping the mouth open during times of great
danger.
In the above scenario a person should squat, with legs together
and mouth open in a zone of safety—but not too near the protec-
tive tree or cliff face. Spread party members out to maximize the
chance that there will be survivors, and thus rescuers, if lightning
strikes appear imminent. Get boats into a zone of safety near shore,
against the tree line or cliff face. Other than the immediate presence
of lightning, is there any warning? At times there will be the smell of
ozone, hair may stand on end, metal climbing equipment may start to
vibrate, or St. Elmo’s fire may be present. Good luck!
HIGH ALTITUDE ILLNESSES

You will not need to worry about high altitude illness of any kind
unless you must depart suddenly from a lower attitude and head for
the hills—the high hills, that is. High-altitude-related illnesses can
generally be avoided by gradual exposure to higher elevation, with
the sleeping ascent rate not exceeding 1,000 feet (300 meters) per day
when above 9,000 feet (2,800 meters). Alternatively, avoid sleeping at
greater than 2,000-foot (600-meter) increments every 2 days when
suddenly traveling from near sea level to 10,000 feet (3,000 meters).
A high carbohydrate diet, consisting of at least 70% carbohydrates
started 1 to 2 days prior to ascent, remaining well hydrated, and exer-
cising moderately until altitude acclimatized, all help prevent high
altitude illness.
The three major clinical manifestations of this disease complex
are acute mountain sickness (AMS), high altitude pulmonary edema
(HAPE), and high altitude cerebral edema (HACE). As will be
noted, the symptoms progress rather insidiously. They are not clear-
cut, separate diseases—they often occur together. The essential ther-
apy for each of them is recognition and descent. This is lifesaving and
more valuable than the administration of oxygen or drugs. To prevent
high altitude illnesses, it is helpful to “climb high but camp low”—
that is, spend nights at the lowest camp elevation feasible.
Acute Mountain Sickness (AMS)

Rarely encountered below 6,500 feet (2,000 meters), acute moun-
tain sickness is common in persons going above 10,000 feet (3,000
meters) without taking the time to acclimatize for altitude. Symp-
toms beginning soon after ascent consist of headache (often severe),
nausea, vomiting, shortness of breath, weakness, sleep disturbance,
and occasionally a periodic breathing known to medical personnel as
Cheyne-Stokes respiration.
Prevention, as with all of the high altitude illnesses, is gradual
ascent above 9,000 feet (2,800 meters) and light physical activity for
the first several days. For persons especially prone to AMS, it may
be helpful to take acetazolamide (Diamox) prophylactically, 125 mg
every 12 hours starting the day of ascent and continuing the next 3 to
5 days. This medication helps prevent or treat the acid base imbalance
of the blood that can occur in some people from the increased loss of
carbon dioxide at high altitudes. The treatment dose of acetazolamide
is 250 mg twice daily for 5 days. This prescription drug should be
added to your medical kit if you expect to encounter elevations above
9,000 feet (2,800 meters) suddenly. See acetazolamide, page 265.
The best AMS treatment is descent, and relief can often be felt
even if the descent is only 2,000 to 3,000 feet (600 to 900 meters).
Full relief can be obtained by descending below 6,500 feet (2,000
meters). Stricken individuals should avoid heavy exercise, but sleep
does not help as breathing is slower during sleep, making oxygen
deprivation worse. Oxygen will help only if taken continuously for
12 to 48 hours. Aspirin may be used for headache. Percogesic or ibu-
profen from the Non-Rx Oral Medication Module may be used. In
addition to descent, Decadron (dexamethasone), 4 mg tablets every
6 hours until below the altitude at which symptoms appeared, has
been shown to help control the symptoms of AMS. Decadron tab-
lets or injection should be added to your medical kit if you expect to
encounter elevations above 10,000 feet (3000 meters). See Decadron,
pages 284 and 290.
High Altitude Pulmonary Edema (HAPE)

High altitude pulmonary edema is rare below 8,000 feet (2,500
meters) but occurs at higher altitude in those who are poorly accli-
matized. It is more likely in persons between the ages of 5 and 18 (the
incidence is apparently less than 0.4% in persons over 21, and as high
as 6% in those younger), in those who have had this problem before,
and in those who have been altitude acclimatized and who are return-
ing to high altitude after spending approximately 2 weeks at sea level.
Prevention is altitude acclimatization as discussed in the section
on AMS above. Nifedipine (Procardia), 20 mg every 8 hours to be
taken during the ascent phase and for 3 additional days at altitude,
has been shown to work prophylactically.
Symptoms develop slowly, within 24 to 60 hours of arrival at high
altitude, with shortness of breath, irritating cough, weakness, rapid
heart rate, and headache that rapidly progress to intractable cough

with bloody sputum, low-grade fever, and increasing chest conges-
tion. Symptoms may progress profoundly at night. Patients should be
evaluated by listening to their chests for a fine crackling sound (called
rales) and checking resting pulse rate nightly. A pulse rate of greater
than 110 per minute, or respirations greater than 16 per minute after
a 20-minute rest, is an early sign of HAPE. Respirations over 20 per
minute and pulse over 130 per minute indicates a medical emergency,
and the patient must be evacuated immediately. Without treatment,
death usually occurs within 6 to 12 hours after onset of coma.
Descent to lower altitude is essential and should not be delayed.
Treatment includes nifedipine, 20 mg sublingual (or chewed and
swallowed), given upon diagnosis and repeated every 6 hours. A
descent of as little as 2,000 to 3,000 feet (600 to 900 meters) may
result in prompt improvement.
High Altitude Cerebral Edema (HACE)

High altitude cerebral edema is less common than AMS or HAPE,
but it is more dangerous. Death has occurred from HACE at alti-
tudes as low as 8,000 feet (2,500 meters); however, HACE is rare
below 11,500 feet (3,500 meters). The symptoms are increasingly
severe headache, mental confusion, emotional behavior, hallucina-
tions, unstable gait, loss of vision, loss of dexterity, and facial muscle
paralysis. The victim may fall into a restless sleep, followed by a deep
coma and death.
Descent is essential. Oxygen should be administered starting at
6 liters/minute for the first 15 minutes, followed by a flow rate of
2 liters per minute. Decadron (dexamethasone) should be given in
large doses, namely 10 mg intravenously, followed by 4 mg every 6
hours intramuscularly until the symptoms subside. Response is usu-
ally noted within 12 to 24 hours, and the dosage may be reduced after
2 to 4 days and gradually discontinued over a period of 5 to 7 days.
Immediate descent and oxygen are recommended to prevent perma-
nent neurological damage or death.
It is hard to imagine how a person planning on suddenly leaving
the grid would require such a rapid ascent in altitude as to endanger
themselves from an altitude-related injury. But I have included this

abbreviated discussion, because that is what prepping is all about,
being prepared for any circumstance.
CHAPTER 11
The OFF-GRID MEDICAL KIT
ALTERNATIVE AND HERBAL THERAPY

Alternative therapy in the context of this book is not therapy pre-
scribed by an osteopathic or allopathic physician—in other words,
not by the usual medical system you have contact with throughout
the grid.
It is not so “alternative” for many. Common household reme-
dies that have stood the test of time are in this category. Some more
ancient, yet probably effective, are also included. I am a traditional
MD-type of doctor. I prefer proven, rigorously studied, outcome-
based protocols to the case-study-influenced or historic, traditional
healing folklore remedies, but there is a place for both when off the
grid. Depending on the issue of being off the grid, or working after
there is no grid, even the greatest achievements of big pharma will do
us no good when their products are not available. Due to my many
years of working in third-world countries and in remote wilderness
situations, certainly off the grid in many regards, I have studied the
best of the traditional remedies, and while I prefer many more proven
methods, I list them throughout this book as alternative therapies
when you are off the grid.
First, what can we bring with us from the grid? What is the most
valuable? How do we obtain them?
With each item we must consider if we are doing a grab and go
or staying put. If the former, can we reposition or stockpile items in a
secure area, or is this not practical? What items are perishable, and do
items have a realistic shelf-life?
To start this process, try to obtain the items in the Off-Grid

Medical Kit. This section indicates that many are easily obtained
over-the-counter medications and items, but some components of
this kit are prescription—when used on humans. Some of these same
items are available without prescriptions when purchased through pet
stores for use on fish, for example.
While it seems it would be of interest to the reader to have a
whole chapter devoted to alternative or folklore therapy, it would be
of no real use except as a reassurance that the items you see being used
are not something you need to consider beyond your normal provi-
sioning. In other words, for the alternative therapies to be of potential
use to you, they have got to be something you can improvise from
stuff that is just lying around long after the grid is gone, items you
did not consider beyond the normal necessities of life or knew that
you could scrounge. In fact, herbal medicine is the earliest scrounging
that humankind has endeavored, other than predator-killed carrion
that prehumans scavenged.
Throughout this book you will be advised when an item from the
Off-Grid Medical Kit should be used and how to use it. Additionally,
an alternative or field-expedient technique will be discussed to aid
you during those moments when the support kit supplies are lacking.
The most compact kit will also be the one that contains both mul-
tifunctional and cross-functional components. This requires the min-
imal number of medications but provides in-depth coverage when a
particular medication is consumed.
Taking the above into account, study the potential first aid mate-
rial requirements, anticipate the most likely serious events that could
conceivably occur, and tailor the kit to the medical skill level of the
participants. Additional factors to consider are the weight, cost, bulk,
and availability of components. Consider the number in the party,
length of survival situation, degree of risk anticipated, and whether
or not other people beyond those of the immediate party will be
treated.
When companies design commercial kits, two additional factors
must also be considered. One is what real estate agents call “curb
THE OFF-G RID MEDICAL KIT 271
appeal.” It must look impressive at first glance. The other is to plan for
various price points to target different markets. These constraints give
commercial kits a disadvantage over the kit you put together yourself.
Most injuries and conditions described in this book can be treated
with very little in the way of kit components. But I have included
here state-of-the-art items that would provide ideal treatment aid.
As this book has been written for those who may be isolated without
ready access to professional medical care, the treatments discussed go
beyond normal first aid. The kit described in this chapter similarly
goes beyond what would be considered a “first aid” kit, but the initial
modules are easily usable under first aid conditions. The Off-Grid kit
consists of 5 units: Topical Bandaging Module, Non-Rx Oral Medi-
cation Module, Rx Oral/Topical Medication Module, the Rx Inject-
able Medication Module, and the Rx Cardiac Medication Module.
The Off-Grid kit is further divided with suggestions for components
of a “bug-out bag,” items to carry in an emergency when needing to
vacate your normal location, and for long-term stockage for your “set-
tlement stock” with both one-year and five-year quantity suggestions.
As a minimum, the Topical Bandaging Module and Non-Rx Oral
Medication Module will generally fulfill the vast majority of emer-
gency treatment requirements. The prescription modules are designed
for long-term and more advanced patient care. All items listed in the
kit modules can be obtained without a prescription, except in the
modules clearly marked “Rx.”
All nonprescription medications have packaging that describes
the official dosages and appropriate warnings or precautions concern-
ing their use. Prescription medications usually have elaborate package
inserts with this same information. When obtaining a prescription
drug for your medical kit, request this insert from your physician or
copy the information from the Physicians’ Desk Reference (PDR) or
from the Tarascon Pharmacopoeia, which are available at libraries and
even as smartphone apps.
All items should be obtained in stock bottles, which usually
come in 90 or 100 count. Stock bottles of the items listed should last
at least 5 to 10 years beyond their expiration date. Some medications
listed are too expensive for a stock bottle or need to be ordered indi-
vidually, such as the injection medications. Obtain what you can;
having more than you require could prove useful if the grid col-
lapses, as these items will be invaluable and might be useful in barter
circumstances.
The quantities of all items can be split into minimal amounts that
would be included in a bug-out bag lasting 2 to 3 weeks. Because
the suggested list includes items with multifunctional capability (i.e.,
the item can be used for more than one purpose) and items with
cross-functional uses (i.e., one purpose can be treated by several of
the items), the quantities of items in the kit can be reduced. Cost is
also a factor in recommending products. When significant treatments
are required, such as implementing the use of antibiotics, the patient
should be evacuated if possible. A patient with any injury, symptom,
or infection that does not improve within 48 hours should be evac-
uated to definitive medical care. For those of you preparing for a sit-
uation where evacuation is unlikely or impossible, evaluate the stock
requirements and plan accordingly.
Most medications will have an expiration date of 1 to 5 years
from the date of purchase. The expiration dates have been calculated
to guarantee the product will not have degraded more than 3% of the
active ingredient. A study has reported that an evaluation of eight
products stored in their original containers for 28 to 40 years past
their expiration date retained greater than 90% of their potency. Stor-
age affects shelf-life—generally heat and sunlight degrade products,
but a study released in 2019 in Wilderness & Environmental Medicine
evaluated a wide range of items that were stored in very unfavorable
conditions over a year beyond expiration date and were found to have
lost none of their potency.
Aspirin does degrade rather fast and will soon smell like vinegar,
indicating it is losing potency. Epinephrine solution turns brown as it
degrades into norepinephrine, which fortunately is an active metab-
olite but works to a lesser degree in treating anaphylaxis. Avoid cap-
sules and choose tablets, since the former are very sensitive to heat
and dampness. Liquids usually degrade faster than solids.
Brand names have been used to simplify spelling and product recognition or to
minimize potential confusion between similar-sounding names and variations in
generic names among American, Canadian, and British sources. Prepper blogs are a
great avenue to find sourcing of many products that are otherwise available only via
traditional physician prescriptions. Some items can be purchased from international,
agricultural, or aquarium vendors. Always give the Internet a shot at it.
4 Alternative improvisation. Alternatives to the use of the medications listed below

are outlined in the treatment discussions for various problems throughout the book.
Alternatives to medical supplies are also discussed below and are indicated by a
check mark. Further, obtain the book Medicinal Plants of North America, 2nd edition,
by Jim Meuninck, for a color-illustrated and concise book to help you identify and use
herbal and plant remedies. See also my discussion on other useful references in The
Preppers Medical Resource Bookshelf (page 298).
Topical Bandaging Module

Spenco 2nd Skin burn dressing kit
Gauze, high absorbent, sterile, 2-ply, 3" x 3", pkg/2, 2 pkg
QuikClot Combat Gauze
Coverlet bandage strips, 1" x 3"
Adhesive tape, waterproof, 1" x 15'
SAM Splint, 36"
Elastic bandage, 2" wide
Maximum-strength triple antibiotic ointment with pramoxine, 1 oz tube
Hibiclens surgical scrub
Opcon-A ophthalmic drops
Hydrocortisone cream 1%, 1 oz tube
Clotrimazole cream 2%, 1⁄2 oz tube
Cavit dental filling paste
Dental supplies as indicated in chapter 5
Protective gloves, nitrile
Irrigation syringes, 30 ml
Surgical kit consisting of 1 needle holder, Adson tissue forceps (1 with
teeth, one without), 3-0 Ethilon sutures, 5-0 Ethilon sutures, and 3-0
gut (dissolvable) sutures
SPENCO 2ND SKIN

Bug-out bag (2 weeks) Settlement stock (1 year) (5 years)
Quantity 1 kit 5 kits 0 (will not
store well)
Truly a major advance in field medicine. This inert hydrogel consists

of 96% water and 4% polyethylene oxide. It is used on wet, weeping
wounds to absorb fluids and protect the injury. This is a perfect pre-
vention or cure for friction blisters. It revolutionized the field treat-
ment of first-, second-, and third-degree burns, as it can be applied
to all three as a covering and for pain relief. This item should be in
every medical kit. The ideal covering pad is the Spenco Adhesive Knit
bandage. If used in treating blisters, remove only the outer covering of
cellophane from the 2nd Skin, cover with the Adhesive Knit bandage,
and occasionally dampen with clean water to maintain the hydrogel’s
hydration. It will last a lot longer this way when in short supply. There
are a variety of similar dressings sold in virtually all drugstores that
are labeled as such.
4 The cooling technique for burns (see page 139) and a piece of tape
over hot spots (see page 138) can simulate the benefits of Spenco 2nd
Skin. Cellophane, plastic food wrappers, or plastic sheeting of any
kind makes an excellent wound covering. When held down with tape
of any type, a cellophane dressing is nonadherent and seepage leaks
from the unsealed edges. The wound can be observed through the
cellophane, and the increased and appropriate moisture level of the
dressing increases the rate of wound healing.
HEMOSTATIC DRESSINGS
Quantity 2 packages 5 packages 10 packages
There are now three hemostatic dressings approved by the military.

Since the addition of QuikClot Combat Gauze (Z-Medica Corpo-
ration, Wallingford, CT, USA; www.quickclot.com) in April 2008 to
the Tactical Combat Casualty Care (TCCC) Guidelines, and based

on the recent battlefield success, Celox gauze (Medtrade Products
Ltd., Crewe, UK; www.celoxmedical.com), and ChitoGauze (Hem-
Con Medical Technologies, Portland, OR, USA; www.tricolbio-
medical.com) have been added. When used they must be placed over
the wound on top of the bleeding vessel, not on top of other bandage
material. Direct pressure must be applied continuously for a mini-
mum of 5 minutes or as per the manufacturer’s recommendation.
QuikClot Combat Gauze has an “official” shelf life of 2 years.
4 Gauze dampened with epinephrine or nasal decongestant can help
decrease oozing blood.
NU GAUZE PADS
Quantity 4 each sterile wrap 100 500
Johnson & Johnson has developed a gauze that is 2-ply yet absorbs
nearly 50% more fluid than conventional 12-ply gauze pads. This
may not seem important until a rapidly bleeding wound needs care.
For years J&J has made a Nu Gauze strip packing dressing; the Nu
Gauze pads are a completely different material. They are a wonderful
advance in gauze design.
4 Cotton T-shirts or other clothing; bandannas
COVERLET BANDAGE STRIPS

Quantity 6 100 500
A Beiersdorf product, these common 1" x 3" bandage strips are the
best ones made. They stick even when wet, will last through days of
hard usage, stretch for compression on a wound, and conform for
better application.
4 Duct tape, climbing tape
WATERPROOF ADHESIVE TAPE

Quantity 1 roll 10 rolls 10 rolls; easy
to substitute
for
This tough tape can be used for splinting or bandage application.

There are no brand advantages that I can determine. A 1" x 15' roll
on a metal spool is a usable size.
4 Duct tape, climbing tape
SAM SPLINT
Quantity 1 3 (reusable) 5 (reusable)
This padded, malleable splint provides enough comfort to be used as

a neck collar. It is adequately rigid to splint any extremity as well as
universal, so that only one of these need be carried for all splinting
needs. This item replaces ladder splints, etc. I never recommended the
inclusion of splints in medical kits until this product was developed.
It weighs less than 5 ounces.
4 Malleable splints can frequently be made from stays found in
internal backpack frames. Other stiff materials can also be used, such
as strips of Ensolite foam pads or inflatable pads, held in place with
tape or torn cloth.
ELASTIC BANDAGES
Quantity 1 each 3" roll 6 of each size roll 12 of each
size roll
Elastic bandage 2"

Elastic bandage 3"
Elastic bandage 6"
Obtain good-quality bandages that stretch without narrowing and

that provide firm, consistent compression.
4 Elastic bandages can be replaced with almost any cloth that is
firmly wrapped in place. Usually the most stretchy form of cloth
available is a cotton T-shirt.
MAXIMUM-S TRENGTH TRIPLE ANTIBIOTIC OINTMENT

WITH PRAMOXINE, 1 OZ TUBE
Quantity 1 tube 12 tubes 36 tubes
Each gram of this ointment contains bacitracin, 500 units; neomycin

sulfate, 3.5 mg; polymyxin B sulfate, 10,000 units; and the anesthetic
pramoxine hydrochloride, 10 mg. For use as a topical antibiotic in the
prevention and treatment of minor infections of abrasions and burns,
this formulation also is an anesthetic that numbs the skin. A light
coat should be applied twice daily. Neomycin can cause skin rash and
itch in some people. If this develops, discontinue use and apply the
hydrocortisone cream to counter this effect.
4 Honey or granulated sugar placed on wounds is painless and kills
germs by dehydrating them. A strong sugar solution draws the fluid
from the bacteria, but human cells are able to actively avoid the dehy-
dration process and are not injured with this technique.
LANACANE CREAM
Quantity 0 tubes 6 tubes 18 tubes
This brand-name cream is used to treat burns, hemorrhoids, and

reduce the itch of insect bites and stings. This product consists of ben-
zocaine (20%) as an anesthetic and benzethonium chloride (0.2%) as
an antiseptic.
HIBICLENS SURGICAL SCRUB, 4 OZ BOTTLE

Quantity 0 1 pint 5 pints
This Mölnlyce Health Care product (chlorhexidine gluconate 4%) far

surpasses hexachlorophene and povidone-iodine scrub with regard
to its antiseptic action. The onset and duration of its action is much
more impressive than either of those two products.
4 Many surgical scrubs are available without prescription and are
ideal for use, but they can all be replaced with potable (drinkable)
water irrigation. Remember, “the solution to pollution is dilution.”
OPCON-A OPHTHALMIC DROPS

Quantity 1 bottle 12 bottles 24 bottles
This product is a combination of naphazoline (0.0267%) and phe-

niramine maleate (0.315%) made by Bausch and Lomb. These eye
drops are used for allergy relief, to remove redness, and to alleviate
discomfort from smoke, eye strain, and so on. They will not cure
infection or disguise the existence of a foreign body. Place 1 drop in
each eye every 6 hours.
4 Rinse eyes with clean water. A wet, cold compress relieves eye itch
and pain.
HYDROCORTISONE CREAM 1%, 1 OZ TUBE

Quantity 1 24 48
This non-Rx steroid cream treats allergic skin rashes, such as those
from poison ivy. A cream is ideal for treating weeping lesions, as
opposed to dry scaly ones, but will work on either. For best results,
cover with an occlusive dressing (plastic cover) overnight.
4 Blistery rashes can be soothed and the leaking fluid dried by apply-
ing a cloth made wet with concentrated salt solution.
CLOTRIMAZOLE CREAM 2%, ½ OZ TUBE

Quantity 0 12 36
This is one of the most effective antifungal preparations available for

foot, groin, or other body fungal infections. Brand names are Lotrimin
and Mycelex (vaginal cream). The vaginal cream in a 2-ounce tube is
less expensive and works well on the skin surface as well as vaginally.
4 Dry, itchy lesions of any type respond to a soothing coating of
cooking oil.
CAVIT DENTAL FILLING PASTE

Quantity 0 3 12
Use this for temporarily filling cavities and repairing broken bridge-
work. Without being able to drill out the underlying decay, the cavity
will need to be seen as soon as possible by a dentist for proper care or
an abscess may form.
4 Use oil of cloves (eugenol) to line the cavity for pain relief. A mix-
ture of zinc-oxide powder (not the ointment) and oil of cloves, made
up as a thick paste, can also be used as a temporary filling.
PROTECTIVE GLOVES
Quantity 0 to 1 pair 2 dozen 2 dozen (do
not store well)
Due to concerns with blood-borne pathogens (e.g., hepatitis B and

C and HIV), it is prudent to carry protective gloves for first aid use.
These can be nonsterile (they are readily sterilized by boiling or treat-
ing with antiseptics). Vinyl gloves will last much longer in a kit than
latex gloves, but the best are nitrile gloves.
4 Use an empty food bag or waterproof stuff sack as a glove, or wrap
your hand in the most waterproof material available.
IRRIGATION SYRINGE
Quantity 0 1 2 dozen (do
not store well)
Required for forceful irrigation of wounds, the best has a protec-

tive spray shield, such as the Zerowet Splashshield ; otherwise, wear
glasses to protect your eyes from splash contamination.
4 The solution to pollution is dilution. Forceful irrigation is the best
method for cleaning a wound and diluting the germ count enough so
that the body’s immune system can kill the remaining germs. With-
out a syringe, augment the volume of water you are pouring on the
wound with a brisk scrubbing action using a soft, clean cloth.
SURGICAL KIT

Quantity
Needle 0 1 1
holder
Adson w/ 0 1 1
teeth
Adson w/o 0 1 1
teeth
3-0 Ethilon 0 12 24
sutures
5-0 Ethilon 0 12 24
sutures
3-0 gut 0 6 12
sutures
Consisting of 1 needle holder, 1 Adison forceps with teeth and 1

without teeth, 3-0 Ethilon sutures, 5-0 Ethilon sutures, and 3-0 gut
sutures. The 3-0 and 5-0 sutures should have 3/8 circle, cutting needles.
The gut sutures are best placed with a half circle for use potentially
within the mouth.
4 Many surgical kits are available online, including practice kits.

Once in the field, butterfly bandages can be fashioned from tape as
described on page 126. Lacking other means of fastening gaping
wounds together, use the technique of open packing the wound with
a wet-to-dry dressing described on page 122.
Non-Rx Oral Medication Module

Percogesic tablets (pain, fever, muscle spasm, sleep aid, anxiety,
congestion, cough, and nausea)
Ibuprofen 200 mg tablets (pain, fever, bursitis, tendonitis, menstrual
cramps)
Diphenhydramine 25 mg tablets (antihistamine, anti-anxiety, cough,
muscle cramps, nausea, motion sickness prevention)
Bisacodyl 5 mg tablets (constipation)
Loperamide 2 mg tablets (diarrhea)
Ranitidine 150 mg tablets (heartburn, certain allergic reactions)
4 Alternatives to the use of these medications are discussed in the

treatment options throughout the book. Each medication is multi-
functional and also has cross-therapeutic versatility. This means that
each item can be used for more than one problem, and problems have
more than one drug that can be used as treatment. This allows a min-
imal number of medications to be carried, yet provides depth of cov-
erage if one medication is in short supply.
PERCOGESIC TABLETS
Quantity 12 tablets 200 tablets 500 tablets
Relieves pain, fever, and muscle spasm. Each tablet contains 325 mg
of acetaminophen and 12.5 mg of citrate diphenhydramine. Ideal
for injuries of joints and muscles, as well as aches from infections.
Diphenhydramine is also a decongestant and cough suppressant. It
also induces drowsiness and can be used as a sleeping aid or to calm
a hysterical person (these indications are not included on the pack-
aging information). Dosage is generally 2 tablets every 4 hours as
needed. One of the most useful non-Rx drugs obtainable.
IBUPROFEN TABLETS, 200 MG

Quantity 12 tablets 500 tablets 2,000 tablets
Brand names are Advil, Nuprin, and Motrin, among others. Relieves
pain, fever, menstrual cramps, and inflammation. Overuse syndromes
such as bursitis and tendonitis are common in work-related activities,
and this is an ideal treatment. The non-Rx dosage is 2 tablets 4 times
a day. Should be taken with food to prevent stomach irritation or
heartburn. The Rx dosage is 4 tablets taken 4 times daily, a dose that
may be necessary for severe inflammation.
DIPHENHYDRAMINE TABLETS, 25 MG
Quantity 0 (use Percogesic) 500 2,000
The brand name is Benadryl; many variations are sold containing

more ingredients than just the diphenhydramine. For antihistamine
action, these capsules can be taken 1 or 2 every 6 hours. To use as
a powerful cough suppresser, the dose is 1 tablet every 6 hours. For
muscle spasm relief, take 1 or 2 tablets at bedtime alone, or in combi-
nation with 2 ibuprofen 200 mg tablets. For nausea or motion sick-
ness, take 1 tablet every 6 hours as needed. For sleep induction take 1
or 2 tablets just before going to bed. The Percogesic included in this
module also contains diphenhydramine.
BISACODYL TABLETS, 5 MG
Quantity 0 100 300
This laxative works on the large bowel to form a soft stool within 6
to 10 hours. Use 1 tablet as needed. It is very gentle, so do not expect
rapid results. The brand-name product’s motto is “Take one in the
PM for a BM in the AM.”
LOPERAMIDE TABLETS (2 MG)

Quantity 12 200 500
An antidiarrheal with the brand name of Imodium. Dosage for per-

sons 12 and older is 2 tablets after the first loose bowel movement,
followed by 1 tablet after each subsequent loose bowel movement,
but no more than 4 tablets a day for no more than 2 days. The pre-
scription use of this medication is usually 2 tablets immediately, and
2 with each loose stool up to a maximum of 8 per day. Follow the
package instructions for children’s dosages.
RANITIDINE TABLETS, 150 MG

Quantity 12 500 2,000
Brand name is Zantac. This medication suppresses acid formation.

It may also be used to treat certain allergic reactions. The non-Rx
dosage is 1 tablet daily. Prescription use goes as high as 300 mg
daily for acid suppression. Stronger formulations of medications are
available to treat stomach heartburn and reflux symptoms, such as
the PPI class of compounds including OTC omeprazole (Prilosec),
lansoprazole (Prevacid), and espmeprazole (Nexium). If you have
severe problems with these conditions, substitute them for raniti-
dine (Zantac).
The Off-Grid medical kit also includes prescription modules.
Prescription items can properly be requested from your family phy-
sician or from a physician who understands your special needs as a
prepper. There are alternative sourcing possibilities. Many items can
be purchased internationally via the Internet. Some materials may
be obtained from aquarium stores or agricultural outlets. As these
sources maybe “moving targets,” the best advice is for you to check
prepper blogs and websites for the latest sourcing suggestions.
Rx Oral/Topical Medication Module

Doxycycline 100 mg tablets (antibiotic)
Zithromax 500 mg tablets (antibiotic)
Levaquin 500 mg tablets (antibiotic)
Diflucan 150 mg tablets (antifungal)
Norco 10/325 tablets (pain, cough)
Atarax 25 mg tablets (nausea, anxiety, antihistamine, pain
medication augmentation)
Mobic (meloxicam) 15 mg tablets (pain medication, anti-inflammatory,
fever)
Topicort 0.25% ointment, 1⁄2 oz tube (skin allergy)
Tobradex ophthalmic drops, 2.5 ml (eye and ear antibiotic,
anti-inflammatory)
Tetracaine ophthalmic solution 0.5%, 15 ml bottle (eye and ear
anesthetic)
Denavir (penciclovir) cream 1%, 5 gm tube (antiviral, lip and mouth
sores)
Stadol nasal spray (severe pain)
Diamox 250 mg tablets (acute mountain sickness prevention)
Decadron 4 mg tablets, 10 per trip (allergy, acute mountain sickness,
specific trauma situations)
Flagyl 250 mg, 16 capsules (trichomonas or giardia infection)
Famvir 500 mg, 24 per person with history of herpes simplex cold
sores, especially if going to altitude or expecting significant
ultraviolet light exposure
Malarone adult dose: atovaquone 250 mg + proguanil 100 mg;
pediatric dose: atovaquone 62.5 mg + proguanil 25 mg (malaria
protection)—only if planning on going into a malaria infected area.
DOXYCYCLINE TABLETS, 100 MG

Quantity 14 200 1,000
The generic name of an antibiotic that is useful in treating many

travel-related diseases. The various sections of the text dealing with
infections will indicate the proper dosage, normally 1 tablet twice
daily. Not to be used in children 8 years or younger, or during preg-
nancy. May cause skin sensitivity on exposure to sunlight, thus pro-
ducing an exaggerated sunburn. This does not usually happen, but be
cautious during your first sun exposure when on this product. Many
people traveling in the tropics have used this antibiotic safely. Very
useful in malaria prevention at a dose of 1 tablet daily, but this must be
continued for 4 weeks after leaving the contact area. Common brand
names are Vibramycin, Vibra-Tabs, Doryx, Doxycin, and Monodox.
ZITHROMAX TABLETS, 500 MG

Quantity 0 60 180
This is the brand name of azithromycin, a broad-spectrum antibiotic

used to treat certain types of pneumonia, infected throats, skin infec-
tions, and venereal diseases due to Chlamydia trachomatis or Neisse-
ria gonorrhoeae, and genital ulcer disease in men due to Haemophilus
ducreyi (chancroid). Dosage is 1 tablet daily for 3 days. These 3 tablets
result in a therapeutic blood level for the next 7 days, thus providing
a total of 10 days of coverage.
LEVAQUIN TABLETS, 500 MG

Quantity 0 60 180
A broad-spectrum antibiotic of a group known as fluoroquinolones,

this medication is useful in treating diarrhea and organisms resis-
tant to the above antibiotics. It is useful in treating sinus infections,
bronchitis, pneumonia, skin infections and skin ulcers, and compli-

cated urinary tract and kidney infections. Avoid excessive sun expo-
sure while on this medication. Avoid in persons under the age of 18,
and during nursing and pregnancy. Drink extra water when on this
medication. Do not take with antacids, vitamins containing minerals,
and ibuprofen; otherwise it may be taken at mealtimes. Some peo-
ple are made dizzy by this medication. There is a possibility that it
might cause tendonitis and should be stopped if muscle pain or ten-
don inflammation occurs, as a tendon rupture may result. While used
to treat diarrhea, it may cause diarrhea, and it may result in vaginal
monilia infection.
DIFLUCAN TABLETS, 150 MG

Quantity 0 48 120
One tablet of this medication is taken to eliminate vaginal yeast (can-

didiasis) infection. These infections are at greater risk after taking
broad-spectrum antibiotics, as they can suppress normal, healthy bac-
teria in the vagina. Tropical conditions are also a risk factor in devel-
oping this condition. While this medication often reacts with other
medications, none are included in the Off-Grid Medical Kit, and
short-term use of 1 pill will normally not be significant regardless.
The most common side effects are headache, nausea, and cramping.
NORCO 10/325 TABLETS

Quantity 24 100 100
The principal use of the drug (composed of 10 mg of hydrocodone

and 325 mg of acetaminophen) is the relief of pain. Hydrocodone is
a powerful cough suppressor and is also useful in treating abdomi-
nal cramping and diarrhea. The dosage of 1 tablet every 6 hours will
normally control a severe toothache. Maximum dosage is 6 tablets
per day. It may be augmented with hydroxyzine hydrochloride; see
below. This product is now a Schedule II prescription, which makes

obtaining it, controlling it, and transporting it much more problem-
atic. This is a good compound and safe when used properly. Unfortu-
nately, misuse has caused very restrictive legislation, both nationally
and internationally. It would be very hard to obtain a large quantity
of this medication, yet it has many uses as indicated and is safe when
used properly. A potential replacement for your medical kit is trama-
dol 50 mg, which can be taken every 6 hours for pain. You may also
take meloxicam, 15 mg daily, or acetaminophen, 500 mg 4 times per
day, simultaneously. Tramadol is a Schedule IV controlled medica-
tion, which will still require a prescription.
ATARAX TABLETS, 25 MG
Quantity 0 100 500
A brand name of hydroxyzine hydrochloride (see also the listing

under Vistaril® in the Rx Injectable Medication Module), these tab-
lets have multiple uses. They are a very powerful anti-nausea agent,
muscle relaxant, antihistamine, antianxiety agent, and sleeping pill,
and will potentiate a pain medication (make it work better). For
sleep, take 50 mg at bedtime; for nausea, 25 mg every 4 to 6 hours;
to potentiate pain medication, take a 25 mg tablet with each dose of
the pain medication. This medication treats rashes of all types and
has a drying effect on congestion. The injectable version, Vistaril, has
identical actions.
MOBIC (MELOXICAM), 15 MG TABLETS

Quantity 24 240 1,000
This anti-inflammatory, analgesic tablet is unique in that it does not

inhibit platelets from aggregating and thus does not increase the same
bleeding tendencies in wounds that occur with aspirin or ibuprofen.
For this reason it is included in the blast first aid kits for combat
troops in Afghanistan and formerly in Iraq. Dosage is 1 tablet per day

taken with food. This is an ideal pain medication, will reduce fever,
and helps in the treatment of overuse injuries such as tendonitis or in
cases of acute trauma (sprains, strains, fractures, contusions).
TOPICORT (DESOXIMETASONE) OINTMENT

(0.25%, 0.5 OZ TUBE)
Quantity 0 12 36
This Rx steroid ointment treats severe allergic skin rashes. Dosage is a

thin coat twice daily. Occlusive dressings are not required when using
this product. Should be used with caution over large body surface
areas or on children. Use should be limited to 10 days or less, partic-
ularly in the latter cases.
TOBRADEX OPHTHALMIC DROPS (2.5 ML)

Quantity 0 6 12
This is a combination of a powerful antibiotic (tobramycin 0.3%) and

a steroid (dexamethasone 0.1%). It can be used to treat infections
or allergies in the eye (for which it was designed) or the ear. It can
be instilled in either location 2 or 3 times daily. This medication can
cause complications in case of viral infections of the eye (which are
rare compared to bacterial infections and allergy conditions).
TETRACAINE OPHTHALMIC SOLUTION (DROPS),

0.5% (15 ML BOTTLE)
Quantity 0 2 2
This is a sterile solution for use in the eye or ear to numb pain. Do
not reapply to an eye if pain returns without examining very carefully
for a foreign body. Try not to use repeatedly in the eye, as overuse
delays healing. Continued pain may also mean you have missed a
foreign body. Do not use in ears if considerable drainage is present;
an eardrum may have ruptured, and if this medication gets into the
middle ear through a hole in the eardrum, it will cause profound ver-
tigo (dizziness).
DENAVIR (PENCICLOVIR) CREAM, 1% (5 GM TUBE)

Quantity 1 6 12
An antiviral treatment useful for cold sores on the face and on the
lips. While not approved for use inside the mouth, this product actu-
ally works well there and is not harmful if swallowed. This may be
used at high altitudes, in deserts, land, and oceans with high reflective
light, to prevent cold sores caused by intense ultraviolet light. Apply
every 2 hours during waking hours for 4 days.
STADOL® NASAL SPRAY

Quantity 1 6 12
This is a powerful pain medication (generic name butorphanol) for-

mulated to be absorbed by the lining of the nose. It is ten times stron-
ger than morphine on a milligram-to-milligram basis. Use only 1
spray up a nostril and wait 60 to 90 minutes before using a second
spray in the other nostril. This process may be repeated in 3 to 4
hours. It should be working effectively within 20 minutes after the
first spray. Overspraying or allowing the medication to drain down
the throat will waste it since it is inactivated by gastric fluids.
DIAMOX TABLETS, 250 MG

Quantity If going into altitude 6/ 0 additional 0 additional
person
This is used to prevent acute mountain sickness (AMS) for those con-
templating rapid ascents to elevations over 9,000 feet (2,800 meters).
Side effects include tingling of the mouth and fingers, numbness, loss
of appetite, and occasional instances of drowsiness and confusion—
all signs of the AMS that one is trying to prevent. Increased urination
and rare sun-sensitive skin rash is encountered. See page 265.
DECADRON (DEXAMETHASONE) TABLETS, 4 MG

Quantity 6 100 100
For allergy, give 1/2 tablet twice daily after meals for 5 days. For treat-
ment of acute mountain sickness, give 4 mg every 6 hours until well
below the altitude at which symptoms appeared. See pages 151 and
266. This medication can also be used in serious head and spine inju-
ries as indicated on page 00).
FLAGYL CAPSULES, 250 MG

Quantity 0 24 48
The brand name of metronidazole, this antibiotic is useful in treating

diarrhea caused by giardia (see page 223) at a dose of 250 mg 3 times
daily. It is also used in treating infections by Entamoeba histolytica and
Trichomonas vaginalis (both protozoal parasites) and certain other
bacteria. May cause numbness and nausea. Should not be taken by
people with central nervous system diseases. Do not drink alcohol
with this drug, as it causes flushing and vomiting.
FAMVIR CAPSULES (250 OR 500 MG)

Quantity 0 24 48
This may be taken as a single 1,500 mg dose as prophylaxis to prevent

herpes simplex lip lesions, which are often activated by high altitude
or reflective ultraviolet light exposure. This medication should be
included in the kit if persons are known to have recurrent problems.
An alternative is to use the Denavir cream (page 289).
MALARONE TABLETS, ATOVAQUONE AND PROGUANIL, 250

MG-100MG FOR ADULT; 62.5 MG-25 MG PEDIATRIC
Quantity 0 48/person only if in Same
malaria area
For malaria prevention or prophylaxis, the adult dose is 1 tablet daily

1 to 2 days before the exposure, daily while exposed, and for 7 days
after exposure. Repeat dose if vomiting occurs within 1 hour after
the dose. The children’s dose is determined by weight. However, two
other dosing regimens may be appropriate. One, a terminal dose for
a short-exposure trip, or a treatment dose for presumptive manage-
ment of illness.
Pediatric Tablets Patient’s Weight

1 22–44 pounds (10–20 kilograms)
1 adult tablet Over 88 pounds (40 kilograms)
Rx Injectable Medication Module

Nubain 20 mg/ml, 10 ml multiuse vial (pain)
Lidocaine 1%, 10 ml multiuse vial (local anesthetic)
3.5 ml syringes with 25-gauge, 5⁄8-inch needles
Decadron 4 mg/ml, 5 ml multiuse vial (steroid), 1 vial per trip for allergy,
3 vials per climber at risk for acute mountain sickness
Rocephin 500 gm vials (antibiotic)
Vistaril 50 mg/ml, 10 ml multiuse vial (many uses)
EpiPen, EpiPen Jr, or epinephrine vials and syringe (bee stings,
anaphylactic shock, asthma)
NUBAIN® (NALBUPHINE) 20 MG/ML, 10 ML VIAL

Quantity 0 2 4
A strong, synthetic narcotic analgesic, this is available only by pre-

scription but it is not a controlled narcotic. It is equal to morphine in
strength. Normal adult dose is 10 mg (0.5 ml) given intramuscularly
every 3 to 6 hours. The maximum dose is 20 mg (1 ml) every 3 hours.
Can be mixed with 25 to 50 mg of Vistaril in the same syringe for
increased analgesia in severe pain problems.
LIDOCAINE 1%, 10 ML VIAL

Quantity 0 2 5
Injection for numbing wounds. Maximum amount to be used in a

wound in an adult should be 15 ml. This fluid is also used to mix
Rocephin. See the package insert that comes with Rocephin.
SYRINGES
Quantity 0 24 100
Many types are available, but generally I find the 3.5 ml with the
attached 25-gauge, 5/8-inch needle to be the most universally useful.
DECADRON (DEXAMETHASONE) 4 MG/ML, 5 ML VIAL

Quantity 0 6 24
For use in allergic reactions, give 4 mg daily for 5 days IM. For acute
mountain sickness, give 4 mg (1 ml) every 6 hours until well below
the altitude where symptoms started. See pages 151 and 266.
ROCEPHIN® (CEFTRIAXONE), 500 MG VIAL

Quantity 0 24 48
A broad-spectrum antibiotic of the cephalosporin class, the inject-

able medication has a wide range of bactericidal activities, including
for pneumonia and bronchitis, skin infections, urinary tract and kid-
ney infections, gonorrhea, pelvic infection, bone and joint infections,
intra-abdominal infections, and some types of meningitis. Each vial
will require 0.9 ml of lidocaine 1% to mix the contents. The reconsti-
tuted medication is stable at room temperature for 3 days.
VISTARIL 50 MG/ML, 10 ML VIAL

Quantity 0 4 12
A brand name of hydroxyzine hydrochloride, uses and dosages are

the same as indicated for Atarax in the Rx Oral/Topical Medication
Module (page 287). Obviously, in the treatment of profound vomit-
ing, injections of medication will work better than oral administration.
This solution can be mixed in the same syringe as the Nubain for
administration as one injection.
EPIPEN, EPIPEN JR, SYMJEPI

The EpiPen and EpiPen Jr are automatic injection syringes. Use only
on one person. The EpiPen delivers 0.3 ml (0.3 mg) of 1:1000 epineph-
rine; the EpiPen Jr delivers 0.3 ml (0.15 mg) of 1:1000 epinephrine.
The EpiPen devices automatically give the medication intramuscu-
larly (IM). Due to the high cost of auto-injection syringes, I suggest
that your physician order several vials of epinephrine 1:10,000 solu-
tion for injection, and the appropriate syringes for administration.
See page 292. The Symjepi is a manually injected prefilled syringe in
0.3 and 0.15 mg strengths, approved in 2019 by the FDA and avail-
able commercially in early 2020.
Cardiac Medication Module

(contains Rx and non-Rx components)
Aspirin 81 mg chewable tablets
Nitroglycerin sublingual tablets, 0.4 mg, sealed bottle of 25 or 100
tablets; or nitroglycerin spray, 60-spray canister
Clopidogrel 75 mg tablets
Atenolol 25 mg tablets (beta-blocker)
ASPIRIN 81 MG CHEWABLE TABLETS

Quantity 14 400 1,000
Do not use enteric-coated (EC) tablets, which are slower to work than
chewable tablets. A larger number of aspirin can be carried to treat
fever, inflammation, and pain. Not for use in children or during preg-
nancy. This medication is used to prevent platelet aggregation during
a heart attack. Aspirin treatment reduced mortality by 23% in acute
myocardial infarction (MI) in a published trial called ISIS-2. Aspirin
is a platelet cycloxygenase inhibitor (see also clopidogrel, below).
NITROGLYCERIN SUBLINGUAL TABLETS, 0.4 MG

Quantity 0 unless someone 100 to 400 100 to 500
at risk
Once the seal on the bottle is open, the medication must be used
within 6 months, regardless of its original expiration date. Brand
name Nitrostat is stable for 24 months after the bottle is opened, or
until the expiration date on the bottle, whichever is earlier. Nitro-
glycerin is degraded more rapidly by heat and moisture. In tropical
environments it is better to carry nitroglycerin spray. This remains
stable for 2 years, even with use. It needs to be primed with a spray
before use. Meta-analysis of pre-thrombolytic-era nitrate trials found
that nitroglycerin treatment resulted in a 35% reduction in mortality
from acute MI (vasodilator).
CLOPIDOGREL (PLAVIX) TABLETS, 75 MG

Quantity 0 365 per person with 5 x as many
diagnosis
This is another platelet inhibitor. This medication is very expensive,

so stocking a kit with more than 10 becomes an economic challenge.
The CURE trial showed that clopidogrel therapy resulted in an 18%
reduction in MI, death, or stroke in patients with acute coronary syn-
drome (ACS) and non-ST elevated MI treated medically. This med-
ication is a platelet ADP-receptor inhibitor, so it works differently
than aspirin, and the effects are additive when both are taken.
If someone has a history of phlebitis, pulmonary embolism, they
should be on this medication routinely for 6 months from the epi-
sode. Persons with cardiac stents need to be on it for life.
ATENOLOL (TENORMIN) TABLETS, 25 MG

Quantity 0 24 24
Atenolol is a beta-blocker. ISIS-I and MIAMI trials showed that

beta-blocker therapy resulted in a 13% reduction in mortality with
either atenolol or metoprolol. Its use reduces heart rate, blood pres-
sure, and ischemia, raises ventricular fibrillation threshold, and
reduces the likelihood of malignant ventricular arrhythmias and sud-
den death. Do not give if the person has a slow heart rate (below 60
beats per minute).
REPLACEMENT MEDICATIONS
It is very common on wilderness trips and in remote areas for families
to trade one item for another, and sometimes this means bartering
items from or for your medical kit. Of course, doctors abhor the con-
cept of writing a prescription medication except for a specific per-
son for a specific diagnosis. But we are talking about a period when
and where the grid does not exist. Trading prescription medications
is illegal and can result in serious jail time. Exchanging or provid-
ing someone medications is not a trivial issue, and it would only be
done in response to a desperate situation. Otherwise your medication
stores are sacrosanct.
It is possible to acquire the skills to augment or replace your med-
ications with herbals, and we all know that some of these can also be
illegal. And some can be poisonous. To use herbal supplementation,
you have to really know what you are doing. Identification, storage,
and extraction of the useful component are all technically challenging.
Prepping in general is technically challenging. It may well pay you
to rise to the occasion and learn about herbal medications. These are
the most useful, common plants for this purpose in North America:
• Garlic: infection treatment, stimulant
• Rosemary: antioxidants, stimulant
• Basil: antioxidants, infections
• Mint: stimulant, digestive
• Lemon balm: tonic for mild depression, irritability, and anxiety

• Fennel: anti-inflammatory, analgesic, appetite stimulant,
antiflatulent
• Lovage: respiratory and digestive tonic, antibronchitic
• Oregano: antiseptic, antiflatulant, stimulant for bile and stomach
acid, antiasthmatic
• Cilantro (coriander): antiflatulant, bloating, and cramps
• Horseradish: perspirant, stimulant
• Thyme: antiseptic, antiasthmatic, stimulant
The identification of and uses for these herbs are explained
in detail by Jim Meuninck in his books Medicinal Plants of North
America, 2nd edition (Falcon Guides, 2016), Basic Illustrated Medic-
inal Plants (Falcon Guides, 2019), and Edible Wild Plants and Useful
Herbs, 2nd edition (Falcon Guides, 2018). These three books should
form the basis of your literary plunge into herbal foraging, but you
will want to take lessons from experienced herbalists to safely and
more effectively use herbals, just as you will need to take advanced
first aid and advanced wilderness first aid courses to effectively form
the basis of your general medical care while off the grid.
Prepper’s Medical
Resource Bookshelf
I have worked with Buck Tilton, Cliff Jacobson, and Jim Meuninck
over the past three decades on multiple projects. They have the attri-
butes in common of being blessed with extraordinary common sense,
great technical skills, and immense firsthand experience. James Green
goes into compounding and storing herbals to a level of expertise
like no one else. The honor of knowing which medicinal plants and
herbs make the most sense to understand, how to identify them, and
how to use them, goes to Jim Meuninck, whom you need to read as
a minimum.
Part of being a prepper is acquiring knowledge, skills, and even
ideal survival supplies. You almost can’t have too much of any of these
things, but you certainly require at least the minimum. These books
are part of the “a least the minimum” for your library on medicine and
survival. There are many other good books and experts, and I know,
love, and respect many others. Frankly, you just can’t learn too much,
so this list is only your starting point. But a good one it is.
Murray Dickson, Where There Is No Dentist. Hesperian Health Guides

(2018).
William Forgey, Basic Illustrated Wilderness First Aid, 2nd edition.
Falcon Guides (2016).
William Forgey, Wilderness Medicine: Beyond First Aid, 7th edition.
Falcon Guides (2017).
James Green, The Herbal Medicine-Maker’s Handbook. Berkeley, CA:
Crossing Press (2010).
PREPPER’S MEDICAL RESOURCE BOOKSHELF 299
Cliff Jacobson, Camping’s Top Secrets, 25th anniversary edition. Falcon

Guides (2013).
Jim Meuninck, Basic Illustrated Poisonous and Psychoactive Plants. Fal-
con Guides (2014).
Jim Meuninck, Edible Wild Plants and Useful Herbs, 2nd edition. Fal-
con Guides (2018).
Jim Meuninck, Medicinal Plants of North America, 2nd edition. Falcon
Guides (2016).
Jim Meuninck and Rebecca Meuninck, Basic Illustrated Medicinal
Plants. Falcon Guides (2019).
Buck Tilton and Frank Hubbell, Medicine for the Backcountry. Globe
Pequot (1999).
Buck Tilton, Wilderness First Responder, 3rd edition. Falcon Guides
(2010).
Clinical Reference Index
A anaphylaxis, 14, 272

abdomen, examining, 13 See also anaphylactic shock
abdominal pain, 65–70 anaplasmosis, 216, 218
antacids for, 66 anemia, 31
abdominal thrust, 16–17 animal bites, 125, 143–44
abrasions. See wounds, treating ankle injuries, 190
abscess, 147–48 antacids, 66
accidents, assessing, 6–11 anthrax, 214
acetazolamide (Diamox), antibiotic ointment, 277
265–66 antibiotics, using, 125–26
acute mountain sickness (AMS), for nasal congestion, 51
265–66 antihistamines, 194
adhesive tape, waterproof, 276 ants, 208
Adult One-Rescuer CPR, appendicitis, 67, 68–70, 72
14, 15 aquatic stings, 208–11
Aedes mosquito. See chiungunya arms
fever examining, 13
African Sleeping Sickness. See forearm fractures, 177–80
trypanosomiasis upper arm fractures, 175–77
airways, checking, 6–7, arthritis. See joint pain
16–17 Aspercreme, 158
alcohol consumption, 66 aspirin, 30, 32, 272, 294
See also pancreatitis and abdominal pain, 66
Allegra, 34 assessments, 3, 4–9
allergic reactions, 33–36 focused, 8–9
allergic dermatitis, 151 vital signs, 9–11
See also anaphylactic shock Atarax (hydroxyzine), 24, 34, 35, 36,
alternative therapy, 269–70 163, 284, 287
See also medical kit Atenolol tablets, 24, 296
anaphylactic shock, 15, 35, athlete’s foot, 34
193–95 atovaquone, 291
CLINICAL REFERENCE INDEX 301
B breath, shortness of. See breathing;

babesiosis, 216, 218 chest pains
back, examining, 13 breathing
See also spinal injuries checking, 6–7
bandages. See elastic bandages CPR, 17–20
bandannas, 275 difficulty, 12, 16, 28
barnacle cuts. See coral cuts foreign body airway obstruction,
Basic Illustrated Medicinal Plants 16–17
(Meuninck), 297, 299 rapid, 15, 21
Basic Illustrated Poisonous bronchitis, 15, 63
and Psychoactive Plants bronchospasm, cold-induced, 254
(Meuninck), 299 brown recluse spider (Loxosceles
Basic Illustrated Wilderness First Aid reclusa), 201–2
(Forgey), 119, 298 brucellosis, 215
basil, 296 bubonic plague. See plague
Bell’s palsy. See Lyme disease burns. See lightening injuries;
Benadryl, 34, 282 thermal burns;
bioterrorism, 212, 214, 216 bursitis. See joint pain
See also infectious diseases butterfly bandages, 126
bisacodyl tablets, 281, 282
bites, treating, 125, 143–44 C
See also insect bites and stings Camping’s Top Secrets
biting gnats, 206–7 ( Jacobson), 299
black flies, 206 canker sore, 61
black widow spider (Latrodectus See also mouth and throat problems
mactans), 200–201 Carafate (medication), 66
bladder infection, 76–77 cardiac evaluation, 15, 22–26
blastomycosis, 216, 219 rapid or slow heart rates, 25–26
bleeding wound, 118–26 cardiac medications, 294–96
check for severe bleeding, 7 cardiopulmonary resuscitation
cleaning wound, 122–25 (CPR), 7, 14, 17–20, 24
blisters, friction, 138–39 for lightning injuries, 261–64
blood pressure, 11 carotid artery pulse, checking for,
body ringworm, 150 7–8
See also Lyme disease caterpillars, 203
body salt, depletion of, catfish, 210
256–57 Cavit dental filling paste, 279
bone injuries. See orthopedics cellulitis, 148–49
botulism, 214 Celox Gauze, 120–21, 275
bradycardia, 25–26 centipede bites, 203
302 CLINICAL REFERENCE INDEX
cervical spine contact lenses. See eye pain and

checking, 7–8 irritation
trauma, 12, 167–70 copperheads. See snakebites
Chagas disease, 240 coral cuts, 209–10
chalazia. See eye pain and coral snakes (Micrurus fulvis), 196,
irritations 198, 199–200
chest See also snakebites
examining, 12 coral stings. See jellyfish
injuries, 15, 191–92 Coverlet bandage strips, 275
chest pains, 62–65 CPR. See cardiopulmonary
bronchitis/pneumonia, 63 resuscitation (CPR), 24
pneumothorax, 63–64 cystitis, 77
pulmonary embolus, 15, 64–65 See also bladder infection
See also cardiac evaluation
chikungunya fever, 217, 219 D
children, assessment of, 9 Decadron, 194, 284, 290,
chillblains, 255 292, 293
chills, 15, 30 DEET, 151, 202, 204–5, 206, 207
Chito Gauze, 275 Denavir cream, 62, 284, 289
choking, 15, 16–17 dengue, 217, 219, 221–22
cholera, 216, 217, 219–20 dental care, 109–15
ciguatera poisoning, 85, 86 cavity, 113
cilantro, 297 gum pain or swelling, 109–10
circulation, checking, 7 loose of dislodged tooth, 114
Claritin, 34 lost filling, 112–13
climbing tape, 275, 276 mouth lacerations, 110–11
clopidogrel tablets. See Plavix pulling a tooth, 114–15
clotrimazole cream, 34, 279 dexamethasone, 35, 166, 167
coccidioidomycosis, 217, 220 diabetes, 86–87
cold sores, 61–62 and rapid breathing, 21
cold-stress injuries, 252–55 Diamox tablets, 284, 290
colitis, 67 diarrhea, 72–74
collarbone, injury to, 170–72 and appendicitis, 68
Colorado tick fever, 217, 220–21 replacement fluids for, 88–89
Combat Action Tourniquet See also typhoid fever
(CAT), 119, 120 Dickson, Murray, 113, 298
Combat Gauze, 120 Diflucan tablets, 284, 286
conjunctivitis. See eye pain and diphenhydramine, 35, 36, 86, 149,
irritation 281, 282
constipation, 74–75 diphtheria, 62, 215
diseases, infectious, 212–45 ophthalmic treatments for,

See also specific diseases 288–89
diverticulitis, 67, 72 patch and bandaging, 37–38
doxycycline, 35, 46, 48, 218, 223, removing foreign object, 38–41
284, 285 snow blindness, 44–45
dressings. See wounds, treating sties and chalazia, 48
duct tape, 275, 276 subconjunctival hemorrhage, 49
E F
ear problems, 29, 53–59 fainting. See vasovagal syncope
earache, 54–55 Famvir capsules, 284, 291
foreign body injuries, 57–58 felon. See nail problems
infections, 55–57 fennel, 297
ruptured eardrum, 58–59 fever, 11, 15, 27, 29–30
TMJ syndrome, 59 and gastroenteritis, 70
Ebola, 214, 215, 216 relapsing fever, 217, 234
echinococcus, 217, 222 fever blisters, 62
eclampsia, 82 See also mouth and throat problems
Edible Wild Plants and Useful Herbs finger injuries, 183–84
(Meuninck), 297, 299 fire ants, 208
ehrlichiosis, 217, 223 fishhook, removal of, 135–38
elastic bandages, 276–77 Flagyl capsules, 284, 290
elbow fractures, 177 focused assessment. See assessments
See also forearm fractures food poisoning, 66, 67
encephalitis, 223 foot injuries, 191
endemic typhus, 217, 242–43 immersion foot, 254–55
Enfalyte, 88 Forgey, William, 298
environmental injuries, 212, fractures. See orthopedics
246–68 Freuchen, Peter, 253
epidemic typhus, 217, 243 frostbite, 252–54
epinephrine, 53, 194, 272 frostnip, 252
EpiPen, 194, 195, 294 fungal infections, 33, 34
examination, physical, 8, 12–13 furosemide, 167
eye pain and irritations, 36–51
abrasions, 44 G
blunt trauma, 49–50 gall bladder problems, 66, 67–68
conjunctivitis, 45–46, 47–48 garlic, 296
contact lenses, 41–44 gastritis, 65, 67
glaucoma, 50–51 gastroenteritis, 66, 67
iritis, 47 and vomiting, 70
Gatorade, 88–89 hemostatic dressings, 120–22,

giardia, 73 274–75
See also diarrhea; giardiasis hepatitis, 31, 66, 67
giardiasis, 217, 223–24 types of, 217, 225–27
glanders, 215 herbal medicine, 270
glaucoma. See eye pain and See also alternative therapy; herbs,
irritations medicinal; medical kit
gloves, protective, 279 Herbal Medicine-Maker’s
glucometers, 87 Handbook, The (Green), 298
See also diabetes herbs, medicinal, 296–97
gnats. See biting gnats hernia, 75–76
gonorrhea, 78, 79 hiatal hernia, 66, 67
See also venereal diseases herpes simplex sores, 62
Green, James, 298 and snow blindness, 45
gum pain. See dental care See also venereal diseases
gypsy moth caterpillar (Lymantria Hibiclens surgical scrub, 123,
dispar), 203 143, 278
hiccups, 35–36
H high altitude illnesses, 15, 265–68
halazone tablets, 90 high altitude cerebral edema
hand fractures, 183 (HACE), 267–68
hantavirus, 217, 224–25 high altitude pulmonary edema
headache, 36 (HAPE), 266–67
head injuries, 165–66 hip injuries, 185–87
examining head, 12 See also pelvis, examining
heart problems hives, 34–35
heart attack (myocardial honey, for wounds, 277
infarction), 22–25 horseradish, 297
heart rate and body Hubbell, Frank, 7, 299
temperature, 29 human waste, disposal of, 94–95
rapid or slow heart rates, hydatid disease. See echinococcus
25–26 hydrochlorothiazide, 167
heat cramps, 259 hydrocodone, 286
heat-stress injuries, 255–61 See also Norco 10/325 tablets
cramps, exhaustion and stroke, hydrocortisone cream, 34, 278
259–61 hydroxyzine, 35
Heimlich maneuver. See abdominal hydroxyzine hydrochloride, 21
thrust hypertension. See pregnancy
hemorrhagic fevers, 214–15 hyperventilation syndrome, 21
hemorrhoids, 75 hyponatremia, 257–59
hypothermia, 10, 15, 246, 247–51 mosquitoes, 204–6

acute, 250–51 no-see-ums and biting gnats,
chronic, 247–50, 251 206–7
cold water submersion, 251 reaction to caterpillars, 203
and CPR, 20 scorpion, 207–8
spider, 200–202
I ticks, 202–3
ibuprofen, 30, 32, 281, 282 insulin, storage of, 87
for eye pain, 41 See also diabetes
for joint pain, 159 iodine, for water purification,
Icy Hot, 158 90–91
illnesses iritis. See eye pain and irritation
diagnosing, 212–13 irrigation syringe, 280
high altitude, 265–68 itch, 27, 33–34
See also specific illnesses
immersion foot, 254–55 J
impetigo, 152 Jacobson, Cliff, 298
See also skin rash jaundice, 10, 225
infections jellyfish, 209
bladder, 76–77 joint pain, 158–60
and fever, 29 See also orthopedics
fungal, 34
See also wounds, treating K
infectious diseases. See diseases, Katadyn Pocket filter, 91–92
infectious; specific diseases knee injuries, 188–90
inflammation. See wounds, treating
influenza, 215, 216 L
injuries lacerations, and home accidents, 116
assessment of, 4–9 See also wounds, treating
cold-stress, 252–55 Lanacane cream, 277
environmental, 246–51 Lassa (virus), 215
heat-stress, 255–61 Leave No Trace Foundation, 95
spinal, 168–70 legs, examining, 13
See also orthopedics; wounds, See also orthopedics
treating; specific types of lemon balm, 297
insect bites and stings, 200–208 leptospirosis, 227–28
anaphylactic shock, 193–95 lethargy, 30–31
ants/fire ants, 208 Levaquin, 48, 56, 65, 159, 284,
black flies, 206 285–86
centipede, 203 for diarrhea, 74
for fever, 29, 30 meningococcal meningitis, 217,

for trench mouth, 62 231–32
Lidocaine, 292 menorrhagia. See menstrual
lightning injuries, 261–64 problems
and CPR, 20 menstrual problems, 80
Loperamide tablets, 281, 283 Meuninck, Jim, 273, 297, 298, 299
Lotrimin, 279 Meuninck, Rebecca, 299
lovage, 297 millipede bites, 203
Lyme disease, 35, 156, 217, mint, 296
228–29 mobic tablets, 284, 287–88
moleskin, 139
M mononucleosis, infectious, 31,
Machupo virus, 215 60–61, 62
malaise. See lethargy See also mouth and throat problems
malaria, 30, 217, 229–30 mosquitoes, 204–6, 218, 219
and diarrhea, 72 motion sickness, 71
Malarone tablets, 284, 291 mountain sickness, 31
Marburg (virus), 214 mouth and throat problems, 59–62
measles, 215, 231, 235 mononucleosis, 31, 60–61
medical history, taking, 12 mouth lacerations, 110–11, 131
medical kit, 269–97 mouth sores, 61–62
alternative and herbal therapy, pain or infection in, 29
269–73 sore throat, 59–60
cardiac, 294–96 mumps, 215, 232
herbal medications, 296–97 muscle pain and spasms, 32,
non-prescription medications, 155–58
281–83 Mycelex, 279
prescription injectable medications, myocardial infarction. See heart
292–94 problems
prescription medications, 284–91
topical bandaging module, 273 N
medications, prescription, 271–72 nail problems, 144–47
See also medical kit, specific nasal congestion, 51
medications See also nose problems
Medicinal Plants of North America NaturaLyte, 88
(Meuninck), 273, 297, 299 nausea
Medicine for the Backcountry motion sickness, 71
(Tilton & Hubbell), 7, 299 treatment for, 70
meliodosis, 215 neck injuries, 165, 167–68
meloxicam, 30, 32, 284 and airways, 6–7
examining for, 12 head and neck injuries, 165–68

See also spinal injuries hip and thigh fractures, 185–88
neomycin. See antibiotic ointment joint pain, 158–60
Neosporin, 41, 46 knee injuries, 188–90
Nexium (espmeprazole), 283 muscle pain, 155–58
nitrile gloves, 118–19 shoulder and upper arm, 172–77
nitroglycerin spinal injuries, 168–70
spray, 23 wrist, thumb, hand, finger injuries,
sublingual tablets, 295 180–84
Non-Rx Oral Medication Module, Osler, Sir William, 78, 213
30, 33, 34, 271 Owl, Grey, 44
Norco 10/325 tablets, 41, 284, oxyimeter, 11
286–87
norepinephrine, 272 P
North America, diseases of, 213, pain, 27
214–17 management of, 31–33
no-see-ums, 206–7 pancreatitis, 65–66, 67
nose problems, 51–53 paronychia. See nail problems
fracture, 53 Pedialyte, 88
nosebleed, 52–53 pelvis, examining, 13
removing foreign body, 51–52 Percogesic tablets, 30, 41, 48, 56, 281
nubain, 292 peritonitis, and hernia, 76
Nu Gauze Pads, 275 See also gall bladder problems
permethrin, 202, 205, 207, 218
O pertussis, 215
Off-Grid Medical Kit, 87, 208, physical examinations, 8–9, 12–13
213, 270, 271 Physicians’ Desk Reference
oil of cloves (eugenol), 279 (PDR), 271
Opcon-A ophthalmic drops, 278 piles. See hemorrhoids
oral medications, non-prescription, pit vipers, 196–98
281–84 See also snakebites
Oralyte, 88 plague, 214, 217, 232
oregano, 297 plants, poisonous. See itch
orthopedics, 154–92 Plavix (clopidogrel), 255, 295
ankle and foot injuries, 190–91 for heart attack, 24
chest injuries, 191–92 pneumonia, 15, 63
collarbone, 170–72 and bronchospasm, 254
elbow and forearm fractures, pneumonic plague. See plague
177–80 pneumothorax, 15, 63–64
fractures, 161–64 See also chest pains
poisoning, 84–86 rash. See skin rash

ciguatera, 85 rattlesnakes, treatment for
paralytic shellfish, 86 bites, 197
petroleum products, 84 relapsing fever, 217, 234
puffer fish, 86 reproductive organs, 77–84
scombroid, 85–86 ectopic pregnancy, 81
polio, 215 menstrual problems, 80
Polysporin ointment, 41, 46 painful testicle, 83
povidone iodine (Betadine), 123 pregnancy, 81–83
pramoxine. See antibiotic ointment spontaneous abortion, 80–81
Precise Five-Shot Skin Stapler, 127 vaginal discharge and itching,
preeclampsia, 82 79–80
pregnancy, 81–83 venereal diseases, 77–79
Preppers Medical Resource respirations, checking, 10
Bookshelf, The, 273 See also breathing
prepping, off-grid, 1–3 responsiveness, level of, 10
Prevacid (lansoprazole), 283 rheumatic fever. See mouth and
prickly heat, 261 throat problems
Prilosec (omeprazole), 283 ribs, broken, 191–92
Proguanil, 291 RICE (rest, immobilize, cold,
psittacosis, 215 elevate), 156–57, 160
puffer fish, 86 for knee/foot injuries, 189, 191
pulmonary embolus, 15, 64–65 See also muscle pain; joint pain;
See also chest pains orthopedics
pulse, taking, 10 rigors. See chills
and blood pressure, 11 Rocephin, 293
and shock, 14 Rocky Mountain spotted fever,
puncture wounds, 133–34, 197 155–56, 217, 221, 235, 242
puss caterpillar (Megalopyge rosemary, 296
opercularis), 203 rotavirus disease, 73
rubella, 215, 235
Q Rx Cardiac Medication Module,
Q fever, 215, 242 23, 65, 271
QuikClot Combat Gauze, 274–75 Rx Injectable Medication Module,
33, 35, 53, 138, 271
R Rx Oral Medication Module,
rabies, 217, 233–34 79, 271
radiation, exposure to, 96–108 Rx Oral/Topical Medication
ranitidine tablets. See Zantac Module, 30, 33, 34, 35, 46, 56,
(ranitidine) 62, 151, 284
S splints
Sam splint, 168, 276 malleable, 276
SARS, 215 pneumatic, 163
Sawyer Products filter, 92, 93 See also sam splint
schistosomiasis, 217, 236 sponges, reaction to, 211
scombroid poisoning, 85–86 Stadol (nasal spray), 33, 284, 289
scorpion fish, 211 STARI, 217, 236–37
scorpion stings, 207–8 SteriPen, 92
scrotum. See testicle, painful Steri-Strips, 126
sea urchins, 208–9 sties. See eye pain and irritations
shigellosis, 73 stinging nettle, 151
shock, 13–15 stingrays, 210
treating for, 142 stings, 193–95
See also anaphylactic shock aquatic, 208–11
shoulders stomach. See abdominal pain
dislocations, 172–74 strep throat, 62, 63
examining, 13 sugar solution, for wounds, 277
fracture of scapula, 174 sun stroke. See heat stroke
upper arm fractures, 174–77 surgical kit, 280–81
skin injuries and ailments, 117–18 symptoms, 27–95
checking skin signs, 10 anatomical location guide, 28
cold sores, 61–62 See also specific illness, body part
See also skin rash; wounds, treating syphilis. See venereal diseases
skin rash, 34, 149–53 syringes, 123, 125, 293
allergic dermatitis, 151
bacterial, 152 T
fungal infection, 150–51 tachycardia (rapid heart rate), 25
seabather’s eruption, 152–53 tachypnea. See hyperventilation
smallpox, 214, 215 syndrome
snakebites, 196–200 Tactical Combat Casualty Care
Special Operations Forces Tactical (TCCC), 120
Tourniquet Wide, 119, 120 tapeworms, 217, 222, 237
Spenco Adhesive Knit bandage, 274 Tarascon Pharmacopoeia, 271
Spenco 2nd Skin, 33, 132, 138–39, teeth. See dental care
141, 150, 274 temperature, taking, 11
for burns, 141, 142 See also fever
for frostbite, 254, 273 tendinitis. See joint pain
spider bites, 200–202 testicle, painful, 83
spinal injuries, 168–70 tetanus, 216, 217, 237–38
checking spine, 7–8 and abrasions, 133
immunization for, 135 typhus, 214, 243

tetracaine ophthalmic solution, 39, endemic, 242
45, 284, 288–89 epidemic, 217
See also eye pain and irritation typhus, endemic, 217, 242–43
thermal burns, 139–43
thigh fractures, 187–88 U
throat problems. See mouth and ulcers, 65
throat problems See also abdominal pain
thumb injuries, 182–83 urinary tract infection, 82
thyme, 297
ticks V
bites, 202–3, 204 vaginal discharge and itching, 79–80
Colorado tick fever, 218 vasovagal syncope, 15
and infectious diseases, 216, 217 venereal diseases, 77–79
tick paralysis, 217, 238 Vistaril (hydroxyzine), 24, 33, 35, 36,
See also Lyme disease; STARI 287, 292, 293–94
Tilton, Buck, 7, 83, 169, 298, 299 vital signs, taking, 9–11
Tobradex ophthalmic drops, 48, vomiting, 70
284, 288
See also eye pain and irritations W
Topical Bandaging Module, 34, water
56, 112, 132, 271, 273 fluid replacement therapy, 88–89
Topicort ointment, 34, 284, 288 purification of, 89–94
tourniquets, 119, 120, 121 water moccasins, treatment for
Tramadol, 287 bites, 197
trauma, assessment of, 4–9, 6 Weil’s disease. See leptospirosis
trench fever, 242 welts. See hives
trench mouth, 61–62 West Nile virus, 217, 243–44
See also mouth and throat Where There Is No Dentist (Dickson),
problems 113, 115, 298
trichinosis, 217, 238–39 Wiel’s disease. See leptospirosis
trypanosomiasis, 217 Wilderness First Responder (Tilton),
African, 239 83, 169, 299
American, 240 Wilderness Medicine: Beyond First
T-shirts, cotton, 275 Aid (Forgey), 298
tuberculosis, 217, 240–41 wounds, treating, 116–53
tularemia, 214, 217, 241 abrasions, 133
Tylenol (acetaminophen), 30 anesthesia for, 132
typhoid fever, 11, 26, 29, 216, antibiotic guidelines, 125–26
217, 242 bites, 143–44
cleaning, 122–25 Y
closure techniques, 126–30, 144 yellow fever, 29, 217, 244
dressings for, 120–22, 132
fishhook removal, 135–38 Z
friction blisters, 138–39 Zantac (ranitidine), 281, 283
infection and inflammation, Zerowet Supershield, 123, 125
147–49 Zika virus, 217, 244–45
nail problems, 144–47 Zithromax, 60, 61, 62, 284, 285
puncture wounds, 133–34 for diarrhea, 74
scalp and face wounds, 131–32 for pulmonary embolus, 65
skin injuries and ailments, 117–18 for strep throat, 30
splinter removal, 134–35 Zyrtec, 34
stopping bleeding, 118–20
thermal burns, 139–43
wrist injuries, 180–82
About the Author
Veteran outdoors author William W. Forgey, MD, is a full-time

practitioner of family medicine and is also a member of the board
of trustees of the International Association for Medical Assistance
to Travelers, a fellow of the Explorers Club, and a past president of
the Wilderness Medical Society. A former Boy Scout scoutmaster
and Medical Explorer Post and High Adventure Post advisor, he cur-
rently serves on the National Health and Safety Committee and as
an advisory board member for the Northern Tier High Adventure
Base for the Boy Scouts of America. He is the author of many wil-
derness medicine and camping books, including Wilderness Medicine
and Basic Illustrated Wilderness First Aid. He is a Vietnam veteran,
a former instructor at the JFK Center for Special Warfare, and was
awarded a bronze star and army commendation medal.

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THE PREPPER’S

I further reach out to my good friend Justin Van Ouse

Preppers all and great friends.

An imprint of The Rowman & Littlefield Publishing Group, Inc.

Distributed by NATIONAL BOOK NETWORK

Copyright © 2020 William W. Forgey, MD

British Library Cataloguing in Publication Information available

ISBN 978-1-4930-4694-2 (paperback)

Chapter 1: How to Prepare for Medical Care Off the Grid . . . . . 1

Chapter 2: Assessment and Stabilization . . . . . . . . . . . . . . . . . 4

Chapter 3: Body System Symptoms and Management . . . . . 27

Chapter 5: Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Chapter 6: Soft Tissue Care and Trauma Management . . . . . 116

Chapter 7: Orthopedics—Bone and Joint Pain and Injury . . . 154

Diagnosis and Care Protocols. . . . . . . . . . . . . . . . . . . . . . . . . . 164

Chapter 8: Bites and Stings . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Chapter 9: Bioterrorism and Infectious Disease . . . . . . . . . . 212

Meningococcal Meningitis • Mumps • Plague • Rabies •

Chapter 10: Environmental Injuries . . . . . . . . . . . . . . . . . . . . . 246

Chapter 11: The Off-­Grid Medical Kit . . . . . . . . . . . . . . . . . . . . 269

Prepper’s Medical Resource Bookshelf . . . . . . . . . . . . . . . . . 298

OFF-­GRID VERSUS NO-­GRID

Two critical components of medical prepping is the concept of

HOW TO USE THIS BOOK

List of Diagnostic Tables/References

ASSESSMENT AND CARE

to physicians at treatment centers, as it indicates either a stable or a

Assessment and Care 4

Adult One-­Rescuer Cardiopulmonary Resuscitation (CPR) 17

Survey the Scene

Check the Airway and Breathing

Still no air movement: Perform chest thrusts, similar to the com-

Check for Severe Bleeding

Check the Cervical Spine

The Physical Exam

when the examination is unchanged and stable, the patient is alert,

General Principles of the Focused Physical Assessment:

Vital signs consist of several elements: level of responsiveness,

MEDICAL HISTORY AND

Shoulders and Arms

Shock can be caused by burns, electrocution, hypothermia, bites,

Shock due to severe allergic reactions is called anaphylactic shock

FOREIGN BODY AIRWAY OBSTRUCTION

ADULT ONE-­RESCUER CARDIOPULMONARY

If the victim is unresponsive with no signs of circulation, start

been continued for 30 minutes without regaining cardiac function,

ADULT TWO-­RESCUER CPR

CARDIAC EVALUATION AND CARE

Heart Attack (Myocardial Infarction)

is carrying any prescription heart medications and note

3. Give Plavix (clopidogrel), 300 mg, loading the dose

RAPID HEART RATE

SLOW HEART RATE

page 14), an attempt by the body to maintain blood pressure. A safety

Table 3-1. General Symptom Care Guide

For a discussion of symptoms localized to a particular body part,

Table 3-2. General Anatomical Location Guide

Evaluation and management of symptoms relating to injuries

If it is possible that the patient has a strep throat, give Zithro-

Sometimes a chronic condition is the source of the lethargy, such

Chapter 11: The Off-Grid Medical Kit . . . . . . . . . . . . . . . . . . . . 269

OFF-GRID VERSUS NO-GRID

Adult One-Rescuer Cardiopulmonary Resuscitation (CPR) 17

ADULT ONE-RESCUER CARDIOPULMONARY

ADULT TWO-RESCUER CPR

If these maneuvers do not work, from the Non-Rx Oral Medi-

From the non-Rx supplies give Percogesic, 1 tablet 4 times a day,

If a wax-plugged ear becomes painful, treat as indicated in the section