A Surgeon's Advice to Preppers, by Swampfox, M.D.

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As a reformed Christian and novice "prepper", I am so glad to have found your blog and all the informative
material that it contains. With your help, I am becoming prepared for the hard times that I believe are
imminent. I am a general surgeon practicing in the southeast. Your writings have caused me to think a lot
about the logistical vulnerabilities that exist in our health care system and how drastically surgery would
change if/when Schumer hits the fan.

The Coming Instrument Shortages

Many instruments and most of the supplies that we use for routine operations are disposable. Hospitals
typically keep no more than one or two weeks worth of surgical supplies on hand. Any interruption would
be devastating to the continued provision of surgical care. Surgeries that require general anesthesia
would be very problematic if not impossible. In such a scenario, Haiti and Zambia may be better
positioned to provide basic surgical services than our "advanced" US hospitals because they already live by
the principle of "use it up, wear it out, make do or do without." In the third world, they routinely re-use
things like surgical gloves, drapes, and suturing needles (after properly cleaning and re-sterilizing
them.) In America, we have far too many government regulations and trial lawyers for us to re-use
anything. Most things here go to the landfill after a single use. It seems that Haiti and Zambia are poor
countries while we are "rich and increased with goods" (Revelation 3:14-19). We have no need to be
frugal in the US. There is no monetary crisis coming, no unsustainable deficits, no federal Ponzi schemes
ready to burst. No, no. Nothing to see here.

Wound Closure
Having read several articles on various web sites regarding medical preparedness and wound care that are
unrealistic, if not harmful, I was prompted to send a few comments regarding the virtues of "wet to dry
dressings." In managing a traumatic wound in a TEOTWAWKI scenario, your readers should keep in mind
that most wounds can be left open without causing any problems whatsoever. A fresh wound is one that
is 1-2 hours old. The longer the time between wound creation and closure, the more bacteria the wound
is exposed to, the greater the chance of infection if closure is attempted. Right now with health care
functioning fairly well, I never close a wound that is more than 6 hours old no matter how clean it
appears as the risk of infection is prohibitive. If a wound is simple (a clean cut rather than frayed skin
edges), fresh, and free from gross contamination, it can be copiously irrigated with saline (do a web
search and print the recipe) or clean water, numbed with lidocaine injections, and sutured up. If there is
any doubt, then leave it open and start a wet to dry dressing using gauze moistened with saline. Wounds
with gross contamination such as the presence of dirt, leaves, or feces should always be left open even
after cleaning them thoroughly. All bite wounds should be left open, especially human bite wounds as
these are perhaps the dirtiest. Nearly all wounds in the body can be safely managed this way. The chief
advantage of suturing a wound closed is that the scar will be more cosmetically appealing than the scar
that will be left if the wound closes slowly over time with wet to dry dressings. Closing the wound will
also obviate the need for painful daily wound packing (the dressing changes stop hurting after about a
week). Suturing the wound can make you look like a hero, but the patient may be placed at unnecessary
risk by doing so. Don't hesitate to leave it open and pack it with gauze. Nobody will care what the scar
looks like if the grid is down. If a wound is sutured and later becomes infected, cut the sutures out, open
the wound with a clean (preferably gloved) finger to its depths, and begin wet to dry dressing changes. It
will usually heal fine once you let the pus out.
Large abdominal wounds that go down through the muscle and fascia would be difficult to close without
general anesthesia. Anyone trying to close such an abdominal wound would risk injury to the underlying
bowel, creating a bigger and smellier problem. Leave it open and do wet to dry dressings. This may
result in a hernia forming, but the hernia can be fixed years later when order is restored. Extremity
wounds involving muscle, fascia, and tendons can safely be left open. Muscle and facial injuries almost
always heal without functional deficits. Tendon repairs can prevent functional deficits, but are probably
beyond the ability of non-surgeons. Most tendons can be repaired at a later date. "Sucking chest wounds"
which go down into the chest cavity exposing the lung would likely be fatal in a TEOTWAWKI scenario so I
will not elaborate on the three sided dressing that ATLS recommends. Open skull fractures would be un-
survivable without a functioning hospital.
Gastrointestinal (GI) surgical cases such as colon cancer resections necessarily cause limited
contamination of the incision resulting in frequent post-operative wound infections in spite of
antibiotics. If the incision becomes infected a week after surgery, we remove the sutures, open the
wound widely with a finger, and start wet to dry dressings. In operations done for ruptured appendicitis
or diverticulitis where there is gross fecal contamination, we leave the incision open from the start and
begin wet to dry dressing changes immediately. I have seen thousands of wounds close using this
method. The wounds typically heal in 3-6 weeks, usually without incident. The wound should be packed
to its depths daily with plain gauze moistened (not dripping) with saline solution. This provides an ideal
environment for healing resulting in granulation tissue formation. Any devitalized or infected tissue sticks
to the gauze as it begins to dry and is removed when the packing is changed. Granulation tissue fills the

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wound causing it to get shallower over time. Each day the wound requires less gauze. The skin edges
begin to close from the sides. The depths fill in, the edges draw together, and the wound closes leaving a
wide scar. It may sound fictitious, but I have seen wounds close in this fashion that were big enough to
hold a 25 pound sack of rice. Leaving the wound open and performing wet to dry dressing changes greatly
diminishes the risk of infection. Antibiotics are unnecessary in treating most wounds that are left
open. Necrotizing (so called "flesh-eating") bacterial wound infections will be fatal in
TEOTWAWKI. Leaving wounds open will greatly reduce the chances of necrotizing fasciitis.
Contrary to some things I have read, gauze sponges do not stop bleeding. We could not live many days
without a functioning clotting system. It is the clotting system that stops almost all bleeding
vessels. Large veins or arteries may not stop on their own. Direct pressure with a finger or two can stop
bleeding from almost any vessel outside of the abdominal or chest cavity where direct pressure cannot be
held. Hold pressure for 20 minutes by the clock (no peeking) and most small and medium sized bleeders
will stop. Large vessels (bigger around than a pencil) may take an hour. Once the bleeding is
controlled, get the patient to a surgeon (or get a surgeon to the patient) when feasible as a large vessel
has a high risk of re-bleeding in the subsequent hours/days. If none is available, two weeks of complete
rest, a snug ace wrap, and a gentle dressing change each day is the best that you can do. Penetrating
wounds to the abdomen or chest cavity with associated large vessel injury would be fatal.
Ligating (dividing and tying off) injured blood vessels is doable, but attempting it without a lot of previous
experience can make the bleeding worse. It should be attempted only if direct pressure for an hour has
failed to stop the bleeding. If the vessel is visible in the wound, clamp it with hemostats above and
below the bleeding point, divide the vessel with something clean and sharp, and tie off both ends with
suture (easier said than done). Sometimes a torn vessel retracts into the surrounding tissue making it
difficult to find for ligation. A figure of 8 suture can be done in such a circumstance. Imagine a square
postage stamp with the retracted bleeder at its center. Insert the needle at the top left corner of the
stamp. The needle should travel in an arc deep through the tissue and exit at the bottom left corner of
the stamp. Pull extra suture through such that the tails are long enough for tying. Next, insert the
needle at the top right corner of the postage stamp passing it deep through the tissue such that it exits at
the bottom right. When the knots are tied the suture will cinch down around the hidden vessel and stop
it from bleeding. I recommend that you do a web search on "figure of eight suture" to see a diagram or
video to make this technique clear to you. (One video shows this technique used for skin closure. I'm
describing a figure of eight suture down in the wound under the skin where the bleeder is.) It can be a
very useful technique in a pinch.
Trying to repair or reconstruct an injured blood vessel would be unnecessary and dangerous even for a
surgeon in TEOTWAWKI except in rare circumstances. The redundancy [of "dual supply"] that God gave
our bodies makes it possible to ligate most blood vessels (even large ones) with few if any adverse
consequences. We should learn from our Designer (Romans 1:19-20). A tourniquet can be used briefly to
stop major vessel bleeding as a bridge to surgery, but a finger usually works better if you can spare a
person to hold pressure. Tourniquets are necessary in badly mangled extremities as there would be more
bleeders than available fingers, but such a severe injury would likely be fatal in TEOTWAWKI. Keep in
mind that limb amputation in the 1800s performed by the best surgeons of the time had a 50-90%
mortality rate. Also consider the fact that a surgeon in the 1800s was far better prepared than a modern
surgeon would be in a societal collapse.
Your readers will do well if they stock up on lots of 4"x 4" and 2" x 2" gauze sponges as well as rolls of
Kerlex gauze. Remember that gauze is woven cotton thread, not the stretchy, synthetic stuff that some
manufacturers call "gauze." Wide tape such as 3" Medipore works well for most wound dressings. ABD
pads come in handy as they are very absorbent and are used to cover the wet to dry dressing before
taping it down. Make sure to get some 4" Ace brand (or similar) wraps. Get the ones with Velcro strips on
the end. These elastic wraps can be used instead of tape on an extremity to hold the dressing in
place. They can be useful in bleeding extremity wounds to tightly wrap the arm or leg to help with
stubborn oozing after the dressing is applied.
I recommend getting some Vaseline impregnated gauze or Xeroform which are non-stick dressings good for
superficial abrasions (scrapes) and burns. Each family needs a gallon of 4% Chlorhexidine gluconate
(Hibiclens or other brand) in case community acquired MRSA infections continue to plague us. It can be
used as skin preparation for wound closure, but may be more useful as treatment for MRSA colonization
and infections. Finally, make sure that you and your kids are current on tetanus shots, hepatitis, and
other vaccines. Hopefully, by leaving all but the cleanest and freshest wounds open and pre-forming wet
to dry dressing changes, more of your readers will be spared the risk of a serious wound infection in
TEOTWAWKI.

Wednesday, February 23, 2011

Letter Re: Antibiotics for Serious Wounds
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A reader wrote to ask: "Dr. Koelker, you explained what each of the antibiotics is good for, but one major
concern was unaddressed. In a TEOTWAWKI situation we may be faced with having to treat gunshot
wounds. And just as likely, if not more so, we may need to treat serious lacerations, such as accidents
with sharp, dirty tools. I think, as am I, the readers of this blog might be interested to know which
antibiotics are the most effective in preventing infections if/when we sustain such wounds."
Doctor Koelker Replies: As usual, such answers come in a short and a long form. At the moment I won’t

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address details of wound cleansing, closing, cauterizing, likelihood of infection or fatality, etc., etc.

Here is the short answer: The microbes that are likely to have been introduced into a wound determine
the choice of both prophylactic and/or treatment antibiotics. When antibiotics are given before a visible
infection is apparent, the assumption is that the wound still contains bacteria in low numbers (most of
which have hopefully been washed away by appropriate cleansing). Killing off these remaining microbes
should prevent infection in most cases – although prophylactic treatment is not always effective.
Where do these germs come from? This depends on the body part that was penetrated, the environment,
and the source of the projectile.
Injuries that pierce the skin carry the risk of contamination from common skin microbes, primarily staph
and strep germs. When orthopedic surgeons place pins and screws in bones, they pierce the skin. Despite
careful antisepsis, perhaps a few bacteria might still be introduced into a bone, where infection can
fester, causing permanent damage, limb loss, or even death. Though in a surgical setting the risk of
infection is low, the potential consequences of infection are so high that prophylactic antibiotics are
standard – one dose before surgery, and one to several doses after surgery. The intravenous antibiotic
Ancef is most commonly employed (which is most similar to cephalexin, see below).
Of the available oral antibiotics previously discussed, the best choices would be cephalexin, Augmentin,
Avelox or Levaquin. Less potent alternatives, if the former are unavailable, would include the
erythromycins (including clarithromycin and azithromycin), tetracyclines (including doxycycline), or
trimethoprim-sulfamethoxazole (TMP-SMX). Amoxicillin, penicillin, and ciprofloxacin are much less likely
to be effective. Normally IV antibiotics are preferred due to their immediate bioavailability and high
blood concentration. If oral antibiotics are used pre-op, they should be given on an empty stomach with
water only, about two hours prior to surgery.
The other large class of potential contaminants is that of intestinal bacteria, especially gram-negative
bacteria and anaerobes. If the source of contamination is external, as an explosion in a cesspool, a
person might live without surgery. If the source is perforation of one’s internal organs, death is likely
without emergency surgery.
But say surgery is an option, or you’ve cut your hand deeply while cleaning out a septic tank – you’ll
probably need a combination of antibiotics to avoid or treat infection. The first should be either
ciprofloxacin, Levaquin, or Avelox, whichever is available (ciprofloxacin is the only inexpensive generic in
this class). Second line alternatives for these would be Augmentin or TMP-SMX. Additionally,
metronidazole should be added to cover anaerobic bacteria. Basically, the same antibiotics useful for
diverticulitis or other intra-abdominal infection are indicated for intra-abdominal wounds.
Lastly, we seldom think of tetanus except to get vaccinated when we’re injured. If you haven’t been
immunized in the last five years, then do so now. The new TDAP vaccine includes immunization against
diphtheria and pertussis as well. If a wound is deep or contaminated with rust, treating with
metronidazole (or penicillin) may decrease the number of tetanus-toxin producing Clostridium tetani
bacteria, but these antibiotics do nothing to counter the toxin that has been produced, and which may
cause muscle spasms that constrict the airway. Without immunization, risk of death is very
high. (Doctor Koelker is SurvivalBlog's Medical Editor. She is also the editor of ArmageddonMedicine.net.)

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