Haiti

the  Major disasters in the last 10 years, 2000 – 2010:

2001 – Gujarat Earthquake, India                                20,000 Deaths

2003 – Bam Earthquake, Iran                                      30,000 Deaths

2004 – Indian Ocean Earthquake and Tsunami    230,000 Deaths

2005 – Kashmir Earthquake, Pakistan                       85,000 Deaths

2005 – Hurricane Katrina, USA                                       1,300 Deaths

2008 – Sichuan China Earthquake, Chine                 70,000 Deaths

2008 – Cyclone Nargis, Burma (Myanmar)              150,000 Deaths

2010 – Haitian Earthquake, Haiti                               170,000+ Deaths

These natural disasters have cost hundreds of thousands of lives, displaced and made homeless millions of people, mostly the poorest of the poor, cost billions upon billions of dollars, and their global impact has lasted for years.

There is no reason for us to expect that these moanings and groanings of our living planet will ever stop. Therefore, it is essential that we are prepared for the worst. First, we have to be prepared in our own home, then in our community, our state, our country, and finally the world.

The point of this brief article is to provide you with a list of the principles of being prepared to go, to help, and to unselfishly SERVE others in their time of need.

The Principles that will help you to prepare to go and to SERVE:
SAFETY
SHELTER
SUSTENANCE
SANITATION
STAYING WELL
STRESS

SAFETY

Safety is first and foremost is having a well-thought-out plan and sticking to it.
There is safety in numbers; always travel in a group, and try to work together as a group. Keep the team together.
When moving around, remember that traveling during the day is much safer than traveling at night.
Know where you are going, how you are going to get there, and who is going to meet you.
Find out well in advance if there are any local concerns for safety or if there are dangerous areas that you should avoid.
Ask questions. Don’t guess. Most people are more than glad to answer questions and be helpful.
Have an evacuation plan. You need to know what to do if someone in your group does become sick or injured. The plan should include how to evacuate them to home.
It is a very good idea to have some form of evacuation insurance from a group such as Global Rescue, the American Alpine Club, or Divers Alert Network to name a few.
If you do have evacuation insurance, make sure that you carry the details of the policy on your person with appropriate contact information and phone numbers. You do not want to leave it at home or back at base camp. It needs to be with you at the time of the crisis, so the plan can be easily and accurately activated.

SHELTER

When you go into areas of destruction, you cannot count on there being any housing.
You have to carry your own shelter, i.e. a tent, and in the tropical climates you have to be able to sleep under mosquito netting at night to avoid bug bites.
Warmth. Check the weather conditions and carry appropriate sleeping bag or bed roll for the anticipated climate conditions. Remember, in the tropics 60F is considered cold.
Know how to and be prepared to bivouac, to be able to make an emergency shelter from a sheet of plastic or tarp.

SUSTENANCE

Food and water:
Like shelter, you cannot assume that there will be potable water or adequate foods supplies. You do not want to use up the resources of the people whom you’ve come to help.
Food:
You have to carry enough food for your team. Preferably, food that does not take a lot of cooking time or preparation time.
Carry food that can be eaten without cooking, such as protein bars or food that cooks quickly in boiling water, such as macaroni and cheese, instant potato, rice, or premade meals.

Water:
You have to be prepared to purify all you water.
Techniques of water purification: BOIL, CHEMICAL, FILTER, UVC LIGHT
All these techniques are very effective.
Boil: Bring to a rolling boil to sterilize. You have to have a source of heat.
Chemical: Chlorine or iodine.
Use chlorine for large supplies of water for a group.
Use iodine for individual water supply, one water bottle at a time. Although iodine is inexpensive, and safe to use, it does give the water an unpleasant taste.
Filtration: You can use for a group, but usually used by individuals.
Use a filter that also contains iodine to kill the viruses that are too small too filter.
UVC or ultraviolet C light.
Steripen is used by individuals for their own water bottles.

SANITATION
Sanitation is more than just good hand washing. It involves:
Wear gloves when examining and treating patients. It is essential that you bring lots of gloves.
Having a plan to properly dispose of human waist, urine and feces.
Choices: digging a pit and making an outhouse for the group to use or you can use commercially available potties or toilet bags with proper disposal. You want to avoid fecal contamination of the local water supply.
Staying clean. Keep the perineal area clean to avoid rashes and a painful butt. Applying a thin layer of Vasoline to the area around the rectum will help to stay clean and avoid chafing.
Bring lots of toilet paper and personal wipes.
Women need to bring sanitary napkins or pads.
You have to know how to bathe in a bucket of water, and do so daily.
Rinse out clothing every day with soap and water, i.e. the skill of hand washing.
Check your skin several days for ticks, bug bites, and rashes.

STAYING WELL

Immunizations/vaccinations:
Go to the CDC.gov website, travel advice, for information on travel vaccines and common diseases in the area you are going to.
Usual childhood vaccinations plus; Hepatitis A and B, IPV poliovaccine, Typhoid, make sure tetanus and diptheria are up-to-date, consider yellow fever and meningiococcal.
Antimalarials:
If you are going into an area where there is malaria, take an antimalarial daily such as doxycycline or Malarone. Remember that malaria is treatable, but not necessarily curable; therefore, malaria porphylaxis is common sense.
Know the modes of transmission of disease and practice good body substance isolation.
Insect repellants and insecticides. Do every thing that you can to avoid being bitten by insects – mosquitoes, black flies, ticks, sand flies, etc. Use insect repellants, wear appropriate clothing, and sleep under mosquito netting.

STRESS

Post Traumatic Stress Disorder:
One of the most difficult tasks is trying to determine who is emotionally prepared to face all the destruction and human suffering that you may be confronted with.
During the deployment, try to get your group together several times daily to share in their ongoing experiences, expectations, concerns, and to pray together if appropriate.
Have a follow-up plan for after everyone has returned home. PTSD can be prevented and is treated by talking about the tough work, the difficult things that you saw and did, and the sense of disappointment or even failure that can haunt you once you are back home, safe and secure.

We have to consider the whole human being; the body, the mind, and spirit. One cannot exist well without the others and they have powerful influences over one another. Being mature, having a wide variety of human experiences, a desire to serve as well as being well grounded in faith can be very helpful and important.

This post is an excerpt from the current special edition of the Wilderness Medicine Newsletter and is reprinted here with the permission of the editors.

Cholera and Diarrhea

CHOLERA and DIARRHEA

At this very moment there is an outbreak of cholera in Zimbabwe– not a worldwide pandemic, but a localized epidemic. This is not a trivial point of interest, but a major news event that will not only have a dramatic impact on the population of Zimbabwe but also on the entire world as the aftermath of this epidemic will require international aid. Cholera will most likely kill thousands of people in Zimbabwe, impact tens of thousands of lives, and will continue to be a constant threat around the world and a very real concern for the adventurous and international travelers.

What is cholera?
Cholera, an acute infectious diarrheal illness that can cause death in less than 24 hours due to the profuse diarrhea, is caused by the bacteria, Vibrio cholera.  Spread by oral-fecal contamination of food or water supplies, it is highly contagious, as has been demonstrated by at least seven worldwide pandemics over the past several hundred years.

How does cholera cause illness?
When consumed, the cholera bacteria passes through the stomach, where, fortunately, most of the bacteria are killed by the gastric juices and acid. Once the surviving bacteria have made it into the small intestine, they invade the lining of the small intestine and begin to multiply. In the process the bacteria produce an enterotoxin, and it is this enterotoxin that is responsible for causing the profuse, watery diarrhea that results in large quantities of fluid and electrolyte loss.

How does cholera cause death?
Death is a result of hypovolemic shock brought on by the profound dehydration from the enterotoxin-induced diarrhea.  The very watery, grayish diarrhea is referred to as a rice water diarrhea. The victim of cholera can easily have massive diarrhea at a rate of 3 – 4 liters per hour or even more, literally dehydrating and shriveling up right before your eyes. Cholera is a very dehumanizing, debilitating disease.

What are the signs and symptoms of cholera?
Diarrhea – copious amounts of watery, rice water diarrhea.
Dehydration leading to hypovolemic shock – rapid, weak pulse; hypotension; rapid, shallow breathing; pale, cool, clammy skin; anxiety; and a sense of impending doom
Headache
Exhaustion and prostration
Malaise
Possible nausea and vomiting

How is cholera treated?
Hydration, Hydration,Hydration
The initial goal, and that means IMMEDIATELY is to replace the lost fluids and electrolytes. Then continue to replace the fluids that are being lost as quickly as they are being lost. As long as these patients can drink, oral therapy works very well. However, you have to replace the electrolytes as well as the water that is being lost. Water alone will not improve their survivability.

Electrolytes are charged ions: sodium (Na+), chloride (Cl-), potassium (K+), and bicarbonate (HCO3-).  Glucose is also required to supply the energy that is needed to live. These electrolytes with the addition of glucose maintain the basic and vital functions on a cellular level to sustain life as we know it.

How do you make an Oral Rehydration Solutions (ORS)?
1. ORS can by made by mixing a commercially available ORS powder with water.
2. Home remedy can by made by simple adding sugar and salt to water.
1 liter of water + 1 teaspoon of salt + 8 teaspoons of sugar
3. Rice water is also a very effective ORS. It is made by cooking rice as usual.
1 liter of water + ½ cup of the cooked rice + 4 teaspoons of sugar + 1 teaspoon of salt. Stir to create a drinkable liquid.
The calories from sugar are very important. If sugar is not available you substitute molasses, brown sugar, fruit juice (contains glucose and fructose), or green coconut water. In fact molasses and brown sugar are better as they contain additional compounds that are also helpful.

Antibiotic Therapy:
Cholera is also caused by the bacteria, Vibrio cholera, and fortunately it is susceptible to several different antibiotic therapies.

Antibiotics that can be used to treat cholera:

Oral rehydration is the cornerstone of therapy. Antibiotics will shorten the course of the diarrhea and speed recovery. Following is a list of several antibiotics and their dosages that will help to eliminate the Vibrio cholera in the small intestine. There are several options, all are equally efficacious.

Single dose antibiotics:
Doxycycline: single dose – 7mg/kg up to 300mg.
Tetracycline: single dose – 25mg/kg up to 1000mg.
Ciprofloxacin: single dose – 30mg/kg up to 1000mg.

Multiple dose antibiotics:
Trimethoprim/sulfamethoxazole:  5-10mg/day, divided bid x 3 days, up to 320mg of the
trimethoprim/day and 1600mg of the sulfamethoxazole/day.
Ampicillin: 50mg/kg/day, divided qid x 3 days up to 2000mg/day.
Erythromycin: 40mg/kg/day, divided tid x 3 days, up to 1000mg/day.

How can the spread of cholera be prevented?

Cholera is spread by oral-fecal contamination of the food and water supplies that are then consumed by others causing further spread of the illness.
Therefore, drink only water that has been properly treated with iodine, chlorine, filtration, boiling, or UVC light.
Avoid ice as freezing does not sterilize water.
Eat only properly prepared foods:
Vegetables that can be peeled or cooked.
Well cooked meats and fish.
Avoid raw or undercooked meats.
Beware of sanitation practices, hand washing, and dirty dishes.
In addition, health care providers must take Body Substance Isolation (BSI) precautions and practice extremely safe hygiene when working with cholera patients.
Quick summary of Cholera and its influence on recent history:
1816-1826: Cholera Pandemic:
The outbreak began in Bengal and then spread across India. Approximately 10,000 British troops and countless Indians died during this pandemic.
1829-1851: Cholera Pandemic:
This outbreak lasted 22 years and extended initially from Russia into Europe. In London, the disease claimed close to 7,000 victims, and in Paris alone another 20,000 perished with approximately 100,000 deaths in all of France.
The epidemic reached Quebec, Ontario, and New York in 1832 and the Pacific coast of North America by 1834. The number of deaths appears to not have been recorded.  In 1848, a two-year outbreak occurred in England and Wales which claimed about 52,000 lives.
1849:  A second major outbreak spread in Paris and London. In London it claimed 14,137 lives, twice as many as the 1832 outbreak.
1849:  Cholera was responsible for 5,308 deaths in Liverpool, England, and 1,834 in Hull, England.
1849: Cholera spread into the Mississippi river system killing over 4,500 in St. Louis and over 3,000 in New Orleans, and thousands more in New York. Cholera also spread along the California and Oregon trails; hundreds died during the California Gold Rush.
1852-1860:  Cholera Pandemic:
The pandemic mainly affected Russia, with over a million deaths.
In 1853-1854, another London’s epidemic claimed 10,738 lives.
1854: An outbreak of cholera in Chicago killed about 3,500 people.
1863-1875:  Cholera Pandemic:
Occurring primarily in Europe and Africa, at least 30,000 of the 90,000 Mecca pilgrims died from cholera during their pilgrimage. Cholera also claimed 90,000 lives in Russia in 1866.
1866: A cholera outbreak took place in North America while at the same time in London where cholera killed 5,596. Also more than 21,000 people died in Amsterdam, The Netherlands.
1881-1896: Cholera Pandemic:
The 1883-1887 epidemic took 250,000 lives in Europe and at least 50,000 in America. Cholera claimed 267,890 lives in Russia, 120,000 in Spain, 90,000 lives in Japan, 60,000 in Persia, 58,000 in Egypt, and 8,600 in Germany.
1899-1923: Cholera Pandemic:
This pandemic killed more than 800,000 in India.
1961-1970s:  Cholera pandemic:
Beginning in Indonesia, this pandemic reached Bangladesh in 1963, India in 1964, and the USSR in 1966. From North Africa it spread into Italy by 1973. In the late 1970s, there were small outbreaks in Japan and in the South Pacific.
January 1991 to September 1994:
An outbreak in South America, beginning in Peru where there were 1.04 million identified cases and almost 10,000 deaths.
November 2008 – Doctors Without Borders, (Medicines Sans Frontiers) reported an outbreak in a refugee camp in the Congo.
November – December 2008
Is has been estimated that more than 11,000 people in the African nation of Zimbabwe are infected, and there have been more than 600 deaths.
Please note that these statistics come from a variety of resources. If you are interested, one of the most complete sources of the history of cholera pandemics can be found on Wikipedia by looking up cholera.

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Improvised Pelvic Splint

In keeping with the other video demonstrations that we have posted on this site, below you will find a video of an improvised splint for a possible fractured pelvis….

Improvised Traction Video

Back in December of 2007 we wrote a series of posts on lower Extremity injuries. Here is a video demonstration of an improvised traction splint to go along with that post.

IX. Patient Assessment System – Checklist

Part 9 of 9: PATIENT ASSESSMENT CHECK LIST:

SCENE SURVEY:
Is the SCENE SAFE?
Is the PATIENT SAFE?

PRIMARY SURVEY: 
Are they CONSCIOUS?
Do they have an OPEN AIRWAY?
How is their BREATHING?
Do they have a PULSE? 
Are they BLEEDING?
Are there any serious injuries on the CHUNK CHECK?
Is their neck and spine STABLE?
Do they need to be MOVED?
Do we need to protect them from the ENVIRONMENT?
How is everyone else DOING?

SECONDARY SURVEY – VITAL SIGNS:
What is their RESPIRATORY RATE & EFFORT?
What is their HEART RATE & EFFORT?
What is their LEVEL OF CONSCIOUSNESS?
What is their SKIN COLOR, TEMPERATURE, & COLOR?

SECONDARY SURVEY – PATIENT EXAM:
HEAD  - scalp, face, eyes, nose, mouth.
NECK  - spine, trachea.
CHEST - clavicles, shoulders, ribs.
ABDOMEN - compress the abdomen.
PELVIS - compress the pelvis anterior/posterior and lateral.
LEGS  - circulation, sensation, and motion.
ARMS  - circulation, sensation, and motion.
BACK  - log roll and palpate the length of the spine.

SECONDARY SURVEY – AMPLE HISTORY:
ALLERGY - allergy to drugs, foods, insects, etc. 
MEDS  - prescription and non-prescription drugs.
PREVIOUS - significant past medical history, surgeries, etc.
LAST   - last intake & last output.
“ EVENT - events leading up to this crisis.

SOAPnote:
Putting it all together and creating a treatment plan.

RESCUE PLAN:
“ Looking at all factors and creating a rescue or evacuation plan.

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VIII. Patient Assessment System – Rescue Plan

Part 8 of 9: PAS – STOP – RESCUE SURVEY: Do we need help?

Are we staying or going?
What is our plan to get help?
Who is going to go to get help?
What do we do to protect the patient while waiting for help to arrive?
What do we do to protect ourselves while waiting for help to arrive?
Is the scene safe?

RESCUE PLAN: Do we need help?

Group’s condition:
How well is each individual in the group doing?
How well prepared is the group to stay put and bivouac?

Decisions:
Do we need to evacuate the patient or can we all go on?
If evacuation is needed, send for help.
While waiting for rescue – build a bivouac.

Sending for help:
Send two to get help if possible.
Send out a SOAPnote on the patient.
Send out a list of the rest in the group and how well prepared you are to bivouac.
Send out a map with your exact location and time marked on it.

While waiting for help to arrive:
Know where everyone is; pair people up to massage each other’s feet, etc.
Keep everyone busy.
Create shelter for everyone.
Get water or melt snow and make something warm to drink.
If food available, make a meal & eat.
Keep spirits up, be positive, reassure, make sure everyone has something to do.
Create light and warmth; build a fire.
Make yourselves big, easy to find.
Continuously monitor your patient.
Continuously monitor everyone else in the group.

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VII. PAS – Secondary Survey – SOAPnote:

Part 7 of 9: PAS – SOAP note: What is our patient care plan? 

The SOAP note is organized into the Subjective date, Objective date, the Assessment, and the Plan.

Subjective:
The subjective date is their age, sex, the mechanism of injury (MOI), and the chief complaint (C/C), i.e., what they are complaining of.

Objective: 
The objective date consist of their vital signs, the patient exam, and the AMPLE history.

Vital signs: 
Time the vitals signs are taken:   
RR & Effort    
HR & Effort(BP)    
LOC    
Skin: C/T/M    

Patient exam:  Describe locations of pain, tenderness & injuries.
                                                                                                                                               
AMPLE history:
Allergies:           
Medications:             
Past pertinent medical history:         
Last intake & output:           
Events leading up to accident:         

A – Assessment:  (problem list)
1.                                                                                                                                                  
2.                                                                                                                                                   

P – Plan:  (plan for each problem on the problem list)
1.                                                                                                                                                   
2.                                                                                                                                                  
3.  MONITOR - reSOAP your patient every 5 – 15 minutes.

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VI. PAS – Secondary Survey – AMPLE History:

Part 6 0f 9: PAS – AMPLE History: What is their past medical history?

ACTION:
Talk with your patient or others to determine the following information:

A – Allergies:
Are they allergic to any medications, foods, insects, etc.? 
If they are what happens and how is it treated?

M – Medications:
What medications are they taking, both prescription and over-the-counter?
If they are taking medications, how often and how much do they take and have they taken their meds today?

P – Previous Injury or Illness:
Is there any recent or past injury or illness that could contribute to the current problem?
Have they ever been hospitalized over night for any medical problems, is so what?

L – Last Input and Output:
When was the last time they had anything to eat or drink?
What did they eat and drink?
When was the last they voided or had a bowel movement?

E – Events leading up to the crisis:
What lead up to or occurred just prior to the critical event?

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V. PAS – Secondary Survey – Patient Exam:

Part 5 of 6: PAS – PATIENT EXAM: What are their injuries?

PRINCIPLES OF THE PATIENT EXAM:
You are trying to discover all possible injuries by:
LOOK:
Inspect:  Is there any bleeding, wounds, impaled objects, or deformities?
Compare:  Are their body parts symmetrical?
LISTEN:
Complaints: Are they complaining of pain or tenderness, if so, isolate where it hurts?
FEEL:
Palpation: Is there tenderness in muscles, bones, or joints?
Circulation:   Are there pulses in all four extremities?
Sensation:   Is there normal sensation in all four extremities?
Motion:   Is there normal range of motion is all four extremities?

ACTION:
Keeping the above principles in mind do a hands on head-to-toe exam:
HEAD:  scalp, face, eyes, ears, nose, mouth.
NECK: cervical spine, trachea.
CHEST: clavicles, gently compress the rib cage.
ABDOMEN: compress the abdomen in all four quadrants.
PELVIS: compress the pelvis front to back and laterally.
ARMS: palpate the muscles and flex the joints.
LEGS: palpate the muscles and flex the joints.
BACK: palpate the length of the back.

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IV. PAS – Secondary Survey – Vital Signs:

Part 4 of 9: Patient Assessment System – Vital Signs:

STOP – SECONDARY SURVEY: How hurt are they?
The Secondary Survey consist of:
How well are they? Vital Signs
What are their injuries? Patient Exam
What is their past medical history? AMPLE History
What is our patient care plan?  SOAPnote

VITAL SIGNS: How well are they doing? 

Respiratory Rate and Effort:
Respiratory rate and effort shows us how well the Respiratory System, the airway and lungs, is doing at oxygen exchange and in particular, in supplying the brain with O2.
LOOK – Do they look like they are having difficulty breathing?
LISTEN – Are they complaining of shortness of breath or difficulty breathing?
FEEL - Is the chest moving properly with breathing?

Heart Rate and Effort (blood pressure):
The heart rate and effort, blood pressure, tells us how well the Circulatory System, the heart and blood vessels, are doing.
LOOK – Do they look shocky?
LISTEN – What is there heart rate, beats per minute.
FEEL – Take a blood pressure by palpation (systolic), if you do not have a BP cuff.

Level of Consciousness:
Level of consciousness tells us how well the Central Nervous System, the brain and spinal cord, are doing.

Action:
Level of Consciousness (LOC) is determined using the AVPU scale:
Awake, Verbal, Painful, Unresponsive.

Conscious: “The lights are on, is anyone home?”
Awake, their eyes are open but, are they alert oriented times 3, person, place, and time?
Person, do they know who they are?
Place, do they know where they are?
Time, to they know the day, week, and year?

Unconscious: If their eyes are closed they are unconscious, but how responsive are they?
Verbal stimuli, “Hello, anyone in there?”
Speak to them, do they react to hearing their name?
Do they follow simple commands?
Painful stimuli, “That’s got to hurt.”
A knuckle rubbed on their sternum?
Is it an appropriate response to pain?
Unresponsive, “Speak to me; say something.”
No response to verbal or painful stimuli.

Skin color, temperature, and moisture:
Skin color varies by individual and race.
Look – What is their skin color, pale, ashen, cyanotic?
Listen – Are they complaining about feeling hot or cold?
Feel – Is their skin dry, moist, clammy, hot, or cold?

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