Human Waste
Human waste is much more of a problem. We are no longer accustomed to dealing with our own waste. The average person produces two to three pints of urine and one pound of feces per day. Multiply that by the number of people in your group for a day, a week, or longer and you begin to see the problem. If the sewer system is working you can still use your toilet by pouring water directly into the bowl to flush the waste. Otherwise, a five-gallon bucket with a toilet seat can be used as a porta-potty. Layering lime, wood ash, and good ol’ dirt can reduce the odor. Buckets will have to be cleaned daily and set up in an area away from any possible contamination sites so that the contents can be used for composting, keeping the compost covered to deter flies, etc. You should not use this compost in food gardening.
A trench toilet is also an option. Dig a trench two feet wide and a minimum of one foot deep and four feet long or more. After use, cover with the dirt from the hole, filling in from one end as you go. Bad bacteria can travel three hundred feet from the original site. Pay attention to drainage, and make sure the manure is covered with lime, ashes, or dirt. The area could attract rodents, dogs, and, worse, flies. The most important things to remember are reducing the fly/rodent problem and washing your hands thoroughly when you’ve finished. Stock up on hand sanitizer as well as soap. Do not attempt to use the trench method for manure that will be used for vegetable or grain growing.
For those of you planning on hunkering down in place if the grid were to go down and the sewer were to quit functioning, pay attention to where the access lids to the sewer are in your area. If you are anywhere downhill, sewage may back up through these portals and even into your drains and toilets. Give this some thought.
Medical
In a TEOTWAWKI situation, people may show up late or be accepted into the group that weren’t there in the beginning. We need to consider that these folks, whether loved ones or strangers, may be bringing something unwanted with them. If possible, a quarantine area should be set up, where these people could spend two weeks away from the group, to make sure they aren’t sick. It may sound cruel, but these people should remain without direct contact with the group. Radio contact or distant voice communication, if acceptable, would help them significantly. Their meals could be dropped off on paper plates that they could burn after they’ve eaten. Anything that is needed should be brought and dropped off so as not to expose the other members of the group. The newcomers would need to remain in the quarantine area at all times and not interact with people, animals, areas, or equipment. If after two weeks they are well, the chances are greatly reduced that they have a communicable disease.
There should also be a separate area for medical procedures—a bedroom or bathroom. This area should be kept spotless at all times. All items being used would need to be boiled or steamed (a steam canner or pressure canner as an autoclave) and all fabrics baked (two hundred degrees for one hour) prior to use. Tables, trays, and equipment should be washed and bleached. Alcohol is a great bacteria killer. New garbage bags could be used to cover tables, chairs, etc., prior to use and after cleaning, and to protect between activities. They are fairly sanitary. Disposable rubber gloves and masks should be worn when treating patients, and if blood is present goggles should be worn (swim goggles, or ski goggles over glasses would work). Used dressings and the like should be burned or buried deeply, away from the area.
Rodents and flies that carry disease will probably be a major concern. In a grid-down situation they would flourish. Rodent control would be a regular requirement, but handling them could be an issue in itself—probably best done with a mask and gloves. Keep flies away from any foods and food areas.
Death
The most difficult area of sanitation we may have to deal with is death. Although many organisms in the body of the deceased are not likely to infect a healthy person, handling the blood, bodily fluids, and tissues of those who have been infected increases that risk. Many fluids leak from a dead body, including contents of the stomach and intestines. The level of decomposition depends on how long the person has been deceased, the temperature of the environment, the damage to the body, and the bacteria present. There are some basic precautions to take in handling the deceased:
• Wear disposable gloves when handling anything associated with the body, and cover all cuts or abrasions with waterproof bandages or tape.
• Wear a mask or face shield, goggles, or some other kind of protection for the mouth, nose, and eyes. Decomposing bodies can sometimes burst and spray fluids and tissues due to the buildup of gases.
• Wear aprons or gowns that can be destroyed.
• Wrap the body in a body bag or several layers of garbage sacks or plastic sheeting. The more quickly this takes place after death, the less chance of leaking bodily fluids.
Cremation requires large amounts of fuel and may not be feasible. Graves should be dug at least one hundred feet away from all open water sources and deep enough that animals won’t dig them up. Thoroughly wash yourself afterward and dip your hands in a bleach solution even if no apparent contact was made. Disinfect all equipment, surfaces, floors, and so forth with a bleach solution. Don’t forget to make notes on the deceased and the circumstances surrounding the death and burial. Take pictures if you can. Consider anything that you think is of importance, in case the authorities come back and question it sometime. This may be the most difficult part of a societal collapse. But the quicker it is dealt with, the better for everyone involved.
Wound Care: An Emergency Room Doctor’s Perspective
As you are cutting wood and swinging gardening tools, you are at risk for wounds. Even a minor wound can be a major problem if not treated effectively. E.C.W., M.D., provided the following essay:
Arguably the most important factor in wound healing is the potential for infection.
Bleeding is nature’s way of cleaning a wound, but a little goes a long way. Remember that as long as the wound is “downstream” from the heart, bleeding will be under pressure, so don’t forget to elevate a bleeding extremity above the level of the heart to get control of bleeding. Scalp wounds especially bleed profusely and may be frightening to the uninitiated. Use multiple layers of absorbent material—sterile gauze or a clean towel (or the cleanest cloth you have available)—and maintain direct pressure until bleeding ceases or is at least reduced to a slow ooze. A patient who is taking aspirin will have a prolonged bleeding time, so you will have to maintain pressure for a longer period of time.
Plain soap and tap water have been shown to be just as good for washing the wound as an antiseptic soap and sterile water. I would recommend a liquid soap to avoid the bacterial culture waiting to launch itself from the bar on the counter, but would avoid the widely available antibacterial soap (which contains triclosan); it has been shown to increase bacterial resistance. In a perfect world I would prefer Hibiclens, but would certainly use a “no-tears” baby shampoo (neutral solution), or even diluted Dawn dishwashing liquid in a pinch. Apply soap to a clean washcloth wet from the tap and use it to gently scrub the wound.
The sterile water solutions that are available bottled are fine, as long as they have not been opened previously (they are contaminated once opened), but nonsterile bottled water is not preferable to tap water. Tap water is sufficient for cleansing of most wounds. I would not use this for an open fracture. Of course, freshly boiled water would be more reliable than nonsterile bottled water or water that you have previously drawn up in a clean milk jug, but it is better to wash a soiled wound immediately if you have clean water available than to take the time to boil and then cool water, leaving a heavily contaminated wound in its dirty state. You could always re-rinse the wound with sterilized water. The length of time that the cleanser is in contact with the wound and the degree of flushing that takes place will determine the number of bacterial contaminants remaining and thus have a significant effect on wound infection rates, so spend several minutes on this step. Of course the examiner/caregiver s
hould scrupulously wash his hands and any instruments used to probe the wound beforehand. Thoroughly cleaning the wound will usually result in resumption of bleeding. When cleaning is finished, pressure can again be applied.
A foreign body remaining in the wound can be a focus of infection and prevent healing, so it is imperative that care is taken to rid the wound of any particles that may be present. A large syringe or squirt bottle can be used to administer a stream of water into the wound under a little pressure in order to thoroughly clean it and dislodge particulate matter. Chain-saw wounds may require debridement (cleaning and removal) of the margins with a scalpel to remove seared tissue as well as particles and clothing fibers, as searing prevents the wound edges from closing together in healing.
Boil or sterilize equipment such as a scrub brush or tweezers before removing all foreign material from the wound. (Cleaning instruments with alcohol and/or soap and water would be better than nothing.) Blood clotted in the wound must also be removed by scrubbing, as dried blood serves as a foreign body in this setting. After thorough cleansing with soap and water, if a wound is to be sutured, Betadine (if available) could be swabbed on the skin in pinwheel fashion, from the skin at the wound edges out to two or three inches away from the wound.
Anesthesia is certainly desirable prior to any painful manipulation or procedure, and if possible should be mercifully administered prior to any vigorous cleaning. Even the most stoic among us can appreciate pain relief, even if it is only temporary. So a vial of lidocaine (1 percent or 2 percent) and a syringe to administer it may be part of your wilderness medical kit. If the lidocaine has epinephrine mixed in, it will help a lot to keep the wound from bleeding as you try to suture it, but you must not use epinephrine in a wound on an extremity such as a finger or toe, as it could result in necrosis (tissue death). On the face or scalp epinephrine is a welcome additive, since these wounds tend to bleed so freely that you can scarcely see what you are sewing without it.
In addition to elevating the wound above the level of the heart, you may use limited tourniquet banding with a wide strip. (In the ER I might use a blood-pressure cuff pumped up to the point at which it stops the bleeding). This should be temporary, to maintain a bloodless field for closure only. Carefully and slowly infiltrating the margins of a wound with a few milliliters of an anesthetic solution, a learned technique, will result in control of bleeding and pain (for closure). Then you must give the anesthetic a few minutes to be absorbed before commencing your repair. Whether you use anesthetic or not it would be wise to administer pain medicine of some kind, either orally or by injection, since the wound will throb even after the repair is done.
Wound closure is a key factor in healing and infection rate as well. Wounds left open will be infected to some extent. The six-hour rule for closure is followed for minor wounds; that is, if care is sought within those limits the wound can be cleaned and sutured with impunity.
Closure may involve suturing (sewing) or may be as simple as using Dermabond (superglue), Steri-Strips, or staples made for this purpose. In the ER I tailor the method to suit the patient and the situation, but you might not have that option in the wilderness or a homebound setting. If you do, or if you can reach qualified medical help within a suitable time frame, I wholeheartedly advise you to do so. But if that is not possible, even duct tape may be preferable to nonclosure.
You must be careful to hold the wound margins together tightly to apply Dermabond, as any solution that makes its way into the wound may itself prevent healing, and with Dermabond the trick is to keep your fingers from being glued to the wound while waiting the few seconds for it to dry. I do not advise using Dermabond for a wound that has a tendency to continue bleeding the minute pressure is removed, nor in a wound that is deep or under stress. It works well on some facial lacerations, but I trust Steri-Strips to do the job, and they could easily be part of a medical kit.
Wound margins should be closely approximated prior to the application of any binding material, including Steri-Strips or tape. If you are reduced to using duct tape, first tear several inches off the roll so that what you use on the wound has not been in contact with a dirty surface. Then tear or cut three or four inches off and cut that into one-eighth-inch to one-quarter-inch strips, taking care to keep your hands from touching the part of the tape that will be over the wound. Pressing the wound edges together with one hand, or having a helper hold them together by pushing from each side, apply the strips of tape, starting on one side and pulling firmly to apply some tension before allowing the tape to adhere to the other side of the wound. Space these strips one eighth to one quarter of an inch apart to allow the wound to breathe, and then cover with sterile gauze secured by tape or an ACE wrap (or cotton bandage) to keep it from being recontaminated.
I would not worry about small defects or ragged edges. Individuals who are sensitive to adhesives may develop blisters where the Steri-Strip or tape is located, but this is usually just a local reaction and does not cause systemic allergic symptoms. In someone who is unable to tolerate adhesives, sutures or staples should be used for larger wounds requiring closure.
Suturing is a technique that is learned and should be practiced prior to use, which is not to say that any accomplished seamstress couldn’t master it. Many wounds will greatly benefit from needle and thread. However, to reinforce the importance of asepsis in wound care, I should again point out that a wound should not be sutured by an untrained individual in a nonsterile environment if there is an alternative. If there is not, then any asepsis that can be accomplished by boiling or autoclaving (pressure-cooking) would be of benefit, and extreme care should be taken not to further contaminate the wound while attempting to close it in the best possible way. What is obvious to medically trained personnel—microbial contamination and how to avoid it—is the major impediment for the layperson. Sterile drapes and sterile gloves are a bonus. But most medical staff would agree that primary closure is better than a large wound left open in most cases. In our current political-legal climate one could be prosecuted for “practicing medicine” without a license if it appeared that extraordinary measures were undertaken by the layman who had other options, so be sure that you are doing so out of necessity. In a TEOTWAWKI setting, you will probably wish that you had at least studied the technique (and had obtained the proper equipment and practiced on some animal skin).
Some wounds are by definition contaminated or infected and are better left unclosed. These include puncture wounds, stab wounds (deeper than they are wide) that are not bleeding profusely, and animal or human bites. These should be cleaned and scrubbed as above, taking even more care to flush them out if possible, with bleeding controlled with pressure only. If that’s not possible, then one or two sutures or Steri-Strips can be strategically placed. Be careful to draw the wound edges together only enough to control the bleeding and not to closely approximate them, as you want the wound to be able to drain easily. These are the wounds for which an ER doctor would probably give antibiotic prophylaxis, with an older drug such as doxycycline or trimethoprim-sulfa, or a cephalosporin such as cephalexin (Keflex). Crush wounds of the extremities also should not be sutured, even if they look awful, but should be cleaned as much as possible given the level of contamination and then bandaged. Because “crush wounds” can be expected to swell so much, primary closure could be detrimental.
In a situation in which it could be days before a medical professional would be consulted, you should know that sutures of the face and scalp should be removed in four to five days, lest the sutures themselves cause scarring. An uninfected facial wound should be healed in that time. Steri-Strips can be removed from the face at that time. For wounds of the upper extremities, leaving sutures in for seven to ten days is advisable, depending on the extent of the wound, and for the lower extremities up to two weeks. If Steri-Strips or tape have been used, they may need to be reapplied during that time period. Keeping the wound clean and dry is the goal, but if sutures are used to close the wo
und, it can be washed daily with soap and water after the first twenty-four hours. If a wound becomes obviously infected, with purulent (yellow or green) discharge, swelling, and redness, it will have to be opened up at least partially and allowed to drain to prevent septicemia.
Tetanus prophylaxis should also be addressed. Puncture wounds and deep, heavily contaminated wounds are considered tetanus-prone. The vaccine for tetanus has been used for several decades and is considered very safe if one is not allergic to any of the components, so keep your vaccination status for tetanus up-to-date.
The best way to avoid wound infection is to avoid the wound in the first place. Be careful. Make your children wear their shoes outside of the house. Lacerations from stepping on broken glass and puncture wounds from thorns or tacks in the feet are fairly common in the ER and are usually preventable. Accidents will happen to even the most cautious, but they will be proportionately less than to the heedless or reckless.
Extended Care of the Chronically Ill in TEOTWAWKI
When thinking through your plans for TEOTWAWKI, it is important to consider caring for chronically ill family members. Some of these issues can probably be foreseen, such as the need for photovoltaically powered CPAP (constant positive airway pressure) machines for sleep-apnea patients, and refrigeration of insulin. But other chronic conditions might arise after the onset of a crisis and are hence more difficult to anticipate and plan for.
How to Survive the End of the World as We Know It Page 15