WRSA Sends More Of The Grid Down Hospital “Patient Assessment”

Grid Down Hospital: Part VI – Patient Assessment Overview

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The latest from the team:

Patient Assessment Overview

Entire medical text volumes have been written about a full patient assessment, and what it should encompass. This will not be one of them, but it will serve as a reasonable overview for your efforts.

The type of assessment you perform is entirely based on time and resources devoted, which dictates the scope.

The first, and largely ignored, is the Eyeball Assessment. What you see in the first few to twenty seconds of contact with your patient.

Are they conscious? Alert? Oriented to person, place, time, and events?

Breathing? Normally?

Bleeding?

Do they have any Stevie Wonder fractures, i.e. obvious deformities?

What color is their skin, as in normal nail-bed pink, or pale, jaundiced, etc.?

In short, can they walk, talk, and basically function normally?

This is a Go/No Go evaluation, and determines the likely severity of their situation, and the scope of your further efforts.

The second, usually deployed in the Mass Casualty Event (a Mass Casualty is ANY event when demands exceeds immediate resources, and could be as little as one patient), is known in the biz as the START assessment, for Simple Triage And Rapid Treatment.

A picture being worth 1000 words, here it is:

gdh-startadulttriagealgorithm

The algorithm above embiggens. Learn it, love it, live it.

Use of this algorithm enables one person, with a handful of triage tags with four color choices (which determine rather exactly your medical future) to triage multiple patients in a few seconds apiece, and then get back to focusing on the worst first without wasting resources on those who died or soon will.

There are multiple videos on YouTube covering START Triage which explain this process. A quick survey showed that they’re all bad (in being poor quality, lousy presenters, boring as f***, but..), but pick one and follow along, because they cover the information, while unfortunately being largely unwatchable.

The next level of patient assessment is used for most contacts – the Primary Assessment.

The list is a little more involved, and from this point onwards, all assessments need to be seen as only one data point. This means while true, they don’t tell you much by themselves; the key is to do multiple assessments, and note the trend, over time. That’s where they gain their true value.

This requires adequate documentation each and every time, and completeness, each and every time, at least of the pertinent items.

You want the following:

Baseline mental ability: awake, alert, oriented times four items?
Body Temperature?
(Note that even lacking a thermometer – which you shouldn’t but…- hot/warm/cold to touch is still clinically useful.)
And skin color and moisture: pink/dry is normal. Pale/diaphoretic(sweaty) is not.
(Note also that if lacking medical terminology, plain English will suffice.)
Pulse: regularity (or not), rate (beats per minute), and quality (weak/strong/bounding).
Respirations: regularity (or not), rate, including chest symmetry, and any further medical description of the respirations (which requires more than laymen-level instruction), if appropriate.
Blood pressure: With a cuff, and where (on the patient’s body) taken.
Pulse oxygenation, if you have the capability.

The above is standard from field and ER triage desks to surgical anesthesiology, and will stand you in good stead if you equip for it, learn it, and do it. Practice now, and on patients from infants to the elderly, any time the opportunity presents itself.

Ancillary equipment in any of those environments can get you more information, but you can’t suffice with less, in most instances, nor should you try.

I repeat: Documentation, Accuracy, and Trend Over Time.

Lastly is the Secondary Assessment. It is a complete review of the body from head to toe.

I can do a pretty thorough one in two to five minutes on a prone patient, even if they’re unconscious. The checklist runs to two or three pages. (Flighterdoc, I , or some other author may devote a separate essay to same in the future.) As this is where patient assessment and other medical texts come in handy, the short summary is that you look at and palpate (touch and feel) everything from the top of the scalp to the soles of the feet, which you have to be able to get to and see – which is why the doctor always wants you in that annoying loose gown first, and why paramedics cut your clothes to ribbons nine times out of ten at an accident scene. Jeans and boots are replaceable, death is not.

You are looking for obvious deformities, bleeding and/or other fluid leaks, bruising, other wounds, skin color, movement, nerve sensation, circulation, intactness of bones, normality of reflexes, or any and all deficits in the above. Head, neck, torso, abdomen, groin, arms to the fingertips, and legs to the toes, including rolling on the side to inspect everything, particularly the spinal column, from head to tailpipe, inclusive.

If the patient is awake and responsive, it also includes hearing, eye movements, and verbal expression checks, because these give you cranial nerve function times twelve (you should look these up) without a CT scan, in about a minute.

After that, you progress to things like laboratory blood, urine and fluid tests, and diagnostic imagery (Xrays, Ultrasounds, CTs, MRIs) which probably are – but need not necessarily be – beyond your scope. For one example, you can get a bedside ultrasound machine for about the price of a thermal weapon scope. One can pick out a target at 1500 yards, and the other can diagnose internal bleeding or appendicitis. You decide whether either of those things are important, and devote your resources appropriately.

You can also, even in degraded conditions, do blood laboratory work and cultures of specimens to detect infection, if you have the equipment, training, and resources. SF 18Ds are expected to meet that standard, and did so in sandbag hooches in SEAsia amidst a war. You get what you pay and train for, and your people will bless or curse you, depending on your abilities and their outcomes.

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JCD

American by BIRTH, Infidel by CHOICE

TOWR Commo Class Prep

The Order of The White Rose (TOWR) will be running a 1 Day Basic Introduction to Radio and Communication Class November 5th 2016 in the Greater Seattle Area.

Class will be 6 to 8 hours, cost is $50.00, location will be provided upon registration. Email us attowr@hushmail.com to register!

This class will touch on the following areas:
– Radio and Communications Basic Theory and Terminology
– Radio Capabilities and Operating Techniques
– Introduction to the Equipment, Radios, Antenna’s, Power, Connections and Cable
– What type of Radio should you buy, Walmart Walki-Talkie, Baofeng, UHF/VHF vs HF
– How Repeaters work and how radio waves act
– Use of Your Radio
– How to Program Your Radio
– Introduction to Scanners and their uses in your area
– Local and National Education Resources
– Introduction to SDR (Software Defined Radio) and Ham-Net

Our goals for this class are:
1st – To give attendees a basic information foundation in the area of Communications. However this is class is notintended to be provide attendees enough information to pass their Ham Radio License Test, its a start but not intended to do that.
2nd – To provide enough practical information that attendees can evaluate the use of Radios in establishing their own Communication networks for families, neighborhood, Group and nearby Groups.
3rd – The Order of the White Rose will be sponsoring Sparks31’s, 2 day Grid-Down/Resilient Communications Class in the Seattle area, June 2017. Our intent is to provide attendees enough information to get the maximum value from what Sparks31 teaches in that class. Without this basic foundation sometimes getting that value is like trying to get a drink of water out of a hydrant.
Sparks31 Grid-Down/Resilient Communications ClassInformation
– Email us attowr@hushmail.com and register for both classes now! The Sparks31 class WILL sell out!

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JCD

American by BIRTH, Infidel by CHOICE

WRSA Sends: The Grid Down Hospital/The Library

Got reference?

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Grid Down Hospital: Part IV – Medical Books For Your Hospital Library

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Flighterdoc sends:

Medical Books

Where to get these books

Obviously, if you have the interest and budget, the easiest place to get these is from Amazon.com. Since you don’t need the latest editions of most of them, buying used books from Amazon, or from Half.com is perfectly adequate. You can also check Ebay, local bookstores (new or used) or most any other source. Public libraries probably won’t have a good collection of this level of medical books, and you can’t keep the books indefinitely. Some may be available as electronic books (legitimately or pirated). If you go this route then print them out. It may be much less expensive to just buy them, then pay for ink to print out a several hundred page book.

The time to get and study these books is before you need the knowledge in them. And since the quality of electronic versions can be spotty, plus electronic readers can fail, get the paper copies even though many of these textbooks (and others) are available

Medical textbooks are normally referred to by the primary authors’ name, and most of these books are listed that way. They are all listed with sufficient information that they can be identified on Amazon or whatever. Many are also available as illegal downloads, as well.

Generally, you don’t have to have the latest version of a medical textbook – but you don’t want one that is decades out of date, either.

Medical science does change, and things that were considered appropriate treatment even ten years ago are now known to be dangerous, or vice-versa, so try and use the most current books available and review several different books for a consensus for treatment.

Before you start

Medical Terminology

Chabner, Medical Terminology: A short course

Medicine has its own language, and words mean very specific things. You need to understand this language.

Medical Dictionary (Professional level). Any of the following dictionaries are fine, preference for one or another is purely personal.

Stedman’s Medical Dictionary
Dorland’s Illustrated Medical Dictionary
Taber’s Cyclopedic Medical Dictionary

Laypersons level

Merriam-Websters Medical Dictionary

English Dictionary

Sometimes you have to get to basics to understand the topic.

Basic Medical Texts: Common textbooks used in current Medical School curriculums, and following a more or less typical progression of courses. These give you the fundamental knowledge to be able to effectively use the specialty books and pocket guides mentioned later.

Anatomy – How the body is put together in a general sense. Keep in mind that nobody is exactly like the pictures, there is no such thing as ‘normal’ when talking about people – just ‘normal range’.

Netter (Drawings of how the body is supposed to look)
Rohen (Photos of how embalmed bodies actually look. Live people, and unembalmbed bodies, don’t look at all like these pictures.)

Gray’s Anatomy – The various commemorative reprints of early editions are not only wrong, they are in some cases dangerous. Avoid them as a reference source and only use a modern version which can be hard to determine since the commemorative reprints have current print dates….it might be better to skip this one for the others.

Embryology (How the fetus develops) Included for completeness, not a lot you can do about the process.

Langmans’s Medical Embryology

Histology (The anatomy and purpose of individual types of cells) If you have access to a good microscope and various stains, you might be able to differentiate cells to good purpose. At the very least understand that the body is made of different kinds of cells, which have specific purposes.

Junqueira’s Basic Histology
Wheater’s Functional Histology: Atlas

Medical Research, Epidemiology and Biostatistics – Being able to interpret reports is critical – aside from the baseline knowledge there is a skill to reading and extracting information from the reports, and understanding what they say and what they don’t say and why. The short version is that popular media reports are usually 100% wrong, and even the executive summary of actual studies sometimes are partially wrong.

Riegelman, Studying the Study and Testing the Test
Clinical Biostatistics and Epidemiology Made Ridiculously Simple

Psychiatry

Kaplan and Sadock’s Synopsis of Psychiatry

Biochemistry (What makes the different ‘machines’ in the body work. Understanding biochemistry and physiology is essential to understanding HOW to fix things, not just a checklist approach.)

Lippincott, Review of Biochemistry
Lehninger, Principles of Biochemistry

Physiology (how the different parts of the body are supposed to work)

Guyton and Hall, Physiology

These next two are only useful if you actually have the ability to monitor EKGs. An AED will NOT give you that capability.

Dubin, Rapid Interpretation of EKG’s
Garcia, 12-Lead ECG: The Art of Interpretation

Genetics

While this is taught in med school, it’s probably useless grid-down (it’s not terribly useful now, except in understanding and explaining what has gone wrong). Genetics is a rapidly expanding field, however, and the technology is becoming more available.

Microbiology

Understanding microbiology allows one to determine what illness a person may have, and which of the many different antibiotics are appropriate (if any) to treat that illness.

Pathology: What goes wrong in how things work in the body

Robbins, Principals of Pathology (any edition after the 5th, and any version except the pocket book).
Goljan, Rapid Review Pathology

Neuroscience (How the brain and central nervous system is built). While working on the brain grid down is probably a losing proposition, understanding the nervous system, especially the spine, is useful.

Snell, Neuroanatomy
Haines, Neuroanatomy in Clinical Context

Pharmacology

Katzung, Basic and Clinical Pharmacology
Pharmacology, Lippincott Illustrated Review

Clinical Skills, Physical Exam

Bates Guide to Physical Exam and History Taking: (Kind of basic, Barbara Bates was a nurse who wrote these books for nursing students, but a good intro). Get the big book, and then the pocket book as a memory aid.

Bates Videos: There are some truly boring videos that go with the Bates Guide. You can find them on Youtube.

Swartz, Textbook of Physical Diagnosis: History and Examination (better for PE)
DeGowin’s Diagnostic Examination (My personal favorite for PE)

Generally, STAY AWAY from the following:

The Dummies Series….your patients don’t need any dummies, and these books are just too basic.
Board Review Series (or similar) books – these are for cramming before medical board tests, and expect you to already have a grasp of the fundamentals. The “First Aid” series (First aid for the boards, First Aid for Surgery, etc) is also a book to stay away from unless you’re cramming for the medical boards.

Not quite Medical school level books that might be useful

These books are commonly community-college or EMT/Paramedic level training

Tortora, Principals of Anatomy and Physiology
Costanza, Physiology

Emergency Care and Transportation of the Sick and Injured – the classic book for training EMT basics
Prehospital Trauma Life Support

Medical Specialty Books

These are commonly used in the third and fourth year of medical school when students are exposed to the various specialties of medicine, and patients, and are also the basic books (there are many more) for each specialty.

Surgery

Schwartz, Principals of Surgery
Skandalakis, Surgical Anatomy and Technique
Giddings, Surgical Knots and Suturing Techniques: While I generally don’t recommend laypeople suturing, this is a good primer on how to.

Internal Medicine

Harrison’s Internal Medicine
Kelley, Textbook of Internal Medicine

Family Medicine

Taylor Manual of Family Practice
Singleton Primary Care
Rakel, Textbook of Family Practice

Emergency Medicine

Rosen’s Emergency Medicine
Tintinalli’s Emergency Medicine
Ma, Emergency Medicine Manual
Buttaraviolli, Minor Emergencies – Splinters to Fractures

Pediatrics (Kids are not just small adults)

The Harriet Lane Handbook of Pediatrics
Nelson, Textbook of Pediatrics

Obstetrics / Gynecology

Beckman, Obstetrics and Gynecology

Orthopedics

McRae, Practical Fracture Treatment
Hull and Bacon, Introduction to Dislocations
Chapman, Orthopedic Surgery

Dentistry

Halestrap, Simple Dental Care for Rural Hospitals
Nara, How to become dentally self sufficient
Oxford Handbook of Dental Patient Care

Disaster Medicine

Koening, Disaster Medicine
Ciottone, Disaster Medicine
Antosia, Handbook of Bioterrorism and Disaster Medicine

Ophthalmology

The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology
The Wills Eye Manual

Anesthesia

Brown, Atlas of Regional Anesthesia
Anesthesia, Longnecker
Miller, Anesthesia

Frequently Handy Books

Merck Manual of Diagnosis and Therapy– From the last 20 years or so

Gomella Scut Monkeys Guide

Tarascon Pharmacopia – Any edition from the last 5 years or so should be fine

Sanford Guide to Antimicrobial Therapy – Any edition from the last 5 years or so should be fine

Giddings and Giddings, Surgical Knots and Suturing Techniques, any edition is good

Trott, Wounds and Lacerations

Special Operations Forces Medical Handbook, 2nd Ed,

Physicians Desk Reference – one from the last 5 year or so should be fine, you can often get them for free from your physician or pharmacist. The pictures are most useful for identifying pills.

Book Series that may be useful; additional (not primary) sources:

Lippincots Illustrated Reviews Series

Medmaster Made Ridiculously Simple Series

The Washington Manual Series

The Oxford Medical Book Series

The Pocket Medicine Series

Current Diagnosis and Treatment Series

The 5-Minute Clinical Consult Series

The Ships Medical Chest and Medical Care at Sea

Auerbach, Wilderness Medicine and the Field Guide

Iserson, Improvised Medicine: Medical Care in Resource Poor Situations

Special Operations Forces Medical Handbook, 2nd Ed,

Ranger Medical Handbook

Special Forces Medical Handbook, ST31-91B This book is useful ONLY for the ideas on austere camp setups and veterinary medicine. The human medical information in it is of extremely poor quality, and consists mostly of war stories and old wives tales that were written down and put into a book. Be very careful with this one.

Buttaravoli, Minor Emergencies: Splinters to Fractures

Oxford Handbook: Acute Medicine

Oxford Handbook: Tropical Medicine

Oxford Handbook: Emergency Medicine

Coffee, Ditch Medicine

Issac, Wilderness and Rescue Medicine

Wilkerson, Medicine for Mountaineering

Flint’s Emergency Treatment & Management, 7th edition (out of print x 20 years, many around, the single best black bag book ever, covers camel bites – ‘Nair’ poisoning – and a million other things found nowhere else)

Medical Training and Education

There are a number of ways the layperson can get medical training. There is a sort of hierarchy to basic first aid training, usually named something like:
Standard First Aid – a one or two day class from the Red Cross
Advanced First Aid –
Emergency Medical Responder / First Responder
Emergency Medical Technician, I or Basic
Emergency Medical Technician, Advanced
Paramedic / Emergency Medical Technician-Paramedic
https://en.wikipedia.org/wiki/Emergency_medical_technician#United_States

Just because a person is an EMT-Advanced, or Paramedic, they don’t usually have any special authority when they are not actually on duty, and under the control of a medical doctor. Some states have scopes of practice for off-duty EMT’s…it pays to check out your local policies.

Wilderness Training

There are several wilderness first aid programs – such as Wilderness First Aid, Wilderness Advanced First Aid, Wilderness EMR, etc…

Except in Colorado, there is no actual official recognition of this level of training. That doesn’t mean you shouldn’t get it, on the contrary I recommend these sorts of classes to anyone who wants to learn more.

Wilderness first aid has to treat people with fewer resources, and fewer people, and often in difficult conditions (terrain, weather), and for longer periods. Unfortunately, the regular pre-hospital training programs all assume that more help (paramedics, hospital, etc) are nearby.

It is possible to get wilderness add-on ratings for existing EMR or EMT ratings, or take wilderness first aid classes. They usually take a few days more than a standard class, and involve a lot of practical field experience. From time to time other organizations (American Red Cross, Scouting USA, various wilderness adventure training programs) offer wilderness medical training. If they don’t provide certification from one of the following, I’d pass them by – you are investing some time and money in a course that may be quite good, or quite bad.

Wilderness Training Providers

Wilderness Medical Associates https://www.wildmed.com/wilderness-medical-courses/
National Outdoor Leadership Courses (NOLS)http://www.nols.edu/wmi/courses/
SOLO Schools http://soloschools.com/
From time to time other organizations may offer wilderness courses, if they are not certified to one of the above organizations standards I’d pass them by.

Online (Free) courses

Actual university (not really graduate) level courses in various medically related topics – free for the taking
Coursera https://www.coursera.org/
Accessed 15 May 2015

EdX https://www.edx.org/
Accessed 15 May 2015

Online Resources

These do not replace the knowledge above, they supplement it. Print the .pdf’s out while you can.

Ethicon Wound Closure: http://www.ethicon.com/healthcare-professionals/products/wound-closure
Accessed 15 May 2015

Ethicon wound closure manual: http://media.xn--benersttning-lcb.se/2012/04/Ethicon-wound-closure-manual.pdf
Accessed 15 May 2015

Stewart and Stewart, Austere Medical Sterilizationhttp://www.moljinar.com/page6/files/Sterilization%20v1-2.pdf
Accessed 1 Oct 2016

World Health Organization

Surgical Care at the District Hospital
http://www.who.int/entity/surgery/publications/en/SCDH.pdf?ua=1
Accessed 15 May 2015

Integrated Management for Emergency and Essential Surgical Care (IMEESC) toolkit
http://www.who.int/surgery/publications/imeesc/en/
Accessed 15 May 2015

International Medical Guide for Ships: Including the Ship’s Medicine Chest
http://apps.who.int/bookorders/anglais/detart1.jsp?codlan=1&codcol=15&codcch=3078
Accessed 15 May 2015

Basic Hospital Equipment
http://www.who.int/medical_devices/innovation/core_equipment/en/#
Accessed 16 May 2015

Global Help

Basics of Wound Care http://global-help.org/products/basics_of_wounds_care/
Accessed 15 May 2015

Practical Plastic Surgery for Non Surgeons http://www.global-help.org/publications/books/help_practicalplasticsurgery.pdf
Accessed 15 May 2015

And many others:

US Army Medical Department Borden Institute
http://www.cs.amedd.army.mil/borden/Portlet.aspx?id=aef88463-dc77-415a-8919-2ae436bd4b30
Accessed 15 May 2015
Many different specialties, all free for the download.

Hesperian Health Guides

http://hesperian.org/books-and-resources/
Accessed 15 May 2015

Home of Where there is no Doctor, Where there is no Dentist, and others geared strictly towards very basic laypeople

Epidemiology and prevention of vaccine-preventable disease
http://www.cdc.gov/vaccines/pubs/pinkbook/index.html
Accessed 15 May 2015

The Medical Aspects of Radiation Incidents
http://orise.orau.gov/reacts/resources/radiation-accident-management.aspxAccessed 15 May 2015

FEMA / DHS publications:
These were written by AMR, the largest private ambulance company in the US…I’d recommend downloading them as soon as possible and then printing them out.

https://www.amr.net/solutions/federal-disaster-response-team/references-and-resources

Available titles include (accessed 9 October 2016)

MASS MEDICAL CARE WITH SCARCE RESOURCES

ALTERED STANDARDS OF CARE IN MASS CASUALTY EVENTS

FEMA – DESIGNING A NATIONAL EMERGENCY RESPONDER CREDENTIALING SYSTEM

FEMA EMS TYPED RESOURCE DEFINITIONS

PARATRANSIT UTILIZATION GUIDE

DISABILITY EVACUATION GUIDELINES

72 HOUR GO KIT RECOMMENDED PACKING LIST

REQUIRED GROUND AMBULANCE EQUIPMENT LIST FOR FEDERAL RESPONSE

EMS SCOPE OF PRACTICE FOR AMR-FEMA FEDERAL DISASTER DEPLOYMENTS

DHS AUSTERE EMS FIELD GUIDE

DHS TACTICAL EMS GUIDE

DHS FEMA ALS AND BLS PROTOCOLS

AMR/FEMA DEPLOYMENT HANDBOOK

CRISIS STANDARDS OF CARE

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JCD

American by BIRTH, Infidel by CHOICE