Surviving the Medical Meltdown (28 page)

MORE SERIOUS CAUSES

Angina or developing heart attack

Appendicitis

Hepatitis

Kidney infection

Obstruction from cancer

Obstruction from old surgery scarring

Pneumonia

Today, when you are sick in any way, you have the luxury of running to a walk-in clinic or to a nearby ER to get a quick check. In the future, when government-funded medicine causes even more shortages of manpower and facilities and gaps in emergency room availability, it is going to become a bigger hardship to access emergency care. Even now, waiting times in big-city emergency rooms may exceed six hours – even for people with chest pain! So it is important to start the search for emergency care early in the course of a problem. This chapter should have given you an idea of those medical situations in which you need to prepare for transport, and it should allow you to take appropriate measures before or while awaiting transport to higher-level care. In the next chapters, we will explore problems you can potentially completely care for at home without having to access scarce medical resources.

HOME REMEDIES FOR ABDOMINAL DISTENTION

• Add lemon and/or lime juice to water.

• Drink ginger, peppermint, licorice, or chamomile tea.

• Eat less food.

• Keep well hydrated with clear liquids.

• Maintain normal caffeine intake and add a little more.

• Stop smoking and drinking alcohol.

• Take a magnesium-containing laxative such as Milk of Magnesia. Also take 800 mg of MagCitrate daily.

• Take small amounts of baking soda.

18
WOUND MANAGEMENT

I
n the course of our lives, we get wounded many times. Most wounds are minor and can be treated easily with a simple bandage. Sometimes they are more severe and require stitches. This chapter gives you a general approach and framework to think about wounds as surgeons do. When confronted with a wound, we automatically think through all the categories and put the wound into one. Then we look at the details and decide on a treatment strategy.

Evaluation:
Wounds demand systematic evaluation and treatment. First, how was the wound made – in a clean environment? Or was it in a barnyard? How deep is the wound, and what structures are involved? Does it need suturing, or can it heal with lesser measures?

Environment:
If the wound was contaminated with grease or road dirt or sand or any number of inorganic contaminants, it is at less risk of infection problems than if it was contaminated with organic material. Fecal material, such as horse manure or barnyard dirt, or mouth germs from bites need aggressive treatment.

What is injured?
The best way to explore the wound without anesthesia is to evaluate function. In the hand, for example, can it move everything? Can it feel everything? Are pulses intact? After that, irrigate the wound with a normal saline solution made with one and a half teaspoons of salt in a pint of water. An ear bulb syringe is generally great for that. Use more than you think is necessary. Make sure the wound is really clean. Then look into the wound if it is deep. Small muscle lacerations don’t need specific care; large ones do and will probably be beyond your ability to handle since they need sterile, deep-layered closure with a variety of sutures.

Butterfly bandage:
Many small wounds can be cleansed and closed by pinching the skin together and sticking one or more Band-Aids or pieces of tape perpendicularly across the wound. In surgery we use tincture of benzoin to make the skin stickier, but degreasing with alcohol can work if you’re careful not to pour it into the wound – that hurts! When you apply the sticky tape to close the wound, pinch the skin together enough so the skin edges “evert,” or rise up a little, like buckled pavement. The reason for this is that when skin heals, it sinks in. If it starts totally flat, it will end a little depressed with a worse scar. In general the skin will need to be kept together for five to seven days. This does not work in any area where the skin is constantly stretched during motion (such as around the knee). This will pull the wound apart.

Suturing:
Large, gaping wounds or wounds around knuckles or joints probably need suturing. Unless you are familiar with suturing, I would seek professional help. But as a surgeon, I keep a suture kit at home to avoid trips to the office or the ER. I sterilize the skin with alcohol and use a sterile towel to make a “sterile field” around the wound.

Leaving the wound open:
Some wounds should not be closed – due to the high risk of infection. If in doubt, don’t close it. The body has an amazing ability to shrink the size of wounds and to heal them with a much smaller scar than you would think. You can leave some part of the wound open for drainage, and close the clean ends with tape. The idea is not to trap bacteria behind a fixed, closed skin but to allow the body to expel the germs. Any wound previously closed that becomes infected should be opened, re-irrigated, and left open. Irrigate with the salt solution given previously and with a drop or two of antibiotic soap. Warm soaks in a tub three times a day are usually a good idea. Use the wet-to-dry dressing technique that follows. Wounds that have lost tissue and are like little craters should not be closed. Don’t close anything you don’t have to. Let the wisdom of the body do its work.

Antibiotics:
Don’t use antibiotics without a reason. For most small wounds, topical Neosporin or bacitracin ointment is sufficient. If you have a dirty wound or one of the aforementioned barnyard injuries, you may need to seek professional help. If you cannot, those involving significant tissue damage or fecal matter need aggressive early antibiotic administration. A combination of clindamycin (adult dose 300 milligrams three times a day) and cipro (adult dose 750 milligrams twice a day) covers most things. A friendly pharmacist may be able to give you good recommendations.

Dressings:
Generally a dry dressing over a small amount of Neosporin is fine. If you need to care for a minor infection, a “wet to dry” dressing is useful.

For a wet-to-dry dressing, take standard gauze and pour onto the bandage some acetic acid solution (see sidebar). Wring out the gauze dressing as dry as possible and lay a single layer on the wound, avoiding much contact with normal skin. Cover with a dry dressing and an ACE wrap or a mesh encircling dressing.

1/4 PERCENT ACETIC ACID SOLUTION FOR WOUNDS

1 ounce white vinegar

15 ounces water

Add the vinegar to the water and mix well. Soak some gauze in the solution (usually 2 x 2-inch gauze pads work well). Wring out as much of the solution as possible so the gauze is only damp. Apply the moist gauze to the wound. Cover with a dry gauze dressing and secure with a circular wrap (preferable) or tape.

Healing Principles:
There are several principles of healing that, if kept in mind, allow you to make good choices of care.

1.
Skin heals best in moist, but not wet, settings.

2.
Bacteria and infection slow healing.

3.
Immobilization helps healing.

4.
Good health and nutritional support are key to good healing.

Given these principles, if a cut keeps breaking open – say, on a finger – it is probably too dry. Add some Neosporin ointment to moisten. If a wound looks white and shriveled and is not healing, it is too wet. Open to air and/or use a dry dressing without ointment for a while. If a wound is at risk of infection or looks a little red, add antibiotic ointment. Big, scabby, road rashes that develop some superficial sliminess or obvious infection are well treated with an acetic acid wet-to-dry dressing in the morning and replaced with Neosporin and a dry dressing at night. And in all cases, vitamin C supplementation of a few thousand milligrams a day plus zinc supplementation of at least 60 milligrams a day have been shown to help wounds heal. If necessary, splint the area to avoid any stretching of the tissues.

Wound care is an art, and considerable experience and practice are needed to do it well. There are physicians whose entire specialization is taking care of difficult wounds. You cannot manage all wounds at home, but you will save yourself time, aggravation, and
unnecessary trips to the ER if you understand the principles of wound care and can make good decisions about when you are able to care for the victim at home and when you need a higher level of care. Finally, it should be noted that wounds heal best in healthy people. Again, the best defense from the ravages of Obamacare on our medicine is to be so healthy you will not need care in the future.

19
RASHES

T
here is a joke in dermatology that it is not always necessary to make the diagnosis, just to make the right treatment. If it is wet – dry it. If it is dry – wet it, and otherwise apply cortisone or antifungal cream.

Most rashes are due to (1) allergic reaction, (2) fungus, (3) infection, or (4) insect bites. Without getting too technical, we are going to sort these out in a general way and give generalities of treatment. But the joke above is actually very true. If the treatment makes it worse – time to do the opposite. Common sense can go a long way in treating rashes.

ALLERGIC REACTION

Contact dermatitis:
A very common “allergic” rash is contact dermatitis, in other words, an allergic response to having skin contact with a substance to which the body reacts. This can be poison ivy, or something as simple as your dish soap. Most such rashes are easy to figure out from the history and the distribution of the rash. If, for example, the rash is distributed in a nonrandom fashion (for example, occurring underneath elastic bands such as pajama waistbands, sock tops, or
shirt sleeves) – voilà! It is either an allergy to the elastic or to something on the elastic, such as soap residue. It is important to know that healthy skin is less likely to react to contact with chemicals. But dry, cracked, or peeling skin can react more easily. Often, contact rashes occur when the skin is dry in the winter, but the same contact will not bother normal skin in the summer or spring.

If the rash seems to be related to clothing contact, it is time to look at your soap (any new soap?) and the quality of the skin. Make sure you use unscented laundry detergent without fillers. Avoid dryer sheets or any additive until you figure out the cause of the rash. You may have to eliminate everything then add things back one at a time. In the meantime, moisturize the skin with scent-free lotion, double rinse the clothes, and watch the rash over time. Do not use harsh soap on the body. Cetafil, if available, is the expensive dermatologist-recommended body wash you can get at a pharmacy. Homemade lye soap from olive oil and lard makes a beautiful mild soap. If you want to try your hand at making soap, you will find it easy, cheap, and great for nearly all skin types. See
appendix C
for my personal, easy-peasy soap recipe.

Contact dermatitis will usually respond to the measures just discussed, but you may sometimes need to apply hydrocortisone cream (0.5% to 1%) three times a day to the area for a few days until the rash clears. If it is getting worse, it may be a fungal rash (see below).

Hives:
Hives are a very characteristic skin reaction to something contacted or ingested that causes the release of a chemical in the body called
histamine
. Hives are not just a skin problem. Of particular importance are hives in the mouth – these are more serious and require urgent medical intervention. Hives means you need to search for a cause. They can be the first sign of a more serious reaction involving facial, eyelid, and tongue swelling, and sometimes even airway compromise.

Hives are a raised, bumpy rash that is often spread far apart initially but becomes closer and closer. Hives sometimes produce
a single sheet of raised, itchy, red skin. They can also “vesiculate” (become filled with clear fluid). This type of allergic reaction is “histamine mediated,” so you generally start by taking an antihistamine. The most common over-the-counter one is probably Benadryl and should be taken orally as soon as possible. (Follow package directions.) This may cause drowsiness and should not be taken while driving or operating any heavy machinery. Topical cortisone cream may also help.

Once it is clear that the hives reaction is not progressing to a more serious allergic response, start looking for what caused them. Are the hives local or generalized? If local, did you come in contact with some nettles or poison ivy, some chemical, or perhaps latex?

If the response is generalized, look at medicines and food. Did you take a new medication within four or five hours of the event? Certain foods – egg whites being a common one – are more prone to causing this type of allergy. Seafood, especially shellfish, is a classic problem-producing allergen.

Eczema:
Eczema is a rash classically produced by food allergies. It is a flat to slightly bumpy rash often involving the fronts of elbows, backs of knees, hands and feet, and occasionally the face. Sometimes the bumps can weep clear fluid when scratched, and it is very itchy. It is generally not rapidly progressive and can be figured out over time. Food allergies – especially eggs and milk – are likely culprits. But sometimes formal allergy testing is advised. I always recommend a gluten-free diet as a baseline.