🏥 Medical & First Aid

1. Wound Care & Infection Control

Hemorrhage Control — Stop Bleeding First

Uncontrolled bleeding kills within minutes. Address it before anything else.

1. Direct pressure: Apply a clean cloth or bandage directly over the wound. Press firmly and continuously for 10 minutes without lifting to check. Most bleeding stops with sustained pressure.
2. Tourniquet (limbs only): For arterial bleeding that doesn't stop with 5–10 minutes of direct pressure, apply a tourniquet 5–7cm (2–3 inches) above the wound. Tighten until bleeding stops. Note the time. Do not remove — tourniquets can be left for up to 2 hours before tissue damage risk escalates. Mark "TK" and time on the patient's forehead or tourniquet.
3. Improvised tourniquet: A wide strip of cloth (not rope or wire — they cut tissue), wrapped twice around the limb and tied with a stick (windlass) through the knot. Twist the stick until bleeding stops. Secure the stick so it cannot unwind.
4. Wound packing: For deep wounds (gunshot, stab, groin/neck where tourniquet is impossible) — pack clean gauze or cloth firmly into the wound cavity. Apply pressure with both thumbs for 5+ minutes. This is painful but necessary.

Wound Cleaning

Infection kills more slowly than blood loss but just as certainly. Proper cleaning is the single most important step after stopping bleeding.

1. Once bleeding is controlled, irrigate the wound with large volumes of clean water under pressure. The ideal: a 20–60mL syringe with an 18-gauge needle (or splash guard) produces the needed pressure. Alternatively, a plastic bag with a pinhole works.
2. Volume matters: Use at least 100–200mL of water per cm of wound depth. A moderately dirty wound may require 1 liter of irrigation.
3. Use saline (1 tsp salt per liter of boiled/clean water) or plain clean water. Avoid hydrogen peroxide (damages tissue), betadine at full strength (use diluted 10:1 with water), or rubbing alcohol directly in wounds (severely damages tissue).
4. Scrub visible dirt from the wound with a clean cloth or soft brush after irrigation.
5. Inspect for foreign bodies (debris, gravel, clothing fragments). Remove what you can see with tweezers. Retained foreign bodies cause chronic infection.

Wound Closure

Simple Interrupted Suture Technique

• Equipment: Non-absorbable nylon or prolene suture (3-0 or 4-0 for skin). Curved needle. Needle driver or locking pliers. Forceps or tweezers. Scissors. Sterile gloves.
• Space sutures 3–5mm apart. Start in the center of the wound and work outward.
• Pass needle through skin at 90° angle, 3–5mm from wound edge. Exit opposite side at same distance. Tie with surgeon's knot (double throw first loop, single throws after, minimum 3 throws total).
• Sutures should approximate edges — not pull tight. Over-tight sutures cut through skin as swelling occurs.
• Check sutures daily. Remove at: face 5 days, scalp/trunk 10 days, hands/feet/over joints 14 days.

Signs of Infection

Monitor all wounds daily. Progressive infection without antibiotics can lead to sepsis and death within days.

• Local signs (wound): Increasing redness, warmth, swelling, pain (beyond first 24–48 hours), pus (purulent discharge), wound edges separating or not healing
• Systemic signs (serious): Fever above 38.5°C (101.3°F), red streaking spreading from wound (lymphangitis — medical emergency), swollen lymph nodes, chills, confusion, rapid heart rate

Treatment: If antibiotics available — amoxicillin-clavulanate or cephalexin for general wounds; doxycycline or co-trimoxazole as alternative. Continue for full 7–10 day course even if improving. Open any abscesses, drain pus, irrigate and pack cavity.

2. Fractures & Splinting

Assessment

• Signs of fracture: Pain at site (especially with pressure or movement), deformity, swelling, bruising, crepitus (grinding sensation), loss of function, numbness below fracture (nerve involvement — urgent)
• Closed fracture: Bone broken, skin intact. Lower infection risk.
• Open (compound) fracture: Bone protrudes through skin or wound communicates with fracture. High infection risk. Critical — irrigate wound, cover bone with moist clean cloth, splint, begin antibiotics immediately.

General Splinting Principles

1. Splint the limb in the position found — do not straighten angulated fractures unless circulation is compromised and evacuation is impossible.
2. Splint should immobilize the joint above and below the fracture.
3. Pad bony prominences to prevent pressure sores.
4. Secure with bandages, torn clothing strips, or improvised materials — firm but not tight enough to cut circulation.
5. Elevate the injured limb above heart level to reduce swelling.

3. Burns

Classification

Immediate Treatment

1. Cool the burn: Run cool (not cold, not ice) water over the burn for 10–20 minutes. This is the single most important intervention. Do it within 30 minutes of injury for maximum benefit.
2. Remove jewelry and tight clothing near the burn before swelling occurs. Do not remove clothing stuck to burned skin.
3. Cover: Non-stick sterile dressing or clean plastic wrap (cling film) applied gently. Do not use cotton wool, fluffy bandages, or materials that stick.
4. Do NOT apply: Butter, toothpaste, ice, egg white, oil, or any home remedy. These trap heat and dramatically increase infection risk.
5. Hydrate: Serious burns cause massive fluid loss. Begin oral rehydration immediately if patient is conscious and not vomiting.

Rule of Nines (Burn Area Estimation)

4. Hypothermia & Heat Emergencies

Hypothermia

Hypothermia occurs when core body temperature drops below 35°C (95°F). It's insidious — the patient may not realize how impaired they are.

Heat Stroke

A true medical emergency — brain damage and death occur rapidly. Distinguish from heat exhaustion (less serious).

1. Move to coolest available location (shade, air conditioning, water).
2. Cool aggressively: Immerse in cool water (ice bath is best). If unavailable, wet all clothing, fan vigorously. Apply ice packs to neck, armpits, and groin. Every minute of delay increases brain damage.
3. Target: reduce temperature below 39°C (102°F) within 30 minutes.
4. Once conscious and recovered, provide cool fluids with electrolytes.
5. Do NOT give aspirin or ibuprofen (damage liver/kidneys in heat stroke).

5. Emergency Childbirth

Preparation

• Clean environment — lay down clean sheets or plastic
• Sterile or very clean gloves
• Clean towels or cloth for baby
• Two clean cord ties (shoelace, strip of cloth) and clean scissors/blade
• Warm water and basin
• Good lighting

Stages of Labor

1. Stage 1 — Labor: Contractions begin and become regular. Cervix dilates from 0–10cm. May last 8–20+ hours for first birth. Support, hydration, position changes (walking, hands-and-knees). Do NOT push until fully dilated (10cm).
2. Stage 2 — Delivery: Pushing. Mother pushes with contractions. Baby's head will appear at vaginal opening (crowning). Support (do not pull) the baby's head with gentle counterpressure. Once head is delivered, check for cord around neck — if present, gently slip it over baby's head. One shoulder delivers at a time. Catch the baby — they are slippery.
3. Stage 3 — Placenta: Usually delivers 5–30 minutes after baby. Do not pull the cord. Gentle pushing with next contractions delivers the placenta. Inspect placenta to ensure it's complete (retained pieces cause hemorrhage).

Newborn Care

1. Dry and stimulate the baby by rubbing vigorously with a cloth — this stimulates breathing.
2. Clear the airway: place baby with head slightly lower than body and wipe mouth and nose with cloth.
3. If not breathing within 30 seconds of drying: give 5 rescue breaths (small puffs — infant lungs are tiny), then 30 compressions with two fingers on the breastbone at a rate of 100/min, alternating with 2 breaths.
4. Warmth is critical — newborns lose heat rapidly. Place skin-to-skin with mother and cover both with blankets.
5. Tie cord in two places (10cm and 15cm from baby's belly), cut between them with sterile scissors. No rush — wait for cord to stop pulsing (2–5 minutes).
6. Encourage breastfeeding within the first hour.

Postpartum Hemorrhage

The most common cause of maternal death. Normal blood loss is up to 500mL (1 pint). More than this is hemorrhage.

• Massage the uterus (firm fundal massage through the abdomen) — it should feel like a hard ball. This stimulates contraction and reduces bleeding.
• Encourage breastfeeding — releases oxytocin, which contracts the uterus.
• If misoprostol is available (400–600mcg sublingual): dramatically reduces postpartum hemorrhage.
• If bleeding doesn't slow, aortic compression (press firmly on the abdomen above the navel) temporarily reduces blood flow while seeking help.

6. Appendicitis & Abdominal Emergencies

Recognizing Appendicitis

Untreated appendicitis ruptures (usually 48–72 hours after onset), causing peritonitis — which is frequently fatal without surgery.

Other Abdominal Emergencies

• Bowel obstruction: Severe cramping, vomiting (eventually fecal), distended abdomen, no gas/stool. Lay patient flat, IV fluids if possible, nasogastric decompression if trained. Surgical emergency.
• Peptic ulcer perforation: Sudden severe "board-like" rigid abdomen, history of stomach pain or NSAID use. Lay flat, antibiotics (metronidazole + amoxicillin), nothing by mouth. Surgical emergency.
• Kidney stones: Severe flank/back pain radiating to groin, may see blood in urine. Usually passes with hydration and ibuprofen. Strain urine to catch stone. Not life-threatening unless obstructed kidney becomes infected.

7. Dental Emergencies

Toothache & Abscess

• Pain relief: Ibuprofen 400mg + acetaminophen 500mg together (synergistic). Clove oil (eugenol) applied to the tooth/cavity with a cotton ball is a powerful local analgesic.
• Temporary filling: Mix zinc oxide powder with clove oil to a thick paste (dental cement). Pack into the cavity. Dental repair kits (dentemp) include similar material.
• Abscess: Swelling below the tooth or along the jaw — indicates bacterial abscess. If fluctuant (soft), it needs drainage. Rinse with warm salt water frequently. Start amoxicillin 500mg 3× daily or metronidazole 400mg 3× daily. Do not ignore — dental abscess can spread to the airway (Ludwig's angina) or brain and become fatal.

Tooth Extraction (Last Resort)

1. Achieve local anesthesia if available: dental lidocaine or 2% lidocaine with epinephrine injected into the gum tissue surrounding the tooth. Wait 5–10 minutes.
2. Loosen the periodontal ligament: use a flat-bladed instrument (dental elevator, thin flathead screwdriver sterilized) to push between tooth and gum, rocking to break the ligament fibers around the root. This is the most important step.
3. Grip the tooth firmly at the gum line with extraction forceps (or strong pliers padded with cloth). Rock in the direction of the roots (front teeth: buccal-lingual, molars: figure-8 pattern). Do not rotate unless the root is clearly round. Apply steady pressure.
4. After extraction: bite on a clean cloth for 30–45 minutes to control bleeding. Do not rinse aggressively for 24 hours (dislodges the clot).
5. Begin antibiotics if any signs of infection. Salt water rinses after 24 hours. Clove oil for dry socket pain.

8. Herbal Medicine

Many pharmaceutical drugs were derived from plants. Herbal medicine offers real benefits but also real risks. Never substitute herbal remedies for essential medications in critical conditions. Know dosing, preparation, and contraindications.

Basic Preparations

Tincture (Alcohol Extract)

Fill a jar with fresh or dried plant material. Cover with 80–100 proof alcohol (vodka works). Seal, shake daily, wait 4–6 weeks. Strain. Dose typically 1–3mL, 2–3× daily.

Poultice

Fresh leaves: chew or crush and apply directly to wound. Dried herbs: mix powder with water to form paste, apply to cloth, place on skin. Cover with bandage. Change 2× daily.

Tea / Infusion

Pour boiling water over dried herbs (1 Tbsp per cup). Cover and steep 10–15 minutes. Strain. Roots and bark require a decoction (simmer 20–30 minutes).

9. Medications & Stockpiling

Storage

• Store in original sealed containers in a cool, dark, dry location (not bathroom medicine cabinet — humidity and temperature fluctuate).
• Expiration dates are conservative — most solid medications (tablets, capsules) retain 80–90% potency for years beyond expiration if stored properly. Liquid medications, biologics (insulin, vaccines), and tetracycline-class antibiotics degrade faster.
• Insulin: requires refrigeration (2–8°C); open vials last 28 days at room temperature. Store backup supply in coolest available location. Refrigerate if any power available.
• Label all medications clearly — name, dose, indication, and expiration date.

10. Triage & Mass Casualty

When multiple casualties exceed available resources, triage ensures the greatest number of people survive. It requires making difficult decisions rapidly.

START Triage System

Simple Triage and Rapid Treatment. Assess each victim in under 60 seconds.

11. Mental Health in Survival Situations

Psychological casualties can exceed physical ones after major disasters. Untreated, trauma, grief, and severe stress degrade decision-making, cooperation, and physical health. Mental health is a survival skill.

Normal Reactions to Abnormal Situations

Expect to see (and experience): disbelief and denial, anger, grief, anxiety, sleep disturbances, intrusive memories, irritability, and difficulty concentrating. These are normal stress reactions — not signs of weakness or mental illness. Most people recover without clinical intervention given time, safety, and social support.

Psychological First Aid

1. Safety: Meet immediate physical needs first (shelter, warmth, water, food). A person cannot process trauma while still in immediate danger.
2. Calm: Help people regulate their physical state — slow breathing, grounding techniques ("name 5 things you can see"), reduce sensory overload.
3. Connection: Reunite people with social supports. Isolation worsens outcomes dramatically. Assign survivors to groups, even if those groups are newly formed.
4. Self-efficacy: Give people tasks and agency. Helplessness is psychologically devastating. Even small, meaningful tasks restore a sense of control.
5. Hope: Provide accurate, clear information about what is known. Reduce uncertainty where possible. Acknowledge difficulty while reinforcing survivability.

Managing Specific Conditions

For Community Leaders

• Establish routines and structure — predictability reduces anxiety.
• Normalize emotional responses — hold community gatherings, allow grief rituals.
• Identify individuals who were helpers before the crisis — they often transition naturally to support roles.
• Watch for compassion fatigue in caregivers — rotate roles, ensure helpers have support.
• Children need: honest but age-appropriate information, maintained routines, the ability to play, and reassurance that adults are in charge.
• Alcohol and substance abuse often spike post-disaster. Manage access to intoxicants within community agreements.

12. Chest Wounds & Pneumothorax

Chest injuries are highly lethal if not recognized and treated immediately. Two life threats dominate: tension pneumothorax and sucking chest wounds. Both can kill within minutes.

Open (Sucking) Chest Wound

A hole in the chest wall allows air to enter the pleural space with each breath, collapsing the lung. You'll hear a sucking or gurgling sound at the wound on inhalation.

1. Position the patient: sitting up or leaning toward the injured side helps the uninjured lung function.
2. Apply an occlusive dressing (plastic wrap, foil, or a commercial chest seal) over the wound during exhalation, when the chest is compressed.
3. Tape only three sides. Leave the bottom edge open to act as a flutter valve.
4. Monitor constantly. If breathing worsens after sealing → suspect tension pneumothorax (see below). Burp the seal by briefly lifting the bottom edge to release trapped air.

Tension Pneumothorax

Air trapped in the pleural space compresses the heart and great vessels, causing cardiovascular collapse. This is immediately life-threatening and progresses rapidly.

Signs (DOPE mnemonic):

• Deviated trachea — shifts away from affected side (late sign)
• Over-inflated chest on affected side — does not rise/fall with breathing
• Progressing respiratory distress — rapidly worsening breathing
• Elevated jugular veins + falling blood pressure + cyanosis (blue lips/fingertips)

Needle Decompression (if trained):

1. Use a large-bore needle (14g or 16g, at least 3.25 inches/8cm long) or improvised equivalent.
2. Locate the 2nd intercostal space, mid-clavicular line (just below the collarbone, halfway between shoulder and sternum) on the affected side.
3. Insert the needle perpendicular to the chest wall, just above the 3rd rib (inserting below a rib avoids the neurovascular bundle running under each rib).
4. A rush of air confirms correct placement. Leave the needle in place; convert to a chest seal.
5. Improvised: a large syringe needle taped in place. Commercial: commercial needle decompression kit.

13. Snakebite & Envenomation

Most snakebites worldwide are from pit vipers (rattlesnakes, copperheads, cottonmouths in North America; lancehead vipers in South America) and cobras/mambas in Africa and Asia. Treatment is almost entirely supportive — many traditional interventions cause more harm than the bite itself.

Immediate Response

1. Move away from the snake — a bitten snake can still bite. Do not attempt to capture or kill it.
2. Keep the bitten limb below heart level and immobilized. Movement spreads venom through lymphatic circulation.
3. Remove rings, watches, and tight clothing from the bitten limb — swelling will be significant.
4. Mark the leading edge of swelling and redness with a pen and note the time — track spread to assess severity and urgency.
5. Evacuate to hospital with antivenom as rapidly as possible. Antivenom is the only definitive treatment.

Pressure Immobilization (Neurotoxic Bites Only)

Used ONLY for bites from neurotoxic snakes (elapids — cobras, mambas, coral snakes, Australian elapids). Do NOT use for viper bites — pressure causes necrosis with cytotoxic venom.

Wrap the entire bitten limb firmly (not tightly) with a bandage starting at the fingers/toes and working up. The wrap should be firm enough to leave a finger impression but not cut off circulation. Splint the limb. Carry — do not walk — the patient.

Signs of Systemic Envenomation (Seek Emergency Care)

Without antivenom, treatment is supportive: airway management, IV fluids for shock, wound care. Approximately 70% of snakebites inject insufficient venom to cause serious envenomation ("dry bites" or minimal envenomation). This does not mean you can delay assessment — envenomation can progress over hours.

14. Stroke Recognition — FAST

Stroke occurs when blood supply to part of the brain is cut off (ischemic stroke, 87%) or a blood vessel ruptures (hemorrhagic stroke, 13%). Time is brain — every minute without treatment, approximately 1.9 million neurons die. Without CT scan capability, you cannot distinguish ischemic from hemorrhagic stroke, so treatment without imaging is limited to supportive care and evacuation.

Additional Signs

• Sudden severe headache with no known cause ("worst headache of my life" — suggests hemorrhagic stroke)
• Sudden vision loss in one or both eyes
• Sudden confusion, difficulty understanding speech
• Sudden numbness or weakness of face, arm, or leg — especially on one side
• Sudden loss of balance, coordination, or difficulty walking

Without Medical Care

1. Keep the patient calm, lying down with head and shoulders slightly elevated (30°).
2. Nothing by mouth — swallowing is often impaired after stroke; aspiration pneumonia is a serious risk.
3. Do not give aspirin unless you are confident this is ischemic (non-hemorrhagic). Aspirin worsens hemorrhagic stroke. Without imaging, you cannot know.
4. Monitor airway — unconscious or semi-conscious patients may need to be positioned in recovery position.
5. Monitor blood glucose if diabetic (hypoglycemia mimics stroke — see Diabetic Emergencies section).
6. Keep patient warm and still. Prevent pressure sores if bedridden — turn every 2 hours.
7. Many stroke patients partially recover over days to weeks. Rehabilitation begins as soon as the patient is stable: speech exercises, range-of-motion movements for affected limbs.

15. Seizures

A seizure is abnormal electrical activity in the brain. Most seizures stop on their own within 1–3 minutes. The danger is not the seizure itself but the risk of injury during convulsions and airway obstruction afterward.

During a Seizure

1. Time the seizure. Most self-terminate within 3 minutes. A seizure lasting over 5 minutes (status epilepticus) is a medical emergency.
2. Clear the area around the patient of hard or sharp objects. Do not restrain movement — you cannot stop a seizure by holding someone down.
3. Turn the patient onto their side (recovery position) to prevent choking on saliva or vomit.
4. Do not put anything in the mouth. The "swallowing your tongue" myth is false. Objects placed in the mouth during seizures cause broken teeth and bitten fingers.
5. Loosen any tight clothing around the neck.

After a Seizure (Post-Ictal Phase)

• The patient will be confused, drowsy, and disoriented — this is normal and lasts 5–30 minutes.
• Maintain recovery position until fully conscious.
• Check for injuries from falling or convulsions.
• Do not give food or drink until fully alert.
• Ask if they have a known seizure condition and whether they have missed medication.

When to Be Concerned

16. Diabetic Emergencies

Two opposite conditions both present as altered consciousness in a diabetic patient. Distinguishing them matters because their treatments are opposite. When in doubt — give sugar. The risk of giving sugar to a hyperglycemic patient is low; the risk of withholding sugar from a hypoglycemic patient is death.

Hypoglycemia (Low Blood Sugar) — The Immediate Killer

• Signs: Shaking, sweating, pale skin, rapid heart rate, confusion, irritability, headache, seizure, unconsciousness
• Cause: Too much insulin, too little food, excessive exercise, alcohol

1. If conscious and able to swallow: 15g of fast-acting carbohydrate — 4 glucose tablets, 4 oz fruit juice, 1 tablespoon honey or sugar dissolved in water, or 3–4 hard candies.
2. Wait 15 minutes. If still symptomatic, repeat.
3. Once recovered, give a complex carbohydrate + protein snack to prevent rebound (crackers with peanut butter, bread with cheese).
4. If unconscious: do not give anything by mouth. Rub honey or glucose gel on the inside of the cheek or gums. Recovery position. Glucagon injection if available and trained.

Hyperglycemia (High Blood Sugar) — The Slow Threat

• Signs: Extreme thirst, frequent urination, fatigue, blurred vision, fruity-smelling breath (DKA), nausea, abdominal pain, deep labored breathing (Kussmaul breathing in DKA)
• Cause: Missed insulin doses, infection (infection raises blood sugar dramatically), illness, excessive carbohydrate intake

1. Give insulin if available and prescribed. Continue food and water.
2. Hydration is critical — dehydration worsens hyperglycemia. Encourage water (not juice).
3. Treat any underlying infection aggressively — infection is the #1 trigger for DKA.
4. DKA: IV fluids and insulin are the definitive treatment. Without these, DKA carries high mortality.
5. Insulin storage: regular insulin is most shelf-stable. Unrefrigerated insulin degrades in weeks at room temperature; store in coolest available location.

17. Drowning & Submersion

Drowning causes death by hypoxia (oxygen deprivation), not by water in the lungs. Most drowning victims have very little water in their airways — the larynx spasms and closes (laryngospasm). Rescue and resuscitation are effective even after several minutes of submersion, particularly in cold water, which reduces oxygen demand.

Rescue — Water Safety

1. Reach before you enter. A drowning person will instinctively grab anything — including a rescuer — and push them under. Use a pole, rope, towel, or clothing to reach them from shore or a boat.
2. Throw before you go. A rope with a float (plastic bottle works) can be thrown to the victim.
3. Row before you swim. Use a boat if available — far safer than swimming.
4. Only enter the water as a last resort. If you must swim to a victim, approach from behind to avoid being grabbed. If grabbed, push away and approach again from behind.

After Rescue — Resuscitation

1. As soon as the victim is on a stable surface: assess responsiveness and breathing.
2. Do not perform "clearing the water" drains or compressions before rescue breaths — this is ineffective and delays oxygenation.
3. If not breathing: begin CPR immediately with rescue breaths. Drowning is a hypoxic arrest — ventilation is more critical than in cardiac arrest. Use a 30:2 ratio (30 compressions, 2 breaths).
4. If breathing: place in recovery position on their side. Monitor airway constantly — vomiting is common.
5. Treat for hypothermia: remove wet clothing, insulate, apply warm water bottles to armpits and groin if available.
6. All drowning victims who required resuscitation should be observed for at least 6–8 hours for secondary drowning (delayed pulmonary edema). Signs: coughing, shortness of breath, altered consciousness hours after rescue.

18. Animal Bites & Rabies

In a grid-down world, animal bites become far more common and far more dangerous: more feral and stray animals, more hunting and trapping, livestock handling, and no emergency room. Every mammal bite carries two threats — wound infection (immediate) and rabies (delayed but almost always fatal once symptoms appear).

Immediate Wound Care (Every Mammal Bite)

1. Wash hard and long. Scrub the wound with soap and clean water for a full 15 minutes. This single step physically removes rabies virus and bacteria and is the most effective rabies prevention available without vaccine.
2. Irrigate deeply with the cleanest water you have — pressure flushing (a syringe or squeezed bag) reaches into puncture tracks.
3. If available, flush with povidone-iodine or diluted (≈1:1000) bleach, which inactivate rabies virus. Soap and water first, always.
4. Do not suture a fresh animal bite closed. Bites are dirty puncture/crush wounds — closing them traps bacteria and causes abscesses. Pack lightly and allow to drain. Exception: large gaping facial wounds may be loosely approximated after thorough cleaning.
5. Leave bleeding to run briefly — mild bleeding helps clean the track. Control heavy bleeding with pressure.

Assessing Rabies Risk

If the biting animal is a healthy dog or cat you can confine, observe it for 10 days. If it is still alive and well after 10 days, it was not shedding rabies virus at the time of the bite and you can stand down. An animal that sickens or dies during observation means the exposed person needs every measure you can find.

Wound Infection Watch

Cat bites in particular drive deep puncture infections (Pasteurella) that flare within 12–24 hours. Watch for spreading redness, swelling, heat, pus, or red streaks tracking up the limb. If you have antibiotics, bite wounds are a priority indication (amoxicillin-clavulanate is first choice — see Medications). Also reassess tetanus status for any bite.

19. Tetanus

Tetanus is caused by Clostridium tetani spores — present in soil, dust, rust, manure, and saliva everywhere on Earth. The bacteria thrive in low-oxygen wounds and release a toxin that causes uncontrollable, agonising muscle spasms. Untreated tetanus kills roughly 1 in 3 and is one of the most preventable deaths in a collapse — yet immunity fades, and a lapsed booster plus a dirty puncture is a classic grid-down killer.

Prevention — Do This Before Collapse

• A tetanus booster lasts ~10 years. Get current now and record the date. Td/Tdap vaccine stored cold is one of the highest-value medical items to stockpile.
• After a tetanus-prone wound, a booster is recommended if it has been more than 5 years since the last dose. With no record, assume non-immune.

Wound Management

1. Open the wound to air. Tetanus bacteria cannot grow with oxygen present — debride (remove) dead tissue, foreign material, and dirt thoroughly.
2. Irrigate copiously. Do not seal a contaminated puncture wound closed.
3. Flush deep punctures with diluted hydrogen peroxide or iodine if available — the goal is to disrupt the anaerobic pocket.

Recognising Tetanus (Onset 3–21 Days After Injury)

• Lockjaw — stiffness of the jaw, difficulty opening the mouth (often the first sign)
• Stiff neck, difficulty swallowing, rigid abdominal muscles
• A fixed grimace ("risus sardonicus")
• Painful, full-body muscle spasms triggered by light, noise, or touch — these can be severe enough to break bones or stop breathing

20. Anaphylaxis & Severe Allergy

Anaphylaxis is a sudden, whole-body allergic reaction that can kill within minutes by swelling the airway shut or collapsing blood pressure. Common triggers: bee/wasp stings, foods (nuts, shellfish), and medications (penicillin). In a world of more foraging, more insect exposure, and unfamiliar foods, first-time reactions will happen.

Treatment

1. Epinephrine is the only first-line treatment. If an auto-injector (EpiPen) is available, use it immediately into the outer thigh — through clothing is fine. Hold 3 seconds. It buys time; nothing else substitutes for it.
2. Lay the person flat and raise their legs (helps blood pressure). If they are vomiting or struggling to breathe, let them sit up or lie on their side — never stand them up suddenly, which can cause fatal collapse.
3. A second dose can be given after 5 minutes if there is no improvement and more epinephrine is available. Stockpiling auto-injectors (and knowing they expire) is high-value preparedness.
4. Give an antihistamine (diphenhydramine/Benadryl) as an adjunct only — it treats hives and itch but does not open the airway or fix blood pressure. Never rely on it alone.
5. Even after a good response, reactions can return 1–12 hours later (biphasic reaction). Observe the patient closely for at least 12 hours.

21. Eye Injuries

Vision is survival. Wood-chopping, metalwork, chemical splashes (lye, bleach, fuel), and blowing grit all threaten the eyes, and a blinding injury is catastrophic when you depend on your hands and senses. Most eye damage is preventable with simple protection — wear it for any striking, grinding, or chemical work.

Chemical Splash — Irrigate Immediately

1. Immediately flood the eye with clean, lukewarm water — hold the lids open and pour from the inner corner outward (away from the other eye).
2. Flush continuously for at least 15–20 minutes (longer for alkali burns — up to 60). Keep going; under-irrigation is the main cause of permanent damage.
3. Remove contact lenses if present once flushing has begun.
4. Have the person roll the eye in all directions while flushing to reach the whole surface.

Foreign Body on the Surface

1. Do not rub. Blink several times; tears may carry out loose grit.
2. Look under the lids: pull the lower lid down, and evert the upper lid over a cotton swab to inspect. Lift a loose particle off with the damp corner of a clean cloth.
3. Flush with clean water if it won't lift off easily.
4. Never try to remove an object that is embedded in the eyeball, on the cornea, or stuck after gentle effort — see below.

Penetrating / Embedded Object — Do Not Remove

1. Do not remove the object or apply pressure. Stabilise it in place — a paper cup or cut-down bottle taped over the eye protects without touching it.
2. Cover both eyes. The eyes move together; bandaging only the injured one still lets it move as the good eye looks around. Covering both keeps the injured eye still — explain this to a frightened patient.
3. Keep the patient sitting up and calm; avoid bending, lifting, or straining (raises eye pressure).
4. Evacuate to whatever surgical care exists.

Blunt Trauma & Snow/Arc Blindness

• Black eye / blow to the eye: apply cold compresses; watch for blood pooling in the front of the eye (hyphema), persistent vision loss, or an irregular pupil — all signal serious injury needing rest with the head elevated.
• UV "flash burn" (snow blindness, welding arc, looking at the sun): intensely painful, gritty, watering eyes hours after exposure. Treat with darkness, cool compresses, and rest — the surface heals in 24–48 hours. Prevent it with sunglasses or slit-eye shields cut from cardboard/bark in bright snow or desert. Reinforces the eye-protection habit for any glare environment.

22. When the Medicines Run Out

The dramatic injuries get the attention, but in a long collapse the quiet killer is the chronic medication that stops coming. People dependent on daily drugs can deteriorate or die weeks to months in, long after the initial event. Plan for this now, while pharmacies still work.

Build the buffer before you need it

• Stockpile ahead: ask your doctor for a longer prescription or “holiday supply”; fill early each month to build a reserve; keep meds rotated and within date.
• Know your exact drugs and doses — write them down (name, dose, what for) and keep the list with your go-bag and on paper, not just in a phone.
• Store well: cool, dark, dry, airtight extends shelf life. Most tablets remain largely effective well past the printed date (a conservative date, not a cliff) — the notable exceptions are tetracyclines (e.g. doxycycline, which can become toxic when degraded), liquid antibiotics, insulin, nitroglycerin, and EpiPens.

The big ones when supply ends

Lifestyle is your most renewable “medicine”: diet, weight, movement, sleep, and stress control genuinely move blood pressure, type-2 diabetes, and mood. See Medications & Stockpiling for what to store, and Medicine Making for herbal supports.

23. Vision & Eye Protection

Lose your glasses and you can become functionally helpless — unable to read a map, shoot, do fine repairs, or recognise a threat. Eyesight is rarely on a prep list, and it should be near the top.

• Keep spare glasses — at least one backup pair (an old prescription is far better than nothing), stored in your kit and go-bag. Write down your prescription and keep it on paper; an optometrist can't look it up after the grid is gone.
• Pinhole trick: looking through a tiny pinhole in card (or a fist with a small gap) sharpens distance vision for the short-sighted — a free emergency “lens.” A card with several small pinholes makes crude usable glasses.
• Protect the eyes you have. Wear eye protection for any chopping, grinding, hammering, or chemical work — see Eye Injuries. A blinding injury with no surgeon is permanent.
• Sun & snow: UV burns the eyes (snow blindness, desert glare). Wear sunglasses, or cut narrow slits in card/bark/leather as improvised slit-goggles in bright snow or sand.
• Eye health: vitamin A (liver, eggs, orange/dark-green vegetables) prevents night blindness and, in severe deficiency, actual blindness — a real risk on a poor survival diet. Keep eyes clean; treat infections early.
• Reading up close: cheap magnifying “readers” and a simple magnifying lens are worth stocking for older eyes and fine medical/repair work.

24. Death, Bodies & Burial

In a prolonged crisis people will die, and there will be no funeral home, coroner, or council to call. Handling the dead with dignity and safety falls to you. Getting it wrong spreads disease and breaks morale; getting it right protects the living and lets the community grieve and carry on.

Handling & immediate steps

• Confirm death (no breathing, no pulse, no response over several minutes; later, cooling, stiffening, and pooling of blood under the skin).
• Higher-risk deaths — cholera, viral haemorrhagic fever, plague, or unknown contagious illness — need extra care: minimal handling, full barrier protection, prompt burial, and disinfection of the body and area. Do not transport these bodies far or hold open viewings.
• Record it: name, date, cause if known, and location of burial — for the family, the law that returns one day, and to track disease. Keep a simple register (see Knowledge → Records).
• Close the eyes and mouth, clean and wrap the body in cloth/sheet/shroud. Cool conditions slow decomposition if burial must wait; otherwise bury within a day or two, sooner in heat.

Burial

• Site: downhill and at least 30 m / 100 ft from any water source and from wells, and above the water table — the same rules as a latrine. Not in a vegetable garden.
• Depth: aim for a grave deep enough that animals can't dig it up and smell is contained — about 1.5–2 m (5–6 ft), less only if ground or effort won't allow. A layer of lime in the grave reduces smell and speeds breakdown.
• Cremation needs a great deal of fuel and a very hot, sustained fire to be complete; it's used mainly where ground is frozen/rock or for high-contagion deaths, and even then is hard to do well.
• Mark the grave so it isn't disturbed and can be found again.

The living matter most

Allow ritual and grief — a few words, a marker, a moment together. Skipping this to "stay efficient" corrodes a group from the inside; ceremony is how humans absorb loss and keep going. Support for the bereaved, and for whoever had to handle the body, is part of the medicine — see Psychology & Morale → Grief.