I am a surgeon with a few decades of experience, including several years as a Level 1 attending trauma surgeon, ATLS Instructor and a couple of brief stints in the Third World. That said, no one knows everything and everyone can always learn more, including Yours Truly. My hope with this nascent series is to spur helpful commentary, thought and action. I am not ex-military, appreciate comments of those who are, and recognize that experience under fire is just one part of the picture.

Medical care under austere conditions has been debated and extensively discussed by many experts and authors, with countless texts and even novels outlining the challenges to be faced and countered. The biggest problem with an efficient search for information regarding the care of ailment and injury in a grid-down environment or in times of economic or political collapse or violent conflict is made difficult because there is no universal scenario or single solution. No one can completely prepare for every eventuality, or be in possession of inexhaustible resources.

WHERE are you? WHO are you with? WHAT are the geographic and human landscape parameters? Is the power on? Does the water flow? HOW do you stabilize your situation and continue? The WHY matters not in the short term. In short, think OODA loop. Many of us have preps, some extensive and detailed, but what if you aren’t home? Recently, on approach into Orange County to teach a surgical course, I was struck by a thought while looking out the window after a three-hour flight from DFW: what if it happened here, now? The LA basin is probably the last place I would want to be and all my preparation would have been for naught, my “stuff” would be 2000 miles away. My bugout bags would never have made it past TSA. Preparing and planning for the worst, with a fluid and mobile mindset, and being pleasantly surprised by lesser challenges, has always served me well in my surgical universe.

We tend to think of collapse scenarios as abrupt, but through history they have often occurred in slow motion. One could argue that our health care system is already in a state of partial, ongoing collapse, especially since 2009. Anyone currently working in that sector knows it, as from a boots-on-the-ground, practical standpoint the PPACA may have actually reduced effective access to care and utilization and has engendered a rather unique set of patient and provider survival skills for the prevailing medical landscape that share commonality with the grid down world. The most important of those are mental, emotional and psychological. Long wait times, restricted access to providers, high deductibles and out-of-pocket expenses, third-party bureaucracy, system consolidation (i.e Aetna + CVS) and increasing use of non-physician providers (not a denigration of them, so please no hate mail, I love my NP) are all potential barriers to care that have parallels in the austere environment. Developing skills for self-care and outright avoidance of the system are increasingly necessary, as things are inexorably getting worse, and it’s not just domestic. The Gray Lady just outlined slo-mo collapse of health care in China.

Primacy of basic, mundane grid-down issues such as water purification, sanitation and disinfection cannot be understated. They are the three most important areas to address; dismiss them at your peril. Grid-down medicine, like all things military and surgical, is mostly boring and even mind-numbing. It’s not all sexy trauma stuff. Most of that will leave you dead. While the products of human violence will most certainly be faced, failure to provide clean water, properly address latrinage, and keep wounds clean will kill many more than bullets and bombs. Monsoon rains after the Haiti earthquake led to a cholera outbreak (traced to Nepalese relief workers) that killed thousands. Dysentery is a big inflictor of suffering and death after disasters. Modern trauma care is very complex, needful of extensive resources and still can not prevent all death. In a grid-down world, my specialty will likely be reduced to Civil War-era skillsets: draining pus and amputation. Anecdotes of soldiers of that era surviving being gut-shot are explainable by considering that they were penetrated by low-velocity musket balls, not select-fire projectiles. The reader may be another physician, former combat medic or EMT perfectly capable of intubation or field management of a sucking chest wound, but no helicopter will be coming and there will be no ICU to arrive at. A femur or pelvic ring fracture can result in exsanguinating hemorrhage; suffering it five or six miles from your base of support will be fatal in short order. Bleak, I know, but reality bites. Avoidance of such injury is of paramount importance; it is said that 95% of self-defense is threat avoidance. If you are reading this, awash in medical experience, beating your chest and eyes abulge, wanting to throttle me, the next paragraph is for you.

I am, by avocation and choice, now a cancer surgeon. I work a lot with plastic surgeons. One of the most important things we try to do is manage expectations in our patients. Your reconstructed breasts should look great, but they won’t FEEL normal. That will be gone. Forever. Helping your tribe or community adjust to new realities and understand what they can expect is critical to their psychological and emotional health, as well as to their survival. As with security, food provision, patrolling and weapons proficiency, the mental and psychological battlespace matters much. Look up Charley Hogwood. Read him. The concept of triage of the sick and injured, managing your resources balanced against what you can fix and who you can save, is foreign to most laypersons who go to the ER for the sniffles. Loss of normalcy and a poor reaction to it will be fatal for many. Consider what happens to the hospitalized sick and injured at the time of a collapse; many will die. Consider the chronically ill, such as those on dialysis, home oxygen or requiring daily life-supporting medication. They, too, will be gone in short order. Lastly, consider the literal hordes of people on psychotropic medications, some legal, others not, who will in time exhaust their supplies and be knocking on your door, more likely than not to be behaving irrationally. One in six Americans takes an antidepressant, a similar number benzodiazepines, and a large number on antipsychotics, with considerable overlap and use of multiple agent classes. We all know about the “opioid crisis” and crystal meth; many such users also take SSRIs and drugs like Xanax. It is estimated that almost ten million children 17 and under are on psychotropic medications; only 3% of the population, you say, but all it takes is one damaged psyche to wreak havoc. These people will not be happy campers and, sooner or later, WILL be at your door. Needless to say, they do not represent good candidates for your group.

I apologize for the length of this piece. I suppose since maybe a couple dozen of you know me personally I wanted to set the tone and expose issues to ponder. Many of my future writings will, like one on foot care, seem mundane, but trench foot or a gangrenous toe is serious, and impaired mobility may not lead you to a happy place. My former news anchor wife says that the human attention span is 15-17 minutes. I may have exceeded that here, but, as a surgical mentor imparted to me, if each one of you takes one thing away from it, a success has been had.


Minimal Med is a middle-aged surgeon practicing in the Deep South who hopes to survive the Coming Excitement.

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