With this segment of the Medical References series we are going to address the next step up the ladder, the advanced references that would be of benefit to medical practitioners such as physicians, PA’s, Advanced Practice Nurses, veterinarians and dentists. The reason for this level of recommendation is that after a grid-down event it is not unreasonable to expect that many practitioners may find themselves thrust by circumstance into roles outside their normal comfort zone.

To use an example of this in the past (World War II era) the Army had considered that anyone with the title of Doctor was a surgeon, no matter what their practice area. The apparent reasoning was they had the same initial training as a surgeon so they were just as capable. That was the theory anyway, and in practice many non-surgeons found themselves immersed up to their elbows in a gut performing meatball surgery. The treatment for traumatic injury is surgical intervention rather than pills, so they made the square pegs fit the round holes because that is what they had to work with.

This segment is not intended to discount, per se, the education and abilities of our more advanced medical practitioners, but rather to recognize that when it comes to a grid-down situation their initial and subsequent practice might not have adequately prepared them for the new environment. Thus these references are intended to be supplements to previous formal teachings rather than replacements for same. You have already studied anatomy, physiology, chemistry and micro. There are also very likely past courses that include biochemistry, immunology and bacteriology. But how hard did your clinical experiences concentrate on areas other than your primary objective of obstetrics, gastroenterology or thoracic surgery? Cracking a chest or manipulating a breech presentation doesn’t translate well to managing a compartment syndrome of the lower extremity or acute diverticulitis. This is where professional references that might provide critical assistance come into play.

Let’s use the example of a trauma patient who has had a significant bleed by the time they present. A respondent in a recent interaction I had elsewhere took exception to the concept of whole blood transfusion, claiming that it “could very likely” kill someone. Unfortunately that manner of thinking is often prevalent among people who have failed to research the concept well. Our modern medical centers have sophisticated blood banks and compatibility and screening determinations, which is all the better for us in the here and now. But consider if that factor was removed from the equation.

The practice of ‘walking blood banks’ is one used even by our US military, with pre-determined volunteers designated and available. While component separation and involved screening is always preferable it is isn’t always practical given circumstances and environment. Sometimes we have to use what is available, including uncross-matched Type O blood. True, there is always a chance of cross-reaction, but the chances are greatly less than the patient dying due to delays in acquiring the properly typed, screened and cross matched blood, which is why the concept is used. Remember, we are talking about survival medicine, not what is practiced at Johns Hopkins.

Less radical but often formally frowned on in our current overly litigious world is the utility of specialized practitioners being recruited to function outside their area(s) of immediate expertise, a la the American Medical Corps of WW II as previously made reference to.  Because we are attempting to address the role of the formally trained practitioner in a grid-down environment, these works are offered to make the transition from the regular clinic to the Conex box office that could potentially be lurking in an uncertain future.

Here then is a modest selection of references you may find useful should you find yourself thrust into an unfamiliar role, with an expectant audience presenting with problems outside of your professional comfort zone.

Merck Manual of Diagnosis and Therapy

Often dubbed the Bible of Medicine, this fine work is now in its 20th edition in 119 years (2018). It has long been the standard by which other such works are judged. Most advanced practitioners should already be familiar with the manual, but may not have the need for one in their regular practice. As such they may have cleared their shelves entirely of something they thought was no longer needed for their particular practice. This tends to be the more true when the Practitioner is highly specialized. Assuming a new role – that of a general practitioner or surgeon or other medical generalist as may be – in a grid-down world may require a ready reference that can cover a wide array of situations and potential diagnoses.

Any recent edition will suffice, and the low cost of well under $100 for a book of over 3,500 pages (current edition) makes it well within range for anyone who may be seeking to build a just-in-case medical references library.

Improvised Medicine: Providing Care in Extreme Environments 2nd Edition

Dr. Kenneth Iserson (the author) has worked in environments as extreme as Antarctica and runs with a desert search and rescue team as part of his continuing practice. His experiences have resulted in this now updated work that goes beyond the mere what-to-do and dives headfirst into the how-to.

Other references tell you where to cut and when. Rather than telling you what you already know this book tells you how to make the cut when you don’t have a proper kit with you and improvisation is the name of the game. Anyone from a Paramedic on up will benefit from this book should they ever find themselves in a resource-poor working environment.

Rather than risk sounding over enthusiastic though, I will caution that this book might best be used in conjunction with other references that offer better illustrations for some surgical techniques such as performing an area block for a laparotomy. That caveat aside this book might be considered to be THE clinical pearls guide for the austere practitioner. The more advanced you are as a practitioner the more you are likely to find useful information in this book.

Professionals’ Handbook of Complementary & Alternative Medicines

This falls under the maybe-you-need-it maybe-you-don’t category. It is going to depend on your thoughts regarding so-called ‘alternative’ medicine and whether you believe you might frequently encounter patients who are adherents of same. If it is something you are personally/professionally interested in you will be better served by seeking more focused references dealing with your particular area(s) of interest.

However, if you expect to be seeing patients who actively seek and perhaps practice alternative therapy methods you may well find this a very useful guide to understanding what may or may not be beneficial, and to what possible interactions there may be between ‘Western” and other medicine modalities.

This is by no means a how-to manual but it does offer qualitative insight researched in conjunction with recognized practitioners of the various schools of theory. It does cover many areas ranging from the Alexander and Feldenkrais techniques to herbalism to osteopathy and many in between. It strives to be objective in its analyses’ and give fair treatment.

Bates’ Guide to Physical Examination and History Taking

The art of physical examination seems to be a lost craft as far as many American practitioners are concerned. Contrary to, say, their British counterparts, many rely on laboratory tests, imaging exams and oral history taking instead. In a grid-down environment such back-ups may be rationed, difficult to access, or completely unavailable.

Given said environment, a hands-on exam performed using a few basic tools – stethoscope, reflex hammer, tuning fork, etc. – can be essential. In a near worst-case scenario it may be the only option available. The next step would be palpation, visual exam and oral complaint only. Having a ready reference as to what to look for might beyond important and well into essential. This book works well in conjunction with the Merck Manual.

Minor Emergencies: Expert Consult

Practical advice on how to handle a myriad of non-life threatening emergencies.  Faced with a locked knee? How about dental pain? That sunburn – is it merely painful or does it progress to an actual second degree level, requiring a different approach? And let us not overlook the dreaded bean-in-the-nose syndrome mostly seen in small children. Sometimes you need more than a nasal speculum and Hartmann forceps.

This is now the 3rd edition since 2000. It includes procedural sedation recommendations and 184 topics in all are addressed. Consider this to be a potentially an invaluable reference for the clinician who does not routinely handle emergent cases.

Essential Drugs Practical Guidelines (2013 edition)

A definite must-have for any clinician who finds themselves by assignation or happenstance working as a primary care provider rather than within their normal specialty area.

The WHO maintains its list of 100 essential drugs that it has determined to be the keys to maintaining health in all environments – be they first or third world – while keeping the cost of acquiring same in mind. Medicins Sans Frontieres has expanded upon that concept with their list born of widespread experience resulting from several hundreds of collective practice years, offering suggestions for alternatives within the same therapeutic frameworks, unlike the WHO which offers one composition per same, and building on the list to include more medications necessary address a wider array of complaints.

The book is over 360 pages in length, and very properly divided by route of administration, alphabetically and by category. The format is easy to use and quite clear and concentrates on providing essential information without a lot of lawyer-inspired fluff.

While available in pdf, I do offer my usual caution against relying on an electronic-only format. The actual hard copy is available for sale by Health Books International in Hertfordshire, England, at a cost last listed as being around $20 USD plus shipping.

Safe Anaesthesia, 3rd Edition: A Training Manual – Where Facilities Are Limited

There have been several books published on providing anesthesia services in the austere environment since the 1980’s, with Maurice King’s work considered to be the founding volume. Thought not quite in the coffee can vaporizer school of practicum this much more recent (2006) work is intended for teaching anesthesia practice in areas where resources tend to be poor.

The book focuses on safe practices that have been proven with time, using what equipment is more likely to be available. Also included are chapters on hypothermia  and pain control, something lacking in previous editions as well as some other earlier works such as King’s.

Also available from Health Books International at very low cost.  https://healthbooksinternational.org/

The Art and Science of Minimal Intervention Dentistry and Atraumatic Restorative Treatment

Finally, someone has written an actual manual you can hold in your hand that focuses on dental ART. The technique has been around since it was developed in Tanzania in the 1980’s as a way of providing appropriate dental care to resource-poor areas.

ART is simple and is often taught to missionaries who themselves are not trained in the traditional manner in either dentistry or medical care. It requires simple tools and is much less invasive than traditional modern dentistry. It is also increasingly being advocated as a mainstream practice worthy of consideration. Most importantly it does not rely on electrically driven equipment.

This is a new book, just out this year, and I must admit I have yet to lay hands on a physical copy. However, knowing the reputation of the author – Jo E Frencken of Radboud Univ, Nijmejen, Netherlands, I believe it is going to be as promoted: definitive.

You will have to pay a bit more for this but it remains under $100 for a 220 page work. Sorry to say that Amazon does not carry it so you’ll have to go directly to the publisher.

Stephen Hancocks Publishing:  https://www.stephenhancocks.com/buy-online/1/restorative-dentistry/

Future articles in this series will continue to develop recommendations for more specialized rather than general care. Included in that will be one addressing veterinary references also, because proper prepping means more than just being able to open cans of Spam or Brazilian beef and gravy.

 

Reasonable Rascal has been plaguing the internet since 1997 and refuses to go away despite years of jeers. He began his medical career using all the skills the Boy Scouts could teach him and eventually found his way into a more formal career as a Paramedic and Registered Nurse. He is one of the authors of Survival and Austere Medicine, 3rd Edition

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