Commercial Quantities of Meds

Thanks to Aesop (https://raconteurreport.blogspot.com/) for the inspiration for this post. See his series of posts, July 10 2019 to July 12, 2019. I write this on 12 July 2019. He may have more: it appears that he is just warming up!

So, TINS©, TIWFDASL© as a midlevel in a county lock up. Our sheriff had a policy of no drugs (I.e, no euphoriants narcotics or sleepers) for inmates. I was told that the rationale was that he did not want inmates to “sleep their sentences away”. Cool story, there were very few occasions wherein I would consider prescribing scheduled meds (euphoriants, narcotics) anyhow.

I was working part time. One morning I came in, and an offecer invited me to step into his office. He showed me a dispenser pack of what looked to be 140 or more tablets, labeled “Methadone 10 mg”. The administration instructions read “take 9 tablets daily”. Holy cow! That’s 90 mg of methadone, equal in pain killing (or sedating) effect to around 1 000 mg of morphine every day. ONE THOUSAND MILLIGRAMS of morphine equivalent, every day! The medical history form related that this had been prescribed for debilitating arthritis.

The officer noted the department’s “No Narcotics” policy, and asked me, the medical authority (Hah!) present, for an opinion. I thought that placing this gentleman in the “detox”/observation cell, and obtaining and recording vitals every hour for the first 24 hours sounded prudent. I also provided a checklist of concerning symptoms to watch or. I provided my cell phone number, and directed that, if certain parameters of vitals or observation were exceeded, send him to ED by ambulance immediately. If any grey area, phone me at ny time of day or night.

So, the officers recorded vitals and made “nurse’s notes” on their guest. I came in early the next day, read the noted, and re assessed the gentleman myself. All nominal, no alarming findings. We repeated this process, now every 4 hours, and, again, the next day, I arrived early and re-re-assessed the inmate. Same nominal vitals, same unremarkable exam. This did not seem to all fit together as it had been presented.

Another day, another 24 hours of vitals and “nurse’s notes”, another benign exam.

After several days of this, the jail command suggested that , with nearly a week of normal vitals and normal exams, perhaps our guest could be moved into general population? It seemed alright to do do, and I seconded their initiative.

So, after nearly a week of no methadone, nearly a week of no abstinence symptoms, my attention wandered to other topics. One morning I arrived, and an officer beckoned me into his office. “Hey, I thought you’d want to see this!”, was his opening conversational gambit.

It turns out that there are surveillance camera throughout the jail. (Who knew?). One had captured the methadone-for-debilitating-arthritis fellow getting into an altercation with another inmate, and whupping same. That’s correct: the “debilitating arthritis” inmate, delivered a whupping onto the person of another inmate.

The officer turned to me, and observed, “I am beginning to think that that prescription is rather more of a commercial opportunity, instead of a medical intervention!”

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“Speck’ ah got it figgerred out!”

So, TINS©, TIWFDASL© at Rural Community Hospital ED one fine summer afternoon, nothing exciting (for me, at least: the folks who were here for sutures, or chest pain, likely thought that their dilemmas were entirely more exciting than they would otherwise desire!).

So, this fellow trotted in, carrying a crying child. He announced that the child had cut his head. Our nurse aid escorted the gentleman to one of the carts, and started to look into the problem. I tagged along.

Quick witted, she promptly determined that stapling this child’s head would likely result in a net minima of drama and caterwauling, so she plucked up a surgical stapler, and some betadine, and began to clean up the lac.

The physician arrived, and she briefed him on her findings. Me? I occupied myself trying to get vitals, allergies/meds/medical history on the child from the (clueless) dad. Doc began to perform his own assessment, as the mother arrived.

This elicited another chorus of wailing, tears, and general drama. Predominantly from the child, although the mother contributed her own share. The physician informed the parents that he was planning to staple the wound, once my friend the nurse aid had completed her task of cleaning things up.

“Is that going to hurt him?” was the mother’s question.

My bad, I answered her truthfully. “Yeah, but it will only be 4 pokes. If we stitch it, there will be 8 or more pokes to numb it, and then another 8 or so pokes to sew it up.”

Likely, it was lost when I used the word “numb”. I suspect that she stopped listening at the word “numb”, and failed to do the math. “Oh, I don’t want him to hurt! Can’t you numb him?”

The aid tried her hand. “Well, yeah, but that will require 8 needle sticks, whereas if the doctor simply staples it, there will only be 4 pokes”.

Mom had One Thing on her mind. “I don’t want him to hurt!”

The physician tried. “Ma’am, nobody wants him to hurt. In fact, if I simply staple the cut closed, he will avoid something like 12 additional punctures, and the discomfort associated with those 12 punctures.”

“Please, numb him up! I don’;t want him to hurt!”

Resigning ourselves to our fate, I collected the lidocaine, syringe and needle, and my friend the aid swaddled the child in a blanket.

The kid promptly figured out where this was going, and he wanted NO PART of this ride. So, I set up the doctor’s suture set and lido, and joined the rodeo.

The kid screamed, and he flipped, and he flopped, and he writhed, and he twisted, and he turned. He shook his head, so I was detailed to seize his head, and immobilize it. Mom, to her credit, laid across her child’s legs, and dad laid across his torso, so the doctor only had to zig and zag over roughly 30 degrees of motion as he was injecting the local anesthetic into the margins of the wound.

Did you know that lidocaine, injected into your skin, burns? Yep, burns like a sonuvabitch, for a minute or two. Now, may I watch YOU explain to an 8 year old, that the burning will go away soon, and then things will be numb? Because, he was not listening to me at all, which, of course, assumes that any earthly creature could distinguish my speech over his screams, and cries, and shrieks, and general high volume protestations. Because, I could not.

So, once the doctor had established that the process was going to be pain free (because, of course, the anesthesia had been SO! MUCH! FUN!), the child was going to lay very still for the suturing?

Totally! And, the Democrat candidates for President are not vying to convince the electorate that they, only they, will be the BEST! At providing free stuff to non citizens, as well as college graduates who find themselves in the food industry.

Of course, no. Just, NO! More rodeo nursing, more Brahma Bull On the Suture Table.

Finally, at long last, we were done. The aid unwrapped the (limp)(sweaty)(hoarse voiced) child from the blanket, and we all stepped away, so Mom could hug the child.

She looked at us all, and said, “That was awful! Ohmigawd! I should have listened to you guys!”

I bit my tongue, and shuffled off to the nursing station, to complete my charting. The aid sat down next to me, and said, “Hey! I did my best!”

“That you did.” I replied. Then, taking on a stereotypical hillbilly voice, I continued. “Hyuck, hyuck! Ah’ve bin doin’ this here ‘mergency nursin’ thang for might’ near six, mebe seven weeks now! Speck’ ah got all figgerred out!”

Backpacking Changes your Perspective

So, when I was younger, I enjoyed backpacking. In the Midwest, unless you are going to travel several, several hundred miles east (Appalachian Trail), or west (Rockies, or their foothills), or north (Northern reaches of any of the Canadian provinces), Isle Royale is pretty much a zenith destination.

Two other medics and I shared this enthusiasm, and we planned on a trip along the Greenstone Trail, after a detour south along the Feldtman Ridge Trail. Traveling from west to east, we planned to wind up at Rock Harbor, where we could shower, get a room at the lodge there, and catch the ferry back to Michigan.

Our first day called for 8 or nine miles of hiking. (remember, we were all south of 30, and pretty much in peak shape. I would bicycle 50 to 100 miles a day, a couple of weekends a month, for amusement, for example). We anticipated the daily mileage would be a challenge, but no tremendous thing.

We read, voraciously, trail guides, commentaries, and articles in the various outdoor magazines regarding Isle Royale. The consensus was that we ought to cut ounces, as over time ounces add up to ponds, and pounds add up to pain. So we turned to freeze dried foods.

After much prep work, and detailed planning, we arrived on Isle Royale, starting our trip at the western end of the island, at Windigo. After registering, we set out, arriving at out campsite after around 8 miles, at Feldtman Lake. We set up camp, washed up with filtered water, and prepared supper.

Our consensus was that the freeze dried meal was superior to not eating, but not by much. One of my partners summarized things: “This mess tastes like salty cardboard!”

In the morning, we set out again after eating and packing up. After another day of up hill and down slope, we arrived at Siskiwit Bay Campground having made around 10 miles on the trail. We set up camp, washed up, filtered water for dinner and the next day, and ate.

We reviewed dinner, afterwards. “This mess still tastes like salty cardboard!”

The next morning, awakened, packed up, headed out. If you are familiar with backpacking, the daily routine is, well, pretty routine. The payoff can be found in multiple areas. There is the being outdoors aspect, very attractive to those (such as me) who find being outdoors to be attractive. There is the scenery to be found as you stroll through nearly pristine wilderness. There is the enjoyment found in physical activity.

So, we walked our next day away, again arrived at our camp, set up camp, filtered more water, cooked supper, and appraised it. “This shit tastes like salty cardboard. You gonna finish all that?”

Again, slept the sleep of the righteous, awakened, breakfasted, and headed out, once we had packed up.

Another day, more beautiful vistas from the Greenstone Ridge Trail, Reaching our campsite, we again set up, filtered water, cooked dinner. For our last night on the trail, we provided another gastronomic review: “This shit tastes like salty cardboard! And, the portions! They’re so small!”

DUTY IN EVERYDAY LIFE

I have spent a lot of time talking, directly or indirectly, about duty. I am by no means any sort of authority on the subject. I have, however, spent some time contemplating what it means to recognize DUTY, to attempt to measure up to one’s duty, to accomplish Duty, and consider what my Duty might be in this or that circumstance.

Let me tell you about a man, who went above and beyond. This is not tale of derring do, of valiant action in combat, or hazardous duty, rather it is the story of a MAN who stood up in circumstances where I could not, and went way, way out of his way to do a good deed for a stranger.

A couple of years ago, in The Maternal State, they had a sizable blizzard. Now, being in or near the northern tier of states, this should be no big deal: winter, Up North, snow, so whucking fhat, amirite?

Yeah, that is generally my go-to response. Well, lemme tell you, this was somewhat more snow, and more wind, and more nastiness than is the baseline for this part of The Maternal State. Power lines iced up, and, swaying in the wind, well, they snapped, in multiple locations. Oops, power outage.

So, my mother is in her 90’s. At this time, pretty independent, but, still, 90 plus, and on the order of 800 miles from her nearest family.

My brother had anticipated the weather, and done some internet reconnaissance. He had identified a hotel in the next town, and, calling the reservation number (remember THAT thought!), had been told that the hotel in question did have an auxiliary generator, and would be in service. He therefore had made a reservation for our mother, securing, he thought, a heated safe place for her.

He filled me in on his plan, but had no idea of how to get her from her, now unheated, house to the hotel. As you might have considered, there was NO FREAKING WAY we wanted Mom driving in this mess. I called the taxicab companies local to my mother, only to find that none of them were answering their dispatch telephones. Shit.

I phoned the local police department, and spoke with the sergeant on duty. He pointed out that while he, and the officers on duty, were certainly willing to make sure my mother made it to the hotel, well, they were kind of busy (read, “extremely”) doing, ya know, POLICE stuff occasioned by the storm, the basic level of idiocy amongst the population in general and The Maternal State in particular, and the way poor weather exacerbates the foregoing. He did not see this happening in any clinically significant time frame. Shit. Again.

I let my fingers do the walking among the internet search results for “transportation services” in The Maternal State, and the Maternal County. I recalled my brother, The World Traveler (not the hotel finder) had spoken of hiring a car service to travel from The Maternal Manse to the airport, or vice versa. I called several car services, and, finally, reached one who answered his phone.

We had a lovely conversation about the weather, and how and why it seemed unlikely that I would find a taxi company who would answer their phone. He, himself, answered his own phone, only because he took this opportunity to come into the office to complete some sort of paperwork.

I told him my tale of woe, featuring my elderly mother, distant children, and so forth. He asked me for her address, and where the arrangements had been made for her accommodation. He told me that he’d swing by, check up on my mother, and give me a call with his appraisal of things. I thanked him, effusively, and awaited his call.

Something around an hour later, I received a phone call. Mom was fine. My new friend, calling me on his personal cell phone, provided me the opportunity to speak with my mother. She asked me who this guy was, and I recounted the story of my brother’s hotel efforts, and how this fellow answered his phone, which, by itself, set him apart from everybody else in her corner of the state. I told her that he could/would transport her to the hotel for heated accommodations. She thought that was a great idea, and handed to phone back to the Car Guy. Shortly, I received a call from him reporting that he had Mom, and her little dog, were on the way to The Hotel. Again, with effusive thanks, I awaited the next situation report.

I received it, and it was infuriating. It appears that the national reservation folks for The Cretin Hotel Chain (by the way, I apologize to cretins, everywhere, for maligning their good name!), (a) did not know a goddamned thing about the power status, or lack thereof, in the subject property, (b) could not possibly care less about said power status, unless somehow The Creator elected to Personally and directly intervene, in a biblical display of His power, to motivate these gormless fuckwads to pretend that they might appear to give a shit (not that they might actually do anything effective to support that pretense. Even The Creator Of All has some limitations upon His power!), (c) would happily spin any line of bullshit that might result in their establishing a reservation, and (d) if kharma actually was a thing, would spend eternity sleeping outdoors, on some forsaken ice floe, adrift on a freezing gale swept ocean of sewage, with a solitary hospital “blanket” to protect themselves from a shivering, frozen, blue demise. If Crom was merciful. Which I hoped He would not be.

You might not be surprised, at this point, to learn that the hotel had no power and no heat.

I just might, one day, tell y’all how I REALLY feel. Assholes. (and I mean no slight to assholes).

My new friend, and Mom’s chauffeur, reported his plan to personally reconnoiter other hotels in the vicinity and report back to me. He did so, and he called me: no joy. None had power, so none had heat. Shit. Again. Again.

So, my new friend drove Mom home, and, arriving and ushering her inside, put her on his phone. Mom felt OK, the house was only around 50 something which, while chilly, was only unpleasant, not life threatening. She had canned food, a Sterno stove, the food in the fridge seemed in no danger of thawing (unsurprisingly, right?), and she had several blankets for cozy sleeping.

I thanked my new friend, again, and again, and bade everybody goodbye.

I spoke to Mom later that night, when one of her neighbors, charged cell phone in hand, stopped by with a hot meal (they had a camp-stove, it seems). Mom was doing OK, the neighbor (PBUH!) came on to reassure me that his appraisal was that Mom was managing OK, and he, the neighbor, would check in on her in the morning.

The next morning, the Car Service Guy called me. He had stopped by Mom’s house, and reported that he found her reading, swathed in a blanket, drinking a cup of (Sterno stove) coffee, eating a cold bagel. He put her on the phone, and she concurred in his report. He came back on, reported that the news was predicting power would be restored in a day or two. We chatted a bit, I thanked him, again. Again. Again. And he slogged back home, driving through the ass deep snow.

I received a call the next morning. Mom was chirpily informing me that the power was on, she had had a lovely, lengthy, hot shower, was cooking a casserole to have, hot, for dinner, and presently was enjoying a hot cup of coffee, and hot muffin. Her second of the day.

So, all is well that ends well, right?

Let me tell you MY take away. God has blessed us with angels. Some we cannot see as they are spirits. Other walk among us.

One exemplar is this guy, warm and dry in his office, piddling around, grateful that he did not have to be out in the butt ugly weather afflicting his hometown. He received a phone call from Sumdood, who he had never met, from Ghawd Only knows where, spinning this tale of his mama who allegedly lived nearby, had no power, and needed somebody, NOT the caller, to chauffeur her tail to refuge. Oh, and her little dog, too!

So, did he tell me to FOAD? Did he tell me it would be a profound pain in his ass? Did he tell me it was not his job? No, no, and no. He gathered the information that would be required to conduct an in person reconnaissance of her circumstances, and promised to report back to me. He did so.

He helped Mom gather her crap for her voyage, and drove her, her luggage, and her dog, to the local property of The Cretin Hotel Chain. Finding that my brother had been bullshitted by the dickless, hapless, shitheads at the Cretin Hotel Chain’s national reservation operation, he called me with this insight, and attempted to find alternate accommodations for my mother. Failing in this quest, he drove her home (through the awful roads associated with an awful storm in winter in the northern tier of states, mind you!), schlepped her stuff inside, attempted to assure her safety, and comfort, and called me. Again. On his personal cell phone.

Then, the next day, with the same (or worse) shitty roads, he got out of his nice warm bed, and drove to my mother’s house, again, to check on her safety. And called me with a progress report. She was chilly, but fine.

Thus far, only mentioned in passing, are the Blessed Souls that are her neighbors. She’s not their mother. They did not grow up in her neighborhood. Simply, they are NEIGHBORS, in the finest traditions of small town America. God Bless Them. They visited, in turns, several times each day the power was out, bringing hot food, visiting, offering to charge her phone (and, just so you know, it works way, way better with a charge on the battery!), and generally being guardian angels for her.

She could not have lived there alone, for as long as she in fact did, without their oversight and backup.

TL/DR summary? Somebody is setting me a good example. I resolve to try to imitate it.

Hospice Nurse Midnight Shift Call Off

A long, long time ago, in a galaxy not so far from here….

No, wait, that is not quite right. Well, anyway, after I had departed Da City’s EMS, and started working as an RN, my father took ill. Years previously, he and my mother had moved back to The Megalopolis, and resided in The Maternal State, nearly half way across the country from me. My brother the contractor did not seem well suited to the demands of helping care for a sick elderly man, so I volunteered.

As it happened, while I was helping Mom take care of my Dad, I was working 12 hour night shifts in various EDs around The Maternal State, receiving my assignments from this or that temporary staffing agency. The money was OK, and I was able to keep up with my house payment, my car payments, and all that stuff.

Things progressed. My father was dying, and there was no stopping it. I was glad that I could take some of the burden off of my mother, who was nearly overwhelmed in any event by the looming demise of her husband of decades. You do that which you can do, correct? Around this point in the process, my father had been admitted to hospice, and his care needs had escalated to the point where Hospice supplied a nurse to care for my dad around the clock.

So one morning around 0900, I arrived home from work, and went to bed. I was awakened for a phone call around 11 am, to find that the agency was informing me that my shift that night had been canceled. I mumbled affirmation, and stumbled back to bed.

Around 1400, I was again awakened to learn from the Hospice case manager that they were unable to find a nurse to care for my dad overnight that night. “I don’t know what we are going to do!” she apologized.

I wasn’t all that wound up over it. “So, it looks as if you have a nurse, then.”

“No, I don’t. I have called, and called, and I cannot find a nurse to care for your father tonight!”

“Yeah, you did. Me.”

“You cannot care for your father overnight!”

“How come? You need a nurse. I’m a nurse. You need somebody who will be reliable. I flatter myself, that I am reliable. You need somebody here. I’m gonna be here, nurse or no nurse. Looks like I know what I’m gonna be doing, instead of watching late night TV!”

“Are you going to be able to do this? Can you handle that responsibility?”

“Do you have a better idea?”

She admitted that no, she did not.

“Well, then, it certainly looks as if I have to do it, and have no alternative to handling it, doesn’t it?”

We agreed, and I returned to bed.

This time, around 1500, I was awakened for another phone call (this appeared to be developing into A Thing!, and I was not liking it!). My agency was calling, and the staffing coordinator perkily informed me that she had found me an assignment for that very night! “Gosh, thanks, but, after you called me to cancel me, I made other plans.”

She was aghast. “What? Are you refusing an assignment?”

“Nope. I had an assignment as of 0730 this morning, when I left duty. I was sleeping, in preparation for reporting for that assignment, when you called me, to cancel it. Once you had canceled me, I had no obligations to anyone, and I have made other arrangements since then. Now, you are calling me and asking, at the eleventh hour, may I remind you, if I can take a last minute assignment. No, I cannot. I am busy tonight, with obligations that I cannot ignore. I’m not refusing an assignment, I am simply not able to accommodate your last minute brainstorms.”

We ended the call at that point, and I resigned myself to my (sleep deprived) fate.

Mom and I had supper, I made some calls, and wrote checks for some of my bills. Once 2300 arrived, the afternoon nurse gave me report, and oriented me to the overnight routine.

We changed my father’s bedding, and bathed him. As we turned him to his left, I held him for her part of the cleaning and linen change, and he sighed once, long and loud. I looked into his eyes, and watched them dilate. I felt for a carotid pulse, and found none. “I think he’s gone”, I told the nurse. She and I tidied up the bed, tucked him in, and she went for my mother.

The next couple of hours were not etched in my memory. Eventually, Mom and I were alone in the house. We cried, we hugged, and we went to our beds.

Monday I had an assignment. I showed up, happy, in a sort of left handed way, to be doing SOMETHING that did not involve constant reminders of my dad’s death. The charge nurse for St. Elsewhere greeted me with, “We heard about your dad. We’re sorry to hear it. How are you doing?”

I was surprised. She was a lovely soul, cute, smart, professional, and capable (all things that I admire in a woman). She was friendly, and I was very open to that. However, I hadn’t told anyone about my dad’s demise. I was touched that she would make the effort to offer consolation to me, a relative stranger. I had been hoping that I could immerse myself in ED nursing, and not think about my dad for a while.

I offered my response, thanked her for her concern, and asked what pod was mine for the night.

Fast forward a couple of weeks. I received another call from the agency, and another assignment offer. I had made plans to take my mother out for dinner, and therefore I declined the assignment. (Yeah, THIS one I straight up declined.). The coordinator took me to task. “I’m getting really tired of covering for you all the time!”

What the fuck? My query was edited before being spoken. “Huh?”

“I said I’m getting tired of covering for you!”

“Uh, what are you talking about? Covering for me? When?”

“Remember two weeks ago? That Friday night, when you had made other plans? That’s what I’m talking about!”

I was almost speechless. Fortunately, this was a telephone conversation, not one taken across a desk. That fact alone kept me from big trouble. I put as much ice into my voice as I could, and clarified: “Oh, wait! Do you mean the night my father died? Do you mean to tell me that you are irritated that I could not work on the night my father died, in my arms, and you are really, no shit, taking me to task for not working that night? Did you really, actually, just say that to me, not two weeks after he died? It sure sounds as if you did, and I cannot think, off hand, of any other way to take that. What did your supervisor say when you told her you were inconvenienced by my not working that night? Say, how about I call her, right fucking now, and ask her? Gimme her goddamned phone number, please. I feel the need for a heartfelt chat!”

For some reason, she was, well, “reluctant” probably does not fully capture her lack of enthusiasm for me chatting with the manager of the office on a Saturday night.

I continue to be surprised. By humanity in general. And, in particular, that she was such a jackwagon, and that she did not provide me that number.

Although, not giving me the number might have been a good thing.

Do It Yourself Emergency Care

First disclaimer: LOONNGGG post warning!

Second disclaimer: for the terminally thick, NO, I AM NOT ADVOCATING THAT YOU AVOID PROFESSIONAL MEDICAL CARE. WHEN IT IS AVAILABLE!

Third disclaimer: I apologize for my computer fumble fingery, but the hyperlinks do not show as hyperlinks for most of this post. Feel free to copy and paste the links into your browser.

So, the preceding obligatory disclaimer having been presented, why might you want to be able to provide your own medical care?

Well, if professional medical care is not available, you might have a zero-sum choice to make. Kind of like Graham’s Kill House Rules. (http://grahamcombat.com/the-killhouse-rules/ )

NOBODY IS COMING TO SAVE YOU.
EVERYTHING IS YOUR RESPONSIBILITY.
SAVE WHO NEEDS TO BE SAVED.
KILL WHO NEEDS TO BE KILLED.
ALWAYS BE WORKING.

If, indeed, nobody is coming to save you, in any clinically relevant time frame, then, indeed, EVERYTHING IS YOUR RESPONSIBILITY! Therefore, you can seek out and achieve training at whatever level you are comfortable with, or not. Good luck with extemporizing on your particular slice of Armageddon. (And, just like with defensive firearm use, exactly at what point are you really “good enough”? And are you willing to bet your life, or your family’s lives on that “good enough” level of expertise?) Because, if help will not arrive, or not arrive “in time” (whatever that is in your emergency scene) then either you are ready to act, or you are not.

Even if you do not anticipate a Zombie Apocalypse, because “that will never happen”, how about coming upon a collision, and Tag! You’re IT! As first on the scene? (BTDT) Or, maybe, you, or your dad, or your kid was chopping wood, or clearing brush, or cleaning up after a windstorm, and the axe, or hatchet, or chainsaw slipped and added a laceration to the wonderful day everybody is having? Or, you (or your wife) (or your neighbor) fell from a ladder?

Have you ever had to extemporize an emergency response kit out of your household stuff? I have (Once. A LONG, Long time ago! Never Again!), and, as you may surmise, I did not enjoy it.

Being an old medic, and an old ED RN, I LOATHE surprises. While The Universe cares not a whit about my preferences in that regard, if I anticipate trouble, and put in place preparations and training and action plans, well, surprise is not quite so disturbing.

First of all, read my blog (shameless plug!)

Secondly, read this guy’s blog in general, and this post in particular. He relates that he’s been a nurse for a considerable time, and everything upon which he opines, for which subject I feel a right to have an opinion, he’s right. (his series on first aid/emergency care, Sept 24 2017, to May 13 2018 is PURE GOLD!. Hit his site, find the “first aid” tag, search, read, learn, find your life enriched.)

https://raconteurreport.blogspot.com/2019/06/aom-how-to-build-first-aid-kit.html

Now, full of resolve to improve your life (and the lives of everyone around you, amirite?), go ye and set up your own emergency response kit. Make It Yours! My list, Aesop’s list, FEMA’s list, your old squaddie’s list, don’t mean nuthin’ if you do not know how to use the items you have at hand, and if you do not have the correct items at hand.

About that last thing: let me tell you a little story. TINS©, TIWFDASL© (well, I wasn’t REALLY Fighting Disease And Saving Lives, but, verily, This Is NO Shit!), as my then girlfriend and I were motoring Up North to visit her family. Fat, dumb and happy, I was motoring along, chatting companionably with my girlfriend, when we observed several vehicles pulled over, on the median of the divided highway that led us on our way. Closer examination led to the insight that likely these folks had pulled over due to the minivan on it’s roof, in that selfsame median.

To paraphrase the Noted Medical Ethicist and Moral Philosopher, Han Solo in the trash compactor, “I had a bad feeling about this!” Once I alighted, medic bag in hand, I noted (Thanks be to Crom!) that the nominal patient appeared trivially hurt, with a small amount of bleeding from her head. This was particularly wonderful because I COULD NOT FIND ANY DAMNED GLOVES! I have no excuse (other than being stupid, I suppose…). It is not like I have spent, mmm, oh, let’s see, carry the ‘nought, seven goes into 11…uh, yeah. FORTY FREAKING YEARS, at that point, in the sick people business or anything. So, yeah, having the basics is kind of important.

So, lists. Make the list that you select, YOUR LIST!. Work that bad boy. Repack your kit on every seventh full moon, if that’s how you roll. Solstices and equinoxes work for me. Or, try your birthday, and anniversary, and two national holidays of your choice. But, repack that kit! You thereby get the opportunity to be sure stuff has not expired, that vermin have not spoiled it, that the elements have not f*cked with it. (And automobile trunks, in Michigan, reach not less than 142 degrees F in the summer. I know. I checked. I logged it, somewhere. In winter, well, MFC [mighty fenomenally cold] just about describes things!) For the record, hot and very cold are not good for shelf life (or trunk life, for that matter!)

As an introduction, and starting point for conversation, here’s my
(annotated) list. First, the list and prices

Green Bag
LAPG Bail Out Bag 26
CPR mask 9.2
BVM 10.94
CAT TQ 29
SWAT-T TQ 12
6” IBD 7.55
4” IBD 6.95
gauze 4×4 4.00/100
ABD 5×9 6.32
celox 28.75
Bandage Shears 2.95
tongue blades
Stethoscope
BP cuff
adhesive tape 2 in 2.6
roller gauze 4 in x 3 1
vaseline gauze
elastic bandage 4 in
elastic bandage 2 in
Elastic Bandage 3 in 1.25
Total 159

Now, with commentary and links:

You may notice that I have selected a LA Police Gear Bail Out Bag for my case.( https://lapolicegear.com/tabaoutbag.html $26 bucks) It really doesn’t matter what sort of container you employ for your emergency supplies, so long as it meets your particular needs for security, identification, accessibility, protection and convenience. My choice (in Fire Department Red) is not water resistant, is not neatly compartmentalized, and does not have an IR glint Star of Life embroidered upon it. On the other hand, I know how my stuff inside is organized, it is convenient to sling over my shoulder when the scene requires that I do so. It will fit beneath a van seat, or in a tub in my trunk, and I can work out of it when I have it slung.

Some fire departments use plastic “totes” to organize supplies required for specific types of calls. For example, haz-mat supplies are packed inside specific totes, and the top secured with a cable tie or some such device. An inventory is attached to the top (sealed in plastic) to identify what is inside, as well as out dates of time sensitive components. When properly closed, such bins are drip and dust resistant, resist crushing or jumbling of the contents, and can be convenient to carry when not overfilled. On the other hand, they will not conveniently fit beneath a vehicle seat, may be unwieldy to retrieve and place into action, and may get buried beneath other stuff in a trunk or truck box.

Others of my acquaintance use ammo cans, or plastic fishing tackle boxes. These are generally more convenient to shlep about (unless your tastes run along the lines of a 20 mm ammo can) and are more drip/dust/duh! resistant than the tubs mentioned above. On the other hand, they may overturn with disappointing ease, spilling your supplies into whatever noxious fluid is abundant on your particular scene.

IN THE TOP, OR IN AN OUTSIDE POCKET

Items that I am likely to require promptly are either in the outside pocket or immediately inside the top flap of the bag. These are things that I do not want to be fumbling for as I approach a scene. I will not list what might be considered “everyday carry” items like pocket knife, flashlight(s), CS spray, sidearm, and a cell phone. While these tools help keep the rescuer from becoming a victim of an ambush laid for a “Good Samaritan”, particularly when employed in concert with a Condition Orange mindset. (I did mention I started out in Da City, didn’t I?), these items do not seem to me to be rescue/first aid/emergency medical tools.

First up is several pairs of gloves. (well, now, anyhow!) I am allergic to latex, so I have nitrile gloves. Current practice is to wear gloves anytime you might reasonably anticipate exposure to blood or other bodily fluids: tears, urine, stool, saliva, gastric contents, or any other moist, body-origin material you might imagine (and perhaps a few you might not!). I have so thoroughly incorporated this into my life that I get uneasy caring for my own children (or, at my advanced age, grandchildren!) without gloving first. These are in a zip-lock bag, safety pinned (now!) just inside the top flap of my green bag.

The upside to all this is that scrupulous gloving and thorough hand washing have so far proven highly effective at preventing the spread of the most common blood-borne infections. Diseases spread via airborne droplets (for example, Legionnaires disease), of course, require additional precautions. Others are spread by organisms coming to rest upon environmental surfaces and then accessing a vulnerable host (just like you and I are vulnerable hosts to “the common cold”) by means of unconsciously touching our faces after touching a contaminated surface. For myself, after 40 plus years of patient contact the worst I have brought home has been an occasional upper respiratory infection due to my conscientiously applying the glove/hand wash/hands away from my face regimen. (https://www.harborfreight.com/7-mil-nitrile-powder-free-gloves-50-pc-medium-68504.html $10/box of 50)

The next item I’ll feel a burning need to have in my hands is a bag-valve-mask (BVM). This is a manually operated ventilation tool. It is employed by sealing the mask over the unbreathing patient’s face, squeezing the self inflating bag, and thereby forcing air into your patient’s lungs. Repeat at a rate of approximately 12-20 times a minute. Advantage: no kissing strangers, required for mouth-to-mouth resuscitation. You are able to maintain situational awareness of such things as evolving environmental hazards (like leaking gasoline), or indicators of your patient’s improving condition (…he said, thinking positively!). On the downside, using a BVM is difficult in untutored hands. It is easier (compared to mouth-to-mouth) to force air into the patient’s stomach (which is a bad thing), which will elicit vomiting (which is WHY that is a bad thing!). Aside from the aesthetic issues this presents, vomiting in a profoundly unconscious patient (such as one so unconscious as to have stopped breathing) presents the opportunity for aspiration into the lungs of that which has been vomited, which may be deadly.

Training in use of a BVM will be part of an EMT class which can (OUGHT TO!) be part of the training that I mentioned earlier. I’ll wait here while you go find out when your local community college or rescue squad will be having their next class. Plan on being a part of that class. You will be making your community, and thereby your family, safer.

You can buy your own disposable model (https://www.liveactionsafety.com/lsp-disposable-manual-resuscitator-adult/ ) for around $14. In the hospital, we use these once and discard them. Your local rescue squad or ambulance may shop locally, and you might want to do likewise. Ya know, if you were to volunteer with your local rescue squad, you might be able to obtain things like this at your agency’s cost. All this on top of the good karma from helping to provide a necessary community service. And, besides, becoming known to the locals (police included) as one of “the good guys” can only be a good thing for many reasons. Your phone book likely will provide the contact information you require. I’ll still be here when you get back.

One of the adjuncts to using a BVM is called an oral airway. Oral airways come in sizes, which may be selected according to the size of the patient. Their purpose is to hold the flaccid tongue of a profoundly unconscious patient forward, so that it does not sag against the rear of the throat and thereby block the passage of air into and out of the lungs. The problem it may trigger is, should your patient be other than profoundly unconscious, he or she will vomit. Among other disasters this may cause, the enzymes from the stomach, designed to digest proteins, will (unsurprisingly) begin to digest the proteins found in the delicate tissues of the air sacs (alveoli) of the lungs, with effects you are likely to be able to imagine on your own. Very Bad Thing.

Another way to fail when employing an oral airway is to bunch up the patient’s tongue in the rear of the throat. This blocks air flow, strangling your patient. This device must be restricted to only profoundly unconscious patients, and only if you are schooled in its use. You can buy them individually, or in sets. Before shipping, they go for around $5.00/set. You might elect to buy them one at a time, but at $5 a pop, they aren’t a particularly major investment. (https://www.buyemp.com/product/curaplex-berman-oral-airway-kit )

When I’m confronted by an actively bleeding patient, I reach for an Israeli Battle Dressing. (https://www.bestglide.com/the-emergency-bandage-4inch-military.html $7 each in the 4 inch size, https://www.bestglide.com/the-emergency-bandage-6inch-military.html $7.55 in 6 inch) It consists of a sterile dressing incorporating an elastic bandage to secure the dressing to the wound.

On a side note, should you shop gun shows or surplus stores for your equipment, be wary of old dressings. They present potential issues of failed sterility as well as mustiness or mildew occasioned by improper storage or imperfect packaging.

Another wound care product is QuikClot. (https://www.liveactionsafety.com/quikclot-combat-gauze-z-fold-expire-2023/ $40 each) This is a mineral product, bound to a dressing, which enhances clotting, and thereby slows and limits blood loss in the bleeding patient (common in trauma, surprisingly enough!) One 2008 article (QuikClot Use in Trauma for Hemorrhage Control: Case Series of 103 Documented Uses. Journal of Trauma-Injury Infection & Critical Care. 64(4):1093-1099, April 2008.) reflected the occurrence of burns in several patients, but the manufacturer’s web site reports that changes in packaging and delivery system have addressed this issue.

An alternative you might consider is Celox.
(https://www.emergencysafetysupply.com/celox-blood-clot-gauze-roll/ $29 each, 3 inch x 5 feet) It appears perhaps to be a reasonable alternative to QuikClot. It is derived from shrimp shells, although it seems to not produce allergic reactions in folks otherwise allergic to seafood. I have no personal experience with either product, but the reports are interesting. This goes on my “further research” list!

SECOND TIER SUPPLIES

The preceding items are to be found in the outside pockets or very top of my jump kit. I don’t want to be searching for them when I feel the need for them Right Freaking Now. Beneath the don’t-wanna-wait-for-them items, I have supplies of somewhat lesser immediacy. These allow me to assess the situation in greater detail, or address issues that may come to light that are of less time sensitivity.

Triangular Bandages are useful for slings of injured arms, or may be folded into narrow strips and then used as a means to secure splints or dressings (as “cravat bandages”). If we were to consider them as a backpacker might, they may be used as expedient dust masks, bandannas, head coverings, or washcloths. I buy muslin by the yard at Wal-Mart, and cut it from one corner to the other, forming (surprise!) 2 triangles approximately a yard on a side. I keep 6 to 8 in my kit.

Bandage shears are the most obvious of the prehospital medic’s tools. You can go with Lister style bandage scissors, often found as “nurse’s scissors”, or the plastic and steel “super shears”. Prices range from $4.00 and up (shop around). Frequently employed to trim dressings to the proper size, cut away clothing from wounds, and to cut bandages.

Did you ever notice that a tongue blade/tongue depressor is almost exactly the width of a finger? And just a bit longer than your Mark 1, Mod 0 finger? Exactly like it were designed to be a finger splint, isn’t it? In addition, should you tape three of them together one on top of the other, you have a dandy tool for tightening that “Spanish windlass” you are going to learn about, when your (probably, in 2019, “Wilderness”…) EMT class teaches you how to apply and improvise a traction splint for a fractured femur (thighbone). Finally, if you are unhappy at the thought of wiggling somebody’s fractured femur (broken thighbone) so you may place ties (cravats: remember them?) for a splint, tongue blades are thin, stiff, and very helpful at limiting the wiggling as you place ties beneath the broken bone of your choice. I keep a handful handy.

You can pay a couple of bucks for them at the corner pharmacy, or you might be able to talk your way into several for free, like when you are volunteering at some public service event with your local volunteer fire department, emergency medical service, or amateur radio club.

Stethoscope/Blood Pressure Cuff. A stethoscope allows you to hear the sounds made as air moves into and out of the lungs, and note changes from normal. These changes might occur because your patient has a collapsed lung, or has pneumonia, or heart failure. When you get that far into your EMT class (hint, hint), you will learn how to evaluate these changes, and what sort of treatment decisions you ought to consider when you notice them. In addition, you will learn how to measure, and interpret, your patient’s blood pressure.

I am certain you will know somebody who will go out and get the cardiology deluxe stethoscope, with Wi-Fi, mag wheels, and gold trim. Do not join them in this folly. Spend $10-80 at the same place the local student nurses get their stethoscopes, and spend the difference on your spouse, whose enthusiastic support you will require, anyhow. If you can show your spouse how your expenditure of family money and time on supplies, education, and volunteering promote values that you both agree upon, the both of you will thereby make your family more crisis resistant. If your family is more crisis resistant, then you are not only NOT a drag on community emergency services during an emergency, you all might even be an affirmative community asset during bad times. That cannot fail to be a Good Thing when you get to explain yourself to The Jewish Carpenter. Me, I’m going to require all the help I can get. I’m volunteering!

Adhesive tape (1 inch, 2 inch) secures dressings, holds loose ends of bandages, and provides a single use notepad (tear off a length, tape it to your thigh, and jot notes. You will not lay it down somewhere to be forgotten). If you listen to some friendly and knowledgeable athletic trainer, you can learn how to use it to support sprained ankles or knees if the preferred treatment (rest, ice, elevation) is not possible. Before you employ these tricks, bear in mind that physicians frequently cannot differentiate a sprain from a fracture, even after an x-ray. In my view, except under the most dire possible circumstances, walking on a fractured (or sprained) extremity is a Very Bad Thing. Two rolls each are at hand when I open my green bag. (https://www.galls.com/dynarex-cloth-surgical-tape-6-pack-?PMSRCH=tape $16/box of 6)

I keep 12 to 15 Gauze pad, sterile, 4×4 in my kit. I employ them as eye pads, padding beneath splints, or as (oddly enough) dressing for wounds. Occasionally I encounter a wound bleeding so enthusiastically that a couple of gauze pads will be overwhelmed. Fortunately, I haven’t come across such a wound off duty, but in the hospital we use a “boat” of sterile gauze. This is a plastic tray of ten sponges in one pack. The tray also may be used as a clean basin for wound irrigation/cleansing solution. In the hospital we use sterile saline, you may elect to use the water from your retort pouch, or fresh from the bottle as you purchased it for storage. I would certainly give it some thought. Gauze, 2 per pack, 10 packs per box: https://www.firstaidsuppliesonline.com/first-aid-products/tapes-wraps-dressing/gauze/sterile-gauze-pads-4-x-4-10-box-2/ $4

If you happen to be the purchasing agent for your entire survival community, ambulance service, or the entire Boy Scout Council, you might find the case price from Vitality Medical to be useful. (https://www.vitalitymedical.com/kendall-dermacea-gauze-sponge.html $50) 1200 sterile 4×4 pads for $50 works out to around 4.2 cents each.

Triple padding/ABD padding, sterile, 5×9 inch. (https://www.vitalitymedical.com/invacare-abd-pad.html $0.12 each) These multiple layer absorbent dressings are designed for wounds producing a lot of drainage of either blood or other fluid. They are my first choice for a bulky dressing or splint padding. I keep 6 in my kit. The frugally minded may note that “sanitary napkins” are designed to absorb drainage, are “medically aseptic”, and are available nearly everywhere.

Roller Gauze, 4 inch https://www.galls.com/dynarex-comforming-stretch-gauze-4-inch?PMWTNO=000000000002328&PMSRCH= $4/box of 12) is typically used to secure a dressing (see Gauze Sponge, above) to the wound. I pack 6 in my kit, and they have “found careers” as bandages to secure dressings, securing splints when I run out of triangular bandages, and upon occasion as packing/dressings for vigorously bleeding wounds. In fact, when one is employed as the dressing, and another as the bandage, I can not only dress the wound, but also (since the bulky roll provides a pressure point) apply direct pressure to the bleeding site. This provides an alternative to the Israeli Dressing, cited above.

Vaseline Gauze (sterile, 3×9 inch) (https://www.buyemp.com/product/kendall-vaseline-gauze-pads $9.50/10) is intended to seal wounds penetrating the chest, in order to prevent collapse of your patient’s lung(s). When you seal the defect in the chest wall, your patient will not draw in air through the wound when s/he inhales, and thereby not fill the space between the lung and the chest wall (the pleural space) with air. When you can avoid this, inhaling draws in air through the mouth, trachea and bronchi, and that inflates your lungs, and we think that is a good thing. Myself, I pitch the gauze and tape three sides of the foil package, sterile side towards the wound, forming a flutter valve sort of effect. In this way I allow excess pressure in the pleural space to vent to atmosphere (stopping further lung collapse, I hope), and seal the hole when the pressure inside the chest is less than atmospheric pressure (like when the patient inhales). The only way left to equalize that pressure is by inflating the lungs, already described with approval above.

The other use for Vaseline gauze is when my lips or hands are dry, in which case I use the Vaseline to remedy that little problem.

We all can think of uses for the common elastic bandage, 3 inch and 2 inch (https://www.amazon.com/ProAdvantage-P156003-Latex-Free-Bandages-Self-Closure/dp/B06XT743T3/ref=sr_1_3?keywords=elastic+bandage&qid=1559746937&s=hpc&sr=1-3 3 inch, 10 pack $5.25, and 2 inch https://www.blowoutmedical.com/elastic-bandage-2-inch-x-4-5-yard-3662.html $0.42 each. Two inch is useful for sprains of your wrist or thumb, and the 3 inch is used for an ankle twist/sprain. In addition, I can use them to secure a splint (there is that rule of threes, seen in posts on other blogs), or as the “swathe” part of a sling-and-swathe to immobilize an injured shoulder, or as part of a pressure bandage over a dressed wound that does not want to stop bleeding.

Large Bulb Syringe (for which you can substitute a turkey baster) functions as an expedient means of removing fluids from the airway of someone who is not managing to do so effectively on their own. It will not work nearly as well as a battery powered or pump action suction, such as you might find on your local rescue squad rig, but it won’t cost you $30 (for the manually pumped version seen on Amazon today for that price. Comparison shop.) either. Second best is superior to nothing.

Mylar “Space blankets” protect you or your patient from the hypothermia-inducing effects of the wind, slowing heat loss. Generally colored bright orange on one side and silver on the other, there are signaling opportunities as well. In a pinch, you can improvise shelter from one or two. Amazon sells the generic copy for $10 for a pack of ten (https://www.amazon.com/Primacare-HB-10-Emergency-Thermal-Blanket/dp/B00DZ1NFSK/ref=sxin_0_ac_d_rm?keywords=space+blanket&pd_rd_i=B00DZ1NFSK&pd_rd_r=2123eee5-db98-41a8-867d-fb632b7e1ffa&pd_rd_w=TNeM6&pd_rd_wg=86xXL&pf_rd_p=91b604bb-c371-4573-970f-bed68a552852&pf_rd_r=SJ8DY55TS6GG0J9T2NQR&qid=1559768962&s=gateway&smid=ATVPDKIKX0DER ). Equip your jump kits, and each member of your family with one or two.

Any accident so severe as to convince suspicious old me (alumnus of Da City’s EMS) to stop and offer assistance will not be fixed with a couple of Adhesive Bandages (aka “Band Aids”). I have six in my jump kit, two entire boxes at home (and parceled out among my camper, car, and household kits).

I keep a couple of Ice Packs around, as assorted adventures may bring on modest orthopedic injuries. Ice is helpful for strains, sprains, or overuse of an over aged joint (…not that I would know anything, firsthand, about that…). Choices include “instant cold packs”, or that old picnicker’s standby, a zip lock bag full of ice from the cooler.

Either option has drawbacks. I do not generally drive about with a cooler of ice at hand, although when camping I am likely to do so. Instant cold packs are kind of fragile, and you might find, when you go to place one in service, that you have a leaking mess on your hands. On the other hand, they are more likely to be there when you want one.

The foregoing lists the contents of my “jump kit”. I keep one kit in each vehicle, and another at home. In addition, there are Subordinate Kits, kept in camper, car and home, for lesser sorts of occasions. I have customized each by adding more dressings, triangular bandages, roller gauze, and gloves. In addition, I improved over the baseline “Wally World” $15 first aid kit, by adding zip lock bags of various household medications. I labeled each bag with the name of the med, the out date of that particular bottle, directions for use, and date of packing. I made my selections by inspecting my own medicine cabinet, and pondering which meds I had wished I had kept handy the last time I was out camping, for example. Most everything commonly needed is therefore in the Camper Kit, Car Kit, or House Kit.

The jump kits are reserved for “Holy Fertilizer!” sorts of events. They are not mere “boo-boo boxes”: THAT is why I have subordinate boxes in each vehicle, the camper, and the house. Reserved in this way, I will not find myself hunting (and swearing) in crisis, as I need this or that widget, which some child (or adult) has used, and not restocked.

IFAK OR “BLOW OUT KIT”

The jump kit is kind of bulky, the subordinate (“Band Aid kits) sort of inadequate, in the event of BFD injuries. I have created “Blow Out Kits”, also referred to as IFAK (Immediate First Aid Kits) for the possibility of arterial bleed, GSW, or similar potentially exsanguinating injury. Hey, I shoot recreationally, and , as “TexasUberAlles” noted (https://disqus.com/by/TexasUberAlles/),
“Always wear safety gear-poor judgment is a team sport, and other people get to decide whether you’re on their team without asking you first”. In short I may hold the Cooper Distinguished Professorship In Safe Firearms Handling, but, Cletus in the next bay who does the macarena when the first round of his 32 round magazine gets lodged in his tank top, might inadvertently put a couple of rounds in my chest. Or somebody else’s. Therefore, I have a handy, smaller, trauma and bleeding focused have-it-on-my-belt kit.

Contents first, discussion after.

IFAK
pouch 14.95
4 “ IBD 6.95
Quick Clot 40
4×4 x 12 1
abd x 2 1
roller gauze 4 in x 3 1
TQ 29
triangle bdg x 2
gloves x 6
Tape 2 in 2.6
shears
Total 96.5

Again, I need a pouch or case for the IFAK. Some of the other blogs addressing this issue, including Raconteur Report, have suggested “SAW” ammo pouches, others have suggested M-16 ammo pouches. My take? Well,folks who are alumni of the military, and have in fact been in combat, likely have opinions that you, and I, ought to listen to. Having said that, I have patched up (temporarily) a few bleeding folks in my day, and here’s what I use:

(https://www.opticsplanet.com/red-rock-outdoor-gear-mavrik-small-medic-pouch.html $6.) (Yeah, my spreadsheet excerpt shows a cost of nearly $15. See? It pays to shop around!). Feel free to employ the case that suits you.

Israeli Battle Dressing (see above, $7 or $8)

You may notice that I specified QuikClot in my IFAK, in contrast to Celox in the jump kit. If you have a reason to prefer one over the other (eg, Quikclot), then go for it.

A dozen sterile 4 x 4 gauze dressings. This for fast, initial care. I anticipate buying enough time to go get (or delegate one of My Minions to go get) my jump kit from my vehicle.

I specify 2 ABDs, 5 x 9, for the same reason.

4 inch roller gauze, similarly. When I require additional roller gauze, well, that is why I have a large handful in my jump kit.

CAT Tourniquet, around $30 on sale at Rescue Essentials (https://www.rescue-essentials.com/tourniquets-holders/ ) Alternatively, you can get a SWATT tourniquet, which is a heavy duty elastic band, with imprinting upon it so you can assess how tightly you have wound it, for around $12, but I cannot know how more (or less) effective it is than the CAT. Get your training, get some experience, and form your own opinions. Myself? I have both a CAT on my belt, and a SWATT in my pocket, every day.

For a discussion of triangular bandages, and tape, and shears, well, see the previously presented material.

One comment on the hemostatic agents (that’s the Celox and the Quikclot), among other contents: read the packaging. Some of this stuff has an out date, and my practice is to rotate outdated material (like outdated TQ, IBD, hemostatics, etc) to the “training bin”. While it MIGHT not be a big deal to use outdated IBDs, or TQs, I betcha outdated hemostatics might be litigation bait. In addition, it is simply good practice to check and rotate your stock at regular intervals.

Finally, remember that training comes first. Years and years ago, I heard a story that, in the early days of the Israeli state, the emergency response planners had the budget required to train their personnel to stabilize and transport spine injured patients, or buy the splints (called backboards), but not both. The story relates that the planners elected to train their personnel, and subsequently noted a spine injured kibbutznik transported to the hospital by his comrades, secured effectively to an entire barn door. You! Over there! Yeah, YOU! Go get trained! Pass that training on to your shooting buddies, camp mates, hiking buddies, family, friends, fellow cube dwellers. You will make them safer, you will make yourself safer, and, in the event of another mass casualty incident, you, yeah, YOU!, might be the reason folks survive, or do not lose limbs.

Seize that opportunity.

Thank you all for reading along this far.

“WHY DO WE NEED FARMERS? I ONLY EAT FOOD FROM THE SUPERMARKET!”

Perhaps I have mentioned that TDW-Mark II grew up on a farm. As you might expect, she is familiar with chickens, and the process whereby eggs are acquired. She is, in addition, familiar with the process whereby chickens are changed into roast chicken, and even into chicken nuggets.

Similarly cows, and milk, as with cows and beef.

So, she was in school studying to prepare herself to be a social worker. Of course, she was required to take a course on ecology, or some similar stuff, because, after all, what social worker will be able to mend broken psyches, or minister to the fearful and ill, should she/he not have studied ecology, amirite?

Please understand that, while I did, indeed , “trade up” with the transition from Wretched EX (formerly TDW-Mark Ø), my wife (TDW-Mark II) is very much a non traditional student. This works both from the perspective of her age (she is not a gosling), as well as her having had some life experience prior to college. In addition, she has developed opinions based upon that life experience, and they are not particularly consonant with the stereotypical gosling/kid kollege student opinion set.

In her class, she learned all sorts of wonderful things, such as why corn in general, and corn syrup in particular, are death in a carton/on a cob, and ZOMG! WE! ARE! ALL! GOING! TO! DIE!, because of the presence of corn and corn syrup in our diets. Nice.

So, this one time, the class took a field trip (no, I do not, either, understand the point of a college class taking a field trip, unless is it a paleontology or archaeology class visiting some dig somewhere. This was not such a class!) Since this is Land Grant College Country, and the local Enormous State University is a Land Grant College, well, her little ecology class visited the Land Grant College Agricultural School. To be exact, the University Farms.

Being a farm girl, TDW Mark II dressed accordingly. Jeans, boots, denim shirt, hair up in a baseball cap, gloves in her pocket. No surprises there, right?

Her gosling classmates, not so much. Once she got home (TDW, not the gosling/classmate), she was laughing (TDW, not the gosling classmate).

TDW started off her after action report with a dramatic foreshadowing. “Ohmigawd! I just cannot believe some people! This one girl showed up for the farm tour in nice, dressy, high heeled boots, a nice dress, and a nicer blouse. You had to see her picking her way around the cow pen! And, she had lots of fun on the ladders! It seems that miniskirts are not really designed with climbing in mind, although the guys in class did not seem to mind very much!”

I had spent the day washing clothes, washing dishes, cutting the grass, and suchlike so that we could spend a nice weekend doing something that was NOT chores, so I nodded while finishing the last of the dishes.

It seemed that TDW Mark 2’s classmate had some difficulty meandering around the farm. Farms, after all, are industrial environments, when you stop to think about it. Once the procession had returned to the classroom, Ms Fine Clothes dove deeper into the vat of clueless in which she had evidently immersed herself.

The instructor initiated some sort of discussion, perhaps seeking to tie the afternoon’s travels back into the nominal subject of the class (ecology, or environment, or some such thing). This student observed that she or he had not appreciated how much effort went into raising and marketing animals for milk, eggs, and meat. Another noted the vast difference between the olfactory experience of a farm, and the Styrofoam cleanliness of the supermarket.

Ms. Nice Clothes stood and made her point. “Oh! My! Gawd! I could NEVER eat an egg from a chicken! They come out of their butts! I’m so glad that I only ever have eaten eggs from the supermarket!”

And, TDW Mark II wonders why it appears that I have a tic, consisting of shaking my head and muttering “What the actual FUCK?!?”