Raconteur Report

This topic, first posted here in 2021, recently came up again (no pun intended) on another blog, so we re-present it, for the newbs:

Prepmeister sensei Commander Zero relates a recent experience (or rather, refusal to experience same) with a ten-years-past-its-"Best By"-date can of chicken soup. You should RTWT.

And now you get this post, by way of follow-up, and piling on.

Historical background: Canning food in tin cans was the genius idea of Nicolas Appert, arrived at in pursuit of a Napoleonic prize, to invent rations that an emperor's army could tote to their campaigns throughout Europe, indefinitely, securely, and without having them all go bad. (Refutation #4,000,087 on the Hit Parade of answers to the historically retarded idiots who spout "War never solves anything.") Which spoilage happened to casks of salted beef and pork with a tedious regularity. Not just for soldiers, but for everyone. Starving soldiers won't fight, because, as the same emperor noted, "An army marches on its stomach". Not literally, of course, that would be silly. But this is why amateurs discuss tactics, and professionals discuss logistics. No beans, no battles. True for Napoleonic legions, true for Roman legions, true in Iraq and Afghanistan, and true for you and your little tribe, same-same.

The early processes have, obviously, changed over the years. How isn't as important as what it means for you, if you're deep-stocking to get you and yours through...Whatever Happens.

So first, a few pointers.

1) Canned foods have a "Best By" date. If this is news to you, you're already too far behind the curve to be in this class. Log off, and come back when you're caught up.

2) "Best By -" dates, exactly like most expiration dates on medicine, are a scam. Exactly like the iconic "Lather. Rinse. Repeat." They were placed there primarily for PR and marketing purposes, because printing "Please consume all of this, even waste some of it in overuse, and then rush back to the store and buy more of Our Stuff" was considered a bit too spot-on. Part of it is also CYA legal boilerplate, because some jackhole will put his canned goods in a corrugated tin shack in the sun in the tropics, paint the whole thing black, located below the water table in a  swamp, and then bitch to high heaven when all his stuff explodes, is rusted and rotted, and smells like a Kardashian's nether bits (we hear). And then sue the company for his own jackassery.

3) For people who understand the concept of "Store in a cool, dry place.", it's a handy guideline for optimum freshness, appearance, smell, taste, and nutritional value. Not to mention safety. It is not, however, the last word, and many products will be just fine long beyond those dates. Who determines what those actual dates are? By the following formula:

4) Caveat emptor. (Common Core grads: google it.)

5) Certain foods (tomatoes, citrus items) have shorter lifespans. Acid: it's a physics and chemistry thing.

6) Oxygen is not your friend. Neither is a lack of it for shoddy or improper canning. There are both aerobic and anaerobic bacteria. This is why bulging cans get tossed. Always. Your ancestors who didn't do that? They're probably not your ancestors, but in any case they usually died for ignoring that rule.

7) As we told you, they don't can foods presently the way it was done in 1970, 1940, or 1870.

The cans and lids are not tin anymore, they're steel and aluminum, lighter now than they were a few decades hence, and they frequently utilize a plastic membrane. See for yourself. 

(Someone with high-functioning Asperger's can share the exact chemical composition of the liner; IDGAF.) The point is, this is why it's unsafe, and untasty, to heat foods in those new-fangled plastic-lined cans, unlike we could do when I was growing up, and most TV came in both black, and white. Because to do so will either ruin the food, and/or expose you to a chemical stew that doesn't go well in your insides. The first aid for that, is to not be a jackass, by not doing it. Put it in a proper cooking container, and rock on.

(That's also why, before you make Hobo Stoves and such, you'd better burn or scrape out that liner, unless you enjoy the aroma of burnt plastic with your meals.)

8) If you open something that doesn't look right, smell right, or taste right, wave goodbye, and toss it. Problem solved. You have five senses for a reason: heed them.

But somebody was too stupid to do that? Now what?

A) Botulism.

Botulism is nasty stuff. Like your cat, somebody who gets a dose of this is either going to crawl under the porch and die, or not. All you're going to do for them is supportive care, and treating the symptoms, and hope for the best.

It's caused by spores, and the kind that remain viable despite sunlight, like anthrax spores, for centuries, and which are highly resistant to most forms of sterilization. The toxin the spores produce (which is the problem) can be inactivated by heating at 185 F. for 5 minutes. IOW, boiling or hotter. But the spores that made the toxin are still in the food. Hence, throw it out if there's any suspicion.

We quote:

Food-borne botulism: The classic form of botulism is caused by the ingestion of preformed toxin in contaminated food. Symptoms include double vision, drooping eyelids (ptosis), slurred speech, difficulty swallowing and muscle weakness that is symmetric and descends through the body (first shoulders are affected, then upper arms, lower arms, thighs, calves, etc.). Death is usually due to respiratory failure and may occur as soon as 24 hours after onset of symptoms.

"Supportive care" may include months of treatment, and multiple courses of appropriate antibiotics. IF you have those. 

Quoting again:Foodborne botulism: Within 1 hour of ingestion of suspected food, the recommended course of action is a gastric lavage, or enemas, and the administration of a cathartic (sorbitol). In some cases intravenous administration of AB or ABE botulinum antitoxin is required, and assisted ventilation if respiratory failure occurs. Treatment may be required for weeks or months.

FTR, you ain't got and aren't getting AB or ABE antitoxin, unless you're far more advanced than the scope of this essay. And you probably don't have any sorbitol either. So that means ingestion will almost certainly prove fatal. We repeat, any suspicion of toxin, throw the food out. This isn't something you risk under any circumstances (unless you're a moron).

B) Everything else.

Most (99.99999%, for a SWAG) "food poisoning" is no such thing. People who are poisoned get sick, and depending on the toxin administered, die. What you've probably got is simply gastroenteritis (GE).

GE is usually caused by spoiled food, and/or lousy sanitation/preparation/food handling.

In most cases, it's caused either by air or insect vectors depositing bacterium on your food (like leaving your aunt's potato salad uncovered on a fly-infested hot day at the family picnic or BBQ), or the cook/server failing to lave los manos before, during, and after preparing, cooking, or serving you your food, including on dirty dishes, or after visiting the porcelain thinking room. It can also be caused by poor water purification, unfamiliar pathogens, etc., but frequently this is the same route, just with a bad water supply in between someone's fecal, and your oral. It is, thus, usually a fecal-oral transmission pathway, meaning someone got their chocolate in your peanut butter. In short, you ate shit.

There are two general stages to GE.

In Stage I, you think you're going to die.

In Stage II, you're afraid you won't.

This is because your body, whether you consider it a miracle of creation, or evolution, has a brilliantly simple feedback loop for letting you know you have unauthorized houseguests in your digestive tract.

Repeatedly.

You will now spend at least the next 12-24 hours with one end, or the other, pointed at the porcelain thinking chair, as you pass from Stage I to Stage II. You may, at times, require a bucket, when both ends are actively offloading. In between, having a few crackers and some ginger ale or lemon-lime soda handy for tiny nibbles and sips may help keep you alive, in between laying on that oh-so-cool tile floor, because it feels so good.

If you can, by hook or crook, lay in a supply of Rx Zofran ODT, you should do so. (Usual caveats about allergies, medical conditions, etc. apply. I.e. : Don 't be stupid.) Zofran is one of the currently best anti-vomiting/nausea meds available, Rx only, and ODT means "orally dissolving tablet" meaning if you can but shove the tiny tab under your parched tongue, and let it dissolve there, it will automagically absorb sublingually, to curb the load-launch-fire sequence from your forward torpedo hatch. By not having to swallow it, you can't barf it out before it kicks in.

For your other end, there's Immodium. Read and follow all label directions; it's an OTC. It's function is to turn your aft torpedo tube load-launch-fire circuit into rush hour traffic on the 405 freeway; i.e. total standstill. Use per directions until respite is achieved, then re-hydrate. You should have stocks of this laid in by, you should pardon the pun, the metric buttload. It should travel with you any and everywhere, when you travel away from home. Period.

Vomiting and diarrhea isn't serious for a few hours, until it is. It both dehydrates you, and jacks up your body's electrolytes, and if you have other conditions, you can't take your meds nor process them, so cardiac conditions, high blood pressure, diabetes, thyroid problems, and all sorts of other complications can take this from bad to worse if untreated.

In extreme cases (dysentery, cholera, etc.) you will literally crap your guts out.

Thus fulfilling the second half of "eat shit and die". It's actually a thing.

If you have the ability to properly administer intravenous (IV) fluids, do so. It bypasses the alimentary canal, and can rehydrate someone rapidly and effectively, if you know what you're doing, and can do so correctly. Bone up extensively; this is not a skill or therapy to attempt on the fly, in the moment. You can exacerbate a number of life-threatening conditions if you overdo it without knowing WTF you're about, and you can cause infection and death in a host of ways if you attempt it half-assed. Killing your patient with CHF or hepatitis instead of dehydration is a poor way to say you care, and a waste of resources if you don't know what you're up to. I cannot stress this enough for the untrained. If you don't KNOW WTF you're doing, leave this for those who do. 

But if you have Zofran and immodium, and a bare minimum of common sense, you can begin cautious hydration and nutrition.

Start simple: clear liquids. Clear means CLEAR. Water. Juice. Gatorade. Clear soups. Jello. Avoid all alcohols and caffeine-containing drinks; they're diuretics, and they'll only further dehydrate your patient. If you can't see through it, it isn't clear. Clear?

Then soft foods, easily tolerated. Parents should know this as the BRAT diet: Bananas, Rice, Applesauce, Toast.

Then regular foods. As tolerated.

If symptoms return, or any level is not tolerated, return to the previous level, and advance as able.

And nobody who's nauseous gets ANYTHING else to eat or drink. EVER.

You feed or water that person, and you're just loading the catapult for the next launch, and you're the one who's going to get a faceful. Don't Do It! 

A couple, by which I mean TWO, pieces of small crushed ice, to wet the mouth that's bone-dry, won't matter. A bowlful of ice and a spoon, however, is asking for trouble.

Throughout the process: 

Monitor vital signs. Pulses should be below 100/min, or they're still dehydrated. Check temperature, to make sure there isn't a fever, and hence this is infection/viral, not GE.

Hydration, elimination, nutrition, in that order.

How much fluid are they taking in?

How much have they put out as pee? (and vomit?)

Bowel movements: watery, runny, loose, solid? How many? How frequent?

And then, nutrition? Diet, and toleration, then quantity, and back to output.

If they don't have a normal pulse, no fever (101F. or greater) and they aren't peeing clear and copious urine, they're not done yet.

GE comes on fast. But it goes away fast too. One to two days, tops.

If this lasts longer, there is something else at play here. Consult your medical people at that point. Your doctor, in normal times. Whatever you've got if you haven't got access to normal care (wilderness, disaster, worse).

Most GE goes away quickly, and leaves nothing but sore abdominal and rectal muscles behind (you should pardon the pun) afterwards. You can minimize it, but generally, the person has to literally gut it out. You can, however, mitigate the symptom duration and severity with proper treatment.

{And if you f**k up proper treatment, you can spread it around to yourself and everyone else. Wash your hands, clean the patient, clean and sanitize linen, bedding, clothing, dishes and utensils, et cetera, or after you die, Florence Nightingale and Clara Barton will kick your ass around the block for eternity for being a dumbshit.}

And if it isn't going away, you've got a bigger problem.

The best way to prevent GE is prevention: proper personal sanitation and cleanliness, proper food storage, handling, preparation, cooking, and serving, followed by proper clean-up afterwards, from dishwashing to sewage and garbage disposal. 

Proper public health measures save more people worldwide than medicines, antibiotics, and surgery combined, since ever. By the billions. The reverse is also true.

See to as much of that as you can, and your experience with it will generally not be firsthand, up-close.

Thus endeth the lesson.

It also requires a dedicated sterile OR. And a sterile pre-op prep area. And a Post Anesthesia Care Unit. With ICU monitoring abilities, and a full Code Blue stocked crash cart and defibrillator. And an ICU. And a cardiac telemetry step-down unit. And one to three board certified cardiothoracic surgeons. And an anesthesiologist or nurse anesthetist. And all the medicines and anesthesia drugs (and their reversal agents) required for that surgery. And all the IVs. And oxygen. And suction. And a central supply unit. And a sterile supply unit. And a circulating nurse or two. And a scrub nurse or two. And the PACU nurse, the ICU nurses, the Tele nurses, and about another baker's dozen techs, from lab, CT, OR, ICU, Tele. And the cardiac rehab folks. And metric f**ktons of antibiotics. All just waiting to take care of one patent.

Got a second patient?

You get to replicate half of that all over again. (I'll spot you the other half, since they're already there.)

Got a third patient? Now you need double everything in the first batch, because you'll need a whole another support pipeline for more patients than one ICU nurse can safely care for.

You can cut corners. That fills body bags, but hey, it's your party.

That's fairly similar to the kind of things you're going to need for one gunshot trauma chest wound.

Guerrilla Hospital? More like Gorilla Hospital. As in run by apes.

Those are based on medical systems you couldn't shoot out of your tailpipe if you ate that whole surgical tray above, and grunted and squeezed for a lifetime.

A military CLS depends on there being a MEDEVAC (which you don't have) to take a casualty to a battalion aid station (which you don't have) or an EVAC trauma hospital (which you don't have), and once stabilized, to transfer them to an out-of-combat-theater tertiary care hospital (which you don't have), followed by ultimate travel to a stateside recuperation and rehab system, (which you don't have). Clever readers will spot a trend here. 

What you can  do is good initial first aid. But short of massive planning and preparation, you don't have any of that second aid, third aid, or rehab. And unless you recognize that, and start to make actual alternative arrangements, what follows your first aid, will be last aid.

I do not recommend leaving things at this stage, but if all you're going to do is stock your IFAK, without even planning for what happens the second time you need that, you're planning to fail. In a Forest Lawn sort of way. Or, far more likely, a Boot Hill sort of way.

Delusional people build castles in the sky, and psychotic people try to live in them. I wasn't being snarky about the OP, but when you start talking about your wonderful ocean liner plan, and all you're missing is, y'know, the BOAT part of that, I'm going to call you on it, 11 times out of 10. And if it stings, that's Reality slapping you in the back of the head.

You want an underground partisan health care system, or a guerrilla hospital? Great.

Why not start with telling me how you're going to do THAT, and do it first, before you tell me the frilly and far less important details at the weed level.

And while you're up, tell me about your partisans, before you start worrying about partisan medics.

If you can't get over your delusions long enough to do that, don't complain when people point and laugh. And if I just pointed and laughed because you share those delusions, maybe it's time to stop smoking mad bongloads of Hopeium, and come back down to planet earth for a spell.

And if all that still goes in your "Too Hard" column, don't you worry none, Snowflake. If you're just going to rely on Turd World/Civil War-era field medicine, you can count on Turd World/Civil War-era casualty levels.

Suture self.

Part One 

Part Two

This part will conclude the series, and we'll include our suggestion for a model Wilderness First Aid Kit at the end.

We pick up where we left off with Jim Baird's article for Field and Stream.

Sprained Ankle

Ankles will roll… This is one of the most common injuries in the outdoors, because of the uneven terrain in the backcountry. The chances of spraining an ankle increase with fatigue, slippery conditions, or when you’re carrying a heavy load. The typical treatment for a sprained ankle begins with the acronym R.I.C.E.S. 

Natzsofast, Guido. It's R.I.C.E., not R.I.C.E.S. 

Stabilization comes first, not last.

So let's helpfully fix that error.

Stabilization:

 This is particularly important for more severe ALL sprained ankles, because they're all potential fractures, plus all obvious fractures or dislocations, when bones aren't where they belong, because it’s hard to tell the difference between a bad sprain and a break, due to your lack of X-ray vision. Added pressure on a break could result in serious injury or a compound fracture in extreme situations. So, if things are bad you will have to get creative: Stabilize the injury by splinting the ankle with hiking poles, a snowshoe, or a foam ground pad. Also, take ibuprofen.

A sprained ankle can be a real challenge in the backcountry because it can destroy your means of transportation to get out. Fashioning crutches to assist with mobility may help, but if you can’t put any weight on your foot at all, you will have to consider other means of evacuation, such as an emergency air lift. Consider carrying an InReach messaging device for such situations.

You should carry a PLB, SatPhone, InReach, SpotMessenger, etc. for all excursions off the beaten path. Because with them, for a measley couple/few hundred bucks (and a subscription fee for messaging or SatPhone service) you could save your life, or someone else's. In any number of instances, not just a bad sprain/broken bone. We'll come back to that at the wrap-up. For now, back to sprains, dislocations, and fractures.

You should absolutely be able to construct your own orthopedic devices. Part of the passing grade for my wilderness medicine class (when Bush the Elder was president, btw) was constructing both a full-leg traction splint, and arm splint, and a working crutch from found items one might carry or add to what you already had in your backpacking/outdoor kit. For example:

50' of paracord, and about a dozen 12" x 3/4" sticks: one forearm splint

One walking stick, plus 2 eyebolts, a couple of nuts and washers, 20' of nylon line or paracord, and a hand towel: one fully functional full-leg traction splint, with stick windlass. 

Two ski poles, a stick, and 20' of paracord: One walking crutch.

So yes, learn to improvise.

Principles of stabilization

1. Stabilization means you immobilize the joint above the injury, and the joint below it. For example, if you break one or both of the bones in your lower arm, you'd have to immobilize both the elbow, and the wrist.

2. Splint it where it lies. Do your best not to move it around. If it's a fracture, jagged bone ends might lacerate a tendon, nerve, or blood vessels. The exception(s) would be if there's no circulation before you start (and if you don't set it better, the limb is going to die anyways). Or any deformity so wildly misplaced that failure to set it better will preclude any movement or further care. If someone can tolerate the movement, you're better off gently and carefully adjusting position when rescue is delayed, and getting it to a more anatomically correct position.

3. Whenever possible, let the victim self-splint. They know what hurts, and what feels best; assist them in this.

4. Improvisation is fun. Carrying a SAM splint is both faster, and smarter.

5. Pad bony prominences. Or else, you'll create new and bigger problems later on.

6. Check CSM (Circulation, Sensation, and Movement) before and after anything you do with injured joints and bones. If you had a pulse in the foot before you splinted it, but you can't find one afterwards, or it goes numb, or they can't move something they could move before, you f**ked up. Put things back, and work out what the trouble is. Make sure you haven't made it worse. Don't make it worse. 

7. Good stabilization usually feels better to the patient when you're done.

Now, let's go back to post-injury follow-up care:

Here’s a breakdown:

1. Rest: To prevent further pain and injury, take some time to rest on the trail. An extra day or even a few hours to take take the stress off of the injury goes a long way.
2. Ice: This helps reduce swelling, and reduced swelling promotes healing. Keep an instant cold pack or two in your first aid kit. Don’t have these? Place your foot in a cool stream or use snow if it’s available. Ideally, you want to be icing your ankle three to four times each day for about 20 minutes each time.
3. Compression: Here’s where your elastic bandage comes in. The tightness helps reduce swelling and it adds additional support to the ankle. Wrap the bandage starting at the end of your foot and continue up above the ankle. Be careful to not make it too tight.
4. Elevation: Rest your ankle above the height of your heart. This will restrict the blood flow enough to reduce swelling.

That's better. If you can, it's okay to dunk a probable sprain in snow, or cold water, for 20 minutes initially, then stabilize.

What else? We'll return to Mr. Baird first.

Final Thoughts on Wilderness First-Aid

Because help can be days away, wilderness first-aid can be more like second-aid in many cases. Being prepared with the proper first-aid kit is one thing—but you also need to have the skills and knowledge if you or someone in your group gets injured in the backcountry. The best motto to go by is: Plan for the worst and hope for the best. Having an exit strategy, carrying wilderness comms, and taking some basic wilderness first-aid training will go along way. Now get out there and enjoy the outdoors, but don’t forget your first-aid kit.

And if you follow what we wrote, rather than what was erroneously suggested in the article, you can avoid a lot of situations where you're doing Last Aid! And avoid making a bad situation even worse.

Learn how to splint anything and everything: hand and arm injuries, broken collarbone, ankle, knee, and hip injuries, as well as fingers and toes. Full explanations are beyond the scope of this post, or the referenced article, but if you know how to do it right, you can improvise it anywhere with minimal assistance or additional supplies. And reading a first aid book while your buddy's (or your own) knee swells up to the size of a cantaloupe isn't wise, nor practical. Learn before you go out to play. Practice what you learn.

The same is true of wilderness first aid in general. You can likely find a two-day weekend wilderness basic first aid class near you, and it should be taken by anyone who leaves paved roads for longer than 5 minutes. Stuff happens fast, and the further you are from cell phone coverage, the greater the odds you'll need the knowledge, sooner or later. Mr. Murphy is a cold-hearted SOB about that.

So, about that Wilderness First Aid Kit...

First, take as much first aid gear as you can get away with, without going full retard.

If you're on a cabin cruiser, or in any motor vehicle, a full M17 bag and even a floating backboard wouldn't be problematic.

For a group on a weekend or multiple days' trip, the standard No. 3 CLS bag is reasonable.

FWIW, when I ventured afield with anyone more than just me, that was the minimum kit I would tote, and for days on end. Good enough for Army medics and Navy corpsmen to tend to a whole platoon; good enough for me. It was the same jump bag I used to take care of 100+ person movie crews in town and out in the boondocks, and 90% of what I needed fits inside it.

Ski patrollers and hiking groups have used an ordinary fanny pack for the same purpose.

If it's just you on a day-trip for fishing, hunting, hiking, or whatnot, the minimum I'd consider would be an IFAK-size bag. 

Just remember the opening lyrics of The Ballad Of Gilligan's Isle: "...a three hour tour, a three hour tour...". Best laid plans, and all that. And from back when they were single-sex, the Boy Scouts' Motto: Be Prepared.

So, what to put/keep in it?

The article links to another Filed and Stream article, where they provide a suggested wilderness kit. FTR, theirs is IFAK-sized.

We'll start there:

1. Tourniquets, Chest Seals, Compression Gauze

Clever readers will note a trend here. Enough said.

2. CPR mask

A big, fat "Meh" to that. How far are you from help? How long can you do CPR? Unless this is for a trip to the zoo, a CPR mask probably isn't going to do much good if you need it for more than 10-15 minutes. An hour, tops. The exceptions would be for cold-water immersion, where you could get back to shore inside half an hour. Or a near-miss lightning strike. Farther from definitive care than that hour, and you'd be better served with a priest's stole, and a small New Testament. Sorry, but that's the reality. People who died tend to stay dead. If you're 5 minutes from paramedics with cardiac drugs and a defibrillator, ROWYBS, you may save a life. If you're a two hour hike cross the desert to the trailhead and cell-phone coverage? Yeah, no. Do what your conscience dictates, but don't expect miracles. If space or weight is a concern, I probably wouldn't bother with this if we were talking far afield. This is also why any version of defibrillator is probably a waste of time, except on a cabin cruiser or RV. NOT on a wilderness trip. ER more than an hour away? Fuggedaboudit. Ruby Slippers would be more useful, if you needed it.

3. Trauma shears

Hell, YES! Use 'em every night, for 25 years. The key here: good quality ones, kept razor sharp. In a good leather or nylon holster.

4. Sterile eyewash

Hell yes! It doubles as wound wash. If you can put it in your eyes safely, you can put it in an open wound safely.

5. Mylar Emergency blanket

That should be in your pack already, but it doesn't take much space in a first aid kit, for preventing shock, blocking wind for treating frostbite, making shade for heat casualties, and signaling for help, among other uses. I'd keep one of the cheap folded ones, and get a better one mounted to a sturdy tarp with eyelets and paracord ties on the corners, to keep in my pack.

6. Bandages: Band-aids, butterfly bandages, etc.

Duh. All you can fit. Then more. Realize heat and time inactivates the sticky. Rotate and replace regularly, and more frequently if the kit lives in a hot car/car trunk.

7. Moleskin

Absolutely. Sheets and sheets of it. Spenco Second Skin too.

8. Medications

Your personal Rx ones, marked and kept separate. 

And aspirin, Tylenol, ibuprofen, Benadryl, Sudafed, Tums, Immodium, Pepcid, hydrocortisone cream, Bactine, povidone iodine, Neo- or Poly-sporin or bacitracin. Throat lozenges, cough drops, and any other snivel meds you want, because it's stupid to suffer needlessly. That's not hardcore tough, it's just dumb. 

(Sunscreen - SPF 15 or better; lip balm; bleach; and water purification tabs should already be in your pack, somewhere. Possibly zinc oxide too. And for the women, any necessary feminine hygiene supplies. If not, you're wrong. Fix that.) 

Maybe Silvadene, if you can get it.

Learn when, why, why not, how much, how often, and precautions for all of the above meds. No exceptions. No excuses. If possible, obtain unit dose (1-2 pill) packages. Watch expiration dates. Rotate out as necessary. If you won't do that, leave it all behind. Or you're going to kill someone, and I will so testify in court for the prosecution.

Times X people.

Times X days.

Plus some cushion. (IOW, if you're going out for 3 days, you should have 10 days' of your cardiac and BP meds, or diabetic supplies. For rather obvious reasons.)

E.g., if you don't have enough Immodium for everyone in the party to get through a group-wide case of the Traveller's Two-Step, you're doing it wrong.

9. Tweezers

And a headlamp. And a magnifier.

10. Cell phone. SATPhone or PLB or SARSAT Messenger or All Of The Above.

Fixed it for ya. A cell phone has a very limited range, and life. But if you're close enough to use it, sure. A PLB talks to space, FFS, and will get you rescued in the middle of the ocean or the Arctic tundra. You decide how much your @$$ is worth. With any of the above, I'd get my hands on a solar panel and hand-crank charging/recharging gizmo. Endless battery life for lifesaving comm gear? Count me in. And BTW: PLBs are designed to work by pressing one button, while floating in the ocean in a life jacket, in a storm. Cell phones aren't. Choose wisely.

BTW, there's damned few places you can't hit a passing 737 overhead on 121.5Mhz with a MAYDAY from a handheld VHF transceiver. The FAA may get pissy for a bit, but life and death emergencies (not "I'm lost and I ran out of trail mix and Twinkies") are absolute excuses to judiciously encroach on the benevolence of commercial air transport pilots to relay a message to SAR. And either way, the food is better in federal lockup waiting for bail than it is starving to death at the bottom of a canyon with a broken leg, fending off wolves or coyotes with a flaming stick. Do what you think is prudent. Judges and juries aren't completely stupid about such things. It's an option in the bag of tricks I'd leave open to consideration.

11. Bag (to keep it in).

We kind of covered that, above. Sturdy non-mil CLS bags can be had in OD green, tan, and black with minimal hassle. Also red, blue, and orange.

And of the stuff Baird added?

• Moleskin ALREADY INCLUDED
• Blister Foam MEH. PROBABLY NOT.
• Orthopedic Felt NOPE
• Duct Tape YES, BUT NOT FOR FIRST AID
• Surgical Tape YES, IN SEVERAL FLAVORS
• Krazy Glue MAYBE, BUT AGAIN, NEVER FOR FIRST AID USE
• Small Scissors DEFINITELY YES
• Alcohol Wipes ONLY TO DISINFECT EQUIPMENT
• Gel Toe Sleeves OPTIONAL
• Scalpel, Pin, or Needle (for popping a blister) YES
• Ibuprofen ALREADY INCLUDED

We would add:

12. SAM splint

13. Stethoscope

14. BP cuff

15. Pulse oximeter

16. Dressings: 2x2s, 4x4s, ABDs, eye dressing(s)

17. Bandages: Kerlix, ACE wrap(s)

We would skip:

Chemical ice packs:

They die in your bag, unless you put it in that day, and they're only good for 10-15 minutes.

Heat packs:

Same reason, unless you're summiting in the mountains, in which case they should probably be in your pack and jacket pockets, not your FA kit

Any nonsensically-carried field suture or surgery kits, skin staplers, and other nonsense.

IVs, start kits, tubing, saline or any other bags, etc.

99% of prescription meds not my own, unless you're talking a Zombie Apocalypse Wilderness Medical Kit. If it's that, I get Darryl on my team, right off. Just saying.

Pretty much anything related to CPR for any trip more than an hour from civilization. Some things, you can't fix, and you're kidding yourself if you think otherwise. (Don't believe me though. get or borrow a CPR mannikin. See how long you, personally, can do one-person CPR, with compressions and ventilations, best case. That's your distance limit.) It's a futile effort for all but an infinitessimally small handful of cases, like cold-water drowning, nearby lightning strikes, etc. Let your conscience be your guide. CPR mask in my car? Sure. In my kit for an eight-day yomp across Yosemite at 8000'-10,000'? Nope.

Don't put anything in your kit you don't know how to use.

Things That You Should Already Have Managed To Include:

The Ten Essentials

Because you're not stupid.

And BTW, this whole first aid kit? It's #4. So you're already 10% good-to-go.

Things That A Kit Will Not Help

You, or anyone else, if you don't get properly trained in how to use everything in it, and when, and then practice doing it.

You, or anyone else, if the kit's at the back of your closet instead of on you, or with you.

BTW, you're far more likely to use it at the side of the road, after you get to the accident (or, are perhaps part of it). If you never learned how to use it, and/or it's sitting in your pack at home, it's worthless. And hey, remember what I said about practice? Being a Good Samaritan counts for that.

Get your kit. Learn your kit. Carry your kit. 

And hopefully, only use it on strangers, rather than friends, relatives, or yourself.

But being prepared for all of the above already puts you halfway there.

[And note to Field and Stream, and any 20 other outdoor publications, if you ever see this: 

FFS, find someone who can find their @$$ without needing both hands, a mirror, a map and compass, and an anatomical chart, and stop getting layman to half-@$$ this topic. There are just over 1,000,000 doctors and 2,000,000 nurses in the U.S., besides P.As and paramedics, and a goodly number of them boat, sail, hike, fish, hunt, and generally recreate in the vast outdoors. Many of them are not only subject-matter experts in wilderness medicine, they can actually write articles cogently and with professional expertise, and they'd love to help you out here. Survive for three months on Vancouver island with just my brother? Jim Baird's the guy for that story, absolutely. Treat a serious injury? Not so much. I yell because I care. - A.]

If you haven't yet, read the first post in this series, wherein we explore the utility and accuracy of one non-medical adventurer's ideas of field medical care, per an article in Field and Stream.

This one continues where that one left off.

Deep Cuts

Axe injuries or the slip of a knife are the most common ways to get cut in the outdoors—but .not the only way. A deep cut from the teeth of a Northern pike can leave a nasty gash too. Here’s what to do when that kind of accident happens:

Don’t panic. The sight of blood from a deep cut be shocking to everyone; not just the victim. When it’s bad, all involved need to remind themselves to stay calm and follow the steps below.

Immediately apply firm pressure. This should slow the bleeding. 

If you are unable to stop the bleeding by applying firm pressure, affix a tourniquet no less than two inches above the injury.

Um, NO. You skipped quite a few steps.

2a. If firm pressure alone doesn't work, elevate the wound above the level of the heart, if possible. Obviously that can work for extremities, but not so much for torso wounds. With scalp wounds, that takes care of itself.

2b. Instead of using just your grubby boogerhooks, you probably should have already reached for a sterile dressing, and perhaps some of those nifty coagulant dressings, like QuikClot, etc.

2c. Then you want to apply firmer pressure, with bandaging gauze , such as Kerlix, etc., or apply an Ace wrap, or strap a military style battle dressing or one of the new Israeli bandages, and then tighten it down firmly, short of it being a tourniquet.

2d. If it's steady bleeding, but not bright red arterial spurts, and on an extremity, you can apply pressure to pressure points. Any place you can feel a pulse, between the torso and the wound, will work. You're trying to lessen the pressure into and out of the affected area, by using skin pressure to press arteries and veins against a bone or bony prominence deep inside the body. This works on bicep, forearm, wrist, groin, thigh, calf, and foot.

2e. Neither 2d, above, nor #3 below, will do anything for torso, neck, or head injuries. Tourniquets only work for extremities. So you'd better have those dressings, clotting gauze, and long bandages with tails big enough to go around heads and torsos, or tie to neck wounds and anchor at shoulders and armpits, without cutting off oxygen to the lungs, or blood to the brain.

3a. And on tourniquets, the following rules apply, every damned time.

1) Buy quality, from quality suppliers of known pedigree. NOT Chinesium knock-offs for the cheapest Amazon price. Caveat emptor.

2) You have four limbs. You (and everyone in your party, if such is a thing) should have four tourniquets available. Minimum. One, at least, should be ready-to-hand at all times. The rest should be in your kit, pack, etc. Unless you want to play "Which limb am I good without, forever?"

3) Get an identical one for training (or maybe one of the bright orange models), and practice, Practice, PRACTICE, applying it to any and every limb, with your strong hand, your weak hand, and your teeth if needs be, and then do the same on someone else. If you can't use it right, you ain't got it. Daytime, nighttime, rain or shine. It's nice to practice inside, in the daytime. Not so bitchin' to do it in the rain, at night, juggling a flashlight and a writhing casualty. Ask me how I know. Even worse if this is the first time you've ever cracked the package. Don't be That Guy.

4) And, you put a tourniquet on? You marked the casualty with a "T" on their forehead along with the time, right? Because you have at best six hours from there to surgical care, or the limb is going to suffer damage, or be lost entirely. Which is another reason not to be slapping one on unless you have to do it, to stop stop severe bleeding. Which means

5) Evacuation, NOW. Period. You've got Boondocks 911 on SARSAT speed dial of some sort, right?

4. Remove your hand from the wound once the bleeding has slowed. Then clean the wound with sterilized water and/or pour disinfectant on it, such as iodine, rubbing alcohol, or hydrogen peroxide.   

NO! We don't pour rubbing alcohol or hydrogen peroxide on people's wounds unless we hate-Hate-HATE them.

a. They're both simply awful choices for disinfection of open wounds.

b. They hurt like hell.

c. And they don't work very well at all to kill the germs.

d. And if the victim/patient decides to slug you, you've got it coming.

e. The same is true for distilled spirits, and for the same reasons.

If you had time and space to bring rubbing alcohol or hydrogen peroxide, you should have brought betadine and Bactine™. Betadine, or any generic version of povidone-iodine, can and should be cut 50:50 with clean water, and the wound washed out, first with water under some force to dislodge debris, then the water/betadine combo, to kill germs (provided your victim/patient is not allergic to iodine, or shellfish). More is better. Think between a pint (500 ml) and a quart (1L), depending on wound size.

The Bactine is mostly benzalkonium chloride, along with a touch of lidocaine. Benzalkonium chloride (hereafter BZK) is a topical disinfectant which, unlike alcohol or peroxide, doesn't kill live healthy tissue, and hurts a lot less than either for that reason, while killing germs in small wounds almost as well as betadine, and with none of the risks of allergic reaction. And it has the lidocaine, which is exactly what the docs in the ER use to numb your wound before they sew it up. Bactine has less of it, but what there is works just fine for minor wounds.

5. Clean the surrounding area with alcohol wipes.  

6. Dry the area around the wound using a sterile gauze pad.  

7. Close the wound. Stitch the cut with sutures, or close it with Steri-Strips or butterfly sutures. In a pinch? Cut thin strips of duct tape. Make sure that the wound is closed tightly. 

NO! Physician Assistants spend four years in a Master's program, and a goodly portion of that time is spent learning when to close a wound, and when not to. You probably have, lemme see...nothing plus nothing...carry the nothing...

Closing an infected wound just bought you sepsis, gangrene, and death. What'cha got in your kit for that, Slick?

Were any arteries still bleeding? Do you know how to close those? (NO, you don't.) What about tendons and nerves? Bone fragments? Foreign bodies imbedded? You're trained in emergency, trauma, orthopedic, and neurosurgery, right? (NO, you effing are not.)

Any wound closed after 12 hours is virtually guaranteed to go septic, so DON'T CLOSE THOSE. Ditto for any dirty wounds (all animal and human bites). This is why wounds should be left to drain, rather than create exactly the septic abscess pocket of putresence you'll make by closing a wound that you haven't cleaned, debrided, and treated aseptically and completely, which will be a lot of them.

I get that some people, in some places, (oil rigs, ships at sea, etc.) may have some experience and good luck with closing wounds and not getting burned by disastrous results. if you don't have PA or MD after you're name, or you weren't a twenty-year 18D Special Forces Medical Specialist Sergeant, kindly stay the F--K away from me with your sutures, skin staplers, Krazy Glue™, or any other wild ideas about field wound closure. F*** off with that $#!^. Got it? You're not that guy. 

8. Cover the wound with bandages to keep it clean.  

9. If possible, elevate the wound. If the wound is not severe, keeping it above your heart will reduce swelling and throbbing and will help slow continued bleeding. However, if the wound is severe, keeping continued pressure on the wound is more important than elevation. 

10. If the wound is severe, lay the person flat on their back and elevate both legs. This will help prevent shock.

With this, we are safely out of Jim Baird's clutches with regard to deep cuts. But before we leave, the best thing you can do, is make sure your tetanus (or TDap) booster is up-to-date before you go. Know exactly when you got your last one. Get another one every ten years, at most. Every five isn't bad. If you're going overseas, or going somewhere where you're leaving first world medicine multiple days' evacuation behind, just get a booster anyways. tetanus is a horrible way to die, and preventable by one stick. Just do it.

And if you want to talk antibiotics, the cephalosporin family are your friend with open wounds. Typically an IM shot (think ass dart) of Ancef immediately, and a course of Keflex p.o. (by mouth) multiple times per day, for multiple days after the injury, and finish the entire course. If you haven't consulted with either your doctor before your expedition, or the Altons' Survival Medicine book, or their book on antibiotic therapy, or something equally authoritative, and know exactly how to do this, leave the antibiotics alone, except for topical ones: Neosporin (triple antibiotic ointment), Polysporin (double antibiotic ointment), or Bacitracin (single antibiotic ointment). [The reason for all three is as follows: Some hospitals, ERs, and doctors recommend and use Polysporin, because the missing third ingredient, which is in Neosporin, tends to be the one to which most folks have an allergic reaction, so they leave it out. If you have NO allergies, go with triple. Otherwise, choose appropriately. Do it right, or don't do it at all.] The ointments are for relatively minor wounds, not for giant ones.

Blisters

Long treks are the main cause of blisters—and they usually form on your heels. Here’s how to prevent getting blisters on your feet:

1. Boots that are subpar in quality, don’t fit right, or are not broken in will cause blisters quickly. Make sure you have boots that fit you properly and consider getting them heated and stretched for a more custom fit. Leather backpacking boots for long treks—including mountain hunts—will last the longest and provide you with more support over non-leather. But, they’ll take a lot longer to break in. Make sure you wear them around town or on short hikes before heading out on a long, backcountry trek.

2. Wear two pairs of socks. This helps prevent blisters and reduces aggravation of existing blisters because the two socks will rub together, effectively reducing the friction against your skin.

If you're taking a trip that will include extended periods of trekking or portaging, carry a blister kit separate from your main first-aid kit. 

What to Keep in a Blister Kit

• Moleskin YES
• Blister Foam NO
• Orthopedic Felt NO
• Duct Tape MAYBE
• Surgical Tape YES
• Krazy Glue NO
• Small Scissors YES
• Alcohol Wipes ONLY TO DISINFECT SCISSORS, ETC., NOT WOUNDS
• Gel Toe Sleeves OPTIONAL
• Scalpel, Pin, or Needle (for popping a blister) YES
• Ibuprofen YES

Over at Captain's Journal, Herschel mentioned an article made some "interesting points", and then excerpted part of the listed first aid supplies recommended.

Which perks our ears up, because we're always on the lookout for new or better ideas. And we haven't done a medical post in awhile.

And after a careful reading of the article in question, we've definitely become interested.

In beating it about the head and shoulders with a stout cudgel. When we find our self saying "No! No!" within the first few grafs, it's not going to be good.

We shall fisk it in (probably) three parts, rather than a mega-post. Because we lead a busy life, and haven't the time to invest in deconstructing it all in one go.

For those similarly time-constrained, the TL;DR version:

1. Your go-to medical texts for wilderness medical emergencies should be authored by someone named Forgey, Auerbach, or Alton. Those are literally the Gold, Silver, and Bronze medalists in the field. There are many other good texts, but those are the reigning champions, IMHO.

2. If you use one of the secondary texts not listed, make sure it is authored by someone with MD, DO, PA, RN, or, ffs, at least EMT-P after their name. There are virtually no "gifted amateurs" in the medical field. Listen to professionals, who've been there, and done that, and not people trying to quote them accurately, from a dearth of professional wisdom.

4. As a general rule, so-called "outdoors" publications are either too stupid, too lazy, or too cheap, to seek out the three subject-matter experts, above, or anyone similarly qualified, and instead keep asking their regular outdoor writers to contribute articles on topics far beyond their expertise. I don't begrudge the authors, because all that adventuring doesn't pay well these days, so anything for an honest buck is understandable. But the lack of competent editorial oversight is glaringly obvious, and you owe your readers a discount if you're not going to do that job. For this reason, often the best use of any article from an outdoors magazine, in a survival situation, would be to fold it carefully, carry it in your kit, and then, if one were forced to survive, to tear it into small strips, and use them to light one's campfires or signal fires. That act, alone, will probably save lives and limbs.

And with that, on to the dissection:

A good first aid kit ranks highest among the gear that you never want to use. Still, taking the time to research and assemble the best first-aid kit is a must before you venture into remote areas. A good place to start is with a pre-assembled wilderness first-aid kit. Then remove whatever you don’t need from the kit and replace it with the items you will need.

Fair enough. So, which things will I not need?  How do you know that? How would anyone? It's nice to sound like you could know that, but the fact you never explained it leads inescapably to the conclusion that this advice is from hindsight, out of one's tailpipe. Just saying.

Will this cost more than your run-of-the-mill first-aid kit? Yes. Will this customized kit be more useful in treating a serious injury in the backcountry? Hell yes. After you’ve assembled your first-aid kit, the next step is learning how to use the items inside it to treat common outdoor injuries. This story covers some of the most common of those injures. But before we get started, I should warn you:

 Graphic images ahead…

Yawn. They're not that graphic. Get on with it. 

Burns 

Few meals are more satisfying than a shore lunch at fish camp. This might seem like the last place you’d encounter an injury—but accidents happen. Especially when hot oil and fire are present. Here’s how to deal with a nasty burn:

1. If possible, get the burn on ice. Otherwise, dose it with cool water. Wrong

No! NO! NO! You never "ice" burns. Period. Full stop. Got ice? Throw it in the water you soak the burn in. Never put ice on a burn. Water pulls the heat out, 25 times faster than air, and burned flesh continues to burn until the heat transferred into it is pulled out. Dunk the burn, or put clean cloths soaked in cool water on it to pull the heat out. But no ice.

2.Blisters will form; don’t pop them. The fluid under the blisters is sterile and, when left intact, your chances of infection are less likely. 

3. When the blisters pop on their own, you face a serious chance of infection forming between the dead skin of the blister and your body. Using a sharp, small, and sterile pair of scissors, trim the dead skin off as close to the outside of the burn as possible. 

4. Wash the wound thoroughly. Soap and water will disinfect the wound as well as anything, but make sure to boil your water first. And then let it cool off before you wash with it! 

5. Keep the wound covered. Dirt or other debris or unsterile water can lead to infection. Keep these things out of the wound by covering the burn thoroughly and changing the bandages daily. Non-adherent gauze pads will create less pain and won’t open the wound when changing bandages.

Duct tape can help secure and waterproof bandages. Remember to bring lots of bandages in your first-aid kit.

We use non-adherent dressings. Bring lots of those. Bandages are what we use to hold dressings in place. Dressings get changed, either daily, or when they're wet/dirty/saturated. Bandages can be cleaned and re-used. Duct tape should be kept the hell away from any burned tissue, unless you want to risk removing the intact skin as well as the burned tissue. Skip duct tape; get some good first aid tape in the first place. Paper, plastic, and silk, and probably the mega-sturdy white heavy-duty first-aid tape.

6. Bring clindamycin—the type of antibiotic most commonly used for treating infections. If the burn starts to become infected, begin taking the antibiotic right away and make immediate plans to get out.

Burns are on the outside. The only antibiotic you should be worried about using is either OTC Neosporin, or, if you have/can get it, Silvadene ointment, which is an Rx item. Put that on the burn. Nothing else. Not butter, grease, Crisco, or any 57 other Granny's Homemade Cure ideas that sound like a good idea at the time. The patient, and the burn nurse who has to scrub all that crap out of the burn, will both thank you later.

And the go-to antibiotic for an infected burn is penicillin, or erythromycin. Resistant strains are another problem entirely. So basically, forget every bit of Item 6, except in case of spreading infection, "make immediate plans to get out." The rest is pure crap.

We would also suggest that it's a lot easier to prevent burns than to treat them. Wear stout leather gloves. You'll lose a fraction of your dexterity, but you'll prevent a boatload of problems by letting your gloves literally take the heat, instead of your fingers and hands. And keep your face out of things that flare up, like lanterns and stoves. Eyebrows grow back, but eyes don't and burn scars are forever.

It gets better: almost the entire section on Frostbite can be used without revision. One correction is redlined.