Armageddon Medicine

Testimonials

Seldom does one read a book that is truly definitive.  But Dr. Cynthia Koelker has indeed written one. . . Armageddon Medicine will save countless lives in coming disasters, but only if its collected wisdom and knowledge are put into action.

James Wesley, Rawles

Editor, SurvivalBlog.com

August, 2011

––––––––

Infection – the bane of mankind since the dawn of civilization.  And when civilization comes to an end, that fact won’t change. Unless you’re prepared to treat pneumonia, sepsis, MRSA, C. diff, and a host of other infections on your own, what you don’t know may kill you. In down-to-earth language, Armageddon Medicine tells you how to care for yourself and loved ones without a doctor, should society fall apart.

Stephen A. Farkas, MD, FACP

Associate Professor of Medicine

Northeast Ohio Medical University

October, 2011

Also by Cynthia J. Koelker, MD

Board-Certified Family Physician for over 30 years

Currently practicing in Akron, Ohio, where she enjoys sharing music and life with her four children, first grandchild, and 3 goldendoodles.

Hypothyroidism – Answers for a Post-Apocalyptic World

How to treat your own thyroid disease when there’s no other option

* * *

Without medication, will you die?

Can you treat without a prescription?

Are there any natural alternatives?

If so, how much would you need?

* * *

Coming soon

The Legacy of Job’s Wife

A Story of Love and Forgiveness

* * *

A family to make you smile

A story to make you cry

A premise to make you think –

And in the end, perhaps turn to God.

Rated 4.7/5 stars

* * *

I once had ten children, ten beautiful children.

But where are they now?

Even Job could not say.

With but few days left to share my story,

I remember it one last time

For my daughters and granddaughters,

And generations yet to come.

I speak for the women, I speak for the suffers,

I speak for those on the precipice,

About to curse God and die.

101 Ways to Save Money on Health Care

Practical Ways to Save Money on Health Care

Every Day

Follow even one suggestion

and the book will pay for itself.

Written before the advent of Obamacare,

the ideas in this book can save you more money

than the government ever will.

Dedication

This book is dedicated to my children and grandchildren,

with the hope that they never need to use it.

Acknowledgments

Though this manual has been a full year in the making, I could spend many more teaching readers of Armageddon Medicine how to care for themselves when there’s no other choice. As always when I write, I thank my family for forbearance and encouragement, when the task seems to overshadow all else. 

I am especially grateful to my longtime friend and colleague, Dr. Stephen Farkas, for lending his expertise to the portions of the manuscript relating to infectious disease. As a respected specialist in the field, Dr. Farkas has spent decades not only healing patients of every sort of infection, from TB to tetanus, but also teaching the next generation of physicians how to do the same. Thank you, Steve, for helping all of us.

It has been an honor to serve as Medical Editor for SurvivalBlog and to work with blog-editor Jim Rawles. Jim has done our country and the world-at-large a great service in bringing together a wealth of information relating to self-reliance and preparedness. I appreciate so much your willingness to contribute the Foreword for this work, Jim, and your encouragement in its creation.

I am also grateful to the readers and contributors to my own blog, ArmageddonMedicine.net.  It has truly become a community of concerned individuals willing to share their knowledge and experience with others. The collective wisdom is truly amazing.

As I write this, I wonder about Armageddon. Will God permit such a disaster to occur in my lifetime or that of my children? I’m hoping not, yet often fear that the writing is on the wall. I thank Him for the prolonged prosperity he has lent our country and for the love He continues to shower upon us. I pray this volume offers hope and healing to many. 

Foreword

by James Wesley, Rawles

Editor, SurvivalBlog.com

Seldom does one read a book that is truly definitive. But Dr. Cynthia Koelker has indeed written one, in Armageddon Medicine. Her book does an excellent job of detailing the key topics and skills that families need to master to be well-prepared for the medical aspects of disaster situations.

Life is full of imponderables, and recent events in the modern era have taught us that the future is truly unpredictable. The 9-11 terrorist attacks of 2001, Hurricane Katrina in 2005, and the earthquake, tsunami, and subsequent nuclear meltdowns in Japan in 2011 together introduced us to a cold, hard, new reality: we simply can no longer blithely expect tomorrow to be a repeat of today. Nor can we expect government agencies to be capable of providing for our needs in the event of disasters. Time and time again, governments have proven that they simply don’t have the manpower, the transport, or the logistics to make that happen in a timely manner. In the next disaster it will be what I call YOYO time — which stands for You’re On Your Own. YOYO time may last for many months. Are you ready for it?

There are many looming threats to our health and safety, ranging from floods, fires, earthquakes, hurricanes and tornadoes, to pandemics and nuclear terrorism. The future is uncertain, and at times this realization can seem overwhelming. But with the grounding knowledge of human physiology, some training, and some fairly modest supplies, we can at least be prepared to guard our physical health, regardless of what the future brings. Cynthia Koelker brings this all together, in Armageddon Medicine.

In the chapters ahead, you will learn the essentials to keep you and your loved ones sane, healthy, and avoid having them assume room temperature. Her chapters detail mental health, acute infections, skin conditions, pain management, acute injuries, health issues for women, nuclear warfare, bioterrorism, and much more.

Quite importantly, Dr. Koelker discusses some topics not found in mainstream texts. For example, she describes in detail how to obtain alternative antibiotics during situations where access to pharmacies is limited or non-existent. She also dares to walk the path that the AMA establishment fears to tread, in discussing herbal medicine and other natural remedies.

To supplement the main text of the book, Dr. Koelker includes three very valuable appendices. The first one outlines key resources both in print and on the Web that you should gather as reference material. The others include outstanding detailed lists of medical supplies that you should assemble for your family.

Don’t just read this book and put it on the shelf. Consider it a challenge and a call to action. Start assembling your medical supplies now. Get enrolled in advanced first aid and CPR training immediately. Practice what you’ve learned, and keep learning. Be ready to adapt and overcome times of adversity.

You need this book. In fact you’ll need two copies, so that you will have one available to lend to friends, relatives, co-workers, and fellow church congregants.

Armageddon Medicine will save countless lives in coming disasters, but only if its collected wisdom and knowledge is put into action. Don’t dawdle and don’t hesitate. When the time to perform is at hand, the time to prepare has passed.

James Wesley, Rawles

Editor, SurvivalBlog.com

August, 2011

Introduction

What if the unthinkable happens? World War III? Global economic collapse? Worldwide plague? An asteroid collision? Biblical Armageddon?

Assuming you’re fortunate enough to live through the initial event, will you be able to care for yourself in an era of no doctors, no hospitals, no pharmacies? No doubt a smattering of physicians will survive, but where are they? Can the few remaining assume care for the devastated population?

2012. It’s upon us. Is the threat real or imagined? What about our less-than-friendly nuclear neighbors? Or a pandemic eclipsing the Andromeda Strain? Or perhaps an economic meltdown extinguishing our currency as well as the national power grid?

I am not an alarmist. My lifetime has been one of unrivaled American prosperity. But I often wonder, how long can it last? In recent years I have come to doubt the continued stability of our nation, our society.

Although I don’t claim to be an expert on end-of-world survival, I do possess decades of practical experience as a family physician. If such an unthinkable event occurs, how will people care for themselves? The young and healthy have little know-how when it comes to injuries, infections, childbirth, and nutrition. Millions of middle-aged souls suffer from diabetes, depression, heart disease, asthma, arthritis, back pain, and ulcers. What about the elderly with poor eyesight, poor digestion, poor mobility, and a poor prognosis? Who will care for them?

If the power grid is destroyed there will be no water, no food, no social services – at least not with the abundance and availability to which we’re all accustomed. What will you do if you contract pneumonia? How long can your diabetic mother survive? Might your infant son die of scarlet fever?

These are just a few of the questions I’ve asked myself. Though the situation sounds grim, there is hope.

Although Rawles[1] and others have written excellent books regarding surviving the end of the world as we know it, the medical information contained therein is limited. If society is to continue, those who remain must know how to care for themselves. Today’s common maladies will continue to plague mankind. No doubt new and unforeseen threats will emerge.

This book is written to aid the survivors – and those who hope to survive. How should you prepare if you have young children? What will you do if you’re diabetic? Is there any hope for your parents with heart disease and arthritis?

You’ll find chapters on preparedness, acute injuries, infections, women’s health, chronic disease, mental illness, and nutrition. Checklists will help you know what to do before the big event and how to prepare for life afterward. Detailed instructions on common illnesses will tell you what a physician would do and how you can treat yourself effectively. Practical advice on managing chronic disease will assure those with serious problems of continued survival.

Even if nothing happens (and let’s hope it doesn’t), this manual is chockfull of practical advice for every patient. Catastrophe or not, the same principles apply. Either way, medical knowledge will remain a powerful tool in assuring your loved ones’ survival.

Cynthia J. Koelker, MD

November 2011

Preface

The Four Phases of Medical Armageddon

Floundering, Fading, Forgotten, Future

Medical Armageddon: the end of modern medicine as we know it.

As terrible as recent disasters have been, they don’t hold a candle to a true national or global catastrophe. Although 9/11 and hurricane Katrina were truly horrific, could America recover if the carnage were magnified ten-fold, a hundred-fold, a thousand-fold? True, fallen nations have been revived, but only with the aid of willing outsiders or long periods of convalescence. What if there’s no one left to help?

The 2009 H1N1 influenza pandemic taught us how unprepared we are to prevent widespread affliction. Vaccine supplies were unavailable in many areas until after the flu had passed, leaving thousands dead in its wake. When the vaccine was finally shipped, many medical offices still received not a single dose, and endless lines at community centers dissuaded uncounted patients from being immunized at all.

Fortunately, H1N1 wasn’t the killer flu it might have been. Consider these statistics: in 2009, approximately 57 million Americans contracted H1N1 influenza. Of these, about 11,690 died.[2] Compare this to 1918­­­–1919 when 850,000 of 20 million infected patients met their death of influenza or pneumonia – 650,000 died in four months alone![3] Had this same flu epidemic hit America in 2009, over a million deaths might have occurred. One might suppose that the reason for fewer deaths was the miracle of modern medicine, but this is not the case. The 2009 H1N1 was simply not as lethal. Had it been a true killer flu in the same unimmunized population, deaths may have multiplied a thousand-fold, even with antiviral medication. And an epidemic can still happen. Authorities say we’re overdue.

No matter what nationwide disaster someday hits America, the health care system will be overwhelmed. Perhaps we should hope for something as minor as a flu epidemic. Only a few per cent of the population would likely succumb, and life would eventually return to normal. A protracted power outage, or severe fuel shortage, or (heaven forbid) war on American soil would soon result in chaos. In a global Armageddon scenario, with two-thirds of the population annihilated, the health care system would flounder, perhaps never to return to its former state.

As communication, transportation, and production grind to a halt, hospitals would soon exhaust available supplies. Health care workers will need to safeguard their own families, leaving suffering patients to fend for themselves. Within days, or weeks, or months, medical scavenging and self-treatment may become the norm.

Yet the memory of modern medicine will not disappear overnight. Many Americans possesses a fair degree of sophisticated knowledge, enough to read a textbook and figure out how to help their loved ones. Diabetics realize they need insulin, and have been taught to check their blood sugar and how to inject themselves. Asthmatics understand that inhalers relieve their obstructed breathing. It’s no secret that nitroglycerin and morphine help a heart attack. Who doesn’t know that antibiotics are the treatment for pneumonia or a kidney infection? As long as supplies can be found, people can treat themselves for many conditions, perhaps for years to come. But as these supplies dwindle, if production, transportation, and communication are not revived, modern medicine will eventually fade.

As with ancient societies, ours, too, will someday pass away. CAT scanners will become relics of a forgotten past. Handy gadgets such as home blood glucose monitors will no longer function, as batteries die and testing strips disappear.

And then what?

If mankind continues to populate the planet, eventually technology will re-emerge, perhaps in new and exciting directions. The future may hold cures we’ve never imagined, answers for the aging, help for today’s hopeless.

Though I cannot see this future, I fear the pathway spirals downward before it ascends to new heights. I trust some along the journey may find answers in this humble book. Today’s medical care is marvelous, and I pray it never flounders. I wonder, though, what my great-great-grandchildren will think if, a hundred years hence, they come upon my writing.

I’m hoping they never need my advice.

SECTION ONE

The Basics

1

Preparedness

What you can do now to help yourself then

Today . . . the sun is shining. The kids are in school, grocery stores are full to overflowing, the house is warm, and gasoline hasn’t reached $5 a gallon. American Idol is in its eleventh season. All is well.

Tomorrow . . . who knows? Will it be $10-a-gallon gasoline? Food shortages? Unaffordable heating? Bioterrorism? Do you have what it takes to survive?

Human beings – what amazing creatures! – at least when we’re not busy killing each other. We can learn, laugh, love, adapt, grow, and most importantly, plan. You, not the government, are your own most valuable resource. Although animals may have the instincts to store food, migrate to a warmer climate, and flee from danger, as a human being, you can do much more. You can plan ahead.

Much of our life is planned, but in a fairly haphazard way. We sometimes get immunizations (if we feel like it, or happen to be at the doctor’s office). We buy enough groceries for a day or a week, whatever happens to be on sale, or is appealing for the moment. We pay our bills, mostly on time, and trust that our heat, water, and electricity will be there tomorrow. If we need more food, we can drive to the store and buy it.

And this works – at least for now. But what if you believed that three months hence, they’d all be gone? You’d start preparing, of course. And if, like Y2K, nothing happened, you’d be none the worse for your provisions.

In the realm of medicine, preparations fall into both general and specific categories. General recommendations apply to the population as a whole, whereas specific advice is dependent on age, state of health, location, mobility, and other factors.

If you have medical problems, no doubt you’re quite worried. Diabetes, asthma, and heart disease won’t disappear just because no doctor’s around. If you’re well, what about your loved ones? Can your parents, or grandparents, or children thrive without a physician’s care?

Fortunately, there is much you can do. Reading this book – and acting on it – is a good place to start. A single volume cannot cover every aspect of medical care, but it can get you started in the direction of securing your own health and that of your family.

The first thing that comes to mind is vaccine-preventable disease. Americans think very little about this because we haven’t seen diphtheria, or tetanus, or typhus first-hand, and scarcely believe these diseases kill people. But I remember having mourned babies who died of meningitis in the 1980s, before the HIB (Haemophilus influenzae B) vaccine, and doctors older than I can’t forget the devastating effects of diphtheria and polio. Nowadays people worry about their babies developing autism or attention deficit disorder from vaccines (unfounded concerns from my point of view), rather than being grateful that their children haven’t succumbed to terrifying childhood infections. For parents who have chosen not to immunize your children, please realize that the reason your children haven’t been exposed to one of these deadly diseases is because the other children have been immunized. When this herd immunity becomes diluted through lack of universal vaccination, your children will be susceptible as these infections re-emerge in the population.

Vaccine-preventable disease is a concern that will only escalate in the future, if and when vaccines become unavailable. And does this next thought worry you? Most American doctors have never even seen a case of diphtheria, or tetanus, or rabies. Younger physicians have never treated measles, mumps, rubella, polio, pertussis, or Haemophilus influenzae meningitis. Do you want your child to be their first case? The generation of health care workers (as well as grandmothers) familiar with many of these diseases is dying off, and all that remains is book knowledge.

Hepatitis (A and B), chicken pox, shingles, and meningococcal meningitis still occur sporadically in the American population, despite vaccine availability, and influenza and pneumonia remain quite common. Some overseas travelers may have received vaccines to diseases not currently seen in the U.S., such as yellow fever, cholera, or typhus. Could these diseases reach American shores? Infectious disease has not been conquered, merely held at bay for the time being.

If national supply chains are disrupted, within mere weeks immunizations to common diseases will become unavailable. With a major catastrophe, it would take years to decades to re-establish the production of safe and effective vaccines.

Therefore, it is vitally important not only to receive currently available vaccines now, but also to learn something about each illness. Though you will be prepared and (hopefully) immunized, others may not be. If you encounter an ill person, how will you determine what infection they have and whether you’re protected against a contagious disease they may harbor?

Which diseases may re-emerge? These are primarily those to which infants and children are routinely immunized. In the United States, this includes hepatitis A and B, rotavirus, diphtheria, tetanus, pertussis (whooping cough), Haemophilus influenzae B, pneumococcal pneumonia, polio, influenza, measles, mumps, rubella, and varicella (chicken pox).

Why are immunizations so important? Largely because no medication works. The majority of these illnesses are caused by viruses. Antibiotics do not kill viruses. The few antiviral drugs we have are generally ineffective against these microbes. Although antibiotics are often effective against bacteria which cause pneumonia, meningitis, or pertussis, without additional supportive care (such as I.V. fluids, oxygen, tube-feeding, or breathing treatments) antibiotics alone may not resolve life-threatening infections, and babies with insufficiently developed immune systems are susceptible to overwhelming infection.

Older children may also be immunized against meningococcal meningitis and human papilloma virus (venereal warts and cervical cancer). Older adults add varicella zoster (shingles) to this list. (Many older adults have not been vaccinated against certain childhood diseases, but catch-up doses are not generally advocated.)

Childhood vaccines are quite expensive, running into hundreds of dollars.[4] Fortunately, most are covered by insurance plans. For those without insurance, check with your local health department or hospital clinic, where prices may be considerably less than at a private office.

Americans who travel overseas are currently encouraged to receive various other vaccines, depending on destination. These may include cholera, Japanese encephalitis, rabies, tick-borne encephalitis, tuberculosis, typhoid fever, and yellow fever. Depending on your personal situation, you, too, may want to consider these vaccinations. Your family physician will not have any of these available, so you should consult with your local or state health department or travel clinic.

At a bare minimum, all adults should update their tetanus shot, which now includes a booster for diphtheria and pertussis (Tdap) for everyone through age 64 (Td alone for older adults).

Next, what is the depth of your medical knowledge? Is someone in your family a doctor, nurse, physician’s assistant, or midwife? If so, perhaps you can rely on them, but educating yourself may become a matter of life or death.

Before people survived long enough to die of heart attacks and cancer, they died prematurely of injuries, infection, dehydration, and malnutrition. These are the primary focus of this book. Many injuries are preventable, as will be stressed in a later chapter. Major injuries (gunshot wounds, head injuries, cervical spine fractures) may well be fatal without intensive (and likely unavailable) medical intervention. Less severe injuries should be treatable and survivable (as long as infection is avoided), though the outcome may be less than ideal compared to current standards. A broken hip can heal without pinning, though chronic pain and permanent disability may result.

Depending on your own health and that of your family, you may want to arm yourself with specific disease-oriented knowledge. Or, if you’re expecting a child, you will want to learn all you can about labor, delivery, and newborn care. If your mother is diabetic, you may want to educate yourself about injecting insulin. Can a needle be re-used? How should she treat her blood sugar if testing is unavailable? Many of these issues will be addressed in later chapters, but thinking about specific health problems now and projecting into the future will bring questions to light that should be discussed with your personal physician.

Appendix A lists helpful books and resources for medical care in situations where doctors and other health care resources are unavailable. Again, depending on your situation in life, you may want to invest in some or all of these.

Appendix B lists supplies and medications to consider for your medical kit, with recommendations for family, community, and professional care.

Appendix C offers a list of over-the-counter medications you may want to stockpile for use by your family or survival group. Later chapters cover questions about using expired medications, alternate therapies, and prescription drugs, with special attention to antibiotic use.

Lastly, what is your level of fitness? Can you walk a mile carrying two gallons of water? When transportation and supplies are not readily available, people will no longer exercise because they should, but because they must. Perhaps planting and caring for your own garden would be a good place to start developing stronger muscles. You’ll want to be at your best in case you must rely on your body as much as your mind. Are you overweight? Approaching your ideal weight is a good idea, though a few extra pounds may see you through lean times.

Identifying health concerns and goals is a first step toward preparing for the worst. But before moving on to specific medical concerns, we’ll address items even more vital to life itself: water, food, and shelter.

2

The Essentials: Water, Food, Clothing, Shelter

Water, Electrolytes, Calories, Protein, Vitamins, Minerals, Clothing, and Shelter

The Garden of Eden – I picture it like Hawaii, but without the rain. Abundant food, ripe for the picking. No mosquitoes nor malaria. No scavenging wolves or stinging insects. No rusty nails to pierce your foot. Plenty of sun, but plenty of shade. Will you be in the Garden of Eden or more likely Detroit when the crisis hits? If you’re lucky enough to have a productive garden, will you reap the rewards? Will packs of dogs threaten your children? Do you have enough shoes to last the rest of your life? Or enough water to last even a week?

A diabetic will die quicker without water than without insulin. Hypothermia is more rapidly fatal than pneumonia. Starvation will kill you faster than cancer.

Water

What good is all the medication in the world without clean drinking water? Can your body fight infection if your immune system is weak from malnutrition? Assuring a dependable supply of potable water is THE single most important thing you can do to safeguard your health. Don’t count on the government doing this for you. If the public water supply runs dry (which will happen if the grid goes down and pumps are offline), it’ll be up to you to solve your own dilemma. Other sources (see Appendix A) describe how to procure safe drinking water in adverse conditions. I’m only reiterating that as far as your health goes, you must think of water first.

The body is about 60% water by weight, but where is all this water? Not in the blood stream. Only about 1/12 of your total body water is coursing through your veins. Most of the water, about two thirds, resides inside the cells of your body, the so-called intracellular fluid. When a person becomes dehydrated, they not only lose water from their bloodstream, but from the inside of the cells. This is the difference between a grape and raisin. You don’t want to become a human raisin.

So how much water does a person require? Is it really true that you need eight 8-ounce glasses of water a day? And what does that even mean, that a person needs so much water? What actually happens when the body is deprived of water?

Generally speaking, human beings and other adult animals maintain a fairly stable body weight. Since most of the body consists of water, this implies the amount of water in your body should remain fairly constant. No doubt you realize that you lose water whenever you urinate, or sweat, or spit, or bleed, or have diarrhea, or even a menstrual period. You’re probably unaware of the amount of water lost just by breathing, or by evaporation from your skin (aside from sweating). These are called insensible fluid losses.

To stay the same weight, the amount of water lost daily must be replaced by an equal volume. One simple way to determine the amount required is to weigh yourself daily on an accurate scale and simply drink enough water (or other non-diuretic fluids) to maintain the same body weight. If you happen to drink more water than you need, your body will simply flush it out in the form of urine. Doctors frequently weigh patients who are taking diuretics (water pills) or receiving I.V. fluids (or both) in order to determine their water balance.

Unfortunately, things are not always this simple. If you are able to stay at home where your handy (non-electronic) scale is readily available, weighing yourself daily is a great way to determine proper fluid replacement. But in an Armageddon scenario, this may well be unrealistic.

So back to the question, how much water do you really need? The short and simple answer for the impatient reader is, ideally, 2 to 3 liters (or quarts) of fluids a day. If there is no cause to suspect greater water loss than usual, even one quart a day may suffice. This gets to the heart of the matter, the real reasons for urination. Obviously, the first reason is to rid your body of excessive water. But the second is equally important, that is, to cleanse your body of toxic waste. If your kidneys do not cleanse your blood of urea and other waste products, they will build up and eventually kill you. Your own body will become a toxic waste dump.

Although 1 quart of water a day may suffice under conditions of minimal loss, a multitude of situations accelerate fluid depletion, and therefore increase the need for additional water intake. Conditions that are will increase a person's need for water include:

fever

hyperventilation (from work, illness, or fever)

high ambient temperature

low humidity

sweating (from work, illness, or environment)

diarrhea (especially secretory diarrhea)

certain medications (most notably diuretics, including caffeine)

excessive urinary loss (from medication or illness)

bleeding (internal, menstrual, or other)

nursing an infant

internal fluid sequestration due to injury or illness

injury or illness that increases the amount of waste produced

Under any of these conditions it becomes extremely difficult to measure the amount of water a person requires. Does a fever double insensible fluid losses? Can intractable diarrhea triple the amount of water needed? The answer to both is yes.

Under stressful circumstances healthy kidneys will do their best to compensate for fluid loss by concentrating the urine as much as possible. The least amount of urine necessary to rid the body of its daily waste production is about half a liter, or 2 cups of water. Obviously, you cannot urinate solid waste, and the colon can only eliminate unabsorbed food, not waste products of cellular metabolism that enter the bloodstream.

The best way to assess the proper amount of fluid intake is to weigh sick patients daily. Even with no caloric intake, few patients lose as much as a pound a day of their own fat or muscle tissue (though we may wish we could). Anything beyond a weight loss of several ounces is actually fluid loss, which must be replaced.

What if the patient’s weight increases? It is nearly impossible for a person with functioning kidneys and a good heart to get too much water by oral intake alone. However, it is very easy to administer too much fluid intravenously, especially in a sick or elderly patient. I’ve seen patients gain ten pounds overnight when excess fluids are administered in hopes of stabilizing blood pressure. This often throws the patient into congestive heart failure, and sometimes cause the legs to balloon out to the extent the skin begins weeping. Patients like this are very difficult to handle: the fluids are keeping them alive yet killing them at the same time.

When a patient cannot be weighed, the next best thing is to measure their daily urine output. Hospitalized patients with any sort of fluid balance concern (fever, diarrhea, vomiting, inability to eat, heart failure, kidney disease, swelling, or diuretic use) should have both done, that is, be both weighed and have their urine output monitored. Urine output below 30 cc per hour indicates an acute need for additional fluids.

In children the water requirement is proportionately much larger. The calculations for fluid replacement become more complex. It is safe to assume that even an infant will need as much water as an adult. If you have young children, purchase an appropriately-sized balance scale or spring scale (electronic scales should be avoided due to the need for batteries or electricity). Whereas it may be difficult to weigh a bedbound adult, it's a simple matter to place a small child on a scale. As a parent you should monitor a sick child's fluid intake closely and increase it accordingly if necessary to maintain a stable weight. A child who has lost 5% of his or her body weight and cannot drink enough to make up the difference is in danger of serious dehydration. Without I.V. fluids, such dehydration may prove fatal. Although in a catastrophic scenario professional medical care may be difficult to come by, this information will at least alert you as to when to attempt to seek it.

Another population at increased risk is the elderly. The thirst mechanism is much less reliable in individuals in their 70s and beyond. Complicating this are both medical problems and their treatments. Diuretics place a person at significant risk for dehydration, especially when accompanied by loss of appetite, fever, confusion, or even swelling. The older generation is at additional risk because they often do not understand their multiple health problems thoroughly or simply forget what the doctor has told them. Conversely, some are so concerned about following doctor's orders that they continue their medication even when they should not. Taking a water pill when you are dehydrated is as dangerous as injecting insulin when you cannot eat.

If you are concerned about losing your parents or grandparents in the face of a crisis, now is the time to educate yourself about their medical conditions. As a physician I always appreciate it when a child or grandchild accompanies their elderly relative to the doctor. Two heads are better than one, and a younger person may have less trouble remembering, or may bring additional issues to light, or pose additional questions relevant to their relative’s condition or environment.

One final note: it seems unlikely that anyone would consider concocting their own intravenous fluids, but just in case, a word of warning: DO NOT use plain water. It can cause serious electrolyte imbalance and even death. Doctors always use solutions containing either dextrose (usually 5%) and/or saline.

Electrolytes

With the advent of Gatorade everyone's heard of electrolytes. But what are they? What do they actually do?

Electrolytes are basically salts dissolved in water, most importantly sodium, chloride, and potassium. They are involved in metabolic processes as diverse as regulation of heart rate, kidney function, cognition, and the circulation. The flow of water to and from cells is dependent on the concentration of electrolytes both inside and outside cells.

Plain drinking water does not contain electrolytes, but this is not a problem in a person who is eating. Food contains electrolytes in liquid or crystallized form. As water and food mix together in the stomach and intestines, the fluids and electrolytes are absorbed in proper concentrations to maintain a healthy body . . . unless something goes wrong.

In a healthy person on a normal diet, it is unusual to see an electrolyte imbalance. However, in a dehydrated person, or one with vomiting or diarrhea, or someone on multiple medications, electrolyte disturbances are common.

Serum potassium levels may drop with diarrhea or vomiting, or secondary to certain diuretics. Low potassium levels may cause weakness, impaired thinking, heart rhythm problems, or even paralysis. A patient's potassium level may rise when the kidneys are not functioning adequately, or secondary to ACE inhibitors or potassium-sparing diuretics, or due to tissue breakdown. High potassium levels may also cause weakness, paralysis, and cardiac arrhythmias. High sodium levels are often a marker for dehydration, although dehydration with low sodium levels is common among patients taking diuretics. Clearly the situation can be confusing, even for doctors, especially without access to blood testing.

The take-home lesson here is that if a person is not able to eat regular food, electrolytes must be added to oral or I.V. fluids, in amounts similar to those normally found in the blood stream. This way, if electrolyte levels are low, they’ll be replenished; if too high, they’ll be diluted.

One of the most significant lessons of the 20th century is that fluids are absorbed more efficiently in the presence of sugar and electrolytes. Grandma had it right when she said a little chicken soup and ginger ale would be good for you. Sports drinks such as Gatorade include the proper amount of salts and sugar for optimal absorption. You can make your own oral rehydration fluid by