I am one of the MD authors of the book - I have spent a good chunk of my working life in the third world and other austere places. The book has been a labour of love for us and we have put thousands of hours into it and we have been over it and over it again and again looking for errors - we know there will be some - but our goal has been to minimise them and repeatedly throughout the book we ask you to contact us and we supply an address and a website to do that, if you identity anything concerning. We know it isn’t perfect - but we think it is pretty damn good and we genuinely think the error rate is low.
specifically to the criticisms:
Re azithromycin - we have adopted a pragmatic approach to the drug information and the goal is to enable lay people to safely use some potentially complicated drugs - the consequence has been a degree of pragmatism and some safe simplification - remembering the goal is to enable lay people to safely use the drug. In Aust/NZ we have three different manufacturers of Azithromycin and each has a subtlety but importantly different drug data sheets (the information wasn’t sourced off Wikipedia) - the data sheets are easily found on google (medsafe + drug name should get the NZ ones) and have conflicting advice on some things. We have tried to to bring out the important information to use the drug safely and that has called for a degree of pragmatism. You have spun the comments around Azithro in a negative light - that’s ok - again your comment is valid - but it doesn’t invalidate the section.
Another example i will put my hand up to is the comparison between amoxicillin vs ampicillin- they are actually moderately different drugs- but at a practical level they are essentially the same - so our description is not technically perfect- but it is pragmatic and achieves what we are trying to achieve. Which is to empower survivalists medically with safe information. I don’t accept that a small degree of simplification is wrong or invalidates the material.
Re blood transfusion - again your right, but in part your comments are out of context - we have stated that compatibility is significantly more complicated than a simple ABO/Rh chart would suggest and the x-match is tool for identifying incompatibility - the goal was to introduce the concept of blood types - to people who may have little understanding and to relate it to blood transfusion - we clearly haven’t been clear enoug. The chapter author, who know this stuff well, concedes he could have written it more clearly and we will tidy it up
In terms of some of your broader comments. A for A and O for everyone else is a simple down and dirty military approach to a field cross match. It relies on the statistical likelihood on the frequency of each type of blood groups (A and O pick up the bulk of the population) in a western population vs. the risk of incompatibility in otherwise healthy patients who have probably not been transfused before whom the majority have low titres (amounts) of antibodies. It is a suboptimal approach in a grid-up situation where a full ABO/Rh crossmatch and titres should be done but a reasonable grid-down or austere approach.
You are absolutely right that RBC and Plasma compatibility is different, but at a practical level with WBT it is addressed by the type / cross-match process - you mix the blood and if you get reaction = incompatibility. But two other issues are important for context - firstly Packed RBCs still have some plasma by volume, just reduced compared to whole blood with a Hct of around 65% from memory - the ratio of cells to liquid - although not all the ‘liquid’ is left over plasma some is preservative and anti-coagulant - but the level of ab is low. Secondly the important bit around most WBT is that the plasma titres ( or levels) of antibodies are low - but not always - in most O blood so we can get away with transfusing it as WB to anyone - albeit with a small risk of ABO compatibility. I hope that makes sense - it is late here and I am starting to feel like I am waffling!!!
The best reference IMO around which discusses the risk profile of WB transfusion in a field situation and compatibility issues (and some numbers around incidence of incompatibility) for anyone who is interested is:
Strandenes G, De Pasquale M, Cap AP, Hervig TA, Kristoffersen E, Hickey M, et al.
Emergency Whole Blood use in the Field: A Simplified Protocol for Collection and
Transfusion. Shock. 2014 Vol 41. supp1
So if what is written is confusing I am sorry, we will improve with the next update - I don’t think in the context of all the words in the transfusion section it is dangerous.
I am delighted to talk or email anyone who wants to chat about any issues or problems with the book. PM me here. Please if you come across anything that you think is dangerously wrong or even just in need of correction, please let us know - pm me. We genuinely want to engage in constructive debate - you will find the authors love debate - it is how you improve your practice - but not destructive debate - although I do get where the negativity started.
Thanks
BCE
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Survival and Austere Medicine book - comments and feedback
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