Wednesday, February 13, 2013

Lesson Twelve: Field Surgical Kits

{Update/Note: In a prior post, I’ve discussed the sorts of supplies for running a care station, effectively a hospital, under extreme circumstances. That scenario envisions both a dire situation this following is not addressing, and/or hopefully the presence of one or more advanced and at-some-time licensed practitioners with skills and training far beyond what 99% of the public at large has any access to, and to whom this lesson is intended. So unless you are or have access to a doctor, etc., and/or are setting up a clinic in some Third-World Trashcanistan, or in the U.S. after the Zombie Apocalypse, the following still largely applies in whole, exactly as written in approx. 2005. When it doesn't is when you're treating someone after trading lead on a two-way firing range, and is discussed in Lesson Eighteen under TCCC guidelines.}

Lesson Twelve: Field Surgical Kits, And Why Most Of You Probably Don’t Need Them

If you've spent ten minutes perusing "survival" sites, links, pages, catalogs, etc., everyone has or includes something about Field Surgical Kits.

Quick pop quiz: How many of you think you'd like to take a crack at taking out a hot appendix in your living room, today?

How about in a snow cave next week? In the back of a camper at a roadside rest just after a Katrina-like natural disaster?


Then what the Sam Hill do you think you're going to do with a "surgical kit"? Look cool?

Let's check out the contents for a second:
Needle holding hemostat (used for suturing)
Perfect! Doctors and physician assistants spend upwards of 4 years of postgraduate training learning to do suturing properly, and all they really needed was a $5 set of pliers with a spiffy nick to hold the needle?
As if!
Unless you're one of them, there's nothing, I repeat nothing on God's green earth you're trained, qualified, let alone licensed to sew closed. I've read the books, practiced on pig's feet, blah blah, blah. And I’m not crazy enough to do it, nor even consider it, unless thermonuclear mushroom clouds are rising over the city, and there’s no other choice. And even then, I’d rate the chance of doing it 50-50, for reasons I’ll get into momentarily.

5-inch hemostat
I carry one of these daily, and we'll get to why. But is it of any use to you? Maybe.

To "remove shrapnel, bullets, etc." See the next item.

To "clamp off that spurting artery"? Not bloody likely.

1) It won't work. 2) It won't hold. 3) You'll make a vascular surgeon's job much harder.

I used to work in a world-class Level I trauma center. I saw dozens of chest cut-downs, where the body is literally cut open on one or both sides to cross clamp the AORTA. With trained surgeons and trauma teams, and full hospital chest trays, I saw 3 successful ones out of dozens of attempts.The rest simply died with their insides hanging out. Why do it?

They were going to die anyways, so there was no harm, and residents have to learn on someone; why not the guy with four bullet holes in him? He's sure not going to invent a cure for cancer, so why not use him to train a new doctor?

That logic doesn't apply to you in any situation you could reasonably name, 999 times out of 1000.

So, what do I use mine for? Opening metal-capped RX injectables, and to clamp IV and gastric suction tubing (which you don't have to deal with). But you might use it to clamp a sterile gauze sponge to soak up bleeding, or pack a wound hole. It becomes the handle of a giant Q-tip. And that's about all.

Scalpel handle
Again, for what? Making new wounds?

There is a use for disposable scalpels: liberating shallow splinters and other foreign bodies. Note I said shallow. As in visible through the skin. Anything deeper gets left inside. If you can't see what it's in, on, or through, you don't want to go yanking things out and ripping new holes in vital structures.

Why? As an exemplar, a few years back the "Miracle Boy Of Mesa Verde" or somesuch, was a 10-year-old in AZ who'd fallen out of a tree onto some threaded rebar rod used as a garden hose hanger and impaled himself standing up into his central chest. The firefighters and paramedics didn’t move him, they painstakingly hand-sawed the rod in place, wrapped it like it was eggs, and delivered him to a trauma center, rather than ripping it out. This saved his life twice, because

1) It had gone through his heart, as in into and out of, and the threading on the rebar helped the heart muscle seal around the wound and continue beating without leaking very much.

2) The end had both severed, and simultaneously pressed closed, his right subclavian artery, pinning it against his rib.

Removal of this object would have killed him two ways in a matter of seconds, from massive dual hemorrhage.

Get rid of the scalpel handle.

Sterile scalpel blade
See above.

Surgical probe
"Paging Dr. Mengele." Untrained you is going to go poking around in a hole, to accomplish what, precisely?

Operating scissors
Another maybe. Get some angled bandage scissors instead, which will be of far better use. And some trauma shears for cutting through clothes, seat belts, etc. The only use for the pointy operating scissors might be to remove obviously non-salvageable flaps of avulsed or dead skin during wound debridement. Or, once in a century, cutting an umbilical cord in an outside of hospital birth, after circumspect sterilization of the scissors.

5 inch pointed forceps
At last, something you should definitely keep. Pulling splinters demands any tool that works, and a set of Carmalt splinter forceps are invaluable. For pulling out shallow splinters in the skin. Period.

Alcohol swabs
For cleaning your instruments? Or a patch of skin? You're gonna need a lot more than a couple to do any good. And remember, alcohol stings like h### on open wounds.

Antiseptic towellettes
You should have a pouchful of these anyway. And not for "surgery."

One or two various sterile sutures
There are perhaps 30 varieties and gauges of frequently-used suture material: nylon, gut, chromic, silk etc., in 2-0, 3-0, 4-0, 5-0 etc.; and half a dozen attached needle types: straight, curved, reverse curved, cutting, etc. Not counting super specialty types. At my ER, it takes up two square feet of double-decked drawer space, about the size of a military footlocker and takes a heap of training to select the proper combination. A complex wound may require 3-4 types for the varied levels of repair. Of course, anyone carrying these will know which ones they need, won't they?

Still not convinced? Let's look at what the kit doesn’t have.

A gallon of Betadine Surgical prep and scrub, plus sterile saline for irrigation, and syringes with splatter shields
Dirty wounds sutured closed become festering puddles of gangrene. Open wounds can be cleaned, and drain. Pick the one you'd like to have.

Yards of sterile drapes
Because even a hospital requires something clean to work around. Let alone that field you're in.

Rx injectable local anesthetics, syringes, and needles
Because cutting and carving on people tends to make them scream, thrash about, and hit you. And it's hard to sew up a wound on someone who's writhing in agony and flinging blood everywhere.

RX IV, injectable, or oral antibiotics, and appropriate supplies for administering them
(including but not limited to, a microbiology lab, ability to culture bacteria specimens, and sufficient stocks of supplies to administer a full course of therapy, or multiple therapies and drugs for resistant organisms, and/or treat potential life-threatening anaphylactic reactions)
Without that stuff (not to mention those years of training you don't have), you're going to do what a lot of 19th century doctors did: Inject your patient with all manner of germs, close things up, and wait for sepsis to finish the job the injury started. Or just kill them quickly when they have a massive systemic allergic reaction that your OTC Benadryl isn’t going to fix.

In contrast, there was a homeless man who came up to our first aid station for treatment at Cinco De Mayo/Fiesta Broadway in downtown L.A. one year. He came limping in, and asked us to look at his leg, because he'd "hurt it". Actually, he'd fallen asleep stoned or drunk in the railroad yard, and a moving boxcar wheel had sliced half of his thigh open, nearly to the bone. Without waking him! (Now that’s anesthetized!)

As he removed his trousers, the skin and thigh muscle flapped open, revealing the inner wound covered in a writhing mass of engorged maggots. After the sight cleared out everyone within 30 yards, we secured from a local restaurant three pitchers of very warm (not scalding) water, and proceeded to clean the wound. We also applied betadine, wrapped everything in sterile dressings and Kerlix fluff, and sent him to the hospital via 911 ambulance.

He survived, as did his leg, despite not having had any surgical or medical intervention for two weeks. The maggots ate the infected flesh (and don't use those either)*, saved him from gangrene, and after much-delayed surgical repair and a course of multiple antibiotics, he was released, with a shiny new scar down his thigh and a well-functioning leg.

Get a good set of tweezers, bandage scissors, and trauma shears.

And throw that other junk away, or save them for your kids' high school frog dissections.


*(For information, there are companies that raise and supply hospitals with, at quite a premium price, absolutely sterile maggots, and leeches, for medicinal use in draining pooled blood and eating away dead flesh in wounds, under medical supervision. The critters are applied to do their business, then disposed of after one use by incineration, and have proven a boon for patients with massive amounts of necrotic tissue that would otherwise lead to massive sepsis, and for draining the pooling blood of reconnected body parts –like fingers – whose circulatory elements haven’t knitted together yet post-surgical repair. Medieval medicine wasn’t entirely the product of morons, it just required a bit of tweaking once we learned about things like bacteria to make it suitable for 21st century medicine. The maggots eat dead and live tissue alike, and the pros can tell when to remove them: when they start nibbling on vital structures, patients report a tingling sensation, which means they’re onto living flesh and nerves, as opposed to snacking on the dead stuff, which the patients don’t feel at all. Sick, twisted, and yet fascinating to those of us in the biz. Just thought you should know.)

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