Tuesday, September 26, 2017

Bandaging: General Principles

General Principles Of Bandaging Treatment

Handwashing/gloves are everything's first step.
Clean hands and fresh gloves will save more lives than anything else you do. Don't be stupid, and make me pull this blog over and explain to you about Pasteur and Semmelweis, or the difference in hospital death rates pre- and post-Nightingale and Barton. Learn from history so you don't repeat it. Wash your nasty hands, with soap and water, or alcohol gel if you've got nothing else, and put on non-latex barrier gloves.
Every. Single. Time.

It's not ready to bandage until it's clean.
"The solution to pollution is dilution." They beat this ditty into medical student's heads for a good reason. Clean wounds heal; dirty wounds get infected. Wash it out, betadine it sterile, rinse it again, get a nail brush or toothbrush (used solely for the purpose) if necessary, but if it wasn't there before the wound, it's got to come out first, before you seal it in place with a bandage.

High Index of Suspicion.
That's not a cut over a fracture, it's an open fracture. That's an entry hole, not a shallow puncture. And yes, it probably did The Worst Thing You Can Imagine. Those are the assumptions you're allowed to make, and be pleasantly surprised if you're wrong. Underestimate, and you'll be unpleasantly surprised, and your patient may die, or have severe complications. Pessimism saves lives.

It's always "going to be fine." Unless it's way too late for that.
Your patient is in pain, scared, and usually reverts to the mental capacity of an airhead when they're hurt. That may be shock, denial, stupidity, or all three. There's no sense scaring the shit out of them. Smile, downplay the injury, and carry on. Calm, re-assuring, and competent solves a lot of problems you don't need to deal with.
The only exception is when someone is going to die, imminently, you know it, they know it, and there's nothing possible that can be done.

The guy who wrote that scene nailed it. Or was there IRL when it happened like that.
If that isn't what's going on with your patient, remember, just like a kid who does a face plant, people see your face and use it to gauge how effed up they are. Poker face, and cool competence are required. If you lose your shit, or look at them like something that crawled out of a zombie flick, they're going to lose theirs too. Now you're going to be trying to treat a panicky patient. Trust me, that never goes well. Calm 'em down, and wrap 'em up.

What goes in, may come out. Anywhere. Find all holes.
Somebody injured, by a bullet, shrapnel, a puncture, debris flying around in a hurricane or tornado, or things during a vehicle crash may have wounds you aren't seeing. Sometimes two for the price of one. This is why you "strip and flip"; it's where that "High Index Of Suspicion" comes in. If necessary, it's what those handy paramedic penny-cutting shears are for. Nothing's fine until you've seen it all, by direct eyeball examination. Don't assume; observe. Your eyeballs are a diagnostic tool. So is your brain. Break them out of storage, and put 'em to use.

Worstest firstest.
Tourniquets before dressings, dressings before ACE wraps, ACE wraps before band-aids, band-aids before ice packs. Splints nearly always come after bandages.
The best cure for bleeding isn't IVs or transfusions (which you may not have); it's to keep the blood inside the person it belongs to. Stop the spurting, then the dribbling, then the oozing. The petty crap will clot up on its own before you get there anyways.
Of course, you'll still have to clean it out and let it do that all over again, but if it isn't pumping when you start, it can wait until last.

If you can't see all of it, don't pull it out. 
I've related in the past the story about the Miracle Boy of Sierra Vista: impaled on rebar which punctured through the right ventricle of his heart, which then went on to sever and tamponade the right subclavian artery against his collar bone. Removal of the impaled object would have killed him twice in seconds. Firefighter/paramedics cutting it off utside the body, splinting it carefully in place, and taking him to have it removed in surgery saved his life. There is no exception to this rule. Cut an object off as needed, but if it goes in beyond what you can see, leave it be, and splint it in place. 

If you can't see inside, don't stick anything in but clotting gauze.
Movies are great fun, but you don't shove things, including instruments like hemostats, blindly into holes and "trust the Force" that you'll find what you're fishing for. Way beyond your scope, unless you're a board-certified surgeon, or a disciple of Torquemada and Mengele. Their exploits are not instruction manuals. Clotting gauze, or nothing.
{And for the inevitable questioner, tampons are stupid because: they absorb blood, without stopping the flow, requiring you to pull it (and all that blood you wanted to stay in your patient's circulation) out, ripping any scabs loose, and starting the bleeding again. And don't even get me started on those asinine sponge injectors. Either stop the bleeding with a clotting agent, or use a pressure dressing on the outside. Period. You might find some use for tampons as absorbent packing on a healing wound, but not to "plug" a fresh one; you'll just make external hemorrhage into internal hemorrhage. Repeatedly.} 

Direct pressure, elevation, pressure points, tourniquet. 
Live it, love it, learn it, use it.

If it's spurting, skip to tourniquet. 
Refer to the lesson notes on TCCC; while designed for combat care, the info on tourniquets is the same for anything requiring one.

Distal to proximal. 
Distal to proximal is medicalese for wrapping from the distant part towards the trunk, i.e. fingers towards hand, hand toward shoulders, or toes toward hips, wherever you're wrapping. It stays in place better, and fits neater.

CSM before/after: Circulation, Sensation, Movement.
Bandages and splints are wonderful things. Unless you've cut off pulses without meaning too, and created an impromptu tourniquet. Or something goes numb. Or it hurts worse than the wound itself, untreated. So you check function before your work, then you recheck it after you're done. And then regularly afterwards. If a bandaged limb was warm and bloody, and it's now cold, pale, purple, and tingly, you wrapped something a little too tightly. Re-do it, until you get it right.

And lest I forget:
Dressings are always sterile, and go next to the wound.
Single use. Appropriate disposal. Failing everything else, by burning.

Bandages need only be clean, and can be washed and re-used as needed.
Cut up a set out of an old cotton bedsheet. After you replace that with fresh-packed high-tech stuff, use those as part of your permanent training set. Almost like I've done this before, huh? (Somewhere amidst the flotsam hereabouts is a full set of now 26-year-old cotton-sheet roller bandages, cravats, torso binders, etc., all carefully banded and stored in an old surplus medic bag from circa WWII.) [Oh, and hydrogen peroxide is lousy for wound cleaning, but great for getting blood out of bandages before you launder or boil them for re-use, if that's practical and/or necessary in your situation. Probably also handy for getting blood stains out of the carpet before the authorities arrive, too. Just saying.]


Anonymous said...

Outstanding as ever!
I'll own to presuming tampons would work as a field expedient, thanks for straightening me ( and perhaps others) out.
As ever valuable, hell VITAL basics here.
Thank You
Boat Guy

loren said...

Interesting article. From reading your blog I believe you're an ER nurse. Perhaps filling out your resume a little will also help me evaluate the information you give since I'm not qualified to do so. The internet is full of advice.
A post on pain meds might also be helpful. What to use or not to use and when. Most of us self medicate on a hit or miss basis.

Aesop said...