Monday, November 9, 2020

Monday Medical: Wound Care

So you've got a wound to deal with; yours, or someone else's.

In order:

Expose the wound(s). Find them all. ALL of them.

Get all the clothes, debris, dirt, blood, etc. out of and away from it.
If you have to cut or rip clothes, do it now, and do it fast.
Strip 'em and flip 'em is the rule to follow.
These all work for that:

If they aren't in life-threatening danger, and you're not a dick, you can cut along seams, and through laces preferentially. Laces can be replaced cheaper than boot leather, and cutting on/along seams lets them sew a garment back to being intact with a lot less trouble.
Which might be a consideration if clothes and sewing machines are hard to come by.
If they are or could potentially be bleeding out, BE A DICK.
Tell them I said it was okay. 

Leave impaled objects where they are.

If there are objects impaled further into the wound than you can see, leave them alone.
November 14, 1990
TUCSON(AP) — An 8-year-old boy was listed in critical condition today after surgeons unscrewed a steel rod that pierced his body when he fell from a roof.
"He probably just thinks this is kind of a slight inconvenience in his life," trauma surgeon Dr. Michael Esser said of Justin Stiner, who asked for some ice and wanted to play Nintendo on Tuesday after waking up from surgery.
The 4-foot-long, 1/2-inch-thick threaded bar used to reinforce concrete was literally unscrewed from the boy's neck and torso Monday in a 2 1/2-hour operation at University Medical Center. Eighteen inches of the rod had penetrated his body.
Esser said that the heart wounds should heal fully and that, although the boy's severed jugular vein was tied off, other veins can provide the needed circulation. The jugular vein carries blood back from the head to the heart.  
The 4-foot-10, 86-pound third-grader from Sierra Vista fell onto the rod while playing with friends on the roof of a house Monday morning. He was suspended two feet off the ground for about 20 minutes, alert the whole time, while paramedics cut the rod, which pierced him just below the breastbone.
Justin, who was taken the 80 miles from Sierra Vista to Tucson by helicopter, neither panicked nor screamed, and on arrival "wanted to know if I was going to remove it. He was very cooperative," Dr. Phillip Richemont said.
Richemont said surgeons were stunned to find that the rod had pierced the heart in two places and divided the jugular vein. "But yet it didn't bleed. It's amazing," Richemont said.
During the operation, the heart seemingly "contracted down between the threads," cutting off bleeding, Richemont said.

The rod was a piece of rebar that he fell onto from his garden shed roof; grandma used it as a stake to coil the garden hose around. After penetrating into and out of the right ventricle of his heart, the rod severed the external jugular (IIRC) and then pinned it against his right clavicle. If it had been moved at all, he would have died from either wound. The paramedics on scene hand-sawed it off , packed it, and transported him to the hospital with it in place. He's 38 years old now instead of dead in his grandma's garden because of that move.

The piece of whatever impaled into the globe of an injured eye may be the only thing keeping the aqueous humor inside the globe. If someone is blind, you won't fix that, but if they aren't, you might create the problem. Leave things alone you can't fix. Splint them so they don't move or cause additional problems.

Clean and disinfect the wound(s).

The solution to pollution is dilution.
Which is a med school canard that means "irrigate all wounds until they bleed saline solution".
Clean tap water is your second choice for superficial wounds.
And the only way to get something clean is to get something else dirty.
True with cars, houses, and patients.  Saline, gauze, rags, etc. will be consumed out of all proportion to the wound. Get over it, and get it done.

For deep wounds, a solution of half sterile saline, and half povidone iodine {Betadine™}solution (not Scrub, which is a stronger and harsher liquid form) gets squirted under plunger pressure from a syringe (5-20cc) into the wound. Splash shields and safety goggles are your friend here, unless you want a faceful of bloody (or something worse, think abdominal wounds) backsplatter.
One blast isn't nearly enough. Keep going, then irrigate with just saline, then repeat, then repeat, then repeat, until you're sure you've gotten everything foreign out.

You can also do this with superficial injuries.

For small stuff, like cuts and scrapes, Bactine[tm] has both BZK (benzylkonium chloride, a relatively harmless disinfectant) and a small amount of lidocaine (which numbs pain).
Use it.
Not isopropyl alcohol, which is flammable, and only for sterilizing instruments.
Not hydrogen peroxide, which is only for getting blood out of clothes, carpet, and fabrics, not cleansing wounds. (Like moving a body before the cops get there, and tidying up...)
Both of the latter also burn like hell in fresh wounds, because they're killing healthy vital tissue, and they don't work well. Using them anyways may get you socked by your patient.
Or their lawyer.
After Bactine, clean tap water, or water you've made sterile by boiling (and cooling, please) is okay.

Water from the ocean, lake, river, stream, pond, or from your or the patient's canteen that's been backwashed in, absolutely not.

We either use sterile solutions, or holy water on wounds.
Holy water? How do I make holy water?
You boil the Hell out of it.

Stop serious bleeding.

Direct pressure.
Direct pressure and elevation.
Tourniquet (TQ).
Pressure points.
In that order, unless you're under fire (in which case, you use the TQ now, get back in the fight, then go back and re-address things after the shooting stops.)

Nota bene: And for deep bleeding wounds, esp. of the torso, this is what that Combat Gauze was made for: as an internal instant scab over large bleeding wounds (assuming you're evacuating your patient to higher care, where someone can surgically repair what you're putting a temporary packing against, which will be removed at a Battalion Aid Station or equivalent, or else in an OR). If that higher level of care is not an option, because Zombpocalypse, Combat Gauze just means they'll die from infection in a couple of days, instead of massive hemorrhage now.
Your call in that case. Just remember, death is final, either way.

Apply Magic Spackle.

By which, I mean products purposely made to keep wounds clean. And help kill germs.
Neosporin (triple antibiotic).
Polysporin (double antibiotic).
Bacitracin (single antibiotic).
Burn gel (for burns, if you have that).

Most of what's in these (like 98% for the first three) is just sterile petroleum jelly, to hold the antibiotic components (the other 2% or so) in stasis where you want them, next to the open wound.

If it doesn't have FDA drug information on it, the answer is generally "No."
In some cases, "F**k NO!"

("But can't you put honey on cuts? I read this outdoors nature manual where Sumdood from the Discovery Channel wrote...")
Yes, honey can work. It also works to attract bees. Flies. Ants. Cockroaches. Etc. While providing a potential growth medium for new bacteria, and sticking them and anything else next to the wound. And getting bloody honey onto everyone and everything nearby.
Save your honey for hypoglycemia patients, or your buttered rolls, unless you have no other choices.

Save also your butter, Crisco, and any other concoction of cat piss, dog shit, and sourdough batter you got from your mom/granny/crazy aunt/some witch in the woods. Dumber than hell, and probably not a good idea, plus someone else will have to traumatize the patient later by scraping all that happy horseshit off again, somewhere down the medical pipeline. Neither patient nor practitioner will thank you for your misguided efforts at that point.

If the Zompocalypse has already occurred, you're on your own; use your best judgment. Starting with some judgment, sil vous plait.

And once a wound scabs over and seals in a few days, topical goo is pointless.

Dress the wound(s).

Sterile dressings, completely covering the injury.
Non-stick, if appropriate.
Absorbent and multi-layered, if appropriate.
Occlusive to air, if appropriate.
This is where your variety of bandaids, 2x2s, 3x3s, 4x4s, ABDs, and multi-trauma dressings will kick in.

Bandage the wound(s).

A dressing protects the wound; a bandage secures the dressing(s). Dressings therefore, must be sterile, because they're going on open wounds. Bandages only have to be clean.
Sterile is nice, but you can, for example, wash bandages that have gotten soiled, bloody, or dirty, and reapply them once they're dry.
Dressings get burned or red-bagged afterwards; they're single-use.
Plain gauze, Kerlix fluff, Kling/Coban/vet wrap, ACE wrap. Or even cut-up sheets in rolls.

Nota bene that old-school field dressings and new Israeli bandages in all flavors are both dressings and bandages. Less flexibility, but less bulk, and handier if you aren't the medic, nor carrying the well-stocked aid bag.

Secure the bandage(s).

Tape gauze so it doesn't unroll. Tape metal Ace bandage clips so they don't pop out (or get the cool ones with Velcro tips). Make things fit, and stay put, despite the patient walking, being carried, put on a helicopter, or just sitting out on a windy spot.

Wounds get dressed and bandaged before splints go on broken limbs.

Dressings get changed daily, and whenever soiled. Note that "soiled" means "funky from the outside dirt, water, and other contaminants". The stuff draining from the wound inside is why you change them daily anyways - unless we're talking dressings that are saturated suppurating puss buckets. In which case you have bigger problems than dressing changes.

There are a host of special application dressings and bandaging, many of which protect skin by not having you rip and replace adhesives daily. These can be learned from the appropriate chapter of a decent comprehensive textbook of nursing care, for instance this one ($25-80 on Amazon):
You can also download the 1957 Army Field Manual on Bandaging and Splinting for free, here.

Smartest would be to acquire both.

One way or another, you will see this material again.


RandyGC said...

I'm getting a "Page Not found" when clicking on the referenced Field Manual

Robin Datta said...

One of the classic books for dealing with this aspect of patients is Pye's Surgigal Handicraft which first appeared in the late 1800s and was updaed until the late 1900s. Varius editions in pdf and other downloadable formats are lurking on the web at various places, and even thiis 1893 edition has numerous nuggets of wisdom. Hardcopies can still be found at online booksellers and bookfinders. An subsidiary is one among such places.

catfish said...

Your FM link was dead apparently. The FM can be found here:
Thanks for the info. Keep up the Good Work.
Semper Fi

Robin Datta said...

This one's a functioning link to a 1950s edition of the US Army Field Manual FM 8-50 Bandaging and Splinting.

Borepatch said...

This is really useful. Can you add an appropriate tag (like "SHTF First Aid") then folks like me can link to it. This needs wider distribution.

docfromjerusalem said...

Until you print your manual for sale, would you make the posts available for easy downloads. Might I add that frequent change of dressing and bandaging and debridement are part of the healing process as are oral or iv antibiotics as necessary. Re-mentioning of the need for Dtp[tetanus prevention] is recommended.

Aesop said...

Thanks for spotting the dead link.
I updated it with the new one Robin provided.
That's what I get when I'm posting between shifts.

Cj said...

I’d like to hear your thoughts on an expired Israeli Battle Dressing, still in the package. Toss it, iris it still useful, or use it for training purposes only?

Aesop said...

What is it that's supposed to have expired?
Elastic may become less stretchy over time, but if it's still sealed, a bandage is a bandage is a bandage.

Most expiration dates on items, like a lot of packaging instructions, are a scam to get you to buy more.
Hence the famous words: "Lather. Rinse. Repeat."

If someone can explain what it is that suddenly doesn't work on a given day, I'd like to hear it.

Reltney McFee said...

Could it be akin to the sterile supply outdates?

Places that I have worked, if the wrapper was intact, and had stayed dry, it was serviceable.

John Galt said...

Aesop, These Medical Mondays are medical gold. I have read, re-read, studied, made notes, and stocked my kit accordingly. I thank you for all this FREE, amazing knowledge and wisdom. If you would consider adding more posts, you have here an eager audience, if you put it behind a paywall I will gladly pay your fee.