Wednesday, November 3, 2021

Wilderness First Aid, & Kits Pt. II


If you haven't yet, read the first post in this series, wherein we explore the utility and accuracy of one non-medical adventurer's ideas of field medical care, per an article in Field and Stream.

This one continues where that one left off.

Deep Cuts

Axe injuries or the slip of a knife are the most common ways to get cut in the outdoors—but .not the only way. A deep cut from the teeth of a Northern pike can leave a nasty gash too. Here’s what to do when that kind of accident happens:

  1. Don’t panic. The sight of blood from a deep cut be shocking to everyone; not just the victim. When it’s bad, all involved need to remind themselves to stay calm and follow the steps below.
  2. Immediately apply firm pressure. This should slow the bleeding. 
  3. If you are unable to stop the bleeding by applying firm pressure, affix a tourniquet no less than two inches above the injury.

Um, NO. You skipped quite a few steps.

2a. If firm pressure alone doesn't work, elevate the wound above the level of the heart, if possible. Obviously that can work for extremities, but not so much for torso wounds. With scalp wounds, that takes care of itself.

2b. Instead of using just your grubby boogerhooks, you probably should have already reached for a sterile dressing, and perhaps some of those nifty coagulant dressings, like QuikClot, etc.

2c. Then you want to apply firmer pressure, with bandaging gauze , such as Kerlix, etc., or apply an Ace wrap, or strap a military style battle dressing or one of the new Israeli bandages, and then tighten it down firmly, short of it being a tourniquet.

2d. If it's steady bleeding, but not bright red arterial spurts, and on an extremity, you can apply pressure to pressure points. Any place you can feel a pulse, between the torso and the wound, will work. You're trying to lessen the pressure into and out of the affected area, by using skin pressure to press arteries and veins against a bone or bony prominence deep inside the body. This works on bicep, forearm, wrist, groin, thigh, calf, and foot.

2e. Neither 2d, above, nor #3 below, will do anything for torso, neck, or head injuries. Tourniquets only work for extremities. So you'd better have those dressings, clotting gauze, and long bandages with tails big enough to go around heads and torsos, or tie to neck wounds and anchor at shoulders and armpits, without cutting off oxygen to the lungs, or blood to the brain.

3a. And on tourniquets, the following rules apply, every damned time.

1) Buy quality, from quality suppliers of known pedigree. NOT Chinesium knock-offs for the cheapest Amazon price. Caveat emptor.

2) You have four limbs. You (and everyone in your party, if such is a thing) should have four tourniquets available. Minimum. One, at least, should be ready-to-hand at all times. The rest should be in your kit, pack, etc. Unless you want to play "Which limb am I good without, forever?"

3) Get an identical one for training (or maybe one of the bright orange models), and practice, Practice, PRACTICE, applying it to any and every limb, with your strong hand, your weak hand, and your teeth if needs be, and then do the same on someone else. If you can't use it right, you ain't got it. Daytime, nighttime, rain or shine. It's nice to practice inside, in the daytime. Not so bitchin' to do it in the rain, at night, juggling a flashlight and a writhing casualty. Ask me how I know. Even worse if this is the first time you've ever cracked the package. Don't be That Guy.

4) And, you put a tourniquet on? You marked the casualty with a "T" on their forehead along with the time, right? Because you have at best six hours from there to surgical care, or the limb is going to suffer damage, or be lost entirely. Which is another reason not to be slapping one on unless you have to do it, to stop stop severe bleeding. Which means

5) Evacuation, NOW. Period. You've got Boondocks 911 on SARSAT speed dial of some sort, right?

4. Remove your hand from the wound once the bleeding has slowed. Then clean the wound with sterilized water and/or pour disinfectant on it, such as iodine, rubbing alcohol, or hydrogen peroxide.   

NO! We don't pour rubbing alcohol or hydrogen peroxide on people's wounds unless we hate-Hate-HATE them.

a. They're both simply awful choices for disinfection of open wounds.

b. They hurt like hell.

c. And they don't work very well at all to kill the germs.

d. And if the victim/patient decides to slug you, you've got it coming.

e. The same is true for distilled spirits, and for the same reasons.

If you had time and space to bring rubbing alcohol or hydrogen peroxide, you should have brought betadine and Bactine™. Betadine, or any generic version of povidone-iodine, can and should be cut 50:50 with clean water, and the wound washed out, first with water under some force to dislodge debris, then the water/betadine combo, to kill germs (provided your victim/patient is not allergic to iodine, or shellfish). More is better. Think between a pint (500 ml) and a quart (1L), depending on wound size.

The Bactine is mostly benzalkonium chloride, along with a touch of lidocaine. Benzalkonium chloride (hereafter BZK) is a topical disinfectant which, unlike alcohol or peroxide, doesn't kill live healthy tissue, and hurts a lot less than either for that reason, while killing germs in small wounds almost as well as betadine, and with none of the risks of allergic reaction. And it has the lidocaine, which is exactly what the docs in the ER use to numb your wound before they sew it up. Bactine has less of it, but what there is works just fine for minor wounds.

5. Clean the surrounding area with alcohol wipes.  
6. Dry the area around the wound using a sterile gauze pad.  
7. Close the wound. Stitch the cut with sutures, or close it with Steri-Strips or butterfly sutures. In a pinch? Cut thin strips of duct tape. Make sure that the wound is closed tightly. 

NO! Physician Assistants spend four years in a Master's program, and a goodly portion of that time is spent learning when to close a wound, and when not to. You probably have, lemme see...nothing plus nothing...carry the nothing...

none of that level of training or experience. Not even a fraction, in 99.9999% of cases. 

Closing an infected wound just bought you sepsis, gangrene, and death. What'cha got in your kit for that, Slick?

Were any arteries still bleeding? Do you know how to close those? (NO, you don't.) What about tendons and nerves? Bone fragments? Foreign bodies imbedded? You're trained in emergency, trauma, orthopedic, and neurosurgery, right? (NO, you effing are not.)

Any wound closed after 12 hours is virtually guaranteed to go septic, so DON'T CLOSE THOSE. Ditto for any dirty wounds (all animal and human bites). This is why wounds should be left to drain, rather than create exactly the septic abscess pocket of putresence you'll make by closing a wound that you haven't cleaned, debrided, and treated aseptically and completely, which will be a lot of them.

I get that some people, in some places, (oil rigs, ships at sea, etc.) may have some experience and good luck with closing wounds and not getting burned by disastrous results. if you don't have PA or MD after you're name, or you weren't a twenty-year 18D Special Forces Medical Specialist Sergeant, kindly stay the F--K away from me with your sutures, skin staplers, Krazy Glue™, or any other wild ideas about field wound closure. F*** off with that $#!^. Got it? You're not that guy. 

8. Cover the wound with bandages to keep it clean.  
9. If possible, elevate the wound. If the wound is not severe, keeping it above your heart will reduce swelling and throbbing and will help slow continued bleeding. However, if the wound is severe, keeping continued pressure on the wound is more important than elevation. 
10. If the wound is severe, lay the person flat on their back and elevate both legs. This will help prevent shock.

With this, we are safely out of Jim Baird's clutches with regard to deep cuts. But before we leave, the best thing you can do, is make sure your tetanus (or TDap) booster is up-to-date before you go. Know exactly when you got your last one. Get another one every ten years, at most. Every five isn't bad. If you're going overseas, or going somewhere where you're leaving first world medicine multiple days' evacuation behind, just get a booster anyways. tetanus is a horrible way to die, and preventable by one stick. Just do it.

And if you want to talk antibiotics, the cephalosporin family are your friend with open wounds. Typically an IM shot (think ass dart) of Ancef immediately, and a course of Keflex p.o. (by mouth) multiple times per day, for multiple days after the injury, and finish the entire course. If you haven't consulted with either your doctor before your expedition, or the Altons' Survival Medicine book, or their book on antibiotic therapy, or something equally authoritative, and know exactly how to do this, leave the antibiotics alone, except for topical ones: Neosporin (triple antibiotic ointment), Polysporin (double antibiotic ointment), or Bacitracin (single antibiotic ointment). [The reason for all three is as follows: Some hospitals, ERs, and doctors recommend and use Polysporin, because the missing third ingredient, which is in Neosporin, tends to be the one to which most folks have an allergic reaction, so they leave it out. If you have NO allergies, go with triple. Otherwise, choose appropriately. Do it right, or don't do it at all.] The ointments are for relatively minor wounds, not for giant ones.


Long treks are the main cause of blisters—and they usually form on your heels. Here’s how to prevent getting blisters on your feet:

  1. Boots that are subpar in quality, don’t fit right, or are not broken in will cause blisters quickly. Make sure you have boots that fit you properly and consider getting them heated and stretched for a more custom fit. Leather backpacking boots for long treks—including mountain hunts—will last the longest and provide you with more support over non-leather. But, they’ll take a lot longer to break in. Make sure you wear them around town or on short hikes before heading out on a long, backcountry trek.
2. Wear two pairs of socks. This helps prevent blisters and reduces aggravation of existing blisters because the two socks will rub together, effectively reducing the friction against your skin.

If you're taking a trip that will include extended periods of trekking or portaging, carry a blister kit separate from your main first-aid kit. 

What to Keep in a Blister Kit

  • Moleskin YES
  • Blister Foam NO
  • Orthopedic Felt NO
  • Duct Tape MAYBE
  • Surgical Tape YES
  • Krazy Glue NO
  • Small Scissors YES
  • Gel Toe Sleeves OPTIONAL
  • Scalpel, Pin, or Needle (for popping a blister) YES
  • Ibuprofen YES

How to Treat a Blister in the Backcountry

  1. As soon as you feel a blister coming on, stop and deal with it. Stick moleskin or foam over the blistered area on your heel and cover it with tape. Or, line the bottom of your feet with duct tape if the blistering is happening on the bottom of your feet. 
  2. If the blistering worsens, the blister will pop from the pressure in your boots. Cut off the dead skin and disinfect the blister.

So far, so good.

Next, use Krazy Glue to attach the dead skin directly back onto the blister, and cover with moleskin, blister foam, and/or tape. 

No. Throw away the dead skin. It's just a magnet for bacteria to infect the wound. Pad the blister with a small dressing. Betadine, Bactine, or Neosporin, like any other open wound, which is what you (or circumstances) created when the blister popped. Secure with sturdy first aid tape, and change daily.

3. If the pain gets really bad, and the blisters area begins to swell, take ibuprofen and continue to change the bandages daily. Wash with soap and boiled water, or use another means to disinfect the blister. A thick layer of foam will provide the most relief and covering it with duct tape will reduce painful friction on your heel.

Actually, if you're walking on it, the padding will fail, and the duct tape will rip good skin from around the wound. If you want to put a donut of moleskin around the blister, possibly in layers, and then put first aid tape (or even duct tape) over all of that, we'd be fine with it. Spenco Second Skin is even better for blisters (it's like adhesive snot that pads them) than moleskin.

And for any tape you apply, be careful you don't make a new friction hot spot, to rub a new blister in a new place.

The advice to wear two layers of socks, and break in your boots (and your feet!) long before you set of on a hike with a load is the best advice of all. Prevention beats treatment, by ounces to pounds.

Thus endeth Part the Second.

Part the Third follows, tomorrow. Along with kit recommendations.


  1. All good stuff, thank you!

    I believe that I am qualified to offer a bit of clarification/amplification on blister avoidance/care. (From months of walking 15-20 mi per day with a 20 lb pack along the Camino de Santiago.)

    "Surgical tape"... I would refine to medical "Paper Tape" used for frequent dressing changes so folks don't get the heavy crap which balls up and comes lose after the feet start sweating. This also lowers irritation risk for those who have adhesive allergies.

    I would advise folks to use said tape to wrap fleshy toe pads every morning before setting out. Aside from heels, that is where I have had to tend the messiest blisters on the inexperienced.

    Next? A small tube of Vaseline is really useful. An aspirin-sized dollop worked into the sole, sides, heels, and between toes (after taping!)is an extra layer of lubrication to reduce friction.

    Finally, I always use merino liner socks for the first layer on feet with a heavier merino sock over that. (That setup is exactly what I wear to evaluate boot "feel" when I buy.) They wick moisture well, wash easily, and dry quickly. (Though the heavy socks may need hanging off the pack for a bit of the next day's walk to dry completely.)

    And, no, the Vaseline does not "gum up" your socks. Trust a guy who had to hand-wash socks every night. I have also used some of the skin-slickeners favored by the cycling community but have had uneven results.

    That is all,

    Da Perfessor

  2. A generally strong treatment of the subject.

    15+ year Wound Specialist MD here.

    The important part of antibiotic ointment, is the OINTMENT. Not the antibiotic. Just forget neosporin, whether you are allergic or not. The other guy may be. Or either or both of you may become to be, with exposure. Then it will look infected, and prompt other useless measures, because you haven't looked at wounds full time for 20 years.

  3. Actually, Doc, I'm keeping the Neosporin, only because I know I'm not allergic to it.
    But if I don't know that for The Other Guy, and he doesn't know either, he's not getting it.
    's why my ED (and every one I've ever worked it) only uses bacitracin, or generic polysporin.

  4. Thank you.

    This article is helpful to me.

    Please keep writing more of them!

  5. Thanks for this guide/review. It is very helpful.

  6. aesop

    the information in your articles pretty much summed up everything i learned in corps school and in the fleet.

  7. moleskin should be cut out to keep the irritated skin from touching the boot. even two or three layers if necessary

  8. I have had good results with KT tape for hot spots. It’s easier to trim than moleskin, and it’s got other uses too.

  9. I knew it would not take too long for ol' Aesop to go over the edge.

    Let me see. When I am back packing in the boonies, I need to have a minimum of four (4) tourniquets. If I am with others, I need four (4) more for each of my compadres. Then, I need between a pint and a quart of betadine or bactine...for each wound. So, I need, just for myself, between a half gallon to a gallon of betadine, plus moleskin, quickclot, israeli bandages, and so on, and so on, and so on. Do I still need the specula from one of his past articles?

    Tell me, Aesop, since I am an idiot. If I am prepared in the way you think I ought to be, where/how will I carry food and water? What about clothing, a tent, a sleeping bag (and maybe a pad)? Should I also have anything with which to arm/defend myself?

    And WTF do I do to ensure that I am properly outfitted for my sherpas who will need, again, 4 tourniquets, a gallon or so of betadine, food, water, clothing, shelter, arms, etc...EACH!! 'Cause I sure as hell cannot carry all the shit your fevered imagination can conjure up with all by myself.

    If I have a mule train, what should I add? What should I leave out?

    Fucking "experts!" Spend more time yapping about their fetishes than giving solid advice.

    Here is solid advice. First, learn how to improvise a tourniquet. then carry only one "real, quality, non-chinesium" tourniquet. If you have to use it, make plans to get back to civilization. If you need more than one, make plans to die. Here is another bit of solid advice. Keep that little bottle of iodine pills for treating water in your pack. If you need a gallon of Betadine or whatever, use lots more of those little pills with the water you have. You can wash your wound with it. Since it does not kill living flesh, you'll be ok. And since the rest of your flesh will die if you don't get your wound treated in the ER, you can suck up a few hours of minor dehydration if you can no longer treat water during the (possibly)last few hours of your life.

    If you have wounds that need tourniquets, you only have so many hours to get real help. I suspect you don't have to worry so much about sepsis as you do getting your ass out of the boonies and into the back of a car on the way to actual medical help.

    Aesop. You need to differentiate between the stuff that actually helps people, and your "verbal selfies."

    Arrogance and ignorance are not happy combinations. Your "expertise" becomes ignorance if you are incapable of looking beyond it to see other factors in play.

    You are just like Dr. Fauci, who is a medical"Public Health" expert, and does not see "Liberty" or "Constitutional Rights" as relevant to the situation.

  10. The stupid, it burns us.

    1) You should have as many tourniquets as you have limbs you want to keep. I'll let you sort that answer out for yourself. When you come up short of the wherewithal to save a limb, enjoy your perspicacity, as we will.

    2) If your are with others, tell them to carry their own f**king tourniquets, unless you have assumed the mantel of medical care for the entire group. In which case, they should still carry their own set of f**king tourniquets. I'm assuming any of you can manage the 8 ounces of gear that would entail without needing oxygen as well.

    3) If you wish to carry pints and quarts of betadine and Bactine, that's your problem. Given that you're not bright enough to excerpt the section where I never suggested anything of the sort, let me help you out: all sorts of stores, not to mention Amazon, sells all sorts of nifty little 1 and 2 ounce bottles, suitable for both fluids. And betadine even helpfully comes impregnated in little gauze squares. if you were bright enough to suss that out, you could pack maybe 4 such little squares in an IFAK, and maybe twice that in an M-3 or M-17 kit, and be well able to handle damned near anything you're likely to stumble into. This weight would amount to about an ounce. For reference, there are eight of those in a pint, and sixteen of them in a quart. If anyone is such a fuckup that they figure they'd go through that much first aid product, maybe they should stay home behind the keyboard. A first aid kit is clearly kicking their ass.

    4) Moleskin would be a single sheet. That's another whole 1/2 ounce. Quick Clot: maybe 2 ounces. An IBD: maybe 4 ounces. We're still not up to even a pound, for something that will save a trip, and your life.

    5) We take you at you're word. Since you're an idiot, we assume you'll forget the food and water, along with the first aid kit, and simply rely on SAR to bring the body bag for your idiot ass when you wander off the pavement in pure HUTA mode, pretty much the same way you wandered into this post, and die in any one of twelve to two hundred predictable ways. Since you asked.

    6) If you're going to need to defend yourself, start by bringing your wits. You're clearly woefully under-supplied with those, and you haven't even left the internet yet. If fitting a minimal wilderness first aid kit is going to break your back, considering it's one of the f**king Ten Essentials going back half a century and more, maybe mommy's basement isn't ready for you to leave the nest yet.

    7) Your weakness of back and feebleness of mind are your problem, not mine. IFAKs and CLS kits, containing what I outlined, are and have been routinely carried by those going out to play in the military for decades, and few if any found themselves felled by the load of their first aid equipment.

  11. (cont.)
    8) Improvise a tourniquet above the tree line, on the plains, amidst a desert, or on a pleasure craft at sea or on a large body of water. Not everyone goes for a jaunt in Central Park. Your suggestion to improvise something which may not be possible shows you're too short for this ride, and haven't given the matter the thought of even a middling competent jackass. I hope we weren't too obscure with that explanation.

    9) "Make plans to die": we see you've already got that well in hand. And have never heard of someone injuring, say, both legs at the same time, because the concept that any number of things, like a good fall, or an encounter with an obnoxious animal, might have overwhelmed your idiotic plans. Darwinian selection awaits your level of intelligence, licking its chops.

    10) More iodine pills don't make betadine. This is evidently news to you. Like so many things.

    11) If you have wounds that need tourniquets and you cleverly don't have them, don't worry about the ER. You'll be dead in minutes. Your buddies can split your gear. The idea that some people might survive for several hours, and thus you might live long enough therefore to get to definitive care, never entered your tiny mind. Once again, like so many other things.

    12) Jackass: You need to differentiate between how bright you sound in your own head, versus how jackassically stupid you sound on this topic in front of the whole Internet, before God and everybody, and in way over your head on such a basic topic. Whatever you do, don't quit your day job. The world needs people who can shovel shit and dig ditches too.

    13) "Arrogance and ignorance are not happy combinations." As we see in just your bravely anonymous post. We defer to your obvious expertise in both areas.

    14) My sincere thanks for you for having the almost-guts to post here, and making untold thousands of people feel immeasurably smarter, just by the fact of your existence. You are the kind of sideshow freak input that keeps shows like Dr. Laura, Dr. Phil, and countless other reality dramedy programs well supplied with viewers and listeners, because everyone feels tons better after they measure even their own mediocre competence, at anything, next to your manifest incompetence at this most basic of tasks.

    This is why every king keeps a Fool handy at the foot of the throne.
    Wear your parti-colored tights and jangly hat with pride, Anonymous Moron!
    If we miss our guess, and you're not Glen Filthie or one of the other Usual Suspects trying to sneak in here under the radar, we commend to you the online ancestry sites: you have a brother from another mother, and we're pretty sure your family tree doesn't fork.