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:

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.

Immediately apply firm pressure. This should slow the bleeding. 

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...

...exactly 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.

Blisters

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
• Alcohol Wipes ONLY TO DISINFECT SCISSORS, ETC., NOT WOUNDS
• 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.