By Dr. Bones and Nurse Amy
January 24, 2013
Although we focus on long term survival situations, many of our strategies will be useful on a long hike or camping trip. During a wilderness outing, it stands to reason that you won’t have ready access to modern medical care. As such, it makes sense to have some idea of how to deal with the occasional wound that might occur. This is a skill set that few rugged outdoorsmen bother to learn; even though you might have extensive experience in bushcraft, it is essential to know basic first aid and have some medical supplies in your pack.
Although your basic goal is to stabilize your victim and transport to the nearest emergency facility, there might be circumstances where you will have to administer wound care for a period of time. In the past, we discussed methods of wound closure, and when a wound should be left open. Let’s talk about the appropriate way to care for certain injuries when you are, temporarily, the end of the line with regards to your patient’s well-being.
Millions of people present to U.S. emergency rooms with an acute injury every year. The typical patient in wilderness settings would be a healthy young adult male who sustains a laceration in either the arm, leg or head and neck. This is a fortunate statistic, in that this person has a strong immune system, no chronic ailments, and is well-nourished. Despite this, the best outcomes will occur with rapid action from an individual with some medical knowledge. Let’s share some of that knowledge today.
Each wound is different and must be evaluated separately. If not present at the time the wound is incurred, begin by asking the simple question, “What happened?”. A look around at the site of the accident will give you an idea of what type of debris you might find in the wound and the likelihood of infection (always assume a wound is dirty initially). Other questions to ask are whether the victim has chronic medical problems, like diabetes, and whether they are allergic to any medications. You might be surprised to find that (even close) friends may have not imparted this history to you in all the time that you’ve known them.
The physical examination of a wound requires the following assessment: Location on the body, length, depth, and the type of tissue involved. Circulation and Nerve involvement must also be evaluated. If an extremity, have the patient show you a full range of motion during your examination. This is especially important if the injury involves a joint. Don’t forget the rest of the patient also: Are they breathing normally, are they mentally alert, and are there other injuries? Don’t be surprised to find an elevated pulse rate right after an injury. This person is going to be agitated, and heart rates surpassing 100 beats per minute will be common right after the incident.
Typical Deep Laceration
A little knowledge of anatomy will help you understand the nature of the wound and what should be done to care for it. The skin is comprised of two layers: The (superficial) epidermis and the (deep) dermis. If the injury goes down to but doesn’t breach the dermis, it is called an abrasion. If it breaches the dermis, we refer to it as a laceration and is more serious. In cases where a flap of tissue has been traumatically removed, it is known as an avulsion. In most areas of the body, below the dermis you will find a layer of subcutaneous fat; below that, muscle and connective tissue (also known as fascia) and, finally, bone.
Your skin is, essentially, a suit of armor. Whenever the skin is entered, infection can easily follow. A wound that extends more deeply will require a close look to see what layers have been damaged. Subcutaneous fat will appear yellow, and muscle will appear a dark red (think steak). Connective tissue is usually grayish white.
Once below the level of the skin, larger blood vessels and nerves may be involved. Assess circulation, sensation, and the ability to move the injured area. You will notice more problems with vessel and nerve damage in deep lacerations and crush injuries. For an extremity injury, evaluate what we call the Capillary Refill Time to test for circulation. To do this, press the nail bed or finger/toe pad; in a person with normal circulation, this area will turn white when you release pressure and then return to a normal color within 2 seconds. If it takes longer or the fingertips are blue, you may have a person who has damaged a blood vessel. If motor function or sensation is decreased (test by lightly pricking with a safety pin beyond the level of the wound), there may be nerve damage. These are signals that your patient will require acute care as soon as possible. We have discussed how to deal with a hemorrhagic wound on this website before, so let’s assume there isn’t much bleeding for now.
In order to fully assess a wound and prevent infection, it is important to clean the wound area thoroughly. Inflammation, infection, or residual debris may delay (or even prevent) adequate healing. Antiseptic solutions such as betadine (povidone-iodine) solution may be helpful if very dilute, but studies have shown that drinkable (sterilized) water is just as good or better. When I say this, I am not referring to a water bottle you already drank from; that water has millions of your mouth bacteria in it.
Hydrogen Peroxide has been put forth as an option, but is traumatic to deep tissues and may impede the healing process. This is especially true when cleaning a burn injury. Remember, if the irrigation solution is not sterilized, you can easily introduce bacteria, even into a clean wound. Remember that your hands can be a source of contamination, so have some nitrile gloves in your kit.
It is important to apply pressure to the water when cleaning the wound. This is referred to as “irrigation”. Using a 60cc syringe to achieve this pressure will cause bacteria that is adherent to the tissues to dislodge. All wound surfaces should be irrigated; pull the wound edges open if necessary to reach the deepest layers. Repeat this procedure and re-examine for remaining debris until clean. If no syringe is available, apply a wet, clean compress using gauze or cloth. The soaking will help rehydrate the wound and improve healing. Many recommend a plastic bag with holes in it to irrigate a wound, but it is likely that you will not achieve an appropriate pressure (say, 12 PSI) using this method.
Debris is both a focal point for infection and may contain toxins that further damage the tissues. A contaminated injury that is not completely cleaned is dangerous to close. Take the example of the young woman in Georgia that was injured in a zipline accident: Her wound was closed with 22 staples and an infection developed in the deep tissues that eventually cost her a leg. This might have occurred due to poor wound cleaning or failing to close “dead space” in the wound. Dead space is a pocket of air or inflammatory fluid that accumulates in the wound. This area is laden with bacteria if not properly cleaned and closed prior to closing the skin.
Dead Space (image A) Dead Space Closed (image B)
The time period from injury to wound evaluation is important if you have the skill to close a wound. 8 hours is considered appropriate for laceration repair (discussed in previous articles), a little longer for the face and scalp. However, lean towards keeping the wound open, especially if you can get your patient to a modern medical facility. Healing occurs in most cases of open wounds as long as the wound is kept moist and clean. This type of healing is known as “granulation” or “second intention”.
Wound Healing by Granulation
Once you have cleaned and irrigated the wound, apply a moist, clean dressing to the tissues directly injured and cover with a dry dressing and tape. This is known as a “wet-to-dry” dressing. A moist healing environment will help prevent cell dehydration and death and promote the development of better circulation in the wound. Moisture also reduces pain and leads to a better cosmetic result. Compression dressings such as the Israeli Battle Dressing are useful for bleeding wounds, but unnecessary for wounds that are hemostatic (dry). Triple antibiotic may be useful on the skin edges and is thought by many to promote skin healing.
Dressing changes should be done at least daily until you are able to access professional care. Each time a dressing is changed, note the status of the tissues. Infection can often be seen on the skin edges in the form of redness, swelling, and heat. This is known as “cellulitis” and must be considered a risk for spread of infection to the entire body (“sepsis”). The presence of pus in the wound is another sign that trouble is ahead. Infections rates differ depending on the part of the body affected; scalp wounds get infected only 2% of the time, while thigh/leg injuries get into trouble in more than 20% of cases. Regardless, treat every wound as if you are dealing with a potential problem.
Many of these injuries may be candidates for antibiotic therapy. Based on how contaminated the wound is, the decision to use antibiotics should be made early, usually within 3-6 hours after the injury was incurred. The deeper the injury, the more you should lean towards starting therapy. Wounds that are most likely to be infected are animal bites or those lacerations contaminated with feces, saliva, or other bodily secretions. If you intend to be out in the wilderness for a period of time, make sure that you include some antibiotics in your medical supplies.
Speaking of medical supplies, what are some medical supplies that a wilderness traveler should carry? Here are some suggestions for the minimum you should have:
- Dressings (roller gauze, sterile gauze, triangular bandages, Combine pads, eye pads, Israeli battle dressings)
- Non-adherent dressings (Telfa pads for burns, Moleskin for blisters)
- Antiseptic solution/wipes (alcohol, BZK, Betadine)
- Sterilizing tablets or other ways to sterilize water
- 60cc or 100cc irrigation syringe
- Nitrile gloves
- Triple antibiotic ointment
- Ibuprofen (Advil) or Acetaminophen (Tylenol) and other OTC meds
- EMT shears (bandage scissors) – to cut clothes away from the injured area
- Adhesive Bandages (Band-Aids or, alternatively, Second Skin)
- Tape (Duct tape will do in a pinch)
- Solar blanket
- Light source
- Splint material (SAM and other splints come in a 36 inch roll you can cut to fit your needs
Being prepared to deal with injuries and other medical issues on your wilderness outing will make sure that they will be just a bump in the road and not the END of the road for the people in your party.