Caring For Wounds In The Field

The picturesque secluded lake offers an abundant source of fresh fish. As you engage in cleaning your catch, a brief lapse in concentration results in the knife inadvertently slipping, causing a deep gash on your leg.

After successfully stopping the bleeding with applied pressure, the next steps become crucial. Where is the medical kit containing essential instruments? When was the last time you verified their sterility? The whereabouts of the emergency medicine guide and the precise technique for sutures become pressing concerns.

Dealing with wounds in the field

There exists a widespread misconception that the closure of wounds is imperative for the healing process. Wilderness medicine literature typically dedicates sections to suturing techniques and equipment, outlining recommended instruments, suture materials, and stitching methods.

Regrettably, these resources often omit the crucial fact that suturing is a skill that requires acquisition and is particularly challenging when self-administered. Furthermore, those contemplating suturing every laceration or wound in remote settings must also familiarize themselves with the identifying signs of various wildlife, such as clostridium tetani (tetanus), clostridium perfringens (gas gangrene), staphylococcus, streptococcus, and pseudomonas.

Overlooking the effects of these bacteria settling in can result in more than one can handle, posing a considerable risk.

Below are brief descriptions of the effects of infection with each of the aforementioned bacteria:

Clostridium tetani (Tetanus)

Effects: Tetanus bacteria produce a potent toxin that affects the nervous system. Symptoms include muscle stiffness, spasms, and difficulty swallowing.

End Result: Without prompt and appropriate medical intervention, tetanus infection can lead to severe complications, including respiratory failure and death.

Clostridium perfringens (Gas Gangrene)

Effects: This bacterium is associated with gas gangrene, a condition where the bacteria release toxins and cause tissue destruction. Symptoms include severe pain, swelling, and the production of gas within the tissues.

End Result: Gas gangrene can progress rapidly and may lead to widespread tissue damage, organ failure, and potentially fatal systemic infection.

Staphylococcus

Effects: Staphylococcus infections can range from minor skin infections to more serious conditions such as pneumonia, bloodstream infections, and toxic shock syndrome.

End Result: If left untreated, severe staph infections can lead to systemic complications, organ damage, and, in some cases, death.

Streptococcus:

Effects: Streptococcal infections can cause various illnesses, including strep throat, skin infections, and more severe conditions like necrotizing fasciitis (flesh-eating disease) and streptococcal toxic shock syndrome.

End Result: Invasive streptococcal infections can lead to rapid and severe tissue damage, systemic toxicity, and life-threatening complications.

Pseudomonas

Effects: Pseudomonas aeruginosa can cause infections in wounds, the urinary tract, and the respiratory system. It is known for its resistance to many antibiotics.

End Result: Infections with Pseudomonas can lead to chronic and challenging-to-treat conditions, potentially resulting in organ failure and a higher risk of mortality, especially in immunocompromised individuals.

It’s also important to mention that the severity of the effects and the end result can vary depending on factors such as the individual’s overall health, the specific strain of the bacteria, and the promptness of medical intervention. In any case, timely and appropriate medical care is crucial when dealing with these potentially dangerous infections.

Identifying a Contaminated Wound: A Surgical Perspective

Surgeons categorize wounds into four distinct classes: clean, clean-contaminated, contaminated, and dirty/infected. These classifications are based on the anticipated level of bacterial contamination present in the wound.

The first two categories are typically associated with hospital settings. A clean wound is characterized by the deliberate opening of prepared (cleansed) skin in a controlled manner without entering internal organs. An example of this is a hernia repair. Clean-contaminated wounds also occur in operating rooms, where internal organs are operated upon under controlled conditions, often with the use of antibiotics. An appendectomy serves as an illustrative example.

Contaminated wounds involve open traumatic injuries or surgeries with bacterial contamination originating from internal organs. For instance, slashing your hand with a knife previously used for cleaning fish or game exemplifies the former scenario.

Dirty and infected wounds encompass dead tissue, pus, foreign materials (e.g., wood, grass), gross contamination (e.g., dirt, manure), or wounds that have received no treatment within the initial hours post-injury but have been exposed to contamination.

This classification system proves valuable as it helps predict the likelihood of an injured area developing an infection. Infection rates by classification are as follows:

• Clean: 1.5-3.9%
• Clean-contaminated: 3.0-4.0%
• Contaminated: 8.5%
• Dirty wounds: 28-40%

It’s evident that the dirtier your wound, the higher the likelihood of subsequent infection. This risk is particularly pronounced if you decide to suture the wound, thereby sealing the contamination within. Within the confines of a warm, enclosed space, bacteria thrive on bloodied, injured tissue, multiplying rapidly.

Employing chemical means, these bacteria can extend into the surrounding healthy tissues, resulting in an infected wound characterized by redness and the drainage of pus. In cases where drainage is absent, the bacteria may traverse tissue planes, leading to fasciitis—commonly known as the flesh-eating disease—or disseminate throughout the entire body, culminating in a potentially fatal infection.

With proper cleansing and the administration of antibiotics, a contaminated wound can often be closed without succumbing to infection. However, even in hospital settings, surgeons typically opt to leave initially dirty wounds open. This approach facilitates the drainage of fluid and bacteria from the wound, allowing antibiotics to effectively combat the invading bacteria. After multiple rounds of cleansing and antibiotic treatment, closure can be achieved with minimal risk of infection.

Caring for wounds within six hours

The following recommendations outline the treatment of a wound when access to medical care is limited and are based on a fundamental question: Can you reach qualified medical assistance within six hours?

If the answer is affirmative, the suggested course of action includes:

1. a) Stop the bleeding by applying pressure to the wound.
2. b) After halting the bleeding, delicately remove any noticeable debris, such as wood particles and rocks. Exercise caution to avoid triggering renewed bleeding. Recognize that the affected area may be highly sensitive, so prioritize comfort for yourself and any injured companions. If local anesthetics are available in your medical kit, use them at this stage. Administer through injection or by dripping into the wound. Once the site is slightly numbed, saturate a gauze with the remaining anesthetic and place it in the wound. After a few minutes, the wound will become less painful and more amenable to cleaning.
3. c) Insert a sterile gauze or clean cloth into the wound and wrap the area with gauze or an ace wrap. If the wound is near a joint, make an effort to immobilize the joint to minimize further bleeding and alleviate pain.
4. d) Promptly transport the individual to a hospital. Reserve antibiotic usage for extended journeys. Hospital staff will likely sample the wound for bacteria and prescribe appropriate antibiotics. If antibiotics are necessary for a prolonged transport and are on hand, consider cephalexin or ciprofloxacin.
5. e) If blood loss is minimal and the person is not experiencing nausea, administer pain medication for the duration of the journey.

Caring for wounds over six hours

In situations where reaching medical care within six hours is impractical or in extremely remote areas, follow these guidelines:

1. a) Stop bleeding by applying pressure to the wound.
2. b) After halting bleeding, cautiously remove any visible debris, like wood particles and rocks. If conditions allow, put extra effort into physically removing these materials. If ample water is available, irrigate the area thoroughly. Though the water may not be sterile, it shouldn’t be grossly dirty or contaminated. Again, be mindful not to clean vigorously enough to induce bleeding, and utilize any available local anesthetics as previously directed.
3. c) Insert sterile gauze or clean cloth as deep into the wound as possible without causing excessive pain. Cover the site with additional gauze pads and wrap it with gauze or an ace bandage. If the wound is near a joint, try to immobilize the joint to prevent further bleeding and reduce pain.
4. d) Expect significant fluid seepage from the wound, necessitating frequent dressing changes in the initial 48 hours. Make an effort to cleanse the site with water and replace the gauze pack. Removing the pack aids in clearing debris that may have been challenging to eliminate initially. After several days, the wound will become less painful, making dressing changes more manageable.
5. e) If antibiotics are available, administer them in this scenario. Topical antibiotic ointments like Bacitracin, Triple Antibiotic, or Bactroban can also be applied to the gauze placed in the wound.

In cases of extensive blood loss, open fractures, or other serious associated injuries (head, chest, abdomen), promptly transport the individual to medical assistance or use available communication to summon help.

For contaminated lacerations with adequate dressing supplies, continuing open treatment is an option. The wound is expected to heal naturally within two to four weeks, potentially resulting in a wider scar. If desired, seeking the expertise of a plastic surgeon for revision is a future possibility.

In a recent movie, I saw, the protagonist, a hitman, displayed remarkable courage when faced with a gunshot wound to his chest. Reminiscent of the iconic Rambo style, he, without the luxury of anesthesia, stitched up the bleeding edges and pressed on with his mission. Unfortunately, his heroic effort came to a tragic end as he succumbed to adversaries, sparing a surgical team from attempting to save him from the complications of an infected wound.

A bullet carrying oil and gunpowder through cloth and unclean skin creates a severely contaminated wound. Closing the skin over trapped blood, dead tissue, and foreign material sets the stage for bacterial proliferation. Avoid repeating this error. Instead, keep the wound open, preventing infection and allowing for a clean healing process. Resist the temptation to seal it prematurely, as this can lead to more significant complications. Learn from both fiction and reality: pack the wound open, steer clear of infection, and let it heal thoroughly.

Concluding

Addressing injuries in the field becomes paramount, particularly when situated in the remote wilderness where medical resources are scarce. Without access to a complete first aid kit, proper wound cleaning becomes challenging, making it crucial to know how to prevent infections. This article aims to offer a comprehensive guide, intending to furnish readers with essential insights.

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