Wilderness Medicine/First Aid Kit

Jeff; thanks for agreeing with me. That always puts me in a good mood.

I must say, though, that I have found in my experience that the tight suturing of dirty wounds leading to infection, and the infection spreading along the fascial planes instead of just forming pus and dripping out of the wound is hardly ever seen. In fact, I have never seen it.

I remember one guy that had been in Mexico, and dinged his leg up on the kick stand of a bike. He had his wound cleansed and sutured, and came to me for suture removal. It was infected, so I opened it up to let it drain, and got a little pus to culture. Turned out the organisms present were sensitive to Cipro, so put him on that and it healed without further problems. Now, this wound had been tightly sutured, and infected, for two weeks. Yet there were no problems except at the wound site.

Sure, if I have a very dirty and/or neglected wound (over 24 hours old), I generally suture the wound loosely, or steri-strip it, and put the person on antibiotics prophylactically. However, we commonly sewed up dog and human bites in a normal fashion, but always put the person on antibiotics.

There is simply no way you can tape or crazy glue a wound tightly enough to cause problems.

Providing I had the proper equipment, I would not hesitate to do a primary closure in the field (doctor speak for sewing up the cut). Walt
 
Hi Walt, that's interesting info.

Do you think most first aid and responder courses preach against suture / glue because of liability reasons and the worry of untrained personnel and liability issues?

I could understand this if so, because even though I've sewn up many animals during vet procedures on the farm, the very few times I've worked on humans had my hands a little shaky.

Is the risk of infection from the invasive procedure of suturing in a wilderness environment any cause for alarm? Personally I wouldn't think it to be if we're already at a gaping wound...what's a few needle punctures going to add?

Also, is a drain tube or wick necessary for emergency suturing if you're able to get to a primary care facility within a couple of days?

Last question, when carrying 1% Xylocaine for use as a local, is this usually injected subcutaneous around the wound area or done as a nerve block. Again, the few times I've been invloved with this has always had a medic or other qualified person doing the injection.

Sorry for all the questions. - Jeff

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Randall's Adventure & Training
jeff@jungletraining.com

 
Jeff; I don't know why the people you mention teach as they do. Infection and faschial spread is certainly a problem, just very uncommon, and not a significant enough risk to justify not doing a primary closure in the field.

Wound infections are almost never caused by the suturing needle. You can cleanse the skin surrounding the wound thoroughly. The problem is bacteria left in the wound through inadequate cleansing. Dirty wounds need really good cleansing. I remember a doctor in Omaha who used to treat a lot of butchers who got cut in the stockyards. He would numb the wound, then stand them over a sink and scrub the wound with a Betadine scrub brush vigorously! He had a VERY low infection rate. Suturing in the field is suturing in an area which probably has fewer harmful pathogens than a hospital. Just maintain aseptic procedures.

The reason you put a wick in a wound is because you expect a large amount of fluid weeping from the tissue. This usually means large lacs. sometimes with crush injury. I would be REALLY hard pressed to put a drain into a lac in the field. Large lacs like these often need the operating room. I would, however, do it if MEDEVAC were not possible for, say, several days. You then remove the drain in a day or two.

Anesthetizing a wound is really simple. Just inject the lidocaine about 1 cm. from the wound edge all the way around. Shoot the stuff down at about a 45 degree angle, as you are trying to numb the skin nerves, not deeper structures. Nerve blocks are something I would not attempt in the field; they require considerable skill, are slow to take effect, and rarely achieve complete anesthesia.

The exception to this rule is the digital block, used for finger and toe lacs. You inject the lidocaine into the base of the finger on each side, slightly palmar. This gets the digital nerve on each side, and provides relatively quick (5-10min.) anesthesia, and has the further advantage of not swelling up the wound so that it is harder to approximate.

Hope this helps, Walt
 
Greg,, as far as drug rep. type packaging goes, I don't think that it really matters as far as helping you protect the potency of your drug. With regard to expiration dates for a tablet it is defined as the last date that the manufacturer will guarantee 100% potency. After that date loss of potency may occur at an unpredictable rate. So after the expiration date a tablet may be 99% potent or 5% potent depending on a number of variables. Expired tablets will not cause harm; expired injectables,eye drops etc may cause harm. This may be over-kill but basically on things like antibiotics I would swap them after expired. Things like tylenol,motrin etc. are not that big of a deal.. Also, I would suggest (unless allergic to it) to reconstitute your 500mg Rocephin with 1ml of Lidocaine and 1gm with 2.3ml of lidocaine instead of bacteriostatic water because Rocephin IM can be very " uncomfortable" when administered and the Lidocaine (for injection!!)will definately help..Enjoyed everyones posts! Rob
 
Walt...I agree with you completely about closing the wounds. BTW, I have never had to use the super glue but if I had I would cover it with steri strips and finally with a dressing (the first few days). I woulld only use it on very simple strait lacerations. There is a new product out that we use at our clinic which works the same way (can't think of what it is called).

Just a note: I do carry a suturing kit to the woods when teaching our wilderness survival classes. If anyone were to cut themselves, I would sew them up. However, :>) :>) our safety record has been outstanding and to date this has not been required (we teach proper knife use right off of the bus).

Jeff, those must be big cuts (huge) if you are planning on putting a drain in :>) I worked with a surgeon for a while and have spent many hours as a Physician Assitant (alone) in rural ER's. Have seen some pretty nasty things (as I am sure walt has) and it is not that often that a drain is needed. About loosely sutering cuts...the only time I have done this is with gaping animal bites (I usually don't suture bites if I can get away with it since the the almost always get infected when this is done).

Rob L. thanks for the pharm lesson. I use my local pharmacist a lot and always appreciate his valuable input on meds.

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Greg Davenport
http://www.ssurvival.com
Are You Ready For The Challenge?
Are You Ready To Learn The Art Of Wilderness Survival?

 
This has been a very helpful discussion, which I have followed with great interest. I have just a few thoughts to add, and I apologize for taking so long to put my thoughts on paper.

There have been lots of discussions over the years about what should be in a good medical kit. Of course, there are no ideals, only compromises. For example,

-- Who is going to use the kit? What is his or her level of training? It makes no sense to pack things that the caregiver is not trained to use, or is not trained to use under adverse wilderness conditions.

-- Who is the kit for? How many people? Are there any special needs -- pregnant women, diabetics, small children, dogs, llamas?

-- How long will the kit have to provide medical care for these people? Is the kit for a 12-hour SAR operation or for a two-week jungle expedition? Under what circumstances is resupply possible?

-- Where is the kit intended to be used? What conditions are likely to be encountered?

-- How much can be reasonably carried? A kit for a backpacking trip in mountainous terrain, or one that will have to be carried through crawlways in a cave rescue, is going to have to be smaller and lighter than one for a canoe trip. And what does “reasonable” mean? The team doctor wants you to carry everything including four bags of IV fluids at 2.2 pounds a bag; but you are a fanatically weight-conscious backpacker who cuts the handles off your toothbrush and the margins off your maps and who wants a kit that weighs less than an ounce. Who is right? (The example, by the way, is from Dr. Keith Conover.)

The answer is that every item in your medical kit needs to be *thought about* in the light of your own experience and skills, not simply copied from someone else. Here is an example – EMT shears. I guess EMT shears would be nice. But in the wilderness environment other considerations intrude. EMT shears are not weightless and dimensionless. There are likely to be lots of other cutting implements around. An inexperienced caregiver should not be encouraged to cut people’s clothes off where hypothermia is a present possibility, even on a balmy day. An injured person is likely to get very pissed off when you use the EMT shears to cut off his $500 Patagonia jacket. Thus, you might consider instead, if you want to carry anything along these lines, a seam ripper. A seam ripper is small, light, and lets you reassure the patient that both his arm and his jacket can be reassembled after evacuation.

I guess my concern is that lists of contents of medical kits is very stuff-oriented, while wilderness caregiving is really very knowledge- and skills-oriented. The rule is: No matter what you pack, the one thing you need won’t be in there. But what you always have is your understanding of the principles that underlie your care, the skills that you have practiced under actual –- or realistically simulated –- conditions, and your ability to adapt, improvise, and overcome.

Also, when making general recommendations, I think we have to bear in mind that wilderness caregivers –- both those who have been forced into the role by circumstances as well as those who have been trained for it -– differ greatly in their training and skills. In addition, the circumstances under which care is given can vary greatly. It is one thing for an experienced ER doc to suture a wound; but I am not sure that having stitched together a capote is sufficient qualification -- not on *my* skin, anyway. Again, the best plastic surgeon in the world might, without considerable wilderness experience, have trouble suturing a wound in a muddy shelter on a dark night in the rain. As always, good judgment, and a knowledge of one’s own limitations, would seem to be the key.

I agree that thorough cleaning and debridement of a wound is the primary consideration, and that arguments about proper closure can come later. And those arguments, again, will take into account the severity and location of the wound, its level of contamination, the skill and experience of the caregiver, and the environmental conditions and time required for evacuation, if necessary.

 
Hi Walks slowly,

You sound like a member of a search and rescue team. You bring up some good points. Some I addressed in my first post on the 30Nov99 date. The materials I recommend are generic and can be used by most EMT's. Note: The recommendations I give are a foundation...not a final solution.

I advise most SAR teams to have at least two emt's and the rest first responder...and all CPR trained.

You bring up some key points about how individuals need to personalize their kits. Excellent! You ask: Who's using it, special needs of group, how long will you be out, environment issues, size of the group, where you intend to travel, size and weight of the kit, etc. etc. Excellent points! The answer is different for everyone. All of these issues must be assessed by each individual and the team.

As far as leting someone suture you that doesn't know what they are doing...Your right...odds are you will be out soon and as long as the area is cleaned and protected it can probably wait. However, if you have Doc Walt, myself, or a former military medic (they suture) with you...I say let them do it if rescue isn't imminent. Also, don't forget that if you have a clean superficial laceration...you can approximate the edges and apply super glue to the outside, hold till dry, steri strip, and cover.

Best bet for SAR teams is to attend a Pre Hospital Emergency Care Class that is put on by someone who is an expert at both survival and wilderness medicine. It just so happens that...we will be offering such classes in the summer of 2000 (if all goes as planned).

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Greg Davenport
http://www.ssurvival.com
Are You Ready For The Challenge?
Are You Ready To Learn The Art Of Wilderness Survival?

 
jrf: to what sort of snake bite kit do you refer?

Joel Stave: (I am banging head on computer desk) yes, a Leatherman type tool would be good to have. I always carry one with me. Can't believe I forgot to mention it.

Another thing that might be good to have is a small pocket screwdriver. Sears makes one which is available in their stores around XMAS time. Cat. # 9 25630. It has a 3 1/2" driver with nine hex bits in slotted, Phillips, and Torx. I add four more Torx bits, Cat. # 9 41402, as many knives now use Torx fasteners. This all fits into the vinyl pouch which comes with the screwdriver, and is about ths size of two butane lighters side by side. Hope this helps, Walt
 
jrf,

This is what the National Safety Council and Wilderness Medical Society recommends and being a victim of venomuos snake bite myself, I agree with their plan of action.

Never cut-and-suck or use a tourniquet, instead use a Sawyer's Extractor. If you can get to your Sawyers Extractor within 3 minutes of the initial 'hot' bite you can extract up to 30 percent of the venom. At 30 minutes it's about 3 percent. If you can't find the extractor, don't waste time and begin first aid and evacuation.

My wife is a nurse and has treated many snake bite victims this year. Contrary to what many believe, death from snake bite is rare in the United States, and many bites from venomuos specie are not 'hot' (injecting maximum amounts of venom).

Sorry to dispel the myth but your not going to die in 5 minutes, and it usually takes hours to reach critical stages from a snake bite in the US - depending on the health of the victim of course. There are several other widlerness emergencies that rank as much more of an emergency than snake bite, such as anaphylactic shock, heat stroke, heart attack, etc.

Another point is don't worry about trying to kill or catch the snake, since there's a liklihood of having another victim and in many cases snake identification is not top priority, since anti-venin may or may not be used at the primary car facility.

Also, forget about the electric shock thing. Number one care for snake bite is to keep the victim calm, immobilize the bitten limb below heart level if possible, and evacuate.

What's your take on this Walt?

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Randall's Adventure & Training
jeff@jungletraining.com

 
I think Jeff is absolutely right. With his permission, I would like to repost here, with some changes, a brief summary of pit viper envenomation treatment which I wrote up for Jeff's board a few months ago:

Jeff got bit by a copperhead, one of three genera of the Crotalidae or pit viper family in the United States. The pit vipers include the copperhead, the cottonmouth or water moccasin, and fifteen species of rattlesnakes. They are called pit vipers because they have a pit or depression between the eye and the nostril on each side of the head, which functions as an extremely sensitive infrared heat-detecting organ.

As Jeff points out, many pit viper strikes in fact are dry and inject no venom. Pit viper venom is a complex mixture of enzymes, which varies from species to species, and which is designed to immobilize, kill, and digest the snake’s prey. Pit viper strikes on humans are overwhelmingly on the extremities. Crotalid venom is capable of causing significant local tissue damage, but deaths in the United States are very rare and limited almost entirely to children and the elderly.

Pit viper envenomation can be excruciatingly painful, and the discomfort can last for several days. The envenomated extremity can also become frighteningly ugly, leading to panic in both the patient and the caretaker. Greater or smaller areas of the extremity can turn blue or black, swell alarmingly, and develop large blood blisters. It is altogether an unpleasant experience.

There is no question that a Crotalid envenomation is a medical emergency requiring urgent evacuation if possible. However, the first step in treatment is to avoid panic. Death is rare; even without evacuation, most cases result in several days of serious misery and then full recovery. Remember that the fatality rate even for *untreated* pit viper bites is extremely low.

The treatment steps are:

-- Use the Sawyer Extractor. If you are in snake country, the Extractor should always be within easy reach in your pack. The Extractor can remove as much as 30% of Crotalid venom proteins if applied within three minutes. Use the Extractor as quickly as possible and then keep it on the bite for about thirty minutes. Because of the great suction it creates, no cutting is necessary.

-- Immobilize the bitten extremity with a splint, just as you would a fracture.

-- Have the patient rest and keep activity to a minimum.

-- Have the patient drink as much fluid as possible, in frequent small amounts, in order to maintain fluid volume and kidney flow.

-- Remember that a snakebite is a contaminated puncture wound, and treat it as such.

-- Get to definitive care as quickly as you can, if at all possible. Otherwise, have the patient rest and drink fluids; keep the wound clean; give lots of encouragement and support.

The following are *not* recommended for pit viper envenomations:

-- Do not make incisions or try to suck out the venom. In wilderness conditions, cutting into analready compromised limb is asking for an infection. You absolutely do not want pit viper venom in your mouth. You do not want the many germs in your mouth contaminating an already compromised limb. And you can’t suck as hard as the Extractor can anyway.

-- Do not use a tourniquet. Tourniquets can result in loss of the limb due to decreased blood flow. In addition, you are just keeping the venom localized where it does the most tissue damage.

-- Do not use an elastic bandage pressure wrap. The pressure-immobilization technique is now recommended for bites from Elapidae or coral snakes, but, with Crotalid envenomation, the pressure may actually increase local tissue damage, and removal of the pressure may result in sudden massive swelling and discoloration.

-- Do not use electric shock. It can be dangerous, and has no proven value in managing pit viper bites. It is the great urban legend of wilderness first aid.

-- Do not use ice. There is no evidence that snake venom enzyme activity diminishes with cold. Freezing already compromised tissue can lead to frostbite, which can damage the limb more than the original bite. Packing in ice has probably resulted in more lost limbs than snakebite itself; this is particularly tragic when limbs have been lost to frostbite because of a non-envenomated bite.

-- Do not give alcohol. It causes vessels to dilate and may speed venom absorption.

-- Do not use antivenin.

Let me explain that last one. As far as I know -– and I am happy to be corrected on this –-the only commercially available antivenom in the United States for pit viper envenomation is Wyeth Laboratories’ Antivenin (Crotalidae) Polyvalent. The antivenom must be dissolved in warm saline and then diluted for intravenous administration. The minimum amount administered is five vials, and more than twenty vials may be indicated as venom effects progress. You have to know how to set up and maintain an intravenous line under dirty and uncomfortable conditions. Most important, the patient may have a severe allergic reaction to horse serum, and you will have no facilities for endotracheal intubation, no oxygen, and probably no epinephrine. In the wilderness context, it seems to me, the risks of contamination, sepsis, and anaphylactic shock –- not to mention that you have to hump the whole damn setup in your backpack –- outweigh the benefits.

So much for the Crotalidae family.

[This message has been edited by Walks Slowly (edited 06 December 1999).]

[This message has been edited by Walks Slowly (edited 06 December 1999).]

[This message has been edited by Walks Slowly (edited 06 December 1999).]
 
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