The performance of daily survival tasks, such as chopping wood and cooking food, may lead to a number of soft-tissue injuries (those that do not involve bony structures). From a simple cut to a severe burn, any damage to skin is a hole in your body’s protective armor.
Each wound is different and must be evaluated separately. If not present at the time the wound is incurred, the medic should 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. Initially, always assume a wound is dirty. Other questions to ask are whether the victim has chronic medical problems, such as diabetes, and whether they are allergic to any medications.
The physical examination of a wound requires assessing the following:
• Location on the body
• Length of the wound
• Depth of the wound
• Type of tissue involved (skin, muscle, bone)
• Circulation and nerve involvement
If the injury is in an extremity, have the patient show you a full range of motion, if possible, during your examination. This is especially important if the injury involves a joint.
This section deals with various injuries, their evaluation, and treatment.
A soft-tissue injury is considered minor when it fails to penetrate the deep layer of the skin, the dermis. This would include cuts, scrapes, and bruises:
Cuts and scratches. These tears in the skin only penetrate the epidermis (superficial skin layer) and become infected on an infrequent basis in a healthy person.
Abrasions. This is where a portion of the epidermis has been scraped off. You probably have experienced plenty of these as a child.
Bruises or Contusions. These result from blunt trauma and do not penetrate the skin at all. However, there is bleeding into the skin from blood vessels that have been disrupted by the impact.
All of these minor injuries can be treated easily:
• Wash the wound thoroughly.
• Use of an antiseptic, such as Betadine; honey; or an antibiotic ointment, such as Neosporin or BactrobanTM (mupirocin) is helpful in preventing infection.
• Treat minor pain with over-the-counter drugs such as ibuprofen and acetaminophen.
Minor bleeding can be stopped with a wet styptic pencil, an item normally used for shaving cuts. If the skin is broken, the wound should have a protective adhesive bandage placed over it to prevent infection. A liquid bandage, such as New-SkinTM, is an excellent way to cover a minor injury.
Applying pressure and ice (if available) wherever a bruise seems to be spreading will stop it from getting bigger. Bruises will change color over time from blackish blue to brown to yellow as they heal.
The following is an alternative process to deal with these issues:
1. Evaluate seriousness of wound; if minor, you may continue with home remedies.
2. Stop minor bleeding with herbal blood clotting agents such as yarrow, cinnamon, or cayenne pepper powder. Compress the area with gauze.
3. After minor bleeding is stopped, clean the wound with an herbal antiseptic. Mix a few drops of oil with sterile water and wash out the wound thoroughly. Essential oils with this property include:
• Lavender oil
• Tea tree
• Other natural antiseptics, including garlic, raw unprocessed honey, Echinacea, witch hazel, and St. John’s wort
4. Dress the wound using clean gauze. Do not wrap too tightly.
5. Change the dressing, reapply antiseptic, and observe for infection twice daily until healed.
HEMORRHAGIC AND MAJOR WOUNDS
In a major disaster, traumatic wounds may be commonplace. Therefore, the medic for a family or group must be prepared for the worst possible injuries.
Cuts in the skin can be minor or catastrophic, superficial or deep, clean or infected. Most significant cuts (also called lacerations) penetrate both the dermis and epidermis and are associated with bleeding, sometimes major. Bleeding can be venous in origin, which manifests as dark red blood, draining steadily from the wound. Bleeding can also be arterial, which is bright red (because of the higher oxygen content) and comes out in spurts that correspond to the pulse of the patient. As the vein and artery usually run together, a serious cut can have both.
Once below the level of the skin, large blood vessels, tendons, and nerves may be involved. Assess circulation, sensation, and the ability to move the injured area. Vessel and nerve damage are more likely to occur in deep lacerations and crush injuries.
For an extremity injury, evaluate the capillary refill time to test for circulation beyond the area of the wound. To do this, press the nail bed, or finger or toe pad; with a person with normal circulation, this area will turn white when you release pressure and then return to a normal color within two seconds. If it takes longer or the fingertips are blue, there may be a damaged blood vessel. If sensation is decreased (test by lightly pricking with a safety pin beyond the level of the wound), there may be nerve damage.
Evaluating Blood Loss
Evaluating blood loss is an important aspect of dealing with wounds. An average-size human adult has about 10 pints of blood. The effect on the body caused by blood loss varies with the amount of blood loss incurred:
• 1.5 pints (0.75 liters) or less. The patient experiences little or no effect. You can donate 1 pint of whole blood, for example, as often as every 8 weeks.
• 1.5–3.5 pints (0.75–1.5 liters). Rapid heartbeat and respiration occurs. The skin becomes cool and may appear pale. The patient is usually very agitated. If you are not accustomed to the sight of blood, you might be, too. Even a small amount of blood on the floor or on the patient may make an inexperienced medic queasy.
• 3.5–4 pints (1.5–2 liters). Blood pressure begins to drop; the patient may appear confused. Heartbeat is usually very rapid.
• More than 4 pints (2 liters): The patient is now very pale, and may be unconscious. After a period of time with continued blood loss, the blood pressure drops further, the heart and respiration rates decrease, and the patient is in serious danger.
As the medic, you should always have nitrile gloves in your pack; wearing them when treating the patient will keep the wound from becoming contaminated. Try to avoid touching the palm or finger portions of the gloves as you put them on. If there are no gloves, grab a bandanna or other cloth barrier and press it onto the wound.
The cornerstone of hemorrhage control is direct pressure. This measure often will stop bleeding all by itself. Bleeding in an extremity may be slowed by elevating the limb above the level of the heart.
Pressure points are locations where major arteries come close enough to the skin to be compressed manually. Pressing on the pressure point for the area injured may help slow bleeding further down the track of the blood vessel.
Using pressure points, we can map specific areas on which to concentrate our efforts to decrease bleeding. For example, there is a large blood vessel, the popliteal artery, behind each knee. If you have a bleeding wound in the lower leg, applying pressure on the back of the knee will help stop the hemorrhage. A diagram of some major pressure points is below.
If this fails to stop the bleeding, it may be appropriate to use a tourniquet. Most are simple to use and could even be placed with one hand. An improvised version can be made with a folded bandanna (at least 2 inches wide) and a stick, but avoid rope or wire. Tourniquets must be placed tightly; arterial bleeding usually requires more pressure than simple venous bleeding to stop it.
The placement of a tourniquet to a wound must be made judiciously. The tourniquet stops bleeding from the open blood vessel, but it also stops circulation in nearby intact blood vessels as well. In survival settings, it is important to note that the tourniquet, once placed, should be loosened every 10 minutes or so, to enable blood flow to uninjured areas. Also, this will enable the medic to determine whether clotting has stopped the bleeding.
Tourniquets are painful if they are in place for too long, and prolonged use could actually cause the patient to lose a limb from lack of circulation. Your body may also build up toxins in the extremity; these become concentrated and rush into your body core when you release the tourniquet. It takes less than an hour or two with a tourniquet in place to cause this problem. As such, you should mark the victim with the time that the tourniquet was placed.
Once you are comfortable that major bleeding has abated, release pressure from the tourniquet but leave it in place. Irrigate (flush) the wound aggressively with sterile water or a solution of 1 part Betadine to 10 parts water. Most studies find that sterilized water is just as good as a concentrated antiseptic solution for wound healing (sometimes better). Although it is acceptable to perform a first cleaning with Betadine or hydrogen peroxide, later cleaning should definitely not use these concentrated products. New cells are trying to grow, and concentrated antiseptics dry out these fragile new cells and slow healing.
Packing the wound with bandages is not just for sopping up blood; the process helps apply pressure. It’s important to make sure that you put the most pressure where the bleeding was occurring in the wound. If the blood was coming from the top of a large wound, start packing there.
Now cover the whole area with a dry dressing for further protection. The Israeli army developed an excellent bandage which is easy to use and is found almost everywhere survival gear is sold. The advantage of the Israel battle dressing is that it applies pressure on the bleeding area for you. This enables the medics to have hands free for further care, or to attend additional victims.
Bandages get dirty and should be changed often, twice a day at a minimum, until the wound has healed.
Knife and Gunshot Wounds
The process described above of stopping hemorrhage and dressing a wound will also work for traumatic injuries, such as knife and gunshot wounds. You have probably heard that you should not remove a knife because it can cause the hemorrhage to worsen. This will give you time to get the patient to the hospital, but what if there are no hospitals? You will have to transport your victim to your base camp and prepare to remove the knife. Have plenty of gauze and clotting agents available.
Bullet wounds are the opposite, in that the bullet is usually removed if at all possible when modern medical care is available. If you do not have the luxury of transferring the patient to a trauma center, you will want to avoid digging for a hard-to-find bullet. Even though there are instruments made for this purpose, manipulation could cause further bleeding and lead to infection.
For a historical example, take the case of President James Garfield. In 1881, he was shot by an assassin. In their rush to remove the bullet, twelve different physicians placed their (ungloved) hands in the wound. The wound, which would not have been mortal in all probability, became infected. As a result, the president died. In austere settings, think twice before removing a projectile that isn’t clearly visible and easily reached.
Remember that the process described above is meant for survival situations where help is not coming.
Commercial Hemostatic Agents
In studies of battlefield casualties, 50 percent of those killed in action died of blood loss; 25 percent died within the first “golden” hour after being wounded. A victim’s chance of survival diminishes significantly after 1 hour without care, with a threefold increase in mortality for every 30 minutes without care thereafter.
The control of major hemorrhage may be the territory of the trauma surgeon, but what if you find yourself without access to modern medical care? In the last decade or so, there have been major advancements in hemostasis (stopping blood loss).
Although there are various types of hemostatic agents on the market for medical storage, the two most popular are QuickClot and Celox. Both are available in a powder or powder-impregnated gauze.
QuickClot originally contained a volcanic mineral, zeolite, which effectively clotted bleeding wounds but also caused a reaction that caused some serious burns. The current generation is made from kaolin, a clay mineral that is the original ingredient in KaopectateTM. It does not contain animal, human, or botanical components.
One negative with QuickClot is that it does not absorb into the body and can be difficult to remove from the wound. This was certainly true of previous generations, but it is claimed no longer to be as big an issue, especially if you use the brand’s gauze dressing.
Celox is the other popular hemostatic agent. It is composed of chitosan, an organic material processed from shrimp shells. Despite this, the company claims that it can be used in patients allergic to seafood. When Celox comes in contact with blood, it bonds with it to form a clot that appears as a gel. Like QuickClot, it also comes in impregnated gauze dressings.
Celox will cause effective clotting even in those on anticoagulants, such as heparin, warfarin, or CoumadinTM, without further depleting clotting factors. Chitosan, being an organic material, is gradually broken down by the body’s natural enzymes into other substances normally found there. Like QuickClot, Celox is FDA-approved. Studies by the US government compare Celox favorably to other hemostatic agents.
A downside to use of hemostatic agents is that they may be difficult to remove in advance of surgical intervention. As such, they are rarely used by emergency medical personnel in normal times.
Both QuickClot and Celox gauze dressings have been tested by the United States and United Kingdom militaries and have been put to good use in Iraq and Afghanistan. Although effective, these items should not be used as a first line of treatment in a bleeding patient. Pressure, elevation of a bleeding extremity above the heart, gauze packing, and tourniquets should be your strategy here. If these measures fail, however, you have an effective extra weapon to stop that hemorrhage.
Soft-Tissue Wound Care
Once you have stopped the bleeding and applied a dressing, you are in safer territory than you were. In an austere setting, however, you must follow the status of the wound until full recovery in your role as medic. An open wound can heal by two methods:
Irrigating the wound
Primary Intention (Closure). The wound is closed in some way, such as with sutures or staples. This results in a smaller scar but carries the risk of inadvertently sequestering bacteria deep in the wound.
Secondary Intention (Granulation). Leaving a wound open causes the formation of granulation tissue, rapidly growing early scar tissue that is rich in blood vessels. It fills in spaces where the wound edges are not together. After a period of time, it turns into mature scar tissue. This scar is larger than if the wound were closed by primary intention, but decreases the risk of infection if properly cared for.
Remember the old saying “The solution to pollution is dilution.” Using a bulb or irrigation syringe (60–100 ml) will provide pressure to the flow of water and wash out old clots and dirt. Lightly scrub any open wound with diluted Betadine or sterilized water. You may notice some (usually slight) bleeding. This is a sign of tissue that is forming new blood vessels and not necessarily a bad sign. Apply pressure with a clean bandage until it stops.
Wound dressings must be changed regularly (at least twice a day or whenever the bandage is saturated with blood or other fluids) to give the best chance for quick healing. When you change a dressing, it is important to clean the wound area with sterilized (drinkable) water or an antiseptic solution, such as a dilute solution of 1 part Betadine to 10 parts water.
An alternative antiseptic solution that is easy to make using common storage supplies is Dakin’s solution. First used during WWI, this solution is used to disinfect wounds on the skin, such as pressure sores in bedridden patients. It is inexpensive to put together, dissolves dead cells, and is composed of the following:
• Sodium hypochlorite solution (regular-strength household bleach)
• Sodium bicarbonate (baking soda)
• Boiled tap water
To make Dakin’s solution, add ½ teaspoon of baking soda to 4 cups of sterilized water. Then, add bleach to reach the strength that you’ll need: 3 teaspoons will act as a mild antiseptic effect (plenty for clean wounds that are healing), and 3 tablespoons will give you a stronger effect for infected wounds. Do not take Dakin’s solution internally, and watch for allergic reactions in the form or rashes or other irritation. Store in darkness at room temperature and make a new batch frequently, as it loses potency quickly. Do not freeze or heat up the solution.
To ensure rapid healing of open wounds, we use a type of dressing method known as “wet-to-dry.” Apply a bandage that has been soaked in sterilized water and wrung out directly to the wound. New cells are prevented from drying out by keeping them in a moist environment. On top of the bandage that touches the healing wound, place a dry bandage and some type of tape to secure it in place. Thus, you have a wet-to-dry dressing.
It may also be a good idea to apply some triple antibiotic ointment around a healing wound to prevent infection from bacteria on the skin. Raw honey, lavender oil, and tea tree oil are some natural alternatives.
As time goes on, you might see some blackish material on the wound edges. This is nonviable material and should be removed. It might just scrub out, or you may need to take your scissors or scalpel and trim off the dead tissue. Called debridement, this procedure removes material that is no longer part of the healing process.
There is always some controversy as to whether to close a wound. When and why would you choose to close a wound, and what method should you use? One rule of thumb is to always use the least invasive methods first; in order, they are tapes, glues, staples, and sutures.
Improvised butterfly closure with duct tape
There are several methods available to close a laceration. It makes common sense to use the simplest and least invasive method that will do the job. The easiest to use are Steri-Strips and butterfly closures, adhesive bandages that adhere on each side of the wound to pull it together. They don’t require puncturing the skin and will fall off on their own, in time. Even duct tape can be used to make a butterfly closure.
The second-least-invasive method is cyanoacrylate, special glue sold as DERMABONDTM. This is medical-grade adhesive made specifically for use on the skin. Simply hold the skin edges together and run a thin line of glue over the laceration. Hold in place until dry. It will naturally peel off as the skin heals.
Some have recommended (the much less expensive) household product Super GlueTM for wound closure. This preparation is slightly different chemically, and is not made for use on the skin. It may cause skin irritation in some, and burn-like reactions have been reported.
You can test Super Glue for allergic reactions by placing a small amount on the inside of your forearm and observe for a rash over the next 24 hours.
Another closure method is the use of skin staplers. They work by “pinching” the skin together and should be removed in about 7 days. You will require two toothed tweezers (“Adson forceps”) to evert the skin edges and approximate them for the person doing the stapling. As such, stapling is best done if you have an assistant. The most skilled person is actually the one holding the tweezers, not the person stapling.
Staples are best removed with a specific instrument known as a staple remover. Stapling equipment is widely available but probably not as cost-effective as other methods.
Using sutures is the most invasive method of wound or laceration closure. As it can be done by a single person, it is the one that requires the most skill. Before you choose to close a wound by suturing, make sure you ask yourself why you can’t use a less invasive method instead. In a long-term survival situation, it’s unlikely you’ll ever be able to replenish those items.
When to Close a Wound
What are you trying to accomplish by stitching a wound closed? Your goals should be simple: You close wounds to repair the defect in your body’s armor and to promote healing. A well-approximated wound also has less scarring.
Unfortunately, here is where it gets complicated. Closing a wound that should be left open can do a lot more harm than good, and could possibly put your patient’s life at risk. The decision to close a wound is not automatic but involves serious considerations.
The most important consideration is whether you are dealing with a clean or a dirty wound. Most wounds you will encounter in a survival setting will be dirty. If you try to close a dirty wound, you have sequestered bacteria and dirt into the body. Within a short period of time, the infected wound will become red, swollen, and hot. An abscess may form, and pus will accumulate inside.
The infection may spread to the bloodstream and, when it does, the patient’s life is in danger. Leaving the wound open will enable you to clean the inside frequently and observe the healing process. It also enables inflammatory fluid to drain out of the body. Wounds that are left open heal from the inside out. The scar isn’t as pretty, but it’s the safest option in most cases.
Other considerations when deciding whether or not to close a wound are whether it is a simple laceration (straight, thin cut on the skin) or whether it is an avulsion (areas of skin torn out, hanging flaps). If the edges of the skin are so far apart that they cannot be stitched together without undue pressure, the wound should be left open. If the wound has been open for more than 8 hours, it should be left open; bacteria have already had a good chance to colonize the injury.
If you’re certain the wound is clean, you should close it if it is long, deep, or gapes open loosely. Exceptions would include any type of animal or human bite.
Lacerations over moving parts, such as the knee joint, will be more likely to require stitches. Remember that you should close deep wounds in layers, to prevent any unapproximated “dead space” from occurring. Dead spaces are pockets of bacteria-laden air in a closed wound that may lead to a major infection.
If you are unsure, you can wait 72 hours before closing a wound to make sure that no signs of infection develop. This is referred to as “delayed closure.” Some wounds can be partially closed, allowing a small open space to avoid the accumulation of inflammatory fluid. Drains, consisting of thin lengths of latex, nitrile, or even gauze may be placed into the wound for this purpose. Of course, you should place a dressing over the exposed area.
Many injuries that require closure also should be treated with antibiotics to decrease the chance of infection. Natural remedies, such as fresh crushed garlic or raw unprocessed honey may be useful in an austere setting.
Deep-layer sutures are never removed, so try to use absorbable material, such as chromic catgut or VICRYL if possible. If you must use nonabsorbables, such as silk, nylon, or prolene, the body will wall off the sutures and may form a nodule known as a “granuloma.” This may be disconcerting, but has little effect on a patient’s health.
Sutures on the skin should be removed in 7 days (5 days if on the face); if over a joint, 14–21 days. Stitches placed over a joint, such as the knee, should be placed close together. In other areas, ½ inch or more between sutures is acceptable. It is alright to allow space for drainage of fluid from the wound.
For an even more in-depth discussion of suturing, stapling, and anesthetic blocks, see our comprehensive book The Survival Medicine Handbook.
Blisters, Splinters, and Fishhooks
Typical broken blister
Anyone who has done any hiking or has bought the wrong pair of shoes probably has experienced a friction blister. For a relatively small soft-tissue injury, it can certainly cause more than its share of problems. More than one hike has come to a screeching halt because the terrain was more than the footwear could handle. Never underestimate the importance of a properly fitted pair of shoes.
Each part of your foot should be comfortable in your new boots:
• The ball of your foot should fit the widest part of the shoe without issue.
• There should be about ½ inch or so from the end of your toes to the end of your shoe.
• The upper part of the shoe should be flexible enough to not cause discomfort on your instep.
• Your heel should not slip up and down when you walk.
Other considerations are important: Soles should be thick VibramTM or other sturdy material. High-cut boots will help prevent ankle sprains by giving more support and will protect against snakebite.
Don’t buy shoes that are too tight and expect them to stretch. They might, but you’ll go through a lot of discomfort to get them there. You might be used to buying shoes online, but you really should walk in a shoe first for a while before making any purchases. Unless you can count shoemaking as one of your survival skills, buy a spare pair or two now while they’re still available.
Heavier boots, such as those with steel toes, are great if you’re chopping wood (you get to keep all ten of your toes) but are heavy. Remember that 1 extra pound of weight in your boot is like 5 extra pounds of weight on your back. In wet climates, waterproof materials such as Gore-TexTM, with flexible uppers, are a good investment.
Socks also factor into the health of your feet. Most people hike in the same pair of socks all day, even in the heat of summer.
Sweaty feet are unhappy feet; wetness increases friction and gives you blisters.
Change your socks often and have replacement pairs as a standard item in your backpack. Consider the use of a lighter, second pair of socks (sock liners) under the thicker hiking socks you use for additional protection. Foot powders, such as Gold Bond, or even cornstarch can help your feet stay dry.
If a blister is just starting, it will look like a tender red area where the friction is. Cover it with moleskin or SpencoTM 2nd SkinTM before it gets worse. If you don’t have any on hand, you can make use of gauze or a Band-Aid or even duct tape. The important thing here is to add padding to lessen the friction on the area.
Most people are eager to pop their blisters, but this shouldn’t be done with small ones, as this could lead to infection. Large blisters are different, however. Follow this process:
1. Clean the area with disinfectant. Alcohol or iodine is especially useful.
2. Take a needle and sterilize it with alcohol or heat it until it is red hot.
3. Pierce the side of the blister. This enables the fluid to drain. This will ease some discomfort and also will enable healing to begin.
4. Preserve loose skin; cover the blister to offer protection.
5. Apply antibiotic cream if possible.
6. Take some moleskin or Spenco 2nd Skin and cut a hole in the middle a little bigger than the blister.
7. Place the moleskin on so that the blister is in the middle of the opening.
8. Cover with a gauze pad or other bandage.
9. Rest if you can.
If you absolutely must keep walking, make sure that your bandage has stopped the friction to the area. Remember, bandages frequently come off, so check it from time to time to make sure it’s still on. Change the bandage frequently to maintain cleanliness.
Several home remedies can help in treating blisters:
• A cold compress to the blister by soaking a cloth in salt water.
• A 10 percent tannic-acid solution to the blister 2–3 times a day.
• A few drops of ListerineTM antiseptic to a broken blister to disinfect the wound. Garlic oil is also very useful for this purpose.
• Place some aloe vera, vitamin E oil, or zinc oxide ointment on the blister.
• Witch hazel on the blister 3 times a day to help with pain and dry it out.
• Tea tree oil to prevent infection.
Being out in the forest or working with wood sometimes leaves a person with a splinter or two to deal with. You can remove a splinter by simply cutting the skin over it until the end can be grasped with small forceps or tweezers. You’ll need a magnifying glass to make this process easier.
If you can see the entire length of the splinter, use a scalpel (number 11 or 15 blade) and cut the epidermis. You want to cut superficially and just enough to expose the tip of the wooden fragment. Then, take your tweezers and grasp the end of the splinter and pull it out along the angle that it entered the skin. Don’t forget to wash the area thoroughly before and after the procedure.
It’s unlikely that a major infection will come from simply having a splinter, with the exception of those that have been under the skin for more than 2–3 days. Redness or swelling in the area will become apparent if an infection is brewing. You might consider antibiotics in this circumstance to avoid having problems later.
Even if you’re an accomplished fisherman, you will eventually wind up with a fishhook embedded in you somewhere, probably your hand. Since the hook probably has worm guts on it, start off by cleaning the area thoroughly with an antiseptic.
Your hook probably has a barbed end. If you can’t easily slide it out, the barb is probably the issue. Press down on the skin over where the barb is and then attempt to remove the hook along the curve of the shank.
If this doesn’t work, you may have to advance the fishhook further along the skin until the barbed end comes out again. At this point, you can take a wire cutter and separate the barbed end from the shank. Then, pull the shank out from whence it came. Wash the area again and cover with a bandage. Observe carefully over time for signs of infection.
If you find yourself off the power grid, you will be cooking out in the open more frequently. The potential for significant burn injuries will rise exponentially, especially if the survival group includes small children; naturally curious, they may get too close to your campfires. A working knowledge of burns and their treatment will be a standard skill for every group’s medical provider.
The severity of the burn injury depends on the percentage of the total body surface that is burned, and on the degree (depth) of the burn injury. Although assessing the surface percentage is helpful to burn units in major hospitals, this practice will likely be of limited helpfulness in austere settings.
Before we discuss the different degrees of burn you might encounter, let’s talk about prevention. Most burns you’ll see will be due to too much exposure to the sun. Take the following steps to avoid sunburn:
• Stay out of the sun whenever possible.
• Avoid work during peak sun hours (say, 11 a.m.–4 p.m.).
• Wear long pants and sleeves, hats, and sunglasses.
• Spend rest periods in the shade.
If you cannot avoid extended exposure to sunlight, be certain to apply a sunblock. Do this before going outside and frequently throughout the day. Even water resistant and waterproof sunscreens should be reapplied generously every 1–2 hours.
By the way, a sunblock and a sunscreen are not the same thing. Sunblock contains tiny particles that block and reflect ultraviolet (UV) light; sunscreen contains substances that absorb UV light, thus preventing it from penetrating the skin. Many commercial products contain both.
The SPF (sun protection factor) rating system was developed in 1962 to measure the capacity of a product to block UV radiation. An SPF of at least 15 is recommended. It takes about 20 minutes without sunscreen for your skin to turn red. A product that is SPF 15 should delay burning by a factor of 15, or about 5 hours or so. Higher SPF ratings give more protection, and are beneficial to those with fair skin.
Besides the sun, injuries will most likely be related to cooking and managing campfires. Using hand protection will prevent many of these burns, as will careful supervision of children near any cooking area.
Burns are traditionally assessed by degree of damage, as described below.
These burns will be very common, such as simple sunburn. The injury will appear red, warm and dry, and will be painful to the touch. These burns frequently affect large areas of the torso; immersion in a cool bath or running cool water over the injury is helpful.
Placing a cool moist cloth on the area will give some relief, as will common anti-inflammatory medicines such as ibuprofen. Aloe vera or zinc-oxide cream is also an effective treatment.
Usually, the discomfort improves after 24 hours or so, as only the superficial skin layer, the epidermis, is affected. Avoid tight clothing and try to wear light fabrics, such as cotton.
These burns are deeper, going partially through the skin, and will be seen to be moist and have blisters with reddened bases. The area will have a tendency to weep clear or whitish fluid. The area will become somewhat swollen, so remove rings and bracelets.
Treat second-degree burns as follows:
• Run cool water over the injury for 10–15 minutes (avoid ice).
• Give oral pain relief, such as ibuprofen.
• Apply anesthetic ointments or gels.
• Use silver sulfadiazine (Silvadene) creams to help prevent infection.
• Lance only large blisters.
• Avoid peeling off burned skin.
• Apply nonstick skin dressings.
Third-degree burns involve the full thickness of skin and possibly deeper structures, such as subcutaneous fat and muscle. The burned skin may appear charred or white. The burn may appear indented if significant tissue has been lost.
Third-degree burns will cause dehydration, so giving fluids is essential to keep the patient stable. Cool the burn area with water for 20 minutes, but never immerse in a bath. Celox combat gauze, when wet, forms a gel-like dressing that may provide a helpful barrier. Silver sulfadiazine (Silvadene) cream is helpful in preventing infections in third-degree burns.
Any burn this severe that is larger than, say, 1 inch or so in diameter, usually requires a skin graft to heal completely. A person with third-degree burns over more than 10 percent of the body surface could go into shock, and is in a life-threatening situation.
Natural Burn Remedies
A successful medic will ensure that everyone will have some knowledge regarding alternate burn treatments. Although of limited use for severe burns, many first- and second-degree burns will respond to their effects. There are many different options:
• Aloe vera. Studies have shown that aloe vera helps new skin cells form and speeds healing. If you have an aloe plant, cut off a leaf, open it up, and either scoop out the gel or rub the open leaf directly on the burned area 4–6 times daily.
• Vinegar. Vinegar works as an astringent and antiseptic and helps to prevent infections. The best way to use vinegar on smaller-sized burns is to make a compress with ½ vinegar and ½ cool water and cover the burn until the compress feels warm, then re-soak the compress and reapply. Alternatively, add vinegar to a cool bath.
• Witch hazel. Another “cooling off” treatment for burns is a witch-hazel compress. Use the extract of the bark, which decreases inflammation and soothes a first-degree burn. Soak a compress in full-strength witch hazel and apply to the burned area.
• Black tea. The leaves have tannic acid that helps draw heat from a burn. Put 2–3 tea bags in cool water for a few minutes and use the water with compresses or dab on with cotton balls.
• Baking soda. Add ¼ cup baking soda to a warm bath and soak for at least 15 minutes or longer if needed, until the water cools off.
• Raw honey. Honey has an acidic pH that is inhospitable to bacteria. Apply a generous amount of honey in a thick layer all over the burned area. Cover the honey with cling plastic wrap or waterproof dressings. Use tape to hold the dressing in place. Change the dressing and add more honey at least 3 times a day.
It is important to know that butter or lard, commonly used for burns in the past, will hold in the heat and are not to be used in the treatment of your patient.
Treating burns without a medical system available will require constant care and close observation. Severe fluid losses lead to dangerous consequences for these patients, so always be certain that you do everything possible to keep them well-hydrated. The damage to the skin caused by burns leaves those injured at the mercy of many pathogens, so watch for fevers or other signs of infection.
In the United States, millions of people are bitten by animals every year. Most animal bites will be puncture wounds on the hands (in adults) and the face, head, and neck (in children). These bites will be relatively small but have the potential to cause dangerous infections.
Most people have, at some time of their life, run afoul of an ornery dog or cat. Domestic pets, including cats, dogs, and small rodents, are the culprits in the grand majority of bite cases. Any of these can lead to infection if ignored, but cat bites inject bacteria into deeper tissue and seem to become contaminated more often.
Besides the trauma associated with the actual bite, various animals carry diseases that can be transmitted to humans. It is possible, for example, to develop tetanus from any animal bite.
Whenever a person has been bitten, the first and most important action is to put on gloves and clean the wound thoroughly with soap and water. Flushing the wound with an irrigation syringe will help remove dirt and bacteria-containing saliva. Be sure to control any bleeding with direct pressure.
Any animal bite should be considered a “dirty” wound and should not be taped, sutured, or stapled shut. If the bite is on the hand, any rings or bracelets should be taken off; if swelling occurs, they may be very difficult to remove later.
Frequent cleansing is the best treatment for a bite wound. Also apply antibiotic ointment to the area, and be sure to watch for signs of infection. You may see redness, swelling, or oozing. In many instances, the site might feel unusually warm to the touch.
Oral antibiotics may be appropriate treatment (especially after a cat bite): Clindamycin (veterinary equivalent: Fish Cin), 300 mg orally every 6 hours, and ciprofloxacin (veterinary equivalent: Fish Flox), 500 mg every 12 hours, in combination would be a good choice, but azithromycin and ampicillin-sulbactam are also options. A tetanus shot is indicated in those who haven’t been vaccinated in the last 5 years.
Rabies is a dangerous but, luckily, uncommon disease that can be transmitted by an animal bite. Commonly associated with dogs, wildlife accounts for the grand majority of cases in the United States. Raccoons, opossums, skunks, coyotes, and bats are possible vectors. It is estimated that 40,000 people in the United States receive rabies prevention treatment every year.
A person with rabies is usually symptom-free for a time, which varies in each case. (The average is 30 days or so.) The patient then begins to complain of fatigue, fever, headache, loss of appetite, and fatigue. The site of the bite wound may be itchy or numb. A few days later, evidence of nerve damage appears in the form of irritability, disorientation, hallucination, seizures, and eventually, paralysis. The victim may go into a coma or suffer cardiac or respiratory arrest. Once a person develops the disease, it is usually fatal.
It is important to remember that humans are animals, and you might see bites from this source as well. Approximately 10–15 percent of human bites become infected, because saliva carries 100 million bacteria per milliliter.
Although it would be extraordinarily rare to get rabies as a result of a human bite, transmission of hepatitis, tetanus, herpes, syphilis, and even HIV is possible. Treat as you would any contaminated wound.
In a grid-down scenario, you will likely find yourself out in the woods a lot more frequently, gathering firewood, hunting, and foraging for edible wild plants. As such, you may encounter a snake or two. Most snakes aren’t venomous, but even nonvenomous snakebites may cause infections.
Venom differs from poison. While poisons are absorbed by the skin or digestive system, venoms must enter the tissues or blood directly. Therefore, it is usually not dangerous to drink snake venom unless you have, say, a cut in your mouth. (Don’t try it, though.)
North America has two kinds of venomous snakes: pit vipers (rattlesnakes, water moccasins) and elapids (coral snakes). One or more of these snakes can be found almost everywhere in the continental United States. A member of another viper family, the common adder, is the only venomous snake in the United Kingdom, but it and other adders are common throughout Europe, except for Ireland.
These snakes generally have hollow fangs through which they deliver venom. Snakes are most active during the warmer months, and therefore most bite injuries are seen then. Not every bite from a venomous snake transfers its venom to the victim: 25–30 percent of these bites will show no ill effects. This probably has to do with the duration of time the snake has its fangs in its victim.
To prevent snakebite, wear good, solid, high-top boots and long pants when hiking in the wilderness. Treading heavily creates ground vibrations and noise, which will often cause snakes to move away. Snakes have no outer ear, so they “hear” ground vibrations better than those in the air caused by shouting.
Many snakes are active at night, especially in warm weather. Some activities of daily survival, such as gathering firewood, are inadvisable without a good light source. In the wilderness, it’s important to look where you’re putting your hands and feet. Be especially careful around areas where snakes might like to hide, such as in or under hollow logs, under rocks, or in old shelters. Wearing heavy gloves would be a reasonable precaution.
A snake doesn’t always slither away after it bites you. It’s likely that it still has more venom that it can inject, so move out of its territory or abolish the threat in any way you can. Killing the snake, however, may not render it harmless: The severed head can reflexively bite for a period of time.
Snake bites that cause a burning pain immediately are likely to have venom in them. Swelling at the site may begin as soon as 5 minutes afterwards, and may travel up the affected area. Pit-viper bites tend to cause bruising and blisters at the site of the wound. Numbness may be noted in the area bitten, or perhaps on the lips or face. Some victims describe a metallic or other strange taste in their mouths.
With pit vipers, bruising is not uncommon and a serious bite might start to cause spontaneous bleeding from the nose or gums. Coral snake bites, however, will cause mental and nerve issues, such as twitching, confusion, and slurred speech. Later, nerve damage may cause difficulty with swallowing and breathing, followed by total paralysis.
Coral snakes appear very similar to their look-alike, the nonvenomous king snake. They both have red, yellow, and black bands and are commonly confused with each other. As the old saying goes, “red touches yellow, kill a fellow; red touches black, venom it lacks.” This adage only applies to coral snakes in North America, however.
Coral snakes are not as aggressive as pit vipers and will prefer fleeing to attacking. Once they bite you, however, they tend to hold on; pit vipers prefer to bite and let go quickly. Unlike coral snakes, pit vipers may not relinquish their territory to you, so prepare to possibly be bitten again.
The treatment for a venomous snake bite is antivenin, an animal or human serum with antibodies capable of neutralizing a specific biological toxin. This product will probably be unavailable in a long-term survival situation. The following strategy, therefore, will be useful:
1. Keep the victim calm. Stress increases blood flow, thereby endangering the patient by speeding the venom into the system.
2. Stop all movement of the injured extremity. Movement will move the venom into the circulation system faster, so do your best to keep the limb still.
3. Clean the wound thoroughly to remove any venom that isn’t deep in the wound.
4. Remove rings and bracelets from an affected extremity. Swelling is likely to occur.
5. Position the extremity below the level of the heart; this also slows the transport of venom.
6. Wrap with compression bandages as you would an orthopedic injury, but continue it further up the limb than usual. Bandaging should begin 2–4 inches above the bite (towards the heart), winding around and moving up, then back down over the bite and past it towards the hand or foot.
7. Keep the wrapping about as tight as when dressing a sprained ankle. If it is too tight, the patient will reflexively move the limb, and move the venom around. Do not use tourniquets, which will do more harm than good.
8. Draw a circle, if possible, around the affected area. As time progresses, you will see improvement or worsening at the site more clearly. This is a useful strategy to follow any local reaction or infection.
The limb should then be rested, and perhaps immobilized with a splint or sling. Keep the patient on bed rest, with the bite site lower than the heart for 24–48 hours. This strategy also works for bites from venomous lizards, such as Gila monsters.
Medical experts do not recommend making an incision and trying to suck out the venom with your mouth. If done more than 3 minutes after the actual bite, it would remove perhaps 1/1,000 of the venom and could cause damage or infection to the bitten area. A Sawyer ExtractorTM (a syringe with a suction cup) is more modern, but is also fairly ineffective in eliminating more than a small amount of the venom. These methods usually fail because of the speed at which the venom is absorbed.
Snake bites cause fewer infections than bites from, say, cats, dogs, or humans. As such, antibiotics are used less often in these cases.
INVERTEBRATE BITES AND STINGS
Southern Black Widow Spider
In a survival scenario, you will see a million invertebrates, such as insects and spiders, for every snake; so many, indeed, that you can expect to regularly get bitten by them. Insect bites usually cause pain, local redness, itching, and swelling, but are rarely life threatening. The hairs and fibers on some caterpillars carry toxins that can also deliver a painful sting that, unless the victim has a severe allergic reaction, is not life threatening.
The invertebrates to watch out for are arachnids—black widow spiders, brown recluse spiders, and scorpions. Many of these bites can inject toxins that could cause serious damage. Of course, we are talking about the bite itself, not disease that may be passed on by the insect. This topic is discussed in the section on mosquito-borne illness.
Bee and Wasp Stings
For most sting victims, the offender will be a bee, wasp, or hornet (a type of wasp). A bee will leave its stinger in the victim, but wasps take their stingers with them and can sting again. Even though you won’t get stung again by the same bee, they send out a scent that informs nearby bees that an attack is under way. As such, you should leave the area, whether the culprit was a bee or wasp.
The best way to reduce any reaction to bee venom is to remove the bee stinger as quickly as possible. Pull it out with tweezers or, if possible, scrape it out with your fingernail. The longer bee stingers are allowed to remain in the body, the higher the chance for a severe reaction.
Most bee and wasp stings heal with little or no treatment. For those that experience only local reactions, the following actions will be sufficient:
1. Clean the area thoroughly.
2. Remove the stinger, if visible, with tweezers.
3. Place cold packs and anesthetic ointments to relieve discomfort and local swelling.
4. Control itching and redness with oral antihistamines, such as Benadryl or Claritin.
5. Give acetaminophen or ibuprofen to reduce discomfort.
6. Apply antibiotic ointments to prevent infection.
Application of topical essential oils (after removing the stinger) can also help. Use Helichrysum (a genus of sunflower), tea tree, or peppermint oil, applying 1–2 drops to the affected area 3 times a day. A baking soda paste (baking soda mixed with a small amount of water) may be useful when applied to a sting wound.
Although most of these injuries are relatively minor, quite a few people are allergic to the toxins in the stings. Some are so allergic that they will have an anaphylactic reaction. Instead of just local symptoms, such as rashes and itching, they will experience dizziness, difficulty breathing, faintness, or all of these. Severe swelling is seen in some, which can be life threatening if it closes the person’s airways.
Although large spiders, such as tarantulas, cause painful bites, most spider bites don’t even break the skin. In temperate climates, two spiders are to be especially feared: the black widow and the brown recluse.
The black widow spider is about ½ inch long and is active mostly at night. They rarely invade your home, but can be found in outbuildings like barns and garages. The female southern black widow (Latrodectus mactans) has a red hourglass pattern on the underside of its abdomens; males and juveniles vary in color and may not have the hourglass, and some widow species also vary from the southern black widow in appearance. Although the black widow’s bite has very potent venom that can damage the nervous system, the effects on each individual victim vary considerably.
A black widow bite will appear red and raised, and two small puncture marks may be visible at the site of the wound. Severe pain at the site is usually the first symptom and appears soon after the bite. Following this, may appear:
Nausea and vomiting
Each person will present with a variable combination and degree of the symptoms listed above. The very young and the elderly are more seriously affected than most. In your exam, you can expect rises in both heart rate and blood pressure.
The brown recluse spider is, well, brown, and has legs about 1 inch long. Unlike most spiders, it only has six eyes instead of eight, but they are so small it is difficult to identify the species from this characteristic.
Victims of brown recluse bites report them to be painless at first, but then may experience the following symptoms:
Pain, sometimes severe, after several hours
Nausea and vomiting
The venom of the brown recluse is thought to be more potent than a rattlesnake’s, although much less is injected in its bite. Substances in the venom disrupt soft tissue, which leads to local breakdown of blood vessels, skin, and fat. This process, seen in severe cases, leads to necrosis (death of tissue) immediately surrounding the bite. Areas affected may be extensive.
Once bitten, the human body activates its immune response as a result, and can go haywire, destroying red blood cells and kidney tissue, and hampering the ability of blood to clot appropriately. These effects can lead to coma and eventually death. Almost all deaths from brown recluse bites are recorded in children.
The treatment for spider bites includes the following:
• Thorough washing of the bite area
• Ice, applied to painful and swollen areas
• Pain medications, such as acetaminophen (Tylenol)
• Enforced bed rest
• Warm baths for those with muscle cramps (black widow bites only; do not apply heat to the area with brown recluse bites)
• Antibiotics, to prevent secondary bacterial infection
Home remedies include making a paste out of baking soda or aspirin and applying it to the wound. The same method, using olive oil and turmeric in combination, is a time-honored tradition. Dried basil has also been suggested; crush it between your fingers until it becomes a fine dust, then apply to the bite. Be aware that these methods may be variable in their effect from patient to patient.
Although antivenins exist and may be lifesaving for venomous spider and scorpion stings, these will be scarce in the aftermath of a major disaster. Luckily, most cases that are not severe will subside over the course of a few days, but the sickest patients will be nearly untreatable without the antivenin.
Most scorpions are harmless; in the United States, only the bark scorpion of the Southwest desert has toxins that can cause severe symptoms. In other areas of the world, however, a scorpion sting may be lethal. Some scorpions may reach several inches long; they have pincers and, as with other arachnids, eight legs. They inject venom through a barb at the end of their tails. They are most commonly active at night.
The nervous system is most often affected from a bark scorpion sting. Symptoms of scorpion stings may include the following:
Pain, numbness, tingling, or all of these, in the area of the sting
Increased saliva output
Restlessness or twitching
Rapid breathing and heart rate
When you have diagnosed a scorpion sting, do the following:
• Wash the area with soap and water.
• Remove jewelry from affected limb (swelling may occur).
• Apply cold compresses to decrease pain.
• Give an antihistamine, such as diphenhydramine (Benadryl).
If you do the following things quickly, this may slow the venom’s spread:
• Keep your patient calm to slow down the spread of venom.
• Limit food intake if throat is swollen.
• Give pain relievers, such as ibuprofen or acetaminophen, but avoid narcotics, as they may suppress breathing.
• Don’t cut in the wound or use suction to attempt to remove venom.
Although not likely available in an austere environment, there is an antivenin that eliminates symptoms in children (the group most severely affected) after 4 hours.
Head injuries can be soft-tissue injuries (brain, scalp, blood vessels) or bony injuries (skull, facial bones). Damage is usually caused by direct impact, such as a laceration in the scalp or a fracture of the cranium, the part of the skull that contains the brain. Anyone with a traumatic injury to the head must always be observed closely, as symptoms may take time to develop.
An “open” head injury means that the skull has been penetrated with possible exposure of the brain tissue. If the skull is not fractured, it is referred to as a “closed” injury. Damage can also be caused by the rebound of the brain against the inside walls of the skull; this may result in rupture of blood vessels and bleeding (a contrecoup injury). There may be no obvious penetrating wound in this case. An example of this would be the violent shaking of an infant.
The brain requires blood and oxygen to function normally. A traumatic brain injury (TBI) that causes bleeding or swelling inside the skull may increase the intracranial pressure. This causes the heart to work harder to get blood and oxygen into the brain. Hematoma (blood accumulation) could occur within the brain tissue or between the layers of tissue covering the brain. Pressure that is high enough could actually cause a portion of the brain to push downward through the base of the skull. Known as a “brain herniation,” without modern medical care, this almost invariably leads to death.
Most head injuries result in only a laceration to the scalp and a swelling at the site of impact. Cuts on the scalp or face may bleed heavily, as there are many small blood vessels that travel through this area. This bleeding does not have to signify internal damage; most cases can be treated as any other laceration. There are a number of signs and symptoms, however, that might help in identifying patients who are more seriously affected. They include the following:
Loss of consciousness
Nausea and vomiting
Bruising around eyes and ears (“raccoon sign”)
Bleeding or fluid leakage from ears and nose
Confusion, apathy, or drowsiness
One pupil more dilated than the other (nerve compression)
Indentation of the skull
A concussion is a head injury that results in changes in brain function, even for a very short period of time and does not necessarily include loss of consciousness. Indeed, most concussions are not associated with loss of consciousness.
If brief loss of consciousness does occur, the patient will usually awaken somewhat “foggy,” and may be unclear as to how the injury occurred or the events shortly before or after. Effects are usually temporary but can include headaches (the most common symptom), ringing in the ears, dizziness, and problems with concentration, memory, balance, and coordination. They may appear sluggish or tired.
It is important to be certain that the patient, once awake, has regained normal motor function. In other words, make sure they can move all their extremities with normal range and strength. Even so, rest is prescribed for a day or two, so that they may be closely watched. Acetaminophen should be given for headache instead of aspirin or ibuprofen, because of the risk of bleeding.
It’s OK to let your patient get some sleep. Once asleep, it might be appropriate to awaken them about every 2 hours to make sure that they can be aroused and have developed none of the danger signals mentioned.
In most cases, a concussion causes no permanent damage if further trauma is avoided. Multiple episodes of head trauma over time, however—as in the case of boxers or some other athletes—can lead to long-term brain damage. This can manifest as follows:
Psychological problems such as depression
Disorders of taste and smell
Sensitivity to light and noise
If the period of unconsciousness is more than 10 minutes in length, you must suspect the possibility of significant injury. Vital signs, such as pulse, respiration rate, and blood pressure, should be monitored closely. The patient’s head should be immobilized, in case there is damage to the spine. Verify that the airway is clear, and remove any possible obstructions. Without advanced care, this person will be in a life-threatening situation, with few options, if consciousness is not regained.
SPRAINS AND STRAINS
Bones, joints, muscles, and tendons give the body support and locomotion, and there is no substitute for having all your parts in good working order. The amount of work these structures will be called upon to do after a disaster will be greatly increased. Therefore, the medic will expect to see more injuries; it is important to know how to identify and treat these problems.
Many people have heard of ligaments, tendons, sprains, and strains but have little idea of what they really are. Therefore, let’s define some anatomical terms:
Joint—the physical point of connection between two bones, usually enabling a certain range of motion, for example, the knee or elbow joint
Ligament—the fibrous tissue that connects one bone to another, oftentimes across a joint
Tendon—tissue that extends from muscle to connect to bone
Sprain—an injury where a ligament is excessively stretched by forcing a joint beyond its normal range of motion
Strain—when the muscle or its connection to the bone (tendon) is partially torn as a result of an injury
Rupture—a complete tear through a ligament or muscle
Our joints are truly marvels of engineering. They help provide mobility and locomotion and sometimes bear an incredible amount of stress without mishap. They are moving parts, however, and moving parts wear down. In a disaster, our level of physical exertion may increase; the risk of injury to the joints increases as well.
You can expect the most common sprains in your group to involve the ankle, wrist, knee, or finger. The most likely signs and symptoms are bruising, swelling, and pain.
Treatment for most sprains is relatively straightforward and follows the easy-to-remember RICES protocol:
Rest. It is important to avoid further injury by not testing the injured joint. Stop whatever actions led to the injury, and you will have the best chance to recover fully.
Ice. Cold therapy decreases both swelling and pain. The earlier it is applied, the more likely it will speed up the healing process. If you’re in the wilderness, have some instant cold packs in your backpack, as ice may be unavailable.
Cold therapy should be performed several times a day for 20–30 minutes or so each time for the first 24–48 hours. This is followed each time by applying compression.
Compression. A compression bandage is useful to decrease swelling and should be applied after each cold therapy. This will also help provide support to the joint. After applying some padding to the area, securely wrap an elastic bandage, starting below the joint and working your way up beyond it.
Any tingling, increased pain, or numbness tells you that the wrap is too tight and should be loosened. An excessively tight wrap may affect the circulation and cause fingertips to turn white or even blue.
Elevation. Elevate the sprain above the level of the heart. This will help decrease swelling at the site of the injury. By elevating the leg, you allow inflammatory fluid to process itself back into your circulation and aid the healing process, or at least not impede it.
This also works for swollen ankles due to chronic medical problems, like high blood pressure; even pregnant women achieve relief from swollen ankles in this fashion.
Stabilization. Immobilizing the injury will prevent further damage. This may be accomplished by the compression bandage alone or may require a splint or a cast. If the patient is unable to place much weight on the joint, this strategy will be especially useful.
Splints may be commercially produced, such as the very useful SAM (structural aluminum malleable) splint, or may be improvised with sticks and cloth or pillows and duct tape. Make sure the injured joint is immobile after placement of the splint.
How can you tell the difference between a sprain and a fracture? Sometimes it’s quite easy, as when a straight bone is suddenly “zig-zag” in shape. Often it’s quite difficult to determine without modern diagnostic tests.
You can, however, look for one or more of these signs that an injury may relate to a fracture rather than a sprain:
• A fracture will generally have more pronounced swelling and bruising.
• A fracture is generally so painful that no traction or pressure may be placed on the injury.
• A fracture may have a deep cut in the area of the injury (called an “open” fracture, which is particularly dangerous because of the risk of infection).
• A fracture may show motion in an area beyond the joint (if your finger suddenly has five knuckles, you probably broke it).
• A fracture may present a grating sensation when the point of the break is pressed.
For sprains, ibuprofen serves as both an anti-inflammatory and pain reliever. Most sprains heal well over time using the RICES protocol, pain relievers, and a lot of rest. Others, however, such as severe knee sprains with torn or ruptured ligaments, may heal completely only with the aid of surgical intervention.
It’s important to get joint issues dealt with while we still have modern medicine to help us. If you need surgery to fix a bad knee, do it now. In uncertain times, you (and your joints) want to be in the best shape possible to face the challenges ahead.
By far, the most frequently seen strain will be to the back muscles. Strains, especially back strains, involve injury to the muscle and their tendons (which connects them to the bone). As the lower part of the back holds the majority of the body’s weight, you can expect the most trouble here. Some of these injuries are preventable with some simple precautions:
• Every morning you should perform some stretching, to increase blood flow to cold, stiff muscles and joints.
• When you lift a heavy object, such as a backpack, keep your back straight and let your legs perform the work.
• The object should be close to your body as you lift it. (Don’t reach for it.)
• For packs, keep the weight on the hips rather than the shoulders.
• If you are on rocky or unstable terrain, consider using a walking stick for balance. Remember, any weight-lifting action that you perform while being off-balance is likely to result in a strained muscle.
Moist heat therapy seems to be effective for relief in back strains. Ibuprofen is an excellent anti-inflammatory and pain reliever for these types of injury. For muscle injuries, prescription relaxants such as diazepam (Valium) or cyclobenzaprine (FlexerilTM) will also provide relief. If these are not available, the patient will benefit from mild massage.
Common herbal pain relievers for orthopedic injuries include direct application of oil—including wintergreen, Helichrysum, peppermint, clove, or diluted arnica—to the affected area. Blends of these oils may also be used. Herbal teas that may give relief are valerian root, willow underbark, ginger, passionflower, feverfew, and turmeric. Mix warm tea with raw honey several times a day.
Some sprains and strains heal well over time with the therapy described above. Other injuries may cause chronic pain and eventual degeneration of the joint. It will be difficult to foretell the progress of an injured joint without modern diagnostic imaging.
A dislocation is an injury in which a bone is pulled out of its joint by some type of trauma. Dislocations commonly occur in shoulders, fingers, and elbows, but knees, ankles, and hips may also be affected. The joint involved looks visibly abnormal and is unusable. Bruising, pain, numbness, or all of these often accompany the injury.
A subluxation occurs when a dislocation is momentary and the bone slips back into its joint spontaneously. Subluxations can be treated the same way that sprains are, using the RICES method. It should be noted that the traditional medical definition of subluxation is somewhat different from the chiropractic one.
Of course, if there is medical care readily available, the patient should go directly to the local emergency room. General anesthesia if often used to resolve the problem. Off the grid, however, you will probably have to correct the dislocation yourself. This is known as performing a “reduction” of the injury.
Reduction is best performed very soon after the dislocation, before significant swelling occurs. Not only does reducing the dislocation decrease the pain experienced by the victim, but, if performed correctly, will lessen the damage to all the blood vessels and nerves that run along the injury.
Expect significant pain on the part of the patient during the actual procedure, however. Some pain relievers, such as ibuprofen, may be useful to decrease discomfort from the reduction. Prescription muscle relaxers, such as cyclobenzaprine (Flexeril), are also helpful.
The use of traction will greatly aid your attempt to fix the problem. Traction is the act of pulling the dislocated bone away from the joint to give the bone room to slip back into place.
The procedure is as follows:
1. Stabilize the joint from which the bone was dislocated (the shoulder, for example).
2. Using a firm but slow pulling action, pull the bone away from the joint. This will make space for the bone to realign.
3. Use your other hand (or preferably a helper’s hands) to push the dislocated portion of the bone so that it will be in line again with the joint socket. The bone will naturally want to revert to its normal position in the joint.
4. After the reduction is complete and judged successful, immobilize the joint to prevent further injury (see next section).
Some dislocations, such as that of a finger, may take as little as 2–3 weeks to regain normal function. Others, such as hip dislocations, may take many months to heal.
If enough force is applied, an injury to soft tissue can damage the skeletal structure underneath. When a bone is broken, it is termed a “fracture.” There are several types of fractures, but for our purposes let’s assume that they are either “open” or “closed.” A closed fracture is when there is a break in the bone, but the skin is intact. In open fractures, the skin is pierced by the broken bone or there is some other penetrating trauma. The end of the bone may be above or below the level of the skin.
Needless to say, there is usually more blood loss and infection associated with an open wound. The infection may be deep in the skin (cellulitis), the blood (septicemia), or the bone itself (osteomyelitis) and could be life threatening if not treated. If poorly managed, a closed fracture can become an open fracture.
The diagnosis of a broken bone can be simple, as when the bone is obviously deformed, or difficult, as in a minimal, “hairline” fracture. X-rays can be helpful to differentiate a small fracture from a severe sprain, but that technology won’t be available in a power-down situation.
Dealing with a fractured bone involves first evaluating the injured area. Use EMT scissors to cut away the clothing over the injury. This will prevent further injury that may occur if the patient is made to remove their own clothing. Check the site for bleeding and the presence of an open wound; if present, stop the bleeding before proceeding further.
Fractures may cause damage to the patient’s circulation in the limb affected, so it is important to check the area beyond the level of the injury for changes in coloration (white or blue instead of normal skin color) and for strong and steady pulses. Usually, normal color returns to skin in the fingertips within 2 seconds of applying pressure and then releasing (capillary refill time.
To find out what a strong pulse feels like, place two fingers on the side of your neck until you feel your neck arteries pulsing. You will do this same action on, say, the wrist, if the patient has broken his or her arm. Lightly prick the patient in the same area with a toothpick to make sure they have normal sensation. If not, the nerve has been injured.
If the bone has not deformed the extremity, a simple splint will immobilize the fracture, prevent further injury to soft tissues, and promote appropriate healing. Often, however, the bone will be obviously bent or otherwise deformed, and the fracture must be reduced, as we discussed with dislocations. Although this will be painful, normal healing and complete recovery will not occur until the two ends of the broken bone are realigned to their original position.
Splint the extremity in place immediately after performing the reduction. Traction to keep the bone straight may be necessary in many cases. In an open fracture, thorough washing of the wound is absolutely necessary to prevent internal infection. Infection will invariably occur in a dirty wound, even if the reduction is successful. Therefore, antibiotics are important to prevent complications, such as osteomyelitis. Always check the pulses and capillary refill time after the reduction is performed; this will ensure adequate circulation beyond the level of the injury.
It is very important to immobilize the fractured bone in such a fashion that it is allowed to heal. When you are responsible for the complete healing of the broken bone, remember that the splint should immobilize it in a position that it normally would assume in routine function.
Splints can be commercially produced or may be improvised, using straight sticks and bandannas or T-shirts to immobilize the area. Another option is to fold a pillow around the injury and duct tape it in place.
Fractured fingers and toes may be splinted by taping them to an adjoining digit, called the “buddy method.” There are small manufactured splints that will also do the job. Neck injuries may be particularly serious, and an investment should be made in purchasing a good neck collar.
For most fractures, you will want to consider the placement of a cast to enforce immobilization. Casting material using plaster of Paris or fiberglass is easy to obtain and lasts a long time. It’s a useful addition to any medical storage.
When placing a cast, you will first start with a liner of cotton known as a “stockinette.” Then, you will need rolls of padding to form a barrier between the skin and the cast. Rolls of plaster of Paris or fiberglass are then immersed in water for 20 seconds or so. Wring out the excess water. (Keep the end of the roll between your fingers or it will stick and be difficult to find.)
Then, begin to slowly roll the casting material around the area of the fracture, smoothing it out as you go along. Advance one-half of the thickness of the roll as you go from beyond the fracture towards the torso. You will want perhaps three layers of casting material on the area, more in places where there is a bony prominence, such as the wrist.
Each fracture is casted somewhat differently, and stockinettes, padding, and casting rolls are available in different widths and lengths appropriate to the particular fracture. Although oscillating saws are used today to remove casts, special heavy-duty shears are still available for the purpose, although some effort is required to use them.
Your goal is to immobilize the fracture in a position of function. Use padding under the splint or cast to keep the injured area stable and protected. Most fractures require 6–8 weeks to form a callous, newly formed tissue that will reunite the broken ends of the bone. Larger bones or more complicated injuries take longer to “knit” together. If the fracture is not realigned well, the function of the affected extremity can be permanently compromised.
Rib Fractures and Pneumothorax
Rib fractures are commonly treated by firmly taping the affected area, as it is the motion of breathing that causes the pain associated with the injury. Although reduction is usually not necessary, taping the area may help provide pain relief.
Rib fractures become more serious if the fracture punctures a lung. This causes a pneumothorax (collapsed lung), a condition in which air from the puncture enters the chest cavity, compressing the lung and collapsing the organ.
Although a person with a rib fracture will complain of pain with breathing, a person with a pneumothorax will have signs of bluish skin coloration (cyanosis), distended neck veins, and signs of shock. If you use a stethoscope, you will hear the sounds snap, crackle, and pop, familiarly associated with Rice KrispiesTM cereal when you listen to the lungs, or perhaps no breath sounds at all from the affected area.
If the pneumothorax has become life threatening, known as a “tension pneumothorax,” you may have to decompress the lung. This should only be attempted if it’s clear the patient will die without this action being taken.
Clean the area of the chest above the third rib, midway between the top of the shoulder and the nipple. Using a sharp object no wider than a pencil, poke a hole above the rib (the blood vessels travel below the rib) deep enough to hear air pass through. A large-gauge (14 or larger) decompression needle is commercially available.
Your goal is to provide a way for the air to continue to escape from the incision you made but not to go back in. This is called a “chest seal” and manufactured versions are available. To improvise, take a square of plastic wrap or a plastic bag and firmly tape it above the skin incision on three sides only. This will serve as a valve, which allows air to escape from the chest cavity and the lung to reinflate.
Inflammatory or bloody fluid is likely to accumulate in many lung wounds. You will have to rig a drainage system to keep fluid from preventing adequate air passage. A rubber tube connected to a jar placed below the patient may perform this duty by using gravity. It will not, however, be as efficient as the electric suction systems available at your local hospital. It’s important to realize that chest wounds will be difficult to recover from without advanced care.
In rare circumstances, damage to a limb may be so extensive that it cannot be saved. Amputation is the surgical removal of all or part of an extremity. This procedure is performed on arms, legs, hands, feet, fingers, or toes. The closer to the torso that the amputation was performed, the higher the death rate will be.
Amputation, even in a survival situation, is a last resort. In many cases, your patient will not survive it. At least 25 percent of American Civil War soldiers undergoing the procedure by trained personnel lost their lives because of bleeding or infection.
Having said that, there are various reasons why amputation might be necessary:
Damaged blood vessels that fail to provide oxygen to tissue
Extensive injury from trauma or burns
Look for the following to identify where to cut and how much to remove:
Where an extremity loses a pulse
Areas when a limb loses normal temperature
Areas of reddened skin (infection) or blackened skin (gangrene)
The place where the extremity is no longer sensitive to touch
Areas where the bone has been crushed beyond repair
The following are basic measures to increase the chances of a successful amputation:
• Sedate the patient as much as possible.
• Clean the damaged area with Betadine or other antiseptics before the procedure.
• Use sterile gloves in a sterile field.
• Remove debris and bits of shattered bone.
• Tie off bleeding blood vessels.
• Preserve an adequate amount of living tissue to cover the exposed end of the bone.
• Shorten and smooth the bone enough to decrease irritation to the covering soft tissue.
• Stitch remaining muscle to the bone lining (periosteum), which is difficult without special equipment.
• Before closing completely, place a drain (discussed earlier in this book) to enable blood and inflammatory fluid to leave the surgical site.
• Adequately close the wound with sutures or staples.
• Change dressings regularly.
• Observe for infection and, if present, start a course of antibiotics.
Amputation is a procedure we hope you will never have to consider. In severe injuries, however, it may be an avenue of last resort.