Field Medicine, part 3
(part 1)
(part 2)
by Steadman
CHAPTER 3
For treatment and recording purposes, wounds are classified by cause, type, or appearance.
a. Classification by cause.
1. Bullet wounds. These wounds differ according to the type of weapon that fires the bullet. Damage to underlying tissue is affected by the size of the bullet and the velocity of the bullet as it strikes the patient.
2. Fragmentation wounds. These are wounds made by fragments of exploding grenades, mortars, mines, booby traps, rockets, bombs, and artillery rounds. The explosion throws bits of metal in all directions, often causing multiple wounds of varying sizes.
3. Wounds due to falls. A fall while a person is taking cover, especially with a pack on his back, can cause twisting, tearing, or wrenching wounds. A fall from a moving vehicle may result in broken bones and bruises.
4. Burns. Burns can be caused by many sources. The ones encountered most frequently are napalm weapons, flame throwers, gasoline, white phosphorus grenades, or marking rounds.
b. Classification by appearance.
1. Bullets and shell fragments make penetrating wounds, perforating wounds, or both. A penetrating wound is one in which the bullet or fragment enters but does not leave the body. Knife or bayonet wounds are also included in this category. A perforating wound is one in which the bullet or fragment goes all the way through the body and makes at least two wounds, one of entrance and one or more of exit. The exit wound is often larger than the wound of entrance and may be located in an area of the body distant from the entrance wound. Therefore, every patient with a bullet wound must be examined thoroughly to see if he has more than one wound.
2. A laceration is a cut or a tear. Unless they involve major blood vessels or impair breathing, lacerations are not a special lifesaving problem for the aid man. Since they can be large an dappear nasty, they may make the patient apprehensive. Usually their is more fright than pain with a laceration. The main problem with a lacerated wound is the problem of infection. To prevent infection and to promote growth of new tissue, the wound must be debrided. The process of debriding, or debridement, is the surgical removal of all dirt, contamination, and dead tissue. This procedure must be done at a treatment facility under sterile conditions. After debridement such wounds are often left unsutured for a few days. The procedure, called “delayed primary closure” or “DPC,” prevents infection and permits better healing.
3. A closed wound is one with internal damage to bones or tissue without a connecting wound in the outer skin. Sprains, strains, dislocations, and certain fractures are closed wounds.
Some pain occurs after most wounds. Pain may be mild or severe, depending upon the patient and the wound. The patient’s state of mind at the time of wounding will have some effect on the degree of pain. Fear and apprehension, for example, make it worse. To some patients the fear of pain is more real than the pain itself. You must decide whether or not the relief of pain is in the best interest of the patient. In many cases, pain is a helpful symptom to medical personnel. Pain is nature’s alarm system; silencing it may be detrimental to the patient.
a. You can give him some relief in these ways.
1. Positioning. The best position is the one which the patient finds most comfortable. Positioning the injured part to relieve stress can do much to relieve pain.
2. Reassurance. Talk to him reassuringly. Make him feel that he is in good hands and more help is on the way. The best type of reassurance is for you not to panic and to act as if everything is under control.
3. Medication. Administer an analgesic such as aspirin or APC. If oral medications and fluid are not contraindicated, aspirin is an outstanding drug and will relieve all but the most severe pain.
b. If the pain is extremely severe, you may have to give morphine if it is not contraindicated.
Morphine is the best pain relieving medicine you have, but it has several dangerous toxic effects. It is a powerful depressor of the central nervous system, greatly reducing respiration and pain sensation. Also it causes vomiting, dry mouth, constipation, and retention of urine. It must not be given by anyone who is not fully aware of its dangers. Never let morphine out of your possession. It may be stolen for personal use or sale on the black market.
a. Morphine is supplied to in 16 mg. (one-fourth grain) syrettes. The number of syrettes you carry are determined by your medical commander on the basis of the tacitcal situation, availability of evacuation, supply, and your ability to administer it intelligently. You must know the indications and contraindications for its use. If not you may do more harm than good. (Contraindication is any condition which makes a particular treatment undesirable or improper.)
b. Morphine is indicated for severe pain especially when the evacuation lag time is more than 20 minutes. In a tactical situation where a psychotic patient must be temporarily silenced or sedated, and no other tranquilizers are available, one syrette of morphine is often effective in controlling such a patient. This is an emergency measure only. There are better, nonaddicting drugs for psychosis than morphine.
c. Morphine is contraindicated when its toxic effect will compound an injury to a dangerous degree. Do not give morphine to: patients who are to be quickly evacuated, who have chest injuries, depressed respirations, or injuries of the head. Never give morphine to an unconcious person. Do not give morphine before surgery. If there is a probability that the patient may soon be operated on, he should not get morphine. Both morphine and surgical anesthesia depress respiration. If the patient is in shock, you should not give him morphine because it will not be absorbed due to poor circulation. (Medical officers sometimes administer morphine intravenously while the patient is in shock. Never should you try to give morphine intravenously. If it is given too fast it will be fatal.) A dose of morphine should not be repeated within 2 hours, or if there is any reason to believe the first dose has not been absorbed.
Control of hemorrhage, relief of pain, and prevention of infection are the main considerations in treating wounds in the field.
a. Acute loss of blood may lead to shock, and shock may lead to death. So, you should do all that you can to prevent loss of blood. The preferred method of controlling bleeding is with a pressure dressing securely applied. Lost vascular fluid (blood) or body fluid (tissue fluid) should be replaced.
b. Some wounds are more painful than others. In some traumatic amputations there may be relatively little initial pain, while in smaller wounds the pain may be severe. Second degree burns and massive tissue wounds involving many nerves are intitially painful. Nearly all wounds cause some pain.
c. Any wound recieved in the field should be considered contaminated. The best way to prevent more contamination is to cover the wound with a sterile dressing. Field wounds are “dirty” wounds. All contain bacteria. In the field, there is no way for you to cleanse a wound of bacteria. Pouring antiseptics into a wound will not kill all the bacteria and may be harmful. Pouring antiseptics on the skin around the wound does little to keep out bacteria and should be avoided. When possible, and when evacuation is impossible or delayed for longer than several hours, gently cleansing of the skin around the wound with soap and water may be helpful.
Infection of a wound involves the number and type of pathogenic organisms entering the wound, condition of tissue in the wound, and the body’s defense.
a. If the number of organisms is extremely large, they may overwhelm the body’s defense by sheer numbers. This is likely to happen in wounds caused by booby traps with filth and contamination about them. Punji stake wounds are another example.
b. Some organisms are more toxic than others. For example, the organisms that cause gas gangrene and tetanus are deadlier than some organisms that form pus.
c. A cleanly cut wound is not as apt to become infected as a torn, jagged wound. In the first type of wound, blood tends to flush out organisms and they have few places to hide and become imbedded. The second type of wound gives organisms devitalized tissue to hide in and has much less flushing action by bleeding. A puncture wound is most likely to become infected with tetanus and gas gangrene because of lack of oxygen. Penetrating and perforating wounds are usually heavily contaminated by foreign material carried into deep parts of the body. Penetrating abdominal wounds often permit contaminated intestinal contents to leak into the cavity.
Treatment of closed wounds
a. Sprain. A sprain is the twisting, tearing, and stretching of ligaments around a joint. Ligaments are strong, slightly elastic, fibrous bands of tissue that hold bones in position. A ligament can be over-stretched and some of its tissue cells injured, or it can be torn loose from its attachment to the bone. An injured ligament heals slowly and sometimes never entirely returns to normal. Diagnosis is made by the presence of a tender, painful joint with swelling. Fracture also must be considered a possibility with these findings.
1. A sprain is treated so as to temporarily replace the function of the ligaments by supporting the joint while allowing some movement. You carry elastic rolled bandages for this purpose. A figure-of-eight bandage around the joint should allow the patient to complete his immediate mission. The bandage should be adjusted as swelling occurs. Have a medical officer evaluate the patient after mission.
2. Analgesics may be given for pain.
3. Routine evacuation may be indicated.
b. Strain. A strain is an overstretching of a muscle or the muscle’s tendon. In abnormal situations, some muscles will be forced to function long after they are tired. This results in acute muscle fatigue or muscle strain. Diagnosis generally involves finding tender, painful muscles. Swelling is uncommon.
1. There is little you can do to treat a strain in the field. The patient needs rest with just enough exercise to keep the muscle from getting too stiff. You cannot provide this type of treatment in the field.
2. Analgesics may be given for pain.
3. Heat and massage are also very helpful.
4. It the strain is severe, routine evacuation is indicated.
c. Dislocation. A dislocation is the displacement of one of the bones forming a joint. A joint is the articulation of two or more bones. When one end of a bone forming a joint is forced out of its articulation, it is dislocated. The dislocation may be incomplete and temorary. In other words, it may jump out of and back into normal position, resulting in a condition much like a sprain. If the bone dislocates from its articulation and remains out of place, it is a complete dislocation. Damage to surrounding blood vessels and nerves may result.
1. You should not try to reduce a complete dislocation in the field.
2. Analgesics should be given for pain.
3. Immobilization of the joint in the position of least pain may be helpful. Usually that is the position in which you find it.
4. Routine evacuation is indicated unless damage to blood vessels or nerves is suspected because of paralysis, numbness, or absent pulse. In that case, priority or even urgent evacuation may be necessary.
Fractures or broken bones, are the result of a strong blow or stress against the body causing one or more bones to crack or break completely. Fractures are either closed (no break in the skin) or open ( skin broken). Open fractures are generally more serious, because of the danger of infection.
a. Diagnosis. The patient with a broken bone is almost always in pain at the fracture site. He will give a history of trauma or stress and often will state that he felt the bone snap or give way. He typically had great difficulty in moving the part of the body beyond the fracture. As you examine the patient, you will find swelling and tenderness at the fracture. The broken limb may be obviously deformed. Ultimately, X-rays will be needed to establish the diagnosis and extent of the fracture.
b. Treatment. As with any wounded patient, the first thing to do is save his life. Make sure he has a clear airway and can breathe. Stop external bleeding. Almost every fracture is accompanied by significant internal bleeding. A fractured femur, for example, may involve loss of as much as 1,500cc of blood into the thigh. Plainly, then, a patient with a fracture of a major bone is in danger of developing hemorrhagic shock. Therefore, intravenous solutions hsould be started as soon as possible on any patient with a fracture of a major bone. Place a dry sterile dressing over the wound if it is an open fracture. Administer analgesics for pain. The patient must be evacuated, but the category depends upon the seriousness of the fracture.
c. Splinting. Do not attempt to reduce or set a broken bone. In general, splint the fractured limb as you find it, checking the pulse beyond the fracture abfore and after splinting. If the pulse disappears after the splint is applied, it is on too tight and must be loosened. Also a record of nerve function distal to the fracture should be made. If the fractured limb is bent so that it pinches off the blood vessels, you may straighten it carefully as long as no force is needed. Never try to force an arm or a leg to lie straight. Splinting is extremely valuable because it prevents further damage to surrounding tissues by the broken bones. Also, splinting helps to reduce bleeding and pain.
d. Splints. Splints and splinting in the field will pose some problems. You do not carry splint sets, such as the Army leg splint set. You may carry the wire fabric splint. Some aidmen carry two wire ladder splint wrapped around the outside of the aid bag. To support missions where fractures might occur, you may carry a few pneumatic splints. The ones used in the field are improvised and anatomical splints.
1. An improvised splint is made of any rigid material that is readily available. Parts of the patient’s gear are often the handiest material you can use. Rolled or folded, the patient’s poncho makes a good splint. So does his rifle when rolled in a jacket. (Be sure the rifle is cleared.) Poles or branches from trees also can be used to make splints.
2. How much time you can spend on improvising a splint will depend upon the tactical situation. There may be instances where you have no time to improvise a splint. In that case, for a fracture of the forearm, quickly place the arm inside the jacket and tuck the jacket as tightly as possible. A fracture of the upper arm could also be treated this way or with a sling around the neck to the wrist. For a fracture of the leg, quickly tie the broken leg to the uninjured leg. This is an example of an anatomical splint, where one part of the body is used to help immobilize another part.
3. The wire fabric splint is useful in supporting a massive tissue wound. It can be fashioned to help support a broken ankle, wrist, or small bone.
4. The wire ladder splint can be used for a fractured arm or leg or to support a massive tissue wound. You should control the bleeding before applying a splint. If not, put on the splint so it can be removed easily and quickly.
5. A pneumatic splint is inflatable and made of transport plastic. You blow air into it by mouth to get the necessary rigidity. Do not use any other means for inflation (such as a tank of compressed air). The splint requires no padding and it can be inflated or deflated as desired. The splint should not be inflated and left on the patient more than 30 minutes at a time. To do so will interfere with peripheral circulation. Reduction of peripheral circulation for a long time causes tissue anoxia, which in turn results in damaged or necrotic tissue. Tissue damage is proportional to the duration of diminished peripheral circulation and the degree of tissue anoxia. Therefore, if the patient must wear a pneumatic splint for an extended time, partially deflate it every 20 to 30 minutes for a few moments to reestablish peripheral circulation if it appears that the blood supply to the extremity has been impaired. Do not use these splints unless you have time to check the patient every few minutes.
A dressing is a pad that is applied directly over a wound. A prepared dressing is usually made of gauze but it can be made of any absorbent material. The main purpose of a dressing for field use is to control hemorrhage and protect a wound against further contamination. Almost all external bleeding can be controlled with a correctly applied field dressing.
a. Sizes.
1. Dressing, first aid, 4 by 7 inches. This small field dressing is the one you probably will use the most. You should carry a plentiful supply of these. Many aidmen carry two aid bags, one filled with dressings and one containing other items. Be sure each person carries at least one small field dressing.
2. Dressing, first aid, 7 1/2 by 8 inches. This is usually called the medium field dressing. The average aidman carries two of these. They are used often to reinforce the small field dressing.
3. Dressing, first aid, 11 by 11 inches. This is the large fiel dressing. You usually carry one of this size. Most aidmen prefer to carry more small dressings and use two or three small ones instead of one large dressing. You can contour two or three small dressings better than a large one. Large dressings are best for extensive burns.
4. Dressing, first aid, field, individual troop, 100 by 120mm. This is a two piece dressing designed to allow one gauze pad to slide along the affixed bandage. One purpose of this adjustable dressing is to allow application of the dressing over a perforated wound of an extremity to cover the wounds of entrance and exit with the same dressing. This dressing is smaller and more versatile than other field dressings.
b. Applications. A field dressing has strips of gauze bandage attached to it. The gauze strips or tails are used to secure the dressings and to apply pressure. First, put a small dressing over the wound and tie the bandage tails firmly over the dressing to apply pressure. If the first dressing does not control bleeding, apply a second one over it. Again, tie the bandage tails firmly. Several small dressings are more effective than one large dressing for controlling hemorrhage.
A bandage is a piece of material used to cover a dressing, apply additional pressure, or immobilize a part of the body. Bandages may be made of gauze, muslin, or elastic cotton. They may be rolled or folded. Most aidmen prefer to carry a few elastic rolled bandages about 3 inches wide. Elastic bandages are used to reinforce dressings in the control of hemorrhage and to support ankles and knees. Rolled gauze bandages are not often used in the field. Triangular muslin bandages are sometimes used for support but are used most as tourniquets. Folded Triangular bandages (cravats) are useful in applying improvised splints.
