2017, May/June Adirondac Adirondoc
Skin lacerations are common backcountry mishaps. Most of the time, they are trivial, and heal well themselves. I have discussed the management of these wounds previously, but some recent new information in the wilderness medicine literature has prompted some comments about one particular aspect of wilderness wound management.
Wilderness physicians would agree that most lacerations can be managed in the backcountry as long as they meet a few criteria: skin edges spread less than half an inch; no involvement of vital underlying structures ( especially on the hand); bleeding easily stopped with direct pressure.
Once the decision is made that the wound can be safely handled in the backcountry, the next step is cleaning it. There is a popular misconception about the purpose of cleaning wounds. The intent is to remove dirt and debris, not to make the wound “sterile.” Our skin and environment are literally teeming with bacteria. Complete removal of these in the operating room, with high-tech equipment and medications, is a challenge; rendering anything truly sterile in a remote environment is impossible.
Particulate matter within a wound can provide a nidus for bacteria to grow and multiply, so removing such matter is important in preventing infection. The microscopic bacteria which inevitably remain within the wound will probably be dealt with very effectively by the body’s own defenses, such as white blood cells. Thus, the goal of cleaning is removal of any items that could allow bacteria to “hide,” then allowing nature to take its course.
Cleaning wounds begins with removing grossly visible particles: Dirt, vegetation, clothing fragments, and the like. This is best done with fine tweezers.
The next step is irrigation with water. This is where there is new information.
Wilderness first aid books are replete with improvised techniques for providing a continuous strong stream of water for cleaning cuts. As is the case with many such wilderness medicine improvisations, many are “cute” ( cutting a hole in a Ziploc bag, for example), but few are actually tested.
The current issue of the professional journal Wilderness and Environmental Medicine reports a study in which several methods, both improvised and commercial, were put to the test. This study was pretty complicated, and actually involved a simulated “test” rather than actual effectiveness on a wound. That being said, two methods frequently mentioned in wilderness medicine texts (bladder hydration systems and holes poked in a plastic bag) appeared to be the least effective. Various types of syringes ( some commercially available without prescription) and compressible water bottles seemed to be the most effective methods.
My personal favorite was not tested, although it actually is just a variation on the compressible water bottle. I always carry a bottle of contact lens irrigation solution in my backcountry first aid kit. Not only does this help anyone who forgot his or her own solution; it provides a ready source of sterile salt water for purposes such as eye or wound irrigation, treating a dental avulsion, and others.
Once the wound has been thoroughly irrigated, current guidelines call for the use of a local antibiotic ointment and a sterile dressing. Such wounds should be examined at least daily for any signs of infection, and immediate termination of the trek for medical evaluation should occur upon any suspicion. Hopefully, tetanus immunization status was updated prior to the trek!
~Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com.General First Aid