After the IFAK: Part III
Thank you for coming back for the final article in the After the IFAK series. The subject for today is wound care; with a goal of solving the mystery of “what now?” So far we have learned about tourniquet conversion and hypothermia, which are lifesaving or limb-saving considerations for minutes to hours after the initial incident.
In this article we are going to stretch the timeline even further. In our hypothetical, we will assume that our patient must wait for 3 days for evacuation, and if the weather or terrain does not permit, up to a week. This can be a dire situation, and it is one that mountaineers and rock climbers have dealt with in the past. If someone sustains an injury that required a tourniquet and conversion, the resulting peril can be very real. How does the average kommando go about decreasing these risks?
To answer that question we will discuss four elements of wound care: debridement, irrigation, dressing changes, and closure.
**NOTE** I do apologize for the lack of images in this article. I have provided some for the other articles in this series, but that is because I had the materials to show. The topics covered in here require real wounds in order to show, and I don’t know anyone with a fresh one just hanging around. Thank you for understanding.
Debridement is derived from the word “debris,” which is foreign material that may have entered the wound. This would be dirt, grass, rocks, or any other matter that could be lodged in the wound itself.
Debridement is generally a surgical technique to be practiced in a hospital. Wounds will produce necrotic tissue that needs to be removed, often during a surgical process or famously with maggot larvae. This is something we will not practice in the field.
For our level, debridement should only include visible debris that we can see is not helping to control the bleeding. Things that can be removed with your fingers or the pliers of a multitool. Do not scrape against the wound cavity to remove debris, because you may remove healthy tissue or cause further damage. We will not attempt to cut any dead tissue out in the field.
Removing as much foriegn matter as possible will help keep more bacteria from residing in the wound and can relieve some of the irritation. This will also give more surface area for the wound to contact clean dressings and be irrigated in later steps.
Irrigation is the process of using a liquid to clean the wound. Often in a hospital this is done with distilled water or a saline solution. Unless you have a medic buddy with the hookups for IV bags, it’s doubtful you’ll have that in the field. So you’ll have on you whatever water you likely brought with the drink.
Water should be the only liquid considered fit for irrigation. Soft drinks will dirty the wound more than it will clean it, and alcohol will not have the cleaning effect that we have come to know as a trope from many movies. Anything that is not water will very likely cause more harm than help.
The water should have two qualities; first it should be clean, second it should be warm.
Cleaning the water can exist in several forms. If it comes from an already clean source, like bottled water, you’ve saved yourself a step. Otherwise, if you must source water locally, you will have to ensure it is cleaned through purification methods such as iodine, filters, or boiling.
The water you irrigate with should be warm to the touch, but not hot. You want it to resemble an internal body temperature as closely as possible to eliminate discomfort or shock that a vast temperature difference could impose on your patient. Water that is too cold or too hot can be a very painful experience, and for a patient that may already be in and out of consciousness, such a shock could be too much to handle.
When you irrigate you want to do so with little to no water pressure, and position the patient so that the wound will drain naturally. You do not want standing water in the wound. As you pour water in, and equal amount should be flowing out and draining, creating a steady stream. The purpose of this irrigation is to carry debris and bacteria out of the wound cavity. There is no benefit to water remaining in the wound. Irrigate for at least 5 minutes if water permits, or as long as the patient can tolerate.
Stuffing the wound with gauze is a skill that’s taught for the initial event that even the dullest tool in the shed could figure out. Shove gauze in until no more fits, wrap it up, call it a day.
However, hours after the injury that simple task starts to complicate. Over time as the body pours blood and puss into the wound, the gauze will soak up every bit of that nasty concoction and the wound will stew in it. This is obviously not good.
When you see that a would has started to soak through the gauze, it is time to change the dressings. This is quite simple, as you just remove the old gauze and put in new gauze. Things that may complicate this procedure do arise. One must carefully consider that the wound may have not stopped bleeding completely, and that removing the dressing may cause a clot to reopen. Whenever you change a dressing, be sure to have a hasty tourniquet or a hemostatic dressing on hand in case you open the blood flow back up.
One must also ensure that the new dressing is clean. If you are out of gauze and must resort to something like a t-shirt or scarf, boil it in hot water and dry it out first. Filling a wound with a dirty shirt may end up causing more harm than good, and you don’t want someone catching a rapid systemic infection after you worked so hard to save them from a hemorrhage.
Frequency of dressing change depends on the wound. For our purposes, monitor the wound area and see if the dressings are becoming soaked. When you can see that the dressing is starting to stain a yellowish-red, it is time to remove the old dressing, irrigate, and change to a new, clean dressing.
Wound closure is a subject that could fill a book all to itself. In a hospital setting, there are many different considerations and techniques. Fortunately for us, in the field we don’t have to consider any of these, because wound closure is something we actually want to avoid.
Movies are rife with people utilizing makeshift sutures, or cauterizing wounds close with their kabar fresh from a fire. This is complete cinematic nonsense.
A little known fact is that quite a lot of harmful bacteria cannot survive in the open air. It can exist and remain inert, or if alive, cannot stay alive very long. It relies on a closed, warm, moist environment to thrive. If inside a wound that is dirty but freshly closed, it has found the perfect home.
Additionally, wounds will swell and produce fluid. Puss and plasma weep out from the exposed tissue as the body pushes materials to the injured area to attempt to heal. Closing a wound that needs draining is quite the recipe for disaster.
But obviously we cannot just leave a wound out to get a sun tan. We will stabilize the wound with a wrap or pressure dressing to ensure it moves as little as possible, but we will not apply any permanent closure such as a suture or staples. Since we will need to access the wound every few hours to irrigate change the dressings, removing staples or sutures each time would cause unnecessary tissue damage in addition to being tedious and difficult.
AFTER THE IFAK: Conclusion
Thank you for reading this three part series. Medical training for the kommando often covers what to do in the first five to ten minutes after an injury. This is great knowledge if someone gets shot in an urban indoor shooting range. Though, on a hunting trip to a remote environment, or perhaps a camping venture miles from town where a fall and a sharp branch causes a freak injury, that training will leave you woefully short. I hope you’ve pulled some helpful tips and good info from this short series of introductions to prolonged fieldcare topics.
If you would like to know any more about prolonged field care, or have suggestions for further medical articles, please consider joining the TKB discord. Myself, as well as other medically trained contributors post regularly and always, always welcome feedback.