(from scrapes to sutures)
By George E. Dvorchak Jr. M.A., M.D.
SKIN, which covers our body, has the important function of pro
tecting the internal organs and tissues from the environment and
physical objects. Technically, this protective covering is also
our largest body organ and the first line of defense from in
juries and bacteria. With injury, the outer layer of skin, the
epidermis, is either scraped away or opened-up to permit bacteria
and materials to enter. In a more severe wound, the next layer
downward, the dermis is penetrated. This contains connective
tissue, sweat glands, hair follicles, nerves, lymph and blood
vessels. Generally speaking, the deeper the wound, the more
serious the consequences it can have for the body.
As survivalists, you want to be prepared for about anything at
any time. Therefore, the best approach to a presentation on wound
care is to cover everything from the simple closed wound to more
serious injuries. In these, the skin has been compromised and the
wound is therefore referred to as open.
CLOSED WOUND TO THE SKIN: This is the common BRUISE or CONTUSION
which is caused by a blunt object impacting upon the body. The
result is that blood will begin to leak from the injured vessel
under the skin which then causes that area to change color to a
black or blue. The good thing with this injury is that because
the skin has not been broken, infection is not a great possibili
ty. Therefore, the immediate first aid treatment is to apply ice
for about 10 minutes and then throughout the day. Even though the
skin was not broken, this could still be a serious problem, one
depending on what was injured beneath the skin and the amount of
force that originally caused the injury. If an internal organ in
the abdominal area was severely injured, bleeding could be taking
place internally without evidence externally. When traveling or
hunting with horses, an injury could happen by simply stopping to
adjust a load on a pack horse. If he gets spooked and you kicked,
an internal injury could result. A hard kick to the abdomen when
days from medical care could cause internal bleeding that may be
fatal. Not all is obvious at all times!
OPEN WOUNDS TO THE SKIN: It is in this category where everything
from a band-aid to sutures are necessary along with special
considerations and concerns. In beginning with the least serious
of six major categories of open wounds, we have the ABRASION.
This is where the outer surface of skin has been scraped away as
from a scratch or rope burn. There is usually some minor oozing
of blood and serum.
Depending on how the injury was obtained, there is usually dirt
or foreign matter ground into it. This problem brings to light
another player against wound healing, infection. The treatment
now goes beyond the application of ice. To treat an abrasion as a
scraped knee, the wound must first be cleansed with soap, water
and if available, hydrogen peroxide. This will remove dirt that
will cause an infection and therefore impair healing.
Once cleaned, the wound should be blotted dry with a clean cloth
or preferably a sterile gauze. It now would also be a good idea
to apply pressure over the injured site for a few minutes for the
purpose of slowing down and hopefully stopping any bleeding. The
application of a first aid or antibiotic cream to the abrasion
could help to prevent infection and keep the bandage that you
will apply from sticking to the raw wound. For the best protec
tion, the bandage should cover an inch beyond the wound. An ice
pack over the final bandage can serve to reduce swelling and some
of the discomfort. The next category of wounds is the INCISION.
This is made from a sharp knife-like object that leaves a clean
cut. To keep this one separated from the next, think of a surgi
cal incision where the cut edges are smooth.
The third is the LACERATION which is similar but with jagged
edges due to a tear. Because these go beyond the outer layer of
skin and into the deeper layers that contain blood vessels, there
is a lot of bleeding. If you were deep enough or unlucky enough
to cut an artery, blood will squirt out with each heart beat due
to the high pressure in these vessels. The best approach here is
to apply a pressure dressing and get to medical care where su
tures will usually be needed to fully or partially close the
wound, depending on if it was dirty or clean. Because suturing is
a common medical procedure, I will later outline some information
on what is involved to better inform you of your doctor's op
tions.
The next wound is the PUNCTURE. As its name implies, this is
when a foreign object is pushed into the skin. This could be a
splinter that only penetrates the superficial layers of skin or a
nail, sharp stick or fishing hook that penetrates deeper. With
this you usually will not see much external blood which does not
mean that there is little internal bleeding. To treat something
such as a puncture wound to the foot from a nail, all you can do
is to put ice on it along with a pressure wrapping and get to
medical care. This is critical since if you are not already
protected against tetanus, you will need to get an injection for
such protection. If you are in the outdoors a lot, it pays to
keep your immunizations updated.
The next skin wound is the AVULSION. This is where skin is
pulled or torn off. As with an AMPUTATION, the severed tissue
should be saved and taken with you to the hospital. If a finger,
a pressure dressing over the stump or if skin, again a pressure
dressing over the wound is about all one can do until medical
facilities are reached. One other point should be addressed
concerning "serious wound" dressings. That is, once a dressing is
applied, leave it alone and do not take it off every 20 minutes
to check the wound. If unnecessarily disturbed, all you will be
doing is to undo the positive measures already applied.
WOUND MANAGEMENT SUMMARY: The first concern with any wound is to
control bleeding. On the first aid level, this usually means
through the use of a pressure bandage. The next concern is to
prevent wound contamination which refers to cleaning the wound
and applying a sterile bandage and possibly an antibiotic oint
ment. Lastly, immobilization of the inured part along with rest
and if severe, medical intervention, are all wise procedures.
The Mystery Of Sutures - Many of us while growing up had to be
sewn back together. My father, a small town GP who did it all put
six in my leg and another six or seven in my chin all before the
age of 12. If you were like me, you just wanted to get it over
with and therefore could not have cared about details. In the
following, I will give a general summary of what suturing encom
passes. Hopefully, this will help to lift some of that curtain of
mystery concerning this common procedure.
THE SUTURE ITSELF: The thread like material attached to a
curved needle or used on a straight one is absorbable and used
internally or nonabsorbable and used internally and externally as
in holding skin together. Some of the materials used in the
non-absorbables and that which we are concerned with are made
from silk, cotton, nylon, dermal and stainless steel. One of the
reasons for all of the different materials concerns tissue reac
tion to something foreign to the body even though it is serving a
purpose. All the body knows is that there is a foreign substance
within it that was not there before. The body can then react
against this invader and you will get a tissue reaction. The
reason stainless steel is popular in surgery by some surgeons is
that of all the suture materials, it evokes the least tissue
reaction.
Suture size is also important since different materials and
weights of thread are matched to the task and tissue. Generally
speaking, suture material should not be stronger than the tissues
it is expected to hold together. Of all the sutures, those of
silk or nylon are most widely used in holding skin together. The
size is designated as 2-0 or 00, 3-0 or 000, etc. The smaller the
number, the stronger the material. To hold skin together, a 000
or 0000 is generally used. Needles attached to the thread can
either be straight or curved with those curved most commonly used
in your doctor's office. With ones curved, a needle holder or
hemostat is required to use it.
A friend of mine who is an orthopedic surgeon told me that he
would recommend a straight needle for use in the outdoors to
close the skin since a needle holder is not needed. When using a
continuous suture with a straight needle, this would be the
quickest way to close a skin wound. If you are heading into
remote areas and feel that you would like to know how to do this,
I would recommend that you ask your family doctor for advice
since he best knows you and would be the one to advise you on
this. Yet, for most lacerations, a pressure dressing over the
wound would be the preferred procedure until medical care would
be available.
Another consideration your doctor will have to be careful about
is that after skin has been sutured back together, edema or
swelling of the tissues usually enters into the picture. If the
suture was originally tight, with swelling, it will soon be too
tight. Therefore, proper tension the first time the job was done
is critical to good healing.
The purpose of suturing is to pull the tissue together just
enough so that there will be no dead spaces below the skin where
blood and fluid can accumulate. If there is, it will eventually
be a breeding ground for an infection. In staying with how su
tures are put in, it is also important that the same amount of
tissue be included on each side of the suture. If the suture
includes more tissue on one side than the other and/or the needle
is inserted deeper on one side than the other, when tied togeth
er, the skin edges can overlap causing poor wound healing and/or
a scar. All your doctor wants to do is to put the severed edges
back like they were before the accident so that the body can
complete the job of healing.
Because a medical emergency as a laceration can happen anywhere
with the worst place being when medical care is not readily
available, I would highly recommend a Red Cross first aid course.
Once this is completed, I would then recommend that you take
advanced courses and hopefully get certified as an Emergency
Medical Technician. Also, if you go on outfitted back country
hunts, one of the questions you should ask of the outfitter/guide
is if he or she is certified in first aid. In the event that your
guide would get inured, it would also be to everyone's advantage
if you were qualified to help him.
A rule of good medicine is to do no harm to your patient.
Therefore, take a first aid course and learn how to help yourself
and if the situation presents itself someone else.
(This article was from :American Survival Guide
January 1992)
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