Sunday, November 11, 2012

Duct Tape and Safety Pins

Wilderness and Remote Medicine is practised in difficult environments with limited or no medical kit. A good medic will know how to improvise medical kit from common items found in an expedition ruck.
   For anyone finding themselves in the wild places of the world should have a roll of duct tape and some safety pins in their kit. While on patrol in the army I would always have black safety pins in my patrol cap within easy reach. You never know when a pocket flap could be torn or a lanyard broken that can easily be fixed with either of these two items. 

   As a Remote Medic, you are in the same environment. You are out providing medical cover for an exploration company, offshore oil platform, or possibly an academic research group. You need to have good kit available at all times and a way to quickly fix that kit once it is broken or torn. 

Practise these techniques at home.
   A good medic will test his or her creation on a noninjured person before applying it to a casualty. This will greatly enhance the efficiency of any improvised system. Creativity is needed when searching for improvisational materials.

Improvised NPA
   An improvised Nasopharyngeal Airway can be designed using a 6 or 7mm tubing measured correctly between tragus of the ear and the frenulum under the nose. As safety pin can be put through the end in order to keep the casualty from inhaling the NPA.

Open chest wound
   Penetrating trauma to the chest can produce a chest wound in which air is sucked into the pleura on inspiration. Place a piece of cling film, aluminum foil or one side of plastic sandwich bag on top of the wound and tape it on four sides with duct tape. 
   In the past, the rule of thumb was to tape just three sides of the occlusive dressing in order for the air to "burp" out. This is not needed as the casualty will also have a needle decompression needle inserted. 

Improvised Traction Splint
   The use of duct tape during the construction of an improvised traction splint is important. Making this device requires ingenuity and a solid understanding on how a commercial femur traction splint works.
   In the remote environment, traction is essential for two fundamental reasons:
     a. Minimise blood loss
     b. Minimise pain

   One of the most ubiquitous components of first aid kits and one of the easiest to replace through improvisation is the triangular bandage. The need to carry this bulky item, which is commonly used to construct a sling and swath bandage for shoulder and arm immobilization, can be eliminated by carrying two or three safety pins. Pinning the shirt sleeve of the injured arm to the chest portion of the shirt effectively immobilizes the extremity against the body.
   If the patient is wearing a short-sleeved shirt, the bottom of the shirt can be folded up and over the arm to create a pouch. This can be pinned to the sleeve and chest section of the shirt to securethearm.
   Triangular bandages are also used for securing splints and constructing pressure wraps. Common items such as socks, shirts, belts, pack straps, webbing, shoe laces, fanny packs, and underwear can easily besubstituted.
Improvised Wound Management
   The same principles that govern wound management in the emergency department also apply in the wilderness. The main problem faced in the wilderness is access to adequate supplies. The decision to close a wound primarily or pack it open should take into account the mechanism of injury, the age of the wound, the site of the wound, the degree of contamination, and the ability to effectively clean the wound.

   The primary determinants of infection are bacterial counts and amount of devitalized tissue remaining in the wound.Ridding a wound of bacteria and other particulate matter requires more than soaking and gentle washing with a disinfectant. Irrigating the wound with a forceful stream is the most effective method of reducing bacterial counts and removing debris and contaminants.
   The cleansing capacity of the stream depends on the hydraulic pressure under which the fluid is delivered. Irrigation is best accomplished by attaching an 18- or 19-gauge catheter to a 35 ml syringe . This creates hydraulic pressure in the range of 7 to 8 lb/ in2. The solution is directed into the wound from a distance of 1 to 2 inches at an angle perpendicular to the wound surface and as close to the wound as possible. The amount of irrigation fluid will vary with the size and contamination of the wound, but should average no less than 3L.

Remember: “The solution to pollution is dilution.”

   There is a lack of consensus on which irrigation solution is the best for open wounds. Those who subscribe to the dogma that nothing should enter a wound that could not be instilled safely into the eye believe that normal saline is the best solution.
   In a study of 531 patients with traumatic wounds, there was no significant variation in infection rates among sutured wounds irrigated with normal saline, 1% povidone-iodine, or pluronic F-68 (Shur-Clens).
   Tap water was recently found to be as effective for irrigating wounds as sterile saline. In fact, the infection rate was significantly lower after irrigation with tap water, and no infections resulted from the bacteria cultured from the tap water.
   Improvised wound irrigation requires only a puncturable container to hold the water, such as a sandwich or garbage bag, and a safety pin or 18-gauge needle.

A Final Note
   Under certain conditions, improvised systems are entirely suboptimal and may not meet standard of care criteria. It would, for example, be ill advised to fabricate a litter for transporting a patient with a suspected spine injury when professional rescue is only a few miles away. An improvised litter system might be entirely appropriate, however, if the injured person is 40 kilometers out in remote locations and needs transport to a sheltered camp or potential helicopter landing zone. The context of the situation should be considered. At times,
persons are obligated to do whatever they can, and a resourceful approach to problem solving combined with a little ingenuity could save a victim’s life. 

Content taken from Wilderness 911. 

More information can be found at Remote Medicine Ireland

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