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  • Paladin Press, Ditch Medicine Advanced Field Procedures For Emergencies (1993) 7 0-2 6 LotB PDF

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    Paladin Press, Ditch Medicine Advanced Field Procedures For Emergencies (1993) 7 0-2 6 LotB PDF

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    © All Rights Reserved
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    von 113
    Whether it isa warzone oc asters, nods dangerous world raumatic injures are hay tcc remote cen unsantay locations However 2s 3 modem emergency medicne —incdng mail hops Shdpidevocuation to establced trauma centers flo teach jr patents the eld sn jst such sero A yee physician arent found patent anspor i ‘measured dys instead of minutes, resoure {nd the environment host that he Pre owt Cae Provider PHCP}isin is orber element. ‘Ditch Meine covers advanced medal proche fied setting. Should the PHCP fd Himself ona ‘teflon the mide of some orm of bt fo employ the procedures coveredin this book # timely and competent manner can mean the diferene between lle and death Through graphic photog, professional rendered uration, and cave tales From Cerral Amari, Southeast Al, and Acs, ugh Coffee provides rao lessons and sep by ep Instruction for smal wound rept, care forte infected wound, decompression and rainage ofthe chest Intravenous therapy, emergency airway procedures, ‘Teatrnt for anaphylactic shock, pin contr, amputation {ueatment of bus, and nution and emotional suppor. ‘ich Medcne sa must forthe well prepared EMT, sate eel professionl, mel werk, or avon wt ‘nieterestin practical Nel appiations SBN 0-873b4-717-3 AMIN For KAREN ‘wih sei hk Sea, Fs, KenPa Din tnd ib Dick Maine Aancd Pld Pree Emerges opi © 120 Mah Cate ine ne Ud Ste Ameren Palate by Pain Pee i of Palla Ese PO Bee 07, ‘Boal Caras SG USA. Gaya. 7290 iets moron he sn de PALADIN PALADIN PRESS, ade“ Wades ste adem begin Pan Enea Aegis ered. Bac re a eve: Peso hbk may beep ny ‘ron Be exes aie msn oe abr ‘ester estrone ‘ey spony fre wear ee ‘wh by Gry la Deie Cg, Voit our We seat wading en Contents a 7 a ut 127 131 155 17 au Iermopucron, Chapter 1 SMALL Wounp Renae Chapter 2 (Cane FoR Tae Isrecren Wound Chapter 3 Drconpwassion ax Dranaci ov 7: CHEST Chapter Ibermavinous Tamer Chapter S [EMaRomNcy Aurway PRoceDURES Chapter ANAPHYLAcTIC SHOCK Chapter 7 PAIN Con. Chapters Chapter 9 Chapter 10 "NUTRINON ax EMOTIONAL SUPPORT Brmuioceariy Warninc sechfigus and procedures i this book are only tobe etre by certified medial profesional. This book is to be a ubstte for proper and thorough education ing in hed of medne and emergency Bit i thor, publisher, and distributors of this book di liability from any damages or injuries of any 7p that reader or user of information contained in this book ‘nay encounter fom the Us of mse of said sformation. -_ AckNoWLEDGMENTS PPh etching medical profesional were of tremendous sinnce, othe experine represented by tr arouse aig contbuted tothe technica accra of the ex. Rd Ate LN. MSN Ste Burns MD.~Piedmont Orthopedic Complex: Macon Goes ‘Sooo, Farm Siem Dome on el Dr. Me.—BaSvizeand Richard. Knuton, MD.—-Dels Medal Center, “The photographs used in this book were contribute by the {following individuals. Their photographs were indispensable, ‘they bring abouta greater understanding ofthe arate. Rose Akers, RN. MSN ‘CN. Allmark—~Tribal Refugee Welfare in Southeast Asia, “Mirrabooka Wester Australia James Byron Dawson, M.D—Deputy Director of the vm Drreu Mapica Division of Forensic Sclence/TThe Georgia Bureau of Investigation Gienn Domer| Shirley B. Fordham—Chief Forensic Photographer ofthe Division of Forensic Science/The Georgia Bureau of Investigation Gerald, Gowitt, M.D_—Chief Medical Examiner for Hall ‘and Henry Counties, Georgia Richard A. Knutson, M.D.—Del Greenville, Mississippi DE. Rosey Ronnie Stutrt—Coroner, Henry County, Georgia Hugh Wood—Austala, Medical Center, ‘The gifted hands of Gary Blot and Denise Chung pro- duced artwork for this book when available photographs ‘would have failed to give the reader a complete understanding ofatopic. [Lynn Fulop and Kathy Shuman’s methodical and pro sional arrangement of sentence format allowed the manuscript to move from subject to subject ina cear, concise manner. ‘Scott Coffee (brary research, Joh Cannon (subject of many staged photographs), Karen Coffee (photographer), Mike Mitchell (photographer and photographie develop- ‘ment), Gary Elite (artwork), and DE. Rossey (military his~ torian) deserve special acknowledgment for their enthusiastic and stadt commitment to this project. Tnrropuction ‘From the days ofthe Roman Legionnaire with his short a plum to the modeen-day infantryman with his tile and grenades, man’s ability to tear the fesh and the bones of his opponent has increased to new levels of ly efficiency. Fortunately, forthe soldier whose luck has ‘in out and in the blink ofan eye has been transformed fom, {combatant toa casualty, pre-hospital care of the injured has improved tremendously. Gone are the backward days when the field surgeon had more in common with an alchemist, protecting his “scientific secrets” of patient care From those ‘who sought to understand the appropriateness of treating 8 {gunshot wound with eg yolk, rose ol, and turpentine. ‘Along with technical advances in emergency medicine, patient care has entered new realms of delivery withthe medi- ‘al community's growing acceptance of medical paaprofes- Sonals. Without these paraprofessional atthe “scene” wo ini- tiate advanced emergency medical procedures, many ofthe ‘newest procedures in emergency medicine would be limited in their effectiveness because patient transport time would spoil ther effects, ‘Modern weapons of warare found in the hands of com- bbaants in the most remote regions. However, as aruleymod- 2 Deve Mapiones ern military medicine, with its mobile hospitals and rapid patient evacuation to definitive health cae, fails to follow ‘combatants into the fields of confit. Iris in just such a sce- ‘nrio—where physicians are not to be found, patient trans- port toa hospital ie measured in days instetd of minutes, resources are ited, and the environments hostile—that the Pre-Hospital Care Provider (PHP) isin his element. “The subject matter in this book covers advanced medical procedures set ina field setting. Should the PHCP find him- felfon an slated batlefeld or in the mide of some form of. civil diester, his ability to employ the procedures covered in this book ina timely and competent manner will have a posi- tive impact upon his patents, For the wounded soldier who ses his strength ebbing into ‘the warm pool of liquid by his side and seeks relief from his ‘la by crushing the blades of gras in his hands, thoughts are ‘ffaily never be seen again and ai from whatever quar~ terhe ean find it. Ditch medicine—thediference berween life snd death—often start wih the thud of a pair of boots land ing beside the soldier anda PHCP simply grasping his patients hand and peering into hie ashen face Eee SMALL WOUND REPAIR For tht Pre-Hospital Care Provider (PEGE), mastery of yond repair techniques sof great importance in & From the laceration caused by an ax while chop- ‘wood to an avulsion caused by an exploding mine, the tions. The traumatized site, if not treated early, can quickly, develop into ife-endangering infection. Cosmetic distortion fad reduced usage of the wound site can result from an open. ‘wound where Sstues are lft ro heal wth no proper surpeal Intervention (Photo 1). The PHCP can eause all three of these debilitating patient conditions to oceur asa result of poor surgical practice. "The use of surgical tools and techniques used in mall wound repair is nor difficult to master. The basic manual Sills—such as cutting, clamping, grasping, ligation, and, tyingtecome secand nature with ite practice. curnine “Tissues are cut cleanly and perpendicular to their surfaces fo promote healing. When skin sto be cut itis first stretched qt, and the scalpel bade is held ata 90-degree angle to the 3 4 Drees Memes hs Thi 27rd Burm pain was sh by hgh ok ou, anh ih ect onli eee Teich hb iqarl aff dp f mp, he nce pny Dao ‘kena ct eames aoe hae Bn tend pe ond na he carmen roa poy ‘thre ci hr a Pees of agh d) surface ofthe skin to ensure « clean cut (1). Ifthe skins held loosely ox the PHCP hesitates, a jagged wo result Il 2). Cuts hesl better if they are made p ‘wrinkle ines anal across the lines of muscle pul (ls. 3 end 4). Foc fine work and cutting of skin, the sealpelis the best too (ll. 5). When holding a #15 blade lke an ink pen, the PCP {sready for most cutting situations Il 6), raion 5: bing bent ‘sf rain he ome erson Common xf a as ‘ mre Manica re ‘arin 7 Con \ \ \ = ‘Scissors ae used for cutting and dissecting the deeper tis- ses under the skin, Surgical scissors come in a varity of, ‘Configurations. For the PHCR, the curved Mecrenbaum and. fore heavily curved Mayo tcissors will be satisfactory for ‘most citing needs. A small par of ris and suture scissors are also useful 7). ‘Blunt-pointed scissors are used when cutting i the ‘wound. This reduces the accidental trauma of pointed blades “stabbing surrounding tissue. The blunt point will allow the ‘scssors to expose tse by thelr spreading action, ‘Sessors cut by crushing, Therefore, dll eissors are dan- ecru, wt they traumatize tissue. wats Wouro Renae 7 CLAMPING ‘During suturing; iis important to visualize all aspects of the wound. This is difficult to do ifthe wound continually ils With blood. Clamping the vessel closed to stop hemorrhage Into the wound i an easy way to maintain a dry fed in which towork. ‘When clamping a vesse!, the PHCP must be careful nt to lnclude surrounding tissue. Clamping crushes tissue and can okt which may interfere withthe healing ofthe wound It Jnbest toute te clamp with is concave side woward the issue ‘Clamps, as wells scissors, are best held withthe thumb land ring finger pushed only partially into the rings ofthe instrument. The index finger is used to stabilize the instru ment (ls. 8 and 9). ‘hon adm gr ‘rahe ny ora Spear ration 9: Tein i goed naiases tomo GRASPING Forceps are used for grasping, The fine-toothed Adson land the larger DeBakey allow the PHCP to hold tissue for ‘exploration ofthe wound (I. 10nd 11. LIGATURE Ligature is a critical technique for the PHCP who must stop life-endangering hemorshage or needs a dry field in ‘which to work. The bleeding artery ot vein is first clamped. ‘As the vessel i lifted and exposed, a fine absorbable suture (0 or 4-0) is ted below the clamp (I. 12). Once the PHCP Anas added an additional knot or two, the vesel is unclamped (o check for leakage I 13). y 0 ‘Drreat Mieco ean 15 Th ft ase isin oe ad ee on bng op ain Te oe Se” ‘With larger vessels or persistent bleeders, a double- ‘clamp, double ligature technique is used. Two clamps are Shed, and the fist ligature is applied under che lowest eRe dil 14). Once this is secured, a second ligature is pulled under the remaining camp CU. 15)."The ast as? sees removed wo check for leakage (I. 16). When tight “ening the ligature, care should be taken not to cut the vessel in half, ‘TIES “There are several suture ties that would be applicable for PHCP usage ‘The instrument te is probably the most useful because it helps conserve the length of the surure when several stiches age uted (Ils. 17 through 26)- aston 17 Th inane Ie Taequre breton Babee abl Ain Wourn Runa Mersin 19 — CLOSING THE WOUND rng awound closed is nt simply a macer of “ttch- oo fs together Fors wound to hel propery ten be given tothe appropriate time to elose« wound, mechanical cleansing, proper suture selection, Wound Closure closure timing i categorized as primary closure, closure, and healing by secondary intention closure of an open wound isthe direct suturing of wound in which there is no significant concern for on. Primary closure is generally indicated ifthe wound satisfactorily debrided and mechanically cleaned, es than 6 hours old." wyason 23 Baran 26 “ ere Memeo Msi 27: Adapt fom rnd i Wound Cae Bator ‘Hames Lote C.K 198 963) 6 Spon Way ‘recy dare ra of nd at ho Shows ld algeria care Thon fs 8 2 er ir I lebepsand dealin} doe eng by scolar in Th ae fit son 2h airy. Itami eran an ton. ‘ld which allows sigoificant bacterial growth inthe wound. ‘The wound is left open and loosely packed with dressings. In 3 t05 days, the wound will develop enough resistance to infection that closing it should not lead to complications (I 28), "During World Wat It became common practice for Allied surgeons to teat ballistic wounds with debridement, ‘wound exesion, and delayed primary closure at3to'S days after primary surgery (I 29 through 33).* A SSuatz Worn Renan as —f aan 2: Delp prinarycaurof evan The sound paced onc ante cd io ae rae 29: High ale ehbatck. The emt has [amal iy andthe. Theundrbing damégd mat eso he ‘i pa at eo opto gren They oe ane ‘ela the ented in on a cand hed a ond om ‘ou apd 2 = cag") ‘ars 30 To ne edd ond damaged al i, te bc at ‘asp $2 Wd he ean foe cu ies proper sig a Art rg and owe eho ao reer eck ond daa lin apa, The ma a eon ‘Sten dred ond open ‘emomol ener ane a sf ao ‘apt 3: Te nun tc th ale resin. st paced Musson 33 Dead primary ce te mundi 16 ay ant oa ache fof acd flame 1 Drrcie Manco Healing by secondary intention is called for in wounds cover 12 hours old, "The wound is let open and allowed to ‘lose itself by contraction and epithelization. This approach to wound care is indicated forthe heavily contaminated, ‘wound with tisue loss and established infection. Wounds of {thi nature often require skin grafts a later date by a skilled suugeon. Temust be remembered that even if a wound isnot to be closed immediately it should sil be debeided and cleansed ‘completely to promote proper healing. An infested wound is always a contraindication to wound closure, regardles ofthe length of time since the wound was inflicted. Further nterven- ing factors that determine whether wound closure is appropri- ste ae the heath of surrounding tissue, general health ofthe patient, and de- ree of satisfac tory blood sup- ply tothe affect- dea Debridement ‘When the de- cision has been made to suture ¢ wound closed, ¢ procedure for ‘converting acon- Taminated wound to a clean one must be imple mented fist. De- bbridement of a wound, along with mechanical cleansing, isthe mostimportant step in decon- taminating a tenuate wound Photo 2). Debridement thas two main foals: 1) to re- ‘a rea Metco tuminated by bacteria and foreign hod Photos 3 and), {nd 2) to remove permanently devitalized nse ee Photo 2Din Chapter?) ¢ "The den oF dying skin, mute and fot that eftn the wound acts caltue mum for both aerebe snd anaro- ticorgansma, These devitalized sracrres icy Become jnfeted and alo inhibit the body’ aby tight infection by Hindering the movement of white cells, ‘The traumatized ‘wound should be derided Soon as posible to prevent the Seralshaent of infection adits spread wo healthy et ‘Ribot are not replacment for debridement But adjunct. "Determining wat sue shouldbe dbrided sb upon identifying the demarcation between compromised and healthy time, Guidelines in determining ae visit are olor consistenc, andthe abi to bleed. Viable tissue wil ‘beredlsh ncaa, fm in consistency, nd fed with an ade- ‘hat Blood supply Healy muscle wil contract when sti- Ine bya cuing Bad. Sha pny me esr neion tn te i sues duc wits good blood supply. This allows the PHCP 0 te conservative the debridement of kn The debridement ‘Senex canbe trite oon a narrow manga on he geo the wound. : "nlc stn, nce must be removed more agressive. Des muscle ta perfect medium forthe development of es tmmgrone. Any discolored brused, or noncntacte maee ‘nostne casved otal, and al ockrs mast be ad open so the mond sacs dab drain ey ‘Specialized sue such as nerves and tendons, present special problem because these structures donot have the degree of reenerative poner that other structures have ‘When tha tsctures become contaminated, hgh-pressre iiation foloned by removal of agents that are no viable ithe bx course fasion. “The procedreof debridement is usually best cari ot vith scalpel A seapel gives precision and avid rushing eee ee a Se wait Wooo Rae a Action if scissors become dull. Effective debridement dependent upon exposure ofthe wound, 9 incisions made either end by the PHCP may be necessary to explore into deep wounds. Repetitive saline irrigation and sponging a also integral parts in the debridement process because iriga- tion loosens and fushes away contaminant while keeping ti ‘Mechanical Cleansing of the Wound ‘In conjunction with debridement, mechanical cleansing of the wound is necessary to ensure proper ascpsis. Mechanical ‘leansing is simple procedure of using hydraulic force and scrubbing the wound with an antiseptic solution in order to Physically remove contaminants and destroy microorganisms. ‘Joseph Lister, a surgeon who lived in Glasgow during the 1800s, is credited with discovering antseptie surgery." His tse of chemicals tol bacteria was a carnerstone in his work, ‘and some fel that his selection of the antiseptic phenol result ‘ed from its use in deodorizing the putrefying sewers of his time. Today, a mild solution of Betadine isthe antiseptic of choice for cleaning a wound. When Betadine is used, the HCP needs to be atentive tothe patient who is allergicto fdophor products. Also, high concentrations of Betadine can bbe toxic to healthy issue and retard healing. Phitohex is effective when Betadine is not avaiable oe cannot be used. ‘When the PHCP begins cleaning the wound, itis best to ‘wear a pair of sterile gloves, which are discarded and replaced with a new pair once the wound is ready for suturing. ‘Aggressive scrubbing is important, as ishigh-pressure isi sion in traumatic wounds (sarge syringe can be used inthe Feld for high-pressure isigation). However, care must be taken not to further traumatize wounded Uesue or surround ing healthy tissue ‘Once the wound ste has been cleaned, draping the wound or sunuring i of particular importance ia the field. Draping Aecreases the chance of infection by providing a sterile barrier (Gel) in which to work. Without a surgical drape over the n Drea Manica ‘wound, the ends of suture would drag through contaminated treas and the PHP's sterile gloves would quickly become ‘iety from contact with surrounding tissue. Commercial drapes are available that ae disposable and have precut hoes. ‘Sterile towels work ast s well when clamped together on the ‘comers (See Photo 7). Suture Selection ‘Suture is broadly classified as cher absorbable or nonab- sorbable. Absorbable suture is used to close muscle and sub- ‘cutaneous tissue and toligate blood vessels. Absorbable ‘sutures broken down over ime by the body and therefore is ‘ef for tssues that le deep and cannot be reached lterin border to remove the suture, Catgut isthe old traditional ssbsorbabl surue; however, synthede sutures such as Dexon ‘and Vieryl are preferred by many due to their more pre~ dictable ate of breakdown, greater tensile strength, and ‘decreased tendency to caus inflammation. ‘Suggested Suture Size Usage For Related Anatomical Areas ‘in Seuteneous asus and muscle Fae Gonjon | #0.50deon ven ap ce ed Tune #Omyon | ‘90.40 der0n, owt Barentee | 40n7on | +0de0n vend Hands fo | 60,40n/en | 5-0 40 ‘le held perpendicular tothe nee- dle holder works well in limited space asthe nee alder is rotat- cdo is axis It's the position for general-purpose work. Placing the plane ofthe needle curve parallel the nade handle i useflin Sowing layers parle! tothe surface in deep wounds. Grasping ‘the ned near the end (oward the suture) is suitable for sof ‘issue, ait allows maximum needle length tobe inserted ‘hough the tissu. Tis action allows for reduced incidence of needle sippage- Grasping the needle near the point may be nec- ‘essary ifinereased driving fore i nesded to pierce tough sue. "The PHP will develop an “eye” for the procedure that ‘has as. goal a wound with a uniform wound line with no ‘wrinkled tissue atthe edges. For best results when closing the ‘wound, the PHCP should remember the following: 1 Appore the various layers accurately. 2. Tie the suture with minimum tension. 3. Use the fines practical sure size 4. Double te square knot Suni Woun Reva » ‘Suture Removal ‘Correct timing for suture removal is dependent upon the ‘patient’ healing powers. If the patient's overall healt is good, ‘emoval ofthe suture atthe earliest approprite time will help [prevent the “railroad track” scaring associated with suture ‘hat has been left in place too long (usually past the four- teenth day of wound closure) If there is uncertainty ato ‘whether the wound will hold up ifthe sutures are removed, ‘Scalp 58 days Face 25 days Back 710 days (chest 7-10 days ao frente Prowimal lomo etry 710 days so Dre Meiers ‘iterating sutures can be removed and the wound rechecked ina few days. A general guide for timing suture removal is sven in Iusteation 4, ‘When removing s sunure, it may be necesary to it it with forceps before cuting, The sutures cut close to the skin (see Photo 18). The goal ofthe technique is to prevent surface ‘material fom being dragged ito the track once occupied by ‘he suture (ee Phow 19). Wound Drains "The application of «wound drain i not usually a step in suturing a wound closed. The PHCP willbe confronted with Seep puncture and penetrating wounds, and for that reason, ‘he would be lacking nis patient care sls ihe were notable toemploy the ure ofa drain ‘Wound drains ae used to remove fui or ps frm cavi= lies or abscesses. In the 1800s, dhe English surgeon Lawson “Tait was quoted a saying, “When in doubt, drain.” * Failure rouse a drain toremove pus was considered negligent in his time, where in that preantibiotic period the drain was often lifesaving. rains are most effective when placed ina deep wound with a narrow opening, which needs to hea fom below first. ‘Bucuse ofa drains not hazard-free. Sine it ia foreign body {nan infected ares, ican allow microorganisms to enter the ‘wound, This ean be compounded by dirty, moist, ong-stand- tng dressings. ‘One ofthe most commonly used drains isthe Penrose (Photo 5). Its a pliable, fla rubber tabetha varies in length, "The Penrose drain san overflow drain and as such should be placed as deep in the wound as possible. T secure the drain, ‘tis sutured wo the wound's edge anda safey pin placedin the ‘exposed end to prevent it from slipping into the wound (I 45), When the drain bocomes clogged, iis generally beter simply replace it with « new one ather than try @ open the obstructed drain Suara Wour Rerare a me Phow 5 Pome drain rion 5: Per of he Pare rin thas lcd ap the (eevnand ne ohn el ani has asf pv la 2 Drea Menten ‘When drainage has stopped or slowed dramatically, the PHCP can consider removal ofthe drain. In determining ‘whether ar not to remove the drain, rt loorenitand slowly ‘advance it further into the wound cavity. If no further

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