1st aid

[Trismegistus]

Pepper is nothing more than an astringent and thus tends to constrict tiny capillaries -- this constriction of the wound edges and capillary bed in essence is really nothing more that the body's way of trying to keep caustic substances out -- and yeah it works but no better than unripen bananas, persimmons, oatmeal, etc. Here in the office we tend to rely on silver nitrate, zinc oxide, tincture of benzoin, etc. for capillary "seepage". But my favorite "at-home" coagulent? Tea bags!! Tannic acid is an excellent coagulent and astringent and by using a tea bag you don't have to worry about tea leaves muckin' up the wound. Tea bags have saved me from many an after-hour emergency.... And are great for that someone you know on anti-coagulent therapy who bleeds forever every time they scratch their leg or arm. Also nice to have a little Avitene ( a microfibrillar collagen hemostatic agent) on hand if you really want prompt coagulation of a deep wound.

Another 'oldie' -- and one I grew up with -- that makes no bloomin' sense -- a kid gets a burn and some adult starts wanting to lather it with toothpaste (my grandmother's favorite), butter, tomato paste, etc. Yeah that be stupid -- let's contaminate the wound, let's trap in the heat, let's place an air-exclusive dressing over the wound to encourage opportunistic infections, etc. The best first aid for a burn begins with cooling the site down as quickly as possible -- say, rinsing it in cold water -- in an attempt to minimize further tissue damage. Moreover by minimizing the buildup of inflammatory mediators at the onset -- there's less swelling, pain, etc. thereafter. The best analgesic we offer patients after say -- wisdom tooth extractions -- is an ice pak -- you keep that initially swelling down and the whole healing process is shortened and made more comfortable.

[dustin harwood]

for those looking for a smaller 1st aid package than the one i advertised on the 1st post, check the nrs catalog for a great selection of med kits varying in sizes and materials.

[bstephens]

Trismegistus, you recommended using either carbocaine or marcaine as local anesthetics for suturing. I do not know your qualifications, but I am a CRNA and I question recommending to laymen to use marcaine. Get a dose of that IV and you will have major cardiac problems. Using it without epi, you could approach a toxic dose fairly quickly. I personally just carry good old lidocaine for nerve blocks.

I would also be very hesitant to do any suturing in the field, and would rather rely on direct pressure to halt bleeding and bandages of one sort or another.

[Trismegistus]

Certainly appreciate your concern however within the context of a field emergency I like using Marcaine for the extended analgesia it gives -- nice that the patient can remain comfortable for an extended period of time. Moreover the untoward effects of Marcaine exist for all the amide type local anesthetics -- any of which can cause adverse cardiovascular responses if infected IV. NOTE: No one should ever inject any agent into their body if they cannot distinguish between a subcutaneous, IM or IV injection and/or handle the ensuing complications that may occur if they inadvertently administer an amide-type anesthetic IV.

However in a field setting in which you are suturing up a laceration you are very unlikely to deliver a toxic dose -- we're talking like mean arterial plasma concentration of 4-5 mcg/mL -- this would be like administering several 1.8cc carpules IV as a bolus. I don't know how many deaths are attributed to Marcaine overdose, etc. but I do know these deaths are usually associated with substance abuse and in mixed cocktails, i.e. morphine. Or were delivered as IV regional anesthesia such as in an epidural. I know of no deaths occurring with use of this agent as prescribed aside from isolated idiosyncratic drug sensitivities. In contrast I like carbocaine because it is short-lived and when free of vasopressors such as epinephrine it has little or any adverse cardiovascular potential.

As for nerve blocks -- in the field, local infiltration will usually get you through most lacerations without resorting to a true nerve block. Most folks have a limited understanding --or have forgotten their -- neuro-anatomy -- so that any nerve block is likely to be a "hit and miss" affair in which most of the anesthesia achieved is likely due to local infiltration anyway.

And indeed optimal wound closure and care can always best be attained in a clinical setting. But many times I find myself days away from such facilities in which case I believe the sooner a wound is adequately debrided, cleansed and closed the better/faster the patient will recover. Moreover I myself find I get the best outcomes when treating fresh wounds and acute abscesses. Reminding of a case I had to deal with this past month -- similar knife wounds to the bottom of the feet following a robbery -- you know, the typical "drug deal gone bad" in which the victim is ordered "lay down on the ground and take off your shoes and pants" and then after collecting the wallet, phone and such the perpetrator slits the soles of the victim to prevent chase -- very effective and very common ploy among our drug-dealin' breathren. Now one kid immediately sought help while the other kid bandaged himself up, walked about 1/2 mile to secure assistance and then didn't seek medical care for 6-8 hours later. Guess which kid just about lost his foot to secondary infection? Again, my general belief is that the quicker a wound is cleaned and closed the better. Often times this means the difference between getting an arm, forehead, or foot sewed up streamside so that the trip moves forward with little delay versus a long day on the river followed by long drive to health care facility followed by an even longer wait in the emergency room.

Again it all boils down to experience and sound clinical decision-making. There are no absolutes. Just guidelines.

[robkanraft]

"I would also be very hesitant to do any suturing in the field..."

Just my uneducated opinion, because I’m not a doc or a health care provider. I don’t carry any pharmaceuticals in my first aid kit, just otc stuff and an epi pen that I have a script for. However, after seeing someone suffer a really, really nasty gash two days into the middle of nowhere on an extended trip, I felt I wanted a suture opton and bought some blood clotting powder and an Adventure Medical Kit skin stapler. It looks wicked, and I hope I never have to use it or receive one of the staples in a conscious state. But I also hope never to be involved in a hele-evac, either. In Arkansas where you are probably never more than a few hours from some kind of assistance, I'd probably never consider using it.

[Trismegistus]

This may have already been brought up but in lieu of local anesthesia delivered by a syringe you can also achieve pretty profound anesthesia solely with topical anesthetics -- two that are particularly good for field anesthesia for suturing (or stapling) are 1) LAT gel (4% lidocaine, 1:2000 adrenaline, 0.5% tetracaine) and 2) TAC gel (0.5% tetracaine, 1:2000 adrenaline, 10% cocaine). I have done some fairly extensive surgery -- including skin grafts -- using nothing but these agents and for a kid who is "scared of needles" these gels can be a life -- I mean ear -- saver. And although the latter is considered a "controlled substance" most clinicians would have no problem writing out a prescription or offering samples for someone's first-aid kit. Pretty good shelf life too.