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Basic Wound Management: Fundamentals of Sutures and First Aid

We all invest a lot in firearms and optics, but learning some first aid and wound management is just as important.

Basic Wound Management: Fundamentals of Sutures and First Aid

One of the best places to start for medical first aid is with an Individual First Aid Kit (IFAK). The Foundation Series IFAK from Blackhawk is a great affordable option for field first aid (Firearms News photo)

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The trip had been years in the planning. Three former college roommates, now grownups with families and responsibilities, had schemed out the ultimate Alaskan man-­cation. They would fly into Fairbanks and then rent a shallow-­draft boat for an epic trek back into the Minto Flats. A full week of living off of the bounty of the land promised to make memories without peer. The trip would be expensive, but the experience was worth it. The meandering quest into the heart of darkness took two days. They had planned four days on-­site and another two to exfil. On their first day at the field site it happened. The northern pike was nearly 24 inches long and would make a proper meal. These big toothy fish fought like dervishes and had a sweet succulent flesh. As the man prepared the big fish for the fire he slipped with his fillet knife, driving the point deep into the palm of his hand.

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Having the right gear and a little skill can make a huge difference when managing wounds in austere spaces.

They irrigated the wound aggressively and bound it up as best they could. However, when it was still bleeding the following morning the three friends reluctantly broke camp and drove hard all the way back to Fairbanks. The ER physician at Fairbanks Memorial cleaned the wound and had it closed in twenty minutes. Realizing there wasn’t time to get back to the campsite the three buddies satisfied themselves with the local tourist sights like Alaskaland and the salmon bake before climbing back onto an airplane for the World, broken and dispirited.

The Problem

The above story is true. We are never more than one accident away from requiring proper medical care. I was stationed at Fort Wainwright, Alaska, before leaving the Army for medical school. There in Fairbanks a local trauma surgeon hosted a basic wound management class for non-­medical folk on a Saturday. Thus two years before I began my own medical training I learned the rudiments of suturing wounds. The surgeon introduced the class with that tale.

You’ll not learn what you need to know to sew up wounds from reading an article in a magazine, even one as awesome as Be Ready! However, I do hope to whet your appetite. Like plumbing, car repair, or electrical work, suturing wounds isn’t hard, you just have to do it enough to be comfortable. The basic techniques wisely applied will address most of the minor trauma you might encounter whilst in an austere environment. Under the right circumstances it can save a vacation. In darker spaces a little medical knowledge can save a life. Most folks are a little squeamish. Every medical student is a wee bit green the first day of Gross Anatomy. However, the human animal can acclimate to anything. A week into Gross I could have happily killed a pizza there. Tolerance for blood and gore is usually an acquired taste. Just suck it up and get past it. YouTube is rife with instructional videos on surgery and basic wound closure. Surgeons occasionally pull up such stuff intraoperatively in the OR if they encounter something unexpected. Watching a few of those videos is a good start. Just be judicious with your Googling. There’s some pretty sick stuff out there.

Basic Guidelines

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You can’t ascertain the details of a wound until you get it cleaned up. Sometimes the most remarkable mis- chief will be hiding underneath all that clot and gore (top left). Before and after (top right and bottom left). Place the first stitch in the center to estab- lish the geometry and then split the difference on each side from there.

Dilution is the solution to pollution. More important than fancy antiseptics, the first step for basic wound management is to irrigate the injured area with plenty of clean water. This will help remove foreign debris and tell you just what you’re dealing with. Blood is reliably opaque. Without cleaning the old stuff out you can’t tell how bad things really are. Sterile saline is best, but tap water will do in a pinch. Urine from a healthy person is sterile and makes a serviceable wound irrigant as well, but I’d have to be pretty bad off before I let somebody pee on my cut arm. Regardless, don’t be stingy with the irrigation.

Controlling the bleeding is the first chore in most any wound management scenario. A typical adult human has five liters of blood. That’s 2.5 two-­liter soda bottles. Lose a liter of that in a brief period and you’ll pass out. Lose two liters and it is life-­threatening. However, a liter is a lot of blood. Some injuries just require professional attention. Exposed bone or a significant severed artery are going to demand a proper facility and trained staff. However, I’ve done this professionally for twenty years. The vast majority of the wounds I manage at work could be addressed just as well at home by somebody with the appropriate tools, will, and skill. If the bleeding is severe and it doesn’t look like you can stop it with more conservative means then a tourniquet is indicated. Commercial versions are easy to use. Punch up YouTube to see how they are managed.

The Lay of the Land

Once you have the wound cleaned make a sober assessment to ensure that sensation, mobility, and perfusion are intact downstream. In many cases even if you lose mobility or sensation it is still appropriate to clean and close a wound to buy time to find a specialist. However, if the end of an extremity is getting dusky and looks like it has vascular compromise I’d seek out medical care without delay. Presuming that’s not the case, then by all means proceed. There is no better bandage than human skin. The point is to reapproximate the skin edges to seal the wound and tamponade the bleeding. This is what happens when the pressure within the sealed wound exceeds blood pressure and staunches further blood flow.

The Gear

basic-wound-management-04
So long as the flesh isn’t devitalized you’re almost always better off covering a wound with the original skin. This gaping leg wound is not as bad as it looks (top left). What looked like a massive hole at first actually came together quite nicely (top right). You can technically close wounds without anesthesia, but you’ll lose a friend in the process. Lidocaine is a much more compassionate option.

There are three tools you will need to suture basic wounds. Practice kits are available through Amazon along with associated suture material. Some of these kits even have simulated lacerated skin you can practice on. You’ll need a needle driver to manage the needle, some forceps (tweezers) to control the skin edges, and then some small scissors to cut the free ends of the suture. Some needle drivers have built-­in scissors and some wounds can be managed without forceps, but I’d want to have it all handy.

The gear you use for real needs to be sterile. Sterile kits are available online. If life goes truly pear-­shaped then at the very least clean your instruments by either boiling them or soaking them in disinfectant. Wound infections can be a terrific mess. There are a wide variety of sutures available for various applications. Some are made from polyglycolic acid, a form of sugar, and will dissolve in the wound over time. The sort you will need are synthetic nylon monofilament and must be removed later. This stuff looks and feels like fishing line except that it readily holds a crimp. That way you don’t have to use any fancy knots to keep it from slipping. Suture size is graded a little bit like shotgun pellets. Larger numbers mean smaller caliber sutures. Modern sutures come with a needle attached. Sutures and suture needles come in a bewildering array of configurations. 3-­0 is quite large, while 7-­0 is quite small. I keep 4-­0 and 5-­0 Nylon sutures handy myself. Something about that size will manage most common wounds. You will also need bandage material to protect the wound later. Kerlix and Telfa are my personal faves. You can get that stuff at any pharmacy.

Anesthesia

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You’ll need some way to numb the wound before you get started. John Rambo was an outlier. Most folks aren’t that tough. Topical anesthetics are available without a prescription. That’s better than nothing, but it’s still suboptimal. The best solution is to befriend a physician and score a prescription for some injectable lidocaine. You’ll need a syringe with two sterile needles. An 18-­gauge is used to draw the medicine out of the bottle. Something smaller like a 25 to 30-­gauge is used to inject the wound. Be sure to clean the top of the bottle with alcohol before you draw it up. With the wound and surrounding area as clean as you can make it and prepped with betadine, insert the needle at a shallow angle just under the skin and inject to form a small wheal. This is the swollen area that forms when the medicine infiltrates underneath the skin. Start at one spot and then track all around the wound. Lidocaine takes effect almost immediately.

Techniques

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Stab wounds can be terribly misleading. Sometimes injuries that appear innocuous on the outside are not.

Grasp the curved needle in its nearest third with the needle driver and hold the instrument in your thumb and 4th finger. Sewing human skin is all in the wrist. Control the skin with the forceps in your weak hand. Approach the skin with the needle at a right angle. Roll the needle through one skin edge from the outside to the inside. Unfasten the needle driver and grab the needle again within the wound. Then push the needle from the inside of the far skin edge to the outside.

There are scads of ways to tie off sutures, but the easiest is the basic surgeon’s knot. This is the medical term for a reef knot. A reef knot is a square knot wherein you wrap the first throw with 2 twists to hold it in place before following up with the next iteration. Right over left and then left over right. Repeat a couple of times and snug everything tight before trimming back the edges and moving to the next stitch. Put the first stitch in the center of the wound and then split the difference on each side until the wound is closed. Disposable skin staplers are easy to use and fast. Particularly on the scalp, you can move with a purpose and sometimes get away without anesthetic. YouTube has the details.

After Care

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At first brush some wounds look simply ghastly (top left). This is the wound after cleaning and repair (top right). Here is the same wound six months later. The regenerative prop- erties of the human body are a tribute to its designer. In the case of significant trauma sometimes we just need a little help (bottom left).

You don’t routinely need antibiotic drugs for a wound unless it is really filthy. Gently clean the wound twice a day with soap and water and keep a dressing on it for the first few days to protect it. Unless it is a high-­stress area I take my stitches out in 7 to 10 days. Pig’s feet are available from your local butcher and make good practice subjects. Just cut them up and then sew the lacerations back together. I have never been hungry enough to actually eat something like that. Amazon.com offers sterile sutures and disposable skin staplers. Their Dynarex Minor Laceration Tray will set you back $14. It includes the sterile drapes and disposable instruments you need for repairing small wounds. Sewing wounds really is fun. Expect the first time or two to be pretty frustrating. An inert pig’s foot is always easier than something that is wiggling and bleeding. However, the goal in the field isn’t necessarily to be pretty. It is to save your vacation or stay alive. Happy suturing.


About the Author

Will is a mechanical engineer who flew UH1H, OH58A/C, CH47D and AH1S aircraft as an Army Aviator. He is airborne and scuba qualified and summited Mount McKinley, Alaska, six times…at the controls of an Army helicopter. After eight years in the Regular Army, Major Dabbs attended medical school. He works in his urgent care clinic, shares a business building precision rifles and sound suppressors, and has written for the gun press since 1989.


The article was originally posted in Be Ready! magazine. You can purchase an original copy at OSGnewsstand.com. If you have any thoughts or comments on this article, we’d love to hear them. Email us at FirearmsNews@Outdoorsg.com.




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