Just like hot spot and blister care, wound and burn care is another key skill to thriving on outdoor trips. You know those little tiny cracks in your skin on your fingers that one often gets after spending some time playing outside? Ever find that you have a local infection for a wound you didn’t even know you had? Ever find that those small cuts and abrasions tend to fester and take a long time to heal? This is all part of working and playing outside. It also applies to everyday living. Just like blister care, there are a variety of tools to add to the bag of tricks.
Tip #1: Prevention, Prevention, Prevention. Observe and catch it early!
Get in the practice of doing a self-body check daily. Look for those tiny skin intrusions, address it, and monitor them. Encourage others to do the same. If you are leading a trip, I recommend the following:
- Build Rapport – start immediately
- Role model, teach, and encourage good self-care. Don’t assume that people know how to take care of themselves in the backcountry. Educate.
- Frequent Check-Ins
- 1:1 check-ins every few days
- Create an atmosphere of daily group check-ins to check areas where problems commonly arise (i.e. hands and feet)
- Set up a grid system for recording and keeping track of student/client concerns.
Tip #2: Carry a variety of items in your first aid kit, foot/hand kit, and toiletries kit.
I tend to divide things up into smaller kits. I create a foot/hand kit that typically gets used daily. I create one kit for every 3-4 people in the group. For more information on this read Hand and Foot Care: Hot Spot and Blister Pro-Tips. My first aid kit has other items that don’t get used as often. My toiletries kit contains personal items that I use daily.
Quantities in each also depend on how many days I will be out/days until the next resupply and how many individuals are in my group.
I recommend carrying the following:
Tip #3: Keep It Simple
Irrigate with clean, drinkable water. When using a water bottle make sure the water has not been sipped on prior to irrigation. Human mouths are filled with bacteria. Hydrogen peroxide, alcohol, and full-strength iodine solutions (~10%) not only kill the bacteria, but they kill good cells too leaving the wound with areas of dead tissue. Dead tissue = bacteria food and can increase the risk of infection. I will consider using a 1% iodine solution if water sources are limited. I can count on one hand the number of times I have used iodine in my outdoor education/guiding career. I don’t use it at home. Keep in mind that some people are allergic to iodine.
Apply a moist (not wet; rung out), clean dressing over the wound. Materials used should be based on the type of wound. Some examples:
- Abrasions, ruptured blister, and very shallow lacerations:
- Apply a moist gauze pad over the site with an occlusive dressing (i.e. Tegaderm, plastic bag).
- Apply a thin layer of petroleum or oil/beeswax-based product and cover (bandaid, gauze/tape, gauze/coban, etc).
- Apply 2nd skin over area and cover with a clean dressing.
- Deep Lacerations:
- Pack moist to dry and cover with clean dressing
Limit the Use of Triple Antibiotic Ointment and Oil/Petroleum Based Products
While ointments can be great for some soft tissue injuries, they tend to impede the healing process for other types. This is also a good time to debunk the myth “Antibiotic ointment prevents infection and helps the wound heal faster”. There is little data supporting these claims. Proper wound care includes keeping the site moist and clean to promote healing. An article published in the Journal of the American Medical Association showed petrolatum was equally effective and posed less risk for allergic reactions.
- Thin film over abrasion after clotting process ceases allowing for the body to form its own natural protective barrier.
- Thin film over ruptured blister.
- Consider applying over a very small laceration (i.e. paper cut size crack on finger).
- Apply to dry/flaky skin (Badger Balm and Vaseline only).
Use of Wound Closure Strips and Medical Grade Glue
This is something I rarely use and have stopped carrying in my first aid kit. I have seen steri-strips, butterflies, and glue used incorrectly leading to infection. When these tools are used on lacerations that penetrate the entire dermis (average of 2mm deep) one risks leaving a hollow pocket underneath the closed surface obstructing the body’s ability to push out contaminants via wound drainage. These items can be effective in closing a very shallow laceration that only partially penetrates the dermis layer and that has straight edges, but they truly are not necessary. The wound will do just fine healing and closing without the help. In addition, it is important to keep a closed wound dry and clean, which may not always be possible.
Tip #4: Catch Infection Early and Get on the Hot Soak Train
It is important to help the body expunge puss at the first sign of infection. Pain is often an early indicator. Other indicators include redness, white/yellowish color, swelling, and hot to the touch.
Hot soaking is a great tool to remove puss. Boil water and allow to cool down just to a point where the patient can withstand soaking the affected area in it. Soak for 10-15 minutes. This may require adding hot water as the water cools down. The hot water bath will soften the tissue. Apply pressure and massage the puss starting away from and working toward the wound opening. If the wound is closed (i.e. scab, nail bed, blister) you may have to make a small incision to allow the pus to drain. This is not a common needed procedure and is another one of those situations I can count on one hand. Continue this process until no more puss comes out. Repeat at least twice a day.
Tip #5: A Variety of Tricks/Tools in Your Bag
Not all tricks/tools can be used in every situation. It is important to have a variety to choose from and understand the pros/cons of each. Treatment should be based on severity and whether it can be handled in the field.
To illustrate I will give two examples:
The above difference has to do with the severity of the wound and if it can be treated definitively in the field or at home. The burn on the left is high risk requiring care in a hospital. The burn on the right is low risk and can be managed in the field/at home. As such, treatment options change. While water-based gels such as 2nd skin are useful for minor burns, they can cause issues for a patient that has a more severe burn. Patients that get sent to the hospital often go through an incredibly painful debridement process. A lot of burn dressings and creams are either made of a gel that consists of a sugar constitute or are petroleum based, which is very sticky and difficult to remove. Even the water-based gel can stick a bit. If you have a patient that has a burn worthy of going to the hospital do them a favor and stick to a simple moist occlusive dressing.
Grossly Contaminated Wound Example
(1.5″ long/.5″ deep calf laceration that has a lot of debris in it)
In this example we have a wound that is at high risk for infection and needs to be debrided. This process is extremely painful and time consuming. It is best done in a clinical setting. If this occurs in the frontcountry or in a backcountry setting where I can get to the trailhead within a few hours I will likely choose not to debride the wound. On the flip side, if I am several hours from higher medical care, I will choose to debride the wound in the field.
Note: Wound debridement and removal of impaled objects is a wilderness medicine protocol for those trained and certified at a Wilderness First Aid or higher level.
Tip #6: Take A Wilderness Medicine Course
Wilderness medicine courses cover wound/burn care in much more detail compared to layperson first aid courses. A standard layperson first aid course simply prepares students to recognize and manage life threatening injuries/illnesses until EMS arrives, which is usually within minutes. Wilderness medicine courses go into more depth and cover a wider range of topics so that a person can make decisions as to whether advanced medical care is needed as well as manage a variety of injuries/illness in a setting where definitive care is delayed.
I encourage you to check out/sign up for one of our course offerings or take a course from a reputable organization.
Isaac, Jeffrey, PA-C and Johnson, David, MD (2013). Wilderness and Rescue Medicine, 6th Edition. Burlington, MA: Jones & Bartlett Learning and Portland, ME: Wilderness Medical Associates International. https://www.wildmed.com/product/wilderness-and-rescue-medicine/
Smack, DP, Harrington, AC, Dunn, C, Howard, RS, Szkutnik, AJ, Krivda, SJ, Caldwell, JB, and James, WD. “Infection and allergy incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment. A randomized controlled trial”. Journal of the American Medical Association, 1996 September 25; 276(12):972-7. https://www.ncbi.nlm.nih.gov/pubmed/8805732