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                           Wound Care
                   (from scrapes to sutures)

              By George E. Dvorchak Jr. M.A., M.D.

SKIN,  which covers our body, has the important function of  pro
tecting the internal organs and tissues from the environment  and 
physical  objects. Technically, this protective covering is  also 
our  largest  body organ and the first line of defense  from  in
juries  and bacteria. With injury, the outer layer of  skin,  the 
epidermis, is either scraped away or opened-up to permit bacteria 
and  materials to enter. In a more severe wound, the  next  layer 
downward,  the  dermis is penetrated.  This  contains  connective 
tissue,  sweat  glands, hair follicles, nerves, lymph  and  blood 
vessels.  Generally  speaking,  the deeper the  wound,  the  more 
serious the consequences it can have for the body.

  As survivalists, you want to be prepared for about anything  at 
any time. Therefore, the best approach to a presentation on wound 
care is to cover everything from the simple closed wound to  more 
serious injuries. In these, the skin has been compromised and the 
wound is therefore referred to as open.

 CLOSED WOUND TO THE SKIN: This is the common BRUISE or CONTUSION 
which  is caused by a blunt object impacting upon the  body.  The 
result  is that blood will begin to leak from the injured  vessel 
under  the skin which then causes that area to change color to  a 
black  or blue. The good thing with this injury is  that  because 
the skin has not been broken, infection is not a great possibili
ty. Therefore, the immediate first aid treatment is to apply  ice 
for about 10 minutes and then throughout the day. Even though the 
skin  was not broken, this could still be a serious problem,  one 
depending on what was injured beneath the skin and the amount  of 
force that originally caused the injury. If an internal organ  in 
the abdominal area was severely injured, bleeding could be taking 
place  internally without evidence externally. When traveling  or 
hunting with horses, an injury could happen by simply stopping to 
adjust a load on a pack horse. If he gets spooked and you kicked, 
an internal injury could result. A hard kick to the abdomen  when 
days from medical care could cause internal bleeding that may  be 
fatal. Not all is obvious at all times!

 OPEN WOUNDS TO THE SKIN: It is in this category where everything
from  a  band-aid  to sutures are necessary  along  with  special 
considerations and concerns. In beginning with the least  serious 
of  six  major categories of open wounds, we have  the  ABRASION. 
This is where the outer surface of skin has been scraped away  as 
from  a scratch or rope burn. There is usually some minor  oozing 
of blood and serum.

  Depending on how the injury was obtained, there is usually dirt 
or  foreign matter ground into it. This problem brings  to  light 
another  player against wound healing, infection.  The  treatment 
now goes beyond the application of ice. To treat an abrasion as a 
scraped  knee, the wound must first be cleansed with soap,  water 
and  if available, hydrogen peroxide. This will remove dirt  that
will cause an infection and therefore impair healing.

 Once cleaned, the wound should be blotted dry with a clean cloth 
or  preferably a sterile gauze. It now would also be a good  idea 
to apply pressure over the injured site for a few minutes for the 
purpose of slowing down and hopefully stopping any bleeding.  The 
application  of a first aid or antibiotic cream to  the  abrasion 
could  help  to prevent infection and keep the bandage  that  you 
will  apply from sticking to the raw wound. For the best  protec
tion,  the bandage should cover an inch beyond the wound. An  ice 
pack over the final bandage can serve to reduce swelling and some 
of the discomfort.  The next category of wounds is the  INCISION. 
This  is made from a sharp knife-like object that leaves a  clean 
cut. To keep this one separated from the next, think of a  surgi
cal incision where the cut edges are smooth.

 The  third  is the LACERATION which is similar but  with  jagged 
edges  due to a tear. Because these go beyond the outer layer  of 
skin and into the deeper layers that contain blood vessels, there 
is  a lot of bleeding. If you were deep enough or unlucky  enough 
to cut an artery, blood will squirt out with each heart beat  due 
to the high pressure in these vessels. The best approach here  is 
to  apply a pressure dressing and get to medical care  where  su
tures  will  usually be needed to fully or  partially  close  the 
wound, depending on if it was dirty or clean. Because suturing is 
a common medical procedure, I will later outline some information 
on  what  is involved to better inform you of your  doctor's  op
tions.

 The  next  wound is the PUNCTURE. As its name implies,  this  is 
when  a foreign object is pushed into the skin. This could  be  a 
splinter that only penetrates the superficial layers of skin or a 
nail,  sharp stick or fishing hook that penetrates  deeper.  With 
this you usually will not see much external blood which does  not 
mean  that there is little internal bleeding. To treat  something 
such as a puncture wound to the foot from a nail, all you can  do 
is  to  put ice on it along with a pressure wrapping and  get  to 
medical  care.  This  is critical since if you  are  not  already 
protected against tetanus, you will need to get an injection  for 
such  protection.  If you are in the outdoors a lot, it  pays  to 
keep your immunizations updated.

 The  next  skin  wound is the AVULSION. This is  where  skin  is 
pulled  or  torn off. As with an AMPUTATION, the  severed  tissue 
should be saved and taken with you to the hospital. If a  finger, 
a  pressure dressing over the stump or if skin, again a  pressure 
dressing  over  the wound is about all one can do  until  medical 
facilities  are  reached.  One other point  should  be  addressed 
concerning "serious wound" dressings. That is, once a dressing is 
applied,  leave it alone and do not take it off every 20  minutes 
to  check the wound. If unnecessarily disturbed, all you will  be 
doing is to undo the positive measures already applied.

 WOUND MANAGEMENT SUMMARY: The first concern with any wound is to 
control  bleeding.  On the first aid level,  this  usually  means
through  the  use of a pressure bandage. The next concern  is  to 
prevent  wound contamination which refers to cleaning  the  wound 
and  applying a sterile bandage and possibly an antibiotic  oint
ment.  Lastly, immobilization of the inured part along with  rest 
and if severe, medical intervention, are all wise procedures.

 The  Mystery Of Sutures - Many of us while growing up had to  be 
sewn back together. My father, a small town GP who did it all put 
six in my leg and another six or seven in my chin all before  the 
age  of 12. If you were like me, you just wanted to get  it  over 
with  and  therefore could not have cared about details.  In  the 
following, I will give a general summary of what suturing  encom
passes. Hopefully, this will help to lift some of that curtain of 
mystery concerning this common procedure.

  THE  SUTURE  ITSELF:  The thread like material  attached  to  a 
curved  needle or used on a straight one is absorbable  and  used 
internally or nonabsorbable and used internally and externally as 
in  holding  skin  together. Some of the materials  used  in  the 
non-absorbables  and  that which we are concerned with  are  made 
from silk, cotton, nylon, dermal and stainless steel. One of  the 
reasons for all of the different materials concerns tissue  reac
tion to something foreign to the body even though it is serving a 
purpose. All the body knows is that there is a foreign  substance 
within  it  that was not there before. The body  can  then  react 
against  this  invader and you will get a  tissue  reaction.  The 
reason stainless steel is popular in surgery by some surgeons  is 
that  of  all the suture materials, it evokes  the  least  tissue 
reaction.

  Suture  size  is also important since different  materials  and 
weights  of thread are matched to the task and tissue.  Generally 
speaking, suture material should not be stronger than the tissues 
it  is  expected to hold together. Of all the sutures,  those  of 
silk or nylon are most widely used in holding skin together.  The 
size is designated as 2-0 or 00, 3-0 or 000, etc. The smaller the 
number,  the stronger the material. To hold skin together, a  000 
or  0000  is generally used. Needles attached to the  thread  can 
either be straight or curved with those curved most commonly used 
in  your  doctor's office. With ones curved, a needle  holder  or 
hemostat is required to use it.

  A  friend of mine who is an orthopedic surgeon told me that  he 
would  recommend  a straight needle for use in  the  outdoors  to 
close the skin since a needle holder is not needed. When using  a 
continuous  suture  with  a straight needle, this  would  be  the 
quickest  way  to  close a skin wound. If you  are  heading  into 
remote areas and feel that you would like to know how to do this, 
I  would  recommend that you ask your family  doctor  for  advice 
since  he  best knows you and would be the one to advise  you  on 
this.  Yet,  for most lacerations, a pressure dressing  over  the 
wound  would be the preferred procedure until medical care  would 
be available.

  Another consideration your doctor will have to be careful about
is  that  after  skin has been sutured back  together,  edema  or 
swelling  of the tissues usually enters into the picture. If  the 
suture  was originally tight, with swelling, it will soon be  too 
tight. Therefore, proper tension the first time the job was  done 
is critical to good healing.

 The  purpose  of suturing is to pull the  tissue  together  just 
enough so that there will be no dead spaces below the skin  where 
blood  and fluid can accumulate. If there is, it will  eventually 
be  a breeding ground for an infection. In staying with  how  su
tures  are put in, it is also important that the same  amount  of 
tissue  be  included on each side of the suture.  If  the  suture 
includes more tissue on one side than the other and/or the needle 
is inserted deeper on one side than the other, when tied  togeth
er, the skin edges can overlap causing poor wound healing  and/or 
a  scar. All your doctor wants to do is to put the severed  edges 
back  like  they were before the accident so that  the  body  can 
complete the job of healing.

  Because a medical emergency as a laceration can happen anywhere 
with  the  worst  place being when medical care  is  not  readily 
available, I would highly recommend a Red Cross first aid course. 
Once  this  is completed, I would then recommend  that  you  take 
advanced  courses  and hopefully get certified  as  an  Emergency 
Medical  Technician.  Also, if you go on outfitted  back  country 
hunts, one of the questions you should ask of the outfitter/guide 
is if he or she is certified in first aid. In the event that your 
guide would get inured, it would also be to everyone's  advantage 
if you were qualified to help him.

  A  rule  of  good medicine is to do no harm  to  your  patient. 
Therefore, take a first aid course and learn how to help yourself 
and if the situation presents itself someone else.