Table 2: Discussion questions for each station.


Discussion Questions

Possible answers

Station 1: Wound Closure

Which provides the stronger wound closure: sutures or wound adhesive/tape?

Sutures provide stronger closure for high tension areas or highly mobile wound sites

What are drawbacks to suturing?

Introducing a foreign body into the wound (suture material); painful method; may trap contaminants unknowingly in wound (bacteria, foreign body); fatigable skill in non-practiced providers

Which seems stronger: improvised Duct tape® steristrips or simply covering the wound with a large piece of tape?

Variable responses

What are the steps of HAT (hair apposition technique) [4]?

1. Perform wound irrigation and exam

2. Twist together 3-7 strands of hair on each side of the wound.

3. Interlock these two hair bundles in a 360-degree revolution. Do not tie a knot.

4. Secure the bundles with tissue adhesive.

5. Repeat to close the length of the laceration

6. The hair will unravel on its own after a week

Is wound adhesive and Super Glue® equivalent options for improvised wound closure? Why or why not?

No. Standard "superglue" is 100% ethyl cyanoacrylate. Medical grade wound adhesive is 2-octyl cyanoacrylate, a nearly identical molecule except with the addition of a 5 carbon “tail” attached. Due to this longer organic backbone, degradation and absorption of tissue adhesive is slowed, remaining below the threshold of tissue toxicity. Due to the potential toxicity issues of ethyl cyanoacrylate, the use of 2-octyl cyanoacrylate for closure is preferred.

Station 2: Irrigation and Foreign Body Management

How clean does water need to be for irrigation?

Clean enough to drink

Rank the water treatment methods by time required to produce potable water.

Seconds: Water filter pump, Ultraviolet light pen

Minutes: boiling

Half-hour or more: Iodine tabs

Can the improvised irrigation devices provide the same irrigation force as the commercial device used in the Emergency department?

Variable responses. Most say yes. Items participants test include a 10cc syringe, a 50cc syringe, a water bottle with sports-top, a water bottle with 14 gauge holes punctured in the cap, a bladder hydration pack with tubing, and a Ziploc® punctured with a 14 gauge angiocatheter

When should you remove a foreign body?

Variable responses

When looking at the pictures provided, how would you manage the wound in terms of foreign bodies/contamination risk?

1. Linear superficial injury with a clean kitchen knife: caution to not over-irrigate and devitalize tissue in low risk wound

2. Abrasion with embedded granite: high infection risk due to foreign bodies, aggressive debridement

3. Fall on outstretched hand with jagged laceration at point of impact: crushed tissue and site results in higher risk for infection, consider antibiotic prophylaxis after cleaning wound

4. Impaled stick in the neck: stabilize and evacuate immediately, stroke like symptoms on presentation due to carotid injury [5].

Station 3: Vascular Damage

What is your experience with uncontrolled bleeding?

Variable responses

What is the most effective way to rapidly control bleeding from an arterial source?

Progression (linear or nonlinear) from interventions including direct pressure, packing a wound with gauze at sites of bleeding, pressure dressing, pressure to proximal arterial source, and application of a tourniquet should be discussed

Regarding hemostasis, does your practice/EMS system/prehospital wound management protocol reflect that thinking?

Variable responses

Are there other means of hemostasis that are safe and suitable for wilderness/remote environments?

Clotting powders can come up. Research current recommendations and products. Chemical burns to application area and systemic clots (remote from site of application) have been reported previously and cautions should be exercised in their use.

Station 4: Case Review

What went wrong? Why did Brad have such a prolonged course/bad outcome?

Open discussion on choice of suturing, use of betadine in an acute traumatic wound, timing and choice of antibiotics, timing of evacuation plan

Is this wound contaminated?

Yes, all wounds in the wilderness should be considered contaminated

What would you have done differently?

Variable responses