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 |