Amputation. First and post aid.
This post is on Amputation. What first aid and also post aid needs to be done.
NOTE: Some of the images at the end of this are graphic. They are of my son’s finger and the wound.
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Normally when I write a blog post its from current events, past experiences both civilian and or military. This time I am using my youngest son as our topic. This past week (Tuesday the 4th of August) he had a pretty normal day at work. He works at a motorcycle accessory shop. Sells gear and he is about the most requested tire man in the city.
People bring him tires to mount that they bought from all over. From the store he works at to mail order The reason he is so requested is he cares for the customer and the motorcycle. Never scratches or damages a rim. He recently did a set of tires that the rims cost 2 grand each. Personally requested by the bike owner. Not bad for a 19 year old young man. Today’s post ties in to one from may on one we did years ago on Emergencies
Where did my finger go?
He and his manager were moving out the old tire machine for the brand new one the store bough. As they were lifting it on the pallet the old one came on, the bead breaker slipped out of position, dropped down and amputated his lift index finger between the 3rd knuckle and the nail bed. (Knuckles are counted from nearest to the hand to the finger tip. Think of drawing and angle from the cuticle backwards from that point at a 45 degree angle to the 1st knuckle. If folks have taken my classes or shooting classes from some of my friends, you have heard me say that a traumatic injury is not a painful as it looks. For a while at least.
According to Ryan it felt like he pinched his finger. Not to bad. He went to keep lifting and he looked down and saw the blood covering the floor and tire machine. His mechanic glove was torn and the end of it was missing. The body has amazing self preservation tools. I’ve know gunshot victims who were shot, walked down a flight of stairs with a suspect in custody, put them in the patrol car and then died.
STOP THE BLEEDING! This cannot be stressed enough STOP THE BLEEDING. Even an injury like my son Ryan has can be dangerous if the bleeding is not stopped. When blood is spilled on the floor it looks 5 times as much as it is.
The blood loss Ryan had was about ¼ a cup 60 cc more or less. It looked like more. MUCH more. 2 fluid ounces is not much in the grand scale of the body. An adult will have approximately 1.2-1.5 gallons (or 10 units) of blood in their body. The average us 1.2 gallons or 5 liters
Now the scary part. The ½ cup of blood he lost was in the first minute! And it was not pure arterial flow. It was a mixed flow. The finger tips do not have large arteries in them The vessels are about 1/32nd of an inch in diameter (.79 mm). DIRECT PRESSURE.
Ryan has been trained extensively in first aid. Well he HIS my and his mom’s son. Growing up in a medical family has advantages. He squeezed below the wound and yelled he needed something to help hold it. His manager and the vendor grabbed shop towels and put pressure on it. Sat him down with his hand higher than his heart and called 911.
If at all possible retrieve the amputated part, wrap in clean cloth or sterile bandage material, place in a baggie, and place that baggie into one containing ice. This gives the surgeons the best chance of re-attachment.
To tourniquet or to not tourniquet.
There is a sorted history on the tourniquet. Lets go back to the 1980’s As an old medic, when we had a wound that needed a tourniquet, we put it on, marked a “T” on the patients forehead with date and time of application. If your patient was going to be with you for a few hours, every hour or so we would loosen the tourniquet for a short time to allow blood to the part below the tourniquet. The reapply it.
This did not work as well as expected. For a tourniquet to work it has to be tight. TIGHT. When it is applied correctly. Tissues will be damaged. When tissue is damaged there is swelling. We call it edema. So when we let off the tourniquet, let some blood down, then re applied it, the bleeding would stop and all was good in the world. Until the patient bled out. What happened was when the tourniquet was re-applied, it compressed the edema, and stopped the flow. But once the edema had been moved, the tourniquet was now loose.
1990’s to early 2000’s
This is the era of Life or Limb. A carry over from the 1980’s of the worry if the distal limb would survive the application of the tourniquet. To preserve the limbs we had to make a decision. Save the patients life and sacrifice the limb. Or keep on with direct pressure and hope for the best. We also used to “stack” dressings. If a dressing became blood soaked, instead of removing it we stacked another on top. In my Battlefield Medic class I used this image:
That’s a lot of blood in a bandage.
Today its recognized that early tourniquet application saved lives. 2 decades of war in the Middle East has given us ample study material. Today for most EMS and all military medics the rule of the tourniquet is: “If you think you need a tourniquet, Use a tourniquet”. We found that the fear of losing a limb due to a tourniquet is not as great as we once thought. So if you think you need it use it. It can always be removed by higher medical authority.
The CAT tourniquet IS the standard of the industry. There are many that imitate, cost less. But there are none better. I have carried and used one for decades, It is worth the money.
Secondary care is once the patient arrives at hospital (Or if SHTF where you have set up a field clinic).
Here the patient is evaluated the wound checked and the viability of the cut off part is evaluated for re-attachment. If things have gone bad and there is no “real”hospital, Everything except the evaluation of re-attachment. It is so much more than putting the 2 parts together and hoping for the best. Secondary care includes evaluation, minor debridement cleaning and then dressing.
If the digit is going to be re-attached, then just the cleaning of the wound and the, well lets just say finger are done. Then both are packaged up and sent to the operating room. For injuries like my son’s then reattachment is not possible.
Since bone is normally exposed, it is not recommended to abrasively clean to end of the wound. The best way is to soak the wound is to use a ½ normal saline solution. Normal saline can burn. Imagine salt rubbed into a wound. If ½ normal saline is not available, STERILE water can be used. Do not use tap water. The normal bacteria that live in a tap water can be possibly fatal to our patient. Infection that passes to the bone without modern antibiotic and hospital care can be fatal.
Per ½ quart/liter of water add 1 fluid ounce/30 cc of Hibicleans. If Hibicleans is not available, .5 ounces/15cc of Betadine. The reason for the less amount of betadine is it is toxic to the tissues in large amounts. Soak for 15 minutes. Do not rinse.
I’m going to deviate from a lot of my fellow herbalists in this. I don’t recommend herbal soaks for the 1st week. Not due to an increased risk of infection. Some of the herbs, namely comfrey, can cause healing to progress to fast. And during the first week good drainage of the wound is very important. By closing the wound to fast, it can cause slowing of the healing.
Dress with a sterile Vaseline gauze or Neosporin on vasiline gauze dressing. This is to prevent sticking to the wound. On my son we alternate Vaseline gauze and Telfa. The Dressing needs should be changed 2x daily. Again, infection is the reason for this. Imagine a kerosene lamp. The oil is drawn up the wick by temperature differential. The neosporin or Vaseline, will soak though the dressing. And bacteria will be drawn in to the wound by “wicking” Neosporin only lasts about 24 hours. After that it is a mineral oil base. And the risk of infection skyrockets if left on.
Today, (08/12/2020) Ryan went in for his wound check. Healing is progressing well. No real changes, except we are to stop adding the neosporin to prevent the dressing from sticking. I understand the reasoning, but I don’t have to like it. The surgeon wants the dressing to do minor debridement. It sounds minor, but the pain it causes my son is well its pretty bad. I’ve seen it before. The body is already pissed off it lost a piece of itself and the nerve endings are exposed as it inner tissues, adipose, and muscle. We’re going to help the debridement, bandage change and healing by soaking the wound.
I don’t want to accelerate the healing by adding comfrey at this time. Just a simple weak tisane of Calundula and Yarrow. Wanting to keep this sterile, so that means bringing it to a boil for a couple of minutes vs the traditional steeping for 5-10 minutes. The idea here is to provide some antimicrobial help while loosing the bandage from the wound. We are still using the petroleum gauze that the MD has ordered. Remember I am no doctor. But I have treated many traumatic amputations from the military.
This is an ongoing blog post. We’ll return to it from time to time as his healing progresses. Ryan and His mom. brother and I are very lucky. This could have been much worse. He could have lost more than the tip of his finger. He could have lost a hand, arm or his life. For that we are very thankful for.
Ok Now the good stuff. Pictures!!!! We have been taking pictures every other day to record the progression of his healing.
In the ER and bandaged up
Hand surgeon office
Dressing change #5
Day 9 Dressing change
Looking better at this dressing change.