In part 1 of this series we discussed medical emergencies.  Now we are going to progress to dealing with trauma.  In the emergency service field, trauma is an umbrella for any injury that is received from kinetic means.  The mechanism of traumatic injury (MOI) can give you a good picture of injuries to look for.  Even though trauma is a blanket term, the variety of injuries are vast and are often difficult to treat, especially in a SHTF situation.

In Part 1 we looked at emergencies based on the type of scenario.  In this part I’m going to change it up a bit and look at the different types of injuries that are most common and how to deal with them in the short term (acute care) and over long periods.

Bleeding Control

Many traumatic injuries will cause blood loss, either internally or externally.  In its most basic form, bleeding control consists of only a few easy steps, all of which can be completed in a relatively short period of time and consisting of the following:

• Apply direct pressure to the wound
• Apply direct pressure and elevate the wound site above the heart
• Apply blood clotting agent
• Apply tourniquet

It is worth noting that clotting agents are generally left out of most emergency medical courses such as first responder and EMT because the agents are not widely available.  I have included it here because I think it’s a very useful and viable means of stopping bleeding until you can get to some kind of help.

It is very important to note that when controlling bleeding you DO NOT remove any dressings that you are using to stop the bleeding.  Removing dressings may remove clots thereby allowing the wound to reopen and start bleeding again.  If the dressing becomes soaked with blood simply add new dry dressings to the top and keep pressure on the wound.  Also, if you have to apply a tourniquet to a patient make sure to record the time that it was applied.  This will allow physicians (if you are lucky enough to be able to find one) to know how long it has been applied which is important when the tourniquet is removed.

Unfortunately, in a SHTF situation, surgery may not be available at all.  Trauma injuries that are easily treated today will likely lead to debilitating wounds, amputations, and death from blood loss and infection (this is where antibiotics will be in demand).

It is worth noting that there are 2 types of bleeding that you can readily identify and which require different prioritization.  Vascular blood is blood which has already been used by the body and is on its way back to the heart and lungs for recycling.  It is signified by dark red oozing blood and typically takes a long time to become life threating.  When assessing a patient with this type of bleeding, you note it and continue looking for other injuries.  Arterial bleeding, on the other hand, must be dealt with immediately.  Arterial blood is oxygen rich blood coming directly from the heart.  It is signified by bright red color and is usually spurting out of the body because it is under pressure.  If you encounter this type of bleeding you must immediately stop and work on controlling the blood loss through the above steps.

Shock Identification and Treatment

Loss of blood is called hypo perfusion (“hypo” meaning a lack of and “perfusion” meaning available blood).  This state is often called shock.  Shock can usually be easily identified.  When a patient loses blood their heart rate will increase to compensate for that loss of blood; it has to beat faster and harder to push a smaller amount of blood around to the various parts of the body.  So a patient’s vitals will be marked by an increased pulse and increased blood pressure and they may begin complaining that they are cold.  If the blood loss is not stopped and shock keeps progressing, because the heart doesn’t have enough blood to pump, the blood pressure will begin falling rapidly and the patient will lose consciousness at some point. Treatment for shock includes controlling blood loss as mentioned above, as well as elevating the patient’s feet and legs above their head and covering them with blankets to keep them warm.  If there is a paramedic, nurse, or doctor they will likely start an IV to offset the blood loss.

Fractures

Fractured bones are generally not immediately life threatening except in only a few rare circumstances.  Broken arms and legs, once set, will generally heal on their own over time.  If a person breaks an extremity you will want to secure and immobilize the affected area by splinting the limb with whatever is available.  I’ve seen simple cardboard splints and improvised splints made out of whatever is available.  All you’re trying to do is keep the fracture from moving and causing damage.  Once you have splinting materials, use some strips of fabric to tie around the splint and limb.  You need to immobilize the nearest joint above and below the injury.  So if someone breaks a bone in their forearm, you will need to splint and immobilize at the elbow and at the wrist.

Generally speaking, if someone breaks their femur (which for those who don’t know is the large bone in the upper leg) they will require a traction splint to immobilize the entire leg.  A person with a broken femur will be in extreme pain and can possibly lose consciousness.  The traction splint secures the upper leg to the device, attaches a ratchet to the ankle, and pulls the fracture slightly apart.  When the fracture pulls apart, the patient generally feels relief from the pain.  At this point, DO NOT release the tension on the device.  Secure the leg the rest of the way and if possible, seek medical help.

Along with the above fractures, compound fractures require a little more care.  Compound fractures are those with obvious deformity, such as an arm that resembles the letter S, or which the broken bone has penetrated the skin.  These injuries are generally painful but are treated in the field much like the other fractures above.  The extremity is secured to prevent motion, and the area of the break is covered with gauze to prevent contamination and infection.

The last type of fracture I will cover is what is known as a flail chest.  This is a condition where a portion of the rib cage is broken away from the sternum.  It is easily recognized when assessing a patient’s breathing.  When you breathe in, your chest expands and rises.  With a flail chest, the patient’s chest will have a marked area where the chest either doesn’t move, or moves in the opposite direction of the rest of the chest.  This is called paradoxical motion.  The only treatment in the field for this type of injury is to apply a bulky dressing to the area and to secure it with tape.  This will give the injury a small measure of support and prevent any further injury.  This type of injury is important to watch because broken ribs can easily penetrate the lungs.  A collapsed lung is not something that you can treat in the field.

Burn Care

When you encounter a patient with burns, the first step to treating them is to make sure that the area is safe.  A patient may have been burned by a downed but still energized power line and the last thing you need to do as a responder is get injured yourself.  Burn care can be broken down into 2 categories of care; acute and long term.  Acute care, which is provided immediately after the injury happens, is pretty straightforward.  When the body is burned, heat is transferred down into the tissues and continues to be released for a period of time.  The easiest way to treat a burn is with lots of cool clean water.  It will help soothe the affected area as well as remove heat thereby stopping the damage.  When it’s time to move the patient, wrap the affected area with clean gauze or dressings to prevent contamination of the wound.  Also monitor the patient for signs of shock as mentioned previously.

Long term care of a burn is relatively simple provided you take some basic steps.  The biggest life threat to a burn victim is infection of the wound.  Keeping the wound clean and covered with clean dressings will do the bulk of the healing work.  If you have some antibiotic ointment, applying this a few days after the burn is also a good idea, however allow the wound to blister and run its course for a short period of time as the ointment may be counterproductive as it may prevent the shedding of dead tissue.  And, as usual, monitoring for signs of infection and treating with antibiotics will be required.

Caring for Wounded

I think it would be prudent at this point to take a moment to talk about what is required of caregivers when someone is injured.  In the short term, patients will need multiple people to help them with otherwise normal tasks.  Something as mundane as going to the bathroom will require effort and assistance.  Patients will need someone to help them bathe and keep clean, they will need clean clothes and linens, they will need to eat and drink adequately to give the body energy to heal.  Some wounds heal relative easily and on their own; others may take weeks or months to fully heal to a level where the patient can do things for themselves.  Someone who suffers a life altering injury such as an amputation or paralysis will need permanent care assuming disease or infection do not kill them first.

So as you can see, and in light of an apocalyptic situation where there is no hospital or medical care, injuries will put a massive strain on your manpower and supplies.  It is absolutely critical to prevent injuries from happening.

During the recovery phase, disease control will be very vital especially for those patients with open wounds.  Any time a care giver must come in contact with a patient, such as when changing a bandage, they need to be sure to thoroughly wash their hands.  Patients also need to remember to not touch the wound unless their hands are clean.  Practicing good sanitation is also imperative.  Sewage and rotting garbage attracts insects that are also attracted to sores and wounds.  This is how disease is spread.  A patient whose body is already working extra hard to heal from a wound will be more susceptible to disease.  And if a wounded patient becomes ill their chances of survival are severely diminished.

Mass Casualty Incidents and Triage

One of the most heart wrenching things to do as a responder is to perform triage of multiple patients.  Triage is the act of prioritizing numerous patients as to the extent of their injuries and their chances of survival.  Triage is usually done on a color code scale, though there are variations.  When you encounter a scene with multiple victims, called a mass casualty incident or MCI, one or more personnel should be assigned to triage.  This allows the greatest care to be given to those patients who need it the most.  Patients are assigned a color based on their injuries.  The colors are Green, Yellow, Red, and Black.

Green patients are considered the “walking wounded” and consist of those with no or only minor injuries.  Injuries are typically cuts, scrapes, minor broken bones, etc.  They are generally used to help move patients to a safer location or treatment area.

Yellow patients are those with moderate injuries.  They will need more treatment but their conditions are not critical.  These patients are placed in a location of comfort, given some basic care, and a set of vitals taken.  They are then left alone with the green tagged wounded who then monitor the yellow patients for signs of worsening conditions.  Periodically, as time and resources allow, the yellow patients are reassessed and, if necessary, prioritized to red if their conditions worsen.

Red patients are those patients who, if not given care immediately, will die.  These are the patients with gross bleeding, not responsive but breathing, compound fractures, etc.  These patients receive the first care in an effort to try to save their lives.  This is the group of patients who receive the bulk of the medical assets.

Lastly, victims who are already deceased or who stand little hope of survival are tagged black.  This is the hardest color to give because the person triaging patients are deciding who receives life saving care and who doesn’t.  Black tags are given to those patients who have injuries that are so severe that they would require extreme and immediate medical intervention to save their lives.

Conclusion

As you can see, helping trauma patients requires a lot of time and effort.  The skills that will be used are much more extensive than what I can cover in this article, and once gained the skills must be practiced on a regular basis.  The old adage of if you don’t use it you lose it is in full effect in this case.  At the bare minimum, everyone should take a basic first aid and CPR class.  This is the minimum level of training that everyone can use.

I encourage everyone to seek out and join their local volunteer fire departments.  The fire service nationwide is made up mostly volunteers.  Ordinary people who come to the aid of their communities in times of need.  Sadly, most fire departments are grossly understaffed and woefully underfunded.  They are always looking for members to come help them out.  If you have even a modicum of interest in learning valuable life saving medical skills, they are typically the best place to go.  Most departments will provide training free of charge to certify you as a medical first responder or emergency medical responder (EMR).  Most of the skills I’ve talked about are learned at this level.  The EMR training is typically a 40-hour course that is taught in the classroom.  As a member of the fire department you will also get to practice your patient skills and become proficient at dealing with injuries.

I also recommend seeking out more advanced medical training such as the EMT-Basic.  This is generally a 120-hour course that includes classroom work as well as spending time riding on an ambulance with teachers where you put the skills and principles you learn into actual use.  The EMT-B skill level also permits you to do certain treatments above and beyond what is afforded to the first responder.

Finally, I highly recommend the reader seek out and acquire copies of “Where There Is No Doctor” and “Where There Is No Dentist” available for free download from http://hesperian.org/books-and-resources/ as well as “Ditch Medicine” from Paladin Press.  There are other important books out there that could also aid in helping you through a tough situation.

Part 3 of this series will cover medical patient assessment as well as rapid and detailed trauma assessments.