Lifesaving Steps

2-7. Once the Soldier has implemented their ISG/EPA, they become their own doctor, emergency medical technician, and surgeon; in an operational environment where they are being hunted, and without any of the medical capabilities that are typically needed to treat the recognized condition/symptoms. The isolated person’s health is of primary importance; taking unnecessary risks, which could lead to injury, are prevented or mitigated. Once isolated, the fundamentals of the MARCH algorithm are applied through a flexible process that prioritizes actions relevant to physical, psychological, and environmental considerations that are continually assessed and prioritized for action by the isolated person.

2-8. The following list of actions enable assessment and lifesaving treatment of an isolated person/isolated personnel. The list is a guide that makes use of the MARCH algorithm. If the isolated person does not exhibit “massive hemorrhage”, the priority for treatment follows the Airway, Respiration (breathing), Circulation, and Head/Hypothermia protocol.

  • In an isolation situation, if an isolated person discovers another casualty they will determine if the casualty is alive or dead. If there are no signs of life —no pulse, no breathing— they will NOT attempt to perform lifesaving steps. The isolated person should note the Soldier’s name, rank, and location. The isolated person should perform field recovery of equipment from the casualty that will aid the isolated person’s survival effort.
  • If the casualty is alive — the isolated person will provide care to the casualty using prioritized actions from Battle Drill 3 “Perform Tactical Combat Casualty Care” referenced in Appendix A, STP 21-1-SMCT, 28 Sept 2017.

Note. Steps 3 through 13 (from the Soldier’s Manual of Common Tasks) are performed as self-aid for the isolated person and buddy-aid for the casualty/other isolated personnel.

Bleeding

2-9. External, life-threatening bleeding. Bleeding is life threatening if any one of the following signs/symptoms are observed:

  • There is a traumatic amputation of an arm or leg.
  • There is pulsing or steady bleeding from the wound.
  • Blood is pooling on the ground.
  • The overlying clothes are soaked with blood.
  • Bandages or makeshift bandages used to cover the wound are ineffective and steadily becoming soaked with blood.
  • There was prior bleeding, and the casualty is now in shock (unconscious, confused, pale).

2-10. Control external bleeding. External bleeding falls into the following classifications:

  • Arterial. Blood vessels called arteries carry oxygenated blood away from the heart and throughout the body. Arterial bleeding is the most serious type of bleeding. If not controlled promptly, it can be fatal. With this type of bleeding, the blood is typically bright red to yellowish in color and exits the wound in distinct spurts or pulses that correspond to the rhythm of the heartbeat rather than in a steady flow. Because the blood in the arteries is under high pressure, an individual can lose a large volume of blood in a short period.
  • Venous. Venous blood is blood that is returning to the heart through blood vessels called veins. A steady flow of dark red, maroon, or blackish in color blood characterizes bleeding from a vein due to the lack of oxygen it transports. Venous bleeding is still of concern. While the blood loss may not be arterial, it can still be quite substantial, and can occur with surprising speed without intervention. It can usually be controlled more easily than arterial bleeding.
  • Capillary. The capillaries are the extremely small vessels that connect the arteries with the veins. Capillary bleeding most commonly occurs in minor cuts and scrapes and generally oozes in small amounts as opposed to squirting (arterial) or flowing (venous). This type of bleeding is not difficult to control.

2-11. If the casualty has severe, life-threatening bleeding from an extremity or has an amputation of an extremity, administer life-saving hemorrhage control by applying a combat application tourniquet (CAT) from the casualty’s IFAK before moving the casualty. Personnel with life-threatening bleeding can bleed to death from a complete femoral artery and vein disruption within as little as three minutes. Isolated persons must control life-threatening bleeding immediately because replacement fluids are not available.

2-12. If a CAT is unavailable, apply an improvised tourniquet made from a rod (made from a jack handle, stick, scabbard, cleaning rod, pipe, dowel), a band of material at least 1-1/2 inches wide (made from a cravat, bandana, towel, ace bandage, shirt, nylon webbing, rifle sling.

Note. Belts, zip ties, should only be used as a last resort, and a securing mechanism as a constricting or compressing device to control arterial and venous blood flow to a damaged extremity for a short period of time.

2-13. The wide band of material is made into a loop that fits over the damaged limb, 2-3 inches above the site of arterial bleeding, and tied tightly with an overhand knot. Next, lay the rod across the overhand knot. The running ends of the loop are then used to tie another overhand knot on top of the rod forming a square knot with the rod through the center of the knot. The rod is then twisted, applying pressure circumferentially around the limb tight enough to stop the arterial bleeding. Do not tighten the tourniquet more than necessary to stop the bleeding. In the case of amputation, dark oozing blood may continue for a short time. This is the blood trapped in the area between the wound and tourniquet. Fasten the tourniquet to the limb by looping the free ends of the tourniquet over the ends of the stick. Then bring the ends around the limb to prevent the stick from loosening. Tie them together on the side of the limb.

2-14. If bleeding remains, place a second tourniquet side by side to the first tourniquet. A tourniquet can be left in place up to two hours without damage to vessels, nerves, muscle or loss of limb. If isolated, the victim or buddy should release the pressure from the tourniquet after two hours, and then retighten if blood loss continues.

2-15. Ideally, the tourniquet will stop or considerably slow down the flow of arterial blood from the wound. As an open wound, the risk of infection is great. Before applying a pressure bandage, rinse the wound with sterile saline or clean water

Note. In isolation or captivity; alcohol, vinegar, natural honey, hydrogen peroxide, and bleach are also highly effective antiseptics. Once gauze or bandage is applied it must not be removed.

Hypoxia

Hypoxia is the result of insufficient oxygen in the blood. It is a potentially deadly condition and one of the leading causes of cardiac arrest. Cardiac arrest is linked to an absence of circulation in the body, for any one of a number of reasons. For this reason, maintaining circulation is vital to moving oxygen to the tissues and carbon dioxide out of the body. Open an airway and maintain it by using the following steps:

  • Check to see if the casualty has a partial or complete airway obstruction. If they can cough or speak, allow them to clear the obstruction naturally. Stand by, reassure the casualty, and be ready to clear their airway and perform mouth-to-mouth resuscitation should they become unconscious. If their airway is completely obstructed, administer abdominal thrusts until the obstruction is cleared. Any one of the following can cause airway obstruction, resulting in stopped breathing:
    • Foreign matter in mouth of throat that obstructs the opening to the trachea.
    • Face or neck injuries.
    • Inflammation and swelling of mouth and throat caused by inhaling smoke, flames, and irritating vapors or by an allergic reaction.
    • “Kink” in the throat (caused by the neck bent forward so that the chin rests upon the chest).
    • Tongue blocks passage of air to the lungs upon unconsciousness. When an individual is unconscious, the muscles of the lower jaw and tongue relax as the neck drops forward, causing the lower jaw to sag and the tongue to drop back and block the passage of air.
  • Using a finger, quickly sweep the casualty’s mouth clear of any foreign objects, broken teeth, dentures, and sand.
  • Using the jaw thrust method (figure 2-1 on page 2-6), grasp the angles of the casualty’s lower jaw and lift with both hands, one on each side, moving the jaw forward. For stability, rest your elbows on the surface on which the casualty is lying. If their lips are closed, gently open the lower lip with your thumb.
Figure 2-1. Jaw Thrust Method

2-16. With the casualty’s airway open, pinch their nose closed with your thumb and forefinger and blow two complete breaths into their lungs. Allow the lungs to deflate after the second inflation and perform the following:

  • Look for the chest to rise and fall.
  • Listen for escaping air during exhalation.
  • Feel for flow of air on your cheek.

2-17. If the forced breaths do not stimulate spontaneous breathing, maintain the casualty is breathing by performing mouth-to-mouth resuscitation.

2-18. There is danger of the victim vomiting during mouth-to-mouth resuscitation. Check the victim’s mouth periodically for vomit and clear as needed.

2-19. If the casualty is unconscious, if respiratory rate is less than 2 in 15 seconds, and/or if the casualty is making snoring or gurgling sounds, insert a nasopharyngeal airway (NPA) from the casualty’s IFAK. Remember these things when inserting the NPA:

  • Keep the casualty in a face-up position.
  • Lubricate the tube of the NPA with water.
  • Push the tip of the casualty’s nose upward gently.
  • Position the tube of the NPA so that the bevel (pointed end) of the NPA faces toward the septum (the partition inside the nose that separates the nostrils).
  • Insert the NPA into the nostril and advance it until the flange rests against the nostril.

Note: Cardiopulmonary resuscitation (CPR) may be necessary after cleaning the airway, but only after major bleeding is under control.

2-20. Continue to check for bleeding by performing a blood sweep. Control external bleeding by the application of direct pressure, indirect pressure, elevation, or digital ligation.

Direct Pressure

2-21. The most effective way to control external bleeding is by applying pressure directly over the wound. This pressure must not only be firm enough to stop the bleeding, but it must also be maintained long enough to “seal off” the damaged surface.

2-22. If bleeding continues after having applied direct pressure for 30 minutes, apply a pressure dressing. This dressing consists of a thick dressing of gauze or other suitable material applied directly over the wound and held in place with a tightly wrapped bandage. It should be tighter than an ordinary compression bandage but not so tight that it impairs

2-23. Circulation to the rest of the limb. Once you apply the dressing, do not remove it, even when the dressing becomes blood soaked. Leave the pressure dressing in place for 1 or 2 days, after which you can remove it and replace it with a smaller dressing. In a long-term survival environment, make fresh, daily dressing changes and inspect for signs of infection. Figure 2-2 shows applications for pressure dressings.

Figure 2-2. Application of a pressure dressing

2-24. The isolated person can make field expedient dressings if a medical kit is unavailable. The purpose of a dressing is to control bleeding, absorb wound secretions, and to prevent bacteria from entering the wound.Materials that make functional field expedient dressings include cloth from a shirt, undergarments, socks, bandanas, handkerchiefs, thin towels, bedding and feminine care absorbent pads. Cut these materials to proper size to cover the wound and sterilized before use. To sterilize, the isolated person can steam the material for five minutes or boil the material in water for ten full minutes at a rolling boil. If needed, the isolated person can clean and sanitize used bandages by boiling them, then reusing them if no other option exists.

Elevation

2-25. Raising an injured extremity as high as possible above the heart’s level slows blood loss by aiding the return of blood to the heart and lowering the blood pressure at the wound. However, elevation alone will not completely control bleeding; apply direct pressure over the wound.

Pressure Points

2-26. A pressure point is a location where the main artery to the wound lies near the surface of the skin or where the artery passes directly over a bony prominence. Personnel can use digital pressure on a pressure point to slow arterial bleeding until a pressure dressing is applied. Pressure point control is not as effective for controlling bleeding as direct pressure exerted on the wound. It is rare when a single major compressible artery supplies a damaged vessel.

WARNING
Use caution when applying pressure to the neck. Too much pressure for too long may cause unconsciousness or death. Never place a tourniquet around the neck.

2-27. If an isolated person cannot remember the exact location of the pressure points, they should follow this rule: Apply pressure at the end of the joint just above the injured area. On hands, feet, and head, this will be the wrist, ankle, and neck, respectively. Maintain pressure points by placing a round stick in the joint, bending the joint over the stick, and then keeping it tightly bent by lashing. Using this method to maintain pressure frees the hands to work in other areas. Figure 2-3 shows key body pressure points.

Figure 2-3. Key body pressure points

2-28. If the bleeding is on the head, above the ears, press the point just in front of the ear, in a direct line to the corner of the eyes.

2-29. If the lower part of the face is bleeding, press the point on the jaw bone halfway between the chin and the end of the jaw.

2-30. If bleeding is from the neck, press the point on the carotid artery, located between the Adam’s Apple and neck muscles. Stopping bleeding from here is a matter of life and death.

2-31. If the bleeding is high on the arm, press the point just above the middle of the collar bone. If the bleeding is low on the arm, press the point in the fold opposite the elbow, on the inside of the arm.

2-32. There are two pressure points on the wrists. The first one is more common, where we normally feel our pulse. The other one is just alongside, down from the little finger.

2-33. If the bleeding is from the groin or thighs, find and press the femoral artery. It is located along the bikini line, half way between the hip and the groin. A lot of pressure is required to control the bleeding here, maybe even both your hands, due to the amount of blood that flows through this artery to supply oxygen to the legs.

2-34. The pressure point on the popliteal artery lies behind the knee. Press this to stop bleeding from the lower leg below the knee.

Digital Ligation

2-35. Slow down major bleeding by applying pressure with a finger or two on the bleeding end of the vein or artery. Maintain the pressure until the bleeding stops or slows down enough to apply a pressure bandage, and elevation.

Assess For Breathing and Chest Injuries

2-36. Fractured ribs are common, painful, and disabling. The isolated person will not have access to pain medications and must understand that the pain associated with rib injuries can lead to reduced movement and cough suppression which can contribute to formation of secondary chest infection. To treat fractured ribs —

  • Protect the injured rib by supporting the arm on the injured side with a sling-and-swathe.
  • Encourage the person to take deep breaths regularly, even if it hurts, to keep the lungs clear.
  • Watch the person for increasing trouble breathing.

CAUTION
Do not wrap a band snugly around the person’s chest.

2-37. Flail chest. It is most commonly a result of serious blunt trauma (falling from a height, vehicle or aircraft wreck or other accident). Ribs are typically broken away from the sternum, or when two, three or more adjoining ribs are broken in two or more places. The condition will make breathing difficult and indicates possible internal bleeding. Detect “flail chest” by observing a section of ribs moving in and out opposite to the rest of the ribs during breathing due to air pressures. The isolated person can try applying a bulky dressing and wrapping it to immobilize.

2-38. Pneumothrax. This is a common injury in isolation where isolated personnel fall or suffer chest trauma associated with blast injuries, blunt trauma and penetrating trauma (sucking chest wound). Sucking chest wounds are recognized by the sucking noise and appearance of foam or bubbles in the wound. This condition requires application of an occlusive dressing to the entry and exit wounds immediately before serious respiratory and circulatory complications occur.

2-39. Ideally, the patient should attempt to exhale while holding the mouth and nose closed (the Valsalva maneuver) as the wound is closed. This inflates the lungs and reduces the air trapped in the pleural cavity. Frequently, a taped, airtight dressing is all that is needed, but sometimes it is necessary to suture the wound to make sure the wound is closed.

2-40. Begin rescue breathing as necessary to restore breathing and/or pulse (Cardiopulmonary Resuscitation (CPR).

  • Place the casualty on a firm, flat surface. Give 30 chest compressions by compressing the casualty’s chest at least 2 inches deep.
  • Push hard, push fast in the middle of the chest at a rate of at least 100 compressions per minute.
  • Give 2 rescue breaths by tilting the head back and lift the chin up, then pinch the nose shut then make a complete seal over the person’s mouth.
  • Blow in for about 1 second to make the chest clearly rise. Give rescue breaths, one after the other. If chest does not rise with the initial rescue breath, retilt the head before giving the second breath.
    • If the second breath does not make the chest rise, the person may be choking. After each subsequent set of chest compressions and before attempting breaths, look for an object and, if seen, remove it. Continue CPR.

Burns

2-41. The following treatments are extreme measures and are only meant to be applied with extreme caution under real-world experiences. Burns sustained during military operations constitute a relatively small, but very real percentage (5%) of combat-related injuries. Even burns to a small surface area can be incapacitating for the casualty and strain the resources of deployed military medical units. It is crucial to remember that burns may represent only one of the casualty’s traumatic injuries, particularly when an explosion is the mechanism of injury. Optimal treatment includes management of homeostatic changes related to the burn and associated traumatic injuries. Resuscitation of the burn casualty is generally the most challenging aspect of care during the first 48 hours following injury, and optimal care requires a concerted effort on the part of all providers involved during the evacuation and treatment process.

2-42. Dress all non-life threatening injuries and any bleeding that has not been addressed earlier with appropriate dressings. Also—

  • Check the casualty for burns.
  • Burns are painful and limit capability and can increase the susceptibility of shock and infection and lead to a loss of body heat, fluids, and minerals. If an isolated person—
    • Catches on fire, the immediate action is to get away from the flame and smother the fire—do not run—Stop, Drop, and Roll. Suspect possible airway complications with burns to the face and/or neck; soot in the mouth and or nose; singed facial hair; or a dry cough.
  • If there is a chemical causing the burn, remove the chemical from the skin by flushing it with copious amounts of water.
  • In case of electrical burns, remove the victim from the contact with electricity. Electrical burns typically affect cardiac or respiratory systems. Always care for cardiac and respiratory problems before caring for burns.

2-43. Once the fire is out, assess the damage and begin to treat the burns. Initiate MARCH (see page 2-1) and protect the casualty from shock and hypothermia. Cool the burning skin with cold water for 20 minutes if possible. For burns caused by white phosphorous, pick out the white phosphorous with tweezers; do not douse with water.

2-44. First-degree burns involve only the outer layer of the skin known as the epidermis. First-degree burns do not blister; they become very red and are quite painful. After about two to three days, the pain should subside and peeling of the skin will begin. Soaking in cool water helps with the pain.

2-45. Second-degree burns are known as superficial partial-thickness burns. These types of burns affect the upper layers of the dermis and have a tendency to swell and blister. They are more painful than first-degree burns. If you suspect a second-degree burn:

  • Remove jewelry or tight clothing from the burned area before the skin begins to swell.
  • Take a pain reliever if available. Flush the skin with cool running water or apply moist cloths until pain lessens.
  • Do not use ice or ice water; this can cause more damage to the skin.
  • Use an antiseptic spray to prevent infection or use aloe cream or the aloe plant to soothe the skin.
  • Do not put ointments, grease, petroleum jelly, butter, or home remedies on a burn.
  • Cover the burn with a clean, dry, non-adhering no-fluff bandage such as a gauze pad.

2-46. Third-degree burns or full-thickness burns involve all layers of the dermis. This type of burn causes a large amount of tissue damage and is extremely painful or painless if nerve damage has occurred. Skin will be leathery and dry and can appear black, white, or brown in color. Do not remove any embedded charred clothing or material. However, remove constrictive jewelry and unburned clothing from the area if they are not stuck on the burn. If you suspect a third-degree burn:

  • Apply cool, wet compresses to the burned area for a very brief to help reduce the body temperature Do not use ice or immerse the affected area in cold water.
  • Cover the burned area with cool, moist, sterile bandages.

2-47. Be prepared to treat injured personnel for shock. If possible, elevate the burn above the heart to assist in reducing swelling and the likelihood or severity of shock. Staying hydrated will help control the loss of body fluids. Isolated persons should replace salt by consuming the cooked eyes and blood of animals or adding ¼ teaspoon of regular salt per quart of water.

2-48. Prevent/treat hypotension and hypoxia to prevent worsening of traumatic brain injury (TBI) and prevent/treat hypothermia.

Head Injury

2-49. During Tactical Field Care, Soldiers assess their condition for an altered mental status. Soldiers with an altered mental status may use their weapons or radios inappropriately and may not be able to accurately assess their condition in relation to isolation criteria and implementation of their ISG/EPA. Injuries to the head pose additional problems related to brain damage and may interference with breathing and eating. Bleeding is more profuse in the face and head area, but infections are less likely. This makes it somewhat safer to close such wounds earlier to maintain function.

2-50. Most important in treating a head injury is maintaining proper airway control. The lack of oxygen to an injured brain can have very detrimental effects. An emergency airway puncture may be necessary if breathing becomes difficult due to obstruction of the upper airways. In the event of unconsciousness, keep the patient still and under close observation. Even in the face of mild or impending shock, keep the head level or even slightly elevated if there is reason to expect brain damage. Do not give fluids or morphine to unconscious persons.

2-51. Traumatic Brain Injury (TBI) is a common injury in isolation where isolated personnel fall or suffer head trauma associated with vehicle and aircraft crashes, blast injury, and blunt trauma. Hypotension (low blood pressure) and hypoxia (insufficient oxygen in the blood) manifest the condition with dizziness and fainting.

2-52. For a bleeding scalp, apply several dressings with your gloved hand. Press gently because the skull may be fractured. On examination, if you feel a depression, spongy area or bone fragments, DO NOT put direct pressure on the wound. Control bleeding with a gauze dressing and diffuse pressure.

2-53. The symptoms associated with mild brain injuries typically include short term memory loss, blurred vision, nausea, dizziness, extreme tiredness and possible neck pain or tenderness. Care for mild brain injury includes—

  • Apply pressure from a gauze dressing on the bleeding scalp.
  • Apply a cold pack, ice, wet bandana, to reduce swelling and pain associated with a bump.
  • Monitor the person for 24 hours.
  • Awaken the person every 2 hours to check for signs and symptoms of serious brain damage.

2-54. The symptoms associated with serious brain injury include—

  • Prolonged unconsciousness with no response to aggressive stimulation, such as shouting or tapping the shoulder.
  • Possible skull fracture.
    • A depression (pressed-in area) in the skull. (DO NOT push on the area.)
    • A fracture that is visible where the scalp has been torn.
    • Bruising around both eyes (raccoon eyes) or behind both ears
  • Clear fluid and/or blood dripping from the nose or ears.
  • Inability to sense touch or move extremities.
  • Eyes that do not respond to light appropriately or equally. (Check pupil response, one eye at a time, by shading the eyes with a hand and then exposing the pupils to light.)
  • Mental status deterioration (from disorientation, to irritability, to combativeness, to coma).
  • Personality changes.
  • Loss of coordination, balance and/or speech.
  • Extremely bad headaches.
  • Vision problems.
  • Seizures.
  • Nausea and vomiting that does not go away.
  • Relapsing into unconsciousness.
  • Heart rate that slows down (less than 40 beats per minute [BPM]), then speeds up.
  • Erratic (irregular) respiratory rate.
  • Unequal pupils.

2-55. Care for serious brain injury includes—

  • Assessing the person for spinal injury.
  • Keeping the person calm and reassured.
  • Using two personnel to help the casualty move if they are able to walk.
  • Being prepared to treat the person for reduced breathing.

2-56. In a situation where a group of personnel are isolated, consideration should be given to removing all weapons and radios away from any casualty manifesting brain injury who is not alert and fully oriented to the tactical situation. The group must exercise the tenets of mission command and ensure that appropriate decisions about ISG/EPA, captivity, and detention are also implemented.

2-57. The individual isolated person with a brain injury should consider immediate movement to and occupation of a hide site to rest and relieve their condition.

2-58. Administer pain medications and antibiotics from the combat pill pack if available.

Shock

2-59. Monitor the patient for shock and treat as appropriate. Shock is a condition of the body that describes the physiologic condition where oxygen delivery to the tissues of the body is not enough to meet the metabolic demands of those tissues. Early detection will be the key to limiting the effects on the body. Signs and symptoms of shock include the following:

  • Apprehension, anxiety, restlessness and irritability.
  • Altered level of consciousness.
  • Nausea and vomiting.
  • Pale, ashen or grayish, cool and moist skin.
  • Rapid breathing.
  • Excessive thirst.

2-60. Anticipate shock in all injured personnel. Treat all injured persons as follows, regardless of what symptoms appear:

  • If victims are conscious, place them on a level surface with the lower extremities elevated 6 to 8 inches.
  • If victims are unconscious, place them on their side or abdomen with their head turned to one side to prevent choking on vomit, blood, or other fluids.
  • If unsure of the best position, place the victim perfectly flat. Once in a shock position, do not move the victim.
  • Maintain body temperature by insulating the victim from the surroundings and, in some instances, applying external heat.
  • If the victim’s clothing is wet, remove it as soon as possible and replace with dry clothing.
  • Improvise a shelter to insulate the victim from the weather.
  • Use warm liquids or foods, a sleeping bag, another person, warmed water in canteens, hot rocks wrapped in clothing, or fires on either side of the victim to provide external warmth.
  • If the victim is conscious, slowly administer small doses of a warm salt or sugar solution, if available.
  • If the victim is unconscious or has abdominal wounds, do not give fluids by mouth.
  • Have the victim rest for at least 24 hours.
  • If the victim is a lone isolated person, the victim should lie in a depression in the ground, behind a tree, or any other place out of the weather, with the head lower than the feet.
  • Reassess the victim constantly.

2-61. Assess shock in all victims as shown in figure 2-4.

Figure 2-4. Treatment of Shock

Illness, Infection, Soft Tissue Trauma

2-62. Isolated persons will face debilitating illness, infection, and soft tissue trauma which can become life threatening during isolation when they are without adequate medical care and basic personal hygiene capabilities.

2-63. Table 2-1 on page 2-14 lists typical illnesses and infection, their signs and symptoms and treatment. Keep in mind that some of the treatments are extreme measures and only meant to be applied with extreme caution during actual isolation.

Table 2-1. Typical Illnesses, Infections, Causes and Treatments

Table 2-1. Typical Illnesses, Infections, Causes and Treatments (continued)

Table 2-1. Typical Illnesses, Infections, Causes and Treatments (continued)

Table 2-1. Typical Illnesses, Infections, Causes and Treatments (continued)

Infection

2-64. During isolation, including detention or captivity, consider all breaks in the skin contaminated, and treat them appropriately. Clean even superficial scratches with soap and water and treated with antiseptics, if available.

Basic treatment

2-65. Open wounds are serious in a survival situation, not only because of tissue damage and blood loss, but also because they may become infected. Bacteria on the object that made the wound, on the individual’s skin and clothing, or on other foreign material or dirt that touches the wound may cause infection. By taking proper care of the wound, the isolated person reduces the chance of further contamination and promotes healing. Clean the wound as soon as possible by doing the following:

  • Removing or cutting clothing away from the wound.
  • Look for an exit wound if a sharp object, gunshot, or projectile caused a wound.
  • Thoroughly clean the skin around the wound.
  • Rinse (DO NOT SCRUB) the wound with large amounts of water under pressure. Water can be pressurized using a syringe, irrigator, or plastic baggie with a small hole poked in it. Water is the most universally available cleaning agent. Water used to cleanse a wound should be potable at a minimum, with sterile water preferred. At sea level, sterilize water by placing it in a covered container and boiling it for 10 minutes. Above 3,000 feet, water should be boiled for one hour (in a covered container) to ensure adequate sterilization. The water will remain sterile and can be stored indefinitely as long as it is covered.)
  • Care must be taken not to rinse/irrigate the wound so vigorously that clots are washed away and bleeding resumes. Allow a period of an hour after the bleeding has been stopped before beginning irrigation with the sterile water. Begin gently at first, removing unhealthy tissue, increasing the vigor of the irrigation over a period of time, and avoid doing additional damage to the wound. The wound should be left open to promote cleansing and drainage of infection.

Open Treatment

2-66. The “open treatment” method is the safest way to manage wounds in survival situations. Leave the wound open to allow the drainage of any pus resulting from infection. As long as the wound can drain, it generally will not become life-threatening, regardless of how unpleasant it looks or smells. Cover the wound (including nerves, bone, and blood vessels) with a clean dressing. Place a bandage on the dressing to hold it in place. Change the dressing daily to check for infection.

2-67. Wounds, left open, heal by formation of infection resistant granulation tissue known as “proud flesh.” This tissue is easily recognized by its moist red granular appearance, a good sign in any wound. A notable exception to “open treatment” is the early closure of facial wounds which interfere with breathing, eating, or drinking

Gaping Wounds

2-68. If a wound is gaping, you can bring the edges together with adhesive tape cut in the form of a “butterfly” or “dumbbell”. Use this method with extreme caution in the absence of antibiotics. You must always allow for proper drainage of the wound to avoid infection. Immobilization in a position to favor adequate circulation, both to and from the wound, will typically hasten the healing of major wounds/lacerations.

Infections in Wounds

2-69. In a survival situation, some degree of wound infection is almost inevitable. Pain, swelling, and redness around the wound, increased temperature, and pus in the wound or on the dressing indicate infection is present. If the wound becomes infected, treat it as follows:

  • Place a warm, moist compress with lukewarm saltwater directly on the infected wound to help draw out infection and promote oozing of fluids from the wound, thereby removing toxic products.
  • Apply a warm compress and change it when it cools. Keep a warm compress on the wound for a total of 30 minutes.
  • Apply the warm compress three or four times daily.
  • Drain the wound. Open and gently probe the infected wound with a sterile instrument.
  • Dress and bandage the wound.
  • Drink a lot of water.
  • In the event of gunshot or other serious wounds, it may be better to rinse the wound out vigorously every day with the cleanest water available. If drinking water or methods to purify drinking water are limited, do not use your drinking water. Flush the wound forcefully daily until the wound is healed over.
  • Continue this treatment daily until all signs of infection have disappeared.
  • Apply heat to further aid in mobilizing local body defense measures. Soak the wound in lukewarm saltwater.

Use of Maggots

2-70. If you do not have antibiotics and the wound has become severely infected, does not heal, and ordinary debridement is impossible, consider maggot therapy. Maggots frequently infest deep open wounds. The natural tendency is to remove these maggots. But, they actually do a good job of cleansing a wound by removing dead tissue. Maggots exude calcium carbonate which alkalizes the wound and increases the destruction of bacteria and dead tissue by the body’s white blood cells. A maggot’s excretion also contains two chemicals (allantoin and urea) which stimulate growth of healthy tissue and hasten wound healing. Use the following process when using maggots.

  • Expose the wound to flies for one day and then cover it.
  • Check daily for maggots.
  • Once maggots develop, keep wound covered but check daily.
  • Remove all maggots when they have cleaned out all dead tissue and before they start on healthy tissue. Increased pain and bright red blood in the wound indicate that the maggots have reached healthy tissue.
  • Flush the wound repeatedly with potable (minimum) sterile (preferred) water to remove the maggots.
  • Bandage the wound and treat it as any other wound. It should heal normally.

Debridement

2-71. Debridement is the surgical removal of lacerated, devitalized, or contaminated tissue. The debridement of severe wounds may be necessary to minimize infection (particularly of the gas gangrene type) and to reduce septic (toxic) shock. In essence, debridement is the removal of foreign material and dead or dying tissue. The procedure requires skill and should be done by nonmedical personnel only in an emergency. If debridement is required, follow these general guidelines:

  • Cut away dead skin.
  • Muscle may be trimmed back to a point where bleeding starts and gross discoloration ceases.
  • Cut away damaged fat.
  • Conserve bone and nerves where possible and protect from further damage.
  • Ample natural drainage for the potentially infected wound and final closure of the wound.

Suture

2-72. Despite the danger of infection, occasionally it may be necessary to suture a wound in order to control bleeding or increase the mobility of the patient. Procure thread from parachute lines, fabric, or clothing, and the wound closed by “suturing.” If suturing is required, place the stitches individually and far enough apart to permit drainage of underlying parts. Do not worry about the cosmetic effect; just suture the tissue together. For a scalp wound, use hair to close it. Infection is less a danger in this area due to the rich blood supply. Remember that in most situations, it is imperative that the wound be left open and allowed to drain.

Medicinal Plants

2-73. In using plants for medical treatment, positive identification of the plants involved is as critical as when using them for food. Proper use of these plants is equally important. Many natural remedies work slower than the medicines you know. Therefore, start with smaller doses and allow more time for them to take effect.

WARNING
The following remedies are for use only in a survival situation. Do not use them routinely as some can be potentially toxic and have serious long-term effects.

2-74. The following terms and their definitions are associated with medicinal plant use:

  • Poultice. This is crushed leaves or other plant parts, possibly heated, that are applied to a wound or sore either directly or wrapped in cloth or paper. Poultices, when hot, increase the circulation in the affected area and help healing through the chemicals present in the plants. As the poultice dries out, it draws the toxins out of a wound. A poultice should be prepared to a “mashed potatoeslike” consistency and applied as warm as the patient can stand.
  • Infusion or tisane or tea. This blend is the preparation of medicinal herbs for internal or external application. You place a small quantity of an herb in a container, pour hot water over it, and let it steep (covered or uncovered) before use. Care must always be taken to not drink too much of a tea in the beginning of treatment as it may have adverse reactions on an empty stomach.
  • Decoction. This is the extract of a boiled-down or simmered herb leaf or root. You add herb leaf or root to water. You bring them to a sustained boil or simmer them to draw their chemicals into the water. The average ratio is about 28 to 56 grams (1 to 2 ounces) of herb to 0.5 liter of water.
  • Expressed juice. These are liquids or saps squeezed from plant material and either applied to the wound or made into another medicine.

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