Just A Flesh Wound: Wound Care on The Water
Medical emergencies can be scary as all get out! You’re not alone. I’m here with you. The path to feeling more comfortable with emergencies is education and practice. Just like when we learned to sail and everything was new. New terms. New concepts. Unfamiliarity at every turn. Let’s talk about it, learn about it, practice it. As sailors we’re experts at the gentle manipulation of expensive parts. Medicine is the same. I’ll bring topics and concepts to you and we’ll work through them together. Today’s topic of conversation is wound care on the water. Our skin is vulnerable to insult in so many ways, especially on a boat. Let’s talk about wound care aboard. You’ve got this…
Our Skin – What Exactly Is It?
Our skin. It is our largest organ in our bodies. It protects our inner selves from the outer world. It keeps fluids in and the microbes with which we share our planet out. It protects our organs from trauma. It plays a major role in regulating our body temperature. It is in a constant state of regeneration, shedding the old and generating new. We spend billions moisturizing it, protecting it from the sun, keeping it young. How can we care for and heal it onboard when it becomes compromised?
Wounds go by so many different names: lacerations (cuts); avulsions (a flap either partially or completely torn away); abrasions (scrapes). For offshore purposes we need only classify and treat them as simple or high risk. We do this by how deep the injury penetrates the skin. Let’s talk a bit about anatomy so we can understand how to tell the difference.
The skin is like a lasagna.
The top layer, the epidermis, is dead skin cells and bacteria. The next layer, the dermis, contains blood vessels, sweat glands, hair follicles and nerve endings. Under the dermis is a layer of subcutaneous fat. Beneath that is a tough, dull, white layer that looks a smidge like unfinished fiberglass. This is called fascia. Below the fascia are bones, tendons, and joints. They appear shiny and yellow or white. Muscle tissue under the fascia strikes us as looking like a deep red, bloody raw steak.
The difference between a simple wound and a high risk wound is how deep the injury penetrates the skin. This depth is not measured in centimeters or inches. It is measured by how many layers of skin the wound penetrates. The dividing line is the fascia, the unfinished fiberglass layer.
Simple vs. High Risk Skin Wounds
Simple wounds do not penetrate the fascia. There is no contamination of muscle, bone, tendon or joints. These wounds are not life threatening and do not have a great risk of infection. They can be managed on the boat and followed up when the risk of evacuating to shore is low. A simple wound, for example, would be a shallow cut from a clean knife.
High risk wounds penetrate the fascia. They are at risk for infection, life threatening bleeding, problems healing, damage to underlying structures like bones, tendons, joints or organs. Examples of high risk wounds include grossly contaminated wounds with gunk in them, mangled tissue, bites, deep puncture wounds, wounds over broken bones (open fracture), wounds that penetrate the chest or abdominal cavities. We don’t want to see shiny white stuff or dark red stuff.
A wound on one’s derrière could be inches deep, depending on the size of the backside, and still be a simple wound. A cut on the back of the hand could be only millimeters deep and be down to the tendon or bone, a high risk wound.
Treating Flesh Wounds Onboard
Onboard, the treatment of simple and high risk wounds is essentially the same. We need to stop the bleeding, inspect, clean, dress and monitor for infection. The difference is that we should consider evacuating high risk wounds, especially if we suspect an open fracture. Ideally, a high risk patient should be off the water within 48 hours. This sailor needs antibiotics and further evaluation. An evacuation plan will look very different if we’re halfway between Hawaii and California versus halfway between Chicago and Mackinac Island.
Bleeding is best controlled with direct pressure. Press firmly with the flat surface of your hand over the wound, preferably with a gauze pad, for 15 minutes, no peeking. Hold for twice as long if your patient is on blood thinners like Coumadin (Warfarin) or Plavix. If the bleeding persists, it’s likely that you are not pushing firmly enough, not long enough or not in the right place. If you can’t seem to get it to stop, reevaluate your technique. Tourniquets have come back into favor in certain situations and can be used to slow bleeding so we can find the source or to buy time to manage a bigger crisis. They’re tricky and can do damage. We’ll cover them in another post, and also I’d like to offer a snippet now because it’s important.
Next, inspect the wound. Some wounds appear simple, but do go through the fascia. If there’s a flap, lift it up and inspect for debris. Wear gloves, protective eye wear and a mask, and keep your mouth closed when working with open wounds. Get a general sense of what’s going on in the wound before we start scrubbing it, and then perform a more thorough examination as we clean.
Wound Cleansing 101
Now that we know what we’re dealing with, it’s time to cleanse the wound. Early aggressive wound cleansing is essential. Cleaning a wound will usually start it bleeding again because we’re disturbing the clot that has begun to form. Direct pressure can be used to stop the bleeding after the cleaning if need be. Never clean a wound that’s associated with life threatening bleeding. You have bigger fish to fry than infection in this case.
Wash the wound area with clean water and soap or a 1% povidone iodine solution. The rule of thumb is that any water that’s clean enough to drink is clean enough to use. Povidone iodine, as it comes in your well stocked first aid kit, is a 10% solution and must be diluted. It’s harmful full strength. This is done by putting 2-4 drops into a bottle of water until it’s the color of a Newcastle Brown Ale (or an iced tea). That fabulous visual comes from Jeff Isaac PA, my offshore medicine idol. If you ever get a chance to take one of his classes, jump at it!
It’s a good idea to irrigate a wound. This is simply using a bit of water pressure to flush out the debris and lessen the bacteria count. Think water pik. A well stocked first aid kit will have a 30-60cc syringe that is perfect for irrigation. If not, get your MacGyver on and poke some holes in the cap of a water bottle, or squeeze the bottle with some pressure to get the job done. A Ziplock bag with the tip of one corner cut off would work in a pinch as well. We no longer soak wounds in a basin because it can increase the chance of infection, nor do we use hydrogen peroxide as it’s damaging to the tissues. Embedded gunk that remains after irrigation can be removed with a toothbrush or instruments from your kit. Continue inspecting as you clean. Get in there, take your time and get a really good look. Probe the wound if need be with your finger or an instrument from your well stocked first aid kit.
Apply some antibiotic ointment (avoid ointments with Neomycin in them – triple antibiotic – as it can cause an allergic contact dermatitis) or clean Vaseline then a clean, preferably sterile, non stick dressing that allows for wound drainage. Bandages protect the wound from further trauma; whacking it on everything in sight; keep the wound from getting contaminated; and absorb drainage. The dressing should not impair drainage or circulation. Traditional first aid kit tape performs poorly in the marine environment. Dressings like Tegaderm, Coban (vet wrap), 3M Nexcare waterproof bandages and elastoplast tape work much better.
There are plenty of fancy, expensive dressings out there, but these guys do the trick. Tegaderm is nice because it’s transparent, sticks well and can stay on for a few days. Coban is the bomb! It holds absorbent gauze dressings and splints in place, sticks to itself, can be reused, is water resistant and pads the injury a touch. Dressings need to be functional, not pretty. Be creative!
High risk wounds that have exposed deep structures like bone, muscle or tendon are best dressed with a wet to dry dressing to keep them from drying out which further damages the tissues. This means putting a moist, antibacterial layer directly next to the wound, then covering it with a dry layer. Depending on the type of sailor you are, your kit will look differently. An offshore kit should have a larger selection of dressings. It would have something like xeroform gauze or a silver impregnated dressing such as Aquacel or Polymem to put directly over the wound surface. With a more modest nearshore kit, moisten a piece of gauze with the Newcastle Brown iodine solution and place that next to the wound, covered with another dry piece of gauze and wrap it with Coban. High risk wounds should get early medical follow up whenever possible. Onboard, these wounds get the same careful cleaning and dressing as any other wound. If we were days away from onshore medical care, we would consider antibiotics, with the first dose as soon as possible after the injury.
Thorough cleaning and dressing is the best practice for preventing infection. Closing wounds with stitches, staples, glue and such is for cosmetic result, and may not be the best choice offshore. We will likely be trapping bacteria in the wound and preventing it from draining. Wounds will heal whether they are stitched or not and scars can be revised later. Early thorough cleaning is essential, closure will keep.
Remember Your Tetanus Shot!
In my perfect world, all of our tetanus shots are up to date. No one would put a toe on the boat without a current tetanus immunization. If you haven’t had one in the last 10 years, get on it!! An outdated tetanus alone isn’t a reason for evacuation if you’ve had one at some point in your life, but why take a chance? Keep it from becoming an issue offshore by keeping up to date. A microsecond of discomfort and a few days of a sore arm are preferable to exquisitely painful muscle contractions, lockjaw, six months on a ventilator and death. Tetanus boosters are given every 10 years for simple wounds. For a particularly nasty high risk wound, a tetanus booster would be given if you haven’t had one in the last five years. They are ideally given within 24-72 hours of the injury.
Monitor for Infection
Now that we have a well inspected, fabulously clean and dressed wound, monitor it for signs of infection. They are unexplained fever, increasing redness or red streaks spreading from the wound, increasing swelling, increasing pain, increasing warmth, or pus coming from the wound. Some redness and swelling in the first few days after an injury is part of the natural healing process, but it should be getting better, not getting worse. Typically signs of infection show up 24-72 hours after an injury. Follow up with a healthcare provider for any sign of infection. If you are days from medical care, follow the protocols you discussed with your physician prior to leaving on your adventure. Wash the wound, check for the signs of infection and change the dressing daily. If you’ve used a transparent dressing that can stay on for several days, check daily for signs of infection. Check often to make sure the dressing isn’t too tight and that circulation is intact.
I hope that I’ve been able to teach you something new and impassioned you to learn more! Please feel free to contact me with any questions you may have.
- For further reading check out Wilderness and Rescue Medicine 6th edition by Jeffrey Isaac and David Johnson. (7th edition reportedly coming soon. Yippee!)
Disclaimer: I am not a physician. I am an offshore medicine certified RN with 20+ years of ER experience and a heck of a lot of common sense. Follow up with your healthcare provider for any questions or concerns. Read my full disclaimer here on my site.