Ready for Anything
Being able to assess wounds, and having a proper onboard medical kit, will prepare you to handle common cruising injuries.
As part of my winter maintenance chores, I was replacing the engine room lights.
A shout broke the silence: “Come quickly! We’ve got a bloody mess up here!”
Indeed, blood was gushing everywhere. A member of my yacht club had sliced open a hand while repairing a sail.
I grabbed my onboard emergency medical kit, assessed the wound and provided medical care. The situation was a reminder that having a proper kit is key for managing most wounds and injuries you may encounter while on a voyage, on the dock or while exploring a destination.
Here are the types of wounds that are common when boating, and how to assess and treat them.
Mechanism of Injury
A simple cut through the skin by a sharp object may cause minimal damage to the surrounding tissues and has a relatively low risk for infection or significant scarring.
Tearing of the skin, such as when the chin strikes the floor, produces irregular wound margins and damage to the surrounding tissues. These lacerations have a moderate risk of infection and scarring.
Direct compression injuries—say, from a blow to the head—split the skin, injure the adjacent soft tissues, and classically cause a stellate laceration. These wounds have the highest risk of infection.
Bite wounds are evaluated for associated injuries and risk of infection, while crush injuries may involve devitalized tissue that must be debrided to decrease the risk of infection. Stab wounds are evaluated for depth; emergency consultation is necessary if underlying structures are injured.
Wound Evaluation
Begin with an assessment of circulation and sensation. Is there an absence of sensation to soft touch, possibly indicating nerve injury or the absence of circulation? This is tested by pressing on the nail bed to turn white, then counting three seconds or less for the color to return. With capillary refill greater than three seconds, there is vascular insufficiency, an emergency condition.
Any wound overlying a tendon should be assessed for tendon function by determining whether the individual can move their fingers, hands or arms. Wounds over joints and underlying structures, such as major blood vessels, require immediate intervention.
Identifying and removing foreign material is important, as retained foreign material increases the risk of delayed wound healing, infection and scarring. Any foreign material that can be easily seen should be removed. If the object can be reliably palpated, the wound can be minimally extended to remove it, provided there is no risk to underlying structures. A non-irritant foreign material, such as glass or metal that is not in a critical area or adjacent to a vital structure, and that will not cause ongoing irritation, may be left in place if unable to be removed, and the wound may be closed. Irritant material, such as wooden splinters, can be a source of later infection and must be removed.
Any of the following conditions may increase the risk for poor outcomes: retained foreign material, heavy contamination, deep wounds with associated tissue trauma, wounds caused by glass or ice, and infection. Medical conditions may also increase the risk for poor outcomes, such as with diabetes mellitus, obesity, peripheral arterial disease, kidney disease, use of steroids, blood thinners or antineoplastic agents.
Wound Healing Types
There are two types of wound healing that occur in stages, including hemostasis limiting blood loss about the injury, inflammatory response acting to remove cell debris and pathogens, proliferation with development of granulation scar tissue, and remodeling where collagen fibers strengthen the wound.
In primary intention, wounds are caused by sharp objects with the skin edges close together and may be closed any time up to 12 to 18 hours from the time of injury. Location on the trunk or proximal extremity and the patient’s lack of other risk factors favor success in later closure. Wounds of the head and neck may be closed up to 24 hours after injury because of the rich vascular supply of the face and scalp.
In secondary intention, the sides of the wound are not opposed where healing must fill in the gap from the bottom upwards, and include deep stab, puncture or animal-bite wounds that cannot be adequately irrigated; contaminated wounds; or abscess cavities.
Stop the Bleeding
Minor to moderate cuts and scrapes require proper care to avoid infection or other complications and will usually stop bleeding on their own. If not, applying gentle pressure with a clean cloth or bandage continuously for 20 to 30 minutes is best. Don’t keep checking to see if the bleeding has stopped because this may damage or dislodge the fresh clot that’s forming and cause bleeding to resume. For finger and toe lacerations, drainage of blood and hemostasis may be achieved by rolling the finger of a nitrile or latex glove with a hole cut in the tip down to the base of the digit.
If the blood spurts or continues to flow after continuous pressure, consider dialing 9-1-1 and preparing your colleague for transport.
There are several over-the-counter agents that promote hemostasis, aid blood clotting and stabilize the wound before definitive treatment. QuikClot is a kaolin-impregnated aluminosilicate sponge; BleedStop contains amylopectin powder; and Nampons are calcium salt micro-dispersed crystals on a polyvinyl acetyl sponge. They all promote bleeding control when applied with pressure over the wound.
Tourniquets may be used to stem bleeding in several cases: from extremity wounds with greater than 2 to 4 cups of blood loss; when the wound is spurting or pulsating blood; if there are deep, large extremity wounds; when there is shock associated with bleeding; and if the individual is pale, sweating with clammy skin, or has slurred speech or confusion. After the extremity has been elevated for one minute to permit venous drainage, a gauze pad is applied with pressure to the wound for at least five minutes, and then the tourniquet is placed on the upper arm or thigh.
Applying a tourniquet is a lifesaving procedure of last resort. It is painful to the individual and must be removed within two hours, or there is a risk of losing the extremity. The tourniquet is applied 2 to 3 inches above the injury, toward the heart. A windlass is used to tighten the tourniquet until the bleeding stops, then is locked in place. Be certain to record the time, as there are only 120 minutes to possibly save the limb.
Clean the Wound
Foreign material or soil remaining in a wound increases the number of bacteria causing infection. Cleaning the wound by using irrigation is the most important means of decreasing the incidence of wound infection. You can use running tap water, which may be an acceptable alternative to sterile normal saline, at least in healthy individuals with clean wounds and in settings where water quality is assured. Soap can irritate the wound, so try to keep it out. If dirt or debris remains in the wound after washing, use pressurized irrigation or tweezers cleaned with alcohol to remove the particles.
Thorough wound cleaning reduces the risk of infection and tetanus. To clean the area surrounding the wound, use soap and a washcloth. There’s no need to use hydrogen peroxide, iodine or an iodine-containing cleanser. These substances irritate living cells. If you choose to use them, don’t apply them directly into the wound.
Debridement has been considered by many to be equally or more important than irrigation in the management of the contaminated wound. It removes permanently devitalized tissue that, if retained, impairs the wound’s ability to resist infection. Devitalized fat, muscle and skin exhibit similar capacity to enhance bacterial infection. If you are not skilled in trimming devitalized tissue, it is best left to professionals. Hair need not be removed unless it interferes with wound closure or scar formation.
Close the Wound
With primary intention healing, the wound margins are brought and kept together using four types of wound closure methods: sutures, staples, tissue adhesives and tapes. In the case of secondary intention healing, the wounds are covered with sterile non-adherent dressings. Then, allow wound granulation tissue to form within the wound, contracting the edges with eventual healing.
Staples are an acceptable alternative to suturing for linear lacerations through the skin that have straight, sharp edges and are located on the scalp, trunk, arms and legs. They do not permit meticulous cosmetic repair and will cause discomfort if used on the face, neck, hands or feet. While requiring some practice, wound staple appliances are readily used, efficient, and most applicable when offshore or in austere environments where skilled professional services are not immediately available. Staples may be left in place for seven to 10 days and may be easily removed with a staple remover.
Tissue adhesive—known as surgical glue or liquid skin—may be used to close minor to moderate lacerations that are small (up to 5 centimeters long) and shallow, and where the wound margins can be approximated using tweezers without tension in any direction. They are not used for deep, infected, jagged-edged wounds or for animal bites, and they are not to be used inside the mouth or moist area, on any actively bleeding wound, or in areas where movement may open the wound. The wound margins are held together using tweezers, and the skin glue is applied to the wound surface only (never in the wound). This method takes a few minutes to set, then usually peels off in five to seven days. Scars may fade within six months.
Wound closure tape follows the same considerations as tissue adhesives and may also be used for the upper one-third to half of the face when the wounds are small (less than 2.5 cm), uncomplicated and well approximated with low tension.
Cover the Wound
After cleaning and closing the wound, apply a thin layer of an antibiotic cream or ointment such as Neosporin or Polysporin to help keep the surface moist. The products won’t make the wound heal faster, yet they can discourage infection and allow the healing process to close the wound more efficiently. The antibiotic ointment can be applied to the wound two times per day.
Certain ingredients in some ointments can cause a mild rash in some people. For individuals with sensitivity to antibiotic ointments, it’s best to dress the wound without topical antibiotics. If a rash appears, stop using the ointment and seek medical assistance.
Gauze and bandages help keep the wound clean and harmful bacteria out. After the wound has healed enough to make infection unlikely, generally in three to four days, exposure to the air will speed wound healing.
Be mindful of infection, and seek medical assistance if the wound is not healing or if there are signs of infection: redness, drainage (with or without odor), warmth about the area, swelling, red streaks extending from the wound toward the heart, honey-colored crusty scab, swelling in the axilla or groin, fever or chills.
When to Seek Medical Assistance
There are times even with best intentions of self-sufficiency when medical assistance is required: complex wounds not able to be closed with available supplies; open bone fracture wounds with underlying tendon, joint, nerve or vessel damage; mammalian or human bites; with any possibility of rabies inoculation; if there are early signs of infection or a large quantity of foreign material, particularly organic in nature; if there are symptoms of systemic toxicity such as fever, alterations of consciousness or shock; in the presence of hypothermia; if there is palpable gas in the soft tissues; or if there is significant associated devitalized tissue.
In these instances, it’s best to have a written personal health history form that can be given to health professionals containing medical and surgical history, allergies, immunizations, current medications and healthcare provider contact.
Having a preventive maintenance schedule is critical to every boater’s success for joyful voyages with families and friends. Building, then regularly checking and restocking the inventory of your emergency medical kit is vital to the health and safety of your crew and passengers.
A Word About Tetanus
Tetanus is a bacterial infection that affects the nervous system and can cause mild to severe muscle contractions in the jaw and neck. These symptoms can progress without treatment to the whole body, leading to paralysis, respiratory arrest and death. Treatment and supportive care can help manage the spasm and complications where there is no known cure. The onset of symptoms is typically three to 21 days following infection. Recovery may take months; about 10 percent of cases prove fatal.
Get a tetanus shot every 10 years. If your wound is deep or dirty, and if your last shot was more than five years ago, you may need a tetanus shot booster.
Get the booster within 48 hours of the injury.
