Wilderness Care of Acute Traumatic Wounds Curriculum

C l i n M e d International Library Citation: Sunde CD, Spano SJ (2016) Wilderness Care of Acute Traumatic Wounds Curriculum. Trauma Cases Rev 2:039 Received: May 23, 2016: Accepted: July 18, 2016: Published: July 20, 2016 Copyright: © 2016 Sunde CD, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Wilderness Care of Acute Traumatic Wounds Curriculum


Introduction
Acute traumatic wounds consistently rank in the top ten reasons for emergency room visits for adult males and pediatric patients under the age of 15 [1].It has been estimated by Flores that the annual rate of outdoor recreational injuries is 72.1 per 100,000 population, with 14.8% being lacerations [2].The National Outdoor Leadership School (NOLS) maintains an incident database; from 1998 to 2002 there were 1940 reported injuries, of which 31% were non athletic soft tissue injuries [3].In the wilderness setting, a comprehensive approach to acute wound care is especially critical.Definitive treatment can be hours to weeks away.The limitation of available medical resources and the variety of acute traumatic wounds present a challenge.This instructional module presents an evidence-based approach to acute wound management, describes techniques that are applicable in remote and unclean environments, and provides a hands-on experience to adult learners.The information is applicable to learners of all backgrounds.Both medical professionals and laypeople are likely to be unfamiliar with treating wounds with limited resources; it is in the setting that small decisions may have great impacts on clinical outcomes.We developed an adaptable curriculum to teach participants of all levels how to appropriately manage wounds using established and improvised techniques.

Methods
The "Wound Management in the Wilderness Workshop" is an instructor-guided, interactive presentation requiring approximately two hours.The intended audience is medical and allied health professionals.The workshop structure involves a brief introduction on pearls of wound management, four small group sessions, and a summary and participant evaluation.Four interactive stations are used for instruction: wound closures, water purification and wound irrigation, vascular damage and hemostasis, and a case review.Supplies used for each station are listed in table 1.

Station 1: Wound closure
Participants are instructed in wound closure using pig's feet.Instruments, suture options, and proper technique should be demonstrated prior to participant practice of simple-interrupted sutures and knot tying.Direct observation of participants facilitates proper technique.While most people are unlikely to carry suture materials in the backcountry, practicing this technique may help with the understanding of improvised closure methods and the goals of wound closure.Improvised techniques are discussed as participants practice suturing.The techniques covered use materials easily carried in a first aid kid and include: duct tape steri-strips, wound adhesives, and the hair apposition technique (HAT) [4].

Station 2: Irrigation and foreign body management
Basic purification methods (boiling, pump/mechanical filters, UV Abstract Introduction: A comprehensive approach to wound care is critical when in the wilderness where definitive care may be hours, days or weeks away.The limitation of resources and the variety of acute traumatic wounds presents a management challenge.Resources for wilderness experiences with wound care are sparse.We developed an adaptable curriculum to teach participants of all levels how to appropriately manage wounds using established and improvised techniques.

Methods:
The curriculum is an instructor-guided course designed to be an interactive presentation requiring two hours.It is presented in three parts.First, a brief description of a general approach to wounds hig-hlighting pearls and pitfalls.Second, small groups rotate through four stations: wilderness closure tech-niques, a vascular damage wound model, water sterilization and wound irrigation strategies, and a case report discussion.A debriefing concludes the workshop.
Results: Participants are evaluated via direct observation, verbal feedback, and group discussion.

Conclusion:
We were able to create an interactive, adaptable, and cost-effective curriculum to teach im-provised wound care techniques.

Station 3: Vascular damage
A commercial moulage model of a significant bleeding upper extremity wound is utilized to address critical actions to control bleeding.A clinical scenario of uncontrolled bleeding eventually requiring placement of a tourniquet proximal to the wound is repeated multiple times.First, participants are allowed to problem solve on their own after being told there is a large wound with bleeding that continues to soak through all dressings and interventions until some type of tourniquet is placed proximal to the injury.Materials (gauze, bandanas, belts, etc) are made available but no instruction is given.Participants then receive direct feedback on proper methods of wound packing and pressure dressing placement.Tourniquet application, using both commercial and improvised methods, is subsequently practiced in pairs first unaided and then followed by focused feedback and instruction.The scenario is practiced a final time without feedback to demonstrate learned critical interventions.
filters, and chemical purification) are demonstrated after open-ended queries on standards for wound irrigant solutions.The principals of volume and force of irrigation with improvised wound irrigation systems are empirically challenged by experimenting with potential 'wilderness' irrigation devices.Participants test the subjective forces resulting from maximum compression of a water bottle with 14 gauge needle holes punctured in the cap, a sports-top water bottle, a 10 cc first aid kit syringe, a commercially available water filter cleaning syringe, a bladder-type hydration pack, and plastic zip top bags pierced with a 14 gauge angiocatheter.Wound foreign bodies are discussed via scenarios and photographs of contaminated wounds and participants were queried on optimal management options.Photographs are sourced from personal collections and published sources and include a figure from a case report of blunt carotid injury from a penetrating stick [5], a linear superficial injury with a clean kitchen knife, an abrasion with embedded granite, and a jagged laceration at point of impact from a fall on an outstretched hand (FOOSH).

Conclusion
Wounds in the Wilderness is an interactive, adaptable, costeffective model for engaging our community and teaching basic wound care with real world application.We hope this curriculum inspires others to share their knowledge and to learn more about wilderness medicine, and we will continue to refine the material and expand our audiences for a richer learning experience.
Study concept and design: SJS; Obtaining funding: N/A; Acquisition of the data: CDS, SJS; Analysis of the data: CDS, SJS; Drafting of the manuscript: CDS, SJS; Critical revision of the manuscript: CDS, SJS; Approval of final manuscript: CDS, SJS.

Station 4: Case review
A case discussion station centers on an article, "They had me in stitches: a Grand Canyon river guide's case report and a review of wilderness wound management literature" [6].The article presents a real life example of a simple wound sustained on a rafting trip, common pitfalls of wilderness wound management, and the potential serious sequelae of even simple wounds that are not aggressively and appropriately managed.Complications including poor wound healing, infections, and hemorrhage are specifically emphasized during the discussion as the risk of these can be reduced with the techniques covered in the course.
Each of the stations are directly proctored and discussion questions that are appropriate for each station and sample answers can be found in table 2. Since groups can be lead by different proctors and experiences differ slightly, these questions are reviewed with key take home points reinforced at the debriefing at the conclusion of the station activity.Direct feedback on strengths and weaknesses of the activity are solicited prior to the conclusion of the course.

Results
The Wounds in the Wilderness curriculum has been used to teach multi-specialty practicing physicians, undergraduate and graduate students, medical residents, and the general public.Workshops can be tailored to specific audiences and each session may be unique given a variety of backgrounds and experiences that are shared through the interactive experience.
Total equipment costs for the workshop is estimated at $800-900 with the most expensive item being a durable, re-usable wound model.A cost per participant has not been established as we have so far taught it on a volunteer basis.Wound models are available through online retailers at varying costs.Some items used in our workshop (water filters) were personal items owned by instructors and many were common supplies available through our residency program's teaching resources, which limited our actual overall cost.
Informal feedback from participants during and at the conclusion of the workshop has been consistently overwhelmingly positive.A limitation of this curriculum is the lack of formal testing to objectively measure retention of knowledge; however, direct observation in the application of skills taught demonstrated skill competence in participants by the end of the sessions.Participants across an array of educational and experiential backgrounds leave the course with skills that they may be of practical utility in real wilderness emergencies.Another limitation of the curriculum is the lack of follow up to determine if there is skill fatigue (from lack of use) in learners who do not regularly manage wounds as part of their professional setting.

Table 1 :
Suggested supply list by station.
*Costs are estimated based on internet search.Many supplies were personally owned, borrowed, or available through our institution without additional cost.ISSN: 2469-5777 Sunde et al.Trauma Cases Rev 2016, 2:039

Table 2 :
Discussion questions for each station.Sutures provide stronger closure for high tension areas or highly mobile wound sites What are drawbacks to suturing?Introducing a foreign body into the wound (suture material); painful method; may trap contaminants unknowingly in wound (bacteria, foreign body); fatigable skill in non-practiced providers Which seems stronger: improvised Duct tape® steristrips or simply covering the wound with a large piece of tape?There may be more skill retention with a longer course.Although, our two hour course focuses on crucial, basic techniques which are repeatedly practiced.
5. Interlock these two hair bundles in a 360-degree revolution.Do not tie a knot.4.Secure the bundles with tissue adhesive.5.Repeat to close the length of the laceration 6.The hair will unravel on its own after a week Is wound adhesive and Super Glue® equivalent options for improvised wound closure?Why or why not?No.Standard "superglue" is 100% ethyl cyanoacrylate.Medical grade wound adhesive is 2-octyl cyanoacrylate, a nearly identical molecule except with the addition of a 5 carbon "tail" attached.Due to this longer organic backbone, degradation and absorption of tissue adhesive is slowed, remaining below the threshold of tissue toxicity.Due to the potential toxicity issues of ethyl cyanoacrylate, the use of 2-octyl cyanoacrylate for closure is preferred.Are there other means of hemostasis that are safe and suitable for wilderness/remote environments?Clotting powders can come up.Research current recommendations and products.Chemical burns to application area and systemic clots (remote from site of application) have been reported previously and cautions should be exercised in their use.Station 4: Case Review What went wrong?Why did Brad have such a prolonged course/bad outcome?Open discussion on choice of suturing, use of betadine in an acute traumatic wound, timing and choice of antibiotics, timing of evacuation plan Is this wound contaminated?Yes, all wounds in the wilderness should be considered contaminated What would you have done differently?Variable responses ISSN: 2469-5777 Sunde et al.Trauma Cases Rev 2016, 2:039