Anatomy of First Aid - A Case Study Approach

Editor: Ronald A. Bergman, PhD Emeritus Professor Department of Anatomy and Cell Biology The University of Iowa Contributing Computer and Graphics Specialists: Michelle Leveille Nola J. Riley, B.A.
Peer Review Status: Internally Peer Reviewed First Published: November 2004 Last Revised: November 2004

Table of Contents Preface

Drawing Blood and Transfusion Closing Cuts of the Skin and Underlying Tissue Stitching a Cut The Eye Fracture of the Jaw The External Ear Bladder Catheterization Choking Sucking Chest Wound Injury to Thigh, Compound Fracture of Femur, Use of Tourniquet Abdominal Wound with Protruding Viscera Amputation Burns Smoke, Gas and Chemical fumes

Anatomy of First Aid: A Case Study Approach

Drawing Blood and Transfusion

Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A hospital corpsman consulted her list of blood donor volunteers and asked one to donate a pint of O+ blood. It was possible that it might be needed for an emergency appendectomy being undertaken by the ship's surgeon while at sea. The volunteer Sailor was brought to sickbay and asked to lie down on the bed. The corpsman determined that the Sailor was healthy; his pulse, temperature and blood pressure were of normal values. She then tied a rubber band around the Sailor's arm, above the elbow, tight enough to stop superficial venous blood flow but not enough to prevent arterial blood flow. The cubital fossa (anterior surface of the elbow) was palpated and the median cubital vein was readily located (see illustrations), facilitated by the Sailor repeatedly making a fist. The corpsman knew that there were several large veins available in the region of the cubital fossa that she could use for venipuncture. She was aware that there is considerable normal variation in the pattern of veins in the arm and this is usually of no consequence. The corpsman then sponged clean the cubital fossa with alcohol and dried it with a sterile gauze pad. She inserted the IV catheter through the skin at an angle of about 45 degrees until she felt the needle enter the vein (by a slight decrease of resistance), then she decreased the angle of the syringe to about 10 to 20 degrees and advanced it slightly. Blood filled the lower part of the catheter reassuring the corpsman that she was indeed inside the vein. The plastic sleeve of the IV catheter was advanced over the catheter needle into the vein. The pressure band was then released. A blood collection bag was connected to the hypodermic needle and the hypodermic needle was carefully taped to the skin to prevent it from becoming dislodged. The corpsman had several types of catheter needles to select from but used the simplest one in this case.

The back of the hand (the dorsum of the hand) is also available for venipuncture or IV insertion and here the veins are usually clearly seen. They are not tightly bound to surrounding tissues, hence they move and are deceptively easy to penetrate. If they are held in place by a finger, penetration is facilitated. Instead of the rubber band being applied around the arm when the back of the hand is selected for venipuncture, it is placed around the lower forearm above the wrist.

Anatomy of First Aid: A Case Study Approach

Closing Cuts of the Skin and Underlying Tissues

Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

Minor or even deep wounds to the skin and underlying tissues can be closed by using Butterfly tape or by suturing. Taping or suturing should be done when the wound is large, clean and nonjagged. Wounds of the chest and abdomen will be considered later in this booklet. Do not close a wound if the area of the wound is dirty (contaminated), is very deep (into fatty fascia or even deeper, into muscle), or is over 12 hours old. Bleeding is to be controlled, by pressure or by tourniquet if necessary. If the wound cannot be closed, tape a sterile or clean, moistened bandage over the entire wound and seek medical assistance immediately. Things to remember: Skin thickness varies. It is thinnest over the eyelids and face and thickest on the palms of the hand and soles of the feet, the back and scalp. It is usually thinner over ventral (anterior) surfaces and in older people. Bringing the edges of the skin together by suturing will be shown. First review the anatomy of the skin and underlying tissues of the limbs in the following illustration:

Anatomy of First Aid: A Case Study Approach

Stitching a Cut
Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A cook on his first deployment, was preparing some meat for a stew when he lost control of the knife and cut his hand. He stemmed the blood flow by placing a clean cloth over the cut and applying pressure above the cut. He hurried over to the sickbay to find a hospital corpsman. The corpsman cleaned the hand with antiseptic and decided to use sutures to close the wound. The size of the cut was too large to use a butterfly tape as a skin closer. The corpsman had several types of stitching to choose from (see illustrations):

Sutures A: a lock-stitch

Sutures B: an interrupted stitch

Sutures C: a continuous stitch.

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An interrupted stitch (B) was thought to be the best to close this cut. The corpsman used a sterilized needle and suture. A stitch was made through the skin (avoiding the superficial fatty fascia as much as possible) at the midpoint of the wound and the edges of the wound drawn closely together. The thread was knotted (square knot) and cut. The corpsman continued until he completed the closure and covered the wound with sterile gauze. The gauze was taped to keep the injured area clean. The corpsman advised the cook to inspect his hand daily for signs of infection (inflammation, heat, pus and no sign of healing). A serious infection may require stitches to be removed to drain the infected site.

Sutures D: remove stitches After 7 days, the corpsman had the cook return to sickbay to remove the stitches using the technique shown in the last illustration (Sutures D). It is important to cut the sutures as shown to reduce the possibility of infection. Before removing the stitches however, the injured hand was again cleaned with antiseptic. Pull up on the knot. Slide scissors under one end with the blades parallel to the skin. Cut suture and pull knot and suture out of skin completely. A corpsman may use the following guideline for the number of days for healing to occur before removing stitches: 5 days for face wounds, 7 days for body wounds and arm and hand wounds, and 8-10 days for leg and foot wounds.

Anatomy of First Aid: A Case Study Approach

The Eye
Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A Machinist Mate is finishing work on a metal object when he suddenly feels scratchy, sharp pain in his eye and hurries to the medical corpsman for help.

The corpsman first, tries to wash out the offending object with lukewarm water by splashing or flooding the eye with water, until blinking is not painful. If this does not succeed in removing the object, blinking alone may flush the object from the eye. This may be very painful because the conjunctiva is richly supplied with pain nerve receptors. If this simple procedure also fails, the corpsman will examine the eye by lifting the eyelid from the eyeball. Several methods are shown in the illustrations.

If the corpsman cannot find any object on the conjunctiva or cornea that would cause irritation, the object may be embedded in the eye. If this is the diagnosis, both eyes are covered with sterile or clean pads and taped in place. Medical advice or assistance will be sought.

The eyelids and eye will be examined and if a foreign object is seen, it will be flushed directly to dislodge it or, with a clean moistened soft swab, the object is loosened and flushed, to remove the offending object. See illustrations.

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If pain, tearing, or vision defects occur after removal of the foreign object or if the corpsman fails to find the cause of the problem he will seek medical advice and / or assistance. Note: If any damage occurs to the eyeball, both eyes must be covered by sterile moist pads, and taped in place. Remember that the eyes are extensions of the brain and infections may ultimately involve the brain; this is to be avoided at all cost. A physician must treat a damaged eye, as soon as possible.

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The anterior eye and eyelids. EYE A. The eyeball is covered and protected anteriorly by two thin , movable eyelids (or palpebrae). The eyeball is also covered by a transparent mucous membrane (the conjunctiva), which is continuous along the inner surface of both eyelids (the palpebral conjunctiva). At the medial angle of the eye a small piece of skin (the caruncula lacrimalis) is located that contains sebaceous and sweat glands. The pupil is the circular opening in the iris. The size of the opening is controlled by the nervous system: at rest, the parasympathetic nervous system constricts the pupil and in danger, the sympathetic nervous system supplies the pupillary dilator muscle to enlarge the pupil.

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The lower eyelid and medial angle EYE B. The lower eye lid has been pulled downward in order to expose its inner surface (i.e., the palpebral conjunctiva), as well as the medial angle (or medial canthus). The gaze is upward (superiorly) and outward (laterally). The conjunctiva is very vascular and very sensitive. The inferior palpebral part and the bulbar part are continuous along a line of reflection (inferior conjunctival fornix). The line of reflection is also found between the eyeball and the upper eyelid (superior conjunctival fornix). When the medial angle is enlarged, a pair of small openings (punctae lacrimali) are visible, located above and below the caruncula lacrimalis. These openings enter the lacrimal canals leading to the nasolacrimal duct and further, to the nose.
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Anatomy of First Aid: A Case Study Approach

Fracture of the Jaw

Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A petty officer was carrying an iron rod on his shoulder. He heard his name being called and swung around. The iron rod accidentally hit a Sailor in the face with great force. He fell to the floor and broken teeth and bloody saliva came from his mouth; he was unconscious. The face of the Sailor began to swell and extensive bruising became evident. A corpsman was called immediately. (It is important for the person providing first-aid to know the anatomical basis of the injured region before treatment starts. This information is provided in the first illustration).

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The Sailor was coughing and choking and it was not certain if there was any neck damage. The corpsman, with additional aid from other Sailors, carefully rolled the patient to his side. Particular attention was paid to the position of the head and neck so that it remained facing forward in its usual position with the body lying on its side. The Sailor's mouth was inspected and cleared of broken teeth and foreign bodies; the choking ceased. Whole teeth were wrapped in a sterile or clean cloth. The patient gradually became conscious but was in great pain, which the corpsman medicated. A neck brace was applied until the extent of the injuries could be accurately determined. The patient was turned on his side so that blood and saliva could drain from his mouth. Bleeding from a small cut on the Sailor's face was cleaned with a moist sterile cloth and controlled by gentle pressure. A cold bandage or package was applied to help reduce swelling of the tissues associated with the jaw.

The following clues were sufficient for the corpsman to diagnose a broken jaw: facial tenderness, swelling, a change in symmetry of the face, pain on moving the jaw, inability to speak and open or close the jaw. The possibility of other damage, e.g., to the zygomatic arch, the orbit and eye must also be carefully considered (second illustration). The corpsman also determined that the airway was clear, controlled bleeding and supervised the transfer of the Sailor to sickbay for definitive medical attention.

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Anatomy of First Aid: A Case Study Approach

The External Ear

Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A petty officer second class took a boat full of supplies to a Marine base located on an island in the South China Sea. While waiting for his boat to be unloaded he found an isolated place to take a nap. When he awakened he heard a buzzing in his ear and became panicked and tried to remove the insect with his little finger to no avail - but the buzzing stopped. A corpsman, assigned to the Marines and who was on the island at the time, told the Sailor the following important things to remember when there are problems with the ears. If there are foreign objects in the ear do not use any liquid to flush the offending object from the ear. Do not place any instrument or tool in the ear canal. Do not hit or thump the head to free and dislodge the offending object. The corpsman suspected that an insect became trapped in the ear. The corpsman had an otoscope in his medical kit and was able see, and to remove, the crushed insect. The corpsman suggested several things that could be done in the absence of immediate medical care. If a live insect is in the external auditory canal one can safely kill the insect with a few drops of alcohol. However, seek medical assistance as soon as possible to remove the insect. The rationale for not putting water in the ear is that some objects swell in water, leading to significant pain and greater difficulty in removal of object.

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Objects that are clearly visible and easily accessible at the entrance of the canal may be removed with a tweezers. A physician should be consulted to confirm the removal of the object(s). To the inexperienced, trying to remove objects with a tweezers can result in damage to the eardrum. One additional method, short of medical treatment, is for the individual to turn his head, with the affected ear down, and to shake his head. Do not try any other procedure -- no oil, water or hitting the head. The corpsman will safely remove the object. Drainage from the ear is another serious event. If there is bleeding from the ears consider a skull fracture; immediate medical attention is essential. If bleeding is from the external ear, it may be controlled by direct pressure with a sterile or clean cloth. Do not try to stop drainage or bleeding from inside the ear. Do not allow the patient to thump his head to restore lost hearing. Have the patient lie on the side of the head that is affected to promote drainage.

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Ear drum

Ear emergencies requiring medical care may include the following: swimmer's ear usually caused by bacteria; varieties of ear pain from middle ear infections, toothache, and mandibular joint pain; excess wax in the ear and perforation of the ear drum resulting in a loss of hearing; poking irritating hard objects into the ear and the introduction of foreign objects. Swimmer's ear may result in disturbing sensations from retention of water in the ear. This can be avoided by placing a few drops of a solution containing 20% white vinegar or dilute 20% rubbing alcohol in the external acoustic canal.

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Anatomy of First Aid: A Case Study Approach

Bladder Catheterization
Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A Sailor aboard a supply ship in the Red Sea reported to sickbay and told the hospital corpsman on duty that he was having great difficulty urinating and that his bladder was full and he could not adequately relieve himself. His distress was obvious. The corpsman donned sterile gloves and then tapped the Sailor's lower abdomen verifying the full bladder. He told the Sailor that he would empty his bladder by catheterization (see accompanying illustrations). Hearing this, the Sailor became very anxious. His anxiety was greatly lessened when the corpsman explained to him that the procedure might look painful but actually was not. In addition, the relief he would feel would worth any discomfort he might feel.

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Anaseptic wash of urethral opening of penis.

Insertion of catheter.

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In order to catheterize the Sailor the corpsman swabbed the urethral opening of his penis with a non-irritating antiseptic. Taking a sterile catheter lubricated for about two inches he inserted it slowly into the urethral meatus (opening), he encountered a slight resistance at the sphincter located in the urogenital diaphragm, then it moved easily through the prostatic urethra into the bladder. A flood of urine entered the collection bag. The corpsman taped the catheter tube to the Sailor's abdomen to secure the collection bag. The corpsman told the Sailor that a physician would take over his case and prescribe a course of treatment for his problem.

Recovery of urine. Catheterization is essentially the same in both male and female; the catheter, by traversing the urethra, enters and drains the bladder. The anatomical route is shorter in the female patient but must be understood in order to effectively perform the catheterization procedure.

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Anatomy of First Aid: A Case Study Approach

Choking
Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A squad of Marines was celebrating the end of prolonged and strenuous maneuvers with a steak dinner. During the meal, one of the Marines stood up clutching his throat, his face turning red. The choking sign was clearly understood; he was unable to speak and he had severe difficulty breathing. The treatment to follow will be considered in 5 scenarios:

Immediately the Marine began coughing. A piece of meat flew out of his mouth and the Marine began to breathe normally. This ends the 1st scenario.

Immediately the Marine thrust his abdomen on the top of a chair back. A piece of meat flew out of his mouth and the Marine began to breathe normally. This ends the 2nd scenario.
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Standing thumper Immediately a corpsman assigned to the squad asked, "Are you choking?" The Marine nodded. The corpsman gave 3 backblows between the shoulder blades to the Marine with the man in a bent over position. A piece of meat flew out of his mouth and the Marine began to breathe normally. This ends the 3rd scenario.

Standing Hemilich

If pregnant

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Immediately a corpsman assigned to the squad grabbed the Marine from behind, between the ribs and the umbilicus (belly button), and gave several strong thrusts or squeezes to the Marine's abdomen (Heimlich maneuver). A piece of meat flew out of his mouth and the Marine began to breathe normally, the red skin color decreased, the heart rate decreased and the panic subsided. If pregnant, the corpsman would give the thrusts mid-sternum. This ends the 4th scenario.

The methods outlined above, coughing, backblows, and abdominal thrusts (Heimlich maneuver) have a very high rate of success. In the event, however, that these methods fail to dislodge the obstructing material from the air pipe (trachea), a tracheotomy must be considered.

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If the choking victim is without oxygen for 4 to 5 minutes he may die or have severe brain damage, if he survives. Tracheotomy is the last resort - the very last resort - a matter of life or death. In order to be successful, several common sense things must be kept in mind.

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Immediately a corpsman that was present for dinner asked one of the Marines to keep time for him and call out the time by the minute. He tried the Heimlich maneuver several times and after this failed to dislodge the obstruction the choking victim became unconscious. The corpsman then palpated the thyroid cartilage and found the "Adam's apple" or laryngeal prominence. The corpsman then traced the cartilage distally in the midline straight down until it ended (about 2.5 cm. or 1 inch). The hard cartilage gave way to a membrane (soft spot), the cricothyroid membrane. It is this membrane that must be opened (see diagrams). (Elapsed time - one minute) The skin was opened with a sharp knife in the sagittal plane (up/down). Pulling the cut surfaces apart (right/left) he quickly examined the exposed area for blood vessels and parts of the thyroid gland. (Elapsed time - two minutes) Avoiding blood vessels and glandular tissue he punctured the cricothyroid membrane with a knife (very carefully and never transversely) (or he could have used a sharp pencil or ball point pen), to enter the trachea. The depth of the puncture should be just sufficient to gain access to the airway. No more than a half-inch or about 1.25 cm. To maintain the opening to facilitate breathing, a soda straw or tube was placed in the opening. (Elapsed time - three minutes) The duty corpsman said he was told by a physician about "the rule of three" - something easy to remember and to be on the safe side - three weeks without food and
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you die; three days without water and you die; but only three minutes without air and you die. The Marine was then taken to sickbay for further treatment. The entire procedure took less than 4 minutes. The opening of the airway allowed the Marine to get the oxygen needed to survive. This ends the 5th scenario. Remember that tracheotomy is the last resort to restore respiration but; the alternative is death. Dangers of anatomic variations covering the cricothyroid ligament

Knowledge, and confidence in that knowledge, makes this procedure as safe as is possible in an emergency situation.
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Anatomy of First Aid: A Case Study Approach

Sucking Chest Wound

Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A Marine on patrol in the desert felt a sharp pain in his chest and had difficulty breathing; he called for a corpsman and then collapsed. He had sustained a penetrating bullet wound to his chest on the right side. Air had rushed into his chest and his right lung collapsed. The corpsman recognized the seriousness of this life-threatening wound and knew that the Marine was breathing with one lung. He cut away the Marine's shirt and looked for entrance and exit wounds; he found only an entrance wound. Bleeding was minimal but uncontrollable. The corpsman recognized that on inspiration air entered the opening in the chest caused by the bullet and, on expiration, air was forced out of the thoracic cavity (see illustrations). He prepared a sterile occlusive dressing that was taped securely to the chest over the wound on 3 sides. One edge was not taped leaving an opening to the dressing. He knew that this would act as a "valve" and on inspiration the occlusive dressing would be drawn tightly to the chest by the negative pressure (hence the name "sucking wound"). External air is excluded. On expiration, the air forced out of the thorax escapes at the unsealed edge of the occlusive dressing. Had the corpsman found an exit wound he would have dressed the wound in the same way. As soon as the corpsman finished with the dressing he covered the Marine with a jacket to reduce shock. He called for a stretcher and because of the life-threatening nature of the wound, he had the Marine airlifted by helicopter to a hospital ship lying off shore. He was immediately taken to a navy surgeon for the definitive treatment that is only available in the hospital.

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Anatomy of First Aid: A Case Study Approach

Injury to Thigh Compound (Open) Fracture of Femur Use of Tourniquet

Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

On an aircraft carrier in the Persian Gulf, flight deck personnel were readying fighter aircraft for a strike at enemy ground forces. One of the Sailors had a problem with ordinance and one rocket accidentally discharged. The rocket flew into and past another Sailor causing severe injury to his thigh and fracturing his femur. Ruptured femoral vessels poured forth blood and the injured Sailor fell to the deck unconscious. An alert Sailor called for someone to summon the corpsman and then he dropped to the deck to close off the blood loss by use of a tourniquet. Very shortly afterwards the corpsmen arrived. The corpsman checked the tourniquet (see accompanying illustrations), and wrote on the forehead of the victim the time of application of the tourniquet. The Sailor was covered with a blanket to reduce the possibility of severe shock and the wound was covered with sterile, moist gauze. The injured Sailor's vital signs were taken (pulse, blood pressure and respiratory rate) as he was taken rapidly to the sickbay. In the meantime, the naval surgeon was summoned to sickbay, which was readied for treatment of the injured Sailor. If this accident had happened on shore, the corpsman would have followed the same procedures but
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would have had to immobilize the leg with a splint. The splint, in combat, might include a branch of a tree or any other inflexible object (preferably clean) a pillow, magazine or newspaper as the supporting structure. The two legs can be merely bound together. The rationale is to avoid causing further damage by the sharp edges of the fractured bones moving about while the patient is being evacuated. The following are useful guidelines when one considers the possibility of broken bones. A corpsman may use the following signs as indicators of broken bones: 1. 2. 3. 4. Pain or soreness over a joint or bone. The victim tells the corpsman that he heard or felt a break. The victim can't move an injured part or that a move is painful. The victim tells the corpsman that there is numbness or tingling in the injured limb. This is also an indicator of possible nerve injury. 5. An arterial pulse cannot be found in the injured part or limb. This is an indicator of blood vessel injury. 6. The corpsman sees swelling or bruising in the injury site. This an indicator of extravasated blood. 7. The injured part is in an unusual or abnormal position and any possible movement is abnormal. How to provide first aid to victims with bone or joint injuries? Without x-rays or MR imaging it is not always possible to know if a bone is broken, a joint is dislocated or damaged, or if ligaments are stretched or torn. The rule-of-thumb therefore, is not to guess, but to immobilize the injured part. However, this is not the first step in the first aid of these victims. 1. Treat for any life-threatening condition first: check breathing, pulse and for any bleeding. Finally stabilize the fractured bone or injured joint. 2. It is essential to keep movement of the individual and the injured part to a minimum. The rational for minimal movement is to reduce the possibility of additional damage to bone, muscle, blood vessels and nerves and the production of additional pain. 3. Immobilize the injured part with bandages, slings and splints.

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4. If there is torn skin avoid contamination of exposed underlying structures using sterile compresses. Infections of bone are very serious and difficult to treat. If there is a compound or open fracture (bone sticking through the surface of the skin) never try to push the bone inside the torn muscle. 5. Swelling of joints can be avoided by cooling the injured part using ice wrapped in a cloth or towel. 6. Treat for shock and secure the aid of a medical corpsman and physician as soon as possible.

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Colle's fracture

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Comminuted fracture

Green-stick

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Impacted

Incomplete

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Linear

Oblique

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Pott's fracture

Spiral fracture

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Transverse fracture

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Anatomy of First Aid: A Case Study Approach

Abdominal Wound with Protruding Viscera

Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A Sailor, on liberty in a foreign port, was returning to his ship when a knife-wielding assassin attacked him. He later remembered that he was slashed, but was able to chase his assailant away, before he collapsed. Two of his shipmates found him, and when it was clear that the injury was severe, one of the shipmates was sent to get the ship's corpsman. The attending shipmate was familiar with "first aid" and set about initial care to reduce the possibility of severe shock. The injured Sailor had regained consciousness and was rational and was told not to stand up. He was covered with his shipmate's jacket and his feet and legs were elevated. His vital signs were satisfactory; pulse was regular (between 60 and 90 beats per second); breathing rate acceptable (about 15 to 20 per minute), and his blood pressure pulse was judged, in the absence of a pressure cuff, to be strong. The corpsman on duty and the other shipmate quickly returned from the ship. The corpsman took over responsibility for first aid and examined the wound. He cut away the Sailor's shirt to expose the abdominal wound and found that his intestines were protruding from the wound. Although bits of the Sailor's shirt were adhering to the intestines they were not removed. The corpsman told his shipmates that the intestines must not be touched and no attempt must be made to replace the intestines back into the abdominal cavity as part of first aid. This is to be performed in sickbay by the naval surgeon. The corpsman carefully covered the wound with a sterile moist gauze bandage taped to the abdomen. The corpsman contacted the ship's duty officer to obtain a stretcher and to alert the medical officer that a severe abdominal wound was on the way to the ship for surgical treatment. When the stretcher arrived, the four Sailors carefully placed the injured Sailor on the stretcher and transported him safely to sickbay for definitive medical care aboard ship.

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Anatomy of First Aid: A Case Study Approach

Amputation
Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A Sailor aboard a destroyer in the Atlantic Ocean lost her hand in an engineering accident. A nearby Sailor called out for someone to summon the corpsman and he immediately applied a tourniquet (see section on Injury to Thigh) on the injured arm. He was able to stop the bleeding and had the Sailor lie down. She was covered with a blanket to reduce the possibility of severe shock. The Sailor also recognized the necessity to elevate her feet by about 8 to 12 inches. He remembered that shock is essentially a sudden drop in blood pressure, which may be so severe that the brain and other vital organs do not have adequate blood flow. These few, simple, things help prevent additional cardiorespiratory complications.

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By now the corpsman arrived on the scene and took charge of first aid. He checked her vital signs (pulse rate, blood pressure, and respiratory rate), which were found to be at satisfactory and stable levels. He located the severed hand, wrapped it in sterile bandages and placed the hand in a plastic bag and then into a carrier he brought with him. It was filled with ice to chill (not freeze) the amputated part. The corpsman then returned to the patient and recorded the time of application of the tourniquet on the patient's forehead with a waterproof marker in large numbers. Ascertaining once again that the bleeding had stopped, he taped a loose, sterile, moist bandage over the stump of the forearm but was very careful not to cover the tourniquet. He then supervised the movement of the patient to his sickbay. Not equipped to handle amputations, he communicated with the medical officer on a nearby ship for further instructions. He then made preparation for ship-to-ship transfer of the injured patient.

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Anatomy of First Aid: A Case Study Approach

Burns (by degree)

Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A submarine rendezvoused with its submarine tender and an electrical power line was requisitioned by the submarine to service the submarine while it took on supplies and the crew worked on its nuclear power plant. One of the submariners handling the power line was accidentally electrocuted. Immediately another crewmen moved the Sailor from the power line with a non-conducting wooden pole. A corpsman had been summoned and arrived in time to take over the first aid treatment.

Before discussing first aid given to the submariner, burns, whether caused by flames, electricity, scalding water, friction, radiation or chemicals are described as first-, second- or third-degree
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burns. The first illustration depicts the tissues effected. A first-degree burn is one involving the epidermis causing erythema (redness) and edema (swelling) but no blisters. A second-degree burn involves the epidermis, the dermis and usually forms blisters that may be the result of superficial or deep dermal necrosis. Burns of this type have epithelial regeneration extending from skin appendages (sweat glands, hair follicles, etc.). A third-degree burn results in the destruction of skin, and may extend into the superficial (fatty) fascia, muscle and bone. Scarring is a consequence of this type of burn.

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Returning now to the Sailor with the electric shock; the corpsman knew that electrical burns, even the smallest, are considered third-degree and both an entry and exit burn was possible. The clothing was removed from the areas of both burns, which were quickly, but briefly, cooled with water. A cold wet compress was placed on the wounds followed by clean dry (sterile) dressings. The patient was breathing rapidly, but denied the presence of pain. The absence of pain is typical because nerves are destroyed in the path of the burn. The burns were seen as charred areas about two inches across. The corpsman asked for a blanket to keep the Sailor warm to reduce the possibility of severe shock; his feet were elevated and his vital signs (respiration rate, blood pressure and temperature) were monitored. The corpsman covered the burns with sterile dressings, and the patient was taken to the subtender's sickbay where a naval surgeon took charge of treatment of the burn victim. Before he left, the corpsman told several interested crewmen that blisters and charred skin would be treated at a later time. In addition he said that butter, household remedies, pain relief medication, ointments or sprays were not to be used for burns of this type and further, if used, may even delay proper healing. The corpsman said that a small third-degree burn might be difficult to recognize if it is located in an area of second- or even first-degree burn skin damage. If there is any doubt, the whole area is treated as a third-degree burn. In addition, because of nerve damage in third-degree burns, a patient must not be allowed to use or put weight on a burned limb, foot or hand. The knowledgeable medical corpsman continued by explaining to the assembled group the differences between, and treatment for, second- and first-degree burns. First-degree burns are characterized by red skin, mild swelling with or without pain. Second-degree burns are deeper, with red coloration and other skin damage, such as swelling, blisters, oozing or leaking skin, pain greater than 1st degree burns and the possibility of shock . See the first illustration to gain an understanding of the depth of tissue damage in various types of burns. As with other first aid treatments, rapid and proper treatment will reduce the severity of the problem for the patient. With burns of the face, or hot air or hot smoke inhalation assume the possibility of respiratory burns; these require immediate medical attention. Do not remove dead burned tissue and do not open blisters that may form, particularly in second-degree burns. Do not remove clothing that may adhere to the burned area. Do not use home remedies, margarine or butter, ointments or sprays except on the advice of a physician or senior corpsman. Pain relief sprays and ointments can be used on minor or small first-degree burns. Seek the advice of the corpsman for any burns but particularly those of the face, second-degree and extensive first-degree burns. Minor seconddegree burns are those small enough to be covered by a small, 3" X 3," sterile dressing but do not involve the face, hands or feet. First aid includes immersion of the burned part under cold running water or if this is impractical, by using cold wet compresses. Continue the cool water treatment until the pain disappears. For second-degree burns of hands, feet, face and/or perineum, e.g., the entire arm or 10 to 15 % of the body, and burns that blister, see the corpsman for advice and additional treatment. Second-degree burns involve deeper areas of the skin that may release fluid from damaged blood vessels that cause blisters. Usual causes are: deep sunburns resulting from prolonged exposure to the sun by Sailors not wearing shirts on outdoor work details, prolonged exposure with hot objects, scalding by hot water or steam, and by flash51

burns from inflammable liquids. First-degree burns involve the superficial layers of the skin, which becomes red but not broken or blistered. Pain receptors in the superficial layers of the skin become irritated and produce the perception of pain, which may be intense. Recovery of the skin from the burn is usually quick and complete. Treatment may include cooling with water, aspirin or other analgesics. The corpsman said he used the "rule of nines" to describe the extent of the burn or area of the burn expressed in percent of the total body surface for an adult. The rule of nines allows that each upper limb is 9%, head and neck is 9%, anterior trunk (chest and abdomen) is 18%, the posterior trunk (back) is 18%, each thigh is 9%, and each leg (not including thigh) is 9%, and the perineum is 1%. Burns need to be treated in the hospital if they are more than 20% of body area, involving a critical area such as face, hands, feet, genitalia, perineum, and major joints, all electrical and chemical burns regardless of size, and smoke inhalation or carbon monoxide poisoning.

The corpsman also discussed chemical burns and stated that exposure to dangerous chemicals must be rinsed from the skin and that contaminated clothing is removed. Water dilutes these substances and flushes them away. No attempts to neutralize the substance should be attempted because greater damage may occur by chemical reaction resulting in additional burning. Frequently encountered products that cause third-degree chemical burns include hydrofluoric acid (rust removers) nitric, sulfuric, phosphoric acids (commercial grade acids) hydrochloric acid (cement and drain cleaners); these chemicals must be used with great care.

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Treatment includes removal of contaminated clothes, flushing the affected area with running water for at least 5 minutes. Relieve pain with cool, wet compresses until the corpsman arrives. The corpsman will decide if a naval surgeon is required. He also said that in burns to the face or the inhalation of toxic chemicals; assume a condition of respiratory burns, which require the immediate attention of a physician.

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Anatomy of First Aid: A Case Study Approach

Smoke, Gas, and Chemical Fumes

Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

Fumes from any unknown source may be flammable! Before proceeding to assist a shipmate in a "smoke-filled" room do not light a match, use a candle, or even turn on a light switch. Do not produce a flame or spark in the presence of gas or unknown sources of fumes.

The cruiser returned to port for refitting and the Executive officer was told to have the deck crew remove the rust on the ship, to chip loose paint and to repaint those areas. The Chief went with a crewman to the paint locker to inventory existing supplies. On entering the locker they encountered overwhelming fumes, were quickly overcome, and collapsed before they could escape the room. Because the Chief was needed for another problem another crewman went to the paint locker to find him. He smelled the fumes and remembered that he might need more assistance when he got to the locker. He also remembered the admonition about sparks and flames and also the need for a hospital corpsman. The Sailor told these things to another shipmate to get help and he and still another Sailor proceeded to the locker. Although dark, he could make out two bodies on the deck. The two Sailors took several deep breaths of fresh air, inhaled and then held their breath. In cases where smoke and fumes are visible above the floor they would stay below them but in this case the paint fumes were evenly dispersed in the entire room. They removed the two men into an area with fresh air and examined the two men for breathing. One was still breathing but the Chief was not. The prompt arrival of the corpsman began with attempts at artificial respiration to restore breathing. Eventually the corpsman was
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successful and the Chief began to breathe on his own. The corpsman made a quick check of the victim's eyes and skin to see if the fumes were toxic enough cause visual problems. The eyes were clear but were flushed with clean (or sterile) water. Before the Sailors could be moved they were treated for shock. Their vital signs were assessed and found satisfactory but weak. The Chief was placed on his back with his head and chest slightly elevated. The Chief was unconscious and vomited. He was placed on his side and his knee of his top leg was bent to help him from rolling forward. Both Sailors were covered with blankets to lessen shock and were finally taken to sickbay for observation. The corpsman provided additional information. The effects of inhaled smoke, gas, and fumes from other sources may not be totally evident immediately. A thorough medical examination is necessary, and a period of observation in sickbay may be beneficial should other symptoms or signs appear subsequently.

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