Teaching Wound Care and Bandaging: An Historical Perspective

Transcription

1 Wilderness and Environmental Medicine, 14, (2003) THE WILDERNESS INSTRUCTOR Teaching Wound Care and Bandaging: An Historical Perspective Steve Donelan Introduction For many years, first-aid courses included a great variety of bandaging and splinting techniques. In the second edition of the American Red Cross textbook, Advanced First Aid & Emergency Care (1979), 1 for example, 22 bandaging techniques are described and illustrated. Many of these bandages were also included in Standard First Aid when it was a lecture/demonstration course about 20 hours long. Yet in Emergency Response, 2 the American Red Cross textbook for a first responder course that supplanted Advanced First Aid in 1993, only 1 bandage is described and shown a simple gauze roller or elastic pressure bandage to control bleeding. Until the last decade of the 20th century, American Red Cross courses were widely accepted as the standard for first-aid training, and they are still among the most popular. The content and objectives of their courses are fairly representative of what was taught in first-aid courses, including both the Standard First Aid course designed for lay people and the Advanced First Aid course (about 50 hours long) designed for professionals. Starting in the 1980s, Standard First Aid was reduced to a 1-day course, including Adult CPR, and the first-aid content was reduced to a few hours. Most of the bandaging and splinting techniques were dropped. And whereas Advanced First Aid remained in the course catalog until 1993, the textbook was not revised after This dramatic change in the content and apparent objectives of first aid courses raises several questions: Who developed the sophisticated bandaging and splinting techniques that were taught for so many years in first-aid courses? Why did lay people need to know all these techniques? Photos courtesy of the American Red Cross Museum. All rights reserved in all countries. Corresponding author: Steve Donelan, P.O. Box 1227, Berkeley, CA (web: donelan@ mindspring.com). Why were almost all of these techniques dropped in the 1980s and 1990s, even from the advanced (first responder) courses? Are these traditional first-aid techniques still being taught in wilderness courses? Are the traditional techniques in the old books still potentially useful for wilderness situations? History of first aid training Let us begin by looking at the history of first-aid training for lay people in the United States. It probably began in 1880, when The Society for First Aid Instruction to the Injured was formed in New York City. Medical doctors volunteered their time to teach the public, who paid a small fee to the Society. In 1889, Dr Matthew J. Shields began teaching first aid to Pennsylvania coal miners for the Jermyn Coal Company, using a textbook that he wrote. The first sentence began What to do before the arrival of the doctor. In 1903 and again in 1908, 3 the American Red Cross produced a first-aid manual, but the program did not really get started until they hired Dr Shields as Staff Physician in He and other physicians toured the United States in railroad cars fitted out as classrooms, teaching first-aid to the public as well as to railroad and mining employees. First-aid contests, with medals to the winning teams, brought a lot of publicity to the program. 4 By 1922, there was a Teacher s Handbook of First Aid Instruction for teaching it in schools, and first-aid stations (staffed by volunteers) were common at large events such as fairs, track and field meets, and parades. Then in 1927, physicians began to train lay people as first-aid instructors, which was the key to the expansion of the program. By 1933, the American Red Cross had issued first-aid certificates to course graduates and published its first standardized first-aid textbook, which was revised in

2 48 Donelan Figure 1. Double spica bandage of the groin. Credit: Davis. 7 First aid training in the 1930s What was in the 1937 textbook? What were the objectives, and what did instructors teach their students to do? Chapter 1, First aid its need and its use, begins with 3 accident scenarios that provide some context for the training. The first scenario is an auto accident with a mishandled spinal injury, the second is a rattlesnake bite on a ranch, and the third is an unconscious swimmer who is not breathing when pulled out of the water. These scenarios lead into some sobering annual accident statistics for the United States: deaths from accidents, total disabilities, people injured in auto accidents, and accidents in the home that result in some disability. Compare this with deaths from accidents in 1988 out of a much larger population in 1940, the United States population was about In this context, the objectives of the book and courses are clear to reduce death and disability from accidents by training lay people to do first aid. For example, there is a detailed explanation of spinal management, including the technique for straightening a bent or twisted patient (missing from many current books), as well as securing the patient to a backboard. The book also explains how to improvise backboards from doors, shutters, or boards. The second scenario reminds us that in the 1930s, a large percentage of the United States population still lived in rural areas, where they were far from medical help and exposed to hazards that we now associate with wilderness activities. And even in urban areas, there was no Emergency Medical Services (EMS) system no way to bring urgent medical care quickly to the accident scene. The third scenario reminds us of how common drowning accidents are. The book has a 22-page chapter on artificial respiration. This chapter describes the different accidents that could require resuscitation, including not only drowning but also electric shock, gas poisoning, and being buried in a cave-in (remember that the first students for these classes were miners). Artificial respiration was still done by the Prone Pressure Method (developed by Sir Edward Sharpey Schäfer in 1903): laying the patient face down and compressing the rib cage. About 61% of the 1937 textbook s 256 pages are devoted to injuries and how to treat them, compared with 25% of the 2000 Edition of Emergency Response. This reflects the changing statistics on the causes of death and disability in the United States. Medical training in the 1930s focused heavily on treating injuries, because they comprised a large part of most physicians practice. For example, farming caused many accidents, keeping rural doctors busy, and safety conditions for industrial workers in the cities were generally very poor. When physicians taught first aid to lay people, they naturally focused mostly on accidents and injuries. First aid training since 1993 By contrast, Emergency Response contains much more information on medical problems, especially chronic

3 Wound Care and Bandaging problems such as cardiovascular disease and diabetes. It also contains sections on many topics absent from the 1937 textbook, such as psychological aspects of emergency care, behavioral emergencies, drug abuse, legal and ethical considerations, preventing disease transmission, care of infants and children, and special populations. Some of these topics are also absent from the 1979 Advanced First Aid textbook, which devotes 56% of its 301 pages to injuries and how to treat them and has only a 19-page chapter on sudden illness. The new topics and change in emphasis in the 2000 textbook reflect not only a shift in the statistics for causes of death and disability, but also an expanded view of what constitutes an emergency and a recognition of cultural diversity. First aiders and first responders, especially in an urban situation, often care for people who are very different from them because of age, culture, or medical conditions. They need to understand these patients to communicate with them and do effective emergency care. On the other hand, the omission of most of the skills for treating injuries reflects a reliance on the EMS system (which began with the Emergency Services Act in 1973) for everything beyond the most urgent treatment. During the 1980s, higher levels of Emergency Medical Technician (EMT) training developed, and in 1993 (when the American Red Cross Emergency Response program was released) the EMS Education and Training Blueprint was published; it described 4 levels of training for EMS professionals: First Responder EMT Basic EMT Intermediate EMT Paramedic Since then, the curricula for each level of training have been standardized and accepted by most states. With this system in place, basic first-aid courses for urban situations now train people to activate EMS and take care of patients for the first few minutes; first-responder courses train people to take care of patients for the first 15 minutes, until more advanced care arrives. But wilderness responders still need and use many of the traditional skills that have been dropped from urbanoriented courses, so it is worth looking at some of the old books to see which techniques have changed (and why), which techniques have been rediscovered, and whether there are more techniques in these sources that would be useful for wilderness situations. Origins of modern bandaging Where did all the bandaging techniques described in the 1937 textbook originate? Because physicians wrote 49 the book and (until 1927) taught all the courses, they trained students to use the same techniques that they used themselves in their medical practices, with bandages of cotton muslin, shaped into triangles or strips, and gauze roller bandages. Because the gauze at that time was not stretchy, students had to learn techniques for making it conform to the limb as they wrapped. As medical bandages and dressings became more sophisticated, however, first-aid courses continued to train students in traditional bandaging techniques, because lay people were unlikely to have hospital quality equipment and might have to improvise from whatever cloth was available. Gwylim G. Davis book, The Principles and Practice of Bandaging (1902), 7 was meant to train surgeons in the art. In his preface, Davis laments Many surgeons seem to wind [gauze bandages] aimlessly around a part without the faintest idea of order or sequence. Instructors who have taught bandaging will sympathize. Among an array of elaborate bandages that only an early-20th century surgeon would use (such as the double spica bandage of the groin), we can recognize most of the simpler techniques that were useful for first-aid and that found their way into first-aid textbooks. Let us look at these bandaging and wound care techniques in the 1937 edition of the American Red Cross textbook, and compare them with what is in the current Emergency Response textbook, as well as some wilderness-oriented textbooks (Figures 1 through 3). Bleeding control In the 1937 book there are 12 pages on bleeding control, starting with photos and descriptions on how to apply digital pressure to the ear, throat, jaw, shoulder, arm, and leg. These are the same pressure points shown in the 1908 American National Red Cross Textbook on First Aid and Relief Columns. Only the brachial and femoral pressure points are still taught in first aid classes. Figure 48 shows an alternate method of clamping the brachial pressure point in the crook of the elbow with the forearm, which might still be useful. Students with small hands have trouble clamping this pressure point with their fingers on a big arm (Figures 4 and 5). Tourniquets are described and illustrated next, before direct pressure and elevation. You have to read the text closely to find that tourniquets were even then considered a last resort and that you should try other methods of bleeding control first. By contrast, all current textbooks direct students to try direct pressure, elevation, and pressure points in that sequence, although these textbooks typically show only the brachial and femoral

4 50 Donelan Figure 2. The gauntlet: a roller bandage covering the fingers and thumb. Credit: Davis. 7 Figure 3. Spiral bandage with nonstretchy material the half-twist helps the bandage to conform to the shape of the limb. Credit: Davis. 7

5 Wound Care and Bandaging 51 Figure 4. Pressure points that were still taught in first-aid classes in Credit: American National Red Cross Textbook on First Aid and Relief Columns. 3 pressure points. Advanced First Aid (1979) 1 gives illustrated directions for applying a tourniquet but warns not to loosen it except on the advice of a physician because of the danger of further bleeding and shock. Emergency Response mentions tourniquets only as a last resort and does not illustrate or give instructions about the technique; it does not require practice of the skill for certification. Some wilderness textbooks, however, have revived the tourniquet and give illustrated directions for its use, although they also warn of its dangers. For example, the National Ski Patrol s Outdoor Emergency Care, 8 NOLS Wilderness First Aid, 9 and Eric Weiss Comprehensive Guide to Wilderness and Travel Medicine 10 all have illustrated instructions on how to apply a tourniquet. Interestingly, although the 1937 book recommends loosening the tourniquet every 15 minutes to see if the bleeding has stopped, the NOLS book and the Weiss book suggest doing that

6 52 Donelan Figure 5. Using the forearm to apply pressure to the brachial pressure point. Credit: American Red Cross First Aid Textbook.5 only after an hour, and the ski patrol book does not mention that option. Why does the 1937 book give so much attention to a technique that is now considered a last resort even in wilderness situations and is not even taught in most urban first-aid courses? One possible explanation is the background of the physicians who taught the courses in the 1930s. Their first students were employees of mining and railroad companies, and some of the physicians also worked for those companies. So they must have treated many severe bleeding injuries from industrial accidents, including crushing injuries and ampu- tations, and may have anticipated that their students would also have to treat such injuries. In that context, it makes sense that they would want to teach students the most powerful and effective techniques of bleeding control that they knew. Moreover, some authors clearly think that wilderness rescuers still need to know how to apply tourniquets, in case other bleeding control methods do not work. Another consideration is that injured people were much more likely to die in the 1930s because none of the life support techniques that we take for granted now, at least in urban situations, were available to prevent

7 Wound Care and Bandaging 53 Figure 6. Four-tailed bandage of the nose. Credit: American Red Cross First Aid Textbook. 5 shock. The only 3 methods for treating shock described in the 1937 book are externally applied heat, elevating the legs, and giving stimulants if the patient can safely drink (pp ). None of these are recommended today. So aside from controlling bleeding, shock treatment in the 1930s was probably not very effective. Wound cleaning then and now For wounds that are not bleeding severely, according to the 1937 book (p. 67), The chief duties of the first aider are to prevent more germs from getting in and to use an antiseptic or germicide to destroy as many germs in the wound as possible. Nobody would disagree with this statement today, but the book does not describe any technique for cleaning wounds except recommending benzine, naphtha, oil of turpentine, or ether to remove grease and oil, reminding us again that many students in these early courses were industrial workers. Irrigation is not mentioned in the 1937 Red Cross book. The 1979 edition of Advanced First Aid also recommends cleansing, but only of superficial wounds, by washing and rinsing, not forceful irrigation. In the 2000 edition of Emergency Response, the American Red Cross textbook for urban-oriented first responder courses, this advice is reduced to a single line on page 248: Cleanse the wound with soap and water. Some earlier books on wilderness first aid have similar advice, to wash or gently irrigate the wound with soap and water, for example Being Your Own Wilderness Doctor (1972). 11 The 12th Edition of Dr Darvill s Mountaineering Medicine still gave the same advice in But the leading textbooks on wilderness first aid and wilderness medicine published since 1990 all recommend forceful irrigation with water, using a syringe or its equivalent, to cleanse a wound. 8 10,13 16 Most wilderness authors began recommending it in earlier editions of their books. This recommendation reflects recognition that in a wilderness situation, forceful irrigation is the only effective way to remove wound contaminants that can become colonization sites for bacteria, although many wilderness textbooks also

8 54 Donelan Figure The triangular bandage has may uses. Credit: Morton B, Handbook of First Aid to the Injured, Revised Edition, mention that tweezers may be needed to remove particles that do not flush out. The art of bandaging For protecting wounds, the 1937 book describes the still familiar sterile gauze and bandage compresses (including the 1-inch bandage compresses now sold under several brand names for covering small cuts and scrapes). To hold dressings in place, the book describes 3 kinds of bandages: Triangular (which can be folded into a narrow or broad cravat ) Roller or pleated gauze Four-tail Triangular bandages are still found among first-aid supplies in stores and catalogs, although the techniques of bandaging with them are seldom taught in urban-oriented first aid or EMT courses. The 4-tail bandage (traditionally used to bandage the nose or jaw, as seen in Figure 6) is now seen only as a battle dressing a thick, sterile dressing with 4 long tails of nonstretchy gauze to secure the dressing anywhere on the body or limb. The rolled or pleated (folded) gauze of the time was sterilized and came in sealed packages. It was not elastic. According to the 1937 book (p. 57), This kind of bandage is extensively used by the surgeon, but, except for use on the fingers and toes, it is not a particularly good first aid bandage. Without considerable practice and much adhesive tape, it is usually quite difficult to make it stay on. However, the first aider frequently finds it necessary to use any material at hand and some knowledge of the roller bandage is desirable. Eric Weiss apparently agrees with the last statement because he explains how to make a roller bandage by cutting a T-shirt in a spiral direction on page 88 of his book. 10 The stretchy and nonsterile gauze rollers now available, however, have become the most common bandages used by urban responders because they can easily secure a dressing to almost any part of the body, and they conform to the contours of the body or limb. They are also included in most wilderness first aid kits. Unfortunately, the traditional techniques for bandaging with gauze rollers are not described in most current textbooks, so students seldom learn how to do good gauze roller bandages. For urban first aiders and EMTs, good technique is not so essential because their bandages only need to stay on for a short trip to the hospital. But wilderness first aiders and first responders need to know the traditional techniques for applying bandages that will stay on throughout a trip or a wilderness evacuation. For bandaging with a stretchy gauze roller, students need to learn and practice: Anchoring the bandage

9 Wound Care and Bandaging 55 Figure 8. Cravat bandage of elbow. Credit: American Red Cross First Aid Textbook. 5 Unrolling the bandage in an overlapping spiral Anchoring the dressing to the bandage Tying the bandage off A variation that applies more pressure for controlling bleeding is the figure 8 spiral, in which one alternately angles the unrolling bandage forward and backward with each turn. For bandaging with an improvised, nonstretchy roller, students also need to know how to do the spiral reverse. Narrow gauze rollers in the 1-inch or 2- inch width can be used to bandage injured fingers. Anchoring and tying off the bandage at the wrist makes it more secure, especially for a patient who has to use the injured hand. Some of these techniques are shown in Wilderness Emergency Care 17 and can be viewed on the artist s web site: Several of them are also shown in the wilderness first aid textbook published by the Wilderness Medical Society in collaboration with the National Safety Council. 18 Triangular bandages are also very versatile. They can be folded into any desired width or used as slings for injured arms. They are especially good for applying pressure to control bleeding, and if properly applied, they make sturdy bandages that can stay on and help protect injuries even during a rough walkout or evacuation (Figures 7 and 8). Conclusion Traditional bandaging techniques have almost disappeared from urban-oriented first aid and first responder courses, but are making a comeback in wilderness courses. Wound cleansing technique has improved since 1937, and it is one of the most important things that a wilderness responder can do for an injured patient. Wilderness responders (unlike urban responders) also need to apply bandages that will stay on even if the patient is active or is being evacuated from the backcountry. They also need to be able to improvise bandages with whatever materials they have. To teach effective bandaging for wilderness situations, instructors can adapt many techniques from old first-aid books, which were designed to train responders when equipment was limited and there was no EMS system. References 1. American Red Cross. Advanced First Aid and Emergency Care, Prepared by the American Red Cross for the Instruction of Advanced First Aid classes. 2nd ed. Garden City, NY: Doubleday & Company, Inc; American Red Cross. Emergency Response. Revised ed. Boston: Staywell; Lynch C. American National Red Cross Textbook on First Aid and Relief Columns. Philadelphia, PA: P. Blakiston s Son & Co; American Red Cross. Brief History of ARC First Aid Program. Information Letter #6; revised 11/ American Red Cross. First Aid Textbook: Prepared by the American Red Cross for the Instruction of First Aid Classes. Revised ed. Philadelphia, PA: The Blakiston Company; Wallechinsky D, Wallace I. The People s Almanac. Garden City, NY: Doubleday & Company, Inc; Davis GG. The Principles and Practice of Bandaging. Philadelphia, PA: P. Blakiston s Sons & Co; 1902.

10 56 Donelan 8. Bowman WD. Outdoor Emergency Care. 3rd ed. Boulder, CO: The National Ski Patrol System, Inc; Schimelpfenig T, Lindsey L. Wilderness First Aid: National Outdoor Leadership School. 3rd ed. Mechanicsburg, PA: Stackpole Books; Weiss EA. A Comprehensive Guide to Wilderness and Travel Medicine. Oakland, CA: Adventure Medical Kits; Kotet ER, Angier B. Being Your Own Wilderness Doctor. New York, NY: Pocket Books; Darvill FT. Mountaineering Medicine: A Wilderness Medical Guide. 12th ed. Berkeley, CA: Wilderness Press; Forgey W. Wilderness Medicine. 4th ed. Merrillville, IN: ICS Books; Wilkerson JA. Medicine for Mountaineering. 4th ed. Seattle, WA: The Mountaineers; Auerbach PS. Medicine for the Outdoors. Boston, MA: Little, Brown and Company; Tilton B, Hubble F. Medicine for the Backcountry. Merrillville, IN: ICS Books; Donelan S. Wilderness Emergency Care. New Port Ritchie, FL: American Safety & Health Institute ( Backer HD, Bowman WD, Paton Bruce C, Steele P, Thygerson A. Wilderness First Aid: Emergency Care for Remote Locations. Sudbury, MA: Jones and Bartlett Publishers; 1998.