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Letter Re: Anesthesia for Traumatic Times
Jim -
I've been reading your blog for a while now. Just thought I'd weigh in briefly
on the anesthesia issue. For background, I am a general pediatrician with
experience
in emergency pediatrics. Also, I am a fellow of the Academy of Wilderness Medicine.
Three quick points:
1. Under the vast majority of circumstances it is possible to work on mild
to moderate traumatic injuries in children without anything more than local
anesthesia. Papuses work
great and should be considered as part of an advanced medical kit that is intended
to treat children. If a papuse is too expensive or bulky, there
are all sorts of ways to immobilize children with sleeping bags, pillow cases,
sheets, etc. (one just has to use imagination - for example, try both arms
in a pillow case across the back). Obviously, the papuse idea only addresses
immobilization of the patient and does not assist with pain management. However,
even in an academic pediatric emergency department, we often concluded that
the risks of non-anesthesiologists administering anesthesia outweighed our
concerns about pain.
2. Dermabond is one of my favorite products. The screaming and struggling at
the University of Chicago pediatric emergency department dropped by 95% when
Dermabond was introduced to the market. It's a bit pricey but very simple to
use. I never had any "formal" training in dermabond use because it
was simply unnecessary. Carefully reading the instructions should suffice for
survival oriented self-training on the product. My biggest concern would be
to avoid gluing an eye shut. Even a glued eye is not a disaster as can slowly
be reopened with cooking oil and massage. People have suggested on your web
site, as well as at Wilderness Medical Society meetings, that super glue (same
active
ingredient - cyanoacrylate) could be used for the same purpose. However, I
have personally found it to take much longer to dry and to be far less reliable
at keeping the wound closed. Just last weekend I tried a new rubberized formulation
of super glue on a laceration of my own and was disappointed to find that it
peeled away the very next day - something I have never observed with Dermabond.
Lastly, Dermabond can successfully be used on joints as long as it they are
immobilized. This is less of a concern in children than it might be in adults
who might have to remain physically active.
3. I've personally experienced a hematoma block. Several years ago, I had a
broken rib that was so painful I couldn't breathe except in small gasps. Worried
about the possibility of a secondary pneumonia, my doctor injected hydrocortisone
and lidocaine directly into the fracture site. The block worked great and I
was able to breathe normally again.
On another note, I have noted a number of formulas on your blog for mixing
up wound cleansing solutions. The current research based consensus at the Wilderness
Medical Society
is that wounds may be cleansed with plain drinking water. So, simply treat
questionable water with a filter, by boiling, or with an appropriate chemical
agent and leave it at that. In fact, a Camelbak (or similar system) is an
ideal wound cleansing device. Just put the bladder under an armpit and squeeze
a large volume stream of drinking water from the tube directly into the wound.
The mouthpiece itself can either be carefully washed or simply removed prior
to use. - A.F., M.D.
