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.