In 1940, Reserve Constable Albert Alexander scratched his face. Accounts differ on whether this occurred while shaving, or an encounter with a rose bush. In either case, the Constable had a minor scratch which became infected. What makes Constable Alexander’s story notable, is that his was the first wound infection treated with the then-new antibiotic, penicillin.
It almost worked.
When first treated, Constable Alexander improved dramatically, but the hand-purified supply of antibiotic available ran out before the infection was eliminated. The infection returned, and he died from the combined staph and strep infection of the wound. Welcome to the reality of wound care without antibiotics. A minor scratch can kill you.
With TEOTWAWKI, we would rapidly re-enter the pre-antibiotic era. So what are we to do with the routine nicks and scratches, let alone, major wounds? The simple answer is that primary wound care, with an emphasis on preventing infection becomes paramount to avoiding the fate of Constable Alexander. Non-antibiotic antiseptics – such as Betadine® — should be a part of your kit and routine practice. Note that Betadine® is the registered trademark of Purdue Products for their povidone-iodine products – I’ll use the term Betadine® in this article, but the discussion below applies to any 10% povidone-iodine solution.
First, get yourself some basic first-aid training. I teach first-aid, CPR and Wilderness First Aid (WFA), and strongly suggest seeking out a WFA course as your basic first-aid training. Standard “urban” first-aid assumes that your victim will have advanced medical care – a hospital – within an hour or so of an incident. WFA assumes that advanced care is delayed – perhaps for days. Providers of WFA training include Stonehearth Open Learning Opportunities (SOLO), National Outdoor Leadership School (NOLS), some chapters of the American Red Cross, and others. A good basic course should have at least sixteen hours of instruction – this is not a one-afternoon class.
Second, get some reference materials for your bookshelf. My favorite WFA references are NOLS Wilderness First Aid (NOLS Library), Wilderness Medicine, Beyond First Aid, by William Forgey, and Wilderness First Responder, by Buck Tilton. These are not tiny “reminder” [or checklist] pamphlets for your kit, but serious texts to be read and practiced in advance of an injury. Practice and drill in first-aid is as essential as in marksmanship.
Finally, lets look at primary wound care. Where you start depends on the wound. In the case of severe bleeding, you must first control the bleeding. I won’t attempt to teach first-aid by typing, but applying a gauze or cloth to the wound to aid clotting, along with direct pressure, elevation and pressure-points are in order. If required, a tourniquet can control severe bleeding in an extremity. Always pay attention to the ABC’s of life first: Airway, Breathing, and Circulation.
With bleeding controlled (and the rest of the ABCs addressed) you need to pay attention to cleaning the wound and controlling infection. If you don’t, as William Forgey points out in Wilderness Medicine,, Beyond First Aid, your patient will still die from infection, but it will take longer and be more painful than bleeding to death. And remember, cleaning and caring for a wound applies to any wound, not just severe ones. The good Constable died from an infected scratch!
Cleaning minor wounds: Simple scratches and minor, shallow cuts can be simply cleaned with soap and water followed by a daub of Betadine®. Do this as soon as possible after the injury. If you are away from soap and water, at least apply the Betadine®, and let it dry on the wound. I’ve used this simple treatment in my home for nearly twenty years and avoided the need for follow-up antibiotic ointment, let alone oral antibiotics.
Larger wounds and abrasions: The best technique for deep or heavily contaminated wounds is take a hint from hospital ERs, and use irrigation. You probably won’t have sterile saline handy, but a dilute 1:10 solution of Betadine® in clean drinking water serves quite well – you’ll need at least a quart for most wounds. The best irrigation device is a simple no-needle syringe. In my pocket first-aid kit, I carry a 10cc oral medication syringe (available at any drug store). In my larger first-aid kits, I carry a 90 cc “flavor injector” plastic syringe (from Bed, Bath and Beyond). In a pinch, a plastic bag with a pinhole will do.
Flush the easily removed dirt and blood from the wound, inspecting closely for particles of embedded debris. If there had been severe bleeding, gently remove the clotted dressing with irrigation, being ready to staunch bleeding again. Using tweezers or a gauze pad, remove embedded bits of dirt and flush again. Using a sharp, sterile blade or scissors, trim and remove disconnected strips of dead flesh – they’ll only serve as a focus for infection. Repeat the process of irrigation, inspection and irrigation until the wound is clean. Gently scrub with the gauze pad if you have to, always toward the outside of the wound. Did I mention that this would hurt, a lot?
If the wound is completely clean, you can consider closing it, but you increase the risk of serious infection if you do. I’ve closed wounds in the field without infection, but they have been “clean” uncomplicated wounds. I’d recommend 3M Steri-Strips for closing uncomplicated wounds, unless you’ve have the materials and practice needed for suturing. This is also the time to use some of your limited stock of antibiotic ointment on a sterile dressing (or dampen the dressing with diluted Betadine®. Infection in a closed wound is a major problem.
If you are unsure if the wound is clean, then pack it open with non-stick sterile dressings dampened with diluted Betadine® and let it heal “open”. Yes, the scar will be nasty, but that is cosmetic, not functional, and you reduce the risk of an infected, abscessed wound. Change the dressing twice daily, and if signs of infection arise (the wound is hot, reddened, tender, swollen, oozes foul pus, or a fever is present), then irrigate again, and apply antibiotic ointment to the dressing.
If you know the wound is still contaminated, then pack the wound with gauze dampened with the diluted Betadine® solution, and let it partially dry before removing. Clotted blood, some of the dirt and dead skin will lift off with the gauze (again, this will hurt). Irrigate the wound, and repeat the wet-to-dry dressing process until the wound is clean, then pack open as above, monitoring for an infection.
A hint for monitoring infection: A normally healing wound is often red, slightly swollen and a little tender, so how do you tell when you have a serious infection? Starting with the first dressing change, gently mark the margin of the red/swollen area with a pen. If the area is getting larger the next day, then you likely are dealing with infection and need to consider irrigation and antibiotics, if available. Even severely infected wounds can heal, so be sure to treat the whole patient, not just the wound: sufficient fluid intake and easily digested foods are important during long term care.
So, why Betadine?
- It kills everything. Viruses, gram negative and gram positive bacteria, fungi and even protozoa. Even iodine-resistant organisms such as cryptosporidium go down with enough contact time.
- It is versatile: You can use is as a surgical skin prep, a simple topical antiseptic for scratches and abrasions, diluted as an irrigation solution for severe wounds, a dental irrigant following tooth extraction, and even as a water purification agent for lake or stream water (8 drops per quart of clear water, with a contact time of 30 minutes at room temperature).
- It stores well, unlike most antibiotics. The manufacture’s published shelf-life is three years at room temperature: in practice, Betadine lasts much longer. The bottle in my medicine cabinet “expired” in 2007, but it is still effective. So long as free iodine is released, the antiseptic qualities of Betadine® remain. This is easily tested by mixing a drop or two of Betadine with a paste of flour and water: if the mixture turns deep purple or blue-black, then free iodine is present, and the Betadine® is still effective as an antiseptic.
- It is cheap. A gallon of Betadine® sells on-line for less than $50, and an 8 oz bottle for about $5. Unless you plan to do daily surgeries at home, skip the gallon bottles and buy multiple small bottles that can be unsealed one at a time – this will reduce the chances of contamination and potentially increase shelf life. The hard to find one-ounce bottles are great for pocket kits.
- It is safe. Allergic reactions to iodine or Betadine® are rare, and typically no worse than a minor skin rash. The irritant effects can be avoided by ensuring that Betadine doesn’t dry on tender skin, especially in skin folds such as the inside of the thigh or elbow.
Disclaimer: The author is not a physician. He is an avid outdoorsman and wilderness first aid instructor.