Minor burns
In this category are first- and second-degree burns. These should be treated in the same way as severe burns (see below).
For information about sunburn, see Sunburn.
Severe burns
In this category are third-degree burns, electrical burns and chemical burns. With the last two, you need to make sure the casualty is moved away from the source of the burn before you begin treatment. And be aware that chemicals can still burn even when watered down, so take care to avoid the water wash-off from your treatment.
Action: Cool the burn to stop the burning process. Flood the burn with water for at least 10 minutes, but watch the casualty’s body temperature. If they start to shiver, it will make the inevitable shock worse.
Remove clothing and jewellery around the burn. If anything is stuck to the burn, cut it down as small as possible and leave it there.
Do not burst any blisters. Do not use any type of cream, lotion or potion, even if it says ‘for burns’ on the packaging.
Take clean plastic, preferably something like cling film as that is sterile on the interior of the roll, and attach it to the burn to prevent infection. Use tape to stick it in place, but make sure it’s stuck to the plastic, not to the skin, as the burn may be bigger than it first appears. If the burn is on a foot or hand, you can encase it in a plastic bag, or even a condom if it is comfortable and doesn’t cut off blood circulation. If there is nothing you can use as a plastic dressing, take something non-sticky, such as a sterile dressing, and use that instead.
The casualty will need to replace lost liquid and salt, so dissolve about half a non-heaped teaspoonful of salt (and a tablespoonful of sugar too, if possible) per pint (500 ml) of water and keep giving it in small doses. However, if there is any chance they could be on an operating table in the next few hours, give them nothing but sips of this liquid.
Warning: A casualty with severe burns will almost definitely go into shock before long because of the fluid loss (see Shock). You need to get them to hospital as soon as possible.
See also Fire.
White phosphorus burns
During Israel’s war against Hamas in Gaza in 2009, dozens of civilians were hit with white phosphorus. This chemical is meant to be used for creating a smokescreen during an attack and it is not supposed to be used directly as a weapon. It burns on contact with air and can be used to set areas on fire, but if it comes into contact with skin, it will set the skin on fire. Even if it doesn’t hurt anyone at first, it lies on the street and around homes, where children can play with it, and causes a lot of damage after the daily battles are done. There are very few doctors who have had to deal with the effects of white phosphorus on a daily basis. As the head of the burns unit in Al-Shifa hospital in Gaza, Dr Nafez Abo Shaban has the dubious honour of being an expert on it. He recommends the following treatment:
‘Cover the affected area with a piece of cloth soaked in water to cut off the supply of oxygen. The phosphorus will burn as long as it is exposed to the air, and the burn will go deep down to the bone. In an ideal situation, the patient should be taken into an operating theatre to remove all the phosphorus. This will stop the burning and also enable the medics to remove the dead tissue.
‘Some with massive burns develop systemic complications, such as an imbalance of salts in the blood. This can be fatal, so they should be admitted to an intensive care unit.
‘If there is no hospital nearby, scrape off the phosphorus with a piece of wood, not metal. This will be very painful as the chemical will be stuck to the patient. In some cases it will rip the flesh away. The patient needs to be aware and supported through the painful process. Once this is done, treat it as a normal burn.’
Chest wound
A penetrating injury to the chest can pierce the lung, which then starts dragging air inside (for this reason it’s called a sucking chest wound). This causes the lung to shrink and the cavity around it to fill with liquid. The result is known as a collapsed lung, and it can endanger the other lung as it gets worse.
First signs: Blood frothing out of the wound. Breathing shallow and laboured. Blood may be coughed up. If conscious, the patient will be panicky, and their skin will become grey-blue.
Action: Calm the patient and ask them to hold their hand over the wound to seal it. Place a sterile dressing over the wound and tape it on two sides. Next take a square of airtight material – a piece of foil or a plastic bag would work – and place over the dressing, taping it tightly on three sides of the square so that it doesn’t get sucked inside the wound. This will not allow air in through the wound, but it will allow air out.
Cholera (see Fever and Dehydration)
People who smoke need to be particularly careful around infectious diseases. Smokers always catch cholera far more quickly than others because they are constantly bringing their hand to their mouth. Samantha Bolton
Choking
First signs: Inability to speak, noisy breathing, persistent cough, blue tinge to lips and nails because oxygen is depleted.
Action: If breathing is not obstructed just encourage them to keep coughing. If it is, first check the mouth for any obvious obstruction, such as vomit. Then, supporting the chest of the casualty with one hand and leaning them slightly forwards, give up to five hard hits between the shoulder blades with your other hand.
With children up to the age of about seven, tilt them downwards and pat rather than hit on the back, their head tipped down so they don’t choke again.
If the hitting or patting doesn’t work, move onto the Heimlich manoeuvre (see The Heimlich manoeuvre).
Collapsed lung (see Chest wound,)
Concussion
A bang to the head can lead to a mild brain injury.
First signs: Headache; balance problems; looking at the light is painful; vision may be affected; possible ringing noise in the ears; seizures may occur; confusion, forgetfulness and speech problems are common. The casualty might show an altered mood, particularly slowness and lack of energy.
Action: Seek urgent medical attention if you or anyone else experiences any of the symptoms above. Meanwhile, rest and monitor vital signs. Symptoms can last for weeks and lead to other brain problems if left untreated.
Dehydration (see Dehydration)
Delivering a baby
I used to help with the lambing at a farm near my granny’s place every year. It always amazed me how easily the sheep seemed to get up and carry on with their day immediately after giving birth, and how simple the process was in most cases. I have neither given birth nor helped any human give birth, but the following information, though basic, has been checked and double-checked by experts.
First signs: Lower back pain, regular muscle contractions, bloody discharge from the vagina are all signs of impending childbirth. When a woman’s waters break, it might look like she has wet herself, but the fluid comes from the amniotic sac inside the womb. Despite what you see in the movies, the waters breaking before labour begins happens in only 13 per cent of cases. It can also be just a tiny bit of unexpected fluid rather than a dramatic gush. By then the expectant mother is likely to know what is happening, and she will make sure that you do too.
Action: I am told that if the birth is sudden and unexpected, it is likely to happen naturally. You just need to offer support as the burden is all on the mother-to-be at this stage. The only things you have to do are to find a clean space, clean towels or clothing, a sterilized blade and a piece of sterile string (boil it if necessary, except if it is plastic, in which case you will have to soak it in a mild bleach or sterilizing solution).
Let’s break it down…
Stage 1: Early labour
The initial contractions are getting the baby into the right position for birth. They will become stronger and more frequent as time passes. It might take hours for the baby’s head to work its way down to the right place. There are many ways to help the labouring woman:
• Find the position in which she
is most comfortable during her contractions – sitting, kneeling, lying, surrounded by cushions or in a bath of clean water.
• Calm her in any way you can – with words, music or touch.
• Make sure she is breathing deeply during her contractions or she might pass out.
• You can massage her back if it helps. Use ice cubes to cool her down if you have them, or just wipe perspiration away with a cool towel.
• Do not give the mother anything to eat. Tiny sips of water are best.
Stage 2: Labour and birth
The pushing begins naturally, when the body prompts it. Help the mother to find a comfortable position: she can sit as upright as possible with her legs apart, or lie on her side with her knees drawn up, or crouch as if she is squatting to pee. Whichever way she chooses, she will need something clean underneath her – plastic sheeting will do if that’s all you have – and, if she would feel more comfortable to be partially covered, something to go over her knees.
• At this stage the mother needs to pant – short open-mouthed breaths. She needs to keep breathing.
• She should not push during contractions.
• Do not pull the baby’s head or shoulders during delivery. Support the head and shoulders as they emerge, and be prepared for the baby to be very slippery. There is a reason why rookie doctors talk about ‘catching babies’.
• If the umbilical cord is around the baby’s neck, gently unwind it. If it gets broken, the baby risks losing vital blood.
• If the baby emerges feet first and the head is stuck in the birth canal for more than three minutes after the shoulders have come out, you can pull very gently, never with any force, by placing your thumbs over the baby’s hips. As you do this, rotate the baby first clockwise then anti-clockwise a few degrees to free the arms.
• If the mother poos during the birth, which sometimes happens, you should wipe it away, front to back.
Stage 3: Immediately after the birth
• Take the baby and hold it upside-down while supporting its head. This allows the fluid to drain from its mouth.
• When it cries, wrap it in something warm and put it on the mother’s chest. If it is not crying or does not seem to be breathing, you need to begin CPR after two minutes (see CPR for babies).
• About 10 minutes after the baby is born the afterbirth is expelled – your work is not done until that is out. Retain this for later so that the doctor can assess if everything has come out.
• If you are expecting help, do not cut the umbilical cord yourself: wait for the professionals. If not, you need to take your sterile string and tie it tightly around the cord 15 cm from the baby’s tummy. It needs to be tight or the baby will lose blood. Tie another knot 5 cm from the placenta, then use your sharp, sterilized blade to cut between the knots. Put a dressing on the cord until it stops bleeding. Tie another piece of string about 10 cm away from the baby’s tummy.
• Now you need to look after the mother. She will need water, sugar and rest. If the bleeding or pain is severe, you need to treat her for shock (see Shock).
Warning: If you are a pregnant woman travelling somewhere dangerous or remote, make sure you have everything you need to give birth – string to tie the umbilical cord, a fresh blade to cut it, and something warm to wrap the baby in.
Diabetes
If someone in the group you are working with has diabetes, you need to know about it. Not telling you is irresponsible; at the very least, it may explain the person’s occasional grumpy mood and needle marks on their body. They should also brief you on how to treat them if anything goes wrong.
If you are in a war zone or a dangerous place, you might get separated, so they should have the fact that they are diabetic clearly written on their helmet and body armour. They should also be wearing a medical warning bracelet (see Recovery position for adults and children).
Diabetes is all about blood sugar levels, either too much (hyperglycaemia) or too little (hypoglycaemia). You need to know the signs in case they have their first-ever experience of either when you’re together. Because it can be difficult to decide which they have, the safest immediate treatment is sugar. Strangely, it has little effect on a hyperglycaemic person, but will get a hypoglycaemic individual back on the road to recovery. That’s why diabetics often travel with sweets in their pockets. If they have type 2 diabetes (i.e. they have some control over their sugar levels but not much), sweets might be all they carry, so don’t always expect to find an insulin pen.
First signs of hyperglycaemia (high blood sugar): Quickened pulse; no sweating; rapid breathing and thirst. Their breath may smell like nail varnish or pear drops. As it gets worse, they will become sleepy and eventually fall unconscious.
Action: Use an insulin pen – place it against their thigh or into the fat of their stomach and press down on the end like a ballpoint pen. Insulin is the chemical normally produced by the body to regulate blood sugar, so it should help to bring them round. Hurry them to a hospital.
First signs of hypoglycaemia (low blood sugar): Sweating; rapid pulse; short temper; weakness and hunger. They may appear drunk and will get less and less responsive before eventually falling unconscious.
Action: Sit them down and feed them sugar and liquid – orange juice or a fizzy drink is ideal. Once they have recovered they can decide when they should have a dose of insulin, usually when it was next due in any case.
Find their glucose-testing kit and help them to use it so you can check you are not giving them too much sugar.
If they fall unconscious before you can get enough sugar inside them, take them to a hospital as soon as possible.
Diarrhoea
I don’t know how many times I have gone to a place off the trodden pathway secretly hoping for a touch of diarrhoea. It seems like a good way of getting rid of that last bit of tummy. But try as I might – drinking tap water in Delhi, eating meat on a weeklong boat trip in Vietnam, consuming fish in Ladakh – it never seems to come when you want it.
I have since learnt my lesson. It started with salmonella on a boat holiday in Turkey – the loos flushed only once every night, so I had to fling myself into the water in the dark to avoid embarrassment. On another occasion I had terrible tummy problems on a 16-hour journey from Basra to Amman that could have got me killed. I was supposed to be invisible in case our presence at a petrol station or food stop alerted hijackers further up the road. But I kept having to run out to use the loo at each place we passed. It was usually a fetid, stinking hole in the ground, with no door and a grinning audience. But the most painful couple of days I ever spent was two hours north of Timbuktu, running to and from a tent in the Sahara. I woke up naked on a sand dune after passing out on a dash to a private corner of the desert to find a Tuareg guard smiling down at me, offering me his hand.
Poo stories are brilliant, but I wouldn’t encourage you to go after them.
Action: Find any way you can to make the person comfortable and give plenty of liquid. Avoid all dairy produce, as that will aggravate the stomach. When they can start eating again, try simple foods – pasta, bread, biscuits and potatoes – before moving onto a normal diet. If the condition is very serious, the loss of fluid could lead to shock (see Shock). Seek medical assistance. A doctor will be able to prescribe drugs to help relieve the pain.
Look out for bloody diarrhoea – the chances are that it’s dysentery, which requires antibiotics. Seek urgent medical assistance. In the meantime, keep well hydrated with whatever liquid you can keep down. Water with a tablespoon of sugar and half a teaspoon (non-heaped) of salt per pint (500 ml) will work.
Monique Nagelkerke advises: ‘Do not take the usual anti-diarrhoea remedies to stop bloody diarrhoea as this could result in bowel damage.’
Dislocated shoulder or finger
First signs: Obvious deformity, with the bone protruding under the skin where it shouldn’t be. The muscles will spasm and hold it there unless it is put back.
Action: Immobiliz
e the shoulder or finger (see Immobilizing fractures) until you can get proper medical help. It is dangerous mending a dislocation as nerves or muscle can get stuck in the joint. It is also incredibly painful.
If you must tackle the dislocation yourself, this is how you do it. Put your foot in the person’s armpit and pull on the arm until the shoulder clicks back into place. For a hand, pull on the finger until it clicks back into place. Once the dislocated part is back in place, immobilize it (see Immobilizing fractures) and let it rest for some time.
Drowning
Action: Carry out ABC (see ABC – the first checks) until the casualty’s vital signs are normal again. Put them in the recovery position (see Recovery position for adults and children) and start to warm them up. Even if they appear to be fine, they will need proper medical treatment because any residual liquid in the lungs will cause irritation and lead to the airways becoming narrowed a few hours later.
Warning: Drowning can also lead to hypothermia (see Hypothermia).
Dysentery (see Diarrhoea,)
Electrocution
If someone has been electrocuted, don’t touch them. You need to turn off the power first – at the mains – not the dangerous plug. If that is not possible, you need to move the source of the power away from them, or them away from it, before you can start treatment. Use a non-conducting tool to help you: a rope to pull the patient away, or a piece of wood, a plastic box or even a book to push them. Once they are safely away from the source of their injury, begin ABC and all other necessary treatment.
How to Avoid Being Killed in a War Zone Page 13
