How would you treat this? (NSFW)

[honeybadger65]

What you are looking at is a negligent discharge to the foot with a 45.

I was wondering what you guys would do to treat something like this:







I notice that there is exposed bone. Can you just throw some topical antibiotic ointment on it with wet to wet dressings or would something like a skin graft be required?

As always, thanks!

(This did not happen to me, and I do not know who it happened too)

[Shiloh]

I'm no first aid expert, but...

1) - Stop immediate bleeding
2) - Go to the F***ing ER

[lowjohn19]

I'm no first aid expert, but...

1) - Stop immediate bleeding
2) - Go to the F***ing ER

Yup. That's not a bandaid kind of injury.

[honeybadger65]

I'm no first aid expert, but...

1) - Stop immediate bleeding
2) - Go to the F***ing ER

Yup. That's not a bandaid kind of injury.

Lets say there are zombies in the ER.

Now what?

[Shiloh]

I'm no first aid expert, but...

1) - Stop immediate bleeding
2) - Go to the F***ing ER

Yup. That's not a bandaid kind of injury.

Lets say there are zombies in the ER.

Now what?

Next course of action- Wonder how I didn't notice the crowds of shambling undead while on the way to said ER.

[Caenus]

Please tell me that is not your toe and you're waiting for us to tell you what to do...

I'd wrap it and then go to ER.

Then keep the toe and put it in a jar and set it next to me every time I went to the range as a reminder...

[Caenus]

Also, thanks for the pic.

Docdredd, thanks for the answer to that. Because I didn't notice the debriding means I obviously wouldn't try anything on my own.

I'd keep wearing the boot though.

[duodecima]

What docdredd said. If there were zombies in the ER, I'd be praying.

Great link doc!

[PotatoMuncher]

Well, first thing I would do is throw that happy ass in the car and get ourselves en route to the ER TIME FRIGGIN' NOW.

While en route, I'd just wrap that sucker up with some Kerlix and keep some solid pressure on it. From there, it'd require a ton of surgery, antibiotics and pain killers. That's gunna feel like like its on fire after a day or two.

[honeybadger65]

Thanks for the responses so far!

Would leaving the toe on and allowing for secondary closure with antibiotic therapy work? I would assume there would be some pretty massive scar tissue there.

What about the bone assuming the periosteum is intact? Will the wound heal if the bone is exposed?

Also, is a skin graph an option or is the chance of infection too great that it is just better to leave it open.

[abelru]

There are so many issues that need to be treated in that pic that it would be a 3 page post if we tried to address

Agree, but there are a few that immediately spring to mind which may be worth mentioning.

AND THIS IN NO WAY IS ME SUGGESTING/ADVOCATING/ADVISING that this person or anyone else use any of the below mentioned material as a substitue for getting proper medical attention by a physician, at a hospital. Simply speaking in loose academic terms and using these pictures as an example.

- in the second pic, (difficult to say for certain) there doesn't appear to be a cortical violation of the bone. If no periosteal involvement, might be GTG with flap coverage or marginal minimization, although the wound characteristics would suggest this approach would be of little help.
- distally, the toe would appear to have well preserved vascularity (again, difficult to determine from pic alone) which would improve the chances of salvage.
- GSW's can be a mixed bag with regard to level of contamination. If no foreign matter is introduced into the wound cavity, and surrounding tissue trauma is minimal, may heal with relatively minimal intervention. Having said that, this wound is, and I quote, "juuuuuuussst a bit outside".
- dovetailing with the above, shoes notoriously harbor pseudomonal sp.
Pseudomonas+bone and deep soft tissue = No bueno

[abelru]

...and I would also advise against wearing thongs for a while

[Creepinjeep]

I'd do away with the toe as well. Less area to treat.

[duodecima]

So what's everybody think they're taking this toe off with, btw? I don't keep sterile surgical stuff for that at home, nor would I be really comfortable doing it, it's not something I'm experienced in. (Not saying it's not the best course of action, it may well be - but it's not a simple course of action at all...)

[PotatoMuncher]

So what's everybody think they're taking this toe off with, btw? I don't keep sterile surgical stuff for that at home, nor would I be really comfortable doing it, it's not something I'm experienced in. (Not saying it's not the best course of action, it may well be - but it's not a simple course of action at all...)

A rubber band, some Tylenol and a metallic spoon aughta do the trick.

[hatchtrikk]

How would one go about amputating a toe?

Sterilize, chop, cauterize?



I've seen nastier things before, but that pic really makes my butthole pucker

[DialM]

How would one go about amputating a toe?

Sterilize, chop, cauterize?



I've seen nastier things before, but that pic really makes my butthole pucker

One or two more .45 rounds ought to do the trick.

[Kutter_0311]

...may heal with relatively minimal intervention. Having said that, this wound is, and I quote, "juuuuuuussst a bit outside".

...and I would also advise against wearing thongs for a while

So, gauze and Tevas on that foot, and keep an eye out for infection, gangreen, the usual nastiness...

This is one of those show-stoppers in the ZPAW. Not only makes running damn-near impossible, but will kill you all by itself without antibiotics and, most likely a surgeon.

So, don't do what that guy did...

[JesterODX]

Damn. In a PAW situation, I'd probably have to go with amputation. And pray to God I had good antibacterial stuff to get it healed up... I mean there is always cauterizing the wound but thats normally to stop bleeding, right???


This is a darn good thread to remind us like myself we need to get some field medic/surgen manuals for just incase.

I've got a little of first aid training, but most of our stuff is still based on the fact the patient will get to the hospital before you have to start thinking about gain green.

[jpg323s]

Percocet. A good cleaning CHG scrub or Iodine scrub, Triple Antibiotic ointment with frequent bandage change. Antibiotics - different depending on where you were & exactly what caused it.

The above is all assuming you are unable to go for professional medical care. Absolutely NO dermabond/super glue or skin graft unless it's done by a professional - the reason for the skin graft should be obvious; the reason for the dermabond/super glue - you'll be sealing any contaminants (bacteria, lead, etc) in the wound - it's easier and safer for the body to push these contaminants out than to try to get rid of them internally.

I would not amputate if you can still move it - regardless of sensation - again, assuming you're doing this yourself.

Also, hopefully you have the percocet (or sub) and antibiotics without professional medical care.

[duodecima]

So what's everybody think they're taking this toe off with, btw? I don't keep sterile surgical stuff for that at home, nor would I be really comfortable doing it, it's not something I'm experienced in. (Not saying it's not the best course of action, it may well be - but it's not a simple course of action at all...)

The question was how you would treat it barring no outside medical aid. I have a sterile supplies and have done one amputation in the past ( it was a finger not a toe but much of the theory of care is the same).
I would not be Comfortable doing it either BUT if its the only choice between getting it treated or sending them on their way then I would do my best.

Yep, I've done exactly one finger myself, also. But the tool we used to do that, I don't have sterile and at home. I was contemplating what tools I could scrub the shit out of and then run thru the pressure canner. I was wondering if anyone did have that kind of thing sterile at home.

I do have lidocaine, I was thinking this may be why the docs in all the cowboy movies drank so much, when you had to listen to your patients screaming in pain, bucking the ropes&people holding them, and still focus on doing your job.

It's the decision making principles and experience applying them- when and why, exactly, is it best to amputate? (which is why I love your link!!!) - that I feel I lack the most, and there's no real room for error in that situation.

[tookieblueeyes]

As a nurse... I would suggest stop the bleeding 1st. Coterize it if you have to. Find a way to the ER next and let them deal with it. The toe may be salvagable, you may not need to amputate it but it does look pretty horrid. If you were far from anywhere where you could get help and you had to treat it yourself then stop the bleeding any way you see fit and keep it elevated as you keep applying wet to dry dressings and keeping the wound clean. If needed maggots can clen off the bad meat of the toe if it were to become infected but this is a total jeramiah johnson scenario if you had to work it out yourself in a doomsday scenario where there was no help to be had, but if it isn't a doomsday scenario and you could find a way to a hospital that would be the ticket to take.

[abelru]

Yep, I've done exactly one finger myself, also. But the tool we used to do that, I don't have sterile and at home. I was contemplating what tools I could scrub the shit out of and then run thru the pressure canner. I was wondering if anyone did have that kind of thing sterile at home.
I do have lidocaine, I was thinking this may be why the docs in all the cowboy movies drank so much, when you had to listen to your patients screaming in pain, bucking the ropes&people holding them, and still focus on doing your job.
It's the decision making principles and experience applying them- when and why, exactly, is it best to amputate? (which is why I love your link!!!) - that I feel I lack the most, and there's no real room for error in that situation.

A Rongeur would be money for nipping back the bone. If none were available, I think I'd opt for a shit-ton of anesthesia (Bier block the leg?) and roll with an Exacto saw or wire saw. Both of which are easily procured and cheap. I know of a few institutions that use wire saws for long bone amps, and they work very well. I would assume that if you were able to secure the distal tip of the toe, a wire saw would fit the bill beautifully.

I would still assert that this injury is likely not nearly as catastrauphic as most here seem to be asserting. Even in a hypothetical ultra-austere environment, using the sound principles of good wound care could (conceivably) result in an acceptable outcome. Perhaps not optimal, but acceptable. Food for thought, YMMV, and all that jazz...

[dallas]

Percocet. A good cleaning CHG scrub or Iodine scrub, Triple Antibiotic ointment with frequent bandage change. Antibiotics - different depending on where you were & exactly what caused it.

The above is all assuming you are unable to go for professional medical care. Absolutely NO dermabond/super glue or skin graft unless it's done by a professional - the reason for the skin graft should be obvious; the reason for the dermabond/super glue - you'll be sealing any contaminants (bacteria, lead, etc) in the wound - it's easier and safer for the body to push these contaminants out than to try to get rid of them internally.

I would not amputate if you can still move it - regardless of sensation - again, assuming you're doing this yourself.

Also, hopefully you have the percocet (or sub) and antibiotics without professional medical care.

Be careful with the neomycin. You could get enough systemic absorbtion to kill the pts kidneys and ears. Betadine and sugar could be an alternative if no medical care is available.