When fire attacks...or why does Jimmy look crispy?

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When fire attacks...or why does Jimmy look crispy?

Post by LowKey » Wed Sep 30, 2009 2:38 pm

Well, it's wintertime in the PAW. Lots of lovely snow, strong cold winds, lovely snow, bare trees, snow, long nights, snow, and foods getting harder to find in all this....snow.
As an added bonus, running on short rations makes it harder for your body to maintain it's temperature. Partially due to loss of body fat and it's insulating properties, but primarily due to fewer calories to metabolize for heat. As a result you and everyone in your group are reluctant to crawl out of your sleeping bags each morning, and hate the moment when you open your tarp shelters flap door.
Your pal Jimmy thought he was going to be slick last night and used an old coffee can and a section of sheet metal rolled into a tube to make a wee little stove to try and keep himself warmer. He even found a few lumps of coal along the abandoned rail road tracks you've been following. He was smart enough to know to break them up a bit and wait until he had some good embers in his stove before adding them and going to sleep. Unfortunately he wasn't smart enough to think about his tarp shelter.....his blue plastic tarp which until a week before was covering a pile of scrap lumber in his neighbors back yard.
Well, as Jimmy slept...warm for the first time in 5 days, he had lovely dreams of lying on the beach in the sun in the tropics. Slowly the dream changed. The sun grew hotter, the air drier, and for some reason the wind was making a roaring sound......ohhh shit! Jimmy just woke up, far to hot and having a hard time breathing or seeing anything but a sooty orange flame. His Frankenstein stove's chimney pipe had set fire to his tarp. In a panic to not let his stuff burn up he tried to put the fire out by swatting it with his coat, and earned himself an arm full of burning plastic.

So, now that you've tackled Jimmy after he ran out of the remains of his burning tent waving his arm in the air and looking like a performer at a Hawaiian Lu-au on crack, how the hell are you going to deal with his arm??
You stuffed it into the snow, figuring that
a)-It would put out the flames
b)-It's cold and that's got to feel good to Jimmy right about now, and
c)- You use what you've got....and you have lots of snow. Dammit.

With mixture of burns from 1-4th degree (the medical pro's keep changing that stuff on me...I remember there only being 1-3. Crap I'm old) how are you going to treat the burn?
How are you going to get the plastic out/off?
How much water will Jimmy need to deal with the fluid loss associated with burns?
How can we limit infections? We don't have a lot of antibiotics.
How do we bandage the burns to protect them as they start to heal?
What do we need to look out for? Do we need to wash the burn every day until the cooked flesh is completely gone?
Is the burn at a higher risk for frostbite/freezing due to the cold?
What should we do to keep scar tissue at a minimum so as to not loose range of motion in the arm?

What are we missing? I mean aside from a medivac to a Burn Center...... :roll:
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Re: When fire attacks...or why does Jimmy look crispy?

Post by whisk.e.rebellion » Wed Sep 30, 2009 2:43 pm

You know what? I've got the same response to all of your theoreticals...

In no particular order:

* Puke
* Freak out
* Give him something for the pain
* Drink heavily
* Assure him he's going to be okay even though he'll be dead within a week
* Find a doctor
* Drink heavily
* Hope he's not going to go zombie on me (we're bugging out from zombies, right?)
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Re: When fire attacks...or why does Jimmy look crispy?

Post by LowKey » Wed Sep 30, 2009 3:07 pm

whisk.e.rebellion wrote:You know what? I've got the same response to all of your theoreticals...

In no particular order:

* Puke
* Freak out
* Give him something for the pain
* Drink heavily
* Assure him he's going to be okay even though he'll be dead within a week
* Find a doctor
* Drink heavily
* Hope he's not going to go zombie on me (we're bugging out from zombies, right?)
:lol: :lol: :lol:
Believe it or not, I'm right there with you :lol:
You missed the second bout of puking though :wink:
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Re: When fire attacks...or why does Jimmy look crispy?

Post by DannusMaximus » Wed Sep 30, 2009 3:23 pm

Well, one nice thing about deep burns is that they come pre sterilized...

The killer is what to do with the weeping, unprotected flesh and muscle after the skin has been repopulated with mother natures critters.

Now, I'm not a board trained burn therapist or surgeon, BUT.....

Irrigate the burn. A lot. This will cool and clean the damaged skin and start getting some of the dead char and plastic bits out of it. At some point Jimmy is probably going to pass out from the pain, so that makes it easy to do the next step, which is clean (not SCRUB) the burned area with soap and water. You gotta get this injury clean and keep it that way, since the natural protective layer (i.e., skin) is goine.

Once the initial irrigation is done, you're simply dealing with a large open wound. That is all. You will need to remove as much of the melted plastic and charred skin as possible - - ideally you want all the tissue that is left to be living stuff, not 1/2 living and 1/2 char. You may not be able to do this intially, since they can't do it in burn centers, either. That's why there is periodic debridement of the injury instead of one, massive initial debridement and that's all.

Anyhoo, once you've got the initial irrigation and cleaning done, the next step is covering the injury with dry sterile dressings and wrapping it all up to protect the dressings. You'll need to periodically change the dressings to help fight infection and visualize the wound to see if granulation (healing) of the tissue is starting). Examine, clean, debride if necessary, rewrap, repeat. At some point it will be important for Jimmy to start attempting to use the limb, or at least start doing some range of motion exercises so it remains flexible. In a severe burn, untreated with skin grafts, you're going to get formation of much deep and surface scar tissue, which will prevent Jimmy from returning to full range of motion and use (probably). I don't know that there is a way around this. In the pre PAW world we use skin grafts and elasticized hosiery to try and prevent excessive scar tissue formation, but that likely won't be possible in this scenario.

Fluid management is going to be important. Jimmy is going to HAVE to drink water and other beverages often, and try to augment his protein intake if you've been rationing meat, etc. Healing wounds requires extra protein - - you may need to dip into your last cans of SPAM if you want him to do better.

Give antibiotics if you've go them. Watch for infection of the wound or signs of sepsis and treat to the best of your ability.

Only let Jimmy wear Nomex overcoats from this point onward... 8)
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Re: When fire attacks...or why does Jimmy look crispy?

Post by Apache » Wed Sep 30, 2009 3:37 pm

99% he's going to die. Shoot him when infection takes over. Consider amputating arm if any surgical skills available. A small surgical wound lot less of a risk that an arm load of burnt necrotic flesh. Leave it and it will get infected. He will die.
crypto wrote:So, yeah, well be fucked when theres no more antibiotics, but so will all the old people without boners.

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Re: When fire attacks...or why does Jimmy look crispy?

Post by thorian » Wed Sep 30, 2009 3:40 pm

Cool the injury for 1-2 minutes treat for shock.

I believe the formula for fluids to a burn patient is if you have a paramedic an IV and the ability to administer it, Lactated ringer's or saline 2-4 ml/kg/%burn/24 hours - given in the first 8 hours post-injury. Using the palmer method the palm of the Patients hand is 1%

After day 1 1 ml/kg/% body surface area burn/day

If jimmy does not have a circumfriencial burn gently removing the burnt in plastic and clothing and keeping him dry and sterile if he survives 4 weeks he should be ok providing you can keep him hydrated and out of burn shock

If Jimmy's entire arm is burnt completely around Jimmy may die with in 2 days due to compartment syndrome when the swelling from his harm is killing off all the blood flow to the rest of his arm. when the swelling goes down Blammo instant septic shock.

With out a Doctor he will probally die anyway perhaps amputation may be the mest for him in this situation if he shows signs for compartment syndrome.
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Re: When fire attacks...or why does Jimmy look crispy?

Post by LowKey » Wed Sep 30, 2009 11:42 pm

Is the burn at higher risk of damage from frostbite/cold?
I ask because, IIRC, most burn injuries occur from fires in the winter. If someone has just burned down their shelter and also suffered a severe burn he may not be as protected from the elements as we might wish.
I have a sinking feeling that the answer for Jimmy isn't going to be a good one.....





*note to self- get nomex pajamas*
Last edited by LowKey on Thu Oct 01, 2009 3:41 am, edited 1 time in total.
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Re: When fire attacks...or why does Jimmy look crispy?

Post by dukman » Thu Oct 01, 2009 3:32 am

Find some maggots and let them start eating the dead flesh. :mrgreen: Too bad they won't be sterile, so he will die anyways. Amputation is probably the best course of action as long as the burns don't also encompass the rest of his body. Otherwise the shock from the amputation might end up being too much for little Jimmy here...
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Re: When fire attacks...or why does Jimmy look crispy?

Post by Kutter_0311 » Thu Oct 01, 2009 3:48 am

I guess I'll add something I didn't notice anyone else throw out there...

Ask Jimmy if he has any surviving next of kin, since he's pretty well screwed...

Then ask Jimmy if he'd like a shot of (your fav booze here) and a bullet chaser. I know I would...
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Re: When fire attacks...or why does Jimmy look crispy?

Post by Risto » Wed Oct 07, 2009 3:53 am

Isn't it considered good netiquette to RTFM (read the effin manual) before posting questions. :wink:

Primary surgery chapter 58.4 "How much fluid does a (burn) shocked patient need"

and

Primary surgery chapter 58.13 "how should the burn itself be treated"

The burn chapter in primary surgery will answer all of your questions, have a look. You'll be surprised how much info you can find there.

I would definitely try skin grafting before having to amputate anyone's arm. It's not that difficult, And there is nothing to lose if you try. If the graft won't take or serious infection occurs, then amputate...

See: Primary surgery chapter 57 "skin grafts and flaps"

But seriously, these are great scenarios to think about and discuss, keep it up. :)

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Re: When fire attacks...or why does Jimmy look crispy?

Post by DannusMaximus » Wed Oct 07, 2009 10:29 am

Risto wrote:Isn't it considered good netiquette to RTFM (read the effin manual) before posting questions. :wink:
What a dull website, though, if everybody just posted links to online manuals... :roll:

OP is trying to stimulate conversation, get people thinking about PAW medicine (in an age in which we all pretty much take modern medicine completely for granted), and get some advice and suggestions from people who may have experience with the scenarios he's presenting.

Yes, you can get the information from reading texbooks or online postings.

Yes, that's pretty damn boring.

No, that doesn't get anybody else involved.

YMMV.
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Re: When fire attacks...or why does Jimmy look crispy?

Post by LowKey » Fri Oct 09, 2009 1:45 pm

thorian wrote:
If Jimmy's entire arm is burnt completely around Jimmy may die with in 2 days due to compartment syndrome when the swelling from his harm is killing off all the blood flow to the rest of his arm. when the swelling goes down Blammo instant septic shock.

With out a Doctor he will probally die anyway perhaps amputation may be the mest for him in this situation if he shows signs for compartment syndrome.
What about cutting some of the burned tissue to allow it to swell without cutting off the blood flow?
I realize this would increase the chances of infection, but seeing as amputation is already a high likelyhood wouldn't trying this first give him a better chance of keeping the arm if we manage to keep the infection down?
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Re: When fire attacks...or why does Jimmy look crispy?

Post by Apache » Fri Oct 09, 2009 5:25 pm

With no sterile IV fluids, no antibiotics and no painkillers it's amputation or lead!

You wouldn't try skin grafting. The technique is easy but there's high failure rate. Huge infection risk.
crypto wrote:So, yeah, well be fucked when theres no more antibiotics, but so will all the old people without boners.

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Re: When fire attacks...or why does Jimmy look crispy?

Post by Risto » Sat Oct 10, 2009 3:33 pm

Apache wrote:With no sterile IV fluids, no antibiotics and no painkillers it's amputation or lead!
You're quite a pessimist :)

Sterile IV fluids: If you have something to improvise distillation equipment and an accurate scale to weigh table salt, you can make sterile IV fluid.

Large amounts of antibiotics should be included in your medical kit.

Painkillers are not necessary for survival, but are also easy to improvise if you choose your garden plants well...
LowKey wrote: What about cutting some of the burned tissue to allow it to swell without cutting off the blood flow?
That is possible, the procedure is called "escharotomy". See primary surgery 58.18 "sloughs and eschars

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Re: When fire attacks...or why does Jimmy look crispy?

Post by Apache » Sat Oct 10, 2009 6:33 pm

Risto wrote:You're quite a pessimist :)

Sterile IV fluids: If you have something to improvise distillation equipment and an accurate scale to weigh table salt, you can make sterile IV fluid.

Large amounts of antibiotics should be included in your medical kit.

Painkillers are not necessary for survival, but are also easy to improvise if you choose your garden plants well...
In shitty PAW conditions them antibiotics will be used up very quickly. A full pot of 500 Amoxycillin will only give somewhere between 23 and 8 courses (of 7 days) depending what dose rate you take. Most people will get them in packs of 21/28. You would need antibiotics for weeks for a burn of the severity described to heel.

I have used tap water and table salt in cows intravenously with no ill effects. I suspect rigging up a still and accurate scale may be pushing it a bit. Oral fluids would help. I'm not been arsey but you wouldn't have the time, skills or equipment to refine opium!

I think we need to get out of the 'how can we improvise 20th/21st century hospital care' to 'how can we maximise this patients chances of living'. IMO the goal shouldn't be wasting all our precious dressings, antibiotics and time trying to save something that is likely going to kill the patient either way.

Harsh choices will have to be made.
crypto wrote:So, yeah, well be fucked when theres no more antibiotics, but so will all the old people without boners.

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Re: When fire attacks...or why does Jimmy look crispy?

Post by LowKey » Sat Oct 10, 2009 9:48 pm

Would the viability of treatments to preserve a limb increase if you had arrived at your BOL? Such as a modernized cabin, due to improved cleanliness, ect?
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Re: When fire attacks...or why does Jimmy look crispy?

Post by Apache » Sun Oct 11, 2009 4:42 pm

LowKey wrote:Would the viability of treatments to preserve a limb increase if you had arrived at your BOL? Such as a modernized cabin, due to improved cleanliness, ect?
I think the biggest issue would be the availability of supplies! You can't order more, you have a finite amount! They need to be rationed if they are the only dressings/antibiotics/painkillers/duct tape you are ever going to have!
crypto wrote:So, yeah, well be fucked when theres no more antibiotics, but so will all the old people without boners.

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Re: When fire attacks...or why does Jimmy look crispy?

Post by LowKey » Mon Oct 12, 2009 3:41 am

Apache wrote:
LowKey wrote:Would the viability of treatments to preserve a limb increase if you had arrived at your BOL? Such as a modernized cabin, due to improved cleanliness, ect?
I think the biggest issue would be the availability of supplies! You can't order more, you have a finite amount! They need to be rationed if they are the only dressings/antibiotics/painkillers/duct tape you are ever going to have!
Okay, I get that.


How about the viability of improvised antiseptic (I'm guessing that's what this would be...).

I seem to recall years ago reading that in Roman times they would often scrape copper or brass shavings into a bowl and add vinegar. After setting long enough to corrode they would use the liquid to disinfect and clean wounds.
I have ZERO knowledge if this would do anything to prevent infection, or even if it would be harmful. This is, after all, something done over a thousand years ago by a people who used lead salts to sweeten their wine :shock: ....
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Re: When fire attacks...or why does Jimmy look crispy?

Post by LowKey » Mon Oct 19, 2009 5:36 am

Anybody?

Behuler?
Behuler?
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Re: When fire attacks...or why does Jimmy look crispy?

Post by Apache » Mon Oct 19, 2009 4:50 pm

LowKey wrote:How about the viability of improvised antiseptic (I'm guessing that's what this would be...).

I seem to recall years ago reading that in Roman times they would often scrape copper or brass shavings into a bowl and add vinegar. After setting long enough to corrode they would use the liquid to disinfect and clean wounds.
I have ZERO knowledge if this would do anything to prevent infection, or even if it would be harmful. This is, after all, something done over a thousand years ago by a people who used lead salts to sweeten their wine :shock: ....
No - don't do this! Antiseptics continually applied damage the new heeling cells and delay heeling.

He's dead by now from sepsis. You should have amputated when I said.........
crypto wrote:So, yeah, well be fucked when theres no more antibiotics, but so will all the old people without boners.

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Re: When fire attacks...or why does Jimmy look crispy?

Post by Redbad » Sun Oct 25, 2009 8:40 am

I hate to say this, but should you be investing all of your scarce medical resources on someone whose long term chances of survival are minimal?

Clean the wound, cover the wound, and keep Jimmy as comfortable as possible until nature takes its course. Save your resources for those who can be saved. Triage sucks and black tagging a living person who you have a relationship with really sucks but if your resources are limited you have to make tough decisions.

If there is a burn center available, take Jimmy there ASAP.
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Re: When fire attacks...or why does Jimmy look crispy?

Post by Jorian » Mon Oct 26, 2009 5:08 pm

Redbad wrote:I hate to say this, but should you be investing all of your scarce medical resources on someone whose long term chances of survival are minimal?
I'm sorry you hated to say that. But thanks - it's all I was thinking while reading the whole thread. :mrgreen:

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Re: When fire attacks...or why does Jimmy look crispy?

Post by SweetTea » Mon Oct 26, 2009 11:33 pm

Lowkey, I think this is the worst one you've put up in terms of survivability. But hey, I'll play along. Here's what I would do:

Initial first aid:
Get that plastic out of there! Your snow treatment has made it cold enough to handle with bare hands, but you should use clean tweezers anyway for reasons gotten into later.
Keep burn area cold until it doesn't hurt him to have it at room temp anymore. Then you know that the damage is done.

Treatment goals:
The name of the game in burns is dehydration and infection. Our skin does a pretty good job of keeping our precious bodily fluids in, as well as keeping invading microbes out. Now that the skin is gone, burn victims' cause of death is almost always dehydration or sepsis. Therefore, we need to minimize these risks while also giving this guy a good dose of palliative care.

Prevention of dehydration:
Push as much oral rehydration solution as he can take without puking. If resources are available (and you have the expertise), dump in at least a liter or two IV fluids as fast as you can. After that, I would prefer oral rehydration since IV is a too tricky to monitor in the PAW, and the IV stick site is an infection vector, which we already have plenty of.

Prevention of infection:
Sanitize everything this guy touches. Before transporting to the room you'll let him recover in, everything needs to be obscenely clean. Bleach everything. Nobody touches him without surgery-level washing up, complete with gowns and masks. Ideally, he would be in complete isolation with humidity maxxed and the temperature around 80. That could be achieved by keeping a pot of water simmering in his room at all times, which can double as an autoclave for sterilizing stuff like his clothes, sheets, utensils, plates, medical instruments, etc (you'll be autoclaving a lot...). In PAW settings, I think the best bet would be a room where you don't mind wiping bleach all over everything and can be easily sealed off. If you can find a house with a "mud room" or laundry room that has a tile floor that would probably be best. Duct tape windows, doors, etc, leaving enough ventilation for him to breathe. Maybe you could put a very fine HEPA filter in the air vent and be able to use it? I don't know if they trap bacteria and viruses. Otherwise, seal it off. This guy can literally be killed by 1 germ.

Healing:
Keep burns covered with dressings that have been treated with triple-antibiotic ointment. If you can get hold of colloidal silver dressings, those would be best since the silver exerts oligodynamic effect on the microbes. But we don't even have heat, much less colloidal silver. This guy is bad news. Half of those 3rd degree and all of the 4th degree burns aren't going to heal without a skin graft. Period. And I don't care how good you are with jury-rigged stuff, a potato peeler is not a dermatome and there is no damn way that anybody's doing a skin graft outside of an OR. The best case scenario is a huge, numb scar. The worst case scenario is necrosis, compartment syndrome, triggering complement and clotting everything up, infection, gangrene, and a bunch of other crap.

If the 3rd and 4th degree burns are most of the burn, or if the burn is such that an important sensory or motor nerve that goes to the hand is destroyed, I would amputate. If it's just a little patch on a nonessential area (just flesh instead of nerve or bone) and the rest is 1st and 2nd, I would try to save the limb. But damn, this guys prognosis isn't very good.
amd2800barton wrote:
LakotaJones wrote:Holy shit. I always thought Sweet Tea was a girl...
actually so did I. Didn't want to be the first one to say anything :P
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Veritas
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Re: When fire attacks...or why does Jimmy look crispy?

Post by Veritas » Fri Oct 30, 2009 11:52 am

Wow, good response SweetTea. I think that summed it up rather nicely.

That is all.
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