Walkthroughs & Resources

Injuries

Find your injury below for quick RP guides

GUNSHOT WOUNDS

Check bleeding –> slow bleeding if necessary (Amylum/Coffee Grounds)
Check pulse and breathing
Clean wrist with saline
Administer IV
Administer pain treatment/medication to help pulse (e.g. cocaine, morphine)
If patient is conscious, put him under with ether (rag)
Check if you find an exit wound (through & through)
- If none is seen, bullet will most likely still be in patient.

Clean wound and dab excess
Check for internal damage or debris –> if there is, proceed from there
Clean suture kit
Rinse wound again before stitching
Remove excess skin with surgical
Suture shut (first exit wound, then entry wound)
Clean sutures (iodine, carbolic acid diluted to 5% with saline, potassium bromide)
Apply herbal salve (ONLY around sutures) & Bandage

Clean wound and dab excess
Check if you can see the bullet in the wound
Dab blood if not
Check again (couple times, max. 3)
Make small incision to widen the wound (scalpel)
Take bullet out with forceps
Clean wound
Check for bullet fragmentation/bone fragmentation (depending on area) (debris)
Check for internal damage
- if any other procedure has to be done, proceed from there
Clean wound
Suture kit –> thread needle –> stitch up
Clean sutures
Apply herbal salve (ONLY around sutures)
Bandage

Found internal damage
- Muscle tissue damage
- Vein/artery
- Organ damage (lung, kidney, heart?, liver?)
Clean wound
Use silk to stitch damage if it is possible
- If not possible, check if cauterization could be an option
Use small stitches, tight

Found debris (bone/bullet fragments, teeth, objects, etc.)
Remove debris with clean forceps
Widen wound with spatula/scalpel if needed
After removal check again
Rinse/flush wound with saline
Clean certain areas
Proceed with normal GSW treatment

Check patient’s pulse and breathing
Remove IV if patient is stable –> clean wrist
Wake patient up with salts or stimulate by talking/reflexes or let patient wake up on his own (depending on injury and severity)
Let patient rest
Do small concussion test (name, place, what happened?, fingers, reflexes)
Pain scale
- Pain treatment
- If cocaine was administered beforehand into the IV, the Pain should be less already
- If the patient is still in a lot of pain, proceed from there
GSW pain treatment usually is
- With moderate severity = laudanum mixture
- With high severity = morphine
! Don’t administer aspirin powder = blood thinner !

Depending on the severity of the injury, as gunshot wounds can cause other injuries such as deflated lungs, internal damage, broken bones, etc.

Rest for 5 – 15 min with minor injuries
Rest for 15 – 30 min with major injuries
Rest for 30 – 60 min with severe injuries

Some extensive RP scenarios could involve physical limitations for 1 – 2 weeks.

BLEEDING WOUNDS

Venous Damage

Indicated by blood oozing from the wound. Also indicated by the dark color of blood.

Arterial Damage

Indicated by blood coming out in spurts. Also indicated by the light color of blood.

Sedate patient with ether rag if not already unconscious
Apply pressure to the wound
- Tourniquet can be placed if injury is present on an extremity
Clean wound and instruments
Apply saline on tissue area
Incise the tissue with a scalpel, avoid hitting more superficial arteries or veins until the source of bleeding is visualized
Apply hemostats (=clamps) to the either side of the damaged area
- Can be replaced with ligatures to take up less space and prevent hemostat from falling off
  - Best applied by passing a ligature behind the vessel with a clamp or forceps and ligating the vessel tightly
  - Ends of the ligature will remain outside the incision to allow more room
Cut away any severely damaged portion of the vessel that can not be used for repair
- Apply traction sutures to the surrounding tissue and vessel as needed for ease of operation
Begin to stitch and connect both ends of the vessel closed with the damaged area now removed.
- The inside of the vessels are to be rinsed with saline or similar isotonic solution prior to closure
Once both ends of the vessel have been stitched together, slowly remove the clamp above the direction of blood flow and check if sutures hold, then remove the clamp blocking blood flow to the rest of the vessel
Check for leaking – if bleeding remains, additional sutures may be needed.
- Reclamping or ligating the vessel may be necessary to perform this
Once hemostasis is obtained flush the area with carbolic acid
Suture wound closed
Check for a distal pulse if on an arterial wound
- If no pulse is noted, exploratory is necessary to see if repair kinked off, thrombosed (=clogged), or blood flow was cut off
- Working on upper arm → wrist for radial pulse
- Working on the femoral artery of upper leg → foot for dorsalis pedis pulse
Clean sutures site
Apply herbal salve (ONLY around sutures) or zinc oxide
Bandage

Immediately after the patient has been stabilized the first thing you should do is relieve pressure on the sutures, this is done in an assortment of ways.

Lower blood pressure by applying morphine to IV
If the patient has already a low pulse (but steady) do not administer cocaine for now to prevent the blood pressure from raising

PUNCTURES & STABS

First, determine the type of wound you are treating:

Less than half an inch deep

Clean
Apply herbal salve or zinc oxide
Bandage

More than half an inch deep

Clean
Examine for any debris/muscle tissue damage
Suture wound closed
Apply herbal salve (ONLY around sutures) or zinc oxide
Bandage

Wider than your pinky finger

Clean
Apply herbal salve (ONLY around sutures) or zinc oxide
Pack with gauze and wrap with a bandage
- As the wound heals, the gauze will be pushed out

Animal caused

Clean
Examine for debris
Cut away the flesh in and around the infected area
- Bite marks and open wounds that have come into contact with the saliva of a suspected/infected animal
Suture the wound unless there is clear indication that the animal had rabies
- If there is indication: cauterize it with fused silver nitrate
Apply herbal salve (ONLY around sutures) or zinc oxide
Bandage
Note: In the event of an animal attack, they MUST be given the Rabies vaccine to the abdomen. RABIES IS 100% FATAL WITHOUT IT!
Note: However, if the patient shows symptoms of rabies, refer to the illnesses -section rather than giving a rabies vaccination
Administration of the Rabies Vaccine: One Rabies vaccine every 14 days, ask the patient if they’ve already had one in that timespan.

Object still in patient:

Do ABC’s ( Airway, Breathing, Circulation )
Don’t remove the item.
Clean the exterior wound. (Blood, Dirt, etc.)
Apply a wrap (Gauze) around the exterior penetrating object firmly and well-packed.
Transport to nearby Office & make sure Object remains well-packed
Then proceed with surgery or anything in a stabilized location.
OPTIONAL: If bleeding ever goes through the gauze, never remove the gauze only apply more on top of the current applied amount

Object NOT still in patient:

Do ABC’s ( Airway, Breathing, Circulation )
Clean wound ( Dirt, Exterior blood, etc. )
Apply direct pressure to the wound.
Transport to hospital/clinic.
Then proceed with surgery or anything in a stabilized location.
OPTIONAL: If bleeding ever goes through the gauze, never remove the gauze only apply more on top of the currently applied amount

Place tourniquet above the wound
Slice wound open between fangs to allow drainage
Remove venom by sucking or cupping
- Cupping
  - Burn a candle or burn ball and place cup over it
    - Burns oxygen away and creates a vacuum
  - Place cup over wound quickly
- Pour ammonia to the wound to neutralize any remaining venom
- Clean wound
- Apply herbal salve (ONLY around sutures) or zinc oxide
- Bandage

HEAD INJURIES

Headache
Nausea and vomiting
Fatigue
Confusion
Dizziness
Sensitivity to light
Changes in sleep patterns
Mood changes
Difficulty concentrating
Memory problems

Hearing/Memory

Ask them about their Name / Where they’re at / what Day it is etc.

Balance/Coordination

Let Patient walk in a straight line (use floorboards for orientation)

Reflexes

Lamp to the eyes & check if pupils dilate normally

Concentration/Vision

Color Test: Have them repeat 3 colors after you
How many fingers am I holding up?

Scent

Have them identify the smell of Coffee grounds/beans with closed eyes

IMPORTANT: Always ask patient about any pressure behind his eyes

If so, patient possible may need a skull drain which must be performed by a general surgeon

NEVER use any opioids for any concussion symptoms. Patients with a concussion need to stay awake for several hours (check the concussion section for more info). When given an opioid, they want to sleep even more. Rather give a stimulant or energy-like cocaine, caffeine, or nicotine.

Asses the situation
Pain on pain scale
Check notes => what is okay to give, what is not

Most important question

What do we not want for the patient with a concussion?
- No sleep
- No unsupervised sleep with waking patient up every 15-30 min

Minor concussion

Pain is low
Maybe no pain treatment
- Especially no swamp herb or opioid, rather give them Coca Cola
- Have to boost patient to stay awake

Mild/severe concussion

Pain is mild to severe
Supervise patient / do not leave unintended
Give patient something to do => maybe herb picking / farming
- Nothing with too much exhaustion
For pain treatment itself: administer cocaine either orally or through snorting
- Relieves pain and stimulates patient to keep him awake

How long concussion patients should stay awake

6 hours for nothing to minor signs
12 hours for light signs
18 hours for mild signs
24 hours for major signs

Symptoms

The most immediate and concerning issues that will point to you needing to do this

A liquid like bump on the head around the skull
White/lightly brown colored liquid secretion from the nose/ears
Pressure behind the eyes

When examining a bump on the head, do not immediately feel the direct center of it,

Start by feeling the edges and working in slowly, applying light pressure as direct forceful contact could worsen symptoms and recovery

Tools needed

Saline,
Scalpel,
Forceps,
Bone Drill,
Suture kit,
Metal Plates,
Metal screws / Fasteners,
Metal Irrigation tubes,
Bucket,
IV Bottle,
Cocaine for pain management

Full procedure

Check if a bump is present,
- Feel the edges gently and move inwards, you will hopefully feel a hard mass, if it is liquid like or soft you will then begin the procedure.
Ensure Patient is unconscious, apply an Ether rag if not.
Clean the immediate areas with needed supplies, scalpel and incision site.
Make an incision along the mass & the portion lowest to the ground.
Drain the immediate fluid (Syringe or Tube)
When drained you will most likely see a small to large fracture (Possible breaks) along the skull cap
Take all loose fragments and put them into a safe area for later
Clean the bone drill, make 3 holes around the area of the fracture / break in a triangle shape.
Rotate the Patient so the area with the wound is lowest to the ground.
Drain the skull,
- Tubes are optional as they prevent less spillage from hitting the table/work space.
When drained fully, give the area a thorough cleaning.
Fit together what pieces of the skull you can (Loose fragments from before) and see if a metal plate can hold them.
You will then take a metal plate and secure it over the drilled holes with metal screws
Use the suture kit you have on hand and stitch the skin back over the area.
Clean the sutures
Apply a herbal salve (ONLY around sutures)
Bandage

Aftercare

Basic Treatment for a mild/severe concussion. But also do a concussion test.

STRANGULATION

Pressure to the neck can be via one or two hands applying the pressure (manual strangulation), by applying pressure using a forearm from behind (chokehold strangulation), or using a ligature or object. Pressure can be gradually exerted, sudden, or on-off in nature, particularly during a prolonged struggle or dynamic assault.

Injuries result from a variety of mechanisms and depend on the duration, degree and area of pressure, associated shearing forces, or forced extension of the neck. Interruption of venous return from the head with ongoing arterial supply to the head causes increased pressure in small vessels in the head and neck and resulting signs of injury such as petechiae bruising or subconjunctival hemorrhage. Sudden interruption of both arterial supply and venous return can result in hypoxic or vascular injury with no external sign of injury. Studies of non-fatal strangulation patients reveal no visible physical injury in around 50% of patients.

Venous occlusion: Pressure behind the eyes, ‘seeing stars’, swelling, headache and nausea, loss of consciousness
Arterial occlusion: Presyncope, syncope, headache, poor memory or memory gaps
Airway occlusion: Hypoxia and hypercarbia, panic, pain, inability to breathe, inability to swallow or speak
Psychological injury due to incident and hypoxia to hippocampus: Fear, sense of being overwhelmed, despair, acceptance of imminent death

Assess vital signs and manage any immediate compromise, particularly to the airway or level of consciousness. Then perform a targeted physical examination.

Airway: Assess for laryngeal or neck injury – change in vocal quality (hoarse, husky, loss of voice), subcutaneous emphysema, neck swelling/deformity, tenderness, pain on swallowing).
Breathing: Assess for serious respiratory distress/changes requiring urgent escalation.
Circulation/carotids: Assess for signs of arterial injury – look for carotid bruising and auscultate for carotid bruits. Assess for signs of increased vascular pressure injuries – examine the head and neck, including the eyes, mouth and throat, looking for petechiae, bruising, subconjunctival hemorrhages, tide mark.
Disability/deficits/decreased level of consciousness: Assess for neurological deficits with rapid screening neurological examination (cranial nerves, gross upper and lower limb examination, similar tests as for concussions) and note any confusion/impairment to level of consciousness.
External signs of injury: Examine for any further signs of struggle or injury – for example, ligature marks, bruising or abrasions on the neck (either from the offender’s hands or ligature, or from the victim’s own fingernails trying to remove the offender’s hands).

Give verbal discharge instructions clearly, as memory may be affected by strangulation and psychological distress. Advise patients to return for a routine follow-up in 48–72 hours with any county doctor if they notice or experience:

Difficulty breathing or shortness of breath
Confusion
Loss of consciousness or ‘passing out’
Changes in voice or difficulty speaking
Difficulty or pain when swallowing, a lump in the throat, or muscle spasms in throat or neck
Tongue swelling
Swelling to throat or neck
Seizures
Behavioral changes or memory loss
Escalating distress and urgency of thoughts of harming self or others.

Drowning Treatment

When coming across a patient that has either drowned in the lake or river please note the following:

Muffled lung sounds
Water in the mouth
Gurgling sounds
Blue skin and lips
Trouble breathing
Persistent cough
Glassy eyes

Place a large folded blanket under the patient’s shoulders
Kneel at the head of the patient and grab both their elbows in each hand
Raise their arms above their head and quickly and forcefully push their arms to their chest pressing downwards
After several attempts turn the patient on their side and check for water drainage
Repeat as many times as needed until the patient expels the excess water from their mouth

COLLAPSED LUNG

Proper Medical Term as of 1888 is called Pneumothorax. (Numo-Thor-Ax)

The lung is made of two layers of skin tissue. In order for your lung to collapse/deflate is when one layer of skin bursts causing your lung to shrink close to the size of half of your lung or smaller.

Pneumothorax is very common from Blunt Force Trauma to your chest or G.S.W’s to the center mass.

Listen to their breathing with a stethoscope. If you hear a hissing or sucking noise that is an indicator that something is wrong. If you cannot hear something, you can ask the patient to take a deep breath and hold it. If air is still leaving the lung without them exhaling, the lung is punctured.

Shortness of breath
Extreme tightness and pain in the center chest area
Sound of Gurgling

If there is fluid in the lung, it will be in the sack surrounding the lungs. The fluid needs to be drained by opening the ribs on the side with a small incision and having a tube draining it (poking through the lung tissue).

Put Patient under if they are not already unconscious
Apply an IV if not already done in the first place
Clean the skin with Saline before making an incision to widen the wound
Use retractors to keep the wound open while you operate
Check what caused the punctured lung (broken rib/bullet)
Remove the Object that punctured the lung with forceps
- If it’s a rib fragment make sure to proceed with re-attaching it (chapter “Bone Related”)
Thoroughly clean the wound
Suture the lung with silk thread to reduce the risk of rupturing
Clean the wound
Suture the wound shut & clean it
Use a new tube-like needle with a tube leading to a bucket attached
Puncture through the skin between the ribcage into the lung (Pleural Cavity) and allow air to escape from the Thorax to create an intrathoracic pressure which will re-inflate the lung & drain any blood through the tube beforehand
Apply herbal salve (ONLY around sutures)
Bandage

Pain Management
Oxygen Therapy
Observation
Physical Therapy

BONE-RELATED INJURIES

Breakages are painful experiences with long-term healing processes that must be managed even after the initial wound is dealt with.

Symptoms

Extreme Bruising around the breakage site
Deformity to an Extremity
Swelling under the skin
Tenderness to the touch

Lay the patient on their stomach or have them lie down
Straighten the arm
Place your knee on their back to both hold them in place and open the socket
Snap the arm back into the socket in the opposite direction of the dislocation in a swift but precise rotational movement – you should be able to feel the bone slide back into place in the ball-and-socket joint
This can also be done while seated or standing with the patient’s back against something straight
Have the patient demonstrate an ability to roll their shoulder
Prescribe appropriate painkillers

Place the sides of your palms on each side of the nose and snap it back into place in the opposite direction of the disfigurement in a swift but precise movement
Check for accuracy of the re-set nose relative to the patient’s face
Swelling and bleeding are common and normal side effects, apply a cold compress and pressure
Prescribe appropriate painkillers

SPLINTS & BANDAGE! A sprain is a stretching or tearing of the ligaments in a joint and, while painful, is not as extreme as breakages in their severity.
A stable fracture is a bone which is not broken through, the crack may reach only to the middle of the bone. The bones are also not moved out of place.
This is how to treat both:

Both can be identified through swelling in the joint/breakage site
Apply zinc paste or herbal salve to reduce the swelling
Bandage the area firmly but comfortably (allow blood flow) for Sprains
Splints & Bandages can be used for the stable fractures to fixate them and restrict movement
Prescribe appropriate painkillers

METAL PLATE! Simple breakages occur when the bone is broken into 2-3 large pieces. This is how to treat it:

It can be identified through swelling and discolouration to the breakage site
If Patient is not already unconscious, put under with Ether & apply IV
Feel where the fracture is and clean the area before making an incision
Use a bone drill to make one-two holes in each bone piece and fixate them together with metal plates & screws + a clean screwdriver
→ 2 Pieces: only 2 holes needed (one for each end)
→ 3 Pieces: The piece that is in the middle requires 2 holes
Flush the wound thoroughly to remove any small, unsavable shards of bone.
Flush wound clean
Suture any incisions made to access the bone
Apply herbal salve or Petroleum Jelly
Bandage

AMPUTATION! This type of break presents complications in the form of segmentation of the bone into fragments – a splitting of a single bone into several shards. The pieces are too small to be reattached with metal plates and amputation is the only way. If a General Surgeon is not present please follow the following steps to amputate the leg correctly:

Ensure the patient is under with Ether, applied by sponge.
Pinch arm and check for any reaction.
Apply IV and Tourniquet
Sterilize surgery tools
Make an circular incision with a scalpel to cut through the skin above the area of amputation

→ Using Double edge catlones to leave a proper flap of skin to be able to close the stump at the end

Apply Zinc paste to the flap to preserve it during the procedure
If possible, clamp the veins to ensure there’s no risk
Use a heavy scalpel to cut through the muscle tissue in diagonal lines.
Peel back the flesh to expose the bone, stripping the area
Saw through the bone till severed with a bone saw, or a bone nipper for smaller bones
Discard limb
Cauterize arteries & Veins to prevent bleeding
Remove the clamps and check for any leaking of the Veins

→ If found: re-cauterize

Scrape/file bone to a rounded point
Flap of skin needs to be pulled across and sewn close in a crescent shape

→ Make sure tissue is smoothly set down before stitching

Suture Stump
Cover the Stump with a layer of petroleum vaseline (to ensure moisture) and wrap with multiple layers of bandages
Get a wire splint and begin to wrap it around the area, securing it in place with a extra layer of bandages
Cast can be removed after 2 weeks and should be renewed weekly or earlier, depending on severity/complications
Give patient proper instructions to come back on a daily basis to check on infection signs and so forth

To create a cast, begin by adding gypsum powder and water in a large bowl and mixing well until a thick paste begins to form

Clean the patient’s appendage and wrap a clean bandage around the skin to create a base layer
Begin soaking bandages in the gypsum paste and applying them in a paper mache-like manner to the clean bandage, creating a thick cast of gypsum bandages around the appendage
Wrap the gypsum-soaked bandages in another clean bandage to protect the cast while it dries (may take several hours to fully harden)

IMPORTANT: Do NOT apply a Cast when someone had surgery that required suturing! The Cast will create a risk for undetected infection! Instead use splints and bandages.

Leg breaks require either a cane or crutches to assist with walking
Arm breaks are best put in a sling even if cast to reduce strain on the bone
Instruct the patient to put as little pressure and strain on the broken appendage as possible – no horse riding, no running, etc.
Provide appropriate pain management as necessary as the patient recovers, pain may persist over several days or weeks as broken bones take a great deal of time to heal
Dislocations should be fixated with a sling & warm compresses used daily to relax the muscle. Should not use the extremity for at least 2 days to avoid re-dislocation
Visit Physical Therapy to build up strength as the muscle atrophies in a Cast due to the immobilization

BURNS

Upper dermis is injured (epidermis –> only skin)

Clean area
Apply aloe gel or herbal salve with fish scale powder [fishscale paste]
Bandage area
Paste must be applied at least once a day until patients discomfort is gone

Dermis is injured (skin & muscle damage)

Clean area
Apply fish scale paste
Bandage area

Paste MUST be applied at least twice a day for a week or until no longer experiencing discomfort

Hypodermis is injured. (skin, muscle, & nerve damage present, no pain)

Clean area
Apply maggots to necrotic (dead) tissue
Clean wound again
Apply a layer of fish scale paste
Bandage area
Change three times a day for two weeks (depending on severeness)

Skin graft (after the procedure with maggots and fish scale paste) → please contact a dermatologist first to have them take over the procedure if possible

Clean skin of an area that is usually not showing, but it must fit the skin type of the injured area (arm = arm, leg = leg, etc.)
Measure how much skin is needed to cover burned area
Carefully remove healthy skin with a scalpel
Apply it on the burned skin after cleaning the area
Suture the wound with the new