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February 10, 2013

Trauma and You, Part Five: Burns
Posted by Jim Macdonald at 02:02 AM * 36 comments

We’ve talked about various heat-and-cold injuries to the body: Cold Blows the Wind Today and Heat Stress. Now it’s time to talk about something a bit more acute and a bit less systemic: Traumatic burns.

The subject has been brushed by: Sumer Is Icumen In (Lightning Strikes) and we’ve even circled around the edges: Stop Drop and Roll.

Now it’s time to get into the guts (so to speak) of Burns. Burns are some of the most frightening injuries. They are some of the most painful injuries. And, they can be life-threatening.

Sorry, folks, no pictures. Y’all can find ‘em on your own.

While burn injuries are classified as trauma, they have some significant differences from most other kinds of trauma. Normally, after (say) blunt trauma (e.g. falling off a roof) the body responds by constricting blood vessels, increasing heart rate, forming clots, shifting fluid to the area to allow white cells to access the injury, and similar good stuff. By contrast, with a major burn, the body’s defense mechanisms paradoxically cause it to shut down, go into shock, and die. Vasoconstriction and clotting can increase the size and severity of the burn while so much fluid may shift that it will throw the body into hypovolemic shock. Treatment of burns, prehospital, focuses on stopping or reversing those processes.

First: Stay safe. You can’t help a patient if you become a patient yourself. Downed power lines stay dangerous until someone wearing a white hard hat says they’re safe.

Second: Stop the burning process. If someone is on fire, put them out.

While the flames (and the thermal burns they produce) are the dramatic part of fire, the most dangerous part of a fire is the smoke. A very small amount of smoke inhalation can be fatal. Smoke, in addition to the particulates, can carry carbon monoxide, hydrogen cyanide, sulfur dioxide, and other chemical goodies. Usually, unless you’re looking at a steam burn, you won’t see a lot of actual thermal injury inside the lungs. Dry air doesn’t carry a lot of heat. But those particulates and gasses can produce chemical burns to the lungs even if they aren’t directly poisonous, producing chemical pneumonia and … this is bad.

The amount of smoke inhaled is the number one predictor of mortality in burn injuries, way ahead of the age of the patient or the surface area of the burn. Continue to be suspicious with someone who has escaped from a fire. Sometimes the symptoms of smoke inhalation don’t appear for hours or days.

The importance of smoke became obvious after the Cocoanut Grove Fire in Boston in 1942. Seemingly uninjured people who had escaped the fire and come to the hospitals looking for friends were falling down and dying in the waiting rooms. The presence of plastics was what had changed: Some of plastics’ byproducts of combustion are purely nasty.

While burns are not just injuries of the skin, that’s where we’re going to start as we look at this kind of injury. Often the first signs of burn injury appear on the skin.

Your typical adult has somewhere around 1.5 to 2 square meters of skin, divided into two layers: The epidermis on top, and the dermis below that. Below the dermis come the subcutaneous layers. The skin of males is typically thicker than the skin of females. The skins of children (<5) and elderly (>65) are typically thinner than adults. The skin is the largest organ in the body. It has three primary functions: Infection control, heat regulation, and water control. Burn injuries compromise all three of these functions.

Sometimes you hear burns classified as superficial, partial thickness, and full thickness. The “thickness” referred to is the thickness of the skin. I’m going to use another system of nomenclature: First degree, second degree, third degree, and fourth degree.

Your body contains an awful lot of protein. Proteins are complex molecules that easily denature with heat. When the body is burned, the central, most highly damaged, part of the burn is called the zone of coagulation. Which is exactly what it sounds like: The tissues have been hard boiled. The proteins have coagulated. The cells there are dead; they will not regenerate. Another cheerful name for this zone is the “zone of necrosis.”

The area surrounding the zone of coagulation is the zone of stasis. The cells there aren’t dead, but they are injured. Blood isn’t flowing to them; nutrients aren’t getting to them; oxygen isn’t getting to them. Without oxygen and nutrients those cells will die, and the zone of necrosis will expand.

Around the zone of stasis is the zone of hyperemia. Cells in this area are damaged, but not too badly, and are getting increased blood flow; the increased blood flow is part of the body’s normal reaction to any injury. The blood vessels get “leaky” to allow fluid to enter the intercellular space (between the cells) which allows white blood cells to access all parts of the injury. This causes swelling (edema) as the area puffs up with water.

It’s deucedly difficult to tell how deep a burn is immediately after the injury using a Mark One Eyeball. A burn that appears superficial may actually be deep, and that fact may not be apparent for up to 48 hours after the injury (when the top layers of the skin slough off). That being said, let’s talk about burn depths.

First degree burns. These only involved the epidermis (from epi - above; dermis - skin). These are the ones that are also called “superficial.” The epidermis varies in thickness from 1/20 of a millimeter on the eyelids to 1 millimeter on the soles of the feet. The signs are redness, the symptoms are pain. Usually they heal by themselves within a week without scarring. Large area superficial burns risk dehydration and the pain may be intense. The classic first degree burn is sunburn. Drink a lot of water and avoid re-injuring the area before it’s healed.

Second degree burns. These are also called “partial thickness burns” because they go part-way through the dermis. The most obvious feature of second degree burns are surface blisters or bare patches with a wet, glistening appearance. Exactly how severe a second degree burn is depends on how deep it is and how it’s cared for. A comparatively shallow second degree burn, with circulation rapidly returned to the zone of stasis, can heal on its own with normal wound care in two to three weeks. A deeper second degree burn, or where the zone of stasis is allowed to progress to necrosis, may require surgical treatment. An improperly treated second degree burn can convert into a third degree burn. Which you’re looking at is hard to determine on-scene. Second degree burns are also quite painful. Even air moving across the skin may be unbearable. (This is because the epidermis may be gone so that the nerve endings are directly exposed to the environment.)

Third degree burns. Sometimes called “full thickness” burns. They go all the way through the dermis. These burns generally have a thick, dry, leathery, white appearance (regardless of the race or skin color of the patient). The skin may appear charred. Blood vessels may be obviously congealed. These burns require surgical care and rehabilitation in specialty centers.

While third degree burns are classically painless (since the nerves are completely destroyed), they are generally surrounded by areas of second and first degree burns which are exquisitely painful.

Fourth degree burns are those that penetrate the skin entirely, with damage to the underlying fat, muscle, bone, or organs.

Let’s talk about blisters for a minute. They occur when the epidermis separates from the dermis and the space beneath the epidermis fills with fluid leaking from the damaged tissues below. This fluid contains proteins; it therefore continues to draw water into itself by osmotic pressure. Thus, blisters tend to grow, putting pressure on the wound beneath and increasing pain. Blisters do not actually act as a barrier to infection since they are not normal skin. But the need to drain and debride them is handled in a burn center, not in the field. If/when a blister opens, topical antiseptics are used to help prevent infection. Secondary infections after burns can be life-threatening.

Burns produce a massive fluid shift inside the body, from the blood vessels to the intracelluar space. Even more fluid is lost through evaporation. This produces hypovolemic shock. The treatment for this is massive amounts of intravenous fluid; according to the Parkland Formula (named after the hospital where it was devised), that’s 4mL of normal saline IV per kilogram of body weight per percent of surface area burned, with half of it delivered in the first eight hours after the time of injury and the rest over the next sixteen hours.

Please note that while massive fluid shifts are taking place, they take place over a period of hours. If the patient is showing signs of shock immediately or over a period of minutes, there’s more going on than just the burns: Look for broken bones, lacerations, and other trauma. Someone who fell down stairs or jumped out a second-floor window trying to escape a fire has those injuries too and you’ll have to deal with them; they may kill the patient before the burn has a chance to do it. Burns are dramatic and grotesque injuries. Don’t let them distract you from noticing that the patient is also having a heart attack, diabetic emergency, stroke, or other medical problem.

So what do we do, in the field, for burns?

First, as mentioned, stop the burning process. This does not mean “cool the burn.” The best way to stop the burning process is by flooding the area with large amounts of tepid water. Applying cold water or ice is contraindicated because that has the effect of making the blood vessels in the area constrict. Constricted blood vessels stop blood flow. But we’re trying to get blood to flow to the zone of stasis. Cold water or ice can convert the zone of stasis to the zone of necrosis and turn a shallow second degree burn into a deep second degree burn, or a second degree burn into a third degree burn. Yes, ice will numb the pain. But you’d be far better off using an oral painkiller for that, or just telling the patient to hang in there and gut it out.

In the course of stopping the burning process remove all jewelery and clothing from the patient. Those items retain heat, or trap chemicals, or constrict the body when the obligate edema occurs. All bad things.

Protect the area with dry, sterile (if you have ‘em) non-adherent (if you have ‘em) dressings. Wrap the patient in a clean dry sheet. You want to limit airflow over the wound. If you have a burned hand, put dressings between the fingers. Don’t put on creams or lotions — they may retain heat, or they may make it difficult for the nice folks at the burn center to assess the injury, and may make it impossible for them to use certain treatments (e.g. tissue-engineered products). (And it’s going to hurt like a dog when they scrape the goo off, too.)

As in any injury, maintain the patient’s airway, breathing, and circulation. While you’re stripping off all his/her clothing, pay attention to other injuries that may be revealed. One thing that you can do: Check every pulse point that you know. Take your Sharpie Pen and mark the ones that have pulses. Later on, swelling may make those pulses vanish, but the nice doctors will thank you for finding them.

Burn patients are unable to maintain their own body temperature. The skin controls temperature; they’ve lost their skin. After you’ve wrapped them in that clean, dry sheet, wrap them in a couple of blankets. Get them somewhere warm. Turn up the heat. If you aren’t uncomfortable it isn’t warm enough.

Now some special kinds of burns:

1) Electrical burns. Typically the injury appears less severe than it really is, since the only obvious surface burns are at the points of contact, but the damage is done internally as the electricity goes from the source to ground. Along with the destruction of tissue in general there’s a special (and this is in common with crush injuries); when muscle is injured it releases potassium, with can cause fatal heart arrhythmias, and it releases myoglobin, which causes kidney damage. Fractures due to muscle contraction are also a real possibility. In an electrical burn assume that the patient’s back or neck is broken.

2) Circumferential burns. That is, they go all the way around either a limb or the chest. On a limb, a circumferential burn can act like a tourniquet and stop blood flow to the outer portions of the limb, resulting in tissue death. Around the chest, a circumferential burn can make it difficult or impossible for the patient to expand the chest and breathe. This is bad.

3) Smoke inhalation. I’ve mentioned this twice already, but it really is that important. Burns to the face or mouth, or a patient who’s spitting up black sooty phlegm, should make you think of smoke inhalation. But just because you don’t see those signs doesn’t mean the patient didn’t get a lethal lungful. Any time you have combustion you have carbon monoxide. Symptoms include nausea, vomiting, lightheadedness, and vague flu-like symptoms. Or, unconsciousness and death. The primary treatment is to get the patient away from the source of carbon monoxide. The half-life of carbon monoxide in the body when breathing normal air is 250 minutes. When breathing 100% oxygen, the half-life of carbon monoxide is forty to sixty minutes. So, oxygen if you have it. Cyanide — the treatment for cyanide is rapid transport to an emergency room that has the antidote available. Particulates: The treatment is even more IV fluid, because the surface area of the burn is lots bigger than it looks. Sulfur dioxide, ammonia, hydrogen chloride — all present in smoke — can create damage in the lungs that doesn’t become apparent for days after the exposure. The amount, the duration of the exposure… don’t assume you’re out of the woods just because the patient seems to be fine the next day. Anyone who’s been in or near a fire needs to be observed for a considerable time.

4) Chemical burns. Treat them like thermal burns, using large amounts of tepid water to stop the burning process. By “large” I do not mean “a liter or two” or even “a gallon or two.” I mean throw-them-in-the-shower or turn-a-garden-hose-on-them for twenty minutes. (Don’t attempt to neutralize acids or bases; the chemical reaction between the two may create heat, producing further injury, and anything strong enough to neutralize a strong acid or base is itself hazardous.) Remember, the water that you’re using to flush the injury is itself contaminated and may be hazardous to you. Be careful. Protect yourself first.

When you’re calling the hospital to tell them that you have a burn patient, the two things they want to know are a) the patient’s weight, and b) the percent of the body surface area that’s burned. One way of estimating body area is the Rule of Nines. (Another way is by estimating how many times the patient’s palm would cover the burn; the palm of the hand is about 1% of the patient’s skin surface.)

Bottom line: All burns are serious, regardless of their size. There is no such thing as a “minor” burn. Unlike other forms of trauma the body has few-to-no natural defense mechanisms. The defense mechanisms that it does have tend to worsen the injury. On the plus side, burns are seldom rapidly fatal. You have time to get the patient to a burn center.

The leading cause of death in burn patients is smoke inhalation. Even in the absence of surface burns any patient with smoke inhalation should be taken to the hospital, and may well be transported to a specialty burn center after evaluation.

A patient with burns means that the situation is dangerous. Be careful. Do not become a victim yourself.


Copyright © 2013 by James D. Macdonald

I am not a physician. I can neither diagnose nor prescribe. These posts are presented for entertainment purposes only. Nothing here is meant to be advice for your particular condition or situation.

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Trauma and You, Part Five: Burns by James D. Macdonald is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License.

(Attribution URL: http://nielsenhayden.com/makinglight/archives/014819.html)


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Comments on Trauma and You, Part Five: Burns:
#1 ::: thomas ::: (view all by) ::: February 10, 2013, 02:19 AM:

Cold water or ice can convert the zone of stasis to the zone of necrosis and turn a shallow second degree burn into a deep second degree burn, or a second degree burn into a third degree burn. Yes, ice will numb the pain.

If it's only a small burn, that might be a good tradeoff. Back at New Year, I managed to pick up a 350F baking tray with the hand that wasn't in an oven mitt. A few hours of cold water, and wrapping it in a wet cloth overnight made the pain largely go away. Six weeks later there is still a bit of scar tissue being shed from my thumb, but it's a vast improvement over what I expected.

For a larger burn this obviously stops being a good idea.

#2 ::: Jim Macdonald ::: (view all by) ::: February 10, 2013, 02:27 AM:

For a smaller burn I'd still go with tepid water and a couple of Tylenol. Vasoconstriction tends to increase the volume of the injury.

#3 ::: abi ::: (view all by) ::: February 10, 2013, 06:23 AM:

Good article, Jim.

I hadn't really understood that smoke inhalation was a burn injury; I'd always thought of it as a "smother the lungs in particles" problem rather than a "burn the insides of the lungs with hot gasses" one.

Also, I'm pleased to note that this writeup didn't trigger me at all, even though I have been severely burned in the past (15% second degree burns from stove fuel in 1991, primarily on the legs). Thanks for that (though I'd rather I had to skip a ML post than that other people go without useful knowledge.)

#4 ::: Dave Harmon ::: (view all by) ::: February 10, 2013, 06:30 AM:

Let's see if I understood the Rule of Nines diagram: (1) The head and each arm are 9% for front and back together. (2) The upper torso, the lower torso, and each leg, are each 9% for front and another 9% for back. The groin is the last 1%.

Is that right?

#5 ::: firefly ::: (view all by) ::: February 10, 2013, 06:41 AM:

Good information - I always appreciate your medical posts. (Been reading ML since 2005; mostly, I lurk.)

Last week I met someone recently from Damascus, where he's lived his whole life. One of the more disconcerting things he has talked about is that the public hospitals are pretty much the last place you want to go if you need help. There are underground hospitals, but you have to know an activist to know where they are, and how to get there, and probably they don't have everything they need to save your life anyway.

I realize how much I take for granted my ability, when I'm at home in the US, to just go to a hospital for a medical emergency. If I don't have insurance, of course that can be an awful burden, but still: I probably won't be arrested, or tortured, or killed outright, by going to a hospital.

#6 ::: Jim Macdonald ::: (view all by) ::: February 10, 2013, 10:28 AM:

Dave #4 : That's correct, for adults. Note that for infants, with proportionally bigger heads, the numbers different.

#7 ::: Jim Macdonald ::: (view all by) ::: February 10, 2013, 10:56 AM:

Addenda: Rule of Nines (Infant)

For Nasty Things In Smoke, you can also get phosgene (used as a chemical weapon during WWI) when you have a fire that involves a freon refrigerator, or a halon fire-fighting system, or from the combustion of certain plastics. In low concentrations phosgene smells like new-mown hay (for people who've never been near a hay field I don't know if this will work). Cyanide reportedly smells like bitter almonds. Hydrogen sulfide (which is more poisonous than cyanide, even) smells like rotten eggs.

Back before firefighters started wearing air packs there were cases where everyone who went to a certain fire call was dead within three to five years; the only guys at the station who survived were the ones who for one reason or another weren't at that fire scene. Things are better now but fire fighting is still a very hazardous occupation. When we have a structural fire here we automatically dispatch an ambulance to stand by until the end of the call -- not for the folks in the house, necessarily, but for the firefighters.

#8 ::: Steven Damer ::: (view all by) ::: February 10, 2013, 11:12 AM:

It may just be the computer programmer in me, but the sentence 'Downed power lines stay dangerous until someone wearing a white hard hat says they’re safe.' makes me think that all rescue kits should include a white hard hat, so that you can make safe any downed power lines you encounter.

#9 ::: Jim Macdonald ::: (view all by) ::: February 10, 2013, 02:37 PM:

The next exciting installment of Trauma and You will probably deal with explosions.

#10 ::: thomas ::: (view all by) ::: February 10, 2013, 03:41 PM:

Jim Macdonald #7:

The scents of the various nasty gases are useful to know, but not at all reliable: some people can't smell hydrogen cyanide; the detection threshold for phosgene is above the danger threshold; and while hydrogen sulfide is detectable at much lower than dangerous concentrations, the smell vanishes at about the concentration where short-term exposure is dangerous (the olfactory nerve just gives up).

#11 ::: Bill Stewart ::: (view all by) ::: February 10, 2013, 04:20 PM:

Here's a picture of the standard NFPA 704 diamond-shaped warning sticker that you'll see on doors, with warnings about toxics, flammables, explosives, and special hazards you might find there. The numbers go from 0 to 4 (4 is bad), and the special hazards have names (like "ACID" or "OXY".)

Most of the ones I've seen have been for petroleum products, paint, or pool chemicals, because those are all common and somewhat hazardous, but sometimes there are more interesting risks around.

#12 ::: Laertes ::: (view all by) ::: February 10, 2013, 05:51 PM:

Thanks, Jim. I love these articles and I always take the time to read and re-read carefully every time you post a new one.

#13 ::: estelendur ::: (view all by) ::: February 10, 2013, 08:17 PM:

I got a small burn on my hand in early January (I think around the 10th? A pot I had made popcorn in brushed against my hand) and I have no idea what degree of burn it was. At first it was very painful, but after a couple hours in cool water it was weirdly painless and the skin was white. Then the skin turned black, and eventually that black layer (which was quite thick) came off, completely exposing the nerves in that area. That would hurt when it hung below my waist without acclimation time (because blood flowing in?), scabbed up nicely, and was fully healed by I think the end of the month.

#14 ::: Jim Macdonald ::: (view all by) ::: February 10, 2013, 08:32 PM:

Weirdly painless and white skin? Then turning black and sloughing off?

I can neither diagnose nor prescribe, nor did I see it, but that sounds very much like a third-degree burn.

#15 ::: estelendur ::: (view all by) ::: February 10, 2013, 08:51 PM:

Fortunate for me that it was less than half the size of a dime, then! Heavy-bottomed pots that have had only oil in them are very hot.

#16 ::: Cynthia W. ::: (view all by) ::: February 10, 2013, 10:27 PM:

This thread and the one on explosions will be bringing up a lot of thoughts and questions for me. One of our black belts (the one next up from me in rank) was a survivor of an explosion with resultant major burns (92% 3rd & 4th degree). I suspect he survived due to pure cussedness - after the burns, the hospital was keeping him doped to the gills on morphine and apparently just waiting for him to die - until he caught a nurse putting in the next dose, and threatened to break her arm if she gave him any more. Twenty years later, he still has major issues - like scars from the bottom of his feet up to mid-ear level, and major amounts of burned away muscle in his lower body - but he's quite surprisingly functional.

#17 ::: B. Durbin ::: (view all by) ::: February 11, 2013, 12:14 AM:

On the chemical burns—any time you're working in an area with chemicals, they should have wash-down stations. I work at a photography studio with comparatively benign chemicals for the digital printer, and we have a sink with a grip sprayer that's always on and a bottle of eyewash. Now the thing about the eyewash bottle is that once you've opened it, you're not supposed to cap it and use it later; the sterile nature of the wash is assumed to be compromised. So they tell you to use the whole bottle—and it's a big bottle. The people who make eyewash understand about flushing fluids off. (Chemistry labs will have eyewash stations with foot pedals and step-in showers. Turn it on and stay there until the EMTs come...)

#18 ::: Dave Harmon ::: (view all by) ::: February 11, 2013, 12:21 AM:

Jim Macdonald #7: The infant diagram seems to only add up to 91%.

#19 ::: Jim Macdonald ::: (view all by) ::: February 11, 2013, 01:23 AM:

#18 Dave Harmon: Actually, it adds up to 101% (after you add in the groin). (If you ever hear someone talking about a "one-percenter burn" that's what they mean.)

Head 18%
Trunk (front) 18%
Trunk (rear) 18%

54% so far.

Right and left upper extremities, 9% each, 18% total, now up to 72%.

Left and right lower extremities, 14% each, 28% total, we're at 100%.

Throw in the one-percenter and you have 101%, which is close enough for a quick estimate on-scene.

#20 ::: Charlie Stross ::: (view all by) ::: February 11, 2013, 10:26 AM:

Jim, #7 -- cyanide does indeed smell like bitter almonds, because bitter almonds get their smell from cyanogenic glycosides (which almonds concentrate); their breakdown products include HCN.

#21 ::: Dave Harmon ::: (view all by) ::: February 11, 2013, 10:42 AM:

Jim #19: OK, serves me right for doing math after midnight.

#22 ::: Jim Macdonald ::: (view all by) ::: February 11, 2013, 11:41 AM:

Charlie, I'm not certain that I've ever smelled a "bitter" almond. I know what regular almonds smell like; to me they're sweet and delicious.

==============

I've long wondered about Michael Jackson: How badly burned was he in that fire (when, essentially, his hair caught fire while filming a commercial). After that point he loses his skin pigmentation, starts getting massive and repeated facial reconstructive surgery, starts taking anti-infection precautions, and develops the need for heavy-duty pain killers.

He looked pretty darn bad. But for a recovering burn victim he looked pretty darn good.

#23 ::: Tom Whitmore ::: (view all by) ::: February 11, 2013, 11:44 AM:

I've been told that "bitter almonds" are the nut inside a peach pit. Which I believe, having seen what almonds look like on the tree. Surprisingly similar to peaches!

#24 ::: alienora ::: (view all by) ::: February 11, 2013, 07:38 PM:

Jim #22: Bitter almond is the almond of almond extract, or amaretto, or amaretti cookies. To me, it is a much sweeter smell than that of regular "sweet" almonds. (Actually, I find it to be an irresistibly good smell, which is a bit problematic for something that should mean "poison")

I think it can be made from the seeds of a number of different species in the Prunus genus (like peaches and apricots: amaretti cookies usually seem to be made with crushed apricot kernels). If you've ever wondered why almond flavored muffins and pastries don't taste much like a handful of raw or toasted nuts, that's why: it's a whole different type of almond.

#25 ::: Lenora Rose ::: (view all by) ::: February 11, 2013, 11:39 PM:

alienora: Whereas the bitter almond smell is almost unbearably, viscerally horrible to my mother and brother. (I didn't inherit this trait: I don't much like amaretto, but it's not that bad.)

Jim: Thank you again for a useful post. Some of this I knew, but the smoke inhalation part is excellent.

TV and movies always annoy me with people standing around talking amidst flame (Arrow most recently), because I knew the smoke was the biggest danger, if not these details as to why.

#26 ::: Lee ::: (view all by) ::: February 12, 2013, 04:36 AM:

After our own experience with a neighbor's house fire, pretty much any structure-fire scene in a TV show or movie is going to bounce me right out of it. Hell, watching the "flaming Denethor" scene in LOTR had us both shaking our heads and saying, "he wouldn't have gotten half a dozen steps like that."

#27 ::: Cal Dunn ::: (view all by) ::: February 13, 2013, 01:38 AM:

The Flatmate and I mildly poisoned ourselves inhaling arsine gas once - we'd been travelling for about four weeks(*) and had stopped overnight in a dodgy-looking campsite, and one of the pieces of timber in our campfire was treated pine. The smoke was distinctly garlicky, which I didn't realise at the time was a problem since dinner (cooked over the campfire an hour or so earlier) had also been rather garlicky.

We didn't kill ourselves or even suffer any long-term effects (that I know of, anyway) but the next day I had the worst brain fog I've ever experienced and a pretty disgusting headache.

(*) From Mildura to Darwin and back through Broken Hill to the NSW coast - about 8000km / 5000 miles. I'd love to do it in six months rather than four weeks.

#28 ::: Matthew Brown ::: (view all by) ::: February 13, 2013, 03:52 PM:

Jim@22: Hmm, makes one wonder, doesn't it? I suspect that the burns from such a fire might be worse than the untrained eye would suppose, given the fact that the skin on the scalp and face is pretty thin and easily damaged. It looks like he had a MASSIVE amount of stuff in his hair, too, and that would provide fuel for the fire.

#29 ::: Mycroft W ::: (view all by) ::: February 13, 2013, 04:00 PM:

Jim, OP: "One thing that you can do: Check every pulse point that you know. Take your Sharpie Pen and mark the ones that have pulses. Later on, swelling may make those pulses vanish, but the nice doctors will thank you for finding them."

Why? May they go away? May they stop working? Is that evidence of worse damage?

Also: is there something special for training to find and know the pulse points, or is it something that can be used from Google-results without potential damage?

Also also: is this a good thing to do in general when faced with trauma cases, or just something special for burn cases?

#30 ::: Lori Coulson ::: (view all by) ::: February 13, 2013, 07:18 PM:

Mycroft W -- You may have missed this part of Jim's post:

2) Circumferential burns. That is, they go all the way around either a limb or the chest. On a limb, a circumferential burn can act like a tourniquet and stop blood flow to the outer portions of the limb, resulting in tissue death. Around the chest, a circumferential burn can make it difficult or impossible for the patient to expand the chest and breathe. This is bad.

Any first aid book will show you where the pulse points/pressure points are -- knowing where to apply pressure to stop bleeding is a good thing. In burn cases, being able to find a pulse (and marking it for the doctor) lets them know that there was blood flow to that area when you found the victim. In fact, when you mark the area with the sharpie, you can also write what time it was when you found that pulse.

If you can't find a pulse, this means SOMETHING has stopped working, and that's BAD. The burn may have compromised circulation to that area. In worst case scenarios, it may mean that shock from the burn(s) has caused cardiac arrest.

#31 ::: Jim Macdonald ::: (view all by) ::: February 13, 2013, 09:52 PM:

What Lori said.

Pulses means that there's healthy (and potentially salvageable) tissue there. The loss of blood pressure, and the pressure inside the tissues from edema, may cut off circulation, or mask the pulses. Knowing where the good tissue is will help evaluate the patient.

You can find pulse points on yourself, or on your partner, without fear of doing it wrong or of injuring someone. (Though to find the femoral pulse on someone you and that person need to be Really Good Friends.)

#32 ::: B. Durbin ::: (view all by) ::: February 14, 2013, 03:11 PM:

... I'd never known that about Michael Jackson. That is an interesting plot point.

#33 ::: Mycroft W ::: (view all by) ::: February 14, 2013, 07:23 PM:

Thanks, Lori, Jim. I didn't miss it; I just couldn't connect pulse points to anything, including that section. The why was not As a needle-phobic, you can guess that I'm reading these posts to be able to be not a harm, rather than actively doing good (because I feel it's uncivil of me to not be basically prepared, in other words, rather than because I actually wish to do this for anyone).

The only thing I could connect it to was "swelling might mask them", rather than "swelling might mask them, or they really could have stopped between now and when the doctor gets there, or they could have stopped when I got there, and it's really difficult to tell which".

#34 ::: Mycroft W ::: (view all by) ::: February 14, 2013, 07:26 PM:

#33, me: The why was not... connectable by me, even with all the parts. I just couldn't get from "things that happen" to "that can cause loss of circulation and that is bad."

Sorry, don't know where that was lost.

#35 ::: Susie ::: (view all by) ::: February 20, 2013, 12:01 PM:

Jim Macdonald @ #9: After reading about the gas explosion that destroyed a Kansas City restaurant yesterday (with multiple injuries and one death so far), I'd be very interested in your next installment.

#36 ::: Jim Macdonald ::: (view all by) ::: February 20, 2013, 11:30 PM:

Today is the 10th anniversary of the Station Night Club fire in Rhode Island.

Requiem aeternam dona eis.

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