Tradecraft: Burn Injuries On and Off The Grid

January 24, 2018 Bridge Agents

BURN INJURIES

Whether caused by a raging wildfire or due to an accident while preparing food, burns are a major challenge both on and off the grid. Injuries from burns that require medical help top one million each year in the United States, with thousands of deaths reported. These numbers are alarming, given the fact that, in modern times, few are us are exposed to fire as often or directly as our ancestors were. Despite this, only a small percentage of families have formulated and practiced an escape plan for their own homestead.

There are different types of burns. the American Burn Association’s statistics show their relative frequencies:

44 per cent: burns from flames
33 per cent: scalds caused by exposure to hot fluids (50 per cent of burns in children)
9 per cent: contact with a heat source
4 per cent: electrical burns
3 per cent: chemical burns
7 per cent: miscellaneous causes

Of course, anyone who sustains a serious burn should be transported immediately to a hospital, preferably one with a dedicated burn unit. After a disaster, however, these facilities may be inaccessible or overwhelmed by a large number of casualties. Therefore, it is possible that the average citizen may be required to provide burn care in disaster settings.

Off the grid long-term, the risks are even greater. Without power, we will be cooking over fires more frequently. The potential for significant burn injuries will rise, especially if small children get too close. It’s important for the “medic” to have a working knowledge of burns and their treatment.

The percentage of body surface area is often used to determine the severity of injury. A system known as the “rule of 9’s” is thought to give a rough estimate of the risks involved. Any burn covering more than the size of, say, your palm is serious enough to be medically evaluated. In survival settings, the general health (not to mention work efficiency) of a group member already under stress may be impacted.

(Note: Normally, the palm area measure is used only for burns that are more than superficial, but I believe that all burns this size or greater should be brought to the attention of the medic.)

Off or on the grid, burns are best categorized by “degrees”, a measure related to the depth of penetration. The deeper the burn damage, the graver the consequences for the victim.

FIRST DEGREE BURNS: First-degree burns affect the epidermis, the topmost layer of the skin. A typical example would be a “sunburn”. These burns appear red, warm, and dry, and are painful to the touch. Mild swelling may occur. Dry, dead skin will cause itching, but peels off after a period of time. No scarring is expected.

Although most first-degree burns are minor, extensive ones must be watched closely. They can cause dehydration and even enough heat loss to cause hypothermia.

Treating a first-degree burn: Treatments for a first-degree burn include:

Cool water soaks for five to ten minutes (many make the mistake of running cold water over the burned area for only a few seconds). Avoid ice, which traumatizes already-damaged skin by decreasing circulation to it.
Pain relievers like ibuprofen (Advil) or acetaminophen (Tylenol). After a day or so, the pain will subside.
Anesthetic ointments and burn gels containing aloe vera.
Antihistamines for itching.

Expect complete healing in a week or so.

SECOND-DEGREE BURNS: Second-degree burns, sometimes called “partial-thickness” burns, affect the deep layer of the skin (the “dermis”). You will see areas that are painful, swollen, and appear moist rather than dry. The area will have a tendency to weep clear or whitish fluid. These injuries often have a number of blisters of various sizes.

Treating a second-degree burn: Treatment for a second-degree burn should be quick and intensive. The faster treatment is begun, the faster the recovery. Consider:

Running cool water on the burn for 15 minutes or longer.
Quick removal of rings, bracelets, and necklaces due to rapid swelling that occurs.
Bandaging the wound with non-stick dressings like Telfa pads. Avoid the use of cotton balls as dressings due to the sloughing off of fibers that can increase the likelihood of infection.
Using specialized burn dressings like Xeroform; similar dressings can be improvised using gauze and petroleum jelly.
Giving pain medicines as needed.
Applying antibiotic cream to blisters to prevent infection.

Blisters may be numerous, but should be broken only if very large or it is clear they would break during normal activity or in bed. The “Popping” of blisters may increase the risk of infection. If you feel it’s necessary, puncture with a sterilized needle at the base and leave the skin covering the raw area.

Keeping the area protected from infectious organisms is important; dressings should be changed at least daily. Most second-degree burns heal in 2-3 weeks without thick scars, but may leave the skin darker than its original color.

THIRD-DEGREE BURNS: A severe type of burn injury, third-degree burns damage the full thickness of the skin and, often, deeper structures like the nerves and blood vessels below the skin. Once the damage goes through the skin, you have lost your body’s “armor”, causing the rapid loss of fluids and ensuing dehydration. Loss of body heat is also a major issue.

Third-degree burns can vary in appearance based upon the type of burn incurred. They may appear white and waxy, charred brown, or black. The area may feel stiff or “leathery”.

Treating a third-degree burn: Start by following the steps for a second-degree burn. Long-term care is much more complex, however. The skin lost in an injury is normally replaced by new skin cells produced by the dermis. The dermis, however, has been destroyed in a third-degree burn, so skin can only grow from the edges of the wound. This not only takes more time than the patient has, but also results in thick scarring.

Sometimes, skin edges have dead tissue which must be cut away so living tissue behind it can grow; this (sometimes painful) process is known as “debridement”.

In normal times, gaps left by extensive burns are treated by “skin grafting”. A skin graft is skin taken from an uninjured area and placed on the site of the burn. Skin taken from the injured person is less likely to be rejected than if taken from another individual.

Of course, the technology needed for skin grafting won’t be accessible off the grid. The best that might be done in a remote setting would be covering the area where skin no longer exists with products like honey or aloe vera gel. A non-stick covering is then applied for protection. Celox hemostatic gauze, when wet, makes for a serviceable burn bandage. Dressing major burns, however, can compromise blood flow as swelling occurs. As such, these wounds shouldn’t be wrapped tightly, if at all. Vigilance is needed to keep the wound clean so as to prevent infection.

Expect these wounds to require a very long time to heal. Often, a “contracture” will develop as a result of scarring. This is a condition where deformity or loss of movement occurs in joints due to the stiffening of muscles and other tissues. The result, at the very least, is loss of range of motion.

FOURTH-DEGREE BURNS: Once considered just a severe case of a third-degree burn, the damage extends down through subcutaneous fat to muscle and bone. The tissue appears dark, dry, and “crispy”. Third and fourth-degree burns are often described as painless, as the nerve endings have been destroyed. These burns, however, often have second-degree and first-degree components at their peripheries, which can be very painful.

Treatment for Fourth-Degree Burns: Even in the most advanced settings, treating fourth-degree burns is complex and may even involve amputation of an affected limb. Without a modern burn unit, the survival rate for third- and fourth-degree burns covering any significant portion of the body will be very low. This is due not only to destruction of tissue; the inability to replace fluids rapidly in these patients and the high frequency of infection will be factors, as well.

COMMON MISTAKES WHEN TREATING BURNS

-Failing to run cool water on the burn for the time recommended.

-Using ice on burnt skin.

-Ignoring airway burns. With smoke inhalation, airways may swell rapidly and cause breathing difficulties. Signs include severe coughing, hoarseness, black-specked sputum, and facial burns.

-Popping blisters unnecessarily. Intervene only when they are very large or interfere with function.

-Assuming a burn is less of an issue than it is. Even a first-degree burn, like an extensive sunburn, can be dangerous if steps aren’t taken to avoid further exposure and keep up the level of hydration.

-Using lard or butter as a home remedy. These substances can trap heat in and cause a delay in healing. Other home remedies, like aloe vera, are more preferable.

BURN PREVENTION

Burn care in an off-grid setting is difficult, so it makes sense to do everything possible to prevent these kinds of injuries. As your people may be performing activities of daily survival to which they are not accustomed, perhaps the most important advice is to be certain that they are wearing appropriate personal protection like gloves, masks, goggles, and footwear. Any burn injury prevented is one less headache (and perhaps, heartache) for the medic. Other considerations:

never allow children to be unsupervised near a campfire or wherever food is being cooked or water boiled.
Don’t let kids play with matches or lighters.
Apply sunscreen 15 minutes before going out in the sun and reapply frequently.
Avoid cooking if you are impaired by exhaustion (or alcohol/drugs).
Avoid smoking inside your shelter or anywhere there are flammable materials (or maybe not smoke at all).
Keep firewood and other flammables away from buildings.
If you have power, be wary of space heaters; leave a good space between them and anything combustible.
Avoid using frayed electrical cords.
Learn how to recognize gas leaks.
Have and know how to use fire extinguishers.
Have functioning smoke alarms.

Last but not least, have a plan of action for a fire at your homestead, and practice drills so that family members will know exactly what to do. This includes a method of communication and a place to meet in the event that you are separated from each other.

The risk for burn injury exists even in the best of times. Off the grid, they represent a major challenge to the caregiver. The ability to recognize and treat different degrees of burns will be an important skill for the medic in tough times.

In future articles, we’ll review electrical, chemical, scalds, and other burns, as well as ways to recognize and treat them effectively. We’ll also discuss some natural remedies that will work to help speed recovery from burn injuries.

Joe Alton MD

Dr. Alton