Wounds and Bleeding

Any abnormal disruption of the skin or surrounding body surfaces is known as a wound. Most wounds can be classified as open—with a break in the skin through which blood and other body fluids may escape. This also permits the subsequent entry of germs, which may in turn cause infection. A closed wound allows blood to escape from the circulatory system but not the body, and is known as internal bleeding. The nature of the force creating the wound determines the type of wound and influences the treatment given.

Summary of Wound Types

Incision Wounds

Incision wounds are made by a clean cut from a sharp edge, such as a knife. There may be profuse bleeding because the edges of blood vessels are cut straight across.

Lacerations

Lacerations are rough tears caused by crushing or ripping forces, occasionally caused when using tools. Lacerations may bleed less profusely than clean cut wounds, though there is more tissue damage. Contamination risk from germs and subsequent risk of infection is high.

Abrasion Wounds

Abrasion wounds are superficial wounds in which the top layers of the skin are scraped off, leaving a raw tender area, and are caused predominatly by a sliding fall or a friction burn. They often contain foreign particles that may cause infection.

Puncture Wounds

Puncture wounds are caused by the entry of a sharp foreign body into the skin, such as stepping on needlethorn. They are characterized by having a small site of entry but a deep track of internal damage. As dirt and germs can be carried far into the body, risk of infection is high.

Types of Bleeding

Arterial Bleeding

With arterial bleeding, the blood is bright red and under pressure from the pumping heart. Therefore, blood is spurted from the wound in time with the heart beat. A severed artery may produce a jet of blood several feet high and can rapidly empty the circulatory system of blood.

Venous Bleeding

With venous bleeding the blood is dark red in coloration. It is under less pressure than arterial blood, but since the vein walls are capable of great distention, blood may pool. Thus, blood from a severed major vein may gush profusely.

Capillary Bleeding

This type of bleeding can be characterized as oozing and occurs at the site of all wounds. Although capillary bleeding may at first be brisk, blood loss is generally negligible.

How The Body Reacts to Control Bleeding

When blood vessels are severed or torn, their damaged ends constrict and retract in order to minimise blood loss. At the same time, the blood that escapes from damaged vessels begins to clot. If approximately three and a half pints are lost from the circulation, the pulse will quicken and sweating will occur. Small blood vessels to areas such as the skin will constrict as the body diverts blood to the major organs. Shock will become evident. If approximately five pints are left, then the pulse at the wrist (radial artery) may become undetectable (use the 'carotid' pulse point found just under the jaw on either side). The patient will become unconscious and life will eventually fail.

External Bleeding

Slight Bleeding

Slight bleeding is not a danger and will eventually stop on its own. The flow of blood helps to cleanse the wound.

Moderate Bleeding

More moderate bleeding is often stopped by the sealing action of numbweed once applied to the wound. If the bleeding still does not stop, a pressure bandage should be applied. A pad of bandaging material should be applied to the wound and held tightly in place. If this soaks through, it should not be removed; instead, a second bandage should be applied on top of the first. In most cases, this will be enough to stop bleeding.

Severe External Bleeding

If bleeding is severe and does not respond to a pressure bandage, or if blood is spurting from a wound, stronger measures are needed. Apply pressure to the artery feeding blood to the area. On the arms, the pressure point is on the inside of the upper arm (Brachial artery); for a leg, it is on the upper inner thigh, near the groin (Femoral artery). It is possible to suture the damaged vessels by asking an assistant to keep up the pressure on the pressure point. This is the preferred method. A Healer should rarely have need to resort to a tourniquet and this is actively discouraged as it usually results in the loss of the affected limb. It should -only- be used when sacrificing a limb to save a life. To produce a tourniquet, tie a piece of cloth around the limb approximately one inch above the wound. Place a stick or similar item on top of the knot and tie another knot over it. Twist the stick until the bleeding stops; loosen it at one minute intervals and re-tighten. Eventually the bleeding will stop when the stick is loosened.

Treatment Of External Bleeding

Once bleeding has been stopped, the greatest danger from wounds is that of infection. Wounds should be well cleaned with both water and redwort, and great care should be taken to remove all dirt or other foreign objects from a wound. This is especially true with puncture wounds, as dirt may be driven deep into the skin. If stitches are to be taken, the wound should be only lightly coated with numbweed, and then re-coated more heavily after placing the stitches. All other wounds should be well-coated with numbweed.

Sutures

Stitches should be taken in any wound that is deep or gaping and in which the the edges of the wound seem unlikely to stay together without some sort of assistance. Stitches help provide a barrier to prevent infection of the underlying tissues. Care should be taken to draw the edges of the wound together neatly, so there is no puckering of the surrounding skin and to take as few stitches as possible, so the scar is as small as possible. A stitched wound should be kept moist, to further avoid scarring. Stitches should be removed by a Healer approximately a sevenday after insertion, but this may be adjusted on a case-by-case basis. In general, when a patient begins to complain of itching, sufficient healing has taken place to allow the removal of the stitches.

Use this procedure to take stitches in a wound:
1) Follow the normal procedure for washing up and cleansing a wound. Apply a thin coat of numbweed, using just enough to deaden the area. Do not forget to oil your hands so that you can perform the dexterous movements required, as redwort oil will protect your hands from numbness.
2) Caution your patient not to look at what you're doing. Many people are distressed by the sight of stitches being put into their skin.
3) Using a sterile needlethorn and treated thread, take small neat stitches.
First stitch in one side of the wound and then in the other with the same piece of thread. Loop one end twice over the other and tighten—this will form a knot. Clip the excess and start of the next stitch. Continue until the wound does not gape.
4) Apply a thicker coat of numbweed and a bandage.
5) Explain the signs of infection to your patient and warn them to see a Healer if they notice any of them.
6) Tell your patient to see a healer in a sevenday to have the stitches removed.
7) Tell them to keep the wound moistened with numbweed, aloe, or dragon's tongue. (This will also ease the itching of a healing wound.)

Use this procedure to remove stitches:
1) Wash up and cleanse the area as usual. Apply a light coat of numbweed.
2) Ask the patient to look away, so they will not be upset by the sight of you withdrawing the threads from their skin.
3) Clip the threads with scissors, or cut them with a sharp knife, being careful not to cut the skin.
4) Using small tongs, remove each of the threads from the skin.
5) Apply a light coat of numbweed over the punctures left by the threads to seal them. Bandage lightly.

Most Healers utilize one method of stitching which can cause substantial scarring of the tissue, leave the wound unsightly. The removal can be unpleasant for the patient as scar tissue can form around the knots. However, some higher qualified Healers now utilize another technique (it is harder to learn). This method consists of starting at one end and not at any point tying off. This means there are no knots for scar tissue to form around and removing the stitches by simply cutting one end and pulling on the other causes less pain to the patients. Scars are less puckered with these 'running' stitches than with regular stitches.

After Treatment of External Wounds

It is important to keep wounds clean and protected from further injury; however, the flow of air over a wound promotes healing. These two objectives may be accomplished by covering the wound for two to three days to allow healing to begin and then leaving it uncovered except when the patient will be doing something that involves getting dirty. Alternatively, the wound can be covered during the day and uncovered at night. These times are approximate and will vary from patient to patient. The patient should be cautioned about the signs of infection and urged to seek a Healer if they should notice any of these signs.

Internal Bleeding

Bleeding within the body cavities may follow injury, such as a fracture or penetrating wound, but can also occur spontaneously, for example with a stomach ulcer. Internal bleeding is serious and may result in shock. Suspect it if, following injury, sighs of shock develop without obvious blood loss. There may be 'pattern bruising' at the site of violent injury—this is discoloration that takes the pattern of clothes or crushing objects. There may also be blood at body orifices.

Eardrum

If blood is observed leaking from the external ear, then it is likely that the ear drum has been perforated. This can occur due to sudden pressure differences and inequalities in air spaces or simply from blowing the nose with a heavy cold. Other causes are blows to the side of the head or foreign bodies pushed into the ear. The patient may have experienced a sharp pain as the eardrum ruptures, followed by earache and deafness. Allow the blood to drain away by tilting the head to one side. Then treat with lavender and chamomile to relieve the ache, hearing will gradually improve as the eardrum repairs itself.

Nosebleeds

The most common of nosebleeds occurs when a vessel inside the nostril ruptures, either by a blow to the nose, or as a result of sneezing, picking, or blowing the nose. Infections, such as colds and influenza, make the blood vessels in the nose more fragile. Nosebleeds can also occur as a sign of high blood pressure, or with exposure to high, dry air. Sit the casualty down with their head tipped well forward. Ask them to breathe through their mouth: this will have a calming effect as well as prevent the disruption of any forming bloodclots. Get them to pinch the nose just below the bridge and give them clean gauze to mop up the dribble. Don't let them speak, spit, cough or sniff if at all possible as this can also disturb blood clots. After ten minutes, get them to release the pressure. If it still bleeds, continue with the pressure. The inhalation of yellow citrus fruit and chamomile oils can help with the bleeding.

Mouth

Cuts to the tongue, lips or lining of the mouth can range from trivial to serious. The cause is usually the patient's own teeth, following a blow, fall or removal of infected teeth. Sit the patient down with the head tipped slightly forward to allow the blood to drain. To control the bleeding, place a gauze pad over the wound and ask the patient to apply pressure, with finger and thumb, to the area for ten minutes. If bleeding from a tooth socket, place the pad over the wound and ask the patient to bite down on it. Here you should replace the pads as necessary. Do not allow the mouth to be washed out as you may disturb blood clots. Inform your patient to avoid hot drinks for twelve hours.
If the gums bleed, the use of a daily mouthwash of yellow citrus fruit and lavender can help.

Vaginal

Bleeding from the vagina is likely to be menstrual bleeding, which is often accompanied by menstrual cramps, but it can also indicate miscarriage, recent abortion, internal disease, or injury as a result of sexual assault. The history of the condition is therefore paramount for diagnosis. If bleeding is severe, shock may develop. For further information, see sections on 'miscarriages' and 'menstruation'; menstrual cramps can be eased with the topical application of chamomile oil.

Anal

Infrequent movements from a poor diet may lead to hemorrhoids (piles) where the veins surrounding the anus become abnormally dilated. Hemorrhoids may also occur where there is obstruction to the flow of blood. You should advise a more fibre-rich diet and medication, typically administration of linseed oil. Yarrow can also give relief.

Urethral

Blood may be present in the urine for a number of reasons, the most common of which is a condition called cystitis, where the membrane lining the urinary bladder may become inflamed. This condition tends to be prevalent in female dragonriders. Males are infrequently affected as the length of the urinary tract is longer and the bacteria have further to travel. Other causes include kidney and bladder infections, and severe blows to these areas. Commonly, these conditions can be treated with barley, uva-ursi, horseradish or pyrole.

Others

Other injuries are less common and are frequently fatal. These include amputation, crush injuries and impalement. The amputation of a limb, or part of a limb, must be treated quickly. Blood loss should be controlled, and numbweed and fellis administered. The wound should be sealed as soon as possible, usually by the sterilizing action of fire. Only minor crush injuries are treatable, such as that of a finger, and may result in the subsequent amputation of the injured site due to impaired circulation and toxins in the circulation. Impalement with things such as knives should be treated carefully, the knife only being removed once the patient is stabilized. In all these cases, a great deal of blood will be lost and the patient will go into shock.

Minor Injuries

Bruises

Bruises are sites of internal bleeding that seep through the tissues to produce discoloration under the skin. Bruising may develop very slowly and appear hours, even days, after injury. They may indicate more severe injuries, for example a broken bone (see 'broken bones') or sprain (see 'sprains'). In most cases, it is beneficial to raise and support a badly bruised area. Applying a cold compress and a bandage may also prove fruitful. All bruises benefit from the external application of a dilute cream of arnica, although this should -not- be done is the skin is broken!

Foreign Bodies

Small pieces of glass, wood splinters or grit lying on a wound can be carefully picked off, or rinsed with cold water, before treatment. Some can cause minor puncture wounds with little or no bleeding, but most can be removed with care and a pair of forceps. However, removal of embedded objects is more problematic. First stop any bleeding, cleanse the wound as throughly as possible, numb the area and then, with forceps, begin to remove each fragment. You must remove as much as possible.

Infection

All open wounds may be contaminated by micro-organisms (germs), either from the wounding source, from the air, or from the breath or fingers. Bleeding flushes some particles of dirt away. Germs that remain may be killed by the body's white cells or alternatively, may multiply and spread infection through the body (septicemia). Wounds that show no signs of healing within two days should be considered to be infected.
In spite of a Healer's best efforts, wounds can become infected. When this happens, a Healer must be able to recognize and treat the condition. The signs of infection include: (1) increasing pain and soreness, (2) swelling, redness and a feeling of heat around the wound, (3) pus within, or oozing from, the wound, (4) swelling and tenderness of the glands in the neck, armpit, or groin, (5) faint trails(along the veins) on the skin of limbs leading to these glands, and (6) if the infection is advanced, signs of fever—sweating, thirst, shivering and lethargy.

Any of these signs is cause for concern and treatment should begin as any of them are recognized. As the infection advances, signs of fever including sweating, thirst, shivering and lethargy become apparent. Hot poultices may be used to try to draw out the infection and are often effective. If this treatment does not produce improvement, it may be necessary to pierce the wound to allow it to drain, or to re-open a wound and re-clean it. Either of these procedures is extremely painful, and the patient should be sedated with fellis juice during the process. Extreme care should be taken to prevent further infection, and infection of others from infected materials. Dressings used on an infected wound should be destroyed, and tools should be boiled in water before re-use. The patient should be watched carefully until the wound is fully healed.

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