Research of less-than-desirable topics (wounds, wound complications, etc.)
- This topic has 185 replies, 20 voices, and was last updated 8 months, 2 weeks ago by Rose.
March 4, 2021 at 2:06 pm #125691Naiya Dyani@naiya-dyani
@deeprun You meanie, Kiet’s pain is all because of YOU. YOU started this. Don’t complain when he doesn’t want to come to your house anymore.
@anne_the_noob14 I’m sorry, I am, Kiet can come hang out with you for a while
Hearts are like matter--they can be beaten down, torn, and burned, but they cannot be destroyed.March 4, 2021 at 5:04 pm #125701
The rumors of my demise have been exaggerated. Not by much, but I am indeed still around. Just. Super. Busy. Studying harder than ever before so I can pass this semester and then go on to earn my RN. A lot of my subject matter has been super esoteric or crazy in-depth stuff – neurologic disorders and cranial trauma, burns, shock — all the ooey gooey vivid trauma drama that we writers love.
So, if you’ve got a question about eye lacerations (or any sort of injury), I’m still happy to answer. It just may take me a little while.
Non nobis Domine, sed nomini, Tuo da gloriam.March 7, 2021 at 11:27 am #125782
How could someone in medieval-y times treat several large (1st or 2nd degree) burns across most of their body alone out in the wilderness.
"Remember, you go nowhere by accident. Wherever you go, God is sending you." - Rev. Peter R. HaleMarch 7, 2021 at 11:30 am #125783
The post duplicated so I’ll just give some context I guess. A character is trying to actively avoid civilization for plot reasons and he’s been attacked recently, which kinda involved him getting set on fire (though that didn’t last long because his fire magic let him extinguish the flames relatively quickly). He’s out in the middle of nowhere on the eaves of a huge forest, so herbs are probably in abundance if needed.
- This reply was modified 2 years, 2 months ago by Skylarynn.
"Remember, you go nowhere by accident. Wherever you go, God is sending you." - Rev. Peter R. HaleMarch 7, 2021 at 2:57 pm #125787
This question is actually perfectly timed since burn care is on my exam for this week anyways. I’m going to cover this first from a modern nursing perspective and then from a medieval historical perspective, including procedures, materials, and mindset. Forgive me if I repeat any information you already know.
A warning – the full answer is a REALLY, REALLY LONG POST. I’ll post it below, but I’ll also give you the TL;DR here:
Burn wounds are hard to survive, all the more so without medical aid (even amateur help). In order to stand a chance of surviving, he will need to guard against infection by keeping his wounds meticulously clean and bandaged (and changing those frequently), keep hydrated (drinking 2-4x his normal intake), and eat a high calorie diet (4000-6000 calories) to fuel his body for the healing process – and rest, as his burned skin is not going to recover if it’s constantly stretching and stressed by activity.
However, for widespread 2nd degree (partial-thickness) burns, he is going to need skin grafts to replace his lost skin, and that’s simply not going to happen without medical help. Until he can get that kind of help, he’s going to just have to keep those wounds bandaged.
If he had 3rd degree burns, the only way to survive would be to amputate before the wound turned gangrenous and he developed sepsis. There’s simply no way a man in the woods by himself can survive that kind of injury without either medical or magical help.
Anyways, verbiage below!
Non nobis Domine, sed nomini, Tuo da gloriam.March 7, 2021 at 3:19 pm #125788
Burn wounds are really, really hard to survive. Even today, the mortality rates aren’t great, varying from 3 to 55% based on the extent of the burns and whether or not inhalation injuries occurred (inhaling soot, carbon monoxide, scalding steam, hot smoke / air which physically burned the lungs, etc.) One of the biggest killers besides sheer fluid losses and multiple organ failure (from the renal effects of general tissue / muscular destruction) is infection, and that is all the more the case with medieval injuries.
Now, some clarification of terminology:
A 1st degree burn is a minor superficial burn, ranging from a sunburn to a mild chemical irritant or a brief steam scald. There’s no loss of living skin, just red irritation and inflammation at the site. These burns are not life-threatening, and we’d treat them with just some cool water and some soothing ointment. 1st degree burns are not an infection risk as the skin remains intact. This sort of burn would be very easy to treat by yourself.
A 2nd degree burn, or partial-thickness burn, is much more serious. Such a burn has completely removed the epidermis and penetrated the dermis (the living layer of your skin). The wound will appear red or pink, often moist and weeping, and will develop blisters; some of these maya also weep a serous (clear) exudate or blood, while others may have a pale, waxy appearance. Weeping blisters are actually less concerning; these indicate a more shallow burn, while the waxy, dry blisters indicate a deeper injury of tissue. In both cases, infection is a serious risk, and the burns will be very painful. However, this should not affect muscular activity, as 2nd degree burns have not completely penetrated the hypodermis (fat layer) beneath the skin, and thus have not reached the muscles or bone. So you may still be able to treat yourself, but it will be much more difficult than with 1st degree burns – and unlike the modern age, your guy will probably not have the luxury of skin grafts, especially being alone in the woods by himself – although skin grafting was attested in India in the 1st century AD, so it’s possible the technique existed elsewhere as well.
WHICH brings us to the matter of treatment (in a strictly medical sense):
Specific to your character, who has suffered widespread superficial and partial-thickness burns, his primary concerns are (1) fluids, (2) nutrition and (3) infection.
The latter is honestly almost guaranteed considering his environment, available materials, and total lack of supportive care. 2nd degree burns will take 1-3 weeks to heal assuming our guy has the time and nutrition to rest, and is able to keep it clean and protected.
Being on the run in the middle of the woods with aught but the shirt on his back? (whatever he hasn’t burned off, that is) His chances are not good.
What he needs are clean bandages, and lots of them, since being out in the woods and presumably active in trying to survive, he’s going to get them dirty very quickly and will need to change them at least daily and probably more frequently than that to prevent infection. (there’s other measures to be taken but I’ll get into that in the historical section).
He will need to drink a lot of water, probably 2-3x as much as the normal fluid requirements, especially in the first 8 and then 16 (24 hours total) of the burn injury. (A note on this later)
His fluid requirements are based on the percentage of burned total body surface area (TBSA), for which we have the very handy Rule of Nines that I’ll go over below. The amount of fluid is based on the following formula: 4 x TBSA (%) x body weight (kg) in milliliters. The BSA is not given as a fraction but as a whole number (so if 50% is .5, just put the 50).
As for getting the body surface area, I present the Rule of Nines, which lets you quickly estimate how much of the body’s surface area has been compromised by burns. Whichever limb (and distinguish front and back!) has a burn contributes to the TBSA%
1. Refers to the Body Surface Area of each limb.
2. The front and back each are half of each limb’s BSA.
a. Arm is 9% front and back. 18% total (both arms)
b. Leg is 18% front and back. 36% total (both legs)
c. Torso is 36% front and back. 36% total
d. Pubic area is 1% 1% total
e. Head is 9% front and back. 9% total
Note that 1st degree (superficial) burns are not counted in this formula, since they don’t compromise skin integrity.
He will also need a huge amount of food and calories.
Patients with >25% TBSA burned (whether partial or full-thickness) will need between 4000-6000 kcal per day for healing and tissue reconstruction. These days, burn patients in the ICU get what’s called a “Burnshake” which is something like a 2L milkshake filled with sugar, peanut butter, chocolate, all the sugary and fatty delights. While it is delicious, it is also medically necessary; your body is physically rebuilding a huge amount of lost tissue. Imagine recovering from a workout, but x10. Your skin accounts for about 16% of your body weight and is the single largest organ in your body by both weight, volume, and surface area. So when it gets damaged, it takes a lot of work to put it back into shape.
<span style=”text-decoration: underline;”>Historical Comments:</span>
<span style=”text-decoration: underline;”>1. Infection</span>
Any sort of open wound in the Middle Ages could be a death sentence. That said, our medieval ancestors were not idiots, even if they had a very different logic than ours. For example, today we perform craniotomies (drilling a hole in the head) to relieve excessive intracranial pressure, prevent brain damage, and treat seizure disorders. The medieval and their ancient forebears performed virtually the same operation, trepanning, in order to treat madnesses, mental disorders, and extreme headaches (potentially strokes, migraines, or seizure disorders), with some level of success. That was a big tangent, but the point is that our predecessors knew a lot more than we often give them credit for, and they worked with what they had.
Keeping his wounds clean is his number one priority. Burns are especially difficult to clean – hence why we prefer to just not let the patient get dirty so that the dressing only has to be changed once every 3-5 days. The reason is that burns cover a huge surface area which is extremely sensitive to irritation of any kind, whether touch, water, or air. Cleaning his wounds is going to be an agonizing process;
First: removing the bandages (he would probably use dry bandages) is going to feel like he’s peeling off his skin, because he is. Dry bandages adhere to your moist living tissue, and when you remove them hours later, your tender fledgling skin tissue gets peeled away with them.
[We no longer use dry bandages in the hospital but always apply wet-to-moist or moist-to-dry bandages to minimize the amount of trauma to the recovering dermis (which is regrowing as tender, pink granulation tissue). However, in his case, wet or moist bandages would rapidly soil in his filthy conditions, so dry bandages are his only real choice. This will also delay the healing process.]
Second: rinsing the wound with water, preferably saline (salty) water that has been boiled over a fire then allowed to cool to a tepid temperature. Wiping the wound with a cloth is going to cause more harm than help, so he will need a lot of water to get them clean.
Third: rebandaging, with clean bandages. The best (re: only) way of sterilizing bandages in his circumstances would be to boil them in water and hang them to dry over a fire. This will also hurt.
Aside from just keeping the wound clean with water, which any peasant would know, there are also other materials and substances that may be available to your man to improve his chances for survival.
Honey is the most prominent of these, and even today is recognized as a potent antiseptic and even healing agent in all types of injuries. King Henry IV of Agincourt fame once received an arrow injury to his neck, which normally would be a guaranteed infection; a poultice composed primarily of honey protected the wound from infection until it healed. So, if he can find a beehive and get some honey without being stung a million times, his odds would dramatically improve. (Honey will also help reduce the trauma to his skin every time he changes his bandages by forming a barrier between skin and bandage). Though there’s still the problem of the wounds and bandages still getting dirty…
Burn ointments are a more vague subject; they often contained vinegar, egg, some kind of oil and a pain-reliever, as well as miscellaneous other herbs which may or may not be helpful. Apart from opium, which was a well-known pain reliever, there is also willow bark – the active ingredient of which is salicylic acid, better known today as Aspirin (acetylsalicylic acid but close enough). Either substance, opium or willow bark (or clove oil, but he probably doesn’t have that in the middle of the woods) would help make the pain a little more tolerable.
A notable herb is Hedera helix, or common ivy. Boiled in butter to render out its oils, it yields saponin, which is an anti-inflammatory chemical. This may help with the inflammation and blisters common to 2nd degree burns. Salt is another common antiseptic, though obviously extremely painful; however it may be useful to make the ivy preparation less likely to attract bacterial growth.
If this were in a modern hospital, this man would be on IV fluids, because the human body just can’t drink enough fluids fast enough to replace fluid losses from burns. It will take a miracle for this man to retain consciousness and drink enough water to stay ahead of impending hypovolemic shock, and there’s just no medieval equivalent to IV fluids.
Once he goes into shock, if he doesn’t get help, he’s toast; his heart and lungs will eventually crap out as they try to maintain blood pressure and oxygen perfusion to the vital organs with unmitigated fluid losses, and there just won’t be enough circulating blood volume left to keep him alive. Apart from the fluid losses from having exposed dermis, burns also mess up the arteries and veins in the area of the burn, impairing circulation there. Less blood will get there, and the blood / fluid that gets there often won’t rejoin circulation, and you’ll end up seeing “pooling” as fluid builds up (edema) in between cells and tissues or leaks out of the body.
Of course, he may also have huge blood volume loss, depending on the intensity of the injuries, and there’s little he can do to fix that. You can’t drink blood to replace your own, unless you’re a vampire. 😛
This is also a problem. The medieval period has a paucity of easily digestible high calorie foods. There’s basically meat and fat, and meat isn’t even that easy; it takes time and energy to digest meat, and he may not be able to eat it fast enough – or even keep his food down. Nausea and vomiting is a common side effect of sustaining this sort of whole body injury.
Fruit has sugar but it’s not concentrated enough, and the fiber makes it slow to digest. Most food sources are starches, complex sugars, or have a high fiber content, and all of those are just not calorically dense enough for him to eat enough to supply his needs. Honey is the only real caloric equivalent, and he needs all of that just to keep his wounds clean.
What he really needs is someone to help tend to him – to help him find food, drink enough water, change his bandages, and care for his wounds. While having him care for himself completely would definitely be a tough guy card for later, it would be hard to carry it off believably, unless it’s revealed he can’t even feel pain – and there is a fourth reality that he’s going to have to face:
Without rest, without medical aid, under constant stress, repeated trauma to his recovering skin from bandage changes and physical activity, and assuming he even survives, he is going to develop some NASTY scars, either hypertrophic or keloid. His skin could end up looking like just masses of tumorous scales from the scars (even if he doesn’t actually have cancer). Depending on the location and extent of his burns where he’s burned, he may not even look human anymore, and peasants who see him wandering into town will either be awed or terrified.
Non nobis Domine, sed nomini, Tuo da gloriam.March 7, 2021 at 3:54 pm #125789
Thank you so much for your response!
It’s funny that you mention this would be more likely survivable if he didn’t feel pain, because I forgot to mention Brendin doesn’t feel pain (or rather he has a greatly diminished capacity to feel pain) as an after effect of a nasty illness he had in his youth. [Think a combination of scarlet fever and the spanish influenza but carried and transmitted by wyverns. Luckily not very contagious.].
The burns are mostly on his chest and arms with the worst of it around his left shoulder/collarbone area but there’s minimal damage to his neck. And I’d already decided on him having some horrific scarring on his arms, so that works perfectly. Could you explain what hypertrophic scars are? I do know keloid.
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- This reply was modified 2 years, 2 months ago by Skylarynn.
"Remember, you go nowhere by accident. Wherever you go, God is sending you." - Rev. Peter R. HaleMarch 7, 2021 at 4:09 pm #125791
Inability to feel pain will help him at least psychologically cope, and will make the task of changing his bandages easier. Doesn’t really reduce the risk of infection, but it will make it somewhat easier to care for himself.
Regarding hypertrophic and keloid scars, hypertrophic scars are defined as excessive scars growth which remains within the bounds of the original wound, while keloid scars are excessive scarification that expands beyond the original wound border.
Non nobis Domine, sed nomini, Tuo da gloriam.March 7, 2021 at 4:10 pm #125792
Dang, this poor guy…
“Enough! Be quiet! I can’t hear myself think! I can’t hear my teeth chatter!"March 7, 2021 at 4:11 pm #125793
@skylarynn WAIT NO IT’S BRENDIN??? NONONONONONO
“Enough! Be quiet! I can’t hear myself think! I can’t hear my teeth chatter!"March 7, 2021 at 4:17 pm #125794
Don’t worry, this isn’t the worst Brendin’s been through (nor is it the first time he’s been set on fire).
- This reply was modified 2 years, 2 months ago by Skylarynn.
- This reply was modified 2 years, 2 months ago by Skylarynn.
"Remember, you go nowhere by accident. Wherever you go, God is sending you." - Rev. Peter R. HaleMarch 7, 2021 at 4:23 pm #125798
@skylarynn *splutters* But… but… D:
“Enough! Be quiet! I can’t hear myself think! I can’t hear my teeth chatter!"March 7, 2021 at 4:25 pm #125799
Brendin’s been through a heck of a lot. In the character castle I outright mentioned his soul’s been damaged.
"Remember, you go nowhere by accident. Wherever you go, God is sending you." - Rev. Peter R. HaleMarch 7, 2021 at 4:38 pm #125800
So how would a medieval skin graft work out? I ask because previously Brendin had been burned badly enough to need one and a very well trained University surgeon was on hand to treat him.
"Remember, you go nowhere by accident. Wherever you go, God is sending you." - Rev. Peter R. HaleMarch 7, 2021 at 5:37 pm #125807
Also might mandrake root have been used as an anesthetic? You’d mentioned something like that earlier, I think.
"Remember, you go nowhere by accident. Wherever you go, God is sending you." - Rev. Peter R. Hale
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