[Flashback] Starting a New Life

[Kavala]

Timestamp: Fall 507 AV
Location: Opal Temple
Purpose: Medicine Training - Classes w/Kanis Obvala

Kanis Obvala was a good instructor. It was just strange for Kavala to sit in on a class full of Konti taught by a Konti. The Kontinese was a struggle too, but the more she was here, the easier it was to pick up on the language. In spite of the language barrier, Kavala was having a good time in her classes. The Konti healer was ancient, though she didn't look a day over the age a thirty year old human would - and she spoke a smattering of Pavi which helped Kavala tremendously when the language became an issue. Slowly, Kanis was bringing Kavala both up to speed on the language, and on her healing.

"Today we are going to start with the most basic of illnesses - wounds and the bleeding therein. There's a great many types of injuries, but most come into play with a wound being created, bleeding, and then often times shock setting in. We are going to begin by talking about how to stop bleeding. We'll talk about the different types of bleeding, and then the different types of wounds. Then, I will be moving into shock and how to treat that tomorrow." The Konti said thoughtfully. Kavala took notes, writing as quickly as her teacher spoke. Her notes were in pavi though, because her written Kontinese was weak.

"The first and most basic rule to stop bleeding is to plug the hole. Just like you cannot get ice to form on a fast moving body of water, blood will not 'clot' or form blockages like ice to naturally stop the flow without the flow first being stopped. The key to this is pressure. All wounds that are bleeding must have pressure applied to them. The flow must be stopped. Use whatever tool is at hand, even your own fingers in the worst case. Best case, use gauze, clean cloth, and hold the wound firmly until the wound stops bleeding. If the bandages get soaked, do not remove them. Keep adding additional layers and leave the pressure in place. Remember, cut off the flow." Kanis repeated. One of the students raised her hand and asked about a bloody nose as well.

"Bloody noses are usually infrequent and happen in children or adults as a result of trauma. If you get one or have someone near you that gets one - Lean forward, not back. Don't try to protect clothing by leaning back. The blood needs to go somewhere and in this case that's highly likely its the throat. If the victim leans back, blood could get in the windpipe causing a blocked airway, or go into the stomach. Blood may irritate the stomach lining and cause the victim to vomit. So, pinch the bridge of your nose or theirs, lean forward, and hold it for five to ten chimes. After the first five chimes, check to see if its stopped. If it has, they should be fine.. but don't let them blow their nose because they will likely get the flow going again." Then, looking thoughtful, she continued. "If bloody noses are regular, its generally a sign of illness or a chronic disease. If they are infrequent, don't worry about them. However, if they are accompanied by a headache and caused by head trauma, please make sure the victim lays down and rests. They could have a brain injury, which we can talk about later." She emphasized.

Kavala took more notes, labeling a new section of her notebook on bloody nose. She added to the wound treatment section and then looked up to hear more. Kavala wanted to learn about treating shock, specifically, then how to handle the rest of the wounds. Shock, it seemed, was going to be an easy one. And they'd handle it the next day after they got done practicing applying pressure to makeshift wounds and pressing their own noses and each other's noses and leaning forward. They also got a small crash course on dry gill and what to do when gills began to bleed. It was similar to nose bleeds though one had to apply wet cloths soaked in salt water and then hold the cloths to the gills until the bleeding stopped. The Konti was then advised to stay under water for several hours and to rehydrate their body. Bleeding was no joke.... regardless of where it was.

[Kavala]

Kanis Obvala then moved into the different types of wounds. As it turned out, there were four types: Lacerations, Abrasions, Contusions, and Avulsions. She took good notes of each types.

1. Lacerations – Injury where tissue is cut or torn. For treatment, tissue is first cleansed of any blood clots and foreign material, débribed and irrigated. Local anesthetic is administered and wound closure is employed, where wound margins are realigned with careful regard to prevention of any further crush injury to tissues. Dressings are applied and immobilization is recommended for complex extremity wounds. Puncture wounds fall into this category.
   
2. Abrasions – Injury where a superficial layer of tissue is removed, as seen with 1st degree burns. The wound is cleansed of any foreign material, sometimes employing a scrub brush to prevent traumatic tattooing by dirt and gravel, and should be performed within the first day of injury. Local anesthetic can be used for pain, however treatment of the wound is non-surgical, using moist dressings and a topical antibiotic to protect the wound and aid healing.
   
3. Contusions – Injuries resulting from a forceful blow to the skin and soft tissue, however leaving the outer layer of skin intact. These injuries generally require minimal care as there is no open wound. However, contusions should be evaluated for possible hematoma deep to the surface or other tissue injuries that may indicate more severe morbidity. An expanding hematoma can damage overlying skin and demands evacuation.
   
4. Avulsions – Injuries where a section of tissue is torn off, either partially or in total. In partial avulsions, the tissue is elevated but remains attached to the body. A total avulsion means that the tissue is completely torn from the body with no point of attachment. In the case of a partial avulsion where the torn tissue is still well-circulated by blood and viable, the tissue is gently cleansed and irrigated and the flap is reattached to its anatomical position with a few sutures. If the torn tissue is non-viable, it is often excised and the wound closed using a skin graft or local flap. In the case of a total avulsion, the tissue is often very thick and demands debulking and defattening methods before it can be regrafted. Major avulsions describe amputation of extremities, fingers, ears, nose, scalp or eyelids and require treatment by an advanced medical doctor or healer with a level two gnosis.

Kavala carefully took notes. She understood the four classifications and the differences between them. Kanis went on to then describe what exactly a hematoma was. "A hematoma is a localized collection of blood, usually clotted, in a tissue or organ. Hematomas can occur almost anywhere on the body. In minor injuries, the blood is absorbed unless infection develops. Contusions (bruises) and black eyes are familiar forms of hematoma." Her instructor said. Kavala nodded with a smile, exchanging glances with the other Konti in the class. They'd all witnessed, outside of Mura, the typical fistfight and black eye.

But, Kanis wasn't done. "Less serious types include subungual hematoma (under a fingernail or toenail); hematoma auris (in the tissues of the outer ear, better known as cauliflower ear); and perianal hematoma (under the skin around the anus)." The girls giggled a little, while one or two of them turned red. Kavala just looked interested. "Hematomas are almost always present with a fracture. They are especially serious when they occur inside the skull, where they may place local pressure on the brain." Kavala looked more concerned now, and hoped they would be talking about fractures soon.

But it seemed Kanis wasn't finished yet again. She went on at length about hematomas and their treatment. "For contusions (bruises), treatment consists of initially applying ice or cold packs a few times a day, to produce a reduction in arterial blood flow which helps to decrease bleeding and swelling. In general, the quicker you apply ice after the injury, the less bleeding will result. If possible, elevate the bruised limb. Blood will leave the area of the wound and there may be less swelling. Resting the limb will also help to prevent further injury. If the area is still painful after two days, apply gentle heat with warm towels,or a hot water bottle. The heat is applied for twenty chimes at a time to promote absorption and repair. Since heat causes swelling and increases tissue fluid, which may impair function, hot compresses may be followed by cold applications to minimize the secondary effects of heat. Pressure in the form of a bandage may be helpful to reduce hemorrhage and swelling. If infection should develop in the wound, the signs and symptoms might be increasingly severe pain, a fever , swelling with surrounding redness, and pus. If any of these signs appear, this is a serious condition that is life threatening. You will need to treat with herbs and possibly the application of Healing Gnosis if available. " The instructor said. Kavala wrote furiously. The subject matter was fascinating, and she hoped they'd actually get to witness some hemotomas.

[Kavala]

The next section of the lecture talked about assessing wounds and the steps in actually dealing with them. This was very exciting for Kavala, since she'd always wanted to learn the proper techniques. The steps were actually fairly easy. Once a wound was presented, the medicine required was fairly simple.

1. Who is the Patient? - Patient assessment is important. Children, for example, might need calming or pain treatment where adults, specifically warriors with high pain tolerances might not. As a medical practitioner, it is your responsibility to assess the patient and determine what their needs are. Do absolutely the bare minimum. If they can tolerate the pain, treat the wound without pain care. If they cannot, then use the least amount of pain care necessary for getting the job done.
   
2. Pain Assessment and Treatment– If the patient merits pain care, take care of the pain BEFORE you begin working with the wound because your care of the wound will most likely cause additional pain. Pain blockers and numbers are recommended for all wounds in all ages - save in the eye.
   
3. Tourniquet – If the wound is bleeding to the point of being life threatening and is on a limb or extremity, a tourniquet must be applied to staunch the flow of blood to either finish the following steps or remove the appendage completely.
   
4. Wound preparation – Cleanse surrounding skin with alcohol or clean water to prevent further tissue damage.
   
5. Wound Exploration and Stabilization – Explore wound carefully for any foreign bodies and to determine extent of injury by assessing tissue injury, amount of tissue lost, and the degree of injury to deeper structures. Then stabilize the wound by means of direct pressure, elevation, or suture ligation.
   
6. Débribement – After viability of wound margins are assessed, remove all ruined tissue and excise ragged edges to prepare for realignment. The goal of débribement is to produce a clean, bleeding margin of viable tissue.
   
7. Wound Closure – Does the wound need to be closed by either dressing it or sutures? If so, do so now.
   
8. Dressing – Does the wound need to be dressed? If so, complete the dressing at this point, though apply herbs before completely concealing the closure or wound.
   
9. Herbalism Usage – Herbs can be used to prevent infection both before and after the wound is closed depending upon the situation. The medicine practitioner should always weigh the options of the need for herbs in regards to how likely infection will set in. In the case of a dog bite, infection is always going to happen. In the case of a cut, it simply depends. In either case, the location and age of the wound, as well as the mechanism of injury should be considered to determine the concern for infection.

At that point Kanis went through the complete step by step process of cleaning wounds and dressing them. The dressing lesson was interesting because they also learned to make bandages and what types of cloth and factors influenced what sort of dressings and bandages used. The konti in class happily pretended various injuries and then the girls were graded on how they decided to treat them based on what they assessed and where they went in terms of treatment after their intital assessments. Kavala got to pretend she had an eye injury and one of the other konti in the class wrapped the wound after she assessed the injury. Kavala, with a laugh, received no pain treating herbs. That made her slightly proud and she laughed the whole time she assessed another Konti's wound (a belly gash) and gave her extra pain herbs.

[Kavala]

The theme of the class today was shock treatment. Kavala came into the class not really understanding what shock was, so the class should be rather interesting. The Konti loved learning new things, especially about medicine.. and shock was a completely new experience for her. Again, throughout the lecture, she took notes. Her notes where vital to her learning process, as she studied them day in and day out after she got her lectures. They were tested, during the courses, for how much knowledge they were retaining.

Kavala's notes looked thusly:

1. Understand the possible causes of shock. Shock usually is associated with:
   
   
   
   • Blood loss
   • Severe head injury, traumatic brain injury
   • Severe infections
   • Heart failure
   • Severe burns
   • Severe trauma
   • Dehydration
   • Severe allergic reaction - this may be due to herbs, foods, insect stings or snakebites.
2. Assess the situation. If the cause of the victim's injuries is still present (fire, dangerous animal, building collapse) and a serious risk, you may have to try to remove the victim to a safer place, or get help before attempting treatment.
   
   
3. Look for shock signs/symptoms. Common shock signs/symptoms include:
   
   
   • Pale, cold, clammy skin (cool to the touch, and sweaty)
   • Rapid pulse
   • Sweating
   • Nervousness, agitation
   • Disorientation/confusion, giddiness
   • Thirst
   • Bleeding/blood loss
   • Rapid breathing, gasping for air
   • Blue-tinged skin (especially lips) or fingernails
   • Nausea or vomiting
   • Weakened pulse
   • Dizziness / fainting
   • Unconsciousness (possible eventually).
   
   
4. Communicate with the victim if he or she is conscious.
   
   • Look for injuries such as bleeding which you may be able to treat.
   • Loosen any constricting clothing around the neck, waist, and chest.
   
   
   
5. Begin treatment immediately if you see any of the signs/symptoms of shock. The sooner you begin treatment, the less likely a person is to go into shock.
   
   
   
6. Make sure that the person is breathing and has a steady heart rate. Keep checking breathing and pulse regularly.
   
   
7. Lay the victim on his or her back, and elevate his or her legs about a foot. This is called the "shock position", and facilitates blood flow to the organs and brain. Make sure that the legs are higher than the heart.
   
   
   
   • Do this only if it does not cause further injury. You should not move someone to this position if he has suffered significant injuries to the legs, neck, head or spine.
   • Do not put a very weak or unconscious victim on his back. Instead, lay him on his side in the recovery position. This will allow the mouth to drain in case of vomiting and prevent the tongue from blocking the airway.
   
   
8. Maintain normal body temperature. You don't want the victim to get too hot or too cold.
   
   
   • If it is cold, remove wet clothing and place an insulating barrier between the victim and the ground, if available, to decrease body heat loss (body heat is lost quickly through cold ground). A blanket, jacket, or a large towel will help. Wrap the victim in a rescue blanket or cover them with any available covering to keep them warm.
   • If it is hot, move the victim to a shaded area and keep him out of the sun. Remove restrictive clothing if you have not already done so.
   
   
9. Watch for vomiting. If the victim vomits, tilt their head to the side and clear their airway. Do not move someone's head if they could have a head/spine injury. Instead, log-roll their head and body as one (you'll need at least two people to do this effectively).
   
   
10. Treat the underlying injury. Do your best to stop bleeding, stabilize fractures, treat a snakebite, or take other steps to prevent the victim from getting worse.

Completing these steps will significantly decrease the risk of any shock setting in and thus increase significantly the likelyhood of someone surviving trauma or injury effectively.

Once Shock was lectured on, the girls broke up with half the room becoming shock victims and the other half becoming healers. Kavala got to be a victim the first time around, letting one of her classmates treat a fake injury that resulted in a 'mild' case of shock - according the slip of paper she drew from Kanis' hat. Then, later in the day, they switched sides and Kavala got to practice medicine by treating shock from a 'sever' case of shock.

Shock took one whole day, in which all the girls had a great time. The next day, one of the harder days of the course, would see them receiving their suture kits and leaning how to stitch up wounds properly. Everyone was excited by the prospect of actual 'tools' and learning the use of those tools... so the girls hurried home and got their rest so they could get a fresh start in the morning.

[Kavala]

The next day, ten Konti medical students filtered in to their classroom and received their suture kits. Kanis spent a great deal of time talking about what each item in the kit did and how it was properly used. The girls got to each have their own kit, so as she lectured, Kavala was able to take the instruments out, give them a good look, and try them out. As always, she took careful notes.

The kit contained several tools:


• Scissors
  
  • Suture Scissors – medium sharp-blunt scissors for general cutting and to trim off excess suture material after placing a suture and tying the knot.
  • Suture Removal Scissors - Small versions of Sharp-sharp scissors are used to cut sutures in order to remove them.
  • Dissection Scissors – Designed to cut tissue towards a certain direction where a scalpel is impractical to cut through certain tissue.
• Probes
  
  • Both sharp and straight, as well as one that is blunt and slightly curved.
• Misc Instruments
  
  • Skin Hook – used to lift a section of skin to facilitate the placement of sutures while minimizing the amount of injury to the tissue.
  • Scalpel – a surgical knife with a fixed or removable blade for cutting tissue.
  • Forcepts – In essence, giant tweezers – used to grab or hold something.
  • Needle Holder – a special type of forcepts that are designed to security hold the surgical suture needle when placing sutures.
  • Sutures – Silk thread used as the material to bind wounds together.
  • Needles – semi-circlular piece of thin rounded metal with a sharpened cutting edge on either the outer or inner curve and an eye on the non-sharpened end in which to fit suture through.

Once the girls were properly familiar with the tools, Kanis went on to give them a detailed accounting of how to thread a needle and prepare it with suture. "Take about twelve to sixteen inches of suture off your roll. Next, Remove one needle from the kit using the Needle Holder. Clamp the needle roughly in the middle of the needle’s body. Secure the Needle Holder by clamping it to the first ratchet and now we can thread. Fold the last 1½-inch of suture double and pass the double thread through the eye of the suture needle. Then, open up the double thread slightly to form a loop, and pass the needle through the loop. Firmly pull the long and short loose ends of the double thread away from the needle - thus tightening the simple loop knot to attach the thread to the needle." Kanis then smiled, and all the girls eagerly began practicing threading her needle. Kavala had some trouble with it because her hands tended to be both lefties when she was working with incredibly small things. But once she got the hang of it and practiced a time or two, it was no big deal.

Next came the knotwork. Kanis handed them out pieces of string, that was half red and half white about ten inches long. The girls would use the string to practice learning their knotwork before they could get on with the process of learning how to actually make the stitches. They learned the differences between a Granny Knot and a Square Knot - utilizing Square Knots always since square knots held while granny knots gave. The lesson was practical and the difference between the two knots were almost indistinguishable save for one loop over another a different way. Kavala was glad she learned the difference, and practiced it carefully over and over until she was sure she would always be tying a square knot rather than a granny knot. Along with the knots, they practiced how to both tie a square knot one handed then two. Kavala found the section enjoyable and took more notes, making sure she could reproduce the knots once she left the classroom. She even added a little diagram as her instructor showed her how to add onto the knots to make them even stronger.

She even took the time to make herself a little sketch in her notes.

Once the square knot was mastered, Kanis moved the girls onto practicing surgeons knots. They were very similar to square knots, but had a minor difference that made them incredibly strong. Later, as they grew in their knowledge, they would use these knots to sew up arteries and blood vessels, even re-attach tissue and muscle together. Kanis was busy explaining up at the front. "The surgeon’s knot is essentially a square knot with the difference that the thread is passed twice through the first loop. The surgeon’s knot is a very important knot. Master it thoroughly -your patient’s well-being or even his /her life will depend on your level of skill when tying this knot." She said, reiterating why it was so important.

And again, another sketch.

With that, the girls were ready for adding sutures and tying them off. Kavala looked on curiously as Kanis explained how this was going to be done.

Then the girls got to practice doing stitches themselves. In this case, each girl was given a large slice of whale skin that still had a layer of blubber attached beneath. The skin was about 8x10 inches in shape, and about two inches thick. The idea was for the girls to take the scalpels and make long incisions in the flesh which they would then sew up again. Kanis guided them through the process, and before they knew it they had three or four long gashes in which to practice their needlework on. Then, once they had their 'gashes' in place, they began their work with her guiding them on how to lift the skin, how to place the stitches, and finally how to use their new found knotwork skills to tie off the work at the end.

As the girls worked, Kanis explained the difference between beneath the surface stitches and stitches to the skin - and then the girls were given even thicker pieces of blubber to practice on so they could reach down and sew up multiple layers of tissue at one time. They learned about leaving drains in, not entirely closing a wound so it could get air and leak pus to speed the healing in some cases - both why and when to do this. Pretty much their day was full up with the work of it... and would be for many more days to come.

[Kavala]

There were two last issues in that particular course that Kavala had to learn. First and foremost, they had to look at multiple real wounds and determine what type they were and what the treatment for them could be. They focused heavily on puncture wounds - stray arrows, daggers, sword cuts - or in the case of Konti Island accidents that mimicked such things since there were really no battles to be seen. They cared for accident victims in the temple clinic and got lots of time in on dealing with animal attacks and bites. They also learned how to treat multiple wounds, which was important. Kanis patiently explained to them that in the case of multiple wounds, sometimes all their training had to fly out of the window in order to save a life.

"Treating a victim of a severe cut is hectic enough without having to address multiple injuries. But in the world we live in, multiple injuries are very common. Most things capable of causing severe bleeding also can cause multiple wounds. As overwhelming as multiple wounds may seem, the trick is to keep calm. Take a look at the victim and find the worst injuries. Stop the worst bleeding first. Concentrate on the wounds that have bright red or actively flowing blood, and then move on to less severe bleeding. Don't go through all the steps to control bleeding before moving on -- as soon as the blood has stopped flowing begin working on the next wound. Sometimes blood stops just because you've plugged a hole. That's good. Move on. Treat for shock if the victim develops weakness, confusion, drowsiness, or sweating." Kanis said, reiterating what she felt was important. Multiple wounds were a fact of life. And they saw it over and over again - shark attack, dog bites, even the occasional pirate raid. The students got hands on training and learned how to handle themselves in the face of a great deal of blood and pain.

The final installment of the class was on tourniquets. They were important in stopping blood flow from wounds while sutures were being applied or cleaning and repair was taking place.

Kanis began the lecture with a serious talk. "Tourniquets are tight bands used to control bleeding by completely stopping the blood flow to a wound. Tourniquets work only on arm and leg injuries, never on the torso, neck, or digits. Tourniquets are usually reserved for the worst bleeding to keep the victim from developing shock. If properly used, tourniquets can save lives. If immproperly used, they can cause tissue damage and even amputation. So training in the use of a tourniquet is vital." The Konti healer said, opening up a cravat cloth and demonstrating what one looked like. She continued after her warning. "Tourniquets can arrest bleeding quite well and are certainly useful in cases of severe bleeding that cannot be stopped any other way. They're popular on the battlefield because they can be applied quickly and do not need to be constantly monitored once they are in place so soliders can focus on protecting themselves and getting help from healers rather than going into shock or dying of blood loss."

Kanis went on to elaborate on the correct use of a tourniquet while Kavala kept notes. "Tourniquets only work if they are tight enough to stop arterial blood flow. Arterial blood is under significantly more pressure than venous blood, and it takes more pressure to stop it. Tourniquets should not be too narrow, or they will cut into skin as pressure is applied. Unfortunately, the wider the tourniquet, the more pressure that is required to stop blood flow. So get a feel for how much you need where - which will come over time. And learn to utilize your surroundings to make tourniquets from. Most healers and medical practitioners also wear bandannas eithr around their necks or throats so they always have one handy." She added before moving on.

" In general, tourniquets should be between 1 and 2 inches wide. Tourniquets on the leg will need to be narrower than those on the arm, due to the increased pressure necessary to stop blood flow in the leg. Remember, narrow equals more pressure, wider equals less pressure." Kandis reminded the girls, who were all furiously taking notes. As usual, she had more to say...

"Tourniquets should used only be used when there is no other way to stop bleeding. Tourniquets that are applied too loosely can actually worsen bleeding. If the tourniquet only stops venous blood return, but does not stop blood flow in the artery, bleeding gets more severe below the tourniquet. Leaving a tourniquet in place too long may lead to tissue damage, but removal may lead to more severe bleeding. The potential for loss of limb is outweighed by the potential for loss of life." The healer said, looking each and every girl in the room. Then, she began to go over the proper way to apply a tourniquet.

Kavala took frantic notes and listened carefully as the step by step process was then described.

1. Use a cravat or bandana and fold it lengthwise until it's between 1 and 2 inches wide.
   
2. Tie the tourniquet around the injured arm or leg, several inches above the injury. If the injury is below the elbow or knee, you may need to tie the tourniquet above the joint using a common square knot.
   
3. Place a stick or other long stout item strong enough to act as a windlass on the knot and tie the loose ends of the tourniquet around it in another square knot. Anything can be used as a windlass, as long as it is strong enough to hold the tourniquet and can be secured in place. Pieces of branches or sticks are the most common items used for a windlass
   
4. Twist the windlass to increase the pressure until the bleeding stops.
   
5. Secure the windlass by tying one or both ends to the victim's arm or leg

Then, afterward, each girl was given her own bandanna with the opal order insignia on it and got to use it to practice tying tourniquets on their limbs - both arms and legs. Kavala found the whole process interesting because by utilizing the tourniquet she could stop blood flow long enough to preform wound care without weakneing the victim and aiding in keeping the wound clean. So far, the classes at the Opal temple were really paying off for her, she decided, as they concluded their 'wounds' section of the course. After the testing and trials in the clinic, they would move on to bones and talking about bone setting, dislocations, and fractures. She was looking forward to that class as well.

[Alice]

Mura Experience Award Please update your CS accordingly! Experience Points Awarded: Kavala - 5 pts Medicine, 2 pts Writing, 2 pts Drawing Lore Awarded: Kavala - Lores of 4 Wound Types, How to Stop Bleeding, How to Treat Bloody Noses, How to Treat Open Wounds, How to Treat Bruises & Hematomas, How to Assess a Patient, How to Treat Shock, Content of a Surgery Kit, Square Knot & Surgeon's Knot, How to Treat Multiple Wounds, Making & Applying Tourniquets Comments: Nice thread! It shows that you really understand the subject you're talking about. Naturally, you can also add the Opal Order bandanna and suture kit to your CS. Edit: I hope you can forgive me my mistake and my confusion (or whatever) at our discussion. I try to learn and I'll gladly fix any future mistakes that are pointed out to me.