Wound Care in Austere Environments: A Framework

How Do You Clean a Wound in the Field?

A wise old trauma attending once said, "Dilution is the solution to pollution." Irrigation is the single most important intervention you can control. The goal is mechanical removal of dirt, foreign objects, and bacteria from the wound. Which solution and method you use depend on circumstances, but we can fall back on sound core principles with literature evidence from Wilderness and Environmental Medicine and Army literature from the Joint Trauma System.

In the absence of sterile saline, The Wilderness Medical Society's guidelines list potable water as the preferred irrigation fluid in the austere setting, whereas military prolonged field care guidance grades the irrigation ladder as: Dakin's solution or sterile isotonic solution (BEST), clean potable tap water (BETTER), and the cleanest water available (MINIMUM) — while the military war-wounds guideline finds normal saline, sterile water, and potable tap water to have comparable efficacy. If the water is not potable, boil it for at least 3 minutes and let it cool before using it to irrigate the wound. Current evidence does not support additional treatment with iodine, bacitracin, or antibiotics in the fluid, as no benefit has been documented.

Literature consensus on how much fluid to use for wound irrigation varies, with standard military guidance advocating 1-3 L for small wounds, 4-8 L for medium-sized wounds, and 9 or more L for large, heavily contaminated wounds. This is far more water than you will likely carry in your ruck, which is why knowledge and experience with competent water-processing techniques are critically important when operating an austere clinic.

Recommendations on the amount of pressure to use when irrigating the wound also differ. The literature and doctrine for military war-wound guidance advocate simple bulb-syringe or gravity irrigation and note that very high pressures confer no additional benefit and can damage tissue. Whereas literature from wilderness medicine journals recommends higher-pressure irrigation (a syringe through an 18-gauge catheter). Our medical practice in austere environments uses potable water, or U.S. standard tap water at a pressure of 6-12 PSI. This can usually be obtained by piercing a plastic bottle with an 18-gauge needle.

Should You Close a Wound in the Field — or Leave It Open?

This is the decision that most cleanly separates the two worlds this series bridges. In the civilian wilderness context, most clean, low-energy lacerations can be safely closed in the field — within roughly 6 hours of injury, up to 10 for the face and scalp. Grossly contaminated wounds should be left open and packed for delayed closure.

War wounds run on the opposite doctrine: high-energy, contaminated wounds are left open, and military guidance is blunt here: avoid closure in the first 48 hours, and in general leave the wound open until you reach definitive care, with the face as the main exception. The variables that decide which doctrine applies to the wound you're treating are mechanism, energy (high or low?), contamination, time since injury, and the austere multiplier of how long you will own this patient and their care. If you close a wound and you are wrong, you will reopen it under suboptimal conditions, possibly without medical backup.

Dakin's Solution: A 1915 Answer to a 2026 Problem

The above recipe is presented for educational purposes only and is NOT medical advice from a physician, nor does it construe a physician-patient relationship. Only use Dakin's solution with a valid physician prescription and under said physician's close supervision.

The precise cautions and clinical judgment around its use are somewhat outside of the scope of this introductory article, but Dakin's solution remains central to the spirit of austere medicine and prolonged casualty care: antibiotic scarcity is not the end of infection control.

The Discipline That Holds It All Together

Patient care in the field degrades without a disciplined framework.

The best care to provide in the field environment is the standard of hospital care in the United States or NATO, and we deviate from that standard only because we have to, not because we can. Just because you're in camo and the dirt does not give you a license to do nonstandard medical procedures when you actually could meet the standard of care.

— Prolonged Field Care Podcast 135, at 1:00:28

And whether you're caring for your buddy until search and rescue finds you, or you are a line medic doing prolonged casualty care, the standard of care is the standard of care. YOU are the nurse, and what you do for your patient will pay dividends, or catch up with you, down the road.

Current PCC nursing guidance:

1. dressings inspected at least every 24 hours
2. limbs distal to splints and pressure dressings checked every 6 hours in the conscious casualty and every 2 in the unconscious
3. every finding is documented, so the next provider inherits actionable data and can extrapolate future needs rather than relying on guesswork.

This series of articles will conclude with controlling human factors in austere wound care and include discipline, fatigue, errors, and mental health considerations.