Blister Care
 

Blatantly copied out of th Journal of Special Operations Medicine, Volume 2, Edition 3 / Summer 02

FOOT BLISTER CARE AT NIJMEGEN 2000
David L. Hamilton, PA-C
ABSTRACT
Forced foot marches have been a staple of soldiering throughout history. Unfortunately, many soldiers' and leaders' desire to cover long distances quickly can cause friction blisters to form on soldier's feet. Many techniques have been used to toughen feet, treat blisters and enable soldier to "Charlie Mike" (continue the mission) with varying results. This work presents an alternative blister care procedure to traditional moleskin donuts and pressure relief techniques. 1 These treatments may cause blisters to enlarge with continued marching, and may require frequent halts for adjustment / reapplication. By treating soldiers with severe early blister formation by taping, and pre-taping feet prone to blistering prior to long marches, soldiers may be returned to marching fitness during a time of need.
(Translation: Keeps you from having to carry them out!!!)
INTRODUCTION
While participating in the Nijmegen 4 Days' March in July 2000, the author observed a unique foot blister treatment system used by the Dutch Red Cross to provide medical support to thousands of marchers. This foot taping and blister management system limits further blister formation and enables marchers to continue marching for several consecutive days; marching 26 miles daily in combat uniform and equipment. The tape is sturdy enough to leave on for several days, if need be, to facilitate continuous operations, making it an ideal system for special operating forces on long foot movements.

PURPOSE:
This work presents an alternative blister care procedure to traditional moleskin donuts and pres- sure relief techniques. These treatments may cause blisters to enlarge with continued marching, and may require frequent halts for adjustment I reapplication. This work presents an alternative blister care procedure to traditional moleskin donuts and pressure relief techniques. These treatments may cause blisters to enlarge with continued marching, and may require frequent halts for adjustment I reapplication. By treating soldiers with severe early blister formation by taping, and pre-taping feet prone to blistering prior to long marches, soldiers may be returned to marching fitness during a time of need. (Translation: Keeps you from having to carry them out!!!)
BACKGROUND
The Nijmegen 4 Days Marches began in 1909, with marchers walking 140 kilometers in 4 days. Military groups now march 160km in 4 days. The walks have been held annually since 1909, except during the war years of 1913-14 and 1940-45. In the 2000 march, 41,000 people from 51 countries started and 36,377 finished.
During the 4-Day's March, military contingents billet at Camp Heumensoord. The Dutch, German and British Militaries establish formal camps and medical treatment facilities, the largest of which is the Dutch Field Treatment Station, roughly the size of a US Forward Support Medical Company Clearing Station, with the addition of Physical therapy.
American soldiers have no formal support (it was withdrawn after 1996 for various personnel draw-down and deployment reasons), and fall in with the Small Contingents formations. Many US units and individual soldiers still participate with their own funding (in 2000, 504 US military personnel started and 470 finished the march).
PROCEDURE
US soldiers receive their medical care from unit medics and the Dutch treatment tent, but as there may be 300-400 soldiers with blisters evaluated each evening at the treatment tent, waiting times are long (up to, 3 or 4 hours) During this waiting time, soldiers are signed in and issued a number, and given an approximate waiting time, so they may return at that time.
The Dutch "blaren" (blister) treatment area contains 20 to 30 treatment tables, staffed with Dutch medical specialists and Dutch Red Cross personnel. Several doctors are available for the specialists to consult regarding serious erosions and infections. Each area is well stocked with these supplies:
Finger lancets
Tincture of benzoin
Leukoplast 1/4 " tape
Large cotton tip applicators
Mild betadine solution foot wash
Cotton balls
2x2 gauze
4x4 gauze
Talc or foot powder Duo- Derm
Elastic Bandages
Epsom Salt or Domboro foot soaks
Sterile Normal Saline Irrigation
Foot basins
Ice (if available)
The system takes approximately 30 to 40 minutes to tape a pair of blistered feet.
The evaluation of the blistered foot requires the determination if the marcher can medically continue marching. Contraindications to continued marching include deep cellulitis surrounding vesicles; foul smelling purulent bullous fluid, deep dermal erosion and repeated bleeding from vesicle after initial debridement. For this article we will classify march blisters in 4 types: (See Figure 1)
1. Sealed vesicles filled with bullous fluid.
2. Sealed vesicles with purulent fluid.
3. Ruptured vesicles with intact roof or de- roofed vesicles.
4.deep dermal/sub dermal abrasions.
Soldiers are initially evaluated with a brief history, including location and severity of pain, ability to walk, types of socks and boots used, previous treatments, allergies, and significant past medical history. If serious injuries are discovered in the history, a medical officer is summoned to further evaluate the patient. If no significant medical problems are discovered, the medical specialist proceeds to examine the foot and ankle, with particular attention to the skin of toes and inter-digital spaces, heel, and ball of foot. Cleansing of the foot with a mild disinfectant solution is followed by removal of old tape, moleskin and tincture with tape remover or acetone. The skin is then re-inspected for signs, of erythema, severe edema or lymphangitis, indicators of cellulitis. If cellulitis is detected, the soldier is usually removed from marching status and treated with appropriate bed rest, limb elevation and antibiotics.
INITIAL TREATMENT OF VESICLES PRIOR TO TAPING (See Figure 2)


To Be Con't...

Blister Care Con't
 

Figures 1 & 2


INTACT (SEALED) VESICLES:
After examining and cleansing to foot, the top of the intact vesicle is disinfected with an alcohol swab. The selection of the drainage site is important, as drainage needs to occur during sleep as well as during marching. Usually a puncture on the posterior aspect of the vesicle will allow for appropriate drainage.
The medical specialist uses a standard finger lancet to puncture the vesicle wall close to the base. The lancet prevents too deep of a puncture, just through the vesical roof. A very small puncture is made, and the vesicular fluid is expressed using the stick of the "Texas Q-tip" (large cotton tipped applicator). This process is extremely painful for the patient. The firm rolling of the plastic handle of the applicator irritates the extremely sensitive vesicular base, even though the roof is still intact. This rolling must be done repeatedly to ensure all of the vesicular fluid is removed.
If purulent fluid is expressed from the vesicle, the vesicular roof must be removed to allow debridement of the wound and further evaluation of the depth of the infection. If, after deroofing the vesical, there is no deep-seated infection and the surrounding tissue is not erythematous, tender and no lymphangitis is seen, the vesical may be treated using the procedure below.
DEROOFED OR TORN VESICLES:
If a vesical roof has tom, or is partially missing, the area is cleansed as above. The loose epidermis must be removed, as it no longer serves a purpose as a physiologic bandage. Use sterile scissors (iris, curved mayos or one point sharps) to fully trim the loose skin, beveling the edge of the erosion to prevent further friction injury. After debridement of the vesicle roof, cleanse the blister base with normal saline irrigation. This area is very sensitive, but gentle irrigation is vital to prevent infection. If active bleeding, extreme beefy redness or purulence exists at the blister base, then the soldier should be treated for cellulitis as outlined above.
DuoDerm is a soft polymer that becomes more flexible with body heat. It is used by the Dutch Red Cross to provide an airtight dressing over the sensitive blister base, and to fill the empty space left by the vesicle's debrided epidermis. Cut a section of 1/8" thick DuoDerm the same size as the eroded cavity, and warm it (or have the patient warm it) in a gloved hand for 5 minutes. When the film is soft, peel the backing and apply to the blister base. This provides a sterile dressing that soothes the wound. Ensure there is no "double thickness of DuoDerm and skin which may case additional friction pressure after dressing and taping.

DEEP DERMAL ABRASIONS
Deep dermal friction abrasions occur when the soldier's level of "Drive-On" exceeds the anatomical structural resilience of the skin and dermis. Deep dermal friction abrasions begin as simple "hot spots" of increased friction, progress to simple friction blisters, and on to deep dermal erosions. These can usually be recognized active bleeding, deeply abraded tissue, and extreme tenderness. Soldiers may recognize there is a problem when they notice bloody socks or blood in their boots.
It is very difficult to restore deep dermal erosions to marching status. It is more appropriate to remove the soldier from weight bearing on the affected foot for several days, dress with a bulky dressing and topical antibiotic, twice daily Domboro's soaks, foot elevation and observe wound for signs of cellulitis.
DUTCH RED CROSS BLISTER TREATMENT TAPING TECHNIQUE (See Figures 3&4)


Figures 3 & 4


For forefoot vesicles, Place the patient in a supine position with the feet extending slightly over the table edge. Tape the entire forefoot, beginning at the base of the toes and continuing to the mid arch. For heel vesicles, place the patient in the prone with the feet extending over the edge. Start at the top of the Achilles' fossa and continue to the mid arch.
Leukoplast 1/4" dressing tape is used because of its thinness and flexibility to molding to the foot. Other thin tapes may be used, but ensure it is cloth and non-stretch.
Begin by measuring the Leukoplast by
pulling from the roll and placing on the area to be taped by the non-adhesive side, then cut to the appropriate length (enough to go from the start of the plan- tar-textured skin on the upper medial foot, to where that type of skin ends on the opposite side of the foot.) It is important to use tape that is long enough; so cut the tape longer rather than shorter (it can be trimmed if it is too long) on the medial and dorsal side of the foot.
You will need different lengths of tape as you tape the different areas of the foot, so measure each area of the foot treated to ensure the proper length of precut tape.
When applying tape, stick the middle of the tape to the foot first, then carefully smooth it to the skin to ensure no wrinkles are applied. Start your next strip by overlapping the previous strip by 1/3 the width of the tape. Continue taping until the entire area is covered, and then ensure no wrinkles or excessive layers of tape are present (these may cause new friction points or hot spots). Tape carefully around blistered toes, cutting wedges from the tape as needed to prevent friction points.
End state must be a smooth, tight, even taping of the affected section of the foot. When this is achieved, dust the taped area with talc to prevent the tape edges from sticking to the socks. Ensure the borders of the taped area are well adhered to the skin and add additional tincture to those areas as needed to ensure the tape is secure.
Advise the soldier to dust the tape with talc every time a sock is changed, and to be aware of any fluid build up in the old blister pockets. These may be drained without removing the tape, a small area of tape may be peeled back from the drainage site, the skin disinfected, a sterile lancet or 18 gauge needle used to drain the vesicle, and reapply the old tape over the site (or, if the tape is non-adherent, apply a section of new tape, ensuring no wrinkles).
The soldier should be instructed to return to medical care in case of extreme pain, purulent or bloody exudate from the blister, or signs of infection occur.
References:

I. Foot Marches. US Army, Field Manual 21-18, US Government Printing Office, I June 1990.
2. Smith, JB., Medical After Action Report, Nijmegen 1995 International 4 Days Marches 19-22 July 1995, US Army 212th Mobile Army Surgical Hospital, 30 July 1995.
3. Versteeg, M.A., International 4 Days Marches Official Web site, www.4daagase.nl. Koninklijke Nederlandse
Bond voor Lichamelijke Opvoeding (KNBLO) 1997-2002. 4. Cobb, S., US marchers get by without help from military, Stars and Stripes European Edition, 20 Jul 2000.
5. Dutch Landmacht, Camp Heumensoord Daily Newsletter (CCVM), Colophon #5, Netherlands, 21 Ju12000.
EDITORS NOTE: This paper was originally presented as the basis for a Poster Contest entry at the Society of Army Physician Assistant's Annual Refresher Course, Fayetteville, NC on 23 April 2002.

That was really great article. Thanks for posting that. Where did you go to get copy of that JSOM back issue?

YES! That was a great addition to the site. Thanks for posting it.

he presented this
 

at the SAPA conference a couple of years back. Good info no doubt, but step 1 is properly fitting boots and step 2 is proper foot conditioning.
Every step counts...it's maintaing it that is so tough.

Eagle

Thank you SC for the info. It will come in handy next month.
Mark

Where are you headed next month? OCS, SFAS??

I started what is called phase 0 of OCS. It consists of three weekend drills until June when phase 1 begins. Then 2 months later I should recieve my commision. 6 weeks ago I had a shoulder operation for a slap tear. I have til June to heal up and pass a PT test. I'm working everyday but still can't lift my arm past parallel to the floor. The therapist says I'll be ready. God I hope so. Thanks again for the help. Can I have your permission to share this info with my classmates?

Mark

You asking me for permission? Have at it.

Best of luck at OCS. Like Eagle5US stated to you in TMC-14, dont push the injury if you are not ready.

I hear you brother, it's hard not to push it though. I'm trying to go slow. When is your SFAS date?

I dont have one for some time yet. I still have OSUT and BAC to pass.

Best of luck to you. From what I know of you from your postings you will do fine.

Regards
Mark

that was a great article, I've been taped the same way in college when I developed deep blisters and it works very well unless the blister is infected or the skin actually cracks in which case the fluid causes the tape to slip.

We continued the taping method until a triathelete taught us the superglue trick and I haven't had too many blisters since then. Basically you spread superglue over the area where you generally blister which for me is on my heels right under the achilles and to the rear of the ball of the foot.
**BE FRIGGIN CAREFUL** while spreading it out. If you don't, I guarandamntee you you will wind up with something weird glued to your foot for a day or so. Worse I saw was a guy who stood up on the tape bench while the glue was wet. Do you know how strongly cyano acrylate glue bonds human skin? It's like lightning.

Anyway, we had to tear that dude off the bench and he played the whole game with a pad of vinyle glued to the bottom of his feet. On the plus side he didn't get blisters though.....


So after you've spread the glue over the blister prone areas (use waxed paper) and let it DRY, put a strip of tape over that area and you are good to go for several days. I've found since while hunting elk that duct tape works pretty well though will soften unhardened areas of skin.

This will keep you from getting blisters in the first place. If you happen to get one, unless it's really bad, you can flatten the blister by draining, squirt some glue in there and push it shut. You glue the blister shut and are good to go for quite a while after this. Warning; you will pretty much have to be a SF soldier to endure this procedure. It will make you see stars. I did it once on a hunt in the Frank Church River of No Return hunt a few years ago and for about a minute, I was contemplating shooting myself to put myself out of my misery. Then it quit hurting and I hunted three more horrible days of straight up and straight down with nary a problem.

Prevent first, cure if you have to.

CrashBurnRepeat

That sounds like the famous SF Medic "Tincture of Benzoin" blister treatment.

STRONG medicine.

Good to see you here again, amigo!

TR

For sure. That stuff burns.