Triple antibiotic ointment is on several gear lists. I have this in my first aid kit too. Mostly I do day hikes, and am wondering if I could reasonably stop carrying the ointment, with the idea of using Purell in its place. (Maybe I would replace the Purell with alcoholic wipes.) What do you think?

Well, the Purell will sanitize a cut thoroughly once and then it would be open to infection again (even after bandaging). I suppose for day hikes it is less crucial but triple antibiotics is not the area where you want to cut your weight from.

Thanks. What exactly does the triple antibiotic ointment do to help prevent infection after the wound is sanitized? Is the idea that the ointment stays in place under and around the edges of the bandage, keeping bacteria from nearby skin and the environment from getting in? This is what I surmise from reading about it online, but I haven't found definite statements that this is what it's for.

A half ounce container seems like an enormous amount of ointment. If a first aid kit should contain this kind of ointment, what's the smallest amount that you think would be safe to take on long day hikes?

Yes, it does a much better job of inhibiting bacterial growth than a single dose of alcohol does. Alcohol/Purell is just a cleaning agent. The antibiotic is for dressing. I think I remember someone on here (Ryan Jordan?) had dressed up a wound w/ triple antibiotics before being escorted to a hospital and was praised by the nurses for it.

For day hikes, you are pretty much set with the smallest container you could find. I usually carry it in those small zip lock packets found in craft stores.

Triple Antibiotic ointment contains neomycin. "Of the 47,559 patients tested, 2.5% had positive reactions to neomycin sulfate" Reference

I suppose it might be possible to test yourself for this but if you are packing first aid for a group you might want to go with double antibiotic ointment instead of triple.

For minor wounds (i.e., the kind we are most likely to get on the trail), a little antibiotic ointment or, even better, a couple of wipes soaked in them in their own small foil or plastic packets cannot hurt. Disinfect the wound with Purell, lay the wipe right on the wound and wrap with duct tape.

In other words, you may never have to use antibiotics, but there are some items in the "JIC" category that we shouldn't be without, UL philosophy notwithstanding.

Stargazer

The overuse of antibiotics is what has caused all the problems with resistant bugs.

I just wash with water and stick a band-aid on. Never had any problems.

If you are really desperate, try some Bismuth Formic Iodide (BFI) powder.

Cheers

It can be very difficult, even impossible to effectively clean a wound (wash away all dirt, dead tissue and bacteria) in the field and the antibiotic ointment's role is to control bacterial growth. Secondarily it keeps the bandaged wound moist, which can enhance healing and reduce scarring.

I spent some "quality" hours in a rural emergency room last month and there was a lot of wound treatment occurring. One fellow had cleaned all of his multiple wounds but only dressed some of them (with neosporin). Per the ER doc, those were healing fine but the others had already developed deep infections that required scrubbing and lots of disinfectant irrigation and further, could not be stitched due to the bacterial growth. The elapsed time was less than 24 hours.

To sum up, we can't anticipate what wounds we might receive nor how many days out they might occur. Small "single-use" antibiotic packets weigh mere grams and should be part of any first aid kit. Alcohol swabs or gel are not a replacement; however, they're quite useful for cleaning wounds. Be careful, because alcohol contact can damage exposed tissue and add to the problem.

Cheers,

Rick

"It can be very difficult, even impossible to effectively clean a wound (wash away all dirt, dead tissue and bacteria) in the field..."

Somewhere in the last year on BPL it was mentioned that the most effective way to clean a wound in the field is "...15 minutes of irrigation..", either with a syringe or a Ziplock with a punctured corner.

After that it will be some sort of 'triple antibiotic' and a loose dressing for me. I have carried SteriStrips in the past, but am now thinking that closing up a deep wound is a bit risky.

"I just wash with water and stick a band-aid on. Never had any problems."

Neither did I, until I did. I had a trip and fall that left me with a grazed heel - just half an inch of skin loss. Washed it out, disinfected it after showering for a couple days and figured it would heal on its own just like every other little cut, scrape or random thing I ever did to myself... the next day my foot swelled, the day after it swelled more, a funny red streak started up the back of my leg, and the end result was a week of daily hospital visits as they pumped antibiotics into my system to avoid a blood infection. Obviously I missed some microscopic little whatever in my initial cleaning. Nothing like getting a crazy little skin tear ten feet from your front door on the way to the car and ending up with an IV in your arm.

These days I put triple antibiotic cream in open wounds of any severity. I'd rather not go there. It may be random and the odds against it, but I seem rather prone to beating odds. Also had a weird post-tick bite infection.

I'm going to second the motion that you carry Triple Antibiotic for several reasons. First I have personal experience with the joys of serious infection. I got infected when I was 14 from a blister I popped on my thumb. In a couple of days it was really infected and I was in the ER. Proper treatment would almost certainly have helped. I got a MRSA (staph) infection twice working at a wilderness camp. One of the boys got one from a blister hiking on the AT .
Botom line I don't mess around with infections. On a short hike you could probably make it back fine but early treatment is good.
Another thing is that good first aid can mean the differance between continueing a trip or bailing out because you cannot deal with a nasty cut.

I have these:


I forget where I got them, they are marked Clay-Park Labs, New York on the back.

"To sum up, we can't anticipate what wounds we might receive nor how many days out they might occur. Small "single-use" antibiotic packets weigh mere grams and should be part of any first aid kit. Alcohol swabs or gel are not a replacement; however, they're quite useful for cleaning wounds. Be careful, because alcohol contact can damage exposed tissue and add to the problem."

+1

In addition, I always carry a 5 day supply of Bactrim, or its generic, SMO/TMP, just in case the bacteria in a wound
go "systemic". Bactrim, one of an older generation of antibiotics, is effective against staph infections in general, and MRSA in particular. MRSA has not been exposed to it frequently enough to develop resistance, YET..... It was part of my treatment when I contracted MRSA several years ago, and has been part of my 1st aid kit ever since. I don't worry about MRSA in the backcountry, but skin is very frequently colonized by other staph bacteria, which can cause nasty infections if they get into the bloodstream. The first line of defense is cleansing a wound, followed by dressing with an antibiotic ointment. Most of the time that does the trick. However, if the wound goes septic and/or red streaks start to move up the affected limb, it's time to start taking the Bactrim and head for civilization.

My medical sources concur with Rick's point about alcohol damaging tissue and say the same applies to iodine or mercury compounds such as mercurochrome. Roger, do you know for sure that the compound you suggest does not fall in this category?

For an initial cleaning I suppose that a spritz of alcohol won't hurt much, but please don't put a Purell-soaked dressing on one. Alcohol is cytotoxic and will actually INHIBIT healing if used repeatedly, as will hydrogen peroxide solution. I can't think of many worse ideas for a dressing.

Just got back from a weekend campout that included short trip cross country to a geographical feature that involved steep granite and class 2 scrambling... I had an unfortunate incident that left me with a bunch of shallower abrasions that are now scabbed over without incident, and two more alarming injuries - at first I thought I had torn my thumb in two and broken my wrist. A loose rock that looked like a part of a larger, near vertical granite slab shot out from under my boot and down I went, taking a lot of my weight on my left hand - apparently my thumb was slightly bent and the bone along my thumb is still sore, but not broken or fractured (no significant pain). I have a two inch open area on my palm and a fairly deep open place along the left side of my thumb nail.

We field dressed it the best we could. I had to use water from my bite valve to wash away all the blood. I was the only one of us with tape, gauze, disinfectant swabs, antibiotic cream and the ace bandage with which I wrapped the whole hand just to keep the gauze/tape in place on my palm. The palm is a very difficult place to tape up or keep a bandage on, too many flex points and bends. I did not have my leukotape with me, alas - it gets wrapped around my eyeglass case and I left that in camp. That would have adhered even to the bends in the palm.

I redressed it that evening in camp, examining it closely with my glasses on, picking out a few stray bits, shooting my palm with Purell (the scream echoed for a bit), and redressing it with antiobiotic cream before bandaging with clean nonstick gauze and tape, then stuffing the hand in a glove. (It got down to 25F and snowed that night, I slept in an extra layer.)

24 hours later, neither area appears swollen, no pus, doesn't seem infected; there will be dead skin coming off eventually as the wounds heal up, but we appear to have gotten out the bits of rock that were driven in and the edges seem clean. The thumb injury looks icky but doesn't hurt. I'm optimistic that it will turn out okay, since it's not my first run in with granite. Anyone who goes scrambling in granite knows better than to leave the gloves on the table at home, but apparently there's nothing you can put in your first aid kit to counter forgetfulness.

Edited by lori999 on 10/04/2009 19:29:06 MDT.

I'm glad you're ok.

It's very nice to be able to read over your description of what happened, and think about how I might deal with a simlar situation with what's in my pack.

For now, the half-ounce triple antibiotic is in my pack. I'll probably look for some single-use packets to reduce the weight a bit.

I still dunno about the gauze paad. Is substituting for a gauze pad with a sock a good option, even though the sock isn't sterile? For me this would be mainly for (long) day hikes.

I think there is no substitute for gauze - your sock will not be sterile, and using a sock in my example would have left me with a really bloody sock. You can't apply enough pressure with a sock to stop bleeding, if you need to, as the sock will absorb and absorb, and leave bits of sock in the wound. I briefly entertained the notion of wrapping it with my bandanna but that too is not sterile.

I really wished I'd had a roll of gauze. I could have wrapped the thumb with something breathable and sterile. But, like you, I got in a mind to reduce the bulk of my first aid kit... it's going back in.

I have found boxes of Neosporin single use packets at several chain drugstores, also quick dissolve strips of Benadryl and other handy one shot items.

http://www.neosporin.com/neotogo/neotogo.asp?sec=0&page=0&from=0

How much does your gauze roll weigh, and do you have a link for it? I'd be curious to see what you settled on.

One drugstore here didn't have single use packets the other day - will keep looking.

pick a size: http://www.curadusa.com/products/Gauze/stretch-rolled-gauze.asp

Gauze is really light; a small roll doesn't register on my (admittedly imprecise) scale. There are different kinds and they are useful for different stages of healing. I try to have a few nonstick patches for fresh injuries, as as blood coagulates anything you put on the wound tends to stick to it. The roll gauze would either go on after the wound has started to heal, to avoid tearing open the scabbing on a high use area like my palm, or it would get rolled on over a nonstick pad to keep it in place while the wound is still wet. Right now I have some plain ol' gauze taped around the end of my thumb so I don't snag the skin while I'm sleeping. I want it to breathe so it doesn't stay moist enough to breed infection, but I'd rather it didn't break open and start bleeding again while I'm asleep.

One of the things to think about is, how will you handle seemingly minor injuries to prevent them becoming major? I am rather cavalier about cuts and scrapes at home but get two days out and it becomes a real pain in several senses of the word to not have everything you need. Some people get by with aspirin and a band aid. I have the feeling as I gear up for volunteering for the local SAR that my kit will only get bigger. I already carry more than most of the people I hike with, but that only means people have been able to take advantage of my checkered past of trips, falls, aches and pains by "borrowing" those pain pills or tape and gauze to patch their skinned body parts.

I've been trimming weight in my kitchen and sleeping gear - the only thing I don't intend to sacrifice are first aid items. So far the only thing in there I haven't used yet this year is the moleskin, but that's only because the folks in my hiking group seem to be getting better shoes.

Edited by lori999 on 10/04/2009 21:09:37 MDT.

FYI -

http://www.minimus.biz/Pharmacymain.aspx

They also have great packets of condiments and single servings of many food items - backpacker heaven.

If you're carrying gauze, maybe you could ditch the mole skin, and make something from gauze as needed, attaching it with duct tape.

>If you're carrying gauze, maybe you could ditch the mole skin, and make something from gauze as needed, attaching it with duct tape.

Gotta agree with this post. I kept cutting the moleskin in half and in half again until there was nothing left. Eventually, I left the gauze behind, as well. I figured a bandaid works just as well for small wounds, and you can always use duct tape and an antibiotic "wipe" for larger wounds.

However, some posts on this thread are making me reconsider reintroducing gauze. especially on longer walks.

BTW, some banaids are treated with antibiotic. Can't hurt to have a few of those along instead of the untreated variety.

Stargazer

Edited by nerdboy52 on 10/05/2009 04:40:36 MDT.

NO duct tape on my skin. Especially on the foot - all that friction rubs it right off. I've never successfully used duct tape in a medical application, it's either been sweated off, rubbed off or rolled off, and not on purpose. Leukotape stays on the skin for a week and protects the hot spot much better. If there is a blister instead of a hot spot, moleskin takes a beating, unlike gauze, and once taped in place it protects better. Cut a hole in moleskin, put over the blister, slap in some antibiotic, add a small piece of nonstick gauze, run a strip of leukotape over the hole, done. If I'm going to take just one type of tape instead of the sports tape, etc. it would be leukotape. I've repaired hydration bladders with the stuff - duct tape just slides right off a Camelbak.

Gauze is too flimsy for use in a boot but it's great for spots that aren't going to see abrasion and need to breathe. Roll gauze wraps on awkward spots like fingers or elbows, keeps things clean and hopefully dry, and an ace bandage provides a good level of protection - I was very grateful to have one because once wrapped around my hand I could continue using the hand in a limited fashion without worrying about re-injuring the palm.

And what's most likely to get injured, due to the endless things you do with it? the hand. What do you rely on the most other than your feet - the hand. Being able to get a cut or scrape clean, and hopefully mostly healed in a couple days, is important. Having stuff that works with a wound when it's wet, and some more stuff that protects it in later stages of healing, leads to a nice dry scab that doesn't need much attention and protects it from infection. It's 48 hours later and my palm has a two inch scab - already the edges are healing inward. Skin is fantastic stuff. No bandages today.

Edited by lori999 on 10/05/2009 09:07:33 MDT.

"figured a bandaid works just as well for small wounds, and you can always use duct tape and an antibiotic "wipe" for larger wounds."

If your antibiotic wipe is an alcohol swab, this would damage your wound. Leave it out to dry for a while and you might reduce the risk.

If the duct tape moves with gauze next to a blister, it could act like sandpaper since it will stick to the bleeding blister base? ..ouch

Here is what I do when I see that a blister is forming. First, I take one of those pre-made thin blister pads and put it on the wound. Next, I take mole foam, fold it in half, cut out a triangular or semicircular shape, unfold the moal foam, leaving a diamond or circular hole in the mole foam, and put the mole foam over the blister pad. Then I duct tape the whole thing.

The purpose of the mole foam in this arrangement is to make some space between the wound and the boot, so that the boot is not directly touching the wound. I have had much better success with mole foam than with mole skin. I carry only mole foam now - no mole skin.

I find that without the duct tape, the mole foam comes off. With the duct tape, the setup stays in place long enough to last the day.

98% of my hiking is in day hikes, so my needs are not as demanding as those for people going on multiday hikes. Duct works ok for me. Maybe people going out for longer periods would want to use use some other tape for this setup, e.g., leukotape.

I'm thinking that gauze with a hole cut into it in the same way as above with the mole foam, and maybe folded over a few times, would do exactly what the mole foam does - provide a space between the wound and the boot. If so, then I could carry only the gauze, and ditch the mole foam. Mole foam is extremely light, and carrying it around is not bad at all, but it'd still be nice to be able to get rid of it in order to reduce the number of items in the pack. Simplicity is good.

Mupuricon (trade name Bactroban) is probably a better choice than "triple ointment". Broader coverage and more potent. Neomycin hypersensitivity rxns are a problem as people are increasingly exposed to neomycin. Usually mild -- cut will itch. In the US, you will need a script for mupuricon ointment. Of course, there exists a great controversy as to whether we should be using any of this stuff without evidence of infection! Soap and water is the most important thing.

Edited by backpackerchick on 10/05/2009 12:50:10 MDT.

Have come across estimates that hypersensitivity reaction to this drug may be as high as 15-20%. Of course, this would depend on prior exposure to the drug.

"there exists a great controversy as to whether we should be using any of this stuff without evidence of infection!"

No controversy in my mind a'tall. If I want to continue hiking without threat of infection, the cut gets the antibiotic immediately. The last time I didn't give a minor scrape an antibiotic I had a lot of medical bills. I don't have the resources right now to take risks, thanks.

I'm not a medical doctor, and at the risk of wading into this issue, my experience has been that it's entirely appropriate to treat a cut or scrape with small amounts of topical antibiotic ointment to prevent infection. Prevention in this case is worth a pound of cure; if a cut on your foot gets infected to the point where you can't walk on it and you're 15 miles out, that can get very bad very quickly.

I think the controversy is over other, less appropriate uses such as the ubiquitous, every day use of antibacterial soap (my understanding is that this soap doesn't improve cleanliness and may foster the growth of resistant strains on your hands, not such a good situation when you DO get a cut or scrape!)

Or the request some people make of their doctors for broad spectrum antibiotics for a cold. Colds are viral, not bacterial and usually run their course anyway, the only thing an antibiotic would do is kill all the healthy bacteria in your gut giving you digestive problems and again, fostering the growth of resistant bugs.

>If your antibiotic wipe is an alcohol swab, this would damage your wound. Leave it out to dry for a while and you might reduce the risk.

Note: Please see previous posts on this thread. An alcohol swab is, as I understand it, antiseptic, not antibiotic. The pads/ wipes soaked in antibiotics work pretty well as the "gauze" part of a bandage. As for the sticky part, take your pick.

To each his/ her own on this point, but IMO alcohol and other antiseptics are of very limited use here because their bacteria-killing powers disappear as soon as the alcohol evaporates. Antibiotics stay on the wound and prevent long-term infection. Given how far you are from a hospital on most-long term hikes, I'd treat every cut and scrape as a potential opening for an infection.

Stargazer

"Note: Please see previous posts on this thread. An alcohol swab is, as I understand it, antiseptic, not antibiotic. The pads/ wipes soaked in antibiotics work pretty well as the "gauze" part of a bandage. As for the sticky part, take your pick."

So you would slap an alcohol wipe on an open wound and tape it down because it's an antiseptic? Despite the warnings upthread that prolonged exposure to alcohol can cause damage? I'm not disagreeing with the use of alcohol - I use it then apply the antibiotic with some sterile gauze for wrapping. But as you say, alcohol evaporates quick. Unless you use it for dressing, which prolongs the exposure to alcohol, which can cause further damage.

I'm with Lori on this. Every little thing gets a smear of Bactroban (much better than triple ointment in terms of microbial coverage, does require a script) and I'm sensitive to neomycin. Similar rationale! I swear things seem to heal faster! But there is very little evidence that such an approach is useful. Soap and water should be enough when it comes to managing minor wounds. Though I DO use antibiotic ointment in the absence of infxn, I doubt that this practice is very useful!

this could actually slow down the healing process, as it kills cells regardless of whether they're nice or bad :D


i carry triple antibiotic for cuts and use the purell for washing my hands

Not to mention alcohol on an open wound hurts like a MOFO.

I do use alcohol to sterilize the abrasion and the surrounding area - and let it dry before applying actual medication. Fortunately it takes no time at all to evaporate.

My understanding is that the current preferred method of cleansing a wound is with clean water or saline solution, NOT alcohol or other antiseptic products. Antiseptics can kill living tissue and haven't proven to be more effective than irrigation. Water irrigation requires pressure to be effective, so I carry a small syringe in my first aid kit. It's been suggested in the past that a water-filled ziplock bag with a clipped corner can be used for irrigation in a pinch but there's debate on whether that provides enough water pressure. Here's a good synopsis of first aid treatment for wounds, including info on irrigation.

G

Edited by swearingen on 10/05/2009 16:16:16 MDT.

Gordon, I'm afraid you are CORRECT. Despite the evidence to the contrary, there are those of us (me included) who think we need a little smear of antibiotic ointment -- this probably isn't going to hurt us. Placebo effect can be powerful. But let's not be fooled -- such ointment is NOT an effective substitute for thorough cleaning (with water and perhaps a drop of dr. bronner's) and drying of the wound. Of course sterile saline is ideal but who wants to carry it. The syringe is a great thing to have in the case of gashes and punctures. Would not care to muck up a wound with Purell and all it's perfume and other additives. As always, current tetanus immunization. Recommendations I believe are every 10 years after initial series. Can probably go some years longer.

If you are recently fallen on a granite slab and in a world of hurt not to mention panic, afraid that you have cracked your tailbone, broken your wrist and thumb, and imagining that the rocks you see surrounded by blood in your fleshy palm are really ends of bones, a little water dribbled from your bite valve really sets your mind at ease quite well. With no third hand, I used what I could as best I could, and pressurized water jets were out of the question. Stopping the bleeding and tweezers had to do.

On the subject of bismuth, this is the active ingredient in Pepto-Bismal. It is much studied and known to have antimicrobial properties in the gut. This is the first mention I've seen of it being used topically. Would probably throw it in with all the other antibiotic ointments as far as initial wound management goes -- probably doesn't matter either way. Certainly, no substitute for cleaning with water and a little gentle soap.

Backpacker Chick writes:
"Despite the evidence to the contrary, there are those of us (me included) who think we need a little smear of antibiotic ointment -- this probably isn't going to hurt us."

To be clear, I did not mention antibiotic ointment in my post. My understanding is those ARE recommended to be applied to a wound once it is clean. I am talking about antiseptics such as alcohol or peroxide used for initial sterilization. Irrigation with clean water should be used for initial cleansing instead of those.

G

Edited by swearingen on 10/05/2009 17:01:00 MDT.

Gordon, thanks for clarifying. Anyway, I think you've hit on the most important aspect of wound management! Flushing it with water. Never heard of cleaning a wound with Purell -- sounds icky and very irritating -- perfume and stuff. Ointments tend to create a bit of a seal between the wound and the outside world so you may end up sealing "germs" in.

Edited by backpackerchick on 10/05/2009 17:31:47 MDT.

"Mupuricon (trade name Bactroban) is probably a better choice than "triple ointment". Broader coverage and more potent."

Spot on. It's the same stuff they prescribe for applying in your nasal passages to kill off MRSA. It's a highly effective antibiotic. It's what I carry in my 1st aid kit.
Only downsides are the weight: ~ 1 oz. and the fact that it requires a prescription.

I had an assignment at a NZ hospital and had to do the MRSA swabs. Was negative. Many people were hoping they were carriers as they would get something like 6 weeks off with pay -- and they aren't even sick! I think testing for MRSA carriage has gone out of vogue. I think about 20% of us are carriers. Sorry off topic but it's an off-topic kind of day.

BTW, the last place you want to find out about neomycin sensitivity is the nose. Years ago, pre-bactroban, had an ENT prescribed neomycin for use in my nose. Really irritating -- sinuses, crying.

If you're traveling abroad, can often pick this stuff up -- "pharmacist's discretion" exists in a lot of countries. This also goes for tinidazole, levofloxicin, cipro, analgesics (tend to be stricter here!) and other drugs one tends to carry.

If you have any reason to visit an MD or other provider, always enquire about sample tubes of bactroban, steroid creams, etc. regardless of what brought you in! Also, mini sample inhalers if this is something you carry! These little tubes are precious! A regular size tube of bactroban would last me a decade probably if the tube didn't fall apart. A little goes along way. The problem with the sachet packets is that they have about a week's worth of ointment (for a small laceration) and there's not really a good way to close them.

Saw a comment about the benadryl wafers -- these are amazing -- use them SL (under tongue) for faster action. Get hives running sometimes -- from vibration I think -- can keep these in pocket. Packaging would probably go through washer and dryer.

Edited by backpackerchick on 10/06/2009 06:39:22 MDT.

> Nothing like getting a crazy little skin tear ten feet from your front door on
> the way to the car and ending up with an IV in your arm.

Everyone seems to have missed a vital clue here. This infection did NOT happen in the backcountry: it happened in suburbia. It is very likely that the source of the infection was urban dog-poo or something similar.

I would wager that most of the infections people talk about come from an urban environment (and very often from dogs), not from a wilderness area. I've treated quite significant wounds in the mountains with no trouble (and no antibiotics) at all.

Cheers

Americans have grown up with the idea of applying antibiotic ointment to their boo-boos. We have TV commercials telling us that this makes our boo boos heal faster. We have "band aids" containing such ointment. Several antibiotic ointments are available in US grocery stores. Did my MBBS at Sydney and don't remember such an obsession among the public there. Last time I checked, I don't think such antibiotic ointments were available without a doctor's prescription in Australia. Don't think there is much evidence to support the use of topical antibiotics in the absence of infection -- no solid evidence that they prevent infection. The real danger may be a perception that such ointments negate the need to adequately clean and care for the wound. If the wound is not clean, the ointment may seal in "germs". Personally, I use bactroban on my boo boos. Placebo effect can be powerful!

Don't really understand the point about infection being acquired in an urban area vs. the backcountry. Most often the culprit is normal skin flora anyway. Once an infxn has manifest, I would think you'd be more interested in treating it than in where you acquired it.

Edited by backpackerchick on 10/06/2009 06:43:26 MDT.

A few years back I was on a 3 day trip and was bitten on my shin at the top of my hiking boot (assumed mosquito). My boot top rubbed the bite and it became infected in a single day. By the time I got out from the trip my ankle was very swollen and the infection around the bite was as big as my open hand. The infection spread incredibly fast and if I had been on a week long trip I would have been in serious trouble.

I now carry prescription antibiotics (Moxifloxacin HCL) as well as triple antibiotic ointment. The antibiotics weigh only .3 of an oz., so not a heavy insurance policy.

Moxifloxacin and the other late generation fluoroquinolones are great antibiotics to have around. Keep a course in my pack. Taken once a day orally, they quickly reach high levels in the body. They have very broad coverage of bacteria affecting the respiratory tract (even the atypical pneumonias and anthrax), GI tract and GU system (chlamydia and gonorrhea as well as the most common causes of UTIs). They do however have an FDA black box WARNING in regard to tendon rupture. Most reported cases have involved the Achilles.

"I would wager that most of the infections people talk about come from an urban environment (and very often from dogs), not from a wilderness area. I've treated quite significant wounds in the mountains with no trouble (and no antibiotics) at all."

Well, good for you - and you missed another point, probably because I didn't state it clearly enough, that I have had years of little scrapes and cuts that did not get infected and did not get antibiotics, both in and out of the wilderness... this was a one time thing out of hundreds of other silly little abrasions. And one time in the wilderness is probably one time I cannot afford, if we're talking about walking 20-50 miles with an infection crawling up my leg/arm. In frontcountry, I'm more likely to take chances - the consequences are less severe.

Remote as the possibility is, dumb stuff happens.

Fairly standard medical advice and some good explanations for the layperson:

http://www.backpackinglight.com/cgi-bin/backpackinglight/forums/thread_display.html?forum_thread_id=11475

BTW, what is this stuff about dogs? Pets? Wild dogs? Never heard dogs implicated in this context. We do exchange skin flora --staph in particular -- with our pets and with each other -- not that big a deal.

It's when our defenses are breached -- in this case our skin is cut that the microbes can more easily overcome our immune defenses. Which is the whole point of irrigating the heck out of wound if possible and if you so desire applying an antibiotic ointment.

Edited by backpackerchick on 10/06/2009 09:20:13 MDT.

Hartley, that's a good post by Patrick you linked to. Roger is australian, land of nappy rash, so who knows what goes on over there...kidding Roger.

Patrick's writeup is helpful. Thanks Hartley.

A couple questions..

(1) Patrick uses the terms "close the wound" and "open wound" without defining them. What is the precise definition of these terms?

(2) What is a good weight to shoot for a 20 cc syringe that one could include in a first aid kit?

I figured I'd ask in this thread, since the thread with Patrick's writeup has only one response since '08.

Edited by northwesterner on 10/06/2009 11:00:20 MDT.

No offense folks, but I think carrying syringes is getting a bit overkill for a basic backpacking first aid kit. We're not going out and fighting VC in the jungle...

If it's a bad enough wound that it can't be cleaned well enough by pouring water on it and washing then I it might be time to get evacuated for real medical care anyway.

I have a hard time imagining cutting myself on anything on a backpacking trip that is filthy enough to cause some sort of rapid and serious infection.

I think irrigation is key. If you are near a waterfall great you can stick your wound under, great. Or if you can pour water in the wound and rub it with a clean finger, great. But cleaning the wound is key. And a small syringe is very helpful for that.

Hike your own hike, but I would rather have a properly cleaned cut and use a old t-shirt for a bandage then not irrigate the wound and use a sterile bandage.

Just my two cents.

I think the post is sound advice. Again, not an MD, but my first aid training and other experience seem to concur. The main points:

1) Get the bad stuff out. That means scrubbing and flushing. I remember some advice for dealing with road rash from biking where they suggest getting a clean brush and scrubbing the scrape with it. Yes, it will hurt but will hopefully get the germs/dirt/rocks out. Also, it's less an issue of how much bacteria are present on the granite rocks at altitude that you fall on (probably very few since it's UV exposed), it's the bacteria on YOUR SKIN that's at issue. It's what you brought with you.

2) Keep the remaining bad stuff from growing. If it's a surface scrape or cut, then antibiotic ointment might help prevent infection. Deep wounds are harder to deal with, irrigation with dilute iodine, as suggested in the article, may help if you have it. Alcohol and peroxide will damage tissue. Closing the wound means holding the skin together so there's no gaping hole and sealing it up from air. This can turn bad if some anaerobic (non-oxygen) bacteria start to grow inside and make pus. Then you have to open the skin and clean it out again.

3) Keep more bad stuff from getting in. Closing the wound does this, but can lead to infection. Certainly covering the wound with something clean would help.

So does everybody else who it happens to. A NOLS instructor in a podcast said an irrigation syringe was in her top five things in a first aid kit.

Craig said,
"I have a hard time imagining cutting myself on anything on a backpacking trip that is filthy enough to cause some sort of rapid and serious infection."

Edited by jshann on 10/06/2009 14:05:36 MDT.

If you are in the backcounrty and need to irrigate a wound but didn't bring your syringe (or like me you just don't carry one)here is a good substitute. Rinse out a zip-lock baggie and fill with clean water. Snip the corner or poke a pin-hole and squeeze!

I know about nappy rash too. LOL

Best to defer the question to Patrick though I will give a general answer. I believe closing a wound in this context implies "surgical closure" of some sort -- sutures, steristrips, butterfly adhesives, "glues" etc. Leaving the wound open would be NOT closing it -- basically cleaning it out best you can and just leaving it open (perhaps with some packing -- the cleaner the better -- and pressure to stop bleeding) until it can be properly addressed. Off hand, here are a couple considerations -- nature and extent of the wound, dirtiness of the wound, the care available at the scene (is the ER doc there with his full kit?), the time it will take to receive more formal medical care. Generally, dirty wounds are best not closed until they are well-irrigated and assessed. Bites and punctures would probably almost never be closed on the scene. They also require specific antibiotic treatment depending on the animal or in the case of a puncture -- what it was and did it go through a sneaker (nasty pseudomonas lives in the "rubber" sole). If you must close a dirty wound, you want to open it back up in controlled settings as soon as possible, REALLY irrigate it and take any further action that might be necessary at that point. Just a couple examples. It's much more complex than this. Bet Patrick would be keen to take this on! Would be interested in what he has to say! And of course, his kit!

Did a winter hike in Tasmania -- met up with an Ozzie ICU specialist who brought next to nothing in terms of a medical kit -- Tegaderm for blisters and some Panadol maybe. Note: he had 50+ lbs and lots of camera equipment so I doubt he was attempting to save weight. He had some nasty stuff going on in terms of blisters but refused any of my quality blister supplies out of pride, I suppose. Admired my collection but refused to take any. We only had 2 days left, and I had a week's worth -- I had needed none. I left them out that night -- hope he snuck some. After all, he spent about 3 hours building a fire from wet wood and fuel blocks so we could attempt to dry stuff while I curled up in my bag with a Nalgene bottle of hot water. He was with another bloke and I think he was keen to show off his fire making skills -- lined up all the materials like he was doing a medical procedure and then proceeded in a very orderly fashion. Works for me!

Edited by backpackerchick on 10/06/2009 14:22:20 MDT.

Here is a 12 cc irrigation syringe at the NOLS web site that weighs approximately 4.8 ounces:

http://www.nols.edu/store/product.php?productid=16249&cat=0&bestseller

I was hoping for something closer to one ounce.

Here is a 10cc one that weighs 1.7 ounces:

http://www.exploroz.com/Shop/FirstAid/Equip/Curved_Irrigation_Syringe_10ml.aspx

(I have no idea about the reliability of those web sites.)

http://www.amazon.com/20-Disposable-Syringe-without-Needle/dp/B0002YFRA2

You can irrigate with a platypus and hose, under a waterfall. Glad this came up. Never bothered to carry a syringe -- would also come in handy for flushing the eye, I would think -- low pressure please. Bigger one might be better -- more serious irrigation -- I'll check the weight differences. Joined here to become obsessive! LOL

Do you actually have that syringe? The product weights at Amazon are often wrong. I hope this one is right!

If anyone cares, I usually bring a few sterile disposable lancets for blisters -- you get 'em in the diabetes care aisle of any drugstore. I don't reuse them -- one per blister popping session. Really try to soak the feet in warmish water and a little soap first. One of my remaining luxuries will surely be my Sea to Summit 5 L Kitchen Sink.

Edited by backpackerchick on 10/06/2009 15:05:07 MDT.

The Monoject 412 irrigating syringe (12 cc) weighs just .35 oz. in a snack baggie. Your dentist should have a free one to give you. We use them to irrigate tooth sockets and also small intra-oral wounds and lacerations. It has a small opening at the tip, so you can get pretty good pressure coming out of it (but you need a fair bit of soft-touch dexterity when flushing an eye...). Cheap, compact, light, functional.

No, I don't have one…yet. I've used plenty of them -- they are real small. Good point re: product weights at Amazon -- usually seem to be high though to accommodate packaging. You can just google the syringes -- many medical suppliers will carry them. How much does the NOLS one weigh? Haven't checked all the posts yet? Think I may have seen them in Target drugstore. Will update.

Bet a lot of people have already weighed them!

Different Materials. Also, some have locking mechanisms, etc. which no doubt add weight. For this purpose, think the vial and plunger is all you need. That cheapy looking one at amazon is probably lighter than the clear ones. You are just squirting water and don't need to worry about exact measurements etc.

"BTW, what is this stuff about dogs? Pets? Wild dogs? Never heard dogs implicated in this context. We do exchange skin flora --staph in particular -- with our pets and with each other -- not that big a deal.

Apparently it's getting to be a bigger deal these days. I have come across two articles recently, one in my local newspaper and the other, IIRC, in the NY Times, stating that dogs have become a vector for MRSA. Researchers are not sure yet exactly how, but the speculation is that human colonized with MRSA plays with their dog, who then plays with dog #2 who in turn plays with its owner, etc. Something to ponder.
If a person who has been colonized with MRSA in an urban environment then goes backpacking and cuts their
self, a very serious infection could ensue if the wound is not properly treated. I, personally, as a former MRSA sufferer, would not want to depend on irrigation alone when treating a wound. That is why I carry Bactroban, with Bactrim tablets in reserve. I assume I am colonized with garden variety staph at a minimum, and possibly MRSA. Any of them can result in serious infection if introduced into a wound or, even worse, the bloodstream. I'll take the extra ounce or so of prevention, just in case.

What happened? Were you just labelled as a carrier and treated to eradicate it.? Or are you one of those people who get chronic soft tissue infections from it? I have been following some of the news reports about families that can't seem to eradicate it from their house -- members suffering serious soft tissue infection. it has been hypothesized that there may be a genetic immune deficiency in some of these clusters or some additional environmental factor. And yes, the family dog can be in the chain.

MRSA is out there. In some, it is just part of the normal organisms that live on the skin, in the nose and elsewhere. There was a theory at one point that healthcare workers should be tested for such "carriage" especially in the nose-- not because MRSA colonization was doing the worker any harm just living there but because the healthcare worker presumably comes into contact with immunosuppressed people and it was assumed MRSA from the nose of the the healthcare worker might infect this already weakened person. Think inadequate hand washing came to be seen as the greater risk -- anyway, for most up date info -- the CDC maintains a fantastic up to date website -- www.cdc.gov.

As would be expected, MRSA is developing increasing resistance to Bactroban and some oral antibiotics that were once somewhat effective. Note: community and hospital patterns differ. Extensive info on this is easily found.

Doubt being labeled as a carrier and having MRSA eradicated from the nasal passages would put one at a significantly increased risk of deep tissue infection. CDC would probably have some good info on this. Still proper wound management is the key. Those who carry it and weren't routinely tested as healthcare workers were for a while, might never know they had it. We don't generally go around testing the noses of healthy people for Staph or more specifically MRSA carriage. We can expect some significant % of healthy people to have Staph and even MRSA happily living alongside them. All sorts of microbes live on our every surface and in our every orifice.

Basic principles stil apply.

Edited by backpackerchick on 10/06/2009 21:32:09 MDT.

I have had occasion to use antibiotic
ointment where nothing else would do.
Both times were in wilderness areas, but with
domestic animals being the carrier.

One was an eye infection from horse manure on the trail,
and contact lenses being left in too long.

You don't put Purel in your eyes.

I aquired Barber's Itch from a cow pond and blister
combination that spread over my whole body wherever
the pack straps rubbed. THAT was miserable. Purel would have
done nothing for that. The water for any irrigation would have
come from that cow pond, tho treated first.

Also, the antibiotic ointment works well for chaffing,
tho staying clean is important prevention.

Edited by oware on 10/07/2009 14:18:45 MDT.

Lots of Purell stuff on this site! Is it any different form other hand sanitizers? Hand sanitizers are for cleaning hands!

Edited by backpackerchick on 10/07/2009 13:53:35 MDT.

And starting fires.

It's sort of like Kleenex. Everyone will recognize the brand name. My current supply has the brand Walgreens on it, but hand sanitizer is hand sanitizer.

It's the Whole Foods Market brand. Comes in a 32 oz economy bottle and smaller bottles. UNSCENTED!!!

"MRSA "sufferer"?"
"Were you just labelled as a carrier and treated to eradicate it.? Or are you one of those people who get chronic soft tissue infections from it?"

Since you put it in quotes, which typically indicates skepticism, I'll go into some detail for you. I finished a backpacking trip in 2006 with some nasty infected hairs in my nasal passages and what I thought was shin splints. The shin splints turned out to be cellulitis, though there was no visible break in the skin. The cellulitis was successfully treated with Levaquin. Two weeks later I developed a very painful infection on an index finger in a matter of hours, again with no visible break in the skin. It became so painful during the night that I couldn't sleep.
At this point I checked into an emergency ward. They lanced the lesion, took a sample of pus to be cultured, and sent me home with a prescription for Bactrim. About an hour
after I got home, I noticed red streaks moving up my arm and headed back to the E.R. where they administered an antibiotic parenterally. The test came back positive for MRSA. At that point they swabbed my nose and tested for MRSA. Again, positive. You probably know the drill from this point on, so I won't bore you with the details. Suffice it to say it took several weeks to get me totally clean. In the meantime, I did a lot of research to educate myself on what I was dealing with. It's a nasty bug. My particular strain was resistant to 9 front line antibiotics.
My guess is that I picked it up in Harborview hospital where my Mother spent her last days. They have had a lot of trouble with MRSA there. Another possibility is the gym I work out at. 2 other people acquired it there. It has also occurred to me that I was the vector for bringing it into the gym, but I'll never know for sure. So, yes, MRSA is definitely out there, B.C. One of the lessons I learned is that because it is out there, there is a reasonable chance I have it happily coexisting with various other bacteria, including garden variety staph, on my skin. Based on my experience with the infection, I would be a fool to go far into the mountains without carrying the few items necessary to either prophylactically address the issue by treating any significant wound or, in the event the wound gets infected anyway, to start taking Bactrim and buy myself enough time to get to a hospital. As I said in a previous post, it's only an ounce or so. I can live with that. I dont', BTW, go around slathering Bactroban on every little granite cut or mosquito bite, nor have I ever used the Bactrim. I am aware as anybody of encouraging resistance in bacteria. I also check with my primary doc every year as to whether Bactroban/Bactrim are still effective against MRSA and other staph/strep strains.
I hope this lays your skepticism to rest.

"not because MRSA colonization was doing the worker any harm just living there but because the healthcare worker presumably comes into contact with immunosuppressed people and it was assumed MRSA from the nose of the the healthcare worker might infect this already weakened person."

I would observe that health care workers also go home from work and, if they are carriers, potentially spread MRSA into the larger community. Hand washing alone is not an adequate response, IMO. Studies have been done indicating we put hands to nose dozens of times per day. Every time the hand comes away from the nose, it is a potential vector for spreading it to other parts of the body, or inert surfaces, and thus to other people or pets. I doubt people are going to wash their hands every time they touch their nose. If MRSA is detected in a person, they should be decontaminated to help prevent an already serious problem from becoming astronomically more so. My 2 cents.

Hey sorry -- just wondering if you were referring to deep tissue infection with MRSA or nasal colonization. So yes, I call what you describe SUFFERING!!!

As for oral antibiotics, when concerned about my personal welfare, larger "resistance" issues be damned! I too am a fan on Bactroban for every scrape. Guess, my point is that simple wound care is probably MORE important. Hope you stay well! :)

"Hey sorry -- just wondering if you were referring to deep tissue infection with MRSA or nasal colonization"

No offense taken-all part of give and take in the forums. I was referring to both nasal and deep tissue, but it was my first and, I hope last, experience with the little buggers.

"I hope last, experience with the little buggers." I think that's the idea behind the eradication strategies. Smart to be prepared just in case.

Well, all the books do say that the only intervention PROVEN to reduce infection in minor lacerations is copious irrigation. Not antibiotics, be they topical, enteral, or parenteral. (Restated: If you've got pebbles in the wound it WILL become infected, no matter what antibiotic you're using...) That said, I carry a triple antibiotic ointment. Hygiene is just a bit unreliable in the wilderness, and I am unaware of any clinically significant issues with neomycin-resistant strains.

I will say that I think Bactroban is a bit overkill, unless you have a solid MRSA history or something. If you react to neomycin just get straight Bacitracin. I really don't see much point in getting the prescription stuff- it's a lot of hassle for trivial gain, excepting MRSA.

(And, as was INTENSELY discussed in these forums a while ago- I too carry a fluoroquinolone as my general-purpose enteral antibiotic. The tendon rupture thing isn't realistically going to manifest with two days or so of use.)

Edited by acrosome on 10/07/2009 21:07:15 MDT.

Paul Auerbach was a little late on talking about the black box warning, but here it is. Yep, mostly takes about a week to develop tendon issues.

http://www.healthline.com/blogs/outdoor_health/2009/05/fluroquinolone-antibiotics-and-tendon.html

Acrosome -- like the username.

The newer fluoroquinolones (levofloxicin and others) are very rapidly absorbed -- many equivalent to IV administration of a drug. High levels are reached very quickly. While the incidence of tendon rupture might be small, IMO it would be a serious consequence. Would be interesting to know whether risk increases in a tendon under stress (backpacking) -- based on the mechanism, I would suspect it would. There are reports of Achilles rupture during/after single 5 and 7 day (quite typical) courses. It's a black box I don't take lightly. I have and would use drugs in this class. But each time I pop one (typically for pneumonia, upper respiratory stuff), I do consider the risk I am taking. It takes pretty good evidence to earn a black box and the powerful pharmaceutical companies fight like hell to avoid it.

Maybe I'm missing something obvious, but why not take a penicillin/clav acid combination like Augmentin Duo Forte or a cephalosporin like cephalexin?

That should cover your gram positives like staph and have enough gram negative coverage for most common things (e.g. E.Coli). Should be enough for pneumonia, cellulitis, utis and most things you could encounter on the trail.

They are cheaper and don't have the tendonitis side effect.
Apologies for the medical jargon.

Good question. You can easily look up the coverages of these antibiotics and their resistance patterns.

But I will say a couple things I remember off the top of my head. Penicillins and cephalosporins are no longer good drugs for empiric (when you don't know what the bug is) treatment of pneumonia since about half of pneumococcus is now resistant. Penicillins do not cover Mycoplasma, often called "walking pneumonia" -- probably the most common pneumonia in young healthy people. Newer fluoroquinolones (cipro is "older" btw) have excellent coverage against pneumococcus, mycoplasma, legionella and anthrax. Much broader coverage of enteric gram negatives. Covers most common causes of urinary tract infections plus gonorrhea, chlamydia. Newer fluorquinolones should adequately cover pseudomonas -- lives in sneakers and gets into skin when you step on a sharp and it goes through the shoe -- a real nasty.

Speed of onset. Many of the newer generation fluoroquinolones reach high levels in the blood and tissues very quickly when taken orally -- as quickly as an IV drug in some cases. Once a day dosing. Usually shorter courses. Sometimes a single tablet in a female with run of the mill UTI -- cystitis. 5 days for pneumonia. Very well tolerated and compliance is good.

Doxycycline would be an excellent choice for a trail kit. You can look up the indications/coverage. Very cheap. Does tend to cause some photosensitivity so keep the skin covered. Reaches high levels in the skin which is good if that is where the problem is. Resistant organisms do not emerge as quickly. Bactrim has some of what you want but sulfa sensitivity is common.

Penicillin allergy is somewhat common -- chance of allergy increases with more frequent exposure.

What drugs are used in a clinical setting has a lot to do with how hard the drug companies are marketing them! Fluoroquinolones have been pushed very hard by their manufacturers -- mega marketing budgets. A fair bit of resistance to them is now emerging as would be expected.

I think Patrick touched on some antibiotic issues -- would be worth having a look. Take his word over mine or better yet look it up.

Edited by backpackerchick on 10/08/2009 05:08:26 MDT.

Thanks- the username goes back to college. A story for another time...

To address the question about why I prefer fluoroquinolones:

Fluoroquinolones are cheap, have great coverage, are very shelf stable, have oral bioavailability equivalent to their IV formulations, and few people have allergies to them. (I do think of the possibility of needing to give the antibiotics I packed to someone else.) But also- most of them are only taken once a day. I'd much rather carry two pills than eight.

The tendon rupture issue was what I meant when I said that my carrying fluoroquinolones was "intensely discussed" in an earlier thread, Hartley. I could dig it up if you like. Basically, I acknowledge the severity of the black-box warning, but maintain that the risk for a short course is manageable. I'm a provider in the US Army and we give TONS of fluoroquinolones to young and VERY active individuals (arguably professional athletes) for short courses with no significant problems. And before some zealous individual jumps all over me- note I am not saying "NO problems".

Anyway, I challenge anyone to produce a case report of a major tendon rupture in an individual who has only taken one or two doses of fluoroquinolone. (I.e. long enough to hike out.) There may be one, but I'm unaware of it.

I will admit that I tend to get huffy with people who expect risk-free medications. But that said I acknowledge that the prospect of an Achilles rupture is especially terrifying to an avid hiker, so I won't begrudge anyone who decides that they want to avoid fluoroquinolones.

Edited by acrosome on 10/08/2009 19:48:18 MDT.

By the way, the REI near where I live has packets of single-use triple-antibiotic ointment. A pack of 10 costs $4. Each packet weighs 1/32 of an ounce.

These drugs penetrate the bone very quickly and bind the bone matrix very strongly which is why they can be very useful in osteomyelitis. They are contraindicated in those under 18 because of problems with bone development. The drug stays in the bone long after you finish a 5 or 7 day course. Such penetration can weaken the attachment of the bone to the tendon for a prolonged period after discontinuation. Tendonitis and tendon rupture can occur. A black box warning IS a big deal, period. A drug really has to earn it! And one would be wise to avoid stressing a tender Achilles while taking this drug! This is a good drug. There are suitable alternatives for those who are not willing to chance it -- doxycycline for one. BTW, some people here travel in areas where they could not be evacuated in two days if at all.

Cheap? What and where are you getting it? Cheap compared to what? BTW, Cipro is simply inadequate coverage for an all purpose antibiotic. Gut and the urinary tract, OK. Gaiti and Moxi are probably the preferred. Levo, OK.

I doubt anyone is at great loss heading into the backcountry without a 4th generation fluoroquinolone. I've got lots of the stuff. I carry it. I've taken it. I DO worry about it. If I had even a slightly sore Achilles in the months following a 5 day administration, I'd seek medical attention immediately. Something for people without health insurance to think about -- do you really want to foot the bill for an ortho consult and an MRI to evaluate possible tendonitis. Especially when good old doxy probably would have been just fine. :)

A couple have been removed from the market and the rest have black boxes for this reason. Black box is a big deal! These drugs are increasingly being avoided in professional athletes as there are almost always better options.

I'm sure this thread is boring everybody else to death, but wow I can't believe you use moxi and gatiflox etc. We reserve those as last line and they are super expensive here. We just tend to have cipro and norflox and they are first line for an oral antipsuedomonal agent here but as stated their coverage against gram positives isn't great (perhaps non existent is a better term).

Our resistence patterns in Australia are much less so we tend to get away with narrower spectrum antibiotics. We also have pneumococcal vaccination free for everybody so we don't have to worry about it as much.

Besides it doesn't matter what antibiotics you're taking as long as their the lightest right? ;)

Took about 1/8" deep by 1" disc or flesh off my heel. Some blood, but lots of deep epidermis exposed. Pored some alcohol on it, and then have been using BFI powder and neosporin, but lots of walking in fresh saltwater makes impossible to keep dry/clean. No sign of infection yet. I have a 30-day supply of cipro 500mg with me. Bad idea to take prophylactically to keep anything bad from starting?

> Bad idea to take prophylactically to keep anything bad from starting?
Definitely bad.

Your body is coping just fine with the problem - why interfere? Why bomb out your gut flora needlessly? Why not let your immune system do what it is meant to be doing?

Hey - the salt water is probably half the cure anyhow!

Cheers

Figured this might apply somewhat.
Couple years back I had an accident on a motocross track with an ATV. Went over the front end off a large jump, was run over by the atv, and was dragged underneath until it stopped. I had road rash over the entire left side of my back from the butt cheek to the shoulder blade, from hard red clay. EMTs were at the track, but simply didn't have enough sterile water to even begin to clean it out. They gave me instructions of what to do at home.
First, the initial cleaning required scrubbing until I got all the dirt and clay out: no soap. Then I had the whole area irrigated with STERILE water (waterfall water still has bacteria; noticed a few mentioned that; boil water for irrigation). After that, we used a product called 2nd Skin to dress it, its like a water gel pad - semi permeable membrane. Tegaderm would be the choice for backpacking (self adhesive, stays very well, and waterproof). Replaced the dressing daily, irrigating with sterile water every time. No ointments or soap or anti-septic of any kind. The EMTs (and my general practitioner agreed) said most things will simply damage the skin, or slow the healing process (ointments will seal the wound, defeating the purpose of the semi-permeable membrane).
Wound was totally healed after about a month, scarring wasn't too bad, especially considering how deep it was (the lower left area of my back has no feeling anymore from nerve damage).