Random thoughts on battle prepping your med kit.

[NinjaMedic]

http://www.wolfetory.com/nasal.php

We have the option now to administer a number of our meds such as Narcan, Benzo's, Fentanyl, etc intranasal using the MAD. Nice option as it is reusable (for a specific pt) and gives you another route of administration if you will be doing repeat admins without vascular access and with a limited supply of needles. Options are always nice but not sure if they are in the DOD system yet.

[Six Feet Under]

Well, maybe we should talk about personal med kits and pain killers.

Pain sucks.... real pain that is.

I stopped carrying morphine auto injectors for various reasons, but mainly because we are not officially issued them, I don't have any narcan, respiratory issues, and because of the long time it takes to kick in. I have had to take IV morphine on two occasions and the shit works well.

Fentanyl lolypops seems to be a better choice in the field and more prevalent over here these days. We will be getting these issued this year.

Is there a difference in time it takes for the drug to take effect in an auto-injector vs. a regular shot? When I was in Tampa General with a GSW to my right elbow (really ****ed my arm up), they gave me a morphine shot after I laid in the ER for six or so hours with nothing but the shot of fentanyl I had on the helo on the way in. I'm not sure how long the fentanyl lasted, but I wasn't in much pain. Then again, before I got loaded in the bird I wasn't in much pain either. I guess it was a "good" thing it clipped my ulner and made my whole arm numb.

As far as my BOK, it's probably going to be real basic. HSGI Blowout/Bleeder pouch with a pair of nitrile gloves, a 4" israeli or two, if it'll fit, a pair of shears and a tourniquet rubber banded to the outside. If I can fit more in there I will, as I have plenty of kerlix and stuff left over from when I had to rebandage my arm every single day. I only have two rows of PALS webbing on each side of my Eagle/SKD universal so that's all the real estate I've got to work with, and I'm on a pretty strict budget. Nobody I shoot/train with knows how to use an NPA or insert a 14ga 3.5" needle to treat a tension pneumothorax. I'm hoping I'll be able to take EMT-B classes this summer or fall before I start the police academy (AGAIN, had to quit due to my GSW) in the fall or January 2011.

[Danny Boy]

Those HSGI blow out pouches are a real tight fitter. I was actually quite surprised as I thought it was a little more roomy inside.



And this is pretty much all I could get in it:



NCD, gloves, NPA, wipes, Occ dressing, tape, 4 inch control wrap and compressed gauze in a baggy with a paracord pull string in it to get the whole thing out of the pouch. Extra gauze sits on top incase it's needed pronto. Glowstick shoved in for good measure. TQ gets shock corded to the side MOLLE with a slide keeper to tighten it. The gauze and wrap take up a lot of room in there. I was only able to fit one IBD in it with nothing else.

[Iraq Ninja]

Is there a difference in time it takes for the drug to take effect in an auto-injector vs. a regular shot? When I was in Tampa General with a GSW to my right elbow (really ****ed my arm up), they gave me a morphine shot after I laid in the ER for six or so hours with nothing but the shot of fentanyl I had on the helo on the way in. I'm not sure how long the fentanyl lasted, but I wasn't in much pain. Then again, before I got loaded in the bird I wasn't in much pain either. I guess it was a "good" thing it clipped my ulner and made my whole arm numb.

If by shot you mean Intramuscular (or IM) injection compared to an auto-injector, then I would say no. I think what you mean is IM vs IV. In this case, IV is faster and preferred. If the drug is given IM, it takes longer, around 45 minutes to work.

I got a question for our Docs here. Say all you have are morphine auto-injectors. Is there any reason why it could not be used straight into an IV line, if it were possible? Or does it have to be a different grade, such as the case with lidocaine and cardiac lidocaine?

[Danny Boy]

IM works a lot quicker than 45 minutes. Shouldn't take very long at all.

Starting dose for IV morphine management the way I was taught was a pretty slow push of 3-5 mg MS. Re-assess and then administer another dose around ten minutes later if needed and so on.

I can't imagine dropping 10mg from an auto-injector straight into the blood stream instantly could be very good, given that it's twice the recommended IV dose given at an instant. Sudden respiratory and cardiac compromise maybe?

[NinjaMedic]

The biggest problem with trying to use the auto injector in an IV line would be the simple logistics of trying to hit the med port with the spring loaded needle and then not subsequently pass out of the side of the tubing or into your fingers. The difficulty of just trying to get the medication to properly go into the IV tubing coupled with the inability to titrate the dosage make it a poor choice.

Most meds will be effective in 5 min or less when given IM, IV usually takes less than a minute.

Six Feet Under, the fentanyl probably only lasted you 25 minutes or so morphine will last longer but you run the risk of hemodynamic changes with the morphine due to a histamine release.

[Six Feet Under]

Good stuff to know. I honestly don't remember what was given in which way, I know they gave me actual shots (like a flu shot, I guess that would be IM?) of dilaudid and two percocets every four hours after my surgery until I left the hospital two days later. The last day they took me off the shots and did just the pills.

The fentanyl and morphine could've either been given through the port they put in in my left forearm, or as a shot the same way the dilaudid was. I don't remember all the specific details about the ambulance ride except I'm pretty sure the girl that was driving was trying to hit every single pothole on the road between my house and the sheriff's department helipad.

I'll have to get all the reports from the shooting (something I still haven't done as the case isn't closed with the sheriff's dept. since it's obvious it was accidental, I don't know why they wouldn't just look at it real quick and close it to have it out of the way so I could get a copy of the full report instead of just the incident report) and see if I can get a surgical report from the doctor, as well as all of the documents in my file at the hospital, if they can do that. The stuff interests me and it would be really cool to know EXACTLY what went on so I have the correct details in my mind.

[Iraq Ninja]

Bad choice of words on my part. I would not want to try to shoot straight into a line with an auto, more interested in the quality of the MS. Wondering if they add something to it to increase the shelf life.

Every TCCC lecture I have seen talks about IM being between much slower than IV, in the range of 30 to 45, but maybe that is the far end of the range.

[Danny Boy]

That's probably when you'll be feeling the maximum effect of the dose. Onset of relief happens much faster. I do a lot of IM pain med injections and it doesn't take long.

[DocGKR]

We do a significant amount of IM injections to initiate anesthesia in younger/uncooperative patients--with agents like Midazolam and Ketamine, onset is usually within 10 min or so.