Let's talk bare-bones BOK

[rob_s]

From the TCCC:
60% Extremity Hemorrhage
33% Tension Pneumothorax
6% Airway Obstruction

Let's assume, for the purposes here, that we're talking about being stateside and with 30 minute response time from EMS and 60 minutes to get to an emergency room or trauma center.

Let's also have a goal of an AR double-mag pouch (or triple if needed) as a size limit.

I think anyone/everyone would include a tourniquet or two.

Trauma dressing (Israeli, Oales, Cinch-Tight, Thin-Cinch, 4" vs 6", etc.) seems to be a common theme.

NPA?

Better to use a dedicated chest seal or rely on the wrapper from the trauma bandage and some tape?

Hemostatics seem to illicit some controversy, but better to have and not need? Worthless stateside with 30 minute EMS response?

[Submariner]

You have, no doubt, already read the Doc Gunn AAR on p. 72 of the Dec. SWAT, an issue in which you have an article.:p

He recommends a tourniquet on the vest or in the range bag along with the basic kit.

The key is having the skill to identify which tool needs to be used and how to properly use it. Tools can be good or better. What do you want to do and how much do you want to spend to do it?

But you already knew this.;)

ETA: I went with the IBD because there is cheap training available which has recently been updated:

http://www.ps-med.com/bandage/bandage_training.html

The six inch IBD (with slider,) NPA, and catheter, all wrapped with three strips of tape, will fit in single Eagle M4 pouch. There is room for an Ascherman if you desire. With a TK-4 in a Blue Force Tourniquet NOW! StrapTM and the Eagle single, you have used three vertical PAL rows.

[Danny Boy]

I have a small one in my range box at home. It's geared mostly toward being shot once accidentally, rather then someone trying to riddle either myself or my wife or someone else with holes.

Kerlix
Ace Wrap
TQ
Hyfin dressing
Three Inch Med Tape
NPA and lube
Celox
No.7 hook

Should fit in a triple M4 pouch.

[rob_s]

You have, no doubt, already read the Doc Gunn AAR on p. 72 of the Dec. SWAT, an issue in which you have an article.:p


Part of the impetus for this thread ;)

The needle thing bugs me. I haven't been trained on it, but I've been told that the training should be a lot more than just "stick here".

graphic example of common dangers of needle decompression! (http://www.youtube.com/user/tacmed2003#p/u/1/fQqPktj_gFc) GRAPHIC

I'd also be interested to know how quickly tension pneumothorax kills. If it takes hours, and stateside EMT response is 60 minutes or less, then it may not be needed in the kind of range kit I'm thinking of for use on established ranges.

Obviously there is an argument to be made that if you're on an established range why not have a full bag with 2-3 of everything you might ever need, but I'd like to skip that argument for now.

[rob_s]

ETA: I went with the IBD

Did you strip off the outer wrapping? I think I'd do that with mine.

[Submariner]

I'd also be interested to know how quickly tension pneumothorax kills.

Good question! This wasn't addressed. I surmise that it can be quick; otherwise the catheter would not be included in the kit. Let me contact him and find out what he says.


Did you strip off the outer wrapping? I think I'd do that with mine.

No. It is a tight wrap. The outer cover has instructions. The tear points are on the ends so the wrapper is large enough to use for the Ascherman substitute. The tear point on the inner wrap is in the center and makes the inner wrap virtually unusable.

One more point: medical supply houses generally say federal law requires them to have a prescription before hey will ship catheters. Tactical Response sells the same 3.25-inch decompression needle included in their VOK without a prescription. It is needle only, though, no catheter.

[Danny Boy]

TPT can vary in time. Getting them to definitive care should be more of a priority.

NCD's - Get training on them. They're not difficult when you know what body part is where.

[Danny Boy]

Tactical Response sells the same 3.25-inch decompression needle included in their VOK without a prescription. It is needle only, though, no catheter.

They have the 14 gauge 3.25 NCD catheters listed on their site. I can't find them without the cath.

[PPGMD]

NCD's - Get training on them. They're not difficult when you know what body part is where.

+1

Not only that, but often there are people there that might be better trained then you are. Those people, may not have their own kit with them, or their kit may not be close by.

Anyways suggestions:
http://www.tacticalresponsegear.com/catalog/product_info.php?products_id=4154

Fits in a double, or triple Mag Pouch.

And it can fit the items that you are most likely to need:
Pressure Dressing (I like the H-bandage)
Quikclot Combat Gauze
TK-4
NPA
Decompression Needle

Of course you can vary the contents.

[Gutshot John]

Bare bones?

Old Paratrooper Pack:


Tourniquet
Pressure Dressing
Morphine Syrette (optional)

[Gutshot John]

As for how quickly a Tension Pneumo kills it really depends.

By definition you have a tension pneumo before you show signs, how quickly it progresses from there depends on the injury. In my experience once the signs are obvious you're behind the curve.

My sense is that you're talking about an open pneumo thorax caused by penetrating trauma rather than a closed pneumo caused by a car accident/paper bag effect or coughing. You can sometimes decompress an open pneumo without a needle by releasing the air then sealing the system with a flapper valve of sorts. You need a needle for a closed pneumo.

A lot of variables there to apply to a barebones kit. Since you're talking about GSW's I'd think a needle kit is less applicable for bare bones.

[rob_s]

For the sake to the topic at hand let's assume that you're going to start with a GSW. While the current trend towards more and more theatrics in training may one day reach the point of car races resulting in the potential for a car crash, let's assume that the worst injury you'll sustain on the range is still the GSW. :D

[rob_s]

Anyways suggestions:
http://www.tacticalresponsegear.com/catalog/product_info.php?products_id=4154

Fits in a double, or triple Mag Pouch.

And it can fit the items that you are most likely to need:
Pressure Dressing (I like the H-bandage)
Quikclot Combat Gauze
TK-4
NPA
Decompression Needle

Of course you can vary the contents.

I'd like to see that combined with the deployment style of the BFG Trauma Kit NOW!. Less overall material, easier to deploy, etc.

[MIKE G]

.....

[PPGMD]

I'd like to see that combined with the deployment style of the BFG Trauma Kit NOW!. Less overall material, easier to deploy, etc.

I don't know of any on the market that combine both requirements.

[rob_s]

Going to meet with a local gear maker on some other projects tomorrow and will have to address this.

[Gutshot John]

For the sake to the topic at hand let's assume that you're going to start with a GSW. While the current trend towards more and more theatrics in training may one day reach the point of car races resulting in the potential for a car crash, let's assume that the worst injury you'll sustain on the range is still the GSW. :D

I think that's an appropriate model.

The statistics you provided from TCCC shows that penetrating trauma/hemorrhage is more lethal than all other causes combined.

Since you're keeping it to the range, rather than a SHTF scenario, and EMS is more or less in close proximity to provide higher orders of tx, for "bare bones" (bare minimum) I'd concentrate on hemorrhage control.

Tourniquet, pressure dressing, maybe hemostat has the most applicability and will treat the most likely injuries.

[MIKE G]

.....

[rob_s]

Not dogging anyone, just wanted to put that out there...


I don't take it that way at all. It's no different than someone asking a question on the firearm side of the forum and some of us saying "go take a class".

[Gutshot John]

By all means get training anyways, but lack of formal training is no reason not to have a bare bones kit.

A bare bones kit of a tourniquet, dressing and perhaps a hemostat requires very little training. Any FR class will make you reasonably competent in their use if you're not clever enough to figure it out on your own (I'm pretty sure everyone here is competent enough).

Needle kits and other more advanced techniques certainly do require training but I wouldn't call that bare bones. That's a pretty specialized technique.

[Iraq Ninja]

Using a mag pouch is a good idea. Not sure if I have mentioned this before, but it is not a good idea to simply pack the stuff in the pouch. What I do is use a bit of duct tape to link the stuff together in a snake like fashion. It doesn't take much.

What you are trying to avoid is pulling out one thing, and something else falls out on to the ground, or in a back seat of a moving vehicle.

I know a few companies make fancy nylon inserts, but they take up room too. Plus, the stuff can still fall out even if it is retained.

[MIKE G]

......

[Gutshot John]

While you may be clever enough to figure out how to use one item, figuring out the order of the items is just as important.

Anyone care to share a step by step treatment of a GSW to the thigh immediately above the knee with pulsatile bleeding? If you have been to a good quality class you should have a step by step protocol for bleeding control.

Just for the sake of reducing confusion, hemostats are a metallic clamp used to grasp tissue, usually a blood vessel. Hemostatic agents are material put into a wound to aid in bleeding control by formation of a matrix.

DOC

God Bless my medical brethren but sometimes overthinking an issue is something of an issue. I'm sure it might matter to a combat medic the vagaries of GSWs to the thigh immediately above the knee with pulsatile bleeding, but for the average civilian who just had an accident on the range and who has to self-treat above the knee, below the knee, in the arm. So long as it's not in the vitals it doesn't really matter. If it is in the vitals... well hopefully EMS is close by or there is a trained medic on hand. Even still the point is probably moot and even if recoverable we're talking well beyond "bare bones."

"Hemostat" in common usage applies to clamps as well as hemostatic agents. Both stabilize blood loss. I'm pretty sure everyone is smart enough to know what was meant.

As for a "protocol" it really doesn't need to be that complicated. In fact simpler is lots better. Is it a good idea to have an idea of what you need to do? Sure but it won't take much more than 10 minutes on google to get a good idea.

Is taking a class a good idea? Absolutely, but in the interim it's also a good idea to have the rudiments of hemorrhage control on your person. Since you've already been shot, there is ZERO downside regardless of your training level.

[MIKE G]

.....

[Submariner]

They have the 14 gauge 3.25 NCD catheters listed on their site. I can't find them without the cath.

I bought nine of them. They call them catheters but they are only the needle. I complained about the ad to no avail.

Remember, we are talking Tactical Response.:rolleyes:


I will do you better than an m4 mag pouch.

I kept this kit in an M18 smoke grenade pouch on my chest for my entire time in Iraq:
...
1-14gax3.25" needle or catheter


Good idea on the Mk 18 pouch. I have a couple of Eagle 1 Qt. Canteen/GP MOLLE pouches I bought cheap ($15) which provide more space.

Would you (or anyone) please compare/contrast the efficacy of needle vs. needle/catheter? 3.25" vs. 2"?

[rob_s]

Using a mag pouch is a good idea. Not sure if I have mentioned this before, but it is not a good idea to simply pack the stuff in the pouch. What I do is use a bit of duct tape to link the stuff together in a snake like fashion. It doesn't take much.

What you are trying to avoid is pulling out one thing, and something else falls out on to the ground, or in a back seat of a moving vehicle.

I know a few companies make fancy nylon inserts, but they take up room too. Plus, the stuff can still fall out even if it is retained.

That extra room eaten up by the insert is a concern of mine as well. I really like the Trauma Kit NOW! as it has a lot of nice features, but it definitely takes up a lot of room inside the pouch.

One thing that a friend, who is a local SWAT medic, does for his team is assemble their kits and vacuum seal them with a Foodsaver-type device. He then cuts notches all around so that they can open them from any side. Yes, one could have everything fall on the ground once extracted, or may need the item at the bottom of the bag not the top, but it's a good way to keep everything together, and I think it does have more application for what I'm talking about here with a range kit.

Which is one advantage of the inserts. you pull it out, open it up, and the thing that you need are sitting right there in front of you, laid out for you to choose from.

part of the reason I'm trying to narrow down my kit is so that I can also be more specific about the carriage with the custom nylon guy today. Right now I have only one side of the TKN filled, which makes me wonder if I can't cut off the other side and reduce the pouch thickness by at least 30%. This is the list of what comes in the filled TKN, with the items I've included in bold, and what I've added in italics.

(1) Cinch-Tight Combat Dressing NSN 6510-01-503-2109
(1) PriMed Compressed Gauze NSN 6510-01-503-2117
(1) TK4 Combat Tourniquet NSN 6515-01-542-
(1) Combat Medic Reinforced Tape NSN 6510-01-549-0927
(1) Petrolatum Gauze Pad 3"x9"
(4) Nitrile Surgical Gloves
(2) .25g Quick Clot Sponge
(1) Bolin Chest Seal

[Iraq Ninja]

Rob,

I would not suggest cutting the insert down. I like expandability.

My personal rule of thumb is to have at least two bandages on my person.

[MIKE G]

.......

[Gutshot John]

One of the more interesting recent developments in battlefield trauma is the far broader applicability of a tourniquet.

When I first began a tourniquet was the method of last resort due to fears of nerve damage/amputation. More recent experience has proven the flaws of that notion. There are recent studies which indicate that there is little significant long-term damage or risk of amputation even after a tourniquet has been applied for hours.

In terms of hemostats I don't believe in the "magic dust" medium. While it beats nothing the more advanced impregnated mediums are far more effective and easy to use. ACS but preferably Combat Gauze by QuikClot. Interestingly enough I also think it becomes something of a crutch.

Two or more extra bandages is an excellent idea because one bullet often makes two holes and occasionally more.

What I would do if I was self-treating a GSW to extremity...


Apply tourniquet immediately to stop catastophic blood loss (they come with instructions, read them before you get shot),
*OPTIONAL - Apply hemostat quickly (using combat gauze or ACS a monkey could do this by packing (stuffing) it into the wound),
Apply pressure-type bandage/s quickly and securely,
Call 911 for escort along the way if no EMS nearby,
Get going to the hospital, time is of the essence - drive if you have to but don't kill yourself or anyone else along the way


Take it or leave it as you will.

[Fireguy275]

My daily carry kit is a CAT TQ, 4" Ace bandage, HH compressed gauze, Celox, and pair of gloves in a waterproof zip-up pouch that I bought from REI. Fits in the side cargo pocket of my pants.

I am wanting to go smaller though (wallet sized) for times when I'm not wearing cargo pants and am planning to vacuum-seal a packet of Combat gauze with a Swat TQ and a pair of gloves.

[brit]

You might want to have a razor to shave hair if you plan on using a chest seal. And maybe an alcohol prep pad, if you only have one chest seal, you're gonna wanna make sure it sticks.

or, you could save the effort, get a 4"x4" piece of plastic and 2' of duct tape and just make your own occlusive dressing.

do you have enough stuff to account for exit wounds as well?

[Submariner]

do you have enough stuff to account for exit wounds as well?

Six-inch IBD with sliding pad.

[Danny Boy]

I can tell you from experience that there's no shaving required with these:

http://www.narescue.com/Products/ProductImages/10-0015t.jpg

[brit]

Do you have to run a chest tube or DC needle with the Hyfin? I couldn't find any information on it.

[Danny Boy]

Only IF required, then yes.

[Submariner]

Six-inch IBD w/slider, 30 NPA and 2" 14 ga. Catheter wrapped together in three pieces of surgical tape is a tight fit in an Eagle single M4 pouch. This is what Dr. Barrera (Doc Gunn) recommends in his class for personal carry; however, he doesn't like the slider. I do. He provides training on proper use of each item.

http://img.photobucket.com/albums/v304/DasBoot56/Eagle2X4005.jpg

[Danny Boy]

Cool.

Not to criticize - and I'm assuming that dealing with penetrating chest trauma is one of the aims of the kit - but I'm curious why it's not just joined with one (or two) wraps of three inch tape rather than one inch. My thinking being that you've got the wrapper for the IBD to occlude a penetrating chest wound but it would be better taped and secured with an optimum 2 of 3 inches of tape making contact with the skin. It would also mean less tape that you'd need to find the end of and unravel to get to your bandage if it was needed quickly, even though I can see it's been dog eared over. Not saying I disagree at all with what you've done.

I'd highly recommend a Benchmade Number 7 hook for the kit too. Would slide into it with or without the sheath and is great for going through clothes or cutting up or modifying dressings.

3.25 length catheters are just the length "they" decided was optimal for clearing the tissue in the chest wall and not overshooting the chest cavity.

[Submariner]

Cool.

Not to criticize - and I'm assuming that dealing with penetrating chest trauma is one of the aims of the kit - but I'm curious why it's not just joined with one (or two) wraps of three inch tape rather than one inch. My thinking being that you've got the wrapper for the IBD to occlude a penetrating chest wound but it would be better taped and secured with an optimum 2 of 3 inches of tape making contact with the skin. It would also mean less tape that you'd need to find the end of and unravel to get to your bandage if it was needed quickly, even though I can see it's been dog eared over. Not saying I disagree at all with what you've done.

I think your idea of wider tape may be better. This is what were were shown/given by the board-certified trauma doc who taught the class. Three pieces of tape, one for each of three sides of the ersatz occlusive dressing/wrapper. The other is a vent, as you know. I suspect it is so folks like me don't screw up. :D


I'd highly recommend a Benchmade Number 7 hook for the kit too. Would slide into it with or without the sheath and is great for going through clothes or cutting up or modifying dressings.

Would this be cost-effective vs. a pair of trauma shears stuck between the mag pouch and plat carrier?

[MIKE G]

.....

[brit]

I made the mistake of handing a paramedic a paltry amount of tape once when I was training. His response was, "We don't charge by the inch for this shit, gimme some more!" I learned my lesson, use more tape than you think you'll need.

[Submariner]

I have to say that Doc Gunn's kit recommendation is a disservice....

I know the guy is published and teaches along side a big name but this is a piss poor kit recommendation and is indicative, to me at least, of minimal real world field application of this gear.

DOC

Thanks. I'll look into the other bandages.

Who do you recommend for training of private citizens?

[Danny Boy]

The Olaes is a great bandage. A little bit more of an odd shape though compared to other things. I *think* you'd have a hard time getting it into and out of an M4 mag pouch. None of my Whiskey instructors at Ft Sam that I showed it to had seen them before.

The IBD is still much better than having nothing. I'd wager that you could fit a pack of Z Pack gauze around the IBD for packing wounds without it increasing the size a great deal.

Of all the training I've done thus far though, I don't think I've ever used an IBD for anything other than for a skills evaluation specifically requiring me to use it. Rest was all just kerlix and ace wrap.

I don't think it's that bad of a kit. I don't have the wealth of experience that Doc Stewie has though, but that also enables him to be able to deal mentally with a greater variety of injuries that someone without either training and/or experience can't. To the average Joe, you just want to be able to control any blood loss as crudely as possible and get on the phone to 911 and get them to deal with it. Until that happens, even keeping a gloved hand over a penetrating wound to the chest would be better than nothing or applying constant manual pressure to a wound or pressure point with any dressing to hand.

[MIKE G]

......

[Submariner]

I thank everyone for their taking time to post responses.


Something I like to do is think through all the uses of each item so I can see what I have that is redundant or what I have that has no redundancy (meaning I may want to carry two).

So what are your uses for each of those items?
...
I will do you better than an m4 mag pouch.

I kept this kit in an M18 smoke grenade pouch on my chest for my entire time in Iraq:

1-Cinchtight dressing (Can also use a thincinch rolled up for even more space savings)
1-Primed gauze
1-TK4
1-30fr Nasal (IN WRAPPER)
1-14gax3.25" needle or catheter
1-flat roll of duct tape

All this fit in a DBT M18 pouch with custom sharpie stenciling to put a cross on it, see pic below.

DOC

DOC - I could ask this in a PM but then the other folks here wouldn't get the info: "So what are your uses for each of those items in your Mk 18 pouch?"

BTW, I just traded an old Eagle RRV for 8 Eagle Mk 18 pouches. We have seven shooters here. I'd like to just get one kit and train everyone with each item in it.

To answer your question, I'm on a farm in Southern Indiana. I wrote the article for two reasons: make money and kindle interest in an aspect of shooting which has been too long neglected. Not everyone can afford Gunsite's TACMED Class.
I've found that writing makes me learn more than simply taking a class.

[MIKE G]

......

[Submariner]

Roger, DOC.

Would you please compare and contrast the Cinchtight with the previously mentioned Olaes bandage?

Why did you select the Cinchtight?

[MIKE G]

.......

[Danny Boy]

Doc - Thanks for the words of advice and the heads up on the good eats. I'll be sure to check it out.

[FFK]

Doc, Gutshot John, or anyone else that knows...

Regarding the 4" vs 6" bandages and the hemostatic's...

My SWAT team is setting up kits for each officer. We are each going to have 2 TQ's and 2 pressure bandages. I requested the OLAES 4" variety. Would I be making a mistake by going with the 4 as opposed to the 6?

Also, IF we were to go with the Quickclot sponges, which size would be optimal? It appears they are available in 25, 50 and 100 mg varieties. I am only an EMT-B, and have absolutely no training with these. I do understand that we need training on whatever we select but money has been found to buy kit and it is a race to spend it before another unit does. My best guess was 2 50's per officer, but again, it was my best GUESS.

Thanks for any help.

[MIKE G]

.....

[Gutshot John]

Allow me to qualify something, when I heard "bare bones" I was presuming as small and basic a kit as possible that would be supplemented by a more definitive set once hemorrhage had been controlled. For a SWAT team setup like you're describing I would recommend A LOT more than bare bones.

I'd agree to go with the 6" as the most versatile.

The ACS issue depends on whether you can fit twice as many of the 50 as you can the 100. Two 50s would be better than one 100. Honestly though four 50s or two 100s is the ideal. It's easier to put two 50s in one hole than split a 100 between two.

This is where combat gauze is maybe a better choice since it can be used to pack wounds where the ACS can't be used to wrap.

It's just a bit more flexible. As a general principle I prefer general use items to one-application gadgets.

[FFK]

Thanks for the responses. I know this is a highjack to the original thread but, having read posts by both of you guys over time, if possible, I would like to expand on this.

We are conducting team training and our Tac Medics (P's) are working with me on developing the program. I generally do not agree with the KISS principle or training for the LCD but in this case that is the only realistic option. Because of this, we have standardized on the large Eagle Med pouch on the upper left side of the rear panel of our armor, in a standardized location. That pouch is to contain a SOF-T TQ, an Olaes, NPA, 2 cravats w/safety pins, 4x4's, gauze, gloves, Sharpie, 2 petroleum gauze, tape, compression wrap, the 2 50 mg Quickclot 1st Responder sponges/gauze, and hopefully 3.25 14 ga catheter needle. At the same time, each officer is to have a pouch, accessible to them, on the front right side of their armor containing another SOFT-T and Olaes. Thoughts?

[MIKE G]

......

[MIKE G]

......

[rob_s]

That's pretty cool doc, thanks!

ETA:
Just realized you got a 6" Oales in there! That's a big bitch!
http://m4chart.com/mediac/400_0/media/DIR_97921/400$20DRESSINGS.jpg

[Submariner]

Thanks for doing the heavy lifting, DOC.

:D

Any reason not to add lube for the NPA?

[MIKE G]

.......

[Submariner]

The Olaes is a great bandage.... None of my Whiskey instructors at Ft Sam that I showed it to had seen them before.

How can this be? Does it lack an NSN?

[Iraq Ninja]

How can this be? Does it lack an NSN?

NSN: 6510-01-558-3443

http://www.tacmedsolutions.com/07/products/product_detail.php?prod_id=3


I think they are not Berry compliant for mil sales though, if it applies to med kit. Made in CHINA, sterilized in the USA.

[Submariner]

NSN: 6510-01-558-3443

I think they are not Berry compliant for mil sales though, if it applies to med kit. Made in CHINA, sterilized in the USA.

So Israeli Battle Dressings are made in the USA?:eek:

[Danny Boy]

I think they are not Berry compliant for mil sales though, if it applies to med kit. Made in CHINA, sterilized in the USA.

It's possible but I don't think so. I saw Made in China on bits of gear in training, mostly on needles.

Why do I think none of them had seen one before? Unless you tend to spend way to much time like I do on the internet buying stupid Emdom pouches to put your BSI in, I suppose you just miss stuff. The private sector tends to move quicker with most things. There's other better bits of kit (IMO) out there that we don't train with but they all revolve around the same principle so it's not that big of a deal.

I think there may be some resistance to moving away from the Tape/Kerlix/Ace Wrap approach, but for replacing the IBD I think it's definitely the way forward. Just the opinion of a dumb Private.

[Submariner]

Nice touch on pinning the safety pins to the tear-off portion of the dressing.

Will any safety pin do or must they be surgical grade stainless steel?

On the 6-inch Olaes, what is the order of loading?

I got my Mk 18 Pouches today. The IBD w/slider pack fills it completely because the sliding pad is so thick.

[MIKE G]

......

[Submariner]

Thanks. Now I understand the advantage of the PriMed - compressed so it stows better.

[Submariner]

Just realized you got a 6" Oales in there! That's a big bitch!


Yup.

Not only can Mike pack an Eagle Mk 18 pouch, he can stuff a flat rate Priority Mail box!

I just got my first Olaes dressings, among other things. Packaged, they are as big or bigger than a 6-inch IBD w/sliding pad. Looks like I'm going to have to use a shoe horn to pack it as he did.

BTW, I highly recommend the Olaes training bandage. Its low cost takes the pain out of actually using it. We have been using the IBD's we used in Doc Gunn's class for training. They are pretty worn.

Added Professional Soldiers Med Kit thread. (http://professionalsoldiers.com/forums/showthread.php?t=18532)

[Submariner]

For the weight- and space-conscious, one of Mike's kits weights just over twelve ounces and takes up only two channels of webbing:

http://img.photobucket.com/albums/v304/DasBoot56/BOK.jpg

[The Doc]

Just my 2 cents on the subject:

Bare bones applies to a lot of things, but I don't want it to apply to something that can be the difference in me getting up the next morning and seeing my wife and kid or not. If space is a premium on your kit, you have to only include what's absolutely important, here's a good jump off point:

A good tourniquet. I prefer the SOFTT, but a CAT is as good. I have broken the windlass on some CAT's so I stick with SOFFT's for personal gear.
Combat Gauze X2. Remember most wounds have an entrance and exit, so packing from both sides will only help staunch the flow of blood. If you don't have access to Combat gauze, regular kerlix works good. I prefer NARP's S rolled. It's a lot flatter to store than the H&H's or other brands.
A roll of 3" tape.
A 6" ace wrap.
2 Bolin Chest seals or Hyfins with a swab of alcohol and a benzoin tincture taped to it. The tincture will help stick it on the chest if sweaty, bloody, wet, ect...
A 4x4 to wipe away blood

The stuff I wouldn't care about CONUS if EMS was 30 minutes ETA:

NPA- Pointless in the unresponsive pt. Pointless in the responsive PT. If someone is conscious, they obviously have a patent airway and an adjunct like an NPA is just going to stimulate their gag reflex and possibly cause them to vomit and maybe aspirate if they are not alert and orientated due to the shock of the trauma or blood loss. If they aren't conscious, an NPA isn't gonna do them much good. The recovery position and a good head tilt chin lift will do them just as much good as an NPA.
A IBD, Thin cinch, ect..... An ace wrap, kerlix, and tape do everything that one of these do, and are easier to use, especially in the untrained, or with someone who doesn't experience trauma situations normally. I'm not saying they aren't great products, but they don't normally come with the little extra white bandage to cover the exit wound, unless you get the bigger size. And it's just as easy to treat a GSW with the kerlix and ace wrap.
So here's the scenario. You're on the range, and a dude pops himself in the leg with his POS Bryco 380. His leg is spurting blood from both sides. Rip away enough clothing to get a good look an the wounds. Apply the TQ until the bright red bleeding stops, pack both wounds with the gauze, wrap tightly with the ace wrap, tape the shit out of it, and call 911... Keep his legs elevated, monitor his pulse (80 beats per minute is normal unless he's a marathon runner) and his respirations (12 per minute) Good and good.....

[Rated21R]

I love some of the discussion in here, very good ideas bouncing around. While they don't have everything you need, the IFAK is a good design and can modified to carrry what you need. It only takes up two columns of MOLLE as well. Here is the NSN: 6545-01-530-0929

A little off topic but it relates to the range scenarios that have been brought up. Each one of my vehicles has a full on CLS bag. They are very useful and unfortunately on a trip home to see my parents in the Springs my wife (USAF Nurse) and I had to use dang near all of the supplies on a girl who had just rolled her car on the highway. :(

You never know when you are going to have use your training or your gear.

[Danny Boy]

So here's the scenario. You're on the range, and a dude pops himself in the leg with his POS Bryco 380. His leg is spurting blood from both sides. Rip away enough clothing to get a good look an the wounds. Apply the TQ until the bright red bleeding stops, pack both wounds with the gauze, wrap tightly with the ace wrap, tape the shit out of it, and call 911... Keep his legs elevated, monitor his pulse (80 beats per minute is normal unless he's a marathon runner) and his respirations (12 per minute) Good and good.....

The only thing I'd question is ripping away the clothing before applying the tourniquet, especially if it was obviously a gusher. Would it not be best to just get that tourniquet on as quickly and as high up as possible on the leg, even over the trousers, to prevent whatever blood loss is possible before further evaluation of the wound and possible addition/downgrading to a pressure dressing?

[The Doc]

The only thing I'd question is ripping away the clothing before applying the tourniquet, especially if it was obviously a gusher. Would it not be best to just get that tourniquet on as quickly and as high up as possible on the leg, even over the trousers, to prevent whatever blood loss is possible before further evaluation of the wound and possible addition/downgrading to a pressure dressing?

Depends on where he shot himself. You can lay him down and apply pressure on his femoral artery with a knee in the inguinal area. It would suck to put on that TQ only to realize that it's not high enough or in an area that your TQ is ineffective... You might have an exit wound that's in the buttocks or wherever. I like to get a good look at what I'm working against before attacking the problem. You can always staunch the blood flow with a good amount of pressure. I weigh about 175, plus kit, say 220. All my weight on my knee on the dudes groin where the femoral artery is gonna slow it down enough for me to do the best job the first time and not have to move an intervention.

But, you do bring up an extremely valuable point. I was simply stating A method, not THE method. :D

[peepee]

Is there a downside wound? There could be one proximal to the wound. The best way to confirm this by:
1) "Oh shit" bleeding = TQ
2) Expose the wound(Rip those pants open like a man!:sarcastic:)
3) Place an object(knee, hand, whatev) on the obvious bleeder
4) Check and confirm no downside bleeder(Dont want to get fixated on the "Obvious" bleeder and miss the actual "Obvious" bleeder).
5) Apply a TQ above the next joint or for a femoral bleed, as far proximal as you can.

In regards to TQ reduction to salvage the limb, thats another discussion. You have plenty of time if youre CONUS. Our protocol is:
1) After a TQ is in place, apply a pressure dressing ASAP.
2) Wait 30 min from time the TQ was placed to allow for clotting.
3) NOW(After the initial 30 min), a 2 hour clock starts. If you have the guy in two hours, attempt to reduce the TQ. IF HEMCON is obtained with the pressure dressing, leave the TQ on loosely and drive on. Also, splint the leg one joint above and below the wound to immobilize it. This prevents moving a clot by manipulating the extremity.
IF HEMCON is not obtained with the pressure dressing move the TQ as far distal as possible and reapply the TQ.

-Be sure to note TQ time. This is imperative. The magic number(s) are/is 4-6 hours... but there are many that say up to 8 hrs.
-This is "A Way, not The Way" ;)

[The Doc]

BSI Scene is safe, I got one trauma patient, me and hadji can handle it! HAHAHA! I know you know what I'm talking about!

[peepee]

Oh no! I tried to forget Doc!

[davey]

The only thing I'd question is ripping away the clothing before applying the tourniquet, especially if it was obviously a gusher.
I dunno about the military, but in the civilian world, you're schooled, "You can't treat what you can't see."

The other issue is the one The Doc brought up - you can't get tunnel vision. Even when a tourniquet is required, you're going to have to go back after it's on and perform a complete head to toe survey to look for the rest of the injuries. You can't treat what you didn't find. Loose the clothes.

[MIKE G]

I think Danny Boy's point is that you know you have an arterial bleed because it is spraying you in the face, every squirt is more RBCs in the dirt and applying a high TQ immediately may save enough RBCs to make a difference down the road.

Is there the potential that you have a high groin injury or a track out the buttock where a TQ may not work? Yes. If the injury is obvious (damage to clothing, obvious soaking of blood, squirting me in the face, etc) and on the lower half of the thigh or BTK I can see an argument being made for immediate TQ application followed by exposure and visualization to address/identify severity of wound and secondary wounds for treatment as well as follow up and application of TQ closer to wound to potentially salvage tissue.

Ultimately the goal is to keep the red stuff on the inside since it is a precious commodity. I dont see Danny's statement indicating that he is treating something he didnt find, he said "especially if it was obviously a gusher".

I agree with peepee, in my mind both are a way and I can appreciate arguments for both approaches.

[The Doc]

It never works that way. That was part of my point. Bullets, frag, parts of IED's and EFP's leave big holes in flesh due to cavitation, but small holes in clothing. Pressure to the artery above the wound and exposing the wound are your best bet. That takes all the guess work out of what you are working with. No guesswork, no chances of screwing up. Works 74.5% of the time, all the time. (I know some people will get that!)

Doc

[MIKE G]

Doc,

My post wasnt in response to yours but to davey. Thanks for your response and I see your point. As my post said, I can appreciate Danny's thought process as well. After all, you did post that it was A method, not The method. I am not saying he is right and you are wrong, I am saying that I understand what he is thinking.

[sniperbusch@hotmail.com]

From the TCCC:
60% Extremity Hemorrhage
33% Tension Pneumothorax
6% Airway Obstruction

Let's assume, for the purposes here, that we're talking about being stateside and with 30 minute response time from EMS and 60 minutes to get to an emergency room or trauma center.

Let's also have a goal of an AR double-mag pouch (or triple if needed) as a size limit.

I think anyone/everyone would include a tourniquet or two.

Trauma dressing (Israeli, Oales, Cinch-Tight, Thin-Cinch, 4" vs 6", etc.) seems to be a common theme.

NPA?

Better to use a dedicated chest seal or rely on the wrapper from the trauma bandage and some tape?

Hemostatics seem to illicit some controversy, but better to have and not need? Worthless stateside with 30 minute EMS response?

Another helpful discussion, thanks rob_s. I am assuming that the BOK topic is directed towards a scenario for the Armed Citizen. The concept for me on the Blow Out Kit is self-aid primarily and maybe aid to others as secondary. I am not going to kit up to treat others for EDC. I do maintain 2 separate kits, trauma/minor first aid in my vehicle. For concealed carry, I make it a habit to carry at least a 4 inch ETB w/mobile pad on my person. I also carry a HSGI Bleeder Pouch on my second line gear that only contains a 6-inch ETB w/mobile pad, C.A.T and shears and all my micro rigs have medical gear. My thought is that I will only be able to treat extremity wounds on my self and will probably not be able to apply any occlusive dressings or stick myself with a needle. My trauma kit is mounted on third line gear and the contents are intended for use on me, if I am fortunate enough to be with someone that has emergency medicine skills. My priority is to survive long enough to make it to a medical facility.

[Submariner]

I make it a habit to carry at least a 4 inch ETB w/mobile pad on my person. I also carry a HSGI Bleeder Pouch on my second line gear that only contains a 6-inch ETB w/mobile pad, C.A.T and shears and all my micro rigs have medical gear. My thought is that I will only be able to treat extremity wounds on my self and will probably not be able to apply any occlusive dressings or stick myself with a needle.

Have you considered adding wound packing material or replacing your ETB with an Olaes (which has on-board packing material?) Here is Mike G's comment on LF:


Originally posted by krax:
Why do you want a pouch to carry just an Izzy bandage? Is it supplemental to a full IFAK? The more I learn about trauma medicine, the less impressed I am with the Izzy. Can't really pack wounds with it, just cover them up. Rather have Z-pack gauze and an Ace wrap.

Originally posted by Mike G:
Any of the basic combat dressings only provide a sponge on the exterior and compression through the elastic wrap. Packing such as the Primed gauze, z-pack, Combat Gauze, etc in conjunction with direct pressure by a hand or knee OR being reinforced with a combat dressing (Izzy, cinchtight, olaes, etc) is going to be preferable.

[sniperbusch@hotmail.com]

Thanks for the critique and any further recommendations or suggestions. I am not in theater but my thought process to improve my survivability in a gun battle during a major incident; is mobility and effective use of cover and concealment. I prefer a stream line kit for uninhibited maneuvering. I do have Olaes Modular Bandages but I do not care for the bulk. My objective of getting off the X if hit, is to render immediate hemorrhage control until I am in a better position to tend to better wound care. Conceal Carry presents a different challenge on med kit.

[Submariner]

I prefer a stream line kit for uninhibited maneuvering.

Got it. Does wound packing material need to be high drag?


I carry a Swat TQ, Combat gauze, and gloves in a vacuum sealed pouch. The whole package is the same size as my wallet and fits in the front pocket on a pair of jeans.
...
Here's a link to a blog entry with photos of each, http://blog.lmsdefense.com/

Doing more with less. From earlier in the thread:

Combat Gauze:
Hemostatic packing material
Basic bandage
Improvised TQ with a windlass

Swat TQ Tourniquet:
Pressure dressing when used with Combat Gauze
Basic sling

From the link in the quote:

http://1.bp.blogspot.com/_pEzxozN3Mgw/S2M1osVBwTI/AAAAAAAAACg/W7ArXnRSCkk/s320/IMG_0485.JPG

[sniperbusch@hotmail.com]

thanks again and I do like the wallet concept.

[sniperbusch@hotmail.com]

Submariner, this may help solve my conceal carry logistical problem, if you are so inclined to help. Quick overview, I do not like carrying a wallet and stow a Raine bi-fold ID holder (MIL, DL, CHL & ATM) in the vehicle. The Ohio Revise Code does requires CHL holders to have their license in their possession while carrying. I then usually carry the ID holder in a 5.11 cargo pocket. My absolute EDC is a CS Recon 1 Tanto, SO-LED, cigar lighter and cell. My CCW compliment is a Kimber Compact w/strong side belt holster, 2-magazines and SF L4. I do not like carrying a lot of stuff unless warranted. I am thinking that an ID carrier worn around the neck with a break away dummy cord, is doable. What can we fit in this carrier, along the wallet size type supplies that will handle a GSW? Would the above mentioned supplies work well? I only asked because I have limited supplies to mess with to see what would work well and I never used a SWAT TQ.

http://i179.photobucket.com/albums/w293/sniperbusch/idcarrier.jpg

[sniperbusch@hotmail.com]

hot damn, thanks for the added pic! Yea, I did not scroll all the way down to Pocket Carry IFAK Update . Is that a Spec Ops T.H.E. Wallet for reference?

[Submariner]

hot damn, thanks for the added pic! Yea, I did not scroll all the way down to Pocket Carry IFAK Update . Is that a Spec Ops T.H.E. Wallet for reference?

Ask Fireguy275 about the wallet. He responded expeditiously when I asked him questions in that thread.

[MIKE G]

I wouldnt use that neck badge holder. That is designed for overt carry of ID and organization of documents. I have used that exact model and it is not thin or lightweight and will be very noticeable under a shirt even empty.

Fireguy's setup can be made even smaller now that QC/Z-medica have come out with an even smaller packaging by vacuum sealing the latest combat gauze.

[Fireguy275]

hot damn, thanks for the added pic! Yea, I did not scroll all the way down to Pocket Carry IFAK Update . Is that a Spec Ops T.H.E. Wallet for reference?

It is.

The wallet sized kit has held up very well. And with the availability of the vacuum sealed Combat Gauze, the footprint can get even smaller as Mike G points out.

I used a Costco bought vacuum sealer for the task.

[sniperbusch@hotmail.com]

Hey thanks Kevin and Mike, I am glad that this was already thought of and a system implemented. I am glad that I do not have to rack my brain over this concern that I had. I further appreciate your experience, professionalism and willingness to share ideas and to provide information.

[Bullwinkle]

I'd also be interested to know how quickly tension pneumothorax kills. If it takes hours, and stateside EMT response is 60 minutes or less, then it may not be needed in the kind of range kit I'm thinking of for use on established ranges.



guy died on me after we darted his chest twice with a 10ga, was 15 min from accident to hospital and he died as we pulled into the hospital.

[Submariner]

At the LMS No Light/Low Light Skill Builder Class in Alliance, OH, we spoke with Mikey G about a really bare bones BOK using cheap Eagle frag pouches. This might go on a war belt and is in keeping with the no needles/NPA position taken by many.

http://img.photobucket.com/albums/v304/DasBoot56/bok1.jpg

Contents:


Gloves

Primed Gauze:
Packing material
Basic bandage (make your own bandage with duct tape)
Tie off for perforated bowel (this is an advanced skill obviously)
Improvised TQ with a windlass

TK4:
Tourniquet
Pressure dressing when used with primed gauze
Basic sling

Duct Tape:
Tape
Improvised TQ with windlass
Joint taping
Occlusive dressing
Improvised Steri strips

Packaging:
Occlusive dressings (either for open ABD/Chest wounds or for water resistant wound protection in particularly dirty enviros)

Two Safety pins:

Pin the tongue out of the way for compromised airways
Use to improvise a sling with pt's t-shirt
Foreign body/splinter removal
Temporary wound closure

http://img.photobucket.com/albums/v304/DasBoot56/bok2.jpg

[rob_s]

Good info Sub. Similar to what I had arrived at. I have been using the TK-NOW from BFG which allows me to carry a couple more items than that but I think that's a great bare-bones kit.

[Frankyoz]

Guys just remember if your not a licensed EMT, I-EMT, or Paramedic or even higher and not up to tip top shape with your skills doing anything invasive is going to open you up for allot of liability so you better know what your doing. Since this is a range scenario Keeping a clear and open airway, supportive care, and basic dressings to stop any immediate bleeding is about as far as I would take it if your not a registered EMT, or Paramedic.

That being said I would recommend carrying Gloves, a OPA, an occlusive dressing, and roll of ACE bandaging.

My kit since I am a Firefighter/Paramedic is a bit bigger, however I have seen people cause more harm then good when they start to meddle with things beyond there scope of knowledge.

In a survival scenario further out from civilization do what you need to keep your buddy alive and pack a bigger first aid kit. Never forget the basic ABC's of first aid, Airway, Breathing and Circulation in that order. If your friends not breathing or his airway is closed up all the needles, and bandaging in the world are not going to save his life. If his heart is not beating you can pump it for him. Bandaging can always be improvised on the fly but an airway cannot.

Hope this helps

[Frankyoz]

Double tap

[motorwerks]

I just picked up an IFAK its a hair bigger then a double mag pouch BUT its perfect for what I need. I used to work for the Fire station closest to the range I shoot at, so I know that with my big bag that I keep in the truck I'm as stocked as they are, but the IFAK would do 95% to 100% of the ABC's I would need to do till they got there (15 out) If I needed I could raid my bag for a C-collar and such but that wasn't part of this thread but its stuff I plan for.

[onado2000]

Never forget the basic ABC's of first aid, Airway, Breathing and Circulation in that order. If your friends not breathing or his airway is closed up all the needles, and bandaging in the world are not going to save his life. If his heart is not beating you can pump it for him. Bandaging can always be improvised on the fly but an airway cannot.
Hope this helps

IMO this statement is the most sensible of the thread. ABCs are a priority. IMO it would be better to have a good stethoscope, b/p cuff & pulse oximeter on hand and good clinical assessment skills. IMO learning to take an accurate b/p, breath sounds and heart rhythms, specifically normal sounds, is important. Once you know what is normal, abnormal will be easier to identify.

[motorwerks]

mehh you dont need a B/P cuff and stethoscope for this kit. If you can find a pulse they have a BP. If not you're about to start chest compressions anyway (if the PT is absent breathing). Besides as an EMT-1 in this area Pulse ox is "out of my scope of practice"

[MIKE G]

IMO this statement is the most sensible of the thread. ABCs are a priority. IMO it would be better to have a good stethoscope, b/p cuff & pulse oximeter on hand and good clinical assessment skills. IMO learning to take an accurate b/p, breath sounds and heart rhythms, specifically normal sounds, is important. Once you know what is normal, abnormal will be easier to identify.

And this is the most disappointing statement I have read on here. There is a huge amount of care that can be performed without any of those tools which for the return on sweat/brain investment is minimal to the lay person. What good does it do to have a firm grasp of heart rhythms (assuming by your follow up clarification you mean heart tones) if you dont know how to manual open airway and clear it of vomit.

A pulse oximeter? Really, we have had this conversation on here. It brings very little to the table and I worry not when my load out does not include one.

Do you really think that having an 'objective' number on BP assists the legit lay person in any way? I would much rather them use the time and effort learning the concept of presentation of peripheral pulses and the implications on perfusion and I would much rather have the weight of even the lightest BP cuff replaced with some tape, bandaging material, a couple pairs of exam gloves, and jumbo trash bag or emergency blanket.

Your statement in quotations above would lead me to believe that you would prefer to have $400 and about 1.5-2 pounds worth of gear debt wrapped up into those tools as well as about 10-12 hours of training to become minimally proficient in them as opposed to $75 (on the high end) and about 12 hours of training to learn to stop bleeding, identify a failing/failed airway, reduce exposure, and call for help. This statement wreaks of an in facility clinician that never worked in the mud or has long since forgotten the experience.

When it comes to immediate care in the ditch you can do skills that fall into three categories, they help, hurt, or accomplish nothing. Assessing heart tones and taking time to take a BP accomplish nothing and border hurting by occupying your time and resources that could be used for something else like stopping a major bleed, clearing an airway, or reducing loss of core temp due to exposure.

If I seem a little perturbed about this it is because I am.

[Gutshot John]

IMO this statement is the most sensible of the thread. ABCs are a priority. IMO it would be better to have a good stethoscope, b/p cuff & pulse oximeter on hand and good clinical assessment skills. IMO learning to take an accurate b/p, breath sounds and heart rhythms, specifically normal sounds, is important. Once you know what is normal, abnormal will be easier to identify.

Not really, I'll meet you halfway in saying that it's kind of a chicken/egg thing and knowing where the balance lies between using ABCs and moving on to more aggressive treatment is vital. Part of the problem has to do with how civilian EMS is kind of behind the curve relevant to what is going on in combat zones. I don't blame you for taking the "old school" tack, it's what you were taught and you sincerely believe that any deviation is fatal, but there are numerous studies that discredit the philosophy. The military has long since abandoned rigid adherence to ABCs and increasingly civilian EMS is following suit.

I don't think you have to be a trained EMT/Paramedic to realize that spurting arterial blood from a GSW is abnormal. Taking the time to secure an airway is kind of irrelevant if the person is losing 50% of their blood volume inside of a minute or two. If you see an arterial bleed you can attach a TQ within a few seconds to control shock, if you have to move the patient to a secure location and then move onto your ABCs if appropriate.

If you were talking about normal, non-acute trauma, first-aid I MIGHT agree that stethoscopes, cuffs and pulse oxes, and ABCs being done in order MIGHT serve a purpose, but a BOK (that's why they call it a blow-out) involves a different set of priorities and generally deals with you seeing the injury take place. A BOK is different from a first-aid kit and is meant to address GSWs specifically. It's meant to be small, light and functional with minimal space devoted to irrelevant stuff.

The ABCs have a time and place, knowing when they should be rigidly adhered to or discarded in favor of more aggressive treatment can determine life and death. While taking an accurate bp, breath sounds and heart rhythms can be useful under the appropriate circumstances, they are useless if a person bleeds out in less time than it takes you to perform those things. If you can see a drop in BP due to hemorrhage you're already way behind the curve.

OPAs (and even NPAs) are of limited value without a BVM. IF you have to go the airway/breathing route a face shield is far compact/easy to use and in the end more useful and even then CPR is increasingly getting away from rescue breathing in favor of compressions. A pulse OX is almost irrelevant except for freeing you from having to take a pulse but it only confirms what you should already know. I see no virtue of it taking up space inside of a BOK.

[onado2000]

Yes I do work in an ICU and have cared for tons of people with pneumo/hemothorax, I do have experience. The subject matter I was discussing in particular was inserting a decompression needle into collapsing lung. Why would you do this in a ditch or in the middle of a firefight? Sealing the wound and sending him off to the field hospital ASAP. I agree patient assessment skills are the most valuable tool. My point was having these other tools instead of everyone with the same stuff. Ten guys all with the same dressings, tape and clotting agents, maybe one or two could have other equipment. Variety is the spice of life :D
A B/P cuff in itself is an excellent tourniquet, to the point of applying minimal pressure required to stop blood flow (having a stethoscope helps to determine that). This minimizes tissue damage & loss. I use a pulse ox to determine the % O2 bound to hemoglobin, and the need for O2. This way I don’t have to give him my 16% when I know he is getting enough of his own 21%. I have one in my bag; it’s about 2X2 inches, a few ounces and cost less than a cheap bolt carrier group. Heart rhythms are important part of assessment, patients in shock, trauma patients with muffled heart sounds. If I was going to insert any needle it would be an IV to start some saline.
Mike G, you’re going to criticize me for "heart rhythms"?
Please explain "concept of presentation of peripheral pulses and the implications on perfusion" and how that relates to assessing patients in the ditch and in shock. And how that subjective method is better than an "objective number".

[Gutshot John]

Not to speak for Mike but he does know what he's talking about and he's correct on all counts.


Yes I do work in an ICU and have cared for tons of people with pneumo/hemothorax, I do have experience.

Experience in an ICU is a lot different than in the field. In an ICU you have the best equipment, personnel support you can get, in the field...you don't. Care in the ICU is definitive, what EMS refers to as "bright lights and cold steel", care in the field is a short-term solution to a long-term problem. You're simply buying time to get them to the hospital. You simply don't have the time or resources to do any of the stuff you're talking about.


The subject matter I was discussing in particular was inserting a decompression needle into collapsing lung. Why would you do this in a ditch or in the middle of a firefight? Sealing the wound and sending him off to the field hospital ASAP.

Generally speaking you wouldn't do this in the middle of a firefight...any more than you'd be auscultating blood pressure, lung sounds of heart rhythms or doing anything so quaint as ABCs. You'd suppress the threat, apply a TQ and then move the patient out of the kill zone to a place where you have enough cover/security to do more comprehensive treatment. It's the "Care under Fire" phase of TCCC and is sanctioned by the NAEMT.

Needle decompression while rare in civilian EMS is still within the scope of most paramedics. In military EMS with extended transport times (assuming casevac is available), NeedleDs are more common. I don't endorse the average joe learning how to do them, but having a needle that a paramedic or other professional who happens upon the scene might be able to use isn't the worst idea of all time.


I agree patient assessment skills are the most valuable tool. My point was having these other tools instead of everyone with the same stuff. Ten guys all with the same dressings, tape and clotting agents, maybe one or two could have other equipment. Variety is the spice of life :D

The BOK is carried by most soldiers not for use on others but for use on themselves. It contains the basic equipment they would need to stop theirs or their buddy's (using the buddy's stuff) BOK. More comprehensive gear/dressings is carried by the squad/platoon Corpsman/Medic. Even that is limited to the most general supplies if they're on-foot and even if on vehicles you can't carry a whole ICU with you.


A B/P cuff in itself is an excellent tourniquet, to the point of applying minimal pressure required to stop blood flow (having a stethoscope helps to determine that). This minimizes tissue damage & loss.

It can be used as a TQ, but I prefer something purpose built for that use. What good do you think that stethoscope is going to do you with gunfire going on around you? Additionally if you've used it as a TQ, you've eliminated its use as a diagnostic tool. For the same space requirement as one BP cuff you could carry 3-4 TQs. Even if you've got a cuff, how are you going to change your protocol even if you detect hypotension? If you're relying on BP to tell you someone is going into shock, than you're waaaayyyy too late.


I use a pulse ox to determine the % O2 bound to hemoglobin, and the need for O2. This way I don’t have to give him my 16% when I know he is getting enough of his own 21%.

You're assuming that people are going to be carrying around O2 bottles with them. Incorrect.


I have one in my bag; it’s about 2X2 inches, a few ounces and cost less than a cheap bolt carrier group. Heart rhythms are important part of assessment, patients in shock, trauma patients with muffled heart sounds. If I was going to insert any needle it would be an IV to start some saline.
Mike G, you’re going to criticize me for "heart rhythms"?

While I like the Pulse OX for its ability to give me a pulse/or lack thereof without having to stop doing something else. O2 bound to hemoglobin doesn't change anything you're going to do.

Actually the notion of heart rhythms are absurd in field care. It isn't going to change your treatment plan one little bit. What do you think people have in the ditch? Alpha/Beta agonists/antagonists?

What difference is knowing that someone is in VTac or VFib going to make? If you have an AED, than the machine will know when to shock or not. If you don't, then you're reverting to CPR.


Please explain "concept of presentation of peripheral pulses and the implications on perfusion" and how that relates to assessing patients in the ditch and in shock. And how that subjective method is better than an "objective number".

Dude, what difference does it make whether you've got a distal pulse or not? It won't change anything you do in the ditch. If you don't have a distal pulse than you've wasted a huge amount of time fiddle-****ing with your stethoscope/BP cuff when you should have been applying a TQ and hemostat.

Sorry but the OP asked about a "bare bones" BOK. You're talking about a comprehensively stocked ambulance.

[onado2000]

Sorry but you're way out of your lane, more to the point the OP asked about a "bare bones" BOK. You're talking about a comprehensively stocked ambulance.


I like this forum and I do not want to get kicked off for arguing. I understand that we are governed by different rules of care. I also understand the EMS golden hour. But EMS also has the same equipment discussed in this thread. Granted I don’t know what its like in the battlefield nor do I care for people while under fire, my input was strictly concerning the idea & risk of inserting a decompression needle. I give medics alot of credit & have respect for them doing their job under the stress of war. But to me it seems crazy to think medics are equipped with AED but not other tools. Maybe I should have written "ideally" instead of "IMO" with my first post. No offense or hard feelings guys.

[Gutshot John]

I like this forum and I do not want to get kicked off for arguing. I understand that we are governed by different rules of care. I also understand the EMS golden hour. But EMS also has the same equipment discussed in this thread. Granted I don’t know what its like in the battlefield nor do I care for people while under fire, my input was strictly concerning the idea & risk of inserting a decompression needle. I give medics alot of credit & have respect for them doing their job under the stress of war. But to me it seems crazy to think medics are equipped with AED but not other tools. Maybe I should have written "ideally" instead of "IMO" with my first post. No offense or hard feelings guys.

I didn't take offense to what your original point was. I think both Mike and I were concerned that you were inadvertently giving bad information by not focusing on what is relevant to a BOK which is far less than a paramedic or corpsman would carry.

I didn't mean to suggest that they would carry an AED, I should have said "even if" they had access to one as they are found in many public places these days and even LEOs have them in their vehicles.

I don't recall Mike or anyone else arguing that NeedleDs should be commonly used/taught to lay people.

[MIKE G]

Yes I do work in an ICU and have cared for tons of people with pneumo/hemothorax, I do have experience. The subject matter I was discussing in particular was inserting a decompression needle into collapsing lung. Why would you do this in a ditch or in the middle of a firefight? Sealing the wound and sending him off to the field hospital ASAP. I agree patient assessment skills are the most valuable tool. My point was having these other tools instead of everyone with the same stuff. Ten guys all with the same dressings, tape and clotting agents, maybe one or two could have other equipment. Variety is the spice of life :D
A B/P cuff in itself is an excellent tourniquet, to the point of applying minimal pressure required to stop blood flow (having a stethoscope helps to determine that). This minimizes tissue damage & loss. I use a pulse ox to determine the % O2 bound to hemoglobin, and the need for O2. This way I don’t have to give him my 16% when I know he is getting enough of his own 21%. I have one in my bag; it’s about 2X2 inches, a few ounces and cost less than a cheap bolt carrier group. Heart rhythms are important part of assessment, patients in shock, trauma patients with muffled heart sounds. If I was going to insert any needle it would be an IV to start some saline.
Mike G, you’re going to criticize me for "heart rhythms"?
Please explain "concept of presentation of peripheral pulses and the implications on perfusion" and how that relates to assessing patients in the ditch and in shock. And how that subjective method is better than an "objective number".

I haven't mastered the art of the multi-quote as John has so I will simply address each point as I go.

Yes, you do have experience. Experience in an ICU which is not experience in the field. Very few if any patient is ever going to present to the ICU without seeing a host of other health care professionals first. You are in a different world or lane as some may call it.

As to the subject matter you were discussing, you failed to communicate that adequately. You simply replied to a post about focusing on the ABCs and added "IMO it would be better to have a good stethoscope, b/p cuff & pulse oximeter on hand and good clinical assessment skills. IMO learning to take an accurate b/p, breath sounds and heart rhythms, specifically normal sounds, is important." My take away from this comment is that you would rather have a good stethoscope, BP cuff, and pulse ox, than a blow out kit such as the members here have been describing. Regardless of whether you would rather have those items in place or in addition to a blow out kit I disagree. Most of the readership of this thread falls into the knowledge level of functionally no training in medicine or up to the EMT level. If I were outfitting that population to go to the range OR to go to war one of the last things I would provide them is a BP cuff, Stethoscope, or pulse ox. Even as a remote duty medical officer I only carried those items in my assessment module of my ruck that stayed with a vehicle 95% of the time. What I kept on my person was used to stop bleeding (tourniquets, bandages, packing, hemostatics), maintain breathing (nasals, needles, crics, BVM, improvised suction), and reduce exposure (jumbo trashbags, thermal blankets). As well I carried some fluids and some basic meds but most of the highspeed stuff stayed in the truck for when we started moving toward a higher level of care.

As to treating in the ditch, tension pneumo is one of the leading three identified causes of preventable death on the battlefield which basically says that when you incur penetrating trauma (like you may find at a shooting range) that one of the top three things that wont kill you before you hit the ground but will kill you before you make it to the hospital is tension pneumo. We treat those in the field. If we reserved that for a physician there would be more people dead on the battlefield especially considering the variety of time frames from point of injury to surgical care in combat. We do not make a habit of treating them in the care under fire phase but do perform this maneuver in the tactical field care phase.

As to variety is the spice of life and cross loading different items to team mates, you didn't say this. Either you failed to communicate that point effectively or you are trying to make excuses for your statements. That being said, I would not carry these items on my first or second line of gear (on my uniform or on my vest). They would be reserved for my ruck and this topic is in regards to bare bones blow out kits. As well, when working in a team tactical environment you can not rely on someone else to be immediately next to you to provide you with trauma gear. This is why the US Military issues all deploying personnel with an IFAK (Individual First Aid Kit).

In regards to the BP cuff as a good tourniquet, it isnt when used in the field. BP cuffs are overly bulky and size specific for the purpose of using as a tourniquet as well they are fragile in comparison to a purpose built tourniquet. Once velcro has mud or dirt in it adhesion is poor until cleaned and rubber bladders have a tendency to develop leaks around sharp point things. Appropriate placement and use of an off the shelf tourniquet reduces death from arterial extremity wounds which trumps tissue damage and loss.

"I use a pulse ox to determine the % O2 bound to hemoglobin, and the need for O2. This way I don’t have to give him my 16% when I know he is getting enough of his own 21%." So you are going to start provider rescue breathes based on a pulse ox reading? As opposed to an assessment of the patients respiratory rate/rhythm, tidal and minute volume? If I were doing telemedicine I would want to know about those factors as well as skin color and mental status well before asking for a pulse ox from a lay person. Pulse ox is great for documentation in the world of Joint Committee but means very little to me in the early stages of trauma treatment. I the field my patients are cold, ambient light can be very bright, and peripheral perfusion can be diminished. All of these things can cause false readings on a pulse ox which still shouldnt replace my ability to look at someone and say "self, that guy looks sick".

The 2x2" unit you have in your bag still costs more than an entire blow out kit and serves minimal actual purpose. Is it good for a medic to have access to one, yeah. Did I carry one in my ruck, yeah. Does it belong on a vest/battle belt/range bag? NO.

Heart rhythms are not important in the early stages of trauma treatment in the field. Not to mention they are difficult to teach to even experienced providers much less every deploying troop and they require a stethoscope. If I want to know if someone is in shock I will assess them with my hands, eyes, and ears.

In regards to the only needle you would place would be an IV. As an ICU RN are you even trained to do pleural decompression? Beyond it being discussed in ACLS? Is it in your facilities allowed scope for RNs? So of course you would default to what you can do and not focus on what you can not. IV fluids in trauma patients with uncontrolled bleeds have been found to cause increase morbidity and mortality because it dilutes clotting factors and breaks up the clots that have formed (think leak in a garden house and you increase the pressure). Current TCCC guidelines recommend minimal fluids in patients with uncontrolled bleeds such as thoracic trauma and joint space penetrating trauma.

My statement about the "concept of presentation of peripheral pulses and the implications on perfusion" means that I would rather someone know that if they check a pulse in a variety of places (carotid, femoral, brachial, radial, pedal, etc) that this provides a general amount of information as to the perfusion status of the patient. If they can not feel a pulse at the radius but they can feel one at the femur than the patient is not perfusing as well as if they had a radial pulse bilaterally. With that being said, if they perform some maneuver like stop bleeding, warm the patient up, provide PO fluids (only to conscious patients that can support their own airway) and that radial pulse returns then they have had a positive change in perfusion.

As to my remark of "objective" in regards to a BP. It takes time for someone to learn to take a BP and environmental noise, experience, etc will effective that "objective" reading making it not so objective. When I was teaching new EMS providers I found that it took about 100 encounters of taking a BP before they could get reliable measurements. Even if the average troop were to carry a BP cuff and stethoscope do you think the time spent getting those 100 encounters is best used doing that or practicing to put a tourniquet on so that when they themselves or one of their buddies gets shot in the thigh at 12k feet in the snow, in the dark, in the middle of Afghanistan.

Would I rather have someone that can take a BP helping me at my local range manage a shooter ho ND/AD into his thigh at the firing line or would I rather they had practiced putting a TQ on, applying a combat dressing, and so on? The latter rings true all day long.


If I seem irritated it is because I am. The message you conveyed in your post is outdated and goes directly against all of the research and training that has been developed based on both battlefield and remote medical care over the last 10 years. We have moved beyond the age of simply doing what is done in facility in the ditch and have begun forming entirely new treatment plans that integrate the environment of the injury. Just as I wouldnt bring a jumbo sized trashbag in to warm up one of your ICU patients in his room dont expect me to use the tools you do in MY ditch. It's a different world, your experience will not work out here, it simply provides you a broader stronger foundation for learning what does. Do not confuse the two. Everything I use has to be carried in my uniform, on my vest, in my pack, or if I am lucky in a vehicle along with other mission essential items ranging from climbing gear to guns, ammo, and explosives.

When I provide information to civilians I am very careful to consider the time they have to learn and maintain a skill, the likelihood they will have to use it, the resources they will have access to, the environment they will be in, and the support they will have. You may want to reevaluate your previous posts with those things in mind.

[MIKE G]

I like this forum and I do not want to get kicked off for arguing. I understand that we are governed by different rules of care. I also understand the EMS golden hour. But EMS also has the same equipment discussed in this thread. Granted I don’t know what its like in the battlefield nor do I care for people while under fire, my input was strictly concerning the idea & risk of inserting a decompression needle. I give medics alot of credit & have respect for them doing their job under the stress of war. But to me it seems crazy to think medics are equipped with AED but not other tools. Maybe I should have written "ideally" instead of "IMO" with my first post. No offense or hard feelings guys.

Hey Mate,
No worries. I understand that a lot of times people want to share their experience and how it could pertain to others. Sometimes things easily translate from one specialty to another and sometimes they don't. Without knowledge of both specialties, the person offering the advice doesn't know how well it translates and inadvertently provide less than helpful info. It happens.

Just as ICU care is most likely your passion, ditch medicine is mine. I am just as passionate about getting good information out as I am about correcting misinformation based on my experience.

No hard feelings, and hopefully someone on here learned something from our discussion.

[TehLlama]

Hey Mate,
No worries. I understand that a lot of times people want to share their experience and how it could pertain to others. Sometimes things easily translate from one specialty to another and sometimes they don't.

Honestly, the scope of anything that can be done out of a 4x4x4" box of anything is going to be limited, and in the case as Rob presented it (primarily focused on preventable loss of life caused by GSW).
It simply isn't going to be possible to treat every case out of something that limited, but opening airways, stopping extremity hemorrhage, and keeping the pleural cavity usable, even by crude means, keeps GSW victims in good enough shape to get to an ICU.

Mike is correct that there is a LOT of dogmatic practice out there that has been simply disproven, or outmoded thanks in large part to medicine performed during the GWOT.

onado - We still want you here, that ICU level expertise is something we still want here, but even I'm amazed at how little use most of my wife's classmates (Med school) would be in a GSW trauma circumstance without half an ambulance at their disposal. Not as a discredit, but it's an entirely new skill, though one that can be greatly enhanced by somebody with better understanding of the anatomy and physiology you bring to the table, just know that a BOK will have different priorities because of how different the aims are.

[Chris@conditionred.us]

GutShot John, Do you know of a good class to attend? LOL!

Gents, A lot of good, valid discussion regarding trauma care resources. A kit is clearly a compilation of personal "tools" of preference. There is no right answer here. I can tell you that Z-Medica's new generation of QuikClot impregnated gauze is the hemostatic dressing of choice, with no thermogenic reaction. It is utilized as wound packing, not a typical external, wrapped, topical dressing. Additionally, the SWAT-T is a multi-purpose pressure dressing or TQ that takes up little space in an IFAK. It is inexpensive, and works very well wet, dry, dirty, sandy, or bloody. Items such as NPA, Ascherman Seals, duct tape and the like are all positive additions. 14g Catheters for needle decompression do require Medical Direction, and training, as it is an invasive procedure (basically, you'd be practicing medicine without a license).

The CAT TQ available through North American Rescue is the recommended mechanical TQ of choice. Whichever you decide to purchase, buy a minimum of two. One to practice with, and one for single use. These items do stretch, hence having one dedicated for practice is ideal. An individual would want to be well versed with applying the TQ to themselves, and the CAT enables one handed operation.

Ideally, a good training program, designed to bring this all together, is the way to go.

Please feel free to check out my web site, www.conditionred.us
We offer a Nationally Accredited TCCC (Tactical Combat Casualty Care) Program. Although there are advanced skills embedded into the curriculum, providers of all levels learn valuable lessons that can mean the difference between life and death.

We will soon post a four day program, that will cover the
TCCC curriculum (16 Hours) , the CDC's Bomb Blast Injury Course (4 Hours), New Mexico Tech's Incident Response to Terrorist Bombings (4 Hours), and a 10 hour day filled with action packed, educational simulation, entry, and team tactics. We have a 15,000 Sq Ft training facility, and we cater to students of all levels.

I hope this helps.

Feel free to contact me with any questions.

Chris

[Gutshot John]

GutShot John, Do you know of a good class to attend? LOL!

I might. ;)

Have you heard anything about the reasons for increasing restrictions on the sale of Combat Gauze to civilians?

[Don Robison]

I might. ;)

Have you heard anything about the reasons for increasing restrictions on the sale of Combat Gauze to civilians?


Some products on Quikclot's website are listed as prescription required; one version of Combat Gauze is listed as such. On their FDA clearance it's listed as prescription and OTC.

http://www.accessdata.fda.gov/cdrh_docs/pdf7/K072474.pdf

[Gutshot John]

Some products on Quikclot's website are listed as prescription required; one version of Combat Gauze is listed as such. On their FDA clearance it's listed as prescription and OTC.

http://www.accessdata.fda.gov/cdrh_docs/pdf7/K072474.pdf

I was wondering more in what separated the prescription stuff and the otc stuff and the reasoning behind it.

My previous understanding was that the difference between prescription and otc was that one had an x-ray visible strip inside of it.

I've heard since that this isn't the case and that ZMedica is cracking down on the distribution of all forms of Hemostatic Gauze.

[NinjaMedic]

Damn, a day late and a dollar short - I missed the party. Concur with Gutshot and Mike G, the day I start basing my decision on when to perform a needle thoracostomy by calculating Mean Arterial Pressure in an upside down car, or listen for a protodiastolic gallop in a hypotensive thoracic injury is the day I need to re-evaluate my career. We are not hanging dopamine, we are delaying death long enough to put them at the mercy of the trauma surgeon. A chance to cut is a chance to cure . . .

[occamsrazor]

Hi, first off thanks to everyone for this very interesting thread.

I've attended some very basic tactical medicine training (3-day course) but in reality my abilities are not much. I'm trying to make a personal blow-out kit for use against gunshot wounds (and possibly blast injuries) in places away from rapid medical care and with items that I realistically would be able to use myself, and with the intention of keeping it as small as possible. It has to fit on a belt-pouch, and should contain only those items that I am realistically able to use without causing more harm. So far I'm thinking:

Quikclot Combat gauze
1 or 2 OLAES bandages or similar
CAT TQ
Shears

My thinking was there was little point me carrying an NPA or decompression needle as realistically I'm not going to be able to use it.

Regarding a chest seal - is this something that a person with very basic training could use and benefit from? I've read many people recommend HALO seals, but also that tension pneumo is a leading problem. Would a seal with no valve such as the HALO used by a person NOT able to do a chest decompression be problematic? Would it be better for such a person to use a seal with a valve (Hyfin, Bolin, Asherman???) that would avoid a tension pneumo developing? Or does the use of chest seals require a level of training/diagnosis such that it is not worth me carrying?

Regarding pressure bandages, I see the OLAES gets recommended a lot but also I saw it discussed here that the package size is quite large. If packed size is an issue, what would you recommend?

Before someone points out that there is value in carrying items you can't use but better-trained others can use on you... I do accept that point, but the people I am with are unlikely to have any real medical training either, so the first medically-trained person encountered post-injury would likely be on arrival by car at hospital that may not be close-by. I may well put such items in a more extensive vehicle-kit, but for now i'm just thinking about a belt/vest pouch with items I can actually use on myself and or others injured next to me.

I realise these are very basic questions, but appreciate any help you can give.

Thanks...

[GTF425]

I'm not a Paramedic, but I am an EMT. I carry a vacuum sealed BOK in my admin pouch with:

1 x Combat Gauze
1 x SOFT-T
1 x Saline Lock Kit
1 x NPA, Adult Medium
1 x Israeli dressing

It's my understanding that the purpose of a BOK is to give you the ability to stop major life threatening injuries until you can provide the patient with more advanced life saving care. My priority is to stop massive external bleeding. Before I hand a casualty off, I always establish a patent airway and administer a saline lock. In the EMS world, I'm sure this is a no-no (especially for someone only EMT qual'd like myself), but for combat lifesaving, it's expected of everyone to be able to perform these simple tasks. Sterilization isn't a big deal to me and I've treated wounds bare handed. Obviously not preferred, but you do what you can with what you have. If you think it'll be a problem, toss in some gloves.

If all you want is a BOK, it's my opinion that all you need is to treat the ABC's. I have a medium medical pouch in my assault pack specifically for more advanced medical care.

[MessedUpMike]

Regarding a chest seal - is this something that a person with very basic training could use and benefit from? I've read many people recommend HALO seals, but also that tension pneumo is a leading problem. Would a seal with no valve such as the HALO used by a person NOT able to do a chest decompression be problematic?
Thanks...

I'm just an EMT myself, but I'll try to help you out a little. If my interpretation is wrong we'll both know soon enough.
If you're not planning on penetrating the chest cavity (and I personally wouldn't be), then a valve is not really going to do you much good. The point of the valve is to let air back out of the chest cavity, but not back in. 20 years ago when I started doing this valves weren't even taught in Maryland, you just sealed the whole thing and ran like hell. In a penetrating trauma, like a GSW, you can get the same effect with a piece of plastic and some tape. Leaving a small corner open would allow some of the air out, but not back in. Personally of I were shot I'd rather have the whole thing sealed of than nothing at all. In my mind the ONLY thing I'm trying to do in the field with my limited training and resources is by the Patient time until we get the an ER.

As a small side note I might be disinclined to making a BOK to fancy. It may seem like goofy logic, but I would be concerned that if my kit were to high speed low drag then Joe Plumber would be either be hesitant to use it if I were the one who went down, or try to needle decompress my throat.

[numberFN1]

This is a great thread wow thanks for all the helpful info! I'm thinking maybe I need something bigger than the HSGI bleeder/blowout pouch now though...

[dyegator]

This is a great thread wow thanks for all the helpful info! I'm thinking maybe I need something bigger than the HSGI bleeder/blowout pouch now though...

I know quite a few guys using this size or smaller ifak. I'm a believer in small Ifaks and recommend the following: Israeli or Olaes, chest seal of choice, either z-packed gauze or combat gauze, npa and NCD needle vacuum packed together, all with rip tape starters and contents list on exterior, TQs (either CAT or SOFTT on exterior kit). Reason being that anything this can't stop is going to need advanced care that will be provided by my aid bag or medevac of some sort.
My $.02

[Wicked]

This is a great thread wow thanks for all the helpful info! I'm thinking maybe I need something bigger than the HSGI bleeder/blowout pouch now though...

Don't know your AO or level of training, but my guess is probably not. That's exactly why I carry the lil' HSGI bleeder pouch - it keeps me from trying to convince myself I might need 3 CATs, 200yds of combat gauze and a kitchen sink in my IFAK. If it won't fit in there, likely I won't need it for the intended purpose of a BOK.

[JohnnyC]

I've got a z-pack gauze, quick clot, olaes, TQ, NPA, and angiocath, gloves and a packet of surgilube for the NPA. It's in an OSOE compact tear-off. It's small enough to be convenient, but enough stuff to be useful. I can rubber band an izzy or olaes or another TQ to the outside too if I want, although that increases the size.