View Full Version : Random thoughts on battle prepping your med kit.
Iraq Ninja
12-28-09, 12:36
I have noticed that a few folks here have posted pics of what they carry, and I need to comment on a few things.
Tourniquets and NPAs need to be battle prepped. Do not keep them in the plastic wrapper. Makes about as much sense as carrying your carbine in the cardboard box you bought it in.
Expect wear and tear and inspect often. Some items are packed for hospital use and the paper and plastic do develop rips and tears. Save the worn items for training.
Probably the biggest issue I see is not what is in your med kit, but what is in your brain. Do you really know how to use that cannula for a tension pneumothorax, let alone know the signs and symptoms? NPAs are cool, but do you know how to insert one and under what conditions?
Can you quickly access and open the packaging? Try opening a bandage with gloves on, coated with oil (simulated blood or sweat).
Pre fold back the corners on wrappers to allow you to quickly find and open them.
Asherman chest seals are a Gucci piece of kit, but do you know what to do if you don't have one, or if the damn thing won't stick to your Uncle Bruno's sweaty and hairy chest? Do you store it flat or crunched in the bottom of your med kit?
Gloves don't need to be stored in nice little plastic bags. Have you tried taking a pulse with gloves on? Do you even know where to check a pulse and what the results mean?
Medical training is highly susceptible to skill fade, more so that shooting skills. The more training I get, the more I realize just how much I don't know. Seek out medical training with the same zeal that you do for shooting.
Do your family members and friends know basic trauma care? What good is that NPA in your vest if you are the only one who knows how to use it, and you end up unconscious with a blocked airway?
I hope the medical professionals here will chime in and give their two cents on the subject.
I hope the medical professionals here will chime in and give their two cents on the subject.
Hard to add much to that. Software beats hardware. Inspect and PM your gear. Preposition it for rapid use under likely deployment conditions. Train often, keep it relevant and current.
Worth repeating...
Like your magazines, don't try to hold on to gear forever. Stuff degrades over time with carry and handling. When in doubt, throw it out or salvage it for training. That widget might have cost you ~$7-$10 or more, but it may get nasty and be a liability.
Most folks are wearing or carrying things they need to manage many wounds. Purpose-built stuff makes it easier, but nothing beats knowledge and the ability to improvise.
Dropping an NPA or relieving a Ptx isn't rocket science, but it isn't something to just wing without forethought, either.
Nothing beats experience. If you aren't in the fight downrange, show up at your local search and rescue, volunteer fire/EMS, etc.
Von Rheydt
12-28-09, 14:30
Good tips mate. Battle prepping kit is a good practice as it can save vital seconds in instances from GSW's to helping with a vehicle accident - I do not know how it stands in the USA but here in the UK we have legislation that allows the act of a good samaritan without liability.
I think that in any situation there is no use in having life saving kit in pouches. With that in mind I have seen these and I am going to get myself a couple one for my hill walking rucksack and the other for my vehicle first aid grab bag.
http://215gearstore.com/tourniquetgpholder-1.aspx
Before Ashermans we used the plastisied wrapping from field dressings.
NPA's are good, when you practice give the dummy ... sorry, volunteer, a couple of drinks beforehand to loosen him up. :)
I always write the expiration dates of contents including meds on a laminated card that I attach to my FAK's.
Skill fade is very true. I finished in hospital 4 years ago and if I did not do refresher courses and keep up with reading it would soon be forgotten.
I forget things everyday. I sleep with my Field Reference guide (no joke) as I drew a mental blank on something a few weeks ago that I should of known or rather I thought I did.
There's plenty of ways that you can try to help someone but without knowing what you're doing end up harming them instead. As mentioned, something as simple as an NPA if used in the incorrect conditions can have rather unpleasant consequences.
I think each of us needs to decide realistically where our "Scope Of Practice" begins and ends.
Iraq Ninja
12-28-09, 15:21
Good tips mate. Battle prepping kit is a good practice as it can save vital seconds in instances from GSW's to helping with a vehicle accident - I do not know how it stands in the USA but here in the UK we have legislation that allows the act of a good samaritan without liability.
I recently heard a story from an ex Brit medic who talked about testing he did for a UK police job. When they were evaluating his skills, they had him do rescue breaths on a dummy. One hand was on top of the throat, so he could multi-task and check the carotid pulse. They evaluator sternly told him not to do that, because the public may think you were choking the casualty!
A lot of our kit is Brit medical, from SP. I notice the Brits don't use saline locks unlike us Yanks.
An EMT once told me about carrying some of those strong altoid mints in a tin. He said they helped when dealing with nasty situations that may cause you to vomit.
I recently heard a story from an ex Brit medic who talked about testing he did for a UK police job. When they were evaluating his skills, they had him do rescue breaths on a dummy. One hand was on top of the throat, so he could multi-task and check the carotid pulse. They evaluator sternly told him not to do that, because the public may think you were choking the casualty!
.
Yeah. They don't like it when you reach across the throat. Check on the side you're positioned on.
Iraq Ninja, great post. Lots of people are gear junkies (myself included). I did a short time as a volunteer firefighter. I was amazed how much I did not know when it came to dealing with a trauma situation. Gear is the fun & easy part. Training takes time & a desire to complete it or rather continue it. My wife & I have both gone though first responder classes. I recommend that if given the ability that everyone should go though this as a minimum. I would love to complete an EMT course & look to do so hopefully.
NinjaMedic
12-28-09, 22:56
The only way to prepare for procedures is repetition and failure so you can know what not to do and what is needed to overcome an issue, with that will come learning how to properly package items to assist you in quickly performing a procedure.
That being said, medicine is not about skills, procedures, equipment, knowledge, voodoo or anything else. They are all important components in treating a person but the key to medicine is judgement. The judgement that comes from experience and mistakes that leads you to know when or more importantly when not to perform a procedure. The judgement that tells you just how sick someone really is. The only way to gain that is by caring for truly sick and injured people. (the 2-3% of US 911 calls) That is difficult for paramedics in busy urban EMS systems, combat medics in theatre, even physicians. Your judgement ultimatly though is what will make a difference for those very few people that you can reach in a timely manner and actually perform a life saving intervention.
I know that I am woefully lacking in training in this regard, and I'm still working on rectifying that situation. I also know I'm carrying more gear than I officially know how to use.
My thinking is that someone that knows more about this stuff than me may be on-site when I get hurt and I'd rather have tools for them to use.
Von Rheydt
12-29-09, 11:09
I recently heard a story from an ex Brit medic who talked about testing he did for a UK police job. When they were evaluating his skills, they had him do rescue breaths on a dummy. One hand was on top of the throat, so he could multi-task and check the carotid pulse. They evaluator sternly told him not to do that, because the public may think you were choking the casualty!
I can believe it. I experienced complete first aid training twice with the Police - once as a regular officer and I had to go thru it again as a reserve officer. They are only prepping you to do the St Johns Ambulance basic first aid exam ( a bit like a basic red cross first aid exam). The problem here is that the higher ups are mainly interested in projecting a politically correct appearance so that there are no investigations that may kill their careers.
A lot of our kit is Brit medical, from SP. I notice the Brits don't use saline locks unlike us Yanks.
My IV [needle] experience was gained in a hospital environment so I don't know what the combat troops are using in the field nowadays.
An EMT once told me about carrying some of those strong altoid mints in a tin. He said they helped when dealing with nasty situations that may cause you to vomit.
I learned the hard way to make sure I had vick with me to smear under my nose at post mortems.
Gutshot John
12-29-09, 12:45
Certainly you "battle-prep" as much as you can, but for most here I'm thinking that means removing your tourniquet and practicing with it a bit. Dressings need to stay as clean/sterile as possible. In terms of infection risk, it's a risk but I'd take my chances with infection over imminent death. If all I have is a dirty NP and someone is going to die without it, it's going to get used.
I'm not sure what the story was on the throat. I don't see how checking a pulse can be construed by anyone as strangulation. If that's the reason given than it's completely retarded though I can certainly imagine some idiot saying it. That said I would discourage resting a hand on the airway as often under stress and with adrenalin you aren't really aware of how much pressure you're really applying. I've had a patient struggle under me as I was trying to work on them, thinking they were freaking out until I realized that my leg was across their arm. I didn't even feel it, but I managed to **** up his elbow. It takes much less pressure to crush a windpipe and so I'd find a better place for my hand. That's not to say it will happen, but it appears to add an additional layer of complexity where it isn't needed.
Medically I see no benefit to keeping your hand on the throat for rescue breathing. It sounds cool, but there is no substantive advantage. The effectiveness (or lack therof) of rescue breathing notwithstanding it's simply poor technique. Secondarily you can still have a pulse and be giving rescue breaths. All that said if you have to check for a pulse than you've moved beyond rescue breathing and into CPR. Moreover the carotid is on the side of the neck not the throat.
The effectiveness of mints in combating puking is dubious. Ask me how I know. With the exception of burns most puking in those cases is probably related to adrenalin than the smell. That said the scent of burning flesh cuts through just about everything. In a post-mortem different rules apply when you start removing intestines.
Gutshot John
12-29-09, 20:29
I think you understand the point was that as a general principle if sterility conflicts with imminent death there is no choice. Would a sterile NP be preferred? Of course, but if you don't have that option and someone's going to die...rinse with water and carry on. Would I put an NP into a patient that was dripping with another patient's blood? No but even rinsed off it's still "dirty." I do agree that an NP might not be the best example of this principle as you say the patient is probably dead anyway or can wait till a better option is available
As a general principle I've avoided NP airways at all costs. Sizing, fitting and insertion all present problems which limits their effectiveness. The only indication for an NP airway is for a conscious, borderline acute, patient. I've never found insertion "easy" and when faced with life-threatening scenarios I prefer ET primarily as a way of completely controlling the airway but also as an alternate means of introducing pharmaceuticals.
I'm skeptical of being able to clean an NP as you describe in the field and still be able to control an acute airway. IIRC alcohol (and most topical disinfectants) on mucous membranes is also contraindicated. Iso Alcohol on mucous membranes will irritate membranes to the extent that infection will be likely anyways. Irritated membranes from trauma or toxins like alcohol will become infected through environmental vectors but you've created the conditions in which they thrive. Having suffered through a lifetime of sinus infections I can tell you that they are mostly unavoidable if you have allergies for the same reason.
Gutshot John
12-29-09, 21:19
Maybe I am not clearly explaining my points. Iraq Ninja (IN) mentioned removing nasals from the packaging to streamline use in an urgent situation. My point was that the amount of time it takes to remove from packaging is not enough that it will effect patient outcome and that maintaining a CLEAN nasal is more important than the .5-1 second it would actually take to remove from the packaging.
In that I'd agree, I think my original point was that "battleprep" for most here is simply taking their tourniquet out of its wrapper.
As for placement, ease of insertion comes with practice and good form.
We tend to use what we're comfortable with. My experience has made me less comfortable with the general application of an NP airway. YMMV.
Insertion straight back instead of up while pulling the tip of the nose up into "piggy" form makes insertion very easy. Most adults can take a 28 or 30 french sized tube. If it doesnt fit in the right nostril it should in the left. Of the hundreds I have done on patients I cant think of one that didnt go in. Of the hundreds of students I coached to insert on fellow students I can only think of maybe 3 or 4 that couldnt take the tube, some of that could be discomfort vs structural inability.
I've never failed to get an NP in, but it usually takes several attempts. I don't know any medics that have put in that many NP airways but most I know view the NP as something of a "joke" unless the patient can't tolerate the alternatives.
Sterility or lack there of will not come into play when I have a guy dying in front of me BUT there is no reason not to take some minimal steps to proactively address infection. If I have to I will pack a wound with dirt as an improvised hemostatic agent but I am not going to bag it up in a ziploc to use as my first line.
I don't think I was implying that you should use a dirty NP tube as "first line." I'm pretty sure I said "if you've got no other choice."
I also play in much dirtier venues than most, managing a patient at the critical care level 4k into a wet cave teaches you that every little bit counts and mistakes made in the first 5 minutes of patient care can and will come back an haunt you in 3 days when you are still working to get the patient out of the woods/jungle/cave.
Once again, you take things as they are. Medical decisions in the field are almost always imperfect, that doesn't mean they're a mistake. If you don't save the patient within the first 5 minutes what difference does it make whether you've got an infection 3 days later?
Where they fall in the spectrum of adjuncts, I wouldnt put them in place of an ET tube either nasal, oral, or cric placement of the ET. I can place a nasal in a patient that isnt completely compromised and turn my back for a second to assess another patient or to improve ease of respirations, an ET tube is going to take much more attention and is a definitive airway. Not to mention the fact that there will be some patients that need airway assistance but it would be inappropriate to place an ET tube even nasally.
I have both. In certain defined circumstances I might chose the NP, but I certainly wouldn't use one as my "first line" when looking to control an airway. An ET requires more attention but in a MCI like you're describing, you make due. Again medical decisions in the field are often (if not always) imperfect, but with ET the airway is patent with no chance of aspiration (which will kill you quickly) like with an NP.
ETA: As for cleaning in the field, the residual alcohol from wiping a nasal down with an alcohol pad will be minimal if not zero particularly after you flap it around a little like a polaroid picture, I know because I have done this on myself in demonstrating nasal placement. I try to use new ones but often dont have a fresh nasal in the teaching box when I didnt prep it before class. Havent rotted my face off yet,
There are a whole lot of steps there that I don't really think are warranted if the airway is genuinely acute. Even if there is no alcohol residue (and you haven't re-contaminated the tube by flapping it around in a dirty cave), it's not sterile and so there is still risk of infection. If you're talking about using wipes you've also got to worry about the interior of the tube. At some point you just have to take say "**** it" and do the best you can.
Von Rheydt
12-30-09, 01:31
It is apparent you all have much, much, more experience than me and I personally appreciate the sharing of experience.
My exposure to bodily smells was gained as a LEO here in the UK. When I attended my first evidential post mortem I had to watch 2 before the one I was there to evidence. Added to which they had suffereded a fridge failure a couple of days before......... afterwards they told me about using vick. LEO's also have to attend fires and witness the body for chain of evidence if there is a death.
Gutshot John
12-30-09, 08:10
It is apparent you all have much, much, more experience than me and I personally appreciate the sharing of experience.
My exposure to bodily smells was gained as a LEO here in the UK. When I attended my first evidential post mortem I had to watch 2 before the one I was there to evidence. Added to which they had suffereded a fridge failure a couple of days before......... afterwards they told me about using vick. LEO's also have to attend fires and witness the body for chain of evidence if there is a death.
I dunno man, you seem pretty competent to me.
Vicks is definitely an improvement and I've used it around helo crashes but I still ended up puking. The smell of burnt flesh and blood is something I can still almost taste. Mints did nothing really for me.
I never really had a problem in post-mortems but the smell (especially when they remove the intestines) still makes me a little queasy.
I gave up on the mints, gum, vicks, vinegar, and other remedies. Short of a respirator (and even then...) you're getting odor. I found that sometimes, the masking agent smell on top of the body/decomp made it worse.
Iraq Ninja
12-30-09, 13:40
Mike,
Good point about the NPAs staying wrapped.
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.
For the civilian, pain meds are really limited if you stick to OTC stuff. Obviously, asprin is not a good choice these days and in fact has been taken off the shelves of the PXs here.
Ok, back to combat prepping stuff. I like to unwrap my cravats and fold them lengthwise, iron em, put a small bit of tape to hold it together and S fold it up. It is an old technique, but a good one.
IN- Nice tip on the cravats. Hope your staying safe over there. Just remember to look out for the turds left in dark places by a shit-n-goer.:p Nothing in the kit for a shit filled sole.
Von Rheydt
12-31-09, 11:13
IN, silly question time. Why have asprin been taken off the shelves? I can't remember, are tylenol asprin?
In my limited outdoor activity environment I prefer Ibuprofen to asprin for pain.
It inhibits blood clotting factors. Tylenol is Acetaminophen. They call Ibuprofen by Motrin over here. I used to love the Nurofen brand when I was in the UK.
Von Rheydt
12-31-09, 16:32
Ah yes, makes sense. Whats good for heart patients is bad for wounded soldiers.
NinjaMedic
01-01-10, 01:34
We dont have much cause for the lollipops for obvious reasons but Fentanyl is my favorite narcotic analgesic, we are not even carrying morphine anymore as fentanyl is almost the ideal prehospital narcotic analgesic.
Is the military giving intranasal narcan yet? (or any IN stuff for that matter, just curious)
Gutshot John
01-03-10, 09:59
Relevant to pain medications like morphine:
There is a percentage of the population that reacts very poorly to morphine or not at all. I learned this as I'm part of that percentage. My body can't process natural opiates.
I had surgery about 18 years ago where they gave me morphine. In terms of pain they might as well have been injecting me with saline. I did sit up and practically projectile vomit across the room. The doctor later explained to me that I "lack the receptors for opiates" (I could be misremembering) and that if I had any more I could go into violent anaphylaxis. He switched to a synthetic opiate and that worked much better for pain even though it was PO not IV.
Fetanyl is an excellent pain medication which I can tolerate. The lollipop is an excellent idea.
NinjaMedic
01-04-10, 00:50
http://www.wolfetory.com/nasal.php (Mucosal Atomization Device)
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
02-03-10, 22:47
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.
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.
http://i180.photobucket.com/albums/x51/coltm733/DSC00181.jpg
And this is pretty much all I could get in it:
http://i180.photobucket.com/albums/x51/coltm733/DSC00183.jpg
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
02-04-10, 15:10
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?
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
02-04-10, 16:39
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
02-04-10, 17:17
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
02-04-10, 17:29
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.
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.
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.
Powered by vBulletin® Version 4.2.5 Copyright © 2024 vBulletin Solutions, Inc. All rights reserved.