ADVANCED AUSTERE CARE NEWSLETTER

(For the advanced trained Medic)

DECEMBER 2019

KITS, PACKS, & SUPPLIES

LEVEL I APPLICATIONS

Medical care is a complex topic. The greater the depth of care provided the more complex the whole package becomes. This includes the “logistics” of providing that care. In contemplating care in austere or medically deprived circumstances, regardless of the level of care being delivered, the issue of what that medic or medical team carries often results in stifling confusion. One kit does not fit all providers and situations. Provider kits, started with the old “doctor’s bag” of 200 years ago. What we carry is always a reflection of what care we provide. True then and still true today.

For you, as graduates of an advanced trauma curriculum, being able to perform (in the appropriate circumstances) what you have learned is usually the student’s aspiration. Secondly, you want to be able to have quality tools and the necessary supplies supporting your knowledge. In our unique positions, these tools and supplies are not something you simply go to the First Aid section of the local pharmacy and buy off the shelf. I recognized this early on as I began teaching students advances concepts and skills. This is complicated with the challenges of finding equipment of decent quality that is affordable (premiere surgical instruments can be prohibitively expensive), and sourcing items that are no longer used in U.S. hospitals. I started on this quest some years ago. Next, is finding a way to store and carry these unique items in a way that helps the mission rather than adds to the complexity of it.

What has evolved with all of this is a way for students and practitioners to access otherwise inaccessible equipment supporting the concepts of prolonged care in austere environments. What it boils down to is equipment that one would reasonably carry in a pack, what one would like to have available in a mobile facility, and what is necessary to have in a fixed facility. Each level of care delivery increases the sophistication of care able to be provided and complicates the logistics necessary to support it.

LEVEL I: This is care in the field, it is the ABC / MARCH concepts. On a more advanced scale it is “damage control” interventions. It is keeping a patient alive in the short term without setting him / her up to die in the long term. This is what you can deliver with what is immediately available – meaning you either carried it, can find it, or can improvise it on site, on the move, etc. Specifically, this is bleeding control, airway management, hypothermia prevention, immobilization of fractures, initial infection prevention, and package and move out of danger. In this context care is always limited, typically rushed, and often incomplete. These issues are not always remediable, but training and experience helps and are about the only remedies there are.

LEVEL II: This takes off where Level I ends. We are now in a more controlled medical environment where some definitive care can be rendered. Rudimentary surgery can be provided supported with sterilization / disinfection, and reasonable essential supplies. This setting is mobile and light, but is supported by security and at least “base camp” level support. Perhaps “aid station” or forward operating base dispensary level stuff in a military context. While care still remains limited, it is far more capable than level I care environments both surgically and with non-surgical acute care capability.

LEVEL III: This is about the best we can expect in the austere environment with the provision of pharmacy / apothecary support on site, perhaps some laboratory support, ideally anesthesia support, nursing support, etc. All deliverable via a medical team that includes providers at various levels of ability and support people. This may also be mobile but not conveniently so. The best would be a limited small hospital like setting, the most challenging would be a guerrilla hospital – by way of comparisons. A regular hospital changes the scenario allowing the total care burden to be transferred from you to them.

WHAT’S A MEDIC TO DO?

RULE #1: Always remember that there are laws, rules and ethics that regulate the practice of medicine. Know what these are and stay within them (necessary legal disclaimer). Laws and rules change from country to country and from situation to situation – but the ethics are a constant.

RULE #2: Training ALWAYS trumps gear. BUT, GOOD GEAR can sure make your job easier and your outcomes better. Never stop learning and Never stop collecting the gear you need. Actively develop and expand networks for equipment and supplies. Avoid the plentiful “gimmicks” of medicine.

RULE #3: The foundation of medical care to your team, family, tribe, kith & kin, whatever it may be is the IFAK and Personal medical (“whiner” or “BooBoo”) kit. That includes YOU! We’ll get more into this in the next newsletter.

RULE #4: If you’re the only Medic on your team, you will not be happy. You need to recruit other healers and fill in their training. This helps everybody (including you).

RULE #5: You have been taught how to extend and compliment your abilities from both the herbal / naturopathic side and the conventional Western medicine side. Use all your knowledge to the best of your ability.

WHERE DO YOU BEGIN?

Begin with where you are. Start with acquiring the Level I stuff then move up as your resources and situation permits. So, the Level I set-up is going to be simple and light weight. Typically, being more heavily focused on trauma intervention than medical intervention. Why? Because trauma is the bigger threat in the austere, post disaster, military, expeditionary, situation. Now, if your target patients already have their own IFAK and Whiner kits, your medical load-out just got a whole lot easier. In this case, they each have their own tourniquets, pressure dressings, NPA’s etc. You don’t need to completely duplicate these items in your medical kit. So, look at what the typical IFAK does not contain that would be relevant to your treating of casualties and let’s start there. Two areas where the IFAK content list falls short is in fracture care and burn care. You’re going to want to make up for those weaknesses with what you carry – if those injuries are reasonably likely.

A good size for a carry-with-you medical kit is the military M-3, sometimes called the “trifold” medical bag. That certainly is not your only option, but the size is about right and the compartmentalization helps you in organizing your medic stuff. The M-3 is not expensive and there are a lot of “copies” of the design. The original U.S.G.I. model is the best designed one. Some of the clones are constructed OK, but the flap just doesn’t fit as well – especially when the pockets are full. The thing about this style of kit bag is its versatility for carrying. You may be the Medic but you’re still going to be carrying your own personal gear if you’re on the move. If you’re using a backpack for the med gear where does your personal gear go? There are some wonderfully designed dedicated medic bags out there, and the back-pack designs are currently popular. The STOMP is one example. Great idea if I’m on a quick out and back mission and I can carry all my needed personal and tactical gear on my LBE. Not such a good design if I’ve got a full rucksack for a five-day operation, my LBE, and a med kit backpack I need to have readily accessible. I don’t know how to wear two back-packs. To me, while the STOMP and other very expensive, albeit well-made and designed medical backpacks are out there (I own a couple) their application may be restricted to a specific mission type. The M-3 and the larger (but much harder to find) M-5 medic bags could (were designed to) be attached to the outside of a rucksack or backpack (or a horse, motorcycle, ATV, etc.) allowing convenient rapid access without making your total load-out look like the Beverly Hillbilly’s moving truck and make your balance on the trail even worse.

From a surgical perspective, what am I really going to be able to do in the field? Simple wound care, and immediate life sustaining interventions – most of which are going to use the individual’s own IFIK (is this starting to make sense?). I will typically carry a small surgical kit. But the bulk of the kit is going to focus on airway, splints, burns, and wraps. It isn’t that complicated. In the field, the medical mission is two fold. 1). Keep the team in the field as long as mission-necessary despite minor expected injuries; and 2) intervene in bigger problems to keep the survivable casualty alive until I (or somebody else) can intervene definitively. That definitive care is base camp (Level II) or established fixed facilities (Level III) options. So, surgery in the field is simple wound care / repair, surgical airway, surgical hemostasis. That’s about it.

There are some grey areas. Could I put in a chest tube set-up? Yup. You all know this procedure is easy, equipment is minimal, etc. I’m not going to set up a sealed drain system on the trail, so a Heimlich Valve and chest tube along with my basic surgical kit – OK I can appreciate that reasoning. Especially given the relatively high failure rate of chest decompression needles. A similar argument is there for being able to put in a surgical airway. I basically need a tube and a way to secure it. I can do all of that and take up less than 20% of my kit bag space. Justifiable – IF the likelihood of an injury requiring those interventions also justifies it!

Which point brings us to the next consideration. It is really poor planning to carry something I am not likely to need. OK, I know how to do a chest tube. That is not necessarily the justification for my kit to contain the gear necessary for me to do so if the likelihood of me needing to do so is about the same as encountering a cobra bite in the arctic. Don’t do stupid stuff – you’re beyond that. If there is no reasonable likelihood of somebody getting shot or pierced through the chest with an arrow or spear, or suffer severe blunt trauma to the chest, you probably aren’t going to need that chest tube stuff in your basic kit.

The key here is to be able to plan ahead, reasonably anticipate what the likely injuries and medical conditions will be, and then stock your kit based upon those likelihoods. Every mission is different and so customizing your medical load-out to match the anticipated needs is really good thinking. Yes, you will be wrong a small percentage of the time so you’ll improvise and do the best you can understanding the pathophysiology of the injury you are looking at. Don’t fall into the trap of overthinking the situation. You can’t pack the whole emergency room in your pack so stop trying. It’s a thing with medics – especially young and inexperienced Medics.

Let’s review the techniques you have learned for Surgical Hemostasis. These techniques are applicable across the injury / surgical spectrum and you’ve learned them. Chief among these techniques is Clamp and Tie. Remember learning to tie that infernal one-handed and two-handed surgical knot? Muscle memory – practice and then practice more until it’s automatic – until you don’t have to think about it, it just happens. The next one is the Figure 8 stitch. The last one, but more applicable in a formal surgical setting is the Stick Tie. These are simple techniques. The clamp and tie and figure 8 stitch can be done in the field effectively, and the tools necessary are minimal. A simple minor surgical pack that takes up about the same space as a checkbook should allow you to perform these techniques almost endlessly.

Because you do know how to use it, a minimalist surgical kit deserves a space in your austere medic bag.

Let’s hit some supply issues. While it is our mantra to find and use durable (reusable) medical supplies, somethings just have minimal reusability. Tape is a good example – hard to recycle tape. There are alternatives like Coban wrap – but this is also hard to reuse. The SWAT Tourniquet might be a reasonable alternative for holding dressings in place. Gauze is another expendable hard to get along without. Yes, there are studies out there that discuss salvaging gauze, washing it out, re-sterilizing it and then reusing it. (Rayon is more reusable than cotton for gauze – but it’s harder to find.) The reusability, albeit limited, is good to know about gauze. But when re-using gauze you have declining absorbability with each re-use and after about three to four cycles it is falling apart. Other things can be used in place of gauze including other cloth-based improvisations. If you’re pushed into that corner, find “low lint” fabrics. The rationale being we seek to leave no trace of our passing – even in surgery (lint balls in a wound is foreign materials and so the infection rates go up – makes sense). One truism in medicine is that you can never have too much gauze. Lastly, gloves. There is a company in India that makes re-usable surgical gloves. Meaning that these are durable enough to be washed and re-autoclaved up to five times. The problem is I have yet to find a supplier from which I can order these and have them shipped to the USA without having to buy 6 pallets of them. I’ll eventually get this worked out and be able to make these available to you, but in the meantime, you might think about picking up some gloves. The nitrile exam gloves come in boxes of 100 – not handy in a kit but OK for stocking. You can buy nitrile gloves paired and packaged as a pair which is pretty convenient. I put pairs in small zip locks and put these in my kits. For surgical applications, pre-packaged sterile gloves are the standard. Easy to purchase but more expensive than the non-sterile types. You will need to protect the sterilized versions from water contamination if you put these in your kit. If the packaging becomes wet the sterility is lost. Great! Now what? Well, then you put on your gloves and wash your hands (gloves on) very thoroughly in betadine. Then there is sterilization and disinfection. Yes, you can make 70% alcohol and there may come a time when you will need to do that. Chances are you already stock some alcohol for herbal preparations. 70% or greater is required for the best antisepsis. I would suggest you add a bottle of Betadine to your stock from time to time. It’s cheap and very effective, even when diluted (ice tea – remember?). The only drawback to Betadine is it stains stuff. Sodium Hypochlorite powder is bleach. Calcium Hypochlorite powder is “pool shock” (for disinfecting swimming pool water). Both are as caustic as hell but effective for mixing small amounts with water to form bleach. Just use extreme caution when working with these powdered compounds. For surface disinfection bleach is great. It is not the best for tissues, although Dakin’s solution (which is a dilute bleach liquid) has been used for decades. You should have the formula for Dakin’s Solution in the materials provided in the advanced courses.

Dakin’s and diluted Betadine (ice tea looking) are suitable for contaminated wound irrigation. But remember to irrigate both of these out of the wound before dressing up or closing a wound. I advocate that your medic bag have a little 1/2 oz or 1 oz Nalgene bottle of betadine. Dakin’s at ¼ strength could be used for wound irrigation as well. Carry a bit of full strength Dakin’s with the plan to dilute it 50% and then 50% again (making a 1/4th strength solution before using it in a wound. In a pinch, either of these solutions at full strength can be used to disinfect the working end of your minor surgical instruments. The working ends would need to sit in the solutions for 20 minutes or so and then rinsed off with clean water before using on a patient. When rinsing, have the working tips upward so water is draining from the working end to the non-disinfected end.

Never stop learning!

Steve E. Pehrson MD