This is the conclusion of this five-part article, and this section contains information about gear selection, some tips and tricks that I learned along the way, as long as some links to some training videos.
Gear Selection
I am a huge believer in redundancy. Things break, get dropped, tear, and get lost. When your car is in the shop and you are driving the rental is when you will need the first aid kit you usually keep in the back. Murphy is alive and well.
On My Person
On my person, pretty much everywhere I go whether on duty or off duty, is a tourniquet [1], gloves, and QuikClot Gauze [2]. This package fits into the thigh pocket of carpenter pants or the cargo pocket of pants or shorts. With these three things, you can stop extremity bleeds, junctional bleeds, have a pressure dressing, and can form an occlusive dressing. It’s kind of like a pocket knife or a spare mag, they weigh nothing, and you feel naked without them. I have an outer vest carrier at work, so I didn’t want to only have gear on my vest, since it is not always on. I wanted it with me. It is when you least expect it and are least prepared for something that it will happen.
Vest
On both my hard plate vest and my soft ballistic armor vest, I have more gloves, a second tourniquet, second QuikClot gauze [3], compressed gauze, an occlusive dressing [4], an NPA [5], trauma shears [6], a pressure dressing [7], and two needle decompression needles. Why two? Well, of the last three decompressions we did, two required a second needle, and we dropped the first sterile needle in the mud on the other. Two is one, and one is none. Notice that this is pretty much the contents of the TCCC-approved IFAK.
Patrol Backpack
I have a dedicated medical bag (carried when going to a medical call), and then I also have a patrol backpack (carried when I’m out on law enforcement patrol and away from my vehicle). There is the same IFAK (two separate ones) on the outside of each bag. Was it cheap? Nope. Is it worth it? Absolutely. I would hate to be on an ATV somewhere and need something back in my truck. I hope you are noticing the redundancy here.
In the patrol backpack, I include some abdominal pads [8], 4x4s [9], shears [6], a SAM splint [10], triangular bandage [11], and some coban [12] and kerlex [13]. I have a pack of OPA’s [14] and NPA’s [15], a stethoscope [16], and an ambu bag [17]. I also have a survival blanket [18] to treat shock. If you are really concerned about space, a CPR mask [19] would do for rescue breathing. For my friends and family (if I was making a personal first aid kit), no mask or a CPR mask would do. For strangers with questionable medical history, I stay far away from vomit, if I can. I also carry two 500 ml IV bags, with a start kit [20], 10 drop tubing, and an 18 and 20 gauge needle taped to each. I have an emergency drug pouch that comes out of my drug box, if I am leaving it. This has epinephrine, Zofran, Benadryl, a narcotic for pain, and a benzodiazepine, glucagon, and narcan, along with accompanying syringes. This can address most issues someone is going to have before I can get them to higher care. A personal version of this could include ibuprofen [21], some prescription pain medicine (Vicodin/percoset or the like), and an epi pen if anyone has allergies, or any other things you think you may need. Doctors are very weary of allergic reactions these days, so it is not hard to get a prescription for one. Notice that this is not what I carry when I am expecting a medical call. This is my bag for when I am on patrol, away from my vehicle, just for things that pop up, and an IFAK is on the outside.
Medical Bag
In my medical bag, I divide sections by use– airway, splinting, bleeding, C-spine and strapping, wound cleaning and eye wash. I have pouches for other items.
Airway supplies get one section of the bag (plus a separate box). In this section I include: King airways [22], OPA, NPA, intubation gear, oxygen masks, and an oxygen bottle.
Splinting gets another section, which contains: SAM’s, vacuum splints [23], kerlex, triangular bandages, ACE wraps [24], and tape [25].
Bleeding Control supplies are in another section, which contains: abdominal pads, a stack of 4x4s, pressure dressing, a tourniquet, more QuikClot, and lots of gauze.
C-spine [26]and Strapping supplies get their own section.
Wound cleaning [27]and eye wash [28] is another.
Diagnostic tools ( Glucometer [29], BP Cuffs [30], and similar items) and Personal Protective Equipment/gear, along with hemostats [31], stapler [32], and tweezers [33] also get a pouch.
A manual suction unit, IV supplies, and hot/cold supplies go into another pouch. So this pouch has not just the suction unit but also IV bags wrapped the same way, with the start kit, tubing, and catheters taped on. I also have saline locks and some flushes, along with some ice packs [34], heat packs [35], and a survival blanket. An IFAK is on the outside of this kit as well. I find this is easier to find what you need, and you have similar things handy when it is divided by use. This kit is my ”go to” one for 99% of calls I deal with.
A few companies make an IFAK that fits in a standard AR mag pouch. These are nice in the third mag slot on a plate carrier. Get creative with it, and plan for redundancy. I have seen a few people recently with ”emergency home defense” style vests, which are basically a soft ballistic panel only in the front of a molle vest [36], usually with a flashlight, mag pouch, and pistol in a holster. The idea is that it goes by the bed, and if you need it in the middle of the night, you throw it on and have everything needed at hand. I would advise all to add a small IFAK to it as well. If you have a rifle for those bumps in the night, I have also seen a magazine pouch on the butt stock used to hold an IFAK.
Tips
Here are a few tips and tricks learned the hard way:
- In an austere environment, you don’t have the support, equipment, or time to get behind the eight ball in treatment of someone. Attack problems aggressively. If the patient deteriorates, chances of survival go down. Solve the problems when the person is at their healthiest, if that makes sense.
- Learn to have an index of suspicion for things. With a chest wound, you are expecting a pneumo and infection, so you are alert for them. If someone is bleeding a lot, expect shock. If someone has diarrhea, expect dehydration. By having an idea of what to expect, you can catch things sooner.
- In each divided area of my drug box where each separate drug goes, I have a laminated business card size paper with the indication and dose of each drug. Sometimes, your brain fades at the wrong time, and dosing mistakes can kill. Trust your memory but verify.
- You wouldn’t dream of putting away a dirty gun and your tactical gear a mess. Don’t do it to your medical kit. Restock what you used from your supply closet as soon as you can. If you are out of something, pull it from a secondary kit and rotate it up. I carry three oxygen tanks in my vehicle at work. There have been too many times when you use up one and another call comes in before you can refill the first. You or a loved one will need it at the most inopportune time.
- There are numerous stories coming back from overseas of engagements with inordinate numbers of preventable casualties dying. In almost all of these, the medics were killed at the onset of action or shortly thereafter. The surviving troops had the training and gear to provide lifesaving care to the wounded parties, but they did not have the right mindset and were unable to. They subconsciously relied on ”the medic” being there, so they didn’t take the training seriously and were not prepared.
- As ”the medic”, you need to realize that the care you receive will be provided by the ones you are teaching. This is a huge incentive to teach well. I have forced EMT’s I work with to take lead on calls and stood by as their assistant to ensure they are getting practice and not relying on me. Even though it is outside of their scope of practice, I have taught them IV insertion and needle decompression. If I need a needle, I would hate to have my coworkers stand by with no clue. My wife has a notarized letter from me stating my consent for my squad mates to provide that care if needed. If you are the medical one, make your spouse diagnose the kids next time one is sick. Put them into that role now, when the stakes are low and they have you to support them. Murphy says the medic will be the one that takes the random bullet on TEOTWAWKI +1. One of the best gifts you can provide your family is the ability and skills to carry on without you.
- Expose your patients. Cut off clothes. Modesty has a place. That place is not when someone is dying. You can’t treat something you didn’t find.
- Two bullet wounds stick out in my mind for being very difficult to locate. The first was a 380 in the arm of an obese male. The arm and fat almost swallowed up the hole. The second was a .223 to the stomach. The entry wound was very difficult to find. Get used to touching your patients. The 223 stomach wound was found by raking fingers across the patient and feeling it. Practice low light or no light care; it will come in handy.
- A nasal cannula with IV fluid hooked up makes a great eye wash station.
- Don’t forget to stock a surgical kit or two…or three.
- Purchase some sterile supplies (usually individually wrapped) and some that are not. For cleaning and field stuff, bulk dressings work. For final bandaging, use sterile dressings if you can. Likewise, get PPE gear, including face shields, masks, and sterile gloves. Regular medical gloves are not sterile. It is as much for the patient’s protection as yours. The last thing you need is to sneeze, cough, or drip sweat into an open wound.
- Tachycardia of unknown origin is usually dehydration or shock. Pulse of 130 just seconds after a painful event is normal. Pulse of 130 fifteen minutes later is not normal.
- Get used to performing a rapid trauma assessment. This skill is learned as an EMT, and the skill sheet can be found online (or YouTube it). This should take less than a minute and is done on all trauma patients. It is a head to toe exam for life threats. Feel the scalp and skull for bleeds and dents. Check the eyes, ears, nose, mouth. Feel the c-spine. Look at the neck veins. Check for tracheal tug. Listen to lungs, and feel the rib cage expand. Expose the chest and abdomen. Feel the abdomen. Check for pelvic stability. Check the long bones by putting pressure with one hand high pushing right and the other hand pushing left down low; this will let you know pretty quickly if a long bone is broken. Then, check the back! I have heard stories of people finding exit wounds and using them to locate entrance wounds from gunshots they missed. This should be a habitual process that is the same every time. At 0200, when you just woke up, in the dark, you want this to be second nature.
- Buy in bulk. A small compound fracture would wipe out the majority of medical supplies most people have. Stock a deep pantry, much deeper than you think. Even a case of IV fluids is not going to last long. The parkland formula for burn victims (fluids given to burn victim in first 24 hours) says that a 75kg person with 20% burns gets 6 liters! That’s half a case! In one day! How many of you have six liters of IV fluid? For that compound fracture, it will take rolls of kerlex and the like to splint it. Vet supply shops often have excellent prices on medical supplies. A bandage past date is still good, too.
- TEOTWAWKI will have no restock. Part of this is addressed with things like starting saline locks to save fluids if not needed. But you still need to store saline locks and catheters. You should be conservative with your supplies, absolutely, but have enough to treat prophylactically.. Have enough antibiotics to run a cycle without infection being present, if needed. Have a dose in each IFAK. In Patriots [37], Mary treated Rose with antibiotics after her gunshot with no infection present. Don’t get behind the eight ball. You can always barter any excess, or supply a local triad if the need arises.
- If you have an oxygen tank, tie a spare wrench to it. Things break at bad times.
- When doing operating room rotations and doing intubations in medic school, I was all excited for my first one. Instead, the Nurse Anesthetist had me manage the airway for a 30-minute surgery using an OPA and a bag valve mask. His point was that basics work to maintain an airway, so if for some reason you run into an airway problem, realize you can maintain it with the most basic skills.
- On using a bag valve mask, bag SLOWLY! Once every six seconds is enough. Some bags have a tab that you pull out that blinks a light every six seconds. It is easy to get excited. Over-bagging blows off too much CO2, and constricts blood vessels to the brain, killing people. Remember the person is unconscious. Their oxygen requirement is very low.
- In your medical preps, do not forget to plan for the ability to quarantine someone. Have disposable bed sheets, et cetera. Do not overlook this. Also, buy some good medical wound cleaning soap, like Hibiclens [38].
- I often see people comment that ”as long as what you are putting on the wound is cleaner than the cut, it’s okay. ” I understand the principle, but I disagree with the approach. Do not plan on being sub-par from the start. If it is all you have, I understand, but plan better. The more you can stack the odds in the patient’s favor, the better.
- Wash your hands. Do not underestimate basic cleanliness. Clean wounds thoroughly. I am aware that they do not meet the current medical requirement, but learn to use your pressure cooker as an autoclave. As stated above, have enough to throw everything away in a quarantine situation, but plan on being conservative and reuse what you can, when you can, if you can.
- If someone has a radial pulse, their systolic blood pressure is at least 90 and their brain should be perfused. If they have a radial pulse and an altered mental status, think about other things, like hypoglycemia or a head injury.
- Learn to have a differential diagnosis, even for trauma patients.
- I keep a small minor first aid kit in my patrol vehicle as well. No use pulling out a huge bag when a fanny pack size one can handle it.
- Make copies of certifications you obtain, and keep them in your bug out gear. People will try to pass themselves off as lots of stuff. If you present yourself as a RN, have your cert with you.
- Identify and treat immediate life threats first: Solve problems with airway, breathing, and circulation, including blood supply. Don’t get caught up treating minor injuries simply because they look bad.
- If you are working a chainsaw or axe, consider keeping a tourniquet close by. These lessons don’t just apply to gunshots.
- Make your own kit. Know what each item does. Rather than buy pre-made overpriced kits, buy in bulk and make your kits from these supplies. You will have more to restock then. As stated before, shop around. Ebay and vet supply stores can be very inexpensive.
- Know your kit well enough so you can describe to someone where the specific item you need is. That’s why I started taping everything needed for an IV together. It was easier to ask for the bundle then explain the start kit, tubing, et cetera if someone new happened to be helping. Likewise, learn your partner’s gear.
- If your partner gets shot, use their IFAK to treat them. Keep yours on you as long as you can. If you get split up later and you get shot, you want to be able to self-treat!
- If new to medicine, first plan on supplies and care for yourself and immediate family. Then plan for guests and extended family. If you have space, time, money, et cetera, plan on supporting a militia longer term, if needed. The items are not different, just the amounts!
- I’d recommend setting up your squad for patrol with an IFAK for everyone, and one or two carrying more extensive medical supplies. (It works for the military, and it works for us.)
- Learn all you can about supportive care. It will return as a major treatment method. Learn about herbal remedies. Start your herb garden now. A remedy book with no garden is not much use. Oftentimes, the herbal remedy is what the pharmaceutical is synthesized from.
- Embrace team care. If you are caring for someone, practice on having a partner take vital signs, prep IV bags, or draw up medicines. When the need truly arises, it will save precious seconds. A paramedic is only worth as much as his EMT partner.
- I’d rather have someone with knowledge and no gear over gear with no knowledge. However, since it’s not TEOTWAWKI yet, you don’t have to choose either or. There is no excuse to not have both.
Resource videos to get you started:
QuikClot [39]
CAT, chest seal, and needle decompression [40]
SWAT-T tourniquet [41]
Israeli Dressing [42]
These are all manufacturer videos. YouTube is also a great source for training and review videos.
I hope some of this is useful to some of you. Trauma happens to everyone, both in the present and an apocalyptic future. Get the training now when mistakes are not life and death. Then pass them on!
God Bless! – a LEO medic