I Wish I Knew Then What I Know Now (Edition 2 – Packs)

Continuing a theme started with a practical post on direct and indirect pressure for haemorrhage control, Greg Brown (Education Manager amongst other things) discusses the things he’s learned about how to figure out what you need in a kit. 

I remember the first time as a young Nursing Officer in the Australian Army I went on exercise (that’d be “manoeuvres” for you Americans, and “war games” for those that watch too many movies) and had to pack a medical kit. Not knowing what was required for the job (and not asking either) I had earlier visited the field pharmacy with a request that was essentially “one of everything you have, please Ma’am”.

The result? I spent three days being cold, wet, hungry and slow – the sheer size and weight of my medical kit meant that I had not enough room for “luxuries” such as a sleeping bag, raincoat or enough food.

Now what?

So, what has changed over the years? Well, I’d like to think that a lot has changed. Firstly, I now have the experience to know that if I cannot do my job (because of issues pertaining to cold / heat / hunger / thirst / ability to keep up etc) then I am a liability and not an asset. I have also learned that the greatest skill ANY prehospital care provider can possess is the ability to improvise. And finally, I’ve learned that big ticket “Hollywood” style medicine does not keep people alive but that, as a popular Australian breakfast cereal advertisement from the late 1980’s stated so eloquently, “the simple things in life are often the best”.

It is important to realise from the outset that there are arguably more variables in life when it comes to medical kits than there are medical conditions that need treating. Okay, that is a bit of an exaggeration, but hear me out. When creating a medical kit the individual must ask themselves a series of five questions that will guide the size, contents and capability of their kit.

Question 1: Who will be using the kit?

If the answer is simply yourself, then you can afford to consider taking items that are your favourite but not necessarily everybody else’s preferred option (caveat: they still need to be evidence based and supported by your clinical practice guidelines / protocols). An example is in regards to airways: you might be an avid supporter of the iGel whereas I sit firmly in the LMA Supreme camp whilst there also exist individuals who like the King-LT. One could argue that they all do similar things and possess commonalities (e.g. blind insertion, semi-secure airway etc) yet they each require necessary knowledge, skill and attitudes in order to make them work. The solution, in this case, is standardisation – not three separate but similar airway devices.

Question 2: What is the kit expected to be capable of doing?

Within CareFlight we have many different lines of operation; for ease lets call them Sydney, Darwin, International and Off-Shore. So, take our Sydney operation – CareFlight Rapid Response Helicopter (CRRH). CRRH works as part of a wider retrieval network to service the Sydney basin. The majority of its taskings are to traumas and near drownings, so its kit reflects this. CRRH is unlikely to be tasked to a ketoacidotic haemophiliac with sepsis on a background of COPD. Why? It services the Sydney basin where there are also around 50 ambulance stations, each staffed with well trained, well equipped and well-motivated paramedics who are standing by to deliver the patient to one of a dozen equally well staffed / trained / equipped / motivated hospitals, that are available 24/7. If CRRH is treating and transporting this patient then it is because they’ve been ejected off of their motorbike whilst completing stunts at the local motocross track (again, perhaps a slight exaggeration for this particular patient), so the activation is to a trauma. CRRH’s kit must reflect this, just as the Darwin, International and Off-Shore kits must (and do) reflect their demographics.

The same goes for medical kits of a more “tactical” nature. If your tactical kit (the one you wear on your rig when conducting a deliberate action / breach / clearance etc, or every day because you are clever and “that’s how you roll”) contains a laryngoscope then I’d respectfully suggest that you’ve got it all wrong. Interventions in this environment need to be high yield and rapidly applied whilst allowing for the maintenance of situational awareness. If you are head down / bum up intubating, you are not accounting for your own safety. Besides, is the expectation now that this patient will self-ventilate? Or does your tactical kit also contain a self-inflating bag or mechanical ventilator?

Question 3: How long does this kit need to last? 

This is a question of stock holdings. When I think back to that first Army exercise in a medical role of mine I now ask myself “it was only three days long, so why did I need seven days’ supply of three different oral antibiotics – especially when we were within two hours walk of a field hospital?” My stock holdings were all wrong. Chatting with many others over the years (both military and civilian) I have found that this can be a common theme amongst pre-hospital care providers.

If some is good, more must be better, right? Wrong – more just means bigger, heavier and slower. Besides, if you brought it – you’re carrying it.

But what if one fails, won’t I need a second / third / fourth? To this I offer that if your plans are built around multiple failures in equipment then it is time to revisit your equipment list and look for alternatives that are more robust and reliable.

An important consideration when assessing how long your kit needs to last is: what is your mission? If your mission is to conduct humanitarian assistance in the wake of a natural disaster for a period of seven days then you are going to need a LOT of stuff – trust me, having deployed to a few natural disasters in my time you will require a very robust supply chain. But if your mission is to treat and transport one victim of that natural disaster at a time with a resupply between each mission then you don’t need that much gear. Besides, generally speaking the less you carry the faster (and further) you can travel.

Stock holdings are a balancing act. It is reasonable to build some redundancy into your medical kits (ever had that one vial of morphine in your kit smash when someone decided to use your kit as a stepladder?) but it must be balanced with the knowledge that if you brought it, you’re carrying it.

Question 4: Is the kit a “stand alone” or designed to be augmented?

Capability should be viewed in terms of three things:

  1. people;
  2. equipment; and
  3. the ability to effectively combine the first two points.

I learned a long time ago that I was never going to be the only person in a group with medical training. Every “operator” (e.g. police officer, fire fighter, soldier, aircrew member, emergency service volunteer etc) has basic first aid training (and sometimes much more) and many will carry their own supply of essential items (i.e. arterial tourniquets, bandages, gloves etc). In situations where medical attention is required, medical personnel need to utilise the capabilities provided by others.

It is always worth considering this concept of capability when forming your plan; planning to combine medical kits in order to create improved capability is a useful concept. Most military and paramilitary units do just this; as an example, the Australian Army’s Parachute Surgical Team (PST; now superseded) built its equipment plans around the “what ifs” of war and how to ensure enough capability without carrying a whole hospital worth of equipment.

What do I mean by the “what ifs”? Well, I’m glad I asked myself this question.

What if the plane carrying the equipment got shot down before we could drop the stores? Well, each member of the PST parachuted with a medical kit that, when combined with those that others carried, formed an interim resuscitation and surgical suite. What if a paratrooper and his / her kit went missing? Well, there were just enough team members to space out on separate aircraft to create two identical suites. What if a paratrooper required more than first aid on the drop zone or during the advance? Well, each kit also contained the stores statistically required to treat a battle casualty.

Each kit creates a capability; but when combined they can provide so much more. This is an important concept to keep in mind when designing your medical kit.

power-rangers
It’s a bit like the Mighty Morphin Power Rangers. Individually they don’t necessarily get the job done but when combined they offer … Spandex. And also getting things done.

Question 5: Can you actually carry it? 

Size matters. I’ve said it a few times already, but size really does matter – if you brought it, you’re carrying it.

For a medical kit to be effective it needs to be capable of getting to and travelling with the patient. Therefore, if it is so big and cumbersome (because you packed one of everything…and some redundancy) that you cannot get to the patient then you need to ask yourself “what is the point?”.

Now, I will freely acknowledge that different sizes are required for different tasks – in fact, I have four different kits in my personal armoury for four different purposes. Similarly, CareFlight has different sized kits for different tasks within its separate lines of operation.

So some things to consider include:

  1. Is this kit staying in a vehicle (if so, what type of vehicle?) or does it need to be portable by an individual?
  2. If it is portable, what else is that person carrying (e.g. a tactical kit will likely sit between other pouches / holsters on a belt or chest rig whereas a bigger kit may come with shoulder straps or need to fit inside another pack)?
  3. When packing it, how many pouches will you need to open in order to perform one intervention? (Note: the answer should be one; if your IV cannula, sterile wipe, venous tourniquet, securing tapes, bung, giving set and fluids are not together then you’ve got it wrong.)
kits
OK I may have a bit of a kit fetish but each one has a specific purpose in life. Beyond just making me happy even.

Summary

So there you have it. Added to the list of “things I know now that I wish I knew then” is medical kits. I now start with an analysis of the mission, draw out the likely tasks, consider the need for redundancy, look at what else I need to carry and consider the overall capability. What I don’t do is request “one of everything please, Ma’am”.

 

Notes:

This one is much more of a recount of personal experience so there aren’t a heap of links to send you to. It would be great if people could give examples of how they think about their kits and what they carry though. It’s a good bet there are clever people out there who would point out things that haven’t come up here.

Oh, and don’t forget if you like the stuff on here there should be a spot somewhere on the page that lets you follow along so you’ll get an email when a post goes up.

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