Let's talk bare-bones BOK

[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
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_d...f7/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_d...f7/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 . . .