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Doc In The Bay – What’s In Your Bag?

Howard Mell, MD and Mel Herbert, MD MBBS FAAEM
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10:05
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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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EM:RAP 2016 September Written Summary 655 KB - PDF

As a medical provider having a personal medical kit is a good idea.  But what to put in it?

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Jonah S., RN -

Re: Dr. Mell's "What's in your bag?".

The most important advice Dr. Mell gives that should resonate with listeners is to stock your bag with gear to handle those emergencies you're likely to see. After that foundation is established, I absolutely agree with fleshing out your kit to treat those more rare emergencies that will require immediate treatment without which the patient will die.
What I want to take contention with is the use of Tactical Combat Casualty Care (TCCC) statistics to build a kit. Part of my background is that I was TCCC certified in the United States Marines Corps (my military occupational specialty was infantry). On deployment to Afghanistan we all carried two tourniquets (I carried more in my Combat Lifesaver bag--Combat Lifesaver being the other name for TCCC). We carried these because TCCC statistics say that something around 66% of preventable combat deaths are due to extremity hemorrhage. This number is as high as it is because of mechanism of injury--namely blast injury secondary to improvised explosive devices that cause traumatic amputation and the like.
As a civilian I was a police officer for six years before entering into EMS and emergency nursing. I see officers coming in all the time (many of whom I know) with a tourniquet on their duty belt; no other medical gear, just a Combat Application Tourniquet (CAT). With my background as a law enforcement officer I get Dr. Mell's thought process in building a kit based around what saves lives in the military. This is where a lot of civilian tactical medics and physicians look for experience. The reality is that the tourniquet isn't nearly as important in civilian tactical medicine as it is in a combat theater. Statistics collected by the FBI from 1998-2007 on U.S. law enforcement officer deaths due to felonious assault showed that of the 533 deaths only two were preventable deaths due to extremity trauma (link below). Further, a July 2016 article in the Journal of Trauma and Acute Care Surgery analyzed 139 fatalities from active shooter events in the U.S. and yielded zero deaths from extremity trauma (also linked below). Civilian tactical medicine shouldn't be a direct reflection of military tactical medicine--only informed by it.
Now, I'm not saying that tourniquets don't have their place and I'm not saying that we're talking just about tactical medicine here. I carry CATs on me during search and rescue operations and in my various kits. I also keep one readily available from the front seat of my vehicle. These studies linked aren't complete because they don't consider injuries from motor vehicle accidents, power tools and all the other creative ways of inflicting trauma that we encounter in the emergency room. Tourniquets are life-saving devices and I recommend that people have them available, I just always caution people that these are not the foundation for your kit (and to be clear, I don't think that Dr. Mell is implying that at all). For most people, the most important thing they'll carry is a pair of nitrile gloves...for everything else there's the emergency medical kit (to continue with Dr. Mell's credit card slogans).

Learning from tragedy: Preventing officer deaths with medical interventions http://valorproject.org/uploads/Sztajnkrycer_W10_NTOA.pdf

The profile of wounding in civilian public mass shooting fatalities
http://journals.lww.com/jtrauma/Citation/2016/07000/The_profile_of_wounding_in_civilian_public_mass.14.aspx

Howard M. -

Jonah,

I absolutely agree, the TCCC is combat deaths, not civilian (although at the Gabby Giffords shooting and the Boston Marathon Bombing, tourniquets were used to great effect on civilians). Sztajnkrycer's work is great, and I don't disagree with his findings at all. The reason I "built my kit around" the tourniquet is that there is nothing I can carry for first aid that is going to save the splenic rupture from the MVC or the subdural hemorrhage from falling off the ladder. In my opinion, for something to be useful enough to carry it has to not only address a condition I'm likely to see, but do so effectively. And as my anxious daughter never fails to remind me (since we moved to NC) "shark attacks do happen!". ;-)

Thank you so much for your service, in the military and in law enforcement. Your heroism is appreciated and we are glad you made it home!

Doug S. -

Thanks for the great piece, and Jonah thank you for your service. Where have you all found is the best online spot to purchase your gear? For prescription items, i.e. EpiPens, etc do you just prescribe them to yourselves or is there a better way to go about it?

Jonah S., RN -

I really like http://www.chinookmed.com/ for my general medical gear. Actual medicines will have to be bought from a different online vendor. My fire department used https://www.boundtree.com/ and this is where I'll get the medicines my search and rescue team carries once I'm done writing out protocols and have our medical director sign off. Boundtree also sells other medical gear as well. If you get a Combat Application Tourniquet somewhere make sure it's from a reputable dealer (which Chinook Medical is) as there are a lot of knock-offs coming out of China.

Xander Merboo -

1+ everything mentioned by Jonah. Well put.

I spend my days in the trauma bay, nights on the SWAT team and weekends in the military reserve. Winters supporting expeditions. Just a couple of quick points. So take it for what it's worth.

1. Perhaps one of the best discussions about everyday medical kits for the medical professional is with Dr Weingart at EmCrit. Great critical discussion and some excellent recommendations on what one DMAT MD carries with him everyday. The anecdote about using his life saving equipment at a medical conference is pure gold.
http://emcrit.org/podcasts/everyday-emergency-kits-keith-conover/

2. There has been far too much emphasis recently emphasizing the use of tourniquets in civilian practice. TQ are great for my soldiers who are heavily armored from head to pelvis and will get extremity blast injuries. TQ are great for my SWAT officers who have armor from head to abd and will likely suffer penetrating extremity injuries. TQ are just plain stupid when considering mass cal incidents where hemorrhagic death will likely be from improvised missile fragments penetrating the chest and abd. Sure one of my deputies had to put a TQ on a perp once [in 5 years], but is that a good allocation resource? Many tactical medicine courses are now endorsing mass cal TQ backpacks to be staged at soft targets; each pack stashed with hundreds of [$30 each] TQ that have a very very low likelihood of providing a lifesaving intervention. Boondoggle.

The EAST townhall discussion brings up some great points on the topic, esp from Dr Alexander Eastman
https://www.east.org/education/online/traumacasts/detail/76/east-town-hall-debate-hartford-consensus-conference-vs-tecc-what-is-the-right-approach-for-the-active-shooter-epidemic

Thanks Docs!

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