The Jump Kit, by Skyrat

Tuesday, Jun 23, 2009

Inside the trunk of my vehicle is a near duplicate of the “jump kit” or “Green Bag” used in my days with the Detroit Fire Department's Emergency Medical Service Division. When I come across a roadside collision before the local medics, everything I need to start patient care is in the green canvas bag I sling over my shoulder. The supplies in my personal vehicle are very much like those I carried in my street medic days, and reflect a strong basic life support/trauma bias.

Basic life support includes those interventions that do not go past the skin, and generally do not require physician direction to implement. Advanced life support, on the other hand, includes therapies that do go past the skin, and include medications, intravenous fluids (IVs), electrical counter shock, and airway intubation.

I do not include intravenous fluids or medications in my green bag for a couple of reasons. First, these items have a limited storage life under the best of conditions, and the rear of a passenger vehicle in Northern Michigan is not calculated to prolong it. Second, the statutes under which paramedics practice here in Michigan requires systematic physician supervision of advanced patient care. Fundamentally, that means that if you are not functioning within an established paramedic system, you are out of bounds should you perform advanced procedures on the street. Third, advanced patient care procedures are occasions of peril even in the hospital, let alone in the rear of an ambulance. This is so, even within a system of continuing education, continuous quality assessment, supervision, and the backup of both your partner, and the physician and clinical staff on the other end of the telephone or radio. Soloing at the roadside provides neither you nor your patient with these safeguards.

Firearms owners are likely acquainted with the “gun shop commando”, classically braying about the bogus “shoot 'em and drag 'em inside” philosophy of home violence management. Likewise, you might consider the existence of the “parlor paramedic”, who seems to reason something like, ”wait until the Schumer hits the fan, and I'll come out of the closet, birthin' babies and saving lives!”

In order to entertain this fantasy, you will need the tools of the trade. Medications are not without risks, do not keep forever, and are expensive. Additionally, there is the issue of convincing a physician that he or she ought to prescribe for you and that you can differentiate your Barneyfrank (ass) from a hole in the ground. If the expense is no problem for you because you have money to burn, please see me after class! If you think that the utility of your medication stash outweighs the other concerns, please contemplate these points: 1) In the absence of a catastrophe the likes of which America has never seen, it is both illegal and immoral to withhold professional medical care required by an ill or injured person. 2) During Schumeresque times, it is unlikely that the infrastructure will be in service which allows the delivery of complex, highly skilled care to those in need. Particularly, you will not have access to that infrastructure, and (if you have your head screwed on straight) you will have no desire to perform skills you are not trained to do, in the midst of a disaster, upon your vulnerable, hurting and injured loved ones.

By way of example, I have 30 yeas of EMS and nursing experience (in ICU, CCU, and ER), as well as licensure as a Physician's Assistant. I have used Dopamine, along with other invasive therapies, innumerable times to support the blood pressure of critically ill or injured patients. Dopamine has potent effects upon the heart, among other systems, and these effects are monitored by a cardiac monitor. I found a Zoll Automatic Cardiac Defibrillator, after a brief internet search, for $3,000, which appears after a casual review to allow monitoring. The question, however, is whether you can make sense of the tracing the monitor displays, identify adverse changes in cardiac rhythm, and respond appropriately. Additionally, do you know the adverse effects Dopamine may have, and how they must be managed? If not, you have no business trifling with it. I have done all these things for years in my Nursing practice, and I do not have Dopamine in my personal stores. You need to assume the risks you both understand and are comfortable with. I am reluctant to assume this risk for myself and my family.

My bias toward trauma derives from the fact that the stabilization and management of the medical patient, in contrast to the trauma patient, calls for assessments and interventions that I generally do not find appropriate outside of the hospital or advanced life support ambulance. Determining the source of the patient's distress will identify what treatment is required. While there are a few medical conditions that are responsive to basic life support interventions, I am not about to pretend that a few thousand words will equip you to make such judgments. Find an American Red Cross first aid class and master it. Better yet, become an EMT.

Just the other day, I came upon a rollover as my girlfriend and I were en route to attend some family function. There were half-a-dozen civilians clustered about, and things seemed well in hand. The first firefighter arrived shortly after me, and I deferred to him. Offering him wound care supplies, I was surprised to discover I could not find any gloves in my kit! Returning home, I undertook an inventory. Here is the result of that tally, and some discussion of my view of why each item belongs in my kit.

Training comes first. There is a story told of the early days of the Israeli state, when the emergency response planners had the budget required to train their personnel to stabilize and transport spine injured patients, or buy the splints (called backboards), but not both. The story relates that the planners elected to train their personnel, and subsequently noted a spine injured kibbutznik transported to the hospital by his comrades, secured effectively to an entire barn door.

I place a priority on training for several reasons. First, neither vermin nor adverse storage conditions have ever ruined training and rendered it unusable. Secondly, “they can have my training when they can pry it from my cold, dead mind”. Third, I have never ever (in my disorganized life) failed to pack my training. Fourth, there is nothing that will be displaced from my supplies in order to make room for my training. Fifth, in contrast to supplies, ability improves with use, and becomes more abundant when you share it with others.

Begin with CPR training. Three or four hours of your time will equip you with the skill that may save a life in the here-and-now. You will gain an introduction to patient assessment, and learn some of he fundamentals of first aid, and whatever dilemma confronts you, your response cannot fail to be more effective with some training to guide you. Effectiveness saves lives.

Look into local outlets for first aid training. The American Red Cross, the National Safety Council, your local community college, as well as perhaps others offer credible training which may serve as an introduction to further studies. The justification for the further expenditure of additional hours may be found in the preceding paragraph. Additionally, if you are more acquainted with what the medical conversation is about, the health care decisions made with regard to yourself and your family will be less mysterious to you, and better informed decisions tend to be better decisions. The better your health, the better your chances of coming out the other side of Schumer times intact, and therefore the better chance of bringing your family with you, likewise unscathed.

Consider EMT schooling. You will learn more emergency care skills (a good thing), and an introduction to elementary anatomy and pathophysiology (how things go wrong in illness and injury). Such education gives you the opportunity to be a more informed participant in your health care decisions, and that is itself a good thing, as well.

SELECTING YOUR CASE
It really doesn't matte what sort of container you employ for your emergency supplies, so long as it meets your particular needs for security, identification, accessibility, protection and convenience.

Some fire departments use plastic “totes” to organize supplies required for specific types of calls. For example, haz-mat supplies are packed inside specific totes, and the top secured with a cable tie or some such device. An inventory is attached to the top (sealed in plastic) to identify what is inside, as well as out dates of time sensitive components. When properly closed, such bins are drip and dust resistant, resist crushing or jumbling of the contents, and can be convenient to carry when not overfilled. On the other hand, they will not conveniently fit beneath a vehicle seat, may be unwieldy to retrieve and place into action, and may get buried beneath other stuff in a trunk or truck box.

Others of my acquaintance use ammo cans, or plastic fishing tackle boxes. These are generally more convenient to shlep about (unless your tastes run along the lines of a 20 mm ammo can) and are more drip/dust/duh! resistant than the tubs mentioned above. On the other hand, they may overturn with disappointing ease, spilling your supplies into whatever noxious fluid is abundant on your particular scene.

I use a green canvas musette type bag. It is not water resistant, is not neatly compartmentalized, and does not have an IR glint Star of Life embroidered upon it. On the other hand, I know how my stuff inside is organized, it is convenient to sling over my shoulder when the scene requires that I do so, and the local military surplus store will sell me another for $10-20 when that becomes needful. It will fit beneath a van seat, or in a tub in my trunk, and I can work out of it when I have it slung.

IN THE TOP, OR IN AN OUTSIDE POCKET
Items that I am likely to require promptly are either in the outside pocket or immediately inside the top flap of the bag. These are things that I do not want to be fumbling for as I approach a scene. I will not list what might be considered “everyday carry” items like pocket knife, flashlight(s), CS spray, sidearm, and a cell phone. While these tools help keep the rescuer from becoming a victim of an ambush laid for a 'Good Samaritan” , particularly when employed in concert with a Condition Orange mindset. (I did mention I started out in Detroit, didn't I?) These items do not seem to me to be rescue/first aid/emergency medical tools.

First up is several pairs of gloves. (well, now, anyhow!) I am allergic to latex, so I have nitrile gloves. Current practice is to wear gloves anytime you might reasonably anticipate exposure to blood or other bodily fluids: tears, urine, stool, saliva, gastric contents, or any other moist, body-origin material you might imagine (and perhaps a few you might not!). I have so thoroughly incorporated this into my life that I get uneasy caring for my own children (or, at my advanced age, grandchildren!) without gloving first. These are in a zip-lock bag, safety pinned (now!) just inside the top flap of my green bag.

The upside to all this is that scrupulous gloving and thorough hand washing have so far proven highly effective at preventing the spread of the most common blood-borne infections. Diseases spread via airborne droplets (for example, Legionnaires disease), of course, require additional precautions. Others are spread by organisms coming to rest upon environmental surfaces and then accessing a vulnerable host (just like you and I are vulnerable hosts to “the common cold”) by means of unconsciously touching our faces after touching a contaminated surface. For myself, after 30 plus years of patient contact the worst I have brought home has been an occasional upper respiratory infection due to my conscientiously applying the glove/hand wash/hands away from my face regimen.

The next item I'll feel a burning need to have in my hands is a bag-valve-mask (BVM). This is a manually operated ventilation tool. It is employed by sealing the mask over the unbreathing patient's face, squeezing the self inflating bag, and thereby forcing air into your patient's lungs. Repeat at a rate of approximately 12-20 times a minute. Advantage: no kissing strangers, required for mouth-to-mouth resuscitation. You are able to maintain situational awareness of such things as evolving environmental hazards (like leaking gasoline), or indicators of your patient's improving condition (...he said, thinking positively!). On the downside, using a BVM is difficult in untutored hands. It is easier (compared to mouth-to-mouth) to force air into the patient's stomach, which will elicit vomiting. Aside from the aesthetic issues this presents, vomiting in a profoundly unconscious patient (such as one so unconscious as to have stopped breathing) presents the opportunity for aspiration into the lungs of that which has been vomited, which may be deadly.

Training in use of a BVM will be part of the EMT class I mentioned earlier. I'll wait here while you go find out when your local community college or rescue squad will be having their next class. Plan on being a part of that class. You will be making your community, and thereby your family, safer.

You can buy your own, and Gall's will ding your for around $15 for a disposable model. In the hospital, we use these once and discard them. You might choose to meticulously clean yours and re-use it. Your local rescue squad or ambulance may shop locally, and you might want to do likewise. Ya know, if you were to volunteer with your local rescue squad, you might be able to obtain things like this at your agency's cost. All this on top of the good karma from helping to provide a necessary community service. And,, besides, becoming known to the locals (police included) as one of “the good guys”. Your phone book likely will provide the contact information you require. I'll still be here when you get back.

One of the adjuncts to using a BVM is called an oral airway. Oral airways come in sizes, which may be selected according to the size of the patient. Their purpose is to hold the flaccid tongue of a profoundly unconscious patient forward, so that it does not sag against the rear of the throat and thereby block the passage of air into and out of the lungs. The problem it may trigger is, should your patient be other than profoundly unconscious, he or she will vomit. Among other disasters this may cause, the enzymes from the stomach, designed to digest proteins, will (unsurprisingly) begin to digest the proteins found in the delicate tissues of the air sacs (alveoli) of the lungs, with effects you are likely to be able to imagine on your own. Very Bad Thing. [JWR Adds: Plastic airways usually come in sets of six sizes, and usually color-coded these days, available for less than $5 per set on eBay. Buy a couple of sets. Someday you may be very glad that you did!]

Another way to fail when employing an oral airway is to bunch up the patient's tongue in the rear of the throat. This blocks air flow, strangling your patient. This device must be restricted to only profoundly unconscious patients, and only if you are schooled in its use. You can buy them individually, or in sets. Before shipping, they go for around $5.00/set. You might elect to buy them one at a time, but at $5 a pop, they aren't a particularly major investment.

When I'm confronted by an actively bleeding patient, I reach for a Carlyle dressing. Mine are the old style The Carlyle iteration includes muslin (cloth) ties to secure as any other tied bandage. The 21st century version is called an Israeli Dressing, and is available from various sources. (see my shopping list/spreadsheet for representative sources) It consists of a sterile dressing incorporating an elastic bandage to secure the dressing to the wound. Should you shop gun shows or surplus stores for your equipment, be wary of old dressings. They present potential issues of failed sterility as well as mustiness or mildew occasioned by improper storage or imperfect packaging. The contemporary Israeli Battle Dressings are available from Cheaper Than Dirt or from Gall's for $9.00 or $10.00 each.

Another wound care product is QuikClot . This is a mineral product, bound to a dressing, which enhances clotting, and thereby slows and limits blood loss in the bleeding patient (common in trauma, surprisingly enough!) One article (QuikClot Use in Trauma for Hemorrhage Control: Case Series of 103 Documented Uses. Journal of Trauma-Injury Infection & Critical Care. 64(4):1093-1099, April 2008.) reflected the occurrence of burns in several patients, but the manufacturer's web site reports that changes in packaging and delivery system have addressed this issue.

An alternative you might consider is Celox. It appears perhaps to be a reasonable alternative to QuikClot. It is derived from shrimp shells, although it seems to not produce allergic reactions in folks otherwise allergic to seafood. I have no personal experience with either product, but the reports are interesting. This goes on my “further research” list!

The preceding items are to be found in the outside pocket or very top of my jump kit. I don't want to be searching for them when I feel the need for them Right Freaking Now. Beneath the don't-wanna-wait-for-them items, I have supplies of somewhat lesser immediacy. These allow me to assess the situation in greater detail, or address issues that may come to light that are of less time sensitivity.

Triangular Bandages are useful for slings of injured arms, or may be folded into narrow strips and then used as a means to secure splints or dressings (as “cravat bandages”). If we were to consider them as a backpacker might, they may be used as expedient dust masks, bandannas, head coverings, or washcloths. I buy muslin by the yard at Wal-Mart, and cut it from one corner to the other, forming (surprise!) 2 triangles approximately a yard on a side. I keep 6 to 8 in my kit.

Bandage shears are the most obvious of the prehospital medic's tools. You can go with Lister style bandage scissors, often found as “nurse's scissors”, or the plastic and steel “super shears”. Prices range from $4.00 and up. Frequently employed to trim dressings to the proper size, cut away clothing from wounds, and to cut bandages.

Did you ever notice that a tongue blade/tongue depressor is almost exactly the width of a finger? And just a bit longer than your Mark 1, Mod 0 finger? Exactly like it were designed to be a finger splint, isn't it? In addition, should you tape three of them together one on top of the other, you have a dandy tool for tightening that “Spanish windlass” you are going to learn about, when your EMT class teaches you how to apply and improvise a traction splint for a fractured femur (thighbone). Finally, if you are unhappy at the thought of wiggling somebody's fractured femur (broken thighbone) so you may place ties (cravats: remember them?) for a splint, tongue blades are thin, stiff, and very helpful at limiting the wiggling as you place ties beneath the broken bone of your choice. I keep a handful handy.

You can pay a couple of bucks for them at the corner pharmacy, or you might be able to talk your way into several for free, like when you are volunteering at some public service event with your local volunteer fire department, emergency medical service, or amateur radio club.

Stethoscope/Blood Pressure Cuff. A stethoscope allows you to hear the sounds made as air moves into and out of the lungs, and note changes from normal. These changes might occur because your patient has a collapsed lung, or has pneumonia, or heart failure. When you get that far into your EMT class (hint, hint), you will learn how to evaluate these changes, and what sort of treatment decisions you ought to consider when you notice them. In addition, you will learn how to measure, and interpret, your patient's blood pressure.

I am certain you will know somebody who will go out and get the cardiology deluxe stethoscope, with the multi disc cd player, mag wheels, and gold trim. Do not join them in this folly. Spend $10-40 at the same place the local student nurses get their stethoscopes, and spend the difference on your spouse, whose enthusiastic support you will require, anyhow. If you can show your spouse how your expenditure of family money and time on supplies, education, and volunteering promote values that you both agree upon, the both of you will thereby make your family more crisis resistant. If your family is more crisis resistant, then you are not only NOT a drag on community emergency services during an emergency, you all might even be an affirmative community asset during bad times. That cannot fail to be a Good Thing when you get to explain yourself to The Jewish Carpenter. Me, I'm going to require all the help I can get. I'm volunteering!

Adhesive tape (1 inch, 2 inch) secures dressings, holds loose ends of bandages, and provides a single use notepad (tear off a length, tape it to your thigh, and jot notes. You will not lay it down somewhere to be forgotten). If you listen to some friendly and knowledgeable athletic trainer, you can learn how to use it to support sprained ankles or knees if the preferred treatment (rest, ice, elevation) is not possible. Before you employ these tricks, bear in mind that physicians frequently cannot differentiate a sprain from a fracture, even after an x-ray. In my view, except under the most dire possible circumstances, walking on a fractured (or sprained) extremity is a Very Bad Thing. Two rolls each are at hand when I open my green bag.

I keep 12 to 15 Gauze pad, sterile, 4x4 in my kit. I employ them as eye pads, padding beneath splints, or as (oddly enough) dressing for wounds. Occasionally I encounter a wound bleeding so enthusiastically that a couple of gauze pads will be overwhelmed. Fortunately, I haven't come across such a wound off duty, but in the hospital we use a “boat” of sterile gauze. This is a plastic tray of ten sponges in one pack. The tray also may be used as a clean basin for wound irrigation/cleansing solution. In the hospital we use sterile saline, you may elect to use the water from your retort pouch, or fresh from the bottle as you purchased it for storage. I would certainly give it some thought.

If you happen to be the purchasing agent for your entire survival community, ambulance service, or the entire Boy Scout Council, you might find the case price from Galls to be a useful bit of information. 1200 sterile 4x4 pads for $89.99 works out to around 7.5 cents each.

Triple padding/ABD padding, sterile, 5x9 inch. These multiple layer absorbent dressings are designed for wounds producing a lot of drainage of either blood or other fluid. They are my first choice for a bulky dressing or splint padding. I keep 6 in my kit. The frugally minded may note that “sanitary napkins” are designed to absorb drainage, are “medically aseptic”, and are available nearly everywhere.

And, on a related note, tampons from the “feminine hygiene” shelf at your local store are also constructed to absorb fluids, and contain them. Should you confront a penetrating wound, “tamponading” a wound is a widely known concept among inhabitants of the medical world. Packing such a wound with a tampon using sterile technique might prove to be life saving, and provide hemorrhage control options not otherwise available. (http://snopes.com/military/tampon.asp)

Roller Gauze, 4 inch is typically used to secure a dressing (see Gauze Sponge, above) to the wound. I pack 6 in my kit, and they have “found careers” as bandages to secure dressings, securing splints when I run out of triangular bandages, and upon occasion as packing/dressings for vigorously bleeding wounds. In fact, when one is employed as the dressing, and another as the bandage, I can not only dress the wound, but also (since the bulky roll provides a pressure point) apply direct pressure to the bleeding site. This provides an alternative to the Carlyle or Israeli Dressing, cited above

Vaseline Gauze (sterile, 3x9 inch) is intended to seal wounds penetrating the chest, in order to prevent collapse of your patient's lung(s). When you seal the defect in the chest wall, your patient will not draw in air through the wound when s/he inhales, and thereby not fill the space between the lung and the chest wall (the pleural space) with air. When you can avoid this, inhaling draws in air through the mouth, trachea and bronchi, and that inflates your lungs, and we think that is a good thing. Myself, I pitch the gauze and tape three sides of the foil package, sterile side towards the wound, forming a flutter valve sort of effect. In this way I allow excess pressure in the pleural space to vent to atmosphere (stopping further lung collapse, I hope), and seal the hole when the pressure inside the chest is less than atmospheric pressure (like when the patient inhales). The only way left to equalize that pressure is by inflating the lungs, already described with approval above.

The other use for Vaseline gauze is when my lips or hands are dry, in which case I use the Vaseline to remedy that little problem.

We all can think of uses for the common elastic bandage, 4 inch and 2 inch. Two inch is useful for sprains of your wrist or thumb, and the 4 inch is used for an ankle twist/sprain. In addition, I can use them to secure a splint (there is that rule of threes, seen in other posts on this blog, again!), as the “swathe” part of a sling-and-swathe to immobilize an injured shoulder, or as part of a pressure bandage over a dressed wound that does not want to stop bleeding.

Large Bulb Syringe (for which you can substitute a turkey baster) functions as an expedient means of removing fluids from the airway of someone who is not managing to do so effectively on their own. It will not work nearly as well as a battery powered or pump action suction, such as you might find on your local rescue squad rig, but it won't cost you $50-$60 (for the manually pumped version) either. Second best is superior to nothing.

Mylar “Space blankets” protect you or your patient from the hypothermia-inducing effects of the wind, slowing heat loss. Generally colored bright orange on one side and silver on the other, there are signaling opportunities as well. In a pinch, you can improvise shelter from one or two. Amazon sells the "Space Brand" blanket inexpensively. Equip your jump kits, and each member of your family with one or two.

Any accident so severe as to convince suspicious old me (alumnus of Detroit's EMS) to stop and offer assistance will not be fixed with a couple of Adhesive Bandages (aka “Band Aids”). I have six in my jump kit, two entire boxes at home (and parceled out among my camper, car, and household kits).

I keep a couple of Ice Packs around, as assorted adventures may bring on modest orthopedic injuries. Ice is helpful for strains, sprains, or overuse of an over aged joint (...not that I would know anything, firsthand, about that...). Choices include “instant cold packs”, or that old picnicker's standby, a zip lock bag full of ice from the cooler.

Either option has drawbacks. I do not generally drive about with a cooler of ice at hand, although when camping I am likely to do so. Instant cold packs are kind of fragile, and you might find, when you go to place one in service, that you have a leaking mess on your hands. On the other hand, they are more likely to be there when you want one.

The foregoing lists the contents of my “jump kit”. I keep one kit in my vehicle, and another at home. In addition, there are Subordinate Kits, kept in camper, car and home, for lesser sorts of occasions. I have customized each by adding more dressings, triangular bandages, roller gauze, and gloves. In addition, I improved over the baseline “Wally World” $15 first aid kit, by adding zip lock bags of various household medications. I labeled each bag with the name of the med, the out date of that particular bottle, directions for use, and date of packing. I made my selections by inspecting my own medicine cabinet, and pondering which meds I had wished I had kept handy the last time I was out camping, for example. Most everything commonly needed is therefore in the Camper Kit, Car Kit, or House Kit.

The jump kits are reserved for “Holy Fertilizer!” sorts of events. They are not mere “boo-boo boxes”. Reserved in this way, I will not find myself hunting (and swearing) in crisis, as I need this or that widget, which some child (or adult) has used, and not restocked.

LONGER TERM CONSIDERATIONS
Some of us might contemplate longer term medical preparations. For those, I recommend Dr. Jane Orient's article. Once I get beyond the 20 year old pricing, the are only a couple of improvements I could suggest. One is in the arena of recently developed antibiotics (as in quinolones). Even in that light, it seems to me to be a very good basis for developing a longer term medical kit (and training plan) for your particular circumstances.

Another substitution I would make, is to delete surgical masks, and substitute NIOSH N-95 masks. I found a carton of MSA Safety Works No. 10005403, Pack of 20 Harmful Dust Respirator Model 10005043 for $18.97/each carton at Home Depot. You may find similar products locally.

Additionally, I would add loratidine (you may recognize the brand of Claritin) as a non-sedating antihistamine. (Personally, I would prefer my personnel pulling OP duty to be non-sedated.) I'd also add the most frugal of the following : ranitidine, famotidine, cimetidine, in lots of 1,000 tabs, as a superior stomach acid blocking medication, to supplement the antacid Dr. Orient suggested over 20 years ago. As the “big gun” for acid stomach problems or GERD, I'd lay in a supply of Prilosec OTC. This class of stomach medication is the yardstick against which all others are presently measured.

If you are planning establishing a longer term medical cache, it is imperative that you do so only in concert with a physician, or other personnel licensed to prescribe. The guidance you will receive will help you avoid causing more illness than you relieve. Medications are a double bitted axe, and may cut on the upstroke as well as on the downstroke. Be aware.


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