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PostPosted: Wed Jul 05, 2017 9:40 am 
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I had a great opportunity recently to test out my multi-tiered medical coverage system, based on the PFC concept of "Ruck, Truck, House, Plane". I spent the last week providing medical coverage for a summer camp, including occupational health, general medical and emergency coverage for 450 campers and 150 staff. Our location was approx thirty minutes from the nearest community ED by ground, with an hour drive to the local level 1 trauma center. Ground services include volunteer EMS (two BLS ambulances) 30 minutes away, with ground ALS not readily available. Roughly 40 mile one way flight to the closest rotor-wing Medivac, which would be used for unstable trauma and burn care. The camp covers more than 200 acres, with water activities (boats, water skiing, inflatables), high ropes/trapeze, climbing, bikes, go-carts, horses, the works. Other than archery no projectiles were used on camp, so no firearms. There are two active construction projects, as well as general maintenance and repairs. There is also a small farm on the property. My facility included an exam/treatment room, bunk for ill campers and staff, and showers for the campers. On site transport included one ATV type vehicle capable of carrying a litter, and a golf cart. Protocols and standing orders had been worked out by an off site MD prior to arrival.

THE PACKING LIST


Ruck

Not wanting to haul everything everywhere, my first line medical bag was a NARP CCRK bag. The purpose of this bag was to give me basic stabilization tools, as well as wound care and basic orthopedics wherever I went. Loaded as follows:
(10) 4x4 gauze
(3) 5x9 ABD
(1) 4x4 Burn Pad
(1) Non-stick eye pad
(1) hydrogel dressing
(2) 5x9 Petroleum gauze
(2) 4" Kerlex
(4) 4" Kling
(20) exam gloves
(1) CAT TQ
(1) 6" ACE
(1) 4" ACE
(1) 2" ACE
(1) Multi-pack cloth band-aids
(1) CPR Mask, BVM compatible
(1) Cravat
(2) 250 ml saline bottles
(2) PVP iodine 1/2 oz bottles
(4) various sized steri-strips
(2) Benzoin ampules
(2) 30 ml Saline bullets
(4) tongue depressors
(2) 2" Cloth medical tape
(1) EMT shears
(1) LED exam flashlight
(1) Adult Epi-pen
(1) Sharpie
(2) 1 qt ziplocks
(1) Tube antibiotic ointment
(1) Mylar blanket
(1) Stethoscope
(1) Notepad
(1) SAM splint
(1) Instant ice pack


Truck

The ATV was loaded for actual medical emergencies. One D size O2 tank, one long board with blocks and straps, the AED, a blanket, laptop (for chart review and documentation), and a STOMP II including:

Bleeding control dressings (4x4, 5x9, 10x12, combat gauze, Kerlex, Kling, CAT's, Burn Sheet)
Chest care (Occlusives and 14 ga Darts)
Instruments (Hemostats, bandage scissors, EMT shears, folding knife, forceps, alligator forceps, #10 blades, #11 blades, magils, tongue blades)
Ortho (ACE, Coban, SAM x2, ACE Collar, collapsible traction splint, cravats, instant ice packs)
Airway/Breathing (NPA kit, OPA kit, Intubation kit, NRB, NC, Adult BVM w/PEEP valve, mini-neb, manual suction)
IV/IO supplies (Saline lock kit x3, IO kit, 500ml NSS, 250 ml NSS, 100 ml NSS)
Meds (Epi, Narcan, D50, Zofran, ASA, Tylenol, Advil, Benadryl (oral and injectable), Immodium, Charcoal, Albuterol, topical lidocaine, Silvadine, oral glucose gel)
Med admin kit (syringes, needles, flushes, sharps shuttle, etc)
Assessment kit (BP cuff, stethoscope, SpO2 meter, Glucometer, exam light, pens, markers, Rite in the rain pad, thermometer)
Basic dental kit
Wound care kit (steristrips, benzoin, 250 ml Saline x2, irrigation syringe, Iodine, CHG scrubs, 2" Silk tape, 3" Trainer's tape)
PPE (Gloves, goggles, hand sanitizer, one trauma kit)

House
Back in the infirmary I hung my SO Tech RAMMP, which rounded out my kit. Along with that we had three additional O2 tanks, spare batteries for everything, large stock of PO OTC's, a second laptop, a stack of blankets and a nebulizer.
Modules were loaded as follows:

PPE
Two quart ziplocks filled with gloves
Sterile gloves x4
Eye Shield

Assessment
UA strips
UHCG kits
ENT kit
Surefire 6p with 600 lumen upgrade
Petzel headlamp
EMT Shears

Bleeding 1
4x4s
5x9s
Combat gauze
Telfa

Bleeding 2
Kling
Kerlex
CATS
Tape

Wound Care
Instrument kit (Hemostats, bandage scissors, forceps, #10 blades, #11 blades)
Sterile Laceration pack
500 ml Saline bottle
Irrigation top
Iodine 4 oz
Steri-strips
Benzoin
2-0 Silk suture

Airway/Breathing
Pedi BVM
NPA's w/lube
14 ga darts

Med's
Epi
Albuterol
Silvadine
Topical lidocaine

Splinting
ACE's (2-6")
Coban 4"
SAM x3

IV/IO
Saline Lock kit x2
500 ml NSS x3

General Purpose
Burn sheet x2
Clean chucks x5
NG tube kit
Foley kit
Bio-wipes
Graduated cylinder
Hand sanitizer
baby wipes
basin

Rear Panel
Recent drug guide
Pre-printed cheat sheets
PFC charts x6
C-Collar

Plane
Plane is a separate consideration from truck, in that it's what would be packed for a medical evacuation. First choice would be the ambulance or Medi-vac flight. In the event that I would have needed to evacuate my own patient, my load out was pre-planned, traveling in a van with the STOMP, the AED, 2-4 O2 tanks (depending on need), and possibly some additional fluid out of the RAMMP.

LESSONS LEARNED

1) Do your homework, and get ready to answer scenario specific questions. When you suddenly find yourself providing medical care for a group, there's a lot of questions that will come up regarding meds, past diagnosis, local resources, etc. I had to scramble for my nearest ED that carried snake anti-venom (thankfully the snake was captured (and released) and didn't have a chance to bite), what our critical evacuation plan looked like when the weather didn't allow for flights, and MSDS info on pool chlorine. That was in my first 48 hours here.

2) References should not just be digital, unless you can provide multiple power sources. A hard copy is very good to have.

3) Cross train and know your resources. I've got a few lifeguards, an EMT, and a nursing student here. All of them have some basic medical/First Aid knowledge, and can be assets in a pinch. They also would be the only personnel immediately available to treat me if I were to get injured.

4) If you are providing medical services to any area bigger than your home, decent communications makes life much easier. If you've got multi-frequency radios, designate a medical channel, but also keep an ear on the main channel. It'll give you a couple minute jump on anything going on around you.

5) I usually preach that your higher levels of preparation should cover everything your lower levels do, and more (IE truck should have all ruck abilities, house should cover everything your truck does). In this case, I wound up packing some unique gear on the vehicle, and augmenting/expanding with the RAMMP in the house. My rational was that this was a completely benign environment, with no chance of losing the ATV to anything shy of a tornado. Any time there was a serious injury, the STOMP was brought into the infirmary to work from. There were more realistic scenarios where I would need the widest capabilities quickly in a remote location than losing the ATV to a flood or lightning strike.


CONCLUSION


So those are the basics. I'd love to hear critique of my chosen load-out, or other methods people have used to provide prolonged medical coverage.


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PostPosted: Wed Jul 05, 2017 11:06 am 
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Wow, thank you for writing this up. I'm pretty sure I need to go back and re-read your post a few times when I get off of work, but some things I was wondering about:

I know that it's always better to have-and-not-need than have-not-and-do-need, but is there anything that you packed or prepared that you ultimately felt was unnecessary? I'm sure with the "truck" or "house" supplies, you may have space to think about, but not worry about weight. For "ruck", was there any weight concern that made you rethink supplies?

Also, do you have any rough stats? How many injuries of what type? What kind and quantity of supplies you've utilized? I've always wondered about how much spare and refill supplies to keep, as I'm sure that is used to refill "ruck" and "truck".

Thank you!


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PostPosted: Fri Jul 07, 2017 12:25 am 
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Thanks for posting.

Couple of questions.

What's your level of licensure?

Whereabouts is the camp located? Just in general terms.

Any environmental issues that determined your gear choices?

Patient count and what sort of treatments did you perform?

Thanks.

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PostPosted: Fri Jul 07, 2017 4:52 pm 
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JohnE wrote:
Thanks for posting.

Couple of questions.

What's your level of licensure?

Whereabouts is the camp located? Just in general terms.

Any environmental issues that determined your gear choices?

Patient count and what sort of treatments did you perform?

Thanks.


My base licensure is RN, with a variety of prehospital, trauma, and emergency medical certs added on.

The camp is in the north eastern US

Environmental considerations would have come in to play far more had it been fall or winter, our average temp was in the 70's. The biggest environmental problem I ran into was an overabundance of mud (producing falls) due to a few days of intermittent rain.

As far as stats, the most prevalent injuries were basic lacerations and abrasions. I would say I saw between 6-12 daily. In the camp environment that meant basic wound care, topical antibiotics, and bandaging. I would estimate one in twenty required followup, to make sure the wound was healing well. I had two smaller suturable wounds, but both presented far outside the closure window, so we treated on site with thorough irrigation, steri-strips, and dressing changes. After that was sprains/strains, between 3-6 per day. The vast majority got ice and rest, but a few ankles wound up wrapped for 24-48 hours, with ibuprofen for pain. Luckily this year I didn't have a single long bone fracture. We did have one dental emergency that required outside intervention, all i did on site was bleeding control and topical analgesic. Speaking to the dentist after, in his absence I could have filled the remaining tooth with dentemp and continued analgesic as needed, but bare minimum he needed some oral antibiotics.

Illness included mostly GI related troubles, either traveler's diarrhea, general nausea, or constipation. I would say about 3-5 per day. Light diet and plenty of oral fluids took care of mostly everyone, I did dose some pepto and immodium to the staff. There were plenty of environmental allergies, and basic ENT issues (sore throat, swimmers ear) about 2-3 per day treated by OTC's including cough drops, chloraseptic spray, decongestant, and ear drops.

I had a lot of foot care to perform this year, including ingrown toenails left for weeks and unattended to blisters that got way out of hand. I don't usually carry epsom salts, but I found a cocktail of salt, iodine, and warm water helped in all cases but one, and that patient wound up being sent out to a higher level of care. In all other cases, having the wounds regularly soaked and cared for allowed me to either trim away the offending nail, or gave the blisters time to heal. I would definitely add a bag of salt to my RAMMP kit next year, I was lucky there was some left over from last year in the med tote.

norcalprep wrote:
Wow, thank you for writing this up. I'm pretty sure I need to go back and re-read your post a few times when I get off of work, but some things I was wondering about:

I know that it's always better to have-and-not-need than have-not-and-do-need, but is there anything that you packed or prepared that you ultimately felt was unnecessary? I'm sure with the "truck" or "house" supplies, you may have space to think about, but not worry about weight. For "ruck", was there any weight concern that made you rethink supplies?

Also, do you have any rough stats? How many injuries of what type? What kind and quantity of supplies you've utilized? I've always wondered about how much spare and refill supplies to keep, as I'm sure that is used to refill "ruck" and "truck".

Thank you!


Interesting question, regarding worth vs weight/space. There were a few items in my RAMMP that are far fetched, but in a critical care setting are going to be absolutely necessary (NG tube, foley cath kit.) Same with the intubation kit in the STOMP. As far as my bag goes, the CCRK is small, a little bigger than a regulation football. The only thing I regularly swap out in it is one of the 250 ml irrigation bottles for a small plano tackle box with meds. I didn't in this case, because I had meds available on the ATV and in the exam room.

As far as injury rates, see my reply above. Things I used plenty of were 4x4's, various sized bandaids, ibuprofen, 4" ACE wrap, and iodine


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PostPosted: Fri Jul 07, 2017 6:17 pm 
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Thanks for the informative post and reply.

Forgot to ask, "saline bullets"?

Eye wash?

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PostPosted: Fri Jul 07, 2017 8:41 pm 
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Yep, those little 30ml saline squeeze bottles, good for washing dirt out of eyes, simple wounds, things like that.


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PostPosted: Thu Jul 20, 2017 2:57 am 
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Good job. Good job. A couple small things. Your lucky you had no language barriers. Also, next time you need names, POC's, and contact numbers, is even go and meet those people .....and as soon as I got there I'd start looking for someone there that could be my backup in case I got hurt. Your medical threat analysis has to be more detailed to even include environmental hazards..... and I don't carry any heavy crap any more most of that crap is in the vehicle. I have a recon mountaineer I use as my primary. The biggest I would go with would be an M9. I remember meeting this other medic on the contact line in the mine fields. It was about A half mile wide these e. Every weapon and sniper within miles was trained on us. I just had my M9 bag, he had brought everything issued. I mean his pack weighed on 110lbs. I do always carry stuff on my belt here and make everyone carry some of the medical gear. I'm not strapping an Israeli stretcher to my carry shit, that's for fucking sure.


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PostPosted: Thu Jul 20, 2017 5:44 am 
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The ambulance service I'm with (Queensland Ambulance Service) is going away from the response kit that has everything, our new response kit has the drugs, diagnostic and that's all. all the bandages, trauma supplies, airways, oxygen are in individual bags, meaning for the average job we take less stuff in now

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PostPosted: Mon Jul 24, 2017 8:55 am 
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IANMCDEVITT wrote:
Good job. Good job. A couple small things. Your lucky you had no language barriers. Also, next time you need names, POC's, and contact numbers, is even go and meet those people .....and as soon as I got there I'd start looking for someone there that could be my backup in case I got hurt. Your medical threat analysis has to be more detailed to even include environmental hazards..... and I don't carry any heavy crap any more most of that crap is in the vehicle. I have a recon mountaineer I use as my primary. The biggest I would go with would be an M9. I remember meeting this other medic on the contact line in the mine fields. It was about A half mile wide these e. Every weapon and sniper within miles was trained on us. I just had my M9 bag, he had brought everything issued. I mean his pack weighed on 110lbs. I do always carry stuff on my belt here and make everyone carry some of the medical gear. I'm not strapping an Israeli stretcher to my carry shit, that's for fucking sure.


taipan821 wrote:
The ambulance service I'm with (Queensland Ambulance Service) is going away from the response kit that has everything, our new response kit has the drugs, diagnostic and that's all. all the bandages, trauma supplies, airways, oxygen are in individual bags, meaning for the average job we take less stuff in now


Thanks guys. Ian, you make a great point. If I was planning on any more time there, reaching out and meeting my local medical assets would have been key. I agree, my NARP waist pack is as big as I would go for 24/7 carry. I would say, in the grand theme of the board, that lighter EDC medical kits supplemented by modular specialty kits are a legitimate organizational system. There's a good PJ medcast about stocking separate burn kits, due to the need for high volume fluids and meds in the PFC environment. Something similar could be done on the personal level for trauma, medical/sick call, orthopedics, transport, rescue, etc.

EDIT TO ADD: Based on the aforementioned podcast, I'd choose to swap out 1-2 of the NSS bags in the RAMMP for LR or Plasmalyte, for cases of burn resuscitation.


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PostPosted: Tue Jul 25, 2017 11:34 am 
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Thanks for your post, and information. One thought I have in terms of preparing is knowing if someone, and who, will be in the primary role of doc. Suffice it to say that this is how I was brought up. Self-aid and buddy aid, including level of training and type of equipment are crucial to staying, well, viable; however, it is always better to have other levels to count on, like an RN or corpsman/medic. The more/better the individual can be trained to, the better -make no mistake. However, it's nice to have a medical expert on the team or nearby.

For this reason, I find it easier to read and understand when someone on the forum adds their level of cert/knowledge.
RN for instance. Thanks.

Most medical posts or info about FAKs, for instance, pertain to self-aid and buddy-aid.

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PostPosted: Wed Jul 26, 2017 11:42 am 
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Asymetryczna wrote:
Thanks for your post, and information. One thought I have in terms of preparing is knowing if someone, and who, will be in the primary role of doc. Suffice it to say that this is how I was brought up. Self-aid and buddy aid, including level of training and type of equipment are crucial to staying, well, viable; however, it is always better to have other levels to count on, like an RN or corpsman/medic. The more/better the individual can be trained to, the better -make no mistake. However, it's nice to have a medical expert on the team or nearby.

For this reason, I find it easier to read and understand when someone on the forum adds their level of cert/knowledge.
RN for instance. Thanks.

Most medical posts or info about FAKs, for instance, pertain to self-aid and buddy-aid.

No Problem, glad to share. I have found myself to be a medical resource for many, many friends, neighbors, and acquaintances, and I only see a regional disaster or emergency increasing that role.


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