Interested to note in your original post that you carry a 14 g Cannula - what are your anticipated uses for this? Relief of Tension Pneumothorax?, Deep irrigation of wound beds?
I notice also that you no longer carry IV fluids (!) - have seen a couple of interesting reports on PR rehydration therapy using improvised equipment - any thoughts?

Other stuff I carry - two most common sizes of Guedel airway, i justify these with the view that in someone with decreased GCS, they greatly simplify the potential airway management issues, again, any thoughts?

I am, among other things, an army surgeon. I am thus also tempted to bring a lot of stuff with me in my medical kit (if nothing else, it is a hell of a lot easier for me to stock narcotics) but I do try to restrain myself. I manage to do without a needle driver and 3-0 silk, as much as it makes me feel naked.

A 5x9? That's rather large, isn't it? I guess someone might get an open fracture or something, but then you're likely to improvise a dressing out of clothing, anyway. Such a wound would certainly justify ruining your $80 jacket. By far most wounds on the trail are tiny, and just need a 2x2, but a 4x4 (as you have) is more versatile and can be cut down to size. I carry real gauze because it is more versatile than those fake-gauze dressing sponges.

CPR barrier? Well, as you say it is very light... But it is also low liklihood of use, and probably not realistic to expect a save if you are far from an AED. Well, maybe my view is skewed a bit, as most of my codes are traumas not cardiac. Your call. But I'd say just keep your immunizations up to date (especially hepatitis) and know your hiking partners.

Quik Clot?!? Where are you hikng? Iraq? I'd wager that on the trail a massively bleeding wound to something that won't take a touriquet (trivial to improvise) is rare. I guess you just have to do your own risk-assessment, though. And even then I'd recommend one of the chitin dressings (such as HemCon) over Quik Clot. HemCon's are expensive as hell, but you are much less likely to injure the patient than you are with Quik Clot. Quik Clot is VERY exothermic. (And a pain in the a$$ for the surgeon to remove later...)

Conceivably you could do with one pair of gloves. Make the assumption that if you need more than one it will be treating the same injured guy until you can get him to safety, store the one pair in a ziplock (that you brought food or something else in) and reuse it. It is for your protection, after all, not his.

It is low likelihood of being needed, but I carry a 14g, too. It is lightweight insurance against tension pneumothorax if anyone takes a fall, and can be lifesaving. I'd hate to lose anyone to something that easily fixable.

Alcohol AND iodine? If you use an alcohol stove you can do without either, and just use your stove fuel. (This was a nontrivial influence on my choice of stove design.) Or use Purell, if you carry it. Purell is also a handy emergency firestarter...

For multi-use antibiotics amoxacillin is a pretty good one. Many will work. Fluroquinolones are handy, too. Just pick a favorite, and try to tailor it to your location. If you are going someplace exotic I find that the Infectious Disease fleas can be amazingly helpful, and actually quite interested. (Mefloquine Mondays, anyone?)

I keep telling myself to remember "I am not a walking tertiary care center." In the field I do not have an obligation to provide definitive care. I just have to get them to EMS alive.

That said, if I am to be the "medical guy" for a large group of people I don't know very well I tend to bring a LOT more stuff. E.g., anyone who needs an epi-pen should be responsible enough to bring his own and attach it to his pack strap where others can see it, but there are a lot of idiots out there. In such groups I also tend to bring aspirin for AMIs. (Otherwise I bring only 800mg Ibuprofens and 650mg Acetaminophens, so I can double-dose and walk out on a sprained ankle if I must. In truly remote areas I bring a couple of Percocet, for the same reason.) I haven't yet brought my own nitroglycerine, but I always think about it, and I might if I was in a large group in a very remote part of the world. Then I could at least give half of MONA therapy. Hmm, would Percocet count as "M", and let me give 3/4? I'll have to look that up.

Again, my world view is colored by my experience, so I tend to think of trauma. There are several injuries that will kill you quickly, but that are easily treatable in a trauma bay. (Emphasis on "in a trauma bay.") Various lists exist, the "7 Killers", the "Deadly Half-Dozen", etc. I'm sure that you have been taught to think of them. Forgive me if my list differs from yours, but I'm trained to think about these things differently than you, so I haven't looked this up in a while:

Exsanguination
Airway Obstruction
Cardiac Tamponade
Open Pneumothorax
Tension Pneumothorax
Hemothorax
Flail Chest

Exsanguination: This is your Quik Clot or HemCon. I maintain that they are low-utility, and improvising a tourniquet is all you have to know. For a solid viscus injury or other internal bleeding, activate the EPIRB and pray. Have you been taught permissive hypotension, or are you an old-school IV fluid guy? I'd recommend learning permissive hypotension for field medicine. For a pelvic fracture, sheet the pelvis. This is another injury that justifies ruining your $80 jacket.

Airway Obstruction: The knife on my Leatherman Micra is damned sharp, and I have hydration tubing, for my crichothyroidotomy That's the best that I think I can do without hauling a code cart with me.

Cardiac Tamponade and Tension Pneumothorax: There is no body cavity that cannot be reached with an 14g and a good strong arm. I would not recommend that the laity try to do a Pericardiocentesis, but I would sure give it a try as a last resort. Any monkey can learn to do a Needle Thoracostomy just by googling it. (Diagnosing the tension pneumothorax, on the other hand, is a little tricker for a layman.) See, that 14g is multi-use! :-)

Open Pneumothorax: Some tape and almost any reasonably flexible piece of plastic can improvise an occlusive dressing, or better yet a semiocclusive dressing with a flutter valve. So, leave the labels on your water bottle. Or use the cellophane from a pack of cigarettes. I wonder if silnylon is airtight enough to work? Tyvek certainly is.

Hemothorax: Hmm. EPIRB and prayer, again? I guess if I was sure of my diagnosis I always have that knife and hydration tubing to improvise a Tube Thoracostomy, but I wouldn't recommend it to the laity. Who cares about the resulting empyema if you can save his life? Some jackass might decide to sue you, though, so he'd have to be nearly dead before I'd do this. Improvise a Heimlich valve from the finger of your glove.

Flail Chest: Definitely EPIRB and prayer. Usually these are caused by MVAs, and the only wilderness scenario I can come up with is a long fall. In such a case you will probably have more pressing problems than the flail chest. There are those who advocate wrapping the chest, but this really doesn't work and causes a lot of pain, thus leading to splinting and even worse oxygenation.

Another thing you will see on some lists is a Subdural or Epidural Hematoma, but I really can't think of a realistic way to do a burrhole in the field. Nobody really does them in trauma bays, either, for that matter. The neurosurgeons can get them into the OR pretty quick. I guess if I was on-call in some sleepy rural hospital with the nearest neurosurgeon hundreds of miles away I'd give it a shot. I know approxmately where to stick the Black & Decker, after all, and he's going to die anyway, right? But the weather would have to be REALLY bad to preclude a helicopter flight...

Edited by acrosome on 06/30/2008 12:48:18 MDT.

personally, i wouldn't use over the counter superglue on a wound ever - massive skin irritation and death of surrounding skin can be expected. the stuff they use in the ER is different. plus chances are in the woods i wouldn't get it clean enough and the docs would have to remove it when i got home anyway. duct tape or butterflies for me please.

Ian,

I'm not familiar with PR Rehydration, but if you're using the abrieviation "PR" in the context that I'm familiar with then wouldn't that resemble an enema! I'll research it though. If it's valid that means I could deliver up to 3 liters of fluid to a patient... and then buy a new hydration pack.

The IV fluids were before I considered going light,

By Guedel airway, are you refering to a nasalpharyngeal airway (NPA)? Just wondering, not familiar with that brand name.

Wow Dr. Fellabaum! Thanks!

Well, first of all, yes, I admit that I CARRIED the 14g cath for a tension pneumo and could use the finger of a glove for a Heimlich valve. I think I could easily diagnose one in the wilderness, even without a set of ears. Even so, I've come to realize that a long fall would be the most likely cause of a tension pneumo and am probally doing away with this, because prevention is the best medicine and hopefully I won't come across any of those idiots you mentioned. Hey, I guess you never know who you'll come across though. I'd be a little freaked about attempting a Pericardiocentesis in the wilderness. For a street medic that may be a once or twice a career procedure and I'd tend to think it would be a tough diagnosis in the wilderness. But your focus is obviously trauma surgery, mine is to get them to the trauma surgeon.

The quick clot is gone from my list... I'm still a fan of 5 x 9s, just because I know they work and I like my jacket;) I also like the idea of something clean on the wound, at least as a first layer, over a dirty pair of socks. I know the wound will get irrigated and all of that good stuff at the ER anyway, but that's just me.

I also agree that any plastic packaging would work for an occlusive dressing, just in case you're mistaken for a deer!

Alcohol pads- gone.

CPR Barrier- eehh.. I guess a 4x4 would keep the big chunks 'o puke out of your mouth. Mmmm... tasty!

I'm not familiar with permissive hypotension. I've been trained to dump fluid to keep 'em at least 100 systolic or until their blood turns into pink Kool-Aid, which ever comes first.

Thanks again, Doc! You have a lot of info to share, and I'd love to talk about it more but I think we're starting to loose the audience here! Feel free to PM me though.

Take care, and thank you for your service to Our Country.

Edited by ekim765 on 07/05/2008 23:06:56 MDT.

Isn't QuickClot toxic?

I don't know that it is toxic. As Dean had mentioned, it has a nasty exothermic reaction. So, I'm guessing it has been known to cause burns or tissue damage around the wound. He also mentioned that it was a pain in the butt for the surgeon to remove at the OR.

www.z-medica.com/quikclot/index.asp

The bandage that I had was called the QuickClot Sport. The website boasts that it has a cooler, less exothermic reaction (105 F max) and it is contained within a surgical sponge. Of course, this is coming from their wedsite and the do have a product to sell, so take it for what it's worth. The original QuickClot is packaged in a powder form and is meant to be poured directly on to the wound. Maybe this is what Dean was refering to. I could see where that would be a hassle to remove later.

The USMC had reported that QuickClot was either blown away or would not come in contact with the wound during arterial sprays. Sounds like they are refering to the power form here. www.defensetech.org/archives/000458.html. Not sure which form the Military is using.

Dean?

Edited by ekim765 on 07/04/2008 09:56:51 MDT.

Hey-
Love the conversation so far! Thought I'd throw in my cent. I'm a former ski patroller, SAR member, W-EMT, paramedic. (I got off the street, and I'm living in a horrible place right now for the wilderness aspects.)

I struggle at paring my kit down, too. Frankly, I haven't had the heart to weigh it recently. Guess I'll have to when I get home. Many of my trips are 10 days+, and I tend to bring a little extra.

There was a question or two about 5x9s. The most common reason I've seen for needing them "out there" is for knife or wood-cutting slips. Whittling, cut through stick, run knife through leg... On non-weight-conscious travels, a bad coincidence of foot and ax... I've just been taking along a maxipad for major bleeds.

I've always got a couple bandanas for headwear, pot gripper, etc., which do nice double duty as sling/swath, compression wrap, tourniquet, and so forth.

Assorted band aids (esp. knuckle/fingertip). Superglue! Plenty of Benadryl, ibuprofen. Iodine wipes. Usually have some whisky along--hey, it's double-duty! I've taken the "nip a corner off a ziploc" route for irrigation, snagged from my food bag.

Duct tape from the repair kit for... whatever. The heaviest two things are probably an Ace wrap and a partial roll of Coban. (Figuring sprains are usually about the worst I'll face.) The friend I'm normally with is diabetic, so there's usually some form of glucose in the kit.

I've always got one of those tiny space blankets for emergency thermowrap, signalling. Oh, and yes, a 14G.

Aloksaks are great. I really like the Equinox tripper travel bag organizer, though. It weighs 1.6 ounces, and I use it to organize compass, whistle, and all those other random miscellany things along w/first aid stuff.

I have to say that I'm a little suprised (maybe relieved) that I found company in those carrying a 14g. To think, I thought I was just being overly prepared. I suppose the weight of it is trivial if you know why you carry it and how to use it. As Dean mentioned, a tension pneumo, which can obviously be fatal, is easy to treat.

I'm going to have to seriously look at this 5x9 thing since that seems to be an item I've seen come under some scrutiny since I started this post. After all, I too carry a bandana and a pair of clean(er) sleep socks.

Is that maxie pad with or without those little wings? ;)

BTW... I'm partial to Southern Comfort myself... makes my belly warm.

Agree with the nontoxic but otherwise annoying properties of QuikClot. The military version is indeed a powder, but I haven't seen it in a while. We are issuing HemCon bandages to every soldier now, so that if you come across a wounded soldier you just pull his own bandage out of his kit and use it. (On a more morbid note, during Desert Storm I was issued my own body bag, and had to carry it around...)

Brad,
Do you really need an ace-wrap AND Co-Ban? Both will give compression, and the Co-Ban is lighter, if not as durable and not as re-usable.

PR (rectal) rehydration is a well-established technique, and doesn't require sterile IV fluid, though the water should at least be potable. And, yes, it does work just like an enema- the colon is a very efficient water scavenger. (I can't remember how quickly you can give it, but I sure wouldn't dump 3L in at once.) The technique is still taught to military medics, for use in tight situations where they have run out of fluid or angiocaths or whatever. The patient has to be conscious enough to make the effort to retain the fluid, though. Historically it was used a lot in children, who would then have their buttocks taped together. Nowadays we tend to do intraosseous infusions.

[Some medical advice removed, at the recommendation of counsel... :-) ]

I emphasize that everyone makes their own choices, especially in the UL community. As I said, I really have to restrain myself sometimes (before I discovered UL I used to carry an army Field Surgical Kit) and I'm trying to help other enthusiastic would-be wilderness savoirs to do the same. Mike, if the 5x9 works for you, keep it. Hell, I carry a huge, clunky Suunto MC-2 compass because, for me, orienteering is half the fun, and I want a precision instrument. And, as I said, if I'm the "medical guy" for a group I still tend to go overboard. I might even bring ABD pads, let alone a 5x9.

Yeah, the pericardiocentesis is something that doesn't get tried until the patient has died at least once and you haven't got anything to lose. Unless, of course, you have an ultrasound and you see the hemopericardium on the FAST exam- in which case, go for it. (For those who care, FAST stands for Focused Abdominal Sonography for Trauma, and includes a look upwards at the pericardium.)

The kind of cyanoacrylate used most commonly for medical purposes (i.e. Dermabond) is indeed different from plain superglue. It is a high-viscosity formula that you can apply in several layers to make a thick coating over a wound. The resulting cap is sort of rubbery. Normal superglue- and a few cheaper medical formulations- are almost the same viscosity as water. Side-note: don't get superglue on cotton- it causes an exothermic reaction that can start a fire. Voice of experience, there...

I'm sure that others have heard of www.wilderness-medicine.com ? I have never taken one of their courses, not least because they are geared more toward EMS and SAR than physicians, but they sound interesting. I also went to a rather unique medical school that issued me a great book called Wilderness Medicine, that has over 1500 pages and weighs approximately 7.2 tons. Mine is an older edition, but see:

http://www.amazon.com/Wilderness-Medicine-5th-Paul-Auerbach/
dp/0323032281/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1215334254&sr=8-1

I split the URL for justification reasons, so you'll have to cut and paste the two halves. Sorry. Apparently the new edition is over 2300 pages!

It is NOT a book for laymen, and it is expensive, but if anyone here has some medical training and enough of an interest it's a great book. It isn't just about practicing medicine in austere environments- it also describes appropriate hospital treatment for injuries that are peculiar to wilderness, like frostbite, envenomation, plant toxicity, altitude sickness, and dysbarism. And it also has a chapter on surviving wildfires, and one on natural disaster management. There is a WHOLE CHAPTER on wilderness medical equipment, and the justifications for bringing each item, including antibiotics.

I've heard of using maxi-pads as dressings before, so don't hesitate to ask any women in your hiking group if you find that you need one. (And many are self-adherent!) For that matter, I've heard of using tampons to pack bad nosebleeds and gunshot wounds, too. No kidding. It has to be uncomfortable, though.

Edited by acrosome on 07/06/2008 04:23:17 MDT.

My kit weighs 2 oz. Since 95% of my hiking is done solo I carry what I can administer to myself. Butterfly strips, antibiotic ointment, Benadryl, some Moleskin along with a tiny half roll of medical duct tape. As an EMT with many decades of experience I depend upon being able to adapt for emergencies, and realize that in a time of severe trauma it is basically impossible to treat oneself. Some deep cuts and gouges haven't been a significant problem, but shredding a meniscus during an isolated winter hike while days from anywhere was.... but a ten pound kit wouldn't have helped much.

As a mental exercise, i have thought more about the Co-Ban. You can tape an ankle with duct tape, though probably not as easily, and it is much more multi-purpose than Co-Ban or ace. So, just take a little more duct tape.

Of course, this is coming froam a guy who carries a 14g angiocath...

Also, the Medipore tape deserves special mention. (Also called Hypafix, or Mefix.) It is a "fluffy" porous surgical tape that:

A) can be used like any other medical tape
B) can be used as second-string moleskin
C) makes a decent burn dressing by itself

But, of course, it still isn't as multi-purpose as duct tape. Still, I would bring some if I was the 'medical guy' for a large group.

Dean,
I've really enjoyed your insight and expertise here. The Co-Ban thing, I dunno, guess it's just a hang-up for me so far. Ultimately, I like the stuff a lot better than ace wrap. But if I'm on an extended trip, the Co-Ban just wouldn't hold up to repeated on/off for soaking in cold water or whatever, whereas Ace excels. I've found that the Co-Ban works great for actually keeping small "dressings" in place on weird curved places or some articulations. My brain's a bit fuzzy on the name right now, but I think there's either a micro-pore or derma-pore I've used as a great tape for holding in less-than-ideal conditions, but... it is extra weight. One other reason I've carried it in the past was for taping bum ankles and such.

You've got me thinking now. Perhaps this is purely academic, but could using duct tape to tape ankles lead to circulation/perfusion problems? What I'm thinking is that over the course of a day's hiking, feet tend to swell up decently. Ace wrap can expand with that swelling. Tape can't. For sports like B-ball or soccer, the ankle might only be taped a couple hours. I'm approaching this primarily from more of a multi-week trip perspective where there's not really a choice of extrication or backtracking a day. What do you think? Problematic or not?

Ohhhhh... Ouch. When I played soccer, my ankles usually got wrapped with pre-wrap first. My trainer got tired of doing that, and started taping onto the top inch or two of leg hair to encourage me to shave. So maybe ankle-type taping should include a razor of some kind?! :-)

FDA Requests Boxed Warnings on Fluoroquinolone Antimicrobial Drugs

The U.S. Food and Drug Administration (FDA) has notified manufacturers of fluoroquinolone antimicrobial drugs that a Boxed Warning in the product labeling concerning the increased risk of tendinitis and tendon rupture is necessary. Through its new authority under the Food and Drug Administration Amendments Act of 2007 (FDAAA), the agency also determined that it is necessary for manufacturers of the drugs to provide a Medication Guide to patients about possible side effects.

The risk of developing fluoroquinolone-associated tendinitis and tendon rupture is further increased in people older than 60, in those taking corticosteroid drugs, and in kidney, heart, and lung transplant recipients. Patients experiencing pain, swelling, inflammation of a tendon or tendon rupture should be advised to stop taking their fluoroquinolone medication and to contact their health care professional promptly about changing their antimicrobial therapy. Patients should also avoid exercise and using the affected area at the first sign of tendon pain, swelling, or inflammation.

The medications involved in this action are: Cipro and generic ciprofloxacin, Cipro XR and Proquin XR (ciprofloxacin extended release), Factive (gemifloxacin), Levaquin (levofloxacin), Avelox (moxifloxacin), Noroxin (norfloxacin), and Floxin and generic ofloxacin.

Edited by jshann on 07/31/2008 08:57:25 MDT.

I can't tell if you are merely being informative, John, of if you are arguing against fluoroquinolones.

Yeah, that announcement was met with a gigantic yawn by the medical establishment. It's an adverse effect that has been known for a very long time. But EVERY medication has adverse effects- you just have to be aware of them and make educated risk assessments. (Which, arguably, is my entire job.) And fluoroquinolones are probably, as a group, one of the most-used antibiotics at the moment. (Total guess, that, but they are used A LOT.) And most of the tendon ruptures were after taking the drug for weeks.

Fluoroquinolones are great drugs, broad-spectrum, and safe. Don't let the new warning mislead you.

Edited by acrosome on 07/12/2008 11:57:24 MDT.

> Yeah, that announcement was met with a gigantic yawn by the medical establishment. It's an adverse effect that has been known for a very long time.
True, but the Boxed Warning on the packet is a different matter.
Haven't you noticed that many pharmacists stick a large adhesive label over the technical information on the packet, thereby preventing the consumer (the patient) from reading the data? It is almost as though the medical system is telling the the consumer to shut his eyes and just do what he is told.

What we need is a new law banning the obscuring of the tech data on the packet, so the consumer can be more educated. Won't solve all the problem, but it might help a bit.

Dean, hopefully you don't claim to speak for the U.S. medical establishment since you don't live here. Europe can ignore whatever warnings they want to. I tend to respect the US FDA when they speak since I got my M.D. degree in this country.

Cipro is a common antibiotic taken on backpacks. If I was over 60, I'd consider taking something different with that information. As always, the older members of this group should talk to their own physicians about it.

In this country, if you were to prescribe that to a susceptible person after a warning goes out and they incapacitated themselves on the trail or worse, you could have some splaining to do to the local judge if/when they filed a lawsuit.

Edited by jshann on 07/13/2008 04:40:58 MDT.

While I don't presume to speak for Dean I think the point he was trying to make is that while it has now been established that there is an accrued risk associated with fluoroqinolones this had already been suspected. Moreover, it's really in when you use them. Sometimes the risk is worth it, some times it isn't. As doctors it's your job to figure that out for the patient which, most of the time, doesn't know anything about these risks, let alone how to weight the risks.

I would tend to agree that giving anything that could weaken tendons to a person over 60 that is going backpacking is a bad idea. However, giving the exact same thing to a 30 year old 9-5 working stiff that commutes from home and doesn't do much of anything might be the best choice.

Also, to my knowledge, in most countries if you prescribe something to someone and they hurt themselves because of it you, as a doctor, are liable. Not just in the US. Even in Europe. :P

As for the technical data obscuring ban, I would tend to agree. Technical data is important and consumers should be able to clearly see it. If not, why print it in the first place? Problem with that is there are boxes where there is nowhere else to place the label. In this case pamphlets in the box are the best solution. IMHO, IANAL, etc., etc., ad nauseam.

Edited by ahugenerd on 07/15/2008 08:08:54 MDT.

I don't think I saw these mentioned and I carry the ones from a Swiss Army Knife (but not the knife)and have used them for splinters and would think for some debris in a wound.

Do any of the rest of you think these are important and if not, how would (do) you remove splinters?

I agree that tweezers are important. My tweezers are part of my Leatherman micro tool. At 1.7 oz I get a lot of use for the weight. Wouldn't leave home without it!

Micro tool includes:
scissors
tweezers
knife (1.5")
nail file
bottle opener
screwdriver standard
screwdriver for glasses
screwdriver phillips

Other first aid items included
ibuprophen
imodium
anti-gas
assorted bandages
neosporin
insect repellent
sandwich bag for irrigation
duct tape for wrapping sprains
hydrocortizone

Edited by mad777 on 07/29/2008 16:13:53 MDT.

Bob,

At my age I need a magnifying glass to make tweezers work. My compass has the magnifying glass and the Buck 350 pliers work for things like cactus needles. The Buck 350 also has tweezers for splinters and I carry a needle in my repair kit.

I do not build fires and none of my gear is wooden. It has been year since I had a splinter.

I have no idea while Buck quit making the 350.