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Thread: RAWTWM Med kit

  1. #1
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    RAWTWM Med kit

    I keep hearing about a "med kit" that "experienced remote providers" discuss. It's a niche kit, as it's contents place it way beyond first aid, it's not an EMS bag, and I would argue that most providers would miss it's utility. It is the base kit, that is your grab and go, that is always in your bag, that you add modules to, depending. Thoughts?
    Last edited by James Huffaker; 03-11-17 at 07:45.

  2. #2
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    This is the approach I use.

    Have a core med bag that can deal with most emergencies and then add modules based on risk, population size, conditions, amount of space I have, treatment mandate. These modules can include advanced medications, advanced wound management, surgical, OB, peds, infectious diseases, dental, etc, etc, Everything is built off the core.

    No matter what happens I can still fall back on the core bag to manage crisis in my team or others and wait for the required supplies to show up / get to the required supplies. It is size of a standard backpack med bag.

    AN

  3. #3
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    Thank you, care to elaborate on the specifics?

  4. #4
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    This is the kit I have carried for being able to manage emergencies / take a first look and decide if I need to refer someone to my walk-in clinic (or dig out my clinic bag/kit or some other specialty kit).

    It has been revised and and revised again after years of use... but I am always open to comments. I have had pretty good luck with this set-up (knock on wood). Quantities vary based on requirement / threat so I have not included them.

    Diagnostic:

    Gloves
    Antiseptic hand cleaner
    Pulse oximeter
    Stethoscope
    BP cuff
    Headlamp
    Penlight
    Trauma Sheers
    Glucometer Kit
    Fluorescein stain strips
    Cobalt blue penlight filter

    Airway / Breathing:

    Oral airway set
    Nasal airway set
    Water based lubricant
    Bag valve mask
    Manual suction
    Supraglottic airways
    Tape
    Cricothyroidotomy kit
    Transtracheal block kit
    Needles for needle decompression
    Chest seal
    Laryngoscope complete with blades / batteries / spare bulb
    Magill forceps

    Fluids:

    IV starter kit
    IV catheters
    Saline lock
    0.9% Normal Saline flush
    IV tubing
    0.9% Normal Saline – 500 mL bag
    Dextrose 10% in Water – 250 mL bag
    IO Kit

    Other:

    Foley catheter
    Foley catheter bag
    Rescue blanket

    Trauma:

    Pressure dressings
    Abdominal pad
    Gauze Pad
    Gauze roller
    Tape
    Triangular bandages
    CAT Tourniquet
    1-0 silk on needle
    10 shot stapler
    Combat gauze
    Pelvic binder
    Folding traction splint
    SAM splint
    Cervical collar
    Eye pads

    Medication Administration:

    1 cc syringe
    3 cc syringe
    10 cc syringe
    IM needles
    SC needles

    Medications:


    Oral: ASA 81 mg
    Sublingual: Nitroglycerin Spray 0.4 mg
    Oral: Ondansetron 8 mg
    Injectable: Ondansetron 2mg/mL – 2 mL vial
    MDI: Albuterol 100 mcg
    MDI: Ipratropium bromide 18 mcg
    Injectable: Epinephrine 1:1000 1 mg/mL – 1 mg vial
    Injectable: Dexamethasone 4mg/mL – 20 mg vial
    Oral: Diphenhydramine 25 mg
    Injectable: Diphenhydramine 50 mg/mL – 1 mL vial
    Oral: Ibuprophen 200 mg
    Oral: Ibuprophen 800 mg
    Oral: Acetaminophen 325 mg
    Oral: Acetaminophen 500 mg
    Oral: Fentanyl 800 mcg lozenge
    Injectable: Morphine 10mg/ mL - 1 mL vial
    Injectable: Naloxone 0.4mg/mL – 1 mL vial
    Injectable: Midazolam 1mg/mL – 10 mL vial
    Injectable: Ketamine 50mg/mL – 10 mL vial
    Ocular: Tetracaine 1% minim
    Oral: Moxifloxacin: 400 mg
    Injectable: Clindamycin 150 mg/mL – 6 mL vial
    Injectable: Cefoxitin 1g vial
    Injectable: Haloperidol 5mg/mL – 1 mL vial
    Oral: Liquid Glucose Gel – 15g tube
    Injectable: Glucagon - 1 mg vial
    Injectable: Tranexamic Acid - 1 g vial
    Injectable: Lidocaine 1% - 10mL vial
    Injectable: Lidocaine 2 with epinephrine - 20mL vial

    Let me know if you have any questions.

    AN

  5. #5
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    Thank you!

    "Austere Nurse" How do you carry/use the above CONUS? RN, NP? Reason I ask is that I couldn't (RN), without scripts, a willing provider to write them and standing orders, or contacting a ER attending that don't know me from a whole, and generally won't order said every time I need something. How do you do what you do?

  6. #6
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    I generally leave the kit packed in my "supplies room" at home with the controlled substances in my safe. When I go into remote areas (where EMS / hospitals are not a reasonable option) I bring it along. I do not carry it in the car routinely as I have no requirement. I am cautious when I take it outside the country, often opting to link up with the pharmaceuticals in the location where I am going. I never cross international borders with scheduled substances.

    I am an ACNP, although in the US I am doing very little bedside care (enough to retain RAWTHM competencies / license). I do most of my clinical work outside of CONUS in the developing world, although I now seem to do less of this also given the leadership role I have found myself in recently. I have a number of friends / people I work with professionally that are MD / ACNP / PA / Pharmacists, so supply has never really been a problem. I get that this is unique to me and I do RAWTHM for a living.

    The problem is the controlled substances above. I have had someone else write an Rx for me for these items, despite the fact that I can write for most of them. It is just easier to explain to a police officer that is rooting though your med bag / specialty kit on the side of the road that a MD wrote you an Rx and here is the letter of explanation versus, "yeah... I am an NP, here is my license, and wrote this scripts as emergency dispensing stock". All are recorded / filed in my state electronic pharmacy records system. The one issue is Actiq. It is a pain to get due to the TIRF REMS process. The value of acquisition pain versus clinical use has become questionable in CONUS, although it is an excellent patient-administered analgesic that I have had excellent luck with (despite being used off label, which is part of the problem).

    Use... if I need to use it, I will use it... especially on my family and close friends. Especially in a disaster man-made or natural. Especially in a remote / wilderness area. Not sure of all the legal issues with this, especially if I am out of the state where licensed (although I am sure there are a number of them if you ask any lawyer). I do not market myself in a professional care capacity in these situations, less sometimes where I do wilderness medicine work in which case I take out additional insurance and ensure that I have the appropriate temp licenses to practice in the jurisdiction where I am working.

    I am not the expert on "how do you get stuff" and would be hesitant to offer dodgy advice in a public forum. I think there are other people here who are far more skilled on these matters, especially when it comes to getting stuff from Mexico. I also expect you have exposure in your work place, although I would never advocate small-scale diversion from an employer. I will tell you that I have never had a problem getting anything (including scheduled medications) in the developing world if I had money and the supply chain existed. In CONUS I think that you would have to know a prescribing clinician well to get them to write an Rx for controlled substances, especially injectables. I think that for many of the other medications it would not be that big a problem, if they know and trust your skills and are like minded. Likely easier with your RN credentials as you have known baseline skills and professional body licensure. I suspect you can get all of the equipment with little drama given the Internet.

    Let me know if you have any questions.

    AN

  7. #7
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    Thank you.

    End of the day, your golden words as far as practice was ACNP. Either that or PA, though they need to sort out their independent practice thing. I work in OHS (M-F 0730-1600, weekends and holidays off), was talking with a doc about this, she said first step, get out of OHS, go to critical care. Agreed, I just hate to give up a sweet deal, but really the only way to brush up rusty skills, learn new ones, and establish relationships. Meanwhile, expand my SOP/ back to school. I can have my friendly neighborhood doc write for whatever, I still need a verbal order (and someone on the other end of the cell, that will verify it when it's questioned) to be able to do anything. Until I have the creds, knowledge, skills and judgement, can't do much.

    Regards, Jim

    Fentanyl Citrate lollypops are cool though.
    Last edited by James Huffaker; 03-15-17 at 21:12.

  8. #8
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    As a side note on traveling with Rx medications the Department of State - Overseas Security Advisory Council - Bureau of Diplomatic Security put this out in early Jan. Interesting read for those that travel with Rx Meds out of the US.

    ---
    Case Studies

    On February 20, 2015, a U.S. citizen was arrested and incarcerated in Nagoya, Japan, for shipping a three-month supply of prescription Adderall from South Korea to Japan. Adderall, an amphetamine, is illegal in Japan, as is Ritalin; both are stimulants used widely in the U.S. to counteract ADHD. The citizen also ran afoul for repackaging her prescription from the original container, in an alleged attempt to maintain privacy and avoid stigmatization from her disorder. She was released after 18 days and heavy U.S. legislative- and diplomatic-level lobbying. For information on bringing medication into Japan, please visit the Japanese Consulate in Seattle or the U.S. Embassy in Tokyo. Many countries require a license prior to arrival.

    The UAE has strict narcotics laws that have landed many travelers in prison: “Up to three months’ supply of a prescription item can be brought into the country by a visitor and 12 months’ supply by a resident if they can produce a doctor’s letter or a copy of the original prescription. Narcotic items can only be brought into the UAE in exceptional cases with prior permission from the director of medicine and pharmacy control…Visitors should contact the Ministry of Health drug control department to check whether their medication is on the controlled list, and needs prior permission for importation.”

    Having as little as three grams of morphine in Singapore is sufficient for a death sentence. Similarly, drug offense convictions result in the death penalty in Turkey, Egypt, Malaysia, Indonesia, and Thailand. Malaysia, Singapore, Iran, and Saudi Arabia can impose judicially-sanctioned caning, flogging, lashing, or whipping for drug offenses.

    Notably, often Catholic-majority countries have conservative laws regarding oral contraceptives and devices, making them either illegal or very difficult to procure. Some countries will allow a three-month supply of oral contraception; others allow six months. In less-developed countries, access to such medications may be more difficult.

    Also, traveling with an epi-Pen, which gives a dose of epinephrine (an adrenaline hormone), to counteract a severe allergic reaction may also be problematic. An OSAC staff member had difficulty in Paris finding a pharmacy that would fill an epi-Pen prescription and had to special order one to arrive at her next international destination. Careful consideration should be taken for groups of travelers who maintain a collective first aid kit that includes an epi-Pen not prescribed to one individual, particularly if an administrator has not been trained to use the device. Ideally, only those to whom the device has been prescribed should self-administer in case of an emergency; otherwise local laws may interpret use as unlawful.

    On average, though, penalties for a drug offense include lengthy prison terms (including death or life sentences) in local jails, heavy fines, and deportation.

    Many international regulations for controlled drugs can be found through the International Narcotics Control Board website. Further, Annex II and Annex III list narcotic and psychotropic drugs that generally would require a traveler to provide a certificate of need. If the country is not listed on this resource, the traveler should contact the country’s embassy in U.S.
    ---

    AN

  9. #9
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    Thank you, very interesting. I learned something. Fortunately I don't travel often, but when I do, I just bring an augmented first aid kit. Additions, ophtho, ENT, dental to a AMK Weekender, and a well equipped BOK. I wonder if the 10g angios (chest darts) would be problematic? Not going to any of those places any time soon anyway.

    Seems like your loadout would fill a reasonable sized pack. Unless you use an expedition sized pack, Dana Designs Astral Plane (over built option) Kifaru EMR etc..
    Thanks again

    Regards, Jim

  10. #10
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    I can fit all that stuff (in limited quantities) in my well-used STOMP II medical bag (without the two pullout bulky inserts). It is packed solid (all 2470 cu. inches of it). Before that I used an REI day bag with ziplock bags / mesh bags for different collections of stuff.... looking back that was a bit of a nightmare to find anything and used to result in medical supplies splayed out everywhere even to find my stethoscope. I am sure that was a sight to see retrospectively, although more comfortable to carry for long periods of time than the STOMP II.

    Although not an equipment junkie, one of my co-workers just got back from Iraq with a bag called the ROUS by a company called the Mystery Ranch. Had a solid look at it and I am impressed... at everything but the price. I will have to keep my eyes open for a used one / one for trade. Seems that the bigger the medical bag (this one is 3500 cu inches) you have the more medical crap you find to fill it with. Not sure I am ready to part with my STOMP II, but if I must (or need more space) and had the cash, this would be the direction I would go.

    Cheers,

    AN

  11. #11
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    What's the smallest kit you'd be willing to carry? Thinking dopp bag +/- size, maybe large side pocket sized. I don't know. I think I'd want to concentrate on assessment, basic trauma/surgery/medicine/meds. My problem, I can fill a pallet, but a small packable bag, that's huge in capabilities, eludes me. But I think such a bag would be with me, when my "med ruck/pallet isn't. If it had the breath and depth to get me to better, that's worth it's space in my ruck. Probably as much a function of ignorance on my part as anything else. Thanks for your time spent educating me. Much appreciated.

    Regards, Jim

  12. #12
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    The STOMP II is really my smallest bag of any function.

    If I am just roaming around with no expectation of medical care to be provided I have a few items in a little ditty bag that I drop into my day sack for self-use / to help my buddy and keep them alive for a few more minutes until help comes / I can get to my core bag.

    Protect Self
    - Nitrile gloves x 2 pair

    Gain Access
    - Trauma Shears

    Stop Major Bleeding
    - Pressure Dressing
    - CAT Tourniquet
    - Combat Gauze

    Manage Chest Injuries
    - Needle for decompression
    - Combat gauze packing (hemostatic)
    - Chest seal

    Secure Airway
    - NPA with lube.

    Triage and Record Care
    - Black permanent marker

    Manage Pain (in an allowable to carry environment)
    - Fentanyl lozenge or 1 x vial of morphine with IM needle and 3 cc syringe.

    AN
    Last edited by Austerenurse; 03-17-17 at 19:21.

  13. #13
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    aside the meds, you described my BOK +/-

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