This week MICA paramedic Rob Simpson put up contents of his prehospital kit for all to see – nice set up, with impressive slide out drawers for kit and even a gas-piston life to make shouldering a backpack that little bit easier.
Seeing Rob’s colour-coded drug vials made me re-visit the contents of my own RERN kit (rural emergency responder network) and do a little labelling & re-ordering of near expired stock.
I’ve posted a video on “what’s in your emergency bag” previously, although my own bag has undergone some revisions since then. Many doctors (particularly rural doctors) ask me about what kit to carry in their car. There are commercially available kits (such as GPKit) but to be honest I think the best kit remains a mobile phone, gloves and simple airway adjuncts such as Guedel’s and bag-mask valve (preferably with PEEP valve).
As a RERN member my role is to support (not replace) existing ambulance officers in rural SA – many of whom are volunteers trained to Cert IV level and supported in turn by career paramedics, intensive care paramedics and extended care paramedics. They are the experts in prehospital care – not passing-by doctors or ‘enthusiastic amateurs‘. Indeed one of my bugbears is the notion that having any old doctor on scene value adds to care – to my mind, the prehospital environment is VERY different to the ED or consulting room, and most doctors have little to add unless they have undertaken specific training in this field. Karel Habig talks about this in the most recent RAGE podcast (No 2) and is worth a listen.
Thus my role is to perform a very limited set of interventions – IV or other drug administration when ICP/ECP not available, facilitating extrication through judicious use of ketamine, needle-finger-tube thoracocentesis through to (very rarely) pre-hospital RSI. So what kit have we got?
Boots – Eye Protection – Hard wearing trousers with reflective strips & knee-pads – Jacket with reflective stripes and ‘Doctor’ ID. Interestingly no gloves or hat…
Most RERN members respond in their own vehicles or arrange to be met by the local ambulance crew en route to a scene. Some locations keep their RERN kit at the local hospital. Due to the geography of my location (KI is 150 x 50km) I keep my kit with me and respond by pager or mobile phone activation. At this stage we do not have a GPS-enabled solution, although I have been looking with interest at the mobile phone-GPS solution being used by BASICS doctors in Scotland.
RERN doctors are supplied with two bags – a green ‘oxygen and basic airway’ bag and a red ‘circulation, IV access & drugs & advanced airway’ bag. We don’t carry a defib or monitor – the Phillips MRX is the standard on SA Ambulances and we would be dependent on the volunteer crews having this to hand. Ditto adjuncts like extra oxygen, IV fluids, dressing, suction etc.
The bags are supplied by SA Ambulance and restocked through RERN. The bags are made by NEANN and are of excellent quality – waterproof, removable ‘boot’ on bottom and with sturdy zips and carry handles.
Green Bag – OXYGEN – BASIC AIRWAY – ADJUNCTS (collars, splints)
This contains oxygen, BMV, oro and nasopharyngeal airways, sphygmanometer, stethoscope, glucometer, Abbotcaths, 3-in-1 masks, nebulisers etc.
I’ve customised mine to a degree, adding a CT-6 femoral traction splint and a Prometheus pelvic binder to the side-pockets, as well as an assortment of Air-Q II intubating LMAs.
Red Bag – CIRCULATION, IV & DRUGS, ADVANCED AIRWAY
The red bag contains more serious kit :
Side pockets hold :
(i) formulary, pens, gloves (always carry a Sharpie)
(ii) local anaesthetic and suture kit
(iii) combines, dressings, bandages
(iv) Tranexamic acid, OLAES/Israeli bandages, combat-application tourniquet, RapidRhino
Main compartment has skin staples, local anaesthetic and more sutures in the zipper top lid (useful to control scalp lacs etc), with individual bags within for ADVANCED AIRWAY and IV ACCESS/MEDICATIONS.
Snuck alongside are some extras – two 500ml bags of N/saline, giving sets and an EZ-IO drill. The latter was a bit of a push to get 0 the local hospital stocks the Bone Injection Gun (a useless piece of kit, no tactile feedback, errors made with deployment even after training) and I was able to badger RERN to supply needles for the EZ-IO if I supplied the gun. used it four times in past 6 months, so reckon it’s worth it. There’s also a pre-packed Guedel’s oropharyngeal airway set.
IV ACCESS & MEDICATION
The yellow IV access / medication module is quite neat, with vial holders, enough room to stash IVs, a mucosal-atomisation device for IN drug delivery plus assorted ventolin inhalers, GTN spray, penthrox inhaler as well as minimal volume extension lines, more tape, a couple more Sharpie pens and as much ketamine as I can cadge.
Drugs include : ketamine, morphine, fentanyl, tramadol, midazolam (5mg per ml and 5mg/5ml), naloxone, adrenaline, atropine, amiodarone, metoprolol, frusemide, metoclopramide, tropisetron, promethazine, chlorpromazine, hydrocortisone, benzylpenicillin, cefazolin.
I tend to stash a couple of vials of propofol, some ephedrine & metaraminol and of course GTN spray, salbutamol and Methoxyflurane (Penthrox) inhalers along with the IVs. Hidden amongst this lot are some 3ml syringes and ‘snot rocket’ mucosal-atomisation devices.
Needless to stay these are kept locked and a written record of S8s maintained.
I will probably ditch the metoclopramide and chlorpromazine soon, and get some droperidol instead.
After talking to Robbie recently, I reckon some wafers of both ondansetron and olanzapine might be useful…
RSI drugs (specifically, induction and neuromuscular blocking drugs) are kept refrigerated.
RSI KIT – ADVANCED AIRWAY
The grey advanced airway bag contains Mac & Miller blades, classic LMAs, emergency surgical airway kit (scalpel, bougie, size 6.0 ETT). I’ve added a pocket bougie as well as the supplied Frova oxygenating bougie and rapi-fit connectors (O2 or BMV), as well as the medSTAR kit dump and challenge-response checklist.
I am not afraid to use cognitive aids in a crisis; the side pockets of the bag contains ‘action cards’ for mixing inotrope infusions, RSI drugs and paediatric calculations.
I also carry the KingVision VL and both channelled and non-channelled blades. Of all the VLs I’ve tried, this works best in sunlight (less glare than the McGrath) BUT I should be clear that VLs do not cope well with blood/vomit (the sensor chip is easily contaminated) and DL remains the core skill. I carry mine as a back up, the logic being that may be useful if performing RSI in back of (stationary) ambulance rather than at the roadside. I also carry the AirQ-II iLMA in a side-pocket of the green bag – these are less bulky than the FastTrach iLMA, less fiddly to deal with (less parts) and allow gastric drainage unlike the FastTrach.
So that’s my kit. My wish list remains for :
– pelvic binders to be carried by SA ambulance crews
– GPS-smartphone to enable location & targetted activation of RERN members
– consider prehospital CPAP device
– common kit between services with recycling of near-expiry stock
– interagency training