Backcountry First Aid Kit, By Richard Rhodes

[mtwarden]

Thanks- looks like Ace bandage it is

 

[Smash]

The other thing I carry just because it is small since anaphylaxis was mentioned is a vial of 1:1000 epi and a TB syringe. I don’t have any severe allergies that I’m aware of (yet) and I don’t want to find out when I’m in the woods.

While not practical for most people it is small light and gives me piece of mind. I would not pack an epi pen however unless I had known allergies as most are just too damn big.

Also the vet bandage or Coban as I call it is great for direct pressure dressings in the hospital but it is not very durable and won’t hold up in the field and not as versatile as an ace wrap.


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[ffparamedic]

The other thing I carry just because it is small since anaphylaxis was mentioned is a vial of 1:1000 epi and a TB syringe. I don’t have any severe allergies that I’m aware of (yet) and I don’t want to find out when I’m in the woods.

While not practical for most people it is small light and gives me piece of mind. I would not pack an epi pen however unless I had known allergies as most are just too damn big.

Also the vet bandage or Coban as I call it is great for direct pressure dressings in the hospital but it is not very durable and won’t hold up in the field and not as versatile as an ace wrap.


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Smash,
I too carry a "homemade" epi pen, I did not include that in the list as it is not practical or generally obtainable for most people. I find that most people that have access to those items and the knowledge to use them generally will. I do not suffer from any type of allergy to my knowledge but it does give me some comfort knowing that I have it with me should anyone need it.

 

[cfdjay]

One thing I didn't see mentioned, maybe I missed it, is some prescription painkillers. I know, it's a dirty word nowadays but after hiking through the slippery deadfall of Montana with a backpack weighing (insert your pack weight here) throwing your balance from side to side, I cringe at the thought of snapped tib/fib, femur or blown out knee. One thing that's just not taught enough is the number one person to rely on, is YOU. I've saved up my painkillers that have been prescribed but not taken for dumb things like dental work, back injuries, etc. I don't take them. I hate them in fact. BUT, given a scenario above, pain alleviation may be what get's you through whatever that next step is to get some help.

 

[Mike7]

Mike, thank you for your response. Not a bad call on the pepto, although I feel that the folks suffering from those aforementioned issues should carry a medicine for each, or double quantity at least. I won't disagree with you on the Bacitracin, however I will leave you with a peer reviewed article on the fact that "bacitracin is the most common topical antibiotic known to cause anaphylaxis" Medscape: Medscape Access I would much rather have a rash than anaphylaxsis, I know this may come across as me "trying to prove you wrong, I am not. I require my medic students to bring me peer reviewed articles to refute a point and that is all I am doing.

4x4 Gauze cannot pack a wound which is what the rolled gauze is for. As far as the 2" ACE wrap, I can agree with you, although my pack will still have it. it is much more useful to wrap a small area like an ankle with 2" than 4" in my experience.

The bandaids are useful to me, maybe not to others. The alcohol is a great disinfectant for small wound cleaning.

Great idea on the Aspirin!!! I can't believe I haven't thought about this. It could be useful even if you and your partner are healthy. Aspirin is the ONLY medication PROVEN to actually help when having a heart attack!

I will ask you about your "thousands of wounds" as most infections occur a significant amount of time post injury can you unequivocally say that your patients never got an infection? If so, you have really dodged the bullet on that!

I will support you on not taking a TQ, but it is a small piece of kit that can help you. Most of the other causes of death you mentioned have no method of treating once it occurs other than the ones already mentioned.

Again, I hope you take this in the tone it is written in! I really appreciate your input.

Richard, no worries. I have no sacred cows when it comes to medical kits, medical info, or any equipment really. Admittedly, I am not a big fan of most all of the OTC medical kits for the backcountry. The bags are cool, but the contents like crappy tweezers, tiny gauzes, etc. are more sales gimmick in my mind. Nowadays with the internet/Amazon, the average person can put together top of the line medical kits in whatever fashion they want. Also, I have been in medicine long enough now to see that what we think we know today, can and often does change tomorrow. And many things in medicine we continue to do out of tradition only. When I first started training we were soaking wounds in betadine whirlpools...leaches would have been far better.

I am personally not a fan of most any ATBx ointment as being needed to treat any non-infected wound, but it is readily available and useful to keep bandages from sticking, so like everyone else I use it for this purpose. Neosporin/triple ATBx ointment that I have seen typically contains Bacitracin as one of its components, so most people have been exposed to it prior to going to the backcountry (maybe not some kids). Bacitracin rarely causes an allergic reaction as far as I am aware of, whether alone or in Triple ATBx ointment, while Neomycin can cause an allergic reaction in up to 10% of people (which is a lot and noted especially the atopic dermatitis/eczema folks). Because of the potential issues with ATBx ointments and some of the literature, for some of my elective procedures like circumcisions, I have went to plain petrolatum ointment to keep dressings from sticking the last few years, and have had no problems with this.

Alcohol swabs do a fairly good job of cleaning small areas of intact skin surfaces, but I was not aware of any recommendations to clean a wound with chemicals toxic to living cells any more like alcohol, iodine, etc. I welcome any correction on that though of course.

I have only worked in primary care (living with and taking care of a few thousand Marines for several years, Family Practice in a suburban area where people follow up with me or my NPs, or I get the notes of every visit they have had to an Urgent Care or ER at night and over the weekend, and working in a rural ER and clinic where all ER patients seen by me then follow up with me or one of my partners), so yeah, literally thousands of wounds now that I think about it with pretty good follow up.

But these are mostly very simple wounds seen soon after injury and with primary closure after being cleaned by me or a PA/NP/Corpsman working with me. The old saying seems to hold true, "the solution to pollution is dilution". Get all foreign bodies/debris out of the wound and debride the dead and devitalized tissue without harming the remaining living tissue, and people just generally heal well. Not luck or magic really I don't believe. Of course there is a separate group of high risk complicated wounds such as people presenting in a delayed fashion for treatment, deep wounds directly overlying bone like in the pretibial region, crush injuries, deep diabetic foot wounds, animal bites, tendon/tendon sheath exposure injuries, etc. that have some significant risk of infection and that get and require more medical attention such as intraoperative cleaning, no closure or delayed closure, oral or IV ATBx's, etc. and these can then still have problems.

Ah, I see how you are using the rolled gauze I think in the field. I had never considered using it like that, because I think I had just planned on using rolled clothing over the top of 4x4's for that same purpose.

One other cool thing Richard to consider for your kit is Plastic Kitchen Wrap. This works amazingly well on 2nd degree burns for keeping them clean and decreasing pain significantly...like a 2nd skin. You can cut a roll in 1/2 to make it more packable. I don't carry it for myself because I figure that pain never killed anyone, but I have used it on others many times with great success. Just remove it daily and wash/lightly debride the burn before reapplying with a little nonstick ointment such as Silvadene. Most people require no narcotic pain med with the use of this, except for a single dose about 1 hr prior to the burn cleaning/debridement.

 

[COlineman78]

One thing I didn't see mentioned, maybe I missed it, is some prescription painkillers.

I too would like to know Richard's opinion on carrying some Oxy (most likely expired from past surgeries, but my understanding is opiates just get less potent over time) in your kit. I hate painkillers as I think pain is important to preventing further injury, but something like Oxy to be able to withstand splinting and walking out with a broken leg would be nice.

 

[mrgreen]

To Richard and Mike, I had an interesting discussion with a NP/Derm recently. He advocated using Aquaphor rather then any ATBx ointment for in-the-field treatment of open wounds. I figured I'd bring it up here, still doesn't sit right with me. Haven't heard that anyplace else.

Thoughts?

 

[William Hanson (live2hunt)]

I carry some prescription painkillers just in case for the same reasons that you guys are asking. In the event that myself or my hunting Partners or even someone else that we run into you are injured and need to get out painkillers might be just the thing needed. Of course my medical expertise is pretty Limited so it might just be making you comfortable until you die if relying on me to save you.

Live2hunt custom shelters

 

[Mike7]

To Richard and Mike, I had an interesting discussion with a NP/Derm recently. He advocated using Aquaphor rather then any ATBx ointment for in-the-field treatment of open wounds. I figured I'd bring it up here, still doesn't sit right with me. Haven't heard that anyplace else.

Thoughts?

Yeah, I've have read exactly this as well within the past several years that there is little if any difference in preventing infection between antibiotic ointment and aquaphor/vaseline (I know a lot of docs, that don't use any antibiotic ointment now for their surgical wounds.). Getting people to believe this though is another story, so I often just hand out the placebo generally harmless antibiotic packets to people.

If you think about it though, it makes sense. A mechanical cleansing of a wound decreases the numbers of all bacteria, and the debris which bacteria can hide in/on, while antibiotic ointment kills the least resistant organisms, possibly altering the balance of the normal skin flora some and potentially not decreasing the numbers much at all of the most resistant organisms.

As far as pain meds go, that is a personal choice. I personally can function in pain, but not on a narcotic, so I don't take any. But I have prescribed them for the medical team member/medic for groups going to Denali, etc. I would say in my opinion that usually they are more of a luxury item in a kit, but there is a certain percentage of people who just don't tolerate any discomfort without "losing it" so to speak and could become really difficult to evacuate without pain meds. I would however not recommend taking them/giving them to someone in shock or with a head injury, because monitoring mental status is necessary in these cases when evaluating their ongoing health status and making treatment and evacuation decisions.

 

[Smash]

Working in an ER our practice is to irrigate the wound copiously with saline or sterile water because it is readily available. Other than that we recommend good old fashioned scent free antibacterial soap and water for treating wounds. Nothing fancy. Our wound expert has recently been pushing medihoney which is basically just an all natural honey. I haven’t read into too much because my specialty is the immediate care of wounds and not so much long term but it seems to be workin well on the in patient side of things.

As far as the guys talking about narcs O have never planned on it because popping a couple of norco or oxy will only numb my senses while trying to effect self rescue with an injury requiring me to take those meds. They don’t work immediately and are not effective enough in treating the pain its self when trying to move with a broken bone. Might as well pound down a fifth of whiskey and try and get out of the back country.

My personal opinion is it would be better to just splint it stay put and have someone come to you.


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[mrgreen]

.........Our wound expert has recently been pushing medihoney which is basically just an all natural honey.........

Interesting, but I could see that creating issues in the backcountry (insects and such)- maybe a good time to incorporate Mike7's Saran Wrap technique.

 

[cfdjay]

Smash and Mike, I'm coming from a prehospital perspective. We can agree to disagree but I've had some good injuries and I think of when I tore my acl. I too function well with pain. I put that situation in a backcountry scenario and something to take edge off would absolutely be the order of the day. Mike you did say it best however, it's a personal choice.

 

[Mike7]

Some studies have shown no significant difference for control of 'acute' pain (including musculoskeletal pain) between NSAIDs which can be obtained OTC and prescription narcotics, when patients didn't know what kind of "pain" medicine that they were receiving. For many people though because of the mental/placebo component to everything, I suspect that the NSAIDs might work best if they had "hydrocodone" or "oxycodone" or "warning very potent pain medication" printed on the tablet.

 

[cfdjay]

Some studies have shown no significant difference for control of 'acute' pain (including musculoskeletal pain) between NSAIDs which can be obtained OTC and prescription narcotics, when patients didn't know what kind of "pain" medicine that they were receiving. For many people though because of the mental/placebo component to everything, I suspect that the NSAIDs might work best if they had "hydrocodone" or "oxycodone" or "warning very potent pain medication" printed on the tablet.

Interesting. I have not seen that study. If you can find a link I’d like to read it.


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[Matt W.]

Great article and conversation. We can never learn to much about this topic. I appreciate hearing you guys debate in a constructive manner. Enjoy hearing the back and forth and the reasoning behind each one's experiences and knowledge. Who knows, this conversation might just save a life! Kudos to Rokslide for kicking this off!!

 

[cfdjay]

Great article and conversation. We can never learn to much about this topic. I appreciate hearing you guys debate in a constructive manner. Enjoy hearing the back and forth and the reasoning behind each one's experiences and knowledge. Who knows, this conversation might just save a life! Kudos to Rokslide for kicking this off!!

Couldn't agree more. Debates in medicine?! Nahhhhhhhh lol

I'd really like to hear from someone who has actually experienced narcs in the backcountry.

 

[ffparamedic]

Guys I apologize for not being responsive. I am attaching the fire academy teeaching an instructor class until tonight. I will respond back to all tonight or tomorrow

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[ffparamedic]

Richard, no worries. I have no sacred cows when it comes to medical kits, medical info, or any equipment really. Admittedly, I am not a big fan of most all of the OTC medical kits for the backcountry. The bags are cool, but the contents like crappy tweezers, tiny gauzes, etc. are more sales gimmick in my mind. Nowadays with the internet/Amazon, the average person can put together top of the line medical kits in whatever fashion they want. Also, I have been in medicine long enough now to see that what we think we know today, can and often does change tomorrow. And many things in medicine we continue to do out of tradition only. When I first started training we were soaking wounds in betadine whirlpools...leaches would have been far better.

I am personally not a fan of most any ATBx ointment as being needed to treat any non-infected wound, but it is readily available and useful to keep bandages from sticking, so like everyone else I use it for this purpose. Neosporin/triple ATBx ointment that I have seen typically contains Bacitracin as one of its components, so most people have been exposed to it prior to going to the backcountry (maybe not some kids). Bacitracin rarely causes an allergic reaction as far as I am aware of, whether alone or in Triple ATBx ointment, while Neomycin can cause an allergic reaction in up to 10% of people (which is a lot and noted especially the atopic dermatitis/eczema folks). Because of the potential issues with ATBx ointments and some of the literature, for some of my elective procedures like circumcisions, I have went to plain petrolatum ointment to keep dressings from sticking the last few years, and have had no problems with this.

Alcohol swabs do a fairly good job of cleaning small areas of intact skin surfaces, but I was not aware of any recommendations to clean a wound with chemicals toxic to living cells any more like alcohol, iodine, etc. I welcome any correction on that though of course.

I have only worked in primary care (living with and taking care of a few thousand Marines for several years, Family Practice in a suburban area where people follow up with me or my NPs, or I get the notes of every visit they have had to an Urgent Care or ER at night and over the weekend, and working in a rural ER and clinic where all ER patients seen by me then follow up with me or one of my partners), so yeah, literally thousands of wounds now that I think about it with pretty good follow up.

But these are mostly very simple wounds seen soon after injury and with primary closure after being cleaned by me or a PA/NP/Corpsman working with me. The old saying seems to hold true, "the solution to pollution is dilution". Get all foreign bodies/debris out of the wound and debride the dead and devitalized tissue without harming the remaining living tissue, and people just generally heal well. Not luck or magic really I don't believe. Of course there is a separate group of high risk complicated wounds such as people presenting in a delayed fashion for treatment, deep wounds directly overlying bone like in the pretibial region, crush injuries, deep diabetic foot wounds, animal bites, tendon/tendon sheath exposure injuries, etc. that have some significant risk of infection and that get and require more medical attention such as intraoperative cleaning, no closure or delayed closure, oral or IV ATBx's, etc. and these can then still have problems.

Ah, I see how you are using the rolled gauze I think in the field. I had never considered using it like that, because I think I had just planned on using rolled clothing over the top of 4x4's for that same purpose.

One other cool thing Richard to consider for your kit is Plastic Kitchen Wrap. This works amazingly well on 2nd degree burns for keeping them clean and decreasing pain significantly...like a 2nd skin. You can cut a roll in 1/2 to make it more packable. I don't carry it for myself because I figure that pain never killed anyone, but I have used it on others many times with great success. Just remove it daily and wash/lightly debride the burn before reapplying with a little nonstick ointment such as Silvadene. Most people require no narcotic pain med with the use of this, except for a single dose about 1 hr prior to the burn cleaning/debridement.

Mike,

Thank you for the very detailed and informative post!! Great discussion we have here. Thank you for your service to our country and Marines.

I am not a big fan of antibiotics, especially in the pre-hospita setting.

Very interesting on the saran wrap! I will certainly give that a try, my initial concern would be the trapping of heat? Can you comment on that aspect of using it?

 

[ffparamedic]

I too would like to know Richard's opinion on carrying some Oxy (most likely expired from past surgeries, but my understanding is opiates just get less potent over time) in your kit. I hate painkillers as I think pain is important to preventing further injury, but something like Oxy to be able to withstand splinting and walking out with a broken leg would be nice.

CO,

I personally do not recommend it. I won't go so far as to say that you shouldn't, except to say that you should NEVER take anything that you have not taken in the past, AKA your wife's pain meds that you snagged for the hunt as you could have some reactions to that. Other than that I am generally opposed to the idea as narcs can cause some issues with cognitive function and if you're using them for pain management then it stands to reason you're already not functioning well and need all of your senses and judgment to be working properly.

As Mike pointed out most OTC pain control works just as effectively. Think 800mg ibuprofen.

Also, you won't walk out on a true non-splinted broken leg.

 

[ffparamedic]

To Richard and Mike, I had an interesting discussion with a NP/Derm recently. He advocated using Aquaphor rather then any ATBx ointment for in-the-field treatment of open wounds. I figured I'd bring it up here, still doesn't sit right with me. Haven't heard that anyplace else.

Thoughts?

Mrgreen,

Are you sure that he was not referring to Aquaphor ointment? Here is a study that I found doing a quick search, again I did not spend much time looking for this and there may be more that I did not see. This is a VERY small study of only 20 people so it's hardly relevant in my opinion but it will give you a reference. Treatment of minor wounds from dermatologic procedures: a comparison of three topical wound care ointments using a laser wound model. - PubMed - NCBI The study is a double blind study, so there is that.