How to Slim Down Your Med Bag
Without fail, a medic will overfill every bag you give them. Before making a packing list for any bag you must first narrowly define what you are doing and with what support. Start with these basic questions:
- What proven equipment will best support the intervention needed in the smallest amount of space?
- What is the most likely time frame you expect to care for a casualty? What is the worst case scenario?
- Will you have a truck bag nearby on which to fallback?
- Will another member of the team be carrying the litter and HPMK?
- Will you have a junior, trained responder or assistant?
For this article and packing list, it is assumed that this is a well-supported DA mission with a trained and well-equipped assault force.
Every member is carrying multiple tourniquets and a well-stocked and inspected IFAK. There is a trained assistant who will carry a similar bag and they won't be geographically separated. We will each carry a unit of blood in an attached CRO Thermal Regulation System or blood box and additional personnel have been identified as Type-O, low-titer donors with donor bags. The Platoon Sergeant, Team Sergeant, or Troop Sergeant Major will have the litter and HPMK. MEDEVAC response time and QRF are on standby and the longest time anticipated to care for a patient is 30 mins. There is no anticipation of sustainment items such as food, bivys, or anything for a rest overnight. If all goes to hell, there is a well-stocked PFC truck bag to fall back on. The medic and Junior/assistant have dangler pouches, fanny packs, or slim belt pouches that have IV/IO access kits, cric kits, some meds, and a couple of syringes and needles along with scissors, tape, gloves, markers, etc.
With all of that behind us, we can now define what would go into a slim DA aid bag. The capability of even the most well-trained medic is necessarily constrained by what can be done well under duress in a short amount of time which would improve the patient's chances at survival before quickly handing over the patient to the next higher level of care. For that reason, the medic must be a master at resuscitation under the most austere of circumstances. Resuscitation of a combat casualty would almost certainly involve the administration of warmed whole blood within the first 30 mins of injury to limit the dose of shock and subsequent oxygen debt before becoming irreversible. This must be accomplished immediately after, or simultaneously with the cessation of hemorrhage and while also securing the airway and adequately decompressing the chest. Whole teams have been known to fail at this at the best trauma centers in the world.
The aidbag must be packed in a manner that will eliminate friction points in delivering care and control for as many human factors that could contribute to omission or error. All of this must be done beforehand while planning in accordance with the priorities of care for an unknown patient. Advanced hemorrhage control options such as junctional or abdominal tourniquets with additional wound packing methods should therefore be included. Everything needed to quickly administer fresh whole blood such as the blood itself in a temperature-controlled container, a fluid warmer and required batteries and cartridges, and some kind of pressure or power infuser. TXA and calcium should also be included along with antibiotics. As stated in the second paragraph multiple IV or IO access is paramount so that both the blood medications can be administered quickly or simultaneously even.
If cric kits are carried on person, a backup and method of suction must be included on the list. A tension pneumothorax can develop and mimic the signs of hemorrhagic shock if caused by penetrating trauma. A method to more definitively decompress both sides of the chest must also be included. This would require minimal surgical tools, some kind of drain, and one-way valves such as the Heimlich or Cook. Backups for items that routinely fail or get lost such as the Emma adapter or scissors should also have redundancy. If you plan on using an item for multiple purposes such as an ET tube for a cric or chest tube, ensure you have enough for all intended purposes for at least a single patient.
Every medic must decide for themselves how they plan on taking patient vital signs. Would the environment even permit the use of a stethoscope? Is trending mental status with an Emma and pulse ox enough or should the systolic also be measured? If the patient is in respiratory failure, do you have a BVM to support respirations? Does a portable ultrasound have a place in the first or second line? There are enough uses for an ultrasound that it should be considered if available.
Drugs, fluids, and medications must be recorded on a TCCC card prior to handover to dustoff or other next-higher capability. If expecting to travel where the wind is a factor such as in a helo with doors open or in an open-back, high-speed vehicle, everything, including the bag itself, must be well secured with a lanyard, velcro, or elastic. The last test is to get the bag closed, open it for use, and be able to close it quickly when called to move out.
Applying these fundamental considerations, I pack out my DCR with GAF/HAF DA mission sets in mind. With these mission sets, I don't need to have a very robust medical kit on my back due to additional medical gear hanging out in the cordon, or having our aircraft loitering in the overhead nearby. I need to be light and fast. This pack allows me to do that.
For DCR: In the outside pouch, I have a Quantum Fluid Warmer, 2xIO handheld drill, IV starter, and a 100ml NS bag. The IV and IO I have broken down from the normal kits they come in and vacuum sealed. I carry one citrate bag (CPD), one fluid warming line (Quantum fluid line) and one single line blood tubing (this can also be used as a normal IV line for drug admin which is why I carry the 100ml bag). As you clamshell the bag open, top left I have the CRO hard narc case, BVM, sz 4 Igel, and peep valve. Below that I have a SAM Junctional or CRO BOA and 2xTCD's with pump. In the center velcro tabs I keep the NAR small sharps shuttle. Top right, I keep my BP cuff, stethoscope, and large stapler. Bottom right, (close to shell-->to outside) IOBAN, Chest tube kit (2xTubes with Cook valves), and a Cric kit. On the outside of the bag on the panel I carry 2xSOF-T and 2xCAT 7's. Above the outside Fluids pouch, I have the small CRO molle panel attached so I can molle on a single unit blood container.
I don't include pressure bandages. I chose not to do this due to my teammates all having pressure bandages in their IFAKs. When I am wearing Cryes, I do however carry 1x4in ACE (S-folded) with combat gauze and kerlix vacuum sealed in one cargo pocket and 1x6in ACE (same set up) in the other cargo pocket. If I'm wearing regular pants I'll just rock 1x4in, in my back left pocket. I used to carry one abdominal bandage in my Graverobber, but recently removed it. What I have now for an evisceration, are clamps (carried in my Hybrid IFAK) large stapler and IOBAN. My mindset with this is, clamp the mesenteric bleed, reduce the bowel, staple closed the abdomen, and IOBAN over the wound. If this fails me, I can revert back to the bandages I have in my pockets or on my teammates to keep the wound closed.
I like to pair the DCR or GRAM with my CRO gunbelt or CRO Hybrid IFAK. The contents of which are mirrored. What dictates which one I'll wear depends on what my team is planning on doing. The left SM/MD bleeder has my Masimo SPo2, Emma, and a 2in z folded ace wrap with 2x fox eye shields. The right SM/MD bleeder has 2xTape rolled IV starter kits, spare tegaderm, and PRN adapters (needle and needless ports). The Hybrid itself, I have 2xNPA's, 2xVacuum sealed, or plastic baggied Cric kits, Talon handheld multisite IO (vacuum sealed) 60cc syringe with 10g 3.25in cath rubberbanded to it for suction and an IV line to suction tubes when I need it, 6xHyfin chest seals, FingerThor kit, 4x10g 3.25in Needle D's, and 6xChloraprep swabs. CAT7 tqt and small NAR trauma shears rubberbanded between bleeder pouches and Hybrid. Outside zipper portion has another IOBAN dressing and inside zipper portion has DD 1380's. I'll carry a sharpie in both left and right hand pockets. I carry a small space blanket in my left quad pocket and my dip can goes over that.
For NARC's, I like to carry the CRO soft NARC case and keep that in my left cargo pocket when I'm wearing Cryes. If I'm not wearing Cryes, I'll put my NARCs in a NAR Armadillo case and put that in an abdominal pouch (I wear the Spiritus SACK pouch if I'm running a chest rig. It's a tight fit, but works pretty well.). I have 2g of TXA in my left shoulder pocket and 1g CaCl in my right shoulder pocket.
I use MARCH for treatment methodology. The same dudes I idolize and look up to utilize this as well. Brilliance in the basics. Doesn't matter what kind of setup you have, or how high speed your kit looks. You could have the enormous STOMP 2 aid bag and if you've gotten the reps in of using that bag being smooth and efficient, you're rock solid in my opinion-"It's not about the bike". With that being said, you get really good at riding a big clunky bike, then you switch to a super nice high dollar bike, you could really look like a rockstar.
I try not to drop my aid bag at first, unless I need my junctional. But, the time will come when I need to grab the blood I've brought, utilize WBB, place chest tubes, and get vitals.
I like the DCR Panel it's small and it can carry a surprisingly large amount of kit. I love how it stays flush to my back and doesn't bounce around. I tend to carry more med kit than a lot of guys and I can still move quickly and athletically with it. The bag itself is incredible with a well thought-out design, with a DA mission set in mind. Having the ability to carry a single unit blood container is pretty nice.
This is my set-up for HAF/GAF DA. My loadout will vary depending on how many people are on the ground and what my team's role is. If my team is main effort, I'll go for DCR panel with either MARCH belt or butt pack set up. If my team is supporting effort, there are a lot of guys on objective, and I'll be receiving casualties from the main effort, I'll be a little bit more robust by carrying a MR Rats pack with a butt pack or MARCH belt (those items are always with me). I also can afford going in relatively light due to having bags in the vehicles we brought in. Or if we flew in, I'll add a few items to my teammates to spread load and give me a bit more capability medically.One might notice a bit of redundancy of some items, specifically with Crics and IV/IO's. I have multiples of these items cause shit happens. It's dark, people are moving around, and items can be kicked or picked up by someone thinking it's trash. If i have multiple casualties in need of critical interventions I have the materials to spare. In a very small package I have everything to cover MARCH and do it effectively.
We look forward to continuing this series on kits pack outs. Keep an eye out for future articles. If you have feedback about this article, please leave in the comments below.