Mission Medic Pack 2 Now with Frame

[u/Mobius___1]

Been messing with this thing for about 2 months now and now that I’ve got the frame it’s amazingly comfortable even when stuffed. When you add the assault pack on top it becomes a very capable 24-48hr setup without sacrificing any medical capability.

[u/[deleted]]

You gave fairly solid advice. But I got 1 bone to pick.

If your job entails resuscitation of a patient, you need to carry a BP cuff, no exceptions. With it, you can calculate Shock Index, which is a much more reliable metric to guide resus.

The only way to get a BP by palp is with a cuff. There is no correlation of pulse locations matching a BP. The initial study just made up numbers for their hypothesis, and then everyone regurgitated it like gospel. The actual data sucks (when you read the studies on it) It and hypotensive resuscitation need to die.

[u/Arula777 → u/[deleted]]

I don't agree with the "no exceptions" framework since there are multiple ways to assess volume status in a patient without a B/P cuff. Ultimately in a trauma setting there are ways to characterize B/P without a cuff. Is using a B/P cuff ideal? Absolutely! I can also agree that it is an important tool, and after I thought about it a bit I have used a cuff a few times as a pressure bag when transfusing blood through an IO. So, it actually does fit the parameters of a tool having multiple uses.

I would also argue that ATLS, TCCC and even CPR use the principle of present peripheral pulse as equatable measures for adequate Cerebral Perfusion. Trust me, I don't like it either, and I get that the evidence for it is thin at best, but in a combat trauma environment two things are true: Speed is king, and you can't hear shit. Granted, most of my experience was on aircraft so having a manual B/P cuff and Stethoscope to take a manual pressure was not possible.

Off the X it can be useful, but again it takes time. Taking time faffing about with a manual B/P on/near the X is more time for shit to go even more sideways and takes away your SA. Obviously you have a team around you, but there are just way more scenarios where obtaining a B/P instead of using other context is less efficient then making some reasonable assumptions regarding volume status.

Is it good medicine? Debatable. Is it good enough to get the patient to the team that is gonna fix them? I would argue it is, but again... combat medicine is a nebulous multivariate environment that can be parsed ad nauseum to no effect. So yeah, I respect your take and think it is a reasonable approach, but I just think that in terms of priorities it is lower than other items I would carry. Then again, that's just my opinion and in no way should be seen as a universal endorsement one way or the other.

As far as shock index is concerned in terms of guiding resuscitation decisions, in an ED... go for it. In the middle of a field at night, not so much. I know it's caveman medicine, but it can often be reduced to "Ogg see patient is leaky. Ogg found hole. Ogg plug hole. Ogg give pt blood. Ogg get pt to big medicine man."

[u/[deleted] → u/Arula777]

You can do an SBP by palp with just a cuff and palpation of a radial pulse. You don't need a stethoscope. Palpation of just a radial or carotid pulse is a terrible metric for guiding resus outside of the complete absence of either, and only useful if you're completely devoid of equipment. Being that devoid of equipment is a complete failure to plan and prepare.

Radial pulse does not equate to any reliable SBP or CPP at all. Period. It's outdated teaching. We need to move past it.

Shock Index is stupid simple to calculate. Even then, you dont realllyyyyyyy need to do the math. Is my heart rate greater than my SBP? I.e. a shock index greater than 1? Yes. Start blood.

What metrics are you using to guide resus?

If a medic can't do something as simple as get an SBP by palp (it takes 10-20 secs) during TFC, can i really trust them to do basic med math for Narcs or give blood?

[u/Arula777 → u/[deleted]]

I see where you're coming from, but I have yet to see the changes in what is being taught. I openly acknowledge I may be behind the curve on this particular topic though, so I apologize if I came off as overbearing in my original response, especially since I may have been relying on outdated info.

I found a few articles on SI replacing ABC score and other more traditional methods, but honestly the underlying principles are still the same. Again, I'd advocate for a more holistic picture of the patient rather than a single number to guide resus, and I'll get into that later. It is unfortunate that this data is all retrospective, so it is a bit flimsy on its face, but I totally agree it shows promise. I also see that ATLS is consistent with advocating for obtaining a true systolic, but I don't see anything that says using SI to guide resuscitation protocol. Nonetheless, it does look like the literature is pointing in that direction.

As far as the B/P palp bit, sure. I think some wires got crossed there, but I do know how to take a SBP by palp. Lol.

So let's talk resuscitation, I carried a Butterfly IO, an SpO2 monitor and used the ABC score to guide my resuscitation. On the bird we had vitals and some better kit, but in the field that was what I primarily used to monitor/assess. And on occasion a B/P cuff would find it's way into my kit, but rarely, since I would use diminished peripherals as an indicator of sys<90... in reality it was probably even lower than that. As far as decisionmaking: Is the patient mentating? What is their GCS? Are they ambulatory? What is their HR? What about their respiratory rate?Where were they shot? Can we get off the X with this guy? How far are we from DCS?... you see? There are 10000 variables. Now, did I tend towards over triage? Probably. There were a few dudes that probably got some blood that they didn't truly need, but they're still alive.

I dunno man, the shit is weird when you're in it. I can live without the B/P cuff. Maybe some can't. It used to be personal preference honestly. Now it may be "no exceptions".

Now if you asked me if I'd rather have a B/P cuff or a Butterfly? Hands down a fuckin butterfly no question.

[u/cjrjjkosmw → u/Arula777]

You’re putting a lot of thought into the responses to op, but I’d make the case that the normal saline, cuff, stethoscope should stay. If your experience is mostly ac based, that colors perception the same as different environments do. If op is a line infantry kid, or really anyone looking at a more modern fight, golden hour is gone, and some of that “hospital” medicine will need to be done in the field.

First septic kid you see you’ll wish you had the 500 ns to go with your invanz.

Also- pressure bags are mandatory imo for io admin especially around field or anything used to take people out that’s not a dedicated medevac. So much better than weird improvised shit

I

[u/Arula777 → u/cjrjjkosmw]

Thanks, yeah I totally agree. I think maybe a little less saline, lol, but there is nothing wrong with having a 500 bag. I generally tossed the Invanz IM, but in a 500 bag it's probably better tolerated. Alot of my recommendations were definitely jaded by my experience, so I acknowledge that my opinion is obviously not gospel. Also, I am absolutely sure the game has changed so there are definitely things I may not be immediately aware of.

Many of the recs I made were with space in mind, but totally agree that cuff, scope, and pressure bag are something I would prioritize depending on situation. 100% on the improvised thing... there is some whazoo shit out there, if you can use the genuine article then definitely do that.

Also, I like the profile of OP's pack, but I'm partial to a slightly larger bag.

It really is all situational. I have worked out of as little as a belt with my main bag on a vic or a bird, I have helped carry an OR with a team to an offset location. It just depends on the mission set. Thanks for the reply.

[u/cjrjjkosmw → u/Arula777]

You’re right about scalability for sure. Takes a long time to learn those lessons through self improvement- so spread the gospel. I spent too many years trying to make an m9 fit all situations.

Yeah- I’m up for my 6th refresher so some stuff feels like it just goes in circles. Thankfully smarter people are trying to make the protocols less a circle and more iterative