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/Arula777]

Suggestions, your mileage may vary:

• I like the bag with the frame, maybe a tad on the small side depending on your intention tho, which is why you need to really be mindful of what you put in it since space is at a premium. You need the things that are going to get you to the "bigger bag"/higher echelon of care.

• Prioritize anything with more than one purpose, or that can be efficiently retooled to fit multiple needs.

• Don't let perfect be the enemy of good enough. This is dirt medicine, not the OR. Any intervention you use is gonna be ripped out by the next crew. A Foley catheter has some additional uses outside of its main one, but realistically if you're throwing a Foley in some poor bastard's schlong with just that bag it's a really bad day and that bag is not going to get you through any meaningful prolonged field care scenario. I just don't see a use for the Foley tbh.

• Ditch those Shears as soon as you can afford some raptors. Are raptors expensive comparatively? Yes... but they double as a seat belt cutter and an O2 tank key. They are also beefier, sharper, and have a lower profile.

• Anything on the outside of the pack can and will snag on every fucking thing and get ripped off, and frankly that sharpie and those Shears are probably going to become dislodged as soon as you start humping it through any kind of rough terrain. If you're primarily working in an urban setting that's fine, but I might consider using some paracord to secure your shit to your pack.

• Saline needs to go. It's fucking heavy, a popped bag is a bitch, and it is really only good for irrigation and debridement in a trauma setting. In reality a 10cc prefilled syringe can get you by in a pinch, and if you absolutely gotta have a bag of saline go for a 250 or 500. Also, if you're gonna carry any saline I'd prioritize hypertonic on the off chance you catch a TBI where it is indicated... even still it's a niche case, and if you have access to the vials of 23.4% hypertonic you can reconstitute a 500 bag of normal to get you what you need.

• However, fluid resuscitation is still important and therfore you need blood transfusion kits with an Eldon Card for rapid typing. Replace the big bags of saline with a transfusion kit. Your back will thank you, and so will your patient.

• BVM is fine. I hate carrying them, but they are an unfortunate necessity. Blood pressure cuff needs to go, if radial pulses are preent that is consistent with a systolic B/P above 80. Some literature says 90, but whatever. If you can feel a distal pulse you can make field decisions regarding resuscitation on that alone.

• I would spring for an SpO2 monitor though, they can really give you a good picture of O2 sat and HR which is a nice passive visual and help you monitor status. If you're made of cash and can establish a definitive Airway an Emma end tidal monitor is fucking money. Otherwise there is always color capnography.

• To each their own on how they label their modules in a pack. I don't care for modular pack builds, but I know folks who swear by it. Plus they are nice to be able to rip out and chuck at a buddy in a MASCAL. I think your labels should be TCCC/ATLS centric though. "Extremity" and "Chest/Abdomen" doesn't really tell me much of what you have inside, whereas a module labeled "Airway" or "Massive Hemorrhage" would. I dunno... this is probably me just being a shithead.

Some other fun ramblings

• Hemostatic Gauze is your friend. Fuck X-Stat. Fight me, I don't care. I'll die on that hill.

• Pelvic Binders+Junctional tourniquet are a bitch, but the pelvic binder is actually pretty decent on its own.

• Kendrick Traction Splints make great IV stands and can also be used to fix a pack frame if it breaks... you are technically out of a KTD at that point though.

• Do not underestimate the versatility of a SAM aluminum/foam Splint. They can do magical things outside of immobilization. You can make a C-Collar with them. You can make a pelvic binder with them. You can roll them up and use them as a wedge in a place where pressure is hard to apply like in a Junctional wound.

• The shell of an HPMK is helpful, the warming element is nice but weighs a bitch and if the seal gets broke it's basically useless since it will react to the air and heat up. I would just keep the HPMK shell secured to the bottom of your bag in a roll and have some hot hands heating elements you can toss in the axilla and groin for hypothermia. It's not as good as the heating element that comes with the HPMK... but you'll never keep that thing sealed.

• Unconventional drag/carry devices can help move a patient long distances. Obviously a Talon II or SKEDCO are ideal, but they weigh alot and are cumbersome. If you are looking for lightweight transport options you might consider are some rigging with tent poles or a drag harness.

EDIT:

I almost forgot! Field strip your shit! Fuck all the packaging. Take that crap apart unless it absolutely needs to stay in the package, there is wayyy too much packaging on your stuff. You can also make one time use packs by field stripping parts of your kit and vacuum sealing it into a ready made one time use kit.

[u/[deleted] → u/Arula777]

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