Medical - Wilderness Med Kit

8/2/2019 Medical - Wilderness Med Kit

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Comments to:

Keith Conover, M.D., FACEP, Medical Director36 Robinhood Road, Pittsburgh, PA 15220-3014

412-561-3413 kconover+ @pitt.edu

Revisions

This revision, 1.2, is offered in prep aration for the release of a major revision

of the WEMSI Personal Wildern ess Medical Kit list, which will be n um bered

2.0, and released at the beginn ing of 2000. You w ill note redlined changes

throughou t the lists, representin g chan ges from version 1.1, wh ich hadremained virtually unchanged for years.

Some of the m ajor highlights of the p roposed ch anges are as follows. These

are explained in more detail in the endn otes:

A saline lock and saline flush have been add ed to the Advan ced Kit, to

allow WEMTs at the scene to start an IV, to give mu ltiple med ications,

and to have a p atent IV ready for when IV bags and tubing arrive.

IM ketorolac (e.g., Toradol) has been taken off the list, as it hasvirtually no ad vantages over oral ibuprofen (see end notes).

Tubex injections an d syrin ges have been taken off the list, as the

containers leak wh en overheated.

A one-way valve has been added to the advanced kit, to provide some

WEMT protection du ring mouth -to-endotracheal-tube ventilation.

A small skin stapler has been add ed, for scalp w ound s and for minor

lacerations.

Droperidol has been added as a multi-purpose replacement for both

proch lorperazine (e.g., Compazine) and halop eridol (e.g.,Haldol) for

PersonalWildernessM edical Kit Version 1.2 10/7/99Version 1.2 10/7/99Version 1.2 10/7/99Version 1.2 10/7/99

Wilderness EMS

Institute
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Personal Wilderness Medical KitPage 2 of 26

sedation, nausea, and migraines.

After du e consideration, we h ave added mid azolam (e.g., Versed) tothe Advan ced Kit, for sedation for procedu res and for control of

seizures, and removed ciprofloxacin (e.g., Cipro), bisacodyl (e.g.,

Dulcolax ), bismuth subsalicylate (e.g., Pepto-Bismol ) andcyclobenziprine (e.g., Flexeril).

After a pu blic commen t period of three months the deadline for comments

is December 30, 1999 we w ill post the n ew official version, n um bered 2.0,

on the WEMSI Web site, and ann oun ce it publicly through the u sual

channels, including the wilderness-emergency-medicine list (send "subscribe

wild erness-emergency-med icine" to [email protected] to su bscribe;

more in formation available at http://www.wemsi.org/).

Choosing a Wilderness M edical Kit : The Basics

Choosing the conten ts of a wildern ess medical or first aid kit is hard . But if

you are pu tting together such a kit, you may look to this docum ent for help.

The Wild erness EMS Institute staff and con tributors pu t a lot of effort into th is

docum ent. One of our missions is wilderness medical education, so we are

makin g the list pu blic, but also show ing how we decid ed on the list. The list

might not be exactly wh at you need foryourmed ical kit. But we hope you

find this d ocumen t, with all of its principles an d explan atory notes, a good

starting place for designing your ow n kit. If designing a large team kit, you

may w ant to look at the WEMSI Team Medical Kit docum ent, available at

http://www.wemsi.org.

As we said, assembling a medical kit is hard . But there are man y ways to

make it easier. You can sim ply get a list from someon e authoritative and

assemble a kit based on that. But it may m ake more sense for you to ask

certain basic questions, and then assemble a kit based on the answers.

Some obvious questions, but on es worth asking out loud at the beginn ing, are:

Wh o is going to use the kit, and wh at is his or h er level of training?

For WEMSI, these are people trained in accordance w ith the WEMSIWEMT Curriculum , wh o also have EMT-basic or EMT-paramed ictraining or the equivalent, and wh o have auth orization from a

physician to carry an d use th e k it as part of a wilderness EMSagency/SAR team.

Wh o will the kit provide for -- how m any? And are there any special

needs (e.g., pregnant w omen , diabetics, small children , dogs, horses)?

For WEMSI, the kits will be used to provide initial care for the subjects

of wilderness and backcoun try search and rescue operations, includin glost person searches and m oun tain and cave rescue operations. Th ekits will also provide care for mem bers of field team s, includin g dogs
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and horses, when they are rem ote from standard m edical care.

How long will the kit have to provide med ical care for these peop le?

For WEMSI, the k it design is for the m ost comm on sort of m oun tainand cave search an d rescue operations in N orth A m erica tasksusually lasting 4-12 hours, rarely lasting longer, perhaps up to a day ortwo without resupply.

Where will the p eople be going? For instance, theres no need for

altitude-related med ications if theyre just in th e App alachian

Moun tains (where altitude illness is exceedingly rare), and n o need for

a snakebite kit if theyre h ill-walking in Ireland or Britain, w here th ere

are essentially no poisonous snakes. For WEMSI, the answer is in an ywild or backcountry area or cave in N orth A m erica, exclusive of the

Arctic.

How much can th ey carry? If its a river rafting trip, a fairly heavy kit

is OK, but if its for a long backpackin g trip along th e Ap palach ian

Trail, where its usu ally possible to get to a road an d to a h ospital

with in a d ay or so, a lighter kit is in order. For WEMSI, the answer

from the field is if we gotta carry this aroun d with u s all the tim e, upand down m oun tains and th rough cave crawlways, its gotta be smalland light.

Asking those questions is just the beginn ing. Next comes a delicate balancin g

act. For example: reconciling the team doctor (wh o wants you to carry

everything inclu din g four bags of IV fluid s at 2.2 lbs. a bag) and the team

mem bers (fanatically weight-conscious backbacker-type on es wh o cut th e

hand les off their toothbrushes and the margins off their maps and who want a

kit that weighs less than an oun ce). Anoth er examp le: we had con sidered

add ing an ampou le of 50% d extrose to the kit. But it is very heavy, and

fragile, and in alm ost all cases, one can get some oral glucose or oth er food

into any hypoglycemic patient in the wildern ess. For that matter, instant

glucose test strips w eigh very little; how ever, they have to be kept in an

airtight con tainer that is fairly large, and have a sh ort shelf life wh en exp osed

to heat (as in a pack or car in the summ er). Since almost all wilderness

patients n eed glucose or food calories, we did n ot includ e glucose test strips

in the kit, either.

Here are a few p rincip les to guid e assembly of your med ical kit, thou gh

competing ones that must be delicately assessed and balanced.

Durabi l i ty

Wilderness medical kits must withstand crushing and drop shocks. The

degree of protection depend s on the environment. For standard m ountain

search and rescue, the pad din g of a soft case, that can be inserted in a

waterp roof bag, may be acceptable. For cave rescue, thou gh, a waterp roof and


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crushproof case such as th ose made by Pelican, or a surplus amm unition box,

is much m ore approp riate. For kits that may be used in both settings, the kit

can be in a soft nylon organizer case, inserted into a w aterproof plastic ornylon bag (or even just a pack w ith a good raincover) for mou ntain rescu e,

and inserted in to a Pelican case or ammo box for cave rescue.

Wilderness medical kits mu st also withstand temp erature extremes

med ications that require refrigeration or a controlled room tem peratu re, or

that are dangerous w hen frozen and rewarmed, are not acceptable.

Information abou t dru g stability und er temp erature extremes is difficult to

find, but some references can be found athttp://www.wemsi.org in the

Pharm acology Lesson Plan.

Wilderness medical kits must also be usable despite occasional outdated

medications medications that are unsafe when outdated, such as

tetracycline, are not acceptable. Medications that still have significantpoten cy after expiration are id eal for wild erness kits. (Most drugs are still

good for a year or two after their expiration d ate, if not grossly abused or kept

at extreme temperatu res, but there are exception s.)

Flexibi l i ty

Wilderness medical kits must have the equipment and medications to hand le

comm on and serious problems. But to save weight, equipm ent and

medications should have mu ltiple uses. Medical kits used by search and

rescue team WEMTs should be u sable for dogs and h orses, as these anim als

are often part of the SAR effort. (Thats wh y the WEMSI WEMT Curricu lumalso contains a section on veterin ary emergencies.)

Ideally, a SAR med ical kit should sep arate into smaller mod ules -- so as not to

have to carry entire kit on every task, especially if it is a "bash" team trying to

get into a patient as qu ickly as possible also to be able to divide the kit

amon g team members. See the Organization section below for WEMSIssolution for this.

Although a SAR medical kit may be used just in one area, it shou ld be

adequ ate for mutu al aid requests to other regions. For example, a North

American SAR WEMT kit should carry m edications for high altitude illness.

Even team s in the Ap palach ian Region of the Mountain Rescue Association,

or the Eastern Region of the National Cave Rescue com mission sh ould carrythese. These out of region med ications could theoretically be left out

except for out-of-region respon ses. On the oth er han d, they don t weigh

mu ch. And , a high-altitude out-of-region response might come du ring an in-

region op eration -- meaning that WEMTs cant go home to get the med ications

that theyve left out. And su dd enly going to altitude w ithout takingDiamox

is definitely not a good id ea.
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Kit Capabil i t ies

There are two m ain targets for the WEMSI Personal Wild erness Med ical Kit.

The first target of the kit is the search su bject or rescue victim. The WEMT

should h ave enough equipm ent and drugs, within th e context of a kit that

weighs less than a p oun d or so and isnt very bulky, to provide stabilizing

care for most severe wildern ess injuries and illn esses. A team with a larger

medical kit will usually arrive within a several hours, and with some items

from a stan dard EMT kit (BP cuff and stethoscope, band ages and dressings,

splints), and maybe some IV fluid s, the WEMT can p rovide reasonably good

care from most common wilderness injuries and illnesses.

The second target of the kit is the field teams members. WEMTs should h ave

enough medication to start treatment for common problems in the field, then

for mem bers to get home, get an ap poin tmen t with th eir family doctor, andhave th e cond ition re-evaluated . Considerin g the realities of both SAR

operations an d getting app ointmen ts with office-based doctors, enou gh for 3

days of treatmen t seems reasonable.

Expense

Some SAR team m embers will have to purchase m edications with their own

mon ey -- man y SAR teams can't afford to issu e expen sive kits to their

WEMTs. Team WEMTs with self-purch ased med ications generally use their

kits for person al trips as well as for SAR operations.

Samp les are often available through p hysician offices, or from m anu facturers,wh ich may h elp decrease the cost of mem bers kits.

Even if the team issues everythin g in th e kits, few SAR teams have m uch

money, so medications and equipment m ust not be too expensive.

Safety

Any wilderness medical kit should contain instructions on the safe use of its

med ications. It is quite possible that the WEMT becomes injured , and a team

member with less training will need to use the kit. And, a reminder about

uses and dosages is always app ropriate for anythin g that isnt used on a

regular basis.

There are (at least) two good app roaches to this. First, the p hysician m edical

director, or prescribing ph ysician, can provide d etailed standin g orders for the

use of medications in certain situations, and a copy of these shou ld be placed

in the med ical kit. Second, a list of med ications, both those in the kit as well

as common med ications carried in w ilderness travelers kits, their comm on

indications, contraindications, dosages, and any cautions, provides a useful

reference. Several of these are available in wild erness first aid books, and


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WEMSI is drafting a pocket wild erness p harm acology reference w ith th e

WEMSI Wilderness EMT in min d. Stand ing orders should be provided by the

WEMTs ph ysician med ical director.

A ccount abi l i t y and Secur i ty

Physicians shou ld be reluctant to prescribe or issue medication to WEMTs

un less the m edications are managed in an acceptable way.

There are two ways for a physician to provide m edications for medical kits.

First is to prescribe the dru gs for each ind ividual WEMT, and expect the

WEMT to use the kit for personal use wh ile in the wildern ess. The WEMT

may then to use these personal med ications for others when n eeded, und er

the various state Good Samaritan Laws, and more importantly, under the

common-law principle that requires one to provide care up to ones capacitywh en aid ing an ind ividual in distress lest one be guilty of gross or willful

negligence.

However, a more professional arrangement is for the p hysician h ave a

ph armacy, usually a hospital ph armacy, issue the d rugs to each WEMT.

Consu lt with th e local Drug Enforcement Ad min istration office, and w ith a

hospital pharmacist experienced in dealing ambulance services.

Many medications in wilderness medical kits are available in inexpensive

generics without a prescrip tion over-the-counter or OTC. While it is

possible to issue OTC medications to each WEMT, the extra cost may be

un warran ted. If each WEMT is responsible for replacing OTC med ications as

they become ou tdated, it may also make sen se to make each WEMT

respon sible for replacing prescription med ications, too. If so, require WEMTs

to inspect their kits on a regular basis, perhaps on ce every two m onth s, and

replace drugs or equipment that are outdated or damaged. Drugs and

equipment used for patient care should be replaced im mediately.

This documen t now provides a place to note the expiration d ate of

med ications, as well a checkbox to use du ring inspections. A Microsoft Word

version of the tables that follow is d own loadable fromhttp:www.wemsi.org --

and then the expiration date can be filled in on ones computer, and a copy

placed in the kit for inspections.

Especially for sched uled dru gs (narcotics) that are issued , it is important to

documen t usage, and to docum ent wh en d rugs are wasted or destroyed.

The local DEA office and a local hospital ph armacist can h elp set up

proced ures to meet federal and state requiremen ts. In general, sched uled

dru gs mu st be kept secure. Durin g wild erness travel, two small, lightw eight

travel locks, one each on external and internal nylon cases provides the dual

locking that is usu ally required; althou gh this is not much of a deterrent,

keepin g the kit in on es pack in th e backcountry is probably better security

than a h eavy steel box in an urban ambulance. However, when a kit is not in
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the backcoun try, it is imperative to keep it secured as well as possible.

Organization

The organization of any kit will be contentious wh enever more than one

person is involved. However, most peop le will agree that making the kit

mod ular, so that a lighter subset can be carried in certain circu mstan ces, or

the kit can be divided among different p eople, is valuable. WEMSI has foun d

it so for our kits, and has organized them as follows. (See Figure.)

Th e Minimum Module is to always be carried by Wilderness EMTs, even if on

a rapid response for a rescue, or on a small, highly m obile scratch ("hasty")

search team. The d esign of several commercial med ical kit bags allows a

pou ch wh ich can Velcro into a larger bag. The smaller pouch w ould be ideal

for the Minimu m Modu le, and the larger bag for the Search Modu le.However, the Minimum Module along with the Advanced Module is big

enou gh that m any WEMTs carry two full-size nylon first aid bags, one w ith

the Minimum an d Advanced Modules, and another with the Search Module.

Th e Advanced Module is for those with ALS (Advanced Life Supp ort) skills

the ability to start IVs and give IV or IM medications, an d to perform d igital

intubation. The Advanced Module is an enhan cement to the Minimum

Module -- every WEMT with advanced training (EMT-Intermediate an d above)

and accreditation to perform advanced skills should carry this additional

modu le whenever on a search and rescue operation.

The Search Modu le should be carried by WEMTs when going on a search, as

opp osed to rescue, task. The Search Modu le is carried for most search tasks,especially if the team is fairly large or will be in the field for an extend ed

period. For some searches, both cave and above groun d, it may be

app ropriate to "stage" a full kit, inclu din g the Search Modu le, at a central

location, easily accessible to all search teams. For a large team that m ay split

up , several WEMTs may each take a Minim um Module w ith only one WEMT

carrying the full kit, includ ing a Search Modu le.

Packaging

First aid kit bags from Atw ater-Carey (1-800-359-1646;

http://www.omnibus.com/atwatercarey/), Outd oor Research(http://www.orgear.com/medical/medical.htm), or similar providers w ork

nicely for organizing the WEMSI Personal Wilderness Med ical Kit. The

Minimum and Advanced modules fit nicely in the Atwater-Carey Expedition

kit bag, and the Search Module fits in an other similar bag. These bags have

the great advan tage of keeping thin gs better organized, imp ortant if you're

usin g the bag all the time.

For above-groun d rescu e, just p uttin g these bags in a p lastic bag deep in on e's
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pack should be adequate protection. For caving, you can pu t the entire

contents into a Pelican case, ammunition box, or Tupperware box that can be

sealed w ith du ct tape.

For pills, it is ideal to have prescription m edications in sep arate blister

packaging from the hospital pharmacy, with an expiration date marked on

each tablet's packaging. Some non prescription m edications are also available

in blister packaging. Most but not all of the blister packs have expiration

dates on them. You can u se a laund ry marker to put expiration dates on each

ind ividual pill's packaging if need ed. For pills not available in blister

packages, its easy enou gh to pu t some in a tiny zip per-lock plastic bag (often

you can get a few free from your local h ospital ph armacist). Print u p a label

on your compu ter with the n ame and strength of the pill, and the expiration

date. Cut out the label, laminate it with some clear tape, and place in the

zipp er-lock bag with the p ills to provide a good label.Some dru gs come only in ampu les that are opened by sn apping off the top.

They h ave the advan tage of being very comp act and light, but th e

disad vantage that they are fragile and d ifficult to pack. Small vials with

rubber p lugs on th e top, covered by flip-off lids, are probably sup erior --

how ever, many dru gs are only available in snap -off amp ules, so you need to

develop packaging for this.

Many peop le have tried many different mean s of packaging. Most of these

have been on small packages people find in th eir "junk" boxes and th erefore

can't generally be reprodu ced by others. What you need is something that is:

cheap , or easy to make

provides m oderate protection against breakage (note that th e outer

packaging of one's med ical kit should also p rovide some p rotection, so

this inner packaging need not be "bombproof" or "caveproof")

light

not bulky

Some have mad e a package using the cardboard "rack" in wh ich amp ules are

shipped in the box. This can be cut down to the right size for the nu mber of

amp ules. One can then cut off a piece of stiff 3/8" closed-cell foam th e same

size as the "rack" and use d uct tape to tape it on the front of the rack. Duct-

tape the bottom, but leave the top open. You can then slide the ampules in

from the top. They seem to stay in just fine with out taping the top. You

could tape some foam or an ad ditional p iece of stiff material to the back to

provide ad ditional p rotection, especially from flexing that m ight break the

neck of the ampu l. But that would add to the bulk and w eight.

For storing medication vials and ampu les, many are pleased with a tiny

Plano fishing tackle box called a Min iMagnu m 3213

(http://www.planomolding.com/tackle/3213.html, available inexp ensively
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from many hardware and sports stores, and via the Internet from suppliers as

http://www.wserv.com/oceanpro/inventory/tbox98.htm) This tiny box has

small comp artmen ts the perfect size for two small med ication vials, and witha tiny bit of padding in each small compartment, provides shock protection,

as well as organization. With some mod ification (cutting) with a h ot

soldering iron or a tool such as a Dremel drill with a small cuttin g saw, the

larger vials of ceftriaxone an d w ater for dilution will fit into th e larger

comp artments of this box.

Repackaging fluids such as StingEeeze, povadon e-iodin e and tincture of

benzoin in to smaller bottles can save weight and bulk, provided th e bottles

don t leak all over the insid e of the kit. StingEeze can be rep ackaged in a

4cc eyedropp er type bottle, available from sup pliers such as Cat No.

0300710A from http://www.fisherscientific.com/, and povadone-iodine

solution an d ben zoin can be repackaged into eight-cc Nalgene bottles,

available from supp liers such as http://www.fisherscientific.com/, Cat No. 02-

923-11A, NNI No.: 2002 9025.
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MedicalMedicalMedicalMedicalKitKitKitKit

SystemSystemSystemSystemOverviewOverviewOverviewOverview

Notes:

1. See WEMSI Team Medica l Kit

and Personal Wilderness Medical

Kit document text for details.

2. Minimum Module carried by all

WEMSI medics at all tim es.

3. Advanced Module carried only by

WEMSI medics w ith ALS

accreditation, at all times.

4. Search Module carried by WEMSI

medics when on a search or otheroperation (i.e., not a rescu e) or as

an option on some rescues.

5. A Personal Wilderness Medical

Kit is to be included in the

Team Medical Kit

6. Items such as litters considered

part of Team Rescue Equipm entrather than Team Medical Kit.

7. Team Medical Kit divided into

modules so can be d istributed

among mem bers of team; or,on some operations, only

selected mod ules may be

carried into field.

Wilderness EMS

Institute


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Min imum Module1Prescription-only items are noted by !!!!

Names are U.S. generic and tradenames. Items removed from version 1.1 noted bystrikeout, items added to version 1.1 underlined; both types of changes also noted bya vertical line in the margin.

Exp2Date

# Item and size/strength Usual DosePain Meds3

20

10

ibuprofen 200 mg tablets (e.g.,Advil,Nuprin,Motrin)4naproxen 220 mg tablets (e.g., Aleve)5

Pain:ii PO, then i PO BID

25

12

!!!! acetaminophen w ith hydrocodone

tablets (e.g., Vicodin ,Lortabs,

Anexsia

: 500 mg acetaminoph en, 5mg hydrocodone)6,7

Pain:ii PO Q4H PRN

Allergy Meds1 !!!! injectable epin ephrine anaph ylaxis

kit (Epi-Pen ) (may omit if haveadvanced m odule w ith injectable

epinephrine)

anaphylaxis:i injection

1 !!!! albuterol Rotocap inh aler8

48 !!!! Rotocap albuterol capsu les forabove9

asthma:

i cap Q4H PRN

6 diphenhydramin e 25 mg tablets (e.g.,

Benadryl)10

allergy/sedation:i-ii PO Q4H PRN

20 5

!!!! Prednisone 1050 mg tablets11,12,13 allergy/asthma:50 mg PO QAM

GI Meds1412 loperamide 2 mg. tablets (e.g.,

Imodium-AD)

diarrhea: ii PO, then iPO q loose BM up to

7/day

10 !!!! prochlorperazine 10 m g. tablets (e.g.,Compazine)15,16

4 meclizine chewable 25 mg. tablets

(e.g., Bonine, An tivert)17

motion sickness:i PO TID PRN

4 !!!!TransDerm Scop transdermal

scopolamine patches

motion sickness:

i to skin Q3DBites and Stings 18

1 Saw yer Extractor Kit as directed

1 Sting-Eeze solution 15 cc bottle19,20 as directed

Cardiac Meds30

4

Asp irin 325 mg (5 gr.) tablets21,22 chest pain:i PO

6 !!!! nifedipin e 10 m g capsules (e.g.,


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Exp 2Date

# Item and size/strength Usual DoseProcardia,Adalat)23

1 !!!!bottle nitroglycerine spray (e.g.,

Nitrolingual)24

chest pain:i spray SL Q3 PRN

Antibiot ics Etc.2524

6

!!!! erythromycin tablets 250 mg

tablets26

azithromycin 250 m g tablets (e.g.,

Zithromax )27

infection:ii PO, then i PO daily

12 !!!! ciprofloxacin (e.g., Cipro) 250 mg.tablets28,29

3 Bacitracin or povadon e-iodine

ointmen t1 g foil packets

30

!!!! 3.5 g tube p olymyxin/bacitracin

(e.g., Polysporin) or bacitracinophthalmic ointment31

wounds:to skin BID

1 mild liquid soap 30 cc bottle, e.g.,Hibiclens; or, a smallpiece of solid soap (to save w eight) ; or, a sm all (e.g., 8 cc)

bottle of waterless han d san itizer32,33

1 Povadone-iodine solution 15 cc bottle (e.g.,Betadine)34

Thermometer1 Becton-Dickinson digital thermometer (may substitute Radio

Shack or similar contin uou s-readin g digital thermom eter)

1 spare battery for above

10 thermom eter covers for above35,36

Misc.4 thiamine (vitamin B-1) 300 mg.

tablets37

starvation, prior torefeeding: i PO

4 !!!! haloperidol 5 m g. tablets (e.g.,Haldol)38

sedation:

i-iiii PO

2 packets Gatoradeor ERG powd er, each to make liter

24 pair exam gloves39

1 pocket CPR shield

1 1" (by at least 10 yards) waterproof adhesive tape40

31 small prep ackaged u nits of tincture of benzoin 41

8 cc bottle tincture of benzoin42

6 sterile cotton app licators ("Q-tips")43

1 3" by 5 yards (stretched) elastic bandage (e.g.,Ace, Coban,Vet-Wrap )

1 3" by 5 yards (stretched) conforming roller gauze (e.g.,

Kling)

8 med ium -size (e.g., 3" x 3") gauze pads 44

12 OB-type comp ressed vaginal tamp ons45


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Exp2Date

# Item and size/strength Usual Dose3 small pieces of clear adh erent d ressing (e.g., Tegaderm,

OpSite)46,47

3 #11 scalpel blades, sterile

1 string for ring removal

1 paper clip, medium size48

2 large safety pin s

1 nylon zipp er bag or equivalent for MedKit

1 waterproof contents/protocols/standing orders49

5 one-pint freezer-style zip lock plastic bags (if not available

elsewhere in SAR pack)

2 small (5-staple) skin staplers50

5 WEMSI Patient Record Forms

51

5 WEMSI Patient Record contin uation sh eets


14/26


A dvanced Module52 Prescription-only items are noted by !!!!

Items removed from version 1.1 noted by strikeout, items added to version 1.1underlined; both types of changes also noted by a vertical line in the margin.

Exp

Date# Item and size/strength Usual Dose

2 !!!! ketorolac tromethamine 60 mg.

injection (e.g., Toradol)53

2 !!!! morp hin e sulfate 10 mg/m L, 1 mL

vials54

pain:2-10 mg IV Q10-Q4HPRN5-10 mg IM Q-4H

PRN

24!!!!

naloxone 1 mg/m L, 1 mL amp ul (e.g.,Narcan)

excess narcotic:1-4 mg IV/IM

1 !!!!midazolam 5mg/mL, 10 ml vial (e.g.,Versed)55

sedation:3-5 mg IV Q10

seizure:14 mg IM

1 !!!! ceftriaxone 2 g powder, an d sterile

water 10 mL, for reconstitution (e.g.,

Rocephin)56

infection/open

fracture:2 g IV/IM

2 !!!! epinephrine 1:1000, 1 mL ampul:

substitutes for Epi-Pen in basic kit

anaphylaxis/severe

asthma:0.3-0.5 cc SQ Q10

2 !!!! diph enhydramine 50 m g/1 mL vial

(e.g.Benadryl)

allergy:

50-100 mg IV/IM

2 !!!! prochlorperazin e injection 10 mg/2cc

(e.g., Compazine)57

2 !!!! haloperid ol 5mg/1cc in jection (e.g.,

Haldol)

4 !!!!drop eridol 2.5 mg/mL, 2 mL vial sedation/nausea:2.5-10 mg IV/IM

2 !!!! dexamethasone 10mg/mL, 10 mL vial

(e.g.,Decadron )58

6 alcohol prep pads, in foil

1 Tubex injector59

2 !!!! 1 cc syringes2 !!!! 3 cc syringes

2 !!!! IM need les

2 !!!! SQ needles

2 !!!! 18 ga, long, over-the-needle IV catheters60

1 venous tourn iquet (for startin g IV)

2 saline lock61

1 20 cc bottle saline flush solution


15/26


Exp


1 !!!! 6.5 mm end otracheal tube621 One-way valve for end otracheal tube63


16/26


Search Mod ulePrescription-only items are noted by !!!!

Items removed from version 1.1 noted by strikeout, items added to version 1.1underlined; both types of changes also noted by a vertical line in the margin.

Exp


Pain M eds Etc.30 acetaminop hen tablets, 325 m g (e.g.,

Tylenol)64

pain/fever:i-ii PO Q4H PRN

4 !!!! cyclobenziprine 10 mg. tablets (e.g.,

Flexeril)65,66

4 !!!! phen azopyridine hyd rochloride

tablets, 200 mg (e.g., Pyridiu m )67

UTI symptoms:i PO TID

Cough, Cold, Allergy Etc.681 315 mL squeeze bottle oxymetazoline

nasal spray (e.g.,Afrin)69

nasal congestion:i spray BID PRN

8 12-hou r sustained -release

pseu doep hed rine tablets 120 mg. (e.g.,

Sudafed)

nasal congestion:i PO BID PRN

8 12-hou r sustained -release

chlorpheniramine tablets 8 m g. (e.g.,

Chlor-Trimeton)70

allergy symptoms:

i PO BID PRN

8 dextromethorphan-containin g cough

drops (e.g.,Hold)!!!!

Humibid-DM

tablets

71

cough:

i PO PID PRN

Eye1 !!!! 1 mL dropper tube tetracaine

ophthalmic solution

painful eye exam:2-20 drops

3 fluorescein strips72 as needed

1 !!!! 3.5 g tube p olymyxin/ bacitracin (e.g.,

Polysporin ) or bacitracin ophth almic

ointment73

1 2 mL drop per bottle cyclopentolate

ophthalmic solution 0.5% or 1% (e.g.,

Cyclogyl)

corneal abrasion orsnowblindness:

GI12

8

antacid tablets

famotidine tablets 10 mg (e.g., Pepcid-A C)74

reflux/hyperacidity:

i-ii PO BID PRN

4 bisacodyl tab lets 5 mg (e.g.,

Dulcolax )75,76

12 bismuth subsalicylate tablets (e.g.,

Pepto-Bismol )77

Allergy


17/26


Exp


1 !!!! 15 g tube fluocinolone acetonid ecream 0.2% or similar high-strength

steroid cream or lotion (e.g., Valisone,Benisone,Lidex , Kenalog,

Aristocort, Uticort, Synalar)

allergic rash/insectbites:apply to rash QID

PRN

1 !!!! 1 oz. tube Pram osone 1% orAveenocream 78

itching:apply to skin Q4HPRN

Altitude Etc.796 acetazolam ide tablets 250 mg (e.g.,

Diamox )

preventing AMS: tab (62.5 mg) PO

BID

treating AMS/HACE:250 mg PO BID

!!!! nifedipin e capsu les 10 mg (e.g.,

Procardia,Adalat)HAPE:10-30 mg PO QID

Misc.1 15 g tube micon azole nitrate cream 2%

(e.g., Micatin ,Monistat)10 mL bottleclotrimazole solution (e.g.,

Lotrimin )80,81

fungal skin infection:apply BID-QIDyeast vaginitis:i m L intravaginally

daily

1 1 cc TB syringe, no n eedle (as vaginal app licator for above

antifungal)

1 pair small sharp scissors (not necessary if available onWEMT's pocket knife)

1 pair fine-point splinter forceps (not necessary if available on

WEMT's pocket knife)

1 SamSp lint or equivalent flexible splint 82

4 3" x 4" pieces of moles kin

10 sma ll adhesive band ages (e.g., 1" x 3"Bandaids,Coverlet)

3 small p ieces of clear adheren t dressin g (e.g., Tegaderm,OpSite)

5 med ium -size "sutu re strips"83

6 sterile cotton app licators ("Q-tips")84


18/26


Physician A ddendumThis provides some general ideas for items that physicians may want to add to theirkits; for purposes of standardization, recommend packaging this separately from the

other kits.

Exp

Date# Item and size/strength

penicillin

ciprofloxacin (e.g., Cipro) 250 mg. tablets

caffeine pills85

trimethoprim/sulfamethoxasole

Duragesic p atches

midazolam

ketamine

IV thrombolytic86

a cobalt blue p enlight

a pocket otoscope and opthalmoscope

prescription p ad

Merocel epistaxis tampon s

a Foley catheter

local anaesthetic

wire saw for amputations87Kelly clamp

needle holder

suture material

12 bisacod yl tablets 5 m g. (e.g.,Dulcolax )


19/26


Notes(new notes since version 1.1 are in italics)

1 Some have suggested to move 2/3 of each of the analgesics, etc. into the search kit, but this

makes the kit as a whole m ore cumbersome; also, it makes it more likely that the min imum kit

will be out of a medicin e when n eeded.

2 Some of the over-the-counter (OTC) m edications recom m end ed for this medical kit do nothave expiration dates stamp ed on them . For such m edications, we recomm end that WEMTsenter an expiration date two years from the date p urchased an d inserted in the m edical kit.

3 In Minimum Kit because: WEMT-Basics may need to give pain m edications to the injured to

assist self-rescue.

4 Oral pain medications may allow a patient to self rescue and th us are part of the Minimum

Kit. The Advanced Kit contains injectable narcotics but a basic provider might have to use the

kit and thu s should h ave access to oral medications.5For all intents and p urposes, naproxen has the sam e side effects and efficacy as ibup rofen,

but can be taken on ly twice a day as comp ared to ibup rofen. Nap roxen is also availablewithou t a prescription as an inexpen sive generic. Som e feel that choline/m agnesium salicylate

(e.g., Trilisate), althou gh a prescription d rug, m ay be a better drug than nap roxen. However, atpresent, this is still a minority opinion , and th e m ajority recom m end staying with aninexpensive OTC drug. See http://www.pitt.edu/~kconover/ftp/trilisate.htm for details and

share your opinion s with the wilderness-emergency-m edicine Internet discussion list,instructions for subscribing at the beginning of this docu m ent..

6 Some su ggested sublingual m orphin e as a nonin jectable stronger narcotic; I've not been able to

find any morp hine p roducts marketed for this use, nor any good information on any p ill

formulations that could be used this way. Also suggested was Duragesic slow-release

fentanyl patches; however, they take a long time to build up , and th us are not very app ropriate

for imm ediate acute pain. They might be acceptable for long-term pain relief during an

evacuation, but that's not the purpose of this personal wilderness m edical kit. They might

make a good addition to a team kit.

7In light of our attem pts to lighten the kit, and the tim e span for which the k it is designed, we

decreased the nu m ber of hyd rocodone/acetaminoph en tablets.

8 Comm ent> I would recommen d usin g a metered dose inh aler rather than RotoCaps in a

wilderness environm ent. Though it is controversial, man y of my pu lmonary colleagues think

there are poten tial problems usin g RotoCaps in hum id (i.e., coastal, rainy, the South in the

summ er) environmen ts. When hu mid, the particles may aggregate and not be deposited

effectively in the distal airways.

Reply> Interesting. I hadn't heard about this. A dispenser and th e four rotocaps that fit inside

(with a little trimm ing of the blister packages) is less than h alf the size of a metered-dose

inhaler, and about a fourth the weight. And rem ember, we're asking people to carry this stuff

with them _all_ the time. Is the extra weight worth it? Ask your pulm onary friends, add in

your own mem ories of carring a pack during a long search, and please get back to me with yourthoughts.

Another comm entor also queried whether there wou ld be problems with the Rotohaler working

well in the field.

Re-Reply> When I queried the attend ings I have heard express skep ticism over the u se of

powd er inhalers in the p ast, none of them could provide a reference to supp ort their claims.

On searchin g the literature, I could find little objective data to substantiate this as a big

problem . In fact, the best article (Hiller et al, J. Pharm aceutic al Sci 1980; 69(3):334-7.)

indicated th at ALL aerosols tested h ad increases in p article size at high hu midity and that

MDI's [Metered Dose Inhalers] tended to be MORE unstable than powder-generated aerosols!


20/26


Given these facts, I retract my concerns about use of powd er inhalers an d vow to distrust all of

my attend ings for at least 6 mos.

I still think MDI's might offer some advan tages in term s of # of doses per oz. and m ore universal

knowledge of techn ique, but I don't feel strongly enough to recomm end one system over theother. The poin t may become moot over the next few years as CFC's are banned in oth er

produ cts and the p rice of MDI's goes up (maybe a lot) since the prop ellant will be less widely

available.

9Experience with severe asthmatics in the backcountry has led m any to recomm end m ore

albuterol.

10Comment> Does one need two sedating antihistamines (benadryl and chlortrimeton?

Perhaps Seldan e would be p referable to the latter.

Reply> 1. Don't like the Seld ane/erythro interaction.

Reply> 2. Seldane is a p oor antihistamine for acute (as opp osed to chronic) use.

Reply> 3. We wanted both a short, strong-acting antihistamine (diph enhyd ramine=Benadryl)

for acute short reactions (beestings, dystonic reactions, etc.), and something longer-acting for

more long-lived p roblems (rhinitis, poison ivy, etc.) and Chlor-Trimeton 12 mg extended pills

are the least sedating good Q12H antihistamine we cou ld find.11 In Minimum Kit because: may be needed to treat bronchospasm or allergy, and the epi and

albuterol will wear off in relatively short order (hours).

12 Comm ent> I would recommen d more p rednisone tablets. 60 mg is one dose for an asthma

exacerbation.

Reply> Agree. Increased from 6 to 20 to allow multiple large doses for problems such as high

altitude cerebral edem a, severe allergy, or severe asthma.

13 Predn isone is available in 10 m g, 20 m g, and 50 m g tablets. Th e usual dose of prednisone forsevere asthm a or allergy is 40-60 m g daily, and lower dosese are rarely n eeded , so switching to

50 m g tablets decreases the weight and bulk of th e kit slightly withou t any significant increasein expense.

14 In Minimum Kit because: motion sickness, vomiting and diarrhea may all immobilize a

rescuer.15 Comm ent> I think comp azine sup positories might be preferable to pills, but I recognize the

storage p roblems etc.

Reply> People can grind up a pill, mix it with an M&M from their gorp, or some antibiotic

ointment, and make their own suppository.

16 Many people qu estioned the u tility of an oral m edication for nausea and vom iting, other than

a chewable pill for m otion sickness (meclizine), and th ough th e pills could p otentially be usedas a sup pository, the u tility seem ed so low th at we h ave rem oved this m edication.

17 Commen t> GI: Isn't meclizin e an Rx in the U.S.?

Reply> If bought as An tivert, yes; if bought as Bonin e, no.

18 In Minimum Kit because: bites and stings occur unpred ictably and th ese treatments mu st be

applied immed iately to be of any use. Local sting treatment is included because the pain from

mu ltiple stings may be disabling to a rescuer.19 Commen t> Is Sting-Eeze of proven efficacy?

Reply (KC)> No good scientific evidence I'm aware of, but anecdotally it works like a charm.

It's a witches' brew of all available OTC anesth etics and stin g relievers. I've used it with good

success m yself; it really helps.

20 Fifteen ccs is a lot to carry for som ething that is u sed in 0 .5cc doses, max . It is easy to

repackage som e of this in a sm all dropper bottle, e.g., a 4cc eyedropp er type bottle, Cat No.:0300710A from http://www.fisherscientific.com/.

21 In Minimum Kit because: aspirin so important in th e early treatment of unstable angina or


21/26


MI, which is becoming more common in th e wilderness.

22 We have d ecreased the d ose, relying on naproxen and hyd rocodone as analgesics, and

reserving aspirin for use in chest p ain.

23 Comm ent> Advanced stuff: I would add su blingual nitroglycerin and/ or paste to the list.

Reply> They d on't last long in a pack, especially in the sum mer and if being kept in a car trun k;

keeping things updated in a SAR pack is a big problem, too. We decided to simply rely on

nifedipine for vasodilation, coronary disease, etc. See below.

24 Nitroglycerine sp ray repu tedly h as a longer shelf life, and better heat resistance, than the

pills. A lso, nifedip ine is m uch ou t of favor for the treatm ent of chest pain, due to the

hyp otensive effect. Th erefore, we have m oved nifed ipine to the altitud e section, because it isstill invaluable for high altitude p ulm onary edem a, and ad ded nitroglycerine spray. When

going to altitud e, the nifedipine an d acetazolam ide can be transferred to the Minim um Kit if

desired.

25 Both erythromycin and cip rofloxacin in Minimum Kit because: might have patient with

open fracture and w ish to administer oral antibiotic immed iately; might have team mem ber

with severe d iarrhea wh o needs ciprofloxacin imm ediately; antibiotics may be lifesaving if thepatient is ill with a serious infection rather than in jured.

26 Comm ent> Rather than erythro, you might consider one of the newer m acrolides.

Azithromycin, thou gh costly, offers the advan tages of good GI tolerance (and we're in the

woods after all) and the ability to carry a 2 week course in 6 pills.

Reply> Yes, but Zithromax [azithromycin] is _very_ expensive, and these peop le need to buy

their own d rugs. If it were the same cost as erythro, would agree. It's also pregnancy category

B, unlike Biaxin [clairythromycin], so azithromycin is a better ch oice for that reason.

However, unlike erythro, azithro is not a ped iatric medication.

Many others suggested azithrom ycin as an alternative, and that samp les are available; but dou bt

we can get enough samp les for all who will need it.

Decreased from 40 to 24; this w ill provi de 6 d ays of 250 QID, or 3 days of 500 QID. Resisted th e

temptation to go with just 500 m g tablets; 250 mg tablets allow spacin g doses better for those

with GI intolerance.

27 We had initially not consid ered az ithromycin becau se of cost, but it now less expen sive,covers m ost bacterial and atypical path ogens likely to affect team m em bers in the backcou ntry,

is safe in pregnan cy and in fancy, has few side effects, and can be taken once a day, im provingcom pliance. Az ithromycin is also now used routinely in all ped iatric age groups, anoth er

argum ent in its favor. Som e recent references includ e the following:1. Hopkins SClinical toleration an d safety of azithrom ycin

Am J Med 1991; 91:40S-45S2. Kuschner RA , Trofa AF, Thom as RJ, et al.Use of azithrom ycin for the treatment of Cam pylobacter enteritis in travelers to Th ailand, an

area where ciprofloxacin resistance is p revalent

Clin Infect Dis 1995; 21:536-413. Juck ett G

Prevention and treatm ent of traveler's d iarrhea

Am Fam Physician 1999; 60:119-24, 135-64. Hoge CW, Gam bel JM, Srijan A , Pitaran gsi C, Echeverria PTrend s in antibiotic resistance amon g diarrheal pathogens isolated in Th ailand over 15 years

Clin Infect Dis 1998; 26:341-55. Khan WA , Seas C, Dhar U, Salam MA, Benn ish ML

Treatmen t of shigellosis: V. Com parison of azithromycin an d ciprofloxacin. A dou ble-blind,randomized, controlled trial

Ann Intern Med 1997; 126:697-703

6. Shan ks GD, Ragam a OB, Aleman GM, A nd ersen S L, Gordon DM

Azithrom ycin p roph ylaxis prevents epidem ic dysentery


22/26


Trans R S oc Trop Med Hyg 1996; 90:3167. Mu rph y GS, Jr., Eche verria P, Jack son LR, et al.Ciprofloxacin- and azithrom ycin-resistant Camp ylobacter causing traveler's d iarrhea in U.S.

troops dep loyed to T hailand in 1994Clin Infect Dis 1996; 22:868-98. Bessette RE, Am sden GW

Treatmen t of non-HIV cryptosp oridial diarrhea with az ithromycin

An n Pharmacother 1995; 29:991-39. Kuschner RA , Trofa AF, Thom as RJ, et al.

Use of azithrom ycin for the treatment of Cam pylobacter enteritis in travelers to Th ailand, an

area where ciprofloxacin resistance is p revalentClin Infect Dis 1995; 21:536-4110. Uchino U, Kanayam a A , Hasegawa M, et al.

[Effects of azithromy cin on fecal flora of healthy ad ult volun teers]Jpn J A ntibiot 1995; 48:1119-30

11. Rak ita RM, Jacqu es-Palaz K, Murray BEIntracellular activity of az ithromycin against bacterial enteric path ogens

An timicrob Agents Chem other 1994; 38:1915-2128 Some have argued for the add ition of various favorite antibiotics: cephalexin, amon g others.

We have resisted the temptation to p rovide an an tibiotic for every conceivable condition,

instead trying for one with good gram positive coverage that can be given to just about anyon e

(erythromycin), and one with excellent gram n egative coverage, includin g all common cau ses

of infectious diarrh ea and UTIs.

Changed from 20 to 12. This sh ould provid e 6 days of 250 BID, or 3 days of 500 BID.

29 Azith romycin is now a secon d-line drug for infectious d iarrhea, especially in areas wherepathogens have d eveloped resistance to quin olones such as ciprofloxacin; azithrom ycin is alsoa reasonably good drug for UTIs and th erefore we have decid ed to elim inate ciprofloxacin from

the d rug list.

30 Can also be used as lubricant if needed.

31

Ophthalmic antibiotic ointment can be used for skin wounds, but not vice versa (the skinformulation is irritating to the eye).

32 Solid soap is not ideal, but is much lighter, and can be combined with some povadon e-iodine

solution for antibacterial effect.

33 Waterless han d san itizer is now widely available in the U.S., and for clearing hand s ofbacteria and viruses, is repu tedly as effective, if not m ore effective, than soap an d w ater.

34 Comm ent> Do we need Hibiclens?

Reply> Dun no about Hibiclen s; might be nice, but again it's heavy. Plain soap (Dr. Bronner 's,

or whatever one's carrying) is probably OK.

Some su ggested u sing foil packets of povadon e-iodine solution; however, we've talked with

enough peop le who've had them explode in their m edical kits to stick with the m ore-rugged

15cc bottles.

35 Can use antibiotic ointment as lubricant.

36 Many have foun d th at heat or pressure in p ack m edical kits causes the covers provided with

m ost digital therm om eters to becom e unu sable. A few sma ll pieces of kitchen p lastic wrap

wrapped around the thermometer can serve as a substitute.

37 Comment> Why do we need thiamine?

Reply> To give to people who have been starving for a long time (i.e., weeks) when first feeding

them, to prevent card iovascular collapse (get a copy of the curren t Section 4 of WEMT

Curriculum from http://www.wemsi.org/, if you w ant the details).

38Comment> I'm not sure I see the need for PO Haldol.


23/26


Reply> EMT-Basics need to sedate patients, too.

39No stethoscope is included, as can sim ply place ear against the chest or abdomen for lun g or

heart or bowel sound s; and, BP cuff and stethoscope too heavy and of only min or utilitycompared to the weight.

40Increased from 3 to 10 yards, and added the word "cloth," to allow for taping an ankle

securely with the conten ts of just one p ersonal medical kit.

41This was ad ded due to the great difficulty of getting tape or even Bandaids to stick in wet

weather.

42 We h ave foun d th at a Nalgene or similar HDPE bottle provides a m uch m ore durable form

of benz oin; and benz oin loose in a m edical kit can be extremely d estructive. Eight-cc Nalgene

bottles are available from sup pliers such as http://www.fisherscientific.com/, Cat No.: 02-923-11A , NNI No.: 2002 9025, for approxim ately US$0.50 each in lots of 12, as of fall 1999.

43 These were moved to the Minimu m Module to allow for application of benzoin.

44 Some have su ggested the ad dition of a triangular bandage; however, this can usu ally be

improvised from someth ing such as the tail of someone's shirt; or, duct tape can be usedinstead.

45 This makes a com pact but very absorbent d ressing; some suggested add ing various types of

trauma d ressing, but we opted to pick something that was very small, not wan ting to increase

the size of the kit. Of course, it can also be used as a tamp on for a female patient w ith

menstru al flow.

46 Several people suggested add ing these, as they are ideal field dressings: waterproof but

vapor-permeable.

47 Moved to the Minimum Module both to protect team m ember wound s against contam inationby patient bod y fluids, and to provide IV site dressings.

48 For trephining subungual hematomas.

49 Will be provided by WEMSI.

50 Discussions about th e app ropriateness of woun d closure in the field continu e to rage, in thestreet prehosp ital com m un ity as well as in the wilderness EMS com m un ity. A d etailed

discussion is beyond the scope of this docum ent, but the principles that guided us in ad ding

this stapler included : 1) the wilderness is at least as clean as m ost Emergency Departmen ts,at least in terms of v irulent and resistant bacteria; 2) delayed p rim ary closure at four d ays fromthe in itial wound provides excellent results, comp arable to p rim ary closure; 3) repairing

comp lex woun ds is a skill that takes mu ch training and experience, certainly beyond the scopeof a stand ard Wilderness EMT class; 4) staples are easier to use than sutures, m ore secure than

sutu re strips for patients or team m em bers who are actively assisting in their own evacu ation,stapling of simp le woun ds can be learned in a few h ours, and is a relatively low-risk p rocedure;and 5) patients can bleed to death from relatively minor woun ds, especially scalp woun ds, and

especially when coagulopathic from hyp otherm ia, du ring long evacuations. Th erefore, we areincluding skin stapling for simple wounds and badly bleeding wounds, especially scalp

woun ds. 3M Precise DS-5 staplers are available from m any sup pliers; in 1998, th ey wereavailable for less than US$7.00 each from http://www.pssd.com/.

51 These can be download ed from http://www.wemsi.org/and printed locally.

52 Physicians may want to add : penicillin, caffeine pills for caffeine withd rawal headach es,

trimethoprim/sulfamethoxasole, Pyridium , Duragesic patch es, IV mid azolam , IV ketam ine, IV

thrombolytic (Eminase is at present the best choice, as can be used in a single dose, though

quite expensive), a cobalt blue p enlight, a pocket otoscope and op thalmoscope, a p rescription

pad, Merocel epistaxis tampons, a Foley catheter, a small skin stapler, some local anaesthetic,

wire saw for ampu tations, and a Kelly clamp, need le holder, and suture m aterial, at least for


24/26


tying off bleede rs.

53 Recent studies e.g., [Turturro MA, Paris PM, Seaberg DC. Ann Emerg Med August 1995;

26:117-120. for exam ple] show k etorolac no better for m uscu loskeletal pain than oralibup rofen; therefore, we have deleted this med ication. In this double-blind, placebo-controlled

stud y, not only were 800 m g of PO ibuprofen an d 60 m g IM ketorolac ind istinguisha ble as far asdegree of analgesia, they were ind istinguishable in terms of time to analgesia!

54 We discussed dilaudid as a possible alternative to morphine; however, many more people

know the dosage for morphine than know the dosage for dilaudid. An d since it is possible,even likely, that this kit m ight occasionally be used by som eone wh o is familiar with a stand ard

paramed ic drug like m orphine, but n ot dilaudid, we elected to stay with m orph ine.

55 Over the years, we have had m any d iscussions about the possible use of m idazolam, oranother benzod iazepines such as Valium . Midazolam acquired a bad reputation wh en large

doses (10-15m g IV p ush ) were used for sedation for endoscop y, without either visual or pu lse-ox m onitoring of ventilatory status. However, sm aller doses (4-6 m g IV p ush for the usu al

adult) provide excellent relaxation, sedation and amnesia for common wilderness proceduressuch as d islocation reduction. An d, larger doses (0.2 m g/kg, about 14 mg for an average adu lt)can be u sed IM for control of seizures. It also has the ad vantage for wilderness redu ctions that

it wears off in about half an h our, leaving the patient ready to assist in rescue efforts. As a

result, we have add ed a single m ultidose vial in the most advan tageous concen tration. Th isrepresents m ore m idaz olam th an is likely to be needed , but is still lighter than an ad equate

dose in man y more containers. Other long-acting benz odiaz epines such as Ativan or Valium

were considered, but the short action and rapid IM absorption led u s to chose Versed.

56 Comm ent> I would consider increasing ceftriaxone to 2 g for a full 24 hrs su pply.

Reply> Agree.

57 Droperidol is increasingly used for both sedation and nau sea, and th us p rovides a single drugthat can be used to substitute for two drugs, prochlorperazine (e.g., Com paz ine) and

haloperidol (e.g., Haldol)

58 For treating high altitud e cerebral edema, asthma or other bronchospastic problems, or severe

allergy.59 We have found that Tubex ampules are not appropriate for most wilderness kits. Many ofthe am pu les, for instan ce the 10 m g Morph ine am pu les, are partly filled with air; and , whenthey get warm , the air expan ds, pu shing out the red rubber plug and emp tying the contents of

the am pule into ones pack. Therefore, we have abandon ed T ubex am pules entirely.

60 For relieving tension pneu mothorax.

61 By add ing saline locks an d a saline flush, WEMTs at the scene can start an IV an d give

m ultiple doses of IV m edications. Too, it is often easier to start an IV before the p atient haslost mu ch fluid, an d wh en IV sup plies arrive, the IV can easily be inserted into the saline lock.We discu ssed add ing a small bag of IV solution to the search kit for exam ple, Navy SEAL

team m em bers always carry a 250cc bag of Hespan in a pan ts pocket but finally decided that

for civilian u se, the usefuln ess was not worth th e weight.

62

Can be placed by digital technique even without a laryngoscope.63 The endotracheal tube can be p laced (and covered with on e thickness of a gauze pad to

prevent insect entry) and used withou t artificial ventilation, for exam ple, in airway burns.

However, if mou th-to-ET-tube ventilation is necessary, a one-way valve p rovides the WEMT

protection from contam ination from the p atients airway secretions. One-way valves with filtersare available, but are generally bulky and heavy, an d p rovide only incremen tal protection overa good one-way valve. One sm all, light on e-way valve that works with an en dotracheal tube is

that m anu factured by Laerdal for use with pock et mask s; the on e-way valves are availableseparately from m any supp liers, including item #36295 at h ttp://www.m ooremed ical.com.


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64 Comm ent> Does one really need aspirin an d ibup rofen? Both d ecent analgesics and NSAIDs.

Reply> Yes, but aspirin can be used by itself for the anti-platelet effect, for example for a

studen t at our last WEMT class; he had coronary-ish ch est pain first relieved by SL NTG but

later returned an d it was unrelieved by NTG. Aspirin is imp ortant for this. And, some peoplereally do better with aspirin than acetaminoph en or ibup rofen for minor aches, or at least think

they do.

65 Comm ent> Rather than cyclobenziprine, valium (though more of a hassle to get and keep

secure) would be more versatile and is an effective muscle relaxant.

Reply> Recent research show th at benzodiazepines d on't really do much to relax muscles, and

that Robaxin and Flexeril (cyclobenziprine) are m ore effective.

Comment> I would also favor the addition of an injectable benzodiazepine.

Reply> For sedation? Can use haloperidol for this. For muscle relaxation? See comm ents on

Flexeril, above.

66 We finally con cluded that th e benefits of cyclobenz iprine (e.g., Flexeril) for mu scle strains isreally quite minim al comp ared to analgesics, rest and stretching. Th erefore we removed th is

from the list.

67 UTIs are more common am ong women than men . Men: if you'd like to leave this out, pleasesee the comments un der antifungal cream.

68 Th e need for, or at least desire for, these m edications can b e sup ported by a trip to an y local

drugstore and a look at the shelves.

69 As of Sep tem ber 1999, 3 m L "samp le" or "travel" bottles of oxym etazoline n asal spray arenot available in th e U.S. However, A frin and some other brands of ox ym etazoline nasal spray

are now available in 15 m L bottles, which are relatively small and light.

70 We chose both long-acting and sh ort-acting antihistamines because th ey have different uses.

For example, stings or other acute allergic reactions usually need only short term treatmen t,

and d iphen hydram ine can also be used as a short-acting sedative. whereas the sustained

drying effect of sustained-release chlorph eniramin e is id eal for viral URIs.

71 Dextrometh orphan -containing cough d rops are no longer generally available in th e U.S.

However, Hum ibid-DM, a com bination of guiafenesin (a possibly-effective expectorantm edication, reputedly to m ake it easier to cough ou t m ucus) and d extromethorphan in asustained -release combin ation that lasts 12 h ours, is still widely available in ph armacies in th e

U.S. and , though it requires a prescription, is a lighter form of the effective cough su pp ressant

dextromethorphan.

72 Comm ent> Eye: Fluorescein strips. Should a blue light be on the list?

Reply> Nice, but the fluorescein even works pretty w ell by daylight or min i-MagLite, and a

blue pen light add s a lot of weight for only a little benefit, compared to the fluorescein strips,

which weigh basically nothin g.

73 Moved to the m inimu m kit where can also be used for skin wou nds.

74 Fam otidine is an inexp ensive, highly effective meth od for controlling gastritis or reflux extremely common problems during SAR operations due to lack of sleep, stress, and excess

caffeine consum ption. Fam otidine tablets are considerably lighter and sm aller than en oughantacid tablets to provide a sim ilar effect.

75 It was suggested that we cu t down on the n um ber of these tablets; though constipation can be

disabling, it's not usually as disabling as diarrhea. Changed from 6 to 4.

76 After long discu ssion, we elected to leave this out of the k it althou gh constipation occurs

frequently in the outdoors and d uring SA R m isions, and som etim es leads to abdom inal pain,

constipation is seldom recogniz ed as the cause, and th us the d em and for laxative pills is low inthe field. A laxative is still app ropriate for distribution as n eeded at the S A R base camp .

77 Since we have a H2blocker, and Imod ium plu s an antibiotic are better treatm ent for


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gastroenteritis, the bismu th tablets seem su perfluous.

78 Aveeno cream has recently become available. Both Pramoson e and Aveeno contains

pramox ine, a topical anaesthetic that is non-sensitizing (non-allergy-provokin g, un like man yother topical agents includ ing diphen ydram ine, e.g., Benad ryl). Th us both are highly

effective for the pain or itching of sunbu rn or poison ivy. A veeno, un like Pramoson e, doesn' tinclud e hyd rocortisone. However, the an ti-itch and anti-allergy effects of hydrocortisone are

m inim al com pared with the high-strength steroid cream , listed above. Av eeno also includes

oatm eal and calam ine, which are also good top ical anti-itch agents.

79 Oral dexam ethasone [e.g.,Decadron] not carried for high altitude cerebral edema, as 30 m g

of predinsone is equivalent to the 4 m g dexamethasone dose u sually used for HACE.

80 Lotrisone was suggested as an alternative for "shotgun" therapy of itchy rashes or vaginitis.

At present, we are still staying with separate an tifungal and steroid creams, as m ore effective

and more flexible.

One suggestion w as to use the n ew, highly effective antifungal terbinafine (Lamasil) instead ofmiconazole. However, it is prescription-only, costs 2 to 10 times as mu ch as m iconazole, and

there is no information on w hether or n ot it can be used to treat yeast vaginitis.

Women reviewing this medical kit have almost universally demand ed somethin g for yeast

vaginitis. Therefore, we discoun t suggestions that we drop this med ication if the suggestion

comes from a man .

81 We also discussed th e use of an oral antifungal, as is com m only u sed to treat yeast vaginitis;how ever, these oral regim es are not currently accepted for jock itch and athletes foot, which

are also com m on w ilderness afflictions. We realized that, to be effective for yeast vaginitis,

antifun gal cream need s to be app lied with an intravaginal app licator, as com es with Monistat-7 and sim ilar vaginal antifun gals. However, such antifu ngal cream /ap plicator com binationsgenerally includ e m ore than 15g of cream, and are relatively heavy 3 oz. We realized that

Lotrimin solution is effective for the organism s that cau se yeast vaginitis, athlete's foot, andjock itch. An d a 10 m L bottle of Lotrim in solution weighs only 1 oz. An d a 1 cc TB syringe,

withou t needle, m akes an ex cellent lightweight vaginal app licator; one can easily pull thedropp er top off of the Lotrimin bottle and suck u p a 1 m L daily dose of the Lotrimin solution

and apply intravaginally.82 Some suggested the addition of a traction d evice; however, a traction device can usually

(though not always) be improvised with m aterials at hand .

83 Removed butterfly strips as suture strips mu ch sup erior.

84 Moved to Minim um Module.

85 For caffeine withdrawal head aches.

86 Eminase is at present the best choice, as can be used in a single dose.

87 WEMSI condu cted some informal research on m ethods of amp utation in confined spaces includ ing races between d ifferent m ethod s. The w inner overall was a two-step process using aserrated lockback folding kn ife to cut through skin , tendon , soft tissue; and then u sing a folding

camp saw to cut the bone. Th is one topic engendered a long discussion on the wilderness-

em ergency-m edicine Internet discussion list see www.wemsi.org for the list archives.

Medical - Wilderness Med Kit

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