Although it is still unrealistic to carry a laboratory analyzer in the physician’s bag, some point-of-care testing consisting of small analyzers using cartridges could be transported. Such tests typically evaluate cardiac-related processes such as troponin and beta-natriuretic peptide, but other additional testing such as electrolytes may also be available. For a physician traveling to an austere environment, such equipment may be desirable, especially if members of the group are older and/or have existing illnesses. Such portable blood analyzers are less likely to benefit the tactical physician on a deployment or rendition. Equipment recharging capability may be available by employing one of a host of over the counter solar recharging kits often capable of slowly charging batteries in portable devices. One piece of equipment that provides broad diagnostic imaging capability is found more and more frequently in tactical and austere settings [5–9]. As Fig. 29.1 shows, the portable ultrasound machine has its place in tactical medicine as well as in austere environments.

The remainder of the gear focuses on critical procedures and traumatic injury care. Since blunt trauma is always a risk, the equipment bag should include a cervical collar and splinting material, the latter of which could be of the inflatable variety. Almost like an athletic trainer, tape and bandages are important to have. In reality, one would bring much of the trauma bay if room allowed. Equipment trays take up too much space, but essential sterile pieces can be brought. Chest tubes, typically two, suture equipment, and a stapler are essential. Clotting material such as a lava rock product is imperative along with tactical tourniquets for hemorrhage control. Compression devices to occlude the abdominal aorta or ipsilateral common iliac artery may be lifesaving in cases of inguinal wounds where hemorrhage cannot be adequately controlled with local compression [10, 11].

Intubation equipment is likely to be limited to one handle and one or two blades as well as several endotracheal tubes. A cricothyrotomy kit is essential, as well as a bag valve mask apparatus. Suction is typically limited to a large syringe and rubber tube to suction the mouth and airway if absolutely needed.

Medications are essential, including intravenous fluids, but providers are unlikely to have more than one or two doses of any medicine, and carrying more than one or at most two liters of fluid may significantly weigh down the medical bag. Antibiotics are more critical for longer expeditions, and a large portion of the pack may have to be devoted to a variety of antibiotics, antiparasitics, and antifungals, depending on the destination. Antibiotics carried would include broad spectrum drugs in states not requiring refrigeration. Coverage would typically include skin, bowel pathogens, and urinary tract and pulmonary tract pathogens. Realistically, a handful of antibiotics such as a third-generation cephalosporin, a broad spectrum fluoroquinolone, and a lincosamide can be used to cover a broad swatch of bacterial illnesses encountered. Tactical physicians will have few antibiotics, mostly in the case of open fractures and deep penetrating wounds providing coverage for skin and bowel pathogens. These would be given when immediate evacuation is impossible such as in a relatively remote area or when the area may remain unsecured for a prolonged period of time, limiting emergency medical services (EMS) or aircraft access. Essential medications include paralytics and sedatives along with standard advanced cardiac life support (ACLS) medications such as epinephrine, atropine, and others. Pain medications are likely to be required with penetrating wounds and blast injuries as well as blunt trauma.

Procedures such as intubation, thoracostomy tube placement, and peripheral and central line placement are performed in much the same way one would in a trauma bay or ICU setting. Intraosseous (IO) access can be a rapid, albeit a very temporizing, measure to obtain access. The inherent vulnerability of an IO line to unknown dislodgement is exaggerated in the field where the patient may be moved rapidly and roughly due to terrain, weather, or even gunfire. However, no backup is likely to be available and, other than portable ultrasound, no follow-up imaging to confirm either chest or endotracheal tube placement. Pain control may be required in either tactical settings or austere environments; in either case, capabilities to provide long-term pain management are likely to be limited. In some cases, nerve blocks may be ideal in dealing with significant extremity injury especially in settings when evacuation is likely to be delayed.

Procedures are likely to be performed in less than satisfactory conditions and improvisation may be required. An example is a resuscitation during a SWAT team deployment in Columbia County, Georgia, in 2006. A SWAT team containing two tactical physicians entered a house of an armed barricaded suspect. Upon entry, the suspect produced a handgun and shot himself in the left anterior chest. The suspect was in impending respiratory arrest but continued to struggle and resist assessment and treatment within the confines of his small bedroom. A peripheral IV was established and the patient was given etomidate and succinylcholine. However, during the struggle the IV infiltrated and he did not receive the medications. Additional saline for dilution of the succinylcholine was unavailable, and the physicians mixed the last dose of etomidate with the powdered succinylcholine. The medication was injected directly into the suspected femoral vein due to the failure of another IV line. The patient was bagged and rapidly intubated. Auscultation, however, revealed no breath sounds in the left chest even after endotracheal tube withdrawal. The patient’s chest was needled and physicians proceeded to place a thoracostomy tube. The equipment bag had been overturned and bedsheets mixed with the equipment. Additionally, electrical power was cut during the raid, and procedures were performed under illumination of SWAT team weapon’s lights. Clamps for blunt dissection to the ribs and penetration into the thoracic cavity could not be located. After scalpel incision, the physician placing the chest tube was forced to bluntly dissect with his thumb through the soft tissue and was able to penetrate through the chest wall, releasing a large amount of air. The chest tube was inserted but no needle drivers could be located to suture the chest tube in place. A utility tool borrowed from a SWAT team member was used to complete suturing. A latex glove with a finger cut distally was taped at the end of the tube to act as a Heimlich valve. A large quantity of chlorhexidine was available and used extensively during the procedure. The patient was later airlifted and survived to discharge. He required no surgical intervention during his stay in the hospital.