While categorization has proven helpful for students to learn what to include in their medical kits, some items cross over from one category to another. An example would be a triangle bandage, which can be in Orthopedics for an ankle brace, in Wounds for a packing or dressing, or Personal Protective Equipment (PPE) as mask for either your patient or yourself.

Selection of medical gear is often trip specific and can be designed for anticipated conditions. Examples include the following:

Look for multiuse items, items that others have found useful in the operational environment. Quantities needed and price are some of the consideration factors of what to include in the kit.

Organize equipment by categories in different colored, numbered, or named clear-sided bags, pouches, or compartments to be easier to locate during emergency. Each bag could include nitrile gloves to save hunting for or forgetting them. Pint and quart zip freezer bags are inexpensive and more durable than ordinary sandwich bags for this use.

Size of all gear, especially that of little use for most outdoor ventures, is usually a factor best held small. It is said you can only pack so much in a 5-lb sack before it explodes. The number of people with you, the number of days, your level of skill, how much you want to spend, and the method of carrying it all are decisive. The size of your kit will vary by preference and level of training. Advances in training seem to bring a bell curve of kit size, with the less critical and improvisational items eventually being left at home than carried in a backpack.

Typical guidelines for minimum kit sizes are 1 lb for day hike for four people, 2 lb for overnight trip for four people, and 3 lb weekend kit for four people. Medical or rescue packs often weigh 5 to 10 lb (Figure 7.2). Military field medics often carry 90 to 100 lb medical gear plus 35 lb personal gear. In consequence, they commonly experience foot, ankle, knee, and shoulder injuries one might expect from carrying such a heavy weight.

Basic airway equipment in the wilderness is a mask or shield to keep infectious organisms in the patient and avoid exposing rescuers to them. Size 100 oral pharyngeal airway (OPA) will fit most adults. Add a size 80 for large children and small adults. We suggest the Guedel style OPA. A new OPA is NUZON (Figure 7.4) with three times the price but one adjustable size. Nasal pharyngeal airways (NPAs) are questionable because there are too many sizes (26) and lube is required. Our favorite bag valve mask (BVM) is Pocket BVM by PerSys Medical, sometimes called the Israeli or micro BVM (Figure 7.5). It is the size of a medium tuna can, is made of silicone, and could be cold sterilized for reuse. It weighs 453 grams. Note it does take effort to repack unless you watch their video or you sandwich bag the mask separately. The easiest-to-use new airway is the supraglottic i-gel (Figure 7.6). It has two sizes fitting most adults, and no laryngoscope is needed for its 30-second insertion. H & H Medical Company produces the Bolin Chest Seal, three valves in line for small storage space, and a modestly priced chest decompression needle.^* On November 15, 2015, H & H Medical released an enhanced pneumothorax
needle of a Veress style, similar to a trocar, which should prevent catheter collapse issues^* (Figure 7.7). Manual suction pumps such as Rescue-Vac and others found on many ton rigs in the EMS gear carry or jump bag will rarely be in a backpack kit, so we will improvise with the patient’s cut-off drink bladder hose for suction. Aluminum O₂ set-ups are at base camps and rescue caches but rarely carried to the field. If carried, rescue crews typically have two E cylinders in a pack by themselves or a modified C with other gear in a multi-item rescue pack. The size, function, output, and price of O₂ concentrator still make them impractical for most applications in the backcountry.

Some expedition or advanced WEMS kits have additional advanced items: tool set for suturing comprising needle holder, Addison tissue forceps, Kelly hemostat, curved Metzenbaum scissors, plus a variety of internal and external suture packets. If there is concern for the need to intubate (Figure 7.8), you may be carrying laryngoscope parts for the EENT Corpsman Set from CMF Inc., consisting of fiber optic blade (mac or miller) and handle complete at 4 oz. You probably will also carry two of each #6, 7, 7.5, and 8 endotracheal (ET) tubes. With a shortened #6 ET tube, Kelly hemostats, #10 scalpel, and a News Tracheal Hook such as offered by H & H and you have an improvised cricothyrotomy kit very close to those also offered by H & H.²

Hemorrhage control products are critical. During the Vietnam era, a sanitary napkin with tails was called the “Blood Stopper” and became the new battle dressing. Military conflicts often bring new products, such as the first compression bandage, the Israeli-developed compression bandage, followed by the far superior American-made, Cinch Tight and H Compression bandages from H & H used by the United States Marine Corps (USMC) (Figure 7.9). Clone compression bandages are available, but usually cost as much or more sometimes with less durability and efficacy. Although a compression bandage can be improvised, they are slower and less effective than the factory ones, which have a tensioning mechanism.

Tefla plastic-covered gauze makes abrasion wound care less painful for the patient, and several 3 × 4 pieces should be in each kit. If you are working around or responding to hunting camps, you may choose to carry three XSTAT 30s (three is their recommended number).² These are injectable plastic pellets in large (6-inch) syringes cleared by the Food and Drug Administration (FDA) in December 2015 for gunshot wounds. XSTAT 30 is not intended for many areas of the body, such as the chest, abdomen, pelvis, or tissue above the collarbone. The sponges in XSTAT 30^* can be used for up to 4 hours, according to the FDA. Cinch Tight and H Compression bandages with a hemostatic agent do not have those restrictions.

The tried and true original hemostatic agent QuikClot (QC) in any of its several forms has saved many lives. Even in its original heat-producing form, a retrospective study with 103 seriously wounded military and civilians showed all who received prompt field application survived. The use of hemostatic gauze (QuikClot Combat Gauze; Z-Medica LLC; www.z-medica.com) in prehospital civilian care is safe and highly effective, with success rates of 95%. This is from the retrospective Mayo Clinic study, which included 203,301 Gold Cross Ambulance and 8,987 Mayo One Transport records; 52 patients were treated with hemostatic gauze in the prehospital setting.³

Other common hemostatic agents are Chitosan, ChitoSam, or HemCon all made with shrimp shell material of varying percentage. On my request, SAM Medical had a study conducted in Taiwan, showing there were no iodine allergy issues with their ChitoSam production.

A chemically treated gauze called ActCel Hemostatic Gauze has been in dental use to control bleeding for years with good anecdotal results.

Tourniquets have once again gained favor in a way not seen since the American Civil War. Of course, amputations were common surgical interventions then, and we hope less so today with modern surgical techniques. You should use a tourniquet when bleeding is heavy, especially in patients on anticoagulants, antiplatelet agents, or hemophiliacs. This includes bleeding suspected to be arterial, which cannot be rapidly controlled with a compression bandage, giving concern for hemorrhagic shock. Full amputations often have some crushing effect that slows down blood loss, while partial amputations often have a “torn or nicked” artery than cannot constrict as easily and need serious help to control. In the urban setting and many combat situations today, the patient is rushed to the hospital for surgery within 30 minutes. When tourniquets are left on for longer than 4 hours (some say 6), we have a different situation leading to potential limb loss. H & H Medical have done work indicating that a good compression bandage will stop many horrific bleeds without a tourniquet.²

Most advanced care givers are sure they can improvise a fine tourniquet, but Lyles et al. in 2015 suggested improvised tourniquets may not be as efficacious as commercial ones. This study, which looked at two types of improvised tourniquets versus the commercial Combat Application Tourniquet (CAT), showed the improvised tourniquets to be inferior.⁴ However, quality training, and most importantly practice with proper materials (strong 1-to-2-inch webbing with strong twisting stick), could change that outcome. Although CAT may be the most popular, H & H has the smallest, the Tourni-Kwik 4 (TK4) (Figure 7.10), which performed with equivalent efficacy to the CAT in United States Navy testing.⁵ In this particular Navy testing, the operators ranked Bound Tree Medical’s Mechanical Advantage Tourniquet (MAT) as their most favorite, with CAT and TK4 coming to a close second.

Traditional EMS textbooks discuss 60-cc bulb syringes for irrigation, but it is rare to see more than a 20-cc syringe in a backpack. The syringe is usually a Luer Lok style with injection needles for epinephrine (22 ga), antibiotics (18 to 16 ga), and large-bore plastic wound irrigation tips plus smaller dental irrigation metal side port tips. Occasionally, some providers will have a 60-cc Luer Lock for irrigation and 5 to 20 cc for injections. Katadyn has an irrigation needle tip for their “BeFree” hollow fiber either with pint or quart soft squeeze bottles, which with the addition of their chlorine dioxide tablets (MP1) give a great backcountry wound irrigation with local water (Figure 7.11).

Medical tape in a WEMS kit needs to be strong with more glue than found on the cheaper brands. I recommend Johnson and Johnson (J&J) or the upper-price-point athletic brands in the 1.5 inch × 10 or 15 yd cloth rolls. The cheaper tapes have significantly less glue, so they do not hold as well. Prepping the skin with benzalkonium chloride (BZK) wipes both cleans and disinfects, reducing risk of infection and removing skin oils for better adhesion. Sepp applicators of tincture of benzoin (TB) will give even better adhesion. Caps on bottles of TB are prone to leak and may destroy your pack. Although we recommend Sepp applicators, if buying in bottles, transfer contents to
high-quality small bottles like Nalgene travel bottles. Providers should still double zip bag all liquids for more pack protection. A field improvisation of TB is tree sap.

“Superglue” products (Krazy Glue and other brand names) are less expensive than various medical-grade glues such as Dermabond, which are specifically designed and FDA approved for wound closure. All these cyanoacrylates compounds work similarly, using the water from the skin to create a strong bond. Some patients find nonmedical glues are more irritating and create a “burning” sensation, likely because of solvents present in them but excluded from medical formulations. According to its creator, Dr. Harry Coover, Super Glue was used in the Vietnam War to help close wounds on soldiers.⁶ But as Forgey points out, “cleaning is more important than closing.”⁷ That is critically true with glues that contribute to a bad infection reaction if germs are sealed in. Although acetone and finger nail polish remover often remove the glue, some glues are difficult to remove. Clean scrupulously first. We recommend using a bioclusive dressing like Tegaderm as a covering to allow vapor out yet prevent infectious agents from entering a wound.

A comprehensive dental kit can be built for less than $100 and used after only a few hours training that could relieve a lot of pain by installing a filling, replacing a crown, doing an emergency root canal, replacing an avulsed tooth, or removing a tooth.

Moleskin used to be the standard, and still may be the only, blister prevention product available in thin form. We suggest using it in a laminated blister treatment package with Spenco Second Skin, adhesive knit, and TB to hold the protective pack together. Two top blister products today are Comped and Liquid Bandage, both from J&J. Little known but really great products are Engo patches, which are uniquely applied to shoes, sandals, or boots themselves to keep the blister from forming (Figure 7.12).

Sucking chest wounds can be treated with a plastic ziploc bag taped on all four sides, leaving the lowest or downhill corner untapped to allow venting (Figure 7.13). In Wyoming, the Asherman chest seal was created by a former Navy SEAL and since 2000 is owned and sold by Rusch. Although there are a few similar devices today, the three in-line valved H & H Bolin Chest Seal is our favorite and was preferred to the Asherman seal in a United States Navy study (see Figure 7.7).⁸

Triangle bandages are far more versatile if they are 45 × 45 × 63 inches at a minimum, made out of sheet-like material (tightweave muslin) versus cheap-kit cheesecloth. You can cut four corners off an old worn-out bedsheet and the two short edges are already hemmed. Washing them with hot water and a little bleach followed with a hot dryer, then folding them to a small package and putting in a zip bag makes them almost sterile and very useful. WMO prints key points on their triangles in bright block letters (Figure 7.14). Bandanas, although handy for some camp and personal chores, are too small for the many medical uses triangle bandages serve. Red or orange are used by some for emergency signaling, with blue or black for heat-absorbing headwear and white for heat-reflecting headwear.

Duct tape, Gorilla tape, or other strong-adhesive tapes can be very handy in many improvisational situations yet should be used with caution on the skin as they may have damaging effect. When thinking of better skin care, Tefla- or plastic-covered gauze is best for the first wound gauze layer as it is far less painful to remove. Nonlatex Band-Aids in 1-inch and gauze pads of 4 × 4 inches can be made both smaller or into different shapes like eye patches so fewer items need be bought and carried. The same is true with the 1.5-inch athletic tape mentioned earlier, as it can be cut or torn to smaller sizes from the 1.5-inch size carried. The newest entry in this field would be wound-closure sheets of clear plastic covered in heavy glue, available from several sources. In its simplest form, it is a temporary wound closer for limbs or torso, folded or rolled sheet to close an open wound on limbs or torso approximately 8 × 7 inches. It helps keep contamination out and blood in, and can be used to seal open lung air passage ways.⁹

Other items of dual use would include 5 × 9 inches abdominal pads or individual wrapped sanitary napkins and small tampons for intended use or for epistaxis/nose bleed and for modest wound packing. The Rhino Rockets, solely for nose bleeds, are rarely carried backcountry but could be carried by a WEMS team if felt to be particularly helpful in a given operational environment, yet this is a single-use item that can be improvised by multiuse ones. A spare diaper could also be a large abdominal wound pad. Coban, COFLEX, and various stretch self-adhesive rolls offer better bandage securing than mere roll gauze. Many vet products are cheaper and are as effective as higher-priced items intended for humans, although application of veterinary products in an EMS environment may not be permitted by a medical director. There is a place for elastic wraps, but not as frequently as some seem to use them, because they do not have a predictable amount of support or compression as solid cloth rolls do.

If actual wound closure is necessary after thorough cleaning and is permitted by the provider’s scope of practice, it can be done with suturing, stapling, or with a multimedia wound-closure processes, taught by some wilderness EMS schools, that takes far lower level of skill than suturing.^* With regard to suturing, aside from the small discussion earlier in this chapter, we will not go into details of equipment needed because entire books are dedicated to this topic, this is typically a clinician-level skill only in the civilian EMS environment, and choosing and carrying a variety of suturing material possibly needed is a complex and clinician-dependent decision. Staplers^* are more likely to be available to a broad array of EMS provider types by scope of practice and may have more usefulness in a wilderness environment in balancing amount of different equipment that must be carried versus chance of necessary use. While Ethicon has made staplers in operating room pistol size for years, they are not as reasonably sized for field use as is 3Ms, which is only 3 × 1 × 0.5 inches. One also needs the staple remover, which is packed in a 2 × 1 × 4 inches case, as infection could require early staple removal. There are some staple size variations. Commonly, regular 5.4 × 3.6 mm or the wider 7 × 4 mm skin staples are used.¹⁰ Implications for various provider types are discussed below because wound-closure techniques have a wide variety of scopes of practice in EMS.

In the context of wounds in general, a more complete discussion of wound management can be found in Chapter 21.