What’s in your first aid kit?

[Michael Gardner]

I don't know that it is toxic. As Dean had mentioned, it has a nasty exothermic reaction. So, I'm guessing it has been known to cause burns or tissue damage around the wound. He also mentioned that it was a pain in the butt for the surgeon to remove at the OR.

http://www.z-medica.com/quikclot/index.asp

The bandage that I had was called the QuickClot Sport. The website boasts that it has a cooler, less exothermic reaction (105 F max) and it is contained within a surgical sponge. Of course, this is coming from their wedsite and the do have a product to sell, so take it for what it's worth. The original QuickClot is packaged in a powder form and is meant to be poured directly on to the wound. Maybe this is what Dean was refering to. I could see where that would be a hassle to remove later.

The USMC had reported that QuickClot was either blown away or would not come in contact with the wound during arterial sprays. Sounds like they are refering to the power form here. http://www.defensetech.org/archives/000458.html. Not sure which form the Military is using.

Dean?

[Brad Groves]

Hey-
Love the conversation so far! Thought I'd throw in my cent. I'm a former ski patroller, SAR member, W-EMT, paramedic. (I got off the street, and I'm living in a horrible place right now for the wilderness aspects.)

I struggle at paring my kit down, too. Frankly, I haven't had the heart to weigh it recently. Guess I'll have to when I get home. Many of my trips are 10 days+, and I tend to bring a little extra.

There was a question or two about 5x9s. The most common reason I've seen for needing them "out there" is for knife or wood-cutting slips. Whittling, cut through stick, run knife through leg… On non-weight-conscious travels, a bad coincidence of foot and ax… I've just been taking along a maxipad for major bleeds.

I've always got a couple bandanas for headwear, pot gripper, etc., which do nice double duty as sling/swath, compression wrap, tourniquet, and so forth.

Assorted band aids (esp. knuckle/fingertip). Superglue! Plenty of Benadryl, ibuprofen. Iodine wipes. Usually have some whisky along–hey, it's double-duty! I've taken the "nip a corner off a ziploc" route for irrigation, snagged from my food bag.

Duct tape from the repair kit for… whatever. The heaviest two things are probably an Ace wrap and a partial roll of Coban. (Figuring sprains are usually about the worst I'll face.) The friend I'm normally with is diabetic, so there's usually some form of glucose in the kit.

I've always got one of those tiny space blankets for emergency thermowrap, signalling. Oh, and yes, a 14G.

Aloksaks are great. I really like the Equinox tripper travel bag organizer, though. It weighs 1.6 ounces, and I use it to organize compass, whistle, and all those other random miscellany things along w/first aid stuff.

[Michael Gardner]

I have to say that I'm a little suprised (maybe relieved) that I found company in those carrying a 14g. To think, I thought I was just being overly prepared. I suppose the weight of it is trivial if you know why you carry it and how to use it. As Dean mentioned, a tension pneumo, which can obviously be fatal, is easy to treat.

I'm going to have to seriously look at this 5×9 thing since that seems to be an item I've seen come under some scrutiny since I started this post. After all, I too carry a bandana and a pair of clean(er) sleep socks.

Is that maxie pad with or without those little wings? ;)

BTW… I'm partial to Southern Comfort myself… makes my belly warm.

[Dean F.]

Agree with the nontoxic but otherwise annoying properties of QuikClot. The military version is indeed a powder, but I haven't seen it in a while. We are issuing HemCon bandages to every soldier now, so that if you come across a wounded soldier you just pull his own bandage out of his kit and use it. (On a more morbid note, during Desert Storm I was issued my own body bag, and had to carry it around…)

Brad,
Do you really need an ace-wrap AND Co-Ban? Both will give compression, and the Co-Ban is lighter, if not as durable and not as re-usable.

PR (rectal) rehydration is a well-established technique, and doesn't require sterile IV fluid, though the water should at least be potable. And, yes, it does work just like an enema- the colon is a very efficient water scavenger. (I can't remember how quickly you can give it, but I sure wouldn't dump 3L in at once.) The technique is still taught to military medics, for use in tight situations where they have run out of fluid or angiocaths or whatever. The patient has to be conscious enough to make the effort to retain the fluid, though. Historically it was used a lot in children, who would then have their buttocks taped together. Nowadays we tend to do intraosseous infusions.

[Some medical advice removed, at the recommendation of counsel… :-) ]

I emphasize that everyone makes their own choices, especially in the UL community. As I said, I really have to restrain myself sometimes (before I discovered UL I used to carry an army Field Surgical Kit) and I'm trying to help other enthusiastic would-be wilderness savoirs to do the same. Mike, if the 5×9 works for you, keep it. Hell, I carry a huge, clunky Suunto MC-2 compass because, for me, orienteering is half the fun, and I want a precision instrument. And, as I said, if I'm the "medical guy" for a group I still tend to go overboard. I might even bring ABD pads, let alone a 5×9.

Yeah, the pericardiocentesis is something that doesn't get tried until the patient has died at least once and you haven't got anything to lose. Unless, of course, you have an ultrasound and you see the hemopericardium on the FAST exam- in which case, go for it. (For those who care, FAST stands for Focused Abdominal Sonography for Trauma, and includes a look upwards at the pericardium.)

The kind of cyanoacrylate used most commonly for medical purposes (i.e. Dermabond) is indeed different from plain superglue. It is a high-viscosity formula that you can apply in several layers to make a thick coating over a wound. The resulting cap is sort of rubbery. Normal superglue- and a few cheaper medical formulations- are almost the same viscosity as water. Side-note: don't get superglue on cotton- it causes an exothermic reaction that can start a fire. Voice of experience, there…

I'm sure that others have heard of http://www.wilderness-medicine.com ? I have never taken one of their courses, not least because they are geared more toward EMS and SAR than physicians, but they sound interesting. I also went to a rather unique medical school that issued me a great book called Wilderness Medicine, that has over 1500 pages and weighs approximately 7.2 tons. Mine is an older edition, but see:

http://www.amazon.com/Wilderness-Medicine-5th-Paul-Auerbach/
dp/0323032281/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1215334254&sr=8-1

I split the URL for justification reasons, so you'll have to cut and paste the two halves. Sorry. Apparently the new edition is over 2300 pages!

It is NOT a book for laymen, and it is expensive, but if anyone here has some medical training and enough of an interest it's a great book. It isn't just about practicing medicine in austere environments- it also describes appropriate hospital treatment for injuries that are peculiar to wilderness, like frostbite, envenomation, plant toxicity, altitude sickness, and dysbarism. And it also has a chapter on surviving wildfires, and one on natural disaster management. There is a WHOLE CHAPTER on wilderness medical equipment, and the justifications for bringing each item, including antibiotics.

I've heard of using maxi-pads as dressings before, so don't hesitate to ask any women in your hiking group if you find that you need one. (And many are self-adherent!) For that matter, I've heard of using tampons to pack bad nosebleeds and gunshot wounds, too. No kidding. It has to be uncomfortable, though.

[John Haley]

My kit weighs 2 oz. Since 95% of my hiking is done solo I carry what I can administer to myself. Butterfly strips, antibiotic ointment, Benadryl, some Moleskin along with a tiny half roll of medical duct tape. As an EMT with many decades of experience I depend upon being able to adapt for emergencies, and realize that in a time of severe trauma it is basically impossible to treat oneself. Some deep cuts and gouges haven't been a significant problem, but shredding a meniscus during an isolated winter hike while days from anywhere was…. but a ten pound kit wouldn't have helped much.

[Dean F.]

As a mental exercise, i have thought more about the Co-Ban. You can tape an ankle with duct tape, though probably not as easily, and it is much more multi-purpose than Co-Ban or ace. So, just take a little more duct tape.

Of course, this is coming froam a guy who carries a 14g angiocath…

Also, the Medipore tape deserves special mention. (Also called Hypafix, or Mefix.) It is a "fluffy" porous surgical tape that:

A) can be used like any other medical tape
B) can be used as second-string moleskin
C) makes a decent burn dressing by itself

But, of course, it still isn't as multi-purpose as duct tape. Still, I would bring some if I was the 'medical guy' for a large group.

[Brad Groves]

Dean,
I've really enjoyed your insight and expertise here. The Co-Ban thing, I dunno, guess it's just a hang-up for me so far. Ultimately, I like the stuff a lot better than ace wrap. But if I'm on an extended trip, the Co-Ban just wouldn't hold up to repeated on/off for soaking in cold water or whatever, whereas Ace excels. I've found that the Co-Ban works great for actually keeping small "dressings" in place on weird curved places or some articulations. My brain's a bit fuzzy on the name right now, but I think there's either a micro-pore or derma-pore I've used as a great tape for holding in less-than-ideal conditions, but… it is extra weight. One other reason I've carried it in the past was for taping bum ankles and such.

You've got me thinking now. Perhaps this is purely academic, but could using duct tape to tape ankles lead to circulation/perfusion problems? What I'm thinking is that over the course of a day's hiking, feet tend to swell up decently. Ace wrap can expand with that swelling. Tape can't. For sports like B-ball or soccer, the ankle might only be taped a couple hours. I'm approaching this primarily from more of a multi-week trip perspective where there's not really a choice of extrication or backtracking a day. What do you think? Problematic or not?

Ohhhhh… Ouch. When I played soccer, my ankles usually got wrapped with pre-wrap first. My trainer got tired of doing that, and started taping onto the top inch or two of leg hair to encourage me to shave. So maybe ankle-type taping should include a razor of some kind?! :-)

[John S.]

FDA Requests Boxed Warnings on Fluoroquinolone Antimicrobial Drugs

The U.S. Food and Drug Administration (FDA) has notified manufacturers of fluoroquinolone antimicrobial drugs that a Boxed Warning in the product labeling concerning the increased risk of tendinitis and tendon rupture is necessary. Through its new authority under the Food and Drug Administration Amendments Act of 2007 (FDAAA), the agency also determined that it is necessary for manufacturers of the drugs to provide a Medication Guide to patients about possible side effects.

The risk of developing fluoroquinolone-associated tendinitis and tendon rupture is further increased in people older than 60, in those taking corticosteroid drugs, and in kidney, heart, and lung transplant recipients. Patients experiencing pain, swelling, inflammation of a tendon or tendon rupture should be advised to stop taking their fluoroquinolone medication and to contact their health care professional promptly about changing their antimicrobial therapy. Patients should also avoid exercise and using the affected area at the first sign of tendon pain, swelling, or inflammation.

The medications involved in this action are: Cipro and generic ciprofloxacin, Cipro XR and Proquin XR (ciprofloxacin extended release), Factive (gemifloxacin), Levaquin (levofloxacin), Avelox (moxifloxacin), Noroxin (norfloxacin), and Floxin and generic ofloxacin.

[Dean F.]

I can't tell if you are merely being informative, John, of if you are arguing against fluoroquinolones.

Yeah, that announcement was met with a gigantic yawn by the medical establishment. It's an adverse effect that has been known for a very long time. But EVERY medication has adverse effects- you just have to be aware of them and make educated risk assessments. (Which, arguably, is my entire job.) And fluoroquinolones are probably, as a group, one of the most-used antibiotics at the moment. (Total guess, that, but they are used A LOT.) And most of the tendon ruptures were after taking the drug for weeks.

Fluoroquinolones are great drugs, broad-spectrum, and safe. Don't let the new warning mislead you.

[Roger Caffin]

> Yeah, that announcement was met with a gigantic yawn by the medical establishment. It's an adverse effect that has been known for a very long time.
True, but the Boxed Warning on the packet is a different matter.
Haven't you noticed that many pharmacists stick a large adhesive label over the technical information on the packet, thereby preventing the consumer (the patient) from reading the data? It is almost as though the medical system is telling the the consumer to shut his eyes and just do what he is told.

What we need is a new law banning the obscuring of the tech data on the packet, so the consumer can be more educated. Won't solve all the problem, but it might help a bit.

[John S.]

Dean, hopefully you don't claim to speak for the U.S. medical establishment since you don't live here. Europe can ignore whatever warnings they want to. I tend to respect the US FDA when they speak since I got my M.D. degree in this country.

Cipro is a common antibiotic taken on backpacks. If I was over 60, I'd consider taking something different with that information. As always, the older members of this group should talk to their own physicians about it.

In this country, if you were to prescribe that to a susceptible person after a warning goes out and they incapacitated themselves on the trail or worse, you could have some splaining to do to the local judge if/when they filed a lawsuit.

[René Enguehard]

While I don't presume to speak for Dean I think the point he was trying to make is that while it has now been established that there is an accrued risk associated with fluoroqinolones this had already been suspected. Moreover, it's really in when you use them. Sometimes the risk is worth it, some times it isn't. As doctors it's your job to figure that out for the patient which, most of the time, doesn't know anything about these risks, let alone how to weight the risks.

I would tend to agree that giving anything that could weaken tendons to a person over 60 that is going backpacking is a bad idea. However, giving the exact same thing to a 30 year old 9-5 working stiff that commutes from home and doesn't do much of anything might be the best choice.

Also, to my knowledge, in most countries if you prescribe something to someone and they hurt themselves because of it you, as a doctor, are liable. Not just in the US. Even in Europe. :P

As for the technical data obscuring ban, I would tend to agree. Technical data is important and consumers should be able to clearly see it. If not, why print it in the first place? Problem with that is there are boxes where there is nowhere else to place the label. In this case pamphlets in the box are the best solution. IMHO, IANAL, etc., etc., ad nauseam.

[Bob Ellenberg]

I don't think I saw these mentioned and I carry the ones from a Swiss Army Knife (but not the knife)and have used them for splinters and would think for some debris in a wound.

Do any of the rest of you think these are important and if not, how would (do) you remove splinters?

[Michael Davis]

I agree that tweezers are important. My tweezers are part of my Leatherman micro tool. At 1.7 oz I get a lot of use for the weight. Wouldn't leave home without it!

Micro tool includes:
scissors
tweezers
knife (1.5")
nail file
bottle opener
screwdriver standard
screwdriver for glasses
screwdriver phillips

Other first aid items included
ibuprophen
imodium
anti-gas
assorted bandages
neosporin
insect repellent
sandwich bag for irrigation
duct tape for wrapping sprains
hydrocortizone

[Richard Matthews]

Bob,

At my age I need a magnifying glass to make tweezers work. My compass has the magnifying glass and the Buck 350 pliers work for things like cactus needles. The Buck 350 also has tweezers for splinters and I carry a needle in my repair kit.

I do not build fires and none of my gear is wooden. It has been year since I had a splinter.

I have no idea while Buck quit making the 350.

[Jeremy Greene]

I love the idea of tweezers, unfortunately many are difficult to use. The ones on my Leatherman micro can come out of alignment (it stays at home). Victorinox ones have a good mating surface for fine cactus, but flex and lose grip on big splinters. Some dedicated tweezers have even given me problems. I often resort to using the tip of a very sharp blade.

I'd like to find high quality tweezers.

Honestly, even though I favor a 1.3" blade (smallest Gerber I know of), I tend to carry a real file and nail clippers. There is a lot of good discussion on keeping feet healthy. Hands are pretty important. Groomed nails help keep the mouth clean and rough nails can snag sensitive tissue.

[René Enguehard]

I rather like the tweezers from the Leatherman Micra. They have good flex but good grip and a nice chiseled tip. Better than I expected. I even used them when I'm at home!

[Dean F.]

Roger,

Pharmacies are required by law to place a label with certain information on all drugs they dispence, including patient data and the prescribed dosing, thus the stickers. Perhaps there is some sort of system problem that can be improved, but the stickers are not a conspiracy to deceive the public. :-) Also, the actual package insert has much more information than the label, anyway. You just have to be motivated enough to read the insert, so I know that a package warning is better, but you can't have a package warning for everything. That's why the inserts are so long. Most pharmacies give patients handouts about every drug they dispense, too. Mine does. So I don't see an easy solution to the sticker problem.

John,

I also got my MD in the United States. I did my residency in Washington state. My license is in Nebraska. I'm a surgeon in the US Army and stationed in Germany, which is why my profile says "Europe", but I am an American doctor. Look very closely at my avatar. :-)

Knowing the U.S. medical establishment as well as I do, I wouldn't presume to speak for it. We are a bunch of bickering, infighting primadonnas. But the truth is, the FDA documentation change went pretty much un-noticed, as nearly as I can tell. Perhaps you have had a different experience.

I also trust the FDA. They are, if anything, OVERcautious. I wasn't denying that fluoroquinolones carry a risk of tendon injury. I was merely expressing puzzlement about why the US media engaged in all that hype about a documentation change regarding a KNOWN, RARE reaction. (Except of course for the sensationalism they get from implying that everyone who ever pulled a tendon while on Cipro should now be able to sue their doctor.) This isn't Vioxx, after all. I maintain that fluoroquinolones are great drugs. They are not without risk- no drug is- but they are great drugs. Disclaimer- I'm not handing out medical advice or telling anyone to take fluoroquinolones. I'm merely saying that the media hype has given them an undeserved bad rap with the lay public. By all means, everyone should discuss ANY medication that they want to carry with their doctor. I will continue to carry fluoroquinolones in my first aid kit. They are very safe, cheap, broad-spectrum antibiotics that are stable over a large temperature range, and I won't be taking them for weeks at a time.

Rene,

You said "if you prescribe something to someone and they hurt themselves because of it you, as a doctor, are liable."

This is not true! If every patient who ever had an adverse reaction sued their doctor, there would be no doctors. EVERY medication carries risk. You can have a lethal reaction from taking Tylenol- back me up here, John- though the risk is VERY low. You really only have a valid suit in the case of negligence or malice, and negligence has a pretty rigorous legal definition.

Take for example coumadin, which is a powerful anticoagulant that is given to people for many indications. It makes it very difficult for your body to form clots. Thus, if you get a serious cut or are involved in an auto accident you could bleed to death very easily. people have died from nosebleeds while on this drug. Spontaneous bleeding is not uncommon. So, if you had a hemorrhagic stroke because of your coumadin could you sue your doctor? Probably not.

Perhaps this is a bad example, because you probably WOULD win such a suit if the doctor hadn't warned you about the possibility of bleeding, but no doctor would prescribe coumadin without warning patients about this. But almost all medications have lists of possible adverse reactions that are HUGE. It is physically impossible to counsel a patient about all of them. Thus, doctors tend to concentrate upon the common ones and the severe ones when counselling patients.

This is a two-way street. If you never mentioned your basketball or mountain-climbing hobbies to your doctor, he probably wouldn't think twice about giving you a fluoroquinolone. Even then- and I'm going out on a limb, here- I think most wouldn't hesitate to give you a single, short course. We, the US military medical establishment, hand out tons of fluorquinolones to a very athletic and active patient population.

I agree about the Leatherman Micra. Handy widget. I also carry one.

[Michael Gardner]

Now that you mention it again, Dean, being a US Army Surgeon and all, you avatar does resemble Hawkeye from MASH, minus the smoking jacket! ;)

[Michael Williams]

> Haven't you noticed that many pharmacists stick a large adhesive label over the technical information on the packet, thereby preventing the consumer (the patient) from reading the data?

By law in Australia a pharmacist must place a label on all prescription medications with the instructions as well as various other legal requirements. As a pharmacist its not often there is a space left on the box for us to place a label so you place it as best you can. As for obscuring 'technical information' there doesn't tend to be any information on the outside packaging other than the medication name, strength, etc (which shouldn't be obscured by a label anyway).

>It is almost as though the medical system is telling the the consumer to shut his eyes and just do what he is told.

I disagree, again I can only comment on Australia, but all pharmaceutical companies when they are granted licence to sell their products in Australia must prepare a Consumer Medicine Information (CMI) which lists every adverse effect as well as other useful information in a format that a lay person can understand. This is included in many products as an insert or can be given by the pharmacist.

I'm all for consumers being more educated on the medications they take but I think increased counselling is more effective than written information on the box.

[John S.]

Hi Dean. I imagine you are entirely correct in the low incidence of tendon rupture associated with those antibiotics (and everything else you said). I only put it out there for info.

The problem is that in the US, once that kind of boxed warning goes out, it would behoove a US doc to not prescribe it in a susceptible person who would be miles out in the wilderness should the side effect occur. There are too many other antibiotics that can take its place. I myself am allergic to cipro, but that is a crazy story on its own how I came to realize that. Take care.

[John S.]

I decided to look it up for myself. Tendon rupture is occuring in as little as 6 days after starting the antibiotic. Even more proof to avoid that one if over 60 y/o or have other risk factors outlined in the FDA alert. The FDA does not move on issues like this unless it is for public safety. Your mileages may vary.

J Plast Reconstr Aesthet Surg. 2008 Jul;61(7):830-4. Epub 2007 Apr 3.

Management of bilateral Achilles tendon rupture associated with ciprofloxacin: a review and case presentation.Akali AU, Niranjan NS.

Fluoroquinolone antibiotics are increasingly being recognized as a cause of Achilles tendinitis and rupture. We report the case of a 62-year old man who developed bilateral Achilles tendon rupture six days following commencement of ciprofloxacin….

J Med Case Reports. 2007 Jul 23;1:55.

Fluoroquinolone-associated tendinopathy: a case report.Ng WF, Naughton M.

ABSTRACT: Fluoroquinolone-associated tendinopathy is well described. This adverse effect however does not appear to be widely known among medical practitioners. We hereby described a case of ciprofloxacin-associated tendinopathy for which the adverse drug reaction was not suspected initially and the patient was inappropriately reassured and incorrectly advised to complete the antibiotic course. Given the frequent use of fluoroquinolones in clinical practice and the potential for severe disability from tendon rupture, we consider it important to remind your readers of this uncommon but potentially devastating adverse drug reaction.

[Dean F.]

John,

I'm really not trying to belittle your point. It's an excellent one. Obviously, fluoroquinolones carry a risk of tendon rupture. I'm just saying that it is low, and thus it is not an unreasonable risk to take it for a few days, if you are otherwise healthy, even while hiking. I doubt that we really disagree- we are probably just emphasizing different points, given that you keep mentioning a hypothetical sexagenarian.

So, I'm not denying that there is a risk. MY point was stated in the first sentence of the abstract that you posted:

"Fluoroquinolone-associated tendinopathy is well described."

MY point was that the US media were hyping a relatively inconsequential change to the medication documentation. Thus the "yawn" comment. Does the tendinopathy (and rupture) happen sometimes? Of course! -Rarely. And the FDA did it's job by making the medical establishment more aware of this fact that they should consider when prescribing fluoroquinolones. But then the media blew it way out of proportion, and thus gave the lay public an exaggerated perception of the risk.

I just don't think we should dismiss fluoroquinolones from our first aid kits on this ONE point. Consider the whole picture, and pick what you feel to be the best antibiotic for your needs. If you are young and healthy, and the fluoroquinolone covers the organisms that you are worried about, and you're only going to take it for a few days at most until you can hike out and get to a provider, then I still say that they are great, cheap drugs. They are broad-spectrum drugs with excellent oral bioavailability that don't cause photosensitization like doxycycline or tetracycline (which is annoying when you're outdoors), they don't carry quite the risk of clostridial colitis that clindamycin does, I can give it to people with penicillin allergies (unlike beta-lactams), etc., etc. I can find SOME kind of scary problem with ANY antibiotic.

Can you present a patient that I WOULDN'T give a fluoroquinolone to? Of course! To choose an absurd example: a sexagenarian with a collagen-vascular disorder should not take a fluroquinolone, especially if he is a hiker.

So, personally, I kind of like the fluoroquinolones. I think that most of us can reasonably carry them.

DISCLAIMER- As always, though, clear it with your doctor before you carry ANY prescription drug.

Out of curiosity, John, what antibiotic do you carry, if any? Perhaps you have come up with a much better alternative that I haven't considered. I hope it's not some $1000/dose gorillacillin. :-)

[Taeji Nedilsky]

For those looking into hemostatic agents like Quik Clot and alternatives (since Quik Clot is known to have caused burns in some applications) check out this article: http://www.lawofficer.com/news-and-articles/articles/lom/0403/Clotting_Agents.html;jsessionid=60D316EDCAA75800A73EE2D8C77EFD94

WoundStat is another agent that is said to have better/quicker clotting properties than Quik Clot and Celox; but it is only effective for a few hours, and its use depends on the ability to get to a medical treatment facility (so, at most, a day-hike not far from a hospital).

[John S.]

Dean, I didn't see your post..sorry. I don't carry an antibiotic since I only do week long trips at most. If I got a nasty wound, I'd be heading out of the woods for a local ER. I probably should add one to my first aid kit.

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