In the last two articles in the series we’ve looked at first line gear, which are the things we always carry, and second line gear for use in the Direct Threat Care phase. In this segment I’ll offer some suggestions for third line gear. This is the equipment we’re carrying to manage casualties in the Indirect Threat Care phase.
Third line gear constitutes the bulk of individually carried medical equipment, and is carried in a medical pack or aid bag and can be dropped at the door of a residence or at a casualty collection point if carrying the bag is impractical. I have also often found myself in a position to secure my third line bag within a bearcat or other tactical vehicle for use in CASEVAC. This is not a large bag like a STOMP, but rather something along the lines of a slimline pack or slingpack that allows the medic to remain highly mobile. A reasonable objective is to treat three critical patients from this bag, as well as a number of less serious medical and trauma issues. As we’ll see, depending on the injuries, it may be used to treat many more.
Because of space and weight constraints, the priority remains managing threats to life and limb. I carry the equivalent of three IFAKs’ worth of tourniquets, pressure dressings, hemostatic gauze, chest seals, decompression needles, and nasal airways. This can be accessed directly or used as a restock for first- and second-line gear. I’ve recently added a SAM junctional tourniquet to the bag as well; see the article on this topic for more.
It is appropriate to initiate IV/IO access in the Indirect Threat phase of care and as such these supplies as well as small quantities of IV fluid (i.e. hextend, if your system allows) should be carried. I run with supplies for four lines and two 250 bags of normal saline. Don’t forget smaller gauge catheters for the odd pediatric or difficult stick victim or bystander. I/O access should also be an option, with the FAST IO representing the ideal solution, but a manual IO needle makes a good lightweight alternative. See the sidebar for a suggested medication list, which will of course vary with local protocols and scope of care.
The indirect threat care phase also affords us the luxury of more time consuming or intricate interventions. Arguably the most important of these is definitive airway management. Supraglottic airways are ideal for the tactical environment due to speed and ease of use.With that said, a small ET setup is small and light enough that I still include a setup in my bag consisting of a pediatric handle, Mac 4 blade, and an 8.0 tube. The cricothyrotomy kit may be carried in the pack if it is not included in the second line; this will vary by regional protocol. My kit includes supplies for both open surgical and needle cric. I find that a commercial tube holder is too bulky; the roll of 1″ gorilla tape I carry will secure a tube well enough for the short term, but at least one compact tube holder is available and may be a better solution.
A vacuum packed BVM and small manual suction device should also be considered here. My suction is improvised from a 60 CC syringe and a length of suction tubing.
Additional third line gear includes hypothermia prevention, SAM splints for fracture management, diagnostic equipment such as a pulse oximeter, a blood pressure cuff and stethoscope, and additional trauma supplies for burn care and non-life threatening injuries. I have also found room in one bag for Morgan lenses for eye irrigation, though this may more appropriately considered a fourth-line intervention.
|Sidebar: Suggested Field Care Medications
Tactical Paramedic Loadout 1: Essentials
Tactical Paramedic Loadout 2: Fighting Load/Direct Threat Care