Although Apollus Medical do not source or supply medical equipment to close protection teams, we can and do advise teams on what should be carried, taking into consideration the factors discussed below, including a medical risk assessment. Our recommendations are based on decades of operational experience within close protection and medical operations.
This article is designed for PHEM Competency levels C,D and E and Level 3 qualifications. This is to include qualifications such as;
- QNUK Level 3 First Responder
- Qualsafe FREC 3
- Qualsafe Level 3 RTACC
Types of Medical Kits
There are three types of medical kits that will be defined and discussed within this article.
- Individual First Aid Kit (IFAK) – carried by each member of the team, predominantly for self-aid
- Grab bags, carried in vehicles and on foot by multiple team members for general use where IFAKs are not carried
- Team vehicle bags, larger medical bags with greater capacity, carried only within the vehicles with the capability of treating all vehicle occupants. Further team bags can also be used in and around the residence area.
The considerations listed below will have an impact on the type and level of equipment carried by the team and along with the medical grade of the dedicated team medic if there is one. For example, a team supporting de-mining operations in Mosul, Northern Iraq, will have a much higher requirement than a team operating in London.
The medical risk assessment should take into account the following (this list is not exhaustive);
- The area of operations and level of threat i.e. hostile, challenging remote, or passive
- The task/activities carried out by the team and individuals that the team are supporting i.e. industrial, diplomatic, commercial
- Medical competency within the team taking into account skill fade and the availability of continuation training
- Clinical governance and medical directives on project
- Ability to source or receive medications and equipment in-country
- Local legislation on the carriage of medications in-country
- Management of medications in extremes of heat/cold
- Team/project size & number of potential casualties
- Team transport methods within the area of operations
- Availability and response time of emergency medical services in theatre for both pre-hospital and definitive medical care in hospital
- Competency of emergency medical services in theatre, both pre-hospital and definitive medical care in hospital (the team elements may be more qualified than the ambulance service)
- In-hospital capability i.e. accident and emergency department (not all hospitals can deal with trauma)
- Distance and transport capability to definitive medical care
- The project medical emergency evacuation plan, medevac versus casevac, and onward medical care including repatriation
- Check-point requirements for access to facilities
- Threat level whilst on route to and whilst at hospital
- Location security plans for hospital admission
- If the team remit includes supporting local nationals
Potential Mechanism of Injury (MOI)
The likelihood and consequence of the potential mechanism of injury identified within your risk assessment will help identify what equipment should be carried to manage that mechanism of injury.
Examples of potential MOI
- Road traffic collisions (RTC) can be common in developing countries where driving standards and road conditions are poor
- Blast Injuries from IED attacks such as recent incidents in Iraq and Afghanistan. These can include head injuries (traumatic brain injury), blast lung, multi-system trauma either from the blast itself or the resulting RTC if vehicle-mounted
- Penetrating injuries to the thoracic cavity such as stabbings, shrapnel injuries, gunshot wounds
- Fractures and soft tissue injuries
- Haemorrhage both major and minor
- Blast Burns and from burning vehicles
Potential Nature of Illness (NOI)
Obtaining a past medical history of the individuals that the team are supporting is notoriously difficult and can hinder the medical planning phase of operations. However, the team must take into consideration the demographic of the individuals that they are supporting and attempt to identify the potential nature of illness that they or team members may experience.
It is essential to take into account environmental factors within your area of operations that may also present a threat to daily operations. For remote operations, this may include sanitation issues and the availability of water and food supply chains.
A case in point: In 2004, whilst operating in Baghdad, Iraq, close protection operations were halted for a short period due to a severe bout of diarrhoea and vomiting that affected the vast majority of operators on a base within the Green Zone (Now known as The International Zone).
Potential Medical Conditions
The list below of potential medical conditions is by no means exhaustive and takes into consideration the team members, individuals that the team is supporting, and also other individuals that the team may be responsible for such as supporting local nationals.
- Severe dehydration
- Asthma/breathing difficulties
- Allergic reaction & Anaphylaxis
- Heart attack
- Cardiac arrest
The provision of close protection is an ever-evolving beast that adapts to the wishes of the individuals being supported and their desired public image, whilst balancing the nature and level of the threat faced.
Carrying an IFAK on a plate carrier or chest rig presents no difficulties in terms of access and time of application of use. In contrast, in areas where the profile has been reduced and plate carriers and chest rigs are no longer acceptable, carrying an IFAK whilst wearing a suit or other civilian clothes can be more challenging and a topic of much discussion on whether it is necessary or not.
The use of vehicle grab bags also became popular in response to reduced team profiles as the threat level was perceived to be reduced. This in itself presents limitations unless the grab bag is carried once the team has left the vehicles.
In all theatres where a team may be operating there is the potential for a team member or an individual that the team is supporting to receive life-threatening injuries. This may be from an RTC, a fall, or a hostile act and once this life-threatening injury has been experienced the clock has started and time is not your friend.
The UK ambulance service will dispatch an ambulance to life-threatening injuries with a response time of 6-8 minutes, bearing in mind that a casualty can bleed out within three minutes or if a casualty has a penetrating wound to the torso that reduces the respiratory process, then 6-8 minutes can be a very long time whilst the team attempt to fashion an improvised tourniquet or a chest seal.
By carrying an IFAK or a grab bag, the treatment time can be reduced and the effectiveness of treatment can be improved significantly promoting a more positive outcome from an incident. This also enhances the professional profile of the team, however, a piece of kit is only as good as the individual using it and this requires training to develop competency.
No one piece of kit in any med bag takes presidency over another, each piece of kit is merely a tool within your toolbox, in the same way as having the knowledge and awareness to recognise a deteriorating casualty and knowing what to do about it. Where possible, try and tailor an element of the equipment to the individuals that you are supporting to ensure that you have adequate correct sizes for those individuals and the team.
IFAK/Grab Bag Contents and Capability
The IFAK or a grab bag can be tailored to suit the threat level bearing in mind the operational performance required of it i.e. to treat immediate threats to life.
- IFAK Pouch or grab bag – carriage of kit
- Head torch – poor light conditions
- Tough cut shears – cutting clothes and getting to skin
- Sharpie pen or marker – writing time on the tourniquet and taking notes
- Gloves – infection control
- CAT Gen 7 Tourniquet – catastrophic haemorrhage
- Haemostatic gauze and or compressed packing gauze – catastrophic haemorrhage (Celox Rapid for 1 minute compression time)
- Trauma dressing – catastrophic haemorrhage
- Russell Chest seal (with valve) – open chest wound
- Occlusive Chest Seal – open chest or back wound
Vehicle Team Bags
Vehicle medical bags designed to provide medical cover whilst on vehicle operations. The quantity of each item can be scaled up or down depending on team configuration. Each bag should be loaded in the same format providing rapid access to the kit in order of use i.e. CABCDE or MARCH algorithm.
Catastrophic Haemorrhage – Massive Haemorrhage
- Head torch
- Tough cut shears
- Haemostatic gauze (Celox Rapid for 1 minute compression time)
- Compressed packing gauze
- Trauma compression dressings to provide direct pressure over wound packing gauzes
- CAT Gen 7 Tourniquets
- Suction Easy Oral suction device – for clearing the airway
- Oral Pharyngeal Airway (OPA) – Size 3, 4
- Nasal Pharyngeal Airway (OPA) – Size 6, 7
- I-Gel Supraglottic Airway – Size 3,4,5
- Tape for securing Airway adjuncts
- Aquagel Lubrication
Breathing – Respiration
- Micro Bag Valve Mask (BVM) (Ambu Bag) – Assisted or Rescue Breathes
- Flexible Catheter Mount – to fix to I-gel and BVM
- Russell Chest seals – sealing open chest wounds (with valve)
- Occlusive Chest Seals – sealing open chest or back wounds (No valve)
- 100% non-rebreather Oxygen mask with tubing if O2 if available
- Automated External Defibrillator AED for Cardiac arrest
- Trauma compression dressings for other bleeds
- Blast bandages for stumps and or abdominal or large wounds
- Burnshield burn dressings- hands/forearms, face, torso
- Clingfilm to act as burns dressings
- Water for irrigation and cooling
- Gauze for minor wounds
- Tape for fitting gauze
- Kendrick traction leg splint for Femur fracture
- Pelvic binder for pelvic fracture
- Sam splints for fracture immobilisations
- Elasticated bandages to secure Sam splints
- Triangular bandage for limb/shoulder fractures, can also be used for wound packing and or splinting
- Minor injuries kit with plasters for simple first aid cuts/grazes etc
Disability – Head Injury
- Eye dressings
- Eye irrigation fluids
- Blast dressings for head wounds that are notoriously difficult to dress
Expose, Environment, Evacuation
- Blizzard blanket/Heat blanket with active heating
- Woolly hat
- Poc-kit Stretcher
Medications – (Where possible)
- CD Oxygen Cylinder if available in a separate sealed bag to protect from grease and dirt
- Aspirin 300mg
- Ibuprofen 200mg
- Paracetamol 500mg
- Glucose Gel
- Adrenaline Auto-injectors (if possible)
- Dioralyte Sachets for dehydration
- Imodium – sickness and diarrhoea relief
- Patient history card (in a perfect world) for each team member and individuals being supported
- Triage kit
- Head torch
- Sharpie pen or marker
- Duct tape
- Sterilising hand gel
- Holmatro Seat belt cutters placed at hand within vehicles
- Clinical waste bags
- Cyalume sticks for marking casualties or safe route to and from casualty
- Obs chart
- Pulse Oximeter
- BP Cuff
- Blood Glucose monitor/Lancets/Strips/Wipes
- Pen torch
- Tympanic Thermometer
Advanced Intervention Kits
If a team has a registered health care professional within the team, then they will carry their advanced intervention kits. Alternatively, the team may carry these items for use by other health care professionals within the care continuum. This could include:
- IV equipment
- ARS For Needle Decompression (14ga X 3.25in) for chest decompression
- ALS drugs
- Tranexamic Acid (TXA)
- Other advanced medications
Medical Kit Suppliers
To learn how to use this equipment and gain a Level 3 qualification follow this link: https://www.apollusmedical.co.uk/courses/first-responder/
Written by Damian Rawcliffe – Apollus Medical