Chapter 129: The doctor’s bag and other emergency equipment

INTRODUCTION

Almost everyone who goes to bed counts upon a full night’s rest: like a picket at the outposts, the doctor must be ever on call.

KARL F MARX (1796–1877)

GPs who perform home visits and nursing home visits require the traditional doctor’s bag that includes the basic tools of trade: drugs (including those for emergency use), stationery and various miscellaneous items. Country doctors will by necessity use their bag for more emergency home and roadside calls. These recommended contents are simply a guide for cross-checking.

ESSENTIAL REQUIREMENTS FOR THE BAG

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Sturdiness
Lockable (e.g. combination lock)
Ready interior access
Uncluttered
Disposable single-use items
Light, portable equipment
Regular checks to ensure non-expired drugs
Storage in a cool place (not boot of car)

Traditionalists may prefer the Gladstone bag, whose style confers a sense of time-honoured assurance. Pragmatists may opt for a fishing tackle box: far from elegant, but the sight of those organised compartments emerging during a crisis can calm the nerves.

Stationery (checklist)

Practice letterhead and envelopes
Prescription pads
Sickness/off-work certificates
X-ray, pathology referral forms
Accounting and Medicare forms
Dangerous drugs record books
Continuation notes
Tie-on labels for emergencies
Recommendation forms (to psychiatric/mental hospitals)
Pens

Many of these items will increasingly be replaceable by a portable computer connected to a virtual ‘paperless’ office.

Miscellaneous items

Quick reference cards:
- – the doctor’s bag checklist¹
- – dosage details of drugs, all age groups
Handbook of emergency medicine

Many details can be stored on a smartphone, including drug dosage apps, local maps and local emergency phone numbers.

Equipment

Sphygmomanometer (aneroid)
Stethoscope
Pulse oximeter
Diagnostic set (auriscope + ophthalmoscope)
Tongue depressors
Tourniquet
Small needle disposal bottle
Scissors
Syringes 2, 5, 10 mL
Needles 19, 21, 23, 25 gauge
Scalp veins (butterfly) needles
IV cannulae 16, 18, 20 gauge
Alcohol swabs
Micropore tape
Thermometer
Spacer (e.g. Volumatic, for asthma)
Artery forceps
Urine testing sticks
Pathology specimen bottles
Skin swabs, throat swabs
Torch
Patellar hammer
Oral airway (e.g. Revivatube, Resuscitube—FIG. 129.1, Guedel)
Laerdal pocket mask (FIG. 129.2)
Scalpel (disposable)
Examination gloves

FIGURE 129.1

The two-way Resuscitube

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FIGURE 129.2

The Laerdal pocket mask

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Drugs

Drugs (oral)

Samples of commonly used:
- – analgesics
- – antibiotics
- – antidiarrhoeal agents
- – anti-emetics
- – antihistamines
- – sedatives
Glyceryl trinitrate (although sublingual tablets deteriorate after opening)
Soluble aspirin (for myocardial infarction)
Sumatriptan

Drugs (sprays)

Glyceryl trinitrate
Salbutamol aerosol

Drugs (topical)

Anaesthetic eyedrops

Drugs (injectable)

Refer to TABLE 129.1.

Table 129.1Drugs available on PBS (except those marked #) <www.pbs.gov.au/browse/doctorsbag>^2,3

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Table 129.1 Drugs available on PBS (except those marked #) <www.pbs.gov.au/browse/doctorsbag>^2,3

Drug

Presentation

Indications

Adrenaline^*

1 mg/mL (1:1000)

Hypersensitivity reactions and anaphylactic shock, asthma^†, ventricular asystole, croup, ventricular fibrillation (to assist CPR)

Atropine sulphate

0.6 mg/1 mL

Bradycardia (after myocardial infarction), 2nd or 3rd degree heart block, ureteric colic^†, organophosphate poisoning

Benztropine^*

Cogentin 2 mg/2 mL

Acute dystonic reactions

Benzylpenicillin^*

3 g with 10 mL water

Meningococcaemia, pneumonia (adults)

Ceftriaxone^#

2 g powder with 10 mL solvent

Meningococcaemia, septicaemia

Dexamethasone

4 mg/1 mL

Severe asthma (esp. elderly), moderate to severe croup, anaphylaxis, acute Addisonian crisis

Diazepam^*

10 mg/2 mL

Status epilepticus and other convulsions such as eclampsia, sedation in acute anxiety and severe tension headache, psychiatric emergencies including acute alcohol withdrawal

Frusemide^*

Lasix 20 mg/2 mL

Left ventricular failure, acute pulmonary oedema

Glucagon^*

1 mg + 1 mL solvent

Hypoglycaemia (insulin or oral therapy)

Glucose^#

50% (500 mg/mL in 50 mL)

Hypoglycaemia

Glyceryl trinitrate^*

Spray 400 mcg/dose

Acute coronary syndrome

Haloperidol^*

Serenace 5 mg/1 mL

Psychiatric emergencies such as severe agitation, psychoses; migraine

Hydrocortisone sodium succinate^*

100 or 250 mg/2 mL

Anaphylaxis, severe asthma, Addisonian crisis, thyrotoxic crisis, acute allergies

Methoxyflurane

3 mL pack with inhaler

Analgesia for acute pain

Midazolam^#

5 mg/1 mL

As for diazepam

Metoclopramide^*

Maxolon 10 mg/2 mL

Severe vomiting (e.g. Meniere syndrome, gastritis), acute labyrinthitis, migraine

Prochlorperazine

Stemetil 12.5 mg/mL

Morphine sulphate^*

15 mg/1 mL or 30 mg/1 mL

Acute pulmonary oedema, relief of severe pain (e.g. cardiac pain, colic)

Naloxone (more than one ampoule)^*

Narcan 0.4 mg/mL

Opiate respiratory depression

Oxytocin

10 units/1 mL

Postpartum haemorrhage

Promethazine^*

Phenergan 50 mg/2 mL

Acute allergic conditions (see FIG. 129.3), anti-emetic^†

Salbutamol^*

MD inhaler and/or nebuliser solution

Bronchial asthma, other bronchospasm

Tramadol

100 mg/2 mL

Moderate to severe pain

Water

5 mL

diluent

^*Essential drugs

^†May be useful as an alternative drug

^#Drugs not supplied as PBS doctor’s bag items

All drugs listed are injectable except salbutamol inhaler

Note: The author recommends the ‘Minijet’ syringe packs for ideal emergency use. The range includes naloxone 5 mL, aminophylline, atropine, adrenaline, dextrose, lignocaine, isoprenaline, sodium bicarbonate

FIGURE 129.3

Home visit to a 25-year-old woman with acute urticaria caused by an upper respiratory viral infection. She was given 25 mg promethazine IM for severe pruritus and vomiting

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A study of 512 Queensland GPs revealed the range of emergency equipment and essential drugs carried.⁴ The most common emergencies were acute asthma, psychiatric emergencies, seizures, hypoglycaemia, anaphylaxis, impaired consciousness, shock, poisoning and overdose. The drugs used most were adrenaline, benztropine, diazepam, glucagon, haloperidol, hydrocortisone, naloxone and salbutamol (inhaler).

The issue of what drugs to carry is always an interesting intellectual exercise. It could reduce to just a few items such as adrenaline, diazepam, naloxone and morphine.⁵ Doctors who are called to manage emergencies more frequently and in more remote locations generally prefer a broader range of drugs, which requires increased checking of stocks.

Drugs (suppositories)

Indomethacin

THE COUNTRY DOCTOR’S BAG

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Rural doctors, especially in isolated areas, usually carry additional equipment in their motor vehicles when called to the scene of an accident or other emergency. The equipment will vary according to geographic factors, the ambulance service and the special interests and enthusiasm of the practitioner.

Storage of drugs

The main issues are safe storage of opioid drugs, avoidance of overheating (keep <25°C), accessibility in emergencies and careful recording of Schedule 8 drugs in a register. Diphtheria and tetanus vaccines should be stored in a refrigerator.

Emergency drugs

The value of emergency drugs for the doctor’s bag continues to be debated. Essential drugs are highlighted in TABLE 129.1. One challenging paper suggests that drugs such as penicillin, diazepam, haloperidol, chlorpromazine, frusemide and tramadol be replaced.² The options recommended as more appropriate would be ceftriaxone or cefotaxime (for severe infections), midazolam, olanzapine and amiodarone, while CPAP or BIPAP is preferable to frusemide for acute ventricular failure.

Medical emergencies in general practice—a management proposal

Note: Using basic equipment and doctor’s bag (mainly adult dosages)

Don’t forget:

Secure IV line (may need rapid bolus N saline)
Oxygen (where recommended)
Measure vital signs

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Acute cardiogenic pulmonary oedema (ventricular failure)

Frusemide 40–80 mg IV (or twice usual dose)

Glyceryl trinitrate 1 dose (spray)

Consider (especially if chest pain)—morphine 2.5–5 mg IV

Acute anaphylaxis

Adrenaline 0.3–0.5 mg (1:1000) IM, repeat every 3 minutes as necessary or set up adrenaline infusion (see CHAPTER 128)

If no rapid improvement:

salbutamol inhalation
IV fluids
? hydrocortisone/glucagon

Angio-oedema and acute urticaria

Promethazine 25 mg IM

Asthma

Salbutamol 6 (<6 years)–12 (adults) puffs by spacer

Hydrocortisone 200 mg IV

If severe:

adrenaline 0.3–0.5 mg 1:1000 IM or SC or infusion

Croup (severe)

Dexamethasone 0.15 mg/kg IM or prednisolone 1 mg/kg (o)

Epilepsy (seizure)

Diazepam 5–20 mg IV or midazolam 0.2 mg/kg IM

Opiate respiratory depression

Naloxone HCl 0.4 (or 0.2) mg IV + 0.4 mg IM

Acute coronary syndrome

Aspirin 300 mg soluble tab

Glyceryl trinitrate spray or tablets (max. 3)

If pain, morphine sulphate 2.5–5 mg IV + metoclopramide

Hypoglycaemia

Glucagon 1 mg/mL SC, IM or IV, then sweet drink or 20–30 mL 50% glucose IV

Migraine (severe)

Prochlorperazine 12.5 mg IV

Metoclopramide 10 mg IV ± dihydroergotamine IV or IM

Haloperidol 5 mg IM or 1V

Cluster headache

100% oxygen 6 L/min for 15 minutes Metoclopramide 10 mg IV

Movement disorders (from antipsychotic medication)

Benztropine 1–2 mg IV or IM

Meningococcaemia

Benzylpenicillin 60 mg/kg IV

Ureteric colic

Morphine 10–15 mg IM or IV ± metoclopramide

Indomethacin suppository

Vertigo (acute)

Prochlorperazine 12.5–25 mg IM or promethazine 25 mg IM

Vomiting

Prochlorperazine 12.5 mg IM or IV or metoclopramide 10 mg

Practice tips

Check your doctor’s bag every month for drugs that may be expired, damaged or in short supply (your practice nurse can do this).³
Replace any used drugs or materials the day after use.
Always have your bag handy but don’t carry it in the car in hot weather. It is best to be able to grab it from a safe, accessible spot when you leave for an emergency.
Security is an issue. Drugs of addiction (tramadol and morphine) may be kept separate and then taken from their secure place when their use is anticipated (e.g. myocardial infarction, severe biliary or kidney colic). Tramadol appears to be a satisfactory alternative but beware of the serotonin syndrome.
Keep a spare kit in your surgery if you or your assistants or locums perform a lot of emergency work.
Familiarise yourself with the layout of your bag so that using it in urgent circumstances is efficient.
Use a large intravenous cannula wherever possible if rapid infusion is required.

REFERENCES

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Hogan C. Home visits, emergencies and use of the doctor’s bag. Medical Observer, 28 April 2000: 73–5.

Holmes J. Time to restock the doctor’s bag. Aust Prescriber, 2012; 35: 7–9.

Baird A. Emergency drugs in general practice. Aust Fam Physician, 2008; 37 (7): 541–6. [PubMed: 18592073]

Johnston CL et al. Medical emergencies in general practice in south-east Queensland: prevalence and practice preparedness. Med J Aust, 2001; 175: 99–103. [PubMed: 11556429]

Murtagh J. The doctor’s bag. What do you really need? Aust Fam Physician, 2000; 29 (1): 25–8. [PubMed: 10721539]

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Chapter 129: The doctor’s bag and other emergency equipment

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INTRODUCTION

ESSENTIAL REQUIREMENTS FOR THE BAG

Stationery (checklist)

Miscellaneous items

Equipment

FIGURE 129.1

FIGURE 129.2

Drugs

Drugs (oral)

Drugs (sprays)

Drugs (topical)

Drugs (injectable)

FIGURE 129.3

Drugs (suppositories)

THE COUNTRY DOCTOR’S BAG

Storage of drugs

Emergency drugs

REFERENCES

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