Cross-Loading Medical Supplies:

A Practical Application for the American Partisan Medic

J

The Guerrilla Medic

7/2024

   Today we’re going to go through a though exercise with a scenario, go over some medical considerations for the possibility of having to operate in a domestic resource-limited environment, ideas for the guerrilla medic to consider when packing and dive into the concept of cross-loading medical equipment throughout the team.

The goal of cross loading medical supplies is two-fold. A) We aren’t loading down the medic with all of the medical supplies for the team, deteriorating his ability to function as a mobile member of the team and B) by spreading the supplies among the team we are able to carry vastly more supplies, therefore enhancing the team’s medical capability. With those goals in mind, let’s breakdown the concept of cross-loading in the context of the American Partisan (AP).

The term “cross-loading” can have different meanings in reference to a team structure for different people with different backgrounds, so let’s define it for our purposes here. Cross-loading is defined as members of the team carrying a pre-determined amount and variety of medical supplies that enhances the capability and survivability of the team. How do we determine what get carried and who carries what? This is where proper planning steps in.

As a group you should have the highest level of medically trained individual functioning as your medic. This induvial should be coming up the with medical standard operating procedures (SOP’s) for the group. For example, what contents go into the groups individual first aid kit’s (IFAK’s) and conducting medical consults will all group members to identify allergies, medications they regularly take, past medical history, previous surgeries or injuries…the list goes on.

When writing up your OPORD or doing your pre-mission planning, your groups medic should be consulted on the medical capabilities needed for the mission. Is this a quick neighborhood patrol or are you doing a movement over multi-day distances to link up with another group for insert whatever spicy Tarkov reason you’d like. Both missions will have some baselines in packing such as standardized IFAK’s but will have more differences than similarities. For short-duration, neighborhood patrols or property patrols being done as a team, I would say that a team equipped with IFAK’s and a small med bag with the medic would be adequate as you are in close proximity to your base of operations….or just your house. Below is a list of what I would carry-medically-in a small med bag for the short duration neighborhood or property patrol.

• Every team member has a standardized IFAK (with small boo-boo kit) in a standardized carry method and location, including the medic
• Bleeder kit (2 tourniquets, 4 packs of gauze, 2 dressings)
• Airway & respirations kit (BVM, cric kit, 2 chest seal twin packs, 2 ARS 10 or 14 ga needles)
• SOL bivvy
• SAM splints
• 2 6in ACE wraps
• Triangle bandage
• Soft litter

Nothing fancy, nothing flashy. Barebones aggressive trauma medicine. We’re stopping the bleeding, addressing emergent life threats and getting them the hell out of there as fast as we can back to our base of operations for higher level care.

All of this can easily fit into a small med bag, and when I say small med bag I mean it. In my experience medics will always try and pack the kitchen sink-typically with a metric ton of bullshit add on’s. In my mind, something like the Spiritus Systems Delta Bag fits this role nicely. It holds just enough for the essentials but is not large enough to accommodate every “But what if” a medic can think of. You can “But what if” yourself into a 50 lb med bag real quick and look like Samwise Gamgee on his way to Mordor to destroy the one ring, frying pans and all. I made all the same mistakes and more as a new guy and was fortunate enough to have some incredible senior Corpsman set me straight. Short duration, around the neighborhood or property is straightforward. We have our resources and people close by so we can afford to pack light and fast. Where cross-loading comes into play is when you are self-supporting or going “beyond the wire” into Indian country.

Scenario:

I’ve always felt that having a scenario drives the rep by giving it context so let’s set one up. As a disclaimer, this is a fictional scenario in Tarkov. Whatever scenario you feel might cause a without-rule-of-law (WROL) situation, it has happened. You-the medic-and your crew, let’s say 12 guys, have a need that necessitates you linking up with some people you have good relations with 10 miles way. Call the time of year mid spring in western Montana. Mid 60’s so heat and cold aren’t too big of a factor. For whatever reason you’re having to do this on foot without the convenience of vehicles. The terrain can be flat and open pastures, to thickly wooded areas to having to contend with the Rocky Mountains as we’re avoiding the main road-of which there is really only one in and out of the area-a 2 lane highway. There’s been some shenanigans in the area that you know from various radio contacts throughout the greater area. Contact, while not likely, is possible with whatever fictional group or groups you envision for this, but firepower reported has been small arms and hunting rifles typical in the AO.

You’re hoping to make it there in a day, accomplish whatever the goal of the link up is and RTB the next day, but Murphy has a great way of showing up. Your home base is the most well stocked clinic you are aware of, but there is a local level IV trauma center about 25 miles away from home that is accessible by truck. You last took an injured community member there a month ago and while they were short on staff and supplies, they were for the most part operational as the county made it a priority to keep it functioning.

You’re the medic and responsible for making sure that you have what you feel you may need if things go sideways. Your supplies is mostly what you could source online prior to the event without a medical license including OTC medications and oral antibiotics, but have some simple “more advanced” items that were acquired in recent months such as IV supplies, fluids, injectable/IV antibiotics and field whole blood transfusion kits. I’ve added these as they are fairly easy to source in the community, either from four-legged medical providers or two-legged-also this is a purely fictional scenario in Tarkov.

Assuming you as the medic have experience with those supplies they are on the table and available. With that scenario in mind (you can fill in the blanks for your own thought exercise), let’s start planning by taking a few things into considerations.

The first thing we need to take into consideration for this thought exercise is that a scenario like this is worlds apart from what the U.S. military was doing for two decades in the middle east. There are no PJ’s coming in on blackhawk’s with drugs, blood and ventilators to whisk a casualty away to a military treatment facility within an hour. You’ve got, maybe, a community hospital if it’s functioning and has supplies in, and the chances of EMS coming to the rescue are nil. This is the reality of any type of grid-down scenario in the U.S. It’s going to be brutal. You and the friends or tribe you’ve made are what you’ve got (key takeaway–make friends and build tribe).

The second is that you have to make do with what you have. How bad are you planning on things getting and for how long? If you’ve got a quality IFAK, that a great start. But what happens if you burn through those supplies? How many IFAK’s do you have stocked up? Does your medic have enough supplies to treat the tribe? I’ve long been an advocate of the “IFAK principle” regarding medical supplies in a crew. As with an IFAK, I’m going to use yours on you. If I need to do wound care on you, I’m going to use your supplies you bought for you and your family, not mine. If you’re tight enough with your tribe to crowdfund supplies, I highly encourage that. The spending power of a tribe is a powerful thing to tap into and allow for bigger, bulk purchases on things like medical supplies than you would have otherwise not been able to get. However, no matter how much you have stocked, you have a finite amount of supplies so resource allocation has to be a priority for the medic. With these caveats in place, let’s walk through some key aspects to think about for the planning phase.

As stated in our scenario previously, you’ve got a team of 12 guys, including yourself. Maybe you have a guy that’s carrying a DMR with heavier ammo and an RTO with radio gear and batteries, that leaves us with 10 guys to cross-load medical supplies onto including you. Given the distance of 10 miles there and 10 miles back with the given terrain and possible enemy in the area, we-as the medic and a team-must remain mobile. When planning a load, remember that you need to be a fighter first and a medic second. If you bring a hospital in a bag-something I see guys try and do all too often-and a loadout of 3 mags, you’re a liability not an asset if things go sideways. Pack to the plan and add in the medicine accordingly. One commercially available tool I always recommend a medic have is at least one large volume smoke-something like an Enola Gay or Mil-X smoke. This is a fast and easy way to add some concealment between you and the casualty and the baddies. After you’ve squared away your fighting load and personal sustainment (food, water & water purification, some type of shelter like a poncho, way to stay warm, etc) lets pack the med bag. Given the proposed above scenario, regarding our potential to need medical care for us and the team, what is the most likely scenario and what is the worst-case scenario and how likely do we think that is?

Starting with the most likely medical scenario, I would say it’s probably the movement itself. For that we’re looking at orthopedic injuries-sprained ankles or knees, followed by back pains. For these, a common first aid kit, SAM splint and an ACE wrap would be sufficient. The next in my mind would be potentially drinking contaminated water if you find a water source. The role of preventative medicine falls on the medic. Have your guys been trained on how to properly conduct water purification and do they carry a means to do so? Simple AquaTabs, Grayl Press Ultra’s, Sawyer filters and H2Go are all methods I’ve used and have worked well in my experience, but we will go into those in a future article. If team members do drink contaminated water, do we have a way to stop the diarrhea in the field such as loperamide? While the body is doing its job by excreting the problem in the form of diarrhea, in the field that can be fatal if not managed. Loperamide can help stop the flow but we also need to replace the lost fluids with clean water and electrolyte’s. For this I am a big user of Drip Drop oral rehydration powders. If it goes beyond what we can manage with oral rehydration and their blood pressure is dropping, we will have to administer IV fluids to help get their pressure back up and hydrate them. All this is taking people off mission and we’re having to hole up somewhere while we do this. Moral of the story is purify your water and avoid this whole mess. Outside of orthopedic injuries and bad water, I would anticipate bumps, scrapes and bruises. Maybe a laceration, but nothing we couldn’t manage with a well-stocked small first aid kit.

From there we move into less likely but more dangerous courses of action. The most dangerous would be getting ambushed, losing a majority if not all the team and the rest running for their lives, with an impromptu SERE rep being the result. That is beyond the scope of this article. What we will focus on is the possibility of one or two guys getting injured with something like a gunshot wound (GSW) and having to manage them with only what you brought for a greater length of time then we are accustomed to now. That is the possibility that I would pack for in this type of scenario. We need to be able to stop bleeding, take and manage an airway, deal with a possible tension pneumothorax, and keep them from becoming hypothermic. With the distances we’re looking at and resource limitations we have, I would say that it will become a prolonged casualty care scenario real quick, so we need to plan for that as well.

Below is what I would consider mandatory on each team member

• Every team member has a standardized IFAK (with small boo-boo kit) in a standardized carry method and location, including the medic
•  

The contents that I add to the IFAKs for my crew are:

1 CoTCCC recommended tourniquet

2 packs of gauze

1 6in North American Rescue Emergency Trauma Dressing (NAR ETD)

1 Hyfin vented twin pack of chest seals with 100mph tape on them

1 NPA sized to the end user

1 polycarbonate eye shield

1 triagle bandage

1 BurnTec dressing

2 pairs of gloves

1 TCCC card, prefilled

1 sharpie

1 pill pack (contains a broad-spectrum antibiotics and OTC pain medication)

Here we come to the division of labor: cross-loading

Designate people based on their kit contents: bleeder guys, airway guys, respiration guys, circulation guys, hypothermia guys and ortho guys. For our purposes we have 10 guys including the medic to cross-load equipment to.  If you have a smaller group A) you don’t have to plan on potentially treating as many and B) you can have a “bleeder and airway” combo. Fortunately, the cross-loaded items aren’t too heavy. In some of the following roles you’ll see that I added a bag of IV fluid to their load. If we have just the medic carrying IV fluids, let’s say same amount as down below, 2L-and that’s packing light-that’s saving the medic from carrying an additional 2 liters of fluids in addition to his bag. That’s saving him from an additional 4.4 lbs of weight. You can see where I’m going with the cross-loading concept now.   

Bleeder guys: 2 guys

• Bleeder kit (2 tourniquets, 4 packs of gauze, 2 dressings)

Airway guys: 1 guy

Note*: While the bag valve mask (BVM) falls under respirations in the TCCC algorithm, a surgical cricothyrotomy kit without a means to ventilate (like a BVM) is useless.

• Surgical cricothyrotomy kit x 1
• BVM x 1
• 1L 0.9% NaCl (normal saline IV fluid bag) or 1L lactated ringers (LR IV fluid bag)

Respiration guys: 1 guy

• Hyfin vented chest seals x 4 twin packs
• Finger thoracotomy kit (sterile, with sterile gloves) x 1
• 10 or 14 ga ARS decompression needles x 2
• NPA’s (generic 28fr size is most common, individual NPA’s in IFAK’s should be measured and sized to the owner of the IFAK). X 2

Circulation guys (IV access): 1 guy

• IV start x 2
• IV tubing x 2
• 1 L LR

Hypothermia guys: 1 guy

• SOL bivvy x 1
• Beanie x 1
• Adhesive hot hands-large ones x 6
• Litter (ideally a semi-hard litter like a skedco, foxtrot or similar that is designed to be carried and dragged)

Ortho guys: 1 guy

SAM splint x 2

4 in ACE wrap x 2

6 in ACE wrap x 2

Triangle bandages x 2

So let’s take stock of what supplies we have by doing this.

Tourniquets

IFAKs: 12

Cross-loaded: 4

Gauze

IFAK’s: 24

Cross-loaded: 8

Pressure dressings

IFAK’s: 12

Cross-loaded: 4

Surgical cricothyrotomy kits

Cross-loaded: 1

Bag valve masks

Cross-loaded: 1

NPA’s (sized to individual)

IFAK’s: 12 sized

Cross-loaded: 2 standard 28fr

Chest Seals

IFAK’s: 12

Cross-loaded: 4

Decompression needles

IFAK’s: 12

Cross-loaded: 2

Finger thoracotomy kits

Cross-loaded: 1

Eye shields

IFAK’s: 12

Cross-loaded: 0

Burn dressings

IFAK’s: 12

Cross-loaded: 0

Hypothermia prevention kit

Cross-loaded: 1

Semi-rigid litter

Cross-loaded: 1 (this will be the primary litter)

As we can see, this is a substantial amount of supplies. Without context, it can be easy to see someone say “That’s way too much stuff and not even including the medic. What is the medic even carrying?”. And at the surface level without the context, I would be inclined to agree. However, we’re planning this around a scenario where we are our own resupply and cool guys in Crye’s aren’t coming to the rescue. So why all this stuff and what does the medic even do?

The medic should be carrying the items that make him special. Tools that he is trained in beyond what the rest of the team can do. From my perspective-take it or leave it-the following is what I would carry as the medic.

Medic:

Point Of Injury kit (POI kit): 2 tourniquets, 4 gauze, 2 dressings, 2 twin packs of Hyfin vented chest seals.

Before ever touching cross-loaded bleeder kits, the medic should be working from the casualties own IFAK. For pulling extra supplies, he’ll work from his POI kit. This should be easily accessible and not in a med bag. The bag itself would contain:

• Vitals monitoring kit: BP cuff (adult long will fit most people), stethoscope, pulse oximeter, EMMA capnography/capnometry (expensive but excellent feedback tool for patients with an advanced airway in place), thermometer
• PPE (gloves, mask)
• BVM
• Abdominal Kit (I’ve done a detailed breakdown of this over on YouTube)
• Junctional tourniquet (can double as a pelvic binder)
• Hemostats/clamps
• IV (or IO) access: IV start kit x 2, IV tubing x 2, saline flushes x 4
• 1L or 2 500mL bags of 0.9% NaCl or LR
• Vascular ligation sutures and wound prep (suture material and iodine/Hibiclens for tying off severed vessels. Think Black Hawk Down guy that bled out on the table. This is a last resort measure for me-I’m not a trauma surgeon).  
• Medications in a small pelican hardcase (antibiotics-broad spectrum for wounds, contaminated water etc. Consider ceftriaxone and azithromycin. Adjust as needed with crew allergies from medical records; pain-whatever you can get your paws on; steroids; H1 blockers; lidocaine 1 or 2%; epinephrine; TXA; calcium; albuterol etc. Source what you can)
• Needle and syringe bundles (27 ga 0.5 in, 25 ga 1.5 in, 21 ga 1.5 in, 18 ga 1 in; 3cc, 5 cc and 10 cc syringes)
• Sharps shuttle
• Surgical cricothyrotomy kit (with bougie)
• Finger thoracotomy kit (with sterile gloves, skin prep and chest seal)
• Field whole blood transfusion kit-donor and recipient packs- x 2 with extra donor bags (There’s a lot of good resources on this out there, would recommend provider level for this be an RN, paramedic or Navy Corpsman/Army 68W or higher)
• Hypothermia prevention kit (with adhesive hot hands, bivvy and beanie)
• First aid kit
• SAM splints x 2
• ACE wrap 4 in x 1; 6 in x 1
• 20-30 ft of tubular nylon
• Admin: Blood roster (pre-screened donors-blood type, Rh factor, titer and if possible infectious disease panel-in the crew with a compatibility chart-who can donate to who), notebook with pertinent info, pencils, sharpies, TCCC cards

The concept of cross-loading allows the medic to focus on the big picture items that increase the odds of getting a patient back to a higher level of care in a resource-limited setting. For this scenario we’ll potentially be 10 miles away from care at our home base and 25-35 miles from a minor trauma center. If we have a casualty out there, we’re looking at having to manage a patient until we can either arrange vehicle transport or having to litter the patient back. This is where Prolonged Casualty Care (PCC) comes into play. Common supplies I would bring are:

Prolonged Casualty Care:

• Foley catheter kit with urine bag
• 2 additional 450mL blood bags (potentially to draw off of friendly locals. These donors will be unscreened for infectious diseases like HIV, hepatitis, syphilis. Use Eldon cards for blood type and Rh factor. Consider a last resort)
• 2 Eldon cards (to screen friendly locals for blood type and Rh factor)
• Wound closure kit (suture, staple and wound prep)
• Wound care kit (4×4’s, Hibiclens scrubber and tissue forceps for debridement, non-adherent pads, tegaderm, bacitracin, tape)
• Trending vitals/PCC forms
• Venipuncture kit with blood tubes for labs (Can use to collect sample off of friendly donors to have hospital do a retro-screening for infectious diseases)
• Reference guides and/or tablet

With all this on the table it gives us options. Options that buy us time for our patients. If the medic were to carry all this cross-loaded equipment as well as the medic-specific supplies, it would be roughly 35lbs. Doing it this way in training with the crew I’ve been able to pare down my med bag and PCC equipment to about 15lbs. While adding 15 lbs to my sustainment bag that usually around 35lbs sucks, it’s still vastly superior to carrying it all which would put me close to 80lbs.

At present there currently is no good bag that allows for the medic to carry his needed sustainment as well as his medical load. Thanks to the scars of the GWOT, most med bags are slim TSSI M9 style or the Spiritus Systems Delta Bag since we could rely on readily availbile vehicle borne systems and air evacuation. However, these two bag options are not easily attachable to a ruck at the moment without taking the ruck and the med bag to a tailor and doing some modification. The best success I’ve had with this is getting a Mystery Ranch Terraframe pack that allows you to sandwich a med bag between the frame and the ruck. For my PCC components, I’ve utilized a packing cube that fits into the body of the pack. All in all, it works ok. I spoke with one of the developers at Mystery Ranch about the issue: there is currently no off the shelf option for a ruck that hold sustainment equipment and can easily accept a med bag that the medic has quick access to. He agreed and recommended the Terraframe option which is what turned me on to it. So if any reader is a maker of quality, U.S. made bags, the DOD will be knocking with an NSN and fat government contract the second we enter into a peer v peer conflict and the medics have to sustain themselves and their patients in an environment with denied airspace for a number of days and not hours anymore.

To wrap this up, I truly hope you got something out of the read. Hopefully it was a good thought exercise that you and your crew’s can kick around and play with the concepts mentioned above. If you want to find more info on some of the supplies and techniques mentioned here I’ve got an Instagram account: theguerrillamedic; YouTube account: theguerrillamedic; and podcast: The Guerrilla Medic Podcast.

Cheers,

J