Introduction

The doctor's bag is very important and the contents of it vary according to the individual doctor and their pattern of work. GPs working in remote parts of the Highlands of Scotland will obviously have very different requirements from those working in the inner city. For security reasons, a GP may prefer to wear a jacket or coat with capacious pockets rather than carry a bag. In this case, the following minimum equipment might be carried:

• Photocard ID - whereas many patients may recognise their regular GP, locums or new GPs may need to confirm their identity before admission.
• Stationery - a limited number of FP10 (prescriptions), Med3 (sick notes), letter headed paper/compliments slips and envelopes.
• Mobile phone.
• British National Formulary or equivalent.
• Stethoscope and pocket diagnostic set.
• Sphygmomanometer and infrared thermometer - sphygmomanometers should have calibration date stickers, a service available from some pharmaceutical representatives.
• Large-volume spacer
• Alcohol wipes, gloves, lubricating jelly.
• Personal alarm - several versions are readily available. The police suggest that when used, an alarm be thrown about 10-20 feet to cause distraction.

General issues

If a bag is carried, the following should should be considered:

• The bag must be lockable and not left unattended.
• Most medicines should be stored between 4° and 25°C. A silver-coloured bag or cool bag is more likely to keep drugs cooler than a traditional black bag.
• Consider keeping a maximum-minimum thermometer in the bag to record extremes of temperature.
• Bright lights may inactivate some drugs (e.g. injectable prochlorperazine) so keep the bag closed when not in use.
• Lock the bag out of sight in the vehicle boot when not in use.
• Use a non-loose leaf notebook to record the origin, expiry date and batch numbers of all drugs administered. This can also be used as a controlled drug register. A record of the patient's name, the substance, quantity and date should be made within 24 hours of issue of a controlled drug.
• Check at least twice a year that drugs are in date and usable (more often for Syntometrine®). Discard all products that have nearly expired and replace them.
• If oxygen is carried, the car should be labelled with the correct 'Hazchem' sticker.
• Patients given more than immediate treatment should also be supplied with a patient information leaflet.

Suggested basic equipment to be carried in a bag, (additional to the list above) includes:

• Local map.
• Additional sphygmomanometer cuffs.
• Reflex hammer.
• Hand decontamination products.
• Multistix.
• Tongue depressors, preferably wrapped.
• Small torch.
• Additional stationery FP7 and FP8 (continuation cards), investigation forms.
• Peak flow meter, preferably low-reading.
• A selection of airways can form part of the car's first aid kit, which can be extended to one's own preference and skills up to full 'BASICS' level.
• A facemask.
• Syringes, needles and tourniquet 2 ml syringes, with a couple of 5 ml should suffice.

Some GPs also carry the following:

• Glucometer.
• Phlebotomy equipment: of value only if there are means of conveying the specimen(s) to the surgery.
• Oximeter.
• Numerical aids: gestation calculator, peak flow wheel/height-weight age ranges on reverse, body mass calculator.
• Vision charts: 3 metre visual acuity and arm's-length colour vision.
• A tape measure.
• A hand-held spotlight plugged into the cigar lighter can highlight house numbers (where they exist).
• A reversible fluorescent jacket (with Velcro® 'Doctor' signs) carried in the vehicle boot can be helpful in emergencies.
• Electronic equipment needs to be used regularly, both for familiarity in use and economic value. Consideration should be given regarding carrying nebulisers/sonicaids/defibrillators.

Drugs

The selection of a particular drug to be carried in a doctor's bag should be based on a number of considerations including the GP's personal familiarity with the drug, storage requirements, shelf life, cost, the availability of ambulance paramedic cover, the availability of a 24-hour pharmacy and the proximity of the nearest hospital.

The list of drugs below, based on guidance from the Drugs and Therapeutics Bulletin,^1,2 can be used as the basis for a selection that can be used to meet common clinical scenarios.

NB: when an antibiotic or antiviral is given, a full course should be provided (i.e. enough medication to treat the presenting condition).³

Analgesia

• Paracetamol - 120 mg/5 ml and 250 mg/5 ml oral suspensions, 500 mg tablets.
• Ibuprofen - 100 mg/5 ml oral suspension , 400 mg tablets.
• Codeine - 25 mg in 5 ml syrup, 30 mg tablets.
• Morphine - 10 mg/5 ml oral solution, 10 mg/ml injection.
• Diamorphine - 5 mg or 10 mg (powder for reconstitution with water for injection).
• Diclofenac - 25 mg/ml injection, 12.5 mg and 100 mg suppositories.
• Diazepam - 5 mg tablets (for muscle spasm).
• Naloxone - 400 micrograms/ml injection (to reverse opioid overdose).

Antimicrobials

• Benzylpenicillin - 600 mg vials (x 2) for reconstitution with sodium chloride or water for injection.
• Cefotaxime - 1 g vial reconstituted with water for injection.
• Chloramphenicol - 1 g vial reconstituted in water for injection.
• Amoxicillin - 125 mg/ml and 250 mg/5 ml oral suspension, 250 mg capsules.
• Erythromycin - 125 mg/5 ml and 250 mg/5 ml suspensions, 250 mg tablets.
• Clarithromycin - 125 mg/5 ml and 250 mg/5 ml suspensions, 250 mg tablets.
• Trimethoprim - 50 mg/5 ml suspension, 200 mg tablets.
• Cefalexin - 125 mg/5 ml and 250 mg/5 ml suspension, 250 mg capsules.
• Flucloxacillin - 125 mg/5 ml and 250 mg/5 ml suspensions, 250 mg tablets.
• Aciclovir - 800 mg tablets.

Asthma⁴

• A short-acting beta agonist - salbutamol metered dose inhaler (MDI) or 1 mg/ml nebuliser solution, or terbutaline MDI or 2.5 mg/ml nebuliser solution.
• Prednisolone - 5 mg soluble tablets.
• Oxygen - delivered via a close-fitting facemask or nasal prongs.
• Ipratropium - 250 micrograms/ml nebuliser solution.
• Hydrocortisone - 100 mg powder as sodium succinate for reconstitution with water for injection (also useful for anaphylactic shock, adrenal crises).

Rehydration

Oral rehydration salts - e.g. Dioralyte® or Electrolade® sachets.

Diabetic hypoglycaemia⁵

• GlucoGel® - 40% dextrose ampoules.
• Glucagon - 1 mg/ml injection.
• Intravenous glucose - 25 ml ampoules (5% and 20%).

Seizures⁶

• Rectal diazepam - 2 mg/ml and 4 mg/ml strengths in a 2.5 ml rectal application tube.
• Midazolam - 5 mg/ml, 2 ml ampoule given buccally via a syringe (unlicensed route).
• Lorazepam- 4 mg/ml injection.

Anaphylaxis

• Adrenaline - 1 mg/ml ampoules, i.e. 1:1,000.
• Chlorphenamine - 4 mg tablets, 2 mg/5 ml syrup, 10 mg/ml ampoules for injection.
• Sodium chloride - 0.9%, 500 ml via giving set.

Nausea and vomiting

• Domperidone - 1 mg/ml suspension, 10 mg tablets, 30 mg suppositories.
• Prochlorperazine 5 mg/ml syrup, 5 mg tablets, 5 mg and 25 mg suppositories, 12.5 mg/ml injection.
• Cyclizine - 50 mg/5 ml mixture, 50 mg tablets, 50 mg/ml injection.
• Procyclidine - (to reverse oculogyric crises) 5 mg/ml injection.
• Metoclopramide - 1 mg/ml paediatric liquid, 5 mg/5 ml elixir, 10 mg tablets, 5 mg/ml injections.

Myocardial infarction and angina⁷

• Aspirin - 75 mg tablets (give two).
• Glyceryl trinitrate spray - 400 micrograms/metered dose spray.
• Streptokinase - 1,500,000 units vial or equivalent (some GPs may administer as per protocol drawn up in conjunction with local cardiologists). Reteplase or tenecteplase are alternatives preferred by the National Institute for Health and Clinical Excellence (NICE) because they can be given by bolus injection (as opposed to streptokinase which has to be given by intravenous infusion) but the acquisition costs are much higher.
• Atropine - 600 micrograms/ml injection for bradycardia.

See separate article Acute Myocardial Infarction Management for further details.

Acute left ventricular failure

Furosemide - 10 mg/ml injection, 20-50 mg by slow IV injection. It is also useful to have 40 mg tablets available for less severe congestive cardiac failure.

Postpartum haemorrhage⁸

Syntometrine - ergometrine maleate 500 micrograms plus oxytocin 5 units/ml injection.

Psychiatric emergencies

• Haloperidol - 1.5 mg tablets, 5 mg/ml injection.^9,10
• Lorazepam - 1 mg tablets, 4 mg/ml injections.
• Flumazenil - 100 micrograms/ml injection to reverse respiratory depression caused by lorazepam.

.

Document references

1. No authors listed; Drugs for the doctor's bag: 1--adults. Drug Ther Bull. 2005 Sep;43(9):65-8. [abstract]
2. No authors listed; Drugs for the doctor's bag: 2 - children. Drug Ther Bull. 2005 Nov;43(11):81-4. [abstract]
3. No authors listed; British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax. 2002 May;57 Suppl 1:i1-24.
4. British Guideline on the Management of Asthma, British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN), 2009
5. Diagnosis and management of type 1 diabetes in children, young people and adults, NICE Clinical Guideline (July 2004)
6. The diagnosis and management of the epilepsies in adults and children in primary and secondary care, NICE Clinical Guideline (October 2004)
7. No authors listed; Tackling myocardial infarction. Drug Ther Bull. 2000 Mar;38(3):17-22. [abstract]
8. Prevention and management of postpartum haemorrhage, Royal College of Obstetricians and Gynaecologists (May 2009)
9. Violence: The short-term management of disturbed or violent behaviour in in-patient psychiatric settings and emergency departments, NICE Clinical Guideline (2005)
10. Taylor D et al. (Eds). The Maudsley Prescribing Guidelines 2005-2006. Eighth edition. Abingdon: Taylor, Paton, Kerwin, 2005; 313-5

Internet and further reading

• Baird A; Emergency drugs in general practice. Aust Fam Physician. 2008 Jul;37(7):541-7. [abstract]

Acknowledgements