The BRIC Box Contents

In this first section, we want patients to focus on clean hands and cleaning up skin around the wound, with special attention to the first dressing change.  At this time the gauze can be stuck to the wound and there can be considerable dried blood that can be difficult to manage.  It is also important they have a way to manage their pain. The CLEAN section begins with the pain pack which contains guidance to use 800mg of Ibuprofen, 1000mg of acetaminophen, and 200mg of Magnesium glycinate to improve the pain before beginning with the dressing change.  Then, the section has two ways to clean hands, including soap and hand wipes, and two pairs of gloves for those first few changes that can be bloodier and more complex.  To help remove the bandage there is a pair of trauma shears to cut away any wrapped wounds.  Finally, the saline wound wash allows the wound to be soaked so that the gauze is wet and sticks less to the underlying wound.  A reusable ice pack can be placed in the freezer for an hour and then placed on the wound to help with reducing swelling and inflammation. This can be applied before or after the wound is changed for up to 15 minutes at time.

In this second section, the patient will have multiple ways to treat the wound that will continue to improve the pain and reduce risk of infection as well as simplifying future dressing changes. First, the adhesive remover allows for the removal of left over sticky components of the tape or adhesive that was initially applied.  This adhesive, if left on the skin, can cause ongoing irritation so is best to remove.  This should not be applied to the wound itself, but can be safely used on the skin around the wound.  The adhesive remover can also be used around the edges of a bandage that is stuck. By soaking the bandage with the adhesive remover, the bandage will come off easier. Then the wound itself can be cleaned using the BZK wipes which contain non-sting antiseptic fluid that is safe to apply directly to the open wound.  This is a step that can be tempting to skip, but it assures that the wound is clean and free of loose debris that will slow down healing.

The wound can then be treated with lidocaine gel (burn gel) to help with any stinging/burning sensation coming from the cut edges of the skin.  This water based solution will also hydrate the wound.  It is a common misconception among patients that wounds should be allowed to dry out or scab over. Another misconception is that the wound should be cleaned daily with peroxide. Peroxide can be caustic to the tissue and dry the surrounding skin, which must stay hydrated and supple in order to heal from the outer edges to the inner area.  It's best to explain to patients that scabbing is a helpful process when the skin layer alone is disrupted, but scabbing when there is underlying fat and muscle that has not healed can actually trap unhealthy tissue inside and slow the process of healing. The lidocaine gel helps with the first few changes. It is a helpful option.

The next ointment to apply is the antibiotic ointment. This petroleum based ointment locks in moisture and protects against infection while also assuring the bandage does not stick to the wound, especially when a nonstick layer is used as the first contact layer.  This is not a practice that is typically used with open wounds. It is more common to use a wet to dry dressing.  However, the wounds associated with bullet injuries are inflamed, not infected.  In this case it is imperative to not worsen the inflammation and to eliminate barriers to dressing changes by limiting the pain of those changes.  In this way, petroleum based antibiotic ointment is an easy and safe way for patients to treat their wounds. This section also includes some dry gauze that can be used to clean any excess liquid or material away.  The gauze can also be used for the next step when the wound is covered.

Step 3 is applying the multiple layers of bandages to cover the wound.  To assure that future dressing changes are as comfortable and doable as possible, the first layer applied should be made of nonstick material.  This can be applied as a two in one dressing where the nonstick portion is already attached to an adhesive, such as with an island dressing or “band-aid”.  For larger wounds or those that require multiple layers of gauze to cover and control drainage, a non-adherent pad can be the first layer of contact.  Then, after this nonstick layer is in place, additional gauze in the form of 3x3 gauze, ABD pads, and rolled gauze can be added to allow for complete coverage of the wound and adequate padding to protect and capture all drainage.  If an all-in-one dressing is used, there are no additional steps needed.   If the nonstick and then gauze are used, it is necessary to hold this in place with either rolled non-adhesive tape, which we call BRIC tape.  It is white and has The BRIC logo on it.  As a final option, plastic tape can be applied directly to the skin.  This approach can once again leave behind irritating adhesive so it is best used as a last resort if no other option will work.

At times, patients will want to be able to shower.  There are two small and two medium waterproof plastic adhesive dressings that can be used in two ways.  They can cover another all-in-one bandage OR they can be placed over top a non adherent (no stick) dressing as the adhesive layer. In either case, they provide a barrier to moisture.  They are NOT good enough to protect if the area of the body is submerged in water such as in a bath. They are adequate for protection in a shower or with sponge bathing.

The guidance is to use the smallest dressing possible so there is adequate coverage and control of drainage.  Dressings that DO NOT become soaked with drainage over the course of 24 hours can be changed once daily.  For those dressings that are becoming soaked with drainage, we suggest changing the dressing twice daily.  For wounds that are at least 7 days out from injury and have minimal drainage, changing the dressing every other day is often adequate. 

It is important to avoid placing dry dressings onto the wound as they become stuck, can cause bleeding, and can exacerbate the inflammation that generally worsens over the first 5-7 days after injury.  The blast effect of the bullet traveling through the tissue is often associated with increasing severity of inflammation in the surrounding tissue such that wounds are often more tender and swollen 5-7 days after injury. Frequently, patients share that their pain experience is far worse in the days after being treated in the hospital than it was when they were originally injured. All of the care for the pain and wounds focus on reducing inflammation, preventing infection, and assuring that patients have the right support to heal.

The last section is an invitation to heal, and it includes the different components of our sensory approach to healing. Using the five senses, we engage the body in comforting ways to help alleviate some of the discomfort that comes with acute injury and hospital based care. We know that right after someone gets out of the emergency room, they probably haven't had much to eat. The snacks in the box include fruit snacks with 100% RDA dose of Vitamin C, a beef stick with 10g of protein, dark chocolate, a CALM magnesium drink packet and some sugar free gum. All of these snacks contribute to a sensory experience of taste that can be comforting and contributing in some way to health and healing overall.  This component is often one of the more popular parts of The BRIC Box.

After having a snack, patients can use the remaining materials to help create a sense of calm.  This includes a votive candle and a palo santo stick which can be burned like incense to create a calming scent.  It also includes a plain black  lava rock bracelet with lemongrass and lavender oil. These essential oils can be placed directly onto the lava rock beads which will hold onto the scent for several days. The lemongrass is invigorating while the lavender is good for calming and promoting sleep. This allows for gentle aroma therapy to be available either by wearing the bracelet or keeping it close by.  Patients are encouraged to do a simple 5 deep breath technique for relaxation through a simple video. There is also a journal and a BRIC Pen where thoughts and concerns can be written down. Finally there is a stress ball that can be squeezed for relaxation as well.

Section 1 - CLEAN:

• Reusable ice pack
• Pain Pack: Ibuprofen, Acetaminophen, Magnesium
• Hand Soap
• Hand Wipes
• Glove Pairs
• Trauma Shears
• Saline Wound Wash
• Chucks Pad

Section 2 - TREAT:

• BZK Wipes
• Lidocaine (Burn) Gel
• Adhesive Remover
• Antibiotic Ointment
• 3x3 Gauze

Section 3 - COVER:

• Non-stick pad
• ABD Pad
• Rolled Gauze
• Small Island Dressing
• Bandaids
• Small and Medium Waterproof Cover
• BRIC Tape
• Plastic Tape

Section 4 - HEAL:

• Fruit Snacks
• Chomp
• CALM Magnesium Drink Packet
• Sugar Free Gum
• Lava Rock Bracelet
• Essential Oil Vial
• Palo Santo
• Votive Candle
• BRIC Pen
• Journal