Friday, November 25, 2011

OTC Pain Management for Remote Areas

   Casualties found in wilderness and remote locations have two main complaints: Thirst and Pain.
How would you as a Remote Medic deal with both of these issues? How can you provide pain management if you are not a doctor and only have access to Over The Counter medications?

***********this post is for information only. Always consult your physician**********

   Thirst and pain are two issues that every casualty with a major injury has. Additional problems are cold, prolonged evacuation time, limited supplies and a myriad of other issues that the Remote Medic has to deal with when assessing and treating illnesses and injuries.
   Pain has been a predominant problem for military medics. Currently in the wars in the Middle East the Combat Medical Technicians are not addressing the thirst and pain issues effectively. One problem is that they rely heavily on the helicopter based evacuation system called the Medical Emergency Response Team (MERT). Currently they have been filmed on the BBC production call "Frontline Medicine." There is a link here to watch it online. It is definitely worth a look.
   Historically, military medics and Remote Medics have been taught that a casualty cannot be given anything orally. Pain management has been limited as well due to the hesitation by commanders to allow medics to have controlled substances out in the field.
   The myth of keeping your casualty from taking any fluids or food goes back to the civilian protocol for casualties who will likely be sent into the operating theatre once they get to the hospital. The surgeons have made this rule for not eating or drinking because they don't want to have to deal with the contents of a casualties stomach during an operation.
   The problem with this rule is that these doctors are quite happy to let their casualty starve and be hypovolemic only because they refuse to be bothered about providing patient care. The surgeons and anesthetists don't want to clean up a mess and to be fair they do have a job to do sorting out all of the traumatic injuries.

   In a remote environment evacuation is always prolonged. If the Remote Medic follows the city based requirement of NPO (nothing by mouth) the casualty will be VERY hungary and VERY thirsty by the time of evacuation. This is not an option for good medical care.

   For wilderness medical protocols it is important to continue to feed and hydrate the casualty. It is important to provide agressive pain management.

Hydration and sustenance
   There are two options in life: hydrate or die. This is the tag line for the CamelBak company and this slogan is applicable to medicine. The casualty must be allowed to continue to eat and drink during the prolonged evacuation.
   The casualty is already injured. They will need nutrients to heal. Feed them oatmeal, soup or something healthy that is warm. Remember that they are also fighting hypothermia.

Pain Management with OTC meds
   There are a few options out there for pain meds for the non doctor. Obviously the best option out there is to have a doctor prescribe some heavy hitters. This post is for those who do not have that option.

1. Ibuprofen
    400mg will have an analgesic effect
    600-800mg will have an anti-inflammation effect
   Ibuprofen is an analgesic and an anti inflammatory. This will benefit any outdoor professional who is in pain from blisters, sprained ankles, or sore muscles. Taking the 800mg dose will address the pain and the inflammation of these injuries.

2. Paracetamol or Tylenol
    1gm up to 4gm per day. Even the military include this for battlefield casualties. It is also has the highest ratio of success of any analgesic. This means that more people can successfully take Paracetamol without dangerous side effects. Definitely a safe option for the Wilderness Settings.

3. Mixing Ibuprofen & Paracetamol
   Recent studies have shown that taking 400mg of Ibuprofen and 1gm of Paracetamol/Tylenol together will be have a higher analgesic effect than some higher levels of narcotics.
   Clin Ther. 2010 Jun;32(6):1033-49

4. Codeine addition to number 1 & 2
   As a Remote Medic, one has to be careful when adding codeine to any mix. Here in Ireland and the UK, it is quite easy to purchase both Paracetamol (Tylenol) and Ibuprofen with codeine.
   Codeine will cause constipation. This means that if you use Paracetamol and/or Ibuprofen with codeine your casualty will need to be given some type of laxative. These are easily found in chemists without a prescription.
   Codeine will suppress a cough which can be helpful in a tactical situation.

5. Piriton
    Clorpheniramine (CTM)
   CTM is used as an anti-histamine. It is great for a runny nose. It can be used for a general analgesic. For Remote Medics who need to debride a nasty wound it would help with calming and partially sedating the casualty.
   Anti-histamines are also quite effective for motion sickness and the prevention of the same.
   For the casualty who is suffering from anaphylaxis (or asthma) having CTM is the second best tool to have in your medical kit. (2nd to epinephrine) more information here
   Treatment for anaphylaxis is: EpiPen, CTM, CorticoSteroid, and an asthma inhaler (Albuterol/Salbutomol)
   CTM also has an anti nausea effect and can be useful for someone who is suffering from motion sickness or other forms of nausea.
6. Diphenhydromine (DPH)
   DPH is used primarily in North America and has the same uses and effect as CTM.

7. Antibacterial
   Neosporin, bacitracin, etc
   Have a few small tubes of a single antibiotic ointment. Skip the triple antibiotics.
   Uses include:
      Ointment for infected eyes
      Ointment for external ear infections
      Ointment for skin infections

8. Antidiarrheal
    Immodium AD
    good for any travel medicine kit

9. Laxative
    Any expedition has a change in dietary habits which means there is risk for constipation as well as diarrhea. Having options for both eventualities should be in every Remote Medic's medical kit. Have this to counteract for any codeine use.

Additional information can be found at

***********this post is for information only. Always consult your physician**********


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