Friday, May 11, 2018

First Aid: Medications

Hour 9

Bonus Review:

TCCC Quick Reference Guide 2017 pp. 41-45, 52

As promised in previous comments, here it is.

As threatened, here are your Important Advisories:

Repeat after me:
1) I am not a doctor. I am not a pharmacist. I do not have the medical training, nor legal authority to officially diagnose illness, nor prescribe or dispense prescription medication.
2) I will know and consider my own allergy status and that of people I treat BEFORE rendering any further treatment.
3) I will read and heed all label directions.
4) I will consult my own doctor and/or pharmacist before taking any medication, or providing it to those under my care, such as my own minor children.
5) I understand that failure to follow those guidelines of both legal necessity and plain common sense makes me a fool, dangerous to myself and others, legally and morally liable for my actions, and expect to be pointed out and laughed at as such, including in open court, should I neglect them, regardless of any and all contrary excuses.

General exemplar: If your friend asks you for some aspirin/Tylenol/Motrin for a headache, and you hand him a package from which he extracts same, you are usually not considered to be prescribing nor dispensing medications.

When your friend says he has a pain at the bottom of his rib cage, and you tell him it's indigestion, hand him a couple of Tums, and he takes them, then falls over dead from a massive heart attack, you have diagnosed, prescribed, and dispensed medication. See advisory 5 above.

I promise you with every fiber of my being, what I've told you so far is equally, if not more, important than anything else you'll get out of this information regarding medications. Really. Cross my heart, and hope to die.
I'm putting this at the beginning for two reasons, one minor, and one major.

The minor one is that if anyone, anywhere in the galaxy, ever attempts to tell the world they did something because Aesop, the World Authority On All Things Medical, told them they could, I will point to it, especially Advisory 5, and then point and laugh. And then I'll get medieval on you.
The major one is because if you take on the huge responsibility of caring for people, even in an emergency or SHTF scenario, you have to remember a couple of things to protect yourself as well, and most importantly your patient.

The first is, Good Samaritan laws provide immunity from legal harm (criminal and civil) for helping someone -- with two important boundaries.
First, anyone can be arrested, and anyone can be sued, for whatever they do. Good Samaritan Laws merely provide a means of affirmative legal defense to make it impossible for the other side to win.

Secondly, they do so ONLY if you, the Good Samaritan in question, are within the boundaries of what a prudent average person with a similar level of training WOULD HAVE done, in your shoes. This is yet another reason why doing field appendectomies and amputations, throwing in a few stitches, or handing out Rx medications, is a B.A.D. idea in all but the most dire Zombie Apocalypse-type circumstances.
The first line of the Hippocratic Oath, which doctors no longer recite upon graduation, but which every one of them knows nonetheless, is one with 3000 years of common sense behind it:

“First, I Will Do No Harm.”
In other words, don't make the problem worse by anything you do. Hippocrates was no dolt.

And one more time: Every medication has contraindications – in layman’s terms, reasons to NOT use them – not least of which is a personal allergic reaction. NOT knowing the whys and why nots of the following medications is YOUR fault, because I’ve told you and you’ve promised to LOOK THEM UP FIRST. This is deadly serious, and I expect if you’re reading this far, you will treat it as such.
Now, to the meat and potatoes: What I carry in my everyday kit, and why.

aspirin The BOMB. A drug company executive once lamented its discovery, as boiled willow bark, too early on in history. The number of uses probably would have guaranteed it would still be Rx-only otherwise. It can be used (in adults) for fever control, pain relief, and to thin the blood (inhibit prostaglandin synthesis for sticklers) in patients who may be having cardiac problems like a heart attack. For children's fevers, it should generally NOT be given, due to risks of certain side effects.

That would be Tylenol to the uninitiated. The fever-reducer with the fewest side affects, considered especially appropriate for children. BEWARE: Many modern OTC (that's over the counter) medications have acetaminophen snuck into them too. Including some things sold by Motrin (see below). Thus you could take a daytime cold/flu med, a nighttime one, and some Tylenol, and end up triple-dosing yourself on acetaminophen. If you want to die a slow agonizing death after liver failure, overdose on acetaminophen. Or, heed Advisory 3, and note the list of active ingredients in ANYTHING you or anyone takes.

Motrin, Advil, and generics, etc. to the public. Like aspirin and acetaminophen, it also reduces pain, and is an anti-pyretic (fever-reducer). Like acetaminophen, it is better for children (once they're over 6 months, and have no conditions which would contraindicate it) for fever reduction. Because ibuprofen and acetaminophen work on fevers differently, they can be safely alternated without double-dosing. A typical fever treatment recommendation is acetaminophen at 12 and 6, and ibuprofen at 3 and 9, following recommended dosages. Your child gets fever reduction every three hours instead of every 6, so they feel better. Fevers lasting longer than 3 days, or unresponsive to treatment (don't go down despite medication) for lesser time periods should still be seen by a doctor/ER. Be safe, not sorry.

Ibuprofen, like aspirin (above) and Aleve (naproxen) are all also in the family of NSAIDs - Non Steroidal Anti-Inflammatory Drugs. That means besides pain and fever reduction, they will reduce swelling. That's what makes ibuprofen, to me, niftier than aspirin or acetaminophen -- it helps with swelling related to strains, sprains, etc., even in the absence of pain.

Note that where use for children/infants is anticipated, liquid forms are available. If you carry this form of ibuprofen or of acetaminophen, learn how to properly calculate/administer dosages. And realize, regardless of age-based (rather than size-based) dosing guidelines, that a 12-year old who's 6'2" and 160 pounds is not the same dose as a 12 year old who's 4'10" and 93 pounds.

Abbreviated sometimes as BZK, sold commercially as Bactine. It kills germs in wounds, and it doesn't make your patient scream. See Lesson One.

Otherwise known as Betadine. Kills germs and disinfects, as noted in Lesson Thirteen. Also note it comes in both “scrub” strength, and “solution” strength. You want solution. Scrub is for killing cooties on surfaces and instruments, not putting on or in wounds.

triple antibiotic ointment
AKA Neosporin. Good superficial wound spackles, with the same provisos from Lesson Thirteen.

Isopropyl, as opposed to vodka or scotch, and usually carried as wipe pads, not the bottle. It's flammable - use with caution. But it will clean INTACT skin, and kill some (not all) germs rapidly, so it's good  to use to clean instruments like tweezers, scissors, needles, etc. before and after use. But it takes 10-20 minutes scrubbing and soaking to truly sterilize them. It's not magical on contact.

Or honey. For diabetic emergencies, when suspected. If someone's sugar is critically low, it will save their life. If it's critically high, a few more points isn't really going to matter. If you suspect diabetes, you can put or pour some under the tongue or between the cheek and gums, and it will be absorbed sublingually without risk of choking. I keep cake frosting because it tastes better than medical glucose (blecch!), and also some honey packets from a restaurant retailer. They found honey in the pyramids in clay jars with wax seals just as fresh as it was when laid down 3,500 years ago. Whatever bees put in their spit, it's good stuff and keeps forever. Just don't spill it in your kit!

For heat emergencies. A very small amount is plenty in a quart to a gallon of water, for oral rehydration. Larger quantities will simply induce vomitting, which is probably not a good idea. Go easy.

My choice is Imodium AD tablets. They pack small, keep well, and can be lifesavers, let alone vacation-savers. If you risk Traveller's Curse, carry the anti-curse.

There are numerous types and versions. My personal choice is Benadryl. It cuts itching in allergic responses, and helps to reduce swelling. Most induce drowsiness. This can be good if you're trying to sleep, but not if you're trying to drive or simply stay awake.

I like Tums for simple acid reduction, because it's basically a calcium salt. But famotidine (Pepcid) and similar family H2 Blockers (Tagamet, Zantac, Axid) not only cut down on acid production, they also reduce the body's histamine response, which is part of anaphylaxis (life-threatening allergic response). The part that helps kill you in serious responses.

{Nota bene: ANY medication used to treat a potential life-threatening anaphylactic (allergic) reaction ONLY BUYS YOU TIME. And quite possibly NOT VERY MUCH. If you use Benadryl, Pepcid, or any form of epinephrine (EpiPen, AnaKit) in treating someone’s allergic reaction, or anytime there is wheezing, tightening in the throat, difficulty swallowing or speaking, you WILL call 9-1-1 ambulance and/or get to an ER ASAP. When the meds you gave wear off, whether in a few minutes or several hours, your patient/friend/family member will possibly be right back where you started, and you’ll have one less dose of meds to cope with this. And possibly also a rapidly closing airway making swallowing the second dose problematic or impossible. If you medicate, you MUST transport. GET THEM TO A HOSPITAL, NOW!}
sterile saline wash
As previously noted, a generic sterile non-preserved saline solution can not only wash eyes and contact lenses, but it'll blast out dirty wounds nicely far away from running water. It runs about 75 cents to a dollar per bottle, and stays sterile until you open it by piercing the tip with the cap.

Oil of cloves
A 1 oz. bottle of this can be used to apply a couple of drops to a cotton ball or Q-tip, and placed on/in a cavity, for a temporary toothache remedy.

Your personal RX and OTC meds
Obviously, if you have any personal conditions which would necessitate Rx medications, you are strongly urged to have a minimum of a one-month supply in your personal emergency kit/supplies. You can rotate this stock, so that your monthly purchase is always the one you put in your kit, and your old kit medication becomes what you use as you rotate stock out. Thus nothing is wasted, and you ALWAYS have a fresh, 30-day cushion on your nitroglycerin, insulin, gout pills, and/or whatever else you may need. Which is harder -- rotating your meds, or being 1000 miles from home, after your doctor's office is under 10 feet of water or buried in rubble, and having no one (and possibly no pharmacy either) to dispense a fresh supply?

Plan ahead. Murphy doesn’t care about your excuses.

You may also decide that, for your comfort, you'd like OTC (over the counter, no prescription) meds I haven't included. Cough/sore throat lozenges, sunscreen, chapstick, etc. and multitudinous combination cough/cold/meds like Dayquil, Nyquil, etc, ad infinitum. Frequently referred to by pseudo-hardcorps types as “snivel meds”. It’s true that you want them because you have the sniffles, but acting like you’re a candyass for wanting/using/carrying them is false bravado and idiotic. I carry them, because I've reached the wisdom to realize that being miserable isn't noble, and being less than 100% may cost you your life from distraction, among other things. Thus you should carry them too. If there are any medications you've "just gotta have" that I haven't listed, by all means include them. And be as familiar with them as the ones I have listed, for your own sake. It's also a sterling idea to keep all your personal medications, whether Rx or OTC, separated from your kit meds, and appropriately labeled as such. It could save confusion, or even a stretch in jail for carrying unlabeled Rx controlled substances. Trust me, this is never funny nor inconsequential when sitting in the TSA/FBI/DEA holding cell (or foreign equivalent) at an international airport or port of entry.

That’s IT.
Unless you or a close family member has a known allergic reaction to something common (like bee stings, seafood, etc.) I would NOT recommend getting/wheedling/conniving your private MD to write an Rx scrip for an EpiPen or the like.

Epinephrine is a cardio-active drug commonly used to treat heart attacks. Improper/inappropriate use of epinephrine can KILL someone, and if you aren't at least a paramedic with ACLS training or higher, I don't have time to list the ways how. Put it in the DUMB category, except for the indicated use above.
Normally, I'm not going into any other Rx medications whatsoever, because 3 people might benefit, whereas 3000 will make foolish assumptions, and 2 of them will kill somebody, and invoke my name.

That said, there are Rx medications listed in the TCCC guidelines. You should familiarize yourself with them.

When  I say "familiarize", that means you need to learn the trade name, the generic name, the primary uses for which it's prescribed (by those acting within their scope of practice), how it works, how fast it works, how long it works, what possible adverse reactions and common side affects my be encountered, and which, if any, medications it should not be used with concurrently.
Then the dosage, frequency, and duration of use for taking it to obtain the results you're after, and when to stop taking it.

This is the non-negotiable bare minimum for EVERY medication you use/carry/hand out, from now until Hell freezes over, and Yes, EVEN ON A DESERT ISLAND AFTER GLOBAL THERMONUCLEAR WARFARE OR THE ZOMBIE APOCALYPSE.
Failure to abide by this common sense marks you as an idiot.
Failure to observe due diligence, and still attempt to treat yourself or someone else contrary to that advisory makes you a DANGEROUS IDIOT.

The gist of that is what it takes to be a paramedic, registered nurse, nurse practitioner, physician's assistant, D.O./M.D., and/or pharmacist. You will see this material again.

The second area that comes up again and again is Antibiotics. Usually expressed as
Q.:"What should I get?" and
     "What should I carry?"

A.: Everything. (Think Gary Oldman in The Professional.)
I'm dead serious. In the context of preparedness for anything from a local emergency to societal meltdown, civil war, or the Zompocalypse, you should, by all means, get your hands on every damned last bit of the modern world at its pinnacle onto which you can glom your grubby little mitts. Most particularly including large quantities of antibiotics. They can save lives, and will if selected and used properly, in accordance with current practice.

And then, exactly as I just told you previously, you need to have a spectacular grasp of treating anaphylaxis, and you should  familiarize yourself to the fullest with everything I told you that entails, above.

For example, you could, in fact, treat anthrax, or possible exposure to same, with commonly-available (as pet antibiotics) Doxycycline. But such a course of treatment for even one person could run to multiple weeks, and multiple doses per day, requiring quite a bit more than just a few tablets.

If you had some common sense, a good recent nursing drug reference handbook, the current editions of the Tarascon Pocket Pharmacopoeia, and the Physician's Desk Reference, (over $120, right there, and a bargain at twice the price) you could figure all that out in about half an hour to an hour of diligent study.

If you were really smart, you'd put together index cards for the 100 medications (including both OTCs and RX meds, esp. the antibiotics) you're ever likely to take, use, or give out, before you EVER thought to do so, because you're not an uneducated idiot, but are instead a diligent and circumspect person eager to do things the right way.

And you don't want to die, or kill anybody else either, even by accident.

That's entirely your choice. Ask around, and see which one your buddies/family/tribe would prefer you to be.

If you're bright enough to comprehend higher levels of medication administration, and foolish enough to attempt doing it without any further training or licensure, you don't need my help to get in trouble, and then try to drag me down with you. To say nothing of what you may do to your patient.
Last note: Be aware that this list is written with names standard in the USP - United States Pharmacopeia. Mexico, Canada, the UK, the EU, and everyone else tend to insist on making up their own generic names for common medications -- even for acetaminophen! I assume no responsibility for those reading this in far-flung locales who don't check on things in their own country's terminology.

I highly recommend you consult previously listed resources, such as nursing drug guides, the PDR, etc. or various websites like WebMD or [] to fill in gaps in your knowledge on this subject, and answer further questions.
Medication and its usage (along with germ theory and antisepsis) is largely the difference between all medicine after 1860 or so, and everything that went before. Modern medicine without modern medication would be largely impossible, for almost everything we do.

If you're going to attempt, at a layman's level, to relieve your own and other family member's pain and suffering, you have a duty to learn all you can in order to do it safely, legally, and properly, using due common sense, diligence, and prudence. Doing so is a very praiseworthy act of the highest order of personal (and civil) responsibility. That's why society generally respects doctors and the like.
Doing so without due diligence simply makes you a witch doctor with access to a modern drugstore.


Anonymous said...

Once again Gold Standard information and advice.
Question; What about Tylenol 3 which is available OTC in many countries? (UK comes to mind)
I have an old PDR - over a decade - help or hindrance?
In my environment chapstick is not snivel gear; it's what's in your pocket every day unless you really like bleeding from your cracked lips.
Boat Guy

Aesop said...

The codeine (an Schedule II opioid narcotic) in Tylenol #3 makes it a Schedule III narcotic in the US.
Carrying same on your person for a US citizen without a specific prescription for it is a narcotic drug offense in 50 states and 7 territories, AFAIK.
Now, imagine the statutory enhancement if you have a weapon otherwise legally carried on your person.

Overseas, with the caveats regarding knowing what it does/doesn't do, etc., if you can get it, use it as needed.
When in Rome, etc., etc.

And while I refer to chapstick as "snivel gear", I think people who think they're hardasses by not carrying such gear are functional idiots.
I've got two or three tubes within sight on my desk at the moment, and it rides in every piece of kit I've ever put together, including survival kits, for the exact reason you outlined.

Anonymous said...

What are your thoughts on expiration dates on drugs? Properly stored of course.

My wife is absolutely tyrannical on the subject. I tend to view them as "sell by" dates, meaning they're still OK to take for some time after. As an example, my wife insisted on tossing an unopened tube of antibiotic ointment (the kind where you need to puncture the end of the tube to get it out) because it expired a couple weeks before. I contended that since it was unopened it should go on our list to buy next time we went shopping, but it was still usable should one of us get a cut before then.

Mark D

Aesop said...

Medications can't tell time.
Know what's in a sterile sealed plastic bag with water and 0.9% sodium chloride 10 years after the "expiration date"?
Sterile saline solution.

They've pulled stored antibiotics out of storage after 20 years. They were all found to be >90% effective.

There are exceptions; early formulation of the tetracycline family turn toxic.
I've read but not researched later generations are more shelf-stable.
Insulin, among others, is another one that has a definite life span.

Expiration dates, by and large, were a concession by the FDA to Pharma.
The pharmaceutical companies agreed to sell Uncle yuuuuuge quantities of antibiotics for military/government use at cost.
In return, Uncle had the FDA agree to let them label things as "expired", to create planned obsolescence, and guarantee ongoing sales.
Color me shocked: governments and corporations acting in their own self-interest.

Meanwhile, we had the same medication bottle in the bathroom cabinet growing up for >15 years.
Somehow, the aspirin and Tylenol didn't know they were "expired" and kept right on working just fine.
Who knew?

Simple rule of thumb:
Replace what you can easily afford to.
As a medic on productions, I cannot be handing out expired meds.
It simply means the expired ones go into my own pile of meds to use for me, or in case of SHTF.
They don't go into the dumpster if they're sealed, intact, and otherwise fine.
(Stuff that's been in a hot car on and off is another story.)

Judgement and common sense come into play: if something looks sketchy, ditch it.
If it looks fine, and intact, it's probably fine.
But YOYO when it comes to making that call.
No one else will be looking over your shoulder, and no one else will have to live with the results of your choices.

Anonymous said...

That's pretty much what I thought. My wife insists that Advil that's a month past the expiration date doesn't work as well. In the interests of family harmony I don't worry about replacing it when we get a chance, but I see no reason to throw it away before we've replaced it, thereby leaving us without in the interim.

Mark D

Aesop said...

Keeping meds in a warm, moist bathroom risks medication effectiveness more than time does.

Honey is still honey in the pyramids 3500 years later.
Ditto for salt.
For chemical compounds that are in dry, stable form, and stored at cool temps, and a week, a month, and probably a decade one way or the other isn't going to do jack.

Like I said, they can't tell time.

Put them in a hot car trunk, OTOH, and you have a much different situation.

Do what you have to for family harmony.

And don't get caught, but you can always pour the old Advil tabs into the bottle with the new stuff, and nobody the wiser but your wallet. ;)

Rich Jordan said...

You've opened up a question for me. I've seen numerous articles about using aspirin if someone appears to be having a stroke or heart attack; if you can do the basic tests that indicate they are, or they have the symptoms but are still capable of chewing the tablet and swallowing some water (or if crushed into the water, drinking it). Many say no harm even if the recipient is not actually having a heart attack.

But if they can't or don't tell you 'give me an aspirin', are you then placing yourself in the 'diagnosing, prescribing, administering' position? And potentially causing harm?

Aesop said...

Aspirin is given upon suspicion of a heart attack, whether they are or aren't, so the reality doesn't matter.

If you suspect one, the standard dose is 325mg by mouth.
That's one regular tablet, or more normally, having them chew up and swallow 4 baby aspirins (81mg@), which gets you to 324mg. i.e. Close enough.

If they can't tell you anything, you shouldn't be giving them anything by mouth.
If, after explaining the facts of life to them, they don't actively consent to taking the aspirin as a precaution, they have the absolute right to refuse.

It's given because it decreases by a small amount the risk of forming blood clots, which could make an ongoing heart attack worse. If there's not a heart attack happening (a far from rare occurrence with chest pain, which is an actual AMI about 1 time in 5 to 10), the effects of a few baby aspirin are no great shakes in most cases, as the potential benefit outweighs the potential harm (i.e. little to none). Explain to them you're not diagnosing, just giving them options.

You're in no different position than a paramedic in the field, minus the ability (unless you have a 12-lead EKG machine, and the skills to interpret its output) to look at cardiac activity, who can't tell otherwise if a patient is or is not having a heart attack. What you or they suspect may be 24K, based on experience and symptomatic presentation.

Which is exactly what you should tell them before they make their decision.

If they say "No", you're off the hook.
If they ask for the aspirin at that point, you're off the hook.

And either way, they need further and higher care than anything you can do on your own.
If it is a heart attack, they need transportation to a facility with a functional cardiac cath lab.
Lacking that, and depending on severity, their outlook may be grave.

In my experience, patients with a prior cardiac history, a good cardiologist, and a lick of common sense will be taking one baby aspirin every day already on doctor's advice, and will take the other three themselves before the arrival of EMS about 30% of the time, if they're experiencing the S/s of a possible heart attack.
We call them "survivors" in most cases.


If someone's having (or might be) a stroke, lacking a CT scanner to determine if it's an occlusive stroke or a hemorrhagic stroke (i.e you don't know whether they're having a blocked blood supply, or have ruptured an aneurysm in their brain), don't give them aspirin. In the latter, aspirin is absolutely a no-go: they'll bleed more into the brain.
Don't even suggest aspirin to them unless and until they have a CT, and someone qualified has ruled out any brain bleeding. IOW, until they're functionally someone else's problem.

If you still have access to functional CT scanning after the zompocalypse, I want to be in your group.

Rich Jordan said...

Thank you for the clarification. Very helpful, as always.

And yes, I was thinking about aspirin as an option only after 911 had been called, and/or other appropriate actions needed to get the patient to real help.