Greentick18d
03-14-2006, 09:25
Meds, Their Uses and other Pearls
By Greentick
Last edited 14 March 2006
By way of introduction, I am not a doctor. I am a physician assistant working in the ER of a metro Atlanta hospital system. I have done this for about 5 years, minus one overseas with the Army. Prior to and concurrent to that I was a Special Forces Medical Sergeant. SF Medics are arguably the most highly trained medics in the world. We have a wide scope of practice from battle trauma to surgery to general medicine, pharmacology, nursing and more. I was an SF medic for 13 years active duty and national guard. Your tax dollars paid for the training, I'm just giving it back to you. I wrote most of this article as a post in a thread but was recommended to submit it as an article so I've added some things as well as clipped in some of my other posts.
This article is intended to supplement any other medical lists not replace them.
I would recommend getting a book on Wilderness Medicine to read prior to hiking.
The med portion of your medical kit could contain:
Ibuprofen 200mg (generic for Advil, Motrin, Nuprin - you can pretty much use whatever store brand is the cheapest) in the 200mg over-the-counter (OTC) dose. Always try to take it with some food, especially if using consecutive doses. For consecutive dosing the rule of thumb for max dose is 1 hour per 100mg: ex. Take 800mg (4 tabs) every 8hr or 600mg every 6hr (better dose for long term use). If using less works, obviously use less. For pain relief use one dose. When used for inflammation it usually takes a couple of days of multiple dosing to get full effect. Works the best for fever control. Use it for burns and sunburn. If you like Naproxen better substitute it here. If you start vomiting blood or see black, tarry stools stop taking it, take some Pepcid, and seek medical care.
Pepcid 20mg (famitodine is the generic). Uses: heartburn (after the trail food and ibuprofen) and allergic reactions. Can take every 12hrs if needed. If you are going to eat something that you know will give you heartburn take it about an hour before (just like the commercial says). If you get into poison ivy, etc you can use it to control itching without the drowsiness of Benadryl. Use 'em together for even better relief.
Aspirin. If you have heart attack risk factors or are hiking with someone who does pack a few. If they start with some chest pain good ole aspirin is still a frontline treatment. You can also crush it, moisten it and put it on bug bites. Will work for fevers too. Avoid long-term use at full doses or your gut may suffer.
Narcotics: 24hrs (4-6 tabs) of a narcotic such as Lortab/Vicodin or Percocet among others. You may only be able to get this if you have a good relationship with your primary care provider. A few tabs will have minimal abuse potential (read: addiction) and if you break a bone and are immobilized a narcotic may make your stay more comfortable until someone stumbles on you. Another fairly common pain complaint: kidney stones. As previously mentioned in this thread, narcotics only MASK your pain, just symptomatic relief, so their use should be in extremis. You can use it in conjunction with an anti-inflammatory. Alternate/multitasking: will slow down diarrhea and will quiet a cough when nothing else works.
Benadryl 25mg, (or whatever store brand, generic diphenhydramine), antihistamine. It has multiple uses but is *sedating*. Allergic reaction: blocks the mechanism that causes it take 2. Cough suppressant take 1. Anti-nausea take 1. Sleep aid take 1-2.
Antibiotic: the best "if you have to carry just one type" is Levaquin (no generic yet) 500mg. 10 pills. Easy dosing, just one per day. Will work for just about anything: urinary tract infection 3-5 days. Respiratory/sinus 10days. Skin infections or penetrating trauma 3-7 days. Anthrax: its got you covered. Persistent (more than 4-5 days) or bloody diarrhea: take for up to 1 week. Again you will need an RX for this and it is a bit pricey (~$8 a pill).
Anti-diarrheal: As I say in the ER, "I love diarrhea!" In the civilized world it is usually just an inconvenience with porcelain never far away. Therefore, it's easy to treat. However, in the woods it can really mess up your day (sorry, bad pun). To treat or not to treat, that is the question. Typically I would advise against anti-diarrheals and say just up the fluid consumption and flush it out. Many times it will resolve itself within 24 hours. If you have to use an anti-diarrheal then just try to reach a point where the diarrhea is slowed as you can end up on the other end of the regularity spectrum, constipation. If you are hiking in hot weather and sweating a lot, a stretch of bad "spontaneous regularity" can set you up for big problems. Might be a good time to take a couple of zeros or neros. Half strength Gatorade will be your friend because you will need the electrolytes as well as the fluid. It's one thing to push on because you have a military mission to complete but when you have spent months planning and preparing for a long distance hike don't be stupid and get yourself dropped. Make it to the next shelter or town and lay up. Also think BRAT diet. Bananas, Rice, Apples, and Toast for a couple of days. This goes hand in hand with the zeros as it is hard to maintain proper calories on the BRAT. If the diarrhea continues past 3-4 days consider starting the Levaquin or seeking medical care. If you have uncontrolled vomiting AND diarrhea (as in "everything I eat or drink comes back up") that lasts longer that a few hours, you need to seek medical care. You can seriously dehydrate in a short period of time. Obviously, hydration is the key. If you are nauseous, frequent small sips of clear fluids are the key. If you are somewhere you can lay up take Benadryl (OTC), Phenergan, Reglan, or Meclizine (Antivert) (RX). These will make you sleepy. Another great RX anti-nausea is Zofran. It is non-sedating and is available in a dissolving tablet. Downside: super expensive, so just keep 3-4 if you carry it. Imodium and Kaopectate both are available in tablets over the counter. Just follow the directions on the box. If you are able to, drink plenty of water/fluids with this and as soon as the diarrhea slows down, stop the meds to avoid constipation. I don't care for Pepto Bismol because when we test for blood in your stool in the ER Pepto will make the results falsely positive. The human body is designed to be amazingly resilient, take care and you will be on your feet in no time. So, to summarize my "diarrhea of the mouth:"
OTC vomiting and diarrhea meds and treatment:
BRAT diet
Half strength Gatorade
Benadryl (nausea) - caution, sedating
Kaopectate (diarrhea)
Imodium (diarrhea)
RX meds for nausea
Sedating: Phenergan, Reglan, Antivert (all fairly cheap)
Non-sedating: Zofran ($$$$!)
Other meds to consider that don't multitask:
- Some cold medicine tabs or strips, ex Dimetapp if you are hiking during cold/flu season.
- Pseudoephedrine for congestion
- Multivitamins
- Hydrocortisone ointment/cream
- Epi Pen if allergic to bees (for last resort use)
I keep a Ziploc container (light, tough, and disposable) with this stuff in Ziploc bags. You can make a little cheat sheet with all dosings, shrink it down to the smallest readable size and drop it in the container too.
If you are carrying RXs snip the info and put it somewhere waterproof in case you run into the thru hiker cops.
Also useful: a card with your full name, contact numbers, SSN, medical/surgical history, daily meds and doses, and allergies in case you end up in the ER somewhere.
Wound Care
No Hydrogen Peroxide/Betadine/or alcohol on open wounds. Kills and or denatures all tissues and can (eventually) make a better environ for bad stuff.
Soap and treated water to clean open wounds. The more irrigation the better with some moderate pressure. You could probably have someone push on your hydration bladder and with the bite valve off get some decent pressure.
Neosporin ointment is a good general-purpose item. Wound care and good for monkey-butt.
Use Betadine/HP/or alcohol on unbroken skin, for example if you are going to bust a blister or an abscess or give an injection. Betadine and HP are anti-microbial, alcohol degreases (and takes the microbes with it).
In the ER I currently do wound prep with Betadine and sterile saline at a 1:10 mix. I will also use this for irrigation of dirty wounds. Be careful, the person may not like you anymore after using this combo - it burns.
If you carry moleskin try to get Tincture of Benzoin. It is a sort of surgical glue to enhance the adhesion factor of moleskin or Steristrips. Just don't get it in the wound. I have watched people drain blisters with a needle and then inject tincture of Benzoin back into the blister (this was in the army not in the ER). I think this is how break-dancing was invented. Make sure it dries (it will be tacky) before applying the moleskin. Should stick for days and days.
Toenails and other interesting tidbits.
This is looking at the treatment of "hiker's black nail," a subungual hematoma, and hangnails.
1. Leave the damaged nail in place if possible. If it comes off don't sweat it but it will act as a splint for its replacement nail.
2. Trimming toenails/hangnail-blacknail prevention. There is a fine line here. Trim them too short and you can predispose yourself to hangnails which are painful. Too long and you run the risk of crunching it in your boot - not to mention wearing out your socks prematurely. The textbook answer for those susceptible to hangnails is to trim them so that the "corners" (for lack of a better term) are out past the end of the skin. However I have seen them hang up anyways (personal experience). I think some folks are just predisposed. There is a happy medium I suppose but if you seem to be having problem you just have to be more diligent and trim the nails a little more often. A wedge excision could be performed in the field on a hangnail if desperate but I may save that class for a different day.
3. Field treatment of the subungual hematoma. A SH can be differentiated from simple black nail by one easily determined symptom - PAIN! It is caused by an injury under the nail and is a pocket of blood. They are characterized by a constant throbbing pain. Sometimes a SH will spontaneously drain, like the old mans (touched a large bubble on one toe and it began to bleed profusely). Sometimes you can bear the pain. Sometimes you gotta drain em. Nowadays in the ER we have the luxury of using an electo-cautery (easy to use and sounds way cool when you say it). However, it's not necessary. Even just a few years ago we used the same technique you can use in the field. Clean the toe. Use a safety pin or better yet a paperclip (but who carries a paperclip). Get the tip red hot and touch it to the nail over the SH and apply light pressure. Repeat until you are bubbling crude. If you are doing this on a buddy watch out, they can squirt pretty far. Don't worry about burning/hitting live tissue. If you pull back when you see blood you won't be anywhere near nerves or viable tissue. As in 1. above, leave the nail in place to act as a splint for the new nail (yes you are probably going to lose the old one). Another technique that doesn't require heat uses an 18ga sterile needle (if it isn't sterile, use your lighter). Spin the needle between your finger and thumb while applying pressure and slowly bore a hole.
The pain relief will usually be immediate.
*When not to use this technique*: If you suspect a broken toe underneath don't drain and consider seeking medical care. If you drain it and have a fracture you can essentially create an open fracture, which is bad news in the field.
That's all for now.
Oh yeah, clean you hands before you eat and after calls of nature. More if someone in your group is sick...
By Greentick
Last edited 14 March 2006
By way of introduction, I am not a doctor. I am a physician assistant working in the ER of a metro Atlanta hospital system. I have done this for about 5 years, minus one overseas with the Army. Prior to and concurrent to that I was a Special Forces Medical Sergeant. SF Medics are arguably the most highly trained medics in the world. We have a wide scope of practice from battle trauma to surgery to general medicine, pharmacology, nursing and more. I was an SF medic for 13 years active duty and national guard. Your tax dollars paid for the training, I'm just giving it back to you. I wrote most of this article as a post in a thread but was recommended to submit it as an article so I've added some things as well as clipped in some of my other posts.
This article is intended to supplement any other medical lists not replace them.
I would recommend getting a book on Wilderness Medicine to read prior to hiking.
The med portion of your medical kit could contain:
Ibuprofen 200mg (generic for Advil, Motrin, Nuprin - you can pretty much use whatever store brand is the cheapest) in the 200mg over-the-counter (OTC) dose. Always try to take it with some food, especially if using consecutive doses. For consecutive dosing the rule of thumb for max dose is 1 hour per 100mg: ex. Take 800mg (4 tabs) every 8hr or 600mg every 6hr (better dose for long term use). If using less works, obviously use less. For pain relief use one dose. When used for inflammation it usually takes a couple of days of multiple dosing to get full effect. Works the best for fever control. Use it for burns and sunburn. If you like Naproxen better substitute it here. If you start vomiting blood or see black, tarry stools stop taking it, take some Pepcid, and seek medical care.
Pepcid 20mg (famitodine is the generic). Uses: heartburn (after the trail food and ibuprofen) and allergic reactions. Can take every 12hrs if needed. If you are going to eat something that you know will give you heartburn take it about an hour before (just like the commercial says). If you get into poison ivy, etc you can use it to control itching without the drowsiness of Benadryl. Use 'em together for even better relief.
Aspirin. If you have heart attack risk factors or are hiking with someone who does pack a few. If they start with some chest pain good ole aspirin is still a frontline treatment. You can also crush it, moisten it and put it on bug bites. Will work for fevers too. Avoid long-term use at full doses or your gut may suffer.
Narcotics: 24hrs (4-6 tabs) of a narcotic such as Lortab/Vicodin or Percocet among others. You may only be able to get this if you have a good relationship with your primary care provider. A few tabs will have minimal abuse potential (read: addiction) and if you break a bone and are immobilized a narcotic may make your stay more comfortable until someone stumbles on you. Another fairly common pain complaint: kidney stones. As previously mentioned in this thread, narcotics only MASK your pain, just symptomatic relief, so their use should be in extremis. You can use it in conjunction with an anti-inflammatory. Alternate/multitasking: will slow down diarrhea and will quiet a cough when nothing else works.
Benadryl 25mg, (or whatever store brand, generic diphenhydramine), antihistamine. It has multiple uses but is *sedating*. Allergic reaction: blocks the mechanism that causes it take 2. Cough suppressant take 1. Anti-nausea take 1. Sleep aid take 1-2.
Antibiotic: the best "if you have to carry just one type" is Levaquin (no generic yet) 500mg. 10 pills. Easy dosing, just one per day. Will work for just about anything: urinary tract infection 3-5 days. Respiratory/sinus 10days. Skin infections or penetrating trauma 3-7 days. Anthrax: its got you covered. Persistent (more than 4-5 days) or bloody diarrhea: take for up to 1 week. Again you will need an RX for this and it is a bit pricey (~$8 a pill).
Anti-diarrheal: As I say in the ER, "I love diarrhea!" In the civilized world it is usually just an inconvenience with porcelain never far away. Therefore, it's easy to treat. However, in the woods it can really mess up your day (sorry, bad pun). To treat or not to treat, that is the question. Typically I would advise against anti-diarrheals and say just up the fluid consumption and flush it out. Many times it will resolve itself within 24 hours. If you have to use an anti-diarrheal then just try to reach a point where the diarrhea is slowed as you can end up on the other end of the regularity spectrum, constipation. If you are hiking in hot weather and sweating a lot, a stretch of bad "spontaneous regularity" can set you up for big problems. Might be a good time to take a couple of zeros or neros. Half strength Gatorade will be your friend because you will need the electrolytes as well as the fluid. It's one thing to push on because you have a military mission to complete but when you have spent months planning and preparing for a long distance hike don't be stupid and get yourself dropped. Make it to the next shelter or town and lay up. Also think BRAT diet. Bananas, Rice, Apples, and Toast for a couple of days. This goes hand in hand with the zeros as it is hard to maintain proper calories on the BRAT. If the diarrhea continues past 3-4 days consider starting the Levaquin or seeking medical care. If you have uncontrolled vomiting AND diarrhea (as in "everything I eat or drink comes back up") that lasts longer that a few hours, you need to seek medical care. You can seriously dehydrate in a short period of time. Obviously, hydration is the key. If you are nauseous, frequent small sips of clear fluids are the key. If you are somewhere you can lay up take Benadryl (OTC), Phenergan, Reglan, or Meclizine (Antivert) (RX). These will make you sleepy. Another great RX anti-nausea is Zofran. It is non-sedating and is available in a dissolving tablet. Downside: super expensive, so just keep 3-4 if you carry it. Imodium and Kaopectate both are available in tablets over the counter. Just follow the directions on the box. If you are able to, drink plenty of water/fluids with this and as soon as the diarrhea slows down, stop the meds to avoid constipation. I don't care for Pepto Bismol because when we test for blood in your stool in the ER Pepto will make the results falsely positive. The human body is designed to be amazingly resilient, take care and you will be on your feet in no time. So, to summarize my "diarrhea of the mouth:"
OTC vomiting and diarrhea meds and treatment:
BRAT diet
Half strength Gatorade
Benadryl (nausea) - caution, sedating
Kaopectate (diarrhea)
Imodium (diarrhea)
RX meds for nausea
Sedating: Phenergan, Reglan, Antivert (all fairly cheap)
Non-sedating: Zofran ($$$$!)
Other meds to consider that don't multitask:
- Some cold medicine tabs or strips, ex Dimetapp if you are hiking during cold/flu season.
- Pseudoephedrine for congestion
- Multivitamins
- Hydrocortisone ointment/cream
- Epi Pen if allergic to bees (for last resort use)
I keep a Ziploc container (light, tough, and disposable) with this stuff in Ziploc bags. You can make a little cheat sheet with all dosings, shrink it down to the smallest readable size and drop it in the container too.
If you are carrying RXs snip the info and put it somewhere waterproof in case you run into the thru hiker cops.
Also useful: a card with your full name, contact numbers, SSN, medical/surgical history, daily meds and doses, and allergies in case you end up in the ER somewhere.
Wound Care
No Hydrogen Peroxide/Betadine/or alcohol on open wounds. Kills and or denatures all tissues and can (eventually) make a better environ for bad stuff.
Soap and treated water to clean open wounds. The more irrigation the better with some moderate pressure. You could probably have someone push on your hydration bladder and with the bite valve off get some decent pressure.
Neosporin ointment is a good general-purpose item. Wound care and good for monkey-butt.
Use Betadine/HP/or alcohol on unbroken skin, for example if you are going to bust a blister or an abscess or give an injection. Betadine and HP are anti-microbial, alcohol degreases (and takes the microbes with it).
In the ER I currently do wound prep with Betadine and sterile saline at a 1:10 mix. I will also use this for irrigation of dirty wounds. Be careful, the person may not like you anymore after using this combo - it burns.
If you carry moleskin try to get Tincture of Benzoin. It is a sort of surgical glue to enhance the adhesion factor of moleskin or Steristrips. Just don't get it in the wound. I have watched people drain blisters with a needle and then inject tincture of Benzoin back into the blister (this was in the army not in the ER). I think this is how break-dancing was invented. Make sure it dries (it will be tacky) before applying the moleskin. Should stick for days and days.
Toenails and other interesting tidbits.
This is looking at the treatment of "hiker's black nail," a subungual hematoma, and hangnails.
1. Leave the damaged nail in place if possible. If it comes off don't sweat it but it will act as a splint for its replacement nail.
2. Trimming toenails/hangnail-blacknail prevention. There is a fine line here. Trim them too short and you can predispose yourself to hangnails which are painful. Too long and you run the risk of crunching it in your boot - not to mention wearing out your socks prematurely. The textbook answer for those susceptible to hangnails is to trim them so that the "corners" (for lack of a better term) are out past the end of the skin. However I have seen them hang up anyways (personal experience). I think some folks are just predisposed. There is a happy medium I suppose but if you seem to be having problem you just have to be more diligent and trim the nails a little more often. A wedge excision could be performed in the field on a hangnail if desperate but I may save that class for a different day.
3. Field treatment of the subungual hematoma. A SH can be differentiated from simple black nail by one easily determined symptom - PAIN! It is caused by an injury under the nail and is a pocket of blood. They are characterized by a constant throbbing pain. Sometimes a SH will spontaneously drain, like the old mans (touched a large bubble on one toe and it began to bleed profusely). Sometimes you can bear the pain. Sometimes you gotta drain em. Nowadays in the ER we have the luxury of using an electo-cautery (easy to use and sounds way cool when you say it). However, it's not necessary. Even just a few years ago we used the same technique you can use in the field. Clean the toe. Use a safety pin or better yet a paperclip (but who carries a paperclip). Get the tip red hot and touch it to the nail over the SH and apply light pressure. Repeat until you are bubbling crude. If you are doing this on a buddy watch out, they can squirt pretty far. Don't worry about burning/hitting live tissue. If you pull back when you see blood you won't be anywhere near nerves or viable tissue. As in 1. above, leave the nail in place to act as a splint for the new nail (yes you are probably going to lose the old one). Another technique that doesn't require heat uses an 18ga sterile needle (if it isn't sterile, use your lighter). Spin the needle between your finger and thumb while applying pressure and slowly bore a hole.
The pain relief will usually be immediate.
*When not to use this technique*: If you suspect a broken toe underneath don't drain and consider seeking medical care. If you drain it and have a fracture you can essentially create an open fracture, which is bad news in the field.
That's all for now.
Oh yeah, clean you hands before you eat and after calls of nature. More if someone in your group is sick...