Naughty or Necessary?

[Bishop]

Naughty or Necessary?
A question for those interested in expedition medicine, homesteading or with prepping tendencies.

Today we enjoy the benefits of many modern marvels that our ancestors would lust over such as ferrocium rods, Bic lighters, silicone, nylon, high quality steel,lightweight alloys, handheld devices that can send messages around the world etc. Yet when it comes to pain relief in an emergency situation things have taken a step backwards.

Now in 2018 if you sustain a traumatic injury for instance a gunshot, burying an axe in your foot or breaking an ankle the only thing I am allowed to give for the pain is a couple of aspirin and piece of grubby leather to bite down on while I get the boot off. Milk of the Poppy along with other herbal remedies and their pharmaceutical derivatives being tightly regulated if not completely illegal for regular people to posses in this enlightened modern era. Was not always the case and here's some Victorian lozenges for Man-Flu.

​

Sure paramedics are only thirty minutes away by helicopter in the mainland UK, provided that is the weather permits flying and they know exactly where you are. Otherwise it's an uncomfortable wait till land based emergency services arrive/find you and rescue times vary considerably. Other more remote areas of the world or post <insert apocalypse here> that help may be some considerable time coming.

What do we do.

Should we discuss the merits of what makes the best gag?
Render the screaming injured unconscious with a choke-hold?
Ask the GP nicely once a year for some Oramorph and Tramadol?

Then there's the whole grey area of Nitrous Oxide aka NOS for pain relief. Banned under UK legislation but technically exempt because of its widespread use in consumer goods, industry & medicine... (Orwellian doublethink at its finest)

At what point do you say.. Hey, do we need a proper doctor for this expedition?

 

[Broch]

Wayne runs (or ran, I assume he still does it) a great expedition first aid course which I found both very educational as well as giving me confidence (I was about to lead a group on an African trek).

I can also recommend "First Aid and Wilderness Medicine" by Duff & Gormly. There's a very comprehensive table at the back listing a great number of medicines, the dosage, side effects and uses.

I always have some form of Codeine in my first aid kit (depending on which country I'm visiting, check before you go) and together with aspirin it can be very effective.

 

[Nomad64]

I’m currently in the process of updating my rusty first aid qualifications and have a couple of questions arising from the scenario suggested by the OP which I couldn’t find an answer to in my text books.

1. When is it appropriate to remove a boot (especially one that will not come off easily), in the field from a casualty with a suspected broken ankle?

2. When is appropriate to ignore the usual “nil by mouth”, protocol at give aspirin and (presumably), water to someone who could require surgery to fix a fracture?

 

[mrcharly]

Never appropriate to give aspirin to someone who is suspected of having a fracture (or about to have surgery). Aspirin promoted bleeding.


Broken ankle question - hmm - I'm guessing that you would do this if you suspect that swelling is restricting blood flow or there is sign of rapidly swelling. Even then I think you would only remove if it came off easily or if you could cut off with scissors. Otherwise just cut away laces and open tongue of boot

 

[Nomad64]

Never appropriate to give aspirin to someone who is suspected of having a fracture (or about to have surgery). Aspirin promoted bleeding.

Good point re aspirin and haemorrhaging risk - I was thinking more about having stuff in stomach in case surgery was needed. Would the answer be the same for paracetamol, ibuprofen or other painkillers?

 

[Nice65]

Good point re aspirin and haemorrhaging risk - I was thinking more about having stuff in stomach in case surgery was needed. Would the answer be the same for paracetamol, ibuprofen or other painkillers?

Large quantities of alcohol, as seen administered in various westerns, also thin the blood. I wouldn't rate aspirin or alcohol as particularly effective pain relief if it's severe.

Ibuprofen should be ok, but many of the codeine based painkillers contain paracetamol so care would be needed. I'm much in favour of the cocaine throat lozenges to be honest, the same sort of thing is available today but use benzocaine to numb the nerves. Janne will correct me if I'm wrong, I'm fairly sure most local anaesthetic that's administered intravenously is Novocaine.

The most effective painkiller, with the least side effects for me when I had a bone graft was Oramorph. Not only did it kill the severe pain, but also instilled a very relaxed and unworried feeling which helped with the anxiety that goes with it. Does bung up the back end a bit though.

Vin Mariani was very popular, a Bordeaux containing coca leaf (not the heavily processed concentrated powder).

https://pilcrow.squarespace.com/stories/vinmariani

Alcohol, banned in Georgia at the time, was replaced by sugar syrup but Dr John Stith Pemberton of Atlanta, and named Coca-cola.

Why these useful plants we have are banned by law in this country is beyond me. Tobacco and alcohol, two of the most damaging when abused are still legal.

 

[Nomad64]

A timely article on the problem of the current problems caused by abuse/misuse of opioids and other prescription only painkillers;

http://www.bbc.co.uk/news/health-42787958

and a reminder of how things were in the “good old days” when anything resembling proper healthcare was reserved for the privileged few but you could by laudanum etc over the counter to make your journey to an early grave a less painful blur.

http://www.historic-uk.com/HistoryUK/HistoryofBritain/Opium-in-Victorian-Britain/

FWIW, in parts of the world where an ambulance (air or otherwise) is unlikely to get you to half decent medical care within the hour, you can usually buy all kinds of prescription only meds (in UK), over the counter at pharmacies and some of them may even be genuine. I know which set up, I prefer.

Some years ago, I did a course for expedition leaders working in remote locations. This included first aid in situations where help would be days rather than minutes or hours away and covered the use of painkillers and other meds which would only be available on prescription in the UK. At the end of the course, successful candidates were able to obtain a prescription for painkillers and other meds that they could show a legitimate need for on an upcoming expedition. No substitute for a proper expedition medic but better than nothing.

 

[deerstalkermedic]

Never appropriate to give aspirin to someone who is suspected of having a fracture (or about to have surgery). Aspirin promoted bleeding.


Broken ankle question - hmm - I'm guessing that you would do this if you suspect that swelling is restricting blood flow or there is sign of rapidly swelling. Even then I think you would only remove if it came off easily or if you could cut off with scissors. Otherwise just cut away laces and open tongue of boot

Assuming by field we are referring to bushcraft field not battlefield where tactical protocols are entirely different to both civilian medical and layman first aid protocols.
The protocol is always to remove the boot if possible.
The check for "circulatory compromise" must actually be done, whether you suspect it or not. The theory being without removing the boot how do you know if bloodflow to foot is taking place? If it isn't, a minor manipulation or reposition may restore it. If the aider does nothing or does not check, loss of the entire foot is possible and probable.
If on the other hand the compromise is a bleed, bleeding will still be happening inside the boot, which admittedly may slow the bleeding. It must be removed to effectively STOP the bleed which itself is of higher priority than the suspected fracture primarily to reduce onset of shock
The casualty is very unlikely to be walking anywhere. That should be enough of a reasurancre to remove the boot.
Hope that helps.
Crushing and entrapment is a bit different
DSM

 

[mrcharly]

Useful info - thanks. I guess that helps people decide what to do.
I had a major fall in the lake district (rock climbing). The MR team left my boots on; just strapped me in the stretcher and ran me down the mountain. Boot and sock weren't removed until I arrived at hospital. I was guessing my reply by my treatment (mind you, they didn't do anything other than stick a half-cast on me and my ankle is pretty stuffed - a surgeon checking it a year later said it should have been operated on to reattach ligaments).

 

[Insel Affen]

Ibuprofen should be ok, but many of the codeine based painkillers contain paracetamol so care would be needed.

I went to the doctors last week and he told me in no uncertain terms that I should cease taking all Ibuprofen immediately!! He said it was due to the long term effects of taking Brufen, especially as I'm now over 40. It may also be linked to being in the Army for over 20 years so being liberally given 400-800 mg tablets and taking them like smarties as we all do in the military. He said the only pain relief he would now advise is Paracetamol. I believe that this is linked to long term damage of the stomach lining.

(He then went on to tell me how the NHS was falling apart and I should immediately take out private healthcare for me and the family - which I found a bit strong for an Army medical centre).

 

[Janne]

My first question would be- how do you as a layman diagnose an ankle fracture? Unless it is a very, very bad one where the foot has an unnatural angle that is.

I personally would not remove the boot, unless the swelling gets bad, and use the boot as one of the anchor points for a splint.
Immobilization of the ankle/foot is crucial for the pain relief.
As the person will be moving on one leg towards a road or similar he does not have his foot flapping around.

I do not know how many Coca leaves you need to chew for a painkilling effect?

I ruined my knee in a parachute landing, and was chomping on various very strong painkillers. As most of the pain was gone, and I was high as a kite, I did use the knee. This did more damage.

Had I known the result I would have not taken any strong pain killers.

If you do take them, keep the box, and know numbers you take and tell the doc, plus do not take more than recommended on the pack!

 

[Janne]

BTW, gags is a good idea, but only on a Friday evening!!