The Medicine Cabinet
First Aid training courses are principally concerned with bandaging and CPR but we can also provide safe, appropriate casualty care by administering medicines. This is especially important if we are working or travelling abroad, far from pharmacies, shops and primary healthcare.
Whoa!! We can't administer medicines!!
In the UK we are terrified of administering medicines; we are told we can't give casualties medicines on First Aid courses all the time and this isn't strictly true. This blanket ban is:
- insulting to reasonably intelligent people who can read and make informed decisions;
- not always in the best interest of the casualty who now has to go and find medication elsewhere which we could simply have given them when they needed it;
- costing the economy. The prescription charge in England as of April 2106 is £8.40 per item (1). No one is going to spend £8.40 on a packet of paracetamol which can be bought for as little as 14p in some supermarkets. But what if there is no prescription charge (as is the case in Wales, Scotland or Northern ireland) or you are exempt from the charge (unemployed, or under 16 years old, for example)? In these cases the government pays. Hooray! Free drugs! In 2015 the UK government spent £80 Million on prescription charges for paracetamol alone. How much was spent on other simple, over the counter drugs? We all paid for that.
The first thing we need to understand is that there are three classifications of drugs licenses; General Sales List medicines (commonly referred to as 'over the counter'), Pharmacy (which can be sold to you by a pharmacist but does not require a prescription) and Prescription Only Medicines.
This article is only concerned with 'over the counter' medicines which we can obtain and, if appropriate, use to treat ourselves or others.
Doing it right.
Be certain. Information printed on the packaging including the indications (when you do), the contra-indications (when you don't), the side effects and warnings supercede anything you read on the internet, including this article!
Be diligent. Ask the right questions: "Do you have any allergies?", "Have you taken this medication before?", "Have you had any problems taking this medicine before?", "Have you taken any other medication today?", "Are you on any medication?", "Do you have any other medical problems?".
If you have asked the right questions and are certain you are giving the right person, the right drug, at the right time, in the right dose through the right route. Go ahead.
Be accurate. Document the casualty's details, their problem, the questions asked and answers given and the date time and dose.
A common 'get out clause' for the ill informed is for someone to say to the casualty "I can't give you this (when referring to a simple over-the-counter pain killer) because I'm not allowed to prescribe. But if I just leave it here on the table and leave the room (wink, wink) and you take it...well, I haven't really given it to you, have I?"
This is the worst thing you can do. You have not asked the questions, you have not advised them on dosages and time, you have not witnessed how many they have taken. This practice does not absolve you of anything. It makes you negligent.
If your friend or colleague is in a mild amount of pain, and you know you have an over-the-counter pain killer in your bag and a shop or pharmacy is not nearby, saying "I can't give you anything, I'm not allowed", isn't being diligent, it's being an arse hole.
What should be in your medicine cabinet?
Here are a range of medicines available 'over the counter' for the treatment of pain, some vary in terms of strength and some are better than others for certain types of pain.
Aspirin is a mild analgesic. It's unique property is that it is a platelet aggregation inhibitor (meaning it prevents clotting) which is useful for the casualty with a suspected heart attack or as prophylactic treatment at high-altitude but not useful if your casualty is bleeding. Aspirin is the only medicine the Health and Safety Executive recommend is kept in the workplace specifically for the treatment of heart attack.
Another mild analgesic but also an anti-pyretic (meaning it can reduce temperatures which may be useful for treating a fever). Paracetamol is also an anti-inflammatory making it useful for musculoskeletal injuries.
The most commonly known anti-inflammatory analgesic. Ibuprofen can be taken with paracetamol for increased efficacy.
Naproxen is, like ibuprofen, an effective anti-inflammatory but is better tolerated with less stomach irritation. Naproxen is a Prescription Only Medicine but is licensed for sale as a Pharmacy medicine for the treatment of period pain under the brand name Feminax Ultra.
Codeine is available in low doses combined with Paracetamol (Co-Codamol) or Ibuprofen, which represents the strongest 'over the counter' pain relief available. Codeine is addictive and should not be used for more than three days and also has a constipative effect so should not be used with bowel pain.
There are a range of antihistamines on the market to reduce the local pain or discomfort of rashes or the systemic symptoms which include congestion and breathing difficulties.
Piriton is the brand name most will associate with oral antihistamines but it's active ingredient - chlorphenamine - is available for significantly less cost at pharmacies and supermarkets as an 'own brand' product.
Tablets are smaller and easier to pack than liquids but for those who struggle to take tablets, a liquid decongestant such as psuedoephedrine (sold as Sudafed liquid) is an alternative. Nasal sprays containing histamine antagonists such as Xylometazoline Hydrochloride (Sudafed, Otravine) or Ephedrine nasal drops can have a more immediate effect than tablets or liquids.
Further Reading - Anaphylaxis
On expedition or in remote areas, especially in humid conditions, generic antifungal treatments such as Clotrimazole (Canesten) should be considered for athelte's foot, jock itch and thrush.
For local rashes and itching caused by eczema, contact dermatitis or allergies, consider a hydrocortisone cream (HC45, Hydrocort) but use sparingly. Pain from insect bites can be reduced with a topical analgesia such as benzocane gel (Lanacane).
Magnesium Sulphate paste can be used for splinter removal by applying a small amount and covering it with a dressing. The paste increases the osmotic pressure at the skin drawing out moisture and, hopefully, the splinter.
For heartburn and indigestion there are lots of product on the market. Simple antacid products such as Milk of Magnesia and Gaviscon in liquid form or there are a bunch of tablets (Rennie, Settlers, Tums). Where these products do not work, renitadine (Zantac) is available over the counter or esomeprazole (Nexium) is available at the pharmacy. Nexium is more effective and lasts longer but is considerably more expensive.
Buscopan is a useful addition for Irritable Bowel Syndrome as well as gastro-intestinal and gastro-urinary cramps.
When traveling abroad, a change of diet can play havoc with your digestive system. If you haven't had a poo for a while eat more fibre but in the short term a laxative such as bisacodyl (Ducolax) can help move things along, especially if you have not been for a couple of days and there is a constant feeling of bloating.
If, on the other hand, you can't stop it coming out, that is your body's way of trying to get rid of something. Your body will be shunting available water to your lower digestive system to flush out the bacteria. The single best treatment is a diet of clean water for 24 hours and nothing else. This (and other heat related illnesses) can lead to dehydration in which case an oral rehydration solution (Dioralyte) should be available.
An anti-diarrhoeal such as loperamide (Imodium) does not solve the problem, in fact it keeps it inside but it is a solution which should only be used for convenience (i.e. the casualty has to travel).
All anti-emetic (anti-sickness) drugs are currently only available as Prescription Only Medicines in the UK. Prochlorperazine is an effective anti-emetic when sold under the brand name Stemetil but is licenced for sale as a Pharmacy medicine for the treatment of nausea caused by migraine under the brand name Buccastem.
Any injury to the eye needs professional assessment and any eye infection is likely to require oral or topical antibiotics, neither of which we can stock up on. Short term pain relief and infection control can be gained from a saline or medicated eye wash.
Again, oral problems either need treatment from a dentist or antibiotics from a pharmacist or doctor but there are some products available to at least deal with the pain until the casualty is able to get to either of those.
Many sore throats are bacterial and can be treated entirely by simply gargling warm, salty water regularly throughout the day. When the pain become so bad an analgesic spray may help. Vicks Ultra Chloraseptic is the most effective available over the counter, certainly compared to 'anaesthetic' lozenges (Dequadin, Tyrozets). There is very little evidence that other lozenges (Lockets, Strepsils) do anything other than feel nice. But remember, the spray will only remove the pain, it will not deal with the root cause.
Mouth ulcers are easily dealt with using a mouth ulcer gel (Bonjela) and toothache may be relieved with an anaesthetic gel (Orajel)
A general purpose antiseptic disinfectant (Dettol, Savlon Liquid) are useful for wound cleaning in weak solution and cleaning equipment, surfaces and instruments in a stronger solution.
Keep all medications in their original packaging along with the patient information leaflets contained within. These are the definitive references. It is also useful to have a simple 'ready reference guide' to be kept with the medicines as a prompt before administering anything.
Click here to download an example.
In addition keep an App on your phone as a quick reference to dosages, indications, contraindications and warnings. Medicines Compendium UK is one of the best for UK medicines, and is searchable by generic and brand names. Available for iPhone and Android.
1. NHS Choices. "NHS in ENgland - Help with Health Costs". http://www.nhs.uk/NHSEngland/Healthcosts/Pages/Prescriptioncosts.aspx accessed 26th July 2016
2. BBC News. "NHS in England 'spent £80m prescribing paracetamol" http://www.bbc.co.uk/news/uk-england-33055847 accessed 26th July 2016