Chapter 12. Medications/Pharmacy/Envenomations

Six primary problems regarding medications arise in austere medical situations. In some cases, more than one of these exist simultaneously. You can have (a) no medications; (b) medication, but have no clue what it is for or how to use it; (c) some medication, but not the primary choice for the condition you need to treat; (d) medication, but in the wrong form; (e) only outdated medication; or (f) medication that might have been contaminated or that has degraded. Each of these is discussed separately.

Have No Medication

If you have no medication, you will have to use local herbal remedies, physical treatments (osteopathic manipulation, thermal treatment, surgery), street drugs, or donated medications.

Donated Medications

After disasters and in Third World countries, the management of drug donations becomes extremely important. The key issue is to specify what you want and need, how much, and when it should arrive. Managing large quantities of unwanted and unneeded pharmaceuticals consumes valuable personnel time and space. After Hurricane Katrina, for example, the area was awash not only in water, but also in cartons of ridiculously inappropriate donated medications. Safely disposing of this mountain of useless pharmaceuticals became an unwanted headache.

Similar problems occur across the globe. A Harvard School of Public Health study found that about 30% of donated medications had an expiration date <1 year from the time they were shipped; 6% had <100 days left before they (officially) expired. Up to 42% of the drugs were not on either the country's list or the World Health Organization's (WHO) list of essential drugs, nor were they therapeutic alternatives for the essential drugs.1

To help lessen problems with international drug donations, WHO has developed the following Guidelines for Drug Donations2:

1. All drug donations should be based on an expressed need and be relevant to the disease pattern in the recipient country. Drugs should not be sent without prior consent by the recipient.

2. All donated drugs or their generic equivalents should be approved for use in the recipient country and appear on the national list of essential drugs, or, if a national list is not available, on the WHO Model List of Essential Drugs (www.who.int/medicines/publications/essentialmedicines/en/), unless specifically requested otherwise by the recipient.

3. The presentation, strength, and formulation of donated drugs, as much as possible, should be similar to those of drugs commonly used in the recipient country.

4. All donated drugs should be obtained from a reliable source and comply with quality standards in both donor and recipient country. The WHO Certification Scheme on the Quality of Pharmaceutical Products Moving in International Commerce (www.who.int/medicines/areas/quality_safety/regulation_legislation/certification/en/index.html) should be used.

5. No drugs should be donated that have been issued to patients and then returned to a pharmacy or elsewhere or that were given to health professionals as free samples.

6. After arrival in the recipient country, all donated drugs should have a remaining shelf life of at least 1 year. An exception may be made for direct donations to specific health facilities, provided that: The responsible professional at the receiving end acknowledges that (s)he is aware of the shelf life and that the quantity and remaining shelf life allow for proper administration prior to expiration. In all cases, it is important that the date of arrival and the expiry dates of the drugs be communicated to the recipient well in advance.

7. All drugs should be labeled in a language that is easily understood by health professionals in the recipient country; the label on each individual container should at least contain the International Nonproprietary Name (INN) or generic name, batch number, dosage form, strength, name of manufacturer, quantity in the container, storage conditions, and expiry date.

8. As much as possible, donated drugs should be presented in larger quantity units and hospital packs.

9. All drug donations should be packed in accordance with international shipping regulations and be accompanied by a detailed packing list, which specifies the contents of each numbered carton by INN, dosage form, quantity, batch number, expiration date, volume, weight, and any special storage conditions. The weight per carton should not exceed 50 kg. Avoid mixing drugs with other supplies in the same carton.

10. Recipients should be informed of all drug donations that are being considered, being prepared, or are actually under way.

11. In the recipient country, the declared value of a drug donation should be based upon the wholesale price of its generic equivalent in the recipient country or, if such information is not available, on the wholesale world-market price for its generic equivalent.

12. Costs of international and local transport, warehousing, port clearance, and appropriate storage and handling should be paid by the donor agency, unless specifically agreed otherwise with the recipient in advance.

What Is This Medication?

Describing this situation at a World War II prisoner of war (POW) camp where Allied prisoners were in desperate condition, Dr. Ian Duncan wrote: "It was ironic that immediately after cessation of hostilities, a large carton of penicillin was dropped almost on top of the hospital in Camp 17, Omuta, Japan. Unfortunately, we had never heard of it and, as no instructions were enclosed, it was never used though we had many men suffering from pneumonia, osteomyelitis, infected wounds and boils."3

This is but one story demonstrating that many common medications have different names in different countries. For example, do you know how to use pethidine? US physicians wouldn't have a clue, unless you told them that it was meperidine. Or, how would you use the common medication, paracetamol? Many clinicians would not know unless they were told that it was another name for acetaminophen. Common drugs with alternative names exist throughout the world. If you face this problem, local practitioners, pharmacists, or Internet sources may provide a solution.

Some medications may no longer be used for their original indication in the most-developed countries, but are still in common use around the world. Four, as examples, are aspirin, scopolamine, chloramphenicol, and chlorpromazine.

Now relegated to the role of antiplatelet drug in developed countries, aspirin can still be used as a potent analgesic and anti-inflammatory agent when other nonsteroidal anti-inflammatory drugs (NSAIDs) are unavailable. The standard dose is 325-650 mg (po or pr) q4-6h prn; or 650-1300 mg (enteric coated) po q8h (adult); 40-60 mg/kg/d divided q6h po or pr (pediatric). For juvenile rheumatoid arthritis, the dose can be up to 60-110 mg/kg/day divided q6-8h.

Scopolamine (Buscopan), common in "seasickness patches," is a potent anticholinergic, often used for stomach cramps, renal calculi, and bladder spasms. As hyoscine butylbromide, the dose is 10 to 20 mg intramuscularly (IM). Chlorpromazine (Thorazine, Largactil), a potent antipsychotic, antiemetic, and anti-hiccup medication, may be the only available antipsychotic available. The adult dose is 50 to 100 mg parenterally. While it is generally administered intramuscularly (IM), it is given slowly intravenously (IV) throughout world. Chloramphenicol (parenteral only), an excellent antibiotic, is recommended by WHO for severe infections and commonly used in the world's least-developed regions.

Other medications are not used in some countries (such as the United States) or may be older versions of those commonly used. These include diclofenac (parenteral NSAID used throughout the world), flucloxacillin (antibiotic), quinine and a wide variety of artemesinin-based medications to treat malaria, and equine snake antivenin.

Have Medication, But Not the Primary Choice for Condition

Alternative Drugs

Multi-Use Medications

If you don't have what you need, use what you have. A number of standard medications can be used for a variety of purposes. Use your normal pharmacology references, poison/drug information center, and pharmacist to determine all the possible uses for available medications.

Some commonly available medications with a wide variety of uses (not all listed) include:

• Diphenhydramine: sedative, antiemetic, antihistamine, local anesthetic
• Chlorpromazine: antipsychotic, hiccup therapy, local anesthetic
• Epinephrine/adrenaline: asthma treatment, cardiac stimulant, vasoconstrictor, allergy/anaphylaxis treatment
• Dexamethasone: reduce tumor edema, bronchiolitis/croup treatment, allergy/anaphylaxis treatment, antiemetic, inflammatory/vasculitis treatment, COPD (chronic obstructive pulmonary disease) treatment
• Lidocaine: antiarrhythmic, local/regional anesthetic
• Dextrose solution: medication admixture, hypoglycemia treatment, osmotic diuretic, sedative (D25W) on a child's pacifier (i.e., binky)
• Oxygen: hypoxia treatment, carbon monoxide poisoning treatment, cluster headache treatment, antiemetic4

Using Street Drugs as Medications

With the caveat that the purity and even the identity of medications purchased from nontraditional sources may be in doubt, they may be beneficial when nothing else is available. Some uses for a group of commonly available street drugs are:

• Marijuana: antiemetic, sedative
• Heroin, fentanyl (and other narcotics): analgesic, local anesthetic, cough suppressant
• Ketamine: analgesic, anesthetic
• Cocaine: local anesthetic, vasoconstrictor
• Benzodiazepines (various): antiepileptic, sedatives, antianxiety, muscle relaxant
• Barbiturates (various): sedative/hypnotic, antiepileptic
• Ethanol: sedative, disinfectant, antidote methanol poisoning, anesthetic
• LSD or psilocybin: cluster headaches5

Medication Substitutions

While many medications have therapeutic substitutes, medications in the following drug classes may be more amenable to substitution than others6:

When substituting another medication, put a note on the medication label or give it to the patient saying: "As a result of the recent emergency, your medication is very similar, but not the identical medication to the one you normally take. When possible, please go to your usual pharmacy to continue with your previously prescribed medication."

Have Medication, But in Wrong Form

Often, medications will be available but in the wrong form or dose for the patient and circumstances. Encourage the pharmacy staff to improvise (and search their literature) for ways to solve these problems. Powders may be used to produce injectables under emergency circumstances. Parenteral drugs can usually be administered rectally at the IV/IM dose.

Nitroglycerine Drip

A university pharmacy sent a message to all their emergency physicians, cardiologists, and intensivists saying that they would be unable to procure IV nitroglycerine for several months (unknown reason). Some physicians asked why the pharmacy couldn't simply make the nitroglycerine drip in-house, as they had done a decade before when it was first being used. The pharmacy staff responded that "one old pharmacist" also thought of that. (The information below was obtained from the inpatient pharmacy, University Medical Center, Tucson, Arizona by Megan Brandon, PharmD, March 22, 2008.)

Prepare a nitroglycerine drip from tablets as follows:

1. Dissolve 125 tablets of 0.4 mg nitroglycerin SL (sublingual) in 50 to 60 mL of 5% dextrose. The pharmacy typically does this in a 60-mL syringe. The solution will be cloudy due to excipients (undissolved materials in the tablets).

2. Using a 0.22-micron filter needle, add the solution to a glass container of D5W and dilute to a final total volume of 250 mL.

3. This solution will be at its final concentration of 50 mg/250 mL.

Nitroglycerine—Alternative Titration

When a patient presented to the emergency department (Casualty; ED) in resource-poor rural Ghana with severe congestive heart failure and chest pain, it appeared as if he would soon die: Almost no options were available to us and we lacked sufficient nitroglycerin tablets—and a filter and a glass D5W container—to make a drip. Instead, we had his wife administer a tablet of 0.4 mg nitroglycerin SL about every 5 minutes for the next 6 hours. By morning, he was over the acute episode and moved to the ward.

Penicillin Solution to Instill in Newborn's Eyes

A penicillin solution is used particularly to treat gonococcal conjunctivitis in newborns. To make a penicillin solution of 10,000 units/mL, use one of these two methods: (a) Boil a clean cup and let it cool. Then add 100 mL sterile water and 1 level teaspoon of salt or add 100 mL sterile saline. Dissolve 600 mg benzylpenicillin in the saline. (b) Dissolve 600 mg benzylpenicillin in 10 mL water for injection. Then mix 1 mL of this solution with another 10 mL of water for injection.7

Converting Tablets/Capsules into Palatable Form

Some patients (especially children, the elderly, and the less-than-conscious patient) cannot swallow tablets. Some medications don't come as a liquid; in austere situations, you may not have the liquid form, even if a medication is manufactured as a liquid.

There are several ways to convert tablets to a more palatable form. For non-extended-release drugs, break or crush tablets into sections—or open up the capsule and pour out the contents. Crush tablets using a hammer, after first putting the tablet in a plastic bag or wrapping it in a paper towel so the pieces do not escape. You can also use a mortar and pestle, a similar implement used to grind grains, or a coffee grinder.

If necessary, administer the medications through a nasogastric tube. Patients can dissolve the powder in liquid to drink, or sprinkle the powder onto food and eat it. Another alternative is simply to mix larger pieces into mashed potatoes, applesauce, or foods of similar consistency.

Storing Parenteral Medication for Reuse

In resource-poor situations, the temptation is to "cap" open vials containing partially used medication. In some parts of the world, medical staff routinely seal partially used medication vials with sterile gauze and tape. Even when the resource is scarce, this is a bad idea, since it promotes bacterial growth and can seriously harm subsequent patients. Rather, store the extra medication in a labeled syringe with a capped needle. Ideally, this can be placed in a cool area for short-term storage.8,9

Medication Is Outdated

Don't believe the expiration date you see on the pharmaceutical packaging. It has little relationship to the quality, potency, or safety of most medications. "Medical authorities uniformly say it is safe to take drugs past their expiration date—no matter how "expired" the drugs purportedly are. Except for possibly the rarest of exceptions, you won't get hurt and you certainly won't get killed."10

Two types of expiration dates may be on medications. The first is a manufacturer's or pharmacist's date, which generally has no major significance. The second type is placed on a partially used, often liquid, medication; pay close attention to this date.

"Manufacturers put expiration dates on for marketing, rather than scientific, reasons. It's not profitable for them to have products on a shelf for 10 years. They want turnover," said one Food and Drug Administration (FDA) pharmacist.10 "Two to three years is a very comfortable point of commercial convenience," stated Mark van Arandonk, senior director for pharmaceutical development at Pharmacia & Upjohn Inc. "It gives us enough time to put the inventory in warehouses, ship it and ensure it will stay on shelves long enough to get used."11 In addition, many US states require that pharmacists assign a "beyond-use" date to medications dispensed in a container; this is routinely set at 1 year shorter than the manufacturer's date.12

A long-term FDA program studying the shelf life of medications for the US military and the Strategic National Stockpile (of medications) has shown that nearly all medications last far beyond their official expiration dates. Some, despite being kept in markedly suboptimal conditions, retained their original quality for decades. Many of the so-called degraded medications undergo only a change in their appearance, rather than their potency. Even when a medication loses potency over time, it often can still be used. In austere situations, use the medication despite the stamped expiration date. Generally, if you need more medication due to lack of adequate effect, it will become evident. However, there are some exceptions.

The practice, for example, has been to avoid using expired tetracycline. Nitroglycerine tablets lose potency over time, as does insulin, some liquid antibiotics, water-purification tablets, and mefloquine hydrochloride (for malaria).11

In an obvious effort to avoid having pharmaceutical manufacturers "dump" nearly outdated and unsellable medications by donating them, WHO's guidelines (as previously discussed) disallow the donation of drugs within a year of expiration; many companies, of course, routinely ignore that rule. However, these medications are, for the most part, still effective. It's sort of a catch-22 situation.

In sum, as Army Col. George Crawford, a pharmacist who oversaw the government's program to test drug stability, said, "Nobody tells you in pharmacy school that shelf-life is about marketing, turnover, and profits."11

Pay close attention, however, to "beyond-use" dates that clinicians write on partially used medications. Some medications for injection and irrigation come in multiple-dose vials or large irrigation bottles containing enough medication to be administered several times. Both drug stability and sterility affect how long these medications can be used after being opened. The stability of many medications decreases once the package has been opened—or once medications have been reconstituted from a powdered form. Such medications must be used within a specific time; that time should be marked on the vial or bottle. After that, they must be discarded.

As for sterility, when a sterile medication is opened and exposed to air, the potential exists for bacteria to grow in the vial or bottle. Some medications have a preservative in them; others do not. For example, large irrigation bottles typically do not have a preservative. If the contents are used for sterile irrigation, the bottle should be discarded within 24 hours of being opened.13

Medication Is Possibly Contaminated or Spoiled

Contamination

In situations with significant airborne contamination, such as after an earthquake or sandstorm, prefilled medication syringes maintain sterility, but medication from glass ampules do not.14

Medications that have been exposed to floodwater, seawater, or unsafe municipal water may become contaminated. If they are not lifesaving medications, or if replacements are readily available, they should be discarded. If, however, they are lifesaving medications that cannot easily be replaced and, although the container is contaminated, the medication seems to be unaffected (such as tablets being dry, intact, and the normal color), then use them until they can be replaced. If the medication itself appears contaminated, discard it.15

Temperature Control

When possible, keep pharmaceutical products at the temperature specified by the manufacturer. For general purposes, the US Pharmacopeia definitions suffice6:

• Controlled room temperature: 59°F to 86°F (15°C to 30°C)
• Refrigeration: 39°F to 46°F (3.9°C to 8°C)
• Freezing: –4°F to 14°F (–20°C to –10°C)

Medications that Do Not Need Cooling

Some medications, such as insulin, may not need refrigeration to maintain clinical efficacy. Regular insulin has been tested after being stored at 25°C (77°F) for 12 months; it lost only about 2% bioactivity.16 Intermediate-acting insulin was tested after being stored at 25°C (77°F) and at 34°C (93°F) for 60 days; it lost no biological activity.17 Lente insulin (insulin zinc suspension) has been found to take 5 weeks to lose 2% of its bioactivity, and 14 weeks to lose 5%. Even at 40°C (104°F), soluble porcine insulin takes 14 weeks and lente takes 4 weeks to lose 5% of bioactivity; most patients use a vial of insulin within this time.16

Medications that Require Refrigeration

Some medications, such as succinylcholine (suxamethonium chloride), require refrigeration, and deteriorate if left unrefrigerated. Disasters can occur if the deterioration goes unrecognized. "During a surgery on what turned out to be a huge hernia, the anesthetist tried to use the ‘Sux' that was on the shelf as he hastily converted an operation under local anesthesia to one under general. The ‘Sux' had deteriorated to the extent that he had to use 20 vials to get an effect."18

Refrigeration is usually available, even in remote areas. For example, in Africa's poorest regions, more than one-third of diabetics have access to refrigeration for their medications (which may not need cooling), although the refrigerator often may belong to friends, relatives, or even to the local butcher shop or beer parlor.19

Medications that Require Freezing

Many medications and vaccines require a "cold chain" to exist between the manufacturer and the end user. In the case of live virus vaccines, for example, this means that there must be a way of keeping them frozen throughout their journey to the patient. Two vaccines that are particularly vulnerable are the measles-mumps-rubella (MMR) vaccine and the varicella virus vaccine live. MMR may retain potency at room temperature. The varicella vaccine, however, must remain continually frozen (–15°C [5°F] or colder). The Centers for Disease Control (CDC) recommends that if any refrigerated or frozen vaccines are warmed, the manufacturer or CDC should be contacted for advice before the vaccines are used.20 Other medications, especially other types of vaccines, must be kept at cool temperatures throughout their travels.

Keeping Liquid Medications/Vaccines Cold

In many areas of the world, electricity for refrigeration may be unreliable or nonexistent; this may even occur in the most-developed countries or regions after a disaster. Refrigerators can also be improvised. (See "Refrigeration" in Chapter 5, Basic Equipment.)

The use of traditional cooling methods may not be an effective method to refrigerate medications. For example, porous, unglazed clay pots have often been used as cooling mechanisms in parts of Africa. They are partially filled with soil and water, then buried in a shady place. Tests show that even under optimal circumstances, these lower the inside temperature only by 1°C or 2°C.21

Most vaccines require refrigeration or freezing, and so do not do well with power outages. While most refrigerated vaccines are relatively stable at room temperature for a limited period of time, it is best not to open the refrigeration units until power has been restored or the vaccines are to be transferred to a functioning cooling unit. The best method to preserve refrigeration- or freezer-dependent medications is to have alternative refrigeration/freezing sites available. When planning to store medications in disaster situations, alternative locations may include any site that has a dependable generator as well as the required cooling devices. To be useful, medical personnel must not only be aware of the availability of such facilities, but they must also have access to them during a disaster. "Access" means they should know the floor plan (to be able to find the cooling units), have portable lights (in case no light is available), have any keys or access codes to unlock doors and equipment, and be aware of any alarm systems that might be activated—and how to deactivate them.

For example, in St. Bernard Parish, Louisiana (adjacent to New Orleans' Ninth Ward), after Hurricane Katrina destroyed nearly everything in the vicinity (including the hospital), quick-thinking physicians took their supply of vaccines to the refrigerators in the telephone switching station, which they knew had a reliable generator. Not only did the vaccines survive, but they also were used to inoculate thousands of people.

Alternatively, refrigerated trucks or train cars can provide temporary storage, as can an available supply of dry ice.

Keeping Pharmaceuticals Warm

A major problem in cold climates is preventing medications and IV solutions from getting too cold or even freezing. Prehospital personnel often use their own body heat for this. Refrigerators or freezers (when turned off), with their excellent insulation, can also function to prevent liquids from freezing.

Pharmacy Layout

While the concept of setting up a field/improvised pharmacy may seem to be a "no-brainer," it may be a challenge to meet the requirements for storage and safe dispensing. Limited workspace may be available, and pharmaceuticals may be mixed together, sometimes in a multitude of unlabeled boxes and bags. Among these may be many donated pharmaceuticals that are unrecognizable or useless.

Basic principles to follow when planning a field pharmacy include:

• The pharmacy should be situated so that access is limited and be arranged so that the personnel and pharmaceuticals within it are secure. If possible, have a locked box or area for controlled substances, such as narcotics.
• For confidentiality, place the dispensing area away from, or at the end of, the flow pattern for patients and personnel.
• Store medication so that pharmaceuticals can quickly be identified and dispensed. Additional materials for dispensing, recordkeeping, and reference should also be easily accessible.
• When possible, separate the larger storage area from the dispensing area.
• Store everything off the ground to prevent water damage. Placing boxes on pallets or empty litters usually suffices.
• Whenever possible, ensure a secure source of electricity for lighting, refrigeration, computers, and other equipment.

Medication Organization

In patient care areas, it may be difficult to keep medications organized. One method is to use a cardboard egg carton to sort medications (Fig. 12-1). Another alternative is to cut down the height of a typical cardboard box in which small bottles are shipped. Both make excellent medication organizers for wards and clinics.

Calculating Drug Doses

Basic medication math that many people forget is how to calculate correct doses. While others may do that for you in routine circumstances, the following may help if you are dispensing or administering medications without much help.

• 1. To calculate the correct dose of drugs expressed as mg/kg or mcg/kg or as mg.kg−1 or mcg.kg−1, multiply the drug dose by the patient's weight.
  • Example: the dose of atropine is 20 mcg/kg.
  • For a 25-kg patient, give: 20 mcg/kg × 25 kg = 500 mcg = 0.5 mg
• 2. When using drugs prepared in solution, calculate the number of milligrams of the drug per 1 mL. Do this by multiplying the number in the percentage of the solution by 10.
  • Examples:
  • For a 2% lidocaine solution, use: 2 × 10 = 20 mg/mL
  • 0.5% bupivacaine = 0.5 × 10 = 5 mg/mL
  • 2.5% thiopental = 2.5 × 10 = 25 mg/mL
• 3. Some solutions, such as adrenaline (epinephrine), may be expressed as 1:1000, or 1:10,000 or 1:100,000. This means that in a 1:1000 adrenaline ampule there is one part adrenaline to 1000 parts solution. To work out how many milligrams of adrenaline are present, use the following equation:
  • 1:1000 solution adrenaline = 1 g adrenaline in 1000 mL solution = 1000 mg adrenaline in 1000 mL solution = 1 mg/mL.
  • 1:10,000 solution adrenaline = 1 g adrenaline in 10,000 mL solution = 1000 mg adrenaline in 10,000 mL solution = 1 mg/10mL, which can also be expressed as 100 mcg/mL.

Weighing Medications

To make a balance scale for medications, use tin cans or the bottoms from two plastic bottles attached to each end of a wood or metal rod by string or wires. Suspend the rod at its center from a fixed point. Have a nail or other indicator sticking up from the center of the rod. When the balance is empty, mark the indicator's "balance point" position. Ideally, it will point up along the suspension wire. Put an unknown quantity in one side of the scale. Then put objects of known weight (such as small coins) on the other, adding weight until the marker returns to the original "balance point" position. Coins and similar items can be "weighed" by putting them in water and measuring the amount of water they displace. Water has a known weight per volume of 1 kg/L. It may be easier to weigh an object using a known volume/weight of water as a counterweight.

Prescription Amounts for Topical Preparations

If prescribing topical preparations, use the following approximations to determine how much to prescribe:

• 1 g covers 100 cm2 (10 cm × 10 cm).
• 22 g will cover an average-sized body.
• 1 fingertip unit (FTU) dispenses 0.5 g, which covers the area of 2 adult palms.
• 42 g covers one arm if applied bid for 1 week.
• 400 to 800 g covers the entire adult body if applied bid for 1 week.

Containers for Dispensing Medication

Medications dispensed to patients do not always have to be in the standard packaging. Rather, the container, the label with instructions, and the manner in which they are packaged may all vary with the situation.

The first concern is the container. Some acceptable containers for various forms of medications include:

• Pills/capsules: Small plastic bag, envelope, old pill bottle (relabled)
• Powders: Envelope, sealable plastic bag, bottle
• Liquids: Clean empty bottle (glass or plastic) with tight cap

Encourage patients to bring these types of containers with them. When refilling medications, ask patients to bring the container from the last time they got the pills.

Label medication containers in the patient's native language. They should have both the generic and the brand names; this allows other practitioners to identify the medication. The label should also contain the total medication dispensed, the patient's and prescriber's names, and the date. The dose and how to take it may need to be illustrated. The medication's expiration and storage information (e.g., refrigerate) may also be useful.

Language difficulties between the practitioner and patient often complicate prescribing medications—either due to differences in language or because the patient cannot read. Use illustrations to specify how much of each medication should be taken at specific times. Figure 12-2 shows a system where each label has symbols illustrating four times of day (sun rising = morning; sun high = noon; sun setting = evening; moon up = night). Beneath each symbol is another box that can be filled in with a picture of one or more tablets, portion of a tablet, capsule(s), or spoon(s) to show how much of the medication should be taken at that time.22

To specify which medication goes with which instructions, use different colors of paper or use a crayon or marker to put a stripe on the instructions that is the same color as the stripe on the corresponding medication. Alternatively, use treatment-related pictures on medication labels and instructions that are culturally relevant and that can be drawn or duplicated—for example, a picture of a heart (cardiac medicine), a drop of water (diuretic), a lightning bolt (analgesic), or a thermometer (antipyretic).

Prepackaged Medications

Prepackaged "pill packs" provide a rapid method of dispensing commonly used medications to many patients or to groups of patients that may encounter similar problems (e.g., soldiers in battle). They are especially helpful when clinics are inundated with patients during a disease outbreak (e.g., flu season), and when a large number of patients need appropriate antibiotic packs, potassium iodide, or self-injector antidotes as treatment for exposure to a specific toxin (e.g., anthrax, radiation or nerve agent). On the battlefield, the US military now supplies Special Operations troops with a package of antibiotics and analgesics for them to take if wounded.23

Estimating Counts: Tablets and Capsules

When preparing to dispense huge numbers of the same medications to a population, such as during an epidemic, approximating the number of tablets and capsules may be much more expeditious than counting them out. One method, successfully used by the pharmacy staff aboard the USNS Comfort hospital ship, is to use scoops cut from paper cups or plastic medication bottles. Cut the first one so that it contains the proper number of tablets/capsules (or perhaps 10% more, to allow for error). Then cut more of the same size for each person to use when filling baggies, envelopes, etc. with the medications.

Making a Tablet/Capsule Counter

An improvised device to count tablets and capsules for dispensing to patients can be built easily and inexpensively (for a few dollars) from wood. It consists of a two-floor, varnished wooden box, with two exits and a sliding wall.24 The box's interior dimensions are 20-cm-long by 10-cm-wide, the height to the groove for the slide is 4.5 cm, the height of the upper floor is 2.5 cm, and the dispensing holes have a diameter of 2 cm. The sliding separator is 2 cm vertical by 5 cm horizontal. Sand the slide so that it is smooth and moves easily; the wood varnish facilitates cleaning the box (Fig. 12-3).

Operate the counter by first sliding the separator to the middle of the box. This allows sufficient space to place medications from a larger container while blocking them from passing to the lower space where they go when counted (Fig. 12-3, A). Then slide the separator to the extreme left to allow the medication to fall into the lower space when counted (Fig. 12-3, B). When the correct number of tablets has been pushed to the lower space, move the slider to cover any medication remaining from the original stock. Put a dispensing container under the tube next to the patient's medication and pour the tablets into the container (Fig. 12-3, C). Then put the medication stock bottle under the tube at the upper ledge and tilt the box, returning the medication to stock (Fig. 12-3, D).

Tablet Cutters

To cut large-dose tablets (but not capsules or extended-release medications) into smaller-dose pieces, use any inexpensive tablet cutter. Otherwise, use a razor blade or scalpel (this method may be more accurate). If the tablet is carefully cut, the pieces should contain fairly accurate doses, especially when using a scored tablet. It helps to weigh the pieces to see if they are equivalent.25

Cutting tablets increases drug availability and reduces costs. For example, the ubiquitous sildenafil citrate (Viagra) generally costs about $10, regardless of the dose. Since many patients require only 6.25 to 12.5 mg to get an effect, 100-mg tablets are the most economical: dividing the 100-mg tablets increases the medication supply and decreases the cost.26

Intravenous Admixtures

Experience shows that in situations where inventory or electrical resources are limited, most IV solutions should be prepared immediately prior to use rather than in large batches on a daily basis.6

Jellyfish

All members of this large group envenomate through thousands of tiny stinging nematocysts whenever an object (such as a person's skin) comes into contact with their tentacles. Most cause immediate, severe pain and some cause a rash. Treatment for the common box jellyfish sting is the immediate, liberal use of vinegar (4% to 6% acetic acid) over any area where stingers adhere to the skin. This inactivates the nematocysts' discharge. If vinegar is not available, a baking soda slurry may suffice. Then, remove any tentacles with a forceps or gloved hands, since even dry nematocysts can be reactivated if later exposed to water.27 Then, if possible, treat the pain by taking a hot shower or immersing the part in water, as hot as tolerable or 45°C (113°F), for 20 minutes or as long as the pain persists. Hot packs or dry cold packs may work if hot water is not available.

Venomous Fish Stings

Pain from stings often can be relieved by putting the affected area in water that is as hot as can be tolerated (generally 40°C to 43°C [104°F to 110°F]), but care should be taken not to burn the patient. Also remove any foreign bodies.27

Stingray Wounds

Dozens of types of stingrays live in the world's coastal waters; they are venomous. Many have more than one stinger on their tail. Stingrays whip their tails backward in a reflexive defensive action that, depending upon the animal's size, may be powerful enough to penetrate leather boots, a diver's wetsuit, rubber, or even the side of a wooden boat. Most of those injured have either been wading in the surf or they are fishermen who have inadvertently landed a stingray. The wound may be a puncture or a laceration with or without an observable foreign body. Victims describe the pain as "being prodded by a soldering iron"; the pain is generally out of proportion to what appears to be a trivial wound. Treat by immersing the affected part in hot (up to 113°F [45°C]) water. Remove any obvious foreign bodies as soon as possible; be aware, as with all penetrating injuries, that some may require intraoperative removal if they are near vital structures. Debride and irrigate the wound, give potent analgesics and antibiotics, and advise the patient that healing may take many months.28

Arthropods

Arthropods include bees, wasps, centipedes, fire ants, and spiders. Aside from other treatments, most arthropod bites and stings usually respond to the application of cold.29 Treat anaphylactic reactions with available or improvised resources.

Scorpion stings can be extremely painful, with the pain requiring opioids over an extended period (sometimes months). In little children, and sometimes in the elderly, scorpion stings can produce acute delirium. Treat this with sedation, if possible. If not, carefully observe patients and protect them from self-harm as they throw themselves around the bed. Delirium usually passes in 24 hours.

Reptiles

Viperidae: True Vipers and Pit Vipers (Subfamily Crotalinae)

Except for inebriated men who try to play with (and, yes, even kiss) pit vipers (e.g., rattlesnakes, moccasins, puff adders), most of these injuries occur in austere wilderness circumstances. About half of these snakes' bites do not inject venom. Of the others, most patients will live, albeit with some deformity of the bitten extremity, even if they do not get antivenin. Victims of most concern are little children and the elderly.

The real key is to know what not to do. Do not put a tourniquet, ice, or anything else on the wound. Do not cut the wound to try to suck out the venom; this is not only ineffective, but also injects flora from your very dirty mouth into the wound.30

Ideally, the victim should keep their arm at heart level and remain calm until help arrives (yes, even after a snakebite). When no help is available, assist the patient to slowly walk to get help. If antivenin is available without a laboratory to do clotting tests, perform a whole-blood clotting assay. Use a glass-walled test tube and let a sample of the patient's blood sit at room temperature for 20 minutes. If no clot forms, it indicates that there is a coagulopathy and antivenin should be administered. This abnormality should begin to resolve 4 to 6 hours after antivenin administration.31

Elapidae

These include the mamba, cobra, coral, and sea snakes. This family produces neurotoxic venom. Unfortunately, other than supportive care, there is nothing much you can do without antivenin. These are nasty envenomations.