Pain control in remote areas – part 1
Unsurprisingly the overall majority of injuries that the UK mountain rescue services deal with are injuries to the lower leg or foot. In the UK we’re lucky – we have well established rescue facilities starting with the local mountain rescue teams and extending to the coastguard search and rescue helicopters or the regionally based air ambulance service.
Overseas, trekking in even the most popular regions of Nepal you might still expect to wait for quite some time before help will get to you or your casualty. Worse, your best or only prospect may be to self-evacuate and in these situations having a firm grasp on what pain management options are available is crucial.
Here we look at differing levels of analgesia that you may reasonably utilise (with a bit of know-how).
The Scene …
You’re on holiday with four mates in Nepal trekking on the Annapurna Base Camp trek. It’s late on the sixth day of the trek and you’re descending with some pace down through the Rhododendron forest headed for your tea house in Sinua. You see your mate slip and fall badly, tumbling forwards. When you arrive at the scene he is audibly in a lot of pain. You have no phone signal and the nearest tea house is maybe a further 300m down the valley. The tea houses have phones that work sporadically. In the meantime local porters are gathering with some interest, discussing with concern and vigour what needs to be done.
You start to think about how you can manage this situation and your casualty’s pain for what will be a long haul …
Your first aid kit …
When putting together a medical kit for a remote trip one of the primary concerns is pain control (analgesia). The ideal pain reliever would have the following characteristics:
- Reduce pain effectively and quickly
- Easy to administer for first-aider and casualty
- Long lasting and safe with no side effects
- No contraindications (conditions which the medicine cannot be used for)
- Not controlled by law and not subject to international transport restrictions
- Lightweight and easily carried
Unfortunately such a medicine doesn’t exist!However with some knowledge it is still possible to achieve good pain relief.
When you break a bone the limb can be deformed, displaced (out of line) and the muscles around it start to go into spasm. So although you can’t see it, broken bone ends may be damaging soft tissue, causing pain and internal bleeding. The limb that is no longer in alignment can prevent circulation to the distal limb – the foot or the hand for example. This is further exacerbated by a build up of fluids (swelling) at the injury site, which itself can inhibit blood flow.
Pain from fractures is significantly reduced if the broken limb can be realigned. But for this to work, any realignment needs to be combined with good quality splinting. You may carry purpose built splints but if not, trekking poles, rollmats, rucksack frames and thermarests (combined with gaffa tape and/or triangular bandages etc.) are all good alternatives. In general, make sure the splint is not too tight and ideally you should be able to get to the fingers/toes to check that circulation isn’t compromised. A good splint, efficiently and correctly applied will make a huge difference for the casualty. It should prevent any worsening and help to promote pain relief.
Being in pain in unfamiliar surroundings will be a scary experience for most people. The perception of pain can be reduced by keeping the casualty comfortable both physically and mentally.
In a cold or wet climate, make sure they are warm enough. Not only is this psychologically important but warm blood (and internally there will be blood loss) clots more effectively than cold blood.
Take the time to explain what you plan to do before you do it, let them know what your plan is and make sure someone is available to talk to the casualty at all times. These measures will reduce anxiety which will decrease heart rate and blood pressure, reducing any bleeding associated with the injury.
This is what most people think of when they consider pain relief. Basic pain medicine is available over the counter without prescription. If you are a first aider you really shouldn’t be medicating a casualty unless you know exactly what you are doing. You need to be aware that even simple over the counter medicines can make a situation worse. (Eg Aspirin given to a casualty suffering from a snake bite can increase the risk of internal bleeding). If you will be giving medicines to casualties you should be familiar with doses and in which situations certain drugs are not suitable or may even be dangerous.
Cicerone Press’s Pocket First Aid and Wilderness Medicine provides a really good aide-memoir explaining what medications can be used for what and what you need to look out for.
Over the counter (OTC) medicines
OTC medicines are most often used for mild pain. While they will not completely relieve severe pain from serious injury they will, when used correctly, certainly reduce pain. Be aware that outside the UK OTC medicines are often sold in different strengths.
Paracetamol: In the UK sold in 500mg (half a gram) tablets. The standard dose is 1 gram (1000mg or milligrams) every 4 to 6 hours. The maximum dose in 24 hours is 4 grams (8 tablets) so although 2 doses can be takes 4 hours apart you cannot administer doses every 4 hours for 24 hours. Taken in the correct dose paracetamol is one of the safest pain medicines.
Paracetamol is also excellent for helping to ease the symptoms of a high temperature when managing a fever or a cold.
Ibuprofen:Ibuprofen is a type of non-steroidalanti-inflammatory drug(NSAID). UK tablets are sold in 200 or 400mg doses (often sold in 800mg tablets abroad). Standard dose is 400mg every 8 hours. Ibuprofen can cause gastro intestinal bleeding so should not be used in anyone with a stomach ulcer or who has suffered from gastrointestinal bleeding in the past. Ibuprofen can worsen asthma, if your casualty has asthma make sure they have had ibuprofen before and not had any problems. (Check, check, check for side-effects and contra-indications).
Codeine: Codeine is opiate medicine in the same class as morphine and tramadol. The only codeine containing medicine available without prescription in the UK is a mixture of paracetamol and codeine, 500mg paracetamol and 8mg codeine per tablet. The dose is 2 tablets every 4-6 hours with a maximum of 8 tablets in 24 hours. Because it is an opiate, codeine is a controlled drug in some parts of the world, check before you go.
Aspirin: Another NSAID and should be avoided with a history of gastro intestinal bleeding. Shouldn’t be used at the same time as ibuprofen. Usually comes in 300mg tablets, give up to 900mg in a single dose every 4-6 hours. Don’t exceed 4grams (4000mg) in 24 hours. Not to be used in children under 16.
Paracetamol, codeine and ibuprofen can all be used together. Combining paracetamol with ibuprofen helps increase their potency. But be careful not to combine two medications that are like with like. Eg you should not combine aspirin and ibuprofen since these are both NSAIDs. Similarly, you shouldn’t combine paracetamol with a product such as Sudafed or Lemsip – which already contains paracetamol. As ever, take care to read the labels to check what is already contained in any given medication before administering it to a casualty.
Prescription only Medicines (POM)
If you’re employed as a leader on a commercial trip you may have access to prescription only medicines. These tend to be stronger painkillers with potentially more serious side effects.
Co-codamol 30/500. Stronger than the OTC preparation these tablets contain 500mg paracetamol and 30mg codeine. The dose is 2 tablets every 4-6 hours, maximum of 8 tablets in 24 hours. Make sure you don’t give any additional paracetamol-containing-medicines. This higher dose of codeine is more likely to cause side effects, commonly constipation and nausea. Codeine is addictive and should only be used for short periods.
Methoxyflurane (PenthroxTM). This is a highly volatile (evaporates quickly) liquid. The 3ml bottle of methoxyflurane is poured into a plastic ‘inhaler’ which looks like a small recorder then the patient inhales the vapour. (See our next article for more details of this very effective, safe and easy to use painkiller).
Tramadol. This is also an opiate. It should not be used with codeine. It has similar side effects and is now tightly controlled by law in the UK and illegal in many countries. Not commonly used by British expeditions.
Fentanyl Lozenges Similar to morphine and comes as a ‘lollipop’ enabling the casualty to control their own pain. These are tightly controlled by law and usually only used by healthcare professionals. Tramadol, fentanyl, morphine and ketamine are all strong painkillers which may be used on expeditions but normally only be healthcare professionals.
Back to the casualty…
As a first-aider always think ABC … You’re happy it’s a safe environment and the casualty is making a lot of noise – so clearly he’s breathing. A quick primary survey of the casualty tells you there’s no heavy blood loss so you decide to focus your attention on the casualty’s damaged ankle.
You ask one of the team to pass you the penthrox from your first aid kit in the top of your rucksack. You allow the patient to self-administer the penthrox while you examine the ankle. It’s significantly swollen but there aren’t any bones protruding from the skin.
You explain to the casualty that you want to stabilise the damaged ankle before moving on any further using half a roll mat and a fewtriangular bandages. One of your mates stays at the head end while two of the others help you support the limb while you immobilise it with the roll mat. You take care to leave the toes accessible so you can monitor the colour and thus the circulation.
With the help of the local porters, you carry your mate to the nearest tea-house. You’re able to organise a rescue but no helicopter will fly before the morning so you decide further analgesia would benefit the casualty. You check with him first about any medical history, any allergies any past experience with medications. You check in your manual what it is you will offer him and decide to administer 2 x 30/500 co-codamol from your med kit and 400mg ibuprofen. You get the casualty into a sleeping bag and then make a detailed record of what has happened and what you have done about it. You continue to monitor your casualty.
Four hours later, the pain is better but still present so you give a further 1 gram of paracetamol. Four more hours and you give another 1 gram of paracetamol and a further 400mg of ibuprofen which keeps pain under control until rescue arrives.
A good first-aider in this context should as a minimum be confident enough to immobilise and splint a damaged limb such as this. A first-aider overseas could also be expected to administer paracetamol and ibuprofen as a minimum for the longer term pain relief. Having a good understanding as to what you should be doing and how, and being confident in what you are doing will make a huge difference for the casualty in the short and long term.
Dr Joe Rowles is an Emergency Medicine doctor and former Special Forces soldier with an interest in pre-hospital, remote and expedition medicine.
He holds a Master’s degree in Austere and Military Trauma Science, Diploma in Immediate Care, is a faculty member for the Diploma in Conflict and Catastrophe Medicine and an Honorary Clinical Research Fellow at the University of Exeter where he is a module lead for the MSc in Extreme Medicine. He co-authored the Royal College of Surgeons of Edinburgh guidelines for medical provision for wilderness medicine and is currently medical director for Survivor USA, the world’s largest reality television show.
From September 2018 Joe will be joining us working on our expedition first aid courses.