An ongoing debate in my survival and wilderness medicine courses is what medicines should one carry in their backcountry medical kit? Ideally one would carry all the medicines they foresee they would need, but practically we know this is not possible to do in a small lightweight kit. So what medicines can really make a difference?
Epinephrine. Since my wife is allergic to bees and has been hospitalized for anaphylaxis, I always carry epinephrine. Before I met my wife, I did not routinely carry epinephrine (unless I was guiding). But a lot of things change when you get married!
Epinephrine comes packaged in many different forms. Historically my wife would carry two EpiPens with her wherever she would go. EpiPen auto injectors are the standard of care in an urban environment but are a little bulky and heavy for wilderness travel. More importantly you only get one dose per auto injector, unless you know how to cut open the auto injector and access the leftover epinephrine for a second dose (never try this on an unused EpiPen. This technique is not approved by the FDA. Check out this link to learn how). This is certainly possible, but easier said than done, especially in an emergency situation with limited equipment. For the above reasons, I carry a 1 mg ampule of epinephrine (1mg/1ml , 1:1000 concentration) with a 1 cc syringe and a 1″ 22g needle. This will allow me to administer up to 3 doses (a dose is 0.3mg) of epinephrine for anaphylaxis (if needed). This is very important considering recent research has showed that 25 to 35% of anaphylactic reactions may require a second dose of epinephrine to counteract airway swelling and hypotension. Another study(1) showed that up to 20% of anaphylactic attacks may have a biphasic (delayed or secondary) attack hours after the initial exposure, once again requiring additional doses of epinephrine.
So knowing how quickly a lethal anaphylactic attack can occur and that epinephrine is quite effective at reversing the complications(hypotension and airway swelling), no doubt it is my “never leave home without it” medicine.
Antihistamine. I carry an anti-histamine like Benadryl for a variety of reasons. First off, antihistamines are a first-line medication for the treatment of allergic reactions. Anti-histamines work by blocking the H1 receptor site that histamine binds to, reducing urticartia (hives), itching and rhinorrhea. The typical adult dose for diphenhydramine (Benadryl) would be 25-50 mg PO q6h (taken orally every 6 hours as needed).
A secondary reason I carry antihistamines is that they are a recommended adjunct in the treatment of anaphylaxis (only epinephrine has an immediate effect to reverse hypotension and airway construction). As I just mentioned, Benadryl will block the H1 receptor site that histamine binds to, working as an adjunct with the epinephrine to reduce swelling. Because most people would be carrying a tablet form of diphenhydramine, the onset of drug action may not occur for 20 to 30 minutes.
In addition to the histamine blocking effects, I also carry diphenhydramine to use for some of its important side effects. Diphenhydramine works as a sedative in most people (and children it may cause hyperactivity). This can be a useful adjunct when traveling on planes or boats to reduce the symptoms of anxiety and nausea if you don’t have Dramamine with you.
Acetaminophen & Ibuprofen for pain management. In the many search and rescue calls I’ve been on over the years, the number one medicine we administer to injured patients is of course an analgesic. Which analgesic should you carry? That alone could be a whole discussion in itself! A medication that offers substantial pain relief, is easy to administer, is durable, and has minimal side effects would be best. Although the standard of care for a wilderness paramedic is IV narcotics (morphine or fentanyl), a best practice for wilderness adventures would be to start off with a non-opioid. By doing this, we may avoid common side effects of narcotics like respiratory depression, sedation and constipation.
Okay I can hear the comments coming in already! Acetaminophen? Ibuprofen? Why not something much more powerful? How about some Percocet or OxyContin that I have left over from my recent knee surgery? Well I’m certainly not against carrying “stronger” analgesics, but remember these are controlled substances with powerful side effects like respiratory depression and sedation. Ever tried rappelling or climbing on OxyContin? BAD IDEA!!!!!!! Let me tell you about several studies that were conducted about pain relief.
Several prospective randomized controlled studies have shown that combining acetaminophen and an NSAID can reduce pain more than taking acetaminophen or an NSAID alone. The study also concluded that acetaminophen and an NSAID taken together would reduce the pain more significantly than taking one of these medicines with an oral narcotic. For years US Special Forces have used the synergy of acetaminophen and an NSAID (like Ibuprofen), called a “combat pill”. This provided the soldiers with pain relief while still being able to handle their weapon.
Another study looked at oral medications that reduced at least 50% of the pain level in acutely injured patients. Guess what medication scored highest in the study? 600 to 800 mg of ibuprofen relieved 50% of the pain 86% of the time! Ibuprofen scored higher than medicines like oxycodone, naproxin and codeine. Check out the Oxford league table of analgesic efficacy study for more details.
So there’s my first couple of medication choices for my survival medical kit. I look forward to hearing what you would carry with you and why? In a later post, I will tell you my 10 favorite backcountry medications and why.
Disclaimer! Always consult your physician before taking or administering any of the medications below. All medications have some contraindications (who should not take the medicine) and side effects and could have lethal complications or morbidity if not administered appropriately. I am not a medical doctor and am not offering medical advice!
Gaudio F, Lemery J, Johnson D. Wilderness Medical Society roundtable report: recommendations on the use of epinephrine in outdoor education and wilderness settings. Wilderness Environ Med. 2010;21:185–187
Clark E, Plint AC, Correll R, Gaboury I, Passi B. A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with muscu- loskeletal trauma. Pediatrics. 2007;119:460–467.
Mitchell A, van Zanten SV, Inglis K, Porter G. A random- ized controlled trial comparing acetaminophen plus ibuprofen versus acetaminophen plus codeine plus caffeine after outpatient general surgery. J Am Coll Surg. 2008;206: 472–479.
As always be safe and enjoy the wild!