Friday, December 13, 2013

Desert Island Drugs





When I was a medical student we had an interesting PBL topic where we were given the scenario of being stuck on a desert island with a population of people similar to what you encounter in general practice. On the island you were allowed to take with you 8 drugs and no others. These are the only ones you can use to treat any illness that may befall your population. You had to present your reasons for picking each drug. It was to teach us some pharmacology and also to think about the populations that we were treating.

Some people took it seriously, picking well thought out medications to help the most amounts of patients, doing what the task was designed to do. Others not so seriously, picking out all the drugs of abuse to go and get nice and high on the desert island.

I thought it would be a good idea to present mine again. Unfortunately I have forgotten completely the ones I picked 5 years ago. So I picked new ones based on my current hospital and primary care experience.

1) Morphine: Sorts your pain out innit. If life on the island sucks you can just get off your tits. Seriously one of the commonest and distressing things for a patient to have is pain. It makes sense to have one of the most powerful pain relievers to hand. I haven't packed a laxative, so my islanders may end up constipated addicts.

2) Co-Amoxiclav: Treats pretty much any infection. I'm struggling to think of a wider spectrum oral agent. Can be given orally. I'm sure I could distill the clavulanic acid out to give it to pregnant women. Not much fun for people with penicillin allergies though.

3) Prednisolone: Rheumatological problem? Dermatological problem? Haematological Problem? Respiratory problem? Sorts 'em all out! Unknown problem? Combine with 2) for best effect. I like my patients Cushingoid and Diabetic.

4) Aspirin: For pain not bad enough to need morphine. Also used in secondary prevention of strokes, MIs, cardiovascular disease in general and recurrent miscarriage. Plus if everyone takes it, it is a good way of avoiding or delaying elective surgery!

5) Haloperidol: Some very common problems - Nausea, vomiting, psychosis, bat-shit crazy, delirium, insomnia, reduced lactation, being a Soviet Dissident. All of which can be cured by vitamin H! I feel we need something to quieten people down and make people feel less sick when they have other problems. Extra-pyramidal side-effects notwithstanding.

6) Amitriptyline: Combine with the above for a quiet night. Although not a great anti-depressant this "dirty" drug (dirty in the sense it blocks a lot of receptors) has found a new lease of life as a second line treatment for chronic and neuropathic pain. Also used to treat urge incontinence, migraines, tension headaches, IBS, peripheral neuropathy and a range of psychiatric disorders. Overdoses are "interesting" to treat and nobody likes a dry mouth.

7) Hartmanns: Ill, Starving, or run out of water on a desert island. Better than Saline, I know this because my boss told me so. Contains a little bit of everything you might need. This can be used to replace fluid lost whilst your Augmentin is working. A good way to deplete somebody's potassium. You could assume I could knock up some IV fluid from local seawater etc. but that's stretching the metaphor a bit.

8) Lignocaine: I'd say this is my most controversial one. Now I'm assuming we have enough equipment and stuff to perform minor surgery on a desert island. Surgery, is a common reason to see your GP. You know, getting moles, lumps and bumps removed etc. Also good during and after child birth for tears. Can be used in joint injections and as a class 1 anti-arrhythmic. There's actually a surprising amount of surgery you can get done with it. It wouldn't contain adrenaline, so I could use it on fingers and penises.

So, there's my 8. Some surprising admissions (5-8) and some less surprising ones (1-4). However I feel I have a balanced bunch based on what I would prescribe in the community and in hospital to treat as much disease as possible. I've made some compromise with efficacy to ensure as many symptoms as possible could be covered. You may notice most of my drugs treat non-life threatening problems. Which exactly what most medical problems are.

Also, some equally surprising omissions from the list, which by the way can only stretch to 8. No insulin? With the 7% of our population with diabetes is a pretty big one to leave off the list. However it's of no use to the other 93% of the population. I'm assuming also desert island lifestyle involves a lot of exercise and fruit so type 2 diabetes rates should plummet.

The ubiquitous Paracetamol? I figured I'd cover it with other things that has 2 uses such as morphine or aspirin.

What if there is a cardiac arrest. No adrenaline? No amiodarone? I'd like to think the boat the washes me ashore would have a defib.

Propanolol almost made the list for its use in treating blood pressure (poorly) but also tachycardia, anxiety and stress.

What about propofol? Have that and we could have some real fun with surgery and sedation procedures. Pulling a shoulder might be easier, but we'd need an anaesthetist around to wield it as A&E folk are unworthy.

We could please the government and their venous thromboembolism gods by giving everyone clexane.

What about PPIs, hopefully coconut milk and lack of coke, cigarettes and beer would reduce acid related problems.

How would we control the population or womens periods without the OCP. Perhaps fashion prophylactics from coconut sap and bamboo leaves? Birth rates and bleeding would increase on the island.

As I alluded to before, what about all the constipated people from all the morphine and amitriptyline? Again hopefully the islands high fibre diet would take care of that.

If you are allergic to penicillin on the island as 5% of people would be? Tough, no room for an alternative. Erythromycin or Ciprofloxacin being possibilities.

Lastly, nothing to treat seizures. Carbamazepine also works for chronic pain. You could argue terminating seizures is more important than depression. Maybe not if the islands suicide rate started to climb.

So a lot to consider, and for a nerd like me very fun to hypothesize. Let me know if you have any suggestions for your list?

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