Medical Lifeboat: The Threequel
When people play actual Lifeboat, if indeed they do, as the only time I actually saw it played was on an inpatient psych unit, but that’s another story, they always want to keep the doctor, or med student or whatever. Really, they should just toss ‘em to the sharks, because without the right technology a world famous doctor, or even a good nurse, can’t do anything more than an intelligent person with a first aid book could.
So far we have identified five drugs that can be used in the stranded situation, and I’ll just throw on one more-loperamide. Sure the runs are hilarious, but pooping yourself to death is actually a lot more possible than you realize. Once you’re into a deadly poop situation, especially for someone who is very young or frail, this could be a life saver.
So right now we’ve packed our theoretical kit bag with all the medicines we can use without more tech.
Almost anyone can tell if a person is feverish, delirious, manic, seizing, nauseous, hysterical, got the runs, having burning urination, bleeding, in pain, can’t breathe, or breaking out in hives.
But if I can’t measure your blood pressure, how could I prescribe medication for blood pressure? If for some reason we are all watching our cholesterol on our desert island, if we can’t measure it, we can’t tell whether or not to give medication. Got diabetes? (Funny how I’ve never seen THAT on one of those oh-so-clever bumper stickers.) You don’t have a clue how much diabetes medication to give, and too much can be deadly. Coumadin is a real brain saver, but without frequent blood monitoring it’s way too dangerous to use, and so on.
So let us change the parameters a bit. Somebody is present who has some medical training. And let’s say we have a blood pressure cuff and stethoscope, some blood drawing equipment and some magic box that lets us check your thyroid function, blood sugar, INR, kidney and liver function and (sigh) cholesterol. You know, one thing we won’t need to check is the ubiquitous CBC (complete blood count) because anything that will mess that up will either be already blindingly obvious or needing treatment too complicated for our circumstances.
Now we can diagnose and monitor a number of potentially deadly conditions but treatable, such as diabetes, atrial fibrillation, high blood pressure, pernicious anemia, hyperthyroidism, hypothyroidism, and evaluate the safety of giving the medications because we can check for liver and kidney damage as well as blood clotting.
So we add methimazole, levothyroxine, oral B12 (works better than the shots, BTW), metformin, HCTZ and propranolol. Again, none of the multiple new sexy drugs for these conditions work any better, and many are actually worse. Whatever HMGCoA reductase inhibitor was cheapest that day can also be added in. Coumadin for atrial fibrillation.
How many meds is that? Let’s see. Eleven, maybe twelve. Let’s just go whole hog and add in the capacity to give IV fluids and some basic IV antibiotics and insulin (requires needles, storage and finger sticks.) Oh heck, let’s go whole double hog and add in some Prozac and Thorazine, and someone who can stitch up a cut and deliver a baby, if nothing too bad goes wrong.
So what have we got? I think some of you will recognize the basic ‘developing country” primary care model. So our medical lifeboat is really about designing medical care for the most bang for the buck if resources are limited. And of course resources are always limited somewhere down the line. Today having a government run health system is a hot topic—and a giant complicated version of medical lifeboat. In my next post, I’ll start talking about what that means for the land of the fee.