Chronic Illness When the Pharmacy Is Empty

Ask your doctor and pharmacist now

While there is still someone to ask, ask. Take these questions to the next visit (rule of thumb):

• "Can I have a 90-day supply, and early refills? How long does each medicine keep?"
• "Which of mine are dangerous to stop? If supplies end, how do I step down, and how fast?" Get it in writing, in plain numbers, for this person's own medicines and doses.
• "Is there an older, cheaper generic?" Generics are often much cheaper and no worse (WTND, p. 333). The WHO essential list names the plain, widely made ones: amlodipine, bisoprolol and enalapril for blood pressure (WHO EML 2025, p. 45); human insulin, gliclazide and metformin for diabetes (p. 54). MSF chooses seizure medicine partly by how likely it is to stay available (MSF, p. 384).
• "What do I do if I get sick, can't eat, or work hard?" Insulin needs change with all three (Diabetes, below); steroid needs rise with illness and injury (WHO Formulary, p. 366).
• "What can I learn to do myself?" Blood pressure, sugar tests, a spacer, rescue seizure medicine.

Build a stock and keep it rotating

• Disaster lists are short: the Red Cross list for seniors says a 7-day supply of medications, and 2 weeks of food and water at home (Red Cross Seniors, p. 5). For a long collapse, build toward 3 months and more of every daily medicine (rule of thumb).
• Put medicines and glasses in every kit (FEMA Are You Ready?, p. 21). Plan for medicines that need a fridge, and keep spare batteries, oxygen and catheters, with the type and model number of every device (FEMA 2004, p. 30).
• Rotate: new stock at the back, old in front, use the oldest first (FEMA, p. 22); every six months, replace expiring medicines and batteries (Red Cross, p. 13).
• Keep them labeled, with their directions, in a clean, dry, cool place away from children and rats (WTND, p. 332). Storage and old medicines: Medical books & found medicines.
• Oregon's lists: Be 2 Weeks Ready adds extra eyeglasses, contact lens solution and hearing-aid batteries to the kit (p. 22). Living on Shaky Ground says to write down each person's needs, "Include medications and special equipment such as ventilators and oxygen tanks", and keep duplicate prescriptions and glasses where they can be reached (p. 17).

Write it down

• A card for each person: illness, each medicine with its strength and times, allergies, the doctor. One copy with the medicines, one in the grab bag (Red Cross, p. 5; FEMA, p. 22); picture cards for people who can't read (📋 WTND dosage blanks).
• Wear a medical ID (bracelet or tag): rescuers look for one in any sudden illness (Hospital Corpsman, p. 206; Medical ID).
• Keep a log: blood pressure, sugar, weight, seizures, pills left, every dose given (rule of thumb). When you find help, the 📋 patient report form says what to tell them.

A card to copy for each person: one with the medicines, one in the grab bag (a form drawn for this guide).

Tools worth having

Signs of diabetes: always thirsty, passing a lot of urine, hungry, tired, losing weight, blurred sight, numb feet, sores that won't heal (WTND, p. 127). Type 1 usually starts young; the body makes no insulin, and "Patients require administration of insulin" for life. Type 2 usually starts after 40 and "may be controlled by diet alone" (WHO Formulary, p. 388; WTND, p. 127).

Type 1: insulin without a fridge

Keeping it (MSF, pp. 425–426; p. 429):

• No fridge: the coolest place that never freezes, checked with a thermometer: a cellar, a springhouse, or a clay-pot cooler, which holds 13–22 °C inside on 30–45 °C days in dry heat (Practical Action, p. 1; written for vegetables, so using it for insulin is (rule of thumb)). More: Root Cellar ("Cooling without power"). Here both ends matter: Grants Pass has hit 108 °F, and Cave Junction's winter nights average 32 °F, with a record of -6 °F (Josephine soil survey, p. 5), so a shed or attic is too hot in summer and freezes in winter. Never leave insulin in a parked car, which can reach 50–60 °C; freezing spoils solutions and cracks vials (MSF, p. 647).

A clay-pot cooler with insulin and a thermometer inside (Practical Action, pp. 1–2; insulin: MSF, p. 426; a diagram drawn for this guide).

• Insulin can't be swallowed: the gut destroys it (MSF, p. 423).
• Match the syringe to the vial. Insulin comes as "40 IU/ml" and "100 IU/ml" (WHO Formulary, p. 393); use "only syringes calibrated for the particular concentration" (p. 388). The wrong syringe gives the wrong dose.
• Test every day, blood or urine (WHO, p. 390). Aim for "4–7 mmol/litre before meals and less than 9 mmol/litre after meals", and work hard to stay above 4 (WHO, p. 389). Stock strips.
• Lows get more likely with hard work, missed meals and alcohol. Extra carbohydrate may be needed for hard work. Beta-blockers can hide the warning signs (WHO, p. 390; MSF, p. 33; alcohol: MSF Essential Drugs, p. 423).

How much insulin. Be honest about this: insulin is set person by person. WHO's dose is "according to individual requirements" for adults and children alike (WHO Formulary, p. 394). What the books do give:

Watch for: lows (above); pain, redness or lumps of fat where it goes in: "Rotate injection sites systematically" (MSF Essential Drugs, p. 423).

High sugar and ketoacidosis

Too little insulin, or a missed dose, lets sugar climb. Then the body burns fat and the blood turns acid: diabetic ketoacidosis (DKA) (Hospital Corpsman, p. 206; Diabetic ketoacidosis).

• Signs: deep or fast breathing, sweet, fruity (acetone) breath, passing a lot of urine, dry and dehydrated, warm dry skin, then confusion, stupor and coma (WHO-ICRC, p. 112; Hospital Corpsman, pp. 206–207).
• Two questions: "Has the victim eaten today? Has he taken the prescribed insulin?" Ate but no insulin means DKA is likely (p. 207).
• What helps: fluids against shock (Hospital Corpsman, p. 207) and insulin. The books treat DKA in hospital with insulin through a drip ("0.1 IU/kg" then "0.1 IU/kg/hour", MSF Essential Drugs, p. 428); no book gives a dose for DKA at home.

When the insulin runs out: without insulin, a person with type 1 diabetes goes into ketoacidosis and dies, usually within days to a few weeks (rule of thumb). No diet or herb replaces insulin. This is the hardest case in this guide: see "When someone can no longer be kept well", below.

Type 2: food and work are medicine

• Eat: plenty of vegetables and high-fiber foods; beans, whole grains and brown rice; protein. Less rice, white flour and potatoes. Cut out sugary drinks and sweets. "The diet for a person with diabetes is very important and must be followed for life" (WTND, p. 127; WHO Formulary, p. 388). MSF: no sugared foods and drinks "(but no excessive restriction of carbohydrates)" (MSF, p. 391).
• Work: "Emphasis should be placed on exercise and increased activity" (WHO, p. 388).
• Feet: always wear shoes and keep the skin clean; for poor circulation, rest with the feet up (WTND, p. 127). Sores heal slowly: keep them clean and change the bandage often (p. 324).
• When food runs short and lows appear, the sulfonylurea is the pill that causes them; metformin "does not usually cause hypoglycaemia" (WHO, pp. 392–393). Cutting back the sulfonylurea first is (rule of thumb): watch the sugar.

High blood pressure

• "High blood pressure at first causes no signs." Late signs: frequent headaches, pounding heart and breathlessness with mild work, dizziness, chest pain. It leads to heart disease, kidney disease and stroke (WTND, p. 125).
• Measure it sitting, after 5 minutes' rest (WTND, p. 412). Around 120/80 is typical, 100/60 to 140/90 healthy; a top number over 160 or a bottom number over 100 needs attention; 160/110 is "seriously high"; a sudden drop, especially below 60/40, is a danger sign (p. 413). MSF's targets: under 140/90, under 140/80 with diabetes, top number under 150 over age 80 (MSF, p. 395).
• Without pills: less salt, less weight, little alcohol, no tobacco, plenty of vegetables, regular exercise. "These measures alone may be sufficient in mild hypertension" (WHO Formulary, p. 286).
• Salt-cured foods (salt pork, salt fish, jerky, sauerkraut) carry a lot of it: soak or rinse them (rule of thumb).
• When food is short and weight falls, the old dose may become too strong. Dizziness on standing, worse in the morning or after a big meal: get up slowly, hold on, and "Ask if any of your medicines should be reduced or stopped" (CDC STEADI, p. 2). No book gives a step-down plan for blood pressure pills. If readings stay well under the target and the person is dizzy, cut back one medicine at a time and watch the readings for a week or two (rule of thumb); never stop a beta-blocker suddenly.
• Careful with painkillers: ibuprofen and similar can raise blood pressure, hold water, and even bring on heart failure or kidney failure in older people (WHO Formulary, pp. 44–45).

MSF starts with one medicine, then adds a second after 4 weeks if pressure is still high (MSF, p. 396).

Heart trouble and heart failure

Signs of heart trouble (WTND, p. 325): breathless after work; breathing attacks that are worse lying down; tiredness, weakness, dizziness; chest, shoulder or arm pain with work that goes with rest (angina); a fast, weak or uneven pulse; swollen feet, worse in the afternoon.

• Regular exercise, but never to chest pain or breathlessness; no greasy food, tobacco or alcohol. With swollen feet or breathing attacks, "little or no salt for the rest of his life" (same page), and feet up whenever possible (p. 323).
• Heart failure: reduce salt to limit fluid build-up, "Normal fluid intake except in cases of very severe oedema", activity to what the person can manage, and a weight chart: weight going up fast usually means water (rule of thumb) (MSF, pp. 399–401).
• A bad night: sudden, severe breathlessness may be acute heart failure. Sit them up, legs down (MSF, p. 402).
• To prevent another heart attack or stroke: aspirin "75–100 mg daily" (WHO, p. 301); WTND says "75 to 81 mg" (p. 325). Angina and heart attack doses: The first minutes, above. Nitroglycerin weakens once opened: Medical guide.
• After a stroke: Rehab guide ("Stroke and spine injuries: the basics"); WTND, p. 327.

Asthma (WTND, p. 167):

• Smoke brings on attacks: cigarettes, indoor cooking fires, burning fields. Wildfire smoke brings asthma attacks, COPD flare-ups and heart attacks, worst in children and people over 65 (EPA, p. 41; Wildfire guide, "Smoke, heat and people").
• Keep the house clean and animals outside; drink at least 8 glasses of water a day.
• Two kinds of inhaler. The rescue inhaler (salbutamol) opens the airways; start it "at the first sign of wheeze or chest tightness". The controller (a steroid inhaler such as beclomethasone), used every day, prevents attacks, so "use salbutamol less"; it takes 3–7 days to work (WTND, pp. 385–386).
• Use a spacer, or most of the medicine lands on the tongue. Both books agree on a plastic bottle with the inhaler pushed into a hole cut in the bottom (WTND, p. 386; MSF uses a 500 ml bottle, p. 106). WTND also suggests two cups taped together; MSF says "The use of a plastic cup instead of a spacer is not recommended (ineffective)".

A bottle spacer: one puff into the bottle, then breathe from it; with a child, 4 or 5 breaths before the next puff (MSF, pp. 104–106; a diagram drawn for this guide).

• Don't use eucalyptus or Vaporub: "They make it worse" (WTND, p. 168). People with asthma should not take "-olol" heart pills (beta-blockers): they "may precipitate asthma" (WHO Formulary, p. 274; WTND, p. 385).

COPD (chronic bronchitis, emphysema): a cough for months or years, worst in old heavy smokers; with emphysema, hard breathing and a "barrel" chest (WTND, p. 170).

• Stop smoking: it slows the damage (WHO Formulary, p. 489).
• Infections make it worse; flu shots help prevent them. Inhalers as for asthma; for a flare-up WHO gives "a short course of an oral corticosteroid" and antibiotics for infection, but no dose for COPD (same page). The asthma prednisolone doses above are the closest. Found antibiotics: Medical guide.
• Ipratropium inhaler (20 micrograms a puff): "ADULT, 20–40 micrograms, 3–4 times daily" (WHO, p. 493).
• Sticky phlegm: drink plenty, breathe steam, then pound the back lightly with a cupped hand (WTND, pp. 168–169). Breathing exercises: Rehab guide ("After long bed rest").

Oxygen helps people with severe COPD live longer (WHO Formulary, p. 489). A concentrator "Cannot store oxygen: provides only when power supply is on"; cylinders store it but need refilling (WHO Surgical Care, p. 364), and a falling cylinder can kill: store them lying down, strap them upright in use (p. 366). Powered equipment fails "if the power is out for more than a few days" (FEMA Power Outage Annex, p. 21): plan the power now (Off-Grid Power, "Start with a load list").

• Epilepsy brings seizures to people who otherwise seem healthy; it can't be caught. Medicines "do not cure epilepsy; they help prevent seizures", often for life, at the lowest dose that works (WTND, p. 178). Start low and raise slowly until the seizures stop (WTND, p. 390; MSF, p. 387).
• Missed doses bring seizures back: "Abruptly stopping or reducing an ASM dose is likely to provoke seizures" (MSF, p. 384). Stepping down: "Never stop suddenly", above.
• Living safely: normal lives are possible with care, such as "not swimming alone, not cooking over open flames" (MSF, p. 385). Off-grid life means open fires, axes, ladders and creeks: give them jobs away from these (rule of thumb).
• When the medicine runs out, expect seizures back. Teach everyone the first aid and rescue doses in "The first minutes", keep a seizure log, and let them sleep low (rule of thumb).
• Pregnancy: valproate "must not be prescribed in pregnant women and girls" (MSF, p. 386).

• Underactive thyroid is treated with levothyroxine. Its effects "may persist for several weeks after withdrawal" (WHO Formulary, p. 398), so a missed day is not an emergency; weeks without it are (rule of thumb).
• Signs that come back: tired all the time, slow thinking, weight gain, slow heart, hardly sweating (Hospital Corpsman, p. 53); feeling cold (WHO, p. 476).
• Iodine: most goiters (a swelling on the throat) come from too little. Use iodized salt; seafood and seaweed help; WTND makes iodine water from povidone iodine when there is no iodized salt (WTND, p. 130). Iodine does not replace thyroid pills (rule of thumb).
• Overactive thyroid: a goiter with a lot of trembling, nervousness and bulging eyes is a different kind (WTND, p. 130); no book here gives a home dose for it.

• Dialysis needs power, water and supplies. "Dialysis centers generally do not have backup generators" (FEMA Power Outage Annex, p. 21). The books in this library cannot teach dialysis at home.
• Diet for failing kidneys: low in protein, salt and potassium, because the kidneys can't clear them; in some chronic cases protein is kept at 40–60 g a day (Hospital Corpsman, p. 327).
• Medicines build up when kidneys fail. WHO's rules: prescribe as few as possible, and avoid medicines that harm the kidneys (WHO Formulary, pp. 621–622). Examples: ibuprofen and similar (pp. 44–45), metformin (p. 393), lithium (p. 476). Insulin needs fall (MSF, p. 423); enalapril starts at "2.5 mg once daily" (MSF, p. 396). WHO's Appendix 4 lists the medicines that need a smaller dose (p. 621).

• First, rule out the body. Strange behavior can come from "Physical illness, chemical or pesticide poisoning, side effects of medicines, or alcohol or drug use" (WWHND, p. 413). Check for low sugar, fever, dehydration and withdrawal.
• Depression is more than a bad day: sad, hopeless or empty most of the time, sleeping badly or too much, no pleasure, slow, no energy, thinking about death (WWHND, p. 419).
• Suicide: ask. "Asking someone if she wants to kill herself does not make her more likely to do so." Ask whether she has a plan and the means. If talking doesn't help, someone stays with her at all times, and dangerous things are removed (WWHND, p. 431).
• Hand out a week's tablets at a time in the first weeks, or give them to someone close to give out (MSF, p. 368), and keep the rest locked away (rule of thumb).
• Psychosis (voices, false beliefs, not caring for oneself): "any person with a mental illness should be treated with kindness, respect, and dignity". Family care at home is common; medicines "should never be the only treatment" (WWHND, p. 432).
• Antipsychotics make the body handle heat and cold badly (WHO Formulary, p. 466): watch them in heat waves and cold snaps. Relapse after stopping may come weeks later (p. 465).
• Lithium turns dangerous when water or salt changes. Keep both steady; the book cuts or stops it in diarrhea, vomiting or illness with heavy sweating. Too much: blurred vision, weakness, vomiting, diarrhea, drowsiness, unsteady walking, coarse shaking, slurred speech; then fits, collapse, coma (WHO, pp. 476–477).

What helps without pills: time alone, hard work when angry, writing or drawing feelings, light, fresh air and some beauty (WWHND, p. 422); a helping friend or group; sleep (WTND, p. 328). More: Community & Barter ("Grief, stress and psychological first aid").

Glasses.

• Put glasses in the kit (FEMA, p. 21): a spare pair and the old pair (rule of thumb).
• After 40, "Reading glasses often help. Pick glasses that let you see clearly about 40 cm (15 inches) away" (WTND, p. 223).

Hearing aids.

• Gradual hearing loss after 40 is usually permanent, "though a hearing aid may help" (WTND, p. 327). Keep it in a container fixed to the bedside table (Red Cross, p. 12). Stock batteries, or a solar charger for rechargeable aids (rule of thumb).
• Hard wax can block hearing: soften it with a few drops of warm vegetable oil, lie ear-up 15 minutes, then wash out with warm water, or squirt with a needleless syringe. Stop if dizzy (WTND, p. 407).

Dentures (Where There Is No Dentist):

• Brush false teeth every day, like real ones (p. 188).
• A sore under a denture: leave it out 2 or 3 days and rinse with warm salt water, 4 cups a day; a denture that doesn't fit should be remade (p. 116).
• White patches that bleed when wiped are thrush: clean the denture and leave it out a while (p. 115).
• A poor fit makes the corners of the mouth crack and sore (p. 117). Without teeth people can't chew enough to stay healthy (p. 174): cook soft food for them (p. 115).

• Water: older people may lose their sense of thirst and drink less to avoid getting up at night. About 2 liters (8 cups) a day (WWHND, p. 126).
• Food: "they will become even weaker if they do not eat well" (WTND, p. 323): a fair share of the ration (Food When It's Scarce).
• Dizzy on standing makes falls likely. Sit up first, sit on the bed edge, then stand; something to hold; no walking while dizzy; sit to wash and cook (CDC STEADI, p. 2). Leg strength: the chair-rise exercise (STEADI); more in Rehab ("Balance and walking again"; "Children and older people").
• Medicines hit harder. By 80 the kidneys work at about half, so "assume at least a mild degree of renal impairment" (WHO Formulary, p. 622). The books start the old on smaller doses: amlodipine and enalapril at 2.5 mg (MSF, p. 396), amitriptyline at half (p. 368), rectal diazepam not over 10 mg (p. 25). Sugar pills cause more lows (WHO, p. 392); antipsychotics bring falls and chilling (p. 466).
• Sudden confusion is not old age. It may be too much medicine, infection, hunger, dehydration, a bladder infection or depression, and often clears when these are treated. Dementia comes slowly: keep routines, familiar things, a calm slow voice, yes-or-no questions, and share the caregiving (WWHND, p. 135; Dementia).
• Someone checks on each elder (Red Cross, p. 8; Community & Barter, "Children, elders and neighbors who need help"). Heat, cold and the bedridden: Field Care ("Heat and cold"; "Nursing a bedridden person for days and weeks").

Some illnesses are held off only by things that may not come back: type 1 diabetes without insulin, kidney failure without dialysis, severe lung disease without oxygen, some heart failure. When those are gone, the work changes from curing to caring.

• Talk early, while the person can still decide. Let them make their own decisions, talk about death if they want, and say what they are grateful for or worried about. "It does not help to act as if the person is not dying" (WWHND, p. 309).
• Tell the truth gently. "If a person who is dying asks for the truth, tell her, but tell her gently, and leave some room for hope." "In the last hours, love and acceptance will do far more good than medicines" (WTND, p. 330).
• Their wishes count. Some ask to be allowed to die rather than see their family go hungry to keep them alive, "and there are times when this may be the wise decision" (same page).
• Near the end they may be unconscious, stop eating, breathe very slowly or fast and unevenly, and stop passing urine (WWHND, p. 309). Family and friends sit with them.
• Scarce medicine (the last insulin, the last oxygen) is a decision for the whole group, made openly and early, not by whoever holds the key (rule of thumb): Community & Barter ("Meetings and fair decisions").
• Then look after the carers and the grieving (Community & Barter, "Grief, stress and psychological first aid").

Comfort and pain medicines

"Pain medicines work best if you take them before the pain gets very bad". Without medicine: distraction, music, raising swollen parts, soft bedding, a dark quiet room for headache (WWHND, p. 308); turning, mouth care and washing (Field Care, "Nursing a bedridden person for days and weeks"). WWHND's ladder: paracetamol, aspirin or ibuprofen first, codeine if stronger is needed, "morphine if the pain is very bad" (same page).