God Of Sleep

We in the LAS will soon have a new drug to play with.
Morphine.

Morphine is an excellent painkiller, in our case it will be given through an injection straight into a vein causing nearly instant relief of pain. It's a pretty safe drug in that few people are allergic to it, and even if we make a huge mistake and overdose someone, it is really easy to reverse using another drug (Narcan) that we have been using for years.

But all is not perfect with this drug. It's potency, and the ability to get people 'high' means that it is a 'Controlled Drug', with whole books of legislation covering it. It should be stored in a double locked wall safe, every usage must be well recorded and every use should be witnessed by two professionals.

This is a bit of a problem for the ambulance service. While we have double locked wall safes on station to keep the stock on, the ambulances are a bit short on these. Instead we have come up with a plan, that for reasons that will are obvious, I won't be mentioning here.

Why won't I mention where we are keeping it? Let me put it this way, junkies love morphine, especially the nice pure, safe stuff that we will be carrying. Junkies also have a habit of turning to crime to get their 'fix'. We don't want junkies stealing our Morphine, if only because it will mean filling in a tree-load of paperwork.

So the Morphine is safely padlocked and hidden away. Although to be honest, the security is all in the hiding, rather than in the padlock…

Even though Morphine is a paramedic only drug, meaning us poor lowly EMTs can't give it, we all have to undergo the additional training. The reasoning behind this isn't because we can't trust the Paramedics not to muck it all up and give the wrong dose, but because we have to sign our name to a bit of paperwork every time Morphine is given to say that the patient got the right dose, and that our Paramedic crewmate isn't shooting up in the carpark/selling it on the street.

So we have all had a look at the drug information sheet, we had a laugh at one of the contraindications (reasons when not to give the drug) as being described as 'rare as rocking horse shite'. You wouldn't get that in a nursing memo.

The issue I have with the use of this drug is in its dosage and administration. For the medical people out there, the dosage is 2.5mg over two minutes, repeated every 5 minutes (I may have to amend this later, I've left the information chart at home). For the non-medical people, this is a dosage that seems almost homeopathic in nature. It is a tiny dose. I'm considering all the times in hospital we'd give 8mg immediately, and another 2mg to 'top up'. While I understand that too much can cause you to stop breathing, we do have the 'antidote' sitting right next to it.

While I understand the concerns of our Clinical director, I hope that this will get reviewed at some point in the near future.

What has been done right is that the drug comes in pre-filled syringes. We won't have to faff around with needles, bottles of water, and shaking up bottles of powder. Instead it is a simple process to pull out a syringe, flip off the top and give the patient some pain relief.

So we are moving forward with our pain relief treatments, which can only be a good thing.

Although I don't think we will be getting paid any more for our new skills…

29 thoughts on “God Of Sleep”

  1. That's excellent news. We've been using morphine in Mountain Rescue for quite some time now, though only IM. I'm glad they finally recognised that you guys should be able to use it, especially with Narcan already in your packs (something that only doctors within MR carry).I'm intruiged – what was the rare c/i? Whilst I've had a list of c/i's, we don't get an indication of their scarcity.

  2. This post has served as a very timely reminder that I should really seriously be wearing my medic-alert bracelet, because not so long ago, 5mg of morphine nearly killed me, causing a chain reaction of body chemistry that meant that six weeks later, two standard over the counter painkillers (of the type I'd taken fairly regularly during my life up until that point without incident) containing codeine nearly killed me.

  3. I wonder what other ambulance services use for doseage? – Will ask at work this week.My Clinical practice guidelines sugest:

    “Initial dose of 5mg by slow iv injection, (2.5mg for elderly).

    Followed by aditional 5mg doses every five mins up to 20mg MAX. Medical cases smaller doses seem effective(2.5mg), Trauma cases larger doses may be required, (5-20mg)”

    and

    “Morphine, when given IV takes a minimum of 2-3 minutes to begin to work, with peek effect not being achived for 10-20 minuites” – So be carefull out there!

  4. Tom,What happens in the case of a FRU arriving at a scene, the vitim of a RTA is in severe pain, you are alone, the ambulance is 40minutes away? Surely you wouldn't be able to use Morphine, so the patient doesn't benefit, or is it only going to be available to 2 crew abulances?

    The Driving Instructor

  5. There's a good bit of individual variation in reactions to morphine, and I seem to remember reading somewhere that Asians, on the whole, tend to react differently to Caucasians. (Don't remember what the actual difference was.) I found out my personal reaction to morphine when I had a violently painful eye inflammation. The morphine did nothing for the actual pain. It put me to sleep, so it helped, but the pain itself was actually unchanged. It was a bizarre effect.

  6. Controlled substances are such a nightmare to work with. I used to make a new drug from four different amphetamines. The paperwork is endless!! Have fun!

  7. 2.5mg is not so homeopathic Tom. I have had plenty of old grannies go ga ga and stop breathing with just that dose. Sure in a fit young adult they won't notice it let alone someone who is errr…..desensitised !It is always fun when some young family member asks “whats that drug you are giving my gran ?” to be able to answer “Smack”.

    Ex

  8. We are lucky in NZ that as far as morphine sulphate is concerned the protocol is relatively open. Titrate 2mg-5mg boluses IV every 3-5 minutes with no upper dose limit (it would be 40mg's as that's all we carry). Paed's have a per kilo IV dosage, adults 10mb IM and kids 0.2mg/kg IM…although there is a dinstinct focus on IV.Contra's/Precautions:

    * No IM in the “shocked” patient or ? MI patient (apparently modifies some enzyme returns

    * Hypersensitivity

    * For severe pain not responding to Entonox

    * Not to be used to facilitate airway establishment

    * GCS > 10

    * Caution with hypotensive pts

    Would tend to agree with some of the comments here about caution in IV incremental doses. My experience in administering to a wide range of people suggests start small, then build consistent with the patients pain, their response to the morphine, physiological changes and overall effectiveness. Sometimes morphine does little e.g. burns, other times it aggravates the base condition e.g. bilary colic.

    Have fun playing the the new Rx. I presume Nubain is a gonna?

  9. wow. no morphine to MI,s. it was introduced in scotland in conjunction to thrombolyisis as the only way to remove central chest pain. infact it is part of the thrombolisys protocol. would be interested in any further info.aside from that i heard that in edinburgh they are building a new “super station”. merging all the current ambulance stations into one, including the PTS (patient transport service). total personel of probably 150 staff. there are 17 car parking spaces – total. it is also situated between craigmillar and niddrie, two areas renowned for the concentration of heroin addicts. Management — god bless their little cotton socks.

  10. Ho there. I've been reading your blog for a while, courtesy of it's RSS feed in Livejournal. It's always interesting reading other people's experiences and perspectives on prehospital care from around the world. πŸ™‚

    For the medical people out there, the dosage is 2.5mg over two minutes, repeated every 5 minutes (I may have to amend this later, I've left the information chart at home).

    2.5 mg isn't huge, you're right, but it's not completely piddling either. Melbourne's Metropolitan Ambulance Service (MAS) only allows its staff to give doses of 2.5 mg, despite the Clinical Practice Guideline (CPG – and what I hope is a working link below) stating that doses of between 2.5 and 5 mg may be give, up to a maximum of 20 mg before a consult is required. The Rural Ambulance Service (RAV) that serves the rest of the state of Victoria is less restrictive on the dosages given within the range outlined by the CPG, partially because of longer trnasport times. In both cases it's been noted that our inhaled analgesic methoxyflurane ('Penthrane') and MS seem to have a synergistc effect, working especially well for acute pain from injuries such as burns. I suspect that you'd get a similar effect while using it with 'Entonox' or similar drugs.

    What has been done right is that the drug comes in pre-filled syringes. We won't have to faff around with needles, bottles of water, and shaking up bottles of powder. Instead it is a simple process to pull out a syringe, flip off the top and give the patient some pain relief.

    Nice. I wish we had a few more drugs presented that way. At the present moment the only one that comes prepackaged like that is naloxone ('Narcan'). It would save a whole lot of faffing about. Muddling up drug calculations is one of the things that really gives me nightmares, and anything that minimises that risk makes me very, very happy.

    CPG Drug Info on Mophine Sulphate

  11. Hi… no IM MS to ?MI's. IV MS is fine.Oxygen and more importantly sufficient doses of GTN remain the most effective first off pharmaceutical interventions, with GTN having the greatest physiological benefit In fact, research (I can't find it at the moment) suggests practitioners are too quick to adopt morphine without adequate GTN amounts.

    CCU staff would prefer that we did not give IM injections in situations of ?MI as:

    * The release of the medication is less predictable with IM vs IV, and therefore delivering the right therapeutic level becomes harder to assess

    * The body during an MI is often cardiovascularly compromised and therefore uptake from the muscle structure may be impaired (similar reasoning to above), therefore the rule concerning shocked patients could apply.

    * However the main reason is that the administration of an IM injection causes a potential false positive cardiac enzyme result, specifically IM injections raise CK (Creatine Kinase) which is a less costly measure of myocardial injury.

    It sounds like your management is trying to adopt the “hub” model our management tried and failed to adopt. Fight it…KPI's will only be reduced when ambulance managers realise they need more geographically spread stations consistent with workload hotzones. It will also destroy station comeraderie and mean more fluid deployment/system status management.

  12. G'day from another MAS amboMAS has recently changed the Morphine Protocol such that we can now give 5mg straight up to a max of 20mg before consult. Maxolon can then be given if nausea arises. I think thats right though, I have just come off a doozy of a 15 hour night shift and am overdue for beddy byes!

  13. “There's a good bit of individual variation in reactions to morphine”Well thats illuminated me a hell of a lot. I had sugery on a broken ankle/leg last year, and when I woke I was easily in the worst pain of my life, their might even have been sobbing involved.

    I was given liquid morphine (tastes like raspberries) which didn't help. then I was given 1 white pill, then two brown pills (that might be the other way round, I wasn't very focused at the time) which did the trick eventualy.

    I always assumed I was in so much pain because they hadn't given me enough morphine for my weight, I couldn't stand at the time, so they couldn't weigh me very accuratley. The nurses did give lots of sympathy, but not much information. So Im glad I understand a little more now. Im also glad for the anonymity of the internet. Because i certainly couldn't have told my freinds that I might have cried like a girl

  14. When I think about giving 10MG, to start, in post surgery recovery. Very different situation, of course. Have actually moved more toward Fentanyl- normally an anesthetic drug. Just 2.5 of MS does seem meagre, but then, you need them to answer questions? OR just so you won't have enough on board to tempt the junkies?Very true that all the pain drugs work differently on different people, all can cause nausea, previous narcotic use dramatically decreases effectiveness, as does smoking.

    Morphine is good for the MI.

  15. And hello to you too. :)It's entirely possible MAS has finally stopped being quite so prescriptive with its ALS people and I failed to notice. I tend to flit between situations and services so my grasp of what's current does fall behind sometimes. ATM, I'm getting used to the joys of driving (both trucks and stretchers again) after a few years playing purely with pt. assessment/care…

  16. I'm interested by the connflicting information here with regards to the use of morphine in MIs. It's something that's specifically indicated for use by mountain rescue (MR) for MI, albeit administered IM not IV – MR don't administer anything IV.Anyone got any pointers to more info?

  17. Eh up Aled,Assuming you're a UK MR team member (I think I recognise your name) I would suggest it depends on the area you cover.

    First thing to say is remember Oxygen/Nitrates/Aspirin in MI. The pain is ischaemic so anything that gets more oxygen through will help both the pain and the MI.

    Working in the Peak District, our transport times to hospital are quite short in MR terms. I would therefore suggest it is rarely appropriate to use IM morphine in our environment.

    The blog people tell me we are now friends – will e-mail.

    Good choice of topic Mr Reynolds. Interesting discussion.

  18. In Queensland the Intensive Care Paras can give Morphine 2.5mg – 5mg up to a max of 15mg – though more than that often seems to be given – “on medical consult”. It's currently being rolled out to the Advanced Care Paras – (the standard level of qualification here) and I will have it as part of my standard armoury when I graduate – IV – although I can't just tell you at the moment what our dosages will be.

  19. Really? Never happened to me in hospital… But yes, I also enjoy telling people that their granny is getting 'smacked up'.And then have a certain Prodigy track running through my mind for the rest of the shift.

  20. Silly, silly idea. Someone's bright idea of 'economy' I suppose.They'll get the wind up them when crews stop hitting ORCON, either that or they'll start putting crews on standby.

  21. I *think* that solo responders will still be able to carry and give it…and that the LAS will trust us not to misuse it. You have to make a note that you are a solo on the paperwork.One more danger for the Solos…

  22. Hiya.Yup, South Wales. Yeah, I know about giving morphine for pain relief after other considerations, it's just with the recent push to use morphine more in cases where it's justified, it's usage has been discussed a lot. It's infrequent, but there are places in the Beacons where the casualty would be at least an hour from the road, unless we get a lift from the nice guys in the big yellow taxi.

    Cheers.

  23. Good stuff, morphine; I'm glad to hear you have it in your ambulance.

    The first time I broke my back (T5), I was picked up by a part time ambulance crew from a village 20 miles from the crash site. They gave me morphine by injection immediately, and that made the 40-odd mile journey to hospital very much more bearable than it would otherwise have been. Great people.

    The second time I broke it (T12; some people don't learn), when the ambulance crew eventually arrived (not their fault – I spent the first 30 minutes trying to persuade the people around me that I was fine and didn't need any medical treatment, and it wasn't until I'd been given a lift to a GP's surgery that someone had the good sense to ignore me) the crew immediately offered morphine. I suppose being in remote rural area there's more urgency to have morphine on the ambulances, but it's really nice to know it's there if you need it.

  24. I've had a fair bit of morphine, most of it due to a climbing accident. MR gave me it straight off (“Hi, I'm John, I weigh 100 kilos, my GCS is 13 and can I have 10 mgs please?” “No, cheeky boy, we'll start you with 5”)Post-op, after plastic surgery, I had 30 mgs in total, 2mgs every 3 minutes. “Can you speed it up at all? England – Argentina are kicking off!”

    Never mind, I was in time to see the Beckham penalty. Oddly, I'd seen the Maradona foul through post-op morphine in '86, after breaking my left leg.

    I don't like it much, it makes everything dull and soupy, and at high doses you become aware that the breathing reflex is depressed.

  25. I can understand that dose as far as 'safety' in terms of junkies etc goes, but it isn't likely to do much :(Mind you, being someone who remains conscious & lucid after 70mg diazepam, 12.5 midaz and 10 of morphine (all IV), it just increases my wish to never be in an emergency situation – I'm *not* a junkie, but have high tolerance levels due to the drugs I take every day for my medical condition…

  26. Morphine is great and all, and I imagine quite a few people picked up by ambulances are broken badly enough to need that kind of pain relief. Unfortunately, for some people, myself included, morphine (and even codeine) affects my mental thinking. And one thing I definitely want when I'm in an ambulance is to know what's going on, to be able to explain myself to the ambulance people, and when I get to hospital, to the doctors. So be sure to ask before giving someone morphine, they might not want it, or they'd rather suffer through a bit of pain but stay awake and alert. And it definitely affects some people a lot more than others.

  27. Any MR member with a current MR E&W cas care cert can carry and administer morphine sulphate IM. Some team doctors administer IV morphine, and there are moves to extend this. Teams are about to start using fentanyl lozenges instead of morphine.

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