Happy Medic has a series of posts on the 12 Days of Christmas. On the 10th day – #HM12DOC 10MGS OF MORPHINE.
But is that a lot?
How do we know what a lot really is?
I have been told that some of the patients I have treated have received a lot of morphine, or fentanyl, or midazolam, or lorazepam, or diazepam, or some combination of these.
When doctors/nurses/medics have stated that I have given a lot of pain medicine, my responses have not been what they expected. I did not agree with them.
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How painful is it to have a large body surface area burned, not a little bit burned, but second degree and third degree burns?
How much do you carry? Assume that you have standing orders for all that you carry or assume that you are able to persuade medical command to give you orders to give as much as you have, if the severe pain continues.
How much do you carry?
Assume a 100 kg patient with 50% of his body burned. No burned airway. No burned genitals.
Has anyone ever seen a patient like this get to tthe level of pain that could be described as tolerable with any amount that would not be described as a lot?
That is the wrong question.
Has anyone ever seen a patient like this get to tthe level of pain that could be described as tolerable with any amount that would make what is usually described as a lot seem small?
1/2 mg per kg of morphine?
Most people would consider this to be a lot. I have heard comments about a lot, when I have given much smaller doses than this.
2nd degree and 3rd degree burns on half of the body.
Should any of us expect 0.5 mg/kg of morphine to make the pain tolerable?
For a 100 kg (220 pound) patient, this would be a dose of 50 mg morphine.
Should any of us expect 50 mg of morphine to make the pain tolerable?
How many of us carry enough to give 50 mg morphine (or 500 mcg fentanyl or 7 mg Dilaudid)?
How many people have seen severe burn pain, such as I described, made tolerable by a dose as small as 50 mg of morphine, except in a very small patient?
How many of us carry even carry 50 mg of morphine?
How many of us would be able to give all of it?
How many would expect this to make the pain tolerable?
I started by asking if 10 mg of morphine is a lot. Since I have moved on to 50 mg, is 10 mg likely to be a lot?
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Due to a supply issue we carry 500mcg of Fentanyl (2x 250mcg/5mL), however, this is changing to 100mcg/2mL vials.
My personal record was a 118 pound woman with necrotizing fascitis to her groin, perineum and left leg.
She got 40 mg Morphine (10 mg at a time), 4 mg Dilaudid, and 100 mcg Fentanyl.
And she was still writhing in pain, breathing adequately and maintaining a higher-than normal blood pressure.
Nowhere I work carries more than 20mg Morphine and 100mcg Fentanyl. In a region with generally short transport times, not many people, especially those old enough to be in charge, consider pain management to be that important- partially because its not been something traditionally emphasized in our local EMS schools, again due to the transport times, and the fact that the instructors are mostly career firefighters who don’t aggressively treat pain in their own practice.
Medical Control is progressing, but I wouldn’t call them progressive quite yet. Our protocols have stepped up to allow one dose on standing order, any subsequent doses, even if the total doesn’t meet our initial dose maximum, requires MC. My biggest order before they went into effect (or since) was 10mg for a 150ish pound patient. Didn’t do much.
We carry 50mg Morphine and 500mcg of Fentanyl total per truck. I always thought that was a small amount for the “what if” situation of a severe burn patient or similar situation. I’m surprised to see that we seem to be in the minority here of carrying more than average.
I should note too that by our protocol we give 2-5mg of Morphine q5min to a max of 0.2mg/kg (or 20mg, whichever comes first) OR 25-50mcg of Fentanyl q5min to a max of 2mcg/kg (or 200mcg, whichever comes first).
Morphine: 2-4mg, may repeat 2-4mg q 5 mins to 20mg
Fentanyl: 50-75mcg, may repeat 25mcg q 20 mins to 200mcg
Dilaudid: 1-2mg, may repeat 1mg q 20 mins to 5mg
Luckily in New Zealand we do not have medical control, we use procedures (soon to be guidelines) and are only limited by common sense constraints on pain management around physiology (generally systolic BP) and the physical quantities we carry. Depending on the qualification level of the crew (basic, intermediate or advanced life support) you are encouraged to use clinical reasoning to determine the best pain relief options. We are increasingly encouraged to use combination pain relief e.g. oral + inhaled or inhaled + IV Rx.
Pain Relief Options (progressive inclusion as you move up the levels)
BLS – Paracetamol, Entonox, Methoxyflurane
ILS – Morphine (max 40mg carried per Paramedic)
ALS – Ketamine, Midazolam
Sorry my USA brothers, but I could never work in what seems like your very restrictive systems.
Oh, and for severe burns we would generally give Entonox, Morphine and Ketamine.
As in most cases, we completely agree.
What is too much is a fairly straight forward question for me to answer. Too much is when the patient starts to have trouble moving air due to respiratory compromise and starts to become symptomatic due to the Cardio-vascular effects of the Morphine that I am giving.
I carry 50mg Morphine with me on shift. I have once given 34mg to a patient for relief of their pain. In my humble opinion, I really don’t see what all the fuss is about regarding getting someone comfortable who is in pain.
Surely if a medic truly understands the concept of ‘titrate to effect’, then the one certainty, is that the patient will receive suitable doses of Analgesia, only controlled by what the medic actually has in their box of tricks to administer
We carry 1.25mgs of fentanyl in 5 250mcg/5ml vials. My personal record is 600mcg to a 100kg individual with an open femur.
Forgot to add we also carry 50mgs of midaz and 10 of lorazepam that can be added if the patient continues to be “agitated”
A paramedic for a nearby city told me that Dallas ambulances carry NO morphine, because it was always getting stolen off the rigs. I didn’t think to ask if they carried other heavy duty painkillers. I really hope I”m never in an ambulance in Dallas in extreme pain, getting no relief and feeling every bump in the road.
I have the quantities total of 200 mcg of fentanyl and 20 mg morphine available as well as Versed/Valium. Our protocols allow for EITHER, but not both, fentanyl(in 25 mcg increments given no faster than 25 mcg per 45 seconds to a max of 200 mcg), or total of 10 mg morphine in 2 mg increments given “slow”. After you max out on either, you have call and play mother may I. If you want to mix both meds, you also have to call. If you want the additional 10 of morphine, you have to call. I have on more than one occasion, given either 20 mg morphine or 200 mcg of fentanyl to non burn patients without full pain relief, and despite the incredulous looks/comments I got from nursing staff, shudder to think what that wouldn’t do for a significant burn patient. At least, most of the doctors usually make some comment about how that 200/20 is a good starting point, so I’m lucky in that regard to have that kind of physician around me.
Morphine doesn’t touch pain from burns. The last burn patient I treated got 250 mcg of Fentanyl over 10 minutes. That made the pain tolerable for him, but otherwise didn’t effect him. He was still conversant, still breathing quite well thank you very much, and not even a bit drowsy. I think we under treat pain from burns more than any other type of pain.
We carry Morphine, Fentanyl, Versed, Ativan, and Etomidate. We stopped carrying Valium a few years ago.