Morphine

suffering

I rank Morphine 2nd out of the 33 drugs I carry.

Albert Schweitzer said, “Pain is a more terrible lord of mankind than death himself…. We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege.”

Like many I began in EMS with visions of saving lives everyday and then having grateful reunions filmed by the crew of the old TV show, Rescue 911.

Now over twenty years into my career, I know that true life-saving calls are few and far between. And many of those few life-saving calls you really don’t do much more than you are taught:

Show up on scene, find recently collapsed patient, apply defibrillator, shock, feel restored pulse.

Show up on scene, find cool, clammy patient with chest pain, do 12-lead, see obvious STEMI, call hospital to activate cath lab, transport.

Show up on scene, find child in anaphylactic shock, eyes swollen shut, airway closing off, no blood pressure, stick them with epi, and watch them return to their normal self.

Some patients are just waiting there for us to save them.

And on other calls, you can work your tail off, do heroic things and the patient doesn’t make it. It was just their day to die.

Today, I see my job not as a lifesaver, but as a comforter.

My EMT instructor told me the emergency ends when you arrive on scene, or at least that’s what you have to make the patient believe.

Today, my reinterpretation of her comments is this; once I am on scene, the patient is no longer alone. I am there to care about them, to provide whatever comfort and care I can, and to try to keep them safe from further harm.

I do that hopefully with a calm voice, a caring touch, understandable words, and with if they are in pain, with everything from pillows and ice to morphine.

“My great and ever new privilege,” as Schweitzer says, “is to take care of people’s pain.”

I can do that, in one way or another, on an almost daily basis.

When I started in EMS, I did not give morphine at all my first year. I gave it only twice for trauma in the next two years, and then in doses too small to provide relief. This is working in a busy system doing 400-500 ALS calls a year.

“I have to hurt looking at you for you to get morphine from me,” an old school medic taught me when I started.

It’s a new day.

Last year (out of 312 ALS calls) I gave Morphine 37 times, more than any other drug except Zofran.

I gave it for hip fractures, and ankle fractures, and shoulder dislocations and wrist fractures, for amputated fingers, burns, for kidney stones, and for all sorts of abdominal pains. Did I get scammed a time or two by a drug seeker? Likely I did, but you know what? I don’t care. I can say I didn’t deny anyone in legitimate pain medication for fear they were drug seeking.

Why is pain management important? Because pain is destructive to the human body. Its only purpose is to alert patients to injury to help eliminate the source of the injury and halt damage to the affected tissue. Untreated, pain stresses the body, damages the immune system, hinders wound healing, and can lead to chronic pain. Not to mention the emotional suffering it causes.

“Prompt treatment of acute pain may prevent both short- and long-term deleterious consequences and resultant chronic pain syndromes.” – Pain Management and Sedation: Emergency Department Management, Mace Ducharme Murphy, McGraw Hill – 2006

Nearly ever study ever done on the issue has showed widespread under use of analgesics in EMS systems and emergency departments across the country.

But times are changing.

When I started as a medic, on-line medical control was required to give morphine. Today, for a 220 pound patient, I can give up to 15 mg (over 20 minutes) on standing orders. Morphine for abdominal pain was prohibited. Today I can give it on standing orders.

I may not be able to save a life everyday, but everyday I can treat my patients with respect and dignity, and if they are in pain, I can ease their suffering.

healer

The oldest mission of medical healers is to treat pain. I accept that mission.

***

Morphine Sulfate

Class: Narcotic analgesic

Action: Decreases pain perception and anxiety

Onset of action: Intravenous – immediate with peak effect at 10 – 15 minutes.

Indications: Moderate to severe pain adults
Moderate to severe pain pediatrics
AMI
Pulmonary Edema
Burns adults
Burns pediatrics

Contraindications: Head injury
Decreased mental status
Multiple trauma
COPD/compromised respirations
Hypotension
Allergic to Morphine, Codeine, Percodan

Side effects: Respiratory depression or arrest
Decreased LOC
Hypotension
Increased vagal tone (slowed heart rate)
Nausea/vomiting
Pinpoint pupils
Increased cerebral blood flow
Urticaria

Precautions: Undiagnosed abdominal pain; Continuous patient monitoring after administration of morphine is required including (when physically possible) pulse oximetry, ECG, capnography (when available), vital signs and respiratory effort; Rapid administration increases the likelihood of side effects.

Adult Dose: Analgesia general: Initial dose 0.1 mg/kg (5 – 10 mg) slow IV over 4 to 5 minutes Repeat dose 0.05 mg/kg slow IV after 10 – 15 minutes if needed
ACS: 2 mg slow IV
Pulmonary edema: 2 – 5 mg slow IV

Pedi dose: 0.1mg/kg (usual dose) slow IV or IM

Route: Slow IV; IO push – slow; IM

4 Comments

  • I completely agree. I don’t view our jobs as life savers. We are quality of life improvers.

  • Dave says:

    In the first 21 minutes (repeat doses every 3 minutes (starting at time zero minutes) of 5,5,2,2,2,2,2,2) I can give 22mg and after 10-15mg I can give 0.5mg of Midazolam every 3 minutes (to a total of 3mg) under our enhanced pain relief guideline. More Midazolam could be given after consult with a Dr.

    The total Morphine I can give initially is 0.5mg/kg so a 220ib man can theoretically get 50mg (we only carry 40mg) so would need another crew to backup.

    We can also continue onto a total of 1.0mg/kg, so another 50mg for recurrent pain.

    Loving these posts.

  • medicscribe says:

    Thanks for the comments.

    Dave, that’s some megadosages there. Times certainly are changing.

    Peter

  • Jordan Collins says:

    I know this is from a while ago but I like reviewing your drug rankings. I have found, even in the 10-15mg range, Morphine has little effect on pain. I would estimate maybe 1 in 5 patients feels any sort of pain relief. It’s frustrating not getting people their relief, while jumping through all of our hoops; we have to fill out a controlled substance usage report on the computer and on paper.

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Peter Canning

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  • Comments
    Jon Kavanagh
    #1 Pain Management and Comfort Care
    We comfort and take care of pain when we remember that the patient is a person. A touch on the hand or shoulder, a compassion for his situation, a desire to do the right thing (vs the easy)... We need to be actively turning his bad day into something less lousy, even when the solution…
    2015-07-20 15:54:14
    Matt ONeill
    Lights and Sirens
    I agree with Peter, Kevin's book is well written and a great read (as is Peter's book). Kevin's book does a great job balancing the illustration (to the layperson) of just how complex the medical aspect of Paramedicine can be coupled with the often viewed 'adrenaline' fueled aspects. I thoroughly enjoyed BOTH books and have…
    2015-07-18 13:14:56
    paramedic441
    Lights and Sirens
    Very well written! I would highly recommend this book to anyone contemplating medic school. While all programs vary, Kevin has captured the essence of what all paramedic programs are about. Anyone that has been through the classroom, labs, clinical rotations and ride time will be able to relate to his experiences.
    2015-07-14 19:09:51
    medicscribe
    Ativan
    Many of the drugs we carry can kill, but they can also save lives. Ativan is one of them.
    2015-07-07 01:04:06
    medicscribe
    Lights and Sirens
    This is somewhat of a prewar story book. It is the only book I know of that focuses almost entirely on what paramedic school is like, and it quite well written. Your overall comment is interesting. I do find and will be writing about this fairly soon, there is a marked difference between EMS nonfiction…
    2015-07-07 01:02:46

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