I have written much about pain management in the last several years. Most of the time when I deal with pain it is for broken bones from falls or motor vehicle accidents. Between snow blowers, lawnmowers and all the machine industry we have in our town, I do several digitit amputations a year – all of which I offer morphine. They may not all be in immediate pain and they are usually tough guys, but all who refuse are in pain by the time they reach the hospital. Since our guidelines changed, I give morphine quite frequently to abdominal pain. I am quite liberal with pain relief and have never yet had a bad outcome beside an occasional nauseous patient that I then treated successfully with an anti-emetic. I admit to having delivered my share of sleeping patients as well as patients singing “The Farmer in the Dell.” All good in my book.
It is fair to say I have become quite comfortable with giving patients pain relief.
Even giving pain meds to kids causes few qualms for me. I say this because I sit on the regional medical advisory committee and the physician from the Children’s Hospital has repeatedly backed our pain initiatives and has made it clear that pain management is great for kids and that they tolerate it quite well.
We used to have to call to give pain meds to kids, but for the last couple years it has been on standing orders. Sometimes I have found parents do not like the idea of “an ambulance driver” giving their child morphine (perhaps they think it is similar to an ice cream truck driver selling them heroin) so I have on occasion called medical control with the parent at my side to have the physician reassure the parent that morphine would be a good medication for their screaming child with the fractured arm. Other parents, of course, have nodded agreeablely when I have told them I am planning to give their child morphine. Anything to ease their child’s suffering is agreeable to them. So pleased were they that I could have been offered honorary unclehood on the spot.
I carry 40 milligrams of morphine. The most I have ever given is 20 milligrams – for a 400 pound patient with a painful back who could not get out of bed and who we could not manage to move. Twenty milligrams and he not only got out of bed, but walked down the stairs. Thank You Jesus, thanks you, Lord. I have often given 15, which is the maximum I can give to a patient of 100 kgs or more on standing orders.
This past month I gave my lowest dose ever.
My Tuesday night partner and I had a rough two weeks. A two month old cardiac arrest and then at the exact same time of the week (just as American Idol was starting) we were called for severe burns for another two month old.
She was screaming like a banshee when we got there. I am not even going to get into what happened or who said what about whose fault it was or whether or not the story made any sense or what I thought about the caregivers.
The bottom line was the baby had severe burns, around her midsection. If you are a parent or know anyone who has a small small child go down right now to your hot water heater and turn the temperature down low. Put it on the vacation setting if you have to. I’ll take a warm shower everyday to protect my daughter from ever getting scalded.
This baby girl weighed 18 pounds. The initial morphine dose is 0.1 mg/kg, which is 0.81 mgs for her weight. Following our protocols I could give up to 1.22 mg without having to call for orders. And while I could give that amount on standing orders I still called the kid’s hospital for medical control. I wanted to make certain it was okay to transport there and not the trauma center across the street or have the child flown to a burn center (it was raining so I didn’t think that was a possibility) and I wanted to tell them how I planned to treat the burns – moist sterile dressings. The burn area was about 15%, but burns have a habit of growing beyond what they first look like. And so while I had them on the phone, I told them I was planning to give the child one milligram of morphine. I rounded up due to the pain. The doctor came back and told me to just give 0.5 mg, as well as agreeing to my treatment plan and agreeing to accept the patient.
I was a little perturbed that by rounding up or even calling I had cost the child some needed pain med, but I went ahead and gave the 0.5 IM.
How did it work?
The screaming banshee was sound asleep by arrival at the hospital.
Here’s a recent article about how giving adequate morphine to young burn patients helps prevent posttraumatic stress disorder:
Preliminary evidence for the effects of morphine on posttraumatic stress disorder symptoms in one- to four-year-olds with burns.
J Burn Care Res. 2009 Sep-Oct;30(5):836-43.
This study tested the hypothesis that very young children who received more morphine for acute burns would have larger decreases in posttraumatic symptoms 3 to 6 months later. This has never before been studied in very young children, despite the high frequency of burns and trauma in this age group. Seventy 12- to 48-month-old nonvented children with acute burns admitted to a major pediatric burn center and their parents participated. Parents were interviewed at three time points: during their child’s hospitalization, 1 month, and 3 to 6 months after discharge. Measures included the Child Stress Disorders Checklist – Burn Version (CSDC-B). Chart reviews were conducted to obtain children’s morphine dosages during hospitalization. Mean equivalency dosages of morphine (mg/kg/d) were calculated to combine oral and intravenous administrations. Eleven participants had complete 3 to 6-month data on the CSDC. The correlation between average morphine dose and amount of decrease in posttraumatic stress disorder symptoms on the CSDC (r = -0.32) was similar to that found in studies with older children. The correlation between morphine dose and amount of decrease in symptoms on the arousal cluster of the CSDC was significant (r = -0.63, P < .05). Findings from the current study suggest that, for young children, management of pain with higher doses of morphine may be associated with a decreasing number of posttraumatic stress disorder symptoms, especially those of arousal, in the months after major trauma. This extends, with very young children, the previous findings with 6- to 16-year olds.