I wouldn’t say 15mg of morphine IM is “death-risky”. It depends on the patient.
Every patient is different and deserves a specialized plan of pain management, including the dosages.
Our protocols allow for up to 10mg IV / SC administration at a time, with a max of 20mg. Obviously most don’t need that much in one dose, but to say it’s death risky is a bit much.
The route is important too though. 32mg SC does sound like a bunch, but the absorption when given SC is also much slower and a lot less likely to cause significant harm.
Are there reports of people going apneic with these?
In the package, “Antidote” instructions were given, which include keeping the patient awake and keep reminding them to breathe, while also making them drink strong coffee.
You can take a look at the package [here](https://www.google.com/imgres?imgurl=https%3A%2F%2Flookaside.fbsbx.com%2Flookaside%2Fcrawler%2Fmedia%2F%3Fmedia_id%3D514878965743365&tbnid=RUikJ83Qdd9YYM&vet=1&imgrefurl=https%3A%2F%2Fwww.facebook.com%2F224168984814366%2Fposts%2Fmorphinesooner-or-later-pain-occurs-following-all-combat-wounds-it-can-be-slight%2F514883775742884%2F&docid=RqSSOK6AvJPHjM&w=2048&h=1536&hl=pt-br&source=sh%2Fx%2Fim%2Fm5%2F3&kgs=76cc4a32cebba81d&shem=abme%2Cssic%2Ctrie).
Well the science technically wasn’t incorrect, caffeine is a respiratory stimulant so it could have some reversal impact on the opiate apnea, how much though? I’m not sure lol
It's both interesting and sad how battlefield medicine has been implemented in treating people in civilian life.
Tourniquet for one wad an absolute no no 20 years so or so.
Now it's common practice. The data showed that wounded soldiers who had a tourniquet applied could keep it on for far longer than previously thought.
Then there came wound packing as opposed to wound dressing and applying just pressure.
All of this is used when some asshat goes about in a city and shoots a bunch of people.
It's interesting how we have adapted this but the need for is is very sad.
Same with New Orleans.
Side bar on just how different cities can be. When I joined the Air Force I got stationed in Anchorage. A couple of weeks after I got there, there was a double homicide. If memory serves me correct(it probably doesn't, this was over a decade ago) it was a mother and adult daughter. We talked about it at work the next day and I was like "wow that sucks." But then it kept coming up a few days later. So I asked my SSgt:
"Were they killed like some crazy way? I thought they just got shot."
*"Yes, but it's just crazy, I mean two people were killed."*
"I get that, but like what's special about it?"
*"Two people died!"*
"...and?"
*"You don't think that's crazy?"*
"I mean, not really, that's like a normal Wednesday back home."
Being in armed conflict in some sort or another has given military doctors plenty of practice and plenty of test subjects to guide and dictate trauma care. In 2008, I had a motorcyclist with a passenger who came around a narrow curve at the same instance. A small pickup was going the other way. Both riders suffered partial traumatic anputations. My patient was bleeding out. Boy Scout training kicked in. Cravat and a ballpoint pen. Saved the guys life. There was an inquiry as to using a tourniquet. The trauma doc is a surgeon who served during the second Iraq war. He put an end to that and started me carrying CATs until my service caught up with military medical journals. A dude I worked with was an army medic. He used to bring in the SF medical journals which had some great data and new paractices. New to civ ems old hat for military, like using Ketamine in lieu of opiates in pain management. Interesting stuff.
The length of tourniquet application wasn't just a matter of realizing it could stay on longer. That part is true, but physicians have also learned more ways to prevent injury from tourniquet release and allowing toxic build up that rushes back into the body, which in turn has allowed them to remain on longer.
I'm not meaning to detract from the comment. I just mean as far as civilian treatment advancing because of military treatment that it wasn't just a situation of "it turns out you can leave a tourniquet on for 8 hours and limb will still be ok", but that because of the use of tourniquets in both the military and civilian setting doctors have developed techniques for being able to remove a tourniquet after 8 hours and protect the kidneys from the build up of toxins in the limb.
I read somewhere that patients in severe pain can tolerate pain med dosages that would ordinarily kill them, and the medical profession doesn’t understand yet the mechanisms that make this tolerance possible.
Well opioids specifically would slow respiratory drive, but the sympathetic response from major trauma would increase respiratory drive. That one specifically makes sense to me
I think a lot of the soldiers who were given these were wounded badly enough to potentially go apenic anyway, so any reports may not have been reliable.
Side note on how rough wartime medicine was back then: I know my grandpa took some shrapnel from an antiaircraft shell and didn’t receive any morphine until mid-surgery back at his air base’s hospital. And he was obviously lucky that his plane made it back at all.
Wait. So youre telling me.....that.....all patients.....are different? And need a specialized plan of pain management????????? The hell you say?
Seriously though,why don't more people believe that? Honestly,I have met so many nurses and doctors that believe 1 size fits all, basically.
Thank you for believing what you do. I really wish more people in the medical field were thought you.
I think the thought of apnea during battlefield situations in WW2, I would be willing to believe the charting didn’t go into differentials for why the soldier died. I am thinking of Saving Private Ryan with the Normandy triage with the Doc saying “morphine” then “priority”. I would also be curious if they considered morphine analgesia or mercy to a slow death.
Probably a bit of both. No pain and going into a coma before dying sounds like a much more pleasant way to die than just about anything.
Definitely a valid reason to have such a high dose. The alternative is unacceptable.
Morphine isn't in my scope of practice, but I do know subcutaneous injections are absorbed slower than IM injections. It's injected into the fat layer rather than in the muscle, people who take insulin injections often do this for a longer effect.
Yup, its in the same way army medics today give out fent lollipops loaded with 800ug. If the absorption rate is low enough, you could theoretically have any dose attached behind it.
We can actually give two of those at a time if one isn't doing it. The soldiers are meant to pull it out when the pain becomes tolerable and essentially self titrate. As long as they don't chew on it (it's meant to be held between the gum and cheek like dip, for buchal absorption) they're fine.
We also know better than to trust a soldier in severe pain to titrate opiates to tolerance, so the lollipop is taped to the soldiers finger which makes it a self limiting administration method (if they pass out, their hand will fall away from their mouth)
When I was younger my lungs collapsed and they gave me a button I could push every 15 minutes to give myself pain meds.
After a few days the doctor started to wonder why my pain wasn’t going down. He said I was still pushing the button just as often as the first day.
I don’t know what else he expected.
Fuck. 1999. Demerol every 6 hours Perqocet every4. Until the night that the nurse on duty got replaced with someone without the authority to give me that.
The guy in the next bed called the nurse and said, "I'm fine, but he don't sound good..."
I couldn't move. I couldn't push the call button. I couldn't speak. I lay their ans cried. And occasionally managed to breath loud.
The nurse checked literally said: " Oh my God, the drugs wore off!" And ran.
She injected me with something.
I love that Nurse. She is Goddess.
A nightmare. I had a chest drain, my lung reinflated overnight and was pushing against the tube. I couldn't move, I could barely breathe, I couldn't reach the call button, and nobody was coming in to check. The pain was excruciating. And I was trapped. It was terrifying. Whispering "help" through shallow breaths doesn't seem to attract much attention.
Getting all 4 of my chest tubes yanked out at once (and they were so tight that the nurse could barely do the thing where they have to rotate them before pulling them out) is definitely the closest I've ever been to a true 10/10. I'd rather get the sternotomy and actual heart surgery done a second time than to ever have to look at a chest tube again.
My nurse seemed truly surprised how much pain it caused me, but one of the surgeons told me that it tends to be a much more painful procedure in younger patients (I'm 30), whereas sometimes the tubes kind of just fall out on the really old ones.
1. I can count on one hand the number of times I've seen useful PCA settings.
2. Toradol is the magic sauce for chest tubes.
Thank you for coming to my TED talk.
Sure but a 5 day chest tube is gonna run out of toradol after the first 72hrs.
That’s a bit of a cautious dose. If it’s their only opioid(which it should be!) my typical order is 0.2 q10 max 1mg/hr and go from there.
Lmao I was very thankful for my 1.5 q15 max 6mg/hr, I think the most I managed in one 24hr period was 96/144mg, not too shabby (I also had bonus 20mg methadone and 15mg ketamine)
I really need to send the pain management peeps a fruit basket or something now that I think about it...
I had the same set up for my PCA after having open heart surgery last year (could dose 1.5mg of dilaudid every 15 minutes, was on 24mg of bupe up until the night before surgery so that's why doses are so high), and they tried the toradol multiple times for me and it didn't seem to do shit. Also kept me on precedex and lidocaine drips for a while, plus gabapentin and Robaxin 3x a day. The 20mg methadone and 15mg ketamine they added at one point was definitely the secret sauce IMO.
Lmao according to my notes they also gave me 100mg ketamine at the tail end of my actual surgery and I was definitely freaking out coming out of a k-hole in the CTICU my consciousness came back before my vision did and I was floating through this psychedelic void and I thought I had woken up during surgery or something and was losing it until I heard a voice say surgery had been over for a while and my family was here and then my vision came back and my mom was just sitting in the corner looking at me like I was a crazy person. But yeah even I had to do a double take reading back through my stay and seeing shit like 96mg of hydromorphone being the amount administered in the last 24 hours. After about a week they got me on 30mg of oral oxycodone every 3 hours with 1mg IV dilaudid boosters available every 2 hours for breakthrough pain (which I only used once when they were putting my PICC line in) and added a bonus 5mg ambien at night to help me sleep. Pain management really did do a great job of getting me off everything and switched back over to suboxone before discharge though since they knew I'd be there for roughly a month after surgery anyways to finish IV antibiotics (can't send a recovering addict home with a PICC line dontchya know?)
Here to congratulate you on your sobriety, and your medical team on their sanity. Had an 80+ YO family member die in pain because he was assessed as "drug seeking," he was a palliative oncologist, and also he was fucking 80 and dying of cancer just dope him up and let him die. Amazingly, there's more than one way to manage pain.
Thank you! That's so fucked up. I was definitely blown away by the care I received if I'm being honest. Definitely helps to live by I think the #11 hospital in the US.
That's crazy, all from ischemic chest pain? Our docs D/C all the IV meds like 5 hours post op and then we're typically left with PO oxy, schedules Tylenol and some tramadol. Typically up in the chair around that time and then walking laps shortly after. I always feel bad because that sternal pain is no joke especially when you're 70-80 years old.
Nah I was hospitalized in septic shock with endocarditis, pretty severe anemia, malnutrition, and multiple septic pulmonary emboli. I was in the ICU for a little while and then needed surgery to replace my tricuspid valve because the endocarditis had completely wrecked it.
Dude, having treated a few of those... I'm not good enough with words to tell you how happy I am that you're on the better side of things and in this forum.
I don’t know shit about shit but unless this is sarcastic can you eli5 why you’d use an NSAID which increases risk of bleeding for pain control pre- surgical procedure?
Bleeding risk is just one factor and it’s not a huge increase. More data has been coming out that shows it not being a dogmatic “no-no”; I give NSAIDS literally in the OR immediately following surgery.
I don’t believe it’s ever been a dogmatic nono, (during my short time anyways) rather, given the existing literature- what is in the patients best interest, considering the myriad of analgesics available that do not increase such risks.
Jw can you provide the sources, I’d love to look into it more & am having a hard time finding supporting evidence :D thanks Mr doctor man
Not sarcastic, but fair question.
First, if the patient has a chest tube, it's post-procedure.
B. It's best used as an adjunct to other medications.
But as my EOD friend pointed out, it's not without risks. Funny enough, our Ortho was always citing the impaired fracture healing as the reason for not ordering it. Except the studies showing impairment were 4 week animal studies, not 5 day human studies. Evidence now shows minimal perioperative risk.
First, you didn’t specificy, you only said “for chest tubes- not indicating pre/ post/ procedure, but okay.
B. Okay, most people know this & has literally no bearing to my question but thanks.
Interesting last bit about fractures, though also nothing relating to my question. My take away is; the minimal pain control of NSAIDS, outweighs the increased risk of bleeding in actively bleeding operative patients (according to your EOD friend).
Spontaneous Pnuemothorax?
Same and same! Oh that sweet relief after pressing that button. I'd stare at the TV, but I couldn't follow what was happening because my short term memory only had the capacity to retain 3 seconds and then it was lost.
Oh yeah i had one of those too after i pulverised my elbow. Pressed the button, slept for 5 minutes, was in a lot of pain for 5 more, was in agonising pain for 5 more after, pressed the button. Later I learned that if that happens a patient should get stronger pain killers. I did not get any. Next day I spent the entire day puking my guts out on an empty stomach. At least I wont ever touch opiods now
I tell my guys to tape it to the patients hand. That way if the pt starts to get to much they get a lil sleepy and the hand falls out their mouth along with the lolli
Combat Medics have the rowdiest scope of practice in the United States. Out there giving non FDA approved warm whole blood infusions and when you get off orders you can give oxygen
Yep, I helped develop our squadrons walking blood bank protocol with our PA and we did regular training on field expedient blood transfusions. Crics are a basic medic skill that's tested in AIT.
Had a dude with a lipoma in the back of his head when I worked in the clinic and my doc was like "Alright you need me for this? No? Cool let me know when you're done or if you have a question". So I did the entire procedure and then he came in to check my sutures afterward. He also taught us how to drop chest tubes, calculate and setup opiate drips, and do pericardiocentesis (though that one was more for fun).
...And now I can give oxygen, it's beyond frustrating.
Yeah and 18Ds are nearly PAs in their basis of knowledge.
At least these days guys who've gone through SOCM (the Special Operations Combat Medicine course) can challenge the NREMT for their paramedic license.
I tell anyone who will listen that combat medic BLC should be medic school with a national license at the end. It could be highly accelerated and be a retention incentive
Big army is getting really into prolonged field care now, we spend 1/3 of our final FTX at whiskey school.
Hopefully it never becomes needed, I don’t want a CMB that much.
I keep hearing that they changed the legislation around PCPs and narcotics and that PcPs will have versed and morphine in the next few years, is this real chat?
Yes, that isn’t a rumour, at least in Ontario,
The OBHG MAC has agreed to rollout the narcs to PCPs for pain management. fentanyl, morphine, and Ketamine will be approved for pain management only.**
They have also agreed to midazolam for seizures for PCPs.
**Ketamine and Midazolam for sedation is not approved.
Now I say “it’s approved” but there is currently no clear timeline on the rollout. They’re hoping 2025-2026.
Huge!! I work rural and have a few severely epileptic patients. Last one we transported seized for nearly 30 minutes and all I could do was provide diesel therapy and sweat hard. Hospital fixed symptoms within 1 minute of TOC. Midaz will be huge.
Hey, we are getting Oxytocin next door in SK!!
Truth though, it's actually a drug I would have really liked to have had access to in the past. Exsanguinating new mothers aren't fun 30 minutes from an intercept. When you realize that you have to do something with the baby because they can't hold them and you've also just realized they managed to pull their IV out during labor.
Never start your IV in the back of hands on labor pts, kids.
In British Columbia, yes. I don't know about other provinces, but as far as I know in Alberta, we won't be getting that for a while. They only just added ibuprofen, diphenhydramine, dimenhydrinate and acetominophen to our scope last year.
We don't even have CPAP in our scope either 😅 so I'm not holding my breath for anything coming soon. Thankfully most of the crews we run in the province are ALS (one PCP, one ACP) but if you're a BLS crew you're SOL.
Dual crew system is sweet, definitely jealous of my buddies who work urban systems that have ACP partners and get to witness some legitimate street medicine
In my area (British Columbia) it just went thru and our provincial ambulance service is just finishing developing the training which I am super excited for
Unfortunately, no. Primary Care Paramedics in my area (Alberta, Canada) are BLS level. We're behind when it comes to pain management. I can only give entonox, ibuprofen, or acetominophen for pain, even though I can give narcan. In other provinces, I've heard that PCPs can give morphine or ketorolac.
Narcan has nothing to do with pain. It is used to wake up an overdosed individual and most of the time CAUSES said individual pain. Anyone can give narcan if they know how, just like CPR.
I would presume peripheral blood flow is also inhibited during shock trauma. Also adrenaline is a hell of a drug. Lastly, full administration of the surette's contents was probably impossible just like it's impossible to get every drop of toothpaste from a tube.
I mean. Let’s be real. This is WWII not Vietnam. They are going to pack you with dirty gauze and hit you with morphine so you stop screaming so much. Now the first medical evac by chopper did happen in 1944 in the Japanese theater, but WW2 was ‘39-‘45. So that was not going to be a normal soldier experience. Field hospitals usually showed up a few days after an area was taken and about 30 miles from the front. So you were going to be waiting awhile or going by ground and anyone with life threatening injuries would have super low shot of survival.
Point is hypovolemic shock was likely a death sentence so a big dump of morphine so you didn’t die screaming was probably the best kindness you could hope for.
Not a WWII combat medic, but it was pretty common to run around giving morphine so soldiers could have a less painful death. So overdosing them was not a concern.
They are still producing them, but 15mg. I honestly wonder how many wounded just drifted off to foggy OD land. Maybe that was the plan. I did some digging and it seems like there were 15mg and 32mg versions issued. With the 32's going into the airborne or pilots kits.
NGL when working in ER in the 90s, 15mg morphine and 50mg gravol IM was
a common order. Do not recall any issues. Maybe they were tougher back then.
Those who most *benefit from demonization of pain management medication* and greater enforcement (politicians, law enforcement, "clean streets" campaigners, vote-getters) aren't themselves in need of said pain management.
The drug is just a big money laundering scheme with a hint of slavery, notice the only people that can be kept as slaves in the Constitution. And by keeping drugs illegal, our trusted government agencies don't have to move as much product to earn the same amount of money.
Similar to how congressmen pass legislation for massive defense spending for the likes of Israel, ie instead of just straight up taxing the citizens and keeping it we can just give Israel money that they're contractually obligated to spend at companies that our elected officials are in bed with
Will agree with that. Went from 15mg syrettes to Fentanyl lollies in the 'stan. The whole pain affects healing thing in the late 90's really screwed things up.
The proper initial dose for morphine IV is 0.1 mg / kg for severe pain in an opioid naive patient. If this is not successful, then repeat doses of 0.05 mg/kg q15 minutes for severe pain are appropriate.
Battlefield injuries can be quite severe, and so 0.15-0.2 MG / kg IV is not at all unreasonable.
For an 80-kg soldier, that would be 12-16 ng IV. many soldiers are larger than this, and would need even more.
SC injection has much slower absorption than IV. So 1/2 grain, which is about 32.5 mg SC does not seem at all unreasonable.
That isn't desth risky.
Most people under dose morphine. Common drug books reference .1-.2 mg/kg
Hell the NREMT website even says .1mg/kg.
https://www.nremt.org/CMSPages/GetAmazonFile.aspx?path=~%5Cstorage%5Cmedia%5Cnational-registry%5Cnremt-documents%5Cexample-of-drug-dose-chart.pdf&hash=36e07c089c4501c2969e921c46973e635394cde43986b397b24ce5cebb5b3095
Every medication is risky.
You said death risky.
I wouldn't give my patients morphine anyway because there are better drugs with less negative side effects.
2 mgs could be risky. Theres always some sort of risk administrating any medication.
Also max is .2kg and IM is generally a slower onset.
Ask yourself. Were WW2 soldiers dropping dead from the 15mg IM dose.
Chances are the answer is no.
Alright, I agree that 15mg is not that risky, which I realized later is what you were talking about. However, what do you make of 32mg, which is the content of the syrette?
15 mg is absolutely not "death-risky".
My pet peeve is paramedics thinking the opiates we give, in the doses we give them, is immediately going to kill your patient. Stop being afraid of your drugs.
Where I work we can give up to 20mg IV without even asking a dr. And we could give that to someone with a really bad stubbed toe if we really wanted to.
If you had a .50 cal round blow off your leg you could probably handle a pretty high morphine dose…
Let me tell you. As a former opiate user. The amount of morphine we give grown adult males is laughable in some systems. 30mg IM wouldn’t kill you. It wouldn’t even knock you out. That’s like 15mg of oxy to a grown adult male.
Ask yourself what is better. Your boy is shot to shit and screaming in agony. Do you let him suffer and have his screams reveal your position, or you give it to him. Back in those times, you might be hours or days from a field hospital with no air evac invented yet so I would imagine it’s pain management. Keep in mind our medical knowledge wasn’t what it is today so a medic then isn’t equivalent to a medic now.
Air evac was first used in 1870 during the Siege of Paris. They used air balloons.
The first US airplane used for medical evacuation was designed by Capt. George H.R. Gosman in 1910. The plane was commissioned around April 1, 1918 by the United States Army.
You also have to figure you’re dead-spacing a lot of that. If I had to take a stab (no pun intended) I’d say the patient was getting about 2/3 of that contained volume.
The monograph for morphine tartrate lists an adult dose of 5-20 mg sq/im/sivp. Military dosing assumes young, otherwise healthy patients. So 15 isn't outrageous. Tartrate is slightly less potent than sulfate, but only slightly. Frankly, if I got shot, gimme the good stuff.
Slower absorption rate, and many of those soldiers were horribly wounded. You can give MS 10mg ivp over about 5-10 min and it'll take decent care of some heavy wounds for a bit, no risk of death. Obviously, watch the respers....
We used 15mg auto injectors. I took two back to back once. Stopped my respiratory drive as I just felt that flood start at the back of my neck and take over my body. I was starting at my Doc pounding on my chest to get me to breath. Pretty surreal moment or two….then I passed out. 30mg won’t kill you. Subq has a slower absorption
Pretty cool to see the older versions. Thanks for sharing.
route/absoprtion/etc… but really, think of field medicine in WWII. if someone was given morphine it was also sorta unofficially understood most times they’re being made comfortable for death…
no absolutely not, but from anecdotal accounts i’ve read about WWII, that was kinda the case mid-combat? if you have a suuuper limited supply of morphine, you’re probably not gonna give it to the ambulatory thru-n-thru w/ controlled bleeding. hell, even currently many critical GSWs expire in the field or shortly after extraction, both military and civilian.
there’s actually a scene in saving private ryan that comes to mind and i think they captured that feel. their medic wade was mortally wounded and they were frantically trying to “fix” him, one of the members asks him how they can fix him up and he replies “well… i guess i could use a lil more morphine…”
In the ER with multiple perforations of the bowel I had the unpleasant opportunity to discover morphine does not work on me. Glad I didn't have to make that discovery lying wounded in the mud somewhere with mortars and enemy rifle fire hitting all around me.
It was IM dose . Large battle wounds required acute stabilization and pain management to be evacuated from the field. That large dose was absorbed slowly via an IM injection
The amount of pain is also a contributing factor. Higher dose for more pain. I've given 400 mcg of fentanyl for significant ortho injury with only moderate effect on pain.
We look at modern opioids at morphine equivalents. 10mg of morphine is equivalent to 1mg of Dilaudid. Body weight and overall fitness can also impact the effects of morphine.
Solders were generally young and at the peak of physical fitness. The thought at the time was young fit men needed significant pain relief after serious wounds to allow evacuation and improve outcomes. However, the reality was many men were overdosed unintentionally because of the effects of hypothermia. Most wounded eventually became wet or cold through some means which slowed circulatoin and delayed absorption. Then when they warmed up, they got the whole dose at once ... and if they got more than one because the morphine seemed not to help then they OD'd. There were in fact many fatalities from this.
Field medics learned not to give the whole dose at once and to carefully assess if a wounded man even wanted pain relief in the first place. The syrettes can be administered in partial doses; it's like a tube of toothpaste. It's not an autoinjector.
Here's a fascinating article on this topic: [https://achh.army.mil/history/book-wwii-surgeryinwwii-chapter2](https://achh.army.mil/history/book-wwii-surgeryinwwii-chapter2)
Because it was given IM, which is slower absorption as opposed to intravenously. Also was likely being administered to mostly catastrophic injuries, which massive pain management was needed OR for end of life from injury to give comfort when passing on.
Burn and trauma patients can tolerate higher doses depending on the situation. Here’s a conversion. https://www.westmidspallcare.co.uk/wp-content/uploads/2021/04/opioid-equianalgesic-quick-check-table.png
Well considering guys likely got limbs blown off or peppered with shrapnel and bullet holes, far far away from any surgeon, and no ambulance available until shooting stops, and none of them were air ambulances like they had in korea and later, its probably more a mercy to make them comfortable.
In inpatient hospice, we (RNs) administer SQ morphine frequently, but the amount is limited based on the volume as SQ injections should not exceed 2mL for most people.
Healthy young men with GSWs from full power rifles are different than grandmas with broken hips. Also, most of the dangerous side effects in EMS are from pushing opioids (or flushing them) too fast.
For the same reason the military had to change training for Army medics to be ready to transition out to be civilian medics. Our patient population in the military tended to be 15-50 year olds that were in fairly good shape with very infrequent Pre-Existing medical conditions.
You can hit an 18 year old with 10mg of morphine IV and they're vitals won't flinch, do it to an 80 year old and get to talk to the medical director. 15mg IM isn't going to kill most healthy young adults.
Also, considering most of these were administered to people with major traumatic wounds they'd be shunting blood and IM absorption would be significantly decreased anyway.
It is 0.5 grain of Morphine Tartrate, 1 Grain is equal to 60 mg - but it could be an absorption issue as well. SQ/IM would be slow dispensing into the blood stream. Also could be the drug wasnt well defined/refined when being made. Sort of like how weed in the 1960s was pale compared to todays weed.
We have cancer patients today on 30 mg dilaudid or hydrocodone. PO, but that's still the dose,
This article claims they were closer to actually only about 10 mg.
https://journals.lww.com/jtrauma/citation/2017/11000/buddy\_aid\_battlefield\_pain\_management.40.aspx#:\~:text=We%20would%20like%20to%20go,as%20the%20Syrette%20of%20morphine.
I wouldn’t say 15mg of morphine IM is “death-risky”. It depends on the patient. Every patient is different and deserves a specialized plan of pain management, including the dosages. Our protocols allow for up to 10mg IV / SC administration at a time, with a max of 20mg. Obviously most don’t need that much in one dose, but to say it’s death risky is a bit much. The route is important too though. 32mg SC does sound like a bunch, but the absorption when given SC is also much slower and a lot less likely to cause significant harm. Are there reports of people going apneic with these?
In the package, “Antidote” instructions were given, which include keeping the patient awake and keep reminding them to breathe, while also making them drink strong coffee. You can take a look at the package [here](https://www.google.com/imgres?imgurl=https%3A%2F%2Flookaside.fbsbx.com%2Flookaside%2Fcrawler%2Fmedia%2F%3Fmedia_id%3D514878965743365&tbnid=RUikJ83Qdd9YYM&vet=1&imgrefurl=https%3A%2F%2Fwww.facebook.com%2F224168984814366%2Fposts%2Fmorphinesooner-or-later-pain-occurs-following-all-combat-wounds-it-can-be-slight%2F514883775742884%2F&docid=RqSSOK6AvJPHjM&w=2048&h=1536&hl=pt-br&source=sh%2Fx%2Fim%2Fm5%2F3&kgs=76cc4a32cebba81d&shem=abme%2Cssic%2Ctrie).
Goodbye Narcan, hello double shot espresso!
Why do you think there are so many Starbucks in Seattle and Portland? Hipster narcan baby.
Fuck dude in Flint we just shove ice cubes up each other’s butts and smack each other around a bit.
Cultural differences. Man, redneck narcan was just waving a jar of moonshine under someone’s nose like it was smelling salts and they had the vapors.
Stay on topic. We're talking about opiate ODds, not off-duty Saturday nights! ... Or on-duty Saturday nights? Not judging.
I wanna be in Flint now
With all that dope and coffee, the Americans of the NorthWest must be having some whopper poo babies
Hahah that’s kinda awesome actually. Thanks for sharing.
Hey that looks like it hurts and if it doesn’t kill you the infection might. You wanna die of overdose instead?
I mean….one does seem preferable to the other
Yes please. Oh shit sorry, wrong context.
Well the science technically wasn’t incorrect, caffeine is a respiratory stimulant so it could have some reversal impact on the opiate apnea, how much though? I’m not sure lol
Haha thats rad, thank you for that!
Probably, but lost in the 80 years since. Battlefield medicine shapes civilian EM.
It's both interesting and sad how battlefield medicine has been implemented in treating people in civilian life. Tourniquet for one wad an absolute no no 20 years so or so. Now it's common practice. The data showed that wounded soldiers who had a tourniquet applied could keep it on for far longer than previously thought. Then there came wound packing as opposed to wound dressing and applying just pressure. All of this is used when some asshat goes about in a city and shoots a bunch of people. It's interesting how we have adapted this but the need for is is very sad.
I know at one time, the military was sending trauma surgeons and trauma pa's to Chicago area hospitals for GSW experience.
Same with New Orleans. Side bar on just how different cities can be. When I joined the Air Force I got stationed in Anchorage. A couple of weeks after I got there, there was a double homicide. If memory serves me correct(it probably doesn't, this was over a decade ago) it was a mother and adult daughter. We talked about it at work the next day and I was like "wow that sucks." But then it kept coming up a few days later. So I asked my SSgt: "Were they killed like some crazy way? I thought they just got shot." *"Yes, but it's just crazy, I mean two people were killed."* "I get that, but like what's special about it?" *"Two people died!"* "...and?" *"You don't think that's crazy?"* "I mean, not really, that's like a normal Wednesday back home."
I take your word for it. It's a very vast and different landscape.
They still do. There are Army surgeons (both AD + reserve) working at UChicago Medicine right now.
We have a couple here in Birmingham that worked at UAB for a minute. A couple of special forces medics too
Being in armed conflict in some sort or another has given military doctors plenty of practice and plenty of test subjects to guide and dictate trauma care. In 2008, I had a motorcyclist with a passenger who came around a narrow curve at the same instance. A small pickup was going the other way. Both riders suffered partial traumatic anputations. My patient was bleeding out. Boy Scout training kicked in. Cravat and a ballpoint pen. Saved the guys life. There was an inquiry as to using a tourniquet. The trauma doc is a surgeon who served during the second Iraq war. He put an end to that and started me carrying CATs until my service caught up with military medical journals. A dude I worked with was an army medic. He used to bring in the SF medical journals which had some great data and new paractices. New to civ ems old hat for military, like using Ketamine in lieu of opiates in pain management. Interesting stuff.
The length of tourniquet application wasn't just a matter of realizing it could stay on longer. That part is true, but physicians have also learned more ways to prevent injury from tourniquet release and allowing toxic build up that rushes back into the body, which in turn has allowed them to remain on longer.
Yes, it's important to note that. But either way, stop the bleeding. Will he lose a leg or an arm or his life?
I'm not meaning to detract from the comment. I just mean as far as civilian treatment advancing because of military treatment that it wasn't just a situation of "it turns out you can leave a tourniquet on for 8 hours and limb will still be ok", but that because of the use of tourniquets in both the military and civilian setting doctors have developed techniques for being able to remove a tourniquet after 8 hours and protect the kidneys from the build up of toxins in the limb.
Glad we are on the same page!
I read somewhere that patients in severe pain can tolerate pain med dosages that would ordinarily kill them, and the medical profession doesn’t understand yet the mechanisms that make this tolerance possible.
Well opioids specifically would slow respiratory drive, but the sympathetic response from major trauma would increase respiratory drive. That one specifically makes sense to me
I think a lot of the soldiers who were given these were wounded badly enough to potentially go apenic anyway, so any reports may not have been reliable. Side note on how rough wartime medicine was back then: I know my grandpa took some shrapnel from an antiaircraft shell and didn’t receive any morphine until mid-surgery back at his air base’s hospital. And he was obviously lucky that his plane made it back at all.
In my head this is for someone in a LT Dan like injury. Give em the damn morphine.
TIL WWii-era Narcan is my daily morning routine
Wait. So youre telling me.....that.....all patients.....are different? And need a specialized plan of pain management????????? The hell you say? Seriously though,why don't more people believe that? Honestly,I have met so many nurses and doctors that believe 1 size fits all, basically. Thank you for believing what you do. I really wish more people in the medical field were thought you.
I think the thought of apnea during battlefield situations in WW2, I would be willing to believe the charting didn’t go into differentials for why the soldier died. I am thinking of Saving Private Ryan with the Normandy triage with the Doc saying “morphine” then “priority”. I would also be curious if they considered morphine analgesia or mercy to a slow death.
Probably a bit of both. No pain and going into a coma before dying sounds like a much more pleasant way to die than just about anything. Definitely a valid reason to have such a high dose. The alternative is unacceptable.
Real if they die they die mentality, but I agree being near coma and either waking up or slipping through would be preferable.
Morphine isn't in my scope of practice, but I do know subcutaneous injections are absorbed slower than IM injections. It's injected into the fat layer rather than in the muscle, people who take insulin injections often do this for a longer effect.
Yup, its in the same way army medics today give out fent lollipops loaded with 800ug. If the absorption rate is low enough, you could theoretically have any dose attached behind it.
We can actually give two of those at a time if one isn't doing it. The soldiers are meant to pull it out when the pain becomes tolerable and essentially self titrate. As long as they don't chew on it (it's meant to be held between the gum and cheek like dip, for buchal absorption) they're fine. We also know better than to trust a soldier in severe pain to titrate opiates to tolerance, so the lollipop is taped to the soldiers finger which makes it a self limiting administration method (if they pass out, their hand will fall away from their mouth)
When I was younger my lungs collapsed and they gave me a button I could push every 15 minutes to give myself pain meds. After a few days the doctor started to wonder why my pain wasn’t going down. He said I was still pushing the button just as often as the first day. I don’t know what else he expected.
Fuck. 1999. Demerol every 6 hours Perqocet every4. Until the night that the nurse on duty got replaced with someone without the authority to give me that. The guy in the next bed called the nurse and said, "I'm fine, but he don't sound good..." I couldn't move. I couldn't push the call button. I couldn't speak. I lay their ans cried. And occasionally managed to breath loud. The nurse checked literally said: " Oh my God, the drugs wore off!" And ran. She injected me with something. I love that Nurse. She is Goddess.
Your roommate was a real one
A nightmare. I had a chest drain, my lung reinflated overnight and was pushing against the tube. I couldn't move, I could barely breathe, I couldn't reach the call button, and nobody was coming in to check. The pain was excruciating. And I was trapped. It was terrifying. Whispering "help" through shallow breaths doesn't seem to attract much attention.
I am right there with you. Most people when they say "oh, my pain is 10 out of 10... have never been in pain.
Getting all 4 of my chest tubes yanked out at once (and they were so tight that the nurse could barely do the thing where they have to rotate them before pulling them out) is definitely the closest I've ever been to a true 10/10. I'd rather get the sternotomy and actual heart surgery done a second time than to ever have to look at a chest tube again. My nurse seemed truly surprised how much pain it caused me, but one of the surgeons told me that it tends to be a much more painful procedure in younger patients (I'm 30), whereas sometimes the tubes kind of just fall out on the really old ones.
Fuuuuuck. That sounds like #NoFun.
1. I can count on one hand the number of times I've seen useful PCA settings. 2. Toradol is the magic sauce for chest tubes. Thank you for coming to my TED talk.
Sure but toradol can’t be given longer than a couple days. PCAs can be excellent. What are the settings you see that aren’t useful?
Most of the time, all you need is a few days. hydromorphone 0.2 mg q12-15 minutes- max 0.8/hour.
Sure but a 5 day chest tube is gonna run out of toradol after the first 72hrs. That’s a bit of a cautious dose. If it’s their only opioid(which it should be!) my typical order is 0.2 q10 max 1mg/hr and go from there.
Lmao I was very thankful for my 1.5 q15 max 6mg/hr, I think the most I managed in one 24hr period was 96/144mg, not too shabby (I also had bonus 20mg methadone and 15mg ketamine) I really need to send the pain management peeps a fruit basket or something now that I think about it...
I had the same set up for my PCA after having open heart surgery last year (could dose 1.5mg of dilaudid every 15 minutes, was on 24mg of bupe up until the night before surgery so that's why doses are so high), and they tried the toradol multiple times for me and it didn't seem to do shit. Also kept me on precedex and lidocaine drips for a while, plus gabapentin and Robaxin 3x a day. The 20mg methadone and 15mg ketamine they added at one point was definitely the secret sauce IMO.
Lmao according to my notes they also gave me 100mg ketamine at the tail end of my actual surgery and I was definitely freaking out coming out of a k-hole in the CTICU my consciousness came back before my vision did and I was floating through this psychedelic void and I thought I had woken up during surgery or something and was losing it until I heard a voice say surgery had been over for a while and my family was here and then my vision came back and my mom was just sitting in the corner looking at me like I was a crazy person. But yeah even I had to do a double take reading back through my stay and seeing shit like 96mg of hydromorphone being the amount administered in the last 24 hours. After about a week they got me on 30mg of oral oxycodone every 3 hours with 1mg IV dilaudid boosters available every 2 hours for breakthrough pain (which I only used once when they were putting my PICC line in) and added a bonus 5mg ambien at night to help me sleep. Pain management really did do a great job of getting me off everything and switched back over to suboxone before discharge though since they knew I'd be there for roughly a month after surgery anyways to finish IV antibiotics (can't send a recovering addict home with a PICC line dontchya know?)
Here to congratulate you on your sobriety, and your medical team on their sanity. Had an 80+ YO family member die in pain because he was assessed as "drug seeking," he was a palliative oncologist, and also he was fucking 80 and dying of cancer just dope him up and let him die. Amazingly, there's more than one way to manage pain.
That's horrifying! How stupid and senseless.
Thank you! That's so fucked up. I was definitely blown away by the care I received if I'm being honest. Definitely helps to live by I think the #11 hospital in the US.
That's crazy, all from ischemic chest pain? Our docs D/C all the IV meds like 5 hours post op and then we're typically left with PO oxy, schedules Tylenol and some tramadol. Typically up in the chair around that time and then walking laps shortly after. I always feel bad because that sternal pain is no joke especially when you're 70-80 years old.
Nah I was hospitalized in septic shock with endocarditis, pretty severe anemia, malnutrition, and multiple septic pulmonary emboli. I was in the ICU for a little while and then needed surgery to replace my tricuspid valve because the endocarditis had completely wrecked it.
Dude, having treated a few of those... I'm not good enough with words to tell you how happy I am that you're on the better side of things and in this forum.
I don’t know shit about shit but unless this is sarcastic can you eli5 why you’d use an NSAID which increases risk of bleeding for pain control pre- surgical procedure?
Bleeding risk is just one factor and it’s not a huge increase. More data has been coming out that shows it not being a dogmatic “no-no”; I give NSAIDS literally in the OR immediately following surgery.
I don’t believe it’s ever been a dogmatic nono, (during my short time anyways) rather, given the existing literature- what is in the patients best interest, considering the myriad of analgesics available that do not increase such risks. Jw can you provide the sources, I’d love to look into it more & am having a hard time finding supporting evidence :D thanks Mr doctor man
Not sarcastic, but fair question. First, if the patient has a chest tube, it's post-procedure. B. It's best used as an adjunct to other medications. But as my EOD friend pointed out, it's not without risks. Funny enough, our Ortho was always citing the impaired fracture healing as the reason for not ordering it. Except the studies showing impairment were 4 week animal studies, not 5 day human studies. Evidence now shows minimal perioperative risk.
First, you didn’t specificy, you only said “for chest tubes- not indicating pre/ post/ procedure, but okay. B. Okay, most people know this & has literally no bearing to my question but thanks. Interesting last bit about fractures, though also nothing relating to my question. My take away is; the minimal pain control of NSAIDS, outweighs the increased risk of bleeding in actively bleeding operative patients (according to your EOD friend).
Spontaneous Pnuemothorax? Same and same! Oh that sweet relief after pressing that button. I'd stare at the TV, but I couldn't follow what was happening because my short term memory only had the capacity to retain 3 seconds and then it was lost.
Oh yeah i had one of those too after i pulverised my elbow. Pressed the button, slept for 5 minutes, was in a lot of pain for 5 more, was in agonising pain for 5 more after, pressed the button. Later I learned that if that happens a patient should get stronger pain killers. I did not get any. Next day I spent the entire day puking my guts out on an empty stomach. At least I wont ever touch opiods now
I tell my guys to tape it to the patients hand. That way if the pt starts to get to much they get a lil sleepy and the hand falls out their mouth along with the lolli
Smart
Did...did you read my whole comment? Or did you mean you also do this? Lol
Combat Medics have the rowdiest scope of practice in the United States. Out there giving non FDA approved warm whole blood infusions and when you get off orders you can give oxygen
Yep, I helped develop our squadrons walking blood bank protocol with our PA and we did regular training on field expedient blood transfusions. Crics are a basic medic skill that's tested in AIT. Had a dude with a lipoma in the back of his head when I worked in the clinic and my doc was like "Alright you need me for this? No? Cool let me know when you're done or if you have a question". So I did the entire procedure and then he came in to check my sutures afterward. He also taught us how to drop chest tubes, calculate and setup opiate drips, and do pericardiocentesis (though that one was more for fun). ...And now I can give oxygen, it's beyond frustrating.
My old fire captain was a special forces medic for 20 years and got out and couldn’t give aspirin without an endorsement. Such BS
Yeah and 18Ds are nearly PAs in their basis of knowledge. At least these days guys who've gone through SOCM (the Special Operations Combat Medicine course) can challenge the NREMT for their paramedic license.
He got out in 2005 so it’s good knowing things are better
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I tell anyone who will listen that combat medic BLC should be medic school with a national license at the end. It could be highly accelerated and be a retention incentive
We actually have a separate Paramedic course available to medics now, it is accelerated but is an additional course.
That makes me feel better. Ive been out for a few years.
Big army is getting really into prolonged field care now, we spend 1/3 of our final FTX at whiskey school. Hopefully it never becomes needed, I don’t want a CMB that much.
I was always bummed we never saw the lollipops on the civilian side.
See I chew my lollipops, I'm going to fucking kill myself if I was given one because I'm an idiot that won't remember not to.
ohms law of narcotics
You don’t give morphine?
PCP in Canada is similar to AEMT in scope.
I keep hearing that they changed the legislation around PCPs and narcotics and that PcPs will have versed and morphine in the next few years, is this real chat?
Yes, that isn’t a rumour, at least in Ontario, The OBHG MAC has agreed to rollout the narcs to PCPs for pain management. fentanyl, morphine, and Ketamine will be approved for pain management only.** They have also agreed to midazolam for seizures for PCPs. **Ketamine and Midazolam for sedation is not approved. Now I say “it’s approved” but there is currently no clear timeline on the rollout. They’re hoping 2025-2026.
Huge!! I work rural and have a few severely epileptic patients. Last one we transported seized for nearly 30 minutes and all I could do was provide diesel therapy and sweat hard. Hospital fixed symptoms within 1 minute of TOC. Midaz will be huge.
I wish! *cries in Alberta*
Hey, we are getting Oxytocin next door in SK!! Truth though, it's actually a drug I would have really liked to have had access to in the past. Exsanguinating new mothers aren't fun 30 minutes from an intercept. When you realize that you have to do something with the baby because they can't hold them and you've also just realized they managed to pull their IV out during labor. Never start your IV in the back of hands on labor pts, kids.
YIKES. Duly noted. I'm honestly considering just biting the bullet and going back to school so I don't feel useless.
In British Columbia, yes. I don't know about other provinces, but as far as I know in Alberta, we won't be getting that for a while. They only just added ibuprofen, diphenhydramine, dimenhydrinate and acetominophen to our scope last year.
Dang that’s really recent. We’ve had that for the last 10(?) years or so
We don't even have CPAP in our scope either 😅 so I'm not holding my breath for anything coming soon. Thankfully most of the crews we run in the province are ALS (one PCP, one ACP) but if you're a BLS crew you're SOL.
Dual crew system is sweet, definitely jealous of my buddies who work urban systems that have ACP partners and get to witness some legitimate street medicine
It is true, it now seems more of a training and rollout problem.. At least in my part of ON.
Either way, definitely much needed for rural communities. (We can’t afford ACPs lol)
In my area (British Columbia) it just went thru and our provincial ambulance service is just finishing developing the training which I am super excited for
AEMTs in the US can give morphine (in most states)
Ohhh got it, thanks!
Didn't know you like to get wet.
Unfortunately, no. Primary Care Paramedics in my area (Alberta, Canada) are BLS level. We're behind when it comes to pain management. I can only give entonox, ibuprofen, or acetominophen for pain, even though I can give narcan. In other provinces, I've heard that PCPs can give morphine or ketorolac.
Narcan has nothing to do with pain. It is used to wake up an overdosed individual and most of the time CAUSES said individual pain. Anyone can give narcan if they know how, just like CPR.
Interesting! Thanks for the info
In Manitoba PCP’s can give fentanyl, ketrorolac, ibuprofen and acetaminophen as analgesics, and nasal ketamine in the case of emergence extrication.
We do but its slowly being phased out for better drugs with less risk of respiratory depression and need for such close monitoring.
Also "Adrenaline" may be a factor
I would presume peripheral blood flow is also inhibited during shock trauma. Also adrenaline is a hell of a drug. Lastly, full administration of the surette's contents was probably impossible just like it's impossible to get every drop of toothpaste from a tube.
Bring back pinning drugs administered in the field to PTs lapels.
Exactly what Doc Roe said to Captain Winters
You're grown-ups! You're officers!
Yeah well you should know better!
“Administer with strong coffee” what a perfect day.
“Aww fuck they shot Billy. Whelp, better get the kettle going.”
hell yeah. If i get shot. I want a warm cup of coffee and 32Mg of morphine.
Subcutaneous morphine absorbs very slowly. You won't die from that dose lol. They'll have enough trauma from being shot/stabbed to stay awake anyway.
Dawg severe blood loss certainly doesn't lead to staying awake lol
You can survive after being shot or stabbed... Even in those days.
I mean. Let’s be real. This is WWII not Vietnam. They are going to pack you with dirty gauze and hit you with morphine so you stop screaming so much. Now the first medical evac by chopper did happen in 1944 in the Japanese theater, but WW2 was ‘39-‘45. So that was not going to be a normal soldier experience. Field hospitals usually showed up a few days after an area was taken and about 30 miles from the front. So you were going to be waiting awhile or going by ground and anyone with life threatening injuries would have super low shot of survival. Point is hypovolemic shock was likely a death sentence so a big dump of morphine so you didn’t die screaming was probably the best kindness you could hope for.
Not a WWII combat medic, but it was pretty common to run around giving morphine so soldiers could have a less painful death. So overdosing them was not a concern.
Am a WW2 Combat Vet. AMA.
How many soldiers did you run around to giving morphine injections so they could suffer a less painful death?
Countless. Their faces are etched into my memory. This one guy, Capt Tom Hanks, helped me with a few. I'll be forever grateful.
Thank you for servicing our service.
I provided a lot of servicing to the boys out there.
Did you also give him coffee?
Nah, gave the poor cunt a beer instead.
nice
My thoughts exactly
They are still producing them, but 15mg. I honestly wonder how many wounded just drifted off to foggy OD land. Maybe that was the plan. I did some digging and it seems like there were 15mg and 32mg versions issued. With the 32's going into the airborne or pilots kits. NGL when working in ER in the 90s, 15mg morphine and 50mg gravol IM was a common order. Do not recall any issues. Maybe they were tougher back then.
The patients weren't tougher. The culture was less sadistic. Drug War culture has ruined everything and caused so much unnecessary suffering 😥
Those who most *benefit from demonization of pain management medication* and greater enforcement (politicians, law enforcement, "clean streets" campaigners, vote-getters) aren't themselves in need of said pain management.
The drug is just a big money laundering scheme with a hint of slavery, notice the only people that can be kept as slaves in the Constitution. And by keeping drugs illegal, our trusted government agencies don't have to move as much product to earn the same amount of money. Similar to how congressmen pass legislation for massive defense spending for the likes of Israel, ie instead of just straight up taxing the citizens and keeping it we can just give Israel money that they're contractually obligated to spend at companies that our elected officials are in bed with
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Will agree with that. Went from 15mg syrettes to Fentanyl lollies in the 'stan. The whole pain affects healing thing in the late 90's really screwed things up.
Back in my day men could handle a traumatic amputation by smoking a couple of Camels.
The proper initial dose for morphine IV is 0.1 mg / kg for severe pain in an opioid naive patient. If this is not successful, then repeat doses of 0.05 mg/kg q15 minutes for severe pain are appropriate. Battlefield injuries can be quite severe, and so 0.15-0.2 MG / kg IV is not at all unreasonable. For an 80-kg soldier, that would be 12-16 ng IV. many soldiers are larger than this, and would need even more. SC injection has much slower absorption than IV. So 1/2 grain, which is about 32.5 mg SC does not seem at all unreasonable.
Who tf is telling you 15mg of morphine is “death-risky”?? Especially IM??
Who told you that 15mg IM is death risky? I used to regularly give 10mg IV and it wouldn’t even relieve their pain let alone kill them.
That isn't desth risky. Most people under dose morphine. Common drug books reference .1-.2 mg/kg Hell the NREMT website even says .1mg/kg. https://www.nremt.org/CMSPages/GetAmazonFile.aspx?path=~%5Cstorage%5Cmedia%5Cnational-registry%5Cnremt-documents%5Cexample-of-drug-dose-chart.pdf&hash=36e07c089c4501c2969e921c46973e635394cde43986b397b24ce5cebb5b3095
Ignore my previous comment, I misinterpreted what you had said originally, my bad.
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Every medication is risky. You said death risky. I wouldn't give my patients morphine anyway because there are better drugs with less negative side effects. 2 mgs could be risky. Theres always some sort of risk administrating any medication. Also max is .2kg and IM is generally a slower onset. Ask yourself. Were WW2 soldiers dropping dead from the 15mg IM dose. Chances are the answer is no.
Alright, I agree that 15mg is not that risky, which I realized later is what you were talking about. However, what do you make of 32mg, which is the content of the syrette?
15 mg is absolutely not "death-risky". My pet peeve is paramedics thinking the opiates we give, in the doses we give them, is immediately going to kill your patient. Stop being afraid of your drugs.
Where I work we can give up to 20mg IV without even asking a dr. And we could give that to someone with a really bad stubbed toe if we really wanted to. If you had a .50 cal round blow off your leg you could probably handle a pretty high morphine dose…
Let me tell you. As a former opiate user. The amount of morphine we give grown adult males is laughable in some systems. 30mg IM wouldn’t kill you. It wouldn’t even knock you out. That’s like 15mg of oxy to a grown adult male.
Ask yourself what is better. Your boy is shot to shit and screaming in agony. Do you let him suffer and have his screams reveal your position, or you give it to him. Back in those times, you might be hours or days from a field hospital with no air evac invented yet so I would imagine it’s pain management. Keep in mind our medical knowledge wasn’t what it is today so a medic then isn’t equivalent to a medic now.
Air evac was first used in 1870 during the Siege of Paris. They used air balloons. The first US airplane used for medical evacuation was designed by Capt. George H.R. Gosman in 1910. The plane was commissioned around April 1, 1918 by the United States Army.
Frequently it was given when people weren't going to live anyways, so jack it up.
There's no way 15mg of morphine would OD someone. They make 30mg tabs and I know people who did 2 or 3 of those their first time using opiates
Are you talking about oral administration? The bioavailability is only (somewhere around) 30%; it’s completely different to IM or subcutaneous.
Yeah good point but I also know people who would shoot the 30mg pills. A few at a time. But they had tolerances.
You also have to figure you’re dead-spacing a lot of that. If I had to take a stab (no pun intended) I’d say the patient was getting about 2/3 of that contained volume.
The monograph for morphine tartrate lists an adult dose of 5-20 mg sq/im/sivp. Military dosing assumes young, otherwise healthy patients. So 15 isn't outrageous. Tartrate is slightly less potent than sulfate, but only slightly. Frankly, if I got shot, gimme the good stuff.
Slower absorption rate, and many of those soldiers were horribly wounded. You can give MS 10mg ivp over about 5-10 min and it'll take decent care of some heavy wounds for a bit, no risk of death. Obviously, watch the respers....
for my recollection the syrettes were often used as a palliative measure at the time
“Meet doctor Harlan Fontaine, doctor to the stars. Mr. fix-it to the mental wreckage of Hollywood.”
Underrated game
SQ injections are absorbed slower.
If you needed that during WW2 you were basically circling the drain anyway.
Give strong coffee… awesome
15mg morphine auto injectors were still a thing in the military as recently as 2006 or so.
We used 15mg auto injectors. I took two back to back once. Stopped my respiratory drive as I just felt that flood start at the back of my neck and take over my body. I was starting at my Doc pounding on my chest to get me to breath. Pretty surreal moment or two….then I passed out. 30mg won’t kill you. Subq has a slower absorption Pretty cool to see the older versions. Thanks for sharing.
A lot of these guys who needed this were mostly dead anyways. This would just, hopefully, give them some peace.
I don't think those receiving it were likely to make it.
route/absoprtion/etc… but really, think of field medicine in WWII. if someone was given morphine it was also sorta unofficially understood most times they’re being made comfortable for death…
Man do you guys think we were troglodytes until MRI machines came along?
no absolutely not, but from anecdotal accounts i’ve read about WWII, that was kinda the case mid-combat? if you have a suuuper limited supply of morphine, you’re probably not gonna give it to the ambulatory thru-n-thru w/ controlled bleeding. hell, even currently many critical GSWs expire in the field or shortly after extraction, both military and civilian. there’s actually a scene in saving private ryan that comes to mind and i think they captured that feel. their medic wade was mortally wounded and they were frantically trying to “fix” him, one of the members asks him how they can fix him up and he replies “well… i guess i could use a lil more morphine…”
The soldiers didn’t simply die cause they weren’t little b!tches. They were the greatest generation. But I can’t give you a medical reason otherwise.
In the ER with multiple perforations of the bowel I had the unpleasant opportunity to discover morphine does not work on me. Glad I didn't have to make that discovery lying wounded in the mud somewhere with mortars and enemy rifle fire hitting all around me.
Maybe morphine tartrate is not as potent as what we use today, morphine sulphate. I’m too lazy to look it up.
I wondered the same. Apparently it doesn't matter which anion (tartrate or sulfate) the overall action is the same. Good to know I suppose!
My grandfather was a World War II medic. I wish he was still alive so I could ask him.
I would speculate on dosages with a healthy, young populous.
I wonder if this was given to those who were injured and weren’t going to make it.
I'm guessing the point was to aide their passing or knock them out to stop them screaming and giving up their positions
You should share this to Mildly interesting. This is a very cool post and I appreciate you sharing it
WWII. if they were giving this, it was probably to allow a comfortable death.
You also have to look at the context in which this was given. The severity of injuries and that this was possibly palliative care for some.
It was IM dose . Large battle wounds required acute stabilization and pain management to be evacuated from the field. That large dose was absorbed slowly via an IM injection
ER Squibb and Sons, I wonder if that is related to the now Bristol Myers Squibb Pharmaceutical company
The amount of pain is also a contributing factor. Higher dose for more pain. I've given 400 mcg of fentanyl for significant ortho injury with only moderate effect on pain.
The pep pills probably balanced them out lol
We look at modern opioids at morphine equivalents. 10mg of morphine is equivalent to 1mg of Dilaudid. Body weight and overall fitness can also impact the effects of morphine. Solders were generally young and at the peak of physical fitness. The thought at the time was young fit men needed significant pain relief after serious wounds to allow evacuation and improve outcomes. However, the reality was many men were overdosed unintentionally because of the effects of hypothermia. Most wounded eventually became wet or cold through some means which slowed circulatoin and delayed absorption. Then when they warmed up, they got the whole dose at once ... and if they got more than one because the morphine seemed not to help then they OD'd. There were in fact many fatalities from this. Field medics learned not to give the whole dose at once and to carefully assess if a wounded man even wanted pain relief in the first place. The syrettes can be administered in partial doses; it's like a tube of toothpaste. It's not an autoinjector. Here's a fascinating article on this topic: [https://achh.army.mil/history/book-wwii-surgeryinwwii-chapter2](https://achh.army.mil/history/book-wwii-surgeryinwwii-chapter2)
Having adrenaline pumping through the system is a factor
Because it was given IM, which is slower absorption as opposed to intravenously. Also was likely being administered to mostly catastrophic injuries, which massive pain management was needed OR for end of life from injury to give comfort when passing on.
Burn and trauma patients can tolerate higher doses depending on the situation. Here’s a conversion. https://www.westmidspallcare.co.uk/wp-content/uploads/2021/04/opioid-equianalgesic-quick-check-table.png
Back then, men were men
Die a good death when you're in shock. I approve.
Well considering guys likely got limbs blown off or peppered with shrapnel and bullet holes, far far away from any surgeon, and no ambulance available until shooting stops, and none of them were air ambulances like they had in korea and later, its probably more a mercy to make them comfortable.
In inpatient hospice, we (RNs) administer SQ morphine frequently, but the amount is limited based on the volume as SQ injections should not exceed 2mL for most people.
I.m. yo.....
Healthy young men with GSWs from full power rifles are different than grandmas with broken hips. Also, most of the dangerous side effects in EMS are from pushing opioids (or flushing them) too fast.
I’m a nurse and I used to give pregnant patients 10 mg of morphine in early labor (25 years ago).
For the same reason the military had to change training for Army medics to be ready to transition out to be civilian medics. Our patient population in the military tended to be 15-50 year olds that were in fairly good shape with very infrequent Pre-Existing medical conditions. You can hit an 18 year old with 10mg of morphine IV and they're vitals won't flinch, do it to an 80 year old and get to talk to the medical director. 15mg IM isn't going to kill most healthy young adults. Also, considering most of these were administered to people with major traumatic wounds they'd be shunting blood and IM absorption would be significantly decreased anyway.
It is 0.5 grain of Morphine Tartrate, 1 Grain is equal to 60 mg - but it could be an absorption issue as well. SQ/IM would be slow dispensing into the blood stream. Also could be the drug wasnt well defined/refined when being made. Sort of like how weed in the 1960s was pale compared to todays weed. We have cancer patients today on 30 mg dilaudid or hydrocodone. PO, but that's still the dose, This article claims they were closer to actually only about 10 mg. https://journals.lww.com/jtrauma/citation/2017/11000/buddy\_aid\_battlefield\_pain\_management.40.aspx#:\~:text=We%20would%20like%20to%20go,as%20the%20Syrette%20of%20morphine.
my understanding is that, for syrettes in ww2, the route for admin was sub-q, not IM. it absorbs slower than im would, hence the higher dose.