# IM Morphine



## Shishkabob (May 30, 2010)

So we have IM Morphine in our protocols for pain management.  I'm still trying to find a time when I would do IM Morphine as opposed to IV.


When would you do IM Morphine (keep in mind I do primarily IFT)



One such case that I debated it was the other day.  I was returning a patient back to her NH after she was checked out at the ER for a fall 2 hours earlier.  She had a deformity of 2" of her right leg near her hip.  IV was DCed at hospital.  Pain of 6/10 resting, 10/10 movement.

Would IM Morphine have been an idea?  I opted against it was we werent going to a hospital, but to a NH where she probably wouldnt have been checked on often and where they didn't have Narcan just in case.


I guess I'll talk to one of my supervisors on Monday about its usage.


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## usafmedic45 (May 30, 2010)

> I'm still trying to find a time when I would do IM Morphine as opposed to IV.



WWII combat medicine reenacting?


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## redcrossemt (May 30, 2010)

When you couldn't obtain IV access???


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## 8jimi8 (May 30, 2010)

i wouldn't give it im without a iv access.  Too much to go wrong with interventions being delayed by no iv access


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## got_shoes (May 30, 2010)

I would say it would be used in IFT hospice pt's for comfort care, MCI's where you don't have time to start a IV line. or in pt's are quads, most of the time they don't have good IV access, or in Pt's who are amputees. only a things i can think of.


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## redcrossemt (May 30, 2010)

8jimi8 said:


> i wouldn't give it im without a iv access.  Too much to go wrong with interventions being delayed by no iv access



I would prefer not to; the truth is, however, that we can't obtain IV access in every patient who deserves pain relief. Our standing orders state to attempt 3 PIVs and if we still are unsuccessful to go to IM.

What complications are you worried about? Respiratory depression? Hypotension? You can always give nalaxone IM as well...

That being said, I am lucky to have fentanyl which I regard as a little safer than morphine in so far as it is shorter acting and has less histamine response. I've heard it also hurts less IM. Not sure why we don't have IN yet, but I hope it's coming soon.


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## medicRob (May 30, 2010)

\
For the purposes of EMS and Emergency Medicine in general, IV administration of morphine is ideal in that it has quick onset and is a more reliable route of administration. However, there are some advantages to the intramuscular administration of morphine in that the slower absorption lessens the risks of respiratory depression, nausea, and other bad ju ju. Moreover, IM does have its advantages in the hospital setting in that the medication has a longer duration and is required to be administered less frequently (q 3-4h). 

 In most situations in EMS, the patient requiring morphine will be in such condition that immediate onset of the medication is required. Also, if I am giving my patient morphine in the first place, I am going to want an established IV just in case of the "What ifs". It all depends on situation.


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## Level1pedstech (May 30, 2010)

You might try the emergency nursing forum over at all nurses.com. They are very helpful over there and Im sure you would get a solid answer to your question. Just a suggestion.


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## the_negro_puppy (Jun 2, 2010)

I think the obvious answer is you give IM when IV access cannot be easily obtained.

In my experience, I have given IM to an 8 year old with a distal humerous fracture that was yelling with the pain, but was not cooperative with methoxyflurane, and would not hold still or allow partner to attempt IV access.

Other case was an obese man with severe lower back pain, writihing in pain, poor lighting in house and had really poor veins. Gave him IM as well.


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## MrBrown (Jun 2, 2010)

the_negro_puppy said:


> I think the obvious answer is you give IM when IV access cannot be easily obtained.



I think you are right mate, we can give it IM if we do not have IV access; not that I have done it but still

When fentanyl replaces morf here I immagine we will get it via IN as well


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## Melclin (Jun 2, 2010)

Surely the bigger question is why your lady was being discharged from hospital with 6-10 pain scores minus any plan for pain relief. 

What was the issue with her hip?

Poor pain management really annoys me.

EDIT: just to add a bit more we have an option for IM Morphine, 10mg with the option for a 15 minute follow up dose of 5 mg for people >60kg. <60kg including kids get 0.1mg/kg with consult with a more experienced paramedic for a follow up dose. I've never seen it used seeing as though we also carry an inhalant analgesic and IN fentanyl.


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## Veneficus (Jun 2, 2010)

In the hospital we sometimes DC patients and gie them an IM morphine w/ epi injection.

The epi slows the absorbtion making the morphine last longer to achieve "breakthrough" of pain, followed up by pain control with oral NSAIDS. (usually ibuprofin) 

In an IFT setting it could help the morphine last long enough for a doc to come and see the pt. the next day and decide how to further control pain.

In poor populations it also removes the need to have them fill a PO script for 1 or 2 pills.


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## Melclin (Jun 3, 2010)

Veneficus said:


> In the hospital we sometimes DC patients and gie them an IM morphine w/ epi injection.
> 
> The epi slows the absorbtion making the morphine last longer to achieve "breakthrough" of pain, followed up by pain control with oral NSAIDS. (usually ibuprofin)
> 
> ...



Interesting...how much of each?


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## got_shoes (Jun 4, 2010)

Vene, how much epi? and wouldn't the concentration be different then what most EMS units carry? like 1:20,000? or have I misunderstood? how does epi slow the reaction? I was thinking that epi would speed up absorption. feeling a bit ignorant on this subject and I can't seem to find anything about this.


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## Veneficus (Jun 4, 2010)

Melclin said:


> Interesting...how much of each?



The epi we usually use is 1:100,000 in H2O. The amount based on how long of a relative delay. Most common I have seen is 1ml of 1:100,000 +4-10 mg morphine, IM for non postoperative pain control.

I am aware that 1:50,000 and 1:200,000 epi concentrations can be used but I have not seen it personally.

Followed up with the common 2400-3200 mg ibuprofin/24 hours. (in other words 800mg 3 or 4 times in 24 hours) 

Epi acts as a local vasoconstrictor which delays the absorbtion of the morphine, similar to lidocaine with Epi. 

a good article on outpatient coctail post op.
http://www.medscape.com/viewarticle/500446

As an aside, 1:100,000 epi soaked dressings work really well for bleeding control, but standard disclaimer applies, don't act on your own, get permission from med control or have it written in to scope of practice.


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## 1badassEMT-I (Jun 21, 2010)

We got fentanyl and morephine and I am not pushing niether without IV access there is to much to go wrong for sure!


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## Veneficus (Jun 21, 2010)

1badassEMT-I said:


> We got fentanyl and morephine and I am not pushing niether without IV access there is to much to go wrong for sure!



???

No offense, but this looks like trolling to me.


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## 1badassEMT-I (Jun 22, 2010)

Veneficus said:


> ???
> 
> No offense, but this looks like trolling to me.



What do you mean TROLLING! because I voice a opinion on what I would or would not do....is TROLLING......GET REAL!


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## MrBrown (Jun 22, 2010)

Can you give IN fentanyl?


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## JPINFV (Jun 22, 2010)

Everyone once in a while I see the docs over on the EM forum at SDN discussing fentanyl lollipops. Does anyone know if any EMS systems use them?


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## 1badassEMT-I (Jun 22, 2010)

MrBrown said:


> Can you give IN fentanyl?



I can!


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## 1badassEMT-I (Jun 22, 2010)

JPINFV said:


> Everyone once in a while I see the docs over on the EM forum at SDN discussing fentanyl lollipops. Does anyone know if any EMS systems use them?



I have heard of this but I have never heard used in EMS.


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## usafmedic45 (Jun 22, 2010)

> I can!



Who is your medical director? I would like to verify this with him.


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## Aidey (Jun 22, 2010)

Veneficus said:


> Epi acts as a local vasoconstrictor which delays the absorbtion of the morphine, similar to *lidocaine with Epi*.



Interesting. I was told that epi was put in the lidocaine (or whatever caine) used for local anesthesia because it caused vasoconstriction and reduced the bleeding. I suppose it works for both. 


I've seen hospice patients /c a sub-q line for their morphine PCA. We don't have morphine, we have fent, but in either case I can think of a couple of situations where I may use it IM. Hospice, as mentioned above, and also if you are unable to obtain IV access. 

I've also used fentanyl IM and IV at the same time for long longer lasting pain control. I think initially we gave 25mcg IV and 50mcg IM, the guy was pretty big with a badly broken/dislocated hip and it was a 45 minute transport.


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## 1badassEMT-I (Jun 22, 2010)

usafmedic45 said:


> Who is your medical director? I would like to verify this with him.



See you are just trying to set me off......well not going to happen!

EMSA-Intermediate
Treatment Protocol
5202
Chest Pain/Discomfort
Acute Coronary Syndrome (ACS)
Page 2 of 3
West Virginia Office of Emergency Medical Services - State EMSA-I Protocols
5202 Chest Pain.doc Final 7/28/2006 Revised 4/17/09; 9/11/09
F. If blood pressure < 90 systolic and/or patient is experiencing severe
bradycardia or tachycardia, treat according to appropriate protocol.
Further treatment per MCP orders. If patient has taken sildenafil
(Viagra) or vardenafil (Levitra) within last 24 hours, or tadalafil (Cialis)
within the last 48 hours, nitroglycerin should only be given by MCP
order.
G. Transport.
H. Contact Medical Command.
I. If chest pain persists:
1. Morphine sulfate 2 mg slow IV per order of Medical
Command.
OR
Fentanyl (Sublimaze) 1 mcg/kg slow IV per order of Medical
Command. Note: fentanyl is in micrograms (mcg), NOT
milligrams (mg).
2. May administer additional morphine sulfate 2 mg increments
slow IV OR fentanyl 50 mcg increments slow IV per order of
Medical Command after five minutes if pain persists and BP
is over 100 systolic.
3. Administer additional nitroglycerin 0.4 mg SL per order of
Medical Command.
J. Treat dysrhythmias according to specific protocols.
K. If transport time permits, complete AHA Fibrinolytic Checklist (STEMI). (See
next page).


I do have to get orders for it but can push...also I can provide another protocol for pain management if you like.....


Further more dont mess with me dude!!!!! I like said in the other post I have my opinion and you have yours.....and thats all I got to say to you! ANYMORE you trying to provoke me will be reported .....SO are we done!


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## Aidey (Jun 22, 2010)

1badassEMT-I said:


> I can!





1badassEMT-I said:


> See you are just trying to set me off......well not going to happen!
> 
> EMSA-Intermediate
> Treatment Protocol
> ...



Whoa there turbo...calm down, please. There is no need to be so confrontational and defensive. 

No where in that protocol did it say you can push fentanyl IN (Intranasal), which was the question. No one is trying to provoke you, we're all here learning from each other, and when someone says something unusual it's pretty common to be asked to back that up.


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## Veneficus (Jun 22, 2010)

1badassEMT-I said:


> What do you mean TROLLING! because I voice a opinion on what I would or would not do....is TROLLING......GET REAL!



When stating that morphine and fent can have so much that can go wrong that an IV is somehow required or safer looks like a statement that is trying to start a fight or based on unfounded fear.

I put in the "?" hoping you would clarify the point for me.


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## 1badassEMT-I (Jun 22, 2010)

Aidey said:


> Whoa there turbo...calm down, please. There is no need to be so confrontational and defensive.
> 
> No where in that protocol did it say you can push fentanyl IN (Intranasal), which was the question. No one is trying to provoke you, we're all here learning from each other, and when someone says something unusual it's pretty common to be asked to back that up.



I think me and usafmedic45 has cleared our differences...... it was from another post that tension rose from... but that is water under the bridge for us ........As for the post I was taken it out of CONTEXT from the other post  and for that I am sorry!!


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## 1badassEMT-I (Jun 22, 2010)

Veneficus said:


> When stating that morphine and fent can have so much that can go wrong that an IV is somehow required or safer looks like a statement that is trying to start a fight or based on unfounded fear.
> 
> I put in the "?" hoping you would clarify the point for me.



Then state it like that then. Please dont call me a troll and leave it at that......??? does not ask for clarification does it! 

Let me ask you this have you ever had a pt to arrest on you after given MS? I have! REASON:: it wasnt because they were allergic either.... They took a OTC called St.John Wort(later when they told me they forgotten he took it) and bad stuff happens when the too meet MS and St. Johns Wort.... without that line I had could have spelled disaster for this pt, had I not got the NARCAN on as fast as I did. My personal feeling and comfort zone is having a line started before pushing my drugs. But that is just me.


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## 1badassEMT-I (Jun 22, 2010)

Aidey said:


> Whoa there turbo...calm down, please. There is no need to be so confrontational and defensive.
> 
> No where in that protocol did it say you can push fentanyl IN (Intranasal), which was the question. No one is trying to provoke you, we're all here learning from each other, and when someone says something unusual it's pretty common to be asked to back that up.



You are right and I was wrong for misreading the question I tought I saw IM....and it was IN..... and no I cant do IN Fentanyl....only IM/IV....only thing I can push IN is ativan. So I am wrong again sorry  for the misread.


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## Flight-LP (Jun 22, 2010)

1badassEMT-I said:


> ....only thing I can push IN is ativan.



Really???

Lorazepam is insoluable in water and uses an oil based solvent, hence cannot atomize effectively. 

Midazolam is the only water based benzo available and is often used intranasally.


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## 1badassEMT-I (Jun 22, 2010)

Flight-LP said:


> Really???
> 
> Lorazepam is insoluable in water and uses an oil based solvent, hence cannot atomize effectively.
> 
> Midazolam is the only water based benzo available and is often used intranasally.



As per our protocol 4603 

Treatment Protocol
4603
Seizures Page 2 of 2
West Virginia Office of Emergency Medical Services – State ALS Protocols
4603 Seizures.doc Finalized 12/1/01 Revised 4/17/09
7. If seizure lasts longer than 5 minutes or two or more episodes of
seizure activity occur between which the patient does not regain
consciousness:
a. If IV access has been established, administer lorazepam (Ativan) 2
mg IV per MCP order.
b. If no IV access is available, then administer lorazepam (Ativan)
2 mg IM or intranasal (IN) via atomizer per MCP order.
8. If seizure continues, further treatment as ordered by Medical
Command.
E. If patient is not actively seizing:
1. Monitor vital signs closely and be alert for recurrence of seizure.
2. Transport.
3. Perform remaining assessment as indicated.
4. Notify Medical Command
Special note: Diazepam (Valium) may continue to be used via IV or rectal route per previous
protocol until agency stock is depleted. All diazepam must be replaced by lorazepam before
4/17/2010.


Got to have a order from MCP to give it.


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## Aidey (Jun 22, 2010)

That is a bit strange. We got into this discussion at work a few weeks ago and experimented with some expired Ativan (with our supervisor's supervision) and it absolutely does NOT go through the MAD device we use. The MAD popped off in one case, and in the rest it shot out in a straight stream from the tip of the MAD.


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## Flight-LP (Jun 22, 2010)

1badassEMT-I said:


> As per our protocol 4603
> 
> Treatment Protocol
> 4603
> ...



Regardless, do you not believe it improper to administer because of the aforementioned fact?


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## Flight-LP (Jun 22, 2010)

Aidey said:


> That is a bit strange. We got into this discussion at work a few weeks ago and experimented with some expired Ativan (with our supervisor's supervision) and it absolutely does NOT go through the MAD device we use. The MAD popped off in one case, and in the rest it shot out in a straight stream from the tip of the MAD.



WV is yet another one of those eastern State's that have antiquated State Protocols.


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## 1badassEMT-I (Jun 22, 2010)

Flight-LP said:


> Regardless, do you not believe it improper to administer because of the aforementioned fact?



I just do as I am told per MCP they hold a way higher CERT than I do!!!!!!!!


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## 1badassEMT-I (Jun 22, 2010)

Flight-LP said:


> WV is yet another one of those eastern State's that have antiquated State Protocols.


Dont say that some people here mite blow you up for that statement or think that you may not be train properly! Go to my other post and see what I mean.


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## Flight-LP (Jun 22, 2010)

1badassEMT-I said:


> Dont say that some people here mite blow you up for that statement or think that you may not be train properly! Go to my other post and see what I mean.



Thanks for the advice, but I'm quite capable of holding my own..............I'm not too terribly worried about others "blowing me up".

Many who know me here are aware that I have been properly trained, and more importantly, properly educated.

Your last comment prior to this one actually scares me. It tells me that you will follow any order given by some unknown entity on the other side of a radio. What if the order is wrong? Who do you believe will be the primary defendant when an error in judgement goes to litigation? Do you honestly believe knowledge of your clinical practice holds no importance? Finally, do you REALLY trust the individual on the other end? You have a brain, use it! Think outside of the book. Make your voice heard! Otherwise, the care available to the citizens of your fine State will never change and will not progress with the evolution of medicine. Is that really what you want for yourself, your family, and your community?


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## Melclin (Jun 23, 2010)

1badassEMT-I said:


> Then state it like that then. Please dont call me a troll and leave it at that......??? does not ask for clarification does it!
> 
> Let me ask you this have you ever had a pt to arrest on you after given MS? I have! REASON:: it wasnt because they were allergic either.... They took a OTC called St.John Wort(later when they told me they forgotten he took it) and bad stuff happens when the too meet MS and St. Johns Wort.... without that line I had could have spelled disaster for this pt, had I not got the NARCAN on as fast as I did. My personal feeling and comfort zone is having a line started before pushing my drugs. But that is just me.



This doesn't make any sense.

In what sense did they arrest? As far as I'm aware st John's wort increases the side affects of opiates a little. Was it a respiratory arrest? Then you could simply ventilate the person indefinitely. Did they arrest because they were haemodynamically unstable anyway and the vasodilation that comes with morphine pushed them over the edge? If they were so compromised already, having a line in is irrelevant, they shouldn't have been getting the morphine in the first place and narcan won't help with the vasodilation as far as I know. 

Besides Narcan can be given IM (and IN as well) so even if it were going to help, you could still give it without a line.


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## MrBrown (Jun 23, 2010)

Nowhere in my education or experience has it been said that naloxone reverses the vasodialatory effect of opiates.

If you're going to be giving medication to a patient it's always nice to have a running IV line but some are simply not good candidates for venous access; small children, neonates, people with no veins, severely shocked patients etc.

A patient that has deep extremity burns for example is going to be a nightmare to get a line into so do you simply not give pain relief?

The most drastic example of this is a guy who was in a car wreck and couldn't get IV access.  He got an IO in the humerus, knocked out with fentanyl and ketamine, sux'd and intubated.  I bet he had a good time on that ketamine thats for sure!

IN administration is a great option for several medications we carry including fentanyl, midazaolam and naloxone.  It's safer (no sharps), easier (no IV access required) and only slightly slower than IV onset times.  

Now, if a patient is so bloody crook that a bit of morphine makes them croak then I am seriously worried about anybody who decides that patient should be getting morphine.


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## Aidey (Jun 23, 2010)

Maybe not the best reference, but this doesn't mention opiates anywhere. 

http://www.herbological.com/images/SJW_table.pdf


Poking around pub med so far all I have found are studies testing if St. John's Wort can help with opiate withdrawal.


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## medicRob (Jun 23, 2010)

Aidey said:


> Maybe not the best reference, but this doesn't mention opiates anywhere.
> 
> http://www.herbological.com/images/SJW_table.pdf
> 
> ...



The Active Constituent of St Johns Wort is a Monoamine Oxidase inhibitor. Some Opiates + MAOIs = Bad Ju Ju. 

See the following:

Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity. (Gillman PK, 2005)

http://bja.oxfordjournals.org/cgi/content/full/95/4/434?view=long&pmid=16051647

Br J Anaesth. 2005 Oct;95(4):434-41. Epub 2005 Jul 28.


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## Veneficus (Jun 23, 2010)

medicRob said:


> The Active Constituent of St Johns Wort is a Monoamine Oxidase inhibitor. Some Opiates + MAOIs = Bad Ju Ju.
> 
> See the following:
> 
> ...



In your article in the conclusion it states specifically:

"In summary, *morphine, codeine, oxycodone and buprenorphine* are now known not to be SRIs and they do not precipitate serotonin toxicity with MAOIs."

Said drugs are also not listed in Table 1. in the same study describing potential toxicity.

"Table 1 Drugs with clinically relevant serotonergic potency from reference29 with permission. Fatalities from serotonin toxicity involving analgesics have been with pethidine, tramadol and dextromethorphan and, possibly, fentanyl."

I do not see how this study supports the conclusion that morphine would have an interaction with St. Johns Wart.

Thanks for the post though, it was a great read. It knocks Fent down a couple of pegs.


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## Aidey (Jun 23, 2010)

medicRob said:


> The Active Constituent of St Johns Wort is a Monoamine Oxidase inhibitor. Some Opiates + MAOIs = Bad Ju Ju.



Reference? I've never seen anything claiming that St John's Wort is an MAOI. The literature I've read suggests that it is mosr similar to a SSRI than anything else.


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## Veneficus (Jun 23, 2010)

1badassEMT-I said:


> Then state it like that then. Please dont call me a troll and leave it at that......??? does not ask for clarification does it!



I ask your indulgence. It has been my experience people who post absolute oversimplified statements are usually looking for a fight.



1badassEMT-I said:


> Let me ask you this have you ever had a pt to arrest on you after given MS?



No, and the frequency and doses i often give it at are for the pupose of anesthesia or complete pain mitigation. I suspect that your patient arrested for a cause that was not stipulated and it is being attributed to the administration of a relatively small amount of morphine. (based on common doses used in ems) 




1badassEMT-I said:


> it wasnt because they were allergic either....



Doesn't frighten me. Even if they were it is a problem simply solved with some IM epi, and by not using the narcan it not only maintains the analgesia from the morphine, but doesn't block the Mu and Kappa receptors so I can try an alternate formulation.



1badassEMT-I said:


> They took a OTC called St.John Wort(later when they told me they forgotten he took it) and bad stuff happens when the too meet MS and St. Johns Wort.....



That doesn't seem to be supported by the recent article that MedicRob posted. Do you have a more comprehensive or alternate source?



1badassEMT-I said:


> without that line I had could have spelled disaster for this pt, had I not got the NARCAN on as fast as I did.



I must once again ask your indulgence, as this seems to be a rather oversimplified statement. Are you suggested the patient went into instantaneous and simultaneous respiratory and cardiac arrest? If not, and they went into respiratory arrest would positive pressure ventilation and a patient airway have a lesser effect than the narcan?

If this was an undocumented case of a severe interaction, since morphine has a longer half life than narcan and it competes for the same receptor sites, were multiple doses or an infusion of narcan required until the morphine was not biologically available? If not it seems logical to conclude that when the narcan was no longer active the patient would have arrested again. (possibly in as little as 15 minutes) 



1badassEMT-I said:


> My personal feeling and comfort zone is having a line started before pushing my drugs. But that is just me.



That seems like a fair opinion. Can I politely inquire what causes you to be uncomfortable with a medication that is prescribed to nonhealthcare providers to self administer for conditions such as Diarrhea, caughing, and home management of pain in chronic conditions?


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## 1badassEMT-I (Jun 23, 2010)

Flight-LP said:


> Thanks for the advice, but I'm quite capable of holding my own..............I'm not too terribly worried about others "blowing me up".
> 
> Many who know me here are aware that I have been properly trained, and more importantly, properly educated.
> 
> Your last comment prior to this one actually scares me. It tells me that you will follow any order given by some unknown entity on the other side of a radio. What if the order is wrong? Who do you believe will be the primary defendant when an error in judgement goes to litigation? Do you honestly believe knowledge of your clinical practice holds no importance? Finally, do you REALLY trust the individual on the other end? You have a brain, use it! Think outside of the book. Make your voice heard! Otherwise, the care available to the citizens of your fine State will never change and will not progress with the evolution of medicine. Is that really what you want for yourself, your family, and your community?



Well your WRONG.... I said  I can push it but did not said I have or will...but on the other is a Medcial Doctor that is far more highly trained better than me HENCE them being a DOCTOR. Have I argue the fact of some treatments hurting some pts YES.....I have got into trouble over yes.... dont telll me to think outside the box because I do everyday I work....And as in my other post WV state protocol is BS.


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## 1badassEMT-I (Jun 23, 2010)

Veneficus said:


> I ask your indulgence. It has been my experience people who post absolute oversimplified statements are usually looking for a fight.
> 
> 
> 
> ...



You seem to think I want to fight.....not the case .....I am simply telling you of a case that happen to me......and was told at the hospital by a doctor that the St Johns Wort was the cause of the reaction when I started my push of the morphine......NO FIGHT! oh and for the record there are equally trained on my truck and it was respiratory arrest not full cardiac and my partner had the airway! Due to the hospital location we were at the doors in 2-3 minutes best I can remember with a driver from city FD.....


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## 1badassEMT-I (Jun 23, 2010)

Quote:
Originally Posted by 1badassEMT-I  
My personal feeling and comfort zone is having a line started before pushing my drugs. But that is just me. 

That seems like a fair opinion. Can I politely inquire what causes you to be uncomfortable with a medication that is prescribed to nonhealthcare providers to self administer for conditions such as Diarrhea, caughing, and home management of pain in chronic conditions? 


Just my personal preference!


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## 1badassEMT-I (Jun 23, 2010)

St Johns wort *increases* *CNS depression* - chamonile, hops, Jamaican dogwood, kava, lavender, mistletoe,nettle, pokeweed, poppy, senega, skullcap, valerian. As a interaction with Morphine.

Reference:: 22nd edition 2009 Mosby's Nursing Drug Reference Page 719 under Morphine.

So you saying that it can not happen? Or my story is just out there?


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## 1badassEMT-I (Jun 23, 2010)

Melclin said:


> This doesn't make any sense.
> 
> In what sense did they arrest? As far as I'm aware st John's wort increases the side affects of opiates a little. Was it a respiratory arrest? Then you could simply ventilate the person indefinitely. Did they arrest because they were haemodynamically unstable anyway and the vasodilation that comes with morphine pushed them over the edge? If they were so compromised already, having a line in is irrelevant, they shouldn't have been getting the morphine in the first place and narcan won't help with the vasodilation as far as I know.
> 
> Besides Narcan can be given IM (and IN as well) so even if it were going to help, you could still give it without a line.



Reference:::: 22nd edition Mosby's Nursing Drug Reference:::::

Naloxone aka Narcan

Actions: Competes with opioids at opiate receptor sites.

Uses : *Respiratory Depressions* induced by opioids, pentazocine, propoxyphene; refactory circulatory shock, asphyxia neonatorum, coma, *hypotension*

I just rather have a line/lock in place but like I said thats just me. Oh and it was a respiratory arrest.


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## 1badassEMT-I (Jun 23, 2010)

Veneficus said:


> I ask your indulgence. It has been my experience people who post absolute oversimplified statements are usually looking for a fight.
> 
> 
> 
> ...



You know what I have read over and over that you are trying to pick me apart....why yes that does bother me to a degree, let me tell you alittle about me.... while I am JUST a EMT-I now and getting my (Paramedic back) , I was once a Paramedic when I got burned out running the busiest truck in a city in NC where I am from I let my card exp.. I have 22 years of EMS exp. NOT CLIAMING to know everything. I know patient care. How I care for a patient may differ from you. I do know what I am doing. I do like to caution on how I care for my patient because this is medicine and I got think of what can go wrong will go wrong. I dont think because I got all the neat tools and toys of the trade that something cant go wrong. SO I use CAUTION on how I do things. Does make me a bad provider? I hope not. Because there are some out there that think just the opposite of that and hurt more than they help. I dont just do a intervention because I CAN, I do it because  it is how I am trained and know what it is there for and it uses and it effects. *So while you are picking me apart please keep that in mind or maybe consider I am no idiot like from your post that reflects you mite think I am. Just as I have showed my references and reasoning on how and why I treated this patient the position I was in at the time was a good treatment.....At the end of the day that patient was ALIVE! and went home to his family.** Now just think of this what if it was your family member that this happen too and I was the one that was treating them would think any thing less of my treatment or would you have been grateful?* And I ask that to all of you picking me apart!


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## 1badassEMT-I (Jun 23, 2010)

medicRob said:


> The Active Constituent of St Johns Wort is a Monoamine Oxidase inhibitor. Some Opiates + MAOIs = Bad Ju Ju.
> 
> See the following:
> 
> ...



None the less you are right = BAD JU JU

St Johns wort *increases CNS depression *- chamonile, hops, Jamaican dogwood, kava, lavender, mistletoe,nettle, pokeweed, poppy, senega, skullcap, valerian. *As a interaction with Morphine*.

Reference:: 22nd edition 2009 Mosby's Nursing Drug Reference Page 719 under Morphine.





Reference:::: 22nd edition Mosby's Nursing Drug Reference:::::

Naloxone aka Narcan

Actions: Competes with opioids at opiate receptor sites.

Uses : Respiratory Depressions induced by opioids, pentazocine, propoxyphene; refactory circulatory shock, asphyxia neonatorum, coma, hypotension


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## MrBrown (Jun 24, 2010)

We wouldn't pick you apart if you constructed a well reasoned, logically and medically sound argument instead of a pile of gramatically poor ramblings that show very little understanding of contemporary Ambulance praxis.

You may have 20 years of experience, but do you actually have 20 years of experience or 1 year repeated 20 times?


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## 1badassEMT-I (Jun 24, 2010)

MrBrown said:


> We wouldn't pick you apart if you constructed a well reasoned, logically and medically sound argument instead of a pile of gramatically poor ramblings that show very little understanding of contemporary Ambulance praxis.
> 
> You may have 20 years of experience, but do you actually have 20 years of experience or 1 year repeated 20 times?



Point noted and taken!  And I am working on that. Sometimes my fingers get slower or faster typing what I think i am saying it just dont come across the screen that way. I do have 20+ years. And would like to think I am a DAMN good ALS provider.


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## Veneficus (Jun 24, 2010)

*Let's have a closer look at it.*

St. John's Wart (SJW) and morphine and narcan.

SJW is listed as a MAOI inhibitor. The stipulated mechanism of action is that it blocks the reuptake of neurotransmitters (monoamines) potentiating their time and effect in the synaptic cleft.

That makes the goal of treatment to increase stimulation and it is used as a last line effort to treat clinical depression.

Morphine inhibits presynaptic neurotransmitter release, acting as a depressant.

With all known effects and excluding some yet unknown or undocumented reaction, taken together, morphine would prevent release and SJW would prevent reuptake. Depending on the half life, affinity, and potency, the reasonable conclusion is one would cancel the other or reduce the effectiveness of one or both. 

I have searched the NIH, FDA, both my pharmacology texts, Medscape, and google. I can find no compelling information or even a suggestion there is an interaction at the synapses between morphine and MAOIs. Though several other opioids do have known reactions. (see my earlier post) I did find a study on medscape listing a study done by a manfufacturer of time release PO morphine stating there may be an adverse reaction. However, the link has been removed.

I also found information that demonstrates that both morphine and St. John's wart are metabolized by cytochrome p450 (multienzyme oxidases) and as such inhibit each other's clearance nd potentiate (lenghten) the affects of each other.

High dose or repeated administration could conceivably raise bioavailability of morphine and cause the toxic effects associated. (respiratory depression, hypotension, altered mental status) 

Liver damage or infection could also reduce the availability of the CYP further adding to the amount of active drug.

It is also logical that this could be compounded in a patient further with hypersensitivity to opioids. 

When adding narcan to the mix, like any competative inhibitor, if the amount of bioactive morphine was elevated, it would increase the probability of morphine blocking the narcan (standard saturation kinetics) reducing the effectiveness and theraputic level of the narcan. A rapid reversal of the opioid without an elevated dose of narcan seems highly unlikely, using anything that is currently known about biochemistry and the properties of the agents involved.


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## Veneficus (Jun 24, 2010)

1badassEMT-I said:


> You know what I have read over and over that you are trying to pick me apart....why yes that does bother me to a degree, let me tell you alittle about me.... while I am JUST a EMT-I now and getting my (Paramedic back) , I was once a Paramedic when I got burned out running the busiest truck in a city in NC where I am from I let my card exp.. I have 22 years of EMS exp. NOT CLIAMING to know everything. I know patient care. How I care for a patient may differ from you. I do know what I am doing. I do like to caution on how I care for my patient because this is medicine and I got think of what can go wrong will go wrong. I dont think because I got all the neat tools and toys of the trade that something cant go wrong. SO I use CAUTION on how I do things. Does make me a bad provider? I hope not. Because there are some out there that think just the opposite of that and hurt more than they help. I dont just do a intervention because I CAN, I do it because  it is how I am trained and know what it is there for and it uses and it effects. *So while you are picking me apart please keep that in mind or maybe consider I am no idiot like from your post that reflects you mite think I am. Just as I have showed my references and reasoning on how and why I treated this patient the position I was in at the time was a good treatment.....At the end of the day that patient was ALIVE! and went home to his family.** Now just think of this what if it was your family member that this happen too and I was the one that was treating them would think any thing less of my treatment or would you have been grateful?* And I ask that to all of you picking me apart!



Not trying to fight, trying to see the logic of your position and how you get to your conclusions.


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## medicRob (Jun 24, 2010)

Veneficus said:


> In your article in the conclusion it states specifically:
> 
> "In summary, *morphine, codeine, oxycodone and buprenorphine* are now known not to be SRIs and they do not precipitate serotonin toxicity with MAOIs."
> 
> ...



Sorry, didnt see your post at first. I was speculating as to the effect of narcotics with MAOI's, thus why I chose to use the word *some* before narcotics. Truth be told, I wasn't entirely familiar with the various interactions of St John with most medications, I usually run meds through our interaction checking db at work. However, this post did inspire me to do a bit more research into such things and expand my knowledge, so all in all-it was a good thing. I learn something new every day.  I feel that after being made aware of such things that I will be more inclined to ask my patient during my SAMPLE history "Medications taken" section, to include any herbal supplements he or she may be taken as well, especially with regard to Syrian Rue or St Johns Wort.


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## 1badassEMT-I (Jun 24, 2010)

Veneficus said:


> St. John's Wart (SJW) and morphine and narcan.
> 
> SJW is listed as a MAOI inhibitor. The stipulated mechanism of action is that it blocks the reuptake of neurotransmitters (monoamines) potentiating their time and effect in the synaptic cleft.
> 
> ...



This was a pt with a broken tib/fib, pt had slightly increased rr at 22, b/p was good, st on monitor of about 110. o2 at 3l nc.  Orders was given for 6mg of Morphine, and to transport.  Pt was packaged and ready to go, started pushing iv morphine, pt handling the morphine rr still at 22.  After all 6mgs of the morphine was pushed pt went into respiratory arrest.  Partner got airway established (ET 7.5 lip line 23) Morphine of course was given for pain mitigation after which was believed by er physician that this was what put pt into respiratory arrest.  Afterwards when found out that SJW taken daily from this pt.  SJW increases the CNS depression (2009 Drug Reference Nursing).  4mg Narcan was administered b/c it is an opiod antagonist, antidote to be used for respiratory depression induced by opiods. (2009 Nursing Drug Reference)  after pushing pt went from respiratory arrest to respiratory depression.  pts vs b/p increased, pulse was still tachy at 118 and rr 16.  So in short, morphine given for pain which caused a reaction with the SJW which again once mixed or in contact with the morphine can or will cause CNS depression, which occurred when pt respiratory arrested, the narcan is a antagonist and its job is to stop the opiod (Morphine) and to assist with respiratory depression (2009 Nursing Drug Reference)
Other than the above what could i have done.  Narcan done its job.  Patient is alive.


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## Sasha (Jun 24, 2010)

retracted


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## 1badassEMT-I (Jun 24, 2010)

Sasha said:


> retracted



Please by all means put your input in. I would really like to have know how you would have handle this.


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## 1badassEMT-I (Jun 24, 2010)

Ok in the end the patient is alive. The interactions between morphine and MAOI's (SJW)  has a unpredictable reaction, Avoid use: MAOI's = BAD JU JU

Naloxone will help in Respirtory arrest after a opioid was administer. 

That was my action and I stand by all my treatments that was redender to this pt read above that the way it happen. End result Patient Alive.
As Forrest Gump would say "That all I got to say about that"


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## Veneficus (Jun 24, 2010)

1badassEMT-I said:


> SJW increases the CNS depression (2009 Drug Reference Nursing). .



You need some better books my friend.

Could I suggest:

Goodman and Gilman's "The Pharmacological Basis of Therapeutics"

Lippincott's "Illustrated review of Pharmacology"

Lange: "Basic and clinical Pharmacology"

"Biochemistry" by Garrett and Grisham

Lippincott's "Illustrated review of biochemistry."

"Anesthesiology" by Longnecker et al.

I have found them to be reputable and exhaustive sources. Far more detailed than a nursing guide.


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## 1badassEMT-I (Jun 24, 2010)

Veneficus said:


> You need some better books my friend.
> 
> Could I suggest:
> 
> ...



Thanks I will look into them. I do have the Basic and Clinical Pharmacology 10th edition Lange let me look into that as a starter.


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## 1badassEMT-I (Jun 24, 2010)

Veneficus said:


> You need some better books my friend.
> 
> Could I suggest:
> 
> ...



Even in brief reading Chp 31 pg 503-509 Lange still supports my treatment. I see what you are saying you are thinking that with a low dose of morphine a pt cant arrest with MAOI (SJW) which didnt need for Narcan to be pushed. And thats ok maybe I got lucky then. Until you can show where my treatment was wrong, we are disagree on what I done. I am a idiot that got lucky ok. I stand by my treatment and thats all that matters. Everybody wants to think Narcan is for over-doses only is bull crap. I know what the indications for it is I used it, and it worked. I dont know why it is a problem nobody can tell why it didnt work... You are all just basing your opinion which is fine. I accept your opinion. Now leave the idiot alone..... That is what you all think. I still got my job and my card. I am happy.

Really thanks for your input. And I will check the other references I promise.


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## 1badassEMT-I (Jun 24, 2010)

Before I am done with this post I got really neat Reference guide I for got I had.


Lexi-Comp Drug Reference Handbook "A Comnprehensive Resource for all Clinicians and Healthcare Professionals" 
the official book for reference APhA.

And it even supports my treatment. OK Im done now.


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## Aidey (Jun 24, 2010)

Can someone please post a link to any study saying SJW acts as an MAOI?

Here is my issue with that claim. MAOIs interact with A LOT of stuff, right down to cold medications and cheese. SJW is a common OTC supplement in the US, and if its MAOI action is strong enough to have such an effect on morphine, I would expect people taking it would have adverse reactions to a lot more stuff that doesn't mix well with MAOIs.


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## 1badassEMT-I (Jun 24, 2010)

Aidey said:


> Can someone please post a link to any study saying SJW acts as an MAOI?
> 
> Here is my issue with that claim. MAOIs interact with A LOT of stuff, right down to cold medications and cheese. SJW is a common OTC supplement in the US, and if its MAOI action is strong enough to have such an effect on morphine, I would expect people taking it would have adverse reactions to a lot more stuff that doesn't mix well with MAOIs.



http://atheism.about.com/library/glossary/paranormal/bldef_stjohnswort.htm

http://www.fda.gov/ForConsumers/ByAudience/ForWomen/ucm118473.htm

http://www.holisticonline.com/herbal-med/hol_herb_med_reac.htm

http://www.webmd.com/vitamins-suppl...activeIngredientName=ST.+JOHN'S+WORT&source=2


Look under interaction it that tab


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## 1badassEMT-I (Jun 24, 2010)

1badassEMT-I said:


> http://atheism.about.com/library/glossary/paranormal/bldef_stjohnswort.htm
> 
> http://www.fda.gov/ForConsumers/ByAudience/ForWomen/ucm118473.htm
> 
> ...



And while it  can be consider SSRI and MAOI:
http://home.caregroup.org/clinical/altmed/interactions/Herbs/Hypericum_perfo.htm

http://home.caregroup.org/clinical/altmed/interactions/Drug_Classes/SSRI's.htm


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## 1badassEMT-I (Jun 24, 2010)

Aidey said:


> Can someone please post a link to any study saying SJW acts as an MAOI?
> 
> Here is my issue with that claim. MAOIs interact with A LOT of stuff, right down to cold medications and cheese. SJW is a common OTC supplement in the US, and if its MAOI action is strong enough to have such an effect on morphine, I would expect people taking it would have adverse reactions to a lot more stuff that doesn't mix well with MAOIs.



EVERY DRUG REFERENCE I HAVE PULLED OUT HAS SAID AVOID MORPHINE USE WITH SJW!!!!!!!!!!!!!! If anybody can show me PROOF I am wrong PLEASE DO! And I WILL eat every word.


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## 1badassEMT-I (Jun 24, 2010)

Veneficus said:


> You need some better books my friend.
> 
> Could I suggest:
> 
> ...



Even in Lange and as you said SJW maybe considered a SSR and MAO pg 1057 Chp 65


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## 1badassEMT-I (Jun 24, 2010)

*This is good I am learning alot!*

This is good!


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## Melclin (Jun 24, 2010)

A couple of things.

*1badassEMT-I* : I'm saying this in a friendly way. When complaining about being treated like an idiot, you have to understand how things like your screen name, and the fact that the some of your posts read like they have been typed by someone having a seizure, instantly impact upon people's perception of you. Without any previous experience of you we are presented with these things:
-a questionable screen name
-shockingly typed and thought out posts. (To the extent that, I at least, have been unable to divine the meaning behind about 30% of your posts.)
-Posts full of what I will tentatively term whackerisms (constant references to saving a life, a dim view of education [although I find it hard to tell what you position actually is], excessive references to equipment, dogmatic application of protocols, overly simplistic appraisal of clinical issues etc]. 

When you then present a questionable idea as a basis for an argument you are making, don't be shocked if people want to pick that idea apart. This would be true in any case, but given the above, you can imagine why people are especially keen to deconstruct you thought processes. That is, after all, the only reason why I and many others come to this forum - to examine ideas. Now I'm not saying you have to change your screen name or anything, but just consider the affect of all these things taken together.

The *scenario*: I can except that a person had a hypersensitivity to morphine and that they subsequently suffered a reduction in resp rate and conscious state. If you are going to say arrest without a qualifier, I don't think it is unreasonable to assume you mean cardiac arrest. Also the whole point was that the IV line was necessary for the immediate saving of the patients life, hence lines are needed before morphine (the presence/action of SJW is essentially irrelevant). I think we can safely say that notion has been debunked. You seem to accept this. So why base an argument on it in the first place? Can't you see why some people are taking issue with your thought processes?

I have also heard that SJW may mildly increase the effects and duration of opiates, but you have yet to provide any reliable references. Where do you think an article on About.COM fits into that hierarchy? Come on mate, If that's what you're going to post as reliable evidence, you're going to have to get used to people taking issue with your posts.


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## 1badassEMT-I (Jun 24, 2010)

Melclin said:


> A couple of things.
> 
> *1badassEMT-I* : I'm saying this in a friendly way. When complaining about being treated like an idiot, you have to understand how things like your screen name, and the fact that the some of your posts read like they have been typed by someone having a seizure, instantly impact upon people's perception of you. Without any previous experience of you we are presented with these things:
> -a questionable screen name
> ...



Like I said MATE I dont care what none of you think about me......Show me a reference where I am wrong and I will shut up....I have reference it all stand by my treatment and dont care what you or anybody else thinks of me. (FOR ONE MINUTE ALL OF YOU HAD ME THINKING DID I DO SOMETHING WRONG HERE BUT NOW I KNOW I AM RIGHT AND DONT CARE)...Put me on ignore if I so grossly bother you..... You guys are intimindated by my SN or the fact you are so in the dark that hey he mite have had  this happen....At the end of the I give a hoot what you or anybody on this forum think. I am a IDIOT in your eyes but I am going to sleep tonite knowing I am better than what you or anybody else on here thinks of me....NOT ONE of YOU HAVE SHOWED ME WHERE I AM WRONG NOT ONE!!!!! I have nothing to prove to NOBODY understand that.....You or nobody else! I have even show my co-workers the BS you guys are posting.....and they are laughing at you...I find it funny now.. I have cause such a up roar that none can say I am wrong this cant happen.....yet nobody has showed that it CANT happen as it did. So once again if I bother you with my post ignore me that simply. Thanks for your input now I can put this aside. I have nothing to prove as I have said!!!!!!!!!!! DONE!!!!!!!! HEAR ME DONE!!!!!!!!!!


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## MrBrown (Jun 24, 2010)

1badassEMT-I said:


> Like I said MATE I dont care what none of you think about me......Show me a reference where I am wrong and I will shut up....I have reference it all stand by my treatment and dont care what you or anybody else thinks of me. (FOR ONE MINUTE ALL OF YOU HAD ME THINKING DID I DO SOMETHING WRONG HERE BUT NOW I KNOW I AM RIGHT AND DONT CARE)...Put me on ignore if I so grossly bother you..... You guys are intimindated by my SN or the fact you are so in the dark that hey he mite have had  this happen....At the end of the I give a hoot what you or anybody on this forum think. I am a IDIOT in your eyes but I am going to sleep tonite knowing I am better than what you or anybody else on here thinks of me....NOT ONE of YOU HAVE SHOWED ME WHERE I AM WRONG NOT ONE!!!!! I have nothing to prove to NOBODY understand that.....You or nobody else! I have even show my co-workers the BS you guys are posting.....and they are laughing at you...I find it funny now.. I have cause such a up roar that none can say I am wrong this cant happen.....yet nobody has showed that it CANT happen as it did. So once again if I bother you with my post ignore me that simply. Thanks for your input now I can put this aside. I have nothing to prove as I have said!!!!!!!!!!! DONE!!!!!!!! HEAR ME DONE!!!!!!!!!!



Your whole attitude is wrong mate.  You deomonstrate this over-the-top Whacker E. Rescue gung-ho save the world mentality and a poor approach to praxis which is most likely the product of grossly inadequate education and clinical support.

I am going to say this as nicely as possible mate.

Stop saying things.


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## 1badassEMT-I (Jun 24, 2010)

MrBrown said:


> Your whole attitude is wrong mate.  You deomonstrate this over-the-top Whacker E. Rescue gung-ho save the world mentality and a poor approach to praxis which is most likely the product of grossly inadequate education and clinical support.
> 
> I am going to say this as nicely as possible mate.
> 
> Stop saying things.



Like I said Brown I am done! That is as nicely as I can say it.


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## Aidey (Jun 24, 2010)

1badassEMT-I said:


> http://atheism.about.com/library/glossary/paranormal/bldef_stjohnswort.htm
> 
> http://www.fda.gov/ForConsumers/ByAudience/ForWomen/ucm118473.htm
> 
> ...



Ok, let me rephrase. Can someone besides this guy please post a reference from a reputable source? 

Sir, your links suck. These are not academic references. The first and third links are useless. The second link doesn't mention SJW anywhere. And the 4th doesn't support your claim that SJW works as an MAOI. It only lists potential complications, which does nothing for your argument. 

I'm asking for science based information with references. Think a reference that could be used in a research paper.


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## 1badassEMT-I (Jun 24, 2010)

Aidey said:


> Ok, let me rephrase. Can someone besides this guy please post a reference from a reputable source?
> 
> Sir, your links suck. These are not academic references. The first and third links are useless. The second link doesn't mention SJW anywhere. And the 4th doesn't support your claim that SJW works as an MAOI. It only lists potential complications, which does nothing for your argument.
> 
> I'm asking for science based information with references. Think a reference that could be used in a research paper.



As I have said in all the drugs references SJW w/morphine is bad ju ju regardless of what studies you find. Thats all I need to go by. I am done arguing this point, It is in the drug references and thats all I care about. Have a good one!


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## Sasha (Jun 24, 2010)

1badassEMT-I said:


> As I have said in all the drugs references SJW w/morphine is bad ju ju regardless of what studies you find. Thats all I need to go by. I am done arguing this point, It is in the drug references and thats all I care about. Have a good one!



To be taken seriously, you need to provide back up for what you claim. You made the claim, the burden of proof is on you. If you can't provide the studies and proof that it is bad with morphine, then you certainly are not going to be taken seriously.


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## 1badassEMT-I (Jun 24, 2010)

Sasha said:


> To be taken seriously, you need to provide back up for what you claim. You made the claim, the burden of proof is on you. If you can't provide the studies and proof that it is bad with morphine, then you certainly are not going to be taken seriously.



Sasha look up morphine in any drug reference in interactions SJW is a interaction. It reacts with the morphine. You are a Educated Paramedic go look for yourself. Dont take my word for it go look. My references dont count as they are in every single Drug REFERENCE book published. I made the claim proved it and it is still not good enough.

I am the idiot here. None of you can discount I am wrong. And I dont have to prove anything else to you or anybody at this forum because when I do it is not good enough...Dont take me serious I have proven all I care to prove. Have a wonderful evening Sasha you are just adding your two cents to this mix and I really got you peg as a crap starter anyway.


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## ExpatMedic0 (Jun 24, 2010)

EZ-IO is your friend...
We don't even use IV's any more for codes, protocol says go strait to EZ-IO


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## 1badassEMT-I (Jun 24, 2010)

schulz said:


> EZ-IO is your friend...
> We don't even use IV's any more for codes, protocol says go strait to EZ-IO



Nice.... makes for fast access to get your cardiac drugs on..... we just got our EZ-IO about 5 months ago. I love them.


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## ExpatMedic0 (Jun 24, 2010)

It seems like a faster more efficient means of delivering the morphine vs IM. Any thoughts or feedback on the use of IO morphine via EZ-IO vs IM morphine?
I know its about the same as delivering it IV, but I am not sure how others will look at the delivery method itself. Is the doc and or the pt. going to look at you weird if you choose the IO method?


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## Veneficus (Jun 24, 2010)

1badassEMT-I said:


> Even in Lange and as you said SJW maybe considered a SSR and MAO pg 1057 Chp 65



I posted that it was. I never suggested it wasn't.

However, it seems there is ample evidence as well as basic scientific understanding that while the effects of said drugs are likely to be potentiated, they do not produce an instant lethal effect.

You described your treatment with morphine in a way that eluded to a full arrest. You later qualified it was respiratory arrest, which is a known and not uncommon adverse effect of hypersensitive reaction to opioids. Aside from posting a nursing drug guide (not impressive to me in the least, there is a reason publishers simplify those guides and why nursing texts are not used for medical students) you used a reference I gave to you to repeat my position that SJW is a MAOI and that it can also have actions similar to an SSRI. I don't understand the point of citing that at all. But I have had a long day and I am tired.


MedicRob posted a extremely well written article which spells out multiple times that while there is an interaction with SJW and certain opioids among other meds, morphine was demonstrated not to be one of them. The only other reference I could find was to a link that was removed. We can only stipulate as to why.

You have attempted to point out that narcan is a competative antagonist to opioids and can be used as a reversal agent to the adverse effects of opioids, which I don't see anyone here arguing against, but you somehow see the need to keep repeating it.

There are many instances in medicine where causations were erroneously attributed to unrelated events. It is possible that you did give somebody who was taking SJW morphine and that patient had an adverse event, but that does not mean that it was the interaction between the 2 substances that precipitated it.

Using narcan to acutely reverse the effects of opioids in the prehospital setting is a recognized school of thought. It is not the only recognized school of thought. I have tried to present another perspective which has seemed to be viewed as a challange rather than an opportunity.

The style of your original post looked like trolling to me. after following several pages of this thread, unfortunately it seems to be a more and more accurate assessment. If you are purposefully posting outrageous or recurrant statements to foster antipathy among this forum for your enteratinment or that of your coworkers, that is trolling.

I have no doubt that you embrace your view of what makes a quality EMS provider, I think it safe to say you have come to a place that has a largely different culture and view of EMS. I think it also safe to say that your coworkers you are sharing this with probably have a similar view. Some people look for consensus to make themselves feel better, some look for confrontation, and still others look for unquestioning acceptance. 

Many people here have made attempts to reach out. It takes a lot more to make it to my ignore list. Only one has ever done it. In my not always humble opinion (I have been around a few years too) it is not what you did yesterday, it is what you do today that determines the type of provider you are. But keep in mind, I have introduced my peers and superiors to this forum as well, and they are a much tougher crowd to impress than a station of US EMS providers. You could be causing real damage to the reputation and development of the "professional" group you represent. (aka EMTs and Paramedics)

There are many EMS providers who have a job. Most will always have a job. Only a few will have a future.


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## Veneficus (Jun 25, 2010)

schulz said:


> It seems like a faster more efficient means of delivering the morphine vs IM. Any thoughts or feedback on the use of IO morphine via EZ-IO vs IM morphine?
> I know its about the same as delivering it IV, but I am not sure how others will look at the delivery method itself. Is the doc and or the pt. going to look at you weird if you choose the IO method?



I think it depends on what your treatment goal is...

Are you willing to penetrate not only the skin and deep facial planes, but also bone in a non sterile environment which carries a real infection risk to deliver small doses of analgesia?

Don't forget that while in the emergent setting an IO is not a sterile procedure, in an ICU it is and for a valid reason. In some patients, just like prehospital or ED IV starts, nonsterile IOs are removed and sterile ones inserted.

Using morphine IM allows you to potentiate the effects of the drug by slowing the rate of absorbtion. I don't see why it would be a first line choice for any other reason.

I would look at you wierd if you stuck an IO in a patient to give relatively small doses of analgesics. I would think you seriously underestimate the risks of deep penetration of foreign bodies. I would also be somewhat concerned about your judgement as to what you think was a reasonable use of invasive procedures that were designed to be used in the most seriously ill patients in less critical populations.


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## ExpatMedic0 (Jun 25, 2010)

Hey Ven,
Thanks for the feedback. The EZ-IO is a new tool for me.

EDIT: I decided to start a new thread about EZ-IO in the ALS section


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## 1badassEMT-I (Jun 25, 2010)

Veneficus said:


> I posted that it was. I never suggested it wasn't.
> 
> However, it seems there is ample evidence as well as basic scientific understanding that while the effects of said drugs are likely to be potentiated, they do not produce an instant lethal effect.
> 
> ...



I have waited for this post. While you share your views as I do my own. I can honestly say you one tuff cookie. And I will take what you have posted to heart and look at my actions as well as others. I know who I am. You know who you are. Let it be and put this to rest. It is what is.


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