Hardcore painful.

Next in the series of first aid and medical posts, in this post i am going to deal with the acquisition and management of medicines aboard boats for non-medical people and discuss the use of controlled drugs.

Having posted about basic pain management and basic medicines knowledge i thought to take that one stage further today with the management of higher levels of pain and the use of the opiate drugs that include morphine and it’s derivatives.  Most of what i have to say comes directly from hospital based management of acute pain and from my last job in which i had to stand in for the clinical nurse specialist in pain.  When i talk about acute pain i am talking about a recent pain problem ie less than 3 months, after that we tend to think about chronic pain.  I for example have long term back pain but with cyclical episodes of acute pain….been having a bad one for the last couple of days.

In hospital we tend to use the major painkillers, morphine as an example, to treat ‘injury’ pain but where the injury is something that we have caused : the easiest example being major surgery.      All of the ‘big’ operations, especially those to the belly and chest and with long incisions do come with a high cost in pain and most of that will be managed at some time with opiates although we do now have other pain management methods for the first few days after major operations.  Just out of self-interest i asked the orthopaedic surgeon how he managed post-operative pain from a knee replacement.  His first answer was great ie ‘don’t know……leave that to the anaesthetist’ which was at least honest but then added that his part was to load the joint capsule with local anaesthetic as he finished the job.       In the kind of practice i did we had the choices of giving set doses of opiates either orally (by mouth) intravenously, or if the kit was in place into the epidural (spinal) space.  Most patients who have big surgery nowadays will tend to have 2 or 3 of those routes used at different stages of their stay.  A useful self-administration route to be at least aware of is subcutaneous (under the skin) as most people could do that where they are less likely to be able to give them selves an intramuscular injection or self-cannulate to give an intravenous dose.  While i am thinking about that route i should mention that i have only placed an IV cannula once at sea and that was to give intravenous fluids to a dehydrated crewmember where oral rehydration wasn’t working.

The primary group of medicines that i am talking about here are the opiates and today most of the ones we still use are derivatives of morphine which is produced from morphine base from the morphine poppy (papaver somniferum) and according to one source about 500.000 kg is produced every year legally.  A large amount of that goes to make medical grade morphine and it’s chemically modified variants.  Alongside that there is of course a long term trade in illegal opiates that end up here as street heroin (smack) although recently there has been a huge increase in the recreational use of medical grade fentanyl in the USA.  Generally all of the opiates have major pain reducing property’s but come with many side effects because their primary mode of action is on the central nervous system….thus pain control but also drowsiness , constipation and a reduction in the function of breathing. There is a well known side effect we call ‘narcosis’ after opiate use in hospital which i am going to use next to describe side effects of medicines and also pattern recognition in my general first aid/medical series.

In my acute care role it was a fairly frequent occurrence to be called to one of the orthopaedic wards to see a patient who would be unrousable and not breathing well, if measurements (observations) were taken it would often be that the patient was only taking around 5 breaths a minute and/or having long periods not of apnoea (not breathing).  The pattern here is that nearly every patient that i was called to see with those 2 problems would be an elderly female who’d had recent hip surgery, had poor kidney function, was a bit dehydrated and had recent opiates…usually a small dose of morphine after surgery.  On examination they would be marginally responsive to a painful stimulus, have very small ‘pinpoint, pupils and only taking 0-5 breaths a minute. The problem is narcosis and a ‘simple’ side effect of the opiate and the treatment is equally and usually very simple….give a reversal agent that directly antagonises the opiate effect.  The actual physiology is that the opiate molecule acts by bonding to a receptor site on the cell surface and the antagonist medicine replaces it.  Usually the narcosed patient responds within a couple of minutes to a single dose of the antagonist…sometimes it takes repeated doses.   In terms of the ABCDE model you could manage it by working logically through the algorythym but you could be wasting time managing the airway and maybe ‘bagging’ the patient until you got to ‘D’ and noted the opiate useage, small pupils, apnoea and patient group.

Talking about appropriate opiate use at sea in first aid and medical problems then we could pose the question “would we ever consider the use of opiates at sea ?”.  And the answer might be yes in certain circumstances.  I have used opiates once for a dental abcess as an adjunct to simple painkillers and non-steroidals because the pain that person was experiencing was severe and a small dose of morphine did the trick. I did consider it in a second case (broken ankle) but got the pain under control by immobilising the leg/foot and giving a combination of simple painkillers.   There is s second use of morphine that might be useful and that is to treat severe chest pain in a suspected heart attack (myocardial infarction) but that is expert territory for the non medic but might be an option at sea when medical advice could be gained.

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The other side to obtaining and keeping opiates aboard a boat is the legal side as these are ‘controlled drugs’ and come under specific legislation.  In hospital for example all controlled drugs are kept in a locked cupboard within a locked cupboard ! and the keys are usually only held by a nurse in charge of that area.   In my workplace for example we use fentanyl a lot and have a controlled drugs storage cupoboard in each treatment area….when i want to prepare and give the drug, or prepare it for the clinician, i have to sign it out in a register and we both have to sign for it’s use. Added to that we have to do a ‘numbers’ check morning and evening….so it’s tightly controlled.  Outside of hospital it is completely different as any patient at home can be prescribed controlled drugs and as far as anyone is concerned that could be stored on their bedside cabinet and nobody would bat an eyelid.   The difficulty for the boater would be to legally obtain and sensibly store a controlled medicine and then be responsible for storing and using it.  I have had controlled drugs on 3 boats, all long distance maxi-yachts and all operating outside Uk sea areas.  In one case controlled drugs were supplied as part of a standard medicines pack and in another i had to meet the port medical officer for an interview and he prescribed the drugs which i then collected as per usual and stored them aboard.  As it happens we had a small safe aboard the boat and i kept them there.  After that voyage i then had to surrender the remaining stock to a police officer who came to the boat and he signed my register (a page in the logbook) to say how many he had removed.

In general it is possible to carry prescription-only medicines aboard a boat and i would add that on long self-reliant voyages that it may be necasary to do so, in that useful category i would certainly include antibiotics, local anaesthetic agents, major painkillers and others in a boat medical pack.  The way of doing it would be to have some degree of appropriate training, an expedition first aid level at minimum or the ship captains course, and then have a good relationship with a friendly and sensible GP.  My route through all that was to be a registered nurse and have a good contact with the port medical officer in Southampton at the time.

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