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ACAD-AE-MED  October 2001

ACAD-AE-MED October 2001

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Subject:

Sedation using morphine/midazolam etc.

From:

John Chambers <[log in to unmask]>

Reply-To:

Accident and Emergency Academic List <[log in to unmask]>

Date:

Thu, 18 Oct 2001 12:11:01 +1300

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (63 lines)

Here goes!
We use morphine/midazolam fairly frequently for reducing dislocations
and fracture dislocations
hip prostheses etc
Has been superseded by Ketamine in children for the past year with
better parental acceptance in keeping with best practice
All of our clinical staff have a low threshold for reversing the
midazolam with flumazenil 
In fact I always give flumazenil unless the patient is routinely on
benzodiazepines eg. as a sleeping tablet (which is very uncommon now)
There is no doubt that we use higher doses of midazolam than in years
previously to a point that total patient amnesia is usual eg. I used 10
mg morphine + 9 mg midazolam on a 48 year old man with a fracture
dislocation of the ankle last night. If the patient can open their eyes
to speech or on brushing the eyelids I gave a little more. I repeat I
routinely reverse the midazolam after the painful procedure is over.
Our large Maori/Pacific islander rugby players not uncommonly require up
to 15+ mg midaz when reducing a first time shoulder dislocation.

Are our anaesthetists happy - of course not (although most don't
actually worry too much)
Are we on the borderline of administering anaesthesia - undoubtedly
Have all of our senior ED registrars and specialists extensive
anaesthetic experience - yes

In the pursuit of truth, justice and restrictive practice the head of
our anaesthetic department sought a definition of "an anaesthetic" from
the New Zealand Medical Council. After many months the medical council
decided that a patient was "anaesthetised" if administered drugs which
rendered them unable to hold a conversation with the doctor!!! At these
times a trained anaesthetist should either present or supervising (in
some way) the doctor performing the procedure.

Now the gastroenterologists and surgeons are up in arms and the Head of
Anaesthesia is back tracking big time. At the board room table he
acknowledged that "of course" many of his colleagues (including
experienced ED registrars) were capable of administering sedation
safely!! The most recent correspondence acknowledged from an
anaesthetist acknowledged our clinical autonomy in with the afterthought
of "but what if anything ever goes wrong just once..."
Give us a break!!

As was acknowledged at the Australasian conference in Hobart last week
all the clinical "battles" which restrict what we should or should not
be doing in the ED have actually been fought and won eg sedation,
thrombolysis, RSI. All we need to do is employ staff with sufficient
experience who whilst working as a team (and often advising) colleagues
from allied specialties  get the job done in the ED.

I think we should use all the skills and medications now available to
improve the experience for patients - especially those suffering or
about to suffer pain. There is no going back but progress does not
necessarily make you popular.

JohnC
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