belis wrote:

clareiow wrote:

I could be completely wrong here, so anyone with first hand experience can correct away but...
I believe if someone has surgery in the UK, you get morphine administered through a drip at a considered dosage which you can administer yourself by the click of a button, but once you've had your limit it doesn't give you any more. My hubby had this when he had major bowel surgery and my sister when she had a hysterectomy.
My grandfather had terminal lung cancer and only agreed to give him as much morphine as he wanted about a week before he died! Up until then, he was on strict dosages of an oral liquid morphine.
So the fact Sherlock can change his up and down, at will, seemed like a little poetic licence to me. Unless Mycroft pulled some strings to stop him being too difficult with the nurses?

You are right. It's called patient controlled analgesia and it's the best thing since sliced bread. There are different ways to set up those infusions. You can have bolus only when you get a bit every time you press a button or a bolus plus a low level continous infusion. It's quite complicated to change the rate of the infusion and the control panal is normally either locked with a key or password protected to stop patients and relatives from messing with it and killing the patient by mistake. So there is an alement of dramatic license with them being able to fiddle with the infusions rates like that.

Morphine is not that adictive in a grand scale of things. In fact nicotine is more so. There are a lot of missconceptions amongst general public and some doctors as well resulting in people getting substandard pain relief.

It's actualy quiet rare for people who take opioids for pain relief to become addicted. Particularly if their are used short term. If opioids are used for weeks and months they develop physiological dependence and will get withdrawals if you stop the medication abruptly but they are not addicted in a strict sense. They will be able to temper off the dose and stop when appropriate without much of a problem.

The main reason why we are keen to stop opioids asap after the surgery is the side effects associated with it. To enhance recovery we need patients eating and mobilising. Being nuseaous, constipated and dizzy doesn't help with that so its better to try and swich to a different pain relief. At the same time though being in pain doesn't help you moving about either so undertreating pain is associated with increased surgical mortality associated with penumonias, blood clots etc I think we tend to get the balance right in the UK with use of PCAs, which deliver just the right amount to keep patient pain free without oversedation.

I will better shut up now. I have an academic intrest in pain and addictions so I could go on about it all for hours. lol

Well, that makes you the person who should not shut up about it!

Nowadays I am usually treated in a postgrad teaching hospital, but I spent many years being treated in Bart's, and I was always the bed where the consultant would deliver his 'why is this patient with pneumonia on opiates' lecture to the assembled students. Traditionally it was the 'why is the retired army officer with a stomach ulcer and pleurisy on opiates' lecture, but they must have run out of them so they made do with me.

There are no pain nerves in the lungs themselves, but to make up for that the pleural walls have a very high supply; it is also very easy to damage the intercostal muscles by coughing, and to occasionally crack the odd rib. All of that makes it likely that the patient will breathe very shallowly, because it hurts less, and a patient with pneumonia who is breathing shallowly is likely to be a dead patient in the near future, hence the consultant's lecture.

I have never found opiates to be seductive, though I have taken them now for 30 years or so; on the other hand I hate taking prednisone because it is euphoria inducing and I prefer my euphoria to be the real deal. It is also a much more dangerous drug; people taper off opiates to avoid the unpleasant effects of withdrawal, but in a pinch cold turkey is possible. With prednisone you taper off from high doses because you will die if you don't. The really odd thing is that people who freak out about opiates will cheerfully hand out large doses of prednisone; I cannot find any logical reason for this


 

belis wrote:

Willow wrote:

Well, that makes you the person who should not shut up about it!  

 
I have plenty of opportunities to go on about it at work, believe me. I do a lot of laison work when on call and severe pain is one of the most common reasons why people become aggitated, confused or suicidal on medical and surgical wards. As a flipside of the same coin quite a few become confused as a side effect of prescription painkillers. It's a difficult balancing act, particularly in the elderly.

Managing pain in people addicted in opioids is particularly tricky and on the whole it's done rather badly.  It's usualy left to some poor junior doctor in the middle of the night who stops their methadone, prescribes homeopatic doses of morphine and than wonders why they are climbing the walls.

Prednisolone is evil. The most acute case of drug induced mania I have ever seen was in a young lady who was given high dose steroids. It took 8 security gouards to restrain her and she sent 2 of them to hospital. She was heavily pregnant and in hospital threatening pre-term labour so not the sort of  patient that you want to be trestraining or sedating. :o

And the person who prescribed the high dose steroids probably never got round to reading the bit about mania and psychosis, and would be horrified at the very idea of prescribing opiates because people get addicted to them. I do realise that sometimes there is no alternative; I've had to bite the bullet a few times over the years but it is, as you say, evil. A couple of years ago I was on high doses of pred, and the end result was a shopping expedition to the West End -which lasted ten hours- with my daughter, who now understands my profound dislike of the stuff, given that it turns me into what she describes as 'a very happy Energiser Bunny on crack'.

You most definitely do not have an easy job; in addition to all your other workload I suspect that you get quite a lot of calls from junior doctors in the middle of the night, completely baffled by the fact that their patient is climbing the walls, notwithstanding their 'homeopathic doses of morphine' I'm going to pass that one on to my daughter, by the way, she will love it , as well as trying to determine what exactly is going on when someone has symptoms which may be caused by illness/surgery/prior medications but also may be caused by one or more mental illnesses. Definitely not an easy job!






 

As a, sort of, aside. I was put in a room on my own when I had been to A&E at one hospital but then had to transfer to another hospital for an op. After a pop home to collect 'stuff'. I assume this was to try and restrict/control cross-infection.

belis wrote:

Willow wrote:

You most definitely do not have an easy job; in addition to all your other workload I suspect that you get quite a lot of calls from junior doctors in the middle of the night, completely baffled by the fact that their patient is climbing the walls, notwithstanding their 'homeopathic doses of morphine' I'm going to pass that one on to my daughter, by the way, she will love it , as well as trying to determine what exactly is going on when someone has symptoms which may be caused by illness/surgery/prior medications but also may be caused by one or more mental illnesses. Definitely not an easy job!

It can be busy but compering to some other specialities I think my on calls are a walk in the park. There is no way I could be a med reg.  I bet your doughter will have her own stories to share about dealing with psychiatrists. We have a bit of a love-hate relationship with collegues in acute specialities.  lol

Well, interdisciplinary rivalry can be fun; last week my daughter was extremely pleased to have spotted that a patient had a flail chest, which had been overlooked by A&E. The patient should have been pleased about it as well since it greatly increased his life expectancy

On the other hand, she'd been transferring a very ill patient to another hospital and on the way back they were flagged down for a bad crash; unfortunately it was just her and the driver. So she ended up having to don a fireman's helmet to clamber amongst the wreckage; the firemen and the police knew perfectly well that what they really needed were paramedics, but felt that any doctor was better than nothing until they turned up. It could have been you in that helmet, and I'm fairly confident that you would have been just as terrified as she was; it's at times like these when you remember what a good thing it is to have all those other specialities




 

Willow wrote:

On the other hand, she'd been transferring a very ill patient to another hospital and on the way back they were flagged down for a bad crash; unfortunately it was just her and the driver. So she ended up having to don a fireman's helmet to clamber amongst the wreckage; the firemen and the police knew perfectly well that what they really needed were paramedics, but felt that any doctor was better than nothing until they turned up. It could have been you in that helmet, and I'm fairly confident that you would have been just as terrified as she was; it's at times like these when you remember what a good thing it is to have all those other specialities

 
Not only terrified but also probably as usefull as a chocolate teapot. lol It reminds me of that dreaded 'is there a doctor on board' when I was flying for a well deserved holiday. I was only just qualified and felt right out my depth. :o Luckily they also found a consultant anaesthetist amongst the passangers so all I had to do was follow the instructions.

TeeJay wrote:

besleybean wrote:

I took it he was merely switching the drip back on, that Janine had switched off.

Also, I don't think Janine had switched off the morphine. If you look closely, he just ups the dosage from a low to a rather high setting. Either he reduced it himself while Janine was there to make sure he wasn't loopy, or the doctors did that, and Sherlock just increased the dosage because he was in a lot of pain and didn't want Janine to see it.

Well, he initially ups the dosage while Janine is there to give her the impression that he's feeding his addiction (in the event she might relay that info to Magnussen or the press). As soon as she leaves, he lowers the dose significantly.

belis wrote:

Willow wrote:

On the other hand, she'd been transferring a very ill patient to another hospital and on the way back they were flagged down for a bad crash; unfortunately it was just her and the driver. So she ended up having to don a fireman's helmet to clamber amongst the wreckage; the firemen and the police knew perfectly well that what they really needed were paramedics, but felt that any doctor was better than nothing until they turned up. It could have been you in that helmet, and I'm fairly confident that you would have been just as terrified as she was; it's at times like these when you remember what a good thing it is to have all those other specialities

 
Not only terrified but also probably as usefull as a chocolate teapot. lol It reminds me of that dreaded 'is there a doctor on board' when I was flying for a well deserved holiday. I was only just qualified and felt right out my depth. :o Luckily they also found a consultant anaesthetist amongst the passangers so all I had to do was follow the instructions.

 
There are a fair number of junior doctors who do not follow the instructions, as my daughter often tells me, through gritted teeth, sometimes at very considerable volume, so the anaesthetist would have seen you as manna from heaven; he'd lucked out with you. I realise that patient confidentiality means that you can't tell us the outcome, but I live in hope that it may have been the pneumothorax tackled with a Biro, a metal coat hanger and an empty plastic bottle.

That last phrase really sounds like a wonderful title for a Sherlock case

Willow wrote:

There are a fair number of junior doctors who do not follow the instructions, as my daughter often tells me, through gritted teeth, sometimes at very considerable volume, so the anaesthetist would have seen you as manna from heaven; he'd lucked out with you. I realise that patient confidentiality means that you can't tell us the outcome, but I live in hope that it may have been the pneumothorax tackled with a Biro, a metal coat hanger and an empty plastic bottle.

That last phrase really sounds like a wonderful title for a Sherlock case

 I can be pretty disobedient myself so I have a soft spot for rebel juniors. There is time and place for everything though and you don't want to mess about in an emergency.

Thanks God we didn't need a chest drain as we would struggle to find a coat hanger at this budget flight lol. Lack of equipment is the worst thing about tackling emergencies outside of hospital. You know what needs to be done, you can do it but there is nothing to do it with. Even if you do have the right kit, conditions are often les then optimal (no light, spece etc). I really admire paramedics for the jobs their do.

Did he not turn the drip back on while Janine was there, rather than increase the dose? She'd turned it off while he was sleeping, hadn't she?
Then she leaves, and he resolves to do what he needs to do to help Mary - something Janine says to him seems to make it clear to him what action to take - he then turns the morphine off so he can remove his drips and leave the Hospital.

Tinks wrote:

Did he not turn the drip back on while Janine was there, rather than increase the dose? She'd turned it off while he was sleeping, hadn't she?
Then she leaves, and he resolves to do what he needs to do to help Mary - something Janine says to him seems to make it clear to him what action to take - he then turns the morphine off so he can remove his drips and leave the Hospital.

I strongly disagree that Sherlock, at that point, was interested in doing what he needed to do to help Mary; he was interested in staying alive. Janine had just tampered with his medication and it was obvious to Sherlock that Janine could, if she had wished, have done a great deal more damage to him than a temporary bout of agony, and what Janine could do, so could Mary. Janine is, after all, supposedly Mary's best friend.

So, Sherlock needed somewhere safer than the hospital, but he needed to get dressed first in order to get out of the hospital. It's actually quite tricky getting dressed when you are attached to lines, but he could get most of the way there before parting company with the morphine. As belis has noted it's a balancing act; too much morphine and he's too groggy to do anything, too little morphine and he's in too much pain to do anything. I know it sounds strange, but getting dressed when you are ill and in pain is actually a huge deal; once you are standing up it's a lot easier, though definitely still not fun. So, turning it up very high gives the bolus belis mentions and then turning it down is the preparation for doing something.

I think the dialogue certainly suggests that Sherlock wanted Janine to believe that he was too drugged up to work, and I infer that Sherlock wants CAM to believe that he's still in much the same state. But the bolus served a practical purpose as well, in allowing Sherlock to get onto his feet ...