oxycodone

Oxy morons. Avoid prescribing oxycodone

It has been interesting moon-lighting at another hospital to see how much oxycodone (common brands names: oxynorm and oxycontin) was being used professionally and recreationally.

I was out with a friend who told me he had been given 1 1/2 oxycontin tabs by an acquaintance a while ago and had been high as a kite for a couple of days.  Interestingly he said there was no “come down”.  Sounds like a very desirable drug of abuse.

In the ED everyone was prescribing oxycodone to everybody, from the ED reg to the ENT reg to the ortho house officer.

“… we are looking at a disaster in the making. We have been complacent about the warnings from the rest of the western world, with harms arising from pharmaceutical opioids overtaking those from heroin. This has reached epic proportions in the United States, with oxycodone particularly over-represented. Pharmaceutical opioids in the United States now kill more people than firearms or road traffic accidents, and more than the combined death rates from heroin and cocaine overdoses. This is shocking and shameful …” Dr Jeremy McMinn* 

Oxycodone is more addictive and more expensive than morphine.

Oxycodone is no safer in renal failure than morphine.

Most people with morphine “allergy” were just given too much  and developed nausea, vomiting, dysphoria or an itchy rash from the histamine release caused by morphine.  It may be worth try a test dose of IV morphine to see if they can tolerate it, check with a senior first.

Generally in ED for analgesia we use paracetamol/acetaminophen and a NSAID such as ibuprofen.  For severe pain we will use a fast acting IV or IN opioid such as fentanyl to control the pain.  Once the pain is controlled if ongoing strong pain relief is required we will move to oral morphine (or IV if unable to take oral).  Oral morphine is available in fast acting and slow release forms.

In our hospital we have made oxycodone only able to be prescribed by order of a consultant, and I’m trying to have oxcodone removed from our ED.

As an aside, at the other hospital, as always, there was a granny who had bounced back into hospital because she had been discharged from the ortho ward on oxycodone, prescribed a bulk forming laxative but no stimulant laxative, and hadn’t crapped for a week and felt rotten.

It’s a shame that the resident who discharged her wasn’t working that weekend.  It would have been a good educational experience for him/her to come down, give the enema and readmit the patient.

This is a problem with all opioids, not just oxycodone.  Always prescribe a stimulant laxative when prescribing more than a few doses of opioids eg something with sennosides in it.  By the way sennosides are Category A (considered safe) in pregnancy.  Shame the resident wasn’t on that weekend.

 

*Dr Jeremy McMinn is a consultant psychiatrist and addiction specialist at Capital & Coast DHB. He is also the Co-Chair of the National Association of Opioid Treatment Providers and the New Zealand Branch Chair of the Australasian Chapter of Addiction Medicine

References:

http://www.bpac.org.nz/BPJ/2014/June/upfront.aspx

http://nzf.org.nz/nzf_882.html?searchterm=sennoside

 

 

 

 

Pull my finger

Pull my finger. Dorsal dislocation of PIP

A young adult male sustained an open dislocation of the PIP for his middle finger while playing rugby.

Pull my finger

Hopefully he wasn’t doing a Hopoate.

195810-john-hopoate

The finger was neurovascularly intact.  The wound was not obviously contaminated.

The finger was anaesthetised using a ring block at the level of the web space and the wound was cleaned.

The clinician puts on gloves to give a better grip.  The proximal phalynx was held in the clinicians non-dominant hand with the clinician’s thumb on the palmer aspect where it can be used to stabilise the distal end of the proximal phalynx.

The clinician then grabs the rest of the finger in her/his dominant hand and pulls and hyperextends the middle phalynx.  The middle phalynx is then flexed reducing the dislocation.

The PIP joint was grossly unstable indicating disruption of the volar plate – the ligament joining the palmar aspect of the proximal phalynx to the palmar aspect of the middle phalynx.  The volar plate prevents hyperextension and dorsal dislocation of the joint.

Volar plate

Where there is a large avulsion fracture, say > 30% of the joint surface talk to hands/ortho about potential fixation of the fragment.

Generally the PIP is splinted with 30˚ of angulation with a zimmer splint (1cm wide malleable aluminium strip with foam on one side).  The middle phalynx does not need to be taped to the splint – so it can flex but not extend past 30˚ of flexion.  This is called a dorsal blocking splint.

dorsal blocking splint

If the joint is not unstable when relocated some advocate simply buddy strapping the finger to one of its neighbour.

The laceration was cleaned and sutured (being careful to avoid the flexor tendons).

Any finger dislocation should be reviewed by a hand therapist at about a week.

Open dislocations should be discussed with hands or ortho who may want to wash the joint.

Audio:

 

Diagrams from: http://www.aafp.org/afp/2006/0301/p810.html

Music: Flume remix of Tennis Court by Lorde

Korero Maori

How to pronounce Maori names. Ned Tapa and Chris Cresswell

Everybody appreciates it if you attempt to pronounce their name or the name of their town properly.

Here Ned Tapa helps me get my tongue around some Māori names.

 

Letters

There are only 15 letters in the Māori alphabet. 5 basic vowels and 10 consonants.   Two of the consonants are written as digraphs (two letters representing one sound): ng and wh

Every Māori syllable finishes with a vowel.

 

Waka

waka

Vowels

There are 5 basic vowels (monophthongs) and many diphthongs (combination of vowels in the same syllable)

Remember “Are there three or two?”

A as in “are”

E as in “there”

I is an e sound as in “three”   (This is allegedly due to a German missionary creating the written version of the Māori language.  Māori did not have a written language before the arrival of Europeans)  This quirk causes a lot of mispronunciation of names and words such as Hipango which is pronounced “He-pa-ngo” not “Hi-pang-o”

O as in “or”

U as in “two”

Double vowels or a macron over a vowel, aa or ā, is a long vowel sound, so stretching out the “are” sound.  As in Māori.

For a vowel combination with different vowels (diphthongs) the two sounds run together. “Tau” in Māori sounds like “toe” in English.

Consonants

Pretty much like English except for the two digraphs Ng and Wh

Ng is a nasal sound. Ng as in singer not in as finger

So Rongo is Ro ngo not Rong go

Wh is f in most of New Zealand except Whanganui and South Taranaki where wh is a breathy wh.  So whanau (family) is fa nau in most parts of the country and wha nau in Whanganui and South Taranaki.

There are some other dialect differences around the country.

R is rolled, a bit like a cat’s purr, with your tongue on the roof of your mouth.

 Whanganui River

whangnui-river

 

 

 

Examples:

Tariana Turia  (Minister of Disability Service and Associate Minister of Health)

Mere

Henare

Hohepa

Haka

Tau Henare

Ranginui

Metekingi

Patea

Rongo

Rongoa (medicine)

Hipango

Whanganui

Aramoho

Raetihi

Ohakune

Taranaki

Taumaranui

Paekakariki

Paraparaumu

Taupo

Tauranga

 

Some simple greetings

Kia ora is a very common greeting that means be well, and can be used for hello or thank you depending on the tone of voice.

Kei te pehea a koe? How are you (to one person)?

Ma te wa    See you later

Nga mihi   Hello / I acknowledge you.

 

Ma te wa!

 

 

Reference

http://www.maorilanguage.info/mao_phon_desc1.html

Waka (canoe) image from http://www.stuff.co.nz/national/1392793/Unfazed-PM-leads-prayers-at-Waitangi

Warrior with taiaha image from http://www.rellimzone.com/2011/08/deadliest-warrior-s01e07-shaolin-monk-vs-maori-warrior/

Music: AEIOU by Moana and the Moa Hunters 1991

 

Strengths

Making use of your character strengths. Dr Johanne Egan

The theory is that by developing your strengths, rather than trying to fix your weaknesses, you get more enjoyment out of your work and will perform better. It may also help you to work well as team with others with complementary character strengths,

The VIA (Virtues in Action) Institute on Character is run by Prof Seligman and Dr Neal Mayerson (psychologists) and has a free online survey which helps you work out your character strengths.

VIA

And here is an interview with Dr Johanne Egan, an emergency department doctor who is doing a PhD in Positive Psychology in Emergency Medicine, on how to put this into practice.