Ketamine: Not Always Magic (Attention, Kiwi)

[DwayneEMTP]

I had a patient recently in pretty severe pain. It was my intention to manage her for the helicopter flight with morphine, but while searching the clinic for their morphine, (I only have 30mg in my jump bad and couldn't justify using it for this patient without a ready resupply.) I ran across big vial of Ketamine...(Of course at this moment the clinic who'd recently swore that they had tons of it, noticed that they were out of morphine.)

Beings I had heard here over and over how awesome it is I called an Aussie doc that I have access to when needed. I told him the same story and his response was, "No, no no...not for this kind of patient! No, put that away. You're a paramedic? You feel comfortable using morphine when you don't know the indications for Ketamine?"

I said, "Yeah..I'm a paramedic, I've pushed buckets of morphine. Are you really an Aussie? I'd heard that you guys love this stuff!!"

Anyway, he lightened up a bit and I put the Ketamine away and will make sure and research such things before calling in the future...

But I am a bit confused how we got from, "Oh my God! It's like the silver bullet for everything only without any hemodynamic effects associated with most bullets!" to "Yeah, it's kind of dangerous with tons of side effects so shouldn't really be the first choice for...anything really...."

[chbare]

Dwayne, it's actually a very good medication with predictable effects in most cases. My point is more about looking at the bigger picture and realising other agents have their pros and cons just like ketamine. I certainly do not think ketamine is a bad medication, only that other agents may be considered by other providers. There are many ways of going about medicine and many come down to bias and anecdotal experience. I think it's important to examine that bias and ensure we don't let it create issues when we are placed in a situation where we may manage a certain situation differently.

[Kiwiology]

What was wrong with the patient, i.e. what was the cause of his pain?

Ketamine is just another tool in the box, sometimes its the best sometimes its the worst you have to know each medication individually and its indications, contraindications, side effects etc to make an informed decision

It is an excellent analgesic particularly to severe pain that is unrelieved or unlikely to be relieved by morphine alone i.e. severely angulated limbs, burns, shattered pelvis, gallstones, renal colic etc

[DwayneEMTP]

I hear you Chris, I was poking fun more than anything. This is the first time that I've even had a vial in my hand, so I've not given it any kind of real thought. But from the things I've seen here I got the impression that it was really easy to control, super effective, with few side effects so was really excited to use it. I thought for sure when I called an Aussie doc he's say, "You have Ketamine?? You rock!! Yay us!" But it didn't go exactly like that.... :-)

Kiwi, she had a possible reinfection secondary to a D/C of a spontaneous ectopic abortion with retained POC, with POC likely still retained, Syphilis, a badly swollen liver secondary to Hep B infection, and a really ugly UTI/vaginal infection or both.

None of those things that I knew for sure of course, but I'd palped the liver and knew it was queered in some way and could smell some type of urinary/vaginal infection, which would have been enough to convince me of her pain, but there was pain to palp in a giant L starting from her liver running right lateral front and back and across her lower abdomen from one side to the other...

But anyway, in my opinion, in very significant pain.

[Kiwiology]

I guess it depends on the individual Physician you encounter

Jeez that lady sounds like she needs the works, did you evacuate here down here?

[DwayneEMTP]

Flew her to Lae...

[the_negro_puppy]

Our indications for Ket:

- Adjunct to morphine (0.1-0.2mg/kg) in patient with severe traumatic pain associated with :

-Fracture reduction or splinting

- Multiple or significant fractures requiring facilitated extricatiln

[Kiwiology]

Our indications for Ket:

- Adjunct to morphine (0.1-0.2mg/kg) in patient with severe traumatic pain associated with :

-Fracture reduction or splinting

- Multiple or significant fractures requiring facilitated extricatiln

Bro, that is sad, you need to talk to Dr Rashford and tell him he is embarrassing himself with such indications

In NZ ketamine is indicated for "severe pain" and may be used in any patient who has "severe pain" regardless of the etiology of the pain but is "preferably" used in combination with opiate

[Eydawn]

And, there's the point I was trying to make all along! Ketamine, like other drugs, has pros and cons. I just figured it was a great setup to write it as a letter to Kiwi, because he's sung its praises incessantly and seems obsessed with it. ;-) It was too humorous and perfect to let that opportunity slip by...

Chris, I want to just sit down and pick your brain one of these days!

Wendy

CO EMT-B

[Kiwiology]

Um, might be funny for you to write me a letter but I am illiterate, way to go exposing my terrible, terrible secret