Welcome to Insomnia and Sleeplessness

It was a very busy day.  I looked at my appointment list, and was surprised to see  Ben (not his real name), a 27 year-old fit young  man, truck driver, was fitted into seeing me-”pain” attached beside his name. 

I saw him a few times for the last few weeks and a few days ago cleared him from workcover for soft tissue injury to his left arm and a sprained neck, after he rolled his truck.  He was very grateful as I gave him 2 weeks off for rehabilitation with the help of competent physiotherapist to manage his injury.

I am usually very quick to respond when dealing with acute pain.  I jumped the queue, and called his name. 

Ben had resumed truck-driving. Unfortunately, the left tip of his 4th finger had been amputated three days ago in a mishap. He was unloading animal feed from the truck and the gate accidentally shut with his finger caught in the slit. 

He was surgically cleaned and sutured under digital block by a doctor in a small hospital.  However, his finger was throbbing in tremendous pain, and he was unable to sleep at night, causing his wife to stay awake all night looking after him.  He was holding his left hand and I could see his eyes were full of tears.  “Did you have any oral painkiller last night and this morning?”, “Yes, panadeine forte not doing anything at all.  I had been taking 12 tablets since last night, it seems like I was swallowing lollies.”

He looked genuine, and I know him well (I have to be careful of drug seeking patients).  I drew up 15mg morphine with 10mg maxolon (=metoclopramide hydrochloride), and given intramuscularly to his left buttock.  I sent him home with 50mg tramal (=tramadol hydrochloride), instruction to take every 6 hours, but could be topped up with panadeine forte (paracetamol 500mg+codeine phosphate 30mg/tablet) 2 tablets in between if needed, with only maximum of panadeine forte of 8 tablets/24 hours.  However, I had to warn him of main side effects of nightmares from tramadol, drowsiness with tramadol or codeine. 

He returned next day for wound check, but this time his pain was well under control with regular oral analgesia, more happily he and his wife able to sleep through the night.   Unfortunately, his wound closure was almost about 30% necrotic and with partly wound dehiscence.  I decided to sent him to hand surgeon for further surgical intervention.

Morphine sulfate : Morphine is the principal alkaloid of opium.  The most common adverse effects are constipation, lightheadedness, dizziness, sedation, nausea, vomiting, sweating, dysphoria and euphoria. 

Metoclopramide hydrochloride : It has a few usages.  In this context, it was used to control nausea and vomting (to prevent nausea and vomiting secondary to morphine).  The most frequent adverse reactions are restlessness, drowsiness, fatigue and lassitude.

Tramadol hydrochloride : It is a centrally acting synthetic analgesic of the aminocyclohexanol group with opioid like effects.  It is not derived from natural sources, nor is it chemically related to opiates.  The possible adverse effects are fits, anaphylactic reactions, gastrointestinal upset, dizziness, sedation, sweating, tolerance, nightmares. 

Panadeine forte : It is an analgesic and antipyretic.   The common adverse effects of codeine phosphate are nausea and vomiting, constipation, dizziness and drowsiness, rarely skin rashes may occur.