title: Is intramuscular morphine satisfying frontline medical personnels' requirement for battlefield analgesia in Helmand Province, Afghanistan? A questionnaire study.
abstract: BACKGROUND
  All deployed British Army personnel carry intramuscular (IM) morphine auto-injectors to treat battlefield casualties. No other nation supplies parenteral opiate analgesia on individual issue. Studies highlight this agent's inefficacy and safety issues, but are limited by a relative lack of inclusion of frontline personnel. We aimed to determine the opinions of frontline medical personnel on current battlefield analgesia.
  
  
  METHODS
  We surveyed 88 British Army frontline medical personnel (medical officers (n = 12), nurses (n = 7), combat medical technicians (CMTs) (n = 67), paramedics (n = 1) and health-care assistants (n = 1)) upon completion of a six-month deployment (September 2011 to April 2012) to Helmand Province, Afghanistan, using Likert scale questions on the efficacy of battlefield analgesia, complications of IM morphine, safety of morphine auto-injectors and its suitability for treating child casualties.
  
  
  RESULTS
  A total of 88/88 questionnaires were returned. Of these, 61/88 had treated casualties on the battlefield, 26/86 agreed that current battlefield analgesia is effective, 80/87 agreed that a more potent analgesic with a faster onset than IM morphine is desirable in the first hour following injury, 47/65 CMTs agreed that they can manage complications of current battlefield analgesia and 53/86 respondents correctly disagreed that current battlefield analgesia is suitable for child casualties. The potential for accidental self-injection was reported.
  
  
  CONCLUSIONS
  A more potent, faster onset analgesic than IM morphine is desirable in the first hour following injury. Pre-deployment training should emphasise management of complications of opiate analgesics and treatment of child casualties. Oral transmucosal fentanyl citrate is now being issued to all frontline medical personnel. IM morphine will remain on individual issue to all deployed soldiers for environments where an oral agent is not suitable, for example, chemical, biological, radiological and nuclear warfare.
  
  
  CONCLUSIONS
  Frontline medical personnel agree that a more potent, faster onset analgesic than IM morphine is desirable in the first hour following injury.The two most desirable features of the ideal analgesic were ranked as rapid onset of action, and when fully onset produces a high degree of pain relief.Oral transmucosal fentanyl citrate (OTFC) has now been issued to all frontline medical personnel as an adjunct to IM morphine.IM morphine will remain on individual issue for situations where parenteral analgesia is required.Consideration should be given to individual issue of OTFC to all deployed personnel in the future.Pre-deployment training should emphasise management of complications of opiate analgesics and treatment of child casualties.
authors.affiliation: HQ Army Medical Directorate, Army Medical Services, Camberley, UK ; Department of Clinical Radiology, Western General Hospital, Edinburgh, UK.
authors.forename: Tom N
authors.initials: TN
authors.lastname: Blankenstein
authors.affiliation: Department of Clinical Radiology, Western General Hospital, Edinburgh, UK.
authors.forename: Lorna M
authors.initials: LM
authors.lastname: Gibson
authors.affiliation: HQ Army Medical Directorate, Army Medical Services, Camberley, UK.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Claydon
keywords: Analgesia/pain control; military; pre-hospital care; remote and rural medicine; trauma