I like writing about healthcare; and the different ways it is provided  and delivered all over the world. So here is a taster.

This is a tale of 68-year-old twins who both suffered fractures in different countries but with very different consequences. Specifically, there were huge differences in postoperative pain management.

Twin one, a female, was cycling in South Germany when she accidently drove her bike into a lake (the path was very narrow and bumpy and probably she should not have been riding on it at all).  She suffered a typical Colles (wrist) fracture, and was taken to the local hospital where it was efficiently plated under regional anaesthesia. Post-operatively she was given IV paracetamol, but only when she asked for it.  It certainly did not get rid of the pain but it was bearable. Apparently the next step up if she had wanted it would have been pethidine. All went well and she was discharged after a few days for follow up later by the NHS.

The second twin had a very different experience. He was not as fit as his sister, being overweight and on tablets for hypertension. He had also fallen and fractured his femur 6 years previously and had a large heavy plate in situ.  This time he fell awkwardly and instead of fracturing his hip, the head of the femur was driven into the socket, fracturing it. He was admitted to hospital in the UK, and put on traction, with regular intravenous morphine.  After 3 days he developed intestinal problems where the gut was paralysed (paralytic ileus) due to the morphine. However transfer was delayed, and the paralytic ileus took over 10 days to settle on drip and suck. During this time he developed early bedsores and was again offered morphine because it was said they did not have IV paracetamol and he was on “nil by mouth”.  By the time he was transferred it was too late to do the operation and his original injury was healing naturally. Altogether he spent 6 weeks in hospital and lost 3 stone in weight.

Morphine is well known for its constipating effect and some people react very badly to it. It is never used on the continent and this was a problem when a locum GP from Germany working in Kent gave the wrong strength to a patient with renal stones resulting in the patient’s death. Academic papers are very keen that adequate pain relief should be given after operations, but paracetamol was the drug of choice in this hospital in Germany, which incidentally is in a skiing area and therefore sees a lot of orthopaedic injuries.

Why do doctors in the UK routinely use so much morphine after accidents and operations? Especially morphine with its rather unpleasant side effect profile? They use pethidine, another narcotic but with different, but definitely fewer, side effects. Should not UK doctors take a leaf out of their German colleagues’ books and only give paracetamol, titrating up if necessary  to pethidine, rather than using morphine as a first line?