Would You Like More Pain Medicine?

Another paramedic tipped me off to a great podcast called Patient Controlled Analgesia by Dr. Edward Gentile.

The bottom line is this physician has come up with an interesting and bias-free pain management protocol.

You apply the same protocol to anyone in acute pain. Young, old, black, white, male, female, rich, poor.

Acute pain protocol for moderate/severe pain

• Administer morphine 0.1 mg/kg IVP (If pt is > 55 y/o, substitute morphine 0.05 mg/kg IVP for this 1st dose) + diphenhydramine 0.5 mg/kg IVP
• 7 minutes later the patient is asked, “Would you like more pain medicine?”
• If the answer is yes, give a 2nd dose of morphine 0.05 mg/kg IVP
• 7 minutes later, the patient is asked again, “Would you like more pain medicine?”
• If the answer is yes, give a 3rd dose of morphine 0.05 mg/kg IVP
• This continues every 7 minutes until the patient answers “no” to the question or the patient is asleep.

This guy is my new hero. His podcast is wildly entertaining and in my opinion, right on.

I have modified his ED protocol to fit the prehospital guidelines we operate under.

If someone is in acute pain, I now simply ask: Would you like pain medicine?

For severe unquestionable pain, I give the first dose 0.1 mg/kg dose spread out over 3-4 minutes. For moderate pain, I may break the first dose down in half, then give the second half fif needed five minutes later. The next 0.05 mg/kg dose, I give ten minutes after the first dose is complete. I dose until I have reached my allowable max which is 0.15 mg/kg up to 15 mg. If they need more, I will call for orders if I am not already at the hospital.

Due to our protocols, I only give the Benadryl if they itch, but I have it on standby as well as zofran if their only complaint is nausea.

I really love this phrase, “Would you like pain medicine?” as well as “Would you like more pain medicine?” I am required to do the pain number scale, but I only ask that after they have answered the pain medicine question. The other day I had a lady who was still a “7’ tell me she was all set as far as the pain medicine after one dose.

I have used the protocol three times now with great success and patient satisfaction.

Dr. Gentile modifies the old slogan “Commit random acts of kindness and senseless acts of grace and beauty,’ to “Commit systematic acts of kindness and sensible acts of grace and beauty.”

I am with him on that all the way.


  • One other use for the Benadryl you may not have considered: the vasodilation following morphine administration is a pure histamine response. If you’re a bit worried about inducing hypotension, co-medicating with Benadryl isn’t a bad idea.

    PS: Are you aware that leaving a comment on your blog requires a WordPress login? Is that a new setting?

  • medicscribe says:

    That’s one of the reasons Dr. gentile uses Benadryl on all patients. We are not allowed to premedicate for side effects. If they start to have a reaction we can give the Benadryl, we can’t routinely give the Benadryl to every patient, otherwise I would be following Dr. Gentile’s protocol .

    Thanks for the tip about my comment settings, I was trying to find away to block all the spam I get that backs up in my to be approved box, I didn’t mean to shut readers out.


  • Rusty says:

    It has always been my understanding and practice to make acute pain tolerable in the prehospital setting. 0.1mg/kg is a lot of morphine. Giving morphine until the patient “says no or is asleep” will make it difficult for the hospital to perform their own assessment and gather the patent’s history, not to mention the dangers of knocking out their respiratory drive. Using the 0-10 pain scale, vitals, and overall patient disposition should be sufficient when deciding how much morphine to give. Our protocols state give 4mg initially then titrate, up to 10mg. Very rarely have I seen a patient receive 10mg in an ambulance.

  • PDXEMT says:

    Really, really interesting. I like it.

    Where does this intersect with the issue of frequently-transported patients with known drug-seeking behavior? I’m talking about the guy we see twice a week that the hospital only sees in triage and never dispenses prescriptions to. Is it part of our job to consider what might be best for the patient in the long run, or should we simply treat pain without prejudice and leave the big decisions to other folks?

    I’m not necessarily looking for answers, just tossing thoughts out. This is stuff I wrestle with sometimes; I tend to err on the side of treating pain and endure the raised eyebrows from nurses and pointed comments from docs (one recently showed me a chronic chest pain pt’s chart with all the notes about “drug seeking” and “only admit for positive enzymes”).

  • medicscribe says:

    Sorry for the delay in answering. My policy is for acute pain with a visibile cause like a fracture or a burn, i always medicate. For back pain, I usally medicate. I would rather medicate a drug seeker and patient will real pain than not medicate the patient with real pain for fear they were drug seeking.

  • medicscribe says:

    Thanks for the comments. Sorry for the delay in responding. 01.mg/kg is actually “the dose” for morphine. For some reason emergency medicine has been fearful of opiates, but few of these fears have been bourne out in the literature. We severely underdose, we cannot recognize others pain, although we think we can, and there is no study that shows that opiates interfere with examinations or history taking. In our system we can give up to 0.15mg/kg on standing order (0.1mg followed by 0.05 mg/kg). I do this fairly often and have never knocked out a respiratory drive or come close. Most of the research coming out shows very little side effects from morphine and fentanyl not related to pushing the drugs too fast. There are areas where even our liberal guidelines are considered conservative. Slowly but surely the direction is for more pain management.