You gave her 20 Milligrams?!!

I have written often in the past about pain management. It has become my passion in EMS. To me, it is the most satisfying part of the job – to ease someone’s suffering. When I started we needed to talk to a physician on the radio to get orders to use our morphine. Today we can give up to 0.15 mg kg on standing orders. In others words a 220 lb person like myself could receive up to 10 mg given over (at least) 4-5 minutes and if the pain is unrelieved, another 5 mg ten minutes later. If more pain medicine is needed, medical control must be contacted for permission.

The reason we had to contact medical control when I started was a state law that required “simultaneous communication” with a physician in order to dispense controlled substances. That was interpreted to mean on-line control. After I discovered other states did not have a similar provision and that controlled substances were allowed to be given on standing order in those states, I went about changing our state’s law. I met with the DEA (who are charged with overseeing federal and state controlled substances laws), and with the state medical advisory committee. I eventually testified before the legislature on the issue and they changed the law to allow standing orders. Then once that was allowed, within our region, we started at 5 mg of morphine on standing order and then in time upped it to 10 mg and then to the 15 mg we currently have as well as broadening the indications for pain management to include abdominal pain.

I must admit while I have been very aggressive about pain management, over the years when I hit my standing order limit, I tend to stop there even if the patient is still in pain. Why? I guess 15 milligrams seems like a lot of morphine considering when I started just giving two was a major event. And of course, there is that whole I have to call in and bother the doctor (or maybe have my request turned down) barrier.

Once we removed the initial need to call for orders to give controlled substances, the use of morphine went up drastically. But here I recognize that the same need to call the doctor (to go beyond the amount we are now allowed on standing orders) has been holding me up from taking care of my patient’s pain.

So I have decided, be damned, if the patient is still awake, breathing and in pain, just because I have hit my standing order limit, doesn’t mean I shouldn’t call in for more. All I have to do is pick up the radio and ask to talk to a doc. How hard is that?

Now I am saying to my patient (provided they are still reporting significant pain):

“I’ve given you all the pain medicine I can under standing orders. To give you any more, I will have to call the ED doctor on the radio. Would you like more pain medicine?”

If they say yes, I call. Simple as that.

My last three cases (all presenting with 10 of 10 pain):

A 50-year-old two hundred and twenty pound female with a spontaneous hip dislocation received 20 of morphine with one milligram of Ativan on top (at the suggestion of the on-line doctor).

An 83-year-old one hundred and fifty pound man with an anterior shoulder dislocation received 14 milligrams of morphine.

An 82-year-old one hundred and sixty pound female with an obvious hip fracture received 15 milligrams of morphine.

In each case, I called and got permission for the additional dosing from the ED physician. And in each case, the ED nurse when I told her the amount of morphine I had given repeated it aloud with an exclamation point on the end in a voice loud enough for everyone within fifty feet to turn and look at us.

My answer has been the same in every case.

“I didn’t give it to the patient all at once. I gave it incrementally over thirty minutes. I spoke with the physician before giving the final dose, and by the way, the patient is still awake, breathing and in pain.”* I wanted to say IN PAIN, but I have better manners.

*although admittedly less than when I arrived.

I know from comments on previous posts that there are some systems out there that our more aggressive than ours and allow up to from 20 to 40 mg on standing order.

We will be meeting as a region shortly to review our current guidelines and I will be pushing for us to be able to give an additional 0.5 mg dose on standing order beyond what we currently do, thus setting our total maximum on standing orders to 0.2 mh/kg or 20 mgs. Keep pushing those limits out a little at a time.

In another note, while fentanyl has been approved in our protocols for the last year and a half, our service will just now be receiving it starting in a few days. I am anxious to try this drug out on my patients and see how it compares to morphine. The medics I know who have been using it, almost universally prefer it to morphine due to its quicker onset.

I also want to add that I regularly discuss my pain medicine adventures with ED doctor friends and other paramedics looking for feedback. I did recieve this caution from one about the problem giving too much morphine to an elderly patient with a dislocation who will likely need procedural sedation in the ED in order to relocate the dislocation. Having that much morphine on board makes his decision on what drugs to give the patient a little more difficult and will require a closer monitoring of the patient. This is one reason he is such a strong proponent of fentanyl because the fentanyl doesn’t last as long as morphine enabling him better control in the ED in these cases. That being said, he stressed if the patient is in severe pain, you need to take care of that pain. I followed up on the patient with the shoulder dislocation. Over the next two hours the patient recieved three milligrams of dilaudid in the ED and then 5 of valium for the relocation attempt that was successful, greatly reducing the pain.



  • JonEMTP says:

    Peter – here in PA, I have both Morphine and Fentanyl on the 911 trucks. I’ve even don IntraNasal Fent. When I couldn’t get access. I’ve pushed narcs on my last 3 ALS 911 calls – gonna see if I get to keep the trend going.

    Oh – and I once did 100mcg of Fent and 5 of Versed for essentially, conscious sedation for a entrapped limb extrication. Woulda worked great, except the PT. Had a Hx. Of opiod addiction.

  • I would like to take a minute to give a sincere “Thank you!” All too often people (both in EMS and out of it) would rather complain about the rules, and often blatantly ignore them (note: Knowing the loopholes is not the same as outright ignoring them) rather than actually taking the time to work inside the system to change the rules.

    You changed the rules, which enabled everyone else to provide better care, and is ultimately more important than the care provided to anyone individual.

  • Not being an all ALS system, there are a lot of patients we don’t give pain medications to. Which is not to start the all ALS vs. tiered system debate again.

    What I’ve found over the past several years is that Fentanyl is much more effective for pain, especially pain from burns, than Morphine. The last burn patient I treated got about 200 mcg of Fentanyl and that made the pain tolerable, but didn’t make him the least bit drowsy. If we had a longer transport time, he would have got more.

  • JAV says:

    My dad was in hospice, dying of lung cancer. He was 5’6″ and about 150lbs on a morphine pump set to 40mg/hr for weeks at a time. While I understand the circumstances are different, it really opened my eyes to how much MS it can take to relieve pain, and how much the body can take.

  • Almost Jesus says:

    When I was doing my clinical time for my paramedic, I was working in a smaller hospital where ortho was going to do a shoulder reduction. The guy has chronic shoulder pain due to a condition and despite being in his 20’s has quite a opioid tolerance. I ended up giving him 50mg of Morphine and 10mg of Versed in 15 minutes and it hardly touched him. He ended up getting Propofol to accomplish the reduction.
    Its interesting how it is all relative. If I wouldve been giving morphine in the 2mg increments that I was told to give it in school, I would have been there forever. The post you had earlier about that doctor’s “high dose” morphine pain protocol has really made a difference on how I treat pain control.

  • Cat Camp says:

    I never even knew EMS could give a “transporting patient” any pain meds at all. Guess you can tell Ive Never (Thank God) had to be transorted in a rescue before. That is until recently, Jan 8, 2018. I slipped and dislocated my shoulder!!! The Pain was unbearable!! I pray I never experience that pain again!!!! I couldnt wait to be driven to hospital…
    My Fiance had to call the rescue, those poor guys!! I was screaming so Loud!! It was awful, I was so afraid to move… but when they finally got me strapped into the cart they stuck an IV in my arm and “IMMEDIATELY” The Pain started to not be “AS BAD! I Never take pain meds as we all know they can be highly addictive, its just sad to see so many people abusing “Life saving” medicines!!!!
    I just want to say Thank you so much to my rescue Team for taking such good care of me and Putting up with my big mouth! Lol… and how grateful I am that as Patients we have access to “PAIN MEDICATION FOR RELIEF FROM OUR INJURIES AND PAIN”!
    Id Like to Appologize to my Rescue Team in Cranston, RI for Screaming so Loud!!! YOU GUYS ARE ANGELS! God Bless You THANK YOU, Catherine

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