Aggressive Pain Control

A 35 year old man presents with a kidney stone, or an 85 year old woman presents with a broken hip, or an 8 year old boy presents with an open lower leg fracture. All these patients have fairly straight forward and very painful medical problems, but in the average emergency room none of them will get prompt pain control.

How long is it okay for a patient to wait for pain control? How about if it’s your 85 year old mother with a hip fracture, your 8 year old child with a leg fracture or you with a kidney stone. Now you know the correct answer, pain control should be prompt, it should come shortly after making sure patients are not about to die and don’t need an immediate intervention. Our patients know this, if we do everything right, no matter how complex, but ignore their pain they don’t think we did a good job. Pain is why they came to see us in the first place.

The EMCrit podcast has a practice changing lecture on acute pain control in the emergency department by Dr. Edward Gentile. The idea is simple, the patient is the one who knows when they have had enough pain medicine and a one size fits all approach is appropriate in the emergency department.

The protocol is simple (with credit to Dr. Gentile); For patients in moderate to severe acute pain and who have no allergies:

  1. Give 0.1mg/kg morphine IV push (0.05mg/kg for patients older than 55) along with 0.05mg/kg of diphenhydramine (since most of the adverse effects of morphine are histamine mediated).
  2. 7 minutes later ask the patient ‘Would you like more pain medicine?’
  3. If the answer is yes give 0.05mg/kg morphine IV push.
  4. Repeat every 7 minutes until the patient’s pain is controlled.
If your emerg is like mine some doctors and nurses you work with probably believe that 10mg of IVP morphine is a lethal dose. The benefit of controlling pain using a one size fits all approach is that everyone gets used to it. After a while all of the nurses have given a 100kg man with pancreatitis 10 mg of morphine as an IV push and 30mg over an hour, and the patient didn’t die and didn’t need naloxone.
I will admit that I used to think it was normal to spend hours and hours getting peoples pain under control. Since I’ve started using a protocolized approach to pain I have happier patients, happier nurses and I feel like I’m doing a better job. We see patients with acute severe pain everyday, it is absolutely a patient priority in the ED and it should be a priority for us too.


  1. CAsey Parker says:

    Hi Aaron. I also loved this lecture by Dr Gentile, great style and approach. I love the idea of cutting out as many factors as possible in dealing with acute pain – makes sense and is such a simple method.
    I use his ‘Would you like more pain medicine?’ question all the time, works well.

    My problem is that it is hard to drag a whole ED dept kicking and screaming into line and try this out.
    Any tips? How do you protocolize in your shop?

    • aaronupnorth says:

      Protocols in my dept. are also like herding cats….very difficult…no one is ever particularly interested in change.
      What I have done is to protocolize what I do, as in I have totally stopped writing a special cocktail of pain orders for each patient and I only write the protocol for appropriate patients. A month into doing this the nurses simply asked me if they could initiate the pain protocol, 2 months in the nurses are pestering other physicians to get on board, 3 months in the other MDs are asking me about how to make it a standing protocol.
      I think the trick is that your nurses will buy into this as soon as they try it. Inadequate analgesia puts them is a much worse position than it does for us as they are doing constant direct care for patients. A huge difference in pain control practice is very noticeable to them (more so than say who is giving B-blockers to STEMIs).

  2. Casey says:

    Nice strategy.
    This is one of those areas we generalists see a gap and should be able
    To fix it. This protocol has been used in OT recovery rooms for years.
    It should apply to all acute care areas, but cultural change is tricky.
    Even in the same hospital the standards if care can vary widely!

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