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.