Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Is It Possible To Be Alert And Oriented With 10/10 Pain – Part I


Unfortunately, with my protocols, an altered level of consciousness prohibits me from giving opioid pain medication on standing orders for burns or for musculoskeletal trauma.


I can call command for permission to treat the patient, just as I can call for permission to treat abdominal pain or other exclusions from my standing orders. My patient does have to wait for me to go through the Mother May I? ceremony of ignorance. This requirement encourages medical directors to authorize incompetent paramedics and distracts paramedics from patient assessment, but it appeals to the insecurities of the hands-off medical directors.

As if appropriately treating pain aggressively is dangerous.

Image credit.

What do you think?

If this is your arm, is pain medicine a bad idea?

Let’s look at the exclusions –

a. Oxygen saturation ≤ 95% [1]


Give supplemental oxygen and give the pain medicine. Unfortunately, waiting for the sat to rise may cause the patient more pain. We should be raising the patient’s sat to 95% anyway, but the low sat may help to decrease alertness and awareness of pain a little bit.

Is hypoxia really a problem when giving fentanyl?

Assessment of the 522 administrations in 279 non-intubated patients revealed no difference in the mean SpO 2 readings before (98.8%, 95% CI 98.5–98.9) and after (98.6%, 95% CI 98.3–99.0) fentanyl administration. There were no instances of hypoxemia in these non-intubated patients receiving fentanyl (one-sided 97.5% CI for 0/279: 0–1.3%). [2]


No cases of hypoxia caused by fentanyl, even though these patients were given large doses. The average total dose was 3.0 μ/kg.

3.0 μ/kg is the maximum total dose available on standing orders in my protocols, but 3.0 μ/kg was just the average total dose for these patients who never experienced any hypoxia.

b. SBP < 100 for adults

c. SBP < 70 + 2(age in years) for children < 14 y/o [1]


Is hypotension really a problem when giving morphine?


Is hypotension really a problem when giving fentanyl?

of 2129 patients receiving an opioid (fentanyl), only 12 (0.6%) had a medication-related vital sign abnormality and an intervention was required only once (in a patient who had no sequelae)(8) [3]


Overall, in 45 cases (4.3% of 1055), fentanyl was administered to patients who were hypotensive. [2]


Oh, no!

They’re all going to die!

In 53% of these cases, hypotension (predictably) remained after the opioid was given—but in 47% of cases in which fentanyl was administered to hypotensive patients, the next SBP exceeded 90. [2]



Is hypotension really a problem when giving fentanyl?


There is no good reason to avoid giving fentanyl for severe pain with hypotension.


The best thing to do for hypotension may be to give fentanyl.


d. Patient has altered level of consciousness [1]


This will be the topic in Part II.


[1] Musculoskeletal Trauma 6003 and Burns 6071
Pennsylvania Statewide Advanced Life Support Protocols
7007 – ALS – Adult/Peds
Page 73/128 and Page 80/128
Free Full Text PDF of All ALS Protocols

For people working in EMS in Pennsylvania, there is a FREE app that includes BLS protocols and ALS protocols from the University of Pittsburgh Medical Center. Rather than have to go through all of the protocols to find the right one, this allows for very quick searching of individual protocols and for the use of other features. I have found this to be very handy for checking the specifics of a protocol I have not looked at in a while. Please, let me know if there are other similar apps out there.
FREE Android app page.
FREE iPhone app page.

[2] Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia.
Krauss WC, Shah S, Shah S, Thomas SH.
J Emerg Med. 2011 Feb;40(2):182-7. Epub 2009 Mar 27.
PMID: 19327928 [PubMed – in process]

Full Text PDF Download at medicalscg.

[3] Safety and effectiveness of fentanyl administration for prehospital pain management.
Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, Vanbuskirk K.
Prehosp Emerg Care. 2006 Jan-Mar;10(1):1-7.
PMID: 16418084 [PubMed – indexed for MEDLINE]

Free Full Text PDF Download from MSTC.



  1. But, but, if you give that much fentanyl to anyone in pain, they’ll arrest. They will. Because the powers that be said so. So it must be true, right?

  2. I’m about to do my exams as an EMT (I think in your system i will hopefully be equal to an Intermediate) in Hungary.In our system there’s no such thing as medical command and sending EKG-s to some docs in the hospital.If I’m dispatched to a patient with chest pain and all the other signs of an MI then I give 1-2 exp. of nitro and 250mgs of ASA. No radioing back and forth. It’s the same with our paramedics, with all the drugs . They decide , they execute(well hopefully not in that way). This medical control stuff seems weird to me.If i have any facts wrong the please correct me by the way. I really like your posts by the way. : )

  3. At least you guys get to use Fentanyl…


  1. […] [3] Is It Possible To Be Alert And Oriented With 10/10 Pain – Part I Rogue Medic Thu, 01 Mar 2012 Article […]

  2. […] from Part I. Unfortunately, with my protocols, an altered level of consciousness prohibits me from giving […]