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 II

Continuing from 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.

d. Patient has altered level of consciousness [1]

Isn’t the problem the severity of the pain?

If I have pain that is truly 10 out of 10, is it possible for me to NOT have an altered level of consciousness?

For example, if I were using a wood chipper and had an arm dragged into the blades before I could hit the safety bar (the orange rail around the opening), I would not expect to be able to provide reasonable answers to any of the level of consciousness questions we routinely ask.

Image credit.

What is my name?

Maybe I can get that one right.

Where am I?

I’m stuck in a chipper. There might be some superfluous adjectives included in my response, but is that question really appropriate at this time?

Do I know what day it is today?

Could today be the day I engage in a bit of justifiable homicide? I ordinarily look at my cell phone to find out the date. My hand appears to be occupied, so I may not have easy access to my phone – assuming that I even want to answer the question.

We do want to know about allergies and medical conditions, but the only reason to ask level of consciousness questions is a misguided effort to treat the protocol at the expense of the patient.

Are there any signs of a head injury? That would be much more useful information than Alert and Oriented Times Three.

The truth of severe pain is that level of consciousness improves AFTER several doses of pain medicine.

We should expect level of consciousness and vital signs to improve after treatment with high doses of medications that would be expected to worsen level of consciousness and vital signs in people who do not have severe pain.

Pain medicine can be morphine, fentanyl, hydromorphone (Dilaudid, Palladone), or other opioid medication. Another possibility to help in extricating me from the wood chipper, that is less likely to produce respiratory depression, is ketamine.

Imagine that extreme amount of pain, the pain continuing at about the same level, then having to reverse the wood chipper to get my arm out.

Do you imagine that there would be a normal level of consciousness on my part?

Is that an acceptable reason to deny me treatment?

Is that an acceptable reason to deny me treatment that will probably improve my level of consciousness?

Suppose that I had severe burns, rather than musculoskeletal trauma. Would the concern about level of consciousness be any different?

What do you think?


[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



  1. I am not going to say that your protocols are wrong, because I don’t practice in the State of Pennsylvania. However, I would encourage a petition to update your protocols. How are they devised? When they are being updated or revised, are those meetings open?

    Here in Colorado, we have a statute, collectively called the 500 Rule, that defines the scope of practice for EMT-B, EMT-I, and EMT-P/APEMT-P.

    Each Prehospital region or area has it’s own protocols. They might use the Denver-Metro Protocols, or the Medical Director for that service might have his own protocols. In addition, at least here in Denver, for the most part our protocols are “bendable”. As long as you’re able to appropriately rationalize why you did what you did, there is usually little negative criticism from the receiving doctors..

    Is it confusing? It might be for the outsider, however, the system works well. If we are transporting from one area to another, the primary ambulance, plays by its own protocols. It allows for the flexibility in treating patients in the different areas, where your resources to appropriately care and transfer your patient vary greatly.

    I’m sorry about getting off topic, however, your protocols for pain control made me, well, flabbergasted.

    I think that the limits for LOC and SpO2 are strict, when there really isn’t literature to back that up. YOU are the one that has first access to the patient. YOU are the one that is in the best position to determine the most appropriate treatment for your patient.

    I always thought there were areas that we were behind in regards to our protocols. I still think there are areas that we can improve in. Even though I am no longer a Paramedic, I still like to stay abreast.

    Your blog has opened my eyes to how good I really had it has a Paramedic in my area.

    If you are interested, links to a portion of our 500 Rule and the Denver-Metro Protocols.



  2. It’s writing protocols to the lowest common denominator. Because a few paramedics are unable to determine when it is inappropriate to give opioids to an altered patient, they make sure that no paramedics have the chance to make that mistake.

  3. “Could today be the day I engage in a bit of justifiable homicide?”

    Your dry humor has been particularly keen lately, sir.