# Resistance to pain medication



## d_miracle36 (Mar 25, 2012)

I have run into a situation at my ems service. I myself advocate pain managment when given appropriately and I do not hesitate to give it. Even though we have a pain managment protocol, morphine and fentanyl a lot of the older medics at my service frown upon it. How do I deal with this and approach it? Also I transported a ventilator pt. interfacility who was on a propofol drip but able to respond via hand gestures. I asked the nurse for analgesia and she comes back with 2mg of morphine. during transport I asked if he was still in pain and he responded with a yes in hand gestures and I administerd 50ug of fentanyl and the field training officer told me he already recieved 2mg of morphine, I responded that the pt. was 300 pounds and intubated. Am I wrong here? how do I deal with this?


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## 18G (Mar 25, 2012)

Im not even sure if I want to get started on lack of proper analgesia in the post-intubated patient! Nobody seems to get the need and I'm including RN's and physicians. The evidence is there as is the many position papers strongly advocating analgesia. 

I run into nurses that think propofol and benzos provide pain relief. I even had an intubated pt. on the cath lab table grimacing with two nurses holding the pt. I ask for fentanyl and one RN say's it's just the patient's reflexes. Luckly, the doctor gave me the order and as soon as the patient received the fentanyl he stoped grimacing and moving.. amazing!

Provide the evidence from the many studies out there. There are physician groups out there with position papers on analgesia in the post-intubated patient. Arm yourself with knowledge and evidence and inform them. 

Did you increase the propofol at all?


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## DrankTheKoolaid (Mar 25, 2012)

Wow this is wrong on so many levels.  

Intubated and awake enough to answer questions......    I would not have any accepted the transfer until the patient was sedated and received analgesia.  and really, 2mg's why did they even bother.

Follow your protocols and QA/QI have nothing to say about it.  If they are dinosaurs that dont believe in prehospital analgesia work hard until you can get into a QA/QI position and change the way your prehospital analgesia is viewed within your company by providing educational material.   EMS providers either need to evolve along with medicine or get out of medicine altogether as they do more harm then good staying it it.


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## d_miracle36 (Mar 25, 2012)

No I didnt increase the propofol but did think about it. I wasnt familiar with propofol drips at the time and was hoping that the fentanly and propofol combined would be enough analgesia and sedation. The pt. relaxed and was comfortable after the fentanyl.


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## d_miracle36 (Mar 25, 2012)

Also one more question, do you think 100ug of fentanly is too much for someone in severe pain? I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?


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## d_miracle36 (Mar 25, 2012)

I agree with you all the way corky. I am quite distressed over the whole situation. We are a private service and operate under state protocols. Just recently got a medical director who is involved. We have 3 q/a officers and only one is on board with pain control but is afraid to voice his opinions. I dont know how far i will get if I keep arguing with them haha. I really hate this and i dont want their opinions to affect my pt. care and just dont know how to deal with it.


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## DrankTheKoolaid (Mar 25, 2012)

No i personally dont.  If you get a chance shadow a CRNA/MD for a while.  Also there are plenty of blog/podcasts out there.

Go to Emcrit.com and look for the bad sedation package podcast and give it a listen


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## bigbaldguy (Mar 25, 2012)

d_miracle36 said:


> I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?



My understanding is that fent doesn't cause as much respiratory as morphine but can still cause it to a lesser extent.


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## Aidey (Mar 25, 2012)

Corky said:


> Wow this is wrong on so many levels.
> 
> *Intubated* and awake enough to answer questions......    I would not have any accepted the transfer until the patient was sedated and received analgesia.  and really, 2mg's why did they even bother.



The OP never said anything about intubated, just that it was a vent patient.


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## Tigger (Mar 25, 2012)

d_miracle36 said:


> Also one more question, do you think 100ug of fentanly is too much for someone in severe pain? I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?



Having been on the receiving end of it recently, I think that is perfectly acceptable. 100mcg of Fent was a good start, but it took 200-300 to actually knock down the pain. My understanding is that the 100mcg initial dose is fairly standard in the ER as well.


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## usalsfyre (Mar 25, 2012)

Corky said:


> Intubated and awake enough to answer questions......    I would not have any accepted the transfer until the patient was sedated and received analgesia.  and really, 2mg's why did they even bother.


I transport quite a few patients that fit this description. They're at the weaning stage of their admission and are going to an LTAC to complete the process. If you snow them you run the risk of setting the process back, and possibly causing your patient to be trached.

Be careful messing around with these patients.


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## usalsfyre (Mar 25, 2012)

Aidey said:


> The OP never said anything about intubated, just that it was a vent patient.



While I can't speak for the OP, patients who are trached generally don't require sedative infusions.


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## d_miracle36 (Mar 25, 2012)

Sorry about the confusion. This pt was intubated. I had a pt recently that I gave fentanyl to and it took up to 125 before he had enough relief from pain.


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## DrankTheKoolaid (Mar 25, 2012)

usalsfyre said:


> I transport quite a few patients that fit this description. They're at the weaning stage of their admission and are going to an LTAC to complete the process. If you snow them you run the risk of setting the process back, and possibly causing your patient to be trached.
> 
> Be careful messing around with these patients.



While this is true, nobody said to "snow" the patient.  Stick a garden hose in the back of your throat for any reason and tell me what you think about it.  And tell me you dont mind that kind of constant stimulation.  Proper analgesia should never be withheld.

And true, i only assumed it was a intubation and not a trach patient, i should have clarified that from the start.

I also transport quite a few intubated on vents patients but it is always to definitive care.  Transport times are 1hour from podunk bandaid station to the nearest Level 2.  That also factors into my thought process on the subject, OP's situation could be different with a short ETA.  But my opinion will always be never ever ever withold analgesia in a vented patient.


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## Aidey (Mar 25, 2012)

Since the patient was alert enough to answer questions with hand gestures I figured they weren't receiving the full anesthetic dose. The pt could always be on the drip as a comfort measure for transport if they don't tolerate the vent well. 


Edit: Nevermind, the intubated part was at the end of the post. I really need to get my prescription updated...


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## usalsfyre (Mar 25, 2012)

Corky said:


> While this is true, nobody said to "snow" the patient.  Stick a garden hose in the back of your throat for any reason and tell me what you think about it.  And tell me you dont mind that kind of constant stimulation.  Proper analgesia should never be withheld.
> 
> And true, i only assumed it was a intubation and not a trach patient, i should have clarified that from the start.



50mcgs of fent was wholly appropriate. But don't be so quick to condem someone being awake on a tube till we know the whole story. 

I really like fent infusions, but the controlled substance issues seem to drive people bonkers.


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## DrankTheKoolaid (Mar 25, 2012)

usalsfyre said:


> 50mcgs of fent was wholly appropriate. But don't be so quick to condem someone being awake on a tube till we know the whole story.
> 
> I really like fent infusions, but the controlled substance issues seem to drive people bonkers.



Oh no I wasnt condeming him, I hope it didnt come across that way as that was not my intention


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## jjesusfreak01 (Mar 26, 2012)

Corky said:


> No i personally dont.  If you get a chance shadow a CRNA/MD for a while.



Burn unit nurses might as well be CRNAs...they're about as good at providing proper analgesia as anyone else in the hospital.


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## DrankTheKoolaid (Mar 26, 2012)

jjesusfreak01 said:


> Burn unit nurses might as well be CRNAs...they're about as good at providing proper analgesia as anyone else in the hospital.



Absolutely agree there.  That is a specialty of medicine that truely knows about pain control


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## systemet (Mar 27, 2012)

d_miracle36 said:


> Also one more question, do you think 100ug of fentanly is too much for someone in severe pain?



No, not for most patients.

What's too much is a dose that causes hypotension, respiratory depression, apnea, or loss of control of airway reflexes.  For most people this will be more than 100ug.



> I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?



Fentanyl can cause respiratory depression / apnea as well.  

For most people 10mg of MS isn't too much for severe pain.  What's too much is a dose causing hypotension, respiratory depression, apnea, or loss of control of airway reflexes.  A reasonable analgesia dose of MS is somewhere around 0.1 mg / kg, which for a larger person is close to 10mg.  Most of us have just been terrified into giving smaller doses, e.g. the homeopathic 2mg MS IVP.

You have to accept that there's a huge amount of interpatient variability.  You will see some people get very very sleepy with even a relatively small dose of morphine or fentanyl.  And it's not always the 45 kg geriatric patient, sometimes it's the big 110kg ex-football player.  

There's also a lot of unpredictability if you are mixing benzodiazepines with opiates.  If you're going to do this, you need to be aware that they're synergistic, and a small amount of the two in combination go a long way.

I think an intelligent approach is to give moderate quantities on a repeat basis until the pain is manageable.  You can always give more, but you can't take it back if you give too much.

I've given 30mg of MS IVP to an end-stage cancer patient with chronic pain (*After consulting with a palliative MD).  I've also given a four year old child 14mg of MS after they poured a pot of boiling water over themselves.  There's no fixed magic number that's "too much", it depends on the patient in front of you, and how they respond to initial and subsequent doses.


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## Melclin (Mar 27, 2012)

d_miracle36 said:


> Also one more question, do you think 100ug of fentanly is too much for someone in severe pain? I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?



I think the 80-100 x stronger is generally quoted. My experience is that its more towards the 80 end of the spectrum. 

Who said it even needed to be severe pain? I picked a bloke up the other day from a local hospital with an incarcerated hernia. He was still uncomfortable after 12.5 mg morphine given at the hospital. I gave him a total of 100mcg of fent, bringing him down from uncomfortable to comfortable. While I'm sure incarcerated hernias are not lovely, 60% BSA burns they are not. But its still pain. Far from becoming becoming comatose, resp depressed and the world generally falling apart, on arrival at hospital, he stepped down off the stretcher, I took him to the toilet, after which we walked to his waiting hospital bed, while chatting about lunch plans. 

Fent especially is easy to titrate. With the addition of a little common sense, its a pretty easy game. Honestly, if my grandmother is trusted to titrate her PO opiate analgesia, surely a healthcare professional can manage a little IV fent or morph.


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## johnrsemt (Mar 27, 2012)

We had a doctor that used to give radio/phone orders for Morphine (above written protocols):  "give them 5mg every 5min until they stop breathing;  then bag them".  When they are unconscious pain is pretty much gone.
   Never went to that extreme;  but my goal is always:  Pain is gone,  patient feels better; and gets better faster.

  My father's doctor told him to take 2 percocet every 4 hours for pain from a DVT:  due to "if your body is fighting the pain, it can't fight the insult/injury to it".


   I hate working with medics who won't give pain meds "because I am afraid that I will get the patient addicted to it"


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## KellyBracket (Mar 27, 2012)

johnrsemt said:


> We had a doctor that used to give radio/phone orders for Morphine (above written protocols):  "give them 5mg every 5min until they stop breathing;  then bag them".  ...



Something for me to aspire to!

And by the way, with all due respect to the experience of usalsfyre, nobody should feel responsible that they'll cause a patient to get trached. Far from it - the evidence suggests that more patients should be trached, and earlier. It's more comfortable, and seals up nice when it's no longer needed!


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## jwk (Mar 27, 2012)

d_miracle36 said:


> Also one more question, do you think 100ug of fentanly is too much for someone in severe pain? I read that 100 of fentanyl is compared to 10mg but I think it is *acceptable because it doesnt produce the respiratory depression like morphine*. Any thoughts?



My thought is you're wrong.  Fentanyl most certainly can produce significant respiratory depression.


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## jwk (Mar 27, 2012)

jjesusfreak01 said:


> Burn unit nurses might as well be CRNAs...they're about as good at providing proper analgesia as anyone else in the hospital.



Seriously?  There's FAR more to anesthesia than pushing a few narcs.  You're wayyyy outside your area of expertise.


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## Hellsbells (Mar 28, 2012)

Our guidelines are generally Morphine 5mg q 5mins to 20mg, 5mg q 15min thereafter.

Or fentanyl 50mcg q 5mins to 200mcg, 50mcg q 15min thereafter. 

If these narcs arnt cutting it, then we can go to Ketamine or toradol as well.


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## Shishkabob (Mar 28, 2012)

d_miracle36 said:


> How do I deal with this and approach it?



Tell them you are your own Paramedic, and that you treat YOUR patients how YOU decide is best.


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## jjesusfreak01 (Mar 28, 2012)

jwk said:


> Seriously?  There's FAR more to anesthesia than pushing a few narcs.  You're wayyyy outside your area of expertise.



I'm not talking about myself here. I have a friend who is a BSN in a burn unit, and they go through specific training about how to provide proper analgesia, which they then get to put into practice every day they are working. While doctors write the orders, the nurses are responsible for seeing how the patients react to the medications and ensuring that the patients pain is being adequately managed. In the end, its years of experience that teaches any provider how to properly manage pain, not classes or degrees.

Also, burn units don't just "push a few narcs". Their patients are very frequently intubated, so they are pushing narcs, dissociatives, sedatives, hypnotics, and paralytics. It appears treatment in burn units is outside of your expertise.


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## Farmer2DO (Mar 28, 2012)

jjesusfreak01 said:


> Burn unit nurses might as well be CRNAs...they're about as good at providing proper analgesia as anyone else in the hospital.





jwk said:


> Seriously?  There's FAR more to anesthesia than pushing a few narcs.  You're wayyyy outside your area of expertise.





jjesusfreak01 said:


> I'm not talking about myself here. I have a friend who is a BSN in a burn unit, and they go through specific training about how to provide proper analgesia, which they then get to put into practice every day they are working. While doctors write the orders, the nurses are responsible for seeing how the patients react to the medications and ensuring that the patients pain is being adequately managed. In the end, its years of experience that teaches any provider how to properly manage pain, not classes or degrees.
> 
> Also, burn units don't just "push a few narcs". Their patients are very frequently intubated, so they are pushing narcs, dissociatives, sedatives, hypnotics, and paralytics. It appears treatment in burn units is outside of your expertise.



I think everyone needs to realize that you guys are talking about 2 completely different job descriptions here.  I agree, burn nurses (in general) are pretty damn good at managing pain.  They "get" the big picture, and for the most part, aren't afraid to use a lot of meds to help their patient.  Doses that would usually be far outside the comfort zone of most nurses, even many ICU nurses.  That does not by any means, however, equate to them being a CRNA, or even close.  Completely different job.  That's a nurse practicing anesthesia (I have my own opinions about the whole topic), not a nurse doing bedside care.  One year at my last employer, where we ran about 35.000 jobs a year, I was 70% of the controlled substance administrations, company wide.  That fact alone does not make me nearly a CRNA.


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## systemet (Mar 29, 2012)

jjesusfreak01 said:


> In the end, its years of experience that teaches any provider how to properly manage pain, not classes or degrees.



You have to have both academic preparation and clinical experience, in my opinion.  If your options for pain control are pretty much give one of more or morphine, fentanyl, demerol, lorazepam, diazepam, midazolam, toradol or ketamine, following a suggested guideline -- that's very different from having a wider range of agents available and having skills like spinal or epidural anesthesia, or the ability to provide nerve block, etc.

Experience can be a good teacher, provided you're willing to listen to the lessons it provides.  Not everyone is, and for a lot of us, experience is just the process of providing suboptimal care on a repeated basis over a long period of time.  

There's a point where your ability to provide treatment is limited by your educational background, and your scope of practice.  While I'm at least a reasonably competent paramedic, I'm pretty certain that an anesthesia provider approaches pain management in a completely different manner to how I do, has a lot more options to consider, and knowledge of a lot of issues that completely elude me.

There's also an issue of autonomy here.  As good as a given burn RN may be, and I accept that they're like very caring, excellent people, and could teach me plenty, how much real power do they have over how the patient is treated?  Part of the difference in the scope of practice of an RN or a paramedic and a specialty physician are grounded in the physician having being exposed to a far greater concentration of patients requiring pain management and experience using a far greater range of techniques.

This isn't to trash burn nurses in any way.  I have lot of respect for them, but let's be realistic here.




> It appears treatment in burn units is outside of your expertise.



Are you aware of what jwk's area of expertise is?  I think you might reconsider your statement.

Have you considered that there might be a medical specialty outside of burn nursing that might have substantially more education in providing analgesia and anesthesia?


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## Veneficus (Mar 29, 2012)

jwk said:


> Seriously?  There's FAR more to anesthesia than pushing a few narcs.  You're wayyyy outside your area of expertise.



you're right, here is the instructional video 

http://www.youtube.com/watch?v=xuZl9tRqjoQ


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## jjesusfreak01 (Mar 29, 2012)

systemet said:


> Have you considered that there might be a medical specialty outside of burn nursing that might have substantially more education in providing analgesia and anesthesia?



Yeah, anesthesiologists and CRNAs...probably pain management specialists as well. I never said burn nurses are the best, just that they are quite competent at analgesia, and are required to provide anesthesia to a limited degree (that is, they push the drugs and they are responsible for monitoring patients under anesthesia in the ward).


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## Rogue Medic (Mar 29, 2012)

*Too much morphine or fentanyl?*

There is a lot of research available on the use of fentanyl, or morphine, for severe pain. Here are just some of what is out there.

-

*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.*

*Fentanyl Study: EMS Research Episode 9*
EMS Research Podcast
*Podcast*

I created my own charts to highlight the effects of fentanyl from the study above - 

*Chart Version – Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia*
Sun, 05 Jun 2011

-

*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.*

-

*A protocol to improve analgesia use in the accident and emergency department.*
Goodacre SW, Roden RK.
J Accid Emerg Med. 1996 May;13(3):177-9.
*PMID: 8733653 [PubMed - indexed for MEDLINE]*

*Free Full Text from PubMed Central*

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*Prehospital use of analgesia for suspected extremity fractures.*
White LJ, Cooper JD, Chambers RM, Gradisek RE.
Prehosp Emerg Care. 2000 Jul-Sep;4(3):205-8.
*PMID: 10895913 [PubMed - indexed for MEDLINE]*

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*Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients.*
Bijur PE, Kenny MK, Gallagher EJ.
Ann Emerg Med. 2005 Oct;46(4):362-7.
*PMID: 16187470 [PubMed - indexed for MEDLINE]*

This is just an abstract, but I wrote about it in detail - 

*Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients*
Fri, 07 May 2010

also - 

*Pain Management: EMS Garage Episode 85.*

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*Avoiding trouble when using opiates to treat patient pain.*
June 2003 ACP Observer, copyright © 2003 by the American College of Physicians.
By Jason van Steenburgh
*Article*

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*ED procedural sedation of elderly patients: is it safe?*
Weaver CS, Terrell KM, Bassett R, Swiler W, Sandford B, Avery S, Perkins AJ.
Am J Emerg Med. 2011 Jun;29(5):541-4. Epub 2010 Apr 24.
*PMID: 20825829 [PubMed - in process]*

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*Elderly Emergency Department Patients With Pain Are Less Likely to Receive Pain Medication*
Tue, 16 Aug 2011

I write about some abstracts published at EP Monthly - 

*Practice Changing Abstracts*

-

*Analgesia in patients with acute abdominal pain.*
Manterola C, Vial M, Moraga J, Astudillo P.
Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005660. Review.
*PMID: 21249672 [PubMed - indexed for MEDLINE]*

*AAP* is Acute Abdominal Pain –


> AUTHORS’ CONCLUSIONS:
> The use of opioid analgesics in the therapeutic diagnosis of patients with AAP does not increase the risk of diagnosis error or the risk of error in making decisions regarding treatment.



-


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## Handsome Robb (Mar 29, 2012)

d_miracle36 said:


> Also one more question, do you think 100ug of fentanly is too much for someone in severe pain? I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?



We routinely give 100 mcg doses. Our Pain/Sedation management protocol says "1-2 mcg/kg to a max single dose of 100 mcg q 5 minutes to a total of 300 mcg" After that we have to call for orders for more. 

My partner was working an OT shift today and brought us a trauma patient and he had maxed out the fentanyl dose and told me he almost called for more. 

It isn't unusual for us to hit our limit on fentanyl.


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## systemet (Mar 30, 2012)

Here's a news article from the BBC, about the use of fentanyl as an illicit drug in Estonia.  It's not particularly well written, especially from a scientific perspective, but I found it interesting.  (Not quite sure about statements like "after fentanyl you just don't feel heroin any more", or words to that effect).

http://www.bbc.co.uk/news/world-europe-17524945


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## d_miracle36 (Apr 12, 2012)

Linuss said:


> Tell them you are your own Paramedic, and that you treat YOUR patients how YOU decide is best.



Like this


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