Nebulized Ketamine to Nebulized Fentanyl for Treating Acute Painful Conditions in the ED

Inclusion Criteria: * age 18+ years * acute painful condition * pain score of 5 or more on a standard 11 point numeric rating scale (NRD) * patient needs to be awake, alert, and oriented as to person, place, and time * demonstrated understanding of the informed consent process and content * patient needs to demonstrate the ability to verbalize the nature of any adverse effects (AE) * patient needs to experience as well as express their pain severity by using the NRS Exclusion Criteria: * patient with a painful condition warranting emergent/urgent intervention in the ED * patients with altered mental status * allergy to ketamine or fentanyl * pregnant or breastfeeding * weight greater than 100 kg * patients presenting with head injury * unstable vital signs (systolic blood pressure \<90 mmHg or \>180 mmHg, pulse rate \<50 beats/min or \>150 beats/min, and respiration rate \<10 breaths/min or \>30 breaths/min) * inability to provide consent * current medical history of alcohol or drug abuse * administration of opioids or opioid antagonist/agonist within 4-6 hours prior to arrival and NSAIDs 6 hours prior to arrival to the t