Pain Management and Tiered Response Are Not Compatible

Pain Management was the topic of the latest episode of the First Few Moments podcast.  Kyle David Bates, Brad Buck, Wilma Vinton, Roland Rolfsen, Dr. Laurie Romig, and Tim Noonan discussed the why, what, when, and who of it. 

Playing devil’s advocate, Kyle asked why it is important for us to manage pain.  After all, life hurts sometimes. He also touched on how pain medication should be incorporated into teired BLS/ALS systems.  For several complaints listed in a popular EMS dispatch triage program, it states the severity of pain is not indicative of the severity of the problem.  A BLS response is usually indicated for abdominal pain, back pain, falls, and isolated injuries, but only ALS is equipped to deliver medication for pain.

Dr. Romig answered that some other chronic conditions may be made worse with pain, especially if it increases during movement.  She sited atrial fibrillation as an example, which severe pain may cause to become uncontrolled.  Now a patient with a hip facture may unncessesarily require management for that also.  Not only would this preventable, it may also go unnoticed unless a cardiac monitor is available.

Tim brought up how orders for pain medicaiton are often denied if there is a short ETA to the hospital. Inadequately medicated patients must then endure more pain while being moved to the ambulance, often strapped to a hard board, and then be given a bumpy ambulance ride to the hospital. First we’re supposed to do no harm, right?

Dr. Romig also pointed out that patient usually wait hours in the hospital before receiving any pain medication.  This has been demonstrated in at least three studies.  In one of them, teired response was sited as a reason for pain medication being given to patient with extremity fractures so rarely.  Medication means ALS has to ride along instead of going available.  So after patients get our dump truck ride to the hospital, they wait in the ER hallway until someone notices them. 

BLS units must request ALS in order for patients to receive pain medication, but what should that request be based on? BLS is taught that pain is not an emergency, and we know that a patient’s self-report is the only reliable way to determine how much pain someone is. An ALS request means that more time must be spent on scene, and is not usually well received by the ALS crew when they arrive.  After all, it’s none of our family members’ pain.  Unless it is, then we know what to aks for when we call 911.

So why isn’t this a bigger priority for us?  It is in other countries. The short answer is because we allow our education and professional standards to remain so low.

Administering pain medication should be a high frequency, low risk procedure.  There is nothing particularly advanced about it.  Side effects are rare and can be easily managed by one competent paramedic. 

Handling narcotics is a big responsibility, and is a privlege that should not be dispensed lightly.  However, EMS practitioners at all levels already care for some of the most vulnerable people, at the worst moments of their lives. We have access to their valuables and medications when no one else is looking.  We are also trusted to drive those patients to the hospital.   We seem to dispense those privileges very lightly, though I would argue that they require even more responsibility than handling controlled substances. 

Very few patients need EMS to save their lives – probably not enough to justify the cost of paramedic systems – but that is the only thing many systems are designed to do.  Many more patients can be helped to feel better, and narcotic pain medication is part of that.  As we grow into a profession, we need to reevaluate what we are here for.

Go listen to the podcast. It is well worth it.


  1. I fantasize about intranasal analgesia, antiemetics, and anxiolytics making their way onto the BLS unit with liberal orders for their use. An emphasis on palliative care would multiply the good we do out there by a factor of a thousand. But that’s not even remotely close to reality.

    • emspatientperspective says:

      Thanks Brandon. It’s not the route (IV vs IN) that those things are given that make it advanced, it’s that it requires an understanding of the pharmacology. IMHO, that topic is not sufficiently covered in most ALS education programs. Life saving comes from BLS skills done well (and thank you for teaching us how to do them better). Assessment and symptom relief is ALS in this country, and we have a long way to go with that, too. Like I said, it’s time we reevaluate what we’re here for and figure out how to better serve the 99% of patients who don’t need their life saved.

      • Right… and the problem is that if I DO call in ALS for pain management, they’re reluctant to do much anyway (for numerous reasons), so it’s seen as a waste of resources. I agree that we shouldn’t just throw around serious pharm, but I raise the possibility to illustrate that it’s at least theoretically possible to introduce such things without large-scale changes in the BLS scope, and I have to wonder if there aren’t reasonable avenues that could be explored here. Perhaps the model could become that BLS provides minor to low-moderate symptomatic relief and meets ALS for anything greater.

        I know that some services overseas are using inhaled nitrous oxide, for instance. And we’re giving IN naloxone over here, with good results, and a few years ago some people would have said that couldn’t possibly be BLS. At some point slippery-slope and worst-case arguments are just fear mongering.

        • emspatientperspective says:

          Brandon, I agree that patients lose in all of these scenarios. BLS does pain management in other countries – after they go to school for two years. If they want to do any of the dangerous stuff – intubation, give antiarrhythics, cardiovert, etc, then they go to school for an additional year. What makes us different? How much more can possibly squeezed into the 150 hour EMT courses we have in this country now?

          We agree that all patients deserve some things from their EMS system, such as CPAP, 12-leads, and pain management. Instead of adding all the things you talk about to the BLS curriculum, why not just have a paramedic on every call?

          • Well, that’s usually the practical answer, not that they necessarily end up doing aggressive palliative care anyway. But in my mind, the difference is that most ALS skills are indicated for relatively low-probability scenarios. Most people don’t need a needle cric or dopamine, so it makes a certain amount of sense for the units that offer it to be available for intercept or dispatched to highly suggestive complaints, but otherwise for us to use a lower tier of care.

            But varying degrees of pain or distress are NOT uncommon; in fact, if you lump them all together they’re probably among the most common symptoms we see (whether the chief complaint or along for the ride). So we end up having to make a decision between just ignoring it, or calling in the “big guns” every time, neither of which works… or simply making everybody big guns, which is not efficient either since those patients still don’t need a needle cric or dopamine.

            I do believe in tiered systems and I work in one, but I think where they fail is palliative measures and certain types of screening (mainly the ability to cast a wide ACS net with the 12-lead)


  1. […] written before about why I believe a paramedic should go on every 911 call, both in EMS World and here. I appreciate Kelly and Chris having me on; it was a spirited discussion on the podcast, and both […]

  2. […] written before about why I believe a paramedic should go on every 911 call, both in EMS World and here. I appreciate Kelly and Chris having me on; it was a spirited discussion on the podcast, and both […]

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