Narc Policies that Make it Hard to Do the Right Thing

Several ALS procedures, such as intubation, IV fluids for trauma,  and ACLS drugs  have not been proven to make a difference or have been shown to cause harm.  Pain management, however, is one procedure that we positive does help.

Consider this excerpt from a 2000 Journal of the Royal Army Medical Care article that Peter Canning wrote about in Street Watch: Notes of a Paramedic:

“The effective management of pain in the pre-hospital environment may be the most important contribution to the survival and long term well being of a casualty that we can make. The pre-hospital practitioner has the first and perhaps only opportunity to break the pain cascade.

My patients are lucky.  We carry Fentanyl in our first-in bag and can administer it before moving the patient.  We have standing ordres to  give up to 200 mcg before calling to ask for more, and I have never been denied a request.  We can give it IN very quickly, before inflicting more pain from starting an IV.  This is different from my experience at other services.

When I worked at McAmbulance, narcotics (Morphine and Valium for seizures) were in a locked box stored in a locked cabinet inside the ambulance.  When a patient was actively seizing, the paramedichad to either abandon the patient and to run back to the truck, unlock the cabinet, and then unlock a box to get the Valium, or carry them to the ambulance before medicating them.  For pain management, a call to medical control was required in addition to those steps to give morphine.  The 2-4 mg doses that the doctor usually allowed never seemed to be worth the effort, so it was rarely done.   Additional paperwork was required, as well as a call to the “narcotics control officer” immediately after the call, no matter the time.  This was a boss that most of us didn’t like, so that was actually an incentive for some people to give morphine in the middle of the night.

At another service I worked for, narcotics were tracked with a log book that had to be kept at each station.  They had to be restocked at a pharmacy deep in the bowels of that service’s mothership hospital.  When narcs were used, units had to return to their station after clearing the call,  fill out the log book, and take it to the hospital to restock them.  That took about an hour for most stations in normal traffic, and even longer for the outlying units.  You can imagine how many patients got narcotics in the middle of the night or near shift change.  Units were in service without any pain medication during the log book retrieval, and the patients they encountered were out of luck if they needed any.

Not giving nitro to an eligible chest pain patient would be a protocol violation, despite mounting evidence that it doesn’t do anything.  But pain medication seems to be optional, despite mounting evidence about how important it its.  It’s not available to most patients in tiered systems, and it is acceptable in other systems for paramedics to release patients in pain to BLS providers.

For some reason we are okay strapping patients with hip fractures to a hard board, carrying them out of their homes for the last time the last time, and driving them over bumpy roads to the hospital without giving them pain medication first.  Too many EMS people think it is not important, and that message is reinforced with these types of narc policies.  After all, it’s not their family member, and it’s just easier for everyone if the narcs stay in the package.

I understand the need to track and account for narcotics, but the way this was done at both services discouraged people from using them.  It doesn’t have to be that way.  If your people can’t be trusted without tight control over narcotics, then they can’t be trusted to be alone with vulnerable patients.  If they can’t be trusted to administer narcotics with out permission from a doctor, then they can’t be trusted to administer any other drug we carry.  If ridiculous state laws are in place, then advocate to change them.  Let law makers know how their loved one’s pain is likely to be treated by their EMS system.

When writing narc policies, think about whether your people will more or less likely to treat patients the way MedStar treated my aunt.  Please make it easier to do the right thing.



  1. I remember a few months into my first civilian EMS job (it was the mid-90’s and I was an EMT), I was at a local trauma center dropping off a pt and another crew was coming in with a pt that was standing by a propane cylinder that ignited and he was >50% 2nd and 3rd degree burns. The unit called for morphine and the doctor ordered 2mg. Another medic in the ER overheard and yelled, “Why don’t you just order them to spray it on the patient?” The doctor reiterated his order and went about his rounds. The patient was later wheeled in screaming about the pain. I talked to a flight crew that was called in for the pending arrival to prep him for a flight to a burn center and their medic said we don’t carry enough morphine on the units for patients like that. I found out later in my career when I was running my own burn patients as a Paramedic what the flight medic was talking about. 20mg was all we carried and I gave it all to a burn patient. We brought the pain from a 10 to a 7 and no hemodynamic or respiratory changes observed.

    • emspatientperspective says:

      Thanks Unwired. Rogue Medic often writes about how we give too low doses of pain medication, and he’s right. Our goal should be to medicate until the pain is gone, not a number in a protocol book.

  2. This is a great review of some of the systemic barriers to the full use of prehospital analgesia. As you point out, these well-meaning precautions become unwieldy in practice, and may work against the public interest.

    One further perspective: When our group of researchers interviewed paramedics about pain control, we specifically sought their thoughts about just these sorts of obstacles to administering, restocking, and documenting opiod medications. We had expected, based on common experience and prior surveys, that medics would describe these elements as significant factors. Surprisingly, almost none of the medics, across a variety of EMS systems, mentioned any concerns.

    Our study was published earlier this year ( If anyone wants a reprint, feel free to DM me at “at” brookswalsh.

    • emspatientperspective says:

      Thanks Brooks. I would like to read your study. I am not surprised, but disappointed that paramedics were not concerned about administering pain medication. I think it demonstrates a fundamental flaw with paramedic education, which breeds ignorance about how important pain management is. I hope that changes.

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