Why do paramedics not want to treat pain in kids?

Forgive me for my provocative title.

Of course, most paramedics do want to treat pain in kids. It's been shown, however, that EMS (like many areas of medicine) doesn't do a great job treating it. Why is that?

Quantitative versus qualitative research

Studying many questions in EMS is relatively straightforward, as you can always look at the numbers.

Does prehospital CPAP prevent intubations? Just count how many people get tubed in the ED! Does use of a CPR-machine save lives? Well, count up how many patients get ROSC!

These sorts of studies, where we look at numerical comparisons, rates, and statistical differences are all quantitative - these rely on obtaining and comparing numbers. To answer this question (about what keeps medics from providing analgesia to pediatric patients), however, EMS researchers in Rochester NY used a qualitative method. 

So this study didn't involve measuring or testing, and collecting a bunch of numbers. Instead, the authors went out and, essentially, listened to what paramedics had to say on this topic!

PubMed link

How they did they do the study?
Getting a paramedic to open up and share their experiences is not exactly the hardest thing in the world...

Pictured: A whole book about medics talking.

 Far from just writing down a bunch of "war stories," however, the authors followed a few steps to ensure they obtained useful and credible information. 

They recruited medics from a variety of agencies in western NY state, with differing levels of experience, and varying levels of comfort dealing with kids. They also brought in a paramedic to actually conduct the interviews, figuring that this would be less intimidating than a physician or PhD. They also tried to figure out a useful way to guide the interviews, designing a set of provocative questions, but also planned to let the medics talk freely and widely on the topic.

So what did the medics say?

Some surprising things!

Now, this sort of research isn't designed to produce statistics or predictions, but I want to highlight some of the results that were felt by the authors to be new and significant, as well as direct quotations from the interviews.

The authors found that "the majority [of medics] viewed relieving pain as unimportant and not part of their job."

They also saw that the medics, in general, "were also concerned that the patients might have an unknown allergy to morphine ... [and had] a similar concern for causing respiratory depression"

Lastly, they found that paramedics "reported receiving generally no response or a negative response from hospital pediatric ED staff."

There are a number of other results and quotations in the article, but I think that these 3 selections convey the general point. Analgesia for pediatric patients is seen as fraught with risks, and is not emphasized as a priority.

As the medics see it, there are few ways to win, and many ways to lose!

Given the inconsistent support from supervisors and ED staff, there is every incentive to shove the issue off, and let the ED handle analgesia.

So, what can be done?

Paramedics are known for their aggressive attitudes in the field, and they don't shy away from challenges. Drilling needles into bone, cardioverting VT with a pulse, or even giving tPA in the ambulance - medics get into the field so that they can tackle the tough problems, not avoid them!

So it's not too hard to figure out where the medics acquired these perceptions about pediatric analgesia. They got these ideas from their supervisors, from their EMS educators, from their rotations in the ED, and in discussions with ED nurses and medical control doctors every day. I agree wholeheartedly with the authors when they conclude that

... the onus of responsibility to change the belief structure regarding pediatric pain management lies not with the paramedic, but with physicians, hospital staff, and paramedic supervisors.

The Bottom Line...

Medics, like all of us, like to engage in a modest amount of medically-appropriate bragging.

"Modest bragging" source

Whether it's sinking a tight ET tube, reversing a bad CHF with aggressive CPAP and nitro, or cardioverting VT in a patient's living room - it's all good material for illustrating your medical prowess. So why not with analgesia?

Perhaps in the future, we'll have quotations from medics that read a little different from those in this study. So, if medical control physicians all do our job right, we'll hear medics bragging about how many mg/kg of morphine they gave, or how quickly they medicated the kid with a femur fracture!

With that in mind, I made my own EMS meme. If we do our jobs right, maybe this will be less of a joke, and more of a reality in the future.

I can getz artsy on Cheezburger!