This research, undertaken in Australia over a period of nine months, aimed to outline factors influencing paramedics' clinical decisions related to provision of analgesia, and report on both frequency of administration and effectiveness of analgesia in older fallers with suspected fractures.
The paper reports on the analysis of a subset of patients extracted from a larger data set collected during a prospective, observational study examining pre-hospital management of older people who had fallen.
The study population for this part of the research consisted of 333 patients; the average age was 82 years and 75% were female. The most common site of suspected fracture was the hip. Although the population was sampled in Australia, based on these broad demographics the findings appear, at least in principle, to be transferable to a UK setting.
The range of analgesics that ambulance clinicians in Australia are allowed to administer is dependent on their clinical grade, which is not dissimilar to the situation in the UK. However, the actual analgesic agents available include drugs which are not common within UK paramedic practice, such as intranasal fentanyl.
In total, 60% of the study population received analgesia. Based on the fact that fracture is generally accepted as being a painful condition, it is surprising that this figure is not higher.
The site of fracture and severity of pain were key factors relating to whether or not analgesia was administered. Patients with suspected hip fracture were significantly more likely to receive analgesia than those with fractures at other sites (67% versus 55%; χ2=4.68; p=0.03). A reassuringly high proportion of patients presenting with moderate to severe pain received analgesia (84%).
Of those not receiving analgesia, reasons such as patient refusal, medication contra-indicated and previously self-administered analgesia were reported. Of those patients who received analgesia, 80% were given opiates, most commonly morphine (63%). We do not know what proportion of patients of the total sample received clinically effective analgesia, since an initial pain score was recorded in only 67% of cases and a final score in 52%. Amongst those patients (n=173) for whom two pain scores were recorded, 62% received clinically effective analgesia.
Compared to other research in the field, this paper found higher proportions of analgesia administration than previously reported. Looking predominantly at published Australian research, the authors suggest that this may be due to the greater range of analgesics now available to paramedics. These rates compare favourably with international research, which the authors attribute to the ‘aggressive philosophy toward pain management’ found in many Australian ambulance services.
‘This paper found higher proportions of analgesia administration than previously reported’
Although morphine was the most commonly used analgesic in this study, the authors observe that amongst this age group administration of parenteral opioids is not without the risk of complications, and they suggest that oral analgesia may be a viable alternative.
Regional anaesthesia in the form of nerve blocks is also briefly discussed as having potential as a method of pain control, citing a currently unpublished source of evidence for this paramedic-performed procedure. Clearly this novel alternative will require further investigation.
The authors identify several limitations of this study, including susceptibility to the Hawthorne effect (changing one's behaviour as a direct result of knowing that one is being observed). Another potential limitation is that the researchers did not include radiological confirmation as to whether the patients actually had a fracture or not. However, the authors explain that this was not essential, as they were focusing on what paramedics did at scene to manage pain in patients with a suspected fracture based on the patients' presenting signs, symptoms and history.
The finding that patients were more likely to receive analgesia if they reported moderate to severe pain was tempered with the observation that amongst those for whom no pain score was recorded, one third still received analgesia. This indicates a need for further investigation as to which factors influence paramedics' clinical decisions relating to administration of pain relief.