This qualitative study, informed by grounded theory methodology, explores emergency medical services (EMS) staff's attitudes towards pain management. The researchers wanted to establish whether attitudes can act as deterrents when making decisions to administer analgesic agents to patients.
The study was undertaken in New England, USA and involved paramedics who had at least 12 months experience on the road. The researchers recruited from rural and urban areas and included a mix of private EMS agencies (n=2) and hospital-based services (n=3) to increase maximum variation within their purposive sampling strategy. As a point of interest, all of the agencies used morphine in their formularies, and some used additional drugs (for example, fentanyl).
Both focus groups and semi-structured individual interviews were used to gather data. The researchers explain they wanted to use both methods because individual interviews allowed them to gain in-depth, individual perspectives while the focus groups facilitated shared discussion revealing a group's response to the topic area.
In total 15 participants were involved: eight people in individual interviews and seven people in the focus groups. Apparently there were five participants in one group and two in another. There is not space in this review to discuss in full whether or not the presence of two participants can be described as a focus group, so readers of this review just need to be aware that there is no consensus in the literature as to whether two people make a focus group or whether this should be acknowledged as a dyad.
Data were analysed by two independent researchers using the constant comparative method. Ultimately, three domains were identified 1) assessment and evaluation; 2) medication strategies and 3) relationship with the emergency department. Each domain included two major themes.
The discussion section explores the findings in the context of other studies highlighting some of the barriers to administration of pre-hospital analgesia identified by the 15 participants. These include participants reporting a need to see objective signs of the cause of pain (such as fractures, other limb deformities or perhaps a change in vital signs etc.) before giving analgesia; expressing worries about the potential for malingerers to abuse the system; identifying some concerns about ‘masking’ signs/ symptoms of other illness or injury; articulating feelings that they do not want to overdose the patient; having some uncertainty about what degree of reduction of pain should be achieved while the patient is in the care of the EMS.
Another theme that emerged addresses the role of patients’ anxiety impacting on paramedics' evaluation and subsequent treatment of patients’ pain. The researchers identify this as a novel finding as paramedics were concerned that management of patients’ pain did not necessarily manage the patients’ acute anxiety; this is an area that the authors recommend would benefit from further exploration.
The limitations of the study, as identified by the authors, include use of an emergency physician as the sole researcher involved in data collection as this might have influenced participants’ responses; plus the research was conducted in one region (New England) so may only reflect local trends.
However some of the findings support other published studies (for example, participants’ concern about treating ‘drug seekers’ or people who may be exaggerating their levels of pain; the requirement to have objective, tangible evidence before agreeing to administer analgesia, and concerns about potential masking of symptoms despite there being published evidence to the contrary in some clinical conditions.
Recommendations by the authors to improve this area of patient care include tailoring EMS education to improve knowledge base and alleviate concerns around ‘masking’ and opiate dosing etc.; and consideration of the use of activities such as peer-mentoring interventions or working with expert pain teams as these may have a role to play in increasing practitioners’ confidence in relation to the area of pain management in pre-hospital care.