• Brooks Walsh, David C Cone, Emily M Meyer, and Gregory L Larkin.
• Yale-New Haven Medical Center Emergency Medicine Residency Program, Yale University School of Medicine, New Haven, CT 06519, USA.brooks.walsh@gmail.com
• Prehosp Emerg Care. 2013 Jan 1;17(1):78-87.

IntroductionAlthough pain is a major reason why patients summon emergency medical services (EMS), prehospital medical providers administer analgesic agents at inappropriately low rates. One possible reason is the role of EMS provider attitudes.ObjectiveThis study was conducted to elicit attitudes that may act as impediments or deterrents to administering analgesia in the prehospital environment.MethodsA qualitative methodology was employed. We recruited experienced paramedics, with at least one year of full-time fieldwork, from a variety of agencies in New England. We sought to include a balance of rural and urban as well as both private and hospital-based agencies. Participants at each site were selected through purposive sampling. A semistructured discussion guide was designed to elicit the paramedics' past experiences with administering analgesia, as well as reflections on their role in the care of patients in pain. Both interviews and focus groups were conducted. These sessions were recorded and transcribed verbatim. The transcripts were topic-analyzed and iteratively coded by two independent investigators utilizing the constant comparative method of Glaser and Strauss' Grounded Theory; coding ambiguities were resolved by consensus. Through a series of conceptual mapping and iterative code refinement, themes and domains were generated.ResultsFifteen paramedics from five EMS agencies in three New England states were recruited. Major themes were: 1) a reluctance to administer opioids to patients without significant objective signs (e.g., deformity, hypertension); 2) a preoccupation with potential malingering; 3) ambivalence about the degree of pain control to target or to expect (e.g., aiming to "take the edge off"); 4) a fear of masking diagnostic symptoms; and 5) an aversion to aggressive dosing of opioids (e.g., initial doses of morphine did not exceed 5 mg).ConclusionsA number of potentially modifiable attitudinal barriers to appropriate pain management were revealed.

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