Bill LordFollow


Freedom from pain is a fundamental human right. Clinicians have a moral obligation to relieve a patient's pain, yet there is evidence that the management of pain is at times manifestly inadequate. Although data relating to the management of pain in the pre-hospital setting is scant, experience gained from studies that have identified practice gaps in the emergency department setting could probably be applied to the pre-hospital context.

Interventions that influence mortality are frequently the focus of attention in the pre-hospital domain. While survival is an important outcome, non-mortality outcomes deserve increased attention due to the impact that paramedic care can make in the immediate and long-term health and well being of the patient.

Relief of discomfort - which encompasses pain - has been identified as a priority outcome measure for pre-hospital care agencies. Pain management is one area of care where paramedics are able to demonstrate significant benefits in patient outcome. However the efficacy of pre-hospital analgesia depends on several factors, including the knowledge, skills and experience of the paramedic. Education is an important component of this process, both initial and continuing. Yet the scope and depth of such education varies, with some paramedic education programs failing to recognise the importance of pain assessment and pain management. Whereas education relating to the management of chest pain receives significant attention due to the recognised correlation between pain and myocardial injury, the management other types of pain may suffer from the lack of an obvious pathological basis.

Pain management practice is also strongly influenced by the values, belief and attitudes of the individual paramedic. Education programs do not always address these attributes. Furthermore, education programs tend to use summative assessment to measure skill and knowledge acquisition at the completion of the course, rather than evaluating the influence that education has on clinical practice.

Education programs must encompass not only the physiology of pain, assessment of pain - particularly in paediatric and cognitively impaired patients - and analgesic pharmacology; paramedics must confront the ethical, social and cultural aspects of pain management in order to achieve appropriate standards of practice. Perhaps there is also a role for paramedics in patient education, as the patient's beliefs and values can themselves be barriers to effective analgesia. However those with the responsibility for ensuring that clinical standards are achieved and maintained need to realise that information disseminated during a course of instruction may have a minimal effect on behaviour, particularly in situations where group norms and organisational tradition are a dominating influence. These variables also need to be addressed in order to overcome barriers to effective pain management practice.

This presentation investigates the epidemiology of pain in the pre-hospital domain, and the evidence relating to the effectiveness of pain management in this setting. Current approaches to pain education will be discussed, and recommendations made regarding the future development of pain management education for paramedics.

Author Biography

BHlthSc, GDipCBL, MEd.

Bill was employed by the Ambulance Service of New South Wales as an intensive care paramedic and paramedic educator before moving to Charles Sturt University in 1996, where he was a senior lecturer and coordinator of the Bachelor of Clinical Practice (Paramedic) course. In 2004 he was appointed to the position of Head, Undergraduate Paramedic Programs at Monash University in Melbourne.

Bill's research interests include clinical decision making and diagnostic reasoning, evidence-based practice, and pain management in the prehospital setting. He is currently undertaking a PhD, which involves a study of paramedic pain management. In his spare time Bill continues to practice as a paramedic with the Metropolitan Ambulance Service in Melbourne.