Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What’s The Worst That Could Happen? Pain Management

Depends on your perspective.

Medical director: Extra paperwork, and a patient might suffer harm from incompetently delivered pain management vs. malpractice for neglect of a patient in pain.


Is it outside of the paramedic scope of practice to manage pain aggressively?

No. Although different states may prohibit the safest medications and/or may prohibit standing orders.

The medical director can still find ways to minimize the number of cases, where otherwise stable patients are transported with no effective treatment of their pain.

Maybe the medical director does not think that is worth the medical director’s time and effort.

That’s where it becomes malpractice.

Would the medical director decide that we should not treat other conditions appropriatelty?

Is it difficult to manage pain appropriately?

Is it dangerous to manage pain appropriately?

Paramedic: Similar to the medical directors concerns, but add in being an accomplice in the torture of a patient in pain.

Accomplice in torture?

The medic has the ability to treat the pain (the training, the medications, everything), but the medical director says, No! Do not help that patient! Make that patient worse!


Moving a patient, without managing the pain is making things worse. The pain increases. The vital signs are responding to the pain in a way that may be harmful to the patient. The patient may move in ways that worsen the injury, by attempting to minimize the pain. The patient is distracted from providing an accurate history by the focus of the pain.

This teaches the paramedic to ignore the patient. What could be worse, from a patient care perspective?

Patient’s family: “Why won’t they do anything for my mother/father/sister/brother/daughter/son/. . . ?”

“Why don’t they care?”

Patient: Has nothing nice to say about people ignoring his/her pain and making it worse. He/She called for help. Instead he/she is receiving the same level of service that a taxi driver could provide, and the taxi driver would charge much less for the abuse.

We are horrible at managing pain, not because we endanger the patients’ respirations, but because we do not treat the pain. There is no right dose for everyone. The right dose is whatever provides significant relief.

For some patients, significant relief might be 2 mg morphine, although morphine is the wrong drug. For some patients that might be 500 mcg fentanyl combined with 10 mg midazolam. If the patient is still awake and alert, with no signs of respiratory depression, and in significant pain, then we have not given too much.

And the lies we tell our patients –

This won’t hurt.

Or the even worse lie –

This won’t hurt a bit.

Then the after the fact insult and lie –

That didn’t hurt.

And the infantile justification, which is also a lie –

You can’t be too safe.

The scary part is that some of the people actually believe this BS they tell patients. They need to be on the receiving end of some of, This won’t hurt a bit.

Why do we abuse our patients like this?