BARRIERS TO AND ENABLERS FOR PREHOSPITAL ANALGESIA
FOR PEDIATRIC PATIENTS
David M. Williams, BS, Kirsten E. Rindal, MD, MS, Jeremy T. Cushman, MD, MS, EMT-P,
Manish N. Shah, MD, MPH
ABSTRACT
Objective. To identify and investigate the barriers and en-
ablers perceived by paramedics regarding the administration
of analgesia to pediatric emergency medical services (EMS)
patients. Methods. This was a qualitative study in which in-
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depth semistructured interviews of a purposively-sampled
group of 16 paramedics were performed before achieving
redundancy. The interviews were structured and the data
were thematically analyzed. Emerging themes were catego-
rized into four domains, and novel themes were identified
and further explored. Results. Thirteen of 16 paramedics re-
ported success with analgesia in children at least once in
their careers. Provider anxiety, unfamiliarity and discomfort
with pediatrics, unfamiliarity with the protocol, insufficient
didactic and clinical education, and concern for adverse ef-
fects from analgesic agents were perceived as barriers to
pediatric pain management. The paramedics had differing
beliefs about the importance of pain control, the role of
For personal use only.
parents in medical care for children, and the paramedic’s
ability to assess pediatric patients. Having a positive rela-
tionship with online medical control and using commer-
cially available assistive guides were viewed as enablers for
pediatric pain management. The response from paramedic
supervisors and emergency department staff, unwanted
attention from authority figures, perceived superiority of
hospital care, difficulty obtaining intravenous access, and
overall culture of stinginess in medication administration
played important roles in an overall preference to defer pe-
diatric analgesia. Some paramedics mentioned a specific ex-
perience or mentoring relationship with a more seasoned
provider who taught them the importance of pain manage-
ment. Paramedics reported various effects of transport dis-
tance on their decision to administer analgesia. Conclusions.
We have identified a number of previously unrecognized
barriers to and enablers for prehospital pediatric analgesia.
The majority of these factors lead to an overall preference
Received February 8, 2012, from the School of Medicine, West Vir-
ginia University (DW), Morgantown, West Virginia; and the Depart-
ment of Emergency Medicine, University of Rochester (KER, JTC,
MNS), Rochester, New York. Revision received April 5, 2012; ac-
cepted for publication April 9, 2012.
The authors report no conflicts of interest.
Address correspondence and reprint requests to: Dr. Jeremy T. Cush-
man, University of Rochester, Department of Emergency Medicine,
601 Elmwood Avenue, Box 655, Rochester, NY 14642. E-mail:
jeremy cushman@urmc.rochester.edu
doi: 10.3109/10903127.2012.695436
519
of paramedics to defer administration of analgesic agents. A
number of educational and EMS system changes could be
made to address these barriers and increase the frequency
of appropriate pediatric prehospital analgesia. Key words:
analgesia; pediatrics; barriers; enablers; pain management;
paramedics; oligoanalgesia
PREHOSPITAL EMERGENCY CARE 2012;16:519–526
INTRODUCTION
Although it has been over 40 years since Baskett and
Withnell demonstrated that effective and safe pre-
hospital analgesia is possible,1 studies continue to
demonstrate that emergency medical services (EMS)
providers underuse analgesic agents.2–5 The impor-
tance of oligoanalgesia is such that a number of groups
have identified prehospital analgesia as one of the top
priorities in EMS research.6–9
The majority of studies have focused on provision
of analgesia to adults. Oligoanalgesia is also prevalent
among pediatric patients,10,11 despite evidence that pe-
diatric pain may lead to a number of undesirable se-
quelae later in life12 and that pain management can
be effective in this population.13,14 Identifying barri-
ers to providing analgesics is the first step to resolv-
ing this problem. To our knowledge, only one study
has specifically examined the barriers to administra-
tion of analgesia to pediatric patients. Hennes and
colleagues surveyed paramedics and found that the
reasons for underutilizing analgesics included a per-
ceived inability of the prehospital provider to assess
pediatric pain, a knowledge deficit of pain manage-
ment, a lack of vascular access, a lack of comfort
with administering morphine, and concerns that pedi-
atric patients were exhibiting drug-seeking behavior.15
As identified by the authors, however, this study
was limited by the survey methods used, and un-
targeted barriers such as those related to organiza-
tional factors, EMS protocol, and culture could not be
assessed.15
We therefore conducted a qualitative study of
paramedics to elucidate their perceived barriers and
enablers when considering pain management in the
pediatric patient. By doing this, the full extent of
needed changes can be understood to design solutions
to ameliorate prehospital pediatric oligoanalgesia.
 520 PREHOSPITAL EMERGENCY CARE
METHODS
Study Design
This was a qualitative study that used in-depth,
semistructured interviews to examine the barriers to
and enablers for prehospital analgesia administration
in pediatric patients. The study was designed accord-
ing to Icek Ajzen’s empirically validated Theory of
Planned Behavior, which argues that intentions and
behavior center on three components.16 The first com-
ponent is behavioral beliefs, which in the context
of this study represents how likely the paramedic
feels his or her care will bring about a reduction in
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pain. Behavioral beliefs lead to the “attitude towards
the behavior,” which is how positively or negatively
the paramedic views the administration of analgesics.
The second component is normative beliefs, which
refers to the paramedic’s expectations of beliefs re-
garding pain management that are held by individuals
whom the paramedic perceives to be important (i.e.,
coworkers, supervisors, and hospital staff). Normative
beliefs give rise to “subjective norms,” which are the
perceived social pressures to use or defer administra-
tion of analgesics. The final component, control beliefs,
results from the paramedic’s perception of barriers to
For personal use only.
and enablers for administering pain medication to the
pediatric patient. Control beliefs lead to “perceived be-
havioral control,” which is the paramedic’s perceived
ability to administer pain medication to a pediatric pa-
tient. These three components of the Theory of Planned
Behavior combine to form intentions that lead to the
decision to administer or defer an analgesic agent.16
Study Setting
Paramedics practicing in a Western New York EMS re-
gion were recruited for this study. The region includes
a mix of rural, suburban, and urban areas with an over-
all population of 795,000. The region’s annual 120,000
requests for EMS are answered by a combination of
40 volunteer and paid agencies. Pediatric patients are
transported to one of two dedicated pediatric emer-
gency departments (EDs), each with its own pediatric
medical control.
Paramedics in the study region follow a common
protocol regarding pediatric pain management, which
recommends, on standing order, the treatment of pain
that is scored greater than 4 out of 10 on a numeric
pain scale or the Wong-Baker FACES Pain Rating Scale
and is due to isolated injuries (i.e., burns, amputa-
tions, isolated extremity fractures) with 0.1 mg/kg
of morphine, provided that the patient has stable vi-
tal signs. Morphine may be delivered intravenously,
intramuscularly, or intraosseously. Paramedics must
obtain verbal authorization from a pediatric medical
control physician for treatment of pain with other eti-
ologies (i.e., abdominal, head, or back pain) or for re-
OCTOBER/DECEMBER 2012 VOLUME 16 / NUMBER 4
peat doses. Morphine is the only protocol-approved
analgesic agent. Paramedics also carry naloxone,
which may be used on standing order for all patients,
as well as diphenhydramine and epinephrine, which
may be used for allergic reactions.17 A Broselow tape
or similar weight-based dosing tape is available to
nearly all paramedics.
Study Sample
Paramedics were individually solicited for voluntary
participation in this study in such a way as to achieve
representation of the system as a whole by practice
location (rural, suburban, and urban), while purpo-
sive sampling was used to ensure heterogeneity of
the study population. The two variables used to cre-
ate the sampling frame were years of experience as a
paramedic and self-rated comfort level in caring for
children, because the investigators believed that these
two factors would notably impact variability in re-
sponses. The self-rated comfort level was scored using
a 10-point Likert scale and dichotomized into “high”
level of comfort if the rating was 6–10 and “low” level
of comfort if the rating was 1–5.
When designing the study, we anticipated interview-
ing 20 paramedics, with five from each cell of our sam-
pling frame. However, as is considered appropriate
with qualitative research, sampling was continued un-
til we achieved redundancy and saturation of the the-
ory.
Paramedics with extensive outside medical training
(registered nurses, physicians, etc.) and paramedic ed-
ucators were excluded because we believed that these
individuals would not represent the views of typical
paramedics. Verbal consent was obtained from each of
the study’s participants as approved by the University
of Rochester’s Research Subjects Review Board.
Semistructured Interviews
We developed a semistructured interview guide to en-
sure consistency between interviews and to ensure
that the key domains of interest were covered in each
interview (Table 1). The guide consisted of probing
and follow-up questions and was iteratively refined
through trial interviews to maximize the clarity and
neutrality of the questions.
A medical student who is also a practicing
paramedic in the study region performed the in-
terviews. A practicing paramedic, as opposed to a
physician or nonmedical research assistant, was cho-
sen to perform the interviews to encourage openness
and minimize social desirability bias, while having
sufficient content knowledge to ensure appropriate
follow-up questions.18 During the interviews, prob-
ing questions were asked, and participants were en-
couraged to elaborate on all statements. Unique and
 Williams et al. BARRIERS TO AND ENABLERS FOR PEDIATRIC ANALGESIA 521

TABLE 1. Semistructured Interview Guide

1. Tell me about the most memorable call you’ve been on that dealt with a pediatric patient in pain.
2. In what types of situations would you administer pain medication to a child?
3. In your experience, how well does administering pain medication to children work?
4. How can the presence of family members affect your assessment of pain in children?
5. What are the top emotions you experience when dealing with pediatrics in pain?
6. Tell me about the paramedic culture regarding giving pain medications to kids.
7. What response do you get from the receiving Emergency Department staff when you have or haven’t administered
pain medication?
8. What kinds of expectations are on you to treat or defer pain medication in pediatric patients?
9. What has most shaped your beliefs concerning administration of pain medication to children?
10. Tell me about your pediatric pain management protocol.
11. Give an example of a situation in which you thought you should provide a pediatric patient with pain medication but
were unable to.
12. Approximately what percentage of calls do you go on involve pediatric patients?
13. Tell me about a memorable conversation you’ve had with medical control regarding a child in pain.
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divergent views were particularly sought out. All in-
terviews were audio-recorded and notes were taken.
Interviews were not timed, but rather were allowed to
be completed without interruption until the goals of
the semistructured interview guide were complete and
any follow-up questions were asked. Generally, inter-
views lasted 45 minutes to an hour.
Data Analysis
For personal use only.
and >5 years of experience, three with low comfort
level and ≤5 years of experience, and three with low
comfort level and >5 years of experience. Figure 1 is
the model we developed representing our results and
how they relate to one another within their thematic
categories. Table 3 provides representative quotations
of these factors divided into their respective domains
and themes.

The field notes were supplemented and edited with a
review of the recordings. A thematic analysis was per-
formed in which two authors coded the notes based
on the Theory of Planned Behavior, with a third au-
thor available to resolve any discordance. Recurring
pertinent novel ideas were discovered and explored
throughout the interview period. From these recurrent
ideas, an additional novel theme was added to those
from the Theory of Planned Behavior.
RESULTS
A total of 16 paramedics were interviewed, at which
point redundancy was achieved and response satura-
tion had occurred. Table 2 provides basic demographic
information of those interviewed. Of note, we inter-
viewed five individuals with high comfort level and
≤5 years of experience, five with high comfort level
TABLE 2. Interviewee Demographics
Age—median [range] 29.5 years [23–40]
Gender distribution 9 male, 7 female
Length of service—median 4.75 years [1 month–16 years]
[range]
Self-rated comfort level∗ —mean 6 (±1.5)
(±SD)
∗
Self-rated comfort level in dealing with pediatric patients using a 10-point
Likert scale, where 1–5 was considered low comfort and 6–10 was considered
high comfort.
SD = standard deviation.
Behavioral Beliefs/Attitudes Toward the
Behavior
We discovered a number of factors influencing the
paramedic’s behavioral beliefs and subsequent at-
titudes toward the use of analgesics in children.16
Thirteen of 16 paramedics reported having directly
administered or assisted in the administration of
pain medication to a pediatric patient at least once
in their careers. All 13 of these interviewees reported
successful analgesic effects, anxiolysis, or both (quote
1 in Table 3) when using pain management. Although
most interviewees reported positive experiences using
analgesia in their pediatric patients, there was a
variable perceived perception of this intervention’s
importance. The majority viewed relieving pain as
unimportant and not part of their job (quote 2), but a
small dissenting number of interviewees viewed it as
a valuable action (quote 3). The paramedics were also
concerned that the patients might have an unknown
allergy to morphine, despite carrying standard medi-
cation to treat an allergic reaction (quote 4). They had
a similar concern for causing respiratory depression
after administration of morphine (quote 5). It was
interesting to note that one paramedic had a unique
view, which displayed a relationship between the
relative importance of relieving pain and its possible
adverse side effects. This interviewee believed that
relieving the child’s pain is not worth the risk of
overdose unless the pain is of major traumatic origin
(quote 6).
 522 PREHOSPITAL EMERGENCY CARE OCTOBER/DECEMBER 2012 VOLUME 16 / NUMBER 4

Mentoring relaonship
with a more seasoned
provider

Lack of didacc and

clinical educaon
Normave
Response from
Beliefs supervisors and
Medical & ED staff
control Subjecve
Norm

Determining Concern for

Assessment weight and adverse effect
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normal vital
Parental signs
involvement
Control Beliefs A
tudes & Behavioral
& Beliefs Beliefs &
Perceived towards A
tude
Familiarity Behavioral Pediatric Pain towards the
of protocol Control Management Behavior
Relave importance
of pain control
IV access
Provider
For personal use only.

Unfamiliarity and anxiety

History of successful
provider discomfort cases of pain
with pediatrics management
Emoons
Preference to Snginess to
Defer administer
Superiority of medicaon
hospital care

Transport
distance
Unwanted aenon
from authority figures

FIGURE 1. Representative model characterizing our results and how they relate to one another within their thematic categories. ED = emergency
department; IV = intravenous.

Normative Beliefs/Subjective Norms Control Beliefs/Perceived Behavioral

We found a number of factors influencing the
paramedic’s normative beliefs, leading to subjective
norms.16 Participants reported receiving generally
no response or a negative response from hospital
pediatric ED staff (quote 7) and from their paramedic
supervisors (quote 8). Paramedics also reported
considerable weakness in their didactic and clinical
education regarding pediatric analgesia (quote 9).
They reported little training from the initial lectures to
their clinical experiences (quote 10), and some recalled
learning to defer administering analgesics if possible
(quote 11). Some paramedics mentioned a specific
experience or mentoring relationship with a more
seasoned provider that taught them the importance of
pain management (quote 12).
Control
In terms of control beliefs, which give rise to perceived
behavioral controls,16 we found that a general unfamil-
iarity with caring for pediatric patients was a large bar-
rier to administering pain medications (quote 13). This
lack of familiarity with pediatric care leads to specific
challenges, including obtaining intravenous (IV) ac-
cess (quote 14). The lack of familiarity was also thought
to give rise to poor familiarity of the EMS pediatric
pain management protocol (quote 15). However, using
commercially available guides was viewed as an en-
abler to pain management (quote 16). A good ability to
assess children in pain (quote 17) and a good working
relationship with online medical control were viewed
as control enablers, though some paramedics reported
 Williams et al. BARRIERS TO AND ENABLERS FOR PEDIATRIC ANALGESIA
TABLE 3. Domains, Themes, and Representative Quotations
Domain Theme
Behavioral History of successful cases of
beliefs pain management
Relative importance of pain
control
Concern for adverse effect
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Normative Response from supervisors
beliefs and ED staff
Lack of didactic and clinical
education
For personal use only.
Mentoring relationship with
a more seasoned provider
Provider discomfort with
pediatric IV analgesia
Familiarity of protocol
Determining weight and
normal vital signs
Control Assessment
beliefs
Medical control
Parental involvement
523
Quote
1. “Not only did it relieve some of his pain, but it relieved some of his anxiety. Calmed him
down a little bit more. It was easier to deal with him so it does have its benefits.”
2. “We were put out there to save lives, to do one type of job and morphine doesn’t really fall
into what we think is our job description.”
3. “Its purpose is to lessen pain and to make things better for the patient and that’s why
we’re here—to make the patient better.”
4. “Morphine is risky if you don’t know a child’s gonna have an allergic reaction to it.”
5. “ . . .you know if you give an adult too much morphine for example and you make them
hypotensive and you depress their respiratory rate and effort, you can fix that pretty
quickly in an adult, but the repercussions of doing that in a little kid? The risk is
higher.”
6. “It can happen and then you overdose them based on that guesstimate [of the patient’s
weight] for some [expletive] little pain problem? No, it’s not gonna fly. But if it’s
something serious, like a femur fracture . . .then at least the ends justify the means. I
can’t justify it for some [expletive].”
7. “When we got there [to the ED] I told them I gave 10 mg morphine and they flipped out.
‘You gave 10 mg morphine?! Why’d you give 10 mg morphine?!’ The doctor was cool
with it. It was the nurses who were all flippin’ out . . .. So that’s another thing to keep
in the back of my head. Am I gonna get yelled at by the hospital staff whether it’s
warranted or not?”
8. “Depending on your boss of the year, some of them are in support of it, while some of
them could care less. Our last boss used to brag about how we had the least narcotics
administrations out of all the area paramedics.”
9. “Not much pediatric education in paramedic or EMT programs at any level of prehospital
training . . . I don’t think there’s a lot of emphasis on pediatrics per se. In class we had
I think five or six sessions on pediatrics and that’s going through the whole gamut of
everything that has to deal with pediatrics . . .. Pain management wasn’t really
covered that much at all.”
10. “[We] are not allowed to touch [pediatric patients] when you’re in paramedic school so
when you get out of paramedic school you’re in a trend.”
11. “When we went through class we were always told to look for reasons to not give
medication and there’s never a great reason to give morphine . . .. I don’t think we
covered too much about it in class at all. I just remember the overall generalization of
medications: always look for reasons not to give it.”
12. “ . . .he [paramedic mentor] is very liberal with his pain meds . . . some of the paramedics
that I’ve been trying to emulate are more liberal with their pain meds and I think
that’s what pushed me in that direction.”
13. “I think it’s more of a familiarity and comfort issue. It’s just not done often enough so that
people are comfortable with it and will go ahead and utilize it . . .. People are just
generally speaking afraid of kids because of a lack of familiarity and particularly pain
management runs high on that list because it’s one of the things we do least often.”
14. “IVs are something we definitely don’t like to do in kids. We cause them more pain
starting IVs a lot of times . . .. Really don’t like to do it . . .. That might be part of our
decision as to whether or not we give pain management.”
15. “It’s something I would look up just because it’s not something that I do as often as other
protocols. I would definitely need to look them [pediatric protocols] up more so than
for adults . . ..”
16. “ . . .carry a Broselow tape and whip it out on every kid because I will admit that I struggle
when it comes to judging a kid’s weight . . .. If the parent knows and they’re pretty
reliable based on a well-baby checkup then I defer to the parent.”
17. “I knew he was in pain because of his presentation. He was screaming with any movement
or palpation to the area. He was tachycardic too. His vital signs coincided with his
presentation and his discomfort. I looked for elevated heart rate, elevated blood
pressures.”
18. “I feel that pediatric medical control doctors are more willing to work with you . . . having
medical control doctors that are willing to chat with you on the phone definitely helps
as far as increasing the usage of pain medication in the field.”
19. “Calling medical control at certain places around here and getting orders for pain control
is an almost impossible task . . .. I have never successfully argued for a pain control
order out of [hospital]. I have never successfully argued for a pain control order out of
[hospital] for kids.”
20. “I would say it’s 50% of the time they’re helping, 50% of the time impeding, because you
get the parents that are very supportive of what you’re doing and they just kind of
stand back and then you have the other parents that are in your face . . ..”
21. “I’ve never had a parent get in the way as far as tellin’ us how to treat, but I think maybe
when they’re upset because their child’s hurt it does hinder our ability to take care of
the patient in the way we’re supposed to.”
(Continued on next page)
 524 PREHOSPITAL EMERGENCY CARE OCTOBER/DECEMBER 2012 VOLUME 16 / NUMBER 4

TABLE 3. Domains, Themes, and Representative Quotations (Continued)

Domain Theme Quote

Provider anxiety/emotions
Preference Superiority of hospital care
to defer
Stinginess to administer
medication
Unwanted attention from
authority figures
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22. “Makes you a little more anxious when you’re dealing with a child. I feel that when our
anxiety level is raised we’re gonna be a little more hesitant about doing things that we
should. A little more cautious I should say. Maybe it hinders our ability to assess the
patient appropriately.”
23. “I deferred when close to the hospital because I think there’s more of a comfort level in the
hospital. They deal with it more. I think they’re better. They have the ability to assess
pain better than we do. They do drug dosages, which isn’t that big of a deal but it’s
just something that they’re more comfortable with . . . .”
24. “I’m stingy with all my drugs.”
25. “I mean all of the controlled substance charts are 100% QA’d, which I’m sure Dr. [agency
medical director] reads as well . . . I know that our ALS chief reads it. So maybe that’s
a part of it as far as deferring . . . ‘Am I really comfortable doing this, and if I’m not

and I screw up am I gonna lose my job? Am I gonna lose my card? Am I gonna get
kicked back down to a basic level?”’
Transport distance 26. “I am indifferent to distance from the hospital in terms of whether to give it or not. If it’s
indicated, might as well get it to them sooner than later.”
27. “If I’m two minutes away from the hospital, it’s gonna take me longer to stop, start the IV,
put the person on the monitor, put the pulse oximetry on cuz you gotta check for that
respiratory effort, and then actually administer the medicine versus driving two and
a half or three minutes and havin’ the hospital do it.”
ALS = advanced life support; ED = emergency department; EMT = emergency medical technician; IV = intravenous (line).

difficulty with each of these aspects (quotes 18 and 19). less than five years of experience generally believed
Paramedics reported variable experiences when deal- that transport time had less effect on their decisions
ing with parents of children in pain, with some parents to administer pain medication when compared with
For personal use only.

helping and some hindering, particularly when they
are anxious about the paramedic’s actions and their
child’s pain (quotes 20 and 21).
Preference to Defer
Throughout the interviews, a universal theme of a
preference to defer administration of pain medication
to pediatric patients was noted. Many interviewees
reported personal feelings of anxiety regarding pro-
viding analgesics, leading to hesitancy and deferral
(quote 22). Further, they perceived that the hospital
is superior at assessing and relieving pain (quote 23).
Paramedics also described a general stinginess to
administer any medication, which some hypothesized
stemmed from their education (quotes 11 and 24).
External feedback, including negative responses from
the hospital (quote 7) or their supervisors (quote 8),
and unwanted attention from authority figures (quote
25) each contributed largely to a preference to defer
prehospital analgesia administration in pediatrics,
although the latter was not identified until late in
the interview phase and was therefore not asked in
each interview. Paramedics reported various effects
of transport distance on their decisions to administer
analgesia (quotes 26 and 27).
Subgroup Analysis
We performed a subgroup analysis of the paramedics
we interviewed by comparing each cell of the sampling
frame (Table 1). We found that paramedics who had
paramedics who had more than five years of experi-
ence. Despite a range of comfort levels, virtually all
paramedics endorsed discomfort in pediatric analge-
sia and caring for children in general. Self-rated com-
fort scores did not correlate with the paramedics’ dia-
logue about their own comfort levels, and both groups
of paramedics felt that the decreased frequency of car-
ing for children compared with adults was the primary
cause of this discomfort. The subgroup analysis found
no other significant differences within our study sam-
ple.
DISCUSSION
This unconstrained qualitative study of paramedics
identified a number of barriers and enablers that af-
fect a paramedic’s decision when considering pedi-
atric pain management; to our knowledge, some of
these barriers and enablers have not previously been
reported. With knowledge of these influences, future
research can target these identified factors, and educa-
tional and system improvements can be implemented
to better serve children in pain.
Interviews with paramedics yielded a novel barrier,
which we termed “unwanted attention from author-
ity figures,” that contributes to an overall preference
to defer analgesia administration to pediatric patients.
Interviewees reported discomfort when their prehos-
pital care report is reviewed by their agency’s medical
director because they fear punishment from that physi-
cian should they make an error. Additionally, previ-
ous research shows that EMS personnel are reluctant
 Williams et al. BARRIERS TO AND ENABLERS FOR PEDIATRIC ANALGESIA
to report errors in treating pediatric patients and tend
to commit errors of omission.19 Combined with these
data, our findings perhaps begin to illustrate a belief
structure centered on a culture of wanting to avoid all
interaction between paramedic and physician, even at
the cost of patient comfort. This belief structure calls
into question whether other prehospital procedures
are being deferred out of a perceived fear of negative
feedback from authority figures, and lays the ground-
work for considerable future research.
Interviewees described subjective norms of am-
bivalence and negativity toward pediatric pain
management. Previously unknown barriers felt to
be involved in these norms were perceived apathetic
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and negative views from hospital staff regarding
analgesia, and mixed responses from online medical
control physicians when requesting permission to
administer analgesic agents. In an illustrative exam-
ple of this, one paramedic described a situation in
which the medical control physician gave him orders
to administer pain medication in the field, yet the
receiving pediatric ED nurse chastised the paramedic
for giving morphine for what she perceived to be a
minor injury. This highlights the importance of ED
system changes that provide paramedics with a clear
For personal use only.
and unified response from hospitals regarding pain
management for pediatric patients. The paramedics
in our study appear to be greatly influenced by their
perceived superiors, which leads us to believe that the
onus of responsibility to change the belief structure
regarding pediatric pain management lies not with
the paramedic, but with physicians, hospital staff,
and paramedic supervisors. This effort begins with
providing positive feedback to paramedics after their
correct administration of pain medication.
Consistent with hypotheses from previous
research,11,19 we found that subjective norms of nega-
tivity and ambivalence were also partly attributed to
perceived educational deficits in paramedic pediatric
clinical and didactic education. Although the deter-
mination of situations in which pain management is
appropriate for children and infants has been an objec-
tive in the paramedic National Standard Curriculum
since 1998,20 neither Pediatric Advanced Life Support
(PALS)21 nor Pediatric Education for Prehospital
Professionals (PEPP)22 includes specific instruction on
such. Additionally, we found that newer paramedics
described a specific mentoring relationship with a
more seasoned provider that helped them understand
the importance of relieving pain. Thus, for the first
time, our study affirms the previously described
importance of the mentor–mentee relationship,23,24
specifically as it relates to prehospital pediatric pain
management.
Most paramedics reported comfort with generally
accepted clinical signs of pediatric pain, including fa-
cial expression,25 guarding of the painful region, and
525
increased vital signs.26,27 Paramedics did, however, re-
port noteworthy difficulties distinguishing between
physiologic pain and a child’s display of anxiety due
to stressful situations. This challenge is not limited to
paramedics, however, as it has been previously de-
scribed in the hospital setting.28 There is currently no
universally accepted method to differentiate between
pain and anxiety in nonverbal pediatric patients,29 yet
hospital staff still tend to better address children’s pain
than prehospital providers.11 These findings lead us to
believe that, contrary to previous data,15 difficulty in
assessing the pediatric patient in pain may be a con-
tributing factor, but is not likely to be a primary barrier
to prehospital pediatric analgesia.
Many paramedics identified difficulty initiating IV
access, the fact that placing an IV line causes additional
pain, and parental anxiety concerning paramedics’
initiating IVs as barriers to their utilization of pain
medication in pediatric patients. However, intranasal
administration of ketamine30 or fentanyl13,31 has been
shown to be effective at attaining analgesia in both
prehospital and ED pediatric patients, and our data
suggest that protocol modifications and subsequent
training could reduce this barrier to prehospital
oligoanalgesia in pediatrics.
Although the paramedics mentioned a number of
barriers to administering pain medication to children,
their positive and helpful relationship with online
medical control physicians and the availability of
assistive guides were seen as predominant enablers.
This suggests that fostering a positive relationship
between physicians and paramedics is crucial for
better patient care. It also suggests the importance of
paramedic access to protocols, weight-based dosing
charts, and commercially available assistive guides
such as the Broselow tape to facilitate provider com-
fort in estimating a patient’s weight and calculating
dosage, particularly in the setting of recent findings
that medications administered to children are fre-
quently administered in orders of magnitude outside
of the proper dose range.32
LIMITATIONS AND FUTURE RESEARCH
It is important to note the limitations of this qualita-
tive study. First, our results may not be generalizable to
all EMS systems. It is possible that the barriers may be
different in other locations because of variations in sys-
tem structure, training, protocols, oversight, and regu-
lations. However, this study provides a more compre-
hensive assessment of factors related to oligoanalgesia
than previously existed in the prehospital literature.
Second, although redundancy of themes was achieved,
it is possible that expanding our sampling frame could
have allowed other themes to emerge. Finally, as with
any qualitative study, these methods are intended to be
hypothesis-generating to identify themes and domains
 526
of attitudes, beliefs, and behaviors that are subjective
by nature.
This study identifies a number of future research
topics in prehospital pediatric care. Future studies
should further examine and qualify the relationship
between paramedic and physician and the resulting
belief structure, focusing on the choice to defer anal-
gesia out of fear of punishment as a central theme.
Further, future work should consider mixed-method
designs to better clarify, quantify, and delineate these
perceived barriers and enablers to pediatric prehospi-
tal analgesia so as to identify solutions that will benefit
our pediatric patients.
Prehosp Emerg Care Downloaded from informahealthcare.com by The University of Manchester on 10/29/14
CONCLUSION
We have identified a number of previously unrecog-
nized barriers and enablers to prehospital pediatric
analgesia administration. The majority of these factors
lead to an overall preference of paramedics in our sys-
tem to defer analgesia administration. A number of
educational and EMS system changes could be made
to address these barriers and increase the frequency of
appropriate pediatric prehospital analgesia.
For personal use only.
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