This study focused on the creation of a new competence for paramedics in a physician based system of prehospital emergency care2, when paramedics usually do not have the competence to administer opioid analgesics. On the other hand, due to the urgency of emergency calls, paramedic crews are often sent to cases of less serious trauma on their own without a physician crew7, but these trauma patients are obviously in pain and paramedics should either call a physician on the scene or consult him for analgesia administration. From the available opioids in pre-hospital care provided in the Karlovy Vary region of the Czech Republic, the most frequently used opioid sufentanil was selected. Although sufentanil is a very potent opioid8 it has been confirmed by this study that when administered within a clearly defined indication and by well-trained paramedics, it is an effective and safe alternative to administration by telephone consultation with EMS physician. In addition, the authors believe that the paramedics training to solve complications after administration of sufentanil is beneficial not only for this independent competence, but it can also be used in other situations where the doctor prescribes by phone and is not present on the scene to solve possible complications.
In the results, there was recorded relatively few side effects, which is probably the result of strict indication criteria. Such a criteria were deliberately set very harshly to ensure that sufentanil was safe and that training was adequate.
Reducing the number of phone-call consultations with an EMS physician leads to a lower burden on paramedics and physicians. This study verified that it is possible to assign other competencies on the basis of simulation training with verification of knowledge and skills.
This single center observational study has several limitations. One of them is that new competence was given to paramedics who voluntary underwent training. This voluntariness could cause the bias of this study. Motivated paramedics have usually better performance than unmotivated. In addition, the analysis of the results was from a relatively short period of time when it was burdened with other special conditions, especially COVID-19 patients. Due to quarantine measures and reduced population movements, trauma in pre-hospital care has decreased.
It is certainly worth mentioning the difference in NRS reporting between groups. The study was conducted as a prospective observational study. The control group performed routine work (blinded) and only trained rescuers had to respect the new standard of care, which includes the obligation to report to the NRS when considering opioid administration9 based on new competence. This may partly explain the difference in complete NRS reporting before and after administration of sufentanil. Likewise, paramedics who should have consulted physicians may have a tendency to underestimate NRS and even monitor for side effects. This statement can be based on the lower need for administration of antiemetics in the control group. From these data it is possible to conclude that increasing the level of competencies of paramedics or education10 can lead to an increase in the quality of care provided thanks to a higher level of responsibility and motivation, which leads to more careful examination of patients, better focus on their needs and in the end also better medical documentation.
In general, the treatment of pain by opioids is still open area in emergency medicine and especially in the pre-hospital setting.11,12 This study focused on the administration of intravenous sufentanil in less severe traumatic injuries. So far it seems to be the first study addresses the use of intravenous sufentanil in acute trauma by paramedics without EMS physician consultation. Most studies focus on the administration of fentanyl or morphine13, ketamine14,15, combination of fentanyl and ketamine16 or on another route of administration (e.g. intranasal or transmucosal).17,18,19 Our study does not address the use of opiates in children or other medical conditions (e.g. myocardial infarction) as it was presented in other studies.13,20
And at the same time, this study is in agreement with other studies from similar health care systems, and confirms that it is possible to entrust prehospital analgesia to trained paramedics.14