Prehospital Pain Management Evidence Based Guidelines


One of the most frequent conditions encountered by EMS professionals in the field is pain. While appropriate use of controlled substances is within the standard of care for treating pain in the prehospital setting, the opioid crisis currently facing the nation has fueled an urgent need to develop evidence-based recommendations on the prehospital use of analgesics.

Working collaboratively with the National Association of EMS Physicians (NAEMSP) and the American College of Emergency Physicians (ACEP), NASEMSO led a project to develop evidence-based guidelines (EBGs) for the pharmacologic management of acute pain in the prehospital setting.

The principal investigator was George Lindbeck, MD, from NASEMSO; co-investigators were Sabina Braithwaite, MD, representing ACEP, and Manish Shah, MD, of NAEMSP. Together they led a multi-disciplinary technical expert panel comprised of an EMS clinician and EMS educator, as well as others with expertise in emergency medicine, pediatrics, pain management, pharmacology, trauma care, guideline development methodology, patient advocacy, EMS data. This project produced the following deliverables:

  1. Two Manuscripts published in a peer-reviewed scientific journal, describing the methodology used to develop evidence-based guidelines. The articles are available at EBGs for Pain Management: Recommendations and EBGs for Pain Management: Literature and Methods
  2. Model EMS treatment protocol on the pharmacologic management of pain incorporating  the evidence-based guidelines, available at Model Protocol;
  3. Performance measures for evaluating adherence to the evidence-based guideline, available at Pediatric IN Fentanyl Performance Measure;
  4. Educational materials for training EMS professionals on the pain management evidence-based guidelines, including a Slide Presentation-pptx, Pain Management Faculty Script, Slide Handout, Lesson Plan and Drug Profiles.

Upon conclusion of the project, several members of the Technical Expert Panel participated in a webinar entitled Evidence Based Guidelines for Prehospital Pain Management. The webinar, hosted by the National Association of EMS Educators, is available here:

The project was funded through support from the National Highway Traffic Safety Administration (NHTSA), Office of EMS, and the Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau’s EMS for Children Program, as well as in-kind support from NASEMSO, NAEMSP and ACEP.

George Lindbeck, MD
Principal Investigator, NASEMSO

Dr. Lindbeck has 30 years of experience in both academic and community emergency medicine, as well as a history of activity in local, regional, state and national EMS organizations. He has Board Certifications in Emergency Medicine and Internal Medicine, and sub-specialty certification in Emergency Medical Services. His extensive experience in EMS medical direction includes service as medical director for career and volunteer 911 emergency services agencies, an air medical transport agency, inter-facility critical care agencies, and both dedicated EMS and fire-based EMS agencies. In addition, he served as a regional EMS medical director in central Virginia before being appointed as Virginia’s EMS and Trauma Systems Medical Director in 2009. He recently participated as a member of the expert panel that developed evidence based guidelines for fatigue management in EMS, a project that provided him background in the application of GRADE methodology. He was a co-author on the publications that produced evidence based guidelines for EMS providers and EMS agency leadership. He currently serves as Chair of the NASEMSO Medical Directors Council.

Sabina Braithwaite, MD, MPH
Co-Investigator, ACEP

Dr Sabina Braithwaite is Associate Professor of Emergency Medicine and EMS Fellowship Director at Washington University in St Louis and Missouri State EMS Medical Director. She has extensive experience as an EMS medical director and in EMS education at all levels. She has been active in leadership of several national organizations and projects, including the National Association of EMS Physicians, American College of Emergency Physicians, International Trauma Life Support and the EMS Culture of Safety Strategy Project. In particular, she was one of the key participants in the development of the original NASEMSO National Model EMS Clinical Guidelines Project. Sabina is board certified in Emergency Medicine and is subspecialty certified in Emergency Medical Services. She also holds an MPH with a specialty certificate in Disaster Management.

Manish Shah, MD
Co-Investigator, NAEMSP

Dr. Manish Shah is an Associate Professor at Baylor College of Medicine in the Department of Pediatrics, Section of Emergency Medicine.  He has served as the Program Director for the Emergency Medical Services for Children State Partnership (EMSC) in Texas, the Chair of the Emergency Medical Services (EMS) subcommittee for the American Academy of Pediatrics Section of Emergency Medicine, the pediatric emergency physician representative for the National Emergency Medical Services Advisory Council, and the prehospital and state partnership Domain Lead for the national EMSC Innovation and Improvement Center.  Dr. Shah was part of the team that published an evidence-based guideline for pediatric prehospital seizures by utilizing the Prehospital Evidence-Based Guideline Model Process. He has been the Principal Investigator for two EMSC Targeted Issues grants to study outcomes after implementation of evidence-based pediatric guidelines in large EMS systems in Texas and/or statewide EMS systems in New England. These evidence-based guidelines have been nationally disseminated through integration in the NASEMSO Model EMS Clinical Guidelines.  Since 2013, Dr. Shah also been the site Principal Investigator for the Charlotte, Houston, and Milwaukee Prehospital (CHaMP) research node, which conducts research in the Pediatric Emergency Care Applied Research Network.

Lorin Browne, DO

Dr. Browne is Associate Professor of Pediatrics at the Medical College of Wisconsin and Associate Medical Director, Milwaukee County Emergency Medical Services. As a board certified pediatric emergency medicine specialist, he is invested in improving the emergency medical care of children through quality clinical research focused on prehospital pediatric care and competent education of emergency medicine providers. He is the Milwaukee Site Principal Investigator of the Charlotte, Houston, and Milwaukee Prehospital (CHaMP) Research Node in the Pediatric Emergency Care Applied Research Network (PECARN) since its inception in 2013. With this research infrastructure now in place, Dr. Browne is focused on high-quality, priority-based research to improve the care delivered to children prior to hospital arrival.

Brooke Burton, NRP, FACPE

Brooke has 25 years of EMS experience working as a paramedic in rural to super urban environments. Brooke specializes in performance improvement and system/data interoperability. After paramedic education, Brooke attended the Ambulance Service Manager program through Fitch and Associates and the American Ambulance Association where she is now faculty, earned the Institute for Healthcare Improvement’s Healthcare Improvement Science certificate, and completed the National Association of EMS Physicians’ Quality and Safety Course where she is also now faculty. Brooke is one of the first women elected to the National EMS Management Association’s Executive Board, serves as Vice President for the National EMS Quality Alliance, and sits on the EMS World Editorial Review Board.

Jeffrey Coughenour, MD, FACS

Dr. Coughenour, is a trauma/acute care surgeon in Columbia, Missouri. He graduated from the University of Missouri at Kansas City School of Medicine in 2001 and following general surgery residency, completed a fellowship in trauma and surgical critical care at the University of Kentucky College of Medicine. He is affiliated with MU Health Care and the University of Missouri School of Medicine. He’s the medical director of the Frank L. Mitchell, Jr., MD, Trauma Center and an associate professor of clinical surgery and emergency medicine. His career in medicine began as an EMT in high school and during his undergraduate college years. He continues to practice in EMS as the Medical Director of the MU Air Medical Service and serves in various roles for the Missouri EMS System.

Paul Dangerfield, MD

Paul Dangerfield is board-certified in Anesthesiology and director of Acute Pain and Regional Anesthesia at The George Washington Medical Faculty Associates. He is also an assistant professor of Anesthesiology at the GW School of Medicine & Health Sciences and a co-founder of Doctors International. His areas of interest include care of the acutely injured patient, acute pain management and regional anesthesia. He chairs the George Washington Opioid Reduction Task Force and serves on a number of committees for GWU, including the Clinical Competency Committee, Medical Executive Committee, Trauma Peer Review, and the MFA Patient Safety Committee. He is also on the Board of Advisors for the Committee for Tactical Emergency Casualty Care and is a contributor for TQIP Pain Control Protocol, American College of Surgeons.

Remle Crowe, NREMT, PhD

Dr. Crowe is an expert in quality improvement and research. From truck clutches to clinical care, she has shown how improvement science and research work to solve problems across fields. As an EMT with a passion for advancing the EMS evidence base, she earned her PhD in Epidemiology and has authored numerous peer-reviewed publications. Now, as a research scientist at ESO and faculty member of the NAEMSP Quality and Safety Course, Dr. Crowe routinely uses data to improve community health and safety.

James J. Gasper, PharmD, BCPP.

Dr. Gasper received his Doctor of Pharmacy from the University of Colorado Health Science Center. He complete residency training at the Denver Veterans Affairs Medical Center and University of California San Francisco. He currently is a psychiatric and substance use disorder pharmacist for the California Department of Health Care Services. His present initiatives include expanding access to treatment for substance use disorders, implementing the availability of naloxone, and improving the safety of opioid analgesics. Beyond his work for the Department, he serves as a consultant for the UCSF Clinician Consultation Center Substance Abuse Warmline which serves providers nationwide.

Eddy S. Lang, MD

Dr Lang is a Professor and Department Head for Emergency Medicine at Cumming School of Medicine- University of Calgary and Alberta Health Services, Calgary Zone. His areas of interest are knowledge translation, evidence-based medicine and operations research. He is a member of the GRADE working group and has led the development of GRADE-based clinical practice guidelines in pre-hospital care in the US as well as with the International Liaison Committee for Resuscitation. Dr. Lang is also an award-winning educator having received recognition at both the university, national and international levels. He also serves as Senior Editor for the Canadian Journal of Emergency Medicine, Associate Editor for both ACP Journal Club and the International Journal of Emergency Medicine. In addition, he is a member of the Canadian Task Force on Preventive Health Care (CTFPHC). Dr. Lang chaired the Canadian Association of Emergency Physicians Conference (CAEP) 2018 and he was appointed as the Scientific Director of the Emergency Strategic Clinical Network ESCN in Alberta.

Connie J. Mattera, M.S., R.N., TNS, Paramedic

Connie has numerous administrative and educational responsibilities at Northwest Community Hospital and for the Northwest Community EMS System in Arlington Heights, IL, She is also the Vice Chair of the State of Illinois Governor’s EMS Advisory Council, chairs the Illinois EMS Education Committee, is a frequent faculty member at local, state, and national conferences, and has published multiple articles in EMS and nursing journals. Connie is a former member of the Board of Directors of the National Association of EMS Educators and serves as a national faculty member for their educator courses. Areas of expertise include Trauma care, EMS planning and leadership; mentoring, curriculum design and multimodal instruction; evidence-based practice standards and best practice models; quality management and performance improvement; testing and measurement and competency evaluation.

Sandra Nasca, RN

Sandra Nasca began her health care career as a registered nurse working in emergency medicine. In 2009, she transitioned to clinical forensics after completing the training at Queens University in Charlotte, North Carolina, and began her work as a forensic medical investigator at the Pike County, Alabama Coroner’s Office where she continues to serve as Deputy Coroner. As a member of the Child Death Review Team and the Perinatal Death Review Team, she reviewed cases of child death to determine causes of death and make recommendations to the state on practices that may help reduce child mortality. Sandra has served as a member of the EMSC Family Advocacy Network for 23 years, representing both Florida and Alabama. She and her husband raised 8 children and numerous foster children, including many who were medically complex. She has extensive experience as a patient advocate, both as a health care provider and foster parent.

Ashish Panchal, MD, PhD

Dr. Panchal is the Director of Research for the National Registry of Emergency Medical Technicians. He oversees the NREMT’s research and serves as mentor to the NREMT’s research fellows. Dr. Panchal also works as an Associate Professor of Emergency Medicine at The Ohio State University Wexner Medical Center. He is also the pre-hospital medical director for the Delaware County EMS and the Newark Fire Department. Dr. Panchal has a Ph.D. in Organ System Physiology from Case Western Reserve University and an MD from The Ohio State University.

Peter Taillac, MD, FACEP

Dr. Taillac is a clinical professor in the Division of Emergency Medicine at the University of Utah School of Medicine. He is also the state EMS medical director for the Bureau of Emergency Medical Services and Preparedness in the Utah Department of Health. In this position, Dr. Taillac chairs multiple statewide committees, including stroke, cardiac, and trauma registry and performance improvement, state EMS protocol guidelines, and others. Dr. Taillac is the past chair of the NASEMSO Medical Directors Council. He currently serves on the National EMS Advisory Council. Dr. Taillac recently retired after 38 years of military service as an Army physician, serving on Active Duty, Reserve, and the National Guard, with the rank of Colonel. He served as the State Surgeon for the Utah Army National Guard for 12 years and provided combat medical care during tours of Iraq and Afghanistan. Dr. Taillac is Board Certified in both Emergency Medicine and Emergency Medical Services.

Mark Warth, BS, NRP

Mark began his EMS career in 1997 as a volunteer EMT for a rural ambulance service. He advanced to an EMT-Intermediate and in 2001 completed the paramedic program at the University of Colorado in Colorado Springs. He holds a bachelor’s degree in health science. Mark has worked for hospital, fire, county, and private EMS agencies in rural, suburban and urban settings. Having previously been a course coordinator for a vocational technical college, university faculty member, guest speaker for several regional EMS conferences, and a hospital EMS training coordinator he brings a vast array of both teaching and field experience to the Technical Expert Panel. Currently Mark is the Fire Medical Program Coordinator for Colorado Springs Fire Department, where he combines his education and work experience to develop and advance quality assurance and improvement programs by bridging the gap between science, data, and education.


For More Information

Mary F. Hedges, MPA
Program Manager