Prehospital Pain Management in Trauma Treated by Helicopter Emergency Medical Services: Association of Patient and Physician Sex.

Abstract

Pain in trauma patients is frequent and associated with adverse physiological and psychological outcomes. Despite the recognized importance of early and effective analgesia, prehospital pain management remains insufficient in a substantial proportion of cases. Emerging evidence suggests sex-related differences in analgesic treatment, with both patient and physician sex potentially influencing therapy. This study investigates whether specific physician-patient sex pairings, alongside clinical and operational factors, are associated with the efficacy of prehospital pain management and explores how these factors interrelate to contribute to inadequate analgesia. We conducted an observational cohort study of trauma patients treated by a Swiss physician-staffed Helicopter Emergency Medical Service between September 7, 2020, and July 24, 2025. We included patients with a Glasgow Coma Scale (GCS) ≥13, a National Advisory Committee for Aeronautics (NACA) Score <VI, on-scene pain of ≥3 on a patient-reported numeric rating scale (NRS), and a second pain assessment at hospital arrival. Patient and physician demographics, injury characteristics, and pain management were extracted. The primary outcome was sufficient pain management at hospital arrival, defined as NRS ≤3 at hospital arrival. Analgesic administration was evaluated for associations with insufficient pain control (NRS >3), persistent untreated pain, and pain reduction. Of the 43,024 prehospital missions analyzed, 5168 met the inclusion criteria. The cohort was predominantly male (3097/5168; 59.9%); the median age was 47 [29-62] years. Extremity trauma was most common (3514/5168; 68%). In 32.2% (1663/5168; 95% confidence interval [CI], 30.9-33.3) of cases, analgesia was insufficient. While male physicians achieved greater NRS reduction (Coef. 0.20; 95% CI, 0.12-0.28), male patients reported less pain relief (Coef. -0.13; 95% CI, -0.21 to -0.05). Higher initial NRS scores (odds ratio [OR] = 1.45; 95% CI, 1.39-1.51) and omission of analgesics (OR = 5.70; 95% CI, 4.54-7.15) were associated with insufficient analgesia. The use of a combination of opioid and ketamine was associated with improved analgesia (OR = 0.69; 95% CI, 0.58-0.83). The greatest pain reduction was observed with ketamine or combination therapy. The median ΔNRS was 5 (interquartile range [IQR] 3-6) for ketamine and 5 (IQR 4-6) for combination therapy. In this large cohort, we found sex-related differences in patient-reported analgesia: male patients were more likely than female patients to report insufficient analgesia. Treatment by male physicians was associated with better patient-reported analgesia. Ketamine and its combination with opioids were associated with greater patient-reported NRS reduction compared to opioid monotherapy in a prehospital setting.