Let me throw a scenario out there for the more experienced of the group I am finishing up MS-II in Virginia. I have also been a paramedic in the state since I was 18. I still work part time to bring in some extra cash and keep up my intubation, iv, ekg, etc. skills. My problem is this: management of acute pain is a joke in our system. For example, two weeks ago I watched one of our medics respond to an ice-skate rink for a closed ankle fx. I continued to watch as he immobilized, packaged and transported this poor lady as she screamed and moaned all the way to the hospital. His pain management went something like this: hang with me sweetheart. We are almost to the hospital and they can give you something for your pain once we get there. He was well-aware that he 20 mg of morphine in a tubex in his drug box. When I asked him why he didnt give it, he responded I dont give narcs. You have to put up with too much crap at the hospital if you give them. The sad part is he is right. I brought in one of our supervisors from work that collapsed with a kidney stone. Since he was unable to speak, diaphoretic and in the fetal position with a blood pressure around 190/100 I thought that some pain management might be in order. I gave him 5 mg iv morphine q 10 min to try and reduce his pain, but with little success. By the time we got to the ER he had a total of 20 mg morphine over about 45 min. He was able to talk, but his pressure was still sky high and he was still in the fetal position. And, as usual, when I told the nurses taking report how much morphine I gave, you would have thought the world had come to an end. Granted, they dont know my background. Butthis is what they do to all of the providers. So, while im trying to get my patient (who is also a friend) some relief, the RNs are too busy b*tching at me about giving pain meds. Of course, when the doctor got into the room I told him how much I gave. His response was well, obviously that didnt do the trick and his pressure is great. Lets try some dilaudid. Luckily the doctor knew me. But, this intimidation of paramedics by the RNs in the ER is keeping them from adequately managing pain in the field. So, I turn to you, the experts. Here is what I want to know: We carry 20 mg morphine and 4 of narcan in each box along with the typical anaphylaxis drugs (but no anti-emetic which SUCKS!!). And while they are not physicians, paramedics are the only means of extending emergency care out into the streets. While I have heard the arguments from the RNs in the emergency dept, I am much more interested to see the point of view from the docs who deal with these drugs constantly. Is pre-hospital administration of opioids safe?? Do I go to the administration and tell them to get the RNs off our back and stop intimidating the paramedics or can the patient wait that 45 min until they get to the ER?? Do I try and re-train my colleagues that narcs are not something to fear?? They are also talking about switching to a premixed nitrous/02 mix for pain in the field. Would that be safer and more efficacious?? Just curious and thanks to all in advance.