Influence of patient sex on pain management practices in Paramedicine: A rapid review

Abstract

Objective: Pain is a subjective multidimensional experience that impacts an individual's physical, emotional, and mental wellbeing. Paramedics are regularly contacted to alleviate pain, in both an emergency and non-emergency capacity. Patient presentation, assessment tools, and clinical judgement, together influence paramedic decision making, and therefore pain management practices will inevitably vary. This research aimed to identify the nature and description of sex-specific discrepancies in the literature in relation to paramedic pain management. Methods: Using the Cochrane rapid review methodology, a search of five electronic databases and nine paramedic-specific journals was conducted on 8 November 2023. Articles were included if they: investigated ambulance presentations of pain; analysed pharmacological analgesic management; compared management between the sexes; and reported on either medication type, dosage, time to administration, or pain score. Eligible articles were assessed for risk of bias and subjected to narrative synthesis. Results: A total of 2545 articles were identified during the systematic search, resulting in 13 studies eligible for inclusion. Seven studies indicated a sex disparity in the administration of analgesia after controlling for confounders, with females statistically less likely to receive analgesia, particularly opioids, compared to males. Five studies found that sex had no effect on analgesic administration. One study noted female paramedics provided better analgesia overall, while two studies found paramedic sex had no influence on analgesic decisions. Five studies indicated that the higher the pain score, the greater the likelihood of analgesic administration, with three studies highlighting that the analgesia provided was effective in reducing pain score. Conclusions: While some studies identified no sex-specific differences in relation to paramedic pain management, a greater number of studies indicated a gender-disparity, where females were found to have higher risk of oligo-analgesia. Ideal pain management practices were demonstrated in the literature, with higher pain scores correlating to increased rates of analgesia.

Keywords

paramedic pain equity community care paramedicine rapid review

Introduction

Background

Pain is a multidimensional experience that is highly subjective and is dependent on the individual's lived experience and tolerance of pain.^1–3 The pain experience encapsulates physiological, emotional, and cognitive components, and can be classified as acute, a transient dynamic pain associated with intense emotions, or chronic, persistent pain that lasts longer than 3 months.^1,2,4,5 Nociception refers to the process that leads to an individual perceiving pain. Nociceptors are sensory receptors present in human tissue, that recognise and alert the brain to pain.^4–6 When noxious stimuli cause direct tissue damage, nociceptors are activated and the pain pathway, or nociception, takes place.^4,5

Paramedicine refers to the provision of medical care in the out-of-hospital setting, in both an emergency and non-emergency capacity.^7,8 The paramedics who operate in this space are exposed to a dynamic, uncontrollable environment, in which they need to be capable of managing and treating a vast range of presentations; from life-threatening to acute conditions; to mental health and socially challenging situations.^7–10

Paramedicine is a steadily evolving field with many variations across different services around the world.^9,11,12 Where traditionally, ambulance services accepted vocationally trained paramedics, there has been a gradual shift in paramedics requiring tertiary qualifications to enter the workforce.^8,9,13 Many services allow paramedics to complete further training or study to become specialist clinicians, in which their scope of practice increases to encompass more specialised skills.¹⁰ Some services allow paramedics to engage in independent decision making without contemporaneous medical oversight, whilst others require consultation with medical professionals to direct treatment decisions.¹¹ This variation in education and scope means that the care provided from paramedic to paramedic may vary.

Paramedics are frequently contacted to alleviate pain for those afflicted in the community.^14–16 In both paramedicine and healthcare as a whole, a range of pain assessment and measurement approaches are utilised including the visual analogue scale, verbal rating scale, Wong Baker FACES pain rating scale, and pain drawing.^17–21 The most used tool for quantifying pain severity in paramedicine is the verbal numeric rating scale (vNRS) which takes less than a minute to conduct and allows for pain to be expressed as a number.^17,18,20 Patients are instructed ‘on a scale of zero to ten, with zero being no pain at all and ten being the worst pain you could imagine, where would you rate the pain you are experiencing right now?’ (p. 67)²² These pain measurement tools are seemingly sex-neutral, and do not consider the subjective nature of the pain experience, nor the biological, psychological or sociocultural influence that sex has on pain expression.^23,24 Whilst, paramedics rely on a patients symptoms and reporting of pain to inform analgesic decisions, a clinicians’ subjective clinical judgment that is influenced by their experiences and scope of practice may at times override the severity of a patients reported pain score.²⁵ For clinicians, being aware of subconscious biases that may impact the quality of care they provide is imperative, whilst patients who receive unbiased pain management have increased trust and confidence in ambulance services and the paramedics who care for them.²⁶

It is therefore evident that pain is a complex phenomenon that is not only dictated by the innate biological process of nociception, but by an individual's lived experiences and understanding of pain. In turn, analgesic decisions are informed off both a patient's response to objective clinical measures and the paramedic's subjective clinical judgement. A patient's sex is therefore imperative to investigate in the context of pain and it's management, as males and females inherently perceive, tolerate and express pain differently.^1–5,24 Sex therefore challenges equitable pain management practices as a whole. It is of note, that the terms sex and gender are used interchangeably throughout this article however both are used to describe a person's biological sex at birth.

The current research conducted into the effect of sex on paramedic management of pain has not been well summarised. This review was intended to inform understanding of a subsequent observational study into actual pain management practice by paramedics. As such, this rapid review aimed to evaluate current literature on gender biases in paramedicine, to identify the influence of sex on analgesic pain management practices.

Methodology

Design

A rapid review methodology was adopted due to time constraints arising from the study being a precursor to a broader epidemiological research project. Rapid reviews are a recognised, robust review typology particularly suited to contexts in which results are required in a more timely fashion than those arising from a systematic review, to identify and critically appraise current studies in paramedicine.²⁷ This review was conducted in accordance with the Cochrane Guidance on Rapid Reviews.²⁸ Prior to conducting the research, a protocol outlining the aims, objectives, methodology, and timeline of this review was uploaded to Open Science Framework.²⁹ The protocol is located at https://osf.io/nkfxc. Changes have since been made to the a priori document in relation to methodology and outcomes. This rapid review is reported in adherence with that PRISMA 2020 statement.³⁰

Eligibility criteria

Articles were eligible for inclusion in the rapid review if they: (i) investigated patients who presented with pain to an ambulance service; (ii) analysed pharmacological analgesic management; (iii) provided comparative analyses based on sex; and (iv) reported on at least one of the following outcomes: medication type, medication dosage, time to administration, or pain score.

Articles were excluded from analysis if they: (i) specifically investigated pregnant populations, older people (>65) or younger people (<16); (ii) provided no analysis of pharmacological interventions; (iii) had no comparisons based on sex; (iv) did not report on any of the primary outcomes; (v) were either conference abstracts, commentaries, clinical trial registrations, and editorials; and (vi) were not published in English.

Search strategy

Five electronic databases were searched on 8 November 2023. These were MEDLINE (Ovid), CINAHL (EBSCOhost), Cochrane, Embase (Ovid) and Scopus (Elsevier). Search results were restricted to full text and English language with no date restrictions applied. A further nine paramedic specific journals were hand searched for relevant articles due to these journals not being indexed in the listed databases. Grey literature was not searched for this review due to time constraints. The paramedic search filter optimised for sensitivity created by Olaussen et al.³¹ was used to inform the search strategy. A preliminary search on MEDLINE was also conducted to identify further relevant terms. A full search strategy for each database and the list of paramedic specific journals can be found in Supplemental Appendix 1. In adherence with rapid review methodology, the literature search was conducted by one researcher (SD).

Study selection

Identified articles were uploaded into the systematic review software Covidence³² via the reference manager software EndNote.³³ Screening of the selected studies was undertaken via a two-step process. Step one had two of the researchers (SD and NN) individually screen the titles and abstracts of all articles. Step two comprised of SD screening the full text of all shortlisted articles, whilst NN screened all excluded full texts. Reasons behind exclusion of full texts are documented in Figure 1. Any discrepancies were settled by a third researcher (PS).

Figure 1.

PRISMA flowchart of included and excluded studies.

Data extraction

Data were extracted by SD with NN and PS checking for accuracy. The following data were extracted from each article: title, author, publication date, country, study design, sample size (sex %) and study results. Data were in turn subject to narrative synthesis. Tables and figure were created using Microsoft Word.³⁴

Assessment of risk of bias

Selected articles were in turn assessed for risk of bias (ROB) using the JBI Critical Appraisal Tool for Analytical Cross-Sectional Studies.³⁵ This tool consists of eight criteria that can be answered as yes, no, unclear, or not applicable. Studies were included as part of this rapid review if they received a “yes” response to five or more out of the eight domains. This would indicate that included studies have a greater than 60% methodological quality rating, which was deemed sufficient for this review. There was a lack of consensus in the existing literature on quality rating thresholds and thus 60% was selected based on consensus from the research team and a rapid review conducted by Pap et al.³⁶ that had similar setting and structure as this present research. SD and NN individually assessed the ROB for each study, with disputes settled by PS. Certainty of evidence was not assessed in adherence with accepted methodological guidance for rapid reviews.

Results

Study selection

A yield of 2537 studies were identified through the database searching with an additional 8 studies located with the searching of non-indexed journals, resulting in a total of 2545 articles. From these, 294 duplicates were removed with 2205 articles excluded for not meeting the inclusion criteria. The remaining 46 articles were assessed for study eligibility by reviewing the full texts. Articles where full texts were unable to be located online were excluded, after emailing authors twice with no response. Subsequently, 33 studies were excluded with reasons provided, while 13 articles remained for analysis. Figure 1 depicts a PRISMA flowchart that details article identification and selection. Critical appraisal was conducted on these 13 articles with all articles meeting the a priori ROB threshold score of at least 60%.

Study characteristics

The 13 included studies were conducted in ambulance services in multiple countries:

USA (n = 5),^37–41 Australia (n = 3),^42–44 England (n = 1),⁴⁵ Italy (n = 1),⁴⁶ South Africa (n = 1),⁴⁷ Switzerland (n = 1)⁴⁸ and Sweden (n = 1).⁴⁹ All but one of the articles,⁴⁹ were conducted retrospectively, analysing data that had been routinely collected by an ambulance service as part of patient management. All the included studies analysed paramedic analgesic practices, with eight articles specifically investigating sex as a primary outcome.^{38–43,45,48} Study results are listed in Table 1.

Table 1.

Characteristics and results from included studies (n = 13).

Author	Year of publication	Country	Study design	Sample size (male%)	Results summary
Supples et al.⁴⁰	2023	USA	Retrospective review	32,463 (49.8%)	− 15% (n = 4989) of patients received analgesia, with fentanyl administered to 94%, followed by ketorolac 5.3%, then paracetamol 0.7%. − Females were more likely to have pain assessed than males (p < 0.0001). − Higher vNRS were more often reported by female patients compared to males (6 IQR 2−8 VS 4 IQR 2–8; p < 0.0001). − Females less often received opioid analgesics (p = 0.006) where it was indicated as per pain protocols. − Logistic regression investigating patients with a pain score of ≥4, found that females had lower odds of receiving analgesia, adjusted for race, age, pain score, transport interval, and Glasgow Coma Scale (adjusted results). − Patients with longer transport times were more likely to receive analgesia.
Ferri et al.⁴⁶	2022	Italy	Retrospective observational study	629 (49%)	− Pain score was not collected in 24.5% (n = 154) of patients. − 46.7% (n = 222) of the study population had pain. − Pain had a similar prevalence between the two sexes (females 53%, n = 118; males 47%, n = 104); with the average pain score between both being insignificant. − 79.7% (n = 177) of patients who reported pain received no analgesia, with there being no difference between the sexes in this population. − Fentanyl was the most used analgesic for patients presenting with severe pain, with no differences found between the sexes. − Statistically significant differences were noted in the decrease in mean pain score after pharmacological management in both males (7.56 ± 1.9 VS 3.11 ± 1.8; t = 5.67, p < 0.001) and females (7.93 ± 1.2 VS 4.29 ± 2.7; t = 5.74, p < 0.001). − There were no statistically significant differences in the mean pain score between the sexes who had received pharmacological treatment, either before or after receiving therapy (Pre: t = 0.58, p = 0.57; Post: t = 1.15, p = 0.26).
Wimbish et al.⁴¹	2022	USA	Retrospective cross-sectional study	27,448 (46.1%)	− 80% of patients did not receive an opioid. − The logistic regression indicated that paramedics administer opioids to females at significantly lower rates (p = 0.004; OR = 0.90) compared to males after controlling for age, number of minutes spent with ambulance, location of the pain or injury on the body, the observability of the pain or injury, and the reported pain score (adjusted results). − No significant difference in the rate of opioid administration to patients of unknown gender.
Johansson et al.⁴⁹	2021	Sweden	Prospective observational study	32 (50%)	− Methoxyflurane was found to be effective with patients having an average vNRS on scene was 8 (IQR 7.25–10.0) reducing to an average of 5 (IQR 4.0–7.0; p = 0.001) when at hospital. − Female patients had an average initial vNRS of 9 while males had an average vNRS of 8. These scores were not significantly different. However, at hospital admission, females had a lower average vNRS of 4 (IQR 3.75–6.0) than males who scored an average vNRS of 6 (IQR 5.0–7.5) which was statistically significant (p = 0.036).
Kiavialaitis et al.⁴⁸	2020	Switzerland	Retrospective cohort study	20,978 (48%)	− The average initial vNRS was 5.2 ± 3.0 where 48% of patients received analgesia. From these patients, 77% were considered to have received sufficient analgesia with an average reduction of vNRS was 2.2 ± 2.5. − Logistic regression indicated patient's sex had no influence on analgesia administration (OR 1.1; 95% CI 1.0–1.1; p = 0.1). Female paramedics were also found to have provided better analgesia (OR 1.2; 95% CI 1.1–1.2; p < 0.001) (adjusted results).
Lourens et al.⁴⁷	2020	South Africa	Retrospective review	2401 (68.7%)	− 18.1% of patients (n = 435) had a vNRS recorded with an average vNRS of 6 (IQR 4–8). No association was found between vNRS being recorded and sex (p = 0.139). − 2.8% of patients (n = 68) received analgesia where 66 received IV morphine, with 52 of them being male (78.8%). − Association was found between a vNRS being recorded and analgesic administration (p < 0.001) and severity of pain and analgesic administration (p = 0.001). Both associations were weak in strength. − No association was found between the administration of analgesia and sex (p = 0.054).
O'Connor et al.³⁷	2020	USA	Pre/post retrospective chart review	22,311 (48%)	− Females were less likely than males to receive an opiate medication (OR 0.78; 95% CI 0.69–0.89) with females more likely to receive non-opiates after the introduction of non-opiate options (unadjusted results). − The overall rate of opiate administration has decreased while the rate of pain medication administration has slightly increased.
Siriwardena et al.⁴⁵	2019	England	Retrospective cross-sectional study	9574 (47.3%)	− During paramedic management, pain was reduced in 45.5% of patients. − Patients with vNRS between 4 and 10 were more likely to receive IV morphine than those with vNRS between 0 and 3. − Multivariate logistic regression could not identify a disparity between analgesic use or pain reduction, and sex of the patient or paramedic.
Lord et al.⁴³	2014	Australia	Retrospective cohort study	42,051 (49.6%)	− 51% of patients reporting a vNRS between 4 and 10 received analgesia. From patients who received analgesia, 26% received an opioid. − Patients reporting a vNRS between 8 and 10 were significantly more likely to receive analgesia than those with vNRS between 4 and 7. − There was no significant difference between females and males reporting a vNRS between 8 and 10 (53% vs. 51%; p < 0.0001). − Univariate analysis found that both male and female paramedics administered opioids more frequently to male patients (p < 0.0001), however, multivariate analysis found no association between paramedic sex and opioid administration or patient sex. − Multivariate regression further identified less female patients were treated with an opioid than male patients (33% vs. 39%; p < 0.0001) with male patients at far greater odds of receiving an opioid compared to females (OR 1.52; 95% CI 1.29–1.79; p < 0.0001) (adjusted results).
Young, et al.³⁹	2013	USA	Retrospective cohort study	6398 (44%)	− vNRS was recorded for 23% of patients, with 25% receiving morphine, compared to 8% of the whole study population receiving analgesia. − Bivariate analysis indicated that females were significantly more likely to receive analgesia than males. − Multivariable regression found sex to have no effect on analgesic administration when controlling for potential confounders such as pain score. It did however find that if no vNRS was recorded, older females were significantly more likely than younger males to receive analgesia (OR 4.6; 95% CI 1.6–13.0; p = 0.004). Higher vNRS and longer prehospital time were both significant predictors of increased analgesia administration (adjusted results).
Bendall et al.⁴⁴	2012	Australia	Retrospective cohort study	97,705 (49%)	− Univariate analysis indicated females were almost 20% less likely to receive an opiate compared to males when a single analgesic agent was used (RR 0.83; 95% CI 0.82–0.84; p < 0.0001) (unadjusted results). − Both alone and in combination with other analgesics, methoxyflurane was the most used agent, being administered in almost 60% of patient encounters.
Lord et al.⁴²	2009	Australia	Retrospective cohort study	1766 (48%)	− At the first pain assessment, females complained of more severe pain (vNRS 8–10) than males (p = 0.05). − 45% of patients reporting pain did not receive any analgesia (95% CI 43–47). − 25% of patients with a recorded vNRS between 8 and 10 received morphine, where 20% of patients with a vNRS between 4 and 7 received morphine. − Significant relationship noted between vNRS and receiving analgesia (p ≤ 0.001). − No sex difference in the reduction of vNRS by 2 or more points (46% vs. 46%; p = 0.82). − No sex difference was identified in the administration of analgesia (p = 0.93). − Multivariable regression identified a disparity in the type of analgesia administered with females less likely to receive morphine than males (13% vs. 17%; p = 0.01) (OR 0.61; 95% CI 0.44–0.84), remaining significant when controlled for type of pain, age, and pain severity (adjusted results).
Michael et al.³⁸	2007	USA	Retrospective cohort study	953 (42.3%)	− 29% of patients (n = 279) received morphine. − Both univariate analysis and multivariate logistic regression found significant differences in morphine administration. − Based on sex, with males having a higher rate of administration than females (32.8% vs. 26.7%) (OR 1.65; 95% CI 1.16–2.36), remaining significant when controlled for income, pain severity and prehospital time (adjusted results).

CI: confidence interval; IQR: interquartile range; IV: intravenous; n: number of participants; OR: odds ratio; p: p value; RR: relative risk; t: t-test statistic; vNRS: verbal numeric rating scale.

Summary of the studies

Effect of patient sex on provision of analgesia

Seven of the studies indicated some form of sex disparity in the administration of analgesia.^{37,38,40–44} This disparity was predominantly in favour of males, with females having a significantly higher risk of oligo-analgesia. That is, females are statistically less likely to receive analgesia, specifically opioids in majority of these studies, in comparison to their male counterparts. This disparity remained significant in these studies when confounders including type of pain, age, pain severity, and time under prehospital care, were controlled.^38,40–43 Lord et al.⁴² identified that there was no sex disparity in the administration of methoxyflurane and/or morphine as a whole, however when looking at morphine specifically, males were significantly being administered morphine at a higher rate. O’Connor et al.³⁷ investigated non-opiate and opiate administration, with the results indicating that males had a higher rate of being administered an opiate whereas females had a higher rate of non-opiate administration. Supples et al.⁴⁰ noted that whilst females were more likely to have their pain assessed and reported higher pain scores overall, males had statistically higher likelihoods of receiving analgesia. Wimbish et al.⁴¹ found sex to be a statistically significant factor on opioid administration, however found opioid administration was not influenced by patients classified as ‘unknown gender’.

The study by Young et al.³⁹ investigating patients presenting with blunt trauma, found that older females were more likely than younger males to receive analgesia if no pain score was recorded. However, in the entire study population it was found that sex had no effect on analgesia. This understanding was further highlighted in the other included studies which indicated that analgesic administration was not influenced by the sex of the patient, even after controlling for potential confounders.^39,45–48

Effect of paramedic sex on provision of analgesia

Three studies investigated paramedic sex and its influence on analgesic administration.^43,45,48 Kiavialaitis et al.⁴⁸ found that female paramedics provided better analgesia overall than male paramedics, whereas Lord et al.⁴³ and Siriwardena et al.⁴⁵ found that the sex of the paramedic was not a relevant factor for the rate of analgesic administration.

Effect of pain score on analgesic administration and effectiveness

While the study by Johansson et al.⁴⁹ did not comment on the difference in analgesic administration, it identified that females reported a higher vNRS for their pain at the beginning of a patient interaction and a statistically significant lower vNRS at hospital admission. Supples et al.⁴⁰ and Lord et al.⁴² also reported on females having higher initial vNRS, whereas Lourens et al.⁴⁷ was unable to find an association with pain score and sex.

Consistent throughout the studies, was that the higher the vNRS, the greater the likelihood of receiving analgesia.^{39,42,43,45,47} This relationship was found to be statistically significant in two of the studies.^42,47 For patients who were administered analgesia, three of the studies indicated that the analgesia was effective in reducing patients’ vNRS by the time of hospital admission.^45,48,49 Lord et al.⁴² found that there was no significant difference in analgesic administration and no difference in the reduction of vNRS by 2 or more points when comparing females and males.

Risk of bias

All studies met the methodological quality rating threshold of 60% with four studies having a quality rating of 100%,^38,40–42 seven having a quality rating of 75%^37,43–48 and two having a quality rating of 62.5%.^39,49 All ROB scores are listed in Table 2.

Table 2.

Risk of bias assessment of included studies (n = 13) using the JBI critical appraisal tool.⁵⁰

ROB criteria	Included articles
	Supples et al.⁴⁰	Ferri et al.⁴⁶	Wimbish et al.⁴¹	Johansson et al.⁴⁹	Kiavialaitis et al.⁴⁸	Lourens et al.⁴⁷	O'Connor et al.³⁷	Siriwardena et al.⁴⁵	Lord et al.⁴³	Young, et al.³⁹	Bendall et al.⁴⁴	Lord et al.⁴²	Michael et al.³⁸
Were the criteria for inclusion in the sample clearly defined?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Were the study subjects and the setting described in detail?	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	Yes
Was the exposure measured in a valid and reliable way?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Were objective, standard criteria used for measurement of the condition?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Were confounding factors identified?	Yes	No	Yes	No	No	Unclear	No	Unclear	Unclear	Yes	No	Yes	Yes
Were strategies to deal with confounding factors stated?	Yes	No	Yes	No	No	Unclear	No	Unclear	Unclear	Yes	No	Yes	Yes
Were the outcomes measured in a valid and reliable way?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Was appropriate statistical analysis used?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Overall appraisal	Include	Include	Include	Include	Include	Include	Include	Include	Include	Include	Include	Include	Include
Overall score*	8	6	8	5	6	6	6	6	6	5	6	8	8

*Overall score out of 8.

ROB: risk-of-bias.

Discussion

From the results of this rapid review, it is evident that there is an inadequate amount of research to indicate if paramedics are treating patients equally when analgesic options are considered. Some studies have indicated that females are disproportionality treated less for their pain, even when the complaints of pain are similar to males.^{37,38,40–44} This may create an equity of care and patient safety problem in prehospital care, as female patients may go longer without adequate pain relief. This is important to note as some research shows that females experience more severe, longer lasting and recurrent pain.^24,51–53 This may therefore indicate that a mismatch in pain presentation and subsequent pain management may exist. This finding is in line with the understanding that pain is subjective and encompasses lived experiences, as well as interactions between biological, psychological and sociocultural factors.^2,3,24 Females experiencing higher pain scores was noted in studies by Supples et al.⁴⁰ and Lord et al.,⁴² however both studies found that females were still disproportionally administered analgesia. Bendall et al.⁴⁴ identified a sex-specific disparity in their study, however did not list the descriptive statistics and univariate results, nor did they conduct multivariate regression to test for confounders, detracting from the reliability of their results. Only three articles that identified a gender discrepancy posited brief justification as to why this may exist.^41–43 However, none of the included studies that identified a sex-specific difference in analgesic administration provided any recommendations on tools or methods to mitigate these differences. All articles made comment on the need for further research into pain management practice in paramedicine.

Three of the included studies indicated that analgesic administration is not affected by a patient's sex and is instead based on the severity of pain described by the patient.^39,45,47 These findings therefore give rise to the understanding that although pain is subjective, and is described and experienced differently by different sexes, patients are treated equally in relation to pain management. That is, if an individual is expressing their pain in such a way that it would be considered mild, moderate or severe, regardless of their gender, analgesia was administered appropriately. Two of the studies that identified a sex disparity also supported this same finding, of a higher vNRS corresponding to better analgesia.^42,43 This may indicate that in these specific studies, males may have articulated their pain as more severe than their female counterparts, in turn, receiving higher rates of analgesia and creating a de facto sex disparity. However, only two of the studies that identified an analgesic administration and pain score relationship commented on this relationship being statically significant,^42,47 with the other studies only identifying vNRS and analgesic administration as an association, detracting from this conclusion. Three of the included studies did comment on the analgesic management provided to patients being effective in reducing vNRS.^45,48,49

Only five studies explicitly identified confounding variables and subsequently controlled for them in their regression model.^38–42 From these, four found sex-specific disparities in analgesic administration.^38,40–42 A further three studies conducted multivariable regression analyses, however did not explicitly state which confounders they were testing for and if they were first found significant using univariate analyses.^43,45,48 Two of these studies found no disparity between the genders, in turn affecting the reliability of the study conclusions.^45,48

The prospective study by Johansson et al.⁴⁹ found, that females had a higher initial pain score, and when treated with the same analgesia methoxyflurane, had statistically significant lower pain scores at hospital in comparison to their male counterparts. This, as a single study, indicates that methoxyflurane may be more effective in reducing pain in females than in males. However, due to this study's small sample size, its conclusion may lack statistical reliability, and therefore requires further investigation.

O’Connor et al.³⁷ highlight that with the introduction of non-opiates such as paracetamol and ibuprofen, the rate at which analgesia was administered increased. This finding suggests that prehospital services may need to increase the variety of analgesic types, as to better allow paramedics to treat pain more specifically. For example, being able to provide a non-steroidal anti-inflammatory drug for muscular pain as to take advantage of its anti-inflammatory properties in comparison to, or in combination with, an opioid. However, O’Connor et al.³⁷ made no analysis on the paramedic practices prior to the introduction of the new medications. The study did identify a sex-specific disparity that males had higher rates of opioid administration, however it is unclear if this disparity existed prior to the new medication introductions. An analysis of this would have strengthened conclusions on sex-specific disparities by O’Connor et al.³⁷

Lourens et al.⁴⁷ found an association with higher analgesic administration among higher qualified paramedics, which may be due to access to a wider range of medications. This was similar to Ferri et al.⁴⁶ who found that statistically lower rates of analgesic administration were noted in nurse-staffed ambulances, as opposed to ambulances staffed by both a doctor and nurse acting in a paramedic capacity. These findings indicate the need to increase scope of practice through further inter-professional training and education, thorough investigation into how certain medications act differently in males and females, and how to incorporate sex-specificity in analgesic decision making.

The decision to administer analgesia is ultimately made by the paramedic, and therefore a paramedic's personal bias may affect analgesic options. However, as demonstrated in three of the included articles, paramedic sex had no influence on the likelihood of a patient receiving analgesia.^43,45,48 Although these findings cannot definitively rule out sex-disparity in pain management, it is evident that patients complaining of severe pain do ultimately receive more analgesia.^{39,42,43,45,47}

Save for the value of equity in healthcare, the authors did not hold any theoretical premise to avoid undue cognitive bias. A posteriori, the authors are aligned with the Swedish researchers Risberg et al.⁵⁴ who developed a theoretical model that outlined how gender bias may present in medicine, how it is understood, and how it can be avoided. This is demonstrated by analysing the assumptions surrounding the similarities and differences, and equities and inequities, that exist between males and females in relation to biology, disease, stereotypes, and life experiences.⁵⁴ The model has been expanded to other categories of diversity, such as paramedicine, and is suggestive of future research and other conscience raising activities.

Limitations

The first limitation is the dearth of available literature on the topic. This is unsurprising given the neophyte research culture in paramedicine as an emerging profession. This is evident in this review as there was only a small number of studies that were eligible for inclusion, with only eight of them investigating sex as a primary outcome.^{38–43,45,48} A second limitation is that all but one of the studies that were included for review were retrospective studies and therefore confounding factors that may have affected pain management could not have been proactively controlled for. This means that some results may have been statistically insignificant if controlled for appropriately. A third limitation was that included studies were from a range of ambulance services from all around the world, where prehospital standards of pain management may lack homogeneity. That is, every ambulance service has different paramedic qualification levels, clinical scopes, medications, and protocols that they work within. Therefore, it cannot be determined here whether results are due to ambulance service governance, or innate sex-specific biases. A final limitation of this research was time. As this type of review is rapid in nature, the researchers were limited in the number of databases they could search, and the amount of time spent analysing selected articles.

Conclusion

The research into equitable pain management practice among paramedics is limited. This rapid review highlighted that while some studies have found no sex-specific discrepancy in analgesic administration, half of the included studies identified that males are unduly privileged (rather than placed at risk) with higher rates of analgesic administration, specifically opioids, in comparison to females, and that females were prejudiced with a higher risk of oligo-analgesia. Moreover, many of the studies reported that the higher the pain score, the higher the likelihood of receiving analgesia, with some studies indicating that paramedic administered analgesia was effective in reducing pain score. None of the included studies that identified sex differences provided recommendations on how to mitigate sex-specific discrepancies. Further research needs to be conducted to better analyse sex disparities in pain management in the interest of promoting gender-equity in pain care responses in paramedicine.

Supplemental Material

sj-docx-1-pam-10.1177_27536386241240286 - Supplemental material for Influence of patient sex on pain management practices in Paramedicine: A rapid review

Supplemental material, sj-docx-1-pam-10.1177_27536386241240286 for Influence of patient sex on pain management practices in Paramedicine: A rapid review by Sooaad Dahoud, Paul Simpson and Navindhra Naidoo in Paramedicine

Footnotes

Acknowledgements

The authors would like to express their appreciation to Lily Collison the Medical and Health Science Librarian at Western Sydney University, for her wealth of knowledge and guidance in the creation of the search strategy and navigation of the databases.

Author contributions

This research emanates from the Master of Research thesis by Sooaad Dahoud. The thesis was supervised by Dr Navindhra Naidoo and Associate Professor Paul Simpson. All authors contributed to and approved the manuscript with thesis reference of: Dahoud S. The Influence of Patient Sex on Paramedic Administration of Analgesia for Acute Abdominal Pain [thesis]. [Sydney (Au)]: Western Sydney University; 2023. All authors of this article therefore meet the requirements for authorship.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research and/or authorship of this article. In respect to publication, Paul Simpson is the Editor in Chief of Paramedicine and Navindhra Naidoo is an Associate Editor at Paramedicine. Neither played any role in the review process nor in the editorial decision making process. The paper underwent double-blinded review in adherence to the journal’s peer-review policy.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Sooaad Dahoud

Paul Simpson

Supplemental material

Supplemental material for this article is available online.

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