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

BACKGROUND: 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. METHODS: 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 3), persistent untreated pain, and pain reduction. RESULTS: 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. CONCLUSIONS: 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.