I have been receiving patients from ED's lately that are intubated and sedated with a combination of propofol and boluses of Ativan but with no analgesea provided.. AT ALL. This is contrary to everything I have been taught and read in the journals, position papers, and other articles. I have been spending a good bit of time researching best practices and everything I have came across strongly say's to provide analgesia ALONG with the sedation and never to provide only sedation especially when the patient receives a paralytic. The one patient I had was a 20 something male kicked in the head with a sub-arachnoid hemorrhage, was seizing on arrival at ED, was RSI'd and sedated with propofol and boluses of Ativan along with titrating propofol up. This patient received no analgesia. Another pt. I had a few day's ago was a 20 something drug OD. Pt. was intubated and was receiving propofol and Ativan boluses. I asked if pt. had anything for pain and the RN literally chuckled when I asked so I gave a brief reason why I was asking. The RN was clueless as to why this pt. should have analgesia. Despite my asking the pt. did not get analgesia but did get vecuronium for transport and I increased the propofol. What are the current practices of ALS providers on the forum when treating and transporting intubated patients? If the patient is fighting the vent however so mildly, do you favor giving a NMBA to better manage ventilations during the 45min-2hr transport? I have found that works well (obviously, right) but without analgesia onboard I am more hesitant to do that. Why are these ED docs not realizing the need for analgesia? I think a lot of people see a sedated/unconscious patient and think that they have no perception of pain and the body is not experiencing any sympathetic surge or other physiological response to the pain. Just having an ETT and a metal blade rammed down your throat is uncomfortable and not to mention the inflammatory response and injury that causes chemical mediator release that enhances pain transmission and perception. Any guidance is greatly appreciated. I really need to advocate for my patients when they have not received analgesia and need to be prepared to make my case when doing so which I am prepared to do now but additional ammunition and points to make is always a plus.