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EMSWORLD.com | MAY 2016 41 seat. On examination you note she is alert but does not respond to your questions. The patient's vital signs are pulse 60, blood pressure 140/95, respiratory rate 20/min with no signs of increased respiratory effort, and SpO 2 96% on room air. The carer tells you the patient's communication is impaired due to deafness and dementia. You are told the carer called 9-1-1 due to concerns that the patient was acutely unwell. You are told the woman is normally well and mobilizes without assistance. You undertake a clinical examination to identify alterations in the patient's health due to illness or injury. This clinical examination should include an assessment of the presence of pain. If pain is present, its severity needs to be measured to guide treatment decisions. How will you undertake this assessment? Case Study #2 A 46-year-old female presents with a four-hour his- tory of hypogastric abdominal pain. The patient is alert and oriented and tells you that the pain began at approximately 0800 today while she was sitting at home. The pain increased in severity over the last 60 minutes. She describes it as "dull" and says it's worse on movement. You undertake a clinical examination to identify alterations in the patient's health due to illness or injury. During your assessment of the patient's com- plaint, you attempt to measure the severity of the pain using a verbal numeric rating scale. The patient's first language is not English, and another adult family member has to translate your instructions to rate the pain on a scale from 0–10, with 0 representing no pain and 10 representing the worst pain imagin- able. You are told that the patient reports the pain severity as 9 of 10. You are confused by this report, as the patient is sitting quietly and not demonstrating behavior you'd expect to be associated with severe pain. You also note the patient is not tachycardic or hypertensive. However, you note she is asking for help for the pain and that there is evidence of lacrimation. Explain why there may be a difference between the paramedic's assessment of pain severity and the patient's report. What factors influence the perception and expres- sion of pain? Introduction The alleviation of pain is one of the most important components of paramedicine. Effective pain manage- ment relies on clinical practice guidelines and a scope of practice that enables independent clinical deci- sions. Yet despite the availability of pharmacologi- cal and nonpharmacological interventions that have demonstrated efficacy in prehospital pain manage- » Review the use of pain severity as a clinical performance indicator » Outline the pain assessment process in the prehospital environment » Describe the use and types of pain assessment scales » Discuss the role paramedics play in the alleviation of their patients' pain ment, the alleviation of pain is highly dependent on the provider's ability to identify, measure and interpret this symptom. Pain affects more Americans than diabetes, heart disease and cancer combined. 1 This symptom is typi- cally associated with chronic pain syndromes, can- cer-related pain and inadequate postoperative pain control, but is also a common finding in individuals with an acute illness or injury. Pain is a common finding in patients requiring care provided by EMS and will often be the chief complaint that results in a call for assistance. 2,3 Research from North America has shown that up to 30% of patients transported by ambulance have moder- ate to severe pain. 4,5 However, information regarding pain severity is not commonly documented on patient care records. Inability to assess pain may be one reason for the lack of data, and this has been cited as a barrier to effective analgesia in paramedic practice. 4 If para- medics do not actively seek information to identify the presence of pain, this symptom may be missed. The lack of data regarding pain severity is particu- larly prevalent in cases involving children. In a 2008 study published in Prehospital Emergency Care that evaluated paramedic assessment of pain in pediatric trauma, just one of 696 patient care records included a pain score derived from a validated pain assessment tool. 6 Even in the air medical setting, few pediatric patients have pain scores documented. 7 Assessment of pain severity has been called the "fifth vital sign." This phrase was initially coined by two researchers in a 1997 American Journal of Nursing article in an effort to highlight the need to routinely question and examine patients for evidence of pain. 8 Standardized recording of pain severity using validated and age-appropriate pain severity scale is useful in the following ways: » Identifying pain when the patient may not vol- unteer its existence or is unable to self-report due to age, cognitive impairment or language difficulties; » Guiding the selection of appropriate interven- tions to alleviate pain; and » Evaluating the efficacy of analgesia through documentation of trends in pain severity over the duration of care. The assessment of pain provides important infor- mation about the injury or illness an individual is experiencing. For example, a sudden onset of chest pain may indicate myocardial ischemia, but this pain may also result from an injury to the chest or a diverse range of diseases. As such, a focused clinical examination is required to make a clinical decision regarding appropriate interventions. This includes decisions regarding the management of the pain. TABLE 1: OPQRST MNEMONIC O Onset P Provokes/ Palliates Q Quality R Region/ Radiates S Severity T Time