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EMSWORLD.com | MAY 2016 43 Several mnemonics can be used to guide the assessment of pain. OPQRST is one that is commonly used to develop a clini- cal impression of the patient's complaint. 19 The information derived from this pro- cess will help guide management decisions. It is important to ask open-ended questions. » Onset of the event: Ask the patient what they were doing when the pain was first noticed. Was the onset of pain abrupt, or did it gradually intensify over time? Has it been constant or sporadic? If it is sporadic, how frequent is it? » Provokes/Palliates: Ask the patient whether anything exacerbates or relieves the pain. This could include posture, movement or analgesics taken prior to paramedic arrival. » Quality: Ask the patient to describe the nature of the pain, such as whether it is sharp and well localized or dull, cramp- like and diffuse. This helps to discriminate between visceral and musculoskeletal ori- gins of the pain. » Radiates: Avoid asking the patient whether their pain radiates because they are unlikely to understand this term. Instead ask the patient to identify the location of the source of the pain and to indicate whether the pain spreads to other body areas—for example the groin, back or shoulder. » Severity: Use a reliable and validated pain severity scale or tool to enable the patient to describe the "unpleasantness" of their pain experience. » Time: Ask the patient to assess the onset of the pain and its duration, as well as whether they have experienced similar pain and, if so, what caused it. 19 Each component of the OPQRST evalu- ation should be assessed in the setting of reported or suspected pain. Pain is a complex personal experience, with both sensory and emotional compo- nents that may be expressed by the suf- ferer in the form of verbal report and/or behavioral cues. However, the expression of pain is mediated by a diverse range of personal and environmental factors. These are responsible for significant interpersonal variations in the way individuals react to the unpleasant sensation of pain. Factors that can affect the expression of pain include age; gender; culture and social norms; prior pain experiences; the context in which the pain occurs; perceived control over the pain; and the consequences of persistent pain .20.21 It is important to acknowledge the sig- nificant interpersonal variations in the ways people express pain, and paramedics should avoid using their own expectations of "normal" pain behavior to validate the patient's report of pain. Research has shown that health professionals tend to underes- timate pain. 22 Underestimation may be exacerbated by a failure to control for the provider's personal beliefs and attitudes, which may affect the provider's assessment of the patient's self-report and pain-related behavior. For example, there may be cultural or social stereotypes regarding the expres- sion of pain. If the patient's expression of pain varies from these accepted norms, the provider might form an inaccurate impres- sion of the patient's complaint. This may lead to errors in clinical decisions due to the effect of bias. 23 Measurement of Pain Healthcare professionals should use a validated pain scale to assist the patient in describing their pain. Although several scales are available to rate pain severity, some of them are impractical for the pre- hospital setting. The following scales are practical for field use. VNRS: The Verbal Numeric Rating Scale (VNRS) is an 11-point scale that is appli- cable for field providers. 5 This scale is now commonly used by EMS agencies in Austra- lia and the U.K. To use the VNRS, instruct the patient to choose a number between 0 and 10 to represent the severity of their pain. Advise the patient that 0 represents no pain and 10 is the worst pain imaginable. Avoid using reference to previous episodes of pain, such as childbirth, for 10 because the inten- tion is to rate the present pain, which may be more severe than any previous episodes or experiences. Use of the VNRS may appear straight- forward, but differences in cognitive abil- ity associated with extremes of age and cognitive impairment due to degenerative diseases, such as dementia, may complicate this process. 24 In addition, language barri- ers may introduce additional challenges in understanding the patient's pain experience. Situations of this type may require the use of different pain scales to overcome the limitations of standard scales. ARS: The Adjective Response Scale (ARS) is also recommended for use in paramedic practice. 25 It uses standard terms to indicate the level of pain severity: none, slight, moderate, severe or agonizing. This may be preferred if the patient cannot understand a request to use a number to describe their pain severity. However, the ARS may not be responsive to significant changes in pain, making it more difficult to validate the efficacy of any analgesic inter- ventions. Limitations of this scale include cultural and language barriers. Figure 1: Visual Analogue Scale Line Representation No pain Worst pain imaginable Figure 2: Slide scale device