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44 MAY 2016 | EMSWORLD.com VAS: The Visual Analogue Scale (VAS) is typically used as a 100 mm line with text anchors at either end (see Figure 1). The patient makes a mark on the line and the result is read in millime- ters (for example, a mark around the midpoint of the line may be calculated to be 50 mm). This score correlates well with the VNRS: A 50 mm on the VAS is similar to 5/10 on the VNRS. 26 A slide scale is also available (see Figure 2). When using this device, move the slider to the "no pain" point and ask the patient to move the slider to a point that rep- resents their current level of pain severity. The result is read on the reverse of the scale in millimeters. Research has confirmed the validity and reliability of the VAS for assess- ing acute pain in adults and children 7 or older. 27,28 Evaluation of Pain Evaluation is the process of combining all the information gathered to form a clinical impres- sion, which leads to a decision about how best to manage the pain. Although this looks like a systematic and objective process, the complex nature of pain and the paramedic's personal beliefs about it may confound this process. The assessment and measurement of pain severity produces data that is quite different from the data obtained during the measurement of weight, blood pressure or temperature. This is because it is impossible to use scientific metrics to directly measure another person's personal experiences, in the same way it is not possible to directly mea- sure depression, happiness or other aspects of mood or emotions. Indirect measures of pain (and other symptoms such as nausea) can be made by asking the patient to rate the experience compared with normal health or mood. Although this enables an estimate of the dimension of the reported experience and allows for observation of trends over time, confusion may occur if health profes- sionals treat the numbers as objective data. This is particularly true if the data is used to compare differences between individuals. It is important to remember that the use of a pain score enables a conversation between the paramedic and the patient to better understand the personal significance of the pain. It is the patient who is judging this, not the paramedic. A perceived mismatch between the pain score a patient reports and the paramedic's observation of the patient may occur in some cases, particularly where there is no observ- able injury or disease associat- ed with pain. For example, the patient may show little overt behavior but still be reporting severe pain. This may be a nor- mal behavioral response for this patient and may not represent a sign of malingering or untruthful reporting of symptoms. When a patient states that they have severe pain, there is no scien- tific (i.e., reliable, repeatable and objective) way of disproving it, particularly in the prehospital setting, where patient history is often limited. As a respected pain researcher and patient advocate once said, "Pain is what the patient says it is." 38 As such, providers need to accept what the patient says. But experience has shown that paramedics and other health professionals For More Information Circle 23 on Reader Service Card TABLE 2: FLACC SCALE 25 1 2 3 Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant quivering chin, clenched jaw Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid or jerking Cry No cry (awake or asleep) Moans or whimpers; occasional complaint Crying steadlly, screams or sobs, frequent complaints Consolability Content, relaxed Reassured by occasional touching, hugging or being talked to, distractable Difcult to console or comfort