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46 MAY 2016 | EMSWORLD.com may engage in unnecessary and unhelpful interpatient comparisons of pain-related behavior and reported pain scores in an attempt to validate the patient's report of pain or believe the patient. It should be noted that a major barrier to effective analgesia in paramedic practice has been identified as "a preoccupation with potential malingering." 39 The measurement of pain severity is a process of enabling a communication with the patient so they can describe their experience by attempting to quantify their level of pain, which helps the paramedic understand their current level of distress. The resulting number (if using a numerical scale) describes the patient's pain at that point in time. Pain is a complex phenomenon involving biological, psychological and environmental dimensions that may change over time. As such it's important to avoid references to prior pain experiences such as childbirth to establish a benchmark for very severe pain, particularly when assessing pain associated with a later, unrelated condition. It is also unhelpful to compare the patient with oth- ers who express similar levels of pain severity. Pain is a uniquely individual experience, and the ways individu- als express their pain is highly variable. Again, the pain score is an attempt to initiate a conversation with the patient to better understand their current level of pain. This information should then be used to guide man- agement decisions, which may include pharmacologi- cal and nonpharmacological interventions. In rare cases the paramedic may reach a clinical decision to withhold treatment for the pain. This should only occur where a risk/benefit analysis has been completed and the patient has been informed of the basis for withholding treatment. Again, this should be a rare situation because although there are contraindications for specific analgesics, there is no contraindication to the alleviation of pain. Research has shown that paramedics are reluctant to administer opioids to patients without significant objective signs of pain being present. 39 However, objec- tive diagnostic tests to confirm the presence of pain are unavailable. Although the use of functional magnetic resonance imaging (fMRI) can identify areas of the cere- bral cortex that are active during episodes of pain, these areas are also active in some individuals who vicariously experience the pain suffered by others. 40 Because of this, no reliable scientific means exists for validating an indi- vidual's level of pain. In addition, the use of fMRI in an ambulance is impractical. Educational resources used by paramedics suggest using vital sign changes to validate the level of pain severity experienced by an individual. In some settings, it is believed that severe pain must be associated with evidence of a sympathetic nervous system-mediated stress response. Paramedics and other health profes- sionals often believe that patients with severe pain will be tachycardic and hypertensive in response to the pain, but research has shown a poor correlation between vital sign changes and pain severity. Therefore, such vital sign changes should not be used to confirm or rule out the presence of pain. 41 EMS providers can use this scale to assist patients in visually identifying the severity of their current level of pain. Instructions for Use: Explain to the person that each face is for a person who has no pain (hurt), some, or a lot of pain. Tell the person, "Face 0 doesn't hurt at all. Face 2 hurts just a little bit. Face 4 hurts a little bit more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don't have to be crying to have this worst pain." Ask the person to choose the face that best depicts the pain they are experiencing Figure 3 Pain is a comple x phenomenon involving biological, psychological and environmental dimensions that may change over time.