Posted on Monday, October 21, 2013
This blog entry is a rough description of the obstacles an E.M.T. might face when questioning a patient about the level of pain that they’re experiencing.
Pain is a very personal experience, and is only known to those who are suffering. We can’t read minds, so communication skills are nice to know.
Pain comes in three parts:
1- Sensory: Location, intensity and nature of pain
2- Affective: Emotional response to pain (urge to escape the unpleasantness)
3- Impact: On functioning levels and awareness of the situation.
The following is a rough list of the various people you might have the honour to treat, and the level of disability that they might present:
1. The ‘normal’ dude:
Experience of pain can be described at many levels using many descriptive words so therefore our ideal patient is someone who can articulate the type of pain they’re feeling using words and gestures, and (neurosis aside) can, when prompted indicate a level of pain between 0 and 10 accurately. Above the age of 3 or 4, usually people can generally relate to your description of this scale and can answer appropriately.
There are reasons why people of sound mind might consciously adapt this pain score however: there are opportunists, or people who might not understand the scale properly, or may not have experienced extremely bad pain in their lives (perhaps a mild kick to the shin is the worst thing this person has experienced in the case of your average 9 year old?) thus this scale of measurement can prove to be inaccurate.
In summary. there will always be people who will intentionally manipulate their score either to receive attention (notably when parents are around), or to receive free medication.
2. The teeny people
Below the age of toddlerhood (≤ 3) when language hasn’t developed yet, you have your group of people who are very honest and can detect lies at 100 paces.
These people can best relate to pictures, but most importantly their facial expressions are very easy to read because they haven’t yet learned how to manipulate either by exaggeration, or suppression of feelings. Very young people are exactly as they present. Therefore the Wong-Baker facial grimace scale can be useful here.
Children are highly intuitive and can recognise facial expressions pretty well by pointing if you have this image ready but as an accessory to this, you can gauge children’s pain levels from their facial expressions which might look like the following on the 1 -10 level:
0 – 1: Alert and smiling (babies are content)
1 – 3: No humour, facial expression is flat.
3 – 5: Furrowed brows, pursed lips, holding breath (babies are anxious and unsettled)
5 – 7: The child’s nose wrinkles, upper lip is raised, patient is breathing rapidly or puffing (babies are crying urgently but may be settled slightly with parental intervention)
7 – 9: The child will have an obvious expression of pain. Their mouths will be open, they’ll blink slowly. (Babies will have a high pitched cry and will be unconsolable.)
10: Eyes closed. Moaning or loud crying. Babies will be screaming at decibels louder than a jumbo-jet.
3. Activity tolerance scale: this is something you can observe at most levels:
0-1: No pain
1-3: Pain can be ignored
3-5: Pain interferes with tasks.
5-7: Pain interferes with concentration (sentences will be completed with difficulty)
7-9: Pain interferes with basic needs!
10: Bedrest required
4: Patients with communication difficulties:
There are obviously a lot of situations where people may not be in the position to verbalise the nature and type of pain they’re experiencing, but you might be able to prompt the person using body language to point to the area which is hurting, and recognise the extremity of the pain from their physical expression. For example, the patient might ‘guard’ an area. Withdrawn socail behaviour might suggest extreme pain, as will moaning with movement and limitation with range of movement of body parts.
If someone shows aggression or shows confusion or agitation, especially in those with dementia or those who can’t express themselves properly… this could be an indication of acute pain.
5: People who might be in pain but not report it:
Ageing patients might be on medication that might blunt pain. They also might not be as receptive to pain because of neuron failure. Indications of pain might be a recent decrease in things like dressing, excercising, grooming etc.) OR they might be afraid of the fact that if they report pain they might be hospitalized or put on medications they don’t want to be on.
Some cultural beliefs might lead a patient to understand that they don’t deserve pain relief, some are afraid of body contamination, some are too stoic and feel that they deserve any pain that may come to them.
Annnnd that’s all I have to say about that. Are there any other pain score recognition structures out there? Help a gal out with her homework hey?