The diagnosis and management of pain is one of the trickiest parts of an EMS provider's job. Even though you'll often spend an hour or less with your patients in the prehospital setting, your decisions about how to interpret and treat their pain can have long-term repercussions. Severe acute pain, improperly treated, can even lead to chronic pain disorders and other comorbidities.

In this guide, we'll review best practices for diagnosing and treating pain in prehospital environments. Note that some of the treatments we'll review are available only to paramedics; all EMS providers must operate within their scopes of practice.

Assessing Pain Severity

EMS providers often underestimate or misdiagnose pain. You may be surprised to learn that this tendency is most common among senior providers (those with ten or more years of experience). There are a few different theories about why this happens. It could be that some experienced providers become jaded after treating thousands of patients, some of whom exhibit drug-seeking behavior or otherwise appear to be exaggerating their pain.

It's important to emphasize the word "appear" in the previous sentence. Unlike most other aspects of emergency medicine, evaluating someone else's pain isn't an exact science because it can't be directly measured. This means that, at least in the prehospital setting, there is often little or no hard evidence with which to support or refute your patient's statements about their pain.

Unless you have very strong, evidence-based reasons to doubt your patient's statements (which is rare), you must take them at their word regarding the character and severity of their pain. In most cases, your patient's answers to your questions are the best data you're going to get. In certain respects, your physical exam findings can corroborate or fail to corroborate your patient's statements, but in no case can your physical exam prove or disprove what they're telling you.

Comprehensive or Rapid Exam?

As you know, a comprehensive physical exam is most likely to reveal helpful information that will enable you to treat your patient more effectively, but it takes longer than a focused, rapid exam, and in the prehospital setting, time is gold. The first thing to decide when you encounter a patient reporting significant pain is whether time or information is more valuable.

As a general rule of thumb, a comprehensive exam should be the default option. Conduct a rapid exam only when it's obvious that your patient's pain is so severe that delaying treatment could negatively impact their prognosis (of course, we're talking specifically about cases wherein pain is the patient's chief complaint; life-threatening injuries and other critical emergencies also warrant a rapid exam).

Tools for Evaluating Pain

As previously mentioned, you have few tools for objectively measuring pain in another person. Start with your first impression of the patient and the scene, namely an AVPU assessment, which you can conduct quickly and easily. Note that, although an AVPU assessment isn't designed specifically for assessing pain, it can be a useful tool for that purpose.

• Is your patient Alert, responsive, speaking coherently and able to answer questions appropriately?

• Is your patient responsive to Verbal commands but otherwise exhibiting diminished responsiveness?

• Is your patient responsive only to Painful stimuli?

• Is your patient Unresponsive?

If you suspect a head injury, severe trauma or an otherwise impaired mental state, conduct a GCS (Glasgow Coma Scale) assessment as well. Your patient's AVPU and/or GCS status can help you assess how their pain is affecting them. Patients in severe or debilitating pain often exhibit diminished responsiveness or an altered mental state. Remember, though, that many conditions — not just pain — can cause these symptoms.

Next, ask the OPQRST questions:

• Onset: What was the patient doing when the pain started? Were they injured or did the pain come out of nowhere?

• Provocation: Does any particular movement or activity make the pain worse (or better)? Does the pain change in any way when you palpate the area? If it's helpful, you can add "M" and "N" to the OPQRST mnemonic: Muscle and tissue pain typically changes on palpation, whereas Nerve pain generally doesn't (there are exceptions to both, especially in the case of nerve pain).

• Quality: What adjectives best describe the pain? Common examples include stabbing, squeezing, crushing, burning, shocking, cramping, shooting or stinging. There's no official list of pain descriptors, though; document whatever description your patient gives. Also ask whether the pain is constant or intermittent.

• Radiation: Is the pain confined to one area or does it radiate to other parts of the body from that point?

• Severity: How badly does it hurt? This is a very tricky question — see the next section for tips on gauging pain severity.

• Time: How long ago did the pain start? Has the patient experienced this particular pain before or is it new?

If your patient can't answer these questions coherently, ask their friends, family or bystanders — anyone who might have witnessed your patient's pain episode or who might know something that could be helpful.

Assessing Pain Severity

Once upon a time, EMS providers were trained to ask patients to rate their pain on a scale from 0 to 10, with 0 representing no pain at all and 10 representing "the worst pain you've ever felt." However, at some point in the last decade or so, pain experts realized that asking patients to rate their current pain relative to their past painful experiences wasn't a diagnostically useful way to phrase the question.

Some people tolerate pain better than others. And, of course, some people have been severely injured or critically ill, whereas others haven't. Everyone has experienced pain in different ways and to different extents. This is why the preferred numerical pain scale is now the Verbal Numerical Rating Scale (VNRS). Like the older pain scale, the VNRS goes from 0 to 10, but 10 is now defined as "the worst pain you can imagine." Putting the question this way gets us closer to an objective understanding of someone else's pain because a 10 isn't defined in terms of your particular patient's past experience with pain, which could be wildly different from your own.

Patient Self-Reporting and Your Exam Findings

Take note of whether your physical exam findings are consistent with your patient's report. One way or another, you need to touch your patient in order to form a complete picture of the situation. Palpate the area in question and watch for grimacing, guarding, withdrawing or other signs of increased pain or sensitivity. Look for injuries, deformities or other abnormalities that could be causing pain, even if your patient didn't report any — you may be surprised how often patients are unaware of a recent injury or change in their bodies.

As you conduct your hands-on exam, watch for changes in your patient's vital signs that generally indicate pain. Patients who are in moderate or severe pain typically have:

• Elevated blood pressure

• Increased heart rate

• Increased respiratory rate, irregular and/or shallow breathing

• Flushed and/or sweaty skin

• Clenched or rigid muscles

• Tremors

• General agitation or irritability

The absence of some or all of these symptoms doesn't necessarily mean that your patient is misrepresenting their pain. Document your findings and stick to the facts. Report your patient's vital signs and carefully record what they told you. Don't make assumptions or write your opinion in your report. Patients do sometimes malinger, but with extremely rare exceptions, the prehospital setting is not the time or place to worry about that.

All that being said, if your exam findings seem to directly contradict the experience that your patient is reporting, consider some additional factors.

• Children and the elderly, in particular, often under-report pain. Depending on the patient, this may be due to a desire to avoid being perceived as a complainer, or it could be a financial issue — some patients may downplay their symptoms in an effort to receive less treatment and therefore a smaller bill. Whatever the case, be sure to dig deeper and ask direct, targeted questions if you suspect your patient may be in more pain than they're letting on.

• If you suspect your patient may be exaggerating their pain, ask polite but direct questions about the discrepancy. Ask if they're making a conscious effort to resist showing signs of pain. Explain that you're not accusing them of lying, you just need to accurately understand their pain so you can treat it appropriately. Emphasize that if you choose a treatment based on incomplete or inaccurate information, your patient may have little or no relief.

• Be sure to choose the best tools for assessing pain based on your patient's age, native language and other relevant factors. For instance, young children, the hearing-impaired and those for whom English is a second language may not fully understand what you want when you explain the VNRS scale to them. In such cases, the VAS (Visual Analog Scale), which uses pictures to represent different levels of pain, may be a better choice.

If your patient's statements and observable symptoms still seem to contradict your exam findings even after asking targeted questions and using the best assessment tools, treat your patient based on their reported pain unless you have rock-solid reasons to do otherwise. If you're unsure what to do, follow your relevant standing orders or contact medical control for direction.

Choosing the Right Pain Relief Treatment

Diagnosing the cause and appropriate treatment of pain is very tricky and is the most important part of pain management. Misdiagnosing pain or applying the wrong treatment can have serious consequences for your patient. Even though it's tempting to "do something" as quickly as possible to provide relief, and although you should act swiftly, you must not act before you've made the strongest evidence-based diagnosis that you can make with the information available to you.

There is one caveat to keep in mind: if you're unable to determine the patient's chief complaint, mechanism of injury or relevant medical history, but if their pain is so severe that failing to intervene could destabilize them, then treat for pain using the most conservative option that is likely to be effective (you may have standing orders that specify a different course of action to take in this scenario).

Basic Pain Management Techniques

When selecting a treatment for pain, start with non-pharmacological pain mitigation techniques before (or while) preparing medications. Encourage your patient to practice "3 by 3" breathing, in which they inhale over a period of three seconds, hold it for three seconds, and exhale for three seconds. Also encourage them to focus on something other than the pain — ideally something positive, such as an upcoming vacation or their hobbies.

Engage your patient in conversation as long as they're able and willing to talk. If you're funny, feel free to crack jokes, if appropriate and as long as laughing wouldn't exacerbate your patient's injuries. Let your patient know that you understand that these basic techniques won't significantly reduce their pain, but they can help take the edge off.

Selecting and Administering Pain Medications

Because pain management protocols vary by location and are updated frequently, we can't offer any specific ALS-level advice about which pain medications to use. Review your standing orders and contact medical control, if necessary, to identify any contraindicated pain meds. Administer meds as needed to achieve at least a 25% reduction in reported pain. Be liberal with pain meds, but not unjustifiably so; many providers are too conservative. Conduct ongoing assessments and administer additional treatment as needed, especially on long trips.

Accurately diagnosing and treating pain is one of the most difficult challenges that EMS providers deal with. Be sure to stay up to date on your continuing education regarding pain management, even if your department doesn't specifically mandate it.