Assessment Scales

Pain does not feel the same for everyone. But communicating how much pain one is feeling can be difficult to convey to a paramedic who arrives during a trauma situation. Pain is a personal feeling and describing it to a stranger, even one who is there to help you during a crisis can be awkward and frustrating when one is scared and does not trust a stranger. One of the hardest things for a paramedic to do when arriving at an accident is to gain the trust of the victim and have them explain to you how much pain they are experiencing since they cannot run a blood test at that moment to show how much this person is suffering.

The paramedic realizes that it is not enough to just have the victim tell them that something hurts. They need to utilize methods to not only assess the pain but also to get the patient to talk about their pain. Paramedics need to utilize different methods to interact with their patients.

A Paramedic knows their patient is in pain, but they need to approach the situation in a way the patient can clearly explain their pain as well as the degree of pain they are feeling. Paramedics need to rely on their training and incorporate innovative methods to assess the pain level of the person or persons they are helping.

One method Paramedics may use in evaluating a patient’s pain is the ABBEY Pain Scale, which was designed to assist in assessing the pain in patients who are unable to verbalize their needs.

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(Abbey et. al,1) The scale does not differentiate between distress and pain, therefore measuring the effectiveness of pain-relieving interventions is of the up-most importance when it comes to treating a patient in the field. (Abbey et. al, 1). The Australian pain society recommends that the ABBEY pain scale be used as a “movement-based assessment” (Abbey et al, 2), and as such, observing the patient while they are being moved is an important tool in evaluating their pain level. Documentation of the following is part of the ABBEY Pain Scale: Vocalization, i.e., whimpering, Facial expressions, i.e., grimacing, frowning, Change in body language, i.e. rocking back and forth, fidgeting, Behavioral change, i.e., going from fearful to angry, Physiological changes, i.e., blood pressure increasing, rapid pulse, perspiring, pallor, Physical Changes, i.e., skin tears, bruising. Scoring each category from 0 to 3, three being the most severe. Then add up the numbers to determine the level of pain your patient is experiencing during transport. Reevaluation should be done within one hour of the initial evaluation; If the patient’s scores increase then notifying dispatch and or the hospital is important in implementing pain-relieving measures (Abbey et al, 2).

The ABBEY pain scale was recommended as the most appropriate means of assessing pain in residents with severe cognitive impairment. This one-dimensional scale is designed to rate pain severity. Although this tool attempts to address acute, chronic, and acute-on-chronic pain using six behavior categories that include physiological and physical changes, vocalization, facial expressions, and changes in body language and behavior, some cues may be non-specific. This is particularly apparent in the facial cue category, where cues such as frowning may not have a strong correlation with pain. The tool takes between two to six minutes to complete, and as such, this tool may be practical for use in the paramedic practice setting (Lord,1).

Another pain assessment tool utilized by first responders is the FLACC scale.

FLACC stands for face, legs, activity, crying, and controllability. The FLACC pain scale was developed to help medical observers assess the level of pain in children who are too young to cooperate verbally. It can also be used in adults who are unable to communicate. FLACC stands for face, legs, activity, crying, and controllability. The FLACC pain scale was developed to help medical personnel assess the level of pain in children who are too young to cooperate verbally. It can also be used in adults who are unable to communicate because of dementia or other health conditions. (Jacques, 1).

The FLACC scale is based on observations, with zero to two points assigned for each of the five areas. The overall score is recorded as follows FLACC scale is based on observations, with zero to two points assigned for each of the five areas.

The overall score is recorded as follows:

0 = Relaxed and comfortable

1 to 3 = Mild discomfort

4 to 6 = Moderate pain

7 to 10 = Severe discomfort/pain (Jacques, 1). By recording the FLACC score periodically, healthcare providers can gain some sense of whether someone’s pain is increasing, decreasing, or stable (Jacques, 1).

In addition to the ABBEY and FLACC scale, paramedics can employ the Comfort scale. The COMFORT Scale is a pain scale that may be used by a healthcare provider when a person cannot describe or rate their pain. Some of the common populations this scale might be used with include: Children, adults who are cognitively impaired, adults whose cognition is temporarily impaired by medication or illness, and people who are sedated in an ICU or operating room setting (Jacques,1). The COMFORT Scale provides a pain rating between nine and forty-five based on nine different parameters, each rated from one to five:

• Alertness is given a score of 1 for deep sleep, 2 for light sleep, 3 for drowsiness, 4 for alertness, and 5 for high alertness.
• Calmness is rated with a score of 1 for complete calmness and higher ratings given for increased anxiety and agitation.
• Respiratory distress is rated based on how much a person’s breathing reflects pain, with agitated breathing given higher ratings.
• Crying is given a score of 1 for no crying, and higher scores for moaning, sobbing, or screaming.
• Physical movement is given a score of 0 for no movement, which can be a sign of less pain or illness. A score of 1 or 2 indicates some movement, and higher scores indicate vigorous movements.
• Muscle tone is rated at a score of 3 if it is normal, with lower scores indicating diminished muscle tone and higher scores indicating increased tone or rigidity.
• Facial tension is rated at a score of 1 for a completely normal, relaxed face, and given higher ratings for signs of facial muscle strain.
• Blood pressure and heart rate are rated concerning the normal baseline. A score of 1 indicates that these measures are below the baseline (abnormal), and a score of 2 indicates they are at baseline, while higher scores are given for elevated (abnormal) levels. (Jacques,1).

‘Any tool used by paramedics must be reliable, valid, and practical, with the latter influenced by operational requirements to minimize time spent on scene.'(Lord 1).

Paramedics have the tools to relieve pain in the form of effective pharmacological – opioid and non-opioid methods. However, management of pain relies on the patient being able to communicate the severity or type of pain they are experiencing at that moment. In patients suffering from cognitive disabilities such as dementia, paramedics may need to use other methods of seeking proof of pain. A patient who cannot clearly explain their pain deserve relief from pain as those who are not suffering from a disability. While some pain assessment tools have been recommended for use in patients with cognitive impairment there is currently a lack of consensus on the most appropriate tool to use. Therefore, the paramedic must make a judgment call to decide which pain assessment tool works best for the patient they are treating (Lord 1).

Unfortunately, Paramedics are not minded readers. Paramedics cannot enter a scene and tell what is wrong with a patient without examining and talking to the patient. However, as important as it may be for the paramedic to rapidly and effectively assess a patient’s pain, the patient needs to assist in communicating to the first responder the severity of pain they are feeling. Many of the recent improvements in EMS have focused on technology, but the fact remains that visual and physical assessments cannot be replaced by gadgets. The paramedic must understand that assessment of their patient affects treatment by narrowing down diagnostic impressions and allowing them to decide the best treatment to implement. Quick and efficient pain assessments of the patient they are treating can affect the outcomes by ensuring that their patients are transported to proper receiving facilities. (Lickiss, 1).

Assessment of a patient’s pain is an important tool in not only treating them but improving their survival rate. Utilizing the ABBEY pain scale, the FLACC pain scale, or the COMFORT scale can improve the way paramedics effectively treat patients in the field in both a timely and safe manner and increase their survival rate. Unfortunately, Paramedics are not minded readers. Paramedics cannot enter a scene and tell what is wrong with a patient without examining and talking to the patient. However important it may be for the paramedic to rapidly and effectively assess a patient’s pain; the patient needs to assist in communicating to the first responder the severity of pain they are feeling. Many of the recent improvements in EMS have focused on technology, but the fact remains that assessment cannot be replaced by gadgets. Assessment affects treatment by narrowing down diagnostic impressions and allows us to track treatment effectiveness. Assessment affects outcomes by ensuring that patients are transported to proper receiving facilities (Lickiss, 1).

Resources:

1. Abbey, J, et al. “The Abbey Pain Scale.”1998 http://www.wales.nhs.uk/sitesplus/documents/862/foi-286f-13.pdf
2. Jacques, Erica. “How to Use Pain Assessment Scales.” Verywell Health,
3. Verywellhealth,www.verywellhealth.com/pain-scales-assessment-tools-4020329.
4. Lickiss, Patrick. “Patient Assessment: Why the Basics Matter.” EMS World, 6 Nov. 2013, https://www.emsworld.com/article/11224733/patient-assessment-why-basics-matter.
5. Lord, Bill. “Paramedic assessment of pain in the cognitively impaired adult patient.” NCBI, 6, Oct. 2009, www.ncbi.nlm.nih.gov/pmc/articles/PMC2765419/