Pain is often the trigger that makes people call for an ambulance (Armour and Murphy-Jones, 2016) and alleviating pain and suffering is one of the first goals of a paramedic upon meeting a patient. However, as easy as it sounds, many factors affect pain perception and reporting on the part of patients, and how the paramedic will deal with the situation (Lord et al, 2014; Siriwardena et al, 2019). Pain assessment is not only a difficult aspect of patient care in the prehospital setting (Lynde and Zorab, 2015), as it is also reported as a challenge to consistently perform and document in emergency departments (Mazara et al, 2016). Although pain is a very subjective parameter, it is important that the paramedic appropriately assesses pain and documents it accordingly. This is the first step in appropriate pain management and alleviation. Other factors to consider include the paramedic's scope of practice and legal aspects associated with the use of analgesic and pain medication. Controlled medication may be potentially lethal if inappropriately administered (Hodkinson, 2016). These elements may further influence or impede the decision-making process of paramedics in determining what pain relief option to adopt.
In a country of around 2.7 million inhabitants with such a culturally and ethnically diverse population as Qatar (Fahy, 2019), healthcare delivery and expectations are accepted to be a challenge despite an organisation's best efforts to meet everyone's needs. Hamad Medical Corporation Ambulance Service (HMCAS) is one of the many pieces that constitute the advanced public healthcare system of the State of Qatar (Alshamari, 2017; Al Jazairi and Alinier, 2021). HMCAS is the main national prehospital care provider, with a modern fleet of vehicles and a competent workforce (Hutton and Alinier, 2013; Gangaram et al, 2017), and despite having mixed-ethnicity crews usually covering at least three languages within each ambulance (Arabic, English, and either Tagalog, Malayalam, Hindi, or French), communication issues with patients are still commonly faced. A study on prehospital analgesia for femur fractures conducted at HMCAS identified suboptimal administration of pain relief at the baseline measure of a quality improvement project; however, this was eventually addressed through a series of continuing professional development (CPD) training sessions using simulation (Howland et al, 2019). The authors also concluded that pain management could still be further improved upon.
A variety of pain assessment tools have been created but are mostly dependant on paramedics being able to communicate with the patient (Hjermstad et al, 2011; Parker and Rodgers, 2015; Armour and Murphy-Jones, 2016). Hence, they are not always very easy to use when there is a language barrier, and the frustration on both sides may further negatively impact the provision of adequate care. Some tools have been specifically designed to overcome this barrier; however, it still relies on the clinician assigning a pain rating to a patient based on their observations. The Critical Care Pain Observation Tool (CPOT) allocates individual scores out of two for each indicator such as facial expression, body movements, muscle tension, compliance with a ventilator or vocalisation (Gélinas et al, 2006). The COMFORT behaviour scale on the other hand assigns a score out of five for nine distinct parameters including aspects such as alertness, calmness, respiratory distress, physical movement, etc (Ambuel et al, 1992). The Abbey Pain Scale is another tool designed to assess pain in people with dementia and scores the severity out of three for six questions that relate to vocalisation, facial expression, body language, behavioural, physiological, or physical changes (Abbey et al, 2004). All of these tools use a broad and holistic approach to pain allocation based on patient observation.
Although it is intended for use with children (Garra et al, 2010) and consists of simplistically drawn faces with different facial expressions, the Wong-Baker FACES® Pain Rating (WBFPR) scale becomes an attractive tool when language is an issue with adult patients (Figure 1). The WBFPR is primarily a visual rating scale, using facial expressions to distinguish pain intensity. However, it also incorporates numerical values and verbal descriptors attached to the faces that help clinicians to understand and document pain. It is only natural to rely on the easiest perceived approach to ascertain someone's pain level, but it is not necessarily very effective or reliable as recently demonstrated (Gangaram et al, 2021). Unsurprisingly, another motivation to conduct that study was that no research had been published on the use of the WBFPR scale in relation to its use with adult patients in the prehospital setting.
Importance of pain assessment and management
Pain assessment is an important clinical feature of patient care as it generally dictates the treatment options that the clinician can offer a patient. Paramedics generally spend a limited amount of time with patients until they are transported to hospital. However, a key intervention that will affect patient wellbeing is how paramedics contribute to reducing their suffering and providing reassurance. All interventions performed on the patient, as well as how they responded, need to be communicated to the receiving team at the emergency department as part of the handover (Shah et al, 2016) to ensure adequate continuity of care. It is however commonly reported that pain management is often poorly documented in the prehospital setting and that all patients are not treated equally (Hewes et al, 2018). Patient factors such as age, race, gender, clinical condition, and level of education affect pain management (Campbell and Edwards, 2012; Hoffman et al, 2016; Whitley et al, 2019). The subjectivity of pain management is concerning, especially if patients face a long waiting time once in the emergency department before they receive definitive treatment (Parker and Rodgers, 2015). As such pain assessment can play a role in the appropriate and timely access to emergency healthcare (Al Jazairi and Alinier, 2021), these aspects were further motivational factors for conducting the pain management pilot study using the WBFPR scale (Gangaram et al, 2021).
Prehospital use of the WBFPR scale on adult standardised patients
A critical element of the validation of a pain assessment tool is how it performs in helping clinicians to assess the level of pain a patient is experiencing. In a given patient situation, the pain score determined independently by different clinicians should be the same if the tool is valid and reliable. Determining this was the aim of the pilot study reported by Gangaram et al (2021) due to the atypical patient group on which the scale is used by the paramedics from HMCAS. Instead of using the WBFPR scale with children only, for whom it was designed, in Qatar, it is also commonly used to assess the pain level of adult patients.
A prospective quantitative pilot study was conducted with a random convenience sample of HMCAS paramedics working in Qatar, while they were on standby at a hub or spoke station (Wilson et al, 2017), but in a way that did not negatively affect operational coverage, similarly to the process described by Alinier and Newton (2013). No prenotification was sent to staff ahead of the study to avoid them trying to refresh themselves on the use of the WBFPR scale. Whoever was present at the location visited by the research team was invited to participate once they had read the information letter. Consenting staff were then allowed to take part in the study which involved a questionnaire and five scenarios with different adult standardised patients. Each of the five scenarios were played by the same persons to ensure good assimilation of their role and consistency in the acting. These standardised patients were actually instructors from the HMCAS training department. The scenarios and their respective predetermined pain score were validated by an experienced team of academics and paramedics and were representative of the types of situations and patients commonly encountered in Qatar. The order in which the participants encountered the standardised patients was determined using a randomisation table.
A total of 35 staff took part in the study, which resulted in 175 pain score assessments. This sample was representative of the overall staff population in terms of gender, nationality, scope of practice, and duration of work experience in Qatar. Critical care paramedics represented 8.6% (n=3) of participants. Despite participants being reminded how to use the WBFPR scale upon consenting to take part in the study, and that the aim of the exercise was for them to have the patient identify their pain intensity score, it was surprisingly observed that many participants were not using the tool as intended. Instead, some were directly basing the level of pain the standardised patients were portraying according to their facial expression instead of asking the patient to show their pain level on the scale. As such, there was poor agreement in their assessment of pain score, and only for the patient portraying the most severe level of pain was their agreement moderate to good. The overall correlation values of pain scores among participants was poor (<0.50) and there was a significant difference of pain score allocation between participants and scenarios. Participants were usually one or two points away from the predetermined pain score of each scenario. This shows poor interrater reliability and sensitivity due to the way the tool was used inconsistently by staff. If the standardised patients had been asked to identify their pain level by the prehospital clinicians, the results of the study would have been very different.
Conclusion
The pilot study discussed in this commentary helped the researchers identify that although prehospital clinicians in Qatar are already attending regular continuing professional development sessions, some refresher training on pain assessment is required. Based on the HMCAS (2017) clinical practice guidelines, the administration of certain medications is based upon the patient's actual pain score; poor use of the WBFPR scale has a direct impact on patient care, which may lead to under- or over-treatment (Schyve, 2007). This further emphasises the need for training in the use of pain-scoring tools, as advocated by others (Harvey, 2014). However, it also begs the question whether it is appropriate to adopt a tool initially intended for use with children for a different age category of patients. The tool requires patients to communicate and self-allocate their pain rating and was not designed to be used as a single indicator for clinicians to ‘impose’ a pain score. Tools such as the CPOT, COMFORT, or Abbey, applied when patients are unable to communicate their pain, use a multitude of parameters to help clinicians determine the level of a patient's pain, rather than just one factor. As it stands, and given the authors' understanding of the local context, further research is recommended using a variety of approaches that will not confuse participants. The intention of the pilot study described by Gangaram et al (2021) was to observe prehospital care clinicians using the WBFPR as they would do under normal circumstances when interacting with their patients. It appears however that the context of the simulation environment, involving colleagues they may know as instructors playing the role of standardised patients, made some believe they could not directly ask the patients for their pain severity level while showing them the WBFPR scale. Another aspect that could be investigated using a much larger sample of participants and a higher number of scenarios or actual patient cases, would be to investigate the influence of patient and clinician ethnicity and gender, on pain scoring and management due to some potential form of bias. Although similar work has been done in North America (Hoffman et al, 2016; Hewes et al, 2018), Qatar has a very different cultural and ethnicity mix.