The challenge of assessing pain
November 24th, 2009
A woman needs emergency treatment for a uterine rupture. MSF sent an ambulance to take her to the Nyanzale hospital in North Kivu. The trip in a four-wheel drive took nearly two hours on rough, uneven roads that jolted the vehicle. But the woman did not say a word. “She never once complained about pain, she didn’t say a word – and she must have been suffering with her uterus torn,” recalls the MSF nurse who accompanied her.
Such cases are common in this province in eastern Democratic Republic of Congo, where conflict has been underway for years. MSF teams regularly see patients who are equally stoic, but that poses a problem. “Pain is a very subjective notion and evaluating and treating it properly requires the patient’s cooperation,” explains Richard who, as the physician anesthetist at the Rutshuru hospital, is responsible for pain management. But patients don’t say anything. “If you ask them if they are in pain, they will often say no,” he notes.
The issue is much more complex than it might appear. Patients in this region are not used to someone asking if they are in pain or to being treated for it. What’s more, they may understand the question as inquiring about more than the pain itself and, rather, addressing their treatment overall. Given the problems associated with describing and expressing pain, it can be difficult for the medical staff to evaluate it.
They must thus persevere and make greater efforts to reach out to patients by using standard tools such as the “simple verbal scale” and clinical signs. Incorporating the patient’s history, the nature of his or her surgery and, of course, vital signs, can overcome problems associated with quantifying pain. To ensure proper treatment, Richard gives analgesics systematically. “This prevents all the physiopathological disorders that pain can cause the body, particularly among patients who have had surgery,” he says.
When the patient has received analgesics or refers to pain, the doctor or nurse can use the simple verbal scale to measure it. The scale quantifies the intensity of pain in a range of 1 to 3, based on the information the patient provides. The responses and results are noted in the patient’s file and will be used to adapt treatment. MSF teams began using this tool in the Rutshuru hospital when they started working there in 2005. The medical staff members are now aware of pain treatment and know that it is a vital sign – just like pulse, blood pressure, temperature and respiratory frequency.
This woman has been suffering from breast cancer for several months and had closed herself off. Cared for – more or less – by her husband, she no longer expresses herself and asks for nothing. However, she barely sleeps because of the pain. A nurse managed to convince her to go to the Rutshuru hospital. After evaluating her, the MSF team placed on her regular analgesics. “We now see this woman on a regular basis,” Doctor Richard says. “Not only can she sleep, but she is smiling again. And a group of her neighbors came to the hospital to thank us for helping her.” As if to say, the treatment really improved her situation.
