You respond to a call for a 28-year-old female whose mother reports that her daughter "suddenly felt paralyzed and couldn't move, even to get out of bed." The pajama-clad young woman has numerous medications on the nightstand and bureau. Adaptive devices like a wheelchair, walker, television and other paraphernalia create a hospital room-like atmosphere.
"What seems to be the problem?"
"I can't move," says the young woman. Her words seem slurred. "I'm paralyzed from the waist down. My meds just aren't working anymore."
Neurovascular assessment shows that the patient can wiggle her toes and flex her ankles and knees, but cannot sit up due to severe pain in her hips and lower back. Further questioning reveals a five-year history of chronic pain due to RSD (reflex sympathetic dystrophy) resulting from a motor vehicle accident. She has severe pain all over her body and has been disabled for three years.
"Why did you tell the dispatcher your daughter was paralyzed?" you ask the mother.
"Because she can't move."
You realize the patient and her mother think that she is paralyzed because increased pain makes movement more difficult than usual.
Treatment and transport are complicated by the fact that the patient cannot even tolerate your touch on her skin, and she screams in pain when the bedsheets brush across her legs. This makes an accurate assessment of her pain scale score nearly impossible. You have never encountered anything like this before. You consider possible causes of the change in her condition. Despite the severe pain, she dozes off while answering your questions. You consider medication side effects and assess vital signs, contacting medical control to discuss pain medication.
This scenario illustrates why emergency response teams must be ready for anything. The first surprise was the misinterpretation of the term "paralyzed." As the crew rode to the scene, they considered stroke, spinal cord injury or poisoning, yet they found a patient with obvious chronic disease, who was using an array of medications and who was in pain but not paralyzed. This meant considering medication toxicities.
Finally, they were confronted with a disease entity that was new to all of them: RSD, also known as CRPS (complex regional pain syndrome).
What Is Chronic Pain?
Emergency personnel must understand chronic pain and its medical implications. Knowledgeable providers can help correct common misconceptions and assist patients in coping with their symptoms.
Pain can take many forms and can originate emotionally or physically, each sphere manifesting itself in the other. Pain is not only integral to life experience, it is necessary, since it is the body's warning of physical danger.1 Although medical science has always treated pain, it has only recently addressed it aggressively.2 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now recommends that pain be identified as a "fifth vital sign" and addressed appropriately. Hospitals are using formal pain scales for assessment, establishing formal bills of patients' rights and providing information about pain treatment. More work on policy, protocol and education is needed to address all aspects of pain management.
Chronic vs. Acute Pain; Nociceptive vs. Neuropathic Pain
Acute ("normal") pain is short-lived and of sudden onset (see Table I). Unintentional, accidental or surgical pain stemming from tissue injury can be intense, but is usually relatively brief, lasting hours or days.3 Acute pain is the type of pain that warns us of bodily damage so we can protect ourselves, either involuntarily (reflexively) or voluntarily (see the sidebar titled Voluntary vs. Involuntary Reactions to Pain).
Most types of acute pain, including that from burns, blunt trauma, cuts, fractures, abrasions and freezing, are called nociceptive pain. Nociceptive pain is an essential part of life and can usually be expected to dissipate in time. It rarely becomes chronic. Everyone can expect some amount of nociceptive pain to occur on a daily basis. Without nociceptive pain, we could not survive because we would leave ourselves susceptible to further injury.