Where does it hurt?

I would bet that within the first 100 calls of your EMS career, you’ve experienced a handful of situations where localizing your patient’s pain proved to be not only beneficial, but treatment-altering. [Fill out the form on this page to download a glossary of pain terms to help localize pain.]

Take, for example, a 56-year-old male patient complaining of chest pain. After a round of OPQRST questions, you find that your patient has this increase or exacerbation of pain whenever he feels like he has to burp ... and in fact, his pain seems more epigastric in nature than chest (so, you choose not to administer aspirin, but you still acquire a 12-lead ECG).

Or, your 87-year-old female patient who fell and complains of neck pain. After some gentle palpation and further questioning, she identifies her pain more toward the upper portion of her back; not her neck (would you still apply a cervical collar as a result?).

Localizing pain – pinpointing it, or narrowing-down its point of origin – may mean the difference between administering fentanyl versus ketamine, applying a cervical collar versus not, splinting a joint versus a bone, or even performing an eFAST examination of the patient’s belly with a portable ultrasound unit (which may be more of a tool-of-the-future for many). It’s about asking more questions; digging deeper into the equation besides, “Where does it hurt?”

Terms like ‘proximal’ (toward the core/trunk) and ‘distal’ (away from the core/trunk) provide you a sense of direction, while those like ‘dull’ (more evenly-spread, constant regardless of action, lacking force/intensity, aching) and ‘sharp’ (abrupt, increased on movement, momentum-stopping, stabbing) describe more of the type or feeling of the pain.

Pain – since we can’t see it – is subjective in nature (which can also add to its complexity). What I describe as a 5 (a “meh” smiley face) on the Wong-Baker Pain Rating Scale, may be perceived as a 9 by others, or even a 2 (by my wife). While there’s no doubt that the objective angulation or bone protrusion is a likely source of the patient’s leg pain, their description of the pain remains their own perception.

Getting back to where the pain is coming from – or where the pain is worse – can also be a bit distracting (pain that draws attention toward one location, only to potentially mask other sources of injury or pain.

Distracting pain

This is often one of the most conflicting points of any selective spinal motion restriction (cervical collar application) criteria in many protocols today; what is considered distracting? Can arm pain after a motor vehicle collision be considered distracting? What if there’s obvious deformity ... does that change your mind? Or, a suspected hip injury on your elder fall patient ... is that distracting enough to warrant applying a cervical collar (but please, no longboard!)?

One report utilizing the National Emergency X-Radiographic Utilization Study (NEXUS) criteria indicated that the definition of the term “distracting” could be a bit more narrowed, outlining that “upper torso injuries may be sufficiently painful to distract a reliable cervical spine examination” [1]. Information like this could impact the frequency of how often you apply a cervical collar (but of course, I recommend consulting with your agency’s medical director).

Where else could your patient’s pain be coming from? How about internal (as opposed to more external in nature, like from the broken bone and the pain produced as it agitates the nerves in the skin)? When referring to more internal sources – like organs – terms like parietal (the lining/wall or exterior of an organ) and visceral (deep inside the organ) are commonly used.

Describing pain for the PCR

Now, it may not be vitally important that you’re able to localize your patient’s pain to the interior/exterior of their stomach, or remember terms like parietal and visceral in order to make your narrative more colorful and descriptive, but it is important that you’re able to isolate their “stomach” pain to one side or another (lateral), front (anterior) or back (posterior), and even provide some other descriptions related to your OPQRST assessment.

When in doubt, simplistic and direct terms are often the best descriptors to not only localize one’s pain, but to provide better context – paint a better picture – related to where it is and how it feels. Picture yourself reading someone else’s narrative ... what information would you want to read that best describes where their patient’s pain was coming from, how it felt, what might have provoked it? This is the information that you want to gather regarding localizing and describing your patient’s pain.

Read next: “Timeless pain management tips.” When treating any patient in pain – child or adult – follow these timeless pain management and treatment principles

[Fill out the form on this page to download a glossary of pain terms to help localize pain.]

This article was originally posted March 4. 2021. It has been updated.