Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage [
Treatment of acute pain in emergency care gets insufficient attention [
An area once faced with an incredible burden of infectious disease, with improved treatments, sub-Saharan Africa (SSA), now suffers from an increasing prevalence of injury [
Within SSA, Rwanda has a thriving prehospital Ministry of Health sponsored ambulance service, Service d’Aide Medicale d’Urgence (SAMU), making it an ideal case study. This study’s aims are to explore the pain experiences and expressions of acutely ill patients on the ambulance in Rwanda from the perspective of those working on the ambulance, investigate emergent pain diagnosis and management on the ambulance in Rwanda, and to develop standardized pain management care guidelines for SAMU staff. This manuscript reports on the conduct of this quality improvement project and its results.
SAMU provides emergency care to the public and serves as the only emergency medical service in Rwanda. SAMU is a division of the Ministry of Health of Rwanda and is fully funded by the government but requires patients to pay a small fee for their service. Ambulances are staffed by nurses and nonphysician anesthetists who have training for in-hospital care. They have received no formal prehospital training, as these programs do not exist in Rwanda. Nurses and nonphysician anesthetists deliver emergency prehospital care through formalized procedures developed as part of a collaboration between SAMU and Virginia Commonwealth University [
This is a cross-sectional study of patients managed by SAMU between 2012 and 2016 in Kigali, Rwanda. A long standing deidentified electronic registry (REDCap, Vanderbilt University; Nashville, Tennessee, USA) was reviewed retrospectively for variables of interest that were routinely captured during clinical care [
Gender, age, and chief complaints were analyzed. Urgency was subjectively assigned as absolute, relative, or no urgency based on a number of factors including vital signs and patient appearance. Pain was classified as yes or no in the registry. There is no formal pain scale used by SAMU during standard clinical care. Records met criteria for inclusion in this study if they documented pain or the administration of pain medication even if pain was not explicitly documented. Other variables included were body location of pain and medications provided. We reviewed the data to evaluate when pain medication was given and under what circumstances, focusing on both patients who reported pain and patients who were provided pain medications.
Descriptive and comparative analyses were performed using SPSS version 25. Continuous variables were compared using
SAMU nurses, nonphysician anesthetists, and ambulance drivers were recruited through convenience sampling for this anonymized portion of the project. Inclusion criteria were voluntary participation and SAMU affiliation for a minimum of one year. This research was conducted in Kigali, Rwanda, at the SAMU headquarters located within the University Teaching Hospital of Kigali (CHUK). SAMU was started in 2007 and became a formal division of the Ministry of Health in 2017. They employ 70 staff, nurses, anesthetists, and drivers. Twelve SAMU ambulances work within the city of Kigali and 270 ambulances throughout Rwanda at provincial and district hospitals [
An interview guide was developed with open-ended questions with follow-up prompts to gain information about the variables of interest. Interviews were 30 minutes in length on average and were audio-recorded and transcribed by two of the authors (AR/DB). Interviews were conducted in English, with a translator, and a Rwandan medical student (TC) was present for a majority of the interviews (13) to translate to the local language of Kinyarwanda if the interviewee preferred. Quotes provided by the translator may not be actual quotes from interviewees but from the translator. All interviews were transcribed verbatim and no identifying information was collected.
The transcripts were analyzed using a comparative qualitative content analysis [
This project was conducted within a Memorandum of Understanding between the Ministry of Health of Rwanda and Virginia Commonwealth University to facilitate trauma and emergency systems in Rwanda. Research ethics approvals were obtained at Virginia Commonwealth University and the University Teaching Hospital, Kigali, for analysis of the deidentified electronic prehospital registry. An additional IRB amendment was sought for incorporation of results of the anonymized interviews in this manuscript.
From December 2012 through June 2016, SAMU managed 11,161 patients, of which 55% (
The most common location of pain was described as the lower limb (
Pain etiology and location by patients with documented pain and those who received pain medications.
Pain characteristic | Patients with documented pain (%) | Patients who received pain medications (%) |
---|---|---|
Total | ( | ( |
Age | 31.5 y (±13) | 31 y (±12) |
Sex | ||
Male | 4,661 (76) | 3,795 (76.5) |
Female | 1,457 (24) | 1,172 (23.5) |
Etiology | ||
Trauma (total patients = 6,266) | 5,724 (93) | 4,618 (92) |
Road traffic incidents | 4,308 (70) | 3,578 (71.5) |
Assaults | 652 (10.5) | 485 (9.5) |
Fall | 452 (7.5) | 330 (6.5) |
Burns | 60 (1) | 53 (1.0) |
Others | 249 (4) | 112 (2) |
Medical (total patients = 3,062) | 439 (7) | 306 (6) |
OB-GYN (total patients = 1,781) | 8 (0.1) | 69 (1.5) |
Location of pain | ||
Lower limb | 2,414 (39) | 1951 (39) |
Skull | 2,186 (35.5) | 1304 (26) |
Face | 1,701 (27.5) | 1695 (34) |
Upper limb | 1,380 (22) | 1069 (21.5) |
Chest | 861 (14) | 551 (11) |
Spine/back | 477 (7.5) | 372 (7.5) |
Others | 609 (10) | 367 (7) |
Acuity | ||
Absolute | 637 (10.5) | 567 (11.5) |
Relative | 4,431 (73.0) | 3,713 (75.5) |
No urgency | 998 (16.5) | 646 (13.0) |
Acuity of illness is assessed by urgency categories. Patients were triaged by SAMU into 3 urgency categories (absolute, relative, and no urgency) based on clinical presentation during field assessment. Patients who were categorized as absolute urgency had lower odds of having documented pain compared to all others (OR = 0.38, 95% CI (0.34, 0.42),
Of those who had documented pain, 4,449 (72%) patients received pain medications. An additional 561 patients who did not have pain documented also received medications, for a total of 5,010 (45%) patients overall. The average age of a patient receiving pain medications was lower (31 + 12 vs. 33.5 + 20,
The most common medications were diclofenac (
Between January 16 and January 31, 2019 in Kigali, Rwanda, 20 semistructured interviews were conducted in person, which was sufficient to reach saturation as a part of a quality improvement project to understand practitioner factors in care delivery. There were 16 females interviewed, with an average age of 39 years (standard deviation (SD): 6 years). The majority of those interviewed were nurses (
In total, three main categories were identified throughout the analysis including differences in pain expression and actions taken on the ambulance. Major themes and contributions to the theme are listed in Table
Qualitative themes, families.
Major theme | Code families included | Sample codes included |
---|---|---|
Differences in pain expression | Age | “Mostly young people cry and shout when there is any pain. But others try to manage it and be patient. Young people are immature, and once they find blood from anyone, they get upset and cry.” |
Gender | “For the females, they obviously try to express what they have in their heart, so you know they are in pain. Also, in the Rwandan culture, the tears of men move down to inside and are not coming outside. Which causes them when they are in their environment, they do not express they are crying because then people will think he is not a manly man because he is crying.” | |
Country/culture | “Rwandans express pain differently from Congolese. The Congolese even in labor, they shout and make people know they are in pain. But the Rwandese, most people especially those who are older, they try to make things seem calm. They try to calm themselves and say that there is no other way.” | |
Urban/countryside | “In the countryside, the reason why they do not express their pain is because they fear people from the city and so do not show pain. Also, their character. The people from countryside are closed compared to city people. In the city, you can talk more, and you can say anything. But the people from countryside are always shy. They need to have much time to assess people from countryside because sometimes they say they do not have pain when they actually are having pain.” | |
Actions on the ambulance | Assess pain | “They use pain scores. Sometimes they use inspection. If the patient has chest pain and shouting, then they know that maybe this patient has 8 out of 10 pain. And also, they look at vital signs: blood pressure is going high and heart rate is abnormal. So, the patient uses signs to show they are in pain.” |
Manage pain | “For minor injury, give paracetamol and ibuprofen. For those who have moderate injury, you give diclofenac but not if bleeding. If severe pain, they give morphine in a titrated way: they give 4 mg and then assess.” | |
Patient expression of pain | “They express in three ways: patients who talk when in pain, others show on face that they are in pain, and then there are those who shout from pain.” | |
Ability to provide medication | “Some refuse injection, they do not even want to see the needle. They try to counsel the patient. If they keep refusing, they do not give. Others might want water to swallow the medication but there is no water in the ambulance. So, some do not want an injection, but even for the tablet, they need water to swallow.” |
The first theme of pain expression can be divided into themes by age, gender, country/culture, and urban/countryside. A recurring narrative among the majority of interviewees was that older people express pain less frequently and less overtly than younger persons. Younger people are perceived to have experienced less pain in their lives, which is mentioned as an explanation for this observation. Several of the interviewees said that women express pain in a more exaggerated manner compared to men, in part due to cultural values. However, other interviewees mentioned the opposite dynamic: men expressing pain more openly than women. The most common cultural/country comparison in the interviews was between the Democratic Republic of the Congo (DRC) and Rwanda. Comparing the two cultures and how they tend to express pain, Congolese are described as expressing pain loudly and in an exaggerated manner, while Rwandans are described as not expressing pain and being patient, sometimes referring to the genocide against the Tutsi in Rwanda as an underlying reason. Urban/city residents were generally viewed as exaggerating their pain and expressing it more overtly compared to countryside residents.
The second theme, actions of the ambulance, can be divided into assessing, expressing, and managing pain. When asked how a patient’s pain generally is assessed on the ambulance, most frequently, pain scores (1–10) are mentioned. In addition, interviewees mentioned patient observation as a pain assessment technique and vital signs such as blood pressure and heart rate. Relating to pain management on the ambulance, most interviewees refer to administering different types of pain medication: paracetamol/acetaminophen (i.e., Tylenol) or ibuprofen, diclofenac, or morphine. The interviewees mentioned a number of different pain expressions by patients—most frequently crying, screaming, and facial expressions. Most of the healthcare professionals interviewed for this study mention that the pain medication they need is always available. However, they do mention some situations where administering pain medication is problematic: among them, patients refusing pain medication because of fear of needles and patients with abnormal vital signs.
Results of both assessments of pain management in the prehospital setting and staff attitudes and perceptions of pain were reported back to the entire team by one SAMU staff member for discussion. Novel pain management guidelines for the service were drafted collaboratively based on the WHO’s standardized pain scale [
Adult and pediatric pain protocols.
This study is one of the first to explore pain expression or provide epidemiologic characteristics relating to pain management in the prehospital setting in SSA [
This study demonstrates differences in the pain documentation, treatment, and expression for males and females. The quantitative data showed that the majority of patients documented as having pain was men. Men were also more likely to receive medications compared to women. This was contradictory to the qualitative analysis where women were perceived as exaggerating pain compared to men. This may suggest some implicit bias. SAMU staff view pain as being expressed differently in men and women, which is supported throughout the literature. For example, studies have found different pain modalities to be perceived differently by men and women [
Another major difference in the assessment and management of pain was the cause of pain. The majority of patients documented as having pain was from injury, although clearly other conditions such as labor can be painful. The number of patients with obstetrics-related complaints documented as having pain was very low. Our qualitative interviews did not ask which chief complaints would require pain medication, so it is unclear if SAMU staff would normally ask every patient if they are in pain when responding to emergencies. However, undertreating labor pain has been raised as a common issue in similar settings. A study from Ethiopia reported that pain medications were used for labor and delivery in only 34% of patients [
Cultural background clearly can influence how people perceive, report, and manage pain. Some may permit the expression of pain while others forbid such a public expression or express it in different ways [
Last, since pain is a subjective experience, the SAMU team’s attitudes towards pain also affect assessment and management of pain in the prehospital setting. Historically, SAMU has had no established way of diagnosing and assessing pain. This has led to heterogenous practices among the staff. For example, some of those interviewed at SAMU were unaware of the pain scale and were not familiar with its use in choosing a pain medication for treatment. Although limited research on prehospital pain management has been performed in sub-Saharan Africa, studies have shown limited pain assessment or use of pain scores [
This study has a number of limitations. First, the quantitative data regarding documentation and management of pain were from EMS records. These data were not collected specifically for this study. Data may have been missing or incompletely documented. Data are limited to prehospital care and is not linked to emergency department or in-hospital data. We have no outcomes data to see the patient’s formal diagnosis or hospital course. The study was an analysis of the current pain treatments but not as much adequacy of care, which will be further studied in the future. Additionally, the qualitative interviews were conducted by a nonnative interviewer which may have created language and cultural barriers, which may have biased results. A Rwandan translator (TC) was assisted with the interviews; however, barriers may have remained. Furthermore, having a male translator may have led to bias on how the staff considered gender in relation to pain and how they spoke to him about it. Furthermore, interview-based data collection can be subject to various sources of participant and researcher bias. Since the interviews were conducted by members who were well known to the SAMU staff and had long-term relationships with participants, staff may have been more open in their responses. However, in this case, acquiescence and social desirability bias on behalf of the SAMU staff and confirmation bias on the part of the interviewing team could have biased the results in various ways. The optimal method to address this would be to conduct follow-up studies including interviewing patients, independent of the treating staff, to get their views on pain expression.
Pain is a personal experience; it is a difficult phenomenon to express and treat. This was the first study to examine pain expression in the prehospital setting in Rwanda and one of the only studies to do so in Africa. This study opened a conversation at SAMU about why the treatment of pain is important and how pain can be expressed uniquely in different populations. The results were used to develop context-specific interventions to standardize prehospital pain management as part of a quality improvement effort at SAMU.
Interview guide questions. Question 1: although everyone feels pain, people express their pain in different ways. How do SAMU patients express their pain, if at all? Question 2: what affects how your patients express their pain? Question 3: how do patients communicate about their pain to you? Question 4: what are some ways you can tell when a patient is in pain? Question 5: how often do you assess a patient’s pain? Question 6: are there types of patients where it is harder to assess their pain? Question 7: can you please walk me through the way you assess a patients’ pain? Question 8: can you list for me all the ways you can address patients’ pain as a nurse/nurse-anesthetist on a SAMU ambulance? Question 9: you mentioned that one option is to give pain medications. How do you decide to give them? Question 10: is there ever a time when you want to give pain medication and you cannot? Question 11: do you talk to patients about giving pain medication?
The data used to support this study are made available from the corresponding author upon request.
Rosenberg A. and Uwitonze E. are co-first authors.
The authors declare that they have no conflicts of interest.
Rosenberg A., Uwitonze E., and Dworkin M. equally contributed to this work.
This work was supported by the National Institutes of Health (R21:1R21TW010439-02 and P20: 1P20CA210284-01A).