Pain Research and Management / 2020 / Article / Tab 2

Research Article

Pain in the Prehospital Setting in Rwanda: Results of a Mixed-Methods Quality Improvement Project

Table 2

Qualitative themes, families.

Major themeCode families includedSample codes included

Differences in pain expressionAge“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.”
The way the youth express pain nowadays is different from the others; they express in an exaggerated way. The reason is because the youth have not had many experiences of pain. There is the example of genocide for the older people. So, when they have pain, they compare the pain they are feeling at that time with the pain they had during genocide, and then, they try to calm themselves. But for the youth (unclear: to have the understanding?) is by sharing the story of how genocide happened because they did not pass through that kind of life.”
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.”
“Men do not express pain the way females do; females exaggerate it. Rwandan culture says men are not supposed to express pain by crying and shouting like how females do. The culture makes men resist.”
“Mostly the men express their pain more than women. Women are exposed to pain many times during labor, and they compare their pain, but men do not.”
“Men express pain more obviously, and everyone can know the man is in pain.”
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.”
“Congolese like to cry. They like to express their pain even if the pain is moderate or mild. We say they exaggerate to express their pain. As I told you before, in Rwandese, you can find someone with femur fracture who is not crying, without expressing pain, and being calm, until you touch or move the limb that is fractured.”
“I think it is because of the culture of Rwandese; they like to hide their emotion compared to Congolese.”
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.”
“… for those in the countryside, they meet with many things in life which hurt them, which cause pain for them. So, it is like to have a pain but it is not pain compared to those in the city who have the easiest life to enjoy always, not having many hard things.”

Actions on the ambulanceAssess 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.”
“First, they use inspection, looking at how the patients look, mostly the face. Those who have weak or shrunken face have severe pain. Then, second, after inspection, they use palpation. When they palpate painful site, the patient tells them not to palpate on that site.”
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.”
“We decide to give painkiller depending on many things. First of all, we look for the scale; even if I do not use the scale, I can evaluate the pain based on the expression. We can also look at vital signs. For example, traumatic patient in shock. If he has pain and is crying, the vital signs will show that the patient is in shock. To decide which painkiller, I have to look at vitals because some painkillers reduce cardiac output.”
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.”
“It depends on personality and severity of pain. Some people have the personality that once they have pain, they exaggerate it. There are others who make it simple even though they have severe pain. Also, there are some with such severe pain that they are not able to resist the pain and so they shout and cry out.”
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.”
“Because they fear medication and refuse it. Sometimes, the patient refuses to go to the hospital or care facilities. They think the medication will be poisoned by their neighbors.”

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