KEY POINTS
- Comfort and reassurance are more important than drugs.
- Protect them from the environment and from further injury.
- Treating pain improves outcomes.
EXPLANATION
Managing pain in the outdoor setting can seem daunting. When confronted by someone with a broken leg, giving some paracetamol (acetaminophen) might seem a bit useless. However, it is not, and there is plenty that you can do to help your casualty.
The most important thing you can do is to provide reassurance. Hold the casualty’s hand and talk to them, tell them what is going on and what everyone is doing to help. This has been shown to reduce pain significantly, as well as to improve outcomes. If you are coordinating a rescue – assign someone to sit at the head of the casualty to talk them through the situation.
Think about what else you could do to make them more comfortable. Perhaps shelter? Warmth? Food or water? Helping them go to the toilet?
Protect them from further injury. This may mean putting on a sling, padding a wound or splinting a limb. Splinting is one of the most effective forms of pain relief.
Finally, if the casualty is alert (talking to you) and can swallow, then you might consider simple painkillers:
- If they are adults, over 50 kg, the appropriate doses are paracetamol (acetominophen) 1g and ibuprofen 400mg respectively.
- If they are adults, under 50 kg, then give half-doses.
Be careful with ibuprofen in asthmatics, as it can provoke an attack in some. The most pragmatic way around this is to ask the casualty if they have taken ibuprofen before – if they say no, don’t give it to them.
Avoid aspirin – it can worsen bleeding.
Why pain relief is not an optional extra
It is easy to treat pain as the last item on the list, something to think about once the bleeding is stopped and the airway is safe. In the remote setting that ordering is wrong. Uncontrolled pain drives a stress response that raises heart rate and blood pressure, increases oxygen demand, worsens shivering and makes shock harder to manage. It also makes the casualty harder to assess, because a person in severe pain cannot give you a reliable account of what hurts and where. Treating pain early buys you a calmer casualty, a more accurate assessment and a better physiological starting point for the hours of waiting that often follow a free flight accident.
There is a longer-term argument too. Severe, poorly managed acute pain is associated with worse recovery and with a higher chance of persistent pain afterwards. The half hour you spend keeping someone comfortable on a hillside is not merely kind; it plausibly changes how the next six months go for them.
Position, splinting and the mechanics of comfort
Most pain in a trauma casualty is mechanical, which means most pain relief is mechanical too. A limb that moves hurts; a limb that is supported does not. Splinting is the single most effective analgesic available to a bystander, and it works immediately, has no dose limit and cannot interact with anything the casualty has taken. The same logic applies to a pelvic binder, to a sling for an injured arm, and to padding placed under a knee or an ankle so that a leg is not held rigid against uneven ground.
Position matters almost as much. Let the casualty find the position that hurts least, unless there is a specific reason not to. People with chest injuries usually want to sit up. People with abdominal pain usually want their knees bent. Fighting a conscious casualty into a textbook position causes pain and gains nothing. If the casualty is still in a harness, think carefully before removing it — a harness with an integrated back protector is often supporting the spine and pelvis, and cutting it away can hurt far more than leaving it in place until better help arrives.
The environment is part of the treatment
Cold makes pain worse and shivering makes injuries hurt more. Insulation from the ground matters more than covering from above, because conduction into cold earth or snow strips heat far faster than the air does; a rucksack, a rolled reserve or a folded wing under the casualty is worth several layers on top. Wind protection comes next, then a group shelter if anyone has one. Getting a casualty out of the wind and off the ground routinely produces a visible reduction in distress before any drug has been offered.
Sun, glare, noise and being stared at all add to a casualty's distress in ways that are easy to overlook. Shade someone's eyes, keep the crowd back, and if a phone is being used as a torch, do not shine it in their face. These are trivial actions that consistently make people calmer.
Simple analgesia, used sensibly
Oral painkillers are worth giving when the casualty is fully alert, able to swallow and not obviously vomiting. Paracetamol and ibuprofen together are more effective than either alone, and the combination is safe for the great majority of adults. Halve the doses for a small adult. Check whether the casualty has already taken anything that day, since people frequently forget that they have.
Ask before you give. The practical screen for ibuprofen is simply whether the casualty has taken it before without trouble, which sidesteps most of the asthma and stomach concerns without requiring a medical history. Avoid it entirely if there is a known bleeding problem or significant ongoing blood loss. Avoid aspirin as an analgesic altogether in trauma: it inhibits platelets for the life of the platelet, and worsening clotting is the last thing an injured person needs. Withhold oral analgesia if the casualty is drowsy, confused, obviously intoxicated, or has an abdominal injury that may need surgery — and if you are unsure, note the time and let the arriving crew decide.
Reassurance, and why it is a clinical intervention
The evidence that calm, continuous, honest communication reduces pain is stronger than most people expect, and it costs nothing to deliver. Assign one person to stay at the casualty's head and do nothing else. Their job is to introduce themselves, explain what is happening, say when something is about to hurt, and keep talking through the gaps. That person should not be the person coordinating the rescue, because coordination pulls attention away exactly when the casualty needs it most.
Be truthful. Telling a frightened person that everything is fine when it plainly is not destroys their trust in everything else you say. ‘This is going to hurt for a moment, and then it will be better supported’ is more reassuring than a false promise, because it turns out to be true. Ask what would help; sometimes the answer is holding a hand, sometimes it is being left in silence, sometimes it is a phone call to a partner. Small requests granted quickly do a great deal of work.
Handover
Write down what you gave, how much, and at what time, along with the times of any change in the casualty's condition. A permanent marker on the back of a casualty card, on tape, or on the casualty's own skin all work. The arriving team's options are shaped by what has already gone in, and ‘some painkillers, a while ago’ is not information they can use. Recording the time is the part everyone forgets and the part that matters most.