Pain Scales

Note: I originally started writing this post around October 26, the date of the blog linked below. Just so ya know!

Just catching up with some of my favorite blogs after work tonight and this one from Scalpel or Sword? really hit home.

As someone who has to deal with the "1-10" pain scale on a daily basis, it's true: Many times, it doesn't work at all. Take, for example, a totally normal, non-drug-seeking patient: DR, my husband. He gets occasional spasmodic muscular back pain, sometimes brought on by stress, sometimes by lifting heavy things, and sometimes because he is...well...not svelte.

The first few times his back seized up, I tried to evaluate his pain level on a 0-10 scale. "Honey, on a scale of zero to ten, where zero is no pain and ten is the worst pain you can imagine, can you rate your pain?" His response was (as he stood frozen like a statue, clutching his middle back and panting) "What? Are you kidding me? Uh, okay, zero stands for what? Can't I just say it really hurts? It REALLY HURTS!!" He really didn't get it. He couldn't relate to the numbers at all. I actually dug up a copy of the "Ouchers Scale" from a pediatric textbook (see link; it's for kids and uses photos of children's faces instead of just numbers). He managed to pick a face from that, but he picked a less-painful face (around 5) than what I was seeing in him (I would have placed his pain somewhere around 8 or so).

He asked me later, when he had less pain, what a pain score of 10 was supposed to feel like. I told him that some people phrase it as "The worst pain you can imagine," like being burned alive (some people say like childbirth). Some say "The worst pain you've ever had." Both of these are inaccurate: I can imagine that being burned alive would be pretty bad, but then I would probably be unconscious from the pain, so is that a 10? Does the patient have to be unconscious? And the "worst pain" some people have ever had is a stubbed toe.

Years ago, I had a bone-impacted wisdom tooth with a bone cyst under it. It was causing me a lot of swelling to my jaw and enough pain that I was taking ibuprofen regularly to control it. My dentist and oral surgeon recommended that it come out and that the cyst under it be cleaned out. This was not going to be a routine extraction, the surgeon explained. (As a matter of fact, his actual words were, "Well, we're going to mess you up good!") It was done under general anesthesia, I was intubated to protect my airway (it's very weird when they take that tube out when you're waking up--I only remembered it days later), and I spent quite some time in the "recovery room" of my surgeon's office until my mother could come take me home. Once home, I began taking the pain meds the surgeon had prescribed immediately, but, due to a mix-up at the pharmacy (read: the complete incompetence of the pharmacist) I had been given the generic of the meds, and not the brand-name, as specified by the surgeon (apparently it DOES make a difference--and how!).

As the local anesthesia I had been given started to wear off, it was as if a fire was starting in my face, neck, and head. I remember thinking, "how bad could it be? I'm sure the meds will kick in at any time now." Then the pain began to grow...and grow...and grow. Tears were streaming down my face, my shoulders were up around my ears, the pain was incredible--and so was my anxiety level. I remember being frantic, feeling like there was nothing I could do to "get away" from the pain. I couldn't breathe, I couldn't move, I couldn't speak: I couldn't think about anything other than trying to escape. My mom (also a nurse) actually said to me, "On a scale of one through ten.." and I remember yelling (well, not yelling...more like mumbling forcefully through my stitches) "TWENTY FIVE!"

Eventually we got the meds issue figured out, and I got some relief. The pain never went away (as it wouldn't for close to a week), but it was...diminished. What I remember is that I cared less about it; it was there, but didn't cause me the panic I was feeling before. That's something I share with my patients who are having pain when I give them narcotics; I say, "This will help you; it may not take ALL the pain away, but it will make you care less about your pain; you'll feel removed from it."

I've had people with terrible injuries or kidney stones or other painful conditions be writhing around and crying and miserable and rate their pain as a 5 (which qualifies for a Percocet, according to the guidelines in our hospital). I've had people who wake up from a deep sleep and yawn and rate their pain as a 10 (which qualifies for intravenous narcotics) . Admittedly, acute pain is different than chronic pain. I've also had people who are crying and writhing around who I don't believe for one minute are having any significant pain at all. And then there are the people who believe they should never have to tolerate ANY pain at ALL, EVER. Which is just not realistic.

What it comes down to is this: JCAHO feels the need to monitor our care of our patients, and the numbers scale allows them to do so. It's annoying.