A friend sent me a link to a funny article on The Gomer Blog. The article was about Dr. Oz and was pretty funny. I started browsing around the blog and found more funny stories. All satirical, of course. Then I found this one,
Patient Still 10/10 Pain Even After a ‘Being-Set-On-Fire’ Analogy
Since ‘terrible’ isn’t a coding measure, Dr. Watters asked “If you had to rate your pain on a pain scale from one to ten with 1 being no pain and 10 being the worst pain of your life, what would you rate it?” This is where Dr. Watters made a horrendous mistake.
“I’d rate it a 10,” the patient that was asleep 7 minutes ago responded. Dr. Watters rephrased the description of the pain scale. “So, a ‘10’ would be similar to the time you gave birth. A ‘4’ or ‘5’ is about where most people start feeling uncomfortable, and ask for pain medicine.” He then asked the patient, who was confused about the pain scale being in base 2 instead of base 10, about the pain medication she had received.
That neatly sums up the problem with the pain scale that all medical care providers are supposed to use. It’s subjective, it varies from patient to patient. In other words, it’s kind of useless for judging anything about a patient.
Apparently some people think that pain is the “Fifth Vital Sign”. Which makes about 10 “Fifth Vital Signs” I’ve been told exist.
Whoever came up with that tripe doesn’t know what a “Vital Sign” is. More specifically, they don’t know what a “Sign” is in medical terms.
A “Sign” is something that the provider can see. You know. like a sign. You can’t see someone else’s pain, although you can see their reaction to pain. The problem there is that some people are more stoic than others. Some people could have serious injuries and medical conditions, but not show outward signs. Other people react visibly and vocally to minor pain.
Which would make that a “Symptom”. Which is what the patient tells you, not what you observe yourself.
If you use the SOAP format or any of it’s variations for charting, pain goes in the first part, the Subjective. Which is where you put what the patient tells you, not what you see. What you see goes in the Objective part of the narrative because it’s measurable. That would be like real vital signs, pulse, blood pressure, respiratory rate and effort, pulse oximetry, and capnography. Since the 1-10 scale is subjective, it’s not a vital sign. I’m not even sure it’s any more valuable than asking the patient “Is your pain better or worse?”, after giving them a medication or doing a procedure.
The blog is pretty funny if you’re at all involved in medicine. Maybe it’s funny if you aren’t involved in medicine, but I wouldn’t know. More than funny, it pokes fun at medical sacred cows.
Medicine needs more humor anyway.
Pain is the fifth vital sign for hospital satisfaction surveys, nothing more. With that said, my approach has always been to take the patient’s word for it; after all, me withholding fentanyl or morphine isn’t going to change their addictive habits or anything. I really don’t even care if they call the next crew of the next shift.
And then there is the ‘if it looks like it hurts, it probably does’. That’s where I really get upset with some of my providers when someone has an obvious, angulated, open fracture, or obviously shortened and rotated lower extremities in the setting of an elderly fall that the patient is documented as ‘hurting’.
In the same vein as the blog, one of my old trainees used to use the ’10 is like b eing mauled by a bear’. Most people picked 2 or 3 after that.
I agree that EMS shouldn’t get in the business of mediating pain control for patients. Let the hospital figure that out. I know of one hospital that instructed a service that transported there not to give pain medication to a specific patient because of the patient’s history of drug seeking. Wisely, the service laughed at the hospital and continued with their protocol. I have little doubt that the hospital will be on the receiving end of some sort of legal action in the future.