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Limitations of Patient Pain Assessment

berry-pain-rating-scale

"Pain is such an uncomfortable feeling that even a tiny amount of it is enough to ruin every enjoyment."
—Will Rogers

“On a pain scale of 1 to 10, with 10 signifying the most intolerable pain you can imagine, how would you—”

“It’s a 35!” The patient curtly interjects.

“A 35?” You echo back, perplexed, but not all that surprised.

“Well, yeah! It hurts, yo!” The patient winces back satirically.

“Did you know that out of 35 industrialized nations, the U.S. is rated 25th globally when it comes to math skills,” you nonchalantly pose to your patient as you apply the IV tourniquet and avoid eye contact with your partner, lest a smirk work its way through the veneer.

“Huh? What does that have to do with any… Hey! That tourniquet is pinching my skin. Ouch!”

Unfortunately, there has never been a specific examination, tool or quantifiable means of objectively measuring a patient’s pain level. As in a hospital setting, EMS providers depend on observational behavior, physiological data and patient self-reporting when assessing the degree of patient discomfort.

With the patient’s testimonial providing the primary means of gauging pain valuation, we should take every patient’s report of their pain very seriously, without condemnation or judgment. And yet, there are times when healthcare providers can find it difficult to keep their minds and hearts open when the patient is playing Angry Birds on their iPhone between the moments they’re screaming for you to end their unbearable and devastating pain.

Maybe we’ve become a nation of wimps, biting on a pacifier rather than a stick during our discomfort. But I believe part of the problem may lie in the illustrated pain scale assessment diagram we present to our patients—the Wong Baker pain scale chart, which combines pictures and numbers to allow the pain to be rated by the user themselves. The faces on that chart range from smiling to sad and crying. In my opinion the faces aren’t graphic enough. Too many patients are too quick to pick the number 10, because the facial expression portrays only that of an oversimplified display of lacrimal raindrops, when it should in fact display paindrops. (See my chart.)

Now don’t get me wrong, folks. I’m all about mitigating aligoanalgesia (try saying that fast after 100 mcg of fentanyl via rapid IV push). I’ve always believed EMS has long ignored and under-prescribed pain meds. I remember a time when, regardless of the patient’s condition, we were only allowed to give morphine in 2 mg increments to a maximum dose of 5 mg with Narcan and bag-valve mask on the ready in case the patient lost their respiratory drive secondary to losing consciousness—a wise concern considering so many of my patients felt like taking a nap after having their lower leg nearly amputated.

I for one have never experienced a level 10. I came close recently when my back muscles went into spasm following three posterior rib fractures, but I don’t want to limit myself to thinking I’ve reached the pinnacle of my pain threshold. Being the positive theoretical poet that I am, I believe there’s always the possibility for an even higher echelon of agony not yet attained throughout my accident-prone existence.

Due to the transient nature of our brief medic-to-patient relationships, it can be difficult at times to distinguish patients with legitimate pain management needs from DSIs (drug-seeking individuals) feigning illness. I may not be a rocket scientist, but I do consider myself somewhat street savvy in recognizing individuals who enlist our services to facilitate their perceived free passage for clinically blessed pharmacological prescribed opiates. Though we should always focus on the patient and not the DSIs’ annoying behavior, we should also trust our instincts.

Wouldn’t it be nice, though, to have a form letter like this that we could give out to DSIs?

Hello and welcome to EMS.

We hope to make your journey to the hospital a pleasant one, and we will do everything within our scope of practice to keep you safe and comfortable. Smoking is not allowed and we ask that you not light up (anything) during our short time together.

We believe every patient has a right to expect relief from their legitimate pain, and if we can identify it, we will certainly try to alleviate it. We were not born yesterday, however, and should you only moan when others are watching you, flinch in pain from us starting an IV, avoid eye contact or threaten to harm us, you may only just see us raise our eyebrows and not our hands for the narcotics—especially if you have said three or more of the following:

1. “I am allergic to Tylenol, ibuprofen, aspirin and Tordal.”

2. “I’m experiencing the worst migraine, back pain, abdominal pain and kidney stones of my life.”

3. “What are the names of the doctors working in the ER tonight?”

4. “I’m from out of town and my regular physician is on vacation ... or maybe he died recently.”

5. “My pain scale is a 100+ on a scale of 1 to 10.”

6. “I lost my prescription. Either that or someone stole it.”

7. “Vicodin is the only medication that works for me.”

8. “I demand you give me something for the pain now.”

9. “Start the IV here. It is the only good vein I have left.”

10. “Last week the ambulance crew started me right off the bat with 10 mg of morphine and 200 mcg of fentanyl, which seemed to help a lot.”

Thank you again for allowing us the privilege to serve you, as we do want to accept your pain at face value in spite of you calling us 2 a.m. to negate your pain that started 12 hours earlier.

Until next time, remember the only thing missing from a pain scale of 35 is the decimal point.

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