The pain scale is stupid

When are we going to stop using the pain scale? We think it’s stupid. Patients hate it.

For God’s sake, we even named a pain scale.

(For this post, we’re not going to talk about the wussies, for whom everything from a cut finger to a stubbed toe is 10 out of 10 painful. They need no more attention from anyone.)

Some hospitals have made the pain scale “the 5th vital sign**,” and, after some cursory research, which really just means that I clicked around, I’m told that this is likely thanks to JCAHO, now called TJC in an attempt to get away from the negative opinions it attracts the same way criminals use aliases. For folks outside of health care, JCAHO is the bureaucracy that believes that such attributes as the locations of trash bins and the number of times per hour the floor is mopped are actually very important in order for hospitals to maintain their accreditations.

(If you can find ONE patient-level provider who does not think JCAHO is absolutely ridiculous, I’m sure all of us would like to meet this person.)

Back in the real world, I must admit I feel like an asshole whenever I ask a patient whose arm fell off what number they would rate their pain. Even if I don’t ask for it – and trust me, most of the times I don’t – the ED will ask for it, not because nurses are blind to human suffering and deaf to all the screaming, but because that’s a box they have to fill out. It’s reached the point of asking for the sake of asking.

It’s quitting time when you preface the question with, “I know this is a stupid question, but…”

The only time I can see it being useful is when it’s used to compare the pain before and after interventions. But, only with reliable patients. Which means, perhaps one patient per week.

For instance, it has some value when we have patients rate chest pain. But, just as I do not typically pay a whole lot of attention to how patients subjectively describe their chest pain, mindful of how most sensations are beyond words and of the deteriorating language ability of the average person thanks to the deteriorating educational standards on this side of the planet, we should remember that asking them to assign their pain a number on a scale of 1 to 10* is just as subjective. And therefore not very reliable.

Now, as a very simple example, imagine for a second you’re having chest pain, and let’s say more likely than not it’s some legitimate badness, because there are sirens and I’m not hiding behind you in the jumpseat, ignoring you and doing paperwork. While you’re trying not to freak the fuck out over the chest pain and silently hoping I don’t have to stick you 4 times because you’re “scared of needles,” I’m making you come up with some random number on a scale of 1 to 10 after every spray of this disgusting, vaguely cherry-like substance that is giving you a raging headache, not to mention the dizziness and the blurry vision that come with it, obscuring the view of your life flashing before your eyes. Even though you’re convinced this is your last day on Earth and you wish you called your mother more often, you spit out a number a few minutes after every spray. How accurate do you think these numbers are?

(By the way, those of you who still push on patients’ chests to see if the pain is worse hoping to “rule out cardiac”: Please stop doing that.)

Besides, wouldn’t you agree that any subjective assessment tool that gets the same result – 10 out of 10 – like 90% of the time is just pretty much useless? (OK, I guess we had to get back to the wussies at some point.)

*Some providers say “on a scale of 1 to 10” and others say “on a scale of 0 to 10” – which is it? I submit that, rather intuitively, “0 out of 10” means no pain. Since the simple fact of having pain typically leads providers to asking for a rating on the pain scale, it would seem that “on a scale of 0 to 10” is a little redundant, since no patient is going to say “0 out of 10” after being asked to rate his/her pain after complaining of pain. If s/he does, then s/he is an idiot, and definitely don’t give that asshole any narcotics, unless you want your bosses on your ass. In either case, I don’t really give a shit because the pain scale is stupid. Have I mentioned that already?
**In other news, the inventor of the slogan “Pain is the 5th Vital Sign” now concedes pain is actually not a vital sign.

9 thoughts on “The pain scale is stupid”

  1. Bravo! I never use the pain scale because it’s so subjective as to be meaningless. A lot has to do with the stoicicity (yeah, I made that up) of the patient. Plus, it leads some not too bright providers to think that a patient can not be having an MI if they have no pain. We have enough trouble getting people to consider non chest pain cardiac events without reinforcing the wrong constantly.

    I’ve likened TJC to an organized crime family. Seems to me that they extort compliance for clinically insignificant administrivia by threatening to withhold certification.

    “Nice little hospital you have here. I’d hate to see anything happen to it’s accreditation because you let someone tape a notice to the wall.”

    1. I’ve likened TJC to an organized crime family. Seems to me that they extort compliance for clinically insignificant administrivia by threatening to withhold certification.

      Did I mention that they can pull it because I don’t have the EXACT location of where the fire alarms are in my department? As soon as I found that tidbit out, I instantly understood why everyone hates the Joint Comission. FYI, in the event of a major fire, I’m grabbing my gear and getting out of there, and you bastards can consider yourselves lucky if I pull the alarm on my way out.

      I agree with TOTWTYTR on the pain scale with chest pain, especially with us non-typical presentation ladies.

  2. Not wanting to be the lone voice of dissent or anything but using that logic wouldn’t any subjective question we ask be stupid ? Such as ” Are you short of breath ?” or “what does the pain feel like ?”…..because both of those are open to interpretation depending on say (a) whether you have COPD or not or (b) your powers of description.
    Just sayin’ !

    1. ask a stupid question, get a stupid answer. i think there’s an art to asking questions in a way to get useful (for our purposes) and specific answers without leading patients on.

      i don’t think that what you pointed out is necessarily the same. artificially and rather abstractly assigning a number to pain is different from describing pain with actual words. how is 5/10 different than 6/10 in any meaningful way? i have no idea. granted, most people are terrible historians and are even worse with words, and we can’t blindly use their descriptions to “rule in” or “rule out” anything, but we also consider history and objective findings and how they fit into the overall picture.

      as for SOB with COPD, there are many other ways to compare it to their baseline level of distress. besides, it’s a little harder to lie about shortness of breath than pain.

  3. As a patient with a high tolerance for pain, it’s worthless in my case. Yeah, when I first fell and fractured the tib/fib it definitely hurt like hell for 20-30 seconds, but then I controlled the pain (don’t ask me how, but I can cancel it out somehow). So what good does it do when you can see a deformity from a break and the patient says “1 out of 10”!?!?!?!?

  4. Just love this entry. I’m a paramedic in Australia and am always copping shit for not allocating pain scores on my case cards for the most obviously painful things. “You didn’t write a pain score before you gave morphine and/or ketamine”. “That’s because he had a fractured femur. That shit tends to hurt a lot. I’ve never had a fractured anything, but I’m pretty sure a big, long bone snapping in two would sting a fair bit.” “You didn’t write a pain scale after analgesia”, “That’s because he was no longer screaming and crying and was laying quite still on the stretcher with a blissful look on his face. I take that as a good sign it doesn’t hurt as much anymore”. Fools!

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