The Objective Pain Scale
As we have discussed previously, the pain scale commonly in use is practically worthless for triage, because almost every patient says their pain is a 10 on a scale of 1 to 10. Except for those jokesters who say their pain is "11" or "15" or some such nonsense, that is. Therefore I present my own pain assessment scale for the benefit (or amusement) of triage nurses everywhere.I think the clinician's assessment of the patient's pain is more useful than the patient's assessment of their own pain, as far as triage is concerned. The currently used pain scale is only helpful in assessing response to treatment (the trend). Mine is more realistic:
Scalpel's Pain Assessment Scale
- 0 - No pain. Patient is asleep, respirations unlabored.
- 1 - No pain. Patient is awake and appears comfortable.
- 2 - Patient appears comfortable but says it "hurts a little."
- 3 - Patient appears comfortable, but says it "hurts."
- 4 - Patient appears comfortable, but says it "hurts a lot."
- 5 - Patient appears to be in pain and is wincing or limping.
- 6 - Patient appears to be in pain and is making painful noises (groaning).
- 7 - Patient appears to be in pain and has abnormal vital signs.
- 8 - Patient appears to be in distress and is writhing in agony, trembling, or crying.
- 9 - Patient appears to be in distress and is writhing/trembling/crying and vomiting
- 10 - Patient is in severe distress: writhing, trembling/crying/vomiting, and screaming.
Note that if a patient appears comfortable in no apparent distress, it doesn't matter how they rate their pain; they are still ranked below those with obvious evidence of pain. I don't expect any bigwigs to endorse or utilize these recommendations, of course, but it should give you an idea how I personally triage patients who are in pain. I don't like to have patients who are screaming or vomiting, so I'm going to expedite their care.
Of course, other factors are important in the official triage assessment such as age, chief complaint, comorbidities, and vital signs (which are the most important feature of triage but perhaps underrepresented by this scale). Often it's the quiet patients we have to worry about. But if you have a screaming kid in the ER, you can rest assured that I won't keep you waiting long.
posted by scalpel at 1:28 PM
47 Comments:
So your drug-seekers who have this figured out get their fixes while those of us who don't follow your rules just get to be in pain? That pretty much sucks. It does seem to be the rule in most ER's though. If your method of dealing with pain is to be very still and keep quiet, you can sit in the waiting room a really long time.
Screaming is quite effective whether or not you're actually in severe pain, though. Got me an epidural when I was in labor with my second child and the L&D nurse wanted me to wait a while longer At 6 cm, I didn't see her point. I never saw an anesthesiologist move so fast with a patient who wasn't crashing. I only had 1 more contraction before he got the catheter placed. Thank God nobody was doing the stupid 10 point pain scale at the time. I'd have had to lie.
If someone has several visits for the same sort of pain then they can scream all they want. They'll eventually leave. We know who the drug-seekers are, don't worry.
The list is a general set of principles, with notable exceptions. Primarily, it doesn't really matter how much pain someone is in...the patients who are "sicker" will always get seen first by me.
If you are able to sit still and keep quiet, you probably aren't in as much pain as the other guy (or as much pain as you think you are in, for that matter). If you aren't screaming, it isn't a 10. If you aren't vomiting, it isn't a 9. Simple enough for me.
After being admitted through the ER for emergency gall bladder surgery, I have an appreciation for the pain scale. I found that the doctor's and nurses appreciated the accurate assessment of my own pain and responded accordingly (and quickly) when I was in need of pain meds.
C.
I presented to the emergency triage desk with "belly pain". I walked myself in, but fell to the floor because it hurt too much to stand and the floor was so cool. I could not lie still for anything and remember trying so hard to stay still for the IV, but failing, especially as I threw up.
I rated my pain a "6" on the infamous scale. I could imagine it getting much, much worse. After all, I walked in (although I didn't drive). I gave my own name and history to the nurse. I had called the 24 hr. nurse line to inquire if I should go the ER before deciding to make the trip. My faculties were intact. Things could definitely get much worse!
I had dilaudid in my IV in less than 20 minutes after arriving. I think the triage nurse knew I had a kidney stone before I limped in the door.
Now I work with women in labor. Most are laboring without medications. I suspect that most get to "10" a few times before the birth - it gets as bad as they imagined it could ever be, and then it gets worse. Maybe the scale needs a reset. "If it's a 10 now, what was it a hour ago?"
As a provider of care, I see how the pain scale is very useful. In class (I'm a nursing student) we're told (over and over again) about how pain is subjective and we have to take the patient's word for it.
Now I understand why this is. It's easy to say "Oh it's not that bad" when it's not you hurting. Of course, the system is imperfect in so many ways
However, as a patient I hate the 0-10 pain scale. A couple of years ago I injured my lower back and needed some pain control. When asked my level of pain all I could really come up with was "I don't know it just hurts". Like the previous commenter J said, I could imagine my pain being much worse. Eventually I got some loratab and felt better as long as I relaxed and didn't try to act like I wasn't hurt.
The back still flares up from time to time. Now I rate my pain like this: motrin works, motrin isn't helping, and I kinda wanna die right now.
I like your pain scale. I know that the doctors at our ER check patients' records to see how many times they have been seen in the ER. I found out when I went into our ER for my twisted ankle. The doctor commented that I never come in unless I'm dying, like when I came to the ER for kidney stones. God, yes, I thought I was dying. I'm printing up your pain scale and I'm hanging it up at work.
MJ
This scale isn't intended to minimize anyone's pain. If you are hurting, you are hurting. But when I have a dozen or more patients who are all hurting, I have to decide what order I'm going to see them.
I'll see everyone eventually and treat their pain to the best of my ability, but some will have to wait longer than others. That's just the way it is, and this is how I do it.
Speaking as a triage nurse, if you drive yourself in with 6 of your family members to keep you company and when I call you for triage you are eating cheeto's and drinking a pepsi and chatting on your cell phone, you chronic back pain is not a "10" or a "12" or a "20"
What about patients like me who underestimate their pain on the pain scale? Patients like me who go without pain medicine after surgery because "I can take it" and I don't want to bother anyone to get me pain medicine when I am not yet positive I would die without it? That must be almost as frustrating as patients who overestimate their pain. I know it frustrated my doctor that I wouldn't just ask for the medicine when I was clearly in a lot of pain.
You forgot the "writhing and screaming except when they think nobody is looking" category, but I'm with ERNursery on that Cheetos and pop scale.
Occasionally you'll get someone who you know is i excruciating pain and they'll say "I dunno, maybe a five". A lot of it's cultural, there are some people who have absolutely no tolerance for pain of any kind, and this whole "scale of one to ten" thing is beyond the math capabilities of a lot of people.
Loss of bowel and bladder control are other signs of pain at a nine or ten level. When you really have that much pain, you don't sweat the small stuff. The most important factor in a patient's self estimate of pain is whether or not they have ever had really significant pain. Some dental abscesses, tic doloureaux, large area second degree burns, and epidural hematomas are a few things that can reach a 10 on a 0-10 scale. In my personal experience, only two of my roughly 25 kidney stones ever exceeded 6/10, and herniated lumbar and cervical disks never exceeded 8/10.
This is another example of how people with chronic pain just can’t win when dealing with the medical profession. If you wince, grimace, groan or show other signs of “pain behavior” you are very likely to be accused of “symptom maginifcation,” malingering or labelled a drug-seeker. If you are stoic, and don’t show when you’re in severe pain, they will write in you chart “patient says he has level 9 pain, but shows no obvious signs of distress.” You are damned if you do and damned if you don’t.
On the whole, there are many personal and sociocultural factors involved in how a particular person expresses their pain that have nothing to do with actual pain level. In American culture in general, there is an enormous stigma about openly expressing or complaining about your pain, and people get very uncomfortable and even hostile to you if you do so. The medical profession in particular is extremely hostile to people with pain. Consequently, many of us learn to hide and mask when we’re in pain, only displaying pain behaviors in the comfort of our home or when we absolutely can’t avoid it.
This is partiucularly true of people with chronic pain who have had years of practice hiding and minimizing their symptoms, as opposed to those who are for the first time experiencing severe acute pain unlike anything they’ve ever experienced before, who are more likely to panic and show signs of distress.
I go to a chronic pain support group and it is rare for people there to show extreme pain behaviors, even though it is a safe place for doing so. Most people give very subtle signs that they are in pain, like grimacing, and not more overt signs, like moaning, and this includes people who suffer from RSD and other excruciatingly painful conditions. There was one guy there who was impaled through the chest by a forklift, and he showed few signs of overt pain other than frequently having to stand and lean on his cane or grimacing. Nonetheless this guy was in horrific pain, and he was even accused of *malingering* by a workers comp doctor because he doesn’t show his pain.
As another example, I get severe stabbing pains in my back that are totally random and unpredictable. Consequently I sometimes wince or cry out when I have them, because I am not prepared for it. For a long time this caused an enormous amount of social embarassment for me, and when I would try to explain that I had severe pain, people would look at me like I was from outer space. Finally I learned an infallible technique for coping with this situation: whenever I flinched from my pain, I would explain that I suffered from chronic hiccups, and suddenly the hostility I once experienced is translated into sympathy as everybody has experienced the hiccups and can empathize with how embarrassing they can be.
The 1 to 10 scale is indeed problematic and counterintutitve, especially when level 10 is defined as “the worst pain you can imagine.” No matter how bad my pain is, I can always imagine it being worse. Similarly, many doctors think level 8 pain is twice as bad as level 4 pain, but in reality, level 4 pain is a manageable pain level whereas level 8 is totally disabling, and being totally disabled is not twice as bad as being functional, it is a hundred times worse.
As a general rule, I have found that not rating my pain but instead explaining how the pain effects my life and functionality is a better way of communicating my pain to genus medicus arrogansis than either grimacing and groaning or trying to play the hero. The idea that the doctor is a better judge of how much pain a patient is in than the patient himself is arrogance squared. Sounds to me that you indeed prefer cutting pain patients down with the sword to curing them with the scalpel.
It is articles like this that convince me we need to take pain medcine out of the hands of the medical profession and go back to the way we did things in the 19th Century, when patients could quickly, easily and affordably treat their own pain without having to justify their existence to adoctor or prove themselves worthy of not being tortured.
That kind of attitude will get you moved to the bottom of the stack. Especially when it's busy I don't want to hear any long-winded diatribes about how unfair life is or how mean doctors are. Just get to the point.
Many a time, I have been called out of the room of a chronic painer in the midst of his rant because someone more emergent needed me STAT, adding a half hour or more to the door to drug time. It's amazing how well the history was focused upon my return.
All else being equal, I would see acute pain over chronic pain anyway. I agree that pain seems more suited to a log scale than an analog one.
I completely disagree with Redhawk. My father has a chronic painful condition, and he is adequately treated for the pain. No one questions it, or looks upon him badly nor do I think others are. If one with pain doesnt communicate with their healthcare provider, adequate pain relief will not be made available. Being overbearing and demanding will not help ever. I agree with Scalpel, get to the point.
C.
The usual 10 point pain scale is indeed a crock cooked up by the gnomes to make the dwarves happy and is clinically useless. I like your scale scapel and think you should print up some forms and start using it.
You might want to add a modifiers for signs of manipluation such as showing more pain behavior when observed directly than when observed indirectly.
I also suggest considering calling the a "Pain Behavior Scale" or "Pain Observation Scale" to clarify that pain, which is subjective, can not be clinically assessed objectively, only pain behaviors (which includes verbal behaviors).
I have treated a lot of chronic pain patients and agree that overt distress is not a reliable assessment of pain in these patients. My Grandfather had a severe disfiguring injury with which he lived for more than 50 years. He never complained about pain. He only told me of his daily pain when I asked once. I witnessed him ill and with other injuries that had to hurt but he never showed it. He continued to work and when in the end near 100 years and in severe distress, he would not ask for the morphine although clearly in pain, so the nurses dosed it to blood pressure and pulse. He was a tough old sharecropper and lived his life with the attitude that how you feel or feel about things is simply not something worth paying attention to.
Regarding the chronic pain patient not getting well treated in the ER, I must ask, what the heck is a chronic pain patient doing seeking treatment in the ER? Chronic conditions are to be treated in outpatient settings. Given the number of substance abusers who bombard the ER's regularly, a chronic pain patient presenting there with pain really can't expect much other than suspicion. It is unfare to the ER doc to expect otherwise.
You are simply in the wrong place to get the service you need and want. It is like showing up at the ER for psychotherapy or to have a root canal--you are and should be disappointed. Go to a pain clinic, keep your appointments, and use the meds as directed.
J -vomiting and kidney stone? You were at a 10! Been there done that.
Joints - 25 kidney stones? YIKES!!!!
The pain scale is described as the "fifth vital sign" but no other vital signs are so completely subjective. You can count a pulse or auscultate a pressure, but to ask someone to give their pain a number is ridiculous. Most people will describe any pain at all as a ten and then think I'll pull a magic syringe out of my ass for an instant cure. Sure, there are occasional stoic individuals who will bear it, even refusing morphine because they think it's a sign of weakness or they fear addiction. Myself, I've had surgery and didn't touch any of the Vicodins I was prescribed because, although I was in a lot of pain, I could deal with it. As far as going to an ER for chronic pain, it's just not a place to address that problem. Even if you're not a malingerer or drug seeker, your problem will not be solved there.
Seaspray,
I have been very lucky. My stones are all small, in the 2 mm. range. The point I would like to make is that most of our patients who claim to have 10/10 pain have never really experienced severe pain. They aren't deliberately exaggerating their pain, they just lack a frame of reference. Scalpel's scale helps to objectify things. It might also be instructive to ask the patients to tell about the worst pain thay have ever experienced. One patient I had years ago was suffering severely with a lumber disk. As a part of his workup, I ordered an EMG. While he was having his EMG I could hear his screams from way down the hall. He later told me that the needle sticks were the worst pain he had ever experienced. I decided that he wasn't a good candidate for surgery. My personal experience has been that even after successful spine surgery one occasionally has a jab of pain worse than an EMG (and I have had quite a few, of both).
Joints - I am sorry about your spine pain and hope you don't get many of those jabs.
My first stone (a couple of yrs ago) was a 6 mm stone which I couldn't pass and has ultimately led to a damaged ureter.
NOTHING I have ever experienced compares to that pain.
I like the log scale for pain. I'd have to agree that a patient who can rate his/her own pain isn't at a 10. I shoved a nursing instructor across the room for touching me when I was in labor (first labor and the main reason I wanted that epidural the second time), and if I could have talked,I wouldn't have rated my pain above an 8.
The two and a half days in the hospital following surgery for a broke hip, I remember someone asking me repeatedly to rate my pain on a scale of one to ten. I was so fuzzy from the anesthesia I could only think "This nice lady wants a number" so I'd give her a number, trying to vary it! But I was in no pain.
Even when the paramedics arrived after I fell I'd felt no pain (only when I tried to get up, then I stayed still!), but was "guarding" that leg ferociously. Don't know why, maybe because it was the leg affected by polio at age six months. Because of the "guarding", I suppose, I was given a lot of morphine before being transferred to ER and until I went into surgery.
However, once I came home from the hospital, still being very compliant I took the pain medications every four hours as prescribed until I noticed that I was getting constipated and was not fully emptying my bladder. I went online and discovered these are side-effects of those medications, so I began to wean myself off them, using them only just before physical therapy, then using motrin and tylenol. Yes, the pain could get pretty bad for a while, but it gradually lessened as I believed it would. My doc was very surprised that I didn't want those prescriptions renewed.
I was so grateful to the nurses and the wonderful surgeon while I was in the hospital, for such marvelous care. But my experience with hospitals was so minimal (only for giving birth) that I had no idea why I was being asked to rate the "pain". No one asked if I WAS in pain! But I figure they were taking perfect care of me and THAT was why I was not in pain!
Interesting. I get menstrual cramps, sometimes bad ones, never more than 18 hours at a stretch though. Because I know they’ll end I don’t become anxious, which has a great effect on my perception.
Twice in the past couple of years I’ve been in such pain I vomited. But I could easily imagine the pain being much, much worse. (They’re bad cramps, but they’re just cramps for goodness sake.) If I’d happened to be in your ER (for some other reason) you would have seen me trembling, sweating, alternately pacing and lying down, groaning and vomiting and rated my pain much higher than I would have.
Question for scalpel: you seem quite used to the idea that chronic painers rant. And to be fed up with them.
What do you think is going on with ranting chronic painers? What is it about being a chronic painer that makes people such annoying ranters?
We don't like people to vomit anyway. I'll assess a vomiter who isn't even having any pain over a chronic painer every time, and I'll treat an acute painer who is vomiting over an acute painer who is crying. But that's just me. Vomiters require more work from the staff, so we want them to stop vomiting as soon as possible.
Annoying ranters are usually the people who have no objective evidence of disease (like many chronic painers). They tend to have multiple nonphysiologic complaints and heavy psychogenic overtones to their complaints. Fortunately, they often tend to get so worked up they leave prior to evaluation by a physician, cursing and yelling on the way out.
We don't miss them. My motto is "if you are sick, you'll stay."
I was always amazed, amused or annoyed (I never showed it though)when people that are sick or in pain or accompanying someone with those complaints,threaten to leave or do leave to go to the other hospital. The other hospital is a half hr away and probably busier.
No rhyme or reason to an ER - so one never knows how long they will wait. The really sick and hurting ones don't leave!
While sometimes I could appreciate their frustration, (and would seriously try to appease them, while also letting staff know)it never made sense to me that they would start out all over again at another hospital. Often it would happen after they saw people that were triaged after them go in before them, never seeming to consider that those people had more serious conditions.
AND sometimes the nurse would come out for them just after they left!
“That kind of attitude will get you moved to the bottom of the stack.”
What “attitude” is that? The kind that questions your infallibility, or just the kind that dares to question doctors at all?
Since you seem to like to move people to the “bottom of the stack” based on nothing more than whether they annoy you or not. If that’s your criteria for who gets treated and when, I’m curious whether you are practicing medicine or running a popularity contest. It seems like the latter.
“Especially when it's busy I don't want to hear any long-winded diatribes about how unfair life is or how mean doctors are. Just get to the point.”
I’ll tell you what, if you are so sensitive you cannot handle dealing with my “attitude,” or find talking with some CPer about his pain and symptoms to be intolerable, don’t ever develop a chronic pain condition. You won’t make it past the first afternoon. You definitely won’t be able to handle 11 hours in the emergency room waiting to be seen by some narcissistic doctor who will promptly tell you your pain can’t possibly be as bad as you say it is, and since you were observed eating cheese doodles you’re probably a drug seeker so we won’t be doing anything for the money we’re charging you, have a nice day.
Nah, you wouldn’t be able to handle that, let alone years of unremitting agony.
“Many a time, I have been called out of the room of a chronic painer in the midst of his rant because someone more emergent needed me STAT, adding a half hour or more to the door to drug time. It's amazing how well the history was focused upon my return.”
And it’s amazing how easy one slip and fall might land you on the other side of the prescription pad some day. After experiencing what your patients have to endure for a few years, you might notice a change in your focus as well.
“Regarding the chronic pain patient not getting well treated in the ER, I must ask, what the heck is a chronic pain patient doing seeking treatment in the ER? Chronic conditions are to be treated in outpatient settings.”
I don’t understand why you don’t consider severe pain to be an emergency. Even people with chronic pain can have acute exacerbations that exceed what they’re normally used to, and sometimes people just reach a point they feel they can’t take it anymore and show up at the ER hoping for some relief, if only for a night. Sometimes that ER visit is their only alternative to suicide.
In either case you can’t expect the typical patient to understand how the whole medical system works. Many people with chronic pain are unaware of the existence of pain clinics and other venues more appropriate for the treatment of cp than the ER, and many so called “pain specialists” won’t treat pain with anything but nerve blocks, epidurals and the like which aren’t effective for everyone.
You might also consider that many narcotics contracts require the patient to go to the ER if he has an acute exacerbation that can’t be controlled by his meds, but how often do doctors coordinate with the ER to let them know they are requiring this of their patients?
“Given the number of substance abusers who bombard the ER's regularly, a chronic pain patient presenting there with pain really can't expect much other than suspicion. It is unfare to the ER doc to expect otherwise.”
So what you are saying in essence is that ER doctors have a bigoted attitude towards people in pain based on their experience with *alleged* drug seekers and therefore can’t be expected to treat their patients on an individual basis. If that is the case, it rather calls into question your ability to discern drug seekers from those with legitimate complaints in the first place, and perhaps the “bombardment” you are experiencing is more a reflection of your negative attitude towards people in pain than the reality.
The fact is the vast majority of people with chronic pain are either unfairly labelled as “addicts” or told their pain is all in their heads at some point in their sojourn in the medical system, and those two attitudes are amply on display in this thread. The rate of true addiction in chronic pain patients is estimated at between 1 and 3 percent, and in the populace as a whole less than 1 percent. So I don’t see where you’re getting all these alleged addicts from.
Maybe it’s all in your head.
Don't ever annoy your doctor, your barber, or the guy cooking (or serving) your meal.
I don't mind hearing anyone tell me their symptoms and their history, as long as it's focused and concise. That's what I'm there for. If they start in with "I've waited 6 hours, this is ridiculous, I have a degree in _____, I want to speak to an administrator, blah blah blah....then I'll go see another patient so they can have a bit more time to focus on what I need to hear to help them.
I don't have time for that crap.
I agree with you scalpel. I am an easy going person and I am consistent in how I treat all patients and fam., etc. However, inwardly - I would feel like I just heard chalk scraping on the chalk board when a person would inform me that they know the administrator or someone else that they would assume I would think is an important connection might somehow prompt me to prompt the ED staff - to move along more quickly for THEM. I hate pretentiousness! Our ED staff always does whatever they can do to help the patients and clear the ED.
I have secretly wanted to ask the complaining patients that think the staff is keeping them around too long - Do they REALLY think the ED staff has nothing else they want to do or need to do other than listen to them complain, etc.? Do they REALLY think the staff wouldn't like to clear out the ED and have a few golden moments of rest?
Of course, I never would. I always did my best to keep them appeased, but I admit I had the thoughts. :)
Everyone thinks their emergency is an emergency or they wouldn't go to the ED, but most can differentiate the severity as compared to others when they get there and they wait to the best of their ability.
I did have one really bad night in the ED as a patient and DO understand how they can feel forgotten and scared.
I had returned to the hospital post stent removal (that day) with what a CT later revealed were 3 more trapped kidney stones. We also didn't know at that time that Dilauded and Morphine will cause me to vomit incessantly. On top of that I got a migraine. I can laugh at this now - I REALLY did not feel too good! :)
Because I have worked on the other side of things, I could hear and sometimes see what a crazy, nonstop need to wear your jet pack kind of night they were having. Admittedly, my husband was standing by my doorway in hopes some staff would come back in to help. Actually, they were all wonderful and did do their best and did try to help in many ways whenever they could.
I never once complained and ALWAYS managed to get a thank you out or even apologized,which I know wasn't necessary, but I wanted them to know that I knew how hard They were working.
RH,
I have read your comments here and on Kevin MD. You make many valid points. People do have CP. Narcotics are safe for CP. Nsaids and other drugs are probably overused.
However you really overgeneralize in your rants, the same thing you accuse the medical profession of.
I give out so much morphine, dilaudid, vicodens in a shift it is unreal. Perhaps some of your contempt should be directed at those who abuse the ER and staff on sometimes a daily basis. (ANd if they are not in my ER they are in the one across town) I have been jumped in the parking lot by someone who somehow "lost" or "spilled" his percocet prescription three days in a row. And yes, it hurt very much.
For these people I say: methadone clinic.
Those with chronic pain should visit the ER infrequently. Like Scalpel says, briefly tell me your story, let me do an appropriate exam and I gladly want to give you want you want, make you feel better, and get you home. I usually tell the nurse to give 2mg of dilaudid, then 1mg every 15-20 minutes until they say they are feeling better and want to go home. (or stop breathing, whichever comes first)
With 20 other ill people I am caring for, I don't have time to listen and psychoanalyze some long tale of woe detailing your chronic pain. The ER is not the place for it.
A curious thing is that many with CP seem to relish the role of being a professional patient. Somehow it fills some void in their life and makes them the focus of attention of family and the medical establishment. They often bring in notebooks of medical records and proudly display lists of tests, procedures, diagnosis like it some kind of hobby. NO, I am not generalizing that observation to everyone, nor to you, lest we endure another diatribe.
“I have read your comments here and on Kevin MD. You make many valid points. People do have CP. Narcotics are safe for CP. Nsaids and other drugs are probably overused.
However you really overgeneralize in your rants, the same thing you accuse the medical profession of.
...I have been jumped in the parking lot by someone who somehow "lost" or "spilled" his percocet prescription three days in a row. And yes, it hurt very much.”
I’m curious why you think I’m overgeneralizing. I never denied that people can and do receive appropriate care for pain, even in ERs, and specifically stated the contrary in at least one of my “rants” or “diatribes.” I am merely pointing out the simple, indisputable fact that there is an enormous amount of hostility and bigotry in the medical profession as a whole towards people in pain—hostility and bigotry that is well evidenced in these medical blogs—and that this can and does result in people being denied treatment, and causes an enormous amount of physical and psychological damage to patients who are treated this way. I personally know people who have comitted suicide after being abused by doctors and denied treatment, and there is nothing I can say here, no matter how extreme or inflammatory, that can even begin to compare to the sheer horror of another human being being forced to kill himself as his only means of escaping pain. If you find my rants offensive, just try to imagine for a moment how offensive it must have been to have to blow the top of your head off with a pistol to escape pain.
As I said to Scalpel, if you can’t stand my attitude don’t ever try chronic pain on for size, because I think you’ll find it a wee bit harder to bear than anything I can say, though I realize a good swift kick in the ego can be as painful to a certain class of doctor as a kick in the cojones is to anyone else.
Now, you can venture any excuse you like for abusive behavior by doctors, whether it be attacks by violent drug seekers, the DEA, the full moon, or whiny chronic pain patients with overlong tales of woe. But at the end of the day, there is such a thing as personal responsibility, and you are directly and solely responsible for how you treat people in pain, and there is no excuse whatsover for people being treated like this. To treat sick people like criminals is both sick and criminal.
You ask that my contempt be directed at those who abuse ER staff on a daily basis. I have heard and accepted the horror stories by doctors of abuse by patients, and I am aware that doctors have been assaulted and even killed by angry patients. While there is rarely an excuse for violence, and I am not trying to blame the victim here, it also must be said that some doctors have a way of talking to people in pain that would send a saint over the edge. If you find yourself being abused more frequently than the norm, you might want to check your conversational style. You know, the same advice you always give to cpers, but in reverse.
Scalpel says you should never piss off your doctor, your barber, or your cook, and that’s certainly good advice. But if he can’t tell the difference between these three professions and the relative degree of moral and professional forebearance that is demanded by each, then perhaps he is in the wrong business. In other words, the moral responsibility you have to your customers is vastly greater than that of a cook or a barber, and sometimes you just have to be prepared to put up with just a little more crap than they do, while hopefully dealing out a lot less than they do, which unfortunately is rarely the case on either count. This doesn’t mean you should have to tolerate abuse or assaults, but that you need to understand that sometimes people who are in severe distress are going to act up from time to time, and you have a moral and fiduciary responsibility to remain calm and professional.
Blacklisting patients in an attempt to sabotage their medical care because they pissed you off is a severe form of malicious libel and medical assault and is as contemptible as attacking a doctor in the parking lot and should be equally prosecuted as a criminal offense.
As for your statement about cpers being professional patients, that is just plain silly, though no comment by a doctor about cpers would be complete without at least one not-so-subtle dig at the character of cpers. One minute, you have doctors like Scalpel saying that he is reluctant to treat pain in patients that have no objective evidence of organic disease, and he tends to see such patients as having primarily psychogenic problems. Then when a cper responds to this reality by bringing in a file cabinet worth of documents in an apparently vain attempt to demonstrate to you that he does in fact have objective evidence and his pain is real, you accuse him of taking some kind of perverse pride in his illness. Lighten up, take an extra Valium before you start your shift, and stop making mountains out of molehills. If your patient brings in extra documentation, consider yourself better informed to deal with his problem and leave it at that.
"The moral responsibility you have to your customers is vastly greater than that of a cook or a barber, and sometimes you just have to be prepared to put up with just a little more crap than they do...you need to understand that sometimes people who are in severe distress are going to act up from time to time"
I disagree. We all have the same moral responsibilities towards each other. You seem to suggest that the moral responsibility of a patient who is in pain is less than that of anybody else. I couldn't disagree more. Just because someone is in pain doesn't give them the moral authority to be rude to anyone or to disturb the peace in the ER, (such as it is). In practice we tend to cut them a little slack, up to a point, because we're calm, caring professionals.
After that point, I'll remain very calm and professional as I have them escorted off the premises with a recommendation to take the Extra Strength Tylenol.
There is no moral or legal requirement for physicians to administer or prescribe narcotics to patients who repeatedly present to the ER, even for visible reasons like dental caries. We certainly aren't obligated to give narcs for clinically subjective conditions like fibromyalgia or migraines.
I personally don't blacklist drug-seeking patients if they "piss me off." Only when they lie to me in an attempt to obtain narcotics. Good luck prosecuting that. If they piss me off, they may just leave empty-handed, but they will still get a bill.
I'd rather patients bring medical documents than not, but only the pertinent ones like MRI reports or discharge summaries. I don't want to flip through pages and pages of normal lab tests.
RH,
You have some valid points on a very complex hard topic. You will never understand my side because you have never experienced it, and vice versa. Every case is unique and different to a degree. You have way more time on your hands than me to talk about it so good luck. Sincerely.
Regarding chronic pain, pain clinics, pain contracts and ER's, every pain contract I have ever seen specifically prohibits seeking any pain treatment from any other provider, including ER's. When visiting an ER for a genuine emergency, the patient is supposed to inform the ER that he/she is under a pain contract and is not to be given pain medicine without the approval of the pain specialist. Violation of this provision generally means no more treatment by the pain specialist.
Redhawk, I think you do have to try and see it from the doctor's point of view, too. Several years ago I had a friend drive me to the ER. I was in a lot of pain from a kidney infection (that I hadn't taken care of as I should have). All the ER doc knew was that I was a young woman presenting with back pain, and I took an antidepressant on top of that. Now if we all stop for a minute and think about how that looks, then I think we can all agree that that looks a little suspicious. The ER doc had no history on me. In all fairness, what was he supposed to think? I remember the doctor grilling me about recreational drug use (I've never even smoked a cigarette and I don't drink either but he didn't know that), and then he said, "I'll give you something for pain but if you're taking something else you better tell me now." Now, I guess I could be angry that he was skeptical, but I was too sick to care. I'm sure they did a drug screen on me, too - but you can you really blame them? How many drug addicts show up at the ER and say yes, you're right I'm an addict now can I have some drugs? Is it fair to those of us that are telling the truth? Maybe not, but he was most likely concerned about overdosing me or feeding an addiction. For all he knew I could be taking a lot of crap at home. And unfortunately a lot of people are.
If you're really sick and in trouble, you just won't have the energy to argue. I didn't even think about arguing, I was having enough trouble just holding up my head. Luckily I did end up giving them some objective data like lab results full of bacteria, and a fever that shot up to 105, but at the time the doc was contemplating whether or not to give me something for back pain he didn't yet have the lab results and really didn't have too much to go on except my word. Also, understand that docs get in trouble with the state board, they can be sued, and can lose their license for giving drug addicts their fix. There are a lot of drug seekers out there, and the anger should be directed at them.
I ended up being admitted for several days and have no complaints about how I was treated. Docs do the best they can with the information that they have.
Left unsaid in this discussion is the fact that many of these drug-seekers we scorn are not just people in pain wanting some relief. Often they are selling their medications on the street.
We are entrusted with the responsibility to be cautious to whom we prescribe these dangerous drugs. A couple of vicodin or valium might not seem like much to the seasoned chronic pain patient, but to your 15 year old daughter who is out with her friends on Friday night, they can be life-shattering.
As a chronic pain/illness patient and frequent flyer in the ER (rarely for pain), I wanted to mention one thing. I carry lists of my medications and medical conditions. Not because I'm "proud" of them or enjoy doing so, but because it's not practical to expect myself to remember and accurately dictate, probably multiple times, such information to the nurses and doctors in an ER. Being able to hand over a list detailing what medications I'm on and what medical conditions I have saves time (given the length of both lists) and reduces errors on my part and on the part of whomever is taking down my history.
Scalpel, I love your pain scale. It's true that pain is subjective, but there is a common body language when people are in real pain. I worked in a pain management clinic for a year (everyone's pain was 10/10 all day, every day - you think you have it bad in the ED), and in the ER for a year, and I learned how to interpret pain from the same signs you describe. Bravo!
Nice work on the pain scale. I recently had to call in the Department of Weights and Measures to get mine straightened out.
Scalpel, I hope you'll forgive me commenting more than a year after the original post.
As a total medical layman, and a lifelong migraine sufferer, I'd like to respond to Redhawk as to why he's just flat wrong concerning nearly everything he's saying -
The emergency room is for three things:
1. You are dying.
(As a "chronic pain" sufferer you are not dying. It sucks, but you’re not going to die tonight, regardless of how much pain you're in.)
2. You aren't dying but if you don't get treated now your problem will become much worse. IE, that broken arm probably won't *kill* you, but let's not let it dangle.
(You, as a "chronic pain" sufferer, will not exacerbate your problem in the slightest by waiting for your physician's regular office hours, given that the condition is chronic and not degenerative.)
3. You are bleeding profusely, unconscious, the bone is showing, or you have objectively observable symptoms of something that is likely to kill you (see #1).
(As a “chronic pain” patient, you most likely have no objective symptoms whatsoever, and the doctors have to go solely on your request to be drugged up for apparently… nothing.)
What you are doing, when you show up with your lists of tests and meds and subjective non-emergency symptoms is wasting everybody’s time and money. You’re taking time away from people like me, who will not go in to the ER unless we’re carrying our arm in an ice chest and will still rate our pain a “5” and ask for a Tylenol. In all fairness I feel exactly the same way about people who come in with colds.
I am indeed angry at pretention and arrogant abuse of the ER to satisfy someone’s drug habit or need for dramatic validation. Full disclosure, I put “chronic pain” in fear quotes for a reason, and if you have time to whine about how you’re not being treated well… it doesn’t hurt that bad.
I'm an RN and sometimes I feel like my current problems are karma from when I would classify patients as drug seeking and not treat their pain as fast as I could have - you know, make them wait until I get done charting or someone else complains and wants a prn too. That sort of thing.
Now I have really screwed up nerves myself. I hope that other medical professionals realize that a few of us can experience severe pain when nothing is really WRONG.
The nerves in my feet are so screwy. I have very extensive nerve damage. Who knows why? Wasn't treated for pain that I had for the year it took the insurance company to approve my nerve tests. Only when they came back really messed up was I finally offered decent pain control. (Tramadol)
Well my son runs over my toes with a chair yesterday. I'd been having a great day - we all were.
I look down at my toes, they are fine. Then it hit me - like they'd just been cut off. And it ramps up, you know, not DOWN like pain is supposed to - like what would happen if I say, hit my thumb with a hammer. Instead of a sharp spike and a slow settling down, I get spike after spike of pain that only goes up, for a very long time - Well I just start screaming bloody murder. OMG I was telling myself "It is ok, it is ok, it isn't hurt, it is just your nerves screaming." I really worked very hard to try to control it, but I was like a woman in labor doing natural childbirth and she gets to the point where she's like 'give me morphine or I'll kill you!" It really was - so stupid but it was - worse than childbirth after about a couple of minutes. Well, I have never done this before - ever, but I hyperventilated to the extreme and I was shivering and I was just out of my head. I lost it. Just totally lost it. My husband got me a bag and got me to breathing ok. Iced my foot down and put some blankets on me. I wasn't even half aware he'd come in from outside. My poor son, he just felt so awful about it and I was so GD embarrassed. Really I just wanted to die from embarrassment. To be honest, I think I did pee on myself some.
I really do not understand it. I know it, but I do not understand it. I have to call my doctor Monday and tell him this happened to me outside of the last time I had surgery. The anesthesiologist said it was b/c I had something called central sensitization. I don't know, I just remember the nurses said they were scared they were going to kill me and it took a team of 3 anathesiologists to get me ok - they finally had to just pump IV diluadid to me. I had even had nerve blocks and they ended up giving me another one.
How I could have the same reaction to someone just running over that foot I don't know. I was telling myself the whole time, relax, it is ok, it is ok, it isn't cut, my toes are fine - but no amount of self talk really helped.
This is a very interesting post. I find most ER blogs quite entertaining, and I cannot understand the "chronic pain" people. I will say I abused the ER once because I thought I was having a migraine. My head was throbbing, light sensitivity and vomitting...the whole bit. I was scared and I just didn't want to keep up with the pain after taking Excedrin. My BP and pulse were elevated so I didn't have to wait very long for my IV fluids, fentanyl and phenergan. Within an hour of the meds and two liters of fluid, I was almost good to go. Everyone was perfectly respectful despite not having a compound fracture or life threatening injury. The nurse didn't ask me my pain rating until I had already had a round of meds. They were even respectful when I told them I was on Effexor, Klonopin and just weaned off Abilify. I was obviously a bit of a nutjob and I received no hint of annoyance from the staff. They did do a CT scan once my pulse came down, I'm sure to avoid any risk of litigation. It was my first time there, but everyone was perfectly nice and even sympathetic. I can't imagine what these people are doing to garner such bad attitudes from medical staff.
And I'll also add since being off all the drugs for six months and taking care to get 8 hours of sleep, I haven't had a headache at all. The pain was real at the time, but I can guarantee you anxiety was an underlying factor even though weaning off those bad boys is nothing to take lightly. I was a mess. Too bad there's no subtle way to suggest a psych consult from a patient who "suffers" from CFS or Fibro without the patient throwing a tantrum.
A VERY late comment, but...
'Migraines' can kill you. No, not every migraine. No, not just status migrainous. How about a recently thrombosed basilar artery aneurysm, invisible on CT, but plain as day on MRI? HMMMM. Guess what? EVERY time my head pain goes past the point of no return, or I have bizarre neuro symptoms, I WILL go to the ER. Period. Should I carry my MRI films in with me, doc?
As a patient who is not a health care provider, this past year I had an ER trip (ankle fracture) and I was asked in the ambulance how to rate my pain. I'm not sure how the ambulance staff described a 1 or a 10 at the time. I was in a lot of pain at the time. In the moment I thought a 10 would have to be getting tortured (literally tortured -- not the metaphoric kind) or seeing your kid be tortured. I'd be slow to give myself a 10 and I think I would have to yell out that 10 if I had it.
I gave myself an 8 by the way. Got an IV and soon I was at 6 which I figure means 60% on the way to being tortured. (It is not a ratio scale but there we are.)
6 was a relief.
The ambulance attendant was irksome though. On hearing my 8 she asked if I'd ever given childbirth. I figure, look, work out your memories childbirth or otherwise with your therapist [or post on a blog or something, ha ha] because I'm here on business. I felt like asking her if she'd ever watched her kid die. Well if not she doesn't know real pain then. Have I ever had childbirth, she asked me. I wasn't amused.
Sorry for rant.
Too bad there's no subtle way to suggest a psych consult from a patient who "suffers" from CFS or Fibro without the patient throwing a tantrum.
Well, at least pretending to respect the patient often helps.
When I had my first episode of kidney stone pain I was taken to hospital by my girlfriend. I was doubled up and screaming in pain. The ER moved fast and got me seen to. Within 30 mins I was nice and quiet.
You are right when you say that if someone is obviously in pain you get them sorted as quickly as possible.
By the way, I had a 5mm kidney stone on its way down to my bladder.
Thank god for fast acting pain meds.
Although I doubt anyone but Scalpel will ever read this because of my lateness, I feel it relevant.
First my sympathy to chronic pain sufferers, ER docs, and PM docs alike. Pain sucks, whether it be physical or figurative. I'll even offer A LITTLE sympathy to addicts. Chronic disorders, even self-inflicted, are tough to live with, but at least theirs can be eliminated. I don't (hydro)condone it, and they should get help. Perhaps you could write them a scrip for a psych eval or NA meetings in that stereotyped doctor's handwriting to avoid tantrums in your ER? Cause if a pharmacist tells em to get help and they throw a fit, said RPH will have no reservations to call a cop. After all, they came for a piece of paper, not help.
All perspectives here are subjective, even those of an ER doctor suffering chronic pain.
Scalpel, great pain scale observation. I agree you should develop it to your standards and publish it. As a CP veteran I finally feel like I have a more objective understanding of a confusing question that I've been told to answer 2-3 times a week in journaling. Even though I was treated unfairly during my only ER visit in my nine year chronic pain history, I'm not a believer that the exception proves the rule, as Redhawk likely is (perhaps jaded by a limited experience or number of experiences with, quite possibly, competent and compassionate professionals that gave him an opinion he didn't want to hear based on his hostility. If he replies to this post five years later, RH doesn't need an RPH as much as a Psy. D). I have to agree also he clearly has too much time on his hands, posting on two forums to this extent. However I have to disagree regarding CP "hobbyists" (I know Scalpel didn't submit that post). I'm sure they exist (and are most likely drug seekers), but with little pain. In my experience there is nothing wrong with having extensive knowledge about something that affects one's life as much as CP has mine. In fact it's pretty helpful, when you sustain an injury in the first thirty years of your life and your PM doc retires, to know as much as I do about chronic pain. It makes that transition less frightening for a patient suffering such a controversial and oft misdiagnosed disability. As for assaulting a doc that must've written a scrip twice for an impatient to come back for a third fix, once is a mistake, twice a coincidence perhaps, but three times he's after your license. He exudes psychopathic and/or abusive behavior. I hope his criminal record was added to for this incident.
My only original opinion is that a ten should indicate worst pain possible, which I think would cause someone to faint, but I guess that would make over a 9 paradoxical, although I'm sure you get 9.5's frequently.
Anyhow, clearly I too have ample time on my hands so I'll close my rant by saying thanks for the perspective on the pain scale.
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