Scalpel's Pain Assessment Scale

[group_theory]

One of the blogs I recently encountered (titled "Scalpel or Sword") maintained by an EM physicain in Texas has this little blog with his version of the pain scale.

It looks promising ... certainly better than waking patients up from their sleep to re-assess their pain after 4 of dilaudid and to hear "yeah, it's still a 13 out of 10"

http://scalpelorsword.blogspot.com/2007/02/objective-pain-scale.html

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

What do you think of this? How can it be improved or modified?

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[SouthSideSteve]

certainly better than waking patients up from their sleep to re-assess their pain after 4 of dilaudid

why would you wake someone up to assess their pain? If they are sleeping they get a 0/10 from me. In a situation like that the objective speaks louder than the subjective. I've had people wake up and say its a 10/10. Sorry but if you're able to sleep I'm calling BS.

 

[docB]

It's good. It gives a 4 to the people who have no visible discomfort and nl vitals yet claim severe pain. That is the crowd who we need a better tool for.

 

[GeneralVeers]

That scale mirrors my own system. I never base the pain score based upon what the triage nurse says, but base it on my conversation with the patient and physical exam. I never ask patients "how do you rate it on a scale of 1-10".

Unfortunately with evil organizations like JAHCO mandating arbitrary asssessment of pain, and control of pain, we will never be able to get around it.

 

[emtp6811]

I still ask for their pain scale, but I certainly document the heck out of my objective assessment of their pain pretty much as stated in the OP. This way, I feel it covers my @$$ a bit better when I decide to treat or not treat a certain way.

 

[Febrifuge]

I like it. As others have said, moving from subjective to objective is (or should be) the goal. I think it's still a little arbitrary (why does 'abnormal vital signs' start at 7 rather than 6, or 8; does a little elevation in BP count as 'abnormal,' how much leeway do you give 2-4 if the patient doesn't use those particular words), but overall it's good to attempt a scale based on what is observable.

Our RNs usually explain the scale as zero being no pain, and ten being "the worst pain you can imagine" or, more interestingly, "the worse pain you've ever felt." I find it informative to ask people what that personal "worst pain ever" actually was. Funny, how women who have given birth tend not to assign a 10 very often...

EDIT TO ADD: There are some interesting comments on the blog page linked by the OP. I like the idea that true 10/10 pain would probably make it impossible for the person to say the word "ten."

 

[DropkickMurphy]

Funny, how women who have given birth tend not to assign a 10 very often...

Nor does this guy who has passed a kidney stone large enough to make an urologist gasp. That ranked a 9 on the "scalpel scale" and in comparison on a 1-10 scale, a broken femur (which I've had) is a 4.

 

[Febrifuge]

Yeah, but on the 1-to-10 scale, it not only depends on the fracture, it depends on whose femur it is. This "Scalpel" dude is not claiming the scale is definitive; it's for the roomful of people at Triage who all say they have pain somewhere between 8 and 15 on a 10-point scale. In that setting, it's a good way to sort it out and decide who gets seen first.

 

[deleted77919]

Nor does this guy who has passed a kidney stone large enough to make an urologist gasp. That ranked a 9 on the "scalpel scale" and in comparison on a 1-10 scale, a broken femur (which I've had) is a 4.

You managed to walk without a limp with a broken femur? And "appeared comfortable"?

Wouldn't that push it to at least a 5 on the scalpel scale?

Even the 1-10 scales normally employed have 5 as "distressing pain." I would be distressed.

 

[paramed2premed]

Just a couple points (citations available on request - kinda doubt anyone will take me up on it!)

- In almost any study where they compare physician (or RN or parent) pain assessments with a pt's reports of pain, there has always been a serious discrepency. provider just aren't good at gauging a patient's desire for analgesia.

- Despite the widespread belief that pain and vital signs are well-correlated, there are a number of studies showing that such a connection is not significant.

Sorry if I sound preachy - don't mean too. I've gone over the literature in this area for a few projects, and I find it interesting stuff.

Too be sure, I think we've all had to wake up a patient to hear their pain is still an "11/10," but I don't think any of the pain-relief studies used "drug-seeking dirtbags" as their inclusion criteria, and "people with a real injury" as an exclusion.

One of the blogs I recently encountered (titled "Scalpel or Sword") maintained by an EM physicain in Texas has this little blog with his version of the pain scale.

It looks promising ... certainly better than waking patients up from their sleep to re-assess their pain after 4 of dilaudid and to hear "yeah, it's still a 13 out of 10"

http://scalpelorsword.blogspot.com/2007/02/objective-pain-scale.html

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

What do you think of this? How can it be improved or modified?

 

[gutonc]

I usually use the following to get a reasonable pain scale out of patients.

"Rate your pain on a scale of 0-10 where 0 is no pain, 5 is I just took out your appendix using Tylenol as the only pain reliever and 10 is I just chopped your arm off."

This has worked fairly well for me except for the (fortunately for me, completely demented) guy who had a traumatic Korean War hand amputation who I asked this question to without thinking. He noted his (septic hip) pain to be a 4.

Keep in mind that the various pain scales have been validated for longitudinal evaluation in a particular patient but not for comparisons between patients.

One person's (usually a middle-aged woman who has had 3 kids and is presenting w/ a perf'd appy) 4 is another person's (usually a 20 year old gang-banger presenting w/ an ankle sprain) 12.

I've always been amazed by the guys who can lay there quietly oozing from a through-and-through 9mm leg wound but hit the damn ceiling when you put in a 22g IV on the first stick.

 

[GeneralVeers]

I've always been amazed by the guys who can lay there quietly oozing from a through-and-through 9mm leg wound but hit the damn ceiling when you put in a 22g IV on the first stick.

For me, the 40+ yo hispanic females are the enemy. Anything from emotional upset to a paper-cut to a heart attack causes 10/10 pain radiating over the entire body. I had 3-4 of these regular patients at King who used to get admitted every time despite a negative workup.

 

[Jeff698]

Unfortunately with evil organizations like JAHCO mandating arbitrary asssessment of pain, and control of pain, we will never be able to get around it.

Yeah, but just remember, if we really cared all that much about what JCAH thought, we wouldn't be eating or drinking in patient care areas, ie most of the ER. I suspect we all know how well that works.

Pain is the 5th vital sign my ass.

Of course, if we'd just put a big bowel of Vicodin 'scripts in the waiting room, we'd never have to hear 10/10 again from people who have to put down their cell phone to whine.

Take care,
Jeff

 

[FISKUS]

Written by the brilliant Dr Edwin Leap:

THE LEAP NON-SEVERITY SCALE

PROFANITY
• 3 – UNABLE SPEAK PROFANITY OR MAKE PROFANE GESTURES
• 2- SLURS PROFANITY, EXPOSES GENITALIA OR MAKES CONFUSING LEWD GESTURES
• 1 – SPEAKS PROFANITY CLEARLY BUT WITH POOR SENTENCE STRUCTURE. RECOGNIZABLE BUT NOT VERY INTERESTING
• 0 – PROFANITY FLOWS LIKE POETRY. SUGGESTS PHYSICAL ACTS NEITHER LEGAL OR EVEN POSSIBLE. ELABORATE GESTURES

SMOKING
• 3 – UNABLE TO SMOKE UNLESS ACTUALLY ON FIRE
• 2 – ASKS FOR CIGARETTE BUT REALIZES THAT HE CANNOT HOLD CIGARETTE OR INHALE SMOKE
• 1 – SMOKES IN ROOM, WITH HIGH FLOW OXYGEN ON
• 0 – WANDERS PARKING LOT STILL PARTIALLY ATTACHED TO BACKBOARD, ASKING EVERYONE FOR A CIGARETTE

VIOLENCE
• 3 – SO ILL OR IMPAIRED THAT BEHAVIOR CAN BE CONTROLLED WITHOUT HALDOL
• 2 – THREATENS STAFF WITH DEATH BUT CANT ACTUALLY MOVE DUE TO PAIN OR DISABILITY
• 1 – POINTS TO EACH STAFF MEMBER AND SAYS “ I KNOW WHERE YOU LIVE AND I’LL KILL YOU” AS POLICE HOLD HIM DOWN
• 0 – ACTUALLY ATTACKS STAFF MEMBER

SCORING
0-3 CAN BE DISCHARGED TO HOME OR JAIL WITHOUT ACTUALLY BEING EXAMINED
4-6 PROBABLY WILL REQUIRE EVALUATION ALTHOUGH ODDS OF DYING ARE RELATIVELY LOW
6-9 MOST LIKELY HAS REAL INJURY OR ILLNESS BUT REQUIRES DILIGENT RE-EVALUATION SO THAT THE PATIENT CAN BE DOWNGRADED AS HE IMPROVES OR BECOMES INCREASINGLY ANNOYING

 

[DropkickMurphy]

You managed to walk without a limp with a broken femur? And "appeared comfortable"?

Wouldn't that push it to at least a 5 on the scalpel scale?

Even the 1-10 scales normally employed have 5 as "distressing pain." I would be distressed.

No, on the normal "1 is minor pain, 10 is the most excruciating pain ever" scale.....

 

[DropkickMurphy]

WANDERS PARKING LOT STILL PARTIALLY ATTACHED TO BACKBOARD, ASKING EVERYONE FOR A CIGARETTE

 

[deleted77919]

No, on the normal "1 is minor pain, 10 is the most excruciating pain ever" scale.....

Ok, misread on my part then.

Or maybe dropkickmurphy is just the type who "WANDERS PARKING LOT STILL PARTIALLY ATTACHED TO BACKBOARD, ASKING EVERYONE FOR A CIGARETTE" after having one leg sawed off with a rusty spoon. I can respect that man.

 

[DropkickMurphy]

Ok, misread on my part then.

Or maybe dropkickmurphy is just the type who "WANDERS PARKING LOT STILL PARTIALLY ATTACHED TO BACKBOARD, ASKING EVERYONE FOR A CIGARETTE" after having one leg sawed off with a rusty spoon. I can respect that man.

Nah, I have a pretty high pain tolerance (kidney stone pain notwithstanding), but I don't smoke.

 

[Jeff698]

THE LEAP NON-SEVERITY SCALE

Damn that Dr. Leap. He made me spew my morning coffee all over my laptop when I read this.

Take care,
Jeff

 

[The White Coat Investor]

For me, the 40+ yo hispanic females are the enemy. Anything from emotional upset to a paper-cut to a heart attack causes 10/10 pain radiating over the entire body. I had 3-4 of these regular patients at King who used to get admitted every time despite a negative workup.

Status Hispanicus strikes again! "Ay ay ay ay ay ay ay"

 

[LovingItAll]

Objectifying the pain scale defeats the purpose. Its *supposed* to be subjective, and its real value is the relative change following intervention. If the patient initially said "x/10" and its still x/10 or x-1/10, then I'm going to reassess and modify treatment. I want them to say 0/10 or 1/10 or "its much better"

 

[Febrifuge]

- In almost any study where they compare physician (or RN or parent) pain assessments with a pt's reports of pain, there has always been a serious discrepency. provider just aren't good at gauging a patient's desire for analgesia.

Ah; I think I may have read some of the same papers. I too am a little interested in the subject. But hold the phone; your conclusion there is based on the assumption that the patient's assessment is "accurate" and the provider's, being divergent, is therefore "inaccurate." I don't think there's anything in the research that can allow us to take that last step. Point well-taken, though...

Finally, everybody knows that the "fifth vital sign" is breath ETOH level.

 

[group_theory]

Does anyone actually treat pain truly as the "fifth vital sign"

imagine a case presentation

"This is a 35 year old white female present with chief complaint of right lower quadrant pain ..."

and vitals are "BP normal, HR normal, RR 20 (of course), temp 98.6 (37), and pain 15/10"


And why can't we document both the subjective and objective pain scale

"Subjective pain scale: 10/10"
"Objective pain scale: ~ 2/10 watching TV in NAD, asking nurse for a sandwich"

 

[FISKUS]

My Jewish grandmother , during times of stress or pain, would often go into oy tach.

OY! OY! OY! OY! OY!

 

[DropkickMurphy]

My Jewish grandmother , during times of stress or pain, would often go into oy tach.

OY! OY! OY! OY! OY!

Ah....the Jewish version of the tachylordy syndrome we see in black women ("Lordy! Lordy! Lordy!" at a rate >100/min )

 

[emtp6811]

...if we'd just put a big bowel of Vicodin 'scripts in the waiting room...

...then I'd never want to take Vicodin ever again for anything, I tell you that!

 

[AmoryBlaine]

Nor does this guy who has passed a kidney stone large enough to make an urologist gasp. That ranked a 9 on the "scalpel scale" and in comparison on a 1-10 scale, a broken femur (which I've had) is a 4.

Agreed, it seems almost as subjective as the old model. It seems to me perfectly plausible that your pain receptors could be basically maxed out and you wouldn't have unstable vital signs except for *maybe* a bit of tachycardia. Am I wrong here?

 

[AmoryBlaine]

For me, the 40+ yo hispanic females are the enemy. Anything from emotional upset to a paper-cut to a heart attack causes 10/10 pain radiating over the entire body. I had 3-4 of these regular patients at King who used to get admitted every time despite a negative workup.

I started using my patented "wrist & ear test." If you are getting a totally +ROS from a middle aged Hispanic lady just say, "y te duelen la muneca y los oidos tambien?"

If the answer is "si!" I stop listening.

 

[docB]

I started using my patented "wrist & ear test." If you are getting a totally +ROS from a middle aged Hispanic lady just say, "y te duelen la muneca y los oidos tambien?"

If the answer is "si!" I stop listening.

I do a similar thing and ask if their hair and townails hurt. On a related note I almost always ask some throwaway question while I palpate the abdomen. No one ever understands the difference between does it hurt when I push and does it hurt here.

 

[Jeff698]

Mine is "do you're teeth itch"?

Take care,
Jeff