Saturday, March 17, 2007

Arithmetic and English 101 for My Patients


Someone with too much grant money and too much time decided many years ago that simply asking a patient about the amount of pain they were in and sprinkling in a good dose of clinical judgement was not good enough. After years of research various pain scales were born; the "visual analog" or "one to ten" scale being the ones most commonly used in the ED. Most ED docs love these scales and use them at every opportunity (as long as we have picked all the lint out of our belly-buttons).

Wikipedia has a nice little blurb on these scales which can be seen by clicking the above title. One of the things that all these pain scales have in common is a complete lack of objectivity and reproducibility between patients. Here's where the math comes in and stay close 'cuz I'm about to throw some mad knowledge your way.

It is impossible to have "1,000,000 out of 10" pain just as it is impossible to have 12 out of 10 pain etc... It fires every passive-aggressive neuron in my very male brain when I have to wake you up from your substance-induced slumber only to have you tell me that you, at that very moment, are having "12 out of 10 pain". "Yes", you say in response to my question, pain that is every bit as intense as if I were, at that very moment, sawing your leg off with a chainsaw (as seen in Scarface which is the usual example I give someone to illustrate something that might approach "10 out of 10 pain").

When you tell an ER doc or nurse that you have "20 out of 10" pain you are not impressing anyone. If you had "9 out of ten" pain you would be crying, probably vomiting, and barely able to speak. If your demeanor, facial expressions, vital signs, level of alertness, and story do not add up to even two then you will be immediately relegated to the "not sick bullshit pile" and treated with all the urgency demanded by your presentation.

If I'm feeling frisky I might decide to play possum with you where I say "screw my patient statistics, I'm keeping this jerk here until he gets tired of getting a different non-narcotic medicine every hour for his "pain" and signs out AMA."

English 101:

Now we all know what you mean when you do this. What you are engaging in is called "hyperbole". defines it as follows; "Obvious and intentional exaggeration."

I have seen "9 out of 10 pain". You can't fake it. Hell, you can't fake "7 out of 10", so give me a break, act a little bit, put on a frown, and settle on, say, four. As the best English teacher I ever had used to say, "Demonstrate, do not assert."


  1. Amen. One of my biggest pet peeves there. More and more the government is taking away the right to practice our clinical skills, someday I expect we will be replaced with chimps that can type.

  2. you're fucking awesome. props from a medic in nebraska.


  3. I went to our local ER last year when I had a kidney stone. I thought I was dying. The doctor asked me what my pain level was. I said 10. He gave me Tordol, and the stone passed. He came back later and asked me what my pain level was. I said 0, and asked him if I was able to go to work in two hours. He was dumfounded. Now I know why he was so surprised after reading your post. I guess it rare when people aren’t trying to pump you for more drugs.


  4. Yep, gotta agree with ya. But what REALLY used to crack me up in the ER was when the patient would fractionalize the pain scale and get all "detailed" on me. "Oh, it's about 5 3/4 right now, nurse" and then later they'd say something like "Well, now it's about 9-ish, give or take..."

    In my head I would be entertaining sarcastic, "detailed", responses such as "Ok, so now it's more like the pain level similar to the pain of a murderer sawing your arm off with a sharp knife-- versus before when it felt like he was using a blunt knife?...

  5. I find than a ball peen hammer to the great toe works. What I do is I smash their toe, then I say what WAS your pain level before I completly smashed you toe. The difference in that level and what they said in triage is usually 8-9 points. Or it goes from a sad face to a happy face.

  6. Dear Mother Jones,
    A kidney stone counts. If not a ten you were close. God bless you.

  7. Dear Bohemian Road Nurse. I do remember a few "statistician patients" like you describe. That kind of answer only short-circuits my brain.

  8. OH MY GOD!! YOU NAILED IT!!! I would love to print and attach that to my triage room so before the next time immature trashy gal comes in laughing and talking on her cell phone (while preparing to rate her pain a 12 out of 10) so she can get a pregnancy test and maybe an ultrasound if its positive-which it will be again....she can read it and perhaps get a clue! Sorry, I know, long rant, they will never get it!

  9. This sort of nonsense happens in day to day outpatient practice as well. I often have women (sigh, it's almost ALWAYS women) tell me about their "sinus pain" in grandiose and florid terms such a: "It's like a an ice pick in my eye." (with a very bland affect)

    REALLY?? I respond. So you've actually HAD an ice pick in the eye sometime in the past that permits you to describe this pain in such accurate terms???

    They usually calm down after a little well-placed sarcasm and begin to describe their complaint in more reasonable terms. (then they file a consumer complaint)

  10. Guilty as charged!

    Almost 3 years ago, I had the experience of having a 6mm stone stuck in my distal ureter, complete with vomiting,back and pelvic pressure, flank pain, etc.,etc and so that was my 10.

    I had a very painfully uncomfortable experience post-op this past December. I had just had another ureteral stent placed in me. I told the nurses I had to urinate and they said I was just spasming post procedure. I have been through this before and knew I needed to go. They did put me on the bed pan and I couldn't go, but I knew I had to and felt that if I could just get up that I would - but they said no.

    Feeling was intensifying and one of the nurses wanted me to relax. I wasn't hysterical but just tried to tell them I was feeling worse. Then, I asked for a foley cath and the nurse said "Oh - you don't want that.", but I did.

    A few minutes later, I nicely tried to tell them I really had to go and the nurse more assertively told me to calm down. So, I got very quiet and suffered in silence.

    At the point that tears were streaming down the sides of my face my urologist came in - (thank God!), saw me and asked me what was going on. I told him. he asked me if I wanted a foley and I hesitated because of what the nurse said (I never told him) and then I said yes. He put the foley in and in a short amount of time,I put out 1000 cc's and one of the nurses said "Oh - you DID have to go!"

    A week later I told my Doc and I told him the pain was a 12! I did it for emphasis, but now after reading this post - I know not to do that.

    Was the pain 10 worthy? 9 worthy? It was different pain. I wasn't vomiting or even writhing. I was crying, hurting and afraid - very afraid because I knew something was wrong and they weren't listening to me and the pain was exacerbating. I don't know what I would've done if my Doc didn't come in when he did.

    I hope I never have a next time, but if I do - I don't think I am going to be so polite, trying to be the good little patient, but I will be careful not to state that my pain level is more than a 10. :)

  11. kidney stones, if not "ten worthy" are certainly close. they are, without a doubt, one of the most painful things around. from women who have given birth AND had kidney stones, most say the stones were worse. here's hoping you do not have any more.

  12. Thank you.

    Yes - the kidney stone is 10 worthy.

    I was questioning the extremely full and spasming bladder pain - whether or not that was 10 or 9 worthy?

    It was so different, yet painful.

    I have been in labor with the simultaneous back pain that never lets up even after the contraction subsides and I think the kidney stone was worse because of the nonstop vomiting - which also was exacerbated by the morphine or dilauded - whatever the drug du jour was.

    No more stones - amen to that! :)

  13. I hate that stupid scale.
    I had a 10 out of 10 once. There is no describing that pain, no words exist for it. The problem is when your personal 10 is so damn bad you were actively looking for a way to kill yourself to make it stop how do you rate any pain after that?

    Any pain is never going to exceed a 1.
    Because just thinking about half that pain? A five on the pain scale? Well that would be awful, terrible pain.
    My problem now is even really bad pain can never, ever, compare to that ten out of ten.
    I guess I take the scale too literally maybe?
    I think some of my patients do too and they wont ask for pain medication because really compared to that 10 any pain can be tolerated.
    I hate that dumb scale.

  14. Man, I hate that pain scale. I was just talking about this with my husband the other night. My "personal best" was definitely a 10/10 when I first discovered I have Trigeminal Neuralgia. I'm usually fairly stoic but this pain had me in the fetal position, in the middle of a full ER, screaming like I was on fire. Twelve hours of natural labor, with twins, wasn't even a 4 compared to this pain.

    Now, whenever I'm asked "If 10 is the worse pain you've ever felt..." I think "Well hell, how do I even compare it to that when the worse pain I ever felt had me wishing someone would put a hatchet in my brain stem".

  15. The scale is useless. I now have a sad tale of woe to relate that I'm ashamed to admit; I once claimed to have 7 of 10 pain with, 'gasp' Norovirus.

    Then the nice nurse who I later worked with offered me narcotics and I said, 'well, it's not that bad!' I felt like a retard. He said, 'it's our policy that anyone with 6/10 pain or greater gets offered narcotics'. Only in retrospect did I notice the JCAHO inspired eye-roll. To his great credit, he still took great care of me.

    But I was a young guy. How much pain has a young guy really had if they haven't been in a car accident or been attacked by a badger? Ankle sprain? Kicked in the schnikies? Stupid scale.

  16. And to think we are taught in nursing school to live and die by that scale. They don't teach you how to interpret the all the B.S. associated with it.

  17. I've had migraines as long as I can remember - in 2nd grade I used to get sent home because of my headaches. I have no choice in life but to keep on no matter how bad my head hurts.

    My only point is that I've had headaches that made me feel like if someone said "you have to feel this way forever or die" I would pick to die.

    But on the outside I'm sure (especially to those who don't know me, usually those who do can tell by the look of me how bad I feel) it doesn't look that bad.

    I've had doctors roll their eyes and tell me to take sinus medicine and stop wasting their time with 'headache.'

    No, I've never had someone put an ice pick in my eye or saw my leg off with a chainsaw BUT WHEN I HAVE A MIGRAINE THAT IS KILLING ME the descriptions that I come up with seem very apt: I usually think of railroad spike in the side of my head. Why is it ok for you guys to roll your eyes at our descriptions of pain "have you ever had an ice pick in your eye?" when you are asking us to decribe how bad it feels - that's a visual that describes the pain.

    Just because my leg isn't hanging on only by flesh doesn't mean I'm not in pain. I've never had a kidney stone but I have given birth twice. Nothing compares with the migraines I've had my whole life.

    I understand you deal with a lot of people trying to get meds they don't need and assholes who think their pain is the worst anyone ever has felt - but I just know I rarely try to explain how much pain I'm in to doctors because my experience has been that I'm not taken seriously. I avoid the things that give me migraines as much as I can because dealing with doctors is more of a pain than my migraines.


  18. I had viral meningitis when I was young. All of a sudden I had the worst headache in the world, bad enough that I was crying, but moving my head made it worse and made me feel like throwing up. I couldn't even see straight. Since then, any time someone asks me how much pain I'm in, I rate it on a scale from one to meningitis. Much more effective.

  19. I never got the scale. My mom's had 10 out of 10 pain most of the past five years (somehow she makes it through the day). What's amazing about her is that she doesn't really look like she's in pain. . . but if you knew all that was wrong with her, you'd understand. She's been struggling with a gallstone, a crushed radial nerve, spinabifida, and she just got over a kidney infection caused by the last kidney stone she had. . . So she has been in 10/10 pain constantly for a while, yet doctors and people look at her and say, "you're not that bad off".

    I think the only time I had a near 10/10 moment was when I got that ovarian cyst last summer. . . I was rolling on the floor screaming, I couldn't move, and on top of all that both of my latissimus dorsi muscles were severely spasming and my blood sugar was running low because I hadn't gotten any protein (I suffer from hypoglycemia, so I was feeling faint and very nauseated). I actually nearly passed out and I dry-heaved a little before my mom finally heard me (I was in the basement of my grandparent's house and they were outside on the porch) and came running to find me lying on the floor in the fetal position, screaming bloody murder.

  20. SeaSpray said: Yes - the kidney stone is 10 worthy.

    According to our pain scale at the Urgent Care, a 9 means you are thrashing about in pain, sobbing uncontrollably, and are unable to listen to instructions.

    A 10 means the pain is unbearable, and you are...unconscious. So a kidney stone is not a 10. More like an 8. (Yes I have had kidney stones before.)