Pain Scoring

When dealing with patients who are in pain, we are told we need to obtain a “pain score” from them.  This is so we can monitor the progress of their pain throughout our treatment. We use a simple method by scoring the pain out of ten.  Ten being the highest and most painful and one meaning no pain.  Simple.

Or so you’d think.  But sadly its not really that simple.  Pain scoring is very subjective and relative to that one person’s definition of pain.  We therefore, as clinicians, have to use a little ‘creative common sense’ when dealing with some people’s definition of pain.

Here are three good examples of why this is so.

Patient 1
An elderly lady from somewhere in India sits in front of me complaining of global-everything pain.  She leans forward and strains to listen.

Binder:          So, on a scale of one to ten, ten being the worse pain imaginable and one being nothing, what number would you give?

As if on cue the lady throws her arms to her head and she starts wailing.

Lady:               Too much pain!
(arms wave and holds head)
(Lady stops to listen)
Binder:           No, I need a number between . . .
Lady:               Too much pain!
(arms wave and holds head)
(Lady stops to listen)
Binder:           Yes, fine, but can you just give me a number . . .
Lady:               Too much pain!
(arms wave and holds head)
(Lady stops to listen)
Binder:           No, a number.  Between . . .
Lady:               Too much pain!
(arms wave and holds head)
(Lady stops to listen)
Binder:           Any number . . .
Lady:               Too much pain!
(arms wave and holds head)
(Lady stops to listen)
Binder:           Right.  I’ll um . . . make it a three then shall I?

Patient 2
A thirty year old male sits before me complaining of chest pain after being in a police cell for a few hours.  He looks ahead nonchalantly.  Two police officers are standing beside him.

Binder:          So, on a scale of one to ten, ten being the worse pain imaginable and one being . . .
Patient:           Ten
(patient looks nonchalant)
Binder:            Ten?
Patient:           Ten
(patient looks nonchalant)
Binder:            Really?
Patient:           Yep
(patient looks nonchalant)
Binder:            Honestly?
Patient:           Yep
(patient looks nonchalant)
Binder:            So this pain couldn’t get any worse
Patient:            Nope
(patient looks nonchalant)
Binder:            . . . . !
Patient:           . . . . .
(patient looks nonchalant)
Binder:            Even if I dropped a large piano on your head this is still a . . .
Patient:           Ten.  Yes.
(patient yawns)
Binder:            . . . . . . . wow.

As I look at the patient I write a three.

Patient 3
I kneel in front of a tiny eighty eight year old lady who’s been lying in an awkward position at the bottom of her stairs for nearly four hours.  One of her legs is shorter than the other by half a foot and her pelvis looks clearly deformed.  Her wrist is bent in the wrong direction and a large gash on her forehead has left her hair and face matted with blood.

After all the obvious primary checks I stumble my next words.

Binder:          So, on a scale of one to ten, ten being the worse pain imaginable and one being nothing, what number would you give?
Old Lady:        Well, it does smart a little.  So, I’d probably give it a four or a five.  But I don’t want to make a fuss.
(patient tries to smile)

My jaw drops and tears well up.  I stare at the patient dumb founded and as one hand scribbles “100” in the scoring box my other reaches for the morphine in my pocket.

Binder

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