Why pain cannot be a vital sign

There’s been a movement afoot for several years now to quantify pain as the so-called “Fifth Vital Sign.” It all started as a well-intentioned effort to raise the level of awareness of inadequate pain control in many patients, but has gotten way out of hand.

The problem is that the word “sign” has a specific meaning in medicine that, by definition, cannot be applied to pain.

When you hear us medicos talk about “signs and symptoms” of a disease, it turns out that they are not the same thing. “Symptoms” are things the patient experiences subjectively; “signs” are things that can be observed objectively by another person. Headache is a symptom; cough is a sign. Itching is a symptom; scratch marks over a blistery linear rash are a sign. Vertigo, the hallucination of movement, is a symptom; nystagmus, the eye twitching that goes with inner ear abnormalities that can cause vertigo, is a sign. If someone other than the patient can’t see, hear, palpate, percuss, or measure it, it’s a symptom. Anything that can be perceived by someone else is a sign.

The traditional “vital signs,” four in number, are measurements of bodily functions: temperature, pulse, respiratory rate, and blood pressure. Technically one could also include weight, height, head circumference, waist circumference, urine output, etc. Vital signs are measured, two of them with specific instruments, and yield numeric results. Normal ranges are defined; values that fall outside those normal ranges are described with specific words (eg, bradycardia, tachypnea, hypothermia, hypertension).

What about pain? It is subjective by definition. If someone says they have a fever, we can measure their temperature. If it is below 99 degrees F, we can say they do not have a fever. If a patients says his or her heart is racing and we count only 80 pulse beats over one minute, he or she is not tachycardic. Not so with pain. If a patient tells us they are having pain, we are supposed to believe them (because they usually are), but we cannot measure or observe it. Sure, there are so-called “pain behaviors”, holding the affected part, writhing, moaning, etc., but as is correctly impressed upon us, the absence of those findings — those signs — does not imply the absence of pain.

It has become fashionable to ask patients to grade their pain on a scale from 1 to 10. It seems so logical. Pain is a 7; give drugs; pain goes down to a 3; success. Much as been written about this ridiculous formulation. Pain is so multidimensional that assigning a single number to it, even subjectively, is nigh impossible. I’m not saying that pain shouldn’t be assessed (serially when administering medications for it), merely that reducing it to a single numerical value is clinically ludicrous.

However you look at it, pain cannot be considered a “vital sign”; not the fifth, nor the twentieth nor the fiftieth. I agree with the importance of assessing pain. It’s right up there with the importance of assessing possible exposure to intimate violence, and the importance of asking if a patient has had a flu shot or a mammogram or a colonoscopy; ad infinitum.

But trying to style “pain as the fifth vital sign” is nothing but an ill-conceived PR campaign.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • http://www.somebodyhealme.com Diana Lee

    You’re absolutely right, and I tend to think looking at pain as a sign rather than a subjective symptom has led to more judgment and less trust of whether the patients is accurately assessing his/her pain score. Since pain is subjective we have to give patients some leeway in describing their own experience of it. Of course sometimes it will be blatantly obvious someone is exaggerating or underrating, but by and large I believe in respecting and acknowledging the patient’s experience.

  • Autumn

    While I’m prepared to throw the pain scale overboard, I do agree that it’s not an objective measurement, not even when the patient is earnestly trying to use the scale appropriately.

    I’ve seen folks over-rate their pain to get narcotics, I’ve also seen them overrate it because they recognize they have a problem, but as soon as they rate the associated pain under a 5 the whole account of symptoms got minimized. The patient wanted concrete answers as to the source of her pain.

  • Autumn

    The above should have read, “Not prepared to throw the pain scale overboard…” ooops!

  • http://@jasonbellakmd Jason Bellak, MD

    Thank you for this literal definition that may help a patient understand the difference between signs and symptoms. However, your article misses the point completely. While I believe managing patient’s pain is very important, the use of “pain as the fifth vial sign” corresponds to the huge rise in the use of opioids for non-cancer related pain and the marketing of these drugs by pharmaceutical companies for management of such. This is well-known and has lead to the FDA requiring REMS for long-acting opioids.

  • Dr Chris

    This one is so hard and so patient dependant-we all have patients who are very stoic, and a “10″ for some patients is a “2″ for others-the patient walking around with a pelvic fracture, or this side of a code from COPD, vs people who cannot tolerate a hangnail, and come in for an emergency tetanus shot..Does the latter get vicoden? Does the first get nada?
    Once this is becomes a vital sign, it will be one more round of paper work….

  • Caroline

    I agree that pain should not be considered a vital sign, or sign at all, for the above stated reasons; however, that does not mean that pain scales, as a whole, are useless.

    Yes, every patient experiences and rates pain differently; but that doesn’t mean the tool can’t be helpful. As, in general, the person who rates the pain from a hangnail high, will rate pain from most mild injuries high. The patient with a high threshold for pain who rates that pelvic fracture low will, in general, rate pain from major injury low. More important, when that latter patient suddenly scores high, it is a sign that patient needs immediate attention. They are personalized. Clinical judgement, of course, needs to be used.

    Of course, to use them this way takes more time and energy than most doctors have. In that sense, they may not practical.

  • http://myheartsisters.org/2010/06/19/women-heart-attack-worse-than-men/ Carolyn Thomas

    Hello Dr. Lucy – Let’s see if I understand this signs-vs-symptoms dilemma correctly:

    A (male) patient is told by the E.R. doc:

    “Your EKG looks fine, your troponin blood tests look fine, your treadmill stress test looks fine. But we’re going to keep you in hospital for observation just to make sure it’s not a heart attack.”

    Meanwhile, a (female) patient (who, coincidentally, happens to be ME!) is told by the E.R. doc:

    “Your EKG looks fine, your troponin blood tests look fine, your treadmill stress test looks fine. But you’re in the right demographic for a GERD diagnosis. So go home and make an appointment with your family doc to get a prescription for antacids….”

    In the first example, the doctor notes the patient’s subjective symptoms, but there are no signs, correct? In the second example, the doctor notes the patient’s subjective symptoms, but there are no signs.

    Hey, wait a minute…. Isn’t the whole point being made here that it’s the clinical signs and not the subjective symptoms that are supposed to drive medical treatment decisions?

    • pcp

      Once again, you say the discussion is all about you and your personal medical history.

      Dr. Hornstein NEVER said medical decisions should be based only on signs. You’re intentionally distorting her post.

      • http://myheartsisters.org/2010/06/19/women-heart-attack-worse-than-men/ Carolyn Thomas

        On the contrary, pcp, I’m not saying anything of the sort. My own story is, however, unfortunately typical of many patients who are misdiagnosed and sent home because their clinical signs appear normal. According to research published in the NEJM, for example, women under the age of 55 presenting with heart attack symptoms (but not signs!) are in fact seven times more likely than men of the same age to be misdiagnosed and sent home.

        The point I’m responding to (but not distorting!) is the subjective and objective nature of all medical diagnostics.

        • pcp

          “Isn’t the whole point being made here that it’s the clinical signs and not the subjective symptoms that are supposed to drive medical treatment decisions?”

          Show us where Dr. Hornstein made that claim.

  • Dr Chris

    I think a whole post could be on diagnoses made on age/gender/obesity/ethnic group.
    But that was not this post.

  • http://www.edhayes.com Edmund Hayes, R.Ph., M.S., Pharm.D., FASCP

    HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a national survey that asks patients about their experiences during a recent hospital stay.
    Most hospitals participate in this scoring system and the results are open to the pubic to view and compare with other hospitals.
    One of the HCAHPS questions is……
    Was your pain was “Always” well controlled.
    ALWAYS – show me a patient that had any procedure that ALWAYS had their pain well controlled.
    Pain is a 5th vital sign because hospital administrators don’t what to have a low HCAHPS score.

  • http://dinosaurmusings.blogspot.com/ #1 Dinosaur

    I also never said pain should be assessed, nor did I say that we shouldn’t use some form of a scale to do so. All I said was that pain should not be considered a “vital sign”, because it doesn’t literally qualify as a “sign”.

  • Denise

    As a nurse in an acute care setting I give patients who ask for pain meds as much as is safe to give. I don’t try to figure out if they are addicted, are wanting to experience the euphoria, or anything else. If the physician has not written for narcotics and the patient wants them then I make the call and I try to get what the patient wants. Pain is subjective and if the patient thinks they need a certain substance then it’s my job to safely give it to them.

    • stitch

      Wow, just – wow.

  • http://www.isicomponents.com/ Carrie

    Well articulated argument – difficult to debate against!

  • http://EasyOpinions.blogspot.com/ Andrew_M_Garland

    This comic Pain Rating at XKCD treats the subject of estimating pain in a humorous way.
    http://xkcd.com/883/

    “How would you rate your pain, from 1 to 10, where 10 is the worst pain you can imagine?”
    It all depends on how you think about the question.

  • Matt

    Pain can absolutely be sign and a symptom. A vital sign? I agree not. But if there is anyone who has posted here that cannot tell when “some” of their patients are in pain, purely through observation, have no business commenting. When possible, we then have a patient qualify and quantify their pain experience. They are qualifying and quantifying their experience to the pain – not the pain itself. Pain is yes or know their reaction is scaled. This does not help with any diagnosis, only as the author points, in the treatment. For instance one does not need to know a patient’s pain scale to make a diagnosis of shoulder dislocation. But, with the reduction of said shoulder, pain all but disappears instantly. And anyone who has done such a procedure or similar on a patient knows, by looking at the patient, Aha – its reduced and the pain is less. No subjectiveness what so ever.
    Think of doing a procedural sedation. We sedate and give pain relieving medication even before we start the procedure. We do this because we know pain is inherent in our procedure. We do not wait for the patient to subjectively rate their pain we treat them objectively.
    A little less defined but still relevant are the multitude of physiologic changes the body has when it is in discomfort. I would challenge that just because we have not developed a tool (sphygnomanometer, thermometer, TENS, pulse oximeter, etc) that can quantify pain does not mean pain is only subjective. I have treated hundreds of patients with altered LOC, who could not tell me they were in pain. I objectively assess, use vital signs as support and treat their pain based on my objective observations, not their subjectiveness.
    Also please don’t assume that a person is just a drug seeker. Drug seekers can have pain also. Unless you are a pain management professional or an addictions professional – treat patients pain regardless of your own bias toward their lifestyle. Its the right thing to do.

    • LisainKC

      I agree completely with NOT treating patients as drug seekers. Too many times patients with chronic pain are treated as drug seekers instead of who they really are; patients who have a real problem with their pain issue and need additional help for the problem they are dealing with. People dealing with Chronic Pain are in a difficult situation. Doctors do need to get rid of their bias against patients and treat them specifically for why they are there – not for why the doctors feel (with a bias) they are there. Treat them as they would any other patient there for pain or for their problems. Pain scales are definitely subjective but they are all we have to describe our pain. Granted one in rather severe pain may rate their pain as a 4 while another may rate it as a 9 or 10, they are in pain! Treat accordingly for the PAIN! Try to help them get rid of that pain, not decipher who they are as a person. They came for help… not to be torn apart by the doctor as a psychologist. That is not your position or job. Treat the pain! I could go on and on on this subject but I will end by saying, the chronic pain patient is misunderstood by most of the medical community and your compassion is needed.

  • CandiO, WHNP-BC

    http://hyperboleandahalf.blogspot.com/2010/02/boyfriend-doesnt-have-ebola-probably.html

    This is actually the best and funniest pain scale I have ever seen. And if patients used this one, the scale might be considered a lot more reliable.

    • http://myheartsisters.org Carolyn Thomas

      So funny…… :-)

  • http://paynehertz.blogspot.com Payne Hertz

    The endless haggling over “sign vs symptom” when it comes to pain is largely meaningless semantics, and entirely misses the point of seeing pain as the fifth vital sign. Though you are technically correct, in the sense of how a “sign” in medicine is usually defined, a patient’s “subjective” report of pain is a powerful and reliable indicator that something is indeed wrong, and should carry as much weight as those indicators that can be directly observed by the doctor. That is the reality that this campaign is trying to get across.

    Pain is one of the body’s principle means of indicating that something is wrong, and the human nervous system is exquisitely fine tuned to accurately detect pain and interpret its severity. We can detect something as mild as a mosquito bite, or as painful as stepping on a nail, but few people will scream in agony over the former while most will cry out in pain at the latter. If you can forget that the patient in front of you is a person for a moment, and see him instead as a pain-detection device, it would be hard for science to come up with a device that is more accurate and reliable than the human nervous system.

    As such, pain is not a “subjective” experience for the patient, as would, say, his ability to accurately determine whether his blood sugar was high based on internal cues. The human body lacks a glucometer, but it has a powerful pain-meter built in. From the standpoint of the patient, the existence of pain is something that can be objectively determined, and therefore, has more powerful meaning diagnostically than most patient reports of symptoms, which may indeed be highly subjective from the patient’s standpoint.

    The power of patient as objective indicator of pain is limited only by the fact patients do not always accurately report their pain, and doctors often refuse to believe them. But even given the fact some patients may lie about or hide their pain, the overall reliability of patient reports of pain is arguably as high or even higher than supposedly “objective” diagnostic tools like MRIs, X-rays or HIV and Lyme disease screenings. I see no reason to assume patient reports or pain produce a higher rate of false positives or negatives than these tests do.

    It is precisely because of this power that some would argue that pain should be viewed as a ‘sign” in the sense that it should carry far more diagnostic weight than a mere symptom. Otherwise, the distinction between sign and symptom is largely meaningless in the medical sense, and one that in this case is only invalid if one assumes that either patients are poor at detecting their own pain, or usually act in bad faith in reporting it.

    Pain fails as a vital sign to the extent the physician fails to recognize this reality, and instead, relegates “signs” to things he can directly observe or those that rely on some external technological device—rather than the human body itself—as the only “objective” indicators of pain. If you are willing to respect the undeniable power of the human body as pain-detector, then the logic of seeing a patient’s report of pain as an objective “sign” begins to make sense.

    Lester S. King, author of “Medical Thinking” is quoted on Wikipedia as stating the following:

    The belief that a symptom is a subjective report of the patient, while a sign is something that the physician elicits, is a 20th-century product that contravenes the usage of two thousand years of medicine. In practice, now as always, the physician makes his judgments from the information that he gathers. The modern usage of signs and symptoms emphasizes merely the source of the information, which is not really too important. Far more important is the use that the information serves. If the data, however derived, lead to some inferences and go beyond themselves, those data are signs. If, however, the data remain as mere observations without interpretation, they are symptoms, regardless of their source. Symptoms become signs when they lead to an interpretation. The distinction between information and inference underlies all medical thinking and should be preserved.

    http://en.wikipedia.org/wiki/Medical_sign

    “Pain as the Fifth Vital Sign” is not some cheap PR campaign, but a needed educational program to get doctors to start seeing the value of patient reports of pain and recognizing the necessity of treating pain aggressively. Your argument is semantically correct, but pragmatically wrong.

    • horseshrink

      From etymonline.com:
      Sign: from L. signum “mark, token, indication, symbol,” from PIE base *sekw- “point out” (see “see”).

      Symptom: from L.L. symptoma, from Gk. symptoma (gen. symptomatos) “a happening, accident, disease,” from stem of sympiptein “to befall,” from syn- “together” + piptein “to fall,”

      * * *
      Symptoms can be subclassified, including objective, subjective, cardinal and constitutional forms.

      Sign has retained its specific meaning of a finding observable by others.

      Subjective vs. objective remain important data discriminators as they inhere different qualities. Signs remain “objective” findings. Symptoms may be subjective or objective.

      “Fifth vital sign” is a PR gimmick that distorts our terminology, which unfortunately undermines the credibility of a well-intentioned educational effort.

      • LisainKC

        Wonderful post – I appreciate it very much!

  • paul

    ahh.. but pain IS the 5th vital sign if jcaho deems it so, webster’s definitions of words like “subjective” and “objective” be damned!

    and immunization history is the 6th vital sign… domestic violence screening is the 7th vital sign… advance directive is the 8th vital sign… special needs is the 9th vital sign… if you’re in ny request for hiv testing with every health care encounter is the 10th…

  • http://www.practitionersolutions.com Niamh

    I think it got labeled this way not for the literal meaning but for practical reasons. It’s not even “vital” for life, let alone a “sign”. 1. there are a bunch of healthcare clinicians and support staff who are charged with assessing pain who would otherwise forget to or not bother to assess it if it was not lumped with the assessment of vital signs. 2. a standardized scale, even though not ideal, is practical to be used by clinicians and support staff as an initial red flag to the presence of pain that requires treatment. It’s also needed to create pain management protocols. 3. People assessing pain are not necessarily interpreting the pain or responsible for treating or alleviating it. 4. The efforts of health care organizations to provide quality care is significantly affected by their response to the patient’s report of pain, pain being a quality indicator, so orgs had to find ways for their clinical team to have it on the radar constantly. We often audit homecare and hospice charts and in the past always found: 1. pain was not addressed 2. pain was reported and interventions to change pain management & alleviate pain were not routinely done. Pain was described differently be every clinician and no protocols for pain management were implemented. Now since pain has been added to the “vital sign” profile, clincians are better at addressing it, taking steps to change pain management and following protocols and guidelines. Having said that, I do see homecare patient’s being discharged with a pain scale of 10! Somewhere….bells and whistles should be ding-a-linging….but seem to be on mute!

    • ninguem

      “……I think it [pain] got labeled this way not for the literal meaning but for practical reasons. It’s not even “vital” for life, let alone a “sign”……”

      There are babies born with congenital insensitivity to pain.

      They have a shortened lifespan.

      So I might quibble over that. Pain IS vital to life.

      • http://www.practitionersolutions.com Niamh

        Having a temperature, pulse, respirations and BP is necessary for life….so vital! However, the perception of pain is not vital. If you have a shortened lifespan….you have life all the same. Similarly….people have no sensation in some body parts and apart from protecting it from injury and exposure to noxious substances, life can be quite functional. We will have to agree to differ…ninguem!

  • Ralph

    Can’t wait to find another career to get out of health care. I Work 60+ hours a week and no matter what you do to “try” to help someone else in academia or government will tell you what you “should do” for a patient who does not want to change. Pain is ALL subjective.

  • Tom Leith

    > I do see homecare patient’s being
    > discharged with a pain scale of 10!

    This is kinda funny. If you ask my 93 year old mother in law to rate her pain on a scale of 1 – 10 she always moans with a great quaver for emphasis (rolling her head) and says “10!!!!” Usually this can be cured with a 500mg APAP and a game of cards. I’m not sure the APAP is really needed.

    Me? I never got the meaning of that question before I experienced back pain that made me drop to my knees and narrowed my field of vision to about 5 degrees. I don’t know whether I made a sound, probably not. OK, so that’s “ten”, I guess. But most of the time I don’t know how to answer the question. What’s “half of blindingly-excruciating”? 5? Or is this a logarithmic scale? What if I’ve gotten used to it — does that make it “2″ or is it “6″? Really folks. What do you want people to say? And do you want to believe that 10 means something? These numbers are easy to do math on, but so what?

  • Dave B

    I have long thought that pain as a 5th vital sign was inappropriate because it is not measureable, it is assessable. We have all seen, especially in ERs and Minor Emergency, that patient that walks in states his/her pain is 10/10 all the while laughing and joking but reading their body launguage states something completely different and in the course of their care will document the difference so that motrin is not inappropriate going out the door. There are physical signs of pain, pale, nausea, sweaty, demeanor, body position or posture, but still use of narcotics is not the only treatment available. Teaching them proper care (Rest, Ice, Compression, Elevation), over use syndrome during the healing phase, pain masked by medication that may allow over use too early. We need to stop handing out narcotics so easily, we are making a already existing problem bigger.

    • Jack Cain

      Dave,

      I have no idea what your history or qualifications are, so please forgive me if I assume too much. This response is to everyone who has posted here about this subject. I invite any of you who wish to further discuss the subject of pain assessment under less than ideal conditions to come to the “Societal Impact of Pain” group discussion on LinkedIn.

      As a chronic pain patient from spinal injuries sustained in a school bus rollover when I was 16, I am told that I should master meditation, guided imagery, distraction, proper pacing of my physical activities and a number of other very good techniques to manage my pain. While good in the short term, I strongly believe the Dalai Lama couldn’t meditate strong pain away 24/7/365. No, I am not joking or using hyperbole.

      Because I *CAN* use those techniques, I *CAN* walk into the ER and make jokes while experiencing severe pain. Making jokes actually distracts me from the pain I am experiencing. Because I can use biofeedback and similar tools to control vital signs to some extent, I may not be sweating, tachycardic or hypertensive. None of those things indicate that I am not in pain, only that I can use the tools I have been taught in the manner in which they are expected to be used.

      By the standards that you mention, I should not be treated for pain at all – I bet you would burst out laughing if I told you that I needed 20 mg of morphine IM with 50 mg of Phenergan just to start. By the standards that you mention, the better a patient is at applying the tools that control severe chronic pain, the less pain control they can expect to get when they find themselves in a situation where all of the tools they have available outside of the ER – whether mental, physical (elevation, heat, etc) or pharmacological – are not controlling the *acute* pain episode they are in at the time.

      Is it any wonder that my complaints of severe pain were ignored to the point that I ended up with a gangrenous gall bladder? I would have died if I had not chosen to go to a different hospital where they took my complaint seriously the FIRST time. Is it any wonder that when I choked on some food a few weeks ago and had the Red Cross 5 & 5 technique used on me that I was denied treatment for the resultant excruciating pain even though I had 13 witnesses? Is it any wonder that if I attempt to get a legitimate second opinion – even inside the same pain clinic (!!) – about ways to treat my condition that I *WILL* be labeled a drug-seeker and my PCP will stop seeing me as a patient?

      I could go on, but everything I listed is true and either has happened to me or would happen to me by written contract. It seems that too many doctors get bogged down in the details about signs & symptoms and forget that the entity in front of them is a living, breathing human being and is likely suffering.

      If you are in some form of acute care and the patient in front of you has a primary care provider, please just alleviate the immediate pain then make sure the PCP is notified of the event. Unlike you, the PCP will have an idea if this is abnormal for the patient and will have the ability to deal with it appropriately.

      I sincerely wish that there was a device that could accurately measure pain as it relates to the individual so that clinicians could safely take the proper course of action. I truly wish there were non-narcotic medications for all of you to use. Since these tools do not exist today, I truly wish every one of you could trade places with me for just 24 hours so you could see what it is like to hear doctors ridicule you and treat you like a criminal first and a sentient being last. Even though I have never exhibited addictive behavior, my PCP calls me an addict to my face. I spent 6 years defending the concept that a person should be innocent until proven guilty just to live in a world where animals have better legal protection from suffering than I do.

      • http://paynehertz.blogspot.com Payne Hertz

        Well said, Dave. Unfortunately, your experience is the rule rather than the exception, as I have learned from many years in chronic pain support groups.

        I have also read medical blogs for years and am fully convinced that many doctors are no more informed about pain than the average Joe in the street. In fact they may be more poorly informed, because they tend to embrace commonly-held views of pain and pain patients that are based on nothing more than medical folklore, stereotypes and memes that have no basis in science and which often defy common sense–such as the myth that if you’re in severe pain, you can’t eat. The average Joe usually grounds his opinions in common sense, and would be surprised to learn that people in constant severe pain can go for years without eating.

        It has been scientifically demonstrated that people with chronic pain do not have the same physiological and psychological reactions to pain as those that may–or may not–be found in people with acute pain. This is the result of natural adaption to the pain, and not the absence of pain. In your case, the reduction of the stress response has been accomplished through meditation, but some reduction in stress reactions would tend to occur naturally over time. The University of Michigan Health System used to have an excellent article on “pain myths” on their site, but I can’t find it. But to quote them:

        The transition to chronic pain is marked by changes in both physiological and psychological responses. Instead of trying to escape the painful situation, the patient is now trying to adapt to ongoing pain.

        The neuroendocrine stress response is typically exhausted in chronic pain states, and catecholamine induced changes are now absent. Vegetative responses predominate, including sleep disorders, irritability, depression, and decreased motor activity. Patients often appear subdued, sleepy or sad in appearance.

  • http://secondbasedispatch.com Jackie Fox

    I hadn’t heard about this debate. This was really interesting–particularly learning the difference between a sign and a symptom. Thanks!

  • Molly Ciliberti RN

    I fully agree with those who remind us of just how many ways people perceive pain from the stoic to the low threshold hangnail sufferer. But also pain can be sharp or dull, constant or intermittant, a burning sensation or a nausiating sensation. It is too difficult to just give a 1 – 10 response. And chronic pain is even more difficult to break down into just a numerical scale. As an ICU nurse, I too didn’t skimp on pain meds, wanted to always be ahead of the pain (playing catch-up is rediculous), medicated before wound dressing changes and made sure that the drug did the trick not just making them groggy. Pain is an individualized phenomenon and should be better described than a number on a scale.

  • Patricia

    Correct – Not a sign, but an assessable symptom for which a three-point scale is all that is necessary: (1) annoying; (2) uncomfortably distracting; (3) really bad! We should remember, too, that sensations not typically thought of as painful (like severe itching) can be interpreted as painful by the patient.

    What is so different about pain is that it is the only symptom that has such judgment by the caregiver attached. We never ask patients to qualify their nausea! My daughter had a severe ankle fracture for which she had surgery. One of her nurses on the first post-op day thought it would be a good idea to try Reike instead of pain med. Reike. For acute orthopedic surgical pain. Are you kidding me?

  • http://www.cedarhillpt.com Paul Weiss

    Just chiming in to say that I agree very much with the author’s premise that pain is a symptom and not a sign.

    I will go on to say that it is a symptom that is often times poorly understood by patients and health care providers. Moseley and Butler have written an excellent book on the topic. It is titled “Explain Pain”. IMHO, it should be compulsory reading for anyone who is experiencing chronic pain and those who are involved in their care.

  • OptimAge

    Pain that is out of character with the physical complaint or insult is a sign tht I’d better keep my ears perked for something else that might be going on with the patient. I also use empathy and gut feelings. Lab results and monitors can be wrong in innumerable ways.
    The difference between physicians and the rest, is the process of critical thinking we’re immersed in, curiosity for the answer, and treating the context of the patient as well as the discrete bits.

  • http://www.bolka.bg Bogdan Rouytchev

    Principally I agree with Mrs Hornstein. Actually there are many signs we can’t measure well like sweating and movement for example, which are exactly vital signs! The point about pain is much deeper and the answer is not at a clinical level. The point is in biological meaning of the pain which is fundamental. The biological role of the acute pain is to be sign saving the life from some danger. In case of chronic pain my own theory is to show to the individual some chronic wrong way of his life, finally to preserve him from vital danger too. Cause of this difference the drugs dose not work same way. More here: http://bolka.bg/en/aboutpain/the-acute-and-chronic-pain-are-two-different-phenomena
    I agree the pain is multidimensional, but the space has only 3 of them. If you want to see more: http://bolka.bg/en/aboutpain/authors-3d-model-of-pain