Reinventing the pain scale in the emergency department

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All people are gifted. As an emergency room physician, I see a wide variety of gifts, such as yodeling, knitting, and swearing (mostly swearing). One gift I rarely see is math. As a whole, the U.S. sucks at math. When compared with other nations, the U.S. ranks 32nd in math (though first in confidence). Despite this, we expect mathematical coherency from our drunkest friends.

I enter the room to find Mom. The chief complaint was “assaulted.”

Me: Hi, I’m here to evalu–

Mom: He’s in the shower.

Me: Excuse me?

Mom: He’s in the shower.

Me: We have a shower?

Patient (drunken shouting): I’m in the shower!

Me: Why is he in the shower?

Mom: I’m not sure.

Patient: I was cold!

Mom: He was cold.

Me: But … he’s been assaulted?

Mom: The doctor’s here to see you!

Patient (drunken anger): I’M TAKING A SHOWER!

Me: Are you in pain? (pause)

Patient: Um, yeah, it’s 10/10, but come back later!

Mom: Can you come back later?

Me: I guess I’ll come back later.

Patient begins singing Michael Jackson’s “I’m Bad” loudly.

I leave the room confused, in part because a 1980s song sung so enthusiastically by a person in the worst pain imaginable seemed odd. Also, who uses an ED’s shower?

My next patient, a 22-year-old with no history, had back pain. Jimbo’s father accompanied him because Jimbo had been self-medicating with beer.

Me: Hi there, Jimbo. What brings you in?

Jimbo: I got back pain.

Me: OK, when did this start?

Jimbo: I dunno.

Jimbo: Maybe 3 weeks ago?

Me: Are you asking me?

Jimbo: I dunno.

Me: OK, where does it hurt in your back?

Jimbo: It hurts IN my back (he gestures vaguely over his right shoulder).

Me: Ah.

Jimbo (leans forward, twists completely to the right to grab his dropped remote, and then twists completely to the left for his video game): It hurts EVERYWHERE!

Me (straight faced): I see. It says here you have 10 out of 10 pain.

Jimbo (a bit peeved): That’s wrong.

Me (a little relieved): Oh?

His father then interrupts.

Dadbo: Yeah, your scale’s wrong.

Me: Well, 0 is no pain, 10 is the worst possible pain. So how’s it wrong?

Dadbo: Yeah. Well, sometimes pain is bigger than 10.

Me (getting queasy): Uh-huh.

Dadbo: Sometimes, I have 15 out of 10, but if it’s gettin’ pretty bad, it’s a 20/10.

Me: I see.

Jimbo: Yeah, I told the nurse it’s a 20/10.

Me: I see. Did you take anything for it?

Jimbo: Yeah, Dad gave me some Norco yesterday, but it still hurts.

Deep breath.

As physicians, we’re driven by numbers. Blood pressure, temp, pulse, oxygen saturation — all these greatly influence our decision on the best course of action. Our desire to quantify everything often overrules logic. Emergency departments frequently encounter absurd situations rarely seen anywhere else. We crave logic, yet receive insanity, which fuels our desire for more coherence. The pain scale demonstrates this perfectly. It can work well; however, with some patients, it can be a cumbersome and dangerous double-edged sword. No one is arguing against treating pain, just how we quantify it.

Personally, hearing about 20/10 pain is like an unpoppable zit on my soul. Possibly, my own desire to obey the laws of mathematics creates this pet peeve. Ever watch Maury?

TV Guy 1: How sure are you that you are not the father?

TV Guy 2: I’m 200% sure. Nah, wait a minute, I’m 300% sure I’m not the father!

If we require a scale, then I propose one without numbers. I understand that people demonstrate and experience pain differently, but a non-numeric scale could still provide that information, while at the same time maintaining some semblance of sanity. Here are a few options.

A pain scale based around childhood toys. Nostalgia can be palliative. “Sir, on a scale from Silly Putty to Slinky, would you say your pain is a Furby, or even as bad as a Teddy Ruxpin?”

Perhaps a color-oriented pain scale? “Sir, on a scale from fuchsia to sea foam, you seem to be about a periwinkle.”

I am a little hesitant to use the alphabet. I see myself asking about a scale of A to Z, but patients might respond … “I’m all the way to ‘won’t you sing with me?’ ”

Then I realized the problem. Currently, the scale is set up so that you almost want to have a high number. You do not want to come into an emergency department and complain of a mere 2/10 pain. No way! That’s pathetic! Thus, anything under a 6 is pretty much off limits. Thus, the new pain scale must make being pain-free something to desire. This is when I came up with … the animal scale.

Read carefully here … Cute, cuddly animals are the worst pain, and cool, scary animals are the least pain. If you rate your pain “great white shark,” you have no pain. However, if you are kitten, I will start the morphine. No one wants to be a puppy when you could be a honey badger.

Armed with my new pain scale, I returned to my showering assault victim. I learned about his assailant: a large flat piece of concrete that, though nonmobile and firmly attached to the Earth, managed to give our showering hero a face hug.

Him: My pain is a bunny. Wait, no … not man enough. I’m at least a goat.

Me: At what pain level do you think you would feel comfortable? Don’t you want to be a jaguar?

Him: Heck, yeah, I do. Give me something to eat and some Vicodin, and this jaguar’s good to go.

Me: Have some Tylenol, and we’ll compromise at woodchuck.

Back to Jimbo.

Me: How’s your pain?

Jimbo: My what?

Me: Your back pain, remember? How do you feel?

Jimbo: I’m a Komodo dragon!

Me: Glad to hear it.

See how much better that feels? No one wants to be a chinchilla. Granted, the scale might have to be adjusted for 8-year-old girls, crazy cat ladies, or My Little Pony enthusiasts (a.k.a. Mel Herbert). Pretty soon we can all be making statements about patient pain that make us all feel better.

“Ma’am, I understand you’re currently a piglet, but with a little medication, we’ll make you a T-Rex in no time.”

Rob Brandt is a an emergency physician and a columnist for ACEP News. He blogs at Read more Brandt.

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