Oh the pain scale

Oh, the pain. (or, the pain scales fell from my eyes)


I recently became a patient, in addition to being a doctor. Simple things can become complicated in no time, as my afternoon ice skating adventure in early January amply demonstrated. I caught an outside edge flipping from backwards to frontwards, flopped down and skidded twenty feet with my arm in front of me, until it caught a gouge in the ice and was carried under me. Then I levered over my right hand with my entire body weight. I felt it stretch, stretch stretch, then snap, and I knew what I had done. I rolled off the arm and looked at it with almost detached curiosity. It looked like a bayonet. It hurt a bit, but so many other thoughts competed for attention just then, pain was only a low-level fact of the experience. I pulled it out straight without hesitation, and then felt faint. I had to lie flat for a couple of minutes, arguing with the bystanders, all of whom wanted to call an ambulance. My sweaty clothes started to freeze to the ice, so I gathered myself up and got to the exit, but felt swimmy again, and spent another three minutes fending off anxious do-gooders from flat on my back. Finally I got up and stayed up, enough to drop my floppy arm into a shin guard for a splint and wrap it up to go. My daughter drove me to my own hospital in my truck, and I walked into the ambulance bay, sheepishly holding my shin-guarded arm in front of me at shoulder height. I was swept off my feet into a world of pain.
After the usual history-and-registration ice breakers, the very next question was “How would you rate your pain?” I said “A four.” (on a zero to ten scale) Now everyone there smiled or laughed out loud, in disbelief, and with innumerable examples in mind of whiny patients with hangnails rating their pain as 10 or 20. Here’s a guy with a broken arm, and he says “four”. But I was not being facetious. Maybe I have a good imagination, but the rating is supposed to be scaled from ‘no pain’ to 10 being the worst pain you can imagine. My pain, at that moment, was unpleasant, and I didn’t want it to linger much longer, but I could imagine much, much worse. As it turned out later, my imagination was not even close to being up to the task. Much, much, much worse was in store for me. They started an IV, after one obligatory missed attempt, required for all health-care personnel. Ouch, now that hurt, but just for a few seconds. And again for a few more seconds. Then they asked the only question that mattered—“Do you want some pain relief?” Sure did. That ‘4’ was no fun for the long haul. The next shock was how little IV Morphine did to relieve the pain. Twelve milligrams later, I couldn’t tell any difference. I turn out to be not very sensitive to Morphine, but a health-care provider might wonder if he didn’t have a covert addict on his hands, as much drug as I had on board, with as little relief achieved. But the real aggravation was the persistent efforts of the nurses to put a number on it. What was up with that? I know damned well what was up with that, and the ‘what’ is political correctness written into a federal mandate by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO, or JCAH to the older and acronym-weary).
Long ago it was recognized that we doctors did a lousy job of relieving pain, despite the availability of generally effective medicines. Why is that so? It should be axiomatic that the essence of doctoring should be the relief of suffering. We had the tools, we had the knowledge, and even the desire, but the polls don’t lie...we suck at relieving pain. What are the barriers? Well the biggest is the subjectivity of the whole experience. How bad does it hurt? Bad, of course. But the weapons we do have don’t have a lot of nuance built in. We have non-steroidals, Ibuprofen and its innumerable cousins, and then we have narcotics. We use various narcotics for lots of pains, from broken bones to terminal cancer pain. All narcotic use, and all drug therapy, really, comes at a price, namely side effects. Non-steroidals have their problems, including allergic reactions, ulcers and lesser tummy upsets, kidney failure, swelling, edema, death, and the list goes on. They are also the only step before dreaded narcotics, and they suffer from an interesting public relations problem. They work quite well for lots of pains, including some pretty tremendous pains, such as kidney stones, gout, and dental abscesses. But since you can buy ibuprofen and others over the counter, they can’t be any good, really. “But Doc, I need something really strong!” And so the game is on. Narcotics, as everyone knows are “Habit Forming”. I love that moniker the best. Let’s face it kids...They are out and out addictive. But they have a host of other problems which are gladly overlooked by the sufferer and addict alike. They constipate, (and I don’t mean a little) they cause dizziness, sedate, suppress breathing, remove all libido and all ambition, (except getting more narcotics). And in doses high enough to really relieve pain, they can suppress breathing enough to kill. They suffer from the reverse public relations problem. They are “big guns”, to be reserved for severe pain, whatever that is. Clearly that should include terminal cancer, and broken legs with bone sticking out, but even there we suck at pain control. And there is the rub. The subjectivity, and the little hammer-big hammer mentality leaves little maneuverability. Add to this a hearty dose of Puritanical politics and the Drug Enforcement Administration, and you have some barriers. How bad does that sprained ankle really hurt? Who can say except the owner? But we generalize the experience—it is only a sprain,it can’t be that bad-and prescribe ibuprofen, or perhaps some codeine. Or, at the other end of the spectrum, we give what seem like huge doses of potent narcotics to someone with genuine pain from an obvious source, and they keep looking at us like we haven’t touched it yet. What is their fucking problem?? I just gave them 10 milligrams IV. Can’t they see I am trying? What do they want from me? Well, Doctor, they want relief, and the number of milligrams is meaningless to them, just as it is excessively meaningful to you. People are different in their responses. Vastly, wildly different. And they are different at different times. Twelve milligrams of Morphine Sulfate IV would knock me on my ass if I weren’t in pain. Twelve mg. IV were so much salt water when I had a broken bone. And so it goes. The point is, relief is the end-point, not the number. And what is relief? Well, that is subjective. We don’t have an Excruciometer® we can hook up to the right ear lobe and left nipple, and watch the needle move, or the digital readout change. We can’t quantify how many milli-limbaughs of pain we had before and after our intervention.
But never fear--into this void Academia will venture, and with a little political pressure, the JCAHO will step in and solve the whole problem. In the rarefied atmosphere of research, the problem of rendering the subjective into quantities has always lurked. Researchers invented pain scales, so that subjects under controlled conditions could be asked to “rate their pain”, so that some notion of effect could be divined from their responses, and more importantly, so that the researchers could crunch some numbers, and generate the all-important “p< 0.05” statistical value, without which no researcher gets grant money. Twain was right—there’s lies, damned lies, and statistics. Well these worked so well at generating FDA approval, grant money, and academic acclaim that they had to be a good thing. They were always garbage, a poor approximation at best, and an artificial division of a basically yes-no problem, and never intended for clincal use, but no matter. Once the righteous (and correct) outcry over our failures at pain relief became public and political, the “do something, even if it is bullshit” crowd seized on pain scales as the holy grail. Scales are academic. That’s good, right? Scales are objective, and quantifiable. That sounds great. And you can force nurses to do them as part of a routine, or else cut off a hospital’s funding. Now there’s a plan we can live with.
So into this maelstrom I come with my paltry broken wrist. Rate my pain? I cannot. It just hurts. What do I need? Relief. Was that enough for you? No. More med. Enough? Nope. Maybe a little more. Enough? Yep, I am still hurting, but I am OK now. I can handle it now. That’s what I want. That’s what everyone wants. Nobody wants to put a number on it. Three fourths of patients don’t even get it. They just smile wanly and try to make the doctor and nurse happy, so they can get better. Hell, three fourths of nurses don’t get it. They think they are doing nursing by entering that number in the computer or writing it in the chart. They wake patients up from sleep to ask them for a number, for cryin’ out loud! When in truth, nursing, (and doctoring) should revolve around looking at the patient and saying “that poor bastard really looks uncomfortable. Let me see if I can help.” The net result is, after all the righteous and correct outcry at our miserable incompetence and failure, we are even worse off than before. We still suck.
So how can we fix this mess? First and foremost, get Congress out of the Practice of Medicine and the Practice of Nursing. Second, abandon Pain Scales as the worst new idea since “Survivor XIV--Hoboken”. Adopt a binary pain scale. “Hurting?” “Yep.” “Want relief?” “Yep.” “That do it?” “Nope.” “How about that?” “Almost.” “How about that?” “Yep. That’s OK, I don’t want anything more.” It is a yes-no problem, Doctor. Third, take the low level oral narcotics off the controlled substance list. Let them be sold over the counter. If the addicts want Vicodin, why should I be involved in that? Why should they be forced to grovel and lie, to poison the whole basis of the doctor patient relationship, just to satisfy their pathetic addiction? Why should doctors worry that their prescribing patterns will be scrutinized, and that they face loss of license or even jail for dealing with controlled substances? Better never to write prescriptions for narcs. Better to let a patient suffer than to take a personal risk, or than to risk being “burned” by a clever poseur once again. No. Wrong, Doctor. Wrong, Congressperson. Better to cut the legs out from under a brisk black market, and to remove a serious cancer on truth-telling between doctors and patients, I say. But who am I? Just a patient with dozens more behind me clamoring for attention, time, and if nothing else, a little relief. And just a doctor who is a victim of political lies, political correctness, and a system that puts me between sad, desperate people and the thing they want most. And someone who longs for a chance to make things better for my patients. Now get out of my way.