# Pain scale?



## marineman (Sep 1, 2008)

I'm new here, just started paramedic classes a couple weeks ago and had a question for all the medics here regarding pain scale. We always learned 1-10 until now when the teacher says he will literally kick us if he hears us use that. He says now that we have pain meds at our disposal we are always shooting for a 0 because a 1 means some pain. So how do you guys ask your patients? Is it 1-10 or 0-10.


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## MMiz (Sep 1, 2008)

This sounds like some of the anal quirks some of the teachers I work with push on their students.  Think this one through with me.

You should be asking all of your patients if they hurt anywhere, and then get more specific.  If they deny pain, then you write on your report that the patient denied pain.  If they have pain, then you know that they have pain, and you ask them to rank it on a scale of 1-10.  You're not randomly asking this question to everyone.

Here's how I approached it:

*Me:*  Are you hurting or are you experiencing pain anywhere on your body?
*Patient:* No
*Me:* Not to sound repetitive, but I just want to me thorough in my evaluation.  So you have no head pain?
*Patient:* No
*Me:* Neck pain?
*Patient: *Yes, my neck hurts
*Me:*  On a scale of 1-10, one being very little pain, and 10 being the worst pain you've ever felt, how would you rate your pain?  This is where they rate it either a two (little), five (mid), or eight (real bad).  I've had very few other numbers 
Then you address the issue and continue the evaluation.

If they answer yes to any of those questions, then I know that they have some, and ask them to rate it on a scale of 1-10.


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## VentMedic (Sep 1, 2008)

There are nationally accepted scales but you must be aware of and consistent with the scale you are using. There are also studies done with other scales designed for different groupings of patients with different backgrounds as well as different disease processes such as cancer. Some hospice groups have their own scales. Kids and patients with language barriers require a different scale and they can be interpreted differently.

This is a whole science to itself and one that is stressed as a requirement to all healthcare professionals, from CNAs to MDs, for good documentation. 


0 - 10 is the more accepted numeric scale. 

Here is a link to the NIH for a list of the commonly used scales. 

http://painconsortium.nih.gov/pain_scales/index.html


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## marineman (Sep 1, 2008)

I can understand that, and definitely agree with that. Seems a little over the top for me as well however I can see the point on a continuing evaluation.

Say a patient rated pain at a 4 initially. During your treatment you push some sort of pain med (sorry haven't gotten to pharmacology yet forgive me). After the medication has had time to work you ask again how they rate their pain then I could see a 0 but it is just as easy to say they deny any pain.

Edit: Vent medic thanks for the link and information I'll have to do some reading. All kinds of good information around here.


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## MMiz (Sep 1, 2008)

VentMedic said:


> There are nationally accepted scales but you must be aware of and consistent with the scale you are using. There are also studies done with other scales designed for different groupings of patients with different backgrounds as well as different disease processes such as cancer. Some hospice groups have their own scales. Kids and patients with language barriers require a different scale and they can be interpreted differently.
> 
> This is a whole science to itself and one that is stressed as a requirement to all healthcare professionals, from CNAs to MDs, for good documentation.
> 
> ...


Seriously, where do you get this crap from? 

Great link, thanks!


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## VentMedic (Sep 1, 2008)

MMiz said:


> Seriously, where do you get this crap from?


 
We just had our JCAHO survey at the hospital.


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## firecoins (Sep 1, 2008)

I say 1 to 10 but people say 0 when they have no pain so I guess its understood as 0 to 10.


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## VentMedic (Sep 1, 2008)

firecoins said:


> I say 1 to 10 but people say 0 when they have no pain so I guess its understood as 0 to 10.


 
Let me quote myself from a previous post.


> There are nationally accepted scales but you must be aware of and *consistent with the scale you are using*.


 
This is important when you are explaining the scale to the patient about how to put a numeric value to their pain. If you are not well informed about your scale or inconsistent in its use, your explaination to the patient will not be clear. The numeric values can also be associated with a treatment plan.


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## firecoins (Sep 1, 2008)

VentMedic said:


> Let me quote myself from a previous post.
> 
> 
> This is important when you are explaining the scale to the patient about how to put a numeric value to their pain. If you are not well informed about your scale or inconsistent in its use, your explaination to the patient will not be clear. The numeric values can also be associated with a treatment plan.



scale is pretty clear. everyone understands it and am very consistant in its use.  Every MD and RN I watch use the scale have done it in the same exact manner. No one say between zero and 10. They all say 1 and 10.


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## Sasha (Sep 1, 2008)

firecoins said:


> scale is pretty clear. everyone understands it and am very consistant in its use.  Every MD and RN I watch use the scale have done it in the same exact manner. No one say between zero and 10. They all say 1 and 10.



Then the hospital I do my clinicals at must be full of no ones! Ive been taught 0-10. I think its really a matter of personal preference.


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## MMiz (Sep 1, 2008)

Sasha said:


> Then the hospital I do my clinicals at must be full of no ones! Ive been taught 0-10. I think its really a matter of personal preference.


It's kind of like the North and the South.  Down here they call pop "soda," and eighth-grade "senior year"


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## VentMedic (Sep 1, 2008)

Sasha said:


> Then the hospital I do my clinicals at must be full of no ones! Ive been taught 0-10. I think its really a matter of personal preference.


 

As long as everybody in that facility or ambulance service has the same "personal preference". If Provide A uses one scale and then the partner, Provider B uses a different scale, that could lead to confusion in an already confusing situation for the patient. 

This is one of the reasons why it is so difficult to pull EMS records for research. People make up their own abbreviations and often use whatever scale they feel like. There is no consistency in education within the schools, departments or even with each individual.

The hospital is following established guidelines or P&Ps and the employees are all on the same page.


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## mycrofft (Sep 1, 2008)

*tell them what they want to hear but mutter "It still moves".*

JCAH or whatever they are calling themselves this decade are sometimes full of crap. Pain is as subjective as art, and where I work everyone's pain rating is "two hundred, man!!!". Do whatever they want yo to do to pass their little test this year, but never be tricked into hanging your treatment onto a quasi-scientific phlogiston scale like that (i.e., if the pain is below eight you cannot give analgesia, and if it is over eight yo have to give MSO4, or other rot).

Do your best to characterize distress, and ask "better, worse, or the same?" as you need to. I'd rather see a report behind me on the overhead projector reading " 'It feels like a zipper in my chest' and we started two large bore IV's" rather than "Oh, about a four...no, five...no...arrrghh".


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## Hastings (Sep 2, 2008)

can you rate your pain on a scale of 1-10, 1 being no pain, and 10 being the worst pain you've ever felt? (If not 10) Okay, and what is the worst pain you've ever felt?


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## VentMedic (Sep 2, 2008)

We use whatever is appropriate for the patient and that group. That is why I posted the NIH link which gives examples of these scales. 

The important part is that the healthcare professional is consistent in their own knowledge of pain scales and how to use them appropriately. 

It is mandatory documentation and should not be taken lightly or blown off as a joke. You can do the math when the patient offers their own commentary. That is only commonsense. 

Nurses also should be well educated in this starting from their first semester of the nursing program. Some of the older nurses have had to learn the documentation, thus old attitudes toward the scales and reluctance to broaden their education also exists in some places.


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## Hastings (Sep 2, 2008)

In my opinion, it's fine to use either, as long as you ensure the patient knows what 0, 1, and 10 relate to. And after that, they're just numbers.


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## ffemt8978 (Sep 2, 2008)

Hastings said:


> In my opinion, it's fine to use either, as long as you ensure the patient knows what 0, 1, and 10 relate to. And after that, they're just numbers.



And very subjective ones at that.

I've got to say that I've used both scales, depending upon how the patient presents.  If I know that they are in pain, I'll use the 1-10 scale.  If I'm not sure they're in pain, and am asking the question as part of my general assessment, I'll use the 0-10 scale.


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## Hastings (Sep 2, 2008)

ffemt8978 said:


> And very subjective ones at that.
> 
> I've got to say that I've used both scales, depending upon how the patient presents.  If I know that they are in pain, I'll use the 1-10 scale.  If I'm not sure they're in pain, and am asking the question as part of my general assessment, I'll use the 0-10 scale.



You know, I think I just do it out of habit these days. Plus it's nice to have a number to document. But really, your patient is either in no pain, a little pain, a lot of pain, or incapacitating pain. And it's so obvious without even asking them a question. That being said, the one time I really find it useful is with the administration of Nitro, for obvious reasons. But even then, if they seem unsure of how to answer (as most do), I just simplify it by asking whether it helped reduce the pain at all. I've yet to meet a patient that can put solid numbers to the amount of pain they're feeling. It's either "I'm not in pain" "It hurts a little. I guess a 4 or a 5 or a 6. Maybe 3." "IT HURTS SO MUCH! 20! 100! HELP!" "AAAAAAAAAAAAHHHHHH!" or "I don't know."


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## mycrofft (Sep 2, 2008)

*It's a sop to lawyers and deskjockeys. And I'm becoming a Bolshie.*

But if used uniformly in an organization it can be a means of communicating and commemorating a clinical finding. I acknowledge that, but I have an everloving bone to pick with rear echelon weenies.

It never ceases to amaze me that JACOH is forever discovering new earthshaking ways to revolutionize healthcare, when they come in, walk over the filthy floors of your overcrowded hospital, take over an office, have your records staff bring over the cherrypicked medical records they will pore over in air conditioned comfort, then drop their little findings about one through ten (or is it "one TO ten"?) onto you like dingleberries from on high. They should have a term limit (one year) and be forced to go through five years of line work before they are *allowed* to become an inspector again.

Years ago, they declared that pain control is the battleline, when infection control, overutilized ED's and overpaid fatcat administrators, including much of JACOH, are the real cancer in the system. The objective result is the epidemic of Rx addiction, and the closure of essential medical facilites due to financial collapse and failure to pass standards.

So sez me. Open fire. (And I SO did like it here.....).


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## Ridryder911 (Sep 2, 2008)

0-10 meaning zero is no pain. One would be having some pain. Many people have a hard determining what levels are so I illustrate it; that a 10 could be similar to me taking their hand and placing it into a car door and slamming it. That usually gives them a hint...


Steve Berry has a humorous lecture on asking what pain level they would like, he describes his CRNA saying we are too concrete, that actually we can have a -3 or -4 .. of course this is when it is easy to set off the apnea alarms. He also does not recommend it as well due to the related nausea with the medicine. 

R/r 911


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## VentMedic (Sep 2, 2008)

JCAHO (Joint Commission on Accreditation of Healthcare Organizations) is an accrediting agency that is used by Medicare and several other reimbursement agencies. NO HOSPITAL would ever want an actual Medicare inspection. These hospitals may not be in existence very long if that happens. If a hospital can not pass a JCAHO inspection, then maybe they should collapse or turn their facility over to management that can run a hospital. At least JCAHO has some mercy occasionally and grades on a curve with recommendations if things are just not exactly the way they should be. 

Some of the different measures that JCAHO uses are defined in other national standards. JCAHO is only one of many accrediting agencies as each specialty also must undergo their own accreditation process. JCAHO is a kitten compared to some of the other inspections. 

Why blame JCAHO for their issues when it comes to patient safety? When hospitals and healthcare providers can not be consistent in patient care or their documentation, then there should be some penalties. Those that don't want to re-educate themselves as times are changing or fail to maintain a safe work environment for their patients are usually the ones that do the most complaining.


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## enjoynz (Sep 2, 2008)

In NZ, on the ambulance they still seem to use the 1 to 10 pain scale. 
The hospital's use the Wong-Baker faces.

Cheers Enjoynz


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## Ridryder911 (Sep 2, 2008)

Pain control is one of the poorest actions that we in EMS are addressing. So many medics feel that they can determine if a patient is in "true pain" or not. Bull Sh*t! 

Health care providers cannot determine such subjective data alone. Kinda like the myth if the patient is sleeping or unconscious they must not be in pain... again B.S. Patients that become so exhausted still have pain, even those in unresponsive state still have nerve responses that are perceived as pain. 

Remember, just because it is a 2/10 does not matter. The person's perception of pain varies. I have seen partial amputations with a rating of 5 and the same person screaming of an IV with a rating of 8. 

Treat appropriately. They have pain, I assess and use knowledge obtained from history and treat accordingly. Fortunately, my medical director is of age where patients should not hurt. We carry analgesics for *that reason* ! 

R/r 911


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## VentMedic (Sep 2, 2008)

But that is the patient's perception of pain. We trend the data we receive from the patient to assess medication titration and treatment plans. Of course, if a Paramedic is only with the patient for 15 minutes, they may not be aware of why the hospital likes to have some information from the patient about pain starting at the onset. If the paramedics themselves have little knowledge in the pain assessment process but rather just ask questions just to be asking them without any consistency, garbage in and garbage out becomes the report we get at the hospital.  

It is reinforced many times in the hospital accreditation surveys about the difference between sedation and pain management. So no, JCAHO is not a useless process for the hospitals if more education is encouraged. Now if only the ambulances had some measure to show them where they need more education. Oh wait! They should be doing their own QA and have active medical oversight.


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## fma08 (Sep 3, 2008)

http://www.youtube.com/watch?v=UM-HWkbnDfg

About 1:30 the whole pain issue comes up, 

(relating to the thread, i use 0-10, 0=none makes sense to me)


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## Bosco578 (Sep 3, 2008)

I use the 0-100, yup. Oh your pain is 73.5 / 100..........

Seriously, I use the 0-10 scale.


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## Airwaygoddess (Sep 3, 2008)

*Pain scale assessment*

0 to 10 is what I was taught.


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## traumateam1 (Sep 3, 2008)

I use the 0-10 scale. I haven't actually heard anyone say 1-10 here in BC.


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## firemedic31075 (Sep 3, 2008)

Seems to me if your asking your patient how bad their pain is then obviously they must be having pain so it makes sense to use a scale of 1-10. Each time I reassess I ask if they are still having pain and if they are I ask them to rate it. I guess whatever works for you as long as your patient understands it.


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## VentMedic (Sep 3, 2008)

firemedic31075 said:


> Seems to me if your asking your patient how bad their pain is then obviously they must be having pain so it makes sense to use a scale of 1-10. Each time I reassess I ask if they are still having pain and if they are I ask them to rate it. I guess whatever works for you as long as your patient understands it.


 
If you are with any hospital affiliated team, Flight, hospital based CCT, ICU, Med-surg or ED, this is a required question or some nonverbal measure of all patients including those that are in a vegetative state, "sedated" and/or on a ventilator. Thus, the 0 - 10 logic for those that can speak or something similar for the nonverbal group. They want no one to feel like their pain, or NOT, was not being addressed. If they state they are having no pain, that is a 0. If all the nonverbal indicators show they are not having pain, that is a 0. Of course, that can be open for interpretation for some patients and is often more difficult to determine unless you are experienced in working with different types of patients. 

Just like mentioned earlier; 


> Pain control is one of the poorest actions that we in EMS are addressing.


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## reaper (Sep 3, 2008)

Unless you are dealing with Pt's like me! I walk around with some kind of pain all the time. Many elderly Pt's are always in some kind of pain, It is just a part of getting older and a side effect of abusing your body when you were younger!


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