Pain Score and Analgesia

Pond Life

Pond Life

Forum Crew Member
Messages
81
Reaction score
20
Points
8
Hi all,
Interesting debate I'm having at present on a UK forum and wondered what you guys in the States would do in this scenario...

Get called to a patient who when asked about pain score 0-10 replies its 20/10 as he/she is laughing on the cell phone to her friends about an incident that has taken place that night

Your index of suspicion that the patient is in extreme pain is low because of the way the patient is behaving.

In the UK there are two approaches - depending on which service you work for and the level of education you have.
Approach 1. if the patient states s/he has a pain score of 10/10 hen you treat with appropriate strong pain relief no matter what you personally believe.
Approach 2. Document the patients pain score and also the reasons why you believe the score to be inaccurate and adopt a stepwise approach to pain relief. Starting with reassurance, stepping up to entonox, paracetamol and onward from there.

How would you approach this scenario, what are your policies and protocols?

cheers
 
Definitely not Approach 1. In general, we're expected to use judgment -- not just blindly follow protocols. Of course, we need to document why we do what we do.

Approach 2 looks wrong to me, too. Nitrous oxide isn't without risk. I can't imagine giving it for diagnostic purposes or just to cover myself. If I didn't believe the pt was experiencing anything more than easily tolerable pain, I probably wouldn't offer any analgesic.
 
I would document using the Wong-Baker faces scale. 0. It's a medical pain rating scale and included in my electronic reporting program.

Although, I would expect in a real world scenario there would be more to it. What is the perceived pain, why, etc...
 
In the ideal world, I would offer this patient "pain medicine." If he assented, I would provide him with tylenol. I think there are plenty of people who can still laugh but also be in an "NSAIDs would be nice level of pain." I am of one of those people I think.

However, I do not have tylenol, and I am not really sure I'd give this patient fent, as that's really all I have. I have a very low threshold for giving opioid pain medication (it's not my pain, I dunno how you handle yours sort of thing), but if you are laughing on a cell phone I think I would probably not offer such a treatment. I think it's risky to document "pt stated 20/10 pain but without any objective pain findings" because there really not many truly reliable findings. I think I'd probably document that the patient was provided with comfort measures with some relief to his pain and leave it at that.
 
Wong-baker for the win. Sorry you are rating your pain so high but your face tells me otherwise. Document that patient is calmly and without distress texting on his phone. I usually add in "patients affect does not match reported pain."

Granted I have given pain meds to people who look like they could be sleeping on the Wong Baker scale... But their vitals and the assessed injury clued me in.
 
  • Like
Reactions: NPO
The widespread misunderstanding of the FACES scale continues to blow my mind. The visual analog scale is meant to help PATIENTS indicate their pain level (particularly when they're not great with numbers). The little faces are not for comparing to patient faces, like in Scrubs.

Non-subjective pain scales, such as the CPOT, do exist. The Wong-Baker scale is not one of them.
 
I'm not about to give fentanyl for your damn 15/10 pain as you sit there napping on the ride over. Then again, I'm not required to give pain meds for an arbitrary number. I'm expected to give it when appropriate. I will give it for non-traumatic causes, but I rarely give it on people despite 11+/10 pain because most of them usually just sit on their phones without a care in the world. More often than not (recently, not as a whole) the people I would give it to I can't because I don't have time.
 
Brandon O said:
The widespread misunderstanding of the FACES scale continues to blow my mind. The visual analog scale is meant to help PATIENTS indicate their pain level (particularly when they're not great with numbers). The little faces are not for comparing to patient faces, like in Scrubs.

Non-subjective pain scales, such as the CPOT, do exist. The Wong-Baker scale is not one of them.
Click to expand...
Good to know! Time for some light research and reading tonight.
 
PotatoMedic said:
Good to know! Time for some light research and reading tonight.
Click to expand...

Sorry for snapping. It's actually a really widespread confusion. I think it's because people want to titrate analgesia according to the patient's appearance, and the scale sorta looks like it's meant for that. Again, there actually are tools for that, such as with intubated patients -- but they're usually more complicated. Example: https://www.mdcalc.com/critical-care-pain-observation-tool-cpot
 
I suppose you could be very passive agressive and walk up to the patient on the phone and have them pick a Wong Baker face for you.
 
Brandon O said:
Sorry for snapping. It's actually a really widespread confusion. I think it's because people want to titrate analgesia according to the patient's appearance, and the scale sorta looks like it's meant for that. Again, there actually are tools for that, such as with intubated patients -- but they're usually more complicated. Example: https://www.mdcalc.com/critical-care-pain-observation-tool-cpot
Click to expand...
No need to apologise. I was taught it was used for that so glad to know I was using it wrong.
 
Hospital regulatory agencies and healthcare education (nursing in particular) spent over a decade pushing Approach 1 "The patient's pain is what they say." Many think this mindset is one of the many contributors to the opioid crisis.

Brandon O said:
Sorry for snapping. It's actually a really widespread confusion. I think it's because people want to titrate analgesia according to the patient's appearance, and the scale sorta looks like it's meant for that. Again, there actually are tools for that, such as with intubated patients -- but they're usually more complicated. Example: https://www.mdcalc.com/critical-care-pain-observation-tool-cpot
Click to expand...

Exactly, most of the scales were validated on intubated patients. Good comparison here: https://www.aacn.org/docs/cemedia/A1524062.pdf

The problem OP brings forth is not whether there is a non-verbal scale that works on verbal adults, but whether there is evidence to validate it in the presence of a conflicting verbal score. I know of no such studies.
 
I only carry fentanyl for pain. If I gave it to everyone who tells me they have significant pain, I'd be out of fentanyl by noon most days. So I mainly reserve it for patients with obviously painful traumatic injuries or those who are screaming/writing in pain and cannot be properly assessed, treated, and monitored without analgesia. Patients chatting on the phone rarely get pain meds from me.
 
Have some Motrin and an ice pack.

I have about the lowest threshold for administering narcotic analgesia possible, but if you're clearly faking or exaggerating, you may place your lips on my buttocks.
 
I think most of us can look at a patient and tell if he is in pain. Document accordingly: patient does not appear to be in distress and vocalizes no complaints. If the patient registers on your Wong evaluation, then by all means administer analgesics.

Talking on the phone does not indicate a need for pain relief. Document it.
 
I have never worked under protocols that mandated the medication treatment for pain. Currently when I work in the field we have all kinds non-nacotic pain medications on standing orders, when I was in the fire service we were more limited but it was pretty rare that I gave narcotics and definitely gave far less than our other medics.

Essentially I assess the patient and decide if we can stay and continue whatever we were doing or if I have to transport them to the hospital.

I don't consider narcotic treatment for any patient that I don't transport (excluding continuation of prescribed regimes) so based on my assessment and potentially discussion with a base physician I start with acetaminophen or NSAIDS and consider treatments that are targeted at the source of their pain. These may include migraine cocktails, cough suppressants, expectorants, IN steroids or vasoconstrictors, and so on.

If we are going to transport then I may give narcotics or benzos depending on etiology, but often still try to target their pain with other medications.

In your case that patient would be receiving no mind altering substance from me, narcotic or otherwise. I instinctively detest when patients report a pain score greater than 10 when asked on a 0-10 scale unless they present signs of acute distress. Since I will be documenting that the patient had normal vitals, no evidence of acute distress, et cetera I don't feel a need to justify why I didn't give them narcotic pain medication especially since I'm not legally or clinically obliged to do so.

If anyone is looking for non verbal pain scores you could consider CPOT and rFLACC, the faces scales are still meant to be presented to the patient and have them chose which face represents their pain (typically for younger children and developmentally delayed patients).
 
That "pain is whatever the patient says it is" is obviously absurd, and has probably cause lots more problems that it solved.

On the other hand, chronic pain is a common and growing problem. Ironically, it is linked to the dramatically increased reliance on opioids that we saw start in the late 1990's. These people don't always look like you expect them to, in terms of the way that their outward behaviors.
 
Remi said:
That "pain is whatever the patient says it is" is obviously absurd, and has probably cause lots more problems that it solved.

On the other hand, chronic pain is a common and growing problem. Ironically, it is linked to the dramatically increased reliance on opioids that we saw start in the late 1990's. These people don't always look like you expect them to, in terms of the way that their outward behaviors.
Click to expand...

I 100% agree with this being absurd but somehow it has crept into our patient care assessment culture. In the UK most services have electronic clinical record and we are expected to complete all the boxes - pain score being one. Failure to do so leaves us vulnerable.
I tend not to follow this doctrine.
 
To me, the 1-10 scale is a subjective part of the assessment, just one part of the assessment, but I include objective parts like if the patient is the patient grimacing, are they guarding, and what they are doing (fetal position, unable to walk, crying vs doing kart wheels to the ambulance) to paint a picture of tolerable vs not tolerable pain. My goal with pain management is to make the pain more tolerable rather than eliminating it, so if they are tolerating it well, there is no need to administer Morphine or Fentanyl; I'm not really concerned if they are lying or not since there is no way I can feel their pain for them. I know some people can put on a good show, but I think they are few of many, and it isn't worth it to discriminate against them (eg the same as trying to discriminate VT from SVT with aberrancy, it's crazy how many people will call VT an SVT with aberrancy). I usually document my reason for giving or not giving narcotics. On my ambulance, we actually do carry 1g IV Tylenol (Ofirmev) due to the Morphine shortage after Hurricane Maria shutdown Puerto Rico.
 
You must log in or register to reply here.
Back
Top