Sternbach Pain Thermometer

[E tank]

I still don't understand what value this has. For starters, acute somatic pain, visceral pain and neuropathic pain are different entities with different qualities, i.e. a broken arm and a wicked kidney stone trip different nociceptors, so unless it's apples to apples, it isn't going to be helpful IMO.

Furthermore, an increase of painful stimuli by a superimposed source (limb ischemia in this case) to spinal cord neurons responsible for pain detection, it would seem to me, would just intensify the overall frequency of pain impulses to the brain and really muddy the waters. That's pretty much the idea of what pain "wind up" is. You just end up with exponentially more pain than you started with.

Interesting conversation, I guess, but there's no getting creative in pre/inter-hospital analgesia.

 

[Carlos Danger]

Again, I realize this is an EMS forum, and I would agree that in the crisis setting, management of moderate to severe acute pain is in most cases best done by medicating (typically with opioids) based on the patient's reported pain level. In the field we are limited to this strategy because of numerous practical limitations.

We aren't debating whether we should take seriously an individual's complaint of pain. And we aren't talking about the "pain thermometer" that the OP posted about. We are talking about why an objective measure of pain intensity might be useful. And the answer to that is this:

1. Pain management can be quite complex (that's why there are medical subspecialties devoted to it)
2. Optimum pain management depends first and foremost on a good pain assessment
3. A good pain assessment (or any assessment) is as objective as possible.

There's plenty of research that indicates that patients are highly inconsistent with self-reported pain scores. And there are numerous reasons for it.

We have all seen people report 10/10 pain as they are literally giggling to the person next to them them and taking silly-face selfies. I have had people in no apparent distress at all tell me with a straight face that their pain is "20/10", and when questioned further, say that their pain has been like that every day for years. I've also seen people in a post-anesthetic stupor with large amounts of pain meds already on board wake up only when the PACU nurse aroused them, and then just long enough to tell me that they are having 10/10 pain, only to immediately doze off and start snoring again. I've had people with nerve blocks that were obviously working well do the same thing.

In these examples, are we really doing what is in the best interest of the patient by blasting them unnecessarily with large doses of opioids, just because they say they are having 10/10 pain? Clearly not. Clearly, pain is not always what the patient says it is.

What about the older person with chronic or acute cognitive deficits? Or the stoic who appears very uncomfortable but says they are "fine" when you try to talk to them about their pain? Should their pain go untreated because pain is always what the patient says it is? There are consequences to untreated pain, just like there are consequences to unnecessary opioids.

We can take a complaint of pain seriously without formulating an entire treatment plan based on the answer to a single question. I can't think of many other examples of where we are expected to form management decisions on a single data point.

There are many types of pain and some don't respond well to opioids - some can even potentially be worsened by large doses of opioids. Many pain syndromes respond best to well-defined pharmacologic strategies. Dosing people with lots of fentanyl or dilaudid is often not the best strategy for a good outcome. It all depends on the history and assessment. This is why objective assessment tools are desirable.

 

[E tank]

Nice post...and the reality is that the vast majority of the pain that we (in and out of the hospital) deal with is of the no brainer category. The weird stuff is, mercifully, the exception, at least in my practice. But for those outliers...are

...objective assessment tools...

really possible for practical application? Folks in full time pain management practices are a breed apart...

 

[akflightmedic]

Remi, you took it out of context. Yes, the post op could rouse and state 10/10 and then doze off....their pain very much could have been a 10 out of 10 in that moment, it is what they say it is. The discussion was not to "blast them" with meds based on this, the discussion was how to measure the pain and proceed from there. If you inferred that I meant dose them when they ask for it, that was not my intent.

I may have stated we treat based on that, however we treat accordingly. I get the Big Picture of it all within context.

Same way in the ICU how we medicate vented patients for pain or discomfort, when they cannot verbalize a scale. Other things are observed and utilized. But in EMS/Pre-hospital and for the most part within any healthcare setting, the pain is what the patient states it is. It does not mean we load up the narcs at that point, however their statements are the tool of measure. How we choose to use that tool now defaults to our clinical judgment and practice, but staying exactly on topic....aside from placing people in MRI or some other brain wave study in the moment, there is no major discerning way to evaluate and document their pain that I know of.

(Again, the caveat was some vitals change, some behaviors change...but this is not a steadfast rule).

 

[mgr22]

I've enjoyed watching this discussion develop among experienced providers. I think the consensus is pretty much that it's hard to quantify pain reliably, but I wonder if we've overlooked correlations between patient feedback and measurable things -- e.g., vitals, EEGs, EKGs, lab values, etc. Maybe there's something analogous to Levine's sign -- low-tech and obvious. Or maybe it's something surprising and subtle. I don't know any more about this than the rest of you, but as an engineer, I think it's a cool challenge to propose and test hypotheses. I'm just mentioning this because some of you who treat lots of patients may be able to pursue inexpensive research and publish meaningful results. Stranger things have happened.