Pain Unit of Measurement

One of the things any Emergency Physician would put on a short list of "things I want" is an objective measurement of pain.  Separating the wheat from the chaff, knowing if pain is being treated adequately and appropriately would be of enormous benefit to medicine in general and EM in particular.

Discussing this with a colleague, a unit description was proposed: the thromb.  It’d be interesting to know whether these wind up being micro-thrombs, or need exponents following their numbers.

Only time will tell. 



  1. I suspect it would be a logarithmic scale. I would be content with the current system, in which all pain is rated ten and I can thereby ignore that data field entirely, except for one major irritation — the “Vital Signs” icon on our ED Tracking Board (IBEX) turns red for a given patient whenever the vitals are “out of range”. So basically, all the icons are red and I can’t use what would otherwise be a nice screening tool. Grrr.

  2. I learned something from one of our ED nurses the other day. When I brought my patient in, she asked about pain. The pt replied in the usual ‘7 or 8’ fashion. The nurse then asked how long the pain had been there, and I believe that the answer was for greater than one day. The nurse then said that if your pain is greater than ‘4’, you are unable to sleep. That seemed to adjust the pain level towards reality. I thought it was a great reference.

  3. Anonymous says:

    It may be helpful to put in coefficient factors, for example, multiple by 0.1 when the patient is a female in her 20s or by 10 when the patient is a 70 y/o male who is a military veteran.

  4. Goatwhacker says:

    I have a different experience than Shadowfax – in the ER’s I’ve worked pain is not always rated a ten, often it is rated 11, 15 or 20, making the scale even more useless. Calling it a “vital sign” is a joke, you may as well ask the patient what he thinks his blood pressure and pulse are too and save the nurse a couple of minutes.

    Patients deserve to have their pain adequately treated but any method of measurement that relies completely on self-reporting will be fraught with error, especially when there is a subset of patients who benefit by mischaracterizing their pain. Proponents of the scale usually acknowledge this, mumble “Well, it’s the best we’ve got” and expect the scale to be used as gospel anyway, at least as how it applies to surveys, studies and inspections.

  5. The only time I find the pain scale at all useful is to judge a persons response to pain meds. Like when they come into the ER at a 15 and it drops to an 8 after morphine, I know I might be getting somewhere.

  6. Anonymous says:

    From a pt perspective I think the pain scale is a joke. I hate it when they ask me this question. One persons 10 could easily be another’s 5. It depends alot on past experience and health history. An example is prior to having cancer surgeries I really had no idea what REAL pain was like. If asked about my pain level (for whatever symptom) I might have responed something was an 8- 10 when in reality after experiencing BAD pain for a long period of time I have a completely differnt notion about what an 8-10 is. An 8-10 keeps you up and awake, curled in a fetal position, crying, not even being able to have a meaningful conversation. people who claim to have an 8 and then fall promtly asleep have no clue!

  7. Bad Shift says:

    I never ask about pain in numbers. But so many of our patients are trained now, that when I ask how are you feeling, many will say, “Oh my pain’s about an 8.” That’s how I can figure out who’s been to the ER too many times.

    The point about the number changing for a given individual is valid–but then, how is that different from asking, “Do you feel better?”

    This job gets more Orwellian all the time.

  8. Anonymous says:

    From what I read here, it appears that the patient’s estimation of his own pain is going to be treated with contempt, so why ask?

  9. Goatwhacker says:

    Anonymous 0154 PM, in most ERs if not all the nurses or docs are required to ask, and usually required to use the 1-10 scale. I think what you are perceiving as contempt for the patient’s opinion is more frustration with both the scale itself and the way its usage is blindly encouraged.

  10. I find the most sincere, honest responses come from the children who use the faces scale. Interestingly enough, I find that when adults use the faces scale, I seem to get a more accurate description of what they actually are feeling.

    I know what severe pain is (10/10), but I rate each pain based on what I think that particular pain is in and of itself, not related to the worse I’ve ever had. So while a thumb vs. hammer could be a seven, a RLQ appy could be a four.

    I hope that makes sense.

  11. doctordel says:

    Depending on the level of comfort the patient and I have developed (or so I believe we’ve developed) during the ER encounter, I will sometimes use a fairly graphic description of circumstances I personally believe would elicit a 10/10 assesment; it usually involves hypothetically accidentally stepping on hot coals in a smoldering campfire. If we haven’t really hit it off and I am inquiring, I may ask them to base it on the pain a relative had to suffer through after I obtain a family history that indicates a history of a painful condition. Or sometimes serendipity saves us the need for objective assessment: I remember I had one young lady who-after I was able to coax her from her cell phone (another topic we could discuss with vigor, I’m sure)-she had just enough time to rate her pain a “10” in between blowing bubbles with her gum and laughing at her boyfriend. Just as I was ready to try and convince her to REALLY think about her assesment, a patient in the next room over screamed in anguish from an I&D that clearly required more analgesia than originally anticipated. I just had to look at my patient and she reluctantly ammended her response-“I guess it’s a 9.”

    BTW anonymous 0154, we ALL take pain-control EXTREMELY seriously but you have to understand something about the practice of western medicine and its inherent foibles. As ER docs in an age of significant pressure to streamline care in the name of cost-effectiveness and temporal efficiency, we have to exercise appropriate diligence with our orders, be they for lab/radiology tests or for therapeutics. As a result of this-and as a result of the medical model pioneered by our forebears and reinforced by our education-we predicate a significant portion of our medical decision-making on what the patient says during the interview. Long story short, this means it is REALLY helpful if the patient tries to be as thorough and accurate as possible when we are trying to help them; pathology is not all that cut-and-dried as it is and sometimes the difference between making the correct diagnosis and any number of wrong ones is the quality of the patient’s narrative.

    But I still order way too many tests…

  12. Here in KY, we’d have to go with the “thob”, for the “thobbin” pains we have all the time.

  13. I hate the pain scale …I hate trying to rate my own pain and I’m so used to pain it gets hard for me to evaluate.

    I have lupus and a few other gems … I recently went into the doctor to make sure the respiratory symptoms I was having was allergy not URI (I was wrong) since I was having surgery on april 4th … I was off my anti inflammatories and prednisone for the surgery … they asked me about my pain level ..and annoyed, I said I don’t know … a 6?

    They took my blood pressure, normally low, I run about 110/64 … my blood pressure was 152/102 … I said “WOW! I guess I AM hurting as bad as I feel!”

    It gets hard when you are in constant pain to rank pain … you also get used to carrying on life as if it doesn’t exist, even when it’s on an 7 or 8 level … because if you don’t …you’d never leave your bed. You don’t get help till it goes WAY out of control ..because it’s always absurd.

    A typical lupus or RA patient lives with a pain level that would drive a healthy person to the doctor or ER ..that day saying “Something is desperately wrong!”

  14. I refuse to use the pain scale when asked … because it’s too relative and subjective. I always try to express what is happening by comparing it to something most people would be able to relate to … be it a toothache, a sprain … whatever.

    A numeric pain scale is only good if everyone communicating has the same reference point … which is almost impossible. Is my idea of 5 the same as yours?

  15. Anonymous says:

    I am Anon 0154 and it looks like I need to rephrase my statement and expand on it.
    Because many people have abused the way they rate their pain, the natural reaction is to question every one; same principle goes as to why we all are assumed thieves at the gas station and have to pay before we pump.
    So my question was: since you do not know whether the patient’s assessment is realistic or not(and you have little trust in it), why do you ask? How does that help you?
    Unless, as Goatwhacker mentions, you have to – even if it serves little purpose.

  16. anon 0154 I am an ED Doc and don’t value the pain scale our nurses are forced to assess on patients. It rarely if ever helps me assess a patient. I can usually see in the patients appearance, voice and mannerisms that they are in mild (lauging on a cell phone) or severe (writhing in the bed screaming) type of pain. the in betweens are the ones we aren’t quite sure about. I ask a simple question “do you need pain medicine?” if they say yes, they get pain medicine. if they say no. then they don’t.

  17. It is only helpful in that you know if you are making a difference in a single patient. The patients it is most helpful for ME, and the only time I insist the patient pick a number from 1 to 10 is for a suspected Acute Coronary Syndrome (heart attack) patient. Many of these patients are the “70 year old former military” guys who just say, “Oh, I guess it’s not that bad” when in the meantime half of their heart is dying right in front of you. When I explain to them that it is our goal that they be completely pain free…that they are experiencing a ZERO on the pain scale…they it becomes meaningful to the patient as well. I can’t think of any other time when I ask people to rate their pain using the number scale.

    Also, not only are the nurses required to ask about the pain scale during triage (as well as domestic abuse screening for ALL patients), it is many times one of the required components to get reimbursement for the patient encounter. If you do not describe the quality of the patient’s pain, you might not get paid for it, even if you correctly diagnosed and treated the injury or illness.

    I hate practicing medicine this way. I much prefer the free clinic in Honduras where I volunteer twice a year.