Monday, 26 April 2010

Ten out of Ten

"Ten, definitely ten". The stock answer of some people when asked how bad their pain is on a scale of 1 to 10. I guess that gives them a genuine reason for having called an ambulance in the first place. The thing is, that they sit in front of you, no wince, not doubled over, just sit calmly and tell you that the pain in their arm or leg, stomach or back, is the worst pain they've ever experienced.
If the patient is a mother, I often ask if this pain is so bad that it's worse than childbirth, a question that regularly has the pain score downgraded, even if only slightly. Either that or they're superwoman. If the patient is a man, I'll compare it to something often involving a gory amputation of one of their limbs, and see what happens then.
These patients, whilst claiming to be in the worst pain known to humankind, then jump sky high as soon as I take a pinprick's worth of blood to test their sugar levels - a procedure that hurts no more than a minor paper cut. And more often than not, haven't bothered to try taking any home-based pain relief such as paracetamol or ibuprofen. The easiest option is to call out an ambulance and discharge the responsibility for their condition and care to somebody else.
Sometimes, I meet the exact opposite. A patient who's pale, sweating buckets and complaining of a slight ache, 2 or 3 at worst on the pain scale. A patient who is so clearly in distress, but denying it, either out of stoicity (if that's even a real word), bravado or genuine fear of the unknown. Regularly these are the sorts of people who wouldn't call an ambulance until they are practically bullied into it by concerned relatives or friends, or have had ambulances called for them without their knowledge.
In both cases, those who overplay their pain, and those who underrate it, I'm left with a dilemma.
On our ambulances, we carry a very limited option of analgesia, or pain relief.
For kids, we have liquid paracetamol to ease pain and reduce fever. To be honest, I don't know why we have it. It should be in the drug cupboard, in plentiful supply, in every child-containing household in the land. There should be no reason for us to give a 4-hourly dose of fever-reducing, pain-easing medication that can easily be bought at any chemist, supermarket or even petrol station. It can be given in the calm, safe and familiar surroundings of the family home by any medically-unqualified parent, rather than in the scary scene of the back of a terrifyingly strange ambulance by unknown, green-attired, martian-looking paramedics. I know which I choose for my kids. If one of them refuses, then just the mere mention of the word doctor or hospital is enough to get them to down the stuff.
We also have Entonox, a mix of oxygen and and nitrous oxide, often referred to as laughing gas. Like any other analgesic, it works well for some people, and not at all for others. Over the last few years I've found that it works particularly well for things like muscular back aches, releasing enough of the tension in the muscles to enable the patient to get on the move again, exercising those tensed backs, instead of leaving them immobile. It also works well enough to enable a dislocated limb to be reduced, enough to allow transport and definitive treatment at hospital.
Then we have Oromorph, and Morphine sulphate. The same thing, but one is swallowed and the other requires IV administration directly into the bloodstream. These are the ones we use for severe pain. Things like heart attacks, nasty fractures, serious burns and other injury or illness-induced agony. There are other options for stronger pre-hospital analgesia, but these require having a doctor on scene, in the form of either HEMS or a Basics doctor.
The dilemma I have is when to use analgesia, and of which sort.
For our first type of patient, the one in such agony as he sits and drinks his cup of coffee in the front room as the caffeine-deprived ambulance crew stand by and watch, do I jump right in and give him some of the heavy stuff? Do I take his answer as gospel, his pain is off the scale, and needs immediate resolution, and so give him the morphine straight away? Is it justified, and is it necessary? Or do I suggest to him to try some paracetamol first (from his own supply, as I don't carry an adult dose)?
And so, on to our second type of patient. Clearly, in my eyes, in severe pain, but refusing to admit it. She declines the offer of either Entonox or morphine, says she's just taken some over-the-counter tablets, and is feeling better already. Both her clinical observations, as well as my observation of her, indicate otherwise. Do I just offer these patients a seat in the ambulance and convey them to hospital, no analgesia, no treatment, no nothing. After all, they've refused any. Doesn't seem right to me.
In both these cases, the question is one of objectivity vs subjectivity.
Is the pain defined by the patient's experience, or by the paramedic's observations and assessment?
Is the treatment decided by the patient's story, or by the paramedic's interpretation of it?
Which of these methods would leave me to treat the patient the best way possible, and afford my treatment, much like their pain, a score of ten out of ten?

10 comments:

nickopotamus said...

In pratice, I try and use the Cynical Real Alternative Pain Score (CRAP - see the base of http://www.messybeast.com/dragonqueen/medical-acronyms.htm). It's a "formalisation" of the common sense approach, which I'm sure you use - if the patient *looks* in pain, give/encourage pain relief. If they're not, either discourage, or give mild analgesia.

The main problem I've come across is the form filling. Most PRFs etc now *require* you to fill in the patient's pain score, and anything >5 needs strong analgesia. So if the patient reports 10/10, yet they're sat drinking their coffee, there's no way to justify not giving some morphine other than in the notes, which aren't even looked at during audits. And even if they are, how do you say "the patient is a big fat liar"? *sigh*

Fee said...

The last time I was in an ambulance (dislocated shoulder, age 13) they offered me the laughing gas , but after one breath I felt so sick I wouldn't touch it again. I described the pain in comparison to my worst previous experience, as "not as bad as a broken leg". The hospital pumped me full of goodness-knows-what before putting the shoulder back. Certainly put me off rope swings, I can tell you.

Sue said...

A lot depends on the patients previous experience of pain, and their medical history I'd guess. I can be sat at work with pain at an 8 on the pain scale and no one would notice, but that's because I'm used to it, and why my handbag has buscopan, ibuprofen, diclofenac, dihydrocodiene and morphine in it, along with ondanstetron for the more 'fun' days. I've turned up at A&E before and been given funny looks when I say I've taken morphine, well obviously to me I wouldn't go unless oral morphine doesn't hit the spot, otherwise I'd go home!

Tom said...

During the 1980's when I started on the service, genuine stoicism was the norm, and wastrels were a comparative exception to the rule.

I think you will have to use your experience and instincts when applying your subjective test.

PS Love the idea of the CRAP score suggested above. A pioneer move in the right direction a patient pain management.

InsomniacMedic said...

Thanks all!
Sue - you have highlighted a group of people I hadn't actually considered when I wrote this post - those who have chronic pain. They (you?) are in a different category altogether. I find those who do have chronic pain very very rarely call ambulances, because they are so used to it. On top of that, just like you, they've already taken the full spectrum of analgesia, know that they are in trouble and there's nothing left that they can try, and leave me little option but to make them as comfortable as possible for a journey to hospital. Thank you for making me think some more and I wish you well (and as pain free as possible)!

Raindog said...

Insomniac,

Over the last month, with my incarcerated hernia, ER visit, and resulting surgery, my wife discovered, I am a classic underreported.

She printed out a pain chart. to show me my level "3" is really a six.

In my life, I have had blinding, crippling amounts of pains. I live with chronic pain in my leg.

My thoughts are always, 'I've had worse. This is tolerable compared to that.'

My personal pain chart is:

1) Nothing.

2) Tolerable.

3) I hate you.

4) I'm nauseous.

5) I'm passing out.

Great post,
RD

Becca said...

Another chronic-pain person here, if I'm asked for a number I usually try to couch it in terms like "this is within my day-to-day normal range and if I wasn't quite so ill I'd be in uni today" or similar. It's in my/everybody's interest to try to frame it so it's clear what you mean.

With that in mind, I really really love this for its rather clearer scale...

Raindog said...

Becca,

The pain scale you linked to is great. My wife showed the first one to me. To me, most of that pain scale isn't real pain. The second one is humorous, but more accurate.

Rosie said...

I'm in the category of having what I suppose would be called chronic pain. I try to rate my pain using the 10 point scale but as someone above mentioned I also try and put the score into context.

Knowing my illness and myself well enough I can quickly recognise when pain is just pain and nothing to unduly worry about. The kind that I take a couple of prescribed pain relief med's for and go back to bed for a couple of hours. If I feel I should worry about the pain I will find a way of getting myself to A+E. I can't imagine ever calling an ambulance out for myself, but I'll never say never.

Even with practice I find it really difficult to place pain onto the scale. Usually because if I say something like 8/10 which, for me, is less than I have experienced before but more than my usual 'normal' medic's seem to have a tendency to panic a little. I absolutely do not blame them for that reaction. I do have a pretty high threshold and I suppose I can sometimes play down how much it really hurts.

Truth be told I really don't like being either worried about or fussed over which is how I view my need for medical care. I'm grateful to everyone on my medical team and they do an amazing job of looking after me but I just wish I didn't have to have so much attention put onto me.

I've definitely said enough, maybe too much...

Jamrock said...

Hiya

This is interesting for a couple of reasons. When I got scraped off the floor by a lovely crew, exactly a year ago, having fallen off my pushbike at speed, we did the pain score thing.

I had radial fracture which was creating sharp pointy bits under my skin.

I weighed in with a pain score of three because to be honest I couldn't really feel much presumably endorphins/shock (disclaimer: not medical person) and I was able to walk (once my arm was stabilised) to the ambulance.

What we all didn't realise was that I had damaged my shoulder and when I went to get something out of my pocket I was hit with a white hot pain. Whatever noise I made caused the crew to go very pale and stare at me (it was all over in a flash) I looked at them and said "ok, I'm giving that a six!"

That's when the Morphine sulphate went in.

What I really liked is that they came back into A&E at the end of the shift to see how I was and find out the final tally of my injuries.

I'm grateful for the post as I always stated I got administered morphine but was told that this could have only happened at the hospital.

Thanks!