In a recent post, I made fun of some of my patient’s uses of pain scales. While I am big advocate for pain management, I am occasionally stumped by the pain scale declarations of 10. This last week in reading the report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research
, I read a section on pain scales that I thought was interesting.
Pain scales were widely introduced into the health care system in 2001 due to the efforts of the Joint Commission of health care Organizations which made pain the “5th Vital Sign” and a requirement for hospital accreditation. Health care personnel were now required to document a pain scale in a patient’s record right next to the more traditional vital signs of pulse, blood pressure, respiratory rate and temperature. It wasn’t long after that EMS began to require pain scales as well. In our region every patient requires a documented pain scale whether or not they are complaining of pain.
Here is what I read in the Relieving Pain book:
The full impact of the fifth vital sign approach is not entirely clear, however, as studies have indicated effects ranging from beneficial and limited outcomes to negative consequences. While adherence to the standard has improved satisfaction with pain management, adverse drug reactions have increased (Vila et al., 2005). In selected trauma care centers, overmedication with opioids and sedatives—attributed by the researchers to compliance with the new standard—reportedly contributed to higher mortality rates, usually resulting from too great a reduction in blood pressure or compression of the airway (Lucas et al., 2007). In a veterans’ outpatient clinic, monitoring pain as a fifth vital sign failed to improve pain management as the assessment was not followed up with recommended treatment, even for patients reporting substantial pain (Mularski et al., 2006). Similarly, in a study of eight veterans’ facilities in the Los Angeles area, documentation of pain—necessary for pain care planning—was frequently absent from the medical records of patients with moderate and severe pain (Zubkoff et al., 2010). Taken together, these studies suggest the need to exercise careful clinical judgment based on a comprehensive patient assessment instead of merely monitoring pain (meeting, in a sense, the letter of the law and not the spirit), using opioids to the exclusion of other treatment approaches, or routinely using these powerful medications when their use is not clinically indicated.
What I take from this is we need to exercise “careful clinical judgment” when evaluating pain. Every patient should get a pain scale, but we should not relay entirely on that scale to guide our treatment. I am not suggesting we revert back to the “I can judge your pain” mentality, when studies have clearly shown people are incapable of accurately judging another’s pain. What I mean by clinical judgment, is that paramedics need to decide, based on a number of factors, what is the most appropriate method of treating someone’s pain. Automatically giving a narcotic analgesic to any patient who says his pain is a 10 is no more right than automatically refusing to give narcotic analgesics because a patient doesn’t look like he is in pain.
It comes down to the old cookbook analogy. Paramedics should never blindly follow a protocol. Instead paramedics should assess, evaluate, consider, and then act in the best interests of the patient. And, of course, document why you reach the clinical course you do.
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