Pain

The Fifth Vital Sign.

It not only sounds like the title of a Bergman film, but pain as a vital sign is like a Bergman film in that it amounts to a conceptual sleight of hand. It has been elevated in the medical and nursing communities from a simple statement about a patient's response to illness or injury--the patient's perception of discomfort--to an indication of the patient's vitality; from a personal reflection upon the human condition of suffering to a quantifiable measure of that suffering. A Bergman film? Yes indeed.

Vital signs are measures of the physiological conditions associated with life-- vitality. The four traditional signs of vitality are blood pressure, pulse, respirations, and temperature. It is necessary to possess some quantity and quality of each of these in order to be alive.

Because they are physical, vital signs are measurable. As well, they may change in relation to the various physical conditions to which the human body is subjected, conditions like physical injury or disease processes. Vitals signs DO NOT depend upon what the patient says about them. They are related to conditions the patient cannot of his or her own will easily control or alter.

But what of pain?

As nurses we are told to think of a patient's pain as whatever the patient says it is. Traditionally, nurses "assessed" pain by asking patients where they hurt, what it feels like, how intense it is, when did it start, what exacerbates it, and what they've been able to do to ease it, if anything.

Now, we are encouraged to "measure" pain by having patients rate it on a scale of 0 to 10, with zero being no pain at all and 10 being the worst pain. We have changed pain from an experience that must be described to one that can simply be quantified.

So, what is the problem with this? Why is treating "pain" as a number potentially detrimental to ER nursing?

As a subjective measure of highly individualized experience, pain is not like the other vital signs. A temperature of 98.6 degrees may not be "normal" for everyone, but 98.6 for one person is the same as 98.6 degrees for another, just as a pulse of 80 in one patient is the same as a pulse of 80 in another. As well, 105 degrees is dangerous for anyone, not just those who think it is a high fever, just as a heart rate of 20 is dangerous for anyone no matter what they think of it (if they're able to mentate at all at this rate.)

But is 5/10 pain the same for everyone? Does the same broken bone produce the same pain for everyone? And how do we know that the patient having 5/10 pain is really having 5/10 pain? If it were another patient with the same injury, would the injury result in the same amount of pain? If a patient's pain of 5/10 eases to 3/10, is this the same as when their 7/10 pain eased to 5/10 or when another patient's pain decreass from 5/10 to 3/10?

When you think of it, the number a patient reports really doesn't mean a whole lot. Whereas "blood pressure of 100/60" tells me something specific about my patient, "pain of 5/10" does not. How am I to know how much pain this is? I know its less than 7/10 and more than 3/10, but I don't know what these values mean anymore than I do 5/10.

With the other vital signs, zero values can be interpreted as meaning no vitality. Zero blood pressure, zero respirations, zero pulse or zero temperature means a patient is dead. With pain, however, a patient with no pain (0/10) is not lacking vitality; this patient might be said to be healthier than those with pain. Oddly, the only immediately understandable and specific value on the pain scale is, in fact, zero.

Then there are the patients who complain of 10/10 pain. These patients don't really have a pain problem, they have a math problem. They don't realize that 10 out of 10 represents all the pain possible! I like to ask these patients "If I ripped your arm off, would you have more pain than the 10/10 throat pain you're complaining of now?"

Fundamentally, that is the problem with quantifying pain: it tells you nothing of the clinical significance of a patient's illness of injury. Other vital signs do.

A Bergman film, indeed.