It’s something we ask all of our patients. As nurses we want, no, need to know if our patient is in pain. So we ask, “On a scale of 1-10, with 10 being the worst pain you have ever had, how would you rate your pain?” Or we use the faces method, or whatever method of assessing pain is in vogue at the moment.
So very often with a straight face, the patient looks at you and says, “I’m in 9 out of 10 pain.” Just like that. Straight faced. Vitals are completely normal. Face calm, nearly serene, talking and laughing on the cell phone, with not a single outwardly visible sign of any discomfort. Since we rely on out patients to report their pain to us, it is not something we can objectively monitor, you have to accept what they say it is.
Now I know people in chronic pain. I know that you can learn to block, modulate, go into a Zen-like trance to mitigate your pain. But I have never seen anyone in true 9/10 pain who is calm. That would be impossible. I always try to give a scenario with pain, so that the patient will understand what I mean. I’ll say, “0 is no pain, 10 is being doused in gasoline and set on fire.” or for the ladies, “10 is giving birth.” But still I get the odd answers.
The reason I bring all of this up is that we have had a preponderance of folks in “pain”. These painieurs always report their pain is 9/10 and that the only thing that works for them is Dilaudid. They watch the clock and call 5 minutes before they are due to “remind” us that their meds are due.
We actually had one come up to us who immediately complained about 9/10 chest pain. The nurse, being thorough asked, “What do they give you normally? Nitro?” “No” she replies, “They just give me Dilaudid.” Straight-faced, looking like she is in a café ordering a latté, yet still having 9/10 chest pain. To me it is a total disconnect.
Partially the disconnect comes from the fact that we color the patients’ report with our own perceptions. The other week I re-injured/aggravated an old ankle/foot injury. It throbbed mercilessly and then it would spasm. At times, the spasms were so painful that I felt like I would vomit from it. Even my wife looked at me grimacing, sweaty and pale and asked if I was OK. Sure I was being John Wayne-esque about it and stoic, but it hurt. I popped a couple of Tylenol, grabbed the ice pack and put my foot up. Even with me almost vomiting from the pain, I would only have rated the pain a 7, maybe a soft 8 of 10. I can imagine what 9/10 pain feels like and I have no desire to feel that. I know that if I was truly in 9/10 pain, I would not be calm. That’s why it is so hard. You wish you could tell the patient to “cowboy up” and deal with the pain, but you can’ – although I did overhear an orthopod tell his patient we was going to have to do just that. We have created a culture where it is never OK to have some discomfort. Just look at the rash of relatively healthy folks showing up to EDs complaining of the sniffles and low-grades temps thinking it is the flu.
So sometimes you don’t ask. You observe from a distance and document. Even when you’re assessing the patient, unless they bring it up, you stay away from it. What I hate the most about the painieurs is that they color your assumptions of everyone else. Where you normally would try to reduce the pain of your patients, you ask yourself, “Are they faking it? Do they just want the buzz?” And I hate they have done that to me.
I know there is no easy answer to this dilemma. I try to take the road where unless they have proven themselves to be dodgy, I treat the pain full force. But with some that you deal with time after time after time, you know that they are drug seeking and all they want is the rush. But moreso I try not to let my own perceptions of pain color my view. I may be able to deal with 7/10 pain better than others due to my nature, so I can’t let that get in the way of effective treatment. And for the most part I don’t. It is just those rare occasions where I question, but more often than not I give the meds and hope we’re not being taken advantage of.
And as for the patient who only wanted Dialudid? The nurse called the doc who pretty much said they were a known drug seeker (which we knew already) and she would not provide their drug of choice. The patient realizing they were not going to get Dilaudid promptly signed out AMA.