How bad does it hurt? I’m willing to go out on a limb and say that this is, quite possibly, the most common question we ask in EMS. And it can be a difficult question to answer. How bad compared to what? How do we reconcile the patient with significant pain who winces and says it only hurts a little. Or what about the patient who is relaxed and seemingly comfortable while reporting the worst pain they have ever felt?
Not everyone feels pain the same way. Some patients feel pain more than others. And, perhaps even more significant, some patients fear pain more than others. What’s a clinician to do?
You and I aren’t the first ones to wrestle with this question. Medicine has devised a multitude of way to ask patients how much pain they are experiencing. We’ve even gone lengths to try to assess which ones are comparatively more accurate. From numeric rating scales to verbal rating scales to visual analogue scales. (No, I didn’t make that up.)
If you prefer to know who’s scale you’re using you can try the Wong-Baker faces scale, the McGill scale or even the Walid-Robinson pain index. (The patient needs to be taking opiates to use that last one.)
The truth is, we may just be wasting or time trying to develop more sophisticated and accurate ways of asking this question. With rare exceptions, prehospital folk tend to use the standard numeric rating scale, A.K.A. the 1-10 scale. It’s simple, it’s relatively fast and it doesn’t require us to carry around cards with faces on them or lists of questions.
I’ve always used the numeric scale and I’ve found it to be simple and useful but it has its pitfalls. You need to be careful how you ask the question. You also need to have a few back-up questions ready to help clarify the answer. Here are some of the questions I ask when I’m assessing pain severity.
“On a scale from one to ten, ten being the worst pain you have ever felt and one being a mild headache, what number would you give this pain you’re having right now?”
Notice that I try to give a specific marker for the extreme ends of the scale. I don’t want to be wishy-washy about where the scale begins and ends. If their going to give that pain a ten it needs to be the worst pain they have ever had. This makes for a good follow up question if the patient does report the pain a ten.
“What was the worst pain you had ever had before today?”
This gives you a good marker for something to compare the pain to. So this is worse than your kidney stone pain? This is even worse than your broken leg?” Sometimes it’s easier to make comparisons than to pull a number out of the sky. If this is not their worst pain ever, you can use another follow up question.
“How does this pain compare to that? [Your worst pain ever.]”
Letting people compare one pain to another may give them a more firm anchor regarding the pain they are experiencing. We tend to recall painful events in fairly vivid detail. Allowing them to consider their ten-pain event may make it easier for them to place this pain on the scale.
If the patient is describing their current pain as a ten, it’s helpful to explore what that means.
“What would you imagine might hurt worse than this?”
Questions like these can seem absurd from the patients point of view, but this question has a two fold purpose. Allowing the patient to imagine a worse pain than they are currently having helps them put this pain event in context. It also helps you to understand if this pain is the worst pain the patient has ever felt or the worst pain they can imagine. The difference is subtle but telling.
When this pain was at it’s worst what number was it? When was that?
Here, we’re considering the severity of the pain in the context of time. I’ve found that this can help the patient shift gears and recognize that we’re trying to be really precises about their level of discomfort. Not just for documentation purposes but so we can understand if they are getting better or worse. This will give us some clues as to where we are on the patients pain progression.
Some patients will only require one or two questions to get a handle on their pain severity. Some patients will require that we dig deeper. This is true for all of our pain questions.
Pain severity is only a small piece of the pain puzzle. Another host of questions are needed to explore the pains quality and other characteristics. When discussing pain I find that severity is a good place to start.