I quite agree with Dr. Edwin Leap about time-outs (“Time-Out: ‘Is This the Meteor That's Going to Kill You?’ EMN 2009;31:6), but I have another topic to rant about: the whole farce about pain scales foisted upon us by what I call the Evil Twins (Medicare and the Joint Commission).
We are supposed to believe the dogma that “you can't measure pain,” and we have to accept however the patient reports his pain and that pain scales mean something. I beg to disagree. I think of pain as a motivating force, determined by its cause and reduced by the person's resistance, not something you can add up like a stack of library books. As an example, a Category 2 hurricane from the Northeast and a Category 2 hurricane from the Northwest only result in a Category 2 hurricane traveling south, not a Category 4 hurricane.
We need to treat the part of the pain we can see, in vital signs, facial expressions, agitation or restlessness, and autonomic signs. The old guy who says his broken leg “ain't that bad” doesn't necessarily need a load of narcotics while the guy dancing around the room and vomiting from a kidney stone certainly needs treatment. Maybe we should focus our time and energy on trying harder to help the poor souls who have unbearable pain from metastatic cancer or kids who are scared because they don't understand their pain instead of loading up healthy-looking people who say their pain is a 14 on the 1 to 10 scale, all the while texting their friends.
What this stupid requirement has done, however, is dramatically boost the frequency and amount of opiates used in our EDs. Perhaps the whole approach to chronic pain is flawed, too, and maybe treatment for chronic pain should be geared more toward increasing resistance. Let me use another analogy. If you substitute cold, another adverse stimulus, for pain, people would think you were nuts to try to deal with cold by taking narcotics instead of increasing your protection by bundling up with parkas and mittens.
Passing out opiates like water is nuts, too, with some exceptions like the examples I cited. Maybe fibromyalgia is really a lack of resistance to the normal pain sensations of daily life, rather than a larger dose of painful stimuli. On the other hand, even intensely painful experiences like labor seem to be ameliorated by preparation. Maybe the Evil Twins should just let us treat the people we can see who truly need treatment. And we should think about what else we can do to help our patients besides just prescribing more controlled substances. What do you think?
Paul Tice, MD