Pain

Many times through my recovery process I think back to when I first emerged from the surgery and stayed in the Pediatric ICU[1]. Unfortunately (or fortunately) much of my memory from there is hazy. My only clear memory was that of pain. I was having dinner with my family recently and the topic of pain arose. My wife said, “Do you realize that you only received 1 mg of morphine? That’s a pediatric dose.” The usual dose of morphine is 0.1 mg per kg every 4-6 hours. I was about 210 lbs (~ 95 kg) at the time of the surgery, which means my dose of morphine should have been 9.5 mg of morphine.

—- Quantifying Pain —-

In medicine, pain is a topic that is poorly understood. We have long used the 0-10 Numeric Pain Intensity Scale. [2] This is our way of trying to make a subjective finding an objective one. The problem is that there is no way to measure how much pain someone is in. Unlike metrics such as blood pressure and heart rate, there is no set number for pain. Thus the question becomes how do we treat pain? If someone is found to have an elevated blood pressure, bringing down this number is easy, but with pain, even though there are medications to alleviate it, there is no tangible number to target for treatment. The Numeric Scale attempts to do this but in reality, clinicians rely on ‘gut feeling’ when it comes to assessing pain. This method lends itself to wide variation and often missteps.

Pain scale
Pain scale

—- Two Sides —-

As with everything, there are two sides to this debate. Someone in pain would assert: When they asked me to rate my pain, I told them it was a ‘7’. But they still refused to give me any medications for it. All I want is something to dull this pain so I can get back to my life. They have the medicine I need for this, so why don’t they give it to me? If you spoke to this patient’s clinician they might say: I have never encountered this patient before and I’m afraid he/she is a drug seeker—only wanting to get a high from certain pain medications. More importantly, these medications have potential serious negative effects—they can stop breathing for one. Also look at his/her heart rate, does that look like a ‘7’ to you?[3] 

There is no right or wrong side here, but what usually happens is that this hypothetical patient would not receive any pain medication, and would not be given an explanation. Both parties have valid arguments. The problem is not the patient or the clinician; the problem is with the system itself as there is no acceptable way to quantify pain. In an ideal world there would be a machine that measures pain. That way, the clinician could see a number in front of him/her: it says here that your pain was measured at 26.55 ounces. That’s high! Let’s go ahead and give you some pain medication and bring that down. Unfortunately, no such machine exists.

—- Chronic Pain —-

image

In a recent study it was found that ~ 30% of all Americans suffer from chronic pain.[4] This could range from daily headaches to unrelenting lower back pain. To put this number in perspective, it has been estimated that less than 1% of the population had a case of pneumonia in 2010.[5] The question that must be answered is are these people getting proper treatment?

—- No Answer —-

Short of a wild, unforeseen advancement in medical technology there is no all-encompassing solution to this question of pain. For now we must deal with the situation as it is. The one aspect that can be improved upon is communication. In the case described above the clinician must make it clear to the patient of his/her reservations while the onus of describing the symptoms falls on the shoulders of the patient. My sister often pokes fun at me as I would often be asked in the hospital to rate my pain– I’m not sure if I was trying to be (what I thought was) tough or I simply didn’t want to think about the pain I was suffering, but my set answer was ‘3’. She knew I was in more pain than that. As I think back to my experience of the small dose of pain medication I received, yes some of the fault lies with the clinicians taking care of me, but it was also due to my poor communication with them.

[1] I mention in an earlier post that due to the complexity of my tumor, my surgery was performed by a Pediatric Neurosurgeon in a pediatric operating room. Thus, after the surgery I was placed in a Pediatric ICU.

[2] With 10 being the worst pain of your life and 0 being no pain at all.

[3] The heart rate is often used to aid in assessing pain. The theory is that someone who rates their pain as high should have an elevated heart rate.

[4] Institute of Medicine of the National Academies Report (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington DC: The National Academies Press.

[5] http://www.answers.com/Q/What_percent_of_people_get_pneumonia_every_year

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