Pain is NOT the 5th vital sign

23 Dec


Today a short post about PAIN. I recently had a discussion on Twitter about PAIN and pain scores and was interested how you feel about the subject. So please answer the poll below.

I was always taught that PAIN is the 5th vital sign, next to heart rate, blood pressure, respiratory rate and temperature….and I was always skeptical about this! Why, you ask? Well, to start with, the others are all objective measures and PAIN is surely not. And if it is a vital sign, it should be 6th behind saturation, which is an important and objective (vital) sign. But the real reason I am skeptical about the pain score is that patients tend to exaggerate to get treated first. Like @CinicalArts wrote on Twitter: “Patients believe that the more they exaggerate pain, the more attention they need. Terrifying sick role implications”. You all have seen the patient with a broken finger, who looks fine and has a pain score 9/10. At the same time the patient next to him with a complicated, open ankle fracture will tell you his pain score is 4/10.


6 Responses to “Pain is NOT the 5th vital sign”

  1. reneverbeek December 23, 2013 at 20:57 #

    Pain, being subjective, is a very difficult parameter. There is the exacerbation Egon mentioned. In Holland we sometimes use the term ‘Mediterranean Pain Experience’: other pain experience due to different culture. On the other hand there are ‘diseases’ with more pain than would be suspected on first clinical examination (i.e. compartment syndrome, necrotising fasciitis, mesenteric trombosis).
    Two recent cases: 70+ mediterranean male, in a lot of pain, normal pulse, (no betablockers or so), normal BP, normal saturation, normal temp, slightly elevated resp. rate. He was pale and clammy: due to pain or was he circulatory compromised? On closer examination: the resp rate was slightly elevated, but he was also breathing deeper, so his minute volume was markedly elevated. And he had a cap refill of 6 sec. Diagnosis: retroperitonal ruptered AAA, with marked displacement of the left kidney due to the haematoma.
    Another case of a young man in extreme pain (10:10) with chest pain. On examination normal pulse, slightly elevated BP en resp rate, normal sat, temp and cap refill. Abdominal pain (RUQ en right flank). Lab, CXR, US, CT-abd all normal. No diagnosis yet.

    Bottom line. Pain is subjective and that makes it a difficult (vital) sign. And not only look at the resp rate, but also the depth and don’t forget the cap refill.

  2. Iwan Dierckx December 25, 2013 at 13:00 #

    As reneverbeek rightly states: pain is subjective. One’s man 10 is another man’s 4. Where does this leave us ? Do we simply stop inquiring after someone’s pain ? Of course not ! We may not always be able to cure a patient (heck, half of the time I’m not even able to diagnose him), but we can(and should) always diminish suffering.
    So don’t ask about a pain score, simply ask what you can do for the pain. That way you may discover that the patient with a 10 out of 10 pain from a stubbed toe only wants alleviation of his fear for a fracture or that the stoic patient who says his peritonitis is a 4 out of 10 thinks that if he receives morfine he will surely die, but when explained that we do not only give morfine to dying patients, is only to glad to accept.

    Once again: pain is subjective. You don’t get to decide how much pain the patient has ! You are the doctor however and you do get to decided what is needed to alleviate the pain. As stated previously not every 10 out of 10 needs morfine.
    And don’t fall in the trap that a patient with pain must have an elevated pulse (they don’t: they have a vagus nerve and adaptive mechanisms) or that the patient can’t have pain because he is eating/sleeping/watching television… (that is called coping behaviour for heaven’s sake).

    So do I believe pain is the x-th vital sign ? Yes ! (And if you don’t believe me then ask your next patient whether he is more concerned about his pulse or about his pain…)
    Do I believe in pain scores ? Only for medical research.

    Disclaimer: This has nothing to do with prescribing opioids for chronic pain: a complex problem for which I claim total ignorance (other than to give them low doses of ketamine when they are in my ED)

    • Egon Zwets December 26, 2013 at 10:19 #

      Great response Iwan and looking at this reaction you know more about the subject than me (as always 🙂 )….and to the most part I agree…except for 1….I still don’t see pain as a vital sign. I know that it is important for the pt and we have to treat it properly, but for me a vital sign is an objective sign. And a patient doesn’t (always) know what is best for him (and I hope I do!). For example…a patient who “is faking syncope” (you know what I mean) because of long QTc after starting meds and breaks his wrist might wants his wrist to be treated 1st, while maybe, just maybe…the long QT should be treated first. Off course opiods also can be given soon also, so it remains important to adjust the pain, but sometimes not as important as the patient thinks. And maybe nowadays pt expect something that is impossible…Being totally painfree!

      And 1 more thing…since pt know they get triaged higher when they have more pain, some will exaggerate their pain. Not fair to the little old lady with abdominal pain 5/10, normal vital and ischemic bowel!

      By the way, you said: “don’t ask about pain scores, but what you can do for the pain”…BRILLIANT!!! Can’t agree more!!!!

      Grtz Egon

      • Iwan Dierckx December 26, 2013 at 16:02 #

        Simple solution: treat pain early, treat it in triage. That way “exaggerating” pain doesn’t get you seen any faster. As an added bonus, it means I only get to see the patient after his pain has been managed, because there is no way to get an accurate history and physical from a patient in pain…

  3. Emil Verhoofstad December 25, 2013 at 19:56 #

    Nice topic/discussion! Did some research on this topic as a med student. Looking forward to talk with you (Egon/Iwan) in Goes. Regards, Emil (poortarts ADRZ)

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