Pain is NOT the 5th vital sign

23 Dec

The discussion on Twitter started because of a tweet by the “father” of FOAMed, Mike Cadogen, who tweeted

Schermafbeelding 2013-12-23 om 19.43.31

He noted that in an interview with Dateline NBC, the inventor of the catchy slogan ‘Pain in the 5th vital sign’, Lisa Washington, now conceded that it is actually not. It came to her in a dream…..WHHAATTT THHEE F….????? And she was able to get this dream into numerous medical orginazations. Incredible, right?

Curious about the topic, I posted this tweet about this topic with an article from thepoisonreview.
Schermafbeelding 2013-12-23 om 19.49.07

As with so many things, it is all about the money! Groups such as the American Pain Society urged tracking of what they called an epidemic of untreated pain and probably they were right back then. They campained for calling it the 5th vital sign. Campaigns like these sadly neglected the risks involved in chronic opiods use. For me it comes to no surprise that the Washington Journal reveals that the director at the time had “disclosed relationships with more than a dozen companies, most of which produced opioid painkillers”. Off course “he wasn’t biased by this”.

During the discussion on Twitter @Skepticscalpel came into the picture. Some people think that calling pain a vital sign is idiotic and he agreed, big time! He even had a very interesting post about it.

The (mistaken) idea that pain medication is capable of rendering patients completely pain free has let to some unintended consequences:

– Becoming completely pain free has now become an expectation of many patients who are incredulous and disappointed when that expectation is not met.
– Diseases have been discovered that have no signs and with pain as the only symptom.
– Pain management clinics have sprung up all over the place. In 2010, 16,665 people died from opioid-related overdoses. That is a four-fold increase from 1999 when only 4,030 such deaths occurred. And the number of opioid prescriptions written has doubled from 109 million in 1998 to 219 million in 2011.
Meanwhile in the 10 years from 2000 to 2010, the population of the U.S. increased by less than 10% from 281 million to 308 million.

And now where this post is all about……the Polls

Hope you liked this post! Keep up the good work and treat your patients as they should be treated, but always be critical about everything you do. So don’t undertreat your patients, but overtreating them is also not a good thing. Just think about overdoses. We always score the patients pain score, but to be honest I also use intuition, experience (6 years) and gut feeling to come to a (in my eyes) more reliable pain score.

And what about “Pain is the 5th vital sign”, you say???….I don’t agree. I believe a vital sign should be objectively measured and it shouldn’t be someones dream.

Until next time and looking forward to the answers!



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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