Evaluating the 1-10 Pain Scale
Every time I am asked, “What is your pain level on a scale of 1-10, where 10 is the worst pain you’ve ever experienced (or imaginable)?” I go through an inner battle. I size up the person who is asking and run through my own list of questions before giving my adapted response. Does this person seem sympathetic? Are they listening to me or looking me in the eye? Have they made any ‘judgey’ looks or comments thus far? Who will be looking at that magic number that gets written down? How quickly do I need assistance? How much help do I want today? And above all else, am I being fair to myself in this situation by rating my pain accurately?
When being actively treated for pain by a healthcare professional my mind flashes to three memories:
Pain level 1: Lying in the ER having been given multiple doses of Dilaudid, a euphoria calms me. I feel as though I’m floating and find myself wondering is this Heaven? The nurse informs me that the wave pattern on the curtains is NOT moving, and she’s happy for me, I’m high, pain free. Is this the lack of pain what most people feel?
Pain level 9: I’m a freshman in college laying in the ER for the 4th time this first semester of school. I can’t feel the inside of my legs and if I even flinch the pain shoots through me and sends my eyes rolling back into my head, I escape blacking out only because more pain shoots me wide awake.
After hours of begging for help and medicine, a friend hands me my cell phone and I call my parents and tell them they have to make something happen. I hang up, the ER phone rings at the nurses station. I get mild satisfaction knowing in that moment someone is getting chewed out for not believing my pain level. MRI ordered, I am laying in my bed sweating, hyperventilating waiting for the results. The smarmy disbelieving doctor wheels himself on the stool closer to me, his hands in a praying position up to his mouth, “I am so so sorry, we will get you something right away.”. One of my disks had exploded against my spinal cord.
Pain level 10 (the worst I have experienced, so far): My tonsils had been removed the day before; the originally simple operation planned for 20 minutes took a full 2 hours. I had been released from the hospital for only 4 hours, when I blew my nose, starting a steady stream of blood flowing from my mouth. We call my surgeon on his home phone on the way to the hospital. A completely full ER, they actually kick someone out of a room. Donor bands on my arm, I insist I only want my Dad’s blood if necessary. Within minutes I am wheeled into the OR, doctors still in their regular clothes rushing their prep. My surgeon apologizes that they can’t spare the time to properly knock me out and they have to just get going. I crawl onto the operating table, where the most caring nurse I’ve ever met looks at me with a face that says “I’m sorry, but I’m here just for you.” Needles shoved in, she strokes my hair, holding my head and pleads with me to stay calm, never losing eye contact with me. I am intibated, meds not working fast enough my body naturally fights it and my lung begins collapsing. Oxygen masks, braces and clamps begin claustrophobically closing me in. The worst level of imaginable pain takes over, and another kind of euphoria hits me. Tears stream down my face and I can’t even fight any more, the operation starts before I am asleep. The nurse soothingly asks me just to close my eyes, I gave in to the pain. If dying hurts, this is what it feels like.
These are the memories that flash through in an instant when I am asked the magic 1-10 pain scale question. How do I equate my everyday to these memories? For me, on either end lies that euphoria, where you can’t care any more, good or bad. Healthcare providers can’t possibly know or understand these memories. Most people won’t ever experience a 10 that makes them stop fighting. So how do we communicate it properly?
With Rheumatologists, or other specialists that treat you for ongoing pain I suggest a worksheet given at the first visit, that would be kept at the front of your chart. Every patient would fill it out according to their own personal experiences, memories that could offer some relate-ability. This shows what a person is willing to deal with, and what they are rating their pain against. Broken bones for instance could rate all over the place, but it’s all about perception. Mine would look like this:
- 1- Total absence of pain due to high pain meds - Dilaudid/Morphine
- 2 - A simple cut or bruise
- 3 - Most days of my life living with joint pain when not in a flare
- 4 - Breaking my skull at age 7 (surprisingly not painful), Sunburns
- 5 - Most days in an average flare
- 6 - Breaking my wrist at age 22, normal migraines
- 7 - Most days in my most recent worst flare, Bunionectomy
- 8 - Migraines with neurological symptoms, Current gastro pains
- 9 - Ruptured disks, Internal bleeding in my knee after surgery, Dry socket after wisdom teeth were removed
- 10 - Surgery beginning on my throat before I was under, or what I have not experienced
Of course this would not work in emergency situations. In that case, we have to try to adapt our pain levels to something that someone else can understand. We have to be fair to ourselves, and take down the tough façade just long enough to gain adequate help, or suggest ‘this is as bad as the time I did blah blah blah’. Along with the pain scale, a fatigue scale should always be used because this symptom is sometimes even more impacting at the moment.
Pain scales will always be subjective and patients will always grow more or less tolerant to pain. Open and honest communication, and a willingness for healthcare providers to not become ‘numb’ to what their patients are saying is crucial. When good communication exists, better and more effective care will follow.
