September 6, 2013 7:43 pm

The Doctor: Why pain is a numbers game

It creates a shared record, unique to the patient but communicable to you, which will assess if treatment has worked

If zero is no pain and 10 is the worst pain you’ve ever felt, how would you rate the pain you’re feeling now?” You can hear this question all over the hospital, at its most jarring when asked by 20-year-old doctors, obtuse with health, who have learnt to copy the singsong tone of their seniors. (Medical history-taking often sounds like a customer survey: as you constantly repeat yourself, it’s difficult to avoid a robotic quality to your questions. “Do-you-live-in-a-house-or-a-flat? Is-anyone-at-home-with-you? Do-you-drink-alcohol? Are-you-a-smoker?” After hundreds of patients this can become even more cursory: “House-or-flat? Alone? Drink? Smoke?”)

Being asked to number your pain can sound callous but it’s meant to be helpful. Pain is personal: everyone perceives it differently and it’s hard to describe. (For example, the pain of a heart attack is usually described in textbooks as “crushing” but I’ve rarely heard a cardiac patient use that word. It’s a bit flowery, perhaps. And how can you know what “crushing” feels like if you’ve never been crushed?) There is also no way to rank pains objectively, no master list of officially painful conditions – though having an awareness of problems that are generally perceived to be agonising, such as renal colic, dental abscesses and cluster headache, is helpful.

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Without a pain scale, it’s hard to get an objective grasp on how someone is feeling. You may wonder how heartless you have to be to need such a thing. Surely telling the doctor that you’re in “bleeding agony” – as an A&E patient once shouted at me – doesn’t need further clarification? (“Can’t you see she’s in pain?” her children asked me, so loudly that the people in the waiting room craned their heads and rolled their eyes – the universal code for “Honestly, Doctors, Don’t They Know Anything?”) But “It feels worse than childbirth/when I had pneumonia/cut off my thumb” only tells you that someone’s pain is hurting them, and you know that already. It doesn’t give you much more information. Asking for a number allows you to create a shared record, unique to the patient but communicable to you, which will allow you to assess whether any treatment has worked and how well. A pain that starts as a 7/10 may be a 2/10 after paracetamol or it may only dwindle to a 6/10, suggesting that the patient needs something more – a different drug, a stronger drug, another approach altogether (some pains can be remedied by positioning the body; nearly all pains improve if you can address the fear that comes with them).

There are other pain-measurement tools for those who find numbers difficult to understand. For children and patients with limited communication there is the Wong-Baker “Faces” scale, developed by Donna Wong and Connie Baker while working with paediatric burns patients. This uses a series of cartoon faces to assess pain. The broad smile on the initial face (“Very happy, no hurt”) gradually fades away as the scale progresses, first flattening to an ambivalent line (“Hurts a little more”) before becoming a downturned mouth with tears on both cheeks (“Hurts as much as you can imagine”).

The last face comes with a reminder: “You don’t have to be crying to feel this much pain.” This is an explanation for the child – they needn’t be crying to be feeling awful – but it’s useful for clinical staff as well. Some patients are so stoical that they’ll neither tell you nor show you how much they’re hurting. The pseudo-objectivity of a scale can allow them to confide: they’re not complaining, or fussing, just helping you measure something.

Sophie Harrison is a hospital doctor in South Yorkshire

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