Feeling Your Pain
Hospitals have to treat agony. But now they must find the best measure of it
Lewis had her left lung removed, and right after surgery she thought her pain rated 8. She had a pump attached to her that streamed in nerve-blocking drugs when she pushed a button. "And the pain went down steadily," Lewis says. "On the third day it was a 6, and then a 4 or 5. It just felt like someone was pulling on me. Then they took the pump out, and I told them it jumped again, but they gave me Percocet." And the pain diminished to a 3. "People were coming around every three or four hours, asking about pain. I think they managed it really well." Nurses at George Washington University Hospital in Washington, D.C., track such ratings on bedside charts.
But the responsibility isn't all with the doctors and nurses. Teaching people how to use a scale, and picking the right one, are crucial, says Ira Byock, a palliative care physician and cofounder of the pain project in Missoula: "After trying several sample tools, we adopted 0-to-10 scales at both our hospitals, St. Patrick and Community Medical Center. Before that, some places were using 0-to-5 scales, and it just got confusing. If you got a call from the intensive care unit saying the patient had a 6, you didn't know if it was off the chart or just midrange. The same scale gave everyone a common language."
Other scales just seem harder for people to grasp. A "faces" scale, for instance, has a smiling face at the low end and a crying face at the high end. The trouble is that not everyone cries in pain or smiles in its absence. (These scales are still useful for children; it's important to match the scale to the abilities of the person using it.) Other scales just use words, like "very severe pain" and "pain as bad as it can be." But different words can mean different things to different people.
So patient education is a premium, but for hospitals it's also a potential pitfall. "A mandate without money" is what the doctor in charge of one major medical center's pain service calls the new standards. "We have only one pain nurse for the whole hospital," the doctor says, "and she's got to do all the patient and staff training on how to use the scales, as well as talk to patients about pain treatments." One stumbling block is that patients don't want to report pain because they don't want to be put on opiates; recent publicity about deaths on drugs like OxyContin have just made this worse. Fears of addiction or of just "being a bad patient" require discussion, says nurse Linda Torma, who teaches at the Missoula campus of Montana State University's College of Nursing. Some patients are in denial about their pain because they fear it means their disease has spread, and they have to learn how important pain is for diagnosis. That's a lot for a pain nurse to handle.
Missoula's solution, says Byock, was to get grant money to go out to the community. "We went to senior centers, churches, malls, you name it," he says. "The goal was to get people to understand how to report pain before they actually needed to. When people started walking into the ER saying, `I have pain between 8 and 10,' we knew that we'd succeeded."
Suffering's Faces
0 No hurt
2 Hurts little bit
4 Hurts little more
6 Hurts even more
8 Hurts whole lot
10 Hurts worst
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