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Redefining the Pain Scale

The smiley faces just don’t seem to cut it any more.

The Wong Baker pain scale was originally created for children. Now it is used by medical providers to precisely gauge pain in adults all over the United States because of the concept pushed on medical providers that “Pain is the Fifth Vital Sign.” Although this phrase was originally created by the Department of Veterans Affairs, The Joint Commission adopted it and ran with it, rolling out Pain Management Standards declaring in 2000 that “the pain management paradigm is about to shift,” that pain control was a “patient rights issue” and that providers would be required to measure pain on a 1-10 scale. See JAMA article here. PDF here.
Skeptical Scalpel weighed in on the “Pain as a Fifth Vital Sign” issue in 2013.
Of course now that the US is in the throes of an opiate epidemic because of the Joint Commission’s actions, the Joint Commission walked back its demands, stating that it only required providers to measure pain, not to use drugs and that it didn’t require the patient’s pain scale to reach “zero.” Then it put out a propaganda bulletin (.pdf) describing “Myths About The Joint Commission pain standards” … but that’s fodder for another post.

So when I get to the whole pain rating thing and someone says his or her pain is a “10” while simultaneously munching on Cheetos and playing Flappy Bird on his or her TracFone, I have cause for concern. Either the patient is dissociated from reality, has some ulterior motive for overestimating his or her pain, or the patient doesn’t understand the pain scale. No matter how many times you shove the smiley faces in front of the patient’s smiley face, the patient just doesn’t get it.

So sometimes I call them out.

“Consider ’10’ as pain that is so bad that you are rolling around on the floor in agony and asking for someone to put you out of your misery.”
[flap flap flap] “Oh, yeah,” [crunch chew chew chew] “it’s definitely a TEN”
“Oh, but my unfortunate patient in distress, you’re not rolling around on the floor.”
[Looking up from the screen momentarily] “OK, then it’s a 9 and a half”
Brilliant. If only everyone could be so mathematically adept.

There have been many memorable attempts to describe the pain scale.

Brian Regan described his experiences trying to outmoan the patient in the next room, then discusses how he decided to describe his pain scale to the nurse. If you’re at work, don’t drink coffee while watching. If you’re at home, pop a beer and fire up the link. It’s worth 8 minutes of your time.

Then there’s xkcd’s take on the pain scale – which piggybacks off of Brian Regan’s stand up routine. How would you rate your pain if 10 is the worst pain you could imagine … ?

Allie from Hyperbole and a Half did an admirable job of it when she took her boyfriend to the hospital for vomiting Crasins and needing to be checked for Ebola. You really need to read that post for some good chuckles.

So then I happened to come across an Improved Pain Scale picture on Reddit that does a reasonably good job at describing pain.

View post on imgur.com

Personally, I still like the Hyperbole and a Half scale better, but this Reddit one isn’t bad.

And before someone out there tries to call me out for all of the links being in the Reddit post, the only one that I hadn’t seen before was the xkcd scale. I’ve passed around the links to Brian Regan’s skit before and have printed out Allie’s scale and posted it in the emergency department.


  1. As a retired NP and a patient with advanced cancer now living in a palliative care hospital, pain scale is a pet peeve. I just can’t really quantify my pain after a certain point. I know that 3/10 is a very do-able level and that I cry uncontrollably when it hits a level of 7. Other than that? I don’t know.

    I remember one nurse who argued with me when I told her my pain was a seven. What was her problem? My orders are for PRN subQ MS if I want it, starting at five. I really needed the relief so I just pretended to agree with her that yes, it’s really a six not a seven so she’d give me the shot. Whatever. Thankfully most of the staff here are not like that.

    Allie’s is still my favorite “revised pain scale”, but thanks for assembling all those others in one post. Some are new to me. It’s a rare post that speaks to me both as a provider and a patient!

    • “I remember one nurse who argued with me when I told her my pain was a seven. What was her problem? My orders are for PRN subQ MS if I want it, starting at five. I really needed the relief so I just pretended to agree with her that yes, it’s really a six not a seven so she’d give me the shot.”

      This is what is wrong. If you are palliative give the analgesia – what did she think was going to happen? Palliative patients should be given what they want when they need it with no argument from me.

    • One of the problems with our society is that we tend to define classes of people by the attributes of their least acceptable members. Pit bulls are thought of as “killers,” people living in rural areas are often equated with “rednecks,” and unfortunately people seeking pain relief are often lumped into the class of “drug seekers.” At least in the US, there is now a stigma associated with prescribing pain medication (while at the same time a directive mandating that we quantify and treat pain). Prescribing habits are tracked by the government and in some exceptional cases, physicians have been criminally prosecuted when their patients overdose on pain medications. Events like these poison the well for the majority of patients who are in pain and who only seek relief. For that I apologize to you.
      On another note, it makes me happy knowing that my post could bring a smile to your face.

  2. Pain is what the patient says it is. Apparently.

    Like you I get fed up of people overrating their pain score. I have now stopped asking them and document an ‘objective’ pain score. I will write – “patient using mobile phone and laughing with partner.”

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