On a scale of 1 to a number you select, part 1

"On a scale of 1 to 10, with 1 being no pain and 10 being the worst pain you can imagine, how would you rate your pain right now?" 

I've asked patients this question, with minor variations in wording, hundreds (thousands?) of times in nearly two decades in EMS. It's strange, and at times frustrating, that this is the only way I can monitor pain. I can view numbers for pulse, respiratory rate, exhaled CO2 levels, pulse oximetry, and blood pressure in real time, but I can't really know what someone else is experiencing. 

It's not an idle question; my ambulance carries narcotic meds that are generally very effective in pain relief. The protocols governing their use leave a great deal of room for discretion: "Administer [medication name] as needed for pain."

Pain, like pretty much everything, is all in your head. In other words, real. I liken it to the sound of fingernails scraping on a chalkboard. People react in all kinds of ways, from relative indifference to great anxiety, and all those responses are "real" to the people having them. I have a high tolerance; the sound doesn't bother me very much. If I tell you to stop minding it just because I don't, that doesn't actually help you at all. 

For every patient who reports pain, I have to make a judgment call on whether it's in their best interests to administer a powerful narcotic prior to reaching the Emergency Room, or whether their pain can be better managed by a physician, and informed by a complete medical workup. I don't necessarily give narcotics to everyone who reports that they hurt. They have potential side effects, and they may be overkill for the pain at hand, which may be better managed through longer-acting meds available in the ER.

But as Paramedics go, I'm pretty aggressive about pain relief. My job is an opportunity to help people and alleviate suffering, so I don't consider it my role to deny medications to someone just because they might be seeking drugs or they don't look like they're really in much pain. I can't necessarily articulate a rationale that guides the decision for any given patient. It's a black box mechanism that I can't open. I do what I think is right. 

Imagine trying to write a strict set of guidelines that would specify when to administer narcotic pain meds in a pre-hospital setting. Should anything above a 7 on the pain scale qualify as "needed," or should you base the decision on physiological measures? Should you factor in the patient's apparent distress, or is this too easily confounded by the vast differences in people's tolerance for pain?

The decision about whether to give pain meds is a bit like scrying within someone else's psyche. It's not uncommon for someone to tell me they're experiencing 10 out of 10 pain, while they sit in apparent comfort, in no visible distress, and with vital signs that look like a person at rest. Do I take them at their word? Is their self-reported number the best indication of whether pain medication is justified, or do I allow my own experience (and possible bias) to factor into the decision? 

Who am I to make the decision, anyway? Well, someone has to, but it's a valid question, and one I still ask myself. 

[Continued Monday]