George Rebane

Due to my bride’s unfortunate fall that shattered her elbow and required urgent and complex orthopedic surgery to put the pieces back together, there has been a lot of talk about pain with the attending surgeon, medical techs, and physical therapists.  Everyone was interested in the magnitude or intensity of the pain.  And today the only way to extract that from a patient is to ask them to assess their pain level on a scale of one to ten, a scale which no one knows how to anchor, calibrate, or even claim whether it is normative.  In clinical lingo something is normative if a large cohort of people in a ‘similar’ situation agree, here in assigning the same pain number to the same intensity of pain.  As you would expect, no one knows; yet they still keep asking and dutifully writing down that number from one to ten.

After noodling about the problem on which I’ve had an opportunity to witness numerous times recently, I have come up with an alternative scale that should at least be more normative and therefore useful to the attending medicos.  My approach is based on behaviorism and requires the patient to relate the level of pain to either ongoing (chronic), planned, or executed behaviors.  Here is a first cut at it.

Level 0 – No pain, or that the former episodes of pain have ceased.

Level 1 – Chronic pain or pain episodes continue, but are inconsequential in that the patient does not think about the pain before acting, and during/after which act only a mild discomfort is noticed that is not intense enough to make it memorable.

Level 2 – Pain that causes patient to become conscious of it or anticipate it before the act, but at an intensity that induces no hesitation to act and suffer the resulting pain.  The episode remains memorable.

Level 3 – Chronic or anticipated pain at intensity that causes patient to consider delaying the pain-causing act.  The episode remains memorable.

Level 4 – Chronic or anticipated pain at intensity that causes patient to contemplate how to entirely avoid the pain-causing act.  After the act, the episode definitely remains memorable.

Level 5 – Pain at an intensity that causes patient to consider changing after-act plans, but most likely will not actually bring about such a plan change.  The episode creates/reinforces a very memorable episode.

Level 6 – Pain at an intensity that causes patient to either avoid the painful act or definitely change after-act plans.  Previous completion of the act created/reinforced a very memorable episode, that made it unlikely that the act would be repeated without some mediation to reduce the pain’s intensity.

Level 7 – Chronic or anticipated pain at intensity such the contemplated act will definitely not be undertaken without some known mediating effect or agent to reduce the pain to an acceptable intensity.  At this level, such prophylaxes and their former absence are vividly remembered during the next precursor to the act.

Level 8 – Chronic or anticipated pain that is/was suffered with attempted analgesics which are/were ineffective.  The sensation/memory of this pain summarily prevents the patient taking/repeating the action since there is no known way to reduce the pain to a level at which the act may again be contemplated.  Suffering is intense and ongoing, causing the patient to essentially avoid all activities that may repeat this level of pain.

Thoughts?