I didn’t want to come to the emergency department. My primary care doctor told me to go after he poked my belly, gave me the most pitying look I’ve ever seen, and he said he’d call the hospital to request an emergency a CT scan.
But at the hospital emergency department, the triage nurse is the gatekeeper of care. My temperature is only slightly elevated. I have no spurting blood, no disfigured limbs or torn flesh.
She is all-powerful: no matter who my doctor talked to, I must answer her questions to cross the bridge, and get help. The stakes feel high for the last, most important question:
“From one to ten, where ten is the worst pain you can imagine, what’s your pain level?”
Wrong answers are punishable offenses. I will receive a lower quality of care if I give the triage nurse any reason to suspect I’m not genuinely in pain–and in fact, I think that’s what this question-barrier is there to guard against. Emergency departments see enough drug-seeking behavior that the nurse has to be on guard.
I don’t want morphine–it makes me forget to breathe, plus other discomforts–but she doesn’t know that. So I focus on answering the exact question she asks, to the best of my ability.
Right now, I can’t take a deep breath, sleep, work, read, or track the plot of even a mediocre TV show. But there are parts of my body that don’t hurt. And I’m not on fire.
The question asks me to imagine the top end of the scale. So if I start with remembering the time I had a gall stone the size of a pecan lodged in my bile duct, and Tylenol and Tums and writhing on the deliciously-cool linoleum floor wasn’t quite helping enough–well, that was pretty bad. Was that a 10?
But I could have gotten in a car wreck that night, on my way to the hospital. What if I had also had a newly-broken limb? Or worse–a crushed limb? Or worse–a crushed joint? Could that be what a 10 feels like?
What if I had had an asthma attack at the same time? While having something removed from my eyeball? While my love lay dying? She said “where 10 is the worst pain you can imagine…”
As far as I can tell, I can imagine big differences between the numbers on the high end of the scale. If were to graph them, they’d look like this:
I realize I can always imagine more pain–heck, I write fiction. That’s part of the job. The way the question defines it, a pain level of 10 is unreachable. The graph goes asymptotic.
The triage nurse blinks. She’s willing to wait.
Am I in the same kind of pain as the lodged gallstone, I ask myself? Well, it’s different, but the floor does seem similarly writhable-upon. But it might be the best answer I have–which puts me at a six. Six doesn’t feel like the right answer.[1]
I want to be thorough–and accurate–so I work on the other end of the scale.
What could a one be–a stubbed toe? Or is one a badly stubbed toe, like when you think it’s probably broken, and it turns colors the next day? How about when I bruised my tailbone tobogganing? That hurt pretty bad–is that what a four feels like? Or is it not even a two?
I realize my understanding of the low numbers is… low. I don’t know how to rank minor pains in various parts of my body. There just doesn’t seem to be enough difference between them to distinguish where they fall on the scale.
If I were graphing the low end of the pain scale, it’d come out flat–I can’t tell the difference between them.
So I still have no answer, so I can’t get past the question, and nothing has improved.
My husband pats my hand and stares at me as if he can make the right words come out of my mouth just with his brainwaves.
So the nurse repeats herself with a new emphasis, because maybe she thought I wasn’t understanding the question well enough. “What’s the pain you’re feeling right now, from zero to ten, where ten is the worst pain you can imagine…”
Oh! Well, that’s different. Because I’ve been sitting on the melamine vomit-proof chair for a few minutes, not moving, mostly holding my breath so that I will hurt less.
But I still doubt. “What if the pain comes and goes?” I ask.
“Right now,” she repeats. She’s stopped blinking–I think she’s irritated.
And I don’t want to lie, so I use the best answer I’ve come up with so far. “Six?” I ask.
Six, it turns out, was the magic number to race to the rear of the triage line. As I waited, every other person was called back to a room before me. They finally called my name, after I laid myself down on the floor (yep, linoleum) of the waiting room because I just couldn’t sit in their godforsaken chairs anymore.
Luckily, my doctor really had called ahead–I did eventually get the CT scan and IV antibiotics that helped me feel better. The attending physician suggested opiates a couple of times–my husband had to intervene to explain that no, I really didn’t want them.
The next day, between naps and antibiotics, I scribbled notes and graphs about the pain scale. It felt like a revelation when I realized two things:
- I’ve been trying to answer a linear scale, but I only have exponential data.
- I’ve been reading the wrong axis–Y vs. X.
So here’s my new system:
- If there is obvious external sign of physical damage, like spurting blood, a limb bent or swollen to unusual size, charring or smoldering–I’ll point at that, and say “8.”
- If there’s no obvious external damage, but a persistent feeling that requires me to breathe, sleep, eat, or work differently or not at all, I’ll say “9.”
- If I’m already at the hospital or doctor’s office, and the pain increases, even if there are probably still parts of my body that don’t hurt, I’ll say “10.”
Next time I get emergency medical help, I don’t care how linear they think their pain scale is, or how they ask it. I will focus on getting past the barrier it presents to getting help.
[1]Anybody who thinks I’m just overthinking this is wrong. This is what actually happens in my brain when I am at my most vulnerable. I don’t need to second-guess how I think in the middle of trying to answer a poorly-constructed, well-intentioned question while I’m in enough pain to be told to go to the ER.
Torreybird 
Wow, I never would have thought of it to be asymptotic – this makes so much sense!
It´s so sad so many people experience this being not understood in such a situation… in my country we don´t have point-to-the-appropriate-face charts (yet), and few docs or practitioners ask about number-on-a-scale; but having been there I eventually made up my own pain scale: from 0-all systems working…5-gotta take pills to continue working somehow…to 10-I can endure this state for just very few minutes before I pass out. Such a scale makes it easier to communicate with insensitive staff, but I don´t think pain and suffering can actually be measured or compared, can it?
Thanks for sharing and all the best!
Thanks Anka! I’m glad you found a scale that works for you!
Consider it not a “patient care” issue, but a “protection of liability” issue. They can’t just dispense pain medication. What they’re basically asking is “do you want to order pain medication, so I can give it to you.” Think of it less like “do you want anything” and more like “rum and coke, a shot of vodka, or a bottle of everclear”…
See, in the same way, I’ve been told it’s specifically designed to weed out people who are just trying to “order pain medication.” Drug-seeking behavior is seen so frequently at hospitals (I’m told, I have no data), that people without symptoms who say they max out the pain-scale have been treated with great skepticism.
In either case, when I finally did get offered pain medicine, what I wanted was a non-opiate like Tylenol–but they couldn’t give it to me, because they didn’t have an IV form, and (at that point) I might still have needed surgery.
You’re right, though–protection of liability *and* our MBA-ish need for “metrics” are what’s at play, here.
Triage damned near killed me, because I didn’t fit in the slots, much as with you, when I first presented with the symptoms that turned out to be my colon cancer. It has some designed-in failure points which (presumably) represent the best-effort compromise of limited resources, but people with sprained ankles were being jumped ahead of me in the queue while I was busy losing 25% of my blood volume, simply because they expressed pain and I didn’t.
The priorities as explained to me at the time were:
1. Anyone arriving by ambulance jumped to the head of the queue.
2. Visible bleeding.
3. High pain scale.
So bleeding out internally, which doesn’t actually *hurt* (or at least didn’t in my case) fails 2 & 3, and I’d arrived by automobile in the interests of not tying up EMS resources when a friend could reasonably drive me, thus failing criterion 1.
If I’d been left in the lobby another 10 or 15 minutes longer than I was (after 5+ hours of waiting), the abrupt collapse of blood pressure I experienced inside the ER could have been fatal. So I’m kind of sensitive to this issue.
Jay, your self-directed patient adventures came to mind while I was there. It’s an extraordinary effort to try to be rational with people, figure out the answer that will work, and manage one’s own discomfort and mental vagaries at the same time.
I really don’t know how you do it. You have my ever-renewed respect.
I used to get hugely frustrated with this until my medical system changed its urgent care procedures.
It used to be:
1. Greeted by triage nurse, who takes vital signs.
2. Unless your vital signs are way off, the nurse attempts to tell you that you really aren’t sick, are faking, are lying, are seeking drugs, etc. Complete skepticism when you explain that you’ve been seen for this condition before and the treatment is XYZ.
3. Nurse puts you to back of line.
4. You are then put in a room where you wait for 45 minutes until a doctor comes in to either diagnose you and prescribe XYZ or send you for testing.
Now it is:
1. Greeted by nurse and physician team. Nurse takes vital signs while doctor asks questions.
2. You are listened to and immediately either correctly diagnosed and treated or dispatched for testing.
Wow, what a difference.
That system makes a ton of sense, Karen. Instead of barrier, instant access!
I recognize that type of thinking. It’s not over-thinking. Rather it’s a quest for accuracy and honesty and, in my case, a small mixing of neurosis.
The most important question I have for you is this: What software did you use to generate your lovely graphs?
Thanks! I used Excel to make them, and PowerPoint to annotate with arrows and text.