Today on Zero MD, we learn more about the
fifth vital sign. Hello my name is Dr. Zero Mella and I am a
Rural Health Physician here in the Philippines. I’m currently at home and I haven’t reported
for work in days because today is actually day 5 post-op.
Last friday, I underwent an emergency appendectomy, the whole experience was a total nightmare.
Because here in the Philippines, most surgeons do not give analgesics even if the diagnosis
is already a clear-cut appendicitis. As part of the vital signs monitoring that
was ordered by my doctor, the nurses would then take turns asking me to grade the pain
that I was experiencing in a scale of 1 to 10 and then they would then jot down whatever
number I came up with and then they would just run away.
Today, grading of pain is now considered as the fifth vital sign.
Back in 2006, I attended a conference arranged by the International Association of Pain in
the University of Santo Tomas Hospital introducing the concept that pain monitoring must be considered
in every patient. Back then, there were like 4 ways to grade
the pain response. Today, there are like 20 or more methods that
depend on whether you are dealing with acute or chronic pain and/or what your institution
is approving. So my Tip number one for grading pain is know
what scale your institution is using or approving. You may be a nurse or a doctor, using a pain
scale blindly but then when an audit comes on your patient like for example in a grand
rounds, you will then be asked most of the time, what pain scale did you use?
And you will be like “Is that even important?” And the answer to that goes hand in hand with
my tip number 2. Study the pain scale you are using and know how to properly use it.
In my case, throughout my admission, the nurses kept asking me to grade the pain from 1 to
10. And already they are making a mistake.
Because in order to use the Verbal Numerical Rating Scale 11 that they were using properly,
you have to be asking the patient to grade any pain from zero “No pain” to 10 which is
“Severe Pain” and that is true for all pain scales.
At one point in my admission, I answered a male nurse that I was experiencing 9/10
And then he would add, “You mean it’s tolerable?” Of course I would answer No
But in using Pain Scales, the only words that you are supposed to be using are No Pain,
Mild Pain, Moderate Pain, and Severe Pain. The idea of pain tolerability is outside pain
grading. Like in my case, I had no analgesia.
I was on NPO. I was on severe pain.
If you ask me at that time, if I will be able to tolerate the pain, I would say NO
But if you ask me today, was I able to tolerate 3 hours of severe pain prior to the appendectomy?
Well I just did because I practically had no choice.
Tip number 3: Know what is 10 over 10 An hour before the operation, I reported 10
over 10. At this moment, I was already limited to speaking
in small phrases. As a doctor, I know to conserve my energy
because at that time, it is useless to spend all of it screaming.
Even at that time, the word tolerable was still being used by the nurses.
Of course instead of using my middle finger, I had to smile and politely say No.
10/10 is the time when the patient cannot think of other things except the pain.
By this time, she’s already crying, cursing or screaming.
So if you see a patient who is crying, cursing or screaming, you don’t need to ask for grading
of the pain. You just need to write 10 over 10 in your
notes and we will never ask you how you got that.
Now for those patients who you can question or who are not experiencing severe pain, you
are supposed to ask a point in their past where they experienced severe pain.
In women, ask if she ever had normal pregnancy. Because, those patients who never had epidural
anesthesia prior to normal delivery experienced severe 10/10 pain right before delivery of
the head. In other patients, you just need to ask if
they were able to have an accident before or if they were ever involved in a fight.
And if that pain that they experienced before which they considered as severe or 10/10,
you just need to compare the pain that they are experiencing now and you will get a good
approximation of the grade of pain and that is what you are supposed to write down in
the notes. Why do we need to use Pain Scales?
Well for starters, pain is a subjective experience. It varies from patient to patient.
A person involved in a gunfight might experience mild pain at the Emergency room compared to
a lady who accidentally clipped her nails. Second, there are suggested treatments for
mild pain, moderate pain, and severe pain which varies depending on the institution.
So it is important for you to refer whatever pain grade that you were able to take from
the patient to the Attending Physician, to the anesthesiologist, or the Pain Specialist
Nurse. And also as far as I can remember, as of 2006,
the International Association of Pain and the International College of Surgeons recommend
the giving of analgesics or pain relievers prior to doing an appendectomy.
So what do you think about the current practice of Filipino Surgeons in maintaining the No
Analgesia, No Antibiotics Policy prior to doing the appendectomy.
Is it cruel? Is it primitive?
What are your thoughts? Write them down on the comments section below.
And if you want to get a hold of the best Pain Scale at use at most hospitals in the
world, you can click this link to get the Wong-Baker Faces Pain Scale which is what
I would also recommend as the best. And if you like this episode and you want
to see more, why not click that subscribe button below.
And also if you are on facebook I can be found at
And on twitter at I am Dr. Zero Mella for the Zero MD show!
Thank you very much for watching! And Mabuhay! Murphy’s?
Obturator? Jarr’s?
Psoas Sign? What is the diagnosis of your patient?

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