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Scales.21/4/2024 Pain
On Facebook and Instagram I run a weekly section on what helped me in terms of medical gaslighting. That led to a discussion about describing pain. There is some frustration among patients and nurses alike about the use of pain scales. This is a common way to establish the level of severity a patient is experiencing. At its simplest, it consists of the question ‘What score would you give your pain, between 1 and 10?’ Sometimes visuals are added, consisting of colour gradients from green to red, happy to angry/hurt faces, or rulers. A Google search on ‘pain charts’ will show you a variety. Some have basic descriptions on them, like ‘Mild pain’ at 2 and ‘Very severe pain’ at 8. The advantages are that it is a quick way to establish the need for painkillers. Anything from 4 upwards grants consideration. It also gives a point of reference to find out if the medication has worked. It can easily be performed by anyone on the team. Frequently students get landed with recording the score. On the other hand it is very limited, and leaves a lot of room for interpretation. How is anyone to know how to score their pain? The usual reply to that is that any answer is correct as it is entirely subjective anyway, so, ‘Go with how you feel.’ I would argue that if the intention is as described above, that is justifiable. For patients who have been subjected to medical gaslighting this is particularly hard, though. They have learnt to doubt their inner compass when it comes to their health, and their experience of pain and any other symptom. They discovered that being honest leads to ridicule and disbelief. Also, it stands to reason that chronic pain sufferers are likely to rate pain differently than those for whom it is a rare occurrence. It helps when more context is given about the interpretation and what is expected. Only, there seems to be confusion about what that should be. Depending on place and person, the guidelines vary. A 10 can be seen as the worst pain you have ever had or the worst pain you can imagine, for example. The second is likely to be higher. And by that measure, how does the 10 of someone whose worst pain was when they stubbed their toe against a coffee table compare to that of someone who was once severely injured? There are inherent problems with quantifying qualitative information, anyway. As long as it is a case of comparing higher and lower within one individual situation, it should be fine. The natural tendency is to start applying math, though. Is a level 9 three times as painful as a 3? And if your groaning knee gets a 2 whilst the headache you have at the same time warrants a 6, does that make an 8 in total, or a 4 as average? Some scales give detailed descriptions of what each score means. An 8 for example might be described as, ‘So bad it keeps you awake’. Again, there are many and they each fill in the details in their own way. A 10 can be screaming with pain in one, and having turned completely silent in another. It is clear then that there is value in seeing these evaluation tools as an opening to a conversation, one in which the professional guides the patient into and through their own description of what they are facing. That takes skill and time. There are other tools that can aid this process. Lists of words that can apply to pain exist, as do assessments based on observation. Gingerbread figures can be used to indicate place, severity, type and recurrence using distinct colours and markings. The same Google search will bring you to this article which presents a collection of them. There is indeed a lot more to say than how much it hurts. The better the patient can express what they are going through, the more understood they are likely to feel. In terms of the trust that has been damaged in gaslit patients, this can be vital to establishing a therapeutic relationship. Again it is clear how important context is. In an emergency room speed is of the essence, whereas a pain clinic requires detailed understanding. Taking the time to explain that is a worthwhile investment. A therapist of mine pointed out to me that in the Western world we tend to describe pain in combative terms. We will say our head is about to explode, we are being kicked in the gut, it feels like a knife is cutting into us. In the East, apparently, more creative and peaceful terminology is used, ‘A bear is dancing in my head’. I bore that in mind when writing my book, and concentrated on how each episode felt specifically. It led me to descriptions like Lilliputians appeared to be playing on a rusty seesaw in my lower belly, a cablecart travelled through my body, and sharp, sour liquid seeping into my muscles, joints and organs. Picturing what it feels like, makes it possible to put words to it that others grasp quickly. Perhaps if we learnt to do that more often, our vocabulary would expand as we become more comfortable with its use. That would save time in coming to clarity. If this was normalised, patients with a medical history that includes gaslighting, would have less reason to be afraid when voicing what they feel in their bodies. The gap between chronic and acute illness would naturally close. What are your thoughts? The talk I refer to was held in Dutch. If anyone would like me to host a chat about this subject in English, I would be very happy to.
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