Pain Scales: Yeeeow!

Pain is subjective; it is whatever the person experiencing it says it is. But to effectively treat pain, it helps to quantify it, which is why medicine came up with pain scales.

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Episode Transcript

Speaker 1 (00:01):
Welcome to Stuff you Should Know from how Stuff Works
dot com. Hey, and welcome to the podcast. I'm Josh Clark. Hi,
there's Charles to be, Chuck Bryant Hi, and Jerry's over there. Silence.

(00:22):
Well you put us three together, you get stuff you
should know. Sorry in advance, those three you just had
a disassociative experience. I did because I want to be
anywhere but where I am right now, which is in
a lot of pain. Are you in pain? Yes? I
just hit my hand with a hammer really hard to

(00:42):
get ready for this episode, right in the middle of
the middle knuckle. You know that one of the very
first dumb jokes I made, like, like, really, I think
I need to go to the hospital. What uh? In
my very first podcast appearance with you, I said that
I was a method podcaster and that I just got

(01:05):
through brushing my teeth and drinking orange juice. Yeah, yep,
you have revived that dumb joke from thirty seven years
ago with the hammer, and here we are, and here
we are Chuck talking about pain. Yeah, you know, I
thought this one, um, for all it's kind of sameness

(01:25):
and basicness, was way more interesting than I thought. Once
you did get in a little bit more. Ye pain,
how about that? Yeah? I thought this one was pretty
cool too. We need to do like a pain episode
just on pain, just in general house of pain. Yeah.
Uh the TV show and the group. I didn't know

(01:46):
that's a TV show. Yeah, it's a Tyler Perry show. Okay,
that explains it. It's about the pains in their house. Yeah,
I get it. I think it's kind of like Mama's
Family a little bit didn't either, same production quality, that
kind of stuff. Looks like it's a recorded on a stage.
Probably is you know what I'm talking about, Mama's Family. Yeah,

(02:09):
I didn't watch that. Well, had you, you would have
known pain, which is weird because I love the Carol
Burnett show. Yeah, this is a pretty far cry from
that Mama's House, Mama's Family, Mama's Family with Bubba the grandson. Man,
it was bad, it was bad. But anyway, um yeah,

(02:32):
there's no segue. Let's just get back to pain. Yes,
and not just pain because like you said, we're gonna
do one on that one day, but pain scale specifically,
which is are I should say, because there are many,
many of them? Um. As this article astutely points out,
there really is no physical instrument, although they have tried

(02:53):
over the ears that can accurately measure pain, and so
doctors rely on a couple of methods, which is, hey, dummy,
how much do you hurt? Hey, hey, you stop crying?
How much pain? Or I'm gonna look at you and
talk to you a bit, and I'm gonna make my
own assessment because I'm the doctor, right and I'm gonna

(03:15):
write like could could brush his hair a little more?
I'm gonna make my own observations about you. Man. I
haven't used a hair brush since I was probably thirteen.
I have two once in a while because my hair
is kind of longish now and when the wind blows
it really turns it into a bird's nest. So yep,

(03:37):
I stand in front of the mirror like Marsha Brady
right before bed and strokes. Yeah, so let's talk about
you know, basically we're talking about self reporting or observation.
Those are the kind of the two methods because it's important,
you know, you gotta there's a lot that goes into
determining how much pain someone's in from the kind of

(03:59):
meds as they get to relieve that pain, to diagnosis
of what the heck is going on. Well, yeah, the
medical community just in the last probably decade or so,
it's really waking up to the fact that it's doing
a lousy job, or traditionally has done a lousy job
of managing pain. Um. There's a lot of assumption that
people are big babies who don't really need medication. They

(04:20):
just need to suck it up. Um. There's a lot
of problems with med seeking where people pretend that they
have pain that they don't actually have, uh and they
because they want the drugs. Um. But then there's also
just this idea that managed pain care isn't quite as
good as it should be. Uh So, part and parcel

(04:43):
of that is realizing like, well, then we need to
be able to quantify levels of pain a lot better.
And this is the idea that they're waking up to.
It is fairly new, but the idea that we can't
quantify pain is a pretty old one. People figured it
out pretty early on that pain is subjective. It's subjective horrible,

(05:04):
terrible experience. And I actually ran across one definition of
pain from a researcher that said pain is whatever the
person experiencing it says it is. Yeah, it's as simple
as that. That doesn't really help a doctor who's trying
to figure out how much medication to give you, or um,
whether to just go ahead and like put a pillow
over your face or something make you go to sleep,

(05:27):
because that's what doctors do. Well, yeah, it's the last resort,
but they it's in their toolbox. Uh yeah, and they
It's become so important that there's a group called the
American Pain Society, which is a great band name. Um,
oh it really is. Yeah right, probably some sort of metal,
right or I could see like kind of like a

(05:50):
sex pop kind of I don't even know what that is.
I don't either. Edith invented a genre. Yeah, um, they're
they're calling it the fifth vital Sign, which means that's important,
kind of like thrill kill cult or um. Who is
the other Lords of Acid? I don't know who they are.

(06:11):
What dude, that's your what you got requested at our
San Francisco show to say that you're so famous for
saying that when I haven't heard of something. What, well,
go listen to those bands and you'll be like, oh,
sex pop, but that's more like sex techno. M I

(06:32):
don't know what sex pop. It doesn't sound like it's
up my alley, but I'll give it a shot, all right. So, uh,
pain or quantifying pain specifically was or pain in general
actually was, like you said, misunderstood for a long time,
and it took all the way into the twentieth century,
quite a bit into the twentieth century with dr still

(06:54):
kind of struggling with how much you know, anesthesia to give,
how many meds to give if you were in pain,
if you were in surgery and childbirth, like you know,
literally people waking up in surgery and going oh, well,
uh we we didn't give that person enough anesthetic, And
we talked about that in our anesthesia episode a little bit.

(07:15):
There's just a lot of trial and error, Like, I
guess that's not enough because someone screaming on the table
in front of me. Well. Plus also, so pain, Um,
apparently it's pretty widespread. I saw that in the US alone,
nine out of ten people regularly suffer from pain at
any given time. Twenty five million people, Uh well, I

(07:36):
guess over the course of a year suffer acute pain.
In the US, another fifty million suffer chronic pain, and
many of those people report suffering chronic pain for five
years or more. So. Yeah, so the medical community says,
we need to do something about this, and it's like
you were saying. The American Pain Society, they say that
pain is the fifth vital sign, the fifth Beatle. What

(07:59):
was his clarence, Yeah, it's great Neddie Murphy's gid. Uh So,
if we go back in time to the time where
they were trying to be a little more objective about
it and actually come up with um a little more
what they thought were like foolproof ways to determine pain
measurement UM. In nineteen forty, there were some researchers a trio,

(08:23):
one James Hardy, uh, one Harold Wolf, and one Helen
Goodell of Cornell University. Those are some nineteen names. Sure,
Harold Wolf, Yeah, James Hardy, Yeah, Helen Goodell, all three
of them. Uh. They actually built a device called uh

(08:43):
dollar LiMETER. And what this was was basically a hundred
what lamp with a lens that they could focus you
know how you do when you're burning ants, Yeah, with
a magnifying glass. That's kind of what they were doing.
And they were cranking up heat on the you know,
they got these nurse volunteers apparently. Uh, and I think

(09:05):
they were all pregnant, which is even a little more sadistic.
But they what they were trying to do was compare
it to their pregnancy pains, their labor pains. Yeah. And
I was like, why would you do that to like
women in labor, And well, you could predict when something
was gonna happen. It was one of those few instances
when you can predict somebody's gonna be a pain. Yeah, yeah,

(09:26):
I get it. But it was also the right so
they didn't care, so like that hurts a lot. They're like, great, great, right,
But I guess these were volunteers, so take that for
what it's worth. And um, they were either nurses or
wives of doctors, which is even a bit more sadistic. Um.
And they would focus this light on the back of
their hand and make it hotter and hotter and said,

(09:50):
you know, compare that to your the intensity of your
labor pains by treking, I guess. And they then made
up a unit. We've reached equal. They even invented a
pain unit called dolls d O l s and you know,
it went supposedly one to ten. But there was a
lady one of them Uh, tough Marge, who cranked it

(10:13):
all the way up to ten point five, maxing out
the machine, and she was still like nope, I can
take it, which is amazing. Yeah, she was like a
hurt so good, but she loves sex pop music. But
there was a problem with the dolorometer, which is they
h in subsequent experience by other doctors that could not

(10:35):
reproduce this, which means it's a junk. Well not only that, Like,
I don't understand how it quantifies pain, right, Well, what
you're really saying is, uh, compare your labor pains to
the amount of heat energy that we're applying to you.
I don't. It just didn't translate to me. I didn't
understand it. But apparently the it created this um this

(10:59):
new cottage in industry for machines that were used to
measure objectively paint. And there's some still around today, but
they do slightly different things like, um, there's one that
that is like a ray gun that's used to see
if someone and under anesthesia, UM is under deep enough, right,

(11:20):
he's just there, and shoot him with it for fun too. Yeah,
and if they don't wake up, great the fun gun.
And then I guess This is just sort of the
decade of trying to perfect these things before they realized
I couldn't. Uh. Time Magazine wrote an article on Dr
Lauren to Julius Bella Glutzek, great name, and um he

(11:45):
had a had a machine. It didn't use heat, but
it put pressure on the chin bone an increasing amount
that sounds awful. Does sound awful? The shin is like
surprisingly sensitive. Oh yeah, so like you know, just put
a coffee table in any room. Yeah, it doesn't make
any sense. It should be like tougher than leather, like
run DMC, but it's not. No, it's not. Uh. And

(12:06):
this one, actually I don't know what the name of
it was, but um he measured it in Grahams to
quantify it and was supposedly and I think this is
self reported by Dr Bella Glutzek accurate. But since you've
not heard of it most of you, that probably means
that was not true. Yeah. He he thought if he
said accurate, people would have been suspicious of his findings. Yeah,

(12:30):
that's right. The funny thing though, is while all this, um,
I wasn't gonna call it quackery because they were they
were trying to legitimately invent something. But while at the
same time all this is going on, there was a
guy named Kenneth Keel who said, uh, why don't we
just ask people, Let's use our brains, people have that.

(12:51):
Why don't we just ask folks and tell him like
zero one or two or three on the scale of
you know, not painful to severe painful. Why don't we
just ask them and see what they say? And that
kind of caught on is the standard. Well let's take
a breakman, then we'll get back to when sensible pain
scales came into effect. That's why Josh Clark. Alright, Chuck,

(13:37):
So the forties were full of um ding bad ideas.
The sixties, Well, actually, I guess the guy you mentioned,
Dr Kenneth Keel, he came up with his idea of
a pain scale, a subjective self reported pain scale, in
the forties, but it seems to have really caught on
in the sixties. Agreed. And so with a self reported

(13:59):
pain scale with any um, well, yeah, any kind of
self reported pain scale. It's basically you are asking the
patient how much pain are you in? And it's not
enough for them to be like a lot, you know,
you have to give them, say like you said, a
scale of like zero to ten or zero zero to

(14:19):
a hundred. Some people just for fun have one that
goes up zero to a million. Sure, and everyone chooses
a million. It's crazy. I always have a difficult time
because I have a high threshold for pain. Um. But
that that that's that makes sense because pain is subjective. Yeah,

(14:39):
but I have a high threshold for pain. But I
also you know, I want the good pills. So do
you wink when you're talking? Like, I'm in a tremendous
amount of pain, doctor, please help me. I usually try
to quanta and this doesn't happen much because I don't
often need uh or have an injury to where I
like would need pain pills or something. Um. But I

(15:02):
always try to quantify it as if I didn't have
a high threshold for pain. You know what I'm saying, Like,
I don't think of my number and then I'll add
a couple so I can get juiced up. You objectively
self report then, rather than subjectively yeah, which they say
is very much wrong and you should be super honest

(15:24):
with your doctor. Yeah uh, Because like you said, there
are addicts who who seek this out. Yeah, I'm not one.
Of those. But I'm just like, you know, the pain
pill makes the pain feel a little bit better. Even
if I have a high threshold, doesn't mean I don't
want that pain to go away something, you know. Yeah. Well,
the way to get around that though, was to just
like dress up, you know when you go to the hospital,

(15:45):
like wear a suit to be sure, tie that kind
of thing. Yeah, I walk up with my baseball hat
and beard in a tie. Well, see, you would seem
med seeking. Yeah, it would at the very least like
cross their mind. Whereas if you dressed up and you said,
um and sure, uh, they'd be like, what what drugs
can we give you? Just write it down, write down

(16:06):
whatever you want and we'll sign it. I don't know
the name of any of them. So, uh. Fentanyl is
a big problem these days, is making its way into heroin,
killing people what taken with heroin. Yeah, they're using fentanol
to cut heroin. I don't know if they still aren't anymore.
But like little towns around America, we're having, like you know,

(16:27):
it would be normal to have one or two overdoses
a year, they were having like a dozen or so
all of a sudden, because people were like it's like
heroin and then the highest grade pharmaceutical heroine mixed in.
And apparently people didn't have any warning or else maybe
they were told this will knock your socks off. I
think that's what killed Philip seymour Offman too. I think

(16:49):
they might have had fentenl and his heroin. But it's
like what these people are used to. The dose they're
used to normally with heroin would not be a lethal dose,
but with fetinal mixed it's you They're dead. Wow. That
reminds me the old, the great Kamal Nagianni joke it was,
which was my intro to him. I heard on him
on This American Life. He was talking about a new

(17:12):
drug the kids are doing, which was Thailand all PM
with heroin, and he was just like, you're already doing heroin.
It's like, what could that possibly add to your experience?
Very funny joke but also sad at the same time.
Aren't aren't the best jokes? Yeah, a little sad sometimes.

(17:35):
Um So with self reporting pain scales, Uh, it sounds
like I said, so basic, like Okay, it's a no brainer, duh.
You asked someone you've got zero to whatever, three or
ten or a hundred people say that, and then the
doctor knows. But you don't think about um like children
or uh like in their understanding of pain, or maybe

(17:55):
the elderly and reasons uh how they experienced pain, or
people that are cognitively impaired and their understanding of pain.
And then you start to think, oh, wait a minute,
well we need all kinds of pain scales and ways
of asking people because not everyone is the same, and
they do have them. Adults specifically are pretty good at

(18:17):
rating their pain on a scale using numbers. They can
also use words like I'm in severe pain or something
like that, um. And usually if you're being presented with
the pain scale, it's not open ended, like describe your
pain in flowery language. It's which of these words best
describes your pain, like no pain, moderate, severe, intolerable. The

(18:40):
one that gets me is um, the worst pain imaginable.
That's that's as bad as it gets, Like I can't
conceive of any pain worse than what I'm in right now.
That's it just runs a chill down my spine, thinking
that something could happen that could put any of us
in that situation where you're seriencing the worst pain imaginable.

(19:03):
It's just I just don't think that should be able
to happen to a person. Yeah, and it's weird too.
It seems like a lot of times, um injuries like
whether it's a cut or a broken bone or something
I've heard. I've never broken a bone, but I've been
cut open a lot of times. You better knock on wood.
I know I'm knocking right now. Um, it seems like

(19:26):
those injuries are are less painful a lot of times,
and other kinds of injuries, like I hear people say like, yeah,
I broke my bone, but it was just sort of
numb and it looked awful, but I didn't feel actual pain,
whereas like like pulled muscles and things like that are
the things that really hurt or bad pain for God's
sake is the worst, you know. I'd like to do

(19:48):
a call out to emergency room physicians or um nurses
or orderlies, anybody who's seen people in a lot of
pain and tell us what is reliably the worst type
of jury pain wise? I think burns. Oh yeah, I'll
bet burns of of uh. I've heard that. That's just

(20:09):
you know, and you know, I've I've had small burns
that it's just that pain that won't stop. Uh. And
you know, I can't imagine like working in a burn,
you know, the kind of pain those people suffered. Man. Uh.
So talking about children, UM, there's this really great story
about the Wong Baker Faces all caps that's right, um

(20:36):
for for treating kids with discomfort and pain. Uh. And
it was developed in the early eighties by two women.
Donna Wong who was a well, Connie Baker is I
think first started with the idea, and Connie Baker was
a life child child life special excuse me, which I
had never heard of. But it's a really cool job

(20:58):
where they work in hospital and they work with children. Uh,
not in like a nursing capacity, but and she's I'd
love to hear from someone who does this, but it
seems like they kind of work in a more of
a social services capacity and helping a kid just deal
with being hospitalized. Does that sound about right? Yeah, that's

(21:21):
that's my impression, okay. Uh. And then Donna Wong, who
was a pediatric nurse consultant and apparently an author, well
not apparently an author, very much an author, but apparently
just this legend in the nursing industry, and she came
to visit uh in Tulsa, where Connie Baker worked, and
they got to talking and she was like, I had
this idea where we can do better with with trying

(21:46):
to determine and get self reporting out of children, because
children don't you know, sometimes they're pre verbal or nonverbal. Uh,
and sometimes they don't get like the numbers or the
color charts. So we need a better way. And ingeniously
they developed this with children. They started with just blank
circles and said, hey, you draw a face that that

(22:08):
looks like the pain that you're having, right, and the
kid would draw and maybe like this is terrible. Do
you do a better job than this? What is that?
Is that a chimney with smoke coming out of it?
They're like that, I feel like I'm on fire. Uh.
So these kids, you know, you look at some of
these early drawings as super cute. You know, they've got
these crayons and they put these details like hair and

(22:29):
noses and you know, the typical kids drawings. And um, interestingly,
some of them drew left or right, some of them
right to left. I don't know how to explain that,
but UM, I guess maybe kids hadn't learned to read
yet might have done right to left and not understood
that that's sort of the opposite of how we learned
to read, or they grew up in a culture that

(22:49):
reads right to left as I don't think so. I
think these were just like, you know, normal dumb American kids. Uh.
And so these kids actually participated started drawing these little
faces that range from smiling, um two tears, And they
got a little bit of heat for using tears as
well as the smiles. Well, they you know, some researchers said, like,

(23:13):
you probably shouldn't use those, but they said, no, you
know that every kid drew smiles, so we think it
should kind of we think that is really informative to
us and them describing how they feel. So let's let's
keep that. Uh. They kept the tears, but they told
the kids, and they continue to tell kids when they
look at this thing, Um, you don't have to have
tears necessarily to have the worst to be in the

(23:36):
worst pain, because not everybody cries when they're in pain. Gotcha.
That's why they said you shouldn't have tears on there. Yeah,
I think so, Yeah, exactly. So what they did was
then they got a professional artist and basically kind of
picked out the most frequently drawn features and had them

(23:57):
draw like a professional composite of these faces, you know,
and I think they ended up on six circles after
experimenting with like less or more and children actually helped
develop the the faces chart, which is, you know, it's
an awesome story. It is. It's pretty cute, yeah, in
a sad way, which makes it a joke. Alright, So Chuck,

(24:19):
let's take another break and then we'll come back and
talk about some other ways of assessing pain. That's why
same we should know. Why knows but Clark, So, Chuck,

(24:49):
you've got pain scales that use numbers. You've got some
that use faces for little kids. But one of the
things they have in common is that they exist on
a spectrum. One of them is so advanced that you
you have on one end no pain and on the
other end extreme pain, and an adult or somebody will

(25:10):
point to them wherever they are on that scale, and
then the doctor has to get out a ruler and
measure in millimeters, right, and then they mark that down.
And then one of the benefits of objectively assessing someone's pain,
even through self reporting is that you can track whether

(25:30):
it's getting better or worse by by assessing it several
times over time, right, um. But part of the problem
with self reporting pain scales is there's there could be obfuscation.
Like we said, like if you're med seeking um, the
elderly apparently don't like to talk about their pain. Yeah.

(25:51):
I mean there's a lot of reasons for that, from
the shame of like getting older and not feeling well
to um all, like you said, just like they don't
want to be a bother a lot of times. Yeah,
I read that they they don't like to talk about
their pain or whether they're in pain, but they will
respond to other words that are virtually the same thing,

(26:13):
like sore, ache, discomfort, and that if you're a good
um physician, you're going to figure out what what words
they respond to most and then just replace pain with
that to get them to talk about the type of
pain they're in. They have a little, uh a little
translation chart pretty pretty much. Yeah, sore it's like a

(26:35):
two achy say three point five and doc oy this
is killing me, that's a eleven. I wonder if there
are any pain scales where it's like like like weather
patterns like you know, spring day to Tornado of Pain,
Tornado of Pain. There's another band name and yeah, oh

(26:55):
yeah that probably is a band. Uh and then they
make them draw that too, right, job better tornado. Oh
I ad meant to say something too about the uh
the faces chart for kids. A lot of times they'll
still even though they have the chart, let kids draw
it because they found that kids really enjoy doing it.
It probably takes their mind off of things. Yeah, and

(27:16):
the kids will like draw it and then take it
home and stuff and uh, yeah, it's kind of cool.
And while they're busy drawing that, the doctor sneaks up
behind them and injects them with a heavy dose of
opioids right into their neck while they're distracted. And most
of those drawings have like a big cran streak going

(27:36):
off the edge of the page. So um. Some other
reasons that you might need to pull out different charts
is maybe someone doesn't speak the language that the doctor
speaks right, Or maybe there's a cultural difference that just
makes the scale a little more difficult to grasp or
or translate, or like you said, they could be cognitively challenged. Um,

(28:00):
there's a lot of different reasons why self reporting scale
might not work in a situation, and so in that case,
the doctor needs to rely on his or her own
observations to come up with a pain assessment. And there's
actually I found this extremely interesting that regardless of your
level of consciousness, if you are conscious and receptive to pain,

(28:23):
your body is going to make you react in predictable
and from what I can tell, universal ways. Right, So,
no matter where you are in the world, no matter
whether you um are cognitively challenged or whether you have
Alzheimer's or whether you are nonverbal baby like, there are

(28:43):
going to be things that you are going to do
when you're in pain, Like, for example, facial expressions tend
to change and take on reliably a reliable um expressions. Yeah,
Like if if you have back pain, then you go
to sit down like they're they're sessing you before they've
even started asking questions. So you come into the room

(29:04):
and you do like, you know, you grab the arm
of the chair and do that when you sit down.
That's a big you know, queue to a doctor, like
you know, this person is having trouble sitting and standing
there and so much back being Yeah, and if someone
took a picture of you at that exact moment, you
would see that your eyes are drawn shut tightly, your
lips are drawn back away from your mouth, and your
teeth are clenched down. You're you're grimacing in pain. Uh,

(29:27):
and you're doing it involuntarily. So these are behavioral behavioral cues. Yeah,
there's there's basically two categories. You can um put observational
pain assessment into behavioral and physiological. Right. Yeah, So on
the behavioral hand, you've got um facial expressions like grimacing,
You've got sounds like moans, grunts, um, even people just

(29:50):
talking about their pain, but not not because they're being interviewed,
just being like you know this this oh my back
or something like that. I make him back. Yeah. It
really worked me like a dog today. Uh. And these
are super important for all the reasons we talked about
people either not being able to report their pain accurately

(30:11):
or um and we talked about a couple of reasons
like the drug seeking, but like little kids may not
want little kids might be afraid of needles and they
might think I'm gonna get I mean, I actually remember
doing this. I remember under reporting pain because I was
afraid I was going to get a shot if I
said I was in too much pain. And so maybe
that's why I have a high threshold now it has

(30:32):
something to do with it. But um, I used to
be really really needle phobic and I am not anymore.
Like I don't love it still, but the needles have
gotten so tiny that it's not that big of a deal.
So when I was a kid, yeah, needles, you know,
they were a lot bigger. It wasn't like I mean
obviously wasn't like the eighteen hundreds where they have like

(30:54):
a railroad spike, but it's not like today where those little, tiny,
tiny thin needles. Um, I don't know the gauges, but yeah,
when I was growing up, they were Yeah, they hated
getting shots. Yeah. I wasn't really big on it either,
But I don't know if I would, i'd be needle phobic.
Do you watch The Needle go In? Sometimes it depends

(31:15):
on my mood. Really, it depends on your mood. Yeah,
I mean if I'm feeling curious and frisky, yeah, I'll
watch it and I'll be like, oh, oh you missed
that one. Just try to psychom out. Yeah, that is
kind of bad when they can't find the vein sure
for blood drawing, right, but but yeah, sometimes I'm just
like I'm not into it today. Look away. Uh. The

(31:37):
other cool thing too about when you get blood drawn
today is they used to Um, they've just come so far. Man.
Remember they used to have to if you had multiple
blood tests, you would get stuck like six times. And
now they have those awesome little tubes that they can
just unscrew. Um. But huh is that what that's called? It?

(31:59):
It's whoever to that? Mr Flobo or Mrs Flobo Phoebe Flobo, MD,
I salute you because that has really changed things for me. Um,
But I still weirdly have this fear of of like
when they're when they're doing that unscrewing it, I had
this fear that they're gonna knock the needle and it's

(32:20):
gonna kind of like rip out of my arm me too. Okay,
So that's is that a common thing? Maybe? Oh? Yeah,
for sure. It's so flimsy looking and it's basically being
held in by the needle, but there's this big, top
heavy tube that's attached to it. Yeah that Yeah, it's
just gonna rip it out and it's gonna pull like
all of your veins and your muscle out right after
it like a bunch of bloody party streamers. Yeah, I

(32:42):
know what you mean. And I'm with slightly phobic still
about them not being able to find the veins so
like you know, they give you the ball to squeeze.
I turned that thing into dust because I want I want,
like and I'm watching them and they're like, I think
I got one here. I'm like, are you sure? I
don't see it? Like I want to see that vein
aulging out for them to go in with that needle.

(33:03):
I don't. Maybe I'm still needle phobic. It sounds a
bit like it. Yeah, I don't think you like the needles. No,
but I mean, hats off to the nurses. That's a
tough job because there are varying degrees of needle phobia,
and I know it's probably never any fun. Well that's
good though. That means your chances of becoming an intravenous
drug user like zero, yes, exactly zero chance, so um chuck.

(33:26):
In addition to those behavioral cues, right like, body language
is another one to where you like you're you you've
got your arm kind of guarding your broken rib or
something like that, like get back and back everybody stay back. Um,
that's fairly universal from what I understand. There's also physiological
changes too, like, uh, you may become nauseous, or your

(33:50):
heartbeat or respiration starts increasing, you sweat. Um, there's a
lot of changes that the body undergoes that can be
objectively observed with that where it's like, oh, that guy's
sweating like a like a chuck okay, Um, he he
must be at like a ten right now, and though

(34:10):
he can't talk. Because that's another one too, like you
may be in so much pain that you can't you
can't talk, you do, you can't focus or concentrate on talking,
so you certainly can't self report your pain. Yeah, or
have an injury that keeps you from talking. Yeah, you know,
like I've been almost bit my tongue off when I
was a kid, oh man, and uh, you know I

(34:31):
couldn't talk very well. Yeah. Well now you talk great,
so much so that I do it for a living. Uh.
And they're all like you said, there are so many
of these pain scales, and they some of them can
get very specific for the kind of person that the
they're they're treating. Um, there's one called the c n
p I Checklist, and this is specifically for uh, cognitively

(34:56):
impaired elderly. Oh, that's specific, and it's a nonverbal checklist
basically that doctors can use. And we've talked about cognitive impairments.
Doctors have to be really uh skilled and careful there
because when they're assessing pain, because if you're assessing behavioral
traits and and someone has a cognitive impairment, it can

(35:17):
be very confusing to assess that because there may be
another need not being met, like they might be hungry
or over stimulated or thirsty and that's coming out, or
anxiety maybe and that's coming out and in the way
they're acting, and the doctor has to be able to
kind of wade through that to get an accurate reading, right.
And then so with with these observational UM scales, in

(35:40):
some cases the doctor will just be like, oh, that
guy is really grimacing horribly, so he's probably at like
a ten um. Other ones actually quantify these different observations,
like the CRIES tool for for um Infants in Pain,
which is about a sad of thought as there is,

(36:01):
but um it's it's basically several different observations like that
fall into behavioral physiological tranches. And then you know, the
doctor rates each one on I think zero to two
or something like that, and then if the sum total
of each category as up to four more, then it's
the baby's in a type of pain that would require

(36:24):
some sort of medication. Yeah. I looked into this one
a bit more. Um c R I E S stands
for crying, requires oxygen for saturation. Greater than that is
a terrible acrimiment. I for increased vital signs E for
expression as for sleepless. Zero would be a cry that's

(36:45):
not high pitched. Yeah, I guess like a whimpering cry too,
I'm sorry. One would be high pitched, but the kid
is easily consoled, and a two would be high pitched
and not inconsolable. Well, the oxygenation Um basically is there
an is there an decrease? Sorry? And O two at

(37:09):
certain levels? Uh number three the vital signs, which is
heart rate and blood pressure. In this case, zero's unchanged
increase less than is the one greater than is it
to expression? No grimace zero just a grimace by itself,
is a one and a griminace, sorry, a grimace with

(37:30):
a non crying grunts it too well because they've already
covered crying, So yeah, a non crying grunt. And then uh,
sleepless continually sleep zero, awaken frequently one and always constantly
awake two and then they total those up, like you said,
that is a sad scale. It is, man. I think

(37:51):
I've said before. I used to do um p a
jobs in l A for this one company who did
uh well. They did to to hospitals. They did City
of Hope Cancer Research, which is where I saw the
head in the bucket, uh, and then Children's Hospital Los
Angeles h l A, which was really rewarding experience, but

(38:12):
the toughest job I ever had, Like you know, the
worst stuff you can imagine. And I gotta say, kids
are the bravest, uh bet best attitudinal. They had the
best attitudes and they were the bravest of it like
any humans I ever saw in the face of like
the most daunting things, like compared to adults. I was

(38:35):
just like, man, adults need to take some lessons from kids,
because it's amazing, like the attitudes these kids had, that's
it was. And you know, I've also been in the
emergency room on the flip side and seeing adults that
I think they think they might be able to get
soon sooner if they wail in pain, like when they're

(38:57):
wailing and wailing and then you see them like oh,
in one eye and look around, and you'll say that
because maybe they are in that kind of pain and
that's just how they express it. But usually in when
I'm in the emergency room, there's one person that's just
like oh, and I'm like, come on, man, you're just
trying to get to the front of the line. H
u r t s. And then I see these kids

(39:20):
in the cancer war that are just like smiling and playing.
I'm like, you know, it's hard to not be a
little cynical about adults and how they handle that stuff. Yeah, no,
it's true. It does seem like you do kind of
get woosier as the as you age. Yeah, up to
a point. Yeah, I agree. So you got anything else?
Uh No, I mean there's you know, there's tons and

(39:41):
tons of pain scales that we didn't cover, and they're
all basically after the same thing in slightly different ways.
So let's just leave it at that. Okay, pain scales.
Who the thought that we would do pain skills before
we did one on pain. Well, now when we do
one on pain, we can just say and they're also
pain scales, which we've detailed. Thirdly, yeah, we do that,

(40:02):
don't we. All Right, Well, if you want to know
more about pain scales, type those words in the search
part how stuff works dot com. And since I said that,
it's time for a listener mail, I'm gonna call this
just an email from a seemingly very nice guy or
a big phony. Hey, guys, been a listener for three

(40:22):
or four years. I think I've always wanted to write in,
but with shy, I thought it was worth mentioning that
I listened to about thirty hours of podcasts per week,
and you are in my top two favorites. Those guy's
a pro, which basically that means we're number two, or
he said we're his favorite. Yeah, I guess you're right,
which is fine. I guess I kind of want to
know what number one is though, Yeah, i'd like to

(40:44):
know as well. To Scott follow up on this, please
uh A second but related, I'm a Master's level Board
certified behavior UH analyst A B C B A and
I am almost finished with my PhD. And I think
you might enjoy hearing that you guys actually do a
pretty decent job handling psychological concepts where many other podcasts don't.
Oftentimes they're too cursory to credulous, or they oversimplify or

(41:06):
something else, And you guys do a great job. Uh.
And it brings me to my third point. You guys
have been on a super hot streak lately. I think
the last month contains some of my favorite material to date.
I don't know what's going on, but keep it up.
I've been listening for two months. We're on steroids, that's it. Uh.
And finally, I really loved your episode on pacifism. Actually

(41:28):
consider myself only more extreme endo pacifism. Do not wish
harm on anyone under any circumstance. Uh. That's that's nice, right. Um.
I like to believe I would die to protect my enemy,
to save a life. Wow, he really is on the
far end. Yeah, he makes Gandhi look like d I mean,

(41:49):
although I've never actually I've never actually tested this to
be fair. That being said, I also don't think that
I could allow someone to come to harm if I
could do something about it, although I'd prefer to take
their play ace and then rather than hurt their attacker.
Also similar to what Chuck said about his wife, I
cannot stand to see harm come to animals. As John
Lennon said, war is over. If you want it, you

(42:11):
guys are fantastic. I wish you all the best. If
you ever have any questions about behavioral psychology, be happy
to be as much of a resource as I can be.
And that is from Scott Miller of the University of Nebraska.
Go corn dogs, corn huskers. Oh yeah, that's right. You
gotta husk the corn before you can make it into
a corn dog. That's true unless you're doing it like

(42:33):
farmhouse style, in which case you would include the husk
into the ultimate corn meal. Yes, and you can find
those at county fairs. Thanks a lot, Scott. If you
wanted to get in touch of this, like Scott did,
you can tweet to us at josh um Clark or
s Y s K podcast. You can hang out with
us on Facebook dot com slash Stuff you Should Know,
or Facebook dot com slash Charles W. Chuck Bryant. You

(42:57):
can send us an email to Stuff Podcast at House
of Works dot com and has always joined us at
our home on the web. Stuff you Should know dot
com for more on this and thousands of other topics
because at how stuff works. Dot com m