Case 10: The Fifth Vital Sign

[Triage Note: 29 yo bicycle accident ten days ago. Has lower back pain, worsening]

It’s early fall and baseball fever has taken over the E.R. Someone has sketched logos on the department white boards and the hospital is encouraging staff to support the front-running Blue Jays by wearing blue and white on Fridays. I have a resident today. He’s eager, smart, but he’s just started his training and I’ll need to see every patient after he’s completed his assessment. He seems to know what he’s doing and he wants to go into Emergency Medicine, so I have no idea why he’s been assigned to me. I usually get medical students, not residents – and I get the ones that nobody else wants: the ones who look at normal chest x-rays, and call out diagnoses like: “fractured hip,”  “migraine,” or “constipated.”

I’ve seen five patients, and am just sitting down as my resident, Alex*, walks quickly over, and begins presenting his first patient. He’s just seen a 65 year old man, who was on his way to see his respirologist this morning. He has emphysema, and uses oxygen at night, but despite this, could barely sleep – in fact, he was so short of breath, he had to sleep in a chair the last two nights. Despite the increased shortness of breath, he hasn’t had any new cough, nor has he had phlegm. He hasn’t had fever, nor has he had sweats, but he’s had right sided chest pain on and off this past week.

“On exam?” I ask.

He rhymes off the vitals, his pen tapping the chart. “Blood pressure is one-fifty over a hundred, respiratory rate is fifty, heart rate is one-twenty-two. Oxygen saturation is 90% on four liters of oxygen. He’s working to breathe, and his lungs sound wet.”

“Respiratory rate is fifty? That doesn’t sound good,” I say. “He should probably be in an acute bed.”

Alex continues: “His heart sounds are normal. and he has inspiratory and expiratory crackles. His abdomen is soft, non-tender.”Other than emphysema, Alex says, he has no medical problems, other than high blood pressure. He lists the man’s medications: three inhalers, a diuretic, and something for acid reflux.

“What do you want to do with him?” I ask.

“Cardiac panel,” he says. “Chest x-ray. I think he’s a a COPD (chronic obstructive pulmonary disease) exacerbation – can I give him a mask?  Ventolin, Atrovent, and IV steroids?”

“Do you want me to see him first?” I ask

He seems unsure. “Could you?”

The patient is in a wheelchair, practically pushing the nasal prongs into his nostrils to satisfy his air hunger. His breaths are so wet, it sounds like he’s drowning. In fact, he is. I bend down and feel the swelling in his legs. It isn’t his emphysema, I tell Alex, it’s heart failure. I scratch out his orders and scribble new ones. The nurse looking after the patient already knows this, and has arranged for an Acute bed, where the patient, will spend the next several hours as he is stabilized. The nurse goes over the clinical exam with Alex, asking him to listen carefully to the wet crackles throughout this man’s lungs.

I will see five more patients in other areas of the E.R while Alex stays in the rapid assessment zone. I’ll see three people with anxiety, one with chest pain, and an unfortunate fifty year old who will turn out to have a perforated bowel. He’s in agony, and before we start investigating I order intravenous morphine, gravol, and fluids. The nurse pushes Morphine in fifteen minute intervals to control his pain.

When Alex catches me again, I’m in front of  a computer as my assistant tries to stream the Blue Jays game.

Alex’s next patient, Will Boxer*, is twenty-nine, and fell off a bicycle a week prior. He’d been assessed, had normal x-rays, and was sent home with painkillers. The pain persists in his lower back. He also has pain down both legs, tingling as well, and when asked, admits to difficulty urinating.

“Physical exam?” I ask.

“He walked into the room no problem when I called him,” Alex says. “No marks on his back, normal reflexes, hips and knees are normal, but he winces no matter where I touch him.”

“So what does he want?” I ask.

“He’s still in a lot of pain,” Alex says.

I ask to see the chart. The patient’s four main vital signs – blood pressure, heart rate, respiratory rate, and temperature – are normal. A few boxes over, the patient’s pain is listed as 9.5 on a 10-scale.

In our Emergency Department, we are often reminded, by administrators, of the fifth vital sign – pain. In 1995, the president of the American Pain Society coined the term “Pain as the fifth vital sign.” Four years later, to improve the management of pain, the United States Veterans Health Administration launched an initiative that encouraged a pain intensity rating (0 to 10) at all clinical encounters.  In the United States, Pain is officially considered the 5th Vital Sign by the Joint Commission on Accreditation of Health Care Organizations.

I skim the rest of the chart: He’s allergic to all anti-inflammatories, as well as codeine. In the history, Alex has written ‘relief with oxycocet – able to sleep.’

“You think he wants more oxycocet?” I ask.

He shrugs.

I minimize the Jays game, and pull up Mr. Boxer’s old records on our EMR. His last visit was yesterday – he’d fallen off his bed, he’d said. The doctor who’d seen him had declined his request for oxycocet. Before that, it was a week earlier, when he’d originally fallen off the bike. Before that, there were several other pain-related complaints – his teeth, his twisted foot, his back, a fender-bender. At each of these visits, his pain, recorded at triage, was nine or higher. At one visit, it was listed as twelve. That’s right. Twelve.

The Merriam-Webster dictionary defines “symptom” as “subjective evidence of disease or physical disturbance.” Subjective.  Sign is defined as “an objective evidence of a plant or animal disease.”

His tooth was sore and his pain was twelve out of ten.  Let’s consider the absurdity of this. It would be similar to a parent coming to the E.R, frantic, complaining that her child’s temperature was fifty-five degrees. If a nurse reported to me that a patient’s heart rate was negative thirty-three, I’d be concerned about that nurse, and scan her head immediately. If a patient’s blood pressure, was written as one-thousand over seven-hundred on a chart, I’d laugh, photograph those numbers, and post them to Facebook. None of this is possible, though, these are signs – clear and objective – and they can be observed, quantified, and recorded.

To call pain a Vital Sign is to objectify something that cannot be objectified. Pain is a symptom. Pain is subjective. In the American Pain Society’s Core Principles of Pain Assessment and Management, it is written: “Pain is always subjective. Therefore, the patient’s self-report of pain is the single most reliable indicator of pain.” In many cases, this is true. One of my most important responsibilities as a physician is to treat my patients’ pain. But to call it a Vital Sign is simply wrong. For example, my patient with the perforated bowel has described his pain as eight out of ten. Eight. His guts are ripped open and his pain is lower than Mr. Boxer’s.

I ask Alex if he wants me to see the patient. “Sure,” he says. “He’s in thirty-nine.”

I follow Alex to the rapid assessment area where Mr. Boxer is sitting on an examining table. He’s slouching, texting, and jumps off the table when another physician asks him to move to a re-assessment area.

“Is that him?” I ask Alex.

“Yes,” he says.

“I don’t want to see him,” I say. “And don’t give him narcotics.”

“What should I give him?”

“Something else.”

Alex calls him over, and writes him a prescription, assuring him it will help his back. The patient takes the prescription, and practically jogs out of the department.

Ten days later, a nurse stops me in the hall. “Did you write this,” she says, handing me a prescription. “Your name was on the original chart.”

“My resident,” I say, studying the script. “Hey -” I say, pointing to the messy print below the first line. “He didn’t write this.”

“That’s why the pharmacy sent it back.” Under Alex’s original prescription, in thick felt, it is written: “Oxycocet, 1-2 tabs every 4 hrs prn. Thirty.” Under this, the pharmacist has written ‘fishy,’ and faxed it back to the E.R. for clarification.

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* not their real names.





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