Stuff You Should Know - Pain Scales: Yeeeow!

Episode Date: March 14, 2017

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. Learn more about your ad-choices at https://www.iheartpodcastnetwork.comSee omnystudio.com/listener for privacy information.

Hey everybody, when you're staying at an Airbnb, you might be like me wondering, could my place be an Airbnb? And if it could, what could it earn? So I was pretty surprised to hear about Lauren in Nova Scotia who realized she could Airbnb her cozy backyard treehouse and the extra income helps cover her bills and pays for her travel. So yeah, you might not realize it, but you might have an Airbnb too. Find out what your place could be earning at airbnb.ca. On the podcast, HeyDude the 90s called, David Lasher and Christine Taylor, stars of the

cult classic show, HeyDude, bring you back to the days of slip dresses and choker necklaces. We're going to use HeyDude as our jumping off point, but we are going to unpack and dive back into the decade of the 90s. We lived it, and now we're calling on all of our friends to come back and relive it. Listen to HeyDude the 90s called on the iHeart radio app, Apple Podcasts, or wherever you get your podcasts. Welcome to Stuff You Should Know from HowStuffWorks.com. Hey, and welcome to the podcast.

I'm Josh Clark. Hi. There's Charles W. Chuck Bryant. Hi. And Jerry's over there. Silence. 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 get ready for this episode. Nice. Right in the middle of the middle knuckle.

You know, one of the very first dumb jokes I made? Like, really, I think I need to go to the hospital. What? In my very first podcast appearance with you, I said that I was a method podcaster, and that I'd just got through brushing my teeth and drinking orange juice. Oh, yeah. Yep. You have revived that dumb joke from 37 years ago.

Right. With that hammer. And here we are. And here we are, Chuck, talking about pain. Yeah, you know, I thought this one, for all its kind of sameness and basicness, was way more interesting than I thought once you did get in a little bit more. Yep. 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. The TV show and the group. I didn't know this is a TV show.

Yeah, it's a Tyler Perry show. Oh, okay. That explains it. It's about the pains. And their house. Yeah, I get it. I think it's kind of like Mama's Family a little bit. I didn't watch that either.

Same production quality, that kind of stuff. Looks like it's recorded on a stage. Sure, probably is. You know what I'm talking about? Mm-hmm. Mama's Family. Yeah, 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. Mm-hmm. With Bubba. The grandson.

Oh man, it was bad. It was bad. But anyway, yeah, there's no segue. Let's just get back to pain. Yes, and not just pain, because like you said, we're going to do one on that one day. But pain scales specifically, which is R, I should say, because there are many, many of them. Mm-hmm.

As this article astutely points out, there really is no physical instrument, although they have tried over the years, 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. Tell me how much your pain is. Or I'm going to look at you and talk to you a bit, and I'm going to make my own assessment because I'm the doctor.

Right. And I'm going to write, like, could brush his hair a little more than he does to make my own observations about you. Man, I haven't used a hairbrush since I was probably 13. 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 you get out of the comb from your pocket? Yep.

I stand in front of the mirror like Marsha Brady right before bed and count off 100 brush 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 got to, there's a lot that goes into determining how much pain someone's in from the kind of meds they get to relieve that pain, to diagnosis of what the heck's going on. Well, yeah, the medical community just in the last probably decade or so is really waking

up to the fact that it's doing a lousy job or traditionally has done a lousy job of managing pain. There's a lot of assumption that people are big babies who don't really need medication. They just need to suck it up. There's a lot of problems with med seeking where people pretend that they have pain that they don't actually have and they, because they want the drugs. But then there's also just this idea that managed pain care isn't quite as good as it should be.

So part and parcel 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. Sure. It's a horrible, 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. 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 whether to just go ahead and like put a pillow over your face or something, make you go to sleep. Yeah. Because that's what doctors do. Well, yeah.

They don't go to the store, but it's in their toolbox. Yeah. And it's become so important that there's a group called the American Pain Society, which is a great band name. Oh, it really is. Yeah, right? Probably some sort of metal, right? Or I can see like kind of like a sex pop kind of.

I don't even know what that is. I don't either. You just invented a genre. Yeah. They're calling it the fifth vital sign, which means that's important. Kind of like thrill-kill cult or who is the other Lords of Acid? I don't know who they are. 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. I don't know what sex pop would be. It doesn't sound like it's at my alley, but I'll give it a shot.

So 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 20th century, quite a bit into the 20th century, with doctors still struggling with how much anesthesia to give, how many meds to give if you were in pain, if you were having surgery and childbirth. Literally people waking up in surgery and going, oh, well, we didn't give that person enough anesthetic. We talked about that in our anesthesia episode a little bit, and there's just a lot of trial and error.

But I guess that's not enough because someone's screaming on the table in front of me. Well, plus also, so pain apparently is pretty widespread. I saw that in the U.S. alone, nine out of 10 people regularly suffer from pain at any given time, 25 million people, well, I guess over the course of a year, suffer acute pain in the U.S. Another 50 million suffer chronic pain. Many of those people report suffering chronic pain for five years or more. Right? 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. Yeah. The fifth beetle. What was his, Clarence? Yeah. It's great that he Murphy's good. 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 a little more what they thought were like foolproof ways to determine pain measurement. In 1940, there were some researchers, a trio, one James Hardy, one Harold Wolfe, and one Helen Goodell of Cornell University. Those are some 1940s names. Sure. Harold Wolfe. Yeah.

James Hardy. Yeah. Helen Goodell. All three of them. They actually built a device called a dolarimeter. And what this was was basically a hundred watt lamp with a lens that they could focus, you know, how you do when you're burning ants. Yeah.

With a magnifying glass. Yeah. That's kind of what they were doing. And they were cranking up heat on the, you know, they got these nurse volunteers apparently. And I think 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 then I was like, oh, well, you can predict that when something was going to happen, it was one of those few instances when you can predict somebody's going to be in pain. Yeah. Yeah. I get it. But it was also the 1940s. Right.

So they didn't care. Right. 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. Sure.

And they were either nurses or wives of doctors, which is even a bit more sadistic. And they would focus this light on the back of their hand and make it hotter and hotter and said, you know, compare that to your, the intensity of your labor pains by a tricking, I guess. Yeah. And they even made up a unit. We've reached equilibrium. They even invented a pain unit called BALLS, D-O-L-S, and you know, it went supposedly

one to 10. But there was a lady, one of them, Tough Marge, who cranked it all the way up to 10.5, maxing out the machine. And she was still like, nope, I can take it. Yeah. Which is amazing. Yeah. She was like, oh, it hurts so good, but she loves sex-pop music.

But there was a problem with the Dullerometer, which is they, in subsequent experience by other doctors, they could not reproduce this, which means it's junk. Well, not only that, like I don't understand how it quantifies pain, right? What you're really saying is, compare your labor pains to the amount of heat energy that we're applying to you. It just didn't translate to me. I didn't understand it. But apparently, it created this new cottage industry for machines that were used to measure

objectively pain. And there's some still around today. Yeah. But they do slightly different things, like there's one that is like a ray gun that's used to see if someone under anesthesia is under deep enough. Right. You just, they're in shoot them with it for fun, too. Yeah.

And if they don't wake up, great. The fun gun. Yeah. That's right. And then in 1945, I guess this was just sort of the decade of trying to perfect these things before they realized they couldn't. My magazine wrote an article on Dr. Lauren de Julius Bella Glutsek. Great name.

And he had a machine, it didn't use heat, but it put pressure on the shin bone in increasing amounts. That sounds awful. It 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. And this one, actually, I don't know what the name of it was, but he measured it in grams to quantify it and was supposedly, and I think this is self-reported by Dr. Bella Glutsek, 97% accurate, but since you've not heard of it, most of you, that probably means that was not true. Yeah.

He thought if he said 98% accurate, people would have been suspicious of his findings. Yeah, that's right. So he was 97. And the funny thing though is while all this, I wasn't going to call it quackery because they were trying to legitimately invent something, but while at the same time, all this is going on, there was a guy named Kenneth Keele who said, why don't we just ask people? Let's use our brains people, how about that? Why don't we just ask folks and tell them like zero, one or two or three on the scale

of not painful to severely painful, why don't we just ask them and see what they say? Right. And that kind of caught on as the standard. Well, let's take a break, man, and then we'll get back to when sensible pain scales came into effect. Hey, everybody, when you're staying at an Airbnb, you might be like me wondering, could my place be an Airbnb? And if it could, what could it earn?

So I was pretty surprised to hear about Lauren and Nova Scotia who realized she could Airbnb her cozy backyard treehouse and the extra income helps cover her bills and pays for her travel. So yeah, you might not realize it, but you might have an Airbnb too. Find out what your place could be earning at airbnb.ca slash host. On the podcast, Hey Dude, the 90s called David Lasher and Christine Taylor, stars of the cult classic show, Hey Dude, bring you back to the days of slip dresses and choker necklaces. We're going to use Hey Dude as our jumping off point, but we are going to unpack and dive back into the decade of the 90s.

We lived it, and now we're calling on all of our friends to come back and relive it. It's a podcast packed with interviews, co-stars, friends, and non-stop references to the best decade ever. Do you remember going to Blockbuster? Do you remember Nintendo 64? Do you remember getting frosted tips? Was that a cereal? No, it was hair.

Do you remember AOL Instant Messenger and the dial-up sound like poltergeist? So leave a code on your best friend's beeper because you'll want to be there when the nostalgia starts flowing. Each episode will rival the feeling of taking out the cartridge from your Game Boy, blowing on it and popping it back in as we take you back to the 90s. Listen to Hey Dude, the 90s called on the iHeart Radio app, Apple Podcasts, or wherever you get your podcasts. All right, Chuck, so the 40s were full of ding-bat ideas.

The 60s, 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 40s, but it seems to have really caught on in the 60s. And so with a self-reported pain scale, with any, 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, oh, a lot, you know? You have to give them, say, like you said, a scale of like zero to 10 or zero to 20 or zero to 100.

Some people, just for fun, have one that goes up zero to a million. And everyone chooses a million. It's crazy. I always have a difficult time because I have a high threshold for pain. But that makes sense, because pain is subjective. Yeah, 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? No.

No, I'm in a tremendous amount of pain, doctor. Please help me. I usually try to, and this doesn't happen much, because I don't often need, or have an injury to where I like would need pain pills or something. But I always try to quantify it as if I didn't have a high threshold for pain. You know what I'm saying? Like I'll think of my number, and then I'll add a couple. So I can get juiced up.

Do you objectively self-report then, rather than subjectively? Yeah, which they say is very much wrong, and you should be super honest with your doctor. Because like you said, there are addicts who seek this out. 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 some, you know? Yeah. Well, the way to get around that though is to just like dress up, you know, when you

go to the hospital. Like where's suit? To be sure. Tie, that kind of thing. Yeah, I walk in with my baseball hat and beard and a tie. Well, see, you would see med seeking. Yeah, I totally would. It would at the very least like cross their mind, whereas if you dressed up and you said

... Unshaved. Sure. They'd be like, what drugs can we give you? Right. Just write it down, write down whatever you want. Yeah. And we'll sign it.

I don't know the name of any of them, so. Fetinol is a big problem these days. Is it? Making its way into heroin. Killing people. What? Taken with heroin? Yeah.

They're using fentanyl to cut heroin. I don't know if they still are anymore, but like towns around America, we're having like, you know, it'd 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 heroin 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 Hoffman, too.

I think he might have had fentanyl in 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 fentanyl mixed in, they're dead. Wow. That reminds me of the great Kamal Nagyani joke, which was my intro to him. I heard him on This American Life, he was talking about a new drug the kids were doing, which was Tylenol PM with heroin. And he was just like, you're already doing heroin.

It's like, what could that possibly add to your experience? Yeah. Very funny joke. Yeah. But also sad, at the same time. Aren't the best jokes? Yeah. Little sad, sometimes.

So with self-reporting pain scales, it sounds like I said so basic, like, okay, it's a no-brainer. You ask someone, you've got zero to whatever, three or 10 or 100. People say that, and then the doctor knows. But you don't think about children or their understanding of pain, or maybe the elderly and reasons how they experience 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 rating their pain on a scale using numbers. They can also use words like, I'm in severe pain or something like that. And usually, if you're being presented with a pain scale, it's not open-ended, like, describe your pain in flowery language. Which of these words best describes your pain? No pain, moderate, severe, intolerable. The one that gets me is, the worst pain imaginable, that's as bad as it gets. I can't conceive of any pain worse than what I'm in right now.

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 experiencing the worst pain imaginable. 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 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. It seems like those injuries are less painful a lot of times than other kinds of injuries. I hear people say, yeah, I broke my bone, but it was just sort of numb, and it looked awful, but I didn't feel actual pain, whereas pulled muscles and things like that are the things that really hurt. Or back pain, for God's sake, is the worst. You know, I'd like to do a call out to emergency room physicians or nurses or orderlies, anybody who's seen people in a lot of pain, and tell us, what is reliably the worst type of injury

pain-wise? I think burns. Oh, yeah. I'll bet burns. I've heard that that's just, you know, and I've had small burns that it's just that pain that won't stop, and I can't imagine working in a burn, you know, the kind of pain those people suffer, man. So talking about children, there's this really great story about the Wong Baker faces, all

caps. It stands for something. That's right. For treating kids with discomfort and pain. And it was developed in the early 80s 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, a child life specialist, excuse me, which I had never heard of, but it's a really cool job where they work in hospitals and they work with

children, not in like a nursing capacity, but, and geez, 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 my impression. Okay. 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 in Tulsa where Connie Baker worked and they got to talking and she's like, I've had this idea where we can do better with, with trying to determine and get self-reporting out of children because children don't, you know, sometimes they're pre-verbal or non-verbal 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 looks like the pain that you're having. Right. And the kid would draw and they'd be like, this is terrible. Did you do a better job than this? What is that? Is it chimney with smoke coming out of it? They're like that.

I feel like I'm on fire. So these kids, you know, you look at some of these early drawings and it's super cute. You know, they've got these crayons and they put these details like hair and noses and, you know, typical kids drawings. And interestingly, some of them drew left to right. Some of them right to left. I don't know how to explain that, but I guess maybe kids that 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 reads right to left. I don't think so. I think these were just like, you know, normal dumb American kids. Oh, gotcha. And so these kids actually participated and started drawing these little faces that range from smiling to tears. And they got a little bit of heat for using tears as well as the smiles.

Why? Well, they, you know, some researchers said like, you probably shouldn't use those. But they said, no, you know, 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. And then they kept the tears, but they told the kids and they continue to tell kids when they look at this thing, you don't have to have tears necessarily to have the worst,

to be in the 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. Now confuse the kids. Yeah, exactly. So what they did was then they, they got a professional artist and basically kind of picked out the most frequently drawn features and had them 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. All right. So chocolate. Let's take another break and then we'll come back and talk about some other ways of assessing pain. Hey, everybody, when you're staying at an Airbnb, you might be like me wondering, could my place be an Airbnb? And if it could, what could it earn?

So I was pretty surprised to hear about Lauren and Nova Scotia who realized she could Airbnb her cozy backyard treehouse and the extra income helps cover her bills and pays for her travel. So yeah, you might not realize it, but you might have an Airbnb too. Find out what your place could be earning at Airbnb.ca slash host on the podcast. Hey, dude, the nineties called David Lasher and Christine Taylor, stars of the cult classic show. Hey, dude, bring you back to the days of slip dresses and choker necklaces. We're going to use Hey, dude as our jumping off point, but we are going to unpack and

dive back into the decade of the nineties. We lived it. And now we're calling on all of our friends to come back and relive it. It's a podcast packed with interviews, co-stars, friends and non-stop references to the best decade ever. Do you remember going to blockbuster? Do you remember Nintendo 64? Do you remember getting frosted tips?

Was that a cereal? No, it was hair. Do you remember AOL instant messenger and the dial-up sound like poltergeist? So leave a code on your best friend's beeper because you'll want to be there when the nostalgia starts flowing. Each episode will rival the feeling of taking out the cartridge from your Game Boy, blowing on it and popping it back in as we take you back to the nineties. Listen to Hey, dude, the nineties called on the iHeart Radio app, Apple Podcasts or wherever

you get your podcasts. So Chuck, 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. So one of them is so advanced that you have on one end no pain and on the other end extreme pain and an adult or somebody will point to them wherever they are on that scale. And then the doctor has to get out a ruler and measure it 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 it's getting better or worse by assessing it several times over time. But part of the problem with self-reporting pain scales is there can be obfuscation. Like we said, like if you're med-seeking, the elderly apparently don't like to talk about their pain. Yeah. I mean, there's a lot of reasons for that from shame of like getting older and not feeling

well to, well, like you said, just like they don't want to be a bother a lot of times. Yeah, I read that 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 like sore, ache, discomfort, and that if you're a good physician, you're going to figure out 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 translation chart. Pretty much.

Yeah. Sore, it's like a two, right, achy, say 3.5. And doc, oh, this is killing me. That's a 11. I wonder if there are any pain scales where it's like, like weather patterns, like, you know, spring day to tornado of pain, tornado of pain. There's another band name. And yeah, oh yeah, that probably is a band.

And then they make them draw that too. They draw a better tornado. Oh, I meant to say something too about 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 enjoyed doing it. Probably takes their mind off of things. Yeah. And the kids will like draw it and then take it home and stuff.

And yeah, it's kind of cool. And while they're busy drawing, the doctor sneaks up behind them and injects them with a heavy dose of opioids right into their neck while they're distracted. And the kids are like, bam, so long pain. Most of those drawings have like a big crayon streak going off the edge of the page. So 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 translate. Or like you said, they could be cognitively challenged. There's a lot of different reasons why a 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, your body's going to make

you react in predictable and from what I can tell, universal ways. Yeah. Right. So no matter where you are in the world, no matter whether you are cognitively challenged or whether you have Alzheimer's or whether you are a nonverbal baby, like there are 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 a reliable expressions. Yeah.

Like if you have back pain and you go to sit down, like they're assessing you before they've even started asking questions. So you come into the room and you do like, you know, you grab the arm in the chair and do the, ah, when you sit down, that's a big cue to a doctor. Like, you know, this person is having trouble sitting and standing there in so much back pain. So 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 grimacing in pain, and you're doing it involuntarily. So yeah, these are behavioral cues. Yeah. There's basically two categories you can put observational pain assessment into, behavioral and physiological, right? Yeah. So in the behavioral hand, you've got facial expressions like grimacing, you've got sounds like moans, grunts, even people just talking about their pain, but not because they're

being interviewed, just being like, you know, this, oh, my back or something like that. My aching back, they really worked me like a dog today. And these are super important for all the reasons we talked about people either not being able to report their pain accurately or, and you know, 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 going to 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 something to do with it. But I used to be really, really needle phobic and 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 you're a needle phobic, huh? Oh, when I was a kid, yeah, needles, you know, they were a lot bigger. It wasn't like, I mean, obviously it wasn't like the 1800s where they have like a railroad spike.

Right. But it's not like today where those little tiny, tiny thin needles, I don't know the ages, but yeah, when I was growing up, they were, yeah, they, I hated getting shots. Yeah, I wasn't really big on it either. I don't know if I would, I'd be needle phobic. Do you watch the needle go in or do you look away? Sometimes it depends. So yeah, I have to look.

It depends on my mood. Oh, really? Yeah, 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, ooh, ooh, you missed that one and just try to psych him out. Yeah, that is kind of bad when they can't find the vein. Sure.

I'm not into blood drawing. Right. But yeah, sometimes I'm just like, I'm not into it today and I'll look away. The other cool thing too about when you get blood drawn today is they used to, they've just come so far, man. And 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.

But I still... Phlebotomy. Huh? Phlebotomy. Is that what that's called? And it's whoever invented that, Mr. Phlobo or Mrs. Phlobo, Dr. Phlobo? Phoebe Phlobo, MD. I salute you because that has really changed things for me.

But I still weirdly have this fear of when they're doing that and unscrewing it, I have this fear that they're going to knock the needle and it's going to kind of like rip out of my arm. Yeah, me too. Oh, okay. So that's... Is that a common thing, maybe? Oh, yeah, for sure.

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 going to rip it out and it's going to pull like all of your veins and your muscle out right after it, like a bunch of bloody party streamers. Yeah. I know what you mean. And I'm a slightly phobic still about them not being able to find the vein.

So like, you know, they give you the ball to squeeze, I turn 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 bulging out for them to go in with that needle.

Maybe I'm still needle phobic. It sounds a bit like it. 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. Sure.

Well, that's good though. That means your chances of becoming an intravenous drug user are like zero. Yes, exactly. Zero chance. So Chuck, in addition to those behavioral cues, right, like body language is another one too where you're like, you've got your arm kind of guarding your broken rib or something like that. Like, get back, get back.

Yeah, sure. Everybody stay back. That's fairly universal from what I understand. There's also physiological changes too. Like you may become nauseous or your heartbeat or respiration starts increasing. You sweat. 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 chuck, okay.

He must be at like a 10 right now, even though he can't talk. Because that's another one too. Like you may be in so much pain that you can't talk. 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 almost bit my tongue off when I was a kid. Oh man.

And I, you know, I couldn't talk very well. Yeah. Well now you talk great. So much so that I do it for a living. Sure. 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 they're treating. There's one called the CNPI checklist and this is specifically for cognitively 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 skilled and careful there because when they're assessing pain, because if you're assessing behavioral traits and someone has a cognitive impairment, it can be very confusing to assess that because there may be another need not being met. Like they might be hungry or overstimulated or thirsty and that's coming out or anxiety

maybe and that's coming out 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 scales, in some cases the doctor will just be like, ooh, that guy's really grimacing horribly. So he's probably at like a 10. Other ones actually quantify these different observations like the cries tool for infants in pain, which is about as sad a thought as there is.

But it's basically several different observations like that fall into behavioral and physiological tranches and then, you know, the doctor rates each one I think is zero to two or something like that. Yeah. And then if the sum total of each category as up to four or more, then it's the babies in a type of pain that would require some sort of medication. Yeah. I looked into this one a bit more.

C-R-I-E-S stands for crying, requires oxygen for saturation greater than 95%. That is a terrible acronym. I know. C-I for increased vital signs, E for expression, S for sleepless, zero would be a cry that's not high-pitched. This would be like a wah, wah. Yeah. I guess like a whimpering cry.

A two, I'm sorry, a one would be high-pitched, but the kid is easily consoled and a two would be high-pitched and not inconsolable. Wow. The oxygenation, basically, is there a decrease in O2 at certain levels? Number three, the vital signs, which is heart rate and blood pressure in this case, zero is unchanged, increase, less than 20% is a one, greater than 20% is a two. Oxygen, no grimace, zero, just a grimace by itself is a one, and a grimace with a non-crying grunt is a two.

That's not a good one. Well, because they've already covered crying, so yeah, a non-crying grunt, and then 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 I've said before, I used to do PA jobs in LA for this one company who did, well, they did two hospitals.

They did city of hope cancer research, which is where I saw the head in the bucket. And then children's hospital Los Angeles, CHLA, which was a really rewarding experience, but the toughest job I ever had, like the worst stuff you can imagine. And I gotta say, kids are the bravest, best attitudinal, they're the best attitudes, and they were the bravest of like any humans I ever saw in the face of like the most daunting things. Like compared to adults, I was just like, man, adults need to take some lessons from kids. Yeah.

Because it's amazing like the attitudes these kids had. Man, that's neat. It was. I've also been in the emergency room on the flip side and seen adults that I think they think they might be able to get sooner, sooner if they wail in pain. Right. Like when they're wailing and wailing, and then you see them like open one eye and look around.

I hate to say that because maybe they are in that kind of pain and that's just how they express it. But usually 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, you're just trying to get to the front of the line. H-U-R-T-S. And then I see these kids 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 wassier as the, as you age. Yeah. Up to a point. Yeah. I agree.

So you got anything else? No. I mean, there's, you know, there's tons and 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'd have thought that we would do pain scales before we did one on pain?

Well now when we do one on pain, we can just say, and there are also pain scales, which we've detailed thoroughly. Yeah. We do that, don't we? Mm-hmm. All right. Well, if you want to know more about pain scales, type those words in the search bar at HowStuffWorks.com and since I said that, it's time for listener mail.

Uh, I'm going to call this just email from a seemingly very nice guy or a big phony. Hey guys, been a listener for three to four years, I think I've always wanted to write in, but was shy. I thought it was worth mentioning that I listened to about 30 hours of podcasts per week and you are in my top two favorites. This guy's a pro, which basically that means we're number two or he would have 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 know as well. It's a Scott follow up on this, please. Uh, second but related, I'm a master's level board certified behavior analyst, a BCBA 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, too credulous, or they oversimplify or something else and you guys do a great job 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. I actually consider myself on the more extreme end of pacifism. Do not wish harm on anyone under any circumstance. Uh, this, 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 Idi Amin. Yeah. Uh, although I'd 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 place and then, uh, rather than hurt their attacker, uh, 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.

Uh, you 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 got to husk the corn before you can make it into a corn dog. That's true. Unless you're doing it like farmhouse style, in which case you would include the husk into the ultimate corn meal. Yes. And you can find those at county fairs. Uh, thanks a lot, Scott.

If you want to get in touch with us 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.com or facebook.com slash Charles, you can send us an email to stuffpodcast at howstuffworks.com and as always join us at our home on the web, stuffyoushouldknow.com. For more on this and thousands of other topics, visit howstuffworks.com. On the podcast, Hey Dude, the 90s called David Lasher and Christine Taylor, stars of the cult classic show, Hey Dude, bring you back to the days of slip dresses and choker necklaces. We're going to use Hey Dude as our jumping off point, but we are going to unpack and

dive back into the decade of the 90s. We lived it. And now we're calling on all of our friends to come back and relive it. Listen to Hey Dude, the 90s called on the iHeart radio app, Apple podcasts or wherever you get your podcasts. Hey, I'm Lance Bass, host of the new iHeart podcast, Frosted Tips with Lance Bass. Do you ever think to yourself, what advice would Lance Bass and my favorite boy bands give me in this situation?

If you do, you've come to the right place because I'm here to help. Get a different hot, sexy teen crush boy bander each week to guide you through life. Tell everybody, everybody about my new podcast and make sure to listen so we'll never ever have to say bye, bye, bye. Listen to Frosted Tips with Lance Bass on the iHeart radio app, Apple podcast or wherever you listen to podcasts.