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Howdy, everybody. We're going to take you back in time to March 14th, 2017 for this week's Selects episode pick, Pain scales, colon, yow! Exclamation point. I know that was a Josh title because it's funny and creative and he's great at those. So pain scales is pretty interesting stuff. If you've ever been to a doctor and they say like, Well, what is it between a one and ten? That's one pain scale, but there are all kinds of pain scales. And believe it or not, they're not arbitrary. A lot of thought went into how they were formed and built and put together. So check out pain scales, colon, right now.

Welcome to Stuff You Should Know, a production.

Of iHeart Radio.

Hey, and welcome to the podcast. I'm Josh Clark. Hi. There's Charles W. Chuck Bryant. Hi. 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.

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 just got through brushing my teeth and drinking orange juice.

Oh, yeah.

You have revived that dumb joke from 37 years ago.

Right.

With a hammer. Here we are.

Here we are, Chuck, talking about pain.

Yeah. I thought this one, for all its sameness and basicness, was way more interesting than I thought once you dig in a little bit more.

Yep.

Pain. How about that?

Yeah, I thought this one was pretty cool, too. We need to do a pain episode.

Just on pain?

Just in general.

House of pain?

Yeah, the TV show and the group.

I didn't know that was 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 like Mama's Family a little bit.

I didn't watch.

That either. Same production quality, that stuff that looks like it's recorded on a stage.

Sure, probably is.

You know what I'm talking about? 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.

With Baba, 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. 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, 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 too. I'm going to make my own observations about you.

Man, I haven't used a hairbrush since I was probably 13.

I have to once in a while because my hair is longish now. And when the wind blows, it really turns it into a bird's nest. So I got.

To- So you get the comb from your pocket?

Yeah, I stand in front of the mirror like Marcia braided right before bed and count off 100 brushstrokes.

Yeah. So let's talk about... Basically, we're talking about self-reporting or observation. Those are the two methods. Because it's important. There's a lot that goes into determining how much pain someone's in from the meds 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 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. It's a subjective, horrible, terrible experience. 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. But 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 put a pillow over your face or something, make you go to sleep.

Yeah, because that's what doctors do.

Well, yeah, it's a last resort, 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 metal, right?

Or I could see like a sex pop.

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 tech-like? No.

I don't.

Know what Sex Pop would be.

It doesn't sound like it's up my alley. Okay. But I'll give it a shot.

All right.

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. There's just a lot of trial and error. I guess that's not enough because someone's screaming on the table in front of me.

Well, plus also pain apparently is pretty widespread. I saw that in the US alone, 9 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 US. Another 50 million suffer chronic pain. Many of those people report suffering chronic pain for five years or more. So sad, yeah. 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 beatle.

What was his? Clarence? Yeah. That's a great Eddie Murphy's kid. Yeah. 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 foolproof ways to determine pain measurement. In 1940, there were some researchers, a trio, one James Hardie, one Harold Wolf, and one Helen Goodell of Cornell University.

Those are some 1940s names.

Sure. Harold Wolf.

Yeah, James Hardie.

Yeah, Helen Goodell, all three of them. They actually built a device called a Dolarimeter. What this was, was basically a 100-watt lamp with a lens that they could focus, how you do when.

You're-burning ants?

Yeah, with a magnifying glass. That's what they were doing. They were cranking up heat. They got these nurse volunteers, apparently. I think they were all pregnant, which is even a little more sadistic. But what they were trying to do was compare it to their pregnancy pains, their labor pains.

Yeah. I was like, Why would you do that to women in labor?

It was the 1940s.

Well, you could predict when something was going to happen. It was one of those few instances when you could predict somebody's going to be in pain.

Yeah, I get it. But it was also the 1940s, so they didn't care.

Right. I'm 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. They were either nurses or wives of doctors, which is even a bit more sadistic. They would focus this light on the back of their hand and make it hotter and hotter and said, Compare that to the intensity of your labor pains by tricking, I guess. They even made up a unit.

We've reached equilibrium.

They even invented a pain unit called DOLS, D-O-L-S. It went supposedly 1:10, 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, 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 Dolorometer, which is in subsequent experience by other doctors, they could not reproduce this, which means it's junk.

Well, not only that. 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, but they do slightly different things. 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 sit there and 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 the decade of trying to perfect these things before they realized they couldn't. Time magazine wrote an article on Dr. Lauren De Julius Bella Glutsec.

Great name.

And he had a had machine. It didn't use heat, but it put pressure on the chin bone in increasing amounts.

That.

Sounds awful. It does sound awful.

The chin is surprisingly sensitive.

Oh, yeah. Just put a coffee table in any room.

Yeah, it doesn't make any sense. It should be tougher than leather, like run-D-M-C, 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 Glutek, 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.

He went.

With 97. 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 the same time all this was going on, there was a guy named Kenneth Keel 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 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? And that 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.

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All.

Right, Chuck, so the 40s were full of ding, bad ideas. The 60s, well, actually, I guess the guy you mentioned, Dr. Kenneth Keel, he came up with this 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.

Yeah, agreed.

And so with a self-reported pain scale, with any, well, yeah, any 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 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 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.

But that makes sense because pain is subjective.

Yeah, but I have a high threshold for pain. But I also, I want the good pills-You know what I'm saying?

-do you wank when you're talking? No. I'm in a tremendous amount of pain, doctor.

Please help me. I usually try to quantify, and this doesn't happen much because I don't often need or have an injury to where I 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? I'll 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. Sure. 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, 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.

Yeah. Well, the way to get around that, though, is to just dress up when you go to the hospital.

Like wear a suit?

To be sure. A tie, that 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, cross their mind. Whereas if you dressed up and you said, and shaved.

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.

Fentanyl 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 towns around America were having like... It'd be normal to have one or two overdoses a year. They were having a dozen or so all of a sudden because people were... It's like heroin and then the highest grade pharmaceutical heroin mixed in. And apparently, people didn't have any warning or 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 the great Kamal Najyani 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. 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 the best jokes?

Yeah, a little sad. Sometimes. With self-reporting pain scales, it sounds, like I said, so basic. Like, okay, it's a no-brainer. Duh, you ask 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 children and 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. 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.

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. Usually, if you're being presented with the pain scale, it's not open ended. 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, whether it's a cut or a broken bone or something, 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 like, Yeah, I broke my bone, but it was just 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 what? 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. 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... I've had small burns that it's just that pain that won't stop. I can't imagine working in a burn unit, the pain those people suffer.

Yeah.

Man. So talking about children, there's this really great story about the Wang Baker faces, all caps, F-A-C-E-S.

F-a-c-e-s for something.

-that's right. For treating kids with discomfort and pain. It was developed in the early '80s by two women, Donna Wang, who was a... Well, Connie Baker is, I think, first started with the idea. Connie Baker was 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 a nursing capacity. And, geez, I'd love to hear from someone who does this, but it seems like they 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 Wang, who is 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 was like, I've had this idea where we can do better with trying to determine and get self-reporting out of children because children don't. Sometimes they're preverbal or nonverbal, and sometimes they don't get the numbers or the color charts. Right. So we need a better way. And then ingeniously, they developed this with children. They started with just blank circles and said, Hey, you draw a face that looks like the pain that you're having.

The kid would draw and they'd be like, This is terrible. Did you do a better job than this. What is that? Is that a chimney with smoke coming out of it?

They're like, I feel like I'm on fire. These kids, you look at some of these early drawings and it's super cute. They've got these crayons and they put these details like hair and noses and typical kids drawings. 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 the opposite of how we learn to read.

Or they grew up in a culture that reads right to left.

I don't think so. I think these were just normal, dumb American kids.

Oh, got you.

These kids actually participated and started drawing these little faces that range from smiling to tears. They got a little bit of heat for using tears as well as the smiles.

Why?

Well, some researchers said you probably shouldn't use those, but they said, no, every kid drew smiles. We think that is really informative to us and them describing how they feel, so let's keep that. 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 be in the worst pain because not everybody cries when they're in pain.

Got you. That's why they said you shouldn't have tears on there?

Yeah, I think so.

Not to confuse.

The kids? Yeah, exactly. Huh. What they did was then they got a professional artist and basically picked out the most frequently drawn features and had them draw a professional composite of these faces. I think they ended up on six circles after experimenting with less or more. Children actually helped develop the faces chart, which is an awesome story.

It is. It's pretty.

Cute in.

A way, which makes it a joke. All right, so Chuck, let's take another break and then we'll come back and talk about some other ways of assessing pain.

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Chuck.

Chuck.

Chuck.

Chuck.

Chuck. Chuck. Chuck. Chuck. Chuck. Chuck. Chuck. Chuck. Chuck.

Chuck. Chuck. Chuck. Chuck. Chuck. 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. 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 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, right? 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 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 word 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.

Soar, it's like a two. Right. Achy, say.

3.5. Doc, oi, this is killing me.

That's an 11.

I wonder if there are any pain scales where it's like weather patterns like Spring Day to tornado of pain.

Tornado of Pain. Tornado of Pain.

There's another band name. Oh, yeah, that probably is a band.

And then.

They make them draw that, too.

Draw a better tornado.

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 enjoy doing it.

It probably takes their mind.

Off of things. Yeah, and the kids will draw it and then take it home and stuff. Yeah, it's cool.

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.

They get.

Like, Bam, so long pain. Most of those drawings have a big crayon streak going off the edge of the page.

Some other reasons that you might need to pull out different charts is maybe someone doesn't speak the language that the doctor speaks. 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 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. Andthere's actually, I found this extremely interesting that regardless of your level of consciousness, if you are conscious and receptive to pain, your body is 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 nonverbal baby, there are going to be things that you are going to do when you're in pain. For example, facial expressions tend to change and take on reliable expressions.

Yeah, like if you have back pain and you go to sit down, they're assessing you before they've even started asking questions. You come into the room and you do like you grab the arm in the chair and do the when you sit down, that's a big cue to a doctor like, This person is having trouble sitting and standing there in so much back pain.

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 grimacing in pain, and you're doing it involuntarily.

Yeah, these are behavioral cues.

Yeah, there's basically two categories you can put observational pain assessment into behavioral and physiological, right? Yeah. So on 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, but just being like, Oh, my back, or something like that. My aches and back. They really worked me like a dog today.

These are super important for all the reasons we talked about, people either not being able to report their pain accurately or, and we talked about a couple of reasons like the drug seeking, but 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. I have something to do with it. But I used to be really needle phobic and am not anymore. I don't love it still, but the needles have gotten so tiny that it's not that big of a deal.

You were needle phobic, huh?

When I was a kid, yeah, needles, they were a lot bigger. It wasn't like, I mean, obviously, it wasn't like the 1800s, where they had a railroad spike. But it's not like today where those little tiny, tiny, thin needles. I don't know the gauges, but yeah, when I was growing up, I hated getting shots.

Yeah, I wasn't really big on it either, but I don't know if I would be needle phobic.

Do you watch the needle go in? Or do you look away?

Sometimes it depends. 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, Oh, you missed that one. I just try to.

Psych them out. Yeah, that is bad when they can't find the vein for blood drawing.

Right. But yeah, sometimes I'm just like, I'm not into it today. 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. Remember... They used to have to... If you had multiple blood tests, you would get stuck like six times. Now they have those awesome little tubes that they can just unscrew.

Yeah.

But I.

Still- thelatomy.

Huh? Thelatomy. Is that what that's called? Whoever invented that, Mr. Flobo or Mrs. Flobo, Dr.

Flobo? Phoebe Flobo, 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 rip out of my arm. Yeah, me too. Okay, 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 is just going to rip it out and it's going to pull all of your veins and your muscle out right after it like a bunch of bloody party streamers. I know what you mean.

I'm a slightly phobic still about them not being able to find the vein. So they give you the ball to squeeze. I turn that thing into dust because 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. 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 intravenious drug user are zero.

Yes, exactly. Zero chance.

Chuck, in addition to those behavioral cues, like body language is another one, too, where you've got your arm guarding your broken rib or something like that. Get back. Get back.

Yeah, sure. Everybody, stay back.

That's fairly universal from what I understand. There's also physiological changes, too. 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. Right. With that where it's like, Oh, that guy's sweating like a...

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. 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 I have an injury that keeps you from talking. I'm almost bit my tongue off when I was a kid. Oh, man. I couldn't talk very well.

Yeah. Well, now you talk great.

So much so that I do it for a living. Sure. Like I said, there are so many of these pain scales, and some of them can get very specific for the person that they're treating. There's one called the CNPI checklist, and this is specifically for cognitively impaired elderly. Oh, that's specific. It's a nonverbal checklist, basically, that doctors can use. We 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 wade through that to get an accurate reading.

Right. And then so with these observational scales, in some cases, the doctor will just be like, Oh, that guy is really grimacing horribly. So he's probably at like a 10. Other ones actually quantify these different observations like the Cry's tool for infants in pain, which is about as sad a thought as there is. But it's basically several different observations that fall into behavioral and physiological tranches. Then the doctor rates each one on, I think zero to two or something like that. Then if the sum total of each category adds up to four or more, then the baby's in a type of pain that would require some medication.

Yeah, I looked into this one a bit more. See, R-I-E-S stands for crying, requires oxygen for saturation greater than 95 %.

That is a terrible acronym.

I for increased vital signs, E for expression, S for sleepless. A zero would be a cry that's not high pitched.

It's just like.

A wimpering cry. 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. The oxygenation basically... Is there a decrease? Sorry, an 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. Expression, no grimace, is zero. Just a grimace by itself is a one. And a grimace... Sorry, 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 then always constantly awake two. 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 L. A. 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. Then Children's Hospital, Los Angeles, ZHLA, which was a really rewarding experience. But the toughest job I ever had. The worst stuff you can imagine. I got to say, kids are the bravest, best attitudinal. They're the best attitudes, and they were the bravest of any humans I ever saw in the face of the most daunting things. Compared to adults, I was just like, Man, adults need to take some lessons from kids.

Because.

It's amazing 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 soon sooner if they wail in pain.

Right. Like when they're wailing and wailing, and then you see him open one eye and look around.

I hate to say that because maybe they are in that 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. I'm like, Come on, man. -you're just trying.

Toit hurts, I say.

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 ward that are just 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 get worse here as you age.

Yeah.

Up to a point.

Yeah, I agree.

So you got anything else?

No, I mean, 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? All right, well, if you want to know more about pain scales, type those words in the search bar at howstuffworks. Com. Since I said that, it's time for listener mail.

I'm going to call this just an 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 listen 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 want to know what number one is, though.

Yeah, I'd like to know as well.

To Scott, follow up on this, please. Second, but related, I'm a Masters 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. 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. Finally, I really loved your episode on pacifism. I actually consider myself on the more extreme end of pacifism. I do not wish harm on anyone under any circumstance. That's nice, right? 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. Although 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 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 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. That is from Scott Miller of the University of Nebraska.

Go corn dogs. Corn Huskars. 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 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 want to get in touch with us like Scott did, you can send us an email to stuffpodcast@howstuffworks. Com. And as always, join us at our home on the web, stuffyoushouldknow.

Com.

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