Pain Scales: Yeeeow!

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, 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

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 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 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,

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, 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 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 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, 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 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 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 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, 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, 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 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. 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 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 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. 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 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

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, 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 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 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, 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, 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 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

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 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, 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 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 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,

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. 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, 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 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 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, 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 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 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, 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 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, 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 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 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. 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 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

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 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. 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 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 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 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 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

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

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 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 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 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 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, 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 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 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, 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, 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 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 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. 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, 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 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 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 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 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, 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, 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 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 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, 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 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 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 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 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

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 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? 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

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

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. 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.

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

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 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 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 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 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 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, 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 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 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 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 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 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 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 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 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 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 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,

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 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

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 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 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, 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 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 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 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