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At Jail Medicine we discuss all aspects of medicines practiced in today's jails, prisons and juvenile facilities.
This entry was posted in Drug Evaluations, Drugs of Abuse, Medical Practice, Pharmacy, Uncategorized and tagged correctional medicine, evidence based medicine, gabapentin, inmates, jail medicine, jails, pain management, pharmacy practice, prisons on February 7, 2016 by Jeffery Keller MD. My good friend Al Cichon wrote the following comments to me about my article on the 10 Point Pain Scale.
Use of a ‘scale’ to measure subjective factors is a true oxymoron (heavy on the moron part). JCAHO has imposed the ‘Pain Scale’ in an effort to assure that the assessment of pain will be factored into patient care. One possible option to stabilize the use of any such scale is some method of anchoring the initial or end point of the scale.
One variant of this is: If you had a ‘bucket labeled depression and a stick marked off from 0 to 10 what is the worst you’ve ever felt and when”?
When you ‘anchor’ the ‘pain scale’ it establishes the assessment in a relatable setting and can be quite helpful in guiding patient care. As noted – ‘chronic pain’ is better measures by an assessment of the patients ADL (what daily activities are disrupted and is that new).
The 10-Point Pain Scale is not the only scoring system in medicine for subjective complaints. This entry was posted in Jail culture, Medical Practice, Practice Management, Withdrawal Syndromes and tagged alcohol withdrawal, correctional medicine, drug prices, evidence based medicine, Hamilton Rating Scale for Depression, inmates, jail medicine, jails, pain management, pharmacy practice, prisons on February 11, 2013 by Jeffery Keller MD. Hospitals have to use the 10 Point Pain Scale because it is mandated by JCAHO, the hospital accreditation body. Even in an ER setting, I noticed problems with the 10-Point Pain Scale.  First, it is entirely subjective. The 10 Point Pain Scale is more useful evaluating responses to therapy via changes in the pain scale. In the end, even using the 10 Point Pain Scale, ER doctors still have to rely on their clinical judgment.


And those are just the problems when the 10-Point Pain Scale is used to evaluate acute pain in ERs.  It is even worse when used to evaluate chronic pain in Correctional Medicine clinics. It seems to me that I have to use even more clinical judgment in a jail than I did in the ER. The subjective 10 Point Pain Scale in such a setting is more hindrance than help, I believe.
But the 10 Point Pain Scale is not as useful for rating chronic pain.  In my opinion, it is the wrong tool for this task.
What is your experience with the 10 Point Pain System used in hospitals?  Do you use it in your correctional facility?  Please comment! This entry was posted in Drugs of Abuse, Medical Practice, Practice Management and tagged 10 Point Pain Scale, Chronic pain, correctional medicine, evidence based medicine, inmates, jail medicine, jails, pain management, prisons on January 31, 2013 by Jeffery Keller MD. Over 100,000 people are hospitalized each year with GI complications caused by NSAID use.  Total spending in theUSto treat NSAID complications is greater than 2 billion dollars annually. The iatrogenic cost factor of NSAID use is approximately 2.  In other words, for every dollar spent on NSAIDS, approximately one more dollar is spent treating NSAID induced complications. This entry was posted in Drug Evaluations, Medical Practice and tagged correctional medicine, evidence based medicine, JailMedicine, jails, NSAIDS, pain management, prisons on January 26, 2012 by Jeffery Keller MD.
The ‘fifth vital sign’ is a misdirected effort to solve a true quality care problem – in my opinion.
Unfortunately, it is a bureaucratic response to a clinical situation – if it can be made to be measurable (regardless of practical validity) it can be enforced. That would then provide a somewhat stable reference for guiding care and transmitting information (about the patient) to other providers.
Now, no matter the number system you have an ‘anchor’ to both the scale and the present condition that can be related to the care process and others. The response will then provide an anchor (9 when I was admitted to the hospital after trying to kill myself). As important as assessing the level of pain is the type – physiologic source – since it is critical in guiding treatment.


If a patient can function (nutrition, hygiene, elimination) and participate in some activities then treatment of the physiologic cause is the most important clinical consideration.
Vital Signs are objective (as in measurable) indicators that have been demonstrated to provide consistently valid data for patient care. My apologies to proponents and defenders – but no matter how well intended; it is still dysfunctional. It does seem that these processes have provided some benefit – yet they all suffer from the same susceptibility – subjectivity.
We don’t have to use it and I personally think we practitioners of Correctional Medicine are better off without it. Whether you are working in corrections (where any subjective report must be verified) or the community (where verification is not always considered) any of these schemes has the same risk – because there is no objective validation. Is the 10-Point JCAHO scale more accurate than a simple “mild-moderate-severe” system?  Probably not. Selected cases of moderate OA can, in the short term, respond to an operation calledA a€?arthroscopy, washout & debridementa€™.
If I could make it happen (wave magic wand) and get you released and home now – what would it be? In this condition it is believed that the patella (kneecap) is compressed against the femoral trochlea during movement, causing a degree of friction. The condition may progress toA a€?Chondromalacia Patellaa€™, chondral defects and osteochondral defects and eventually Patello-femoral OA. A number of anatomical factors can predispose to the condition, and in particular weakness of the Vastus Medialis Oblique muscle (VMO). Surgery does exist to re-align the kneecap although it is rarely required and results are variable.A Iliotibial Band SyndromeA - Seen in Runners and Walkers.




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