Give Me a Sign

A show for salvation.

Posted Mar 09, 2012

Sometimes it slips out when I am alone in a room with a patient. I ask whether a patient has had any signs or symptoms. I am usually met with a puzzled look. Patients tend not to know what I mean by a sign or a symptom. Unfortunately, there is an element of the health care profession that share the same knowledge deficiency.

Or perhaps they share the same proclivity to sacrifice the importance of the differences between a sign and a symptom.

Vital signs are measures of various physiological statistics—generally taken and recorded by health professionals—that assess the basic body functions: Taking vital signs involves these four acts: recording body temperature, pulse (heart) rate, blood pressure, and respiratory rate. The equipment generally used is a thermometer, a sphygmomanometer, and a watch.

I can remember as an intern being given my first "pronouncement": I was to pronounce someone as officially dead. The bored nurse stood by, chart in hand, ready to record for posterity my decision. I observed the still and pale patient, held my head next to his to feel for a breath, all the while looking at the chest wall for signs of respiration. There were none. I felt for a pulse, but there was none, and this was confirmed by the flat line noted on the monitor, which of course also showed no evidence of blood pressure.

I pronounced. There were no vital signs. There was no sign of life.

The patient was dead. He would never report another symptom to any one. He certainly will not be telling me how he feels; subjectivity had died with him, and there was not much left for me at that point. There were only memories left for those who knew and loved him.

Over the many years since those days and nights there has been a concerted effort to add vital signs, one incarnation of that effort being the attempt to make pain the Fifth Vital Sign. Originally, it was hoped that this would raise the general level of awareness regarding inadequate pain control. However, it was doomed to fail, as it can never be anything but a symptom: It is not something that can be perceived by the senses of others.

It is a symptom, something that someone other than the patient cannot see, hear, touch, and therefore something that cannot be objectively measured.

And even when that alternately lethargic behemoth of bureaucracy and bastion of quality health care for those with few health care alternatives, the Veterans Administration (VA), decides to make the measurement of pain the fifth vital sign, it falls flat, failing to improve the quality of pain management, and perhaps endangering those it was supposed to help.

A paper published in 2006 in the Journal of General Internal Medicine describes how the VA responded to accusations that clinicians were not treating pain adequately. In a 1999 memorandum, the Veterans Health Administration instituted the measurement and documentation in the electronic medical record of patients' self-report of pain. This initiative was called "Pain as the 5th Vital Sign." Unfortunately, the authors found that this initiative did not improve the quality of pain management in the outpatient internal medicine setting. Moreover, for patients who had pain levels greater than or equal to 4 on a ten-point scale, substantial deficits in the evaluation and therapy of pain were demonstrated, even though there is a greater volume of opioid prescriptions being written by VA practitioners.

There is further evidence that the problem with ideal pain management is not because physicians are stingy with the prescription pad. In January of this year, The Centers for Disease Control and Prevention, as described in its publication "Morbidity and Mortality Weekly Report," found that practitioners throughout the country have greatly increased their rate of opioid prescribing over the past decade. Persons who abuse opioids have learned to exploit the clarion call for increased sensitivity to a patient's pain. So, we are all left with the daunting task of not only identifying pain in the patient population, but also who in that population is at the greater risk of abusing the drugs used to treat pain. The latter subset may make up the majority of those who claim the need for greater pain management, whereas in reality the true need is to feed an addiction.

The "5th Vital Sign" appears to be many things to many people. But it is not a sign. I certainly don't need it to pronounce someone dead.

Its unwitting role might be that of the killer of those I am asked to pronounce.

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