Crash Cart: What to do with the “fifth vital sign,” truly sick hospital designs, and super bad super bugs

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This week: Half of our colleagues support eliminating pain as the “fifth vital sign.” Plus, the WHO announces their list of priority pathogens. Join in as our editors discuss the week’s headlines.


A Medscape survey says half of doctors and nurses support eliminating pain as the “Fifth Vital Sign.” 

The majority of docs use functional status when evaluating, while the majority of nurses use pain scale. About a third of both report pressure to prescribe pain meds. Original Article by Time.

Nicholas Genes, MD, PhD: I’m going to yield my space and quote Sergey Motov, from our recent interview: “This whole ‘fifth vital sign’ thing is plain awful. It’s been forced upon practicing ED doctors by several prominent organizations and agencies to meet certain metrics or benchmarks. These numerical values increased visibility of pain but did not affect the quality of pain management. I am all for frequent assessments and re-assessments of pain in ED patients, but I’m not for assigning a number to pain. It is impossible to assign a numerical value in order to objectify a purely subjective, intimate, individual experience such as pain … I am a firm advocate for ED pain assessments based on patient’s functional status and subsequent need for analgesia, rather than simply on the basis of a patient’s reported pain score. My goal in the ED is to get patients back to their regular daily activities by engaging them in shared decision-making about analgesics and the level of pain they are willing to accept that would not interfere with their ability to return to normal functioning. It allows me to use language patients can understand or relate to, and let me gauge progress over time.”

E. Paul DeKoning, MD, MS: If we are to keep pain as the 5th vital sign, I’d like to make several suggestions: 1. Create the “Objective Pain Stimulator”. First proposed to me by one of my attendings in residency (thanks Mike! I wish I could take credit), I believe it is the only way to objectively measure pain. My modification to the original design would be to have various settings, including 10/10, 12/10, and the ever elusive 20/10. It’s the only way to be sure. 2. Follow that up with the “Hunger Score”, with the following continuum: no I’m fine => ice chips => water => peanut butter and/or crackers => meal tray => happy meal/fast food meal combo (large). 3. Option to Super Size either 1 and/or 2 with a work note.

Ryan McKennon, DO: I applaud AAFP for taking a stance to remove pain as a vital sign. All other vital signs are objective, are independent risk factors for badness, and generally have a goal endpoint. What do I do with a pain score? What is the magic number I need to hit? Is a pain score of 7 an unstable vital sign? What if the patient states they are much more comfortable and ready to go home but still rate their pain as a 9/10? Or what if the pain score is 6/10 but the patient states he or she is in too much pain to walk? Pain is subjective and individualized, why do we try and make it fit into rigid boxes? Functional status should be the goal, not elimination of the pain or some arbitrary number. The frustrating part is the kickback you can get if you advocate removing pain as a vital sign. “You don’t care about a patient’s pain?” or “Pain management is important!” Of course I do and of course it is. Just because it is not a “vital sign” doesn’t mean it will not be addressed (it may be that pain is more ignored now then before it became a vital sign). It should be assessed and addressed in an H&P just like every other subjective complaint. Is pain always more debilitating than nausea? Vertigo? Should those be vital signs too?

Jyoti Mahapatra, MD: I couldn’t agree more with Ryan. There is more eye-rolling with pain ratings now than before it was a ‘vital sign’. I chose emergency medicine as a specialty because I wanted to make patients feel better now and not in 2 weeks at a follow up appointment. But our culture’s current belief that no amount of pain is acceptable is completely unreasonable and has fostered a sense of entitlement that needs its own pain scale for EPs. I want my patients to feel better, but for many of them, the only acceptable level of pain is none at all. I can’t make someone with a radius fracture or pneumonia pain free. My definition of making them better means developing a plan for pain control, disease management and appropriate follow up. Which all too often is translated by patients as ‘they didn’t do anything for me’. I prefer to assess for pain improvement, not necessarily pain resolution. Even measuring functional status which the article references, is entwined with a patients’ expectation of pain control. If they won’t be able to scuba dive tomorrow with a torn ACL or compete in their softball tournament with an amputated thumb, its not because their physician failed at pain control.


Poorly designed hospitals make Dr. Khullar sick

He argues simple design changes are needed to reduce infections, falls, and noise (leading to loss of sleep), while improving privacy and recovery. Original Article by Time.

Nicholas Genes, MD, PhD: New hospitals are usually designed with private rooms – for infection control and simple patient satisfaction – and a better focus on reducing noise and improving lighting. Older hospitals, like this author’s MGH, were built in a time where more patients were indigent, and sicker. The concept of design as a factor in inpatient health might have been on some people’s minds back then, but the idea seems laughable compared to the utility of antibiotics, sterile surgical technique, or the host of other innovations that improved inpatient mortality in the early modern hospital era. Many of the patients we admit today aren’t actually “sick” in that traditional sense – they need an inpatient bed for further risk stratification, or an “expedited workup”, or because they’re awaiting placement. Of course a good night’s sleep is going to be more important to these patients’ health.

E. Paul DeKoning, MD, MS: Ok. Despite my hospital’s commendable attempts at creating a healing environment (hospital in the woods, carpeted floors, no overhead paging, windows in almost every room overlooking the aforementioned woods, etc) there are still HUGE signs on the walls telling everyone to use their library voices. I plan to commence sshhing people.

Ryan McKennon, DO: No problem, all we need to do is tear down and rebuild or completely redesign 85% of the nations hospitals to make sure that every room is a private “east-facing…with morning sunlight” and a view of “trees.” Most newer hospitals are being built with private rooms, as Nick mentioned. I would love it if all the rooms in the hospital were large aesthetically-pleasing private rooms with windows. It is simply not feasible for every bed at every hospital at this point. I think there are many areas that we can focus to improve health before we look to the direction a room faces to make sure patients can see the morning sun.

Jyoti Mahapatra, MD: Personally, I think the best layout for patient healing and privacy is to line them up head to toe in hallways for hours at a time. I know this is best for patients because hospitals ensure this practice continues in EDs all over the country day after day. I also know that windows do nothing for patient well being because in the emergency room, where many of the most critically ill patients in the hospital are located, there isn’t a single window in the entire department. If you want patients to look at something that will make them happy, maybe just enlarge their cell phone screen onto the wall. It seems to be soothing during pelvic exams, laceration repairs and especially when speaking with a physician directly in front of them.


The WHO announced its first list of antibiotic-resistant “priorty pathogens” that kill millions each year

With 12 families of bacteria posing serious threats and no new classes of antibiotics since 1984, the outlook is grim. Original Article by Time.

Nicholas Genes, MD, PhD: “This list is not meant to scare people about new superbugs” – WHO spokesperson. “That’s ok, this article will do the job!” – Washington Post.

E. Paul DeKoning, MD, MS: “WHO’s list follows a summit on superbugs that world leaders held last fall — only the fourth time they had addressed a health issue at the U.N. General Assembly.” Can you just imaging sitting through that committee meeting?! Claw my eyes out! We should all sleep better now knowing that the UN is on it.

Ryan McKennon, DO: “[Twelve] families of bacteria that agency experts say pose the greatest threat to human health” maybe overstating it a bit. According to the article it estimates that 23,000 people in the US die each year from antibiotic resistant bacteria. These bacterial most commonly affect patient in the ICU, people with transplants, or those on chemotherapy. By comparison, heart disease killed almost 614,348 people in the US last year according to the CDC. Don’t get me wrong, this is incredibly important and I’m glad to see an international effort to focus research. But the greatest threat to human health is a bit of an exaggeration.

Jyoti Mahapatra, MD: Mother Nature has various methods of keeping the human population under control, and will always be many steps ahead of us. In developed countries we don’t have to worry about dying from cholera or malaria, but have instead created an environment where superbugs have the opportunity to develop. A devastating and terrifying prospect, but no less alarming than the hundreds of thousands of lives lost daily to the simple old bugs that have been around longer than humans.


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