The C.R.A.P. Score

A fellow nurse brought this in the ED where I work and I thought it was cute.

THe C.R.A.P. Score by D. Slow P., MD

CRAP=(OPS+AF)(SC)(EC)

OPS=Old Pain Score
AF=Adjustment Factor
SC=Story Credibility
EC=Exam Credibility

Situation: We are supposed to documents our patients' pain on a 10 point scale in order to objectify if and make sure we address it and provide timely and appropriate analgesia

Observation: There sure seems to be a lot a variability in the way people measure their pain. It's enough to make you want to throw the whole pain scale away. We all know it's true. Some people not only verbalize their pain more effectively, they also seem to experience it more effectively. These patients may come to the ER once a month with "10 out of 10 pain". They also seem to require more work notes. It seems that what was meant to be an objective scale, couldn't be more subjective.

Assessment: If the pain scale is to survive-and I'm by no means suggesting that it should-but if it is, I'm sorry to say we may have to find a way to adapt it to each individual patient. We used to think that "mild, moderate, or severe" was adequate, but now we know better, a ten point scale is quite superior. But, is it good enough? If you want to practice cutting edge medicine, get ready for yet one more complexity.

Plan: I propose that a formula be developed to enhance the functioning of the current pain scale so that each patient can be treated as an individual. The Canadian Relativity Adjusted Pain, or CRAP for short, will be calculated as noted above.

The key value here is the Adjustment Factor. For "LPT" patients (Low Pain Threshold" this will be calculated as follows: For every point over 10, which the patient reports, subtract one. If they say their pain is a "12" then subtract 2 points and start with an 8. For every visit the patient has had to your ER in the past 12 months for a painful condition that was either chronic or went undiagnosed, subtract 1 point. If you push on a non-painful or uninjured area of the patient's body, the shin for example, and they say "Ouch", subtract 1 point. For every allergy to a non-narcotic medication that could be effective for their condition, subtract 1 point. If they are wearing sunglasses, subtract 1 points. If they still have tape or EKG lead residue on their body from a prior hospital visit, subtract 2 points. For "HPT" patients (High Pain Threshold" you will be adding numbers to their pain score. If a spouse fo family member forced them to come in, add 1 point. If you check their records, and every time they've come to your ER for a painful condition something was torn, broken, ischemic, or perforated, add 2 points. If they have no allergies add 1 point. If they are tachycardic or hypertensive and 1 point.

Here is an example. A young man presents to your ER for his 7th visit this year for a migraine headache and reports his pain as "12" on a 10 point scale. He is allergic to Reglan, Imitrex, Toradol, Prednisone and Tylenol. He also has been to the ER 5 other times in the past year for back pain or abdominal pain, all times sent home with normal studies. When you enter the room he is yelling at someone on his cell phone and eathing Cheetos, but tells you, "This is a bad one doc." On exam his VS are normal and his abdomen and back are both tender. "I didn't even notice they were hurting," he says. His CRAP score sould be (10-6-2-5-5-1)(0.5)(1) which would be negative 4.5, but since his number is negative, you decide to leave out the credibility conversion for a score of negative 9. You tell him that pain medications are not indicated for his headache because his CRAP score in negative 9 and he can go home whenever he is ready.