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The Glasgow Coma Score and Pain

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The Glasgow Coma Score and Pain

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Glasgow Coma Score and Pain

Glasgow Coma Score and Pain

A judge had a unique interpretation of what I was allowed to explain to the jury about pain and the Glasgow Coma Score last week. The issues in the case centered around a woman who went into surgery for a routine orthopaedic procedure. About 24 hours after surgery, she suffered a stroke. She received treatment in the ICU for a week before being moved to the Hospice Unit for her final week of life. My analysis of the medical record showed that she had some awareness. Following her stroke, she was described as being alert and awake, used her eyes to follow people around the room, said “ouch” when her arm was moved, reacted to pain, and followed commands. However, she also had periods when she did not react this way. The plaintiff attorney asked me to prepare a report that summarized her condition, offer an opinion on her pain and suffering, and come to court to testify. I stated in my report that I believed the patient had pain and suffering to some degree during the days after her stroke. The plaintiff attorney also hired a physician to opine on pain and suffering.

The defense objected to me testifying. While the jury was out of the room, my role in the case, my qualifications, and my testimony were discussed. The defense pointed out I was not a neurologist or neurosurgeon and could not testify about pain. The plaintiff attorney pointed out that I have edited a book about pain and suffering, evaluated patients for pain and taught healthcare professionals about how to chart. The judge decided he would allow me to testify about what the chart said but not offer opinions. However, he had one requirement that caused me to do a continuous tap dance while I answered questions. He ruled that if the chart stated what stimulus had been used to elicit a reaction of pain, I could say the chart stated the patient was in pain. But if the chart simply said the patient had pain, I could not mention this chart entry. The result of this ruling created an extremely tense environment while I answered questions. I could feel the judge glowering at me while I sat on the stand.

Glasgow Coma Score
The difficulty with the judge’s ruling is that medical records describe the patient’s response to the Glasgow Coma Score, but typically do not state how they were obtained. The Glasgow Coma Score was developed in 1974 to assess a patient’s level of consciousness. It has become a widely accepted method of evaluating a patient’s best response to painful stimuli. Three components are measured: eye opening, verbal response and motor response. Each response is assigned a point value.

Eye Opening
4 spontaneous
3 to speech
2 to pain
1 none

Verbal Response
5 oriented
4 confused
3 inappropriate words
2 incomprehensible sounds
1 none

Motor Response
6 obeys commands
5 localizes painful stimulus
4 withdraws from painful stimulus
3 abnormal flexion
2 extension
1 none

A healthcare practitioner who tests for the patient’s reaction to pain may stick the skin with a needle, pinch an arm, press knuckles on the sternum, press against the top of the eye socket, or use a pencil or pen to press against a fingernail. Rarely does a healthcare practitioner document which method he or she used to elicit pain.

The judge chastised me once when he felt I was not sufficiently adhering to his ruling, but backed off when the attorney asked me to explain the Glasgow Coma Score. The plaintiff attorney was able to take me through the components of the score. He asked me to explain how healthcare practitioners tested for pain, and pointed out that the table I constructed showing the patient’s reactions used the terms directly from the Glasgow Coma Score. I felt like I had danced through a minefield after I got off the witness stand. The Glasgow Coma Score should have been my friend, but the lack of specificity in the chart made testifying a challenge.

Med League is a legal nurse consulting firm that assists attorneys handling cases involving medical negligence, personal injury and other litigation with medical issues at stake. Call us for assistance.

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