Kindness kills: the negative impact of pain as the fifth vital sign

J Am Coll Surg. 2007 Jul;205(1):101-7. doi: 10.1016/j.jamcollsurg.2007.01.062. Epub 2007 May 17.


Background: The current emphasis on pain assessment as the fifth vital sign and the use of unscientific pain scales is causing serious injury and death from overmedication.

Study design: This premise was tested by reviewing the case reports of all trauma center site surveys performed by the authors for the American College of Surgeons Committee on Trauma verification program during 2 separate time periods: 1994 through 1998 and 2000 through 2004. A total of 2,907 and 2,282 reports summarized by one of the authors, plus a total of 53 and 50 other reviewers, respectively, were analyzed from the records of 120 and 94 trauma centers. Most patients were men (71% and 66%) and had sustained blunt injury (83% and 79%). Average age was 35 years for both periods, with a range of 3 weeks to 97 years and 3 days to 98 years, respectively. The most common injuries involved head (33% and 34%), chest (13% and 13%), abdominal (22% and 21%), orthopaedic (18% and 18%), or multiple (9% and 14%). There were 1,459 and 867 deaths, respectively; all had a multidisciplinary peer review.

Results: Overmedication with sedatives/narcotics, during the two periods, clearly contributed to deaths in 13 and 32 patients and probably contributed to deaths in 5 and 14 patients, respectively. This occurred in 17 and 43 patients, respectively, after blunt injury and in 1 and 3 patients, respectively, after penetrating injury. Two clinical scenarios predominated, ie, overmedication in preparation for an imaging study and overmedication after discharge from ICU to the floor. The sequel of hypotension and compromised airway requiring intubation initiated a cascade of negative events that led to death. One patient in each period died as a result of prehospital overmedication.

Conclusions: The current assessment of pain by computer-stored pain scales is in a state of imbalance, with excessive emphasis on undermedication at the same time ignoring overmedication. This imbalance reflects pain-service attempts to comply with external accrediting agencies. This preventable cause of death and disability in trauma patients is also occurring in noninjured patients. Surgeons must correct this problem by insisting on a balanced assessment of overmedication versus undermedication.

Publication types

  • Case Reports
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Cause of Death
  • Child
  • Child, Preschool
  • Female
  • Humans
  • Hypnotics and Sedatives / administration & dosage
  • Hypnotics and Sedatives / adverse effects*
  • Infant
  • Infant, Newborn
  • Male
  • Middle Aged
  • Narcotics / administration & dosage
  • Narcotics / adverse effects*
  • Pain / drug therapy*
  • Pain / etiology
  • Pain Measurement
  • Respiratory Insufficiency / chemically induced*
  • Respiratory Insufficiency / mortality*
  • Retrospective Studies
  • Wounds and Injuries / complications*
  • Wounds and Injuries / mortality


  • Hypnotics and Sedatives
  • Narcotics