By Martin Schiavenato, PhD, RN
I will never forget her name. As an NICU nurse, I was accustomed to working with preemies and micro-preemies — babies small enough to fit entirely in the palm of my hand, and I have very small hands. Jessica* was different. She was full-term and appeared so beautifully healthy. Unfortunately she suffered from a genetic disorder that rendered her skin useless; her epithelium would shed as if unattached. The condition is called epidermolysis bullosa, and it meant that every measure of comfort that I did for her — a diaper change, providing a pacifier, feedings, holding or touching her — hurt her. She lived a short life in excruciating pain before she succumbed to infection. It was then that I decided I would do something to help relieve pain in newborns.
I decided to pursue a PhD in nursing and my focus became pain assessment. I reasoned we could not treat pain effectively if we couldn’t measure it. But how do we objectively measure pain? I was immediately drawn to the polygraph, a device that claims to detect lies. If we can determine veracity based on a couple of physiologic signals, why couldn’t we determine the level of pain in a similar fashion? As it turns out, the accuracy of polygraph technology is questioned today, despite its broadly accepted use, but the principles behind the technology were enough to turn me on to a device-based solution for the problem of pain. You see, at its core, the polygraph was built to measure changes in autonomic nervous system response, that is, fight or flight. The physiology is very similar to the pain response, however, measuring pain turned out to be much more complex than I ever imagined. There is no gold standard in the measurement of pain. Pain is at once both sensory and emotional; it involves the brain and also the mind.
It is about personal experience and also about interpretation. Pain is intimate and subjective, but its detection and treatment requires communication and objective assessment. How do you do this with babies who can’t verbalize their suffering?
For about seven years, my colleagues and I have been working on what we call the Orb Project, a device that combines three physio-behavioral signals and computes a pain score, indicated as a change in color inside a round, glass lamp. I chose a change in color because there are enough alarms in the NICU. One of the signals we are attempting to monitor is facial grimacing, a sign well-associated with pain. We originally tried measuring particular muscles involved, but that approach did not work. We are still developing and testing new methods to objectively capture not just the presence of pain, but also perhaps more importantly, its level.
We recently received a grant from the Life Sciences Discovery Fund and are attempting a different approach to measure facial grimacing. Along the way we are fine-tuning algorithms to detect and measure heart rate variability, another pain signal, and using artificial intelligence methods to train our system to predict or match a clinician’s pain assessment around the clock and in real-time. We hope to have a new prototype in about 18 months and then secure further funding for broader clinical investigation and instrument refinement to particular clinical sub-populations.
We have expressions like “little boys don’t cry” or “no pain, no gain” that seem to suggest pain is something you overcome or beat by force or will. However, that’s not the case with preemies. We now know the pain experience during this vulnerable period is toxic to the developing brain. That’s right, pain in prematurity damages and rewires neural connections in ways that have profound long-term consequences for these babies. Therefore, there is a palpable sense of urgency in our work; in all of our work as nurses.
What a wonderful gift we have in this vocation; the gift of meaning, import and consequence in what we do. The time to “someday do something” is right now. As nurses, we are poised to solve clinical problems with a unique combination of skills broadly based on technical expertise, the sciences and interpersonal communication; we are experts in the human factor. This is the approach we’ve taken with developing our “Orb” and other solutions that our CUB Health Lab (Creating Unique Breakthroughs in Health Lab) is currently involved in.
Nursing offers a valuable perspective in tackling the complexities of modern healthcare; the sooner we realize our value as a profession, the more effective we will become as agents of change.
Martin Schiavenato, PhD, RN, is associate professor at Washington State University. Schiavenato began his research on the Orb while at the University of Rochester (N.Y.). The CUB Health Lab recently launched its Facebook page, which will be updated regularly. Photo of Martin Schiavenato (above) by J. Craig Sweat Photography.
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