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Lesson

We Underdose Pain

11 min Meds & Pharma Skip to quiz

Objective: Treat the common error — we undertreat pain: assess pain, offer protocol analgesia, reassess, and do not skip treatment because the ride is short.

Why This Is Hard

We undertreat pain. It is documented over and over in EMS: no score, no drug, or one tiny dose and no recheck. Consider patients with acute traumatic pain as candidates for analgesia regardless of how short the ride is. Assess, treat, reassess. Fear of “masking the exam” and fear of the airway both drive undertreatment. The injury is still there. The patient is still hurting.

On this truck
  • Ask a number (or an age-right scale). Write it down. Ask again after the drug.
  • Short ETA is not a contraindication. The hospital can still examine a treated patient.
  • Life threats first. Then pain. Uncontrolled bleeding and an unprotected airway still win.
  • Whatever your protocol names — opioid, ketamine, acetaminophen, NSAID, IN fentanyl in kids — use it as written. This page does not own milligrams.

Street Sequence

  1. ABCs and the bleed first. Then ask: “What is your pain from 0 to 10?” Use faces or FLACC (face, legs, activity, cry, consolability) as your service uses.
  2. If they have moderate–severe acute pain and your protocol includes analgesia, treat. Do not wait for the driveway.
  3. Monitor after an opioid: mentation, respirations, EtCO₂ if you have it. Naloxone is for the rare overshoot — not a reason to never treat.
  4. Reassess in minutes. If they are still in severe pain and protocol allows another dose, that is the job. Document the scores.

Field Rules

  • Assess: prefer the patient’s number over your guess. Quiet people still hurt.
  • Treat regardless of ETA for acute traumatic pain.
  • Kids without an IV: IN fentanyl is favored over waiting for an IV when protocol includes it. Protocol owns the device and the dose.
  • Reassess: one dose is not the whole job. Pain that returns is a reason to follow the redose rule, not to shrug.
Say out loud
  • Pain score now.
  • Treating per protocol.
  • Watching respirations.
  • Score after the drug.

Field Pitfalls

  • “We’re close” as the analgesia plan.
  • No pain score anywhere on the chart.
  • Withholding because you might “mask the belly exam.”
  • One micro-dose and no recheck.

Practice

60-second drill

Partner: isolated ankle fracture, 8/10, 8-minute ETA, stable vitals. What do you do besides splint? Then: still 8/10 after one protocol dose. Next move?

Related: Fentanyl for Pain Management, Ketamine in the Field, Oral Analgesics in the Field.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.

1. For acute traumatic pain, consider analgesia:
2. The common EMS pain error this lesson names is:
3. After a protocol dose of analgesia, you should:
4. In children with severe pain and no IV, teaching strongly favors:
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