A Simple 1–10 That Isn’t Simple at All
“Rate your pain on a scale of one to ten.”
It’s one of the most routine questions in EMS. Yet no other symptom relies so heavily on trust, interpretation, and provider bias. We treat pain like a number, but it’s far more than that. Pain is a reflection: of the patient, of the situation, and of us. Unlike temperature, pulse rate, or blood pressure, pain is entirely subjective. And so, too, is how we as clinicians choose to respond to it.
In the field, we like to believe that we’re objective. We follow protocols and algorithms, act on measurable data to guide our clinical decisions. However, pain challenges that structure. When a patient tells us they’re in pain, we tend to filter that information through our own experiences, assumptions, and comfort levels. We weigh their facial expressions, tone of voice, the mechanism for the pain, and unfortunately sometimes our own fatigue and frustrations. Pain is the only symptom in which our personal lens shapes care as much as any clinical assessment. And that’s exactly why I’m asking you to look at how you approach pain management. Ask yourself, are we giving patients what they need, or what we think they deserve?
Unlike the metrics we rely on every day—oxygen saturation, blood pressure, end-tidal CO2—pain doesn’t come with a waveform or trending data. We can’t measure it, graph it, or verify it. We can only hear it. That makes pain unique: It requires us to practice medicine in a space where trust is the primary diagnostic tool. And that can feel uncomfortable. So instead, we listen for the “right” kind of complaint. But the uncomfortable truth is, that’s not a reliable indicator of how much someone hurts. Patients can be stoic and suffering or dramatic and genuinely in agony.
Bias in pain management isn’t usually intentional. It slips in quietly, shaped by our personal experiences, our clinical training, and the culture of EMS. Most of us don’t even notice it happening. But once we start paying attention, patterns emerge. In EMS, we’re trained to prioritize life threats. Airway. Breathing. Circulation. Because of that, many clinicians subconsciously view pain as a lower priority, something to address only after the “real” emergencies are ruled out. That mindset can cause us to downplay or delay treatment, even when pain is the patient’s primary reason for calling for help.
We all bring our personal history into our assessments. Maybe we grew up being told to “shake it off.” Maybe we’ve endured pain that we consider worse than what we’re seeing now. Maybe we see ourselves as tough and expect others to be the same. These ideas can quietly shape how much we believe a patient’s report, and how willing we are to intervene. We’re quick to medicate the patient pulled from a wrecked vehicle, but slower to offer relief to someone with “just back pain.” We may be more attentive to pain from visibly dramatic injuries and less so with conditions that don’t create obvious external signs. Yet the patient’s nervous system doesn’t differentiate between “deserving” and “undeserving” sources of pain; it only knows distress.
Even when our intentions are solid, the EMS environment itself can make consistent pain management difficult. Many of the decisions we make in the moment are shaped not just by patient presentation, but by the realities of field operations. Depending on the service, providers may have a narrow selection of analgesics or protocols that dictate specific pathways. Fear of side effects, hypotension, or respiratory depression can make clinicians hesitant, even when medications are indicated. Some providers also worry about giving narcotics when transport time is short or hospital response is close. Protocols guide care, but they can’t remove the human element of uncertainty. In many agencies, there’s a subtle but persistent culture of “toughness.” Whether we admit it or not, that culture shapes how we understand pain. Providers who are encouraged to power through discomfort may unintentionally adopt the expectation that patients should do the same. Culture is not policy, yet it influences practice all the same.
Despite our best intentions, research shows a consistent pattern: Pain is one of the most undertreated symptoms in EMS. Studies across the country reveal that many patients with moderate to severe pain receive no analgesia at all before reaching the hospital. And when pain medication is given, it’s often delayed or administered in lower doses than recommended.
Evidence shows that race, age, gender, and socioeconomic status can influence whether a patient receives pain control—and how much. Pediatric patients and older adults are particularly likely to be under-medicated. Women reporting severe pain often receive less intervention than men. These disparities aren’t intentional, but they reflect how unconscious bias can shape clinical decisions at the bedside. Fear of hypotension, respiratory depression, or masking a more serious condition leads some clinicians to avoid analgesics. But when used appropriately, prehospital pain medications have strong safety profiles. The evidence supports that patients are more harmed by inadequate pain control than by judicious analgesia. Effective analgesia can improve cooperation, reduce movement during procedures, and make transport safer for both patients and providers. Treating pain is part of high-quality clinical care.
Pain is one of the most human experiences we encounter in EMS and one of the most complex. It forces us to step outside the comfort of objective numbers and navigate a space defined by trust, perception, and humility. When we decide how to respond to someone’s pain, we aren’t just applying protocols; we are interpreting another person’s suffering through the lens of our own experiences, beliefs, and biases.
None of this makes us bad clinicians. It makes us human. But recognizing those human tendencies is how we get better. By approaching pain with curiosity instead of judgment, by grounding our assessments in consistency instead of instinct, and by remembering that patients call us because they are vulnerable, we move closer to the kind of care our profession should strive for.
In the end, pain may be subjective, but our responsibility to treat it compassionately and equitably is not. If we challenge ourselves to examine how we think about pain, we can transform how we address it, and ultimately, how our patients experience us.
