"Education is an admirable thing, but it is well worth it to remember from time to time that nothing that is worth knowing can be taught." - Oscar Wilde, Intentions

What connotations does the word suspicious have? For most, the word carries a negative association. The media is full of suspicious types, from TV shows about detectives to the old Mission: Impossible shows in which the Border Patrol asks for the character's identity with predictable results. Can being suspicious ever be a good trait?

Let's examine this month's case to see if this EMS crew was suspicious enough.

Scenario

This sunny day finds you working with your regular partner. The radio suddenly squawks, "43 X-ray for motorcycle MVA, in front of the cemetery at the intersection of Woodhaven Blvd. and Metropolitan Ave. Time out is 1139." Nice, you think, a motorcycle down in front of a cemetery-how convenient for the rider.

As you move through traffic, you think of all the possible motorcycle accident permutations. They're the trauma equivalent of a sick call: the severity could range from no injuries to traumatic arrest and anything in between. You never quite know what you're getting yourself into.

You arrive on scene to find a motorcycle on its side. Your patients are an elderly husband and wife dressed in leather riding outfits. You and your partner each take a patient.

You approach the wife. She's 64 years old and has bilateral, open fractures of the lower legs. The bone ends have ripped through her pants-a dramatic injury, but with only a small amount of visible bleeding.

Both patients were wearing helmets, and both remain conscious and alert. The wife says a car struck their motorcycle at the intersection. She has no other complaints, and your examination confirms no other injuries. She takes no medications and has no pertinent medical history. Her vitals: pulse 104, respiratory rate 20 and blood pressure 140/88. Her pupils are equal and reactive.

Your partner's patient, a 67-year-old male, complains of flank and back pain that radiates to his groin, along with some abdominal tenderness. He claims to have had most of these pains for the past week or so. He also has abrasions on his right hand, elbow, cheek and chin. He has no other complaints or physical signs of trauma. He doesn't see a doctor regularly, takes no medications and claims never to need either because he's never sick. He denies chest pain or shortness of breath. His chest is intact and shows no sign of injury. His vitals: pulse 100, respirations 22 and blood pressure 160/96.

You and your partner agree to transport the wife to St. Carolyn's Trauma Center, and the newly arrived BLS crew will follow after immobilizing the husband on a longboard. You present the patient to the emergency department (ED) after a 12-minute transport.

While cleaning your unit, you hear the BLS crew over the radio requesting a trauma alert for the husband. You grab your partner and tell him what you heard. When the husband arrives, ED staff members take over CPR, establish an IV and insert an endotracheal tube. The surgical team notices the patient has an ECG but no pulse. They open the patient's chest, and blood cascades out the thorax. After an hour of unsuccessful surgical machinations, the patient is pronounced dead.

Later, the surgeon asks why you didn't transport the husband first. He listens to your detailed description and rationale, but he doesn't understand your reasoning. An elderly patient plus collision plus belly pain equals an unstable patient. Always.

He also informs you that flank pain radiating to the groin, abdominal tenderness and back pain are the classic presentation of an abdominal aortic aneurysm (AAA). He adds that AAA occurs more often in men than women and is associated with a history of hypertension. You knew this guy had been in pain for several days before the accident; the patient told you that. If you had paid attention to his more subtle signs, symptoms and complaints, the surgeon goes on, this guy could've been rapidly transported and perhaps arrived at the ED salvageable.

Conclusion

Suspicion is an important trait for EMS practitioners to embrace. In order to look beyond the obvious in EMS, you must develop a suspicious nature that will allow you to critically evaluate all the tip-offs to your patient's conditions and injuries. If you don't turn a critical eye toward an injury or pattern of injuries, errors can occur.

How do you "read" your patients for injuries and sniff out symptoms that aren't obvious? The answer is simple. You need to remain suspicious and search for them on every call.

Paul Werfel, NREMT-P, paramedic program director for the University Medical Center at State University of New York, Stony Brook, may be reached via e-mail at pwerfel@epo.hsc.sunysb.edu.

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