Quality Corner: Index of Suspicion

Chest pain, respiratory distress and unresponsive patients have always been treated appropriately, for the most part, mainly because their acuity is obvious. But many potentially critical patients with non-specific complaints are not always taken as serious as they should be by all EMS providers.

Generalized weakness, abdominal pain and falls can be a gray area for EMS. There are many things they could be—not all critical, but many which are—so you cannot just lump them all together and dismiss them away. Like any patient the EMS provider encounters, they need to be carefully and objectively evaluated with a bias toward finding significant illness.

Generalized weakness is among the most under- and untreated patient complaint categories I’ve seen. There are about a hundred different causes of generalized weakness; not all are life-threatening, but several are, such as: stroke, AMI, hypo- and hyperglycemia, and sepsis. How sure can you be sure a patient of yours complaining of generalized weakness is not one of the life threatening illnesses based simply on a blood pressure, a pulse check and glance across the room? There’s no emergency physician in the country with 12 years of medical training to our average of 12 months of training who would be daring enough to make that assumption without first ruling out the possible life threats. But, even if they were willing to shoot the odds, most hospitals in this day and age would not tolerate it—not even from a doctor.

Abdominal pain is one of the most difficult diagnoses for even the best emergency physician to make. Like generalized weakness, the list of causes is long and impressive. Some of the more serious possibilities that need to be considered are AMI, gastritis, appendicitis and abdominal aortic aneurism. Additional considerations for women of child bearing years are ectopic pregnancy, miscarriage and the other complications of pregnancy.

If a patient complains of chest pain they're highly likely to get a full cardiac work-up and appropriate life-saving treatment. If a patient complains of epigastric pain, despite the fact that it’s literally two inches away from chest, they’re much more likely to get a quick set of vital signs and a ride to the hospital. The fact is as many as one third of AMIs do not present with classic chest pain, but epigastric pain, generalized weakness, diaphoresis or nausea and vomiting instead. These are definitely more subtle symptoms than chest pain, but the risk of morbidity and mortality is the same, if not higher, at least in part due to the likelihood of delayed recognition and treatment.

Patient falls and patient assists is another category of calls where the potential for underlying pathology is frequently not fully appreciated. The familiar scenario involves an elderly patient who falls and can’t get up. EMS is summoned, we pick the patient up, ask them sign here and we’re out of there. The problem is there’s frequently not enough or no effort made to determine the cause of the fall. Did the patient slip, trip and fall, or get dizzy, weak or faint and fall. Keep in mind due to altered mental status and decreased sensibility due to advanced age or chronic illness, the patient may not be aware of what caused their fall. Additionally, several common medications that elderly patients take such as antipsychotics, analgesics and sedative-type drugs may also depress their sensory perception.

Many times the only hint you’ll have of impending doom, is something as subtle as a single syncopal episode, an onset of acute weakness or a sudden episode of nausea and breaking out in a sweat for no apparent reason prior to your arrival. If you blow off these complaints just because you didn’t witness them yourself, even if the patient is now back to baseline and looking perfectly normal, you run the risk of catastrophe.

So to resolve these problems, should we expect the patient to be capable of self-diagnosing themselves by telling us they think they may be having a heart attack? Or should we as medical professionals be more diligent and perhaps put a little more effort into appropriately assessing these patients?

Index of suspicion is key. If you don’t consider the potential for serious illness and don’t look for it, it’s unlikely you’ll ever find it. Index of suspicion should also increase with the patient’s age and presence of significant past medical histories. And beware the patient who says, “I just don’t feel right,” but cannot clearly articulate their concern beyond that. The patient did their part by realizing something was wrong even if they weren’t sure what it was by calling 9-1-1. Likewise we as the EMS professional must remember there are a lot of things we’re not taught about medicine in just 12 or even 24  whole months of our paramedic course. Just because you’ve never heard of it or don’t understand it, doesn’t mean it doesn’t exist.

The best way to approach “every” EMS call is to maintain a high index of suspicion and be willing to look a little further just to be sure. You can have the lowest IQ legally allowable by law to be a practicing medic and still be a paramedical genius if you do nothing more than maintain a high index of suspicion.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years’ experience in EMS. Contact Joe at jhayes763@yahoo.com.