Blood Glucose Testing Protocols/Standing Orders

TheMowingMonk

TheMowingMonk

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Hey Everyone,

I'm writing for a little help. Right now i'm trying to change the Protocols with one of my EMT squads to allow us to take blood glucose readings. I know title 22 in California states EMTs are allowed to check blood glucose. And i know one other organization similar to our in the area that does it but i haven't been able to get a hold of them. What I'm looking for is a protocol or standing medical order that another EMT squad uses for their EMTs to do blood glucose. Especially from a squad in California so i have something to kinda model the protocols I'm trying to get going after. So if any of you guys have copies of anything like this or have any info you could help me out with i would really appreciate it. Thanks
 
As an EMT-B from the Denver Metro area, I have to say that I strongly DISAGREE with our protocols for BGL's, well, more-so BGLs combined with the administration of Oral Glucose and D50

Now, in order to perform a D-stick, in the Denver area you must be "IV Certified". This basically means that you have taken a coarse that extends onto your EMT-B cert that allows you to start IVs. This certification is also what allows you to administer D50, without calling for a drug order.

Without an IV cert, you are allowed to administer only Oral Glucose, which you must be given an order for my a physician.

The reason that I disagree with our protocol is because it's obviously very important to perform a BGL check on the hypo/hyperglycemia patient before administering a drug that will significantly raise the levels, however if you are not IV certified, you can still administer Oral Glucose, but cannot perform a BGL stick.

I hope this makes sense......
 
So you basic EMTs can administer oral glucose but can perform a "finger stick" to verify that they are dealing with a diabetic problem?
 
Why do you feel you need to check blood glucose levels to give oral glucose?

If the patient is acting like their sugar is low, (altered, confused, etc) and they can maintain their own airway, (not drooling all over themselves); we just gave them oral glucose.
If their BGL was already high, it won't hurt them, and if it was low it helped.

Where I work now, the glucometers we carry are for inside use (don't work in extreme cold/hot temps; but we can't convince management that the $3000 units don't work: half the time that we check BGL's we get bad readings (the best was the 22,000), or failures. So we check them once and give them oral glucose or D50.
 
When our second out ambulance has to go on a call BLS, our d-sticks and oral glucose are standing orders. I personally have never given oral glucose without a d-stick first to back it up. I also like to take several en-route (x5-10min), usually the pt.'s mental status will improve, but the hospital likes to have them as well.
 
johnrsemt said:
Why do you feel you need to check blood glucose levels to give oral glucose?
Click to expand...

Don't think there's a need, but rather than spending time coaching an altered person to keep eating swallowing the glucose, time might be spent trying to get a better history from bystanders, etc. Again, it's not needed, but it's a convenient tool to eliminate suspicion of hypoglycemia. That's all.
 
I mainly want to use it as a diagnostic tools and to have it ready for the ERs, I have talks with the ER docs at our local hospitals and our squad asked if there is one thing the ER Docs want to know about a PT from prehospital providers what would it be and they consistently answer blood glucose levels. Since it is a diagnostic tool that actually tells you alot (Given that you equpiment works). like right now i have a medical director that is willing to give us the training that california requires and EMT-B to take to be allowed to do blood glucose, I just have to write the protocols and stuff then get the standing order from our medical director which is why im trying to hunt down an example of a protocol another squad uses so i have something to base mine off of.
 
Mowingmonk, I think you are asking about the standard procedures per se, not content?

It and the rest of your SP's should follow a set format (What the procedure is, who can do it, where, under which circumstances [when], why [course of action based on your data]).

Probably the glucometer procedure should be part of the diabetic treatment SP as the "what", and maybe as treatment steps regarding pt with unknown hx but exhibiting seizures, obtunded/LOC. SP's need to be written starting with the presenting problem (i.e., obtunded patient without history), proceed through the diagnosis, then result in the treatments keyed directly to each diagnostic. The directive as to how to do the glucometry should probably be a "policy and procedure" of your company.

Anyone can do a blood glucometry (the devices do not require a prescription), but you will need the SP to allow you to use it in treatment, and to help clue in people later on as to the company's policy.

The important thing about a SP is that no data gathering is done "just because"; it has to have a reason (c/o or S/S) and actions steps tied to the readings (at this blood glucose reading you will do that, if THIS reading you do THAT, etc.).

Go to your medical director for help. She/he's going to have to sign off on it anyway, no? The SP is, in essence, the medical director's order to a class of people employed by his/her company.

And while you are at it, write about five good test questions about it to be inserted into your company's SP refresher quiz.
 
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I'd have to disagree that giving an already hyperglycemic patient glucose/D50 won't hurt them. Absolutely it will, especially if they are postprandial or present with a BGL over say 250mg/DL. High blood sugar also has more effect on major organs than low sugar does. Ketoacidosis may even develop if their sugar is pushed too high.

I'd stay safe with every diabetic/AMS/drunk patient and still perform a finger stick, just to cover your own a**. Better safe than sorry




johnrsemt said:
Why do you feel you need to check blood glucose levels to give oral glucose?

If the patient is acting like their sugar is low, (altered, confused, etc) and they can maintain their own airway, (not drooling all over themselves); we just gave them oral glucose.
If their BGL was already high, it won't hurt them, and if it was low it helped.

Where I work now, the glucometers we carry are for inside use (don't work in extreme cold/hot temps; but we can't convince management that the $3000 units don't work: half the time that we check BGL's we get bad readings (the best was the 22,000), or failures. So we check them once and give them oral glucose or D50.
Click to expand...
 
Exactly why im trying to set-up the system so my service can start doing them. Thanks Mycroft, your post is very helpful, ill have to go over the guidelines with our medical director see what she things they should be but i think im getting the general idea going. but if anyone else has any more input im all ears, thanks
 
First, I don't know of any protocols that allow any level EMT/medic to push D50 without some sort of blood sugar check.

Second, you're telling me that some oral glucose is going to have a profoundly negative impact on a diabetic's condition? That sounds like the argument some folks give for withholding temporary high-flow O2 to COPD patients.
 
We ought to combine pulse oximetry and this thread together, they have the same answer. Diagnostic and monitoring tools are just that, tools. They are to aid and assist, confirm a diagnosis.

Yes, there are times that I am surprised of the reading or go .. well, we know the cause now. With this, we should had already known that either hypoxia or hypoglycemia could or was the underlying cause. The tool was just a confirmation tool to be able to document or give us a base number to work at.

Should Basics be able to perform FSBS? Probably, but that itself is not the real issue as many is making out here. The real issue is the EMT should be trained and educated enough to be able to perform an adequate history and assessment to determine if this is hypoglycemia/insulin shock. Yes, a FSBS reading would definitely assist in differential of altered LOC such as in CVA vs. Insulin Shock; but in the case you cannot perform, cannot one treat appropriately? Again, similar to the pulse oximetry are you going to withhold oxygen on those that still have symptoms of respiratory distress but the number is still adequate? Of course not.

The way things is changed in medicine is by getting them changed. Posting on forums is a nice way to vent, but does nothing in change. Get your medical director to either write protocols or become involved in changing your state laws performing this procedure(s). Better yet, demand that the EMT level obtain additional and better education in both areas, by doing so one might see the ability to perform more assessment tools.

R/r 911
 
DenverEMT said:
I'd have to disagree that giving an already hyperglycemic patient glucose/D50 won't hurt them. Absolutely it will, especially if they are postprandial or present with a BGL over say 250mg/DL. High blood sugar also has more effect on major organs than low sugar does. Ketoacidosis may even develop if their sugar is pushed too high.

I'd stay safe with every diabetic/AMS/drunk patient and still perform a finger stick, just to cover your own a**. Better safe than sorry
Click to expand...

If an EMT is not allowed to check a BGL, but is on the scene of a possible hypoglycemic pt. It will not hurt them to administer oral glucose, if the pt is responsive enough to maintain an airway.

We are not talking D50 via IV, we are talking oral glucose. It takes a lot of oral glucose to raise the BGL to extreme measures. It also takes time for it to reach the effect. In that time, you can transport them to the hospital.

If you do an assessment and suspect low BGL and they are alert, give them glucose. The ED will deal with their BGL levels, when you transport them. If you have ALS available, then wait for them to arrive on scene.

Yes, High BGL has effects on a lot of organ systems over time! Low BGL affects the brain immediately!! Deal with the emergency you have on hand Now. A BGL of 250mg/dl is not considered that high anymore. You would be surprised how many people walk around every day with a BGL of 250mg/dl.;)
 
DenverEMT said:
. High blood sugar also has more effect on major organs than low sugar does. Ketoacidosis may even develop if their sugar is pushed too high.
Click to expand...


Wrong, wrong, wrong... The major organ that the low sugar effect upon is the brain. Hyperglycemia is rarely a life threatening emergency. Yes they are definitely serious, but it takes a w-h-i-l-e to go into ketoacidosis, then Diabetic coma. Unalike hypoglycemia, which has an acute or rapid onset and is a true emergency. As well there is NO treatment that a EMT can provide for hyperglycemia.

In reality, there is very little difference between a sugar of 400mg/dl than a sugar of 600 or even a 1000mg/dl. Yes, the range of effects can be detrimental on all three but again the emergency focus again is the same. One tube of oral glucose is NOT going to be the breaking point.

Again, we need to re-focus upon history and physical assessment NOT just the tool that allows me to know what to focus or where to treat.
 
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Just a side question... Can't giving glucose to a patient with a CVA be really bad?

Can't remember where I heard that. I may be mistaken, would like some clarification ^_^
 
gillysaurus said:
Just a side question... Can't giving glucose to a patient with a CVA be really bad?

Can't remember where I heard that. I may be mistaken, would like some clarification ^_^
Click to expand...

Not as bad as not giving a diabetic glucose that needs it. Remember, without glucose the brain DIES.. a given real fact. High concentration levels of glucose can increase cerebral infarct but the usual dosage and amount we give is questionable if this occurs.

One has to weigh the treatment... allow the brain to definitely die or possibility of increasing an infarct size?... Treat the hypoglycemia!

Didn't we already have this discussion multiple times before?

R/r 911
 
gillysaurus said:
Just a side question... Can't giving glucose to a patient with a CVA be really bad?

Can't remember where I heard that. I may be mistaken, would like some clarification ^_^
Click to expand...

I was actually thinking the same, but don't know enough about what amount would be detrimental.

The thing about checking BGL is that it WILL affect your treatment. You WON'T spend ten minutes coaxing your ALOC patient to eat the entire tube.

The OTHER benefit is for paramedic-Basic teams. Medic can get a history from family while EMT can do things like d-stick.

Again, not a huge deal. We do fine without it. We don't NEED it. But there would be benefits.
 
Interesting discussion. I know our dept really emphasizes getting BGL on every patient, unless it is extreme trauma. Their opinion is better safe then sorry, and it is another piece of info to give the ED. Whether or not it is because in the past diabetics got confused with "drunks" or vice versa, I am not sure. I do know that there is no such thing as drunk tank anymore at local LEO depts. Any decrease in LOC gets a ride to the ED in a big ambulance and a nice bed to sleep it off in.
 
Bgl

I'm in Pennsyltucky. There's been noise about giving B's glucometers for a while (mostly made by B's whining that we don't have ability to do 'em), but honestly, I fail to see the point of doing this. I've been in a couple of heated arguments with my position on the topic -I am a B- but my stance hasn't changed.

Sure, it's kinda screwy that Joe Average can do a finger-stick and get a number for ya, and as a B (here) you can't. And there's a very small window for an untoward result of doing a finger-stick, I'll grant that as well.

I just think it's a practicality issue: what does a glucometer tell you, really, and how will knowing an exact figure change a B's treatment of this? If they're altered and able to swallow, Oral glucose. If unable to swallow, grab a medic. It's not like PA is going to let B's start lines or anything like that, so...


Later!

--Coop
 
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