# To check a blood sugar, or not check?



## Amycus (Feb 18, 2011)

Just a question on a call I ran today that I'd like some outside opinions on, as my thoughts differed from the medic on scene and my partner.

Presented with a 45yo male, c/c CP x3 days, s/c shortness of breath and dizziness. PT is hunched over when we get in (not true tripoding though), flushed skin, warm, clammy. PT was placed on a NRB by Fire before BP 160p, Pulse 100, SPO2 of 100% on the NRB (PT prolly woulda been fine on a cannula). PT appears lethargic, and is slow to respond to questions, usually had to repeat myself 1-3 times for each question. Only med Hx I can get from him is that he's a diabetic and no cardiac history. So I figure, while getting all other vitals, I'd grab a blood sugar, due to presentation, hx, etc. Got an ALS intercept, etc.

On arrival, the medic asks why I took a sugar, saying it was basically not indicated due to not being true AMS, and the nature of the call being cardiac- also making a point that if the glucometer gave an incorrect reading, patient care/treatment may have gone in the wrong direction. My partner basically agreed, said if it was her tech, she wouldn't have checked.

Besides possibly poking the PT's finger unnecessarily, I don't see the harm in having done it on this call. Yes, the lethargy and slow responses could have been due to his shortness of breath, but my train of thought was it also could have been related to a dipping blood sugar possibly- in either case, it's another, in my opinion, "relevant" vital to take on this person due to his history.

Opinions?


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## Aidey (Feb 18, 2011)

If the patient is a diabetic and can't tell you when they last checked their BS, checking their BS is appropriate. Maybe it won't be the first thing you do, but it should be done. It is also important to remember that a patient can be having more than one problem at a time. The pt wasn't acting right, and it doesn't sound like there was evidence of profound hypoxia or hypoperfusion that would cause the AMS. 

I've also had a few DKA calls come out as "Shortness of breath" because the 911 caller confuses hyperventilation with difficulty breathing. 

What ended up being wrong with the patient?


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## Shishkabob (Feb 18, 2011)

If the presentation could be caused by hypo- or hyperglycemia, they need a BGL check.

If they have altered mentation, give it a check.




Heck, even if you don't think it has to do with the presentation, check it.  Really no reason not to, much like a temperature.  It takes mere seconds and you;ll save yourself looking like an idiot when you go in and the hospital staff finds the BGL to be low.


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## medicdan (Feb 18, 2011)

I agree with you-- a sugar is certainly nice, but not a priority in my assessment, if you are treating this as cardiac. While i'm a fan of not subjecting patients to pain and risk when not necessary, this is very minimal. With a history of diabetes (Type I or II?), and confusion, it can only contribute to your assessment- and clinical perspective.


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## abckidsmom (Feb 18, 2011)

I'm not impressed with the little bit of info you gave about the medic.  

I tend to check the blood glucose of lots of patients, whether they look hypoglycemic or not.  You were completely justified in this case.


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## reaper (Feb 18, 2011)

I check BGL on most pts, whether they have hx or not. It is a vital sign, just like a temp. It is part of an assessment.


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## Amycus (Feb 18, 2011)

Aidey- I have no idea to be honest. The medic gave him a duoneb en route (he admitted to a hx of asthma during transport and said he felt like he was having an attack...oh the miracles of one person getting different information), and he said he felt some relief from that. EKG came up clean as far as I know.

Dan- I agree. It was the last thing I did before packaging. Showed up- O2, tried to get a history, mostly ineffective, vitals, some ASA, sugar, packaged.


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## phildo (Feb 18, 2011)

I check a BGL on just about everyone. When I don't, its usually a trauma alert that has me up to my @ss in alligators and even then I'll check it if everything else is done.  I remember a sick call from over 10 years ago. N&V, no D x 5 days.  Went to the doctor that morning, left with a dx of a stomach virus.  Phenergan had not helped and she felt worse than before.  We checked all vitals, including BGL and guess what.  Sugar was over 1200.  She was admitted for DKA.  No stomach virus.  Some medics (and doctors) get tunnel vision. I do my own assessments, even when responding to a doctor's office.  I have come up with different differentials more than once, and been right. If its your call, do what YOUR judgement tells you.


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## mc400 (Feb 18, 2011)

phildo said:


> I check a BGL on just about everyone. When I don't, its usually a trauma alert that has me up to my @ss in alligators and even then I'll check it if everything else is done.  I remember a sick call from over 10 years ago. N&V, no D x 5 days.  Went to the doctor that morning, left with a dx of a stomach virus.  Phenergan had not helped and she felt worse than before.  We checked all vitals, including BGL and guess what.  Sugar was over 1200.  She was admitted for DKA.  No stomach virus.  Some medics (and doctors) get tunnel vision. I do my own assessments, even when responding to a doctor's office.  I have come up with different differentials more than once, and been right. If its your call, do what YOUR judgement tells you.



Correct^


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## medicdan (Feb 19, 2011)

phildo said:


> I check a BGL on just about everyone.



Yeah, I agree. I've started treating it as just another vital, alongside LS and Pupils in my assessment. Even at a BLS level, it's a good piece of information to have.


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## sir.shocksalot (Feb 19, 2011)

phildo said:


> I check a BGL on just about everyone.


I completely disagree with this, I find that arbitrary numbers tend to distract from treating the patient first and taking the numbers under advisement. To the OP, I think you were right to check a sugar, confusion and lethargy are certainly signs of hypoglycemia, it might be their SOB or a cardiac event but without a BGL you can't say it isn't a sugar problem. 

To me checking a BGL when there is no clinical indication for a sugar problem is cruel and shows a lack of critical thinking. Hypo and hyperglycemia have signs and symptoms that you should know as a medic. You should know that abd pain is a symptom of hyperglycemia, you should know that hypoglycemic people don't have syncopal events with an immediate return to normal and appropriate mentation. I think paramedics should use their brain before performing painful testing for no reason other than "it's a vital sign".

If you want to check it off the IV stick (understanding that it may be lower depending on your glucometer) it's kinda different since they are getting stuck anyway. I just don't believe in unneeded tests, or the default philosophy of IV, o2, monitor, transport cocktail. It just proves how horribly deficient our education is.

Again to the OP: sounds like you made an appropriate choice.


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## usalsfyre (Feb 19, 2011)

sir.shocksalot said:


> I completely disagree with this, I find that arbitrary numbers tend to distract from treating the patient first and taking the numbers under advisement.



Statements like this always confuse the heck out of me. How is a BGL "arbitrary"? It's a pretty concrete number, if it correlates clinically than you treat it. The whole "treat the patient not the monitor" argument is complete bull skat to me, if we're going to do that why do we carry the dang things around? To me this is just an excuse that really says "I can't clinically correlate vital signs and diagnostic results to patient condition". 




sir.shocksalot said:


> To the OP, I think you were right to check a sugar, confusion and lethargy are certainly signs of hypoglycemia, it might be their SOB or a cardiac event but without a BGL you can't say it isn't a sugar problem.



Agreed



sir.shocksalot said:


> To me checking a BGL when there is no clinical indication for a sugar problem is cruel and shows a lack of critical thinking. Hypo and hyperglycemia have signs and symptoms that you should know as a medic. You should know that abd pain is a symptom of hyperglycemia, you should know that hypoglycemic people don't have syncopal events with an immediate return to normal and appropriate mentation. I think paramedics should use their brain before performing painful testing for no reason other than "it's a vital sign".



So hospitals don't routinely run labratory diagnostics, including BGL, in these types of cases? I'm fairly big on patient comfort, however your the first person I've ever heard describe this procedure as "cruel". It's a pin pr!ck. I've had it done, it hurts for 10 minutes then stops. A lack of critical thinking is saying things like "syncopal episodes (an alteration in LOC) are NEVER caused by hypoglycemia". I've had a patient who when asked the normal four questions was alert and oriented, but seemed just a little "off". His BGL was 24. 



sir.shocksalot said:


> If you want to check it off the IV stick (understanding that it may be lower depending on your glucometer) it's kinda different since they are getting stuck anyway. I just don't believe in unneeded tests, or the default philosophy of IV, o2, monitor, transport cocktail. It just proves how horribly deficient our education is.



Why are we sticking patients at all? My patient just a few minutes ago complained about the B/P cuff, so is it cruel to use it? Medical care is sometimes uncomfortable. I won't argure our education is horribly deficent, but I can't say routinely obtaining a BGL is ANY proof of that. A FSBGL is, if not exactly a benign test, pretty dang close to one. I'm having a hard time wraping my head around how obtaining another piece of information in a relatively harmless manner marks one as a bad medic. 




sir.shocksalot said:


> Again to the OP: sounds like you made an appropriate choice.



Agreed.


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## Veneficus (Feb 19, 2011)

Amycus said:


> Presented with a 45yo male, c/c CP x3 days, s/c *shortness of breath and dizziness.* PT is hunched over when we get in (not true tripoding though), flushed skin, warm, clammy. PT was placed on a NRB by Fire before BP 160p, Pulse 100, SPO2 of 100% on the NRB (PT prolly woulda been fine on a cannula). *PT appears lethargic, and is slow to respond to questions*, usually had to repeat myself 1-3 times for each question. Only *med Hx I can get from him is that he's a diabetic *and no cardiac history. So I figure, while getting all other vitals, I'd grab a blood sugar, due to presentation, hx, etc. Got an ALS intercept, etc.



I think it would have been deficent not to get a blood sugar on this patient.



Amycus said:


> On arrival, the medic asks why I took a sugar, saying it was basically not indicated due to not being true AMS,



I do not agree with this reasoning.



Amycus said:


> and the nature of the call being cardiac-



So what? People have multiple illnesses, some of which predispose to others. A hx of DM certianly predisposes to a vascular and therefore coronary pathology.



Amycus said:


> also making a point that if the glucometer gave an incorrect reading, patient care/treatment may have gone in the wrong direction. My partner basically agreed, said if it was her tech, she wouldn't have checked.



That is the most pathetic thing I have heard this week and it ounds like your partner was just brown nosing.



Amycus said:


> Besides possibly poking the PT's finger unnecessarily,



It was necessary. He had a history a C/C and if he is like 99% of diabetics I know or have seen, never run controls on his glucometer, making his equipment uspect, not mine.



Amycus said:


> I don't see the harm in having done it on this call. Yes, the lethargy and slow responses could have been due to his shortness of breath, but my train of thought was it also could have been related to a dipping blood sugar possibly- in either case, it's another, in my opinion, "relevant" vital to take on this person due to his history.
> 
> Opinions?



You made the right call. The patient story can change over time. In your later post it sounds like the pt was treated for a respiratory illness. So it was not any more clearly a cardiac call than a diabetic one.

There is a lot to be said for pertinant negatives.


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## reaper (Feb 19, 2011)

> > I check a BGL on just about everyone.
> 
> 
> I completely disagree with this, I find that arbitrary numbers tend to distract from treating the patient first and taking the numbers under advisement. To the OP, I think you were right to check a sugar, confusion and lethargy are certainly signs of hypoglycemia, it might be their SOB or a cardiac event but without a BGL you can't say it isn't a sugar problem.
> ...



It is a vital sign and should be obtained as often as possible. A majority of pts do not obtain regular medical care. You checking a BGL, may be the one person that can pick up on a border line diabetic. So they can now to follow up on this, before it is out of control. Not all pts show s/s with diabetic problems. 

This is part of community medicine. Something that EMS should be pushing towards. I also routinely run 12 leads on pts over 50, that do not have regular medical care. I will print it out, write pt's vitals for that time on back and explain to pt to keep in purse or wallet. Then when they do have problems, either EMS or the Dr have a previous 12 lead to compare it against. 

Why are we not doing all we can for our pts? For some of them, we may be the only medical exam they will see.  

For a medic to say that a BGL is a cruel test and not part of a normal vital sign, shows our lack of education and being stuck in the past. Does the ED not runs labs and tests to look for abnormalities? Why are more of you not doing this? Especially for pts that may not want to be transported.


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## Veneficus (Feb 19, 2011)

reaper said:


> I also routinely run 12 leads on pts over 50, that do not have regular medical care. I will print it out, write pt's vitals for that time on back and explain to pt to keep in purse or wallet. Then when they do have problems, either EMS or the Dr have a previous 12 lead to compare it against.



That is a great idea, i like it.


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## MrBrown (Feb 19, 2011)

Veneficus said:


> That is the most pathetic thing I have heard this week and it ounds like your partner was just brown nosing.



Hey you leave Brown out of this! 

This patient could very well have been a dehydrated hyperglycaemic.  A blood sugar can be used as a pertinent negative if the primary problem is mental status alteration but not if it is say .... leg pain.

Brown would have done a BGL


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## lampnyter (Feb 19, 2011)

Basics here arent allowed to check BGL lol.


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## Pittma (Feb 19, 2011)

As Venny said, there's a lot to be said for pertinent negatives. I would have done the same. I would rather try to be a clinician than a technician, treating only cardiac would seem somewhat tunnel-visioned. My question would be how can we try to figure out what's causing this "cardiac" issue. What was the outcome of this, I'd be curious to know...


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## Scout (Feb 19, 2011)

Amycus said:


> Presented with a 45yo male, c/c CP x3 days, s/c shortness of breath and dizziness.



At this point I have decided I want a full set of vitals.

Pulse
Resp
BP
SP02
BGL
ECG
TEMP etc



After you take them you can decide you did't really need them. Now that you know they are ok/off the wall, but you will not know unless you have the information


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## jjesusfreak01 (Feb 19, 2011)

A BGL is always a pertinent negative in any diabetic patient. The medic doesn't sound very competent here, you treat the patient, not the "nature of the call", which is often incorrect as dispatched, as Vene clearly noticed. 

Any altered mental status patient should get a BLG check, and here is why:

1) They might be having a diabetic emergency
2) They might be a diabetic drunk and throwing their blood sugar off
3) They might be a diabetic and sick and throwing their sugar off
4) They might not be a diabetic at all, but they aren't lucid enough to let you know
5) This goes with one, but it could be an episode of DKA and they didn't know they were diabetic

A stroke patient might present similarly to a diabetic emergency, and we need to rule out the diabetic problem, or else you risk taking a healthy hypoglycemic patient into the ER and getting laughed at. That is, after they've dumped a ton of D50 into the pt to fix their real problem.


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## medicdan (Feb 19, 2011)

I'll throw a complication into this...

The glucometers we all use in the field are the same used by patients for daily testing. FDA standards haven't changed for these units since the mid-1980s, where they were only required to have a sensitivity or accuracy range of +/- 20%. Yes, I said that right- glucometers in the US have a margin of error of +/- 20%. 

Some links that discuss and provide research/evidence:

http://www.fda.gov/MedicalDevices/NewsEvents/WorkshopsConferences/ucm187406.htm
http://www.scribd.com/doc/28534516/FDA-ISO-Standards-for-BG-Meters-06-24-2009
http://www.nytimes.com/2009/07/19/h...l=1&adxnnlx=1298124021-fEgRNPsG/iimfRts+yVQSg
http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=26309
http://www.ncbi.nlm.nih.gov/pubmed/16143321

So, thoughts? Knowing that this tool may potentially be inaccurate, how does it play into your clinical assessment?


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## Veneficus (Feb 19, 2011)

emt.dan said:


> I'll throw a complication into this...
> 
> The glucometers we all use in the field are the same used by patients for daily testing. FDA standards haven't changed for these units since the mid-1980s, where they were only required to have a sensitivity or accuracy range of +/- 20%. Yes, I said that right- glucometers in the US have a margin of error of +/- 20%.
> 
> ...



Every piece of medical device or test has some level of inaccuracy. You correlate what you see as the results with what you see on the patient.

When we see asystole on the monitor, the first thing we do isn't open the airway, check for breathing, give rescue breaths, and start CPR. 

The first thing we do is look at the patient to see what they are doing.

Why would a blood glucose be any different? 

If it came back as say 60, with the error, that could be 48 or 72. If it was 72 and I gave them some glucose, so what?

If it was 500 it could be 400 or 600. How does that change anything?

What really makes a change is the pathology of why the number is such. Which is not always going to be possible to discover without more specific testing. 

In EMS as well as all parts of medicine, you make the best decision you can with the information you have. It is not always perfect.


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## sir.shocksalot (Feb 19, 2011)

usalsfyre said:


> Statements like this always confuse the heck out of me. How is a BGL "arbitrary"? It's a pretty concrete number, if it correlates clinically than you treat it. The whole "treat the patient not the monitor" argument is complete bull skat to me, if we're going to do that why do we carry the dang things around? To me this is just an excuse that really says "I can't clinically correlate vital signs and diagnostic results to patient condition".
> 
> 
> 
> ...



You didn't read the post, people seeming "off" should get a BGL. I don't base AMS off whether they can answer the magic 4 questions. 

Also in the hospital a BGL is automatically run with labs, not at the point of care. For example, the iStat devices run a BGL with the Chem test automatically so it's a number that will just come with the other numbers that you want. 

My question is: if you take a BGL on an 18 yro male, mechanical fall from a bike with no past history that is awake and appropriate, and it comes back at 55. Are you going to treat that? If not than why did you take it in the first place. 

I'm not saying there isn't a large portion of patients that need their BGL checked. I think I check about half my patients BGL due to being drunk or "off". But I certainly don't check it routinely on everyone.


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## the_negro_puppy (Feb 22, 2011)

Anyone with a hx of diabetes, patients with altered conscious states and PTS where I am unsure of the cause of their woes get a BSL done. This means most pts. The amount of times I have done a BSL just in case including on trauma PTS and found hypo/hyperglycaemia warrants this. Let us be real, this is not really a very invasive procedure particularly on diabetics who do it on themselves frequently. If in doubt check it.


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## EMSrush (Feb 22, 2011)

Amycus said:


> On arrival, the medic asks why I took a sugar, saying it was basically not indicated due to not being true AMS, and the nature of the call being cardiac- also making a point that if the glucometer gave an incorrect reading, patient care/treatment may have gone in the wrong direction. My partner basically agreed, said if it was her tech, she wouldn't have checked.



They are entitled to think whatever they like; it doesn't mean that they are correct. Good job getting a BGL.


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## TransportJockey (Feb 22, 2011)

I tend to go for a CBG if it's an elderly female hispanic, someone on dialysis, someone w/ a hx of diabetes, hx of malnutrition, hx of ETOH abuse or intox, actin funny, suspected CVA, or just about whenever I feel that it might benefit the patient.


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## Scout (Feb 22, 2011)

Why Hispanic?


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## TransportJockey (Feb 22, 2011)

Scout said:


> Why Hispanic?



High risk factor for diabetes, especially the ones in my district


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## Scout (Feb 22, 2011)

Interesting, Thanks  Must have a read up when I have time


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## rook901 (Feb 23, 2011)

Let me preface this by saying I only read OP's posts.

I don't see any reason to not take the BGL, especially considering that the pt has a hx of DM. I don't care if the pt is presenting with obvious hypo or hyperglycemia. I'm going to get a BGL just to add that in to the overall picture. It only takes a moment to check, and there is no contraindication for obtaining a BGL. Just remember to treat the patient and not just the numbers.

Don't let the other medic get to you. It's your call.


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## MasterIntubator (Feb 24, 2011)

Given the scenario in the beginning.... totally appropriate.  Did well grasshopper.

To expand on further posts... I don't do them on every call or every pt, I will take in account of history, scenario, clinical findings, good judgement and go from there.  We actually have protocols that define when it will be used, if it is outside of that and appropriate, it will be done.  But I do not support the "Lets do every test in the book cause we can and cover our butts".... Many new doctors do this, and it drives up unneeded bills. The missed diagnoses is far and few in between when a strong clinician does a good job and does not do drive-thru medicine.  Media pumps that malpractice fear into us.


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## EMSDude54343 (Mar 10, 2011)

you did the right thing, although the pts sob and cp could be contributing to the ams, pt is a diabetic so its better to check. plus our local protocol is that any pt with ams not from an obvious traumatic inj gets a finger stick, even obvious strokes....


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## calebsheltonmed23 (Mar 11, 2011)

I check blood sugars on just about every patient I come across.  I've seen people be standing up talking to me, c/c of just not feeling well, and their BGL be in the low 40's.  It does'nt hurt to check!


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## MEDIC802 (Mar 15, 2011)

I see nothing wrong with checking a BGL on the pt you described. I check a BGL on almost all of my PT's, if they are sick enough for an IV they are sick enough for a BGL check, just treat it as you would a BP, Pulse, respirations, O2 sat, cardiac monitor ect its all a dianostic tool to help you determine the proper course of treatment (yeah I know EMS dosen't diagnose , we only treat S&S)
BTW a finger stick is not crule I am a diabetic and check mine ever day twice on sunday.


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