# New Scenario



## Medivixen (Nov 27, 2006)

38 y/o F
Found lying in the middle of a maintenance shed UnCx by her brother
Unresponsive to painful stimuli
Scene is safe, no evidence of trauma
A-patent
B-deep and slow
C-rapid and weak
You are overcome by heat when walking into the shed (+38 celcius outside) 
Pt is about 300+ lbs
Diabetic alert bracelet on
Brother cant give much of a hx since he hasnt been home since this AM (now it is 1pm)

Vitals
BP 90/60
Pulse 110
BGT 1.7 mmol/L

Using your local protocol what do you do?


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## trauma1534 (Nov 28, 2006)

Medivixen said:


> 38 y/o F
> Found lying in the middle of a maintenance shed UnCx by her brother
> Unresponsive to painful stimuli
> Scene is safe, no evidence of trauma
> ...



Well, first things first... what does BGT 1.7 mmol/L mean?  Is that standing for blood glucose?  If so, does anyone know what the numbers would convert to on a standard scale?


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## FFEMT1764 (Nov 28, 2006)

It's a maintanance shed...how can is be safe...hello HAZMAT team...until proven otherwise...too many people store fertilizers next to other hazardous stuff and one thing leaks into the other and whammo, organophosphate city!!!


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## Medivixen (Nov 28, 2006)

> It's a maintanance shed...how can is be safe...hello HAZMAT team...until proven otherwise...too many people store fertilizers next to other hazardous stuff and one thing leaks into the other and whammo, organophosphate city!!!


the scene is safe, it is a maintenence shed as in she keeps wood carving hobbies in it or something no chemicals involved.



> Well, first things first... what does BGT 1.7 mmol/L mean? Is that standing for blood glucose? If so, does anyone know what the numbers would convert to on a standard scale?


And as for the BGT yes that is blood glucose test. I am not sure as to what it would be on your scale just say it is VERY low.


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## FFEMT1764 (Nov 28, 2006)

Well if the sugar is low, then IV NS large vein, like an AC, then D50 25 grams IV. Remove the patient from the hot environment. IV fluids 250cc bolus, reassess vs and sugar. High flow oxygen (15lpm by non rebreather). Remove excess clothing from patient if the are very hot to touch. Place patient on cardiac monitor and obtain 12 lead EKG to rule out cardiac involvement in the LOC.


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## jeepmedic (Nov 28, 2006)

FFEMT1764 said:


> Well if the sugar is low, then IV NS large vein, like an AC, then D50 25 grams IV. Remove the patient from the hot environment. IV fluids 250cc bolus, reassess vs and sugar. High flow oxygen (15lpm by non rebreather). Remove excess clothing from patient if the are very hot to touch. Place patient on cardiac monitor and obtain 12 lead EKG to rule out cardiac involvement in the LOC.



This is a BlS thread. Not an ALS one. Let the EMT-B's handle this. This is how they learn to operate in there level.


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## c-spine (Nov 28, 2006)

With a 300lb + pt, I'd be calling the fire dept for a lift assist. After the pt was removed from the shed, I'd want her on a cot in the rig ASAP with the AC on to try and cool her down. I'd begin the a rapid trauma assessment while my partner calls for an ALS intercept. 

I would monitor the pt, apply high-flow O2, re-check vitals every 5 minutes or so, as I'm not sure how long she will remain fairly stable. 

If the brother is around, I'd want him to give me as much of a hx as possible. I want the SAMPLE history....I'm sure he can tell me at least some of it... at least the AMP part.

Would you want to treat for possible shock with the low BP?


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## FFEMT1764 (Nov 28, 2006)

jeepmedic said:


> This is a BlS thread. Not an ALS one. Let the EMT-B's handle this. This is how they learn to operate in there level.


 
Ok, have fun with it.


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## trauma1534 (Nov 28, 2006)

c-spine said:


> With a 300lb + pt, I'd be calling the fire dept for a lift assist. After the pt was removed from the shed, I'd want her on a cot in the rig ASAP with the AC on to try and cool her down. I'd begin the a rapid trauma assessment while my partner calls for an ALS intercept.
> 
> I would monitor the pt, apply high-flow O2, re-check vitals every 5 minutes or so, as I'm not sure how long she will remain fairly stable.
> 
> ...



Ok... remmber, we are dealing with a low blood sugar here.  What would you do for an unresponsive low blood sugar at the basic level?  There are a couple things you can do.


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## yowzer (Nov 28, 2006)

Remove from the heat, call medics to give IV glucose as there's no way you can safely force frosting down her. O2. Check her temp? What does her skin feel like? Is she sweating? Dry?


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## trauma1534 (Nov 28, 2006)

yowzer said:


> Remove from the heat, call medics to give IV glucose as there's no way you can safely force frosting down her. O2. Check her temp? What does her skin feel like? Is she sweating? Dry?



Well... there is something you can do.  Think outside the box.


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## Jon (Nov 28, 2006)

#1 - Unconscious Person - if ALS isn't already in on the job, get them rolling.
#2 - Big Person - if I don't have at least 6 folks onscene... call FD for lift assist.
#3 - Remove patient from warm enviroment.
#4 - Unconscious Diabetic - If they have an intact gag reflex and aren't totally out, give oral glucose.


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## trauma1534 (Nov 28, 2006)

Jon said:


> #1 - Unconscious Person - if ALS isn't already in on the job, get them rolling.
> #2 - Big Person - if I don't have at least 6 folks onscene... call FD for lift assist.
> #3 - Remove patient from warm enviroment.
> #4 - Unconscious Diabetic - If they have an intact gag reflex and aren't totally out, give oral glucose.




Two things I remember we were taught back in EMT-B class, you can take a toungue depressor and put some instant glucose on it a little at a time and administer it under the toungue, or in the cheek area.  I've never had to try it.  Also, we were taught that you can give glucose rectally, if you had to.  I've heard of alot of providers administering oral glucose under the toungue or in the cheek a little at a time in an uncontious patient and it working.  Like I said though, never tried it.  

FD always comes in handy for lifting assistance!  

You may be left there with this patient for a little while untill adiquate lifting assistance and ALS arrives.  You will have to manage this one thinking outside the box.  If you can get the sugar up, then you won't need the lifting assistance or the ALS anymore, since this is more than likely the sole problem.  After you get the sugar back up and the patient comes compleatly around, you can even go as far as fixing them something to eat!  LOL  That has even been done at 2am, a certain provider I know cooked a patient a full course breakfast meal, got a refusal signed and went back to quarters, and was no longer next up!  LOL


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## FFEMT1764 (Nov 28, 2006)

trauma1534 said:


> Also, we were taught that you can give glucose rectally, if you had to.


 

Interesting, no one around here was taught to give glucose rectally, I even asked our med control and he gave me a dirty look, then asked if I was joking.

Not saying that you weren't taught it, just very wierd to me.


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## Medivixen (Nov 28, 2006)

yes definitly remove pt from the hot environment, transport 3/4 prone, opa(if taken)O2, oral glucose on dependant cheek, iv n/s piggyback 100mls d10w and 50 mg thiamine push, if no improvement 100ml d10 again and cont assessment, check bgt if below 4.0mmol/L another d10w. continuing assessment with vitals , contact EP  if bp is still below 90 start for NS bolus


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## trauma1534 (Nov 28, 2006)

Medivixen said:


> yes definitly remove pt from the hot environment, transport 3/4 prone, opa(if taken)O2, oral glucose on dependant cheek, iv n/s piggyback 100mls d10w and 50 mg thiamine push, if no improvement 100ml d10 again and cont assessment, check bgt if below 4.0mmol/L another d10w. continuing assessment with vitals , contact EP  if bp is still below 90 start for NS bolus




Not putting your judgement down because everyone has thier own way of treating thier patients, plus, I don't know what you were taught.  But, why would you consider an OPA over a NPA if the patient has a simple low blood sugar?  Nasal airways fix the problem of the smoring resp found in low blood sugar patients.  

Also, why thiamine?  Why not D-50 or Glucagon?  

This patient just needs to come back from the low blood sugar.  This just seems like a long way around an easy solution.  Do your Basics start IV's there and give thiamine?  Just wondering.  I know different places allow basics to do different things.

The thing about rectal Glucose, it is not anything that is in the curriculam, or in our proticols, it just can be done.  Why not?  It works like a supository.  It still can me soaked into the blood stream.  It's just one of those think out side the box things.


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## yowzer (Nov 28, 2006)

trauma1534 said:


> Two things I remember we were taught back in EMT-B class, you can take a toungue depressor and put some instant glucose on it a little at a time and administer it under the toungue, or in the cheek area.  I've never had to try it.  Also, we were taught that you can give glucose rectally, if you had to.  I've heard of alot of providers administering oral glucose under the toungue or in the cheek a little at a time in an uncontious patient and it working.  Like I said though, never tried it.



My teaching was that you don't give anything orally to someone who's unconcious. Only if they can swallow on their own. 

And I'm not giving ANYTHING rectally, even if it was in a protocol. Especially not to someone who's big enough they probably can't reach to wipe... =)


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## yowzer (Nov 28, 2006)

trauma1534 said:


> This patient just needs to come back from the low blood sugar.



With an unknown downtime in a really hot room, it's quite possible that she now has more going on than just that.


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## Medivixen (Nov 28, 2006)

> Not putting your judgement down because everyone has thier own way of treating thier patients, plus, I don't know what you were taught. But, why would you consider an OPA over a NPA if the patient has a simple low blood sugar? Nasal airways fix the problem of the smoring resp found in low blood sugar patients.
> 
> Also, why thiamine? Why not D-50 or Glucagon?
> 
> This patient just needs to come back from the low blood sugar. This just seems like a long way around an easy solution. Do your Basics start IV's there and give thiamine? Just wondering. I know different places allow basics to do different things.



we dont do NPA's out here and we dont give d50. Glucagon is only given if IV access is unobtainable. Thiamine always goes in conjunctions with d10 for our protocols.


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## fm_emt (Nov 28, 2006)

If it's like an old roommate I had, just wave a bacon cheeseburger and she'll wake right up.

As for the rectal way? I've certainly read about it, but I dunno how happy a patient would be with a tube of glucose paste jammed in their arse.  If it's on the allowed protocols, sure. But if it's not, here come the bloody lawyers again...


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## Fedmedic (Nov 29, 2006)

I've never heard of the rectal valium either, but it makes sense. I'll have to research it a little further to give an educated answer about it. It makes sense because the rectal administration route is about the fastest route after IV. I have given rectal valium to actively seizing patients that I could not obtain IV access and it worked just about as fast as IV valium, although I will have to admit when I followed it up with the air bolus it was pretty nasty...:wacko:


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## trauma1534 (Nov 29, 2006)

fm_emt said:


> If it's like an old roommate I had, just wave a bacon cheeseburger and she'll wake right up.
> 
> As for the rectal way? I've certainly read about it, but I dunno how happy a patient would be with a tube of glucose paste jammed in their arse.  If it's on the allowed protocols, sure. But if it's not, here come the bloody lawyers again...



Well... I highly doubt I'd get sued for waking someone up from a low blood sugar.  And I don't think they will care too much about the butt plug of glucose when they were unresponsive.


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## Ridryder911 (Nov 29, 2006)

Diastat is a trademark Valium rectal gel, that many EMS carry in case one cannot get a line. In comes in a syringe type dispenser made for rectal insertion. Most ER's should have this on hand as well... used it many times on kids, in lieu of I/O's when you cannot  get a peripheral line. 

I would not administer Glucose rectal. IV Glucose is very caustic to mucosa membranes, and if one ever has seen a infiltration and the necrosis it causes, one would understand. It is safe, however; to administer oral glucose (little at a time) to the mucosa and sublingual, if the patient is in a "coma" position (monitor for aspiration) understandably, one does not "squirt" the whole tube... 

The reason for Thiamine, is Wernicke's encephalopathy. All Paramedic units should have protocols to administer Thiamine before D50W or concurrently, to prevent this from occurring (massive seizures due to rapid glucose). I as well routinely give all poor nourished alcoholics Thiamine and Mg++ ... their body is probably depleted. 

R/r 911


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## Epi-do (Nov 29, 2006)

Per protocol around here, high flow O2, request ALS, remove patient from hot environment, loosen clothing & apply cold packs to arm pits/groin area to attempt to cool patient if she appears hyperthermic.  Since she is unresponsive, our medical director would string us up if we attempted to give oral glucose, even if we did it slowly, as some of you have described.  We are not to give anything orally, under any circumstances, to an unresponsive patient.  (And, unfortunately, after working for several different services in the area, I have seen the results of the actions of the very few basics and medics which led the med. dir. to that decision.)


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## Fedmedic (Nov 29, 2006)

Fedmedic said:


> I've never heard of the rectal valium either, but it ...



I mean't to say I had never heard of giving oral glucose rectally, not rectal valium. I have given rectal valium many times, and not the Diastat. Our agency was to cheap to buy it. We just pulled up the valium in a syringe from the ampule and administered it rectally, minus the needle of course...ouch!!


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## jeepmedic (Nov 29, 2006)

Fedmedic said:


> I mean't to say I had never heard of giving oral glucose rectally, not rectal valium. I have given rectal valium many times, and not the Diastat. Our agency was to cheap to buy it. We just pulled up the valium in a syringe from the ampule and administered it rectally, minus the needle of course...ouch!!



You didn't asst. the valium with manual air pressure did you????   :lol:


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## Fedmedic (Nov 29, 2006)

jeepmedic said:


> You didn't asst. the valium with manual air pressure did you????   :lol:



Yeah I just stuck the IV tube up their rectum and blew it in manually............. *w i t h ...         m y    ...      m o u t h* ........ha ha ha .....yeah whatever....although we know someone who did that.....don't we?(RIP):lol:


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## trauma1534 (Nov 29, 2006)

Fed, I tell you another old medic, now a PA who would do the rectal Instant Glucose in a heartbeat, and has ordered it when providers call in on a BLS truck.  He was the king of thinking outside the box.  To give you a hint of who I am talking about, if you haven't figured it out yet, he would say "have no fear, God is Here".  He was the shet!


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## jeepmedic (Nov 29, 2006)

trauma1534 said:


> Fed, I tell you another old medic, now a PA who would do the rectal Instant Glucose in a heartbeat, and has ordered it when providers call in on a BLS truck.  He was the king of thinking outside the box.  To give you a hint of who I am talking about, if you haven't figured it out yet, he would say "have no fear, God is Here".  He was the shet!



Now you are talking OLD


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## fm_emt (Nov 29, 2006)

trauma1534 said:


> Well... I highly doubt I'd get sued for waking someone up from a low blood sugar.  And I don't think they will care too much about the butt plug of glucose when they were unresponsive.



I'm in California. You can't swing a dead cat without hitting a lawyer around here. :|


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## jeepmedic (Nov 29, 2006)

I was told that I got an order for rectal glucose one time but my radio started doing funny things and I could not hear a thing they said.:blink:


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## Anomalous (Nov 29, 2006)

fm_emt said:


> I'm in California. You can't swing a dead cat without hitting a lawyer around here. :|



What;s the difference between a dead cat lying in the road and a dead lawyer lying in the road?


The cat has skid marks around it.


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## ffemt8978 (Nov 30, 2006)

Anomalous said:


> What;s the difference between a dead cat lying in the road and a dead lawyer lying in the road?
> 
> 
> The cat has skid marks around it.



And the lawyer's has burn out marks heading straight for it...h34r:


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## Medivixen (Nov 30, 2006)

> Also, we were taught that you can give glucose rectally, if you had to.



I dont know but around here you can't just get away with shoving things in peoples orifices, one day it will catch up to you and you may find yourself on the other side of things.

Rolling the patient 3/4 prone and applying oral glucose to the dependant cheek is an excellent alternative when dealing with uncx diabetic pts. 

I am a little confused as to what your protocols are like wherever you work? Do you set have a set out algorithm that has different steps as to what the situation hands you ?


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## trauma1534 (Nov 30, 2006)

Medivixen said:


> I dont know but around here you can't just get away with shoving things in peoples orifices, one day it will catch up to you and you may find yourself on the other side of things.
> 
> Rolling the patient 3/4 prone and applying oral glucose to the dependant cheek is an excellent alternative when dealing with uncx diabetic pts.
> 
> I am a little confused as to what your protocols are like wherever you work? Do you set have a set out algorithm that has different steps as to what the situation hands you ?




Our OMD will tell you, along with the ER staff, that our protocol's are ment as a guide, not a stone written law that you must follow.  

For example... you get a call for chest pain.  Are you going to automaticly follow chest pain protocol, if it is not cardiac related?  In other words, are you going to give nitro if the pain is more consistant with a pulled muscle, or a breathing problem even?  I mean just because they say it is chest pain, are you going to give Aspirin, Nitro, Nitro Paste, Morphine, if you have a 16 year old who's chest pain started after he was lifting weights?  

You have to be able to think outside the box.  In our area, the OMD, ER staff and Doctors, PA's, all promote taking the knowledge that we have and applying it the best way we can for the best outcome for the patient.  

Alot of EMS treatment is based on trial and error.  You try one thing, if that's not working or isn't possable, then you find something else that will work, as long as it does no harm.  That's where it comes into play knowing your signs and symptoms, knowing your indications and contraindications of every drug.  Knowing what that drug is used for and what it will do.  What you can and can't give it with.


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## Medivixen (Nov 30, 2006)

trauma1534 said:


> Our OMD will tell you, along with the ER staff, that our protocol's are ment as a guide, not a stone written law that you must follow.
> 
> For example... you get a call for chest pain.  Are you going to automaticly follow chest pain protocol, if it is not cardiac related?




That goes without saying tho, I mean, we would first investigate the complaint before giving any kind of drug tmt.  My chest pain protocol is called "Chest Pain (Cardiac in Nature) Protocol" and we only give Nitro if the pt has a previous Px for Nitro and they met the criteria for the protocol.

I can give up to 0.3 mg Epi SC for anaphylaxis but my pt must meet 4 seperate criteria before I declare it anaphylaxis instead of an allergic response.  The four indications of anaphylaxis here are:
- Pt with S/S of anaphylaxis (urticaria and/or angioneurotic edema and/or hypotension/shock)
- Pt with PHx of allergy
- Pt exposed to known allergen
- UNSTABLE (decreased LOC or hypotension or respiratory distress)

If my pt meets that, they will get a needle in the thigh and then some Benadryl tabs.  But if they don't meet all four, then they are just getting the Benadryl and I'll mix up some Ventolin for them if they have asthma secondary to allergies (that's actually 2 protocols run together).  But it is all an algorithm that I follow including when to initiate transport and when to call EP if things are going south.

Now obviously, we will have to adapt when the time comes to do so; EMS is famous for adaptability, but on paper it better follow the protocol or we may as well start applying for work at McDonalds.


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## BossyCow (Dec 1, 2006)

Glucose paste can be used.  'Just a pinch between the cheek and gum' to keep it from getting into her airway.  The glucose will absorb through the skin. Aside from ABC's and monitoring for that impending seizing episode, I'm getting ALS with needle sugar for her.


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## medic2be (Jan 22, 2007)

Epi-do said:


> Per protocol around here, high flow O2, request ALS, remove patient from hot environment, loosen clothing & apply cold packs to arm pits/groin area to attempt to cool patient if she appears hyperthermic.  Since she is unresponsive, our medical director would string us up if we attempted to give oral glucose, even if we did it slowly, as some of you have described.  We are not to give anything orally, under any circumstances, to an unresponsive patient.



exactly...


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