# Tough call not sure what was going on.



## rhan101277 (Oct 3, 2011)

Scenario:

You get a call that initially comes out as heart problems.  A 27 y/o male with previous heart hx and a A.I.C.D.  In route the call updates to a domestic violence and the scene is not safe.  You stage two blocks down.  About 15 seconds pass and someone stops and is hysterical, saying she is his sister and he is dying on the ground.

We ask what happened and she states he was found on the floor of the basement breathing rapidly and unable to talk.  Is anyone arguing? I say.  Nope she says, no weapons no nothing.  Due to the nature of the call I make a split second decision to go to the scene without law enforcement.  Before getting out of the truck I look over the scene, no weapons, knife's etc.  No yelling.  We approach and I am looking for weapons, I know this is dangerous but with the urgency in her voice, I wondered well what if he is dying.

Patient is on the floor breathing about 50 times/minute, HR 85 sinus rhythm.  Only medical hx is seizures and panic attacks, neither have occurred recently.  No meds, no allergies.  The patient is pounding on his chest, he does have some wheezing but I can't tell if it patient created or new onset asthma.  We get him to truck and 15L NRB and he sucks all air out of the bag.  His pulse ox is 98%, pupils dilated, denies drug use.  He is flailing around but it is not seizure activity, he can make purposeful movements and is breathing, he has not urinated on himself.  He gets tired of breathing in route and RR slows, I try to put in a OPA and he is alert enough to try to spit it out.  I start assist bagging and he is still at 98%.
IV 18ga left upper arm saline lock.  I start to think excited delirium because he is hot to touch, but temp reads 98.  I think panic attack, but all I have seen have tachy rates above 110.

I was not sure what was going on so I provided support.  We got to ER and he got .5mg ativan to calm down and then they infused mag sulfate.  The docs weren't really sure what was going on either.

Thoughts?


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## Shishkabob (Oct 3, 2011)

EtCO2?  BGL?  12-lead?

As far as breathing goes, was there extra effort?  Accessory muscle usage?  Pt complaining of corpal-pedal spasms?  Any complaints or dyspnea at all, or was it just rapid breathing?






Wouldn't be the first time I've seen self-induced hyperventilation.


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## rhan101277 (Oct 3, 2011)

Linuss said:


> EtCO2?  BGL?  12-lead?
> 
> As far as breathing goes, was there extra effort?  Accessory muscle usage?  Pt complaining of corpal-pedal spasms?  Any complaints or dyspnea at all, or was it just rapid breathing?
> 
> ...



Was so wrapped up helping him breathing I forgot about EtCO2, unable to get BGL due to patient agitation, no 12 lead done.  While it is easy for me to see what I could have done, I was concerned about his airway and breathing.  I always use EtCO2, It was so hectic I guess it slipped my mind.


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## Handsome Robb (Oct 3, 2011)

Why the mag? Maybe for alkalosis due to the increased respirations? The ativan makes sense since he was so amped up. 

Where did you get the temp from? Hx of seizures but no meds, that doesn't make any sense to me but I'm new to the whole ALS word. I've learned to take dispatch info with a grain of salt, they follow protocols to certain key words and answers. 

I don't know if anything else could have been done for this guy prehospitally, I would have considered 1 mg versed to calm him down for his and my safety but that's about all I got. Sounds almost like an extreme anxiety attack, were you able to find out anything about onset? Possible trigger maybe? The wheezing may be helped with albuterol and if that didn't work a duoneb but that's just me.

Did you get a SpO2 prior to the NRB? Flushed skin? Was the wheezing audible or auscultated?

This is an interesting one.


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## slb862 (Oct 3, 2011)

I am going to side with the panic attack and hyperventilating.  
Give them 1 - 2mg of Atvian.  Either a paperbag or a NRB (with no O2 flowing)Continue to monitor and deliver to the ED.


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## bigbaldguy (Oct 3, 2011)

I wouldn't have suggested this until about 3 months ago when we came across a kid in a true full blown panic attack but yeah it sounds like a panic attack. I've seen some since that sound like this guy.


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## Akulahawk (Oct 3, 2011)

slb862 said:


> I am going to side with the panic attack and hyperventilating.
> Give them 1 - 2mg of Atvian.  Either a paperbag or a NRB (with no O2 flowing)Continue to monitor and deliver to the ED.


While this may be a panic attack w/ hyperventilation, I disagree with use of a paper bag or NRB without O2 flowing. IMHO, if it's a panic attack and he's hyperventilating, as soon as he passes out, his RR will drop right down. I've had pretty good luck with coaching someone's breathing pattern. I like the idea of giving ativan though. If not in the standing orders, could it have been possible to get an order for IM ativan?


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## Handsome Robb (Oct 3, 2011)

slb862 said:


> I am going to side with the panic attack and hyperventilating.
> Give them 1 - 2mg of Atvian.  Either a paperbag or a NRB (with no O2 flowing)Continue to monitor and deliver to the ED.



When was the last time you were in school or did any reading on the subject? This isn't the 90s. A paper bag or NRB reduces their available o2 and increase their anxiety...  I agree with coaching the pt as Aidey said.


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## fast65 (Oct 3, 2011)

I'm gonna go with a panic attack as well, however I would also like to have seen a 12-lead and ETCO2 and this guy. That aside, did you consider a duoneb for the wheezing?

I would have started with the NRB, tried a duoneb, given 1 mg Versed, and attempted to coach his breathing down. Other than that, I don't see much else that we can do for this guy.


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## slb862 (Oct 3, 2011)

Working in a hosptial ED, I go with what the doctor orders.  Yes, they still order a paperbag.  And yes, they sometimes do order a NRB without oxygen. Nothing wrong with trying to calm your pt. But, calming and doing something the patient thinks is benefical (NRB mask without O2) is also calming and reassuring to the PATIENT.  
I treat the PATIENT, unlike some of you who feel you should treat the patient by reading a book or going back to school. 

I do have protocols to give IV or IM ativan. 

Just wondering why? NVrob you feel it is necessary to make the comments the way you?


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## fast65 (Oct 3, 2011)

slb862 said:


> Working in a hosptial ED, I go with what the doctor orders.  Yes, they still order a paperbag.  And yes, they sometimes do order a NRB without oxygen. Nothing wrong with trying to calm your pt. But, calming and doing something the patient thinks is benefical (NRB mask without O2) is also calming and reassuring to the PATIENT.
> *I treat the PATIENT, unlike some of you who feel you should treat the patient by reading a book or going back to school.
> *
> I do have protocols to give IV or IM ativan.
> ...



Ummmm, what?


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## Handsome Robb (Oct 3, 2011)

slb862 said:


> Working in a hosptial ED, I go with what the doctor orders.  Yes, they still order a paperbag.  And yes, they sometimes do order a NRB without oxygen. Nothing wrong with trying to calm your pt. But, calming and doing something the patient thinks is benefical (NRB mask without O2) is also calming and reassuring to the PATIENT.
> I treat the PATIENT, unlike some of you who feel you should treat the patient by reading a book or going back to school.
> 
> I do have protocols to give IV or IM ativan.
> ...



When your treatments are outdated, that's why. That's harmful and disrespectful to a patient. Sure there are placebo studies out there but the patients sign an acknowledgment that they may or may not receive a placebo medication.

INFORMED consent....how is that informed when you don't tell them what your doing? I do treat the PATIENT and adhere to their rights as a PATIENT. You may receiver orders from an MD but you are a PATIENT advocate and have the right to refuse their orders with the PATIENT's best interest in mind.

Apparently you need to go back to school to review patient consent. Don't call me out like that, I know there are people here who will support me and my statements.


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## Shishkabob (Oct 3, 2011)

NVRob said:


> When your treatments are outdated, that's why. That's harmful and disrespectful to a patient. Sure there are placebo studies out there but the patients sign an acknowledgment that they may or may not receive a placebo medication.


  Our waiver for treatment states "I allow my EMS, physician and hospital staff to treat me in the way they deem best".  



> INFORMED consent....how is that informed when you don't tell them what your doing?


  Commonly accepted that while informed consent is a great thing to give, it's not always applicable in an emergency situation.   Implied consent in an emergency is as good as it gets at times.





NVRob said:


> When was the last time you were in school or did any reading on the subject? This isn't the 90s. A paper bag or NRB reduces their available o2 and increase their anxiety...  I agree with coaching the pt as Aidey said.



The paper-bag idea is based around the thought process of ceasing corpal-pedal spasms by re-introducing CO2, which when a panic attack stricken patient starts having cramps in their hands and feet and they don't know why, that sure as hell will up their anxiety.


It's not a 'wrong' idea, but you have to do it right.



Honestly, the best thing to do is moderate-flow O2 via a simple face mask (If you can be sure this is purely panic-attack induced hyperventilation)


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## Handsome Robb (Oct 3, 2011)

I understand the concept around the paper bag. My argument is that if it was still considered as a good treatment it would still be tough, but it isn't. It is taught as a big no-no in these types of emergencies.


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## Shishkabob (Oct 3, 2011)

NVRob said:


> I understand the concept around the paper bag. My argument is that if it was still considered as a good treatment it would still be tough, but it isn't. It is taught as a big no-no in these types of emergencies.



Not because it doesn't work, but because they don't want someone seeing hyperventilation, thinking it's nothing more than a panic attack, giving them a paper bag and looking for a refusal, when as you know, there are quite a few true emergencies that can cause hyperventilation (MI, for example)


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## Handsome Robb (Oct 3, 2011)

Linuss said:


> Not because it doesn't work, but because they don't want someone seeing hyperventilation, thinking it's nothing more than a panic attack, giving them a paper bag and looking for a refusal, when as you know, there are quite a few true emergencies that can cause hyperventilation (MI, for example)



Thanks for the clarification.


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## bigbaldguy (Oct 4, 2011)

NVRob said:


> When your treatments are outdated, that's why. That's harmful and disrespectful to a patient. Sure there are placebo studies out there but the patients sign an acknowledgment that they may or may not receive a placebo medication.
> 
> INFORMED consent....how is that informed when you don't tell them what your doing? I do treat the PATIENT and adhere to their rights as a PATIENT. You may receiver orders from an MD but you are a PATIENT advocate and have the right to refuse their orders with the PATIENT's best interest in mind.
> 
> Apparently you need to go back to school to review patient consent. Don't call me out like that, I know there are people here who will support me and my statements.



Your statement was fine I think it's your delivery that was the problem. Jumping down someones throat is a poor way of getting your point across. Educate don't berate. The purpose of this forum is to share ideas and knowledge. Knowledge is a tool not a weapon.


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## Handsome Robb (Oct 4, 2011)

bigbaldguy said:


> Your statement was fine I think it's your delivery that was the problem. Jumping down someones throat is a poor way of getting your point across. Educate don't berate. The purpose of this forum is to share ideas and knowledge. Knowledge is a tool not a weapon.



My apologies. I woke up on the wrong side of the bed this morning.


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## FFEMT427 (Oct 4, 2011)

If you look at this PT's presentation with hot skin rapid RR dilated pupils muscle movements sounds it may have been sympathomimetic overdose ( our patients lie to us....shocking) or even a panic attack either way  lil ativan would probably help. If it is self induced hyperventilation then when the pt. gets tired he will slow down either way the use of paperbag therapy has been eliminated(as far as I know) in the prehospital ring and I thought the same was true in-hospital as well. As for the reason it was removed it does'nt fix the problem and causes adverse reactions like death. As for the switch to the NRB that is not hooked up the people who died by paperbag therapy did not die of paperbag toxicity they died because they were therapeutically smothered. Either way the recomendation's (from people alot smarter than me) speak for themselves


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## rhan101277 (Oct 4, 2011)

We don't have protocols for treating anxiety and I am not sure how appropriate it would be, if at all, to ask a physician for such an order.  I was really leaning towards a panic attack, I did try a duoneb for the wheezing it didn't help so I stopped treatment.  SpO2 was always 98%+.

I realize patients don't always tell the truth, this guy definitely had meth mouth.


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## systemet (Oct 4, 2011)

1- Benzo's to control the agitation SL, or preferably IV.

2 - bG to r/o DKA / HHNC.

3 - Hopefully a 12-lead if benzos have rendered them compliant.

4 - A frank discussion about any drug use.

It could be many different things.  Without benzodiazepines your ability to assess this patient is going to be limited.  Differentials include hyperventilation syndome / anxiety / psych. issues, toxicology, PE, hyperglycemia, infarct, CVA, etc.

Best guess from available information: psych +/- drugs.  But at the same time, while the least serious condition may be the most probable, you have to rule out the less probable but more serious conditions first.


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## Shishkabob (Oct 4, 2011)

rhan101277 said:


> We don't have protocols for treating anxiety and I am not sure how appropriate it would be, if at all, to ask a physician for such an order.  I was really leaning towards a panic attack, I did try a duoneb for the wheezing it didn't help so I stopped treatment.  SpO2 was always 98%+.
> 
> I realize patients don't always tell the truth, this guy definitely had meth mouth.



If SpO2 is within good ranges, I see no cyanosis and no real work of breathing besides the tachynpnea, my last thought is "Oh crap I need to control their airway".



Does your system allow benzos for agitation?  At our agency, the ground EMS cannot treat 'anxiety' (again, for fear of thinking it's just a panic attack) but we're allowed to treat agitation, using the same dosages.

One of our QA/QI /education guys is fond of saying "EVERYONE is agitated!" if you catch his drift...


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## AlphaButch (Oct 4, 2011)

No meds? Aspirin usage? denies drug use - communicative between breaths? nodding? Was he able to slow down his breathing with coaching or just by exhaustion?

Dispatch sent as an AICD w/heart hx. Did he have an AICD? Any actual complaint of chest pain? smothering (lungs or chest)? Pulse rates ok, but how did it feel (weak, bounding,etc)? any BP on scene? Nausea, tremors, twitching or head angulation?

Given the info, I'd veer to overdose/poisoning. Would want to conduct tests to r/o PE or MI induced panic.


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## rhan101277 (Oct 4, 2011)

Linuss said:


> If SpO2 is within good ranges, I see no cyanosis and no real work of breathing besides the tachynpnea, my last thought is "Oh crap I need to control their airway".
> 
> 
> 
> ...



Well GCS was 9.


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## Shishkabob (Oct 4, 2011)

rhan101277 said:


> Well GCS was 9.



People can fake a GCS of 3


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## bigbaldguy (Oct 4, 2011)

NVRob said:


> My apologies. I woke up on the wrong side of the bed this morning.



No worries happens to us all


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## FFEMT427 (Oct 4, 2011)

Linuss said:


> People can fake a GCS of 3


Ive seen lamps that can pull a GCS of 3 pretty well....LOL


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## rhan101277 (Oct 4, 2011)

I might could have used the behavioral protocol, although it is geared towards uncooperative psych patients.  It has 2mg midazolam.


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## epipusher (Oct 4, 2011)

If possible, attempt to coach the patient in slowing or controlling their resps. If not, they are going to pass out eventually. Monitor the patient, and enjoy the quiet ride to the ed.


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## rhan101277 (Oct 4, 2011)

epipusher said:


> If possible, attempt to coach the patient in slowing or controlling their resps. If not, they are going to pass out eventually. Monitor the patient, and enjoy the quiet ride to the ed.



Yeah I tried coaching, I was aware he would pass out eventually.  I was just curious why the ER went with mag sulfate with no positive hx of asthma, maybe they were using it to relax muscles.

Doctors can do shotgun medicine and I cannot.


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## Handsome Robb (Oct 4, 2011)

I was wondering why the mag as well. My thought was maybe trying to correct possible respiratory alkalosis since it has a pH of ~6.0 if it was adjusted? That seems like bringing a gun to a fist fight though especially without ABGs first.


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## FFEMT427 (Oct 4, 2011)

Using mag to relax the pt. seems like a poor method. Was the pt. still having a wheeze if so did the hospital start with first line treatments (Nebs ect.). As for the alkaliosis I did a little searching and didnt find mag as a treatment that doesnt mean they were not trying it(Im not being argumentitive just throughing out ideas


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## Handsome Robb (Oct 4, 2011)

I agree with you. It doesn't seem like a common treatment for alkalosis. From what I found some solutions can contain sulfuric acid or sodium hydroxide to adjust pH levels. Haven't been able to find other sources to support this though.


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## rhan101277 (Oct 4, 2011)

FFEMT427 said:


> Using mag to relax the pt. seems like a poor method. Was the pt. still having a wheeze if so did the hospital start with first line treatments (Nebs ect.). As for the alkaliosis I did a little searching and didnt find mag as a treatment that doesnt mean they were not trying it(Im not being argumentitive just throughing out ideas



Yeah he was wheezing, they didn't try the nebs and went straight to mag.  He was in distress but with no asthma hx, I tried one breathing tx and that was it.  I didn't want to try anymore tx because he had no asthma hx and it would just cause more cardiac oxygen demand.  They must have thought asthma when I came in but later said it was all in his head.  It sounded like he was causing this wheezing from his upper airway alone (you can do it yourself).  I verified he wasn't choking.


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## FFEMT427 (Oct 4, 2011)

NVRob said:


> I agree with you. It doesn't seem like a common treatment for alkalosis. From what I found some solutions can contain sulfuric acid or sodium hydroxide to adjust pH levels. Haven't been able to find other sources to support this though.


Yeah I found that they use sodium and potasium chloride hydorchloric acid IV (WOW) and dialisis but these treatments are all for severe metabolic alkaliosis which they would want to have labs back before they treated anyway. 
I think this is a pretty valid question is the hospital staff of the hospital you went to pretty on the ball when it comes to treatment because just because just because some of the providers in hospital went to higher education than us doesnt mean they learned a d!@# thing


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## rhan101277 (Oct 8, 2011)

Physician diagnosis was agoraphobia.


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## BrushBunny91 (Oct 26, 2011)

I was informed that the paper bag method was heavily outdated and should never be attempted on account of recent legal action.


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## systemet (Oct 27, 2011)

NVRob said:


> I was wondering why the mag as well. My thought was maybe trying to correct possible respiratory alkalosis since it has a pH of ~6.0 if it was adjusted? That seems like bringing a gun to a fist fight though especially without ABGs first.



* The patient could be hypomagnesemic +/- hypokalemic.  Any recent history of prolonged vomiting or diarrhea?  However hyperventilation would be unlikely as a compensatory mechanism in this setting, as it produces metabolic alkalosis.  Hypomagnesemia is also common in alcoholics, who can also develop ketoacidosis.

* Pure respiratory alkalosis is treated by controlling the minute volume.  In the context of hyperventilation syndrome, this is usually by calming the patient +/- sedation.  If they derrange their pH too badly, they'll pass out, go apneic for a while, and then start breathing again at a slower rate (If it's psychogenic).

* Outside of psychogenic causes, hyperventilation and respiratory alkalosis is often a compensation for metabolic acidosis.  Alphabutch suggeted possible salicylate toxicity.  Organic alcohols are another potential factor.  A PE can also cause hyperventilation to maintain gas exchange, as part of the surface area for diffusion is potentially lost.

* The paper bag works.  It's just not advised in EMS due to fears of litigation.  You can't know (even if you can reasonably suspect) that this is some sort of anxiety syndrome.  So if you take a patient with a large PE, and given them a paper bag, it might expose you to legal liability.

* I've run labs where we take ETCO2 on conscious volunteers, and get them to rebreath from a plastic bag containing 100% O2.  It's impressive to see people get their ETCO2 up to 60 mmHg, and then watch the facial flushing, tachycardia, HTN that result.  Hypercapnia is cool.  None of the subjects desaturate.  If you were to have a patient rebreathing CO2, then any fall in SpO2 should suggest the presence of another underlying pathology.


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## MediFaithLoveCoffee (Dec 7, 2011)

Maybe i missed something? Wheezing and pounding on his chest and no Albuterol was given?


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## Dwindlin (Dec 7, 2011)

Someone may have answered this already, but incase the didn't. . .

Mag can be used in acute, severe asthma attacks.  Not given for acid/base reasons.

http://summaries.cochrane.org/CD001490/magnesium-sulfate-for-treating-exacerbations-of-acute-asthma-in-the-emergency-department


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## Hunter (Dec 7, 2011)

rhan101277 said:


> Was so wrapped up helping him breathing I forgot about EtCO2, unable to get BGL due to patient agitation, no 12 lead done.  While it is easy for me to see what I could have done, I was concerned about his airway and breathing.  I always use EtCO2, It was so hectic I guess it slipped my mind.



too agitated for a BGL? but not for an IV?


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## rhan101277 (Dec 7, 2011)

Hunter said:


> too agitated for a BGL? but not for an IV?



Yeah you are right, stupid on my part.


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## Handsome Robb (Dec 7, 2011)

rhan101277 said:


> Yeah you are right, stupid on my part.



Meh everyone makes mistakes. You can always nab a sample off the needle from the IV although I'm sure someone will get grumpy with me for recommending this.


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## usalsfyre (Dec 7, 2011)

NVRob said:


> Meh everyone makes mistakes. You can always nab a sample off the needle from the IV although I'm sure someone will get grumpy with me for recommending this.



I'm really not sure why people get so spun up about that. Most of my research indicates it's a 10-15mg/dl difference. If it's that freaking close retake it off a finger. Otherwise we're ruling out acute issues, not managing the disease process longterm.


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