# Diabetic Question



## cm4short (Sep 4, 2009)

I'm in my internship now and my preceptor gave me a question based on the call we ran this morning. I'd just like to share the info for learning purposes...

Which type of diabetic would you not want to AMA after glucose administration and why? Is it the insulin dependent type 1, or the non-insulin dependent type 2 taking oral pills. Don't forget they why portion.


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## rescue99 (Sep 4, 2009)

cm4short said:


> I'm in my internship now and my preceptor gave me a question based on the call we ran this morning. I'd just like to share the info for learning purposes...
> 
> Which type of diabetic would you not want to AMA after glucose administration and why? Is it the insulin dependent type 1, or the non-insulin dependent type 2 taking oral pills. Don't forget they why portion.



Type II patient with hx of oral meds. Glucose will continue to dip for up to 24 hours.


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## rescue99 (Sep 4, 2009)

Guess I should add that different medications have different mechanisms and vary in half life as well. Renal / liver function may play a role to boot.


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## emtjack02 (Sep 4, 2009)

rescue99 said:


> Type II patient with hx of oral meds. Glucose will continue to dip for up to 24 hours.



I like your answer...But what about the diabetics on those wonderful new long acting insulins like lantus and levemir?


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## rescue99 (Sep 4, 2009)

emtjack02 said:


> I like your answer...But what about the diabetics on those wonderful new long acting insulins like lantus and levemir?



There wasn't enough information in the question to answer insulin.


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## Akulahawk (Sep 4, 2009)

emtjack02 said:


> I like your answer...But what about the diabetics on those wonderful new long acting insulins like lantus and levemir?


It would have to depend upon the blend of insulins that the patient is using. If they're going to be on longer acting insulins, they're likely to be blending short medium and long duration insulins to provide for insulin coverage throughout the day. If the patient goofs up on the long duration insuin dose, the Blood Glucose level could also continue to drop for a long time... I'd be very reluctant to AMA that type of patient as well.


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## cm4short (Sep 4, 2009)

I'd have to disagree somewhat based on the reasonings' given. The duration of insulin and glucose medications are pharmakinetically acting as they are intended. Now, if the person continues to eat, then where does it change from being a "medical condition" to become a "medical concern." 

My theory is when a diabetic is on oral pills, they are often on different types. these pills act as synergist of eachother. But, synergistic effect of the oral pills aded to thethe changing pattern of a type 2 diabetics insulin production my lead to irregular blood glucose levels.


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## rescue99 (Sep 4, 2009)

cm4short said:


> I'd have to disagree somewhat based on the reasonings' given. The duration of insulin and glucose medications are pharmakinetically acting as they are intended. Now, if the person continues to eat, then where does it change from being a "medical condition" to become a "medical concern."
> 
> My theory is when a diabetic is on oral pills, they are often on different types. these pills act as synergist of eachother. But, synergistic effect of the oral pills aded to thethe changing pattern of a type 2 diabetics insulin production my lead to irregular blood glucose levels.



My answer comes from the information given in the question. Simple question gets a simple answer..lol


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## cm4short (Sep 5, 2009)

Yeah, I kinda rushed that answer. We were getting a call just as I was typing. :sad: But, to add to the question. 

The patient we had this morning was a 44 F c/o ALOC secondary to low blood sugar. The patient had a BS of 28 after D-stick. The Pt was placed on O2 IV started, D50 given. Pt went ALOC and didn't wanna go to the hospital. This was one of this stations semi-regular AMA's. She is an Insulin Dependent diabetic with no other Hx and A to PCN. Negative recent illnesses or complaints after return of LOC's. Negative secondary. V/S intact. the Pt does happen to have a very poor diet. Their meal proportions are small and are often just enough to keep her BS up for the next BS reading. Her meal the night before was to drink honey before she went to bed for the night. she stated she was already feeling tired. 

After administration of D50, assuring a meal was prepared and contacting base; she was cleared AMA. I was asked the question upon leaving the call.


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## JPINFV (Sep 5, 2009)

cm4short said:


> Which type of diabetic would you not want to AMA after glucose administration and why? Is it the insulin dependent type 1, or the non-insulin dependent type 2 taking oral pills. Don't forget they why portion.



Based off of just this information provided, neither should be AMA'ed immediately because without additional food the D50 would wear off quickly. Of course another tricky question is can you deny a patient who is now alert, orientated, and understands the risks of signing out AMA from signing out AMA? Just because a patient needs more definitive care or could collapse again doesn't mean the patient loses the ability to refuse treatment and transport.


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## 46Young (Sep 5, 2009)

We've had several diabetic pts who do a poor job of controlling their BGL. These pts would typically refuse further tx/txp after fixing them up. The answer? Treat 'em in the bus, push the D50 on the way to the hospital. Too late to refuse txp at that point. Maybe then they'll try a little harder to control their disease. Again, this is for chronic pts who have demonstrated significant apathy toward their condition, and keep relying on EMS for a quick fix rather than take an active role in controlling their disease.

This tactic sounds harsh, but has shown fantastic results in my experience.

I've had pts on oral hypoglycemics that have kept us onscene for over an hour that insist on eating and drinking, only to have the BGL stay low. After a certain point, it becomes a waste of time and resources to keep the crew onscene. Time to go to the hospital. If one round of OJ and a PB&J sandwich doesn't do the trick, an ER visit should be indicated.


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## rescue99 (Sep 5, 2009)

JPINFV said:


> Based off of just this information provided, neither should be AMA'ed immediately because without additional food the D50 would wear off quickly. Of course another tricky question is can you deny a patient who is now alert, orientated, and understands the risks of signing out AMA from signing out AMA? Just because a patient needs more definitive care or could collapse again doesn't mean the patient loses the ability to refuse treatment and transport.



Ah Ha...but I did consider a person with IDDM would have eaten after, since this is just a part of the S/R protocol. I've never left a less than AOX4 patient until after I see him/her eat at least part and family is present to ensure the rest is finished. Oral meds...different story completely.


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## TransportJockey (Sep 5, 2009)

My thought would be type I on long acting insulin. That's our usual type we don't let go AMA here.


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## rescue99 (Sep 5, 2009)

jtpaintball70 said:


> My thought would be type I on long acting insulin. That's our usual type we don't let go AMA here.



History and meds clears that up...history and meds.  All the stuff we do to begin with prevents a lot of unanswered questions.


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## Markhk (Sep 5, 2009)

Hrm, interestingly our EMS Agency put an advisory up last year specifically on oral hypoglycemics. 

----

http://sccemsagency.org/SCC/docs/Em...hments/7.29.08Lessons Learned August 2008.pdf

Extract

DIABETIC PATIENTS ON ORAL HYPOGLYCEMIC AGENTS
Hypoglycemia is a frequent and dangerous complication for diabetic patients. This is particularly the case for patients who are treated with oral medications.
Hypoglycemia is most often associated with the sulfonylurea oral agents glipizide and glyburide. Glyburide can produce severe, prolonged hypoglycemia that may necessitate intravenous glucose infusion for several days and is the most common cause of hypoglycemia and death related to sulfonylurea use. The risk factors for sulfonylurea-induced hypoglycemia include advanced age (over 65 years), inadequate caloric intake, concomitant drug use (e.g., ß-blockers, insulin), recent initiation of sulfonylurea therapy with limited or no prior exposure to sulfonylurea therapy, and long-acting versus short-acting sulfonylurea use.


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## Sieldan (Sep 6, 2009)

cm4short said:


> Yeah, I kinda rushed that answer. We were getting a call just as I was typing. :sad: But, to add to the question.
> 
> The patient we had this morning was a 44 F c/o ALOC secondary to low blood sugar. The patient had a BS of 28 after D-stick. The Pt was placed on O2 IV started, D50 given. Pt went ALOC and didn't wanna go to the hospital. This was one of this stations semi-regular AMA's. She is an Insulin Dependent diabetic with no other Hx and A to PCN. Negative recent illnesses or complaints after return of LOC's. Negative secondary. V/S intact. the Pt does happen to have a very poor diet. Their meal proportions are small and are often just enough to keep her BS up for the next BS reading. Her meal the night before was to drink honey before she went to bed for the night. she stated she was already feeling tired.
> 
> After administration of D50, assuring a meal was prepared and contacting base; she was cleared AMA. I was asked the question upon leaving the call.



ALOC = ?  Asomething Loss of Conciousness??
And whats the A to PCN?  No clue on that one.

Thanks


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## Akulahawk (Sep 6, 2009)

Sieldan said:


> ALOC = ?  Asomething Loss of Conciousness??
> And whats the A to PCN?  No clue on that one.
> 
> Thanks


ALOC = Altered Level of Consciousness
A = allergy
PCN = Penicillin

Hope that clears up something for you.


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## Sieldan (Sep 6, 2009)

Akulahawk,

Thanks a bundle.  And I have to say, brainfart.  I knew those, just couldnt recall them.  Guess I can say I 'relearned' something today.


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## fma08 (Sep 6, 2009)

JPINFV said:


> Based off of just this information provided, neither should be AMA'ed immediately because without additional food the D50 would wear off quickly. *Of course another tricky question is can you deny a patient who is now alert, orientated, and understands the risks of signing out AMA from signing out AMA? Just because a patient needs more definitive care or could collapse again doesn't mean the patient loses the ability to refuse treatment and transport.*



Key statement there, but doesn't mean one just rolls over when they say they don't want to go in. We are obligated to do all within our power that which is in the best interests of the pt. When we have and they still say no, then it's sign here please.


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## Akulahawk (Sep 6, 2009)

Markhk said:


> Hrm, interestingly our EMS Agency put an advisory up last year specifically on oral hypoglycemics.
> 
> ----
> 
> ...


I used to work in that system. Back when I did, I thought that in some ways, Alameda County was a bit ahead of SCC. That, however, was before Dr. Ghilarducci became the EMS Medical Director... and generally, even before he'd finished his residency. I do, however, like the direction that he's taken the SCC EMS agency...

I had a chance to read that info PDF you posted. It's a good read, but I also noted the use of "should" vs. "shall" where hypglycemic patients on oral meds... which tends to reinforce the idea that while you've managed to correct the instant problem and the patient is alert/oriented, if they refuse transport, you're going to have to let them go... lest you get a kidnapping charge... and just be aware that someone could be going back there in a few hours.


> When you are presented with a diabetic patient on oral medication who has had a hypoglycemic episode, *that patient should be transported for further treatment and observation even if the hypoglycemia is corrected in the field*. Most oral agents are long acting, and the patient will often have another hypoglycemic event even after treatment. Unfortunately many diabetes patients who have hypoglycemic episodes prefer to sign out AMA after treatment.


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## Akulahawk (Sep 6, 2009)

Sieldan said:


> Akulahawk,
> 
> Thanks a bundle.  And I have to say, brainfart.  I knew those, just couldnt recall them.  Guess I can say I 'relearned' something today.


You're welcome!


fma08 said:


> Key statement there, but doesn't mean one just rolls over when they say they don't want to go in. We are obligated to all within our power in the best interests of the pt. When we have and they still say no, then it's sign here please.


Gotta try to impress upon the patient the gravity of the situation... and they can still say "no"...


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## 46Young (Sep 6, 2009)

Like I've said before, if you have a chronic pt that does a poor job of controlling their disease, and typically refuses txp after a momentary correction by EMS, load them up after obtaining diagnostics/O2 admin and push some D50 enroute to the hospital. If the family questions you, tell them that you've seen similar pts in the past drop their BGL dangerously low despite oral/IV sugar, and you want them to be seen at the hospital before they suffer unbreakable seizures and/or irreversible brain damage (or death!) as a result. Put the fear into them. Legally circumvent the whole decisional capacity refusal thing.

I've played the whole "drink some juice, eat a sandwich, check the BGL 95 times while onscene" thing way too many times. If one round of oral intake doesn't work, it's txp time. And if someone needs Glucagon, it's really no question at that point.

Besides, if someone's BGL has dipped with no discernable reason, such as a fever, increased activity, missing a meal, etc, an attending's eval is definitely in order.


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## rescue99 (Sep 6, 2009)

46Young said:


> Like I've said before, if you have a chronic pt that does a poor job of controlling their disease, and typically refuses txp after a momentary correction by EMS, load them up after obtaining diagnostics/O2 admin and push some D50 enroute to the hospital. If the family questions you, tell them that you've seen similar pts in the past drop their BGL dangerously low despite oral/IV sugar, and you want them to be seen at the hospital before they suffer unbreakable seizures and/or irreversible brain damage (or death!) as a result. Put the fear into them. Legally circumvent the whole decisional capacity refusal thing.
> 
> I've played the whole "drink some juice, eat a sandwich, check the BGL 95 times while onscene" thing way too many times. If one round of oral intake doesn't work, it's txp time. And if someone needs Glucagon, it's really no question at that point.
> 
> Besides, if someone's BGL has dipped with no discernable reason, such as a fever, increased activity, missing a meal, etc, an attending's eval is definitely in order.



 I'd never lie to a patient (or family) to achieve my own end goal. Just do a shake n wake, check the patients glucose, take new vitals and make a transport decision. If I've been someplace twice within 24 hours I won't argue about transport. This is true for those who require 2 amps in most cases and of course, those taking too long to come around.


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## Akulahawk (Sep 6, 2009)

46Young said:


> Like I've said before, if you have a chronic pt that does a poor job of controlling their disease, and typically refuses txp after a momentary correction by EMS, load them up after obtaining diagnostics/O2 admin and push some D50 enroute to the hospital. If the family questions you, tell them that you've seen similar pts in the past drop their BGL dangerously low despite oral/IV sugar, and you want them to be seen at the hospital before they suffer unbreakable seizures and/or irreversible brain damage (or death!) as a result. Put the fear into them. Legally circumvent the whole decisional capacity refusal thing.
> 
> I've played the whole "drink some juice, eat a sandwich, check the BGL 95 times while onscene" thing way too many times. If one round of oral intake doesn't work, it's txp time. And if someone needs Glucagon, it's really no question at that point.
> 
> Besides, if someone's BGL has dipped with no discernable reason, such as a fever, increased activity, missing a meal, etc, an attending's eval is definitely in order.


Being that I rarely like to sit on scene... and I do NOT want to be trying to manage diabetics (especially brittle ones) with the few tools we have available, I'd most likely prefer to load, go, treat en-route. At least the patient will get an evaluation... before they AMA.


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## 46Young (Sep 6, 2009)

rescue99 said:


> I'd never lie to a patient (or family) to achieve my own end goal. Just do a shake n wake, check the patients glucose, take new vitals and make a transport decision. If I've been someplace twice within 24 hours I won't argue about transport. This is true for those who require 2 amps in most cases and of course, those taking too long to come around.



Who's saying that I'm lying? I'm merely advising the family of the possible (real) consequences of refusal of further Tx/Txp. Any good medic will put the fear of death into a pt wishing to refuse if their condition is serious. If the pt generally takes good care of themselves and had a slip up, no worries. Take a look around and see how well they're taking of themselves from a lifestyle standpoint. If the pt is a frequent flier who has shown profound disdain and apathy (vs neglect from caregivers, a totally different issue) toward their disease, I'm going to employ the above tactics. They look to us to fix the problem repeatedly, rather than take an active role in managing their condition. After having to spend repeated nights at the ED, I've seen many change their tune.

There's nothing negligent about performing interventions enroute to the hospital, provided that they're stable enough to make the trip to the bus. Treat an arrest, a severe asthma/COPD exac, APE, MI, etc in the house, absolutely. An altered diabetic with an adequate BP/RR/airway/pulse will certainly survive the trip out to the bus. It's all implied consent until you bolus them out of AMS, and by that time you're halfway to the ED. They're certainly not going to have you stop the bus, sign a refusal, and hike it back home.


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## austinmedic77 (Sep 9, 2009)

while you may not be lying you are at minumum being purposely evasive and misleading (and depending on definition lying may not be a stretch).  Not to mention unethical and potentially harmful by withholding neccesary treatment in order to keep this pt obtunded to meet your personal goal of txp.  While I will not argue that this patient should be transported, if for nothing else then to ensure a followup with an endocrinologist for medication adjustment and increased monitoring.  However, you are saying that you would justify withholding tx so that you could tell the family about the "what if's" when you are in fact increasing the likelyhood of these conditions ensuing through your actions.  Do it the right way spend the time needed with the pt and family to explain the need for txp include all of the possibilities and possible negative outcomes then allow them to make an informed decision. This is a basic pt right in almost all developed nations.  It may not be what you want the outcome to be but your alternative is unacceptable.  If you are unhappy about having to come to the pt's house to help them, then find another job this isnt the one for you.  It's not our place to make these decisions for them.  If the only thing preventing a patient from making an informed decision is our refusal to treat the cause of their condition when we have the ability to do so then the law and intent of the law are being circumvented.  Yes, explain the benefits of txp and the consequences and "put the fear of god" into them as you put it but don't resort to unethical behavior to essentially make a point and try to impress your opinion of the pt's actions on them.  What do you do when your pt that you now put in your rig and medicated them enroute becomes alert and now wants to refuse txp.  If you force them to go to the hospital you are kidnapping them, so do you now dump them on the side of the road.  That doesn't seem to be in their best interest.  Or do you lead them to believe that now that they are in your truck they no longer have the right to refuse treatment and transport?  Or worse yet are you withholding neccesary tx until right as you pull up to the dock at the ER so that the pt doesn't have the ability to exercise their right to refuse tx.  Any of the above are unethical and could border on illegal depending on the option you are participating in.  Ok I'll get off my soapbox its just the "burned out paragod" mentallity aggrivates me immensly.


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## 46Young (Sep 11, 2009)

austinmedic77 said:


> while you may not be lying you are at minumum being purposely evasive and misleading (and depending on definition lying may not be a stretch).  Not to mention unethical and potentially harmful by withholding neccesary treatment in order to keep this pt obtunded to meet your personal goal of txp.  While I will not argue that this patient should be transported, if for nothing else then to ensure a followup with an endocrinologist for medication adjustment and increased monitoring.  However, you are saying that you would justify withholding tx so that you could tell the family about the "what if's" when you are in fact increasing the likelyhood of these conditions ensuing through your actions.  Do it the right way spend the time needed with the pt and family to explain the need for txp include all of the possibilities and possible negative outcomes then allow them to make an informed decision. This is a basic pt right in almost all developed nations.  It may not be what you want the outcome to be but your alternative is unacceptable.  If you are unhappy about having to come to the pt's house to help them, then find another job this isnt the one for you.  It's not our place to make these decisions for them.  If the only thing preventing a patient from making an informed decision is our refusal to treat the cause of their condition when we have the ability to do so then the law and intent of the law are being circumvented.  Yes, explain the benefits of txp and the consequences and "put the fear of god" into them as you put it but don't resort to unethical behavior to essentially make a point and try to impress your opinion of the pt's actions on them.  What do you do when your pt that you now put in your rig and medicated them enroute becomes alert and now wants to refuse txp.  If you force them to go to the hospital you are kidnapping them, so do you now dump them on the side of the road.  That doesn't seem to be in their best interest.  Or do you lead them to believe that now that they are in your truck they no longer have the right to refuse treatment and transport?  Or worse yet are you withholding neccesary tx until right as you pull up to the dock at the ER so that the pt doesn't have the ability to exercise their right to refuse tx.  Any of the above are unethical and could border on illegal depending on the option you are participating in.  Ok I'll get off my soapbox its just the "burned out paragod" mentallity aggrivates me immensly.



Find another job, burned out paragod, whatever. I get paid well, I enjoy my work, and I don't plan on going anywhere any time soon.

 I don't see how I'm being evasive or misleading if I'm advising all possible risks and consequences relating to refusal of further tx/txp to the hospital. It's what we're supposed to do each and every time a pt wishes to refuse. It's required for the pt/family to be fully informed, nothing less. I always mention death as a possible consequence when applicable. That's where the "fear of god" thing comes into play.

If EMS is fixing a diabetic 5-6 times a week or more for months on end, something is obviously wrong, no? You're a long time diabetic, you should know that. The pt may need their meds adjusted, or maybe they need a plan for lifestyle adjustment or dietary guidelines. Or, as you suggest, I could just keep giving them a quick fix and help hasten their degeneration as in PVD, CAD, HTN, renal failure, CVA's, MI's, amps, numerous trips to the hyperbaric chamber for wound care. Or death, like I tell the family, if they go hypoglycemic yet again and no one's there to summon help until it's too late.

In my experience, those that I've transported a few times per my tactics have taken better control of their disease as a result. I find a way to get them to the ED so they can start taking better care of themselves, not because I'm tired of running them. I come to work to run calls. Fixing them up every day isn't really helping them. In reality, it's hurting them by facilitating the progression of the disease and it's related comorbidities.

If I need to take them to the bus while altered (not obtunded, as I'm not going to risk brain damage and such by withholding tx if they're that bad off) to facilitate txp to get them definitive care, or at least have them take better care of themselves to avoid repeat trips, then that's what I'm going to do.

None of this applies to the diabetic pt that has occasional dips in BGL. I'm more than happy to sit onscene and straighten them out with P.O. intake if possible. However, it shouldn't take over an hour to stabilize their BGL. Txp is strongly suggested via advisory of risks/consequences, "fear of god" and all.

If none of this jives with you, it's really none of my concern.


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## austinmedic77 (Sep 11, 2009)

if they are altered there is brain damage occuring and withholding treatment in order to force them into TXP is unethical regardless of their mental status.  I advocate discussing all possible outcomes including death if appropriate and explaining what they are doing to their brain and the rest of their body by having their sugar continually fluctuate low in this case and high when we don;t see them.  That being said the decision of transport is still theirs.  Again i ask what about the patient you just woke up that now wants out? do you let them out there (which is what you legally should do) or do you noe let them exercise their right to refuse because they are in your truck.  You say you want to be honest with them about the consequences of how they manage their disease (and I truly believe you) then in the next breath are at minimum evasive about their tx and txp options.  The fact remains that an altered patient and an obtunded patient are both experiencing cellular damage, yes not to the same degree, but they are all the same and both require immediate intervention.  You dont withhold O2 on an altered patient until you get them to the truck or adenasine to an SVT pt do you.  No I'm sure you don't, but in your opinion its ok for that diabetic because they are only altered and not obtunded for the sole purpose of forcing txp on someone that if treated would be fully capable of making an informed decision.  Hey I'm not gonna tell you how to practice as you don't work for me or in the same system as I do, but what you are doing whatever your motivation is unethical and in some instances possibly illegal.

Like I said do as you wish and what your medical director allows you to but all it will take is one educated pt (and yes educated people don't manage their disease well just like some uneducated folks, a lot of diabetic md's are common offenders) and you will lose a law suit and possibly your license no matter where you live.  My statements aren't any of your concern as I don't live near you and won't have to ever treat me however, dismissing someones rights because you have had to run them 5 times a week isn't the right answer either.


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## 46Young (Sep 11, 2009)

When dealing with these chronic pts, I let them know beforehand, "If this keeps going on, I'm going to start treating you in the bus as we leave for the hospital". I shoot straight from the hip, and don't look to intentionally deceive my pts. These pts and I are thoroughly familiar with each other after frequent interactions. They've been advised of risks/consequences numerous times. I tell them that I'm going to do what I need to do to get them help, as it can't keep going on llike this. Now, if my pt tells me that I'm kidnapping them, or tell me something along the lines of "You had better not try and take me out to the ambulance before fixing me up next time", I won't do it.

Getting them to definitive care and therefore better control of their disease is of much more benefit to the pt than treating them on a sometimes daily basis, which results in cumulative brain injury from the numerous hypoglycemic insults. I could drop a lock in the house and push D50, or I could take the 90 seconds or so to get them in the rig and do the same thing. A minute or two of delay in D50 admin vs sparing them injury from further frequent hypoglycemic episodes (minutes, hours before EMs is summoned) is of no comparison.

If and when they become alert during transport, and demonstrate adequate decisional capacity, the pt is aware that they can refuse further tx/txp. No sane person is going to ask to be let out halfway to the hospital, but I'll do it if they absolutely insist. I've let pts out of the back on their request after stopping during txp on several occasions, albeit for different reasons. I tell the pt that they are also free to go after we arrive at the ED but before going in to triage if they wish. We advise against it of course, but they know that they can just walk away if they want. But I'll tell them "Hey, since we're already here, why don't you just let the doc check you out and see if there's something wrong?"

Call it "ghetto" urban medicine or whatever (the majority of the medically ignorant/apathetic population resides in the inner cities, particularly in areas of poor socioeconimic standing in my experience), but it does get results, and it results in a better outcome for the pt, from a quality of life standpoint. I won't lose any sleep at night.


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## austinmedic77 (Sep 11, 2009)

I've made my point you have made yours and I will support your right to make you own decisions, your stated intent of getting them to the truck was to initiate txp so that they couldn't refuse after being fixed on scene and that is unethical.  I understand that you say you are doing it because you feel it is in the best interest of the patient in the long run but it isn't doing them any good now.  I understand your desired result and respect it I just don't agree with it as you don't agree with the point I am making.  So no hard feelings and none intended, your last post is drastically different then you OP and the implication that was read.  No worries just hope it doesn't bite you in the end that's all.


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## 46Young (Sep 12, 2009)

austinmedic77 said:


> I've made my point you have made yours and I will support your right to make you own decisions, your stated intent of getting them to the truck was to initiate txp so that they couldn't refuse after being fixed on scene and that is unethical.  I understand that you say you are doing it because you feel it is in the best interest of the patient in the long run but it isn't doing them any good now.  I understand your desired result and respect it I just don't agree with it as you don't agree with the point I am making.  So no hard feelings and none intended, your last post is drastically different then you OP and the implication that was read.  No worries just hope it doesn't bite you in the end that's all.



Thanks. I should have explained the intent of my actions during my earlier posts.


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## Akulahawk (Sep 12, 2009)

And all of this assumes that you're dealing with a hypoglycemic patient... in the hyperosmolar non-ketotic diabetic... or the patient in DKA... none of this will work... about the ONLY thing that most of us carry is NS or LR. What will that do for the patient? Well... dumping a liter in will dilute the BGL... thus reducing the serum osmolality... but this does NOTHING for driving glucose into the cells, where it's needed.

Generally speaking, ambulances don't have proper labs on board or insulin to properly begin to treat those conditions. It can take DAYS to get those patients back under proper control.


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