# Diabetic question



## remote_medic (Nov 16, 2008)

I'm a pretty new paramedic (but experienced nurse). Here is my question. A little while back myself and another medic rolled on a diabetic at around 3am. We find a 50 something lady in bed, drenched with sweat. Glucose was 14. She is awake, alert, orientated. Only sympton is the diaphoresis and she's tremulous. She is sitting up dangling in bed. Hubby called us because she was so sweaty. I'm the tech, my paramedic partner is the driver.

My experienced paramedic field preceptor partner grabs the equipment to start an IV. I ask him to wait because I want to try oral glucose/food first. He agrees reluctantly. Just then the fire dept (paramedic level) comes in and I have them recheck a sugar because I'm not believing my glucometer. Theirs reads 12. 

I get the patient to take a tube of glucose, her husband gets her a turkey and cheese sandwhich and a glass of OJ. 10 minutes later (after we clear the fire dept) I recheck her sugar and it's now reading 12. No change in mentation, no change in consciousness. My partner starts a line and we have the patient walk out to the rig. Once in the back we give an amp of D50 and her sugar comes up above 80. She agrees to transport. Patient is a long time insulin dependant diabetic, very well controlled. This is her first episode of hypoglycemia requiring EMS. No other new illnesses or symptoms. I'm thinking an accidental overdose on her insulin?

Here are my questions: 

1) Should I have gone directly to D50 because of her sugar or was I right to try food/oral first. Again I go back to treat the patient...not the equipment

2) Should I have waited longer before giving D50?

3) Would anyone's protocols have called for thimaine on this patient? (mine don't)

4) Any other comments? Suggestions?


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## Onceamedic (Nov 16, 2008)

I think food/oral is always best as long as the patient is alert and orientated enough to protect their airway.  D50 is extremely hypertonic and there is always the risk of tissue necrosis when administering it.

On the D50, did you check BGL after walking the patient to the ambulance?  There is nothing at all wrong with D50 AND food.  Often, D50 is given first (due to the LOC issue) but needs to be followed up with food.  D50 is not really that much sugar (25 grams or so, compared with 37 grams in a can of Coke) and will raise the blood sugar quickly, but it will fall pretty fast too if the patient doesn't eat.  

Thiamine is given whenever I suspect malnutrition.  If the patient is not alcoholic or appear anorexic or otherwise malnurished, then I do not give thiamine in a conscious patient.  I certainly consider thiamine in a coma cocktail.

That is my two cents worth..


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## remote_medic (Nov 16, 2008)

no, didn't check blood glucose after the short (30 or so steps to front door) walk. Probably should have but didn't. I'm more wondering what peoples thoughts were about waiting more time with her on scene before starting IV and giving D50 where she was essentially asymptomatic. At a blood glucose of 12 she has to be losing some brain cells I would think.


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## akflightmedic (Nov 16, 2008)

remote_medic said:


> no, didn't check blood glucose after the short (30 or so steps to front door) walk. Probably should have but didn't. I'm more wondering what peoples thoughts were about waiting more time with her on scene before starting IV and giving D50 where she was essentially asymptomatic. At a blood glucose of 12 she has to be losing some brain cells I would think.




Exactly! If cells are dying somewhere, then she isn't totally asymptomatic is she? She is simply symptomatic on a level you can not assess, right?

With that thought in mind, when they are that low, I have no issue giving them the D50 to perk them up and then staying with them while they eat. They need both as you are aware, as I do not expect a meal to greatly perk their BGL reading in your presence.

Thiamine use varies by region, in this case I would not have given it.

On another note, since you are a new medic, do not let others set the tone for your treatment or your habits; develop your own and stick to them when it is your call.\

This is purely food for thought as it stuck out in my brain and granted you may not have provided all relevant info.\

1. Did you assess cardiac as well? Diabetic, older woman feeling uneasy and diaphoretic. Yes, classic signs of hypoglycemia, but always do a complete check and make sure there is not something else beneath going on simultaneously.

Sometimes, it just is not black or white but you do not realize it until you peel an additional layer back and do not allow others around you to persuade you with their preconceived notions.

2. I am a huge fan of walking patients when prudent, but there are some that I just am not comfy with. Chest pain, altered LOCs and a few others get my full red carpet service regardless of the inconvenience on my behalf. In this scenario, you just caused a patient with a very low BGL to burn even more energy by exerting herself to walk to your truck and presumably step up into it. There are so many scenarios that could have gone wrong here, I simply can not list them, but I am sure you can realize what I am saying.


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## remote_medic (Nov 16, 2008)

I appreciate the feedback regarding walking the patient. I should be more concise...we walked her from her bedroom to the front door of the house where we had our main cot (all same level)...could we have used the stair chair? Absolutely we could have. In the future I will definitely consider it.

I did not do a 12 lead on her (but did put her on the monitor). I wasn't thinking cardiac patient.

Again, many thanks from this new medic...its a very different world on the streets


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## tydek07 (Nov 16, 2008)

Hey,

From the information you have provided us, I would would have gone the same route you did. If the pt is A&Ox3 I would always try food/drink first... as it is safer and more convenient. But, if her BS remained at 12, I would give an amp (even try 1/2 amp) of D-50 to bring it up to what she usually runs. If the pt is still A&Ox3, I would probably lean toward giving 1/2 amp and see where that gets us. 1/2 amp would be easier on the body and there really is no great need to just push the full amp if the pt is stable. Know what I am trying to get at? 

Remember that D-50 is just a quick fix, as others have stated, so no matter which route you take... the pt is going to have to eat in order to maintain proper BS levels. 

I know everyones body reacts differently in situations like this, but after a case like that I would be sure to test my AccuCheck meter to see if it is working properly. That way I know 100% sure that it is giving me an accurate reading.

Take Care,


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## MSDeltaFlt (Nov 16, 2008)

remote_medic said:


> I'm a pretty new paramedic (but experienced nurse). Here is my question. A little while back myself and another medic rolled on a diabetic at around 3am. We find a 50 something lady in bed, drenched with sweat. Glucose was 14. She is awake, alert, orientated. Only sympton is the diaphoresis and she's tremulous. She is sitting up dangling in bed. Hubby called us because she was so sweaty. I'm the tech, my paramedic partner is the driver.
> 
> My experienced paramedic field preceptor partner grabs the equipment to start an IV. I ask him to wait because I want to try oral glucose/food first. He agrees reluctantly. Just then the fire dept (paramedic level) comes in and I have them recheck a sugar because I'm not believing my glucometer. Theirs reads 12.
> 
> ...




Walking the pt is up to your assessment.  Glucose levels are not "even-stephen" throughout your entire body all the time, even though we are mostly water.  We have varying degrees of concentration when things change and at the speed in which they change *until homeostasis is reached* as made evident of the 12 sugar and her LOC.  It doesn't matter how you checked it; be it FSBS or whole blood.  The lady had more sugar in her brain than where you checked it.  As long as you didn't make her go on a hike in the mountains, you were fine.  30 feet or even 30 yards to the truck is not that far *as long as they're C-A-O X 3 or better, verbally appropriate, and can move all extremeties well.*

That being said, when the sugar's that low, regardless of how it was checked, I wouldn't even attempt oral.  I'd go straight to D50.  Get the sugar up.  Let the ER feed her.  Then she can go back home.  Remember that IV D50 does not last long, and your 1 amp only got it up to what?  80?  Punt going oral.  Go straight to D50.


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## bonedog (Nov 16, 2008)

Personally I would have trialed oral first as these patients need what viens they have.
D10W would be my choice for this patient as it is less hypertonic.

Silent MI must always be part of your differential with diabetics.

I always encourage transport so blood work can rule out ACS.

I have seen several occasions where the crew on scene's BG monitor hadn't been maintained and my readings were significantly different than theirs.

There is nothing wrong with input from your partner on treatment plan's, makes for better patient care as long as it is rational. I would never reject anyone's idea's before I heard them


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## akflightmedic (Nov 16, 2008)

bonedog said:


> There is nothing wrong with input from your partner on treatment plan's, makes for better patient care as long as it is rational. I would never reject anyone's idea's before I heard them




If this is referenced to my comments about developing your own habits and not letting others dictate, you have taken it out of context.

I was referring to the ones that show up and say "Oh it is just low BGL" and that is all they focus on. I also mentioned doing further assessments for underlying conditions to compliment the above statement.


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## bonedog (Nov 16, 2008)

akflightmedic said:


> On another note, since you are a new medic, do not let others set the tone for your treatment or your habits; develop your own and stick to them when it is your call.\
> 
> 
> 
> Sometimes, it just is not black or white but you do not realize it until you peel an additional layer back and do not allow others around you to persuade you with their preconceived notions.



10-4 taken out of context.

Having seen many new medics use bravado to camouflage their lack of experience/judgement, I feel they should attenuate their attitude and as you have stated do further assesment and not let others change your POV with thier preconcieved notions.

Always apply the two golden questions, what is the worst thing it could be and what part of the picture doesn't fit with your differential.


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## cprguys (May 17, 2009)

*hypo*

BLS before ALS!!!!!!  This patient was cao, why then did you go right to checking her blood sugar?  You stated that she was diapharetic?  I would have started with a cardiac assessment.  As I was obtaining pt history I would then have possibly checked her blood sugar.  blood sugar of 12 or 14 would have thrown up a lot of red flags with the direction of my treatment.  Remembering BLS before ALS I would also do my ABC's.  Airway patent now but what happens if I give oral glucose and the patient aspirates?  However does this mean I should go to D50?  Well if you are nervous that you may cause necrosis from the D50 then you can use glucagon IM.  There are appropriate times to walk a patient to the ambulance and inappropriate.   I was not there but from what you have said I think this was an inappropriate time to walk your patient to the ambulance.  However, with this all said, you made the decisions you made and good for you to stand up for yourself when you decided to give oral glucose.  Stick by your decisions.  The way you know that you did the right thing, did your patient make it to the hospital?  Did the doctor question your treatment?  Would you do the same thing if you had the exact same call?  Good Luck in your career.


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## mycrofft (May 17, 2009)

*Hypoglycemic seizures*

Blood glucose that low it is a surprise she did not seize. That was a very high likelihood. I've seen actual frank seizures at 21. While _my_ favorite oral tx, after a hit of oral glucose gell, is a PBJ or PBH (PB and honey), FS's below a certain point (see your protocols) need to be treated with seizure precautions, i.e., if she seized I would not want solid food in her airway nor walking.
Good point about not getting target fixated upon her diabetic status. Diabetics have CVA's, MI's, thyroid problems, etc as well. BLS before ALS, safety before all. Didn't do anything bad, might have been a little better.

Anyone have a specific tx for hypoglycemic seizure besides IV glucose?

Anyone bringing up the subject of Glucagon?


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## 46Young (May 17, 2009)

Be careful when advising family to feed pt. Our P.O. protocols only mention oral glucose, not food/drink. If the pt chokes on a sandwich or something per crew's medical advice, you're screwed legally. The pt had tremors and was diaphoretic despite baseline mental status. The pt's brain knows it isn't getting enough fuel, be it O2 or glucose, and had a subsequent adrenaline release. With a BGL so low, I wouldn't be going P.O. anything, especially turkey & cheese(slow absorption of protein/fats). this pt needs I.V. glucose yesterday. You were advised that the pt's BGL is typically well maintained, so something is seriously wrong. Glucagon will force the liver to give some glycogen up, but then the pt will have absolutely no reserves left. Prior to D50 admin, a full assessment is warranted. Long time diabetics in particular typically have comorbidities such as CAD, HTN, neuropathy, possibly masking a cardiac event. I'm suprised that the pt's BGL remained so low. I've only seen that with type 2's  on orals. Was there any other significant Hx such as cardiac S/Sx, fever, illness, etc?


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## AnthonyM83 (May 17, 2009)

MSDeltaFlt said:


> 30 feet or even 30 yards to the truck is not that far *as long as they're C-A-O X 3 or better, verbally appropriate, and can move all extremeties well.*
> 
> That being said, when the sugar's that low, regardless of how it was checked, I wouldn't even attempt oral.  I'd go straight to D50.  Get the sugar up.  Let the ER feed her.  Then she can go back home.  Remember that IV D50 does not last long, and your 1 amp only got it up to what?  80?  Punt going oral.  Go straight to D50.



Now, I don't know any calorie use to BGL conversions, but I imagine BGL of 12 isn't healthy. The fact they are alert/oriented does not necessarily mean all cells of her body have sufficient glucose (?). It would seem like we shouldn't deprive her of anymore reserves, despite brain and extremities checking out fine. Like you said, it might not all be evenly distributed. Some organs may be deprived (with BGL of 12, one has to assume it's so).


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## mycrofft (May 18, 2009)

*When a measurement is screwy, question the measurement too.*

I've seen repeated wrong fingerstick glucometry due to calibration of machine to electrode, oversqueezing the puncture site, and sometimes just because that machine's gone AWOL. If LOC and orientation are ok, one thnks about a low blood glucose being exaggerated.
IF LOC....some confabulating people can be very disarming, and especially if a family member is there prompting themas they do the rest of the time.

Where was I?


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## Melbourne MICA (May 18, 2009)

*Metric*

Can someone give me quick conversion - our RBSL's are measured in mmol/L and the normal range is about 4 -8. Under 4 we treat. Oral if GCS 15, glucagon IM if altered conscious state and if unconscious, IV 50% Dextrose - (we are going to 10% shortly).

Cheers

MM


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## fma08 (May 18, 2009)

Here's my question, wouldn't it take a little longer than 10 min for the sandwich to be digested and absorbed into the blood stream, at least enough to raise the BGL up a decent amount? The OJ is a little different story obviously, but for me personally, not seeing a big/any change in BGL 10 min after a sandwich isn't real surprising. I'd also agree with MSDeltaFlt, with a sugar that low, I'd want to raise it up quickly with D50 then go with the sandwich/OJ for a longer term solution after. Just my humble opinion. Sounds like you did a good job though, congrats on a well run call ^_^

And to the above post, it's mg/dl here with a normal range between 80-120 (according to the textbook, but obviously, treat the patient, not the glucometer)


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## Outbac1 (May 18, 2009)

Melb.. MICA

 12 mg/dl is about 0.66mmol/l. 4mmol/l is about 72mg/dl. So it was very low. I probably would have gone the D50 and food/drink route as well. My experience says OJ and food will take 10 - 20 min. for a noticeable rise in bgl to be apparant. OJ and pop(soda) are faster than food.  Glucagon seems  to take 10 - 20 min as well. 

 How to treat first seems to me to be a combination of pt presentation, diagonistics, and experience. 


Here is a web site for a converter http://www.childrenwithdiabetes.com/converter.htm


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## Melbourne MICA (May 18, 2009)

Outbac1 said:


> Melb.. MICA
> 
> 12 mg/dl is about 0.66mmol/l. 4mmol/l is about 72mg/dl. So it was very low. I probably would have gone the D50 and food/drink route as well. My experience says OJ and food will take 10 - 20 min. for a noticeable rise in bgl to be apparant. OJ and pop(soda) are faster than food.  Glucagon seems  to take 10 - 20 min as well.
> 
> ...



Thanks Outbac1 for the conversion  - I was just being lazy. By the way; interesting choice for an avatar - "outbac"  - considering most of sunny Oz is exactly that!!!

On the thread subject - this pt was 12-14mg/dl O/A so that is very low indeed. Quite remarkable actually that she was still with it. Our Dextrose 50% pts are usually around the 1mmol/L mark  - around about what she was.

So If I had treated this lady she would have got the 50% without question irrespective of the GCS. Complex carbos once the pts BSL rises is always a good idea I think. She isn't going to crash rapidly after the 50% IV so there is time to absorb the goodies from a decent meal.

Most long term diabetics are very conversant with their BSL fluctuations and the illness generally so an offer for transport is typically declined. If its new or other factors may be impacting we will encourage immediate further evaluation at A&E or worst case, with their local Doc/Endocrinologist ASAP.

I do agree with Mycroft and others as to BLS first. A Full expeditious assessment whilst preparing the IV goodies and taking relevant history including insulin, meals schedule, alcohol use, existing infections etc. It always pays to be thorough and methodical.

Small reflection here - it never ceases to amaze me how the same crap that is making me fat can turn around the brain so rapidly - the human body is a wonder to behold. Fuel to the fire.

If only we could burn off our fat as fast as we can burn off our sugars.

Thanks for the conversion and link once again.

MM


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## mycrofft (May 19, 2009)

*Ah, the brain..a "top fuel dragster" of organs.*

Runs on oxygen and sugar.
Sort of like a hummingbird.


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## Melbourne MICA (May 19, 2009)

*Bird Brain*



mycrofft said:


> Runs on oxygen and sugar.
> Sort of like a hummingbird.




In my case like an old buzzard may be closer to the mark.

MM


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## SoCal (May 19, 2009)

Kaisu said:


> (25 grams or so, compared with 37 grams in a can of Coke)



Not to be Nit Picky... but isn't D50 a 50% solution, if so then wouldn't an Amp be just 12.5g?


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## Outbac1 (May 19, 2009)

D50 is 50%. An amp of D50 is 50mls of solution. 100% solution is 1g /ml. Therefore 50mls with 25g glucose is a 50% solution.


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## SoCal (May 19, 2009)

Gotcha, ours is packaged differently... ohh well...


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## atropine (Jun 4, 2009)

sugar  sugar kisses


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## iclause (Jun 7, 2009)

For me being an insulin dependant diabetic for >20 yrs. I always give my paiteients oj & food to raise their blood sugar if there CAO, but if they aren't completely with it (not unconscious yet)...i go for the oral glucose inbetween the cheeks.  then i would go for D10, since i'm only an intermediate.  ofcourse, i would have a paramendic on their way if D50, if i was unable to raise it myself.  you really wont see a difference in blood sugar raise in 5 min or less... it takes a good 15 mins to see results... i know from experience...


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## djmedic913 (Jun 10, 2009)

I did not read every response given for this topic, so I may and probably repeat a few people.

You are asking us all to play armchair medic without being there and limited info.
with that said.

I agree with oral glucose and food 1st. many of have seen CAO patient with blood sugar levels (BGL) in the teens or even lower.

As you have said, you treat your Pt not your equipment. As someone else said BLS before ALS.

For question 2, should you have waited longer? tough to say. I think that comes down to your discretion. you were there and we were not. From what you have told us and the info given, I don't think it was bad...but as someone mentioned should always check bgl before D50...but D50 is not gonna ever makes thing all that worse even if their sugar was 500.

question 3: Thiamine was just removed from protocols this year. BUT I believe and many agree as well, as well disagree, but I believe Thiamine should always be given with D50 for more than the obvious reasons of malnutrition and alcohol. Thiamine does help to facilitate the glucose across the cell membranes. So I look at it as anything that will help their brains cells from dying.

question 4: in case with this that after eating and D50 and sugar still stayed low, transport (which you did). then the Monday morning medic questions, did you access for CVA, or anything else that help coz the low BGL, or diaphoresis? Did you put her on the monitor to take a look? any O2? again this all may have happened but info just omitted from story


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## austinmedic77 (Jun 20, 2009)

I am a long time diabetic and having a very good track record with regulating my bgl personally (in excess of 20 years) I will say that (and I have the support of my personal endocrinologist and medical director) that if you can raise that persons bgl with food then that is the way to do it keeping in mind that you need to operate with in the confines of your services guidlines.  Whenever you give glucose IV you are setting that diabetic up for days, weeks, even possibly months of getting their bgl regulated again.  Feed them that is what they need and remember that digestion takes time.  Until and unless your treatment plan would be to give them IO d50 if you could not get a line then oral is the way to go as long as they can protect their own airway as it sounds like your Pt could.  Just my 2 cents as I have a personal interest in this subject.


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## 46Young (Jun 20, 2009)

Point well taken. I've seen various methods for raising the pt's BGL. I've seen the typical OJ, a peanut butter & jelly sandwich, soda, and a turkey and cheese cold cut sandwich, and of course the glocose tube. I personally prefer OJ/cranberry/apple juice until BGL WNL, then a Pb&J or two, for maintenance. What do you recommend?


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## djmedic913 (Jun 20, 2009)

46Young said:


> Point well taken. I've seen various methods for raising the pt's BGL. I've seen the typical OJ, a peanut butter & jelly sandwich, soda, and a turkey and cheese cold cut sandwich, and of course the glocose tube. I personally prefer OJ/cranberry/apple juice until BGL WNL, then a Pb&J or two, for maintenance. What do you recommend?



I agree. BLS before ALS. If the Pt can swallow safely, feed them. I had 1 diabetic who told me milk helps get her sugar up. So milk she got and it worked.

After I get their sugar back up with whatever I used, I tell them to eat a real meal, more than just a sandwich.


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## 46Young (Jun 20, 2009)

Milk, huh? Sounds like a great idea. speaking of which, have you ever heard of the gallon of milk in one hour challenge? The one tsp of cinammon challenge, or the six saltines in one minute challenge? We're so immature at my station. It's awesome.


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## djmedic913 (Jun 20, 2009)

46Young said:


> Milk, huh? Sounds like a great idea. speaking of which, have you ever heard of the gallon of milk in one hour challenge? The one tsp of cinammon challenge, or the six saltines in one minute challenge? We're so immature at my station. It's awesome.



I have heard of the 6 saltines in a minute...tried it...failed it...lmao

just so 46Young & I don't get attacked again for some of our comments...these challenges have NOTHING to do with patient care or would be tried on patients...


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## SoCal (Jun 20, 2009)

djmedic913 said:


> just so 46Young & I don't get attacked again for some of our comments...these challenges have NOTHING to do with patient care or would be tried on patients...



Really?? My next shift was going to be entertaining too. Damn


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## 46Young (Jun 20, 2009)

No, I'm just going off on one of my frequent tangents. I like to have fun at work, as long as I'm not hurting anyone. the cinammon challenge is on youtube.


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## B.K. (Jun 20, 2009)

the Cinnamon challenge!!!
its intense. everyone try it


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## 46Young (Jun 21, 2009)

On a serious note, things like cinammon, fish oil, and intense excercise have been shown to improve insulin resistance. A type II diabetic would be better off replacing all of their refined carbs with fruits, vegetables, nuts, quinoa and such. Stop making your pancreas work so hard. Coupled with exercise, they would eventually be able to wean themselves off of oral hypoglycemics. Orals just allow the pt to keep eating as they have, which is typically a big part of the problem in the first place.


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