# 32 yo Male - general illness



## NomadicMedic (Apr 6, 2017)

Dispatched at 0205 to a private residence for a 32-year-old male who is "not feeling well." Dispatcher says it may be a diabetic problem.

  You arrive to an apartment building. The caller's Apartment is on the second floor, nicely furnished. Clean. Very angry girlfriend meets you at the door. She says, "he does this stuff for attention all the time. And I'm sick of it."

 You walk into the apartment and see a guy sitting on the couch. Actually kind of sprawled there. There's a puddle from fresh vomit on the beige rug. And he just looks wiped out.

 You walk in and say, "Hey, I'm the paramedic. What's going on tonight?"

He says, "I don't feel very good..."


And go.


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## FLMedic311 (Apr 6, 2017)

Easy Turf.. lol


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## VentMonkey (Apr 6, 2017)

V/S? Most important and pertinent to this patient a BGL. H/ A/ M? Aside from DM. Is he Insulin dependent, does he take oral meds, or both? Any pain in his epigastrium or elsewhere?


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## DesertMedic66 (Apr 6, 2017)

Start of with a good set of vitals (BP, pulse, resp, SpO2, pupils). Medical history? Events leading up to the issue today? Drugs/alcohol? Would also like to get a BGL check and a 12-lead.


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## NomadicMedic (Apr 6, 2017)

FLMedic311 said:


> Easy Turf.. lol



Get on the radio, "medic 12... send me an AMB". Hahahaha


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## NomadicMedic (Apr 6, 2017)

OK. You get a set of vitals and it looks like this:

HR: 120
BP: 118/62
Resp: 28
Pupils: PERRL
BGL : "hi" 

He mumbles, "I took some insulin, I don't member how much. Either eight or 10 or 12 units of Humalog..."

He seems confused, asking several times if you were gonna take him to school. He also says he took some other medication. Maybe a pain pill?

 His girlfriend says he hasn't been taking care of himself and he hasn't had much to eat or drink or manage his blood sugar for the last couple of days. She's royally pissed. Stomping around and slamming doors. 

 He has a history of back pain and PTSD, for which he takes OxyContin, Klonopin, Valium, Cymbalta and some other meds that he can't remember.


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## VentMonkey (Apr 6, 2017)

NKDA? Load, place on cardiac monitor, SPO2 with waveform pleth, O2 @ 2 lpm N/C with ETCO2 if available. 

Establish IV access and give liberal fluids en route to the ED (500 ml NS FC) with repeat accuchecks as time permits; probably grab a 12-lead ECG en route to the ED, but not as high up on my list currently as rehydration therapies. Grab a second IV via lock, and also administer some Zofran IVP.


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## NomadicMedic (Apr 6, 2017)

You and your partner help him down the outside staircase to the ambulance and get him inside. He's really restless and really confused now. 

12 lead: Sinus tach at 130 with no ectopy or ST changes. 
SpO2 is 100% on ambient air. 
HR: 130
BP: 106/52
Resp: 30, non labored. Lungs clear. 
BGL: HI  (BTW, that's greater than 600 on my glucometer) 

He is an extremely poor historian. 

The critical access hospital is less than 10 minutes, or you can go to "the city", 40 miles away.


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## VentMonkey (Apr 6, 2017)

NomadicMedic said:


> You and your partner help him down the outside staircase to the ambulance and get him inside. He's really restless and really confused now.
> 
> 12 lead: Sinus tach at 130 with no ectopy or ST changes.
> SpO2 is 100% on ambient air.
> ...


Clearly he's in a metabolic acidosis---probably compensated, or a mixed disturbance, at this point---and cannot R/O HHNK based off of your glucometers reading. I'd head for the critical access, reassess en route, if he remaines agitated transport to the closest; if he perks up, divert to the city.

He needs an insulin gtt, a full set of lab work, and quite possibly potassium; that's all I got for now. Can we get a temp en route, and/ or is he abnormally hot to the touch?


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## NomadicMedic (Apr 6, 2017)

VentMonkey said:


> clearly in a metabolic acidosis, and cannot R/O HHNK at this point (based off of your glucometers reading). I'd head for the critical access, reassess en route, if he remaines agitated head for the closest, if he perks up, divert to the city.
> 
> He needs an insulin gtt, POC, and quite possibly potassium; that's all I got for now. Can we get a temp en route, and/ or is he abnormally hot to the touch?




He not nauseous, so you hold off the Zofran. Access is an 18g in the left forearm and 1000ml of NS running wide open. A temporal temp is 97. Off to the CAH you go.


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## VentMonkey (Apr 6, 2017)

He's vomited once (that I know of) already, 4 mg of Zofran can't hurt.


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## E tank (Apr 6, 2017)

NomadicMedic said:


> He not nauseous, so you hold off the Zofran. Access is an 18g in the left forearm and 1000ml of NS running wide open. A temporal temp is 97. Off to the CAH you go.



Slight derail alert....If I had a balanced salt solution, I'd give that over NaCl every time. Hyperchloremic acidosis is a thing and I can't believe we're still giving patients that stuff, let alone ones that might be acidodic. 

This isn't a personal criticism, Nomad, it's a system thing and a lot of systems need to catch up. Nothing you're not aware of, I'm sure. 

Carry on...


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## captaindepth (Apr 6, 2017)

Just jumping in here,

What prompted the pts girlfriend to call? How quickly did he become "wiped out" and "not feeling very good?" Did girlfriend witness any seizure like activity, falls, trauma, other recent illnesses prior to this event? He almost sounds postictal from the mentation description of him throughout the call so far. Clearly he is hyperglycemic and the treatments mentioned so far sound on point and absolutely appropriate, but I feel like something is missing. Was there a count on the remaining pills in his medication containers? He is definitely on some heavy hitters with a pretty good amount of Benzos as well as Oxycontin. How were his pupils? Any sings of oral trauma? Any drugs/alcohol in the house? And also if girlfriend states "He does this kind of thing all of the time!" Then what has been the reasons (other than piss poor diabetes management) in the past? How does he look during this event compared to past events? 

I know I just asked more questions then answered but I feel like there is a curveball somewhere in here.

p.s.
If I have a P-student with me, I'm instructing him to smell the pts breath for acetones....... and vomit nastiness


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## DrParasite (Apr 7, 2017)

skin warm and dry?  or hot and moist?

honestly, if his temp was a little higher, i'd be thinking infection that has been left untreated for too long


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## NomadicMedic (Apr 7, 2017)

So, you guys are right on. It was totally a DKA call to me. Truck->fluid->Hospital. I didn't even think it could be anything else.

Later on the morning I was sent on a stat transfer from my hospital to the ICU in the city.

Not only was he in DKA, turns out he was also septic, with a lactate >8, elevated white count and creatinine double. Bacterial pneumonia, and in fairly bad shape. I transported him with insulin, zosyn, vancomycin and maintenance fluid running.

His girlfriend minimizing his reported illness and his drug use were big distractors. I didn't do anything wrong with his treatment, but I certainly tunnel visioned on the DKA.

I guess I shared this scenario as a "it wasn't what I thought" experience.

If I had a lactate pro in the truck I would have got a POC lactate and bypassed the local CAH.


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## E tank (Apr 7, 2017)

NomadicMedic said:


> If I had a lactate pro in the truck I would have got a POC lactate and bypassed the local CAH.



A pretty high lactate isn't uncommon in DKA. How would you have teased out sepsis from that? Even given that, I'd still think closest would be a defensible call, given what you knew already.


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## NomadicMedic (Apr 7, 2017)

E tank said:


> A pretty high lactate isn't uncommon in DKA. How would you have teased out sepsis from that? Even given that, I'd still think closest would be a defensible call, given what you knew already.



I didn't realize that. I just googled up some studies. Thanks. And honestly, I might have only had a higher index of suspicion. The treatment would have still been fluid and hospital. 

Our local transfers just about everything, I'm thinking he probably should have gone to the city straight off the bat.


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## E tank (Apr 7, 2017)

NomadicMedic said:


> I didn't realize that. I just googled up some studies. Thanks. And honestly, I might have only had a higher index of suspicion. The treatment would have still been fluid and hospital.
> 
> Our local transfers just about everything, I'm thinking he probably should have gone to the city straight off the bat.



Yeah, maybe so, but the other thing is that his sepsis may not have really declared itself clinically until you dropped him off.  Sounds like the lid came off when you began treatment for DKA and moved him. CAH's should be prepared to take, treat and discharge a "routine DKA". Maybe just a regional thing...


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## NomadicMedic (Apr 7, 2017)

Fair enough. I think our local's capabilities change day by day.


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## FLMedic311 (Apr 7, 2017)

NomadicMedic said:


> So, you guys are right on. It was totally a DKA call to me. Truck->fluid->Hospital. I didn't even think it could be anything else.
> 
> Later on the morning I was sent on a stat transfer from my hospital to the ICU in the city.
> 
> ...



Dispatch this is M12, go ahead make that amb red! LoL, good job, great call thanks for sharing!  @E tank, great point out about the lactate!


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## SpecialK (Apr 8, 2017)

Easy as pie.  Simply based on his unrelenting tachypnoea and tachycardia and the fact has says he took an unknown quantity of insulin means I cannot leave him in the community or send him on down to the GP or local A&M .. the GP or A&M doc would run a mile at the sight of this bloke.

Now, as to what treatment I'd give him? I can't see anything specific, maybe a dribble of IV fluid if hospital was ages away.


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## Akulahawk (Apr 8, 2017)

SpecialK said:


> Easy as pie.  Simply based on his unrelenting tachypnoea and tachycardia and the fact has says he took an unknown quantity of insulin means I cannot leave him in the community or send him on down to the GP or local A&M .. the GP or A&M doc would run a mile at the sight of this bloke.
> 
> Now, as to what treatment I'd give him? I can't see anything specific, maybe a dribble of IV fluid if hospital was ages away.


Given that his BGL reads "HI" after taking some unknown amount of insulin, you really shouldn't leave him there. The tachypnea and tachycardia tell me that he's probably quite dehydrated. The CAH I worked at could easily stabilize him and get things rolling for a transfer to a more capable facility. We got these patients a few times per week and I got reasonably decently good at initial stabilization. 

My treatment en-route would have been bilat IV lines (because I know he's going to need them), and probably 1L wide open to start. Since our ambulances aren't allowed to carry insulin, I can't give it... 2nd liter will go up once the first one is done. I'd leave the 2nd line as a saline lock. 

As to destination decision-making, I probably would have gone to the tertiary facility because of the drug use as it could be messing with his head too, making him a DKA with possible OD (or at least intoxicated) because of the stuff he's known to take. It's only another 30 minutes and it gives me time to really reassess him as he's getting rehydrated. If he develops coarsening lung sounds, I'm not going to suspect fluid overload as I doubt I can overload him in 30 minutes using 1 liter of fluid, given his present state. I might start thinking aspiration pneumonia is developing. He did vomit and he's wiped-out. Aspiration could have happened.


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## NomadicMedic (Apr 8, 2017)

This is another of the ALS "bread and butter" calls. We all run these at least a couple of times a year. Its right up there with chest pain, diff breathers, abdominal pain of unknown origin and general malaise. 

Thanks for all the input.


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## SpecialK (Apr 8, 2017)

Akulahawk said:


> Given that his BGL reads "HI" after taking some unknown amount of insulin, you really shouldn't leave him there. The tachypnea and tachycardia tell me that he's probably quite dehydrated.



Hence why I said I would not.  I'd leave him at home or send him down to the A&M if he hadn't taken the insulin and unknown other medicines.  If he just needed a bit of IV fluid and somebody to give him a lookey loo for a couple hours then the A&M could do it fine.  Most patient's don't want to go though because they have to pay whereas the hospital is free.  And I don't bloody blame them, rubbish idea charging people for healthcare ... criminal. 



Akulahawk said:


> My treatment en-route would have been bilat IV lines (because I know he's going to need them), and probably 1L wide open to start. Since our ambulances aren't allowed to carry insulin, I can't give it... 2nd liter will go up once the first one is done. I'd leave the 2nd line as a saline lock.



Oh good heavens no! If you pour IV fluid into him aren't you worried about upsetting his sodium osmoality and potentially causing cerebral oedema?


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## E tank (Apr 8, 2017)

SpecialK said:


> Oh good heavens no! If you pour IV fluid into him aren't you worried about upsetting his sodium osmoality and potentially causing cerebral oedema?



With a balanced salt solution? Besides, that's a rare pediatric complication. 20-30 kg of crystalloid will definitely not hurt this guy. He needs the fluid.


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## medichopeful (Apr 8, 2017)

VentMonkey said:


> Clearly he's in a metabolic acidosis---probably compensated, or a mixed disturbance, at this point---and cannot R/O HHNK based off of your glucometers reading. I'd head for the critical access, reassess en route, if he remaines agitated transport to the closest; if he perks up, divert to the city.
> 
> He needs an insulin gtt, a full set of lab work, and quite possibly potassium; that's all I got for now. Can we get a temp en route, and/ or is he abnormally hot to the touch?



What's your thinking on HHNK as complared to DKA Vent?  If you're thinking that he's in metabolic acidosis, I'd lean more towards DKA than HHNK.

Any idea what the EtCO2 was?  And do we have access to an iStat by any chance?


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## VentMonkey (Apr 8, 2017)

medichopeful said:


> What's your thinking on HHNK as complared to DKA Vent?


Aside from an extremely high BGL, which can hardly be confirmed via accucheck alone, not much. It's merely something I could not, or would not rule out.

This kind of patient made for a good learning experience with interns I've had, as I would throw HHNK at them just to get their wheels turning.

Will it change our treatment modalities? Hardly, but nonetheless, these are the sought after interesting medical cases in my book.


medichopeful said:


> If you're thinking that he's in metabolic acidosis, I'd lean more towards DKA than HHNK.


Generally agreed, though I'd argue a patient in HHNK would present as metabolically acidotic in their own right in the absence of ketone production.

And again, the similarities in the prehospital setting are often too close to discern (though I suppose one could argue the rapid respiratory rate would favor more of a compensatory mechanism seen with a ketone byproduct over one with a "non-ketotic" presentation), nor should it matter with respect to prehospital therapies.


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## medichopeful (Apr 8, 2017)

VentMonkey said:


> Aside from an extremely high BGL, which can hardly be confirmed via accucheck alone, not much. It's merely something I could not, or would not rule out.
> 
> This kind of patient made for a good learning experience with interns I've had, as I would throw HHNK at them just to get their wheels turning.
> 
> ...



I definitely agree that with prehospital therapies it wouldn't matter (unless we had more info, like labs and ABGs).  The RR is borderline, so I don't think there's anyway to tell without lab work like you said.  I was just curious if I had missed something that you had picked up on!


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## VentMonkey (Apr 8, 2017)

@medichopeful not at all, I just like to keep my wheels turning. Also, here's a fairly straightforward question I pose to others on here:

If you had to intubate this patient, how would you go about managing their airways post ETI? What would your vent management goals be, and why?

@SpecialK the amount of crystalloids we'd typically infuse in these (adult) patients prehospital isn't enough to warrant cerebral edema. That said, the pediatric DKA population seems much more prone to this a lot sooner.


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## E tank (Apr 8, 2017)

Just for the sake of the conversation, as this guy is clearly a Type I diabetic, the odds of this not being DKA were pretty low.


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## StCEMT (Apr 8, 2017)

@VentMonkey standard tidal volume, higher rate of maybe 25 since increases RR is to compensate for the acidosis. Don't want to take his compensatory mechanism away. 

If NS leads to worsening acidosis and we are dumping fluids, would there not be a role for bicarb mixed with fluid administration? I remember some mention of cerebral edema regarding this, but I don't know how prevalent that is in an adult. I'll look it up when I get home.


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## medichopeful (Apr 8, 2017)

VentMonkey said:


> @medichopeful not at all, I just like to keep my wheels turning. Also, here's a fairly straightforward question I pose to others on here:
> 
> If you had to intubate this patient, how would you go about managing their airways post ETI? What would your vent management goals be, and why?
> 
> @SpecialK the amount of crystalloids we'd typically infuse in these (adult) patients prehospital isn't enough to warrant cerebral edema. That said, the pediatric DKA population seems much more prone to this a lot sooner.



I'll be 100% honest, vent management is a weak point of mine and I'm currently studying up on it to improve my knowledge regarding them (at my current job, we only mess with FiO2 in emergencies and the alarm silence button, the most important button there is).

With that being said, I do know that for this type of patient, one of the things that can kill them or cause serious issues is underventilating them (thus completely eliminating or screwing up their ability to compensate for their metabolic acidosis through hyperventilation, leading to decreasing pH/increasing acidosis and then cardiac arrest).  Trying to at least match their pre-intubation minute volume would be extremely important, and EtCO2 would be important to make sure they are not becoming even more acidotic through CO2 retention (though ABGs in addition would be better).  A quick intubation would be necessary, too: you don't want to have any lengthy periods of apnea (again due to taking aware their compensatory breathing).  It's all about controlling their airway, while allowing the (now mechanical) breathing to continue to blow off CO2.  I also know that placing someone on a vent can also raise PaCO2, so that's something we'd have to consider, and we might need to even increase their minute volume to cancel this out.


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## VentMonkey (Apr 8, 2017)

StCEMT said:


> @VentMonkey standard tidal volume, higher rate of *maybe 25* since increases RR is to compensate for the acidosis. Don't want to take his compensatory mechanism away.
> *You don't want to arbitrarily guesstimate these patients RR, though you're on the right path by increasing their  rate (f).*


I'll let others chime in if they so wish.


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## Handsome Robb (Apr 8, 2017)

Get a pre-intubation EtCO2 and titrate your RR to target that number. That's the number their body is happy at and has gotten itself to. Ultimately we need serial ABGs to truly managed him on a vent for any extended periods of time. 


Sent from my iPhone using Tapatalk


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## VentMonkey (Apr 8, 2017)

Handsome Robb said:


> Ultimately we need serial ABGs to truly managed him on a vent for any extended periods of time.


While true, a most accurate and up to date ABG would yield our target Ve, we can still calculate this patients RR in the field without POC ABG fairly accurately utilizing another formula.

Also, just a personal note:

I would not bother intubating this patient prehospital unless there was some inherent reason to such as evidence of aspiration, or impending aspiration.

They're compensating on their own, and this is one patient where an overzealous and aggressive airway management approach can be extremely detrimental. Their ultimate cure is not ETI, it is Insulin.


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## StCEMT (Apr 8, 2017)

@VentMonkey, it's not entirely arbitrary. All I know is I don't want to cut their rate in half. 25 is simply a starting place. Adjust their tidal volume from the generic male volume to something more appropriate, then adjust the rate to maintain their EtCO2 within a few points of what it was initially. Same concept as my dopamine shortcut, just trying to start close then dial it in.

ETI seems like it isn't often needed, at least never in the DKA cases I've come across. I'd rather avoid messing with them all together and let the docs do all the lab work ups.


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## VentMonkey (Apr 8, 2017)

StCEMT said:


> @VentMonkey, it's not entirely arbitrary. All I know is I don't want to cut their rate in half. 25 is simply a starting place. Adjust their tidal volume from the generic male volume to something more appropriate, then adjust the rate to maintain their EtCO2 within a few points of what it was initially. Same concept as my dopamine shortcut, just trying to start close then dial it in.
> 
> ETI seems like it isn't often needed, at least never in the DKA cases I've come across. I'd rather avoid messing with them all together and let the docs do all the lab work ups.


Right, but for the sake of continued conversation this patient has already vomited once. What if you did elect to divert to the tertiary hospital 40 minutes away, and they vomited again?

SGA's certainly have their place, however, this would not be one of them. What if the combativeness did not resolve as well? What if your service doesn't carry in-line ETCO2 NC's? Where would you come up with a starting point for goal directed ETCO2? How would you manage this patient once you realized it was "too late" to turn back, or not worth it to re-route to the CAH?


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## ERDoc (Apr 8, 2017)

One thing to remember with DKA is there is often some sort of precipitating cause.  Sure, medication noncompliance is common but infections are another pretty common cause.


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## Akulahawk (Apr 8, 2017)

SpecialK said:


> Oh good heavens no! If you pour IV fluid into him aren't you worried about upsetting his sodium osmoality and potentially causing cerebral oedema?


Actually no. What this patient needs is fluids. NS will do this just fine. He's going to need a LOT more than that. Chances are pretty good that his sodium level is low and 0.9% Saline will start bringing that up. In the short run I'm actually more worried about K+ loss. While an initial lab draw may show a relatively normal K+ level, as he's rehydrated, an underlying hypokalemia will likely begin to show. Sure the CAH can start doing K+ replacement but their ED may not think about doing that during their initial eval and tx of this patient. They'll be concentrating pretty closely upon getting the blood glucose level lower while they arrange for a transfer to that same "big" hospital that's 30 minutes away. Once the patient is there, their ICU will likely do a huge eye-roll, start doing K+ replacement, continuing insulin replacement while considering when to change over to something like 1/2 NS or D5 mixed in. They may take a few DAYS to fine-tune the patient, getting the sodium level, chloride level, K+ level, and even phosphorus all back to normal while maintaining relatively tight glycemic control. Catch the patient early enough and the K+ and phos derangements may not even occur...

Now if the patient was, say, fairly young (early teens or younger) then I'd be quite worried about cerebral edema but even then initial resus with NS isn't likely to kick-off cerebral edema. Continued use of it may. Repeat stat labs should help keep them from correcting the sodium levels too quickly.


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## StCEMT (Apr 8, 2017)

VentMonkey said:


> Right, but for the sake of continued conversation this patient has already vomited once. What if you did elect to divert to the tertiary hospital 40 minutes away, and they vomited again?
> 
> SGA's certainly have their place, however, this would not be one of them. What if the combativeness did not resolve as well? What if your service doesn't carry in-line ETCO2 NC's? Where would you come up with a starting point for goal directed ETCO2? How would you manage this patient once you realized it was "too late" to turn back, or not worth it to re-route to the CAH?



Suppose it depends on his mental status and ability to maintain his own airway.

An SGA wouldn't be my preference here, I'd rather not take the airway unless necessary and if so then SGA will just remain the backup. My service actually doesn't (for a while longer) have them, it is something I have wondered myself recently. Off topic, but I've been curious about the accuracy of having someone just blow on a ET end tidal adapter, but I have never actually tried this. Not that this is of any use in the case of ALOC.

Assuming I had no baseline to work with? Doctors recommendation, along with anything else I would want to know. While I've seen a few DKA cases, I haven't seen any at this level of severity where intubation and long term management was required on my end. Knowing when that time has come would be unfamiliar territory and 40 minutes gives me plenty of time to consult and proceed from there.


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## zzyzx (Apr 9, 2017)

As ERDoc has said, the fact that he was also septic is not surprising. I see a lot of DKA patients, and infection is often the underlying cause.


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## Brandon O (Apr 9, 2017)

Bear in mind that the sodium is not usually truly low in DKA. There may, however, be pseudohyponatremia, which is not clinically important except as a confounder.


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## RocketMedic (Apr 22, 2017)

Special K, y'all leave DKA at home routinely?


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## MikeC (Apr 27, 2017)

NomadicMedic said:


> Dispatched at 0205 to a private residence for a 32-year-old male who is "not feeling well." Dispatcher says it may be a diabetic problem.
> 
> You arrive to an apartment building. The caller's Apartment is on the second floor, nicely furnished. Clean. Very angry girlfriend meets you at the door. She says, "he does this stuff for attention all the time. And I'm sick of it."
> 
> ...


 
As a BLS crew assuming no ALS is available,

I'd ask him questions while another EMT would do obtain vitals (pulse ox/SpO2, Pulse/resp rate, blood pressure, blood glucose reading,).

- I'd ask him first an open question if he knows why he might be feeling like this. His response would help me determine a general impression, level of consciousness, etc. I'd be observing for any aphasia, altered mental status, skin color, temp, etc.

- I'd ask of any symptoms, OPQRST, SAMPLE, if he has a history of diabetes.  I'd pay special attention to last oral intake and what specifically was ingested and when. I'd ask him when he threw up, how much looks expelled, color, all that fun stuff.

By the end of these questions, we should have vital signs established. I'd have a better understanding of what specifically needs treated.

We'd load him in the ambulance and head to the closest appropriate facility.


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## MikeC (Apr 27, 2017)

NomadicMedic said:


> OK. You get a set of vitals and it looks like this:
> 
> HR: 120
> BP: 118/62
> ...


 
Ok so Ketoacidosis is the field dx. I'd call for ALS if available to meet en route who would most likely administer Glucagon or D-50.  EMT administers oral glucose while en route to closest hospital.


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## NomadicMedic (Apr 27, 2017)

MikeC said:


> Ok so Ketoacidosis is the field dx. I'd call for ALS if available to meet en route who would most likely administer Glucagon or D-50.  EMT administers oral glucose while en route to closest hospital.



Hold up a second. Why would you give him sugar?


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## GMCmedic (Apr 27, 2017)

MikeC said:


> Ok so Ketoacidosis is the field dx. I'd call for ALS if available to meet en route who would most likely administer Glucagon or D-50.  EMT administers oral glucose while en route to closest hospital.


Why do you suspect ALS would administer glucagon or D50 to a DKA patient whose BGL is greater than 600? 

Based on the description oral glucose is contraindicated in this scenario......for more reason than one. 

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## MikeC (Apr 27, 2017)

correction no glucose should be administered, and insulin not glucagon would be indicated.


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## DrParasite (Apr 27, 2017)

MikeC said:


> correction no glucose should be administered, and insulin not glucagon would be indicated.


I'm curious, how many ALS agencies do you know of that would treat this person with Insulin?  I don't know of many that even carry it on their trucks.

I know several ER docs that wouldn't even do that, they would let the endocrinologist investigate why it's so high and lower it at a much more controlled pace.


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## MikeC (Apr 27, 2017)

DrParasite said:


> I'm curious, how many ALS agencies do you know of that would treat this person with Insulin?  I don't know of many that even carry it on their trucks.
> 
> I know several ER docs that wouldn't even do that, they would let the endocrinologist investigate why it's so high and lower it at a much more controlled pace.


 
No insulin would have to be given at the ER. I don't know of any ALS that carries it either.


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## StCEMT (Apr 27, 2017)

I think our CCT trucks carry insulin. If they do, I don't know how often they actually use it.


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## medichopeful (Apr 27, 2017)

MikeC said:


> No insulin would have to be given at the ER. I don't know of any ALS that carries it either.



Probably not a good idea to start giving insulin without a full electrolyte panel.  The treatment for a "hi" BGL isn't necessarily just insulin.  It's slightly more complicated than that.


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## VentMonkey (Apr 27, 2017)

medichopeful said:


> Probably not a good idea to start giving insulin without a full electrolyte panel.  The treatment for a "hi" BGL isn't necessarily just insulin.  It's slightly more complicated than that.


This^^^. You need a starting point in which to base your BGL titration off of. Not to mention D5, or D10W alongside of the Insulin drip.

Cerebral edema is bad. Very bad.


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## NomadicMedic (Apr 27, 2017)

MikeC said:


> Ok so Ketoacidosis is the field dx. I'd call for ALS if available to meet en route who would most likely administer Glucagon or D-50.  EMT administers oral glucose while en route to closest hospital.




The bad news is, you would probably do this. You didn't realize that glucose, dextrose or glucagon was contraindicated until we pointed it out.

This is just one example of why I believe that EMT-Bs should not be the first level in a tiered response.


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## DrParasite (Apr 27, 2017)

NomadicMedic said:


> The bad news is, you would probably do this. You didn't realize that glucose, dextrose or glucagon was contraindicated until we pointed it out.


Agreed





NomadicMedic said:


> This is just one example of why I believe that EMT-Bs should not be the first level in a tiered response.


disagree.  Just because one EMT didn't know something, doesn't mean no EMTs know that.  I happen to know this, and I am pretty confident that most EMTs know it too.

If we are going for least common denominator, how many medic skills and drugs should be taken away because a medic somewhere doesn't know something, or makes a mistake?


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## DrParasite (Apr 27, 2017)

medichopeful said:


> It's slightly more complicated than that.


But only slightly


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## NomadicMedic (Apr 27, 2017)

DrParasite said:


> Agreeddisagree.  Just because one EMT didn't know something, doesn't mean no EMTs know that.  I happen to know this, and I am pretty confident that most EMTs know it too.
> 
> If we are going for least common denominator, how many medic skills and drugs should be taken away because a medic somewhere doesn't know something, or makes a mistake?



Sorry. I think most BLS providers lack the education to do anything more than very simple treatments (read: splints and ice packs) and most lack any sort of critical thinking skill that will determine transport decision or level of care needed. 

CPAP for cardiogenic shock? EpiPen for some diffuse urticaria on the trunk? Sugar for DKA? Narcan for a head bleed?

Let's teach EMTs how to drive safely. How to move patients safely and how to act more as a mobile CNA and limit their role to BLS IFT.


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## VentMonkey (Apr 27, 2017)

@DrParasite I agree we can't "blanket term" all EMT's as such, just like we can't do the same with all paramedics.

The sad fact of the matter--as is in life--is we cannot force anyone to take education seriously. So to apply this to even the prehospital environment basically boils down to  this:

You're only as good as your own ambition.

I cannot teach ambition, or self-motivation, but I can sure flick a pebble at an ocean of EMT's and medics who talk a big game, but do not deliver. Why? They have no internal drive, period.


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## FLMedic311 (Apr 27, 2017)

VentMonkey said:


> @DrParasite I agree we can't "blanket term" all EMT's as such, just like we can't do the same with all paramedics.
> 
> The sad fact of the matter--as is in life--is we cannot force anyone to take education seriously. So to apply this to even the prehospital environment basically boils down to  this:
> 
> ...



Absolutely agree in regards to ambition being important, simply stated you cannot not teach anything to anyone whom doesn't want to learn.  And you cannot make someone "Want" to learn, but you can make it a culture and use other types of social pressures to make this a norm.  It is not something you can do over night, it has to be grown and nurtured.. Admittedly no small or simple task, yet not out of the realm of possible.  



NomadicMedic said:


> The bad news is, you would probably do this. You didn't realize that glucose, dextrose or glucagon was contraindicated until we pointed it out.
> 
> This is just one example of why I believe that EMT-Bs should not be the first level in a tiered response.



Was actually stunned when I had first read the comment regarding Tx a DKA Pt with Glucose, and felt the same as you.  Because of what you and Ventmonkey had pointed out I agree that the tiered system is not ideal for Most systems.


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## FLdoc2011 (Apr 27, 2017)

DKA is one of the more time consuming/labor intensive things we treat acutely in the ICU.  As a medical resident in the ICU we spent many nights up trending electrolytes/glucose/metabolic panels every couple hours adjusting fluids and drips.  

From a prehospital standpoint I'd say start on fluids get to a hospital.    What's really needed is several hours or a night or close monitoring and frequent labs.


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## xterrabuzz (May 24, 2017)

It wasn't until I joined this forum that I realized that medics really do have a f**kin chip on their shoulder.  Let me fill you in on a little secret...there are also **** medics out on rigs that don't have a f**kin clue.  The guy makes a typo and NomadicMedic jumps all over his ****?  Really?  As an EMT-B and RN student and working for level 1 system as an ER tech and on the rigs and can tell you there is a hell of a lot more incompetent medics than basics.  You take a year class and think your god?  And guess what mister I work in urban area.....rural areas don't have a choice in most cases.   Sorry, the rural volunteers are not as brilliant as you NomadicMedic!  I see you are in education..when was the last time you were on a rig?


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## VFlutter (May 24, 2017)

Uh...that did not appear to be a typo but rather a profound lack of understanding of a basic medical concept. 

I see you are new to the forum. Don't poke the bears.


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## VentMonkey (May 24, 2017)

xterrabuzz said:


> when was the last time you were on a rig?


I'm pretty sure it was sometime last week, but I'll let him call it. Anyhow, you're the one who's coming across as having a major chip on their shoulder.


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## DrParasite (May 24, 2017)

oooo you work as an ER tech for a level 1 system?  so that makes you the nurses assistant right?  not really all that impressive..... the RN student isn't all the impressive either; come talk to me once you passed you nursing boards, and have earned your RN.

A typo is a misspelling....calling it insolin instead of insulin.   saying you would give sugar to a guy with a high BGL is not a typo, it's a lack of understanding to what is occurring with the patient, and potentially delivering a contraindicated medication.

I know quite a few idiot paramedics that I wouldn't let treat my worst enemy.  I know quite a few idiot EMTs that shouldn't even be on the ambulance.  And I know both who work in urban areas and some who work in the sticks.  Regardless of where you work, it's expected that the provider who show up has a competent grasp of the material for their level of certification; doesn't matter if they are paid or volunteer.

Maybe you should calm down a little bit, you seem to have an over inflated sense of self, and that won't help you when you do become an RN, and you disagree with a doctor regarding a treatment, saying "well I'm a nurse" and he says "well I have MD after my name, so until you do too, STFU and do what my order tell you to do."

BTW, NomadicMedic works full time on a truck, so I'm guessing the last time he was on a truck was in the last day or two.  I'm an EMT with 10 years of urban experience, and teach EMT classes.  And if any of my students ever did that in a skill station, it would be an automatic fail for that scenario.  If they did it in the field, they would likely get taken off the truck and sent to a clinical educator for remediation.


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## NomadicMedic (May 24, 2017)

Yikes. 

Well, I was last on a truck over the weekend and I'm on my way in to work my night shift in an hour or two. So, I guess it's been about 3 days. 

I think the other guys covered it all. Is there anything else? 




xterrabuzz said:


> It wasn't until I joined this forum that I realized that medics really do have a f**kin chip on their shoulder.  Let me fill you in on a little secret...there are also **** medics out on rigs that don't have a f**kin clue.  The guy makes a typo and NomadicMedic jumps all over his ****?  Really?  As an EMT-B and RN student and working for level 1 system as an ER tech and on the rigs and can tell you there is a hell of a lot more incompetent medics than basics.  You take a year class and think your god?  And guess what mister I work in urban area.....rural areas don't have a choice in most cases.   Sorry, the rural volunteers are not as brilliant as you NomadicMedic!  I see you are in education..when was the last time you were on a rig?


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## medichopeful (May 24, 2017)

xterrabuzz said:


> It wasn't until I joined this forum that I realized that medics really do have a f**kin chip on their shoulder.  Let me fill you in on a little secret...there are also **** medics out on rigs that don't have a f**kin clue.  The guy makes a typo and NomadicMedic jumps all over his ****?  Really?  As an EMT-B and RN student and working for level 1 system as an ER tech and on the rigs and can tell you there is a hell of a lot more incompetent medics than basics.  You take a year class and think your god?  And guess what mister I work in urban area.....rural areas don't have a choice in most cases.   Sorry, the rural volunteers are not as brilliant as you NomadicMedic!  I see you are in education..when was the last time you were on a rig?



Welcome to the forum!  Let me take a few minutes to give you some hints to make your stay more education and enjoyable:

1) Congrats on your accomplishments and furthering your education.  Seriously.  With that being said, if this is the attitude you have as a student, you're going to be in for a rather rude awakening.  Trust me, as an RN student and EMT-B you don't know as much as you think you know, and with that attitude nobody is going to care to listen to what you do know.

2) NomadicMedic is one of the more senior members on this forum.  As a new member, I'd treat him with more respect.  See point 1 for further information on this.  

3) There are plenty of typos in your response above, so I'm assuming that you know what a "typo" is.  It's possible that the glucose comment was a typo, but suggesting D50 or glucagon as well suggests that it is more a lack of understanding of the situation, or a failure to read appropriately (which we're all guilty of).  Either way, if we in the medical field make a mistake, we need to be called out on it.  That's how problems get fixed and we learn.

4) Ask questions, get involved, and learn from the posters on this forum.  If you check the attitude at the door, you'll be able to learn a lot from this place.

Hope this helps!


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## DesertMedic66 (May 24, 2017)

xterrabuzz said:


> It wasn't until I joined this forum that I realized that medics really do have a f**kin chip on their shoulder.  Let me fill you in on a little secret...there are also **** medics out on rigs that don't have a f**kin clue.  The guy makes a typo and NomadicMedic jumps all over his ****?  Really?  As an EMT-B and RN student and working for level 1 system as an ER tech and on the rigs and can tell you there is a hell of a lot more incompetent medics than basics.  You take a year class and think your god?  And guess what mister I work in urban area.....rural areas don't have a choice in most cases.   Sorry, the rural volunteers are not as brilliant as you NomadicMedic!  I see you are in education..when was the last time you were on a rig?


Oh this is going to be fun. 

Thank you for your insite EMT/ER tech. I think bed 3 just left and needs to be cleaned....


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## Akulahawk (May 24, 2017)

xterrabuzz said:


> It wasn't until I joined this forum that I realized that medics really do have a f**kin chip on their shoulder.  Let me fill you in on a little secret...there are also **** medics out on rigs that don't have a f**kin clue.  The guy makes a typo and NomadicMedic jumps all over his ****?  Really?  As an EMT-B and RN student and working for level 1 system as an ER tech and on the rigs and can tell you there is a hell of a lot more incompetent medics than basics.  You take a year class and think your god?  And guess what mister I work in urban area.....rural areas don't have a choice in most cases.   Sorry, the rural volunteers are not as brilliant as you NomadicMedic!  I see you are in education..when was the last time you were on a rig?


Actually, most of the folks here _don't_ have a chip on their shoulder. They're mostly very knowledgeable and professional folks. You're an EMT-B and RN student and you work as an ED Tech. Guess what? Most of the folks that chimed in are Paramedics, RNs, and currently work in the ED, ICU, or in the field (flight or ground). We have a couple of Physicians and a couple of PAs that grace our forum as well and I'm glad they're here! I'm an ED Nurse and a Paramedic that's Sports Med trained. Very unusual but thorough education. You really don't know what you don't know.

You, as an RN student haven't completed your education and EMT-B education is very, very basic. Once you graduate RN school, you _won't_ be ready to work on your own. You'll go through your initial orientation time and then you'll still have about a YEAR of steep learning curve. Then at some point, you'll meet a new grad and you'll see just how much you didn't know...


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