# Called for 40ish/M Unresponsive...



## NBfire841 (Aug 13, 2009)

I used to work for a service that ran a 24 hr truck and a 16 hr truck 7 days a week.  I worked Fri/Sat 16s so I just slept in a spare bunk sometimes.  Occasionally, I would get up with the 24 hr crew if they might need help.

Anyway, we were toned for a mutual aid call, 40ish male, unresponsive.  U/A, found pt laying supine in middle of kitchen floor, cool, pale, diaphoretic, snoring respirations @ 10 RR.  I announced that I'll get vitals, EMT & Medic told me no.  Thought to myself... ok, 2 EMTs and noone is getting vitals?  Wife states Hx of DM type I, awoke, went to kitchen.  Evidently to eat something.  Crew EMT checks CBG while Medic gets IV kit.  CBG = 413.  I asked if he used an alcohol prep, he said there weren't any in the glucometer so I got 1 out of the IV kit which he refused to take.  Pt seizes for approx 1 min, Medic got a 20ga RAC, we got a sheet under him and moved to stretcher, O2 @ 2lpm via NC, to unit.  

Crew EMT drives L&S, I'm back with the Medic.  Pt has not improved at all obviously.  4 lead = NSR about 64, NiBP = 80/60 range, SpO2 = 88%.  Pt seizes every 2 mins now, lasting about 1 min.  RR now 8, I ask "BVM?"  "No, OPA, NRB 15lpm"  ok.... Medic gets 18ga LAC.  Refuses to check CBG again, gives valium for seizures, seizures subside.  

We get to the ED, doc wants a CBG reading... 11.  11!!!!!  Hmmm... I think maybe someone should have gotten some D50 like 25 mins ago.  Pt was up and talking before we ever left the ED.  I don't work for that service anymore.  No one got reprimanded about that call.  No vitals in the house?  Trust the glucometer reading of 413 and NEVER checked again?  WTF??  What would anyone else have done in my situation?  I was still pretty new, but now I think i would handle that differently.


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## Shishkabob (Aug 13, 2009)

Holy hell, I'll make sure to never get sick in that town....


How'd that medic, let alone the basic, get their certs?


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## Ridryder911 (Aug 13, 2009)

Appearantly you handled right, you no longer work there. 

R/r 911


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## Sail195 (Aug 13, 2009)

thats unreal, wtf were they thinking?! I really don't see a way to justify that


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## NBfire841 (Aug 13, 2009)

I don't know how/why the call went as it did.  There is almost zero accountability at that service, unless the director decides he doesn't like you, normally for things that happen outside of your actual patient care duties.  I know several other EMTs and Medics that used to work there and they had similar experiences.


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## NBfire841 (Aug 13, 2009)

Linuss said:


> Holy hell, I'll make sure to never get sick in that town....
> 
> 
> How'd that medic, let alone the basic, get their certs?



I don't know about the EMT, but the Medic used to work for a company that did almost no 911 calls, mostly inter-facility transports.  That's no excuse though, he had to pass the national registry just like every other Medic.  He's the type that will send questionable things BLS, and at least thinks about sending mild SOB, dizziness, N/V, BLS even though the pt could benefit from ALS care.  Pure laziness.  My goal is to put in 8 or so more months in as a basic and start looking at a Paramedic program.  I surely don't want to have that kind of thing happen to me again.


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## firecoins (Aug 13, 2009)

just go for the medic.


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## MrBrown (Aug 13, 2009)

Alcohol wipes have glucose in them!!!!


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## rescue99 (Aug 13, 2009)

NBfire841 said:


> I used to work for a service that ran a 24 hr truck and a 16 hr truck 7 days a week.  I worked Fri/Sat 16s so I just slept in a spare bunk sometimes.  Occasionally, I would get up with the 24 hr crew if they might need help.
> 
> Anyway, we were toned for a mutual aid call, 40ish male, unresponsive.  U/A, found pt laying supine in middle of kitchen floor, cool, pale, diaphoretic, snoring respirations @ 10 RR.  I announced that I'll get vitals, EMT & Medic told me no.  Thought to myself... ok, 2 EMTs and noone is getting vitals?  Wife states Hx of DM type I, awoke, went to kitchen.  Evidently to eat something.  Crew EMT checks CBG while Medic gets IV kit.  CBG = 413.  I asked if he used an alcohol prep, he said there weren't any in the glucometer so I got 1 out of the IV kit which he refused to take.  Pt seizes for approx 1 min, Medic got a 20ga RAC, we got a sheet under him and moved to stretcher, O2 @ 2lpm via NC, to unit.
> 
> ...




Glad to know someone had a clue. Too bad it wasn't the one in charge! 
This medic needs the be taken off the road until his skills have been appropriately evaluated and remediated.


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## Tiberius (Aug 13, 2009)

This is why they say "Treat the pt. NOT the machine!"

Blood sugar should have been checked again. Pt. should have been bagged. 

I, too, would have left the employ of that service.


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## NBfire841 (Aug 13, 2009)

MrBrown said:


> Alcohol wipes have glucose in them!!!!



I was unaware of that.  I've never had an issue with that same glucometer before or after that call, both taking blood from the line and via lancet.  I'm thinking that the guy started to eat/drink something (OJ, cookie, etc.) before he went unresponsive, so he had a sugary substance on his finger, thus the crazy reading.  No way to confirm it now though.


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## NBfire841 (Aug 13, 2009)

Tiberius said:


> This is why they say "Treat the pt. NOT the machine!"
> 
> Blood sugar should have been checked again. Pt. should have been bagged.
> 
> I, too, would have left the employ of that service.



what scares me the most is that there is a very real possibility that the pt suffered at least some loss of brain cells, and that i wasnt yet sure enough of myself to speak up.   I guess I should be glad the wife didn't know any better


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## bstone (Aug 13, 2009)

MrBrown said:


> Alcohol wipes have glucose in them!!!!



They do? I took organic chemistry and I distinctly recall there being no glucose in alcohol. Primary, secondary or tertiary alcohols, methyl, ethyl, isopropyl or tertbutal all had zero glucose.

Am I missing something?

And it seems the nurses at allnurses.com say that alcohol gives a "false low".
http://allnurses.com/general-nursing-discussion/fingerstick-glucose-testing-220967.html


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## NBfire841 (Aug 13, 2009)

bstone said:


> They do? I took organic chemistry and I distinctly recall there being no glucose in alcohol. Primary, secondary or tertiary alcohols, methyl, ethyl, isopropyl or tertbutal all had zero glucose.
> 
> Am I missing something?
> 
> ...



The comments suggest that this is only the case if the finger is still wet with alcohol.  I prefer to take some blood from the line right before the medic puts a lock on it anyway. 1 less hole in the pt, less garbage to pick up, less restocking too!


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## bstone (Aug 13, 2009)

NBfire841 said:


> The comments suggest that this is only the case if the finger is still wet with alcohol.  I prefer to steal some blood right before the medic puts a lock on the line anyway. 1 less hole in the pt, less garbage to pick up, less restocking too!



Yeah, I noticed the drying advice. I'm going to start doing that.


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## atropine (Aug 14, 2009)

give these guys a break thier only emt's what else could they do. There was no paramedic on the rig if read the op right.


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## JPINFV (Aug 14, 2009)

atropine said:


> give these guys a break thier only emt's what else could they do. There was no paramedic on the rig if read the op right.



You might want to reread the thread and the original post again. There was a medic on board and no one is bashing the Basic.


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## daedalus (Aug 14, 2009)

NBfire841 said:


> The comments suggest that this is only the case if the finger is still wet with alcohol.  I prefer to take some blood from the line right before the medic puts a lock on it anyway. 1 less hole in the pt, less garbage to pick up, less restocking too!



You shouldn't do that. It is no wonder why we don't let most EMTs take blood glucose! Glucometer you carry on the truck are designed for capillary blood, not blood from a vein. If you do not believe me, check the user manuel for your glucometer, or call the manufacture and ask. They are very explicit and are not accurate with venous blood. I am pretty shocked and disappointed that your medic lets you do this.

MrBrown, why would alcohol wipes have a substance that supports microbial life in them? I do not recall glucose or any other carbohydrate as an ingredient in prep pads.


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## NBfire841 (Aug 14, 2009)

daedalus said:


> You shouldn't do that. It is no wonder why we don't let most EMTs take blood glucose! Glucometer you carry on the truck are designed for capillary blood, not blood from a vein. If you do not believe me, check the user manuel for your glucometer, or call the manufacture and ask. They are very explicit and are not accurate with venous blood. I am pretty shocked and disappointed that your medic lets you do this.
> 
> MrBrown, why would alcohol wipes have a substance that supports microbial life in them? I do not recall glucose or any other carbohydrate as an ingredient in prep pads.



I won't argue, I believe you.  However, the "no wonder" comment was unnecessary.  I was taught that by a medic.  I will not continue that practice, but how far off is it?  Just curious.  Learning things like this is why I joined this forum.


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## traumamama (Aug 14, 2009)

MAYBE SOMEONE SHOULD HAVE CHECKED THEIR BLOOD SUGAR:glare: THEY WERE OBVIOUSLY HAVING ALTERED MENTAL STATUS:excl:


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## NBfire841 (Aug 14, 2009)

traumamama said:


> MAYBE SOMEONE SHOULD HAVE CHECKED THEIR BLOOD SUGAR:glare: THEY WERE OBVIOUSLY HAVING ALTERED MENTAL STATUS:excl:



Did you read the OP?  Sugar was checked, but it was unanimously agreed upon (after the fact) that the reading was false for whatever reason.  It should definitely have been re-checked, but I wasn't running the show.


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## Ridryder911 (Aug 14, 2009)

traumamama said:


> MAYBE SOMEONE SHOULD HAVE CHECKED THEIR BLOOD SUGAR:glare: THEY WERE OBVIOUSLY HAVING ALTERED MENTAL STATUS:excl:



It was checked.. "_CBG = 413"_

With any abnormal results one should always double check though..... Blood pressure, FSBS, etc... 

R/r 911


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## NBfire841 (Aug 14, 2009)

Ridryder911 said:


> It was checked.. "_CBG = 413"_
> 
> With any abnormal results one should always double check though..... Blood pressure, FSBS, etc...
> 
> R/r 911



Indeed.  It is _almost_ humorous that the medic was so lazy he wouldn't even have _me_ check it again.  Almost.


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## traumamama (Aug 14, 2009)

Not the pt's blood sugar. The medic's blood sugar:excl: That would have been his only good excuse for not doing what he was supposed to do. Someone should have checked it. If it was ok then he should have had a full lobotomy!


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## NBfire841 (Aug 14, 2009)

traumamama said:


> Not the pt's blood sugar. The medic's blood sugar:excl: That would have been his only good excuse for not doing what he was supposed to do. Someone should have checked it. If it was ok then he should have had a full lobotomy!



ooooooh lol.  Yes, yes.  He is quite an altered individual.


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## Tiberius (Aug 15, 2009)

NBfire841 said:


> what scares me the most is that there is a very real possibility that the pt suffered at least some loss of brain cells, and that i wasnt yet sure enough of myself to speak up.   I guess I should be glad the wife didn't know any better



Exactly! I've seen some shoddy pt. care, but that is interesting.

As bad as it was to run with someone that holds a paramedic certification, as opposed to a running with a PARAMEDIC-if you get my drift, this can be a good learning experience. You'll learn from the card-holders what NOT to do, as well as acquiring some valuable knowledge with some good medics.


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## NBfire841 (Aug 15, 2009)

Tiberius said:


> Exactly! I've seen some shoddy pt. care, but that is interesting.
> 
> As bad as it was to run with someone that holds a paramedic certification, as opposed to a running with a PARAMEDIC-if you get my drift, this can be a good learning experience. You'll learn from the card-holders what NOT to do, as well as acquiring some valuable knowledge with some good medics.



hmm, I see your point.  I try to learn something on every call, even IFTs.  I definitely learned from this call.


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## Aliakey (Aug 17, 2009)

daedalus said:


> You shouldn't do that. It is no wonder why we don't let most EMTs take blood glucose! Glucometer you carry on the truck are designed for capillary blood, not blood from a vein. If you do not believe me, check the user manuel for your glucometer, or call the manufacture and ask. They are very explicit and are not accurate with venous blood. I am pretty shocked and disappointed that your medic lets you do this.



Normally I try to just lurk 'round here, but IMHO, that was a pretty harsh statement that EMTs should not take blood glucose measurements.  Our protocols allow them to not only obtain the measurement, but treat with Glutose (PO) or Glucogen (IM), depending on the patient's presentation.  ALS or MICU intervention is highly recommended when possible, but can be delayed out here in the "sticks" with nothing but cotton fields for as far as you can see.  Prior to any treatment though, any low reading must be confirmed with a second sample at a different site (another finger, whatever).  

Please be aware that there *are* several brands of glucometers that are specifically labeled for use with capillary or venous blood.  The _Accu-Chek Inform System_ comes to mind in the hospital setting, and the city 9-1-1 EMS system I work for also uses a glucometer specifically intended for both blood types (and includes umbilical and arterial blood, but I'm hoping not to play with either )

Now, you are correct that the manual and strip bottle should be checked first before assuming that glucometer is set up for multiple blood sources.  My personal glucometer (yeah, I'm a diabetic) takes only five or so seconds to give me a reading, and it is labeled only for capillary blood.  The glucometer on my ambulance takes forever to provide a reading, costs a heck of a lot more, and since this is hospital-based EMS service, obtained through the hospital inventory.  It's quality and functionality is very different to my own cheapo pocket meter.

While there are differences in the glucose readings of venous and capillary blood samples, it is in the order of about 10%, from my understanding with the lab folks.  If using a capillary blood only meter, the venous sample is going to probably read on that order higher. 

Even with that difference in mind...

Let's say your protocols indicate that you should treat for hypoglycemia if the patient is symptomatic and the blood glucose measurement is 70 mg/dL or below (keeping this simple, I'm going to disregard patients taking beta-blockers, etc.).  If you obtain a capillary sample that reads 60 mg/dL, you would probably treat with dextrose (oral), D50W, or glucagen (IM)... whatever is most appropriate if the patient was symptomatic, correct?  

Now, if the same patient's blood sample is obtained through the venous blood, your BGL reading could instead show as 66 mg/dL.  You'll probably still treat if the patient was symptomatic, correct?  It all falls under 70 mg/dL, so your butt is covered in the protocols.  Right???  Ummm.

If you are looking for that magic line of 70 mg/dL to determine if you will treat your symptomatic patient, then you are treating your monitor, not your patient.  For example, my own afternoon BGL is normally 150 mg/dL.  If I drop to 80 mg/dL, my glucose is low for me, and I am going to present as someone symptomatic for hypoglycemia even though it's above the protocol's magic line. Drop it any lower, then I'm a hellava fighter at 60 mg/dL.  Should you wait that long, even when you can clearly see my DM necklace and multiple brown dots on my fingertips?  In that case, good luck holding me down for a line, and it'll be quite a ride until the IM shot of Glucagen finally works.    The first thing I ask any diabetic patient who is conscious (and may be symptomatic) is what their average or normal BGL should be... what is expected for them.  I continue my assessment and decisions with that in mind.

Just my humble opinion and experience.


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## Hossifelter (Sep 11, 2009)

Aliakey said:


> The first thing I ask any diabetic patient who is conscious (and may be symptomatic) is what their average or normal BGL should be... what is expected for them.  I continue my assessment and decisions with that in mind.



I must say this is one of the easiest and smartest things I've heard in a long time. I'll have to remember this one. You are correct. Good friend of mine was near-comatose @ 90. He normally ran, he found out after this, in the mid-upper 200's, though. Prime example of pt. over machine treatment. Again, very good way to find a baseline normal. I do this with all my hypertensive pt's. Easy way to find out if it's something to worry about or just keep in mind.


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