# Blood Glucose Testing Protocols/Standing Orders



## TheMowingMonk (Sep 13, 2008)

Hey Everyone,

I'm writing for a little help. Right now i'm trying to change the Protocols with one of my EMT squads to allow us to take blood glucose readings. I know title 22 in California states EMTs are allowed to check blood glucose. And i know one other organization similar to our in the area that does it but i haven't been able to get a hold of them. What I'm looking for is a protocol or standing medical order that another EMT squad uses for their EMTs to do blood glucose. Especially from a squad in California so i have something to kinda model the protocols I'm trying to get going after. So if any of you guys have copies of anything like this or have any info you could help me out with i would really appreciate it. Thanks


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## DenverEMT (Sep 13, 2008)

As an EMT-B from the Denver Metro area, I have to say that I strongly DISAGREE with our protocols for BGL's, well, more-so BGLs combined with the administration of Oral Glucose and D50

Now, in order to perform a D-stick, in the Denver area you must be "IV Certified". This basically means that you have taken a coarse that extends onto your EMT-B cert that allows you to start IVs. This certification is also what allows you to administer D50, without calling for a drug order. 

Without an IV cert, you are allowed to administer only Oral Glucose, which you must be given an order for my a physician.

The reason that I disagree with our protocol is because it's obviously very important to perform a BGL check on the hypo/hyperglycemia patient before administering a drug that will significantly raise the levels, however if you are not IV certified, you can still administer Oral Glucose, but cannot perform a BGL stick.   

I hope this makes sense......


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## uscgk9 (Sep 13, 2008)

So you basic EMTs can administer oral glucose but can perform a "finger stick" to verify that they are dealing with a diabetic problem?


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## johnrsemt (Sep 13, 2008)

Why do you feel you need to check blood glucose levels to give oral glucose?  

  If the patient is acting like their sugar is low, (altered, confused, etc)  and they can maintain their own airway, (not drooling all over themselves);  we just gave them oral glucose.
    If their BGL was already high,  it won't hurt them,  and if it was low it helped.

    Where I work now, the glucometers we carry are for inside use (don't work in extreme cold/hot temps;  but we can't convince management that the $3000 units don't work:  half the time that we check BGL's we get bad readings (the best was the 22,000), or failures.   So we check them once and give them oral glucose or D50.


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## pumper12fireman (Sep 13, 2008)

When our second out ambulance has to go on a call BLS, our d-sticks and oral glucose are standing orders. I personally have never given oral glucose without a d-stick first to back it up. I also like to take several en-route (x5-10min), usually the pt.'s mental status will improve, but the hospital likes to have them as well.


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## AnthonyM83 (Sep 13, 2008)

johnrsemt said:


> Why do you feel you need to check blood glucose levels to give oral glucose?



Don't think there's a need, but rather than spending time coaching an altered person to keep eating swallowing the glucose, time might be spent trying to get a better history from bystanders, etc. Again, it's not needed, but it's a convenient tool to eliminate suspicion of hypoglycemia. That's all.


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## TheMowingMonk (Sep 13, 2008)

I mainly want to use it as a diagnostic tools and to have it ready for the ERs, I have talks with the ER docs at our local hospitals and our squad asked if there is one thing the ER Docs want to know about a PT from prehospital providers what would it be and they consistently answer blood glucose levels. Since it is a diagnostic tool that actually tells you alot (Given that you equpiment works). like right now i have a medical director that is willing to give us the training that california requires and EMT-B to take to be allowed to do blood glucose, I just have to write the protocols and stuff then get the standing order from our medical director which is why im trying to hunt down an example of a protocol another squad uses so i have something to base mine off of.


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## mycrofft (Sep 13, 2008)

*Mowingmonk, I think you are asking about the standard procedures per se, not content?*

It and the rest of your SP's should follow a set format (What the procedure is, who can do it, where, under which circumstances [when], why [course of action based on your data]).

Probably the glucometer procedure should be part of the diabetic treatment SP as the "what", and maybe as treatment steps regarding pt with unknown hx but exhibiting seizures, obtunded/LOC. SP's need to be written starting  with the presenting problem (i.e., obtunded patient without history), proceed through the diagnosis, then result in the treatments keyed directly to each diagnostic. The directive as to how to do the glucometry should probably be a "policy and procedure" of your company.

Anyone can do a blood glucometry (the devices do not require a prescription), but you will need the SP to allow you to use it in treatment, and to help clue in people later on as to the company's policy.

The important thing about a SP is that no data gathering is done "just because"; it *has to* have a reason (c/o or S/S) _*and actions steps tied to the readings *_(at this blood glucose reading you will do that, if THIS reading you do THAT, etc.).

Go to your medical director for help. She/he's going to have to sign off on it anyway, no? The SP is, in essence, the medical director's order to a class of people employed by his/her company.

And while you are at it, write about five good test questions about it to be inserted into your company's SP refresher quiz.


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## DenverEMT (Sep 13, 2008)

I'd have to disagree that giving an already hyperglycemic patient glucose/D50 won't hurt them. Absolutely it will, especially if they are postprandial or present with a BGL over say 250mg/DL. High blood sugar also has more effect on major organs than low sugar does. Ketoacidosis may even develop if their sugar is pushed too high. 

I'd stay safe with every diabetic/AMS/drunk patient and still perform a finger stick, just to cover your own a**. Better safe than sorry






johnrsemt said:


> Why do you feel you need to check blood glucose levels to give oral glucose?
> 
> If the patient is acting like their sugar is low, (altered, confused, etc)  and they can maintain their own airway, (not drooling all over themselves);  we just gave them oral glucose.
> If their BGL was already high,  it won't hurt them,  and if it was low it helped.
> ...


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## TheMowingMonk (Sep 14, 2008)

Exactly why im trying to set-up the system so my service can start doing them. Thanks Mycroft, your post is very helpful, ill have to go over the guidelines with our medical director see what she things they should be but i think im getting the general idea going. but if anyone else has any more input im all ears, thanks


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## MMiz (Sep 14, 2008)

First, I don't know of any protocols that allow any level EMT/medic to push D50 without some sort of blood sugar check.

Second, you're telling me that some oral glucose is going to have a profoundly negative impact on a diabetic's condition?  That sounds like the argument some folks give for withholding temporary high-flow O2 to COPD patients.


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## Ridryder911 (Sep 14, 2008)

We ought to combine pulse oximetry and this thread together, they have the same answer. Diagnostic and monitoring tools are just that, tools. They are to aid and assist, confirm a diagnosis. 

Yes, there are times that I am surprised of the reading or go .. well, we know the cause now. With this, we should had already known that either hypoxia or hypoglycemia could or was the underlying cause. The tool was just a confirmation tool to be able to document or give us a base number to work at. 

Should Basics be able to perform FSBS? Probably, but that itself is not  the real issue as many is making out here. The real issue is the EMT should be trained and educated enough to be able to perform an adequate history and assessment to determine if this is hypoglycemia/insulin shock. Yes, a FSBS reading would definitely assist in differential of altered LOC such as  in CVA vs. Insulin Shock; but in the case you cannot perform, cannot one treat appropriately? Again, similar to the pulse oximetry are you going to withhold oxygen on those that still have symptoms of respiratory distress but the number is still adequate? Of course not. 

The way things is changed in medicine is by getting them changed. Posting on forums is a nice way to vent, but does nothing in change. Get your medical director to either write protocols or become involved in changing your state laws performing this procedure(s). Better yet, demand that the EMT level obtain additional and better education in both areas, by doing so one might see the ability to perform more assessment tools. 

R/r 911


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## reaper (Sep 14, 2008)

DenverEMT said:


> I'd have to disagree that giving an already hyperglycemic patient glucose/D50 won't hurt them. Absolutely it will, especially if they are postprandial or present with a BGL over say 250mg/DL. High blood sugar also has more effect on major organs than low sugar does. Ketoacidosis may even develop if their sugar is pushed too high.
> 
> I'd stay safe with every diabetic/AMS/drunk patient and still perform a finger stick, just to cover your own a**. Better safe than sorry



If an EMT is not allowed to check a BGL, but is on the scene of a possible hypoglycemic pt. It will not hurt them to administer oral glucose, if the pt is responsive enough to maintain an airway.

We are not talking D50 via IV, we are talking oral glucose. It takes a lot of oral glucose to raise the BGL to extreme measures. It also takes time for it to reach the effect. In that time, you can transport them to the hospital.

If you do an assessment and suspect low BGL and they are alert, give them glucose. The ED will deal with their BGL levels, when you transport them. If you have ALS available, then wait for them to arrive on scene.

Yes, High BGL has effects on a lot of organ systems over time! Low BGL affects the brain immediately!! Deal with the emergency you have on hand Now. A BGL of 250mg/dl is not considered that high anymore. You would be surprised how many people walk around every day with a BGL of 250mg/dl.


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## Ridryder911 (Sep 14, 2008)

DenverEMT said:


> . High blood sugar also has more effect on major organs than low sugar does. Ketoacidosis may even develop if their sugar is pushed too high.




Wrong, wrong, wrong... The major organ that the low sugar effect upon is the brain. Hyperglycemia is rarely a life threatening emergency. Yes they are definitely serious, but it takes a w-h-i-l-e to go into ketoacidosis, then Diabetic coma. Unalike hypoglycemia, which has an acute or rapid onset and is a *true emergency*. As well there is NO treatment that a EMT can provide for hyperglycemia. 

In reality, there is very little difference between a sugar of 400mg/dl than a sugar of 600 or even a 1000mg/dl. Yes, the range of effects can be detrimental on all three but again the emergency focus again is the same. One tube of oral glucose is NOT going to be the breaking point. 

*Again, we  need to re-focus upon history and physical assessment NOT just the tool that allows me to know what to focus or where to treat*.


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## gillysaurus (Sep 14, 2008)

Just a side question... Can't giving glucose to a patient with a CVA be really bad?

Can't remember where I heard that. I may be mistaken, would like some clarification ^_^


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## Ridryder911 (Sep 14, 2008)

gillysaurus said:


> Just a side question... Can't giving glucose to a patient with a CVA be really bad?
> 
> Can't remember where I heard that. I may be mistaken, would like some clarification ^_^



Not as bad as not giving a diabetic glucose that needs it. Remember, without glucose the brain *DIES*.. a given *real fact*. High concentration levels of glucose can increase cerebral infarct but the usual dosage and amount we give is questionable if this occurs. 

One has to weigh the treatment... allow the brain to definitely die or possibility of increasing an infarct size?... Treat the hypoglycemia! 

Didn't we already have this discussion multiple times before?

R/r 911


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## AnthonyM83 (Sep 14, 2008)

gillysaurus said:


> Just a side question... Can't giving glucose to a patient with a CVA be really bad?
> 
> Can't remember where I heard that. I may be mistaken, would like some clarification ^_^



I was actually thinking the same, but don't know enough about what amount would be detrimental.

The thing about checking BGL is that it WILL affect your treatment. You WON'T spend ten minutes coaxing your ALOC patient to eat the entire tube.

The OTHER benefit is for paramedic-Basic teams. Medic can get a history from family while EMT can do things like d-stick.

Again, not a huge deal. We do fine without it. We don't NEED it. But there would be benefits.


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## reaper (Sep 14, 2008)

It takes some pounding in!


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## HeavyCrow (Sep 14, 2008)

Interesting discussion. I know our dept really emphasizes getting BGL on every patient, unless it is extreme trauma. Their opinion is better safe then sorry, and it is another piece of info to give the ED. Whether or not it is because in the past diabetics got confused with "drunks" or vice versa, I am not sure. I do know that there is no such thing as drunk tank anymore at local LEO depts. Any decrease in LOC gets a ride to the ED in a big ambulance and a nice bed to sleep it off in.


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## 41 Duck (Sep 29, 2008)

*Bgl*

I'm in Pennsyltucky.  There's been noise about giving B's glucometers for a while (mostly made by B's whining that we don't have ability to do 'em), but honestly, I fail to see the point of doing this.  I've been in a couple of heated arguments with my position on the topic -I am a B- but my stance hasn't changed.  

Sure, it's kinda screwy that Joe Average can do a finger-stick and get a number for ya, and as a B (here) you can't.  And there's a very small window for an untoward result of doing a finger-stick, I'll grant that as well.  

I just think it's a practicality issue: what does a glucometer tell you, really, and how will knowing an exact figure change a B's treatment of this?  If they're altered and able to swallow, Oral glucose.  If unable to swallow, grab a medic.  It's not like PA is going to let B's start lines or anything like that, so...


Later!

--Coop


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## TheMowingMonk (Oct 2, 2008)

My motivation for wanting it is as a time saving tool, because I dont know how many times ive had an ER nurse get mad at me for showing up to the ER and not having a sugar reading even after telling the nurse in my report that we are a BLS transport. So if we could grab a quick number and have it read for the ER it would save time in treating the PT once we arrive. also in my county, our protocols dictate we cant transport blood sugars below a certain level, but we can transport ALOC on BLS, so if its an ALOC because of a sugar issue and we transport then technically we are violating protocol because we done know what the sugar level is. I mean sure I admit we could live with out it, but if its available why not have the one more piece of the puzzle. So basically its not that we have to have it, but more like why should we have it. And i know everyone has the argument is it wont change our treatment when at least the way I see it, it can, like in administering oral glucose. Cause if a pt is a known diabetic that can swallow and all that jazz we can administer oral glucose. but say we do a finger stick and their sugar is fine, then we can save the pt from having to swallow that nasty stuff and we have one more piece of info to give the ER when we arrive.


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## 41 Duck (Oct 2, 2008)

Okay.  Seems you guys out there work a bit differently than we do--and my area of response was the basis of my argument.  It may not be applicable in all locales.  

Here, if they're altered, they're supposed to be ALS anyway, so it's really out of a B's hands.  PA pretty much makes you upgrade everything the other side of a cannula, a 4x4 and a SAM splint (and some locales, even the SAM splint is pushing it). 

My fault for not taking local differences into consideration.


Later!

--Coop


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## Markhk (Oct 3, 2008)

MowingMonk,
I think I work in the same county as you. When I work BLS and it's an interfacility transport from a nursing home, and I feel that a BSL is indicated, I'll ask the nursing staff to take one last check on the glucometer. That way at least you can document a recent BSL done by the on-scene staff. I've never had a problem from the NH staff when I've asked this. 

Incidentally, when I've worked BLS and take patients to the ER, I've never had a nurse poo-poo me for not getting a blood sugar...if they ask I usually let them know we're not a paramedic ambulance and they're cool with that. If this is a persistent problem you might want to tell your chain of command...have an EMS coordinator mention it to the nurse manager on site that hey, our County doesn't let us do what Title 22 is suppose to allow us to do so stop talking smack to our EMTs!


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## TheMowingMonk (Oct 3, 2008)

Markhk said:


> MowingMonk,
> I think I work in the same county as you. When I work BLS and it's an interfacility transport from a nursing home, and I feel that a BSL is indicated, I'll ask the nursing staff to take one last check on the glucometer. That way at least you can document a recent BSL done by the on-scene staff. I've never had a problem from the NH staff when I've asked this.
> 
> Incidentally, when I've worked BLS and take patients to the ER, I've never had a nurse poo-poo me for not getting a blood sugar...if they ask I usually let them know we're not a paramedic ambulance and they're cool with that. If this is a persistent problem you might want to tell your chain of command...have an EMS coordinator mention it to the nurse manager on site that hey, our County doesn't let us do what Title 22 is suppose to allow us to do so stop talking smack to our EMTs!



lol, i like your style, yeah, about 60% of the time I can get a BSL from a nurse at the facility, the rest of the time ether the nurse disappears or at one SNF that calls us frequently they can never seem to find their equipment....like send out a guy with a fever and not being able to find there thermometer to get a current temp and the last temp was taken an hour ago....gotta love SNFs


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## JPINFV (Oct 3, 2008)

I had a nice long post being written about this section, but my browser crashed. 

In essence, I doubt that this will get approved for the following reasons:

1. D-sticks are an optional skill packaged with a variety of medications including activated charcoal, glucagon, sub-q epi, nitro, ASA, and broncodilators.

2. Proficiency must be shown in the entire package every 6 months.

3. The medical director must show a need to use an optional skills package to the state for approval. After approval, they must show that it's benefiting patients. I doubt that making snippety and stupid ER RNs (heck, I've been yelled at for not calling medics when my transport time was under a minute. Just because one RN was a blithering idiot doesn't mean that all are or that I'm going to be calling paramedics when I can see the ER from the patient's room) happy is going to be a reason. If paramedics are readily available, then you will have a really hard time justifying the optional skill,


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## AnthonyM83 (Oct 3, 2008)

Where did the six months proficiency thing come from?


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## JPINFV (Oct 3, 2008)

http://www.emsa.ca.gov/laws/files/FinalApprovedChapter3242007.pdf

The section that contains BGL checks starts on page 16, line 9 and goes to page 18 line 4. 


> (4) A local EMS agency shall establish policies and procedures for skills competency demonstration that requires the accredited EMT-I to demonstrate skills competency every six months after initial accreditation.



Page 18, lines 2-4.


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## AnthonyM83 (Oct 4, 2008)

Not that it's not a good rule . . . but can you think of a LEMSA who actually does this?


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## Buzz (Oct 4, 2008)

It would be nice if we had them here for relaying information to the ED over the radio. Many times I'll be bringing a patient in with abnormal vitals, I'll be asked what the Pts blood glucose level is only to have to have to restate that we're a basic unit (though they should have picked that up by the B in my unit number, eh?).


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## JPINFV (Oct 4, 2008)

AnthonyM83 said:


> Not that it's not a good rule . . . but can you think of a LEMSA who actually does this?



I would imagine that the same small, rural systems that get approval for EMT-II use (there are a handful of counties that do use them and the amount of EMT-IIs in California are less than 200 from the last report I saw) would be the same counties that could be approved for this and be small enough to implement it. I agree, though, that it is essentially impossible to properly monitor in a county that has hundreds or thousands of EMT-Bs (LA, OC, SD, SF, etc. After all, in the systems with this approval, everyone is going to be trying to get approved to do the interventions). Of course these small systems are also going to be the system that would have a lack of medic service that would give them a need to have the optional skills.


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## JPINFV (Oct 4, 2008)

Found a county that utilizes some of the optional skills. Imperial County covers 4,482 square miles with a population of 142,000 people and a population density of 34 people/square mile (source: wiki) (to compare, San Diego County has a population density of 671 people/sq mile). Imperial uses both EMT-IIs (but they don't have any EMT-II courses in the county) as well as combitubes, the medication package (discussed in this thread), and the IV package (IV starts, normal saline and dextrose only).
The protocol concerning the optional skills package can be found here:
http://www.icphd.org/menu_file/Policy_2200_rev_6-07.pdf?u_id=1


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## TransportJockey (Oct 4, 2008)

NM states EMT-Bs can do a finger stick anytime it is warranted. I take one if I'm transporting a DM patient and don't have one from the last 2 hours or so (or if they got fed right before we take em)


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