# Treating hyperglycemia on a BLS level.



## Explorer127 (Jan 21, 2009)

Is there anything that can be done for the pt?
For example, BGL of 220, what can you do for them?


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## vquintessence (Jan 21, 2009)

Nope, nothing for ALS either since we don't carry insulin, and thank god.  Who the hell would want to guess the units to give.  No training - education = me? no thanks.  Damn now ya gots me curious.

Willing to bet that pt can tolerate that BG anyhow.  Just keep in mind what the number could represent.  High BG can represent an active infectious process.


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## Ridryder911 (Jan 21, 2009)

Take them to the hospital. 

R/r 911


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## rhan101277 (Jan 21, 2009)

Take the to the hospital is my answer as well.


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## akflightmedic (Jan 21, 2009)

You tossing 220 out as an example reflects the lack of knowledge you posses in regards to care and treatment needed for diabetic patients.

Do them a favor and transport.

Do yourself a favor and continue advancing your medical education and once you are at an educated and experienced level to treat these sort of things, you will look back and realize how silly you once were.

Yes, I was silly. I still am silly. I learn more each year, look back and say, man...just last year I was silly.


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## daedalus (Jan 21, 2009)

akflightmedic said:


> You tossing 220 out as an example reflects the lack of knowledge you posses in regards to care and treatment needed for diabetic patients.
> 
> Do them a favor and transport.
> 
> ...


Amen.

Yesterday I got a call from an EMT co-worker asking me if a BS of 300 needed CCT level transport (it was an IFT). I laughed and asked him what the patient looked like "Awake and talking, no apparent distress".

We regularly saw non-compliant DM II patients at a community free clinic I volunteered at, and would present to the outpatient clinic with BS sometimes up to 500. Dangerous and terrible for you, but geez they must tell EMTs to only worry about numbers in school or something.

_Note- the following is not directed at the OP, or anyone on the board, just some frustrations of mine_
I also got into an argument with my partner last night, he thought as EMTs we had a solid grasp of medicine. I asked how his 2 hours of A&P, no pathophysiology, and cursory descriptions of the most basic diseases made him qualified to have a grasp on medicine. This guy thinks that knowing how to take vital signs and knowing high/low values is the same thing doctors are taught, he must think the pool of knowledge is pretty shallow.

Me "tell me about essential hypertension than, if you know all about it because you can take vital signs. I want the pathophysiology nuts and bolts"

Him "Hypertension means high blood pressure. Like, 150 and up is pretty high"


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## JPINFV (Jan 22, 2009)

daedalus said:


> We regularly saw non-compliant DM II patients at a community free clinic I volunteered at, and would present to the outpatient clinic with BS sometimes up to 500. Dangerous and terrible for you, but geez they must tell EMTs to only worry about numbers in school or something.


Highest I've seen (well, heard during report) was on a CCT IFT for patient who walked into the ER with a BGL around 1500.


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## Explorer127 (Jan 22, 2009)

akflightmedic said:


> You tossing 220 out as an example reflects the lack of knowledge you posses in regards to care and treatment needed for diabetic patients.
> 
> Do them a favor and transport.
> 
> ...



I really, really do not need you tell me that I don't know how to care and treat diabetic patients and that my question "reflects the lack of knowledge" that I posses.

I am not yet an EMT and I have not yet taken an EMT class. I'm an explorer who is trying to learn a few things about patient care.

If you didn't mean that as an insult, I apologize for jumping out on you like that....

Anyways,

Let's say the pt is not diabetic, and has a BGL of 220 and is "not feeling right"... What can cause that? And once again, there is nothing that can be done for the pt? Is there anything that can cause a false-high reading?


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## JPINFV (Jan 22, 2009)

No, there's nothing to do prehospitally for a patient with an elevated BGL of 220. Yes, the value you're using shows inexperience and you probably won't understand what we're talking about until you complete school and start working. Complaining that a BGL of 220 is elevated is like saying a respiratory rate of 26 is elevated. Sure, both are technically elevated, but neither are emergent situations.


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## rhan101277 (Jan 22, 2009)

Explorer127 said:


> I really, really do not need you tell me that I don't know how to care and treat diabetic patients and that my question "reflects the lack of knowledge" that I posses.
> 
> I am not yet an EMT and I have not yet taken an EMT class. I'm an explorer who is trying to learn a few things about patient care.
> 
> ...



Well i am a new EMT myself.  I don't know what would cause a false-high reading, besides outdated strips or hosed glucometer.  If someone has a high BGL, then their body is not able to use glucose and it just keeps going up.  Soon the body has to use fat reserves for energy which causes you to start to see the signs of hyperglycemia.  Once it is high enough maybe over 400 or so, you may start to smell a fruity odor on their breath.  They will be thirsty, complain about urinating alot, skin should be warm and dry.  I think hyperglycemic patients are in a danger of dehydration if they don't continue to drink.  The acids created from your body trying to get energy from fat causes your blood to become more acidic and your body works to maintain homeostasis to that point.  Your blood Ph can't stand to much movement before you start getting hosed, long time hyperglycemics probably have damaged capillary walls as well.

Anyway my 2 cent.


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## seanm028 (Jan 22, 2009)

JPINFV said:


> Highest I've seen (well, heard during report) was on a CCT IFT for patient who walked into the ER with a BGL around 1500.



_Walked_ into the ER?  I'm impressed.  Just goes to show you, there's never a black-and-white value for anything, especially vital signs.  We've got guidelines, but every patient has different tolerances.


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## JPINFV (Jan 22, 2009)

http://forums.studentdoctor.net/showthread.php?t=115359

Emergency Medicine Residency Forums "Hall of Fame" thread. Chock full of amazing lab values.


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## rhan101277 (Jan 22, 2009)

Lol I like that forum..

Pick up a sprained ankle in the ortho room... Dont need an xray per your medical expertise... patient insists b/c her friend had the exact same fall and had a fracture..order the xray, easier than the fight.

This thread is a hoot.

http://forums.studentdoctor.net/showthread.php?t=595297


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## mycrofft (Jan 22, 2009)

*Cutting back to the OP...Good on you for asking the question!*

Hm. I'd be a lot more concerned about other stuff which can kill or disable you between point A (pt location) and the receiving hospital. 220 is not emergent by itself. It is not good long-term. Look up the subject in the American Diabetes Association website, etc.

BLS level: any unconscious diabetic needs transport pronto. A diabetic pt who tells you they are hungry, are diapohoretic, or thirsty, as long as they are capable of swallowing safely _*and it is in your protocols*_, ought to either give them glucose (a little gel or honey at a time is safest), or allow them to do their glucose thing (most diabetics have a way worked out). If nausea or trouble swallowing are any sort of consideration, just get em in. Do not abbreviate your assessment due to discovering diabetes, they can also have other serious considerations like the rest of us, but don't dawdle because diabetic ketoacidosis IS an immediate emergency.(Again, look to your texts' portocols, and the ADA website).

 Diabetic control is a wobbly tripod of insulin (endogenous or artifical), glucose metabolism (faster when exercise and wound healing or disease recovery are occurring), and diet (including sugars, starches which the body can convert to sugars, and proteins/fats which the body has a hard time using to fuel organs and esp. the brain). If you start pushing one leg of a tripod up or down, the whole thing loses balance, and subsequent attempts to recover balance while it's tottering can bring it crashing.

PS: Who had a blood glucose measurement of 1500?! Mrs Butterworth?


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## mycrofft (Jan 22, 2009)

*Metacommunicative note*

Explorer and AK, (and everyone else) I wish we could get together for a beer (or root beer for us teatotalers). We're on the same page, it is just hard to read people's faces when they are immobile and the size of a postage stamp.


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## WiFi_Cowgirl (Jan 22, 2009)

Call a helicopter, and take the time you would have used for transport, to get donuts.


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## VentMedic (Jan 22, 2009)

mycrofft said:


> PS:* Who had a blood glucose measurement of 1500?!*


 
I'm hoping you are asking that as a serious question since it could lead to a great discussion for DKA vs HHS.


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## BossyCow (Jan 22, 2009)

Explorer127 said:


> Is there anything that can cause a false-high reading?



Yes there is. I saw a peg the meter reading (my glucometer read "HIGH") from a pt who was to all appearances fine. Turns out the EMT who did the stick didn't wash the area first. The pts hands were sticky and the sugar from the candy she was eating to raise her blood sugar was all over her fingers. Not allowing the alcohol to evaporate from the test sight also can skew a reading. But these are operator errors.

Highest reading I've ever seen was 800 and something


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## mikeylikesit (Jan 22, 2009)

as  a diabetic let me educate. a high for one diabetic may be a normal for another with poor control. 300 may be what the patient likes to keep his BS at for activities. 220 is normal for someone who works out as it is recomended so they don't crach while there exercising. high glucose can be treated in many ways, fastest in R or Regular insulin which take effect in 5 minutes and is out of there sytem in 1 hour, most common is give them liquads and let them pee it out if you have a long transport. most diabetics will pee out anything over 180 mg/dl. this is not as fast as insulin but it does work. keep in mind that there are hundreds of reasons a diabetic gets high readings for example adreniline will spike it due to the breakdown of glycogen. False readings can occur if the meter is not properly coded, unwashed hands, ALTITUDE, anxiety, water or alcohol still on the finger at the time of sampling.


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## daedalus (Jan 22, 2009)

rhan101277 said:


> Lol I like that forum..
> 
> Pick up a sprained ankle in the ortho room... Dont need an xray per your medical expertise... patient insists b/c her friend had the exact same fall and had a fracture..order the xray, easier than the fight.
> 
> ...



There is an actual scale that can rule out ankle fractures diagnostically without x-ray. Its got like a 95-98% sensitivity and specificity. It escapes my mind the name of it.


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## piranah (Jan 22, 2009)

remember TREAT YOUR PT NOT YOUR TOYS.......ive had that pounded in my head and it helps.....i had a guy with a BGL that read..."high, over 600" i was like...hmmm so i took a sep. site with diff. glucometer...same....while doing my assessment realized gang green of the L big toe....pt was + ETOH and even the hospital glucometer was out of range...he needed labs.....anyway...you never know...always treat your pt....cuz the time you dont itll bite you in the butt.


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## BossyCow (Jan 22, 2009)

daedalus said:


> There is an actual scale that can rule out ankle fractures diagnostically without x-ray. Its got like a 95-98% sensitivity and specificity. It escapes my mind the name of it.



I remember an ER shift with a woman about my age with a 'twisted ankle'. She walked into the ER from her car only because her husband made her go to the ER. She's moving the ankle around with full mobility and standing on it saying.. "It can't be broken, I can move it just fine.. it hurts a little, but not bad"

On the wall was her x-ray with a twin of the broken ankle I had about a year prior. I was in unbelievable amounts of pain, with my vision going into that tiny little shrinking circle with any movement at all. 

Morale of the story is: People are different. Anatomy is different. Pain is subjective.


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## marineman (Jan 22, 2009)

What kind of meters does everyone use that you're getting such high readings or are you citing lab results? Our meters only go to 500, anything over that comes up as high. 

To the original question without worrying that the number you posted isn't really that high, at the basic level for a patient that has a high blood sugar and is in an emergency state the best you can really do is aggressive BVM ventilations (not popping their lungs or anything just slightly faster than normal and make sure you're getting an adequate but not excessive volume). People with high blood sugar will naturally have an increased breathing rate and depth to rid themselves of the excess ketones, don't expect to work any miracles using this technique but it's about as good as you're going to get in the field as a basic. 

At the ALS level it's the same thing with the possibility of giving fluid to slightly dilute the blood but neither one will really help that much, the patient needs insulin which we don't have.


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## artman17847 (Jan 22, 2009)

daedalus said:


> There is an actual scale that can rule out ankle fractures diagnostically without x-ray. Its got like a 95-98% sensitivity and specificity. It escapes my mind the name of it.



...could you be thinking of the Ottawa foot, ankle or knee rule?


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## JPINFV (Jan 22, 2009)

marineman said:


> People with high blood sugar will naturally have an increased breathing rate and depth to rid themselves of the excess ketones, don't expect to work any miracles using this technique but it's about as good as you're going to get in the field as a basic.



There was an interesting discussion in another EMS forum regarding Kussmaul's and when to take over breathing. Just remember, acidosis will kill just as easily as hypoxia.


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## lightsandsirens5 (Jan 22, 2009)

Keep them comfortable and transport. 

Higest BGL I ever actuall saw was 910. A 15 y/o male pt. Was on insulin by IV and was out cold for my entire 12 hour ER clinical shift.


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## marineman (Jan 22, 2009)

JPINFV said:


> There was an interesting discussion in another EMS forum regarding Kussmaul's and when to take over breathing. Just remember, acidosis will kill just as easily as hypoxia.



Maybe one of the more experienced members can correct me if I'm wrong but I believe at a certain point the Kussmauls respirations will slow down and the patient will no longer have the breath odor as the body is shutting down and basically realizes that it's a futile effort. That's the point I would personally begin bagging the patient. If they are having Kussmauls respirations then their tidal volume and rate should be adequate that I won't help any by bagging unless something is causing hypoxia still and the bag on the NRB won't stay inflated. 

That's my take on it but who knows vent or rid could come and tell me I'm completely off base so we'll wait and see what they have to say.


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## VentMedic (Jan 22, 2009)

marineman said:


> Maybe one of the more experienced members can correct me if I'm wrong but I believe at a certain point the Kussmauls respirations will slow down and the patient will no longer have the breath odor as the body is shutting down and basically realizes that it's a futile effort. That's the point I would personally begin bagging the patient. If they are having Kussmauls respirations then their tidal volume and rate should be adequate that I won't help any by bagging unless something is causing hypoxia still and the bag on the NRB won't stay inflated.


 
This is what I was referring to by DKA vs HHS (Hyperglycemic Hyperosmolar state) in an earlier post.

Once glucose gets over 600 mg/dl it may not display the same symptoms as ketoacidosis.  There is a differential diagnosis to be made here.


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## medic417 (Jan 22, 2009)

Explorer127 said:


> Is there anything that can be done for the pt?
> For example, BGL of 220, what can you do for them?



Enjoy your conversation with them enroute to the hospital.

Now once you become a paramedic there are many things you will be able to do for the patient.  Insulin is one option but honestly unless this patient has other signs and symptoms besided the 220 probably no more than an IV with normal saline.  

My advice to you is to go forward with your education.  Get your paramedic degree and be there to provide the best patient care possible.


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## Sasha (Jan 22, 2009)

medic417 said:


> Enjoy your conversation with them enroute to the hospital.
> 
> Now once you become a paramedic there are many things you will be able to do for the patient.  Insulin is one option but honestly unless this patient has other signs and symptoms besided the 220 probably no more than an IV with normal saline.
> 
> My advice to you is to go forward with your education.  Get your paramedic degree and be there to provide the best patient care possible.



Hmm.. I've never heard of anyone's protocols that allow the adminstration of insulin.


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## medic417 (Jan 22, 2009)

Sasha said:


> Hmm.. I've never heard of anyone's protocols that allow the adminstration of insulin.




Funny we carry 2 types.  But then again I am from very rural, very poor area with many that can not afford to properly care for diabetes, and with no hospital close by round trip is at least 4 hours many time longer for our outer areas.  Often I have patients into normal ranges and ready to go home by the time we get to the hospital.  Amazing what Paramedics with proper education can do.  Sadly though many even at Paramedic certification are not truly educated so they are not allowed to actually do very much for their patients.


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## marineman (Jan 22, 2009)

In WI we are allowed to transport patients on an insulin drip, and it is within the scope for CCEMTP's on the CCT trucks but I don't know how many of their medical directors allow them to carry it.


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## JPINFV (Jan 22, 2009)

marineman said:


> In WI we are allowed to transport patients on an insulin drip, and it is within the scope for CCEMTP's on the CCT trucks but I don't know how many of their medical directors allow them to carry it.



I'm going to take a leap and say that insulin is in the scope of a paramedic running critical care calls (since WI doesn't have an official CCEMT-P certification) in the sense that they can transport/monitor it, but not initiate it.


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## Sasha (Jan 22, 2009)

medic417 said:


> Funny we carry 2 types.  But then again I am from very rural, very poor area with many that can not afford to properly care for diabetes, and with no hospital close by round trip is at least 4 hours many time longer for our outer areas.  Often I have patients into normal ranges and ready to go home by the time we get to the hospital.  Amazing what Paramedics with proper education can do.  Sadly though many even at Paramedic certification are not truly educated so they are not allowed to actually do very much for their patients.



Oh get off your high horse.


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## medic417 (Jan 22, 2009)

Sasha said:


> Oh get off your high horse.




What did I do?  Sometimes I think you hate me or something.  I have done nothing but respond to answer your post.


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## VentMedic (Jan 22, 2009)

JPINFV said:


> I'm going to take a leap and say that insulin is in the scope of a paramedic running critical care calls (since WI doesn't have an official CCEMT-P certification) in the sense that they can transport/monitor it, but not initiate it.


 
Not in most of CA or FL. An RN (MICN -CA) will usually accompany the patient. There are other drips that they can monitor but not titrate. Neither state has an official state title of CCEMT-P.  The scope in CA, is of course, on a county by county basis.  Florida's scope can be medical director dependent for specialty.


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## JPINFV (Jan 22, 2009)

^
...but I thought we were talking about WI?


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## akflightmedic (Jan 22, 2009)

I have worked for a few services that allow paramedics to carry, initiate and administer insulin.


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## VentMedic (Jan 22, 2009)

akflightmedic said:


> I have worked for a few services that allow paramedics to carry, initiate and administer insulin.


 
In Florida? How did you store it?


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## marineman (Jan 23, 2009)

JPINFV said:


> I'm going to take a leap and say that insulin is in the scope of a paramedic running critical care calls (since WI doesn't have an official CCEMT-P certification) in the sense that they can transport/monitor it, but not initiate it.



No we don't have a CCEMT-P certification level but we do have specialized CCT ambulances that will depending on the patients needs usually carry at least one medic who has passed the CCEMTP class and shown proficiency in more critical care areas. Those units as far as I know usually don't carry insulin due to the storage requirements (insulin is quite finicky) but they can either get some from the hospital prior to transport or if a patient is already on insulin they can titrate what they have going.

At the standard paramedic level depending on your service protocols we can transport a patient on an insulin drip but any problems and we divert to the nearest hospital since we're not allowed to titrate or change the drip at all.

Edit: Wisconsin has 3 approved drug lists, one for the normal paramedic practice, one for IFT's for paramedics (we're allowed to oversee more drips then), and one for advanced service medics on flight teams or CCT rigs.


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## akflightmedic (Jan 23, 2009)

In Alaska Vent.


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## daedalus (Jan 23, 2009)

VentMedic said:


> Not in most of CA or FL. An RN (MICN -CA) will usually accompany the patient. There are other drips that they can monitor but not titrate. Neither state has an official state title of CCEMT-P.  The scope in CA, is of course, on a county by county basis.  Florida's scope can be medical director dependent for specialty.



I think I may live in the one county in SoCal that allows paramedic transport of nitro and heparin drips, for "heart express" calls. (Emergency STEMI transport to a hospital capable of PCI)

Vent, an MICN in california is an RN who is trained by the county to give "orders" to paramedics over the radio. They must follow the exact protocol the paramedics are required to learn so the whole thing is an extreme exercise in redundancy. For example, the Chest pain protocol may allow IV placement, O2 administration, Cardiac monitoring and up to 2 sprays of nitro before contact to the base hospital. The protocol than goes on to order the use of aspirin and morphine after asking the nurse. The paramedic knows exactly what the nurse can order per the protocol. 

An RN on a CCT truck need not be an MICN. In fact, none of the CCT RNs at my service are MICNs, the only requirement is 2 years of critical care or ER experience, ACLS and PALS, and an RN license. Some companies mandate CEN or CCRN.

There are CCT RNs who are also MICNs but this is the exception, as MICNs are very very well paid in the ERs around here and have a very low patient load.


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## Jon (Jan 23, 2009)

akflightmedic said:


> You tossing 220 out as an example reflects the lack of knowledge you posses in regards to care and treatment needed for diabetic patients.
> 
> Do them a favor and transport.
> 
> ...





Explorer127 said:


> I really, really do not need you tell me that I don't know how to care and treat diabetic patients and that my question "reflects the lack of knowledge" that I posses.
> 
> I am not yet an EMT and I have not yet taken an EMT class. I'm an explorer who is trying to learn a few things about patient care.
> 
> ...




Explorer:

I don't think AK was trying to jump down your throat... he was just making a point that prehospitally, hyperglycemia doesn't become an issue unless it is REALLY, REALLY elevated... like 400/500 or more... 

Now.. for some more questions:
What state are you in? Do you have glucometers at the BLS level?
How do you know the BGL is that high?
When was the meter last calibrated?


Jon


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## Sasha (Jan 23, 2009)

Jon said:


> When was the meter last calibrated?



Very good point!! At my old job one day we had a glucometer that was so out of callibration it was throwing us for a loop. We were getting readings in the low 40s for a patient just sitting there fine and dandy, decided to hold off on oral glucose due to the fact she wasn't presenting like a BGL of 40 something normally would, re-check at the hospital showed they were actually at a normal range :]


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## rescuepoppy (Jan 23, 2009)

Sasha said:


> Very good point!! At my old job one day we had a glucometer that was so out of callibration it was throwing us for a loop. We were getting readings in the low 40s for a patient just sitting there fine and dandy, decided to hold off on oral glucose due to the fact she wasn't presenting like a BGL of 40 something normally would, re-check at the hospital showed they were actually at a normal range :]



 A great point about treating the patient not the numbers. We all know that all of our toys are man made machines that can and will at some time fail. Hence the need to use your skills of evaluation.


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## Arkymedic (Jan 23, 2009)

Not allowing the alcohol from the prep pad to dry can cause a false reading. Have seen several report a high CBG and then we took it to get a normal reading. When I do a CBG, I always wipe the first drop of blood I squeeze out off and use the second to ensure a better read.



Explorer127 said:


> I really, really do not need you tell me that I don't know how to care and treat diabetic patients and that my question "reflects the lack of knowledge" that I posses.
> 
> I am not yet an EMT and I have not yet taken an EMT class. I'm an explorer who is trying to learn a few things about patient care.
> 
> ...


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## Arkymedic (Jan 23, 2009)

Please lead us down that road Vent. I love learning from you and Rid and the discussion that occurs. I also think since diabetic emergencies are a large portion of call volume, it will benefit all. 



VentMedic said:


> This is what I was referring to by DKA vs HHS (Hyperglycemic Hyperosmolar state) in an earlier post.
> 
> Once glucose gets over 600 mg/dl it may not display the same symptoms as ketoacidosis. There is a differential diagnosis to be made here.


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## marineman (Jan 23, 2009)

Jon said:


> When was the meter last calibrated?
> Jon



Ok, I'll bite. How often does everyone calibrate theirs? we have the simple test strips you put in and if the glucometer comes up with the same number you're good to go. That's part of our daily rig check and of all the things people jump over that's one thing that seems to actually get checked daily.


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## Ridryder911 (Jan 23, 2009)

If you have noticed I have not been posting as much in the past two weeks. The reason being, I was recently diagnosed as a Diabetic and having HTN. Unfortunately, I have to admit that I realized what was occurring with the classical .."3 P's"... Polydispia, polyuria & polyphagia & passing some ketones. As a typical medic & nurse, I continued to work. Even knowing most physicians in town I was not able to be seen in their clinic for a while. 

I will admit having high sugar is a horrible feeling. I have been blessed to never had been ill or ever had to take medications...something that changed. Discussing my s/s with my EMS director he bluntly questioned me on "really how do you know that is what it is?"... As one being chicken to even do a FSBS, my crew members basically infringed me and performed one. It would only read high. That was enough persuasion for my director to notify a P.A. friend of our service and was able to see him immediately. My fasting glucose was 670mg/d and for the first time ever had HTN. The P.A. of course decided to relieve me of some additional poundage from my gluteal area..giving a well deserved arse chewing; describing I should know better. 

Well its been two weeks. My body is still adjusting to taking med.'s and fortunately the glucose and BP has maintained within reason. I will say lower your sugar 500 points even over time is not fun, but better than the alternative. 

So it was an awakening and life changing event. I am proud to say I have continued to eat properly (within reason) and have a exercise program. I also have formally moved into my position of only being on the truck as needed. Yeah, its hard to pass the touch but I have a few that will do good. Now, all shifts will have to deal with me. 

The reason I am posting, I might suggest for ALS to administer fluid therapy (if the patient can tolerate such) for dilution. I would NEVER recommend Insulin for several reasons. There are very few true hyperglycemic emergencies that EMS can treat accurately. Even DKA patients usually require glucose levels to be performed twice or diluted as most FSBS do not > 500 or definitely NOT reliable to make an accurate adjustment. As well there is a major difference between Diabetes Mellitus and Diabetes Insipidus, Non-ketonic Hyperosmolar syndrome. Without proper lab data, you are risking a lot. Regular Insulin should be adjusted accordingly and can be very DANGEROUS even administered by a well educated Paramedic. Even short acting Insulin can have rebound effects when combined with regular Insulin IV. I would presume that prehospital orders for Insulin would be based upon known diabetics and are more a sliding scale, than initial treatment. 

I can understand patients in DKA; and with the use of EtCo2 in aiding my dx of DKA. I might call for orders for fluids and a NaHCo3 drip.   

In regards to Insulin drip, the CCEMT-P program addresses such administration of Insulin and maintenance drip. Alike Heparin, it should be double checked and monitored closely with assigned periodical FSBS and only per IV pump with special tubing. 

R/r 911


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## marineman (Jan 23, 2009)

Man rid, I was just going to comment the other day asking where you had been lately. Glad you got it taken care of and it apparently didn't kill off any of those brain cells, another good post.


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## MSDeltaFlt (Jan 23, 2009)

Ridryder911 said:


> If you have noticed I have not been posting as much in the past two weeks. The reason being, I was recently diagnosed as a Diabetic and having HTN. Unfortunately, I have to admit that I realized what was occurring with the classical .."3 P's"... Polydispia, polyuria & polyphagia & passing some ketones. As a typical medic & nurse, I continued to work. Even knowing most physicians in town I was not able to be seen in their clinic for a while.
> 
> I will admit having high sugar is a horrible feeling. I have been blessed to never had been ill or ever had to take medications...something that changed. Discussing my s/s with my EMS director he bluntly questioned me on "really how do you know that is what it is?"... As one being chicken to even do a FSBS, my crew members basically infringed me and performed one. It would only read high. That was enough persuasion for my director to notify a P.A. friend of our service and was able to see him immediately. My fasting glucose was 670mg/d and for the first time ever had HTN. The P.A. of course decided to relieve me of some additional poundage from my gluteal area..giving a well deserved arse chewing; describing I should know better.
> 
> ...



Careful, though.  Hyperglycemic pts tend to die, not from from hyperglycemia, but from cerebral edema from too much fluid.  Blood glucose levels need to *trend* down; not drop like a stone.

Glad you're back, Rid.  Vent always thought you were sweet.  Now there's clinical proof.

Sorry, guys.  The shot was there.  I had to take it.


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## ErinCooley (Jan 23, 2009)

marineman said:


> Ok, I'll bite. How often does everyone calibrate theirs? we have the simple test strips you put in and if the glucometer comes up with the same number you're good to go. That's part of our daily rig check and of all the things people jump over that's one thing that seems to actually get checked daily.



Ditto... I do the same thing @ the beginning of each shift along with the rest of my check off duties.

I'm confused....Is a typical BLS crew not allowed to begin IV fluids in some states?  In Ga, if I'm an the truck w/ another EMT-I, working as a bls crew, i can still begin fluid therapy.


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## JPINFV (Jan 23, 2009)

I would venture to say that it's typical of crews comprised only of EMT-Bs in most states to be unable to initiate an IV.


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## Arkymedic (Jan 23, 2009)

Glad to have you back here Rid. I missed your thoughtful insights and food for thought. Hopefully you will keep taking care of yourself and you can manage this thing. 



Ridryder911 said:


> If you have noticed I have not been posting as much in the past two weeks. The reason being, I was recently diagnosed as a Diabetic and having HTN. Unfortunately, I have to admit that I realized what was occurring with the classical .."3 P's"... Polydispia, polyuria & polyphagia & passing some ketones. As a typical medic & nurse, I continued to work. Even knowing most physicians in town I was not able to be seen in their clinic for a while.
> 
> I will admit having high sugar is a horrible feeling. I have been blessed to never had been ill or ever had to take medications...something that changed. Discussing my s/s with my EMS director he bluntly questioned me on "really how do you know that is what it is?"... As one being chicken to even do a FSBS, my crew members basically infringed me and performed one. It would only read high. That was enough persuasion for my director to notify a P.A. friend of our service and was able to see him immediately. My fasting glucose was 670mg/d and for the first time ever had HTN. The P.A. of course decided to relieve me of some additional poundage from my gluteal area..giving a well deserved arse chewing; describing I should know better.
> 
> ...


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## Sasha (Jan 23, 2009)

marineman said:


> Ok, I'll bite. How often does everyone calibrate theirs? we have the simple test strips you put in and if the glucometer comes up with the same number you're good to go. That's part of our daily rig check and of all the things people jump over that's one thing that seems to actually get checked daily.



THAT'S what that's for?

Just kidding!  I tend to use the little tester strip thing when I do the truck check in the morning, that morning I was on a different truck and somehow the test strip slipped my mind.


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## EeyoreEMT (Jan 29, 2009)

You would be surprised how many EMTs B-P, don't check their equipment or even clean them. It is totally so gross, plus, like duh, it could give you a false reading.


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## exodus (Feb 5, 2009)

ErinCooley said:


> Ditto... I do the same thing @ the beginning of each shift along with the rest of my check off duties.
> 
> I'm confused....Is a typical BLS crew not allowed to begin IV fluids in some states?  In Ga, if I'm an the truck w/ another EMT-I, working as a bls crew, i can still begin fluid therapy.



EMT-B Can't puncture skin other than EPI, but EMT-I can do IV's I think. Don't quote me on that.

And Explorer, how would you even know what the BGL is since you can't test it as a basic? Only way is to have a family member or the PT test it.   But if we get reliable information, in San Diego County, if the pT has a history of Diabetes, we administer oral glucose as long as the pt is able to swallow per protocol. Edit: Without a BGL reading. Just altered.


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## Summit (Feb 5, 2009)

mikeylikesit said:


> False readings can occur if the meter is not properly coded, unwashed hands, *ALTITUDE*, anxiety, water or alcohol still on the finger at the time of sampling.



That's a new one... altitude gives false readings why?


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## VentMedic (Feb 5, 2009)

Summit said:


> That's a new one... altitude gives false readings why?


 
Many medical devices are calibrated by barometric pressure.

For my equipment including any blood testing devices, I calibrate by two barometric pressure measuring devices in the Pulmonary lab as well as a check with the local authorized weather reporting agency to ensure accuracy.


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## Sasha (Feb 5, 2009)

> And Explorer, how would you even know what the BGL is since you can't test it as a basic?



Maybe your area can't, but some areas do allow BGL testing at the basic level. 

Before I started bopping around on this site, I had no idea that there were areas that didn't allow basics to do BGL finger sticks. Suprising, since you gotta be pretty dumb to mess up one of those.


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## Summit (Feb 5, 2009)

VentMedic said:


> Many medical devices are calibrated by barometric pressure.
> 
> For my equipment including any blood testing devices, I calibrate by two barometric pressure measuring devices in the Pulmonary lab as well as a check with the local authorized weather reporting agency to ensure accuracy.



Right, but finger stick instant check units are not laboratory instruments. The only option most finger stick units have is to put in the cal strip which calibrates the unit to a particular batch of test strips. There is no option to calibrate based on barometric pressure. Thinking in terms of chemistry and physics, I'm not getting how the measurement of a nonvolatile like glucose would be significantly affected by barometric pressure. I'd think that humidity and temp would have much larger effects! Anyways, altitude screwing up finger stick units it certainly isn't a worry that I've ever heard before living up high (and we talk about altitude affects all the time). Maybe I need to research how blood glucose is measured by these devices. It does make me wonder, does patient hydration level or crit have a significant affect? Those are two things affected by short and long term exposure to higher altitudes.

I'd be more worried that at extremely high altitudes (above 18K) you might have units failing as tiny air bubbles trapped in the ICs when they were manufactured at sea level expand stressing and fracturing the interconnects (most consumer electronics are guaranteed to about 10K for this reason, but seem to work above that without issue that I've ever seen).


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## VentMedic (Feb 5, 2009)

Summit said:


> Right, but the only option most finger stick units have is to put in the cal strip which calibrates the unit to a particular batch of test strips. There is no option to calibrate based on barometric pressure. Thinking in terms of chemistry and physics, I'm not getting how the measurement of a nonvolatile like glucose would be significantly affected by barometric pressure. I'd think that humidity would have a bigger affect! Anyways, altitude screwing up finger stick units it certainly isn't a worry that I've ever heard before living up high (and we talk about altitude affects all the time).


 
Basic fundamentals of relative humidity and barometric pressure affect any measurements for liquids and gases as well as the sensitive sensors in the equipment. Even the oxygen your breathe includes a barometric pressure measurement in the calculation.

When you are do a cal strip, that machine is performing that cal at the barometric pressure you are at. If you fly or climb at altitude where the pressure changes, you may have to do another cal. This is also an issue with other POC machines for flight teams.

The manual for your equipment should explain this.


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## Summit (Feb 5, 2009)

VentMedic said:


> When you are do a cal strip, that machine is performing that cal at the barometric pressure you are at. If you fly or climb at altitude where the pressure changes, you may have to do another cal. This is also an issue with other POC machines for flight teams.
> 
> The manual for your equipment should explain this.



Well the manual said to check the piece of paper found in the test strip box. The paper in the test strips said:

"When should I calibrate my monitor? You must calibrate your monitor each time you open and use a new box of test strips."

"Clinical testing demonstrates that altitudes up to 7200ft do not affect results."

Interesting. Maybe I will call the manufacturer since I only operate between 8,000-14,500ft ASL. Maybe I'll break one of those units open and see if I see a barometric pressure sensor (which would certainly indicated an accompanying temperature sensor). I find it surprising a unit would contain those sensors with no ability to calibrate them or at least to check calibration.


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## Scriptor (Feb 5, 2009)

*Bgl >2000*

When I was diagnosed my BGL was over 2000 (~2100 or so).  ALS tried to get me some IV fluids to combat the extreme dehydration, but because i was so dehydrated my veins wouldn't hold.  Ultimately, I was hospitalized in ICU for about a week with a steady drip of insulin.  The blindness was the worst part, i think.  That and the smell of insulin all around me.  As for BLS treatment, comfort is key.  Keep the feet warm, the periphrel blood vessels become so inflamed that blood flow to the extremities is dangerously low.  In most cases, anyway.  Trust me, if you BGL is anything over 1000, it's difficult to remain awake and oriented.  And remember vision problems.  Any more questions about diabetes please let me know.  I am always happy and eager to share information about the subject.

On another note, how can I go about changing standing orders to allow EMT-b and even EMT-p to administer glucagon injections for low BGL emergencies?  We can't do much else for them.  If a diabetic is unconsious, it's a matter of how fast one can drive that determines the likely hood of saving the pt from death and possible permanent brain damage.  With one shot of this stuff, that diabetic will be awake and puking in your truck in a matter of seconds.  There's no prescribed dosage for the injection, it just requires a little mixing and is intermuscular (much like the epipen we carry, only it's in a real syringe).  Any ideas questions or comments please let me know.


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## Nycxice13 (Feb 19, 2009)

Explorer127 said:


> I really, really do not need you tell me that I don't know how to care and treat diabetic patients and that my question "reflects the lack of knowledge" that I posses.
> 
> I am not yet an EMT and I have not yet taken an EMT class. I'm an explorer who is trying to learn a few things about patient care.
> 
> ...


 Give o2 and transport....


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## OzAmbo (Feb 19, 2009)

i believe that aussiephils protocols for hyperglycemia and an altered conscious state were NS 10ml/kg, but unsure if this is this case now.
Other than that, its the only pre-hospital treatment i have seen writen up for a hyper.


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## DevilDuckie (Feb 19, 2009)

Treat the associated symptoms as best as possible, as well as giving appropriate attention to comfort and take them in. I didn't read all the posts, but I don't believe under current protocols, anything can be done prehospital to directly lower the blood sugar.


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## medic417 (Feb 19, 2009)

If patient is very high with s/s of such, pretty much at BLS be prepared to suction if patient begins to drool or vomit.  O2.  And call ALS.  

When ALS gets on scene they will establish IV.  Run fluid bolus.  12 lead.  Double and triple check reading you get for glucose level.  Administer insulin.  Possibly will intubate to protect airway.


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## DevilDuckie (Feb 19, 2009)

I have yet to see an ALS unit w/ Insulin


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## ffemt8978 (Feb 20, 2009)

DevilDuckie said:


> I have yet to see an ALS unit w/ Insulin



Same here.

Isn't insulin normally supposed to be refrigerated?  If so, how would you keep it refrigerated on the rig?


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## Sasha (Feb 20, 2009)

ffemt8978 said:


> Same here.
> 
> Isn't insulin normally supposed to be refrigerated?  If so, how would you keep it refrigerated on the rig?



Read back in this thread and you'll see where akflightmedic mentioned his service in Alaska carried insulin.


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## DevilDuckie (Feb 20, 2009)

People live in Alaska? :unsure:


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## Sasha (Feb 20, 2009)

DevilDuckie said:


> People live in Alaska? :unsure:



Apparently!

In igloos!


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## medic417 (Feb 20, 2009)

ffemt8978 said:


> Same here.
> 
> Isn't insulin normally supposed to be refrigerated?  If so, how would you keep it refrigerated on the rig?




We have fridges on our ambulances,  they remain powered either by shore line or inverter.  Hopefully so do you if you have RSI as those drugs also require being kept cool.  

I can not believe any MICU 911 ambulance would not have insulin.  Makes no sense not to have means to start correcting the problem which is one of the most common calls EMS gets.


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## medic417 (Feb 20, 2009)

DevilDuckie said:


> I have yet to see an ALS unit w/ Insulin




Sad to hear that.  Sounds like maybe they are not true ALS as diabetic emergencys are one where EMS can do so much for the patient.


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## ffemt8978 (Feb 20, 2009)

medic417 said:


> We have fridges on our ambulances,  they remain powered either by shore line or inverter.  Hopefully so do you if you have RSI as those drugs also require being kept cool.
> 
> I can not believe any MICU 911 ambulance would not have insulin.  Makes no sense not to have means to start correcting the problem which is one of the most common calls EMS gets.



And not every 911 ALS unit is a MICU...

I know for a fact that none of the ALS rigs in the area have refrigerators on them.


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## medic417 (Feb 20, 2009)

ffemt8978 said:


> And not every 911 ALS unit is a MICU...
> 
> I know for a fact that none of the ALS rigs in the area have refrigerators on them.



Do they not perform RSI?  Or are they improperly storing their drugs?  We have a number of drugs that have to be refrigerated.


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## CAOX3 (Feb 20, 2009)

ffemt8978 said:


> I know for a fact that none of the ALS rigs in the area have refrigerators on them.



Then where the hell do you keep the beer.  You guys really need to become more progressive:lol:


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## ffemt8978 (Feb 20, 2009)

CAOX3 said:


> Then where the hell do you keep the beer.  You guys really need to become more progressive:lol:



Since we're a fire department, we have a 5000 gallon tender for that.


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## medic417 (Feb 20, 2009)

ffemt8978 said:


> Since we're a fire department, we have a 5000 gallon tender for that.



Wondered why fire medics always seemed off balance.


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## CAOX3 (Feb 20, 2009)

ffemt8978 said:


> Since we're a fire department, we have a 5000 gallon tender for that.



Now thats a party I dont want to miss.


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## reaper (Feb 20, 2009)

medic417 said:


> Do they not perform RSI?  Or are they improperly storing their drugs?  We have a number of drugs that have to be refrigerated.



Sucs can be stored out of refridgeration for up to two weeks. I have never worked in a system that kept it refridgerated on a truck. It is swapped out every two weeks!


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## medic417 (Feb 20, 2009)

reaper said:


> Sucs can be stored out of refridgeration for up to two weeks. I have never worked in a system that kept it refridgerated on a truck. It is swapped out every two weeks!




What a waste.  You can buy a small fridge cheaply.  Plus besides sucs we carry other drugs that last longer stored cool.


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## reaper (Feb 20, 2009)

Sucs run around $2 a vial. That is a cheap price for less strain on a trucks electrical system.

If more systems carried insulin, then I could see the need for it.


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## medic417 (Feb 20, 2009)

reaper said:


> Sucs run around $2 a vial. That is a cheap price for less strain on a trucks electrical system.
> 
> If more systems carried insulin, then I could see the need for it.



It is not any strain really.  They draw hardly any power.  

Here is just one type available just so you can see how small and how little they actually draw.  
http://www.bigfrogmountain.com/Engel 15.htm
http://www.roadtrucker.com/engel/engel-12-volt-acdc-refrigerator-freezer.htm


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## BruceD (Feb 25, 2009)

Explorer127 said:


> I really, really do not need you tell me that I don't know how to care and treat diabetic patients and that my question "reflects the lack of knowledge" that I posses.
> 
> I am not yet an EMT and I have not yet taken an EMT class. I'm an explorer who is trying to learn a few things about patient care.
> 
> ...



This is probably off topic now, but if it's not been posted:
Diabetes would be diagnosed as
1)a fasting bg  > 126
2)a bg of >200 with any dm symptoms
3)a bg of >200 after a 75g loading dose of glucose(glucola)

A high bg can also occur during periods off stress, infection,etc.

Keep up the learning!
Rid - glad you got that under control.


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