Blood sugar?

[Akulahawk]

My point is that "because I started an IV" is not an indication for getting a glucose level.

Curious - do you charge the patient for that test or are your charges all bundled together?

Waaay back when, I usually got a BGL as part of the process of starting a line. However, the fact that I started a line isn't the reason I'm getting the BGL sample... I had a reason for starting the line (never precautionary) and if I can articulate why I'd get an FSBG, I can articulate why I'd get a BGL from the IV instead. If I'm going to need that info anyway, why stick the patient twice when I can get a clean sample with one stick and establish an IV all at once?

 

[jwk]

I apologize for using the qualifier "all" when I should have used "most." Anecdotally, checking a BGL on patients without the usual "valid indications" as you put it, has revealed abnormal values and subsequent diagnoses of new onset type ll diabetes in patients who "just didn't feel well." We don't charge the patient extra for the test. I hope that's less absurd in your observation.

I'm playing devils advocate as much as anything, but this is something that's hard to teach, especially when I have new anesthetists and docs straight out of training jumping into my private practice. If you don't charge extra for it, that's fine, and since it's not invasive if you're doing it with an IV start, it's pretty much no harm, no foul.

In the hospital, we need an indication for everything, which is quite different than the way it used to be. 35 years ago, every patient that was admitted to the hospital got an admission chest X-ray, EKG, CBC, UA, and what is now called a BMET. That applied to the healthy 18 yr old male and the 96 year old female and everything in between. Sure, we occasionally found something important, and something that changed our management of the patient. Most of the time we didn't. When they started adding up the cost of all these "routine tests", the totals were astronomical.

Also - I don't know how government regulations are intertwined with EMS on this type of thing - but I can't even perform a fingerstick in my hospital. Even with a master's degree, a PA license, and nearly 40 years experience, I have to be "trained" to use a specific glucometer, possess a bar code on my nametag that can be read by the scanner on the glucometer, and must pass annual "competency exams" on BG policies and procedures. Bite me - I'll let the nurse do it. And of course EVERY finger stick we do in the hospital and read by the glucometer is transmitted wirelessly to the lab so a charge can be generated for each and every fingerstick.

Even so, with the BG - I'm curious how often do your findings alter your management, outside of perhaps the diabetic patient? My guess would be not much.

 

[Carlos Danger]

In the hospital, we need an indication for everything, which is quite different than the way it used to be. 35 years ago, every patient that was admitted to the hospital got an admission chest X-ray, EKG, CBC, UA, and what is now called a BMET. That applied to the healthy 18 yr old male and the 96 year old female and everything in between. Sure, we occasionally found something important, and something that changed our management of the patient. Most of the time we didn't. When they started adding up the cost of all these "routine tests", the totals were astronomical.

Not only that, but the unnecessary treatment that can result from unnecessary testing has been shown to cause much more harm than good.

Absent clinical signs of hypoglycemia, I really have no idea why you'd bother checking a BGL.

 

[DesertMedic66]

Our hospitals still draw bloods on every patient who takes a seat on their beds. They still want us to draw bloods on all prehospital patients who we start a line on.

 

[MonkeyArrow]

Our hospitals still draw bloods on every patient who takes a seat on their beds. They still want us to draw bloods on all prehospital patients who we start a line on.

So do you not have fast track? It seems awfully inefficient to draw labs on the 33 year old healthy male that came in because of abrasions to the knee via a trip and fall at a 5k. At my hospital, labs are drawn out of necessity. Our fast track probably draws labs at a 1 out of every 30 patients rate. But with the i-stats coming into use, I see that number going up a bit.

 

[DesertMedic66]

So do you not have fast track? It seems awfully inefficient to draw labs on the 33 year old healthy male that came in because of abrasions to the knee via a trip and fall at a 5k. At my hospital, labs are drawn out of necessity. Our fast track probably draws labs at a 1 out of every 30 patients rate. But with the i-stats coming into use, I see that number going up a bit.

Those patients are seen/treated/ and released from the triage area and never set foot in the actual ER.

Now if for some reason that patient was brought in by EMS and not sent to the triage area or the patient was taken into the actual ER there is a 99% chance they will get an IV and a rainbow blood draw.

 

[MonkeyArrow]

Those patients are seen/treated/ and released from the triage area and never set foot in the actual ER.

Now if for some reason that patient was brought in by EMS and not sent to the triage area or the patient was taken into the actual ER there is a 99% chance they will get an IV and a rainbow blood draw.

Do you guys also prescribe meds (narcos in particular) from triage too? Is it staffed with a mid-level or a nurse? Just curious as to how you guys do it as opposed to us.

 

[DesertMedic66]

Do you guys also prescribe meds (narcos in particular) from triage too? Is it staffed with a mid-level or a nurse? Just curious as to how you guys do it as opposed to us.

It's staffed with nurses and either a PA or NP. The doc may float by if needed. And yes they will prescribe pretty much anything up there.

 

[rabidrider]

I got a kind of stupid question that really dont matter but its something I have been wanting to know for ever.

Back in EMT school I did a couple scenarios (more than a couple but these 2 stood out). I dont remember the scenarios anymore just the first was with my main instructor and he asked why I didnt check the BGL of a patient with a altered mental status. Ok he got me I should have.

A few days later I did a similar scenario with a different instructor and this time I did check the BGL and he nearly took my head off saying it was a ALS skill.

So which is it? Is it ALS or BLS? I know on clinical rides it would depend on the medic. Some would pretty much let me do anything I felt ok doing. Others not so much lol.

I am in Medic school now so it really no longer matters but it has always had me wondering if it is a ALS skill why? I can see pulling blood from the IV cath but sticking the finger really?

 

[TransportJockey]

I got a kind of stupid question that really dont matter but its something I have been wanting to know for ever.

Back in EMT school I did a couple scenarios (more than a couple but these 2 stood out). I dont remember the scenarios anymore just the first was with my main instructor and he asked why I didnt check the BGL of a patient with a altered mental status. Ok he got me I should have.

A few days later I did a similar scenario with a different instructor and this time I did check the BGL and he nearly took my head off saying it was a ALS skill.

So which is it? Is it ALS or BLS? I know on clinical rides it would depend on the medic. Some would pretty much let me do anything I felt ok doing. Others not so much lol.

I am in Medic school now so it really no longer matters but it has always had me wondering if it is a ALS skill why? I can see pulling blood from the IV cath but sticking the finger really?

Some states it's an als skill. Never understood that, but part of that is becaise here in nm its a bls skiLl all around

 

[DesertMedic66]

I got a kind of stupid question that really dont matter but its something I have been wanting to know for ever.

Back in EMT school I did a couple scenarios (more than a couple but these 2 stood out). I dont remember the scenarios anymore just the first was with my main instructor and he asked why I didnt check the BGL of a patient with a altered mental status. Ok he got me I should have.

A few days later I did a similar scenario with a different instructor and this time I did check the BGL and he nearly took my head off saying it was a ALS skill.

So which is it? Is it ALS or BLS? I know on clinical rides it would depend on the medic. Some would pretty much let me do anything I felt ok doing. Others not so much lol.

I am in Medic school now so it really no longer matters but it has always had me wondering if it is a ALS skill why? I can see pulling blood from the IV cath but sticking the finger really?

In some areas it's a BLS skill and in other areas it's an ALS skill. It all depends on your local and state protocols. For my area it is a BLS skill only after a medic or AEMT asks the EMT to check the sugar.

 

[rabidrider]

I guess that makes some sense. I will have to do some more digging for here in florida. It just didnt make sense to me as the instructor that almost took my head off told me that as an EMT-B if you suspect hypoglycemia to just call medical control to administer oral glucose because the benefits outweigh the risks. To me that make no logical sense. I get the benefits would outweigh the risks but if I was to call medical control the first thing they are going to ask is what is the BGL. If I say I dont know I just want to give him some :censored::censored::censored::censored: for hypoglycemia they would be looking like this guy on the other end :rofl:

 

[ABQmedic]

I'm playing devils advocate as much as anything, but this is something that's hard to teach, especially when I have new anesthetists and docs straight out of training jumping into my private practice. If you don't charge extra for it, that's fine, and since it's not invasive if you're doing it with an IV start, it's pretty much no harm, no foul.

In the hospital, we need an indication for everything, which is quite different than the way it used to be. 35 years ago, every patient that was admitted to the hospital got an admission chest X-ray, EKG, CBC, UA, and what is now called a BMET. That applied to the healthy 18 yr old male and the 96 year old female and everything in between. Sure, we occasionally found something important, and something that changed our management of the patient. Most of the time we didn't. When they started adding up the cost of all these "routine tests", the totals were astronomical.

Also - I don't know how government regulations are intertwined with EMS on this type of thing - but I can't even perform a fingerstick in my hospital. Even with a master's degree, a PA license, and nearly 40 years experience, I have to be "trained" to use a specific glucometer, possess a bar code on my nametag that can be read by the scanner on the glucometer, and must pass annual "competency exams" on BG policies and procedures. Bite me - I'll let the nurse do it. And of course EVERY finger stick we do in the hospital and read by the glucometer is transmitted wirelessly to the lab so a charge can be generated for each and every fingerstick.

Even so, with the BG - I'm curious how often do your findings alter your management, outside of perhaps the diabetic patient? My guess would be not much.

Fortunately, most BGL's that I check are benign. It follows most other "vitals" in my experience. Most abnormal BGL's are a result of diabetes and require the usual management. I have had one coincidence of BGL > 200 and AMI, though. Honestly, I considered it a "gee whiz" finding, until the receiving cardiologist commended me for checking the BGL. At that point, I approached my medical director and received some great education on the relationship with stress/inflammation response and blood glucose elevation.

 

[drjekyl75]

It used to be part of our protocols to draw labs, this was until a mix up happened. On a MVA with multiple patients, 4 ended up going to the same trauma center. The medic drew blood and in haste taped the wrong tubes to the wrong patient. This happened a few times and we lost the field blood draw from the protocol.

 

[Brandon O]

It depends if the glucometer is calibrated for venous blood samples, capillary blood samples, or both. I would say most modern ones are now calibrated for both.

I think I've read before that if distal circulation is poor, venous blood may be more accurate to use, however, I read that from a blog rather than from a study or something super legit so I am not sure how true that is.

That may have been me. Not sure I've see anybody else recommend that.

So I am guessing overall the glucometer that is calibrated for only capilary blood samples would think there is less glucose than there really is? Right?

Right. More glucose has been used when you sample from the veins (it's already given up its glucose), so using a meter calibrated for capillary blood (i.e. the one you have) on venous blood will result in a falsely low reading. But only by, oh, maybe 5-10 mg/dl, which is a small and predictable difference... whereas in sick people, capillary samples can be dramatically, significantly wrong in unpredictable ways. I say use venous blood if you has access.

 

[Aprz]

Well, I know which blog is associated with you , and found it quickly with "emsbasics blood glucose" on Google, haha.

In sick people, circulation is often impaired; this is particularly true in situations like shock, sepsis, and the mother of all shock states, cardiac arrest. When perfusion is poor, the first thing we lose is the peripheral circulation, and it doesn’t get more peripheral than the capillaries of the fingertips. What does this mean? It means that in many acute patients, when it’s important to have accurate diagnostics, capillary blood sugars can be utterly, totally inaccurate. Since blood is no longer moving actively through the periphery, it tends to “pool” there stagnantly, letting the tissues chew through its glucose supply without resupplying it. This results in a falsely depressed capillary BGL even when the venous BGL is normal. Conversely, it’s also possible that in poor circulation, the distal capillaries are the “last to hear” about a drop in sugar, resulting in a falsely elevated BGL. But high or low — usually low — it’s not reliable. Anybody with impaired circulation should get a venous glucose if there’s a chance of it affecting care. (And if there’s no chance of it affecting care, then why do it?) By the way, this includes impaired local circulation, such as patients with PVD. Not that a diabetic would ever have PVD…

http://emsbasics.com/2012/05/04/glucometry-how-to-do-it/

 

[Brandon O]

That's the one. Not gonna lie, I had to check it myself to remember some of the details. (Perk of educational writing: when you forget something, your "notes" are indexed by Google.)