Diabetic Question

[cm4short]

I'm in my internship now and my preceptor gave me a question based on the call we ran this morning. I'd just like to share the info for learning purposes...

Which type of diabetic would you not want to AMA after glucose administration and why? Is it the insulin dependent type 1, or the non-insulin dependent type 2 taking oral pills. Don't forget they why portion.

 

[rescue99]

I'm in my internship now and my preceptor gave me a question based on the call we ran this morning. I'd just like to share the info for learning purposes...

Which type of diabetic would you not want to AMA after glucose administration and why? Is it the insulin dependent type 1, or the non-insulin dependent type 2 taking oral pills. Don't forget they why portion.

Type II patient with hx of oral meds. Glucose will continue to dip for up to 24 hours.

 

[rescue99]

Guess I should add that different medications have different mechanisms and vary in half life as well. Renal / liver function may play a role to boot.

 

[emtjack02]

Type II patient with hx of oral meds. Glucose will continue to dip for up to 24 hours.

I like your answer...But what about the diabetics on those wonderful new long acting insulins like lantus and levemir?

 

[rescue99]

I like your answer...But what about the diabetics on those wonderful new long acting insulins like lantus and levemir?

There wasn't enough information in the question to answer insulin.

 

[Akulahawk]

I like your answer...But what about the diabetics on those wonderful new long acting insulins like lantus and levemir?

It would have to depend upon the blend of insulins that the patient is using. If they're going to be on longer acting insulins, they're likely to be blending short medium and long duration insulins to provide for insulin coverage throughout the day. If the patient goofs up on the long duration insuin dose, the Blood Glucose level could also continue to drop for a long time... I'd be very reluctant to AMA that type of patient as well.

 

[cm4short]

I'd have to disagree somewhat based on the reasonings' given. The duration of insulin and glucose medications are pharmakinetically acting as they are intended. Now, if the person continues to eat, then where does it change from being a "medical condition" to become a "medical concern."

My theory is when a diabetic is on oral pills, they are often on different types. these pills act as synergist of eachother. But, synergistic effect of the oral pills aded to thethe changing pattern of a type 2 diabetics insulin production my lead to irregular blood glucose levels.

 

[rescue99]

I'd have to disagree somewhat based on the reasonings' given. The duration of insulin and glucose medications are pharmakinetically acting as they are intended. Now, if the person continues to eat, then where does it change from being a "medical condition" to become a "medical concern."

My theory is when a diabetic is on oral pills, they are often on different types. these pills act as synergist of eachother. But, synergistic effect of the oral pills aded to thethe changing pattern of a type 2 diabetics insulin production my lead to irregular blood glucose levels.

My answer comes from the information given in the question. Simple question gets a simple answer..lol

 

[cm4short]

Yeah, I kinda rushed that answer. We were getting a call just as I was typing. :sad: But, to add to the question.

The patient we had this morning was a 44 F c/o ALOC secondary to low blood sugar. The patient had a BS of 28 after D-stick. The Pt was placed on O2 IV started, D50 given. Pt went ALOC and didn't wanna go to the hospital. This was one of this stations semi-regular AMA's. She is an Insulin Dependent diabetic with no other Hx and A to PCN. Negative recent illnesses or complaints after return of LOC's. Negative secondary. V/S intact. the Pt does happen to have a very poor diet. Their meal proportions are small and are often just enough to keep her BS up for the next BS reading. Her meal the night before was to drink honey before she went to bed for the night. she stated she was already feeling tired.

After administration of D50, assuring a meal was prepared and contacting base; she was cleared AMA. I was asked the question upon leaving the call.

 

[JPINFV]

Which type of diabetic would you not want to AMA after glucose administration and why? Is it the insulin dependent type 1, or the non-insulin dependent type 2 taking oral pills. Don't forget they why portion.

Based off of just this information provided, neither should be AMA'ed immediately because without additional food the D50 would wear off quickly. Of course another tricky question is can you deny a patient who is now alert, orientated, and understands the risks of signing out AMA from signing out AMA? Just because a patient needs more definitive care or could collapse again doesn't mean the patient loses the ability to refuse treatment and transport.

 

[46Young]

We've had several diabetic pts who do a poor job of controlling their BGL. These pts would typically refuse further tx/txp after fixing them up. The answer? Treat 'em in the bus, push the D50 on the way to the hospital. Too late to refuse txp at that point. Maybe then they'll try a little harder to control their disease. Again, this is for chronic pts who have demonstrated significant apathy toward their condition, and keep relying on EMS for a quick fix rather than take an active role in controlling their disease.

This tactic sounds harsh, but has shown fantastic results in my experience.

I've had pts on oral hypoglycemics that have kept us onscene for over an hour that insist on eating and drinking, only to have the BGL stay low. After a certain point, it becomes a waste of time and resources to keep the crew onscene. Time to go to the hospital. If one round of OJ and a PB&J sandwich doesn't do the trick, an ER visit should be indicated.

 

[rescue99]

Based off of just this information provided, neither should be AMA'ed immediately because without additional food the D50 would wear off quickly. Of course another tricky question is can you deny a patient who is now alert, orientated, and understands the risks of signing out AMA from signing out AMA? Just because a patient needs more definitive care or could collapse again doesn't mean the patient loses the ability to refuse treatment and transport.

Ah Ha...but I did consider a person with IDDM would have eaten after, since this is just a part of the S/R protocol. I've never left a less than AOX4 patient until after I see him/her eat at least part and family is present to ensure the rest is finished. Oral meds...different story completely.

 

[TransportJockey]

My thought would be type I on long acting insulin. That's our usual type we don't let go AMA here.

 

[rescue99]

My thought would be type I on long acting insulin. That's our usual type we don't let go AMA here.

History and meds clears that up...history and meds. All the stuff we do to begin with prevents a lot of unanswered questions.

 

[Markhk]

Hrm, interestingly our EMS Agency put an advisory up last year specifically on oral hypoglycemics.

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http://sccemsagency.org/SCC/docs/Em...hments/7.29.08Lessons Learned August 2008.pdf

Extract

DIABETIC PATIENTS ON ORAL HYPOGLYCEMIC AGENTS
Hypoglycemia is a frequent and dangerous complication for diabetic patients. This is particularly the case for patients who are treated with oral medications.
Hypoglycemia is most often associated with the sulfonylurea oral agents glipizide and glyburide. Glyburide can produce severe, prolonged hypoglycemia that may necessitate intravenous glucose infusion for several days and is the most common cause of hypoglycemia and death related to sulfonylurea use. The risk factors for sulfonylurea-induced hypoglycemia include advanced age (over 65 years), inadequate caloric intake, concomitant drug use (e.g., ß-blockers, insulin), recent initiation of sulfonylurea therapy with limited or no prior exposure to sulfonylurea therapy, and long-acting versus short-acting sulfonylurea use.

 

[Sieldan]

Yeah, I kinda rushed that answer. We were getting a call just as I was typing. :sad: But, to add to the question.

The patient we had this morning was a 44 F c/o ALOC secondary to low blood sugar. The patient had a BS of 28 after D-stick. The Pt was placed on O2 IV started, D50 given. Pt went ALOC and didn't wanna go to the hospital. This was one of this stations semi-regular AMA's. She is an Insulin Dependent diabetic with no other Hx and A to PCN. Negative recent illnesses or complaints after return of LOC's. Negative secondary. V/S intact. the Pt does happen to have a very poor diet. Their meal proportions are small and are often just enough to keep her BS up for the next BS reading. Her meal the night before was to drink honey before she went to bed for the night. she stated she was already feeling tired.

After administration of D50, assuring a meal was prepared and contacting base; she was cleared AMA. I was asked the question upon leaving the call.

ALOC = ? Asomething Loss of Conciousness??
And whats the A to PCN? No clue on that one.

Thanks

 

[Akulahawk]

ALOC = ? Asomething Loss of Conciousness??
And whats the A to PCN? No clue on that one.

Thanks

ALOC = Altered Level of Consciousness
A = allergy
PCN = Penicillin

Hope that clears up something for you.

 

[Sieldan]

Akulahawk,

Thanks a bundle. And I have to say, brainfart. I knew those, just couldnt recall them. Guess I can say I 'relearned' something today.

 

[fma08]

Based off of just this information provided, neither should be AMA'ed immediately because without additional food the D50 would wear off quickly. Of course another tricky question is can you deny a patient who is now alert, orientated, and understands the risks of signing out AMA from signing out AMA? Just because a patient needs more definitive care or could collapse again doesn't mean the patient loses the ability to refuse treatment and transport.

Key statement there, but doesn't mean one just rolls over when they say they don't want to go in. We are obligated to do all within our power that which is in the best interests of the pt. When we have and they still say no, then it's sign here please.

 

[Akulahawk]

Hrm, interestingly our EMS Agency put an advisory up last year specifically on oral hypoglycemics.

----

http://sccemsagency.org/SCC/docs/Emergency%20Medical%20Services%20(DEP)/attachments/7.29.08Lessons%20Learned%20August%202008.pdf

Extract

DIABETIC PATIENTS ON ORAL HYPOGLYCEMIC AGENTS
Hypoglycemia is a frequent and dangerous complication for diabetic patients. This is particularly the case for patients who are treated with oral medications.
Hypoglycemia is most often associated with the sulfonylurea oral agents glipizide and glyburide. Glyburide can produce severe, prolonged hypoglycemia that may necessitate intravenous glucose infusion for several days and is the most common cause of hypoglycemia and death related to sulfonylurea use. The risk factors for sulfonylurea-induced hypoglycemia include advanced age (over 65 years), inadequate caloric intake, concomitant drug use (e.g., ß-blockers, insulin), recent initiation of sulfonylurea therapy with limited or no prior exposure to sulfonylurea therapy, and long-acting versus short-acting sulfonylurea use.

I used to work in that system. Back when I did, I thought that in some ways, Alameda County was a bit ahead of SCC. That, however, was before Dr. Ghilarducci became the EMS Medical Director... and generally, even before he'd finished his residency. I do, however, like the direction that he's taken the SCC EMS agency...

I had a chance to read that info PDF you posted. It's a good read, but I also noted the use of "should" vs. "shall" where hypglycemic patients on oral meds... which tends to reinforce the idea that while you've managed to correct the instant problem and the patient is alert/oriented, if they refuse transport, you're going to have to let them go... lest you get a kidnapping charge... and just be aware that someone could be going back there in a few hours.

When you are presented with a diabetic patient on oral medication who has had a hypoglycemic episode, that patient should be transported for further treatment and observation even if the hypoglycemia is corrected in the field. Most oral agents are long acting, and the patient will often have another hypoglycemic event even after treatment. Unfortunately many diabetes patients who have hypoglycemic episodes prefer to sign out AMA after treatment.