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You're welcome!
Gotta try to impress upon the patient the gravity of the situation... and they can still say "no"...
Diabetic Question
- Thread starter cm4short
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Like I've said before, if you have a chronic pt that does a poor job of controlling their disease, and typically refuses txp after a momentary correction by EMS, load them up after obtaining diagnostics/O2 admin and push some D50 enroute to the hospital. If the family questions you, tell them that you've seen similar pts in the past drop their BGL dangerously low despite oral/IV sugar, and you want them to be seen at the hospital before they suffer unbreakable seizures and/or irreversible brain damage (or death!) as a result. Put the fear into them. Legally circumvent the whole decisional capacity refusal thing.
I've played the whole "drink some juice, eat a sandwich, check the BGL 95 times while onscene" thing way too many times. If one round of oral intake doesn't work, it's txp time. And if someone needs Glucagon, it's really no question at that point.
Besides, if someone's BGL has dipped with no discernable reason, such as a fever, increased activity, missing a meal, etc, an attending's eval is definitely in order.
I've played the whole "drink some juice, eat a sandwich, check the BGL 95 times while onscene" thing way too many times. If one round of oral intake doesn't work, it's txp time. And if someone needs Glucagon, it's really no question at that point.
Besides, if someone's BGL has dipped with no discernable reason, such as a fever, increased activity, missing a meal, etc, an attending's eval is definitely in order.
I'd never lie to a patient (or family) to achieve my own end goal. Just do a shake n wake, check the patients glucose, take new vitals and make a transport decision. If I've been someplace twice within 24 hours I won't argue about transport. This is true for those who require 2 amps in most cases and of course, those taking too long to come around.
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Being that I rarely like to sit on scene... and I do NOT want to be trying to manage diabetics (especially brittle ones) with the few tools we have available, I'd most likely prefer to load, go, treat en-route. At least the patient will get an evaluation... before they AMA.
Who's saying that I'm lying? I'm merely advising the family of the possible (real) consequences of refusal of further Tx/Txp. Any good medic will put the fear of death into a pt wishing to refuse if their condition is serious. If the pt generally takes good care of themselves and had a slip up, no worries. Take a look around and see how well they're taking of themselves from a lifestyle standpoint. If the pt is a frequent flier who has shown profound disdain and apathy (vs neglect from caregivers, a totally different issue) toward their disease, I'm going to employ the above tactics. They look to us to fix the problem repeatedly, rather than take an active role in managing their condition. After having to spend repeated nights at the ED, I've seen many change their tune.
There's nothing negligent about performing interventions enroute to the hospital, provided that they're stable enough to make the trip to the bus. Treat an arrest, a severe asthma/COPD exac, APE, MI, etc in the house, absolutely. An altered diabetic with an adequate BP/RR/airway/pulse will certainly survive the trip out to the bus. It's all implied consent until you bolus them out of AMS, and by that time you're halfway to the ED. They're certainly not going to have you stop the bus, sign a refusal, and hike it back home.
austinmedic77
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while you may not be lying you are at minumum being purposely evasive and misleading (and depending on definition lying may not be a stretch). Not to mention unethical and potentially harmful by withholding neccesary treatment in order to keep this pt obtunded to meet your personal goal of txp. While I will not argue that this patient should be transported, if for nothing else then to ensure a followup with an endocrinologist for medication adjustment and increased monitoring. However, you are saying that you would justify withholding tx so that you could tell the family about the "what if's" when you are in fact increasing the likelyhood of these conditions ensuing through your actions. Do it the right way spend the time needed with the pt and family to explain the need for txp include all of the possibilities and possible negative outcomes then allow them to make an informed decision. This is a basic pt right in almost all developed nations. It may not be what you want the outcome to be but your alternative is unacceptable. If you are unhappy about having to come to the pt's house to help them, then find another job this isnt the one for you. It's not our place to make these decisions for them. If the only thing preventing a patient from making an informed decision is our refusal to treat the cause of their condition when we have the ability to do so then the law and intent of the law are being circumvented. Yes, explain the benefits of txp and the consequences and "put the fear of god" into them as you put it but don't resort to unethical behavior to essentially make a point and try to impress your opinion of the pt's actions on them. What do you do when your pt that you now put in your rig and medicated them enroute becomes alert and now wants to refuse txp. If you force them to go to the hospital you are kidnapping them, so do you now dump them on the side of the road. That doesn't seem to be in their best interest. Or do you lead them to believe that now that they are in your truck they no longer have the right to refuse treatment and transport? Or worse yet are you withholding neccesary tx until right as you pull up to the dock at the ER so that the pt doesn't have the ability to exercise their right to refuse tx. Any of the above are unethical and could border on illegal depending on the option you are participating in. Ok I'll get off my soapbox its just the "burned out paragod" mentallity aggrivates me immensly.
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Find another job, burned out paragod, whatever. I get paid well, I enjoy my work, and I don't plan on going anywhere any time soon.
I don't see how I'm being evasive or misleading if I'm advising all possible risks and consequences relating to refusal of further tx/txp to the hospital. It's what we're supposed to do each and every time a pt wishes to refuse. It's required for the pt/family to be fully informed, nothing less. I always mention death as a possible consequence when applicable. That's where the "fear of god" thing comes into play.
If EMS is fixing a diabetic 5-6 times a week or more for months on end, something is obviously wrong, no? You're a long time diabetic, you should know that. The pt may need their meds adjusted, or maybe they need a plan for lifestyle adjustment or dietary guidelines. Or, as you suggest, I could just keep giving them a quick fix and help hasten their degeneration as in PVD, CAD, HTN, renal failure, CVA's, MI's, amps, numerous trips to the hyperbaric chamber for wound care. Or death, like I tell the family, if they go hypoglycemic yet again and no one's there to summon help until it's too late.
In my experience, those that I've transported a few times per my tactics have taken better control of their disease as a result. I find a way to get them to the ED so they can start taking better care of themselves, not because I'm tired of running them. I come to work to run calls. Fixing them up every day isn't really helping them. In reality, it's hurting them by facilitating the progression of the disease and it's related comorbidities.
If I need to take them to the bus while altered (not obtunded, as I'm not going to risk brain damage and such by withholding tx if they're that bad off) to facilitate txp to get them definitive care, or at least have them take better care of themselves to avoid repeat trips, then that's what I'm going to do.
None of this applies to the diabetic pt that has occasional dips in BGL. I'm more than happy to sit onscene and straighten them out with P.O. intake if possible. However, it shouldn't take over an hour to stabilize their BGL. Txp is strongly suggested via advisory of risks/consequences, "fear of god" and all.
If none of this jives with you, it's really none of my concern.
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austinmedic77
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if they are altered there is brain damage occuring and withholding treatment in order to force them into TXP is unethical regardless of their mental status. I advocate discussing all possible outcomes including death if appropriate and explaining what they are doing to their brain and the rest of their body by having their sugar continually fluctuate low in this case and high when we don;t see them. That being said the decision of transport is still theirs. Again i ask what about the patient you just woke up that now wants out? do you let them out there (which is what you legally should do) or do you noe let them exercise their right to refuse because they are in your truck. You say you want to be honest with them about the consequences of how they manage their disease (and I truly believe you) then in the next breath are at minimum evasive about their tx and txp options. The fact remains that an altered patient and an obtunded patient are both experiencing cellular damage, yes not to the same degree, but they are all the same and both require immediate intervention. You dont withhold O2 on an altered patient until you get them to the truck or adenasine to an SVT pt do you. No I'm sure you don't, but in your opinion its ok for that diabetic because they are only altered and not obtunded for the sole purpose of forcing txp on someone that if treated would be fully capable of making an informed decision. Hey I'm not gonna tell you how to practice as you don't work for me or in the same system as I do, but what you are doing whatever your motivation is unethical and in some instances possibly illegal.
Like I said do as you wish and what your medical director allows you to but all it will take is one educated pt (and yes educated people don't manage their disease well just like some uneducated folks, a lot of diabetic md's are common offenders) and you will lose a law suit and possibly your license no matter where you live. My statements aren't any of your concern as I don't live near you and won't have to ever treat me however, dismissing someones rights because you have had to run them 5 times a week isn't the right answer either.
Like I said do as you wish and what your medical director allows you to but all it will take is one educated pt (and yes educated people don't manage their disease well just like some uneducated folks, a lot of diabetic md's are common offenders) and you will lose a law suit and possibly your license no matter where you live. My statements aren't any of your concern as I don't live near you and won't have to ever treat me however, dismissing someones rights because you have had to run them 5 times a week isn't the right answer either.
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When dealing with these chronic pts, I let them know beforehand, "If this keeps going on, I'm going to start treating you in the bus as we leave for the hospital". I shoot straight from the hip, and don't look to intentionally deceive my pts. These pts and I are thoroughly familiar with each other after frequent interactions. They've been advised of risks/consequences numerous times. I tell them that I'm going to do what I need to do to get them help, as it can't keep going on llike this. Now, if my pt tells me that I'm kidnapping them, or tell me something along the lines of "You had better not try and take me out to the ambulance before fixing me up next time", I won't do it.
Getting them to definitive care and therefore better control of their disease is of much more benefit to the pt than treating them on a sometimes daily basis, which results in cumulative brain injury from the numerous hypoglycemic insults. I could drop a lock in the house and push D50, or I could take the 90 seconds or so to get them in the rig and do the same thing. A minute or two of delay in D50 admin vs sparing them injury from further frequent hypoglycemic episodes (minutes, hours before EMs is summoned) is of no comparison.
If and when they become alert during transport, and demonstrate adequate decisional capacity, the pt is aware that they can refuse further tx/txp. No sane person is going to ask to be let out halfway to the hospital, but I'll do it if they absolutely insist. I've let pts out of the back on their request after stopping during txp on several occasions, albeit for different reasons. I tell the pt that they are also free to go after we arrive at the ED but before going in to triage if they wish. We advise against it of course, but they know that they can just walk away if they want. But I'll tell them "Hey, since we're already here, why don't you just let the doc check you out and see if there's something wrong?"
Call it "ghetto" urban medicine or whatever (the majority of the medically ignorant/apathetic population resides in the inner cities, particularly in areas of poor socioeconimic standing in my experience), but it does get results, and it results in a better outcome for the pt, from a quality of life standpoint. I won't lose any sleep at night.
Getting them to definitive care and therefore better control of their disease is of much more benefit to the pt than treating them on a sometimes daily basis, which results in cumulative brain injury from the numerous hypoglycemic insults. I could drop a lock in the house and push D50, or I could take the 90 seconds or so to get them in the rig and do the same thing. A minute or two of delay in D50 admin vs sparing them injury from further frequent hypoglycemic episodes (minutes, hours before EMs is summoned) is of no comparison.
If and when they become alert during transport, and demonstrate adequate decisional capacity, the pt is aware that they can refuse further tx/txp. No sane person is going to ask to be let out halfway to the hospital, but I'll do it if they absolutely insist. I've let pts out of the back on their request after stopping during txp on several occasions, albeit for different reasons. I tell the pt that they are also free to go after we arrive at the ED but before going in to triage if they wish. We advise against it of course, but they know that they can just walk away if they want. But I'll tell them "Hey, since we're already here, why don't you just let the doc check you out and see if there's something wrong?"
Call it "ghetto" urban medicine or whatever (the majority of the medically ignorant/apathetic population resides in the inner cities, particularly in areas of poor socioeconimic standing in my experience), but it does get results, and it results in a better outcome for the pt, from a quality of life standpoint. I won't lose any sleep at night.
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austinmedic77
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I've made my point you have made yours and I will support your right to make you own decisions, your stated intent of getting them to the truck was to initiate txp so that they couldn't refuse after being fixed on scene and that is unethical. I understand that you say you are doing it because you feel it is in the best interest of the patient in the long run but it isn't doing them any good now. I understand your desired result and respect it I just don't agree with it as you don't agree with the point I am making. So no hard feelings and none intended, your last post is drastically different then you OP and the implication that was read. No worries just hope it doesn't bite you in the end that's all.
Thanks. I should have explained the intent of my actions during my earlier posts.
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And all of this assumes that you're dealing with a hypoglycemic patient... in the hyperosmolar non-ketotic diabetic... or the patient in DKA... none of this will work... about the ONLY thing that most of us carry is NS or LR. What will that do for the patient? Well... dumping a liter in will dilute the BGL... thus reducing the serum osmolality... but this does NOTHING for driving glucose into the cells, where it's needed.
Generally speaking, ambulances don't have proper labs on board or insulin to properly begin to treat those conditions. It can take DAYS to get those patients back under proper control.
Generally speaking, ambulances don't have proper labs on board or insulin to properly begin to treat those conditions. It can take DAYS to get those patients back under proper control.