Glucagon then a Refusal?

[NPO]

There's a topic of discussion on another EMS social media page, but it doesn't really sprout discussion, mostly just bickering.

So I'm bringing it here. The topic is administration of Glucagon then allowing the patient to refuse transport.

Several people were adamant that allowing a patient to refuse after Glucagon was akin to "signing their death warrant" as one user put it.

I'm familiar with the process of glycogenolysis prompting the release of energy stores, but is there more to this medication than I'm aware of?

Is Glucagon administration more deserving of a hospital visit than a treat and release with D10 (assuming proper follow up care is available at home.)

 

[VentMonkey]

IIRC, depending on the patients Insulin intake, and type(s) that they may utilize they may qualify for automatic admission with certain physicians and/ or hospitals. This is regardless of the med given as a reversal agent (D10/50 vs. Glucagon).

I understand “diabetic wake ups” are more than standard in many systems, but even I learned that some patients will end up being admitted regardless only a few years back.

Lol, guess just some more food for thought to stir the pot in your SM page.

 

[RocketMedic]

Also, support system at home. I am a lot more comfortable with leaving someone at home with an attentive caregiver than I am with leaving them alone.

 

[DrParasite]

So I'm bringing it here. The topic is administration of Glucagon then allowing the patient to refuse transport.

Several people were adamant that allowing a patient to refuse after Glucagon was akin to "signing their death warrant" as one user put it.

Two thoughts come to mind here....1) patients can refuse care any time during their interaction with EMS.....

2) Glucagon is a hormone, and I have spoke to several nurses who were uncomfortable with EMS administering a hormorne in the field. I guess this is a similar line of thought to having EMS administer Insulin. I know of ER docs that would rather the endocrinologist handle the insulin/glucagon balance.

I would imagine Glucagon would absolutely warrant a trip, more so than a treat and release using D10. With D10, you have some gluose in the reserve just in case something happens. once you give glucgon (assuming you can't establish IV access to give dextrose), you don't have those reserves, and the person already has issues maintaining their BGL levels.

Death warrant might be a little extreme, but definitely more of a high risk.

 

[mgr22]

Why would a refusal after glucagon be treated differently than a refusal after other interventions?

 

[NPO]

2) Glucagon is a hormone, and I have spoke to several nurses who were uncomfortable with EMS administering a hormorne in the field. I guess this is a similar line of thought to having EMS administer Insulin. I know of ER docs that would rather the endocrinologist handle the insulin/glucagon balance.

Excuse my ignorance, but why?
What about it being a hormone makes it more taboo?
Is it just the idea that we are tapping into and dumping the last of the glycogen reserves, that causes concern for another drop in BGL being unrecoverable? Or is there something more complicated that I don't understand?

The term hormone was thrown around a bit as well, and I don't understand why it being a hormone made any difference versus a synthetic medication.

 

[DrParasite]

honestly, I am not sure. it was several years ago (the last time i asked was either over lunch with a very intelligent charge nurse, or maybe it was after dinner, don't really remember), but i distinctly got the feeling that she, as a experienced ICU, L&D and ER nurse didn't feel comfortable giving glucagon, and didn't think paramedics should either.

It might have been as simple as she didn't think anyone other than a doc should be messing with hormones, but I don't remember what her exact logic and reasoning is.

 

[Bullets]

Two thoughts come to mind here....1) patients can refuse care any time during their interaction with EMS.....

.

This, here, end of discussion.

 

[Gurby]

i distinctly got the feeling that she, as a experienced ICU, L&D and ER nurse didn't feel comfortable giving glucagon, and didn't think paramedics should either.

 

[Carlos Danger]

Glucagon has more side effects than dextrose, but provided they are tolerating those well, there really isn’t any difference leaving a person after waking them up with glucagon or dextrose. The thing about glucagon being a hormone is just silly.

Provided they are oriented and appear to understand the situation, are able to (and do) eat, and have a responsible person with them to call back if needed, I’m completely comfortable leaving them. I am not comfortable leaving them alone, no matter how oriented they are and how much they promise me they will eat. It would be a true AMA refusal in that case.

 

[NPO]

This, here, end of discussion.

We have an obligation to inform them of the risks. To inform them, we need to understand them.

 

[Peak]

Two thoughts come to mind here....1) patients can refuse care any time during their interaction with EMS.....

100%. If they are competent to refuse care we cannot force them to go to the hospital just because they may become hypoglycemic again, that would be battery/kidnapping/chose your exaggerated felony. I would rather have the patient come in to determine if they have a serious underlying etiology, but when they know that they didn't eat breakfast and decided to mow the lawn and will now go eat breakfast I understand why they wouldn't want to spend hours in the ED.

2) Glucagon is a hormone, and I have spoke to several nurses who were uncomfortable with EMS administering a hormorne in the field. I guess this is a similar line of thought to having EMS administer Insulin. I know of ER docs that would rather the endocrinologist handle the insulin/glucagon balance.

Honestly, they need to get over themselves. I don't think that glucogon should be the first line, it requires the liver to have sugar to release and has more side effects than just giving dextrose, but that doesn't mean that it doesn't have a valid use in EMS. We give it to families to give to their kids if their sugars are low and are unresponsive (and thus will not take PO sugar), and they do great with it.

Side note, that epi we give is a hormone. The decadron/solumedrol/solucortef we give mimics endogenous steroids. Just because it has global effects doesn't mean that it is automatically unsafe to be given prehospital.

 

[Tigger]

Two thoughts come to mind here....1) patients can refuse care any time during their interaction with EMS.....

2) Glucagon is a hormone, and I have spoke to several nurses who were uncomfortable with EMS administering a hormorne in the field. I guess this is a similar line of thought to having EMS administer Insulin. I know of ER docs that would rather the endocrinologist handle the insulin/glucagon balance.

I would imagine Glucagon would absolutely warrant a trip, more so than a treat and release using D10. With D10, you have some gluose in the reserve just in case something happens. once you give glucgon (assuming you can't establish IV access to give dextrose), you don't have those reserves, and the person already has issues maintaining their BGL levels.

Death warrant might be a little extreme, but definitely more of a high risk.

An ED doc is more than capable of starting a hyperglycemic patient on an insulin protocol and to do otherwise is not a particularly great use of resources.

As for the "EMS shouldn't give hormones," not sure I understand. It isn't like IV Dextrose provides some large glucose reserve. Any patient that receives EMS treatment for hypoglycemia needs to demonstrate that they can care for themselves, to include eating a real meal with complex carbohydrates. At this point whatever glucose the glucagon/IV/PO Dextrose provided is kind of moot. Patient's receiving glucagon are more likely to have comorbid factors which may necessitate them going to the hospital but not just because they got glucagon.

We have standing orders to leave patients who received glucagon, may it be for hypoglycemia or esophageal obstruction, should the provider find it appropriate.

 

[DrParasite]

Seemed kinda relevant....

https://www.ems1.com/diabetes/articles/373633048-Study-EMTs-cant-administer-glucagon/

 

[mgr22]

Seemed kinda relevant....

https://www.ems1.com/diabetes/articles/373633048-Study-EMTs-cant-administer-glucagon/

Maybe I'm missing the point of the original post, but isn't this a thread about refusals after glucagon administration? That article just talks about how unlikely it is your friendly, neighborhood EMT will be allowed to give you glucagon.

 

[DrParasite]

look at the actual study: http://annals.org/aim/fullarticle/2...ccessKey=a7c7e279-10e2-4492-ad6b-abae52b3314a

The relevant parts are that only paramedics can give glucagon and EMTs can't yet the author was saying Glucagon was so safe and effect that event EMTs should be able to give it. If it's that dangerous (which I can see why paramedics don't want a refusal after administering it) why are these educated individuals advocating for EMTs to administer it?

 

[mgr22]

look at the actual study: http://annals.org/aim/fullarticle/2...ccessKey=a7c7e279-10e2-4492-ad6b-abae52b3314a

The relevant parts are that only paramedics can give glucagon and EMTs can't yet the author was saying Glucagon was so safe and effect that event EMTs should be able to give it. If it's that dangerous (which I can see why paramedics don't want a refusal after administering it) why are these educated individuals advocating for EMTs to administer it?

I'm not following your argument, but I agree the study represents knowledge, and knowledge is good.

 

[Tigger]

In much of the rest of the developed world, base level EMS providers administer glucagon. Also in the rest of the world it doesn't cost 2-300 dollars a dose.

 

[E tank]

Glucagon is a hormone, and I have spoke to several nurses who were uncomfortable with EMS administering a hormorne in the field. I guess this is a similar line of thought to having EMS administer Insulin. I know of ER docs that would rather the endocrinologist handle the insulin/glucagon balance.

epinepherine is a hormone. nurse's "discomfort" isn't a recognized treatment category in any medical milieu I'm familiar with. I'm also unfamiliar with emergency physicians uncomfortable with acute management of blood glucose. I do appreciate folks that know when they're out of their depth, but is this the same thing?

 

[Aprz]

I'm not following your argument, but I agree the study represents knowledge, and knowledge is good.

It seems pretty straight forward what @DrParasite is saying, but I'll try to reword it. If educated folks are pushing for entry level EMTs to administer it, then how come people view it as dangerous for a paramedic to do a refusal after administering it?