I had a call today, and she wound up being severely septic. She was a diabetic, but wasn’t on insulin, so that made me less suspicious of BGL being low. She had been vomiting for a few days, and was just getting worse. She was responsive, but somnolent and only responsive to voice. Her BP was around 70/40 the whole time, so I was more concerned about that and getting her to the hospital as fast as possible. Here’s the bad thing… I didn’t check her BGL. Per the ER labs from the ER it was 13… so plain and simple, how screwed am I? I really hope I don’t lose my license or something. I realize now it was a big screw up that won’t happen again. Anyone with any advice?
I made a mistake, any advice?
- Thread starter bdoss2006
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CCCSD
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I thought you were the Be All of EMS and our suggestions to your vast amount of questions were all wrong? Per your posts, you are over your head and again, you should really think about what you Don’t Know.
As to your current predicament: Hire an Attorney.
I never once said that. I knew you would come in here with your attitude. No, I’m not over my head, and I know I should have checked it. It was an oversight, not an issue of not knowing. I guess you’ve never made a mistake
CCCSD
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Nothing that would potentially kill or permanently disable a pt.I never once said that. I knew you would come in here with your attitude. No, I’m not over my head, and I know I should have checked it. It was an oversight, not an issue of not knowing. I guess you’ve never made a mistake
Well this didn’t kill her, and I doubt she will have any permanent effects from it
CCCSD
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Did you read what I posted?
Uh, yeah?
DesertMedic66
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A lot of questions on this one. During your treatment of this patient you thought her blood sugar was low but did absolutely nothing to test it or to treat it?
You said she ended up being severely septic at the hospital but then her blood sugar also ended up being 13. Is that 13 in mg/dL where it is very low or is it in mmoL in which case it is in the higher range?
It is pretty rare for a patient with no known history of diabetes to become hypoglycemic when they aren’t taking any medications for it, rather these patients are hyperglycemic. Since the cells have no way to get/use the sugar it just builds up in the blood.
I’m assuming you are an EMT, were you so close to the hospital that calling for a paramedic was not possible to help with that BP of 70/40 that has a MAP of 50?
You said she ended up being severely septic at the hospital but then her blood sugar also ended up being 13. Is that 13 in mg/dL where it is very low or is it in mmoL in which case it is in the higher range?
It is pretty rare for a patient with no known history of diabetes to become hypoglycemic when they aren’t taking any medications for it, rather these patients are hyperglycemic. Since the cells have no way to get/use the sugar it just builds up in the blood.
I’m assuming you are an EMT, were you so close to the hospital that calling for a paramedic was not possible to help with that BP of 70/40 that has a MAP of 50?
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At the BLS level, what you're seeing should be a very high alarm for getting an ALS provider to this patient's side as fast as possible. While I'm not necessarily super enthralled that you didn't check a blood glucose level, having a somnolent/voice responsive patient with a low BP should set off some serious alarm bells. Same goes for nausea/vomiting for days and history of diabetes. As a BLS provider, you usually don't have the ability to do anything about a low blood sugar level in a patient that is probably not likely able to follow commands. However, whenever I see a patient with nausea/vomiting (especially for days) and a history of diabetes, I will check blood glucose level. When that's paired with hypotension, I get REALLY anxious about getting an ALS provider to the patient NOW. As an ALS provider (and I don't think you are one yet), take all that stuff and at least I have something I can DO about some of the problems. I'm going to do a couple of things REALLY fast. First I'm getting IV access, even if I have to do an IO, and starting a fluid bolus and that's with a pressure bag. Then I'm looking for some D10 or D50 to go in to address the low blood glucose level. Somewhere along the way I'll start looking for a 2nd line if I can and the entire time I'm going to be watching her vitals. If I have EtCO2, I'll use that as it'll give me an idea about how the patient is breathing, how often, and if they're blowing off a LOT of CO2. That 2nd line, if I'm able to get it, will allow me to either add more fluids, start pressors, or at least give the ER a "get ahead" for doing all that stuff... in addition to having another line for other meds like antibiotics if it's truly a sepsis and not a DKA problem that's gone way down hill...
Now to answer your question... yes you screwed up. Probably not in a way that will result in additional harm to your patient. You'll be "educated" about your mental lapse. However you'll probably be released back to work after that, and they'll keep a very close watch on you for a while. What did you do? You noticed that you had a patient who was altered, hypotensive, and a diabetic and you didn't bother to check a blood glucose level. At the BLS level, there's very little you can do with a patient like that except do lights and siren (you or an ALS intercept) to get ALS to the patient as fast as safely possible. If the hospital was your time-closest option, then you've done the one intervention that BLS has that would benefit the patient the most. Sepsis and/or DKA can easily result in the the presentation of the patient you had. You had a really sick patient on your hands.
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First, take a deep breath - we've all had calls where we look back and realize we missed a step in our assessment. What's important is that you recognized the error, are taking it seriously, and are learning from it.
From what you've described, you were dealing with a critical patient with clear signs of shock. Your focus on the severely hypotensive BP and rapid transport was absolutely appropriate. While a BGL check is part of a complete assessment, especially in diabetic patients, your primary concern of getting a critically ill septic patient to the hospital makes sense.
Some suggestions moving forward:
1. Document the call thoroughly, including your clinical decision-making process and focus on the critical hypotension
2. Consider submitting an incident report to your supervisor proactively
3. Use this as a learning opportunity to refine your assessment routine - perhaps add BGL to your initial vital signs for all altered mental status patients, regardless of history
Regarding your license - a single missed BGL check, while not ideal, is very unlikely to result in license action, especially given that you:
- Recognized the critical nature of the patient
- Provided appropriate care for septic shock
- Got the patient to definitive care quickly
- Are showing appropriate reflection and commitment to improvement
Id review your protocols for altered mental status and sepsis to ensure you're completely familiar with all required assessment steps. If you're still concerned, you might want to discuss this with your medical director or supervisor.
From what you've described, you were dealing with a critical patient with clear signs of shock. Your focus on the severely hypotensive BP and rapid transport was absolutely appropriate. While a BGL check is part of a complete assessment, especially in diabetic patients, your primary concern of getting a critically ill septic patient to the hospital makes sense.
Some suggestions moving forward:
1. Document the call thoroughly, including your clinical decision-making process and focus on the critical hypotension
2. Consider submitting an incident report to your supervisor proactively
3. Use this as a learning opportunity to refine your assessment routine - perhaps add BGL to your initial vital signs for all altered mental status patients, regardless of history
Regarding your license - a single missed BGL check, while not ideal, is very unlikely to result in license action, especially given that you:
- Recognized the critical nature of the patient
- Provided appropriate care for septic shock
- Got the patient to definitive care quickly
- Are showing appropriate reflection and commitment to improvement
Id review your protocols for altered mental status and sepsis to ensure you're completely familiar with all required assessment steps. If you're still concerned, you might want to discuss this with your medical director or supervisor.
Check BGL whenever you think mental status is altered, regardless of what else might be causing AMS.
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I find it interesting that a local provider checks BGL for all patients.
I've known people who did that. I wouldn't.
Another guy told me, "Everyone on my ambulance gets an IV."
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As an ALS provider, I do not start an IV line on everyone (patient) in my ambulance. Not everyone needs one. That being said, I will usually check BGL on my patient if I'm starting a line. If I have an indication to start a line, then checking a BGL doesn't require an additional stick as I've already got a drop of blood available from the IV start. In the ER, I don't normally do that as labs are drawn on nearly everyone anyway... but I will still do a POC BGL when the patient is altered or showing signs of potential stroke. The POC result won't be as accurate as the lab but it will result MUCH sooner (seconds vs 20 min).
Everyone who gets an IV from me, gets a BGL from it, or a finger stick.
Everyone who seems altered in any way, including possible CVA gets a BGL. I have cured at least 3 CVA's (people with every symptom we can check) by giving the patient Oral Glucose, D 50 or D10.
When I can't figure out what is going on with the patient I check BGL. No brainer, easy check, gives me time to review (mentally) what may be going on with the patient.
Everyone who seems altered in any way, including possible CVA gets a BGL. I have cured at least 3 CVA's (people with every symptom we can check) by giving the patient Oral Glucose, D 50 or D10.
When I can't figure out what is going on with the patient I check BGL. No brainer, easy check, gives me time to review (mentally) what may be going on with the patient.
You don't really mean you're curing CVAs with glucose, do you?
DrParasite
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no, he's not... but some hypoglycemic patients can present exactly like are having a CVA: clear facial droop, one-sided weakness, the works.
a little sugar and all of their symptoms magically go away.
Yes, I know, and I know you know. I'm not sure he does.