JPINFV
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...because diabetes is the only thing that can cause a decreased blood glucose level?
...because all diabetics have medic alert bracelets?
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- Thread starter Shishkabob
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...because diabetes is the only thing that can cause a decreased blood glucose level?
...because all diabetics have medic alert bracelets?
Too Old To Work
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I said that he was passed out when you found him, not that he was persistently unresponsive.
How about using verbal or light painful stimuli to see if he wakes up? Then assess his mental status. Then if all of that is normal, don't even worry about a number.
Let's say he wakes up when you do the "shake and shout" that you were taught on day one of EMT school. Or maybe it was day two. Anyway, he tells you that he's been drinking, drinks every day, and has no medical problems.
He consents to let you stick a sharp object into his flesh and you find his BG is 69 mg/dl. What do you do now? Force him to go to the hospital? Buy him a sandwich? Call the paramedics so they can buy him a sandwich?
Use your clinical judgment, well if you have any, to make a decision based on your exam.
I think a lot of people don't have any idea what "altered LOC" means.
Too Old To Work
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A decreased blood glucose level does not necessarily mean altered mental status. Non diabetics can generally handle low blood glucose levels that diabetics can't.
Oh really...?
People without diabetes.
http://diabetes.webmd.com/tc/hypoglycemia-low-blood-sugar-symptoms
With diabetes.
http://www.emedicinehealth.com/low_blood_sugar_hypoglycemia/page3_em.htm#Low Blood Sugar Symptoms
I'd say a lot of those symptoms are AMS. And of COURSE they can handle low blood glucose levels that a diabetic can't. That's why those "other" people are called DIABETICS.
If his bgl is 69, I don't worry about it. Would I take him to the hospital if he had AMS? Of course. It's in my protocols. I can't out rule a head injury just by looking at him.
Too Old To Work
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So, what is the instance of treatable hypoglycemia in non diabetic patients? Non diabetics have compensatory mechanisms that diabetics don't. And again, what is "AMS"? If someone wakes up easily to verbal or light painful stimuli, answers all of the questions in your screening exam appropriately, denies any history of trauma, and has no evidence of a head injury, what to you do then? How do you claim AMS to justify taking them to the hospital? Especially how do you do that if they adamantly refuse to go?
If they have AMS they wouldn't be AAOx4, would they? If they check out alright, they aren't going. But if they are showing any symptoms of a head injury, I will beg them to go.
OP
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Shishkabob
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Sure they could be.
You're telling me someone can't know their name, location, date and events and not be extremely lethargic, mentally retarded, slow, or one of many psych conditions that WOULD make them altered?
You're telling me someone can't know their name, location, date and events and not be extremely lethargic, mentally retarded, slow, or one of many psych conditions that WOULD make them altered?
OK, I'll bite. You find a patient "passed out", using your EMT skills that you learned on day one of school, you perform a "shake and shout". They are slow to wake up. They can answer all of your questions appropriately but have slurred speech, unsteady gait and are slow to respond. He admits drinking heavily all day and has a history of alcohol abuse. Being the astute prehospital practitioner that you are, you check a BGL and it comes back 20. Now what?
Are you comfortable letting this patient sign a refusal? Would you decline to check a BGL in the first place?
Too Old To Work
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It this guy can do all that at 20, better to toss out the glucometer. My point is that it's the clinical signs, not the number that's important. Which too many people don't seem to get.
Slurred speech? Lot's of things cause that. Could be baseline from a previous injury or stroke. A lot of factors go into the decision of what might be wrong with a patient and what we can do about it.
reaper
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OK, lets say no history of TBI or stroke. Only significant history is alcohol/drug abuse and "they told me I was probably diabetic".
Too Old To Work
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That's why we still give thiamine to all hypoglycemics that we give D50. That's supposedly more pronounced among the alcoholic population, but I've never seen hard numbers on it. Most other systems don't seem to give thiamine. At least when I tell medics from other areas that we still use it, they think we're weird. Which of course we might be, but for many other reasons.
Too Old To Work
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I would contend that this is meaningless because people say things like that all the time. I work with a guy that had one set of elevated LFTs and now he tells everyone that he has "Stage II Liver Disease".
You're also changing the scenario from what I presented quite a bit, so the answer isn't valid to the original point that I made.
BTW, I wouldn't do a 12 lead ECG on this guy either to rule out cardiac related syncope. Well, not if his heart rate and BP were withing the expected range for a patient of his age.
Too Old To Work
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Yup. The hypoglycemic patients that I've seen, which would be a few thousand over the years, don't wake up and talk to you coherently if when you use BLS to get them up. If they can do that, chances are a couple of Twinkies and 20 oz Mountain Dew (not the diet kind) are all they need. Chances are they'll tell you that, too.
Also, I don't recheck a BG after giving D50 and thiamine. If the patient wakes up, and demonstrates a "normal" mental status, the BG is not telling me one thing that I need to know. If the patient doesn't wake up, the BG is still not going to tell me anything other than something else is probably going on.
If you have a patient who has been treated with D50 who is still disoriented, what are you going to do when you find out that their BG is 250? You're not going to rebolus them with MORE D50. What you're going to do is take them to the hospital so that they can figure out what's going on. Similarly, if the patient wakes and their BG is now 65, but they are oriented, what are you going to do? Give them more D50? I think not. You're going to do what you would do if their BG was 120. You're going to have them eat something. You're going to try to convince them to go to the hospital, warn them that their BG might drop again, make sure that they have someone who will stay with them and advise that person to recontact 9-1-1 (or 999 or whatever number). You're going to document your findings and get a refusal. The number on the glucometer is not going to help you decide what to do with this patient.
How about if someone is complaining of dyspnea and chest pain, but has a diabetic history? Are you going to focus on that if they have a normal mental status? Use your clinical judgment to help you sort things out. If you don't have clinical judgment and are more worried about protocols and meaningless numbers than you are in treating the patient's problem, you're probably in the wrong field.
reaper
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Why do you give Thiamine to all Hypoglycemics? Are you still treating with coma cocktails?
Between your answer with BGL and 12 lead, you would not last a week in a progressive system. You are paid to treat pt's. Any AMS pt deserves to be treated to the full extent. If you haven't learned this over the years, there is a problem there.
BTW- Passed out drunk is AMS!
Too Old To Work
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Why do you give Thiamine to all Hypoglycemics? Are you still treating with coma cocktails?
Between your answer with BGL and 12 lead, you would not last a week in a progressive system. You are paid to treat pt's. Any AMS pt deserves to be treated to the full extent. If you haven't learned this over the years, there is a problem there.
BTW- Passed out drunk is AMS!
I'm in a pretty progressive system, at least it seems so. I've lasted over 30 years, so I'm not too worried. I think you mean that I wouldn't last a week in a cook book medic system, which is probably where you work.
The thiamine thing is a hold over from the old days, I don't know why it hasn't been changed, but it hasn't. The rationale back then was similar to your AMS rationale because of the relatively high number of homeless we see. However we've PROGRESSED past that in most regards.
Passed out drunk is passed out drunk. It's not a hypoglycemic emergency. Now, if you or someone would invent an easy to use BAL meter that functioned like a glucometer I'd use that. If for no other reason than to establish a betting pool for the highest per shift, per week, per month, and per year. As with the Price is Right, if someone could guess the highest BAL without going over, they'd win fabulous prizes.
Sigh.
Let's say you find a pt. with a BGL of 10. You give them D50, and they wake up. You don't recheck a BGL. If you did, you'd find that their BGL was now 130. If you'd recheck it again in another 15 minutes you'd find that it's 80. Congratulations, you've just signed a refusal on someone who's sugar is continuing to fall because they took too much insulin. You leave and they're now unresponsive again.
You used the example of a pt. with a BGL of 65 after administering dextrose. I'd be seriously worried about a pt. with a BGL of 65 if I just gave them D50.
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JPINFV
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Oh, really?
http://tinyurl.com/36n49ho
This is, of course, ignoring the fact that untreated diabetes is not the loss of the ability of a patient to elevate their blood glucose level. For that, we can thank the medications.
Too Old To Work
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System wide we don't transport 80% or more of diabetics we wake up. We've been doing that for about 20 years. You think maybe our medical directors know a thing or two about how this works. The key is to make sure that they eat after you give the D50. Their BG is going to fall even if they didn't OD on insulin, because that's what the insulin does. It metabolizes the Dextrose that we just gave them. Do you know what the hospital is going to do if you transport this person? Give them a meal, watch them for a couple of hour and then send them home. As I said, feed them, explain what happened, make sure that they are not alone, instruct the patient and whoever is with them what to do if symptoms re-occur.
I really have to wonder about some of the people here who think that they work in progressive systems. Does that mean that you don't have to call in to medical control before you start an IV on a cardiac arrest?