Thoughts on taking BGL as part of your assessment.

[TransportJockey]

Round these here parts our Basics can check BGL, give ASA, Albuterol, Nitro, Epi 1:1000 IM(by drawing it up, not an EPI pen) Oral Glucose, and Oxygen. They give a good amount of life saving drugs.

Our basic have a very similar scope to yours

 

[NYMedic828]

Strange, so if I get rear ended at 5mph your gonna poke my finger?

I'd slap you. Those freakin lancets hurt! I'd take an IV over a finger stick any day. (I've been an IV dummy quite a few times)

 

[Fish]

I'd slap you. Those freakin lancets hurt! I'd take an IV over a finger stick any day. (I've been an IV dummy quite a few times)

Thats what I am sayin

 

[Shishkabob]

When you have a call and it's medical or even a mva, do you routinely check the BGL? Why or why not? Is it part of your protocols? Just your routine assessment?

If signs, symptoms or complaints indicate something could be glucose level related, yes.

If I'm running to the hospital with a GSW, then I have more important things to worry about unless they've unconscious.

 

[wigwag]

In NYC basics can't check BGL. In NYS, they can.

It's really stupid. Would save me a lot of runs to BLS CVA jobs that the BLS crew assumes to be a diabetic... Granted they should still know better without BGL but it can be tricky sometimes...

Actually, it's NOT in Westchester Co's protocols either.

 

[Thricenotrice]

Check it if its indicated by presentation

Or if you've already stuck them. Might as well at that point

 

[Akulahawk]

As a normal part of my patient assessment? No. Just because I showed up at your door doesn't mean that you're going to have your finger stuck. Now if I'm going to start an IV line on you because you've suddenly met some criteria that says that an IV is indicated, I'm going to get a BGL, but it's going to likely be venous if my glucometer is certified for venous blood. Why? I've already poked you, you're likely to lose a drop or two anyway, so why not put those wasted blood drops to good use? Now if I don't have to start a line, I'm not going to poke you for a BGL unless something tells me that it's indicated. One way it's a "nice to get" result that is a happy byproduct of another procedure, the other is invasive all by itself.

If you're coherent, warm, pink, dry... and have no complaints that make me think "check BGL," I'm going to leave the lancets well enough alone...

 

[JPINFV]

In NYC basics can't check BGL. In NYS, they can.

It's really stupid. Would save me a lot of runs to BLS CVA jobs that the BLS crew assumes to be a diabetic... Granted they should still know better without BGL but it can be tricky sometimes...

Never had a hypoglycemic mimic a stroke? Without a BGL, both CVA and hypoglycemia are squarely in the differential, one of which a paramedic can easily treat or rule out.

 

[NYMedic828]

Never had a hypoglycemic mimic a stroke? Without a BGL, both CVA and hypoglycemia are squarely in the differential, one of which a paramedic can easily treat or rule out.

Are you asking if I ever had a hypoglycemic mimic a stroke or are you stating that you never have?

I realize and understand the different signs and symptoms of each process but it is not my choosing to constantly be called to the scene of a CVA patient that the BLS crew presumes may be having a diabetic event. Granted they are wrong, but if they at least had the capability of checking the patient's BGL they could confidently rule out hypoglycemia on their own and save the patient another 20 minutes.

Mind you I find it hard to differentiate CVA from hypoglycemia when a patient is entirely unconscious in both scenarios. Granted, it seems to be a rare occurrence in a CVA.

 

[Veneficus]

We're actually required to take BGL as a part of our normal patient assessment. The only times we really don't are in the case of something like a lift assist, etc.

Somebody needs to insert a facepalm picture.

 

[JPINFV]

Are you asking if I ever had a hypoglycemic mimic a stroke or are you stating that you never have?

Asking if you've ever had one? I had one when I was working IFT. Granted, receiving facility was as close as paramedics thus paramedics weren't indicated under the circumstances. However I did feel like an ignorant schmuck when my "CVA" patient had complete symptom relief with a dose of D50.

I realize and understand the different signs and symptoms of each process but it is not my choosing to constantly be called to the scene of a CVA patient that the BLS crew presumes may be having a diabetic event. Granted they are wrong, but if they at least had the capability of checking the patient's BGL they could confidently rule out hypoglycemia on their own and save the patient another 20 minutes.

Mind you I find it hard to differentiate CVA from hypoglycemia when a patient is entirely unconscious in both scenarios. Granted, it seems to be a rare occurrence in a CVA.

So, how do you rule out hypoglycemia in a patient with a history of diabietes and taking hypoglycemic agents, including but not limited to insulin (this is, of course, ignoring the differential of insulinomas)? Patients lie, patients misremember, patients accidentally take two doses of their medications. More importantly, how many EMTs know which medications can induce hypoglycemia and which can't? It certainly isn't in the education beyond "Diabetic, think hypoglycemia if altered."

Is it not presumptuous to, absent of data leading elsewhere, exclude a valid emergency level differential? If you have a patient presenting with unilateral neurological signs, would you just call a code stroke and not get a BGL?

If the patient is entirely unconscious, thus presumably no or very limited HPI, then how are you going to narrow a differential down to hypoglycemia vs CVA anyways, instead of adding the other bajillion differentials that can lead to an unconscious state?

 

[NYMedic828]

Asking if you've ever had one? I had one when I was working IFT. Granted, receiving facility was as close as paramedics thus paramedics weren't indicated under the circumstances. However I did feel like an ignorant schmuck when my "CVA" patient had complete symptom relief with a dose of D50.



So, how do you rule out hypoglycemia in a patient with a history of diabietes and taking hypoglycemic agents, including but not limited to insulin (this is, of course, ignoring the differential of insulinomas)? Patients lie, patients misremember, patients accidentally take two doses of their medications. More importantly, how many EMTs know which medications can induce hypoglycemia and which can't? It certainly isn't in the education beyond "Diabetic, think hypoglycemia if altered."

Is it not presumptuous to, absent of data leading elsewhere, exclude a valid emergency level differential? If you have a patient presenting with unilateral neurological signs, would you just call a code stroke and not get a BGL?

If the patient is entirely unconscious, thus presumably no or very limited HPI, then how are you going to narrow a differential down to hypoglycemia vs CVA anyways, instead of adding the other bajillion differentials that can lead to an unconscious state?

I'm pretty sure we are agreeing on the same point... My point is that EMTs not being equipped with glucometers is ridiculous for this reason. The only definitive way we can rule out hypoglycemia to differentiate from CVA in an ambulance is a glucometer. One of the simplest skills to perform and we do not allow EMTs to do it. Which results in an extended time to definitive care for the patient if the BLS crew calls for an ALS unit, solely to rule out hypoglycemia over transporting to the ER.

When I was an EMT, I would ask the family member to check the patients BGL for me with their home glucometer or I would do it myself off the record... Not everyone is comfortable doing that when the family member tells you they can't do it. I just can't fathom why we wouldn't equip all of our BLS units with an invaluable $50 tool that literally spills a single drop of blood. An epi-pen is far more invasive and its on standing orders for BLS anaphylaxis and severe asthmatics...

 

[JPINFV]

The only definitive way we can rule out hypoglycemia to differentiate from CVA in an ambulance is a glucometer.

is not compatible with

It's really stupid. Would save me a lot of runs to BLS CVA jobs that the BLS crew assumes to be a diabetic... Granted they should still know better without BGL but it can be tricky sometimes.

How should they "know better" if they can't check a BGL and rule out hypoglycemia? If mimics happen, how can they always be wrong? Does it not make sense that if an emergent differential is present that paramedics can rule out and treat, that paramedics should be called assuming that an ED is not within a reasonable distance (in terms of time) from the EMT crew's location?

 

[NYMedic828]

is not compatible with



How should they "know better" if they can't check a BGL and rule out hypoglycemia? If mimics happen, how can they always be wrong? Does it not make sense that if an emergent differential is present that paramedics can rule out and treat, that paramedics should be called assuming that an ED is not within a reasonable distance (in terms of time) from the EMT crew's location?

I suppose you are right and I was a bit contradictive there but by know better I didn't literally mean it in the sense of they should be magically capable of presumptively diagnosing one over the other.

In NYC we are usually no more than 5-10 from a hospital. Calling for ALS to differentiate one over the other without extreme suspicion for hypoglycemia will hinder the patient reaching care. If the cause turns out to be CVA, I can still do nothing more than the BLS crew could. If they had a glucometer, this problem wouldn't exist. But unfortunately it does, and people need to realize transporting is sometimes more valuable than waiting for someone else to show up who still only have a 50% chance of treating that problem.

Id rather that unit get a potential CVA patient to the ER 20-30 minutes faster and find out that the patient just needed some sugar than to have that CVA patient wait around at home for an extra 30 minutes.

 

[EpiEMS]

We're actually required to take BGL as a part of our normal patient assessment. The only times we really don't are in the case of something like a lift assist, etc.

Somebody needs to insert a facepalm picture.

Now I see why you guys don't want BLS providers doing BGLs. Finger sticks for everyone make about as much sense as O2 and full spinal immobilization for everyone.

 

[Clare]

A BGL should be part of your assessment for patients where you suspect dysglycaemia as a cause of their problem.

Examples where I'd routinely check a BGL include seizures with no known history of seizures, unconscious or altered level of consciousness with no other obvious cause and patients who feel generally unwell where DKA or non ketone hyperosmolar hyperglycaemia is suspected.

Some people say to check blood sugar on all patients who have a seizure but honestly, if your patient has a known history of seizures and a good acute exacerbating event for a seizure (such as being ill, medication change or other predisposing factor known to cause a seizure such as too much XBOX or Japanese seizure robots) then I don't think its necessary.

Same goes for syncope, if a patient faints and then recovers that is not hypoglycaemia.

There may be a role for checking a blood sugar on patients who you suspect are having a myocardial infarction or are septic however I am unsure of the pathological basis for such a test (probably has something to do with anaerobic metabolism) but I don't know any more than that.

 

[Jon]

I do finger sticks on anyone that, through assessment, is having an unknown problem or might be diabetic.

I grab blood from the IV site for the glucometer on almost every IV stick. It's quick and easy, and sometimes I'll find something interesting.

 

[Earthworm Jim]

I agree, BGL is really quick and easy to do and may reveal pertinent information, but of course it depends on the situation.

 

[Clare]

I grab blood from the IV site for the glucometer on almost every IV stick. It's quick and easy, and sometimes I'll find something interesting.

Using the cannula needle for glucometery is now severely frowned upon (at least locally) because the glucometer is not calibrated for venous blood and it increases the risk of a needle stick.

 

[Medic Tim]

Using the cannula needle for glucometery is now severely frowned upon (at least locally) because the glucometer is not calibrated for venous blood and it increases the risk of a needle stick.

The ones we use are good for venous blood and the caths we use allow us to get the blood from the flash chamber without risk of a needle stick.