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I had a strange call recently. Called for an unresponsive/syncopal patient. When we roll up, he is awake and looking around but not interactive even to pain. Family said he was completely unconscious when they found him and his eyes were closed. He had no seizure history, oral trauma or incontinence but for all intents and purposes, he appeared postictal. He had a diabetic history (and insulin pump) but CBG was 128. Skin was pink, warm, and dry, and pupils were equal and reactive. He was young (late 20s) and very fit, last seen normal two hours prior when he was complaining of a headache. Family stated that he has never complained of a headache in his life, much less one that he would lie down for. He moved all of his extremities but not to command and even his grunting wasn't related to painful stimuli. Sinus rhythm in the high 80s, normotensive, SpO2 100% and….hyperventilating. I didn't notice it initially but then caught him breathing close to 60 times per minute. By the time he is on capnography, he is back down to 16 breaths per minute. He has some meaningful movement as we roll him onto a sheet to move him, almost assisting with movements. Respiratory rate continues to vary but the changes are sudden, not like Kussmaul's, with the gradual changes in depth and rate. It really was like flipping a switch. We move to the bus and when I am looking for an IV, he is cooperating with his arm movement. I stick him and get no reaction. Within a minute or two, he is awake and oriented with clear speech, initially drowsy but quickly awake and lucid. His breathing sped back up to 40 but slowly decreased with coaching and explaining why he had carpopedal spasms. He was cooperative and lucid. He had no history of anxiety or respiratory issues. He remained awake and oriented all the way to the to the hospital. In talking about his headache prior to all of this, he described it as intense pressure behind his right eye and was easily the worst headache of his life. He remembered walking to the bedroom and then nothing until he awakened in the bus. Now here's the problem. Later, I get a call saying he was hypoglycemic (CBG was 28 when ER checked) and am accused of not treating it. I checked his CBG and found it normal. He improved without intervention and once awake, was well oriented and remained pink, warm, and dry. His skin was also normal prior to arrival and during his time with me. By the time we arrived in the ER, his only complaint was carpopedal spasms. Breathing had slowed to 20 and appeared to be well controlled. Am I missing something? Could it be an insulin pump malfunction? If so, wouldn't the CBG continue to rise or fall until an intervention is made? Why didn't he become cool and clammy? By his own admission, he usually becomes diaphoretic when his CBG drops. Where did the hyperventilation come from? I generally associate that with hyperglycemia, and slowed or even snoring respirations with hypoglycemia, although neither are hard and fast rules.

You realise that you have all the room you could ever need....yer just lazy.

Interesting case. Just a few questions: When was the last time the glucometer on your ambulance was calibrated? How old were the test strips? Finger stick? Or the old tip of the pen to the flash chamber trick? (Not that the difference between the two should be *that* big.) What other history does this kid have? What else is going on with his headache? What did the hospital tell you besides their BGL finding? Do you know his discharge diagnosis?