BLS and Glucometers

[akflightmedic]

Scenario: 60yo F complains of bilateral leg weakness. Gradual onset, it's 3AM now, she woke up to go to the bathroom and noticed her legs were very weak. No other complaints. History of IDDM and HTN. Good strong PMS. BGL turned out to be 48 mg/dl. Gave her some orange juice (or oral glucose) and suddenly she feels fine and has no complaints. With a BLS crew that didn't have the option of checking BGL, their options would have been: Transport while twiddling thumbs saying "I don't know what's going on!", or request ALS so that ALS can do the exact same thing BLS would have done on scene if they had a glucometer. Is that really what's best for the patient?

It's also important to remember that not all BLS providers are part of BLS-only crews. I work with a paramedic and being able to check someone's glucose is a valuable tool for me as a Basic or Intermediate to have. When we have an unconscious patient, for example, it's nice for my partner to accomplish the "more ALS" aspects like starting a line, hooking up the monitor, etc. while I check the BGL. It's just one less thing the medic has to worry about and one more thing the basic can accomplish for the good of the patient.

You just demonstrated one major problem. You are assuming because all the signs are there for low BGL, that is all that is involved. You have no other tools or KNOWLEDGE to determine otherwise. Again this is "protocol learnin" or" rote checksheet mentality". WHY is her BGL low? Isn't she controlled? I would be very uncomfortable with a BLS crew making this diagnosis and giving the OJ treatment, then getting a refusal on my grandmother. Sorry, its just the way I feel and it is not what is best for the patient.

As for freeing up the medic, again it is another lame argument. Most medics can handle everything in a systematic order for any call by prioritizing what is best and what is needed. By this statement, I do not mean to imply all medics are stellar and godlike, I am implying that most tasks are simple, easy and require minimal skill and time. No one has ever said skills are difficult (IV's intubating,etc); anyone can be taught to do these.

As for you getting a BGL while I do an IV, guess what? I will have done an intial BGL myself while you get a BP and pulse, or on known diabteics that I have treated before, I may do an IV and BGL at the same time. Then while you are placing the electrodes (provided I have trained you and trust you know proper placement) I will be inserting an IV. Any subsequent BGLs will be done by me while you are driving me to the ER or while I am assessing whether or not to get a refusal for this particular patient.

There are so many other ways you can assist as an EMT than worrying about a BGL. You can work on your assessment skills, interview the patient up to a certain point, set up for IV, monitor lead placement, prepare stretcher and give a smooth ride. You doing all of those are way more important and valuable to me than you being able to prick a finger.

Ok, now can we leave the tangent of "what if" an EMT is working with a medic, cause that was not the point of this thread. The point was referencing BLS crews and what/how they should handle the knowledge of a number on a machine.

[Just Plain Ruff]

Scenario: 60yo F complains of bilateral leg weakness. Gradual onset, it's 3AM now, she woke up to go to the bathroom and noticed her legs were very weak. No other complaints. History of IDDM and HTN. Good strong PMS. BGL turned out to be 48 mg/dl. Gave her some orange juice (or oral glucose) and suddenly she feels fine and has no complaints. With a BLS crew that didn't have the option of checking BGL, their options would have been: Transport while twiddling thumbs saying "I don't know what's going on!", or request ALS so that ALS can do the exact same thing BLS would have done on scene if they had a glucometer. Is that really what's best for the patient?

It's also important to remember that not all BLS providers are part of BLS-only crews. I work with a paramedic and being able to check someone's glucose is a valuable tool for me as a Basic or Intermediate to have. When we have an unconscious patient, for example, it's nice for my partner to accomplish the "more ALS" aspects like starting a line, hooking up the monitor, etc. while I check the BGL (among other things, of course). It's just one less thing the medic has to worry about and one more thing the basic can accomplish for the good of the patient.

You just made the argument for BLS crews not having access to a glucometer. You are working with a medic who can interpret and fix the issues presented with the glucometer result you just obtained.

A Bls crew without glucagon or instaglucose could not do that.

My whole argument is this - BLS Crews should not be doing glucoses in the field without ALS backup. Remember, some conditions present as decreased blood sugar as their main presenting symptom yet have something that a medic has to attend to so let's say you check a blood sugar and it's low, you give glucose and the patient doesn't get better. What are you gonna do now. Your precious glucometer did nothing but make you call ALS and have them transport anyway.

[PatrickW]

You just demonstrated one major problem. You are assuming because all the signs are there for low BGL, that is all that is involved. You have no other tools or KNOWLEDGE to determine otherwise. Again this is "protocol learnin" or" rote checksheet mentality". WHY is her BGL low? Isn't she controlled? I would be very uncomfortable with a BLS crew making this diagnosis and giving the OJ treatment, then getting a refusal on my grandmother. Sorry, its just the way I feel and it is not what is best for the patient.

As for freeing up the medic, again it is another lame argument. Most medics can handle everything in a systematic order for any call by prioritizing what is best and what is needed. By this statement, I do not mean to imply all medics are stellar and godlike, I am implying that most tasks are simple, easy and require minimal skill and time. No one has ever said skills are difficult (IV's intubating,etc); anyone can be taught to do these.

As for you getting a BGL while I do an IV, guess what? I will have done an intial BGL myself while you get a BP and pulse, or on known diabteics that I have treated before, I may do an IV and BGL at the same time. Then while you are placing the electrodes (provided I have trained you and trust you know proper placement) I will be inserting an IV. Any subsequent BGLs will be done by me while you are driving me to the ER or while I am assessing whether or not to get a refusal for this particular patient.

There are so many other ways you can assist as an EMT than worrying about a BGL. You can work on your assessment skills, interview the patient up to a certain point, set up for IV, monitor lead placement, prepare stretcher and give a smooth ride. You doing all of those are way more important and valuable to me than you being able to prick a finger.

Ok, now can we leave the tangent of "what if" an EMT is working with a medic, cause that was not the point of this thread. The point was referencing BLS crews and what/how they should handle the knowledge of a number on a machine.

First off, you are the first one to bring up the possibility of a low BGL being all that is involved, and you are the first one mentioning an EMS diagnosis and refusal. I did not say anything about either in my post, and it is in fact you who is making that assumption.

Second, monitor placement is another skill that Basics are not allowed to perform (at least here). I'm not saying it never happens, but it's not in our scope. But let me get this straight, you're suggesting Basics should be forbidden to perform dextrosticks as part of their assessment because it only provides a BGL of which Basics can do little about, but instead we should be placing limb leads as part of an assessment even though we can do nothing with a rhythm strip?

As for the point of this thread, the question posed at the end of the OP was "Who can offer reasons for and against this diagnostic tool for BLS providers?" You'll have to excuse me for pointing out how it is useful for me everyday I work.

[akflightmedic]

The electrode placement ONLY comment was directed to the tangent that you spun of working WITH ALS. I would never endorse this for a BLS crew as again there is nothing they can do about it.

Sorry you got confused while reading, as so often happens here because one takes immediate offense and types a response instead of stepping back and fully comprehending what was just said.

Please do not confuse the two entirely different scenarios of BLS only on scene and a mixed crew of ALS/BLS.

I guess I should never had entertatined your tangent whereas to limit the confusion and address the original issue.

Now these are your words, forgive the improper quoting:

Gave her some orange juice (or oral glucose) and suddenly she feels fine and has no complaints. With a BLS crew that didn't have the option of checking BGL, their options would have been: Transport while twiddling thumbs saying "I don't know what's going on!", or request ALS so that ALS can do the exact same thing BLS would have done on scene if they had a glucometer. Is that really what's best for the patient?

In this very statement where you said give OJ and all is well, that would indicate or imply the thought process of "everything is dandy and all it was is a low BGL, lets get a refusal now. Did anyone else here not think the same thing?

Secondly, you stated ALS would do the exact same thing on scene as BLS. Hmmm, interesting theory but I beg to differ. I will allow you a chance to further support that ludicrous claim with something more tangible, fact related other than you just saying so.

Also, you said BLS would be transporting, twiddling their thumbs saying "geez I dont know whats going on"? Once again, this implies that IF you knew this magic number, that you would know exactly what is going on and that is all there it is to it. Which as I and Ruff stated previously is incorrect, there could be so much more going on, yet once again the lack of knowledge is what prevents one from realizing that.

So, in closing, I toss back at you sir, that it was you who implied the things you accused me of.

You don't know how much you don't know...

[PatrickW]

The electrode placement ONLY comment was directed to the tangent that you spun of working WITH ALS. I would never endorse this for a BLS crew as again there is nothing they can do about it.

Sorry you got confused while reading, as so often happens here because one takes immediate offense and types a response instead of stepping back and fully comprehending what was just said.

Please do not confuse the two entirely different scenarios of BLS only on scene and a mixed crew of ALS/BLS.

I guess I should never had entertatined your tangent whereas to limit the confusion and address the original issue.

Now these are your words, forgive the improper quoting:

Gave her some orange juice (or oral glucose) and suddenly she feels fine and has no complaints. With a BLS crew that didn't have the option of checking BGL, their options would have been: Transport while twiddling thumbs saying "I don't know what's going on!", or request ALS so that ALS can do the exact same thing BLS would have done on scene if they had a glucometer. Is that really what's best for the patient?

In this very statement where you said give OJ and all is well, that would indicate or imply the thought process of "everything is dandy and all it was is a low BGL, lets get a refusal now. Did anyone else here not think the same thing?

Secondly, you stated ALS would do the exact same thing on scene as BLS. Hmmm, interesting theory but I beg to differ. I will allow you a chance to further support that ludicrous claim with something more tangible, fact related other than you just saying so.

Also, you said BLS would be transporting, twiddling their thumbs saying "geez I dont know whats going on"? Once again, this implies that IF you knew this magic number, that you would know exactly what is going on and that is all there it is to it. Which as I and Ruff stated previously is incorrect, there could be so much more going on, yet once again the lack of knowledge is what prevents one from realizing that.

So, in closing, I toss back at you sir, that it was you who implied the things you accused me of.

You don't know how much you don't know...

Well, I don't think there are different scopes of practice for EMT-Bs on a BLS-only truck vs. EMT-Bs working with EMT-Ps, and I didn't know you were arguing for one.

If you'll notice, in the scenario I posted, I stated only objective criteria. That scenario is from a call I was on, and all I stated was the facts of what happened. BGL low, symptoms, BGL brought up, no symptoms. Make of that what you will, but no where did I state that the low BGL was the only issue and no where did I state that the patient should not be transported.

With such a condescending, holier-than-thou attitude I don't understand how you can expect people to not be offended by your posts. I understand you're passionate, however I don't think too many adults would agree that name-calling, insulting intelligence, and a general condescending attitude are helpful in anyway to proving your point.

Really, you're qualified to tell me that "I don't know how much I don't know" from a few posts of mine with a differing viewpoint on BLS use of glucometers. Seems somewhat hypocritical, even.

Thanks for "entertatining my tangent", though.

[Timmy]

After reading though all this I’m rather confused :? When you say BLS use a Glucometers are you implying that they stick the person, get the reading and that’s good enough? Or they stick the person, get a reading and have an understanding/education as to what the number means?

[EMS49393]

I didn't want to get involved in this discussion, but I just can't believe some of the "pro" arguements.

I can say, as a paramedic, when I'm faced with a patient that has an altered mental status, I have a methodical way of assessing and treating said patient. I assess the airway, especially the adequacy of ventilations and place oxygen/support the airway. I look at skin signs, and I assess the circulation. I place the cardiac monitor on the patient. While I'm doing this, I'm asking questions relevant to this particular patient. I attempt to get a history, both medical, and events leading up to the patients current condition. I establish an IV. The venous blood I aquire from the IV stick is what I use to check a BGL. If I absolutely can't establish an IV, I'll get a fingerstick. I'll continue with my assessments and treatments based on my initial assessment. I try very hard not to open up two routes of infection in any patient. A fingerstick, no matter how benign you feel it is, is invasive and breaks the skin, also known as the first line of defense against unwanted organisms feasting on the body.

I'm against basics having oral glucose, and I'm even more against them having glucagon. There is a lot of pathology involved in diabetic emergencies. Giving them some glucose, waking them up and letting them eat a peanut butter sandwich while they sign your refusal may see like a logical and appropriate treatment. It's not even close to all that is involved in appropriate treatment, especially the refusal part. I don't often buy the "I took my insulin and forgot to eat" story. I rarely get refusals on patients after a D50W miracle. It's easy for me to stay away from refusals on these patients... I don't administer the glucose until they're packaged, in my truck, and on the way to definative care. I've seen too many patients with more than one problem. There is nothing that says you can't have a stroke and have hypoglycemia at the same time.

I'm sorry if I hurt your feelings, but you are not helping me by getting a BGL off a fingerstick prior to my arrival. There are a lot of things I'd rather you do for me, that in my opinion, are far more important to me. Make sure the airway is open, and the patient has adequate ventilatory effort, make sure they have adequate circulation. Move all the crap in the house out of the way so we can expedite removal of the patient. Gather a name, history, allergies, event leading to incident. If we're going to intercept, then get moving out of the house so we can speed up time to definative care. These are the things I need from the BLS crew on scene before I get there.

If you can't tell me everything I had to learn about a drug, than you shouldn't be administering it, period. Everytime you administer anything, you're jacking with homeostasis. Make darned sure you know what to expect.

Now, give me all the pathophysiology behind diabetes, including all the types of diabetic emergencies, and how they are treated, and I might let you have a glucometer.

Pros: none

Cons: lack of education

[akflightmedic]

Yes I did call you "Sir". Sorry for giving the respect, my bad.

Thanks again for pointing out my spelling error. As many of the regulars know, I am dyslexic and sometimes insert random letters as well. I refuse to utilize spell check as that is how I train myself by forcing myself to go back and reread, yet sometimes still am unable to catch my errors.

I think context is being misinterpreted as often happens on a forum board because I specifically stated in one of my posts on this thread that I was not implying a holier than thou attitude.

I do agree I was slightly condescending towards the end, but i never claimed to be perfect. I explained why I quoted your post and how it was interpreted and why I thought what was implied as I am sure others thought the same.

And yes again it is tiring, yet true..."you do not know how much you do not know."

This is a quote and I can not cite the source but it holds true for EVERYONE. This was not aimed at you, it was shared with you. There is much truth in it and it is not until you reach a certain stage in your life/education, etc that one comes to realize this and accept it. Unfortunately, the majority of the young and inexperienced, under educated do not posess it.

Now, I was not arguing for different scopes depending on partner of the day. It was you who brought up how you work on ALS rig, therefore the problem can be "fixed" because a medic is there to do so. I am trying to stick to the OP in regards to BLS only and what should they do. The standard should be the same for all EMTs, so no, regardless of you being with a medic or not, you should not have this in your scope.

In your rapid response, you also failed to address my last two paragraphs, so maybe that will come later. Again an example of not fully reading, digesting and composing a well thought out response.

This is a debate. Do not allow your feelings to be hurt. Do not take it so personal. Instead, compose accurate, fact based suportive information and convince me otherwise. I am all ears/eyes and willing to hear what you have to say.

[Just Plain Ruff]

hey AK how bout this quote I heard from a good doctor friend of mine

"when you really don't know that you really don't know, then you really don't know!!!!!"

[Just Plain Ruff]

correct me if I'm wrong but doesn't glucagon deplete the stored glucose in the liver and if not treated appropriately post administration this could cause significant problems in the diabetic patient.

I've not had the luxury of having glucagon as a med choice in a long time so I'm not up to speed on glucagon.