Hypoglycemia

[paramedicmike]

Is it possible that the fluctuations could be something simple? Like a problem with the glucometer?

Sometimes it can be the simple things. We have a tendency to think the problem always lies with the patient. Machines can break, too.

Just a thought.

-be safe

[4kids]

Absolutley Mike about the glucometers.

I've used my and stuck myself in my ringer finger, gotten the reading, questioned it and stuck myself in another finger and come up with two totally different numbers. Not just off by one or two points but by 30 or more.

[Boolancedriver911]

So, who got the blood sugar the medic or EMT? O wait, thats another thread...

[JakeEMTP]

Is it possible that the fluctuations could be something simple? Like a problem with the glucometer?

Possible? Absolutely. Not in this case however. They are checked before every shift and I personally checked this one.

[paramedicmike]

Possible? Absolutely. Not in this case however. They are checked before every shift and I personally checked this one.

Great! Good to know you take checking your equipment seriously.

Now, can you say when was it last calibrated? By whom? Following the manufacturers recommendations? Just because you checked it at the start of your shift doesn't mean it will work for the duration of your shift. Given the readings you were getting in the time frame you described it sounds as if this was a mechanical problem and not so much an actual blood sugar problem.

I'll be honest with you. I check the glucometer at the start of every shift I work, too. I don't, however, calibrate it each and every day. (If you calibrate it every day then you've got way too much time on your hands. ) Besides, if I had a nickel for every time I checked my equipment at the start of the shift only to have it crap out on me right when I needed it I'd have a huge pile of nickels.

I've gotta ask, too. Did you initiate the "no transport" request or did the patient? It's unclear from your original message. It sounds, based on how you wrote it, that you brought up the idea of a transport refusal.

-be safe

[JakeEMTP]

Mike, sorry I wasn't clear.

I cannot in all honesty say when it was calibrated last. I agree it could have been an equipment failure, but I didn't want to leave her with her BGL fluctuating like that. Perhaps I didn't need to transport her to the ED, but I just was a little perplexed as to the readings.

The " no transport" was initiated by my partner. It is common to do this in our corner of the world. Once the patients BGL has been corrected, why would we transport them to the ED? What would they do at the hospital differently?

Not trying to be a smart ass, I genuinely am wondering why. That's why I posted it here.

[AZCEP]

An equipment failure is a possibility, but the likelihood of it being a significant medical problem is very real. Considering this is a patient you see regularly, two readings from the same device should not vary that much. Especially when done that close together.

This patient's response to her medications, and any thing new to throw her homeostatic balance off is a much more likely cause.

[paramedicmike]

I don't think you're being a smart-ass, Jake. No worries there.

You can't discount that there was a real medical problem at play here. Especially when it takes more than a single amp of D50 to get results with which you're more comfortable. However, a glucometer that offers significantly different readings over the course of a few minutes leaves me wondering if it was mechanical.

My experience, for what it's worth, has not once produced a patient who's blood sugar has varied that widely over the course of a few minutes. Sure, a couple point difference isn't uncommon. But 33 to 112 to 68 over the course of what? Seven to ten minutes? And then, after the *second* amp of D50 to see a near 100 point drop in the course of five minutes? Seems a little unlikely that such a widely varying blood sugar was at play.

Your decision to transport was sound. I think that was the right call.

As to initiating a refusal, it can be really shaky legal ground depending on how you broach the subject. Personally, I'll offer to take the patient and then let him/her tell me "no" as opposed to asking "you don't really want to go, do you?". (Not saying that's how you did it...just as an example.)

Taking the patient to the hospital after the sugar's been corrected will depend on the situation and the patient. If it were an isolated event from an otherwise well controlled diabetic that would be one thing. But this was a diabetic patient known to you (which tells me you've been there several times). If you're there that frequently then there are larger issues at play. Whether those issues are medication non-compliance, metabolic, medication compatibility or something else, it is irresponsible of us to continue to show up, drop an amp (or two) of D50 then leave without ensuring that they receive some sort of physician follow up.

I'm not discounting there was a real medical issue here. My point was to not ignore any real medical issues but to not discount a mechanical issue. I think, from what you posted, you handled the call appropriately (the refusal question aside as that could be a completely separate topic). I'm not trying to fly off on some crazy tangent. However, for some reason I could see a "treating the number" situation here.

As to what they'll do in the ER, talk to your docs about that. You'll have some very interesting discussions, I'm sure.

-be safe

[Just Plain Ruff]

Let me ask this question. Do you know what her eventual diagnosis was?

Could she have been suffering from some infection of some sort which in diabetics causes sugars to go all hinky at times.

There is a definate cause for concern when the blood sugars do not stabilize after everything you did for that patient.

[als2170]

The first dose of dextrose you administered was used up rapidly by the cells that were responding to the insulin that was there. Once it was gone, the BGL started dropping.

70/30 is 70% long-acting, 30% short acting insulin. The idea being to mix the onset and durations of the two into one simple to administer solution. This patient obviously needs to consider that there are some better options available, but that is for the endocrinologist to decide. I am curious which "heart pill" she is taking though. Most cardiac meds do not mix too well with insulin, and have to be monitored very closely until the dose is figured out.

I agree with what you're saying. The question is how long ago did she take her insulin, how long has she been on this insulin, or is she on a new one? Although, I would think she would have to take a lot of insulin to burn through 2 amps of D50 like that? Any chance she took too much insulin?