2nd Guessing

[Just Plain Ruff]

called on a unresponsive. On arrival found a 54 year old male patient GCS=7(2,1,4) whos family say that he has been this way for an hour or so.

He is a known dialysis patient, known cabg(4vessel bypass) and known diabetic.

He is sitting in a chair with family holding him. HIstory in past hour of stumbling and nearly falling.

I get there and do a d-stick and it's 362. Family stated (I did not hear this part) that they have been feeding him Jelly because his blood sugar was 82 before we got there.

Start an IV, see elevation in leads v1-v4. Just had dialysis yesterday.

Call for a bird, get him to the helicopter and put him in the helicopter. They fly to the city, do a repeat glucose and find it to be 27.

They give him an amp of d50 and he wakes up.

I am kicking myself for not doing a 2nd glucose but with his signs and symptoms he didn't need any glucose according to our d-stick machine.

When I was told of this reading by the flight crew of 27 I immediatly check the machine I tested him on by using my own blood and also as a control I used my glucose machine also. Both readings were 154 with my blood so I know our machine is not out of whack.

I know that I should have checked his sugar again and it may not have required a helicopter ride but I didn't think to check it a 2nd time.

I feel bad that this guy got a helicopter ride but if I had it to do over again I'd probably do a repeat blood sugar but who knows.

I just feel that I missed something on this one.

Wait, that feeling is going away, yeah, it's gone, it was there but not anymore. I feel better venting about it.

[Lone Star]

You know what, Ruffles?

EVERYBODY who runs EMS has room to 'second guess themselves'. It's what you do with it that matters!

Now I have a couple questions for you:

1. You stated that the family was feeding him jelly prior to your arrival, and that the pt's BGL was 82.

A. Isn't 82mg/dl still within the 'acceptable average' for BGL readings?

B. How long between the administering of the sugar and the BGL reading you took?

C. How high does a BGL have to be to be considered a 'diabetic emergency'?

D. How long does this type of 'sugar bolus' really last?

E. Was his BGL meter properly calibrated?

There's quite a few variables that had to be taken into consideration, and at the same time you have to act...for the benefit of the patient. That's alot of information you have to process all at the same time, and some days, it just don't matter what time of the day it is!

Electronic devices are notoriously 'fragile', and you can only go off the information you have at the moment.

Ultimately, you learned something, and isn't that a 'good thing'?

[Lone Star]

You know what, Ruffles?

EVERYBODY who runs EMS has room to 'second guess themselves'. It's what you do with it that matters!

Now I have a couple questions for you:

1. You stated that the family was feeding him jelly prior to your arrival, and that the pt's BGL was 82.

A. Isn't 82mg/dl still within the 'acceptable average' for BGL readings?

B. How long between the administering of the sugar and the BGL reading you took?

C. How high does a BGL have to be to be considered a 'diabetic emergency'?

D. How long does this type of 'sugar bolus' really last?

E. Was his BGL meter properly calibrated?

There's quite a few variables that had to be taken into consideration, and at the same time you have to act...for the benefit of the patient. That's alot of information you have to process all at the same time, and some days, it just don't matter what time of the day it is!

Electronic devices are notoriously 'fragile', and you can only go off the information you have at the moment.

Ultimately, you learned something, and isn't that a 'good thing'?

[Just Plain Ruff]

look there it is again, that dreaded double post bug

[CharleeFoxtrot]

Stuff happens man, and I guess it's part of the huge learning curve this profession has. Put that one on your "learning pile"...mine is so tall now I have to climb up on top of the rig to throw things on the top. Had a similar thing happen to me, the call was from a nursing home for an altered. We get there, Pt is on dialysis, cardiac HX, hypertensive and diabetic. The staff says she was 'fine' two hours ago but is now out of it. I asked the right questions-did they do an accucheck? They said her BGL was 194. Did she eat breakfast? They said no. We loaded her up, got a line/12 lead etc. She was a bit hypertensive but not alarming. Halfway to the hospital I think to recheck her BGL. It was 15 . I thought I asked the right questions- but I didn't ask how long ago her BGL was 194, and if she didn't eat had they given her usual insulin dose. I took their word the accucheck was recent-bad move. Of course after some D50 she wakes up and starts screaming....sigh.

[fiznat]

Do you guys routinely fly medicals like that? How far away is the hospital?

Anyways, on patients like this who's sugar "should" be low considering the presentation and the history, I usually do doublecheck the sugar. The first time I get a finger stick, and the second time I check after I get an IV using the blood in the flash chamber. I think it is a good practice because I actually had a similar scenario before and caught it on the second check.

A question: if you were ruling out hypoglycemia on this patient, what was your working diagnosis? Was there another reasonable explanation for the altered mental status?

That said, don't worry about it man. Things really do happen, just learn from them and you'll be fine.

[cfaulknor]

Do you guys routinely fly medicals like that? How far away is the hospital?

Anyways, on patients like this who's sugar "should" be low considering the presentation and the history, I usually do doublecheck the sugar. The first time I get a finger stick, and the second time I check after I get an IV using the blood in the flash chamber. I think it is a good practice because I actually had a similar scenario before and caught it on the second check.

A question: if you were ruling out hypoglycemia on this patient, what was your working diagnosis? Was there another reasonable explanation for the altered mental status?

That said, don't worry about it man. Things really do happen, just learn from them and you'll be fine.

I've heard this both ways and was wondering if anyone could help me..

Would there be a difference in the sugar of a blood sample from the capillaries (finger stick) or from a vein (flash chamber)? If the blood had already been through the body and back, would the sugar not be depleted?

[Just Plain Ruff]

for the question on routinely flying these medical patients out.

Sometimes, but with the recent dialysis, the elevation in v1-v4, the high blood sugar of 362 and the slight facial droop Our facility that we run out of would have transferred this patient out of our ER in a heartbeat and they would have gone by helicopter so I just took out the middleman.

I still stand by my decision to fly him but I will be darned certain to repeat a glucose just on arrival to the helipad from here on out.

I'm taking this one to the learning bank and that bank just keeps getting a bigger balance in it.

[robert gift]

I would never have thought to recheck.

I would have trusted my glucometer.

Though would doubt family could cause such a rise in BGL from injesting jelly beans.

Don't they need time to digest?

Why not transport by ambulance rather than helluvaexpensivecopter?

[Just Plain Ruff]

question between transport by ground versus air

Based on patient presentation

ST elevation in leads V1-V4

Elevated Blood Sugar

slight facial droop to right side of face

BP of 70/40

Would you have transported by Ground ambulance to the receiving facility which is one hour away on the ground or would you have opted for Air transport?