Pushing D50

[Just Plain Ruff]

90% of the time the diabetic patient that you wake up is going to refuse transport. (no studies to back it up but that's what my numbers seem to show).

10% of the patients that don't refuse transport fall into the following two categories

1. they are the ones who I've already put in the ambulance and started to transport

2. The others are the ones who are feeling poorly before this happened and they want to be looked at.

I ALWAYS offer transport, never offer refusal.

Now for the IO discussion

I have started a IO on three adults in the last 12 months.

1. seizure patient who by our experiences with him had no veins whatsoever and he required IO to administer valium for the seizure

2. Trauma patient with near total circulatory shut-down

3. Diabetic patient without any vein including the EJ - (patient was transported prior to infusing the d-50)

If you don't have an IV and you need one there is nothing wrong with starting an IO. From what I've read there is no more risk in an IO than an IV. Plus I have been told that the IO hurts less than some IV's but I'm not sold on that.

We use the EZ IO drill and it seems to work great on the three I've started the IO's on.

Removal of the IO is pretty straightforward and simple and from the responses I have seen from the 3 patients it hurts more coming out than in.

[P_Instructor]

Another point on D50, how many patients do we push a full amp (25g) of D50 and get a refusal for transport when we should be talking our patient into going to the ER to be checked out. The number of times I have heard a medic say "well your sugar was just a little low, you don't need to go to the hospital just sign here" when dealing with a patient they found altered or unresponsive makes me sick. If the patient is to altered to eat something then they need to be checked by a doctor even if the only reason their sugar is low is something as simple as they did not eat dinner last night. I work under the

you call we haul theroy, I would much rather get called in to a supervisor's office to explain someone calling to complain about me trying to talk them into going to the ER then having to go back and work a full arrest on a patient I talked out of going to the hospital. Just my two cents on D50 in EMS

Watch out. Pushing D50 and the patient waking up is one thing, but when they refuse and you have them sign a refusal without contacting medical control, you are basically practicing medicine without a license. Check the legalities with your medical director. I agree the patient should be treated and transported. If there is some sort of dilema that you have to treat in the dwelling (because of size, extrication problems, etc.) do so, and then if the patient refuses, talk to medical control or have the patient talk to medical control to put that on their shoulders, not yours.

If you have to use an IO, you have poor IV skills.

AMEN BROTHER!

90% of the time the diabetic patient that you wake up is going to refuse transport. (no studies to back it up but that's what my numbers seem to show).

10% of the patients that don't refuse transport fall into the following two categories

1. they are the ones who I've already put in the ambulance and started to transport

2. The others are the ones who are feeling poorly before this happened and they want to be looked at.

I ALWAYS offer transport, never offer refusal.

Now for the IO discussion

I have started a IO on three adults in the last 12 months.

1. seizure patient who by our experiences with him had no veins whatsoever and he required IO to administer valium for the seizure

2. Trauma patient with near total circulatory shut-down

3. Diabetic patient without any vein including the EJ - (patient was transported prior to infusing the d-50)

If you don't have an IV and you need one there is nothing wrong with starting an IO. From what I've read there is no more risk in an IO than an IV. Plus I have been told that the IO hurts less than some IV's but I'm not sold on that.

We use the EZ IO drill and it seems to work great on the three I've started the IO's on.

Removal of the IO is pretty straightforward and simple and from the responses I have seen from the 3 patients it hurts more coming out than in.

I know this is off subject for this particular forum, but why not try Midazolam (Versed) IM for the seizures before the IO? It absorbs faster than Valium and does work well in our system.

[CBEMT]

Watch out. Pushing D50 and the patient waking up is one thing, but when they refuse and you have them sign a refusal without contacting medical control, you are basically practicing medicine without a license.

Your protocols don't apply everywhere. Not all areas require Medical Control contact for refusals.

[AnthonyM83]

I disagree that lack of IV flash means line is not patent. With certain types of setups, I've known I was in, but lacked flash. When I retracted needle, blood started flowing. Yet, with other needle types, I've never had that occur.

As far as needing an IO meaning your IV skills are poor. Technically correct in most cases, but not always much one can do about it. I had a great experience being taught adult IV's during clinicals. I'd say I'm above proficient at them. But very little exposure to infant IV's. Now, I'm limited to pediatric patients I get in the field. What can one do once training is over? (Other than ask to start IV in the rare case you see an infant about to get one while in the ER...which is technically not allowed here).

[P_Instructor]

Your protocols don't apply everywhere. Not all areas require Medical Control contact for refusals.

I stand corrected. However, what are the protocols for this area. The base of what I stated is true, unless there is a protocol written by medical direction for this scenario.

[Just Plain Ruff]

P-instructor

do you successfully start IV's on all your pediatric codes or do you use IO's?

Are you 100% successful in all your IV starts?

Blanket statements like if you have to resort to an IO your IV skills suck have a tendency to come back and bite you in the butt.

If you can say that 100% of all your IV's are started successfully then I'll bow down to your IV prowess but IO's do have their place.

[P_Instructor]

P-instructor

do you successfully start IV's on all your pediatric codes or do you use IO's?

Are you 100% successful in all your IV starts?

Blanket statements like if you have to resort to an IO your IV skills suck have a tendency to come back and bite you in the butt.

If you can say that 100% of all your IV's are started successfully then I'll bow down to your IV prowess but IO's do have their place.

Never would I state that I am 100% in IVs, anyone that does state this are morons. Look for IV site first, and if you have one, try once. If successful, great, if not, don't screw around and get the IO. If you need it now and don't want to bother getting the IV, get the IO. Of course, this is me and everyone does it their own way. This became deeper than the original question. Stick the IV for the D50, or give the Glucagon. I wouldn't give the D50 IO personally, but would go with the Glucagon. I never stated anything about resorting to IO because IV skills suck. The statement I agreed to was from Crotchity - "If you have to use an IO......". It was his statement and I guess my reply was taken a little overboard.

[Mateo_1387]

I ALWAYS offer transport, never offer refusal.

So do you tell patients their options?

[Just Plain Ruff]

Never would I state that I am 100% in IVs, anyone that does state this are morons. Look for IV site first, and if you have one, try once. If successful, great, if not, don't screw around and get the IO. If you need it now and don't want to bother getting the IV, get the IO. Of course, this is me and everyone does it their own way. This became deeper than the original question. Stick the IV for the D50, or give the Glucagon. I wouldn't give the D50 IO personally, but would go with the Glucagon. I never stated anything about resorting to IO because IV skills suck. The statement I agreed to was from Crotchity - "If you have to use an IO......". It was his statement and I guess my reply was taken a little overboard.

I didn't take your reply overboard, what I was getting at was this. When you emphatically agree and put down AMEN BROTHER to someone's comment that gives the impression that you agree with their statement completely.

So the way I took your AMEN BROTHER was that you believed that resorting to an IO was because someone's IV skills sucked and an IO was the only way you were going to get the iv.

I have talked to several people on this forum who said that they got the same message from your post as I did.

But I digress, I would also not be comfortable to give d-50 through an IO but it can be done though. What I'd like to turn to is the glucagon if my service carried it. Hopefully all our diabetics would never drop so low as to needing d-50 or glucagon.

As for offering refusal versus transport. Yes Matt, I give them their options and I should have been clearer. I never offer refusal as the first option for the patient. There are some medics who do offer refusal as one of their first options.

But hopefully the d-50 is being given in the back of the ambulance enroute but if you give the d-50 in the house you have to expect that the patient is going to want to refuse transport.

If your protocols are written correctly you don't need to contact medical control. But I always involve medical control on refusals just so the doctor is on board with me. Our physicians do not routinely order patients to go to the hospital (I wish they did) but they don't so if the patient wants to refuse then so be it.

Our physicians do order patients who are suicidal to go to be transported. That's not up for debate with our docs here.

[P_Instructor]

I didn't take your reply overboard, what I was getting at was this. When you emphatically agree and put down AMEN BROTHER to someone's comment that gives the impression that you agree with their statement completely.

So the way I took your AMEN BROTHER was that you believed that resorting to an IO was because someone's IV skills sucked and an IO was the only way you were going to get the iv.

I have talked to several people on this forum who said that they got the same message from your post as I did.

Thanks, I will work on my reply skills (more CEU's!!...laugh). I again appreciate your reply.