Medic induced patient refusals of Hypoglycemic Patients.

[RomeViking09]

You are called out to a 73 year old female patient for altered LOC, you get on scene and in your assessment you get a blood glucose reading of LLL. Your partner starts an IV, draws blood samples, and then you administer 25g D50, the patient comes around and is feeling much better. You recheck her BGL and it reads 290 now, the Patient says she feels better and thanks you for coming out. What do you do next?

[akflightmedic]

You are called out to a 73 year old female patient for altered LOC, you get on scene and in your assessment you get a blood glucose reading of LLL. Your partner starts an IV, draws blood samples, and then you administer 25g D50, the patient comes around and is feeling much better. You recheck her BGL and it reads 290 now, the Patient says she feels better and thanks you for coming out. What do you do next?

Start rooting through her fridge and cabinets cause if we are not transporting, we are chowing down. Then, I insist that we notify a friend,relative or neighbor that can check on her (if no one else lives with her) and then we discuss the importance of eating/diet control along with the timing of insulin injections (again assuming she has a hx of this).

If this is her first time, no prior hx, then we get very persuasive and it is easy to do, especially with an elderly woman. Employ every trick in the book to convince her to take a ride with ya...

[ERDoc]

You do what you can to talk the pt into going to the ER. Eventually your failing attempts will outlast the D50 and she will become unresponsive again and then you load her up and start transport before pushing more D50.

[HERBIE1]

The assumption here is that the person is a known diabetic. If not, at 71, that person needs to be transported.

Take a good history once they are alert and find out why they became hypoglycemic. What are their other medical conditions and medications that may contribute to their drop in sugar? Did they forget to eat or eat less than usual? Did they take too much insulin? Did they fall asleep- or slept in late before they got a chance to eat? Did they engage in more physical activity than normal? Are they brittle diabetics- meaning their glucose levels fluctuate wildly and are difficult to control? Are they long time diabetics or new onset? Are their vitals abnormal in any way? Any other complaints, signs or symptoms? Do they have someone else to keep an eye on them? Can you ensure they will eat an appropriate meal before the sugar boost wears off?

If I get satisfactory/reasonable answers to all these questions that could explain their drop in glucose levels, then I am more comfortable in allowing them to refuse. Personally, I would always rather transport vs obtaining a refusal, and I always encourage them to take a ride with us. It takes far more documentation and justification to allow someone to refuse than it does to simply transport them.

Bottom line- it's up to a competent person. If you explain the risks, consequences, etc, it is their choice to refuse. Advise them to follow up with their endocrinologist or personal MD. As always- document with medical control.

Another facet of this is the almighty dollar. Many folks do not want the added expense of an ambulance ride and an ER visit. Their insurance may not be great or is nonexistant, they do not want to miss work, they have child care issues, etc- and I feel for these people. It's a tough call and in a perfect world, money is no object. Gawd knows this is not a perfect world.

[DwayneEMTP]

A flight medic friend of mine was showing me a study he'd found concerning this. It was printed out and I can't find it now but will email him and see if I can get it...

If memory serves, and it often doesn't as well as I'd like, the study created a very specific protocol to study hypoglycemic refusals. It covered the language used, the amount of time spent on scene to deliver instructions, etc. Basically it made sure that Pt's were alert, had a very thorough explanation of their needs secondary to post d50 delivery and instructions to follow up with their usual physician.

They followed up with each pt 24 hrs post contact to attempt to see how well the instructions were followed, and found, (I'm pulling this out of my rear) that something like 80% not only did not remember the instructions, but had no memory of having been attended to by EMS.

I was floored! And it has certainly changed the way that I handle refusals concerning hypoglycemic emergencies. If it isn't obvious to me that there is a support system in place to guarantee that the pt will receive the proper care without intervention necessitating their own initiation, I do all in my power to transport.

Dwayne

[HERBIE1]

A flight medic friend of mine was showing me a study he'd found concerning this. It was printed out and I can't find it now but will email him and see if I can get it...

If memory serves, and it often doesn't as well as I'd like, the study created a very specific protocol to study hypoglycemic refusals. It covered the language used, the amount of time spent on scene to deliver instructions, etc. Basically it made sure that Pt's were alert, had a very thorough explanation of their needs secondary to post d50 delivery and instructions to follow up with their usual physician.

They followed up with each pt 24 hrs post contact to attempt to see how well the instructions were followed, and found, (I'm pulling this out of my rear) that something like 80% not only did not remember the instructions, but had no memory of having been attended to by EMS.

I was floored! And it has certainly changed the way that I handle refusals concerning hypoglycemic emergencies. If it isn't obvious to me that there is a support system in place to guarantee that the pt will receive the proper care without intervention necessitating their own initiation, I do all in my power to transport.

Dwayne

Interesting stat about people not remembering the instructions given to them about follow up care. I wonder if that is unique to a hypoglycemic episode. I suspect that in many cases, people remember little of what a doctor/EMS person/RN tells them regarding their follow up instructions, care, options and responsibilities- especially if it is not specifically written down for them. For many people, medical information causes their heads to spin and they tune out.

I know hospitals give discharge instructions to patients that are specific to their particular problem, so I wonder if handing out a similar form for prehospital refusals would be a good idea. Does anyone do this?

We have patients sign an electronic form that lists the reasons why they are competent, and supposedly releases us from liability, but what about specific instructions for them? They do not receive a copy of that electronic form.

IE- Eat a good meal, closely monitor their glucose levels, make appointment with your MD, call back PRN, etc. I wonder if there are legal problems- other than a false sense of security- with giving out prehospital "discharge" instructions?

BTW- I wholeheartedly agree about the support person being there for a diabetic. If there is nobody else at home (usually not the case if the patient was severely incapacitated) you are playing with fire when you allow them to refuse. If all else fails, I have been known to prepare a sandwich for a patient and watch them eat so that I know they won't fall asleep and drop their sugar again.

[Kiwiology]

We have several protocols for things like this and they are absolutely brilliant I do like them! lol

Within our service we can give somebody PO gulcagon (at the entry to practice level) or IV glucose (intermediate and higher) and make a recommendation they don't need to go to hospital provided that

- There is a clear reason for the hypoglycemia eg a missed meal

- The hypoglycemic episode was uncomplicated by seizure

- They have recovered, are fully alert and have a GCS of 15

- They have access to food and a support person

- They agree to follow up with thier GP (primary care provider)

These protocols also exist for uncomplicated seizures (for known hx of epilepsy) and pallative care pt's.

[DwayneEMTP]

I know hospitals give discharge instructions to patients that are specific to their particular problem, so I wonder if handing out a similar form for prehospital refusals would be a good idea. Does anyone do this?

At our service we do. We have about a dozen or so written by our medical director that are given to all who refuse if appropriate. Hypoglycemia, syncope, trauma, head injury...I can't remember them all, but I do go through them whenever I write a refusal, which is rare. I think it's a great idea and doesn't really take any extra time.

Dwayne

[HERBIE1]

At our service we do. We have about a dozen or so written by our medical director that are given to all who refuse if appropriate. Hypoglycemia, syncope, trauma, head injury...I can't remember them all, but I do go through them whenever I write a refusal, which is rare. I think it's a great idea and doesn't really take any extra time.

Dwayne

Does the patient receive a hard copy of these instructions, or is it something you simply recite to them?

I think we all know what to ask, what to say, and instruct patients as to what to do, but if patients truly do not retain this info, then what good is it?

We have several protocols for things like this and they are absolutely brilliant I do like them! lol

Within our service we can give somebody PO gulcagon (at the entry to practice level) or IV glucose (intermediate and higher) and make a recommendation they don't need to go to hospital provided that

- There is a clear reason for the hypoglycemia eg a missed meal

- The hypoglycemic episode was uncomplicated by seizure

- They have recovered, are fully alert and have a GCS of 15

- They have access to food and a support person

- They agree to follow up with thier GP (primary care provider)

These protocols also exist for uncomplicated seizures (for known hx of epilepsy) and pallative care pt's.

Again- does the patient actually receive a copy of these instructions?

[DwayneEMTP]

Yeah Herbie, it's recited as well as a hard copy. We keep an accordion folder with them behind the seat.

Dwayne