Question about D50

[Dustdevil]

On the original topic, if you run many cardiac emergencies, it doesn't take you long to realise that a pretty significant portion of acute cardiac patients are mildly, but noticeably hypoglycaemic. And if you're well educated in physiology, it's not any big surprise when you realise it.

I agree with Crotch to a degree. You cannot just go blindly "treating" signs and symptoms without any intelligent regard for the total clinical picture. That is an extremely valid and important concept in medicine. However, in order to make that intelligent decision, you do first need all the facts, which means getting all those tests and exams done before jumping in feet first with potentially contraindicated interventions, i.e. D50.

It does appear, from the story presented here, that the crew did make an uneducated mistake by jumping at the chance to pop the top on another drug vial without any clinical indication, and without sufficient knowledge of the potential consequences.

Education FTW. If your agency doesn't make a major learning issue out of this incident, your agency sucks.

[ERDoc]

Croaker hit the nail on the head, "TREAT THE PATIENT, NOT THE MACHINE". But don't feel bad, this is a common problem throughout healthcare. Just find a labtech who is over age 50, and ask them their opinion of today's doctors who can not make a diagnosis without a minimum of 7 labtests. As we become more technologically advanced, many in our profession rely on that technology way to much.

There are so many things wrong with this. It is not, "treat the pt, not the machine," and it is not, "treat the number, not the pt." It is a combination of both. You have to treat the machine, otherwise what the hell are you using it for in the first place? But you also have to think if the machine makes sense. I think the OP gives a great example of this. As an aside, I once saw a guy who was fully conscious and not compaining of anything with a finger stick of critical low. Repeated it 3 times with the same reading. One of the nurses checked it on herself twice and got normal numbers. Sent the chem to the lab and got a glucose of 12. Sent it again with the same result. Sometimes the info you get is not going to make sense but you have to respond to it. I don't want to find out how long he was going to remain stable for with a glucose like that.

As for your comment about not being able to make a dx without 7 lab tests, you missed the boat. Most of us can make the diagnosis, which is how we figure out what tests to order. We could probably cut back on the number of tests ordered if we didn't have to CYA. Sometimes we are wrong and miss something. How do you defend yourself in court for missing something when a simple test would have changed your dx? If I knew that I could discuss with my pt what I thought was going on and what I wanted to do without fear of litigation should I be wrong, I would probably cut the number of tests I do in half. I don't want to be someone's lottery ticket.

[DartmouthDave]

Hello,

Here is something interesting that I found the other day in the library at work. I was kicking back in a comfortable chair on a coffee break and I saw an Annals of Internal Medicine on the desk. Sorry I can not cite the actual journal......

But, it was a review of management of BGL in ICU patients. Some interesting facts came to light.

1--> Management of BGL has been proven effective in cardiac patients (DIGAMI) and for surgery patients only (study...can't recall).

2--> BGL control have been applied to other types of patients without as of yet controlled studies.

3--> Therefore, control of BGL in other ICU patients (sepsis...for example) is uncertain for a couple of reason.

A------> Tight glucose control (...and the r/o hypoglycemia...) worsen outcomes.

B------> So, is a higher range (...high normal?...) better for non-cardiac or non-surgery patients?

C------> Or, management with sliding scales?

D------> Or, management with oral/NG/OG medications?

For example, point 3A. Our insulin infusion gtts has a goal of 4-6 mmol. Sometimes, keeping it there is like balancing on a tip of a needle.

Time to go. Sorry for the lack of citations. I will try and track theme down. It is hard to type and watch a my 3 year-old daughter at the same time!

[crotchitymedic1986]

I am not saying you should abandon all technology, but at the same time you have to know the technology's limit. Without googling or dragging out your glucometer's trusty handbook, tell me at least 6 medical conditions that can cause a false high or low on a glucometer (not even going to go into the fact that most EMS glucometers are not properly cleaned/maintained, and glucometer controls are usually ran monthly at best (if at all, after the controls machine and strips are housed in ambulances that are too cold or hot per manufacturer recommendations). I imagine many of you can, but I imagine the vast majority can not; and there lies the problem. The medic who will push or not push D50 based on a glucometer reading ALONE, is just as dangerous as a medic who gives NTG tabs to a patient who has chest pain, because they just struck their chest on a steering wheel in an MVC.

[Dustdevil]

It really seems that all three of us were pretty much saying the same thing. ERDoc's example was excellent. The glucometer showed a seriously low BGL. Yet, rather than go, "Oh boy! That's another 'skill' I get to perform on this patient!", the time was taken to both confirm the reading multiple times AND to analyse the patient's overall clinical picture before precipitously implementing a plan. I believe that is exactly what Crotch was originally suggesting, as it is certainly what I was suggesting.

[ambodriver]

Croaker hit the nail on the head, "TREAT THE PATIENT, NOT THE MACHINE". But don't feel bad, this is a common problem throughout healthcare. Just find a labtech who is over age 50, and ask them their opinion of today's doctors who can not make a diagnosis without a minimum of 7 labtests. As we become more technologically advanced, many in our profession rely on that technology way to much.

let it be noted the pt. had a smell of etoh.

i don't know most of the details as i was not there

thanks for the feedback

On the original topic, if you run many cardiac emergencies, it doesn't take you long to realise that a pretty significant portion of acute cardiac patients are mildly, but noticeably hypoglycaemic. And if you're well educated in physiology, it's not any big surprise when you realise it.

I agree with Crotch to a degree. You cannot just go blindly "treating" signs and symptoms without any intelligent regard for the total clinical picture. That is an extremely valid and important concept in medicine. However, in order to make that intelligent decision, you do first need all the facts, which means getting all those tests and exams done before jumping in feet first with potentially contraindicated interventions, i.e. D50.

It does appear, from the story presented here, that the crew did make an uneducated mistake by jumping at the chance to pop the top on another drug vial without any clinical indication, and without sufficient knowledge of the potential consequences.

Education FTW. If your agency doesn't make a major learning issue out of this incident, your agency sucks.

You act like you were there? Was this you on the call? I did not provide much details....and there is more to the story. You guys got way off topic and started spouting off your mouths without knowing the full story. This topic was meant to discuss what I had posted about it...no to bash the crew based on the little information I gave. From what I understand the pt. had smelled of ETOH and was acting intoxicated, but was AAO X 3

With that being said thanks for the inoformative stuff that was posted by you and others on this topic.

Edited February 21, 2010 by ambodriver

[tskstorm]

let it be noted the pt. had a smell of etoh.

i don't know most of the details as i was not there

thanks for the feedback

You act like you were there? Was this you on the call? I did not provide much details....and there is more to the story. You guys got way off topic and started spouting off your mouths without knowing the full story. This topic was meant to discuss what I had posted about it...no to bash the crew based on the little information I gave. From what I understand the pt. had smelled of ETOH and was acting intoxicated, but was AAO X 3

With that being said thanks for the inoformative stuff that was posted by you and others on this topic.

So the crew could have been smelling ketones and they went ahead and gave d50 to a pt who was A+O X 3 ?

Nope can't think of a single reason to bash anyone.

********

Next everything that was said was said as a generalized post, not to any specific crew or crews. Everything that was stated was dead on. You certainly seem to be getting very defensive considering you were not on the call. After years of not having glucometers, we got them last week, I know huge breakthrough there so my use with them is limited. So even if I was concerned about a failed reading/misreading I'm confident in seeing the 'whole picture' and treating accordingly. Had the patient been having an MI yes it could have had a poor outcome if you pushed the D50, however my question is, what was the outcome of this patient? Did they have an MI or were they just drunk or what?

[DartmouthDave]

Hello,

If the patient was having a MI I think the risk of a bad outcome here from pushing the D50W is quite small. If he wasn't having a MI.....then no big deal.

Really, even AMI patients admitted to hospitals who are managed with an insulin infusion have spikes in BGL. Also, most MI DIGAMI protocols (..that I have seen...) only start if you have had TWO sustained BGL ( <10mmol) in a 4 hour period.

Second, I think the point here is to discuss elevated BGL in the MI patient. Not to start a flame war. Of course one should treat the patient and not the machine. Of course understanding the pathophysiology and the physiology is important as well.

Did the crew make a mistake? Maybe. But in all honesty who knows with the information that we have. Maybe he was drowsy, confused, sweating, pale and c/o chest pain. They were having equipment issues. Maybe they we new and nervous?

What is worse......an untreated episode of hypoglygemia or worsening a marginal case of hyperglycemia (150mg/dl = 8.3 mmol)???

Was it their best day....odd are no. I have seen worse and I have done worsen (...we all have...)!

As for ketones. I think it would be hard to have ketones with a bgl of 8.3 mmol. IMHO.

Cheers

[ambodriver]

One thing I hate about EMS forums and really EMS in general is that everyone is a know-it-all.

And thanks Dart

Edited February 22, 2010 by ambodriver

[croaker260]

Oh I can't disagree more.

I am so sick of this treating the patient not the machine thing that everyone is so hung up on. How bout an UnCx diabetic??... just intubate & transport? What about perfusing V-Tach? What about silent STEMI? How many diabetics have you seen that can go as low as 1 mmol without having any read symptoms? Your saying just wait till they become altered??

To be honest I think the crap that is spewed in this "treat the symptoms" is a catch-all for those who can't critically think for themselves. The machines are an assessment tool, they should be used to guide Tx.

Reactive medicine treats symptoms. Proactive medicine treats signs.

You decide.

As for the bold text above; I would be interested to know if these same Dr's could diagnose without the "fancy tests".

I gotta tell you though...... feel free to ultrasound, draw blood, or CT me anyday to ward off "exploratory surgery". Each to thier own though.

I had this very discussion about 14 years ago with a doctor, a General Practitioner from Rural Tennessee, who for MANY YEARS was the only FT doctor in this county...who still worked the "ER" (Three total beds- Major 1, major 2, and Hallway )in the small clinic.

His very astute assessment is that while there are more tools available today, todays doctors are so dependant on them they for get the most important tool...the assessment. Especially the SUBJECTIVE assessment. According to him, and I have heard it repeated elsewhere, 80% od the DX is derived from the SUBJECTIVE ASSESSMENT. I know that when I teach, I stress this point, that the assessment is as IMPORTANT as the monitor, the glucometer, or the CT.

In short, we dont teach our EMT's , Medics, or even Doctors, to talk and interact to patients anymore, to assess them beyond a few basic steps. We belive that they will learn it on the job, and saddly they dont, or at least not quick enough not to have some purely avoidable mistakes occur. Like the one discussed above.

I would stand right beside you and say that anyone who intubated a diabetic unconscous and hypoglycemic patient should have to explain themselves...but I would also say that there are cases where that same hypoglycemic , unresponsive diabetic patient should be intubated too....and that the total assessment, not just the glucometer, tells the whole story.

To use your xample....while ultrasound/CT will prevent some surgeries, an assessment will prevent unnessessary untrasounds and CTs, and catch the need for CT's and Ultrasounds that a lesser practitioner would have missed.

Yes, its not perfect. But thats why medicine is a PRACTICE and an ART as much as a science.

Edited February 22, 2010 by croaker260