40 Y/O female not acting right.

[FireEMT2009]

We are called to a residence for a 40 (ish) y/o female not acting funny. Upon arrival she is found asleep on the bed. We awoke her and she stayed lethargic throughout the call. I have gotten vitals and they are all in normal range. Her BGL is read as HI. We transport her, as we get her to stand up with assistance she begins to puke but states that no ETOH or drugs were used today. She has IDDM although hasn't eaten today nor taken her insulin. I am unable to start a line due to lack of veins. She stays lethargic and altered level of consciousness. We transported to the hospital and did EKG monitoring and found no etoptic reasoning within the EKG. I told some of my fellow classmates about it and those that I asked stated that they would have tried to start an IO. To me this patiennt was not in the criteria nor the critical condition to conduct an IO. I thought about an EJ but she would keep turning her head randomly and say something slurred and become lethargic again. She did not meet any other stroke criteria, except for the slurred speech. My field impression of this was HHNC or starting DKA. I was wondering if I was correct in making the decision to not start an IO. My only thought that kept me from attempting an EJ is the fact that her head jerking motion could cause it to blow thorugh the extrernal jugular and possibly go into the carotid artery which is a major problem. So from all the medics out there, how would you have handled this call?

I would have startred the EJ and given fluid to try and break down her BGL while keeping check on her lung sounds, which were clear during the transport.

[HERBIE1]

Depends on the transport time.

As long as the patient is perfusing well, good BP, O2 sats, pulse, stable EKG, etc) I would NOT start an IO, As for the patient turning their head frequently- place them in a cervical collar if you really feel the need to go jugular..

Let the ER start a central line.

[Bieber]

Hmm, this is a good scenario, and I'm not sure I can give you a straight answer!

I know at least one crew that is big on starting IO's if they need them, but most of the partners I've worked with seem somewhat hesitant to. In this case, it's a question of risk/benefit. What are the risks of NOT having a line on this patient? Are you comfortable not having one on her? What are the benefits of a line? Yeah, you can give her fluids, but depending on how long your transport time is, will you be able to give her enough to make a difference? She bought herself a stay in the ICU, that's for sure, and like Herbie said, she'll probably get a central line not to mention insulin (which doesn't need a line to be administered) to bring her sugars down.

I suppose if it were me, I would probably just keep trying to get an IV (even trying the EJ) and hold off on the hospital (keep in mind, my transport times are usually around 15 minutes). But at the same time, you don't want to be afraid to bust out the IO if you need it, and if you had started one on this patient, I wouldn't knock you for it. Yeah, it carries some risks with it, but it's also not this humongous super-scary thing that it sounds like.

Hope that helps.

[FireEMT2009]

Mr. Herbie,

I only had about a 10 minute transport time. The patient was as stable as could be even though she was lethargic. To me she did not meet the criteria for it, if she had worsened and started going down hill I would have started either an EJ or the IO. Thanks for the response.

Mr. Bieber,

I am not huge on using IOs unless absolutely nessecary., My patient was as stable as she could be and showed no signs of deterieration in the sligthest. I did not attempt any other methods of venous access. The transport time was about 10 minutes as I stated above. I figured that since we had a short transport time what little fluid I could have administered would not make much of a dent. I left it up to the ER docs on this one. I just thought it was an interesting scenario and just wanted to see what other experienced medics would have done in the same situation. My preceptor told me that they pick her up regularly with the same problem and can never get an IV line on her. Thank you for your response.

FireEMT2009.

[BushyFromOz]

I think my friend that using an IO for this patient is probably not warranted.

Your classmates opinion of starting an IO, based on what youve posted i think is probably a little tainted by wanting to use some of those new shiny toys more than they realise, which isn't necessarily a bad thing because it shows some eagerness and it shows a willinness to get aggressive with management, and for those few times where its desperately needed thats a good thing, but more ofte than not our patients arn't that sick.

The hardest thing for ambo's to do is take the minimalist approach when its an appropriate option and in this case a quiet ride, maybe stripping the pt down if they are hyperthermic and 5 minutely pats on the head with some insulin therapy at hospital is more apropriate than drilling a hole in her.

Good work mate

Edited July 10, 2011 by BushyFromOz

[FireEMT2009]

Mr. Bushy,

I completely agree, the IO was not warranted in this scenario. I would have liked to have had at least an IV in place and some fluids in and lowered the pressure a little bit. I talked to my OMD and he said a liter of NS can lower the BGL by a good 100 g/dl. It also would have hurried her care up a little bit as well. Oh well, what can you do? Thank you for your comment and advice.

FireEMT2009

[DwayneEMTP]

Mr. Bushy,

I completely agree, the IO was not warranted in this scenario. I would have liked to have had at least an IV in place and some fluids in and lowered the pressure a little bit. I talked to my OMD and he said a liter of NS can lower the BGL by a good 100 g/dl. It also would have hurried her care up a little bit as well. Oh well, what can you do? Thank you for your comment and advice.

FireEMT2009

Excellent answer. Truly.

Now your transport time is 30 minutes. What do you think?

It's 60 minutes now? Same answer?

I have a little trouble with your opinion that this patient isn't critical. I had this exact patient, only with a penis, showed Hi, only I was able to easily obtain access and run a ton of fluids. Labs showed a BGL of 1500 at the ER and he died before the next morning.

And though Beiber may not have meant me, I do think that folks take I/Os, and EJs, way to seriously. Some patients need fluid or meds, others will simply benefit physically, mentally or emotionally from fluids or meds..to deny any of these folks any of these things because you (general you) are afraid of more aggressive access should get you fired. Or, as I've proved at least once...giving it to them may get you fired too.

But I think that your logic is awesome. A couple of pieces of advice, meant friendly as I'm already a fan. Could you break your posts up into smaller paragraphs? It makes them much easier to read...easier on the eyes, and much more likely to generate responses. In my opinion.

Also, having the balls to post a case review before you have 20 posts? Yeah man, I'm confident that I'm going to remain a fan.

Also, you're not a hosemonkey here, so sir isn't necessary. Every now and then Babs says it, and it friggin' rocks! But it sounds to me that you've earned your place here. There's no hazing, there's no 'noob' hoops to jump through. All are judged on their heart. commitment and logic. Good on your for the respect, but take it brother, don't ask for it. I'm grateful that you're here. Many here like Paramedic Mike and Herbie are so old they won't remember that you were nice to them anyway.

Thanks for participating..

Dwayne

[Bieber]

Mr. Bieber,

I am not huge on using IOs unless absolutely nessecary., My patient was as stable as she could be and showed no signs of deterieration in the sligthest. I did not attempt any other methods of venous access. The transport time was about 10 minutes as I stated above. I figured that since we had a short transport time what little fluid I could have administered would not make much of a dent. I left it up to the ER docs on this one. I just thought it was an interesting scenario and just wanted to see what other experienced medics would have done in the same situation. My preceptor told me that they pick her up regularly with the same problem and can never get an IV line on her. Thank you for your response.

FireEMT2009.

First of all, you are the first person to ever call me "Mr." Bieber, which is hilarious in and of itself. =P

Secondly, and don't take this like I'm trying to criticize you or anything 'cause I've only been a paramedic for six months, but why aren't you a fan of using IO's unless they're absolutely necessary?

I have a little trouble with your opinion that this patient isn't critical. I had this exact patient, only with a penis, showed Hi, only I was able to easily obtain access and run a ton of fluids. Labs showed a BGL of 1500 at the ER and he died before the next morning.

And though Beiber may not have meant me, I do think that folks take I/Os, and EJs, way to seriously. Some patients need fluid or meds, others will simply benefit physically, mentally or emotionally from fluids or meds..to deny any of these folks any of these things because you (general you) are afraid of more aggressive access should get you fired. Or, as I've proved at least once...giving it to them may get you fired too.

I completely agree with the first thing you said about the patient being one hundred percent critical. While we may only see the beginning of DKA, once it's just getting bad enough for them to call 911 for help, the truth is patient's with these high sugars have already bought themselves a stay in the ICU, and the lab chemistries that get out of wack by hyperglycemia can have very serious, life-threatening and life-changing consequences.

I also did mean you, and agree that IO's and EJ's are taken way too seriously. It's a tool, one that in the wrong hands can have serious consequences, at the same time, it's one of those things where you have to way the risks and benefits and I think that the risks are sometimes overhyped due to the simple idea of drilling a hole into someone's bone. Yes, like any invasive procedure, it can have dire and even life-threatening consequences. At the same time, I don't believe it's SO dangerous that you should feel you like you have to have a code blue to whip it out. Use it when you need it, and learn to recognize when you need it (and when I come across that patient that I need to do an IO on, I'll be sure to share it with everyone to let you know my experience!).

Take care.

-Bieber

[FireEMT2009]

Excellent answer. Truly.

Now your transport time is 30 minutes. What do you think?

It's 60 minutes now? Same answer?

I have a little trouble with your opinion that this patient isn't critical. I had this exact patient, only with a penis, showed Hi, only I was able to easily obtain access and run a ton of fluids. Labs showed a BGL of 1500 at the ER and he died before the next morning.

And though Beiber may not have meant me, I do think that folks take I/Os, and EJs, way to seriously. Some patients need fluid or meds, others will simply benefit physically, mentally or emotionally from fluids or meds..to deny any of these folks any of these things because you (general you) are afraid of more aggressive access should get you fired. Or, as I've proved at least once...giving it to them may get you fired too.

But I think that your logic is awesome. A couple of pieces of advice, meant friendly as I'm already a fan. Could you break your posts up into smaller paragraphs? It makes them much easier to read...easier on the eyes, and much more likely to generate responses. In my opinion.

Also, having the balls to post a case review before you have 20 posts? Yeah man, I'm confident that I'm going to remain a fan.

Also, you're not a hosemonkey here, so sir isn't necessary. Every now and then Babs says it, and it friggin' rocks! But it sounds to me that you've earned your place here. There's no hazing, there's no 'noob' hoops to jump through. All are judged on their heart. commitment and logic. Good on your for the respect, but take it brother, don't ask for it. I'm grateful that you're here. Many here like Paramedic Mike and Herbie are so old they won't remember that you were nice to them anyway.

Thanks for participating..

Dwayne

Dwayne,

Thank you for enjoying my posts, our instructors told us that they would make sure we were not goonaj be the "cookbook" medics that know what drugs to push, they wanted us to know why we push it and what it does. They require logic for all of our treatments and the rationale behind it. If I had a longer transpsort that was about 30 minutes I would have probably done the EJ and gave fluids but being so close to the hosptial I let the docs handle it.

I was brought up that anyone that was older or more experienced than me gets sir or mam no matter what, until told otherwise.

I think I probbly should have been more specific than using just the word "critical" in the after thought of yours and biebers posting. The patient was not in shock, she was perfusing well, vitals were good, and she remained conscious throughout transport. If she started going down hill or starting decompensating from the hyperglycemia I would have went the IO route. I believe that if my patient requires an IV and I am unable to obtain one I will use the IO without fear. I wanted to be aggressive, but you can only do so much treatment in 10 or so minutes of transport time for this scenario.

First of all, you are the first person to ever call me "Mr." Bieber, which is hilarious in and of itself. =P

Secondly, and don't take this like I'm trying to criticize you or anything 'cause I've only been a paramedic for six months, but why aren't you a fan of using IO's unless they're absolutely necessary?

I completely agree with the first thing you said about the patient being one hundred percent critical. While we may only see the beginning of DKA, once it's just getting bad enough for them to call 911 for help, the truth is patient's with these high sugars have already bought themselves a stay in the ICU, and the lab chemistries that get out of wack by hyperglycemia can have very serious, life-threatening and life-changing consequences.

I also did mean you, and agree that IO's and EJ's are taken way too seriously. It's a tool, one that in the wrong hands can have serious consequences, at the same time, it's one of those things where you have to way the risks and benefits and I think that the risks are sometimes overhyped due to the simple idea of drilling a hole into someone's bone. Yes, like any invasive procedure, it can have dire and even life-threatening consequences. At the same time, I don't believe it's SO dangerous that you should feel you like you have to have a code blue to whip it out. Use it when you need it, and learn to recognize when you need it (and when I come across that patient that I need to do an IO on, I'll be sure to share it with everyone to let you know my experience!).

Take care.

-Bieber

Bieber,

As i stated above with Dwyane, respect is given to anybody who has more experience or is older. I think the IO and EJs are great tools and options to have and can make a huge difference when used properly. Looking back on the scenario I think that the situation was treated as best as possible with the situation and transport time that I was given. I am still learning and still a little fearful of some of the skills I have been given although I practice them regularly to keep up my skills. I appreciate your comments and showing that I shoud be a little more specific with the wording of my posts.

FireEMT2009