Would you take a blood sugar here?

[SooC]

Acosell,

One of my instructors works in one of the GTA base hospitals (and is an ACP), and throughout the year he has impressed upon us the fact that base hospital isnt out to get you. Just think, there are much worse things you can do- like shocking a pt 21 times (one of the stories my teacher has told us about- would love to see how they were draining batteries left right and centre lol)

[vs-eh?]

Couple of things...

1) Yes Dust, from an ambulance perspective EVERYONE pays the same in Ontario regardless of what is done prehospital. Cardiac arrest or I hurt my finger at work = $45. Doesn't matter what drugs or procedures are used, if it is deemed "essential" (which 99% inevitably always are) the bill is the same. The $150 for doing that "unneeded" glucometry, wouldn't affect the patient dollar wise.

2) For my PCP friends who are playing the semantics game with standing orders, I will say this...they are simply guidelines. I'm sure you have heard the saying "follow the spirit of the standing orders". Ya...as long as you rationalize it adequately on the ACR I don't see how you ever could be faulted. If you do get the form back, just tell them why you did it if it wasn't clear to them. I have given ASA for example to patients who don't SAY they are having CP per say, but I rationalize it as a cardiac event. That 80 y/o Portuguese woman who doesn't speak english, is a little senile and who is in (what I deem to be) a new onset say, afib? I will give them ASA, even though they don't explicitly say they are having CP, nor can they qualify/quantify it. They look a little tired, little pale, little weaker, no coumadin or dig or anything, but are in afib? Easily rationalized as new onset, and therefore a cardiac event. Not saying I'd nitrate them, but ASA does reduce mortality...I've done this several times...

[Acosell]

Just thought I'd make a post from another Ontario point of view.

Acosell, for this post I'm going assume you're a PCP (like me!) If not, apologies, please correct me.

Without reciting word for word, here's the provincial Primary Care Paramedic directive for Hypoglycemia.

--Indications - patients who exibit any of these SERIOUS signs and symptoms: agitation, altered LOC, syncope, confusion, seizures, symptoms of a stroke

--Conditions - patients who have a suspected BS level less than 4.0 mmol/L

-- Contraindications, etc.

So, as a PCP in Ontario, you would have to have a patient with one or more of those serious symptoms, plus suspect they are hypoglycemic in order to perform a BGT.

I know all Base Hospitals have slight variations in medical directives, but I believe most in Ontario follow the provincial directives fairly closely.

So in this case, if your auditor is a 'By the Book' kind of guy, he could rightly say that you may have deviated slightly from the directive. Personally, I don't think it's worth being written up for. Perhaps on that call I would have done a BGT as well, but I can't say. I wasn't there.

ACP's on the other hand are different. Their scope is much broader and are not restricted as to when they can check the blood sugar level of a patient.

Cheers,

Later.

Yes, I'm a PCP (like you! )

That protocol you quoted above is the protocol to administer D50 or Glucagon for hypoglycemia. The part of this order I am referring to isn't regarding medication administration, but blood glucose checks. Under the notes section:

(and I quote this directly only because it was already opened)

"Ontario Provincial

Primary Care Medical Directives

Notes

1. A Paramedic may perform blood glucometry on a patient with signs or symptoms

that may be related to a glucose problem (hypo- or hyper-glycemia)"

^^ That is all we need under my protocols to check a patient's blood glucose level.

As far as I know he IS a by the book kind of guy, but what book he goes by, I don't know. Sure doesn't seem like it's the same book that I've got.

Edit: Oh, and VS-eh?, Apparently it doesn't matter how well you rationalize it, if that GCS is 15, you get the minor error on your record.

[vs-eh?]

Edit: Oh, and VS-eh?, Apparently it doesn't matter how well you rationalize it, if that GCS is 15, you get the minor error on your record.

Whelp that's stupid. Getting called to a syncopal episode that happened 15 minutes ago, the patient will likely be GCS 15. Agitated people are GCS 15 the majority of the time. See, I don't even look at some of the standing orders like that, if you feel that taking a sugar would be beneficial into leading to a better differential diagnosis, then do it. Just don't do it cause "you can".

If these "minor errors" will end up biting you on the ass after some accumulation, then ummmm... I would perhaps have a chat with your regional base hospital rep with some of your rationalized ACR's and see if you can be vindicated.

It's the same with my ASA example. I've never received a form back.

EDIT - and with your examples. #1 I'd need more info. #2 I would sure.

[hammerpcp]

Yes, I'm a PCP (like you! )

That protocol you quoted above is the protocol to administer D50 or Glucagon for hypoglycemia. The part of this order I am referring to isn't regarding medication administration, but blood glucose checks. Under the notes section:

(and I quote this directly only because it was already opened)

"Ontario Provincial

Primary Care Medical Directives

Notes

1. A Paramedic may perform blood glucometry on a patient with signs or symptoms

that may be related to a glucose problem (hypo- or hyper-glycemia)"

^^ That is all we need under my protocols to check a patient's blood glucose level.

As far as I know he IS a by the book kind of guy, but what book he goes by, I don't know. Sure doesn't seem like it's the same book that I've got.

Edit: Oh, and VS-eh?, Apparently it doesn't matter how well you rationalize it, if that GCS is 15, you get the minor error on your record.

Actualy jw is right. He was paraphrasing the Ontario protocols for pcp's for "suspected hypoglycemia" to administer glucagon. Recheck, or i can send them to you if you would like, and show them to your form reviewer person. According to these protocols a BS check is necessary for pt #1 and could be justified for pt #2. Where do you work? Sounds more messed up then here ( I didn't think that was possible)...LMAO Oh, also the protocols just became much loser for BS checks, so get the most recent version if you can. I f not talk to your BH doc. I'm sure they will not consider what you are doing to be any kind of error. Anyhoo, good luck wading throught the BS (and I don't mean blood sugar).

[Nate]

If you have reason to believe that blood sugar might be a factor then check it. Your glucometer is a tool, so use it (just don't treat it and not your patient). I know that if I start an IV I'll get a BGL off of the blood in the flash chamber (granted I have to remember to use the glucometer that is calibrated for this). We draw a lot of blood, it is expected by the ER that we have blood for anyone who isn't going to the waiting room.

As far as trauma goes (Dustdevil said something about the guy breaking his leg on a bike) I would check it because you don't know if he blacked out due to a low blood sugar and that is why he hit a tree or car.

[srs911]

Yes to both.

My rules o' thumb:

1. BLS patient but not sure what's up? Get a BG

2. ALS patient/Start an IV = get a BG

3. BLS patient with a diabetic history? Ask myself "why shouldn't I get a BG?". If I have a good answer (like, they called for a hangnail), fine.

I am of the opinion that there is not much room for question here. It's another tool to be used, like a stethoscope; why do we listen to and document lung sounds on a patient with a twisted ankle? Because we recognize that missing a respiratory insult can be detrimental to the patient, as well as our freedom to practice paramedicine! It's automatic. Try to think of obtaining a BG in the same light... sure it's not likely that the guy who presents with a broken leg after dumping his motorcycle has a decreased BG, but it could be the case (maybe that's what caused him to dump his bike?). And with that MOI he's probably a precautionary ALS anyway, you're starting a line, take the BG. As far as cost, all the services I have worked for (6 total) have never charged extra for BG determination, so considering cost to the patient was never a factor and has certainly contributed to my views on this matter.

I guess my feeling is just check it unless it is so freaking clear that BG is not an issue you would bet your dog's life on it. Let me make myself clear, I'm not saying that every patient should get a BGL. Plenty don't need one. However, plenty others require one. Takes a few seconds, is a useful piece of data, and i guarantee you that if you do this job long enough there will come a patient where you never though that BG was a factor, you catch it, and you management decisions will change based on it. I error on the side of caution, and never presume that I know all of what is going on unless I check it.

Here's another thing to consider, especially you guys/gals with considerable experience.... a lot of paramedic students and new paramedics come to forums such as this to get info, which is often provided by peeps with some experience. Addressing this specific thread, should a new paramedic error on the side of taking too many BGLs, and develop through experience (albeit anecdotal) a sense of who "needs" BGL determination or should she error on the side of taking too few?

[bassnmedic]

I consider Blood Sugar readings as part of my vital signs and do one on each patient.

[medic922]

I have made it my own to take a BSG on all cardiac, stroke, and any pt the exhibits any weakness, dissiness (my cee button dont work lol), it has actually saved me in many instances. Even if the pt doesnt have a past Hx of diabeties. It takes only 10 seconds to check a blood sugar, might as well do it. How many of you take an oral temp.? It doesn't take long, it can tell you alot of a pt's condition. Common sense is a virtue, might as well use it.

[medik8]

As far as trauma goes (Dustdevil said something about the guy breaking his leg on a bike) I would check it because you don't know if he blacked out due to a low blood sugar and that is why he hit a tree or car.

This just happened to me again a couple weeks ago....mva...appeared to be a partier....turned out to be low blood sugar. Very low... If it hadn't been checked he probably would have gone to jail...and then never saw the light of the next morning. It only takes a few seconds to check. I see everyone's point...but temps and d-sticks, I think, are sometimes basic tools that we all tend to overlook. No...don't do it "just 'cause you can", but let's also not be complacent and fail to use them them to reinforce our thinking, or as a means to rule something out. The results can, obviously, be deadly...

xoxoxo

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