Diabetics-Treat n Release or Transport?

[G]

Howdy!

Just curious how everyone else out there handles hypoglycemic known diabetic patients after treatment.

Do they all get transported or just those who don't respond well enough to treatment?

Do you only release them if the scenario makes sense (e.g., they changed their routine today, took their insulin, but didn't eat yet
or increased exercise, etc..)? Or do you release anybody who comes around? And for those who don't go, what if any measures
do you take to ensure the patient will eat soon, followup with the private physician, ask the MD to consider prescribing glucagon
injection kit or tabs to fix future episodes, etc.?

Some services attempt to transport all diabetics. Especially if they required ALS to fix them up. Just because it's very common
doesn't mean it's benign.

My concern is it might be more complicated than "simple" Hypoglycemia. What caused it? Is it related to other complex illnesses or meds they're taking? Do their diabetes or other meds need to be adjusted? (Can this be handled with a followup phone call to their doctor?)

Many diabetics just have a mishap, no big deal. But the other possible scenario would greatly benefit from going to the hospital
where countless other tests can be performed. This includes documenting this episode/ scenario for the private physician and any future folks who need to know. (similar to a seizure patient who legally cannot drive for six months in most states) What about liability after we leave if the patient doesn't followup with complex carbs,etc.? Lots of events could occur harming the patient or others depending on how responsible, smart, cooperative, compliant they are with our suggestions before we leave.

I suggest the simple hypoglycemia episode is far more complicated than just the quick fix and bail.

Your thoughts/SOG's/suggestions?

G

NREMTP, Preceptor



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These are my own thoughts/opinions; not necessarily those of my affiliations-YES,I THINK!

[DED1645]

Not speaking as a medic, but we have in our local a repeat customer you could call him. We are call third party at least once a week to a resident for a 34 M w/ a known hypoglycemic condition. We don't even start to package prior to medic arrival for we all very well know once the medics arrive and start their line and administer the glucose and the PT regains conciseness he is going to refuse treatment/transport. One time they felt his blood sugar was so low they waited till we were actually loaded and moving before administering the glucose for they didn't want him to refuse. He really needed to goto an ER. So that was are founded solution. Let me reassure you that at know time was the PT in any more danger for waiting to administer the glucose. He was being observed closely!

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David DeCant
firefighter/NREMT-B
Originally Mantua,NJ
Presently Lindenwold,NJ(I'm not a member of any of this District's dept's.)

[fyrmedik]

Our system does treat and release hypoglycemic diabetics. As long as they are willing to eat, and have someone to watch them for the time being. But in the same instance, we always transport elderly patients.

[afd767]

We currently treat the patient and if we see results from the treatmeat. We will release the patient. The patient has to answer our questions correctly and there has to be a history there. We make sure the patient has a meal to eat to hold their levels up. Most of my patients have had good results with d50 or oral glucose. Most diabetics will refuse to be transport. We try to talk them into going to the hospital and if still refusing we have a check list on our refusal form that the patient must read and check to legally covers us.

[pompanofd]

HI , IF PT. RESPONDS QUICKLY AND HAS GOOD MENTATION , I RECOMMEND TRANSPORT TO ER, IF PT. IS PERSISTANT THAT THEY DO NOT WANT TO GO . I LET THEM SIGN OFF. LAST I REMEMBER IT'S YOUR RIGHT TO REFUSE. IF FOR SOME ODD REASON I GO BACK TO THE SAME PT, ON SAME SHIFT THAT I DID NOT TRANSPORT EARLIER , IT'S AN AUTOMATIC RIDE TO ER. NO QUESTIONS , PD CALLED IF NESSESARY... TAKE CARE.....

[lt/medic]

We have a treat and release protocol for hypoglycemia that is reasonably strict, it includes:

Must get a post blood sugar 10 minutes after D50; and before IV DC'd.

Pt. must be advised of all complications of treat and release as per informed consent.

Treat and release must be cleared with Medical Control.

Documentation on full runreport vs refusal form.

[Medic019]

How about this, A recently new "frequent flyer" that has called several times in a two week period with a presentation of Hypoglycemia. Last we got called there I opted to load her into ambulance due to I felt she needed ER eval to see why just recently she's been having this problem - she always refuses after D-50.

I get a baseline Glucometer of 30, load her into unit and begin the 4 block transport to hospital. Enroute I start oxygen therapy and IV of NSS ( which I got started on the street in front of Hospital )..Took her into Er and gave them the full scoop on the frequency of calls lately & that she has not had the D-50 yet. ( Mind you this patient is lethargic without any airway compromise ).

My next shift I show up to work and find the ER called and complained that I didn't give the D-50 prior to arrival at ER. Needless to say, it leaves me sitting back wondering...Is thinking in the best interest of the patient's future welfare worth having the ER come down on you.

Personally, I will next time treat all DM patient's totally on-scene as far as I can possibly due without endangering their welfare prior to transport..and allow them the refusal.

I was curious, Anyone else have this experience or wish to input in ???

Thanks

[Romania]

What typically happens with patients we don't run on alot is that we establish an IV and give the pt Dextrose. Once we have a LOC increase we get the patient to eat a good meal, if we have to prepare it we do. Than we patch and consult with the doc, I have never had a doc refuse a refusal in this situation. On frequest flyers I let them know that next time they are going in, and have never had an argument the next time.

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Alan Romania, CEP
romania@uswest.net
IAFF Local 3449

My Opinions do not reflect the opnions of the IAFF or Local 3449.

[PHMEDIC93]

I think a good way to approach a diabetic that this hasn't happened to before is to get them in the truck, start the IV on scene, then push the D50 enroute. However if it is a diabetic we've been out on before I'm happy to wake them up and make sure they get food. I just get nervous when someone isn't there with them to make sure they can get back to normal after their meal. I like diabetics, they are one of my favorite types of calls to go on provided I can get an IV on them or Glucagon works. It's one of those calls that makes me feel like being a paramedic really matters, plus most of them end with good results and they are generally not real depressing calls.

[cdstafford]

In my system if an amp of D50 brings a diabetic patient around, they are allowed to refuse further care if we advise medical control about the situation and they OK it. Personally, since the patient is obviously having a hard time regulating their blood sugar correctly and I like to avoid going to the same place multiple times in one shift for the same c/c, I like to wheedle, cajole, or otherwise convince the patient that they need to take a trip up the road with us for their sake. I remember one medic I worked with didn't take this approach and documented a refusal from a diabetic who became lucid after getting an amp of D50 and we ended up going back not half an hour later, only this time she DFO'd and cracked her head against a chair on the way down, making her a diabetic trauma patient. Not fun. I'd rather just use the extra 15 minutes it takes to transport and get the patient somewhere they can be monitored more closely than crack 2 drug boxes and be out of service for 2 hours total due to the return trip, but everybody's different ;)

[ALSfirefighter]

I treat and release every time it is feasible. Generally, if the patient wants to refuse following an amp of D50/100 Thiamine it is his/her choice. I do attempt informed consent for legal purposes, but more times then not they still will want to RMA. We also must contact medical control to allow the patient to sign an RMA with any condition in which ALS is warranted or was performed. We do not have any specific protocol that states what is needed to give an RMA with a diabetic, however I as well as most of my co-workers, will give the D50/Thiamine, when the patient comes around another glucocheck is given, then 10-15 minutes later, again it is checked, if there is a sharp decrease in the level, they will again attempt to transport and contact medical control for additional amps or permission to still RMA the patient. Patient rights are not based on presumption, so if they are CAOx3 at the time you ask, they can RMA here in NY. I'm also more comfortable in leaving them with someone. If not I usually tell them they have to drink 2 glasses of juice or other sugar drink before I'm allowed to go. I also advise them to call their MD who prescribes their insulin or oral hypoglycemic.
The thing to keep in mind is that it is the patients personal MD who needs to see them more then the ER. In situations like my area, the amount of diabetics that could fill the ER could leave them on diversion much longer then they already have to. Medic019, I would have given her Glucagon, unless at 30 she was really out of it, she would have gotten the D50, she can refuse it after she's CAOx3. But I do have to say if I have to use Glucagon, they get transported.

[shammrock54]

I follow protocal. If the pt responds to treatment and is AOx3 and is of legal age i will strongly make my case that they take the ambulance ride, no matter what they say, or tell them to call their primary care doctor. Other than that i let em sign the refusal wish them good luck, warn them to be careful w/ their diabetes and go back into service.

[SilverCity4]

You raised this topic from the dead, didn’t you PHMEDIC93?

I hated frequent fliers as much as anyone else when I still rode a bus (and someday I will again). I always recommended hypoglycemic patients go to the ER with us as a CYA measure. Secretly on the inside, I would hope they said no and signed the refusal form. In Oklahoma if you are A&O x 3 and older than 18, you can refuse—doesn’t matter if you have a severed leg with a spurting femoral artery bleed.

I’m really not a cold-hearted person, but USUALLY, diabetic emergencies (and hypoglycemia specifically) is a problem caused by the patient not taking medication, not eating right or radically changing physical habits. And the frequent fliers aren’t going to smarten up by taking them to the ER four times a week.

I’m being cynical, but it’s not my job to make sure someone is checking up on a patient after I leave them, whether it’s their mom, son, or family doctor. Except for the occasionally exceptional case, it’s a waste of time. Take, as an example, the following:

My favorite frequent flyer of all time lived out in the county when I worked for a combo department. We’d run on her all the time—she lived WAY out in the county. The normal scenario was for her and her current squeeze to get nice and slobbering drunk on Jack or Crown, after which she doesn’t take medication or eat. Then her sugar gets low--so her normal solution to the problem was to drink maple syrup. On more than one occasion, we would end up waiting for the county sheriff’s deputy to show for 15 minutes (and it was a 14 minute response time) because she and the boyfriend were throwing too much stuff at each other for us to enter. She died last fall at age 37 and it doesn’t surprise me a bit. But, as she told us on more than one occasion, she didn’t need anyone telling her what to do.

Sorry for the bitter-sounding post, but you’ve all got your own “unfavorite” person. You know who I’m talking about. Just so happens mine was a diabetic. I'm off my soapbox now!

[Kobersteen]

I have no problem treating and appropriately (Non-AMA) releasing hypoglycemics post D50.

The only thing that I am animate about is the fact that I will fix them a sandwich and a glass of milk (not OJ) and sit there until they eat and drink it all. That way I can get my >10 minute post D50 ChemStrip and I know that they have had complex sugars to keep the level good at least until I get back to the firehouse. :D

[rcrompm46]

We are able to treat with appropriate measures (d50 or oral glucose). If they are ax3 over 19 they can refuse. My personal
favorite is to have them perform their own repeat glucose test. If they are able to perform at this level they can refuse. They are
advised to eat and call again if they need to.

Stay safe