Thanks, I`ll Stay Here

     Attack One responds to a business office for a report of a man down. They find the patient on the floor of the entrance area: a middle-aged man in business attire, unresponsive and diaphoretic. The staff reports he is a visitor to the business, and was making a sales call. He had been meeting with a company official, asked to excuse himself and then collapsed into a chair. He is breathing and has a regular, strong pulse. The office staff knows his name, but not his medical history.

     He is unresponsive, and after a quick search, an alert bracelet is found that indicates he has insulin-dependent diabetes. There are no smells of intoxicating substances. No signs of trauma are present. He has large veins in his arms.

     The Attack One crew does a quick intervention, starting an intravenous line and using a drop of blood from the catheter to perform a dipstick blood sugar test. It shows a blood sugar of 28. The man has a free-flowing IV line, so they inject him with 50 cc of 50% dextrose solution. Within 30 seconds the patient stirs, then opens his eyes, then begins to move around. The IV line is secured, and the remaining vital signs are taken. He has a pulse rate of 72 and is perfusing well. His responsiveness keeps increasing until he asks: "What happened?"

     "Your blood sugar dropped. Do you know why?"

     The patient clears his thoughts over a few minutes, then is able to give a history. He flew into town, arrived late, grabbed his rental car and drove into a traffic jam. He arrived late at the office for his appointment, and couldn't take time to get any food en route. He took his usual dose of insulin this morning, and hasn't eaten since 0700 hours.

     "Are you feeling ill in any way?" asks the lead paramedic.

     "Not at all. And I can't go to the hospital. My bills are too high already from my diabetes, and I can't afford it."

     "Can you eat something for us?" the paramedic asks. The patient agrees to do so.

     Further medical history is obtained, and the man has no nausea, abdominal or chest pain, palpitations or fever. He was not sweaty until he became unresponsive. The office staff finds some sandwiches and a container of juice, and the patient consumes them without problems. A repeat fingerstick blood sugar result is 132. The patient says he feels fine, apologizes for creating a problem and asks to have the intravenous line removed so he can finish his business.

Rational Approaches to Transport
     There is good literature demonstrating a low rate of problems in those released after treatment for insulin reactions. It is unpleasant, and potentially problematic, to "kidnap" patients and force them to go to hospitals after treatment. The legal issue is the assessment of competence after the patient is aroused, and whether they have clear mental status at that time. Some systems make the transport/nontransport decision with the assistance of online medical control.

Many EMS organizations have a conservative approach to patients treated for acute hypoglycemic reactions due to insulin, asking the EMS provider to assess and document that:

• There is a reasonable explanation for the hypoglycemic episode;
• The patient has absolutely no other medical complaints or problems (fever, chest pain, palpitations);
• The patient is not nauseated or vomiting;
• Vitals are stable;
• A blood glucose test after treatment shows blood sugar levels normal or slightly above;
• They observed the patient eating (or drinking) something, to make sure the patient was able to tolerate oral intake of calories;
• Someone else competent is with the patient, and that person understands the patient and the potential for later problems, and can assist the patient or recontact EMS, if needed;
• The patient will not be put in a situation where others will be placed at risk, as in driving a car, flying a plane or working in a factory.

     There are a couple of important groups to exclude from a "treat and no transport" policy. In these situations, the underlying issue causing the low blood sugar can't be adequately treated in a short time by EMS personnel, and blood glucose is likely to drop again without ongoing treatment. These groups include:

• Diabetics who aren't taking insulin, and have the low blood sugar due to the use of oral agents to lower sugar;
• Poorly nourished persons with alcohol abuse problems;
• Diabetics on insulin pumps.

     Local medical direction should be followed so that consistent approaches are in place for your group of providers.

     For some complicated diabetic patients, it may be appropriate to contact the patient's personal physician to get their advice. Many are happy to see the patient in their office if the patient does not want to go to the hospital.

Case Resolution
     Considering the criteria outlined above, the patient's request for nontransport could be respected:

• There was a reasonable explanation for the hypoglycemic episode;
• The patient had no other medical complaints or problems;
• The patient had no nausea or vomiting;
• All vitals were stable;
• A blood glucose test after treatment was slightly above normal level;
• EMS personnel observed the patient eating and drinking;
• The office staff offered to have the patient stay with them for the rest of the afternoon, and call if further medical issues developed. At closing they would drive him to his hotel;
• The patient would not be put in a situation where others were placed at risk.

     The Attack One crew removed the intravenous line, gave the patient complete instructions, including a request to call if further problems occurred, and had both him and a member of the office staff sign a refusal-of-transport form. The completed patient care report was used to restock the supplies and medication.

Waking Diabetics
     Waking up the diabetic, whether with oral sugar, intravenous sugar or an intramuscular dose of glucagon, leads to some very interesting clinical situations, and then transportation decisions. Almost all EMS providers have memorable occasions related to the struggle to get patients this treatment. Here are a few examples.

Most memorable struggle
     It took 10 firefighters and a brave emergency department nurse to hold down a raging bull of a male and administer a dose of IV glucose. He awoke as the meekest and gentlest man, asking "Why are you all so sweaty?"

Favorite first line      A very pregnant young woman who was administered IV glucose at her office asked: "Did I keep my clothes on this time?"

Quickest conversation      The police were finally able to nudge a car off the road and into a soft yard, after its erratic driver had hit a dozen or so other cars, chased pedestrians off sidewalks and clipped a natural gas line. The man had a blood sugar of 15. After his dose of intravenous glucose, he insisted on driving his car the rest of the way home.

Least favorite conversation      A man was awakened with two doses of IV glucose. He had been ill with a fever for two days, and had chest pain. He wanted to refuse transport, due to his high medical bills, and said, "If you insist on taking me to the hospital, I will tell my family never to call you again when I have an insulin reaction!"

Learning Point
     There is little paramedics do that is more dramatic than waking up a diabetic patient whose blood sugar has dropped too low. It's a grateful feeling when the patient awakens, but one that may be followed by dread when they announce, "I'm not going to the hospital." There are processes of good medical care and documentation that can allow such desires to be honored. In other circumstances, though, they cannot be, and some patients must be transported.

James J. Augustine, MD, FACEP, is an emergency physician from Washington, DC. He serves as deputy chief-assistant medical director for Washington, DC Fire and EMS. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH. He is a member of EMS Magazine's editorial advisory board. Contact him at James.Augustine@dc.gov.

EMS EXPO™
     Jim Augustine is a featured speaker at EMS EXPO, October 15–17, in Las Vegas, NV. For more information, visit www.emsexpo2008.com.