NYS EMT's To Be Able To Check Blood Sugar

[ems-buff 81]

then by the Patients Doctor who was on the floor.

THE TRUE was he on the floor B/C you put him there after you found out what he did lol

[chazEMT 5]

I must admit that when I first started reading this thread, I thought "Great!!" I was all for teaching EMT-B's glucometry. My wife is a diabetic, and I learned quite easily how to check her sugar using her glucometer. Then I started thinking: "WHEN does it become necessary for me to check her sugar--something she can do in her sleep, with both hands tied behind her back....??" The answer: "When her sugar goes LOW!!" And when that happens, I recognize the signs & symptoms and TREAT HER FIRST!!! Then, as the symptoms begin to alleviate, I check her sugar. But AFTER FIRST TREATING HER!!!

EMT's must recognize the signs and symptoms of possible hypoglycemia, and TREAT IMMEDIATELY!! NOT monkey around with a machine (as simple and user-friendly as the machine may be), trying to confirm what the patient's presentation and history are already SCREAMING at us. NYS Protocol tells us - AMS + hx of diabetes = GLUCOSE (provided pt is conscious, able to swallow & maintain their own airway.) And when the patient is hypoglycemic, prompt treatment is key.

Yes, the EMT cirriculum needs to be expanded. But not to teach EMT-B's how to use more TOYS. EMT's should be taught good, thorough, and EFFICIENT assessment skills-and the proper emergency care steps based upon their assessment findings!

Now (and here's where my ignorance will shine through) is there any way a more effective treatment for hypoglycemia (at the BLS level) could be developed (or maybe it already exists??) It was mentioned earlier that oral glucose is less effective and much slower acting than IV dextrose. Would dextrose administered IM (via autoinjector) be more effective than oral glucose (kinda like an Epi-pen??) For all I know, such a thing already exists-and if so, I haven't heard of it. Anyhoo, just a thought.

[WAS967 97]

Now (and here's where my ignorance will shine through) is there any way a more effective treatment for hypoglycemia (at the BLS level) could be developed (or maybe it already exists??) It was mentioned earlier that oral glucose is less effective and much slower acting than IV dextrose. Would dextrose administered IM (via autoinjector) be more effective than oral glucose (kinda like an Epi-pen??) For all I know, such a thing already exists-and if so, I haven't heard of it. Anyhoo, just a thought.

To complement previos posts I will add what any doctor will tell anyone: You're better with a patient with a high glucose level than a low one. That being said, if the patient is AMS, give the sugar as long as it can be done safely.

There is a medication called Glucagon that can administered Intramuscularly (IM). It is readily available and I have seen several diabetics with a "Glucagon Emergency Kit" which is usually a small orange case about the size of a large magic marker. It has a small syringe of saline and a vial of powder (glucagon is unstable in liquid form and needs to be reconstituted before usage - a major hurdle for those who are unfamiliar with it's use). It works by releasing glucose that is stored in the muscles, thus raising the patient's blood glucose level. Go to the above link for pictures and more info.

The problem with giving Dextrose by any route other than IV is the fact that high concentrations of Glucose/Dextrose/etc (Like the 50% Dextrose that is typically given to adults IV) have a necrotic effect and can cause destruction of tissue - a major concern if you have an IV infiltrate and you are thinking or already giving Dextrose.

I wouldn't be surprised to see Glucagon (and even Narcan - used for opiate overdoses) make thier way onto BLS rigs in the near future. There are relatively few side effects and even if they are given inappropriately/unecessarily they won't do much to harm a patient - the pros far outweight the few cons.

Glucagon Emergency Kit Information

Edited July 28, 2005 by WAS967

[Guest]

Your link takes me to http://www.iso.org/iso/en/ISOOnline.frontpage, and I don't see anything like what you were describing. Can you check the link?

Thanks.

[WAS967 97]

Your link takes me to http://www.iso.org/iso/en/ISOOnline.frontpage, and I don't see anything like what you were describing.  Can you check the link?

Thanks.

Wierd. For some reason the link didn't post properly. Try now, it SHOULD work. (Here's to hoping).

[Guest]

Thanks for fixing the link. It looks interesting, but it would be nice if they could make that in auto-injector form. I don't know enough about auto-injectors to know if they could store the substances separately and mix them immediately before injection. Any thoughts?

[x635 4,066]

I believe there is a study underway that, like Narcan, you can give Glucagon intra-nasally. Which would make it easier to get onto BLS rigs, since you won't have to deal with needles and IM injections. Then again, mothers of diabetic children are trained how to give Glucagon IM.

[Guest EMSwhitecloud]

Glucagon is just like epi, only for diabetics. Leaves nice big bruise too. ( had to use it on my baby brother while having a seizure) Works nice too. As far as i know about the nasal thing is that it is a air mist insulin not glucose(as far as I know) Just another thought...Should EMT's and Paramedics be trained in how to deal with an Insulin pump in an emergency situation??? Because new pumps will have a sensor that detects your BS and if it sees it rising wll give you insulin automatically...which will be enough to counteract D-50 after having a low.

[WAS967 97]

As far as i know about the nasal thing is that it is a air mist insulin not glucose(as far as I know)

Air misting insulin into a person who is already hypoglycemic would probably be detrimental if not deadly. Maybe there is a mist that they are experimenting with for people who have HIGH glucose levels (HYPERglycemia)?

Just another thought...Should EMT's and Paramedics be trained in how to deal with an Insulin pump in an emergency situation??? Because new pumps will have a sensor that detects your BS and if it sees it rising wll give you insulin automatically...which will be enough to counteract D-50 after having a low.

Excellent point! My thought: Absolutely! One of the EMTs from Somers is a diabetic and has an insulin pump and brough up the same question. She was going to show us one day what to do but I don't get to see her often. Maybe ChazEMT can get her to write a quick blurb/post on houw it's done. I'll also see if I can find a website that talks about insulin pumps and thier impact on pre-hospital care.

[Guest EMSwhitecloud]

Try www.minimed.com......its where mine is from. I think they have a whole bunch of educational tools for Insulin pumps. Ive only had mine for 3 months, shes had hers a lot longer though. Shes one of the people who convinced me throughout EMT class to get it.

[Guest EMSwhitecloud]

In order to shut the pump off...

1. hit ACT

2. Down button once to suspend

3. hit ACT

4. ACT again

To Turn it on again....

1. ACT button twice.

Very Simple...but not all pumps may be that way I think all of MiniMeds are though

[Guest]

I believe this is a great idea, but I also have a problem with it. When I first became an EMT 10 years ago, I actually had to know what the I was doing. It seems like the new age EMT's are learning the fundamentals and it kind of scares me that now we are giving them advanced care capability. Almost every EMT I work with nowadays relies on ALS. Don't get me wrong, I also love having ALS, but remember "BLS before ALS".....

[chazEMT 5]

Hey EMSWhiteCloud, glad to hear you got the pump, too!! Good for you!!

The pump is an AMAZING little gadget....I call my wife's pump her "bionic pancreas!"

The pump my wife is on does not automatically check her BS...her glucometer is "linked" with her pump, and readings from the glucometer transmit automatically to the pump. The pump then "suggests" a bolus amount based upon her preprogrammed "insulin sensitivity" number. The pump will not, however, deliver the bolus without being told to do so.

Insulin pumps give a constant "basal rate" flow of insulin, which would counteract glucose administered.

We teach the students in our EMT class about the insulin pump. How to disconnect it, how to suspend the operation of it, and most importantly, how to RECOGNIZE IT. We also show some of the places the pump might be hidden (in a pocket, clipped to an undergarment, or that pager your patient is wearing.) Another thing to be aware of--Medic ID "jewelry." My wifes pretty silver bracelet on her wrist, with all the lovely colored stones....it's her Medic ID bracelet, and you'd never know it from a glance! The Medic ID stuff is getting more and more inconspicuous. They have watches, necklaces, etc...and most of it looks like "everyday jewelry!"

Anyhoo....this may be a little off the topic of EMT-B's using glucometers...but it is important. More and more diabetics are wearing the insulin pump...it's important we know how to recognize it and deal with it if necessary!

[WAS967 97]

WhiteCloud: When you follow those direction you gave, is there any prompts given on a screen by the pump or is just a series of beeps or something to let you know you're doing the right thing?

Worst case scenario, if you can't get the pump to shut down, clamp the hose with some forceps. DO NOT CUT THE LINE.

[Guest EMSwhitecloud]

it beeps when you "ACT" on something but you will know when it is suspended...it will make a series of three beeps and will say suspended and beep every 15 minutes.....

CHAZ first off i love the pump best thing i ever did and i have that meter too but they are coming out with another"sensor" to place on your body that will tell blood sugars and will tell the pump what to do(high BS or Low BS) so it will be like an artificial pancrease and you only have to test every 12 hours

[Guest EMSwhitecloud]

Worst come to worst disconnect it.....its two pieces squeez the prongs and pull out.....no need to clamp a line thats so tiny anyway or cut it their replacable....

Edited September 6, 2005 by EMSwhitecloud

[loopy31 12]

I really don't understand why paramedics get so defensive when EMT's are tryng to get better trained. Taking a glucose reading is very simple and easy to perform. While the EMT is waiting for the ALS fly car to arrive this is a test they can do to give the medic more information and waste less time waiting for the medic to do it. As far as pulse ox and AED monitoring. Well may we forget that some EMTs are volunteers and have other full time jobs that could be related to healthcare. Those EMT's may have more knowledge and training than you think.

[WAS967 97]

I really don't understand why paramedics get so defensive when EMT's are tryng to get better trained. Taking a glucose reading is very simple and easy to perform. While the EMT is waiting for the ALS fly car to arrive this is a test they can do to give the medic more information and waste less time waiting for the medic to do it. As far as pulse ox and AED monitoring. Well may we forget that some EMTs are volunteers and have other full time jobs that could be related to healthcare. Those EMT's may have more knowledge and training than you think.

I'm all for any healthcare provider expanding thier scope of knowledge. What I have a problem with is people (not specifiying level of cert either) getting blinded by having "toys" and forgetting the basics. [Medics can be just as prone to this as anyone else - don't even talk to me about RSI]

War Story (sorry if this has been heard before but it's just glaring) - I get called to a house for a person with chest pains. PD meets me at my truck to tell me they have the monitor on the patient, that patient is in "V-Fib" but they are "awake and talking". I respond - "No they're not". They guy gets all defensive and I state: "People in V-Fib don't usually talk". I get inside and find the patient in agonizing pain on the stairs of his house, AED (with crappy screen) on the patient BACKWARDS. What's the first treatment for a patient in chest pain? OXYGEN. Was it provided? NO.

KNOWING HOW to use a glucometer is just one part of the equation. Knowing how to integrate a glucometer into patient care is another.

[loopy31 12]

Well treating the patient is the first thing that must be done, but sometimes the "toys" help give us more information.

War story: Dispatched for a guy who fell out of bed and has shoulder pain. Upon arrival he was diaphoretic and grey. Treating what the symptoms showed, more was going on than a shoulder injury, we dispatched ALS. I read EKG's for a living, so I hooked him up to the monitor leads of our AED. He was having tombstone ST elevations. Basically he had a massive MI, and had CABG the next day. At first this call sounded like BLS, but fortuatley ALS was dispatched quickly. In my eyes, the "toy" seemed to have helped this man.

[Guest SQUADco119]

HEY 119 firstdue i take serious offense to that lol. You know unless the medic is absolutey needed ill ride alone as bls i rather take on the challenge lol . But i do agree with everyone for the most part EMTS should be able to check blood sugar. I mean we are allowed to treat the problem might as well be able to know what and the extent of the problem were treating.

[Guest]

True point squad119...I wish the newer EMT's would know their BLS skills before they take on new advanced skills....No offense to u..lol

[WAS967 97]

Well treating the patient is the first thing that must be done, but sometimes the "toys" help give us more information.

Sometimes. When used properly and well integrated into an effective treatment modality yes. When they become blinders to the basics they can be detrimental. Which do you think occurs more frequently?

War story: Dispatched for a guy who fell out of bed and has shoulder pain. Upon arrival he was diaphoretic and grey. Treating what the symptoms showed, more was going on than a shoulder injury, we dispatched ALS. I read EKG's for a living, so I hooked him up to the monitor leads of our AED. He was having tombstone ST elevations. Basically he had a massive MI, and had CABG the next day. At first this call sounded like BLS, but fortuatley ALS was dispatched quickly. In my eyes, the "toy" seemed to have helped this man.

Sounds like the outcome was good. But I fail to see how the mentioned "toy" affected outcome. You (properly) dispatched ALS based on a good patient assessment that picked up signs and (possibly) symptoms of a greater problem. How did the AED impact your care of this patient?

[loopy31 12]

Tombstone ST elevations are usually only seen during the active MI, we had good clean lead II pictures of it to bring to the ER. They started flattening out quickly after ALS arrived.

[WAS967 97]

Tombstone ST elevations are usually only seen during the active MI, we had good clean lead II pictures of it to bring to the ER. They started flattening out quickly after ALS arrived.

Actually it would be tombstone T-Waves. They are visible most commonly in the first 30 minutes of MI and then progress into the ST segment elevation you mention. ST segment elevation is also common in electrolyte abnormalities, especially in Hyperkalemia. I have a cool 12 lead of an acute hyperkalemic patient (kidney failure). The advanced stages take on the appearance of a sine wave. Very ominous sign.

A single lead isn't very diagnostic either. I've seen many a bad ECG mimicked by poor positioning of leads. A medical group had a few leads switched on a 12 lead that mimicked an MI. The cardiologist got a good laugh from that one. I understand the single lead raises suspicision in your mind of an MI, but I still don't see how it affected patient care. Did the Paramedics or the ER jump right on top of the MI protocol based on your single lead ECG? I sincerely hope not. I would rather hope that is was a well executed physical exam that found the patient diaphoretic and pale (and perhaps other S&S) that peaked thier interest more.

I wish more EMTs had your rhythm recognition skills. But unfortunatly most do not. Rhythm recognition isn't even part of the BLS skill set anymore. Far gone are the days of the EMT-D who would sit in a one day class, learn some quick rhythms (NSR, Asystole, V-Fib (Fine and Coarse), V-Tach) and come out thinking they could save the world.

Like I said before, I'm not 100% against the addition of glucometers to the BLS skill set. But I'm not 100% for it either. Call me on the line. But I still fear the day someone shows up at an unresponsive, whips out the glucometer before the oxygen, gets a reading of "Lo" and then proceeds to dump a tube of oral glucose down the patients throat. I've seen more negative outcome from the addition of now "toys" then positive.

[loopy31 12]

I firmly agree with the fact that you have to treat the patient signs and symptoms first and foremost. That is the most important thing a EMT can do. However having a bit more knowledge helps everyone.

Edited September 14, 2005 by loopy31

[chazEMT 5]

This is ChazEMT's wife (a.k.a. EMT/Diabetic with Insulin Pump)

I do a lecture/demonstration on the pump for our EMT class...if anyone would like for me to do the presentation for you or your agency, let me know...

There is no true protocol in place as of yet for dealing with the pump at the prehospital level, but maybe something can be put together!! I have the first hand knowledge on the pump...so what would the next step be towards making a protocol??

[Guest]

IMO, the EMT's coming out of a lot of these classes really isnt all that prepared for some of the things they are going to encounter.  I see people having trouble taking simple vital signs and doing basics like applying oxygen and splinting and we want to give them more toys to play with. Sure Id like to see EMT's doing more, but maybe we should either make the class a little longer or do something, patient care should be getting better and it sure doesnt look like thats the case to me.

←

I haven't seen this steady decline in the quality of pt. care that you speak of. I understad that there will always be EMTs (and Paramedics for that matter) who struggle to do their jobs well, but to imply that the EMTs that are coming out of class now are in any way less trained than those of years ago is insulting.

EMTs are perfectly capable of using a glucomter. 10 year old diabetics do it every day. I am an EMT, and I can't see how using a glucometer will affect how we treat our patients. Eiteher the signs and symptoms indicate oral glutose, or they don't. That is why EMTs don't need glucometers, not because they will be so busy sticking every patient that they come accross that they won't notice that the patient is not breathing.

[Eagle24 2]

I think it "generally" helps EMT's...traditionally you shouldn't really need it...however, if I was a diabetic and passed out outside of a bar @2am. . .maybe even AOB...you get the night crew that comes out and assumes you're "just another drunk". . .medic is maybe 5-10 mins because he was also woken up...wouldn't it be convenient if they just ran the test out of curiosity and found out, wow his sugar is really low. This happens maybe 1/1000 drunks, but if i was that one diabetic it makes a difference. It all has to do with what you see on the scene--I personally like to double check myself anyways (yes I have a pulse/ox, and I use it usually to confirm when I already DON'T think I need to use O2). . .someone made a point about new emt's not being able to even take vitals---once again, if i was in diabetic shock-i wouldn't want to count my life on an EMT who maybe has never even dealt with diabetics before......thermometers---technically "evasive procedure"-use your hand-but when you get to the hospital what sounds better-"his skin is really warm" or "he's got a temp of 103.1". . .the more info we can get the better we can treat them---"If it walks like a duck, talks like a duck, treat it like a duck".---and for all you medics---giving us this tool will allow even the new EMT's to cancel you earlier when they find out that the pt. is not having diabetic issues

[Guest alsfirefighter]

I think some of you are losing sight of what some are saying in their posts.

I haven't seen one person say an EMT wouldn't be capable of operating a glucometer. Kids do it, so what does that say? What some are saying including myself is that it isn't a replacement for good clinical assessment skills which for many medics, including myself have noticed that there seems to be a decline in assessment skills by EMT-B's. Which in turn isn't a reflection necessarily on the individual themselves in all cases but the way the curriculum has been structured over the past few years. I utilize a glucometer more to rule out hypo or hyperglycemia then I use to back up my clinical findings. I have given D50 or glucagon if I can't get a line in cases where the glucometer read normal because my assessment told me otherwise and what if the device wasn't operating correctly or some other action caused a inaccurate reading.

As far as the "war" stories mentioned I liked the input. However, I must also point out that per NYS BLS protocol, M-12 "Adult Respiratory arrest/failure it states if the patient is in cardiac arrest to refer to the AED Protocol (M-15). A AED is only supposed to be attached to a patient when they are in cardiac arrest. In protocol M-5 which is an "Adult Cardiac Related Problem," it doesn't state anywhere to attach an AED, even in monitor mode. I'm not a cookbook medic or EMS provider and never was, however some things in protocols need to be followed and if an agency has a good QA/QI and supervision these are things that will be picked up on and stopped. I've seen many emt's more and more attaching monitoring pads with AED's and no oxygen is on, no vitals and then want to walk a chest pain to the stretcher or ambulance. Good treatment starts with good practice of protocol and routine medical care.

[Guest]

I have to jump in on this one. First of all EMT's walking Pt. with chest pain..I have to laugh. I see more Medics do that then EMT's and I have been around for a while. As far as glucometers on an EMT-B level, why not. I agree that you do not treat the machine. You treat your Pt. but to be honest D50 and IM Glucagon does a number on your liver, and as a Diabetic myself I have enough problems..so unless I am in no way able to swollow you can keep your IMs.

To make a general statement that EMT's assesment skills are bad, and to further say it mostly comes from training or lack there of is very opinionated on your part. I am a Nurse and an EMT. there are Doctors that are EMT's, I would bet my last dollar that my assesment skills and many other EMT's are just as good if not better then a Medics.

I am also a Lab instructor and can honestly say that our students have good assesment skills and also get real life training not Just book training.