I crouch down next to the skinny white guy. He looks to be in his mid 60s and he’s not breathing. Little old guy in a tiny house. It’s a narrow, shotgun shack, redolent with the acrid stench of cat urine, crowded with piles of old newspapers and bags of empty bottles ready to go to the recycle bin. The guy shared the cluttered floor space with a Naugahyde Barcalounger and a massive 70’s vintage RCA console TV, which was blaring a green tinted rerun of The Rockford Files at an ear splitting volume.
Captain McGillis is tucked in tight behind the guy’s head, wedged up next to the wall, the BVM pressed tightly on the man’s face. He is rhythmically squeezing the bag every 5 seconds and watching me through his safety glasses.
Eric is on the right side, getting a blood sugar. The glucometer beeps. “Low”, he said, as he looks across the guy’s chest at me.
Doug, my preceptor, is standing back. Unable to fit in the room, he leans against the door jamb, also watching me.
There are IVs you want, and then there are IVs you need.
This one fell into the “need” category.
Now, in the interest of full disclosure, I have to admit that I usually blow IVs when my preceptor is standing there watching. I’m pretty damn close to 100% in the ER, but when it comes to getting the line on scene or in the back of the truck, it’s a 50/50 shot. Nerves? Maybe. Whatever it is, I’m working on getting over it.
I also know there’s a big difference between the line you want, and the line you need. This guy needed a line. He needed an amp of D50 and that meant he needed an 18 gauge or better. And it needs to be done right now.
There was no room to get the drug box, or anything else, for that matter, into the room with us, so I look over my shoulder at Doug and ask him to hand me the IV roll and an amp of D50. As he turns away, I smack my hand down on the TV’s power button, silencing James Garner in mid sentence.
“Hey! I was watching that!” Captian McGills says, from his spot at the head. We all chuckle as Eric manages to maneuver the lifepack around the small end table that is tight against the man’s leg to stick some patches on.
The IV gear appears in Doug’s hand over my shoulder as the ECG prints. Eric hands me the strip, because I can’t see the screen at the angle I’m at. Normal Sinus at 72.
I wrap the tourniquet around his skinny arm and silently pray that he’s got decent veins. BAM! Before I can even blink, his cephalic vein pops right up and I grab the chloral hexidine and scrub away. Quickly slipping in an 18, I attach an extension set, tape down the hub and push in the D50.
It’s ten minutes later and our guy is sitting up and looking a lot better. The Cap is puttering around in the tiny kitchen whipping up a peanut butter sandwich and our guy’s blood sugar is now 77. It turns out his name is Louis and he took his insulin this morning, but forgot to eat. No, he’s not married, but his daughter checks on him twice a day. And there was, “no F’in way that he was gonna go to no hospital!”
I get on the phone with Laurie, his daughter, who arrives less than 10 minutes later and talks her dad into taking the ride with us.
Back at the fire station, Doug sits down at the table with me to review the call. He tells me I did the right things. Made all the right moves and nailed the IV when everyone was watching. But the thing he is most proud of, he tells me, is the fact that I just grabbed the phone and called his daughter and got her there to help me talk Louis into going.
“That’s really being a solid patient advocate,” he says. “That’s what I want to see.”
He gets up from the table and pours two cups of coffee. He hands one to me and together we walk out to the bay to restock the medic.
So why the transport?
I’m not opposed to transporting diabetics to the ER but why in this case why did you feel the need to transport. You did what you were trained to do as a medic. You assited the airway, you discovered the low blood sugar, treated it, rechecked it to verify it was 77 and prepared a meal, and you even called a family member that you knew could stay with the patient after arrival. You know the root cause that the patient took insulin without eating after you talked with him “he’s orriented” and it wasn’t caused by some unknown medical condition that could drive his sugar back down again. What do you believe will be gained for the patient to be transported to an ER. If there was other additonal circumstances then I say fine but if this is just a straight case of insulin without food, even with the depressed respirations, then you now have a patient in an ER for 4-6 hours at a minimum having unnessecary bloodwork done, tying up a bed, exposing the patinet to additional illness, and followed up with a discharge to home with the discharge instructions stating “Take your insulin with food” and “Follow up with your PCP”.
Do you have diabetic refusal protocols?
Are the people you are precepting under transporting patients to bill since most refusals cannot? (Bold accusation but it happens a lot!)
Was the breathing really absent or slow and shallow and you were assisting (based on the NSR@72BPM means he probably still has some O2 present?
If he was orriented why make him go?
Again, I’m not saying what you did was wrong but I’d like to know more details. Not every patinet needs the ER.
I’ve left plenty of diabetics home after giving them some sugar and a sandwich, but this guy was different. A few more details might have helped when I was writing this story. For one, his daughter couldn’t (or wouldn’t) stay. Second, our protocols say if they get a line and D50, they get transported. Is that right? Maybe. Maybe not. But, it’s not my battle to fight. It’s the protocol where I’m riding. I said that he was conscious, I never said he was fully oriented. He was still pretty out of it by the time his daughter showed up.
As far as “transport just to bill”, it doesn’t happen here. Our service is a municipal agency and we “soft bill”. If we don’t collect from insurance, it’s written off.
Was he sick? Septic? Malnourished? I don’t know. If his living conditions were any indication, I’d say yes.
So, all in all I think this guy needed to be seen at the ED. This was not the typical diabetic that perks right up with OJ and a sandwich. It just didn’t feel right.
Yeah, I feel you. I’m new at IVs and it’s not even 50/50 yet. They want me to practice on anybody that gets in the truck. I’ve got issues with doing an invasive, painful (when I do it lol) procedure on people that don’t need it just for the practice. I’ve asked to go to the hospital for practice, nothing yet. I’m not inclined to try when it’s truly life or death yet. Hate to blow what turns out to be the only viable vien. Anyway I agree with your transport decision. I’ve been to herds of diabetics, don’t think I’ve come across one not breathing before.
I always try to talk Patient’s into going. Even Diabetics that possibly don’t need to go. I’ve learned my lesson about refusals (death, repeat call for unresponsive Pt because they didn’t eat enough and the family member didn’t stay when they said they would, law suits, etc) and that lesson is that I HATE refusals. If I could I’d wait to start treatment until we got closer to the hospital but I don’t want to delay care. Too much stuff happens then. As my Medic Instructor pounded into our heads “If you have to err, err on the side of the Patient” and “Treat all the Patients (even the really annoying ones) like they are your closest family member.” You never know when the seemingly simplest diabetic call can turn into something really complex.
Cool Story. I agree that this patient should have gone to the hospital. He may have been alert then, but if he was left home alone, things could have gone bad. Your preceptor is 100% correct. Our primary function should be patient advocate; sometimes that means pushing meds and sometimes not. Until we get out of the mindset of us being technicians we will continue to be treated like outsiders.
Good Story but The patient should a stayed home with the daughter no need for transport to an overcrowded ed to recheck BS and give him a meal. Pt should of stayed home. I would of agreed to transport if this was a regular and multiple x’s of LBS. A call by his daughter to PMD would of sufficed. Along with her coming there and rechecking BS. Good dialog and use of expressionistic content.
Medic22,
You absolutely did the right thing. Protocols and EMS practices of course vary by region and company. IMHO, not all diabetics need to be transported to the ED after on scene treatment. BUT… it has been my experience that most of them do. Either way you look at it, we just don’t have the same tools that hospitals often take for granted. In the field, we must rely on our training, our experience, and our instinct. If there is any doubts whatsoever, we must do everything in our power to get the patient the care he deserves, even if it sometimes results in an “unnecessary” transport, so to speak. It is *much* better than the alternative.
All too many patients lack appropriate advocacy, and it is their health and quality of life that suffers in the end. Keep this attitude up, and you will be well worthy of that patch… and you’ll have the added bonus of knowing that you are making a difference. =)
Thank you for writing this. Enjoyed your clear description of all-too-familiar living conditions and the “gotta make this stick count” situation. And I thank you as well for being a patient advocate…I am often dissed for going beyond the “you don’t want to go to the hospital, do you?” mentality. It’s nice to know there are others out there that are not always just thinking about how fast they can get back to station…
God bless you!
Thank you for the follow up with the additional details. I agree, there some diabetics that you just don’t feel right about and transport. The IV and gotta transport protocol is new to me though and sorta surprising because if a diabetic becomes orriented they can always refuse transport regardless of what was medically done prior to that condition. I would hope the average medic would allow the line to be pulled and have the patient refuse because to not allow the patient to refuse if they are AAO would be kidnapping no matter what the protocal says.
I think you handled the call well… yea, he didn’t want to go, but you gained expressed consent after his daughter talked to him…he forgot to eat? maybe he has an underlying issue, such as alzheimers, where he is not able to care for himself on his own anymore, since he cannot remember to balance his medication and diet. Always err on the side of the patient….good job!
everything is all well and good except for 1 thing. You dont NEED an 18g IV to give a person D50. You can give a person D50 in a 20g just as easy as 18g. To be quite honost you can give a person D50 through a 22g if you really NEEDED to… I wouldnt recomend a 22g though just because that becomes time consuming and what not. But a 20g is perfectly fine. And if you really want to look at the glass halfway empty say you didnt get a line. 1mg glucagon is perfectly acceptable. Not preferred but accecptable. So what the guy NEEDED was to wake up with some form of glucose wether it be D50 or glucagon. Something our medical director preaches down here is you can do anything through a 20 or 22 that you can through an 18 it just may take an extra minute. Our protocols even state as long as it is appropriate it is preferred that in medical patients to place an 20g in medical patients and 18g in trauma. So next time you get that patient who is a diabetic and has crappy veins.. dont worry about freakin over trying to get an 18g in a small lady. Do something that will actually benefit the patient. Outweigh the benefit over risk.
Very true Texas, I also belong to the “smallest cath I can use” club, however, if I can, I like to push D50 through an 18. Just personal preference. Interesting how protocols differ from place to place. And yes, Glucagon would have been a great option if I didn’t get the line. But, I did. So, all’s well that ends well.