Routine

Routine. Routine. Routine. Twice in just a couple weeks I have been saved by routine.

Here’s what happened this time.

First, a little background. The first responders in one of the towns I work in have decided they will no longer respond to lift assists without injury. It was argued to the high-ups that well, you never really know until you get there, but to no avail. The first responders have other priorities and the ambulance can do the lift assist if no one is injury. I just found out about the policy. I didn’t even know it was in effect. We have such a good relationship with the first responders. It seems they are always there helping us.

Anyway, so we get sent to the “lift assist, no injuries,” and are told there will be no first responder. I explain the policy to my partner, who hadn’t heard of either.

The call is at an elderly apartment complex. A neighbor meets us at the door and leads us into a bedroom, where we find an obese sixty-year-old woman laying flat on the bed, unable to sit up. She is alert and oriented. I touch her forehead it is warm and dry. She says she is weak, and while she normally could get up, she can’t. I ask her if she is a diabetic. She says she is. I ask if she checked her sugar. She said she did earlier and it was fine. Her speech is clear, but when I test handgrips, her left side is weaker. I do the arm drift test and she can’t hold her left arm up. She looks like she might have slight facial droop, but I’m not sure of it. She says she was up around four to have breakfast, and was walking fine, and then she went back to bed, and couldn’t get up when she heard her neighbor knocking at seven.

“This may be a priority after all,” I tell my partner. “We may be on the clock.”

The woman is a difficult lift – it would help to have the first responders there, but we don’t have time. She is already close to the three hour prehospital stroke window. With her neighbor’s help – holding the woman’s feet, we are able to spin her around from the far side of the bed to the closer side, and then lift her on the bed sheet onto our stretcher.

Out in the ambulance, as we race to the hospital lights and sirens, I ask the woman if she has ever had a stroke or a TIA before.

“Is that what I’m having now?” she asks, “A stroke?” Her eyes tear up.

“It could be. You’re left side is weak. We’ll let the hospital decide.”

I search for a vein. She says they need to use a butterfly on her. I take a stab at the AC, but come up with nothing. When I pull the needle out of her arm, there is just a small dab of blood from the hole I made. I take out the glucometer and do a sugar check off of it. Just to cover all my bases.

LO

LO means less than 20.

“This might be good news. You’re sugar is low.”

“That can cause a stroke?”

“Not a stroke, but it can make you look like you are having a stroke. I’m not saying that’s the problem, but I’m going to give you some sugar and we’ll see.”

I’m wondering what she is doing talking to me if her sugar is less than 20. In most people she would be unconscious.

I renew my search for a vein, and find a tiny one on her right arm – enough to fit a 24 in. I recheck the sugar again – just to be sure in case my first reading was contaminated.

It still reads LO.

I then push the sugar – it actually flows quite well.

“Squeeze my hands.”

Equal grips.

“Hold your hands up in the air.”

They both stay up.

I unbuckle her strap. “Can you sit up for me?”

She sits bold upright.

“I think you’re fixed,” I say. To my partner, I say, “Slow it down and cut off the lights.”

**

I check a sugar on just about everyone – and of course it is part of the stroke protocol to check the sugar just in case it is the sugar causing the problem, but the key part is your routine just makes you used to doing it so you don’t forget, so you don’t end up at the hospital with a stroke protocol only to have the doctor say, “ah, did you check the sugar? It’s less than 20.”

**

Maybe that’s why first responders shouldn’t pick and chose calls. Sometimes “unable to get up – not injured” means a stroke or hypoglycemia. Sometimes it means cardiac arrest. I’ve had that happen before. A woman says, “My husband can’t get up…He’s cold.”

Sometimes there’s nothing routine about routine.

4 Comments

  • Anonymous says:

    Hear, hear for our routine ALS rituals! Every now and then I’m surprised by a patient whose sugar shouldn’t be low, but is. We could do a better job of teaching the students in our profession the value of good habits. – just a medic

  • Anonymous says:

    You did right for the pt, but I’d question the “LO” reading especially considering how asyptomatic she was. You even said yourself < 20 usually = unconscious.I had a call the other day for weakness/general malaise/”feeling like i’m going to pass out” in a diabetic. Did CPHSS and found no defects suggesting stroke. Did the fingerstick and it came up LO. I found it odd, as you did, considering how my pt didn’t present as AMS or even skin signs of hypoglycemia.Pushed the amp of D50 without much change, she said she felt slightly better. The hospital’s fingerstick on arrival was over 300. Thats awfully high to go from < 20 to now over 300.At that point I really questioned wether my glucometer was accurate. I tested myself after the call and I came up at 50 (I’m not a diabetic and I had snacked all day). I test myself with another glucometer and I get 80. Later I find out the first glucometer had the batteries replaced earlier in the day without being recalibrated and put back in service. Oops.As someone put it to me later: treat the patient, not the glucometer. While in your case it worked out well, in mine maybe not. I think in retrospect, though I suspected something was amiss by having a “LO” reading and no other significant findings, I’d rather push the D50 and drive her sugar up (300 never killed anyone) than bring a diabetic complaining of those symptoms in to the ED, have the RN do her own fingerstick, find a low blood sugar and me to feel stupid for doing nothing.

  • PC says:

    As far as inaccurate glucometer readings, I have been burned in the past by them, but most of the time it has been because my glucometer was too low. I have had people in picture book DKA with sugar readings in the 200s. I treated them the same – oxygen and fluid, but was baffled by the low readings. The hospitals were 800s.I carry an extra glucometer at my suburban post so I can double check any time I have a suspicious reading. I forgot to do it this time, although I did do two checks on the one glucometer.In your case, a jump from Lo to 300 does seem like a lot, although I find one amp of D50, can often put a hypoglycemic into the high 200’s. The number soon drops.In this case, I had no reluctance in giving the woman D50 for several reasons. She was NOT asymptomatic. While her symptoms were unusual for a hypoglycemic patient, they were not beyond the range. True her shin was warm and dry and she was alert, but she was weak, and had some neurological deficit. The sugar check is a part of the stroke protocol because on occasion, as in this one, hypoglycemia can mimic stroke.I have had a few occasions in the past where people with sugars in their twenties have been alert. Everyone has a different threshold. What was unusual in this case was not just the low sugar, alertness, and warm dry skin, but that she was not insulin dependent. She also had never had an episode like this before.I spoke with the nurse who took care of her for awhile in the ED today about her case, and she said, that the woman kept dropping her sugar, and had to be given D50 on two more occasions. Obviously something was going on inside her that was burning her sugar up. If I find out what, I’ll post it.

  • Anonymous says:

    When I said asymptomatic, I meant relative to what you’d expect from someone with a BS of < 20 mg/dl. Thinking about the 300 number now, the patient was a relatively small, thin female and I had just finished pushing the D50 when we arrived at the hospital, so its possible if the sugar had been circulating for a little while longer the number might have been slightly more reasonable.Still its obvious the glucometer calibration was off in my case, given my own testing with it.Though I know certain areas, New York City for example, where glucometers are not in widespread use on medic units and pushing D50 is protocol on any AMS patient. Their protocol requires that the patient has no s/sx of hypoglycemia AND a minimum BS of 120 mg/dl for D50 to be withheld.

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