Moment of Truth

Your patient is unresponsive. They are also cool, and diaphoretic. You are thinking they are diabetic. You have pricked their finger to get a capillary blood glucose. This is the moment of truth. You are actually hoping for the reading to come back LO or at least less than 50. If it does, you relax, you believe the issue is simply low blood sugar and some IV dextrose will have the person back to normal and maybe even signing a refusal in no time. But if the blood glucose comes back normal, that’s bad. That means something else is causing the patient to be unresponsive and cool and clammy, something far more sinister and less responsive to treatment than hypoglycemia. You wait as the meter counts down. 5, 4, 3, 2, 1.

If it is LO – You give IV Dextrose. If it is normal – you start thinking maybe this is a stroke or cardiac (what does the monitor say?) or it is hypovolemia (You would likely already know this by an absent or weak thready pulse).

If they are hypoglycemic, there can be a second moment of truth. In most cases, they respond and wake up and swear that they knew they should have eaten and damn, where are they? And no, absolutely, no, they don’t want to go to the hospital. But sometimes, they don’t respond and you check the sugar again, and it is now normal or even high, and they are just like they were – cool, clammy, unresponsive. The low blood sugar either wasn’t the cause of this episode and is just a symptom of it, or they have been with low blood sugar so long some damage has been done.

I have had several patients over the years who I encountered with low blood sugar, who ended up going into cardiac arrest on me. One was a man with very poor IV access. I couldn’t get a line, so I took out the glucagon. Unfortunately, I dropped one of the vials, and had to get down on all fours and reach under the stretcher for it. When I finally reached it and came back up, now eye level to eye level with the supine patient, he looked different to me. Different like his eyes were open and lifeless and he was not breathing. I know one medic who encountered a patient with low blood sugar, loaded him into the back of his ambulance, told the family their loved one would be fine, and when they met him again at the hospital, the ambulance doors open, the embarrassed medic was doing CPR.

The other day I had a woman found unresponsive in a car and vomiting. She was cool and diaphoretic. Her husband said she was a diabetic. Something didn’t strike me right about the call. As the first medic there checked the sugar, the number came back – 129. Normal. All right, let’s get moving, we both agreed. The woman was hypotensive. BP of 80/40, then 70/36. The heart rate was 60. We didn’t have knowledge of her meds other than she took insulin. The woman groaned and was alert enough now to complain of severe abdominal pain, as well as pain in the back. We popped in two IVs and called in a medical alert. Her belly was hard and distended. We were both thinking maybe a GI bleed or a AAA. The 12-lead was normal – no STEMI. The lady was so clammy and hypotensive, I thought she was going to code on us.

They met us at the hospital with a full team. They did an emergency ultrasound that was inconclusive. When I checked back on the patient later, she was looking much better. Still in her ED room – not in the OR or up in ICU. Her skin warm and dry, her BP in 118/78. Pulse of 60. Sat – 98% on a cannula. Yesterday, I saw a nurse who take of her and asked for the bottom line. Likely constipation. It seems the patient hadn’t had a bowel movement in 5 days. Maybe she vagaled, the nurse said. She was disimpacted and went home that night.

Twenty years of this, and you never really know what you have. Diabetic, Triple AAA, GI bleed, or a vagaled constipation?

5,4,3,2,1…the answer isn’t always the answer.

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