Routine II

It never ceases to amaze me when it happens. When routine saves you.

I was talking with another EMS Clinical Coordinator recently, and he said he did not understand why some medics seem to check the blood sugar on virtually everyone. Why don’t they do it only when it is indicated? I argued that medics don’t do it on everyone, just likely everyone within a very wide net. Almost any medical patient who gets an IV and some trauma get their blood sugar checked by many of us. Why? Well, the hospital often asks what the patient’s blood sugar is, and you look like you are on top of your game when you can fire back a number. And two, and more importantly, it is just prudent care. Now when I speak of checking the blood sugar, what usually happens after I get an IV, is I take the catheter and using my pen push against the back of it, causing a small drop of blood to come out the front, and I press that against the glucometer strip. What I am testing is not the capillary blood from the finger tip, but venous blood, which is often slightly less than the capillary blood. I am not too concerned with 10 points here and there. I am looking to see if there is a big issue. Is the sugar abnormally high or abnormally low?

The other day, I had a patient with weakness, who’s caregivers said she was not herself, and had been deteriorating, and was much worse this morning. They mentioned her blood sugar was 150. In my head, I ruled out hypoglycemia. I did my assessment. We carried her out to the ambulance in a stair chair. In the ambulance I did a 12-lead and put in an IV. I checked the sugar almost as an afterthought, and there was the number – 43. I now rechecked it with capillary blood just to make sure – 37. Okay, now I understoodd. She was hypoglycemic and her glucometer was not working properly. Some D10 (we are trying not to use the concentrated D50 now) and she was now chatting with me. How stupid would I have looked if I hadn’t checked it? In my almost 20 years as a paramedic, when expecting a normal result, I have gotten a surprising diagnostic result probably 20 or 30 times. You are not thinking hypoglycemia and bingo, there it is. I don’t have to face the “You know that lady you called the stroke alert for? Her sugar was 20 ” from a know-it-all ED staffer. I have caught hypoglycemia as late as the ED parking lot. “You know the stroke alert I called in,” I tell the triage nurse, “Never mind.”

I get called for a seizure. Patient history of seizures, not taking her meds, had a seizure last night and another one this morning. They are described as nonconvulsive seizures with altered mental status. A BLS crew is on scene with patient. The address is not more than a mile from the hospital. The BLS crew will likely be fine to take her in, but I decide to ride it in, just as a precaution. With seizures, you never know, and I am by nature, cautious. My routine with seizures is I ride in with them and I do them ALS. Again, I put in an IV just as a precaution. The lady is a hard stick, but the IV gods are with me, and I snake in a 22 in her forearm.

We go on a non-priority. Then just as we get to the ED, the patient’s eye starts twitching. By the time we have her in the room, she is now full blown, tonic-clonic, earth-quaking, bed shaking seizure. They thank me for the IV, through which they push Ativan to control the seizure.

Why did I ride it in? Why the IV? Did I know she was going to seize again, and this time have a full-blown seizure. I did not. I did it because it was my routine. It’s what I have taught myself to do.

I get called for a man with weakness. He is diabetic and has been feeling light-headed this morning. He has trouble walking, no strength in his legs. I follow my routine. I pop him on the monitor, put in an IV, check his sugar – its 187. I do a 12-lead. The machine spits it out. If the ST elevations by themselves aren’t enough to open my eyes, the machine is screaming it out as well — ***ACUTE MI SUSPECTED***. Oh, my gosh. I radio ahead. Get the cath lab ready.

There are some medics who can walk in a room and in one glance tell you what is going on. I can do this sometimes, but I am not always right. Nor do I need to be. I just need to not tunnel vision on my first impression. I need to keep an open mind and follow my routine, which casts a wide net for all possibilities – hypoglycemia, recurrent seizure, STEMI.

There was no brilliance involved on these calls, just following a day to day routine. You never know when it will save you.

4 Comments

  • I agree with you completely. I strive to do this everyday and I try to instill this into my students. Nice to know that your still writing, I’ve been away for a few years but now I’ll be coming back to read your posts!

  • h dawg says:

    All of your described cases were indications for a glucose check.

    Acute crushing chest pain radiating down the arm with concurrent dyspnea, however, is not an indication for a blood glucose check.

    There are indications for things and there are not, as with oxygen and saline fluids.

    Just because the hospital asks does not mean that they actually HAVE to have it, or even care. Most of the time they do a CMP/BMP anyway.

    I teach as well and disagree with your practice and that is because you are not teaching your students to think or know when procedures are indicated.
    Actually, yes, I will say that is wrong. Indications for a glucose check are signs/symptoms of any glucose problem. Seizures, lightheaded, malaise, dizziness, vertigo, etc etc. I don’t do a BGL on trauma alerts because there is no point. My time is spent managing the patient. It is irrelevant to the prehospital provider what the BGL is when, for instance, there is a bilateral traumatic AKA.

    Is one wrong for doing a glucose check on everyone? Nope, not at all. My point is that people doing a BGL on everyone, in my opinion, need to work on patient assessment…a lot. And read roguemedic’s site to learn a thing or two 🙂

    • medicscribe says:

      Thanks for the comments h dawg. You are doing a bit of misreading here however. I use the phrase “within a wide net” to describe who should get a BS check. As far as trauma, as you should know, there are patients who’s trauma is caused by falls or MVAs related to hypoglycemia. My point also is routine can save you when you are not always thinking clearly. I’ve been doing this for twenty years and I can tell you I have missed the boat and still do on calls, not for lack of experience, knowledge, or assessment skills. None of us are always on the top of game, not on every call. that’s when routine can save you. It has me.

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