In Part 1, I groused about over use of Blood Glucose Level (BGL) checks in patients that don’t need them. Of course shortly after that I came across a case where the patient absolutely should have had his BGL checked.
Briefly this was a male in his mid 30s who had a seizure. When EMS made contact, the patient was no longer actively seizing. He was post ictal, which is a generic description of the mental state of a patient after the seizure has ended.
The range of post ictal states can range from unresponsive, to sleepy, to slightly irritable, to wildly violent.
This patient was sleepy until the medics decided to pick him up and move him to the stretcher. At which point he became wildly violent. He fought with the medics, the firefighters, and the police on scene.
Once on the stretcher, he calmed down and became sleepy. So, the medics decided to continue their assessment. At which point, he started fighting again. The medic who wrote the report documented that they were unable to start an IV (understandable), and unable to place EKG electrodes for cardiac monitoring (also understandable). They administered 6mg of Versed which made the patient barely manageable. That’s well within their protocols.
The report documents that the patient continued to buck the restraints and try to get off the stretcher. That’s a bid odd, but not inordinately so, when Versed is used. Ativan is actually a better drug, but is not authorized in the state where the medics work.
Up to this point, they were doing things within the protocols and care was appropriate.
Here is where they went off track.
They didn’t perform a BGL. The medic didn’t explain why he didn’t do one, but he didn’t. That’s a major deviation of the protocols and one that absolutely needs explanation.
The only thought that I had was that they just didn’t think of it. Most medics will do a BGL when the start an IV. Technically, they are supposed to do a separate finger stick with a lancet and get the reading that way.
Medics can debate for hours whether there is a real difference between a finger stick (capillary) or IV (venous) Blood Glucose Level and whether the difference is significant. This is much like theologians debating how many angels may dance on the head of a pin.
In truth, it’s going to be pretty close no matter which method you use. The important part is to actually get a reading.
While obtaining a BGL on every patient may drive me nuts, there’s no rule against it. I just think it’s an indicator of a lazy provider who doesn’t or can’t think the situation through.
On the other hand, not getting a BGL when it’s indicated by good clinical judgement or the protocols is going to get a call flagged for further review. Many EMS and a few law enforcement careers have been ended by the “It’s just a drunk” syndrome when encountering a patient with an Altered Mental Status.
My last observation, or if you prefer gripe, in this series is overuse of IV fluids.
There are several indications for administering boluses of IV fluids. Generally so called Normal Saline is the fluid of choice, but there are others that are used in some systems. Normal Saline is good for several things, although it’s use has been curtailed for trauma patients in many situations over the past few years.
It’s good for Septic patients. In fact, in the EMS setting it’s the best treatment we have for Sepsis and it’s also the one that’s used first in the hospital.
Briefly, in Sepsis the underlying problem is dehydration. The treatment for dehydration is… hydration. That is IV fluid. That is not dependent on blood pressure, as there are several markers for Sepsis other than that.
Hyperglycemia is another good indication for Normal Saline.
Shock, to a limited extent depending on the underlying cause is another good use for saline.
All of which I see on a regular basis when I’m reading ambulance reports.
The problem lies with the other things I see. While it has many uses, there are sometimes when Normal Saline can be dangerous to the patient.
Think of Normal Saline as a medication. All medications have indications, doses, contraindications, and adverse effects. There are no “harmless” medications.
In the case of Normal Saline, the things that should give a provider pause before administering doses of Normal Saline are patients with a history of Congestive Heart Failure, Hypertension, cardiac arrhythmias, any sort of cardiac pump disease, among others.
Given large doses of Normal Saline to patients with medical histories like those can have serious adverse effects.
The one that always comes first in my mind is pushing fluid into the lungs. Lungs are designed to hold air and fluid overload will displace air and make it much harder for the patient to breath. This isn’t a huge risk in most younger patients, but may elderly patients have minimal cardiac and/or respiratory reserves so an amount of fluid that someone in their 20s, 30s, or even 40s will tolerate with no adverse effects could well kill a person in their 60s, 70s, or older.
Like every other medication, it’s important to know not only it’s benefits, but the draw backs to using it.
Which will bring me to my last complaint, at least for now.
When I was a young medic and even before that when I was a younger EMT a wise older (like his late 30s) medic told me that medications have specific indications and if I understood a medication list, then I’d have a pretty good idea of what the patient’s medical history was. That would be true even if the patient or other people on the scene couldn’t give me any information.
It was not, and is still not, unusual for patients no to know what a a particular medication was for. If you asked why the patient took a medication, the answer often would be “Because my doctor told me.” This doesn’t mean that the doctor didn’t tell the patient why they were prescribing a medication. It very likely meant that the patient forgot, or didn’t understand and was afraid to ask questions, or maybe didn’t listen in the first place.
The best current example of that is a newer drug called Eliquis. Depending on your TV viewing habits you may have seen a commercial for that medication. It’s prescribed for one thing and one thing only. Atrial Fibrillation not caused by a heart valve problem. That’s what the advertising says.
So, if I were working in the field and saw that on the medication list, I’d be looking for an irregularly irregular pulse and if the patient complaint indicated an EKG, I’d be looking for Atrial Fibrillation.
If the patient list included Metoprolol, I’d be looking for Atrial Fibrillation or Hypertension, maybe both as part of the Past Medical History.
There are a lot of medications out there. Even in the years since I retired several newer medications have come on the market. No one is going to be able to remember them all. That’s where a Smart Phone comes in handy. Even in the last few years of my active field career, I’d turn to my phone and type in an unfamiliar medication name to see what it was for.
Not only would it tell me what it was for, but I could find out if any of the medications I might plant to administer would result in an adverse or allergic reaction.
It’s better to avoid an adverse reaction than have to treat the patient for one on top of whatever there original complaint was. At a minimum it means some risk to the patient and more work and documentation for the provider. At maximum, it can cause the patient significant harm and a loot more documentation, possible remediation, possible career ending actions by an employer or regulatory body.
EMS can be a hard field to work in, but it’s a lot harder if you don’t pay attention and don’t use your brain while you’re doing it.