Author: Brandon Oto

Am I Normal? Finding the Baseline

When it comes to vital clinical skills that simply aren’t taught in EMT class, it’s hard to think of one more important, more frequently called upon, and less formally instilled than this: the ability to determine a patient’s medical baseline.

What’s that even mean? Simple enough. People call us because they have problems — specifically, new problems, or at least new complications of old problems. They don’t call us because of the stroke they had five years ago, or their existing stable angina, or because they still have dandruff. (Okay, sometimes they do, but then we ask why they really called.) So when you’re presented with the patient who has all of those things, the question is: what’s new?

Usually, of course, they tell you. “What’s going on?” “Oh, my stomach hurts.” Most days their stomach doesn’t hurt, today it does, they want to know why. Fair enough. But then you continue through your history and physical — does this hurt too? can you feel that? look here, please — and you find various other abnormalities. Are those new? If so, they may be important. If not, nobody cares. Nobody will thank you for performing a masterful assessment, stroking your beard, and announcing to the world: “I believe the patient has… cancer!” when it was diagnosed a year ago and the patient is already undergoing a planned course of treatment.

This was all much easier in the textbook. They spent quite a while teaching us what healthy people are like — their vital signs, their anatomy, their physiology — so that we’d recognize when someone deviated from that, and we could figure out why. And of course, that method works. As long as your patients are healthy. Unfortunately, healthy people don’t call 911 nearly as often as sick people. Forty years ago, maybe the majority of our patients were generally well individuals with acute problems — broken legs, allergic reactions, unexpected heart attacks — but nowadays, the bread and butter of EMS consists of treating acute exacerbations of chronic disorders, or new complications in the setting of multiple comorbidities.

So how do you figure out which irregularities are worth remarking upon, and which are unremarkable for the patient? Here are some tips.

 

1. Ask the Patient

When they’re able to help out, the patient is one of the best sources of information. Do you know how your blood pressure usually runs? Is your pulse normally a little slow? When did you get this bruise?

Patients with adequate memory and cognition are generally pretty good historians about their own bodies. Not necessarily the details — sometimes the endless litany of acronyms, tests, and diagnoses can blur together — but the personal stuff. They are intimately aware of the fact that they’re usually nauseous in the mornings, they’re told about their high BP whenever they visit the doctor, and they notice their abnormal pupil every time they look in the mirror. Patients with some cognitive impairment may be less able to help you out here, but as a rule, they should still be your first source — you should simply view their input with the appropriate amount of weight based on their perceived reliability. Of course, you should try to corroborate, and the best way is to…

 

2. Ask Someone Else

Most sick people, particularly those who aren’t 100% capable of taking care of themselves, have other people closely involved in their care. For those who live at home, these people are often family members or occasionally an aide or visiting nurse; for those living in a facility, it’s the nursing staff. (And for a patient being discharged from the hospital, it’s the doctor or nurse responsible for them.)

These people have spent ample amounts of time with the patient, so they “know” them — but moreover, they’re medically trained (or in the case of family, often have a sort of on-the-job medical familiarity of the patient’s conditions), so they know them medically. They not only have a reliably story to tell, they can often answer questions about the kind of medical signs you may be puzzled by. Oh yes, he’s got A-fib, his pulse is always like that. No, normally he’s alert and oriented, conversational, I don’t know what’s wrong with him now. Even friends or bystanders can sometimes help you out here — oh yes, Jeff has epilepsy, he takes medication for it, but he hasn’t seized like this in years.

This is the kind of information to gather before you leave a scene, because not only can it be important, you may be the only person who can obtain it. Once you show up at the hospital, if relevant history is missing from the clinical picture, the ED staff may try to make some calls and ask questions, but it’s much more difficult than if you did your job right to begin with.

This is also why it’s highly advisable, whenever time permits, to perform a reasonably full assessment prior to leaving the scene. That way when you find something striking, you can simply ask someone — is this normal? Nothing’s worse than taking an initial set of vital signs ten seconds after you start transporting, finding a blood pressure of 86/40, and wishing you’d done it five minutes earlier so you could’ve asked the nurse. (In fact, if you did this before leaving the floor on a discharge, they might just decide not to send the patient after all.)

One trick I’ve tried when I wasn’t smart enough to assess on scene is to simply call back. You’re bringing someone from a facility, and on the way, you find something funny. You’d love to know if it’s new or existing. Crack open the paperwork (or ask your dispatch) and find the phone number for the sending facility, punch it into your phone, ask for the floor or wing you took the patient from, and request the nurse who covered your patient. Then you can identify yourself and just inquire: “Hey, this dude’s got a blown pupil. Is he always like that?” This probably won’t work with most scene calls, unless you have a number for an emergency contact, but I suppose you can try to track someone down.

When nobody’s available to answer your questions, your best bet is simply to…

 

3. Consider the Context

As we often talk about, clinical decisions and diagnoses aren’t made from isolated findings. You have to look at the whole picture.

I love dialysis patients, because they’re like case studies in exercising clinical judgment. I have had regular dialysis patients who were at baseline non-verbal, marginally responsive, routinely hypo- or hypertensive, routinely tachy- or bradycardic, dyspneic, hemiparetic… pretty much anything you can imagine. Obviously if you know them you might have a better idea of their baseline, but again, with some of these people, I would not bat an eyelash to find them with a blood pressure of 80/70 on one day and 176/100 the next. Was either one an emergency? Not necessarily. It was probably something the dialysis staff and potentially their nephrologist would like to know about, but once again, it’s not helpful to anyone if you throw up your hands and announce that the person with kidney failure is sick. They know.

In any case, how do you figure out when their derangement is significant? Look elsewhere. Big problems have a big footprint. If the patient is communicative and reliable, how do they feel? Lousy? Fine? Weak, dizzy, nauseous? Pain in their chest, their head? Consider their history, look elsewhere in the body, and examine their medications. Assemble all the data you can, so that your findings are no longer a lonely, isolated result, but just one of many meaningful indicators.

To suggest that something might be important yet has no effects is to invite the question: if it’s not affecting anything, who cares? For instance, I once discharged a patient whose pulse was in the low 40s. No notation of this was found in her documentation, nor any obvious reason why she should be bradycardic. I eventually called back to her floor and her nurse confirmed that it was typical for her. But even if this hadn’t been possible, I would still have known the rest of her presentation: she was alert, oriented, mentating well, pleasantly conversational, and had a reasonable blood pressure and normal skin signs. She was experiencing no distress or acute complaints, and she was reliable enough that if she had been, she’d have been able to communicate her symptoms. So what were the chances that her bradycardia was something new, alarming, and indicative of a dangerous situation? Not very high.

The biggest challenge here is the patient with so many other comorbidities that they become difficult to clinically assess. If they can’t communicate well (or can’t communicate in your language), and at their baseline they have a wide variety of derangements, it can become difficult to wade through everything and isolate new badness from the tangle of typical badness. Use your noggin and do your best.

Finally, your fallback is always…

 

4. Get to the Right Hospital

Barring anything else, even in the most baffling of situations, most clinical mazes can be untangled if you transport the patient to their usual hospital.

By this I mean wherever they’re typically followed. It may or may not be their requested destination, although it usually is; in any case it’s where they get most of their care (often a nearby community hospital, although sometimes it may be more distant). Some providers give little consideration to these requests, preferring to push for transport to the closest facility or specialized points of entry, but this isn’t just a matter of where the patient likes the meatloaf and the nurses. If you show up with the non-communicative patient with a bizarre presentation and minimal available history, at a hospital that’s never seen them before, they are going to be just as baffled as you are. Eventually they may be able to sort most of it out, but only after substantial time and potentially invasive and unnecessary testing — not exactly the most timely and appropriate care. Remember that although one hospital can usually request records from another, it’s often a cumbersome process involving phone calls and faxed charts, and will never be as comprehensive as what the original facility has access to. (The exception may be hospitals that share an affiliation, which may use the same computer system and hence can mutually access shared records.)

Extremely complex medical histories should go to their customary hospital whenever possible. In some cases, the situation may be so unique that an outside facility won’t even want to touch it — your patient will simply be stabilized and transferred to their normal hospital. This is particularly true when there’s been a recent procedure, devices like an LVAD are in place, or the patient has a rare medical disorder; these patients really may need to be attended to by the specific physician who knows their case, and that kind of familiarity can’t be transmitted by fax.

 

Long story short, this whole process can be challenging, but managing it is one of the basic skills we need to hone if we’re working in the field. Any monkey can point to the ways that someone differs from textbook normality; it takes a discerning eye to pick out the changes that are relevant to our business of emergency medicine.

Your High Horse

What happened to kneeling?

People have problems, so they call the ambulance. We arrive and find them — mostly — seated in a chair, or lying in a bed, or perhaps down on the ground. Then we kneel beside them and introduce ourselves. We ask questions, put our hands on them, give medicines, and so on down that clinical flow you learned in school.

Here is what we don’t do: stand six feet away, look down at the patient (and maybe, maybe deign to bend over a little, with our hands on our thighs like we’re admiring a gregarious puppy), and shout in their direction. “Do you want to go to the hospital?” This is not yodeling practice. This is caregiving.

When did we stop kneeling? More and more, this practice seems to be spreading, and it’s reached the point where I can hardly remember the last time I saw one of us kneel beside a patient. Occasionally somebody will kneel to take vitals, but the provider actually speaking and interacting with the sick person still towers over them like a cop chalking off a body.

Yes, yes, I get it. Your knees are bad. I’ve been there. And your back, it’s stiff. You’re not 21 anymore, you can’t go kneeling willy-nilly. Sure.

But we’re not talking about an Olympic sport here, okay? We’re talking about kneeling, at least for a moment, in whatever manner you can successfully perform. At the very, very least, sit down on something so you’re level with the patient. Park your butt beside them on the sofa or pull up a chair.

It’s about patient comfort, because they want to feel like they’re engaging with a fellow human, not yelling up at Rapunzel’s tower. But it’s also about the dynamic it creates between you. As a novice provider, when I first read Thom Dick write about humility, I didn’t understand. But as time passed, it made more and more sense to me (something that happens suspiciously often with Thom’s stuff). Body language says something, not just to others, but to yourself.

When you kneel, you’re saying: I’m here to help. I’m here to serve you. We don’t kneel very much anymore, not in the modern Western world, but we understand instinctively why one would kneel before a king. It’s not in spite of the effort it takes you to get down there, it’s because of it: by making yourself uncomfortable, you’re demonstrating a willingness to put someone else’s needs before your own.

It’s not saying that they’re your master, and you’re not making them the boss of anything. They’re not making you kneel, which is all the difference: it’s a gift, freely given. You’re acknowledging that the patient is important. More prosaically, it’s very much like the relationship that the cashier at Wal-Mart is supposed to have with you (at least in theory). If you met him on his day off, he might cut you off in traffic, flip you the finger, and drive away cackling. But while you buy batteries, at least, it’s his job to help you out. If he’s lucky, he enjoys doing that; if he’s not, he feels forced into it because he wants to keep his paycheck. We’re in a different boat, though, because our obligation doesn’t come from a boss looking over our shoulder. It comes from the fact that we accepted a duty (perhaps sacred, perhaps mundane, but a duty either way) — that when someone calls 911 and asks for our help, we’ll come and serve them. That makes us servants, and not in a bad way.

Something different happens when you refuse to lower yourself before a patient. It tells everyone in the room, including the patient and especially including yourself, that although you’re here, and although you might perform the clinically-indicated medical treatment, you’re not putting yourself out at all. Drive-by care is all you’re willing to offer. It’s like telling the patient: “Just to be clear, we were in the area anyway, and I thought you might have some snacks.”

I have great respect for police, and we work alongside them often. But their business is very different from ours, and it highlights the dangers in conflating the role of EMS with that of public safety. The job of a caregiver is to serve. The job of a cop is to enforce. It means they have to elevate themselves — you can’t exert authority unless you’re coming from a place of some kind of superiority (legal, moral, even physical). It means they have to judge. I don’t know if they enjoy it, and I do know that it’s highly necessary. But it takes a different kind of person, or at least a different kind of thinking, to judge people than it takes to serve them. Try to imagine a cop kneeling, or helping to wipe Mrs. Smith’s bottom. Now imagine yourself wearing aviators, crossing your arms and leaning against the wall while you bark at her, and understand that it’s just as misplaced.

What’s funny is that when you accept this “lesser” role, you can find an awful lot of meaning in it, because it’s a privileged place too. The privilege isn’t something you exert over others: rather, it’s freely granted to you by the patient. When they see that you’re here to help them, they give you permission to enter their home, to touch their body, to ask them the most intimate questions. This is essential, because you need that access to do your job (and it’s why I believe that mixing EMS and law enforcement would mean a major blow to our ability to treat people). But it’s still a gift. And I think that’s worth something. Even sore knees.

A Million and One Towelplications

Yes. Towels, sir. I said towels.

What’s the big deal with towels? Well, you’ve got them around, first of all. Or you ought to. A decent stock of linen really amounts to essentially supplies for an ambulance, and yes, I maintain that even if you do use the crinkly disposable paper sheets. Blankets for sure, sheets if you use ’em, and towels. Lots of towels.

Towels are the duct tape of padding-related conundrums. If you can’t do it with a towel, it doesn’t need doing. Other than stopping bleeding, checking your oil, and (I suppose) actual cleaning, most applications involve using them as some sort of padding. But to become a towel samurai, you’ll first need to learn the three basic towel forms: Rolls, pads, and snakes. (Towel supply is a little limited at this exact hour, so I’ve substituted an old bath towel, which I’ll thank you not to abuse.)

 

The Towelbox

Pads are simply towels folded flat, into squares or rectangles of the desired size, like a napkin. Good for basic flat padding purposes — just make sure you fold intelligently to obtain the size and thickness you need (and don’t be afraid to stack multiple towels together).

 

Rolls, on the other hand, are constructed by folding long rectangular pads and then rolling them into fat, tight little cigars, like toilet paper. Great for makeshift pillows, extra-thick padding, and anything requiring bulky structure or space-filling.

 

Finally, snakes are towels unfolded to their full length and then twisted (or folded very thin) to make long noodles. You can even tie them end-to-end to make ropes. Great for “lengthwise” padding, makeshift towlines, wrapping around stuff, etc.

Got it? Good. Now, here’s a few uses for the things beyond just cleaning up your messes.

 

Padding Voids

You were taught to do this in school, and then you promptly stopped bothering. Shame on you. It takes practice to get good at it, but if you do, you can seriously reduce the physical abuse you’re inflicting on your patients by backboarding them.

Make small rolls to fill the lumbar void, and rectangular pads for thick spaces like between the legs. Blankets may be needed for particularly large areas, which is fine — blankets are just towels on steroids, after all.

Take the time to pad in a similar fashion when applying splints, particularly box-style splints, and you can substantially increase their effectiveness. Works great for scoop stretchers too. Patient with a hip fracture on the ground or in a bed? Scoop them up, and generously pad between and over their legs. Once you secure the straps there should be nowhere to move, and you’ve turned the device into a secure, large-scale lower-body splint with essentially no movement of the limb. Not bad.

 

Silencing Equipment

We talked about this before — particularly when it comes to backboards, which have a habit of banging around in their enclosures, a towel roll (or if the gap is slim, a thick pad) can be a quick fix to muffle the noise a little.

 

Head Immobilization

Most services nowadays have gone over to commercial head blocks or headbeds; the days of sandbags (or liters of saline) are sadly over. However, there are still places that use primarily towel rolls, and even if you carry commercial blocks they make a great backup — and we always need backups. Frankly, I think good towel rolls work better than most other methods, too; they compress and mold against the head, making them both comfortable and secure.

Stack together two or three large towels, folded into long rectangles, then roll them together tightly into a thick cylinder about the same length and not much thinner than a human head. Take some tape (I like 2″ cloth tape for this) and tape a couple rings to hold it together — a loop near both ends seems to yield better padding than looping the middle. Make a second roll just like it, and you’ve got headblocks! (The roll depicted is probably a little longer than necessary.)

Secure them alongside the patient’s head and tape the same as you would commercial blocks. Just make sure they’re fat enough to provide real support; a single rolled towel, for instance, never seems like enough bulk.

 

Ghetto Collars

So you sized the patient, you reached for a no-neck C-collar, and it’s too small. Oh, it’s not a matter of neck length; they are indeed neckless. Rather, it’s a question of girth. They’re just too big for the collar to reach around. And sadly, although most rigid cervical collars come in a variety of heights, there are usually no options to size for diameter (pediatric collars may be smaller, but there’s rarely any “bigger” size available). What to do?

Try a towel snake. Using a long towel (or two), twist it into a thick rope and wrap it around the patient’s neck like a scarf. Don’t choke them, but wrap it snugly; most towels seem long enough to circle a typical neck with plenty of overlap, which I leave in the front as a chin support. Slap a little tape across the overlap to more or less secure it, and there you have it — a good-faith attempt at cervical immobilization, not as effective as a rigid collar but far better than nothing. (You can always sit there holding manual immobilization too, I suppose. But remember that the collar is mostly a reminder, and the blocks and straps are doing the majority of the work to actually limit motion.)

 

We could go on forever about towels, and I don’t even know most of the tricks; this is the sort of thing you figure out gradually over the course of a long career. (Although Christopher Watford did turn us onto towel animals as popularized by Carnival Cruise Lines, and if you can master those you’ll be a big hit at parties.) Thom Dick has a stellar collection of ideas that he writes about in his columns. We’ll probably do a sequel to this eventually, but in the mean time — what are your favorite uses for towels?

Glucometry: Clinical Interpretation

Continued from Glucometry: Introduction and Glucometry: How to Do it

Implementing glucometry into your overall assessment means understanding three things: when to use it, what the results mean, and when it fails.

 

Indications

First of all, by and large the only people with derangements of their blood sugar should be diabetics. The rest of us are generally able to maintain euglycemia through our homeostatic mechanisms, except perhaps in critical illness causing organ failure and similar abnormal states. Now, if someone injected you — a non-diabetic — with a syringe of insulin, you’d become terribly hypoglycemic, since it would overwhelm your body’s ability to compensate for the loss of glucose. But nobody’s likely to do that if you’re not a diabetic, unless it’s meant for somebody else and a drug error occurs, or I suppose if they’re trying to assassinate you.

With that said, people walk around who are diabetic and don’t know it. I’ve lost track of the patients I’ve transported who presented with signs suggestive of a diabetic emergency, denied a history of diabetes, and came back with a BGL of 600. Well, my friend, I have some bad news for you. “Everybody is diabetic, even if they’re not” is my attitude. Almost a fifth of older Americans are diagnosed, and the older and sicker they are, the more common it is.

Which brings us back to: who needs a BGL?

The most correct answer is anybody with clinical indications of either hypo- or hyperglycemia. As we saw, diabetes itself is really associated with hyperglycemia, which is why the classic signs of hyperglycemia are usually used to diagnose diabetes: polyuria (excessive urination, as extra glucose is excreted by the kidneys and brings water along with it osmotically), polydipsia (excessive thirst and water consumption, to replace the fluids urinated out), and polyphagia (constant hunger, since despite all the sugar floating around it’s not reaching the cells very easily). If your patient is complaining of those, you might be the first one to discover their condition. The diagnosis doesn’t require elaborate tests and imaging; a fasting glucose over 126 BGL tested on multiple occasions, or just once in combination with clinical symptoms, or a post-prandial (after eating) glucose exceeding 200, is the definition of type II DM. (With that said, I wouldn’t go around diagnosing your patients; that’s not your job, and you’re not quite that good.)

Once the glucose gets higher than the “renal threshold” — usually around 180 in average folks — the body starts to excrete it into the urine. This can actually be detectable by chemical dip-stick, or even by odor and texture at very high levels.

When hyperglycemia becomes severe and prolonged enough, we start to worry about diabetic ketoacidosis. Although burning fat and protein is not necessarily dangerous (some popular diets actually put you into a mild ketogenic state intentionally), extensive accumulation of ketones caused by a total lack of insulin (as in type I diabetics — DKA is rarely seen in type II) creates a metabolic acidosis in the body. This is when the long-term harm of hyperglycemia becomes a short-term hazard. DKA causes altered mental status, usually elevated states of confusion and disorientation, and combative behavior isn’t uncommon. Combined with the acetone odor that sometimes presents on the patient’s breath — which can smell like alcohol — DKA patients can seem suspiciously like drunks, and treating them like drunks is a great way to go down a bad path. (A word of wisdom: not only is everybody diabetic, but drunks are definitely diabetic.) DKA also frequently presents with symptoms of dehydration, due to the osmotic water loss in the urine; nausea and vomiting; and deep, rapid Kussmaul breathing to blow off the acidic CO2.

A few situations can cause short-term hyperglycemia, including stressors of any kind (there’s even “white coat hyperglycemia,” where patients tend to produce elevated sugars at the doctor’s office), but these typically won’t produce anything like the massive levels leading to DKA.

With all of that said, you need to really build up some glucose before hyperglycemia becomes symptomatic, and even more than that before it becomes acutely dangerous and unstable. That’s why as a rule, we’re more concerned with hypoglycemia, usually due to medication administration, physical exertion, or metabolic demand exceeding what was expected. Hypoglycemia again presents as altered mental status, in this case more often an inhibited rather than an elevated state: confusion, lethargy, disorientation, inability to focus or follow commands, weakness, headache, seizures, and eventually coma and death. The fun part is that the impairments can present as focal as well as generalized deficits: unilateral weakness of the limbs or face, speech slurring, poor gait, vision abnormalities, and more. In fact, hypoglycemia is a neurological chameleon, and can look like almost anything; it’s particularly notorious for imitating strokes, and for causing (not imitating) seizures. Interestingly, kids are particularly prone to hypoglycemia due to their gigantic heads, full of glucose-hungry brain.

Despite all this, the primary manifestations of early hypoglycemia are actually not symptoms of hypoglycemia. Rather, they’re caused by catecholamines — by the body releasing stress hormones, primarily epinephrine, in a response to the emergency. (This is not an irrational move: epinephrine helps us release and retain glucose.) As a result, we often seen the same signs we’d expect in anybody with a profound sympathetic stimulus: pale and diaphoretic skin, anxiety and shakiness, tachycardia and hypertension, even dilated pupils. Wise diabetics recognize the early signs of this sympathetic response and drink some Pepsi. As levels keep dropping, these symptoms combine with the neurological effects of glucose starvation to produce a confused, sweaty, increasingly stuporous individual. If left untreated, finally the sugar drops until we’re looking at the picture of impaired and diminished consciousness caused by true hypoglycemia. So just like always, the signs of compensation are our early warning system; once the body decompensates, it’s already late in the game.

To make a long story short, anybody with altered mental status, or any kind of general systemic complaint (weakness, fatigue, anxiety, nausea, etc.) should probably get their glucose tested, whether or not they have a known history of diabetes. This is true even if you suspect another cause, such as stroke. Not only can diabetic emergencies look like anything, they can also be comorbid; it is extremely common for patients to have another problem, yet also to bring a high or low sugar along for the ride, due to the illness throwing a wrench in their normal intrinsic and extrinsic glycemic homeostatic systems.

A number of years ago, there was some limited but compelling research that suggested poorly-controlled blood glucose (meaning not severe derangements but merely small deviations from the ideal range) was associated with increased mortality among an inpatient population with a wide variety of conditions. In other words, if you were hospitalized with something like sepsis, you were more likely to end up dying if your sugar tended to float around 160 instead of 110. As a result, it become trendy to practice extremely tight and aggressive glucose management for virtually everybody; diabetic patients were being tested every few hours and ping-ponged around using medication to keep their numbers textbook-perfect. More recently a number of studies have suggested that this may be less important than was thought, and in fact that excessive paranoia leads to a lot of iatrogenic harm from accidental insulin overdoses. This battle is still being fought in the hospitals, but for our purposes a reasonable take-away would be: when managing acute illness, from sepsis to head injury to cardiac arrest, once everything else is done it’s not a bad idea to check the patient’s sugar.

 

What’s the Number Mean?

So you’ve taken a blood glucose, either by capillary finger-stick or from a venous sample. Now what?

We mentioned that the “normal” range is something like 70–140. Diabetics seeking to control their condition and not have their toes falling off in a few years usually strive for tighter control of their BGL than is needed for acute care; a sugar of 175 is a little on the high side for a routine check, but a pretty meaningless elevation for our purposes.

All things are also relative, in that a given BGL must be compared to the patient’s baseline to predict its effects. In other words, poorly-controlled diabetics who are routinely sitting at 200 may become symptomatic of hypoglycemia at relatively high levels, whereas very well-controlled diabetics who usually run lower may be able to drop very low indeed without noticing it. However, a few rules-of-thumb are useful:

Non-diabetics usually become noticeably symptomatic below a sugar of, on average, about 53. (Diabetics, particularly those who are usually poorly-controlled, are more variable — their average symptomatic threshold is more like 78.)

After a recent meal, diabetics may demonstrate hyperglycemia to various degrees depending on whether they ate a Cobb salad or an entire chocolate cake. Non-diabetics should not exceed 200 or so. A few people can exhibit hypoglycemia after meals, due to alcohol consumption, “dumping syndrome,” or some other phenomena, but far more often they’ll exhibit similar symptoms without any true hypoglycemia; some people get shaky and sick due to postprandial epinephrine release.

After an unusual period of fasting (“haven’t eaten since yesterday”), non-diabetics should still have a largely unremarkable sugar. For diabetics, it will depend mainly on how much and what type of medication they’re using.

There’s usually a gap of 10–20 mg/dL between hypoglycemia that’s noticeable to the patient (i.e. sympathetic effects) and hypoglycemia that causes cognitive impairment (i.e. neurological changes). This is their safety margin, when they’re taught to eat or drink some fast carbs; if it keeps dropping they may no longer be able to take care of themselves.

But here’s the problem: the sympathetic “warning signs” can be mediated or impaired for various reasons. For one thing, if your body has to flip that switch often, you become numbed to it, and your hypoglycemic thresholds becomes lower and lower. And many patients with various metabolic and endocrine failures simply can’t muster much of a stress response — the same reason why the elderly may not produce tachycardia and other shock signs when they become hypovolemic. Finally, drugs like beta blockers that directly block sympathetic activity can seriously obscure hypoglycemia. Grab your nearest bottle of beta blockers and read the list of adverse effects: one will be hypoglycemic unawareness, a five-dollar term that means beta blockade can make it difficult to know when your sugar drops low.

Another important consideration in evaluating glucose levels is the expected trend. For instance, a BGL of 70 in a diabetic patient might not excite anybody. However, if you’re testing her because her nurse said that she just accidentally received four times her normal insulin dose, then a BGL of 70 should be alarming, because it’s probably going to keep dropping, and she doesn’t have very far to go.

To make a long story short, the clinical effects of both hypo- and hyperglycemia can vary substantially. What to do? It’s simple: assess the patient physically, obtain a history of their oral intake, medications, and metabolic demands (such as exercise), test their sugar if there’s any possibility of glucose derangement, and compare all those data against each other. A low number in the setting of obvious clinical symptoms is bad. A low number in an asymptomatic patient, or a normal number in a patient with highly suggestive signs and symptoms, should force you to bring out your thinking cap and weigh the odds.

What about treatment? Severe hypoglycemia needs ALS or the hospital — they’ll receive IV dextrose. Severe hyperglycemia needs the hospital only, where they’ll receive carefully-dosed insulin; this is generally considered too dangerous to administer in the field (although patients may have their own), so paramedics are reduced to giving fluid boluses, which may help dilute high glucose concentrations (not a very elegant solution) and is probably needed by a patient in DKA anyway, but isn’t really a fix.

What about oral glucose, in the cute little tubes we carry? Typically these are gels containing 15g of glucose, taken orally (either swallowed or held in the mouth — against the cheek or under the tongue — until it’s absorbed). Do they work? Sure. But it’s not much sugar and it’s not very fast. I found one source that suggests 15g of oral glucose should raise the BGL by 50 mg/dL within 15 minutes of administration — but I’ve never found it to be nearly that effective. In my experience, a bump of about 10 mg/dL per tube is about the best you can hope for in the short-term. If you need more than that, go with the medics and the IV syrup.

 

Testing Errors

When is a tested capillary or venous glucose unreliable? Usually it’s your fault.

Well over 90% of BGLs that test outside the maximum error range (remember, around 15%) are due to user error. Some of the main ones:

  • Your meter requires lot coding, and you failed to do so or used strips from the wrong lot.
  • You failed to clean the skin before lancing, contaminating the sample (not to mention creating an infection risk), or you had some D50 on your glove and it got mixed in there.
  • Rather than gently wicking the sample into the strip, you “smeared” the two together with mechanical pressure, interfering with the expected reaction process.
  • You drew blood from an arm with an IV infusion of D50, TPN, or other meds distal to it. Particularly when peripheral perfusion is poor, always try to sample at a different limb from any running drips.
  • You tried to reuse a non-reusable strip (gross).

Okay, okay, so nobody’s perfect. Factors that may not be as obvious include:

  • Temperature. The test reaction is designed to function within a specific temperature range, which is broad (often around 40–104 degrees) but not limitless, so don’t use them in freezing weather, and try not to leave your equipment ungaraged without climate control when it’s very hot or cold out.
  • Altitude. Just in case you’re an Everest expedition doctor.
  • Humidity. The strips have trouble when it gets very humid.
  • Air. The reagents in the strips will actually degrade if exposed to air for sufficient periods of time, so make sure that you keep them in their tightly-sealed case, and follow their printed expiration dates.
  • Time. If you draw whole blood and leave it around (much more likely to happen in the laboratory than in the ambulance), the erythrocytes will metabolize glucose at about 5-7% per hour.

The good news is that in many of these situations, internal error-checking within the glucometer will recognize the problem, and flash an error rather than a reading. Errors messages are usually numbered and can be informative, but each manufacturer uses different codes, so read the manual if you want to know what “ER2” means. (Hint: not enough blood in the sample is by far the most common.) Many of the other problems can be caught if you regularly check the meter using a known-value test solution, which you should be doing anyway according to most drug and safety agreements. (By the way, both the test strips and those vials of solution are usually meant to expire a few months after opening — the printed date is for an unopened bottle — so if they’ve around forever it’s probably time to retire them.)

What about physiological states that can interfere with the reading? We’ve discussed a few, but briefly:

  • Hematocrit. Anemia from any cause, including cancer or blood loss, causes falsely high readings. High crit, common in neonates, causes falsely low readings.
  • PaO2. Oxygen interferes with the electrochemical redox reaction; thus high concentrations of dissolved oxygen cause falsely low readings, and low PaO2 (i.e. hypoxia) cause falsely high readings, potentially masking a true hypoglycemia.
  • pH. Primarily in meters using the glucose oxidase enzyme, alkalosis will cause falsely elevated readings, while acidosis causes falsely low readings. The acidosis of DKA can therefore cause falsely low readings, masking the profound underlying hyperglycemia, so if the clinical picture screams DKA, don’t necessarily let the glucometer tell you different.
  • Macronutrients. High levels of circulating proteins or fats can cause falsely low readings due to dilution.
  • Hypoperfusion and inadequate circulation. See our previous remarks on this, and remember that venous sources will be more accurate than capillary.

Finally, are there medications that can interfere with glucometer accuracy? There sure are. These in particularly are highly device-dependent, with the glucose oxidase-type meters most often affected. Generally, the effects are not profound, but occasionally they may be clinically relevant.

  • Ascorbic acid. Better known as Vitamin C, some people take megadoses of this stuff, thinking it’ll cure their cold or flu. Depending on the meter it can cause falsely high or low readings, usually a minimal change, but at “megadose” levels the effect can be significant.
  • Acetaminophen. Also known as Tylenol. The effect is similar to ascorbic acid, but even more modest; it should only be considered in major overdoses, and even then the difference is unlikely to break 35.
  • Dopamine. Massive doses, such as might be used for intensive inotropic support, can modestly influence glucose dehydrogenase-based meters.
  • Mannitol. High doses can elevated the measured BGL by around 35.
  • Icodextrin. This is a dialysate solution used for peritoneal dialysis (not hemodialysis — this is where they pump fluid into the abdomen, let it sit, then drain it out), mainly in patients with diabetes. It metabolizes to maltose, which can cause falsely elevated readings in certain meters. There’s at least one tragic and unfortunate case report of a patient death resulting from massive insulin overdose due to this effect, not noticed until the true BGL was obtained by laboratory analysis. If your patient undergoes peritoneal dialysis, try to find out what dialysate is used, and if that’s not possible, it may be safest to assume their sugar is lower than you’re measuring.

 

Conclusions

After all this you’re probably thinking glucometry is so convoluted and rife with pitfalls that you’re better off just eyeballing how sweet your patients are. But don’t let me turn you off! This remains one of the best assessment aids we have, because diabetic emergencies remain some of the most common, most treatable, and most easily confused disorders that we encounter. We can’t perform exploratory surgery, and we may never see prehospital CT scans, but this is a diagnostic test that’s so cheap and simple, with such real potential to affect your decisions, that it should be available everywhere. If you maintain your equipment, learn how to do it right, and keep a few basic confounders in mind, it’ll serve you well as one of your most reliable tools.

The Laws of EMS

One more post about glucometry is pending, but for now, something lighter.

Decades of medical interns have been raised on the Laws of the House of God. The House of God was a cynical and dark look into the world of modern medicine, and its “Laws” were about as uplifting as condensed soup, but they rang true enough that you’ll still hear them quoted in the halls of medicine today (including those of the real-life “House of God,” where I find myself more shifts than not).

In any case, laws come in handy. Although I’m a believer in the nuanced and detailed analysis, as I age and my neurons gradually turn to cotton candy, I increasingly see the value in basic rules of thumb to guide us through the tangled web of life, and especially of this job.

A good law is simple. It’s always true, or almost always, and the exceptions prove the rule. It’s not specific to a certain region or company, but is something you can keep under your hat and carry with you throughout your career. It’s clear and it say something fundamental about the kind of provider you want to be. But most of all, a good law is not just an empty platitude, but rather an actionable guide-post that can answer real questions in real situations. When times are hard or temptations loom, it’ll tell you what to do.

With no further ado, then, here are mine. I believe in them, I follow them, and like good unguent, I wholeheartedly prescribe them for universal application. I am not wise, but whenever I do a good job of faking it, it’s by following these principles.

 

THE LAWS OF EMS

  1. Help your patient in any way you can.
  2. Be nice to everybody. It’s your job.
  3. If you can’t save their life, make their day a little better.
  4. Protect your partner.
  5. Have a reason for everything you do.
  6. Leave the patient better off than when they met you.
  7. It should get calmer when you show up.
  8. Good habits make doing the right thing easy.
  9. Tomorrow, nothing will remain but your documentation.
  10. Everything’s a bigger deal to the person on the stretcher.

 

But that’s just me. What laws do you believe in?

Editor’s note: this post was expanded into a feature piece for EMS World Magazine in the March 2014 issue.

Glucometry: How to Do it

Read part one at Glucometry: Introduction

So we want to know how much glucose is in our blood. How can we determine this?

Most modern systems involve a handheld electronic meter, which accepts disposable test strips. The general method:

  1. Insert a strip into the meter; this usually turns it on automatically, and the screen will indicate when it’s ready for a sample.
  2. Clean the patient’s fingertip with an alcohol swab.
  3. Using an automatic lancet (a spring-loaded needle), prick their finger-tip, drawing out a droplet of blood. You may need to push or massage the skin toward the puncture site in order to “milk” blood out, particularly if there’s poor circulation.
  4. [Optional] Many services recommend wiping away the first drop of blood and drawing out a second for your sample.
  5. Once you have a sizable, “hanging” drop of blood, apply it directly to the sample site on the test strip. It will wick inside and be absorbed.
  6. The meter will usually display some kind of count-down. Once it’s finished analyzing, it will show the blood glucose concentration (BGL) in mg/dL or mmol/L.
  7. Apply a band-aid to the site, and dispose of the test strip, lancet, and other bloody bits as appropriate.

What magic happens when you apply blood to the strip? There are a few methods.

(Skip this paragraph if chemistry wasn’t your favorite class.) As a general rule, the glucose in the sample is broken down by an enzyme (often glucose oxidase, or a version of glucose dehydrogenase). This reaction is proportional to the glucose concentration, and can be visualized by the accumulation of an indicator; the more glucose that reacts, the more color develops, and this is measured by a photometric transmission sensor. Alternately, in most current sensors, a more modern and somewhat more robust electrochemical method is used; here glucose is selectively oxidized, and electrons are pulled across a mediator to an electrode, which measures the current generated — either average, peak, or total depending on the type of analysis.

 

Results

Across the US, blood glucose is measured in the units mg/dL (milligrams per deciliter). In much of the rest of the world, the unit is mmol/L (millimoles per liter). This means that if your paramedic buddy from the UK is telling you about a diabetic he treated, the numbers may seem peculiarly low. Since we’re mostly Yanks here, we’ll be working in mg/dL, but if you ever need to convert to mmol/L, you can simply divide it by 18 (or multiply by 18 to get from mmol/L back to mg/dL).

Much like vital signs, textbook ranges for “normal” blood glucose levels vary. A loose range for practical purposes would be around 70–140, although ideally we should be under 100 most of the time, and routinely testing over 125 is not a great indicator for your health. Numbers will be elevated after eating, but non-diabetics still shouldn’t break 200 or so.

Although we’ll talk more about clinical interpretation later, in general it’s safe to say that the lower the number, the more each point matters. The difference between 70 to 50 can be profound, while the difference between 200 and 180 may be totally undetectable.

 

Accuracy and Precision

Glucometers have evolved through quite a few generations by now, and they continue to improve in robustness and reliability. Most diabetics use them regularly to track their sugar and thereby guide their diet and medications.

How accurate are they? Depends on who you ask. The American Diabetes Association says that at a minimum, they should give readings within 15% of the true value, and ideally manufacturers should shoot for an error of under 5%, at all concentrations. But percentages can be a confusing way to measure it, because as we observed, a 15% difference at a sugar of 500 (a possible range of 425–575) may mean little, while a 15% difference at a sugar of 60 (a range from 59, which is low, to 69, which is about normal) can be rather important. So the FDA says this instead: 95% of the time, for values below 100, meters should be within 20 points of the true value, while for values above 100, they only need to be within 20 percent.

Whatever the case, every meter varies, but generally they can be relied upon to fall within about 15% of reality, as long as no user errors or confounding factors (we’ll talk about those) are present.

 

Blood Source

Traditionally, capillary blood for glucometry is taken from the fingertips. This is painful, so most modern glucometers have been evaluated to determine their accuracy when blood is drawn from alternate sites. Any location with lean, vascular muscle close to the surface (i.e. not too much fat overlying, which you may not be able to penetrate with a lancet) can be usable — the forearm is the most common site. The research has shown that this practice is generally fairly accurate for routine purposes, but the danger is that BGL from the forearm lags behind that from the fingertips. It takes longer for these readings to approach reality — about 30 minutes, in fact, before you’ll read the same from the forearm as you’d read at the fingertip, and until then the numbers may be radically wrong (for instance, a reading of 145 when it’s really 50). So glucometer manufacturers recommend that diabetics always use the fingertip when there’s any question of hypoglycemia, when they’ve recently eaten, or any time when it’s important to have the most current and accurate figure. Obviously, this is always important for EMS, so we should generally stick to fingers.

On the other hand, in many areas it’s common for paramedics to start IVs and then use a drop of blood from the catheter’s flash chamber for glucometry. Briefly, like so:

 

A used catheter (needle inside)

 

The rubber stopper behind the flash chamber

 

Press on the rubber until a usable drop of blood comes out the end

 

This method works, saves you the trouble of lancing a finger, and spares the patient some extra pain. But it’s usually considered technically incorrect, because the blood in the catheter is venous, whereas glucometers are calibrated for capillary blood. See, since venous blood has already given up glucose to the tissues whereas capillary blood is still in the process of doing so, venous BGL is lower than from capillary sources — usually about 5–10 mg/dL. (If by chance you have a source of arterial blood, then that should be higher still.) However, after eating, particularly carb-rich foods, capillary sugar may be as much as 25% higher than venous, because of the extra glucose sequestered in the muscular tissue. (Stockpiling this fuel is why marathon runners like to “carbo load” before events.)

With that said, I’m going to make a controversial recommendation: in most cases, whenever it’s available, venous blood should be used instead of capillary blood. If someone has started an IV, then you should be using that instead of a fingerstick. Why? Despite the small and usually predictable difference, in sick people, it’s actually a more accurate result.

In sick people, circulation is often impaired; this is particularly true in situations like shock, sepsis, and the mother of all shock states, cardiac arrest. When perfusion is poor, the first thing we lose is the peripheral circulation, and it doesn’t get more peripheral than the capillaries of the fingertips. What does this mean? It means that in many acute patients, when it’s important to have accurate diagnostics, capillary blood sugars can be utterly, totally inaccurate. Since blood is no longer moving actively through the periphery, it tends to “pool” there stagnantly, letting the tissues chew through its glucose supply without resupplying it. This results in a falsely depressed capillary BGL even when the venous BGL is normal. Conversely, it’s also possible that in poor circulation, the distal capillaries are the “last to hear” about a drop in sugar, resulting in a falsely elevated BGL. But high or low — usually low — it’s not reliable. Anybody with impaired circulation should get a venous glucose if there’s a chance of it affecting care. (And if there’s no chance of it affecting care, then why do it?) By the way, this includes impaired local circulation, such as patients with PVD. Not that a diabetic would ever have PVD…

(Edited 6/12/12: A few commenters have pointed out that the practice of drawing blood samples from used IV catheters can present a safety risk; although modern safety catheters usually retract or obscure the needle, this is not a fail-proof mechanism, and pushing on the plunger can potentially lead to an accidental stick. We should all be sensible about this sort of thing, so be cautious and give a moment of serious thought to the conditions, equipment, and your technique before trying such a move — and of course be aware of any policies your service has on the subject.)

 

Coding and Calibration

The important business during glucometry is taking place in the test strip, where the actual chemical reaction occurs. Since this is a rather minute organic event, individual test strips tend to vary a little in their performance.

Traditionally, this is handled by lot coding. Each batch of strips (they come in packs of so-many) would usually include an electronic coding strip, which looks like a regular test strip, with some extra electronics attached. You insert it into the meter, and it automatically calibrates it for the current lot. If your device works this way, it is essential that you code your meter for the lot you’re using, and do not mix your strips with those from other lots; your results can be off by over 30% due to using the wrong code. However, many current glucometers no longer require coding, either by automatically self-calibrating using information in the strip itself, or by controlling manufacturing tolerances so that all strips are the same. Read the manual or check your policy!

Now, is a rose a rose, or are there different BGLs out there? Really, there are two that matter. When we prick the finger and sample capillary blood, we’re measuring the glucose concentration in whole blood — the raw, unmodified stuff running through your veins. We could also take that blood, centrifuge out all the big cells (particularly red blood cells), and measure the glucose in the plasma that remains. This latter method is how it’s done in the laboratory, and this is the gold standard for this type of test. (In the handheld glucometer, the test strip usually uses a filter to either absorb or lyse the red cells, but their presence still affects the measured concentration.)

Why does this matter? Only because whole blood BGL differs slightly from plasma BGL. Since the number is a concentration, and the presence of hemoglobin slightly dilutes the blood, plasma values are typically 5-15% higher than than whole blood values. In most of us it’ll be about 11%, but the exact difference depends on how much space your red blood cells are filling up, aka your hematocrit, so that estimate only works for people with a normal “crit” (around 45). The higher your crit, the larger the difference (and the levels of other circulating lipids and proteins can be relevant as well). The good news? In order to make home BGL readings comparable to laboratory readings, most glucometers report results as a “plasma equivalent,” either by assuming a normal crit and performing a quick mathematical adjustment, or by actually measuring the hematocrit. Some meters can be set to display either whole-blood or plasma equivalents, and ideally we should know which we’re looking at, but plasma is usually the default.

 

Ketones?

We know that when hyperglycemia becomes severe, the body often develops high levels of ketones in the blood and urine. (These are involved in a secondary metabolism that cells can use as an alternative to directly consuming glucose.) Lots of ketones in a diabetic is a corroborating sign of a highly elevated sugar, and suggests deterioration to diabetic ketoacidosis, a dangerous state involving a deranged pH.

There are handheld meters that can measure ketone levels, but simple glucometers can’t. However, many models have a feature where, if BGL is found to be over a certain level (often around 300), an indicator will light up with a warning like: ketones?

This is not indicating that ketone bodies are present, which the meter can’t know, but is merely a reminder that at these glucose levels, we should consider the possibility of their presence. Which, as clinical wizards, we already knew, so it doesn’t tell us much. (In fact, it’s more intended for patients, who may have the specialized strips with which to measure their ketone levels.)

 

Takeaway points:

  1. Glucometry can vary by around 15% even when it’s working correctly.
  2. Use venous blood (e.g. from an IV) rather than capillary blood (from a fingerstick) whenever possible.
  3. If using capillary blood, use a finger rather than alternate sites like the forearm.
  4. If your meter needs coding, make sure you do it.
  5. Remember that many conditions (such as shock, PVD, and a recent meal) can alter capillary BGL, and some (such as anemia or hyperlipidemia) can even alter a venous reading.
  6. Ordinary glucometers don’t measure ketones.

 

Tune in next time for a discussion of more clinical phenomena that can influence blood glucose readings, as well as interpreting and applying the results in real patients.

 

Editor’s note: Remember that although we often don’t cite specific references for our figures and data, if you ever want to know what studies or evidence we’re using to support our claims… just ask! We’re happy to oblige. This applies to all of our posts, but may be particularly germane for this one, where some specific and possibly controversial points have been made.

Glucometry: Introduction

 

Glucometry — i.e. bedside measurement of blood glucose levels, usually from a capillary finger-stick — is an ALS skill almost everywhere, and in some systems it’s available to BLS providers as well. Even in places where it isn’t technically permitted for BLS, it’s often still widely allowed on a “wink and nod” basis, especially on mixed-staffing units where the paramedic has better things to do than apply droplets to test strips.

In other words, it’s something we do. Moreover, it’s something very valuable that we do. I work in a system that allows BLS glucometry along with various other “extras,” and if I had to give up all of it (nebulized albuterol, nasal naloxone, and more) to keep the glucometer, I’d do it in a heartbeat. It serves an invaluable and often irreplaceable role in patient assessment, and it’s used often, not sometimes.

As with any tool, though (such as pulse oximetry), intelligently using the device requires understanding how it works, how its results should be clinically applied, and when it fails. Unfortunately, this is rarely taught in depth, beyond perhaps a brief “How’s how you press the buttons” in-service. So let’s talk about glucometry. And talking about glucometry means starting with glucose.

 

Glucose Physiology

Practically speaking, glucose is the fuel of human life.

What’s a fuel? Imagine I’m starting a campfire. I build a pile of wood, I light it with a match, and it begins to merrily burn. As any firefighter (or Boy Scout) knows, a fire needs certain things. It won’t burn without a supply of oxygen. It won’t light without a heat source. And, of course, it needs something to actually burn — a fuel.

Although humans have a few different metabolic processes that allow us to survive in difficult circumstances, for the most part, we work the same way as the campfire, except our fuel isn’t wood: it’s glucose. We make a pile of glucose, mix it with oxygen, “light” it with some excess energy, and we’re rewarded with an outpouring of energy far greater than we put in. It’s called aerobic respiration, and almost all of the energy we need to live (sing, dance, hunt the mammoth, think about cellular metabolism, buy cheeseburgers) is generated in this way.

Glucose comes from food; in other words, we eat it. Glucose itself is a very simple sugar, and generally, we don’t literally spoon glucose into our mouths; instead, we eat more complex foods (like cheeseburgers), and our bodies break them down or transform them — either directly into glucose for immediate use, or into a form we can store (like fat), which can be readily broken down to burn later.

Remember, folks: the basic “fire” of life burns glucose and oxygen. We know that without oxygen, we quickly die. For the exact same reason, without glucose — we die. This is not optional stuff, and the only reason we survive longer without cheeseburgers than without air is because our bodies can store substantial amounts of fuel for later use, whereas we can only retain a few minute’s worth of oxygen. (We can also generate some energy through anaerobic metabolism, an “oxygenless fire,” but only very little; it’s a short-term reserve that burns out fast.) Every cell in the body therefore needs a constant supply of fuel to keep its machinery running, and this is supplied by glucose circulating in the bloodstream. Since this stuff is so important, our bodies are very good at monitoring the amount of circulating glucose, replenishing it from reserves when it’s low, and dumping it off when it’s high.

One of the main ways that this fine-tuning is done is using a hormone called insulin. Glucose needs to enter cells in order to be burned, but we want tight control on how much of it enters at any given time (since we need to keep enough circulating for the rest of the cells), so access is managed by a “lock-and-key” mechanism. To pass into most cells, glucose needs to “unlock the door” using an insulin “key.” Without insulin, we can have all the glucose in the world circulating through the blood, but it won’t be able to enter the cells hungry for it, any more than you can get into your house to feed your cat if you’ve lost your keys.

 

Diabetes

Now, let’s say that I have glucose in my blood. And I’m releasing insulin to let it access my cells. But my cells aren’t listening. It’s like somebody changed all the locks on me; we still have the key, but suddenly, it’s no longer opening the doors.

Why would this happen? There are various reasons, including genetics, certain medications, and a few diseases. But often, a key factor is habituation. If we keep our glucose levels elevated all the time (say, by eating a lot of rapidly-digested sugars), then our insulin levels will also be elevated all the time, and eventually, the insulin receptors on the cell membranes will say: “Boy, it seems like there’s a ton of this stuff around; I must be too sensitive to it. I’ll start ignoring some of it.” This is called insulin resistance, and it can range from mild (only some receptors of some cells are a little resistant) to severe (most cells are practically ignoring insulin). Unfortunately, this problem tends to exacerbate itself, because when our control centers see that releasing insulin isn’t lowering the circulating blood glucose as much as it should, we release more insulin, which encourages further insulin resistance… and so on.

The result of this is that more glucose tends to remain in our blood than we need: hyperglycemia. This isn’t a good thing; all that extra sugar zooming through our veins has a habit of piling up in the wrong places, which leads to strokes, heart attacks, pulmonary embolisms, DVTs, peripheral vascular disease, kidney failure, and more. It sucks, and it’s called type II diabetes mellitus. (Mellitus refers to sugar, and it distinguishes DM from diabetes insipidus, a totally unrelated disease.)

On the other hand, what if we can’t make insulin at all? Usually, this happens when our body’s immune system attacks the emitters that produce insulin, for unclear but unfortunate reasons. It usually begins when we’re young, and although it can be precipitated by various triggers, it generally happens more or less on its own. Whatever the case, if we can’t produce insulin, we’ve lost the key, and glucose can’t enter our cells. Without glucose, the fire doesn’t burn, and we die. It’s called type I diabetes mellitus, and without treatment, it’s always fatal.

Nowadays, type I diabetics survive by taking exogenous insulin — since they can’t make their own, we synthesize it for them, and they simply inject it. (They still make their own insulin, so most type II diabetics don’t need to inject the stuff; they manage their blood sugar through careful control of how much they eat. In some cases, however, particularly in the elderly or anyone who is less able to tightly manage their diet, type IIs will also use insulin to help adjust their levels.) How do they know how much to take?

There are ways to estimate insulin doses by, for instance, measuring how much food you’re eating, or from past experience. However, it’s also incredibly easy to misdose. Insulin is a powerful, powerful drug, and a small change in dose can mean the difference between bringing you to a normal, healthy blood sugar, and sucking every last glucose molecule out of your blood until you’re dangerously low — hypoglycemic.

Although hyperglycemia is unhealthy in the long run, and massive hyperglycemia can be an acute danger, even brief periods of modest hypoglycemia can be deadly, so it’s something to avoid. As a rule, the problem in diabetes is too much sugar, not too little, so left on their own, almost no diabetic would become hypoglycemic. However, since all type I and some type II diabetics take exogenous insulin, hypoglycemia happens all the time due to overdosing. In other words, we do it to ourselves — or to our patients — accidentally. (Even when type IIs don’t take insulin, they almost always take other drugs that help mitigate glucose levels or sensitize their insulin receptors, and some of these meds can also cause hypoglycemia.) Getting it right isn’t as easy as it sounds, because numerous factors can cause changes in your blood glucose and/or your insulin sensitivity; for instance, exercise depletes glucose (the hotter fire needs that fuel), so if you hit the gym and forget to eat more or to reduce your dose to compensate, you can easily deplete your available sugar and collapse.

The best way to get the right insulin dose is to accurately track your current blood sugar, and nowadays, this is done easily and quickly using a hand-held glucometer. Tune in next time, and we’ll talk about how they work and how to use them.

Continued in Glucometry: How to Do It and Glucometry: Clinical Interpretation

Product Review: Shoes for Crews Maverick

About a month ago I was solicited over email by a marketing agent working on behalf of Shoes for Crews, a designer and vendor of its own line of work shoes and boots. They offered me a free pair of their boots — my choice — in exchange for a review on this site.

I was, at the time, extremely reluctant and uncertain about this. I have very little to offer as a blogger and “authority,” and the small service I do provide is largely predicated upon my credibility; in other words, I may not know much, but I try to be as honest, impartial, and accurate with the small amount of information that I do provide. Taking free swag in exchange for kind words seems like a slippery slope at best. It’s more important to me to be able to, in the future, recommend a specific product because it’s worked well for me — without anybody wondering if I’m getting a kick-back for it — than to benefit from occasional free goodies.

I eventually agreed under the clear and explicit terms that I would write exactly what I thought, with no prevarication or white-washing. If I liked the boots, I’d say that; if I had reservations, I’d share them; and if I thought they had no role in EMS, then I’d say that too, and in that case their marketing effort would be counter-productive. They agreed to this, which I suppose was a calculated gamble.

So here’s the review. I doubt that this company will be sending me more boots, whether or not they appreciate this post, but in the future the same type of situation may arise, so I’m very eager to hear any opinions — positive or negative — on this practice. Does it leave a bad taste in your mouth, and make you less inclined to run your eye over our next volume on drug interactions or pulsus paradoxus? Or do you find this sort of thing useful?

 

The Company

Shoes for Crews is not a new company, although they’re new to me; they’ve been around for several decades now. Their claim to fame seems to be their slip-resistant soles, which use a patented tread-pattern and material to allow high traction in dangerous environments like wet floors or oil splatters. Their line runs from slip-ons to high-top firefighting boots, and the general theme is similar to Red Wings — basically footwear for working folks who are on their feet all day and need both comfort and protection.

Lately they seem to have been making a marketing blitz, possibly due to enlisting the help of the service that contacted me, and I’ve been seeing their ads everywhere. I even received a memo from HR at my job offering a company discount for their products. The social media angle has been aggressive (via Facebook, Twitter, and obviously blogs like this), and on some level I have to admire it. After all, it’s clearly working.

In my experience, boots for EMS fall into about three ranges. There’s the low-end range, ballpark of $40 or so, which is mainly low-cut shoes you find at Walmart or other generic retailers, intended for waiters and entry-level jobs. They can look good and seem somewhat serviceable for brief periods, but invariably they fall apart, sometimes catastrophically, after a few months. After that, there’s the mid-range, around $100, where the bulk of workhorse EMS and police boots fall — Bates, 5.11, Rocky, etc. These are good boots that wear well and last, perhaps, from 1–4 years depending on care and your tolerance for their final appearance. (All of my own boots have been this type.) Finally, there’s the high-end lines — Haix, Danner, and others — usually in the $200 range. These should last approximately forever, are built from high-end materials with scrupulous manufacturing, and ideally add an extra level of comfort.

Shoes for Crews seems to sit on the low end of the mid-range category. Many of their boots are in the $70–$80 territory, which is a pretty affordable boot if you’ll wear it for a solid few years.

 

The Boots

As I flipped through their collection, my first impression was that there weren’t too many styles that seemed suited for EMS. Typically our uniforms require black footwear that will take a polish, and I like a side-zip for easy ins and outs.

The models that seemed most appropriate included the Ranger; the Yukon; the Expedition; the Empire; and the Legionnaire. (None, sadly, included a zipper. Maybe next year.) Eventually, I settled on the Maverick, a recent release.

Here they are new out of the box:

First impression: well-built, good looking all-leather boots. They are relatively low-cut, but they are clearly boots and not shoes; here’s a comparison next to my 5.11 ATACs.

They do have a white-threaded stitching, adding a bit of accent against the black; however, it is barely noticeable and I doubt would run afoul of anybody’s uniform policies. After a few polishes it will probably fade completely.

The lacing system is a typical hiking-boot style, with hooks instead of D-rings for the top two pairs. This is supposed to make it easier to get your foot in and out, but to me it just adds to the lacing process and makes donning and removing them a bit of a chore. I also noticed a couple of the hooks get bent outward during regular use; they bent back easily, but it may be a common issue. Although I didn’t try it, I wonder if you could use a pair of pliers to fold them tightly in around the lace, converting them into semi-permanent lace-retaining tubes instead of open hooks.

Here’s the slip-resistant soles after some wear:

Slip resistance, although undoubtedly positive, is not exactly something I lay awake at night worrying about. However, I admit that these soles felt good, with solid traction on all surfaces including soapy washfloors and the occasional grease patch. They seemed to do well on loose soil as well, although I didn’t do much off-roading in them. They are also, for any aspiring ninjas, very quiet.

The uppers are all leather, without any nylon or mixed surfaces. Although it takes longer to polish, I prefer this look to a two-tone or “patchy” style; one does wonder how well it breathes in the heat, but I had little trouble on some reasonably hot days. They felt decent in the cold as well (it’s been a rollercoaster month), so for moderately extreme temperature ranges I’d give them a thumbs up.

The product page makes the fairly strong claim of “waterproof.” Many boots say water resistant and some say waterproof, but within the low and middle price ranges this usually means some kind of external treatment or half-hearted membrane that lasts a year or two at the most. I saw no mention of a Gore-Tex or similar liner on mine, so that may be the case here as well. However, they do have a gusseted tongue, and on moderately rainy days, as well as a leisurely test session of soaking them in several inches of bathwater, I noticed not one drop of moisture penetration.

This is how they look after about a month of use (every shift at work plus many days off):

So they’re reasonably durable. The leather is actually somewhat soft, so I have some concern for how it’ll hold up in the long-term; you notice one small cut already on the left boot. I gave them one quick shine when I first received them, and that’s held up well. The particular style at the edges also seems to help prevent scuffing the toe. The included laces do seem pretty frail, already looking a little scruffly after a month, and I’ve read reviews that others have had similar experiences; laces are easily replaceable, of course.

These have a composite toe, which I found quite light compared to steel toes I’ve used in the past. Combined with the lower cut, they’re overall not heavy boots, although obviously heavier than a soft-toed variant. The good news is that the toe is very roomy and never felt confining, which is something I’ve always experienced with safety toes; the box is built quite high, which is actually noticeable from the outside, giving a bit of a square, blocky look.

How about comfort? These are actually quite comfortable boots. Partly it’s because of the low cut (which makes driving particularly easy), but mainly they just feel like boots designed for humans to wear, unlike many uniform boots which seem primarily intended as ornate buttcaps for bipedal robots. They are quite rigid, with a steel shank and more arch support than I’ve ever had in a boot, and the feel of the heel and overall “stance” against the ground is very stable and comfortable. I feel better lifting in these than in my current boots, extremely stable while stair-chairing, and I could almost certainly wear these to the gym to squat, press, and deadlift without any difficulty. The collar is heavily padded, and although it took a few days before it stopped feeling noticeably stiff against my ankle (the only real break-in), after that it’s been perfect. The insoles are replaceable, too, if you have your own orthotics.

My two biggest gripes, in the end, are these:

  • The low cut. Every pair of uniform paints I’ve ever received has been (at least after a wash) laughably short, barely reaching my instep while standing and “flooding” embarrassingly whenever I bend my leg. As a result, wearing a low-rise boot like this makes the gap extremely noticeable; my pants almost don’t reach my boots even while standing. With properly-fitted pants, it wouldn’t be as bad, but I still feel that a medium-rise boot is a more professional look.
  • No zipper. I tried to adjust to this, but particularly on overnight shifts, it’s a deal-breaker; having to lace and tie these every time I pull them on, and reverse the process to get them off (even just to rest my feet for a bit) is like switching from a cotton T-shirt to a corset. It’s enough to make me wonder if I could buy a center-zip panel like Haix makes and lace it into the front, but I doubt it would fit.

Final Thoughts

So with all of that said and done, what are my take-away impressions of these boots?

They are generally well-thought-out work boots, very appropriate for their primary market (for instance, warehouse personnel, contractors, or repairmen), and with an overall pretty good quality. They are obviously not specifically aimed at the EMS/fire/police market, but there are not too many gaps (targeted “EMS boots” are usually bizarrely overbuilt, anyway), and the main difference seems to be one of feel. My quibbles with them are enough that they won’t be replacing my existing boots, but I will wear them occasionally, and in fact they make decent-looking off-duty shoes (my girlfriend approves). Moreover, I know many field staff who don’t mind, or even prefer, low-cut and zipperless uniform boots, and for them I do recommend the product. The value is good, and if you can find some sort of discount (and they seem to be falling from trees), all the better.

I’d love to hear from anybody else who’s tried these, or better yet, one of the other Shoes for Crews models; I’d suspect that many of them are pretty similar in the overall feel, but there may be some important distinctions.

Best of all, SfC has provided me with a coupon code for one more free pair of any of their products to give away to one of you lucky folks. EMS Basics isn’t exactly The Price Is Right, and we don’t do a lot of contests, but here’s what I’d like to do: if you’re interested in a free pair of boots, post to the comments below describing:

  1. What boots you currently wear, and what you like/dislike about them
  2. What features are important to you in a pair of uniform boots
I’ll pick a random winner from those who respond.

Eight More Tips on Ambulance Wrangling

Our apologies for the lack of updates while we battle technical difficulties here at EMSB HQ. Here’s a few quick tips to tide you over until the next meaty helping of knowledge.

Still learning your way around that temperamental home-away-from-home we call the ambulance? Try these ideas for making life easier. As always, they apply foremost to the Ford diesel chassis, but may work elsewhere as well.

  1. If your stretcher mount is misadjusted, you may have trouble getting the side-rail to “release” and lock home when you insert the stretcher. Whether it’s too tight or too loose, try the following maneuvers, in this order: pull back (toward you); stand on the step and lift it directly up; sit on the leftmost side of the bench seat, place your feet on the lower deck of the stretcher base (this is the rail upon which the wheels are mounted, not the upper rail that holds the mattress), and use your legs to firmly press it into the side bracket. Do not, except in utter extremis, solve this problem by “slamming” the stretcher against the wall.
  2. If your backboards don’t fit their slot snugly, they tend to bang around at every turn. Try folding a large towel or two into a thin strip (6″–12″), rolling it tightly so that it forms the thickest possible pad, then stuffing it into the void so that everything’s held snug. (You can stuff anything in there, but you need something pretty substantial and the rolled towel seems to work best.)
  3. If you have a module power switch in the cab, but no remote switch for the patient compartment heat/AC, get in the habit of leaving the thermostat switched on in the back, blasting whatever air is appropriate for the weather. Then to save the battery, kill the module power whenever you shut off the engine. That way, you can pre-heat or cool the passenger compartment while on your way to a call by just throwing the switch up front.
  4. If you’re not feeling up to shutting your door to the cab, you can usually get it to close by shoving it outward hard and letting it “bounce” off the hinge and recoil shut. In fact, you may be able to bounce the passenger-side door closed (if you’re at the wheel and an absent-minded partner leaves it open) by tapping the gas and then hitting the brake. A caveat: I have yet to hear the opinion of fleet maintenance on this practice.
  5. If it’s a truly scorching day, park in the deepest shade you can find, set the high idle (usually by locking the parking break), and prop open the hood to help ventilate. (The hood will often stay open without use of the support rod if you lift it all the way up and rest it against the windshield.) Remember that “Max A/C” recirculates the interior air, making it increasingly cold, while “Norm A/C” will continuously introduce fresh air.
  6. From the “off” position, turn the ignition key backward (towards you) rather than forward to activate the “accessories” mode. This activates the FM radio, windows, etc. but will automatically shut off power before your battery runs dangerously low; that way you can sit there with power without running the engine. However, test this to see if your two-way radios will remain on in this mode; I’ve seen it work both ways.
  7. Look around the passenger compartment, particularly on the rear doors. Are there any speakers visible? If so, you can probably pipe music back here from the FM radio in the cab, a great way to keep patients entertained if they’re game. Just like in your car, the radio should have settings to adjust the balance, which controls how much volume comes through the left vs. the right speakers, and the fade, which controls how much volume comes through the front vs. the rear speakers. Normally, it will be faded all the way forward; just adjust it into the middle to pump your jam through the speakers in both compartments. Try asking what genre they prefer, and for bonus points, plug in your iPod for a fully DJ-able experience. Just remember to fade everything forward again at the end of the call, or you’ll inadvertently subject all your future patients to your Taylor Swift Experience.
  8. Run your seatbelt adjuster (there should be a slider where it attaches to the wall) all the way up to the top, keep it buckled, and the belt will make a pretty decent pillow for your cheek.
Anyone else have some good ones to share?

Psychological First Aid

Eventually, we all reach EMS satori — I’m referring, of course, to the realization that most of our job doesn’t involve saving lives, or performing any high-level, acute medical interventions. Once we understand this, the question becomes: what does our job consist of?

One good answer among many is the management of psychological rather than physical injury. Can we help the person, even when there’s little need to help the body? We sure can, and it seems like after all the hours we spent studying airway management, we should spend at least a little time developing this other skill. If we’re going to surrender our identity as ET tube samurai, we’d better become experts at dropping mental balms.

It may not be rocket science, but there is certainly a right and a wrong way to help. One good source of ideas for doing it the right way is called psychological first aid.

Psychological first aid, or PFA, is a system developed jointly by the National Child Traumatic Stress Network and the National Center for PTSD. It’s meant to be a psychological counterpart to medical first aid — not a replacement for long-term professional therapy, but merely a method for addressing the immediate, acute mental stress response following crisis. It’s largely aimed at post-disaster scenarios, such as the victims of hurricanes and mass casualty incidents, and it’s become the preferred methodology for American Red Cross personnel. However, it also has valuable concepts that we can use every day on the ambulance, to help us care for both patients and any of their family or friends who are struggling.

This sort of thing may come naturally to some people, but PFA rolls it together into a standalone curriculum that can be transmitted to any professional, particularly those of us who don’t specialize in mental health. It’s also evidence-based: there is research behind most of its interventions, and the science tells us that it generally works. (Contrast this to CISM, which many feel is baseless at best and counterproductive at worst.)

Classes are available; check with your local Red Cross for more information. But here are some of the concepts:

 

General ideas

  • Take your cues from the patient. If they want to talk, listen. If they don’t, don’t force them.
  • You’re here as support and to listen, not as Dear Abby; limit your input and resist the urge to offer advice. Be sparing with relating personal anecdotes or “war stories,” even if they seem germane; it’s the patient’s crisis, not yours.
  • Cater your approach to the patient’s age and culture. Children in particular will need a different style than adolescents and adults. When approaching children, make contact with parents first, and understand that both parties will probably need to be attended to.
  • Reassure them that their emotions and reactions, no matter what they may be, are understandable and acceptable, not pathological.
  • Use language that’s clear, simple, and personal, avoiding medical terminology or jargon.
  • Understand your own role and limitations, and be ready to bring in better-trained specialists.

Avoid these types of remarks:

  • I know how you feel.
  • It was probably for the best.
  • She is better off now.
  • It was his time to go.
  • Let’s talk about something else.
  • You should work towards getting over this.
  • You are strong enough to deal with this.
  • You should be glad she passed quickly.
  • That which doesn’t kill us makes us stronger.
  • You’ll feel better soon.
  • You did everything you could.
  • You need to grieve.
  • You need to relax.
  • It’s good that you are alive.
  • It’s good that no one else died.

 

Major Goals

 

1. Contact and Engagement

As you go about the business of the call, make sure that you’re orienting yourself as somebody who’s willing and able to help. From the initial patient contact all the way until you shake hands and part ways, you should be presenting yourself as a compassionate professional; all it takes is one slip of the tongue or roll of the eyes to betray that you’d rather be back at quarters finishing your burrito.

 

2. Safety and Comfort

Obviously, you should ensure that you are both physically safe, and that immediate medical concerns are managed; this also includes the recognition of patients who could harm themselves or others (like you).

If you’re still at a scene or in the ED where upsetting things are happening (such as a resuscitation), try to move somewhere more quiet and controlled. Keep them physically comfortable, with blankets, a chair, food or water, etc. Remove them from anyone who is themselves panicked or emotionally distressed, but do help to put them in contact with social support, such as friends, family, or clergy.

Try to give people active, familiar things to do, rather than sitting there passively being overwhelmed. Anything, even minor tasks (“here, hold this”), that involve them with their own care or the care of their loved one is beneficial; perhaps they can make some phone calls or locate insurance information.

Share whatever information you have regarding what’s currently happening, including what’s happening to others affected, and what can be expected next (do use judgment on how much they want/need to hear at this stage, though). But don’t lie, guess, form unfounded predictions, or make promises beyond your control (“they’ll/you’ll be just fine”). Consider a broad interrogatory like “Is there anything else you’d like to know?”

Kids may appreciate something like a teddy bear, and you can use it as a proxy for their own care, for instance: “Remember that she needs to drink lots of water and eat three meals a day — and you can do that too.” Also, children especially are sensitive to alarming sights and sounds; try to shelter them from unnecessary stimuli.

 

3. Stabilization (if needed)

As we’ve talked about before, anyone experiencing an acute, uncontrolled emotional response needs to be stabilized and grounded before much else can be done. Be on the lookout for things like: glassy-eyed or vacant stares; aimless wandering or unresponsiveness; uncontrolled crying, hyperventilating, shaking, or rocking; or frantic, illogical, even potentially dangerous behavior such as perseverating on simple tasks (continuously searching for a pair of glasses) or walking thoughtlessly through traffic. Remember that reactions may ebb and flow in surges.

Rather than broad reassurances — “stay calm” — try to determine their specific concerns, even if not entirely rational, and help address them. If completely adrift, patients may be assisted in “grounding” by deep breathing and asking them to describe where they are or concrete aspects of their surroundings (I see a table, I see a clipboard).

Consider both giving them some brief privacy (do tell them when you’ll be back), and remaining present and available yet non-intrusive, such as sitting nearby while you finish paperwork.

 

4. Information Gathering: Current Needs and Concerns

Determine the specific problems and needs of the patient. Individual responses may be flavored by their own psychological backdrop (such as depression or anxiety), history of similar incidents (a prior MVA or death in the family), or other unpredictable elements (they can’t stand the waiting room music). In some cases, the need for referral to a specialist may become obvious here, such as uncontrolled schizophrenia or major stressors in the setting of known PTSD and a history of self-harm; don’t try to “wing it” in complex psychiatric cases.

Follow their lead, and don’t press for details — a CISD-type debriefing can come later, if appropriate. Listen actively and openly. Look for expressions of emotion in their remarks, then make clarifying comments such as: “It sounds like you’re being really hard on yourself about what happened” or “It seems like you feel that you could have done more.” No matter what, don’t judge.

 

5. Practical Assistance

Assist the patient with any practical issues, which may be dominating (or over-dominating) their attention. Offer to notify friends or family, arrange for needed support, or obtain information about their care. Larger needs (such as questions about the costs of treatment) may be beyond your immediate power to address, but you can often take the first step, such as notifying hospital staff of their concerns. At the very least, provide whatever information you can and discuss a plan for resolving the problem. Even small measures like a warm blanket can have both practical and psychological benefit.

Remember that, although you may not be the most knowledgable or appropriate resource for many concerns, as an EMS provider you may be the only person who has the time and ability to address them. If you don’t make that phone call or find them a glass of water, it may be a long time until anybody else does; and it may not seem like a priority to find someone to move their car, but imagine how much better they’ll feel after it gets ticketed and towed.

 

6. Connection with Social Supports

Make an effort to enlist the patient’s support structure. In some cases, the first step may be to actually ask some version of, “Do you have a support network?” Some patients, such as the elderly or homeless, may not, and may need to rely particularly on institutional support, such as social workers.

When multiple individuals are in a group, such as family members at a scene or in the waiting room, ask if they have any questions or requests; this can provide a jumping-off point for further communication.

Make particular effort to bring children together with their parents or caregivers, and try not to separate them unnecessarily. Consider engaging children with simple activities, such as tic-tac-toe, “air hockey” (wad up paper and try to blow it across a table into the opposing person’s “goal”; this also promotes deep breathing), or the scribble game (one person scribbles on a paper, and the other tries to make it into something coherent).

 

7. Information on Coping

This step focuses on describing common stress reactions so that individuals will be more equipped to manage them. It is probably best left to more specialized professionals, since our own training is usually limited here.

 

8. Linkage with Collaborative Services

Help pass the patient along to existing resources, either by providing contact information or through direct referral. Most hospitals will have phone numbers or extensions for mental health, social work, counseling, and other services, and there are hotlines available for individuals not in care at a facility. (It’s worth having this sort of thing in your phone or on a cheat sheet, so that it’s available when you need it.)

When bringing in other aid, and even when making routine hand-offs to ED staff and the like, try to smooth the transition of care. Patients often feel as if they are passing through the hands of an endless series of personnel, with each one demanding to hear their story (and probably take their vital signs). Make an effort to give full, complete reports, and to establish your credibility through word and deed so that receiving staff feel less of a need to do it all over again; in particular, try to communicate whatever concerns or emotional state the patient is currently experiencing, so that the job of managing it can be seamlessly turned over. Introduce the new “helper” (for instance, the RN) directly to the patient, and let them know that they’ll be taking care of them; don’t just disappear, or they may feel abandoned.

 

Further information can be downloaded here from the National Center for PTSD.