Thanks, I'll Stay Here

     Attack One responds to a business office for a report of a man down. They find the patient on the floor of the entrance area: a middle-aged man in business attire, unresponsive and diaphoretic. The staff reports he is a visitor to the business, and was making a sales call. He had been meeting with a company official, asked to excuse himself and then collapsed into a chair. He is breathing and has a regular, strong pulse. The office staff knows his name, but not his medical history.

     He is unresponsive, and after a quick search, an alert bracelet is found that indicates he has insulin-dependent diabetes. There are no smells of intoxicating substances. No signs of trauma are present. He has large veins in his arms.

     The Attack One crew does a quick intervention, starting an intravenous line and using a drop of blood from the catheter to perform a dipstick blood sugar test. It shows a blood sugar of 28. The man has a free-flowing IV line, so they inject him with 50 cc of 50% dextrose solution. Within 30 seconds the patient stirs, then opens his eyes, then begins to move around. The IV line is secured, and the remaining vital signs are taken. He has a pulse rate of 72 and is perfusing well. His responsiveness keeps increasing until he asks: "What happened?"

     "Your blood sugar dropped. Do you know why?"

     The patient clears his thoughts over a few minutes, then is able to give a history. He flew into town, arrived late, grabbed his rental car and drove into a traffic jam. He arrived late at the office for his appointment, and couldn't take time to get any food en route. He took his usual dose of insulin this morning, and hasn't eaten since 0700 hours.

     "Are you feeling ill in any way?" asks the lead paramedic.

     "Not at all. And I can't go to the hospital. My bills are too high already from my diabetes, and I can't afford it."

     "Can you eat something for us?" the paramedic asks. The patient agrees to do so.

     Further medical history is obtained, and the man has no nausea, abdominal or chest pain, palpitations or fever. He was not sweaty until he became unresponsive. The office staff finds some sandwiches and a container of juice, and the patient consumes them without problems. A repeat fingerstick blood sugar result is 132. The patient says he feels fine, apologizes for creating a problem and asks to have the intravenous line removed so he can finish his business.

Rational Approaches to Transport
     There is good literature demonstrating a low rate of problems in those released after treatment for insulin reactions. It is unpleasant, and potentially problematic, to "kidnap" patients and force them to go to hospitals after treatment. The legal issue is the assessment of competence after the patient is aroused, and whether they have clear mental status at that time. Some systems make the transport/nontransport decision with the assistance of online medical control.

Many EMS organizations have a conservative approach to patients treated for acute hypoglycemic reactions due to insulin, asking the EMS provider to assess and document that:

• There is a reasonable explanation for the hypoglycemic episode;
• The patient has absolutely no other medical complaints or problems (fever, chest pain, palpitations);
• The patient is not nauseated or vomiting;
• Vitals are stable;
• A blood glucose test after treatment shows blood sugar levels normal or slightly above;
• They observed the patient eating (or drinking) something, to make sure the patient was able to tolerate oral intake of calories;
• Someone else competent is with the patient, and that person understands the patient and the potential for later problems, and can assist the patient or recontact EMS, if needed;
• The patient will not be put in a situation where others will be placed at risk, as in driving a car, flying a plane or working in a factory.