Lazy & Sorry

Dear Paw Paw:

The Director of our EMS got mad at me and my partner the other day. We picked up an old lady who was unresponsive, sweating, cold and breathing funny. Family claims they told us she was a diabetic on insulin, but I couldn’t hear them too good above my Sony Walkman. Our Director got really huffy and said we were a bunch of slackers for not checking her glucose, starting an iv line and giving her some D50. We were only 9 miles away from the hospital, so we just loaded her up and took her to the ED. After all, we needed to get back to the station for dinner and to watch America’s Funniest Home Videos. Besides they can do all that and check her vital signs once she gets to the ED just as well as we can.
Lazy and Sorry from Wyoming


Dear Lazy and Sorry:

Are you guys serious? You need an I-Pod! Walkmans are so “last year”. I agree with your Director, if you can’t upgrade your music listening accessories and start stealing songs off the Internet, you obviously don’t have enough ambition in life. You should be fired immediately.

Oh, by the way, expect a call from this poor old lady’s attorney. You can look forward to hours of depositions, and weeks of rest and relaxation in your county courthouse explaining yourself to 12 of your friends and neighbors. They will actually expect that you do your job which is to provide emergency medical service. After all you are part of the Emergency Medical Service aren’t you? Isn’t that why they call it EMS?

Hypoglycemia is an emergency. It should always be considered in unresponsive patients and treated promptly. Glucose is the sole energy source for the brain. And so the longer the brain goes without an adequate level, the greater the risk of neurological problems. Hypoglycemia can mimic strokes, TIA’s, seizures, and psychotic episodes. Be wary and check finger stick blood sugars.

If patients are awake enough to take food or liquids orally, that should be the method used to treat low blood sugar. Sometimes giving something sweet to rapidly elevate the glucose can be given. But to achieve sustained elevations food in the form of complex carbohydrates and protein should be given, like a sandwich or real food.

Hypoglycemia is a common problem in patients on insulin, but it can occur with oral hypoglycemics such as the sulfonylureas like Diabinedse (chlorpropamide) and other conditions as well. Sulfonylureas can cause prolonged hypoglycemia, and patients who have overdoses on sulfonyureas usually should be admitted as recurrent hypoglycemia is common. Insulinomas are unique pancreatic tumors that secrete insulin and cause frequent hypoglycemic episodes. , The diagnosis is made when the c-peptide fragment of insulin is elevated coincident with a low blood sugar. Measuring the c-peptide fragment distinguishes endogenous insulin from exogenous which has no measurable c-peptide fragment.

Malnourished alcoholics or small infants commonly suffer from hypoglycemia. Intravenous dextrose D50 is often used, but because of irritation of the veins, D25 is used in children and D10 in neonates. Glucagon, which can be given intramuscularly, causes conversion of glycogen to glucose. But in alcoholics, the malnourished and infants, glycogen stores in the liver are often depleted and glucagon may not work. The dose is 1 – 2 mg im or iv.

The usual dose for iv dextrose is 0.5 – 1 gram/kg. D 50 has 0.5 gram / ml, D 25 has 0.25 gram/ml and D10 has 0.10 gram/ml. High concentrations can cause pain, phlebitis and tissue necrosis if extravasated. Also D 25 and D50 are hyperosmolar. It is for these reasons that D 10 is used in infants and neonates.

You guys need to decide if you want to do your job or not. If you merely want to drive a meat wagon and not care for patients, then go immediately to the nearest Oscar Mayer plant and see if there is an opening. You two should be hired on the spot since you are both full of baloney.

Paw Paw