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Blood Glucose Measuring Devices in the Pre-Hospital Setting

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1 Blood Glucose Measuring Devices in the Pre-Hospital Setting
Collaboration by: Central NY REMSCO Finger Lakes REMSCO Mid-State REMSCO Monroe-Livingston REMSCO North Country REMSCO Susquehanna REMSCO Approximately 1 – 1 ½ hour training session.

2 Purpose To prepare currently certified EMT-Basics to utilize a Blood Glucose measuring device when operating under an approved EMS agency and in accordance with NYS DOH Policy Statement and regional protocols. At the January, 2005 meeting of the New York State Emergency Medical Advisory Committee (SEMAC), the use of glucometers by Emergency Medical Technicians (EMT) in Basic Life Support (BLS) EMS agencies was approved. The SEMAC approval was granted with the specific condition that the EMS service wishing to use a glucometer at the BLS level, be granted approval by the local Regional Emergency Medical Advisory Committee (REMAC), each EMT complete an approved training program and the service apply and be granted a Limited Laboratory Registration. The purpose of this policy is to explain the approval process for agencies wishing to implement a glucometry program. The addition of pre-hospital blood sugar evaluation is intended to assist in the recognition of hypoglycemia and improve the speed with which proper treatment is received.

3 Objectives History of program Understanding Diabetes Mellitus
Physiology of hypoglycemia and hyperglycemia Individual EMT skills Indications for use Demonstrate use of device Act appropriately to findings Sharps safety Additional patient care Agency responsibility The goal of this in-service training is to be both a short refresher and new training on the use of a glucometer by BLS as an additional assessment tool.

4 History Each REMAC, interested in allowing their BLS EMS agencies to participate, will adopt protocols which will allow a basic EMT to obtain a blood sample, using a lancet device, or equivalent and test the blood sample in a commercially manufactured electronic glucometer. The REMAC will also determine the type and level of record keeping and quality assurance required for this procedure. To be authorized to use an electronic glucometer, the EMS agency must make written request to the local Regional Emergency Medical Advisory Committee (REMAC). The request must include, but not be limited to the following items and possess the necessary Clinical Laboratory authorizations required by Public Health Law. Include a letter from the service medical director supporting the request and indicating an understanding of their role in the Clinical Laboratory requirements and quality assurance process. Complete the NYS Department of Health Clinical Laboratory Limited Laboratory Registration application (DOH-4081) for blood testing licensure. Develop written policies and procedures for the operation of the glucometer that are consistent with local protocol. This shall include at least the following: written policies and procedures for the training and documentation of authorized users; a defined quality assurance program, including appropriateness review by the medical director; documentation of control testing process; and written policies and procedures for storage of electronic glucometer, and proper disposal of sharps devices.

5 Agency Responsibility
Any local or regional approvals CLIA Waiver Equipment acquisition Training and retention Equipment calibration and maintenance Go to and the required forms are on the website for downloading.

6 History Pilot Program with Albany FD.
Basic EMT’s independently used the glucometer 778 times during the study period No blood borne pathogen exposures or sharps injuries occurred Physician Medical Control available 24/7 No requests for Medical Control Albany FD pilot program showed that EMT/Basics can effectively use a glucometer to further assess a patient with a possible diabetic emergency. Of the 778 patients in the pilot study, only 2 patients were identified through Q/A where providers violated the study protocol. This means that 99.7% of the patients in this study were properly assess with a glucometer.

7 Other States Wisconsin Massachusetts Nebraska Virginia Oklahoma
South Carolina Arizona Allow BLS Glucometer use

8 Albany FD Learning & Retention
Practical Skill Evaluation 111 Basic EMT’s Pretest pass rate 100% Post-test pass rate 100% Protocol Evaluation Exam

9 Can a EMT/B properly do a BG?
Study Results Can a EMT/B properly do a BG? Of course they can do it

10 Physiology The body uses glucose and oxygen to create energy
Glucagon functions to stimulate the liver to release stored glucose into the bloodstream The bloodstream distributes hormones throughout the body The endocrine system maintains homeostasis and responds to environmental stress Without a proper glucose level, organs can malfunction The brain is very sensitive to glucose levels Abnormal levels may result in permanent brain cell death Diabetes is a disease that affects more than 10 million Americans Diabetes is not contagious. People cannot "catch" it from each other. However, certain factors can increase the risk of developing diabetes Diabetes is a very common disease, it is estimated that is affects about 6% of the population. Without treatment, blood glucose levels can become too high and can cause coma and death. Diabetes can have many severe complications that affect the quality of life, side affects of diabetes include: blindness, kidney failure, cardiac disease, also do to poor circulations issues long term effects of loss of digits and limbs.

11 Glucose / Insulin Balance
When normally balanced, body uses glucose for energy. Fats and proteins are less efficient fuels. Insulin is released by the beta cells of the pancreas. When insulin decreases, cells cannot use all glucose. Insulin is a hormone. Glucose spills into urine. Urine output increases. Patient becomes thirsty. Most patients with diabetes can live a normal lifestyle, but they must be willing to adjust their lives to the demands of the disease of diabetes, especially their eating habits and activities. The two types of diabetes are equally serious although non-insulin dependent diabetes is easier to regulate. Both require life long management. The severity of the diabetic depends on how high the average glucose level is and how early in life the diabetes begins.

12 What is a “Diabetic”? The condition where the pancreas produces insufficient insulin is “diabetes mellitus”. A patient suffering from this condition is “diabetic”. What is diabetes? Diabetes is a disorder of metabolism--the way our bodies use digested food for growth and energy. Most of the food we eat is broken down into glucose, the form of sugar in the blood. Glucose is the main source of fuel for the body. After digestion, glucose passes into the bloodstream, where it is used by cells for growth and energy. For glucose to get into cells, insulin must be present. Insulin is a hormone produced by the pancreas, a large gland behind the stomach. Glucose if the body’s basic source of energy. Sugars that a persons eats thru food is converted into glucose and then absorbed in the body blood. When the sugar intake and insulin are balanced, the body can effectively use sugar as an energy source. Diabetes is brought about by a decreased insulin production, this is more common in older patients, this results in high blood sugar. The prevalence of diabetes in the United States is likely to increase for several reasons. First, a large segment of the population is aging. Also, Hispanic Americans and other minority groups make up the fastest-growing segment of the U.S. population. Finally, Americans are increasingly overweight and sedentary.

13 Brain Cell Metabolism Brain cells do not need insulin to utilize glucose. They do, however, need adequate levels of glucose in order to function properly! When glucose levels drop too low, the brain cells cease to function normally and changes in behavior and LOC follow. There is no “set” level at which patients show S/S of low blood glucose as it differs from person to person

14 Normal Blood Glucose Levels
Normal ranges for blood glucose levels: Infant (40 – 90 mg/dl) Child < 2 years (60 – 100 mg/dl) Child > 2 years to Adult (70 – 105 mg/dl) Adult (70 – 105 mg/dl) Elderly patients (50 y/o +) often have a slightly elevated blood glucose level, but should not normally exceed 126 mg/dl. These readings will be altered by time of day and last oral intake. Values reflected are fasting values.

15 Decreased Blood Glucose Levels
Indicative of several potential processes: Insulinoma Hypothyroidism Addison’s disease Extensive liver disease Hypopituitarism Pancreatic disease or cancer If untreated can lead to Insulin Shock Unconsciousness Permanent brain damage

16 Resulting from Too much insulin, wrong dose
Took regular dose of insulin but didn’t eat enough food Had an unusual amount of activity or vigorous exercise Sick, feverish

17 Increased Blood Glucose Levels
Indicative of several potential processes: Diabetes mellitus Acute stress response Cushing’s disease Diuretic therapy Corticosteroid therapy If untreated can lead to Diabetic Ketoacidosis (DKA) Dehydration Diabetic Coma Dehydration results from a process called osmotic diuresis Death or brain damage

18 Resulting from Too little a dose of insulin
Dose no longer controls levels Too much sugar intake Enough food was eaten but forgot to take insulin

19 Diabetes Type I Usually juvenile onset
May have onset after pancreatic trauma / disease Insulin is not produced Usually take Insulin injections There are two types of classifications of diabetics Type I and II. Type 1 diabetes In people with type 1 diabetes (formerly "juvenile-onset diabetes" or "insulin-dependent diabetes mellitus"), the body loses the ability to make insulin. This occurs when the immune system destroys the insulin-producing cells. As a result of this attack, these cells stop making insulin over time. Insulin is a very important hormone made by the pancreas, a gland in the body near the stomach. Insulin is necessary to change glucose, which is the body's energy source, into energy. When insulin is not available, glucose stays in the bloodstream and cannot be used as energy. People with type 1 diabetes must take insulin shots (injections) to stay alive. Type 1 diabetes usually occurs in children or in young adults under age 30. Most cases of type 1 diabetes develop for unknown reasons. A number of important genetic factors are very likely associated with the development of type 1 diabetes, but many of these factors are not yet known. Environmental factors such as viral infections, chemicals, stressful situations and others may also play a role, but the specific role of each of these factors is still not clear.

20 Diabetes – Type II Usually adult onset…
Produce insulin – but not enough Usually take oral meds to stimulate insulin production If severe enough, insulin injections may be necessary Changes in diet necessary Less likely to experience hypoglycemic episodes Type 2 diabetes The most common form of diabetes is type 2 diabetes. About 90 to 95 percent of people with diabetes have type 2. This form of diabetes is associated with older age, obesity, family history of diabetes, previous history of gestational diabetes, physical inactivity, and ethnicity. About 80 percent of people with type 2 diabetes are overweight. Type 2 diabetes is increasingly being diagnosed in children and adolescents. However, nationally representative data on prevalence of type 2 diabetes in youth are not available. When type 2 diabetes is diagnosed, the pancreas is usually producing enough insulin, but for unknown reasons, the body cannot use the insulin effectively, a condition called insulin resistance. After several years, insulin production decreases. The result is the same as for type 1 diabetes--glucose builds up in the blood and the body cannot make efficient use of its main source of fuel. The symptoms of type 2 diabetes develop gradually. Their onset is not as sudden as in type 1 diabetes. Symptoms may include fatigue or nausea, frequent urination, unusual thirst, weight loss, blurred vision, frequent infections, and slow healing of wounds or sores. Some people have no symptoms.

21 Gestational Diabetes Definition: Onset of diabetes with pregnancy.
Most women need two to three times more insulin when they are pregnant than they usually do. In gestational diabetes, there are often no warning symptoms. All pregnant women need to be tested for diabetes during the second trimester. This is especially important for women who are already at risk. After the baby is born, blood glucose levels usually return to normal. A woman who has had gestational diabetes is at risk for developing type 2 diabetes later in life. Gestational diabetes Gestational diabetes develops only during pregnancy. Most women need two to three times more insulin when they are pregnant than they usually do. This happens because of hormonal changes that are normal in pregnancy. Insulin is a hormone made by the pancreas, a gland in the body near the stomach. Insulin is necessary to change glucose, which is the body's energy source, into energy. Glucose, a form of sugar, is made when the body digests food. When insulin is not available, glucose stays in the bloodstream and cannot be used as energy. Gestational diabetes occurs when a woman's body cannot make the amount of insulin needed during pregnancy. In gestational diabetes, there are no symptoms. All pregnant women need to be tested for diabetes during the second trimester. This is especially important for women who are already at risk. After pregnancy After the baby is born, blood glucose levels usually return to normal. A woman who has had gestational diabetes is at risk for developing type 2 diabetes later in life, it occurs more often in African Americans, American Indians, Hispanic Americans, and among women with a family history of diabetes. Women who have had gestational diabetes have a 20 to 50 percent chance of developing type 2 diabetes within 5 to 10 years.

22 Unrecognized or Untreated...
Diabetes is a time bomb! Diabetes leads to: Weakness Weight Loss Heart Disease Kidney Disease Blindness Death…. Left untreated diabetes leads to a wasting of the body tissues and death. Even with medical care, some patients with aggressive forms of diabetes will die relatively young from various complications of diabetes.

23 Insulin Pump Insulin pumps are small, computerized devices (about the size of a pager) that you wear on your belt or put in your pocket that allow for a continuous flow of a rapid-acting insulin to be released into your tissue. The insulin pump is designed to deliver a continuous amount of insulin, 24 hours a day according to a programmed plan unique to each pump wearer. The amount of insulin delivered can be changed by the user. Many people prefer this continuous system of insulin delivery over injections. Between meals and overnights, a small amount of insulin is constantly delivered to keep the blood sugar in the target range. When food is eaten, a bolus dose of insulin can be programmed into the pump. When using an insulin pump, you must monitor your blood glucose level at least four times a day. You set the doses of your insulin and make adjustments to the dose depending on your food intake and exercise program. An insulin pump can help you manage your diabetes. By using an insulin pump, you can match your insulin to your lifestyle, rather than getting an insulin injection and matching your life to how the insulin is working. When you work closely with your diabetes care team, insulin pumps can help you keep your blood glucose levels within your target range. Why Use an Insulin Pump? Some health care providers prefer the insulin pump because its slow release of insulin mimics how a normally working pancreas would release insulin. Studies vary on whether the pump provides better blood glucose control than multiple daily injections. Another advantage of the insulin pump is that it frees you from having to measure insulin into a syringe.

24 “So what makes diabetes a medical emergency?”
Hypo (low) glycemia (blood sugar) Too much insulin in blood. Not enough sugar for brain Hyperglycemia Hyper (high) glycemia (blood sugar) Too much sugar in blood. Not enough insulin in system to let glucose into cells. Two different conditions can lead to a diabetic emergency, hypo and hyperglycemia. The signs and symptoms of hypoglycemia and hyperglycemia can be similar, examples are staggering and intoxicated appearance, complete unresponsiveness. Your assessment of this medical emergencies should not stop you from care and transport.

25 Clinical Presentation
Hyperglycemia (BG > 200 mg/dl) Kussmaul respirations Dehydration with dry, warm skin and sunken eyes Polydipsia: excessive thirst A sweet or fruity (acetone) odor to breath Polyphagia: excessive hunger Poor wound healing Rapid and weak pulse Polyuria: excessive urination Blurred vision, fatigue Normal or slightly low BP Varying degrees of unresponsiveness that onsets more slowly than in hypoglycemia Hypoglycemia (BG < Normal) Normal or rapid respirations Pale, moist skin Diaphoresis Dizziness, headache Rapid pulse Normal or low BP Altered mental status Anxious or combative Seizure or fainting Coma Weakness simulating CVA

26 Glucometry Indications to perform glucose test
How to obtain blood sample Instruction on glucometer operation What to do with test result? Proper disposal of sharps / contaminants Proper action for blood borne pathogen exposure There are many blood glucose testing machines in the marketplace. They all have one thing in common, they require a blood sample for analysis. How that sample is obtained may vary, you will need to read your equipment manufacturer guidelines for the proper operation for your agency glucometer. While these devices are very dependable, it is a common practice to test their accuracy on a regular basis. This is done with a premixed solution of sugar.

27 Indications for BG Measuring
Signs and Symptoms consistent with Acute Stroke Weakness, slurred speech Altered Mental Status Confusion, disorientation Diabetic Emergencies

28 Altered Mental Status – Common Causes AEIOU-TIPS
Alcoholism Epilepsy Insulin Overdose Underdose Trauma Infection Psychiatric Stroke/Seizure As an EMT, you will encounter many patients for some unknown reason are experiencing an altered mental state. There are many reasons why a patient would have an altered mental status. Some are due to chronic health conditions, however many altered mental states are caused by acute changes within the body that are the result of disease or trauma. These acute changes can lead to serious complications or even death. Any time a patient is confused or disoriented about person, place or time, the patient has an altered mental state. You should never assume that a patient who is not awake, alert and oriented is normal. Erring on the side of caution, you should treat every patient as if the patient has a cause for their altered mental status.

29 But First!!!! ABC’s Vitals Signs O2 Administration SPO2 if available
Complete SAMPLE history Good BLS Comes First………….. Remember the glucometer is an adjunct assessment tool, you still need to perform your primary assessment and any immediate treatments first, then you should perform the BG check afterwards.

30 BLS Pre-Hospital Care Scene Safety/Survey Perform initial assessment
May require airway control, definitely oxygen Ensure cervical spine immobilization as indicated Activate ALS! If the patient is a known diabetic and is combative, STAND BACK! As an EMT you are under no obligation to tackle a combative patient, on the other hand you cannot sit back and wait for the patient to become unconscious. Request law enforcement assistance for restraining the patient. When it is safe, then proceed with assessment and treatments. Time is important, quick thinking and action by you can prevent a bad situation from getting worse.

31 BLS Pre-Hospital Care Perform focused history and physical exam
SAMPLE history Signs/Symptoms (when did they start?; how long did they last?) Allergies Medications (When last taken?) Prior Medical History (diabetes?, seizure disorder?) Last oral intake (When did patient last eat)? Events leading to illness/injury Form a general impression of the patient, does the patient appear anxious, restless or listless? These initial observations may help you to suspect high or low blood sugar. With patients with an altered mental state, past medical history, family or bystanders input, events leading up to EMS being called are key factors that have to be obtained.

32 BLS Pre-Hospital Care Focused history & physical exam, cont.
Take base line vital signs Determine blood glucose level Evidence of hypothermia or hyperthermia? Can the patient swallow normally?

33 On-Going Assessment Is the patient’s mental status improving?
Reassess ABCs, Monitor VS every 5 minutes if unstable; every 15 minutes if stable. Carefully document your assessment findings. Notify incoming ALS unit or receiving hospital as soon as possible

34 Common Diabetic Emergencies
Hypoglycemia Hyperglycemia

35 Hypo vs Hyper Hyper Hypo Onset 12-48 hours <1 hour LOC Confused
Skin Warm / Dry Diaphoretic/Pale Pupils Normal Dilated BP Slightly Elevated Respirations Deep Rapid / Shallow

36 Hypoglycemia “Looks Shocky” used to be called Insulin shock. Pale, diaphoretic, altered mental status. May Vomit. BG <80mg/dl Reality is this is a hypoglycemic state, not a shock state. Hypoglycemia used to be called insulin shock, but in reality is low sugar. Hypoglycemia can cause greater damage more quickly than hyperglycemia. Permanent brain damage can occur if sugar is not replenished. Hypoglycemia is caused by a variety of means, some of these include: Takes too much insulin Reduced sugar intake by not eating Over exercises or overexerts themselves, this uses sugar faster than normal Vomits a meal Also illness can lead to a hypoglycemia event, especially with fevers.

37 Emergency Treatment Hypoglycemia Scene size up & BSI
Initial Assessment Determine need for rapid transport Focused H&P Medical with vitals Blood glucose check If < 80 mg/dl, give oral glucose if LOC intact If < 80 mg/dl and LOC is ↓, activate ALS assistance Detailed, on-going assessments with transport to appropriate facility Supportive care as needed

38 Treatment for Hypoglycemia
Oral Glucose only if they can swallow on command, otherwise protect airway Never assume it is a hypoglycemic episode until BG is done. Never Assume that Hypoglycemia is only problem.

39 Emergency Treatment Hyperglycemia Scene size up and BSI
Initial Assessment with O2 and determine need for rapid transport Focused H&P Medical with vitals Monitor blood glucose level If blood glucose is > 200 mg/dl the patient may need re-hydration and insulin per physician direction Consider ALS Assistance if vitals signs compromised Detailed, on-going assessments with transport to appropriate facility Supportive care as needed

40 Glucose Measuring Devices
Used to check Blood Sugar Levels. Many different types and models. NYS law requires that any EMS service testing blood glucose, whether by electronic glucometer or chemstrip, be required to possess a Limited Laboratory Registration. In order to obtain the Registration, EMS agencies must complete and submit the following documents: Limited Service Laboratory Registration (DOH-4081) Disclosure of Ownership and Controlling Interest Statement (DOH-3486) The information and appropriate application paperwork is available at: No EMS service may engage in the testing of blood glucose without a registration permit.

41 Use of Glucometer Equipment needed: Exam gloves Alcohol prep pads
Test strips Cotton balls or gauze pads Band-aid Lancets Sharps container and proper waste disposal container

42 Procedures Careful attention to BSI & safety Select Finger
Massage blood into distal end Clean finger with alcohol & allow to dry Use Auto-lancet device Apply drop of blood onto test strip and follow individual glucometer instructions Dispose of sharps and soiled supplies

43 Device Variations Some glucometers turn on automatically.
Know the features of the glucometer your service uses.

44 Patient Preparation Clean the site;
Make sure you explain to the patient why you are performing a BG. This can be done as you assemble the BG equipment. After donning gloves, you should select a site preferably a fingertip of a non-dominant hand. Prepare the site by cleaning it with an alcohol wipe, allowing time for the alcohol to dry. It is important to ensure that the alcohol has dried, so not to mix alcohol with the blood sample and alter the results. Clean the site; Use a finger tip on the non-dominant hand

45 Cleanse skin with alcohol prep
Prepare the site by cleaning it with an alcohol wipe, it is important to make sure to clean the area at and around the intended puncture site. Depending on the cleansing of the site, you might have to use a second alcohol wipe to fully clean the site. Make sure to allow time for the alcohol to dry. It is important to ensure that the alcohol has dried, so not to mix alcohol with the blood sample and alter the results.

46 BG Procedure The glucometer reading indicates the amount of
Massage the finger before using the lancet, it helps increase blood flow. Use the side of the finger, it is easier to draw blood from. Press the lancet against the skin firmly, any hesitancy may cause some discomfort to the patient. Push the lancet hard into the skin before pushing the spring loaded lancet. The object of the procedure is to produce a swift deep puncture. You should squeeze a large droplet of blood, this is placed on the test strip as per the manufacturer guidelines of your device. But you may have to “milk” the finger to get a droplet of blood. The reading takes between seconds. The glucometer reading indicates the amount of glucose in the patient’s blood stream.

47 Proper disposal of sharps
What Now? What do to based on the reading? If below 80 and the patient follows commands: Oral glucose If high – then Transport, Contact ALS for specific therapy if over 400 and symptomatic, Transfer information to ALS provider. Be careful many glucometers will have a limit on readings, when a blood sample exceeds those high numbers, the display may read high only. Be familiar with your machine capabilities. Once the glucometer provides a reading, it should be noted and recorded later on the PCR. Appropriate treatments should be taken according all presenting factors, Remember to treat the patient, not just the numbers. It is your responsibility to properly discard the lancet into an approved sharps container and discard any bloody dressings into an appropriate bio-hazard waste container. Treat the Patient Document Results Proper disposal of sharps

48 Administering Glucose
If the patient is alert enough, let them squeeze oral glucose into her mouth

49 Administering Oral Glucose
Make sure the tube is intact and has not expired. Squeeze a generous amount onto a bite stick.

50 Administering Glucose
Open the patient’s mouth. Place the bite stick on the mucous membranes between the cheek and the gum with the gel side next to the cheek. Repeat as needed. Usual dose of oral glucose is one tube. The only contraindication for oral glucose is if a patient is unconsciousness or has an inability to swallow, this could cause aspiration. Oral glucose has no side affects if administered properly, however the risk of aspiration in a patient who does not have a gag reflex can be dangerous.

51 Maintenance Set up requires identification of:
Proper batch numbers for test strips Routine control testing Calibration when necessary Follow CLIA guidelines Log daily (shift) testing Follow manufacturer’s directions

52 Care of the Blood Glucometer
Handle with care! Do NOT expose to excessive heat, humidity, cold, dust, or dirt Clean as directed by manufacturer Store the glucometer in the case provided by the manufacturer

53 Blood Glucometer Errors
Can result from: Wrong calibration of glucometer. Lack of glucometer maintenance and cleaning. Battery failure. Test strip failure. * Proper care and maintenance of glucometers can help prevent these errors.

54 Case Study 1 Your unit receives a call for an insulin reaction. You find, upon arrival, a 44 year old female patient who presents giddy and nervous. The family states that she is an insulin dependent diabetic who had her insulin today and has not eaten. What are the treatment steps for this patient?

55 Case Study 2 Your unit receives a call for an unconscious subject. Upon arrival at the business, you find a 22 year old male patient who is supine on the floor and unresponsive. There is vomitus on the floor beside him and around his mouth. He is breathing and has a strong pulse. He has no identification or medic alert tags on him. What are your treatment steps for this patient?

56 Case Study 3 Your unit receives a call for a traffic crash. Upon arrival you find an elderly patient behind the wheel of a car that has gone off of the road and is up against a tree by a creek. The patient presents unresponsive, but with no specific signs of injury. Vitals are stable except for the decreased LOC, which is found to be responsive to painful stimuli. What are your treatment steps for this patient?

57 Case Study 4 Your unit responds to a home for the report of a diabetic who is found unresponsive. You find the patient unresponsive and breathing shallow. Skin is warm and dry. Vitals are within normal limits. The patient, a 77 year old female is an insulin dependent diabetic who has eaten today, but it is unknown if she had her insulin. What are your treatment steps for this patient?

58 QUESTIONS ? Refusal after treatment, it is best to have an ALS unit continue to the scene if you have confirmed that the patient had a diabetic emergency, but know appears to be normal and is refusing transport to a hospital. In the event that ALS is not available, the contact medical control for further instructions, have medical control talk to the patient before obtaining a sign off. It is best to have a family member be with the patient after treatment and refusal to further monitor the patient condition and makes sure that the patient has more food to eat to help increase their sugar level for a longer duration. Remember, even after increasing a patient sugar level thorough oral glucose or other means, this sugar boost can be depleted quickly by the body, the body needs more fuel to recharge fully. The simple sugar boost is like jump starting a car, if you do not fully charge up the battery it will die again.

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