Diabetic Coma is your office prepared...

[Uncle Fester]

A diabetic patient starts to fade before my eyes last week, slow speech, glazed eyes but responsive as I ask "what's wrong". His labored response is "I need some sugar". I've kept a couple of small christmas candy canes hanging from a cork board for years for just this occasion. I took an EMT course years ago and for the first time was witnessing someone going into a diabetic coma. I gave him one and watched as he chewed and swallowed it. I now realize that I should have insisted he suck on it under his tongue to get the sucrose into his bloodstream sooner! Fast forward 10 minutes and he hasn't improved but he hasn't digressed. We find some orange juice and boom, he responds and after an appropriate amount of time and observation, and a promise of going to get something to eat I send him out the door. Was I wrong to not call Emergancy Medical Sevices?

I know by not calling EMS (an ambulance) I exposed my doctors to litigation should he have had further complications but I also didn't incur an unnecessary expense for him (with him saying "don't call EMS"). It's now your call. What would you have done for this relatively common condition?

PS: I now know there is an over the counter lozengere for just this scenario.

PPSS: Of course if you're in doubt CALL 911!!!
Diabetic shock kills quickly!

[Leo Hadley Jr]

Great job!!!

This is a very important issue. You can get fast acting glucose over the counter and keep it in your first aid kit. I recommend everyone should do this. Sometimes the first symptom of low or high blood sugar is blurred vision. This may lead them to you in the first place.

I also have extensive advanced first aid training and I like to be prepared for everything. Over the years I have seen many people drop while getting an eye exam or getting new eyewear. I have never lost a patient yet:bbg:

The only thing I wasnt prepared for was the guy who couldnt quite make it to the bathroom.

[AutumN]

We've always had juice on hand for just this purpose. As far as calling EMT-our docs are MD's so they monitor the patient and decided if further eval is required.

[hcjilson]

We always have candy on hand. I think it is a mistake not to call rescue regardless of the wishes of the patient. The patient is in no position to make a medical judgement, and while the ophthalmologist is a physician, unless he is a specialist in diabetes, he too would defer to the EMT's. Like most physicians my guess is that your answering machine says something to the effect that if you have a medical emergency, hang up and dial 911. It is not because they're not trained, its because of our liable concious society.

[chip anderson]

Use grape juice, it tastes better. Actually a packet of sugar will work well and keep a long time.

[HarryChiling]

We keep candy in the office at all times for just that occasion, although thankfully we have never had to use it. My mother as well as our front end manager are both diabetic, so I am very familiar with diabetes and it's effects. I have gone through 4 ammonia packets for waking someone after passing out, nothing to do with diabetes (1 was on my brother in law). Congrats for your fast thinking and acting, it's one thing to know what to do, but another to do it.

Our policy would have been drag them out the front door and say you found them that way. :bbg:

No seriously you probably should have called the EMS, but if they never hit the floor you have an arguement, at least thats how I see it.

[npdr]

What if this was a hyperglycemic or hypertensive crisis? What would you do then?

[ShuString]

Glad it was my day off......

[HarryChiling]

What if this was a hyperglycemic or hypertensive crisis? What would you do then?

Hyperglycemic - get their insulin for them and hope they are still conscious enough to administer it.

Hypertensive - maybe an aspirin.

And in both cases call 911.

[chip anderson]

Don't think they have to be conscious to give them insulin, of course if not concious it's hard to get them to tell you how much.

Chip (Diabetic)

[DragonLensmanWV]

Yes, this can be very deadly. In my second summer after graduating high school, I was waterfront director of Camp Galahad, a camp for various disabled children. We had two-week sessions of three different age groups of retarded children, a two-week session for diabetic children and a two-week session for blind children.
During our second session of retarded children (this was when the term special was just getting started as were the Special Olympics that were not nationwide yet), we had one 10 year old boy not wake up one morning and he could not be roused. The nurse checked him out and called the EMTs. Since we were nearly an hour away from the nearest hospital, this took some time. By the time the ambulance got there, the boy had died. Turned out he was an undiagnosed diabetic with no previous symptoms. Naturally, the nurse was beating herself up over this, but there was no mention of it on any of his medical records. Even the parents, when they came to retrieve his belongings, were trying very hard to reassure her that it was not her fault, but she was nearly inconsoleable.
Makes you wonder. Nowadays that would be a huge lawsuit.

There was one particular boy that was difficult, but intrigueing. He was unable to talk, being highly autistic and withdrawn, making no more than the occasional honking sound. His big thing was he came with a bag full of mirrors. He would not look directly at anyone or anything. He would hold his hand mirror up in various angles above, below, and beside his eyes and look into the mirror to see the reflected images of everything. Somehow he was able to walk around and go through doors and everything by looking at his mirror. They had a doctor come to examine her and her theory was that maybe his eyes were hard-wired backwards and normally everything looked backwards to him.I guess that would involve some brain defect. Anyway, I've never run into anything like that since.

If there's one thing I've learned in 35 years(This August 14) in the business is:


NEVER EVER THINK YOU HAVE SEEN IT ALL!

If you do, the next guy through the door will prove you wrong!:D

[npdr]

I posed the question because it appeared that the thread was leaning toward some kind of formula answer. In other words, just because you have a patient in malaise or stupor one cannot presume hypoglycemia or hyperglycemia. Administration of either glucose or insulin in the incorrect phase would significantly harm the person. Just yesterday, a patient was in acute distress and claimed that he needed insulin because of hyperglycemia. In fact he was hypoglycemic. Per protocol, we check RBS first.

[HarryChiling]

I posed the question because it appeared that the thread was leaning toward some kind of formula answer. In other words, just because you have a patient in malaise or stupor one cannot presume hypoglycemia or hyperglycemia.

I guess round here we just don't get that fancy book lernin' you folks get around your way.:hammer:

It was the actions he took not a diagnosis that should be commended, and yes when their is an emergency situation a basic first aid course will suffice doctor, at least long enough to get the person to the proper person. I am curious how you would take an RBS (glucometer?) do you have one in the office for such situations? Wouldn't the patients response as to if they need insulin or glucose suffice?

Per protocol, we check RBS first.

Are you serious you have a protocol for that? How often does it occur in your office? What's your demographic?

[drk]

Good call, Dr. H.

I think the lesson here is to NOT initiate treatment unless you are certified to do so. Too risky and dangerous.

Call EMS.

I've learned from this thread.

P.S. Harry, I know "NPDR". He works in a hospital and has extensive experience, especially with diabetes. He is by no means an average OD. I trust his judgement.

[HarryChiling]

Thanks drk, I don't know npdr and his post came off as a little high brow.

I know how a car works. Doesn't mean that anyone would want me poking around under the hood to fix their car, but if we were stranded on the side of a desolate highway, you can bet you would appreciate the fact that I knwo how a car works.

Kinda the same situation, Uncle Fester had an emergency present itself and the guy did the right thing, luckily he knew what diabetes was and knew about getting him some candy, does that mean the patient should come in for regular monitoring or to have his Random Blood Sugar worked up by Uncle Fester, "NO".

[drk]

Gotcha.

NPDR has that high-brow effect everywhere he goes, nevertheless...:D

I think UF should be congratulated for his good work...way above and beyond the norm. Don't know if I'd be as smart.

But I think NPDR's implication is for the masses who read this thread: You'd better know what you're doing, and if you don't, don't proceed with only a fragment of knowledge: get a pro.

Again, UF's outcome was a good one, and he should be congratulated.

[HarryChiling]

Don't know if I'd be as smart.

The guy "asked" for sugar. I am confident you would have handled yourself well. :bbg:

But I think NPDR's implication is for the masses who read this thread: You'd better know what you're doing, and if you don't, don't proceed with only a fragment of knowledge: get a pro.

It seems you are just more eloquent at getting that across, it helps when it's not posed as questions with a zinger waiting. I think the most important thing we can walk away from this thread with is that:

NPDR is a pro. :bbg:

[drk]

Yeah, he is. NPDR is benign and generous, but his "E.Q." needs help :)

You're right, H: the guy did ask for sugar. I could've done that!

[npdr]

Lest you ignore the "science" behind the request, you might find a different result. My retort was meant to convey that patients may ask for something that is actually harmful to them because they are self diagnosing themselves. Therefore, to treat based upon self diagnosis by the patient (and you are treating them) is risky without additional analysis by the person(s) present.

Akin to saying I'm myopic, give me soft contact lenses for myopia of -5.00. And you do so and discover that they are actually -6.50 and cannot see with th em to drive. ANd gets into an accident.

[HarryChiling]

Lest you ignore the "science" behind the request, you might find a different result. My retort was mean to convey that patients may ask for something that is actually harmful to them because they are self diagnosing themselves. Therefore, to treat based upon self diagnosis by the patient (and you are treating them) is risky without additional analysis by the person(s) present.

That was a lot easier to understand and does have a point, as for mean, check this out:

:angry::angry::angry::angry:
Hows that for MEAN

PS - :angry:

[chip anderson]

Of course you could get an $8.00 meter and check the patient. You don't need to be a rocket scientist to learn how to do this. All us diabetics even stupid ones like me which are not "certified" in anything but optics do this several times every day.

[npdr]

Less than half measure their own serum glucose levels at home.

[drk]

I'm not allowed to prick a finger in Ohio!




(Stop with the joke inside your dirty little mind, right now...)

[chip anderson]

DRK;

I think you will find that as long as you don't represent yourself to be a physician and do not charge for the service. You will find that you can do any sort of first aid indicated in an emergency.
Now if you were to start pricking fingers as part of a diabetic retinopothy treatment, or diagnosis you probably be crossing the line. But in good samartian emergency care, even optometrists are concidered as good as the rest of us.

Chip

[drk]

That makes sense, Chip.