Posted by: medicblog999 | September 10, 2009

What would you do? – Blood Sugar Monitoring

BloodSugarTesting[5]Heres a quick survey question for you, but I would also like to know your rationale for your decision in the comment section if you have time.

Heres the scenario :

Called to a  1 year old girl, fitting. Has had previous fits and is now on anti-convulsants, although without a firm diagnosis of epilepsy yet. You arrive on scene to find her distressed, acting post ictal (confused and disorientated) but with no evidence of continued seizure activity.

She is apyrexial (doesnt have a temp), a good colour and moving all four limbs. After a short period, she appears back to normal, but Dad states that this fit was different from the others, i.e. longer and more violent. Thats enough reason for me to take her to hospital, so off we move to the ambulance. Once on the ambulance, the new paramedic I am working with states that he wants to do a B.M test on her (i.e. a blood sugar test which involves a small drop of blood being drawn from the finger or heel of the child to check she isnt hypoglycaemic (low blood sugar). Our guidelines state that all patients who have seizure activity require a blood glucose test as hypoglycaemia can sometimes cause a patient to fit.

Now, my question is this:

The child has just got settled with Dad on the back of the ambulance. Dad has just calmed down from getting the fright of his life (it’s usually his wife who witnesses the seizures whilst he is at work).You are less than 10 minutes away from the hospital, and as is their want (as I am sure is the case in most areas around the country and world), no matter what diagnostic tests we do, they will be repeated as soon as the patient enters the department, including another ‘prick’ for another drop of blood.

Do you perform the B.M test now as is stated in the ‘guidelines’, causing the little one some pain and likely to distress her again (bearing in mind she does not show any clinical signs of hypoglycaemia), or do you leave off and wait for the hospital to it if they require.

I really dont think there is a right or a wrong answer to this. It comes down to clinical judgement based on the assessment of the child. The guidelines we use are just that, ‘guidelines’. We dont have protocols anymore.

Im curious to hear youre rationale for your decision. Please leave  a comment.

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Responses

  1. Blind adherence to a ridiculous protocol is not medicine, it’s stupidity.

    If there is reason to believe that hypoglycemia is involved, but all means, do the finger stick. If not, then there’s no rationale behind it.

  2. Personally I would say forget it. The child and father had calmed down and the ride to the hospital would at least be quiet and peaceful compared to the ruckus at the ER. However… the province has recently implemented “PCR Auditing” where I volunteer. This means that exact protocol MUST be followed, and PCRs must be completely (and I mean totally full) filled out. The PCRs are all audited by our peers on the department (we can’t do our own) online and the information we document goes directly to the provincial medical director. If there is a protocol deviation (one of the more serious infractions) it is dealt with on a medical director’s level – which means our certification could be in jeopardy. Therefore – I would have to follow protocol no matter what 😦

  3. It’s interesting how no one else has commented that has voted yes…

    The patient may not be showing any signs of hypoglycaemia, but not all patients present in the same way for absolutely everything (except I bet in this case they do and I’ll look foolish…)

    It may cause a little more distress, but it’s one less thing to worry about, and one more answer you can give when you get the child to hospital.

  4. Ahhh, I remember back when we didn’t even carry glucometers in the field. Remember that? When we had to do a detailed physical assessment? When we had to rely on physical signs and symptoms to diagnose that?

    If the kid is conscious and alert per her baseline, with no signs and symptoms of distress, let her be. The hospital is going to prod her anyway. “Just following orders” is no excuse for poor patient care. Use your best assessment skills and have a rationale for why you do anything.

    With that said, if I thought there was a clinical need to poke the kid, I would. In a second.

  5. Based on your history I want to know if this is something I can help reverse in the 10 minutes transporting.
    It completes the picture. If taking her pulse rate agitated her would we not assess it?

    The protocols are out the window anyway since they are diagnosis based and you have made none.
    We can get the sample.

  6. Yes – Reason prior experiance of a diabetic uncle that managed to treat 5 patients including a resus case with a blood sugar that would lead to most people being unconsious!

    Plus better safe than sorry especially for the little girl. However id most likely do something else less truamatic 1st to see how the child handles being treated. If the slightest thing result in her being distressed I may be tempted to leave it!

  7. Part of being a paramedic clinician is to use sound clinical rationale in clinical decision making. To way up the risk/benefit analysis and come to a decision that reflects the best interests of the patient that may improve outcome. Didactic procedures, although necessary promulgate decisions based on procedural expediency. What is in the middle is the thinking practitioner that ways up the pros and cons. This seperates the technician from the clinician. My response…what is to be gained by upsetting the child and father? A blood sugar would be prudent if you had reasonable grounds to assume that the child is still altered. However if the GCS is improving and the overall picture is reassuring…leave the kid alone. My two cents worth..take a hollistic view and do what you do for the right reasons what ever they may be! As you say…no right or wrong but contextually based decision making. Scotty the Advanced Paramedic from down under in NZ

  8. Why not the middle ground? Most testers these days allow for forearm pricking. It’s not going to be the most accurate test (I believe there’s a 15 minute delay on it, so whatever your test result is, that’s the blood sugar of the patient 15 minutes ago), but it can give you an idea that a low blood sugar has occured in the past.

    Plus, it’s practically painless.

    I don’t know what materials ambulances use (I’m just a lowly first aid attendane), but I know we have a tester in our office that uses a tester that allows forearm testing.

    My two cents.

  9. No need to stick her unless you’re going to do something to fix it if it is low. Especially as the ED will retest anyway, no point doing it for their benefit. Besides which, even if she is hypoglycaemic, could this not be an effect of the seizure, rather than the cause?

  10. Great post – my mum has been diabetic for the last 20 years so I know all about low blood sugar levels. I have voted for do the test in the ambulance because in my limited experieince it’s better to be safe than sorry.

  11. Could this seizure be the result of HYPERglycemia ?
    Not that we can fix this in the field but we can start to treat it. Little O2, little IV fluid may stop her from seizing again on the way to the hospital.
    Do it !…..go on, Do it !

  12. Ok first off she has a Hx of seizures with no definate diagnoses as of yet. The father states this seizure was more violent than the norm, but as you stated he is usually at work when she does seize so is this a normal seizure. The childs mentation is improving, her temp is normal and im assuming all her other vitals are within normal limits. This doesnt appear to be a sugar related problem. With a stable child I usually prefer to let let mom or dad comfort the child and try to do as little invasive interventions as possible unless needed. As you said they are going to do their own glucose check at the ED so you have to do whats best for the child. Is knowing what her sugar is going to change your treatment for her? As its doubtful to be a sugar related problem probably not.

  13. I wouldn’t take the sugar because I wouldn’t be able to give the patient any medication to change it. I’m always torn when it comes to pediatrics as to how much I will do if the child is doing better and has calmed down.

  14. If you poke and get a low sugar……then you have to treat it. Being that the child is young and post ictal, oral glucose may or may not be the best option, so then you have to go IV. Both of which the child is NOT going to like or likely be compliant with. Not to mention, it may delay transport. My thought, as a mom and a nurse, call hospital and ask. Weigh your benefits verses risks. What do you have to gain? What do you stand to lose? How close to hospital are you and will they repeat the test, causing more trauma to child and parent alike? I do not like to traumatize kids with pokes any more than I have to. If the child’s exam is good and she has no immediate life threats, then let hospital get it….where it can be combined with an IV, quite possibly. Kids remember trauma, esp. pokes, or at least all of mine do. Keep her calm and dad calm too. Have a nice peaceful ride to hospital.

  15. agree, per above. it really depends on what the treatment plan is on the way to the hospital. Am I planning on starting an IV? What other assessment?

    However much I hate inflicting pain on pediatric patients, I am inclined to complete a full assessment (based on findings, not only protocols). I tend to like to have my partner or parent distract small children while complete my (? invasive) assessment.

  16. I voted to yes check it. But I agree with a couple others that it depends on the treatment plan to the hospital. Will the hospital just pull your IV and replace it with theirs?

    As what EMT.dan said and what I know about local hospitals, I would perform a complete assessment including invasive procedures (IV/IO, glucose) if possible while having some sort of distraction for the child.

  17. Yes, for several reasons:

    You’d check it on an adult. It may distress her, but with some children so may trying to take a pulse, and you’re going to do that.

    Will the hospital accept your BM? If they’ll take yours maybe it’s better the little girl hates you for 10 minutes than distrusts the nurse caring for her for the next few hours. Depends on how much your local paeds dept likes/trusts the ambos.

    There’s also a CYA aspect – you’d need to document very well why you didn’t do a BM, and if the seizure was due to sugar levels (although it seems unlikely), you’d be up a certain creek. Don’t Ever Forget Glucose and all that.

    Finally, maybe I’m just lucky, but I find it’s unusual for a kiddie to create much of a fuss from a BM, if they do there are usually tears on the go already.

  18. Yes! I would, wouldn’t you feel a lot better getting a low reading and treating it than having a child fit again on the way in!?

    And also, how would you look to the staff when you havnt ruled out a hypo as caus? Like a strecher monkey!

  19. Yes! I would, wouldn’t you feel a lot better getting a low reading and treating it than having a child fit again on the way in!?

    And also, how would you look to the staff when you havnt ruled out a hypo as caus? Like a strecher monkey!

    Futher, if the kid is waiting in the ED for any length of time (most likely where I work) it could have horible concequences if they are low!

  20. I usually wait til I’m 30 seconds out from the ED and poke them real quick before they realize what happened.

  21. If it were a sugar related problem as to the reason she fitted I doubt her mental status would improve.

  22. Being a bit of a newb to the road myself (5 months), I would go ahead with the BSL test. So far, all the kiddies whos sugar levels I have taken haven’t flinched at all, thanks to them still being post ictal. I agree with ak, it also looks silly when you rock up at hospital without havng taken many obs…and if you get ramped at hospital (no beds available) then you gotta do it anyway….may change the triage score, who knows?


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