Emergency Medical Services (EMS) Agency
CASE OF THE MONTH – JUNE 2019
Paramedics respond to a 68 year-old male who was found unresponsive in his home, where he lives with his adult daughter and her family. His grandson called 911 after he found him unresponsive on the floor in the living room. On arrival, the patient has a GCS of 3. His skin is cool and diaphoretic. His vital signs are BP 116/74, HR 98, RR 14, and oxygen saturation 96% on RA. His grandson knows that the patient has a history of hypertension and diabetes.
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The differential diagnosis in this patient is broad. Given the patient’s past medical history and vital signs, hypoglycemia should be high on the list of things to immediately evaluate. A blood glucose should be checked and assessments performed for signs of trauma, stroke, drug overdose and toxic exposures. If the cause of the patient’s altered level of consciousness (ALOC) is not immediately apparent, it is reasonable to begin with a provider impression of ALOC and initiate treatment of the patient using TP-1229, ALOC, while evaluating for an underlying cause, recognizing that this provider impression is only appropriate if no specific cause is identified. All causes of ALOC should be considered:
A – Alcohol, abuse, atypical migraine
E – Epilepsy, electrolytes
I – Insulin (hypoglycemia)
O – Oxygen, overdose
U – Uremia (kidney failure)
T – Trauma, tumor
I – Infection
P – Psych, poisoning
S – Seizure, Subarachnoid hemorrhage, Sepsis, Stroke
The patient’s blood glucose is 30 mg/dL. The primary provider impression is now Hypoglycemia and the patient is managed in accordance with TP-1203, Diabetic Emergencies. The provider impression of ALOC is no longer appropriate, because a specific cause has been identified. After administration of Dextrose 10% 125 mL IV the patient is reassessed. Within 5 minutes of Dextrose 10% administration, he is awake and able to answer questions appropriately. He eats a breakfast sandwich and returns to his normal disposition according to his family. The patient states he does not want to go to the hospital. He says, “I think I just took a little too much insulin.” He has a regular doctor and says he can follow-up the next day. His updated vitals signs are are BP 136/80, HR 85, RR 16, oxygen saturation 99% on RA. His repeat blood glucose is 134mg/dL.
Importantly, patients must not want transport to the emergency department for evalution and must be stable for referral to the patient’s regular healthcare provider or doctor’s office/clinic.
To meet criteria for “Treat and Refer” per Ref. No. 834, EMS personnel must:
- Ensure the patient has capacity to decline transport
- Ensure the patient does not have an ongoing emergency medical condition
- Determine that the patient does not have any “high-risk features” which include:
- Extremes of age ≤ 12 months or ≥ 70 years old
- abnormal vital signs (except isolated asymptomatic hypertension)
- high risk chief complaints (including chest pain, shortness of breath, abdominal pain, gastrointestinal or vaginal bleeding, and syncope)
First, to ensure that this patient has decision making capacity to decline transport, EMS Personnel must confirm that the patient is able to understand the nature and consequences of his decision regarding his proposed health care (in this case, not being transported to the hospital) and be able to communicate such a decision. He should understand the need for treatment, the implications of receiving and of not receiving treatment, relate this understanding to his personal values, and convey an informed decision.
This patient does not have any high risk features, which would require signing out against medical advice (AMA). But further assessment is needed to determine if this patient has an ongoing Emergency Medical Condition before one can determine if he meets criteria for “Treat and Refer”.
An Emergency Medical Condition is one where a patient needs immediate medical attention. Any patient that meets any criteria for Base Contact or Receiving Hospital Notification are considered to have an emergency medical condition. An emergency medical condition is also present when there are abnormal vital signs (with the exception of isolated asymptomatic hypertension), or per provider judgement.
In this case, the final question to determine appropriateness of treat and release, is whether or not the patient is stable to wait to see his doctor. Therefore, EMS personnel must determine if this patient is at risk for recurrent hypoglycemic episodes. They should confirm that the patient has a known history of diabetes and obtain an accurate list of medications. If the patient is on any long-acting hypoglycemic agents, he is at high-risk for recurrent hypoglycemia and has an ongoing emergency medical condition. EMS personnel should also confirm that the patient has no intention of harming himself and that there is no indication of an intentional medication overdose.
Figure 1. List of common long acting hypoglycemic agents. The list is dynamic with new drugs entering the market frequently.
Patients are considered to be low risk if they have a known history of diabetes and are only on short acting hypoglycemic agents, have someone with them, and are able to tolerate oral intake. Low risk patients can be treated and referred for follow-up as per Ref. No. 834.
Paramedics obtain a complete medication list. The patient currently takes:
lisinopril, hydrochlorthiazide, glimepiride, metformin and sliding scale regular insulin (Novolin R).
He denies any intention to harm himself. He explains that he missed his glimepiride dose yesterday and his blood sugar was in the high 200s when he checked it this morning before breakfast. To make up for missing his dose, he took “a few extra” pills today in addition to his sliding scale insulin.
Because the glimepiride is a long acting sulfonylurea, paramedics should explain to the patient that he is at high risk for recurrent hypoglycemia. It would be inappropriate to “Treat and Refer” this patient because he has an Emergency Medical Condition. The family becomes worried because his daughter and her husband are going to work and his grandson will be at school all day. Should a hypoglycemic episode recur, the patient would be alone.
- To meet criteria for “Treat and Refer” patients must not desire transport to the emergency department, and not have an ongoing emergency medical condition such that they are stable for referral to a clinic/doctor’s office.
- EMS personnel must ensure that the patient has decision making capacity to decline transport and make sure the patient has no high risk features.
- Certain hypoglycemic patients are at high risk for recurrent hypoglycemia. Patients with abnormal vital signs, history of alcohol abuse, possible non-accidental ingestion or poisoning, no prior history of diabetes mellitus, or those taking long acting hypoglycemic agents are at high risk and should be considered to have an emergency medical condition. Patients treated by EMS for hypoglycemia must also be able to eat and have someone with them in order to be considered low-risk.
- EMS personnel are responsible for advising the patient of the risks and consequences that may result from refusal of treatment and/or transport. For patients who are appropriate for treat and refer, counseling should emphasize 1) the need for followup with their doctor or clinic and 2) recontacting 911 if condition worsens. It should not include advising the patient of risks ‘up to and including death,’ because a patient at risk for deterioration is not appropriate for treat and release; those patients should be transported or sign out AMA.
After paramedics fully explain the risks of not being transported to the hospital, the patient’s daughter is able to convince the patient to agree to be transported by EMS to the emergency department for further evaluation and monitoring. He is transported to the MAR. During his time in the emergency department, he has 3 subsequent episodes of symptomatic hypoglycemia, he is started on a glucose and octeotride drip, and is admitted to the hospital. He is discharged from the hospital the next day after receiving education on diabetic medication management.