Sunday, 20 April 2014

Guest Blog - Diabetic Emergencies and the Paramedic

This is a guest blog post written by Mark Turner.

Here is a little about Mark:
  • Previously an economist
  • Can speak English, Irish and Spanish
  • Trained in the USA and UK as an offshore and remote medic, lifeboat medic and ECP
  • LOVES - Nurses, Guiness and his job
  • Diagnosed with Type 1 Diabetes on November 15th 2013
  • Works worldwide and lives in Ireland and Southampton
This is what Mark wrote about seeing Hypos from his view as a paramedic...

Diabetic Emergencies and the Paramedic

..or 999, what we know, what we do and how it works out for you...

We learn a lot about Diabetic emergencies from the earliest level of our training for our medical degrees; Type 1 (usually diagnosed early in life, insulin dependant), Type 2 (usually lifestyle related, later in life, often controlled by diet, metformin or gylclazide).

In particular, we are well trained in recognising, and treating the Hypo, and also the DKA patient.

Working in some areas, I might get one or two Diabetic patients in a run of four 12 hour shifts, but in others (especially London – 8 million potential “customers”!) 3 or 4 diabetic emergencies in a single shift!

Hypo 999’s are usually called by a member of the public (finding someone U/C or confused and helpless) a family member, or increasingly – the Police!
The Police often call us as they are unsure if someone is drunk, or under the influence of drugs or indeed having a hypo! All three situations we can deal with, and are part of the routine of any shift.

I was once called to a man, lay on a train track – the police were stood on the platform, and network rail were struggling to cut off the electricity supply to the live 3rd rail. The poor man was confused, wailing and very frightened – everyone assumed he was either drunk and/or suicidal. By the time it was safe for me to climb down onto the track, I already had a suspicion.... Sure enough, he was stone-cold sober with a BM of 2.0 The poor fellow simply had a hypo and fell onto the track. He was a very lucky man.

Patients often say “its ok, I’m not diabetic, you don’t have to test my blood...”  - Paramedics ALWAYS test your BM! Its part of every single patient assessment – Resp rate? BP? BM? SP02%? Pulse? PEARL? Skin colour? AVPU? ECG? History taking, Medications, Allergies, Social Situation, Safeguarding etc.. etc.. BM isn’t just for the diabetic patient -  it can be low in an elderly patient with Diahorrea & Vomiting, a marathon runner or swimmer, or high in a patient with a Heart Attack; where the body is using sugars as part of the “flight or fight” reaction to stress.

Hypos are usually easy enough to treat in the pre hospital environment – we recognise them quickly as part of our opening assessment of the patient, even if no one is around to tell us they are Type 1 D’s using insulin (so wear a wristband people!!!!) – we can give you “oral carbs” if you are conscious and able to swallow (cup of sugary tea madam?), or “hypostop” sugary gel (not very nice stuff).

If you are U/C we can give you an Intra-muscular injection of Glucagon (although not useful in children or alcoholics) – its a useful and fairly rapidly working treatment – but you must be careful to get it into muscle and not a vein! Last resort for the Paramedic is to cannulate and begin running through intravenous Glucose .

The important thing for the medical professional to remember is to KEEP CHECKING THE BM over AT LEAST 30 MINUTES! Your body has been starved of glucose – part of the triangle of life (water, oxygen, sugars) and the Brain will immediately suck up all the sugar the Paramedic is introducing to the patient – followed by all the other organs that are sugar-short; its like a gang of grannies at a car boot sale, with all that sugar “selling out” quickly, so often you need a repeat treatment to stabilise your patient!

Often you will find a Diabetic who is very dependant upon their partner to manage their condition – its almost always Males relying upon the wife or girlfriend to look after them!!!!

A good example of this is a patient I attended when on the Rapid Response Car in Winchester. He was U/C in the foyer of the theatre. The staff were upset, worried and bewildered that this well dressed and well spoken (sober) man, suddenly seemed to behave oddly and collapsed. They of course suspected a heart attack and I was despatched at speed to attend. Within moments, I was getting a set of “obs” and his BM was 1.1mmol (what a good memory I have for patients I attend? ). I put a line in, and administered around 30G – about 300ML – of 10% Glucose. It took awhile for him to come around, and sure enough, as I wrote above ; his BM was up and down until it stabilised. He explained that his wife was away – she usually cooked and helped to administer his insulin. She was away visiting family for a few days, so he worked late, alighted from the train and decided to see a play. Sure enough – BANG! HYPO! I took him into Winchester A&E for observation for a little while, and once there he told my Nursing colleagues and myself that he made his living as a Medical Negligence Lawyer prosecuting us guys! Needless to say, he was an absolute gentleman and thanked us all – I ended by hoping I would not see him again either in the street or in a courtroom!

Hypos can be difficult for the Paramedic. Especially if you are alone with someone. Each of us can react differently – after all we have different brains with bodies requiring or accustomed to different levels of sugar for energy.

Luckily I was attending a patient with my colleague Harry – we arrived at a house where the wife and daughter of the patient were maintaining a safe distance from the patient. He was a 120kg, six foot plus, builder – long term type 1, but normally well managed. However, he was known to become aggressive during hypos, and we had to gingerly inject the Glucagon, and once he began to assume normality, encouraged him to drink coca cola from a straw in a can. Within moments he was the perfect gentleman, with no memory of his angry hypo!

DKA’s are more scary than hypos – not fun to deal with – IV line in, run fluids and run straight to Resus in ED on blue lights, where our Nursing and ED Dr colleagues will get some arterial blood gases and call “upstairs” to the Endocrine guys who know more (and can do more) for those patients. More about this subject another time.....

It helps to have been a Paramedic in a number of countries, over 14 years – although Diabetes is Diabetes whoever and wherever we are! Nonetheless, the shock of being diagnosed myself was dreadful. The only good thing I can take from it, is that I somehow manage an extra 1% from my personal reserve of care for each and every person who is suffering the same as me. All my patients get 100% - I don’t need to have their condition or trauma to do that, but now I find myself giving 101% and that little extra support, care and reassurance to the Diabetic.

Mark Turner

You can follow Mar on twitter at - @markturner30

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