Unresponsive in the waiting room of a large medical clinic. The woman is a GCS of 3 – no response at all. The staff thought she was sleeping, and then after walking by her multiple times, they finally noticed she was awfully pale and clammy. They checked her sugar. It was ten. I notice what looks like blood running out of the side of the patient’s mouth like she has severely bitten her tongue, but then I see it is not blood at all, but a sugary gel. The doctor explains they have given the woman two tubes of insta-glucose. That explains the gurgling sound.
My partner recognizes the woman. “We had her yesterday,” she said. “Same thing. Be careful she’s had rehab issues.” She hands me a pair of gloves. I am already taking out my IV kit. “She’s a hard stick,” my partner says. “We had to give her glucagon.”
There is always a great challenge in the IV on the diabetic in front of a crowd. I usually put a patient on the stretcher and work them up in the ambulance, but with unresponsive diabetics I work them where they are. I get the IV and wake them up – I am a hero. I miss – I look like poor excuse for a paramedic. I consider myself a first rate IV tech, but I am not finding anything but track marks. I try a little twenty four in the upper bicep, but get noting. Ditto with a twenty-two in the other arm. I finally pull out the glucagon, but I am worried it won’t work because she got the glucagon yesterday and the glycogen stores may be depleted. In the meantime three of the clinic doctors are standing around. The boss doctor has come out and is getting a report from the other doctors. “Do we have a pulse SAT?” he asks. “She obviously needs her insulin adjusted. I can help you get an IV if you’d like?”
I look up at him. This and the nurse the other day I described in No Problem are getting to be too much. “No, we’re all set, thank you,” I say. “I’m giving her glucagon now and then I’ll try again for an IV on the way to the hospital. I appreciate your offer though.”
“Oh, okay,” he says. He seems relieved. The last time he did an IV was probably in medical school.
There is no immediate response to the glucagon, but I am not expecting anything for awhile. We have a hard time picking the woman up because she is dead weight and so diaphoretic, she is slippery.
Down in the ambulance, the gurgling increases. She has surely aspirated some of the insta-glucose. I try an oral airway, but get a deep gag reflex. I see no veins, except for the jugular vein in the neck. What the hell. I go for it. I sink an 18(I know I should be using at least a 16, but it has been awhile since I’ve had to do an EJ). No immediate flash, but a little maneuvering and I get it, blood filling the chamber. I flush the lock, then attach the D50 to the saline lock, pull back on the D50 to see blood fill the line again to confirm I’m in, and then I push forward. She has a jowly neck so I am a little cautious, but each time I pull back I get blood flow, so I empty the entire amp.
We start to the hospital. I have the patient on a nonrebreather and ETCO2. I can’t get a SAT reading, but the ETCO2 is 35(so I know the ABCs are intact). RR is 40. The electrodes won’t stick because of all the sweat. We never did get a pressure(Oops). I start to wrap the cuff around her arm, but she is coming around now, and I have to block her hands as she tries to take the mask off and also pull out the line in her neck. Her eyes are open, but she is still nonverbal and she has a crazed look. She seems aware of her gurgling and starts gagging. I have an emesis basin ready. A few more times she reaches quickly for her neck, but I block her. I manage to hold her down enough to get another blood sugar – 180. She has calmed down some by the time we pull into the hospital driveway.
A doctor walks by at triage and remarks the patient doesn’t look too good. I explain it’s a diabetic who probably aspirated on oral glucose, but then I shout to the woman to open her eyes. She does. Say Hi to the doctor, I command. She waves. Okay, he says.
The SAT with the nonrebreather is 100, but there is still a lot of rhonci. The patient is alert, but very tired. They take a chest X-ray and when I walk by the room later she is on bi-pap.
**
Afterwards, my partner compliments me on the EJ. She says she has only seen a medic put an IV in the neck once before and she has been working there for eight years. I do about one a year so I am happy I got it.
“You should have done the EJ in the waiting room there,” she says. “That would have impressed them.”
I think about that. Standing there in front of the worried, anxious staff, calm as can be, then suddenly wiping a 14 gauge needle out of my pocket, giving a karate jujitsu kung fu shout, and plunging the needle deep into the patient’s neck. If I done that and gotten it, I would have been an awesome hero stud. If I had missed, the appalled clinic staff would probably would have called the cops on me.
You should report the clinic staff to the Health Department. Anybody who gives an unresponsive diabetic oral glucose is obviously the one we’re talking about when we say “What do you call the guy who graduated last from med school?”
yeah i hope you documented who gave the two tubes of oral glucose and your findings consistent with aspiration. If anything just to CYA
I have not yet had to do it, but many on the service have literally scooped oral glucose out of the mouth of an unresponsive, GCS 3, patient due to oral glucose orgy by Fire. Not just out of the gums either. But the whole tube right down the gullet. Lovely.
I agree with the idea of reporting the clinic staff. I’ve seen 1st responders do the same thing a time or two. On a side note…. You and your writing have been a big inspiration to me. I’m sure that you get that a lot, but I really enjoy your insights. Keep up the good work. If you get a chance, check me out at blueridgemedic.blogspot.comregards,BRM
When I run across a situation like this I usually just tell the people not to do it again. We didn’t say antything this time because we were in a public area with many patients around us, and we were sort of busy trying to take care of the patient. Plus if we reported every mistake we saw in a clinic or nursing home, well…it would be a lot of paperwork. Also, whenever I publicly complain about someone, it seems I end up invariably doing something stupid myself, so to prevent my own stupidity, I try not to attack others. Still, we should have spoken up to the staff. I had just never seen so much goo coming out of one mouth before. We certainly did document it in our paperwork as well as our verbal report to the MD at the hospital.