RE: D-Sticks As A Baseline Vital Sign

[Guest guest]

 I have never seen it as a baseline vital but it is done frequently at the

service I work for. Esp. if we are going to start an IV or for calls about

weakness or AMS. It never hurts to do one

 

________________________________

To: texasems-l

Sent: Mon, August 30, 2010 8:15:39 PM

Subject: D-Sticks As A Baseline Vital Sign

 

Does anyone know of an ambulance service or first responder organization which

currently has in its protocol that a blood glucose test should be a part of the

set of baseline vital signs on all patients?

If you do and you could contact me off-list, I would appreciate it.

Thank you,

Alyssa Woods, NREMT-B

CPR Instructor

[Guest guest]

 I have never seen it as a baseline vital but it is done frequently at the

service I work for. Esp. if we are going to start an IV or for calls about

weakness or AMS. It never hurts to do one

 

________________________________

To: texasems-l

Sent: Mon, August 30, 2010 8:15:39 PM

Subject: D-Sticks As A Baseline Vital Sign

 

Does anyone know of an ambulance service or first responder organization which

currently has in its protocol that a blood glucose test should be a part of the

set of baseline vital signs on all patients?

If you do and you could contact me off-list, I would appreciate it.

Thank you,

Alyssa Woods, NREMT-B

CPR Instructor

[Guest guest]

While I don't recall it ever being mandated by protocol, it has always been my

practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

Over the years I have found numerous undiagnosed diabetics who presented with

totally unrelated conditions.

I think it should be a component of baseline vital signs, along with

temperature, but many medics and services probably will not see it that way.

After all, it adds a significant workload to the medics (sarcasm font in

operation).

One thing to remember is that most of the BGL devices used in prehospital

medicine are designed to be used with capillary samples, not venous samples.

While many have the practice of using blood from the catheter to do the BGL,

studies have shown significant differences in reports when venous blood is used.

There is some evidence that venous stasis due to tourniquet effect will skew the

results. The differences can be as little as 5 mg/dL to 20 mg/dL.

There has, over the last few days, been a thread on one of the other EMS lists

about this, and a number of studies have been cited confirming these

differences.

Mr. Bledson and Mr. Grady are both on record as opposing the use of venous

samples for BGL. A finger stick is still the best and most accurate way with

the devices we use in the field.

Other opinions welcome.

Gene Gandy, JD, LP, NREMT-P

PERCOM EMS Education

Tucson

D-Sticks As A Baseline Vital Sign

Does anyone know of an ambulance service or first responder organization which

currently has in its protocol that a blood glucose test should be a part of the

set of baseline vital signs on all patients?

If you do and you could contact me off-list, I would appreciate it.

Thank you,

Alyssa Woods, NREMT-B

CPR Instructor

[Guest guest]

While I don't recall it ever being mandated by protocol, it has always been my

practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

Over the years I have found numerous undiagnosed diabetics who presented with

totally unrelated conditions.

I think it should be a component of baseline vital signs, along with

temperature, but many medics and services probably will not see it that way.

After all, it adds a significant workload to the medics (sarcasm font in

operation).

One thing to remember is that most of the BGL devices used in prehospital

medicine are designed to be used with capillary samples, not venous samples.

While many have the practice of using blood from the catheter to do the BGL,

studies have shown significant differences in reports when venous blood is used.

There is some evidence that venous stasis due to tourniquet effect will skew the

results. The differences can be as little as 5 mg/dL to 20 mg/dL.

There has, over the last few days, been a thread on one of the other EMS lists

about this, and a number of studies have been cited confirming these

differences.

Mr. Bledson and Mr. Grady are both on record as opposing the use of venous

samples for BGL. A finger stick is still the best and most accurate way with

the devices we use in the field.

Other opinions welcome.

Gene Gandy, JD, LP, NREMT-P

PERCOM EMS Education

Tucson

D-Sticks As A Baseline Vital Sign

Does anyone know of an ambulance service or first responder organization which

currently has in its protocol that a blood glucose test should be a part of the

set of baseline vital signs on all patients?

If you do and you could contact me off-list, I would appreciate it.

Thank you,

Alyssa Woods, NREMT-B

CPR Instructor

[Guest guest]

make that *all systems* at a cellular level..

for a gold star, what is the mechanism of the injury, and how do we measure

it?

ck

In a message dated 08/31/10 19:55:13 Central Daylight Time,

amwoods8644@... writes:

Because ultimately, the patient doesn't have to feel the damage as it's

being done to their cardiovascular system on the cellular level.

[Guest guest]

In a message dated 08/31/10 20:10:46 Central Daylight Time,

rick.moore@... writes:

Using your logic every time someone seeks medical care the care provider

should run every diagnostic test available just in case they have some

process that may or may not be related to the chief complaint. That should

reduce the cost of health care nicely.

You should treat the patient based on recognized standard of care as

dictated by the chief complaint. And say you do find a normally responding

patient with a BGL of 500. What are you going to do about it Alyssa? It's not

your job to diagnose the worlds ills. Even Internal Medicine docs don't run

every test every time.

Rick

that being said, I could justify at least a finger stick BG on any patient

I saw in the ED based on any complaints of weakness (global or specific),

mental status change from slurred speech to loss of consciousness, loss of

energy, depression, anxiety, fall, blurred vision, headache, nausea.....

So how many patients do you think that I saw didn't need a BG?

you check blood pressure, pulse and respirations on every patient, even if

they don't have a history of hypertension, irregular heart beat or lung

problems...

the triage nurses ask about safety at home (including questions designed to

identify abuse)...won't that also increase the cost of health care by

identifying people who need social service intervention?

There are good arguments about using a blood glucose as a screening tool to

identify folks who need further evaluation for diabetes....in order to

catch them earlier, before significant end organ damage is done, which *will*

ultimately reduce the cost of health care in most of those folks.

I'd have to see a better argument than the one you have advanced, Mr.

before I condemned Ms. Woods' idea.

I will admit that I was a bit unusual, being a physician who 'came up

through the ranks' and actually tended to listen to the reports of the Basics

and Medics (many of whom I helped train in my early career) that I worked

with.

That being said, even someone who 'felt normal' but had a field BG of 500

would deserve at least a referral for follow up after evaluation in the

ED....and even someone who 'feels normal,' but has a BG that high should be

considered for transport.

ck

[Guest guest]

In a message dated 08/31/10 20:10:46 Central Daylight Time,

rick.moore@... writes:

Using your logic every time someone seeks medical care the care provider

should run every diagnostic test available just in case they have some

process that may or may not be related to the chief complaint. That should

reduce the cost of health care nicely.

You should treat the patient based on recognized standard of care as

dictated by the chief complaint. And say you do find a normally responding

patient with a BGL of 500. What are you going to do about it Alyssa? It's not

your job to diagnose the worlds ills. Even Internal Medicine docs don't run

every test every time.

Rick

that being said, I could justify at least a finger stick BG on any patient

I saw in the ED based on any complaints of weakness (global or specific),

mental status change from slurred speech to loss of consciousness, loss of

energy, depression, anxiety, fall, blurred vision, headache, nausea.....

So how many patients do you think that I saw didn't need a BG?

you check blood pressure, pulse and respirations on every patient, even if

they don't have a history of hypertension, irregular heart beat or lung

problems...

the triage nurses ask about safety at home (including questions designed to

identify abuse)...won't that also increase the cost of health care by

identifying people who need social service intervention?

There are good arguments about using a blood glucose as a screening tool to

identify folks who need further evaluation for diabetes....in order to

catch them earlier, before significant end organ damage is done, which *will*

ultimately reduce the cost of health care in most of those folks.

I'd have to see a better argument than the one you have advanced, Mr.

before I condemned Ms. Woods' idea.

I will admit that I was a bit unusual, being a physician who 'came up

through the ranks' and actually tended to listen to the reports of the Basics

and Medics (many of whom I helped train in my early career) that I worked

with.

That being said, even someone who 'felt normal' but had a field BG of 500

would deserve at least a referral for follow up after evaluation in the

ED....and even someone who 'feels normal,' but has a BG that high should be

considered for transport.

ck

[Guest guest]

that is the most common measurement, which reflects the average BG level

over approx 60 days....care to offer a reason why that length of time? What

is another measurement, that is accurate over a span of 2 to 3 weeks?

and what is the mechanism of the injury?

ck

In a message dated 08/31/10 20:45:59 Central Daylight Time,

amwoods8644@... writes:

Glycation of hemoglobin, as measured by HbA1c (glycated hemoglobin) levels.

HbA1c basically reflects the average blood glucose level of the patient.

(During the normal lifespan of a red blood cell, if it is exposed to higher

than normal levels of glucose, it will become glycated, and so levels of

glycated hemoglobin in patients with poorly controlled diabetes are

significantly higher than those in euglycemic patients.)

The ADA has A1c greater than or equal to 6.5% as a diagnostic factor for

diabetes.

Close?

Alyssa Woods, NREMT-B

CPR Instructor

>

>

> make that *all systems* at a cellular level..

>

> for a gold star, what is the mechanism of the injury, and how do we

measure

>

> it?

>

> ck

>

>

> In a message dated 08/31/10 19:55:13 Central Daylight Time,

> amwoods8644@... writes:

>

> Because ultimately, the patient doesn't have to feel the damage as it's

> being done to their cardiovascular system on the cellular level.

>

> [Non-text portions of this message have been removed]

>

>

>

[Non-text portions of this message have been removed]

------------------------------------

Yahoo! Groups Links

[Guest guest]

Not only does it add a significant workload to the medics, but it adds to

the patient's bill, and causes them " emotional distress " . ...Hey, I think I

hear the world's smallest violin playing!

And if you don't mind my asking, did they use a different (more accurate)

method for determination of blood glucose levels with these studies you're

referencing? If not, how did they prove that samples from capillary versus

samples from venous measurements were skewed due to an actual difference in

blood glucose as opposed to being due simply to the machine's error margin

(I know many of the glucometers we use in the field have been accused of

being inaccurate)? Or is it simply because of a difference in the

composition of the blood? Or due to sample contamination from something on

the person's skin?

Alyssa Woods, NREMT-B

CPR Instructor

>

>

> While I don't recall it ever being mandated by protocol, it has always been

> my practice to do a D-stick on every patient unless emergency interventions

> and time prevented it. I recognize that sometimes your hands are so full

> just keeping the patient alive with airway and other mandatory interventions

> that you don't have enough hands to do it. But even in codes, I have always

> tried to do it if there is enough personpower. We don't hear much about

> hypoglycemia's role in cardiac arrest, but I have had some patients who

> arrested and were seriously hypoglycemic. Also hyperglycemic.

>

> Over the years I have found numerous undiagnosed diabetics who presented

> with totally unrelated conditions.

>

> I think it should be a component of baseline vital signs, along with

> temperature, but many medics and services probably will not see it that way.

> After all, it adds a significant workload to the medics (sarcasm font in

> operation).

>

> One thing to remember is that most of the BGL devices used in prehospital

> medicine are designed to be used with capillary samples, not venous samples.

> While many have the practice of using blood from the catheter to do the BGL,

> studies have shown significant differences in reports when venous blood is

> used. There is some evidence that venous stasis due to tourniquet effect

> will skew the results. The differences can be as little as 5 mg/dL to 20

> mg/dL.

>

> There has, over the last few days, been a thread on one of the other EMS

> lists about this, and a number of studies have been cited confirming these

> differences.

>

> Mr. Bledson and Mr. Grady are both on record as opposing the use of venous

> samples for BGL. A finger stick is still the best and most accurate way with

> the devices we use in the field.

>

> Other opinions welcome.

>

> Gene Gandy, JD, LP, NREMT-P

> PERCOM EMS Education

> Tucson

>

>

> D-Sticks As A Baseline Vital Sign

>

> Does anyone know of an ambulance service or first responder organization

> which

> currently has in its protocol that a blood glucose test should be a part of

> the

> set of baseline vital signs on all patients?

>

> If you do and you could contact me off-list, I would appreciate it.

>

> Thank you,

>

> Alyssa Woods, NREMT-B

> CPR Instructor

>

>

>

[Guest guest]

checked Wiki, did you? those are some pretty good articles on the subject.

Medscape has others, with more clinical detail.

since the enzymatic attachment is often called 'glycosylation,' there is a

push to call this action glycation.

What happens is that there is a non enzymatic attachment of glucose,

fructose or one of several other 'reducing sugars' to any of several amino acid

groups that is affected by the 'area under the curve' of the glucose

concentration in the blood, intracellular or interstial fluid. The average

levels

of glycated proteins is therefore directly related to the concentration of

the sugar and the length of time that concentration is maintained, and

inversely related to the turn over time of the protein involved.

ck

In a message dated 08/31/10 21:16:37 Central Daylight Time,

amwoods8644@... writes:

Well, some argue that HbA1c is only accurate for approximately the past 4

weeks, while others argue 4 weeks to 3 months. The reasoning is the red

blood cell's lifespan of 60-120 days. It's heavily weighted towards the 60

day mark, because at 120 most of the RBCs have already expired.

Are you speaking of Advanced Glycation End product and it's stimulation of

cytokine release, role in the inflammatory response, and ultimate positive

feedback loop resulting increasingly high levels of kidney damage?

And I assume you're talking about the alternative fructosamine test, which

measures the product of fructose and ammonia or carbonyl glucose and an

amino acid chain reacting. It's measured as glycated albumin, and as far as

I understand, is only used when there's been a recent change in diet or as

a

way to test for gestational diabetes.

Closer?

Alyssa Woods, NREMT-B

CPR Instructor

>

>

> that is the most common measurement, which reflects the average BG level

> over approx 60 days....care to offer a reason why that length of time?

What

>

> is another measurement, that is accurate over a span of 2 to 3 weeks?

>

> and what is the mechanism of the injury?

>

> ck

>

>

> In a message dated 08/31/10 20:45:59 Central Daylight Time,

> amwoods8644@... writes:

>

> Glycation of hemoglobin, as measured by HbA1c (glycated hemoglobin)

levels.

>

> HbA1c basically reflects the average blood glucose level of the patient.

>

> (During the normal lifespan of a red blood cell, if it is exposed to

higher

> than normal levels of glucose, it will become glycated, and so levels of

> glycated hemoglobin in patients with poorly controlled diabetes are

> significantly higher than those in euglycemic patients.)

>

> The ADA has A1c greater than or equal to 6.5% as a diagnostic factor for

> diabetes.

>

> Close?

>

> Alyssa Woods, NREMT-B

> CPR Instructor

> (210) 842-6428

>

> On Tue, Aug 31, 2010 at 8:09 PM, krin135@... >

> wrote:

>

> >

> >

> > make that *all systems* at a cellular level..

> >

> > for a gold star, what is the mechanism of the injury, and how do we

> measure

> >

> > it?

> >

> > ck

> >

> >

> > In a message dated 08/31/10 19:55:13 Central Daylight Time,

> > amwoods8644@...

> writes:

> >

> > Because ultimately, the patient doesn't have to feel the damage as it's

> > being done to their cardiovascular system on the cellular level.

> >

> > [Non-text portions of this message have been removed]

> >

> >

> >

>

> [Non-text portions of this message have been removed]

>

> ------------------------------------

>

>

[Guest guest]

Strawman argument, Rob- for starters, Pap smears are indicated for far more

things that just female reproductive health, including some conditions in

the male. Additionally, they are generally *much* more expensive and time

consuming than a BG, AND have a much more limited utility in health care in

general.

ck

In a message dated 08/31/10 21:18:15 Central Daylight Time,

rob.davis@... writes:

Agreed. That's why I do a Pap Smear on all patients, regardless of

presentation. The patients in Oak Lawn seemed to really appreciate my extra

effort.

[Guest guest]

Strawman argument, Rob- for starters, Pap smears are indicated for far more

things that just female reproductive health, including some conditions in

the male. Additionally, they are generally *much* more expensive and time

consuming than a BG, AND have a much more limited utility in health care in

general.

ck

In a message dated 08/31/10 21:18:15 Central Daylight Time,

rob.davis@... writes:

Agreed. That's why I do a Pap Smear on all patients, regardless of

presentation. The patients in Oak Lawn seemed to really appreciate my extra

effort.

[Guest guest]

Well Gene I would have to agree with your practices since I have pretty much

subscribed to the same thought process. But hey, what do we know huh??????

Lee

________________________________________

From: texasems-l [texasems-l ] On Behalf Of

Alyssa Woods [amwoods8644@...]

Sent: Tuesday, August 31, 2010 5:11 PM

To: texasems-l

Subject: Re: D-Sticks As A Baseline Vital Sign

Not only does it add a significant workload to the medics, but it adds to

the patient's bill, and causes them " emotional distress " . ...Hey, I think I

hear the world's smallest violin playing!

And if you don't mind my asking, did they use a different (more accurate)

method for determination of blood glucose levels with these studies you're

referencing? If not, how did they prove that samples from capillary versus

samples from venous measurements were skewed due to an actual difference in

blood glucose as opposed to being due simply to the machine's error margin

(I know many of the glucometers we use in the field have been accused of

being inaccurate)? Or is it simply because of a difference in the

composition of the blood? Or due to sample contamination from something on

the person's skin?

Alyssa Woods, NREMT-B

CPR Instructor

>

>

> While I don't recall it ever being mandated by protocol, it has always been

> my practice to do a D-stick on every patient unless emergency interventions

> and time prevented it. I recognize that sometimes your hands are so full

> just keeping the patient alive with airway and other mandatory interventions

> that you don't have enough hands to do it. But even in codes, I have always

> tried to do it if there is enough personpower. We don't hear much about

> hypoglycemia's role in cardiac arrest, but I have had some patients who

> arrested and were seriously hypoglycemic. Also hyperglycemic.

>

> Over the years I have found numerous undiagnosed diabetics who presented

> with totally unrelated conditions.

>

> I think it should be a component of baseline vital signs, along with

> temperature, but many medics and services probably will not see it that way.

> After all, it adds a significant workload to the medics (sarcasm font in

> operation).

>

> One thing to remember is that most of the BGL devices used in prehospital

> medicine are designed to be used with capillary samples, not venous samples.

> While many have the practice of using blood from the catheter to do the BGL,

> studies have shown significant differences in reports when venous blood is

> used. There is some evidence that venous stasis due to tourniquet effect

> will skew the results. The differences can be as little as 5 mg/dL to 20

> mg/dL.

>

> There has, over the last few days, been a thread on one of the other EMS

> lists about this, and a number of studies have been cited confirming these

> differences.

>

> Mr. Bledson and Mr. Grady are both on record as opposing the use of venous

> samples for BGL. A finger stick is still the best and most accurate way with

> the devices we use in the field.

>

> Other opinions welcome.

>

> Gene Gandy, JD, LP, NREMT-P

> PERCOM EMS Education

> Tucson

>

>

> D-Sticks As A Baseline Vital Sign

>

> Does anyone know of an ambulance service or first responder organization

> which

> currently has in its protocol that a blood glucose test should be a part of

> the

> set of baseline vital signs on all patients?

>

> If you do and you could contact me off-list, I would appreciate it.

>

> Thank you,

>

> Alyssa Woods, NREMT-B

> CPR Instructor

>

>

>

[Guest guest]

in line at @@@

In a message dated 08/31/10 21:56:17 Central Daylight Time,

rob.davis@... writes:

On Tuesday, August 31, 2010 21:28, krin135@... said:

> Strawman argument, Rob- for starters, Pap smears are indicated for far

more

> things that just female reproductive health, including some conditions

in

> the male.

Well, being primarily in paediatrics, I certainly can't claim any

particular expertise in Pap Smears, so I'll give that one to you. However, I

was

specifically referring to male patients with my Oak Lawn reference. It's a

Dallas thing.

@@@ok..when I think of Oak Lawn, I think of either a marble orchard or a

psych hospital

But I would disagree that it is a straw man argument. There are just way

too many things we " could " be testing for that we don't, and won't be. How

about a rapid strep for every cough, fever or headache? What the heck, we

know it didn't cause the gunshot wound, but we should still hit them with

IV cephalosporins just in case, right? Head injuries? Burr holes for

everyone. You just can't be too careful!

@@@actually, those are all good examples of overkill. Again, you are

missing the price/performance problems. I also spent quite a bit of time in

rural primary care before moving to full time ED work....and got high ratings

for my percentages of preventive med efforts (Pap smears, prostate checks,

fecal occult blood, flu/pneumonia shots, etc.), so I have a fair appreciation

for the comparison.

Yes, there IS a point where it simply becomes silly to poke our patients

full of holes for every test known to man, just because we can. And, in

fact, if you are in private practice, and depending on insurance payments to

stay in the black, you learn that lesson very quickly, and sometimes

painfully. That's assuming your senior residents didn't already beat it into

you

years earlier.

Rob

@@@ I actually lost a job because I refused to substitute laboratory and

imaging for a careful history and hands on physical exam.

@@@ And I was in the business long enough to have had the advantage of

having professors and preceptors who had been 'raised' before the advent of

modern imaging and lab work, or even Medicare payments.

ck

------------------------------------

Yahoo! Groups Links

[Guest guest]

in line at @@@

In a message dated 08/31/10 21:56:17 Central Daylight Time,

rob.davis@... writes:

On Tuesday, August 31, 2010 21:28, krin135@... said:

> Strawman argument, Rob- for starters, Pap smears are indicated for far

more

> things that just female reproductive health, including some conditions

in

> the male.

Well, being primarily in paediatrics, I certainly can't claim any

particular expertise in Pap Smears, so I'll give that one to you. However, I

was

specifically referring to male patients with my Oak Lawn reference. It's a

Dallas thing.

@@@ok..when I think of Oak Lawn, I think of either a marble orchard or a

psych hospital

But I would disagree that it is a straw man argument. There are just way

too many things we " could " be testing for that we don't, and won't be. How

about a rapid strep for every cough, fever or headache? What the heck, we

know it didn't cause the gunshot wound, but we should still hit them with

IV cephalosporins just in case, right? Head injuries? Burr holes for

everyone. You just can't be too careful!

@@@actually, those are all good examples of overkill. Again, you are

missing the price/performance problems. I also spent quite a bit of time in

rural primary care before moving to full time ED work....and got high ratings

for my percentages of preventive med efforts (Pap smears, prostate checks,

fecal occult blood, flu/pneumonia shots, etc.), so I have a fair appreciation

for the comparison.

Yes, there IS a point where it simply becomes silly to poke our patients

full of holes for every test known to man, just because we can. And, in

fact, if you are in private practice, and depending on insurance payments to

stay in the black, you learn that lesson very quickly, and sometimes

painfully. That's assuming your senior residents didn't already beat it into

you

years earlier.

Rob

@@@ I actually lost a job because I refused to substitute laboratory and

imaging for a careful history and hands on physical exam.

@@@ And I was in the business long enough to have had the advantage of

having professors and preceptors who had been 'raised' before the advent of

modern imaging and lab work, or even Medicare payments.

ck

------------------------------------

Yahoo! Groups Links

[Guest guest]

This was a good question. I work now where a d-stick is part of our

baseline and have worked for others where they almost cringe when you take

one.and it was for a syncopal episode.

I like it as a baseline.

From: texasems-l [mailto:texasems-l ] On

Behalf Of Lee

Sent: Tuesday, August 31, 2010 5:35 PM

To: texasems-l

Subject: RE: D-Sticks As A Baseline Vital Sign

Well Gene I would have to agree with your practices since I have pretty much

subscribed to the same thought process. But hey, what do we know huh??????

Lee

________________________________________

From: texasems-l

[texasems-l ] On

Behalf Of Alyssa Woods [amwoods8644@...

]

Sent: Tuesday, August 31, 2010 5:11 PM

To: texasems-l

Subject: Re: D-Sticks As A Baseline Vital Sign

Not only does it add a significant workload to the medics, but it adds to

the patient's bill, and causes them " emotional distress " . ...Hey, I think I

hear the world's smallest violin playing!

And if you don't mind my asking, did they use a different (more accurate)

method for determination of blood glucose levels with these studies you're

referencing? If not, how did they prove that samples from capillary versus

samples from venous measurements were skewed due to an actual difference in

blood glucose as opposed to being due simply to the machine's error margin

(I know many of the glucometers we use in the field have been accused of

being inaccurate)? Or is it simply because of a difference in the

composition of the blood? Or due to sample contamination from something on

the person's skin?

Alyssa Woods, NREMT-B

CPR Instructor

On Tue, Aug 31, 2010 at 12:55 AM, wegandy1938@...

> wrote:

>

>

> While I don't recall it ever being mandated by protocol, it has always

been

> my practice to do a D-stick on every patient unless emergency

interventions

> and time prevented it. I recognize that sometimes your hands are so full

> just keeping the patient alive with airway and other mandatory

interventions

> that you don't have enough hands to do it. But even in codes, I have

always

> tried to do it if there is enough personpower. We don't hear much about

> hypoglycemia's role in cardiac arrest, but I have had some patients who

> arrested and were seriously hypoglycemic. Also hyperglycemic.

>

> Over the years I have found numerous undiagnosed diabetics who presented

> with totally unrelated conditions.

>

> I think it should be a component of baseline vital signs, along with

> temperature, but many medics and services probably will not see it that

way.

> After all, it adds a significant workload to the medics (sarcasm font in

> operation).

>

> One thing to remember is that most of the BGL devices used in prehospital

> medicine are designed to be used with capillary samples, not venous

samples.

> While many have the practice of using blood from the catheter to do the

BGL,

> studies have shown significant differences in reports when venous blood is

> used. There is some evidence that venous stasis due to tourniquet effect

> will skew the results. The differences can be as little as 5 mg/dL to 20

> mg/dL.

>

> There has, over the last few days, been a thread on one of the other EMS

> lists about this, and a number of studies have been cited confirming these

> differences.

>

> Mr. Bledson and Mr. Grady are both on record as opposing the use of venous

> samples for BGL. A finger stick is still the best and most accurate way

with

> the devices we use in the field.

>

> Other opinions welcome.

>

> Gene Gandy, JD, LP, NREMT-P

> PERCOM EMS Education

> Tucson

>

>

> D-Sticks As A Baseline Vital Sign

>

> Does anyone know of an ambulance service or first responder organization

> which

> currently has in its protocol that a blood glucose test should be a part

of

> the

> set of baseline vital signs on all patients?

>

> If you do and you could contact me off-list, I would appreciate it.

>

> Thank you,

>

> Alyssa Woods, NREMT-B

> CPR Instructor

>

>

>

[Guest guest]

This was a good question. I work now where a d-stick is part of our

baseline and have worked for others where they almost cringe when you take

one.and it was for a syncopal episode.

I like it as a baseline.

From: texasems-l [mailto:texasems-l ] On

Behalf Of Lee

Sent: Tuesday, August 31, 2010 5:35 PM

To: texasems-l

Subject: RE: D-Sticks As A Baseline Vital Sign

Well Gene I would have to agree with your practices since I have pretty much

subscribed to the same thought process. But hey, what do we know huh??????

Lee

________________________________________

From: texasems-l

[texasems-l ] On

Behalf Of Alyssa Woods [amwoods8644@...

]

Sent: Tuesday, August 31, 2010 5:11 PM

To: texasems-l

Subject: Re: D-Sticks As A Baseline Vital Sign

Not only does it add a significant workload to the medics, but it adds to

the patient's bill, and causes them " emotional distress " . ...Hey, I think I

hear the world's smallest violin playing!

And if you don't mind my asking, did they use a different (more accurate)

method for determination of blood glucose levels with these studies you're

referencing? If not, how did they prove that samples from capillary versus

samples from venous measurements were skewed due to an actual difference in

blood glucose as opposed to being due simply to the machine's error margin

(I know many of the glucometers we use in the field have been accused of

being inaccurate)? Or is it simply because of a difference in the

composition of the blood? Or due to sample contamination from something on

the person's skin?

Alyssa Woods, NREMT-B

CPR Instructor

On Tue, Aug 31, 2010 at 12:55 AM, wegandy1938@...

> wrote:

>

>

> While I don't recall it ever being mandated by protocol, it has always

been

> my practice to do a D-stick on every patient unless emergency

interventions

> and time prevented it. I recognize that sometimes your hands are so full

> just keeping the patient alive with airway and other mandatory

interventions

> that you don't have enough hands to do it. But even in codes, I have

always

> tried to do it if there is enough personpower. We don't hear much about

> hypoglycemia's role in cardiac arrest, but I have had some patients who

> arrested and were seriously hypoglycemic. Also hyperglycemic.

>

> Over the years I have found numerous undiagnosed diabetics who presented

> with totally unrelated conditions.

>

> I think it should be a component of baseline vital signs, along with

> temperature, but many medics and services probably will not see it that

way.

> After all, it adds a significant workload to the medics (sarcasm font in

> operation).

>

> One thing to remember is that most of the BGL devices used in prehospital

> medicine are designed to be used with capillary samples, not venous

samples.

> While many have the practice of using blood from the catheter to do the

BGL,

> studies have shown significant differences in reports when venous blood is

> used. There is some evidence that venous stasis due to tourniquet effect

> will skew the results. The differences can be as little as 5 mg/dL to 20

> mg/dL.

>

> There has, over the last few days, been a thread on one of the other EMS

> lists about this, and a number of studies have been cited confirming these

> differences.

>

> Mr. Bledson and Mr. Grady are both on record as opposing the use of venous

> samples for BGL. A finger stick is still the best and most accurate way

with

> the devices we use in the field.

>

> Other opinions welcome.

>

> Gene Gandy, JD, LP, NREMT-P

> PERCOM EMS Education

> Tucson

>

>

> D-Sticks As A Baseline Vital Sign

>

> Does anyone know of an ambulance service or first responder organization

> which

> currently has in its protocol that a blood glucose test should be a part

of

> the

> set of baseline vital signs on all patients?

>

> If you do and you could contact me off-list, I would appreciate it.

>

> Thank you,

>

> Alyssa Woods, NREMT-B

> CPR Instructor

>

>

>

[Guest guest]

On Monday, August 30, 2010 23:35, " shannon beltran " angelzwings2000@...>

said:

>

>  I have never seen it as a baseline vital but it is done frequently at the

> service I work for. Esp. if we are going to start an IV or for calls about

> weakness or AMS. It never hurts to do one

I completely agree with Gene on this one. It is good practice in performing a

full patient exam, and can keep complacent medics from getting too

tunnel-visioned. However, that said, I do have to say that I HAVE seen it

" hurt " to do one.

Anytime you start cooking by the book, and just performing a procedure " because

we can " , you eventually start ending up with unintended, negative consequences.

Most medics never see or hear of the consequences of their actions, because they

never see or hear anything about that patient after they leave the ER. For

those of us who see the patients on a longer term, it never surprises us how

many of the people who the medics slammed D50 through a small peripheral IV on,

just because they thought the BGL might possibly be somewhat borderline (even

though there was no AMS), end up with a long term thrombophlebitis, sometimes

even septic. That's a pretty harsh price to pay for a D50 you didn't even need

for your sprained ankle to begin with.

Unfortunately, assessments by the numbers leads to cooking by the numbers, with

little to no consideration to the patient's actual status and needs. So, for

that reason, it is exceptionally important to teach that, even though you are

evaluating the BGL as a matter of routine, you should not necessarily react as a

matter of routine. And that is a lot easier said than done.

Rob

[Guest guest]

On Monday, August 30, 2010 23:35, " shannon beltran " angelzwings2000@...>

said:

>

>  I have never seen it as a baseline vital but it is done frequently at the

> service I work for. Esp. if we are going to start an IV or for calls about

> weakness or AMS. It never hurts to do one

I completely agree with Gene on this one. It is good practice in performing a

full patient exam, and can keep complacent medics from getting too

tunnel-visioned. However, that said, I do have to say that I HAVE seen it

" hurt " to do one.

Anytime you start cooking by the book, and just performing a procedure " because

we can " , you eventually start ending up with unintended, negative consequences.

Most medics never see or hear of the consequences of their actions, because they

never see or hear anything about that patient after they leave the ER. For

those of us who see the patients on a longer term, it never surprises us how

many of the people who the medics slammed D50 through a small peripheral IV on,

just because they thought the BGL might possibly be somewhat borderline (even

though there was no AMS), end up with a long term thrombophlebitis, sometimes

even septic. That's a pretty harsh price to pay for a D50 you didn't even need

for your sprained ankle to begin with.

Unfortunately, assessments by the numbers leads to cooking by the numbers, with

little to no consideration to the patient's actual status and needs. So, for

that reason, it is exceptionally important to teach that, even though you are

evaluating the BGL as a matter of routine, you should not necessarily react as a

matter of routine. And that is a lot easier said than done.

Rob

[Guest guest]

Yes, but sometimes you can't just go off of how the patient feels. If a

person has a chronically high blood glucose (let's go with 500 or

thereabouts), it IS still damaging them, despite the fact that they may feel

fine. Now, admittedly, that is something that a physician should treat, not

a field medic, but let's not get it twisted and say that that patient is

fine.

And how can you fully determine that it's an unrelated issue? What if they

broke their ankle because they were dizzy because of hypoglycemia? If they

wrecked because they were hyperglycemic? If that panic attack in that 11

year old girl is really DKA caused by juvenile onset diabetes?

Even if you CAN determine that there is NO POSSIBLE WAY that the chief

complaint is related, it can cause complications of their

chief complaint. (Hyperglycemia in the critically ill has been linked to an

increased mortality rate, length of ICU stay, and risk of infection.) And

according to some figures, 2/3 of people presenting to the ER have an

abnormal BGL reading with no history of diabetes - ie, stress induced

hyperglycemia.

I think that overall, it's a good idea to take a blood glucose on a patient.

I think it's also probably a good idea to have a competent person treat the

patient for a blood glucose which is abnormal which it is within their

protocol and scope to treat.

Because ultimately, the patient doesn't have to feel the damage as it's

being done to their cardiovascular system on the cellular level.

Alyssa Woods, NREMT-B

CPR Instructor

On Tue, Aug 31, 2010 at 7:00 PM, rob.davis@... <

rob.davis@...> wrote:

>

>

> On Monday, August 30, 2010 23:35, " shannon beltran " <

> angelzwings2000@... > said:

>

> >

> > I have never seen it as a baseline vital but it is done frequently at

> the

> > service I work for. Esp. if we are going to start an IV or for calls

> about

> > weakness or AMS. It never hurts to do one

>

> I completely agree with Gene on this one. It is good practice in performing

> a full patient exam, and can keep complacent medics from getting too

> tunnel-visioned. However, that said, I do have to say that I HAVE seen it

> " hurt " to do one.

>

> Anytime you start cooking by the book, and just performing a procedure

> " because we can " , you eventually start ending up with unintended, negative

> consequences. Most medics never see or hear of the consequences of their

> actions, because they never see or hear anything about that patient after

> they leave the ER. For those of us who see the patients on a longer term, it

> never surprises us how many of the people who the medics slammed D50 through

> a small peripheral IV on, just because they thought the BGL might possibly

> be somewhat borderline (even though there was no AMS), end up with a long

> term thrombophlebitis, sometimes even septic. That's a pretty harsh price to

> pay for a D50 you didn't even need for your sprained ankle to begin with.

>

> Unfortunately, assessments by the numbers leads to cooking by the numbers,

> with little to no consideration to the patient's actual status and needs.

> So, for that reason, it is exceptionally important to teach that, even

> though you are evaluating the BGL as a matter of routine, you should not

> necessarily react as a matter of routine. And that is a lot easier said than

> done.

>

> Rob

>

>

>

[Guest guest]

Using your logic every time someone seeks medical care the care provider should

run every diagnostic test available just in case they have some process that may

or may not be related to the chief complaint. That should reduce the cost of

health care nicely.

You should treat the patient based on recognized standard of care as dictated by

the chief complaint. And say you do find a normally responding patient with a

BGL of 500. What are you going to do about it Alyssa? It's not your job to

diagnose the worlds ills. Even Internal Medicine docs don't run every test every

time.

Rick

Sent via Blackberry

Re: D-Sticks As A Baseline Vital Sign

Yes, but sometimes you can't just go off of how the patient feels. If a

person has a chronically high blood glucose (let's go with 500 or

thereabouts), it IS still damaging them, despite the fact that they may feel

fine. Now, admittedly, that is something that a physician should treat, not

a field medic, but let's not get it twisted and say that that patient is

fine.

And how can you fully determine that it's an unrelated issue? What if they

broke their ankle because they were dizzy because of hypoglycemia? If they

wrecked because they were hyperglycemic? If that panic attack in that 11

year old girl is really DKA caused by juvenile onset diabetes?

Even if you CAN determine that there is NO POSSIBLE WAY that the chief

complaint is related, it can cause complications of their

chief complaint. (Hyperglycemia in the critically ill has been linked to an

increased mortality rate, length of ICU stay, and risk of infection.) And

according to some figures, 2/3 of people presenting to the ER have an

abnormal BGL reading with no history of diabetes - ie, stress induced

hyperglycemia.

I think that overall, it's a good idea to take a blood glucose on a patient.

I think it's also probably a good idea to have a competent person treat the

patient for a blood glucose which is abnormal which it is within their

protocol and scope to treat.

Because ultimately, the patient doesn't have to feel the damage as it's

being done to their cardiovascular system on the cellular level.

Alyssa Woods, NREMT-B

CPR Instructor

On Tue, Aug 31, 2010 at 7:00 PM, rob.davis@... <

rob.davis@...> wrote:

>

>

> On Monday, August 30, 2010 23:35, " shannon beltran " <

> angelzwings2000@... > said:

>

> >

> > I have never seen it as a baseline vital but it is done frequently at

> the

> > service I work for. Esp. if we are going to start an IV or for calls

> about

> > weakness or AMS. It never hurts to do one

>

> I completely agree with Gene on this one. It is good practice in performing

> a full patient exam, and can keep complacent medics from getting too

> tunnel-visioned. However, that said, I do have to say that I HAVE seen it

> " hurt " to do one.

>

> Anytime you start cooking by the book, and just performing a procedure

> " because we can " , you eventually start ending up with unintended, negative

> consequences. Most medics never see or hear of the consequences of their

> actions, because they never see or hear anything about that patient after

> they leave the ER. For those of us who see the patients on a longer term, it

> never surprises us how many of the people who the medics slammed D50 through

> a small peripheral IV on, just because they thought the BGL might possibly

> be somewhat borderline (even though there was no AMS), end up with a long

> term thrombophlebitis, sometimes even septic. That's a pretty harsh price to

> pay for a D50 you didn't even need for your sprained ankle to begin with.

>

> Unfortunately, assessments by the numbers leads to cooking by the numbers,

> with little to no consideration to the patient's actual status and needs.

> So, for that reason, it is exceptionally important to teach that, even

> though you are evaluating the BGL as a matter of routine, you should not

> necessarily react as a matter of routine. And that is a lot easier said than

> done.

>

> Rob

>

>

>

[Guest guest]

Glycation of hemoglobin, as measured by HbA1c (glycated hemoglobin) levels.

HbA1c basically reflects the average blood glucose level of the patient.

(During the normal lifespan of a red blood cell, if it is exposed to higher

than normal levels of glucose, it will become glycated, and so levels of

glycated hemoglobin in patients with poorly controlled diabetes are

significantly higher than those in euglycemic patients.)

The ADA has A1c greater than or equal to 6.5% as a diagnostic factor for

diabetes.

Close?

Alyssa Woods, NREMT-B

CPR Instructor

>

>

> make that *all systems* at a cellular level..

>

> for a gold star, what is the mechanism of the injury, and how do we measure

>

> it?

>

> ck

>

>

> In a message dated 08/31/10 19:55:13 Central Daylight Time,

> amwoods8644@... writes:

>

> Because ultimately, the patient doesn't have to feel the damage as it's

> being done to their cardiovascular system on the cellular level.

>

>

[Guest guest]

Glycation of hemoglobin, as measured by HbA1c (glycated hemoglobin) levels.

HbA1c basically reflects the average blood glucose level of the patient.

(During the normal lifespan of a red blood cell, if it is exposed to higher

than normal levels of glucose, it will become glycated, and so levels of

glycated hemoglobin in patients with poorly controlled diabetes are

significantly higher than those in euglycemic patients.)

The ADA has A1c greater than or equal to 6.5% as a diagnostic factor for

diabetes.

Close?

Alyssa Woods, NREMT-B

CPR Instructor

>

>

> make that *all systems* at a cellular level..

>

> for a gold star, what is the mechanism of the injury, and how do we measure

>

> it?

>

> ck

>

>

> In a message dated 08/31/10 19:55:13 Central Daylight Time,

> amwoods8644@... writes:

>

> Because ultimately, the patient doesn't have to feel the damage as it's

> being done to their cardiovascular system on the cellular level.

>

>

[Guest guest]

Well, some argue that HbA1c is only accurate for approximately the past 4

weeks, while others argue 4 weeks to 3 months. The reasoning is the red

blood cell's lifespan of 60-120 days. It's heavily weighted towards the 60

day mark, because at 120 most of the RBCs have already expired.

Are you speaking of Advanced Glycation End product and it's stimulation of

cytokine release, role in the inflammatory response, and ultimate positive

feedback loop resulting increasingly high levels of kidney damage?

And I assume you're talking about the alternative fructosamine test, which

measures the product of fructose and ammonia or carbonyl glucose and an

amino acid chain reacting. It's measured as glycated albumin, and as far as

I understand, is only used when there's been a recent change in diet or as a

way to test for gestational diabetes.

Closer?

Alyssa Woods, NREMT-B

CPR Instructor

>

>

> that is the most common measurement, which reflects the average BG level

> over approx 60 days....care to offer a reason why that length of time? What

>

> is another measurement, that is accurate over a span of 2 to 3 weeks?

>

> and what is the mechanism of the injury?

>

> ck

>

>

> In a message dated 08/31/10 20:45:59 Central Daylight Time,

> amwoods8644@... writes:

>

> Glycation of hemoglobin, as measured by HbA1c (glycated hemoglobin) levels.

>

> HbA1c basically reflects the average blood glucose level of the patient.

>

> (During the normal lifespan of a red blood cell, if it is exposed to higher

> than normal levels of glucose, it will become glycated, and so levels of

> glycated hemoglobin in patients with poorly controlled diabetes are

> significantly higher than those in euglycemic patients.)

>

> The ADA has A1c greater than or equal to 6.5% as a diagnostic factor for

> diabetes.

>

> Close?

>

> Alyssa Woods, NREMT-B

> CPR Instructor

>

>

> On Tue, Aug 31, 2010 at 8:09 PM, krin135@... >

> wrote:

>

> >

> >

> > make that *all systems* at a cellular level..

> >

> > for a gold star, what is the mechanism of the injury, and how do we

> measure

> >

> > it?

> >

> > ck

> >

> >

> > In a message dated 08/31/10 19:55:13 Central Daylight Time,

> > amwoods8644@...

> writes:

> >

> > Because ultimately, the patient doesn't have to feel the damage as it's

> > being done to their cardiovascular system on the cellular level.

> >

> >

[Guest guest]

Well, some argue that HbA1c is only accurate for approximately the past 4

weeks, while others argue 4 weeks to 3 months. The reasoning is the red

blood cell's lifespan of 60-120 days. It's heavily weighted towards the 60

day mark, because at 120 most of the RBCs have already expired.

Are you speaking of Advanced Glycation End product and it's stimulation of

cytokine release, role in the inflammatory response, and ultimate positive

feedback loop resulting increasingly high levels of kidney damage?

And I assume you're talking about the alternative fructosamine test, which

measures the product of fructose and ammonia or carbonyl glucose and an

amino acid chain reacting. It's measured as glycated albumin, and as far as

I understand, is only used when there's been a recent change in diet or as a

way to test for gestational diabetes.

Closer?

Alyssa Woods, NREMT-B

CPR Instructor

>

>

> that is the most common measurement, which reflects the average BG level

> over approx 60 days....care to offer a reason why that length of time? What

>

> is another measurement, that is accurate over a span of 2 to 3 weeks?

>

> and what is the mechanism of the injury?

>

> ck

>

>

> In a message dated 08/31/10 20:45:59 Central Daylight Time,

> amwoods8644@... writes:

>

> Glycation of hemoglobin, as measured by HbA1c (glycated hemoglobin) levels.

>

> HbA1c basically reflects the average blood glucose level of the patient.

>

> (During the normal lifespan of a red blood cell, if it is exposed to higher

> than normal levels of glucose, it will become glycated, and so levels of

> glycated hemoglobin in patients with poorly controlled diabetes are

> significantly higher than those in euglycemic patients.)

>

> The ADA has A1c greater than or equal to 6.5% as a diagnostic factor for

> diabetes.

>

> Close?

>

> Alyssa Woods, NREMT-B

> CPR Instructor

>

>

> On Tue, Aug 31, 2010 at 8:09 PM, krin135@... >

> wrote:

>

> >

> >

> > make that *all systems* at a cellular level..

> >

> > for a gold star, what is the mechanism of the injury, and how do we

> measure

> >

> > it?

> >

> > ck

> >

> >

> > In a message dated 08/31/10 19:55:13 Central Daylight Time,

> > amwoods8644@...

> writes:

> >

> > Because ultimately, the patient doesn't have to feel the damage as it's

> > being done to their cardiovascular system on the cellular level.

> >

> >