RE: D-Sticks As A Baseline Vital Sign

[Guest guest]

On Tuesday, August 31, 2010 19:55, " Alyssa Woods " amwoods8644@...> said:

> 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.

It's more the people under 100 that I am worried about us harming with

unindicaated D50 slams. Although yeah, eventually some nimrod will slam D50 on

someone with a 500 BGL too, it's not a seriously regular concern.

> And how can you fully determine that it's an unrelated issue?

The same way you get to Carnegie Hall. Practice, practice, practice!

> 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.

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.

Rob

[Guest guest]

On Tuesday, August 31, 2010 19:55, " Alyssa Woods " amwoods8644@...> said:

> 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.

It's more the people under 100 that I am worried about us harming with

unindicaated D50 slams. Although yeah, eventually some nimrod will slam D50 on

someone with a 500 BGL too, it's not a seriously regular concern.

> And how can you fully determine that it's an unrelated issue?

The same way you get to Carnegie Hall. Practice, practice, practice!

> 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.

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.

Rob

[Guest guest]

So THAT'S why pap smears are a part of the Chem 7!

You know, I'd always wondered...

Alyssa Woods, NREMT-B

CPR Instructor

On Tue, Aug 31, 2010 at 9:18 PM, rob.davis@... <

rob.davis@...> wrote:

>

>

> On Tuesday, August 31, 2010 19:55, " Alyssa Woods "

amwoods8644@...>

> said:

>

> > 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.

>

> It's more the people under 100 that I am worried about us harming with

> unindicaated D50 slams. Although yeah, eventually some nimrod will slam D50

> on someone with a 500 BGL too, it's not a seriously regular concern.

>

>

> > And how can you fully determine that it's an unrelated issue?

>

> The same way you get to Carnegie Hall. Practice, practice, practice!

>

>

> > 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.

>

> 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.

>

> Rob

>

>

>

[Guest guest]

So THAT'S why pap smears are a part of the Chem 7!

You know, I'd always wondered...

Alyssa Woods, NREMT-B

CPR Instructor

On Tue, Aug 31, 2010 at 9:18 PM, rob.davis@... <

rob.davis@...> wrote:

>

>

> On Tuesday, August 31, 2010 19:55, " Alyssa Woods "

amwoods8644@...>

> said:

>

> > 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.

>

> It's more the people under 100 that I am worried about us harming with

> unindicaated D50 slams. Although yeah, eventually some nimrod will slam D50

> on someone with a 500 BGL too, it's not a seriously regular concern.

>

>

> > And how can you fully determine that it's an unrelated issue?

>

> The same way you get to Carnegie Hall. Practice, practice, practice!

>

>

> > 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.

>

> 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.

>

> Rob

>

>

>

[Guest guest]

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.

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!

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

[Guest guest]

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.

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!

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

[Guest guest]

Alyssa,

In the ED we get the glucose level as part of a basic or comprehensive

metabolic panel which the majority of our patients that are triaged yellow

(urgent) or red (emergent) will have ordered, usually as part of a triage

protocol. A finger stick is a separate test and therefore a separate

charge. The normal glucose of 70-110 is for a fasting blood test performed

first thing in the morning before eating. A 120 glucose is outside the high

norm of 110 but does not cause a concern as blood glucose fluctuates based

on when and what the patient ate or drank. I would say the 2/3 number of

people presenting have an abnormal BGL reading has to be looked at in

context. A reading of 111 is elevated and would work to substantiate the

2/3 number.

The hyperglycemic patient with a glucose above 200 is usually symptomatic.

Their initial chief complaint may be weakness, fatigue, etc. or one of the 3

Ps. A good history and physical exam along with blood work will identify if

new onset diabetes is the problem. While initial treatment and education

will start in the ED for the new onset diabetic, the patient is usually

referred to a primary care provider for further testing and treatment or

admitted, which is usually not the case.

EMS providers, which are required to receive a CLIA certificate of waiver to

perform quantitative glucose testing, normally use consumer or home testers.

The testers are calibrated for capillary blood. The waiver requirements

states you must follow the manufacturer's recommendations for performing the

test. Venous blood will cause a different reading if used in the home

machines. Several studies proved this using different study methods. One

study I remember reading had 3 different tests performed on each patient. A

finger stick was performed using a glucometer, an IV was started and venous

catheter blood was used in the same glucometer, and a sample was drawn in a

vacutainer for lab analysis. The difference between capillary and venous

blood was 20 points either way low or high in test subjects. The capillary

blood was usually close to the lab results on the vacutainer sample. In the

hyperglycemic patient 20 points either way is not a big deal as the

treatment is usually just a NS bolus. In the hypoglycemic patient 20 points

could be the difference in whether protocol requires giving or not giving

D50W (and thiamine for those of you still carrying it).

CLIA is starting to do educational " visits " (inspections) on 2% of waiver

holders each year. It will be interesting to see if EMS is visited and the

results of the visits. I hope we don't have to go back to dip sticks in the

field for glucose determinations. They don't require a waiver.

Hospital testing is governed by CLIA standards. The glucometer we use in

the hospital is calibrated for arterial, venous or capillary blood. It has

to have high and low controls performed every 12 hours. If the controls are

expired you have to run them before testing can occur. Each approved

operator receives an ID code after training and demonstrating competency on

an annual basis. Each patient has an unique ID code. The device has to be

cradled and downloaded at least once a day. I daresay most EMS providers

will not spend the money or the time to have better quality devices. In my

experience the devices are usually given to the service by the vendor or

manufacturer's sales rep. We never had to buy the glucometers. The vendor

wants to sell you the test strips which is where the vendor makes their

profit.

Randy E. , R.N., L.P.

[Guest guest]

Alyssa,

In the ED we get the glucose level as part of a basic or comprehensive

metabolic panel which the majority of our patients that are triaged yellow

(urgent) or red (emergent) will have ordered, usually as part of a triage

protocol. A finger stick is a separate test and therefore a separate

charge. The normal glucose of 70-110 is for a fasting blood test performed

first thing in the morning before eating. A 120 glucose is outside the high

norm of 110 but does not cause a concern as blood glucose fluctuates based

on when and what the patient ate or drank. I would say the 2/3 number of

people presenting have an abnormal BGL reading has to be looked at in

context. A reading of 111 is elevated and would work to substantiate the

2/3 number.

The hyperglycemic patient with a glucose above 200 is usually symptomatic.

Their initial chief complaint may be weakness, fatigue, etc. or one of the 3

Ps. A good history and physical exam along with blood work will identify if

new onset diabetes is the problem. While initial treatment and education

will start in the ED for the new onset diabetic, the patient is usually

referred to a primary care provider for further testing and treatment or

admitted, which is usually not the case.

EMS providers, which are required to receive a CLIA certificate of waiver to

perform quantitative glucose testing, normally use consumer or home testers.

The testers are calibrated for capillary blood. The waiver requirements

states you must follow the manufacturer's recommendations for performing the

test. Venous blood will cause a different reading if used in the home

machines. Several studies proved this using different study methods. One

study I remember reading had 3 different tests performed on each patient. A

finger stick was performed using a glucometer, an IV was started and venous

catheter blood was used in the same glucometer, and a sample was drawn in a

vacutainer for lab analysis. The difference between capillary and venous

blood was 20 points either way low or high in test subjects. The capillary

blood was usually close to the lab results on the vacutainer sample. In the

hyperglycemic patient 20 points either way is not a big deal as the

treatment is usually just a NS bolus. In the hypoglycemic patient 20 points

could be the difference in whether protocol requires giving or not giving

D50W (and thiamine for those of you still carrying it).

CLIA is starting to do educational " visits " (inspections) on 2% of waiver

holders each year. It will be interesting to see if EMS is visited and the

results of the visits. I hope we don't have to go back to dip sticks in the

field for glucose determinations. They don't require a waiver.

Hospital testing is governed by CLIA standards. The glucometer we use in

the hospital is calibrated for arterial, venous or capillary blood. It has

to have high and low controls performed every 12 hours. If the controls are

expired you have to run them before testing can occur. Each approved

operator receives an ID code after training and demonstrating competency on

an annual basis. Each patient has an unique ID code. The device has to be

cradled and downloaded at least once a day. I daresay most EMS providers

will not spend the money or the time to have better quality devices. In my

experience the devices are usually given to the service by the vendor or

manufacturer's sales rep. We never had to buy the glucometers. The vendor

wants to sell you the test strips which is where the vendor makes their

profit.

Randy E. , R.N., L.P.

[Guest guest]

I didn't read all the studies that were cited, but I read enough of them to see

that they compared both capillary and venous analysis from the same patients and

found significant differences when using the same analyzers.

Dr. B thinks it's because of the touniquet being applied to the arm before

starting the IV. I'm not sure about the mechanism of that, but there would be

some stasis involved.

G

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 didn't read all the studies that were cited, but I read enough of them to see

that they compared both capillary and venous analysis from the same patients and

found significant differences when using the same analyzers.

Dr. B thinks it's because of the touniquet being applied to the arm before

starting the IV. I'm not sure about the mechanism of that, but there would be

some stasis involved.

G

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]

como se dice.... " screening test " ?

no, a CLIA waivered finger stick blood sugar meter is NOT a diagnostic test

for diabetes, but it is a very good screening tool for same.

characteristics of screening tests:

low cost

ease of use

minimally invasive

reasonably accurate

low rate of false negatives

acceptable level of false positive

A finger stick BG meets those criteria if there is even a moderate rate

(say 10%) of undiagnosed/ undertreated diabetics in your service population.

And I've seen too much out of the Joint Commission in the past decade that

smacks of " Just Because We Can " to cite them as a reason to do or not to do

anything from a rational basis.

And if that stubbed toe is a result of " oh, I suddenly got dizzy, and I

still don't feel quite right " (which I have seen in the ED- turned out that

the toe was broken and the 60 something patient had suffered a TIA). I don't

recall seeing many calls for EMS from 'just' a stubbed toe....I've also

diagnosed full blown Type 1 Diabetes with (early) ketoacidosis in a 10 year

old with a severe sore throat.

ck

In a message dated 09/01/10 07:59:14 Central Daylight Time,

rick.moore@... writes:

You are comparing apples to oranges. I agree that a BG is needed on the

patients with those complaints and in the ED most will get at least a basic

metabolic panel which would include the glucose. My point is that an EMS

crew using a home BGL monitor under less than ideal conditions is not a

diagnostic test. Even in an ED where the staff listens very well to the EMS

report they will still run baseline chemistries to confirm or deny any of these

readings. To me a protocol to perform a finger stick BG on every patient

falls under the " because we can " category. In reality taking baseline vital

signs on every patient falls under the " because we have always done it that

way " doctrine, however JC and the legal community have established this as

a standard of care and they are not invasive. A triage set and then a

discharge set at a minimum has been established as the way to indicate the

patient " improved " or at least didn't deteriorate under your care. The home

safety type question

s are mandated by JC and CMS. I don't know of any regulatory or

accreditation agency that mandates random blood glucose testing.

I am not opposed to finger stick BGL's when the presentation indicates,

but to perform it on a stumped toe or sore throat because it is protocol is

inappropriate in my opinion.

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

Behalf Of krin135@...

Sent: Tuesday, August 31, 2010 8:25 PM

To: texasems-l

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

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

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

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

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

Yahoo! Groups Links

[Guest guest]

como se dice.... " screening test " ?

no, a CLIA waivered finger stick blood sugar meter is NOT a diagnostic test

for diabetes, but it is a very good screening tool for same.

characteristics of screening tests:

low cost

ease of use

minimally invasive

reasonably accurate

low rate of false negatives

acceptable level of false positive

A finger stick BG meets those criteria if there is even a moderate rate

(say 10%) of undiagnosed/ undertreated diabetics in your service population.

And I've seen too much out of the Joint Commission in the past decade that

smacks of " Just Because We Can " to cite them as a reason to do or not to do

anything from a rational basis.

And if that stubbed toe is a result of " oh, I suddenly got dizzy, and I

still don't feel quite right " (which I have seen in the ED- turned out that

the toe was broken and the 60 something patient had suffered a TIA). I don't

recall seeing many calls for EMS from 'just' a stubbed toe....I've also

diagnosed full blown Type 1 Diabetes with (early) ketoacidosis in a 10 year

old with a severe sore throat.

ck

In a message dated 09/01/10 07:59:14 Central Daylight Time,

rick.moore@... writes:

You are comparing apples to oranges. I agree that a BG is needed on the

patients with those complaints and in the ED most will get at least a basic

metabolic panel which would include the glucose. My point is that an EMS

crew using a home BGL monitor under less than ideal conditions is not a

diagnostic test. Even in an ED where the staff listens very well to the EMS

report they will still run baseline chemistries to confirm or deny any of these

readings. To me a protocol to perform a finger stick BG on every patient

falls under the " because we can " category. In reality taking baseline vital

signs on every patient falls under the " because we have always done it that

way " doctrine, however JC and the legal community have established this as

a standard of care and they are not invasive. A triage set and then a

discharge set at a minimum has been established as the way to indicate the

patient " improved " or at least didn't deteriorate under your care. The home

safety type question

s are mandated by JC and CMS. I don't know of any regulatory or

accreditation agency that mandates random blood glucose testing.

I am not opposed to finger stick BGL's when the presentation indicates,

but to perform it on a stumped toe or sore throat because it is protocol is

inappropriate in my opinion.

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

Behalf Of krin135@...

Sent: Tuesday, August 31, 2010 8:25 PM

To: texasems-l

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

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

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

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

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

Yahoo! Groups Links

[Guest guest]

Time out!

Alyssa: I think that Wes' finger was firmly in his cheek when he wrote

that.

Rick: Since Alyssa seems to have been responding to Wes, and not you, your

response is a bit beyond measured, ESPECIALLY since Alyssa has proposed a

research project evaluating the use of the FSBG as a reasonable additional

'vital sign' in a population suspected of a significant underdiagnosis of

diabetes. She's trying to replace 'best opinions' and 'dogma' with

research/science.

and anyone who knows Wes (and his apprenticeship with Mr. Grady) would

expect something like his response.

ck

In a message dated 09/01/10 08:40:58 Central Daylight Time,

rick.moore@... writes:

" But no, really - *I'm* the immature and inexperienced person here. "

If you are considering this a personal attack on you and not an attack on

the fact that we in EMS depend more on dogma than science then I would

agree with the sentence above.

Rick

Re: D-Sticks As A Baseline Vital Sign

> >

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

> > rick.moore@...

rick.moore%40stdavids.com > 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

> >

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

> >

> >

[Guest guest]

ok...I would accept that. I've had some long email conversations with

Alyssa on this subject before she broached it on the newsgroup and she's got a

good plan for the research into the subject.

And, yes, you have almost as much of a self selecting population as an

inner city one, where the local FD transports 'without cost to the patient.'

ck

In a message dated 09/01/10 08:59:54 Central Daylight Time,

rick.moore@... writes:

I think we are actually agreeing with each other and don't know it. I have

no problem with screening tests on patients that need them based on

clinical exam. My objection is an automatic finger stick just cause I called

911.

I have experienced patients transported by EMS for stubbed toes (because

they were clumsy not dizzy or weak), sore throats, migraine headaches and

medication refills. Admittedly this may be in large part to working in an

area with a University EMS that transported students for free as a benefit of

the tuition.

Rick

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

Behalf Of krin135@...

Sent: Wednesday, September 01, 2010 8:51 AM

To: texasems-l

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

como se dice.... " screening test " ?

no, a CLIA waivered finger stick blood sugar meter is NOT a diagnostic test

for diabetes, but it is a very good screening tool for same.

characteristics of screening tests:

low cost

ease of use

minimally invasive

reasonably accurate

low rate of false negatives

acceptable level of false positive

A finger stick BG meets those criteria if there is even a moderate rate

(say 10%) of undiagnosed/ undertreated diabetics in your service

population.

And I've seen too much out of the Joint Commission in the past decade that

smacks of " Just Because We Can " to cite them as a reason to do or not to do

anything from a rational basis.

And if that stubbed toe is a result of " oh, I suddenly got dizzy, and I

still don't feel quite right " (which I have seen in the ED- turned out that

the toe was broken and the 60 something patient had suffered a TIA). I

don't

recall seeing many calls for EMS from 'just' a stubbed toe....I've also

diagnosed full blown Type 1 Diabetes with (early) ketoacidosis in a 10 year

old with a severe sore throat.

ck

In a message dated 09/01/10 07:59:14 Central Daylight Time,

rick.moore@... writes:

You are comparing apples to oranges. I agree that a BG is needed on the

patients with those complaints and in the ED most will get at least a basic

metabolic panel which would include the glucose. My point is that an EMS

crew using a home BGL monitor under less than ideal conditions is not a

diagnostic test. Even in an ED where the staff listens very well to the EMS

report they will still run baseline chemistries to confirm or deny any of

these

readings. To me a protocol to perform a finger stick BG on every patient

falls under the " because we can " category. In reality taking baseline vital

signs on every patient falls under the " because we have always done it that

way " doctrine, however JC and the legal community have established this as

a standard of care and they are not invasive. A triage set and then a

discharge set at a minimum has been established as the way to indicate the

patient " improved " or at least didn't deteriorate under your care. The home

safety type question

s are mandated by JC and CMS. I don't know of any regulatory or

accreditation agency that mandates random blood glucose testing.

I am not opposed to finger stick BGL's when the presentation indicates,

but to perform it on a stumped toe or sore throat because it is protocol is

inappropriate in my opinion.

From: texasems-l

[mailto:texasems-l ] On

Behalf Of krin135@...

Sent: Tuesday, August 31, 2010 8:25 PM

To: texasems-l

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

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

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

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

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

Yahoo! Groups Links

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

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

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

Yahoo! Groups Links

[Guest guest]

ok...I would accept that. I've had some long email conversations with

Alyssa on this subject before she broached it on the newsgroup and she's got a

good plan for the research into the subject.

And, yes, you have almost as much of a self selecting population as an

inner city one, where the local FD transports 'without cost to the patient.'

ck

In a message dated 09/01/10 08:59:54 Central Daylight Time,

rick.moore@... writes:

I think we are actually agreeing with each other and don't know it. I have

no problem with screening tests on patients that need them based on

clinical exam. My objection is an automatic finger stick just cause I called

911.

I have experienced patients transported by EMS for stubbed toes (because

they were clumsy not dizzy or weak), sore throats, migraine headaches and

medication refills. Admittedly this may be in large part to working in an

area with a University EMS that transported students for free as a benefit of

the tuition.

Rick

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

Behalf Of krin135@...

Sent: Wednesday, September 01, 2010 8:51 AM

To: texasems-l

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

como se dice.... " screening test " ?

no, a CLIA waivered finger stick blood sugar meter is NOT a diagnostic test

for diabetes, but it is a very good screening tool for same.

characteristics of screening tests:

low cost

ease of use

minimally invasive

reasonably accurate

low rate of false negatives

acceptable level of false positive

A finger stick BG meets those criteria if there is even a moderate rate

(say 10%) of undiagnosed/ undertreated diabetics in your service

population.

And I've seen too much out of the Joint Commission in the past decade that

smacks of " Just Because We Can " to cite them as a reason to do or not to do

anything from a rational basis.

And if that stubbed toe is a result of " oh, I suddenly got dizzy, and I

still don't feel quite right " (which I have seen in the ED- turned out that

the toe was broken and the 60 something patient had suffered a TIA). I

don't

recall seeing many calls for EMS from 'just' a stubbed toe....I've also

diagnosed full blown Type 1 Diabetes with (early) ketoacidosis in a 10 year

old with a severe sore throat.

ck

In a message dated 09/01/10 07:59:14 Central Daylight Time,

rick.moore@... writes:

You are comparing apples to oranges. I agree that a BG is needed on the

patients with those complaints and in the ED most will get at least a basic

metabolic panel which would include the glucose. My point is that an EMS

crew using a home BGL monitor under less than ideal conditions is not a

diagnostic test. Even in an ED where the staff listens very well to the EMS

report they will still run baseline chemistries to confirm or deny any of

these

readings. To me a protocol to perform a finger stick BG on every patient

falls under the " because we can " category. In reality taking baseline vital

signs on every patient falls under the " because we have always done it that

way " doctrine, however JC and the legal community have established this as

a standard of care and they are not invasive. A triage set and then a

discharge set at a minimum has been established as the way to indicate the

patient " improved " or at least didn't deteriorate under your care. The home

safety type question

s are mandated by JC and CMS. I don't know of any regulatory or

accreditation agency that mandates random blood glucose testing.

I am not opposed to finger stick BGL's when the presentation indicates,

but to perform it on a stumped toe or sore throat because it is protocol is

inappropriate in my opinion.

From: texasems-l

[mailto:texasems-l ] On

Behalf Of krin135@...

Sent: Tuesday, August 31, 2010 8:25 PM

To: texasems-l

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

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

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

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

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

Yahoo! Groups Links

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

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

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

Yahoo! Groups Links

[Guest guest]

You are comparing apples to oranges. I agree that a BG is needed on the patients

with those complaints and in the ED most will get at least a basic metabolic

panel which would include the glucose. My point is that an EMS crew using a home

BGL monitor under less than ideal conditions is not a diagnostic test. Even in

an ED where the staff listens very well to the EMS report they will still run

baseline chemistries to confirm or deny any of these readings. To me a protocol

to perform a finger stick BG on every patient falls under the " because we can "

category. In reality taking baseline vital signs on every patient falls under

the " because we have always done it that way " doctrine, however JC and the legal

community have established this as a standard of care and they are not invasive.

A triage set and then a discharge set at a minimum has been established as the

way to indicate the patient " improved " or at least didn't deteriorate under your

care. The home safety type questions are mandated by JC and CMS. I don't know of

any regulatory or accreditation agency that mandates random blood glucose

testing.

I am not opposed to finger stick BGL's when the presentation indicates, but to

perform it on a stumped toe or sore throat because it is protocol is

inappropriate in my opinion.

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

Of krin135@...

Sent: Tuesday, August 31, 2010 8:25 PM

To: texasems-l

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

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]

You are comparing apples to oranges. I agree that a BG is needed on the patients

with those complaints and in the ED most will get at least a basic metabolic

panel which would include the glucose. My point is that an EMS crew using a home

BGL monitor under less than ideal conditions is not a diagnostic test. Even in

an ED where the staff listens very well to the EMS report they will still run

baseline chemistries to confirm or deny any of these readings. To me a protocol

to perform a finger stick BG on every patient falls under the " because we can "

category. In reality taking baseline vital signs on every patient falls under

the " because we have always done it that way " doctrine, however JC and the legal

community have established this as a standard of care and they are not invasive.

A triage set and then a discharge set at a minimum has been established as the

way to indicate the patient " improved " or at least didn't deteriorate under your

care. The home safety type questions are mandated by JC and CMS. I don't know of

any regulatory or accreditation agency that mandates random blood glucose

testing.

I am not opposed to finger stick BGL's when the presentation indicates, but to

perform it on a stumped toe or sore throat because it is protocol is

inappropriate in my opinion.

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

Of krin135@...

Sent: Tuesday, August 31, 2010 8:25 PM

To: texasems-l

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

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]

But Rick, my partner's ex-cousin's brother-in-law's preceptor had a patient once

broke both of his legs and they did a blood glucose and it was high..... so they

backboarded him then flew him to a big hospital in the helicopter and everyone

was so upset that they had to have a debriefing.

Wes

Sent from my iPad

> You are comparing apples to oranges. I agree that a BG is needed on the

patients with those complaints and in the ED most will get at least a basic

metabolic panel which would include the glucose. My point is that an EMS crew

using a home BGL monitor under less than ideal conditions is not a diagnostic

test. Even in an ED where the staff listens very well to the EMS report they

will still run baseline chemistries to confirm or deny any of these readings. To

me a protocol to perform a finger stick BG on every patient falls under the

" because we can " category. In reality taking baseline vital signs on every

patient falls under the " because we have always done it that way " doctrine,

however JC and the legal community have established this as a standard of care

and they are not invasive. A triage set and then a discharge set at a minimum

has been established as the way to indicate the patient " improved " or at least

didn't deteriorate under your care. The home safety type questions are mandated

by JC and CMS. I don't know of any regulatory or accreditation agency that

mandates random blood glucose testing.

> I am not opposed to finger stick BGL's when the presentation indicates, but to

perform it on a stumped toe or sore throat because it is protocol is

inappropriate in my opinion.

>

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

Of krin135@...

> Sent: Tuesday, August 31, 2010 8:25 PM

> To: texasems-l

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

>

> 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]

But Rick, my partner's ex-cousin's brother-in-law's preceptor had a patient once

broke both of his legs and they did a blood glucose and it was high..... so they

backboarded him then flew him to a big hospital in the helicopter and everyone

was so upset that they had to have a debriefing.

Wes

Sent from my iPad

> You are comparing apples to oranges. I agree that a BG is needed on the

patients with those complaints and in the ED most will get at least a basic

metabolic panel which would include the glucose. My point is that an EMS crew

using a home BGL monitor under less than ideal conditions is not a diagnostic

test. Even in an ED where the staff listens very well to the EMS report they

will still run baseline chemistries to confirm or deny any of these readings. To

me a protocol to perform a finger stick BG on every patient falls under the

" because we can " category. In reality taking baseline vital signs on every

patient falls under the " because we have always done it that way " doctrine,

however JC and the legal community have established this as a standard of care

and they are not invasive. A triage set and then a discharge set at a minimum

has been established as the way to indicate the patient " improved " or at least

didn't deteriorate under your care. The home safety type questions are mandated

by JC and CMS. I don't know of any regulatory or accreditation agency that

mandates random blood glucose testing.

> I am not opposed to finger stick BGL's when the presentation indicates, but to

perform it on a stumped toe or sore throat because it is protocol is

inappropriate in my opinion.

>

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

Of krin135@...

> Sent: Tuesday, August 31, 2010 8:25 PM

> To: texasems-l

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

>

> 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]

Ah, the personal attack and mockery which indicates complete lack of an

argument, or otherwise lack of the ability to hold a civilized discussion

with intelligent points on the topic.

But no, really - *I'm* the immature and inexperienced person here.

Alyssa Woods, NREMT-B

CPR Instructor

>

>

> But Rick, my partner's ex-cousin's brother-in-law's preceptor had a patient

> once broke both of his legs and they did a blood glucose and it was

> high..... so they backboarded him then flew him to a big hospital in the

> helicopter and everyone was so upset that they had to have a debriefing.

>

> Wes

>

> Sent from my iPad

>

>

> On Sep 1, 2010, at 7:59,

rick.moore@...wrote:

>

> > You are comparing apples to oranges. I agree that a BG is needed on the

> patients with those complaints and in the ED most will get at least a basic

> metabolic panel which would include the glucose. My point is that an EMS

> crew using a home BGL monitor under less than ideal conditions is not a

> diagnostic test. Even in an ED where the staff listens very well to the EMS

> report they will still run baseline chemistries to confirm or deny any of

> these readings. To me a protocol to perform a finger stick BG on every

> patient falls under the " because we can " category. In reality taking

> baseline vital signs on every patient falls under the " because we have

> always done it that way " doctrine, however JC and the legal community have

> established this as a standard of care and they are not invasive. A triage

> set and then a discharge set at a minimum has been established as the way to

> indicate the patient " improved " or at least didn't deteriorate under your

> care. The home safety type questions are mandated by JC and CMS. I don't

> know of any regulatory or accreditation agency that mandates random blood

> glucose testing.

> > I am not opposed to finger stick BGL's when the presentation indicates,

> but to perform it on a stumped toe or sore throat because it is protocol is

> inappropriate in my opinion.

> >

> > From: texasems-l [mailto:

> texasems-l ] On Behalf Of

> krin135@...

> > Sent: Tuesday, August 31, 2010 8:25 PM

> > To: texasems-l

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

> >

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

> > rick.moore@...

rick.moore%40stdavids.com > 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]

Was the debriefing before or after they found out that the glucometer had not

been calibrated in 6 months?

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

Of Wes Ogilvie

Sent: Wednesday, September 01, 2010 8:24 AM

To: texasems-l

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

But Rick, my partner's ex-cousin's brother-in-law's preceptor had a patient once

broke both of his legs and they did a blood glucose and it was high..... so they

backboarded him then flew him to a big hospital in the helicopter and everyone

was so upset that they had to have a debriefing.

Wes

Sent from my iPad

On Sep 1, 2010, at 7:59,

rick.moore@... wrote:

> You are comparing apples to oranges. I agree that a BG is needed on the

patients with those complaints and in the ED most will get at least a basic

metabolic panel which would include the glucose. My point is that an EMS crew

using a home BGL monitor under less than ideal conditions is not a diagnostic

test. Even in an ED where the staff listens very well to the EMS report they

will still run baseline chemistries to confirm or deny any of these readings. To

me a protocol to perform a finger stick BG on every patient falls under the

" because we can " category. In reality taking baseline vital signs on every

patient falls under the " because we have always done it that way " doctrine,

however JC and the legal community have established this as a standard of care

and they are not invasive. A triage set and then a discharge set at a minimum

has been established as the way to indicate the patient " improved " or at least

didn't deteriorate under your care. The home safety type questions are mandated

by JC and CMS. I don't know of any regulatory or accreditation agency that

mandates random blood glucose testing.

> I am not opposed to finger stick BGL's when the presentation indicates, but to

perform it on a stumped toe or sore throat because it is protocol is

inappropriate in my opinion.

>

> From: texasems-l

[mailto:texasems-l ] On

Behalf Of krin135@...

> Sent: Tuesday, August 31, 2010 8:25 PM

> To: texasems-l

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

>

> 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]

" But no, really - *I'm* the immature and inexperienced person here. "

If you are considering this a personal attack on you and not an attack on the

fact that we in EMS depend more on dogma than science then I would agree with

the sentence above.

Rick

Re: D-Sticks As A Baseline Vital Sign

> >

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

> > rick.moore@...

rick.moore%40stdavids.com > 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]

Touché, well played. Match point Alyssa.

Sent from my iPhone,

McGee, EMT-P, EMT-T

Ah, the personal attack and mockery which indicates complete lack of an

argument, or otherwise lack of the ability to hold a civilized discussion

with intelligent points on the topic.

But no, really - *I'm* the immature and inexperienced person here.

Alyssa Woods, NREMT-B

CPR Instructor

But Rick, my partner's ex-cousin's brother-in-law's preceptor had a patient

once broke both of his legs and they did a blood glucose and it was

high..... so they backboarded him then flew him to a big hospital in the

helicopter and everyone was so upset that they had to have a debriefing.

Wes

Sent from my iPad

On Sep 1, 2010, at 7:59,

rick.moore@...wrote:

You are comparing apples to oranges. I agree that a BG is needed on the

patients with those complaints and in the ED most will get at least a basic

metabolic panel which would include the glucose. My point is that an EMS

crew using a home BGL monitor under less than ideal conditions is not a

diagnostic test. Even in an ED where the staff listens very well to the EMS

report they will still run baseline chemistries to confirm or deny any of

these readings. To me a protocol to perform a finger stick BG on every

patient falls under the " because we can " category. In reality taking

baseline vital signs on every patient falls under the " because we have

always done it that way " doctrine, however JC and the legal community have

established this as a standard of care and they are not invasive. A triage

set and then a discharge set at a minimum has been established as the way to

indicate the patient " improved " or at least didn't deteriorate under your

care. The home safety type questions are mandated by JC and CMS. I don't

know of any regulatory or accreditation agency that mandates random blood

glucose testing.

I am not opposed to finger stick BGL's when the presentation indicates,

but to perform it on a stumped toe or sore throat because it is protocol is

inappropriate in my opinion.

From: texasems-l [mailto:

texasems-l ] On Behalf Of

krin135@...

Sent: Tuesday, August 31, 2010 8:25 PM

To: texasems-l

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

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]

I think we are actually agreeing with each other and don't know it. I have no

problem with screening tests on patients that need them based on clinical exam.

My objection is an automatic finger stick just cause I called 911. I have

experienced patients transported by EMS for stubbed toes (because they were

clumsy not dizzy or weak), sore throats, migraine headaches and medication

refills. Admittedly this may be in large part to working in an area with a

University EMS that transported students for free as a benefit of the tuition.

Rick

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

Of krin135@...

Sent: Wednesday, September 01, 2010 8:51 AM

To: texasems-l

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

como se dice.... " screening test " ?

no, a CLIA waivered finger stick blood sugar meter is NOT a diagnostic test

for diabetes, but it is a very good screening tool for same.

characteristics of screening tests:

low cost

ease of use

minimally invasive

reasonably accurate

low rate of false negatives

acceptable level of false positive

A finger stick BG meets those criteria if there is even a moderate rate

(say 10%) of undiagnosed/ undertreated diabetics in your service population.

And I've seen too much out of the Joint Commission in the past decade that

smacks of " Just Because We Can " to cite them as a reason to do or not to do

anything from a rational basis.

And if that stubbed toe is a result of " oh, I suddenly got dizzy, and I

still don't feel quite right " (which I have seen in the ED- turned out that

the toe was broken and the 60 something patient had suffered a TIA). I don't

recall seeing many calls for EMS from 'just' a stubbed toe....I've also

diagnosed full blown Type 1 Diabetes with (early) ketoacidosis in a 10 year

old with a severe sore throat.

ck

In a message dated 09/01/10 07:59:14 Central Daylight Time,

rick.moore@... writes:

You are comparing apples to oranges. I agree that a BG is needed on the

patients with those complaints and in the ED most will get at least a basic

metabolic panel which would include the glucose. My point is that an EMS

crew using a home BGL monitor under less than ideal conditions is not a

diagnostic test. Even in an ED where the staff listens very well to the EMS

report they will still run baseline chemistries to confirm or deny any of these

readings. To me a protocol to perform a finger stick BG on every patient

falls under the " because we can " category. In reality taking baseline vital

signs on every patient falls under the " because we have always done it that

way " doctrine, however JC and the legal community have established this as

a standard of care and they are not invasive. A triage set and then a

discharge set at a minimum has been established as the way to indicate the

patient " improved " or at least didn't deteriorate under your care. The home

safety type question

s are mandated by JC and CMS. I don't know of any regulatory or

accreditation agency that mandates random blood glucose testing.

I am not opposed to finger stick BGL's when the presentation indicates,

but to perform it on a stumped toe or sore throat because it is protocol is

inappropriate in my opinion.

From: texasems-l

[mailto:texasems-l ] On

Behalf Of krin135@...

Sent: Tuesday, August 31, 2010 8:25 PM

To: texasems-l

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

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]

Actually, meant solely as a commentary on the urban legends of EMS.

My preference is to do a glucose check on any patient whose condition requires a

rule-out of a diabetic abnormality as part of reaching my field differential

diagnosis.

Wes

Sent from my iPad

> Touché, well played. Match point Alyssa.

>

> Sent from my iPhone,

> McGee, EMT-P, EMT-T

>

>

>

> Ah, the personal attack and mockery which indicates complete lack of an

> argument, or otherwise lack of the ability to hold a civilized discussion

> with intelligent points on the topic.

>

> But no, really - *I'm* the immature and inexperienced person here.

>

> Alyssa Woods, NREMT-B

> CPR Instructor

>

>

>

>

> But Rick, my partner's ex-cousin's brother-in-law's preceptor had a patient

> once broke both of his legs and they did a blood glucose and it was

> high..... so they backboarded him then flew him to a big hospital in the

> helicopter and everyone was so upset that they had to have a debriefing.

>

> Wes

>

> Sent from my iPad

>

> On Sep 1, 2010, at 7:59,

rick.moore@...wrote:

>

> You are comparing apples to oranges. I agree that a BG is needed on the

> patients with those complaints and in the ED most will get at least a basic

> metabolic panel which would include the glucose. My point is that an EMS

> crew using a home BGL monitor under less than ideal conditions is not a

> diagnostic test. Even in an ED where the staff listens very well to the EMS

> report they will still run baseline chemistries to confirm or deny any of

> these readings. To me a protocol to perform a finger stick BG on every

> patient falls under the " because we can " category. In reality taking

> baseline vital signs on every patient falls under the " because we have

> always done it that way " doctrine, however JC and the legal community have

> established this as a standard of care and they are not invasive. A triage

> set and then a discharge set at a minimum has been established as the way to

> indicate the patient " improved " or at least didn't deteriorate under your

> care. The home safety type questions are mandated by JC and CMS. I don't

> know of any regulatory or accreditation agency that mandates random blood

> glucose testing.

> I am not opposed to finger stick BGL's when the presentation indicates,

> but to perform it on a stumped toe or sore throat because it is protocol is

> inappropriate in my opinion.

>

> From: texasems-l [mailto:

> texasems-l ] On Behalf Of

> krin135@...

> Sent: Tuesday, August 31, 2010 8:25 PM

> To: texasems-l

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

>

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

> rick.moore@...

rick.moore%40stdavids.com > 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

>

>