In addition to their many lifesaving skills, paramedics must also have expertise in treating people with diabetes in emergency situations. For instance, about once a year 36-year-old Craig Lloyd’s sugars plunge unexpectedly into the 30s and he loses consciousness.
“The last time it happened I’d stayed up real late the night before. I tested my sugars before bed and they were 200 – I didn’t think they’d drop so drastically,” he says. “I got up the next morning to get a glass of orange juice and the next thing I know I’m looking at the ceiling of an ambulance, and some paramedics are asking me what day it is.”
Unfortunately, cases like this happen every day, and paramedics must deal quickly and effectively with these critical situations.
DIABETES HEALTH talked with Russ McCallion, the captain in charge of the San Francisco paramedic division’s education and training program. McCallion gave tips and advice on the best way to successfully deal with a diabetic emergency.
DI: Do you feel that the diabetes community is informed about what to do when somebody has an insulin reaction?
Russ McCallion: I think there needs to be better networking. I’d like to connect with the local branch of the ADA or diabetes support groups. Paramedics could come and address concerns or questions about what happens when people access 911. We could also arrange first aid and CPR classes for people with diabetes and their families. The more we are able to do to empower people to deal with medical emergencies effectively the less they’ll need to rely on 911, which can be disruptive and expensive.
DI: How much does an ambulance ride to the hospital cost?
Russ McCallion: The average ambulance ride costs 500 to 700 dollars. It’s a big chunk of change, especially for the elderly on fixed incomes. Fortunately, most people with diabetes have some sort of insurance or MediCal or Medicaid. However, sometimes the ambulance ride isn’t covered.
DI: Has paramedic care changed in the past few years?
Russ McCallion: We’re now able to treat and release patients more often in San Francisco. It used to be mandatory that a person who had been unconscious from low blood sugars would be taken to the hospital even if he or she was conscious and didn’t want to go. Now, we give people dextrose intravenously and then if they come around and can explain what happened – “Whoops I forgot to eat or I exercised too much,” – and they have friends or family who are present, we won’t take them to the hospital.
However, there are other surrounding communities where any time you start an IV the paramedics are mandated to take that person to the hospital to cover themselves from any liability issues. I think if I had diabetes and if I was fully alert and conscious I’d like to have the right to refuse going to the hospital and then go on with my day. I think it is much less burdensome on the patient and certainly less costly.
DI: With the advent of HMOs, have there been any cutbacks on the amount spent for care?
Russ McCallion: In some communities they are looking at sending out physician assistants in ambulances to reduce costs. HMOs are, in many cases, helping along this change because it decreases their costs, which they like.
This brings up a big question for the future: if technology improves and there is more that can be done for people with diabetes, are HMOs going to support these new innovations and treatments if they are more expensive?
DI: Have you noticed a rise in people being treated for insulin shock?
Russ McCallion: Actually, I’m not seeing as many as in the past. I’m wondering if this is because medical professionals are doing a better job at working with patients and families to make sure they are checking their blood sugars and taking better care of themselves. Also, in the past people were using less effective blood glucose technology. Things have improved.
DI: What form of ID do you suggest a person with diabetes wear to let emergency technicians know about his condition?
Russ McCallion: It’s extremely helpful if a person wears ID, because there are certain medications that we may or may not try depending on the medical history of that person. Unfortunately, half of the people with diabetes that we see don’t wear ID. I suggest a MedicAlert bracelet or necklace. Also, what’s very important in the days of managed care is a Kaiser health card or a card from whatever health plan that person belongs to. Then, for instance, we’ll take them to Kaiser directly instead of another hospital, which would result in us having to transfer them again later.
DI: What do you suggest if a family member or co-worker becomes unconscious because of diabetes?
Russ McCallion: Family members should know how to administer glucose gel between the gums and cheek. Also, family members should consult their doctors about how to use glucagon in an emergency situation.
It’s also a good idea for family members to train in CPR and first aid. They should understand what an insulin reaction entails and what to do if a person has a seizure: 1) Move objects away that might hurt him; 2) Don’t restrain him, and don’t put anything in his mouth; 3) Roll him on his side so fluid doesn’t get in his lungs, and check his breathing and his pulse (sometimes a heart attack can first appear to be a seizure); 4) Call 911, and, most importantly, don’t panic.
I recommend contacting the American Red Cross, the American Heart Association, or your local fire department or paramedic association. You can get a very good handle on how to deal with a wide range of medical emergencies after about four to eight hours of training.
DI: What’s the average low you’ve seen before people become unconscious?
Russ McCallion: It’s usually in the 40s range. I’ve seen as low as 9 before. Anytime we test a blood sugar and it reads under 80 we’ll automatically give the person 25 grams of dextrose intravenously and keep doing this until it rises. When somebody has low blood sugars there can be lasting damage to the brain. That’s why it’s imperative that people keep their sugars in check.
If someone is suffering from hypoglycemia give him a cup of orange juice or a cola, but only if he can hold the glass himself.
DI: What’s the highest blood sugar you’ve seen?
Russ McCallion: In the 400-500 range. We see this frequently in type Is with diabetic ketoacidosis.
DI: Do you see many diabetes-related driving accidents?
Russ McCallion: Very rarely – probably three to four a year.
DI: What’s the procedure you follow after a diabetes-related driving accident?
Russ McCallion: If someone has a seizure while driving or passes out, the physician who treats him is required by law to report it to the DMV.
DI: Do you think it’s safe for people with diabetes to be driving?
Russ McCallion: I think 99.9 percent of people with diabetes do a great job. I know a few paramedics who have diabetes themselves. If you have diabetes and are worried you may not be able to drive home, call 911 if you have questions. We have dispatchers who will give information or send an ambulance crew out if you’re having doubts about driving. This will probably cost anywhere from 60 to 100 dollars depending on where you’re located. Fortunately, insurance will often cover the charges. It’s better to be on the safe side than to have an accident. 911 is a safety net; don’t be afraid to use it. Your tax dollars pay for it.
DI: Any advice you’d like to give people with diabetes ?
Russ McCallion: Be aware of the complications: heart disease, stroke, etc. People with diabetes are often more prone to having “silent heart attacks” because of neuropathy. Instead of chest pain they have vague feelings of discomfort, sweatiness and shortness of breath. Also be aware that it’s sometimes harder to make a diagnosis for people with diabetes, so these people should be sensitive to their own bodies, and those who care for them should be aware of symptoms. We need to get people help early. Our motto is: “Call early, call fast, call 911.”