Your patient is unresponsive. They are also cool, and diaphoretic. You are thinking they are diabetic. You have pricked your finger to get a capillary blood glucose. This is the moment of truth. You are actually hoping for the reading to come back, or at least 50. If it does, you relax, you believe the issue is simply low blood sugar and some IV dextrose will have the person back to normal and maybe even signing Refusal in no time. But if the blood glucose comes back normal, that's bad. That means something else is causing the patient to be unresponsive and cool and clammy, something far more sinister and less responsive to treatment than hypoglycemia. You wait as the meter counts down. 5, 4, 3, 2, 1.
If it is LO - You give IV Dextrose. If it is normal - you start thinking maybe this is a stroke or cardiac (what does the monitor say?) Or is it hypovolemia (You would probably already know this by an absent or weak thready pulse).
If they are hypoglycemic, there can be a second moment of truth. In most cases, they respond and wake up and swear that they knew they should have eaten and damn, where are they? And no, absolutely, no, they do not want to go to the hospital. But sometimes, they do not respond and you check the sugar again, and it's now normal or even high, and they're just like they were - cool, clammy, unresponsive. The low blood sugar either was not the cause of this episode and is just a symptom of it, or they have been with low blood sugar so long some damage has been done.
The other day I had a woman found unresponsive in a car and vomiting. She was cool and diaphoretic. Her husband said she was a diabetic. Something did not strike me right about the call. The first medic there checked the sugar, the number came back - 129. Normal. All right, let's get moving, we both agreed. The woman was hypotensive. BP of 80/40, then 70/36. The heart rate was 60. We did not have knowledge of her meds other than she took insulin. The woman groaned and was alert enough to complain of severe abdominal pain, as well as pain in the back. We popped in two IVs and called in a medical alert. Her belly was hard and distended. We were both thinking maybe GI bleed or AAA. The 12-lead was normal - no STEMI. The lady was so clammy and hypotensive, I thought she was going to code us.
They met us at the hospital with a full team. They did an emergency ultrasound that was inconclusive. When I checked back on the patient later, she was looking much better. Still in her ED room - not in the OR or up in ICU. Her skin warm and dry, her BP in 118/78. Pulse of 60. Sat - 98% on cannula. Yesterday, I saw a nurse who took her and asked her for the bottom line. Likely constipation. It seems the patient did not have a bowel movement in 5 days. Maybe she vagaled, the nurse said. She was disimpacted and went home that night.
Twenty years of this, and you never really know what you have. Diabetic, Triple AAA, GI bleed, or a vagaled constipation?
5,4,3,2,1 ... the answer is not always the answer.
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