"If the blind lead the blind, both shall fall into the ditch." - Matthew 15:14
We are all products of our training. In many cases, if our instruction was weak, major holes in our knowledge base exist. Example: Instructors still recommend looking for cherry red skin in cases of carbon monoxide poisoning. In the field, however, you hardly ever see this sign. Most of the time, cyanosis is evident in these cases. In fact, the only time I've ever seen cherry red skin in CO poisonings was on a corpse.
Some of the most important information an instructor can convey to students is in the form of diagnostic pearls: little maxims you can use to remember critical stuff. A good example of a diagnostic pearl: Assume abdominal pain in a woman of childbearing years denotes an ectopic pregnancy until proven otherwise. Remembering this pearl could save a young woman's life. For a more in-depth example, read this month's case.
Scenario
You and your partner are dispatched to a diabetic emergency at 636 Brooklyn Ave. at the corner of Hawthorn Street. On scene, you find an unconscious 49-year-old male, breathing deeply at 30 times per minute. His airway remains open and maintainable with position. His skin feels warm and dry. His mouth and mucous membranes appear dry. His heart rate is 100 with a blood pressure of 120/80. Your partner places the patient on high-flow oxygen and records an ECG while you obtain the patient's history from the family.
They report he's an insulin-dependent diabetic who rarely takes his medications. He's been vomiting for the past two days and has complained of nausea and excessive thirst. The family denies the patient has any history of heart disease, respiratory problems, seizure history or allergies and says the patient doesn't smoke.
Based on what you see and hear, you believe the patient displays all the hallmarks of diabetic ketoacidosis (DKA), including increased respiratory rate. Your partner starts an IV, and you examine the patient and review the possible causes of DKA: too low an insulin dose, failure to take insulin, infection, increased stress, increased dietary intake and decreased metabolic rate.
While you continue to think, your partner reveals the glucometer won't calibrate, making it impossible to obtain a blood glucose reading. You think to yourself that giving this guy a bolus of dextrose should pose no problems, especially because his blood glucose remains unavailable. After all, instructors have drilled into your mind that all unconscious diabetics should receive dextrose because it's potentially lifesaving. Besides, bringing unconscious diabetics into the ED with single-digit glucose levels can be a real showstopper.
You continue your assessment. Something about this patient presentation isn't right. Some signs keep pulling you away from DKA. Those same instructors who hammered on you about giving dextrose to unconscious diabetics also told you that patients with DKA are seldom this deeply comatose. You remember that head trauma, drug overdose and stroke can all cause coma. These may also cause the alteration in respiratory pattern that you documented.
You secure the patient's airway and place an oropharyngeal airway. He doesn't struggle as you intubate him. While taping the tube, you notice his pupils appear unequal in size. "It sure looks like a stroke now," you think.
Per protocol, you administer naloxone to rule out opiate overdose. You don't give the patient any dextrose because you know it may exacerbate cerebral damage in stroke victims. You promptly transport the patient to the hospital, and a subsequent CT scan confirms stroke.
Discussion
Your medical director affirms that your decision not to administer dextrose was right on target. He also reaffirms your suspicions that DKA patients are almost always rousable and can typically answer questions.
Conclusion
Education in EMS and most medical fields is an interesting animal. We try to teach skills that normally can only be learned through experience. We give our students countless clues and presenting symptoms so they can recall any one of them on demand. Instructors and students must remain aware that some of these clues may prove false. We expect them to be present in many cases, and our suspicions are aroused when they're not. As instructors, we need to teach our students to think and process patient information-not simply recall facts from memory.
Paul Werfel, NREMT-P, paramedic program director for the University Medical Center at State University of New York, Stony Brook, may be reached via e-mail at pwerfel@epo.hsc.sunysb.edu.
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