“Tell them we are really sorry and we are going to change our policy, okay?” I say to the RN on the phone. We are now going to have a strict hand washing policy when this sort of thing happens.
Perhaps in the near future, the title of this blog may change to “Mistakes that I made that you should read about so you do not make the same mistakes as I did.”
Hours earlier we were on the steps outside a local breakfast restaurant. The patient is middle aged and they look generally pretty healthy. The fire department arrived on scene three minutes earlier and got vitals and hooked them up to the monitor. They report the blood sugar is 313 mg/dL.
“Do they have any history? Are they a diabetic?” I ask.
Fire tells me that they have no history and take no medications.
There is no way that sugar is right. I make a mental note to check with fire and make sure their machine is calibrated correctly.
The patient complains of near syncope, being a bit dizzy and says they have felt their heart racing a few times in the past week. They look a bit pale and lightly diaphoretic. I confirm the lack of any medical history and decide to obtain another glucose reading with our glucometer. I am shocked when it comes back at 303mg/dl.
I explain to the patient that they are likely suffering from a new onset of diabetes and need to be evaluated at the ER today. ETCo2 comes back at a concerning 21mmhg. There are no Kussmal respirations but the patient is tachypneic, coupled with the orthostatic intolerance and sinus tach it is a no brainer that they are dehydrated from osmotic losses as well.
I tell the patient again that they needed to go to the ER. Not that they necessarily needed to go by an ambulance for the one mile transport, but they needed to go and see a doctor today and we would be glad to take them if they liked. A brief overview of the physiology of diabetes and DKA was presented to the patient. The importance of diagnosing why and halting the process before it progressed was explained. Sensing their hesitation the complications of not seeking medical care were listed off in no particular order: coma, seizure, severe dehydration, kidney issues, acidosis, and even death.
I feel bad for them and explain that this is not a death sentence and that with diet and medication it is very manageable. I add my standard disclaimer that I am not a doctor and I could be completely wrong about everything.
The patient does not want to go by ambulance due to financial reasons and I cannot say I blame them. A thousand dollars for a few hundred milliliters of saline doesn’t seem like a great deal to me either. We talk to the ER and give them a heads up that a patient is coming into them with new onset diabetes or DKA from some other cause.
On the way back to the station my partner and I discuss whether it could be alcoholic ketoacidosis (AKA) and whether pancreatic cancer could somehow affect the beta cells and cause an insulin deficiency (it can). I hope this is not some form of insidious pancreatic cancer and this is the first sign. A sugar of 300mg/dl would be high for AKA, but not impossible. I talk about how DKA can result from a lack of insulin or when there is increased insulin demand and the pancreas cannot keep up. I talk about the three ketone bodies and how only acetone is excreted from the breath and it is a common misconception that DKA patients are “blowing off ketones” and they are actually blowing off co2 to attempt to compensate for the acidosis. I am highly educated on ketones. I just do not know that much about breakfast foods.
Several hours later I call the ER to get some follow up. Dehydration and a low H&H is the answer. “That’s it? Did you guys check the glucose? We checked it twice on scene, with two different glucometers and two different sets of strips and both were over 300mg/dl.”
“We got 122mg/dl.”
“Really? Really?” I ask.
“Yep.” She says.
There seem to be two conclusions I can arrive at. One would be that the hospital’s lab analyzer is wrong, way wrong. The other would be that we missed something here.
Enter: “Science”(*in an n=1 and anecdotal science sort of way)
I check my blood sugar and it is 94mg/dl. I kind of wish it was lower, to be honest as I am on the keto diet, but this is after eating a ton of food already.
I take some fake maple syrup and smear a thin layer on my arm. After it dries I take my sugar again, placing the lancet on the slightly sticky spot. I get a reading of “high”. I wet a paper towel and do a poor job of washing off my arm, just giving a quick wipe of the spot. This time the glucometer comes back at 213mg/dl.
Number one ingredient in fake maple syrup – High Fructose Corn Syrup (HFCS). When the water component of HFCS is removed it is usually around 55% fructose and 45% glucose.
Next, I wondered if the glucometer would only read glucose or not. I made a paste of table sugar and a few drops of water and rubbed it on my other arm. After it dried I checked a blood sugar in the area, it came back only slightly elevated at 121mg/dl.
We are now going to institute a handwashing policy for the patients. Not all patients, but those with suspiciously high blood glucose readings; those with no history of diabetes and no reason to have an elevated blood sugar. An alcohol pad is not enough, nor was a second wipe with an alcohol pad enough to prevent me from trusting my equipment.
I hope the nurse told the patient how bad I felt about the whole thing. Do I know for sure that the patient was contaminated by maple syrup or some other glucose containing product? No, I don’t, but it seems like the most likely explanation at this point.
Afterword: I just talked to the patient. I apologized for telling them they had diabetes. It turns out the patient had a GI bleed with an H&H of 6/20. I explained the issue with the glucometer and our experiments we performed and the patient admitted to having a significant syrup exposure that morning. They said it meant a lot that we came and talked to them.