# 304 'At your back door' Sweaty & Confused
It's 11:00 a.m. The local Basic Life Support ambulance service (not permitted to give drugs other than oxygen) gives an 'at your back door' radio call (will arrive in less than a minute) of a patient with altered mental status and who is very diaphoretic. He is able to stand and be 'steered' in the correct direction. Your workplace is only 'a block and a half' away from the bank in which he was found; thus, the short notice and abbreviated history.
Before the monitors are completely affixed, you have in your mind a likely diagnosis (having felt a regular pulse or heard the sounds of it from the pulse oximeter. What's your guess? You ask for an immediate glucometer reading, which at 28 mgs/dl, confirms your hunch of hypoglycemia. After correction of the blood sugar, the patient is completely recovered. You have correctly reasoned that AMS + profuse diaphoresis + a cool day, is more likely hypoglycemic in origin than cardiac (although you sort through all possibilities).
What is your principle activity to be? There are two: 1) investigating the reason for the hypoglycemia, 2) and patient education.
What happened? Took insulin; no breakfast, only ate a piece of lettuce. Why? May be a simple "I was rushed-interrupted and forgot"; might be going heavier on insulin for 'weight control' (I've got to lose a dress size before the prom). Is awareness to onset of hypoglycemic symptoms are being blunted over time, or masked by a beta-blocker?
There are no identification documents on the patient … was he already hypoglycemic when he left the house? Was he driving? Is mandatory notification to the health department (and, through them, to the Department of Motor Vehicles) required? Was a wallet left behind at the place where he was found?
Circumstantial confirmation occurred in that his only pocket contents was a plastic cap from an insulin syringe package. A strong conversation should take place over the value of wearing Emergency Medical Identification, such as a wrist band or necklace, preferably one backed by a system of medical files, identification of the patient (unlike ''drug & variety store devices" that do not identify the patient) and his contacts. As it is possible to be separated from cards, wallets, and purses, it is wise to have something that remains on the person!
This patient, though he may be discharged in the company of someone who can look after him, should definitely have a firm follow-up set with his primary care, preferably when you have had a talk with the primary before discharge. The patient and his companion should be strictly warned that he should not
drive or do risky activities, until cleared by his primary care clinician. In less firm circumstances, one or more follow-up calls to the patient to assure that no recurrences have happened, and an appointment has been made. It would be good if a message left for the primary includes a request for a call-back to verify that the patient has been seen.
Do not omit any mandatory reporting paperwork.
All Tips: 2013 2014 2015 2016 2017 2018 - Updated! (11/04/2018)