Many patients with diabetes wake up after EMS treats low blood sugar and want to stay home instead of going to the hospital. A refusal is reasonable only when the patient has decision-making capacity, a simple known cause, a normal repeat glucose, food to eat and a responsible adult nearby.
Key symptoms
- Before treatment: sweating, shakiness, confusion or unresponsiveness
- After glucose: alert, oriented and back to baseline
- Hunger, headache or tiredness as the episode resolves
- A clear cause, such as a skipped meal after insulin
- Wish to stay home and avoid transport
What you find on exam
- Mental status: oriented, understands the risks, can repeat the plan
- Repeat vital signs within normal limits
- Neurologic exam with no focal weakness
- Signs of injury, infection, alcohol or overdose
- Medications: type of insulin and any sulfonylurea
Tests
- Repeat glucose above 80 mg/dL after treatment
- Another glucose check before leaving the scene
- Decision-making capacity assessment
- 12-lead ECG if chest pain or other complaints
Treatment basics
- Have the patient eat a meal with complex carbohydrates and protein before EMS leaves
- Explain the risks of refusal in plain words and confirm understanding
- A responsible adult stays with the patient and can call 911
- Advise transport for sulfonylurea or long-acting insulin overdose, kidney failure or an unclear cause
- Document capacity, glucose values, advice given and the signed refusal; call medical direction if unsure
Red flags
- Taking a sulfonylurea such as glipizide or glyburide
- A second episode or glucose falling again
- Patient alone, intoxicated or not back to baseline
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Related guides
Sources: NASEMSO National Model EMS Clinical Guidelines; NREMT psychomotor skill sheets (EMT and Paramedic); National EMS Education Standards (2021). Written by Making Synapses. Making Synapses is not affiliated with these organizations.