Peter A. Kahn, MD, MPH, ThM; Nicole E. Wagner, BA; Robert A. Gabbay, MD, PhD
Note: The authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
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Nationwide emergency medical services policies on use of glucagon and blood glucose testing by emergency medical technicians.
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In this video, Robert A. Gabbay, MD, PhD, offers additional insight into the article, "Underutilization of Glucagon in the Prehospital Setting."
Kimberly Pruett, Chelsea White IV, Darren Braude
Department of Emergency Medicine, University of New Mexico Health Sciences Center
January 24, 2018
Prehospital treatment of hypoglycemia not as dire as stated
In the December 26, 2017, issue of Annals, Kahn et al make a case for greater use of glucagon by EMT-Basics in the prehospital setting(1). We concur that glucagon should be more available to those lacking access to more preferred options for profoundly hypoglycemic patients. However, we believe that the authors' misunderstanding of modern prehospital care has lead them to overstate the magnitude of this situation.The authors are correct that EMS use of glucagon is restricted to Paramedics in most states. They then assume that because EMTs comprise 76% of all EMS providers and may not have glucagon that this "probably" impedes patient care, though their "data did not allow for precise review of crew composition." Indeed, many EMS systems respond with both EMTs and Paramedics. Paramedics responding with EMTs can provide glucagon as well as intravenous dextrose, the preferred prehospital treatment for obtunded patients with hypoglycemia(2). Furthermore, oral glucose is widely available to EMTs and both effective and safe (even when applied to the buccal mucosa of the obtunded patient.) Thus, despite workforce statistics cited by the authors, effective prehospital treatment of profound hypoglycemia is more available than they fear.The authors also worry that because dispatch coding is not specific to diabetic emergencies, incorrect crews are dispatched. 911 callers often present incomplete information, potentially causing a hypoglycemic event to receive an urgent but non-specific dispatch code. Regardless, these calls are managed with the same degree of urgency with the most advanced level EMS provider available. Interestingly, the authors eliminated EMS calls with response times over 60 minutes from their analysis. Patients in rural and frontier settings are more likely to experience long response times and EMS crews comprised only of EMTs. While EMS outcomes data for these patients is scarce, our anecdotal experiences have shown benefits of EMT administered glucagon and ill-effects of not having it in this population.We agree that glucagon should be more available to those EMS providers and members of the public that have no other options for treating profound hypoglycemia. However, we wish to reassure Annals readers that the problem the authors identify is not as dire as they describe. Kimberly Pruett, MDEmergency Medical Services FellowUniversity of New Mexico Health Sciences CenterAlbuquerque, New MexicoChelsea C. White IV, MD, NRP, FAEMSDirector, University of New Mexico Center for Rural and Tribal EMSAssistant Professor of Emergency MedicineUniversity of New Mexico Health Sciences CenterAlbuquerque, New MexicoDarren Braude, MD, EMT-P, FACEP, FAEMSChief, Division of Prehospital, Austere and Disaster MedicineProfessor of Emergency Medicine and AnesthesiologyUniversity of New Mexico Health Sciences CenterAlbuquerque, New Mexico1. Kahn PA, et al. Underutilization of Glucagon in the Prehospital Setting. Ann Intern Med. 2017 Dec 262. Rostykus PP. Variability in the Treatment of Prehospital Hypoglycemia: A Structured Review of EMS Protocols in the United States. Prehospital Emergency Care. 2016 Jul-Aug.
Michael E. Mullins, William H. Dribben, Bridget Svancarek
Washington University School of Medicine
January 31, 2018
Glucagon is outside EMT scope of practice
Kahn and colleagues assert that every basic emergency medical technician (EMT) should carry and be able to give intramuscular glucagon and that every patient with diabetes should have access to glucagon at home (1). They further assert that wider availability of glucagon should decrease ED visits and hospital admissions with the implicit assumption that preventing diabetic patients with hypoglycemic events from seeking immediate medical care is highly desirable.While the proposal that EMTs should be able to administer intramuscular glucagon appears reasonable, it overlooks the fact that injectable medications fall outside the nationally recognized scope of practice for basic EMTs (2).The proposal to deploy glucagon also overlooks the substantial fraction of patients whose hypoglycemia arises from sulfonylureas. The preferred antidote for sulfonylurea-induced hypoglycemia is octreotide (3, 4). The cheaper and more flexible initial treatment for undifferentiated hypoglycemia is oral glucose. We recommend glucagon primarily for patients who cannot take oral glucose and who lack IV access. Their proposal comes at some cost. If glucagon costs $212 and if only 1 in 500 Medicare patients receives it at a total cost of $5 Million, then putting glucagon in the hands of the remaining patients will raise the cost to $2.5 Billion. With over 23 million Americans diagnosed with diabetes (5), this doubles to $5 Billion if all patients receive home glucagon prescriptions.The authors twice state that family members “routinely” administer glucagon at home. This statement has no supporting reference, belies their statistic that only 0.2 percent of diabetic patients have access to glucagon, and is inconsistent with our cumulative experience in pre-hospital and ED care.We doubt that wider use of glucagon in the field will or should reduce ED visits and hospital stays related to hypoglycemia as these events likely signal individual problems in diabetes management or changes in the patient’s health. We conclude that the best pre-hospital treatment for hypoglycemia is glucose and that hypoglycemic events are opportunities to optimize diabetes treatment and to educate patients.1. Kahn PA, Wagner NE, Gabbay RA. Underutilization of glucagon in the prehospital setting. Ann Intern Med. [Epub ahead of print 26 December 2017] doi: 10.7326/M17-22222. National Highway Traffic Safety Administration. National EMS Scope of Practice. https://www.ems.gov/.../EMS...Systems.../National_EMS_Scope_Practice_Model.pdf (accessed 30 January 2018).3. McLaughlin SA, Crandall CS, McKinney PE. Octreotide: an antidote for sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2000;36:133-138.4. Dougherty PP, Klein-Schwartz W. Octreotide’s role in the management of sulfonylurea-induced hypoglycemia. J Med Toxicol. 2010:6:199–2065. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2017. Accessed at https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf (accessed on 30 December 2017).
Robert A. Gabbay, Peter A. Kahn, Nicole E. Wagner
Joslin Diabetes Center
February 20, 2018
Response to Comments
We thank the commentators for their enthusiasm about this topic and for providing an opportunity to further elaborate and discuss our research. Although the precise makeup of nationwide EMS crews is unknown and varies by location as well as daily staffing requirements, it is undeniable that the numbers of EMTs significantly outweigh the relatively small numbers of paramedics nationwide. Even if for every single EMT on an ambulance there was one paramedic assigned, there would still be countless EMT’s left without paramedic partners. Without clear agency by agency data, it is not possible to fully assess crew composition and the makeup of each response team, which as noted above, varies by region. More generally, however, even in instances where paramedics are indeed present, the administration of glucagon is a skill which EMT’s should be able to practice. EMTs can already administer certain injectable medications such as epi-pens or other formulations of intramuscular epinephrine, and we believe that there is no reason that intramuscular glucagon should be any different. We agree that oral glucose is safe and effective; however, our paper was concerned with episodes of severe hypoglycemia necessitating emergency medical response. The most definitive study of its kind has suggested that oral glucose may not be well absorbed through buccal mucosa as authors suggest (1). It is the widespread practice to avoid providing oral glucose to obtunded patients. This is supported by the widely used practice guide UpToDate out of concerns for effectiveness and aspiration (2). We agree with these concerns and therefore believe an intramuscular option is of crucial importance. In regards to dispatch coding, our data indicates dispatchers frequently are not able to identify in advance those callers or events which require glucagon from caller information alone. As a result, they will often not be able to decide on team composition to treat severe hypoglycemia properly. Drs. Mullins, Dribben and Svancarek describe that occasional hypoglycemic episodes are caused by sulfonylureas. We agree in these cases octreotide may be preferred, however most EMTs or paramedics would not be sure of the etiology of hypoglycemia and thus in the immediate term glucagon is effective and can easily be deployed in most settings without severe side effects. We too appreciate the importance of cost saving metrics, however our suggestions are aimed to only those who are at high risk for hypoglycemia or who frequently treat them (such as EMTs), not all individuals with diabetes mellitus. According to the American Diabetes Association Standards of Medical Care in Diabetes 2018, “glucagon should be prescribed for all individuals at increased risk of clinically significant hypoglycemia, defined as blood glucose <54 mg/dL (3.0 mmol/L), so it is available should it be needed (3). Caregivers, school personnel, or family members of these individuals should know where it is and when to administer it. Glucagon administration is not limited to health care professionals.” This is the standard of care and at Joslin Diabetes Center where we ensure that in all instances where glucagon is prescribed, family members have access to appropriate training. We believe that it is only through expanding access to glucagon that additional lives can be saved and hypoglycemic complications prevented. Robert A. Gabbay, MD, PhDChief Medical Officer and Senior Vice PresidentAssociate Professor of MedicineJoslin Diabetes Center and Harvard Medical SchoolBoston, MassachusettsPeter A. Kahn, MDYale School of Medicine, Department of Internal Medicine, New Haven, ConnecticutNicole E. Wagner, BAJoslin Diabetes CenterBoston, Massachusetts(1) Gunning RR, Garber AJ. Bioactivity of Instant Glucose Failure of Absorption Through Oral Mucosa. JAMA. 1978;240(15):1611–1612. doi:10.1001/jama.1978.03290150057025(2) Cryer PE, Hirsch IB, Mulder JE. Management of Hypoglycemia During Treatment of Diabetes Mellitus. UpToDate, https://www.uptodate.com/contents/management-of-hypoglycemia-during-treatment-of-diabetes-mellitus updated November 8, 2016.(3) American Diabetes Association. Glycemic Targets: Standards of Medical Care in Diabetes – 2018. Diabetes Care, 2018 Jan; 41(Supplement 1): S55-S64. https://doi.org/10.2337/dc18-S006.
Kahn PA, Wagner NE, Gabbay RA. Underutilization of Glucagon in the Prehospital Setting. Ann Intern Med. [Epub ahead of print 26 December 2017]:. doi: 10.7326/M17-2222
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