7:12 a.m.- The Paramedic from the Ambulance contacts the Emergency Department Nurse (ED Nurse) and notifies her that the Ambulance is on route to the Emergency Room with a comatose 23 year old female Diabetic. The mother was unable to arouse her this morning to get ready to go to work. Her current blood sugar was registering on the I-stat at 844 mg/dl (normal Blood Sugar is 70-115). The Paramedic has already started an IV of Normal Saline, applied Oxygen at 2 liters per minute by Nasal Cannula, drew rainbow tubes (full set of blood draw tubes to save time so that the Lab Tech does not have to waste time drawing blood at the hospital), the heart monitor shows Sinus Tachycardia (faster than normal heart rate) and should be arriving in 3 minutes.

7:15 a.m.- Already notified by the ED Nurse, the doctor is at the bedside as the Ambulance Crew rolls the patient into the main room. She is still unresponsive at this time.  The doctor orders a battery of tests that would cover complications of a Diabetic with such a high blood sugar. The doctor orders the ED Nurse to have the Lab verify the high blood sugar from one of the tubes drawn at the girl’s house. He also orders for Cardiopulmonary to run an ABG (Arterial Blood Gas test that is taken from the artery in the wrist or the groin rather than the vein where most labs are drawn).

7:17 a.m.- The Lab Tech notifies the ED Doctor that the blood sugar is 852. Satisfied with the accuracy, the doctor orders 10 units of Humalog Insulin (fast acting type of Insulin) subcutaneously (under the skin, but not in the muscle; can be given in the pinched up fat on the abdomen or upper arm) and prepare an IV drip of Regular Insulin 100 units in 100 ml of Normal Saline, and begin at 5 units (5 ml) per hour; do fingerstick blood sugars every hour.

7:20 a.m.- Cardiopulmonary enters the room with a Ziploc bag full of ice, ready to do the ABG (the blood must be iced after it is drawn if it cannot be analyzed right away; the blood can metabolize and give false readings if not iced). Meanwhile, the doctor has added a CT Scan without contrast of the Head to the orders, just to make sure there isn’t something else going on, such as a bleed.

7:24 a.m.- The CT Tech arrives to take the patient to the CT Trailer by gurney. The nurse accompanies to help move the patient from the gurney to the CT Gantry (trough-like area where the patient lies to move in and out of the actual CT machine).

7:28 a.m.- Cardiopulmonary reports that the patient’ pH is 7.12 (normal is 7.35-7.45) and the Bicarb is 30 (normal is 35-45). This tell the doctor that the patient is in Acidosis (the blood pH is too low; acidosis).

7:32 a.m.- The patient returns to the ED and the doctor orders the nurse to insert a Foley Catheter (a tube into her bladder) in order to get a urine sample and monitor her urine output.

7:35 a.m.- As the nurse begins placing the catheter, the patient starts to respond to the discomfort of the catheter. Although she is not awake at this time, it is the first real response they have gotten from the patient. The nurse secures the catheter and drains some urine to do a dipstick test on it; it registers “Large” for Ketones (when the body is not utilizing sugar like it is supposed to, it starts breaking down fats resulting in elevated levels of Ketones in the urine).

7:40 a.m.- The physician views the CT Scan and does not see any bleeding or anything unusual. The patient is still quite lethargic but is responding to what they call “noxious stimuli” (sternal rubbing, squeezing the Trapezius muscle on the neck/shoulder area), the patient is a known Diabetic with a severely high blood sugar, her blood is Acidotic and urine is spilling Ketones. All indications show that she is in Diabetic Ketoacidosis.

7:45 a.m.- As he heads toward the ED Office to call the Transfer Center to get this patient to an ICU with a specialist in Diabetes (Endocrinologist), he orders the nurse to get a new blood sugar level and a recent set of Vital Signs to give to the Transfer Center. He then adds to give her 25 ml of Sodium Bicarb to bring up her blood pH a little. He notifies the ED Tech that the patient is going to be transferred and to get the chart ready.

The Ambulance bringing the patient to the Orchard Hospital Emergency Department to stabilize was a good choice as the services were readily available. Also, testing and treatment began almost immediately. Had the Ambulance had to go on into Enloe Hospital, another 33 minutes to get there, testing to assure there was no bleeding in the brain causing her comatose state would not have been able to happen until the Ambulance arrived at the other facility. Further, Lab and Cardiopulmonary verification of the patient’s actual glucose and acidosis status couldn’t have happened, having to rely on equipment in the field until the 33 minute trip to the other facility occurred.

This patient was diagnosed, started on treatment and headed for recovery in the Orchard Hospital Emergency Room in the time it would have taken to get to the other facility.

Please vote “Yes” on Measure M to keep these services available at Orchard Hospital in order to diagnose and stabilize critical patients in a timely manner.