Articles Of The Week July 26, 2020

This is a great podcast from a pain researcher and an exercise physiologist so you can better understand central sensitization and pain. Great stuff!

“Central Sensitization And Pain” – Ben Cormack & Melissa Farmer

You know if there’s something regarding exercise and pain, we’re going to share it. This one I really like as it focuses not so much on a specific exercise, but physical activity, and the person in front of you.

“Exercise And Pain, An Opinion Piece” – Rhyesson Cornilla

I really like this one, as I have a disdain for insurance companies due to my former life before being an RMT. But, this shows us how to help those who have pain, yet no objectionable measure of pain to in turn satisfy said insurance companies.

“Secondary Gain, Really?” – Bronnie Lennox Thompson

We are constantly talking to patients recommending self-care. But, what are we doing for ourselves when it comes to self-care? Here’s some dynamite advice on how to do just that.

“How to Customize a Self-Care Plan That Works For You” – Aleksandra Slijepcevic

This pandemic has changed a lot of things. One of which is the way we provide first aid to people. For me at work, we’ve gone through massive changes in the way we do things at the Firehall. For those of us in sport, this outlines some changes we should take into account.

“Medical Care And First Aid: A Framework For Organised Non-Elite Sport During The COVID-19 Pandemic” – Steffan Griffin

 

When You SHOULD NOT Treat Your Patients Thoracic Pain

When I was in physical therapy school, PTs in the States didn’t have direct access. 

I figured I needed to mainly focus on differential diagnosis of musculoskeletal issues and not worry about cancer or visceral referral pattern.  However, the States slowly has been adopting direct access for physical therapy and I also learned that regardless of having a referral, physicians don’t always spend enough time with patients to properly rule out other causes. 

The purpose of differential diagnosis is not to just identify a specific structure involved, but to also help determine prognosis, other psychosocial factors and to rule out serious pathology and identify conditions not appropriate for physical or massage therapy.

My patient was in her late 20’s and 6 weeks postpartum.  She had been having mid-thoracic pain and right scapular pain for almost 12 weeks.  Her physician sent her to therapy to receive manual therapy and strengthening. 

During the examination, I had difficulty reproducing her pain, but she stated her pain was worse at the end of the day after lifting, carrying and feeding her child all day.  She had weakness in her extensors and scapular retractors.  Even though I couldn’t reproduce her pain, I gave her some stretching and started some scapular stabilization exercises.  I figured her pain was from a sudden increase in lifting and carrying, sitting with her child and a change in her chest size.

Admittedly I treated her for 3 follow-up visits (with little change) before I realized what the problem was. 

On the third visit, her husband said: “I just don’t understand why the pain is always so bad late at night.”  He was more specific than she had been (end of the day).  The pain was late (10 pm) and often caused his wife violent vomiting.  That minute the lightbulb went on (and according to my patient I shouldn’t play poker because she knew!).  I asked her if she had ever had a White or light stool, she denied it, but her husband said: “don’t you remember the one when you were pregnant?”  She had a white bowel movement back when she was about 26 weeks pregnant!  She had denied pain anywhere else, but the minute I palpated her upper right abdominal quadrant she jumped off the table and reported radiation to her back/scapular area.

There it was….GALLBLADDER!  

She was admitted to the hospital an hour later and was in surgery 4 hours later.  The surgeon said she was days away from a rupture.

Quite honestly, I felt like an ass. 

I had seen her for 4 visits total before the husband had said the words that made gallbladder click in my head.  I realize she had seen both her Obstetrician and her Primary Care physicians prior to coming to see me, but that did little to make me feel much better at the time.  I had just started treating pregnancy and postpartum and couldn’t believe I almost missed something so important!  I went back and reviewed all my red flags and visceral referral patterns after this incident. 

I also share this story with every obstetrics in therapy class I teach.

Also, women and men often present differently with visceral referral patterns.  For gallbladder, women tend to have more vomiting than men.  Also, during pregnancy, the increase in estrogen leads to an increase in cholesterol in the bile and estrogen reduces gallbladder contractions.  The decrease in contractions leads to less bile leaving and an increased risk for gallbladder stones.  This can lead to severe pain and potential for infection.

Summary of Gallbladder symptoms:

  • Chills and/or low-grade fever
  • Dark colored urine
  • Jaundiced appearance
  • Light-colored stools
  • Nausea and vomiting (especially at night)
  • Stomach pain particularly after a high-fat meal
  • Right shoulder/scapular, mid back pain

We are never going to be perfect, but the goal is to learn from past patients and pick up on patterns faster the next time.  It also helps to share our experiences.  So keep these risk factors and symptoms in the back of your mind the next time your patient’s mid thoracic pain isn’t making sense! 

Red Flags For Low Back Pain, Or Clinical Decision Making?

It’s only happened a couple of times in my career.

You know that feeling you get when something just isn’t right? You’re not quite sure what it is, but something just seems off?

Twice I’ve had people come in where their pain and limited mobility had me questioning if they needed a trip to the emergency room. In one instance I called a family member who took the patient in, and everything checked out fine.

The other instance, the persons low back pain was so extreme, it just didn’t add up. There was no history of trauma or anything else that suggested the hospital was necessary, but I could barely touch the patient during the treatment because their low back was so sensitive. Afterward, I recommended seeing a doctor, or emergency room, but they refused. I never saw them again, so I’m not sure what the outcome was.

So how do we know when low back pain is an emergency, or just really painful?

Traumatic Injuries And The RTC

In old First Aid terms, there were criteria we would use at the scene of an accident to quickly decide if a patient had to have spinal immobilization used and if they needed to be immediately sent to the hospital. 

It was called the RTC (Rapid Transport Category), and it was a simple list which made it easier to decide how to provide the appropriate care to a patient. While this isn’t as useful in a clinical setting, it could be invaluable in a sport, or outreach setting if some type of emergency were to happen and you are required to provide care. In a clinical setting, it would be helpful during your patient interview in case you weren’t quite sure why a patient is having the issues they are presenting with.

The RTC criteria include quite an extensive list of things to watch for. Not all of them would be applicable to us, but here are some that would be:

  • Mechanism of injury
    • Fall from greater than 20ft
    • High-speed accident
    • Pedestrian struck at speeds higher than 30 km/hour
    • Broken windshield damaged steering wheel, or airbags deployed
    • A rollover accident
    • Severe crush injuries
    • Any other people involved in the accident that result in a fatality
    • Electrical injuries (we always assume spinal damage with electrocution)
  • Anatomy of injury
    • Severe brain injury
    • Penetrating injuries to anything but the limbs
    • Depressed skull fracture
    • Pregnant woman with fairly moderate trauma
  • Findings in the Primary Survey
    • Decreased level of consciousness
    • Cardiac arrest
    • Suspected heart attack
    • Poisoning
    • Status Epilepticus

Particularly for us in the clinical setting the mechanism of injury should be one category to take note of. Hopefully, if someone has been through an accident that traumatic, they have already been to the emergency room, or at least a doctor to be checked out, but this doesn’t always happen. Sometimes a patient may play it off and just think they need to see a chiro, physio, or massage therapist and book in with you before ever seeing a doctor, or even calling 9-1-1 after an accident.

I’m sure we all see patients on a regular basis who have been in a car accident. Knowing those above criteria and being able to ask some of those specific questions in your interview may give you a better idea as to how severe their injuries could be. Or, if they played it off and haven’t been checked out, you may want to refer them to a doctor just to be safe.

Whenever I teach a first aid course we talk about the signs and symptoms of a heart attack. This is where there could be a bit of a red flag, as it is quite common for women to experience back pain associated with a heart attack. However, it would be back pain combined with other symptoms like chest pain, nausea and vomiting, sweating, and shortness of breath.

This is certainly part of our role as healthcare professionals to recognize and help our patients if this is happening. 

Photo by: Lucina Medina

The Red Flags Of Low Back Pain

There seems to be a wide array of information on the red flags of acute low back pain.

Most of the concern is driven toward four issues:

One red flag that is unrelated to specific disease was the onset of pain in patients under 20 years old. However, one study actually calls this a “dubious distinction” and shows that age alone combined with pain is not enough to be considered a red flag, as most of the participants in the study were diagnosed with non-specific mechanical spinal pain.

When we look at the risk factors associated with spinal fractures, most information cites major or significant trauma, age, a history of osteoporosis, and the use of corticosteroids as the red flags to look out for. A systematic review showed that all of the above combined with the presence of a contusion brought the probability of a fracture up from 4% to a range between 9 and 62%. An Australian study showed that when three red flags (female, over 7o years of age, severe trauma, and use of corticosteroids) were all present, the chance of a fracture went from 4% to 90%. So, when looking at red flags for fractures, one red flag alone is not likely an issue, but a combination of the red flags is more likely to result in a fracture.

The commonly used red flags for infection were:

  • Fever/chills
  • Use of corticosteroids or immunosuppressant therapy
  • IV drug use
  • Pain worse at night
  • Night and rest pain
  • Tenderness over the spinous process

But the same systematic review showed that there is a lack of standardization with these red flags, and the risk of serious disease in patients with low back pain is less than 0.1%.

The same can be said for malignancy, as the one big red flag, in this case, is a history of cancer. Yet “history of cancer” isn’t clear enough as it doesn’t specify how long ago the person was diagnosed or the type of cancer they had. There are several cancer types that apparently put a person at greater risk for spreading to the spine, but if the person didn’t have one of those types, or had it 20 years ago, the likelihood of spinal malignancy is probably a lot less than someone diagnosed recently.

The two most common red flags with Cauda Equina were saddle anesthesia (perineal numbness)  and sudden onset of bladder dysfunction. Either way, I’d be referring out for that!

One thing that came out of most of the studies I could find was one resonating point. Clinical decision making and judgment of the therapist to determine if the patient needs to be referred out is more reliable than the list of red flags. So in other words, when in doubt, refer out! There are some other things to take into account with this whole red flag discussion and one review makes a great point as to why screening for red flags isn’t reliable. As practitioners, we don’t actually screen, we manage low back conditions. They actually encourage watchful waiting for changes in symptoms, as evidence is showing that early intervention with low back pain may actually be more harmful.

One thing I hadn’t ever heard of was “yellow flags,” however, I found it encouraging that it was mentioned in a paper from rheumatologists. They listed these yellow flags as:

  • A belief that back pain is harmful or disabling
  • Fear of pain and movement avoidance
  • Tendency to low mood and withdrawal from social interaction
  • Expectation of passive treatments rather than believing active participation helps

Biopsychosocial approach anyone? It’s great to see these “yellow flags” being mentioned with the same importance as the dreaded red flags.

Overall, it is probably good to be aware of those red flags to help guide your clinical decision making, but they aren’t the be all end all like we once thought they were. The valuable thing will be your judgment call and also making sure to monitor your patients progress. If your spidey senses start tingling, and something doesn’t seem right, don’t hesitate to refer out, it’s better safe than sorry.

Therapeutic Exercise And Inversion Ankle Sprains

When she came in, you could see the pain on her face.

Wincing with each step toward the treatment room, her limp was noticeable as she was protecting the ankle.

As I helped her sit down, of course, my first aid protocols popped into my head first, so I ran through the typical questions:

“What happened?”

“Did you hit your head at all?”

“Did you hear a pop in your ankle?”

“How are your pain levels?”

Fortunately, she didn’t hit her head and there was no “pop.”

She had just rolled her ankle and had a pretty typical inversion sprain, the swelling was already noticeable. What made it worse for her was the stress and worry of whether she could run as it was her favourite thing to do.

She wanted to get that ankle back to her normal activities ASAP.

Helping Protect The Injury

As I mentioned, the first thing I thought of was the first aid protocols when it comes to an injury.

This particular incident was obviously in the acute stage, so all the RICE protocols are the first thing I thought of. While there has been lots of debate online about using ice and rest, I still believe that in the acute stage it’s the best way to go.

Where I have changed my opinion is how long to use RICE.

In the past, we would use ice and rest for way longer (at least I did) than was probably appropriate. During the inflammation phase, (which is the first 48 hours) it is important to rest and support the tissues involved in the injury but still, keep up with some movement and continue to load the tissue within pain tolerances.

Since most of you probably already know how to rest, ice, and elevate I thought we would go over the compression portion and demonstrate how to properly wrap and inversion sprain, to give it some support and help control swelling over that first 48 hours.

Properly wrapping an ankle like this can give it that little bit of extra support (and confidence) in order to help the patient continue to move and also help with pain management.

Loading The Tissue

More and more over the past few years, we have been hearing and seeing more research on the importance of loading tissues post injury.

I’m sure we’ve all heard the stories about how they get patients up and moving almost immediately after surgeries.

Research is showing that loading the tissue or causing mechanical tension (muscular force) is actually a way to help influence wound healing. As the injury enters into the repair phase we can start to load the tissue even more.

This, of course, depends on pain and weight bearing abilities. If the patient can do full weight bearing pain-free you should be able to load the tissue more than if they can’t do full weight bearing. If they can’t bear full weight, giving the patient something to hold for balance will help decrease the amount of weight we are loading into the tissue and help with a decrease in pain, but still have the ability to move and load the tissue.

Here is an example of how you can begin some weight bearing exercises and load for an inversion sprain.

Once the patient feels more comfortable and pain has decreased, you can then progress them to this kind of exercise in order to load the tissue more:


As the patient continues to progress, here is a 3rd progression you can use to load into the injury more:


It is important to work within your patients pain tolerance when doing any kind of exercise, but one study showed that doing isometric contractions actually helped to decrease pain in patients with a tendinopathy. While an inversion sprain isn’t a tendinopathy, we can use it as a reminder that it is okay to load the tissue early in the healing process. So, in addition to doing some massage therapy, actually loading the tissue will not only help strengthen the area but also assist in decreasing pain for the patient. However you decide to set up your treatment plan, these are movements that can be taught in the clinic and incorporated into your treatment but also given as homecare exercises to help the patient progress. For those of you who don’t have “exercise” in your scope of practice, let’s just call it “therapeutic movement!”

Understanding And Managing Groin Pulls

I felt a little tweak on the inside of my leg, but kept playing anyway.

It was the final game of the tournament that weekend, so I knew I just had to get through the last period.

As the game continued, the pain in my inner thigh was getting worse.

Each time I pushed off and my skate cut into the ice it felt like a shock going up into my groin.

As soon as the game was over, I pulled some ice out of the beer cooler, wrapped it up and put it on the inside of my leg. It helped a little, (or it could have been the beer) but I had never felt something like this before.

The next day I had a snowboard trip booked for a week.

By the time I got up to the chalet, I could barely lift my leg. Going up a flight of stairs was almost impossible.

Just getting up out of a chair was excruciating. I was basically limping for 5 days.

I have never pulled my groin before, but holy was this painful.

Contributing Factors To A Groin Pull

A groin pull is common among athletes, especially in sports where the athlete is required to change directions quickly or where explosive movement is part of the sport.

Hockey and soccer seem to be the sports where a groin strain/pull is most common with athletes, but are also found in fencing, handball, football, cross country skiing, hurdling and high jumping.

A groin strain can be graded into three classifications and can involve any one of the six adductor muscles

There has long been a belief that Janda’s lower cross syndrome played a major role in what contributed to groin strains in athletes. 

In fact I did a case study in college on a marathon runner experiencing hip pain and based a lot of the treatment on this syndrome. But in talking to many of my pain science friends, it appears that this syndrome is not as accurate as we once thought. 

However there are parts to it, which I believe plays a role in an athlete experiencing a groin strain (this is where my pain science friends will probably want to correct me).

Essentially the thought was a muscle imbalance, or strength imbalance between the gluts and adductors and the strength of the gluts was pulling on the adductors, thus causing a groin pull.

Some of the research back then was pointing to this being a specific cause in hockey players (most hockey players have big butts from skating) and this being a major contributor to groin pulls in these athletes, although I couldn’t find any current research to support that, so we’ll just leave it in the past for now.

However there is a strong indication that weak adductors are a major contributor to these injuries. 

One systematic review compared 17 studies and found limited evidence to support the theory of weak adductors but it was dependant on positioning. At 45° during a squeeze test there was strong evidence of adductor weakness. 

A study done on Australian Rules Footballers demonstrated that weak adductors could be a factor in groin injuries. Their adductor muscle strength was tested weekly. Of the seven players that suffered a groin injury (over a two season period), they all demonstrated decreased strength in hip adduction two weeks prior and the week of their injury.(1)

While this is a very small study, it helps to support weak adductors as a possible contributor to groin injuries. 

Some other studies have shown there to be several other risk factors involved. With hockey players there was a greater chance of having a groin strain if you had a previous injury to the same area and less likely to suffer the injury if they had practiced in the off season.

When it came to soccer players, previous injury was also a risk factor but so was limited hip abduction. Groin strains were most common during the action of kicking the ball.

Either way it seems that weak adductors can be one of the contributing factors to suffering a groin strain. 

I also think (and this is strictly opinion) the motion of skating is also a contributor as the legs are continually going into extension, external rotation and abduction placing a greater strain on the adductors, but again, just opinion.

It would also be interesting to see the significance between player positions, if I even tried doing what the goalie in the picture below is doing, I probably wouldn’t walk for a month. 

 

By Mike Salvucci (Flickr) [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

Treatment Of Groin Injuries

During the acute stage you are going to follow your R.I.C.E protocol and rest the area.

  • R – rest
  • I – ice
  • C – compression
  • E – elevate

As the healing progresses (keep in mind if walking is difficult the person may be on crutches) manual therapy and exercises can begin, in the acute stages the injury will be too painful (depending on grade) to do much in the way of hands on therapy.

The acute phase should be getting better in about five days. If there is no progress, they should be referred to their doctor to check for other possible injuries like osteitis pubis, myositis ossificans or nerve entrapment.

Once it settles down, then try and determine which muscles specifically are having the issue by doing some manual muscle tests, although it may be tough to determine as it could be a group of muscles, not just one.

There aren’t many research articles I could find that specify exact methods or provide a treatment outline.

One recommends using muscle energy techniques, but it was referring to the sacrum for an anterior rotated innominate because of a positive standing flexion test, but research has since shown us that doesn’t happen.(2)

Another one demonstrated placing tension on the muscle with one hand while the other hand is used to take the leg into abduction and external rotation while the knee is fully extended, for use with chronic injuries.(3)

With the management of strains once the pain of the acute phase is gone, doing some manual therapy along with pain free stretching is recommended. As we have seen, some strengthening is going to have to happen as well. Having the patient begin some strengthening (if it is within your scope of practice) will be crucial in getting over the injury. Doing some balance exercises, lunges or walking up and down stairs pain free are some easy ones to start with. One of our biggest goals is to prevent this from becoming a chronic injury. As we have seen in some of the research, once someone experiences a groin pull it is then easier to re-injure the area again. Although I haven’t pulled my groin since that hockey tournament, I will never forget how painful it was. If I had gone somewhere for manual therapy, there is no way I would have let someone work on it during that first five days. Fortunately it didn’t become a chronic issue. And even though some may disagree, I’m still going to work into my hockey players gluts if they pull their groin!

References

  1. Turk P. IS THERE A RELATIONSHIP BETWEEN HIP ADDUCTOR STRENGTH AND GROIN INJURIES IN AUSTRALIAN FOOTBALL LEAGUE FOOTBALLERS?. Journal Of Australian Strength & Conditioning [serial on the Internet]. (2016, Oct), [cited January 9, 2017]; 24(5): 21-28. Available from: SPORTDiscus with Full Text.
  2. Brumm L, Carrier D, Nogle S, Johnson S. Looking beyond the soft tissue: illustrative case studies of groin injuries. Athletic Therapy Today [serial on the Internet]. (2001, July), [cited January 9, 2017]; 6(4): 24-64. Available from: CINAHL Complete.
  3. Weir A, Veger S, Van de Sande H, Bakker E, de Jonge S, Tol J. A manual therapy technique for chronic adductor-related groin pain in athletes: a case series. Scandinavian Journal Of Medicine & Science In Sports [serial on the Internet]. (2009, Oct), [cited January 9, 2017]; 19(5): 616-620. Available from: SPORTDiscus with Full Text.

Treating A Diabetic Reaction In Your Massage Clinic

 

It was a few years ago and we were having a great conversation about our favourite topic, hockey.

Being a big Jets fan, he excitedly told me the news that Winnipeg was approved to get their team back.

You could feel the excitement come across the phone: “did you hear the Jets are coming back!?”

Not 30 seconds later, he said it again: “did you hear the Jets are coming back!?”

Umm yeah, we just talked about that.

Then he repeated it again, this time his speech was a little slurred.

Something was off.

Then I clued in and asked: “did you take your insulin this morning?”

“Why would I do that”, his speech was getting more slurred.

“When was the last time you ate?”

“Why would I do that, I don’t need anything!?”

I hung up and started phoning every extension in the office, no one was answering.

I drove to the office and found him slumped over his desk, looking and sounding very confused.

The small sugar drink he had taken wasn’t working, or more likely just wasn’t enough.

I ran next door to the coffee shop and grabbed some food, Coke and orange juice.

When I got back, I held everything up and asked what would work best.

He pointed at the Coke.

I took the top off, handed it to him and he took a sip. He sat up a little, then took another drink. The third drink perked him up some more, with each drink his condition improved.

Then he looked at me and said: “what the hell were we talking about!?”

“Hockey”

“Oh yeah, did you hear the Jets are coming back!?”

Understanding Types Of Diabetes

I’m sure we all know someone and have at least a few patients who have diabetes. However it is important to know which type of diabetes they have.

There are two different classifications, although one kind doesn’t get talked about or recognized as much.

  • Diabetes Insipidus:
    • Results because of dysfunction of the posterior pituitary.
    • Causes defects in antidiuretic hormone (ADH) receptors or can’t secrete it.
    • Neurogenic Diabetes Insipidus makes too much ADH because of a brain injury.
    • Nephrogenic Diabetes Insipidus the kidneys do not respond to ADH which results in too much urination leading to dehydration.
    • This type of diabetes is typically treated with hormone therapy.
  • Diabetes Mellitus:
    • The more common form of diabetes, with classification of Type 1 and Type 2 resulting from an inability to make or use insulin.
    • Type 1 referred to as juvenile diabetes or insulin dependent, the persons immune system destroys the beta cells in the pancreas, so they don’t produce insulin.
    • People with Type 1 typically have to take insulin injections to deal with the condition.
    • Type 2 aka: non-insulin dependent diabetes or adult onset diabetes most commonly caused by cells becoming less sensitive to insulin.
    • Type 2 diabetics may need insulin injections but it is typically managed with checking blood sugar and regulating with diet.

Diabetes Mellitus is the condition we are most likely going to be faced with in our clinic, so it is important for us to understand what is happening and how to deal with this if we are ever faced with someone having a diabetic emergency before or after a treatment.

If someone who requires the use of insulin takes too much (hyperinsulinism) this can cause the body to use up any extra glucose in the blood (hypoglycemia), which then deprives the brain of the sugar it needs.

When this happens the brain cannot function properly and the body begins to shut down.

If someone is having this kind of a diabetic reaction, it can eventually lead into a diabetic coma and eventually death if it is not dealt with appropriately.

It is then our responsibility as healthcare professionals to be able to recognize and deal with this, preventing the coma and reversing the reaction.

Signs And Symptoms Of A Diabetic Reaction

If we have a patient with diabetes, chances are it is going to be Type 1 or 2.

Those with Type 2 typically manage their blood sugar with diet and monitoring blood sugar levels (sometimes they use insulin as well). This comes on later in life, usually past the age of 35.

However those with Type 1 (who use insulin) can end up suffering from hyper or hypoglycemia.

If they are experiencing hyperglycemia, there is sugar in their blood, but not enough insulin to allow their cells to be receptive to the sugar.

When this happens the body attempts to get the sugar from other sources, such as fats from within the body. This produces increased waste in the body and knocks pH balance off and the person starts to feel ill.

When the person is experiencing hypoglycemia (not enough sugar), the sugar in the body is used up and in turn affects brain function which can be life threatening.

This can be caused by a few different things:

  • Takes too much insulin.
  • Hasn’t eaten enough, or regularly enough.
  • Exercise has burned off their blood sugar faster than normal.
  • Great emotional stress.

In order to recognize a possible emergency, there are similarities between the hyper and hypoglycemic conditions:

  • An altered level of consciousness, dizzy, drowsy and confused.
  • Rapid breathing.
  • Rapid pulse.
  • Feeling ill as well as looking ill.

If you know one of your patients has diabetes and starts to show any of these symptoms, it is essential to provide the appropriate care.

Photo by: stevepb

Photo by: stevepb

Providing Care During A Diabetic Emergency

There are some specific steps to take when trying to help someone during a diabetic emergency.

If you’re not sure why the person is having an issue, we do what is called a Primary Survey. Check to see if they have their ABCs (Airway, Breathing, Circulation). If they are unconscious, call 911.

If they are conscious and speaking to you, then the ABCs are present and you can go into your Secondary Survey.

During the Secondary Survey we do a quick check of the rest of the body to see if there are any injuries that could be causing the issue. It’s just a quick rapid scan of the persons body from head to toe looking for possible injuries.

This is where you could possibly find a medic alert bracelet or necklace that could tell you they are diabetic. Nowadays some people are also getting them as tattoos, so you may see this as well.

Assuming the person can talk to you, then there is a series of questions to use called the SAMPLE questions. It is just a simple mnemonic which can help you determine what is going on:

  • S – signs and symptoms?
  • A – allergies?
  • M – medications?
  • P – past medical history?
  • L – last meal?
  • E – events leading up to the emergency?

In the case of a diabetic emergency, there are a few questions that can really help you out.

If you didn’t already know it was a diabetic emergency, knowing their medication (insulin), past medical history (diabetes) and their last meal can give you great insight into what is going on.

The person might tell you right away what is wrong and ask for something to help, but just in case they don’t, asking those questions can get you the information you need.

Now that you have determined the emergency, we need to get sugar into their system.

Keeping fruit juice, candy or non-diet soft drinks in your clinic are all great resources to help someone in this condition. After they have some sugar, it will help quickly, actually it’s surprising how quickly it can turn things around.

If the person is unconscious, do not give them anything, you could end up compromising the airway and making things worse.

Just monitor their ABCs until further help arrives.

There is a bit of controversy about determining the difference between hyper and hypoglycemic conditions as there could be a concern about giving someone sugar who already has too much sugar in their system.

While this could cause some more damage, it is not going be as life threatening as it is for someone who has low blood sugar and needs to get sugar in their system.

For our purposes in a clinical setting, we are going to treat the person with sugar because it will be difficult to know which condition is causing a problem.

Since we are not authorized to give medications we don’t inject insulin for people. If this happens before a treatment, you cannot carry on with the massage even if the patient has some sugar and starts to feel better. They need to go eat a proper meal to help balance out blood sugar. It doesn’t mean they need to go to the hospital (unless they don’t start to feel better within five minutes of getting sugar in their system), remember this is something they deal with on a regular basis (if they go unconscious, call 911). Since 9.3% of the population has diabetes and a large population remains undiagnosed, as well as the prevalence of gestational diabetes affecting 9.2% of pregnant women, there is a strong chance you will have to deal with this kind of an emergency in your clinic one day. Knowing the signs, symptoms and ways to deal with it will be the biggest way you can help any one of your patients should this happen. And yes, the Jets came back and I still get to talk to my buddy about it regularly.