3.3 Protocol 13: Diabetic Problems & Protocol 23: Overdose / Poisoning

Protocol 13: Diabetic Problems & Protocol 23: Overdose / Poisoning

Metabolic disturbances and toxic exposures represent frequent medical calls where patient presentation can range from subtle behavioral alterations to profound coma and fatal respiratory failure. Under the Medical Priority Dispatch System, Protocol 13: Diabetic Problems and Protocol 23: Overdose / Poisoning (Ingestion) establish structured assessment pathways to identify life threats, prevent dangerous caller actions, and deliver time-sensitive pre-arrival interventions.

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1. Protocol 13: Diabetic Pathophysiology & Triage

Diabetes mellitus involves defective insulin secretion, insulin resistance, or both. For the emergency medical dispatcher, the primary operational challenge is distinguishing acute hypoglycemia (insulin shock) from hyperglycemia (diabetic ketoacidosis or hyperosmolar hyperglycemic state).

Hypoglycemia vs. Hyperglycemia Comparison

The Neuroglycopenic Emergency

The human brain relies almost exclusively on continuous blood glucose delivery, as neurons cannot synthesize or store glucose. When serum glucose plunges—often caused by a diabetic patient administering their usual insulin or sulfonylurea dose but skipping a meal or exercising heavily—the cerebral cortex experiences acute starvation (neuroglycopenia). Initial manifestations include bizarreness, belligerence, or slurred speech (frequently mistaken by bystanders or law enforcement for acute ethanol intoxication). If untreated, it progresses rapidly to generalized convulsions, coma, and irreversible cortical necrosis.

Protocol 13 Determinant Levels

Protocol 13 is unusually compact — exactly five codes, with one DELTA, three CHARLIE, and one ALPHA, and no ECHO or BRAVO level:

• 13-D-1 (DELTA Level): Unconscious. The only DELTA code on Protocol 13.
• 13-C-1 (CHARLIE Level): Not alert.
• 13-C-2 (CHARLIE Level): Abnormal behavior. The suffix C (combative/aggressive) is appended when the patient is fighting or aggressive, warning responders to stage for law enforcement without changing the determinant level.
• 13-C-3 (CHARLIE Level): Abnormal breathing.
• 13-A-1 (ALPHA Level): Alert and behaving normally (minor diabetic symptoms, glucose meter check request).

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2. The Golden Rules of Oral Glucose Administration

When a diabetic patient is symptomatic, callers frequently want to force sugar, orange juice, or syrup down the patient's throat. Dispatchers must enforce strict clinical prerequisites before permitting any oral administration.

                      [Protocol 13: Diabetic Problem Assessment]
                                        |
               [Check Patient Consciousness & Level of Alertness]
                                        |
                   -------------------------------------------
                   |                                         |
     [Patient NOT Alert / Unconscious]               [Patient FULLY Alert]
                   |                                         |
     [13-D-1 DELTA / 13-C-1 CHARLIE]                       |
                   |                           [Can patient swallow unassisted?]
     [CRITICAL DISPATCH RULE:                      [Is patient sitting upright?]
      NEVER administer anything by mouth!]                   |
                   |                            -----------------------------
       [Place in Recovery Position]             |                           |
        [Monitor Airway Continually]          [NO]                        [YES]
                                                |                           |
                                       [Withhold Oral Sugar]       [Administer Fast-Acting Sugar]
                                       [Maintain Airway]           (Fruit juice, regular soda, sugar)

Strict Oral Administration Criteria

An EMD may authorize oral administration of sugar only when all of the following conditions are confirmed:

1. The patient is fully awake, alert, and responsive to verbal questions.
2. The patient is sitting upright (never supine or slouched).
3. The patient has an intact swallowing reflex and can hold a cup or swallow on their own without assistance.

⚠️ Fatal Hazard: Liquid in the Airway

Never pour fruit juice, honey, syrup, or granulated sugar into the mouth of a semi-conscious, stuporous, or seizing patient. The depressed gag reflex allows fluids to pour directly past the vocal cords into the bronchial tree, causing immediate laryngeal spasm, complete mechanical obstruction, or fatal aspiration chemical pneumonitis.

3. Protocol 23: Overdose / Poisoning (Ingestion)

Protocol 23 encompasses accidental toxic ingestions (pediatric exploratory ingestion of household chemicals, geriatric dosing errors) and intentional overdoses (deliberate self-harm, recreational drug toxicities). The dispatcher must maintain rigorous scene safety, identify critical toxidromes, and extract structured pharmacological data.

The Structured Toxicological Interrogation (The 5 W's)

During Key Questioning, the EMD must systematically ascertain:

1. What substance was taken? Trade name, generic chemical name, formulation (extended-release vs. immediate-release, liquid, powder, caustic bleach, hydrocarbon).
2. What route was involved? Oral ingestion, inhalation, transdermal absorption, intravenous injection, or ocular splash.
3. How much was taken (Quantity)? Number of pills missing, volume in milliliters/ounces, container size, empty blister packs.
4. When was it taken (Time elapsed)? Exact time or approximate window; critical for antidote therapeutic windows (e.g., N-acetylcysteine for acetaminophen, activated charcoal eligibility).
5. Why was it taken (Intent) & What else was involved? Accidental vs. suicide attempt; co-ingestion of ethanol, prescription sedatives, or illicit adulterants.

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4. The Opioid Toxidrome and Naloxone Pre-Arrival Coaching

The ongoing synthetic opioid crisis (fentanyl, carfentanil, nitazenes) has elevated opioid overdose to one of the most frequent DELTA/ECHO medical dispatches. Synthetic opioids are potent mu-opioid receptor agonists capable of crossing the blood-brain barrier within seconds, inducing acute respiratory depression and fatal wooden chest syndrome (severe intercostal and diaphragmatic muscle rigidity).

The Pathognomonic Opioid Overdose Triad

An emergency medical dispatcher must instantly recognize the clinical triad of opioid toxicity:

1. Severe Central Nervous System Depression: Unresponsiveness, stupor, or profound coma.
2. Severe Respiratory Depression: Hypoventilation, bradypnea (< 8–10 breaths per minute), shallow breathing, cyanosis, snoring stertor, or agonal gasps.
3. Miosis (Pinpoint Pupils): Constricted, unreactive pupils (though pupillary size may normalize if severe anoxic brain injury has supervened).

Naloxone (Narcan) Dispatch Life Support Instructions

When callers have access to intranasal naloxone (Narcan nasal spray 4 mg):

• Dispatch verifies the patient is unresponsive with abnormal breathing.
• EMD instructs caller: "Peel open the package and take out the device. Place your thumb on the bottom of the plunger and two fingers on either side of the nozzle. Insert the nozzle into either nostril until your fingers touch the bottom of the person's nose. Press the plunger firmly to release the dose into their nose."
• EMD instructs caller to monitor breathing. If effective breathing does not resume within two to three minutes, or if second doses are available, repeat administration in the opposite nostril.
• Airway Support First: If the patient is not breathing at all, the dispatcher must never delay CPR while the caller searches a house for Narcan. Compressions and ventilation must commence immediately; naloxone is administered concurrently if instantly accessible.

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5. Poison Control Coordination vs. 9-1-1 Emergency Dispatch

A common dilemma in emergency communications is determining when to dispatch field emergency medical services versus transferring the caller to the regional Poison Control Center (1-800-222-1222).

Absolute Criteria Requiring Immediate 9-1-1 Field Response

Under MPDS standards, an emergency medical response must be dispatched immediately—and never delayed for Poison Control consultation—if the patient exhibits any of the following:

• Decreased level of consciousness, stupor, confusion, or unresponsiveness.
• Abnormal, labored, shallow, or absent breathing.
• History or threat of intentional overdose / suicide attempt (demands EMS and law enforcement scene safety response).
• High-threat ingestions: Caustic acids/alkalis, organophosphates, hydrofluoric acid, toxic alcohols (methanol, ethylene glycol), or cyanide.
• Presence of active seizures or chest pain.

When Poison Control Consultation is Appropriate

If the exposure is completely accidental, the patient is 100% alert and behaving normally, and there are zero priority symptoms, the EMD may connect the caller to Poison Control via a three-way call or follow local medical direction for non-emergency triage.

Absolute Contraindications in Ingestion / Poisoning

• Strictly Forbid Inducing Vomiting: Never tell a caller to give syrup of ipecac, stick fingers down the throat, or administer salt water. If the ingested substance is a caustic agent (drain cleaner, battery acid, lye), vomiting re-exposes the esophagus and pharynx to severe chemical burns, causing esophageal rupture and mediastinitis. If the substance is a hydrocarbon (gasoline, kerosene, lighter fluid), vomiting leads to immediate pulmonary aspiration and fatal chemical pneumonitis.
• Strictly Forbid Chemical Neutralization: Never advise a caller to administer vinegar to neutralize an alkali or baking soda to neutralize an acid. The chemical neutralization reaction is highly exothermic; the intense heat released inside the stomach causes severe thermal coagulative necrosis on top of chemical injury.