Diabetic Emergency Training for Law Enforcement - Refresher

You’re patrolling your beat, the Ford truck ahead of you is driving erratically, you light him up, he sideswipes a parked car as he pulls over.  As you approach the car and ask the driver for his license and proof of insurance. The driver is confused; slurring his words, irritable, sweating, and pale. When you ask him to step out of the car, he staggers. He becomes aggressive when you try to cuff him. Looks like a classic deuce. Then again, maybe not.

Is he intoxicated? Or could he be a diabetic in a hypoglycemic crisis (dangerously low blood glucose)?  Do you call for backup, do you call for medics, do you give him some sugar packets, or do all three?

Many of the signs of hypoglycemia are similar to signs of someone who is drunk or on illegal drugs.  Failing to recognize severe hypoglycemia may result in death. These situations, while relatively rare, grab headlines and lead to lawsuits. People with diabetes and their friends and family may know how to recognize low blood sugar, but do you?

The following case represents an example of when things go terribly wrong in a hypoglycemic emergency. It is being offered for training purposes.

In October 2010, Adam Greene was removed from his car by law enforcement officers from the Henderson, Nevada, Police Department and the Nevada Highway Patrol (NHP).  Mr. Greene was thought to be driving under the influence. A NHP dash cam video recordered the incident. Shortly after Mr. Greene was placed onto the roadway, officers suspected he was not driving under the influence, but was instead suffering from a diabetic emergency and losing consciousness. In 2012 Greene agreed to accept $292,500 from Henderson police and the state of Nevada to settle a federal civil rights, battery and negligence lawsuit.

Despite continuous training programs which focus on diabetic events, law enforcement officers may unintentionally “misread” a person. DO NOT assume that the person you are speaking to is “drunk,” “high on drugs,” or in a state of excited delirium. It is important to remember that any individual experiencing an altered state of mind as being in a medical emergency.

Definition: In diabetes, insulin, a hormone produced by the pancreas, is either totally or partially lacking. Insulin is needed by the body to convert sugar, starches and other food into energy needed to sustain life. Without insulin, life is not possible for long due to high sugars and toxins that increase in the blood. On the other hand, too much insulin lowers the blood sugar so much that the brain and other organs cannot function.

The Facts:

·        Prevalence: In 2015, 30.3 million Americans, or 9.4% of the population, had diabetes.

·         There are two major types of Diabetes:

        o   Type 1 Diabetes - Accounts for 10% of all diabetes cases (formerly called Juvenile but can occur at any age). This condition requires daily insulin because the body does not produce insulin. It is administered via needle injections or an insulin pump. The absence of insulin can lead to severe illness and death.  

        o   Type 2 Diabetes - The body does not produce sufficient quantities of insulin. This condition requires diet, exercise, pills and sometimes insulin injections and pumps to control the blood sugar.

·         Deaths: Diabetes remains the 7th leading cause of death in the United States in 2015, with 80K death certificates listing it as the underlying cause of death, and a total of 252K death certificates listing diabetes as an underlying or contributing cause of death.

·         Diabetes has no cure.

Diabetic Emergencies

(1)  Insulin Reaction (Hypoglycemia-very low blood sugar):  Hypoglycemia is a medical emergency in which there is an abnormally low level of glucose in the blood. It can lead to a variety of symptoms, but the most notable effects occur when there is a lack of glucose to the brain, a state called neuroglycopenia. Patients can be asymptomatic or have symptoms such as dizziness, fatigue, emotional lability, seizures, coma and death.

This condition is caused by too much insulin or certain diabetes pills, alone, or in conjunction with, too little or delayed food intake, exercise, alcohol, drugs, over the counter medication, or any combinations of these factors.

Signs and Symptoms

·         Possible sudden onset 

·         Staggering or poor coordination (may be mistaken for intoxication or drug use)

·         Slurred Speech

·         Confusion 

·         Poor concentration

·         Bizarre behavior

·         Changes in personality or mood swings (irritable, displaying anger, bad temper or combative!)

·         Pale color 

·         Sudden hunger

·         Excessive sweating

·         Trembling

·         Eventual unconsciousness and seizures

(2) Diabetic Ketoacidosis – Diabetic Coma (Hyperglycemia - very high blood sugar): Diabetic ketoacidosis (DKA) always results from a severe insulin deficiency and results in the body becoming too acidic.

This condition may be caused by insufficient insulin, illness, dehydration, a heart attack, stroke or other medical problems. 

·         Gradual onset

·         Drowsiness

·         Confusion

·         Extreme thirst

·         Very frequent urination

·         Flushed skin

·         Vomiting

·         Fruity breath odor (may be mistaken for alcohol on breath)

·         Heavy breathing

·         Eventual unconsciousness

Other Indicators of Diabetes

        1.       Check for medical identification bracelet, necklace, or card (wallet).

        2.       Diabetes devices and supplies such as blood, glucose meters and strips, finger-stick lancing devices, insulin vials, syringes, medication pens, an insulin pump with or without tubing, and a continuous, glucose monitor with a sensor under the skin.

        3.       A supply of emergency snacks nearby.

Steps to Take in a Diabetic Emergency

• If you suspect the subject has diabetes, roll fire and paramedics
• Obtain as much history as possible to provide medical professionals. If the subject is able to communicate, ascertain when the last time they used insulin or ate was to provide info to paramedics.
• There is a chance the subject is carrying his personal blood glucose monitor, if he’s able, checking his blood sugar before medics are on scene can help save time.
• It can be hard to tell if a victim has a high or low blood-sugar so treat the low blood sugar first.
• For hypoglycemia give 3 sugar packets, 6 oz coke, or ½ glass of any kind of juice box. A slice of bread or crackers will also work. It is not a bad idea to carry these items in your car.
• Do not force an unconscious person to swallow.
• For hyperglycemia only give the subject water. Do not administer insulin. Insulin can only be provided at the hospital.

Detaining a Diabetic Suspect

1.       Promptly after individuals are taken into custody, a medical checklist or other recording method must be used to identify persons with diabetes. Make sure this information accompanies the detainee to all facilities while he/she is in custody.

2.       Detainees with diabetes should only be held where there is immediate access to health care professionals who are able to manage their care and respond to diabetes emergencies.

3.       Detainees with diabetes must continue their medication schedule without interruption to avoid dangerously high blood glucose levels (hyperglycemia) and must always have access to food to avoid dangerously low blood glucose levels (hypoglycemia). It is important to coordinate meals and medication to maintain blood glucose levels in a safe range. If a detainee with diabetes requests a source of sugar to treat his/her diabetes, immediately provide that person with the appropriate food or beverage.

Civil Rights of People with Diabetes

Every year, the American Diabetes Association (ADA) receives requests for assistance from individuals who allege unfair treatment by police officers or prison or jail officials because of their diabetes.

These include:

• Inappropriate use of force when an individual is experiencing a diabetes emergency
• Inadequate diabetes care during custody prior to trial
• Inadequate diabetes care while serving sentence

The ADA’s legal advocacy volunteers (doctors, nurses, lawyers and parents) have been working with law enforcement personnel to educate their communities. First responders (police, firefighters, and emergency medical technicians) are training on how to spot and care for people in diabetic crises.