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Scenario: Unresponsive Male — Shiprock Chapter House

Difficulty: MODERATE Category: Medical — Altered LOC / Pharmacology (when NOT to give oral glucose) Generated: 2026-04-04

Dispatch

Unit 7, respond to 3 Road 6575, Shiprock — Chapter House parking lot. Bystanders report a male down, not responding. Unknown age. Time out: 1347.

Scene Size-Up

Arrive to find a group of 4–5 bystanders around a male lying on his side on the asphalt. Mid-afternoon, hot (92°F). No obvious trauma. No weapons visible. One patient. Bystanders say he was "acting strange" for about 10 minutes before he went down. They do not know him.

Patient Presentation

Chief complaint: Unresponsive — cannot provide history.

Bystander info: He was walking across the parking lot, started "talking nonsense," then sat down and stopped responding. No seizure activity witnessed. No fall. No bottles or drug paraphernalia visible.

Physical exam: - AVPU: Unresponsive — no response to voice, withdraws to painful stimulus (P) - Airway: open, gurgling sound with each breath - Breathing: 8/min, shallow - Circulation: pulse 112, weak and thready. Skin cool, pale, diaphoretic. - Pupils: 4mm, equal, sluggishly reactive - No obvious trauma - Medical alert bracelet on left wrist: DIABETIC / INSULIN

Vitals: - BP: 88/60 - HR: 112, weak - RR: 8, shallow - SpO2: 89% - Skin: cool, pale, diaphoretic - BGL: 32 mg/dL

Assessment Steps
  1. Scene size-up — BSI, scene safe (bystanders cooperative), hot environment noted, 1 patient, medical NOI. No c-spine mechanism unless bystander info changes.
  2. Primary assessment — Unresponsive to voice. Airway: gurgling → needs immediate suctioning + positioning. Breathing: 8/min, shallow → inadequate, requires BVM. Circulation: weak/thready pulse, hypotension, diaphoretic → shock physiology. This is a critical patient.
  3. Simultaneous actions — Suction airway, open airway (jaw thrust if any trauma concern), begin BVM ventilation with O2 at 15 LPM. Call ALS immediately.
  4. BGL — 32 mg/dL confirms severe hypoglycemia as likely cause of AMS.
  5. Secondary assessment — Medical alert bracelet confirms diabetic. Full head-to-toe to rule out occult trauma (he may have fallen before bystanders noticed).
  6. Reassessment — Continuous. Watch for improving LOC if glucose corrected by ALS.
Interventions
  1. Suction airway immediately — gurgling = secretions/vomit obstructing.
  2. BVM ventilation — 8 breaths/min = inadequate. Assist at 10–12/min with O2 reservoir at 15 LPM. OPA if gag reflex absent (test first).
  3. Oral glucose — DO NOT GIVE. BGL is 32 and the indication exists, but the patient cannot swallow and is unresponsive. Administering oral glucose gel to an unresponsive patient risks aspiration. This is the pharmacology trap.
  4. ALS intercept — IV dextrose (D50) is the correct treatment; this is ALS scope. Get ALS en route now.
  5. Position — Recovery position once airway is managed, or continue BVM supine. Do not delay airway for positioning.
  6. Treat for shock — Supine, elevate legs (unless respiratory compromise), warm (despite ambient heat, he's in compensatory shock), O2.
  7. Rapid transport — Gallup Indian Medical Center or Northern Navajo Medical Center (Shiprock) depending on protocol and ALS availability.
Transport Decision

Immediate priority transport. Do not wait on scene for ALS — meet intercept en route on NM-491. Destination: Northern Navajo Medical Center (Shiprock) if open for this acuity, otherwise transport toward Farmington (SJRMC) and meet ALS on US-64.

Patient requires IV dextrose. Every minute of severe hypoglycemia at this level risks permanent neurological injury. Scene time should be under 3 minutes.

Key Takeaways

What this tests: Airway management + recognizing the oral glucose contraindication (unconscious patient) + shock recognition in a diabetic emergency.

The traps: 1. Giving oral glucose to an unresponsive patient — this is the most tested wrong answer for diabetic emergencies. Three criteria must ALL be met: AMS + known diabetic + able to swallow. He fails criterion 3. 2. Skipping the airway — students see the low BGL and go straight to glucose. Airway and breathing first. Always. 3. Underestimating the shock physiology — BP 88/60, HR 112, cool/pale/diaphoretic. This isn't just "low blood sugar." He may have been hypoglycemic for hours. 4. Missing the OPA assessment — if he has no gag reflex, OPA improves BVM seal. Test before inserting.

NM protocol note: IV/IO dextrose is ALS scope. EMT-B cannot administer D50. Oral glucose contraindicated in patients who cannot swallow or are unresponsive.

diabetic-emergencies | oral-glucose | altered-loc | bvm-ventilation | shock | primary-assessment