You are a paramedic on a crew doing a standby at a room-and-contents fire. After about 30 minutes, the fire is under control and you are setting up a small rehab area. Suddenly you notice some commotion as one of the younger firefighters is being escorted over to you.
Fully controllable, diabetes can do incredible damage when not managed
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He seems to be fighting the other firefighters a bit as they do so.
Paul is a 19-year-old college student who has been with the department for three years, joining as a junior firefighter while in high school. He comes from a firefighting family — his father, two brothers and grandfather are all active members.
His crew puts him on the stretcher and informs you that he started acting weird, stumbling around, not able to do any of the typical tasks that he has gotten to be quite good at. They say he was acting drunk but everyone knows he is not a drinker.
You start to assess him and find his vitals within expected limits — his heart rate is a bit elevated at 120 but nothing out of the ordinary for someone who just finished fire duties. He is certainly altered and a bit combative, definitely out of the ordinary for Paul, an easy-going guy with a long firefighting career in front of him.
A few of his crew are hanging nearby but his best friend comes closer to you while you are running through some differential diagnoses.
"Um, I think you should check his sugar."
"OK, but why?" you ask.
His friend seems reluctant to say more.
"Look, if you know something that will help me treat Paul, you need to tell me," you advise him.
Finally his friend states, "Paul was diagnosed with diabetes six months ago. He swore everyone to secrecy because he thought it would prevent him from being a firefighter. He takes insulin at every meal and at night."
You check his blood glucose and it is 37 mg/dL, quite low. An IV and some D50 and he is much more alert and acting normally. He is upset that his secret is out and is on the verge of tears.
All too real
Is this a realistic scenario in the fire service? You bet.
We all know that there are certain conditions that the National Fire Protection Association recommends is automatic disqualifier. Diabetes used to be one of those disqualifiers. The latest edition of NFPA 1582, from 2007, permits diabetics to be firefighters but there are a number of strict standards.
In fact, this incident that Paul just experienced will disqualify him per NFPA 1582 for a period of one year.
The role of the NFPA medical standard varies from department to department. Some will honor them word for word, others will allow their fire department physician to make the recommendation and follow that. Some do not follow the NFPA at all.
I am not a labor lawyer. However, simply because NFPA makes a standard does not mean this standard would override other laws such as the Americans with Disabilities Act or other applicable laws.
Thus, issues involving medical conditions will continue to play a role in the fire service and those of us who care for firefighters need to be aware of these conditions. Unfortunately, some firefighters will hide these conditions if they feel that disclosure will prohibit them from doing what they love.
OK, back to Paul. What happened to him today?
There are two types of diabetics, Type I and Type II. Type I used to be called juvenile diabetes and Type II was adult onset. However we are seeing more and more children, usually those who are overweight, with Type II diabetes so these terms are not really appropriate any more.
Another term not really used anymore is IDDM and NIDDM – Insulin Dependent Diabetes Mellitus and Non-Insulin Dependent Diabetes Mellitus. More and more patients that develop diabetes later in life, Type II diabetics, are requiring insulin as well, so this term is a misnomer.
Type I diabetics are typically younger and their condition results from an auto-immune attack on the pancreas. The pancreas is an organ in the abdomen that makes insulin, among other substances. In Type I diabetes, the body, for reasons we in medicine do not fully understand, attacks and destroys the cells in the pancreas that make insulin. Thus, insulin is not created.
Insulin is a hormone that helps the cells of the body use sugar — it is a key that opens the door to allow sugar to enter the cell to power its functions. Without insulin, the sugar remains in the blood. The cells, including the cells of the brain, receive no sugar and are unable to function as well.
Paul likely took his insulin at his last meal, but then the tones dropped for this working structure fire. His level of exertion was increased significantly. Exercise not only increases the amount of sugar the body needs, but also makes the insulin that is present work more efficiently.
Thus it is common for Type I diabetics to have their blood sugar drop during exercise or exertion. In fact, diabetics are often told to check their blood sugar every 30 minutes during exercise.
If they are low, typically less than 70 mg/dL but perhaps even less than 100 mg/dL if the exercise is going to continue, they are advised to eat a snack with carbohydrates in it to raise their blood sugar a bit.
Type II diabetics are different. Here, the pancreas is still making insulin, but the cells of the body are not listening to it. These individuals are often (but not always) overweight, and have other medical problems such as hypertension and heart disease. If they were to lose weight, they would often have an improvement in their condition and my even not need treatment anymore.
The treatment for Type II diabetics is typically oral medications to make the cells listen a bit better. These can include metformin (Glucophage) and thiazolidinediones (Avandia, Actos), which will not lower the blood sugar. Another option is medications that make the pancreas release more insulin, such as sulfonylureas (glipizide, glyburide, glimepiride).
Patients on these medications could actually present similar to our Firefighter Paul, because the increase in insulin release with less food intake and increase in activity can make the blood sugar drop.
So we can treat Paul's low blood sugar — this is the bread and butter of EMS and diabetic emergencies. He does not need to go to the hospital — we fixed the problem and we generally know why it happened.
Managing the diabetic firefighter
But what can we do to manage a firefighter like Paul in the future who the department and the fire department physician chooses to keep on active duty?
Paul should keep a supply of snacks that are high in carbohydrates in his bunker gear. On the way to a fire or any activity, he should have a snack with 15 to 30 grams of carbs. Every 30 minutes, he needs to check his blood sugar. If it is low, he needs to have more carbs.
Those of us staffing rehab need to know to look out for Paul and help him be able to check his sugar quickly. Monitor his behavior for symptoms of low blood sugar. If it is significantly low, such as less than 70 mg/dL, he should be done for the day. If he keeps his blood glucose up, then he should be fine.
Diabetics of all types need exercise and activity; in fact, all firefighters need this. In my opinion as a physician, excluding Paul simply because he is diabetic is not necessary. Excluding him for a year because his blood glucose dropped is also not necessary.
Educate him and his fellow firefighters. Consider the job descriptions that he can and cannot do. Perhaps he should not be at the top of a ladder, but being on a hose line or extrication company may be very reasonable.
A fire department's leaders, physician and lawyer should all be able to sit down with a diabetic firefighter to decide the best approach. If they decide to follow NFPA to the letter, then so be it.
But everyone, and every department, is different — keep an open mind. It would be a shame to lose a dedicated firefighter such as Paul just as he is learning to manage his condition.
I would like to dedicate this article to my 12-year-old daughter, who was just recently diagnosed with Type I diabetes. The ability of children to adapt to life changing conditions never ceases to amaze me, and she is no exception. Stay safe.
About the author
The Rehab Zone. Kenneth G. Lavelle, MD, FACEP, FF/NREMT-P, is Clinical Instructor of Emergency Medicine at Jefferson Medical College, Philadelphia, and Attending Physician at CapitalHealth, Trenton, N.J. He was previously an attending physician at Albert Einstein Medical Center, and previously spent 14 years working as a firefighter and EMS provider.
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