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Underutilization of Glucagon in the Prehospital Setting

TO THE EDITOR: Kahn and colleagues (1) make a case for greater use of glucagon by providers of basic emergency medicine in the prehospital setting. We concur that glucagon should be more available to providers without access to more preferred options to treat profoundly hypoglycemic patients. However, we believe that the authors' misunderstanding of modern prehospital care has led them to overstate the magnitude of this situation. Kahn and colleagues are correct that use of glucagon by emergency medical services (EMS) personnel is restricted to paramedics in most states. They then assume that this factor probably impedes patient care, because emergency medical technicians (EMTs) make up 76% of all EMS providers and may not have glucagon. However, their data did not allow for precise review of crew composition. Indeed, many EMS systems respond with both EMTs and paramedics. Paramedics who respond with EMTs can provide glucagon and intravenous dextrose, the preferred prehospital treatment for patients with hypoglycemia who are obtunded (2). Furthermore, oral glucose is widely available to EMTs and both effective and safe (even when applied to the buccal mucosa of patients who are obtunded). Despite workforce statistics that the authors cite, effective prehospital treatment of profound hypoglycemia is thus more available than they fear. Kahn and colleagues are also concerned that incorrect crews may not be dispatched because dispatch coding is not specific to diabetic emergencies. Those who call emergency services often present incomplete information, which may cause a hypoglycemic event to receive an urgent but nonspecific dispatch code. Regardless of coding, these calls are managed with the same degree of urgency and by the most advanced-level EMS provider available. Of note, Kahn and colleagues excluded EMS calls with response times greater than 60 minutes from their analysis. Patients in rural and frontier settings are more likely to experience long response times and have EMS crews that comprise only EMTs. Although EMS outcomes data for these patients are scarce, our anecdotal experiences have shown benefits of EMT-administered glucagon and ill effects from its absence in this population. We agree that glucagon should be more available to EMS providers and members of the public who have no other options to treat profound hypoglycemia. However, the problem that Kahn and colleagues identify is not as dire as they describe.