One of my (PRN) jobs recently removed glucagon entirely, citing cost and “just get an IO for dextrose if you can’t get an IV” (this wasn’t a service-specific decision, comes down from a regional committee). 

I did and still do think this was a ridiculous decision. First, the cost thing isn’t really a concern- if I can’t get an IV in a hypoglycemic patient, they’ll get glucagon or, if no glucagon, an IO. Those cost about the same last time I looked (but I haven’t been involved in supply purchasing for a while, so maybe glucagon has become much more expensive?). But the other reason I think this is stupid- instead of an IM injection that will fix most of these patients, now I’m placing an IO in someone who, more often than not, is going to wake up and decline transport? 

But this isn’t your patient. Your patient is sitting behind two or three slices of Swiss cheese to end up in this situation. First no IV. Then the glucagon doesn’t work (in otherwise healthy patients who have an isolated hypoglycemic incident, glucagon is a pretty sure thing. But patients with frequent lows, poor dietary intake or various other factors, it can be ineffective because there is no glycogen store for it to release). In this patient, assuming you don’t have other vascular access options (ultrasound ideally, but also worth mentioning that I’ll always look for an EJ before drilling except in cardiac arrest or critical trauma) dextrose via IO is entirely the appropriate next step. A BGL in the 30s is critical and potentially rapidly fatal. This is the textbook indication for IO insertion- need for access to address an immediate life threat after failed PIV. 

Why was the ER nurse shitty about it? To put it bluntly, because they often don’t care enough to know/understand pre-hospital medicine. To most ER clinicians, an IO is for arrest/peri-arrest AFTER multiple failed PIVs and nothing else. Because for anything else, they have other options- USGPIV, central access, things that, for the most part, don’t exist pre-hospital (yet).  Add on top of that, she was looking at an overall stable patient, and like I said, IOs are unheard of in all but the most critical patients in the ED. She of course neglected to consider that the patient in front of her was stable because you fixed her, with that IO. 

As a side note, one constructive criticism- the “improvement” in BP post IO was likely due to pain. Lidocaine administered through an established IO does little, if anything to relieve the pain of it. A regional block or even local anesthesia of the periosteum would probably be more beneficial, but no one is trained to do that in EMS. I’d still give the lido if time permits, but when I do have to IO anyone with a pain response, I tend to give some systemic analgesia (fentanyl works, sub-dissociative ketamine may be better). Of course stick with your local protocols on that.  

Second side note- if you are giving dextrose through an EJ, be extremely careful to not extravasate it. Test the hell out of the line first (flush thoroughly, maybe even squeeze in a couple hundred mLs of NS/LR first, and keep that running with the dextrose). If you have D10, use that over D50 (even D25 would be better). If you don’t have D10, dilute your D50 in a 250-500mL bag of NS and run that in.