Collapse at a village health camp with a glucose of 48 mg/dL

The priority is hypoglycaemia, and it is a treatable cause of altered consciousness, so it is treated first while other causes are considered.

Supporting it: a measured glucose of 48 mg/dL with sweating, tremor and slowed answers; insulin taken at 07:30 with breakfast at 07:00 and a 2 km walk, so the insulin effect is meeting unaccustomed exercise; the autonomic signs fit. Neuroglycopenia - slow answers - means the brain is already short of glucose, so this is not a mild episode to be watched.

Alternatives: a stroke would explain slow answers but not usually the sweating with a low glucose, and there is no asymmetry recorded; dehydration or heat at a camp would not give a reading of 48 mg/dL; sepsis would give fever. The deciding argument is that a low glucose is measured, cheap to correct and causes brain injury if left, whereas giving sugar to a patient whose glucose is normal is harmless. So treat as hypoglycaemia, then recheck, rather than wait for the doctor.

The doctor should still be informed now and the ambulance alerted, because the response to treatment will decide whether she can stay at the camp.

1. Sit her upright, stay with her, and tell the doctor and the camp in-charge what is happening. Reason: she must not be left alone; she could deteriorate and no one would know.
2. Give 15 to 20 g of fast-acting carbohydrate. The gel tube or about 4 to 5 level teaspoons of sugar in a little water is practical; avoid anything with artificial sweetener, which does not raise glucose. Reason: 15 to 20 g is enough to raise glucose in 10 to 15 minutes without causing a spike.
3. Give it by spoon in small sips while she is fully upright and swallowing. Never lie her flat and pour, and never give fluids to a drowsy or unconscious patient. Reason: aspiration is the main avoidable harm here.
4. Recheck glucose after 15 minutes. If still below 70 mg/dL, repeat the 15 to 20 g dose. Reason: the standard is treat, recheck, repeat, not one dose and hope.
5. Once glucose is above 70 mg/dL and she is fully alert, give a longer-acting carbohydrate such as roti, biscuits and milk. Reason: the insulin is still in her body; a single sugar dose will take her low again.
6. Do not give insulin or her oral tablets, and do not send her home alone or let her walk back. Reason: she is at high risk of a second episode.
7. Advise review of the insulin dose and the meal-to-injection timing with her doctor, and record everything with times.

Everything taken by mouth stops. The steps:

1. Stop oral sugar immediately and remove the spoon. Reason: an unresponsive patient cannot swallow, so the next spoonful can cause aspiration.
2. Place her in the recovery position, keep the airway clear, check breathing and pulse, and call for the doctor and the ambulance at once. Reason: airway and circulation come before glucose now.
3. Give nothing by mouth - not water, not sugar, not ORS. Reason: an unresponsive patient cannot protect her airway, and the risk is choking and aspiration pneumonia.
4. Check the glucose again, and tell the doctor and the ambulance crew the reading and the exact time of the last oral sugar. Reason: the receiving team needs to know what was given and when to interpret further readings.
5. Do not give another oral dose and do not wait to see if she wakes.

Documentation: onset of symptoms at 11:40, glucose 48 mg/dL, what was given and how much, the time of each dose, the recheck value, the time she became unresponsive, the position used, the doctor informed, the ambulance called. The handover repeats the same facts aloud, because the biggest risk is the next team assuming she has already been treated and not rechecking glucose.