Confused and sweating in a hot galley: glucose 2.4 mmol/L
It is 1320 in the galley of a vessel alongside in Apapa and the ambient temperature is 34 degrees Celsius. The chief cook, 46, is a known type 1 diabetic on daily insulin. He skipped breakfast because of a late cargo operation and has been working since 0600. A messman finds him on the galley floor, sweating heavily, confused and aggressive when helped up. He is conscious, breathing normally and able to swallow. His skin is cool and moist, his pulse is 112 and weak, and his capillary blood glucose reads 2.4 mmol/L on the ship's meter. He has a bump and a small cut on his forehead from the fall. There is a glucagon kit and glucose gel in the medical chest. The second officer wants to give him his usual insulin 'to settle him', and the master wants him back on duty after a rest. There is no doctor on board; the port clinic is 40 minutes away by car.
1. He is confused and pushes the cup away. How do you give the glucose safely, and at what point do you stop trying by mouth?
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He is conscious and able to swallow, so oral glucose is the fastest route and should be attempted first, but his confusion and aggression make aspiration a real risk, so this is a controlled procedure, not a drink.
Sit him upright, never flat, and have a second person support his shoulders. Give about 15-20 g of fast-acting carbohydrate - glucose gel, or three to four teaspoons of sugar stirred into a little water - slowly, spooned or syringed into the side of the mouth, a small amount at a time. Stop immediately if he coughs, gags or his voice changes. Do not force a cup between his teeth while he is resisting, and do not tip his head back to pour.
Recheck the glucose after 10-15 minutes and repeat the dose if it is still below 4 mmol/L. Stop oral attempts and switch to the unconscious-patient route if he becomes drowsy, stops responding, cannot swallow or vomits: nothing by mouth, recovery position, high-flow oxygen, glucagon 1 mg intramuscularly if available and covered by medical advice, and urgent transfer to the clinic. Never give insulin.
2. Fifteen minutes later the reading is 6.1 mmol/L and he is lucid. What are your next decisions, and what do you say to the second officer and the master?
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Give a longer-acting carbohydrate now - bread, biscuits, a proper meal - because the insulin he has already taken is still circulating and without sustained carbohydrate he will drop again.
To the second officer: no insulin. His glucose is 2.4 mmol/L; insulin lowers glucose and would be potentially fatal, whatever his behaviour looked like. His aggression was a symptom of the hypoglycaemia, not a discipline problem, and it resolved when the glucose came up.
To the master: he does not go back on duty. He has had an episode with impaired consciousness and a fall, so he needs assessment ashore, a wound check on the forehead and a head injury review - a bump plus confusion deserves a second look even though the confusion cleared with glucose. Keep him under observation, not alone, with a responsible person, and record the episode, the readings, the treatment and the times in the medical log. Explore why it happened: missed meal, heat, workload, infection, alcohol, a change in insulin dose. Recurrent episodes are a fitness-for-duty question for a doctor, and a crew member who has had one severe hypoglycaemic episode is at risk of another.
3. Why is heat illness also on the list here, and how would you tell the conditions apart at the bedside?
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The galley is 34 degrees Celsius, he has been working since 0600 without breakfast, he is sweating heavily and he is confused. Heat exhaustion and hypoglycaemia produce overlapping pictures - sweating, weakness, confusion, a rapid pulse - and can coexist in the same patient, so the differential has to be worked consciously rather than assumed.
Discriminators: a glucose of 2.4 mmol/L with cool clammy skin and a weak rapid pulse points strongly to hypoglycaemia, and improvement within minutes of glucose confirms it. Heat exhaustion typically shows a core temperature up to about 40 degrees Celsius with heavy sweating, thirst, headache, nausea and dizziness, a normal glucose, and improvement with rest in a cool place and fluids. Heat stroke is altered mental state with a core temperature above 40 degrees Celsius, often hot skin, and is a life-threatening emergency needing aggressive cooling and evacuation. Measure temperature if the medical chest has a thermometer.
Also consider stroke - facial droop, unilateral weakness, slurred speech - which will not correct with glucose. Treat the low glucose first because it is immediately reversible, then reassess rather than closing the case.