Acting Drunk at the Bus Terminal
You are called to a city bus terminal for a 45-year-old man who is acting drunk. He is sitting on a bench, sweating heavily, and slurring his words. He is awake but does not answer questions appropriately and cannot tell you his name. A medical alert bracelet reads insulin-dependent diabetes. A bystander says the man injected insulin about 30 minutes ago and then did not eat. His skin is pale and clammy, pulse 118 and weak, respirations 20. Your glucometer reads 42 mg/dL. He will not reliably swallow and has already coughed when a bystander tried to give him a soda. Your service does not carry glucagon; ALS is 10 minutes away and the hospital is 12 minutes. He is on a bench next to a busy curb.
1. What are your first moves, and what makes this scene and this patient riskier than they look?
Read the worked answer
Scene hazards first, then the patient.
- He is beside a live traffic lane and is confused and unsteady. Move him away from the curb before anything else - a hypoglycemic patient can bolt or fall into traffic. Use the bench area set back from the lane.
- Do not let him stand and walk.
Then:
- Position him safely - sitting supported or lying on his side. He is confused and may vomit; the recovery position protects the airway.
- Assess the airway and gag - he is slurring and not answering appropriately. That is airway risk, not just confusion.
- Confirm the glucose reading: 42 mg/dL with sweating, pallor, tachycardia, and altered mental status is a coherent picture - low blood sugar causing the behavior, not intoxication.
- Treat the cause of the scene hazard - the altered behavior is the medical problem. Expect it to improve if glucose is corrected, but do not count on it.
- Request ALS early. They carry glucagon and can give IV dextrose; you cannot.
Document that the bystander's soda attempt caused coughing, because that changes what you are willing to put in his mouth.
2. A bystander keeps insisting you just give him sugar because he is diabetic. Explain why you are not giving oral glucose, and what you will do instead.
Read the worked answer
Because the sugar is not the risk here - the airway is.
Reasoning:
- He is confused, cannot tell you his name, is slurring, and has already coughed and choked when liquid was put in his mouth.
- Oral glucose requires a patient who can swallow reliably and protect their airway. He cannot demonstrate either.
- Aspiration in a bus terminal, with no suction immediately at hand and 10 minutes to ALS, is a worse outcome than a few more minutes of low blood sugar.
- Altered mental status alone is enough to withhold anything by mouth until he can prove he can swallow.
What you do instead:
- Recovery position, suction ready if available; monitor breathing continuously.
- Oxygen if his saturation is low or he is working at breathing.
- Request ALS for glucagon or IV dextrose and say the glucose is 42 with altered mental status - that gets a response.
- Transport toward the hospital and meet ALS en route rather than sitting on the bench for 10 minutes.
- Reassess mental status, airway, and breathing every few minutes.
If he becomes alert enough to swallow safely, oral glucose becomes reasonable - the decision is reassessed, not fixed.
3. En route he becomes unresponsive with slow, snoring respirations. What is your next action?
Read the worked answer
Airway and ventilation, immediately.
Snoring in an unresponsive patient means soft tissue is obstructing the upper airway. This is a ventilation emergency, not a blood-sugar problem right now.
Actions:
- Open the airway - head-tilt/chin-lift, and check for vomit or a foreign body; suction if present.
- Insert an oropharyngeal airway if he has no gag reflex. If he gags, remove it - do not force it.
- Assist ventilations with a BVM and high-flow oxygen. Snoring that does not clear with positioning needs positive pressure support.
- Recheck the glucose if you can while ventilating - it may have fallen further, and the underlying cause is still hypoglycemia.
- Reassess chest rise, rate, color, and mental status after each intervention.
- Update ALS and the receiving facility with the change in status.
The trap is to keep chasing the blood sugar with the mouth shut and the airway snoring. The airway gets fixed first; the glucose problem gets fixed by someone with glucagon or dextrose.