Should EMS Improvise? And the Recipe for the “Kaiser Cocktail”

Here’s the recipe for what I call the “Kaiser Cocktail”:

  1. Look in the patient’s kitchen cupboards until you find a box (or a bag) of some type of granulated sugar, powdered sugar, or brown sugar. (in a pinch, you can use honey or syrup)
  2. Find one of the patient’s own cups or glasses, wash it if you have to.
  3. Dump a bunch of the sugar in the glass.
  4. Look in the patient’s refrigerator until you find some soda pop or some type of sweet juice like orange, apple, or grape juice.
  5. Pour that in the glass with the sugar.
  6. Mix it up really well with some type of stirring device. Don’t use your pen or your finger. (Your partner’s pen or finger is ok though.) (Not really.)
  7. Serve warm, chilled, or tepid. Garnish with a peanut butter and jelly sandwich.

Have you guessed what the “Kaiser Cocktail is used for? If you’re in EMS I’m pretty sure you may have figured it out. It’s for sweetening up your local mild hypoglycemic… and no, it’s definitely not for serving to my son right before I drop him off with the in-laws for revenge purposes. The Kaiser Cocktail is for those patients who have blood glucose levels in the mid double digits but that still have the mental faculties necessary for drinking fluids and for protecting their airway while they do it. It’s a home remedy of sorts and it isn’t exactly the kind of thing that they teach you in EMT school. It works like a charm every time and I’ve never seen it not be well tolerated by the patients I’ve used it on or by the families that watch me do it. In fact, the families always seem more than willing to help whip one right up when I ask them to do so.

Picture this scenario: Your ambulance is dispatched to the “Known Diabetic with Altered Mental Status” at an address a short 8 minutes away. You respond to a well kept address in a nice neighborhood and are directed into the residence by a twenty-something female who tells you that her grandfather “Just isn’t acting right and won’t get out of bed”. Seeing no obvious hazards, you enter the residence with the granddaughter and follow her to the back bedroom of the residence to find a 60-something male patient sitting on the bed. He acknowledges you when you introduce yourself and you can see that he’s trying to talk but that he cannot seem to form the words. You say to him “Howdy! How are you feeling??” He answers: “Um… hello…” with a normal voice quality. His airway is patent, his skin is pink, warm, and sweaty, and he doesn’t appear to have any hemispheric neurological deficit. His pulse is bounding and regular at the radial and his respirations are normal. The granddaughter tells you that the patient is diabetic and that he takes insulin.

Got the case diagnosed yet? I’d bet you do. The next thing I would do with this patient is to take a quick finger stick glucose check. For the above fictional scenario, the reading would be 40mg/dl (which is um… “something’ MMOL for you British folk). It’s mild hypoglycemia. I ruled out a possible stroke (CVA/TIA) with the Cincinnati Pre-Hospital Stroke Scale and he patient’s cardiac function seems very normal with his bounding, regular pulse rate. The diaphoresis (sweating) and skin color are differential signs of hypoglycemia, and the patient’s past medical history helps clinch the field diagnosis. This patient’s blood glucose level dropped too low for his brain to function normally and he needs more sugar coursing through his veins in order to feed his brain.

You may be wondering why I brought forth such a common, run-of-the-mill patient presentation on the blog today. As pre-hospital providers, we have a few options available for us that could be considered proper care for this patient. Most EMTs have oral glucose paste at their disposal and a growing number of EMT-Basics carry Glucagon for IM injection. EMT-Intermediates and Paramedics usually have both of the previous medications available and almost all of them carry D-50, or 50% Dextrose solution in water, for IV administration. All of these treatments could be considered for this patient; however I would pull out my namesake concoction in this case. Call it experience, but starting an IV and giving D-50 seems like it would be risky overkill for this patient and an IM injection of glucagon saps the patient’s natural reserves of glycogen for quite a while after administration. Patients seem to hate the taste of oral glucose paste (Lemon?? Really??) and one tube never sees to do the trick. We only care two of them anyway.

That’s why I use a Kaiser Cocktail with these patients. As long as the patient can maintain their own airway and there’s not an aspiration risk, I can’t think of any contraindications once you rule out a possible stroke. It’s cheap, easy, and it has worked like a charm for me every time I’ve tried it. I like using it too, as it feels like a “Mr. Wizard” type home remedy that always fascinates the patient’s family members who watch me make it up.

Here’s the rub though, nowhere in my protocols does it give me authority to give a patient any nourishment or fluids by mouth. In fact, I can’t give a patient anything to eat or drink that isn’t specifically allowed by my standing orders. In EMS, even something as innocuous as sugared-up orange juice can be a legal difficulty. Common sense isn’t allowed by lawyers, unless of course they’re saying you should have used some. The reality is that every time I whip up a Kaiser Cocktail, I’m putting my license at risk.

I used a Kaiser Cocktail as recently as of the day I’m writing this post and I’m asking for a debate here. I’d like it if you would please answer some questions for me below the post in the comments section:

  1. Do you think that the Kaiser Cocktail is an appropriate treatment for mild-to-moderate hypoglycemia in a known-diabetic patient with a patent airway?
  2. Do you see any contraindications or risks that I have missed?
  3. Would a tube of oral glucose paste (or tablets, if you use them) be more appropriate than the Kaiser Cocktail?
  4. Should EMS providers be allowed to improvise treatments such as the Kaiser Cocktail for these and other like situations? Why or Why not?

I can’t wait to see your answers.

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  • PGSiva

    I have been there and done that. Yes I agree that's well within the limits of “OK”, as long as you are “smart” about it…

  • http://portraitofalady-lizzie.blogspot.com/ LadyLizzie

    You get lemon oral glucose? Jealous…I've only seen cherry flavoured around here and it tastes like you're eating old cough syrup that's been chemically sanitized.
    To answer your questions in the shortest possible way; it's all good until someone decides to sue. The “home remedies” are good and, for the most part, they're still around because they work. As you pointed out, there are benefits to them that the “approved” methods don't have. Also, I think they force EMS providers to think about the “why” of the treatment instead of just matching Treatment A with Symptom Set A. However, once someone gets cranky and sues you, it doesn't really matter which one works better – you'll never be allowed to use it again.

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  • Jess

    Our (UK) guidelines suggest oral glucose for patients like the one you describe – it specifically suggests sugary drinks/chocolate. We then make them a sandwich or some other type of carbs.

    I’m really quite surprised you’re not officially supposed to do this – why use up glucogel or inject someone when they can just have a snickers?

  • Girl in Green

    We have a similar thing down under. At uni home remedies are mentioned however it is not stated within our services protocol. I believe that your concoction is an appropriate treatment for mild-to-moderate hypoglycemia providing that the patient is a known diabetic, as quite often these patients will refuse transport as they may find themselves in this situation fairly frequently; and if no medication had been administered then it's a less complex process to undertake. If the patient is not known to be diabetic, best to stick to the book I feel incase something else is bubbling under the surface that EMS cannot find.

    I can't see how giving someone with a patent airway sugar can cause harm, providing that they are not overloaded with it, we have been taught to only give small amounts the prepare a sandwhich for slowering releasing energy to sustain the patient so they don't crash again. Plus if a patient can see that something they can do themselves, or a family member can do for them should the patient present like this again it may help to ease the workload on an already burdened system.

    Should the Kaiser cocktail not work, then for sure move on to the paste, glucagon, dextrose…

  • http://twitter.com/murphquake Bill Murphy

    Chris, NYC & NYS BLS protocols specifically mentions juice and soda.

    NYC REMAC/REMSCO BLS Protocol 411 Altered Mental Status:
    7. If the patient is conscious, is able to swallow, and is able to drink without assistance, provide a glucose solution, fruit juice, or non-diet soda by mouth.
    a. Do NOT give oral solutions to unconscious patients.
    b. Do NOT give oral solutions to patients with head injuries.

    NYS BLS Protocol M-2 Altered Mental Status
    IV. B. If the patient has a known history of diabetes controlled by medication, is
    conscious and is able drink without assistance, provide an oral glucose
    solution, fruit juice or non-diet soda by mouth, then transport, keeping the patient
    warm.

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  • http://twitter.com/murphquake Bill Murphy

    Chris, NYC & NYS BLS protocols specifically mentions juice and soda.

    NYC REMAC/REMSCO BLS Protocol 411 Altered Mental Status:
    7. If the patient is conscious, is able to swallow, and is able to drink without assistance, provide a glucose solution, fruit juice, or non-diet soda by mouth.
    a. Do NOT give oral solutions to unconscious patients.
    b. Do NOT give oral solutions to patients with head injuries.

    NYS BLS Protocol M-2 Altered Mental Status
    IV. B. If the patient has a known history of diabetes controlled by medication, is
    conscious and is able drink without assistance, provide an oral glucose
    solution, fruit juice or non-diet soda by mouth, then transport, keeping the patient
    warm.

  • Jsleight

    I've always felt that something like your home mix, or a Coke or Mountain Dew is much more effective than oral glucose. Coke has what, 60 Grams of sugar, oral glucose maybe 25. Personally I'd rather give em a Coke and see results much quicker. Unfortunately most of our diabetic patients are not alert so we just hit em up with D50

  • http://oregonemtstudent.blogspot.com/ Brad

    Our protocols for BLS treatment of a Diabetic/Hypoglycemic patient are administering oral glucose if patient is alert and oriented and can maintain airway. If not, then call for ILS or ALS to give glucagon or D50. I don't see any reason why you shouldn't be able to use the “Kaiser Cocktail” or other appropriate sugar delivery system. My instructor said if at all possible to use what is available in the patient's house, and he didn't mention anything about potential liability issues. However, I am only an EMT Basic Student, and have yet to run my first call, so take my comment with a grain of salt.

    Regards,
    Brad
    @EMTGoose

  • CBEMT

    So long as the patient is not on oral hypoglycemics, I've got no problem whatsoever. I've seen patients in the ED given juice before they're even off the EMS stretcher.

  • Pamedic275

    In my area we frequently treat and release hypoglycemic pt's ( all ALS providers), but, this policy has strict guidelines as to when they can be released. We need to do the initial assessment, including blood sugar analysis. If the pt is able to eat/ drink without assistance, we can provide sugar to them in that fashion. Nothing dictates what we sue to accomplish this. If IV D50% is used, we still do not need to contact medical command to release. If glucagon is sued, we MUST transport, due to the robbing of the glucogen stores.In any case, we must follow up with a secondary exam, have blood sugars in the proper range, have the pt promise to eat carbs afterwards, and have someone present who can help them accomplish this task.

  • Rescuebill

    Don't know if anybody above mentioned it, but one could also seek guidance from on-line medical direction. If in doubt, give him or her a call, when and if any legal poop hits the fan, you got an MD in your corner to help you dodge it !

  • FS14

    Protocols, protocols, protocols. They weren't designed, approved, and implemented just to kill trees for more paper. Any time you're designing your own interventions you are placing your certifications and those of your medical director on the line. Is it worth it? I can't find a faster way to lose certifications than to free-lance, not to mention the possibility of legal action being taken by a family if some treatment goes south on you even if it hasn't happened before. Insta-glucose was developed for a reason, and unless I'm wrong, it's carried on most trucks.

  • FS14

    There is a difference between the treatments in the ED and the pre-hospital care we provide in the field. The ED personnel have other diagnostic equipment and treatments applicable to their setting, and assuming they have taken the hand-off of the patient, it becomes their responsibility. If we're directed to provide the treatment in the ED then we're golden. Otherwise, protocols!

  • emschick

    1. Do you think that the Kaiser Cocktail is an appropriate treatment for mild-to-moderate hypoglycemia in a known-diabetic patient with a patent airway? Yes, I've done it myself on more than one occasion. One time the patient shared her OJ and cookies (girl scout, thin mints) and that was awesome.

    2. Do you see any contraindications or risks that I have missed? no

    3. Would a tube of oral glucose paste (or tablets, if you use them) be more appropriate than the Kaiser Cocktail? sure but we carry lemon, too. and for our basics they have to call med control to ask if they can give it, med control will say sure but call for ALS and have them come do their thing.

    4. Should EMS providers be allowed to improvise treatments such as the Kaiser Cocktail for these and other like situations? Why or Why not? This is the tough one. I've had suspected heart attack patients take one of their own aspirins before leaving the house if I didn't have ALS on the way (our protocols finally caught up and allow basics to give aspirin this year). Should every emt in the field do this? Well, not every emt in the field should even be allowed near an ambulance so this is where you can run in to trouble.

  • medic7481

    Our protocols in West Michigan state…..”If the patient is alert but demonstrating signs of hypoglycemia, administer oral high caloric fluid if available.” This gives us then the ability to give them those cocktails with the approval of our medical control authority. I don't know about everywhere else but once we wake up a diabetic they have the right to refuse transport. We then make sure they have something to eat…even the formerly unresponsive diabetics. Of course we do call our medical control to get their approval for the no transport and more often then not they will question if the pt has had anything to eat, to stabilize those sugar levels that are achieved. So in short, I have used this treatment, and I will continue. Then of course we do have permission right in our protocols for it.

  • http://profiles.yahoo.com/u/UCDOAAPBPZLKK46I3MMGL6D6PQ cindi

    I know our protocols don't allow “feeding” but we do it anyway. Besides the oral glucose, we carry tubes of frosting, which seems to be tastier. I have also taken frequent callers to the local restaurant and fed them when they called EMS because they were hungry. They have no medical reason to ask for hospital care, but our protocols are that anyone who asks should be taken to the ER, where we are given nasty looks and muttered reprisals under the breath of nurses and MD's. Yes we fight stupid protocols all the time and try to do the best we can for our patients. Most reasonable people don't want to go to the hospital if they don't have to. I can hear the audible sigh of relief that they've learned how to handle yet another medical crisis themselves and saved on the cost of an ER visit.

  • Medicprincess72

    British Columbia has moved from a protocol based system, to a “Treatment Guidelines” system. All of our protocols have a medical principals document attached to them, and our priority is to meet our objective within the scope of practice and based on the appropriate medical principals, ie, get his blood sugar up in this case. Juice and a “medical sammich” as you are doing here would be encouraged, as the risk is lower for administering juice than for IV D-10 or glucagon, with the same likely benefit. As I said, accomplish the objective, within your scope of practice, and based on the medical prinicipals involved, with a consideration to risk / benefit ratios, and you're golden. Scared me at first, but I can not imagine going back to medicine by cook book now ( A + B = C, etc)

  • Tracyb4403

    Prior to working in EMS, I worked in an “assisted living facility” and I used this many times with our residents in 2005. Of course, it was only used in patients exhibiting classic signs of hypoglycemia, and after a stroke was ruled out. I never saw one adverse reaction or negative displayed due to the resident drinking it and most of the time once the medics arrived the blood sugar was well within normal and usually they didn't even transport. Our protocols do not give us permission to give anything by mouth either, however in an pinch, if nothing else was available I would definitely use it.

  • MedicMac

    This is similar to treatment the patient would receive at the hospital – awake and mostly oriented with a patent airway = oral intake of sugar/nutrients, NOT injections or IVs. Is the treatment appropriate and acceptable? Yes. Does it put you at risk in pre-hospital? Yes. While I consider it appropriate, it's also really 'winging it' because you're moving beyond any 'remedies' you are provided on the ambulance. A key issue is whether your medical director thinks it's appropriate pre-hospital treatment. If the medical director doesn't have an issue with it, I wouldn't have an issue with it. If uncomfortable with an 'unwritten approval/protocol', then I would recommend a call to on-line medical control, providing them with my patient assessment, differential diagnosis, and treatment plan – if approved, you save the patient a trip to the ED. If denied, then the doctor can provide a similar treatment when the patient arrives. Still covered by 'protocol' but advocating what you feel is right for your patient.

  • CBEMT

    Yeah, why think critically and advocate for the patient's needs. It's so hard. Monkey see/monkey do protocols 4eva! w00t!

    I was talking about TRIAGE. The only thing they do for those patients before they break out the juice is… oh wait, they did the exact same thing- a capillary blood sugar. The same thing EMS did 10 minutes ago.

    Point is. If I assess the patient to be suffering from a known diabetic condition resulting from a clearly identifiable cause, and can treat it with something less invasive and risky than an IV and far more palatable than the tube of suck we carry, I will, and I can guarantee the state med director will back me up on it.

    THINK- it's not illegal yet!

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  • Jdmedic

    As a “recovering attorney” (my thanks to Harold Cohen for use of that phrase), not only will I endorse your cocktail but I will advocate the cause of common sense by stating I have used similar strategies. If using some variation of the cocktail is not permitted by your state/local protocols you could wind up having to deal with a beaurocrat however, a court of law is different. In the event there was some adverse event from this treatment (the Pt was allergic to OJ?) you would be judged by the “reasonable man” standard. What would a reasonable man in the same situation do? I would argue vehemently a reasonable man would say: provide help, do no harm and save the poor person an additional medical bill he/she does not need because of all the rest of the medical bills the person probably has.

    As far as the “cocktail” goes, I have learned a lot more from my fiancee who has been a diabetic since 16 than from medic school. No sugar is needed in any fruit juice. In fact apple juice has more available sugar than the same amount of soda. The only time you have to add sugar to soda is if the family has been giving the person diet soda and can't understand why the Pt's BGL has not risen.

  • http://www.lifeunderthelights.com Ckemtp

    JD! I was wondering when you were going to come back and weigh in on something. I'm glad it was this one. I like having your perspective and appreciate the comments.

    Stick around. I plan on upcoming controversy.

  • Jacqueline EMT-B, NJ

    i don't see a problem with this, in NJ we have started carrying cake icing(i am dead serious) on our rigs in place of oral glucose because lets be honest: that stuff tastes like crap.
    And i have made a sandwich on more than a few occasions for a patient who was a known diabetic and who had pricked herself to prove her sugar was low.

  • Jdmedic

    Uh Oh – just when my doctor said I was doing so well you want me to jump into a controversy. I guess it’s back to the electro shock room for me. LOL

  • FoxxNY

    Sounds great, i like that a lot, very good improvising but i ‘d ensure they have no allergies to the Honey or syrup prior to administration, there are those who can be allergic, some highly. God forbid something happens you might get screwed. If its in their house it’s probably unlikely there allergic to it, but they could be. I suppose the Honey or syrup is the only possible contraindication so you could leave it out and the rest seems okay to me. Most Regions allow you to administer soda and fruit juice.

  • Midwest Medic

    Sorry I’m late to the game with my comment, but I just found this today. Our protocols don’t specifically ban oral intake. My question would be if it’s specifically forbidden, how do you document it? Otherwise this is great. I’ve worked in two different ERs in the past year and I’ve even seen “food boluses” as treatment for Insulin ODs where the patient was still coherent enough for it to be safe. The complex carbs are a more sustained way of boosting sugars. Plus it’s cheaper for the patient, and your service as you’re not using medical supplies. It’s a win all around!

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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