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  • CPR and COVID-19

    Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in first aid and community settings Whenever CPR is carried out, particularly on an unknown victim, there is some risk of cross infection, associated particularly with giving rescue breaths. Normally, this risk is very small and is set against the inevitability that a person in cardiac arrest will die if no assistance is given. The first things to do are shout for help and dial 999. Watch what to do in an emergency. First responders should consult the latest advice on the NHS website ( https://www.gov.uk/government/publications/novel-coronavirus-2019-ncov-interim-guidance-for-first-responders/interim-guidance-for-first-responders-and-others-in-close-contact-with-symptomatic-people-with-potential-2019-ncov). Those laypeople and first responders with a duty of care (workplace first-aiders, sports coaches etc.) that may include CPR should be guided by their employer’s advice. This guidance may change based on increasing experience in the care of patients with COVID-19. Healthcare workers should consult the recommendations from the World Health Organisation and Department of Health and Social Care for further information, and advice by nation is at the conclusion of this statement. Resuscitation Council UK Guidelines 2015 state “If you are untrained or unable to do rescue breaths, give chest compression-only CPR (i.e. continuous compressions at a rate of at least 100–120 min-1)”. Because of the heightened awareness of the possibility that the victim may have COVID-19, Resuscitation Council UK offers this advice: Recognise cardiac arrest by looking for the absence of signs of life and the absence of normal breathing. Do not listen or feel for breathing by placing your ear and cheek close to the patient’s mouth. If you are in any doubt about confirming cardiac arrest, the default position is to start chest compressions until help arrives. Make sure an ambulance is on its way. If COVID 19 is suspected, tell them when you call 999. If there is a perceived risk of infection, rescuers should place a cloth/towel over the victims mouth and nose and attempt compression only CPR and early defibrillation until the ambulance (or advanced care team) arrives. Put hands together in the middle of the chest and push hard and fast. Early use of a defibrillator significantly increases the person’s chances of survival and does not increase risk of infection. If the rescuer has access to any form of personal protective equipment (PPE) this should be worn. After performing compression-only CPR, all rescuers should wash their hands thoroughly with soap and water; alcohol-based hand gel is a convenient alternative. They should also seek advice from the NHS 111 coronavirus advice service or medical adviser. Paediatric advice We are aware that paediatric cardiac arrest is unlikely to be caused by a cardiac problem and is more likely to be a respiratory one, making ventilations crucial to the child’s chances of survival. However, for those not trained in paediatric resuscitation, the most important thing is to act quickly to ensure the child gets the treatment they need in the critical situation. For out-of-hospital cardiac arrest, the importance of calling an ambulance and taking immediate action cannot be stressed highly enough. If a child is not breathing normally and no actions are taken, their heart will stop and full cardiac arrest will occur. Therefore, if there is any doubt about what to do, this statement should be used. It is likely that the child/infant having an out-of-hospital cardiac arrest will be known to you. We accept that doing rescue breaths will increase the risk of transmitting the COVID-19 virus, either to the rescuer or the child/infant. However, this risk is small compared to the risk of taking no action as this will result in certain cardiac arrest and the death of the child.

  • Herpetic whitlow (whitlow finger)

    Herpetic whitlow (whitlow finger) Introduction A herpetic whitlow, or whitlow finger, is an abscess of the end of the finger caused by infection with the herpes simplex virus (the "cold sore virus"). It usually affects the fleshy area of the fingertip. What are the symptoms? The fingertip suddenly becomes red, swollen and extremely painful. Small white blisters develop underneath the skin of the finger, which may break to release fluid, eventually crusting over. What's the cause? There are two types of herpes simplex virus (HSV), type 1 and type 2. Both HSV-1 and HSV-2 can cause a herpetic whitlow. These viruses can also cause cold sores and genital herpes. A herpetic whitlow can develop as a secondary infection if you already have a cold sore or genital herpes and you touch the sore area of skin, transferring the virus from your mouth or genitals to your finger. It can also develop if you touch the sore or blister of another infected person. You're at greater risk of becoming infected if you have a weakened immune system. How is it treated? Antivirals A herpetic whitlow may be treated with an antiviral drug such as aciclovir. You may be prescribed a five or seven day course of 200mg aciclovir to take five times a day or 400mg to take three times a day. But this is only worth taking if you start the treatment within 48 hours of symptoms starting. Using an antiviral after this initial period is unlikely to have any effect. Antiviral drugs may help to heal a herpetic whitlow, but they do not get rid of the herpes simplex virus or prevent future outbreaks of herpes simplex viral infection. A whitlow will heal without an antiviral drug within two to three weeks. Antiviral treatment may: reduce the time taken for the abscess to heal reduce your risk of a secondary bacterial infection reduce your risk of the herpes simplex virus spreading to other parts of the body Caring for the whitlow at home You should cover the whitlow with a light dressing so the infection doesn't spread any further. Avoid wearing contact lenses until the infection has healed, to stop the virus spreading to your eyes. You can take an over-the-counter painkiller such as paracetamol or ibuprofen for pain relief. Do not attempt to drain the fluid, as this may cause the virus to spread or cause a bacterial infection. Will it come back? The herpes virus remains dormant (inactive) in nerve cells and may reactivate at a later date, sometimes following stress or an illness. This can result in another whitlow at the same site as the first one If a whitlow does return, it can be treated in the same way, with an antiviral drug. If the whitlow returns often, the antiviral drug can be given for long periods of time (years) to reduce the number of times it comes back. This suppressive antiviral treatment will also reduce both the severity of the whitlow and the length of time it takes to heal. #communicablediseases #Herpes #childcare

  • Early years foundation stage: coronavirus disapplications. Updated 24 April 2020

    Our online training course in Paediatric First Aid meets these requirements if you are an existing student who has completed our FAW or EPFA course in the last three years and needs to during this COVID crises up-skill due to no PFA staff availability. Training will only be valid during the crises. After restrictions are removed students will just need to attend a 1 day practical session to hold full PFA status. Email paul@paulkenny.co.uk for more details. 6.2 Paediatric First Aid The changes: The requirement for at least one person who has a full paediatric first aid (PFA) certificate to be on the premises at all times when children are present remains in place where there are children below the age of 24 months. Paragraph 3.25 and Annex A of the EYFS set out more detail. However, if children are aged 2-5 within a setting, providers must use their ‘best endeavours’ to ensure one person with a full PFA certificate is on-site when children are present. If after using best endeavours they are still unable to secure a member of staff with full PFA to be on site then they must carry out a written risk assessment and ensure that someone with a current First Aid at Work or emergency PFA certification is on site at all times children are on premises. ‘Best endeavours’ means to identify and take all the steps possible within your power, which could, if successful, ensure there is a paediatric first aider on site when a setting is open, as per the usual EYFS requirement on PFA. Please note this does not apply for childminders as they must already have a full PFA certificate. New entrants (levels 2 and 3) will not need to hold a Paediatric First Aid (PFA) certificate within their first 3 months in order to be counted in staff: child ratios, during the COVID-19 outbreak. Additionally, if PFA certificate requalification training is prevented for reasons associated directly with COVID-19, or by complying with related government advice, the validity of current certificates can be extended by up to 3 months. This applies to certificates expiring on or after 16 March 2020. Providers remain responsible for ensuring all children in their care are kept safe at all times. What this means in practice: For providers with children below the age of 24 months in their care, the requirements around PFA remain the same as in the current EYFS framework, with the exception that during the COVID-19 outbreak new entrants do not need to have a PFA certificate to be counted in ratios. This is in recognition of the greater risk factors for babies and young children in this age bracket, including choking risks and different cardiopulmonary resuscitation (CPR) procedures for those aged 0-1 as set out by the NHS. For providers who have children aged 2-5 in their care they must use ‘best endeavours’ to have one person with full PFA, as set out in the EYFS, onsite. By best endeavours we mean providers must be able to demonstrate they have identified and taken all the steps possible to appoint a suitable person. This should include liaising with their local authority to find a suitable person, this could include identifying and looking to appoint: a person with a PFA certificate and Disclosure and Barring Service (DBS) check from a local provider who has closed; or a registered local childminder with a PFA certificate and DBS check who is approved to work on non-domestic premises Looking to secure full PFA training for staff that includes the specific risk factors and techniques required for the care of young children including but not limited to choking, seizures, and issues related to sleeping. Annex A of the EYFS statutory framework sets out the criteria for effective PFA training. After these actions have been carried out and if it is still not possible for someone with a full PFA certificate to be on site at all times children are present, providers must undertake the following actions in order to remain open: Carry out a written risk assessment to consider and mitigate the likely occurrence of a serious incident. Ensure at least one person with a current First Aid at Work or emergency PFA certification is on site at all times children are on premises and must accompany children on outings. Paragraph 3.65 in the EYFS continues to apply and outings should only be undertaken if it is safe to do so. Providers must take account of any Govt advice in relation to the COVID-19 outbreak. The written risk assessment should take into account all relevant factors with the aim of enabling the setting to ensure they can provide the safe care needed by children of critical workers and vulnerable children during COVID-19 outbreak, including: The number of children on the premises The staff to child ratios The types of activities undertaken with the children on the premises The likely need for first aid based on the needs of the children attending the premises First aider knowledge among staff on the premises: and The mitigations available to reduce the risk of such an incident Providers will need to keep the written risk assessment available in the setting throughout the COVID-19 breakout. This does not need to be sent anywhere but must be available on request. Providers could help members of staff who have a First Aid at Work or emergency PFA certificate to help bridge the gap between their current qualification and full PFA by looking to secure online training to cover elements required for the care of young children. HSE provides guidance on choosing a first aid training provider. As set out in HSE guidance, any training in relation to paediatric CPR and choking should be in line with the Resuscitation Council’s guidance and NHS England guidance.

  • Wearable Defibrillators Are a Safe and Effective Alternative to ICDs in Certain Pediatric Heart Pati

    Study Highlights: Study finds external wearable defibrillators are safe and effective in children with ventricular heart rhythm disorders that put them at risk for sudden cardiac death. The wearable devices may provide a reliable alternative to surgically implanted defibrillators in patients who cannot have surgically placed devices or who do not need them long term. DALLAS, TX--Wearable cardioverter defibrillators — vest-like devices that deliver electric shocks to interrupt a dangerous heart rhythm – may be a safe and effective alternative to surgically implanted devices in children with ventricular heart rhythm disorders that put them at risk for sudden cardiac death, according to new research published in Circulation: Arrhythmia and Electrophysiology, an American Heart Association journal. “Our results, which stem from the largest study to date among children in the United States using wearable cardioverter defibrillators, suggest that these external devices can help save the lives of children who are at the time, not good candidates for surgically implanted defibrillators because of their medical condition,” said the study’s principal investigator David Spar, M.D., assistant professor of pediatrics at the University of Cincinnati and a pediatric electrophysiologist at Cincinnati Children’s Hospital. Sudden cardiac arrests in children are usually caused by heart abnormalities that the child is born with. Cardiac arrests are often triggered by an electrical malfunction that results in a rapid heartbeat that causes the heart to pump ineffectively. With its pumping action disrupted, the heart cannot pump blood to the brain, lungs and other organs, and death can occur if the heart’s rhythm is not restored or corrected. Surgically implanted cardioverter defibrillators — the main therapy for children at high-risk for sudden cardiac death due to heart rhythm disorders, known as arrythmias, are effective in averting deaths from potentially lethal heart rhythms, but invasive surgery or prolonged hospitalization is required. However, many young patients are not good candidates for these surgically implanted devices because they need only a temporary “bridge” to help their heart. For example, if they are waiting for a heart transplant, are a newly diagnosed heart failure patient who is recovering cardiac function or if they have an infected implanted cardioverter defibrillator, they wouldn’t be good candidates, Spar explained. Even though wearable cardioverter defibrillators were approved by the U.S. Food and Drug Administration for use in pediatric patients in 2015, data about their safety and efficacy in children has remained limited. This gap in knowledge has been particularly troublesome in how effective the device would be in younger patients in treating dangerous arrhythmias. If effective, the wearable cardioverter defibrillator could avoid prolonged hospitalizations while still offering arrhythmia protection, researchers said. The newly published results -- based on a review of clinical outcomes among all U.S. pediatric patients who wore wearable cardioverter defibrillators between 2009 and 2016 -- is the first to describe appropriate therapy with a wearable cardioverter defibrillator in a pediatric population. Of the 455 patients (average age 15) included in the analysis, eight (1.8 percent) received at least one shock treatment to interrupt a dangerous heart rhythm. Six of the eight patients in whom the device discharged received appropriate therapy for the type of heart rhythm the device is designed to detect and stop. In the two cases of inappropriate therapy, the device misfired when it misread a signal from the patient’s heart. In all cases, the dangerous heart rhythm was successfully interrupted, normal heart rhythm restored and the patient survived. This study did not receive outside funding.

  • New Guide from the HSE for Healthcare workers on Masks

    The HSE have released a new video on the correct use of masks by Health care professionals. The video is also useful for childcare professionals who are wearing the FFP2 or N95 Masks. Respirators are used to prevent inhalation of small airborne particles arising from AGPs. All respirators should: be well fitted, covering both nose and mouth not be allowed to dangle around the neck of the wearer after or between each use not be touched once put on be removed outside the patient room or cohort area or COVID-19 ward Respirators can be single use or single session use (disposable) and fluid-resistant. Note that valved respirators are not fully fluid-resistant unless they are also ‘shrouded’. Valved, non-shrouded FFP3 respirators are not considered to be fluid resistant and therefore should be worn with a full face shield if blood or body fluid splashing is anticipated. FFP3 respirators filter at least 99% of airborne particles. The HSE states that all staff who are required to wear an FFP3 respirator must be fit tested for the relevant model to ensure an adequate seal or fit (according to the manufacturers’ guidance). Fit checking (according to the manufacturers’ guidance) is necessary when a respirator is donned to ensure an adequate seal has been achieved. The new guide and video are on the main website COVID-19 page

  • Sudden change from hot to cold can harm healthDoctors say that a sudden drop in temperature from hot

    DUBAI //The sudden change in temperature from extreme hot to cold can have a serious effect on people who have a history of cold-related disorders. Doctors say managers of malls, offices, public buildings, mosques and even hospitals, which sometimes record temperatures as low as 19°C, have a responsibility to ensure that the inside of their establishments is not unhealthy. "Extreme and sudden variance between outside and inside temperatures has adverse effect on body as it undergoes a certain amount of stress when it is forced to go from a boiling hot environment into an air-conditioned one", said Dr Aamerah Shah, a primary care specialist at the American Hospital Dubai. "It dries off your skin, the mucus membrane and the eyes. We see patients who say they went to the malls or their offices and it was extremely cold. Eye infections, respiratory infections and muscular spasms are caused by this change in temperature," Dr Shah said. She treats several patients each month for asthma attacks, runny noses, muscular pain, flu, pharyngitis, sinusitis, cold, sore throat, muscular aches and severe pains, all mostly the result of air conditioning. Dr Shah said the recommended temperature should be between 23°C and 25°C to prevent susceptibility to ailments and ensure healthy living. Another medical expert said low temperatures can exacerbate medical conditions of existing patients. "These extreme differences from outside to inside might affect the human body," said Dr Tarek Abdul Hadi Azeem, a professor and consultant of internal medicine at Al Noor Hospital in Abu Dhabi. "The change in temperature can exacerbate coronary heart diseases, vascular cardiac, vascular brain diseases and peripheral vascular [artery and vein] diseases. "The condition of people with respiratory diseases might also worsen. I always advise patients to switch their air conditioners off when possible and avoid being exposed to low temperatures." Another doctor said the hospital where she worked set the temperature sometimes as low as 19°C, which was unhealthy for patients and medical practitioners. A prominent hospital whose inside temperatures The National gauged with a thermometer recorded about 22.5°C at 11am on a Wednesday. "It is too cold for the patients," said the doctor. "It is something that all hospital administrations should look into. The temperatures of all buildings including hospitals should be monitored closely. If offices and hospitals are too cold, they should let the management know." Dr Azeem agreed: "Many patients are sick, they might fall more ill. Hospitals should pay attention as they are providing health care. They have a responsibility. Even mosques are so cold. No place should be very cold." PinnedOthers

  • Terrible’ Spike in Cardiac Arrest Deaths During Lombardy’s COVID-19 Surge

    Investigators believe theirs are the first published data showing high numbers of at-home cardiac arrests amid the pandemic. By Shelley Wood May 01, 2020 Chilling numbers out of northern Italy point to a 58% increase in the number of out-of-hospital cardiac arrests (OHCAs) in the first 40 days of the COVID-19 pandemic there, as compared with the same period last year. This spike in arrests appeared to follow the geographic time course of the outbreak, such that the percent increase in OHCA was steepest in the two provinces that experienced the earliest cases of COVID-19 and had the highest number of cumulative cases per 100,000 people, Simone Savastano, MD (Fondazione IRCCS Policlinico San Matteo, Pavia, Italy), senior author on the study, told TCTMD. For the province of Lodi, the increase in OHCA was 187%, and for Cremona, it was 143%. In Pavia and Mantova, where the epidemic hit later and fewer people were infected per capita, the increases in cardiac arrest were 24% and 18%, respectively. “When the COVID epidemic started, we noticed an important reduction in STEMI and so some of us thought that maybe cardiac arrest can also be reduced, so we questioned our database and very quickly we had a terrible answer,” Savastano said. “It was exactly the contrary: out-of-hospital cardiac arrests were increasing day by day, and they went hand in hand with the COVID-19 trend.” The dramatic drop in acute MIs during the COVID-19 epidemic has emerged as a devastating side story, with cardiologists and researchers increasingly convinced that hospital avoidance by patients terrified of the contagion has helped to drive the numbers down. And while some of these “missing STEMIs” are arriving to the hospital late, with dire complications from that delay, there are growing fears that many patients are arresting and dying at home, the cause of death impossible to disentangle from COVID-19. Savastano believes their Lombardy data, published as a research letter in the New England Journal of Medicine, is the first to provide a snapshot of cardiac arrest numbers in a region hit hard, and hit early, by the COVID-19 pandemic. Cardiac Arrest Also a Killer in COVID-19 The research letter draws on data from the Lombardia Cardiac Arrest Registry, first launched in 2015, as well as daily reports of new COVID-19 cases from the National Department of Civil Protection and the emergency medical system’s electronic database that tracks symptoms and cardiac deaths. COVID-19 positivity was inferred from symptoms suggestive of infection prior to the arrest (fever lasting ≥ 3 days before OHCA, plus cough, dyspnea, or both) or on the basis SARS-CoV-2-positive pharyngeal swabs obtained either prior to the arrest or after death. All emergency response personnel were instructed to ask about patient symptoms prior to arrival and don protective equipment before administering care. In all, there were 362 OHCAs between February 20 and March 31, 2020, as compared with 229 in over the same period in 2019. Among the 2020 patients, 103 had confirmed or suspected COVID-19. While it’s impossible to differentiate between arrests directly caused by complications of COVID-19 versus those resulting indirectly, as a result of hospital avoidance, the authors estimate that COVID-19 accounts for 77.4% of the increase in cases of out-of-hospital cardiac arrest observed in these four Italian provinces. In COVID-19 patients, Savastano speculated to TCTMD that “hypoxia, pulmonary embolism, or mechanical complication of MI may have played a role.” Overall, the proportion of cardiac arrests due to medical causes (as opposed to causes like trauma, drowning, or electrocution) was 6.5% higher than in 2019, out-of-hospital arrests were 7.3% higher, unwitnessed arrests were 11.3% higher, and median time to emergency medical services (EMS) arrival was 3 minutes longer. In patients for whom EMS attempted resuscitation, deaths were almost 15% higher than during the same 40-day period in 2019. Tragically, the proportion of patients receiving bystander CPR was 15.6% lower than in 2019. Overall mortality was nearly 89%, up from 77% in 2019. More Lessons From Lombardy To TCTMD, Savastano stressed that cardiac symptoms and the risk of cardiac arrest in COVID-19 patients need to be on the radar of physicians and hospital systems now facing down this pandemic in other parts of the world, emphasizing also that advice to stay home does not extend to patients with fast-evolving symptoms. “If I can make a suggestion to our colleagues, I would say that COVID patients are very hard to take care of at home,” he advised. “Our hospital system was very burdened by the epidemic, so we tried to leave patients at home and to prescribe drugs at home; probably, sometimes, we didn’t pay the right attention to symptoms. Regretfully, we now know the progression of respiratory distress is very, very quick, so it's quite difficult to decide which patients can be left at home and which need to be taken to the hospital. “We have to be very careful to pay attention to symptoms and also to instruct the patient to be very careful with their symptoms and to activate the emergency response system quickly” if they need it, particularly in the case of chest pain or other symptoms related to the heart, Savastano said. Sources Baldi E, Sechi GM, Mare C, et al. Out-of-hospital cardiac arrest during the COVID-19 outbreak in Italy. N Engl J Med. 2020;Epub ahead of print. https://www.tctmd.com/news/terrible-spike-cardiac-arrest-deaths-during-lombardys-covid-19-surge Disclosures Savastano reports no relevant conflicts of interest.

  • COVID-19: guidance for education settings

    This guidance will assist staff in addressing coronavirus (COVID-19) in educational settings. This includes childcare, schools, further and higher educational institutions. This is the latest advice for Education in the UK. Go to the COVID-19 page on our website to download this or follow the links here. COVID-19: guidance for education settings

  • Prescribing an automated external defibrillator for children at increased risk of sudden arrhythmic

    Abstract BACKGROUND: Automated external defibrillators can be life-saving in out-of-hospital cardiac arrest. OBJECTIVE: Our aim was to review our experience of prescribing automated external defibrillators for children at increased risk of sudden arrhythmic death. METHODS: We reviewed all automated external defibrillators issued by the Scottish Paediatric Cardiac Electrophysiology Service from 2005 to 2015. All parents were given resuscitation training according to the Paediatric Resuscitation Guidelines, including the use of the automated external defibrillator. RESULTS: A total of 36 automated external defibrillators were issued to 36 families for 44 children (27 male). The mean age at issue was 8.8 years. Diagnoses at issue included long QT syndrome (50%), broad complex tachycardia (14%), hypertrophic cardiomyopathy (11%), and catecholaminergic polymorphic ventricular tachycardia (9%). During the study period, the automated external defibrillator was used in four (9%) children, and in all four the automated external defibrillator correctly discriminated between a shockable rhythm - polymorphic ventricular tachycardia/ventricular fibrillation in three patients with one or more shocks delivered - and non-shockable rhythm - sinus rhythm in one patient. Of the three children, two of them who received one or more shocks for ventricular fibrillation/polymorphic ventricular tachycardia survived, but one died as a result of recurrent torsades de pointes. There were no other deaths. CONCLUSION: Parents can be taught to recognise cardiac arrest, apply resuscitation skills, and use an automated external defibrillator. Prescribing an automated external defibrillator should be considered for children at increased risk of sudden arrhythmic death, especially where the risk/benefit ratio of an implantable defibrillator is unclear or delay to defibrillator implantation is deemed necessary.

  • First Aid Considerations for First Aid in the COVID-19 workplace

    First Aid response COVID-19 considerations: Everyone should treat themselves as a possible path for sharing the virus and should consider other people as a possible risk too. Protecting yourself or the ill/injured person can be done by good hand hygiene, wearing masks, or better yet, working from a reasonable distance. The ill/ injured person can also be source for first aid. For example, they could put direct pressure on their bleeding injury, cool their burn, or take their own temperature, allowing the first aid responder to stay 2 meters apart in many situations. Other people who are less at risk or already exposed to the ill/injured person and can also be given directions by the first aid responder. Assessing breathing can be done from a distance by asking them a question, and observing chest rise/fall, both which avoid being exposed to their exhalations. If there are no signs of life or regular breathing, compression only CPR is reasonable. Ideally breaths are administered with the use of a mask with one-way valve or bag-valve-mask device. Example: Laerdal Pocket Mask with Valve and Filter from Amazon for £12.84 better than a face shield because of the oneway valve. If the person is breathing, place a cloth mask on the person while you assess or treat them if it doesn’t make breathing more difficult for injured/ ill person to protect yourself from their exhalations. Any life-threats found should be addressed in this stage along with notifying emergency services. A detailed or focused assessment follows life-threatening issues are dealt with and includes a head-to-toe physical check and an interview of the person to identify all first aid issues which can give more background to advanced care. COVID-19 Considerations The following are factors to consider if a person is exhibiting signs of COVID-19 A person who is sweaty Fever(>100.4F/37.8C) Age over 50 depending on underlying health conditions like heart/ lung disease, diabetes, or is immunocompromised Coughing Asking if the person might have taken anything specific to COVID-19 to prevent it or help could also identify potential poisoning situations. People with significant medical history should be considered at risk, these might include recent surgeries, cancer treatment, or diabetes. This information is very valuable to the call taker at emergency services or a tele-health provider to help you make the best decisions on where to go for advanced care.

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