A Diabetic rant

Specialties Endocrine

Published

Hey guys.

I've been a type 1 diabetic for fifteen years now and I'm set to graduate the program in May 2013 -- I clarify that because I don't want anyone to think I'm already working or think that I'm trying to be a know-it-all, but this drives me nuts.

At a few facilities I've been to I've noticed an alarming trend regarding Lantus. Now, I'm sensitive to this because I actually take Lantus and know how it works, but a lot of med-surge nurses don't seem to know -- and equally alarming is SOME DOCTOR'S DON'T, EITHER!

A patient had a blood glucose of 56 (low, not that terrible, to be honest... an OJ will fix it just fine) at bedtime check and because of that the nurse called the doctor and with held the lantus!

Now, lantus is a baseline insulin. It lasts ~24 hours and keeps the blood sugar at normal operating level (65-110 or thereabout) for that time period. If you with hold lantus there is no insulin left in the body (for practical purposes) to keep glucose normal!

Needless to say, patient woke up with a glucose of 500+ because they had no lantus on board. Morning shift nurse (more experienced) corrected the error by calling doctor again and administering the lantus.

Please, please, please be a patient advocate. If I were in the hospital you couldn't pry my insulin from my cold dead fingers because I don't trust that the knowledge is out there on exactly how diabetes and the meds work. If you're not diabetic and your glucose has never hit 500, I can't explain to you how crappy you feel for a long time even after it returns to normal.

/rant

I would probably do what cjcsoon2brn said...I'm not giving any insulin until I know the BS is stable. There could be myriad reasons why the pt dropped. Sure it could be something as simple as pt didn't eat much with his dinner insulin, or something more complicated could be going in in the body.

Then, ShantheRN said she (he? - dont want to assume) felt more comfortable managing insulin herself. That is great! I love when pts know what they should do/get, they definitely know better than we do (the pts that are with it, of course - I work in psych, LOL) because BS control is such an individualized thing. I will work to get an order that is reflective that the pt can have some control in getting their insulin the way THEY are used to. If I'm not sure what to do in certain cases, I always ask an AxO pt, what do you normally do in situations like this? And then call the doc of course to cover myself.

I do agree that there was something missing in the OPs scenario, no follow-through after holding the lantus being the big thing.

But on the broader idea of nurses not knowing anything about DM/insulin, I just want to throw this out there - it is easy to point fingers and criticize each other for a lack of knowledge, but if we are all being honest there is just no way we can know exactly what any given pt is going to need exactly for their insulin control. My goodness, the endocine system is so fragile in many ways, and there are millions of things that can affect it. Heck, it can take endocrinologists months and months just to get a pt on the regimen that is right for THEM. And the best way to manage BS levels in an inpatient setting is the subject of scores of research trials, scholarly articles, etc., & I'm not sure even experts agree on the best approach.

This isn't an excuse for not learning more, and educating ourselves further. But it does underscore the importance of 1) obtaining accurate med recs/histories ON ADMISSION, and getting the correct orders for pts to continue their regimen during their admission. Otherwise the docs (hospitalists, psych docs - in my case) just order whatever sounds right, and sometimes pts are afraid to speak up about not getting the right things.

having my insulin pump drives the clinicians CRAZY in the hospital!!! When I delivered my twins they sent an endo in the room (not my regular provider) and he flat out asked me if I needed help and I refused it and he left - guess he figured I knew what I was doing. Last summer I had my gallbladder removed and every nurse on the floor had to come in and see my pump and ask me questions - I was happy to oblige, but had to laugh when they kept trying to tell me how many units I needed based on "sliding scale". I take my own BG meter when I have to go and I really don't pay attention to their "sliding scale".

Great post OP! Can I smell a future diabetic educator?

I have been type 1 since 2001 and have been on a pump since 2003. What most docs and nurses know about diabetes is scary. I started on a continuous glucose monitoring system 9 months ago. I wear a sensor/transmitter in my abdomen. I check a FSBS q 12 hours. The system transmits a BG q 5 minutes to a receiver so I know what my BG is at all times. It even has arrows to tell me if I'm trending up or down. It alarms if I'm below 70 or over 200. Most people have never seen one or heard of one before and those who have don't have a clue how it works.

I was in the ER for a migraine a few months ago. I went in w a BG of 225. They did a FSBG and wanted to do SSIC. I told them I had a pump and a CGMS, that I was trending down, and that if I was getting fluids I would be hypo in about an hour and a half. The doc mumbled about "non compliance" ordered pain meds, fluids, etc. which were administered. In my pain fog, I forgot my glucose tabs. 30 minutes after my IV bolus finished my sensor beeped that I was below 70. I called the nurse, told her I was going hypo, she argued w me that my BG was high an hour ago, etc. By the time she got the glucometer, I was 53, sweating and headachy. Needless to say, the treated my hypo, and I was able to have a teaching moment w an ER doc, a nurse, and an ER tech about IV fluids effects on BG, the pump, and CGMS.

The bottom line for me is that I always listen to my patients symptoms and if they tell me they are feeling a certain way, I listen. I also think that SSIC often do more harm then good. Proper basal insulins/meds, carb counting w meals, and SSIC for the rare time for clean up would solve a lot of problems. IMHO.

too tight a control has had some less than stellar consequences, from what i have read. Inre: post prandial BS, YES. It has been years that it has been known that many type II go undx, d/t compensation in FBS but obvious in post prandial, and the neuropathy that can come with diabetes can occur in this time period, can be, in fact the presenting complaint for type IIs. Need a GTT of at least 3 hours, or longer, with insulin draws, to get the "picture"''. What we really need is some one to invent a way to check blood sugars without "sticking" someone, over and over again. I have seen persons whose fingers were black and blue, ALL of them.

The technology is here, but not used often due to cost. Some type 1's (and maybe some type 2's that are insulin dependent) use continuous glucose sensors that get a bg reading every few minutes. It would be great if all patients in the hospital that are insulin-dependent could use these, and we'd have much better control because we could see what was happening and the trending, including if the bg is headed up or down.

Another issue is that the lancets used in hospitals are huge and basically slice the fingertip open instead of a smaller puncture. It's brutal on their fingers, and unnecessary, imho.

Specializes in ER ( Peds/Adult).

VBRNJD99, How frustrating that must have been for you!! I too have an insulin pump, although when in the hospital (which thankfully, isn't very often) the nurses and docs usually listen and let me manage my BS/pump, they usually concede that in order to have an insulin pump, one must be very knowledgeable about the management of their sugars etc...and frequently I am able to educate them. So sorry you had a bad experience in the ED!

Specializes in ICU.

In my hospital, most of the nurses are well aware of how Lantus works. (The newer nurses not so much~ but they are learning.) That being said, our protocol is that we must call the doctor for any glucose level below 60, then it is up to the doctor to say "hold the lantus," or "give a reduced dose." We don't hold it unless the doctor tells us to, because that is against the rules of our practise. We have a large poplulation of non-compliant diabetics, and many times it becomes "trial and error" for us, just to get their glucose levels regulated.

Specializes in orthopedic/trauma, Informatics, diabetes.

I got in SO many discussions with instructors about D. I have a son T1 (dx @ 2; 6 years ago) I am T2; dx 2 years ago, I had Gest. D while pregnant with both children. I, too, am amazed at how little is taught/known in general med profession. My 8 year old knows more about treating his D than most. I had a pt in clinical (I am a new grad) that hx had her T1 on one sheet, T2 on another???????? (uncontrolled either way) When I would ask questions in clinical, no one could answer them. I have strict instructions on my son's medical ID bracelet as to his care if he needs emergency care and I am not there.

I just started at a LTC/Rehab and there are several pt that are on FSBS 2x/week with SS (how in the heck does that make sense in ANY world).

I am seriously thinking of eventually becoming a CDE for hosp staff/nursing. It is truly amazing the lack of knowledge. I always asked when presented with a scenario/question in school when the situation said "pt is diabetic" whether it was T1 or T2 and was ALWAYS told-it didn't matter. Being a T2, my treatment would be VERY different that my T1 son. OY!

Specializes in I/DD.

It is my hospital's policy that anyone who has an insulin pump is automatically referred to the endocrine service, which has an endocrine NP who takes a look at the pump and provides staff education as needed. If the patient is alert and oriented they stay on the pump, if not then they make a decision on what kind of glucose control is most appropriate (SS, insulin gtt, etc.).

Glucose control for long-time diabetics is often pretty complicated in the hospital (at least where I work). Obviously the patient is sick and under increased stress, their eating habits change, their activity levels change. All of these factors will affect the patient's sugar, and what works at home may not work here. However I am in agreement that the patient needs to be as involved in the management of their blood sugars as possible. After all, who is going to be doing it after discharge?

Specializes in Quality, Cardiac Stepdown, MICU.

When my husband, who is type 1 brittle, is hospitalized, I'm right there with him at his bedside 24/7 with his meter and his Apidra. I tell the nurse right up front what I'm giving him and when, as a courtesy -- I want her to know what he has on board while he's in her care -- but we do not leave his treatment to the floor nurses under any circumstances. Not to mention they are only allowed to give sliding scale ACHS, when I can give it to him whenever he wants/needs it! I've received very little resistance from it; just a few sour looks sometimes (this was when I was a student nurse -- now that I'm an RN we haven't had this problem much but we shall see).

Specializes in Hospital Education Coordinator.

this is frustrating to me as well. Some people think all insulin is alike. It speaks to how we need to constantly be educating ourselves on medications.

Specializes in Post Anesthesia.

I am obviously one of the ignorant, but, a blood sugar of 500 will throw you out of sorts for a day or two-even if it is corrected quickly, but a glucose of 20-30 can throw you into the morgue- for a lot longe than a day or two. I know Lantus is long acting basilar insulin, but if the dose is so far out of the needed range for the patients needs, it seems like adjusting the dose at 56 would be in order. It would depend on if the patient was depending on short acting insulins to cover meals or if the lantus was the only source of this dangerously low glucose. Were they NPO for the day? Are they NPO for something tomorow? Lantus meets your insulin needs based on a pre-determined caloric intake and energy demands. If thise have chaanged- why shouldn't the dose if Lantus change? Snacks sound like a great idea, but sugar/juice is often the only option at hs in the hospital. I can't tell you how many times I've gotten into my own lunch to provide something other than simple carbs/sugar for my patients hypoglycemia snack. Giving a short burst of sugar dosen't fix the problem, but just moves the hypoglycemic crisis to 3am when it is difficult to assess the patients status. Hypoglycemic coma or sleeping quietly?- I have to wake them up and/or check thier sugar to know. I am fine with giving Lantus to a patient with a low sugar if I have come protien/fat/complex carb to give that Lantus something to work on. What I'm seeing is the dose of Lantus has already proven itself to be excessive in reducing the patients blood glucose. Why not make the adjustment in the dose when this is discovered rather than try to play catch up with hypoglycemia when you could be 10 hours from the next meal. I'm willing to admit it if I'm wrong, but I rather err on the side of hyperglycemic but "not dead" if there is a question.

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