Friday, June 26, 2009

I'll start off by saying I really, really wish there were other options. I do. I wish we had the technology, the capabilities, to monitor diabetes and to treat type 1 diabetes without having my patients resort to pricking their fingers 4 times a day, and injecting insulin. Because the other alternative is simple: death.
I really wish we had options. But alas, we don't.
My last patient of the day was a struggle. Strangely enough, they come late Friday afternoons. I diagnosed her with type 1 last month, and she was back for a review, since I was concerned she wasn't accepting it well. Fervently refused the fast-acting insulin so I started her gently with just the long-acting basal insulin to keep her out of trouble.
She complains today that she feels like crap. Has been nauseated the last 2 weeks. Feels tired. Tummy pains. Thirst, urinary frequency. I asked her if she has been taking her insulin.
"Only if I remember it. Maybe 2-3 times a week."
What about her blood glucose?
"My machine's broken. The last 2 weeks it read H1 so I stopped checking."
I gently had to point out that it was working fine, that it had been so 'HI' that the glucose levels could not be measured. I suggested we send her to the ER for urgent evaluation, since she probably was in mild DKA.
She refuses. Also refuses to do more than what she is doing now. Will only give the insulin if/when she remembers, and will NOT start prandial insulin. Despite my gently but firmly telling her she has type 1 diabetes, and once the insulin deficiency is absolute, unless one takes insulin, is not compatible with life. She doesn't care. And what irritates me is she has a husband, and a child at home. Even if she doesn't care about herself, does she not care about her family? I couldn't help but think.
I really wish there were painless, less complex options for my patients. After all, it is easy for me, the doctor, to tell patients they need to stick themselves 4 times a day when I don't even give it a thought how many grams of carbohydrates I'm consuming in that croissant, let alone learning to carb-count and self administer insulin. I really wish there were other options. But there isn't, and though I shouldn't judge, I can't help but get irritated by her selfishness.
I've done what I can aside from spanking her like a parent. I've explained the risks. I've presented the options. I've called and reminded her numerous times at home. I've spoken to her family when they last came with her. All I can do now, is to inform the oncall physician about her eventual inevitable emergent hospital visit. And document everything. She is 25, and she is of sound mind. She'll have to make her own decisions.


Blogger walla said...

10:50 PM  
Anonymous Lady in Red said...

It is tough to help someone in need when the latter refuses to help herself or himself. Your patient is really immature to put herself at risk and yet expect you to have solutions to her health problems.

12:39 AM  
Blogger jon said...

how about insulin pumps for her ? ( i mean this will take some time for her to initially manage and control her glucose, to establish baseline etc etc)

3:24 AM  
Blogger vagus said...

it's a misconception that the insulin pump is a 'fire and forget' treatment for diabetes. in fact in pts who are noncompliant, most patients actually worsen their hemoglobin A1c after going on the pump because they stop checking completely, thinking they no longer need to be responsible anymore.
The main reason I'd suggest a pump to a pt is mainly lifestyle flexibility, and not usually as a means to better control the A1c.
a recent metaanalysis (JCEM) showed an a1c lowering of only 0.2% in type 1 pump patients compared to multiple daily insulin. in that study, there was a hint that the a1c actually got worse in type 2 pts who went on a pump.
so no, a pump would not be a good idea for this pt.

9:25 PM  
Blogger jon said...

ooo...learning something here... am still in the midst of grasping papers/trials etc. could you kindly give the author or the title of the meta analysis ?

will try to glean something from it in my spare time

thanks again

8:29 AM  
Blogger vagus said...

Fatourechi MM et al. J Clin Endocrinol Metab, March 2009, 94(3):729–740

10:07 PM  
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8:36 PM  

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