Sometimes it is the silliest of things that expose some of the systemic deficiencies of what we do. One of the psychiatrists asked me to see a patient with a glucose of 295 taken by finger stick in the ER The patient had no known diabetes. He had been in the hospital the year before with a random lab glucose of 117 and otherwise normal lab work, so the progression from pre-diabetes to diabetes was plausible. During his few days in the hospital, several bedside glucoses were obtained and were all normal. A HbA1c measured 4.9%. By all evidence he does not have diabetes but had a spurious ER fingerstick, which made for a very brief consult and the lowest billing code available.
What caught my attention, though, was that the entire evaluation was done by the psychiatrist. Every psychiatric inpatient gets seen by a medical physician, typically the nurse practitioner or on weekends the resident, with review of the hospitalist. Even though that 295 was the most recent glucose obtained in the ER the day before, there was no recognition of it by the Internal Medicine people, not to repeat it, not to do a HbA1c, not even a concern that he might be a newly identified diabetic. But the psychiatrist either was attentive, or was the recipient of this lab value by verbal report from the ER and took it upon himself to check it out when it whizzed past the medical people who often function more as scribes to put a paper in the chart than as consultants to take advantage of a patient on the psych unit who frequently slips through the ordinary venues of scheduled outpatient care.
And we have erroneous lab data. Did that fingerstick belong to somebody else who should have been treated? Was it contaminated? Should it prompt a lab draw from the ER? No, it was just added to the chart, assumed to be true and passed along to somebody, though not necessarily the person best able to act on it.
And yes it is ok to give him Risperdal if it helps the psychosis. No risk of severe hyperglycemia this time.
