Reviewing Medicines

Obsessive-compulsive, probably not.  Attention to detail, probably.  Inquisitive, for sure.  Two interesting encounters this week, both very typical consults on uncontrolled diabetics.

First fellow came in with ketoacidosis following a lapse in insulin from a previous prescribing snafu that left him without basal insulin for two days.  He had been a type 1 diabetic for more than 50 years.  His history was an interesting one, being started on NPH and regular insulin in the 1960's as a preschooler, then having a number of revisions in his protocol as the fashions for using these types of insulins changed from decade to decade.  He had been on the same treatment since the 1990's, maintained by his primary doctor from visit to visit, never converted to the current analogs.  he had been seeing a nephrologist as his creatinine rose.  At his last encounter, the switch was made but he had marginal prescription coverage and never received it, resulting in the current hospitalization.  After treatment of the ketoacidosis, Levemir and Humalog were initiated and an endocrinology consult was requested.  He had an interesting glucose pattern for the previous three days:  normal or low in the morning but 400+ at lunchtime every day.  On looking at the medicine record, it seems he had not received the Humalog at breakfast for each of the last three days, since the nurse opted not to give it based on the morning glucose, which was never extremely low.  That's easy enough to figure out and correct for that patient, a lot harder to correct as a system-wide policy where the aggregate nurses think this is the right thing to do for that situation each time it arises, despite the predictably adverse outcome.

What struck me more was the conversation with the referring resident who asked why I thought those spikes were occurring.  Having received the patient from the ICU, he never expanded the history beyond that needed to address the presenting crisis.  He also never sought an explanation of why the glucose would spike the way it did, even though it would be obvious from a review of what insulin the patient actually received.

The other consult was also very typical, a man with uncontrolled diabetes that came under reasonable control after resumption of insulin following an unintended interruption.  He had injured an amputation site which was revised.  However, five days later he was still requesting his prn iv opiates at just under the minimum allowed interval.  The residents were next to me in the computer room.  I asked them how his pain was doing, told OK, and then showed them the narcotic administration record.  Either he is having a lot of pain, or the sensation that he desires from the hydromorphone is more euphoria than analgesia.   Needless to say, he needs his pain revisited as he should not be needing that much IV narcotic.  Or if the pain were not going to resolve, there are many better ways to give this than q 4-6 IV dosing.  In either case, nobody read what is actually being given and therefore did not appreciate the need to reassess the pain management before they sent him home with that iv prn order still in place and no better long term alternative.

The essence of work rounds in my era, and in my office encounters today, has been to focus primarily on the medications.  What are people taking and how are they doing on what they are taking?  What is prescribed often differs considerably from what is actually being swallowed or injected.  At least the hospital medication records are accurate, the office ones border on fiction.

And there is also the question of being inquisitive.  If something looks extreme, as a glucose going from 70 to 400 on consecutive days would be, this cries out for an explanation.  Even if it had no bearing on what I am there to do, it's presence would attract my attention, as did the opiate schedule which was really not integral to the endocrinology consult.

One of the attending physicians of my residency, an outstanding rheumatologist, once pulled me aside and told me how he was taught to do consults and passed the advice to me.  Be thorough.  If you see something that needs to be fixed that seems to be neglected, mention it in the note even if not rheumatology.  It is that ingrained attention to detail that has kept the patient encounters professionally challenging, even as other elements of being a physician in the modern age have taken their toll.

Keeping People Independent

Diabetic blindness used to be much more common than it is now but fortunately with laser photocoagulation and vitrectomy, sight preservation has advanced greatly as more diabetics live longer and become more subject to this.  Still, visual loss is an unfortunate reality while their diabetes and need for testing and insulin continues.

Such a person came to my attention recently, nice fellow on oral agents whose family member had been testing his glucoses twice a day.  He developed a foot wound, came to the hospital rather hyperglycemic.  Hyperglycemia persisted after below knee amputation while the residents tinkered with his pills and eventually added basal insulin.  Cavalry called in, basal insulin increased, pills discontinued, and prandial insulin introduced.  Quick, easy, straightforward,  Glucoses corrected in a day and remained controlled the remainder of his stay, with a slight insulin dose reduction toward the end.

In New Age Hospital Medicine, once corrected people just kind of go on auto pilot with no refinements to medical care but all sorts of efforts to move people to their post hospital destination. And so it was here. Ready to go, all fixed.  And then came the phone call from the intern, what do we do about his insulin if he cannot see?

Forgive me, but the medical center pays through the nose for a very expensive discharge planning process that includes a meeting on every floor every day from the day of admission attending by a who's who of hospital functionaries experienced at sending people home.  This isn't really very hard, and why was it not addressed by these people of professional title earlier?  So I asked the intern, who lives at home with the patient?  He didn't know.  How was he getting his finger sticks done all these years?  He could not tell me if the patient had an auditory machine or if somebody at home did it for him.  I knew, because I asked him as  part of the initial consult.  Basically there is somebody else home most of the time.  And he had one leg less than when he arrived, not that the infected leg was of much use for walking prehospitalization.  So keeping him independent would require more than providing him insulin.

Basically, they had two choices, either pre-fill syringes one week at a time and keep the two types of insulin separately in the refrigerator in different shape containers that he could identify by feel and inject himself, or send him home with pens that either somebody else could give him or since the doses are low, he could probably just count clicks on the dial with each injection.  Amid the grandiosity of a hasty exit from the hospital, sometimes the simplest of things cause the impediments.