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.