How to Manage Your Diabetes: Lessons from Doc-of-the-Day

 

“Put it this way…between the hospital and taking care of a family, I’ve been awake for 27 hours, I’ve been puked on twice, pissed on once, and after that last patient, I believe I’ve permanently lost my ability to smell. I’d rather wear a wire thong than stay here one minute past shift change.” … ER Resident

 

Doc of the Day Series: PART I

It was just another day on-call as an Intern. The beeper sounded and I ran off to the Emergency Room to do another admission to our team- ‘Yellow#2, Doc of the Day Service.’ The medicine teams at my hospital are subdivided into Colors and Numbers, each team representing a sub-specialty of medicine.  My admission came late in the evening, just as I was putting in the last orders into the computer for the following day. The page came from the Medicine Triage Resident, the doctor that remains in the ER all day to admit patients to the various Internal Medicine teams. As an Intern or Resident on ‘Medicine Doc-of-the-Day service’, we never know what type of admission we are going to get. It could be a patient presenting with Chest Pain, Stroke, Asthma exacerbation or Pneumonia. One just never knows. On the Yellow 2 team, we admit patients to our service that do not have a Primary Care physician, and need emergent care, hence the name “Doc of the Day”.

images-6

When I arrived at the ER, on a stretcher in the hallway of the overcrowded emergency room was my new admission, Mr. H.I. I actually knew Mr H.I., I had just discharged his the day before. “Why was he back?” I wondered. Have I made my first mistake as an intern and sent him home too early?

Mr. H.I. was a homeless man, 50 years young. His only medical history was Type I Diabetes, where there is a lack of Insulin production by the pancreas. And needless to say, he unfortunately never takes his Insulin. He was just on my service for a week, after we treated him for Diabetic Ketoacidosis, a medical emergency when the blood sugar levels are severely high. Most of the time this is seen in Type I Diabetes, where there is a lack of insulin production from the body, and may be precipitated when patients do not take their insulin. Insulin lowers blood glucose levels by bringing it into the cells where it is used in glycolosis, or energy production. Without Insulin, the sugars rise in the blood, which can further lead to nausea, vomiting, abdominal pain, altered mental functioning, followed by coma in severe cases where the sugars reach 800 and above. Mr H.I.’s blood sugar in the ER was 850, high enough to cause serious damage.

images-3“Mr. H.I., Why are you back so quickly to see us?”  I asked. He smirked, turned his head away from me, smirked and gigggled as if he were privileged to be readmitted for his own non-compliance with medication. Like many of our patients and hospitals across the city, He knew in the ER there would be a bed and food for him to eat, once his sugars came down, of course.

“I’m H.I. he said. H.I.? What is that? I asked. “Do you not speak English? I’m High! My sugars. They are High!  He admitted not taking administering his Insulin injections after leaving the hospital.  And here he was. AGAIN- In the ER.

Mr H.I. was being admitted under my service again in the hospital. For the hours that followed, I work diligently to lower his blood sugars so that he would not end up in the Intensive Care Unit on an Insulin IV drip. I had the nurses watching his mental status, checking his blood sugars every 2 hours, and administering Insulin. But Mr. H.I. continued to disrespect the staff, even when we were saving his life. 10 minutes wouldn’t go by not being paged by nursing to be informed that Mr. H.I. was roaming the halls, yelling that he wanted to eat, and laughing at the staff. After tending to another patient, I paid Mr. H.I. a visit. To no surprise, there he was, in the pantry, eating food off of the other patients trays after I told him he can not eat until his sugars come down with the Insulin.

As a Physician, we do everything in our power to care for the best interests of the Patient. We go to school for eons, take test after test to gain the knowledge needed to practice medicine, and we spend long hours at the hospital during residency with very few days off. Overall, we treat to the best of our ability. One lesson, amongst the many, that Residency has taught me is that sometimes things are out of our control. Patient compliance with our treatment recommendations, for example, is frustrating for us, not to mention, costs our country billions of dollars every year in hospital stays that could have been avoided. But before Residency came, nothing prepares us for the social aspects of medicine, which unfortunetly is a big part of society and the patient population we are exposed to in major cities across the country. At times, the thought crosses my mind to give up, but I do not. I keep moving forward with my head high and a smile on my face. I get back to work, caring for all of my patients despite the disrespect they have for those that care more about them than they do themselves.

Mr. H.I.’s uncontrolled Diabetes could have easily killed him that night. The scary part is, he was told as such. He was made aware of the consequences of his Diabetes, and made aware that he may not be so lucky to make it to the hospital the next time his sugars rise and he does not take his Insulin. My patient was discharged a few days later, after he was well enough and his sugars came down on the appropriate Insulin dose. I gave him enough Insulin to last him a few days and a list of health clinics around the city of Philadelphia where he can get his Insulin free of charge. I feel comfort I did my job as a doctor, but the mystery remains when I will see Mr. H.I. again.

What is Diabetes and how can we keep it controlled?

Types:

There are two types of Diabetes: Type I Diabetes, characterized by insulin deficiency and Type II, characterized by insulin resistance, impaired insulin secretion from the pancreas and excess glucose production by the liver. Essentially, Insulin is responsible for taking blood glucose into the cell, and without it, Sugars remains in the blood and can lead to serious consequences.

Diagnosis:

The prevalence of type II Diabetes in the United States is rapidly increasing, which can be attributed to the epidemic of obesity. The criteria for diagnosis include one of the following: a fasting plasma glucose level of >126 mg/dL, symptoms of diabetes (excess urination, excess thirst, fatigue, weakness, blurred vision, poor wound healing) plus a random blood glucose concentration of >200. Screening for Diabetes is recommended every 3 years for individuals over the age of 45, as well as for younger individuals who are overweight and have one or more additional risk factors.

Treatment:

When it comes to Diabetes management, Glucose control is the central theme. Keeping your blood sugar within normal means can help you live a long and healthy life. Here are some Dailydose tips to promote diabetes awareness:

1. Exercise

Exercising is an important part of your diabetes management plan. When you exercise, your muscles use sugar (glucose) for energy. Regular physical activity also improves your body’s response to insulin. These factors work together to lower your blood sugar level. The more strenuous your workout, the longer the effect lasts.

images-7

What to do:

  • Talk to your doctor about an exercise plan. Ask your doctor about what type of exercise is appropriate for you. If you’ve been inactive for a long time, your doctor may want to check the condition of your heart and feet before advising you.
  • Keep an exercise schedule. Talk to your doctor about the best time of day for you to exercise so that your workout routine is coordinated with your meal and medication schedules.
  • Check your blood sugar level. Talk to your doctor about what blood sugar levels are appropriate for you before you begin exercise. If your sugars are too low, this may cause you to not have enough energy to burn during a strenuous work-out, and the potenial for serious consequences such as becoming lightheaded and passing out. Check your blood sugar level before, during and after exercise, especially if you take insulin or medications that lower blood sugar. Be aware of warning signs of low blood sugar, such as feeling shaky, weak, confused, lightheaded, irritable, anxious, tired or hungry.
  • Stay hydrated. Drink plenty of water while exercising because dehydration can affect blood sugar levels.
  • Adjust your diabetes treatment plan as needed. If you take insulin, you may need to adjust your insulin dose before exercising or wait a few hours to exercise after injecting insulin. Your doctor can advise you on appropriate changes in your medication. You may need to adjust treatment if you’ve increased your exercise routine.

2. Food

Healthy eating is a cornerstone of any diabetes management plan. But it’s not just what you eat that affects your blood sugar level.

images-1

What to do:

  • Make every meal well-balanced. As much as possible, plan for every meal to have the right mix of starches, fruits and vegetables, proteins, and fats. It’s especially important to eat about the same amount of carbohydrates at each meal and snack because they have a big effect on blood sugar levels. Talk to your doctor, nurse or dietitian about the best food choices and appropriate balance.
  • Eat the right amount of foods. Learn what portion size is appropriate for each type of food. Simplify your meal planning by writing down portions for the foods you eat often. Use measuring cups or a scale to ensure proper portion size.
  • Coordinate your meals and medication. Too little food in comparison to your diabetes medications — especially insulin — may result in dangerously low blood sugar (hypoglycemia). Too much food may cause your blood sugar level to climb too high (hyperglycemia). Talk to your diabetes health care team about how to best coordinate meal and medication schedules.

3. Medication

Patients with Type I Diabetes strictly require Insulin injections, as their body’s ability to make it is flawed. Patients with Type 2 Diabetes may be managed with diet and exercise alone or in conjunction with oral glucose-lowering agents. If adequate control is not achieved in Type 2 Diabetes, then Insulin injections may be required.

images-2

What to do:

  • Report problems to your doctor. If your diabetes medications cause your blood sugar level to drop too low, the dosage or timing may need to be adjusted.
  • Long-Term Management. If you have been recently diagnosed with Diabetes or are uncontrolled, your doctor will enroll you in Patient Education courses in Diabetic Management. Your doctor will also ensure that you have proper blood pressure control, are up to date with immunizations, receive annual foot exams and eye exams.

 

 

 

 

 

 

 

Related Posts Plugin for WordPress, Blogger...
DanielleKrolMD
Dr. Danielle Krol, a native of the Philadelphia area, spent the majority of her early life growing up in New Jersey. With over 15 years’ experience in Dance and Theatrical Arts, Dr. Krol was pursuing a career as an actress until her mother was diagnosed with metastatic breast cancer. For the 3 years that followed, Dr. Krol placed her life on hold and took the responsibility of Caretaker for her terminally ill mother. Her passion for medicine came about during her mother’s illness, and her determination to become a doctor came about after her passing in 2002.