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Monday, January 13, 2014

Diabetic spirits

DIETETIC INTERNSHIP: Weeks 33 & 34 (of 41)
Intensive Diabetes Management: Week 33
Pediatrics: Le Bonheur Week 34

What type of pills would you like to take?
Let me be honest.  I didn’t take many (personal) notes during the above-named rotations.  I toiled, but I left significant lacunae in my bank of memories.  Here are a few memorable moments:

Intensive Diabetes Management was primarily outpatient driven and functioned like playing a game of Magnum PI crossed with Dr. House.  Patients come in reporting high and low blood sugar extremes with seemingly perfect compliance to medication and insulin.  Dietary compliance?  That is always questionable.  I saw patients with blood sugars ranging from 30 to 460 daily, and supposedly taking the correct dosage of insulin.  Riiiiiight.

Using detective skills it takes creativity and focused pursuit to learn that literally every single patient was taking their specific insulin at the wrong time, the wrong dose, or there was a huge lack of understanding between doctor and patient.  More and more, I realized that the average doctor, nurse, or endocrinologist does not educate the patient on appropriate insulin dosing, or plainly they don’t know either.  It is the Certified Diabetes Educators of the world, who are usually Registered Dietitians or Registered Nurses, that are REALLY needed for these patients.  If you are a diabetic with an HbA1c >8% that has never met with a CDE, then get a referral pronto!  Interesting notes: 75% of all amputations at the Memphis VAMC (not unlike most hospitals) are due to diabetes.  The first amputation is the beginning of the problem, not the resolution or the treatment.

Le Bonheur Children's Hospital "Big Bird"
You make me so dog gone happy
 I had one particularly memorable patient this week that was more than just a diabetic patient.  He possessed another side that took me a little by surprise…  As we talked he suddenly said, “I cannot take that insulin at night sometimes, they won’t let me.”  WHO is “they”?  Without missing a beat, he told me that the spirits won’t let him take his insulin sometimes, or won’t let him have a snack when his blood sugar begins to fall.  Not wanting to appear there was a problem, I responded in kind, “What will the spirits let you do?  What do they allow?”  Before his departure, we worked a way to please the spirits while adhering to insulin needs, but not without a lot of ingenuity and imagination at work. After he left, my preceptor and I scoured his medical chart to find psychiatry notes alluding to illusions.  NOT ONE!  Needless to say, we put in a referral…stat!

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