The end of the month for me is a time to see how many patient’s I’ve seen this month, get a recap on the heart surgery patients to see if we met SCIP measures, scan consult sheets and make sure my productivity spreadsheet is complete. As I think about the patient population I have seen this month, there were some repeat offenders (as usual), some general and heart surgeries, patients who couldn’t afford their medications, new diagnosis, you know the type of patients we would expect an inpatient educator to see.
One of these patients was a young woman who has had Type 1 diabetes for a very long time and with an A1c to make paint peel. Unfortunately, she has succumbed to some of the complications we know that these patients have, and lost her foot this admission. But that isn’t the interesting part to me. I happened to be seeing her the day I had a nursing student shadowing me. So of course I’m on my best CDE behavior and I asked her about her injections.
Now, when I say she has had Type 1 a long time, I mean almost her entire life, since she was 2 years old. You would think, she knows she needs to change where she gives her shots. Surely, I confirmed that the last time she was in the hospital. Turns out she wasn’t. When you look at her, you think, okay, her sugars are awful, so she is really thin and her shoulders are bony. Until you touch them. I was so glad I had a student with me. It was the most perfect example of lipohypertrophy I have ever seen. Perfect half baseballs over each deltoid muscle (because we all know getting a pen injection into the back of the arm is hard!). SO, when the nurse gave her her home dose of Lantus, she of course bottomed out. She’s now down to a third of what she was taking at home.
We all have these examples of poor injection technique, but do we always remember to ask or observe. I had a retired physician who thought that each mark on the pen was 10 units, so when turning to the “1” didn’t work, he went to 20 units: the “2” mark. He was doing this for months. Or the patient who was squirting his insulin into his mouth instead of injecting. His Lantus tasted bad, so he went back to injecting that, but kept “drinking” the Humalog. One of our dietitians found that out for me, after I had already seen him.
This morning I received an email about a near miss issue we should all look for with the new Flextouch Pens for Levemir. They dial to 80 units. I know I’ve had the patient on 60 that just thinks, “I’ll dial till the pen won’t go further.” That was this near miss example. But how many other med errors are patients committing without realizing it because they didn’t have a diabetes educator in the office to help them learn how to safely take their insulin? How hard is it to ask, can you show me where you take your insulin? Where do you store it? Maybe even on a questionnaire sheet in the waiting room or reminding your floor nurses or office nurses or medical assistants to be looking for issues on their physical exam and reminding them about good technique. The best thing a preceptor taught me as a new nurse was “You should be able to teach/reinforce a patient something with every interaction.”
Just some thoughts on this September morning. Happy Fall everyone.