Thursday, August 28, 2008

Gimme some sugar

NewFNP sees diabetes each and every day. Double digit A1Cs are, sadly, all too common. But she has very few patients who are as bad off as her 23-year old diabetic with an A1C of 15.7. The lowest A1C she has ever had since her diagnosis in 2006 was in the 13's.

Generally, during her all too infrequent clinic visits, this young woman presents with sugars above the limits of detection on the clinic's glucometer. Once, she came to clinic almost unresponsive in a hyperosmotic - hyperglycemic state (HHS) - mouth dry as a bone and in and out of consciousness. NewFNP sent her promptly to the ER. She passed out another time in the supermarket and again, was sent to the ER in HHS. This last time, she felt herself reaching that HHS point and called the paramedics herself. That's good, right? Understanding one's symptoms and acting accordingly. Sure, a little prompter intervention would have been prudent, but newFNP is feeling generous tonight.

She spent a week in the hospital and left with a glucose of 130, according to her discharge summary. She had prescriptions for insulin, but had not been able to afford the medication when she presented to newFNP's clinic the morning after her discharge.

Her glucose less than 24 hours after hospital discharge? HHH.

NewFNP got her to a detectable level after 30-something units of insulin in clinic, did insulin instruction, diet education and sent her to the nutritionist. This was not the first time in three years that newFNP did diet education, but it is the first time that, when her patient told her that she had eaten two tamales and some pancakes for breakfast, newFNP stated, "That is just like putting a gun in your mouth and pulling the trigger."


NewFNP has never been one to respond to or to employ scare tactics, but she cannot tell you how many people have told her that they changed a behavior because someone showed them a picture of a foot with an amputated toe or because they saw their friend suffer from and STD, etc. Others providers have told newFNP that they use the patient's fear of adverse outcomes regularly in their counsling. NewFNP has just always felt that that is an ugly tool. If newFNP's provider would have said something like that to her, she would have thought, "Whatever- screw you." But newFNP said it and saw that her patient heard it - for better or for worse.

OK, so pretty harsh. NewFNP is certain that the nutritionist delivered the message in a more nurturing fashion.

Whatever message stuck for this patient, it really frigging stuck because when she can into the clinic yesterday, her glucose was fifty-frigging-one. In the course of the six hours newFNP kept her in clinic, this young woman consumed a 75g glucola, a 4g glucose tablet, a turkey sandwich, salad, fruit, a second helping of glucola - this time only 25g - and, thanks to newFNP's awesome student, a chicken breast from El Pollo Loco (thanks BC!). During the course of the six hours, her glucose measured between 45 and 215.

What the hell?

NewFNP reviewed how much insulin she was using and if she was using it correctly. She was. NewFNP therefore lowered her insulin doses and have her strict instructions regarding glucose monitoring, ER indications and follow up.

NewFNP likes to be an outlier if it is something like 2 standard deviations above the mean in fashion sense or test scores, but she does not like glucose outliers on either end of the spectrum. And she isn't sure why this young woman is all over the glucose map.

And now she'll wonder about this patient as she spends two luxurious weeks on vacation after only one more eight-hour shift this Saturday. She'll have to hit up Dr. Dual-Ivy-League-Degrees for an update.

NewFNP's service commitment ended today. Her six-figure nursing school loans are forgiven. Now she only has five-figure pubic health school loans with which to contend. Aaaahhhhhh! What a relief.


DamselFish said...

I'm happy that you will be moving on to a job that isn't killing you daily, but will miss your honesty about the public health arena. Much of what you write sounds remarkably like my dear Baltimore. I hope you keep writing -- I'm sure there will be some kick ass stories from your new job, as well.

LovenLife said...

I'm really glad you're moving on to something bette- good luck on the new job! I have loved every entry and kept up your blog from the beginning. Its the real deal for this fnp-to-be! I hope you keep on blogging about health- I will definately be checking in! Enjoy your downtime and get some shopping in!

LilSass said...

I am sorry that I am just joining you now. Wait, what?

How the heck did you get loans forgiven? Was this through the Health Service Corps?

As I am starting a very, very expensive program in June, I am trying to do all the research possible. If you could spare a minute after your vacation for some guidance (or simple links) I would greatly appreciate it!

You can email me at lilsass at omgdgms dot com.


Anonymous said...

Can anyone suggest a really nice warm tropical fun way to get CMEs?

Anonymous said...
This comment has been removed by a blog administrator.
Anonymous said...

It's tacky for a PR person to post product info on a website like this. My vote is that you get rid of it!

The guy has got to earn his money some other way than trolling the web for sites like this one.

Boo on Alec Drozdowski.

Beth said... this the last FNP post? I hope not, I find your blog SO encouraging and just wonderful.

Tony. said...

I can't believe the last line wasn't the first. Congrats on achieving forgiveness; I hear it's somewhat akin to divinity.