poured out before bed
“The last time Dr. Jones saw you was back in July, and at that time she adjusted your insulin a bit because your sugars were pretty high. It looks like you were unable to make the scheduled follow-ups…”
I wait. The woman, perhaps a bit younger than I, shoots me a blank look, then goes back to fiddling with her iPhone. I continue.
“I’m sorry we couldn’t connect with you then, but I’m glad you were able to come in today. Anything new since we last saw you – changes in your health or personal life?”
Ms. Smith squints a moment, then shakes her head.
“Nope, nothing I can think of.”
“Any questions or concerns you’d like to address today?”
“How have your sugars been since we changed the insulin?”
She shrugs, her long, fake eyelashes oscillating quickly as she momentarily meets my gaze.
“Were you able to bring your meter with you?”
“Yeah – but the nurse couldn’t get it to sync with your system to make a print out for you.”
“Oh, that’s OK. Can I see the meter?”
Ms. Smith goes slightly pale, but hands me the little pink meter, her faux nails clicking against it’s pristine plastic surface.
I turn the meter on and access the memory. For the last three months there are six recorded readings. They are all am blood glucoses of greater than 300-400.
“Is this your only meter?” I ask quietly.
“Yes,” she answers, equally as quiet.
“From this meter it looks to me like you’ve only been checking your sugars about once every two weeks or so… Is that correct?”
There is silence as Ms. Smith tries to think of what to say. Finally, she nods.
“I hate pricking my finger. I just give myself my basal insulin and sometimes some regular based on what I think I might need.”
Inside, I sigh. Outside, I nod and give a half smile.
“Well, thank you for being honest. But you know that I’m going to tell you how dangerous that is. You also know that Dr. Jones will speak to you about it as well.”
“I know,” she says wistfully.
I continue through the medical interview, taking down details of the ludicrous – and dangerous – insulin regimen she has developed for herself and discovering she has all the symptoms of uncontrolled diabetes – polydipsia, polyuria, polyphagia, and unintentional weight loss, as well as a number of episodes of hypoglycemia after administering too much insulin. Furthermore, she’s noticed that her vision has changed and blurs after meals, and she has a burning sensation in her feet, suggesting the appearance of both retinopathy and neuropathy secondary to years of poorly controlled type 1 diabetes.
“Wouldn’t the pump make this all better?” Ms. Smith asks, her tone suddenly adversarial.
I recall from my chart review that Ms. Smith at her last visit lobbied for an insulin pump – a convenient tool, but reserved for those patients who have demonstrated a good grasp of the gravity of their disease and have shown that they can be compliant in checking sugars and correctly administering insulin. Such a device is no more helpful than standard insulin administration – and can be actually quite dangerous – for non-compliant patients who do not check their blood glucose and use insulin willy-nilly.
“In some cases, but not always. We can talk to Dr. Jones about that.”
Ms. Smith sulks.
“She won’t let me have it. She’ll say I have to be better at checking my sugars. But I don’t want to check my sugars! And I don’t want to give myself shots! I want the pump to do it all for me!”
“Ms. Smith, with a pump you will still have to check your sugars, and you may still have to give yourself shots sometimes… I can’t imagine how hard it is to have to do all these things, and I know you really would like a pump. But Dr. Jones just wants what’s best for you, I promise you.”
Ms. Smith shakes her head and points to the heavens, punching her index finger toward the center of the room to emphasize her anger.
“She just wants to control me! She even told me I shouldn’t get pregnant right now! Can you imagine someone telling a person that?! That they shouldn’t have a baby?! She said it would be bad for a baby to grow in a bad diabetic. But I know she meant thats she doesn’t think I’d be a fit mother. And that is terrible – just terrible! She should be ashamed!”
I think of Dr. Jones, who builds excellent rapport with her patients, boasts an impeccable bedside manner, has a careful and detailed way of explaining complex and emotional topics to her patients.
“I’m so sorry you had a bad experience with Dr. Jones. If she offended you, I’m sure she didn’t mean to, but I’m so sorry that she upset you.”
Ms. Smith sniffs dismissively.
“I will tell you that she was being truthful when she told you it isn’t ideal to become pregnant with poorly controlled diabetes. It can cause real harm to the baby, and to the mother. We do have special clinics and classes for type 1 diabetics who are trying to conceive, in hopes of improving control and minimizing those risks. Did Dr. Jones offer you that service?”
“Yeah. But I don’t need that.”
“I can get you a pamphlet for it, in case you change your mind.”
“I said I don’t need it.”
“That’s OK, just know it’s there for you if you do. Is there anythi – “
Ms. Smith leans in and with a sudden, secretive grin interrupts my question.
“I did it on my own… I took a test last week – it was positive!”
Inside, I scream. Outside, I nod and give a half smile.