I am trying to figure out if this is funny or sad. On the fence…
So my approach to politely decline services involves a two person approach. Often times referred to as “good cop / bad cop”. The “bad cop” part of this seems to come naturally to me.
So the “bad cop” goes on a tirade in somebody’s face about how this is awful and that is crazy and who is your supervisor and I am filing a complaint and I am not paying for third-rate service and so on. Yeah - I find this role easy. lol.
Then the “good cop” tells the “bad cop” to “talk walk”. “Bad cop” leaves the room. “Good cop” now says “lets just get this worked out nicely before he comes back”.
Suddenly the other party is very eager to work with “good cop”.
Its complicated. I don’t feel like its funny or sad, I can’t pass judgment. It just tells me that what we do is more complicated than what they imagine that we do.
I believe that if they don’t feel like they can dose insulin safely to run us at ‘good’ levels without killing us, then they should just do the best they can. If running me at 350 is the best they can do, then that’s what they should do. It is what it is. However, I don’t want to stay in the hospital for very long because I don’t feel very well at 350. I stop eating in order to bring the numbers down. I just don’t recover very well, or very happily, in the hospital.
Last time I was in the hospital, my mom snuck in a bottle of Humalog to try and convince me to eat. But, the Doc suspected something and said that if they discovered insulin in our possession, that he would throw her out and not allow me to have any visitors. It all gets very hairy. My dad is the smart one. He could see me starting to quietly plan an escape. So, he told me that if I made a break for it, that I would never find my way out because the exit was not on the 1st floor and I would never find it before I was re-captured. He tried to negotiate my release with the Doc and the Doc scheduled it for two days later. So, my Dad just kept telling me, “2 days, you can leave in 2 days.” But, then the Doc reneged and he got very frustrated. That’s why I need a healthcare directive that says, “Can be released to father.” I trust his judgement about when I am able to care for myself. He will give me a ride.
If the hospital steals your insulin, that is theft pure and simple. Hospitals, doctors, and in fact anyone other than the patient are terrible at managing your own insulin dose. As I reported on this forum a while ago, I was in the hospital once and the doctor said, “Since you were a bit low yesterday you should eat breakfast with no insulin and then we’ll check your blood sugar again at lunch to see if you need any insulin then.” I was barely able to control myself as I explained, patiently I hope, the basic physiology of type 1 diabetes and why his ‘professional’ treatment plan was moronic.
Ugh, thats a real bummer indeed. I’d rather not explain to Docs. That doesn’t typically work well for me. Especially, if I have animal brain. I can deliver pump bolus by muscle memory, even if my brain is screwed up, but I would probably give possession of my pump receiver to a trusted individual, or ‘accomplice,’ just to ensure that I didn’t bolus more than once and/or verify that I delivered basal insulin once a day. I’m not 100% sure that I could change a POD because I can’t always see very well. I don’t think that my type 3’s could operate a receiver or change a POD. That’s beyond their pay grade, but they know how manual injection works because I spent most of my life on MI. I should probably teach them how to operate a Dex. They know darn well how to operate a reciever, but not how to change a sensor. That would be important.
I find it interesting that you know that all hospitals, doctors, and nurses know less than every diabetic does about their care and their insulin dosing. Wow I wonder why every week for the last 40+ years I’ve had to take care of diabetes that know better than anyone else how to take care of themselves but have A1C’s of 12 and 14. The same diabetics with lab glucose levels at 1000 and are fully awake, and functional which means they are far from being controlled for some time. There is a lot of reasons for dosing insulin, and insulin drips, IV fluids to include D5W when coming off insulin drips due to DKA and acute acidosis. There are reasons for keeping glucose levels at 200 and bring it down slowly. I am a type 1 with a insulin pump, I’m well versed in caring for my self but like you I don’t know everything about diabetes nor does the doctor and that why they do consults, use care pathways that are true and tested. Possibly someday a hospital, doctor and nurse may save your life and probably won’t even get a thank you.
@David61, Please don’t take offense. I believe in everyone doing the best that they can. It’s an honest reality that diabetics who make an effort to manage their systems, probably can do it better than a Doc who has never tried to manage sed system before. That’s just a practical reality. Now, the percentage of people who can honestly be said to try to manage their systems might be 20%, I dunno. But, the people on Tu could be assumed to be in that upper 20%. If someones comfort level is that they run me at 350, then by all means, run me at 350. I trust people to know their own limitations, even doctors. LOL. Patients get to take liberties that Doc’s can’t because Doc’s are responsible for someone else.
I know that I could beat a randomly selected ER Doc, first try, basal/bolus dosing a pt over the course of a week. I bet most people on this site could. However, as a diabetic Doc, I bet you could beat my dosing success rate because it’s one of those skills that increases exponentially with experience. Its a practical thing to worry about BG, in AND out of the hospital. It’s also a pretty reasonable/common question for a pt to ask - “When can I refuse care?” It’s a question with significant affect on emotional, physical, and financial health. Its worth asking.
Thank you for being a healthcare provider with increased attention to diabetes. Your awesome. I could never be a Doc, especially a Doc working with diabetics. It would just be too frustrating and sad. The sad truth is that how ever much effort you put in, you can never help anyone as much as they can help themselves. Most people aren’t that motivated to help themselves. People have other attentions.
Why they give dextrose for DKA? I don’t understand. Please explain.
Please let me know if you have any strategies for exiting the hospital quickly. It smells like urine there and I hate it. Waiting so long for release. God bless the hospital doctors, nurses, medics and janitors. Lord knows it aint an easy racket - perhaps the worst I can think of.
The explanation we had was that the BG was so high and the condition was so bad that an immediate drop with just insulin could be even worse. This was a really bad situation.
The ER docs wanted the sugar IV (whatever it really was) and the insulin IV to balance more or less and do a slow and gradual reduction over many hours.
Hang in there, everybody. This gets discussion gets contentious. Blame me and Tim35. We started it in a brief argument on someone else’s (distantly related) post. Sorry.
The only time that I have successfully escaped the hospital, the law made it to my house before I did (on foot) and promptly escorted me back to the hospital. Thus, I learned that I need a safe house after escape. I’m getting older. I might need paperwork to escape from now on.
I was a Detroit ER nurse for a good chunk of my career. Great job! But as I read this discussion it seems many think hospitals are out to get them, strip them of their rights, and hold them captive. Well, in 40 years, I NEVER saw that happen. Not once. Oh, there are a few fringe cases like when a heroin overdose arrives unconscious in respratory arrest. We’d bag 'em, line 'em, restrain 'em, and give an amp of Narcan. Why the restraints? Because about a minute after that Narcan was given they’d go from unconscious to punching the nearest face. They’d also be screaming to be let go - as in leave the hospital. Problem was, depending on how much narcotic was in the body, they might just be back in deep trouble when the Narcan wears off in 30 minutes. What to do? It was a delicate walk to try to meet their needs. And it varied from patient to patient how it would go. Often, we’d just let them walk, knowing they were in danger. You can’t fix everyone but it gets real tricky to fix someone who doesn’t want fixing. But I’m rambling here.
What I mostly want to say is hospitals and their staff don’t care if you sign AMA. Really, that’s your right. We’ll do what we can to make sure you understand the concerns or issues at play, but when the relationship gets adversarial, well, we understand and silently support your leaving against medical advice. So, no sweat. Do what you have to do. We get it. And always be aware that anger and good judgement are often at odds with each other.
All of that makes sense and is eminently reasonable. Nevertheless there is a difference between being restrained for your own or others’ safety, and being forcibly taken into custody because of an arbitrary number on a meter, without regard to any other factor—particularly when the number is well within the range many class as “normal”.
Even restrained for your own safety is only allowed if you are not competent in the moment.
Certainly high on drugs or alcohol are the classic cases of not competent while conscious. Being unconscious of course is not competent at that moment. There would be other cases and obviously as with many things you could quickly get into the grey area.
But absent reasonably being able to call a person incompetent (at that moment) an adult can not (legally) be restrained for the purposes of medical treatment (in the United States).
One of the most arrogant and stupid things doctors do with a type 1 diabetic in the hospital is that they assume they can somehow know what insulin dose the patient requires, even though they should know that patients have an enormous variation in insulin requirements. For a given blood sugar level, one patient may require two units of insulin and another may require ten, and many patients have themselves varied between a requirement of two and ten at different times, yet attending physicians barge through with a dose of 5 units when their new patient might require 10 or be unconscious at 2.
Another problem is that a hospital is both of place of medical treatment and a large organization having to operate efficiently. With type 1 diabetic patients, the latter characteristic seems to predominate, so patients are run at an absurdly high blood sugar level because the staff does not want to have to cope with the occasional hypoglycemic episode.
Many articles have been published in medical journals on the topic of how poor the care of diabetics is in the hospital setting, so others have recognized this as well.
@mremmers, I’ve never been physically restrained. Last epileptic seizure I had, they shot me full of Versed. I didn’t even know where I was for 24-48 hours. But, when its time to go, its time to go. Can I tell a type 3 to bring a written permission slip to the hospital that was signed in advance (if I’m there for more than 2 days if they are just doing observation)? Should I include paperwork with diagnosis from my Doc so the hospital feels better that its just run of the mill epileptic seizure, not a stroke? The hospital might be more lenient with me if I have a formal epilepsy diagnosis on med tags around my neck ??? Not sure. If the medics find me, then I’m probably out cold on the sidewalk, in which case, they and I are gonna do buisness. But, once I get to the hospital, no one has ever offered me a refusal. I have the worst time getting out. Do you know how most epileptics escape? I know very few want to be transported, if at all possible. Does that paperwork plan jive with your experience, as opposed to just making a break for it?
What does narcan feel like, if your not on drugs? My highschool buddy’s dad got the narcan for septic shock last month. I really don’t want the narcan. eeepppp! You know that’s not super unlikely, if they don’t find my med tags pre-hospital, Detroit. Especially, if they see the syringes before they see the med tags. You think that I should get my diagnosis tattooed on my forearm? I know multiple type 1’s who have done that. I’ve never liked the idea because I don’t want to announce it, but perhaps I have just reached that age.
This is common enough that the medical staff have given it a name, “permissive hyperglycemia.” I think this borders on medical malpractice. Post-trauma/operative hyperglycemia delays or prevents healing and puts the diabetic at increased risk to catch a hospital super-bug.
Sometimes dextrose is given when insulin has caused a greater reduction in blood glucose than is safe. The body that is in DKA needs some time to move sodium, potassium back into intercellular system and needs time for acidosis to slowly correct. The body is a fine tuned system that doesn’t do well with sudden extremes including going back to complete normal in a very short time. Over the years I’ve only given dextrose a few times at a very slow rate for a very short period. Normally insulin drips are stopped at around 250 glucose to prevent a sudden drop but everyone reacts differently and also acts different than their normal due to an over stress, over worked body system. You think DKA is bad, look up Hypermolar Hyperglycemia which effects Diabetic Type 2 it isn’t pretty and far more deadly think goodness I only have cared for one patient with that.
Permissive hyperglycemia is only used in Trauma Care Units, Surgical Critical Care Units, and ICUs and there very good reasons why it is used and for how long it is used. Has a lot to do with my post above. studies show decreased death rate in those that meet the guidelines. it is also common for non-diabetic patients to receive insulin with acute stressed conditions while in CCU, SICU, NICU. this does not border on malpractice at all.
Are you saying that deliberate allowance of hyperglycemia in the hospital is limited to “Trauma Care Units, Surgical Critical Care Units, and ICUs”? My experience indicates that the practice and knowledge of permissive hyperglycemia exceeds that scope. I encountered it with nursing staff in an out-patient surgery setting.
I reviewed some of the literature today and I do not find that it is a settled issue.
there is a significant and growing body of evidence that uncontrolled hyperglycemia poses an unacceptable risk of infection in the postsurgical population. Therefore, although the 80–110 mg/dL goal may be too aggressive, allowing consistent serum BG levels above 150 mg/dL is likely also detrimental.
