Recently I was hospitalized at a major Boston hospital for broken ankle surgery. I use MDI and Tresiba. Fasting for surgery. At 11 pm a finger stick shows 243. My sensitivity factor is 110, indicating a correction dose of 1 unit. The hospital orders a lethal dose of 4 units!!! They claim to use a “sliding scale”. I explain to the nurse why I am declining to take more than 1 and ask that she relay the arithmetic to the source. Morning dawns and there’s a similar BG reading. Another order for 4 units arrives!
Again I take 1. I tell the nurse my endo has instructed me to take 90% Tresiba on day of surgery. She has never heard of Tresiba and asks pharmacist to come and look at the pen. She scans it and goes to consult with 3rd party, never to return. I go ahead and take mine. They never mention it again before 4 pm
surgery.
I write to surgeon from hospital bed on patient gateway describing insulin dosing problems. In OR, he is extremely angry with me for having done so.
My own daughter, a medical resident, tells me that this is not unusual. Sometimes the patient is consulted. But the patient’s medical records are never checked. The sliding
Scale takes into account weight, even though patients have been on insulin for many years. It does not distinguish between Type 1 and Type 2. It does not use insulin sensitivity factors or insulin; carb ratios. How many patients have died, with cognitive issues or not being sufficiently alert at the time of the dose to defend themselves,
It seems the only way to be safe is in a hospital that permits insulin pump usage, if sufficient supplies are brought and set changes are possible.
I have amended my health care proxy to direct hospitalization in the hospital where my endo had admitting privileges and to flatly prohibit admission to the Boston Hospital I just described.
I am MDI and have had all my surgeries in Major Boston hospitals and have never had any issues. When scheduling surgery, I notify the staff that I will be managing my insulin injections as long as I am coherent before and after surgery. I have found that both the surgeons and anesthesiologists question me to realize that I know what I am doing. They have always been very helpful in giving me tips, such as to make sure I take into account the small amount of glucose in the IV fluid, and they also tell me the range the hospital requires me to be in taking periodic finger sticks during surgery. That is protocol, even though I wear a CGM and keep my phone where the staff can follow my BS levels. The acceptable hospital range is always higher than I am comfortable with but tell them that the low end of their range is my normal day-to-day high end and that is what my body is used to.
This always leads to an interesting discussion and it is evident that the staff wants to gain knowledge and treating the staff with respect, has always led to great results.
The secret is to let the staff know your requirements during scheduling, weeks before surgery, not spring it on them the day of the surgery. I also find it helpful to let the staff know that I have managed my MDI for 37+ years and make my own decisions, so my endocrinologist does not have to get involved with my surgeries.
Hospitals in Boston were better about it for me. I filled out a form to say I took responsibility for my diabetes management, and they had me log while I was admitted at one point on a worksheet, but it was doable after a bit of a fight. Everywhere else I have lived, there’s no option to fill out any liability release, and they know even less than the doctors in Boston did about diabetes, so they are both anxious and uninformed, which is a bad combo.
@CJ114 I’m on Dexcom G6 at the time when I had several outpatient procedures and 1 major surgery at St Luke’s Texas Medical Center. I was allowed to mange my BG and the pump could be active while anesthetized.
The odd thing is that there was no data from the pump or Dexcom during the procedures. I assume there’s too much RF in the OR. All returned to normal operations in recovery.
Last sentence of In Reply to CJ 114 is cut off.The form releasing hospitals from liability makes complete sense as their actions constitute obvious negligence. Have read 2 MA decisions holding MA General and Brigham & Women’s liable for malpractice re; insulin overdose. One death, one permanent brain damage.
I’ve been in a hospital twice since I pre been type 1. Both times I was on MDI and I decided to handle it myself. The nurses are usually busy and also don’t really understand the insulin timing.
So I would wait until my food arrived, because you just never knew what was coming even if you ordered something.
I would take my insulin and wait 15 min and eat.
My sugars were not perfect because I was in bed so much and not getting exercise. But it was ok.
In comparison to when I was hospitalized at diagnosis. The nurses managed it never timing it right. Insulin would come and food an hour later or food would come and no insulin.
So I knew to manage it on my own for the 2 surgeries I needed.
Of course I was diagnosed in 1987. That was before fingerstick machines were small enough to carry. Cgm was a pipe dream.
Still itbthink it’s best to mange your own diabetes because no nurse, doctor or institution is going to manage it better than you can.
Sure wish I’d been allowed to do that.
You can insist on it. You can tell your doctor that before you are admitted and then to the staff before you are admitted.
I don’t know what they would do if you just administered your own insulin and refused their injections.
Truth is you have rights. You don’t ask them if you can. You tell them “ I will handle my diabetes” you handle the rest.
They should have you sign a waiver.
Option 2 is find a different hospital. That is if it’s not an emergency. But even if so, they can’t stop you from taking your own insulin even if they don’t like it
So… Mass General Brigham? I still have my account though I’ve since moved out of state. I never ran into problems with hospital stays in that network, partly because I learned my lesson when I was in the BIDC network. Had major abdominal surgery requiring a 3 day stay, back when I was on Lantus/Novolog MDI. I was flummoxed when I was in recovery and they weren’t going to let me use my own stuff. There too the dread words “sliding scale” appeared, with NPH/R, which I’d only recently gotten off of and loathed with the flames of a thousand suns. Weird thing is BIDC is also the network of Joslin, where I was a patient, so I was shocked they didn’t seem to know what was current standard of care. This was back around 2005. Anyway, I dug in my heels and got my way, but I learned to ALWAYS get this worked out ahead of time in writing for any planned surgery/procedure. Last one was at Brigham and my endo knew the head diabetes resident, so smooth sailing all the way.
ETA
I think the main impetus behind the “sliding scale” crap is twofold. One is that they may have strictures against patients administering their own medications of whatever type that don’t account for the fact that T1 doesn’t work that way. T’other is that dosage calculation is highly specific to the individual and not straightforward, what with carb counting, I:C ratios etc, and they can’t expect nursing staff and non-specialist MDs to have to be conversant with all that crap for a relatively small number of patients, so to have a consistent policy it makes sense to have something simplified. Unless you work out something ahead of time or make a big stink, that’s what they’re going to default to. My BIDC stay was the first time I really came to terms with the fact that they by and large don’t really know that much about T1, because why should they?
Hi, Dr. BB,
This was emergency surgery for a broken ankle. The hospital was in the MA General Brigham network, but neither of those two hospitals. I have read two MA judicial decisions, one against MA General, one against Brigham and Womens Hospital for malpractice insulin overdose resulting in death (1) and permanent brain damage (1).
“Sliding scale” is clear negligence. I am a retired lawyer.
Joslin Clinic is in the Beth Israel Deaconess network and I never experienced this type of problem when I was a Joslin patient hospitalized for childbirth at Brigham and Women’s.
If I have a planned hospitalization in the future, I will know what to do. I have amended the terms of my health care proxy to specify a preferred hospital ( where my endo is on staff) and to ban the hospital which ordered the lethal overdose.
Thank you,
Sue
Yeah, I kinda wandered into the general situation—it’s a perennial topic—but obviously emergency ain’t planned. Point taken.
Translates as “we don’t know what we’re doing” yup. Thing is, that actually was standard of care back in the day, before the analog insulins came along, and I think it got into the institutional memory way back when (remember exchange diets? yeah that worked). The training be like: “Now if you do happen to have a juvenile diabetic come in, here’s a handout for how we deal with that. Next lesson.” Once it gets in the system, it’s hard dislodge. At least we can be thankful they don’t still do blood-letting. Though I think leeches are still in use for some things…
On the positive side, I think the proliferation of CGM tech into the type 2 space has made some inroads into systemic awareness. I’m finding a much higher level of familiarity where it used to be “what’s that thing on your arm?” MRI staff have been much more knowledgable about letting it stay on under appropriate circumstances, even to the point of having a protocol around it. At least in the YNH system here in CT, where I live now. Now it seems more like, “You’ve got one of those? Cool, we can let you handle it then.” I think it lowers their anxiety level toward insulin therapy over all.
BIDMC was better about it. Both BWH and MGH eventually let me self manage, but only after I argued repeatedly that what they were doing was dangerous, showed them my excellent a1cs at the time, called my endo, had a friend there to back me up, and signed release forms to manage my own insulin and blood glucose levels. I had to fill out an insulin and glucose log throughout the day and give verbal updates.
I’ve heard good things about YNH in general. What are your thoughts on them as a whole? I’m currently in NYC, and they’ve been worse at diabetes here than anywhere else I have ever lived, oddly enough.
I had back surgery last fall. I live in Nebraska and the hospital I was at didn’t seem to have a good grasp on proper blood sugar levels and insulin dosing. While the surgery went great, after my surgery my BS was high at 250 and I consider it OK after surgery. I had brought my own bolus insulin as I carry with me everywhere and had planned to carefully bring my BS down slowly. I mentioned this and the Hospital nurses freaked out and took it away from me. Toward bed time my BS was running about 450 and 500 and they said they see that all the time, it is no problem. I then argued with them about it so they gave me five units bolus. I stated I need more than that but they refused to allow it. I even argued with the medication manager about it mentioned that I was concerned about blood clots with that high of BS. She showed me the sliding scale they used and insisted that 450 to 500 is OK and I showed her my sliding scale that I use accounting for total daily insulin use. The day after the surgery they wanted me to stay another night but I insisted that I go home as I thought I could take better care of my BS. My diabetes doctor was on vacation so he could not chime in. I’ve been taking insulin for about 20 years my doctor allows me to dose according to my numbers, food intake, exercise and prior experience. I keep a through daily log of my daily/hourly BS levels along with notes about food, dosing, steps walked, etc on an excel spread sheet stored on the cloud and is available to my computers and phone. My main point here is that those of us who manage our insulin intake should make sure that the patient, hospital staff and your doctor as on the same page as far as insulin dosing/treatment.
The thing that is super frustrating about all this is that someone who’s experienced, able and cognizant is up against a system that protects against the ever-dreaded ~low~ at all costs and no matter the patient, and in the process keeps bg levels too high during the critical post-surgery period when normal bg’s are essential to the healing process.
Definitely a reason to pre-arrange when you can, and yeah, super difficult in unplanned circumstances.
My experience was the opposite 4 times the insulin I could tolerate. A death sentence.
I misread your original post. So difficult to be in care of 50-yr old thinking and practice.
It’s been a pretty good network so far. Wife had a bad ankle break (speaking of which) a couple of years ago and the orthopedics were first rate, from surgery to after care. Can’t believe how fast she got back to walking on it. I had a couple of general anesthesia procedures for kidney stones (yuck) and they were very knowledgeable about cgm, had surgery with the anesthesiologist keeping tabs on it (“These things make my job much easier with you T1s!”), keep my pump on etc.
I’ve always had very good luck with endos up in Boston, Joslin and others, so my standards are pretty high. Love my current one down here in the YNH network. Really went to bat for me with insurance about getting Munjaro covered (which is working really well btw). She respects my knowledge about my own T1 but is well-informed on her side about current state of care. Nothing but good things to say.
@DrBB – Nice to read about good diabetes care in the hospital. We are right to expect such care and it’s healthy to express gratitude!
A bit off topic, but OR and ICU related.
I thought this device was in production, but maybe not. It is called GluCath and gives a true blood glucose reading of either venous or arterial blood displaying for the anesthetist to monitor along with other vital signs.
The company that was working on it, Glumetrics Technology has been bought by Medtronics.
Currently anesthesiologists and ICU nurses rely upon finger sticks.
As to using Dexcom or other CGMs I am concerned that the high level of electronic noise in the OR will render wireless devices unreliable.
My own experiences with both out patient and full surgery is that both my pump and CGM data was a blank during the time I was in the OR. Both were in operation when I entered the OR and after.
Remembering my classes on WIFI there is a problem with packets colliding that can cause issues. I have no doubt that bluetooth has similar may be worse issues.