Two ends of a spectrum

The first patient was a middle-aged male who had come in complaining of a painful and swollen left leg. The doctors told me I should see him–I think after a while you get tired of the way private patients treat the Emergency Room like a clinic.

I walked in, introduced myself and started taking a history. He said his foot had been warm, swollen and extremely tender for the last week, but that the pain had only gotten unbearable that morning. When I dug around for an antecedent incident, he denied any trauma or insect bites. He only admitted to frequent headaches and fever, and said he remembered having a small sore under his foot a few weeks prior. No previous hospitalizations, but a known Type I diabetic who claimed his sugars were controlled.

“That’s good, what do your values normally look like?”

“My sugar is usually between sixteen and eighteen Doc.”

I was so shocked I didn’t even correct him for calling me Doc. “Sixteen to eighteen? Are you sure?”

“Yes, I test it every day.”

“Sir,that’s too high. That’s dangerously high. Your sugar really shouldn’t be above eight on a regular basis.”

“Really? Oh. Well, sometimes it’s twelve.”

“That’s still too high. How long did you say you’ve been diabetic?”

“Since I was a child. My sugars have been like that for years.”

“That’s not good, Sir. It’s not good for your heart, it’s not good for your brain and it’s not good for your kidneys. It’s also not good for your blood vessels and nerves, which is what I suspect is going on with your foot. Can I see it?”

He took off his socks and treated me to a vision of an oedematous, erythematous lower leg that he could only stand me touching for a few seconds and a time. And right on the plantar surface of his foot, medially, was a crater of about four by four centimeters with a very dark base, yellow bordering and a very clearly demarcated raised edge, like it had recently been a blister that had been cut off. It wasn’t bleeding, and he didn’t complain to much when I touched it.

“Sir, was there a blister here?”

“Yes, that’s the sore I told you about. I popped it yesterday.”

“You didn’t say that,” I pointed out. Then I removed my gloves. “Okay, this ulcer and the cellulitis are evidence that you suffer from something called the diabetic foot. I’m just going to prick your finger quickly, I want to know your sugar value for today. Then we can talk about why this happened and what we need to do now and in future to prevent you having to lose your foot.”

“Lose my foot? You’re going to amputate me? My mother was amputated, I don’t want that.”

“Was she a diabetic too?”

“Yes, I think so.”

I bit my tongue and excused myself to find a fingerprick glucose testing kit. The nurse offered to do it for me while I finished clerking the patient.

“Okay, sir, while she does that, I need to ask you a few more questions. Have you ever had ny surgeries?”

“Not really.”

“Not really?”

“I’ve had three eye operations. The last one was in 2010.”

“Was it to remove cataracts?” I guessed and the patient’s face lit up.

“Yes, how did you know, Doc?”

“Lucky guess.”

“Wow. Maybe you can tell me why I keep having them.”

“Because your sugar is too high and according to you it’s always too high. What medication are you taking?”

“Twenty seven, Doc,” the nurse reported. I ignored the Doc-dig–the nurses like teasing me about how the patients complain to them that I’m too young to see them–and stared at her.

How much?

“Twenty seven.”

“Okay, please call the doctor. But so long, bring me ten units of insulin so we can start bringing the sugar down. I’ll put up a drip up.”

When the nurse left, the patient turned to me and said, rather sheepishly, “It was twenty one this morning…”

“Did you use your insulin?”

“Yes, but I ate my breakfast first.”

“Sir, please explain to me why you ate when your sugar was so high?”

“I didn’t know it was high.”

“Then why did you use the insulin?”

“Because I use it whenever I eat.”

“Okay, I understand,” I said even though I really didn’t. Diabetic for nearly half a century, and he didn’t understand why he was even taking his medication. “We’ll talk once we’ve gotten your sugar down.”

* * *

This patient was a middle-aged paramedic who had been brought in by his colleagues when he had collapsed after they’d noticed that he’d grown progressively more confused throughout his shift.

He was brought in with an altered level of consciousness, not responding to any stimuli, with cold and clammy peripheries, his clothes drenched in sweat. We performed the primary survey and when we got to DEFG (Don’t Ever Forget Glucose), the little machine beeped out that his blood sugar was one point one. 1.1.

After putting up an IV with 50% dextrose the man went from staring vacantly up at the ceiling to looking alert if a bit disoriented as we moved on to the secondary survey. Dextrose is a wonderful thing, considering it took less than a minute to bring him back around.

“Sir, do you know where you are?”

“Hospital?”

“Yes. Do you know what day it is? Can you tell me your name?”

“My name is Mr Hypo,” he said, frowning.

“That’s right, and the date?”

“I don’t know. What happened?”

“Your colleagues brought you in after you collapsed. Your blood sugar is very low. Are you a diabetic?”

“Yes. I use the tablets.”

“Did you eat today?”

“I can’t remember…I think I might have forgotten to.”

“Has that ever happened before?”

“No. I was pulling a double shift and I got distracted. What did you say my sugar was?”

“One. One point one.”

“Crap.”

“Yes, crap is a good way to describe it,” the doctor interrupted as he walked in. He read through my notes and then asked me what I planned to do next. I suggested a 5% dextrose infusion and a recheck of his blood glucose. He nodded and then reminded me to educate. “You’ll be fine sir. The student is just going to explain to you why this happened and how to prevent it in future, okay. Oh, and MedicalRose, your notes are still too long.”

“I know, I’m working on it,” I said. He left me and the patient alone again.

“I know, I know,” he preempted. “I shouldn’t be skipping meals. I should be having small snacks in between. I should exercise and drink water. I usually do all that, today was a bad day. I feel like an idiot.”

“Don’t be too hard on yourself, people do forget. But you are aware that you just can’t afford to?”

“I know. We pick up hypoglycemic patients every day, and I’m always judging them because I feel that they should know better. I feel terrible, this won’t happen again.”

“Well,” I said, a little deflated by how thoroughly the man wanted to abuse himself. At least he knew what he’d done wrong.

“Are they still here?”

“Your colleagues? Yes. Which reminds me, neither of them knew you’re a diabetic. You might want to disclose that to the people you work with, just to be on the safe side. It could save your life next time.”

“There won’t be a next time, Miss, I promise.”

“You should disclose it all the same. Just to be safe.”

“Okay. Thanks for everything. When can I go?”

“We just ran some blood tests, kidney functions and the like. And we need to change your drip. When that’s done, I think the doctor will let you go.”

“Okay thanks.”

“Okay. Don’t forget to tell your colleagues.”

“I’ll consider it.”

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