Wednesday, July 23, 2014
Life at Grady: Insulin showdown
Grady Primary Care Center, Summer 2014
Patient assessment: Poorly controlled diabetes
Plan: Initiate insulin therapy
“I think I can manage this with diet and exercise.”
“I believe that being careful about your diet and getting more exercise will help. But my recommendation is that we start you on insulin. I know you don’t like needles, but--”
“I’m definitely not taking insulin. That’s out of the question.”
“I see. Remember that blood test we checked? The A1C test?”
“The one that says how your sugars have been for a whole month?”
“Sort of. More like three months. But yes, that.”
“Well. Yours was very high. In the double digits.”
“Where should it be?”
“I’d be ecstatic if it was between 6% and 7%. It was 12.5%. That calls for insulin.”
“I hate needles. You’ll have to try something else.”
“You’ve tried pills already. They aren’t working. You need insulin.”
“Is there an insulin that isn’t given through needles?”
“Not that I have to offer.”
“I’m sorry. I wasn’t sure what you meant by ‘oh well.’”
“I meant, ‘Oh well, guess we in a jam, ain’t we?’”
“Aaaah. I see. I guess we are then.”
“Insulin ain’t gonna happen.”
“I hear you. And I’ve already talked to you at length about the things that can happen if you ignore your high blood sugar, right?”
“You have. And I’m not ‘ignoring’ it.”
“Well, I meant not doing whatever it takes to control it. Sorry about that.”
“I’ll do anything. Just no insulin.”
*pause for a moment*
“Okay. Well listen--I’m pretty disappointed that I can’t convince you to go with my recommendations. I have the pharmacists here and everything to teach you about using insulin. But I guess you’ve made up your mind.”
“So what pills are you going to add?”
“What the hell?”
“You need insulin. And that is my recommendation. You’re already on three different pills for diabetes. They aren’t enough. At this point, you need insulin.”
“Well, I am letting you know that I need an alternative.”
“I don’t have one.”
“So that’s just it? Insulin or nothing? That’s crazy.”
“I’m sorry you feel that way.”
“Why can’t you just up my pills some more?”
“Because that isn’t right. And it won’t be enough.”
“Hmmmph. I feel like you’re forcing insulin on me.”
“I’m sorry you see it that way. I just care.”
“You care about making money.”
“Making money? Um. No. Definitely not the case. You just need insulin.”
“I have a question. If I was your own sister what would you do? Your own sister with high blood sugar who really, really, really didn’t want to take insulin.”
“My sister? Oh, that’s easy.”
“I’d pin you to the ground with my knee in your chest and hold you there until you got your insulin. I’d sit right on top of your and draw it up and stick you in the back of the arm. Sure would. And I’d do it every single day until your A1C was under 7.”
“Are you serious? That’s what you’d do to your sister?”
“You’d put your knee in her chest?”
“You’d better believe it. Or I’d just put her in a headlock.”
“Damn. I’m just not ready for insulin.”
“I hear you, sis. But listen--insulin is ready for you.”
“I hear you, doctor.”
“Do you? Like really hear me?”
“Yes. And I can feel your knee on my chest.”
Happy Wednesday. And yes, she took insulin.
Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.
Labels: Life at Grady
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