My last post introduced the subject of diabetic malingering. In this post, I present several patients I have encountered in my correctional medicine career and the various scams they have used to manipulate their blood sugars. Continue reading
We recently had a 46-year-old male patient booked into our jail who reported a history of diabetes but who had not seen a physician or taken any medications for “years.” He said he used to take a medication for diabetes “a long time ago” but he could not remember the name. He also could not remember the name of the doctor he had once seen. He reported basically no other medical history. Continue reading
People come to jail taking the weirdest insulin regimens. Often times, I don’t know whether these insulin schems are the result of a practitioner who does not understand insulin dosing well, or whether the patient “tinker” with their insulin dosing, themselves. Here is a case from one my jails (I have changed some of the data and patient characteristics to protect patient privacy).
A type 1 diabetic comes to jail taking Lantus 15 units in the morning and 40 units in the evening. He says he takes his Humalog on a sliding scale, but when asked to define exactly what the parameters of his sliding scale are, it becomes apparent that he basically decides his Humalog dose based on gut-feeling. He may take nothing; he may take up to 15 units. He certainly has no concept of counting carbs. He thinks his average Humalog dose is 6 units. His admission HbA1C is 12.8, or an average blood sugar of over 300. In other words, he is not doing a very good job of controlling his blood sugars on the outside.
Anyway, let’s apply the rules of insulin dosing to this patient: Continue reading
I have found, in my years of practicing correctional medicine, that few practitioners who come to corrections are comfortable with insulin dosing. In my experience, this is especially true for physician assistants and nurse practitioners, but many physicians have problems, too. Insulin dosing can be complicated and tricky at times, but for most patients, 10 simple rules will get you to where you need to be.
We first need to cover some groundwork and some terms. Insulin terminology can be confusing. First, it is very important to remember that this discussion applies to type 1 diabetics only. Type 2 diabetics sometimes use insulin, but that’s a “whole ‘nother ballgame.”
I had yet another patient recently who demonstrated what I call the “Compliance Trap” of corrections. The Compliance Trap is simply this—on the outside of jail, in the real world, most people do not take their medications perfectly. They miss doses. They forget sometimes. Many studies have demonstrated this. But when these same people come to jail, they get their medications passed to them every dose—they do not miss doses. They are compliant with their medication dosing in a way they weren’t on the outside. And this can sometimes get them into trouble.
Take for example, the patient who came to my jail with a prescription for Dilantin 600mg a day. This is a huge dose! But he had a legitimate prescription for it and so it was continued at the same dose in jail. However, two weeks late, he began to have nausea, vomiting and dizziness. We checked his dilantin level and it was 32–he was toxic! Dilantin 600mg a day was, indeed, too big of a dose for this patient. In fact, after we had adjusted his dose and checked levels a couple of times, we found that the proper dose of Dilantin in this patient was a more modest 400mg a day.
So how did this happen? I did not interrogate this patient’s outside doctor, but I think I know what happened. He kept returning to the outside clinic with subtherapeutic blood levels of Dilantin and the doctor kept increasing to dose. However, the reason the patient had subtherapeutic blood levels was NOT that he was a super-rapid metabolizer of Dilantin; rather he just hadn’t been taking it every day. He had been missing doses.
But when he came to jail, the jail nurses made sure he did not miss any doses and quickly, he was toxic.
So that is the Compliance Trap. Outside of jail, many patients do not take their medications regularly or at all. When they come to jail, they don’t miss doses. Outside–not compliant. In jail–compliant. And sometimes this can make them sick.
The Compliance Trap–Examples