When I learnt not to make assumptions (Rachel Hall)

Some consultations stick in your mind forever. For me, one such consultation with a 45-year-old man with type I diabetes really stands out. He had not visited his GP for over 18 months — despite numerous requests. He attended my clinic because the insulin treatment he was prescribed was about to be discontinued.

At first glance, he appeared dishevelled — as if he wasn’t taking care of himself. He had been prescribed Insulatard and Velosulin twice daily and was still using vials and syringes. I had no idea what his blood glucose control was like because, according to my computer system, his last blood tests had been conducted two years previously.

I arranged a blood test for him on the same day, since I wasn’t confident he would return for another appointment. This recorded a worryingly high HbA_1c level of 11%. Two years before it was 9.2% so his control had been poor for quite some time.

After discussing the case with a diabetic specialist nurse, I decided to prescribe Novorapid (with meals) and Insulatard (twice daily) — to mimic the patient’s current regimen as closely as possible — with the intention of changing the Insulatard dose to once a day at a later date.

I also suggested that insulin pens and cartridges would be easier to use (and more discreet) than syringes and vials. He was hesitant at first but, once I had demonstrated how to use them, he agreed that the pens would be more convenient.

I reduced the dose of his rapid-acting insulin because he would be administering this with each meal instead of twice daily. I intended to retitrate this according to his blood sugar levels, so I asked him to monitor them regularly.

However, he returned for his next appointment without having recorded any levels and saying he had lost his pot of test strips. A few days later, he returned with his new machine and said that it wasn’t working.

I was concerned by the situation and figured something wasn’t quite right so I asked him to show me how he used the machine. I watched in shock as he dabbed blood onto the wrong end of the test strip and inserted it into the machine. He then admitted that he’d never been shown how to use it properly. I demonstrated its correct use and he has been testing regularly ever since.

On reflection, I realise I had just assumed that he knew how to use his machine. Obviously, this assumption was wrong. The reason he wasn’t testing was not because he didn’t want to, it was because he couldn’t!

 

Rachel Hall is clinical pharmacist at The Old School Surgery, Bristol