Sometimes second-best is number one

I had a patient who kept being admitted for high blood sugars. They were known to the hospital. They would routinely be admitted with blood sugars from 800-1,000. The term “noncompliant” rakes over my last nerve and this patient is one of a list of reasons why.

Through the day, I learned the patient had housing insecurity (no home). They lived in their vehicle. They said they tried to manage their diabetes, but they couldn’t. People under stress have different reactions. This person’s reaction was to the problem completely. I looked at the chart. The diabetic regimen given to this patient after multiple admissions had them visiting their diabetes SIX TIMES PER DAY across multiple insulins. Think about that.

In my mind, I thought the patient may have lacked education or understanding. What I found was that the system was busy providing the “best” care with the most current protocol – despite it being unsustainable for the patient. One of the insulins prescribed was probably the most susceptible to temperature changes. Not great for someone who has no home to put it. Can you imagine carrying around supplies to check your blood sugar and medicate yourself six times through the day while you are trying to merely survive? Me either.

I asked the patient how often they may be able to reliably visit their diabetes? They said they could visit it twice. We could work with that. I called pharmacy. I explained the situation. I didn’t want to upset anyone, but maybe we could consider what would be the second-best treatment for this patient? We got buy in from the team. We updated teaching and I had them teach me how to draw and inject their insulin.  They benefited from the practice. They also suggested they could get a small cooler for their glove box to help protect the insulin from the temperature fluctuations in their vehicle. Wow! The patient who’d disengaged from their treatment is back in the game! Ultimately, prescriptions were reduced from 90 day to 30 day to protect the integrity of the medications. The patient could get to the pharmacy. This process delayed discharge by one day. It also stopped the readmissions for hyperglycemia immediately.

This is why I appreciate the value of the second-best treatment.