The wrong injection
My cell phone rang at a little after nine at night. It was one of my patients. “Sorry to bug you at home, but I really fucked up.”
How so?
“I mixed up my pens.”
In a flash I knew what happened. You just took fast-acting instead of basal?
“Yeah. I’m scared shitless.”
No fear. We can fix this. How many units did you take?
“Seventeen. Of NovoLog. I can’t fucking believe that I did that.”
This guy is pretty insulin sensitive. Seventeen units is more fast-acting that he usually takes in the better part of a week. Bygones. Shit happens. Don’t worry about it. Tell me what you’ve got to eat in the house that’s sweet.
He had a few glucose tabs, a pint of Ben and Jerry’s chocolate ice cream and granular sugar for his humming bird feeder. No juice, soda, honey. OK, start eating the ice cream… No, all of it... then to Deb, Bade, fetch my lap top.
I don’t let any fear creep into my voice, but I know this is damn serious. I’ve got to stay clear headed and figure this out; and I gotta do it right. I’m thinking I need to get about 300 carbs into my guy to soak up the insulin.
He tells me the package of sugar he has reports four carbs per teaspoon. I call up the recipe math web site. OK. Three teaspoons in a table spoon…so 12 carbs per tablespoon…four table spoons in a quarter cup….so 48 carbs in a quarter cup….four quarters makes a cup…so a full cup of sugar has 192 carbs. I want you to mix a cup of sugar into four cups of water and dink it down. I chose 4 cups to make it quick and easy to get the sugar into solution. I stay on the phone while he mixes the concoction and drinks it down.
“It’s pretty nasty,” he reports.
Deb tells me you could have made some awesome lemonade if you’d only had fresh lemons. Do a fingerstick.
His BGL is 126. I wish like hell he had a CGM. Every diabetic should have CGM. And every pre-diabetic too, maybe it’d make them think more about what they are eating if they could see what the food choices they make are doing to their bodies.
We chat about marine archeology, a passion of his, while we wait to see what happens. He’s home alone. The hospital is too far for a safe drive with this much insulin coursing through his body. An ambulance ride will bankrupt him. And I know we can fix this.
In fifteen minutes his sugar is 218. I’m relived he’s going up.
My cell phone battery is giving out, making a strangled beeping noise every ten seconds. I ring off, promising to check on him every fifteen minutes until I’m positive we’ve got it under control.
Then I go off to find my emergency phone charger. This is a really handy little device. It’ll set you back about twenty bucks, but it can bring a cell phone back to life in under a minute using a pair of AA lithium batteries. Made by Energizer. Oddly enough, I found them at Home Depot. Amazing what you can come across buying paint for your mother.
I read a few pages of a biography of Sir William Mathew Flinders Petrie, the early Egyptologist. We recently took in a Santa Fe exhibit of artifacts he excavated. Very cool.
I call fifteen minutes later. He’s at 277.
I call fifteen minutes later. He’s at 294. This turns out to be the crest.
I call fifteen minutes later. He’s down to 243.
It’s getting late, things are looking pretty good. I instruct him to stay up until 1 a.m., to check his sugar every fifteen minutes. Thank God we were able to get a cheap strip program in place for our low income folks (ten bucks for 100 strips), and that he had just stocked up. If he was above 150 at 1 a.m. he could hit the hay. If he dropped below 150 at any time before that he was to call and wake me up.
I put the phone on top of the Petrie book and turned out the light. It had been a very long day.
The phone did not ring.
In the morning I called. Good morning, just wanted to see if you were still alive.
“Yeah, turns out you can’t get rid of me that easily,” his voice the normal gruff-but-friendly that I was accustomed to; no underlying tone of fear and borderline panic that had tainted it the night before.
Well, I think you’re worth keeping around for a while yet, where did you land in the end?
At 8 a.m. he was at 146.
So all’s well that ends well. But what if he had not realized his mistake? On the one hand we’ve got personal responsibility to keep our shit together, on the other hand the damn Novo flexpens all look alike. How many D-folk have killed themselves by taking the wrong injection? I doubt we’ll ever know, but recently there has been an interesting change in the pens.
It use to be that the only real difference in Novo’s three flexpens was the color of the injector button on the very tip of the pen. The label also had a very small patch of color: orange for Novolog, Teal for Levemir, and…. What the hell color is the Mix? Huh, we script so little of the mix I can’t recall the color off the top of my head. I’m thinking its some sort of blue, but I could be wrong. The buttons also have some brail-like ridges so you can tell the difference in your pens when you are trapped in a coal mine at midnight during a lunar eclipse. Always best to be prepared.
Recently, however, the pens have a new label, that takes up a full third of the pen, with prominent color. Hmmmmm….. I wonder how many wrong injections silently lead to that change?
How so?
“I mixed up my pens.”
In a flash I knew what happened. You just took fast-acting instead of basal?
“Yeah. I’m scared shitless.”
No fear. We can fix this. How many units did you take?
“Seventeen. Of NovoLog. I can’t fucking believe that I did that.”
This guy is pretty insulin sensitive. Seventeen units is more fast-acting that he usually takes in the better part of a week. Bygones. Shit happens. Don’t worry about it. Tell me what you’ve got to eat in the house that’s sweet.
He had a few glucose tabs, a pint of Ben and Jerry’s chocolate ice cream and granular sugar for his humming bird feeder. No juice, soda, honey. OK, start eating the ice cream… No, all of it... then to Deb, Bade, fetch my lap top.
I don’t let any fear creep into my voice, but I know this is damn serious. I’ve got to stay clear headed and figure this out; and I gotta do it right. I’m thinking I need to get about 300 carbs into my guy to soak up the insulin.
He tells me the package of sugar he has reports four carbs per teaspoon. I call up the recipe math web site. OK. Three teaspoons in a table spoon…so 12 carbs per tablespoon…four table spoons in a quarter cup….so 48 carbs in a quarter cup….four quarters makes a cup…so a full cup of sugar has 192 carbs. I want you to mix a cup of sugar into four cups of water and dink it down. I chose 4 cups to make it quick and easy to get the sugar into solution. I stay on the phone while he mixes the concoction and drinks it down.
“It’s pretty nasty,” he reports.
Deb tells me you could have made some awesome lemonade if you’d only had fresh lemons. Do a fingerstick.
His BGL is 126. I wish like hell he had a CGM. Every diabetic should have CGM. And every pre-diabetic too, maybe it’d make them think more about what they are eating if they could see what the food choices they make are doing to their bodies.
We chat about marine archeology, a passion of his, while we wait to see what happens. He’s home alone. The hospital is too far for a safe drive with this much insulin coursing through his body. An ambulance ride will bankrupt him. And I know we can fix this.
In fifteen minutes his sugar is 218. I’m relived he’s going up.
My cell phone battery is giving out, making a strangled beeping noise every ten seconds. I ring off, promising to check on him every fifteen minutes until I’m positive we’ve got it under control.
Then I go off to find my emergency phone charger. This is a really handy little device. It’ll set you back about twenty bucks, but it can bring a cell phone back to life in under a minute using a pair of AA lithium batteries. Made by Energizer. Oddly enough, I found them at Home Depot. Amazing what you can come across buying paint for your mother.
I read a few pages of a biography of Sir William Mathew Flinders Petrie, the early Egyptologist. We recently took in a Santa Fe exhibit of artifacts he excavated. Very cool.
I call fifteen minutes later. He’s at 277.
I call fifteen minutes later. He’s at 294. This turns out to be the crest.
I call fifteen minutes later. He’s down to 243.
It’s getting late, things are looking pretty good. I instruct him to stay up until 1 a.m., to check his sugar every fifteen minutes. Thank God we were able to get a cheap strip program in place for our low income folks (ten bucks for 100 strips), and that he had just stocked up. If he was above 150 at 1 a.m. he could hit the hay. If he dropped below 150 at any time before that he was to call and wake me up.
I put the phone on top of the Petrie book and turned out the light. It had been a very long day.
The phone did not ring.
In the morning I called. Good morning, just wanted to see if you were still alive.
“Yeah, turns out you can’t get rid of me that easily,” his voice the normal gruff-but-friendly that I was accustomed to; no underlying tone of fear and borderline panic that had tainted it the night before.
Well, I think you’re worth keeping around for a while yet, where did you land in the end?
At 8 a.m. he was at 146.
So all’s well that ends well. But what if he had not realized his mistake? On the one hand we’ve got personal responsibility to keep our shit together, on the other hand the damn Novo flexpens all look alike. How many D-folk have killed themselves by taking the wrong injection? I doubt we’ll ever know, but recently there has been an interesting change in the pens.
It use to be that the only real difference in Novo’s three flexpens was the color of the injector button on the very tip of the pen. The label also had a very small patch of color: orange for Novolog, Teal for Levemir, and…. What the hell color is the Mix? Huh, we script so little of the mix I can’t recall the color off the top of my head. I’m thinking its some sort of blue, but I could be wrong. The buttons also have some brail-like ridges so you can tell the difference in your pens when you are trapped in a coal mine at midnight during a lunar eclipse. Always best to be prepared.
Recently, however, the pens have a new label, that takes up a full third of the pen, with prominent color. Hmmmmm….. I wonder how many wrong injections silently lead to that change?
posted by Wil | 6:22 AM
4 Comments:
Man,that's scary-glad your patient is ok!!!Good for you for being calm,cool,and collected enough to figure him out the right amount of carbs to get him through the storm.
I've mixed up injections before,(back in 2 shot/day regimen) there is no worse feeling on earth then that. Eating like heck and praying nothing happens.
Nothing more exciting than real-life adventures! To your point of cgms for the pre-diabetic you are absolutely correct. I recently got the cgms for my daughter and I went ahead and wore the first sensor as easy intro for the family to continuous. Of course I went to the fast food and ordered up something straight out of the movie "Super-Size" and watched my blood sugar sky rocket. There were plenty of highs and also lows (verified by finger-stick) that I got a real appreciation for how food choices and activity levels affect blood sugar.
So much so in fact that I have a goal to lower my A1c (which I also had checked) through increased activity and better food choices.
Glad to hear it turned out alright this time for your patient!
Maybe there was something good about old fashioned NPH.
The only time I've ever used identical-except-for-the-colour-of-the-top pens was when I was using Insulatard (NPH) and Actrapid (funny that, it doesn't act-rapidly!). Since I switched to Humalog on its release in 1996, that would be over 11 years ago. Those pens really were identical like the flex pens you describe, but I always did a double take if my insulin wasn't "uniformly cloudy" last thing at night. The only times it wasn't uniformly cloudy was when I'd picked up the wrong pen!
In almost 25 years, I've managed never to have the unfortunate experience of your poor patient, probably more by luck than design. There isn't much I could eat that quantity of carbs as, but Ben and Jerry's must just be it!
Glad this worked out ok!
I've had the T-1 for 43 years. At some point, long ago - maybe 30 years ago, I have a vague recollection that insulin bottles had different colored labels. Then they were switched to all look alike. The reasoning? so the user (or the nurse) would have to LOOK at the bottle to see which insulin was being used. The change was to prevent mistakes but I think it caused more, at least for the shoot it yourself people. We all want things to be easier and the visual certainly helps.
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