Well, at least buy life insurance, you dumb ass

That’s NOT what I said. But I had to bite my tongue to keep from saying it. If his three kids and his mother hadn’t been with him, I probably would have been more direct.

But I was pissed, pissed, pissed, PISSED.

Plus I was cold. And tired. And my feet hurt. I was at our clinic’s 30th Anniversary health fair. We’d converted the front parking lot into a festive carnival of health. Complete with jugglers. No shit. Actually, I shouldn’t say “we,” because all I did was show up on my day off to lend a hand by testing blood sugar, checking blood pressure, and chatting to people about all things diabetes.

I had my pound of fat with me. And the cracker. A pair of my favorite visual aids.

The pound of fat is a lumpy yellow squishy piece of plastic about the size of tub of margarine that simulates both the size and weight of a real pound of human fat. It always catches people’s eyes. “Eww…. What’s that?”

The cracker is also plastic, but looks good enough to eat. If I had used a real cracker, sure enough, before the day was over, someone would have eaten it.

Once people ask about the pound of fat and the cracker, you can tell them that eating one Zesta cracker more than your body needs everyday will buy you that one pound of fat at the end of a year. Yup. Ten calories more than your body burns adds a pound in a year. And one hundred calories more than you need adds ten pounds.

Gaining weight is easy-peasy.

But the same math works in reverse, too. Eat ten calories less a day than you need and lose a pound in a year. One hundred calories less than you need in a day, and you’ll lose ten pounds in a year.

I also had my body-systems-effected-by-high-blood-sugar model on the table, along with a pile of donated pedometers to give out. The model is a wonderful chrome tree with a stroked-out brain on the top and a necrotic foot on the bottom. In-between are an eye, the heart, a kidney, a neuron, an occluded artery, and a fatty pancreas.

I love visuals.

The message of course is that diabetes, per se, doesn’t effect this wide range of body systems; it’s high blood sugar that ruins the party, at which point most people are up for a fingerstick test to see what their blood sugar is.

A lot of new faces were cruising the 20 or so booths in the parking lot, but a number of my regulars came by, along with a few “missing in action” folks who showed up for the free food and weren’t expecting to bump into me. I would gently tease them, depending on the personality of the patient:

Oh my God, you’re alive! What? Well, it’s been so long since I’ve seen you I just assumed you had died!

Or…

How was your trip to Africa? What? You didn’t go to Africa for three months? Really? Then where have you been?

Or…

I’m beginning to think you don’t love me anymore, I can’t recall the last time you dropped in to visit me.

You get the idea.

Then I saw Victor (not his real name). Now Victor is a big, tough-looking dude. He’s tall for a Hispanic man, almost as tall as me. And he has huge muscular arms bigger than my head. He wears biker leather and a chrome chain connects his wallet to his belt. He’s covered in tattoos.

Which is odd, because when it comes to needles, Victor is a complete pussy.

Yep. Victor is the poster-boy for needle-phobic. A shame, as he has diabetes. And you know, anyone with diabetes will have to get friendly with needles in the fullness of time.

In fact, Victor is soooooo afraid of needles that he even freaks out at the idea of testing his blood sugar.

Now, in addition to being a pussy, Victor is also an idot. About once a year or so he manages to convince himself he doesn’t have diabetes anymore and stops taking his pills. And then he goes into glucose toxicity and then I have to save his sorry ass.

We’ve been through this three times before. Last year, rather than take his pills, he moved them from the pill box back into the bottle so his wife wouldn’t know he’d stopped again. He was only busted because after about two months it occurred to her she hadn’t needed to refill his scripts for quite a while.

I told him, Dude, if you’d just flushed ‘em down the john you might have gotten away with it. Well, up until you went blind and your kidneys failed, anyway.

But this last round, he pushed the envelope too much. My clinic meter greeted Victor with “Hi,” meaning his blood sugar was above 600 mg/dL. And I haven’t been able to jump-start his pancreas with pills this time. He would need insulin for a while. It would probably only take a month or six weeks of insulin-induced normal blood sugars for his beta cells to get back on the job.

But his phobia of needles was so extreme he announced he was prepared to die, rather than take shots. His wife, however, was not so keen on the idea of early widowhood with three small mouths to feed.

He finally consented to letting her give him a shot a day in his massive forearm (crazy to me, but less scary than a shot in the stomach to him) with a Levemir flex pen.

And that’s when the second problem cropped up. Victor drives a truck for a living. That means he needs a commercial driver’s license. And that means if he’s prescribed insulin he could lose his license. Lose your license, lose your job.

The work-around that was decided on was to provide Victor samples of basal insulin as a short-term treatment for acute hyperglycemia—which was actually true. His diabetes is controlled just fine on orals when he takes the damn things and behaves himself.

But it starting taking a lot more insulin than I thought it would to jump start his pancreas. His wife titrated him up to 50 units a day before she could even read his blood sugar. When we got to 75 units we were still in the high 200s. And I had a problem.

A flex pen only has 300 units in it. This guy was posed to plow through a pen every three days. We didn’t have enough sample pens to keep up; and he couldn’t afford to pay for them out of pocket, even at our bargain price of 20 clams a pen. The only solution was to switch to vials, which have 1,000 units each, and a sack of syringes.

I trained the wife on how to fill and inject with some donated syringes.

Victor freaked. “I won’t do it,” he said.

“Yes he will,” said his wife, her tone even and flat, with no room for argument.

Victor shook his head back and forth. She nodded hers up-and-down.

I emailed the doc on the case though our electronic medical record:

Pt states refusal to take injection via syringe. Spouse states she will ensure compliance. My money is on the mare.

That was a week before the health fair. When I saw Victor in the crowd I knew I had the unusual opportunity to get a mid-day blood sugar check. Like some sort of diabetes education vampire bat, I pounced on Victor and stuck his finger with a one-shot disposable lancing device.

His blood sugar was back up into the 380s instead of down well below 200 like I expected. Then it dawned on me. I’d just lost money on the horse race.

You’re not letting her give you the shots, are you? I asked.

“I told you I wouldn’t,” he replied stubbornly.

I sighed. Dumb ass, I thought to myself. Then I said to him, Well, then at least bring me the vials back. That’s two-hundred bucks worth of insulin we gave you. If you’re not going to use it to save your life, let me give it to someone who will.

Reverse psychology failed. He assured me he’d bring the vials back.

Dumb ass. Dumb ass. Dumb ass.

As he disappeared into the crowd, I felt like I had failed, and it depressed me. I don’t like to give up on anybody, and I hate losing to diabetes. With all the tools we have at hand, there’s no reason to ever lose anyone to diabetes; but all the tools in the world won’t do any good if people refuse to use them. Still, I view it as my job to figure out how to deploy those tools and how to convince people to use them. I had the tools for Victor, they were free, and they didn’t threaten his livelihood. But I just couldn’t convince him to use the tools.

The human element is the wild card variable in diabetes care. You can lead a horse to water…

I think we went the extra mile for Victor, and I don’t think we were asking too much. So at what point, if people won’t take some responsibility, do you give up?

At what point is it morally OK to abandon people to their fate?