Insulin for breakfast

I was ambushed in the hallway not ten paces from the door. I had slipped in the ambulance entrance because that’s the most likely way to get into the building and to my office without being seen. Of course, I wasn’t likely to succeed because my office faces the giant glassed-in fish bowl that’s the nurses’ station, but it was still worth a try.

As this was going to be my first day seeing patients again, I wanted a slow start. I was, well, nervous. Nervous that I’d forget something important. Nervous that I’d make a mistake. Not confident that I can function in my clinical role, once again, I have not packed lunch.

I was supposed to have half an hour to get my bearings, and do a through chart review on the two patients I was to see this morning. I normally do a brief chart review anyway, but I’d been gone so long that who knows what might have happened in my absence. Plus, I simply needed to remember who the hell these people were in the first place.

Last week, when I peered ahead at my schedule, some of the names were unfamiliar to me. I called up their records to see their faces and strangers starred back at me from their driver’s license-like mug shots on the computer. Yet below the mug shots were notes, apparently written by me, documenting visit after visit after visit after visit. Clearly these people were my patients and many of them, it appeared, I had worked with for years. But both the visits and the people themselves were missing from my memory. They were alien and the chart notes seemed like someone else’s—stirring no memories, awakening no recall.

It was worse than unnerving.

Of course, if that had happened with all the patients scheduled to see me this week, I would have left my keys and resignation on my desk and walked away. But luckily not all my patients were blank canvasses. Some were fuzzy, like distant mirages, but still in my memory. Isn’t she my Butterfinger addict? Hmmm…. Is that the one with the little dog… No, that’s her sister. Wait, isn’t she the one who stabbed her husband with a steak knife at the family reunion?

Yet still others were crystal clear. I could remember everything about them: The patterns of their blood sugars, the meds they used now, the meds we tried but failed with in the past, what motivated them, what their roadblocks are, the names of their children, their stresses and challenges.

Why some were so clear; some were so fuzzy; and others so completely absent from my mind, I have no clue.

But the slow start I was geared up for was not to be. As I made my way down the hall, one of the providers popped out of a treatment room like a spider and literally grabbed me. With a vice-grip-like hold on my bicep, she spun me around in the opposite direction of the safety of my office. “I need you to do an insulin start. Right now.” A cold chill cascaded over my body. Insulin starts are the most delicate, most difficult, most dangerous thing that I do clinically.

Normally, I relish the opportunity.

Insulin, done right, is the best weapon in our anti-diabetes armory. Insulin, done right, makes people happy and whole again. But insulin has a bad rep. It’s widely feared for no fair reason. To start insulin is more than just a, here, this is how the pen works. We have to deal with the fear factor and overcome it. Patients need to understand how it works, and how it doesn’t work. I need to ensure the starting dose is high enough to work but not too high. Bringing people down too quickly triggers relative hypoglycemia, and worse. Retinopathy “explodes” when sugars are normalized too quickly. But choose a dose too low to do any good, and patients get frustrated at taking shots without results.

Normally, I’d have a week’s worth of BGL data to study and make sure we knew the range, the curve, the shape, the lowest reading and the highest. And I’d have an hour with the patient.

This time I had no data and a time frame of only 15 minutes.

My new patient is a “visitor” from Mexico, pawned off on us by the free clinic as being too complicated for them to manage. Her sugars are screaming high. Her English is good but her husband doesn’t speak a word. He’s come along to be supportive, but she needs to provide him a running translation.

I feel like a fish out of water. A shirt without a tail. A bear out of the woods. OK. I seem to be out of good idioms.

After being introduced, I take the couple back to my office. My brain is like a car on a cold morning. I keep turning the key and it goes Wrrrrrrr….Wrrrrrrr…..Wrrrrrrr…. but never quite fires up and runs. I try to keep a calm exterior, but inside I’m freaking out.

Don’t fuck this up. Don’t fuck this up. Don’t fuck this up.

She has kind eyes, but is afraid. Dissipating that fear is job one. Assessing her further, I note that she is globally chubby, with significant truncal fat, and has heavy staining of acanthosis nigricans around her neck. Adding all of this up tells me she’s probably more insulin resistant than usual. Her starting dose needs to be adjusted accordingly. I throw my go-bag in the corner, take off my coat, and put it across the back of my chair. I motion to the pair of chairs under my new painting of the little airplane diving into the storm. Siéntese, por favor.  

Here we go again, little plane. Into the jaws of the storm we’re both destined to fly.

I sit in my chair and open my rat’s nest drawer. My approach to drawers is to simply let them fill up until you can’t cram another thing into them, or until you have to move your office. Over the last eight years, I’ve found myself moving offices more often than cleaning drawers.

I rummage around for a minute, and then get out a saline training pen and a few pen needles and lay them on my desktop. Something is missing. There should be more stuff. Think. Think, damn it!

I don’t have a clock in my office, but I swear I hear one ticking.

Like a swarm of gnats, snippets of thoughts buzz around in my head. Bzzzz...…site rotation…titration…air shot…bzzzz…needle sheath…plunger…hold time…hypo warning…bzzzz…sharps disposal…BG target...room temp…bzzzz...bzzzz...bzzzz...bzzzz...

I can’t really grasp one complete thought. They are all in motion, all fragmentary, a blizzard of fragmentary sticky notes that are not yet a speech. They are all the things I need to tell her but I can’t figure out where to start and how to weave the thoughts together. In the past the various elements just flow through my mind, mouth, and hands. Normally, when it comes to insulin starts, I’m graceful.

Today is the mental equivalent of the first time I wore ice skates.

Um… sorry if I seem a little distracted. I’ve been out for a time and I’m just back on the job…

I don’t know how it went. To me it seemed awkward. Rushed. But I don’t think I did anything wrong and Bill Clinton didn’t interrupt the process. I guess I’ll know how I did at her follow up in two weeks time. Or sooner if I fucked up.

As the day wears on, we have two new diagnoses that I don’t think I handled as well as I should have. I also see some old patients. I’m able to download their meters with little difficulty, but the swirling patterns of dots and lines aren’t whispering to me in their secret language. I’m not seeing the mystic ebb and flow of insulin and sugar that normally appears to me like heat applied to messages written in invisible ink.

The pain in my gut rises and falls like the tide, but as the short day wears on I find that more and more, the fog in my mind is beginning to lift.

My last patient is a pumper on a CGM. I plug her Dex 4 into my laptop and the computer sucks the data out of the device like an electronic vampire. I turn the screen to share it with the patient and an advanced nurse practitioner student who has been assigned to me for the back half of the day to begin to learn all things diabetes. I warned her she was being led by a blind man.

“Wow,” says my student.

“Augh,” says my patient.

I don’t say anything. The tangled mass of colored trace lines on the computer screen looks like the cat has gotten into grandma’s yarn collection. I can’t make sense of it, but fell I should be able to. I wrote the book on CGM, fer God’s sake. Literally.

The silence stretchs on. Uncomfortably so.

Finally, my student clears her throat, “Uh… What am I’m looking at?” she asks.

I snort. I have no fucking idea. It’s the truth, but probably not the best teaching method. My patient giggles. They love it when I swear. OK, I tell my student, this is an X-Y graph. We are looking at time left to right and the level of the blood sugar vertically. The device checks the glucose level in the interstical fluid every five minutes. Each test has a mark. The trail of marks is called a trace. I run my finger along the computer screen to show her. The marks change color every day and we can… we can… Suddenly, I see it. My finger freezes. Wait a minute.

Well, what do we have here? Hidden in the forest, I suddenly spot a grove of trees. Amongst the chaos, a pattern is emerging.

Wrrrrrrr….Wrrrrrrr…..Brum-burm-burm…Vroom!

My brain restarts.

Nearly hidden by wide variation during her sleeping hours, and the insane tangle of variety that follows her breakfast, her blood sugar traces show a pre-dawn rise. Every day. In a flash I know she needs more basal insulin an hour upstream. I smile, This we can fix.

Tomorrow I’ll pack lunch.