Insulin Safety

Different Types of Insulin
I always feel some concern when a patient goes home from the hospital with orders to add insulin to his or her blood sugar management routine. Insulin is a powerful hormone, and used safely, it is an excellent way to manage blood sugar and prevent the complications that diabetes can sometimes cause.  However, I fear that too many patients go home from the hospital without a clear understanding and respect for insulin and how to use it properly. The first thing to understand is that there are different types of insulin. In this post I will cover only long-acting and rapid-acting insulin and describe the most common insulin regimens.
Long-Acting or Basal Insulin
Lantus and Levemir are two brands of long-acting insulin. Long-acting insulin lasts up to 24 hours, and it is usually taken once a day.  Sometimes it is taken twice a day, in the morning and in the evening. The important things to know about this type of insulin is that it must be taken at the same time every day, and it cannot be mixed with other types of insulin in the same syringe. Long-acting insulin provides a slow, even background dose of insulin, and it has little or no peak, so there is less risk of low blood sugar events, although low blood sugar is a possible side effect. This insulin should be taken faithfully even if the blood sugar is in the normal range. This insulin takes hours to start working, so it is not used to correct a blood sugar that is currently too high.
Rapid-Acting Insulin
Humalog, Novolog, and Apidra are all different brands of rapid-acting insulin. They start to work in 10-15 minutes, peak in about 2 hours, and they are gone from the body in about 4 hours. Rapid-acting insulin is used to correct a blood sugar that is currently too high, and it is also often used to cover food that you are about to eat in order to prevent a large spike in blood sugar after your meal.
Post-Hospital Insulin Orders
Not all patients who go home on insulin are given the same orders, and your physician may order a different insulin routine than your Aunt Susie or your neighbor Sam was given by their physicians. Your physician may order any of the following:

• Long-acting insulin only (Lantus or Levemir) once or twice a day
• Long-acting AND rapid-acting (Humalog, Novolog, or Apidra) with a set dose (mealtime or nutrition dose) of rapid-acting insulin before each meal.  Again, the purpose is to cover food that is about to be eaten.
• Long-acting and rapid-acting insulin with a rapid-acting insulin correction dose in the form of a sliding scale. If you are sent home on this order, you MUST have the sliding scale detailed out for you.  For example, the order may say something like "If blood sugar is 151 to 200, inject 1 unit of Humalog. If blood sugar is 201 to 250, inject 2 units of Humalog and so on."  This is just an example, and the actual sliding scale may differ.  The important thing is that you cannot guess how much insulin to give yourself.  You must have a detailed order.
• Long-acting insulin AND a set mealtime dose AND correction dose of a rapid-acting insulin

Other Types of Insulin
The types of insulin described above are quite expensive, and if you do not have insurance, your physician may order a less expensive insulin that has a different start time, peak, and duration time. If that is the case, it is important to ask your nurse for clear instructions before you leave the hospital.
Important things to know
If you are to give yourself both a mealtime or nutrition dose and a correction dose of a rapid-acting insulin, you can add the two doses together in the same syringe to avoid two injections. Just remember that no other insulin can be combined with a long-acting insulin the same syringe. If the correction dose is ordered to be given four times a day at meals and at bedtime if needed, then you will give yourself a correction dose at bedtime only if your blood sugar is high and the correction dose is needed. Always check your blood sugar before injecting insulin. Write down the time, your blood sugar, and the insulin dose in a log book so you can look for trends and also so you can take the logbook to your doctor appointment.
Recognizing and Treating Low Blood Sugar
When you check your blood sugar before meals, it should be higher than 70. If it is lower than 70, it is too low and must be treated before you eat your meal. Low blood sugar is treated with about 15 grams of a fast-acting simple carbohydrate.  In other words, the treatment should be something that is almost pure sugar and can digest quickly. Some examples are half a cup of juice or regular soda, a small handful of jelly beans or other sugary candy that does not contain fat, or a cup of fat-free or low fat milk.  After eating or drinking the carbohydrate, wait 15 minutes and recheck your blood sugar.  If it is still below 70, eat or drink some more.  If your blood sugar does not come up after two treatments, continue to eat or drink more carbohydrate and also call your physician. If the blood sugar was below 50, eat or drink double the amount of carbohydrates.  Once the blood sugar is higher than 70, eat your meal.  If it isn't mealtime, eat a snack that contains fat, such as peanut butter and crackers, which will help stabilize blood sugar.  Right after eating, I recommend checking your blood sugar again. If it is at least 90, you might give yourself half the mealtime dose of insulin when you finish eating. Do NOT give yourself a correction dose, also, even if blood sugar is now high.  Half the mealtime dose may be sufficient. Check with your physician to make sure he or she wants you to take half the mealtime dose after you have eaten.
The signs of low blood sugar may include:

• Tremors
• Clammy sweat
• Blurred vision
• Headache
• Dizziness
• Confusion
• Weakness
• Lethargy
• Racing heart

If you ever feel at all strange, it is best to check your blood sugar to find out if it is high or low.  I should mention that if your body is used to a very high blood sugar, you may have the symptoms of low blood sugar even if your blood sugar is actually in the normal range!  If that happens, take just a bite or two of something to relieve the symptoms, but not enough to shoot blood sugar sky high. Your body needs a change to adjust to normalcy!
Don't Assume Anything When it Comes to Insulin
Please don't guess or assume anything about your insulin, when to take it, how much to take, or anything else. If you are unsure of anything related to your insulin or insulin routine, always call your physician for clarification. If you can't reach your physician, you might try calling your pharmacist for general insulin questions.  But make sure you get accurate answers from a professional!
If you have any questions, feel free to post them here.  I'm happy to try to help you.

The Patient Advocate as a Witness

A Reader Shares Her Experience in the Hospital
A reader who purchased my Smart Patients, Safe Patients book left a review with some honest feedback that I very much appreciated.  I am posting her review here without her permission, since I don't have a way to contact her.  I assume she won't mind, since her review is public. Here is what the reader, Jean, wrote:
I think the book has good ideas but it's not is Emphatic enough about how dangerous hospitals are. Personally, I was dropped in bed by a technician and a nurse came to my aid when I was in the hospital. But my nurse covered up the accident. The nurse never reported the accident in the daily notes. I told subsequent nurses and the resident on Saturday and Sunday morning but when I confronted the hospital there's just an empty spot in my medical notes – so this book guides you to say that when nurses change shifts they should discuss in front of you your care. But A patient's medical needs go further than that. A patient needs a witness to virtually everything that goes on in a hospital. Nurses and technicians lie for each other – nurses technicians and doctors cover up each other's mistakes and the only way A patient is protected is to have a witness. This information is glaringly missing from the book.


I completely agree with Jean that the patient's medical needs go further than having the nurses do report at the bedside, and I did attempt to convey that message.  I can understand the desire for a stronger message after the experience Jean shared.
By Sharing Experiences, We Can All Benefit
I think of this blog as a dynamic book, and it is one that we can all create together. If you have had an experience and have learned something as a patient that might help others, I would be most happy for you to share it here.  I only ask that you do so in a manner that is respectful and helpful to others and not as an opportunity to bash or demean anyone.
About Jean's Experience
I'm sorry Jean had a bad experience when she was a patient, and I hope no one else has that kind of experience. I would like to share what should have happened in Jean's case based on the information she gave. 
Jean was dropped by a technician.  Either the technician or the nurse was required to complete an incident report, which would go to the manager of the floor where the event occurred.  The nurse should have notified Jean's physician about the event.  If there was any question of injury, the physician should have ordered an appropriate follow up test, such as an x-ray to check for fractures. The physician notification should have been documented in Jean's chart. The nurse should have also written a nurse's note or possibly completed an event form, depending on the type of documentation used.  Jean doesn't say why she confronted the hospital, so I'm unclear if she wanted a copy of the documentation for legal purposes or simply wanted to make sure the event had been documented.  It's entirely possible that an incident report was filed, because those are separate from the chart.
What Would I Do in This Case?
If I was dropped by a technician, and I had any concern that I might have suffered an injury, I would verify with the nurse that an incident report was filed and the physician was notified.  I would request that she ask the physician to obtain an order for an x-ray of whatever part of my body I felt might have been injured.  Even if there was no injury, I would still ask if an incident report was filed.  The purpose of the incident report is to give the manager an opportunity investigate the event, find out exactly what happened, and do whatever can be done to prevent another event.  In addition, I would ask the nurse if he or she documented the event in my chart, and I would ask to be shown the documentation. I would also tell the nurse, "Please don't feel that I don't trust you. This is simply my practice and it is what makes me comfortable."
I do want to add that in all my years of working in the hospital, I personally have never known caregivers to cover up for each other when a mistake was made, although I don't doubt that it happens on rare occasions.
Questions and Stories are Always Welcome
I love questions, and I love for people to share their stories when they feel comfortable doing do!  If you have had an experience as a patient in the hospital and don't quite understand something that happened or simply want to know how to make it a better experience next time, I would love to help if I can.  Questions asked and answered can benefit everyone.
 

Students and New Graduate Nurses

Allowing Students to Care For You
You may wonder if it is safe to have a student care for you.  The answer is yes, as long as the student, their preceptor nurse, and their clinical instructor are observing the patient when necessary and communicating frequently with the student. There may be certain tasks the student should not attempt on some patients. For example, if you have found in the past that getting an IV in you is a monumental task, then it is appropriate to kindly tell the student that you require someone with a great deal of experience.  The student will be grateful for your honesty! If you need an NG tube threaded through your nose, and this task has been difficult for nurses in the past, a student should not be the one to attempt the NG insertion. The same is true of any task that has been proven to require a highly skilled nurse in the past.
What Students Can Do
Students are generally allowed to do a head-to-toe assessment of you, administer medication under the watchful eye of an experienced nurse or their instructor, and perform dressing changes, IV starts, urinary bladder insertion, and numerous other tasks.  The students are expected to communicate any and all pertinent information to the nurse who is supervising them as well as to their instructor.  If your blood pressure is high, for example, the student should communicate that information to the your primary nurse and to their instructor.  In some respects, you are even more safe due to the watchful eyes of your primary nurse, the student, and the student's instructor. Also, students tend to be very attentive, and that's always a nice thing. Students usually care for only one or two patients, so it's a great time to ask for the back massage that nurses rarely have time to offer these days.
How Patients Can Help Students Learn and Grow
Patients can be a great help to students who are learning how to be great nurses. If you give the student positive feedback when deserved and also make tactful suggestions when appropriate, the students can learn a great deal. Students spend more time than ever in simulation with mannequins, and we sometimes fear the art of nursing is being overshadowed by the science of nursing.  Both aspects of patient care are vitally important, and the patient can help students fine tune the art of nursing in a way that benefits both the student and the patient.

If I were a patient being cared for by a student, I would ask the student at the beginning of the shift, "Would you like me to give you honest feedback during the time you care for me?"  Almost certainly the student will respond with an enthusiastic "YES!"  Here are some things I would suggest to a student caring for me:

• I would suggest that the student always ask patients, "What are the three most important things to you while you are a patient in the hospital?"  I would then ask the student if he or she would like me to share my three most important things with him or her.
• I might give the student the following feedback if it is applicable: "I've noticed that sometimes when you come in the room, you are very focused on the task at hand, and I think you forget to look at me.  I feel more connected to you when you make a point of looking me in the eye."
• When I have been a visitor to a patient in the hospital, I always appreciate it very much when the nurses acknowledge my presence.  I would suggest to the student that he or she should do the same with family members or visitor, if I've noticed it hasn't yet become a habit. 
• There is often a hand sanitizer dispenser outside each patient's room. I would tell my student that I like to actually see my nurses sanitize or wash their hands inside my room, and it would be great if they would be willing to do that for their patients.

There are many things a patient can teach a student, and if the student is willing to learn from the patient, it can be a beneficial experience for everyone, including the student's future patients! (By the way, patients can also learn from students, and all students should be teaching their patients!)

New Graduate Nurses

New graduate nurses, or "new grads," generally have a lengthy orientation period under the guidance and leadership of an experience nurse called a preceptor.  As with students, I recommend that new graduates not be expected to perform tasks that require extra skill and experience, such as starting an IV on a patient whose past experience with IV starts has been very bad. 

New grads need to be observed the first two or three times they perform a new task.  I feel it is appropriate to ask your new grad how many times they have performed a certain task if you have any concern about the difficulty or complexity of the task in question.  It is also acceptable to request that the preceptor be present if it will help you feel more comfortable.  New grads need to get experience, and they can be safe practitioners from the very start as long as they are following protocol and demonstrating safe habits. If you notice any unsafe practices, bring it to the new grad's attention in a tactful way, and let them know you understand there is a lot to remember in the beginning.

Receiving care from a student or a new grad can be a good experience as long as communication between all parties is open, honest, and helpful for everyone.

For Patients Who are Very Difficult IV Sticks

No Need to Become a Human Pin Cushion!
Some of you may have had the experience of being a patient in the hospital and getting poked so many times that you felt like a human pin cushion.  I don't need you tell you it is not a fun experience!  What can you do to avoid multiple attempts at starting an IV, when you know from experience that it is futile? There are several things you can do!
Vein Finders
Ask if the hospital has an ultrasound machine or "Vein Finder" made specifically for finding deep veins.  If the hospital has such equipment, insist that the nurses use it.
Hospital Policy
Hospitals have policies that dictate how many times each nurse can attempt to start an IV.  The policy likely limits it to two or three attempts at the most.  Don't allow the same nurse to keep poking you over and over again without success. 
Ask For the Most Talented IV Starter
Ask for the best IV starter available.  Many nurses have a talent or gift for starting difficult IVs, and it's perfectly ok to ask for that person if you know from experience that special skill is required in your case.
Requesting a PICC Line
Perhaps in past hospitalizations you have always ended up with a PICC line or other central line because you are such a difficult IV stick, and maybe when a nurse does get an IV in you, it doesn't last for any length of time.  If that is the case, you should share that information with the first nurse who sees you in the ER and with the doctor as well.  The problem is that in the beginning, the urgency of your need may require immediate IV access, and it takes time to get a PICC (Peripherally Inserted Central Catheter) line in.  Also, in the beginning, it is usually unknown as to how long you will be in the hospital.  A picc line is used for extended stays or longer term antibiotic administration.  They are costly, time consuming to insert, and not appropriate for a very short stay.  That said, the doctor may know early on that your stay will likely not be a short one, and in that case, you or your advocate should ask for a PICC line if you are still an almost impossible "stick."
When You Meet Resistance
Patients sometimes feel they meet with resistance even after telling horror story after horror story about dozens of IV sticks, blown veins, and massive bruises on their arms from countless IV starts or attempts.  Some patients have found that these numerous sticks have left them with painful areas that take weeks or even months to heal.  One patient had difficulty using her thumb for months after an especially painful IV stick in her thumb after she had asked the nurse not to try to put an IV in that particular place.  The patient explained that it had been used before and had created problems in the past.  When it seems you are not being heard, you always have the option of asking to speak to a manager. 
Document Your Experience
I hope you don't have another bad experience, but if you do, document the experience with detailed facts that include exactly how many IV sticks you received, when you received them, how long your IV sites lasted before they had to be changed, and how many sticks each nurse attempted.  Finally, I suggest you take a photograph of any bruises or other signs of the numerous sticks you endured. Print out the photo and be prepared to take it and your written documentation to the hospital the next time you have to go.  Show the photo and documentation to the caregivers, or have an advocate do it for you.  The physician and nurses will likely take the situation more seriously if they can see and read what you have endured during previous hospitalizations.
Finally, Be Patient When Patience is Required
Your safety is the most important consideration, and sometimes the need for IV access is so urgent that there simply is no time to wait for equipment, locate someone skilled in starting a PICC line, or make any other special arrangements. Someone has to get an IV in you and FAST!  When that is the case, you may end up with an IV in your neck, if no other site is feasible.  Once the crisis has passed, then you or your advocate can begin to work with the caregivers to make plans to avoid numerous unnecessary IV starts or attempts for the remainder of your stay in the hospital.
I hope these suggestions help, and I hope you never have to endure the human pin cushion experience again!

Headaches in the Hospital

Headaches: a variety of causes and a variety of treatments
For some reason this morning I feel inclined to say a few words about headaches in the hospital.  Over the years, I have seen many patients dealing with headaches in the hospital.  A patient might come to the hospital because of a severe headache, and it can be very serious. Other times, a headache is one of several symptoms related to a high blood sugar level, infection, or other condition. Treatment for headaches vary depending somewhat on the cause. Treatment might be as simply as starting hydrating IV fluids and insulin for high blood sugar, and range to narcotics for a headache caused by meningitis. But there is one type of headache that I often see treated in a manner that I consider to be overly aggressive, and that is the headache I want to talk about here.
The NPO Headache - otherwise known as caffeine withdrawal
When patient are admitted to the hospital, they are often made NPO, which means they aren't allowed to have anything to drink or drink - "nothing by mouth" we say.  Patient who are used to drinking coffee first thing in the morning, or tea throughout the day, or Coke, Pepsi, Mountain Dew, or other drinks that contain caffeine are likely going to experience caffeine withdrawal, which usually incudes a throbbing headache. Some patients who don't necessarily drink anything that contains caffeine, might also have a headache from sugar withdrawal.
Treating a caffeine-withdrawal headache
If a patient has a headache in the hospital, they might want to ask themselves if it could simply be a caffeine-withdrawal headache.  I have seen patients receive IV morphine or oral narcotics for such headaches, when Ibuprofen or Tylenol would likely be effective. Those headaches can be pretty painful, but fortunately, they don't last more than a day or so. If someone is going into the hospital for surgery, it would be a good idea to go off the caffeine before surgery and avoid the withdrawal headache.  There is a way I have found to prevent them, and it has worked well for me.
Preventing a caffeine-withdrawal headache

• On the first no-caffeine day, drink more water than usual to help flush your system
• That night, before you go to bed, take two Ibuprofen (200mg. each) (I happen to prefer Ibuprofen over Tylenol, but it's just a personal preference)
• Upon waking the next morning, take two more Ibuprofen
• If you start to feel even a hint of a headache as the day progresses, take two more Ibuprofen

I have found that this will prevent a caffeine-withdrawal headache for me. My headache never starts until the second no-caffeine day.  If you know yours start earlier, then you can take the headache remedy sooner, before your headache would usually start.  We are all different, so it might not work for everyone, but this is the process I would use if I knew I had surgery coming up and would be NPO for a period of a day or more. (I've also done this a number of times when I have sworn off those darn colas!)
NOTE: I am certainly not a medical doctor, so I can only say that the process I follow is safe for me.