Wally’s story began in March 2002 when I received a call from the Wellness Works Coordinator at the hospital about an employee with diabetes who was experiencing difficulty with high and low blood sugars. His diabetes management was unstable, and the situation was creating safety and productivity issues for his department, not to mention for the employee himself! She also told me that he had been labeled “non-compliant,” and was wondering if I could help. As a person with Type 1 diabetes for years, I have a passion for helping people manage this disease.
For the record, I dislike the word “non-compliant.” I think it is a term that clinicians use too frequently and too easily, especially in the world of diabetes, without evaluating all of the factors that affect control such as work schedules, food preferences, religious and ethnic preferences, and the different actions of medications.
The day arrived, and I met Wally. He was a pleasant, bespectacled, dark-haired man with a beard, and hints of white at his temples as well as in his whiskers. I figured that he was in his 50’s. I had seen him around the hospital, and it seemed he rarely smiled. He appeared a little uncomfortable, not sure what to expect. We wanted to determine the best way for him to manage his diabetes so that extreme high and low blood sugars were not the norm, and to encourage him to utilize the various resources available to him.
Wally was willing to receive any help that was offered, but expressed his frustration with the healthcare system, and the fact that no matter what he did, this control was never good. He had basically given up and felt defeated!
We immediately requested Wally make an appointment with his physician and sign a release of information form so that all parties could communicate and not breach confidentially. Wally was enrolled in Trigon’s Better Prepared Program and was scheduled to attend the Diabetes Education classes that are offered free to its members. He happened to attend the evening session that I taught, and it helped us get to know one another better and begin to establish mutual trust.
Wally would also monitor his blood sugar for three days, two days during the week and one during the weekend. He would monitor and record fasting, before meals, two hours after meals, bedtime, and any time that he felt that he was having a low or high blood sugar, or if he just did not “feel right.” This is important for anyone newly diagnosed, anyone changing treatment plans, or when trying to “troubleshoot.”
As part of the Trigon insurance Better Prepared Program, Wally would also have a one-to-one appointment with the dietitian in Diabetes Services. She would evaluate his work schedule, eating preferences, ethnic and religious practices, Body Mass Index (BMI), glucose levels and medications to determine the best meal plan for him.
I think it was hard for Wally to believe that no food is off limits; it has been so ingrained in us that people with diabetes cannot have anything with sugar in it. However, people with diabetes can have sugar and desserts. It is as with anything else – in moderation and portion controlled! And you have to evaluate the effect on blood sugar, blood pressure, lipid and weight.
Things started out well. Wally attended the classes and said that he learned several things that he did not know. He went to his physician’s office and signed the release forms. I made the recommendation that Wally be changed from a twice a day dose of NPH insulin with Regular to cover any high blood glucose levels to Lantus at bedtime and Humalog before each meal or snack. NPH insulin or the combination of 70/30 insulin does not work for everyone; and it was creating swings in his blood glucose levels. Lantus, a new insulin that does not have a peak and works for 24 hours, would give him better all day coverage and then he would take small amounts of the quick acting insulin, Humalog, to cover his meals.
He met with the dietitian and learned to count carbohydrates, which meant he would take a specific amount of Humalog for every 15 grams of carbohydrate eaten and anytime his blood sugar was elevated. He made the appointment with Options, which is Riverside’s Employee Assistance Program .
The only thing that didn’t happen was Wally had not brought his meter in for me to check. He brought in his logbook, but no meter. He gave me verbal records, but no meter. I was beginning to think that the numbers were not real, that he was telling me what I wanted to hear. I knew that I could check the memory on the meter and verify the logbook and verbal readings. If the numbers did not match, then I knew that we were in trouble. And I did not want to even think that way. I liked Wally. I thought we communicated well and that a bond had been established. Had I been wrong? Did I fail? Were my expectations too high?
Thankfully, the answers were no! One month after our initial meeting, Wally came to see me, with meter and logbook in hand. He had been on the “new regime” long enough to see positive changes in his blood sugar levels. He no longer had the highs and lows he was previously experiencing.
He could tell when his blood sugar was beginning to lower,, which he had not been able to do before. He was prepared to treat a low blood sugar, whether on the job or in his car. His logbook had notes written on the side as he related any blood sugar out of range to a choice he made, an illness, or additional exercise. His attitude had changed, and he was very positive.
Wally reported feeling better than he had in a long time. And better yet, his hemoglobin A1c (HbA1c) level, which was originally 8.4%, was coming down. This was a true indicator that the changes were working. This blood test gives an idea of blood sugar control during the past three months.
Hemoglobin, a part of the red blood cell, and blood sugar attach to each other, and when a blood sample is drawn, the results are expressed in percents. The average for a person without diabetes is 4-6%. A person with diabetes wants to have their result 7% or below. If the result is 8% or above, the person’s diabetes is out of control. This goes back to my statement about disliking the term “non-compliance.” Wally had been labeled such, but in reality, his previous treatment plan, which had not been changed much since his diagnosis, was not working. With a change in insulin therapy to meet his body’s needs, some education, support, and a listening ear, Wally was controlling his diabetes; it was not controlling him.
It has been nine months since I first met Wally. He is feeling good, has more energy, his weight is stabilized, and he has not had any severe low blood glucose levels at work. He even looks happier. He is enjoying a new level of wellness that he did not think was possible for him. He found hope.
He came into my office the other day whistling, with a grin on his face and some great news to share. His last HbA1c was 6.5, which is lower than mine, his diabetes educator. Success!
Janet Batten, RN, CDE
Director, Diabetes Services, Riverside Regional Medical Center
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