Blood Sugar Dump And Falling Into Walls

I didn’t feel that great yesterday.  Nothing specific, just a headache (which isn’t unusual for me at all), some queasiness, and just not feeling right.  So, I limited what I ate to jello, mashed potatoes, and other bland foods that provided some carbs to deal with the basal insulin dose I take twice a day.  The bland food helped the queasiness, and I figured I’d had enough carbs for the insulin.  I’m usually pretty good with my diabetic and  RN knowledge (nearly 28 years since graduating from nursing school; 20 years as a working RN taking care of a lot of diabetics, 17 years as a diabetic, and 8+ years of being disabled and learning a LOT from a patient’s point of view). I figured wrong.

I went to bed around 6:30 p.m.  Normally, I’m up until 2:00-3:00 a.m., easy.  I’m a night owl. And don’t talk to me before noon.  But, I was really tired, so I decided I’d either go to bed, sleep for a few hours, and then resume my normal night owl schedule, or I’d sleep straight through. I didn’t care.  I was still awake at 7:00 p.m., so decided I’d just take my nighttime meds (including my main dose of Lantus insulin) and be done with it for the night.  I crawled back into bed and fell asleep.

At 9:40 p.m. (it’s written down in my blood sugar log) I woke up to go to the bathroom, but felt really odd.  After falling into the walls walking to and from the bathroom, it dawned on my that I needed to check my blood sugar. It was 37mg/dl; I double checked it and it came back at 40mg/dl. It shouldn’t go below 70mg/dl, and my endocrinologist doesn’t want mine below 80mg/dl because of my history of epilepsy; I’m prone to seizures anyway- no point in adding hypoglycemia to the risks.  I was still with the program enough to grab one of my tubes of ‘gel’ candy (‘Squeeze Pops’ – cheaper than products marketed to diabetics, and tastes like Jolly Rancher candy, but in a tube, and a gel consistency). With some of that on board, I got some ginger ale. I checked my blood sugar about every 10 minutes until it had settled in the 90s (took about 30 minutes).  That was ‘safe’ enough to go to bed. I knew I needed a fat and protein source to keep from having rebound hypoglycemia, so justified a Reese’s Peanut Butter Cup 🙂  I was still really tired, but at least didn’t feel like I was having for force myself to stay conscious. That was better.

It’s really important to not ‘just’ do the simple carbs, or the hypoglycemia WILL come back.  I’ve been treated in a local ER, and they are clueless about the protein/fat source after getting the blood sugar back up. One time when I’d been brought in by ambulance for hypoglycemia, I was sent to the waiting room to wait for a cab, and was told the cab would be there in 45 minutes. The basic instructions for hypoglycemia are to  have a snack if the next meal is more than 30 minutes after treating the low blood sugar episode.  That’s ‘diabetes 101’ for lay people, yet the genius ER nurse was either clueless or just didn’t care (typical of that facility’s ER). When I was waiting for the cab, my blood sugar went down to the 50s again, and I told the triage desk person. She told me that since I’d already been seen, one of the nurses would talk to me IF she got time. I was safer in the cab going home.  It was really pathetic, and there’s no excuse for them.

My endocrinologist had prescribed a glucagon kit to me somewhat recently- but I live alone. Glucagon is designed for someone who has already lost consciousness, and requires someone else to mix the syringe of sterile solution with the little vial of powder, mix it up, pull it back into the syringe, and ‘shoot’ the person who is out of it.  I’m not sure how that is supposed to help me, except that I’ve dropped to the 30s before and couldn’t get it to come back up, while remaining alert. (I ended up calling 911 for that one, and getting IV D50W- that stuff feels awful going in)  I guess I could shoot myself.  Glucagon can be given under the skin (subcutaneously) or into a muscle (intramuscularly), so basically any good dart throw at the person will work.  I could do that. My outer mid-thigh would probably be the best place to aim for… a fair amount of real estate for a blurry eye and shaky hand.  But the kit I’ve got right now is expired by a month. It would probably still work, but last night, the edible carbs were working. I need to call the pharmacy for a refill on the glucagon….

For those ER nurses (and others; I’ve given it a few times working on a med-surg floor) who have given D50W, here’s a little inside information. The stuff doesn’t feel good.  It causes a strange warm feeling, and a feeling of needing to go to the bathroom NOW.  It’s unpleasant. It can also cause dehydration, depending on how high the blood sugar goes, with frequent urination and hyperosmolar  diuresis (frequent peeing from concentrated sugar in the blood).  Knowing this, and offering to help someone to the bathroom would be nice.  Go a little slow pushing the stuff- a few extra seconds isn’t going to cause brain damage.

It’s also important to realize that the half-life of D50W is dependent on the degree of hypoglycemia and the individual patient. Once it wears off, the blood sugar drops again UNLESS there is something to help prolong its effects, such as fat and protein.  Peanut butter and crackers, a candy bar, milk and crackers, or other protein/fat source is needed.  That’s also the reason that those items are not good for treating the severe low blood sugar. For ‘borderline’ or mild hypoglycemia (above 60mg/dl those will probably work OK… but always listen to facility policy if you’re treating a patient; if something goes south, that will be the criteria used to judge you).   The blood sugar will not rise quickly with protein and/or fat in the item being used to treat it.  Candy bars are NOT good ‘first aid’ for hypoglycemia, and will delay return to normal blood sugar because of the fat and protein. Once the blood sugar is raised with simple carbs, it’s necessary to give a fat/protein source- not before.

Anyhoo… I survived the night.  I hate the feeling of having low blood sugar, and last night included balance problems. Had the walls not been there, I would have hit the floor, which would have been bad news for my knees.  I’m not feeling that great today (same queasy, fatigue stuff as yesterday), but know to check my blood sugar more often today.

Emergency Room From Hell

There is a local emergency room that actually scares me.  I’m not the only one- whenever I mention its name to someone (even my new oncologist who works for the same organization) the reaction is usually “Oh, I know what you mean. I/my brother/mom/ dad/friend/ etc went there and they almost killed me/them.”  Their posted patient satisfaction percentages have been in the %60 range. That is BAD.  Hospitals run on patient satisfaction surveys (which is a whole other nightmare for healthcare professionals).  Reputations are hard to fix.  What is so bizarre is that the rest of the hospital is fine, or at least survivable. I’ve had many outpatient tests, a couple of admissions from the ER, and also a knee replacement at the same place, and the staff was tolerable.  I did have some complications after the knee replacement that were figured out a bit late, but nothing as bad as their ER.

One time when I was admitted, I had a nurse tell me that I needed to go home.  At the time, I was on a heart monitor because my heart rate had dropped into the 30s and was being erratic. But she looked familiar- I think she was one of the hags from the ER who was working on the cardiac floor.  I never could figure out how nurses could be so nasty.  I’ve had some unlikable patients, and some that were really unpleasant to deal with- but I’d never be inhumane or callously disregard their dignity.

I’ve got multiple chronic illnesses, and I’ve been an RN since 1985.  I’m on disability, but I keep my license current, and I know the appropriate manner in which to speak to and deal with patients. I’ve been a staff nurse, supervisor, charge nurse, and department head.  I’ve also been sent to various ERs over the years, though this scary one has been the worst, hands down.  Not even a close second comes to mind.   I was often sent there from work, unconscious, either from being post-ictal (what happens after seizures when people sleep very deeply) or my blood pressure bottomed out from my autonomic nervous system not working right (dysautonomia), and I’d pass out.

Other times, someone called 911 when they were either with me, or on the phone with me, and they could tell something wasn’t right (turned out I had some medication interactions that weren’t figured out for quite a while that contributed to some of the blood pressure problems).  I was labelled a ‘frequent flyer’, which is an extremely derogatory term given to patients who generally don’t have primary doctors and are often non-compliant. Neither of those applied to me. I saw my regular doctor monthly, and all blood levels of anticonvulsants were always therapeutic. I’m on disability because my seizures are not controlled. I’ve had testing done to see if part of my brain could be removed to stop the seizures, and that turned out not to be possible without causing more damage than it could help.  I’m not some joke patient who shows up for the heck of it (I’ve been accused of being bored, and using the ER for entertainment at the bad one).

But, the nurses and doctors at this ER didn’t care about me as a human at all. They never asked about regular doctor visits.  I was told I was a ‘wasted bed’ because I’d been brought in with seizures.  I was told that it was highly unlikely that I was compliant with anything.  They didn’t understand- or even try to find out- what I was really like as a patient- when I said anything that contradicted their assumptions, it was ignored. They made their assumptions and treated me as the parasite they thought I was.  The dysautonomia isn’t all that common as a given diagnosis.  It causes extremes in blood pressure and heart rates (and for me, heat and pain are major triggers).  My blood pressure would drop to a dangerous level at home  and per my primary doctor’s instructions, I would call 911 when it got below 70/50.  It was often much lower, and the lowest I know it to have gone is 44/16 during a tilt table test.  Even with objective symptoms, I was treated like a head case.

I rarely remember getting to the ER.  I had learned that when I woke up and saw the drop ceilings and bright lights and equipment, I was in the ER.  One night I woke up and a doctor was counting my pills from medication bottles EMS had brought from my apartment when a neighbor called them after I passed out in her apartment.  I asked him what he was doing, and he asked if I’d overdosed. I said definitely not- and asked what happened. It had taken 4 bags of IV fluids to get my blood pressure up to 80 systolic, and the nurses were getting me ready to go to ICU for dopamine (a resuscitative drug to maintain blood pressure). I ended up not needing it, since I managed to stay around 80 systolic, and I was making sense once I regained consciousness. But in the preparation to send me to ICU, a urinary catheter was inserted.  The balloon that keeps it inside was inflated before it got all the way into my bladder, and stretched my internal sphincter (what keeps the urine in the bladder) and upper urethra…talk about pain. I told the nurse it wasn’t all the way in, and she turned to leave the room without saying a word. I pushed it in the rest of the way myself.

Another time, I had just ‘come to’ and saw a doctor walking past the stretcher. I was still groggy, and he didn’t say anything to me, so I didn’t talk to him. I didn’t know what he wanted (or for sure that he was even a doctor for that matter- some guy in a white coat). He proceeded to begin to insert a breathing tube into my airway- something that isn’t done without someone to suction in case the patient vomits, some paralytic drugs to dull the gag reflex (to prevent vomiting) and calm the patient IF they need to be intubated, and without asking the patient if they are awake and know what is going on.  I have no idea why he wanted to intubate me (which more than likely would have landed me on a ventilator). He started putting the metal blade of the laryngoscope down my throat (has a light on it to see where to put the tube), and then the tube, which did trigger my gag reflex and I started to throw up. I turned my head to the right to let the puke fall out, and the metal blade (still down my throat) nicked my right tonsil, and it started bleeding. A nurse came in (finally) and since I was trying to breathe and reflexively trying to get the stuff out of my mouth and airway, they tied me down.  The doctor finally took the stuff out of my mouth and asked if I’d OD’d… I said “No!”.  He said “That’s all you had to say.” I couldn’t believe it… that was all HE had to ask !  I didn’t even know why I was there (still don’t), and it was HIS job to assess me before attempting to put in an endotracheal tube. It could be that because he assumed I’d OD’d that they were going to pump my stomach, and the ET tube was part of keeping my airway safe. But, nobody said anything to me. My medical record would have shown other ER visits with similar symptoms and ‘clean’ drug screens… There was one nurse who was helping me get cleaned up after the throwing up who was kind. She had a daughter with seizures and understood the post-ictal period.  I was just mortified.

I never got on the call light (when I could reach it), and would undo the monitors myself if I had to go to the bathroom, and put myself back on the monitors when I got back. I never asked for pain meds. I didn’t ask for anything.  I was never there for psychiatric reasons (patients who are not thought of well in most medical facilities, mostly from lack of knowledge and exposure to the various disorders). And yet I was treated like I was a total pain in the butt and whack job.

When someone comes out of seizures, there is generally a period of time when they are either extremely sleepy (and even coma-like) or mildly confused for a little while. Not everyone ‘comes to’ the same way. Not everyone has ‘TV seizures’.  I have complex partial seizures that turn into generalized seizures at times (when I end up ‘out cold’ the worst).  When I come to, I can hear things first, and then gradually get back up to speed- but sometimes my response time is slow.  The nurses at this ER from hell didn’t like that, so they’d double team me and put TWO  ammonia inhalants under my nose and hold them there as I gasped for air.  I was awake and knew what they were doing- but I wasn’t ‘all the way back’, so my response time was too slow for them- so they assumed I was a psych case being difficult. Or faking.  They were punitive.

When Social Security was reviewing my disability paperwork, they had over 1000 pages of medical documentation over the previous 3 years, including abnormal EEGs (brain wave tests used to help diagnose seizures/epilepsy) and blood pressure crashes.  But the nurses at that ER thought I was a nut job.  I was horrified that SO many nurses like that exist.  When I’d worked in Texas for 17 years before returning to Illinois, I worked with great nurses. Even if someone wasn’t necessarily going to be a ‘friend’ outside of work, I never saw cruelty or pure meanness.  We had a lot of wild shifts at work- and I never saw one of my coworkers in Texas act like those hostile nurses in that one ER.  I’d worked in another hospital in this town (pediatrics) and then a nursing home- and those nurses were also good to their patients.  But the nurses in that ER of the religiously-affiliated hospital were downright nasty. The docs weren’t much better.

When I was taken in for very low blood sugar one time, they got my blood sugar up with two ‘amps’ of D50 (sugar solution given IV), and then called a cab.  The nurse told me that it would be about 45 minutes until the cab got there, and I should wait in the waiting room. Basic treatment of hypoglycemia instructs people to eat a snack with protein and fat to prevent blood pressure from crashing again once the D50 ‘wears off’, unless their next meal is within the next 30 minutes.  I was sent to the waiting room with nothing (usually a half a sandwich, or peanut butter and crackers is standard hospital fare for low blood sugar after it’s brought back up).  Fortunately, I had my purse with some change for vending machines, and my own blood sugar monitor.  Within a few minutes, I could feel my blood sugar dropping even though I’d gotten a bag of peanuts from the machine.  I tried Coke, and it was still dropping. When I told the person at the triage window, she told me I’d already been treated, and if a nurse had time she’d come and talk to me.  I was safer on my own.

There had been a weird period of time when I was having episodes that were much like the autonomic disorder, and a bit like seizures, but not quite. I had been in the ER (per home health instructions) several times in one month. One night, I was having more trouble with my blood pressure, and went to the ER. The doctor actually told me I’d been there too much that month, and he wasn’t going to do anything. I asked if they could at least check my blood pressure again (it had come up somewhat from being moved from the ambulance stretcher to the ER gurney), and he refused to tell the nurse to simply push the button to do another BP reading.  He never got within 5 feet of me.  Ten days later, I had severe chest pain, and ended up going to another ER (per the instructions of my doctor’s nurse, who was affiliated with the scary place), and it was discovered that I had multiple blood clots in my right lung (all three lobes) and right pulmonary artery that were pushing into the base of my heart, causing EKG changes that showed my heart wasn’t getting enough oxygen (just from the pressure of the junk in my lung).  The clots were of various ages- acute, subacute, and chronic- so would have been present during the time when the doctor negligently blew me off. He could have killed me with that decision.

I’ve written to the hospital with the creepy ER, and got the standard ‘we aim to give the best possible care’ letters. My own doctor was told by one of the few nice doctors at the bad ER that he’d witnessed how I’d been treated. It wasn’t just me being snarky.  My doctor believed me. The ‘new’ ER saved my life.  I had asked the doc at the ‘good place’ that night the pulmonary emboli were found if I could go home and get a few things since I was being admitted for a few days, and she told me she didn’t think I’d live that long; the next night I was in ICU getting clot-busting drugs when I started having the same pain again.  I’d driven myself to the ER… not recommended.

For those in nursing school, new grads, or starting to work with different types of patients,   consider this:  You aren’t going to understand everything about everybody you encounter as a nurse. But just because YOU don’t get it doesn’t mean it’s OK to take out your lack of knowledge on the patient,  who could very well teach you something.  Cruelty during urgent/unstable medical situations  is never justified.  And it’s not something that can be ‘fixed’ later. You represent where you work, and your profession.  It’s not about you when you’re assigned to take care of someone.

And You People WORK In The Emergency Room?

Early on when I was starting insulin I had some learning curves in the area of low blood sugars (hypoglycemia). I’d been given the diabetic teaching about what to do, and I’d been an RN for 22 years by the time I started on insulin.  Generally, I did well at home getting my blood sugars back up with regular soda or glucose tablets/gel.  One day, nothing was working. I had to call 911 when I hit 37mg/dl, and couldn’t get it to go up no matter what I did.

The paramedics got there, and I was still in the upper 30s.  They gave me more gel, and got an IV going in the ambulance.  I was still conscious and able to talk to them, but I felt BAD. They  radioed ahead that I was coming, and unfortunately I had to go to the closest ER which was notoriously horrible. En route, they gave me an amp of IV dextrose (D50). I had my purse with me that had my backup glucose meter and change for the vending machines. That proved to be incredibly important.

I was given another amp of D50 , and my blood sugar went up to 128mg/dl.  The nurse  (who rarely made eye contact, and just muttered as if I were the most ridiculous thing she’d seen come through the door all day) said she’d called a cab for me; they’d be there in 45 minutes.  I knew that I had to have some source of protein and/or fat to keep my blood sugar from tanking again. The basic information for hypoglycemia says that a snack is needed if the next meal is more than 30  minutes away.  Evidently the EMERGENCY room people didn’t know that basic information.  Straight glucose will spike and then drop. That’s just how it works.  I was sent to the lobby to wait.

Within about 10 minutes, I could feel my blood sugar drop.  I checked it, and it was in the 70s. I got a Coke and some Starburst candy from the vending machines. It wasn’t helping. I got some peanuts to help my blood sugar stay put.  The peanuts didn’t help.  My blood sugar was in the 50s by then.  I went to the triage desk and told them what was going on. I was told I’d already been seen, and a nurse might be able to get out and check on me in a while. Really?  I’d been brought in by ambulance for hypoglycemia, I was bottoming out again, and I was thrown to the whim of some nurse who might get to me?  I was safer in the cab.

I managed to stay in the 50s until the cab got there, and got home where I could work on evening out my blood sugar on my own.  The ER obviously wasn’t going to complete the process with protein/fat sources.  I got some peanut butter, and that helped.  Now when I go anywhere I take glucose tablets or gel and portable peanut butter.  I make sure my blood sugar is in a range that lets me function before I eat the peanut butter, or it will slow down the glucose’s ability to work. The duration of action of D50 is dependent on the degree of hypoglycemia (and the symptoms of low blood sugar are different for everyone at different levels of hypoglycemia).  One person can be unconscious at 40 mg/dl, while someone else can be talking at 30 mg/dl…both are in severe hypoglycemia and need immediate treatment.

I learned a lesson about the emergency personnel’s lack of comprehension on how fully to deal with hypoglycemia.  I have to take care of myself even IN the emergency department at a hospital. At least the shoddy one.  I can’t depend on anyone to help me; I have to be prepared and advocate for myself.