Cortlandt Forum - A Most Unusual Case (February 25, 1997)

Thanks to My Staff

I need to cancel my appointment." This simple statement saved the caller's life.

Joan, a 56-year-old woman with an eight-year history of insulin-dependent diabetes met-titus, had been followed at a local charity hospital and placed on a sliding-scale insulin program. However, she was often treated there not only for ketoacidosis but for hypoglycemia because she either would not take, or took incorrectly, her extra insulin. I first saw Joan one year ago, when she weighed less than 90 lb. She was given instructions in better insulin dosing and management techniques and was repeatedly told that she had to take her insulin as scheduled.

Joan called to cancel a previously scheduled appointment because she did not fee) well enough to drive and the sister with whom Joan lives was in Atlanta that day visiting a relative. To provide maximum efficiency in my practice, no-shows are charged unless my office is contacted. Although on Medicaid and not obligated to pay, Joan still felt the need to call. My receptionist, sensing that Joan had more than just a minor illness, transferred her call to my nurse, who immediately understood there was a greater problem. Joan, contrary to all of our previous instructions, had not taken her insulin that day nor, as we found out later, the day before. My nurse insisted that Joan take her dose of insulin immediately and go to a specific emergency room, She did neither.

Later that day. Joan called my office again. This time, the call was answered by my laboratory technician, who was unaware of the previous conversations. Joan asked if she could wait for her sister before going to the ER. My tech sensed the gravity of the problem and insisted that Joan call an ambulance immediately. She even called Joan back to ensure that this had been done.

When Joan arrived at The designated ER, she was clearly in ketoacidosis and would have died if she had remained at home to await her sister's return.

Had any of my three staff members failed to recognize the seriousness of the situation, appropriate medical care would not have been obtained. Since Joan had not taken any insulin during the preceding 24 hr, she was almost completely metabolically decompensated by the time she arrived at the ER.

Two lessons: (1) You can never teach diabetes management often or carefully enough. (2) A physician is no better than the quality of his or her office staff.

This article appeared in the February 25, 1997 Issue of Cortlandt Forum, p. 54.