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Listening and thus avoiding more harm


A short while back, I had the sad fortune of being called in consultation for a patient whom we had seen just a few weeks prior in the hospital. This woman had suffered a heart attack three weeks ago. Her diabetes was very poorly controlled, as shown by her A1C of over 11%.{{more}} When she was being prepared for discharge from the hospital 3 weeks ago, we (my entire diabetes team) recommended that she NOT resume her diabetes pills and instead stay on insulin only. Why? Because this woman had suffered a heart attack that left her heart damaged and not able to pump effectively. As we explained to her, many diabetes pills are NOT SAFE to be used in people with decreased heart function, and certainly not with kidney problems, which she also had. She seemed very reluctant to accept our recommendations and we were concerned she would return to her prior medications, so we spent a good deal of time going through the risks involved with returning to her prior pills, and the reasoning for us recommending insulin only. She was discharged from the hospital in overall good condition and with prescriptions for insulin.

She soon returned to the hospital with severe shortness of breath and was instantly put on a breathing machine, because she has progressed to respiratory failure. As it turns out, she was in frank heart failure this time, with fluid throughout her lungs. I had two thoughts: 1) Thank goodness we did not send her home on those prior pills and 2) I hope she did not start taking them on her own, because they could really make this heart failure situation worse.

PLEASE, I am begging you: even when your doctor or nurse makes a recommendation that you do not like, please take it seriously and try to follow the recommendations. If you have serious doubts about whether or not it will help you, then seek another opinion. But do not simply disregard their input. In this woman’s case, I had acknowledged to her three weeks ago that we were asking her to make a big change. She previously had been taking three diabetes pills and one shot of insulin at night. We switched her OFF the pills and onto 4 shots of insulin per day. I knew we were asking her to do a lot more work and self-checking, but we seriously did not feel like there was a better, safer option for her at that time.

Now, critically ill and in the intensive care unit, we know that taking her diabetes pills in the setting of heart failure could have worsened the situation in many respects, including causing repeated low blood sugars, worsening fluid build-up, complicating her respiratory status further etc. So, I am extremely relieved we stood firm and refused to send her home on those pills. Ultimately, she did recover and was sent home, this time.And yes, we kept the same insulin recommendation.

Remember, even if the advice you receive is not popular or easy, it is sometimes the best and safest for you; so please do not disregard it.

Until next week, stay safe and healthy Vincies!

Anita Ramsetty, MD [email protected]

Medical Director Endocrine Care Group

Tel: 843-798-4227