I think that delirium happens on nights. People who normally have sense lose it and act like they say to each other, “let’s call the nurse practitioner,” for everything. It began legitimately with an admission, that for a change needed to be admitted. There are times that you see someone who has “given up.” It makes you sigh while the note is completed, and meds and dosages are double checked. The phone drones in the background only stopping when it’s answered to respond to every odd request that makes me wonder how folks survive without adult supervision.

“I’m in pain,” which spawns the inevitable discussion of, “wanting something for it.” It’s not to say that most people don’t have legitimate pain, but a good deal of pain I tend to see is somatic with a specific medication request. They are allergic to everything except a specific medication or have “tried that before, and it doesn’t work.” Usually, it is for Dilaudid, which is a joke for most acute care folks.

“I am not sure what they gave me last time, starts with a D, I think?” (Insert dick joke here…) (Double points for double puns, right?)

Of course, we always chuckle to ourselves as we hear this joke repeatedly. It’s the gift that keeps on giving. Kind of like a bizarre acute care Groundhog Day (complete with Sonny and Cher). I say no most of the time because I don’t like to give narcotics for anything but acute pain, as they actually do little but get the person high and feed into addictions or pseudo-addictions. Inevitably, it will get around to folks that the best they will score is Tylenol or Ibuprofen.

Then there was the inevitable 2300, “I am not able to fall asleep.” He had enough of a sleep aid, called trazodone, to knock down a mule, but he said that clonazepam always helped him sleep. Dude, you were just tapered off clonazepam because you were overusing it. Do you think I don’t read your chart? I’m not sure if the benzo or opiate seekers are worse sometimes.

In the middle of the night, a call about a foot and a “sore” that was bleeding a bit. When I arrived, he had two ulcers on his foot, called diabetic ulcers. These ulcers are particularly scary because they can develop with very little friction or warning. In many cases, the person with diabetes is unable to even feel the presence of these ulcers, and they often have a difficult time healing.

One of the worst things about having diabetes is the subtle damage that occurs to the body from a continually high blood sugar. That is the major reason we providers are always harping on patient’s and finding ways to lower the blood sugar of their patients, especially this provider who needs to watch his carb intake.

So quick diabetes lesson; diabetes is diagnosed with high blood sugar or blood glucose. This is measured by two different possibilities. The first measure is multiple fasting blood sugars above 150 mg/dL. Fasting means nothing but water for 8 hours before blood is drawn. The other measure is the hemoglobin A1C. This is more accurate as it can tell the pattern of blood sugars for approximately 90-100 days. If this number is over 6.5, it typically shows that the patient is diabetic. You do not have to be fasting to have a hemoglobin A1C drawn, typically, your provider screens for blood sugar annually. If that number is between 100-110, then your provider continues to screen annually to ensure that the number doesn’t increase. If that number remains normal, then your provider can screen you every three years based on current guidelines. Typically, if the glucose is over 90, your provider will check your A1C (you don’t mind I get familiar here, I hope).

A person with diabetes has many potential problems ahead. They can develop neuropathy, which is a loss of sensation in the extremities, usually the feet. This loss of sensation can be so severe that a person with diabetes could step on a tack, have that tack embedded in their foot for days, even weeks, and not notice it. In my career, I have seen several feet that have had embedded objects in them and have become infected to the point that the skin around the object became necrotic (turned black). This can be particularly life-threatening because the patient can develop sepsis or an infection of the bone. The diabetic ulcer I was talking about develops from friction on the foot or ankle, sometimes on the calf. This ulcer develops because of poor circulation and sensation in that area. Poor circulation is another hallmark of diabetes because it causes “hardening” of the microvasculature (small blood vessels) of the extremities.

The ulcers can be mild to rather nasty, and it sort of depends on how much the patient can feel, as to how soon they are treated. I have seen everything from mild reddening, all the way to necrosis where you could see tendons and bones. This is why I do a foot check when a person with diabetes comes into the office. In a foot check, we test sensation and movement as well as look for sores or redness. We also teach the person how to look for these problems on their own. We hope that we can prevent injury instead of having to treat it. Prevention is key.

We can save a lot of trouble by managing blood sugar. Usually, with someone who develops type 2 diabetes, we have several oral options before we must try insulin. Type 2 diabetes is typically insulin resistance where the body has lost its ability to metabolize glucose (sounds kinda scientific doesn’t it?). This is oversimplified simply because who wants to read a lecture on glucose metabolism? If we fail to manage blood sugar, this can lead to neuropathy and microvascular damage but also heart disease, kidney failure, and even a stroke. None of these are very fun, and quite honestly, if you have significant heart disease or a stroke, it may be better than kidney failure. The first two can kill you fairly quickly. However, kidney failure can last for a long time and requires dialysis three times a week. In my past, I have been a dialysis nurse, and I can tell you that it is a brutal process for the patient.

So, after a careful assessment of the wound, we applied an appropriate dressing and sent the patient on his way. I’m not really sure why he waited until two in the morning to have his wound looked at but to each their own.

A quick note about things of late before I go tonight. We’ve had a little technical difficulty the past couple of days and some personal issues. These have now resolved, at least the personal issues, and we are back writing blog entries. The technical difficulties have been with the podcast and a software glitch that was causing large chunks of audio to not be recorded. It was frustrating, but it was also a learning experience. You are essentially watching someone who has never done any of this before, except maybe radio, but I had a lot of support to deal with audio software, hosting services, and vendors such as iTunes (on a personal note I don’t understand why anyone buys Apple products. They are so not user-friendly… Also, this is a preference so please do not barrage me with emails about how good Apple is). Now that the podcast is recorded, it should be out by Saturday at the latest. Thank you for your support, even if all you’re doing is reading these entries every day. I hope to soon be more reliable with daily postings, even if it means beating Igor’s hump (Which means Master needs to actually write them…).

Well, time to check on the bats. They’re inside because of single digit temps.