The strange case of the rising blood sugar

So, patient whose dinnertime blood sugar was 88 jumps to 528 at bedtime when the tech checks it. i check it about 20minutes later it was 574. Order said give 16units SSI and notify HO. Patient refused SSI and self-administered 9.7units of novolog via her insulin pump. recheck a little after an hour later, was more than an hour cuz i was busy and the fingerstick was now 584. Patient finally consented to getting SSI but the max she'll take is 10units. spoke to doctor who ordered it and administered. Rechecked a little over an hour and it was 594. at that point, gave 10 units and notified doc again.
Doc says give 20units. Then she says "i'm afraid she'll go into DKA, how much do you think i should give her?". I reply 10. She's NPO. She goes "If she keeps going up, she may not be able to go for surgery in the morning. give her 20units. if she drops too low we can always give d50." Surprisingly, i saw where she was coming from and didn't argue about the dose. Now was that a faulty logic? I don't know and i think it's hard to decide.


The thing with blood sugar levels is that too high is bad and too low is also bad. How will a person's body respond to insulin administration? It's hard to tell. For example, this lady's fingerstick kept climbing up despite multiple administration of insulin. Did the doctor think it was going to keep going up? Yes. She told me over the phone that "she needs a high dose of insulin".

Anyway, i recheck at 440am, it had dropped to 212. At 0639, it was 93. When i left patient, she said she was fine. After walking into the room to introduce new nurse, The patient stated i feel 'low'. Since i was done report, i told my coworker to have the tech check it while i complete the patients OR checklist. So at 0735, it was 31.
Coworker who left me in a crappy situation comes in this morning and tells me you shouldn't have administered 20units. Well, if the lady kept climbing high as she was and went into coma, first it would've been my fault and i'm sure this same person would've criticized the doctor for not being aggressive. Can we treat DKA? yes, insulin drip, IV NSS and a whole bunch of crap. I remember when i worked at Jeff, i had a lady who came in with bloodsugar reading "HI" on machine, she was on a insulin drip, q1hr fingersticks and it took more than 12hours for blood sugar levels to come to the 500 range. And we've had patients here at who've had to be transferred to the ICU so they can get an insulin drip. Can you push D50 and have the blood sugar come up in 30minutes, yes. Sometimes, you may have to administer D50 twice.

So was the doctor's reasoning faulty logic? i don't think so. I mean she could've looked the other way and said, let's not give her anything and the bloodsugar could've gone past 600 and she coulda been in a coma. Neither one of us can predict how the patient would react. It's bifurcated road that leads to the same place. You don't treat aggressively, you risk the patient going into DKA. You treat aggressively, you risk the patient bottoming out. At least in this case the patient was conscious and communicative and action was taken.

There's been times when i've looked at out comes and thought, this doctor could've done this or this should've been implemented in the patients care to avoid such and such. Today, i support the doctors judgement. I know on my drive home, i tried to think if there was anything i could've done differently and honestly? i couldn't think of any. Between 10p and 6am, the lady got 8 fingersticks. One almost every hour except during the hour between 5 and 6am. I did 6 of those fingersticks myself and my tech did 2. i documented 6 times each time i took it. Knowing i'd given the patient 20units insulin, i checked the blood sugar levels afterwards and 20minutes before shift change, i rechecked and documented. She was 93. How was i supposed to know she'll drop considering i held her AM dose of insulin? The doctor didn't play God. I feel like she did the best she could do. Her reasoning led her to the choice she made. It was based on sound logic considering the inability predict an individuals reaction.

I know some nurses look at medical judgement and think it shouldn't be done that way but i think we see things differently. Doctors stand far away and see a picture those of us standing close to the patient don't see. This time, i think the medical judgement, however aggressive it may look, was a fine decision.