Advanced Technology: Sometimes, Just Say No

October 27, 2008

Despite some caveats, the vast majority of people I know on insulin pumps are very happy with their control and flexibility.

This past week I did something I later felt somewhat guilty about, but still knowing I did the right thing: I may have talked a patient out of getting an insulin pump.

Several times a year I have patients referred to my Endocrine clinic with the reason being “patient interested in insulin pump.” No problem, that’s cool. Then the patient shows up and almost invariably they are under the impression that (a) an insulin pump does all the work for them and/or (b) I can start them on the pump THAT DAY . Needless to say, neither of these is correct and I often end up spending the vast amount of time during this first appointment essentially deflating balloons of hope that were filled by their primary provider with incomplete/false information.

So what did I tell this young man?

NUMBER 1: the pump takes work,WORK I tell you!!! Too many people walk into my clinic thinking we will put a pump on them and let them walk out the door without any preparation or teaching. I had one gentleman get very upset when I told him he would have to go to sessions with our diabetes educator. He said a buddy of his had gone to another doctor and was fitted with a pump the next day without any teaching at all. And I thought to myself, “ There’s not a chance under the sun of that happening with my name attached to it.” Our patients, as do most at diabetes centers across the country, meet several times with a CDE to learn about carb counting, insulin action for safe corrections etc as well as the manual aspects of having a pump, before they get fitted during the marathon 4-hour session on pump-start day. And for the first week they are required to check their blood sugars probably more than they ever will in their lives again. You don’t put someone behind the wheel of a car without a lot of instruction and test drives; the same goes for an insulin pump.

NUMBER 2: The pump is not a closed loop. Patients often think that the pump checks their sugars and automatically administers insulin. They know the pump infuses insulin all day and assume it works as an independent mechanical pancreas. Not so. The pumps can calculate the dose for you, but that is still based on your input. And patients still need to check blood sugars, A LOT in fact, to be safe with this amazing device. They always appear crestfallen when I say, “Nope, you still need to check blood sugars, unless you are fitted with a sensor device(that really throws them and I have to stop talking).”

NUMBER 3: the pump is not for everyone. I have stopped pumps in a few people. In some cases they simply did not like it, especially the fact of having it attached to them night and day. In others, it was just not what they expected and most times it was actually that they were started (by someone else, not me) without adequate preparation and found having the pump was much more work than they anticipated.

Do I tell patients the upsides? Of course, as I did with this young man. Despite those caveats, I say, the vast majority of people I know on insulin pumps are very happy with their control and flexibility, It has changed their lives in many ways, almost always for the better.

So why was this young man not ready for a pump? In addition to many misconceptions about not checking blood sugars etc, he was not sure he liked the idea of the pump being attached to him night and day, he had only JUST started showing improved compliance with his current regimen of only two shots a day(history is our greatest teacher—if he can’t handle that simple regimen , what on earth am I doing throwing him under the bus of intensive insulin treatment with a pump???) as well as keeping clinic appointments.

I am glad he is interested in a pump and in his care overall. He agreed to graduate into a more intense MDI regimen of Lantus and Humalog , met with the CDE, and then make a final decision about the pump. I’ll see him back in about a month, and I promise I’ll be gentler then.