Insulin Pump on Demand

February 12, 2009

It is never good when you and your new patient appear incredulous at the same time.

It is never good when both you as the doctor and your new patient appear incredulous at the same moment. This occurred during a recent new patient visit to my clinic. I had been having a “disaster diabetes day” where all of my patients had worsened glycemic control for various reasons. I checked the A1C at the front of the new patient’s chart: 5.1%. Hallelujah! Finally some good news today, I thought.

I walked into the room and sat facing a woman in her 40’s, pregnant with her third child and a due date in 8 weeks. It did not take long for the purpose of the visit to come out: she had been referred by her OB to be placed on an insulin pump for improved glycemic control during the remainder of her pregnancy. Okay, not a bad idea, I thought. Then the other shoe fell: she was expecting to be started on the pump today. TODAY?

I tried, likely without success, to appear calm when I explained that this simply was not possible. I wanted to ask, “What, does everyone think endocrinologists walk around with pumps in their pockets, ready to start them at a moment’s notice? “ You must have me confused with Super-Endo, who can control glucose with a single press of a button. The rest of us mere mortals need a great deal more time for pump starts, even if, as in the case of this lady, the patient has previously been on an insulin pump. Time is needed to calculate how much insulin someone likely will need, to get insurance approval, to actually order the pump so that is there physically, and most importantly to ensure the patient is comfortable with carb counting and has good working knowledge of insulin action in order to avoid dangerous situations while on a pump.

With this being the first time I ever set eyes on this patient, I was in no position to even entertain starting a pump without further demonstration from her that she would be able to do this safely. Not to mention ordering the pump itself—it turned out that she was using large amounts of insulin, thus taking some types of pumps immediately out of the running. I managed to contact one of our diabetes educators to review the current dosing with this patient, and unfortunately she did not have a good handle on carb counting or insulin action. Caramba, what a disaster!!!

Thankfully this patient understood why starting a pump that day was just about impossible, and she agreed instead to transition to insulin pens for the time being. She likely will not pursue a pump if she maintains good control with the insulin pens. Her main issue with her current regimen was the trouble it took drawing up insulin 6-8 times a day from vials, so once that aspect was made easier she was not focused on a pump anymore.

Needless to say, I was somewhat annoyed with this situation and wondered how this came to occur. It is of course possible that the patient misunderstood the information provided by her OB who may have told her correct information. I do not know where the breakdown in communication occurred, or if the initial information was outright wrong. But the truth of the matter is this: insulin pumps cannot and should not, be started on ANYONE without adequate evaluation of their knowledge and understanding of carb counting, insulin action, review of their dietary habits, and teaching regarding how the pump works. This period of time is what my co-worker CDEs refer to as “homework.” Even after all of that preparation, a typical pump-start day takes 3-5 hours, and the patient needs to be wiling to check BS at various times of night for the first two weeks. This is not like putting a patch on someone; it is much more involved, and potentially dangerous if not done correctly. As irritating and disappointing all of this homework can be to the patient, we aim to first do no harm, so education and preparation are key.

And no, endocrinologists do not have a stack of pumps in the clinic that they can start on demand. We leave that up to Super-Endo…