Friday 20 October 2006

How to kill fewer patients.

Six days to go till I become a dad. Excellent.

Back in March, I mentioned one of many problems with the NHS:

NHS hospitals are now insisting that no patients be allowed to administer their own medication, and that includes diabetics giving themselves insulin. When a diabetic is admitted to hospital, they are expected to give their insulin to the staff and rely on nurses to check their blood sugar and inject their insulin. This is a Bad Thing.

In our experience, the trouble is not merely that your average nurse or even doctor knows very little about diabetes, but that your average doctor or nurse is so keen on ignoring or overruling their absent colleagues. So, when you're on a hospital ward, the advice of your diabetic specialist consultant who's been treating you for years really carries no more weight than the opinion of the duty nurse who's known you for twenty minutes, because the nurse is there and the consultant isn't. This isn't a huge problem when you're injecting yourself, because you can in turn choose to ignore the idiotic advice of the ignorant nurse and do what your consultant advised you to anyway. But that, apparently, is no longer allowed. The people who don't know what to feed you, how much insulin to give you, or whether to put you on a glucose drip are now solely in charge of feeding you, injecting your insulin, and deciding when to put you on a glucose drip.

It will come as a surprise to no-one with any experience of the NHS to learn that this approach has so far killed two people in Northern Ireland alone.

Vic, my wife, is diabetic, so, as you might imagine, one of the things that has been worrying us both about the impending birth is her being killed, put into a coma, or otherwise badly damaged by a nurse giving her an insulin overdose. It's not as unlikely as you might hope. We've had first-hand experience of exactly the arrogant idiocy I was writing about above. A couple of years ago, she was admitted to hospital the night before a minor operation so that she could be put on a glucose drip — you have to fast before being given a general anaesthetic, but fasting, obviously, is dangerous for diabetics, so they get brought into hospital the previous day so they can be given a glucose drip and have their blood sugars controlled without eating. This is entirely sensible. On being admitted, Vic was faced with a ward nurse who refused to give her the glucose drip on the grounds, when you get down to it, that she thought she knew better than the surgeon, the anaestetist, and the diabetic consultant, and it was her opinion that mattered because she, unlike them, was there. The drip was the only reason Vic was even in hospital — were it not for that requirement, she wouldn't have come in till the following morning. So the nurse in charge refused to give her the only thing she was in hospital to receive. The next morning, unsurprisingly (to us), Vic had a hypoglycaemic attack — ideal preparation for an operation. I'd love to say that this experience was a one-off, but it wasn't. It's the norm.

So the prospects aren't good, even before you take pregnancy into account. Pregnancy, you see, does a couple of things to diabetics: firstly, you need lots of extra insulin to convert sugar into a baby's body; secondly, your insulin resistance increases dramatically — a lot of non-diabetic women, in fact, become temporarily diabetic during pregnancy. Both these things mean that your insulin dose increases — by the end of the pregnancy, by a factor of about three. What this means, for those of you who don't know much about insulin, is that a heavily pregnant diabetic woman is injecting herself four times a day with what would usually be a lethal dose. As soon as she gives birth — within minutes, in fact — the required dose goes back down, not only to what it would be usually, but, as sugar is now being converted into milk instead of stored as fat, even further down that that.

So, you have nurses who know sod all about diabetes and are arrogant enough to overrule the instructions of diabetic consultants and the protests of experienced patients, in charge of giving insulin to a diabetic whose required dosage was about thirty-six units a couple of hours ago but who would now be killed stone dead if injected with even twenty units, whose ideal dosage is far lower than anything that has ever been recorded in her medical records, and who, on a drip and having just given birth, is in no condition to resist being given the medication. Really, it's amazing only two people have been killed.

So it was a great relief to us when, earlier this week, Vic's diabetic consultant told us that he has "an arrangement" with the nurses and midwives at our hospital whereby his patients are allowed to medicate themselves. He says they're all under strict instructions to allow his patients to inject their own insulin and to bow to their expertise over what dosage they should be taking. If there's any argument, we're to tell the nurses to call him, and he'll tell them that the ideal dose is whatever Vic says it is. Which is great.

For his patients.

For this is sheer luck. If we had a different postcode, Vic would have a different diabetic consultant, who might not have decided to overrule NHS policy and whose patients would therefore have to run the gauntlet whenever they went to hospital. If we move house, even if our new location is perfectly convenient for visiting the same consultant, the NHS might still insist that Vic be assigned to a different clinic, and there'd be sod all she could do about it. They did actually try to change her consultant a year or so ago, due to a bureaucratic reorganisation, but luckily that one was semi-optional — "semi" because they don't tell you it's optional unless you protest, as Vic did, thank God. This is how the NHS works: thanks to her address, Vic's chances of surviving next week are slightly higher, and her chances of not being a victim of negligence or malpractice are much higher. All the diabetics in our area who simply accepted that reorganisation when they were told about it — that's probably most of them — do not have that advantage.

I did rather get the impression that the two deaths are something of which the consultant is well aware, though he didn't mention them. He did tell us what the reaction used to be when his patients attempted to refuse to take the insane dose of insulin that a nurse was trying to give them: the nurses would call for a houseman to come and harass and bully the patient into taking the dose. The attitude was that patients who refused to take their medication were bad, and needed to be told off; patients who asked nurses to double-check with diabetes specialists were just being difficult.

Think about that. I don't know the details of those two deaths, or of the other deaths in other parts of the UK brought about by the same NHS policy. Maybe the patients were asleep, or senile, or delirious, or otherwise unaware. Or maybe they knew that the dose they were about to be given would kill them, and so kicked up a stink, and appealed for a diabetes specialist to give a second opinion, and did all they could to stop it happening, and were calmly and professionally overruled and sedated so that the nurses could get on with their job.

Like I said, knowing that we will not be subject to standard NHS policy on this issue is a great relief.

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