I pit homicidal killers who also lie about their blood sugar levels

The BBQ Pit
41

Yeah guys, I understand the Docs situation. In my years of nursing, five of them were spent in one of the seven federal prisons we have in our area.

The difference may be in the respective prison systems in our countries.

When I nursed in prison, any diabetic patients who were not diet controlled, were required to present themselves each day at a given time and WE did the glucometer test. They came to the prison hospital and at some point during the day every one of them was tested. ( We didn’t test each and every inmate)

Given that, my incredulity still stands. Who determines who needs insulin? How much. Who draws it up? Who administers it?

I can guarantee one thing. Based on readings given to me by the inmate, it sure as hell wouldn’t be me!

42

An important thing to remember is that the great majority of diabetics, in the general population (and the correctional system as well) are type II, not type I. They don’t need insulin, and can be controlled with oral medications or diet and exercise. However, they still need to check their blood sugars, often even several times a day. The medical thinking has changed greatly on this - it used to be thought that type IIs not on insulin didn’t need to be checked at all except at great intervals, but that is no longer the case.

The thinking on what a ‘good’ blood glucose is has changed as well. Many endocrinologists are now recommending an average of around 100 or so (US system), or a hemoglobin A1c of under 6.0. The ‘tight and low’ BG control philosophy is winning the day.

I currently work as a nurse educator/manager for a disease management company, and diabetic education is a huge part of my job. It’s tough to keep up with all the changes, there’s something new every day!

43

Hmmm. Those are very interesting points. Who DOES give the injections? (I’m a nurse).

As to the finger stick lancets–they are so small, it would be hard to hurt someone with them, but then again–I could see some moron sticking it in someone’s eye…
Inquiring minds want to know–who and how does one check sugars and give insulin in prison?

44

I understand that QtM has taken an oath, but if his patient chooses that he (the patient) would rather die sooner of untreated diabetes than die later after spending decades living in prison, isn’t that entirely up to his patient?

(Umm, perhaps fodder for a new thread.)

45

When I worked in the prison system ( and it was a few years ago ) the nurses did it.

The situation was, we had a small unit in the admin building (six beds) and a reasonably stocked medicine cabinet. We were hardly ever full and anyone who we suspected to need the resources of a real hospital was shipped downtown under guard.

In the morning, certain inmates and they knew who they were, arrived at the door before breakfast and two nurses started testing. IIRC there were approx. twenty of them. Perhaps out of this number, two of them would require insulin.
And this is where my point comes in. The nurse who did the test, drew up the insulin and administered it.

Fortunately it was a rather mundane process. I never came across the particular type of whacko the Doc is dealing with. Most of my whackos were pretty concerned about their health.

46

My mother used to manage nurses in federal prisons–I could ask her. but then it would be 45 minutes of How Wonderful a Manager I Was and I don’t feel up to that tonoc. (my mother would be a forum all by herself).

If memory serves, there was some kind of dispensary where the inmates would line up to get meds and shots etc.

(sorry, but I have a funny picture in my head of a nurse pushing a med cart down the corridors of a cell block…hee!)

47

These guys have a duty to take responsibility for their disease. Once they’re out of prison, noone’s going to check their blood sugars for them, draw up their insulin for them, inject it for them, etc etc etc. Just like a diabetic living in their own home, these guys need to take responsibility for managing their disease, with the advise and counsel of physicians and nurses who are knowledgeable about the disease. We teach, we demonstrate, we counsel, but the patient is the one with the disease, so the patient must manage it.

In Canada, are all diabetics who take insulin expected to show up at their doctor’s office to have the nurse poke their finger, check their glucose, decide how much insulin to inject, draw it up for them, and administer it to them?

My institution has 1,600 inmates. At any one time, 60-80 of them need insulin at least twice a day. And we have 700 new inmates coming in every month, with 700 leaving too.
We’ll give these people the tools they need and the training they need to use them, but we will not do it for them if they are physically and mentally capable of doing it for themselves.

I’m in a max security institution, so the inmates are not allowed to have pokey things of their own in their cells. At 4 discrete times a day, diabetic sugar check happens in the health unit. At that time, before each meal and before bedtime, the diabetic may come down and check the glucose, dose with insulin, and leave. 1 nurse rides herd over them all.

Some insulin using diabetics come down twice a day, 3 times a day, 4 times a day, depending on the regimen that’s been established for their disease. Some diabetics who don’t use insulin come down for routine monitoring too, often twice a day on 3 days of the week, to give them feedback on how well their pills/diet/exercise regimen is working.

48

We seldom force treatment. Only when an inmate’s behavior is clearly acutely suicidal, or if it poses a risk to institution security.

But sometimes the inmates try to manipulate the system by refusing treatment. One guy doesn’t like a certain dialysis nurse, and refuses to dialyze during her shift. He’s willing to dialyze on another shift, or at an outside dialysis unit. But he doesn’t want to stop dialysis, he just wants it on his terms. In those cases, such behavior disrupts smooth functioning of security, jeopardizes his health, and we will get a court order to force dialysis.

For the patient who says to me “fuck it doc, I’m gonna die in prison, and in the process I’m gonna eat all the junk food I want, not take my insulin, and make the state spend a lot of money to take care of me and my problems”, I tell them they’re making stupid choices. But until their health breaks down in a real major way, I can’t force anything.

49

I really don’t see the prison sending all the type IIs down to the infirmary four times a day for glucose checks, especially if they’re controlling with oral meds and/or diet and exercise. It just becomes a real impracticability when people are being monitored or self-monitoring at that level. Once a day checks don’t cut it any more even for a lot of type IIs if you want to manage the disease most effectively; my husband is a type II and management has changed a lot in the last few years.

Seems to me that even in a prison population, if a guy doesn’t want to take care of himself, there’s not a whole lot that can be done to make him do it. It might cost the state $$ in medical treatment to let him get out of control, but it might also save the state even more $$ when he dies ten years earlier than he might have otherwise. We can lock a guy up, but can we force him to take proper care of his health?

50

Oops, looks like I posted at the same time as Qagdop. I stand corrected about going in to the health unit for glucose checks. But I still don’t believe the state can force a guy to manage his diabetes to the level we’d like just because he’s under the state’s physical control; that does seem to tread a very narrow ethical line.

51

Many type IIs use insulin.

I manage to get a fair number of my non insulin dependent type IIs to come down twice a day every day to check. Most are rather resistant tho, and we often end up compromising on twice a day 3 days a week.

Ideally I’d like to have all the insulin-using diabetics coming down 4 times a day, but many are resistant to that. I insist on at least twice a day for them.

We adhere to the standard of trying to get the patient to have a HgBA1C and clinic visit at least every 3 months if one is on insulin, and at least every 6 months if one is not. Also annual dilated fundus exams, annual comprehensive foot exams, annual microalbuminuria tests, annual flu shots, a pneumococcal vaccine, and nutritional counselling at admission and every 2 years.

Our last review of how successfully we did all these things showed that we were outperforming most local HMOs dealing with non-incarcerated people in meeting and exceeding recommended standards.

52

As a type 1 for 24 years, I can attest that high blood sugar does not make one feel good at all. It doesn’t give the “sugar high” that people keep saying exists as a result of “high blood sugar”*. It makes you feel bloated, nauseous, sweaty, irritable, etc. Similar descriptions to low blood sugar, but it’s…different. Feeling sweaty and irritable from high’s is different from low’s. It’s difficult to describe, and is one reason on some days I end up testing as many as 10 times during the day (thank goodness for great health insurance that buys me unlimited test strips…) Even modertely high (such as 150-190) will in time make me start to feel nauseous and definitely make me feel bloated.

  • Another myth I wish would go the fuck away is all the people who claim to be “hypoglycemic” and yet have not ever been diagnosed such. Basically, people who use it as an excuse to stuff Ding-Dongs and Twinkees in their faces at regular times during the day because they “feel low”. And yet, every time I’ve offered to test one of these people who are heading towards the Grim Reaper with low blood suger, and they’ve accepted, their glucose is typically 120 and up. Hey, if you want to be on a 4000 calorie a day diet, I’m cool with that, but at least be honest about it…yeesh.
53

The state pays for it. If that homicidal killer were in my state I sure would rather buy him insulin now than whatever expensive surgery etc. later.

54

Did you ever see March of the Penguins? Get the HD DVD version, with the wider picture. You’ll see that at the end of the long line of penguins marching across the ice is some creepy-looking bastard with an Uzi. What, you think they did all that voluntarily??

55

Mornong everyone. Crashed early last night.

A lot more details in your last couple of posts Doc and I now see what you’re really up against.

As I said earlier, it was a few years ago since I was in the Corrections Service and things may have changed since then. I’ll check with a couple of buddies who are still there. Corrections Canada is so paranoid about contraband I can’t see them being that laid back about inmates handling needles and insulin. There is a market for anything in prison. I do know there is an aids program in our local pens and the guard staff are making a helluva fuss regarding the way it’s being implemented, so maybe the inmates are handling the paraphinalia.

My only concern when I initially read the thread was that I was under the impression that a nurse was given an arbitrary number and based upon that they were drawing up insulin and administering it. That surprised me because here in Ontario the CNO (College of Nurses of Ontario) would be on me like shit on a wool suit. You don’t accept anyones numbers but your own.

However, as you explain it, the responsibility lies with the inmate, relieving the nurse. Not a bad system.

Thanks for the clarification and good luck with the nutjob.

56

[mildly interesting sideline]

Here, the nurse’s aides usually take the sugars and report back to the nurse. We can double check it via the hand held memory or redo it ourselves, but mostly we trust the aide’s numbers. I work adult acute care with a very noncompliant pt population. Believe me, 120 would look good!

and now back to prison…

57

** QtM** Do you feel there is a higher number of Diabetics inside the prison walls than, say, the general outside population ( of where are you going to get 1400 or so males 18-60) in one concentrated area like that?
Do you think it is a combination of dietary habits,and socio-economic conditions (poor overall education) that might lead to this seemingly diabetic epidemic inside the walls?

If these guys get out, do they have insurance at all to cover their meds?

58

I don’t agree. There is no good reason for a diabetic on oral meds with a good HbA1C to test his blood sugar more than once a day, and there is a reasonable argument that they don’t need to check it at all at home.

What is such a patient going to do differently based on the result of that test? The glucose isn’t likely to be low on orals, and if it is it would be reflected in a morning fasting glucose. There isn’t anything to be done if it’s high except to eat better and be compliant with medications, which the patient should be doing anyway. If the glucose is so consistently high that an increase in medication dose or a switch to insulin is merited, that will be reflected in the HbA1C.

An important rule of good medicine: if you’re going to do the same thing regardless of the result of a test, don’t do the test.

Nothing makes me madder than when patients lie to me. Usually, in my case, they’re trying to get pain pills or “nerve pills” (benzodiazepines), for which the black market around here is beyond belief. Here’s a conversation I’ve had more than once:

Me: You know, anxiety disorders respond far better to medicines called SSRIs than to drugs like Xanax, without the potential for addiction. Why don’t we try some Zoloft?
Patient: I was on Zoloft before, it didn’t help.
Me: OK, how about Paxil?
Patient: Been on that. Didn’t work.
Me: Effexor?
Patient: Tried it.
Me: Lexapro?
Patient: Mmm-hmm. No help at all.
Me: What about Remoulade?
Patient: Yep, been on that.
Me: When were you on Remoulade?
Patient: A couple of years ago, for about six months. It didn’t help at all.
Me: That’s because remoulade is a mustard-based sauce that’s tasty on shrimp.
Patient: <pause, blank stare> Can’t you just give me some Xanax?

59

DoctorJ, I never found remoulade that tasty on shrimp, myself. :wink:

I’ve got a lot of motivated type IIs who don’t take insulin, but do modify their behavior based on what their blood sugar is. If they see it’s drifting up, they’ll modify their diets and exercise more. That’s why I like to get them on a twice-a-day check at least 3 times a week. I’ve seen tons of type II folks not on insulin who have marvelous fasting glucose levels, but hit the 250 mark or more many evenings. If they only check in the AM, they never realize this. When they see the high PM levels, they kick up their exercise, watch what they eat later in the day, and get satisfaction when they bring the PM levels down. And they can make those adjustments in days or weeks, rather than waiting for the every 3 month feedback of the glycosylated hgb result.

But if my diabetic won’t do anything different based on his glucose level, then the need for more frequent checks disappears. So you’re correct: No need to check if nothing is to be done because of the information. But recognize that there are things a motivated individual can do with the information besides decide how much insulin to give.

As for inmates with pointy things: when they check in for sugar check, they’re issued a lancet and a syringe. Before they leave, they must return both. If they fail to do that,they are taken to the segregation unit and thoroughly searched. Then they stay in the segregation unit for a while.

And each diabetic has his own individual medication regimen, created by me and/or one of my colleagues after exam. A common type of regimen for a brittle diabetic would include 4 x a day checking, with a fixed dose of regular before eating a meal or the bedtime snack, a sliding scale of regular to normalize their sugars if they are running high, and a dose of Lantus insulin at bedtime. Just what the dose is depends on the individual diabetic’s needs.

We don’t use asparte insulin as it acts too damn fast. If there’s a delay between the inmate injecting the insulin in the health unit and him getting to eat, suddenly his glucose is 45 and falling and there’s trouble.

I don’t know if we have more diabetics in prison than not, given the enormous epidemic of diabetes out in public right now. But our diabetics sure come in sicker, as many (most) have not been taking care of themselves. The highest HgBA1C I ever saw was on an inmate when he arrived in prison. It was 20.

And if a diabetic inmate refuses the standard diabetic diet, eats the regular meals served, buys junk food in canteen, doesn’t use the exercise yard, and neglects to take his meds properly, then he’ll be out of control in prison.

And if a non-diabetic inmate sits around and eats all the time, doesn’t exercise, etc. he’ll pack on 50 lbs in his first 6 months in prison and voila, a new diabetic!

60

then when they get out, none of their clothes fit, so they get new clothes, look sylin’, start using again, get skinny again, get arrested again, go back again, pack on the pounds.

it’s a whole package system. :smiley: