University of Minnesota

“If It Isn’t Fun.” – A Bad Case of Diabetes – and Guilt

“I am not naturally a good man, but I have been scared to death so many times that I have learned regretfully, but definitely, that honesty is the best policy.”  William Allen White

During my fellowship in medicine, I regularly moonlighted at a neighboring fraternal hospital in the Midway area of St. Paul where our family first lived in Minnesota. One quiet Sunday morning I was called urgently to see a diabetic woman who had just been admitted in impending coma. Our new patient was middle-aged, of wispy build with pinched features exaggerated by dehydration. In an obtunded state of classical diabetic acidosis, and with a strongly fruity breath, she responded weakly, with slurred speech, to shouted questions. I had just missed seeing her husband, who had dropped her off in admissions and left immediately. This seemed a little strange, considering how ill she was.

Just that week of my fellowship at the university, I had learned what was considered the “latest trick” in emergency management of diabetes, a semi-quantitative ascertainment of the severity of acidosis. In it, one tested, by simple color reactions, progressive dilutions of plasma for ketones, the acid by-products of abnormal glucose metabolism. This new test was appropriate to a rapid evaluation, particularly when there were no facilities for immediate determination of blood pH and electrolytes, as was the case in this small hospital on a Sunday in the late 1950s. The rule of thumb for the test involved administration of a certain number of units of regular insulin for each serial dilution of serum that proved qualitatively positive for ketone bodies.

Our patient’s serum that morning was positive out to the fourth dilution, requiring by the thumb rule an immediate and hefty dose of regular insulin, the precise amount of which I don’t recall. Let’s say that the estimate totaled 120 units of regular insulin to be administered in a bolus.

The practical nurse on duty, who had never had anything to do with I.V. insulin or with single insulin doses of such magnitude, shook her head in consternation and clucked her tongue when I ordered it, remarking, “She’s just a little slip of a thing, Doctor.”

I agreed and settled on half the calculated dose, but felt that our patient was going into deeper acidosis, blood pressure falling, with respirations now Cheyne-Stokes, that is, alternately fading away and then remounting with deep gasps. Our patient now responded only to painful stimuli. I was concerned that we get to the core of the issue rapidly and reverse the hyperglycemia, to set her on a metabolic path away from the fatal acidosis.

Within half an hour after the 60-unit dose of insulin we administered, half intramuscularly and half into the I.V., the patient’s condition worsened, her blood pressure falling out of sight. I drew blood for potassium and glucose and sent this off with an emergency order to the Sunday-morning lab., and then stepped up the I.V. drip, adding glucose and potassium chloride to the saline solution.

Within the hour the frail woman died before our eyes. The practical nurse looked at me, and I at her. I found her look accusatory. Mine pled for her acceptance that we had done the best we could. I knew in my heart by then, however, that I had not had enough experience with the serial dilution method, and that any commonsensical approach would have given frequent, smaller doses of insulin to such “a little slip of a thing” and then closely followed her progress.

I left the room crushed and asked the floor nurse to summon the husband from home — he who had not felt it necessary to remain at the hospital for another of his wife’s oft-repeated episodes of uncontrolled diabetes. He was stunned by the news and came rushing to the hospital full of contrition and remorse that he had abandoned his wife in her last moments. On arrival, he bemoaned the fact that he had waited too long to seek care, remarking that she had indeed been getting into trouble with her diabetes for several days. I tried to reassure him that it was not his fault. I was not displeased, however, that he was thinking mainly of his role rather than mine in her speedy demise. I did not volunteer my thought that it was substantially my fault that she had died so rapidly. We ended up shaking hands and then embracing, each of us desperately needing the other’s support.

I then called the chief of the small hospital at his country home and told him the story. He murmured, “Well, she must have been very hypoglycemic or hypokalemic. What do you think, Henry?” I said, “I think it was both of those. I hit her hard with insulin because I thought she was going out in acidotic coma. We’ll have the lab. data back before long.”

His voice was steady — the voice of a man of great experience who had seen many people die, and who had, like most of us docs, undoubtedly contributed to some untimely deaths by errors of judgment. He was reassuring: “I’m sure you did what was in your best judgment, Henry,” which left the blame on me but assured me that he was aware of my thinking process and good intentions. Talking with him, I suddenly felt the “fancy-pants” university resident, condescending to take call in this modest private hospital. In fact, I was devastated. It was likely that my untried and purely academic knowledge of the serial dilution gimmick had killed prematurely the wife of one of his fraternal brothers. He was, nevertheless, kind and supportive, clearly “covering” for me.

That was the last I ever heard about the wisp of a patient, except for the blood report that eventually returned, revealing a glucose level before death of 19 mg % and a potassium of 2.0, clearly from an insulin overdose. Fortunately, in those days, people didn’t automatically think “malpractice.”

Requiescat in pace.

Rest in peace, then, dear lady. May your family have found solace. And may they, and the powers-that-be, forgive a too-smart young resident who thought he was doing his best, but whose best was unproven — and clearly not good enough.

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