Hospital knocks your diabetes care
Marcia is 56 and has schizophrenia. She has been stable for three years on olanzapine. She and her son Jimmy, who has learning difficulties, live independently in a flat in a unit supported by a resident social worker.
Marcia also has type 2 diabetes. Her control has never been good, despite maximal doses of metformin and rosiglitazone. The community dietitian has tried her best. Marcia has background retinopathy.
She was admitted to hospital with gallstone pancreatitis. Today she has come to see you, and you have received three letters: the surgeon will not operate until she has lost 20kg and improved her diabetic control; the specialist registrar in diabetes declares herself 'surprised and disappointed' you have not improved Marcia's diabetic control; and the psychiatrist is very pleased with her mental state. Marcia denies osmotic symptoms but smells strongly of urine.
Three GPs discuss a tricky problem
Dr Peter Moore
'Our number one priority is Marcia's mental health'
This case is a good example of why general practice is a specialty in its own right. Primary care requires unique skills. Not only do we have to consider every aspect of
the patient's medical problems we have to take into account psychological and social aspects before assessing priorities. The specialist registrar is only considering the diabetes.
Any doctor looking purely at Marcia's diabetes could criticise the use of olanzapine. The BNF states it should be used with caution in diabetes. It can cause hyperglycaemia and weight gain, a problem for a diabetic who needs to lose weight for surgery. With the poor control it could be argued that she should also start on insulin.
Our first priority must be Marcia's mental health. The schizophrenia is well controlled after many relapses. She is even looking after Jimmy. Should she have another relapse, any diabetic control we have will be lost and Jimmy will suffer too. It is unlikely that she could manage insulin injections. The risk of a hypoglycaemic attack outweighs any benefit from improved diabetic control. But we cannot ignore her diabetes. With poor control and diabetic retinopathy she is at risk. Should she develop serious visual or cardiovascular complications her care of Jimmy would be jeopardised.
Her care needs to be co-ordinated. I would try to arrange a meeting with the psychiatrist, the resident social worker, the hospital diabetic liaison nurse, district nurse and the specialist registrar. The registrar may not be able to attend, but if she could, a discussion of the problems might help her to understand the difficulties. Control of the schizophrenia is the priority but the psychiatrist may have an alternative to olanzapine. If insulin was suggested our district nurse might be able to visit her to check the blood sugar and give the insulin.
Everyone must be realistic. We must maintain Marcia's psychiatric health so that she can care for Jimmy. It may be unrealistic to expect tight control of her diabetes and the loss of 20kg at the same time.
Dr Nigel Stollery
'I would ask the surgeon if there is a laparascopic alternative'
In an ideal world everything would be possible. In the real world this is often far from the case and sometimes we have to accept it. For anyone, a weight loss of 20kg would be a mammoth task; in Marcia's case this is totally unrealistic.
If the surgeon refuses to operate without the weight loss, she will probably remain inoperable forever. But recurrent gallstone pancreatitis will not only make her ill, it will affect Jimmy's care.
I would once again explain to Marcia that weight loss is essential, not only to help her diabetes, but also before her gallstones can be treated. I would consider medication such as sibutramine, but probably not use it. If I did, it would depend on her blood pressure and would mean prescribing out of National Institute for Clinical Excellence guidelines. But with Marcia's record its success would be doubtful.
I would check on her compliance, her mental state and whether she had any symptoms relating to the gallstones and pancreatitis. I would ask about her home life with Jimmy.
Later I would call the surgeon to discuss her weight and our attempts at reducing it, to see if there was a laparoscopic alternative, or a way to prevent the pancreatitis. I would also call the diabetic registrar, to explain our efforts over the past five years with Marcia, and ask what else she would suggest.
Dr Michael Crawford
'How did the psychiatrist not notice Marcia's hygiene?'
Seething with anger, I must refocus on Marcia and avoid lashing out because of the correspondence. I must also say the first letter is wholly understandable, the second unbelievable and the third downright irresponsible.
No surgeon with any sense would want to be dunking for gallbladders in Marcia's fat-laden abdomen unless in an emergency. I do not feel the need to lift the phone and berate the surgeon, but as for the 'diabetologist', a short phone call may shake her into reality.
If Marcia, on maximal oral hypoglycaemic therapy with dietary advice blowing vainly over the top of her head, does not improve her diabetic control perhaps she would like to consider her for insulin.
That Marcia's psychiatric team could fail to notice her inattention to personal hygiene or, indeed, attribute it to 'non-psychiatric' condition outside their realm of understanding, would constitute an indication for verbal contact. Just how did they find Marcia? Was her hygiene up to standard that day, did she appear to be compliant with medication? If so, there has been a dramatic change.
Early review by our practice nurse is essential and a joint home visit by the nurse and myself to see her living conditions and how the cupboards are stocked may give me some insight into her situation.
Marcia needs to be advised again about her medication. Does she get confused about her tablets or is she suffering side-effects? Could we help by arranging with the pharmacist to have her tablets made up weekly?
I would let her know how seriously ill she was when admitted and say this will happen again unless she can improve her diet, stick to her medication, exercise more, get some weight off and become a surgeon's dream patient.She needs to know the risks that diabetes brings if poorly controlled. She will have heard this before, but obviously needs to hear it again.