Sweating the small stuff

Recently I have been reading Canadian astronaut Chris Hadfield’s excellent book, ‘An Astronaut’s Guide to Life on Earth’. In it, he writes about how important it is in space exploration to ‘sweat the small stuff’. He gives an example of how a crucial and expensive spacewalk was almost ruined and his life put at risk simply because he didn’t polish his visor enough. It has got me thinking about how this might apply to general practice.

One regular patient with diabetes has been struggling immensely with her blood sugars. She’s on insulin, and it seemed that for some reason her sugars were always high and making her very unwell despite the fact that she took her insulin regularly and engaged fully with the practice’s diabetes team. We were puzzled why this ‘ideal’ patient wasn’t getting better (which, of course, included a fully introspective and CPD-accrediting multidisciplinary review as to whether her personalised treatment package met NICE and local formulary guidance and considered input from specialist virtual clinics whilst meeting the patient’s choice and expectations and was cost-effective – in ten minutes).

She rang one duty surgery and was unfortunate enough to receive me as duty doctor.

‘Doc’ she said, ‘I don’t feel very well.’

I looked wistfully at my otoscope, ‘Tell me your thoughts, your fears, your worries.’

‘Well…’ she began,

‘Actually what’s your blood sugar,’ I interrupted.

‘It says “HI”,’ she replied.

‘Ah,’ I thought, aloud. ‘What do you normally do when it’s high?’ I find this an excellent question to ask most people who live with a chronic disease who often offer very sensible suggestions.

‘Well I do what I always do. I eat a bag of jelly babies,’ she replied.

‘Bloody hell,’ I thought, inside my head this time.

‘What’s wrong doc? You just said bloody hell down the phone! I was always told when I have a hypo I should eat some jelly babies, so that’s what I do.’

What was happening, as you have probably guessed by now, is that she had mistaken ‘HI’ to mean ‘HIPOGLYCAEMIA’ [sic] and took the action we would have told her to do at every diabetes review.

It turns out then, this one small piece of the puzzle was having a huge effect on her health and no-one had thought to consider it. It appears that ‘sweating the small stuff’ can be very important indeed, whether in space or in the surgery.