Abstract
Sam
17-year-old male
As I enter the room, the tension is palpable. At the conference table sits Mom, checking her iPhone, Sam slumped in a chair angled away from her with an empty chair in between them. Sam’s head is down, Yankees baseball cap pulled over his eyes. Mom acknowledges me. Sam never raises his head.
The BG download from his meter that I had printed and quickly gone over before coming into the room is a picture I had seen many times. Not enough insulin at some meals combined with overcorrection for highs, which triggered a deep dive into hypoglycemia and the reason for the urgency of this visit—a trail of high blood glucose levels leading to Sam’s last hospitalization for DKA.
The clinical pharmacist side of me sees an obvious fix; get this guy off a twice-daily premixed insulin and onto multiple daily injections, carb counting, correction factors, and eventually onto an insulin pump.
But years of experience as a CDE are telling me that this is only half the equation or less. The long-term answer is getting the Yankee cap to rise.
As I ask the obligatory interview questions, Sam gives me one-word answers with Mom doing the elaborating.
“So Sam, what do you think brought this last DKA episode on?”
“I dunno. I think maybe I got busy and missed a dose of insulin.”
Mom helps out. “What he did was stayed over at a friend’s house for the weekend. They ate a lot of pizza and junk food and he went off with an insulin pen that was empty. I packed up everything for him and reminded him twice to be sure and check, and when he came home on Sunday night sick I got that out of him.”
Sam slumps down further, shoulders up and hat down. At this point I actually welcomed the empty chair between the two of them.
As the conversation continued, I could tell that every word from Mom’s mouth was like fingernails on a chalkboard to Sam, and it is just not helping. I subtly and then not so subtly ask Mom to let Sam answer my questions. I then point out the good days Sam has had along with the not so good ones and ask him what took place with each. I get nothing.
Where to go from here?
Doing a quick rescan of his self-assessment form I find his contact information to include his email:
“So are you a baseball guy?”
“Yeah.” (Head no higher than before.)
“Yankees man?”
“Not really. I like ’em. This was my summer team last year.”
Signs of life. Think I see the hat move.
“You play on the high school team?”
“I did. Just got too weak and couldn’t hold up. Had to quit.”
I considered this part 911-care to keep Sam out of the ED and alive while we worked on all the other facets. For one thing, with teenagers the work often begins in earnest but the novelty can wear off quickly.
“Well that’s something we have in common, Sam. Baseball’s my thing. Went to spring training for 7 years, caught some big league pitchers and even batted off a couple. Man, you can hear the ball coming when those guys let go! I had a good friend that pitched in the bigs so I went with him. Got to hang out with Nolan Ryan, Roger Clemens, and some other guys you’ve probably heard of.”
“You know those guys?” Hat comes up a full 90 degrees and stays there.
“Not as well as I would like to, but they are a good bunch of guys. I could tell you some stories about ’em but I would have to kill you.”
Thirty minutes into the session and this is the first true show of emotion. I have my opening.
“Sam, what if we could get you back out on the ball field again?”
I see full-on concentration now. “I guess I want that as bad as I want anything right now. Center field in the summer league. We were city champions last year.”
“I think we can make that happen. It’s going to take some work, but it starts here. Want to make that our first goal?” I held up an insulin pen, and he nodded his head.
Home run.
Coming out of that meeting I knew there were a lot of issues to cover. I considered this part 911-care to keep Sam out of the ED and alive while we worked on all the other facets. For one thing, with teenagers the work often begins in earnest but the novelty can wear off quickly. We also had issues with Mom, with Dad, and with Sam’s social life to contend with. If nothing else, 3 episodes of DKA in 1 year told me he needed psychological help as well as a redo of diabetes self-management training.
This was a start. I knew that Sam didn’t care about his A1C at that point, or his day-to-day BGs, or even about his school work as much as he cared about getting back to baseball.
Sam and I became partners in getting him to reach his goal. And in working to reach the goal he wanted, he stood a much better chance of achieving the goals he needed to be healthy.
Webster defines a partner as “the other person in a dance.” My thinking is that you’ve got to get them to the dance before you can teach them how to waltz.
Sam and I had begun to dance. ■
Footnotes
Jerry Meece, RPH, CDE, FACA, FAADE, is director of clinical services with Plaza Pharmacy and Wellness Center in Gainesville, Texas.