Recently, an elderly female patient with a 10-year history of diabetes experienced suboptimal glycemic control despite being administered multiple oral hypoglycemic agents. She complained of persistent thirst, fatigue, unexplained weight loss, and general malaise. Her fasting plasma glucose level stood at approximately 17mmol/L, while her postprandial blood glucose was measured at 28mmol/L. Additionally, her Hemoglobin A1C was recorded at 13.4%, indicating a range of chronic complications, which led to her hospital admission.
During her stay, she was put on a 'three short and one long' insulin regimen, comprising insulin aspart injections before each meal and insulin glargine before bedtime. Under this treatment plan, her blood glucose levels began to decline steadily, accompanied by improvements in her mental state and physical strength, along with effective control of her fasting and post-meal blood sugars. Following three days of close monitoring and stabilization of her glucose levels, she was discharged from the hospital.
However, within less than a week of being discharged, the patient was readmitted due to severe hyperglycemia. At the clinic, her random blood glucose soared to 30mmol/L, with symptoms of thirst, fatigue, and discomfort resurfacing. The attending physician meticulously questioned her to identify the cause behind her recurrent condition—whether it was an infection or other stress factors, immoderate eating habits, insufficient physical activity, discontinuation of concurrent oral anti-diabetic medications, inadequate or missed insulin doses, insulin potency degradation due to improper storage temperatures, or the use of corticosteroids. The patient negated all these possibilities. Upon re-admission, the 'three short and one long' insulin regimen was reintroduced, swiftly restoring her blood glucose levels to a manageable range.
The doctor remained perplexed by the sudden spike in the patient's blood sugar levels. Together with the patient, they meticulously scrutinized every aspect of her treatment, eventually uncovering an issue with the insulin injection process itself. Up until the "dose selection" stage, the patient had executed the procedure correctly, including attaching the needle, adjusting the insulin cartridge, and priming the pen. However, at the critical step where the dose selector should be pulled out and rotated to set the desired insulin dose (as depicted in Figure 8), the patient inadvertently turned the unscrewed button back to its original position, effectively resetting the dose indicator to zero. Consequently, no insulin was actually administered, which resulted in a dramatic rise in her blood sugar.
In clinical practice, healthcare professionals often encounter a myriad of unexpected issues and complexities. Despite providing thorough, step-by-step instruction to every insulin-injecting patient until they demonstrate proficiency, patients occasionally encounter difficulties when administering the injections independently. Therefore, it is imperative for medical staff to remain patient and meticulous, allowing patients ample opportunities to practice until they become adept at the injection technique. Patients must also be educated to regularly monitor their blood sugar levels and promptly notify their healthcare providers in case of inexplicable fluctuations. Failure to do so could result in significant under- or over-dosing of insulin, which can lead to irreparable health consequences, with potentially life-threatening outcomes in severe cases.