You have made a point of checking your blood glucose and getting your annual eye and foot checkups. You track your blood cholesterol and blood pressure. But now the pain in your hip is unbearable and interfering with your walking program, so your doctor suggests hip surgery. You will be admitted to the hospital for hip surgery, not diabetes.
You will likely end up on a medical floor staffed with skilled nurses experienced in orthopedics, not diabetes. The surgeons are skilled and experienced in repairing joints but are generally less skilled in the newer therapies for diabetes.
Diabetes Takes on a Whole New Dimension When You’re Hospitalized
Unfortunately, diabetes cannot be checked in and kept in a safe with your rings and cell phone, and unlike your cat, you cannot ask a neighbor to take care of your diabetes while you are in the hospital!
Diabetes is one of the most common chronic conditions in the United States. The prevalence of diabetes has increased greatly over the past decade, affecting 18.2 million of the U.S. population in 2004.
Now add the fact that we are an aging population incurring the usual hospitalizations, such as those for orthopedic surgery.
Despite these startling statistics, most hospitals lack referenced protocols for institutions when caring for patients with diabetes. In fact, the proliferation of newer medications, testing devices and delivery devices, coupled with the promoted “patient in the driver seat” individualized approach to diabetes management make for a hospital protocol nightmare. Shared decisions are commonplace in the outpatient medical arena, but written orders are the law of the land in the hospital.
There’s no need to cancel the surgery, just as there was no need to cancel the Caribbean cruise when you first learned you had diabetes. Like other events you have weathered, you can get through the surgery with a little planning.
Adopt a ‘Wedding Planner’ Mentality
Let’s start at the beginning of a typical planned hospital event. Start by establishing the day of surgery and get out your notepad dedicated to the “event.” Start early! Don’t wait until the day before to call your internist to ask for dosing instructions.
Many patients assume doctors talk to each other about patients. Patients assume their internist has called the orthopedic surgeon with instructions, but this is rarely the case.
Make sure you have a list of all your medications, insulins, timing, doses, correction formulas and devices in your bag.
Carry your glucose meter and ketone strips with you. If you assume that the hospital staff will take care of all the arrangements regarding your diabetes, you are in for a surprise. At best you will be sadly disappointed and at worst may end up staying longer while staff wrestles with “poor blood sugar control.”
Don’t Assume All Medical Professionals Know About Diabetes
As you might expect, you will need an individual plan. However, there are some common general guidelines that often appear for patients admitted to hospitals.
You may be asked to stop taking aspirin at least two weeks before the surgery. While the current American Diabetes Association Clinical Practice Recommendations support consideration of aspirin use for cardiovascular disease prevention for adults with diabetes, stopping aspirin ahead of time is definitely doable if advised by your physician.
Next, you will be asked to fast, that is, absolutely no food or drink after midnight the day before surgery. Not eating at midnight is not a problem, but what about breakfast? Should you take your bedtime insulin dose of NPH, Lantus or Ultralente?
What if the surgery is delayed and the IV isn’t started until 9 a.m. or later? Will the pre-op team know to check your blood glucose?
These are good questions to ask your surgeon. Most people assume a medical doctor is well-versed in all disease pathology, while in fact many surgeons lament not knowing more about the newer developments in diabetes care.
Typically, nursing education is devoted to learning the pathophysiology of diabetes, but unless an RN has made a point of keeping up on current diabetes care, Lantus is the name of a submarine, not a new insulin!
So you will need to be your own advocate and also the staff educator. This is best done before you are sedated!
Write down your typical testing regime, and be sure to describe how you react when your blood glucose is low. For instance, one person might write that she tends to ramble without making much sense, while another person might write “cranky and irritable.”
What About Food?
While in the hospital, clear liquids become noncaloric, as you will likely be given diet gelatin, sugar-free soda, no-calorie broth and sugar-free Popsicles.
While you understand that these products have no caloric value, nurses consider these to be food, and they will follow medication administration orders. This could mean you will be given your regular dose of antidiabetic medication or insulin.
Think about this scenario: Imagine you are given your regular dose of anti-diabetic medication, but the only food you are consuming has no actual food value, and the next check of your blood glucose is in four hours! As you break into a cold sweat, struggling to focus, shaking to reach for the nurse call light, you say, “I think my blood sugar is low.” Your nurse asks if you are having chest pain, listens to your heart, then leaves you to go get the hospital’s glucose meter. Meanwhile, you become more confused; it seems as if the nurse must have taken the scenic route.
Finally she returns, the glucose monitor goes through a systems check, and the nurse punches in her identification number, then your identification number, and by now you are unable to recall your name, but you remember vaguely that your nurse panicked as she read 40 on the meter. Hurriedly she leaves the room, returning to give you either orange juice, or cranberry juice, followed by a glucose gel and maybe even intravenous glucose. You overhear nurses in the hallway muttering about “brittle diabetics.”
Think that this would never happen in your modern hospital? Don’t take the chance.
Use the suggestions in this article to prepare for your surgery. As we all know, self-management means never assuming someone else will take care of us. This also applies to any planned admission to the hospital.
Christine Olinghouse, MPH, RD, RN, CDE, BC-ADM, is a diabetes educator at Emanuel Children’s Diabetes Center and a part-time hospital staff nurse for Kaiser Permanente in Portland, Oregon