Monday, November 24, 2008

The Line Between the Two

I've been thinking about the concept of using CGM's in the hospital and have come to the conclusion that that there is just no way it could EVER work.

Patient "M" is extremely sick, in the ICU. Patient M's blood sugar is going up and down like a pregnant women on steroids. Patient M could really benefit from stabler bgs and fewer hypos. Patient M, however, is being pumped full of acetaminophen/narcotics and that pretty much voids out the usefulness of a CGM.(acetaminophen makes the moniter read HI) Throw in the occasional (or not so much,if they are in the ICU they might have a few of those) MRI and the staff had better remember to remove the sensor or the patient will be dead. (due to the metal in the sensor) You think about the lawsuits waiting to happen, it's rare for staff to be acquainted with pumps, let alone CGM's. (I have a question for anyone who has ever been
in the hospital, with a pump...assuming they even permitted you to continue using it, did they even ask if you were changing the site every 2-3 days? I don't, so it doesn't disturb me,but many people are prone to infection + that needs to be addressed. Breeding ground to further issues, is the pump site infection.)
And for infection prone patients, it is something else for the staff to forget. (changing it occasionally) In its current form, CGM's would be a headache for use in the hospital setting. I'd far rather have frequent bg checks then rely entirely on the CGM it is a good thing that there are many more type 2's then type 1's in the hospital or even more staff would be required.(so I think) There are so many D's in the hospital, they make up like 2/3 of the patient population.(according to Diabetes Forecast) The CGM is a very valuable tool, but someone has to be following it, tweaking, looking at patterns and another characteristic of non-endocrinologists is they are REACTIVE,(aka the "sliding scale") rather then proactive. I realize I'm lumping all of them into one generic group but its a case of guilty until proven innocent. Until someone demonstrates their D-savvyness, I do not assume that they've got it. And I would not use a CGM without meter confirmation. A CGM, does not replace the need for meter monitoring.

I think the answer lies in being more proactive with management, rather then the highly unpractical, time-consuming, expensive CGM. How about an insulin pump or IV insulin drip rather then then NPH/Regular shots?(for starters) Or how about not serving juice, jello, and various other high glycemic foods to skyrocket the patient's blood glucose even more? The goal is to prevent complications, not encourage them. I'm not sure things will ever improve, to where they should be, even in the enlightened hospitals. I wish I could tell this to a few hospital CEO's, better blood sugars translate into money(and lives) saved.


Bernard said...

I heard a rumor (not very strong one) that Dexcom is working on something to screen acetaminophen from the measured fluid so that readings wouldn't be affected. I do hope this is in a future version, because acetaminophen is the only pain killer I can use.

You raise some interesting concerns. But the market is lucrative enough that I'm sure they (Dexcom) will be working to address as many of these as possible.

Sara said...

I have waaayyy less medical knowledge than you, but I have been wondering basically the same thing.
I have seen the meters they use, and heck, even the 'outdated' insulin they are using and I can't imagine most doctors having the understanding of the most accurate usage of the CGM devices.

I didn't even think of the whole MRI issue! :)

Did you see the recent episode of ER where they didn't switch the gurney?

Christine-Megan said...

I think if we see CGMS in the hospital it will be via intravenous monitoring of actual blood, not the subq interstitial monitoring we see now.

Anonymous said...

^^ nice blog!! ^@^

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