Ask any insulin pump trainer if he has ever seen a pump user with inadequate training and the first response is usually a sigh. “I always think of this sign I saw once that said, ‘We fix $8 haircuts,’” says Ginger Such, RD, CDE, program director of the Indiana University Diabetes Center in Indianapolis, Indiana, after issuing the obligatory sigh.
Pump trainers tell tales of people who don’t recognize climbing blood glucose levels as a sign that their pump may be malfunctioning — even after giving themselves several doses of insulin with it. Others know of people who have developed diabetic ketoacidosis — a life-threatening condition characterized by very high blood glucose — after ignoring a “low battery” alarm at bedtime or failing to check their blood glucose level after changing their infusion set to see if insulin was indeed being delivered.
“We’ve just seen too many people show up here without any training,” says Karen Chalmers, MS, RD, CDE, an advanced practice diabetes specialist for nutrition and pumping at the Joslin Diabetes Center in Boston, Massachusetts. “They’re in and out of emergency rooms with high blood glucose levels, low blood glucose levels… They have [only] one basal rate and [have had only] one hour of training. They go around bad-mouthing the pump, and the problem is not the pump; they just don’t know how to use it.”
A particularly alarming story was told by Stephen Ponder, MD, CDE, Director of Pediatric Endocrinology/Diabetes at Driscoll Children’s Hospital in Corpus Christi, Texas, who cared for a four-year-old boy airlifted to a hospital at 4 AM because he was having seizures from a low blood glucose level. Dr. Ponder summarized the child’s situation as follows:
- The child’s HbA1c level was 10.2%. (The American Diabetes Association’s [ADA] recommended target HbA1c level for most people with diabetes is less than 7%, and the American Association of Clinical Endocrinologist’s is 6.5% or less. The higher the HbA1c, which is a measure of blood glucose control over the previous 2–3 months, the higher the risk of diabetes complications.)
- The child’s mother didn’t understand that he needed bolus doses of insulin at mealtimes, believing that the pump would meet all of his insulin needs.
- The pump’s “auto off” feature, which was activated, was turning the pump off frequently because boluses weren’t being given.
- The mother didn’t know about carbohydrate counting.
- The child was routinely having serious low blood glucose during the night and high blood glucose during the day because of incorrectly adjusted basal insulin infusion rates.
That one incident prompted Dr. Ponder to submit a resolution to the American Association of Pediatrics (AAP) Annual Leadership Forum focusing on the need to develop guidelines for the proper training of families of children with diabetes who were considering insulin pump therapy. His resolution, with some modifications, was accepted in August 2005. While physicians are under no obligation to adhere to policies set forth in resolutions and position statements, “Plaintiffs’ attorneys love to use them during depositions,” says Ponder.