Notes from the On-Call Endocrinologist
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Day and Night of Diabetology
Serious and humorous moments are encountered at every step in the work of a pediatric endocrinologist.
The two hospitals where I attempted to manage diabetes in children and adolescents were complete opposites of each other.
The first clinic, a deeply academic, leading institution in the field, where only experienced diabetes patients were admitted, never newly diagnosed cases, was a place I visited during the day. Each patient had 2–3 doctors, not counting the on-call physician, senior and chief scientific researchers, and resident doctors. They approached endocrinology very thoughtfully, installing insulin pumps and sensors, conducting clinical trials of new insulins, staying up-to-date on the latest global diabetes news, and organizing and participating in congresses, training sessions, and schools. Everything there was planned in advance, scheduled, and surprises were rare. Most of the families of our patients were well-informed, motivated, and consciously striving for diabetes compensation.
My night shifts took place in a ward on the second floor of another hospital, with the E.R. on the first floor, where a constant carousel of ambulances was spinning. In the best-case scenario, the on-call endocrinologist was called to the emergency to admit newly diagnosed diabetes patients; in the worst-case, they went to the intensive care unit to consult their endocrinology patients, write insulin therapy recommendations for the on-call resuscitators, and a few days later, they would receive an improved version of the patient who had been brought out of ketoacidosis. Parents of children with a newly diagnosed serious illness were in shock, unprepared for the lifestyle change for the entire family, and knew little or nothing about diabetes. They grasped at elusive chances, protested, and bargained with fate.
It would be tempting to compare the two clinics to determine where diabetes is better managed, but that’s impossible. Each clinic excels in its own time. The second clinic is like a real emergency service, where patients are rescued, brought out of ketoacidosis, and prescribed insulin therapy for newly diagnosed Type 1 Diabetes. Parents and children are given their first lessons. From there, parents who quickly and efficiently learn to manage on their own, or are less concerned about diabetes compensation, may remain within the city healthcare system. A smaller portion, already equipped with basic knowledge, find their way to the academic institute (the first clinic) and continue refining their compensation under the guidance of scientific staff.
Buns vs. Science
In the explanation of the doctor leading your first diabetes school, everything sounds clear and logical: evaluate the carbs on your plate, measure glycemia before and after eating, calculate the number of insulin units, and compensation is in the bag. Not quite! The novice diabetologist faces many bumps and potholes along the way. You follow the instructions, but the glucometer or sensor screen shows values far from the target!
I faced this sad reality as the attending resident doctor of a smart and charming teenager with a long history of Type 1 Diabetes in an academic institution. With a pre-meal glucose level of 5 mmol/L (90 mg/dL), we eat 40 grams of carbs and administer 4 units of fast-acting NovoRapid, and the expected post-meal result should be 7-8 mmol/L (125-145 mg/dL). But the math wasn’t adding up! Time after time, I saw glycemia at 10 or 15 mmol/L (180-270 mg/dL). Occasionally, for variety, we'd get the right numbers or even hypoglycemia, preventing us from calmly increasing the insulin dose for lunch. I racked my brain, changed injection sites and insulin cartridges, and checked her plate in the cafeteria. Everything else was fine — her morning and nighttime sugars were on target, there were no complications, but I couldn’t discharge her because of the uncontrolled daytime sugar spikes. I was tired of the cycle of ‘adding or subtracting 1-2 units of insulin for meals’.
The mystery was solved simply. Like any academic institution, we had a cafeteria for staff and outpatients, where my patient secretly bought sweet buns from the kind cafeteria ladies. It all ended predictably. Rushing to my night shift at another hospital, hastily cramming my coat and stethoscope into my bag, I ran through the lobby when I spotted my ‘responsible’ girl munching on a poppy seed bun. Around her, adult patients and their relatives were sitting, academically discussing their health problems and achievements. I didn’t have time to deal with it, so in front of the shocked audience, I snatched the half-eaten bun from the hungry child, grabbed the bag with a couple more buns for later, and dramatically exclaimed, ‘How could you? I trusted you! Tomorrow morning you're discharged, out of the hospital!’ I ran to my shift, only to discover the bag of buns in the subway. Waste not, want not!
The next morning, my patient and I made peace. We agreed that she would give herself and me an ideal glucose profile for two days so I could discharge her, and we laughed, remembering the unforgettable House M.D. with his "Everybody lies!"
In the future, Occam’s Razor principle worked in most cases, but there were still medical histories that didn’t fit into it.
Diabetes Undercover
Here’s another case that shows us that parents, who are committed to managing their child's diabetes, definitely know more about the progression of the disease in their family member than the doctor, who sees the child once a year during a scheduled hospitalization.
There was a boy who was diagnosed with Type 1 Diabetes before preschool, and by the time he reached puberty, he knew everything about compensation and could manage it, but he had no motivation to follow the doctor's recommendations or understand the risks of long-term complications. During a routine daytime hospitalization, a very strange situation emerged: his glycemic profile looked good, but his glycated hemoglobin was extremely high, and neuropathy had already begun. How could this be? The glucometer memory showed genuinely good readings. The boy’s mother conducted an investigation after she noticed that the family dog had started to avoid him.
Have you guessed it? The boy was taking blood from his dog so that his parents wouldn’t scold him for high blood sugar. Half of the glycemic profile readings didn’t belong to Homo sapiens.
Twice the Trouble
In the article on hypoglycemia, we mentioned that glucose is normally absent in urine and only appears when the renal threshold is exceeded, i.e., when blood glucose concentrations are higher than 8-9 mmol/L (145-160 mg/dL). The renal threshold varies individually, but overall, the presence of glucose in urine ("glucosuria") is an unfavorable sign. In the recent past, glucosuria was a reliable indicator of decompensation of carbohydrate metabolism and diabetes.
A teenage girl was admitted to the hospital with suspected Type MODY 3 Diabetes. Her blood glucose wasn't that high, at 6.9 mmol/L (124 mg/dL), but concerning glucosuria reached up to 18 mmol/L (324 mg/dL). Through a careful medical history, the story of her illness unfolded, the diabetes diagnosis was ruled out, and the clinical diagnosis of salicylate poisoning was confirmed. The key factor was that aspirin poisoning (acetylsalicylic acid) can cause elevated blood glucose and a lowered renal threshold, leading to glucosuria at lower blood glucose concentrations than normal. This is what happened with our, or rather not our, patient after taking a very high dose of aspirin due to a psychologically stressful situation (a quarrel with a friend).
The phrase "careful medical history" hides the details that didn't make it into a formal medical article describing the clinical case, but which played a crucial role in the correct diagnosis. The girl's mother mentioned to the attending physician that there was an "epidemic" of diabetes in the family: both her daughter and their cat were diagnosed at the same time. Even the cat had a diabetes diagnosis based on glucose in the urine test! And here, once again, Occam’s Razor comes into play: don't multiply entities unnecessarily! The cause of glucosuria in both family members was the same; the girl, wanting to take her beloved pet along with her, had given the cat a pill as well.
The happy ending to this story is perfect in every way for me: a sensitive, loving mother who cared for both her daughter and her cat, and an attentive and knowledgeable doctor who worked together to find the correct answer in a complex and rare clinical situation.
"GMO-Free" Insulin
This is yet another illustration that not all doctors are experts in every field of medicine. Therefore, parents of a child with Type 1 Diabetes must strive to understand all recommendations themselves rather than follow them blindly. It’s crucial to study and understand the course of diabetes in their child. Doctors must also regularly update their knowledge, attend conferences, and read articles beyond their specialty. Completing medical school years ago does not guarantee up-to-date knowledge in a field that evolves rapidly—outdated treatments and notions about diseases are replaced by new, progressive medications and methods.
One evening, a teenager with newly diagnosed diabetes was admitted to the hospital in moderate condition. Nothing too serious: an IV was set up, ketoacidosis was managed, and the treatment plan was NovoRapid plus Lantus. The boy was already asleep in the ward while I was finishing the day’s medical documentation. It was nearing 2 a.m. when a very determined woman — his mother — burst into the resident’s room, demanding the best, most progressive pork insulin for her son.
At first, I was taken aback. Pork insulin was considered progressive 100 years ago, but since then, we’ve added a variety of human insulin analogs to our arsenal, engineered through bioengineering methods with well-known pharmacokinetics that don’t cause severe allergic reactions. It was like someone demanding that I treat a festering wound by blowing red streptocide powder into it instead of using antibiotics! She wouldn’t accept analogs (which she saw as “counterfeits”) and insisted on natural, original GMO-free pork insulin ☺. I spent the entire night persuading her, showing her textbooks, guidelines, prescription sheets of all the other patients in the department, and the refrigerators with insulin. By morning, she was convinced, trusted me, and went to work.
It turned out that the mother worked in an office with a medical station, and when the doctor there learned that her colleague's son had been hospitalized with Type 1 Diabetes, she advised, with the best of intentions, to demand only natural pork insulin. Apparently, this doctor hadn’t updated her knowledge of diabetes since her med school lectures, so the advancements in treatment over the past 30 years had passed her by.
Why do I remember these cases for so many years? Probably because, in the end, like in a fairy tale, each has a moral. “The road will be mastered by the one who walks it”: patients, parents, and doctors who are determined to manage diabetes will undoubtedly reach their goal.