I hate memorising things – even something as straightforward as the Glascow Coma Scale. Fortunately there are plenty opportunities for me to practise the important things in the clinical environment.
The first time I had a patient with an obviously lower than 15/15 grading the patient was in her early fifties and referred from an old-age-home. Note the discrepancy here. Her grading was M5, V2, E2 with a total of 9/15. In other words, she localised pain but could not obey commands, made noises but no words and opened her eyes only to painful stimuli.
She was known with epilepsy and hypertension, but when she was found unconscious by her caregivers her rapid glucose displayed only “Hi” – in other words, higher than 30mmol/ℓ. They administered Actrapid and sent her our way. When she arrived at hospital her glucose still displayed “Hi” and we administered more Insulin while rehydrating her.
The bloods drawn for a formal HGT read 74mmollℓ. She had high ketones in her urine – not high enough for the sickly-sweet ketotic smell.
This patient had no previous history of diabetes, yet she had DKA or HONK (hyperosmolar non-ketotic coma). The truth of the matter is that these complications of diabetes do not simply arise overnight.
Whatever the reason for her being admitted to the care-facility (we later saw that she had some cognitive developmental issues), her family clearly wanted her to have a good standard of care. The fact that she had to slip into a coma before they even checked her glucose means that the care she was given was decidedly sub-standard.
I won’t go into the details here, but upon placing her urinary catheter this was confirmed to be so.
In trying to get a collateral history from her sister – I was trying to ascertain just how conscious the patient usually was, considering her epilepsy-medication was Phenobarbitone – it dawned that the sister hadn’t seen her in months.
We are said to have humanity because unlike a great many animals, who don’t merely get rid of the weak: we find ways to help them flourish, or to help them live their last days in dignity. It did not really seem to be the case here. I must remind myself to remain non-judgmental.
Many disease processes are not preventable. A healthy young man dies suddenly of a heart-attack, while an obese one lives well into his eighties. A young baby suffers epilepsy and in one attack the oxygen deficit causes permanent brain damage.
But this episode was preventable.
Our patient recovered well and her sister decided to take her out of the nursing home. A week later, when they came to collect the glucose-monitor, our patient was dressed in new clothes and her hair was clean and cut. She waved at us, smiling her half-toothless smile. Childlike, you could say.