"Juvenile" Diabetics

Holy shit... another young diabetic in crisis (physically and mentally). Very high blood sugars but no ketosis/acidosis. Bring her in before things get worse. She yells at the nurses, demands a Coke, goes out to smoke and finally refuses to use our insulin?!? She wants her NovoPen despite assurances that we use the same preparation of Novolog. My nocturnist partner okays it when the RN calls at midnight. In the morning her labs now show she is in full blown DKA (clearly a bad thing) that developed while under my care in the hospital - that will get a notice by the Joint Commission!

How did this happen? Long story short: the RN never checked how much she dialed in on her NovoPen or even whether she really injected it. Through the wisdom (or skepticism) of my 16 years of doing hospital medicine I knew the patient had created this situation, nothing else made sense: turns out that after I told her "we knew she hadn't injected her insulin" she admitted that she dialed in a few units and then shot it into the pillow. Don't teach ya this stuff in Med School do they... I also don't recall any board questions with scenarios like this.

Juvenile diabetics are some of the toughest patients to treat: they are often extremely immature and there is something about losing control of one's life (needing exogenous insulin to live) at a young age which makes them all very oppositional. I suspect having over-doting parents riddled with guilt about having "created" this situation doesn't help either (even though there is nothing the parents could've done). They whine, scream, make unreasonable demands, are often self-defeating, rarely treat their diabetes appropriately and therefore often die at a very young age.

As a final note: she left AMA later that day from the ICU in roaring ketoacidosis. I got Risk Management and Psych involved to assess competence and allow her to make the worst decision of her life. Haven't heard any follow-up so far...