七十五歲的陳婆婆已經有糖尿病八年，最近更引起了腎功能衰竭。 口服的降血糖藥經已無效，所以必須要每天注射胰島素。 以她這個年紀來說，她的「血糖中位數(HbA1c)」 最少要壓到7.5才叫做合格。 可是，她過往幾年的血糖中位數卻一直高据9 度不下，最新一次的還高達11.3 度。 她對醫生說，每天也有自己注射胰島素，很「聽教聽話」。 然而，血糖中位數是可以反映病人於過去三個月的血糖有否好好控制的。 婆婆那些不合格的血糖中位數，很叫人懷疑她是否真的有乖乖的注射針藥。 有一次覆診的時候，醫生要她即場「篤手指」滴血來驗，血糖竟然高達33.1度，直迫血糖中毒的危險界線，於是，醫生馬上要她入院治療。 理論上，我們是應該為她打胰島素點滴的，但醫生故意不打點滴，就照原來在覆診中開給她的血糖針劑量來打，目的是要試試她有否撤謊。 當打針的人換了是護士時，她的「篤手指」血糖在短短6小時內便降至6.9度的合格水平。 如果她在過去三個月，真的有每天遵從醫囑去注射，照道理血糖中位數應該只有6-7度左右。(＜新英格蘭醫學雜誌＞310(6):341-6) 但是，我們也不能夠太早對婆婆有否撒謊莽下定論，最少，也要找些可以解釋和改善的理由：「是否抽錯了劑量？是否打針的技巧不好？」 然而，在糖尿病專科的護士面前，她卻可以很清脆俐落地打好一支胰島素針。 當醫生嘗試旁敲側擊地問婆婆「你是否真的有打針？會不會有些時候沒有了？」的時候，她的反應很強烈，強調自己一直也有依時依候打針，更拿出一張自己做的「功課」，列出過往自己在家「篤手指」的血糖紀錄，辯稱過往幾個月來，自己的血糖全都低於7度。 醫生鍥而不捨地去請教化驗科的醫生，「血糖中位數會不會有機會出錯呢？即是，比正常的高了？」 答案是：除非病人有溶血性貧血或者鐮刀狀細胞症，否則很少很少機會出錯。 這個答覆進一步證明她的而且確在說謊。 婆婆有兩個孩子，現都長大成人了。 想必在孩子還小的時候，她有教過孩子做人要誠實吧？ 我相信，在我們的小時候，也曾經為掩飾自己的過失而向老師或長輩說謊吧？ 父母想孩子「聽教聽話」，而孩子卻「扭計」；醫者父母心，我們眼前的這位婆婆，可以稱得上是返老還童吧？ （為了好說故事，小弟把兩個病人的故事二合為一。）
Mrs Chan is a 75-year-old lady, with a history of diabetes mellitus for eight years and developed nephropathy recently. Oral hypoglycemic drug failed to control her condition and insulin injection has been started for two years. Her HbA1c level raised to 11.3% in the latest check up. The level stayed well above 9 throughout the years despite several increment in insulin dose. She claimed to be compliant and do the injection herself every day. In one follow-up the physician have a spot check of blood glucose by H'stix and it turned out to be 33.1 mmol/L. This necessitated an urgent admission since she was at the edge of developing hyperosmolar non-ketotic coma. Normally she would have been put on sliding scale of insulin, however, the physician deliberately ordered regular insulin injection this time, in the same dose as prescribed for her home injection. You know what, when the same dose of insulin was injected by the nurse but not Mrs Chan herself, her glucose level returned drastically to 6.9 mmol/L within six hours. If she had really injected the same dose of insulin for the past three months, her HbA1c should be around 6-7% only. (NEJM 310 (6):341–6.) Everyone is innocent until proven otherwise. Is it due to drawing the wrong dose into the syringe, or due to her poor injection technique? She was referred to the diabetic nursing specialist for inspection of skills, and a nice injection was demonstrated to the nurse successfully. The doctor further probed if she was really skipping the insulin, and she strongly denied it. She also refuted his argument by showing a "homework" of home H'stix blood glucose monitoring - all the values were well below 7 mmol/L. The painstaking doctor consulted the chemical pathologist, if there is any condition that HbA1c can be falsely high. The reply was, "If the patient is not suffering from any haemolytic anaemia recently or having any haemoglobinopathy like sickle cell disease, there shouldn't be any errors." This further comfirmed that this lady was making up those figures. She is a mother of two. I bet she must have taught her children to be honest. I also bet when we were young, we must have lied to our parents and teachers to conceal our fault or laziness, etc. Yes, we know that she is actually lying. But what can we do? I agree that this is a kind of rejuvenation, are you convinced? (I merged the stories of two non-compliant patients into one for convenience of story-telling. ) |