Boys,
What a bit of excitement! David gave Gregory a shot of 30u of 'nothing'.
With syringes, you can inject air; in fact, when you intend to remove insulin from a vial you are instructed to first inject a volume of air equal to the amount of insulin you intend to remove.
Being the bad person that I am, I usually inject a few hundred units of air at a time and then only draw up the syringe with insulin when the pressure inside is enough to start pushing the plunger out. I don't go past this point since I assume that with enough pressure the top will eventually pop just as the cartridge did when Gregory went to camp 3 hours away.
With insulin pens, there is a bottom that moves according to the pressure of the contents. Since I frequently mix insulin for you guys since you aren't quite 'there' yet, I will draw out of an insulin pen leaving a gap between the bottom and the screw that forces it out.
So, first let's assess if this needs to be addressed immediately:
RISK ASSESSMENT: Priority
Is it important to tell someone when a mistake happens with Insulin?
YES! First, you simply do not have enough education nor experience to know what will kill you and what won't kill you. Until you do, you need to know who you are going to immediately ask, "Will this mistake kill me?" If in doubt, 9-1-1. No, I am not kidding nor exaggerating. Today, I was your GOTO person.
As your GOTO Person said, if you inject enough air and it hits one obscure bad path, you can die from an 'embolism' so it is worth the time to assess your risk of embolism.
RISK ASSESSMENT: Embolism
What is an embolism? In medicine, an embolism (plural embolisms; from the Greek ἐμβολισμός "insertion") refers to the lodging of an embolus, which may be a blood clot, a fat globule or a gas bubble in the bloodstream, which can cause a blockage.[1] Such a blockage (vascular occlusion) may affect a part of the body distanced from the actual site of the embolism.
How confident are we that air was injected into Gregory?
As we finally determined, We are confident that air was NOT injected into Gregory. Why? Because David was able to queue up more units and it was still air.
AWESOME! Gregory gets to live to see another day! T1D wiped us a few times this go, so let's check the combat log and learn something.
CHECK THE COMBAT LOG & LEARN SOMETHING:
When Gregory was in the hospital, several different professional T1D trainers explained that the biggest danger of air in the syringe is that it displaces insulin so there will inevitably be a high BG. That was reinforced during the annual pede T1C lectures through KP. I seem to remember that it is also apparently quite painful. That said, someone always ends up winning the lottery and every year someone gets struck by lightning so it could be you! What precautions should we take?
HOW DID THIS HAPPEN?
First, it's always my fault. I pulled a job too big and the group wiped. Tank's fault.
I set us up for this problem by adding variety to our routine and mixing insulin to halve the number of shots you get.
Also, I usually triple check you double checking each other. In fact, I think this was the first time I purposefully didn't. The wipe means my job of triple checking isn't complete yet.
David should have caught that the plunger was not flush against the insulin when he double checked.
Gregory should have done a safety shot where he would have noticed the problem because insulin didn't come out.
RISK ASSESSMENT: RECIDIVISM
What is RECIDIVISM? Recidivism (/rɨˈsɪdɨvɪzəm/; from recidive + ism, from Latin recidīvus "recurring", from re- "back" + cadō "I fall") is the act of a person repeating an undesirable behavior after they have either experienced negative consequences of that behavior, or have been treated or trained to extinguish that behavior. It is also used to refer to the percentage of former prisoners who are rearrested for a similar offense.
There is a reason we do safety shots. There is a reason we double check queued shots. There is a reason I've been triple checking you double checking each other. And finally, there are reasons that I want you to not need me to be triple checking your double checking.
I think that the Recidivism Risk is HIGH until we have BGs more consistently in a healthy range and a better system for meals.
Therefore, I need to keep triple checking stuff.
GAMBATTE!
-mom
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