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Administering insulin by injection

For diabetics who are going to need insulin, it is usually necessary to admit them to hospital for a day or two for what is called 'initial stabilization'. Insulin is dramatic in its blood-sugar-reducing effects and its dosage has to be carefully tailored to the individual's needs. Blood-sugar estimations have to be made, perhaps three or four times a day at first, during the first few days of insulin injections. This is to make sure that neither too much nor too little insulin is given.

The problem with the stabilization of diabetes is that it is all, once more, a question of balance. Some years ago, when the routine with newly diagnosed diabetics was to admit them to hospital for a fortnight or so, what was then achieved was a good balance of insulin against food intake for the individual living the life of a hospital patient. They would then be discharged home from the ward, excellently controlled, but as soon as they were at home there was shopping to be done, housework to cope with, going to work and all its demands, or attending school in other words, a huge increase in exercise demands by comparison to the fairly sedentary life of being a hospital patient. Exercise can double, treble and quadruple the amount of energy the body cells need and so the blood sugar can drop. Because of the insulin, or the tablet, being taken daily, the blood sugar would then fall even below the normal fasting level and the patient would feel ill, collapse and perhaps even lose consciousness. This 'hypo' reaction, as it is called, would then mean the patient's readmission to hospital and balancing would have to start all over again.

Nowadays in many areas the hospital policy is different. Patients are only kept in the ward for a few days while the necessary blood tests are done; then, as soon as they feel they understand the problems of diabetic control, they are sent home each day to return in the evening. After a few days they are allowed to stay at home for the night as well, to self-inject and to simply attend the hospital each morning for the check of a blood test. Once they are following as normal a life as possible with dose and diet keeping them in reasonable balance, they are discharged, and appointments are simply arranged for routine follow-ups at the hospital out-patient clinic. In the intervening period their family doctor will keep a check on their health and advise with regard to any changes that are necessary, according to the evidence of the urine tests.

The diabetic who is dependent on insulin has to learn to self-inject. At first, this is the most frightening aspect of it all the idea of sticking a needle into oneself one or even two times a day can be terrifying to some people and it can be even worse when parents have to learn to do it to their young children. Nevertheless, hospital staff are very used to patiently explaining how it is done, and most of the time, after practicing by injecting an orange for example, the skill is quickly learned.

The first thing to learn, however, is how to draw up the dose from the rubber-capped bottle, without bubbles of air getting into the syringe. The second thing is the measurement of the correct dose. Both of these will be taught by the close supervision of the medical and nursing staff. The syringes are again supplied as part of the treatment prescription and the current ones available are glass and metal; a carrying case is also available for them. Plastic syringes are coming into wider use nowadays, however (in Britain, they are available for the under-16s from hospital or can be bought for around 10p each for adults) and it is likely that soon they will all be in this form. The syringes are graded in units and cubic centimeters or milliliters, and the insulin is available in a variety of forms of standardized strengths expressed as so-many units per cubic centimeter (e.g., 20, 40, 80 and 120). Thus half a cubic centimeter (cc) of 20-unit strength insulin equals 10 units and that is how the dose per patient is usually expressed.

Insulin injection

The variety of forms of insulin are known as soluble (called 'regular' in the United States), crystalline, protamine zinc, isophane (called N.P.H. in the United States) and lente (also ultra-lente and semi-lente) all names which, along with others, indicate their duration of action. For example, the effects of soluble, or regular, insulin last for only six to eight hours, the insulin's blood-sugar-reducing effect peaking at three to four hours. By contrast, lente insulin, because like other longer-acting ones it is combined in a special way to be slowly released after injection, produces its results over a period of 24 to 28 hours, peaking after eight. Thus it is possible with this range of types of insulin to give a dose that precisely meets the patient's needs in some cases by mixing two types (soluble and isophane, for example) together in the one injection to provide a balance for 24 hours, or in some cases to control the blood sugar with two soluble-insulin injections a day. In children who are 'brittle' diabetics (see later), difficult to control because or their intensely variable energy requirements, the twice-a-day routine is often necessary.

Diabetes, like any metabolic disorder, has its complications that occur because it is chronic and incurable. The obese, more mature patient can sometimes revert to normal from being diabetic if they diet with care, even if they do not lose all their excess weight. However, if their diabetes is not controlled with diet alone, or with diet and tablets, they may have to become insulin dependent. For the insulin-dependent and young patient there is usually a gradual increase for the growing child. Some unfortunate individuals demonstrate insulin resistance and have to have larger increases made in their daily insulin; while most normal-sized adults will maintain a daily balance on around 40 units of insulin per day, ten per cent require 80 to 100 units, and a small number considerably more.

Once the regime is decided upon, as a result of the initial stabilization, then the patient faces, unfortunately, a lifetime of injections. Insulin is not a cure for diabetes; it is a maintenance therapy. The daily routine of the 'jab' can at first be a painful procedure, emotionally and to the senses as well. The skin is naturally sensitive at first, though with time, it is amazing how used to the procedure the patient, even a child, becomes. Some patients like to swab the skin's surface with surgical spirit to cleanse it first before injection, and many doctors used to recommend it as a standard procedure. However, the skin becomes hard if this is always done, and sometimes it also makes the puncture of the injection sting. Normally, if the skin is clean, there is no risk of infection occurring and most long-established diabetics have given up the surgical spirit routine. A piece of cotton wool is useful, however, to rub the skin after the needle is withdrawn in case a drop of blood appears.

The glass syringe can be kept in spirit in the carrying container to keep it clean; it will also need boiling periodically to remove any accumulated grease or grime. It is always advisable for a diabetic to possess two syringes in case of accidents; and, when travelling, also to have one in hand baggage and another in the luggage in case of loss or breakage. The needles can be renewed for each injection, but most diabetics use the same needle for several injections, although a sharp one is certainly an advantage over a blunt one when it comes to quick and painless piercing of the skin. In addition, plastic syringes can be used more than once.

The usual sites in the body used for injection are the upper arm, upper leg ('along the seam of the postman's trousers' as they say when teaching the patient) and the abdomen or tummy wall, usually below the navel. This latter site is a two-handed one, like the leg, for the flesh can be pinched between finger and thumb and the needle inserted quickly. Which site in the body to inject is largely a matter of personal choice the upper leg is probably the most common but it is important to use alternate sides for alternate injections, otherwise one side can get too sore. Similarly, because the fat beneath the skin of the injection site gets 'lumpy', the area chosen for the injections should be reasonably spread out and previous 'lumps' should be avoided.

For the new diabetic or the nervous one who has trouble conquering their initial and understandable fear of sticking a needle in themselves several types of aids are marketed which,by means of a spring-loading device, 'fire' the loaded syringe needle into the skin. The injection gun and 'Hypoguard' work on this principle and can help the individual patient, parent or other to overcome their hesitation as the needle is not seen. Once the needle is in, however, depression of the syringe's plunger must in all cases be firmly and completely achieved before the needle is withdrawn.

Injector gun
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