When Ordering Medical Supplies for You or Your Child, Know What it is, The Mistakes Can Be Fatal

It is no secret, one of my children has type one diabetes. It was so hard on him until we figured out what equipment worked for him. There were several hospitalizations until there was a good routine on things. He has an amazing endocrinologist, which his vital. I was told this is quite normal for new parents and its most of the time not the parents fault. Every decision you make for this child effects them. 

Once we got the hang of it, it was smooth sailing. We know what to look for etc. Every month we order his pump and continuous glucose monitor (CGM) supplies. The combination he uses now is a Tandem T-slim and deacon combo. Both devices talk to each other via bluetooth and we can see what his glucose is even when he isn’t home, when his phone is connected and charged. 

What Happened To Make this So Important

Anyway, once A was first approved for the T-slim as he had been on the Dexcom (CGM) for years we made an order for them to send the pump and all the supplies. When we got the supples, we assumed everything was right. In a perfect world, this would happen. We used the infusion set, cartridge and the new pump. We went through the steps to connect the Dexcom to the pump. We were excited for him to have an automated system where we would not have to mess with him that much. 

A day later, he was running high and he had ketones in his blood. We called his doctor and she said to push water and put him on a temporary basal. A temporary basal is a raised insulin dose to get rid of the ketones. Non diabetic get ketones too but insulin gets rid of them. A type one diabetic does not produce insulin on their own so this is necessary. 

When his ketones get past a certain level, he can’t keep anything down so we give him a chewable called Nauzene which allows him to keep water down in order for the water and insulin to work. This time after a couple of hours it was not working. Insulin take 2 hours to work once infused so a minimum of 2 hours waiting is necessary. 

After this, we brought him to the hospital and he was admitted on the children’s floor. His doctor came to see him. That is how we found out that the wrong infusion set was sent. A is on the lean side, which is common for young children with type one diabetes. There are two different types. One is the auto soft 90, which is the one he was sent. Its a short cannula that goes straight into the skin. 

This sounds fine and good BUT when you have a lean child or adult, this can get kinked extremely easily and they can be hospitalized for diabetic ketoacidosis. The infusion set he was supposed to have was the auto soft 30, this is a longer cannula which is injected at an angle which is more appropriate for leaner children. 

Once this was figured out, she was on the phone with the distributer and said some words I don’t recognize in Spanish, as the doctor is Hispanic. They said they couldn’t fix it but the doctor had some samples to last him for that month. 

A was in the hospital over a week until his insulin/ketone gap was closed and his blood sugar normalized. 

A month later, when it was time to reorder the supplies, I double checked the infusion set they were going to send. They were going to send the auto soft 90’s AGAIN. I didn’t order and I called the doctor. She set them straight and they sent the auto soft 30’s. 

This has not happened since he had the correct infusion set with the correct cannula for insulin delivery.

What Happened This Morning

This morning I got the monthly call to order supplies. In my mind was telling me to check the Dexcom (CGM) transmitters, which get changed every 3 months. It has been a while since they sent them, and they usually come 2 at a time. 
Anyway, I asked the agent to check and he asked me why we haven’t gotten them since September. Someone who works for medical supplies should know that transmitters are not sent every month. I flashed back to when they really screwed up with the infusion sets and A was in the hospital due to a horrible mistake. 
I asked to speak to someone else, and he refused so I hung up and called the company back. When the new agent picked up, we went through A’s order and he said auto soft 90’s for the infusion set. That nightmare was almost relived. The new agent looked over the prescription and changed it on the computer. 
This company sells life saving equipment and their employees need to be better trained so this type of mistake doesn’t happen in the future. 
This is why it is extremely important to know what your medical supplies are and the slightest variations could have horrific consequences.  Know doses, sizes, models, company, route, angle, everything. 

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