Turning a
Short Term Mission Into a Long Term Mission
1. There is a lot of diabetes
in Limon and surrounding areas, there is a high population
of blacks and hispanics and they are genetically more
predisposed to it, there is both Type I and Type II.
2. We are currently woefully undertreating. We
did 40 hemoglobin AIC tests this year, the average was
between 12-13%. Many random blood sugars were 400-600. We
started a 12 year old Type I on insulin, he was diagnosed
over a year ago, but never had any insulin (AIC of 14). There
are no insulins in the government clinics and the people
cannot afford to buy it.
2. We are currently woefully
undertreating. We did 40 hemoglobin AIC tests this
year, the average was between 12-13%. Many random
blood sugars were 400-600. We started a 12 year
old Type I on insulin, he was diagnosed over a year ago,
but never had any insulin (AIC of 14). There are
no insulins in the government clinics and the people
cannot afford to buy it.
3. Although orals work OK
for some, MANY of the diabetics are woefully undertreated
with orals and need insulin.
4. We estimate there are
at least 100 diabetics in the community, about 50 of
them get seen more or less regularly. Many have
blindness, amputations, strokes, etc., already.
5. Some of the problems
we face are: no regular care, running out of medications
(particularly from October to February where no teams
go), lack of education, lack of accustrips for home monitoring
(cost about $0.50 each), fear of insulin, lack of refrigeration
for insulin, lack of any consistent standards or algorithms
in treating diabetics, frequently changing from one branded
to another branded oral med, no daily aspirin (class
A recommendation), no ACEI, no statins.
We have tried to address some of the above problems
with the following program.
1. We have conducted two
diabetic classes this year - between 35-40 patients came
to each one. At the class we educated, measured
AIC, glucose, BP, adjusted medications and gave adequate
supplies of medications for between 2 and 4 months, depending
on how long until they could return to the clinic.
2. We are training Gloria
and Claudia (new lab tech in Limon) to check FBS and
adjust long acting insulins according to an algorithm. They
dispense insulins for l month, store the rest in the
clinic refrigerator and see the patients regullarly from
October through February. They check FBS on patients
who are out of control between every 3 and every 7 days
and adjust insulins accordingly.
3. We put every diabetic
patient we saw on an aspirin, ACEI (lisinopril), and
appropriate glycemic medications. And gave enough
medications until the next teams arrived.
4. We try to stick to mostly
generics (except for insulins). That means we focus
on aspirin, metformin, glipizide and lisinopril.
5. Insulins are expensive,
even the generics. We put most patients on Levemir,
Lantus or 70/30 - supplies by pharmaceutical companies. We
are working with the pharmaceutical companies to try
to assure a steady supplly of these insulins that can
be shipped there directly as needed from the US
6. We focus on LONG ACTING
INSULINS such as Levemir, NPH, Lantus, etc., even for
Type I - because we can't afford to do frequent accuchecks
we feel this is less likely to result in hypoglycemic
events.
7. We have modified goals
for our diabetics in Limon - we would like to see AIC's
in the 8% range (FBS 150-100). This will avoid
most complications of diabetes without causing the life
threatening hypoglycemic events we have difficulty controlling
due to lack of monitoring strips.
8. We plan on doing yearly
AIC tests which will be recorded in patient's charts
along with medication changes. These cost $10 per
test, but we are funding this, along with paying Gloria
and Claudia for monitoring the patients during the wet
season.
Again, our goal is to improve
quality and consistency of care and we appreciate any
input or help from any other teams. We are trying
to do a better job of charting so that communication
is better between the teams.
Thanks so much for your interest.
