Introduction
Gibb’s Reflective Model is a holistic approach to clinical issues for medical professionals. It betters the practice of the medical profession and ensures that patients get better care that is evidence-based. The setting of Gibb’s model is convenient for many medical cases and enables the evaluation of practice to ensure past errors do not recur. It also prevents medics from making catastrophic errors in the future through efficient consideration (Momennasab, Ghanbari, and Rivaz, 2021). The first aspect of Gibb’s model requires medal practitioners to describe the case at hand, preventing the emission of crucial details. The second part is the feelings domain which considers the feelings of a practitioner, ensuring their humanity is factored in the care process. This enhances the view of medical sciences as disciplines rooted in human interactions and ensures patients are not treated like faulty machines but instead as people in need of care.
The evaluation stage of the model makes informed interrogations of the cases at hand while the analysis phase fosters a holistic understanding of medical cases. The conclusion offers a crucial breakdown of the entire medical case, enabling an objective view of the situation before the action plan is instituted. The action plan is the last part of Gibb’s reflective model and makes the cycle desirable for medical cases (Constantinou et al., 2020). This part provides crucial corrections for medics involved in reflection by taking a critical view of what should have been done instead. The action plan is immensely informative and ensures the same cases are managed better in the future, fostering evidence-based practice and minimizing medical errors. Medical errors are detrimental in practice and cause life-threatening medical emergencies. This essay is a reflective paper grounded in Gibb’s model and seeks to establish the truth in a patient with diabetic ketoacidosis (DKA).
Description
A 35-year-old known diabetic male presented at the emergency department with drowsiness, fever, cough, dry skin, abdominal pain, and slight confusion. On admission, it was discovered that his fever had been present for two days now and his COVID-19 test was negative. He remarked that he did not eat enough food before admission and that his fluid intake was lower than usual. The patient was on regular insulin supplements, which included Lantus at night and Humalog before each meal. His admission notes were crucial in the realization that he had type 1 diabetes mellitus, hence enabling the medical team to take prompt action. Additional symptoms of the DKA in the patient included heightened metabolic activities that were characterized by a high heart rate. His breathing rate was increased above normal, indicating respiratory distress. Additionally, he had a capillary blood glucose level of 25 mmol/dl which is a high figure for diabetics. Blood ketones were investigated and discovered to be above the necessary range, prompting further tests and admission.
The patient was subjected to various lab tests that would be essential in determining his treatment needs based on the severity of his condition. The investigations including ABG, other hematology, and biochemical tests would be vital in offering a clinical picture of the patient’s condition. An investigation of the acidity of the patient’s body fluids revealed a low pH which was acidic, pointing to acidosis in the blood. The bicarbonate (HCO3) levels of the patient were remarkably low, and explanatory of the low pH. The complete blood count investigation showed elevated white cell counts. A urea/creatinine investigation indicated that both compounds were elevated in the patient, providing an essential understanding of his protein metabolism. The patient was treated with IV sliding scale Actapid insulin, fluid, and electrolyte correction, and antibiotic therapy. A chest X-Ray and blood culture were taken for possible lower respiratory tract infection investigations. After three days in the intensive care unit, the patient was transferred to the ward.
Feelings
The feelings around the entire case in entirety were those of worry and concern for the welfare of the patient. The patient suffered from hyperglycemia yet he had not been feeding properly or taking fluids regularly. The presence of adherence to insulin injection by the patient was also contradictory to their presenting symptoms (Ziegler et al., 2018). I was worried that there might be dishonesty on the insulin intake part and was keen to establish the facts of the scenario. I was also worried about the complications caused by DKA in patients with type 1 diabetes due to the number of fatalities associated with the condition. In diabetics around the age of our patient, DKA is the biggest cause of mortality and presents with the symptoms identified in the patient, eventually causing fatalities (Benoit et al., 2018). I was apprehensive of the possibility of causing fatality in the patient through poor management hence the need for careful consideration. Poor management might have precipitated the condition and caused the death of the patient.
The fear of making errors made me keener with all the aid that was administered to ensure that I was within medical requirements hence careful testing of various parameters. The case was also unclear and some of the measures taken would be speculative to ensure the patient’s life was saved while tests were being conducted. The pure administration of aid such as antibiotics for respiratory suspicion without X-Ray results was worrying due to the potential of setting the patient on a course of antibiotic resistance. The chance to deal with diabetic patients was also exciting as it offered me a chance to put the theoretical knowledge I had into practice. I wanted to establish my credibility as a medical practitioner by ensuring the life of the patient is rescued. I had a point to prove and I was going to do everything within my prowess to ensure recovery was achieved. I knew that tackling that case would be a propellant for future medical emergencies, increasing my confidence and bettering my understanding.
I felt that the patient’s DKA complication was caused by their negligence in feeding and drinking. I felt that when they did not have enough glucose for the insulin to act on, the body resolved to produce hormones that increase blood glucose. These hormones include glucagon, growth hormone, cortisol, and epinephrine (Gruber et al., 2021). I thought that these enzymes overpowered the insulin shots the patient took, causing an unregulated increase in the blood sugar level. The high blood sugar level must have been directly responsible for the acidosis the patient was diagnosed with within the emergency department. I realized that in addition to the production of glucose that was stimulated by the alternate hormones, lipids were also broken down. The breakdown of the lipids produced fatty acids which were metabolized to produce ketones hence ketoacidosis (Ehrmann et al., 2020). The ketones were confirmed by the lab tests which indicated that these components were higher than normal. The ketones were responsible for the alteration in body fluids that caused drowsiness.
Evaluation
The evaluation of the case reveals that the patient may have omitted insulin does due to worrying about hypoglycemia. This vindicates earlier suspicion of non-adherence to medication that was made upon admission of the patient to the emergency department. The patient was noted to have poor feeding and drinking schedules, which prompted him to think that he did not need the insulin since he was not feeding. This means that his blood sugar was always low and the assumption was that regular insulin shots would lower the blood glucose level to detrimental levels. This assumption was misguided as a low blood glucose level can be regulated by the body through certain compensatory mechanisms already examined in the feelings section of this reflective paper. The compensatory mechanisms are very fatal when initiated by the body and lead to DKA which is detrimental to the health of patients (Barski et al., 2018). The insulin exception in itself was an error on the part of the patient which endangered his life greatly. Cells were deprived of glucose forcing them to turn to alternative energy reserves such as ketones.
The experience was good because it enabled me to understand the pathophysiology of DKA in diabetes mellitus better and the role of cooperation in medical care and practice. The experience was also essential in enabling me to critically evaluate the available DKA management protocols and realize their practicality. This means that I was able to ascertain the aspects that are applicable in all healthcare centers and which ones require certain modifications to fit certain variations. The variations include the status of the patient such as other presenting complaints such as difficulty breathing (Maulidiyah et al., 2018). The difficulty was initially diagnosed as pneumonia which was managed appropriately. It is noteworthy that all cases of DKA do not present with other conditions such as the case under study and that variations are to be expected and investigated. The management of the additional conditions must be effective to ensure the attainment of total health by the patient (Shahid et al., 2020). This requirement is in adherence to the codes of practice that mandate medical practitioners to provide holistic care.
The tests ordered for the patient were prudent and necessary in ensuring the efficient assessment of their situation and the eventual provision of care. The X-Ray would be instrumental in determining the presence and extent of pneumonia in the patient. The assessment of various products in the blood such as bicarbonate ions was essential in ensuring that sufficient doses of various substances were administered for correction. The correction would be aimed at correcting identified deficiencies hence no unnecessary intervention measures upon the patient (Zaiton, Relloso, and Manood, 2019). It is crucial to note at this point that no unnecessary tests were ordered and that this is in line with medical care requirements. These standards mandate caregivers to ensure that no unnecessary tests are ordered for the patients, causing them to incur additional costs in treatment (Lyerla et al., 2021). Such practices ensure that staff adheres to set standards of care and avoid harming the patient in any way, including financial harm.
Analysis
The easiest way for type 1 diabetes patients to ensure that complications do not escalate and threaten their lives is by maintaining communication. These patients should have better lines of messaging their doctors and other healthcare professionals at all times to ensure medication adherence. Communication is also vital as it would act as part of monitoring methods so patients’ conditions can be reviewed regularly (Parrott, 2019). The advancement of technology and the use of mobile phones has come as a blessing that can improve healthcare (RodrÃguez and Wägner, 2019). Mobile phones are very reliable and deliver information promptly between healthcare providers and patients. The patient who presented with DKA at the ward could have made the most of their situation by seeking clarification from the healthcare team and preventing DKA. The patient thought it was reasonable to avoid their regular insulin injections just because they were not feeding and drinking regularly. This assumption was based on the rationale that hypoglycemia is not harmful and that the two events could occur concurrently without harm.
The ideal alternate scenario would have been the patient asking the healthcare workers including nurses about this decision. The medics would have clarified the detrimental effects of insufficient nutrition and insulin on the patient and prevented the occurrence of DKA. Phone calls in patients with chronic conditions do not necessarily have to occur as a matter of emergency (Doupis et al., 2020). Healthcare centers should instead establish open lines of communication and regular checks on patients for updates on progress. The regular lines of communication can have medical centers calling diabetes patients every time they are required to have a meal or insulin injections. Such a measure guarantees that patients do not skip their medications and make awful decisions like the one admitted to ICU for DKA (Adu et al., 2018). Additionally, telephone calls can ensure patients can make complaints when complications commence. Handling a complication during the early stages guarantees better results compared to when the same is done later. During the preliminary stages, the damage is minimal and reversible for the patients.
When the patient had complications beginning, they could have called the hospital and been instructed to report at once. This would have enabled the medical team to handle the DKA early, preventing ICU care. The phone calls with diabetes patients can also ensure arising health conditions are treated adequately and early before they complicate the effects of the chronic condition (Eiland, Thangavelu, and Drincic, 2019). The patient in question may have been suffering from pneumonia for a while without realizing the seriousness of the condition (Jeffrey et al., 2019). He may hay have suffered extensive lung damage by the time he was getting admitted to the hospital. Ensuring that the medical team is made aware of such developments through the telephone would have ensured better handling of the respiratory condition. The existence of symptoms such as difficulty breathing and fever may have been crucial pointers towards the possibility of chronic conditions. Such issues could have been avoided by ensuring early reporting and care, hence the condition could have been arrested at the acute phase and prevented unnecessary admission.
Phone calls have been used as a means of managing diabetic patients in some parts of the world and have demonstrated massive success. Phone calls are convenient and readily available in the developed world, minimizing the risk of failure (Mackillop et al., 2018). Studies indicate that patients managed through the use of phone calls when suffering from chronic life-threatening conditions achieve better survival than those not subjected to this therapy. The symptoms of the ones managed through phone calls are managed and escalation to chronicity is prevented in these cases (Yang et al., 2020). Advice through the phone doesn’t necessarily have to involve phone calls but the alternative of messaging is also available. Messaging is also instant and more affordable compared to phone calls and ensures that the written instructions are clear. While speech may become distorted in some instances, text messages are intentional and clear in a language the patient comprehends. The use of this feature is also supported by the many communication applications such as WhatsApp which offer a plethora of features. They ensure patients and physicians can share data in the form of documents, messages, voice notes, and images.
Conclusion
In conclusion, the error encountered in the case of the diabetic patient was solely prompted by ignorance. The patient did not realize the effects of the action on his health due to the lack of information on the checks and balances available. These include a lack of information on sick day rules which require them to seek aid and the steps involved in the entire process. Information on personal blood sugar level checks would have saved the patient the inconvenience of being admitted to the ICU. If the patient knew what should have been done, they would have checked their blood sugar, realized it was low, and made better decisions on their feeding. Such information would have also saved the healthcare team the hustle of managing a diabetic patient with serious complications. Insulin dose adjustments are an additional method that would have saved the patient the pain of DKA complications. The patient would have simply checked their insulin level and determined whether it was within the normal levels. Such knowledge would have been essential in guiding their decision to starve, instead of being guided by a pure hunch.
Action Plan
The management of patients with DKA should follow some crucial guidelines that encompass maximizing patient safety and quality of care. Support of professional best practices is also crucial and should include adherence to evidence-based practices. The care of DKA patients should also deliver enhanced patient satisfaction to ensure patients are holistically okay aftercare. Operating costs must also be minimized during the management process to ensure that patients can afford the care (JBDS-IP, 2021). The length of stay at the healthcare facility must also remain minimal to ensure that this objective is achieved (Diabetes.co.uk, 2022). Healthcare providers are required to always draw insulin for these patients using an insulin syringe instead of an IV syringe. The subcutaneous injections of insulin for these patients must also be continued as previously required, guaranteeing the one administered through the syringe is merely compensatory (Eledrisi, Beshyah, and Malik, 2021). All prescriptions for insulin must be authorized by qualified healthcare providers with sufficient pharmacological knowledge to prevent mismanagement.
The patient should also be tested for various parameters that are telling about their condition such as capillary blood ketonaemia. This parameter enables medics to ascertain the seriousness of the situation and determine the intervention they will employ. Venous bicarbonate levels indicate the degree of acidosis in the patients and also enable therapy aimed at compensation (JBDS-IP, 2021). Management includes intravenous fluid management and prescription to resolve dehydration which is common in cases of DKA. Intravenous insulin therapy is dependent on the weight of the patient and informs the dose provided on an hourly basis (Evans, 2019). The patient should thereafter be observed for changes in their bicarbonate and ketone levels before further action is taken. If the levels do not improve, the insulin dose can be increased by 1.0 unit/hr until these quantities begin falling to acceptable ranges (NICE, 2022). The urea and creatinine levels in the blood are essential markers and must be monitored regularly to ensure they decrease back to normal ranges. The checks should be performed every few hours, preferably two hours to prevent lapse and enhance recovery.
The targets are usually for blood ketones to fall by at least 0.5mmol/L/hr while venous bicarbonate is supposed to rise by at least 3mmom/L/hr, and glucose should fall by at least 3mmol/L/hr. The DKA is said to resolve when blood ketones are less than 0.3/L and/or pH is less than 7.3 (JBDS-IP, 2021). In addition to the management of the ketoacidosis in the male patient, his respiratory issue should also be handled using antibiotics that treat pneumonia (Diabetes UK, 2017). Patient education should take center stage upon the recovery of the patient to prevent the occurrence of such a complication in the future. Educational courses should be recommended for these patients given the chronicity of their conditions and its lifelong status (JBDS-IP, 2021). The education can include prevention measures along with actions to take should the complications arise in the future. Sick day rules are also a critical component of this management as they enable patients to visit their healthcare providers regularly, preventing the advancement of complications.
Reference list
Adu, M.D., Malabu, U.H., Callander, E.J., Malau-Aduli, A.E. and Malau-Aduli, B.S. (2018) ‘Considerations for the development of mobile phone apps to support diabetes self-anagement: Systematic review’, JMIR mHealth and uHealth, 6(6), p.e10115.
Barski, L., Brandstaetter, E., Sagy, I. and Jotkowitz, A. (2018) ‘Basal insulin for the management of diabetic ketoacidosis’, European Journal of Internal Medicine, [online] 47, pp.14–16.
Benoit, S.R., Zhang, Y., Geiss, L.S., Gregg, E.W. and Albright, A. (2018) ‘Trends in diabetic ketoacidosis hospitalizations and in-hospital mortality — United States’, 2000–2014. MMWR. Morbidity and Mortality Weekly Report, [online] 67(12), pp.362–365.
Constantinou, C.S., Andreou, P., Papageorgiou, A. and McCrorie, P. (2020) ‘Critical reflection on own beliefs for cultural competence in medical education: An analysis of tutors’ reflective narratives.QUALITATIVE RESEARCH IN EDUCATION, [online] 9(3), pp.273–299.
Diabetes UK (2017) What is DKA (diabetic ketoacidosis)? [online] Diabetes UK.
Diabetes.co.uk (2022) Woken up with ketones. [online] Diabetes Forum • The Global Diabetes Community.
Doupis, J., Festas, G., Tsilivigos, C., Efthymiou, V. and Kokkinos, A. (2020) ‘Smartphone-based technology in diabetes management’, Diabetes Therapy, 11(3), pp.607–619.
Ehrmann, D., Kulzer, B., Roos, T., Haak, T., Al-Khatib, M. and Hermanns, N. (2020) ‘Risk factors and prevention strategies for diabetic ketoacidosis in people with established type 1 diabetes’, The Lancet Diabetes & Endocrinology, [online] 8(5), pp.436–446.
Eiland, L., Thangavelu, T. and Drincic, A. (2019) ‘Has technology improved diabetes management in relation to age, gender, and ethnicity?’, Current Diabetes Reports, 19(11).
Eledrisi, M.S., Beshyah, S.A. and Malik, R.A. (2021) ‘Management of diabetic ketoacidosis in special populations’, Diabetes Research and Clinical Practice, 174, p.108744.
Evans, K. (2019) ‘Diabetic ketoacidosis: Update on management’, Clinical Medicine, [online] 19(5), pp.396–398.
Gruber, N., Rathaus, M., Ron, I., Livne, R., Sheinvald, S., Barhod, E., Hemi, R., Tirosh, A., Pinhas-Hamiel, O. and Tirosh, A. (2021) ‘Fatty acid-binding protein 4: a key regulator of ketoacidosis in new-onset type 1 diabetes’, Diabetologia, 65(2), pp.366–374.
JBDS-IP (2021). The Management of Diabetic Ketoacidosis in Adults*. [online] pp.1–49. Web.
Jeffrey, B., Bagala, M., Creighton, A., Leavey, T., Nicholls, S., Wood, C., Longman, J., Barker, J. and Pit, S. (2019) ‘Mobile phone applications and their use in the self-management of Type 2 Diabetes Mellitus: a qualitative study among app users and non-app users’, Diabetology & Metabolic Syndrome, 11(1).
Lyerla, R., Johnson-Rabbett, B., Shakally, A., Magar, R., Alameddine, H. and Fish, L (2021) ‘Recurrent DKA results in high societal costs – a retrospective study identifying social predictors of recurrence for potential future intervention’, Clinical Diabetes and Endocrinology, 7(1).
Mackillop, L., Hirst, J.E., Bartlett, K.J., Birks, J.S., Clifton, L., Farmer, A.J., Gibson, O., Kenworthy, Y., Levy, J.C., Loerup, L., Rivero-Arias, O., Ming, W.-K., Velardo, C. and Tarassenko, L. (2018) ‘Comparing the efficacy of a mobile phone-based blood glucose management system with standard clinic care in women with gestational diabetes: Randomized controlled trial’, JMIR mHealth and uHealth, [online] 6(3), p.e71.
Maulidiyah, N., Indriani, S.I., Prasenohadi, P. and Rasmin, M. (2018) ‘Respiratory failure in pneumonia with diabetic ketoacidosis (DKA)’, Jurnal Respirologi Indonesia, 38(1), pp.57–63.
Momennasab, M., Ghanbari, M. and Rivaz, M. (2021) ‘Improving nurses’ knowledge, attitude, and performance in relation to ethical codes through group reflection strategy’, BMC Nursing, 20(1).
NICE (2022). Recommendations | Type 1 diabetes in adults: diagnosis and management | Guidance | NICE. [online] www.nice.org.uk.
Parrott, M.G. (2019) Factors Leading to DKA Readmissions: A Qualitative Study. thescholarship.ecu.edu. [online]
RodrÃguez, A.Q. and Wägner, A.M. (2019) ‘Mobile phone applications for diabetes management: A systematic review’, EndocrinologÃa, Diabetes y Nutrición, 66(5), pp.330–337.
Shahid, W., Khan, F., Makda, A., Kumar, V., Memon, S. and Rizwan, A. (2020). ‘Diabetic ketoacidosis: clinical characteristics and precipitating factors’, Cureus, 12(10).
Yang, Y., Lee, E.Y., Kim, H.-S., Lee, S.-H., Yoon, K.-H. and Cho, J.-H. (2020) ‘Effect of a mobile phone–based glucose-monitoring and feedback system for Type 2 Diabetes management in multiple primary care clinic settings: cluster randomized controlled trial‘, JMIR mHealth and uHealth, 8(2), p.e16266.
Zaiton, H.I., Relloso, J.T. and Manood, E.G. (2019) ‘Barriers and strategies of implementing DKA care set in the emergency department within the banner system as perceived by nurses’, American Journal of Nursing Research, [online] 7(4), pp.664–669. Web.
Ziegler, A., Williams, T., Yarid, N., Schultz, D.L. and Bundock, E.A. (2018) ‘Fatalities due to failure of continuous subcutaneous insulin infusion devices: A report of six cases’, Journal of Forensic Sciences, 64(1), pp.275–280.