[antasvara]

Reading this, my takeaway was less about the pump and more about how every part of the medical system is disconnected from every other part.

There were some mistakes made but they were all pretty reasonable decisions. But the situation that caused this in order:

1. The support line for the pump won't suggest sending it to where you are because you say you have a backup plan.

2. The support line also isn't a doctor; they can't evaluate how good or bad your backup plan is, just how to deal with the pump.

3. You message your GP. But the message system doesn't connect you live to the on-call practitioner; that's a phone number that is not easily findable.

4. Your GP fills a prescription for the backup pen and sends it to the closest pharmacy.

5. The pharmacy takes the prescription, but they don't actually know if they can fill it until later. They also can't find a pharmacy farther than 25 miles away from the current location.

Each issue is reasonable by itself, but the end result is that the patient had to call 2 different people, go to a pharmacy, and still wasn't able to get what they needed. The gaps that could have (theoretically) been patched are:

1. Support could have known the possible workarounds. I realize that legally it could have been dicey, but the "fix" suggested on Reddit seems like something that could have been mentioned as an interim solution.

2. Your GP could make it more obvious which communication method reaches the office on a weekend.

3. The GP should be able to talk to the pharmacy to ensure they have the medication in the prescription.

4. The pharmacy should be able to search farther than 25 miles to find a medication for a prescription they've been sent.

It should be much more difficult for a patient to hit every edge case like this, especially when just being able to talk to each other would have stopped some of these.

[cperciva]

One issue here which is obvious to me is that access to insulin should not be gated on paperwork. I can walk into any pharmacy in Canada and say "I'm diabetic and need insulin" and the pharmacist will sell it to me. They'll ask questions of course since this is not the usual path but my doctor's office being open will have no influence on whether I get it -- just on whether it's a 5 minute process or a 15 minute process, and potentially whether I have to pay myself or have it covered by insurance.

[tick_tock_tick]

You can in the USA too. Every Walmart in the country (and by god there are a lot of them) caries OTC insulin for $20-$25.

[zamadatix]

This is good info. I was going to say you can't in Indiana (where I used to live) but it turns out they changed their mind and it went into effect in 2021. Now (at least according to a current search) all states allow for at least a few forms of over the counter insulin (not the modern analogs, but it's better than nothing!)

[Projectiboga]

True but that is the old Human insulin which is in some way not a drug the way the current modified insulins are. Thanks for giving people this heads up.

[darth_avocado]

Also, to people in the US worried about having to go to the ER, Urgent Cares are the way to go with the kind of time the author was working with. You’ll be immediately seen, and not break the bank like an ER even if your insurance doesn’t cover it. They also should have all kinds of insulin at hand.

[s1artibartfast]

Is that true for every type and format? You can walk into walmart and get regular and NPH insulin over the counter, no questions asked. Newer ones require a Rx.

I do think that the US is obnoxiously conservative, and far more medications should be OTC.

Instead, you cant even buy kidney friendly cat food without an expensive Rx from a vet and tons of controls. Heaven forbit someone buy it without proper consultation. Think of the Kittens!

Edit: after some reading, it seems that Canada and US are outliers in the west for allowing OTC insulin. UK and Europe requires Rx for all insulin.

Asia is more mixed. Japan, Korea: Rx required. China, Rx on paper, OTC in practice. India OTC

[dehrmann]

> you cant even buy kidney friendly cat food without an expensive Rx from a vet and tons of controls

There are a few law suits over this. Essentially, the claim is that they call it "prescription," but it has no prescription medications in it and isn't approved by the FDA to treat anything. So if you have an extra bag and sell it, this is OK since it isn't actually a drug, it's allegedly a price fixing scheme between vets and pet food makers.

[cperciva]

Is that true for every type and format

Yes, OTC for everything. I've heard that some pharmacists ask more questions about types which are commonly abused by body builders but that's about the extent of it.

Funny story since you mention cats: My brother's cat was diabetic and prescribed long acting insulin which cost $250/vial. I looked it up and... apparently it was just relabeled lantus, because of course nobody is going to waste money on a separate manufacturing line. Ended up buying it from my local pharmacy, without a prescription, instead of using the vet prescription.

[bonyt]

> Each issue is reasonable by itself...

The problem of many hands - when responsibilities in a group that collectively does harm are divided between many people, who can be held accountable when each person individually acted reasonably?

I think organizations are, more and more, siloing roles in this way intentionally (or at least emergently), such that blame can only ever be collective if they do harm. Since it's so much harder to redress collective blame, this can be effective in avoiding consequence entirely.

[jerf]

I think it's mostly emergent. I can even point to a plausible mechanism, which is that if you think of an organization as a network of people and how they are connected together, you can think of "responsibility" as something that arcs through an organization like electricity and burns out whatever it courses through, prompting the creation of alternatives to avoid getting zapped the same way in the future.

It isn't completely inevitable, I think it's possible for relatively strong leadership to understand that the processing of responsibility through an organization is a necessary feature and people handling it without external forces conspiring to make it even more like that it will "burn out" a part of the org is a necessity and a good thing. But it's really easy for an organization to just default to burning out the path and evolving ways to avoid it in the future, and it is very motivated to make it happen.

[testaccount28]

the correct answer here is that they are all accountable. there is not some fixed quantity of blame to divvy up: each malfunctioning leg is responsible for the outcome.

[close04]

They all contribute but they can’t all have the same degree of accountability.

[ajb]

I think the GP's point is that accountability/responsibility isn't a substance, it doesn't have to be conserved like energy or momentum. I agree with them.

It would be perfectly valid for the law to be that individuals don't need to unpick the corporate web of relationships, but hold any of those who contributed (above some size threshold) culpable for the whole injury, and leave the corporates to arm wrestle about how culpability is assigned between them.

[s1artibartfast]

Liability laws incentives play a big part. Good faith effort and patient care increase the surface are for attack.

[FireBeyond]

Potentially. However, depending on the nature of the interaction, abandonment is equally a concern for a provider. If I'm treating or begin care of a hypoglycemic patient (and I'm not saying that in this case, such a thing has happened), then legally, I can be found guilty of abandonment if I don't transfer care to a higher level provider or conclude the course of treatment or intervention planned. I can't just say "I can't do anything for you, you're on your own."

[s1artibartfast]

I think we are saying the same thing. There is a line that triggers obligation and liability. If the location is abigious or the liability is extremely high, then there is incentive to error on the side of avoidance.

This might mean not taking a patient or class of patients into care.

[FireBeyond]

THat's fair.

One other point to note, in general) is that depending on your provider type, avoidance may not be an option. On duty EMS cannot "avoid" a patient encounter, likewise with emergency medicine (though I'm honestly not sure whether immediate/urgent care is considered there, too).

[cucumber3732842]

>The problem of many hands - when responsibilities in a group that collectively does harm are divided between many people, who can be held accountable when each person individually acted reasonably?

"You can't justify hanging us all from the overpass" is the magic of the system.

And not just the medical system.

[throwaway173738]

The pump manufacturer is at fault a few different ways. They have a responsibility to make pumps that don’t break, and they should probably issue a recall. They shouldn’t rely on the availability of a product they don’t supply as a backup unless they can guarantee somehow that the patient always has access. Their staff should ask where you want the thing shipped to and include options like receiving the replacement at a Fedex or UPS location. Their staff should be trained to ask “are you traveling or otherwise away from your home address?” And finally they should train staff on follow-up questions for a patient’s plan and confirm the patient has enough insulin on-hand to cover executing the plan.

[kelnos]

Hah, "make pumps that don't break". Well, when you figure out how to keep entropy at bay, please tell us, because that would be a cool trick. Pumps will break. It's genuinely amazing that the author went twenty-five years before experiencing her first broken pump.

The author screwed up. "I'm not at home and need you to send the new pump to my hotel." Problem solved. Yes, the customer service rep should have pro-actively offered to do that, but c'mon. That is a super basic thing to request, and people need to advocate for themselves. And that's not even "advocacy" in any difficult sense; it's a basic request that the company should have had no problem complying with. If they did refuse to send it to where the author was, then that would be grounds for an angry blog post.

On top of that, the author, clearly a functioning adult human, seems to have never had the imagination to ask herself, "what happens if my pump breaks; what is my backup plan?" Hell, that's an important question to have an answer for when you're at home, not just when away on a trip. Based on her words in this blog post, she clearly absolutely knows that this device is critical for maintaining her life. Devices break sometimes. You need a backup. Preferably two backups, for something as critical as this. This is just basic common sense.

[s1artibartfast]

Why is any of that their responsibility? Their staff did ask if they would be fine without the new pump and op said yes. They were fine. They could have gone to a hospital. They could have gone to Walmart and bought some insulin syringes for their supply

[kelnos]

The thing that frustrated me most reading this was #1. And not even that the support person didn't suggest sending the new pump elsewhere (though they should have), but that the author didn't simply say, "I'm not home and need you to send it to a different address". I get the general point that she didn't want to make waves with someone who is going to be helping her deal with a condition that is life-threatening, but that simple sentence is not "waves", it's just... normal, reasonable communication.

This would have solved the entire problem, right there, immediately. The author would have been doing the annoying cartridge swap until the next morning, and then would have had a new pump waiting at their hotel. No more stress, no need for a blog post longer than, "my insulin pump was on its last legs while I was on vacation, but the company got me a new one in less than 24 hours and everything was fine and not particularly stressful at all, whew!"

I agree that #2 is reasonable. The insulin pump manufacturer isn't going to put a doctor on the phone for any random call to their customer service line. I do think they should have doctors on staff who can be escalated to, though, if needed.

#3 I'm not sure about. When I send a message to my doctors, the messaging system is very clear to warn me with every message I send that it may be several business days before they respond. If the messaging system in question has that same warning, that's on the author again, even if they were lulled into a false sense of on-call levels of response times based on past experience.

#4 doesn't feel reasonable to me at all. Insulin should not be gated by a prescription. I'm fine-ish with the idea that insulin can be available through a prescription (because then you'll likely get a better deal on it when your insurance company covers it). Downthread it seems that in the US you can walk into any pharmacy or Walmart and buy some forms of insulin without a prescription, for a fairly reasonable price. I guess the author didn't know about this.

#5 is not reasonable in the least. Any pharmacy employee should be able to search for the closest branch with insulin, regardless of distance, or be able to say "give me the closest insulin to these coordinates" or something like that. That's just absolutely terrible UX in whoever specced out and implemented that search function.

[smcin]

You don't understand the context: the issue was not that the pharmacy software somehow innocently can't (automatically) find a pharmacy farther than 25 miles away from the current location. It was specifically CVS prevented this since 2023 arising from their opioid settlement, to prevent "pharmacy-shopping", and to comply with with "Good faith dispensing" legal requirement under the federal Controlled Substances Act (insulin is a non-controlled prescription medication but the PBMs and pharmacies seem to widely apply these restrictions on search (and prescription transfer), which seems silly). Here's [0] one 2024 article (from RI, but whatever) listing all the new controls they imposed on pharmacists and doctors (among other things, transferring prescriptions across state boundaries triggers alarms). As you read this insanity, remember that the Purdue Pharma execs convicted didn't go to prison [1], at most got 400 hours of community service + fines. The Sackler family were still sponsoring the NY Metropolitan until 2019, and none of them were even criminally charged. Anyway, there's your root-cause. It should not affect insulin or other things but clearly the knock-on effect is it does.

[0]: https://www.risehealth.org/insights-articles/article/justice...

[1]: https://en.wikipedia.org/wiki/Purdue_Pharma