Twenty-Two Times
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May 27, 2026
The chart said twenty-two. I read it the way you reread a sentence that can’t be right. Twenty-two admissions for diabetic ketoacidosis in ten months. Our patient, our hospital. Twenty-two times we fixed the glucose, restarted insulin, let him go. I’ll call him Marcus. This was twenty-three.
The nurse’s voice came through wryly, laden with experience. “He won’t talk to you. Puts the hoodie over his head. Social work tried. He’s left AMA before. Just order the protocol.” I understood her. Twenty-two failures had eroded everyone’s trust in helping Marcus, including ours. The protocol had become ritual, something we performed so we could say we did.
Thin, curled on his side, hoodie up, blanket over face. The IV pump clicked. Blood sugar 743. pH 6.92. The insulin drip had pulled him back to consciousness, but he lay still, as though wakefulness were a thing done to him, not for him.
I didn’t educate him. He’d received diabetes education twenty-two times, and I knew education was never the problem. I pulled a chair to his bedside, close enough to hear him breathe. “I’m not here to lecture you. I just want to understand what’s going on.” Marcus didn’t reply. I sat with the silence; told him I’d come back. I came back the next morning, and the morning after that. On the second day he pulled down his hoodie and looked at me. On the third day he talked.
He told me, in pieces, about the ADHD, the bipolar disorder, the PTSD, the seizure disorder, all undertreated. Type 1 diabetes demands executive function most people never think about: checking glucose, calculating doses, injecting insulin, multiple times daily. If your brain can’t sequence steps from one hour to the next, compliance isn’t a matter of willpower. It’s architecture without foundation. In twenty-two admissions nobody treated the conditions that made the foundation impossible. We just kept writing “noncompliant” when the building fell.
I called his mother. She picked up before the first ring finished.
“You’re the first person to ever call me,” she said.
I’ve turned that sentence over more times than I can count. Twenty-two admissions. Nobody called. I didn’t call because I was extraordinary. I called because it was obvious, and I’m not sure what it means that obvious wasn’t obvious before me, or whether I would have called on admission two, or twelve, or whether I’m telling this story only because I happened to be on twenty-three.
She told me he struggled with daily tasks. Doctors explain insulin once and expect him to do it. He forgets. He’s lost, she said. She had been thinking about this for years, watching him cycle through hospitals, waiting for someone to ask. Nobody asked.
I brought our conversation to the team, and something shifted. Psychiatry evaluated his executive dysfunction for the first time. Social work sat with his mother to map what had failed in every prior discharge. Endocrinology reconsidered the regimen. Diabetes education stopped repeating content he’d heard twenty-two times and started teaching his mother, meeting his cognition where it lived. We were finally talking about Marcus, and the glucose was secondary.
The next day I was anxious and excited to see Marcus on his new treatment.
He had left against medical advice the night before.
I wish I could say I didn’t take it personally. I felt betrayed, certain I could have fixed this, which is its own kind of arrogance, or maybe its own kind of care. The system failed Marcus twenty-two times the same way, and I expected something different on twenty-three. You can’t build trust in seventy-two hours with someone the system spent ten months teaching to disappear under a hoodie and a blanket. Professionalism, in the end, was the willingness to question why twenty-two teams hadn’t.
We owe trust to patients, and we default on it every time we discharge someone into a plan we know won’t hold. One phone call can’t undo twenty-two systemic failures. It needs to be structural: embedded in how institutions flag patients falling through, how we screen for cognitive barriers hiding behind “noncompliant.” But before the structural, there’s a chair beside a bed.
Marcus will come back. His chart will hold something it didn’t before: a record that someone asked about him as a person, that a team organized around real barriers, that his mother’s voice entered the record. I don’t know if it will be enough. But I think trust begins precisely there, in the not knowing, in the staying.
