Fogged Up

Thinking back on this past 10 months on the pump, things haven’t been too bad. I wasn’t sure what to expect or if I would prefer pumping vs. injecting but I have to say the convenience has been great with my pump. Having access to insulin constantly has been great. Previously I would have to excuse myself to go to my bag, get out my insulin pen, load a needle, find some skin to expose without making anyone around feel awkward, load the dose, inject, make sure I didn’t bleed, remove the needle, cap the pen, and put everything back into my bag. While there seemed to be a lot of steps involved, I typically could do this in a very short amount of time. Today I only have to press a few buttons on the pump and I’m done.

I have enjoyed this relative anonymity without making it a bid deal. Many people haven’t even noticed when I load a dose of insulin from my pump. At a glance, it probably looks like I’m just checking my phone quickly. Being the introvert I am, this has been great. I have also been able to catch pending lows by paying attention to the trend graph provided by the CGM as well. One of the best features of the pump has been the ability to stop all insulin delivery; something the injections aren’t able to provide. I often correct the inevitable low blood sugar before it gets too low and before warning “BEEPS” go off.

Everything has been going well until recently. As a part of one of my recent rotations, students are required to read about a relevant topic related to a current patient and to present it briefly to the team. Typically, speaking in small group settings is not difficult for me. It does not induce fear or anxiety thankfully. On this particular day I began speaking from the notes I had made the previous night about syncope and the diagnostic steps regarding the work up but they weren’t making as much sense to me. I thought I had a decent grasp on the material but I just wasn’t making things clear. Rambling and taking frequent “uh…” pauses quickly ensued and I could tell I was losing my audience. I was in a fog.

“What the heck is wrong with me?”, I thought. “You have to focus and recover this thing.”

BEEP! BEEP! BEEP!

I immediately recognized the sounds and knew this was exactly the wrong time for this to happen. I stopped speaking and immediately checked my pump to find my blood sugar at 54 and dropping. At this point everyone was looking at me and seemed confused. The gig was up. I had made it 2 weeks without telling anyone here I had diabetes but at this point everyone knew. When I announced my current blood sugar situation the puzzled looks all turned to surprise/concern and chocolate chip cookies were immediately made available. Doubting the group’s concern was never my issue but like I have said before, I just don’t like talking openly about diabetes.

I don’t offer my diagnosis up freely because most people live with their diseases silently until they are in a medical office. You don’t introduce yourself at the company Christmas party saying “Hi I’m Mike, the husband of Sarah from accounting and I have hypertension!”

….thanks Mike…

After apologizing for my incoherent rambling the team seemed glad there was an explanation for my confusion. Two chocolate chip cookies later I was feeling better and we were all able to move on.

Not that the experience was life changing or something that I look back on wishing I could have curled up into a corner to disappear but it did change things. By showing a little vulnerability I showed my humanity. While traversing medical education (and in everyday life) there are ups and downs. I read about heart failure and feel like I have a good idea of what is going on, only to be reminded by an experienced provider that the book is not always the way something presents in real life. It can be a humbling experience to be told you are completely wrong. Trying to put the confidence face on and push forward is something I have gotten better with but this is often done by keeping others at an arms distance.

Some of my best interactions with strangers have come with personal connections and this experience was no exception. After I showed some vulnerability our team has actually been closer, more open, and supportive of each member. There is a big lesson here, and one that introverts like me often have a tough time accepting. While there is a time and a place for everything, sometimes showing the real you can open doors you have not considered. It can bring support and camaraderie for everyone involved. Don’t wait to be forced into it like I was with the “BEEPS”. Take a step in faith and see what happens. You may get more from it than you think.

PSA: Take Care of Yourself

After spending the past year as a student in hospitals and clinics I have seen a lot of patients. While in medical school we learned about a lot of different diseases but when working with patients I have seen re-occurring themes. There are a few diseases that come up day after day after day…. High blood pressure, high cholesterol, and diabetes. These three diseases are present in an astonishing number of patients I see every single day. The vast majority of these diabetics are type 2 but stripping away the contributing causes we still have similar outcomes; hyperglycemia leading to damage within multiple organ systems.

Another reoccurring theme is poor control. Now for the most part those with good control are not seen as often and do not typically need to be hospitalized. There are too many people today who do not meet the goals for therapy with blood pressure, cholesterol, or diabetes management. These together can contribute to major health issues like stroke and heart attack. Poorly managed diabetes can lead to neuropathy presenting as numbness, tingling, and possibly pain in your fingers, toes, and feet. These changes are often not reversible and can lead to terrible outcomes including sores, ulcers, bone infections, and amputation. I have seen many patients missing toes, feet, and legs because of both poorly controlled diabetes and peripheral vascular disease related to increased cholesterol. These patients can have significant changes to their daily lives following these surgeries.

I have seen people with poor vision because of damage to their eyes directly related to diabetes. The National Eye Institute has a great website explaining eye problems associated with diabetes, symptoms, and common treatment options. If you don’t mind poor vision or eventual blindness from poorly controlled diabetes then don’t worry about it. For those wondering, two possible treatments include lasers burning small spots on the retina and injections directly into your eye itself. If you, like me, don’t want to risk vision loss and these pleasant treatment options then good glycemic control and regular visits to an eye doctor are both good ideas.

The American Diabetes Association recommends keeping an A1c of less than 7% which correlates to an average blood sugar (eAG) of 154 mg/dL. I have always wondered about life expectancy having diabetes if you take care of yourself. In my experience so far I have met a man above the age of 80 who had kidney function better than mine, had no issues with neuropathy, and no vision problems. His A1c was always below 7% and he was well managed on a pump. Conversely, I recently saw a patient in her early 40’s admitted with hyperglycemia who had significantly reduced kidney function and diminished vision with an A1c of 23.3%!!! This is an astronomically high value and according to this handy ADA A1c/eAG calculator her eAG was 622 mg/dL!

At the end of the day diabetes is similar to other diseases and life choices. It’s the thing we hate hearing when you ask how to prevent obesity, high blood pressure, high cholesterol, and many other diseases. ” In order to avoid poor health outcomes we have to take care of ourselves. This is clearly easier to talk about than to execute but the effects of ignoring your health can be catastrophic. It won’t hurt today. It may not hurt tomorrow, but eventually these choices catch up to us.

Public Service Announcement: TAKE CARE OF YOURSELF!!

The concept is simple but not easy. Going through the daily grind that every diabetic goes through can be difficult at times and there are many days I would rather ignore everything and do what I feel like. I know this would ultimately catch up to me and there are too many positive things I want to live for. You too have things to live for and to be healthy for. For those having a tough time compiling a list, ask a friend or loved one for help. You may feel alone but ask for help. This site is designed to help connect diabetic patients in similar situations and experiencing similar concerns so USE IT to say something. We can all learn from and support each other.

My Pancreas does NOT Suck!

Here is one option…

If you talk to enough people about diabetes, eventually you might hear someone say “Your pancreas sucks!” Heck, I have heard people with diabetes say their own pancreas sucks. Are they right and should we all start wearing shirts denouncing the evil pancreas?

This one is a little more aggressive…
More passive aggressive here…

NO!! is the short answer

Wait. How can my pancreas be anything but sucky if it can’t even make insulin? It’s hard to forget I have to check my blood sugar all the time and then somehow get insulin under my skin, EVERY DAY! That sucks!

To understand why my pancreas doesn’t suck we have to understand all the jobs a normal pancreas takes on. For the readers who like the science details, keep reading. For the Reader’s Digest version skip to the heading “Does Any of My Pancreas Suck?” below.

Endocrine and Exocrine Functions

When broken down by function, 95% of the pancreas is comprised of cells with exocrine function and the remaining 5%, known as the islets of Langerhans perform endocrine function. Exocrine means the enzymes produced in the pancreas are released to another part of the body via ducts directly to the target area. Endocrine means the hormones produced are sent in the blood to the entire body before finding their target.

The pancreas sits just behind the stomach as seen here.

According to Medical News Today the pancreas produces about 1 liter of exocrine enzymes everyday. These aid directly with digestion in the first part of the small intestine and are produced by the acinar cells. Some of these enzymes include amylase, used to break down carbohydrates, trypsin and chymotripsin used to break down protein, and lipase used to break down dietary fats.

The endocrine function of the pancreas is broken down to different cell types in the islets of Langerhans that each produce specific hormones. These include Alpha, Beta, Delta, Epsilon, and F cells.

Alpha cells produce glucagon which travels to the liver and stimulates glycogen (the liver’s stored form of glucose) into glucose to be used right away. It also converts amino acids into carbohydrates for the same function. Both of these processes lead to increased blood sugar values.

Beta cells produce the hormone insulin. Once released, insulin travels to cells of the body to allow glucose uptake for immediate use or storage. When sugar leaves the blood and goes into the cells, the blood sugar drops. Because the brain uses a lot of glucose and does not store much itself, difficulty with thought processing and confusion can result when the blood sugar supply drops too low.

Since insulin is a hormone it is not very resilient. Gastric acids and heat can easily break it down rendering it non functioning fairly easily. This is why insulin is not supposed to be in hot environments prior to use and why there is not any way to take insulin as a pill. Here is a good article explaining insulin.

Delta cells produce the inhibitory hormone somatostatin. This hormone blocks the release of both glucagon and insulin. It acts to block growth hormone and also decreases acid production in the stomach.

Epsilon cells produce ghrelin. This hormone plays a role in energy balance. When the stomach is empty ghrelin is released leading to increased hunger sensation. It also stimulates the GI system indirectly to begin peristalsis movement in order to make space for a meal. Once a meal is consumed and the stomach stretches, grhelin secretion stops.

F Cells (sometimes referred to as PP cells) produce pancreatic polypeptide which aids to self regulate the endocrine and exocrine function of the pancreas. Its release increases with protein meals, fasting, hypoglycemia and exercise. It decreases with somatostatin release and with IV glucose.

Does Any of My Pancreas Suck?

It’s a numbers game. Of all the diabetics living in the US an estimated 5-10% are type 1. Since type one diabetes typically involves an autoimmune attack of the Beta cells alone within the islets of Langerhans that means there is still a lot of good tissue in your pancreas. According to this page beta cells make up about 70% of the Islets of Langerhans. As we talked about earlier the Islet cells make up about 5% of the total pancreas so if we knock out 70% of the 5% of total pancreas that means 96.5% of your pancreas is still awesome! That means we have a lot to be thankful for!

Does your pancreas annoy you sometimes? – Sure

Does your pancreas perform below 100%? -Yes

Is your pancreas the culprit? NO!

Don’t forget your pancreas was attacked by antibodies your own body produced! Let’s not pick on the victim here. After all this little 6 inch organ withstood the attack with only damage to about 3.5% of its total mass which is great. There are many bad things that can happen to a pancreas causing awful disease. Diabetes and it’s treatment often sucks but we can live long healthy lives if we play our cards right. I recently found a great quote from at irunoninsulin.com

” Well controlled diabetes is the leading cause of nothing.” ~Alexis Hauptman

From one fighter to another, keep up the good work pancreas! You do NOT suck.

That’s more like it!

Thanks to Johns Hopkins and Healthjade.com for the graphics used for educational illustration purposes.


Anniversary

It’s that time of year again. Somewhere around this time in February 2011 is when I was diagnosed with Diabetes. No specific date comes to mind because I was suspicious of why I was feeling bad prior to going for a full work up. Having access to urinalysis strips at work, I quickly found out I had a lot of glucose in my urine which is abnormal.

I can honestly say there have been entire years that go by where I don’t think about my initial diagnosis. The event itself was not earth shattering to me but the subsequent changes to my lifestyle definitely weighed more heavily on me.

Just a week ago I had another check up. My A1C was within the recommended range (<7%) again. After 8 year on the diabetes treatment train I am fortunate to have only been above the recommended A1C once. The one poor A1C value came just after completing my didactic year in PA school and I was definitely not making my health the priority I should have.

Thinking about all this time I can’t help but wonder what toll the disease has taken on my body already. The picture posted at the top makes me think about how many injections I gave myself over the years. I’m fortunate today to use the pump and not have to take so many injections. Thankfully by keeping my A1C and blood glucose values within (mostly) recommended ranges I have been able to stave off insidious complications like neuropathy among others. I hope to be able to continue this trend but I still need to make some changes.

Do you have a good anniversary story? How have you or your loved one been doing since that first A1C?


Let’s See Some I.D.

Shortly after my diagnosis I remember going to the grocery store looking for foods with no carbohydrates. If I could avoid carbohydrates then I could avoid taking insulin, right? Wrong…

Realistically, most foods have carbohydrates in one form or another. All I wanted to do was blend in and not stick out. Eating in social situations was similar. I remember thinking if I could avoid carbs, then maybe I wouldn’t have to leave the table to take an insulin injection (in the days before starting the pump) and be noticed doing so. I wanted to live as normally as possible. At that time I lived alone and did not carry much with me besides my wallet most days. Surprisingly I never had any hypoglycemic episodes at that time and thankfully so. I had no medial ID jewellery, tattoo, or card.

Over time like most other people, I grew smarter and gained a better perspective. I eventually purchased my first medical ID necklace. I didn’t like most of the designs but I settled on a dog-tag necklace. It was simple with my name, type 1 diabetes, and my mom’s phone number. In retrospect this didn’t make much sense because I lived 900 miles from her. I didn’t have any local numbers I wanted to contact in case of an emergency. 

One night I was at a bar talking to a girl when she noticed the necklace.  The music was loud but it sounded like she asked something about the military as she pulled the necklace out from my shirt. She studied the inscribed words for a second and then dropped the tag. An open mouth look of disgust came over her face as she stared at me. Without a word she promptly turned around and walked away. Apparently she was looking for a military hunk and not and a diabetic hunk. Bye Felecia!

Tattoo

Another identification medium people turn to is permanent. Medical alert tattooing has increased a lot recently. Here are some awesome examples:

The goal here is to make sure the tattoo is easily read and in a place likely to be found in cases of emergency. This site provides some useful advice when pursuing medical Tattoos, especially as a diabetic.

The most recognized symbol relating to diabetes is the blue circle. You can see its easily recognized above. Read more about it’s significance and origins here. I personally like the idea of getting  permanent identification but I would have to give it a lot of consideration.

I would love to see any examples you guys want to share. I have saved my favorite for last…

If you need some context >>>Liberty Medical Diabeetus (opens in a new tab)” href=”https://www.youtube.com/watch?v=6znUgimo-gA” target=”_blank”>Informercial


Abscess

I was inspired this week to address a relatively common issue that can have big consequences for diabetics. With this post I will try to avoid getting too scientific and keep everything basic but we have to begin with some background.

Abscesses start with a small break in the skin that allows bacteria to enter and start a local infection. Most often this is caused by a type of staphylococcus (staph.) bacteria. The primary bug found is staph. aureus. From here you can break it down to methicillin susceptible staph. aureus (MSSA) and methicillin resistant staph. aureus (MRSA). MRSA is fairly well know in the general public and requires strong antibiotics. The good news is that with early treatment, these infections can be taken care of pretty easily. The bad news is that staph. and it’s many forms exist on our skin as a part of normal life

Normal infections can be cured by antibiotic medications  but abscesses present a different challenge. At the center of an abscess is a collection of pus and bacteria and medication does not do a good job penetrating to the core. Ultimately, the best treatment for an abscess is drainage. For anyone who has had an abscess, you know the last thing you want is for someone to cut and squeeze at this painful area.

These pictures both show classic examples of abscess from the surface.

Who saw a spider?

Many patients seek advice from their medical providers after a suspected “spider bite”. 

#1 Did you see a spider?

#2 Did you witness a spider bite you?

If your answer is no to both of these, then you probably have an abscess. Cancel the Orkin appointment for tomorrow and just get some medical help….

Why is this potentially serious for a diabetic patient?

Most people do a good job keeping anything on their skin out of their bodies. Most diabetics break their own skin daily for blood glucose checks and insulin injections. Even worse, some of us wear implanted CGM’s and insulin infusion sets which provide direct communication between the outside environment and our tissue for days at a time. The skin is unable to protect us from infection when there is a compromise in its layering. On top of these possible entry points for bacteria, elevated blood glucose values can impede our natural immune response and gives bacteria extra help with its growth. Left untreated, abscesses can lead to sepsis.

The best way to prevent infection and abscess is to keep any skin compromise areas clean. For me, I always use Hibiclens prior to alcohol wipes before I inject insulin infusion sites and CGM sensors. By doing this and not keeping anything in my skin for too long I have cut skin issues down to almost zero. The other thing I have added is using Hibiclens in the shower. By using this weekly, I am able to help reduce bacteria found on my skin. Working on rotations within clinics and hospitals I am constantly surrounded by potentially dangerous bacteria. Again, sitting on top of intact skin I am safe but if any bacteria is allowed past my skin I am at risk for infection and abscess.

It’s a constant battle but one that can be easily managed if you know what to look out for. Here is a link to a site with some basic information about abscess. As with anything, if you think you may be developing an abscess, consult with your medical provider.


Just Plain Wrong

My current rotation has me working days and nights and switching between them often. Today I was taking a nap when I woke to 6 missed calls from my wife. I managed to answer the 7th to find my wife was coming home from work. “Why?” I asked her. She told me her Dexcom Follow app showed that I was at a blood sugar of 44 and without hearing from me, she feared the worst. I assured her I was fine and that this was incorrect. Looking back, I should have tested to see what it was but I am positive it was not that low. Thankfully I have not lost the ability to sense hypoglycemia at this point and my wife is keenly aware when I seem off. She has seen me with measured blood glucose values from 450 to 23.

While my wife loves being able to see exactly where my blood sugar is in real time, I really like the trend arrow telling me where I am heading and how fast I’m heading there.  Knowing if I am going down slowly or quickly is very good to differentiate. Unfortunately I have grown to realize I can’t take the CGM numbers as 100% accurate. A few weeks ago I had trouble getting my blood sugar down most of the day. Before I went to bed my CGM said I was “high” meaning >400. I took a large correction dose of insulin and checked my glucometer as well. I was actually at 214. Too much time had passed to cancel the insulin bolus but I was able to set a 0% insulin delivery rate for the next several hours. Avoiding hypoglycemia, I was able to rest with no issues. Problems like this happen often. My CGM tells me I am high, low, or at a good value only to find out later that this is just plain wrong. While the numbers are often incorrect, the arrow is always correct so I still see benefit to continuing its use.

Interestingly an research study recently came out confirming this. The ADA Diabetes care journal presented this and the study is summarized here for those who hate reading research journals. Only 6 of 18 tested CGM systems were found to be accurate (within 15% for blood glucose values >100 mg/dL) for all 3 study trials. I have contacted Dexcom about this issue before and while they try helping by replacing sensors, transmitters, and updating the receiving app, the results are always the same. Part of the issue comes from the very basic misnomer.

Blood sugar can only accurately be measured with a sample of blood. The CGM devices measure interstitial fluid (fluid between cells and outside of the circulatory system) glucose and estimate blood sugar values. There is also inherent risk for superficial infection and abscess (I have had both) from leaving any device sticking into your skin for days at a time.  Leaving a device in your blood stream for an extended period of time can have much worse complications and why this is typically done by medical professionals. For now, this is the best option we have and I am still grateful for it.

At the end of the day the life of a diabetic today is better than it was 10+ years ago. I still have my gripes but with wearable technology, we are allowed to make treatment choices on the fly. We can be warned as we are heading for trouble but before we get there. We are still making improvements but it can seem slow at times. Blood, needles, shots, infusion sets, and skin tape are “normal” today  but maybe not in the future. As Scott says in his July 30th blog post, “It is not normal!”

 

-PS-

My wife is a trooper and I really appreciate all she has done for me. She has been with me at some of my best and worst times and without her, I know I would not have survived.  She celebrated a birthday this week so I wish her a very Happy Birthday and thank you!