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!

Unaware

I’m currently in my second year of PA school which means I am in month long clinical rotations. I have seen a vast array of diseases, patients, and situations but one thing still bothers me. Seeing a patient unaware of his or her own disease and how to deal with it is very frustrating. A patient who had a broken bone fixed doesn’t have to understand in great detail what happened 2 years ago with the surgery. She knows the bone was broken, the surgeon fixed it, and now she is better. Chronic disease is different and a patient must understand their own disease and how to deal with it on a daily basis. A heart failure patient may not understand why he must avoid excessive salt in his diet but he does so knowing he will feel better.

I have come across a large number of diabetics who do not seem to understand their own disease and how to treat it. One type 2 diabetic didn’t seem to be concerned that she had lost 70 pounds in under a year without any major changes. She was concerned about her belly pain and GI issues but not about her last A1C of 13! I encountered a type 1 diabetic who read the following Gatorade label and took insulin based off a carbohydrate total of 28g per serving.Gatorade Label

These are only two examples of poorly informed and wholly unaware patients. The first patient was suffering from gastroparesis as a result of chronically elevated blood sugar. The second patient was confused why he became hypoglycemic following the insulin dosages he calculated. He did not know the “total carbohydrate” value included all values below this heading including “sugars”. Both patients  were experiencing complications of diabetes that could be avoided with simple education.

Many diabetics do not see endocrinologists for their disease maintenance and are managed by family medicine or internal medicine practitioners. There is no reason to believe a provider in any of these three areas is incapable of providing adequate care, education, and resources for diabetic patients under their care. Regardless of who patients see, the patient’s understanding and compliance to treatment protocols should be the ultimate priority. If you have a question about care, treatment plans, risk for complications for yourself or a loved one affected by this disease the first place to look is with your provider. Good providers will do their best to answer all of your questions but great providers will also set you up with colleagues. Diabetes educators are a great resource and typically have much more time allotted to explain things and allow for questions. 

Shortly after my diagnosis I remember meeting with a diabetic educator nurse for an hour or two. She provided a lot of information but it was a single meeting and I was turned free. I don’t think meeting with a diabetes educator should be a single event following diagnosis. After seeing the lack of knowledge in many diabetics I think it would be best to have follow up visits until the patient is really comfortable with all the material. I have been fortunate to study in the medical field and have learned many things regarding diabetes I would not have known had I not been in this field.

I remember seeing my endocrinologist for the first time after my diagnosis and being given a prescription for a glucagon pen. I knew it was for severe hypoglycemia events but not much else, which is why I took it with me to the grocery store a couple times in the first couple of weeks after the appointment. It never occurred to me I would have to explain how to reconstitute the vial and then explain where to inject it to a stranger all while in the middle of a hypoglycemic event. I lived alone so there was no one who would be able to give me the injection if I really needed it but I didn’t understand this at the time. Thankfully the only time I have ever needed glucagon was 7 years later and my wife knew exactly what to do.

As with many things in life, ultimately we have to be our own best advocates in order to succeed. If you need help don’t be afraid to speak up and ask for it! You may be surprised where you end up as a result.