Tuesday, June 25, 2013

Hypurrrglycemia

A routine part of any standard doctor's appointment involves updating the patient's family history, including any new diagnoses that have been given to immediate family members or otherwise. Usually, no news is good news.

I almost dismissively asked this question to a patient who had relatively recently been diagnosed with Type 1 Diabetes. We see these patients every 3 months and there is usually not much to report by way of health changes in such a short time period.

She looked at me with a smile and said that someone in her family was recently diagnosed with Type 1 Diabetes. Her smile confused me, and so I glanced at her parents who threw their arms up in the air in disbelief. "We can't believe it!" her mother exclaimed with exasperation, "there is only so much diabetes I can handle!"

They could tell I was in need of a lot more information than this, but they were toying with me.

"And it was me who picked up on the signs and made the diagnosis, " her father piped in proudly.

They finally divulged that their 6 year old cat was diagnosed with Type 1 Diabetes. The father noticed that the automatic water-bowl filler needed to be refilled daily instead of every 2nd or 3rd day, and that the litter box was more full than it had ever been.
The mother called the veterinarian and told her that their cat has diabetes. Skeptical (as anyone would be) the vet asked to examine the cat and re-assured her that it was likely not diabetes. The vet was forced to eat her words the next day via telephone when she delivered the diagnosis. It just goes to show that D-parents know their stuff!

The cat was started on twice daily injections of NPH. I asked if they check his blood sugar, and they explained that it is a long, tortuous process involving the warming of a rice pack in the microwave, chasing down the cat, pressing the warm pack to the cat's ear, and then wrangling the cat down while trying to prick his ear for the test. Needless to say, they don't test him all too frequently.

I wondered aloud about hypoglycemic episodes, especially being on an insulin like NPH with all of it's peaks.
My patient said that her cat sometimes goes low, and she knows because his walking becomes wobbly and that "one time he walked straight into the wall."
"He also slurs his purrs," her dad joked.
When this happens, the family has to again wrangle the cat and try to coax it into drinking sugar water. And I thought taking care of a small child with diabetes was difficult! I never thought about a cat! But if it had to happen, at least the cat ended up with a family who really gets it. Slurred purrs and all.

Thursday, June 20, 2013

What a Gas

The ENDO 2013 conference is the annual meeting of The Endocrine Society, and over 9,000 people related to the field of endocrinology attend. There are many very important people and very important topics discussed.That being said, people ARE people and they get tired. And hungry.

When one of the sessions I was attending was finished, I gratefully walked out of the lecture hall to find lunch. I was feeling a bit lazy that day, and decided to stick to the few options available on premises instead of venturing outside to one of the restaurants in the blocks surrounding the Moscone Center in San Francisco. The hallways were filled with the delicious scent of fresh crepes, and my mind was made up. My nose led me to a line at least 30 people long, standing behind one singular man making hand-made crepes.

I stayed. I wasn't lying about feeling lazy.

The line moved at a snail's pace. I checked all  of my email via phone. I had full text conversations with long-lost friends. I discovered the cure for diabetes.*

I finally reached the point were only 3 people stood between me and my crepe-alicious lunch. My reverie was suddenly interrupted by loud sirens. Everyone did that confused, exchanging glances thing where you are silently deciding whether to run like hell or simply ignore it. I chose to ignore it. I was going to get my crepe, dammit!

But the sirens continued, and then a loud announcement came overhead. "There is an emergency. Everyone exit the building immediately. Everyone must leave, even if you have been waiting 30 minutes for a crepe."

I  swear I heard it say that, though I was delirious from my hunger at that point, so who knows. I stood in line and watched as people dutifully made their way down the hall and up the escalators in droves. I looked at the crepe man and he just put his crepe-tools up in a shrug. A security guard shouted at me from a distance. FINE.

9,000 conference attendees standing outside  of the conference hall is a sight to behold. It turns out it was a legitimate emergency, as a nearby construction crew had accidentally hit a gas line. The smell of gas outside the Moscone Center was suffocating, and the gas line involved was part of the network that ran directly below the convention center. Had this been a Marlboro convention instead of a medical one, we might have been in big trouble.


9,000 people, feeling gassy.
I walked further away from the convention center alongside a physician I did not know. He told me he was in a bathroom that some unfortunate soul had just "exploded in" (his words, not mine) and when the alarms went off he told me he was sure it was from THAT kind of gas leak.

Doctor bathroom humor. The worst. And I thought it was hysterical, which re-affirms my career choice.

Luckily no one was injured, but the gas leak took several hours to contain and the majority of events for the day were cancelled because we were not allowed re-enter the convention center. But it was a beautiful, sunny San Francisco day, and if anyone were to be a bothered by a little mandatory Vitamin D intake, it's definitely not a group of visiting endocrinologists.


*Total lie, except the email and texting part.

Thursday, June 13, 2013

I'll Get It Together, I Promise

I am traveling to San Francisco tomorrow for a big Endocrinology conference. I always factor extra time into my schedule for the security line, mainly because my pump and CGM require me to get a pat-down in lieu of the body scanner.

I think of this commercial every time I go through security and it makes me snortle just like the Pillsbury doughboy:




Sunday, June 9, 2013

Two for One


A middle-school aged kid went to his Pediatrician this week with the complaint of headaches, fever, and a skin rash. The Pediatrician suspected Lyme Disease and send off some bloodwork.

He sent the kid home with some doxycycline and called the mother the next day to report that the electrolyte panel he ordered showed a blood glucose level of 268 mg/dL. He asked the family to come into the office for a re-check. It was 270 mg/dL.

He was sent to the ER and that is when I got called.

I really doubted that this kid had diabetes. He had absolute no symptoms of diabetes such as drinking too much, peeing too much, waking up to pee, weight loss, etc.

Zero, zip, nada. 

With only a random blood glucose over 200 mg/dl, you cannot diagnosis diabetes without the classic symptoms. After continuing to question the presence of those symptoms, he just shrugged and said “I feel great!”

So I ordered an A1C and he got admitted for a little more observation. We checked for ketones every time he peed and measured his blood glucose before and after he ate.

I came in to work this morning expecting to tell them that this was simply “stress hyperglycemia”, or elevated blood sugar in relation to illness. It goes away once your illness resolves.

But the A1C came back at 6.8%. To us established diabetics, this sounds excellent. But to a person without diabetes, this means they now have it.

I always have a hard time breaking the bad news of new-onset Type 1 to families. This time was especially hard. I had to tell them that, despite their son feeling so good, he now has this chronic illness that will change all of their lives forever. He came into the hospital with one diagnosis and left with two.

It is never an easy thing to do, but at least when new-onset patients are dehydrated from peeing and gaunt from weight loss and breathing heavy from ketones I can swoop in with insulin and make those patients feel better than they did when they came in. I can give the family an answer to the bizarre symptoms that plagued them in the weeks leading up to that day.  I can provide hope.

Today, there was no silver lining to that dark cloud.  I had no chance to make this patient feel better. I only made things worse.