Elf on the (Hospital) Shelf

My social media updates are full of pictures of elves on shelves - those playful little elf dolls that carefully watch children during the day and fly to Santa at night to inform him of their good and bad deeds. The elves, upon returning to the childrens' homes, often get into a little mischief.

I do not have children of my own, but I very much enjoy the endless stream of elf scenes on my computer and how creative those elves can be. When kids wake up in the morning, they find their elves taking marshmallow bubble baths or riding My Little Ponies.

The parents of my patients comment that the "Elf on the Shelf" is an amazing motivator for good behavior, including good diabetes care. Many of my patients eagerly check their blood sugar and take their insulin without a peep under the watchful eye of their elf. It seems like a win-win for all.

Holiday time should be full of innocent joy like this, but it can be a little more bitter than sweet at work. It feels as though we always get a handful on new-onset type 1 diagnoses too close to what should be a happy and festive time. No one wants to spend the days leading up to Christmas learning how to count carbohydrates instead of simply counting down the time until Santa arrives.

As if on cue, a little 7 year old girl came into the pediatric intensive care unit two days ago with very bad diabetic ketoacidosis from undiagnosed type 1 diabetes. She was so sick that she was not quite conscious the night she came in to the hospital. With the help of IV insulin and lots of fluid overnight, she was back to her usual self by the morning.

She awoke in the morning and stared up at the ICU ceiling where there was an unused hook for hanging IV bags. Her face lit up with excited recognition.

Magically, her elf had found her...even in the hospital!

The Secret Life of D's

I carry my diabetes with me throughout the work day, sometimes sharing it with patients and sometimes not. I pick and choose based upon whether or not I feel it will be beneficial.

As a physician still in the final leg of training to be an independent pediatric endocrinologist, everything I do has to be signed off by my superiors. I follow many patients that I consider "my own" and often pick up others that "belong" to my bosses.

Last week there was a particularly busy diabetes clinic, and I picked up a patient that I had not previously seen. I rushed from the patient before him and quickly scanned his medical chart for the pertinent information about his diabetes history. He was 6 years old, on Lantus and Humalog, and still honeymooning from his diagnosis only 6 months prior. It was noted in his chart that he has had a hard time coping with the diagnosis, which struck me as sad yet impressively mature for a child his age.

I swept into the room all smiles in an attempt to start the appointment on a positive note. I said hello to him, then to his mother and father sitting to either side of him. I introduced myself and my role, and assured them that their usual doctor would also be seeing them after me. His parents were polite but clearly exhausted, the stress of the previous 6 months weighing heavy on them. His mother was very attentive, his father just nodded without taking his eyes off of his cell phone. With my focus on the boy again, I asked him how he was doing. Not the diabetes, just him.

"But everything is diabetes," he said with sadness and an understanding that was beyond his years. "I don't really want to do it anymore." My heart ached at the sentiment, and I decided that this was an appropriate time to share my own.

"I understand that feeling. I wish you did not have to do it anymore, either. I feel that way sometimes, too, because I also have diabetes," I carefully explained.

His eyes widened in disbelief. He stayed quiet for a few moments and then shouted in disbelief "You have diabetes like me?!"

He studied me carefully, almost looking to see if there was something on me that he missed. Something that would have declared me as diabetic had he looked closer the first time.

He then pointed to his father and said, "My dad has diabetes, too! My mom is the only one here who doesn't!" His smile widened bigger than his amazed eyes.

Now it was my turn to be surprised. I turned to his father and our eyes met as he looked up from his cell phone. I smiled at him and looked back down at the chart. It was listed there: father with longstanding Type 1 Diabetes, with diabetic retinopathy and nephropathy. I caught myself thinking that I would have never guessed he had Type 1 despite knowing firsthand that diabetes is an invisible disease.

"Guess we're all in the D-Club together, huh?" I said to the boy.

"Haha, yeah! It's like a secret club!" he said with a giggle.

More insightful words from a very insightful little boy.

Diabetes Awareness Month

I have never been more acutely aware of diabetes than this particular month. And all I want to do right now is ignore diabetes completely.

I know that designating November as Diabetes Awareness Month was not meant for making the patients themselves aware, but for the public. For the masses that don't know anything about Type 1 or Type 2 or any other type and for those that think diabetes is not as big a deal as breast cancer and heart disease. I appreciate that. I just can't bring myself to join the movement at this moment in time.

I got bad news at the ophthalmologist at the start of this month regarding my recently diagnosed retinopathy. It is news that will be more eloquently fleshed out in a future post, when I have the strength to chip this mountain of emotion down into words and sentences.

For now, I just want to bury it. All of it. The tears, the guilt, the frustration, the anger, the shame, the fear, the regret. The massive regret. I can't face it all head-on right now. I want to walk away from diabetes.

But diabetes is holding me hostage. As much as I want to ignore it for even a few hours, knowing that ignoring it is what gave me this complication in the first place forces me to pay closer attention. Test, bolus, repeat. I am shackled by the guilt of it and fear of doing even more damage. The ball and chain has always been attached, it's just never felt so heavy before.

Work has been busier than ever, but I have been slower to get out of bed. I drag myself there and put on a happy face. I encourage patients to keep doing their best. I diagnose kids with new-onset Type 1 and tell them that they can live a perfectly healthy, normal life free of complications. This is the truth. It isn't my truth, but I keep that to myself. And I constantly feel like a hypocrite behind my cheerful facade.

My very situation is why Diabetes Awareness Month needs to exist. We need to get the word out to fund the research that improves and eventually eradicates this illness so no one else has to feel what I feel right now. I am grateful that the diabetes community has been so involved in getting the word out and wish I was a more vocal participant, but my rally cries have been overcome by a different kind of cry.

Pump Surgery

I have been on-call this whole month and it has been chock-full of interesting patients, though the majority involved issues with every hormone besides insulin. Keeping my head above the proverbial water has been a struggle.

So, of course, life decided to throw me a few more challenges in the midst of the work-related ones. Nothing serious - just annoyances like flat tires and stolen credit cards. And tonight I had my own medical issue that stole my attention away from the many tasks on my to-do list.

It started with a simple need for a pump site change. Then I got that low battery warning. No big deal, except that the battery cap on my pump appeared to be cemented on. I pushed and pushed and pushed the quarter against that plastic slot like it was the only job I had and it did not give me a hint of a budge. I pushed so hard that the plastic started to deform, causing the quarter to slip and slide out of place with each push. I started to doubt my approach.

Lefty loosey, righty tighty, yes? YES! I was definitely lefty loosey-ing, but without the loosening. It figures my husband was working late on the one night I REALLY needed him, haha.

I broke down and called the pump technical support, and the nice lady on the other end of the line suggested I find a pair of needle-nose pliers to help pry that battery cap off. She was willing to wait for me to find some, but I knew that was a lost cause. I went for a different kind of tool.

Rummaging through my husband's desk, I found a pair of surgical forceps -- medical pliers! They are normally used for grabbing on to surgical suture or vessels or skin, but I used them to operate on that battery cap and operate they did! It was off in less than 5 seconds.

We may not have the most traditional toolbox in our house, but it gets the job done!

Washed Away

A childhood in Florida is amphibious. The summer heat is suffocating, and the only way you feel you can breathe is to keep yourself submerged in the cool water of pools, lakes, and oceans.

All of my fondest childhood memories involve the water. I would jump and doggy paddle and dive and dunk to my heart’s content. Hours later my parents would shout for me to come inside the house, but I would quickly duck under the water and pretend I never heard it.

Only diabetes had a real way of pulling me out. But not for long. Keeping juice near the edge of the pool or next to the beach chair would have me back in action minutes after a swimming-induced low. As a child, I felt invincible in the water.

But it wasn’t until just prior to my wedding that my now-husband convinced me to try SCUBA diving. He is a diving enthusiast, but I had never given it much thought before our relationship because no one close to me was a SCUBA diver. I finished my certification a few weeks before our wedding, and after the ceremony we jetted off to beautiful blue waters to try out my new skills. It was love at first dive.

I am extra vigilant of my diabetes before I dive. I check my blood sugar just prior to jumping in to be sure I am running between 200-220 mg/dl before the 45 minute swim. Sometimes there are strong currents that force me to work harder than expected and it can zap my blood sugar. Rising to the surface for a glucose source during the dive is not an option for risk of getting the bends, so I pack my dive vest with one or two 30g carbohydrate gel packs that I can squeeze into my mouth in case I go low under water.

I am also sure to be extra vigilant once I’m out of the water, again checking my blood sugar and treating any residual high or low blood sugars.

But being under water allows me to feel free in a way that I never am when I am above it. My oxygen tank and BCD replace my pump and CGM. Any electronic beeping comes from dive computers and underwater cameras, not high and low alarms. The only thing stinging my skin may be an occasional brush with fire coral, not pricks of a lancet.

The shouts and demands of life above are replaced by the calm sound of the bubbles flowing from my mask. I float effortlessly over underwater landscapes and creatures, the weight of the life with diabetes washed from my shoulders.

Until the Cure

Diabetes is Goliath, and researchers often feel like David. How are we ever going to take down such a huge opponent? Where is the cure?

I want those researchers to focus on the cure. But I also support work that looks into how we can live well alongside the beast that is diabetes.

But I have been seeing a lot of angry comments swirling around the internet regarding support of non-cure based research, especially pertaining to the artificial pancreas.
"We don't want another fancy pump! We want a cure!"
"The artificial pancreas is just another money-making device for big pharma! We want a cure!"

I understand. I have had diabetes for 20 years and would give anything to not have it. I would be delighted to be "out of a job" in caring for kids with Type I. There are few other wishes I use on birthday candles and fallen eyelashes.

But I still have a hard time fully sympathizing with those sentiments.

I gave a lecture this past week to first year medical students. They wanted to learn about the dual-hormone artificial pancreas, but starting there would be like picking up a book and reading the second to last chapter first. I had to start from the beginning to help them really appreciate how significant the artificial pancreas will be.

We went over how doctors did not even know that a lack of insulin was what caused diabetes for the 3,500 years it was recognized as an illness. How people died within a year of diagnosis from starvation until Drs. Banting and Best discovered how to effectively use insulin. How the insulin had to be drawn into glass syringes that had to be sterilized with heat and how the very long, very thick needles had to be hand-sharpened each day. And about how the insulin came from animals, which created a series of side-effects in many patients until human insulin was able to be synthesized. And once we had human insulin, things improved again with fast-acting Humalog/Novolog and long-acting Lantus. Insulin pumps were invented and refined year after year.
We also discussed how the measure of insulin's effectiveness could only be examined through urine, then through cumbersome blood tests, and ultimately with the advent of continuous glucose monitoring.

We have made such amazing strides in the last 90 years, but mostly rapidly within the last 30 years. Lantus came out when I was in high school and completely changed my quality of life -- no more rigid time schedules, no more inflexible meal plans. I felt like my day wasn't dictated by diabetes in nearly the same way it had been for so many years. And when pump technology improved, it changed my life for the better tenfold. And my CGM is the only reason I have been able to maintain the tight control that I'm in now.

It is hard to appreciate how far we've come when all you have known is pumps and CGGs. All of these advancements were only possible through research - in petri dishes, in animals, in humans. Research gave us these gifts.

The development of refined insulin saved millions of lives. But what if we had stopped there and only focused on the cure? We wouldn't have any of the amazing products that help us live well with diabetes today.

The artificial pancreas is going to be the next big life-changer. The preliminary data is astounding, with Dr. Damiano's study giving trial patients projected A1Cs of 6.3% with less work than they put into their diabetes now. Why would we not support this? Researchers are devoting their lives to this work and many have children and other family members with Type 1 Diabetes. They hunger for the cure, too. But they hope to make life with diabetes better in the meantime.

People often mistakenly believe that supporting non-cure based research detracts from finding the cure. There are armies of researchers trying to realize hundreds of different possibilities. Projects are taking place simultaneously all over the world to treat, prevent, AND cure diabetes.

Shouldn't we continue to tackle this beast from all angles? My answer to that question will always be yes.

And in this way, we'll eventually take it down.

Grinch

I don’t like denying patients anything. I always try to find a way to make things work. An appointment time on a day I don’t usually work? I can swing that. A diabetes supply that isn’t covered by their insurance? I will do my best to figure something out.

But the other day I was asked to sign off on a wish – of the Make-a-Wish variety. Except the Make-a-Wish foundation had already deemed the patient medically unqualified for their services, so they forwarded the requested wish to a similar foundation. That foundation called me.

I asked them what their criteria are for granting wishes so I could better assess this patient’s qualifications. They told me they fund wishes for children aged 2 ½ to 18 years with “life-threatening illnesses” that are either “progressive, degenetrative, or debilitating.”

I mulled it over in my mind.

Is diabetes a life-threatening illness? Yes, it can be.
Is it progressive? Maybe. Taming it does not always become MORE difficult over time, but some people do develop hypoglycemia unawareness later in life.
Degenerative? No, that term is usually reserved for horrible neurologic diseases that render patients unable to communicate, feed themselves, ambulate, etc.
Debilitating? Yes. But only with poor control for years and years. And even then, it isn’t debilitating for everyone.

Our office knows this patient well. His family is lovely and his father has a prominent position in the community. His diabetes has been impressively controlled since he was diagnosed seven years prior. He actively participates in multiple sports and after-school activities. He is planning on attending a competitive university. Diabetes has never held him back and was showing no signs that it ever would.

I decided that I had no choice but to sign that the patient was not medically eligible for the wish as he did not meet the criteria put forth by the organization. The woman on the phone – clearly seeking the opposite answer – told me that their criteria are “more open to interpretation” than those of the Make-A-Wish Foundation.

I mulled this over, as well.

There are other patients in our practice that qualify to have the rules bent a little more in their favor. For instance, there is a child that had to be taken from his home because his father is in jail and his mother has a drug addiction that left her unable to care for him and his diabetes. Foster homes are difficult for ANY child, but even more so for him because few families are willing to undergo the training and devote the time necessary to care for a child with diabetes. His diabetes is holding him back and making his life palpably more difficult – a life that is gut-wrenchingly difficult already.

It made me uncomfortable to tell the foundation representative that I could not sign off on the request, even though this particular patient is living such a full and vibrant life.

“It breaks my heart to have to call them and tell them they were denied,” she said to me.

“I’m sorry. But it breaks my heart even more to use your funds on this request that would be better served for a child that needs it more,” I responded. I signed the denial and faxed the form with resolve.

Nevertheless, I have felt like a grinch ever since.

Time Bomb

Time slips by quietly until you are almost 18 years old. It seems like everyone counts down the days until that big milestone. And when it arrives, you instantly morph from child to (young) adult.

At least in the eyes of the law.

The day a child turns 18 can be bittersweet for pediatric physicians. Graduating a patient from the practice can be difficult to do if a close rapport has been established over many years, or it can be difficult for many other reasons.

Not long ago I treated a patient admitted to the pediatric intensive care unit for diabetic ketoacidosis, but was not familiar with him as he was followed elsewhere for his routine outpatient diabetes care. I looked at the long list of visits that filled his hospital chart and was appalled – in the 4 years since he had been diagnosed with Type 1 Diabetes he had been admitted a handful of times for DKA and had over 10 documented hypoglycemic seizures. There were notes about his ongoing refusal to partake in treatment with psychology or psychiatry despite his family’s pleas and how he would become combative and strong-arm his way out of the hospital. He could not legally sign himself out of the hospital, but his parents were always left with little choice but to sign the discharge papers against medical advice. His relationship with them was so strained over his poorly controlled diabetes that he often lived with friends for weeks on end instead of coming home.

I waited until he was alone in the hospital room to sit down and talk with him. I pointed out the number of admissions he had in 2013 alone, and he corrected me. “It’s actually way more than that, they just haven’t all been at this hospital. I’ve had over 20 hypoglycemic seizures and over 10 admissions for DKA. I feel like I’ve been in the hospital longer than I’ve been out.”

I asked him if he had thoughts of suicide, because his erratic insulin administration (skipping shots and then ultimately overdosing) could very well kill him. He denied suicidality, but his actions spoke louder.

“I just don’t care,” he said as he looked at me. His face was as indifferent as his words.

Looking back down at his chart, I realized he was only a few weeks away from turning 18. This was significant, because in a few short weeks he would have the legal power to refuse all treatment for himself at his will. If he kept going down his current path, he would surely meet a premature death. Our endocrine team discussed the situation with his own endocrinologist and the ICU team. We all agreed that something drastic had to be done while we still had any power over him -- while he was still a minor.

His parents were approached with the idea to admit him to a medical-psychiatric unit and carry through with it even if he fought and argued and refused. They worried about his potential reaction, but knew that his health was dangerously at stake. His parents, desperate for any intervention that would help their son, agreed.

When the patient heard about the plan involving inpatient med-psych treatment, he said no.
When we did not accept that answer, he ripped his IV lines out and headed for the door.
When security blocked him, he tried to fight them off.
When he continued to fight, we had to give him a sedative and transfer him to a unit that rested behind a double set of locking doors.

It felt like a harsh way to handle a person who is almost an adult. But he wasn’t an adult – not yet. After that day, the time leading up to his 18th birthday may have ticked by very slowly for him. But it is our job to ensure that his time keeps ticking at all.

Attachment

Every once in a while, the tables turn and your own life experiences stare back at you. It is an odd feeling, to view things from the other side.

I have been going to the ophthalmologist each week, like a good patient, to patiently sit while he burns my retina. The lasering itself is only slightly uncomfortable (probably more anxiety-driven discomfort than anything else) and is relatively short. Every week my mother calls me on my way to the appointment to wish me well and express her distress over her being so far away from me. Her calls are like a warm hug and ease my pre-appointment jitters. And she is always the first person I call after I’m out, though the conversation is always the same. She expresses her pride that I am doing what I need to do to stay healthy, and then offers to fly up to be with me for the next appointment. It is sweet, but silly.

She did finally fly up to visit with my father, though not because of my eyes. We had long planned a visit over Labor Day weekend with a short stop-over in New York to attend the U.S. Open tennis tournament. It was a wonderful weekend, and I didn’t think about my eyes and the damaged retinas inside of them as they followed those tennis balls back and forth across the tennis court. Things were good.

But over breakfast the next morning I could tell something was wrong - though not with me. My mother looked like she hadn’t slept at all. She told me that throughout the previous day she had seen “floaters” in her right eye and before bed she saw a series of “lightning-like” flashes in her right eye. We only briefly covered common eye problems in medical school, but I remembered enough to be concerned that she was possibly experiencing a retinal detachment.

I quickly called my ophthalmologist and explained, but the doctors were in the operating room that day. The nurse recommended an optometrist that the office trusts, and thanks to some amazing luck he was able and willing to squeeze my mother into his schedule for an urgent dilated eye exam.

As we drove to the appointment, I felt my mother’s stress build the same way mine does before my eye appointments. I held her hand as we walked toward a scenario I thought was only ever going to pertain to me.

I took a seat near my mother’s exam chair and, in an effort to lighten things up, chatted up the optometrist. I joked about how I had been spending so much time with eye doctors lately given my recent diabetic retinopathy. His own eyes widened, and he shared that he has had Type 1 Diabetes for 20 years as well, and that he too is on a pump. Even though it had no bearing on his examination skills, our common bond somehow put me at ease. And he was wonderful with my extremely nervous mother, speaking softly and answering her questions clearly.

Her retina had not detached, but her posterior vitreous had. He explained to her that the gel in the eye shrinks with age, and the vast majority of older people experience this. The shrinking gel causes some pull on the retina, causing the flashes and floaters. She is at risk of retinal detachment as it shrinks further, but the risk is small and it will be caught early if it does happen. It just needs to be watched.

As we walked out of the office, again hand in hand, I better understood why she always wishes she was there with me during my own appointments. Health scares are scary for the whole family, not just the patient.

The tables may have turned on us that day, but I am so grateful I was able to sit right next to her.

Grave Mistake

An endocrine emergency takes place right next to an endocrinologist, but she cannot do anything about it. Why?

Endocrinologists have all resuscitated patients and dealt with common medical emergencies, as they must train in either internal medicine or pediatrics prior to sub-specializing. But when you spend all of your time in a subspecialty, you don’t routinely practice the other skills. Endocrine emergencies are limited to adrenal crises and episodes of DKA, not heart attacks and strokes.

I thought about this a few months ago as I was walking to the ENDO conference. Attendees were given bright purple tote bags, and the streets were flooded with purple. I laughed to myself thinking that despite thousands of doctors milling about, how useful would we really be in an emergency that wasn’t involving hormones?

I met a lot of different people over the four days that I was there. One was a physician from Europe hoping to train to be an endocrinologist and he hung out with me and a group of friends the whole time. He noticed my insulin pump over dinner one night and we had a long discussion about it, as they are not commonly used where lives.

He and a co-worker of mine went sight-seeing around San Francisco the next day, which involved a heavy amount of walking. A few hours into it, they were at a street corner waiting to cross and he suddenly went pale and started speaking incoherently. My friend who was with him, and who is an adult endocrinologist, feared that he was having a stroke or maybe displaying signs of encephalitis. She sat him down and called 911 because he was completely unstable and deteriorating rapidly.

EMS showed up and immediately tested his blood sugar. It was 31 mg/dl. It turns out he had Type 1 Diabetes. He had not told any of us about it, even after I had spoken very openly about my own diabetes the evening before. He was not wearing medical alert jewelry, but he did have a messenger bag full of glucose tabs. The only problem was that he went hypoglycemic so quickly that he was unable to verbalize that they were in there and she did not know to look.

How ironic that one of the few emergencies that endocrinologists are really good at dealing with happened right in front of one and she was still unable to help. People cannot help in an emergency unless they are equipped with the right information. Despite being a doctor in the company of doctors, he felt so self-conscious about his diabetes that he was uncomfortable sharing it.

He learned his lesson the hard way. Luckily for him, he got glucose in time and then started to think more clearly about being open about his health.

Breaking Point

There is no use crying over spilled milk. Or spilled Lantus. But that doesn't stop anyone.

 Every once in a while, a frantic call comes in via the emergency pager about this very thing. More often than not, the call comes in the night the patient was first discharged from the hospital. The night we nudged the entire family from the nest, with the parents feeling like the flailing baby birds.

They are so very green - only 3-4 hours into unsupervised life with diabetes. Lantus is the last hurdle of the day, but it's a high one. Do you remember the first time you held a vial and syringe? The first time you tried to hold both with one hand while pulling back the plunger with another? It seems so fluid now - having done it a countless number of times - but it wasn't always so mindless.

Sure, they spend lots of time practicing while in the hospital. But nurse and doctor supervision is a warm, comforting blanket that got left behind. Doubt and fear quickly creep in, chilling parents to the bone, and they panic. They tremble. They drop things.

The insulin spills everywhere, permeating everything. But so does the fear, sadness, frustration, and anger that has been building and building and building since the first news of the diagnosis. Having not had diabetes long enough to build up a stash of supplies, they have no recourse but to contact the on-call doctor.

Those emotions come spilling through the phone line, too powerful to stop. I've heard parents at their most panicked, rambling incoherently over my attempts to soothe. I've heard husbands and wives carry out screaming matches that I am forced to awkwardly sit through, unable to mediate because no one is able to hear me. I've had parents take out their frustration on me, yelling that I should have prescribed two bottles instead of one.

I can easily call in a prescription to remedy the insulin shortage. But when that first bottle hits the ground and shatters into a million tiny pieces, it always manages to crack their spirit, too.

And there is no prescription I can write to remedy that.

I'll Dye Another Day

I survived my first retina lasering session. I know, I know. I sound extreme. Why wouldn't I survive it? Well, I wasn't so much concerned about the laser as I was about the dye test they had to administer beforehand.

At the appointment during which I was told of my retinopathy, my doc explained that he would have to insert a needle into my hand to administer sodium fluorescein, a fluorescent dye that helps light up the blood vessels in my eyes to faciliate picture-taking so he could have a good road map for zapping those unwanted vessels on my retina.

As is standard protocol for consenting a patient for a procedure like this, he listed off the possible side effects of the dye. In residency, I consented patients for procedures and surgeries all the time. No big deal. Let's get on with it: Nausea (pfft, that's nothing), vomiting (meh), hives (itchy, but I can deal), and anaphyctic shock (hmmm, not so fun), and about 1 in 250,000 result in death (um, WHAT!?).

But I was so overwhelmed and emotional from hearing that my eye was trying to invade itself with wayward blood vessels that I just sort of thought I heard him wrong.

When I got home, I talked to my husband about it. I thought 1 in 250,000 sounded kind of high. He thought it did, too. But why would they do it so commonly if the risk was that high? I convinced myself that I misunderstood him. Wanting the truth, we both used our doctor-tools to look up doctor-papers and come to doctor-conclusions. I wasn't able to find that exact stat, but I did find papers that detailed a few patient deaths. I fixated on one that occurred because the patient had no access to life-saving epinephrine (to stop the anaphylactic shock). I felt better! Surely, the office had epinephrine.

But then doubt crept it, mostly because I work in hospitals and clinics. I know that supplies aren't guaranteed. Things expires. Things go missing. I wanted to call the office to ensure they had epinephrine, but I stopped myself because I didn't want to be "that patient". You know, the crazy one.

Fast forward a few days later, and the issue is still haunting me. So when the office called to confirm my appointment, I hesitated for a brief second and them meekly asked if I could ask a question. "Of COURSE we have epi, the staff assured me." Cue sigh of relief.

So I go the next day, petrified of the unknown but determined all at the same time. The tech who would administer the dye asked if the doctor had listed the possible side effects. With a smile, I said yes. Then (I don't know why I said this) I continued with, "But he said 1 in 250,000 resulted in death. I heard that wrong, didn't I?"

She looked at me and simply said, "Oh no, that is correct."

My heart rate rising a bit, I pushed it, "Oh, but only those without access to epi die, right? I mean, they go into anaphylactic shock and then die because they don't have epi, right?"

And she says, very matter of factly, "Well yes, they go into anaphylactic shock. But 1 in 250,000 die regardless of the use of epi."

I think I turned white. She took note and quickly tried to comfort me, "But don't worry! I've been doing this a long time and that has never happened! It will not happen to you!"

Cardinal rule #1 of medicine: Never speak in absolutes. Doctors tend to be superstitious folk. In residency, if someone told you "Oh don't worry, you'll have a quiet overnight shift!" it pretty much guaranteed you would have the worst, most disastrous night of patient care you have ever experienced and would ever experience in you entire career.

So her well-meaning words of comfort only served to send me into panic overdrive. I was going to die.

I was sent into the waiting room so my eyes could work on dilating. Waves of sadness and fear washed over me. Of all the ways to die, I wasn't really keen on it being that day, in that office. I thought about backing out of the test, but knew I was being unreasonable. Nevertheless, I wanted to tell my parents and husband I loved them...you know, just in case. These were the thoughts flitting around my scattered brain. If I called them, I would (probably) unnecessarily freak them out. So I sent heartfelt text messages. That made me feel better for a minute, and then I lost it all over again.

Trying to muster all of my powers to self-soothe, I figured a comparison might work best. There are far more common ways to die, I thought! Things I do every day, like driving! I happily googled, "chance of dying in a car accident." I am the most morbid person I know.

BUT, it completely worked. I found this great New York Times article and felt comforted by the fact that I have a 1 in 84 lifetime risk of dying in a car accident. I get in cars all the time regardless of this horrific fact! And I also learned that I have a 1 in 79,746 lifetime risk of dying by lightning. I spent over 20 years of my life in Florida, which is lightning central!

Smiling like a loon, I found comfort in my macabre fact search. They called me back, inserted the needle, pushed the flurescein, and I forced myself to take a deep breath.

I'm still breathing.

It's Complicated, Part Two

I have previously written about the first time I was told I had some small signs of diabetic retinopathy. Though wrecked by that news, I pushed myself to move forward with optimism and resolve. I have been going to the ophthalmologist's office every 4 months with bated breath since then, and every 4 months I left that office with a "no change" report card and a sigh of relief.

I have kept my A1C at 7.2% or lower since that stressful day, fueled by both my desire to reduce the risk of complications and to one day expand our party of two. These past few weeks I hit my lowest ever and got the green light from both my Endo and my OB/GYN to get pregnant. A small part of my former poorly-controlled self always doubted my ability to get here, to achieve this. I floated home to my husband to share the news - the thought of possible parenthood both thrilling and horrifying us at the same time. I was a bundle of emotions at thought of being allowed to work toward a bundle of our own.

As timing would have it, all of my appointments were grouped over a 2 week period, the last being a follow-up ophtho visit the day before we left for a week-long European vacation. I was packed and ready to go make memories (and maybe a baby - that "green light" thing was all I could think about).

But this time I traded the sigh of relief for the uncontrolled gasps between sobs. I had proliferative change for the first time. There were appointments made for mapping out my eye vessels with an angiography study followed by laser therapy. He only saw changes in the left eye, but when I whispered through tears that I had gotten the go-ahead to get pregnant, he said we would have to be extra-conservative and laser any possible changes in the right eye, if present. Pregnancy can worsen retinopathy.

Then he gently said that I should hold off on starting a family, until we knew how the course would go.

I left the office silent and stunned. I called my mother from the car, my voice not revealing the turmoil building in the pit of my heart. She excitedly launched into conversation, starting with, "Shara! You won't believe what happened today! You won't believe it! I'm so mad!"

I let her continue, not feeling ready to release the floodgates of my emotions.

"Your father played the lottery and today he found out he got 5 out of 6 numbers! We almost won 42 million dollars! Can you imagine that? He was one number away! I can't even believe it, I'm so ANGRY!"

I sat, still and quiet, in my car. Over a thousand miles away, my mother then felt that something was wrong through the invisible phone line. I shared. And I cried. And I realized that I did not care that my father had almost won 42 million dollars. It wouldn't have reversed the changes in my eye. It wouldn't buy back the life I had before diabetes struck. It wouldn't change anything of worth.

They say health is wealth. I understand that in this moment, more than ever.

My green light has turned to red, and I would pay anything to be able to change it back.

Diabetes: How to Cheat

A1C's don't lie.

I don't personally use this statement when talking to patients because I find it a little too harsh. The second you offend a patient is the second they stop listening to you, so I always choose my words carefully in the office.

But the truth, though harsh, is that A1C's really do not lie. The problem is that they do not tell you the exact truth.

We see patients every 3 months for routine diabetes visits. Many patients modify the truth of exactly what went down during those 3 months. Modification runs the spectrum of simple omission, to sugar-coating (the irony), to flat-out fabrication. Parents are sometimes the offenders, but more often than not it is the teenagers. Teenagers long for independence with everything and then quickly find complete diabetes independence to be too overwhelming. But pride/embarrassment/immaturity often prevent them from coming clean and asking for help, so instead they simply lie.

Blood sugars - how does one lie about thee? Let me count the ways!

Some simply write down false numbers into a log book and then conveniently "forget" their BG meter at home. Others have parents who check their BG meter but do not actually SEE them doing the BG check, so those kids have to get craftier. They find out that they can dilute their blood to lower the BG numbers, whether it be with a generous swab of an alcohol pad or simply mixing their blood with water.
Others don't bother to prick their fingers, so they just check blood sugar levels with anything other than blood. They use regular soda, juices, and my personal favorite -- control solution! Because who really uses control solution for it's true purpose? Who even knows what control solution's real purpose is?! The beauty of "checking your BG" with control solution is that you'll get a perfect number every time. It also makes it one of the easiest tricks in the book to sniff out, because we all know that diabetes isn't that perfect.

But I saw a teenage girl and her father for a routine diabetes appointment over a month ago and am still impressed by her method. It's completely novel and she almost - almost - got away with it.

The suspicion started when her father anxiously asked what her A1C was at the beginning of the appointment. I first asked him what their expectation was based on the numbers they were seeing - and he answered "something in the 7's." My insides seized up when I saw that the the result was 10.9%.

I am extra sensitive about how I approach potentially untruthful teenagers because of my own nightmare experiences when I was a teenager and in poor control of my diabetes. So I carefully broke the news as gently as possible and then asked her and her father their feelings about it.

The girl was silent and looked nauseated. The father's mouth hung open in utter shock. He incoherently started sputtering that he uploaded the numbers from her meter every 2 weeks for the last 3 months and how her numbers were all under 160 mg/dl. He proclaimed that he sees her prick her finger almost every time!

I waited for the girl to speak but she remained silent and I thought she might vomit on me. Red flag #1.

I looked over the BG print-out. A standard day's worth of numbers included a 133 mg/dl at breakfast, 136 mg/dL at lunch, and 131 mg/dL at dinner, with a rise all the way up to 142 mg/dl at bedtime. What kind of pattern is that? A false pattern. Red flag #2.

I went over questions about snacking without bolusing, injecting insulin after eating instead of before, use of control solution to calibrate the meter to ensure accuracy, and even raised the possibility of a meter malfunction. I tried desperately to uncover a reason for the 10.9% other than manipulation.

Uncovering nothing, I transitioned to the physical exam. The girl's skin was clammy as hell and she had a tremor. Red flag #3? Perhaps. But first I had to be sure she wasn't going hypo on me.

"You're very clammy. Why don't you test your BG now to make sure you aren't going low?" I suggested. "And we can also see if there is a problem with the meter."

She silently went to her purse and took out her meter. Her hands would have broken the Richter scale the way they were shaking, and I knew in my heart that I was about to catch her in her lie.

The 5 second count-down to the result felt like 5 years. 289 mg/dL. According to her logs, she hadn't been over 200 mg/dL in 3 months. Her father almost fell out of his seat when he realized she had been duping him all that time.

So how did she do it?

She figured out that if your OneTouch bottle of strips says Code 25 but your meter is programmed to 24, it will give you falsely low readings. She burst into tears during her confession. My brain burst at the news of it all. No one in our diabetes office had ever witnessed this trick and we were dumbfounded.

We hugged her and thanked her for being honest. We set her up with counseling services and talked about the burden of diabetes. I hope that this was a big step toward coming clean and starting a new, healthy life with diabetes for her.

And I'm really glad that we were able to see the truth through the smoke and mirrors.


** DISCLAIMER: The tricks listed in this post are not meant to help anyone lie about BG numbers, but instead to help raise awareness of what can and is being done in order to recognize these cover-ups earlier. **

Jeeves!

I used to wish for an assistant. You know, the kind celebrities have to handle the everyday, mundane tasks like grocery shopping and answering the phone.

Today, I realized what I really, really want instead is a diabetes butler. I'm feeling some diabetes burn-out big time and I'm having a hard time shaking it.


This would be a total non-issue if I had a diabetes butler.

Wouldn't it be so amazing to just pay someone to constantly check your blood sugar, count your carbs, get you glucose tabs and juice, change your infusion sites/administer shots, keep track of the expiration date on the glucagon, argue with insurance companies, schedule your 487291278 appointments, and pat you on the back when diabetes just plain sucks?

I'm sure my husband would find it a little intrusive, but I'm sure he'd eventually get over it.

Jeeves! Where are you? 

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.

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.

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:

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.

Saucy

My husband I have just returned from a very nice dinner out with his grandfather, who happens to be 94 years old. He also happened to travel 2 hours from New York City to Providence...just to have dinner with us. He's truly a fantastic individual.

Selecting a restaurant is a bit of a tricky task when he comes to visit -- we have to find a place that qualifies as fine dining (he has a discerning palate) but also one that is quiet enough to carry on a conversation considering his hearing is not what it used to be. The typical corner joints usually don't fit the bill, and so we end up at places that get quite creative with their menus.

Eating out in general is always an adventure in blood sugar management. See how positive I was with that descriptor? It's an adventure. I always pick dishes that SHOULD be low carb, but somehow end up with blood sugars that skyrocket in defiance of my choice. Sauces are almost always to blame...restaurants are SO GOOD at hiding sugar in pomodoros, Indian curries, Thai sauces, etc. But tonight was a particularly ridiculous example.

Upon scanning the varied menu, I skipped over pastas and demi-glazed meats in favor of a dish simply called "shrimp + scallops". The plus sign was probably foreshadowing all the insulin I'd be adding to myself afterward. I swore the sparse caption underneath mentioned pearl tomatoes and fingerling potatoes. Totally carbohydrate countable options -- minimally guessing required.

What I received defied my taste buds. The shrimp and scallops were artfully placed over three side-by-side mounds of what I thought, on first glance, were grated potatoes. My first forkful sent my tastebuds into a sugary explosion, prompting me to finish the first mystery mound just trying to figure out what I was eating. There were bits of sweet corn imbedded in the display, so at first I thought it was just really ridiculously sweet corn. But my carbohydrate radar was going haywire. It couldn't be the corn.

When the server returned to refill water glasses, I asked him to remind me what I was eating as I pointed to the remaining two mystery mounds under the seafood.

"Oh yes, " he said as he clasped his hands together in delight, "that is spaghetti squash prepared in a bit of olive oil and then thoroughly doused in pure maple syrup."

I choked on his words. He used the words "doused" and "maple syrup" in a sentence describing my plate.

Who am I? Buddy the Elf? Who does this to dinner food?

Needless to say, I made my husband finish off my plate (because I felt like it would be rude not to finish an entree the server was so excited about) and I neurotically checked my continuous glucose monitor for the remainder of the meal. I've been dousing myself in insulin ever since.

Nail-Biter

During my first year of Pedi Endo training, I hold the on-call emergency pager for 6 months out of the year. It can go off at any time of the day, as many people have the number. Mainly, the doctors in the children's hospital and Neonatal Intensive Care Unit call with any hormone-related questions or about our admitted patients, the community Pediatricians call (for the same reason), and every single one of our patients has the number for any issue that may arise. Every single patient.

It can make for a lot of pager ringing.

When I hold the pager, I put other things on hold. Things like going to the movies or nice long baths, because it wouldn't be worth it if I got interrupted by an urgent call. I don't mind this in the least -- it is what I signed up for -- but I am sure to take advantage of the time I do NOT have the pager.

So last week I went to get my nails done, something I don't dare do with the pager in tow. It was a late Friday afternoon and the salon was packed. I picked out one of my favorite colors (a grey hue named Smokin' Hot, which is partly why I love it so much) and flashed a peak at my continuous glucose monitor. It was telling me my blood sugar was 80 mg/dL with a southeasterly arrow indicating that I was potentially headed toward a low. I popped a sugary mint in my mouth and dialed down my insulin pump before I sat down for some pampering.

Half-way through my manicure I start to feel smokin' hot, but not in the way the nail polish intended.  I had suddenly broken out into a clammy/flushed/word fumbling mess. I asked the nail lady to please hold on as I gingerly tried to search my purse for sugar without ruining her work. During my search, I didn't find anything sweet but I DID find my CGM all red and angry, screaming that my glucose was 55 mg/dL and dropping. After what my hypo-brain thought was 5 seconds but was probably closer to a minute, she asked if something was wrong. 

"Do you happen to have anything with sugar in it?" I meekly asked her.
"Do you have diabetes?" she asked, her eyes widening in concern.
"Yes, and it's so dumb because I always carry something with me but I switched purses and forgot to transfer it," I replied.

She shot out of her seat, ran over to one of her co-workers and whispered in her ear. They both started frantically searching the drawers in the nail work stations. The woman sitting next to me took note, and her eyes caught mine.

"Listen, I don't want to intrude but I overheard your conversation and I just wanted to let you know that I'm a doctor and I'm concerned about you," she whispered to me.

"That's so funny! I'm a doctor, too! It's pathetic. And you know what is even more pathetic? I am a Pediatric Endocrinologist. I TREAT KIDS WITH DIABETES AND THIS IS STILL HAPPENING TO ME," I confessed to her.

"That IS pathetic," she said with a smile.

At this point, the entire salon was searching for something sweet to give me. Finally, a woman in the far corner triumphantly shot her fist into the air, her fingers tight around a tube of Mentos as if she had found the holy grail. 

The salon collectively breathed a sigh of relief and I gratefully stuffed my mouth with 4 or 5 of them. Fresh-maker indeed. I was feeling much better after a few minutes and my manicure resumed. Turns out I didn't even need to be holding the endocrine emergency pager to have an endocrine incident interrupt my me-time. 

Freaky Friday - DBlog Week, Day #5

Just like in the movie, today we’re doing a swap. If you could switch chronic diseases, which one would you choose to deal with instead of diabetes? And while we’re considering other chronic conditions, do you think your participation in the DOC has affected how you treat friends and acquaintances with other medical conditions? (Thanks to Jane of Jane K. Dickinson, RN, PhD, CDE and Bob of T Minus Two for this topic suggestion.)

So many chronic disease, so little time.

The truth is, I appreciate that Type 1 is a chronic disease that - if done right - is one that can potentially make you healthier than you'd be otherwise. All that carb awareness and exercise. Good stuff. And even though pricking fingers and injecting insulin can sting, it doesn't hurt nearly as bad as a Sickle Cell crisis or Rheumatoid Arthritis. 

But if I HAD to switch, I'd choose a chronic illness that is way less high maintenance than diabetes. And being that I work in Endocrinology, you know I simply must choose something hormonal.

So I pick Hashimoto's thyroiditis, otherwise known as autoimmune hypothyroidism. It's still an autoimmune disease that destroys a hormone-producing part of your body, but replacing thyroid hormone is like pre-school compared to the university-with-summer-school-followed-by-grad-school that is insulin replacement. 

One tiny little pill per day instead of multiple injections? Only worrying about taking the pill on an empty stomach instead of timing insulin 15 minutes before eating? No immediate adverse effects if you forget a dose? Not having to count every carb? No thyroid hormone swings with food, exercise, stress, or just breathing? One doctor's visit per year instead of every 3 months? One lab draw per year instead of 8+ finger sticks per day plus annual lab tests? Yes, please! PLEASE!

And I know there are plenty of people with diabetes AND hypothyroidism. About 10% of Type 1's, to be more precise. But the deal is to swap, not to add on. If I can't swap out for hypothyroidism, I'll just stick with my current sweet ol' type. 

Click for the Freaky Friday - Friday 5/17 Link List

Accomplishments Big and Small - DBlog Week, Day #4

We don’t always realize it, but each one of us had come a long way since diabetes first came into our life. It doesn’t matter if it’s been 5 weeks, 5 years or 50 years, you’ve done something outstanding diabetes-wise. So today let’s share the greatest accomplishment you've made in terms of dealing with your (or your loved one’s) diabetes. No accomplishment is too big or too small - think about self-acceptance, something you’ve mastered (pump / exercise / diet / etc.), making a tough care decision (finding a new endo or support group / choosing to use or not use a technology / etc.). (Thanks to Hilary of Rainie and Me for this topic suggestion.)

I would not be writing this blog today if it weren't for my decision to finally start seeing a counselor for my very deep dark Diabetes denial.  I was a perfectionist in every aspect of my life - especially school. I was incredibly hard on myself in order to achieve my best possible results. Except with diabetes. And because I wasn't conquering it, I started ignoring it entirely. Guessing insulin doses, not testing for weeks on end...this went on for almost a decade. 

During this time I was on a horrible 3 month cycle -- diabetes appointment with horrible A1C, ugly cry with empty promises, repeat. Each time I convinced myself that I didn't need anyone else to help me. Every other goal I had set out to conquer I was able to accomplish all by my lonesome. Diabetes was supposed to be no different, but it was.

Something clicked inside of me during one of my subsequent ugly cries in front of my Endocrinologist. The words "I need help" came creeping ever so quietly around the lump into my throat and into the open air. Exposed, vulnerable, desperate words.

I was given the number to a counselor who only treated people with diabetes. She was a godsend, and I credit her with saving my life. She didn't just save it, she gave it back to me all shiny and new.

Through counseling I realized that suppressing my fears and anxieties about diabetes was incredibly exhausting all those years. It was even more exhausting to expel them, to open myself up to a stranger about a topic I couldn't even talk to myself about. But after each session I would float out of that office, lighter than helium. I was free floating into happiness and health and a normalcy I didn't know could exist alongside diabetes.

I started talking to other people through support groups. I got introduced to the DOC, and the DOC blogosphere. I now have the best A1Cs of my 20 years of this disease and I look forward to (hopefully) tackling a scary thing like pregnancy in the future. I never thought I could do it, but I am.

I am. 

Click for the Accomplishments Big and Small -Thursday 5/16 Link List

Memories - DBlog Week, Day #3

Today we’re going to share our most memorable diabetes day. You can take this anywhere.... your or your loved one's diagnosis, a bad low, a bad high, a big success, any day that you’d like to share. (Thanks to Jasmine of Silver-Lined for this topic suggestion.)

It was 2 months after my 9th birthday. Only 6 weeks after my diagnosis. 

I sat in my parents' bathroom. My skinny, bare legs pressed against the cold marble step leading up to the bathtub. I noticed how the orange plastic cap of the syringe in my right hand perfectly matched the skin of the orange I was holding in my left. My eyes darted from the syringe to the orange, the orange to the syringe, but otherwise I was paralyzed by fear.  

I had practiced injecting the orange and now my left thigh was slated to be the next target.

My father was right next to me, but he sounded so far away as he whispered words of encouragement. "You can do this, it won't hurt. It doesn't hurt when we give you your shots." 

I was frozen. A fat, salty tear rolled down my cheek and several more followed suit. They threatened to melt me into a puddle on the bathroom floor. 

I sat on that step in the bathroom for over an hour. I did not question why I had to learn to self-inject that day, instead of the next day, or instead of years from then. My third grade brain did not process that it was just too young to take on such a responsibility because it was just that - too young. I could see the worry furrowing my father's brow and kind, patient eyes as I refused again and again. I didn't like for my parents to worry, so I tried to stifle my sobs. It only served to make them louder.

As I proceed through my Pediatric Endocrine training I sometimes look back on that day. I've asked my parents about it and they explained that they were instructed by the medical team to make me as self-sufficient as possible. They were told that the earlier I learned to do things like injections myself, the more successful I would ultimately be. 

That belief has been shattered across the years, with study after study showing that the earlier the diabetes independence, the poorer the outcome. We encourage parents to continue to inject their children for as long as the child allows it. Hopefully, this memory remains just a memory for me and never a reality for future newly-diagnosed little ones.