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.
Tuesday, June 25, 2013
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.
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.
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. |
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:
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.
Tuesday, May 28, 2013
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.
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.
Saturday, May 25, 2013
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.
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.
Friday, May 17, 2013
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
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
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