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.