Thursday, January 30, 2014

What I learned from the Atlanta Ice Disaster of 2014

In the event you're unaware, Atlanta recently experienced some snow and ice. Long story short, and politics aside, nobody did anything to prepare any of the roads for this mess. It did come down quickly. My professor said we still had class at 12:30 when campus was closing at 1. I normally give myself 45 minutes to get up to school and park, but I was playing it safe and left at 11:30 for class. It started like this:

An hour later, it had progressed into this:

My parents live significantly closer to my school than I do, so I decided to go to their house and ride it out. Normally it takes me maybe 30 minutes to get to their house, depending on traffic. Tuesday it took me 4 and a half hours. I looked like this:

Not my best day, I assure you. I got to my parents' house, where I was not prepared to stay. I didn't bring any clothes or D supplies with me. It is my parents' house, and I usually have a horde of stuff here, just in case. Buuuuut I used my spare insulin when I was staying here over Christmas. I have tons of pump supplies, a few syringes, a spare meter, but I had no insulin. And then my pump started beeping. Fantastic. I dug through a bag that had been in my old room since a week after Christmas, and I came up with an unopened bottle of insulin, still in its box, sitting in a bag I had brought over in the week following Christmas. Great? Okay. That room gets really, really cold when nobody is there to crank up the space heater. The bag was in the sun for about an hour every day. Having no other viable option, I used it. And I ran high for a long time. Then I started increasing my boluses by 20%. Success! Well, success until I overcompensated and dipped to 50 overnight. Oops. But I'm still alive and kicking. 

So, next week when I show up for dinner, I'm bringing some insulin and test strips to restock my supply. Just as the city of Atlanta thought it was prepared, so did I. Fortunately I was only in my car for 4.5 hours, and I came out of it on the other side. Unlike the city of Atlanta, there is a good chance that I will learn from this experience and be better prepared in the event this ever happens again. 

Personal Reflections on Journal Article- Optimizing Insulin Pump Therapy: A Quality Improvement Project

I spent part of my lunch break reading an article from the November/December issue of the Diabetes Educator. The title is  Optimizing Insulin Pump Therapy: A Quality Improvement Project.

From the abstract:

Purpose The purpose of the study was to assess insulin pump use and provide ongoing education.

Methods A quality improvement project using a pump assessment questionnaire was implemented at an endocrinology office in the southeastern United States. The questionnaire was designed to evaluate all aspects of insulin pump therapy, including pump operations, infusion set failure, management of acute complications, and usage of advanced device features. Eighty-nine patients (80% with type 1 diabetes and 20% with type 2 diabetes) completed the questionnaire at the endocrinology practice. A certified diabetes educator reviewed the questions with each patient, identifying deficiencies and training opportunities.

Results The most common areas of deficiency identified after implementation of the assessment form included the following: expired or no basal insulin prescription in the event of pump failure or removal, no mupirocin (Bactroban®, GlaxoSmithKline, Research Triangle Park, North Carolina) prescription for suspected site infections, lack of insulin syringe if pump stopped working, failure to check urine ketones, no antiemetic prescription for sick day intervention, using manual bolus instead of bolus calculator, and lack of in-date glucagon kit.

Conclusions Use of a pump assessment questionnaire allows for focused discussion concerning patient behaviors related to pump operations, troubleshooting, and self-management. Incorporating use of a pump assessment questionnaire into routine practice may result in improved patient education and avoidance of adverse events specific to insulin pump therapy.

Essentially, the authors of this paper gave questionnaires to patients in an endocrinology office who used insulin pumps.  Those who were included in this study were exclusively Medtronic users with a minimum of one year of experience using their pump. The survey used closed-ended questions to facilitate conversations between the PWD and their health care team. The office has 2 endocrinologists, and an FNP who deals with most of their pumpers. It's unclear from the paper as to whether or not annual visits to assess pump use were a given for this practice or not, but it seems the office will start using these questionnaires annually.

The authors achieved their goal of identifying weaknesses within their practice. Through use of their surveys, they were able to determine which topics each patient needed to cover in order to increase the effectiveness of pump therapy. I'd be interested in a follow-up paper to determine if spot retraining helped with overall control.

My personal reflection on this post is that I can identify with many of the shortcomings elucidated in this paper. The one that worries me the most, but I continually forget to mention with my doctor is a lack of a backup plan if something were to go wrong with my pump. I have not had a prescription for a basal insulin in over 10 years. Only once has anything gone wrong, but when it did I was testing and injecting Humalog like nobody's business. For a day and a half. It was pretty crappy. I should really do something about that.

Along the lines of preparedness, I haven't owned Glucagon probably since diagnosis. Thankfully, I've never needed it. But I suppose the point of emergency preparedness is to, you know, be prepared for emergencies that hopefully never happen. The article also stresses that we pumpers should have a prescription for mupirocin in our bag of tricks in the event of a site infection. It's not a bad idea, but the few infected sites I've ever gotten were easily worked out with Neosporin.

Other than those things, I feel pretty good.. Of the identified shortcomings, most of them deal with being prepared and not having prescriptions for glucagon, mupirocin, and antiemetic drugs. With the exception of basal insulin, I am decently prepared.

The key to using an insulin pump is using it effectively. Perhaps more endocrinology practices should use similar questionnaires to identify weaknesses in pump use. Personally, I haven't had pump training in... well... pretty much since Medtronic introduced the Paradigm with the Bolus Wizard. I think I got mine in 2007 or so. I'm sure there are some gaps in my pump education.

Thursday, January 9, 2014

D-goals for 2014.

Inspired by the DSMA chat last night (1/8), I set out to make a list of diabetes goals that I have this year. It's not a long list.

  • Bring A1C down below 8. How?
    • Get better at carb counting. After 16 years, I've got the basics. What I need to get better at is determining the "weird" factor. For example, my body is weird with peanut butter sandwiches. Even when I measure the peanut butter, my blood sugar goes higher than it should, and I have to give an extra unit of insulin when I eat a PB sandwich. I need to identify more food patterns like this so I can bolus more effectively.
    • Choose the lower carb option. This is self-explanatory
    • Change my sets more regularly. I need to start putting my set changes on a calendar so I can keep better track.
  • Figure out how to exercise without dropping 50+ points. It's annoying. Even when I disconnect my pump, my blood sugar drops at least 50 points when I exercise. It's not a big deal if I start out around 160, but anything below that usually ends with a snack. Which doesn't help me lose any weight, which I would like to do.
  • Make this the year of the CGM. I've wanted one for a long time. Really. I've done my research on them, but I haven't brought it up with my endo in over a year. This falls under my non-D goal of being more assertive. 
That's it. That's my goal list. I don't normally set goals. Usually I give myself challenges like seeing how many days I can go without breaking 200. It's not a "go X days" goal, because diabetes is NOT as formulaic as we would like it to be. I only let myself get upset about breaking the streak if it's something I could have prevented, like forgetting to bolus, not changing my set in time to prevent bad absorption, etc. 

Someone remind me of this post in June. I'd like to see how I'm doing, and kick my own ass for not having had the CGM talk by then.

Wednesday, January 8, 2014

Change of (educational) Plans!

Depending on how well you know me, you might know that I'm quite passionate about anthropology. I have a Bachelor's in anthropology. I completed one semester of grad school for anthropology. I've been to Greece to study bones. My bookshelf is overflowing with anthropology texts. But... I quit. Anthropology no more, well, not as a career goal. What am I doing with myself now? I'm going back to school. For nursing. With any luck, I can eventually become a CDE. Even if  I don't make it that far, I think I will be happy in nursing. 

Don't get me wrong. I still love anthropology. I do. I doubt I'll ever be able to shake it. Why do I want to leave it? It's complicated. I am actually good at writing papers and giving presentations. I love reading. Unfortunately, I don't think I can spend the rest of my life doing it. Papers, teaching college, conferences. Even if I found a job as a career academic, I don't think it would make me as happy as it used to. 

I was hanging out in the grad lounge, waiting for my advising session when all of this hit me like a ton of bricks. I went into my advising session anyway, discussed research and classes to take, and walked out of there feeling numb. Suddenly I didn't care about any of it anymore. 

I don't cry. When I get upset, I get physical. I get deadly quiet and unleash it when I'm alone. I cried the entire walk back to my car. Anthropology was all I wanted to do since I was a junior in high school. I had a degree in the subject, and suddenly I didn't care at all. What was I going to do? As suddenly as it had hit me I didn't care about anthropology, another idea hit me: nursing. Before I wanted to be an anthropologist, I wanted to be a doctor. I don't want to be a doctor anymore, but nursing is something I think I can do. 

For people who know me casually, it seems like something I could do, caring for others. For people who know me pretty well, caring for others doesn't seem like something I'd do. I'm that misanthropic, caustically sarcastic bitch. For people who know me incredibly well, they know that caring for others is something that would fit me perfectly. 

My realizations hit me really fast, but it's taken a LOT of thought to actually go through with this. Dropping out of grad school and re-enrolling in my alma mater as an undergraduate again... it's hard. I'm on waiting lists for the important pre-requisite classes (chemistry and anatomy/physiology). I can (hopefully) apply for nursing school in the fall, to begin nursing school in fall 2015. I'm not sure how in hell I can pay for any of this. I don't have a job. It's going to be a long road ahead, but I think I can do this. Wish me luck. 

Monday, January 6, 2014

If diabetes were a person...

I think I'm going to make this a continual game on my blog. If diabetes were a person, what would I say to it on any given day? Today diabetes is being that friend that everyone has that they tolerate. Today diabetes is being that clingy friend that you feel irrationally bad about hating sometimes.

It started out simple enough. Like most of my Tweets, I just spat it out.

Why did I choose to express my hate at that moment? My BG was fine, my pump was perfect: set, reservoir, battery... all good. Diabetes wasn't even being challenging at the time. Why the rage?

I've been... otherwise occupied. Not busy, exactly, just occupied. My mother had back surgery on Friday. Since then I've been hanging out at my parents' house helping out. Cooking, cleaning, laundry. I'm trying to register for classes I need that are all full. I miss my boyfriend. It's really cold outside (seriously, 17 degrees in Atlanta. Yuck). Like it normally does, diabetes has been that "friend" following me around screaming "BUT WHAT ABOUT ME?!?" I just have to deal with it. Take a few minutes to assure it that I haven't forgotten about it, and manage things. All things considered, I suppose diabetes hasn't been so demanding recently; my numbers have been okay and my pump hasn't done anything stupid for a few days. 

I'm just tired of dealing with it. I have better things to be doing with my time. Here it is:


I know I haven't been giving you the attention you're used to. I haven't synced my pump in a while. I know. But we did those blood tests together today. I changed my reservoir. I corrected for that high. Thank you for being understanding right now. I am helping my family right now and trying to get things together for the semester. So, thanks for not throwing a temper tantrum. I am fully aware you could be making things so much worse right now. Just know that while I do still hate you, I don't hate you any less just because I haven't been giving you the attention you're used to. I promise you at least 4 blood tests per day.