#1155 Grand Rounds: School Nurse

March 27, 2024Scott Benner

Scott and Jenny discuss proper type 1 diabetes management in schools.

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Hello friends, welcome to episode 1155 of the Juicebox Podcast

Welcome back everyone to the Grand Rounds series. I hope you're enjoying it. Today's episode is for school nurses. If you know a school nurse who'd like to know more about type one diabetes, send this one to them. Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes. If you'd like to help with type one diabetes research, you can do that right there from your smartphone or your tablet in just 10 minutes. T one D exchange.org/juicebox. They're looking for US residents who have type one diabetes or are the caregivers of someone with type one. You're going to help people living with type one diabetes, you may help yourself you're definitely going to support the podcast in less than 10 minutes T one D exchange.org/juice box please go fill out that survey. I cannot tell you how much it helps.

This episode of The Juicebox Podcast is sponsored by cozy earth.com Cozy Earth is where I get my clothing, linens and towels from they're incredibly comfortable and temperate. I love them. I really do love them. And I love that I can give you an offer code that will save you 40% off of your entire order. Just use the offer code juice box at checkout and you will save 40% at cosy earth.com This episode of The Juicebox Podcast is sponsored by the ever since CGM. Ever since is going to let you break away from some of the CGM norms you may be accustomed to no more weekly or bi weekly hassles of sensor changes. Never again, will you be able to accidentally bump your sensor off. You won't have to carry around CGM supplies and worrying about your adhesive lasting. Well that's the thing of the past. Ever since cgm.com/juicebox. This show is sponsored today by the glucagon that my daughter carries. G voc hypo Penn. Find out more at G voc glucagon.com. Forward slash juicebox. Good morning Jenny. How are you?

Jennifer Smith, CDE 2:44
I'm fine. How are you?

Scott Benner 2:46
It's Monday, I'm on my way to the dentist after this. I don't know how good I am actually.

Jennifer Smith, CDE 2:50
Oh fun. Hopefully they find nothing. They say you have sparkling tea.

Scott Benner 2:55
This is the end of a thing for me. So this is this is the easy visit after the two where he's like, sorry for the pinch and then stuck a needle through the palate of my mouth. Oh, oh, sorry, for the pinch. What a way to put that the pinch, sorry that it feels like someone's running a hot poker through your face. Actually, our dentist is terrific. So I shouldn't say that he's very good at making injections. Today, we're gonna go over the school nurse portion of the Grand Rounds series. And this one is great, because we added it late to the list you and I did. But then through happenstance, I started seeing a mass flood of school nurses come into the private Facebook group. And it turns out that just it just took one person in a different Facebook group for school nurses to say, hey, if you're having trouble with helping kids with type one, you should go check out Juicebox Podcast. So like a serious influx came in. And I took that opportunity to make a post and say to everybody that's in there, 45,000 people in there, there's gonna be a bunch of new school nurses in here, new members that are school nurses, what would you like to tell them? And then oh, my gosh, Jenny, the post ended up reaching 18,000 of my members, which if you don't know how the Facebook algorithm works, that's generous. Because even though there's 45,000 people in there, it doesn't serve it to everybody all the time. And it's

Jennifer Smith, CDE 4:21
interesting. I know nothing about the like people, they are looking at putting a picture in here for the algorithm. I have no idea what that means.

Scott Benner 4:30
Means the algorithm likes pictures, so it'll show it the more people and people like picture so they click on them. But this post got 170 replies, wow, after being seen by 18,000 of the members. Nice. And all I said was there's a large influx of school nurses who have just joined the group. I'd love to see a vibrant conversation aimed at them. What are your best tips? So that's what we're gonna go over today. Great. Yeah. So this is feedback from the community. These are from real moms and dads, and I have some input because I had a kid go completely through school. With a with type one diabetes, yes, I want to start by highlighting the anxiety that I felt our daughter was diagnosed when she was two. She was MDI for a couple of years. My first compelling feeling about getting a pump was I don't want another person to stick my daughter with a needle every day. Oh, interesting. That was just it. I mean, I don't know why that occurred to me like that. But I was like, I don't want that. So we got Arden and Omni pod. And that took away that one little thing, but you know, didn't really help anything else. So,

Jennifer Smith, CDE 5:36
right, it still means somebody else is pushing buttons. Yeah, right. And I don't know, like, I've always felt when I've gone to the doctor, and had to supply the thing to have them download. It's almost like taking a piece of my body and handing it over is kind of how I felt. And it feels very weird to hand that over. So I can imagine being a caregiver of a child or some, you know, or for somebody else. Yeah, the idea of that being touched, right?

Scott Benner 6:07
I'm glad you brought that up. Because I had this experience with Arden all the time, where I found, like, she's the nominee pod, right? So it's an insulin pump, that's tubeless. And the controller for it is therefore not attached to her. Right. But it has a physical distance limitation. It won't work if you're a certain distance away from somebody. And I used to have to tell her, Hey, stay still for a second, like stand here. While this thing makes a connection. It wasn't long, but it felt the humanizing to me a little bit.

Jennifer Smith, CDE 6:42
Yeah, I can see that. Because from a tubed perspective, you already have that mental piece of understanding that it's there. Sure, I have to sit here and a child might even not think about the fact that they need to sit there because the tubing clearly is a is a visible connection piece, also

Scott Benner 7:00
push a button on a two pump and hand the pump back to them. And then it does what it's going to do while they're walking away. And yes, before, I don't know, I just did something that always stuck with me that there was something not right about, even though it wasn't a demand, it was all done very kindly, but it was like you have to stand here stand here for a second. And it just made me think of that when you said, even just handing my data over to somebody else feels like I'm giving something away. It does. Yeah. So anyway, I would say keep that in mind. You know, when you're dealing with these kids that, you know, and you'll see as you go through the feedback here that there are a lot of opportunities to create moments where they get to feel poorly about things and and you're not gonna know they're happening, you know,

Jennifer Smith, CDE 7:44
and I think that in this same kind of line of talk, as a school caregiver or school nurse, that piece of hand the product over to me, when I mean, this is a beginning start of talking to the family, does the child actually know how to button push, and all you really do need to do is truly watch them push the button and make sure that the figures in the facts that they're putting into it are exactly what they need to be then great. Don't touch the product. There's there's no reason or anxiety,

Scott Benner 8:16
if they're going to do it wrong. Give it to me. If that makes the person feel like Oh, I'm that you lose your autonomy, right? Yeah. And I'm sure there are kids who aren't old enough or don't know how to do it or anything like that. That's one thing. But that is needed, you make a good point. I'm going to start here with this, this person just says I absolutely love our school nurse, she and the two ladies that helped her have become like, Mom, number two to my son. Oh, yeah. And the other diabetic kiddos at the school, I couldn't ask for better support system, and I have them, they're willing to learn more willing to help my child, I don't even think they realize how hard it is for me to give up control, but I completely trust them. Now, that's great. And many of you might be doing that already. But as we get through other feedback, you're gonna see that that's not everybody's experience. And I'm always the one the first one to say like, school nurses are no different than other health care professionals. You don't know who you're getting until you get them. And, you know, my problem always is that if you get somebody who's combative, or egotistical, or whatever might happen there and you have you get into this battle with them, you could just think this is normal and just take it. And that's, you know, upsetting to

Jennifer Smith, CDE 9:25
you. And as you bring that in, I think I've seen that more in working with families. I've seen that attitude, if you will happen a lot more with nurses who have and again, this is not all of them. But nurses who've been around for a while and have had experience with type one diabetes, or have an idea in their head about it, and how it should be managed. But it's very aged information. It's the old 15 and 15 rule right for treating lows, it gets stuck there. And no matter what is told to them, that's what they're going to do. And this is where those plans that you come in to school with, to care for a child who has some type of medical special need, like diabetes, those become really important and can be more of a teaching tool, then to say, Hey, I see that you, you didn't know what you were doing. But that was years ago, and we have to update this or each child that diabetes is into, you know, an individual same

Scott Benner 10:32
for every person, or even every food and people bring this up in their feedback, two main messages through through all these 170 comments are, please don't talk down to us. What I'm hearing is that that's how people these are their experiences and work with us. You know, like, yeah, and that that struck me too, is like, how did it become adversarial so quickly? I just want my kid to be healthy and in class and not missing time. And I'm assuming you want that as well. Right? How's it possible? We're arguing, you know, like, like, we're, we're literally on the same team. This person just says, Please don't talk down to parents about how they manage. This journey has been evolving over time. For us. It was quite emotional in the beginning. I didn't appreciate the discussions about checking everything through the doctor. Yeah, so it sounds like the school nurse anytime the mom said hey, could we change this or give her a little more a little less? Well, we'll have to call the doctor. I'm assuming from the school nurse side. That's something they have to do. But you got to see what it feels like here like I know what I'm talking about. Give them another half a unit I've lived through this 50 times right? Like on oh, we're gonna call the doctor with a law you're calling the doctor which is not going to get a response today. And maybe not this week. Right now my kid's blood sugar is going to be high all week long. Because you know, what's the point like at some point you got to be a an ally in this. If you take insulin or sulfonylureas you are at risk for your blood sugar going too low. You need a safety net when it matters most. Be ready with G voc hypo pen. My daughter carries G voc hypo pen everywhere she goes because it's a ready to use rescue pen for treating very low blood sugar and people with diabetes ages two and above that I trust. Low blood sugar emergencies can happen unexpectedly and they demand quick action. Luckily G vo Capo pen can be administered in two simple steps even by yourself in certain situations. Show those around you where you storage evoke hypo pen and how to use it. They need to know how to use G vo Capo pen before an emergency situation happens. Learn more about why G voc hypo pen is in Ardens diabetes toolkit at G voc glucagon.com/juicebox. G voc shouldn't be used if you have a tumor in the gland on the top of your kidneys called a pheochromocytoma. Or if you have a tumor in your pancreas called an insulinoma visit G voc glucagon.com/risk For safety information. This episode of The Juicebox Podcast is sponsored by cozy Earth and right now I'm looking at cozy earth.com to see what's going on. I got oh look at this bamboo pajama set for ladies. That jogger pants for ladies looks like plush lounge socks. That's one of Oprah's Favorite Things. There's the bath collection. We love the waffle towels, but there's also premium plush bath towels. Everything that you see here can be had for 40% off with the offer code juice box at checkout. Even the sheets now we use the bamboo sheets, you may choose different linens I don't know what you're going to love when you get to cozy earth.com But we sleep on bamboo sheets from cozy Earth. They are incredibly comfortable. And I bought them myself with my own money using my own offer code juice box at checkout 40% off is what I saved you can as well at cozy earth.com today's podcast is sponsored by the ever since CGM boasting a six month sensor. The ever sent CGM offers you these key advantages distinct on body vibe alerts with higher low, a consistent and exceptional accuracy over a six month period. And you only need two sensors per year. No longer will you have to carry your CGM supplies with you. You won't have to be concerned about your adhesive not lasting, accidentally knocking off a sensor or wasting a sensor when you have to replace your transmitter. That's right. There's no more weekly or bi weekly hassles of sensor changes. Not the Eversense CGM. It's implantable and it's accurate ever since cgm.com/juicebox, the Eversense CGM is the first and only long term CGM ever since sits comfortably right under the skin and your upper arm, and it lasts way longer than any other CGM sensor. Never again will you have to worry about your sensor falling off before the end of its life. So if you want an incredibly accurate CGM that can't get knocked off and won't fall off. You're looking for the ever since CGM ever since cgm.com/juicebox. You know.

Jennifer Smith, CDE 15:28
And I think another piece that adds into this, especially more recently is that a good majority of people are using some type of an algorithm driven pump. Yeah. And that brings in some adjustment to what the parents have learned how to navigate because they're with it 24/7, right every minute of every day, and they're looking at data, and they're analyzing it for adjustments and what to do and what works. And while school nurses have kids every day of the school week, their interactions with them are very momentary. They're right, they're not all the time. And so again, what they might have learned about something like treating a lower blood sugar, is there's a difference now with algorithms in how you treat and how quick you leave, how quickly and what amount you use in the same for highs. Maybe the pump is suggesting this amount, but you know a little bit better because of your experience. Those are things that, again, they technically have to be written down as a guiding post for the nurse to use. But they may shift and change through the course of the year, especially because kids grow.

Scott Benner 16:39
And even if they're not using an algorithm, they might be acting as one, not even knowing it, like oh, you know, correct after this meal, we always do a Temp Basal increase, or, you know, like, little adjustments to insulin, which in the end is what an algorithm is doing, making like, unseen adjustments. But these people might already know, like, Oh, I know that with popcorn, and this drink. She needs you know, X, Y, Z insulin, right? That's not going to be reflected in the orders that the doctor put together that said, like, you know, for every 10 carbs, it's a unit of insulin, right? Yeah, except for when she eats like this, or except after lunch, or I mean, after gym or something like that, like they might have? I mean, might they're definitely going to know something about this, you don't know. And then the touch point here is that you've put yourself in a position where if you're not being flexible as the school nurse, you are now in the power position, you're holding these people hostage, right? They're trying to do something with their with their health, you're saying no, you're not a doctor, you're not even their doctors. They don't know you, you know, I mean, you're the person at the school who's a school nurse, like that's a lovely job. And everyone's thrilled you're there. And thank god, you're there, because plenty of schools that don't even have nurses. But you can't become the I don't know the border guard and say, No, you're not allowed to do that, like I do this 24 hours a day when I'm not with you like why are you the you know, the end all be on this? I think that that's just important to hear if you're the school nurse, like, Oh, is that how that could feel? On the other side? I'm just trying to do the right thing. I'm following the orders here, right now. And

Jennifer Smith, CDE 18:20
I think too, because there's there's a lot to navigate in a school environment, right? There's a lot as you mentioned it before, that we don't really want kids to be consistently pulled from class, it decreases what they're therefore which is learning, right? And especially if that pull is always at the time of a class that's already kind of harder for the student or that they might be falling behind in because they're constantly being pulled from that class. So I think, you know, in using a lot of these tricks that as the parent or the caregiver, you've learned, you also have to think about it from the angle of the nurse as well, and the angle of your child in that we want to simplify as much as possible. So that, you know, little Lucy doesn't always have to go back and forth to the office four times a day to figure out what is typical coverage for this type of a meal. Maybe you don't feed that meal at school then, right? Maybe they're reserved for the weekends when you have the navigation tool, and you make the weekday a little bit more simplified. I mean, there are there are ways to work it on both angles. I think school nurses, they tried to do as well as they can in some school nurses don't even have coverage of just one school. They're not there all day. They might be navigating between five schools. Yeah,

Scott Benner 19:42
I've never met an ill intended school nurse. Right. Right. But I have dealt with some of them that were problematic for our life. Yeah. Oh, I'm, I'm quite sure. Yeah. So I know I've said this on the podcast in other places, but it very much fits here in second grade. My daughter had a standard time she'd go to the school nurse to have her blood sugar check. There were no CGM at that point. And she went every day, every day at this certain time. And then she'd come back. She was only gone for a couple of minutes, 10 minutes she was back, and we were on our way again. But she was falling behind significantly at math at like, really, really badly. And it, we didn't know why. And it wasn't till the following year, because her teacher carried over with her class. She went, she took took on the same class and third graders she hadn't second grade. And over the summer, she like literally called me and said, I know why Arden is struggling with math. And I was like, why is that she was while I was just sitting down and filling out my lesson plans and getting my book ready for next year. We are sending her to the nurse, right? Like two minutes before the math portion of the day. And she's missing the explanation every day, like every day, but she comes back and she puts her head down and tries to figure it out. She doesn't make you know, she doesn't say anything. But in a year and a half. Like we were literally I've joked about this before we thought like oh, maybe he's a little dumb. You know, like, like she was really she she was really struggling in math. And you know, it took a couple of years to like, get her caught back up again. But that wasn't the worst part. The worst part was that for years and years after that, Arden believed she was not good at math. Oh, but she is, you know, and it's taken a number of like now that she's in college has taken a number of advanced like, mathematics stuff that you look I look at and I go I don't understand why numbers and letters are on the same piece of paper. And like, what's that shape? But she gets that now but lived a long portion of her young life thinking?

Jennifer Smith, CDE 21:46
I'm just not good at that. I'm

Scott Benner 21:48
not good at this. Yeah. And that's just from that one decision. Let's send her every day at 9:45am. Right.

Jennifer Smith, CDE 21:53
And it was a decision that was we

Scott Benner 21:56
had to do it.

Jennifer Smith, CDE 21:57
You had to do it right. And it circulated around one piece of her life, which was diabetes is circulated around when we don't have a CGM. This is the time that we need to have a blood sugar or some visibility to what's happening. Probably it was coming into snack or maybe it was just before lunch or whatever was happening. But you have to kind of mold all of these things together to make it work for the child. Yeah,

Scott Benner 22:22
if you go through these, this list of people, please let my kids stay in class, do everything you can to let them stay in the classroom. One person says, if you have the ability to go do what you need to do in the classroom, like don't even make them come to your office. You know, also, you know, there are a lot of sick people in the nurse's office, right? And I'm not looking to get sick. The you don't I mean, like I don't want the cold is going around the building. Like don't bring me into the small room with all the sick people. If

Jennifer Smith, CDE 22:51
you don't everybody is vomiting, please. There's

Scott Benner 22:55
some kids, they drink a juice. They're like, I'm good. They're like now you gotta sit here. Now you're sitting there for 15 or 20 minutes. And you know, right. Also, psychologically, I'm always with sick people. Right? Like the kid you intersect in the nurse's office on Mondays? Not the same kid you see on Thursday. Correct? All your brain sees is that I'm always with sick people. Right? And am I sick? You don't I mean, right?

Jennifer Smith, CDE 23:19
There's making a connection for the child of I have diabetes, it must be an illness. I'm sick i n. You know, unfortunately, that kind of crosses over into a lot of them. You know, what they might hear in the doctor's office about being safe and being careful. And you know, you're more prone to getting ill and like, kids hear an awful lot even though they may not verbalize or question what they're hearing. But eventually it kind of starts to sink in. So that's a very good point to make. Honestly,

Scott Benner 23:52
when Arden got into high school, the we were at the meeting in the summertime and the nurses like where your daughter and I were going to be best friends. And I was like, Listen, I don't want my daughter in your office at all if we can help it right. Yeah, I don't. Don't be friendly. I mean, you can be friendly with her. But like, don't keep her there. You don't I mean, this isn't a club. She's like, got the kids hanging out. I'm like, no, no, they're at school. are hanging out with you? This is not the sick kid club. No, thank you. Like, like, but she meant it so positively sure, you know, and upbeat. And then then there's a pushback. And then we had to explain, you know, listen, in the summer before art and went to kindergarten, I went to the elementary school that was local to me where my son had already gone. So I was a person who they at least knew. I went into the office and they said, Hey, I'd like to set up the groundwork. You know, for my daughter being here with diabetes. And they said Your daughter's not here. I said, No, no, it should be here next year. And they laughed, like literally stood the office and laughed at me. I was like, No, I really think this is something we should be ahead of you Yeah, there's like, no, no, like, we're gonna get your 504 plan set up. It's gonna be fine, right? I was like, Okay, I don't know anything about it, Jenny. I was like, my kid had only had diabetes for a couple years. I'd never send a kid with diabetes through school. And they said, We're gonna have a 504 meeting. And I was like, great. So they bring me in a couple of weeks before school starts. If they sit down to give me a piece of paper, I'm not lying to you had five bullet points on it, I'm sure. And it was the most basic stuff. And they were like, This is the plan we're going to follow. And I looked at it, and then I got the laugh at them. You're like, I know, I said, if this is all you know about diabetes, my kid's gonna be dead in a month. Like so like, this isn't gonna do it. She's five, she weighs not very much her blood sugar bounces around a lot. CGM is weren't a thing yet. Like, you know, like, this is right. Using going to work, you know. So I went home. And I read, I think three different 504 plans that were available online. I think I got one from the ADEA. I got one from JDRF. I got one from somewhere else. I read over them. And then I cherry picked from them the things that I thought impacted her. And I built a 504 plan. I brought it back and this is the 504 plan. And they laughed at me. They're like, we're not doing all this. And I was like, oh, no, you are. And then we got into it. Right. I did not win that fight. And about whenever the spring was, you know, so a few months later, they had a system like we had Oregon come down at certain times, I was able to get that done. Check her blood sugar at this time. Bring her back before recess. Check her blood sugar before she goes outside for recess. Check her blood sugar before lunch, give her insulin, check her blood sugar two hours after lunch. I think that's about how I had it set up. So one day, this little boy comes into the nurse's office with a breathing problem. And they had to give them a breathing treatment. And it was a lot of like it was unexpected. Sure. And you know, a lot of running around I guess in the office a little bit. But it happened right before Arden's recess. So they just forgot Arden they were supposed to call down to have her come up. They didn't do the call. She's five, she just was like, right out on roles right out on the playground. Now, Scotty had a backup plan. Okay, so all the stuff that was set up, I had an alarm on my phone. So I know I'm supposed to hear from them. At this time. I give a little bit of leeway. But a couple minutes later, I'm like, I call the nurses office. I said, Hey, you didn't call me about art. And the nurse goes up. Oh, Arden and then hangs up the phone. I was like, Okay,

Jennifer Smith, CDE 27:39
so like, can you get in your car and you're driving, sat

Scott Benner 27:43
next to the phone going, Oh, my God, like just my heart, my throat. Oh, and I get a call back. Obviously about 10 minutes later, hey, it's us. Arden's fine, and I'm like, oh, yeah, she goes, and she tells me all about the kid with the breathing treatment. I'm like, fantastic. I said, where, you know, how's Arden doing? Well, she was low. And then goes on to tell me how she's on the top of one of those turtle like jungle gym things crawling around, and they tested her blood sugar. It was like 52. So I took that opportunity to say, look, that stuff I brought you in the 504 plan that you laughed at me about this is why it's there. Pretty important. Yeah, you know, and we use that opportunity to move forward. But it was a it was a growing experience for them. Because they finally were like, Oh, that guy's not crazy. The thing he said was gonna go wrong, actually went wrong. You know, and that was the beginning of the relationship. Then those two nurses and I all through elementary school, we were like, thick as thieves because they trusted me that right. But I was a soothsayer, I predicted the future. Right? You know, and, but we had such a great process. And then I'll tell you that the what we did then is when art and went to like middle school after that, I brought those nurses with me to meet the nurses from the middle school for the first time. That's a great idea. Because they sat there, they're like, whatever that guy says. Just do it. And like like getting a you don't and that built that I had built in confidence then with the new nurse. And then we did it again. At high school. I brought the middle school nice to the high school when the high school nurse started pushing back, that middle school nurse was like, Listen, I have never seen a kid with a stable or steady blood sugar's as this kid, like, listen to what he's saying, you know, but there's a lot or Jenny, like it was a ton. It's

Jennifer Smith, CDE 29:25
an enormous amount of work. And then when you've got schools that really do give a lot of pushback, no matter what information and what data you provide, to prove what you're trying to have written into their plan of care. I mean, that is a lot of the reason that, you know, I actually encourage people that you sit down with your endo and go through that and even get their signature on it because as you said early on, many times they're gonna say, Well, we have to call the doctor about that. But the doctor signatures at the bottom of that plan If you're more likely to decrease the need to call the doctor because clearly everything on this plan was already okayed by the doctor

Scott Benner 30:09
I have or had when Artem was in school. I don't know the sentence Exactly. But there was a sentence in the 504 plan that said, you know, these are all the rules, but decisions about food dosing, all that stuff are adjustable by the parents. Yeah, that was it. You know, another

Jennifer Smith, CDE 30:32
similar line that, again, something usual written on a lot of people's, as parents have final say, or final decision in dosing, meals, snacks, low treatments, all of that kind of stuff. This is the plan. But, you know, if questions, call the parent, the parent has the final say, it

Scott Benner 30:51
protects the nurse, honestly. And also, I think, allows the nurse to feel a little comfortable, because, I mean, I can put myself in their position, the doctor's orders, say, you know, three units for this, and I'm like, No, do four. And they're like, Oh, I'm gonna do put an extra unit and so on this kid, send it back to class, so they can pass out, right? And then I didn't know, you know, like, so it's a big deal to get that into your 504. If you can, right? This person says, Please be careful about how you talk to children. They are sensitive, they know a lot. Don't comment on their numbers, or the carbs on their plate. Don't scare them about high low blood sugars. Be patient with them, because their blood sugars can affect their moods. This lady also says please, please don't ask me to do more than I'm already doing. Like, I have enough on my plate till I'm doing the best I can. I think that's a big deal. They're like, don't scare the kids don't try to it is, you know, I don't know, take what you think, you know, and pass it on to them in a split second in passing moment when their blood sugars are all over the place. Correct.

Jennifer Smith, CDE 31:54
And I think from that judgment standpoint, it was this person said something about, you know, don't judge on the carb kind of thing. Don't judge on the food in general, right? That's not your job. As a school nurse, quite honestly, there's probably somebody else in the background, who's already assisting the family to navigate proper nutrition and an intake and everything that might be needed. And you know what, maybe the kid has a lot of really considerable food preferences, right? Maybe the only three different things at lunch, and that's what has to be sent. And maybe it is 80 grams of carbohydrate. And as a school nurse, you're like, well, their blood sugar will look better if they didn't eat so much carbohydrate, that's not your business, just not their

Scott Benner 32:34
blood sugar would look better if their pancreas was working, right. But a lot of ifs in there, the no shame thing comes up over and over again, with the feedback from people like please don't shame my kid. It's all hard enough already. Open communication, big deal. You know, like, let's go back and forth be on the same team? Why are we fighting with each other? Like, that one's fascinating. You know why, right? Like the nurse is protecting their professional life. And, you know, and you're trying to protect your kids health. And you know, that in the middle are these orders that are probably not going to work most of the time. So, you know, sucks? Could you help us with our 504 plan, so that, yeah, I'm throwing that in there for school nurses, like people don't know what the hell a 504 plan is, when their kids are diagnosed, usually, it'd be helpful for them, if you could walk them through it, tell them how the process works through the school, that kind of stuff.

Jennifer Smith, CDE 33:25
And if you've worked with somebody who has a system that's working really well with type one, and you have their 504, obviously, getting rid of all the personal information that might be in it, but maybe have those as a good example, for families who are new that you're working with and are questioning, I don't even know where to start with a 504 plan. Or maybe you have a list of sites of available examples to be able to provide them with. And then they can pick and choose because again, all of these 504 plans being very individualized, you're very likely to find one that is almost similar enough to what you're doing with your child. And you can start it as a template that it works better than somebody else's 504 plan that's like, you know, not eating very much, or whatever it is,

Scott Benner 34:12
yeah, and make little adjustments to fit you. And I also I like to say to, Don't be unreasonable in it. Because when you start being like, hey, you know, my kid really needs a Ferris wheel, you start making big asks, or like, you're trying to take advantage of this. And then you don't get taken seriously, because you look like you're, you're grabbing. You know, like, I think that's important. I also, I like to remind people that usually as the kids grow, there's something on your 504 plan that was super important in second grade, that doesn't matter in fourth grade anymore. And if you want to be a real hero at your 504 meeting, say oh, you know, like line three there, we can strike that you guys don't need to do that anymore. Like it feels like you're giving something back to them. You know, like there's one less thing for them to worry about. So, you know, I think that's a good idea too, especially

Jennifer Smith, CDE 34:58
as things like recess and whatnot change. I mean, my, my little guy has two to three recess sessions a day. And my not so little older child has only two recesses once he gets to middle school, he'll only have one recess a day. So all those things are, as you said, their points of navigation from one year to the next that may change based on schedule, and what's going on for that child. And there might be some new things, there might be several things that are able to be taken out. Yeah,

Scott Benner 35:28
two opportunities in that example, to not replicate out of a classroom, for example, you know, that kind of stuff. This person says, I, our school nurses, terrific, I have nothing bad to say, but here's why she's terrific. She'll like discreetly pop into my son's classroom, check on him for a second, make sure everything's alright, slipped back out again, instead of him leaving class and missing that class time. But she goes on and on. But I think what she's really saying here is she has a school nurse who's putting that kid in the same polling that kids health at the same level as the mom does, yes. Like, do you know what I mean? Like she's, that's that extra effort that you have to put in when you you have a kid with type one. And

Jennifer Smith, CDE 36:05
in today's world, with the technology that we have, it's lovely that the school nurses even just popping ahead in to just visibly see that the child looks like they're okay. But I've gotten a lot of families whose school nurses are absolutely able and willing to do like, like Dexcom has Dexcom follow, or they might be using something like sugar meat in which they can look and follow online, they can even make notes about what was what was used for a treatment or whatnot, which translates right over into the parents. So it's a it's almost a seamless communication. And there's a lot less texting and stuff that kind of can happen. i There are there are kids, teachers and classrooms and even nursing stations that have things like was it sugar pixel and the glucose just visit they might have the name on, you know, so they know which one they're looking at. And again, that means that the nurse doesn't necessarily have to get up out of her office. She's just visibly able to see where are things going. What's this next child's schedule look like? You know, from that standpoint, it can be useful tools, technology

Scott Benner 37:05
was brought up over and over again from people especially because a lot of people do get into that situation where I think I've seen it, I'm seeing it shift more over the last couple of years. But in the beginning was CGM. So for people who are listening who don't know a continuous glucose monitor the device that the kids wearing, it's reporting back their blood sugar in real time that you can see on a number of different devices, right, like phones, Android, Apple phones, iPads, stuff like that. There was a time where they would say, well, we don't want that data, because then it's a liability, because now I know if the kids low, and if I don't react well or I don't see it for some reason, or my phone's not near me. Now it's my fault if the kid has a low blood sugar. To me, that was a really strange way to think about it. But it is that was the initial pushback from from school nurses. Like, I'm not at fault, if I don't know. So don't tell me. Some nurses were like, Yeah, give me the information. I want that. And more and more. I am seeing nurses following kids on CGM in schools, just to watch a kid's blood sugar for a day or two, it would take so much of your anxiety away, you don't I mean, you'd see what's happening. You can make adjustments or in you know, in concert with the parents make adjustments and not have all the worries that you had before. So embrace the technology, for sure. Right?

Jennifer Smith, CDE 38:21
Learn a little bit about it. I mean, that might be an additional session that you end up spending with the parents to learn from them. What what is the technology doing, especially if again, like I mentioned before, they are using an algorithm type of pumping system, learn what's the system really doing? How does it act, because all of them are a little bit different, right? And so it's really important to understand what one child system might do that another one's not necessarily going to do the same way. Yeah,

Scott Benner 38:49
I have some stuff here from actual school nurses. It says I am a school nurse, but I'm also a type one parent. It's extremely hard to follow doctor's orders when you know that that's not the right thing to do for the student. Luckily, I am the school nurse for my son so I can do what I want. But it's very frustrating when having to follow the typical standard orders that don't fit for everyone with other students. Yeah, then that's something to really remember is that you might have a great school nurse who is right there with you. I don't know why they wouldn't say that though. Like why why why not just like whisper go, Hey, listen, you know, I'm stuck here. Let's fix the water. So I can give me a little more autonomy here to help you write another school nurse on the school nurse and also a mom of a type one. school nurses with diabetics just have to understand that each student's diabetes needs are different. Just like student's educational needs are different in the classroom as a parent with type two a type one. What I didn't understand until working as a nurse in school is that you are held to the doctor's orders. Yes, the parents know how to manage, they know how to manage better. They know how to help keep the numbers in check, but I've got to do what the doctor put So on that piece of paper, yeah, so that's really, it goes all back. It's that one sentence on the 504. Yeah. Would you say you put it eloquently and succinctly?

Jennifer Smith, CDE 40:10
Yeah, it's just parents have final say it's dosing, snacks, treatments, etc. Whatever you want to include in that statement is that follow the orders. But parents have final say

Scott Benner 40:20
this parent says, I would just love to know what the nurse needs from me. Yeah, like, I want to help you help my kid like, so if your hands are tied, or you're having trouble with something come to me and tell me that let's see if we can work it out together. Right? That's excellent. This person made your point from earlier, don't settle for the way things used to be done. Yeah, a lot has changed significantly for the better for type one diabetes, for kids for health and safety, embrace the new technology, try to dive into it. This is exactly everything you said. If you've been at this for a long time, learn how to use an iPad, if you don't know how you figured out the apps that you can track the kids on, help us to push our kids to take, you know, good control for themselves. Sometimes an outside caregiver can really help the transition to more in dependency, that's a good point. Like, you have an opportunity there, right? Because the parents might be butting heads with a kid. But all of a sudden, you know, what's that analogy? I always say like, you know, if your kids play baseball, and you're the coach and your kids the pitcher, you never go out and talk to your own kid, you know, send a different coach out there, right? Not gonna go well. So work with the parents, not against them be an ally, stand up for my kids. This was interesting. Oh, that's a great one. If the district is making some ridiculous policy, or school administrators aren't allowing you to do something like for instance, a remote monitor with a CGM, you could use your voice to stand up. You could say, Hey, I know this is the rule. But these people are right. This would be great. If we did this, you know,

Jennifer Smith, CDE 41:49
and bring in safety whenever you're right. Very likely what the parents are bringing up and that you know yourself. It's a safety consideration. And if you can prove that what they're asking for actually increases the safety and decreases the risk to the school. That's a hit point.

Scott Benner 42:07
One of the best moments for Arden in going through schools regarding her diabetes care. It's also one of the saddest moments I've experienced. So I came up with something that I think is it's episode for the podcast. It's I think that episode is called texting diabetes. And there was this day where I was in the house and Arden was upstairs. And she I could see on her CGM, she needed a little more insulin. And I was about to get up and walk upstairs and tell her and I just didn't feel like it now post lazy and I was like, I don't want to do this. I picked up my phone and I was like, hey, I need you to Bolus a half a unit and admitted to later she goes, okay. And then I was like, Oh my god. That was easy. That was so easy. To move again. And my brain started racing. I was like, it worked from here to upstairs. It would work from here to down the street at her friend's house. Schools not that much farther. It would work from here. Oh, wait a minute. And then I froze, because I had trouble doing it at first. But I had trouble doing it. Because it turns out when she was in the house, and I felt like oh, if something went wrong, I was there to help. Right? Yeah. When she's not with me, I didn't have that same comfort. But then suddenly, I was like, well at school. I mean, the nurses there they have glucagon. They know what to do. I've explained it 1000 times. Like, you know, Arden was never a seizure at school. Like I don't want that. But I bet she'd be okay. Right. And then I stretch my legs. I was like, alright, well, now we're gonna start doing it at school. Arden's blood sugar's were never so good. As when she and I are in concert, we're just managing right through through texting. It's the it's the unsung hero of diabetes, texting seriously. And you

Jennifer Smith, CDE 43:47
may have also had leeway then in terms of what she could have on her person. I know some schools are really strict. And even if doctor writes that it's okay, or whatever their protocol is that things like, especially the older school blood glucose meters, or like the PDM for the controller, or what's now the controller for Omnipod had to stay in the nurse's office, it couldn't even stay with the child. Right? And so in that case, texting diabetes is a great idea. But you're not going to get anywhere because the child no longer holds their product to you. Well, I

Scott Benner 44:27
had to what did I have to do? I had to get her phone set up as a medical device in her 504 plan. That was the first thing I had to accomplish. Then I had to get them to put her phone on the teachers Wi Fi. Oh, so that we had, you know, stage stable communication. And that came with we had to go to a meeting where they got to look at Arden and tell her like you're not allowed to use your phone during school. Like like nowadays, I don't think it matters. I honestly I think that things have changed so much since then that's probably laughable to kids, but She took it very seriously. Like I told her, I was like, Look, this is a thing they're letting us do. It's making your day much easier. Like, you know, it's nice to say to kids, like your health is better, but kids don't think about that day to day. I'm like, Look, your life is easier. You're not going to the nurse. You know, if you need a little bit of insulin, you and I are talking it takes a split second, instead of you having to go through this whole rigmarole like, just be cool. And don't use your phone at school, right? One day she came home so seriously, she was so earnest. She goes, we got out of class early today. I was like, great, because I opened Instagram, do you think I'm gonna get in trouble? I was like, Oh, honey, I don't think anybody's gonna know. So

Jennifer Smith, CDE 45:36
it was like after getting out of bed, it was

Scott Benner 45:38
done. It was just the day was over. But she's like, I did open it while I was on the Wi Fi. And I was like, what an opportunity. I wish a teacher could have seen how much it meant to her to have that access. You know what I mean? But yeah, those are the things we had to do. Because the regular school Wi Fi sucks. Most of your buildings are built out of bricks and blocks, and you're not going to get good signals in some places. And that's going to panic the hell out of you. You know, when you can see the blood sugar, see it see it all of a sudden, it's just gone. So school teachers Wi Fi. In the end, they were very cool about it. I had a really wonderful experience throughout art in school. But I want to say this too. I recognized early on. When I came in that day, you know that that before kindergarten started that to those people I looked at in my mind. Like, do you mean like you were that you did? Yeah, I know. I wasn't I know that pre planning was the right thing to do. But to them, it wasn't something that we're used to I look, I look like a crackpot. And so I spent a lot of time not looking crazy. And I and I found the best way to do that is you don't over explain. Because diabetes has so many variables and steps and intricacies and nooks and crannies, that when you just start talking about it, you sound nuts. Like, you know, maybe you're like You're like because if the insulin goes into soon, and then she gets active, that activity is gonna bring her insulin down, then she might have a seizure, she has a seat like you You sound crazy to other people you're not by the

Jennifer Smith, CDE 47:03
way, you're not it's like a it's like a flow of everything that you honestly don't know. Right. But it's in terms of what needs to be applied in the school setting. That's all they need to know.

Scott Benner 47:17
Yeah, I'll also tell you, this emails that you send to nurses or people in the office that go over about three or four sentences make you look crazy. Gets into manifesto types. Yeah, you're also seeing it as a, you know, I hate to say like, seeing it as a, you know, a marathon, not a sprint, because it sounds, you know, sounds sounds douchey. But like it it is like, right? Like, you're not trying to get all the information to them today. Like, you know, it's it's a slow process, you're given an out a little bit by a little bit, you're building a relationship, you don't want end their people to they're just at work, right? You know what I mean? Like, don't, don't beat the hell out of them. They're, they're not, they're not, you know, they're just at work, like you go to work to you don't want people lump of extra stuff for you to do on all day. So pick and choose and, and try to, you know, try to not ask for more than is really necessary. Right? You know, it's all you're looking for is for your kids blood sugar to be stable and to be able to like, react to emergencies,

Jennifer Smith, CDE 48:18
and to allow them to also stay in class as much as feasibly possible. Right. I mean, that's again, what they're there for.

Scott Benner 48:25
This person said, you know, please be compassionate show patients over and over again, I want to point out how thankful people were in the feedback for the nurses and all the things they do this one person says, I think the Joslin diabetes Center in Boston has school nurse training sessions of maybe twice a year. Oh, yeah, that may be your local hospital has something like that? Yeah. Do you have anything to add that you think we might have missed? No.

Jennifer Smith, CDE 48:49
But that's interesting. Along the same lines, if you are a school nurse, and in your area there is a pediatric endocrine practice are several of them. It may behoove you to actually call and see if any of them have class type of education for people with type one. And that you could very well get some good information by just attending even one of those classes. Yeah. Right. Because that's free information. And while it is your time, yeah.

Scott Benner 49:24
Also joining the Facebook group for the podcast. Even if you just lurk in there for a couple of weeks, your understanding will lift way up. I don't want to end on a sour note. But I do want to bring this up. There is a line to like, you have to know your place a little bit. So I don't remember I honestly don't remember what it was but in high school, art in school nurse had a question about her care plan that she didn't understand. And instead of asking me are Arden she called our doctor's office? Yeah, no, yeah. And then I yelled at her a lot on the phone. So That's not any of your business. Like that is not uncommon, by the way, I see a lot. That happens a lot. Like, I don't know what you think you're doing calling somebody's doctor, but don't do. Yeah, yeah. And I want to say to this episode comes very much from the perspective of people who are trying really hard, who were very involved. And you may be also involved as a school nurse with people who don't understand a damn thing about diabetes and aren't putting any effort into it. But you got to not be jaded when you get to the next person who is trying, like, right, like, those are two different situations. I don't know how to tell you to help those people. I really don't. But, you know, right. Anyway,

Jennifer Smith, CDE 50:42
outside of giving them information about where they can get better. Yeah, information, go

Scott Benner 50:46
check this out. Have you heard you know, like, there's probably nice little ways to drop that in there. But saying things like, your numbers are crazy. And you're gonna, like, that's doesn't work, it doesn't work for doctors, it's not going to work for your school nurse. And anyway, I appreciate all the great school nurses that my daughter's had over the years. They were all fantastic. In one way or another. I would say that any stumbling blocks we came upon. I stayed calm, they stayed calm, we got past them. You know, the worst thing you can do, in my opinion, as a parent, is be the person who, when you walk into the building, or when the phone rings, they think Oh, it's this one. Like you don't you don't want your comes Jenny. your loins? Yeah, like, you don't want to be that person. Like, it's no, it's definitely not gonna have a good ending anyway. And I think too, as

Jennifer Smith, CDE 51:35
a as kind of a last point, it's also, you know, your child has one thing, or maybe a couple of different health things to navigate. And in those, I guess, instances, you expect the school nurse to become really knowledgeable about that issue. And you have to think that the school nurse isn't just there to navigate kids who have type one diabetes, they're there to navigate a whole host, you know, allergy medications, dosing of specific things for for irritations and allergies are through their heads. Yeah, there is. And so you have to understand that while you're, your child's needs are absolutely important. There are other kids who have needs that are just as important to and so expecting to establish some type of schedule that obviously works based on what's happening for the school nurse, ya

Scott Benner 52:30
know, it's, there's, there's a lot to consider there's a lot of human beings involved a lot of pressure. And, you know, I think there's some grace has to come from all sides to be perfectly honest, you know, and in the end, you're trying to help the kid be healthier, happier, become educated, and not leave with some sort of a feeling that they're, you know, broken or a problem or, you know, that kind of thing. So, anyway, I appreciate when everybody does, and I appreciate you, Jenny. So I'll talk to you soon.

A huge thank you to one of today's sponsors, G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox. You spell that g VOKEGL. You see ag o n.com. Forward slash juicebox. I want to thank the ever since CGM for sponsoring this episode of The Juicebox Podcast and invite you to go to ever since cgm.com/juice box to learn more about this terrific device. You can head over now and just absorb everything that the website has to offer. And that way you'll know if ever since feels right for you. Ever since cgm.com/juice box. I'd like to thank cozy Earth for sponsoring this episode of The Juicebox Podcast and remind you that using my offer code juice box at checkout will save you 40% off of your entire order at cozy earth.com That's the sheets, the towels, the clothing, anything available on the website. If you or a loved one was just diagnosed with type one diabetes, and you're looking for some fresh perspective, the bold beginning series from the Juicebox Podcast is a terrific place to start. That series is with myself and Jenny Smith. Jenny is a CDC es a registered dietitian and a type one for over 35 years. And in the bowl beginning series Jenny and I are going to answer the questions that most people have after a type one diabetes diagnosis. The series begins at episode 698 In your podcast player, or you can go to juicebox podcast.com and click on bold beginnings in the menu. I know that Facebook has a bad reputation, but please give the private Facebook group for the Juicebox Podcast a hell The once over Juicebox Podcast, type one diabetes. The group now has 47,000 members in it, it gets 150 new members a day, it is completely free. And at the very least, you can watch other people talk about diabetes, and everybody is welcome type one type two gestational loved ones, everyone is welcome. Go up into the feature tab of the private Facebook group. And there you'll see lists upon lists of all of the management series that are available to you for free in the Juicebox Podcast, becoming a member of that group. I really think it will help you it will at least give you a community. You'll be able to kind of lurk around see what people are talking about. Pick up some tips and tricks. Maybe you can ask a question or offer some help Juicebox Podcast type on diabetes on Facebook. Thank you so much for listening. I'll be back soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com