#1017 Diabetes Pro Tip: Bump and Nudge II
Bump and Nudge II expands on episode 1017.
You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.
You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - Radio Public, Amazon Alexa or wherever they get audio.
Key Takeaways
- Drifting vs. Dropping: A "drift" is a slow change (e.g., 5-10 points over 30 minutes), giving you time to make minor adjustments like temporary basal changes. A "drop" or "spike" (indicated by straight up/down arrows) is a rapid change requiring immediate action with carbs or a larger bolus.
- Avoid the "Rollercoaster": If you "jerk the wheel" by over-treating a high with massive amounts of insulin or over-treating a low with massive amounts of food, you guarantee a severe swing in the opposite direction. Bumping and nudging is about small, measured corrections to stay in range.
- Evaluate Insulin on Board (IOB): Before reacting to a drifting blood sugar, check your IOB. If you are drifting low and have 3 units active from a recent meal, decreasing your basal won't save you; you need food. If you have 0 IOB, a basal decrease might work perfectly.
- Beware of Over-Bumping: If you find yourself constantly bumping and nudging every single day just to keep your blood sugar in range, your underlying settings (basal rates, carb ratios, or insulin sensitivity factors) are likely incorrect and need to be evaluated.
- Trust the Data over the "Rules": Outdated rules like "15 carbs, wait 15 minutes" or waiting 3 days to see if a basal change works often fail in real-world scenarios. Use your CGM data to see what is actually happening and make adjustments based on that reality.
Resources Mentioned
- Wrong Way Recording: wrongwayrecording.com
- Diabetes Pro Tip Series: diabetesprotip.com
- Juicebox Podcast: juiceboxpodcast.com
- Integrated Diabetes Services: integrateddiabetes.com
- Juicebox Podcast Type One Diabetes (Private Facebook Group): Join on Facebook
- Dexcom CGM
- Dexcom Clarity App
Introduction and the Evolution of the Pro Tip Series
Scott BennerHello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CDE and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisitable. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. So let's start like this. I just put up like the 340/5 episode of the show, which is mind bending to me honestly,
Jennifer Smith, CDEwhat was the first first year first, cuz you've been blogging for a long time before
Scott BennerI blogged from 2007 consistently until 2015 When the podcast started. And now I have to admit the blog a little more of a way of me sharing, I don't sit down and write from my heart as much as I used to because, right, it's so much easier to do on the podcast, and you reach more people. But I blogged for that many years the blog was strong, it was a million million and a half clicks a year 111 block of maybe two or three years, I got to like 2 million clicks, which was really big. But then I saw it kind of like trending away. And so in 2015 I started the podcast. And I really thought it was going to be I guess this isn't maybe a neat place to say this. I thought I was going to go back and read my most popular blog posts like into this microphone. Because that was my expectation for us. Like, you know, some of these blog posts are really helpful to people. I'll read them and make them audio. I did that for 20 minutes one time, stopped, deleted the file and was like, This is stupid. Yeah, yeah, nobody cares about this.
Jennifer Smith, CDEAnd well, I can say there are some people that would care about that. I've actually got a couple of clients who really, they love the podcast because their their audio. And when they read things, it doesn't stick. And so they have to reread and reread. And finally some of the adults that I've got are like, I just put the book down because they're like, I can't keep reading. I'm not retaining it. But if I hear it, it's there. It's in my brain. So
Scott Bennerno, I hear that I should just felt boring to me. Like I thought someone would like it. But I mean, if I'm being honest, I was trying to reach more people, not just, you know, people who literally be willing to listen to somebody read something dry, you know what I mean? I mean, at least put some music behind it. You can imagine how funny that would be if I was reading with music behind me and there's like this guy's talking about It'd be terrible. And then it picked up and picked up. And, and like, you know, but for people who are maybe coming in late to it. After a number of years of the podcast, I started thinking there's like a real system here. Like I knew that while I was blogging, but when I could hear it I thought Oh no, it's this piece and this piece and these these four or five ideas and when you bring them together, there are five five A1C like you just do these things and that's what happens, you know. And I, and I had had you on the show, maybe twice. And I always wanted you to be back. And I thought she's the best guest I've ever had. Like, I mean, honestly, you, when you when it comes to diabetes, you and I think exactly alike about it from two completely different perspectives, which is weird and interest. Nice, right? Yeah. And it's nice. And so I was somewhere one day, and I thought I know what I'm going to do. I'm going to take the tenants of the podcast and break them down with Jenny, if she wants to do this, I'm going to get a hold of her and see if she wants to do it. And that was a weird leap for me, because until then, my real belief was that if you just listen to all the episodes, you'd hear things come up very kind of organically, and they would stick to your brain better, because you heard them conversationally, and I was a little scared to do. Specific, more bulleted specific topics. But then I realized I could do it with you. Because we have a rapport. Like, I've talked to other people in the podcast, and I tried to talk to him about stuff. And I find I'm stopping and starting and like, I'm like, Oh, they're talking over me. I'm talking over them. I can't find a vibe, you know, I knew I had that with you. So I contacted you. And you were like, I'll do it. And at the time, I was like, it'll be like six or seven, Jenny. And I sent you a little list. And you were really great. Like you took the list and you're like, I'd put them in this order. I think they make more sense in this order. And I was like, Okay, great. And now I'm going to look, I'm actually going to diabetes pro tip.com. Now, because that little idea now has its own website, which is even strange. It's great. 1-234-567-8910 1112 1360s, there are 17 pro tips. And this is going to be the 18th one, and then we're going to do pregnancy and we're going to keep going right? And it spawned like defining diabetes, which I never thought was a thing that was needed until this one person sent me a note that said, Hey, I wanted to thank you. Because until I listen to the podcast, I didn't realize I was on MDI. They took and you told me that right. And that made me think, wow, there's some people really not understand some of the terms we're using. Let's define the terms for them, but simply not an hour conversation. Right. Right, a little bit. Anyway.
Jennifer Smith, CDESo not a not a dictionary definition. I think, as I said, you know, before some people get things because they hear it in a different way, or they read it in a different way. And I think the great thing about the podcast too, even with the pro tips, part of it is that it's broken down much more like layman's, applicable, it's, it's not what you get in a typical Doctor education clinic.
The Pitfalls of Bumping and Nudging
Scott BennerAnd we did it a couple of times. And I was like, damn, this is good. It went so well that I was like, give me your address. Jennifer, I am sending you a microphone. So it sounds better now. Let's go. But one of the things that we did was bump and nudge, it gets talked about in the episodes, but it doesn't have its own episode. And I always kind of thought that was okay. Until in the last year. I looked at algorithm based pumping and saw how my bumping and nudging was too much. It had gotten out of hand and it didn't realize it because it was so easy for us to do that. We never looked back at the root cause of why we were bumping and nudging. And so this has been bothering me for like six months now. And I said that Jenny, I need a pro tip episode on this because not that bumping and nudging is a bad idea. It's a terrific idea. Right? But you need to understand it more. It's a bigger topic than I thought it was.
Jennifer Smith, CDEAnd I think you really I think you really like realized it when you guys started using the do it yourself, right?
Scott BennerAs soon as day one came.
Jennifer Smith, CDEWe talked and I was like, how much are you using Temp Basal? Yes. How much? Are you adding little micro corrections or adjustments or whatnot through the day and you're like, oh,
Scott BennerI don't know. I never thought about it before. So So Jenny's the one who said it to me because we were trying to find it was such an easy thing. Like you guys would hear me say before, like, I don't know Arden's insulin to carb ratio doesn't matter to me. I don't know what anything is. None of it matters, right? I know, we're Basal rate. And I know food. I look at food and I see food but
Jennifer Smith, CDEyou're like, Oh, that looks like five units up up. That looks like I got to split it off and give some now and a whole bunch later and right.
Scott BennerBeing flexible, which is terrific and important. What I didn't realize it was doing to me. You have to kind of like step back and look at a timeline of months. Maybe the developing two years is that at some point, you know, meal X took two units. At this Basal rate of whatever it was, and then it took two and a half and three, and three and a half and four, but it happens so slowly, I didn't notice, I didn't realize that I was now bolusing six units for something I used to Bolus four units for. I mean, I did. But I never stopped and thought, I wonder how much of this meal insulin is attacking the food and how much of it is staying in our system for hours afterwards and maybe acting as Basal. Right. And so I had bumped so much with insulin that I lost track of what Arden's baseline need was, it didn't matter because we were doing so well. But it did matter. And I learned that when I when I said I don't this algorithm won't work. This is ridiculous, her blood sugar's all over the place, right? It's just crazy. And it's because I had lost track of how much insulin we were actually using versus how much my setting said, we were using that did I say very clearly how much
Jennifer Smith, CDEwas actually needed, versus how much you were just intuitively correcting with right, adding a little bit extra because you needed it, but not really realizing. In general, I'm always adding extra here. And it probably is a setting issue. It's an I shouldn't be adding this much more all the time,
Scott Bennerright. And it becomes such a way of life. Right? I didn't think of it anymore. So now, I want to leave that thought here. And we're going to come back to it later. Because I do think that being fluid around diabetes is incredibly important. And that you can't just keep resetting your Basal rates every day for all the variables that are going to come up in your world. And I noticed a long time ago, that idea that concept is what causes people problems, right? The idea of like, well, I'll go to my doctor, and we'll find a Basal rate and Oh, my doctor was great. They saw between 2am and 4am, we had some highs. So we moved our basal up at 1am or 12:30am. And it worked. But then they started getting low, you know, a couple weeks later, but I just fed the lows for two and a half months and went back to the doctor, the doctor moved the basal again. And that's how people that was considered a successful use of your physician and your insulin right. It probably still is in many people's minds. I saw that and thought this doesn't work. I don't want to be involved in this and I've said it before and I'll say it again this podcast is a it's partly in place because I don't like the math around diabetes. I don't like the waiting. I don't like the we'll wait and see. I don't all that stuff makes me uncomfortable. Like all the things that you're supposed to do. I just was always like, Oh, that seems wrong. Like I don't I don't want to do that.
Jennifer Smith, CDEwithin it I think you also have to say that the technology that we have available today makes it more user friendly for people to learn how to make their own adjustments in the here and now. That might work then for a while, and then they make more adjustments. But, you know, years ago without technology, going to the doctor every three months, every six months, like I used to do when I was younger, that that was the way to make adjustments now. Could we have taken and done more data, more data analysis in between the doctor visits we could have? And my mom actually did, she was like, this isn't working anymore. Let's just adjust here, let's Nope, you need some more insulin here. And I don't think she ever like to set it like that. But her explanation was always like, Well, this was just too high. And if it's going to be too high again, tomorrow, then you're just gonna use more insulin for the next meal. Right? Right. Okay, my whatever.
Scott BennerI'm with you, you're cooking, right? So you seem to care. So I'm gonna go. And another issue in the space of people talking about diabetes in the past, it's kind of it's a number of folds, but one of them is that nobody ever wants to say too much, right? They're always like, worried that they'll say something, and it won't apply to the third person that hears it. And I so that was part of what the protests were for was to take information down to a point where, you know, this really does apply to everyone, like not saying things that only worked for you, or me, or noticing that my daughter needed something different after she started getting your period than she did before. And taking the time to talk through those differences were writing about it is hard, because you write something down, it's static, you know, I write a blog post around about my nine year old daughter, somebody reads it, it now feels like a rule. I don't spend time for my
Jennifer Smith, CDEnine year old child, this is going to be the applicable method that I use.
Scott BennerAnd you don't take time to philosophize out that I bet you this will be different when she's 15. And you just writing doesn't work that way. But you can conversate that way. And so a lot of people in the past who were impacting the diabetes space, were parents of younger children, who until your child gets older, you don't realize you think this is diabetes, but this is diabetes. In a kid that's not, I don't know, like, coursing with hormones or growing as much as you think. Or as active as you believe they are. Like, you know, like, when you're eight, you're like, Oh, my kid plays baseball, like Yeah, okay, well, you know, your kid really plays baseball, like, like, we know, they weigh 200 pounds, and they're flying around, and it's 110 degrees outside, and they're throwing things through walls, like it's an impact on your body weight, or your kids playing ice hockey, as a high schooler. Like, you know what I mean? Like, we got
Jennifer Smith, CDEpractice from six until eight in the morning, and they've got practice, again, from you know, four until eight, six o'clock at night. I mean, sometimes, those practices I'm amazed with the kids that I work with, their parents are like, Oh, she's got tennis for you know, from six o'clock until 7:30. And then she goes off to school, then she's got another practice from four to six and like, like, seriously, like, she's the tennis thrower.
Scott BennerThat's how you make a tennis pro. One in a million times. The other 990,000 times is how you make a kid who hates tennis eventually, right? So Right, exactly. But so these people were doing great stuff. And they were talking about these these ideas, but they didn't realize how specific they were to the age group they were talking about. And, and I think that that's why this longer conversation while I mentioned how long the podcast has been up has been important, because in my heart as crazy as it sounds, I think if you want to have great success with your type one diabetes, you go back to Episode One, and you'll listen through, because you'll take a journey through somebody who's talking about a kid with a nine or 10 year old body that you know, you actually can hear in this podcast art and get older art and grow art and have problems her start to get out period, changing devices meters, like all the way through. And I know it sounds crazy, but in your 347 hours as of today. I think when it's over, you'll go who Okay, and then your kids just gonna have an A1C and the fives it like if you want it to be or maybe you you'll make an adjustment and it'll be in the sixes. Right. It'll also works for adults. And that was that was really cool. I hadn't had that like greater expectation. I thought it would but it didn't have a lot of a lot of adults weren't reading me as a blogger. You know what he mean? There were some, but there weren't a lot. Anyway, at some point, I recognized that was really long winded, but I guess the people there I guess there are used to that at this point. But it's a very long way of saying that you can't just set your Basal rates up, set up your insulin to carb ratios and go with that's what the pump told me and that's what they've done. After told me to put in the pump, right? Because things are going to change, sometimes day to day, sometimes hour to hour activity to activity, there are going to be too many variables. And you can't stop every time. Like imagine if I had to get up tomorrow and go, today is going to be a sedentary day. I will now go fix all of my Basal rates for sedentary and change my insulin to carb ratio for sedentary by the way, do you realize that that could end up for some people meaning more for some people meaning less, it could end up meaning less for basal and more for insulin to carb or vice depending who you are and what you eat. And so when all that exists, what ends up happening to people is they just go Ah, today was a good day. Today was a bad day. Yeah, right, they leave the settings, and then they have good days and bad days. And what I thought was, if we stay fluid enough, you can almost be ahead of what's happening and make these adjustments. Okay, right. All right. That's a long, long explanation. But to me, that's what led me to bumping and nudging. Now, for context, while Jenny and I are talking about it, I think of bumping as using insulin bumping your blood sugar down. And I think of nudging as nudging your blood sugar up with carbs, Jenny thinks of it the exact opposite way. So don't get confused. If one of us says one thing and one of us says the other. But in the end, the idea is to keep yourself between these smaller parameters, a range, a smaller range, and the range is defined by you, right? Doesn't matter to me what range you choose, right? It's
Jennifer Smith, CDEit's your chosen range. But the idea is to use food in an insulin in a good advantage in both directions, so that you can stay within that
The Steering Wheel Analogy: Drifting vs. Dropping
Scott Bennertarget, right. And so some of the things I learned is, I wish people could
Jennifer Smith, CDEsee us by the way, our hands
Scott Benneraround good and bad. Oh my god, you keep saying that out loud. Someone's gonna ask you to turn this into a YouTube thing. And then we're going to be on camera, and neither of us are going to be happy about that. Because you're gonna have to hang up that stuff behind you. And I'm gonna have to get a haircut.
Jennifer Smith, CDEWhich by the way, is just like bags. And you know, it's not random strangeness. It's like bags and like colas. That's it.
Scott BennerJenny is now apologizing for something you can see. That's very Midwest of you. By the way. You're like, oh, it's it's not unclutter. It's nice people. It's a very important thing where the children hang their bags.
Jennifer Smith, CDEThe easiest for them to get to
Scott BennerOff topic now. So anyway, so I'm going to do a little thing here. And please jump in whenever you want. In my mind, I take the I guess I should first say that I understand this would be more difficult without a continuous glucose monitor. I really do. What I'm saying would be harder, you could do it. I still think you could do it, you'd have to do it a little less aggressively, probably. And you'd be testing more but But what in my mind, what I see is that graph that goes along my daughter's Dexcom has a high line and a low line. And I take those lines from running. Oh my god, which way is this? Is this parallel? To the ground? Yeah, it is. Right? Correct. Yeah, I was asleep a lot in high school. listening to this podcast, just so you know. So I take those two lines that are spaced apart evenly, that run parallel to the ground, and I flipped them up on their end. So they're vertical, they're running vertical in my mind. And now they are a video game. To me. They're like driving, right? There are it's a football field, I don't want to run out of bounds on the left, or on the right. That's all it is. To me, there's in play an out of play. So when I describe it, and like talks, I discussed that like driving is interesting because it's um, you make a lot of imperceivable moves when you're driving, but if you jerk the wheel around, you swerve and you don't want to do that. So as you notice yourself approaching a, you know, the shoulder, you just turn the wheel back a tiny little bit and you come back into tow again, right? Like you're, you're it comes back. Same thing with you know, if you're gonna cross into the other lane, you just come back a little bit, you don't jerk the wheel around because if you jerk the wheel around, you end up in the ditch or in the other lane, where you end up with much higher or lower blood sugars than you mean. Right? So I bumped myself back, I bump. You know, I nudge back. I use that insulin to help art and stay in range. The problem that comes with jerking the wheel is that once you're in the ditch, you have to overcorrect again. And then you're on the roller coaster right now I've said roller coaster which now takes the graph back to being you know By the way, it belongs in your mind for a second, not vertically, but you're up and you're down and you're just overcorrecting the whole way with food with insulin, and you get the timing of the insulin so far off that some people it doesn't stop. It goes, it goes into
Jennifer Smith, CDEkeep going that way. Yeah. Yeah. For
Speaker 1for not just for a day, for weeks and months and lifetimes of just that's what my blood sugar does. It bounces up and down. And people say that, and it's heartbreaking me like no, just turn the wheel a little less like, right, like, it's okay. I understand how it happens.
Scott BennerAnd I think there are ways out of it. So I want to talk about some functional ways out of it. I guess people should understand the difference between a following and a drifting blood sugar. So why don't you talk about that for a second?
Jennifer Smith, CDEYeah, drifting is slow. And dropping is fast. I think that's the easiest way, drifting down and or even drifting up, happens gradually over time. So again, if you're using a continuous monitor of any kind, you'll see this slow continual change in blood sugar, little little nudges, kind of happening over the course of time. And since on all CGM, each of those little dots on your graph represents about five minutes, each little drift up or down, could be a change in glucose over a five minute time period, right? Yeah. So drifting being slower, means you have more time to implement a change right now, that could also be a smaller change, than having to make drastic adjustments with food or insulin. When you're dropping or rapidly rising, kind of the opposite. That requires more whether it's more insulin or more food, it requires more because the change is happening very quickly now. And usually I see drifts happening either with a horizontal arrow on your CGM, or you might get that slight angled arrow either down or up. That's I consider those drifts, I consider drops or rapid rises, when you've got arrows pointing straight up or poor straight down. That's fast. So you need to do something now.
Scott BennerSo to start with lows, if you're 75, straight down on a Dexcom, that could mean two or three points per minute, is that right? So every five minute change, you could go, you could end up moving 50 up to 15 points or something like that. I don't hold me to that. But fast is the point. Correct. So you don't like you know, when you're, when you're 80, straight down, you don't say hey, you know what I'm gonna just going to, I'm going to do a Temp Basal off for a half an hour here, that's not going to work. And there's reasons prior in the diabetes pro tip episodes, seriously, listen to them in order that will make sense to as why. But if you're just drifting down one of those situations where it's noon, and you're 100, and then it's 12:15, and you're 95, and you just got this little drift happening, you could possibly be at the end of a Bolus that ended up being a little too strong, right. And maybe there's, you know, an imperceivable amount of insulin left in there a quarter of a unit, a half a unit, depending on your size, maybe it's two units if you're an adult, right. And if you take away your Basal insulin right there, it's possible that you can trade that extra Bolus that's left and create what I sometimes talk about as like a black hole of Basal, right. So keeping in mind that everything you do with your insulin now is for later because insulin doesn't work immediately. Like, what if at noon, when you started to see that drift down, you took some basal away, and that created a level. So now, the end of that too strong Bolus was acting as your basal and your basal wasn't there. But keeping in mind if you shut your basal off at noon? It's not going to probably start impacting you for at least one o'clock. Yeah, right for a while. But at the same time, you were only drifting anyway, it was probably going to take you an hour to get from 100 to 60, where either you'd then be drinking a juice but instead, as you're hitting that 70 Mark, you're all the sudden into the timeframe where there's no Basal insulin, and you just level out that doesn't always work. I've done it and thought I'm a genius and I've done it and thought oh, I missed that like but trial and error will teach you because there are a lot of different
Jennifer Smith, CDEand I think some some visuals into that, too, as you said, you know, sometimes it works. And sometimes it didn't quite hit the mark, but you weren't necessarily wrong to take the basal away. I think especially again, with the technology that we have today, not only can you see the drift, but if you are somebody who's using an insulin pump, you also have the visibility of insulin on board, right. So if you have an idea how much insulin is left, like you said, an earlier Bolus of maybe you were a little heavy handed in it, or it was just you know too much, because you haven't quite figured out your ratios, or maybe it was, you know, a guesstimate completely, or whatever it was, you still have some insulin on board, if you have an idea of where your basal is right now. And you know how much insulin is on board, taking basal away, could substitute for some of the iob that's left? Absolutely. And like you said, it could nicely smooth things out and you just drift into a stable blood sugar. That might work if you've got iob of one and your Basal rate at that point is like point eight or point nine or even one that could absolutely smooth out if you've got three units of iob and your Basal is at point five, not going to help you to have you in a way it's going to help a little but you're still going to ask him to
Scott Bennerget the result. years ago, I used to think of scale. So think of like the scales of justice where each side has this big dish and you can you know, pile weight you know. And so think of insulin on one side and carbs on the other or weight the weight of your blood sugar on the other. And you can kind of imagine yourself throwing it a little on one dish and going oh, that was too heavy and taking a little out. And you know, we're taking some out. Like that's how I think of insulin like put a little in take a little out. You know and then you know I say a lot on the podcast and that I think we talk too much just about how insulin impacts the number. And there are so many other things to think about how food impacts insulin right like, like you'll hear me tell a story about like creating a drop, and then catching it with food. And write to me that's how the food impacts the insulin. And it's just there's it's a weird thing. But there's a lot of different ways to think about what's going on that little game that's going on in your body between the sugar that's in your blood, or that's going to be in your blood or the food that's going to put the sugar there and the insulin that's trying to take it out again. So anyway, you can bump with a Temp Basal, right it just as like to take it away like Jenny and I have explained. Also the same goes for going up. If you see, you know a 90 that turns into a 95 it turns into 100 It's going to be one of those slow drifts up. There's nothing worse than that, in my opinion. I always think of it as the the mountain climber on the prices right? That guy because every time you're like it's gonna stop, there's no way that guy is falling off the end. They're gonna figure this out like and it just totally HE WHO and it just goes on forever, right? And then that little guy just pops off the end and then Drew Carey takes your money back from you and you're screwed and you walk away. Right? So like you see this 90 blood sugar that's drifting up. Two hours later, it's 250. And you think, Oh, why did I do something? Yeah, like I should have done something. You know. Maybe that's a Temp Basal increase. Maybe it's a Bolus. But all All I know is that a 120 or one you know, whatever you wherever You decide to be diagonal lop can be brought back to a stable 90 with far less insulin than it will take to address the 250 two hours later. And when you're only using small bumps of insulin, you're very less likely to cause a low. And so when you see that 120, to me, that's you approaching, you know, the, the line on the side of the road. And you just want to come back almost in perceivable amount with the wheel or the tiniest bit of insulin to bring it back in line. Now. I have done this with my daughter for years with an amazing amount of success. And I've seen people, scores of people who listen to this podcast do it too. And it works. It really does. But the idea is that you're not always going to get your Bolus right. You're not always going to have the right amount of basal going for your specific situation that's happening right then in there. Correct? Wow, I'm more comfortable. You're with me? Don't tell your
How Much Do I Nudge? (Math and Guidelines)
Jennifer Smith, CDEI think you know in to have you want to do if you wanted to add some definition to like people always ask, well, how much? How much when I start to see this drift? How much should I add? Well, you know, one, again, everybody's ideology is a bit different your sensitivity to insulin. So a point one might be what works for you a point seven might be what needs to be in, you know, somebody else's case. But I think if you give definition to direction of blood sugar, again, using today's technology, beneficially. And you mentioned before, kind of the directional arrows, and what that indicates as far as a drift up or a drift down, and how much is happening. If you're wondering how much to add with insulin, when you do start to see a drift up, the angled arrow is really kind of a rate of change of about one to two points per minute. Right? So if you're aiming to see, okay, I'm at 90, I've not done anything. And now my blood sugar, it looks like it's starting to come up. I don't know why, but it's happening. If you excuse me, you know, experience that a 90 with a angled arrow up one to two points per minute in the next 30 minutes. If you do nothing, your blood sugar could be 30 to 60 points higher. Right? Right. So if you use that to your advantage, and you say, Okay, I could be on the low end 30 points higher, I could be one at 120, I kind of know what I would use to offset, you know, a 50 point rise in my blood sugar, maybe I need to just add a little bit like point two, or maybe I need to take a point five extra, you know, that's kind of a way that's a little bit more, if you're the math person right, may help you to get a little bit more precise and not worry about then ending up on the down drift later.
Scott BennerAnd if you were me, what you do is you try something and then the next time you try something different if that didn't work, right, less or more, yes, just more or less whatever try. And it's important to remember that it's not, you're not going to get it right the first time. And even if you do get it right the first time, the variables may change the second time it becomes an art, like it really does like just knowing how much to push just a little bit like you know, you squeeze too tight, and it's too much not enough and you let go. And using Jenny's example right there and flipping it to getting lower. You don't always need the whole juice box, you don't always need every piece of candy in the package. Sometimes you can nudge with food, right. And I know that 15 carbs 15 minutes is the rule of thumb. But if you're using a CGM, you can see it better. You don't have to 15 carbs to 10 minutes is when people are blind to what their blood sugar is. And they're trying to stop themselves from having a seizure. That's important. I'm not saying no. Okay, and I'm not telling you not to do it. But I'm telling you that if you do it, and find yourself to be 300 Later, you didn't need all 15 carbs, right. And by the way, if you do get into a panicky situation, and you've got to just Horkan carbs, I'm not going to tell you to not do it. What I am going to tell you is that when you when the dust settles, you need to figure out how much insulin you've got to Bolus for that food you just took correct Right, right. Like maybe not for all of it, but some of its going to need insulin. You have to stop the bouncing. You gotta make sure you can't get on that roller coaster like don't get on it. It's maddening. And the only way off of that roller coaster, by the way, in my opinion, is you stop taking in carbs and you get back to level again and like, like, I can listen, I can knock Arden off that roller coaster while she's still eating. But that is a ninja level event, like, like you need to be really good at that to stop to stop a roller coaster in between food. And you'll get it
Jennifer Smith, CDEtakes understanding sensitivity, right? You very well know and I'm sure Arden does as well, you guys know her sensitivity, and you've paid enough attention to say, Okay, we need this much right now because of all of these other variables in the picture, or you need this much less right now or whatnot. And you do get to that level when you start to pay enough attention, you know, to your personal sensitivity and the precision that you need. I think you know, the 15 and 15 is age old. I mean, that's what I started with 32 years ago, is 15 and 15. And we didn't have the visibility of blood sugar changes at that point, we did it or even just a meter,
Scott Bennerby the way that only takes a tiny drop of blood right isn't and this beautiful lancet, you know, it doesn't hurt that badly while you're doing it, you were stabbing yourself with a sword and dumping or dumping your blood and
Jennifer Smith, CDEcalled it the guillotine and it was like this big ol drum that like hammered down on your finger. And like I would like I would like inch my finger like slightly away from like the little underneath platform from where it like jabbed my finger I would like just hold it back. So it didn't quite jabot. That was my like, adjustment to the lancet depth. Right? That was the only adjustment I had at that point. But point being really that you have some tools now that allow you a lot more precision and how you bump and nudge you do. And with smart tools. Today, too, I think this is a good place to mention it is with our with our smart hybrid closed loop systems that are on the market today. That adjustment with carb, the 15 and 15 is 100% Too much 100% Too much with most of these systems on the market today. When you're adding a little bit of carbohydrate, we're talking like a little bit of carb, because the system has already been helping you coming into this drop in blood sugar. So 15 grams, 100% is going to be way too much. You might need two or three Skittles, which is like two or three grams of carb, you might need half of a glucose tablet, you might need a quarter of a juice juice box.
MDI Challenges and the PDM Alternative
Scott BennerSo well, you know, I want to go a little deeper into this, like faster rises and falls. You see people online every once in a while it's very common, actually. They're injecting and they all put in the measurement for their slow acting insulin as fast acting by mistake like oh, I take like you'll see an adult like I take 20 units of Lantus every day. And I just gave myself 20 units of Novolog. And they're online. What do I do? What do I do what I do? And I'm just like, figure out how many carbs that takes and eat them. Like, that makes sense to me. Right and give that a try. So say you do that. Not that but say you have a meal that really needed five units. And for some reason you thought seven. And the next thing you know, 40 minutes later, there's an arrow down on your CGM, you're falling fast, you need to eat the carbs to stop that. So it's a much bigger nudge, right? It's more like a nudge with a sledgehammer now, and you need to eat the carbs to stop that. In the same thought process. If you miss greatly with that insulin, it should have been seven and you use five and 30 minutes later, your two arrows straight up. I don't mess around there. Like I am stopping those arrows. Right? And you think well, okay, see, I don't know say it was literally like a mistake you meant to do seven and you did five. So you think oh, okay, two units, that two units isn't going to do it anymore. Because you have all this momentum, right? Like there's this momentum, you have to stop the momentum, you've got a higher number than you thought about when you decided on the insulin the first time. There's a lot to think about. There's the number, the momentum and getting you back without making you Well, there are times that I'll take what I think the amount is that's going to stop the arrows plus the amount that's going to change the number back to where I want it to be. And I realize if I give her this insulin right now, she's going to end up low later, but I still give it to her. And then there's a moment where I take the basal away away, right to try to do what I mentioned earlier, eat up that extra so I needed all that force from that insulin upfront because of the situation we're in. But I don't need the tail of it later, but details going to be there. So what if I took her basal away so that it wasn't basal plus the tail, right? And so I get the benefit of the oath upfront without the kick in the pants again, what comes later? Right? Right. That's another way to think of bumping and nudging, in my opinion. So there's no
Jennifer Smith, CDElearning the tools, it takes learning the tools to use, you know, things like people who are using MDI or multiple daily injections, it becomes harder because you can't take basal away, once it's injected, it's there. So if you are heavy handed with a correction, because you really want that double arrow to stop, you're gonna be have to be, you have to be ready on the back end with carbs to stop,
Scott Benneryou want to do you want to know what a pump does that multiple MDI doesn't do, it stops you from having to take a bunch of injections that allows you to do temporary Basal increases, decreases, extended boluses. That's it, then you don't have to carry pens with you and wonder if your insulins getting warm while you're at the waterpark. Like like that's, that's, that's it? I mean, I think to me, it sounds like a very little bit. But it's a lot. If you're going to be reactive like this and stay flexible and things like that. I'm not saying you can't do it with injections, I know plenty of people who do. Yeah, they very commonly are adults, or, you know, kids who just don't care about the injections, because there's going to be a moment when you're going to put in a little insulin and realize it's not enough and have to put in a little more. And now that's two needles, you know, instead of two pushes of a button, I think certain kinds
Jennifer Smith, CDEof food, which we've talked about in other episodes, leading a pump to cover differently over a longer period of time. With a with an injection, you can't do that, unless you're willing to just take more injections with more insulin.
Scott BennerSo now here's the next thing about bumping and nudging, you get what you expect a little bit. And I want to just before I tell you about that, I wanted to tell you that what Jenny just said, shouldn't have been glossed over. There's other parts to this, I'm talking about bumping and nudging within a fairly perfect system, meaning I have my daughter's basal well in hand, I'm not that far off with her meal. boluses if I miss, like, we're not just like running around with our hair on fire. And I'm like, Yeah, you know, like, and I just hear
Jennifer Smith, CDEfeed here, give more here.
Scott BennerInsane. And I do mean this without sounding like I'm trying to pimp the the content, if you go back and start at the beginning of the pro tips. Or if you want to power listen to by the way, those of you who start at the beginning of the podcast and listen right through, you have my respect, I thank you very much. Because why the downloads are so good. And I really helps me. So thank you very much. But at least go back to the protests, and listen through, because then you'll get to a point where bumping and nudging really is a good tool. But it
Jennifer Smith, CDEdoesn't happen not 100% of the time. It's
Scott Bennernot always gonna work. Right, right. Like there are gonna be times where it doesn't work. And it happened to me last night with Chinese food. So we came out of a pump change and went right into Chinese food, which just shows my arrogance, really, because I was like, this won't be a problem. But what I didn't take into account is this for the past 72 hours, Arden has just needed more insulin, like there are foods that don't make Arden spike that are making your spike for the last three days. I don't know why it's not important, why it's just happening, you know, like, like soup. She's having like, a clam chowder out of a cannon. I can't get her under like 250, like 45 minutes later, like, like what's happening, you know, and it'll go away. Because the day before this started, her blood sugar was like 85 for 17 hours in a row. So, you know, it'll, it'll cycle through, we'll figure it out. Maybe it'll end up being a variable that needs adjusting. I don't think it will be but I'll see. But that's not the point. The point is we came from a pod change, right and do Chinese food. And boy luck with that. I did not do well with that. And so I want to first tell you that when I say oh my god, I did not do well with that. What I mean is her blood sugar was between like 175 and 210 for a number of hours afterwards. I know you're thinking Shut up. I would love that. Right? You're hungry? Yeah. Yeah. People People are like, really? That's your complaints? Not a complaint. It's just I missed Right. Right. And there was a time five hours honestly, where she needed. I Bolus a bunch of times and I never once got it right. I was never strong enough with it. And I have to admit, it was because I was tired and I didn't want to be up all night. So I just I erred a little on the side of caution not a lot and and I kept pushing. So but I did not cause her to get Low afterwards, which was, which is a winner. It felt like that to me. And I'll tell you why. And I want to put this in this episode too. So very recently, I wore the Dexcom pro continuous glucose monitor and I was very happy to find out that I am apparently not pre diabetic as I was texting Jenny's ice put it in, I'm like, you know, this, I'm gonna find out I have type two diabetes, right? Like I'm I was very happy that I didn't. Obviously, I was grateful. But I got to see what a pancreas does, what it's doing what it's supposed to do. And I have to tell you that there is nothing I ate no matter how low glycemic or high glycemic, they got my blood sugar over. I mean, I told you that I had eat two pieces of cake to get my blood sugar to like 135 140 one time, right? But as I look back over the day, my standard deviation was like 11. You know, my, my average blood sugar was I don't know, like 90 or 80 or something 85 or 90, right. But I still went up a little gracefully 120 Most of the time back down again. You know, that happened when I ate. And I had already changed my mind about my expectations for Arden over the last couple of years, and you guys have heard me loosen up on the idea of like stopping every spike like I don't, I'm not a flatline person. I don't feel like my daughter's blood sugar needs to be a flatline, I do believe that she has type one diabetes, and that letting a flatline get away from you turns into a disaster that takes way too long to fix, which is why all this is important. But I don't care if she eats and her blood sugar goes up to 120 130 and comes back down again. I think that's fine. As long as she's not low on the other side, I start getting a little hinky over 140 In my heart, I'm a little much, you know. And it's not to say I wouldn't try to stop a 120 If I thought I had the answer to it. But I don't know it just it seems important for me to tell you that if your pancreas is working your blood sugar is not always at 85, it you know, it just isn't. So be a little easy on yourself, have good expectations, but understand that my daughter, you your kid, Jenny, you don't have the mechanism to just, it isn't just going to put the brakes on for you. So that's why you can't you know, I say you'll never get high if you don't get high. That's sort of what I mean by that, like stop the arrows stop before it starts, right?
Jennifer Smith, CDEWell into this kind of experience that you had to I think one of the funny texts was relative to Pre-Bolus.
Scott BennerYeah, I was tested on you're like,
Jennifer Smith, CDEI Pre-Bolus better than my own pancreas Pre-Bolus. This, I think is what your text was because you had seen a difference in what you had done for the same meal for Arden with her Pre-Bolus Yes versus what your own pancreas was doing. And I think you said something like, I wish I could get my pancreas to Pre-Bolus. And I was like well, your pancreas kind of does actually do that the working pancreas body kind of does do this like pre Bolus Bolus, right?
Scott BennerSo Jenny's tried to explain to me and I got if this is true, she said that sometimes when you smell food or you get hungry, your body anticipates that your blood sugar is gonna go up and it gets a little working on things prior. That's really cool. But what she's pointing out and I am a little embarrassed is that after a couple of days, I would look at, like I haven't be cooking. And I think to myself, like I think rubbing my stomach wherever I thought my pancreas was, you know, I don't even know. And so I was just like, man, now do it. Now brother. We're about to have pasta. Go, you know. But no, Jenny's not wrong. And I'm not bragging. I was better at stopping spikes with Arden that my body was for me. And I was really, like, comforted by that. You know, I was like, Wow, this this bolt on that podcast really works. And I was I was just really, I was really thrilled. You know, I was like, wow, I because it felt like it wasn't overkill. Do you know what I mean by that? Like, I thought oh, I'm not taking this too seriously. I'm taking this the right amount of serious, right and it just really was it was a it was a great experience. I want to thank Dexcom for letting me wear the Pro. And it was really nice. I was the only that was only worn by national media outlet people. And me and I was very grateful and I really appreciate the Dexcom appreciates the podcast and sees it as what it is. Yeah, not not just not a guy with a podcast like I was like wow, they really like oh, it made me feel good. Anyway, point is the last point I guess of all this is Is, is that bumping and nudging is terrific. It's great while you're learning things, while you're learning about how to Bolus for meals while you're learning about activities, you know, all that stuff's great, but it's not a long term, everyday solution. And I didn't recognize that people wouldn't translate out of it eventually, like, just go like, Oh, okay, um, didn't happen to me. You know, I said at the beginning, I didn't realize it wasn't happening to me. And then finally, and again, I have to thank the people listening, because we started the private Facebook group, which I'm not particularly active in. But see, every day, I started watching and this is when I said to Jenny, I need a pro tip on pumping and nudging. I was like, Oh, my God, these people are doing this all the time, like constantly and like it's not for constantly. And so here we are. So if you heard us do defining diabetes, bumping nudge, which literally just came out last week, I said in there, what I didn't realize about bumping and nudging when I started doing it was that it says much of a diagnostic tool as it is. Yeah, a tool for keeping your blood sugar's in order. Correct. So Jenny, when you start seeing yourself bumping and nudging too much, what should you be doing?
Jennifer Smith, CDEThen you should be going back. Personally, what I do, and with the people that I work with, what I do in in data analysis is, I look at a cumulative and I say, over the course of this time, whether it's a week, or three days, or two months, or whatever we want to look at together, we can say, well, goodness, we've had a lot more use of Temp Basal, that are not specific to like activity reason, or a food based reason, like you always eat Friday night pizza, or whatever it is, and you need that kind of a tool for but goodness we're having, there's a lot of corrections happening after meals all the time, or there's a lot of you know, you're using Temp Basal is to cut off insulin all the time, if that's happening, and while it might be proving to give you the results that you want, there's a bigger picture, they're saying there's either not enough insulin for some reason now. So we need more in the Basal or we need to add a change to the year ratios so that you do get more robust type of Bolus for food. And then you shouldn't have to follow it so heavily after an adjust with extra insulin all the time. So that becomes looking at information and saying, for whatever reason, I just need more basal. Now, let's pop it into place for whatever reason, my ratios look like they're not covering Well, or they're covering too much. Let's take some away, let's add some in. And let's make sure that I'm not bumping and nudging now 100% of the day, because that shouldn't be the case. Right? You shouldn't have to work that hard, essentially. Yeah,
Conclusion and Series Outline
Scott Bennerone of the I think one of the benefits of the podcast is that it eventually should make the management of diabetes simpler and less impactful on your, your moment to moment, you shouldn't constantly be like, Okay, a little more, a little less, a little more like, that's, you know, algorithms do that. But you shouldn't have to do that. Right? If you find yourself doing it, looked back and just tried to separate a variable from constant and address the constants and keep bumping the variables. That's, that's all it gets that easy. I took me a while to figure it out. And that's why I'm here saying it to you because I thought, oh, gosh, what if people don't figure it out? Like I started having this heart in my head that people would just be like, bumping
Jennifer Smith, CDEfollowing my child until they're 50. And I'll be 89. And you know, what's happening to their
Scott Bennerpicture, people in my head that haven't seen the sun in three years, have their hair all wired, like they've been electrocuted, and they're like, my kids, my kids at A1C was 5.5. Her blood sugar hasn't gone over 110 and six years, I'm fine. Like, please don't be like, Oh, my God, it would break my heart if that's what's happening to you. And don't get me wrong, by the way, in the beginning, while you're starting to figure it out. You may be
Jennifer Smith, CDEthat is one field, you
Scott Bennershould be able to get past that. Right. And I hope this has been helpful. Did we miss anything, Jenny? Because you guys, don't you really everyone listening should should just take a second to realize that Jenny and I don't have any notes in front of us. Like we're not working off a list. And I still think we got in the timeframe through everything I wanted to say. Do you feel like Absolutely. We did a good job should ring a bell. I'm going to spike a football. That's right. I want to say this is something I was going to say later when I was editing it together. But I want to say it was Jenny here instead. I appreciate that the people listening care about this. Like I really do like I I think it's wonderful that you all want better or easier or simpler, and aren't just throwing up your hands and saying, I don't know, there's good days, and there's bad days. I think it's really wonderful. I think that we're creating a feeling throughout the diabetes world that's going to help people in the future, it might not help you as much as it's going to help someone else. But I got, you know, it's funny, it's not a note, but somebody posted this on social media the other day, and I'm not going to put their comments and their name into it. But I want to tell you like how amazing I thought this was. This person is relaying that their child, a 13 year old who's only been diagnosed for four weeks, listens to the podcast with their parents went into the doctor four weeks later, advocated for themselves for a pump explained, explained that she wanted to use extended boluses. She tried it with MDI showed her doctor how she tried it, explained that she wants to do Temp Basal adjustments in the anticipation of exercise and activity, and started rattling off everything she learned from the pro tip episodes. Wow. And even rolled in with her on the pod demo that she passed, and persuaded the endo to approve the pump at the next appointment. And that's awesome that endo normally makes you wait six months. And that's from these episodes. And so I imagine not just the happiness for that child that's coming. But that maybe now the doctors like Hmm, why am I waiting? You're not making people wait, couldn't I just do this with them? That's exciting for me. And it's so it's everyone's desire to do better. And then your willingness to say it when you get to the doctor's office, it's,
Jennifer Smith, CDEwell, then maybe even from that doctor's perspective, maybe you know, this person obviously went in and said, Hey, I've learned all of this from this one place, maybe the doctor now has a reference to say, hey, you know, if you want a little bit more, and you come back to me knowledgeable enough and can say, hey, this is what I know. Now, this is what I want to be able to use why I want to be able to use it. Again, I think a lot of clinicians are just conservative, because they're worried right there. They're conservative, for many reasons, but I think worry is a big one. And they want some outcomes showing. Yes, my patient is now ready for this. And unfortunately, I think again, with the technology we have today, I think people are more ready earlier than they may have been years ago. So
Scott BennerI think that I don't think that people should make the mistake that this is some special girl. Do you know like she is seriously it's, it's it sounds self aggrandizing I really don't mean it to be she just listened to the 17 or 18 pro tip episodes. And in four weeks, look where she is. And and I don't know that everybody could be but I think my experiences are that a lot of people are and so that it's possible. I'm in my heart. I hope right now that doctors listening to this going well, that sounds like something that happened and like I hope he went in was like, I wonder what that kid listen to you. Right? You know, right? Like, that's what I want. I want everybody to be healthier, and easier and less encumbered and anxious and all the crap that comes with having diabetes. So, Jenny, I want you to hear that. Thank you.
Jennifer Smith, CDEYeah, no. And I think that's a good cumulative of kind of, I mean, my overall when I had set out, going to college, knowing what I wanted to go to school for and eventually what I wanted to become just it was a very, it was a very, like, General, I want to become a diabetes educator, because I had had really awesome educators as a kid myself. But I never like I didn't have a broad like idea of what I really wanted. I just wanted, I knew I wanted to be able to share what I knew, with people and I wanted it to make a difference. Like it made a difference for me when I was younger, you know, and didn't have the technology or anything that we have today. Right? So, you know, in what I get to do every day, that's, I love it. But what I like more is that I love this connection that I've that I've had because of you because of the podcasts and the end what you've put together. I feel like I've reached so many more people than just the individual people that I get to work with every day. You know, I feel like kind of especially these pro tips what we've put together it's just able to reach so many more people in a way that's it's free. Yeah, you know, it's great.
Scott BennerUm, thank you. i You made me. I felt like little butterflies and I looked. I looked away from Jenny while she was tucked away embarrassed that I couldn't keep looking at her through a video screen while she was saying something nice. I need therapy. Thank you i It really is terrific. It would obviously not be the same without you. So I really appreciate it. Okay, cool. All right. Well, we did a good job here. I'm gonna go back to your life which is probably just talking to somebody else about diabetes in a second.
Jennifer Smith, CDEActually it will be my husband went off to work and my my kids are out there watching I think they're watching dyno Dan right now and I could hear my little man outside the joystick. Mommy, I want us now. Like, okay, well, I'll be there in a minute.
Scott BennerWork. Go back to what you're doing. Go take care of him. And thank you very much.
Jennifer Smith, CDEYeah, absolutely. Have a great weekend. Thanks.
Scott BennerI hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1018 pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025 We talk about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A1C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable For you and your family, if it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.
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#1016 Diabetes Pro Tip: Long-Term Health
Scott and Jenny discuss optimizing long-term health with type 1 diabetes.
You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.
You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - Radio Public, Amazon Alexa or wherever they get audio.
Key Takeaways
- Target Confusion is Normal: Different medical organizations have wildly different target blood sugar recommendations (e.g., under 180 vs. under 160 vs. under 120 for pregnancy). Find a target that makes you feel healthy and vibrant without causing severe burnout.
- Don't Be Afraid of a Lower Target: Earning an A1c in the 5s isn't inherently dangerous if it is achieved through reduced variability (smaller standard deviations) rather than constant severe lows. High numbers shouldn't be accepted as simply "safe."
- The "Sandblast" Analogy: Think of high blood glucose like coarse sand running through your veins. Over time, it scrapes and damages the lining of your blood vessels. To repair the damage, the body creates cholesterol patches, which eventually narrow the vessels and lead to long-term complications (heart, eye, kidney disease).
- Focus on How You Feel: Blood sugar management isn't just about avoiding death at 70; it's about how you feel every day. Chronic high blood sugars alter your mood, your cognitive abilities, and your energy levels.
- Don't Let the "Diabetes Fairy" Take the Blame: If your blood sugar isn't doing what you expect, don't just chalk it up to bad luck. Trust your gut. If your pump site seems bad, change it immediately. You don't have to suffer through 48 hours of unexplained highs.
Resources Mentioned
- Wrong Way Recording: wrongwayrecording.com
- Diabetes Pro Tip Series: diabetesprotip.com
- Juicebox Podcast: juiceboxpodcast.com
- Juicebox Podcast Type One Diabetes (Private Facebook Group): Join on Facebook
- Dexcom (CGM and Clarity app)
Introduction and A1C Target Confusion
Scott BennerHello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CDE and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisitable. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. So Jenny, this whole time we're going to talk today. I think we're gonna just talk about this one email that I got.
Jennifer Smith, CDEYeah. Which was great. And I think I mean, we've touched on some of these points in like some of the I know we did like up a safety in a hospital preparedness and all of that kind of stuff. But I think this hits a really specific mark of most people that go to an emergency room in an very emergent setting. They don't really know, and why would they know that the staff there is not prepared to deal with type one diabetes. Yeah, they're not in they're not in. I don't say that in like a god. They're not educated they are they're highly educated, they're educated in a million different things, right. But their focus is so much not type one. And because the scope of how we manage type one, especially in the past 10 years, has changed so dramatically. They the staff, they can't keep up with that. They don't they don't have time to keep up with that. So when you come in, you know, on these fancy gadgets and all these things, and they're like, Well, I know an insulin drip and I know how to, to hook you up to glucose and that's what we're gonna do. Like and you step back and you're like, No, no, no, no, that's not how I do this,
Scott Benneryou you come to realize what they really understand is just how to keep you from having a low blood sugar incident while you're there. That's what they know how to do. So you may or may not be surprised by the number of emails I get yearly from nurses and doctors who have children who were diagnosed or sometimes who have themselves diagnosed. And inevitably, there are three sentences, three sentences in their email that describe I'm a good nurse, I'm a good doctor. I don't understand type one diabetes at all every time. It's just, you know,
Jennifer Smith, CDEwith a family right now the the father is a physician and the mother is a nurse practitioner and their little child they I mean they came to us and they were like we know diabetes, but we don't know diabetes. You know, I mean, we know the coded book description of this is what you do and that should be cut and dry. When you limit not cut and dry. There is no book anything A
Scott Bennerbit of nuance just a bit. Right. Right, right. So I don't think Misty would mind her name being used, Misty came into the private Facebook group that we have for the podcast. And she shared that, you know, her child had to go to the hospital. And then she had all of these questions afterwards, and statements and things like that. And when it ended, she said, I would love it, if you and Jenny talked about this stuff. And I said, Okay, you go ahead and put a list together of what you think of, you know, as emergent that came from this experience. And Jenny, and I'll try to talk about it. And she really did. So Misty, congratulations, this, you are the founder of this feast today. So
Jennifer Smith, CDEshe did a banana, I mean, from the topics that she noted, would be helpful to cover and everything. I mean, quite honestly, it kind of speaks to the amount of medical education you get, yes, it's only in one field. But the amount of medical stuff you learn, when you become either the person with diabetes, or the caretaker for someone with diabetes, I what she has here is very much in a very, very specific way really important, and should quite honestly be like taken to the emergency department heads. And this is what your Doc's should have a list of protocol to follow up. So
Scott Bennerthat's what we're gonna say the real question becomes, excuse me, the real question becomes, what happens in an emergency situation in a medical situation, when you are the most knowledgeable person in the room and have the least power? Right, apparently to you in the moment, right? Doctors lab coats, people bumbling around, you're not a doctor. But it turns out, you do have power, you just need to know how to assert it. And we'll we'll did exactly. So let me read a little bit here. This, this email is not miss these initial post in the, in the Facebook page. This is the email she sent to me. And so she said, Hey, thanks for considering making this as an app. Thanks for considering making an episode about emergency care. Going through the sickness with my son, which was the first time he had had a stomach bug since diagnosis almost a year ago, made me start thinking about how to figure out what else I don't know. In this instance, probably the three biggest mistakes made in the ER, ended up being the doctor turning off his basil. They didn't hang textures, and a refusal, an absolute refusal to call an endocrinologist. And she said, I knew that these things weren't right. But by doubting herself, and assuming that the doctor must know better than she did. You know, she had no idea in the end, how to make him do those things that she knew needed to be done. And she should have been more assertive, she says, and sooner. So she puts she just puts a bulleted list here. That's terrific. I and I think we should just go down the list. Right?
Jennifer Smith, CDEAbsolutely. Because it's it's a great list. And I think some of the points can actually even be kind of melded together in a way. But it is it's a very well put together list. It's actually in fact, many of the things on here, when we talk to people, the people that we work within our practice, and we give them our information about prepping for a hospital stay, we have not only a hospital stay or expecting like for a planned surgery, but we also have a lot of these things covered so that you do know how to advocate for yourself, because that's really what it becomes. When you go to the emergency room. Unless you are the person with diabetes, and you're completely out. Well, you know what? They're gonna do what they can do to save your life. And you have no control there then. But
Scott BennerYeah, and maybe you can get into a situation where you don't end up like you've heard people in the past talk about in the podcast, where they have family members sneaking them in insulin, and they're doing like, you know, like, Wouldn't it be nice if that's not how this went? Right? It wouldn't be lovely for your, your medical doctors to know about the insulin in your body. So I have a couple of experiences that I'll I'll interject if they fit, and I know you're gonna have some. So first question was, how do I know when it's time to go to the hospital or even at least to call the Endo? When it's a specific type one problem, I guess around illness? The when do you tell people to call?
Jennifer Smith, CDEYeah, I mean, we usually tell people to call at least to call their endo or I guess even a step before that is make sure that you've addressed with your Endo, a 24 hour emergent line to be able to contact somebody at because I guarantee that your specific endo isn't going to be there at two o'clock in the morning and everything every time something happens, right. So the step ahead of that is knowing who to call, what's the number, who will I actually talk to, is it just going to be a nurse triage or is it really that I'm going to get to talk to somebody that's going to give me some information mission without playing phone tag
Scott Bennersharing services still exist. So you might just be getting a person taking a message, right? Correct.
Jennifer Smith, CDEI mean, most systems, most healthcare systems do have 24 hour nursing care within your like, you know, whatever your insurance coverage or whatever system you're in, right? And that nurse should also be the one who can help determine what are your symptoms? What's going on? Or what's happening with your child? Is this emergent enough? I'm going to call the doctor on call and we're going to get some answers for you or no, you need to go to the emergency room there. I mean, we've used it a couple of times for for our boys when they've been like sick fever, like, you know, rolling around, not feeling great. I'm like, Okay, let's call the nurse and see if the time to go to the doctor, you know. But so they're from our experience, they've been very, very helpful and good. So that's a first step, if it's daytime, certainly tried to call your endo office get in a very emergent message that, hey, this is what's going on and have some very good facts to give them, you know, we've checked blood sugar, we've given insulin, we've checked ketones, you know, my child won't take any fluids, or my child can't stop vomiting, or those are very, very important things to be able to give facts. So they know what to do with you.
Scott BennerI also think that it's important not to get caught up in the emotion of it, start telling stories and like they need the facts. They don't need, you know, the extra stuff my mother in law was over. And yeah, let that go. That's not
Jennifer Smith, CDEthe kids friend was over three weeks ago, and had you know, the flu two days later, they don't care about they don't need to know,
Scott Bennerwe've all been around a person telling a story who's telling a story. They're five minutes into it, you're bored out of your mind, and then they go. So anyway, it was one o'clock in the afternoon. Wait a minute, was it? Was it one o'clock? Or was it 130? Right? I you know, I think and you're like, listen, going, it doesn't matter. Just tell me the story. So yeah, and I think to to recall, to remember, is that it's possible, you'll get a really learned person on the phone who can hear you and respond from their own brains knowledge. And you might also get someone on the phone who's just following a flowchart waiting for you to say a key word. So you know, exactly. temper expectations, I guess, too, right?
Jennifer Smith, CDEAnd definitely, you know, like I said, have the facts in order that you can tell them so they can direct what they need to tell you in the right way. And then, you know, if you really just don't know, you know, when is it actually time to just pick up and go to the hospital? I mean, certainly, we usually say if it's, in this case, you know, her son had a stomach bug. So my expectation is that there was a lot of vomiting, or maybe there was vomiting, and the other end as well, kind of coming out. I don't know, stomach bugs are pretty nasty. And for little kids, or kids of any age, even adults, you could be so like, just out of it, that even remembering to take a sip every couple of minutes or remembering to get, you know, some food in or some carbs in or to try adjusting your insulin this way. Some of that may completely go out the window. So I mean, when is it time to go the hospital when you've put everything in, and you've adjusted, and you've tried all the sick date protocol that you've been given to try, and it's not working, and especially if there are more. So that higher ketone level, you need to go to the emergency room, don't play with it.
Scott BennerSo is the idea. The illness is not fixable, you are ill now you're ill, you're either able to manage it at home in a way that isn't going to become dire. Or you need to be at the hospital prior to it becoming dire. Right, right. That's correct. That's the idea.
Jennifer Smith, CDEAnd a lot of some of the evaluation in this case would be hydration, for a stomach bug, when to go to the hospital, especially for little kids. If they haven't been able to even take anything in fluid wise or fluid with a little bit of carb. It's it's time to go hydration is a really, really, if you get dehydrated, it's hard to
Scott Bennerget to recover from that and pay attention to your ketones. I would imagine when you're sick, yeah. Okay. All right. So then she says, What do I take with me? Maybe you should talk about the stuff you have prepared in case you're too sick or unable to speak for yourself a list of medications, outlining of what your normal type one care is like what hospital is best for you to go to if you have a choice. She she lives very far from her hospital, which is interesting. I live in a metropolitan area. I never think about that. Like I never I don't realize that some people have to take an airplane to an airport to fly somewhere else. Like that's not the life I live. I wanted to go to a children's hospital right now. I could go to Five of them if I wanted to, right? Yeah. Right. So, but that's not everybody's situation. So what should you I mean, you've talked before though about having a go bag for yourself, yeah.
Jennifer Smith, CDENext to the door or even if you keep it in the car, as long as doesn't have any psych meds or anything that'll freeze, you know, if you live in a cold place or way too hot place. But I mean, some of those things that should be in a bag, a bag, especially if you're on a pump, things like extra reservoir, tubing, infusion site, even a bottle of water, extra batteries, tapes, adhesives, you know, all those kinds of things, even some extra like glucose, glucose gels, and bull sugar uses simple sugar, all the things that you would pack to potentially take along on like a vacation, let's say, could be in that bag along with and I love that, you know, she pointed out things like a list of meds 100% Because you know what, when you're bringing your child someplace emergently like that, while you may the back of your hand know exactly what the rates are of Basal delivery and what they get, and maybe if they're on injections, how much and when, when you're in that emergent situation that may completely go out of your brain. And you may be fumbling to remember. So having that all, you know, written down, even, you know, if you upload your pump, do a printout once a month of the changes that are in your rates, ratios, you know, time of action and everything that's available on every pump load site, right, download it, put it in the bag, that way it's there. Yeah,
Scott Benneryeah, I think too, as you were talking, it made me realize I'm going to do something. So Jenny, and I have topics for some of our episodes. And we just keep them in a simple note in an iPhone, right. And it's a shared notes. So I type in a list, Jenny goes back and strikes things out or adds things we go back and forth. And as we make changes to it, the other person can see the changes, you could just simply have a note in your iPhone that is shared with your husband and your mother and and those people, that is a list of medications, what Basal rates are stuff like that, so that everybody has access to that information in a second.
Jennifer Smith, CDEThe other really good like I'll like I never take off my ID bracelet. But many ID Bracelets like mine on the very back of it. Now of course I can't get it off. But on the very back of my ID bracelet is actually a an 800 number and a website, that's it's free. All they would have to literally do is look at my ID bracelet. And login to that and all of my medical history is there. So if your child wears a necklace or a bracelet or something like that, many like American medical ID does a really good job. Most of the other websites. I don't know if they offer that as a free service when you buy a bracelet, but it's a nice way that again, you don't have to have that list, like printed out. It's there.
Scott BennerThat's excellent. Okay. Okay. Misty says what are the universal non negotiable things once you're at the ER, like for your safety? She says that in their case, it was not shutting off the pump. You know that hanging dextrose not saline by that's why that one's interesting, isn't it? They gave him because the saline drops your blood sugar, like well,
Jennifer Smith, CDEand the dextrose versus the saline may, you know, in her circumstance, she's right. But in other circumstances, depending on where blood sugar was, you know, hanging saline versus dextrose. If somebody's coming in, in DKA, obviously feeding them more glucose, at least initially, you know, you're going to actually you need hydration, right? So there are some pieces that go along with the illness that you've come in for to pay attention to. But I think what she's really saying here is asking what's being hung? Right? Right. It's it's knowledge to say, Okay, you're hanging saline, he's come in with a stomach bug, I understand that you're trying to provide some hydration. But let's look at where blood sugar is. Let's look at all these things, then she's, you know, again, also very correct. And it's a big thing that I go over all the women and men and parents that I work with. If you go to the emergency room, do not let them take your pump. Do not let them take your pump. I mean, like if you have to like scream and yell and whatever, then advocate and don't let them take your pump. If you come in because you've had a pump malfunction. Obviously your pumps not gonna be doing what you needed to be doing.
Scott BennerTake your busted pump. There's a
Jennifer Smith, CDEdifference in the story, right, but definitely not shutting off the pump. The other thing here too, is they don't necessarily know pumps well enough to even be able to know whether you've shut it off.
Scott BennerSo Jenny just brought something up. Interesting.
Jennifer Smith, CDEOkay, so I kind of I kind of sugarcoat that in a way like that. They don't know.
Scott BennerIt's like, it's like when my kids were little, we used to go into a spare room, pull the sofa away from the wall a little bit and hide Christmas presents behind the sofa. And the kids never knew where they were because they just didn't know to think about that. So So I have two hospital experiences with Arden. And they both come within the last year. So they're fresh in my mind. One of them is an emergency room visit, where our son had abdominal pain. It was bad. We went into the ER, the first thing I started doing and now keep in mind that this ability to do this comes from a confidence standpoint, like I was confident when I got there, so you know what you're doing. So I got I said to the nurse, and anybody who walked in Arden has type one diabetes, she's wearing an insulin pump and a continuous glucose monitor. Her continuous glucose monitor is reading her blood sugar live, here it is I held it up and showed it to them. And her insulin pump is giving her Basal insulin and Bolus just in case she gets larger. We want to keep these devices on her. Okay. Now you would think they'd be like, Oh, I don't know. But when people realize, you know, and they realize they don't know, they get a little smaller in the conversation, if that makes sense. Like someone's in charge and someone's not. Now it is not the you're not trying to lord it over them. You don't want them to be like, you're not like, Hey, I'm here, I know what I'm doing back up. It's a very symbiotic thing you're trying to set
Jennifer Smith, CDEup because you've also come in for help. For something else, respect what they
Scott Bennerknow, right? Respect what they know, try to get them to respect what you know, it's very important not to come off crazy during those initial conversations flustered, like you don't realize it. But if they look at you and your hair on fire, they read that as I'm not listening to that person, right? You know, and that's good on them, they shouldn't. And also keep in mind, that emergency room, people deal with a lot of crazy people. So they don't know if you're crazy or not. And so you have to build a little quick rapport, simple conversations, ask questions. And I also found that I was kind of in my mind scoring the people. What did they understand? What, when did they get a blank look? Or when did they have a response that made sense, you know, and try to figure that out, then sometimes, there were people in the scenario I just stopped talking to about diabetes, I directed it more towards the nurse who seemed to understand what I was saying, the one who wanted to give me a little space, and did and that's how I did that. And, and it worked out really well.
Jennifer Smith, CDEAnd I think at the same time in your scenario, kind of bringing in until she she mentioned a little further down, not until the nurse really was like, I need to set you straight. And I'm going to call in somebody else to talk to you and set you right and whatever. And she called it an endo consult. Quite honestly, when you go to the emergency room, and you know that you may have a stand up and put your hands up and say I got this I know. And you know what you can call an endo bring them in, because I would like another advocate for what I'm doing. Right up front ask for them. There's always an endo on call. There's there's always a specialist on call that will come.
Scott BennerAnd if I can play psychologist for a second when the nurse says that to Misty that's the nurse saying, Well, I really don't know enough to right to be the stop in this situation. I think that woman should stop telling me what to do. But I don't have enough facts to Stop or I'll go get a person with facts that come in. And then we'll see later that the person with facts came in and, you know, told the nurse instead of Misty.
Jennifer Smith, CDEKelly, you know, hopefully overall the nurse may have learned something in that setting too. You know, everything is kind of with diabetes, I find it's if people are willing to listen, it's a teaching moment. So you know, hopefully for the next person who comes in or the next parent with a child who comes in this nurse will be a little bit more in the know and be able to say you know what, I don't know enough about this. I do understand that you feel like you know what you're doing? I'm going to call the endo let's just make sure everything is is is good. Everything is the way that it's supposed to be going based on what you came in here for you know, three.
Scott BennerYeah, exactly. One second, I gotta tell ya. One second, I gotta tell you something
Jennifer Smith, CDEelse you follow fallen asleep in class because she's so tired from studying so late last night.
Scott BennerShe's actually on her way to lunch. She's been at school for 25 minutes and she's going to watch now which is great. No,
Jennifer Smith, CDEwe always we always talk at the time that she's into lunch. Yes. And you're always texting her do this or did you do this or today?
Scott BennerTell me to pull the curtain back a little bit. People like hearing about that. So there's a reason why I'm always recording while Arden's at lunch and not another time. I'm much more well thought out than I give myself credit for or the way that I let you believe I am. Okay, and then she asks the end is it ever okay to shut off insulin so Misty, I'll tell you that I was rockin Arden's blood sugar for hours in the emergency room and there was no food going into her like we had some juices once in a while we were sipping juices always let the nurse know juices happening. Because the nurse was always like, Look, if you can't manage this, we'll use I don't know what it is dextrose or glucose or something like that. I entered it trip. And I was like, okay, you know, but I was trying really hard for that to happen because just like the nurse who called the endo on Misty, I didn't have any perspective for that. I did not know what was gonna happen next. And I use texting Jenny, I was like, what's gonna happen if they give her this? Like, what trying to be ready because I've taken insulin away, like, I don't know what to do. Right. And we kept it going for a long time. But finally I just couldn't, I couldn't keep it up anymore. Right? And so they gave it to her. And the woman's like, let it go for a minute to see what happens. She was right, like it's shot up. But it came back down pretty quickly again, like had I given her insulin for that that would have been a major like prostate, right? Yeah. And then once we got that drip regulated, and then got her Basal rate to where, like I just adjusted her Basal to manage the dextrose instead of what it was usually a manager, she was getting a very tiny bit of insulin, but a little bit, and that was it. And it's making me realize as we're talking the tools really do work anywhere. Like they work in that situation too. So I guess confidence and honest actual confidence that comes from it comes from experience that you know is gone over and over again the right way is really helpful.
Jennifer Smith, CDEAnd I think that you know, as far as what you were doing because you know how to manage and you know how to adjust you know how to turn things down or turn them up or micro Adjust with little bits of juice, if you know the person can take a little bit by mouth, and it's okay according to what, you know, their protocol is in the emergency room, or again, like a dextrose drip, if that's an option, and you can adjust accordingly with your Basal insulin drip. Great. But it's and I hesitate to say, is it a yes or no? Is it ever okay to shut off insulin? Technically no, for somebody with type one? I mean, really, it's not. I mean, we know what happens if there's 100% deficit of Basal insulin, you're not going to see the impact right now. But you are gonna see the impact in the next several hours based on that deficit of basal that was supposed to be there, even if they needed less Basal insulin, they will always need Basal insulin.
Scott Bennerand you and if you get to that spot where your it all is out of control, they're going to take it over, then they are going to take it over the minute your life feels a danger, and they don't think that what you're trying helps him or you're going to lose control the situation. Right, right. And that's, that's obvious. I want to fill in here that Misty said that eventually, it seemed like the ER doc was probably confused about pump therapy in general, and didn't realize that her child wasn't also getting a long acting previously injected insulin. So that doctor did not understand what the pump does.
Jennifer Smith, CDEAnd that's not a common misunderstanding, quite honestly, like I said, initially. The docs and the nurses and the staff that work in the emergence in the emergent setting of an emergency department, they know a lot, they really do. But they're they're not schooled in, in this setting. What was the difference? Again, between type one and type two, they're just, I mean, they know if they sat down at a desk and talk to somebody, they could tell you the difference, right? But I think because they don't work it all the time. There really is this disconnect in understanding someone with type one diabetes, and I hope lots of health care professionals. Listen, maybe. But that there is a Deaf that you don't have insulin production, you have got to have at least the background drip drip, drip, drip drip of insulin. And if you're somebody on MDI, which Missy also asked, you know, what about people who are using multiple daily injections, what about them, if and that kind of goes along with the emergency preparedness bag, if you can grab your supplies and take them along to the hospital with you, and you're on multiple daily injections, I guarantee you need to grab your Basal insulin, whether it's you know, whatever brand you're using, bring it along, because while the hospital will have within their formulary, a Basal insulin to use. They may want not know how much you're using, and they'll base it on a formula to calculate how much to give you. But if you don't tell them when you've taken your last dose, or when you usually take your doses of Basal insulin, in the hectic nature of what they're trying to do for you. Maybe you take it at 5pm Every night, and you end up going to the emergency room at 3pm in the afternoon, and you're there for seven hours. Well, you know what 5pm comes and you don't get your Basal insulin, you're going to be at a deficit, but they don't know
Scott Bennerthat. And they're going to be not inclined to give you medications they don't understand. So here's she says, How should you advocate for yourself for your child? If things aren't happening, right? Like, she's like, What if like asking nicely, just doesn't work? I think then it's okay to ask to speak to someone else. Correct. You know, like, at some point, you have to just say, Listen, I really do see that you're trying to help. And I don't I always put it back on myself. So there's a little trick I use sometimes in personal communication, where if things aren't going the way I want them to, and I believe it's because the other person's not understanding me. I put that misunderstanding on me. Maybe, you know,
Jennifer Smith, CDEI think I can explain it right. Yeah, I
Scott Bennerknow, I'm not explaining this correctly. But it's obvious that we're not on the same wavelength here. Could I just talk to someone else and maybe re explain, maybe they'll hear me differently, you know, maybe how I'm saying it will hit them differently, whatever, but just know that I've been at this a long time. And I know this isn't right. And so this can't, this can't be the end result where we're at right now.
Jennifer Smith, CDEAnd that's where I think advocating sooner than later. If you are getting any pushback even in the first you know, minutes of being there. Ask for a consult with an endo ask for somebody to come in who can from an understanding place. Advocate with you and or for you based on what you then tell them and I think another piece that I've obviously goes into It is, what is your typical plan of care for a day? Right? How much insulin, how sensitive Are you all those dosing, you know, strategies that you use all those doses and everything that you use from a ratio standpoint, sometimes having it just written down rather than trying to explain it visually to somebody who is medically trying to help you at that point. They could read it, and it may just click
The "Sandblast" Analogy and Dealing with Highs
Scott Benneryet because they're not used to looking at your pump settings or talking about it, maybe even the way you talk about it. And I listen, I speak to a ton of people as you do. There are a million different ways that people explain the same things all the time, right? Like you hear somebody say it one way, then someone else says it another way. And then a third person found a fun way to say it. And like, you know, the emergency situation, you don't want to be using the fun way around the house to explain it to the doctor, because they don't know what the heck you're talking about. No. So So Arden's emergency room visit was eventually it turns out because she had a cyst next to her fallopian tube, and it would cause her like incredible, like stomach pain. So eventually, after a lot of testing for other things, we figure that out. And we found ourselves getting surgery for Arden and to have the cyst removed. So we must have met with the surgeon, four times prior to the surgery. And every time at the end, I would just say, Hey, just wanted to remind you that Arden has an insulin pump, and a glucose monitor, right? And that we want to keep them on her during what is really only a 45 minute procedure. And the doctor was Oh my god. Yeah, that's great. Yeah, you guys are doing great. Just do it. She just boom, yeah, sure. Then we get to the hospital that day, and we're doing intake. And I realized the first nurse is just getting her set. She's not going to be part of the procedure. But then eventually another nurse comes in, who's obviously going to be in the room, I say, Hi, I don't know if the doctor told you. But my daughter has type one diabetes, and she picks the chart up. And look, she goes now I didn't know that. And I was like, I was like, okay, and I said, Well, she she does. And she's wearing an insulin pump, a continuous glucose monitor and look at her blood sugar right now, look that I've kept my daughter's blood sugar between 100 and 130 for the last 12 hours, because you made her fast for this. Okay, right. And so keep in mind that that's incredibly difficult to do. And I don't want you to take this the wrong way. I've done it. Okay. So and if you need it for another 45 minutes, I can do that too. Okay. She goes, Well, protocol is and I went oh, okay, so now my brain starts going argue with the doctor said it was okay. No, don't do that. Ask for the doctor, maybe. Then another nurse works, walks in the room, I swear to you, I turned away from the woman I was talking to looked at the next and I went Hi. I don't know if you know this or not like the first nurse wasn't even standing there anymore. But my daughter has type one that and I went all through it. And luck have it she goes, my best friend has type one diabetes. While you're doing great. Let me see your graph. I think my daughter, I think my friend has a Dexcom too. We talked about this sometimes. You're doing great. Yeah do whatever you want. Yeah. And that was it. And I said, Okay, great. I said, if she does get low, you feel free to give her glucose to bring your blood sugar up? Would you like to take her phone into the operating room? And they were like, yeah, absolutely. And they put it in a surgical bag, they stuck it on the operating table so that it could stay connected to everybody. Once I found somebody who got it, she was thrilled to not be involved in it. Right? Much like your school nurses, and your and your administrations at school once they realize you can take care of this and you're like, we don't want to go to the nurse anymore. That's their dream not to take care of your kid, you know. So I found that very same situation kept her blood sugar nice and stable during the procedure. And then as soon as she was out, and her blood sugar tried to go up, I stopped that I was much less aggressive than normal. But I had a goal like I'm going to try to keep her under 170 You know, without getting her low? Because she was she was loopy.
Jennifer Smith, CDEYeah. Not fun,
Scott Bennerright? And, and it worked. But it didn't work. Because I had the conversations with a doctor. It didn't even work because I had it worked because I kept having the conversation. And so don't get into a position where you feel like I've said this once because you said it once to somebody doesn't understand.
Jennifer Smith, CDEAnd it's also hard in that scenario when you've explained it. And now you come in and said you have to explain it yet again. And then they come in with more people and you have to explain it yet again. It's hard not to start to get like this escalation of, oh my god, if I seriously have to explain this to one more person. I'm gonna like my head's going to explode. We I mean, you really have to take that level down so that you can advocate well for yourself and you don't start to look like the crazy person,
Scott Bennerright? Think about the suspension of I don't know what it is expectation or ego or some thing like that you're just, you're just and I always explained, I never explained it from a asking point of view, I was always being matter of fact about it. Like you don't I mean, like there's, there's a, there's an idea behind having, you know, whether you're buying a car or any kind of like a situation like that someone's in charge, right? Like someone's in charge. And when you start at the hospital, by default, the hospital people are in charge, if you become subservient in the conversation, you are immediately under them, and you'll never go anywhere else. Right, right. And it's just, it's all human interaction. So you start with high, you know, I don't want to sound crazy or fool of myself, we're really good at this, let me show you how good we are at it, I promise, I'm gonna, you know, this is the truth. And here's what I'd like to do, here's what I think I can accomplish with that work for you, then you kind of loop them back into the process, again, showing them they're important. It's manipulation, really, but other people call it communication. But you know, what you gotta do
Jennifer Smith, CDEis you and sometimes it's sometimes even the team might have, you know, in a scenario of going to the hospital, even for like a planned procedure, like the case of Arden in surgery, right? I mean, in in August, I had surgery for kidney stone. And it was entirely different than the surgery I had just a couple of months before that in May. In August for my kidney stone. I had to, like my mom came to the procedure with me after it when she was bringing me home. She's like, I can't believe how many times you had to explain to different people, the same exact thing. And I was like, Yeah, I know, I've done this many times now. And she's like, I know, but she's just like, you know, really proud that you didn't get so flustered. And like she's like, I would have like hit somebody over the head with a chart. She's like, I wouldn't have done that, like, well, you would have but you know, it was actually the anesthesiologist who was the most besides the admitting nurse, who was the anesthesiologist, for me, who was really phenomenal. He, he was really interested in my CGM graph he was really interested in in fact, he kept my phone in his pocket. The whole entire procedure, you know, and he, he was awesome. It was actually the surgeon who kept asking me like, how much did you turn your Basal insulin down? And like, I didn't turn it down? Because I know what my Basal insulin does. Totally fine. Are you sure you don't want to turn on like, Look, buddy? I know what I do. I
Scott Bennerdo your part. I'll do mine. How's that? So
Jennifer Smith, CDEYeah, it was but yeah, you'll encounter different people. And just continuing to kind of continuing to know that you have rights, you have rights, you as long as you do know what you're doing. Your rights include advocating for yourself, and also asking for other care team members to come in, that may be able to help you better, right,
Scott Bennerright? It's like being on the phone with customer service, and you realize the person you're talking to is does not have the power to do what you need them to do. And you gotta get to somebody else, you just gonna have an argument. All right, Missy says, you know, what rights do patients have once theyre in the hospital setting? And what she means specifically by that is, can you demand things be done in a certain way? But then it's interesting in her in her question, she doubts herself, she says, and how do I verify that what I'm asking for is actually the best for treatment? So how do you like how do you make the leap in your head that this is what we do at home? But maybe this doesn't work here? Right? Yeah, maybe they know more than I do.
Jennifer Smith, CDESome of it's also in terms of, you're going to the hospital with a condition that you know how to manage, but you're going to the hospital, let's say it has nothing to do with that condition. You're going to the hospital because you got severe abdominal pain. Clearly, Scott, you don't have any idea why Arden had abdominal pain, you can't like see into her belly and see what was going on. I mean, some of those things, you have to say, You know what, I came here for this year, the team, you're the experts, I expect you to figure out what the pain is, but I've got this part of it. I've got the diabetes management part of it because I do this 24/7 And you don't. So some of those things, you have to you know what you're requesting. I mean, if you're requesting something like jelly beans that your kid needs to eat, but he's throwing up, quite honestly, they're probably going to look at you like you're crazy and say you know what jelly beans might be what works really well, but he's not going to keep them down. So let's do a Dextrose drip. Yeah.
Scott BennerAgain, I'm a big fan of keeping people involved. So we were not the last thing we did before Arden surgery was I said to the doctor, here are all the places I can put Arden's insulin pump for the day of surgery. Which of them would you like it on? Now? Let me tell you a secret Jenny, it wouldn't matter which one it was on. I was actually giving her something like, Do you know what I mean? Like, I do the same thing in 504. It's like I find something in a 504 for that. I'm like, Oh, we don't need that anymore. And when I go into the meeting the next year, I give it back like It's a present. I'm like, oh, you know what, we don't need this line anymore. Take that out. I'd like to make this as easy for you as possible. Yeah, like, Oh, look how nice he is. Right? So in this case, it's a little ego stroke for the doctor. You tell me what's best here. That was arm or it was thigh. Like neither of those were going to be in their way. And I let the doctor pick. Yeah. And that was it. Right. And by the way, double down on my maniacal thinking. I was trying to get Arden to use her arm again. And I thought he'll probably say, she'll probably say arm over thigh. So I'm just going to give her arm or thigh. She'll pick arm. I'll make her feel better. And I'll get Arden's pump back on her arm again. Haha. Yeah, I was like an evil genius in that moment. What is okay to let slide and she's like, What hills? Should you die on? I think we're answering that question along the way, right? Like you just you what's important to the management of the diabetes? What keeps insulin going as best as you can? So what do I do about pump settings that I don't, I don't even follow myself all the time becoming and so so she's a fluid person, like she listens to the podcast, right? And so what happens when your management is fluid, and then all of a sudden someone wants to make it static for the situation? Right? To me, I would tell them that, I'd say look, let's start here. If this doesn't hold it down, we might have to amp it up a little bit. And if it's too much, we might have to take it away. But I don't know, because this is a different scenario than we usually manage. And these numbers are not set in stone like Jesus. That's the that's the core of the podcast, right. And I
Jennifer Smith, CDEthink a better part of it too, is to explain in a more simple way, maybe to them. This is the baseline that we work off of based on what's happening with glucose, because we've got a trend on our fancy CGM. I can because the pump settings, the smart features of my pump, allow me to do this, if, if his blood sugar is starting to go up, I'm going to do something that temporarily allows me to just up, I'm also going to temporarily adjust down in this scenario. So explaining that in the simplest way that you can help them to see that what's there as settings, is it's meant to be fluid. You know, it's these are what we start with, and, you know, in the in the case of something like the carb ratios, you know, she's like, well, then carb ratios are a little bit more of a suggestion. They're really not something that we 100% hard number go off of, you know, what, if in the emergency room, you get to the point that they're bringing you food, and you're bolusing you know what, you give them the ratios that are in your pump, and you do what you know, works. What they will usually ask for is what dose did you give, because they need to put that in the medical record, right? They don't know that it's been adjusted or just a down based on you know, whatever you say, This is what my pump suggested I take this is what I'm taking adjustment up or down that that's a piece that quite honestly, they're not really going to care nor know about. I mean, when I was in the hospital for both post deliveries of my boys, the nurses every shift, they would ask what is your Basal running at? Have you made any adjustments? Where's your blood sugar? Have you taken any boluses? Have you eaten? All they needed to do was really document what was going on? That's it. There's a lot of butt covering going on? It is a lot of exactly. 100% Yeah.
Scott BennerAnd so even if you're MDI, that's really the same advice. Like it is no, if she does make the point that they like to give like a set dose? They do. Right. And so, you know, but and that kind of leads into one of our other questions. Is it ever a good idea to just do things on your own and not tell the staff? And I would have to say, I mean, no, but but probably
Jennifer Smith, CDEin some of it is a little bit of like coding an answer, right. Like I said about the Bolus thing, right? It's Is it ever a good idea to do things and not tell the staff not not know, but if you're bolusing for a meal, and they ask you did you Bolus or to have you taken any corrections or whatnot? I mean, the simplest answer yes. And this is what the dose is. That's kind of the level that they need. They don't need to know that you factored in. Well, it looks like his blood sugar is dipping. So I adjusted backed by this, but they don't, again, too much story, right? They don't need to know,
Scott Bennertheir loss because they don't have diabetes, right? And then they start
Jennifer Smith, CDEthinking I've got a crazy person who's like just giving willy nilly doses of insulin. I don't I don't agree with it. Let's shut the pump off. Yeah,
Scott Bennerit might seem disconnected. But you know, when you hear a late night talk show host make a joke about diabetes. And you think, how could they possibly do that? When I know all of this stuff about life with diabetes? They don't know. That's the answer. The answer is they don't know any of that stuff. And so these people you're talking to very well may not know most of what you're saying. So listen to what Jenny's saying. I've said it one way, she's saying it another way, get them to do what you need them to do, if they say five units, because that's what we do. But you know, it's six, and maybe it's okay to do six. If if they want to do five, and you think it's 15, that you're probably gonna have to say to them, right, because you're protecting your own safety. That's what you're really doing, right? You're trying to protect your safety against your blood sugars. And going high is how it feels most of the time. But the truth is, too, you would need to protect it from going low, you would not want to give yourself way more insulin than your doctor knew about because if you did get low, that would be unfair. needed. Yeah,
Managing Expectations and Time in Range
Jennifer Smith, CDEexactly. And, you know, for some of the MDI users that I've worked with, and a very good friend of mine, some don't even really have a true set ratio as a dose to use. And I think you had done this for a while, too. It's like, you can look at a meal. And you can say, like, my good friend, ginger, she can look at she knows her apple and her peanut butter is this many units of insulin. This is what she takes for it all the time, unless her blood sugar's higher, or lower or whatever. But this is always what she takes for it. That's not really a ratio, could she figure out a ratio to tell them? Sure, right? She could. But technically, there's no ratio there, because you've just figured it out. Because they're standard foods that you eat. And you know, that five units or two units or 12 units always works for it.
Scott BennerAnd so when you're not ginger, or you or me, or maybe a lot of the people in his podcast, what do those people do, people really don't understand this yet about their diabetes, are you just in the hands of that,
Jennifer Smith, CDEand that's where these protocols are put into place, with the expectation that the medical staff knows best, and that the people coming in, aren't taking that type of level of care for themselves. So they have protocols, they've got these, if this, then do this, if this is where it is adjust by this much change to this, add this, plug this in whatever. And those are safety protocols they are. But I think from the staff position, or the medical, you know, person position, you do have to look at the individual, you have to look at the person who like you comes in with Arden's as I got this, I'm following it, we do this, we do it this way. I know where things are, she's beautiful, she's level, I can manage it, versus the person who comes in and can't even tell you the last time that they took their insulin, or what their rates are running at in their pump, okay, that person may be the time that one, the staff should then get an endo consult in and two the staff needs to follow their protocol, because they can definitely say this person has no idea what they're doing.
Scott BennerMaybe that would be a wonderful opportunity for somebody on staff to help that person, you know, because at the end of Arden's initial emergency room visit that I mentioned, as we were packing up and leaving and getting ready to go home and everything the nurse did come in and say, I really appreciate all the help. I hope I was good. You taught me a lot today. You should understand, though, the way you and I started today, because it was a little contentious at the beginning, I just tried to stay away from it, because 99% of the people I see in here don't understand their diabetes in any way.
Jennifer Smith, CDERight. And the majority of people she sees that come in are likely type two, who had much less education, even if they are on insulin, have had much less education than somebody with type one.
Scott BennerNo, of course. I mean, so it's just to kind of go on the side of the doctor for a second and talk about it from their perspective. You and I talked to a lot of people in our private lives who are constantly raising and crashing their blood sugar's like all day long, but by what they're doing, they don't realize that they think it's happening to them, but they're doing it, you know, and they don't know what they're doing. And what if I get you into a situation where you have multiple units of insulin going and your blood sugar's crashing. You want to have a seizure here at the hospital and in front of the nurse who doesn't particularly understand it to begin with, like, you know, But then, you know you have, you just have to understand their perspective and not just understand it for like, you know, nicely understand it so that you can tell them what they need to hear. Like, right? Like you just, I don't know a better way to say it when you're, you know, when you're arguing with your spouse, right? And you in your heart, you're like, why are they not hearing what I'm saying? It's because they think differently than you think. But if you understood how he thought, or vice versa, you could say to him the thing that would put him at ease, and help him understand you. And that's what you're trying to do here, you're trying to communicate on a better level than we all communicate on most days. Right? That's all right, right. And,
Jennifer Smith, CDEyou know, when I worked clinically with an endocrine group, in DC, at our hospital, we actually worked with the emergency room staff to develop a protocol for both type one and type two diabetes for when somebody was admitted to the emergency department. And we also had a protocol within the type one. If somebody came in on an insulin pump, it was an automatic endo call. They got somebody there. And if the endo couldn't make it, which was most often because they were busy, one of us, the CDEs got called to the emergency room to help the ER Doc's manage, right. So you know, not all hospitals obviously have that. But we did it mainly because we saw the need, we were getting called so frequently to the emergency department to manage that they were like, well, let's just get something in place. So we better know what we're doing, and when to actually bring you guys here,
Scott Bennerright? That's a it's not an easy fix. But these are just ideas that hopefully some of them will make something better for you or the conversation or your health. It's, there's no, there's no like, do this, this and this, and you're going to be okay. After this all got posted online, they actually sent me a follow up question. And it was from another person. And the idea basically was, What if you're an adult friend of a person who has diabetes and is not capable of talking? Right, can't speak for themselves in the moment? Like, is there a way to advocate for them? I mean, as I read that, I thought, That's a wonderful idea. I just mean, if you're not a blood relative, first of all, you can't, they're not going to listen to you to begin with. I mean, they might listen a little bit, but what are you even going to say you don't understand their diabetes, probably any better than? Right? You know,
Jennifer Smith, CDEI think the easiest, the easiest way to advocate then would really be to ask the emergency room staff, if they could get an endo consult, quite honestly. Because you know, you can, if you know your friend well enough, and hopefully you do, if you're taking them to the emergency room, you haven't just met them on the street corner, and, you know, took them in or whatever was in a
Scott Bennerbar, and this guy passed out and
Jennifer Smith, CDEdecided to help. Like, he's wearing this pager with a tube, and I'm not quite sure what that is. But, you know, if you're enough of a friend, bringing another friend to the hospital, you would, you would typically know that they've got a pump, or that they use injections, you may not know how they use it, but you could at least say hey, you know, he or she has the pump on here. He or she wears and uses this thing that tells them what their blood sugar is, you know, those kinds of things would be easy enough to be able to share with the staff at least Yeah, I think
Scott Bennerinstead of trying to find a way to talk to the friend, we have to be talking to you listening who has diabetes, you you have to as crazy as it sounds, you probably have to try to break down your diabetes into six bullet points. And explain that to your friend so that they have that information to ask somebody, listen, you've all been diagnosed, right? And someone downloaded an hour's worth of talking into your head and you got home and went. So you know, like your friend over you know, dinner once in a while when you mentioned your blood sugar. That's not how they're gonna do. But if you had a bullet pointed, like five point list, like, make sure they know, this is what my Basal rate is, make sure they know you know that I'm MDI and that means I inject my slow acting insulin and my fast. They're two different insulins like that kind of like simple stuff, like break it down into t shirt slogans for it. Right, exactly,
Jennifer Smith, CDEthen even even when you change therapy, then it's important to share with them, hey, I'm not using injections anymore. I'm using an insulin pump. Even that as a simple statement can be very helpful within those simple bullet points of do this, or do this is behaving this way, you know, help me this way, whatever. That just the other day I brought up with my husband in the, you know, couple of years that I've changed over the type of pump Same strategy that I use. I, my husband was very good with my other pump. He knew how to push the buttons and how to do everything. And since I've changed over, while he knows what I'm doing the button pushing and stuff. I've never gone over with him again. And just the other day I was thinking, I really need to like reteach him. Yeah, all of this in case of me.
Scott BennerI really do. Yeah, 100%. Jenny, we've done it again, I really believe that this is a good episode.
Conclusion and Series Outline
Jennifer Smith, CDEIt's a good episode, a really great awesome that your, Miss Misty, decided that it was a really good topic, because
Scott Bennerit was really thoughtful of her to do. Really, super, actually. That's what I like about Listen, all of you listening are terrific. You know whether I've ever met you or I'll never meet you, or you'll never say a word to each other. But I've gotten to meet some of the people online a little closer. And it's really wonderful like that Facebook group is little more than a couple 1000 people who really understand what's being spoken about on the podcast. And when new people come in, they're really helpful. And I just put a post up the other day where I very proudly said, No one's ever been banned or deleted from this place. And even when they when they don't disagree as much as they, they they have conversations. It's really lovely. Actually, that's nice. Yeah, it's wonderful. You can actually talk to people you don't know who disagree with you and not yell at them. And it's still okay. Yes. So do that while you're at the hospital. Let me say this right, before I let you go. Yeah, I don't know that most of what we just said here today does not apply also to when you're in your general practitioners office. Right, like the idea that they probably don't understand as much about your diabetes as you hope they do. Correct. Right. So don't make that assumption. I think I think that's really it. Like, don't assume anyone understands. And you don't if you're an adult with type one, and you're worried you're going to be in the hospital by yourself, make that bullet point list for yourself and keep it keep it on you. You know,
Jennifer Smith, CDEAbsolutely even you mentioned that, like the iPhone with the notes or the you know, the phone with the notes and whatever. I know some people even use, I know iPhone has the swipe screen that you can actually have your medical ID right up there with all of your information within that medical ID. You can put it right there. Right in the health app.
Scott BennerYep. Yeah. And again, for all and please don't take this the wrong way. But for you type A lunatics be brief, okay. Yes. Doesn't need to be a dissertation. Right. Then one time when she was six, okay. The doctor stopped reading when they got to that
Jennifer Smith, CDEplantar wart that I treated this way 40 years ago.
Scott BennerNow my blood sugar was a little higher during that week and I really think that plantar wart in medicine is what? So please keep that in mind. I don't have one now. But I mean, say I'm unconscious for four or five months here at the hospital and I develop a plantar wart and you decide to take it off for me? I really want you to keep in mind what happened before? Yeah, just keep it simple. What did they say? KISS keep it simple, stupid, right? Like, I don't think they're calling the person stupid. They're saying super simple. And there is a way if you think about it. And if you listen to this podcast, really, you probably have it now. There's a couple of simple ideas that will keep you within a reasonable range and safe. So tell the doctor that stuff. All right, or just don't get sick. I say is my nose is stuffy this
Jennifer Smith, CDEyear. So it's harder to do that than other years really?
Scott Benner100% right. There's a lot going on. There's a lot
Jennifer Smith, CDEof illness going on.
Scott BennerSo I'm gonna tell Jenny, a really gossipy story that you guys don't get to hear so goodbye. Bye bye. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs. In Episode 1015, Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two, in Episode 1018 pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022, weight loss 1023 Honeymoon 1024 female hormones, and in Episode 1025, we talk about transitioning from MDI to pumping.
Before I go, I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us.
This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active took me already from a decent 6.5 A1C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis.
I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.
Jennifer Smith, CDEJenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.
Scott BennerIf you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community
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#1015 Diabetes Pro Tip: Emergency Room Protocols
Scott is joined by Jennifer Smith, a registered dietitian and certified diabetes educator, who shares her insights on visiting an E.R. with type 1 diabetes.
You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.
You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - Radio Public, Amazon Alexa or wherever they get audio.
Key Takeaways
- Assume ER Staff Aren't Type 1 Experts: ER doctors and nurses are brilliant at saving lives and treating acute trauma, but they rarely manage modern Type 1 Diabetes technology (pumps/CGMs). Do not assume they know how your specific gear works or what your personal insulin ratios are.
- Protect Your Pump: The default protocol in many hospitals is to remove the patient's insulin pump and hang an insulin/dextrose drip. If you are conscious and capable (or have a capable advocate), firmly but politely advocate to keep your pump on to maintain control.
- Bring an "Endo Letter": If you are planning a hospital visit or surgery, get a letter from your endocrinologist stating you are cleared to manage your own pump and CGM. This covers the hospital's liability and eases the minds of the nursing staff.
- Call for an Endo Consult Immediately: If you face strong resistance in the ER regarding your pump or your diabetes management plan, immediately request an endocrinology consult. Get a specialist in the room who speaks your language.
- Create a "Cheat Sheet": Don't rely on your memory during an emergency. Keep a simple, bulleted list of your current basal rates, carb ratios, correction factors, and emergency contacts in your phone or in an emergency "go bag" so you can hand it to medical staff. Keep it brief and to the point.
Resources Mentioned
- Wrong Way Recording: wrongwayrecording.com
- Diabetes Pro Tip Series: diabetesprotip.com
- Juicebox Podcast: juiceboxpodcast.com
- Integrated Diabetes Services: integrateddiabetes.com
- Juicebox Podcast Type One Diabetes (Private Facebook Group): Join on Facebook
- American Medical ID
- Dexcom CGM
- Omnipod
Introduction and the ER Disconnect
Scott BennerHello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CDE and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisitable. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. So Jenny, this whole time we're going to talk today. I think we're gonna just talk about this one email that I got.
Jennifer Smith, CDEYeah. Which was great. And I think I mean, we've touched on some of these points in like some of the I know we did like up a safety in a hospital preparedness and all of that kind of stuff. But I think this hits a really specific mark of most people that go to an emergency room in an very emergent setting. They don't really know, and why would they know that the staff there is not prepared to deal with type one diabetes. Yeah, they're not in they're not in. I don't say that in like a god. They're not educated they are they're highly educated, they're educated in a million different things, right. But their focus is so much not type one. And because the scope of how we manage type one, especially in the past 10 years, has changed so dramatically. They the staff, they can't keep up with that. They don't they don't have time to keep up with that. So when you come in, you know, on these fancy gadgets and all these things, and they're like, Well, I know an insulin drip and I know how to, to hook you up to glucose and that's what we're gonna do. Like and you step back and you're like, No, no, no, no, that's not how I do this,
Scott Benneryou you come to realize what they really understand is just how to keep you from having a low blood sugar incident while you're there. That's what they know how to do. So you may or may not be surprised by the number of emails I get yearly from nurses and doctors who have children who were diagnosed or sometimes who have themselves diagnosed. And inevitably, there are three sentences, three sentences in their email that describe I'm a good nurse, I'm a good doctor. I don't understand type one diabetes at all every time. It's just, you know,
Jennifer Smith, CDEwith a family right now the the father is a physician and the mother is a nurse practitioner and their little child they I mean they came to us and they were like we know diabetes, but we don't know diabetes. You know, I mean, we know the coded book description of this is what you do and that should be cut and dry. When you limit not cut and dry. There is no book anything A
Scott Bennerbit of nuance just a bit. Right. Right, right. So I don't think Misty would mind her name being used, Misty came into the private Facebook group that we have for the podcast. And she shared that, you know, her child had to go to the hospital. And then she had all of these questions afterwards, and statements and things like that. And when it ended, she said, I would love it, if you and Jenny talked about this stuff. And I said, Okay, you go ahead and put a list together of what you think of, you know, as emergent that came from this experience. And Jenny, and I'll try to talk about it. And she really did. So Misty, congratulations, this, you are the founder of this feast today. So
Jennifer Smith, CDEshe did a banana, I mean, from the topics that she noted, would be helpful to cover and everything. I mean, quite honestly, it kind of speaks to the amount of medical education you get, yes, it's only in one field. But the amount of medical stuff you learn, when you become either the person with diabetes, or the caretaker for someone with diabetes, I what she has here is very much in a very, very specific way really important, and should quite honestly be like taken to the emergency department heads. And this is what your Doc's should have a list of protocol to follow up. So
Scott Bennerthat's what we're gonna say the real question becomes, excuse me, the real question becomes, what happens in an emergency situation in a medical situation, when you are the most knowledgeable person in the room and have the least power? Right, apparently to you in the moment, right? Doctors lab coats, people bumbling around, you're not a doctor. But it turns out, you do have power, you just need to know how to assert it. And we'll we'll did exactly. So let me read a little bit here. This, this email is not miss these initial post in the, in the Facebook page. This is the email she sent to me. And so she said, Hey, thanks for considering making this as an app. Thanks for considering making an episode about emergency care. Going through the sickness with my son, which was the first time he had had a stomach bug since diagnosis almost a year ago, made me start thinking about how to figure out what else I don't know. In this instance, probably the three biggest mistakes made in the ER, ended up being the doctor turning off his basil. They didn't hang textures, and a refusal, an absolute refusal to call an endocrinologist. And she said, I knew that these things weren't right. But by doubting herself, and assuming that the doctor must know better than she did. You know, she had no idea in the end, how to make him do those things that she knew needed to be done. And she should have been more assertive, she says, and sooner. So she puts she just puts a bulleted list here. That's terrific. I and I think we should just go down the list. Right?
Jennifer Smith, CDEAbsolutely. Because it's it's a great list. And I think some of the points can actually even be kind of melded together in a way. But it is it's a very well put together list. It's actually in fact, many of the things on here, when we talk to people, the people that we work within our practice, and we give them our information about prepping for a hospital stay, we have not only a hospital stay or expecting like for a planned surgery, but we also have a lot of these things covered so that you do know how to advocate for yourself, because that's really what it becomes. When you go to the emergency room. Unless you are the person with diabetes, and you're completely out. Well, you know what? They're gonna do what they can do to save your life. And you have no control there then. But
When to Call the Endo vs. When to go to the ER
Scott BennerYeah, and maybe you can get into a situation where you don't end up like you've heard people in the past talk about in the podcast, where they have family members sneaking them in insulin, and they're doing like, you know, like, Wouldn't it be nice if that's not how this went? Right? It wouldn't be lovely for your, your medical doctors to know about the insulin in your body. So I have a couple of experiences that I'll I'll interject if they fit, and I know you're gonna have some. So first question was, how do I know when it's time to go to the hospital or even at least to call the Endo? When it's a specific type one problem, I guess around illness? The when do you tell people to call?
Jennifer Smith, CDEYeah, I mean, we usually tell people to call at least to call their endo or I guess even a step before that is make sure that you've addressed with your Endo, a 24 hour emergent line to be able to contact somebody at because I guarantee that your specific endo isn't going to be there at two o'clock in the morning and everything every time something happens, right. So the step ahead of that is knowing who to call, what's the number, who will I actually talk to, is it just going to be a nurse triage or is it really that I'm going to get to talk to somebody that's going to give me some information mission without playing phone tag
Scott Bennersharing services still exist. So you might just be getting a person taking a message, right? Correct.
Jennifer Smith, CDEI mean, most systems, most healthcare systems do have 24 hour nursing care within your like, you know, whatever your insurance coverage or whatever system you're in, right? And that nurse should also be the one who can help determine what are your symptoms? What's going on? Or what's happening with your child? Is this emergent enough? I'm going to call the doctor on call and we're going to get some answers for you or no, you need to go to the emergency room there. I mean, we've used it a couple of times for for our boys when they've been like sick fever, like, you know, rolling around, not feeling great. I'm like, Okay, let's call the nurse and see if the time to go to the doctor, you know. But so they're from our experience, they've been very, very helpful and good. So that's a first step, if it's daytime, certainly tried to call your endo office get in a very emergent message that, hey, this is what's going on and have some very good facts to give them, you know, we've checked blood sugar, we've given insulin, we've checked ketones, you know, my child won't take any fluids, or my child can't stop vomiting, or those are very, very important things to be able to give facts. So they know what to do with you.
Scott BennerI also think that it's important not to get caught up in the emotion of it, start telling stories and like they need the facts. They don't need, you know, the extra stuff my mother in law was over. And yeah, let that go. That's not
Jennifer Smith, CDEthe kids friend was over three weeks ago, and had you know, the flu two days later, they don't care about they don't need to know,
Scott Bennerwe've all been around a person telling a story who's telling a story. They're five minutes into it, you're bored out of your mind, and then they go. So anyway, it was one o'clock in the afternoon. Wait a minute, was it? Was it one o'clock? Or was it 130? Right? I you know, I think and you're like, listen, going, it doesn't matter. Just tell me the story. So yeah, and I think to to recall, to remember, is that it's possible, you'll get a really learned person on the phone who can hear you and respond from their own brains knowledge. And you might also get someone on the phone who's just following a flowchart waiting for you to say a key word. So you know, exactly. temper expectations, I guess, too, right?
Jennifer Smith, CDEAnd definitely, you know, like I said, have the facts in order that you can tell them so they can direct what they need to tell you in the right way. And then, you know, if you really just don't know, you know, when is it actually time to just pick up and go to the hospital? I mean, certainly, we usually say if it's, in this case, you know, her son had a stomach bug. So my expectation is that there was a lot of vomiting, or maybe there was vomiting, and the other end as well, kind of coming out. I don't know, stomach bugs are pretty nasty. And for little kids, or kids of any age, even adults, you could be so like, just out of it, that even remembering to take a sip every couple of minutes or remembering to get, you know, some food in or some carbs in or to try adjusting your insulin this way. Some of that may completely go out the window. So I mean, when is it time to go the hospital when you've put everything in, and you've adjusted, and you've tried all the sick date protocol that you've been given to try, and it's not working, and especially if there are more. So that higher ketone level, you need to go to the emergency room, don't play with it.
Scott BennerSo is the idea. The illness is not fixable, you are ill now you're ill, you're either able to manage it at home in a way that isn't going to become dire. Or you need to be at the hospital prior to it becoming dire. Right, right. That's correct. That's the idea.
Jennifer Smith, CDEAnd a lot of some of the evaluation in this case would be hydration, for a stomach bug, when to go to the hospital, especially for little kids. If they haven't been able to even take anything in fluid wise or fluid with a little bit of carb. It's it's time to go hydration is a really, really, if you get dehydrated, it's hard to
Scott Bennerget to recover from that and pay attention to your ketones. I would imagine when you're sick, yeah. Okay. All right. So then she says, What do I take with me? Maybe you should talk about the stuff you have prepared in case you're too sick or unable to speak for yourself a list of medications, outlining of what your normal type one care is like what hospital is best for you to go to if you have a choice. She she lives very far from her hospital, which is interesting. I live in a metropolitan area. I never think about that. Like I never I don't realize that some people have to take an airplane to an airport to fly somewhere else. Like that's not the life I live. I wanted to go to a children's hospital right now. I could go to Five of them if I wanted to, right? Yeah. Right. So, but that's not everybody's situation. So what should you I mean, you've talked before though about having a go bag for yourself, yeah.
Preparation: The "Go Bag" and Communication
Jennifer Smith, CDENext to the door or even if you keep it in the car, as long as doesn't have any psych meds or anything that'll freeze, you know, if you live in a cold place or way too hot place. But I mean, some of those things that should be in a bag, a bag, especially if you're on a pump, things like extra reservoir, tubing, infusion site, even a bottle of water, extra batteries, tapes, adhesives, you know, all those kinds of things, even some extra like glucose, glucose gels, and bull sugar uses simple sugar, all the things that you would pack to potentially take along on like a vacation, let's say, could be in that bag along with and I love that, you know, she pointed out things like a list of meds 100% Because you know what, when you're bringing your child someplace emergently like that, while you may the back of your hand know exactly what the rates are of Basal delivery and what they get, and maybe if they're on injections, how much and when, when you're in that emergent situation that may completely go out of your brain. And you may be fumbling to remember. So having that all, you know, written down, even, you know, if you upload your pump, do a printout once a month of the changes that are in your rates, ratios, you know, time of action and everything that's available on every pump load site, right, download it, put it in the bag, that way it's there. Yeah,
Scott Benneryeah, I think too, as you were talking, it made me realize I'm going to do something. So Jenny, and I have topics for some of our episodes. And we just keep them in a simple note in an iPhone, right. And it's a shared notes. So I type in a list, Jenny goes back and strikes things out or adds things we go back and forth. And as we make changes to it, the other person can see the changes, you could just simply have a note in your iPhone that is shared with your husband and your mother and and those people, that is a list of medications, what Basal rates are stuff like that, so that everybody has access to that information in a second.
Jennifer Smith, CDEThe other really good like I'll like I never take off my ID bracelet. But many ID Bracelets like mine on the very back of it. Now of course I can't get it off. But on the very back of my ID bracelet is actually a an 800 number and a website, that's it's free. All they would have to literally do is look at my ID bracelet. And login to that and all of my medical history is there. So if your child wears a necklace or a bracelet or something like that, many like American medical ID does a really good job. Most of the other websites. I don't know if they offer that as a free service when you buy a bracelet, but it's a nice way that again, you don't have to have that list, like printed out. It's there.
Scott BennerThat's excellent. Okay. Okay. Misty says what are the universal non negotiable things once you're at the ER, like for your safety? She says that in their case, it was not shutting off the pump. You know that hanging dextrose not saline by that's why that one's interesting, isn't it? They gave him because the saline drops your blood sugar, like well,
Jennifer Smith, CDEand the dextrose versus the saline may, you know, in her circumstance, she's right. But in other circumstances, depending on where blood sugar was, you know, hanging saline versus dextrose. If somebody's coming in, in DKA, obviously feeding them more glucose, at least initially, you know, you're going to actually you need hydration, right? So there are some pieces that go along with the illness that you've come in for to pay attention to. But I think what she's really saying here is asking what's being hung? Right? Right. It's it's knowledge to say, Okay, you're hanging saline, he's come in with a stomach bug, I understand that you're trying to provide some hydration. But let's look at where blood sugar is. Let's look at all these things, then she's, you know, again, also very correct. And it's a big thing that I go over all the women and men and parents that I work with. If you go to the emergency room, do not let them take your pump. Do not let them take your pump. I mean, like if you have to like scream and yell and whatever, then advocate and don't let them take your pump. If you come in because you've had a pump malfunction. Obviously your pumps not gonna be doing what you needed to be doing.
Scott BennerTake your busted pump. There's a
Jennifer Smith, CDEdifference in the story, right, but definitely not shutting off the pump. The other thing here too, is they don't necessarily know pumps well enough to even be able to know whether you've shut it off.
Managing the Staff and the Situation
Scott BennerSo Jenny just brought something up. Interesting.
Jennifer Smith, CDEOkay, so I kind of I kind of sugarcoat that in a way like that. They don't know.
Scott BennerIt's like, it's like when my kids were little, we used to go into a spare room, pull the sofa away from the wall a little bit and hide Christmas presents behind the sofa. And the kids never knew where they were because they just didn't know to think about that. So So I have two hospital experiences with Arden. And they both come within the last year. So they're fresh in my mind. One of them is an emergency room visit, where our son had abdominal pain. It was bad. We went into the ER, the first thing I started doing and now keep in mind that this ability to do this comes from a confidence standpoint, like I was confident when I got there, so you know what you're doing. So I got I said to the nurse, and anybody who walked in Arden has type one diabetes, she's wearing an insulin pump and a continuous glucose monitor. Her continuous glucose monitor is reading her blood sugar live, here it is I held it up and showed it to them. And her insulin pump is giving her Basal insulin and Bolus just in case she gets larger. We want to keep these devices on her. Okay. Now you would think they'd be like, Oh, I don't know. But when people realize, you know, and they realize they don't know, they get a little smaller in the conversation, if that makes sense. Like someone's in charge and someone's not. Now it is not the you're not trying to lord it over them. You don't want them to be like, you're not like, Hey, I'm here, I know what I'm doing back up. It's a very symbiotic thing you're trying to set
Jennifer Smith, CDEup because you've also come in for help. For something else, respect what they
Scott Bennerknow, right? Respect what they know, try to get them to respect what you know, it's very important not to come off crazy during those initial conversations flustered, like you don't realize it. But if they look at you and your hair on fire, they read that as I'm not listening to that person, right? You know, and that's good on them, they shouldn't. And also keep in mind, that emergency room, people deal with a lot of crazy people. So they don't know if you're crazy or not. And so you have to build a little quick rapport, simple conversations, ask questions. And I also found that I was kind of in my mind scoring the people. What did they understand? What, when did they get a blank look? Or when did they have a response that made sense, you know, and try to figure that out, then sometimes, there were people in the scenario I just stopped talking to about diabetes, I directed it more towards the nurse who seemed to understand what I was saying, the one who wanted to give me a little space, and did and that's how I did that. And, and it worked out really well.
Jennifer Smith, CDEAnd I think at the same time in your scenario, kind of bringing in until she she mentioned a little further down, not until the nurse really was like, I need to set you straight. And I'm going to call in somebody else to talk to you and set you right and whatever. And she called it an endo consult. Quite honestly, when you go to the emergency room, and you know that you may have a stand up and put your hands up and say I got this I know. And you know what you can call an endo bring them in, because I would like another advocate for what I'm doing. Right up front ask for them. There's always an endo on call. There's there's always a specialist on call that will come.
Scott BennerAnd if I can play psychologist for a second when the nurse says that to Misty that's the nurse saying, Well, I really don't know enough to right to be the stop in this situation. I think that woman should stop telling me what to do. But I don't have enough facts to Stop or I'll go get a person with facts that come in. And then we'll see later that the person with facts came in and, you know, told the nurse instead of Misty.
Jennifer Smith, CDEKelly, you know, hopefully overall the nurse may have learned something in that setting too. You know, everything is kind of with diabetes, I find it's if people are willing to listen, it's a teaching moment. So you know, hopefully for the next person who comes in or the next parent with a child who comes in this nurse will be a little bit more in the know and be able to say you know what, I don't know enough about this. I do understand that you feel like you know what you're doing? I'm going to call the endo let's just make sure everything is is is good. Everything is the way that it's supposed to be going based on what you came in here for you know, three.
Scott BennerYeah, exactly. One second, I gotta tell ya. One second, I gotta tell you something
Jennifer Smith, CDEelse you follow fallen asleep in class because she's so tired from studying so late last night.
Scott BennerShe's actually on her way to lunch. She's been at school for 25 minutes and she's going to watch now which is great. No,
Jennifer Smith, CDEwe always we always talk at the time that she's into lunch. Yes. And you're always texting her do this or did you do this or today?
Scott BennerTell me to pull the curtain back a little bit. People like hearing about that. So there's a reason why I'm always recording while Arden's at lunch and not another time. I'm much more well thought out than I give myself credit for or the way that I let you believe I am. Okay, and then she asks the end is it ever okay to shut off insulin so Misty, I'll tell you that I was rockin Arden's blood sugar for hours in the emergency room and there was no food going into her like we had some juices once in a while we were sipping juices always let the nurse know juices happening. Because the nurse was always like, Look, if you can't manage this, we'll use I don't know what it is dextrose or glucose or something like that. I entered it trip. And I was like, okay, you know, but I was trying really hard for that to happen because just like the nurse who called the endo on Misty, I didn't have any perspective for that. I did not know what was gonna happen next. And I use texting Jenny, I was like, what's gonna happen if they give her this? Like, what trying to be ready because I've taken insulin away, like, I don't know what to do. Right. And we kept it going for a long time. But finally I just couldn't, I couldn't keep it up anymore. Right? And so they gave it to her. And the woman's like, let it go for a minute to see what happens. She was right, like it's shot up. But it came back down pretty quickly again, like had I given her insulin for that that would have been a major like prostate, right? Yeah. And then once we got that drip regulated, and then got her Basal rate to where, like I just adjusted her Basal to manage the dextrose instead of what it was usually a manager, she was getting a very tiny bit of insulin, but a little bit, and that was it. And it's making me realize as we're talking the tools really do work anywhere. Like they work in that situation too. So I guess confidence and honest actual confidence that comes from it comes from experience that you know is gone over and over again the right way is really helpful.
Jennifer Smith, CDEAnd I think that you know, as far as what you were doing because you know how to manage and you know how to adjust you know how to turn things down or turn them up or micro Adjust with little bits of juice, if you know the person can take a little bit by mouth, and it's okay according to what, you know, their protocol is in the emergency room, or again, like a dextrose drip, if that's an option, and you can adjust accordingly with your Basal insulin drip. Great. But it's and I hesitate to say, is it a yes or no? Is it ever okay to shut off insulin? Technically no, for somebody with type one? I mean, really, it's not. I mean, we know what happens if there's 100% deficit of Basal insulin, you're not going to see the impact right now. But you are gonna see the impact in the next several hours based on that deficit of basal that was supposed to be there, even if they needed less Basal insulin, they will always need Basal insulin.
Scott Bennerand you and if you get to that spot where your it all is out of control, they're going to take it over, then they are going to take it over the minute your life feels a danger, and they don't think that what you're trying helps him or you're going to lose control the situation. Right, right. And that's, that's obvious. I want to fill in here that Misty said that eventually, it seemed like the ER doc was probably confused about pump therapy in general, and didn't realize that her child wasn't also getting a long acting previously injected insulin. So that doctor did not understand what the pump does.
Jennifer Smith, CDEAnd that's not a common misunderstanding, quite honestly, like I said, initially. The docs and the nurses and the staff that work in the emergence in the emergent setting of an emergency department, they know a lot, they really do. But they're they're not schooled in, in this setting. What was the difference? Again, between type one and type two, they're just, I mean, they know if they sat down at a desk and talk to somebody, they could tell you the difference, right? But I think because they don't work it all the time. There really is this disconnect in understanding someone with type one diabetes, and I hope lots of health care professionals. Listen, maybe. But that there is a Deaf that you don't have insulin production, you have got to have at least the background drip drip, drip, drip drip of insulin. And if you're somebody on MDI, which Missy also asked, you know, what about people who are using multiple daily injections, what about them, if and that kind of goes along with the emergency preparedness bag, if you can grab your supplies and take them along to the hospital with you, and you're on multiple daily injections, I guarantee you need to grab your Basal insulin, whether it's you know, whatever brand you're using, bring it along, because while the hospital will have within their formulary, a Basal insulin to use. They may want not know how much you're using, and they'll base it on a formula to calculate how much to give you. But if you don't tell them when you've taken your last dose, or when you usually take your doses of Basal insulin, in the hectic nature of what they're trying to do for you. Maybe you take it at 5pm Every night, and you end up going to the emergency room at 3pm in the afternoon, and you're there for seven hours. Well, you know what 5pm comes and you don't get your Basal insulin, you're going to be at a deficit, but they don't know
How to Advocate for Yourself
Scott Bennerthat. And they're going to be not inclined to give you medications they don't understand. So here's she says, How should you advocate for yourself for your child? If things aren't happening, right? Like, she's like, What if like asking nicely, just doesn't work? I think then it's okay to ask to speak to someone else. Correct. You know, like, at some point, you have to just say, Listen, I really do see that you're trying to help. And I don't I always put it back on myself. So there's a little trick I use sometimes in personal communication, where if things aren't going the way I want them to, and I believe it's because the other person's not understanding me. I put that misunderstanding on me. Maybe, you know,
Jennifer Smith, CDEI think I can explain it right. Yeah, I
Scott Bennerknow, I'm not explaining this correctly. But it's obvious that we're not on the same wavelength here. Could I just talk to someone else and maybe re explain, maybe they'll hear me differently, you know, maybe how I'm saying it will hit them differently, whatever, but just know that I've been at this a long time. And I know this isn't right. And so this can't, this can't be the end result where we're at right now.
Jennifer Smith, CDEAnd that's where I think advocating sooner than later. If you are getting any pushback even in the first you know, minutes of being there. Ask for a consult with an endo ask for somebody to come in who can from an understanding place. Advocate with you and or for you based on what you then tell them and I think another piece that I've obviously goes into It is, what is your typical plan of care for a day? Right? How much insulin, how sensitive Are you all those dosing, you know, strategies that you use all those doses and everything that you use from a ratio standpoint, sometimes having it just written down rather than trying to explain it visually to somebody who is medically trying to help you at that point. They could read it, and it may just click
Scott Benneryet because they're not used to looking at your pump settings or talking about it, maybe even the way you talk about it. And I listen, I speak to a ton of people as you do. There are a million different ways that people explain the same things all the time, right? Like you hear somebody say it one way, then someone else says it another way. And then a third person found a fun way to say it. And like, you know, the emergency situation, you don't want to be using the fun way around the house to explain it to the doctor, because they don't know what the heck you're talking about. No. So So Arden's emergency room visit was eventually it turns out because she had a cyst next to her fallopian tube, and it would cause her like incredible, like stomach pain. So eventually, after a lot of testing for other things, we figure that out. And we found ourselves getting surgery for Arden and to have the cyst removed. So we must have met with the surgeon, four times prior to the surgery. And every time at the end, I would just say, Hey, just wanted to remind you that Arden has an insulin pump, and a glucose monitor, right? And that we want to keep them on her during what is really only a 45 minute procedure. And the doctor was Oh my god. Yeah, that's great. Yeah, you guys are doing great. Just do it. She just boom, yeah, sure. Then we get to the hospital that day, and we're doing intake. And I realized the first nurse is just getting her set. She's not going to be part of the procedure. But then eventually another nurse comes in, who's obviously going to be in the room, I say, Hi, I don't know if the doctor told you. But my daughter has type one diabetes, and she picks the chart up. And look, she goes now I didn't know that. And I was like, I was like, okay, and I said, Well, she she does. And she's wearing an insulin pump, a continuous glucose monitor and look at her blood sugar right now, look that I've kept my daughter's blood sugar between 100 and 130 for the last 12 hours, because you made her fast for this. Okay, right. And so keep in mind that that's incredibly difficult to do. And I don't want you to take this the wrong way. I've done it. Okay. So and if you need it for another 45 minutes, I can do that too. Okay. She goes, Well, protocol is and I went oh, okay, so now my brain starts going argue with the doctor said it was okay. No, don't do that. Ask for the doctor, maybe. Then another nurse works, walks in the room, I swear to you, I turned away from the woman I was talking to looked at the next and I went Hi. I don't know if you know this or not like the first nurse wasn't even standing there anymore. But my daughter has type one that and I went all through it. And luck have it she goes, my best friend has type one diabetes. While you're doing great. Let me see your graph. I think my daughter, I think my friend has a Dexcom too. We talked about this sometimes. You're doing great. Yeah do whatever you want. Yeah. And that was it. And I said, Okay, great. I said, if she does get low, you feel free to give her glucose to bring your blood sugar up? Would you like to take her phone into the operating room? And they were like, yeah, absolutely. And they put it in a surgical bag, they stuck it on the operating table so that it could stay connected to everybody. Once I found somebody who got it, she was thrilled to not be involved in it. Right? Much like your school nurses, and your and your administrations at school once they realize you can take care of this and you're like, we don't want to go to the nurse anymore. That's their dream not to take care of your kid, you know. So I found that very same situation kept her blood sugar nice and stable during the procedure. And then as soon as she was out, and her blood sugar tried to go up, I stopped that I was much less aggressive than normal. But I had a goal like I'm going to try to keep her under 170 You know, without getting her low? Because she was she was loopy.
Jennifer Smith, CDEYeah. Not fun,
Scott Bennerright? And, and it worked. But it didn't work. Because I had the conversations with a doctor. It didn't even work because I had it worked because I kept having the conversation. And so don't get into a position where you feel like I've said this once because you said it once to somebody doesn't understand.
Jennifer Smith, CDEAnd it's also hard in that scenario when you've explained it. And now you come in and said you have to explain it yet again. And then they come in with more people and you have to explain it yet again. It's hard not to start to get like this escalation of, oh my god, if I seriously have to explain this to one more person. I'm gonna like my head's going to explode. We I mean, you really have to take that level down so that you can advocate well for yourself and you don't start to look like the crazy person,
Scott Bennerright? Think about the suspension of I don't know what it is expectation or ego or some thing like that you're just, you're just and I always explained, I never explained it from a asking point of view, I was always being matter of fact about it. Like you don't I mean, like there's, there's a, there's an idea behind having, you know, whether you're buying a car or any kind of like a situation like that someone's in charge, right? Like someone's in charge. And when you start at the hospital, by default, the hospital people are in charge, if you become subservient in the conversation, you are immediately under them, and you'll never go anywhere else. Right, right. And it's just, it's all human interaction. So you start with high, you know, I don't want to sound crazy or fool of myself, we're really good at this, let me show you how good we are at it, I promise, I'm gonna, you know, this is the truth. And here's what I'd like to do, here's what I think I can accomplish with that work for you, then you kind of loop them back into the process, again, showing them they're important. It's manipulation, really, but other people call it communication. But you know, what you gotta do
Jennifer Smith, CDEis you and sometimes it's sometimes even the team might have, you know, in a scenario of going to the hospital, even for like a planned procedure, like the case of Arden in surgery, right? I mean, in in August, I had surgery for kidney stone. And it was entirely different than the surgery I had just a couple of months before that in May. In August for my kidney stone. I had to, like my mom came to the procedure with me after it when she was bringing me home. She's like, I can't believe how many times you had to explain to different people, the same exact thing. And I was like, Yeah, I know, I've done this many times now. And she's like, I know, but she's just like, you know, really proud that you didn't get so flustered. And like she's like, I would have like hit somebody over the head with a chart. She's like, I wouldn't have done that, like, well, you would have but you know, it was actually the anesthesiologist who was the most besides the admitting nurse, who was the anesthesiologist, for me, who was really phenomenal. He, he was really interested in my CGM graph he was really interested in in fact, he kept my phone in his pocket. The whole entire procedure, you know, and he, he was awesome. It was actually the surgeon who kept asking me like, how much did you turn your Basal insulin down? And like, I didn't turn it down? Because I know what my Basal insulin does. Totally fine. Are you sure you don't want to turn on like, Look, buddy? I know what I do. I
Scott Bennerdo your part. I'll do mine. How's that? So
Jennifer Smith, CDEYeah, it was but yeah, you'll encounter different people. And just continuing to kind of continuing to know that you have rights, you have rights, you as long as you do know what you're doing. Your rights include advocating for yourself, and also asking for other care team members to come in, that may be able to help you better, right,
Scott Bennerright? It's like being on the phone with customer service, and you realize the person you're talking to is does not have the power to do what you need them to do. And you gotta get to somebody else, you just gonna have an argument. All right, Missy says, you know, what rights do patients have once theyre in the hospital setting? And what she means specifically by that is, can you demand things be done in a certain way? But then it's interesting in her in her question, she doubts herself, she says, and how do I verify that what I'm asking for is actually the best for treatment? So how do you like how do you make the leap in your head that this is what we do at home? But maybe this doesn't work here? Right? Yeah, maybe they know more than I do.
Jennifer Smith, CDESome of it's also in terms of, you're going to the hospital with a condition that you know how to manage, but you're going to the hospital, let's say it has nothing to do with that condition. You're going to the hospital because you got severe abdominal pain. Clearly, Scott, you don't have any idea why Arden had abdominal pain, you can't like see into her belly and see what was going on. I mean, some of those things, you have to say, You know what, I came here for this year, the team, you're the experts, I expect you to figure out what the pain is, but I've got this part of it. I've got the diabetes management part of it because I do this 24/7 And you don't. So some of those things, you have to you know what you're requesting. I mean, if you're requesting something like jelly beans that your kid needs to eat, but he's throwing up, quite honestly, they're probably going to look at you like you're crazy and say you know what jelly beans might be what works really well, but he's not going to keep them down. So let's do a Dextrose drip. Yeah.
Scott BennerAgain, I'm a big fan of keeping people involved. So we were not the last thing we did before Arden surgery was I said to the doctor, here are all the places I can put Arden's insulin pump for the day of surgery. Which of them would you like it on? Now? Let me tell you a secret Jenny, it wouldn't matter which one it was on. I was actually giving her something like, Do you know what I mean? Like, I do the same thing in 504. It's like I find something in a 504 for that. I'm like, Oh, we don't need that anymore. And when I go into the meeting the next year, I give it back like It's a present. I'm like, oh, you know what, we don't need this line anymore. Take that out. I'd like to make this as easy for you as possible. Yeah, like, Oh, look how nice he is. Right? So in this case, it's a little ego stroke for the doctor. You tell me what's best here. That was arm or it was thigh. Like neither of those were going to be in their way. And I let the doctor pick. Yeah. And that was it. Right. And by the way, double down on my maniacal thinking. I was trying to get Arden to use her arm again. And I thought he'll probably say, she'll probably say arm over thigh. So I'm just going to give her arm or thigh. She'll pick arm. I'll make her feel better. And I'll get Arden's pump back on her arm again. Haha. Yeah, I was like an evil genius in that moment. What is okay to let slide and she's like, What hills? Should you die on? I think we're answering that question along the way, right? Like you just you what's important to the management of the diabetes? What keeps insulin going as best as you can? So what do I do about pump settings that I don't, I don't even follow myself all the time becoming and so so she's a fluid person, like she listens to the podcast, right? And so what happens when your management is fluid, and then all of a sudden someone wants to make it static for the situation? Right? To me, I would tell them that, I'd say look, let's start here. If this doesn't hold it down, we might have to amp it up a little bit. And if it's too much, we might have to take it away. But I don't know, because this is a different scenario than we usually manage. And these numbers are not set in stone like Jesus. That's the that's the core of the podcast, right. And I
Jennifer Smith, CDEthink a better part of it too, is to explain in a more simple way, maybe to them. This is the baseline that we work off of based on what's happening with glucose, because we've got a trend on our fancy CGM. I can because the pump settings, the smart features of my pump, allow me to do this, if, if his blood sugar is starting to go up, I'm going to do something that temporarily allows me to just up, I'm also going to temporarily adjust down in this scenario. So explaining that in the simplest way that you can help them to see that what's there as settings, is it's meant to be fluid. You know, it's these are what we start with, and, you know, in the in the case of something like the carb ratios, you know, she's like, well, then carb ratios are a little bit more of a suggestion. They're really not something that we 100% hard number go off of, you know, what, if in the emergency room, you get to the point that they're bringing you food, and you're bolusing you know what, you give them the ratios that are in your pump, and you do what you know, works. What they will usually ask for is what dose did you give, because they need to put that in the medical record, right? They don't know that it's been adjusted or just a down based on you know, whatever you say, This is what my pump suggested I take this is what I'm taking adjustment up or down that that's a piece that quite honestly, they're not really going to care nor know about. I mean, when I was in the hospital for both post deliveries of my boys, the nurses every shift, they would ask what is your Basal running at? Have you made any adjustments? Where's your blood sugar? Have you taken any boluses? Have you eaten? All they needed to do was really document what was going on? That's it. There's a lot of butt covering going on? It is a lot of exactly. 100% Yeah.
Scott BennerAnd so even if you're MDI, that's really the same advice. Like it is no, if she does make the point that they like to give like a set dose? They do. Right. And so, you know, but and that kind of leads into one of our other questions. Is it ever a good idea to just do things on your own and not tell the staff? And I would have to say, I mean, no, but but probably
Jennifer Smith, CDEin some of it is a little bit of like coding an answer, right. Like I said about the Bolus thing, right? It's Is it ever a good idea to do things and not tell the staff not not know, but if you're bolusing for a meal, and they ask you did you Bolus or to have you taken any corrections or whatnot? I mean, the simplest answer yes. And this is what the dose is. That's kind of the level that they need. They don't need to know that you factored in. Well, it looks like his blood sugar is dipping. So I adjusted backed by this, but they don't, again, too much story, right? They don't need to know,
Scott Bennertheir loss because they don't have diabetes, right? And then they start
Jennifer Smith, CDEthinking I've got a crazy person who's like just giving willy nilly doses of insulin. I don't I don't agree with it. Let's shut the pump off. Yeah,
Scott Bennerit might seem disconnected. But you know, when you hear a late night talk show host make a joke about diabetes. And you think, how could they possibly do that? When I know all of this stuff about life with diabetes? They don't know. That's the answer. The answer is they don't know any of that stuff. And so these people you're talking to very well may not know most of what you're saying. So listen to what Jenny's saying. I've said it one way, she's saying it another way, get them to do what you need them to do, if they say five units, because that's what we do. But you know, it's six, and maybe it's okay to do six. If if they want to do five, and you think it's 15, that you're probably gonna have to say to them, right, because you're protecting your own safety. That's what you're really doing, right? You're trying to protect your safety against your blood sugars. And going high is how it feels most of the time. But the truth is, too, you would need to protect it from going low, you would not want to give yourself way more insulin than your doctor knew about because if you did get low, that would be unfair. needed. Yeah,
Jennifer Smith, CDEexactly. And, you know, for some of the MDI users that I've worked with, and a very good friend of mine, some don't even really have a true set ratio as a dose to use. And I think you had done this for a while, too. It's like, you can look at a meal. And you can say, like, my good friend, ginger, she can look at she knows her apple and her peanut butter is this many units of insulin. This is what she takes for it all the time, unless her blood sugar's higher, or lower or whatever. But this is always what she takes for it. That's not really a ratio, could she figure out a ratio to tell them? Sure, right? She could. But technically, there's no ratio there, because you've just figured it out. Because they're standard foods that you eat. And you know, that five units or two units or 12 units always works for it.
Scott BennerAnd so when you're not ginger, or you or me, or maybe a lot of the people in his podcast, what do those people do, people really don't understand this yet about their diabetes, are you just in the hands of that,
Jennifer Smith, CDEand that's where these protocols are put into place, with the expectation that the medical staff knows best, and that the people coming in, aren't taking that type of level of care for themselves. So they have protocols, they've got these, if this, then do this, if this is where it is adjust by this much change to this, add this, plug this in whatever. And those are safety protocols they are. But I think from the staff position, or the medical, you know, person position, you do have to look at the individual, you have to look at the person who like you comes in with Arden's as I got this, I'm following it, we do this, we do it this way. I know where things are, she's beautiful, she's level, I can manage it, versus the person who comes in and can't even tell you the last time that they took their insulin, or what their rates are running at in their pump, okay, that person may be the time that one, the staff should then get an endo consult in and two the staff needs to follow their protocol, because they can definitely say this person has no idea what they're doing.
Scott BennerMaybe that would be a wonderful opportunity for somebody on staff to help that person, you know, because at the end of Arden's initial emergency room visit that I mentioned, as we were packing up and leaving and getting ready to go home and everything the nurse did come in and say, I really appreciate all the help. I hope I was good. You taught me a lot today. You should understand, though, the way you and I started today, because it was a little contentious at the beginning, I just tried to stay away from it, because 99% of the people I see in here don't understand their diabetes in any way.
Jennifer Smith, CDERight. And the majority of people she sees that come in are likely type two, who had much less education, even if they are on insulin, have had much less education than somebody with type one.
Scott BennerNo, of course. I mean, so it's just to kind of go on the side of the doctor for a second and talk about it from their perspective. You and I talked to a lot of people in our private lives who are constantly raising and crashing their blood sugar's like all day long, but by what they're doing, they don't realize that they think it's happening to them, but they're doing it, you know, and they don't know what they're doing. And what if I get you into a situation where you have multiple units of insulin going and your blood sugar's crashing. You want to have a seizure here at the hospital and in front of the nurse who doesn't particularly understand it to begin with, like, you know, But then, you know you have, you just have to understand their perspective and not just understand it for like, you know, nicely understand it so that you can tell them what they need to hear. Like, right? Like you just, I don't know a better way to say it when you're, you know, when you're arguing with your spouse, right? And you in your heart, you're like, why are they not hearing what I'm saying? It's because they think differently than you think. But if you understood how he thought, or vice versa, you could say to him the thing that would put him at ease, and help him understand you. And that's what you're trying to do here, you're trying to communicate on a better level than we all communicate on most days. Right? That's all right, right. And,
Jennifer Smith, CDEyou know, when I worked clinically with an endocrine group, in DC, at our hospital, we actually worked with the emergency room staff to develop a protocol for both type one and type two diabetes for when somebody was admitted to the emergency department. And we also had a protocol within the type one. If somebody came in on an insulin pump, it was an automatic endo call. They got somebody there. And if the endo couldn't make it, which was most often because they were busy, one of us, the CDEs got called to the emergency room to help the ER Doc's manage, right. So you know, not all hospitals obviously have that. But we did it mainly because we saw the need, we were getting called so frequently to the emergency department to manage that they were like, well, let's just get something in place. So we better know what we're doing, and when to actually bring you guys here,
Conclusion and Pro Tip Series Outline
Scott Bennerright? That's a it's not an easy fix. But these are just ideas that hopefully some of them will make something better for you or the conversation or your health. It's, there's no, there's no like, do this, this and this, and you're going to be okay. After this all got posted online, they actually sent me a follow up question. And it was from another person. And the idea basically was, What if you're an adult friend of a person who has diabetes and is not capable of talking? Right, can't speak for themselves in the moment? Like, is there a way to advocate for them? I mean, as I read that, I thought, That's a wonderful idea. I just mean, if you're not a blood relative, first of all, you can't, they're not going to listen to you to begin with. I mean, they might listen a little bit, but what are you even going to say you don't understand their diabetes, probably any better than? Right? You know,
Jennifer Smith, CDEI think the easiest, the easiest way to advocate then would really be to ask the emergency room staff, if they could get an endo consult, quite honestly. Because you know, you can, if you know your friend well enough, and hopefully you do, if you're taking them to the emergency room, you haven't just met them on the street corner, and, you know, took them in or whatever was in a
Scott Bennerbar, and this guy passed out and
Jennifer Smith, CDEdecided to help. Like, he's wearing this pager with a tube, and I'm not quite sure what that is. But, you know, if you're enough of a friend, bringing another friend to the hospital, you would, you would typically know that they've got a pump, or that they use injections, you may not know how they use it, but you could at least say hey, you know, he or she has the pump on here. He or she wears and uses this thing that tells them what their blood sugar is, you know, those kinds of things would be easy enough to be able to share with the staff at least Yeah, I think
Scott Bennerinstead of trying to find a way to talk to the friend, we have to be talking to you listening who has diabetes, you you have to as crazy as it sounds, you probably have to try to break down your diabetes into six bullet points. And explain that to your friend so that they have that information to ask somebody, listen, you've all been diagnosed, right? And someone downloaded an hour's worth of talking into your head and you got home and went. So you know, like your friend over you know, dinner once in a while when you mentioned your blood sugar. That's not how they're gonna do. But if you had a bullet pointed, like five point list, like, make sure they know, this is what my Basal rate is, make sure they know you know that I'm MDI and that means I inject my slow acting insulin and my fast. They're two different insulins like that kind of like simple stuff, like break it down into t shirt slogans for it. Right, exactly,
Jennifer Smith, CDEthen even even when you change therapy, then it's important to share with them, hey, I'm not using injections anymore. I'm using an insulin pump. Even that as a simple statement can be very helpful within those simple bullet points of do this, or do this is behaving this way, you know, help me this way, whatever. That just the other day I brought up with my husband in the, you know, couple of years that I've changed over the type of pump Same strategy that I use. I, my husband was very good with my other pump. He knew how to push the buttons and how to do everything. And since I've changed over, while he knows what I'm doing the button pushing and stuff. I've never gone over with him again. And just the other day I was thinking, I really need to like reteach him. Yeah, all of this in case of me.
Scott BennerI really do. Yeah, 100%. Jenny, we've done it again, I really believe that this is a good episode.
Jennifer Smith, CDEIt's a good episode, a really great awesome that your, Miss Misty, decided that it was a really good topic, because
Scott Bennerit was really thoughtful of her to do. Really, super, actually. That's what I like about Listen, all of you listening are terrific. You know whether I've ever met you or I'll never meet you, or you'll never say a word to each other. But I've gotten to meet some of the people online a little closer. And it's really wonderful like that Facebook group is little more than a couple 1000 people who really understand what's being spoken about on the podcast. And when new people come in, they're really helpful. And I just put a post up the other day where I very proudly said, No one's ever been banned or deleted from this place. And even when they when they don't disagree as much as they, they they have conversations. It's really lovely. Actually, that's nice. Yeah, it's wonderful. You can actually talk to people you don't know who disagree with you and not yell at them. And it's still okay. Yes. So do that while you're at the hospital. Let me say this right, before I let you go. Yeah, I don't know that most of what we just said here today does not apply also to when you're in your general practitioners office. Right, like the idea that they probably don't understand as much about your diabetes as you hope they do. Correct. Right. So don't make that assumption. I think I think that's really it. Like, don't assume anyone understands. And you don't if you're an adult with type one, and you're worried you're going to be in the hospital by yourself, make that bullet point list for yourself and keep it keep it on you. You know,
Jennifer Smith, CDEAbsolutely even you mentioned that, like the iPhone with the notes or the you know, the phone with the notes and whatever. I know some people even use, I know iPhone has the swipe screen that you can actually have your medical ID right up there with all of your information within that medical ID. You can put it right there. Right in the health app.
Scott BennerYep. Yeah. And again, for all and please don't take this the wrong way. But for you type A lunatics be brief, okay. Yes. Doesn't need to be a dissertation. Right. Then one time when she was six, okay. The doctor stopped reading when they got to that
Jennifer Smith, CDEplantar wart that I treated this way 40 years ago.
Scott BennerNow my blood sugar was a little higher during that week and I really think that plantar wart in medicine is what? So please keep that in mind. I don't have one now. But I mean, say I'm unconscious for four or five months here at the hospital and I develop a plantar wart and you decide to take it off for me? I really want you to keep in mind what happened before? Yeah, just keep it simple. What did they say? KISS keep it simple, stupid, right? Like, I don't think they're calling the person stupid. They're saying super simple. And there is a way if you think about it. And if you listen to this podcast, really, you probably have it now. There's a couple of simple ideas that will keep you within a reasonable range and safe. So tell the doctor that stuff. All right, or just don't get sick. I say is my nose is stuffy this
Jennifer Smith, CDEyear. So it's harder to do that than other years really?
Scott Benner100% right. There's a lot going on. There's a lot
Jennifer Smith, CDEof illness going on.
Scott BennerSo I'm gonna tell Jenny, a really gossipy story that you guys don't get to hear so goodbye. Bye bye. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low BGs. In Episode 1015, Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two, in Episode 1018 pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022, weight loss 1023 Honeymoon 1024 female hormones, and in Episode 1025, we talk about transitioning from MDI to pumping.
Before I go, I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us.
This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active took me already from a decent 6.5 A1C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis.
I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.
Jennifer Smith, CDEJenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.
Scott BennerIf you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community
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