Scott Benner 2/7/24 Scott Benner 2/7/24

#1126 Grand Rounds: Technology Part II

Scott and Jenny discuss diabetes technology. Part two of two. Part one is episode 1125

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

Scott Benner 0:00
Hello friends, welcome to episode 1126. This is part two of the Grand Rounds episode on technology. For part one, go to Episode 1125.

Today Jenny Smith and I are continuing on with the Grand Rounds series, we're going to discuss technology in this two part episode and the first half general overview of CGM and pumps and in the second half different pumps technology and understanding the differences between them. Please don't forget 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 health care plan or becoming bold with insulin. When you place your first order for ag one with my link, you'll get five free travel packs and a free year's supply of vitamin D. Drink ag one.com/juice box. Don't forget to save 40% off of your entire order at cozy earth.com. All you have to do is use the offer code juice box at checkout that's juice box at checkout to save 40% at cosy earth.com. If you're looking for the diabetes Pro Tip series, it runs between Episode 1001 1025. For subscribers to the podcast, those episodes are ad free. For everyone else. There's just a couple of ads episodes 1002 1025 diabetes Pro Tip series from the Juicebox Podcast. Today's episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. This is the meter that my daughter has on her person right now. It is incredibly accurate and waiting for you at contour next one.com/juice box. If you're interested in checking out the diabetes Pro Tip series, the bold beginning series or any of the series within the Juicebox Podcast, there's two quick ways to find them. First, go to juicebox podcast.com. Go up into the menu. And you'll see links for each of the different series, pro tips algorithm pumping, after dark etc. Click on them, there's a player in there to check them out. Or you can use that player to see which episodes correspond and go find them in your podcasts that the other quick way is to go to the private Facebook group, click on the feature tab. And there there are lists upon lists of all the series. Jenny has been a week and we're back. Yay. Last time we kind of stopped in the middle. Not really in the middle of the episode we'd already recorded quite a nice episode already. But we'd run out of time your schedule didn't allow. And you and I have just listened to the voice note that we that I left for us. So we're going to pick up by talking to doctors about why insulin pumps are so important for people. I think we should just start maybe at the misnomer that still exists that a pump is just a way to avoid injecting and nothing else.

Jennifer Smith, CDE 3:04
Yeah, that's a great way to start. I'd certainly not it takes the place of injections. But it is not a one for one conversion. By any means. There is a major difference between injections even the smarter injection devices that we have today. 100% difference when you change to an insulin pump, it's a really strong way to assist somebody in improving management, just because of the much more I guess in general, just the much more precise dosing that you are offered with an insulin pump. Yeah, you

Scott Benner 3:38
have fine control over Basal insulin, extending boluses creating, you know, patterns. Yeah, you can you can create a little here's the I think a great example is that, you know, if you experience a fat rise after a meal with fat in it, you push a button again to give yourself more insulin, or you tell it Hey, 90 minutes from now I'm expecting a rise, let's put some in here, you're not coming back at somebody with a with a needle again. And I know it feels like Oh, so you're just saying I'll avoid having to inject. But that's not it really, it's the psychological part of it, that people won't remember to do that. Or if it comes to, well, I have to do it to inject, they may just avoid it.

Jennifer Smith, CDE 4:21
And in one of one of two ways of avoidance there, that's a good thing to bring in. It's either they'll avoid doing it kind of resulting in sustained high blood sugars because they're just avoiding taking 10 injections a day versus the four that they were told were necessary, despite them knowing better. Or secondly, they may actually go the route of just avoiding additional food that may be necessary. I

Scott Benner 4:44
just interviewed a lady the other day that said that her newly diagnosed son changed his eating patterns and she couldn't figure out right away what was happening and then it hit her that she'd say Are you hungry and moments when she knew he was hungry and he's saying No, thank you. And then he kind of like soak away. But he was just trying to avoid injecting. Yeah,

Jennifer Smith, CDE 5:05
absolutely. And it is a not only from the standpoint of injecting more, there are people absolutely, who that's their desire is just to manage with an injection and to do it multiple times a day in there, they're fine, and they do a wonderful job. But then there are the people who could do so much better. By having the precision instead of the smallest dose really is about a half a unit unless you really eyeball on a syringe and assume you're getting a quarter of a unit, which is again, not very precise. But you know, the precision of a pump to be able to deliver for somebody who is ultra sensitive to insulin. It's not there with injections.

Scott Benner 5:49
Yeah, yeah. Where my concern comes is that if a doctor were to tell you, the contour, next gen blood glucose meter, is sponsoring this episode of The Juicebox Podcast. And it's entirely possible that it is less expensive in cash than you're paying right now, for your meter through your insurance company. That's right. If you go to my link contour next one.com/juicebox You're going to find links to Walmart, Amazon, Walgreens, CVS, Rite Aid, Kroger, and Meijer. You could be paying more right now through your insurance for your test strips and meter than you would pay through my link for the contour next gen and contour Next, test strips in cash. What am I saying my link may be cheaper out of your pocket than you're paying right now, even with your insurance. And I don't know what meter you have right now, I can't say that. But what I can say for sure is that the contour next gen meter is accurate. It is reliable. And it is the meter that we've been using for years contour next one.com/juicebox. And if you already have a contour meter, and you're buying test strips doing so through the Juicebox Podcast link will help to support the show. Even as they're handing you a pump, if they were to tell you this is great. Now you don't have to inject any more and make it feel like all we've done is take away like times you're getting poked, it takes your brain away from thinking that this thing could do other stuff for me. Like do you know what I mean by that? Yes, you neglect to mention that, if you get low every night at 2am, we could turn your Basal back at 12:30am to stop the low from happening at two, which if you're injecting Basal insulin is not a thing you could do even just correct. Think about that small idea, instead of messing with, oh, maybe we should, you know, shoot the Basal insulin an hour earlier, let's do it at night, instead of during the daytime, let's try 20 units instead of 21 units. Like instead of going through all that you just go I get low every night at 2am. I'll just take away some basil and see what that does. It's magical. But if the doctor puts in your head, oh, it's just a replacement to stop you from having to get poked so much. I think you don't wonder what else you could possibly do. Right? That's not me guessing that's me, having talked to so many people who've really told me that story. So

Jennifer Smith, CDE 8:15
Right. And I think it also goes along with the lack of explanation of the pluses, or smart features, let's call them on today's pumps, even conventional versus the newer kind of algorithm and whatever that is out there. Myself example really is. Before I switched to a pump, I was taking a Basal insulin that required me to have a snack before I went to bed. If I did not, I was low by three o'clock in the morning. I was every and if I change every night, and if I changed my mind was worse with exercise and everything. If I changed my dose of the Basal insulin, it messed other things up that were not great. And so again, it brings in because food is such a center of diabetes management, it brings in the precision of a pump means that you're not feeding insulin that shouldn't be there. Yeah, yeah, right. I didn't want to have to have a snack at night. Most people don't want to have to nibble and snack when they don't want to or have to have very kind of timely meal intake to offset the action of a Bolus of insulin or their Basal action or whatever it is, as you said, if you can navigate those pump settings to accommodate for high need times are low need times you got something that can take care of that need to feed the insulin. Yeah.

Scott Benner 9:39
I want to say to to empower somebody to make an adjustment or make adjustments to their insulin through their pump is would be huge. I can't possibly tell you how many people live months at a time waiting to get back to the office where let's be honest, if you're listening in your dock You're you're throwing darts at a wall going, I don't know, try this, you know, like, turn it this way, see what happens how you suppose. And that's no shade on the doctor how they're going to know, from a couple of graphs, what happens, you know, it's ridiculous. And then it puts the doctor in a position of trying to pretend they know what's happening, which then just makes you look bad in the long run. And it leaves the person in a in a position where they're never doing as well as they could be. And you could end up turning a knob in March, that's even worse. And they don't come back till April, May June, like you don't even talk till the spring. Correct. And these people don't feel like a thing I hear the most from people about the podcast is it gave me the courage to try something.

Jennifer Smith, CDE 10:47
Yeah, people should try something specifically with the main control factor of diabetes, which is insulin. Yeah.

Scott Benner 10:52
100%. And, and my point is, is that doctors should be encouraging that, like, you can't sit there and tell people like on one hand, wow, you're gonna know more about this than I do in six months. But don't do anything till you come see me. Right? You know, it's weird mixed messaging, and it freezes people and it leaves them with higher or lower blood sugar, either some people are eating, they're like crazy trying to keep their blood sugar up. You just made that example, like if I adjusted an injectable Basal insulin. Okay, I didn't get low anymore at 2am. But all day long, I'm 45 points higher than I want to be, you know, so it's not a fix. It's a anyway, and none of that's necessary. And if you're listening to this and thinking it is, it's not plenty of people live with lower stable blood sugars that don't create crazy lows and, and huge spikes all the time. Absolutely.

Jennifer Smith, CDE 11:42
I think that is really, it kind of goes along with the fact of teaching people about their pump in the right way, right? If you're recommending a pump, you've got a patient, you've started on a pump, you're getting them going, their education needs to go beyond the basic of filling it with insulin, putting the tubing on or slapping on, you know, the pod device or whatever, and hitting go, and it just starts delivering insulin. That's not teaching. That's just learning how to use a device. Right there, there's so much more to learning because again, of the smart features, even the simplest smart features like a temporary Basal rate, when to use it, why to use it, how long to use it for before actually making true set adjustment. When you're using an extended Bolus, write a square wave or a dual wave type of Bolus. Those are advantages in the aftermath of food, or coverage for different types of, you know, different types of intake. And you can't do that as precisely with injections, unless you're willing to be the person to give multiple multiple injections to cover that type of intake. Right.

Scott Benner 12:53
I want to say that plenty of people that I've met, manage amazingly on MDI, yes, but they understand how insulin works and when they need it. That's that, like, if you and I talked about this all the time, people would come to us and say, hey, the Pro Tip series is so like for people with pumping, can't you do more for people with MDI and I said, Oh, it's the same thing. I said, just when you hear me say, pump, think needle. And if you hear me say extended Bolus go, oh, I can't do that. I'll have to inject again. Like, that's the difference, really. But if you don't know that, Jenny, if you're the doctor, and you don't know that, and then someone comes in and says, Hey, every night at 3am, I get low, but I changed my basil, it didn't work. I'm still getting low at 3am. Now I'm getting high at, you know, 5am I don't know what's going on. The doctors gonna be like, Oh, they tried turn the basil down. That didn't work. They're gonna skip right over the idea about timing of insulin, which is why we talked about it so much in the other episode, because it's all about timing. And I don't regardless of the delivery method, no, right. It doesn't matter how you're putting it in the timing of the insulin. There's not much of a parallel about how basil works. When it's injected versus basil works through a pump. They're pretty different. They accomplish the same thing, but they're not manipulatable by the user at all. And that's it really like, and by the way, stop giving people Basal insulin that was invented 20 years ago, when there's stuff that works a lot better if they're going to be on MDI, at least give them modern basals that that have longer coverage and actually make it not just 20 more stable.

Speaker 1 14:25
Yes, just stability. You know, I don't know how much time I spent. While Arden was on Leba mir wondering what the hell was happening when the truth was this 11 year wasn't lasting 24 hours.

Scott Benner 14:39
It doesn't. I mean, a year and a half maybe of my life just staring at a wall and thinking about running my head through it trying to figure out what was going on. Then one day somebody said to me, oh, you should split that. I was like, why wouldn't somebody who said that to me sooner? I give her half now and half 12 hours now work, right? That was it, right? Yeah. So and that's timing. That's insulin time it is

Jennifer Smith, CDE 15:01
it's insulin timing. And it's also based, you know, the kind of insulin I think that's another place to, to navigate within whether you're multiple daily injection, but definitely, if you're on a pump is we're talking about Basal insulin here, the understanding from a practitioner, that you still need to really recommend and have the person understand, they need to have a Basal insulin as a backup, right? Because we're talking about technology, technology can and at times will fail. And you have to have that backup as an injectable, in case. But I think it also is really important to explain that once you're on a pump, that Basal insulin gets put in the fridge with a label that says do not use unless pump fails. I've had a number of people over the years, who couldn't understand the concept that the pump was going to do the Basal and the Bolus delivery, but with one kind of insulin in the pump,

Scott Benner 15:59
are you going to tell me they put two different insulins into the pump? They

Jennifer Smith, CDE 16:03
did not. But they thought that they still needed to tow they were shooting? Oh, along with their pump? And then you know, I mean, clearly you clear that up very quickly, etcetera. I mean, it all goes into proper information and proper education from the get go. You know, there's a checklist of things that definitely, I told them this, I took care of this, this, this and this. They're all really important pieces that I think they sort of either get missed, but I don't think from I don't think it's a miss because they mean to miss it. Okay.

Scott Benner 16:36
All right. Well, it's interesting. All right. So that would be just the conventional pump, what we would consider old school, instead of Basal rate, it gives it to you, you tell it how many carbs and you've preset your insulin to carb ratio, and it does the thing. But I mean, honestly, every company now, Omni pod has Omnipod five, tandem is control like you. Yeah, Medtronic, what is it? The mini med? was an ad G seven AG, that's the new one from them. Okay, I'm pretty new. So there now, I mean, those are the three major pump manufacturers, right? Like I'm not missing anything.

Jennifer Smith, CDE 17:12
So you're in the States, those are the major rights.

Scott Benner 17:14
So wherever you live them, there might be others that you're using. But these algorithms are prevalent. They're available. You know, they require you to wear a CGM at the same time. But correct. Let's say this. How do I put this? If I let you, Jenny, would you put an algorithm on everybody? You could? Or no, I'm interested in your feedback?

Jennifer Smith, CDE 17:35
That's a really good question. I think, I think it depends on the algorithm. Okay. I think that an algorithm can improve the vast majority of people with diabetes, whether it's type one or insulin dependent type two diabetes, and insulin pump absolutely will be an advantage, and the algorithm within that will improve things. And I think the biggest group of people with diabetes that it improves are those who, for whatever reason, in life, they're just not navigating management, to the degree of effectively bringing glucose levels down to a place that long term is going to be healthy, right? And an algorithm again, depending on which one what system you're using, an algorithm can and will improve things. So for the majority of people, yes, I think it's a fantastic idea.

Scott Benner 18:37
So let's stick with that for a minute. If you are, what do you think the cut off is in your head? If you're a one sees above, seven, seven and a half an algorithm is going to help you for almost for sure if the settings are right, and you're even reasonable about announcing carbs, is that fair? Correct? Yeah, yes. If you're rolling around with a five, five to a one C, you might not have that same outcome. If you just let the algorithm roll. As a matter of fact, they all target God, it's a What's the target for t? So obviously, it's something weird, like 100. And

Jennifer Smith, CDE 19:12
technically, we just say 110. It's one 12.5, whatever you got, right? But yeah, one 12.5 or 110, Omnipod, five, the lowest adjustable is the 110. And then Medtronic, interestingly, with their 780 G, they have the lowest in an FDA approved product, which is 100.

Scott Benner 19:32
Okay, but so those are still your targets, they're, they're a target. And if a doctor is probably listening, they're like, Oh, my God, you mean somebody could have 110 blood sugar most of the time, like, yes, like, I don't see that with anybody. But there are plenty of people who know how to use insulin in such a way and are are thoughtful about it in such a way that they're achieving lower agencies, but I remind myself constantly Jenny, I don't know if you run into this as well. Is it making the podcast your often talking to people who are either so lost, that they're just looking for information, or they're very. And maybe this is an end or so interested in doing better for themselves. It's a certain type of personality and you forget that you're, it's also a certain type of, sometimes it's a certain type of financial ability to write because these people have pumps they have you know, CGM is oftentimes, which means they have insurance. Yeah, I remind myself all the time, that that's not nearly most people, you know. And so, you say so easily, like, you know, I say so easily will put an algorithm on, it'll help them I don't even know if they have insurance, correct?

Jennifer Smith, CDE 20:40
Yeah. Right. And those are, I think, from a provider standpoint, those are the pieces that many are trying to understand and trying to navigate. Because there are so many different carriers, right, when you get into the group of people are using Medicare, and the restrictions and the things that you have pay attention to, or Medicaid, or even the general insurance plans that are national plans. Each of them has different pieces that work in a certain way in terms of coverage. And so that may dictate product to product, what you may be able to tell somebody about, I think, in general, all products should be an offering. And then when you boil it down, what's available in terms of coverage? What can you use? Great, you can have your choice of all the products, fabulous, you know, we're looking at your lifestyle next, then what does your lifestyle dictate? Do you you know, swim six times a week? Well, great, you probably may not love a tube pump, then it's going to be a lot of on off, disconnect, reconnect, etc. Do you really want an algorithm that's a little bit, you know, less your work and more at work, or a little bit less input? You know, there are certain systems that work person to person, and that's where you individualize once you know, what is available to them.

Scott Benner 22:02
Yeah, so Jenny's point is, if you don't understand how these different algorithms work, you can't just hand somebody out and say, like, here, you know, it's not like you're just handing them a lighter, and it makes a flame at the end. You're all good, right? Like it's, I guess, be more specific. Right. On the part five is a little more, we take care of it, you don't take care of it. Right, right. Yeah. Yes. And what do you think of the other ones to what is control IQ? Is it a little more?

Jennifer Smith, CDE 22:28
Yeah, I think that one is the most unique of the three that are on the market, it's most unique, because for those people who have fairly good settings coming from maybe a conventional pump that isn't giving that assistive help, right, if they've got fairly good sis settings, are there willing to test some settings, the control IQ system from tandem allows the users Basal profile, insulin to carb ratio correction factors and everything to be used by the algorithm to adapt or Anatidae app to adjust up and down. Their algorithm is really simple. It takes your baseline, it adjusts up or down based on factors that are very simple. But the great thing is that it works off of a pattern that for the most part, you know, works well. You just need some help navigating cleaning up little ups and downs that you otherwise would have to do on your own. Yeah.

Scott Benner 23:23
How about the new Medtronic, I'm starting to hear people speak really well about it?

Jennifer Smith, CDE 23:27
Yeah, the new Medtronic actually has a I think of, of the three systems on the market. It's, it's auto micro boluses. Or it's micro corrections along the way, are the most aggressive quite honestly. And a lot I've heard the same thing I only have a handful of people that I've been able to use it with us far because it's again newest kind of but it really it quite honestly does a lovely job. It's adjustments in between its corrections for those climbs and whatnot makes it a lot less the person's job to try to navigate. So yeah, it's a they've done a really nice job with updating that Yeah. And then

Scott Benner 24:08
there's the the newer eyelet pump, which I don't know how like readily available that is Yeah, but there's a pump that tells you you don't really need to do anything like you just tell it I'm having a what is it a normal large or extra large meal something like that and it's breakfast lunch or dinner normal? Yeah, small normal large This is breakfast lunch or dinner and it's going to dig make adjustments where you know your blood sugar's are going to maybe go up from that it's going to I don't even know what they're saying. Like, I think they're trying to promise in a onesie in the sevens. But still, for my opinion, if you're a doctor, and you've got somebody running around with an 11 a one see that you're just like, look, they're not going to take care of themselves. This is a this is a great idea. And I don't know where that pump is with Medicare. Yeah, I don't know where they're at with that. Like I know Dexcom is good with it, right, the CGM czar now Omni pod, I think has Medicare coverage. I think they all like probably do.

Jennifer Smith, CDE 25:04
Definitely, yes, I've got a couple of people I work with on Medicare who are using tandem. But

Scott Benner 25:10
then that's the next spot is that you can't just tell somebody, oh, you should get a pump. Right. Okay. Like, I don't know how to do that. Do you know how many people don't know how to? I'm not going to sit here and argue whether or not people should or shouldn't understand how to handle their lives. Okay, they should. But if they don't, that doesn't mean they don't get an insulin pump, or that they have to have an A one C and the elevens. I think it's got to be incumbent upon that the doctor to build an office staff that can help shepherd people through these things. No, absolutely

Jennifer Smith, CDE 25:39
have an office staff that's knowledgeable in technology is really important. I think, you know, it's one of the it's one of the filters, that when you are searching out clinician who can help with your diabetes management. It's certainly one of the things that you can ask when you call to make a new appointment. How does your office navigate this? What technology do you understand? What's the especially if you're type one versus type two? How much of the clientele that you see is type one, right? The all those questions are a good way to filter when you're in the search for a new endocrine providers specifically. Because there may very well be some that are very tied to one pump, despite there being multiple options available. They have known and kind of gotten used to the one and they're very inclined to recommend that one versus the other ones being very likely just as good or maybe better for your personal need. Yeah,

Scott Benner 26:40
at this point, too. There's, I mean, if you live in the Midwest, upper midwest, you're very likely are being told about a Medtronic pump, because the company's nearby there, and it's just sort of like a thing that's happened, right? I'm assuming back from Salesforce days where people were just probably working for the hub, you know, Omni pod is very sexy online. Like it has like a social media following Do you know what I mean? Like, yes, they have that. Like, you don't see people taking pictures of their tandem pump, as much as you see people taking pictures of their on the pod, which is interesting. You never see pictures of people with their Medtronic pumps. But I also assume that those are more like that slated and people who are like, well, I'll just take what the doctor tells me to get, and I'm not going to think about it again. But they're all different segments, I guess is what I mean, like in business, if that makes sense. Yeah,

Jennifer Smith, CDE 27:30
absolutely. And I think sometimes to even in, you know, working with so many people, I've had people who were one pump for such a long time. And again, my job as a diabetes educator is to be able to help somebody with individualizing, their, what they need in their life. And we can say, well, you know, what, you've been using this, you're using it really, really well. But you know that this new product, think about these things in your life, this would fit you better, you're coming up for a new pump, you know, your end of warranty is coming. Research this, let's talk about this. And those are all steps that as again, a clinician, you need to have in the forefront of your mind whenever you're working with somebody. Because if you're not getting the results that you want, and they're complaining, because they're not getting the results that they want, but you're not changing anything, then you're kind of at a standstill. Something has to change. And it might be their technology. Yeah,

Scott Benner 28:32
not very well could be also I think it's important to remember that moving from MDI, to pumping or pumping to algorithm pumping, feels like starting over to people, and they're going to be very, a certain kind of person is going to be incredibly resistant to that. And by the way, a certain kind of person is going to be like incredibly enthusiastic, maybe more so than they should be like, You know what, I mean, people, some people jumped around from devices all the time. But, you know, even if it's in your head, like, Hey, I think if you use the pump, like Jenny was just saying, we we'd see a difference here. And the person goes, No, thanks. I don't know. Like, I think he maybe should dig into that a little more. Because I know you're picking up the chart and going asked about a pump check. You know what I mean? Like, like, don't

Jennifer Smith, CDE 29:15
don't do don't do don't just check a box. But there is your that's a great point. It's No, I don't think so. I mean, it begs the why, right. And if they offer some really good reasoning, I'm doing well here. I think I you know, I needed this there. Maybe there are some pieces that you could be more informative as to how could a pump actually improve some of the things that they're bringing in as concern? Right,

Scott Benner 29:41
right. I'm also not talking about badgering people. I'm just saying that. I've just spoken to too many people who will eventually say my doctor asked me for years, and I finally broke down at Oh, I wish I would have done that sooner. Right. Absolutely. All the time. Yeah, not just about pumps, CGM EMS Paying attention to like the food I'm eating like like the Oh, I wish I would have paid attention sooner sentiment is wallpapered around diabetes, you know? And yes, what I'm saying is, is, is there not a way to say something, do something, ask a question that leads to people? You know, right, giving it harder consideration and moving. Exactly. Yeah,

Jennifer Smith, CDE 30:22
absolutely. And I think your technology is, for those who are, who have grown in the years with diabetes, I think, if that hasn't been a discussion that's revisited recently, for somebody who's been using, as we said, more of a conventional pump, right? They've been on it. And they're, you know, they're doing baseline, they're doing pretty good. And they're kind of at this place of comfort. But there are some things that you can see could be better with some of the newer systems, sometimes, those are a little bit more in depth discussion of bringing in, hey, you know, I know you've probably seen this, I know, you've probably heard about this, let's have a discussion about how this could really be a benefit beyond what you're doing. Right. And sometimes that that's hard. The growth of technology is really, really, really moved in the past couple of years.

Scott Benner 31:18
It's happening much more quickly now than it has in the past, which I think is also another reason why doctors are getting left behind and why I'm, I'm talking to people who are saying, at the end of my appointment the other day, the doctor asked me if I would stop and explain how am I pumped work to them? Which by the way, the person was not filled with, like confidence when that happened? No, there's there's a two headed argument there. At least the doctor asked, I maintain, they should have asked in a way that didn't leave the person going, Oh, my God, am I seeing the wrong physician? You know, yeah, because I can see the doctors perspective, by the way, like, you know, I don't know, I don't have diabetes. I don't know how this works. Can you show it to me? So Jenny, overall, we need the doctors to understand these devices, how they work, why they're important, how they can be helpful to help people get them, help them with their insurance, that stuff. And you know, make sure they have a choice. There's a lot of different options, those options work for other people for important reasons. Know what those reasons are, ask those probing questions, make sure you're getting them on a good device. And then I just want to add from the feedback that we got from people, Oh, yes. One person said that as an older type one, they equated a pump with being a bad diabetic, which is a term you hear a lot from people, you know what I mean? Like, and so, you know, that idea, like, cuz you know, what, from type two diabetes, oh, if you can't control it with food, then you didn't try hard enough. So now we're gonna give you a pill, oh, the pill didn't work? Well, you're gonna have to give you answered, you must have the really bad kind like that right? Progression or right

Jennifer Smith, CDE 32:47
or failure, right? That really brings into the person with diabetes, I've clearly failed. And then you're on a slippery slope of getting them back up. And acknowledging this isn't a failure. This is progression. This is many times where things navigate and let's get you using what's going to be appropriate to improve and prevent further issues down the road. It's

Scott Benner 33:11
another reason why the communication is so important. Because if you communicate failure to them, they might then start getting what they expect. And if they expect that they're failing, then they might let go of things, the amount of times that people just like throw their hands up, because they're so frustrated is true. So, you know, please let them know that getting these devices doesn't mean they're doing a poor job. This is going to help them experience something they didn't think existed, right? Not, you're doing a bad job, we need to do better. This is like, Hey, you should see what exists now, like, this is incredible, you know,

Jennifer Smith, CDE 33:43
should be put out there as a step forward, not a step back. Yeah, it should be an example of, well, this hasn't been working the way that we wanted. But you know what, if we bring this into the picture, we're going to be moving forward with your health, overall quality of life, all these things that should be given examples as why it would be positive to include this type of technology. That's where you should be explaining things and coming from a clinician standpoint, so that you don't get that negative. Oh, well, I failed anyway, I guess I have to do what the doctor says. And then you do the baseline, right? You never go forward with asking for more information, because clearly, I've failed. I just have to deal with this new thing now and not learn any more about it. I'm gonna

Scott Benner 34:32
leave this here at the end for anybody listening agenda. You can do this too, if you want to. I'm not pressuring you. I'm looking at my daughter's last 24 hours. She manages her diabetes the way I told her to she understands timing. She understands how insulin works. She understands how food impacts her. She's wearing a CGM and an algorithm. Her highest blood sugar in the last 24 hours was 154. That was a spike after a meal that lasted for no more than an hour and a half. And since Then her blood sugar has not been over 125 or under 72 For the last 24 hours. That's fabulous. That right there. That's an algorithm right there. Yay, no input, Jennifer, not like nobody's doing anything except announcing carbs and right. That's it, right. So please, if you're a doctor, and you don't know about this stuff, please learn about it. Because you could move an entire generation of people with diabetes, not forward, you can delete them. It's the difference between driving from New Jersey to Connecticut for vacation, and getting on a rocket ship and going to Mars. So,

Jennifer Smith, CDE 35:40
you know, we talked to talk to clinicians about, you know, educate yourself, one one step of navigating education for yourself is get in touch with your area reps, get in touch with the clinical for all of the companies for these technology, you know, driven devices, and learn about them. Many times, they've got demos, they can pull, bring in for button pushing and whatever. There are even online resources like Dana tech for the clinical who, you know, if you look under their Panther services, essentially, you can look up all the devices you can play with simulated devices online. Yeah, I mean, they're wonderful resources for your reference,

Scott Benner 36:19
whereas CGM, I mean, you can wear dummy, like, No, you can wear like a, like a Omni pod. That's not a real pump. That's just gonna give you the idea of what it's like to wear it. But you could actually wear a CGM and watch it work. Yes, that would be a big deal. And take a meter homes, you know, if you have to calibrate it,

Jennifer Smith, CDE 36:37
and learn how the meter works. Yeah, learn how the

Scott Benner 36:39
meter works. First, it really would be incredibly beneficial for people. Okay, gentlemen, thank you so much. Appreciate it.

Jennifer Smith, CDE 36:45
Oh, course thank you.

Scott Benner 36:52
Arden started using a contour meter because of its accuracy. But she continues to use it because it's adorable and trustworthy. If you have diabetes, you want the contour next gen blood glucose meter, there's already so many decisions. Let me take this one off your plate. Contour next one.com/juice box. If you know a health care professional that could use this series, send it to them, or anybody else for that matter. And if you're really enjoying it, please take the time in your favorite podcast app to leave a five star rating and a thoughtful review. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Die diabetes Pro Tip series is available for you from Episode 1000 to 1025. And for subscribers in Apple podcasts. You'll get those same episodes ad free. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

#1125 Grand Rounds: Technology Part I

Scott and Jenny discuss diabetes technology. Part one of two. Part two is episode 1026

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:00
Hello friends, welcome to episode 1125. This is part one of the Grand Rounds episode for technology part two is it episode 1126.

Today Jenny Smith and I are continuing on with the Grand Rounds series, we're going to discuss technology in this two part episode and the first half general overview of CGM and pumps and in the second half different pumps technology and understanding the differences between them. Please don't forget 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 health care plan or becoming bold with insulin. When you place your first order for ag one with my link, you'll get five free travel packs and a free year's supply of vitamin D. Drink ag one.com/juice box. Don't forget to save 40% off of your entire order at cozy earth.com. All you have to do is use the offer code juice box at checkout that's juice box at checkout to save 40% at cosy earth.com. If you're looking for the diabetes Pro Tip series, it runs between Episode 1001 1025. For subscribers to the podcast, those episodes are ad free. For everyone else. There's just a couple of ads episodes 1002 1025 diabetes Pro Tip series from the Juicebox Podcast. This episode of The Juicebox Podcast is sponsored by touched by type one touched by type one.org. And find them on Facebook and Instagram touched by type one is an organization dedicated to helping people living with type one diabetes. And they have so many different programs that are doing just that check them out at touched by type one.org. This episode of The Juicebox Podcast is sponsored by the insulin pump that my daughter wears Omni pod, learn more and get started today with the Omni pod dash or the Omni pod five at my link Omni pod.com/juice box. Alright, Jenny, we are back doing the Grand Rounds, which I guess is gonna get called by default, because I can't think of anything else.

Jennifer Smith, CDE 2:26
I think it's a great name.

Scott Benner 2:27
I love the name until one person online. It took one person to say to me, I don't think every hospital calls it that. And I was like, Oh, I pick the wrong. And but I think it makes the point, right?

Jennifer Smith, CDE 2:37
It makes the point it does. Yes.

Scott Benner 2:41
So today we're going to talk about continuous glucose monitors and blood glucose monitors in the same short conversation here. I guess we'll just start with BGMs blood glucose monitors and go over very quickly, that they're not all the same. And I'm beginning to wonder if doctors offices know that. That makes sense. These are not incredibly expensive items. Most people's insurance, if not all people's insurance are going to be covering a blood glucose meter. Yes, in a world where they're right. That's

Jennifer Smith, CDE 3:16
some kind, it's fair. It's fair, I wouldn't say that they even good insurance companies have sort of a preferred glucose meter. Right. And you may pay more for one that you expect in reviewing is better in terms of accuracy. Insurance will typically cover up a meter. Yes,

Scott Benner 3:36
I just think that it's worth mentioning that this meter that I'm giving you may not be as accurate as other meters, perhaps you should look into it or I don't understand why doctors offices don't begin with here are the top three, right? Because I think there's about three of them that kind of fall in similar space as far as accuracy goes, right? So here's the top three. If your insurance company doesn't cover the test strips for this, then you know, here's a declining list of accuracy. I just don't think that is a conversation that's ever had, I think you Gill, whatever the office leans towards maybe or I don't know how it even works to be honest, true.

Jennifer Smith, CDE 4:11
Years ago, when I was working in office, the standard that would be is that you would get from different companies, you would get sent meters and the meters are not the expensive piece. The meters are actually more of like the freebie that kind of like we would give for newly diagnosed we would give them either Yeah, the prescription and the pay part comes with the test strips, right? So it then depends on what test strips are kind of covered at what cost they're being covered. But most of the offices like I said when I worked in the past would get a good supply from all of the brand name ones not the typical ones, that you're gonna find it like Walmart or any of the pharmacy places that might have the generic brands, but we would get all the way Any ones and we would essentially help to kind of figure out which one would work best for this person size, what other things that they might be working with, et cetera. For

Scott Benner 5:11
my money, its accuracy and being able to read it. That's what I'm concerned with, and blood drops at this point. They're all pretty smaller, like requirements.

Jennifer Smith, CDE 5:21
They are for the most part. I mean, you know, when I was first diagnosed, it had to be this hanging blood. Like this gigantic off your finger? Yeah, exactly. Yes, to get enough. But these days, pretty much they're all about the same tiny, you know, head of a pin sort of size that Yeah. And the other nice thing is that many of the good ones actually allow second drop applications so that if it didn't get enough to begin with, you have a certain number of seconds in order to reapply some additional blood to get enough of the sample.

Scott Benner 5:52
Yeah, yeah. Are mucking it up. So it's not as accurate. Correct. So that to me, that's it just like, explain to them, here's the accuracy. I don't know what your insurance company is going to cover. I mean, even be clear and say, Look, from a purely business standpoint, the game is selling the test strips, like that's where they make money, right? So the meter is your, you know, caretaker meter, and then hopefully, you'll buy our test strips, because you like the meter afterwards. I would imagine there are people listening right now that are thinking, Wait, some of these meters are more accurate than other ones. I honestly 100% believe that that's not a thing everybody understands. And why would you think that? You know, why would you consider one to be less than the other or better. So I think have that conversation. And then on top of that, even if you're giving someone a CGM, which we're going to talk more about, you still give them a blood glucose meter. It's important. And you know, you test your blood sugar, if your blood sugar's really 110. And the the meter says, it's 150. That's a lot more insulin you're about to take, you know, right. And that's just not okay. So

Jennifer Smith, CDE 6:56
all right, it's a safe place that you think that you're starting based on what you're planning to do after this test. And you may be aiming for that, when in fact, you might actually be lower. Or maybe you're actually higher than that. So yeah,

Scott Benner 7:08
it's just important and I want to say to just because you're gonna give somebody a CGM doesn't mean, they don't need an accurate blood glucose meter. So right, you take five seconds to make sure they understand how to use it. Here, I'll ask you a question. You test your finger sometimes, right? Yes,

Jennifer Smith, CDE 7:26
when's the last time more than sometimes,

Scott Benner 7:28
sometimes, when's the last time you cleaned your hands with alcohol before you tested? In 2015, I needed support to start making this podcast and Omni pod was there. They bought my first ad, in a year when the entire podcast got as many downloads as it probably got today. Um, the pod was there to support the show. And they have been every year for nine seasons. I want to thank them very much. And I want to ask you to check them out at Omni pod.com/juice box. My daughter has been wearing an omni pod every day since she was four years old. And she turns 20 This summer, it's been a friend to us along the way. And I think you would enjoy it as well. Omni pod.com/juice box links in the show notes links at juicebox podcast.com to Omni pod and all the sponsors. I don't use

Jennifer Smith, CDE 8:22
alcohol to wipe my finger. There may

Scott Benner 8:24
not be alcohol in this house, actually. So I

Jennifer Smith, CDE 8:27
do use it to clean sites. I do use it to clean the back you know those little ports. And again, we'll talk about CGM, but I do use it to clean that off. But in terms of it's really a degreaser, right? an alcohol swab is kind of a degreaser, you're better off honestly just washing your hands with warm, soapy water, sing the birthday song to make sure that you you know, get as much bacteria off as you're supposed to get off and then wipe your hands nice and dry. And then do the fingers.

Scott Benner 8:56
So here's the question. That health aside, I don't mean like you don't want to open up a hole into your hand while there's bacteria and germs and everything in your hand that I know No, I don't want to do. But for the accuracy of the test. Dirty hands don't matter, right? Well, it depends what they're dirty with. Right? So glucose in your hand sugar on your hands that would interfere with the test. True, but if I was muddy, and I just rubbed my hands real quick and found a clean spot, would I get an accurate test? Jenny's like I don't want to say

Jennifer Smith, CDE 9:25
that? It's a great question. It really is. I mean, I've I've never actually thought about it. Although I will have to say that so in I in college, I used to do Habitat for Humanity and we would do trips out of state for spring break. And there were many times on the worksite it's honestly that it wasn't easy to get to just like running water with soap. So I I would actually just dip it in like my water bottle. Wipe it off. I'm assuming it was clearly I never had any infections. I'm not by any means recommending this as a therapy or an option.

Scott Benner 9:59
I just want to have the conversation. Jenny's not recommending it. Listen, I saw Mark Andrews get catch a touchdown pass a few weeks ago, and I'm telling apply somebody went on the sidelines tested his blood sugar didn't see him stop and wash his hands. So, right? Correct. The reason I bring it up is because I've seen newly diagnosed people kind of crippled by it. Like, oh, I have to test but I don't have a an alcohol swab, or somebody's like, I think I'm low, but I have to go get an alcohol. I'm like, Just test your blood sugar. You're like, yeah, let's get moving here. So anyway, that's my little bit for that. Why?

Jennifer Smith, CDE 10:31
I think as far as accuracy, too, I think that that's something that, unfortunately, unless, as a, you know, we're speaking to, hopefully, practitioners here, too, right. And in terms of their understanding about accuracy, you really do have to read the fine print, this is where you might need to get your reading glasses out and read that tiny little print that comes inside each and every one of the meters that you may be recommending or handing out from your office space. Because if you haven't read that, right, all of the different blood glucose meters on the market, including continuous glucose monitors, they all have marred, right. It's an accuracy rating. And so you'll be able to tell by easily lining those papers up with the little graphs inside of them. Which ones are the better ones to be recommending to your patient? Why

Scott Benner 11:24
do you care which one lives as long as it's the better one and their insurance covers it? Correct? Look, I'm not saying if you have no other options, or you're a cash payer, and it's hard for you, whatever, then take what you can get, you know, the best you can get. But while we're handing them out, it just it seems to me, it seems to me that you probably said that, and a number of physicians probably just in their mind with these meters are different. Like why would you think that their blood glucose meters? Seriously, you know, you would expect that

Jennifer Smith, CDE 11:50
if they're on the market, they've been approved? And yes, they've met some type of accuracy rating in order to actually be on the market. Yes. But there are, as you said earlier, there are three that are pretty much the top tier and align with each other in terms of accuracy. I mean, I have two of the top three. And I will not often but probably, you know, once or twice a month, I'll actually pair them off of each other with the same drop of blood, just to see how they're still, you know, on par with each other

Scott Benner 12:24
remarkably close every time you do it. They

Jennifer Smith, CDE 12:27
are Yeah, very, I would say within about five milligrams per deciliter, honestly, they're very close to each other.

Scott Benner 12:34
I just last night. So I mean, they're sponsors of the show. But you know, our news is a contour next meter, one of the content x meters, and there's a number of them, but she was bolusing for a blood sugar. And I was looking at her CGM. And I thought, that's not right. I know that's not right. Your blood sugar is not this high. From what she ate, and how much we Bolus. It just didn't make sense to me. I knew her site was working well. So I was like, you just gotta test real quick. And she tested and no kidding like her. I think her CGM had her at 190. And she was 150. So I was like, I knew it. And before we were gonna make another big Bolus. I was like, Don't do that. Again. I'm like, we have to check first. And I have to say I trust that meter pretty implicitly. So pretty great meter. Okay, so but CGM seems good, or do you have more to say on meters? No, I

Jennifer Smith, CDE 13:25
wanted to make a point, though, about what you just brought up in terms of sensing or having a sense of where glucose should be. And as we move into talking about continuous glucose monitors, the accuracy of your blood glucose meter, where you're doing a finger stick and getting a number from, if at any point you need to calibrate that CGM, the accuracy of the blood glucose meter also makes them very big difference in terms of the CGM.

Scott Benner 13:58
I left that out. But that was the last bit of what we did. As soon as that number came up. I was like, go ahead and calibrate the CGM it. Yep. Well said, I know that marketing wise. You know, all the CGM companies like to say like, you know, you don't have to calibrate you don't have to calibrate but you can, if you you know, so why can I if I don't need to sometimes. Right. And you know, and I'm down with that. I know, some people say it'll figure it out and we'll figure it out. But I mean, this is, is four or five days into this thing, her blood sugar. You know, it's she's got her period stuck a little higher using some extra insulin like stuff like that. But I was like, that's not right. And that's, by the way, we're not talking about management right now. But I don't mean that you can figure out what your blood sugar is by wandering out the space. It's a lot of years of experience and knowing what she ate what we Bolus and I think that can't be right. Also how the line moved on the CGM. It just wasn't acting the way I expected it to whichever Which made me think that something was up. Okay, but CGM. Give one to everybody. There. That's my advice. I mean, just everybody, if you've got type one diabetes, given the CGM, I would give type two CGM. I don't know if they're covered by insurance, I think they're incredibly helpful

Jennifer Smith, CDE 15:17
depends on insulin use for type two diabetes. And other factors, obviously, but insulin use the big one. somebody with type two who is on insulin is going to have sort of priority, I guess, in terms of the ability to get one. So but I would 100% mean, if I was going to lobby for something, I would say everybody with diabetes should have a continuous glucose meter. Because that's the only way that you're actually going to see trends based on the variables in your life.

Scott Benner 15:49
Right? I put up an episode today. It's an after dark with this 27 year old girl who said that when she was younger, they told her she was brittle, because her blood sugar's would bounce up and down, up and down. By the way, she's 27. She only had diabetes for 17 years. So it's in the last 20 years. Somebody told her she was brittle. So after I explained to her that that probably isn't really what was happening to her. All I could think was that she had a CGM. Maybe it would have like, struck a chord in or maybe she would have seen it, you know what I mean, instead of just guessing and testing when she wanted to. And by the way, all that led to and this is for the doctors. I mean, obviously timing wise CGM is didn't exist for this person. But not having one being told she was brutal, lead to an eating disorder. It led to manipulating her weight with insulin. It led to this anxiety about food she barely eats now, because of it, you know, all this stuff from just not being able to, like, witness what her blood sugar was doing and make some cogent decisions based on it. Right. So CGM, I mean, listen, Dexcom is a sponsor, but I still I just want to speak honestly here like, you know, I'm not trying to skirt anything. Big difference between g7 and libre three, like, no right

Jennifer Smith, CDE 17:06
now, and that's it's a good point to bring up because I think all the sensors honestly have fair enough similarity and accuracy. What may be the difference person to person is how their body actually interacts with that sensor. Right? I mean, I've said before, I don't know anything about the new Medtronic sensor, the newest one with their seven ATG insulin pump system. I've had people have told me it's a lot better for them compared to previous models. The previous models never worked for me. But Dexcom has always worked very well for me. And prior to going off the market in 2010 ish. I think Abbott used to be called the Navigator. That one was phenomenal. It worked wonderful. I switched to Dexcom it works similar and accuracy now is quite great. The libre as well, I haven't used it in yours. But there are a lot of people that actually prefer that to Dexcom. Right. So there are I think, accuracy. They're similar. But then person to person, you may also have adhesive issues. So don't discard somebody's comments about one system. Because the other systems may work in terms of accuracy, but it may work for other things like adhesives, skin issues under the skin, you know, reactivity and all that kind of stuff.

Scott Benner 18:31
I've seen people who can't wear a certain sensor just doesn't even give them a reasonable reading. And right, who knows, you know, they, I mean, you're not you're never there, but they say I'm hydrated. They say, you know, I did the right things when I put it on and they've tried sometimes for months and eventually abandoned them go to the other company or whatnot, is the sensor from Medtronic called a guardian still did they just keep that name? through it. It's just the newer one, or I wonder if they renamed it.

Jennifer Smith, CDE 18:58
I think it's still the Guardian, I'd actually have to check. But it's it's the newest that works with their seven ATG system. So

Scott Benner 19:06
there's Dexcom libre, Medtronic, there's the Sensi onyx, the implantable one, ever since ever since. Right, right. Yeah. And is that it at the moment?

Jennifer Smith, CDE 19:18
here and I'm trying to think here in the United States. That is

Scott Benner 19:23
it. Yeah. And those are the ones that are that are accurate enough for somebody to dose insulin from them. There's a crap ton of them now that are for like exercise and stuff like that. But yeah, those are not

Jennifer Smith, CDE 19:34
right. Those are not what would be recommended to use for dosing. Oh,

Scott Benner 19:40
Jenny, that was a big word out of you recommended. Okay.

Jennifer Smith, CDE 19:46
Not usually use big words. No, no, I

Scott Benner 19:48
mean it I thought it had a lot of implication when you said it. Maybe I was reading more into it. But no, you're not saying they work but they're not recommended.

Jennifer Smith, CDE 19:55
They're not recommended mainly because they're not you know, There's no indication on them.

Scott Benner 20:02
They haven't gone through the FDA process, right? That they're not going to pair with AI D systems or, you know any of that. Right? And really, you know, for doctors who are listening who might not know, I do think we should dig into it for a second, I'm just gonna let you speak from your own experience. But what is the difference between managing type one diabetes or insulin with diabetes with a CGM or without a CGM? Oh,

Jennifer Smith, CDE 20:28
it's night and day. Really, I mean, as and I think I've said before, in other episodes about the number of times I was doing finger sticks to gather enough information in my day, to make enough decisions about things right, my doctor had written my prescription for 15 test trips a day, just so that insurance would give me enough test strips. And I wanted all of that information at my fingertips are now very happy since about 2005. That I don't have to do that. finger sticks every day. But there's a really good graphic that came out eons ago, when sensors really first sort of started to get a foot in the door. And it gave a graph a 24 hour graph of, I think it was four or six finger sticks on the graph at different times of the day. And then what brought in the visibility of the sensor, kind of what the sensor provides is an overlay behind all of that of the ups and downs from every five minutes of a sensor reading, compared to just the four to six finger sticks values. So I know you've said before, too, you thought you guys were doing really well. When Arden was little right, you'd put her to bed at a certain number. she'd wake up at this number. But then once you had to CGM, you could see that she was going hypo overnight, right? Yeah. And landing in a place that you thought was good. Without the sensor, you didn't know that was happening. I also didn't know where there were problems in the aftermath of my meals, despite doing what is a lot of finger sticks in a day. Yeah,

Scott Benner 22:03
in the time, it took you to say that I with my pen in my hand, and my whiteboard in front of me, wrote down mental health, physical impacts, accuracy, being able to adjust your blood sugar. Well, being able to deal with difficult foods with insulin better being ready to pair with an algorithm. Those are just the reasons that I could think of in two minutes to have a seat salutely. So absolutely. It's not a fancy thing. It's not an extra it's not a nice to have like it really is. In my mind. It should be the first thing like you should get one in the hospital, when you're diagnosed. All these things that you hear people talk about years of diabetes, you know, the things old timers talk about the problems they have, I think many of them are completely alleviated with a with a CGM. Absolutely.

Jennifer Smith, CDE 22:52
And I think in terms of where it should be prescribed in hospital would be great. Because if you've got it in the hospital, you would at least have an education component to what you're seeing, you know, sending somebody home with a prescription newly diagnosed and then they're supposed to slap on this device and make heads and tails out of what they're actually seeing, along with all of these other things that our new variables to pay attention to. That's an overload. It really is. Can it help if they get quick intervention of information after they get it? Yes, and it can make a big difference from the beginning. But it just goes to also demonstrate how important it is that follow up right after diagnosis with all of this stuff being valuable. It's it's just really,

Scott Benner 23:43
even for people who are not like, dialed in super motivated about their diabetes, right? People who are just getting by not paying a ton of attention to it, let them see this number is when I don't feel good. Or this you know, I didn't know I started feeling dizzy at this number, but I still had time to do something about it before I got really low. Like those. I think that showing people those, those little guardrails maybe allows them to retrain their brain over time, to the point where they don't even know they're doing it. You know, until one day someone just says, Oh, I got a beeping it and wherever they ended up setting their, you know their CGM to beat that. I know when I'm 95 Diagonal down, I need like 10 carbs, that's another thing they would know before they would test their blood sugar See 95 And they Oh my god, this is perfect. And then you know, end up low a half an hour later. And that's when the mental part comes in the the instability is like, this is unknowable, and I'm never gonna figure this out. It doesn't make any sense because without that data, it doesn't make sense plus, it helps the doctor you know, it does

Jennifer Smith, CDE 24:47
and the you know, we're talking about general medicine, primary care who may be working with more of the type two population. That also means that you now have to do a bit of homework and understanding and live Learning how to read reports, if you are going to prescribe these, being the primary person, this person with diabetes is coming back to, to relay information, you have to know what you're looking at and how to help them, you know, maybe you've talked to them before about not drinking two glasses of orange juice every single morning, hey, this isn't good for your blood, sugar, et cetera. Well, now that there's information and a view of what that actually does, that has to be brought back into the conversation, if that's the point you were trying to make. And sometimes it's just one point at a time, it's one point per visit,

Scott Benner 25:35
it also helps people see the impacts of certain like foods to that they think are like Staples, like great stuff for them, but maybe they'll like, I don't know, maybe the third time they have mashed potatoes, they'll think I you know, that's not worth my blood sugar be in 250. For the next three hours, I'm gonna have, you know, a smaller amount or not eat this anymore, do something different to it, like all kinds of small things. We're always telling people to do the right thing. And then not giving them the tools to do it with, you know, or even the direction to do it with you just say you should eat better. exercise more, what does what does all that mean? You know, like, it's nice to say, but it's not actionable. Right? My brother is a type two, he got a hold of samples of a G six, get G six samples on time, enough to keep him going for like a month. And the significance was huge, like things that a doctor had been saying to him for years that he thought he understood, it turns out, he didn't understand that at all. And he was telling me, he understood, I get what they're saying, you know, and then he wears the CGM for three, three weeks, you know, a month and boom, he understands it.

Jennifer Smith, CDE 26:39
He's like, Oh, that's what happened. That's what

Scott Benner 26:44
they meant. I didn't get it. So anyway, I mean, again, back to insurance, everyone who can get it should get it. And even people who, you know, can't, Medicare, right covers Dexcom, I know, I'm pretty sure for Dexcom, these things are only going to get more and more popular and covered as time goes on, in my opinion, you should start at, we want you to have these things. Let's see if we can get your insurance to cover it. If not, you know what wouldn't be wrong to say to somebody, if your employer is self pay, maybe you should go talk to them. Because they might say okay to this for you, but you have no idea what you can work out. And as a doctor, I think that's the minimum you should understand to say to somebody, right, that's all that's what I got, there. We missing anything with this stuff, and what you want doctors to know about them. I

Jennifer Smith, CDE 27:36
don't think I you know, I mentioned it before in terms of technology really takes some desire to learn about in order to be able to know what you're recommending to your patients. And so, you know, take some of your time, whether it's a class that you take, that you don't really think is purposeful for you that somebody is going to come in from Dexcom, or somebody is going to come in, you know, from Avid or whatever it might be. And you're like, whatever. But you know what you might grasp something from it. There are a lot of actual online tutorials. So you don't even have to go and sit in a class, though, do an online tutorial, but how does the system work? What type of information does it give, and they're all professional based tutorials. So it might take you 15 or 20 minutes, but you know what, now you can better serve your patients, you're actually more informed. And that goes across the board for the technology. Because not only do we have the continuous glucose monitors and the blood glucose meters, but we also have apps and things that sync with them. So from a clinical standpoint, the ability to get that information from somebody and be able to make sense of it and send them some thoughts back or in a visit, discuss that with them becomes even more for facilitating their well being.

Scott Benner 28:55
There should be some continuing education for you. You know, diabetes, insulin, that the technology I mean, come on, like you have to understand how that works. And I don't know how you ever buy a car, and then had the person show you the car, but they didn't know how it works. And all you can do is sit there and think you work here. Shouldn't you know this? Did you know this? Yeah. What do you mean, you don't know what this switch does? You work here, you only sell for cars. You don't know what the switch is? That feeling that immediately removes your ability to trust the person you're talking to? Yes. Right. And, and what Jenny's saying about educating yourself about how these systems work, so you can speak about them is it's not just about that. It's not just about helping the person feel better and not going like Oh, they'll figure it out. You know, it's about them trusting you moving forward. Yes, it really is. You shoot yourself in the foot and it's hard to get back from it. I've had that experience where a physician has said something so bad bonkers, that I was like, Oh, now I know not to listen to them anymore, which isn't fair either. You don't mean like, but it is how it makes you feel. And

Jennifer Smith, CDE 30:08
in today's world of, again, technology, technology being an online driven review system, honestly, shooting yourself in the foot is kind of a bottom of the barrel way of saying it. There's so much feedback that's given in online forums and everything in all different types of professions that you can make one little kind of misstep, and you're getting a bad review. And then it's bad review after nobody coming to you after somebody commenting. It's that it's sort of just snowball.

Scott Benner 30:44
Yeah, you're in business to might be important for people to think that you're a value to them. Yeah. Especially in a world where by the way, people now can go to walk in clinics and get prescriptions if they needed. Even some people have, through their insurance through their employers have access to physicians now. Like, Yeah, everybody's not just going to come to you because you're there. But let's go through real quickly, Jenny, what everybody said, Oh, yes, for CGM, SB gems. My doctor didn't even tell me to watch even a YouTube video. He just prescribed it and left me on my own. So that's such a crazy idea. Here. Take this it does this good luck.

Jennifer Smith, CDE 31:22
Right. Yeah, I know. I mean, when I and I don't know what you guys had when you first got the one because you only started with Dexcom. You never used anything else. Right? Correct. Yeah. So I'm assuming that you got some education given that Arden was a child? Yes.

Scott Benner 31:40
But it felt like they were building the plane as they were flying it because it was so early on. You know, it's like you were learning together in the office with somebody which I appreciated. They, they were like, look, it's new. We don't really know. Right, which I thought that was great. Because we'd also had an experience in the past, where we were told not to use an omni pod. Because I forget, what did they tell us? Or they said Your daughter's to lean for that. And oh, and I was like, I don't know what that means. But we're getting this anyway. And so we got it. I mean, I went with Omni pod originally, because of the just the generally the tubeless nature of it seemed, for a number of reasons like the way to go. It took two years for the endocrinologist to pull me aside one day and say, We want you to know that because of RT and success on Omni pod. We're now writing prescriptions for Omni pod to younger kids that we weren't before. And I said, Why did you tell me all those years ago like not to use it, and in a very quiet tone, the person said to me, it was newer, and we weren't comfortable with it. So we didn't want you using a device we didn't understand. So it had nothing to do with how lean Arden was it had to do with they didn't understand it. They didn't want to take the time to learn it. And so they weren't going to they were going to just push me towards another device. And

Jennifer Smith, CDE 32:55
or they had experience with what was already on the market. And in comparison, which wasn't a fair comparison. They were able to say she may be too lean, she may not do well with this or whatever. And again, their comfort level and I find this not as much now but years ago honestly, many offices had a comfort level weren't talking just about insulin pumps with one particular pump. Yeah, that's what they maneuvered everybody toward this pump. Because we know this pump Oh

Scott Benner 33:29
yeah, that was a whole day of somebody saying to me animus ping animus ping, which by the way doesn't exist anymore?

Unknown Speaker 33:34
No, it wasn't good pump.

Scott Benner 33:35
I was on it. Everyone I've ever spoken to says they love it. Absolutely. But Arden is also used Omnipod for she started on a pump when she was four. She's 915 artists been using Omnipod for 15 years. So I think we did okay, but that point of understanding what you're talking about, so that you can actually talk about this person says they should know that CGM 's are extremely important at diagnosis, not knowing exactly how insulin affects you. And all of the other factors that go into managing sugars are very helpful in determining all of your personal factors. Yes. And I wrote a note after that, they just said, Look, patients shouldn't even have to ask for CGM. You shouldn't make a person. They don't know anything about diabetes. You don't I mean, now you're asking them to choose what they're supposed to be. You know, using they don't have any idea this person's like, You got to tell me, you know, she goes on to talk about, about catching loads how important it was, especially for their child. And then this other person says, I'm, uh, I was diagnosed at 29 I needed this the same for the same reasons, right? And then oh, this is interesting. This person had a libre back when back when they were scan only you had to hold the device up to the libre to get that number. And the physician told them that they were scanning it too frequently. You have you ever heard somebody say don't look at it so often.

Jennifer Smith, CDE 34:51
Yes. Yeah. From a mental health standpoint. I think that there are there are some people obviously who they you Use it. Not quite to their health. But as almost an obsessive, I have to check, I have to check. I have to know where I am. Oh, it's going down. Oh, it's going up. And there's a difference in that versus I need to see where I am because I have this planned. And I need to see what my action is right now. For the coming, you know, plan? Yeah,

Scott Benner 35:21
the best way I've ever found to make people comfortable there is to tell them, Look, let's set more reasonable alarms. And then don't look. Unless the alarm sounding. That's it, but we can't make your high alarm 250. Like, you know, we can't do that,

Jennifer Smith, CDE 35:35
right? Because then you're gonna miss the mark. And that's going to make you hyper vigilant, again,

Scott Benner 35:39
not gonna be the point. And for a doctor who says, Oh, if I don't make it to 50, the thing will be beeping all the time, I would say to you, you might want to go listen to the Pro Tip series, because it doesn't need to be beeping all the time. It doesn't need to be going high all the time. There's simple ways about using insulin that will help you right, so Okay, agreed. All right. Thank you very much. Yes, of course. Let's do this. Let's move into pumping. But if it doesn't fit here, I'll split it up into two different episodes. That way I have it here. But I can maybe put in its own if it needs to be is that okay? That's fine. I have about 15 minutes where you're going to go through the people's questions. And if we have to come back later and finish up we will. So cool. I wish they would have explained the difference in detail between t slim and Omni pod. Oh, isn't this interesting? In the new device world. This person doesn't even mention Medtronic. They were extremely vague and our toddler is on Omni pod. And so you made this point already in the CGM episode, but you need to understand what these things do. This is Omni pod, this is how it works. Here's why it might be better for you or you are here's what I'm even seeing from people who are using it. This is what the T Slim is. This is what control IQ is like. Do you think that it's possible that doctors just like tube, no tube, you think they're like, it's that simple.

Jennifer Smith, CDE 36:55
Could be practice to practice, quite honestly, it could be that simple. It could also be, these are the pumps, they all deliver insulin. And I think they're trying to save people from some of the very little tidbits of information that make you different. But I also think that that's really important. From an individual need perspective, really good pediatric practices, I know often will have like pump exploration days, where they'll have you know, all of the different pump options come. And you can walk around almost like a fair, right, you can explore talk to the representative, you can feel it, pick it up push buttons, get kind of an idea of what it would look like feel like you know, you can even like clip it on and see what it would be like to kind of have it dangling on your pants or whatever. But those are all really important things when you as a clinician are recommending something, don't recommend based on your preference. That's the bottom line, you have to really consider what does the person need to know if they are a swimmer? And a competitive swimmer? Well, you might tell them a little bit more about why one may be more optimal than another. But it's still up to them to make the decision.

Scott Benner 38:16
I think they should blend information to like I mean, the person who comes out to explain the device to you is the salesperson, right? So like, you know, okay, here's these are the highlights of the pump, that's great. But also go do some research on your own, and talk to users and get their feedback. And go online and hear what people are saying there. And then blend that together. When you're talking about don't just like you're not a salesman for T slim or for Omnipod you're you know, you can't just go by what the pamphlet says the pamphlets, its marketing, right? So right. I'm not saying that one of them is hiding something or something like that. But it's not going to give you a full understanding of it by just reading the brochure. I mean, that would be like making a decision based on my ad. Like if you hear an ad for something, these are the highlights. You should now go figure out the rest of it. Like you know, don't make a decision based on this. I think that's incredibly important. And it goes back to that thing you said during the CGM. It's like you have to educate yourself on how these things work. And especially with the algorithms now. It's not just the I mean, honestly, before the algorithms pumps were, they were just basic,

Jennifer Smith, CDE 39:23
basic delivery that makes it easier than taking

Scott Benner 39:27
injections. The idea behind going from MDI to pumping is that with pumping, you gain control over your Basal insulin. You know, you could set up extended boluses squarewave Bolus, things like that. You can vary basil Yeah, right. You know, you could temporary basil your insulin completely off if you wanted to, if you were in a situation these are things you can't do with MDI. But it wasn't some like insane leap. Like it was just here's the extra things you to me. It's amazing and it's incredibly helpful. But now you're gonna go from those Is to these algorithms, they all are aiming for the same thing, but doing those things differently. And you should know the differences. It just makes sense to me. Because when I stop and think about, where are doctors going to struggle in the coming years with algorithms? I think of it's like little things like fat and protein becomes really important. Right? Like, you know, because a doctor is gonna, like, say, oh, no, the thing does it. But it doesn't. It doesn't know, the thing doesn't know that there's a bunch of fat and the carbs that you told him about at one o'clock and 90 minutes later, your blood sugar's gonna start going up. And then people are like, Well, what should I do? Should I wait for the thing to do it? The thing is gonna take, I mean, honestly, hours to make another decision. And to

Jennifer Smith, CDE 40:44
clarify, will the thing do it? It'll do it? Well, yeah. But as you just said, it'll take hours of time, because all the systems are based on with their algorithm are based on an sort of an extended time of action of our rapid acting influence, which are not rapid. It's a horrible word, whoever came up with that word for today's insulin, yes, it's faster than what I used originally, but it's not rapid, as fast

Scott Benner 41:11
as the word makes it sounds correct. If the algorithm is thinking on a, I don't know, on a six hour timeframe, then your blood sugar shoots up an hour after you eat. And five hours later, the algorithms gonna be like, Oh, we should probably be more aggressive with this, you know, that happens to you at two meals, well, then this, I don't know what good the algorithm is to you at that point, like, you know, if your blood sugar in the 200. Now, if it's holding your blood sugar at 200, and eventually gets it back down, I see the doctors argument, this is way better than these people were doing before. And it is yeah, and I understand that, but a tiny bit of a tiny bit of understanding how insulin works. And a tiny bit of understanding how the algorithm works could lead you to tell them, here's a secondary Bolus maybe we could make that would help us, which the company isn't going to tell you about, because they're not legally allowed. That's not how that works. Like the FDA doesn't allow insulin pump manufacturers to direct you about how to use insulin. That's just the thing that they're not allowed to do. What you're

Jennifer Smith, CDE 42:09
getting into is the idea that, and we've been talking about all along is that as a clinician, you have to educate yourself. Right? There are so many things that you learn as somebody with diabetes, because of the huge benefit of continuous glucose monitors. And when you fold that continuous information of what your glucose is doing, into a system that can now dose insulin, along with that, you have to know how to look at the data to help somebody best make decisions for their life. I mean, we started MDI, it is what it is you could Bolus 16 times a day and sort of mimic what you think you need to do. Sure, go ahead, but it's not going to have precision, conventional pumping. Next line, you've got some smart features, but who's the driver, the person, the person drives the the use of those precision parts of that technology. And then algorithms bring it even further. But not far enough. Our algorithms are not AI, right? They're not learning. They're not saying Oh, every Friday night pizza is coming in, you got to be ready for this. It's not there yet. So the smart driver is still the human. And the human needs the right information in order to be able to navigate blood sugars in a target range that's going to keep them healthy, long term,

Scott Benner 43:32
we made a significant adjustment last night to get Arden's blood sugar down. We didn't wait for the algorithm to do it. We were like, No, I know what to do here like to get this down and did not cause a low or anything like that afterwards. I think maybe I'm just as you were talking, I thought maybe doctors should do ride alongs with people who have type one, right? Because you always hear my endo is terrific. They have type one diabetes, like people say that all the time. Like I hate to say it, but my endo is better because they have type one my nurse practitioner knows, I mean, listen, you have type one, right, like so. I do. Wonder if that's not doable. I wonder if doctors couldn't just like, live a day with a patient every once in a while. Just I mean, honestly, that's how you if you lived here for a week, you wouldn't, you'd know everything you needed to know.

Jennifer Smith, CDE 44:17
But I wouldn't even say to go there. If you are a doctor who is prescribing these, an easier ride along really would be take the product, put it on your body and use it as if you were somebody with diabetes as if you were following the directions that you're giving people to walk out of your office with. Right? Yeah, you know, look up your carbs. Check what is happening before you go for a run, look at your data and know it's not going to reflect shifts like somebody with diabetes has, but it'll get you in the mindset of all of the considerations along with using this piece of technology that is delivering insulin, which is not a silly medication. Even

Scott Benner 45:05
like, maybe this is the right along idea. Maybe it's Can't you just follow one of your patients for a week? Like, can you get somebody like get there? They say, Look, I'm trying to learn more about all this, would you help me? I'm gonna follow your CGM. I know that sounds crazy. But for a few days, just text me, I just ate this, it was this many carbs like that, like, here's how much insulin I put it, it wouldn't take you long to like, go, okay, I get this. And now you've had this, you take this thing you take time, one time. And now you can take what you learned and give it to everybody. It's just none of you are going to do that. I know when I said let me just tell you right now, that's the best idea I've ever heard. So if you're a doctor trying to help people with type one, following a type one, knowing what they when they ate it, and how much insulin they got, then watching their CGM, you would understand in no time at all what was happening. And you'd be able to not only just help that person, but you'd be able to transfer that knowledge on to other people. So anyway, you would I'm 100%. Right about that. I'm not I'm not backing down off of that, quickly, if this person says hey, if you're having issues with like a glucose monitor, or a pump or something, it would be lovely if the doctor would help us when we need help with our insurance, oh, writing letters of medical necessity, things like that, you know, don't just give people a script and then go, Oh, it didn't work out. That's tough. There are times they need you to step up. I would also say that giving somebody an arbitrary amount of time before they're allowed to have a device, I don't think makes a ton of sense,

Jennifer Smith, CDE 46:37
is ridiculous. It needs to be individualized. Yes. Yeah, I

Scott Benner 46:40
mean, I get that my assumption is, is that they've had this experience with insurance companies. And they know that the insurance companies deny in the beginning, but that's also you can get around that, and you know it. So you know, people are begging for insulin pumps, just telling them Oh, it has to be six months, or the practice has a rule. You have to be on MDI for a year, correct. You know, I mean, a year Jesus, you can't figure it out, you know,

Jennifer Smith, CDE 47:04
yeah, I was gonna say that, that's often what it actually boils down to is a protocol that's within the practice, or within the department or whatever, that says, you have to meet all of these pieces. And typically, it takes six months. So we're gonna say, within about six months, then we can start working towards getting you a pump. Yeah, but again, that everybody is so different in their life, and has so many different variables and needs, that you really have to throw those protocols out. And you have to say, well, you know what, this person definitely needs a weight, there is a lot going on here, this person could definitely have it within the next month, because they need it and they, they get it, they're at a higher level of learning, or they've reached certain, you know, points of education that are already important. So individualize. Okay,

Scott Benner 47:58
thank you, Jenny. I'm gonna leave a voice note here for both of us. So when we come back and re record again, we're going to talk about why insulin pumps are so important. What they do for people, they're not just replacements for injections, and what value they'd get out of pumping and what value they'd get out of an algorithm. And we're gonna actually like continue this conversation next time you're back. Fantastic. Thank you so much, of course.

A huge thanks to Omni pod, not just my longest sponsor, but my first one Omni pod.com/juice box. If you love the podcast, and you love tubeless insulin pumps, this link is for you. Omni pod.com/juice box. A huge thanks to touched by type one for sponsoring this episode of The Juicebox Podcast. Check them out on their website touched by type one.org or on Facebook and Instagram. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome. Type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community check out Juicebox Podcast type one diabetes on Facebook. To continue this conversation jump now to Episode 1126. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

#1124 Fifty Fifty Custody

Ethan's ex told him about the podcast and they are both active in the management of their type 1 daughter.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:00
Hello friends, welcome to episode 1124 of the Juicebox Podcast.

Ethan and his ex have a 14 year old daughter who was diagnosed with type one diabetes when she was 11. Today I'll be speaking with Ethan to learn more about his daughter who's very athletic plays volleyball and spends her time 5050 Between her mom and dad's house. Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. Don't forget to save 40% off of your entire order at cozy earth.com. All you have to do is use the offer code juice box at checkout that's juice box at checkout to save 40% at cosy earth.com. When you place your first order for ag one with my link, you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juice box. If you're not already subscribed or following in your favorite audio app, please take the time now to do that it really helps the show and get those automatic downloads set up so you never miss an episode

this episode of The Juicebox Podcast is sponsored by the Dexcom G seven made for all types of diabetes Dexcom G seven can be used to manage type one, type two and gestational diabetes, you're going to see the speed, direction and number of your blood sugar right on your receiver or smartphone device. dexcom.com/juicebox This show is sponsored today by the glucagon that my daughter carries. G voc hypo Penn Find out more at G voc glucagon.com. Forward slash juicebox.

Ethan 2:09
I'm Ethan. I am a proud parent of a type one athletic daughter who's 14 Getting ready to start high school. Again, very athletic. She's a great volleyball player. And this is our we're embarking on our third year of this new lifestyle change of diabetes

Scott Benner 2:34
event. She was diagnosed when she was 11.

Ethan 2:39
Yeah, she went into DKA in September 2020 2020.

Scott Benner 2:42
Wow. Okay, we'll talk about that in a minute. But first, tell people what you said before we started recording

Ethan 2:52
that this was a fairly year ago I've ever seen something on Facebook posting. I think there's like three questions more like along the lines of, you know, being a parent of, but I don't remember the gist of it, honestly. So I tried to look it up. I'm like, Okay, well, let's just do this. This is a diabetic podcast. So let's go for it. But yeah, I don't really remember the

Scott Benner 3:15
context of it. The schedule is so far out in the future that so here's what ends up happening is I start getting pressured around this time of year, like mid mid July, August. And people are like, I want to be on the show and be on the show. I'm like alright, well, my schedule is full like right now. Ethan, if you signed up to be on the show today, I think I don't have an opening until third week of January. February is almost full already. So that's the situation we find ourselves in. And so because people are trying to jump on the schedule, because it fills so quickly, their length of time to be on the show like just the record is sometimes it's sometimes it's a year after you sign up and then six months after that for your episode. It takes 18 months to hear your voice on the podcast basically.

Ethan 4:06
Oh wow. Really? Okay, so that's okay, I was gonna I was actually going to send it to the end like when when would the expected to have this run but

Scott Benner 4:13
your daughter should be able to listen to it at her wedding? I think for sure. So and I've tried a couple of things to pare it back like I've stopped like I'm not gonna take any more like you know recording for a while and then I just the emails keep coming. I want to talk about this. Oh my god that's a great idea. We should we should talk about I'm gonna have to start putting out episodes twice a day. Yeah, to keep up with but anyway, I appreciate you keeping the appointment even though you were half not sure what it was about anymore. Anyway,

Ethan 4:46
I just remember seeing it and it was a responded to you. It was a schedule. And yeah, you know, a year later here we are at the state was a fast year.

Scott Benner 4:58
It helps you realize that life moves by too quickly. Yeah, exactly. Alright, so your daughter is diagnosed at 11 years old. 2020 NDK. Now, my question is, did you see it coming? Or did it completely surprise you?

Ethan 5:12
It's a great question. Actually, around this time 2020 She started to, to drop some weight. And but you know, it's one of those things that we, you know, her mom and I kind of chalked it up as she's going through a growing spurt, type thing, you know, and, but keeping an eye on it. And what what happened was the night before she actually went into GK, or about a week or so, but definitely the night before, I started noticing that she was drinking a lot of water. And the afternoon before she went in, this was this was a Monday evening. We went to go grab something to eat. And as we're waiting for food, I had ran over to the to the grocery store next door, and she asked me, she's like, what's going on? Like, you know, I just stocked up on water, you're drinking like a fish, you know? And she got home he ate she actually ate more than she ate me, which, you know, sometimes that can be easily done, but not really. And I was like, wow, you know, and I but again, I grew up watching her, like, dropped this way again, thinking because she didn't have like this, this crazy growth spurt in there too, as well. And then, that night, when she was going to bed, I had actually told my mother, I had said, you know, I think she's diabetic. She's like, when I go, she's drinking that this water. I'm just like, there's just something that's not, I'm kind of getting a strange sense that I think I think she needs to be checked. And then that next morning, I was actually I work from home and I was I was working in, and I wouldn't check on her. Because she was she was just starting off because this was COVID Still, there's still during a pandemic. So she was homeschool. So she wouldn't get on live for another few hours, like at least know that three hours by time I was up. So so there was some gap. And luckily, you know, grandma was available and had went to go, she was actually leaving for work. But something held her around that day, that morning and went in her room and had seen that she actually had gotten sick and then that's where I was just like I just kicked into, I have to take her in, you know, not you know to chalking it up with a stomach bug or anything like that. I'm like she has to go in. So at that point, when she got to the ER which was during the pandemic was kind of difficult to get her in as well because it was like you know, is it COVID Like that this is I would COVID was so far away from my mind at that point. I was and I don't have any experience with diabetes but it was just that instinct there.

Scott Benner 8:04
What made you think diabetes though the day or two before

Ethan 8:08
don't her water intake

Scott Benner 8:09
but that that told you something so you knew a little bit about it?

Ethan 8:13
That's pretty much yeah, that's kind of all like exposure wise, but the water intake I thought was was our water intake had like triple like it was the she drinks water we know but not the way how she was okay,

Scott Benner 8:29
all right, so Okay, great. So you snap into action you take her to the hospital I imagine and and COVID makes it a little weird but you get in what are the what do you learn about our blood sugar after she's admitted

Ethan 8:41
after she was admitted because we had to kind of keep swapping in and out I wasn't in there when her her first diagnosis of her blood sugar's I can't remember exactly the range and it's remember getting a sheet because she was actually the she had to get transferred to a children's hospital. And which was about an hour away. So we were waiting for transport and that's where I got the kids. They're only leaving one parent at a time. I don't want my came out and said she's Yeah, they they. They diagnosed her as being a diabetic.

Scott Benner 9:11
Are you guys together? No. One co parent. Okay. So she was with you? When when when you figured it out? Do you have like time later to go back? Like because of the co parenting situation? Was your ex thinking? Um, if she was your ex I'm sorry. Was she was she thinking the same thing? Did she notice stuff going on? Were you communicating it? What was that process like prior to being at the hospital? We

Ethan 9:39
both knew there was the the weight loss and the eating more. I had not yet voiced my concern. Like I said it was at night the night before it's we're like it triggered and we have to get around so I hadn't even made that call yet. This was like, while I was really just thinking this lesson 12 HOURS. Here we go, I think. Yeah, yeah. But leading up to that, you know, she had like she's, you know, like I said earlier, we were kind of chalking it up as to like, she's going through, you know, her gross for being a kid. Yeah.

Scott Benner 10:12
You just think she's stretching out right. Yeah. Losing losing weight because she's getting taller. Yeah, I think that's what everybody thinks. So, okay, so she was in DKA. So did they keep her for a number of days?

Ethan 10:23
Yes, she was in. Pick you for four days.

Scott Benner 10:29
That seems about right. Now, when she comes home, she go to her mom's she goes to you.

Ethan 10:36
When she got discharged, she came. We have a 5050 split. When she got discharged, she came home to me for for the for that for our scheduled visit visitation.

Scott Benner 10:44
That's what I was gonna say like, did it happen to fall on your day? Is that how it worked out?

Ethan 10:48
Yeah. If you happen to her discharge happened to fall during my time? Yes. So

Scott Benner 10:52
then how do you guys learn about this? You learn about it. I don't know what your relationships like I guess. But are you in the same room learning about this? Are you gathering information and sharing it back and forth with each other? How

Ethan 11:05
does that we were actually in we were both there spending the night? I think there's only one night to where we actually were not in there together. But we're both learning it they had us both on the same schedule. No. Crash Course of the same Yeah,

Scott Benner 11:20
that's good. It really is. Because I think when the the information gets disseminated to one person, I don't know. It's tough, right? Like you don't know what, you don't always know what to share. And, you know, there's a lot of questions. And if you're not the same house, when the questions arise, it might be difficult. So, it

Ethan 11:35
we still do that to this day through, you know, like I said, three years into this, if there's any questions or any like, you know, because this is this is that thing, this is that, unfortunately, the thing with diabetes, it's every day every second. So there is the, you know, the reassurance that we do co parenting that we give each other about, you know, you don't can't feel bad if, or don't be too hard on yourself, if she has a pattern to where she is kind of high or she's low. It just, it is kind of winging it, we do have a good exchange communication of okay, this is her what her pattern was for, like the last five days that she was over there, or here. This is what I'm experiencing. Either she's resistant or She's sensitive, just kind of watch out type thing. Yeah. And then you know, it's that first night, like for last night because that was her first night home for five days. And you kind of have to get used to what's been going on for the for the first couple days. But again, it's nothing that static because it's it's

Scott Benner 12:37
changes constantly. It

Ethan 12:38
really exactly right. I mean

Scott Benner 12:41
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Ethan 15:17
It doesn't matter what she's eating or whatever it just, it's just, you just kind of had to adapt to it. You know, just it was it

Scott Benner 15:25
was your co parenting situation harmonious before the diagnosis?

Ethan 15:31
We were getting there. Yes, yeah.

Scott Benner 15:32
Okay. Has it gotten? I don't care how it was. My question is, does it has it gotten better? Or worse than the diagnosis?

Ethan 15:39
It's gotten better, actually. Because I think we had to kind of put everything aside and realize, you

Scott Benner 15:44
know, that's our team. Good for you. Is seriously and to your, you know, to your I don't know what to call our former partner.

Ethan 15:53
Sheila, she listened. So I'm pretty sure I'll tell him when this one comes out. Yeah, she's actually the one who told me about you. Smosh.

Scott Benner 15:59
That's great. Well, I just I'm really impressed with how you're handling it. Is this what I wanted to say? But I wasn't sure if you were married or not. So I don't know if I'm saying x or if I'm say, anyway, doesn't matter to me. But I think it's been handled really well. It's impressive that you move forward so well. And that you've that you've not just kept it harmonious, but made it better for your daughter. It's really wonderful. Do you guys have other kids together? No. Okay, so this is the one now do we have we figured out? Are there autoimmune issues on anybody's family sides?

Ethan 16:31
Um, not? On my it's more thinking on hers, but it's not. I think it's a second would be my daughter's second cousin. So I don't think who's was also type one. Okay. But I think that from based on if I remember correctly from a doctor is like, that's not a an actual connection. Because

Scott Benner 16:50
the doctor can say whatever he wants, it seems like I can actually

Ethan 16:54
sound something like if it was not on the maternal side, I can't remember. But it was like, maybe there's two different too far of a distance between the second because yeah, it would be your second cousin.

Scott Benner 17:05
Does your daughter have any other autoimmune issues?

Ethan 17:07
Not that I'm aware of right now? No.

Scott Benner 17:09
Are you looking for something to knock on effect? You're like, Wait

Ethan 17:12
a minute. Yeah, exactly. Yeah.

Scott Benner 17:15
No, why? Okay, that's terrific. So what was her management? Like out of the hospital? I'm assuming like MDI, would they give her pins or needles?

Ethan 17:27
That's a good question. We actually, were I kind of talked about this all the time about how good of a program that we see, you know, some people on Facebook or other groups that are who are trying to adjust and adapt so they can kind of say, how I kind of chalk it up as they tell us old school to where it was John. It was pins. Yeah, she was on pins. And then she didn't get her her CGM, or go to go to the pod until like six months, six plus months after.

Scott Benner 18:03
Okay, six months was the CGM first. The CGM was ferocious. Okay. And then she got a pump soon after.

Ethan 18:11
Clearly close. Yeah, they're probably pretty close on top of each other. Yeah.

Scott Benner 18:16
What leads you to get those devices? Is that your doctor saying you should do this? Or is it you checking out? You know what other people are doing?

Ethan 18:25
It was more of a research and just trying to be really kind of being really realistic of having Hey, this there is this tool, you have to understand that this technology is not going to always be 100%. But it does give you some peace of mind, especially with her going back to school. And being away. How are we going to have visibility on and helping her helping her assist remotely? Yeah, and that was that was a decision to go with the pod and CGM.

Scott Benner 18:53
It's a great idea, honestly. Okay, so she's going into high school now. You said she's playing sports? How is she making out during activity? Yeah,

Ethan 19:01
she was she was playing volleyball. About a year or so or two before? Maybe two before she like before diagnosis. And she, you know, she hasn't let it stopped or stop or at all? Yeah, she, I mean, this kid is, is constantly working out trying to improve her game. She just stayed, doesn't she? It's hard to get her off the court. But managing it she does really good. There is a like I said that's the other thing was having the ability to see with the CGM and her with her her pump to see what's going on. But knowing, okay, you're going to go from, you know, one clinic or from 290 minute to two hour practice, to another practice. And I mean when I say that when I say another word, sometimes there's probably 90 minutes maybe in between. Yeah, so it's like trying to kind of carve But begin where are you at? And, you know, I get it too. I was actually you know what you were, you're not real pilot 100, you know, but you kind of you have to kind of refuel that. So that's still a learning curve, but it's gotten better, you know. But then also during games and stuff, even though with the technology, sometimes she loses connectivity in because she plays a club ball. And with all the Bluetooth interference, it's not pleasant sometimes because you just have to really kind of go off of her feelings or how she's looking. Because you won't see the you won't stay connected all the time. What pump is she using? She's using the

Scott Benner 20:41
Omnipod dash dash, okay, no algorithm. No, no. Okay. So, alright, so you're using the connection just to see what her blood sugar is? And do you find that volleyball is like an adrenaline thing? Is her blood sugar tried to get high? Or does the activity bring it down?

Ethan 20:59
That's a great question. The beginning was like when I said in the beginning, like, I would say the first six, seven months after like, when she had her first season. It was anything was was bringing her blood sugar's out. I mean, just like, Okay, you're going high. Let's go for a walk. You know, it was just to go for a brisk walk for 10 or 15 minutes it was bringing her down. And I would say now for like the last two years, it's been the complete opposite with what I think when she hit her. When her hormones her teenage hormones started coming in and everything playing a factor. It actually became more of a resistance. She doesn't go down as easily when she's in, in very heavy sports.

Scott Benner 21:46
Okay, yeah, no, I was gonna say she's right at the age where I was assuming that that was happening. So you're gonna see it, it changes pretty significantly. Yeah,

Ethan 21:56
she's not dropping like she she you know, coming out. It's not, you know, that's not the the out anymore, you know of, okay, you're kind of high. Let's go ahead and do something and get you moving. Or no, the only time that that seems to work with activity is really kind of like throwing her in a pool.

Scott Benner 22:11
Swimming. That's it. Yeah. Makes her job. Yeah, that's me. That's a lot of anaerobic activity. The dash is

Ethan 22:20
really just kind of just sitting in there. Oh, really?

Scott Benner 22:22
Oh, she's just chilling out and relaxing. Yeah, just

Ethan 22:25
chilling out and relaxing. She can start to drop. That's interesting.

Scott Benner 22:29
Okay, so let's see. How do you set your your Can I quit? What should I call your ex? You're sure you're like, what?

Ethan 22:41
How to deal with it later, right?

Scott Benner 22:44
There's nothing to do I just want to use the right phrasing. I don't know the lady the like the person. I don't know. How did her mom find the podcast? Did she tell you about

Ethan 22:54
Facebook? I honestly think he just on social media, possibly Facebook. And

Scott Benner 22:59
I'm assuming it was valuable enough to her that then she told you about it. Correct? Yeah. Do you listen?

Ethan 23:05
I've listened to a few. I'm not an avid listener, but I have listened to a few of them. Don't ask me which ones right now. Because I have to be able to tell you

Scott Benner 23:14
they were they more management based or conversational? They were more conversational if I remember correctly. Interesting. Okay. Is her mom doing stuff with her management that she got from the podcast? And then you kind of go along with it and it's working. So you're like, that's fine.

Ethan 23:32
I know it was I believe there was one podcast where it was the how was it a bit about like, not being afraid of of Ebola seen you know not being afraid of insulin?

Scott Benner 23:47
Was that is that something you were struggling with?

Ethan 23:51
The lifestyle i mean i There are some times to where I can be a little hesitant on giving her and that's one thing to that's good about the that I personally like about the the Omni is it's you know I can just increase her when she needs to be increased or you know I'm we're not afraid to change set any of her Yeah, any of the settings her Basal she knew her Basal needs to be increased or you okay, you're going higher or even suspending or I mean, that's one thing you know, especially with her being active, depends on what range she is. Maybe she needs to be suspended for for duration or okay. Yeah, she suspended that case. She's going back up. Okay, let's turn it back on. So yeah, there's that definitely that flexibility

Scott Benner 24:32
is incumbent upon me Ethan to tell you that if you want to suspend Basal insulin, you should do a Temp Basal decrease of 100%. Because if you suspend insulin, it won't come back on. So you don't want to put yourself in a situation where you turn off basil forget to turn it back on. So you can do a Temp Basal and then set it for an amount of time and then at the end of the time it pops back.

Ethan 24:55
Absolutely correct. And that's actually what we kind of just use that jargon is suspended In short, it is it is a set Temp Basal that we're actually doing.

Scott Benner 25:05
I'm just, you know, cuz we're making a podcast and everything, covering the bases. Yeah. Don't suspend your Basal people like, cuz it won't come back on, you have to do tasks, right? Yeah. All right. So you like the flexibility of the insulin pump? Would you call yourself? If I had to say one of you? Was the main caregiver of diabetes? Would it be you or her mom?

Ethan 25:25
I think we're actually pretty equal. Okay.

Scott Benner 25:29
You think you get you guys do you have basically the same style of management, there

Ethan 25:35
is some difference to where, like, I think there's, there's, there's a slight difference on how we address winds went to over I wouldn't say over Bolus, but to give me an extra Bolus or give me extra insulin. Like I said, I more to be a little timid, of, and concern with the lows. Not in saying that she's not but a little bit more of a, I would say a little more aggressive than I am when it comes to that. So there's that slight difference there. But like I said, either, but we are completely equal when it comes to making the judgments that our daughter needs at that time.

Scott Benner 26:15
I have to tell you, this is very interesting. Because I've I've recorded with people who are, you know, separated divorced, whatever, co parent kids, and you listening to you talk, you're, you're it feels like you're like walking through like a field of landmines. And there are women who come on, and I'm like, so you know, does your axe and they're like, no, he's an idiot. And I'm like, Okay. I know I'm generalizing. But it just feels like, more often the ladies are willing to be like, you know, direct and guys are always like, no, she's lovely. Everything's fine. Like, I'm not trying to say she would let a low blood sugar. I certainly didn't mean that's when you made me laugh with the like, no, no, she doesn't do that. Like you corrected yourself. But I understood what you meant, like nobody's letting your kid be low. But but your your, your ex is more aggressive. And you're more timid about it. Now, is that a personality thing? Or is that something that you've had an experience with? With insulin? It's made you feel that way?

Ethan 27:16
Well, that's a good question, because I've experienced her getting sick twice. afterwards. And what Well, there was one that was really bad to where she came home from school. She had this like, grayish look on her when I picked her up from school and she said she was feeling fine, but I can again, just when those instinct things like something was kind of off and later that that evening, the he had an exorcism, Exorcist, sewed the delivery like, and so yeah, I mean projectile. But no, she's not gonna be having saying that. But she did. And it was having to bring her back up. Yeah, because she was low and okay. And she's not wanting to eat. So I'm on with her Endo. Like, and right before she did that I was I taught her and because I'm like, How do I deal with because she's not like, I know, I had to bring her up. And I did check for ketones and she had moderate ketones at the time. And I'm like, Okay, I ketones me and she needs insulin. She doesn't want to eat how do I get carbs in her? You know, she's not wanting any juice. She's just been and I get it? She was filming? Well, yeah. So her endo had told me all you guys gotta gotta keep bringing it up. And I'm actually I was I was on the phone with her. Grandma came out and said she's getting because I was I think the inner light said, If she starts to vomit, and call her back and just watch it because that can be me hurt. Her ketones gotten large. And as I was hanging up, that's where I got the she's getting sick. And and that was one that was really when I say she was low. She was in like the 50s If I remember and trying to bring that up, and then knowing I have to give her insulin.

Scott Benner 29:01
So she was sick. She was like what we call real people sick. It wasn't like the she had an illness of some sort. And then she, by the way, when you said we had an exorcism, I was like, how are these people like doing exorcisms in their house? Like what do I have to ask about next? And then you were like exorcist and I was like, oh, okay, I know what he's talking about. It's all about bombing. So, but But are you guys, but you had this experience? And it was scary enough to that it's stuck. Yeah. Yeah. But she's not sick all the time. So what stops you from being more aggressive on days when illness isn't an issue?

Ethan 29:37
Because of the unknown of how fast you can possibly drop? Is

Scott Benner 29:41
that happened frequently? Or was it just overtime?

Ethan 29:44
It's just me. That's a personality thing.

Scott Benner 29:48
That I'm gonna have to leave you to what are we doing here? I'm just kidding.

Ethan 29:53
That's just me and I you know, that's one of those things like I last night, I mean, I think it is You might sleep last night because she was she had what I would call a stubborn eye and not you know, being aggressive with giving him I mean, I was increasing her. So you know, as increased nursing, that's how she was going to react and she started going down, and then all of a sudden, it's like, okay, we're heading, you know, her trajectory is going in the correct right direction. And then all of a sudden, it's like, Nah, ha, ha, playing with you. I'm going back the other way.

Scott Benner 30:26
Yeah, how many episodes or something did you get through last night? Exactly.

Ethan 30:29
Say it again.

Scott Benner 30:30
How many episodes of your new show did you get through last night? What? While you were sitting up fighting with the blood sugar? Were you watching? Are you watching something? Exactly?

Ethan 30:39
No, I was actually I was just on social media. I was yeah, it was just kind of just scrolling through social.

Scott Benner 30:45
Well, so. So you're doing that thing. You're you're kind of just nickel and diming that the high blood sugar because you don't want to cause a lobe and then you get a little movement. But then whatever is forcing the blood sugar up is still there. So you haven't overwhelmed it yet? It's coming back up. It's probably dinner. Right? Was there a fat or protein and dinner? Here

Ethan 31:05
was protein and dinner for sure. And that's what I was thinking to him. Okay, this is dinner and but she also has kind of its tendency to wear around a certain timeframe. Between like three and six to her, she'll show just kind of drop, you know, her blood sugar's were start to go down. And you know, this is one kind of anticipating that happening. But then I'm going okay, why don't I just give her more instead of constantly increasing? Yeah. What's happened to questions in this going? Yeah, so I tend to do more of the sets, increasing or just adjusting her or basil increasing instead of just going okay. What is it actually wanting me to give her? You know, it's wanting to be the giver? You know, it's saying he wants to units, do I do that? Do I cut sometimes I kind of cut it in half. Because sometimes it's because, again, when I'm getting that is, it is a tool. It's a great tool, but it doesn't know exactly what, what was ingested. Yeah, right. High protein was more sugars, what kind of carbs was, so it doesn't obviously know that. So that's where I feel like you have to come in with that factor of, okay, this is what she actually had. And it's like that, it's it's kind of help, you're helping me, it's your tool helping you but then you have to help it too. Yeah,

Scott Benner 32:21
you have to you have to be the one to understand the impact of the food. You know, because if dinner had, you know, protein that got digested late and push blood sugar back up, if it had fat in it, that slowed down digestion kept the food in your stomach longer, like that's that, like if she's getting lower every night at 3am? Is it possible that like, is she having a snack before bed? Or something that's sitting in her? Or do you think that you're maybe seeing growth hormone early in the evening that you're being more aggressive with? And then she's getting lower later? Have you figured out what it might be?

Ethan 32:53
Not, there's nothing to really kind of figure that out, like, Okay, this is your certain pattern, what you're exhibiting because it can also depend on what she did that day, or his activities, you know, due to conditioning, and how many practices does she go to she Less is more, because that also takes plays into it too. Because sometimes it's like, as soon as she lays down, it's like, she's settling. So she's starting to drop, you know, yeah. And I kind of we got discharged or we was getting trained, there was that rule of thumb of kind of, you know, putting, making sure her blood sugar's are like 120 Plus, and I actually have a colleague of mine who's I think she says, She's type 1.5. Like, goes by that rule of thumb to have, you know, going going to sleep it at 120 Plus,

Scott Benner 33:46
and they're drifting down every night. wordstat Again, does the blood sugar drift down every night? Or does it stay in the 120? Sometimes?

Ethan 33:55
It will, it can fluctuate. It does it really? Honestly, it does. She's active all night. I mean, there's a good pattern to where she'll stay like 100 between maybe like 80 and 100. But then there's the patterns to where she'll stay between 100 and like, 140. Okay.

Scott Benner 34:15
Yes, so sometimes leaving are high is necessary, and sometimes it's not. Yeah, it

Ethan 34:22
sounds like a lot like I'll leave around 140 Or maybe even like, 160 depends on the time. I always have to look at the time like, Okay, is it it's 1030 She's 160 Do I just give her a little bit of a thumping freeze? And let's see what happens like around 1:32am. Okay, it's time for him to adjust again. Yeah, I

Scott Benner 34:40
guess all the activity is really the linchpin. They're trying to figure out where it's when it's happening. Doesn't happen constantly. There's a lot of activity doesn't mean there's activity every day. The activity on top of different meals probably looks different later, too. So yeah, boy, it's a lot. I commend you for paying it. added to it. And it's, I mean, it's hard to find patterns and stuff like that is what I was gonna say. So like, you have to just kind of pay attention. So you see, like, there's, I don't know, hints that happened along the way, like you said, like, at this certain time, if what's happening at 10pm Looks like this, then I might leave the number one place or the other. You know, what else I'm thinking? Is that it really feels like I mean, it feels like an algorithm could help her. Because if you don't have to, you know, like you're leaving it at 120 in case she falls, but if an algorithm sees her falling, it's going to take the insulin away anyway. So you might be, maybe that is the situation where that would be really helpful. Have you ever thought about it?

Ethan 35:48
I mean, I could actually be completely wrong. She her I think there is a certain period. Yeah, she is there. There are I was completely incorrect. There are certain periods in her program to where it will do the adjustment,

Scott Benner 36:05
as well. Well, so is she using all the power five already? Yes, she

Ethan 36:09
is on the phone. Oh,

Scott Benner 36:10
I thought you said that. Well, you did say dash but it's she's on Fox.

Ethan 36:14
I'm sorry. She's on she's on the dash. But there is so that's wrong. Excuse me, for me, me and Pete novice here. But um, yeah. There's certain years. There are certain periods throughout the day when her program to where it will give her we'll make that adjustment for

Scott Benner 36:31
All right, hold on, we got to pick through this evening because something don't make sense. So I'm the pod dash does not have an algorithm, it won't shut off basil automatically turn it on, on the pod five gives insulin takes insulin away as it's trying to keep you in a range. And Omnipod. Five would be trying to think of how you could differentiate the two?

Ethan 36:55
Well, it doesn't shut off. But I know there's there's a certain point to where it will give her an increase if it needs to. When I programmed it.

Scott Benner 37:05
It'll give her an increase.

Ethan 37:07
I mean, let me see. We're I think you're

Scott Benner 37:09
just not using the words that I'm expecting to hear. But I'm just there's some like, do you mean you've done like a Temp Basal increase?

Ethan 37:17
No, hold on a second. So okay, yeah, we're probably just not using the same.

So she has it was, oh, I'm seeing this. It's a target. Target. Target BG and correct. Above. So if she is 19. Above it says it will correct. And that's turned on. It's called her Bolus Catholic. Calculator.

Scott Benner 37:39
Okay, oh, I see. You're just using, like different language than I expected, I'm sorry. So in her settings on her dash, there's a, the Bolus calculator either gives you insulin or doesn't give you insulin based on the target you have set. So for instance, if your target is 110, but you're 90, and you open it up, it's not going to say give us give yourself more insulin. If you're 120, it might ask for more insulin, depending on how much insulin is on board. But that's not an algorithm what I was talking about, like, yeah, on the pod five, would actually it would make boluses and take basil away and add basil and stuff like that on its own. Like literally like aggressively it would it would give and take away insulin to try to keep her in a range. There's an analyst there's episodes about it, you should check them out and see what you think. But that might help like an actual algorithm making a decision about insulin completely on its own. The way I thought about it for her was instead of putting her to bed at 120 because you think she's going to drift down. You don't worry about that. And the algorithm will just take away her her insulin to try to keep her at a stable number. So I don't know it's it's worth looking into. Okay,

Ethan 39:04
well, thanks for that. Yeah, yeah, I mean, I LD we have a scoped for anytime soon to move over to the five so I haven't done I'll be honest, I haven't done my due diligence on on that actual product. Yeah,

Scott Benner 39:18
yeah, I wouldn't look into anything I wasn't thinking of getting I was just saying I like as you're describing the overnights I thought we algorithms are maybe the best overnight, because there's no extra food, right? You're not eating and they do they do a really good job. sleeping overnight aren't used as she's using loop three right now. But her overnight is like last night was so incredibly stable. Like it's hard to put into words how stable it was. It's pretty awesome, actually. Yeah, take a look when you get a chance save, you know, I'm not saying run out and do it or anything like that, or they even have to but it's worth understanding. For sure. Absolutely. How, no, of course how was your conversation? is with your daughter about diabetes they how do you think she thinks about it? And what is it as a parent you're considering when you're talking to her?

Ethan 40:08
Yeah, it was definitely the beginning the adjustment. She's, he is. He's my inspiration to be honest with you. I mean, I could imagine this happening to me at her age and having to deal with it and going to school, but try to keep an open dialogue. There's definitely good days and bad days or good weeks and bad weeks. She's coming along great with with an understanding the management She surprises me sometimes like she's like, Okay, this was on Bolus and myself. I'm like, dang, you, you landed? Great. You mean? All right. You know, like, okay, you know, and then there's the occasional questions like, Okay, this is only half what do you think I should do? And, you know, we figure it out. But she is, she has she, like I said, she is my inspiration. I tell her.

Scott Benner 41:05
She mind that our friends know.

Ethan 41:08
Her friends, she has a good supporting cast of friends. There is the occasional dismissive Oh, she just wants to, to blend but I always tell you know, she's, she's special. But her she's, she had to get used to that, you know, and realize that she has to let those in her circle, understand, understand what's going on with her. Okay. And, you know, one of the things to explain it to her, I said, it's something very similar to someone who has a peanut allergy, you know, you're out with your friends, and you don't want to hand them a Snickers bar, you know, because they're gonna react to that, or someone who has any other type of reaction, you're going to want to know you're going to need to know your circle is going to eat and understand. Yeah, so yeah, I mean, her circle is, is a very supportive that she has, and that's I commend them too, for, you know, for her being as young as they are, and in supporting their friend out. Yeah.

Scott Benner 42:08
So while she wants to not think about it at times, she's not hiding it from anybody.

Ethan 42:14
Now. No, I mean, you finally gonna get any for this when she was just telling me. I think this was in seventh in seventh grade to where we're talking about the alerts. Oh, because I was I was writing a program, actually. And I had said, I see I see what your settings are. And what I mean by the settings is her phone alerting her. And she was just telling me yesterday that one point, or alert had went off, and she kind of charted up there as it was an Amber Alert. She liked the teacher think it was amber alert there for a second.

Scott Benner 42:47
So be beep oh, there's like, yeah, it was a kid in the Volkswagen. We're supposed to be looking for this. She just didn't want people to think that. Yeah, I mean, I get that, like, nobody wants to be singled out, like by anything.

Ethan 43:03
It's already kind of a challenge, you know, middle school, sorry, difficult as it can, is, you know, that, you know, let alone and then adding something else on top of it, and to where you're, you have these little sidewalk on my cyborg sometimes too, because, you know, gadgets owner, people seen seeing it and her having to adjust to that. So she's, we've got through that period, I think, to where she's more, she's more open about it now. And they especially like, say with her being, being in sports, she had to be very open about hey, this is what's gonna happen with me. Yeah, or, yeah, with her coaches and her teammates.

Scott Benner 43:45
I think it's a it's a process, obviously, but it's a delicate age. 1112 1314 year old girls, right. And she's, you know, finding her way through it. It sounds impressive, that she's figuring out how to manage it. That, you know, her friends know about it. That's terrific. Does she hide her devices? I mean, like, I don't mean like, what do I mean? I was No, I

Ethan 44:09
get what you're saying. In the beginning. It was there was some some don't want to bring attention to it. Let's just say it that way. But now she's she's, she's getting comfortable. She's gotten comfortable with it. She has golfer that's excellent. Yeah. And she there's more to get comfortable with but she's, you know, it's and like we were she was just a camp last week and another volleyball camp and there happened to be a another another player who is T one and you're able to see the device. So you know, we've seen that when we're as we're traveling around in her world and volleyball. There are some so it's like, yeah, see that their sport and it you know, yeah, rockin it's you. I

Scott Benner 44:50
saw a woman wearing it. I don't think this is FDA approved. But I saw a woman wearing her G six on her forearm, the top of her forearm yesterday and I I was like, wow, that's like, but it's right there. You know, I thought that was kind of cool it I asked her about it. I was like, Hey, do you wear the G six there? Often she wasn't she started telling me the other place. She wears it. She's like, Yeah, sometimes she's like, I get good readings here. I was like, no kidding. Cool.

Ethan 45:14
I seen one that posted a picture to where she had it like, on her between her shoulder blades, like right below her neck. Oh, yeah. Yeah, my dad does not look comfortable with. But works, right? Yeah, she says she got really good. She gets her best readings there. I always think I kind of she lay down and I get a compression.

Scott Benner 45:36
Hey, how tall is your daughter? Exactly? Are we going to make some college money off this volleyball thing or what?

Ethan 45:42
That's the goal, right? She is. She just wanted to doctors a few few days ago. She's five, eight and a half.

Scott Benner 45:48
Oh. Oh, how tall are you? Not at all. How about her mom? Not at all. Do you think five eight might be a good five eighths tall for a younger? Yeah,

Ethan 46:00
she's definitely in the in the setters range for sure. So yeah, she's been playing for FIFA. She's been playing travel. I think this is going into her third season. Now. She's been playing for a while she's double champion back to back champion in her middle school.

Scott Benner 46:17
Does she want to play call? Does she want to go to college? Yes,

Ethan 46:20
yeah, she we actually last Saturday. Yeah, or two weeks ago, she went to a program to meet with it was one day, but you meet with college recruits. So I kind of thought maybe it was going to be cuz she's only going into, she'll be entering high school here in like two weeks, actually, two weeks. Um, I thought maybe it was too soon. But we just went for it. And it was surprised. I was surprised with how many other players that are in her graduating class of 2027 that were there. Ready to go

Scott Benner 46:56
coast, my son started. I think he started talking to college coaches, maybe when he was 15, closer to 16. That, that that summer. And it felt like it was enough for them to like see you and say like, oh, you're athletic, or you definitely look like a baseball player or something like that. You should come back next year. And then when he was 16, that's when it was like, it was intense for a while. There's a lot of like, how do you do it in? In volleyball, though, like in, in baseball, you show up and play in? Like, you know, tournaments? Or recruits? Do they show up and play volleyball together? How do they do that?

Ethan 47:36
Yeah, for that one for that Pacific Pacific specific program. There were I think there's like eight different universities that showed up. And then they just broke them down into teams, based off of actually I really don't even know. I think it's kind of like at random. It didn't but but what you you're actually signing up on the preferred position, top two positions that you play, okay. And then And then each coach you're like spinning you're spending x amount of time with each university recruit recruiter there and they're teaching you based off your skill level on how they would actually teach their in their program. And then they get split up for the for the rest of the Pearson's like five hours to where they're actually playing that with that coach and then playing against the other others, the other universities in their teams, so

Scott Benner 48:30
their small team, you have to pay for this or is it very nice

Ethan 48:34
it is what's free run here? Or

Scott Benner 48:37
you're in California, right? Yeah, yeah. start charging for air. Exactly. Okay. Yeah. I mean, the things that cold did, generally speaking, were not free. But they were. Yeah, they were, they weren't overly expensive that I think it it felt like you were paying, like helping pay the coaches for their time, basically, is what it is what it felt like, I think it's kind of how they make some of those like assistant coaches make a little bit of their income that way, you know, some of them are not making a ton of money to coach in their colleges. So

Ethan 49:11
exactly. Some of them are in now. This is like their, their second or second job. Exactly. So but that's a lot of it with travel too, I believe. Yeah. having to pay for the for that expense. But yeah, this was not a free program. She actually enjoyed it. There was a lot, a lot of feedback. And then beans being told or they were told to her. If you're going into your freshman year, your first year. It's it is that summer, like you're just saying that 1516 tour. That's where the tapes are gonna start coming in and that sort of conversations are going to be like you can make you can reach out, but you're probably just going to get that. Thank you for reaching out. Oh, yeah. Because I don't think they can actually legally

Scott Benner 49:56
talk to you until you're certain age. Yeah. Listen, the best the best thing I can tell you is that if there's two things you can do, you have to be a real honest assessor of, of her and take a lot of video. Those are really the things you can do. So, I spent a lot of my time pointing a camera at my son until a baseball game to him then, and laying out a lot of dead stuff, and you know, in the video, but in the end, he was able to, I think he got as much interest through video that we made as he did through being in person. So like, you start sending them videos and saying, like, hey, look, I'm going to be at this thing this weekend. And I come say hello. And then they'll watch your video. And if they like it, they'll say, yeah, come find me. That's how it kind of worked there. It was baseball was little it was I mean, I don't know how different it is really, you're trying to get somebody to notice you in a sea full of people doing the same thing. So exactly. Yeah,

Ethan 50:55
that's there's different programs that I seem to where you can actually do a, you know what tournament, you're going to be in jail. You know, whoever you're reaching out to you just kind of like send them a note. I will be at this. And then they'll fill actually, if they're interesting, because they didn't explain this. They will find you on the court. They'll figure out what court are you can you say, Hey, I'd be at this tournament. I'll be on this court. This is what time this might position and they still feel that way.

Scott Benner 51:23
I mean, I they say that I would say that it's more your job to get yourself in front of them. Oh, absolutely. Yeah, it's it's because they can't be everywhere all at once. And they might I mean, listen, you could I remember a day where we're Cole made this like, incredible catch and centerfield. And he followed up with like, this insane throw, and nobody was there. And then the next day, people showed up and the ball like just never once came to him. And that was it. Like he just was standing out there. So taping them no, I had the video. So after the weekend was over you you sent out he sends an email to those guys this Hey, Coach, you know, I noticed you weren't at the game where you know, this happened, blah, blah, blah. But here's me doing this and this. And that kind of stuff really helped them by the time Cole was rolling, he had a good 15 or 18 colleges interested in him. Like once he really got it moving. But we did that a lot with video. Honestly, it was a lot of it was a lot of effort on our side. You know, because they all show up to see the same stuff. And you know, I I watched Cole playing a game once in Florida maybe where there were no lie 40 college coaches at the game, they played them. So they brought they brought our kids in basically to be sacrificial lambs against this like, like national team, like a baseball team made up of kids from all over the country. And the pitcher was in thrown in the 90s. And they were only like 16 or 17 years old. So there were like 40 coaches standing behind home plate with radar guns, trying to see how hard this kid to throw. Now he could not locate a fastball to save his life. But they did not care. They loved him. The he couldn't throw strikes, he was ineffective. Our team was beating them handily. And even though our team showed up and beat this collection of like studs, they didn't pay attention to one kid on our side, they paid attention to the kid who threw the ball really hard, even though he couldn't throw a strike. It's interesting what they get enamored with is what I'm saying. So you need to bring you need to remind them sometimes you also need a person to do this, not just the guy who's there was 90 miles an hour. And yeah, that sort of thing. I don't know if she really wants to do it. And she's a good student. I guarantee she's a student. Yeah. Good.

Ethan 53:53
She gets that from an excellent student. Well,

Scott Benner 53:56
that's a big deal. I mean, and we did save a lot of money off of college. I only want to say how much but it was a lot. So you know, it can help if you if you get the right situation. Yeah,

Ethan 54:11
that's definitely her. Her goal is to play college ball. They were talking about, you know, scholarships, and you know, what's the possibility? And obviously, it all depends on if it changes from you know, your D one private to D one public in Chem three. So that's it's all you know, it's that fluctuates, right? But yeah, but that's absolutely her goal. And I always told her when she started that I will support her. However, whatever that means that they you know, she's this is what she wants. I I mean, I was actually I played I played basketball when I was in high school and stuff, but I only play Dooku once a year. And what reason why I end up playing Dooku I know we're kind of going off topic here. I played I played yuku is I didn't have that tape. When I was actually talking to a university, and had asked me, Hey, can you send me over tape? I'm like, What's that? Yeah, how

Scott Benner 55:11
am I doing that?

Ethan 55:13
And, you know, he's like the coach parents like, that didn't happen. So I got actually got invited for a one day. It was like a one day showcase play. And I remember when I came out during the during the game, I got asked if I was actually the MVP of my team. And I'm like, No, actually, I said, you know, but what I'm getting out with the tape, is that something that stood with me, because I realized that that I only had this one shot and I that was the best that best I've ever played. Don't even know where it came from, to tell you the truth. Like I was channeling something else. But the tape when I had heard the No, I don't have this. Yeah, like you that hesitation on the other end of the phone. So yeah, when uh, when recently my daughter started really talking about this. I'm like, I will make sure that you are tape.

Scott Benner 56:11
Sure. Yeah. Good. Good for you. It's, it's nice. And actually, now that Microsoft is out of college and doesn't play baseball anymore. Like still once in a while, like in my, you know, in my pictures, I'll pop up and see him like in a photo standing on a field or playing or something like that. The other day, I watched him hit his like, last college home run in a video. Like stuff like that. It's nice, you know? So you guys have a good time. Plus, I'll tell you a ton of good time spent in the car. Like the driving to and from games and stuff like that is? I remember very fondly. So

Ethan 56:50
yeah, there's been we've we've done a lot of travel. I mean, we went to Salt Lake City, this this last season up to Washington. So you know, it's the travel, as expensive as it can be. It definitely has the memory.

Scott Benner 57:05
Memory, trying to think about what the hotel room costs, just trying to remember the lovely conversation. Yeah, the car.

Ethan 57:11
Oh, my God, and it's rather you're doing good or bad. You're like going?

Scott Benner 57:16
Oh, yeah, yeah, there's nothing like flying somewhere to lose. That's fun.

Ethan 57:22
Yeah, we're gonna see a couple of those so far. It's like, Oh, man. But

Scott Benner 57:26
But that's why also, when you're collecting video, you can still play well, in a situation where the team does not do well. And you still might have something to share at that point. So absolutely

Ethan 57:38
not, there's definitely that then there's also the character building, even though she's not gonna like it when I say that. But to overcome that adversity, you know, that versity that you're going up against to kind of keep thriving and pushing each other. That's that goes a long, long way, in my opinion. Oh, yeah. Because of what is being, you know, there's no give it up. You're fighting as long as you guys are fighting together, you know, and trying to bring them to morale up as a team, that there is to me, that's the big takeaway. Oh, for

Scott Benner 58:06
sure. Yeah. Oh, Ethan. Most of these, like, most of those girls aren't gonna end up playing volleyball in the Olympics. You know what I mean? So, exactly, you're gonna

Ethan 58:15
see something that's definitely going to carry over into that work into your

Scott Benner 58:19
real life? Oh, for sure. Like, I think the more the most successful kids I know, now, in their early 20s, were the kids who lost at baseball, more like the kids that were super successful. Like, I don't know what they took from it, they won baseball games, but they didn't have a ton of life lessons at all. And you also get in the real world, like, I don't know how valuable it is to be like, I can hit a baseball, like good for you, that doesn't help me at your job. You know, like, maybe the I work out hard, or I'm consistent. Like that stuff's all valuable. But I mean, the losings far more valuable than the one, I think,

Ethan 58:55
absolutely. And totally agree. You know, it's just like, how do you overcome this, you have to figure out how to overcome this together. Because something can happen at work, or something can happen in your personal life and you know, in her family, and you have to figure out how to communicate and overcome it. And it's challenging, you might not be in that headspace because you're upset, you're frustrated, you're playing bad, your teammates playing bad, but how do you support and so I keep instilling like, how you have to figure out how to support that.

Scott Benner 59:21
Yeah, we're gonna do this again, tomorrow. This went terribly. And we're gonna get up tomorrow and do it again.

Ethan 59:26
I always say short term amnesia. Short term amnesia. Just keep going out there. Yeah, just keep going and get the next one. Get the next one.

Scott Benner 59:32
Perfect life lesson. Honestly, it's the way you have to take care of diabetes too. You can't you can't have a bad now Ethan now I finally have brought this all the way around to you being scared from the one time your kid was sick. Don't you have to forget that and move on? Yes,

Ethan 59:48
yeah, I see what you did there.

Scott Benner 59:52
Took me a while even but I did get to it. Honestly, I thought I was gonna get it done 10 minutes ago and then we we went off track a little bit but Yeah, but seriously that, you know, sports life, diabetes, it's all it's all the same really, just, you know, you gotta get back at it. So I don't know, I don't want you to leave in your kids budget or 161 20 overnight if it doesn't need to be. Because you're

Ethan 1:00:16
absolutely like I said, I'm I'm always adjusting that and seeing what she's gonna do. I don't want her be in a pair to know she feels she's feeling bad either. But, you know, and but, ya know, I do have to figure out how to, I mean, for one that one thing is she is, she's kind of like, in the middle of me and her mom, like, she'll be more. Okay, this is what I'm gonna, I'm gonna do, I'm gonna go ahead and be a little Orbitz which is good for her. Because at the end of the day, and a few years when she guys go off to college, we'll still be watching from afar, because who knows where she'll be at? Yeah. And it's going to be completely on her so that it's more, even though I might be hesitant and reserved. At least she's not,

Scott Benner 1:00:57
well, you'll grow with it, too. I mean, you're not going to be the person you are right now for for the whole time. I also think for you for your sadly in your sleep. If you could make one more slightly aggressive Bolus at night, instead of like little ones, little ones, little ones and sitting up for hours, that'd be better for you, which would be better for her. You know, like, you could actually, like knock a number down and get some sleep. Yes, yeah, I don't want you to sit up all night meant that the no sleep thing. I'll tell you from my experience, the no sleep thing in the beginning. I was like, Oh, I can do this. Like, this is what needs to be done. And I can do it. But I'm just going to tell you that after a while it's untenable, and you just can't keep it going anymore. And now you're just gonna not know how to handle the high blood sugar overnight, and you're gonna pass out and be asleep. A lack of sleep has such a horrible impact on a person. And it's very incremental the way it comes over you so you don't notice it happening. Just one day you're exhausted. And yeah, that's your new normal. And that sucks. So anyway, I don't want that for you.

Ethan 1:02:03
Appreciate ya.

Scott Benner 1:02:04
Ethan. You were terrific, man. Is there anything we haven't talked about that we should have?

Ethan 1:02:09
Now, this is actually great. I mean, this is actually my first podcast doing this so that you're terrific. Thank you for the experience. Of course. No, it's

Scott Benner 1:02:17
my pleasure. I appreciate you wanting to do it. I appreciate your ex making you do it. Why did she want you to do it?

Ethan 1:02:22
No, actually, I just I just recently told her about it because it popped up saying hey, yeah, I'm doing this podcast, by the way. Oh, she

Scott Benner 1:02:29
didn't know you reached out. Yeah,

Ethan 1:02:31
I reached out. I had seen her on Facebook. Nice. Good for

Scott Benner 1:02:33
you. You enjoyed it. You enjoy doing this? Yeah, absolutely. How come your headset sounds so good. You're like gamer headset?

Ethan 1:02:41
No, actually, from for I just conducted my first interview as a podcast host last week, so I do what I do for I'm into technical marketing. Okay, so yeah, I create content videos and stuff like that. So that's why Oh, no

Scott Benner 1:02:57
kidding. Good for you. That's actually what you sound terrific. So you're off to a good start there. Thank you. I appreciate it. Hold on one second for me. Okay.

A huge thanks to Dexcom for supporting the podcast and for sponsoring this episode dexcom.com/juicebox Go get yourself a Dexcom g7 right now using my link. A huge thank you to one of today's sponsors, G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com Ford slash juicebox. You spell that? G VOKEGLUC. Ag o n.com. Forward slash juicebox. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community check out Juicebox Podcast type one diabetes on Facebook. Thank you so much for listening. I'll be back soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com