Scott Benner 9/23/23 Scott Benner 9/23/23

#1015 Diabetes Pro Tip: Emergency Room Protocols

Scott is joined by Jennifer Smith, a registered dietitian and certified diabetes educator, who shares her insights on visiting an E.R. with type 1 diabetes.

You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.

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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 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter, and they have an amazing offer for you. Right now at my link only contour next one.com forward slash juicebox free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen, find out more at G voc glucagon.com. Forward slash juicebox. So Jenny, this whole time we're going to talk today. I think we're gonna just talk about this one email that I got.

Jennifer Smith, CDE 2:32
Yeah. Which was great. And I think I mean, we've touched on some of these points in like some of the I know we did like up a safety in a hospital preparedness and all of that kind of stuff. But I think this hits a really specific mark of most people that go to an emergency room in an very emergent setting. They don't really know, and why would they know that the staff there is not prepared to deal with type one diabetes. Yeah, they're not in they're not in. I don't say that in like a god. They're not educated they are they're highly educated, they're educated in a million different things, right. But their focus is so much not type one. And because the scope of how we manage type one, especially in the past 10 years, has changed so dramatically. They the staff, they can't keep up with that. They don't they don't have time to keep up with that. So when you come in, you know, on these fancy gadgets and all these things, and they're like, Well, I know an insulin drip and I know how to, to hook you up to glucose and that's what we're gonna do. Like and you step back and you're like, No, no, no, no, that's not how I do this,

Scott Benner 3:53
you you come to realize what they really understand is just how to keep you from having a low blood sugar incident while you're there. That's what they know how to do. So you may or may not be surprised by the number of emails I get yearly from nurses and doctors who have children who were diagnosed or sometimes who have themselves diagnosed. And inevitably, there are three sentences, three sentences in their email that describe I'm a good nurse, I'm a good doctor. I don't understand type one diabetes at all every time. It's just, you know,

Jennifer Smith, CDE 4:30
with a family right now the the father is a physician and the mother is a nurse practitioner and their little child they I mean they came to us and they were like we know diabetes, but we don't know diabetes. You know, I mean, we know the coded book description of this is what you do and that should be cut and dry. When you limit not cut and dry. There is no book anything A

Scott Benner 5:00
bit of nuance just a bit. Right. Right, right. So I don't think Misty would mind her name being used, Misty came into the private Facebook group that we have for the podcast. And she shared that, you know, her child had to go to the hospital. And then she had all of these questions afterwards, and statements and things like that. And when it ended, she said, I would love it, if you and Jenny talked about this stuff. And I said, Okay, you go ahead and put a list together of what you think of, you know, as emergent that came from this experience. And Jenny, and I'll try to talk about it. And she really did. So Misty, congratulations, this, you are the founder of this feast today. So

Jennifer Smith, CDE 5:42
she did a banana, I mean, from the topics that she noted, would be helpful to cover and everything. I mean, quite honestly, it kind of speaks to the amount of medical education you get, yes, it's only in one field. But the amount of medical stuff you learn, when you become either the person with diabetes, or the caretaker for someone with diabetes, I what she has here is very much in a very, very specific way really important, and should quite honestly be like taken to the emergency department heads. And this is what your Doc's should have a list of protocol to follow up. So

Scott Benner 6:23
that's what we're gonna say the real question becomes, excuse me, the real question becomes, what happens in an emergency situation in a medical situation, when you are the most knowledgeable person in the room and have the least power? Right, apparently to you in the moment, right? Doctors lab coats, people bumbling around, you're not a doctor. But it turns out, you do have power, you just need to know how to assert it. And we'll we'll did exactly. So let me read a little bit here. This, this email is not miss these initial post in the, in the Facebook page. This is the email she sent to me. And so she said, Hey, thanks for considering making this as an app. Thanks for considering making an episode about emergency care. Going through the sickness with my son, which was the first time he had had a stomach bug since diagnosis almost a year ago, made me start thinking about how to figure out what else I don't know. In this instance, probably the three biggest mistakes made in the ER, ended up being the doctor turning off his basil. They didn't hang textures, and a refusal, an absolute refusal to call an endocrinologist. And she said, I knew that these things weren't right. But by doubting herself, and assuming that the doctor must know better than she did. You know, she had no idea in the end, how to make him do those things that she knew needed to be done. And she should have been more assertive, she says, and sooner. So she puts she just puts a bulleted list here. That's terrific. I and I think we should just go down the list. Right?

Jennifer Smith, CDE 7:59
Absolutely. Because it's it's a great list. And I think some of the points can actually even be kind of melded together in a way. But it is it's a very well put together list. It's actually in fact, many of the things on here, when we talk to people, the people that we work within our practice, and we give them our information about prepping for a hospital stay, we have not only a hospital stay or expecting like for a planned surgery, but we also have a lot of these things covered so that you do know how to advocate for yourself, because that's really what it becomes. When you go to the emergency room. Unless you are the person with diabetes, and you're completely out. Well, you know what? They're gonna do what they can do to save your life. And you have no control there then. But

Scott Benner 8:48
yeah, and maybe you can get into a situation where you don't end up like you've heard people in the past talk about in the podcast, where they have family members sneaking them in insulin, and they're doing like, you know, like, Wouldn't it be nice if that's not how this went? Right? It wouldn't be lovely for your, your medical doctors to know about the insulin in your body. So I have a couple of experiences that I'll I'll interject if they fit, and I know you're gonna have some. So first question was, how do I know when it's time to go to the hospital or even at least to call the Endo? When it's a specific type one problem, I guess around illness? The when do you tell people to call?

Jennifer Smith, CDE 9:27
Yeah, I mean, we usually tell people to call at least to call their endo or I guess even a step before that is make sure that you've addressed with your Endo, a 24 hour emergent line to be able to contact somebody at because I guarantee that your specific endo isn't going to be there at two o'clock in the morning and everything every time something happens, right. So the step ahead of that is knowing who to call, what's the number, who will I actually talk to, is it just going to be a nurse triage or is it really that I'm going to get to talk to somebody that's going to give me some information mission without playing phone tag

Scott Benner 10:01
sharing services still exist. So you might just be getting a person taking a message, right? Correct.

Jennifer Smith, CDE 10:06
I mean, most systems, most healthcare systems do have 24 hour nursing care within your like, you know, whatever your insurance coverage or whatever system you're in, right? And that nurse should also be the one who can help determine what are your symptoms? What's going on? Or what's happening with your child? Is this emergent enough? I'm going to call the doctor on call and we're going to get some answers for you or no, you need to go to the emergency room there. I mean, we've used it a couple of times for for our boys when they've been like sick fever, like, you know, rolling around, not feeling great. I'm like, Okay, let's call the nurse and see if the time to go to the doctor, you know. But so they're from our experience, they've been very, very helpful and good. So that's a first step, if it's daytime, certainly tried to call your endo office get in a very emergent message that, hey, this is what's going on and have some very good facts to give them, you know, we've checked blood sugar, we've given insulin, we've checked ketones, you know, my child won't take any fluids, or my child can't stop vomiting, or those are very, very important things to be able to give facts. So they know what to do with you.

Scott Benner 11:19
I also think that it's important not to get caught up in the emotion of it, start telling stories and like they need the facts. They don't need, you know, the extra stuff my mother in law was over. And yeah, let that go. That's not

Jennifer Smith, CDE 11:35
the kids friend was over three weeks ago, and had you know, the flu two days later, they don't care about they don't need to know,

Scott Benner 11:41
we've all been around a person telling a story who's telling a story. They're five minutes into it, you're bored out of your mind, and then they go. So anyway, it was one o'clock in the afternoon. Wait a minute, was it? Was it one o'clock? Or was it 130? Right? I you know, I think and you're like, listen, going, it doesn't matter. Just tell me the story. So yeah, and I think to to recall, to remember, is that it's possible, you'll get a really learned person on the phone who can hear you and respond from their own brains knowledge. And you might also get someone on the phone who's just following a flowchart waiting for you to say a key word. So you know, exactly. temper expectations, I guess, too, right?

Jennifer Smith, CDE 12:23
And definitely, you know, like I said, have the facts in order that you can tell them so they can direct what they need to tell you in the right way. And then, you know, if you really just don't know, you know, when is it actually time to just pick up and go to the hospital? I mean, certainly, we usually say if it's, in this case, you know, her son had a stomach bug. So my expectation is that there was a lot of vomiting, or maybe there was vomiting, and the other end as well, kind of coming out. I don't know, stomach bugs are pretty nasty. And for little kids, or kids of any age, even adults, you could be so like, just out of it, that even remembering to take a sip every couple of minutes or remembering to get, you know, some food in or some carbs in or to try adjusting your insulin this way. Some of that may completely go out the window. So I mean, when is it time to go the hospital when you've put everything in, and you've adjusted, and you've tried all the sick date protocol that you've been given to try, and it's not working, and especially if there are more. So that higher ketone level, you need to go to the emergency room, don't play with it.

Scott Benner 13:40
So is the idea. The illness is not fixable, you are ill now you're ill, you're either able to manage it at home in a way that isn't going to become dire. Or you need to be at the hospital prior to it becoming dire. Right, right. That's correct. That's the idea.

Jennifer Smith, CDE 13:57
And a lot of some of the evaluation in this case would be hydration, for a stomach bug, when to go to the hospital, especially for little kids. If they haven't been able to even take anything in fluid wise or fluid with a little bit of carb. It's it's time to go hydration is a really, really, if you get dehydrated, it's hard to

Scott Benner 14:19
get to recover from that and pay attention to your ketones. I would imagine when you're sick, yeah. Okay. All right. So then she says, What do I take with me? Maybe you should talk about the stuff you have prepared in case you're too sick or unable to speak for yourself a list of medications, outlining of what your normal type one care is like what hospital is best for you to go to if you have a choice. She she lives very far from her hospital, which is interesting. I live in a metropolitan area. I never think about that. Like I never I don't realize that some people have to take an airplane to an airport to fly somewhere else. Like that's not the life I live. I wanted to go to a children's hospital right now. I could go to Five of them if I wanted to, right? Yeah. Right. So, but that's not everybody's situation. So what should you I mean, you've talked before though about having a go bag for yourself, yeah.

Jennifer Smith, CDE 15:10
Next to the door or even if you keep it in the car, as long as doesn't have any psych meds or anything that'll freeze, you know, if you live in a cold place or way too hot place. But I mean, some of those things that should be in a bag, a bag, especially if you're on a pump, things like extra reservoir, tubing, infusion site, even a bottle of water, extra batteries, tapes, adhesives, you know, all those kinds of things, even some extra like glucose, glucose gels, and bull sugar uses simple sugar, all the things that you would pack to potentially take along on like a vacation, let's say, could be in that bag along with and I love that, you know, she pointed out things like a list of meds 100% Because you know what, when you're bringing your child someplace emergently like that, while you may the back of your hand know exactly what the rates are of Basal delivery and what they get, and maybe if they're on injections, how much and when, when you're in that emergent situation that may completely go out of your brain. And you may be fumbling to remember. So having that all, you know, written down, even, you know, if you upload your pump, do a printout once a month of the changes that are in your rates, ratios, you know, time of action and everything that's available on every pump load site, right, download it, put it in the bag, that way it's there. Yeah,

Scott Benner 16:36
yeah, I think too, as you were talking, it made me realize I'm going to do something. So Jenny, and I have topics for some of our episodes. And we just keep them in a simple note in an iPhone, right. And it's a shared notes. So I type in a list, Jenny goes back and strikes things out or adds things we go back and forth. And as we make changes to it, the other person can see the changes, you could just simply have a note in your iPhone that is shared with your husband and your mother and and those people, that is a list of medications, what Basal rates are stuff like that, so that everybody has access to that information in a second.

Jennifer Smith, CDE 17:10
The other really good like I'll like I never take off my ID bracelet. But many ID Bracelets like mine on the very back of it. Now of course I can't get it off. But on the very back of my ID bracelet is actually a an 800 number and a website, that's it's free. All they would have to literally do is look at my ID bracelet. And login to that and all of my medical history is there. So if your child wears a necklace or a bracelet or something like that, many like American medical ID does a really good job. Most of the other websites. I don't know if they offer that as a free service when you buy a bracelet, but it's a nice way that again, you don't have to have that list, like printed out. It's there.

Scott Benner 17:58
That's excellent. Okay. Okay. Misty says what are the universal non negotiable things once you're at the ER, like for your safety? She says that in their case, it was not shutting off the pump. You know that hanging dextrose not saline by that's why that one's interesting, isn't it? They gave him because the saline drops your blood sugar, like well,

Jennifer Smith, CDE 18:22
and the dextrose versus the saline may, you know, in her circumstance, she's right. But in other circumstances, depending on where blood sugar was, you know, hanging saline versus dextrose. If somebody's coming in, in DKA, obviously feeding them more glucose, at least initially, you know, you're going to actually you need hydration, right? So there are some pieces that go along with the illness that you've come in for to pay attention to. But I think what she's really saying here is asking what's being hung? Right? Right. It's it's knowledge to say, Okay, you're hanging saline, he's come in with a stomach bug, I understand that you're trying to provide some hydration. But let's look at where blood sugar is. Let's look at all these things, then she's, you know, again, also very correct. And it's a big thing that I go over all the women and men and parents that I work with. If you go to the emergency room, do not let them take your pump. Do not let them take your pump. I mean, like if you have to like scream and yell and whatever, then advocate and don't let them take your pump. If you come in because you've had a pump malfunction. Obviously your pumps not gonna be doing what you needed to be doing.

Scott Benner 19:36
Take your busted pump. There's a

Jennifer Smith, CDE 19:38
difference in the story, right, but definitely not shutting off the pump. The other thing here too, is they don't necessarily know pumps well enough to even be able to know whether you've shut it off.

Scott Benner 19:51
So Jenny just brought something up. Interesting.

Jennifer Smith, CDE 19:53
Okay, so I kind of I kind of sugarcoat that in a way like that. They don't know.

Scott Benner 20:01
It's like, it's like when my kids were little, we used to go into a spare room, pull the sofa away from the wall a little bit and hide Christmas presents behind the sofa. And the kids never knew where they were because they just didn't know to think about that. So So I have two hospital experiences with Arden. And they both come within the last year. So they're fresh in my mind. One of them is an emergency room visit, where our son had abdominal pain. It was bad. We went into the ER, the first thing I started doing and now keep in mind that this ability to do this comes from a confidence standpoint, like I was confident when I got there, so you know what you're doing. So I got I said to the nurse, and anybody who walked in Arden has type one diabetes, she's wearing an insulin pump and a continuous glucose monitor. Her continuous glucose monitor is reading her blood sugar live, here it is I held it up and showed it to them. And her insulin pump is giving her Basal insulin and Bolus just in case she gets larger. We want to keep these devices on her. Okay. Now you would think they'd be like, Oh, I don't know. But when people realize, you know, and they realize they don't know, they get a little smaller in the conversation, if that makes sense. Like someone's in charge and someone's not. Now it is not the you're not trying to lord it over them. You don't want them to be like, you're not like, Hey, I'm here, I know what I'm doing back up. It's a very symbiotic thing you're trying to set

Jennifer Smith, CDE 21:25
up because you've also come in for help. For something else, respect what they

Scott Benner 21:29
know, right? Respect what they know, try to get them to respect what you know, it's very important not to come off crazy during those initial conversations flustered, like you don't realize it. But if they look at you and your hair on fire, they read that as I'm not listening to that person, right? You know, and that's good on them, they shouldn't. And also keep in mind, that emergency room, people deal with a lot of crazy people. So they don't know if you're crazy or not. And so you have to build a little quick rapport, simple conversations, ask questions. And I also found that I'm was kind of in my mind scoring the people. What did they understand? What, when did they get a blank look? Or when did they have a response that made sense, you know, and try to figure that out, then sometimes, there were people in the scenario I just stopped talking to about diabetes, I directed it more towards the nurse who seemed to understand what I was saying, the one who wanted to give me a little space, and did and that's how I did that. And, and it worked out really well.

Jennifer Smith, CDE 22:31
And I think at the same time in your scenario, kind of bringing in until she she mentioned a little further down, not until the nurse really was like, I need to set you straight. And I'm going to call in somebody else to talk to you and set you right and whatever. And she called it an endo konsult. Quite honestly, when you go to the emergency room, and you know that you may have a stand up and put your hands up and say I got this I know. And you know what you can call an endo bring them in, because I would like another advocate for what I'm doing. Right up front asked for them. There's always an endo on call. There's there's always a specialist on call that will come.

Scott Benner 23:16
And if I can play psychologist for a second when the nurse says that the misty that's the nurse saying, Well, I really don't know enough to write to be the stop in this situation. I think that woman should stop telling me what to do. But I don't have enough facts to Stop or I'll go get a person with facts that come in. And then we'll see later that the person with facts came in and, you know, told the nurse instead of Mr.

Jennifer Smith, CDE 23:39
Kelly, you know, hopefully overall the nurse may have learned something in that setting too. You know, everything is kind of with diabetes, I find it's if people are willing to listen, it's a teaching moment. So you know, hopefully for the next person who comes in or the next parent with a child who comes in this nurse will be a little bit more in the know and be able to say you know what, I don't know enough about this. I do understand that you feel like you know what you're doing? I'm going to call the endo let's just make sure everything is is is good. Everything is the way that it's supposed to be going based on what you came in here for you know, three.

Scott Benner 24:14
Yeah, exactly. One second, I gotta tell ya. The remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free Meet her head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well on your hand, and features Second Chance sampling, which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash juice box free meter go get yourself a free starter kit. while supplies last US residents only touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org. Go up to the top of the page where it says programs there you're going to see all of the terrific things that touch by type one is doing and I mean it's a lot type one it's school, the D box program golfing for diabetes dancing for diabetes, which is a terrific program, you just click on that to check that out. Both are caused their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touch by type one touched by type one.org or find them on Facebook and Instagram. links in the show notes links at juicebox podcast.com To touch by type one and the other great sponsors that are supporting the remastering of the diabetes protip series touched by type one.org. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G voc hypo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk. One second, I gotta tell you something

Jennifer Smith, CDE 27:43
else you follow fallen asleep in class because she's so tired from studying so late last night.

Scott Benner 27:48
She's actually on her way to lunch. She's been at school for 25 minutes and she's going to watch now which is great. No,

Jennifer Smith, CDE 27:52
we always we always talk at the time that she's into lunch. Yes. And you're always texting her do this or did you do this or today?

Scott Benner 28:00
Tell me to pull the curtain back a little bit. People like hearing about that. So there's a reason why I'm always recording while Arden's at lunch and not another time. I'm much more well thought out than I give myself credit for or the way that I let you believe I am. Okay, and then she asks the end is it ever okay to shut off insulin so Misty, I'll tell you that I was rockin Arden's blood sugar for hours in the emergency room and there was no food going into her like we had some juices once in a while we were sipping juices always let the nurse know juices happening. Because the nurse was always like, Look, if you can't manage this, we'll use I don't know what it is dextrose or glucose or something like that. I entered it trip. And I was like, okay, you know, but I was trying really hard for that to happen because just like the nurse who called the endo on Misty, I didn't have any perspective for that. I did not know what was gonna happen next. And I use texting Jenny, I was like, what's gonna happen if they give her this? Like, what trying to be ready because I've taken insulin away, like, I don't know what to do. Right. And we kept it going for a long time. But finally I just couldn't, I couldn't keep it up anymore. Right? And so they gave it to her. And the woman's like, let it go for a minute to see what happens. She was right, like it's shot up. But it came back down pretty quickly again, like had I given her insulin for that that would have been a major like prostate, right? Yeah. And then once we got that drip regulated, and then got her Basal rate to where, like I just adjusted her Basal to manage the dextrose instead of what it was usually a manager, she was getting a very tiny bit of insulin, but a little bit, and that was it. And it's making me realize as we're talking the tools really do work anywhere. Like they work in that situation too. So I guess confidence and honest actual confidence that comes from it comes from experience that you know is gone over and over again the right way is really helpful.

Jennifer Smith, CDE 29:51
And I think that you know, as far as what you were doing because you know how to manage and you know how to adjust you know how to turn things down or turn them up or micro Adjust with little bits of juice, if you know the person can take a little bit by mouth, and it's okay according to what, you know, their protocol is in the emergency room, or again, like a dextrose drip, if that's an option, and you can adjust accordingly with your Basal insulin drip. Great. But it's and I hesitate to say, is it a yes or no? Is it ever okay to shut off insulin? Technically no, for somebody with type one? I mean, really, it's not. I mean, we know what happens if there's 100% deficit of Basal insulin, you're not going to see the impact right now. But you are gonna see the impact in the next several hours based on that deficit of basil that was supposed to be there, even if they needed less Basal insulin, they will always need Basal insulin,

Scott Benner 30:51
and you and if you get to that spot where your it all is out of control, they're going to take it over, then they are going to take it over the minute your life feels a danger, and they don't think that what you're trying helps him or you're going to lose control the situation. Right, right. And that's, that's obvious. I want to fill in here that misty said that eventually, it seemed like the ER doc was probably confused about pump therapy in general, and didn't realize that her child wasn't also getting a long acting previously injected insulin. So that doctor did not understand what the pump does.

Jennifer Smith, CDE 31:28
And that's not a common misunderstanding, quite honestly, like I said, initially. The docs and the nurses and the staff that work in the emergence in the emergent setting of an emergency department, they know a lot, they really do. But they're they're not schooled in, in this setting. What was the difference? Again, between type one and type two, they're just, I mean, they know if they sat down at a desk and talk to somebody, they could tell you the difference, right? But I think because they don't work it all the time. There really is this disconnect in understanding someone with type one diabetes, and I hope lots of health care professionals. Listen, maybe. But that there is a Deaf that you don't have insulin production, you have got to have at least the background drip drip, drip, drip drip of insulin. And if you're somebody on MDI, which Missy also asked, you know, what about people who are using multiple daily injections, what about them, if and that kind of goes along with the emergency preparedness bag, if you can grab your supplies and take them along to the hospital with you, and you're on multiple daily injections, I guarantee you need to grab your Basal insulin, whether it's you know, whatever brand you're using, bring it along, because while the hospital will have within their formulary, a Basal insulin to use. They may want not know how much you're using, and they'll base it on a formula to calculate how much to give you. But if you don't tell them when you've taken your last dose, or when you usually take your doses of Basal insulin, in the hectic nature of what they're trying to do for you. Maybe you take it at 5pm Every night, and you end up going to the emergency room at 3pm in the afternoon, and you're there for seven hours. Well, you know what 5pm comes and you don't get your Basal insulin, you're going to be at a deficit, but they don't know

Scott Benner 33:24
that. And they're going to be not inclined to give you medications they don't understand. So here's she says, How should you advocate for yourself for your child? If things aren't happening, right? Like, she's like, What if like asking nicely, just doesn't work? I think then it's okay to ask to speak to someone else. Correct. You know, like, at some point, you have to just say, Listen, I really do see that you're trying to help. And I don't I always put it back on myself. So there's a little trick I use sometimes in personal communication, where if things aren't going the way I want them to, and I believe it's because the other person's not understanding me. I put that misunderstanding on me. Maybe, you know,

Jennifer Smith, CDE 34:08
I think I can explain it right. Yeah, I

Scott Benner 34:10
know, I'm not explaining this correctly. But it's obvious that we're not on the same wavelength here. Could I just talk to someone else and maybe re explain, maybe they'll hear me differently, you know, maybe how I'm saying it will hit them differently, whatever, but just know that I've been at this a long time. And I know this isn't right. And so this can't, this can't be the end result where we're at right now.

Jennifer Smith, CDE 34:33
And that's where I think advocating sooner than later. If you are getting any pushback even in the first you know, minutes of being there. Ask for a consult with an endo ask for somebody to come in who can from an understanding place. Advocate with you and or for you based on what you then tell them and I think another piece that I've obviously goes into It is, what is your typical plan of care for a day? Right? How much insulin, how sensitive Are you all those dosing, you know, strategies that you use all those doses and everything that you use from a ratio standpoint, sometimes having it just written down rather than trying to explain it visually to somebody who is medically trying to help you at that point. They could read it, and it may just click

Scott Benner 35:27
yet because they're not used to looking at your pump settings or talking about it, maybe even the way you talk about it. And I listen, I speak to a ton of people as you do. There are a million different ways that people explain the same things all the time, right? Like you hear somebody say it one way, then someone else says it another way. And then a third person found a fun way to say it. And like, you know, the emergency situation, you don't want to be using the fun way around the house to explain it to the doctor, because they don't know what the heck you're talking about. No. So So Arden's emergency room visit was eventually it turns out because she had a cyst next to her fallopian tube, and it would cause her like incredible, like stomach pain. So eventually, after a lot of testing for other things, we figure that out. And we found ourselves getting surgery for art and to have the cyst removed. So we must have met with the surgeon, four times prior to the surgery. And every time at the end, I would just say, Hey, just wanted to remind you that Arden has an insulin pump, and a glucose monitor, right? And that we want to keep them on her during what is really only a 45 minute procedure. And the doctor was Oh my god. Yeah, that's great. Yeah, you guys are doing great. Just do it. She just boom, yeah, sure. Then we get to the hospital that day, and we're doing intake. And I realized the first nurse is just getting her set. She's not going to be part of the procedure. But then eventually another nurse comes in, who's obviously going to be in the room, I say, Hi, I don't know if the doctor told you. But my daughter has type one diabetes, and she picks the chart up. And look, she goes now I didn't know that. And I was like, I was like, okay, and I said, Well, she she does. And she's wearing an insulin pump, a continuous glucose monitor and look at her blood sugar right now, look that I've kept my daughter's blood sugar between 100 and 130 for the last 12 hours, because you made her fat for this. Okay, right. And so keep in mind that that's incredibly difficult to do. And I don't want you to take this the wrong way. I've done it. Okay. So and if you need it for another 45 minutes, I can do that too. Okay. She goes, Well, protocol is and I went oh, okay, so now my brain starts going argue with the doctor said it was okay. No, don't do that. Ask for the doctor, maybe. Then another nurse works, walks in the room, I swear to you, I turned away from the woman I was talking to looked at the next and I went Hi. I don't know if you know this or not like the first nurse wasn't even standing there anymore. But my daughter has type one that and I went all through it. And luck habit she goes, my best friend has type one diabetes. While you're doing great. Let me see your graph. I think my daughter, I think my friend has a Dexcom too. We talked about this sometimes. You're doing great. He had do whatever you want. Yeah. And that was it. And I said, Okay, great. I said, if she does get low, you feel free to give her glucose to bring your blood sugar up? Would you like to take her phone into the operating room? And they were like, yeah, absolutely. And they put it in a surgical bag, they stuck it on the operating table so that it could stay connected to everybody. Once I found somebody who got it, she was thrilled to not be involved in it. Right? Much like your school nurses, and your and your administrations at school once they realize you can take care of this and you're like, we don't want to go to the nurse anymore. That's their dream not to take care of your kid, you know. So I found that very same situation kept his blood sugar nice and stable during the procedure. And then as soon as she was out, and her blood sugar tried to go up, I stopped that I was much less aggressive than normal. But I had a goal like I'm going to try to keep her under 170 You know, without getting her low? Because she was she was loopy.

Jennifer Smith, CDE 39:03
Yeah. Not fun,

Scott Benner 39:06
right? And, and it worked. But it didn't work. Because I had the conversations with a doctor. It didn't even work because I had it worked because I kept having the conversation. And so don't get into a position where you feel like I've said this once because you said it wants to somebody doesn't understand.

Jennifer Smith, CDE 39:24
And it's also hard in that scenario when you've explained it. And now you come in and said you have to explain it yet again. And then they come in with more people and you have to explain it yet again. It's hard not to start to get like this escalation of, oh my god, if I seriously have to explain this to one more person. I'm gonna like my head's going to explode. We I mean, you really have to take that level down so that you can advocate well for yourself and you don't start to look like the crazy person,

Scott Benner 39:52
right? Think about the suspension of I don't know what it is expectation or ego or some thing like that you're just, you're just and I always explained, I never explained it from a asking point of view, I was always being matter of fact about it. Like you don't I mean, like there's, there's a, there's an idea behind having, you know, whether you're buying a car or any kind of like a situation like that someone's in charge, right? Like someone's in charge. And when you start at the hospital, by default, the hospital people are in charge, if you become subservient in the conversation, you are immediately under them, and you'll never go anywhere else. Right, right. And it's just, it's all human interaction. So you start with high, you know, I don't want to sound crazy or fool of myself, we're really good at this, let me show you how good we are at it, I promise, I'm gonna, you know, this is the truth. And here's what I'd like to do, here's what I think I can accomplish with that work for you, then you kind of loop them back into the process, again, showing them they're important. It's manipulation, really, but other people call it communication. But you know, what you gotta do

Jennifer Smith, CDE 41:02
is you and sometimes it's sometimes even the team might have, you know, in a scenario of going to the hospital, even for like a planned procedure, like the case of art in surgery, right? I mean, in in August, I had surgery for kidney stone. And it was entirely different than the surgery I had just a couple of months before that in May. In August for my kidney stone. I had to, like my mom came to the procedure with me after it when she was bringing me home. She's like, I can't believe how many times you had to explain to different people, the same exact thing. And I was like, Yeah, I know, I've done this many times now. And she's like, I know, but she's just like, you know, really proud that you didn't get so flustered. And like she's like, I would have like hit somebody over the head with a charge. She's like, I wouldn't have done that, like, well, you would have but you know, it was actually the anesthesiologist who was the most besides the admitting nurse, who was the anesthesiologist, for me, who was really phenomenal. He, he was really interested in my CGM graph he was really interested in in fact, he kept my phone in his pocket. The whole entire procedure, you know, and he, he was awesome. It was actually the surgeon who kept asking me like, how much did you turn your Basal insulin down? And like, I didn't turn it down? Because I know what my Basal insulin does. Totally fine. Are you sure you don't want to turn on like, Look, buddy? I know what I do. I

Scott Benner 42:35
do your part. I'll do mine. How's that? So

Jennifer Smith, CDE 42:37
yeah, it was but yeah, you'll encounter different people. And just continuing to kind of continuing to know that you have rights, you have rights, you as long as you do know what you're doing. Your rights include advocating for yourself, and also asking for other care team members to come in, that may be able to help you better, right,

Scott Benner 43:02
right. It's like being on the phone with customer service, and you realize the person you're talking to is does not have the power to do what you need them to do. And you gotta get to somebody else, you just gonna have an argument. All right, Missy says, you know, what rights do patients have once they're in the hospital setting? And what she means specifically by that is, can you demand things be done in a certain way? But then it's interesting in her in her question, she doubts herself, she says, and how do I verify that what I'm asking for is actually the best for treatment? So how do you like how do you make the leap in your head that this is what we do at home? But maybe this doesn't work here? Right? Yeah, maybe they know more than I do.

Jennifer Smith, CDE 43:39
Some of it's also in terms of, you're going to the hospital with a condition that you know how to manage, but you're going to the hospital, let's say it has nothing to do with that condition. You're going to the hospital because you got severe abdominal pain. Clearly, Scott, you don't have any idea why Arden had abdominal pain, you can't like see into her belly and see what was going on. I mean, some of those things, you have to say, You know what, I came here for this year, the team, you're the experts, I expect you to figure out what the pain is, but I've got this part of it. I've got the diabetes management part of it because I do this 24/7 And you don't. So some of those things, you have to you know what you're requesting. I mean, if you're requesting something like jelly beans that your kid needs to eat, but he's throwing up, quite honestly, they're probably going to look at you like you're crazy and say you know what jelly beans might be what works really well, but he's not going to keep them down. So let's do a Dextral strap. Yeah.

Scott Benner 44:42
Again, I'm a big fan of keeping people involved. So we were not the last thing we did before Arden surgery was I said to the doctor, here are all the places I can put Arden's insulin pump for the day of surgery. Which of them would you like it on? Now? Let me tell you a secret Jenny, it wouldn't matter which one it was on. I was actually giving her something like, Do you know what I mean? Like, I do the same thing in 504. It's like I find something in a fiber for that. I'm like, Oh, we don't need that anymore. And when I go into the meeting the next year, I give it back like It's a present. I'm like, oh, you know what, we don't need this line anymore. Take that out. I'd like to make this as easy for you as possible. Yeah, like, Oh, look how nice he is. Right? So in this case, it's a little ego stroke for the doctor. You tell me what's best here. That was arm or it was thigh. Mater. Like neither of those were going to be in their way. And I let the doctor pick. Yeah. And that was it. Right. And by the way, double down on my maniacal thinking. I was trying to get Arden to use her arm again. And I thought he'll probably say, she'll probably say arm over thigh. So I'm just going to give her arm or thigh. She'll pick arm. I'll make her feel better. And I'll get Arden's pumped back on her arm again. Haha. Yeah, I was like an evil genius in that moment. What is okay to let slide and she's like, What hills? Should you die on? I think we're answering that question along the way, right? Like you just you what's important to the management of the diabetes? What keeps insulin going as best as you can? So what do I do about pump settings that I don't, I don't even follow myself all the time becoming and so so she's a fluid person, like she listens to the podcast, right? And so what happens when your management is fluid, and then all of a sudden someone wants to make it static for the situation? Right? To me, I would tell them that, I'd say look, let's start here. If this doesn't hold it down, we might have to amp it up a little bit. And if it's too much, we might have to take it away. But I don't know, because this is a different scenario than we usually manage. And these numbers are not set in stone like Jesus. That's the that's the core of the podcast, right. And I

Jennifer Smith, CDE 46:59
think a better part of it too, is to explain in a more simple way, maybe to them. This is the baseline that we work off of based on what's happening with glucose, because we've got a trend on our fancy CGM. I can because the pump settings, the smart features of my pump, allow me to do this, if, if his blood sugar is starting to go up, I'm going to do something that temporarily allows me to just up, I'm also going to temporarily adjust down in this scenario. So explaining that in the simplest way that you can help them to see that what's there as settings, is it's meant to be fluid. You know, it's these are what we start with, and, you know, in the in the case of something like the carb ratios, you know, she's like, well, then carb ratios are a little bit more of a suggestion. They're really not something that we 100% hard number go off of, you know, what, if in the emergency room, you get to the point that they're bringing you food, and you're bolusing you know what, you give them the ratios that are in your pump, and you do what you know, works. What they will usually ask for is what dose did you give, because they need to put that in the medical record, right? They don't know that it's been adjusted or just a down based on you know, whatever you say, This is what my pump suggested I take this is what I'm taking adjustment up or down that that's a piece that quite honestly, they're not really going to care nor know about. I mean, when I was in the hospital for both post deliveries of my boys, the nurses every shift, they would ask what is your Basal running at? Have you made any adjustments? Where's your blood sugar? Have you taken any boluses? Have you eaten? All they needed to do was really document what was going on? That's it. There's a lot of but covering going on? It is a lot of exactly. 100% Yeah.

Scott Benner 49:02
And so even if you're MDI, that's really the same advice. Like it is no, if she does make the point that they like to give like a set dose? They do. Right. And so, you know, but and that kind of leads into one of our other questions. Is it ever a good idea to just do things on your own and not tell the staff? And I would have to say, I mean, no, but but probably

Jennifer Smith, CDE 49:28
in some of it is a little bit of like coding an answer, right. Like I said about the Bolus thing, right? It's Is it ever a good idea to do things and not tell the staff not not know, but if you're bolusing for a meal, and they ask you did you Bolus or to have you taken any corrections or whatnot? I mean, the simplest answer yes. And this is what the dose is. That's kind of the level that they need. They don't need to know that you factored in. Well, it looks like his blood sugar is dipping. So I adjusted backed by this, but they don't, again, too much story, right? They don't need to know,

Scott Benner 50:04
their loss because they don't have diabetes, right? And then they start

Jennifer Smith, CDE 50:08
thinking I've got a crazy person who's like just giving willy nilly doses of insulin. I don't I don't agree with it. Let's shut the pump off. Yeah,

Scott Benner 50:16
it might seem disconnected. But you know, when you hear a late night talk show host make a joke about diabetes. And you think, how could they possibly do that? When I know all of this stuff about life would die? They don't know. That's the answer. The answer is they don't know any of that stuff. And so these people you're talking to very well may not know most of what you're saying. So listen to what Jenny's saying. I've said it one way, she's saying it another way, get them to do what you need them to do, if they say five units, because that's what we do. But you know, it's six, and maybe it's okay to do six. If if they want to do five, and you think it's 15, that you're probably gonna have to say to them, right, because you're protecting your own safety. That's what you're really doing, right? You're trying to protect your safety against your blood sugars. And going high is how it feels most of the time. But the truth is, too, you would need to protect it from going low, you would not want to give yourself way more insulin than your doctor knew about because if you did get low, that would be unfair. needed. Yeah,

Jennifer Smith, CDE 51:15
exactly. And, you know, for some of the MDI users that I've worked with, and a very good friend of mine, some don't even really have a true set ratio as a dose to use. And I think you had done this for a while, too. It's like, you can look at a meal. And you can say, like, my good friend, ginger, she can look at she knows her apple and her peanut butter is this many units of insulin. This is what she takes for it all the time, unless her blood sugar's higher, or lower or whatever. But this is always what she takes for it. That's not really a ratio, could she figure out a ratio to tell them? Sure, right? She could. But technically, there's no ratio there, because you've just figured it out. Because they're standard foods that you eat. And you know, that five units or two units or 12 units always works for it.

Scott Benner 52:02
And so when you're not ginger, or you or me, or maybe a lot of the people in his pockets, what does those people do, people really don't understand this yet about their diabetes, are you just in the hands of that,

Jennifer Smith, CDE 52:15
and that's where these protocols are put into place, with the expectation that the medical staff knows best, and that the people coming in, aren't taking that type of level of care for themselves. So they have protocols, they've got these, if this, then do this, if this is where it is adjust by this much change to this, add this, plug this in whatever. And those are safety protocols they are. But I think from the staff position, or the medical, you know, person position, you do have to look at the individual, you have to look at the person who like you comes in with ordinance as I got this, I'm following it, we do this, we do it this way. I know where things are, she's beautiful, she's level, I can manage it, versus the person who comes in and can't even tell you the last time that they took their insulin, or what their rates are running at in their pump, okay, that person may be the time that one, the staff should then get an endo consult in and to the staff needs to follow their protocol, because they can definitely say this person has no idea what they're doing.

Scott Benner 53:30
Maybe that would be a wonderful opportunity for somebody on staff to help that person, you know, because at the end of Arden's initial emergency room visit that I mentioned, as we were packing up and leaving and getting ready to go home and everything the nurse did come in and say, I really appreciate all the help. I hope I was good. You taught me a lot today. You should understand, though, the way you and I started today, because it was a little contentious at the beginning, I just tried to stay away from it, because 99% of the people I see in here don't understand their diabetes in any way.

Jennifer Smith, CDE 54:03
Right. And the majority of people she sees that come in are likely type two, who had much less education, even if they are on insulin, have had much less education than somebody with type one.

Scott Benner 54:19
No, of course. I mean, so it's just to kind of go on the side of the doctor for a second and talk about it from their perspective. You and I talked to a lot of people in our private lives who are constantly raising and crashing their blood sugar's like all day long, but by what they're doing, they don't realize that they think it's happening to them, but they're doing it, you know, and they don't know what they're doing. And what if I get you into a situation where you have multiple units of insulin going and your blood sugar's crashing. You want to have a seizure here at the hospital and in front of the nurse who doesn't particularly understand it to begin with, like, you know, But then, you know you have, you just have to understand their perspective and not just understand it for like, you know, nicey understand it so that you can tell them what they need to hear. Like, right? Like you just, I don't know a better way to say it when you're, you know, when you're arguing with your spouse, right? And you in your heart, you're like, why are they not hearing what I'm saying? It's because they think differently than you think. But if you understood how he thought, or vice versa, you could say to him the thing that would put him at ease, and help him understand you. And that's what you're trying to do here, you're trying to communicate on a better level than we all communicate on most days. Right? That's all right, right. And,

Jennifer Smith, CDE 55:47
you know, when I worked clinically with an endocrine group, in DC, at our hospital, we actually worked with the emergency room staff to develop a protocol for both type one and type two diabetes for when somebody was admitted to the emergency department. And we also had a protocol within the type one. If somebody came in on an insulin pump, it was an automatic endo call. They got somebody there. And if the endo couldn't make it, which was most often because they were busy, one of us, the CD EES got called to the emergency room to help the ER Doc's manage, right. So you know, not all hospitals obviously have that. But we did it mainly because we saw the need, we were getting called so frequently to the emergency department to manage that they were like, well, let's just get something in place. So we better know what we're doing, and when to actually bring you guys here,

Scott Benner 56:44
right? That's a it's not an easy fix. But these are just ideas that hopefully some of them will make something better for you or the conversation or your health. It's, there's no, there's no like, do this, this and this, and you're going to be okay. After this all got posted online, they actually sent me a follow up question. And it was from another person. And the idea basically was, what if you're an adult friend of a person who has diabetes and is not capable of talking? Right, can't speak for themselves in the moment? Like, is there a way to advocate for them? I mean, as I read that, I thought, That's a wonderful idea. I just mean, if you're not a blood relative, first of all, you can't, they're not going to listen to you to begin with. I mean, they might listen a little bit, but what are you even going to say you don't understand their diabetes, probably any better than? Right? You know,

Jennifer Smith, CDE 57:37
I think the easiest, the easiest way to advocate then would really be to ask the emergency room staff, if they could get an endo consult, quite honestly. Because you know, you can, if you know your friend well enough, and hopefully you do, if you're taking them to the emergency room, you haven't just met them on the street corner, and, you know, took them in or whatever was in a

Scott Benner 58:01
bar, and this guy passed out and

Jennifer Smith, CDE 58:04
decided to help. Like, he's wearing this pager with a tube, and I'm not quite sure what that is. But, you know, if you're enough of a friend, bringing another friend to the hospital, you would, you would typically know that they've got a pump, or that they use injections, you may not know how they use it, but you could at least say hey, you know, he or she has the pump on here. He or she wears and uses this thing that tells them what their blood sugar is, you know, those kinds of things would be easy enough to be able to share with the staff at least Yeah, I think

Scott Benner 58:38
instead of trying to find a way to talk to the friend, we have to be talking to you listening who has diabetes, you you have to as crazy as it sounds, you probably have to try to break down your diabetes into six bullet points. And explain that to your friend so that they have that information to ask somebody, listen, you've all been diagnosed, right? And someone downloaded an hour's worth of talking into your head and you got home and went. So you know, like your friend over you know, dinner once in a while when you mentioned your blood sugar. That's not how they're gonna do. But if you had a bullet pointed, like five pointless, like, make sure they know, this is what my Basal rate is, make sure they know you know that I'm MDI and that means I inject my slow acting insulin and my fat. They're two different insoles like that kind of like simple stuff, like break it down into t shirt slogans for it. Right, exactly,

Jennifer Smith, CDE 59:30
then even even when you change therapy, then it's important to share with them, hey, I'm not using injections anymore. I'm using an insulin pump. Even that as a simple statement can be very helpful within those simple bullet points of do this, or do this is behaving this way, you know, help me this way, whatever. That just the other day I brought up with my husband in the, you know, couple of years that I've changed over the type of pump Same strategy that I use. I, my husband was very good with my other pump. He knew how to push the buttons and how to do everything. And since I've changed over, while he knows what I'm doing the button pushing and stuff. I've never gone over with him again. And just the other day I was thinking, I really need to like reteach him. Yeah, all of this in case of me.

Scott Benner 1:00:26
I really do. Yeah, 100%. Jenny, we've done it again, I really believe that this is a good episode.

Jennifer Smith, CDE 1:00:32
It's a good episode, a really great awesome that you're, Miss Misty, decided that it was a really good topic, because

Scott Benner 1:00:41
it was really thoughtful of her to do. Really, super, actually. That's what I like about Listen, all of you listening are terrific. You know whether I've ever met you or I'll never meet you, or you'll never say a word to each other. But I've gotten to meet some of the people online a little closer. And it's really wonderful like that Facebook group is little more than a couple 1000 people who really understand what's being spoken about on the podcast. And when new people come in, they're really helpful. And I just put a post up the other day where I very proudly said, No one's ever been banned or deleted from this place. And even when they when they don't disagree as much as they, they they have conversations. It's really lovely. Actually, that's nice. Yeah, it's wonderful. You can actually talk to people you don't know who disagree with you and not yell at them. And it's still okay. Yes. So do that while you're at the hospital. Let me say this right, before I let you go. Yeah, I don't know that most of what we just said here today does not apply also to when you're in your general practitioners office. Right, like the idea that they probably don't understand as much about your diabetes as you hope they do. Correct. Right. So don't make that assumption. I think I think that's really it. Like, don't assume anyone understands. And you don't if you're an adult with type one, and you're worried you're going to be in the hospital by yourself, make that bullet point list for yourself and keep it keep it on you. You know,

Jennifer Smith, CDE 1:02:08
absolutely even you mentioned that, like the iPhone with the notes or the you know, the phone with the notes and whatever. I know some people even use, I know iPhone has the swipe screen that you can actually have your medical ID right up there with all of your information within that medical ID. You can put it right there. Right in the health app.

Scott Benner 1:02:29
Yep. Yeah. And again, for all and please don't take this the wrong way. But for you type a lunatics be brief, okay. Yes. Doesn't need to be a dissertation. Right. Then one time when she was six, okay. The doctor stopped reading when they got to that

Jennifer Smith, CDE 1:02:45
planters war that I treated this way 40 years ago. Now my

Scott Benner 1:02:49
blood sugar was a little higher during that week and I really think that plainer word in medicine is what? So please keep that in mind. I don't have one now. But I mean, say I'm unconscious for four or five months here at the hospital night developer planners Weren't you decide to take it off for me? I really want you to keep in mind what happened before? Yeah, just keep it simple. What did they say? Kiss keep it simple, stupid, right? Like, I don't think they're calling the person stupid. They're saying super simple. And there is a way if you think about it. And if you listen to this podcast, really, you probably have it now. There's a couple of simple ideas that will keep you within a reasonable range and safe. So tell the doctor that stuff. All right, or just don't get sick. I say is my nose is stuffy this

Jennifer Smith, CDE 1:03:32
year. So it's harder to do that than other years really?

Scott Benner 1:03:36
100% right. There's a lot going on. There's a lot

Jennifer Smith, CDE 1:03:38
of illness going on.

Scott Benner 1:03:40
So I'm gonna tell Jenny, a really gossipy story that you guys don't get to hear so goodbye. Bye bye. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at GE Vogue glucagon.com Ford slash juicebox you spell that GVOKEGLUC AG o n.com Ford slash juice box. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees. In Episode 1015, Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two, in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022, weight loss 1023 Honeymoon 1020 for female hormones, and in Episode 1025, we talk about transitioning from MDI to pumping. Before I go, I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.

#1014 Diabetes Pro Tip: Glucagon and Low BGs

Everyone needs to understand the role of rescue glucagon when they live with type 1 diabetes.

You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:03
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you right now at my link only contour next one.com forward slash juicebox free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter while supplies last US residents only. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen. Find out more at G voc glucagon.com forward slash juice box. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. Hello, everybody. Welcome to Episode 301 of the Juicebox Podcast. Today in a pro tip episode Jenny and I will talk about glucagon emergency Lowe's, just you know how they manage that kind of a scenario? And what happens if you need glucagon? And how do you use it? That kind of stuff? It's not a bummer. Don't worry, Jenny and I laughed more during this one than most of them. So we're gonna go over how to use the glucagon. What glucagon is, what is it do the three different kinds that we could think of there on the market? Pretty much. It's a nuts the bolts glucagon extravaganza talking about low blood sugar somewhere else you're going to talk about people having seizures, and hearing them laugh at the same time. I mean, who else is putting out diabetes content laughing about a seizure? It's not funny, by the way, it's just the situation was fine. You'll see when you get to it, don't get upset. I liked your idea, a lot of doing a pro tips for glucagon. And I was wondering if we couldn't meld it together with like emergency situation ideas as well. You know what I mean? So I just I realized, well, we'll talk about what we're talking about it. I don't know how to start this. Honestly. I can tell you that. We buy glucagon religiously. I always have some when it expires, we always get more. We've never used it. We've had opportunity to use it twice when Arden was little and both times opted to try glucose gel instead. Which worked. Here's the best place to tell the story, I guess. And I'm sure I've said it here before, so I'll encapsulate a little bit. But, you know, when Arden was really newly diagnosed, she was probably like two and a half years old. And thinking back now knowing everything that I know, she's probably honeymooning still, right. And I had no one ever spoke those words to me ever. I didn't know that was a thing back then. And we got kind of ahead of ourselves one day and Kelly was getting ready to leave on a business trip. She was gonna go overseas. And it was like, six or seven hours before her car was going to come to take her to the airport and she's like, Hey, I need another piece of luggage. Like let's go to the mall and you know, a little piece of luggage looks like alright, so we get over to the mall and it's a Sunday. And we're hungry while we're there. So we grabbed you know, the worst thing in the world like mall food, Chinese food, just not just more food, more Chinese food. And I was just like, boom, I counted my carbs. And I was like, pull up my insulin and the needle, bang, go ahead and eat. I figured this out. And she ate the food we ate, we bought the bag, we went home. It was super little. So she fell asleep in the ride home during the ride home only like 15 minute ride. And I carried her into the house and put her in her crib. My wife's packing and my son's watching the football game and everyone's living their life. And all of a sudden, it sounded like there was a wild animal trapped in the house. Right there was like this grunting and grunting and grunting. And you know, it's like anytime, like, I'm just like, what is that, and I start moving through the house towards the sound that's coming from Arden's room, and I get into her room and look in the crib, and she is having a seizure, you know, and I was just like, I did not 100% know what to do. So I picked her up, and I went through the house to where Kelly was. And we had just this kind of little area rug. And I said, I'm like Arden's having a seizure. And so I put her on the floor, and I got out the glucagon. So the red box, you know, that

Unknown Speaker 6:13
has changed

Scott Benner 6:16
forever and ever. And this is the one Lilly sells, right. And so the red box, I pop it open, and there's a needle in there, the needle needs to be put together, the needle has liquid in it, I know the liquid needs to be shot into the powder, that it has to be reconstituted and drawn back out. And I'm going to be 100% honest with you, I was so freaked out that I fumbled with that thing. And I was nowhere near getting it put together before Kelly was rubbing glucose gel into her cheek. And I'm not embarrassed because I look back on that time. And I remember when they gave it to us, the nurse made such a big deal of saying, This is life saving glucagon. But but don't worry, you'll never need it. And so when she said that, I was like, well, I'll never need it. Whatever

Jennifer Smith, CDE 7:09
was in the house, at least it wasn't like, you know, in the bottom of the dog's bed or something. Right? You knew where credit

Scott Benner 7:17
for knowing where it was. Fair enough. So So literally, during you know, the Kelly put the glucose in her cheek, she started to come out of it. I will tell you 100% of the the experience of watching art and have a seizure will never leave me i have never forgotten any of the details of it. She was blind, like she couldn't see anybody. She couldn't talk. But I don't think that meant that she wasn't aware of what was happening. Because there's a I've shared it on the podcast recently. But there's, you know, there's a video of her from a year or so later explaining how it felt to have a seizure. And so you even when you touched her, it scared the crap out of her when you touched her, you know. And so I just never even figured out how to put it together. I had shown it to nurses, I had shown it to people like everything, but when the time came, I was like, not very high. Anyway, the glucose gel did work. And then we went to the hospital, we call 911. And we went to the hospital. And then you get to the hospital and then the hospital kind of treats you like, you don't really need to be here. Like there's that kind of feeling. And then you realize like, Oh, it's over. Okay. Yeah, it's okay. So, later, while we're talking, I'll tell you about the second time I've had a seizure, people are gonna be like, Why am I listening? This podcast only happened twice, relax. It was in the beginning. So I guess, let's really start at the very beginning, right, like, what is glucagon? And what does it do when you inject it?

Jennifer Smith, CDE 8:59
It's made by the body to begin with glucagon, right. And so in the human body, it's a piece of the glucose management system that your body has in place without diabetes in the picture, right? So you've got this management system of your body releases insulin, your body also releases glucagon, which enables the body to break down glycogen, which is stored form of glucose, right? And so you get this drip, drip, drip, drip, drip, drip drip of both, and that helps to keep things stable through the course of your life. So you know, in a person without diabetes, you've got blood sugars that might start dipping down your body releases a little bit of the glucagon, which enables the body to break down the glycogen into glucose and it starts to navigate things back up, but it's a seamless system, right? I mean, nobody walking around on the street right now. Right now, even the most highly educated biochemist, whatever is probably thinking, Oh, I wonder what my body's doing. thing right now

Scott Benner 10:03
is just one of those things

Jennifer Smith, CDE 10:04
like breathing, you don't think about it, it happens. But in diabetes, we, we kind of have like a faulty system, obviously, right, our body isn't making insulin anymore. But we still do have this like drip drip of glucose into our system, or we wouldn't need Basal insulin. Right? Glucagon, however, is, as you explained, well, it's an emergency, we know it as an emergency, we have to use this if this situation is here, right? A low blood sugar, treat a, you know, a friend, a child, a spouse, whoever it might be. So when we inject glucagon, it stimulates a very large amount of breakdown of the glycogen, the stored form of glucose, so that the glucose can get into the system, thus bringing the blood sugar

Scott Benner 10:58
up. It's stored in your liver, right?

Jennifer Smith, CDE 11:01
Glycogen is stored in both liver and muscle cells.

Scott Benner 11:05
And muscle cells. Okay? So, in an in a functioning person who doesn't have type one diabetes, your body really is bumping in nudging. It's giving you it's giving you insulin, and then it's saying, oh, this person needs a little more glucose. And so I I'll release a little here, I'll release that. And that's happening constantly back and forth, back and forth all the time. So so when we're diagnosed with type one diabetes, when someone's diagnosed, we always I mean, for me at least, like, in my mind, what happened is Arden's pancreas stopped making insulin, but more happened in that right but we just don't talk about the rest of it usually, like, you know what I mean, like, in because you hear people say like, my pancreas is dead, but it's not that does other it does way more things than absolutely,

Jennifer Smith, CDE 11:54
absolutely it doesn't mean you got more things in your pancreas than just the beta cells 100% In fact, the the glucagon actually is made in the alpha cells of the pancreas. So a completely like different little cell hanging out, you know, Lottie, da here I am to do this thing, right. So overall, our pancreas isn't dead. It's just a piece of it. That's, it's purposeful,

Scott Benner 12:20
as well as you want. Yeah. And, okay, so what what's interesting, right, like, So how often do you think how often you speak to someone who's needed to use glucagon in an emergency situation?

Jennifer Smith, CDE 12:35
In if I had been doing this 20 years ago, likely more mainly, because I think that with the influx of the technology that we have, now, we've got alerts to actually tell us when things are dipping, before we would even get to the place of needing glucagon. Now, I mean, that doesn't mean that it isn't potentially, you know, necessary, we've got the standpoint of prolonged exercise, you know, or you've had, like, people who do like a whole entire Ironman Triathlon, in that's a huge depletion in your body's glycogen stores, even if you've been fueling along the way as you should be. That's a huge depletion, your body has tapped into your stored glucose to fuel that long duration movement. So, I mean, if you have exercise like that, potentially, you're going to need something to boost glycogen out of the system to bring a low blood sugar up and or you've got too much insulin there to begin with, for whatever reason the dose was wrong or the dose was wrong along with a long act, active day or whatever this scenario, glucagon will potentially at some point be necessary. I knock on wood, I'm not really superstitious, but that's like, my grandmother's thing to do is like, knock on wood. Whatever works, right, but I mean, in 31, in plus years with diabetes, I've never had to be given glucagon. I haven't. I mean, my husband knows how to use it. My parents knew how to use it. My teachers at school, my Girl Scout leaders, that I mean, everybody that I interacted they all knew how to use glucagon and went to sleep overs with the glucagon in my bag. I did never had to use it. Thankfully, in the amount of people that I now work with, I would say it's not it's not common to have had to use it, at least not. I mean, we may talk about this a little bit later, like different kinds of emergencies settings of use, but mean there is the benefit of also many dosing, and some adults especially The adults that I work with are much more proactive in in trying to offset something they know is not working right, you know. And so, ability to micro dose a glucagon injection and offset a low that you don't pass out from and nobody needs to help you. You can help yourself, right? It's,

Scott Benner 15:21
it's funny the way you put it because I'm thinking back now, you know Arden's very infrequently low, but she has like a crazy low once a year that just comes, it appears to come out of nowhere, right? And when you think back on one of those, you realize that without the sensing technology, like if she didn't have a Dexcom those she would have seizures, yes. Moments, right? Because it's, it's unexpected. First of all, it's not like I've done anything different that day than another day. I'm not standing around all day going, Whoo, this is going to be the day it never happens. It never happens on a day when you're like something's gonna get squirrely today. Right? It's never that day, right. And so you know, you're it's one two o'clock in the morning, and you get the alarm, and you realize she's falling way faster than you would have any expectation for. So there's something, whatever it is pushing down on her blood sugar, and nothing to resist it in the other direction. And it's just falling and falling and falling. So we get, you know, we get an alarm to go in, you give her I mean, for me, I give her juice first, because I find that works very quickly. Like it's the way I think of it is like let's get something in there working. While we do the rest. Right? Then I look for things like that are like palatable quick. I always look for like a banana in that situation. Because it's not hard to eat a banana. It's sugary, right. And then you know, I'll roll back to another juice if I have to. But you'll see those, those crazy lows go like 70 6050. And they fall really quickly. And before you know it, you're treating at 50. And you would have treated sooner you just there was no time and you're treating it 50 You're into the 30s. Now you're testing now you're doing the like, are you feeling? Oh my mind? Yeah, let me double check this right. So you're 50 You finally have a second there's some food in. So now you hit a finger stick, and it says something like 30 or 26 or something ridiculous. And you're just like, Okay, now I'm here waiting for her to either have a seizure or not. Like that is really what it feels like, like I've put the food in, it's in there, it's going to do something. And you know, and you're just the I don't know about everybody else, but I test and then I wait like, not long, you know, it's like four or five minutes later, and you test again, and you're looking for just any sign of stability? Did the 38 stay at 3840? Good? Did it go to 40? Because if it went to 40, I don't think she's gonna have a seizure. Right, like, and so I think everyone needs to know how to handle a moment like that. Absolutely. You know what I mean? But I'm now now, you know, having seen that moment, a few times in my life. I see, as you're talking that without the sensing technology, she would have went from 50 to 30. And the, the alarm I would have gotten would have been the grunting and the disabled and the seizure. And without and then I would have been and without

Jennifer Smith, CDE 18:09
this technology. I mean, I I think fully even to this point, I I still have symptoms for Lowe's. I do even with the technology that I have that alerts me and whatnot. I still know when I know usually even before my system is going to tell me I can tell where I am. What's your number

Scott Benner 18:28
when you know you're low? My number is usually in the 60s. Arden's it's yeah, she knows it's six. But you

Jennifer Smith, CDE 18:35
know, years ago when I was first diagnosed, in fact, a good a good case where my parents probably could have used glucagon, but didn't. It was the summer like several months after I was diagnosed, we were camping, had been out playing, you know, rafting in the pool at the beach, doing everything that you would normally do when you're on vacation, you know, and it was the evening and my dad was making popcorn at the fire. And we were all going to sit around and whatever you do at play games, and it was time for me to check my blood sugar because it was like nighttime, right? It was bedtime almost. So I sit down to check my blood sugar. And my mom was like, that number is not right. And I looked at the number. And I mean, I was the age that I knew numbers and I knew where my numbers should technically be. And it was 26 on my meter.

Unknown Speaker 19:21
Like you were fine, right?

Jennifer Smith, CDE 19:22
Like old meters that took like four minutes to test you had to swipe the blood off, stick it back in the machine, push another button, wait for it to actually give you a value but yeah, 26 My mom's like, that's not right. She's like, Did you wash your you know, all the things I washed my hands again. And like, I tested again, my hands like how are you feeling? I'm like, I feel like I did like 30 minutes ago. I'm like, totally fine mom, you know, she tested again. It was like 25 It was like literally it hadn't moved and my mom was like, like my mom is the kind of person who's just like, oh my god, like seriously, you know, and my dad was right there and he's like, Oh, just give her some juice. And my mom was like This number isn't juice. This is like we got to do. He's like, give her the juice. She's talking. She's fine. She's answering questions. You know, I mean, I can remember this very vividly. Give her the juice, I drink the juice. You know, my mom's like, let's check again. You know, like, all the thing is certainly, it started coming up. It was slow. And it's a painful Wait, it really is. But maybe my mom was like, there. She was like that glucagon is going to be here in 15 minutes if this juice that your dad wanted to give you is not working. I mean, and who knows? What was the accuracy of a machine like 30 years ago? You know, I mean, my blood sugar could have been 50. Who knows? But yeah, again, I think you also have to judge those scenarios, like, okay, she can take something in to eat, she's talking, he's talking the person's, you know, with me? Can we actually like do the glucose gel? Can you do glucose tablets? Can Is it safe to do something to chew? Or should we just do some juice? I mean, but glucagon is always there, if you don't know. And you can't tell us the glucagon. It's, it's going to work for you.

Scott Benner 21:08
But it's the only thing you have at that point. So it's because, you know, just as I'm describing Arden, having a you know, a bad Lo, she could still eat and reason and talk and all that stuff. And so that's fine. But when she was seizing, you couldn't have, she couldn't have drank anything or eaten anything that wasn't happening, she was gone. You know what I mean? So she needed she, you know, in perfect world situation, we would have used the glucagon in that scenario for certain, you know, it's just it's in it's, listen, I have to say this, too. It's frightening. But if you think you're going to live a whole life with type one diabetes, and not get into a situation where you test and see a 26. And I think you're wrong. I think it's going to happen. At some point, I used to tell. It's funny, because you described how everyone in your life knew how to use glucagon. And then I've done the same thing, right? You've explained to a million people that it never comes up. And I think that sort of builds a false narrative in those people's heads like, oh, this diabetes isn't as bad as these people say, right? Because they showed us this emergency thing. We've never used it. It's this. That's not a real concern, because it never happens. I do think that's one thing that happens, but but the other thing is that is that you have this kind of feeling of I don't know, like, like, it's it's never going to happen. But it could, it just really could happen. And and if it does, you can't be freaking out in that moment. Because trust me, I freaked out once. And if Kelly wasn't there, I don't know what would have happened. Because I was like, not processing. Well. And then since then, you know, you learn the second. Yeah, you know, storytime, the second time our had a seizure. We were Disney. And we had spent the entire time day at a party. And we were coming coming back later at night. It was hot. We were walking, she was eating we were giving her insulin, you know, the way we thought we should we were testing she didn't have glucose meters long time ago. And we're we're within like visual sight of our hotel walking back through the park. And this popsicle salesman's walking at us. It's like 1030 at night. And I remember looking up and seeing this guy holding these giant popsicles thinking like, what devil sent you in my path? You know what I mean? You know? And so the kids are like, can we get those? And we're like, yeah, of course, and we gave her some insulin for it and gave it to her right? Looking back now, I never would have given her insulin for a popsicle and that sort of scenario, knowing your blood sugar or not knowing your blood sugar. And so we you know, she eats the popsicle, we walk back to the hotel kids are again, exhausted, she goes to sleep. The About an hour later, the grunting sound happens. And I'm like, this time I'm like, oh, there's no raccoon in the house. Arden's having a seizure. I know what this is. And so it was both comforting and hilarious and scary. All three, excuse me, not both, but all three. I went into the other room got her. Sure enough, she was having a seizure. We went right for the glucose gel because you're like, Well, we know this works. And take the cap off the glucose gel and go to squeeze some out. It won't come out. And in the panic, I just thought, I don't know what I thought. But just the little silver paper was still over the thing, the freshness seal. They squeezed it way too hard. The freshness seal did not come off. But it sprung a pinhole in the back corner of like the sealed part of the tube. So imagine icing tubing and M squeezing it and I am writing in calligraphy all over the ceiling of the hotel room in this laser thin beam. You know, and we all look up everyone laughs we spin the thing around and shoot the glucose challenge Her mouth out of the pinhole and out of the thing rubbing her cheeks, she wakes back up again. She's fine, she's kind of looking at you like yo, what's up, and we get, we get her stable, make sure she's not fallen, and we put her back to bed, the whole thing took like 15, right? And then that was sort of the end of it. And she's never had one since that, you know, but we learned a lot in that in that time. So if you don't think that's going to ever happen, I hope it doesn't happen to you. But to live like it can't happen. That's a mistake. And so back to my original point, when when I used to spend time before when I was younger going into school, and saying, look, here's what you really need to understand about diabetes, and I would go over the stuff. But I would always end with I know, you feel like we're sitting here today, getting ready for when it happens, because it's something we can prepare for I'm like, but the secret about the diabetes and an emergency is, you sort of can't prepare for it. Like, if you knew it was coming, you'd stop it. And that's always the weird part about this stuff is it always happens just when you would never expect that to happen, like because otherwise you'd be sitting around going, oh, you know what's going on this afternoon. It's totally a seizure situation. Like no one thinks that way. And so I don't know, I just, I think it's incredibly important to be prepared as

Jennifer Smith, CDE 26:17
well. And one additional to that, like preparation. Let's say you are prepared, you've done all of your homework, you know, you've got the glucagon, you know how, you know to use it, your friends know how to use it or whatever. And I, I bring this in, because it's something that I do discuss, especially with like older teens, and like college students, and anybody who does a lot of socializing within their job. I think it's, it's really important to know that there may be a point at which glucagon may not work.

Scott Benner 26:50
And that is mess around drinking, right?

Jennifer Smith, CDE 26:53
And I mean, there really is, there's a real reason it's not like the glucagon is like, Oh, I'm just not gonna work today.

Scott Benner 26:59
That's not upset with you for being a drunkard. It's like, you know what? Jenny drinks too much. She doesn't deserve for me to work. It's not like, you're not being judged by the

Jennifer Smith, CDE 27:09
beer. And I would rather she had, like, you know, a Mai Tai or something? No, not at all. It's just, you know, it's the there are biological reasons, right? I mean, your liver again, your liver is like this phenomenal organ in your body. It really is. It's, it's fantastic. And it does a tremendous amount of stuff for you. One of them is, and we kind of call it your body's detoxifier. Right? I mean, that's a really like nutshell term for the things it does. But the livers task of ridding the alcohol out of the system, which it sees as a toxin, it's going to do that first. Before it does its job, it's going to see a toxin is gonna be like, this body doesn't need this, let's get rid of it. And it takes a while for your body to process that alcohol. So I think it's like one drink takes about an hour and a half to process out of the body. Okay. So in that time period, your liver isn't going to as efficiently as effectively check into what's happening with your blood sugar. Right?

Scott Benner 28:15
Yeah. It's not a multitasker.

Jennifer Smith, CDE 28:18
If you give glucagon in that scenario, and now you're asking the liver to do another task, it's not a multitasker. Juggle. I'm

Scott Benner 28:30
busy already. So are you. I feel like Jenny's saying that a liver is more like a guy. Like you give it a thing to do. And it does that thing until that thing's over. And then it moves on to something else. I know, this is a generalization. It's sexist. But, you know, I don't know that. It's, I don't know that it's that wrong?

Jennifer Smith, CDE 28:49
Yeah. And drinking in and of itself can also, you know, do some crazy things just to blood sugar levels in general, right? So if it's got carbs, and if it doesn't have carbs, if it's pure alcohol, etc, you may not have been eating with the alcohol. So I mean, there are a host of other things that could go into a low blood sugar in terms of alcohol consumption. But one of the things of course, is that the livers not doing that drip drip of glucose, right, or glycogen to turn into glucose, etc. So your Basal then that's dripping in the time period that it was beautifully tested. It should be working great. Your Basal is managing without the normal glucose drip.

Scott Benner 29:35
Right? I feel like that's a very important point.

Jennifer Smith, CDE 29:37
So yeah, if it's not doing that, then what happens you get a low blood sugar. Now when you take the glucagon, you're now telling your liver like I said before, to do something to release this glycogen and to give you some extra glucose to bring the blood sugar up. And there's either a major delay or it doesn't, it doesn't do it. So really injury thinking some emergency you know, if you're with it enough to know that your blood sugar is dropping, obviously simple carb, you can do the juice, you can do that as if you're with friends, college friends, a spouse, a significant other whatever, they should know where the glucose gel is something safe. If it's not glucose gel, they should know where the honey is, if they don't know where the honey is, make sure it's cake frosting, something that can be squirted into the cheek can be rubbed in massaged in, it starts to absorb and it can bring the blood sugar up. So

Scott Benner 30:30
we don't want it we don't want to have to swallow it to make this process happen. We want it to absorb through the lining in your mouth.

Jennifer Smith, CDE 30:36
Correct. Exactly. So that's one I think one in that like emergency time of potential Oh, get the glucagon out.

Scott Benner 30:47
Try some other stuff first.

Jennifer Smith, CDE 30:49
Obviously even calling you know, emergency services. Obviously, if you're with somebody you really don't know what to do. Call 911.

Scott Benner 30:57
Yeah, so Well, it's so interesting, because what you just said about when the liver stops making, you know, it stops dripping out this glucagon, this glucose, we always talk about, you know, you need your Basal insulin set up, I'm always saying, right, it's like timing and amount of the right amount of insulin at the right time against carbs or body function. And you know, then we talked about body function being like stress or anxiety or pain, or, you know, all that or your liver and what your liver is doing, that's a body function that's causing your blood sugar to try to go up. And if all of a sudden it's not trying to do that anymore. Now your Basal match, right? It's actually on top of everything else,

Jennifer Smith, CDE 31:35
right. And it's actually the reason that with alcohol, our standard of of education that we see to do is for every alcoholic beverage to take your Basal rate, if you're using a pump, that is take your Basal insulin down by 40% and set it to last duration, at least two hours for every drink consumed. So if at the end of the night, you've had, you know, four drinks, that's eight hours worth of a decreased Basal. So,

Scott Benner 32:06
okay. All right. So let me so now I have this question as we're having this conversation, and maybe I'm wrong. But this thing that we call glucagon that we inject inject in emergency situations, is it actually glucagon or is it something that makes your body produce glucagon? When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G Bo Capo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk. The remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour you can get a free contour next gen starter kit by visiting this special link contour next.com forward slash juice box free meter. When you use my link you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen it fits well on your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now through your insurance. Contour next one.com forward slash juicebox free meter go get yourself a free starter kit. while supplies last US residents only touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org Go up to the top of the page where it says per grams. There, you're gonna see all of the terrific things that touched by type one is doing. And I mean, it's a lot type one, it's school, the D box program, golfing for diabetes dancing for diabetes, which is a terrific program, you just click on that to check that up ball for a cause their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touch by type one touched by type one.org, or find them on Facebook and Instagram, links in the show notes, links at juicebox podcast.com. To touch by type one, and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org.

Jennifer Smith, CDE 35:43
No, it I, I understand that it's glucagon.

Scott Benner 35:47
So glucagon makes your body make more glucagon,

Jennifer Smith, CDE 35:49
glucagon injected makes your liver release glycogen and transition it into glucose.

Scott Benner 35:57
Okay, so is this stuff that we're injecting helping bring up our blood sugar? Or is it just making that function

Jennifer Smith, CDE 36:04
that's making that function, right? It's the glucagon that you inject is telling your body to release the stored glucose and send it into the system. That's what raises the blood sugar.

Scott Benner 36:15
Gotcha. It seems like such a simple thing. But as we were talking, we're a half an hour into this. And I'm like, maybe I don't understand what's in the vial.

Jennifer Smith, CDE 36:22
It's unless somebody else knows something else. I all the years, it is glucagon in the it's in that little vial. And it's not as very stable compound at all. I mean, that's why it's in that like, it's why it should shift the way it is. That's why it expires so frequently. That's why you have to mix it and use it. You know, I mentioned briefly before even using mini glucagon, a small portion of what you mix up, if you are you know, alone and you can use it yourself that vial that you mix up then it's only good for 24 hours kept in the refrigerator. So so

Scott Benner 37:00
and so you're talking right now about the one that comes in the red box, the one that's made by Willie so I guess let's break them down a little bit because now they're suddenly on the market more glucagon it for ever and ever. It was the you got the red box, right? And so inside of that red box familly is a vial like a glass vial. And it's got powder inside of it. And then there's a, a needle with and it's an inter muscular needle. It's not an under this. It's not an under the skin like little insulin needle. It's like a

Jennifer Smith, CDE 37:30
all the way and it's a good size. No, yeah, it's

Scott Benner 37:33
a hunk of a needle is what it is. And so you pull out the vial with a powder in it. You take the needle, and you inject the liquids, it's in the needle into the vial, then you kind of spin it together, you know, between your two hands. I know you can't see what I'm doing. But you write that and then it, it constitutes it, it mixes the powder with the liquid, then you have to draw it back into the syringe. And then you're supposed to stick that syringe like into the muscle in your butt, right? Or something like that

Jennifer Smith, CDE 38:00
right into the bot. Yep. I mean, yes, that's the easiest place.

Scott Benner 38:04
You're injecting that glucagon into the muscle. All right. Now that's one glucagon. But since that's happened, another company made a nasal glucagon who made that you remember?

Jennifer Smith, CDE 38:15
Gosh, I don't remember the name of the company. It's back shimmy is the name though? Of the

Scott Benner 38:23
so now that's sort of like, you know, everyone, I think assumed it was like an aerosol, but it's more powdery, right? Have you talked to anybody who's used it? I've

Jennifer Smith, CDE 38:32
not talked to anybody who used it. I have it myself. I did get a prescription for it. And part of the reason quite honestly, that I got a prescription for it is well, twofold. It's it's certainly much easier to use from all of the research and all the studies. The there's a significant decrease in accuracy of use, or a significant increase in the accuracy of use with the back shimmy compared to the mixed injectable.

Scott Benner 39:03
Okay, um, let me do me take it first. And I'm looking at it so it's actually also made by people and and it's so it looks like it comes in a thing that looks like you know, sailing, you'd say the tube looks like a sailing thing you'd sprained your nose, but I'm reading it here it is a powder, dry powder spray in a portable single use ready to use device now. I have only heard from a couple of people who have tried it. And so far the people who have tried it have said to me they burned their nose interesting, like so the inside of their nose. I don't they didn't say about how well or not well at work, but Jenny's hearing that it works more that it works better than the

Jennifer Smith, CDE 39:42
in terms of accuracy. It was from what I know it works the same as dosing, but the accuracy if somebody else has to give it to you, it's more accurately delivered.

Scott Benner 39:53
Okay, so in a panic situation, your friend is a little more able to stick somebody Your nose in squeezing than it is to do everything I just described, and then tricking your body.

Jennifer Smith, CDE 40:04
I mean, I guarantee that Arden was two and a half, if you had had something like this, taking it out of the bottle, sticking your nose and pushing it in, you would have had no trouble doing that, you would have been able to figure it out. And I, you know, a big part of having it in the house is because with little kids, you know, I, my seven year old is a smart kid. And while he would know to call 911, he would know to go to the neighbors if I was a whole loan with them, and I wasn't right. Yeah, this is something that I easily showed him in two minutes. And I was like, this is all you got to do and then run to the neighbors. That's that's all you got to do.

Scott Benner 40:47
You know, you're gonna sleep soundly one day and wake up burning up burning in your nose and your front door Why No, kids gonna be like mommy's down, and you'll be like, I was just sleeping. So now there's a third one on the market. And I just left Arden's appointment the other day, and I got our glucagon change to G voc. Okay, so, so g voc comes in a syringe still, but it is the I think the kind of the genius of what this company figured out is, is that it's, it's pre constituted, you don't have to mix. It's not a powder in a liquid. And it's incredibly stable. So my assumption, I'm making an assumption that you might, you know, maybe people who used to think, oh, one day, we're going to make a closed loop system with glucagon and it but we couldn't, because they couldn't figure out how to keep that glucagon stable long enough. I'm starting to think maybe that that might be the next step after these algorithms. You know what I mean? Maybe it will be a dual chamber pump with an algorithm. And this, but I went with this one, and I will be 100% Honest, why? There's two things. The nasal thing to me, seemed everything what Jenny just said, like, seems super easy to do. And all that stuff. As soon as I started hearing about the burning, I thought, okay, like, that makes sense. And I still was gonna go with it. Until and again, this is me being very honest, the makers of jokes said, we'd like to come on the podcast and talk about the glucagon. And so sometime in the future, you're gonna hear an interview with the CEO, and he's gonna tell you why the company started and all this stuff. And it was super hunched, hitting an incredibly interesting life. i It's possible that when you listen to it, I mean, if you listen to this podcast enough, you might not be surprised by this, but I don't know exactly how much we're gonna talk about the glucagon how much I'm just gonna be like, so what did you do after college? That's weird. And, you know, but that, so I went with it, for two reasons. One, because it's stable. And you know, I don't have it doesn't have to be mixed. The injection isn't intermuscular it's just normal. It's just a normal like, little needle. And I thought, maybe I can use it for bumping, like doing glucagon, like little bumps to and that wouldn't be possible with.

Jennifer Smith, CDE 43:10
And there is, I mean, there is a guide, certainly for using you're talking about like that mini dosing kind of of glucagon. And there is a guide for it. In fact, it's, it's actually a guide that starts with, you know, a tiny, tiny amount for little people.

Scott Benner 43:26
And you and I talked about it on the prototyping so yeah, about Elvis, we talked about that, right. So people can check that out if they want to hear that but and so incredibly, ironically, I guess, not long after you and I recorded the the illness Pro Tips episode, Arvind, got sick for a number of days. And unlike most people who are like, Oh, I got sick, and my blood sugar went up, Arden gets sick, and our blood sugar goes down. So there was this one time her blood sugar was, you know, was at 70. And I'm like, it's gonna hold it's gonna hold eat something. And then the food didn't do anything to her. And it kept drifting down. And I gave her more and more. And then there was this moment, you know, we're like, 45 minutes into this, and she's now 55. And I'm like, Jesus, none of this food is touching her. And I so I'm thinking to myself, what's next? Like, I have to do something right now. I walked up to her with a juice box. She goes like this. Put your hand up and she goes, if it's my time, it's my time. But I'm not drinking another juice. Like girls super serious and trying to be funny at the same time. I said, right on, okay, I hear what you're saying. She's like, seriously, if I drink another juice, I'm gonna throw up and I was like, gotcha. So I went downstairs. This is probably look first of all, this is completely off label. But it's also why at the beginning of the episode, I tell you, this isn't I'm just telling you what I did. It's not medical advice. And I took my old you know, read kit from Lily and I mixed it up. I went back and listen to what you and I said to each other. This is maybe like, I'm like, I wonder what I'll do. You know, like, there's a podcast episode about this hold on. Then but and I remembered and I drew up like I kind of spit balled it a little bit. It was off based off of weight, I remember that I drew up seven units. And I gave it to her. And it took a little while. But no, why her blood sugar went back up, not too far. And it leveled out. It stayed there. And I was like, right on, I am definitely getting the G voc instead of the nasal stuff, because this might happen again. And that that was my reasoning for going that

Jennifer Smith, CDE 45:30
big question about the G voc would really be the pen itself? How How, how much is in the pen? Like how many? You know, what's the dosing because when you look at how much to give, it's, I think it's if you're over 50, in the doses, 15 units of mixed up glucagon. And that would be given kind of like we talked about before, and the other, the other episode, a certain amount of time. And then if it doesn't bring the blood sugar above 80, then you reduce with the double the amount. So just with the G voc, my question would really be how, how much do you know that you're giving as a mini dose? Right?

Scott Benner 46:12
And I'm gonna find out because you're 100%? Right. And so I'm gonna try it. I'm gonna find out. And if it's not right, I'll switch to something else. Yeah, no, but I think is this gonna work enough to

Jennifer Smith, CDE 46:22
do any of that extra stuff? That's really awesome. Yeah.

Scott Benner 46:26
I think that as a replacement for the lily one, this one's a no brainer, right? Because you don't have to mix it up. And it's not this giant needle. But I think and this is not something the company said to me. My but my assumption is, the real excitement here is about the possibilities for dual chamber pumping, right? Because it's stable. And not only that, I think the bigger excitement and I think the CEO alludes to this, if I'm not mistaken, I'd have to go back to listen. But my assumption is, they figured out the science of making something liquid stable, which now means that science could get applied to other things. I'm guessing, I'm guessing, I'm guessing this is the very infancy of this company is what I'm is what I'm thinking and run by nice people. So that's cool. Okay, so we went over the three different kinds of glucagon. What and the when? Right, you're going to use glucagon when somebody can't physically take something in their mouth? Right, right. When Arden had a seizure, we only use the gel and rubbed it into her cheeks. We weren't trying to get her to swallow it. If you try to get somebody having a seizure to swallow something, you're gonna get them to aspirate. It's bad. Right? Right. Don't do that. Right.

Jennifer Smith, CDE 47:40
Maybe even a you know something for, as we know, symptoms of low blood sugar, even if you're not passed out or having a seizure, you could be not together with it, right? I mean, many people complain about their spouse, significant other child child getting very violent, or very abusive, or whatnot. I mean, getting them to eat something is maybe impossible. So using glucagon, in a scenario like that may be your only option.

Scott Benner 48:11
Yeah, you might be maybe

Jennifer Smith, CDE 48:13
tackling them and holding them out. Exactly. But you hold

Scott Benner 48:16
the needle, I'll tackle them that hand me the needle, it's gonna be a lot of fun. Yeah, well, well, that really is, you know, I've heard the stories too. And there's been people who've come on here and told them, but I've heard them privately two of the worst scenario ends up being when you're two adults, and one of us physically smaller than the other one. And the larger person, you know, becomes combative or angry. And I've heard about, I've heard about people throwing furniture and, you know, say saying terrible things. And you know, and everything.

Jennifer Smith, CDE 48:49
From a safety standpoint, you know, if the person is up and moving and in, let's call it like a violent sort of behavior, and you're not safe. Just call 911. Call 911. That's really, I mean, don't try to get close to them with a needle and try to stab them is not a good idea.

Scott Benner 49:09
It's such a, it's such a bad television show. You just see two people standing across from each other and one guy's ranting and raving and holding a lamp and you've got a needle in your hands. Really, it's like every bad movie I've ever seen in my life. I think the goal would be not to get that low. You absolutely can. But like we said, these are emergencies, they don't happen on purpose. I think it's just very important to remember, like, you can't plan for an emergency. I mean, you can plan for what to do when it gets here, but you can't plan for when it's going to happen. Right. So let's talk about since we're in this vein right now, and we're using up our time and we have a couple more minutes. Let's talk first about low symptoms. Some of the things you've heard people saying I will start with the one that aren't in tells me what is happening. Why or why am I being treated poorly here? Oh, you know what, actually, this is funny. It's Express Scripts I have to say okay to prescription to the to the glucagon prescription. I'll call them back off the call them back in a little bit. But I know that's what that is. Now my wife has picked it up downstairs and she's busy listening to a recording. And she's trying to figure out why she's listening to it probably. So are we the other day? She she got a little low, right? We were going right into a restaurant. So she went like quickly from like, 75 to 60. And I was like, Hey, you're dropping? And she's like, Yeah, I know. And I was like, how do you know? And she said, My lips are numb. And I was like, really? She goes, Yes, she's like, that's the one that I like. That's my physical tell. She's like, my, my lips get numb. And she goes, and if you don't take care of it. She's like, I didn't realize before. So she told me a story. She said one time she was out with my wife. And this happened. And my wife gave her a drink to have. And she drank it in orange, like, oh, this tastes terrible. And my wife said, really? And my wife tried it and said, Kelly's like no, it seems fine. And Arden kept drinking a little while later, I think we were at a baseball game for my son's and I was on the other side of the field. So I came back over eventually. And my wife said, Hey, Arden was low earlier, but we took care of it. She drank this. She said it tasted weird. And so I tasted it. I was like, I'm zone tastes fine, you know. And so it took Arden She said, It took her years to figure out that when that numbness comes, it's it's affecting like her tongue in her mouth to she feels it on her lips. It says everything. Everything tastes weird. At that moment, I was like, Oh, no kidding. So I was wondering if that happened, anybody? But what are some of the, like, what happens to you?

Jennifer Smith, CDE 51:42
So and I think that's, it's good to acknowledge symptoms and understand that there are many symptoms, because they can also change over the years. Like I, you know, when I was younger, my symptoms were the classic like, I would get, like, visibly shaky, I could hold my hand out and I was like, visibly shaky, beyond just the internal symptom. It was there was a visible cue there, too. In college, I also had something very similar to what Arden is describing. But it was more it was more like an internal mouth numbness. It wasn't really my my lips, it was more like an internal mouth like it almost like you know what it feels like to be numbed at the dentist that like you feel like your whole mouth is thick, and like, puffy. That's what it felt like to me. Now,

Scott Benner 52:36
how long did it last after you ate like after you brought your blood sugar back did it last?

Jennifer Smith, CDE 52:41
Ah, for gosh, I mean, I would say it probably lasted a bit of time after my blood sugar was actually normal. Because they specifically remember it. Like in college, I was still on injections. And so I would often have that as I came into lunch, because they had pretty full mornings of like zooming around on campus and getting back and forth to classes and whatnot. And so I would often have that at lunchtime. And I can say that, before I headed out into my next course of classes in the afternoon, I still had that feeling even though my blood sugar was already back up from having eaten. So I guess for a bit of time, it seemed to last. Whereas my symptoms now don't last after I've treated, they don't last long unless it is, unless it's been a significant drop. That's happened very, very quickly. And it takes a while for the carbs to kind of start to make me feel better. My symptoms now are much more like this, like feeling of everything rapidly moving. Like I feel like the world is spinning and moving. And my thoughts are fast. But I I feel like I'm walking through mud. I feel like I just I can't keep up with the way that my brain is thinking about things. So

Scott Benner 54:16
I wonder if we'll never know, obviously. But I wonder if your thoughts are at regular speed and your body is slowed down? Or if your thoughts are sped up and your bodies that regulate. I'm so interested in that. There's no way to know, because it's one or the other, right like your one part of you is being fooled about something. Yeah, yeah. And everything feels like it's like, you feel like that might be what it is. Maybe it's like that. Maybe you feel like you're in slow motion. I don't know. Isn't it weird? It feels like it makes me feel like you're in a country. And you're like kind of screaming like you know what's going on but you can't affect anything. Is it that kind of a feeling or no? Am I wrong?

Jennifer Smith, CDE 54:58
It's somewhat Yeah. The other one is kind of feeling like drunk. Like I get kind of tipsy. And I'm like, I've I've literally been like drunk maybe three times in my whole entire life. Right, but that's what it feels like. But that's not every time but some of my lows feel. And I'm a I'm a very happy like drunk person, like everything is fine and happy. I'm not an angry drunk. So, I get kind of tipsy with a low blood sugar sort of like, Ha ha ha, that's funny when it really isn't funny at all.

Scott Benner 55:39
It's and it's like I'm describing with Arden to like, cuz she's done that a couple of times, like, you know, I'll be like, aren't getting up, you have to do something, your blood sugar's low, and she'd be like, I'm just gonna die over here, like, but that's very jovial when she says it, like she's very like jokey about it, like, I guess. Yeah, it'll just be fine. But you know. Yeah, I think it's interesting. So when people have you heard from other people like some of the stuff because they are, before we go into that, let me ask you this one. When you wake up after you've been low for a while, and you didn't know, why are you so sweaty? Do you know, it will sweat when their blood sugar is

Jennifer Smith, CDE 56:14
low? It's a body response to the low blood sugar. All of the physiologic like mechanisms that make it happen, I, I can't really speak to, but I do know, it's very, very common to wake up in a sweat.

Scott Benner 56:30
Yeah, like bad, like change your clothes after you treat your blood sugar. Like, take the sheets and wave them around for a while. You're just like,

Jennifer Smith, CDE 56:39
right, I even kids. You know, I've heard some parents comment too, that, you know, an older child will obviously wouldn't be wetting the bed anymore. With a low blood sugar may have mainly because they've not got the conscious, I guess, ability during that time period for their brain to wake them up to actually get up and go to the bathroom. Because they're low, you know, so but I mean, outright symptoms, you know, even blurred vision can be one of those sort of like a tipsy feeling on your feet. The shakiness in the hands, people talking kind of like, kind of like off the rocker sort of like you ask them a question. They don't make sense. Yeah.

Scott Benner 57:21
Confused, confused. Right. And I guess it's funny to like I, I've read, you know, back in the day, like all kinds of blog posts from people where they talk about being low, and everyone describes it like slightly differently, but I think it's situational, too. It's really interesting. There's somebody I keep thinking of having on just to describe a low one time because this person's low was like an amazing story. And I'll have to see if I can figure that out someday. Okay, treating things. Like let's so let's talk about it for like to finish up real quick. My blood sugar's falling, but I don't want to get high again. I'm ahead of it now. Like, you know, I know people know Arden's a juice box person, if you know if, if she's looking for a quick hit, if she's not hungry, juice boxes work for her, we use this very specific juice box. I think it's important to remember that you're not looking to drink. So I found the smallest box I can with the most carbs, so that she's not having to us like I started helping Arden's friend the other day. And you're gonna and she's doing great boy. Yeah, and but you know, at the first time was like, hey, I need you to drink some juice. She pulled out this juice box, and it was huge. And I'm like, Yeah, you that's fine. here and I sent her a link. I was like, get these like, you're killing yourself. You drink eight ounces of juice to get 15 carbs. I only want you to know, the juice is medicine. It's not for fun, like you know what I mean? So juice boxes work. I've talked to people who use jelly beans, Skittles glucose glucose tablets Skittles like so you're you're looking for something that's a real simple sugar that's getting absorbed in your mouth and then hitting your body quickly when you swallow it like that's it so what sometimes people say milk but I don't think milks is fast right that's

Jennifer Smith, CDE 59:08
yeah, I mean ages ago that was one of the treatment things even on my list when I was little for low blood sugars it was milk. Well when you consider like whole milk when there's fat there, there's protein there. And the body actually has to has to break down the milk sugar in order to get the glucose part out of it, which is what actually brings your blood sugar up so I don't ever recommend milk. I really don't think it's I don't think it's a good low I mean obviously if you don't have anything else around, have at it, drink your milk, but there are much better simple sugar things to carry along with you even dried fruit. And you know when I was little, my mom actually used to give me the little mini mini boxes of raisins. And then I at the end of the school year had these like dead raisins sitting all over the bottom of My backpack that had to be like, they were disgusting. They were like, you know, full of dirt. And they were gross. But that was what worked. I mean, raisins were easy. They they worked well. They got the glucose tablets when I was little were horrid. They were horrid. I mean, if you think they're bad, or no, they were bad years ago, I mean, now, the only ones and I don't even I don't I don't know if they're on backorder still, but the gluco lift brand is the only one that I love. They taste good. They don't come from a GMO glucose source. All the colors and the flavors come from natural fruit and fruit extract. So they're not artificial. You know, no Lake number 70, or whatever it is. So but something simple. I like your juice box, though, I actually have kind of the opposite. I look for the smallest juice box that has the least amount of carbon it because I want to drink either I'm like half awake, if I ever do have to treat a low overnight, which thankfully, I haven't had to do in a really long time. But I don't want at two o'clock in the morning to have to be completely fully conscious like

Scott Benner 1:01:14
to say to yourself, I really just need half of this juice box.

Jennifer Smith, CDE 1:01:18
boxes I get are actually they're they're four ounces. And they're only eight grams of carb apiece. That's Oh, cool. So you know, they work Nice.

Scott Benner 1:01:27
Nice. I know. Arden also carries those little pouches of fruit snacks, whether and they always have like eight or nine fruit snacks in them. And it will sometimes eat for fruit snacks to eat to for snacks. So the other morning, we were heading to school and she goes here, throw this out for me. And she gives me a package of open fruit snacks. I still have four in them, but their heart is a rock, you know. And she's like, they're hard. And I was like, Okay, I'll get rid of them for you. And but yeah, she always has one of those. So in her bag, she has a juice, a small juice box and a small pack of fruit snacks. And she always has that whether and then and then there's juice boxes sort of spread around the school. So Arden's in high school, so she changes, obviously, you know, classes. So there's, you know, in a closet somewhere, there's a couple of juices in each class. And then wherever she is and she has to take one out and drink it from her purse, if she does, she just hits the closet and replenish his or hers. You know, I have to say that we don't you know, the beginning of the school year, it's not as it's not as intense. When you're older. And you've done it for a while, we just take two bricks of juice boxes and spread them around, like, you know, like rose petals that are at a wedding, we're just like, there are some here and there, then you're done. And then maybe once a year, Arden will be like, hey, I need more juice boxes. So she might go through. I don't know, she might go through 1020 of them a year at school. But that's

Jennifer Smith, CDE 1:02:49
pretty minimal. That's actually pretty good. You know, when you when you get to be an adult with diabetes and have kids in your house, you actually have to be kind of good at hiding things. before disappearing, appears like literally I mean even I mean, even my husband will drink them or eat them. And he I mean, you know, he'll tell me if they're obviously not there anymore. But me my kids, if I have my glucose tablets out, they'd love them. So I hide them. And so it's like it becomes really important like purses, by purses. I have like these internal like hidden pucks pockets in many of my purses. Because when they see an open purse on the table or the floor, they're like, Oh, does mommy have any of her stuff in here? Like, mommy stuff is for a really important reason.

Scott Benner 1:03:37
You actually reminded me that during during a family vacation once there was an argument. Because we were we were in a moment where it was summertime. And we now by the way, we now because of Disney knew how like magical popsicles were right. They give you a little bumper that didn't make you go too high or anything like that. And for our net lease, and so we bought these box of popsicles, like you know, you get to a shore house, you go out and go shopping. And someone said, Oh, I'm gonna have a popsicle. And I was like, hey, you know, I just need you to not touch those where you've got them in case Arden gets low, which prior to all the technology was going to happen like you were going to use those popsicles. And one of the parents said, that's not fair to the other kids. And I remember Kelly going will tell them to get diabetes and then they can have all the popsicles they want out of the box, you know, but like for right now, just don't touch the popsicles. But it actually caused it was like, ah, like, you know, that's that's not fair. Are Kelly's like, are we talking about fair because my kids

Jennifer Smith, CDE 1:04:34
got diabetes got.

Scott Benner 1:04:38
If we're measuring fair, I think I win, you know, like, so anyway. Do you feel like we did a good job here? I do too. All right. Cool. So I will so let me say goodbye let you get back to your business. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free Contour. Next One. starter kit at contour next one.com forward slash juice box free meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC A G o n.com. Forward slash juice box. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed or starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and an episode 1025 We talk about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

#1013 Diabetes Pro Tip: Illness, Injury and Surgery

Scott and Jennifer discuss getting ready for a hospital stay with type 1 diabetes.

You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you. Right now at my link only contour next one.com forward slash juicebox free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen. Find out more at G voc glucagon.com. Forward slash juicebox. J Let's do a big Sick Day episode. And so I'd like to try if we can to get through sort of a regular sick day like you know, little beyond the sniffles the the flu a stomach virus, an injury like a broken bone or something I might have to take, you know, steroid for and then an actual surgery and have you where do I want to start? You've had a surgery pretty recently, haven't you?

Jennifer Smith, CDE 2:50
I've had multiple surgeries. I've had a week surgeries I've had I've been out surgeries. I don't like surgeries. But I've had them. Yes.

Scott Benner 2:59
So let's start there a because you got good information about it and be because Arden is going to have a cyst removed in a couple of weeks. So I'd like to hear about this. So let's start with something you were awake for. I guess also, like dental procedures would probably fall in this category a little bit maybe, maybe not,

Jennifer Smith, CDE 3:20
they could they would be a little bit different only because like a dental surgery if you're going to be awake for it like just a tooth removal or something like that. Usually, the awake component to it means that you don't really have to go in fasting or without any food in your system, you know, those kinds of things. If it were going to be a no now, they usually try to take all the wisdom teeth at once if they're going to do that. And oftentimes now I've heard a lot more people being completely put under my son was for wisdom tooth, you know, extraction, I didn't I my dentist said Your mouth is not big enough. You need to have your teeth come out, but there's nothing wrong with them as they come in, we're going to take them out. So as my teeth kind of came out and honestly my wisdom teeth didn't completely come through until I was well into my 20s and so they just took them out in office.

Scott Benner 4:25
I mean, I'm gonna make a note here to myself, because it has nothing to do with this. But my wisdom teeth extraction story is absolutely insane. And I will tell it at the end. So why don't we just made a note to myself. So okay, so if I'm just going to the dentist to have a cavity down or something like that. Not a lot for me to do probably handle things the way I normally do. You know, I guess

Jennifer Smith, CDE 4:49
your big thing to make sure is especially if you're new to having it done is and you've never had any like pain medication. No, you may experience a little bit of a higher blood sugar, potentially a stress component from having like the Novocaine. I mean, that needle is, it's scary, it's a scary looking needle that they're shoving in your mouth, right. And it doesn't feel very nice either, as they inject it several times. So for those of you know, those people who have never had this done, I, it's not very fun. And if you ever do have to have it fun, done, it's not a fun thing. But it could cause a rise in blood sugar because of a pain component, because you're just in a setting that's completely not under your control. So, but other than that, yeah, you shouldn't, you shouldn't have to go there fasting, or make any true adjustments to anything. You know, in the future, if you had a second surgery, or a tooth extraction or tooth work, and you knew what happened the first time, you could potentially look back, and maybe make adjustments like setting a Temp Basal increase, or taking a small amount of Bolus ahead of time to offset arise if you don't want it, or just correct after if you're not quite sure what's going to happen.

Scott Benner 6:07
Yeah, especially I'm thinking if, you know, if you're trying to, I'm not usually up for like, run high to avoid a low kind of situation. But if it's an hour, an hour and a half, and the dentist office, and it makes you comfortable, you know, let your blood sugar be a little higher for that. And then and then get at it. And because I guess too, if you're numb, taking in juicer gel or something like that could end up so you don't want to be in that situation be harder.

Jennifer Smith, CDE 6:29
Exactly. Yeah. So it's it mean, in some things like that, it sure it's a little bit safer to potentially be a little higher, if it does end up rising. I mean, obviously, don't go in at a blood sugar of 250, just because you're scared. But if it rises up, you know, higher than you'd love it to be, again, an hour hour and a half of being too high, you can correct it after without worrying that things are going to drop too much. And you can't chew anything, then that's okay.

Scott Benner 6:56
So this is so funny, I'm going to ask you, when I say leave it a little higher, I have a number in my head, what's your number?

Jennifer Smith, CDE 7:03
Let's say a little higher would be like 180 ish. Yeah,

Scott Benner 7:06
I might be insane. Actually. It's like, I was like, he could comfortably be 35 ish in there, I don't want to get crazy, that thing starts drifting to 160, I got a fight with it, then you know. But the point is, is wherever you feel like you can keep the control. And if you're real stable, that could just mean like dialing your Basal back a little bit to just let your blood sugar kind of come up a little bit, you might not have to eat something to make it happen. Okay, so that's simple. Now, moving on to the kind of the next step of it. Wisdom teeth knocked out cold. Now, I do know this from my son, if you get a good doctor, you're only under a very short time. But when you come back, you are not in any shape to make decisions. drink, eat, my kids said some crazy stuff on the way home from that doctor. And then even once his head cleared out, which I have to admit, didn't take too long. He's bleeding, his his mouth is packed with gauze and everything. So I guess we're in are we in that situation, now we're better high than low,

Jennifer Smith, CDE 8:12
it would be better than to be I mean, again, in that case, you know, if you went into that surgery to be put out and your blood sugar was nice and stable, let's say 120 even, it should for the short amount of time of that type of a procedure, it should remain stable, or it might climb again, from the stress on the body. In the aftermath of that, though, again, it would definitely be better to be a little bit higher than you're typically running. And again, I'm not saying like 180 200 High, obviously, you could correct to bring that down safely. But if you're running like 140 Leave it i that there is no detriment there whatsoever at 140 You know, as long until you can take something in or start to eat, or, you know, whatever the dentist told you for when you could start to eat again. I mean, even with my wisdom teeth being taken out one at a time, I think there was I think I had two taken out the first time it was a bottom and it was a top wisdom tooth. And I remember a couple of days of like just soft it was you know where the chewing component just was not pleasant. So having a plan of action to just like any other sick day kind of thing, having some things ready to go especially if you're an adult and you're taking care of yourself. You know having some soup or some broth or some jello or yogurt or popsicles or even ice cream or whatever it is that you can tolerate soft enough don't have to chew it that you can get something in.

Scott Benner 9:46
I think that I think that my as I'm thinking about this happening for Arden next year, probably my plan would likely be higher, not so high that it could get away from you higher but control And then if it tries to move, just kind of keep tamping it back down a little bit like so that you're in the power position, right? It's not out of control high. So that you're, you're going, Oh, geez, I have used a lot of insulin here. And it's not low, just you know what it tries to come up, push it back down, like, play, play that game for a little bit. So you've got the level you're looking for, but you're still reasonably in control of what's happening. I put yourself in a power position there, I think that's happened to handle it.

Jennifer Smith, CDE 10:25
That's correct. Considering the fact that as we've said before, the littler incremental adjustments sooner mean less insulin sitting there to potentially dump you down to low later. And then a setting where you can't actually take anything in, whether it's a mouth surgery, or this might even move in to kind of like stomach bugs or those kinds of things where you may not be able to take anything in or not quite sure when you can take anything in. It's it's certainly better to nudge little by little rather than take this big walk being adjustment and then you can't eat anything to offset.

Scott Benner 11:01
Yeah, I think bumping is the nudging is the way to go. That's i So as I'm considering it right now, for the first time talking to you. And when artists wisdom teeth come up, I think that's definitely what I'm gonna do. I'm gonna shoot for 140 in that range, take your advice over my advice, maybe more like 141 50. And then just keep knocking it down. If it's if it tries to run away, basically, just kind of keep tripping it as much as it tries to get up, I don't know.

Jennifer Smith, CDE 11:29
And find out ahead of time what her favorite soft or cold things are, so you can have them ready.

Scott Benner 11:34
Well, yeah, the pre like, you're gonna have to prepare, right? Like you're gonna hate. This is not something you're gonna want to think about after the surgery is over, you're gonna want this stuff

Jennifer Smith, CDE 11:41
like parking lot of the grocery store while you run in and be like, What did you want to get in her mouth is full of gauze. And she's like,

Scott Benner 11:49
I can't get her to pick food when she's not sick or injured. Like we were at the grocery store yesterday. I'm like, you just grab a couple snacks for lunch, whatever you're looking for. I don't know, you decide. And I said, How about those? She goes, No. And I went, Well, how are you going to tell me the side? And then I say something? He told me? No. I was like, what if I grabbed something that cheers if you show it to me, I'm gonna say no, if you bring it home, I'll eat it. And I went, Oh, that's a reasonable understanding of your psyche. I was like, Okay, great. So I did anesthesia impact at all.

Jennifer Smith, CDE 12:19
So some people, myself being one of them, not only do I have experience with surgery I've experienced with anesthesia, not my body doesn't like it. So again, if you're going into something where you've never had any anesthesia whatsoever before, just be aware that it can cause some like, post operative nausea. Many people get a little bit like woozy headed, I myself just don't tolerate it at all. I talked to the anesthesiologist ahead of time, I say, you need to load me up with whatever tools you have. Because I will probably throw up on the nurses when you get me awake. And there's only literally been one time that I had a I had a hernia surgery and umbilical hernia. And, man, if I could carry that anesthesiologist around in my pocket, if I ever needed surgery again, and his little toolkit of medications, he used post surgery, I was golden. I didn't feel horrible. I mean, you know, normal, but not like nauseous, whatever. So anesthesia can cause some nausea. So just be aware of that. If you know that's an issue, again, talk to the doctor about it ahead of time, there are many different kinds of medications they can use to stop that. And it depends, you know, on post surgery, sometimes they'll try to get you to nibble or drink a little bit of something in the post op when you're you know, recovering waking up. You can also be really really woozy, like in and out of like waking up and then getting really drowsy again and that it takes for everybody it takes a little bit of time to wear off. Usually in a post op setting. They'll probably have you in recovery for at least an hour. It could be longer than that, depending on how you seem to be doing. So it's I've always brought somebody along who knows how to look at my pump, how to potentially do a finger stick for me even though the nurses there could definitely do that for you. So my mom has come to a couple of my surgeries. My husband was there obviously for both C sections that I had. So it's really really really advantageous if you've got a go to person to be there after

Scott Benner 14:43
so funny. I alluded to this while we were recording recently, but you I have a question that's on the tip of my tongue. And if you would have paused I would have asked what you said. I'm like, one of us doesn't need to be here. I'm afraid it's me. So I was gonna say Did you wear your pump? And yes, you know, how did you take control of it? What did you do? So, as long as you were coherent, you were doing it?

Jennifer Smith, CDE 15:09
Correct. As long as I was coherent I was doing it's also really an ahead of time for any type of surgery. I mean, again, like a dental all kinds of things. Dentists could probably really care last as long as things are okay and controlled when you come in. They may if they know you have diabetes, they're definitely going to ask when you come in are your sugars, okay? Are they control? Are you feeling well, you know, whatever, they're not going to know anything about telling you to do or dial back or dial up or anything that's a dentist, people, doctors, though, will be more involved will be more involved. And they think it's really important thing to talk ahead of time,

Scott Benner 15:49
right? Because they're as a default, gonna just err on the side of I'd rather see your blood sugar be 300 for the next couple of hours, they're always going to feel that way. They don't really want to be managing your blood sugar. I really don't. Yeah, I've seen this now in multiple people in my life type two type one, you know, all the way down to my my friend Mike, who was in a, you know, in a coma at the end of his life. And they nobody would nobody? Gosh, I don't want to say they care. They didn't care. But it was a problem. They they weren't prioritizing, I guess, you know, it was a

Jennifer Smith, CDE 16:24
secondary issue. Yeah.

Scott Benner 16:26
They think of it that way.

Jennifer Smith, CDE 16:29
They're they're concerned. I mean, from the medical standpoint, in fact, if you don't address the fact of staying on your pump, and keeping your CGM on and whatnot, as long as you can keep them on, there are some medical procedures that include machines in the operating room that could potentially require you to be off of your products, just from a machine. I guess, interference standpoint, there may definitely be some things, there may also be length time of a procedure or a surgical procedure that determines you need to be on an insulin drip versus being left on your pump. So you know, those kinds of things, there is a definite difference. But for shorter lived surgeries. If you go in with your team, and you talk to them, and you say hey, you know, you know that I'm on an insulin pump. If you've got backing of your Endo, you can have your endo write a letter of approval for you to remain on your pump and your continuous monitor through the surgical procedure. Your doctor may even include in it, you know, glucose levels, we've, we've discussed, she or he will come in with a glucose level here to here, she or he will have a temporary Basal adjustment set, many doctors are a lot more conservative than you need to be for surgery. Many doctors will say dial the basil back by 50%

Scott Benner 17:52
just seems like a lot, again, which is a lot.

Jennifer Smith, CDE 17:55
And for most people again, there are the rare people who have a drop in blood sugar from that stress impact and whatnot. But it's not common. It's more common for stress to cause a rise in blood sugar. So, you know, dialing basil back kind of goes back to some of our other episodes about like testing things. If you're going into surgery, first thing, they will usually have somebody with diabetes on insulin, have surgery first thing in the morning, they will not push it into the later afternoon or the evening, mainly because they'll want you to come in in a fasting state. And it's easiest to get that in the morning for somebody with diabetes. They're in lies, do you know that your Maysles are doing what they're supposed to do? If you've got time?

Scott Benner 18:45
Well, yeah. Can you imagine to you're going to need to be fasting for a procedure at 8am and you wake up and your blood sugar's 45. What are you going to do? You know, you're gonna have to do something. And now you're gonna have to show up at the hospital and say, I drank juice this morning, and then they're gonna Bucha back out again and you have to reschedule. So, alright, that makes sense to so conversations ahead of time with doctors. I'd like to control my own insulin pump, I can do it when I'm on, you know, when I'm not capable. I've got a person here to help me. Here's a letter from my endocrinologist outlining you know, some of my goals for my blood sugar's that they'd like me to be able to stay on my devices. If I'm MDI, I don't want to be on a, you know, on an insulin drip, I want to, I want to inject my slow acting, you know, the way I always do, and probably having a little bit of, I don't know if charting is the word or records to be able to show the doctor like, look, here's what I do. Normally, I feel confident I can come in and accomplish this correctly is probably important

Jennifer Smith, CDE 19:45
because it eases their ability to also chart and say, you know, this is the plan of action. This is where you know this patient's glucose levels, they're controlled, the insulin doses are here. The glucose levels are huge. Willie here, this is where they came in the morning of the surgery, even showing them. I mean, every surgery I've gone into they've all the nurses have been fascinated with the continuous monitor. They've been fascinated with it. What happened

Scott Benner 20:14
to art and when she went into the emergency room for that belly pain, and you and I talked that they actually, yeah, and the other nurse who was way in charge, super confident and competent. And she, when she saw that thing, she's like, This is amazing. And I was like, Yeah, right. And she's like, alright, well, you know, what do you want to do? And I was like, I, you know, it was that moment. And I said, Listen, I'm not trying to be like, I'm not, you know, I'm not blowing a horn here or anything like that. I'm like, but my daughter is a once he is incredibly stable. On the lower side, her blood sugars. And I showed her like, this is her blood sugar for the last 24 hours. And like, I am completely confident that I can keep her blood sugar here. And if I can't, could we just do it? She's got an IV and right, you could hear you could hit her with, you know, yeah, with glucose. dextrose. Right. And so that actually happened, we were there for so long that they did have to run dextrose. And it was really interesting to watch, because it took forever to hit, and then it jacked her up. But if you gave her any insulin at all, it went right away in two seconds is very, very interesting to watch how it works. But when going into that scenario, right away, I mean, after we were settled, like I didn't run in the door yelling, she has type one diabetes, and we're gonna take care of it. Like, you know, after we were settled, you know, we were there for a little while. I'm like, Hey, listen, here's the situation. We'd love to stay like this. And that, to be honest, she seemed thrilled to let us do it. It almost felt like, well, then I won't have to do this. So perfect. You know, it was a little bit of that. And okay,

Jennifer Smith, CDE 21:44
that's actually for the most part, what I've actually what I've experienced, there's almost like you, you can't physically see it, but you can see it because with diabetes, we've become very intuitive to other people's like, what you can see them thinking you can like hear their gears going right. And every time I've come in for a surgery, I can almost like see the nurse let go. Their shoulders like relieved. They're like somebody has control of this. And we don't have to worry about I mean, they will, they will ask where your glucose is, if you do a finger stick or look at your CGM. Report it to them make sure that they know and are aware of where things are going. If you didn't at all make an adjustment to your insulin doses or take anything, make sure to note it to them so that they can chart it. Because it becomes part of the medical record then. But yeah, I mean, my, the my first child when he was born, we knew it was going to be a C section. And so we came in planned everything. And the nurse anesthetist who was there during the C section. She actually at that point in time, I had the receiver yet for my Dexcom. Right, I was still using it. And I she was holding it because my husband was like, you know, with me, obviously. And she was amazed by it. She kept like, she's like you changed again. He's like, that was 81. Like, yeah, it'll give you a new number every five minutes, right? Yeah. But she was like she was so just enjoying watching. She's like, this is a really steady line. And I was like, Yeah, that's what happens when your insulin is dialed in the right way.

Scott Benner 23:32
So you know, to your point, I'm recalling a conversation I had with a nurse in a hospital setting. And we talked about this. And she told me that one of the things she dreads the most is running up on somebody who really, you know, doesn't have a firm idea of what they're doing. And she's like, but that but it's, they feel like it's working for them. Yeah. And then you feel like you're in the position of explaining to them like, Oh, this isn't okay, this should be more like this or more like that. She's like, No, that's not my job. And you know, and they don't take it well, and they're already under stress over a lot of other things. And now here you are in the corner of the room going, Oh, by the way, you don't do a very good job of taking care of your diabetes, here's what you should be doing. She's like, it's not the right time.

Jennifer Smith, CDE 24:16
No, not at all. In fact, I when we went in for my second son's birth, you know, management had already been established endocrine and my MFM team had already written Jenny will manage, if she's unable her husband is here, he can help her manage, she will remain on her pump, et cetera, et cetera. And the nurses were really really surprised by that because they had had a woman the week prior, come in on a pump. And they thought she knew just like, you know what everything I was saying. They said, Okay, we need you to dial back, you know your rates by this much blah, blah blah because she didn't come in with a plan of action herself and This woman, unfortunately, literally didn't even know how to button push on her pump. So I don't I don't know the whole story other than the fact that the nurses and the doctors were like, well, we you can't safely we cannot allow you to stay on your phone. And so she was so excited. She's like, so glad you know what you're doing. Like this was the scenario we had.

Scott Benner 25:19
I hope hopefully, that'll this will give the confidence to other people to make these kind of like pre planning decisions to. Okay, so let's, you know, injury. And I only have one example. But Arden got hit really hard in the kneecap with a softball bat at softball ones. And her blood sugar began to rise almost immediately after the pain hit her and stayed up for the better part of 18 or 24 hours, she needed a lot more insulin now. You know, I don't think there's a lot to say to this other than there was an impact coming from her body that required more insulin, and I gave her more insulin. But that's Is that is that a hard and fast rule that paying put your blood sugar up in constant pain can hold it up? Or is that that's person to person? I would imagine to? For the

Jennifer Smith, CDE 26:05
most part, yes. I mean, as as kind of just a blanket statement. Yeah. For the if you're in pain, and it's considerable pain, blood sugar's will be higher. If the pain ebbs and flows, you may find a little bit of kind of a drop down as things feel much better. And if it starts up again, maybe between pain medication or whatnot, it may start to escalate again. So So yes, pain, pain is a horrible thing. You know. And that's actually one of the things that I in having had two births. The management of pain, post delivery, was, most women's insulin needs fall dramatically, after they deliver child and placenta and everything, and all those pregnancy hormones are gone. But after a surgical delivery, like a C section, or a more traumatic delivery, potentially, you may actually see that the stress of that, and the pain that you're in, could leave those glucose levels higher requiring more insulin, despite the pregnancy hormones being gone. So that's kind of a similar example. You're swapping

Scott Benner 27:17
the hormones for the pain. Right? Right. And I did see with Ardens needed when pain issues only taking Advil, but when it worked for she needed less insulin. And then at the end of that Advil if I if I didn't overlap it correctly, then she'd start to go up again. Okay, well, I just wanted to hit that. But now we're gonna, we're gonna jump into the like, the illnesses, you know,

Jennifer Smith, CDE 27:38
yeah. What Can I Can I comment on one thing, of course, prior to illnesses, as we've been talking about, like, planning for surgery, and all of those kinds of things, if you do have a plan of action, and you know, you'll be going into the hospital. The other things to definitively know is your length of stay for that, okay, because you do have to plan ahead for how much may you need to bring along as far as supplies, right, especially if you're on a pump. If you're on a CGM, you want to make sure that you have enough that you don't have to either send somebody home, the hospital will not have anything to help you out with your pump supplies,

Scott Benner 28:18
they're not going to offer you an omni pod, if you know,

Jennifer Smith, CDE 28:20
they're not going to they you know, I mean, certainly they've got glucose glucometers in the hospital, they've obviously got insulin, if you're really stuck on your type of rapid acting insulin for another example, and you've got something planned coming up, make sure to bring your insulin to the hospital with you, you may have to give it to the nursing staff, they may have to hold it in in the medical area with your name and label on it. But otherwise, you're kind of going to be at liberty of whatever's on formulary at the hospital and it could be the kind of rapid insulin either you've never used, or maybe it just doesn't work as well for you.

Scott Benner 28:56
Do you ever? Have you ever had an experience yourself or spoken with somebody who's had the experience where they go into the hospital, the hospital wants to leave their blood sugar higher. The people say I don't want that. But the hospital resists. And then the person sort of Mission Impossible style gets insulin to themselves because I've heard that from a lot of people. Like I had to I had to hide my pen from the nurse like that kind of stuff. Now that

Jennifer Smith, CDE 29:25
I'm sure she wouldn't mind me answering it because ginger who I wrote my book on type one with Yeah, you know, she is she is an MDI. She takes multiple daily injections. She doesn't use an insulin pump. And her first delivery. That's what she had to do because the nurses were like, We don't want to I don't know what they told her to take her insulin dose down or up by so much that ginger was like, that's gonna kill me. She's like, you can't do that. And so yeah, she had her like insulin pens in her room with her and When the nurses weren't in the room, she just dosed herself. Now, am I advocating for that as a health care professional? No, I'm advocating that you talk to somebody. But you know, what if in the case of the question that you asked if they're just leaving it, like so much higher, detrimentally higher than would be healthy for healing. I would advocate for bringing in like, a patient advocate asking the hospital to bring somebody into the room to talk with because there has to be a safe work around that. You're being safe in the hospital staff knows what you're doing, but that you're doing what you know is better for you.

Scott Benner 30:42
You know how this always happens. Because it happens in so many different walks of life in and around diabetes and separate over to, especially at school, by the way with, like how people take care of their children at school. There's this idea institutionally, this is how we do it. And when you come in and say, hey, that's really cool. I'm glad that works for people. I would like to do it like this. No, no, no, this is how we do it. But no one remembers why this is how we do it. Right. Like and it really is. It's the meatloaf story. You know, it's it's that I ever told you the meatloaf story. I've said on the podcast, it's here I'll do an abridged version of it. Mother and a young girl it's a pot roast actually mother and a young girl and making a pot roast. Mother gets out the pan cuts the ends off the pot roast, puts it in the pan sticks it in the oven. The daughter says Why did you cut the ends off the pot roast? Mom thinks for a second says I'm not really sure that's how my mom made pot roast. So they find the grandmother asked her grandmother says I don't know. You're gonna have to you know next time you're at the old age home, find my mom and ask her why. So they visit the old age home they find the mom she's 100 years old and all curled up in a ball. Great Mom, do you remember why we cut the ends off the pot roasts? You know, when we make them? And the old lady thinks and thinks and she goes? Oh yeah, I had a really short pan. Right? You know? Exactly. So. So you don't know why the hospital's saying what they're saying. You don't know why the school is saying what they're saying. And sometimes you just have to be reasonable, like you said, and talk and say, I get this is what you normally do. But hey, this is what we do. And look how well it works. Couldn't we? Couldn't we find a middle ground here? Correct. The problem is sometimes that communication breaks down because of I mean, I know on my end, when I would break down for me in the past, it's always emotion, like, you know, you're very emotional and you feel like oh, you're gonna, you're gonna ruin my kid's life or something like that, or you know, you're gonna hurt somebody and you feel and then you start wrong. And then before you know it, you're arguing. And so you have to really, you gotta come at it from a real calm place. But But that's, yeah, I'm not advocating anybody doing that either. I'm just saying that the number of people I know who have done that is more than I can count on my fingers. So something that kind

Jennifer Smith, CDE 32:50
of goes along with that, too, would be sort of an emergent type of setting where you come to the hospital unplanned, like an emergency room, right? Really important thing is that you if you can, if you're awake with it, or somebody who's with you can advocate for you. It's not odd for them to want to disconnect a pump, right? Do not let them disconnect your pump. Say that like more forcefully or whatnot. I mean, if you are with it enough, do not let them take your pump, right? Because they don't You don't know. I mean, emergency department personnel. They're, they're great clinicians, but they see a host of things like trauma problems, issues, whatnot, they are not schooled in insulin pump management, they're not. So that's a really, really important one.

Scott Benner 33:49
And these are emergencies that aren't the top end of the emergency, like if you're really injured. You know what, these people are going to try to keep you alive. You stopped thinking about your insulin pump now, but like that, that kind of stuff. But yeah, in moments where you're cognizant, it's, it's a weird thing. Like, why would you give over the control of your insulin pump to somebody just because you broke your toe and you're in the emergency room now? Correct? This doesn't make any sense.

Jennifer Smith, CDE 34:12
Okay, that's also the benefit of having a

Scott Benner 34:15
medical alert. Look at Jenny is wearing her bracelet, don't you? Oh, it's

Jennifer Smith, CDE 34:19
always on. I think actually, I glued it closed. Because I've lost it. It comes from American medical ID by the way, it's they do a great job. But my clasp had come like it unsnapped twice already. And I've had to reorder the same bracelet. So now it's glued closed. Like they would literally have to cut it off of me to get it off.

Scott Benner 34:42
I was gonna joke that Jenny is making side money by mentioning American medical bracelets on the podcast, and then she said it broke twice and I thought well, that's probably not what they want people to hear.

Jennifer Smith, CDE 34:52
Class I'm quite sure that it was, you know, my fault of catching it, whatever. It's just Yeah, it's so See, it's funny, because when I went into the hospital the last time for my kidney stone, it was not fun. It was a whole bunch of extra visits and whatnot after, but I told them I was like you. They wanted like all jewelry and like everything removed, and I was like, well, you're gonna have to cut it off then because it's glued together. And the doctor was like, Okay, well, we'll just put some, whatever it's called, like, coal ban, or KBN or whatever around it, and he's like, you're fine. We'll be

Scott Benner 35:29
fine. Oh, there you go. There's Jenny's had diabetes for 30 years, and she's wearing her bracelet now. Don't you all feel bad for not wearing yours? I don't even think Arden has one. So I'm feeling particularly bad in the moment. Oh, I'm sorry. You know, it's funny. It's when she gets older. Like, then I think of it like right now she's with somebody constantly. Who knows she has diabetes. It's you know, but it's those other moments. I guess it's the ones you can't plan for, you know,

Jennifer Smith, CDE 35:58
I've got a lot of friends who have gotten tattoos actually, you know, type one wrist tattoos. I've actually got a good friend in Michigan who she even talked to some EMTs. And she asked specifically about her design so that she could know from a medical perspective, would this be visible enough? Would this be recognized as a medical ID and whatnot. So there are some beautiful designs that are out there? I just have never one day gone that route. I have a tattoo but I just don't have a tattoo on my wrist.

Scott Benner 36:34
are we sharing where your tattoo is? Or no,

Jennifer Smith, CDE 36:36
it's on my leg. Okay.

Scott Benner 36:38
I have a couple of tattoos. I have one at the top of the crack and right now I'm just kidding. It's on my shoulder and one of my shoulder and one of my mine aren't that cool though. Maybe they are I don't know. I've had them for so long. That sometimes I look in the mirror and I see it and it startles me the one on my shoulder happens with on sometimes like what is on me. And then I realize that 25 years ago I got a tattoo and I don't I don't see it because it's behind me. Anyway, okay, so So let's start with the easiest version of a sick day right like a cold sniffles a cough like something that doesn't you know morph into something worse, just something that is you're under the weather. How does that does that always present with your blood sugar the same way it for you personally. The remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution and to carry case but most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well on your hand, and features Second Chance sampling, which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash juice box free meter go get yourself a free starter kit. while supplies last US residents only touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org Go up to the top of the page where it says programs there you're going to see all of the terrific things that touched by type one is doing and I mean it's a lot type one it's school, the D box program golfing for diabetes dancing for diabetes, which is a terrific program. You just click on that to check that out. Both are caused their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing. Just like touch by type one touched by type one.org or find them on Facebook and Instagram links in the shownotes links at juicebox podcast.com. To touch by type one and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. GE voc hypo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com. Forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk.

Jennifer Smith, CDE 40:45
For me personally it does, I've found that just the typical sniffles I'm not really feeling bad, I'm just feeling kinda like stuffed up or something. Typically, I don't see any change in my blood sugars whatsoever, I don't see any change in my insulin needs whatsoever. It's not really until I start feeling sick, where I might feel a little more fatigued, tired kind of rundown, like I could go to bed like at 8pm instead of 1030. You know kind of thing that I like a good thing for me to know that I really don't feel good is that I just don't want to work out because I typically do something every single day for a workout. And if I really would rather like skip the gym, I know that I'm really not feeling great. But blood sugar wise, I've already I already know that I'm not doing great because I'll see an incremental creep excuse me, I usually need about 20 25% more insulin with something that's got me kind of just not feeling the best at all

Scott Benner 41:49
right so with Arden when she has the regular just sick day sickness she needs her blood sugar's are so easy to control those days. I don't like it not, not like I'm coughing and My chest hurts, or there's, you know, snot flying out of my nose or something like that. Just when she's a little under the weather. Her blood sugar's easier. Now maybe if I really delve into that maybe she doesn't eat as much during those days. But like there could be another reason that I'm wrong about. But I have heard people say, you know both ways I need more, I need less. And so for this right? Hydration really is got to be step one, in probably all of these right? You have to stay hydrated, keep food in, you know, as best you can. So you don't get into one of those deficits where you've got a bunch of insulin going and there's nothing inside of you and you drop quickly, is kind of morphing that from just a regular sick day to a slightly more sick day where you're under the weather, maybe have a bit of a fever is the biggest fear. What if I need to eat and I can't or what if I get sick to my stomach and my stomach empties like what do you think of the biggest fear around being sick as being

Jennifer Smith, CDE 43:00
I would say it's more the it's not like the congestion, the nasal the bronchitis, the ear infection, that's usually not, it's more the bugs that hit the digestive system that are the fear for most people, high blood sugars. Most people will realize that they need more insulin, whether they're just throwing insulin and correcting because they're staying high or they actually intuitively are like, oh, I need to bump my basil up. I'll use a Temp Basal here because I obviously I'm just running across the board. Hi, that's not so much the worry, it's more the Gosh, I really don't feel very good things could be coming out one or both ends and nothing really seems to be sitting well or you have consistent enough nausea that you can't really do more than a sip every hour. Yeah, those are more of the bugs that worry people. So I mean, there are there are some kind of hard and fast rules, you know, if your blood sugar is on the lower end declining or dropping, and you can catch it ahead of get being too low. You can if you're using an insulin pump, set a Temp Basal decrease about 80% for about two hours. So if you're really nauseous to the point that you can't take anything into stop that drop off, you can decrease basil enough again before you actually are too low to stop the drop and sort of curve you off until you could get a little bit of something usually extreme nausea doesn't last like nine hours at a pop. It kind of ebbs and flows through a stomach bug. So you know, at some point you can get in something even in the case of honey, you can put put honey in the gum and sort of just massage it in. You don't even have to swallow it but some of it does start to get absorbed in You know, through the mouth. So it's funny.

Scott Benner 45:02
So you just described exactly how I help Arden sleep in really long. So on a Saturday if she you know, she goes to bed late and or she's been really exhausted all week or something like that this Saturday is going to be one of those, like, she's got a lot going on this week, and I know she's gonna sleep in. There's a moment, like in the in the beginning of the day, the six o'clock 789 o'clock hour, it's like a 50% decrease in her insulin. And that keeps her at 90, right. But if she starts power, sleeping into that 10 o'clock, 11 o'clock, 12 o'clock, I sometimes have to go down to like an 80% decrease, just because everything in her body that could possibly keep her blood sugar up, is gone. Now it's just, it's really gone. She's been asleep for 12 hours, you know, 10 hours, it's really gone. So I've learned that I can't take all the insulin away. Because if I do that, she's going to jump up or be really high two hours after she wakes up or something like that. So you have to leave some in, but almost not enough for it to impact the moment at all, just for to help overall. And then from there. It's great. I mean, the idea of the honey in the cheek, something that doesn't make it to your stomach, because the lining your mouth is really absorbent for things. So your cheeks under your tongue, right? Yep, that kind of stuff. So you can get sugar in there without actually swallowing? I'll tell you, I'll tell you two in a panic situation, if you don't have anything even table sugar, you know, you can dissolve sort of in the saliva of your mouth and leave it there. Yep, yeah, there's a lot of ways you bet, you're going to have to get creative unless you're planning to head right, and you have sports drinks that you can take these kind of micro steps off of throughout the day, you know, but all we're talking about here is, is maintaining that balance with the extra variable of your stomach maybe being sour or incapable of holding the feet, right?

Jennifer Smith, CDE 47:04
When it comes to also prepping similar to other illnesses and whatnot, kind of, you know, like the discussion about mouth surgery, just prepping and making sure you've got some things on the shelf in your house, kind of, if it's popsicles that you always keep in the back of the freezer that have a sticker on that say, don't touch unless, you know, sick days, Sick Day stash, or whatever it is, there's actually a really good electrolyte. It's not pre mixed, it comes in like one of those little two, not tubes, but like packets, kind of like Crystal Light, almost. It's called Drip Drop. That one works really nice. I think each packet, if you'd consume the whole thing, it's only about like nine or 10 grams of carb. But the nice thing is that it's got the electrical light component to it too, for replacing what might be coming out. Yeah. So just some options.

Scott Benner 47:54
It's very dense with what you need to and I know about it for completely different reasons. But when Cole was recruiting for college, he got stuck at this three day event in August. And it was like 115 degrees. And he was playing baseball for three days in a row trying to you know, it's like, look at me, someone take me on their damn team, you know, but he was downing Pedialyte throughout the day to stay in that. So it is really impactful.

Jennifer Smith, CDE 48:22
The other component to stomach bugs and adjustments would be if you are able to take in a little bit usually because of stomach bug means that you're not absorbing well. Digestive leave, we really expect that you're probably absorbing only about 50, maybe 60% of the carb amount that you might be taking in one don't Bolus until you know that it's going to stay down. So in this circumstance, you're not doing Pre-Bolus thing at all. You take the food in, you make sure it's going to sit there, it's going to stay you Bolus only for about 50% of what you actually consume. This is a survival situation, right? It's a survival. And again, if you see it coming up sure that's where that like little bump nudge, kind of with a little bit more, maybe a little bit more whatnot, but be conservative to begin with. Because stomach bugs don't last long. They're not like the common cold five to seven days, maybe even 10 days. Usually stomach Bugs Are Gone within about a 72 hour time period, you may still have decreased absorption for days after you're feeling better. So don't don't think it's odd that you might be dropping a little bit low when you're back to eating what you consider normal food after meals. It might just be that your digestion is just not up to par yet. So

Scott Benner 49:37
if you're a person or a parent of someone who is prone to stomach issues, is having a prescription on hand for So Fran or something like that. Is that a good idea? Like something like an anti nausea medication? Yep. We'll talk about that.

Jennifer Smith, CDE 49:52
There's another one that's over the counter. It's called Emma trawl. e m e t r o l I think it comes in a lot. Little white bottle has got a rainbow on it. That was something that the, my second, my second wisdom tooth extraction, the dentist actually recommended for me for nausea, so and it seemed to work really well. So.

Scott Benner 50:17
So if I'm on MDI and I have this illness coming up, how do I cut back my, my slow acting insulin? Is it a percentage do you think? Or where do I start

Jennifer Smith, CDE 50:28
to, you know, it again, in the circumstance that you wake up in the morning throwing up or you know, just not feeling the greatest and you're taking your Basal dose in the morning, you can adjust it absolutely. And you can take it back by 10 20% as a starter. If it's really considerable nausea, and you're not really sure that you're going to take anything, and you may cut it back even a little bit more than that, and then just cover with boluses of your rapid insulin, if you are riding higher through the course of the rest of the day. But don't take an additional dose of your long acting insulin from what you missed. From the initial dose to make up don't just wait the next time you need

Scott Benner 51:12
to know. So you know, when you're talking about taking care of kids. I mean, anybody who's a parent who's had a child is sick, you realize, you know, for sure, like everything in your life stops, right? It worked doesn't matter. You know, the television show you really want to watch tonight disappears out of your life, you know, the weather doesn't you're you're keeping your kid alive. But But what if I'm an adult, and I'm alone, right? I'm living by myself and I have type one diabetes. I'm sick, and I'm exhausted. And I know I am going to fall asleep and stay asleep. Like, what what do I do before I fall asleep because that kind of illness you see people sometimes 10 hours, they're out like a light, right? And it's the kind of illness in the in the stress on your body. You might not wake up if you have a problem. And you don't want to be in that scenario. You don't even want to wake up with an extremely low blood sugar. I can imagine having a 40 on top of a stomach virus, right? It's gotta be horrible. I'm guessing. So do you do you ever? I mean, how long have you been married? You ever lived alone? Like, what would you do in that scenario? Would you?

Jennifer Smith, CDE 52:17
I've personally never lived alone. I either I went from my parents to having college roommates, to having off campus college roommates, too, then I think I lived alone for about a month between my college roommates moving out graduating and then getting married to my husband, your husband

Scott Benner 52:36
should take a lot of comfort in the fact that your face did not go Oh, geez, I do have to get divorced. Isn't that what Scott saying? No, no. Jenny has to fly. You look very comfortable.

Jennifer Smith, CDE 52:50
I've traveled alone. Right? You know. So in that circumstance, too. There are always like safety pieces. You know, when I when I travel alone, I actually set my CGM alert for a little bit higher over in the overnight time period, just because I want to know sooner than if my husband was sleeping next to me, because he's usually the one that hears it before I do.

Scott Benner 53:14
I got hit the shoulder last night. Don't you hear that? And I'm like, no, because I'm sleeping. She's like, it's beeping I was like,

Jennifer Smith, CDE 53:22
but for those living alone, I think some some strategies. Again, this would be a staying safe, by being potentially a little bit higher is actually better. So if you know that you are just like Dawn and you are out and you are gonna go to bed and you may not be up for the next 1012 hours. Just set a Temp Basal decrease. Or again, if you're going to bed at night, and you know that wake up in the morning at six o'clock is probably not going to be until 10 o'clock because how horrible you feel. Maybe you take your Basal insulin injection dose down a little bit. You know, I mean, there's safety things. Yeah, you may wake up higher than you want to be. But it's in this scenario of being alone. That would be the safer case. I mean, I'm not advocating obviously for waking up at 200 or 300, or whatever. But yeah, you wake up at 180 instead of waking up at 100. You know what, at least safe?

Scott Benner 54:19
Well, I mean, the idea is to get through this unconscious time period and back to back to conscious safely. That's what you're shooting for.

Jennifer Smith, CDE 54:27
The other component too could be you know, setting alarms on your phone, or setting an alarm clock in that time period just to wait I mean as much as you want to sleep in need the rest because you don't feel good. If you really are worried because you already took your Basal insulin and you can't adjust it now or you're getting to that point of just needing to lay down and you just had a meal and you're not quite sure what that Bolus is going to do for you. Set an alarm,

Scott Benner 54:55
right? Yeah, I mean, everybody should have an old $8 windup alarm clock they can pull out of a drawer right and send across the room so that you can't just reach over and touch snooze on your phone. Yeah. And, and get out of it that quickly. Okay. Well, that's, that's really, I think we're finding a lot of good ideas here. So real quick medications around illness, cough medicine, you know, they make some without sugar I guess or I could Bolus for like

Jennifer Smith, CDE 55:21
they do. It's called diabetic tossin. Diabetic tussen. That's what it's called.

Scott Benner 55:27
They really should just call it diet Tostan. But all right, I mean, I'm not a PR department over there.

Jennifer Smith, CDE 55:33
It's cough syrup that doesn't have any sugar added to it whatsoever does the same job but doesn't have any, you know, glucose raising component to it.

Scott Benner 55:43
Chris Rock in his stand up, it was like, rub some testing on it was that my mom used to say, Rob, so it was that? I don't remember figure out I'll figure that out. Okay, so diabetic Causton. What about is there? I mean, steroids. Steroids are going to push my blood sugar up the entire time they're in the body, right?

Jennifer Smith, CDE 56:04
Correct. Yes. And the increase can be considerable, depending on the dose. So injected, injected steroids, like a cortisone injection into a joint or something like that, those will cause considerable increase in blood sugar, definitely within the 12 hours after, you're going to need an increase at least 50%. Many times people see 100% increase. And then that that increase will last for a couple of days until the dose from an injection sort of starts to dissipate. I mean, the impact of it stays within the body, but the impact of the actual let's call it you know, cortisone, or whatever else has been injected on what other kind of prednisone or whatever it might be, it's going to dissipate enough that you're going to see the need for that increase in in Basal dose come back down. I, you know, it's, it's not odd to see 100% More 150% More Basal dose, especially, many people who are also paying close enough attention will often also need an adjustment down in their insulin to carb ratios, their correction factors. A, as far as oral steroids, depending on the dose, and again, on a potential hard stop or a taper of the dose. Most often, those are people who have like a bronchial illness, and they have like a background like asthma or some other type of lung condition that the doctor really wants to attack the illness to prevent pneumonia or something else, you know, progressing. Those types will usually again, increase the need significantly, and the insulin to carb and the sensitivity factor will need to be adjusted.

Scott Benner 57:59
Okay. And to medications that may have a side effect of nausea, you should be careful about if they want you to take them with food, give yourself a chance to not show up, you know, not make yourself nauseous when you when you might need to hold something down. I want to double back a second to the idea of an alone adult or even a kid whose parents, you know, might feel like it's slipping away. Like, when do I it's so funny to ask this question, because we spent some time talking about the fact that hospitals don't seem to particularly you know, value, like your blood sugar that much. But that wins the moment when you wave the white flag and go to the hospital. Like Like when am I like, you know, not that you should be running every time you're sick. And by the way, I feel terrible. Because some people get sick more frequently than others. I can count I can count on two hands. The times both of my children have been ill. Arden doesn't get sick much at all. Which by the way, too, for those of you who do, what a horrible joke that is from nature, right? Your immune system was strong enough to beat the crap out of your pancreas. Can't make bronchitis go away. Right? Yeah, like whoa, come on, man. But But So when do I like what's the Mendoza line for when I think I better get the professional help. And why do I want to do that? Like what is it I'm avoiding?

Jennifer Smith, CDE 59:18
That kind of comes in and I know we had a whole discussion, an episode all about ketones and how to look at that and whatnot. But that kind of brings that into the picture as far as blood sugars and or hydration. And if you are ill and you're really not feeling good check ketones. You know, because in the case of moderate to high ketones, those often especially if you are not feeling well and you can't get enough hydration and fluids in you may very well need to go to the emergency room. In that case, it's just and your blood sugar's may not look like high enough To say, Well, gosh, I This is really bad I have to go to, you know, to the emergency room or the hospital. But if your ketones are at that moderate high level, you definitely need some help clearing those or you're going to be in trouble and IV would help with that, right? Is that IV would help with that, because they're not gonna make you down a whole bucket of water via your mouth, because I have could put an IV in and they're going to push it in through your vein, because if

Scott Benner 1:00:27
you could, you would, too. And and I know I know that because and I think I've told this here before, but Arden woke up one time with should have bent cannula, one bent cannula, and like 14 years is amazing. But she will come it's pretty. She woke up with a higher blood sugar. She was nauseous. I tested her ketones. They were high. And I said to her, I'm like, Look, here's your options. Now she wasn't sick. Like, you know, I mean, shouldn't have a stomach vise. I said, you pound this water down. I crush you with insulin. And you promise me that you can eat something to stop the fall. Right? Like and or we're going to the hospital. And and she's like, and she took a bottle of water for me and Arden is I've mentioned this here before she's a princess slipper. When she drinks water. It's like, Oh, little bit a little bit. She took that bottle of water. And she pounded it all down. And she was like, is that good? And I went yeah, you can sit with the next one, you know, and we got like three bottles of water in or over two hours. We made a big Bolus. She, her blood sugar broke, and her ketones began to fall. And we caught it with a little bit. We caught it with something. And that was it. It took us three hours to not go to the hospital. But she was willing to do it. And it was hard. She told me later that drinking that water was incredibly difficult because of the pain she had from the elevated ketones. Yeah, she was she felt very nauseous from it. Obviously, she wasn't sick. But yeah, at some point, there's going to be a safety issue, please don't get to the point where you're calling an ambulance, you know what I mean? Like, like, you might have to give up at some point. Right?

Jennifer Smith, CDE 1:02:06
This kind of, it kind of brings into it. A component of like nausea in pregnancy can be a very considerable thing for some women, especially in early pregnancy. So if you have significant enough nausea, and you're not literally able to take things in, or you've gotten to the point of actually vomiting, because of the significant nausea, it's always better to try to go and get at least IV hydration so that you don't run into an issue of ketones. Even though blood sugar levels may not be elevated in that circumstance. You could develop ketones mainly because you're just not keeping anything in. And that's very, very, very bad in pregnancy.

Scott Benner 1:02:57
Can I ask you a question? And I don't usually put you on the spot for this because it's a question about how to do the podcast. When I put this episode out, I was thinking to put the ketone, defining ketones right with it. You see them as compact these are companions to each other. Okay, absolutely.

Jennifer Smith, CDE 1:03:12
That's a great idea.

Scott Benner 1:03:13
We'll definitely do that then. This is usually the time where I say Is there anything I didn't say that I should have said

Jennifer Smith, CDE 1:03:20
the only thing I would say is for all of this the biggest thing comes from like my years with Girl Scouts be prepared. Okay, great to be prepared. And one of the best things I can recommend doing is having you never know when you're going to have to run out the door to like an emergency like situation right or even in the case of I know this is an illness specific but this is like just being prepared like you have to run out of the house because I don't know your stove is on fire. I mean, if you have a diabetes emergency bag packed get a backpack or red backpack cheap go to Target or wherever get one put in it. All of the things you could potentially have to take with you quickly out of the house. It'll be a lot easier in a an illness emergency especially especially somebody has to take you out of the house right? If you got stuff packed to go at least you know you've got you know, a set change and extra test strips and batteries and whatever they're all in.

Scott Benner 1:04:29
So a Jumanji situation when giant vines and lions are going through your living room and you really need to get out. You want to be able to grab this bag. Correct and at least have it packed somewhere and no, it doesn't have to be hanging by the back door chasing you through the kitchen. We're very mean in that movie. Hey. I know Robin Williams and now now people are like Robin Williams wasn't in that movie. That was the rock. How did you confuse those things? And who is Robin Williams but there's been two Jumanji movies so young people please leave me alone. I want to close As by saying that as we were talking, I was proudly struck by how much of what is normally spoken about on the podcast translates very well to this idea of sick days. That, you know, obviously, there's heightened scenarios, but that the tools you use really aren't much different. You might use different ones in different times than normal, but, but it's not like. And the reason I say this is because when people are trying to figure things like this out, I oftentimes see them believing that there's some extra special knowledge that they don't have about diabetes that applies only to the day you're sick. And I still think that one of your greatest diabetes tools is common sense. And so I think that, you know, we obviously broke things down a lot more granularly here, but it's still the tools. It's the Pro Tip series, you know, applied slightly differently. So right, um, I thought this was really terrific. I appreciate you doing this. And we talked so long that I can't ask you to define Lada so I'll do that next time. Okay, so that you can go I will say thank you. You're welcome. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. 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 GVOKEGLUC AG o n.com. Forward slash juicebox. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1009 teen explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025 We talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son on how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active, took me already from a decent 6.5 A one C down to a 5.6. In the past eight months, I've never met Scott. But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.