Diabetes Wise

Another Pump Bites the Dust

There is a definite theme emerging amongst diabetes bloggers in recent days. And it seems like my pump is the latest one to join the club.

Last Sunday afternoon, as I lay curled up the sofa with R and my MacBook, my pump started up an insistent pattern of 6 vibrations. Uh-Oh.

"MOTOR ERROR"

Huh? Well, I've never seen that before.

Without really thinking, I cleared the alarm and, since it was due for a change anyway, loaded a new reservoir. Problem solved.

Until yesterday evening.

"Buzz... buzz... buzz..... look at me" demanded my pump.

"MOTOR ERROR"

This time I figured I'd look it up on line.

This is what I found out:

Motor Error
Insulin delivery has stopped. This alarm occurs if your pump detects a motor error.

No shit, Sherlock!

None the wiser, but with a cruising blood sugar of 10.7 (185) I went ahead and rewound and reloaded the reservoir and plugged in a bolus. I figured I'd give Medtronic's 9am-to-5pm-weekdays-only helpline a call in the morning to check it out.

But then, around 15 minutes later and approaching the midnight hour, the pump piped up again.

"Buzz... buzz... buzzz..... look at me"

"NO DELIVERY"

Hmm. Coincidence?

Unsure, I dug out the cost-of-a-local-call-connect-you-to-Medtronic-in-California-24/7 telephone number and dialled.

I explained the problem, finishing up with "so I just wanted to check what those alarms actually mean, since I couldn't find anything in the user guide."

To be honest, I could have done with Mr Medtronic-California being a little more chipper. It was approaching midnight for me so I guess I was allowed to sound tired and jaded. But midnight for me meant 4pm in California. Being even more honest, though, I guess I knew it was coming before he said it, probably before I even picked up the phone to dial.

"For safety, we have to recommend that you discontinue using the pump and revert to the back-up plan you have in place with your medical professional."

Damn.

Mr Medtronic-California couldn't arrange a replacement directly,  but to give them credit, I did receive a call from Mrs Medtronic-UK this morning. She had all the details in front of her and was ready to arrange a replacement to be shipped to arrive tomorrow.

I admitted to her, sheepishly, that I was still using the pump in question.

"Were you not advised you to discontinue using it?" she asked, surprised.

"Yeah." I admitted. "It's just that reverting to back-up isn't as simple as it sounds."

"My blood sugars are doing great." I added, as an afterthought.

"MOTOR ERROR" responded my pump, smugly.

Examination Questions

Next Monday I'm sitting an exam that will count towards my first post-graduate qualification.

And I'm nervous.

The English school's examination system, coupled with my high desire to achieve and my choice of degree programmes means that I'm no stranger to exams. In fact, they were a summer ritual for eleven straight summers in a row. The moment the weather started warming up and the scent of fresh mown grass and barbecues started drifting in through the windows, I'd know it was time to get my head down into my books. I'd emerge pale, pasty and blinking like a mole several weeks later to enjoy the rest of my summer.

This, though, will be my first exam in three years and that is definitely a contributor to my nerves. The ritual of revision and preparation seems strange, alien almost.

But there is more to it than that.

There is diabetes.

Being diagnosed at such a young age, diabetes has undertaken every exam with me. I'm glad to say, it has rarely been a problem (the odd French and German spoken language exams aside). But then, I've always been in a secure environment. At school my diabetes, and the adjustments that may be necessary to accommodate low and high blood sugars, were common knowledge.

Even at university, where some of my exams were sat in vast, impersonal halls with a thousand other students, my diabetes, my pump, my need for testing supplies and snacks were all listed in my record. Even if an over zealous invigilator should question what the little silver device - my Freestyle meter - on my desk was, as normally happened, I knew it would get straightened out without problem. I never felt that my sitting an exam would be jeopardised by diabetes.

Diabetes being an unregistered candidate for this exam didn't occur to me until I received the candidate information letter.

There it is, towards the bottom:

"mobile phones or any other electrical device are not permitted in the examination hall... Use of any electronic device is not permitted during the examination and regular checks of the hall will be made."

My pump, CGM and testing kit are suddenly prime candidates for getting me kicked out. Even after putting in a call to the examination office, I still feel uneasy.

As if the stress of just trying to  pass the exam won't have a deleterious enough effect on my control!

So the question is, will trying to hide my pump, given that I may want to pull it out to deal with CGM alerts, end up drawing greater unwanted attention than having it "out-there". And would I be foolish to try and rely on CGM alone for the 3 hour paper? Your thoughts are welcome and appreciated.

Book Meme

What could be better than writing about reading books? Following on from Kerri, Nicole, Rachel and Allison I absolutely had to jump in on this one.

Total Number of Books Owned:

I honestly have no idea! New book shelves (along with new DVD and CD storage) has been high on my list of things to sort out for a very long time. As I write this, I can see the book shelf in the corner of the room where the books are stacked double-depth. The Harry Potter's and Roald Dahl's have found a precarious home on top of my speakers, my growing collection of travel guides is squashed beneath the magazine rack and an enormous pile of recent purchases teeters on top of the stereo. In my bedroom, a stack of at least five books sits on the floor by my bed, and there are countless books stashed under the bed as well. All this is without mentioning the half height bookcase in my second bedroom-cum-study that houses nothing but dental, medical and sociological books! In short, we're talking in the hundreds.

R's book collection is just as vast and un-contained. If we ever end up living under the same roof, I dread to think where the books will go! If all else fails, we could always build the house out of books.

Last book bought:

That will be books, plural.  Whenever I start clicking on Amazon, or walk I in to my local Waterstone's book shop, I don't seem able to stop myself ending up with at least 3 new purchases! The most recent bundle included a guide book for Brugge, ahead of a trip in December, a book with a very un-scintillating title about the National Health Service and The Story of You by Julie Myerson.

Last Book Read:

Depends if we're talking properly read, like from cover to cover. If so, that would be The Story of You. But I've also been dipping in to a lot of dental stuff, as I have a post-grad exam looming in less than two weeks and completing my 06-07 Tax Return over the last couple of weeks has lead to furious double checking of several chapters of The Financial Times Guide to Personal Tax. Exciting times!

Five Books That Mean a Lot to You:

Difficult to pick just five, but:

1. Happy Like Barnacles by Karen Testa.
I discovered this book as a 14 year old in the grip of my first bout of depression. It made me cry solidly from around mid-way through (and still does, to be honest). Yet I came away from it feeling that I valued life just that little bit more. At that time in my life, in terms of its impact,  there probably couldn't have been anything better for me to read. I'd recommend it to everyone but it's long been out of print.

2. Say Goodnight Gracie by Julie Reece Deaver.
I read this the same summer. Again it manages to sadden and uplift in almost equal measure.

3. Hideous Kinky by Esther Freud. Helps me reconnect with my inner child every time. I still refuse to see the movie, because nothing can top the book.

4. Catcher In the Rye by JD Salinger.
A cliche perhaps, but it has long been one of my mum's favourite books. When I left home, a battle even ensued over ownership of our dog-eared copy! I've read this at least half a dozen times, but I still discover a different slant at each re-visit.

5. Curious Incident of  the Dog in the Night Time by Mark Haddon

This was the book that got me back in to reading for fun following months of nothing but study for my final dental exams. It is also a book that is inextricably linked with the year I spent away from London, living in Plymouth.

Best Five Books You Read in the Last Year:

I just can't whittle this down to five. I read with a voracious appetite, often going through more than five books a week! So I have cheated slightly, and grouped these into related titles:

1. Harry Potter and the Deathly Hallows
Absolutely it's on my list. I forced R to stand with in the pouring rain on Bold Street in Liverpool, waiting for our midnight copies. Torn between wanting to make it last and wanting to reach the end, I finished it by 3pm on the Saturday! I've also re-read all the books this year, and although the final installment has replaced Goblet of Fire as my favourite, they are all still up there.

2. Philip Pullman's His Dark Materials trilogy.
I can't believe I waited so long to read these! Go out and get them!

3. One Unknown by Gill Hicks, Out of the Tunnel by Rachel North and One Morning In July by Aaron Debnam
These all focus on the London Transport bombings of July 7th 2005. By virtue of including them all here, it may almost appear that I have a fascination with the event. But these people, who were intimately involved in the attacks, have a story they wanted to share. Each of them has done it in an honest and moving way. As a Londoner, July 7th had a profound impact on me. So did these stories.

4. Books based on blogs - Blood Sweat and Tea (London Ambulance), Wasting Police Time (Police Force), Its Your Time You're Wasting (Teaching) and In Stitches (A&E Doctor)
All brilliantly crafted tales of life within each given profession - perfectly blended gritty realism and political rant.

5. The Jodie Picoult collection.
My Sister's Keeper was the first Jodie Picoult book I read, almost exactly one year ago. I began it on a early morning train in Italy and was almost done by the time our plane touched down back in England that afternoon. My travelling companion remarked "That must be really good, you literally can't put it down." More favourites include Salem Falls, The Pact and The Tenth Circle.

If you want to play, I'm keen to read.

P.S. Does anyone here Library Thing?

Covered Without Conditions

I travel fairly frequently. I love holidays and visiting new places, but the one thing I'm always super-fastidious about is travel insurance. This isn't directly down to diabetes, but more down to the memory of a short stay in a Florida hospital aged nine and what it would have cost my parents without insurance coverage.

However, I've always found travel insurance something of a sticky issue. In fact, I have at least two "free" policies, as part of a bank account and membership of an organisation, that I don't use. Why? Because given that they exclude all pre-exisiting conditions, they are next to useless to me. I know how these insurers work, and believe me, they'd try to blame a broken leg on diabetes somehow.

A few years ago, I found a good deal for an annual policy. They were willing to accept my pre-existing conditions, provided I went through an extended medical questionnaire with a nurse representative and accepted certain conditions that they placed on me - such as limitation on coverage for loss of or damage to routine supplies. They hiked my premium up too, in line with my risk status, but it still worked out a pretty good deal. I've always been thankful just to be covered.

I've renewed the same policy each year since, too afraid to let it go in case I can't find more cover elsewhere. In fact, I didn't even claim for the 36 hour delay I endured on my return from Barbados in January, for fear of rocking the boat.

So imagine my surprise when I renewed the policy today.

The usual questions:
You want Worldwide or European? Do you want wintersports with that?

Then it was time to concentrate. Here comes the medical bit.

"Have you had, or are you waiting for any tests or specialist appointments, other than for routine follow up, in the last year?"

I'm thinking carefully. No. This was all done and dusted over a year ago. And diabetes and other endocrine issues are definitely just routine follow up at this point in time.

"Have you or a close family member or business partner been given a terminal diagnosis in the last year?"

Thankfully that is definitely a no.

"Have you received a diagnosis of, or are you awaiting results of testing for, HIV?"

Offering up more thanks, that'll be another no.

And so it goes on in a similar vein.

Every question was a no.

"That's fine" says Mr Insurance Representative. "You cover will..."

"Hold on, hold on" I countered. "I need to check this. I answered no to all your questions, but you need to know that I have several pre-existing conditions. I usually have to speak to your medical representatives too. You see, I'm a type 1 diabetic, and I've... umm... had problems with insurance before. I just want to make sure that I'm definitely going to be properly covered."

"Oh. Erm... Ok. If you can hold the line, I'm just going to check this out with my supervisor."

I'm plunged into a telephonic abyss, punctuated by occasional bursts of tinny electronic music. A few minutes pass as I doodle over the back of the renewal reminder notice. Mr Insurance Representative comes back on line.

"Thanks for holding. No one has never asked me about that before."

I'm raising my eyebrows, but he can't see tat down the phone line.

"As long as you could truthfully answer all the questions with a no, then you're all set to go."

I'm almost too dumbfounded to actually give him my credit card details.

Covered, without any conditions at all. I still can't get my head around it now.

The number, the whole number and nothing but the number

Imagine, for a moment, an adult attempting to explain to small child, in appropriate terms, where babies come from. Or how Santa Claus makes it round the whole world in a single night. The course of the conversation will doubtless be punctuated by frequent buts, whys and hows on the part of the child. Small children have an uncanny knack of seeing straight through any confustication and sadly the skill of explaining complex things in simple terms is not widespread.

Imagine, then, trying to explain not only the concept of blood glucose values but also the information CGM and/or knowledge about past and future food and activities adds to those values, to the uninitiated. A comical situation rather like that between a father and his small son could easily ensue. In most areas of daily life, mathematicians aside for a moment, a number is just a number. If someone asks you for three pounds/dollars/groats, three is what they want. But a number in diabetes? Is a number ever just a number?

So let's start with the real basics: Under 4 is low, requiring sugar. Over 8 is high. Or sometimes over 7, or even over 12.  What's that? Why? Well it just depends. Different people have different needs and different situations require different targets. Yes, it is a bit like shooting. We're aiming for a target. Yes, that's right, it sometimes moves.

But anyway, high numbers need insulin. Got that?

OK.

Whats my number now? Well, yes, 3.9 is low and yes, normally that means sugar. But hold on, I just ate 10 minutes ago and look at this line on my CGM - it shows I'm going up. So yes it's low, but no I don't need sugar.

You want me to test your number? You're at 3.5. No, no. That doesn't need sugar either. You see, you don't actually have diabetes, so your body will take care of your numbers for you.

A little later...

See - I came up just fine. I'm 8. No 8 isn't high today. Yes, I see from the graph that it's going up, but I'm just on my way to the gym. So 8 going up very slowly is just fine today.

Later still...
What's that? You want to know what my number is now? Hold on...

Oooh... 5.5.

Yes, yes... I think you understood the basics and yes, that is a normal number. But look, my pump says I still have one whole unit of active insulin from what I gave earlier and look how far my CGM graph has dropped in the last hour. So I'm normal, but actually I need to eat.

What do you mean you think I' making it up as I go along? I'm really not. It's quite simple and logical when you look at it. We have low numbers and high numbers. But we also have normal numbers that can act like low numbers if we are falling, and normal numbers that can act like high numbers if we are rising. And a high number isn't always a high number, for example if we are about to drive a long way or do something where it is really important we don't have a low. And a falling number is...

What's that? You just want to know where babies come from? Now that's a much easier question to answer...

Reflections on Practice

From the moment I tossed my mortar-board hat in the air and spun around beneath it, laughing giddily, on graduation day, I've had the importance of professional development drummed in to me.

To me, at least, it's about so much more than recording a few courses you've attended, or articles you've read and then submitting a return of your hours once a year. It's about growing as a professional and as a practitioner. Which is why, from the outset, I've adopted the habit of reflective self assessment.

Looking at the way I do things now and why. Looking at what is and isn't working. Looking at the evidence. Looking for new techniques and solutions to old situations and problems.

Perhaps I'm good at this after so many years of doing it with diabetes and blood sugar management.  If that is the case, it is ironic that one area of my professional practice that I hadn't regarded in this way was my management of patients with diabetes.

This post started the process.

Jenny is right. We are - I am - too closeted, at least in my professional arena. I stand by the judgment that most of the time my diabetes isn't a relevant disclosure to make, but where other people with diabetes who happen to be my patients are concerned, it is probably time to change that.

I, too, would love to meet more health professionals who "get it" without me having to make painstaking explanations. I've realised through reflection that it is possible that I do. Perhaps they just aren't telling me.

And perhaps I continue to assume their ignorance by the way they act.

This post from Penny made me think in to this further. In her own comments section, Penny writes:

"Then, his dentist asked me yesterday if Riley's sugars were well-controlled. I just looked at her and nodded my head. What do you say to a question like that? It really depends on which day you ask."

I hate as much as the next person how uninformed medical professionals (or those I perceive to be uninformed) phrase questions in ways that are impossible to answer. I hate when they imply they know all about diabetes, when the way they ask their questions implies otherwise.

But I'm guilty as charged.

Although disclosing that I have diabetes will make an immediate difference to how my patient's with diabetes perceive me, I still need to go further. I need to be more explicit in my questioning. Make clear that I'm looking for the general picture, the most recent A1c value if they know it, and the aspects of diabetes management that could most influence their oral health.

I need to go further because, on reflection even people with diabetes can be guilty of acting in the ways we all hate. When I wear my professional hat, it seems I definitely can.

 

Blurring the Boundaries

I've been a pumper for more than half a decade. Yet everyday I deliver more than a dozen injections.

They're not injections delivered subcutaneously, through tiny needles. They're not injections of insulin. Most importantly, they're not injections given to myself. They are local anaesthetic injections, given to  my patients just as routinely as I once gave myself insulin.

There are really few similarities between local anaesthetics and insulin injections. The differences reflect the size of the boundary I like to keep in place regarding every aspect of the relationship between my diabetes and my dentistry. I like to keep them very separate.

I don't disclose to my patients that I have diabetes. Partly because it normally simply isn't relevant. But it's also in part down to fear. Fear of being judged. Fear of people losing their confidence in me, or believing me to be unfit to do my job. I've nothing to base this on, but I don't want to take a chance. As I write this, I realise how crazy it sounds. Anyone of you reading this could in future be a patent of mine and I've no problem discussing diabetes here. But still...

I've repeatedly found myself cringing when I meet a patient with diabetes and I find myself asking "How is your control?"

It's a very important question. Poorly controlled diabetes can increase the risk of dental disease, in particular periodontal disease. Conversely, poorly treated periodontal disease can worsen glycaemic control. I know that people can easily lie, saying what they think I want to hear. And I also know how feel when a perceived uninformed medical professional, or other person, asks me about my control.

Who are they to judge? I think. What do they know anyway?

I've certainly met this wall of defence when I've questioned patients before, no matter how sensitive my approach. I've longed sometimes to break down my barriers, share a conspiratorial smile and say "It's ok, I get it. I understand."

I've also been met with a degree of curiousity before now. People who regard me warily, as if trying to figure out how a dentist would know so much about diabetes and blood glucose values. Some even seem impressed. I wonder now how may might have guessed correctly how close my relationship to diabetes is.

Outside of the professional-patient relationship, I'm very open about diabetes. I'm excited when I meet others wearing insulin pumps, eager to share stories and experiences.

Two days ago, the boundaries blurred.

"So how do you feel your diabetes control is?" I asked the young man sitting in my surgery.

"Well, good, you know. I wear a pump...."

I wonder if he expected me not to now what a pump was. I wonder if he was expecting to be questioned, or to have to explain as we've all done countless times before. In all the time I've been pumping, I've never had a patient tell me they have a pump too.

My reaction was more automatic that considered. I smiled, flicked up the corner of my tunic to reveal my pump, clipped to my waistband.

"Snap."

The world didn't end. The patient didn't leave. Instead he just knows that his dentist really does get it.

The Time Thief

WANTED - THIEF.
REWARD ON OFFER

Have you seen him? Have you seen anyone creeping around suspiciously, perhaps with a SWAG sack full of watches and clocks?

Maybe he is tall and thin, with legs long enough to lift him up to the second floor and arms long enough to snake in through my windows.

Maybe he is small and compact, nestling in the bottom of my sock drawer with all the odd ones that lost their partner in the laundry.

Maybe he is invisible. Or disguised. Or moving so fast I just can't see him. But he's definitely creeping around somewhere near.

The Time Thief.

Sneaking in to suck the hours, minutes and seconds out of my watch, to flick the days rapidly forward on my calendar until they feel to me to be almost nothing more than a blur.

I've had little time to take breath. Working long hours, studying for post-graduate exams, attending appointments. Paying the bills, filing my tax return, doing the laundry. Those are all the things he has left me room for, with a few bonus hours to invest in my relationship.

The Time Thief is selectively stealing my 'me' time. No time for relaxtion. No time to take proper care of diabetes, accurate carb-counting and proper record keeping slipping off the radar again.

And no time to blog either. Or at least, no time to write something I can regard as worthwhile - to get something off my chest, to share an experience or tip, to support others and be supported. Writing something worthwhile is important to me, and I wish I could get some of the missing minutes back in order to do it.

Can you help? Have you seen him? I'll caution you not to approach him. He is insidious and dangerous. I wouldn't wish him to get you in his clutches too.