Diabetes Wise

CGM Reflections

Tomorrow, it will be exactly 18 months since I first got hooked up to Medtronic's original Guardian RT and I got to learn for the first time what truly amazing things my blood sugar could be doing while I wasn't looking.

Back then, the device looked straight out of the 1980s. The monitor was cumbersome and heavy and had a tendency to make a death leap from my waistband more than once a day. The numbers were real-time, but the graphs weren't. To figure out the trend, the true value of this device, you had to scroll back through the last dozen or so numbers and draw a mental picture of where you were going.

But compared to fingersticks alone, compared to what I'd had for the previous 23 years, this thing was a revolution. The drawbacks of irritation from the adhesive and the size of both the transmitter and the monitor were easily outweighed by the information it gave me. And the timing for me could not have been better, coming just days after the diagnosis of Addison's threw a huge spanner into the workings of my diabetes.

From the get-go, I didn't want to not have regular access to this technology ever again. I couldn't see that I'd ever really want to be without out. That still holds true, but I cannot believe it was only 18 months ago. Things have come so far since then.

After starting up with the Guardian I cycled between that and a loaner 722 until I got my own 522 pump which I've been using for the last 14 months. The real-time graphs were as much of a revolutionary step-up from the numbers alone as the numbers alone had been from fingerstick data. We've all heard the analogy about it being like driving with the windshield uncovered for the first time. It's true.

CGM really has made an enormous difference to me. Right back at the beginning it was the biggest single thing in helping me retrieve my confidence, bruised and battered as it was from  countless episodes of severe hypoglycaemia  as my cortisol deficiency went undiagnosed.  It was the major reason I went back to work so soon and makes a regular difference to my working life now.

As a dentist, I cannot afford to be hypoglycaemic on the job. For my patients' safety. For my safety and the safety of the people who work with me. Even if a high-speed drill in hypoglycaemic hands weren't dangerous, how would I be able to do a good job, a job up to my high standards, if my brain were fogged by a low? I couldn't, plain and simple.

Previously, my only defence against lows was regular fingersticks, prevention and relying on my symptoms to alert me to quick drops between tests. With my hypoglycaemia awareness shot by recurrent lows and so many years of diabetes, I lost that weapon. The only other way I could see to cope was letting myself run higher, much higher, during the working day. That would have meat trading the immediate risks for the long term risk of my practicing life being cut short by complications such as retinopathy and neuropathy, as well as making me feel awful.

I do run looser targets at work, for safety's sake and because my mind is very focused on the job and not always so much on diabetes. But with my CGM in pocket to alert me when things are amiss, I feel safer. Without the worry of diabetes I stay focused and my patients get the best of me. And the targets are still tight enough that I haven't had an A1c over 6.6 in the last 18 months.

And outside of work, it makes innumerable differences too. I've written before about the difference between a blood sugar of 5.5 that is stable versus one that is going down or up. More than 50% of my bolus calculations are now influenced by the information about where I'm coming from and likely to be going to. Travelling across time zones, working out at the gym and living alone are all helped by the numbers from my CGM.

Of course I can, and did, do all these things without that information. Many people lived with diabetes long before even fingersticks were available. Anyone who strives for good control wouldn't dream of doing that now, and I'm beginning to feel the same about CGM. After all, a healthy body knows where it's at at all times, why shouldn't I?

There are drawbacks, of course. A recurrent problem is irritation from the transmitter rubbing on my skin, although I've recently begun placing a piece of gauze under the transmitter, which seems to help. I've written before about accuracy, and while it's true that I have few problems and I find the trend is almost always right, screwy sensors do happen.

I can get burned out by it too. Rob recently described my pump/CGM combo as a little bit like being permanently attached to a Tamogotchi pet, and it was a good analogy. When the fifth or sixth alert of the day starts up, I sometimes want to kill it! Sometimes when my numbers stay consistently above the high target range I get frustrated much more easily than I would by a series of fingersticks showing the same trend.

The bottom line though is that I still love it. The breaks I take these days are mainly for financial reasons. Eighteen months on, I'm still no nearer securing funding but the longer I go on using CGM, the happier I am about choosing to forgo something else and instead spend the money on sensors. I can't really give it a much higher endorsement than that.

 

Bruges!

I'm incredibly slow with this update, but Rob and I spent last weekend in the beautiful Belgian city of Bruges.

We'd planned the weekend to visit the Christmas markets and experience the newly opened St Pancras International and High Speed 1 rail link on the Eurostar. However, we'd timed it principally to coincide with my parents visiting Bruges as part of a short winter cruise break.

Saturday morning felt particularly early, given that my work Christmas party had ended up scheduled for the evening before. But the check in and security procedures for Eurostar are a dream for someone who has regular experience of Heathrow Airport! The new high speed line, opened along with the new St Pancras International Station on Novemebr the 14th, allows for 185mph operation over the entire route with the exception of the Channel Tunnel itself, where speeds are capped for safety reasons. It took just a little over two and half hours from check in, and a little under two hours from the train departing, to reach Brussels.

Which is faster than my regular London-Liverpool commute! Enough said.

Sadly the onward journey from Brussels was not so smooth. Some kind of staff action was causing horrendous delays and there was very little information on when and if trains to Bruges would be departing. What little information there was was provided in Flemish and French, which it fell to me to translate, since Rob does not speak French at all. I always find it surprising how much French I am able to understand, and even at a push actually speak, given how long it is since I studied it. More surprising still is how much Flemish I am accurately able to read given that I've never studied the language, but this perhaps because in written form it has strong similarities to the three languages I have studied - English, French and German.

The transfer to Bruges ended up taking as long as the London-Brussels leg, but we made it in time for a quick lunch before visiting the Snow and Ice Sculpture Festival at the Stationsplein.

 

Me, with an ice penguin

It was a cold weekend in Bruges, but after wondering around the sculptures we were keen to get back outside, where it was warmer!

We headed to our central hotel and then took a wander around the Christmas markets. It was not only cold, but also quite wet, which provided ample excuses for frequent stops to get warm and shelter. We began with waffles, drenched in Belgian chocolate sauce (absolutely divine) followed later by warming gluwein and plenty of local beers.

The only diabetes moment of the weekend came shortly before dinner when the cold, the walking and probably an overestimated bolus for the waffles caught up with me and sent my blood sugar crashing to 1.9 (35), which left me feeling a little hungover and reduced my appetite for dinner. We still had a wonderful evening though.

Sunday was a brighter day, if still very cold. We had a leisurely buffet style breakfast at our hotel and had time for some Christmas shopping before meeting my parents in the central market square. Although time was limited, we fitted in some sightseeing, a further perusal of the markets, more Gluwein and a delicious lunch of Mussels washed down by more Belgian beer!

Sadly we didn't have a lot more time before we had to hop on a train back to Brussels and the Eurostar home and my parents had to get back to their ship. I would have loved to have stayed longer, but had to work on Monday morning. The beauty of Eurostar is that it brings several European cities close enough for a very short trip like this, or even a day trip, without necessitating taking time off work. I've no doubt we'll go back soon.

Rob didn't have to work on Monday or Tuesday and I was treated to the novel experience of being greeted with a ready prepared dinner and a glass of wine as I arrived home on Monday evening. It made me wish just that little bit harder that we weren't two hundred miles apart on a daily basis.

Overall though, it made for a wonderful weekend!

Sensible vs Stupid

Sensible Caro: Stayed comfortably asleep in bed this morning.

Stupid Caro: Got up and went out in the cold.

Sensible Caro: Drank cups of tea and watched daytime TV without worrying about anything else.

Stupid Caro: Went to work, because there was no one else to cover and she was worried about that.

Sensible Caro: Chilled out and relaxed.

Stupid Caro: Snapped at everyone and burst into tears because she felt terrible and couldn't cope.

Sensible Caro: Managed to keep her blood sugars somewhat in range.

Stupid Caro: Saw every number from the sky to the floor.

Sensible Caro: Feels much better tonight.

Stupid Caro: Feels somewhat better, but now realises she did herself no favours.

Guess which one is the real me?

I really have no idea what I was thinking when I got out of bed this morning. Perhaps it was simply that I wasn't thinking. Trying to work? Who was I trying to kid, more like!

It would be easy for me to blame it all on the responsibility of my job and not wanting to let people down, but sometimes I'm just my own worst enemy. After everyone so generously sent me their best yesterday, I go and pull my worst on myself!

I am feeling a bit better though, and my eyes in particular are much less swollen and sore. Now, if I could just shake off this damn cough... cough... cough.... cough

Friday 'Fings

A couple of things to share on this sunny Friday. Except they're 'fings, rather than things. This is for more than alliteration's sake. I went to high school in a town where a large proportion of the population were unable to pronounce the 'th' sound, using instead a 'ff' sound. Today I sound a little like those people.

Which brings me to:

Fing One

Early yesterday morning I was somewhat abruptly reminded of the perils of hypoglycaemia, especially when you live on your own. The hunger might drive you to the insensible option of eating your own lips. Or more likely your jelly legs might forget how to do the simple one-in-front-of-the-other walking thing (I mean, come on legs, how hard is that?) and put you splat on the floor. Taking a bite of your lips on the way down.

Which is roughly what happened to me.

It appears I smacked my chin on the hard edge of the bed frame and sent one of my top front  teeth through my bottom lip.

Being a dentist is a blessing and a curse if you manage this kind of injury. A blessing in that I was able to simply go to work and get looked after and stitched up by my wonderful colleagues. Who truly were wonderful, even down to pointing out that I was probably shaking like a leaf because  this was a pretty nasty shock and I'd completely forgotten to kick up my steroids.  I really need other people around when my brain flakes out! I've also been able to cheat and use dental anaesthetics for relief at times when the pain has got really bad during the last 30 hours or so.

Being a dentist with this kind of injury is curse because it sparks obvious jokes about being on the receiving end and getting my comeuppance. Oh yes, the patients really do find it funny. (Not that I ended up doing much work yesterday.)

I won't post pictures, because even I  think I look hideous, but suffice it to say that I have some lovely bruising and look a little like I've over-done some lip filler treatments! Please keep my front tooth in your thoughts. It has endured this kind of bashing before and I fear this may be the time it gives up and dies. Come on little tooth!

Fing Two

As if I wasn't unintelligible enough speaking through my fish lips, I appear to have lost my voice this morning. Damn cold  that is doing the rounds. A few hot lemon and honey drinks (through a straw of course) have picked it up a bit, but I definitely sound as though I have a frog resident in my throat.

A frog talking through a fish's mouth. Now there is a thought!

Fing Three

On a more positive note, I was very honoured this week to receive notification that I've been awarded a 'Health Leader Award' by the Irritable Bowel Syndrome Treatment website. These awards recognise sites that are "squarely on the side of the patient." Since that is exactly where I aim to be, I'm very proud to been given this award.

There is a list of other winners over on the site, which are worth checking out.

Fing Four

This article from the BBC came to my attention yesterday.

To say that it makes me mad is an understatement. I've not looked in to it further, and it could be that my own Primary Care Trust is one of those still in deficit, but it makes me angry to hear of so much money essentially going to waste when I'm still being denied any coverage for the CGM technology that has changed my life and allowed me to keep working (for the NHS, oh the irony!).

And it isn't just about me either. Up and down the country patients are having test strips rationed and told that, although they are good candidates, they'll have to go on waiting lists before they can commence pump therapy (actually illegal regardless of resources, but that is a story for a different day). All the while there is money burning a hole in the Treasury's pocket. All this anger without even touching on even bigger issues outside of diabetes care.

I couldn't agree more with John Appleby, who, in the article, states:

"A surplus of that size [is] not necessarily a healthy sign, as the money could have been spent on services. If the NHS does end up with a significant underspend at the end of the financial year, that will be a real loss to patients".

Too true.

Have a great Friday.

 

The Road Taken

This month marks ten years since my interviews for a place at dental school. It was a dream I cherished and worked towards. It was what I really, really wanted to do. Although I had a very clear idea of where I wanted to end up, I applied to five schools, to give me the best chance of getting a place somewhere. Because anywhere doing dentistry was better than nowhere at all.

My first interview was in Birmingham, and I was offered a place. The second interview that came up was in London - where I wanted to be.

I remember the day clearly, from getting on the train to ending up in a McDonalds, the closest place to hand, drinking regular coke because my blood sugar was low but I was too nervous to eat anything, including glucose tablets. I remember meeting my brother, already a student in London, afterward. We went up to Regent Street, where the Christmas lights were in full blaze and I remember thinking how this was the city I wanted to call home. I didn't want to be a faceless stranger in the crowd, I wanted to be a Londoner.

Two weeks later, a frosty morning in early December, I was woken up by my parents waving a letter bearing the university stamp. I didn't waste time in considering whether the envelope was thick enough to contain an offer. Without even getting out of bed, I tore it open.

And that was the first moment that shaped my future.

The offer of a place at my preferred school meant the interview trail was over. The grade offers I might get elsewhere could not reasonably be expected to be any lower, so I withdrew my outstanding applications and accepted my London offer, examination results pending.

The next decisive moment in shaping my future came on August 20th 1998, the day I received my Advanced Level Exam results. For the first time in my over-achieving life I didn't care about the actual grades. All I cared about was meeting the grade requirements set out for my dental school place.

My dad summed it up nicely six years later when he recalled how I'd phoned him and, rather than telling him my grades, I'd simply said "I'm going to be a dentist."

In retrospect, it's a poignant statement. I didn't have any idea on that day how hard it would actually be to get there. I had no reason to. I'd never struggled academically and although I'd been ill, it had somehow never got in the way of me achieving what I wanted to.

Now, ten years on, I can't help but reflect on the path I chose. The road I took.

Not dentistry.

I love dentistry. It is a job that you can't do well, if at all, if you don't love it. It's too intense, too involved. And I never did really struggle, either academically or clinically, as a dental student either. I emerged from six years of university with an enormous debt, and two degrees. I don't regret any of that.

What I wonder about is how life would have turned out if I'd not chosen London.

Don't read this wrong. I also love London. The seventeen year old on Regent Street is still alive and well inside me. I adore this city, with all its history, its winding streets, its icons of architecture and transport. I'm so glad to have called this place home for so many years, and enjoyed all the opportunities this nation's capital has to offer.

But this month also marks eight years since my life changed.

Being diagnosed with epilepsy had a profound effect on my life. Frequent seizures bring real life to a stand still. I became afraid to go out. My seizures brought out the very worst in some other people, whose lack of understanding and treatment of me drove me deep in to depression. The cruelty I endured is difficult to think about. Impossible to put in to words.

But most of all, I could no longer be sure of becoming a dentist.

I'd taken it for granted, since the moment I opened the brown envelope containing my exam results in my high school car park in August 1998. The thought of not achieving my dream, of failure, was devastating.

You know the ending to this story. You know that I did make it through.

It's looking back on the struggle, all the extra effort, the cruel treatment I received, that makes me reflect on the path I took.

If I'd gone to study dentistry somewhere else, what might have been? Would I have avoided catching meningitis, and so avoided developing epilepsy? I know I can't answer that. No one can. But since, unlike with diabetes, I can trace my diagnosis back down a path of specific turning points, it's natural to question it.

Epilepsy is a tiny part of me now. It remains engraved on to my medical ID bracelet. I still don't hold a driving license.

I still meet people who question. Critcise. Discriminate.

The stigma is still firmly attached.

What if? I can't help but wonder...

 

A Long Week

This week feels as though it has been going on for at least a month.

It may be the double whammy of an important personal anniversary on Monday with World Diabetes Day on Wednesday.

It may be because my blood sugars have been carrying on a ridiculous dance.

It may be down to a professionally draining week.

I've sedated a number of patients for treatment this week. I've discussed before about how routine the delivery of injections in patients' mouths has become to me. The conscious sedation technique, however, has more parallels to pumping insulin than injecting it. It involves placing a cannula in to a vein through which a drug is delivered to relax and sedate the patient.

The cannulas themselves are similar to insulin infusion sets in that they have a guide insertion needle and a teflon tube. I'm used to sticking this kind of equipment into my body every three days, but putting it through the skin of someone else's arm or hand, trying my best to hit the vein first time and spare them a repeat performance, is something that I still find slightly tough, no matter how many times I do it. And positioning something in a vein is far harder than just positioning it sub-cutaneously.

I also know what it feels like to be on the receiving end.

Despite a good first time success rate this week, and only one "Oh eek, third time lucky" moment, these procedures still have the ability to take far more out of me than my more routine dentistry.

To finish up the week, I was faced with a six year old child who'd fallen at school and cleanly knocked out his front tooth. He seemed quite happy about it, proudly showing me his gap. Since I spend a considerable amount of time each week taking teeth out, putting them back in is a novel variation. Sadly, the young patient didn't seem that impressed with my efforts, bursting in to howls after we reinserted his tooth and restored his cheeky grin.

I was still happy to know that I may have made a real difference to that kid, even if he doesn't know it yet.

It was a welcome end to a very long week.

Sunday Working, Sunday Blogging

If I thought a 9-6 day yesterday was bad, imagine the prospect of 8.45-4.30 on a Sunday. I may occasionally blog on a Sunday, but I very rarely do anything work related. Dragging myself out of bed at an ungodly hour this morning, I was very glad that I'd modified my plans last night. Instead of the scheduled night out, I ended up heading back in to Greenwich with my practice principal (i.e. the dentist who actually owns the practice where I'm an associate) where we ate noodles before heading up to Blackheath to catch the fireworks, which were pretty cool.

The second half of our conscious sedation update today went pretty well. You'll be unsurprised to learn that my veins weren't used for any cannulation practice! I was the example of a difficult patient! The session also included good, accurate coverage of diabetes, which is always refreshing to hear.

And no, I still didn't make it back to the scene of the crime.

I've spent a chunk of this evening attacking my NaNoWriMo project. I'm more than 10% of the way there, at 5331 words. I'm a little behind where I should be at the end of day 4, but I'm still hanging in there and finding it an excellent motivation to get writing everyday.

Hope everyone had a great weekend!

Reduced to Words

"Diabetes, poorly controlled. On insulin"

"Epilepsy. Suffers grand-mal fits."

These were phrases that jumped out of patients' records at work today. Records not made by me, I hasten to add.

These few words, accurate as they may have been, really told me nothing about the people they referred to.  Beyond the fact that there is no mention of what "poor control" means or why the person with diabetes  has it; beyond the fact that "grand-mal fits" is a somewhat out-dated description; these words seemed like such an tiny, unimportant entry of things that no doubt shape the people they describe enormously.

They do nothing to justify the impact of diabetes on that person's every waking decision, from what to eat to how much to exercise. They do nothing to show the time and effort that person may already be putting in to improve their control, or the fear of complications that may grip them.

A short description goes no way to defining how the risk of a seizure can impact on a person's life, the scars on their face a much starker reminder of the force of a condition such as epilepsy.

Reducing a life changing medical condition to a few words is a near impossible task and at the beginning of a month I'm dedicating to the writing of words, it struck me what a poor job words sometimes do.

The Verdict?

That exam that I took: I PASSED!

To say I'm happy would be an understatement.

I spent yesterday afternoon at a revision session for the next part - the practical part - of the exam. In addition to five face-to-face grillings with examiners the afternoon included the bizarre experience of or a mocked-up patient encounter with a female character played by a man! The feedback for this scenario? I was told that I was "too aware that I was being watched" and "seemed to be acting." No kidding! It wasn't exactly reality!

I also had to smile when during a generic advice session we were told: "If in doubt about a medical condition say diabetes. Diabetes is somehow related to everything!" I guess I couldn't argue with that.

In other news, it is a good job that I'm not entered to sit this exam at its next sitting in November. Somehow I've found myself signed up for both NaBloPoMo and NaNoWriMo and have therefore kissed goodbye to my November!

I've tried all the excuses:

"It wasn't me."

"I was just holding the computer for someone else when it signed me up...."

"I didn't mean to do it" (This one is true, I really didn't. Well, not both anyway.)

I'm actually hoping NaBloPoMo will help me cement a regular blog writing routine and possibly expand my subject matter outside of diabetes. As for NaNoWriMo... Well, it'll be fun.

Go on, you know it will. Come and join me!

And finally, October 15th is Blog Action Day. One Issue. One Day. Thousands of voices.. In its inaugural year Blog Action Day will be coordinating bloggers to tackle the issue of the environment. Check out the site, and join in.

Updates - Exams and Pumps

1. My new pump has arrived.

Yay!

And, it arrived on time as promised. Double yay!

In fact, even Medtronic were impressed at their own efficiency. On Friday morning, when I already had the new pump attached and pumping the telephone rang.

"Hi, I'm just calling from Medtronic. I understand that you have a pump that needs replacing" came the chirpy greeting.

"Well I did. It's been replaced though, thanks" I replied.

"Oh no, the American technical assistance line isn't able to replace them direct, so it hasn't actually been replaced yet" she said, with the patient manner of someone who has had to explain this point before.

"Erm... I can assure you that it has. The new pump arrived this morning and I'm wearing it now!" I responded.

"Oh, I'm terribly sorry..."

"No problem, it was already dealt with yesterday."

"Well, that's great..." I don't think she knew what else to say, caught off guard that the job had already been done. I'd definitely rather they tried to replace it twice than not at all!

I'm also pleased to find that Medtronic no longer demand that I pay the cost of shipping and insurance to get the old pump back to them. This was an aspect of their customer service that really bugged me a few years back. I once had two pumps to ship back to them at once where the total cost would have come to around twenty pounds. In that case I dropped the pumps off at my hospital and let the rep pick them up from there, but glad I can simply send this one off at the Post Office.

2. The exam went pretty well.

Went well, insofar as there were a decent number of very straightforward questions that I definitely knew the answers to.

Went well, insofar as nobody batted an eyelid about my pump, clipped visibly on my waistband, or  my test kit laid on the desk and called in to service twice during the three hour paper. After all my panicking it turned out that I actually knew the exam coordinator from when I was an undergrad!

The exam did not go so well with regard to my actual blood sugars, which hovered between 10 and 13 (180 - 235) throughout, failing to respond to corrections.

It must have been stress, because the minute I left the exam hall, it started falling nicely.

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.

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.

Heigh-Ho, Heigh-Ho...

I went back to work today.

It was strange. It was exhausting. But it was good.

It was great to be totally absorbed in the needs and problems of my patients. It was great to be focused on what I was doing - a bunch of fillings, some root canals, new patient exams. It took the focus off me, off diabetes and off illness. I felt more 'normal' than I have in over a month. And it felt good.

The stress, or maybe just the change of routine, sent my blood sugars up to a cruising altitude of between 12 and 13 for most of the day (215 - 235) but even so I wasn't particularly pre-occupied, or frustrated, by the numbers. I needed to avoid lows at all costs - for my patients' sakes - and had even thought I may need a basal reduction to do that. And the good thing is that I was pretty steady all day. If this keeps up I'll be able to do an across the board basal increase for the days I am at work, just to run on a slightly lower level.

From the moment I got home I've been dropping nicely back in to range!

In other news, I saw my diabetes consultant and nurse specialist yesterday. I chatted with my consultant again about this and he assured me that something positive had come out of my hospital stay other than the fact that I was better. Apparently there is now an ongoing dialogue between the diabetes specialist team and some of the general staff as a result of some of the issues I raised. Which is, I think, excellent news.

I've also been recommended (although I think there is actually more of a concrete expectation) to bring my A1c up before it is tested again in four weeks. Apparently if I eliminate all the lows a rise of between 0.5 and 1% is possible in that time. It is just such an odd instruction! I'm usually focused entirely on keeping my A1c down!

An Open Letter

I've been overtaken by life in the last week, and that is why I haven't written anything here. What I am publishing here now is an open letter, to someone who will know who they are if they happen to read it, although I recognise that the chances of that are quite small. This is the only way I feel able to coherently put down my side which I feel a need to do before moving on. If you are reading this rest assured that every word is written in truth - fact and emotion.

For everyone else... perhaps you will be able to read between the lines.

Dear...

You have hurt me so much in the space of the last week. You earned my trust, but then broke in through all of my defences, surprising even me with your power.

Just so we can get this clear… You are wrong.

Nothing about my health has ever influenced my ability to do a job, and that is why it isn’t relevant. I haven’t been dishonest, because I would have told you everything at the relevant point in time. It is not something I ‘fess up about on first meeting someone because it doesn’t define me and it has no bearing on my ability to do my job, which should be your only concern.

As a student, I had to fight. First I fought for my life. When I was done with winning that battle, I had instead to fight the prejudices of narrow-minded, cold-hearted people, all alongside getting two good degrees.

You cannot comprehend how it feels to have these prejudices resurface at this distance from their origin, when the information that spawned them is old, and no longer accurate. After all, you didn’t get this from anyone with the legitimate authority to know the current details.

Perhaps that is what hurts most of all. That you didn’t ask me. You didn’t come to me to talk it over. You didn’t let me point you to the only people who have up-to-date records about my health for further, accurate, information. You jumped to conclusions based on evidence from an illegitimate source. And as far as my real referees were concerned, you only had interest in putting words in their mouth, not listening to what they had to say. And then had the gall to project your own feelings on to them, to blame them for all of this.

And just so we are clear… I know that you lied.

It hurts that you planted a seed of doubt in my mind about the integrity of people I trust, people I’ve always believed to be on my side and who have only ever been supportive of me. For the record, those people are still on my side, and no one else can believe what you have done either.

The betrayal of confidence, the giving of old and irrelevant personal information, wasn’t just to you, it was also done by you. I know you didn’t get your information from the sources you claimed, because I have the proof. But when you spoke with those people, you were less than discretionary with the information. I have no doubt that you were panicking, that you felt desperate enough to try to put the words in their mouth so that you could tell me that it was them that betrayed me. But it was you who betrayed me. Suppose those people hadn’t known those things about me, and suppose I didn’t want them to. I have a right to privacy and confidentiality, and to forget that is so unprofessional it beggars belief.

At the end of the day, just who do you think are to judge? None of the people that matter share your opinions. The GDC do not share your view, neither do the providers of my professional indemnity, or my doctors. And most crucially, neither do I, because I know my limits. I know what I can and what I cannot do. You talk to me as if I have never worked in stressful situations before, and were rude enough to suggest I hadn’t actually completed my vocational training, although you have a copy of the original certificate. I know my capabilities as well as my limits. So yes… lets get this clear, you are being narrow minded and discriminatory.

To say that you are not being discriminatory because of who you have now employed is irrelevant. If you made rude comments about a particular race, you would be a racist, even if your best friend were black. Not discriminating against one person does not mean you do not, or have not, discriminated against others.

What I don’t understand is exactly what you think the risk is. You seem to think that I need to live in a hospital, to have constant access to medical care. For what, exactly? I live alone, and have done for a long time, even at the height of my ill health, although admittedly with support. I have travelled across the US alone, and am soon to travel there alone again. I don’t take a doctor with me in my suitcase!

You also give no credit to the awareness for my own health that all this gives me. How it means I don’t push things, I don’t burn the candle at both ends and I listen to everything my body tells me. In many ways, I am less at risk of the collapse you seem to so fear, because I don’t take my body for granted. This has also given me empathy and a passion for caring about others, not to mention problem solving skills, the ability to multitask and to work under pressure. All, I’m sure you’ll agree, good professional qualities.

Perhaps the final irony is that, despite the stress you have caused, my health through this time, including the control of my diabetes, could not have better.

I'm moving on now, and putting this behind me. I just have to be thankful that I had a lucky escape. And hope that maybe one day, someone does this to you. Then maybe you will understand what you have done.

Getting Personal

It wouldn’t take great powers of observation to realise that I’m being pretty generic here. I’ll hold my hands up. I’ve been deliberately avoiding giving too many specifics. In short, I’ve been hiding.

I’ve got my reasons, though I guess they may not seem very compelling to anyone else. I don’t want, or at least haven’t wanted up until this point, to bare myself for judgment from people who know me in my offline life. Yes, I worry too much about what other people think of me. And yes, even if they think this is junk, or a waste of time, I’ve got good reasons for doing it, which is what matters. But I guess I wanted to establish myself before giving identifying clues to people who could pick up on them.

Now, anonymity is stifling me.

And now, I have begun to give clues – narrowing the very generic ‘England’ down to the (only slightly) more specific ‘London’ and clues through the tag game, for example – that along with my name and age would probably be plenty enough to reveal me to anyone that knows me well, who happened to pass by.

So I guess now is time to get a little more personal. Honestly.

My name is Caro, I’m 26 years old, and I live in London. That much you know.

Caro is short for Caroline. I have a brother, who lives in San Francisco.

I told a small lie in the 'Tag'  post, in that I actually grew up in Kent, not London, and I have also lived in Plymouth, Devon. When I put that post together I wasn’t committed to coming clean, and that is a pretty specific combination of places. I hate lies, but I see this more as an omission, than an out and out lie. I hope you’ll forgive me.

I’m a qualified dentist, but I hope that you'll forgive me for that too! How I came to be a dentist is definitely a story for a whole other time! I don’t want to give you my full name, because people who know me recognising me is one thing, but I don’t particularly want my patients googling my name and reading me here. Believe me, some of them would, and for the most part I don’t actually want them to know that I have diabetes, because it isn’t necessary to our professional relationship.

That is about it for now, although more will almost certainly follow in the natural course of my posts.

Because I’m not hiding anymore.

And I’m not caring about being judged anymore either. I’m in this for me. The real me and anyone who cares to read me.