#1015 Emergency Room Protocols (REMASTERED Diabetes Pro Tip)

September 23, 2023Scott Benner

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.