#1097 Grand Rounds: Hospitals, Urgent Care and Initial Contact

January 2, 2024Scott Benner

Scott Benner and Jennifer Smith RD, LD, CDCES share diabetes insights for clinicians who want to do better. Today, they talk about the importance and impact of the initial contact in hospitals and urgent care when first diagnosed.

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

Scott Benner 0:00
Hello friends, and welcome to episode 1097 of the Juicebox Podcast.

Welcome back to the 10th season of the Juicebox Podcast we are starting strong in 2024. With a brand new series called Grand Rounds, these episodes will be myself and Jenny Smith. And Jenny and I are going to be talking to two distinct audiences in these episodes. On one hand, these conversations are directed to clinicians. But on the other hand, they're also directed to patients. People living with type one diabetes deserve good care, and they need to know what to expect and demand from their physicians and physicians. It feels like sometimes some of you don't know you're from a hole in the ground. So with good humor, and much love, this is the Grand Rounds series, where we're going to try to explain to doctors what they don't know about diabetes. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan, or becoming bold with insulin. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show. This episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. Learn more and get started today at contour next one.com/juicebox. This episode of The Juicebox Podcast is sponsored by touched by type one touched by type one.org. And find them on Facebook and Instagram touched by type one is an organization dedicated to helping people living with type one diabetes. And they have so many different programs that are doing just that. Check them out at touched by type one.org. Hey, Jenny, welcome back. Hi, how are you? I'm good. Thank you. How are you? I'm fine. Look at us on a Monday again. We've been doing so many Fridays lately. And now today, beginning of the week energy you're getting from us? Yay. I don't know what that means.

Jennifer Smith, CDE 2:23
Like, I don't know, weekend into Monday. I don't know if there's energy there. Maybe Yeah,

Scott Benner 2:29
well, we're about to find out. It's funny. We did the first Grand Rounds episode, which is like an overview of what we're going to talk about. And I think I vacillated a little bit I said I like it's hospitals. First, it's diagnosis first. And then as I really thought about today, like most people are going to end up in some sort of an urgent care hospital care scenario first, right? It's it's very few and far between where people figure out they have diabetes, and, you know, go right into a hospital like, right into a diagnosis. I mean, like, you don't end up at your physician going, Hey, I'm here I have diabetes, like you manage me from here. Like I think a lot of people end up in some sort of an emergent situation initially, do you think that's fair?

Jennifer Smith, CDE 3:12
I think it's fair in the majority of like a diagnosis setting, I think for adults, who may be a little bit more in tune with what their body has been feeling like, and they've just paid enough attention recently to say, This isn't me, like I, I feel horrible, or I've noticed, you know, I clearly can eat like the whole entire refrigerator. And I'm still like losing weight, or I, you know what I mean? That might prompt them to make an appointment with a primary care doctor to actually just go in and go over. And that obviously isn't an emergent, especially unless they call and they get a really good sort of intake nurse who's like, I don't know these symptoms, maybe you should just go to the emergency department instead of coming in here most often they're going to be and sometimes they're also caught, like, you know, you go in for a new job, and they might have you do a physical and you get a fasting glucose or even just a random glucose that kind of sparks up. Hey, we should do more testing here because this glucose number is out of range. But in general, yes, it's more emergent.

Scott Benner 4:20
I'm thinking then that these these two topics are kind of one one a there, you know, I don't know if I can, for sure say but I'm just going to start with hospitals. Because I think hospitals, urgent care, those sorts of things. These are the people who are probably least prepared to give you information and most likely to say something, it's just gonna say, Look at me starting right off most likely to say something that puts you on a bad path.

Jennifer Smith, CDE 4:51
Correct? Not in not because they're meaning to but because again, as we said in the you know, initial sort of discussion, it's because they Really, that's not a specialty for them? Sure they have, they have broad knowledge of a lot of different conditions. And a lot of honestly, I mean, emergency departments are a lot of like test results, right? And what do you do? What specialty do we knew now call it and because of this test result, or this type of trauma or this type of thing that the person came in with, so they have a lot of information. But they're like snippets, right? It's just the tip of the iceberg of information.

Scott Benner 5:27
And I think through that their professional experiences, especially if you're in an emergency room, or, you know, urgent care, any emergency situation, when you see people who have diabetes, they're not coming there, because things are going great normally. So these are people whose blood sugars could be wildly swinging around, they might be having a ton of low blood sugars, they might be having so many highs that they're having other kinds of concerns. And so that when that's your experience with people with diabetes, I think it's then when you meet a new person, newly diagnosed person, whether you mean to or not, you're colored in that direction, right? Like, you lean into, oh, this is bad. Or you want to make sure about like this, because all when I see the people they can't feel their feet and like like, and then does, it may not become a self fulfilling prophecy, then when you bring a newly diagnosed person who is going to be in shock, once you tell them what's going on, their blood sugar's are probably very high. So they're altered to begin with. And now you're saying all these things to them that they did not expect in their life. And if you're coming from the, oh, this is really bad. Then you predispose somebody to believe they now have a thing that's really bad. And you know what I mean by that? Yeah, I

Jennifer Smith, CDE 6:43
do. And I think something that also goes along with it, I mean, my husband would be the first to say that I clearly should never be a poker player, I have no poker face, I just don't like I, if something's up with me, like it's, I have a different expression for a lot of things. And so I think that's another piece in this. That's not verbal. But you know, if you're walking in with lab information, or a urinalysis or something, as the first point of contact of this new information for the family, or for the adult, or whoever it is, you're going to say, hey, you have diabetes, you know, I know you shouldn't be like looking like a happy, happy person. But really, you should also look like this isn't like the Grim Reaper expression on your face, right?

Scott Benner 7:31
I don't mean to say that people should be disingenuous. As a matter of fact, one of my favorite restaurants, there's a teacher, a school teacher that works there as a as a weight as waitstaff. And she teaches very young children. And so she comes at you with that energy. And the entire time you're talking to her you're like, I don't feel like this is real. But I actually think it's who she is. But it's still like, it makes you feel like is she pretending? And so you don't want to come to somebody with this happy energy? Like, oh, don't you have diabetes? No big deal. Because Correct. That's also like a lot about what we're going to talk about here is the path you're sending someone on. So you don't want to send them down a doom and gloom path, because if they think there's no hope they might live, like there's no hope. And they might educate themselves as if it doesn't matter what I learned, because I'm gonna end up back in that hospital one day, right? You also don't want to let them think like, everything is just amazing. And this is super easy. And you know, or that, you know, we talked about earlier to, you don't start telling them about a cure that you heard about an even yet, right? Because Because I know where that comes from, it comes from a, I want to make you feel happier, we're better about this. Correct. But what you might not know if you're in an emergency room is when you tell somebody something's going to be cured. Soon, you predispose them to not learning about it and not taking care of it because they think it's a temporary issue. Right?

Jennifer Smith, CDE 8:56
Yeah, absolutely. And I think that's another piece that temporary, it's a good, it's a good word, because I think something also that gets laid down early on not every time but many times is just do these simple steps. And it will, it will work right. And or, here's your here's your dose, you know, let's say this is a new diagnosis of type one diabetes, obviously and here are your doses. The explanation beyond that, even though you may not know what that transition may look like, should never lead the person to believe that these start these starting doses or this starting is where it is going to be that there will be movement you will follow up with a care team the care team will direct this your doses may change they will change you know all these all these points to have them understand that this is a like a moving picture. All right,

Scott Benner 10:00
if you put me in this position, I would tell people, listen, this is scary, I understand, it's going to get easier over time. But that's only going to come if you learn a few things. And really, at its core, you're gonna have to learn how insulin works. Now we're setting you up best we can, with some settings, and some ideas, just like you said, These things are going to morph and change. As a matter of fact, it's possible. Don't say things to them, like you might be in a honeymoon period, say it's possible, you may still be getting some assistance from your pancreas that will over time, and I can't tell you how much time will dwindle to nothing. And that could be a week, it could be a month, it could be a year, I don't know. But I can tell you that that's going to keep changing as that changes the how you use manmade insulin, the amounts. And I think, you know, a lot of the strategies are going to change as you move forward, leaving them with the idea that it's not going to stay static is super important in a society where people think about pills fixing things, correct? Yeah, right, exactly.

Jennifer Smith, CDE 11:09
Because most of the medications, honestly outside of insulin, and maybe a couple of other things, other medications, oral or even injected Ra, I take it in the morning. And that's it, I don't have to think about what I'm doing the rest of the day, because the medication just does what it's supposed to do. The understanding that you're giving them of this medicine, I hate calling insulin medicine, because it is something that your body does naturally make, right, just in the case of diabetes, it doesn't. But this insulin that you're taking essentially, will need to be adjusted, we are just at a starting place. And to understand, again, we're not your specialty team, we're setting you up with a place to be able to get out of the hospital, essentially, and then move forward into a team that can provide you with that detailed information. We are just covering the basic,

Scott Benner 12:08
I think when you're doing triage work, which is what that is, right? It's triage and initial, and then you move people on to something else. For most things that happen in an emergency room, the thing that's happening now goes away, when you get to the next step, I broke my leg, you know, hey, broke your leg, it looks good, it looks bad, I just shouldn't be a problem, we're gonna get you to somebody, boom, you leave. Right? A day or two later, what was said to you in the emergency room is no longer impactful to you. It's over. Now, this is a situation where the least knowledgeable person in your care plan and I mean care plan from day one being diagnosed, the day you die. The least knowledgeable person is the first person you see. And they imprint ideas on you. And they don't know like, I'm talking to the doctors. Now I know you don't know you're doing it. It's because you don't have diabetes, like and I get it. But you start saying things like, Don't worry, it'll be fine makes people not pay attention. When you tell people to worry, you ruin their lives. Like they, some people will go home and be burdened in ways you can't imagine. You need to say, I don't know a lot about this. But what I know for sure is all of management, at its core is how insulin works. You need to get to an endocrinologist and learn about insulin. And if your endocrinologist doesn't teach you go out into the world, do your best to find that information. Otherwise, you get lost in a direction you either get lost in over management direction, which causes significant psychological issues for people. Right, I was just talking to a girl the other day on the pocket. She's 21 diabetes, and she was five years old. And still, when she got to her adult endocrinologist who would just tell her you're a one sees too high. Just say that to her a couple times. Then one day, he said, Eat Fewer carbs. Well, then it got in her head. And that's all she could think about. Right? I'm not gonna eat more than 20 carbs today. And then she started having a disordered eating pattern. And if somebody else in her life hadn't come around to her and said, Hey, you're not eating well at all. This is what she would have done out of that fear. Because she said once she started using such a small amount of insulin, even though she wasn't nourishing herself. After she started using such a small amount of insulin, she saw more stability. And that's the building made her ignore that she wasn't eating anymore. Of course, yeah. And then when somebody finally came along and said, I don't think you're even nourishing yourself, and it was time to inject more insulin for her her meals. She was frightened and she couldn't do it. Right. I tell you that like quick story that people were listening, because that all came from a someone who just didn't know how to help her with her insulin and said once you just need fewer carbs, that throwaway idea caused that landslide of problems for that lasted two years. contour next.com/juicebox. That's the link you'll use. To find out more about the contour next gen blood glucose meter, when you get there, there's a little bit at the top, you can click right on blood glucose monitoring, I'll do it with you go to meters, click on any of the meters, I'll click on the Next Gen, and you're gonna get more information, it's easy to use, and highly accurate. smartlight provides a simple understanding of your blood glucose levels. And of course, with Second Chance sampling technology, you can save money with fewer wasted test strips, as if all that wasn't enough, the contour, next gen also has a compatible app for an easy way to share and see your blood glucose results. Contour next one.com/juicebox. And if you scroll down at that link, you're gonna see things like a Buy Now button, you could register your meter after you purchase it, or what is this, download a coupon, oh, receive a free contour, next gen blood glucose meter, do tell contour next one.com/juicebox head over there now get the same accurate and reliable meter that we use.

Jennifer Smith, CDE 16:08
Right, and you're talking about somebody who had been speaking with what we would consider is a specialist within the diabetes, you know, community, right. And so back stepping to the baseline. And I don't say baseline in a very generic way or in a you know, a not not educated way. But it's a baseline of information that those who don't have a specialty outside of this specialty of navigating so many different types of things that come in to an emergent situation, I mean, that that takes a special type of clinical mind, right to be able to navigate between, you know, this type of wound versus this type of vomiting versus that type of headache, there's a lot of consideration there to figure out and know what tests to do. It's a very quick paced environment. So nobody would expect them to be specialists in just one thing. But I do believe that from a general place. diabetes in and of itself is a hate thing easy, but it is, if you understand the baseline of type one versus type two diabetes, then in an emergency situation, test results are something that should be easy to interpret, right? And then what you provide with the family or the person who is going to be newly diagnosed, it should come from at least that baseline of this is what type one diabetes is. This is what it means. And I think those those basics for the person who this is very new four, are really important. Because again, I mean, we've talked in other things about, you know, blame or feeling guilty, and from the person who now has this diagnosis. And I think that even keel of you know what, we found out why you're feeling the way that you do you have type one diabetes, this is what that means. And, you know, I think that's at least a way for someone to accept the information, as well as for you to give them none of these like gray areas of like the unknown what to do with it.

Scott Benner 18:20
You know, it's funny, you said that we don't, we wouldn't, and shouldn't expect a person in an emergency room, for example, to know the ins and outs of diabetes. That's great. And you and I sitting here philosophizing about it is exactly right. But the person who's just been diagnosed five seconds ago, you're the most learned person in the world to them. Correct. And so if you don't know, the best thing you can say, is I don't know a lot about this, you know, and I'd be afraid to tell you something that would lead you in the wrong direction. But I hear I listen to this podcast, I probably don't tell them that you but but but you know, here's what I do know, it's a lot about how insulin works. When you get to the next step. If you feel like you're not getting good information about how insulin works. Don't accept that as a baseline. Everything's about how insulin works. You know, it's not difficult. Once you understand it, it takes a while to understand it. Be patient, be kind to yourself, I mean, that's the thing. I always feel dopey saying stuff like that, but it's absolutely true. Like you gotta give yourself a break. It's gonna take some time. This is the kind of stuff you can lead them with. You know, you're gonna learn as you go, right? I know plenty of people who live well with this by the way, if you don't, it's okay still lie and say you do. Okay. Like you know, like you don't say Nick Jonas to them, apparently that's one of the feedback things from the people that are like, without telling me about Nick Jonas when I'm diagnosed. But But ironically enough, down the road, there are some people who are very comforted to know that people who they they see as they know, functioning well in the world and that they're aware of have Diabetes. But yeah, it's funny how many people said like, Please don't tell me about Nick Jonas? Well, my kids being tagged

Jennifer Smith, CDE 20:05
with that is what? And again, that's, it's almost a, like you said before, oh, there'll be a cure kind of comment. It's not that bad. Yeah, when really, you're the one living this new thing. It is it's, it's

Scott Benner 20:20
ever happened to you the worst

Jennifer Smith, CDE 20:22
thing that's ever happened to you, right? I mean, in general, to when someone comes in emergent lead with this diagnosis, nine times out of 10, especially for kiddos are going to be admitted, there is going to be at least a day or two, depending on the status, when you come in with this type of diagnosis, depending on the status of the child, the teen, the young adult or the adult, there's going to be an admission, which means that you're again, you're the first explanation of this new diagnosis as the clinician who's there. But expanding on that, being able to say you know what, we're going to admit you, if that's what's going to happen, and there will be there will be specialists who will come and explain this further. I don't know all the answers, I'm not going to pretend to know all of the answers, you will have specialists who come in and explain and sit down and talk with you and answer all of the many questions that I know are probably sort of circulating in your head right now. And I think that's important to explain, because like you said, You're the first know all like, you're like everything right now in terms of delivering this new diagnosis to somebody, but also explaining, I know, I know what you have, but I can't do much more. That's why we're going to get you to the people who do

Scott Benner 21:47
it's an awesome responsibility to have one of those jobs that people just blindly trust teachers, police officers, doctors, you know, you don't realize that what gets said is it's gospel. It just it right away is and you know, if you're listening right now, and you're a nurse that's in working in an ER or a doctor that works in some sort of intake, and you think I've I went through this in school, I know, you don't know anything about diabetes, if that's all you know, and I will offer as a personal anecdote about that, that this podcast is strewn with doctors and nurses whose children or selves have been diagnosed with diabetes. And when they were diagnosed, they thought, oh, this will be easy. I know about this. I learned about this in school. And then five minutes into it, they realize, oh, they only told us enough. So we don't kill somebody. Right. Right. And, and bringing up that kind of language. There's this phrase I used in the podcast a number of years ago. I swear to you, I wasn't trying to start a catchphrase. I said, I think some doctors not all by the way, by the way, there's plenty of doctors listening right now and nurses and doctors who are very good with diabetes and insulin management who are just saying Hallelujah, like preach to people, right, but, but for the ones that aren't, I used to say, I haven't said in a while. Often you get what I call don't die advice. Like it's enough management, that you'll you'll be alive today. And you're not going to have a seizure. But there's no no view of long term health or long term stability mentally, physically. It's just enough that you won't die today. Oh, yeah. Yeah, once the seven, that's pretty good. You know, like that kind of stuff. Your blood sugar went up to 300. But it came back down. Yeah, yeah.

Jennifer Smith, CDE 23:32
And in an emergent situation, I think that you're not going to die right now information. I don't think that that's, that's very important. It's really, really important. This is a baseline, this is what's going to get us through to the next point, right. And that next point, again, is specialty. It's someone who's going to teach you not just how not to die, but is going to teach you how to live honestly, with this and strive and do all the things that you want to do in life that comes from a good specialist that that's not don't and as the person with diabetes, you know, newly diagnosed, shouldn't expect to get that either. Yeah, but as the clinician addressing them for the first time there, you should explain that to them. I am I am your baseline of information. This is what I know from the test results that we have. This is what it means. This is the basic definition of what you have. And we are going to get you people who can really explain this at a much higher level for you and I think that's really important for to not try to be the No at all. In that situation. Right? to not try to explain beyond what you truly don't grab it points. Essentially stick

Scott Benner 24:55
to what you know, and check into what you think you know, before you start spreading it around As if it's true, because there was two pages in your book in college. And, you know, even when you think about managing diabetes in a long term setting in a hospital, I mean, honestly, Jenny, they, you know, if your blood sugar's under 300, while you're in the hospital, they're going to be thrilled. They're going to be focused on not making you low, and they're gonna have you eat, and then they'll shoot your insulin later, even when sometimes people who really understand their care will say, I, you know, I can't let my budget or up to 200 and sit here all day. Oh, no, we're okay with that. Whose way? Like, I'm not okay with that. But once you say it's okay, now a person goes out into their life, and it's okay. You know, 200 is fine. Like, because that's what happens in the beginning, you're giving good you're giving don't die advice, which is very, very important. But if you don't say the rest, like over time, we need to tighten these tolerances, right? They'll just live like that forever, right? Some feedback from people, even a small pamphlet with resources and basic information would have been amazing to get to the hospital. Please, somebody educate the hospitals, I want doctors to understand that a diagnosis also causes mental trauma. And not just a mental trauma. But it's, I went through it having my daughter diagnosed, I didn't know which way was up. Like I've said it a million times in this podcast, it feels like someone ran up to me, hit me in the head with a shovel and started yelling math at me. And if I didn't remember it, my daughter was gonna die. That's exactly how it felt. And it went on for days. If you think the third day I was better off than I was on the first day. I wasn't every conscious moment you sit there thinking, Oh, my God, Everything's ruined. Like it's over. Like everything I thought is gone. Like because you don't know. Right? You don't you don't know that. It's, it's incredibly doable. And that millions of people live with it well, and like all that stuff. So you're just sitting there in a panic. And you're like, Oh, it's my problem to take care of the kid. But if you're an adult, it's almost worse, because it's on you. And you're the one who's going to get a low blood sugar and not be able to think at the same time. And you're going to end up with an adult endocrinologist who has you point out all the time very likely, mostly helps people with type two diabetes, at least when you're a kid you get at Children's Hospital? It's a little more. Yeah, yeah. Right.

Jennifer Smith, CDE 27:23
You know, right. I, you know, I think too with that, because of the constraints of hospital stays, that are dictated by essentially diagnosis status within that diagnosis, and honestly, insurance that covers all of that, right. I think that many times from a clinician standpoint, they're trying to pack as much as they possibly can to send you out the door with more than just the This Is How Not to Die. Right? And what gets lost in that it's great that you bring in the mouth mental component to that because what gets lost is the consideration for how much in of traumatic type of setting the human brain can actually retain.

Scott Benner 28:10
Very little from my experience. Yeah, well, and you're,

Jennifer Smith, CDE 28:13
I mean, you're not a dumb person by any means. So you know, I know it just in the many discussions we've had you grab on to information very easily and very quickly and you get it and you can dig deeper and you can understand much more so I think it was it not your daughter I would have been alright probably would have been okay, you would have gotten it you know if it is a nephew, okay, you have to care for him over the weekend, I got this, I got this, like I can do it, you know, but for somebody that you like your, your arm, right? It's like a piece of your body is your child, honestly, as a parent, and so you, you have this mental piece of not only do I have to keep them alive, but oh my gosh, I have to keep them alive with this new stuff that

Scott Benner 28:57
I'm supposed to do. And they'll say to you look too much is gonna kill them too. And you're like, wait, what, and then it's not enough is gonna cause long term complications. And too much is gonna cause a lot of it's about how it's said. It's the delivery, it's your communication and your delivery and listen, and to Jenny's point. I'm pretty good at diabetes. But on day four. On day four, I was crying in a room because someone was trying to teach me how to add fractions a thing that by the way, I knew how to do. I was beside myself. And it wasn't because I was learning how to like figure out a dose based off of carbs. That was easy. It was because of the pressure that came with it. Like what do you mean? Like she's like, when her doses were i My daughter was two years old when her doses are a half a unit and you make a math mistake and now you're at a unit and a half. Well, geez, right? I might just we'll just toss her out the window right? Like let's get it over with because I'm like, I'm gonna screw this up and I'm gonna kill her and then that fear turns into while just let her blood sugar boil little high. And then all the sudden it's, the doctor will say to you like, well, you know what? Let's make your let's make it I don't know 70 to 200, but we're going to treat 90 is low, but two hundreds, okay? Well, once somebody tells you two hundreds, okay, 220 doesn't seem that far over 200 Correct. And then you start, like, getting farther and farther away from healthy. And no one tells you on day one that a high blood sugar makes someone altered. I don't know that my daughter's not the person she's supposed to be because their blood sugar's 250. No one says that the mean, if they said it to me would have freaked me out more. So you're in this like paradox where you need the information, but you need it correctly. And that means time, it means a thoughtful explanation. And again, if you can't give it, I think it's better not to say anything. Right?

Jennifer Smith, CDE 30:54
That's, that's where understanding that those beginning pieces of information need to come with the explanation that this is a start, we will adjust. And you will, again, have some specialists who are going to help navigate the adjustments. Right now, the safe target range may be this to this and it may be very broad. This, again, is a starting place. So everything as the as the first person that this person who's newly diagnosed, is going to encounter, the baseline you give them should be this is just the start, this is going to be an OK place. And we're going to move further beyond this. So that you can really, again, live the life or have your kid live the life that they want.

Scott Benner 31:45
The number of people pointed out that as a an adult diagnosis. They're like I needed an endo console in the hospital, and didn't get one because the hospital so don't worry, like leave here, call this number, we'll get you set up with an endocrinologist. And then the endocrinologist sometimes will tell you, they don't have an opening for three months. So now you're holding insulin, you know that. And somebody told you it's dangerous, be careful, or worse, they didn't tell you it was dangerous. And they make it off you like loosey goosey and fancy free. And then there's so much feedback from here from people like I gave myself way too much insulin almost killed myself. And you know, and because who knew it was? Because if you take two Advils or three Advils, you're kind of okay. And that's how and until you've had a tea, you've had a serious medical issue, like a day to day thing that's always with you, right? You don't ever think about your health that much. And people just don't think about it, it's a thing you take for granted, you know? Correct, right.

Jennifer Smith, CDE 32:45
And as the adult level, which is great to bring in, because as I mentioned initially, many, many adults are actually not diagnosed in an emergency room scenario, right? They're actually, as an adult, they're like, I just don't feel good, or I just have not felt great i or I'm doing this and I didn't used to do this or whatever it is, and then they it's a primary care. And then like you said, the primary care may say, hey, let's get you to see a specialist, especially if that primary care, did a great job and actually did enough testing to diagnose type one versus type two diabetes, hey, you know, I'm not your specialist, let's get you to the specialist. But again, there is there's a problem in that we don't have enough specialty, with enough time on their schedule, to be able to get that newly diagnosed person in within two days or even three weeks, it many times is much delayed, and what does that leave the person who now has to take medicine, they now have to take, you know, their blood sugar, they have to understand a little bit about food and about, you know, activity and maybe their job is a heavily active kind of lifestyle in all of these things that in no way can primary or general medicine really expand on to the degree that's needed. I think there's a very big deficiency in our healthcare system in terms of the ability to get what you need when you need it. There just is and that's not, that's not a knowledge component from the clinical staff. That's, that's just the way that healthcare is set up. And it's

Scott Benner 34:24
unfair to talk to people who are working in emergency and, and to put this on them. But I think it's incredibly true. You're whether you know it or not, you're in charge of what happens to those people 30 years from now. And and it's you might say, Well, how is that possible? But I mean, I've done my best to say it here over and over again. If you put someone on the wrong path, they might never get off of

Jennifer Smith, CDE 34:48
it. Especially if they never get to see somebody who can clear it up for them

Scott Benner 34:52
right or the next person they get to is inept, or whatever. And you know, and now you have a doctor telling you Oh, you're a onesie aid. I mean, ADA says seven. So that's not too bad. Right? Right. Right. Yeah. And it's gonna be a problem. And so I think some people also go to scare tactics. I can't believe how often I hear from people that they've been scare tactic than a hospital before, but telling them trying to relate to people by telling them your dog has diabetes, your cat has diabetes. That's not good. Don't do that. Now, right? Telling them Oh, my grandmother lost her foot. I know all about diabetes. Don't do that either. Don't do that either. Right? There are some things that feel confident. It's funny, isn't it? When you see a conversational thought, hit someone's head, and then they speak it out loud? And you think, why would you say that? And even I think a moment later, the person might even think like, oh, I shouldn't have brought that up. But it's too late, then. Like it's too late. So you're sitting with a person who thinks their life, they either think their life is doomed, or they have so little understanding of it, they don't know, to put the effort into it to stop their life from being doomed. Right? Right, they need, they need a good launch from you. And that launch might just hopefully be to across the street tomorrow for another appointment. But you don't want to put a thought in their head that they can't get rid of that that sticks with them. And, and especially in that scenario, like you have to treat them like they were just in a car accident, and that they aren't following what's happening. Right? Because the other thing here, I this is also, I think very important. If the people are healthcare professionals who are being diagnosed, the parents or the adult, do not assume they don't need your help, or they don't need someone's help. And they've got it because they're doctors, because the amount of conversations I've had with doctors who said I was not educated properly, because they looked at me and thought, Oh, well, you're a doctor, you know. And that was it. That's incredibly dangerous. Those people then have to go home, by the way, and fight with their own ego for a minute where they're like, I should know this, then they feel defeated. That's a big one. Don't do that to health care professionals. I don't know like there's I feel like I could just talk about this forever. But I don't want to muddle it.

Jennifer Smith, CDE 37:07
Yeah, well, I think, you know, from my previous hospital and clinic based sort of experience, I had the unique advantage to work with a really wonderful endocrine team, within a big hospital system. And within this hospital, the emergency department actually came to the endocrine team and said, you know, we actually know that we don't, we want to navigate managing those with diabetes, both type one and type two and newly diagnosed, especially who come in better. But we also are a big city emergency department, right. And so from a staffing standpoint, we don't have time to walk through somebody's medication, exactly other than take it once a day or take at this time of day, and some of the education and so they worked really, really intensively with our endocrine team to develop actually a protocol of education specific to diabetes. And in stackable hours, not that we were there at two o'clock in the morning. But within hours of normal daytime operation, when people with diabetes were diagnosed, we got a page to come to the emergency department and actually provide the education as well as the medication dictation about how to start something and how to dose it, et cetera. So I think, you know, system to system if they adapted or adopted something similar to this. And if you have any, say within your, you know, for kind of talking to emergency or urgent care kind of staff, if you have any ability to have some poll about what could be done, you may actually be able to make more of a difference for those who are diagnosed with diabetes in that emergent situation, by just pulling somebody in, even if they're not going to be admitted for additional information that especially for the adults, if there's somebody on staff that could come, that would be a huge advantage for

Scott Benner 39:12
that big deal. Right. Now, of course, I don't want to overwhelm the person who's in that position who probably doesn't have enough information. I don't want them to and I don't want them to. But But I think again, saying things you don't know, is maybe the worst thing you can do. Like really and assuming too, that the next person they get to is going to fix the whole thing is also like so there is some responsibility there for you to give them some basic information and education. Or tell them there are places online you could go to, like meet other people who have diabetes, because unlike if I come into the emergency room in heart failure, I'm going to go to a cardiologist who is now going to manage my heart. I will just do what that person says and this thing will go as well as it could if I come in there with cancer, I'm going to go to an oncologist and they're going to take care of everything a broken leg, someone's going to fix it, they're going to teach me and then they're going to send me to physical therapy afterwards, you get diabetes, you go talk to somebody, they go, here's insulin, good luck. And then you go home, and now you're in charge. And that is just what happens type two or type one. That's what happens to diabetes, it's not a thing that the doctor is helping you with, or putting you on a path. And then you don't really have to do anything except take this thing on an empty stomach or like that. It's so different than that. And I know it's a misunderstood thing within the population, and that part of the population are nurses, and doctors and everything else. And I know it's misunderstood by them as well. But it's why we're doing this. And also, the opposite side of this, which I'm going to at the end of every one of these episodes bring up. This episode is not just for somebody who's a physician, or in a position to help somebody, you should be listening to this and saying, This is what I should be expecting. You know what I mean? Because maybe you're listening now. And yes, you already have diabetes, but you're gonna end up back in the emergency room one day for something if your mount but odds are, and you get there, and those people are going to still not know anything about your diabetes, you know, and they're, but they're gonna say they do and, etc.

Jennifer Smith, CDE 41:15
No, that's a great point to bring up. Because I, I was gonna bring up similar that as the person with diabetes or the family with diabetes, you have to know how to be an advocate for yourself, honestly, you have to be the one to say, You know what, I don't expect you to know all the answers here. I know that you can help me with this emergent situation, or maybe not. So let's can we get the specialty? Right? Is it within hours that a specialist would be here? Let's get them in here. Because I don't know what to do. I've clearly not done something right. Or I've been sick enough to bring myself to the emergency department with diabetes. I want to make sure that this gets, you know, figured out the right way.

Scott Benner 41:57
There's also a way to not I mean, it's hard, but you got to not flip out a little bit. These people. It's not their fault. They don't know about this. Like it's no, no, not not a little bit. It's not negligence, it's not apathy. It's just It's the system and the way it works, right. So it's a number of years ago, but Arden and I take her to the emergency room once for stomach pain. And we're there for a couple of minutes, and the nurse comes in and she goes, we're gonna get that insulin pump off of her. And I went, No, we're not. No, we're definitely not doing that. She has no, we'll get her some Basal insulin. I'm like, Whoa, no, no, you want to inject. I'm like, I haven't done that in 10 years. I don't even know how to do that right now, like, because you see that that's what the pump is doing. The pumps already doing that. And then at one point, her blood sugar as they gave her an IV, I guess that dilutes your blood a little bit. And her blood sugar started to go lower and lower. And she says, I'm gonna give her dextrose through the IV, maybe? I don't know, exactly, she was gonna get extra hit or something, you know? So I said, Listen, she's on an algorithm. As soon as her blood sugar jumps up, it's gonna, like start giving her instantly and we don't want that either. So tell me what you're doing. And I'll adjust the algorithms so that that doesn't happen. And then she's like, Oh, what's that? And then I explained it to her a little bit, then she became interested. And then she was a lovely person, and a thoughtful person. And in 10 minutes, she knew what we were doing. And then we were partners, you know, and now I had taught her a little something. And now she wasn't saying things like, let's take the pump off of her. Correct, trust me an hour into it. No one was more thrilled in that room than that nurse. sure that we had come to an understanding and educate each other.

Jennifer Smith, CDE 43:40
Because you had stepped up and been an advocate for your daughter, right? And or the person who has diabetes, as long as you come in. I mean, this is a piece in the education that I typically do with like, either preparing for a hospital stay or a surgery or planning for an emergency, right? Is the idea that if you come in and urgently know that they're one not going to have any extra supplies to help you, right? Right. And so you do everything you can, as long as you are verbally, okay, you can address and talk to them and you're not out of it. Then great 100% You're keeping your pump on you or 100% You're talking to them about these are the doses that I take this is this has nothing to do with the sore on my toe right now. Don't worry about

Scott Benner 44:31
it at all you want. I'm not taking the CGM off if I have one ether, like it's alright. We don't trust that thing. I'm like, Okay, I've been living my whole life trust in that thing, and it's working out pretty well for me, right? It really is. I don't know it's to dance. It's a little bit of a dance and you have to be a good community to cater to you can't just start ranting and because the minute you rant, it's over. You know, like they're gonna be like that lady's yelling at me and I don't want to be involved in this and then you're never getting anywhere. Correct. It's just a very it's incumbent on both sides to, to want to, you need to want to work together, I think. And it's it's hard because they're in and out of the room. They're tired, they probably overworked, they're probably underpaid. They've probably been eaten in six hours. And you're trying to explain your, you know, your, I don't know, your algorithm to and they're probably like, well, I don't even know what you're talking about. Right. Right. I was lucky once as Arden went into medical procedure, that one of the nurses in the room was like, my friend has diabetes. And all that happened was I used a word that she recognized. And that was enough to make her look, amigo tell me more about that. Yeah, that was it. And I said, Okay, here's how this is working. And she goes, Oh, that's great. We would probably love to use that. Let me get the doctor and find out doctor comes in and re explain it. He goes, Yeah, let's keep that on her. And I was like, great, but five minutes before that people were pulling at it. Because they don't know why it's just what they do. You know, and, and to feel, then that puts you in a position where you feel attacked. And and then you lash out. And it's tough to because you know, I have this note for myself in this in this document that we're working from for this series. It struck me a couple of weeks ago, while I was thinking about this, we always tell people, you have to advocate for yourself. But it has two different meanings. If you don't know what you're talking about advocate means please teach me you have to I need to know more. I don't have enough information, blah, blah. But if you know what you're talking about, what advocate really kind of means is you have to make them do a thing, right? They don't want to do

Jennifer Smith, CDE 46:34
advocating for yourself as explaining what you know, it's almost like proving yourself essentially proving that, like you did, hey, we've got this thing it does this, it will really help beyond what you think your protocol says. Yeah, this is above that. And this way, and again, from advocating sometimes you have to simplify it right? You don't want to tell them all the bells and whistles because quite honestly, they don't need that. And it's going to be confusing. Do

Scott Benner 47:04
what I did when I was dating my wife tell her the good stuff. Okay, no, yeah, she can find out the rest after it's too late. Way too late. Arden had a surgery once. But it was a quick one was like a 30 minute like laparoscopic thing where they were just kind of going in and looking around for something. I said, Look, she's wearing an algorithm. It's run from her cell phone, you have to keep the phone with her. And they said, Okay, that's fine. But I want you to turn off the auto Bolus thing. And I was like, Okay. And then I just didn't do that. I just picked the phone up. I was like, oh, yeah, I got it. There you go. And then I just go ahead, because she was gonna go in there, and very likely not eat insulin. Like she's sedated. Like I thought her and by the way, I thought that's what was going to happen too. But the minute she woke up, and she was like, you know, at her adrenaline kicked in everything, and her blood sugar started to go up, that thing started to Bolus in the recovery room, and I couldn't get into that recovery room for like, 30 minutes, right. And we stopped a blood sugar that was easily gonna go to 300 by just letting her algorithm run. And I never told anybody about that. And if they know me, this is when they're finding out right now. So and I don't believe they'll ever hear if you know, best then say, is really is what I'm thinking. And I think listen to this conversation, recognize that these poor people, they're not trying to screw you. And they just don't know. And it's not their fault, you know? Correct.

Jennifer Smith, CDE 48:36
They've got a protocol, they're not picking weird stuff from the air, right? They have a protocol. And the protocol is a safety based protocol. And it's based on a line of here is okay for the majority of people, or here is okay for the majority of peds. Right. And that's what they're going to use. Is it going to keep you from having a low blood sugar? It is absolutely, but it will not, you know, prevent you from having a high

Scott Benner 49:10
blood sugar. It's not a way to live long term. No, it's perfect for that set and setting in the moment. That's all the problem is again, and to end is you do not want to leave thinking this is how it works. Because you when you get into your regular life that is it's not going to fly. Right anyway. Okay, great. This is a good start. Awesome. Thank you very much. Excellent, thank you. I'm excited.

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