#1098 Cold Wind: Healthcare Whistleblower, Clinical Pharmacist

January 3, 2024Scott Benner

Today's anonomous guest is a clinical pharmacist working with patients in the hospital.

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Scott Benner 0:00
Hello friends, welcome to episode 1098 of the Juicebox Podcast.

Today I'm introducing a brand new series called cold wind. The long title is cold wind health care whistleblowers. On today's show, we'll be speaking anonymously to a person we'll be calling Valerie. Valerie is an inpatient clinical pharmacist working with patients in the hospital. She has a five year old son who has type one diabetes. And she's here on the show today to give a behind the scenes look at what happens at her place of work. We're going to learn about Valerie's comfort level with taking her own son to the hospital she works at and so much more. Each episode of cold wind will feature an anonymous guest whose voice has been changed to protect their identity. The voice altering process we're using feels natural. You'll never know what they actually sound like. Just listen to how well the voice alternative works.

Speaker 1 1:18
My name is Beth and my oldest child has type one diabetes diagnosed in October 2020. My name is Beth and my oldest child has type one diabetes diagnosed in October 2020.

Scott Benner 1:33
When you place your first order for ag one with my link, you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juice box. This episode of The Juicebox Podcast is sponsored by us med U S med.com/juice box or call 888721151 for us med is where my daughter gets her diabetes supplies from and you could to use the link or number to get your free benefits check and get started today with us met.

"Valerie" 2:10
My name is Valerie I am inpatient clinical pharmacist, which means that I work in a hospital with patients who are in the hospital as opposed to like a retail pharmacist who would work at say a CVS or Walgreens. I have been doing this for about 10 years now. Well, I currently work at a pretty large hospital in an urban setting. So it's like an 800 Plus bed hospital. It's part of a larger healthcare system with Sister hospitals and other locations. Excellent.

Scott Benner 2:39
And you're so you're a pharmacist by trade though?

"Valerie" 2:41
Yes. Okay.

Scott Benner 2:42
went to undergrad, then how does all that work? How do you get that degree? Yeah,

"Valerie" 2:47
so, pharmacy has changed a lot over the years that used to be able to practice with just an undergraduate degree basically with like an extra two years. And then they made pharmacy a doctorate degree program. So most people have an undergraduate degree and then they go to four years of pharmacy school. I have my undergrad degree in biochemistry. And then I attended pharmacy school and I actually did a joint degree programs. So I have a master's in clinical research and an MBA as well as my doctor of pharmacy.

Scott Benner 3:20
Valerie, that is a lot and thank you for explaining it. Do you have a connection to type one diabetes? Yes.

"Valerie" 3:27
And so my son is five years old, he was diagnosed type one when he was one.

Scott Benner 3:33
Any other autoimmune in your family? No, no. Okay, so you have a five year old who's had type one diabetes for four years? Correct. Okay. Do you have any other kids?

"Valerie" 3:45
I have a seven year old also seven year old as well. Okay.

Scott Benner 3:48
Now you're on the show today, because I reached out into the world and said that I was looking for people working in hospitals, nurses, doctors, pharmacists, anybody at all? Who would be willing to talk about why the treatment of diabetes in a hospital setting is the way it is. That's what got you to come on. Is that correct? Correct.

"Valerie" 4:13
Okay, yes. And my specific role in my health system now is unique, and we are trying to improve our treatment of diabetes in the hospital. So we are implementing a lot of things within our healthcare system, which has included the role of the pharmacist being part of the diabetes management team, and patient as well as inpatient diabetes educators. That is something that our health system used to outsource to a third party without the pharmacist component. And now it's a more of an internal program and it's been going on for about a year now and our health system so you've

Scott Benner 4:52
been doing it for a little while. So what did What job did this give you? How are you helping in the process?

"Valerie" 4:58
So what my job is tells now is every patient who is in our hospital, we can run a report and look at if they have had glycemic excursions. And so we sort of prioritize looking at those and look at the hyperglycemia. First, anyone who had a blood sugar less than 70 in the last 24 hours, then we try to look at all the patients who've had a blood sugar over 300. And then we'll look at patients that have had at least two blood sugar's over 180. And we do this on a continual basis. So it's always just looking back at the last 24 hours to patients in the hospital. Is

Scott Benner 5:33
that happening for every patient that's in the hospital or just people who are flagged,

"Valerie" 5:37
it is happening, the report is run for every patient in the hospital. Our team, as it exists currently cannot address every patient that shows up on that report. So that's why we try to prioritize the way that we deal with the extreme like the hypoglycemia is first and then the extreme hyperglycemia.

Scott Benner 5:56
If this is seen, if if hyper or hypose are seen what happens then do you contact the physician? What do they do?

"Valerie" 6:05
Yeah, so as the pharmacist, there are certain things that we can do now within our scope. And that sort of as we're expanding the program, there are more things that we can do. So we can modify their sliding scale or their nutritional insulin orders, kind of going back and forth about modifying their Basal regimens. And with or without provider approval, depending on which particular physician is covering the patient's determines a lot about what we will do automatically. Or if we want to ask that provider first. And then as far as the, the nurses who serve as the diabetes educators, they try to meet with all of the patients who they have a little bit different report. So they're looking at agency mostly and trying to meet with all the patients that have the agency greater than mine. So

Scott Benner 6:52
if there's someone being treated in the hospital, and your system flags them as having higher blood sugars, you can make an adjustment to their dose for their meal, for example, and then the nurse that comes in the room with the actual insulin, they're not making that decision, it would be the pharmacy in your situation.

"Valerie" 7:11
Yes, a bedside nurse has no autonomy to make any decisions about the orders. Okay, and the computer

Scott Benner 7:19
from the gecko. I bet that surprises a lot of people. Don't you imagine the wind you think that people think like the nurse must be the one making decision about this or the doctors making like there's a doctor outside the door somewhere he's making or she's making the decision? I

"Valerie" 7:33
think that people with children with type one that have dealt with this school nurse will have some kind of understanding of this, because that's a lot of the conflict that comes up with school nursing, right? It's like the nurses saying, Well, I have to follow what's in the doctor's orders right here. And the parent is saying like, well, they're sick, or well, this happened, like I know that they need more insulin today. And the nurses kind of saying, well, that's not what the orders say. So that is also how it works in the hospital,

Scott Benner 7:59
your health system, or at least the hospital you're working in. What did they see that made this program come about? What do you think got it started? Well,

"Valerie" 8:09
there's, there's more kind of a push from the accrediting bodies. So Joint Commission and CMS to say that we need better glycemic management, in hospitals. So that was sort of the pitch behind it. So this is one initiative that our health system has chosen based on like kind of initiatives that were put out there saying like, we need hospitals to do better at these things. This is one thing that our health system decided to focus on. Okay.

Scott Benner 8:36
Did you have anything to do with this? Or were you just happily surprised when you heard about it?

"Valerie" 8:41
No, it just happened to coincide with my son having recently been diagnosed with diabetes, I have always worked in an inpatient hospital setting. So I have not really as a person, like, I don't know, as a health care professional, I would say, I don't really like like the ambulatory care setting as much the diabetes that was never a disease state that really interested me, it was always like, oh, diabetes is boring, until my son was diagnosed. And then it's like, oh, you know, all of that changed for me, I have a completely different perspective on it. So then, as this program happened to me implemented, you know, right after that, and that was why I, you know, got involved in it and applied prior to that I was working on overnights,

Scott Benner 9:25
can you maybe try to tell me something that maybe you haven't thought of before, I'm going to ask you to think about something prior to your son's diagnosis. If this new thing would have happened at your hospital, do you think you would have been met by you with like, oh, I don't know why we're doing this or this is more work. Like you see the value in it now because you know about type one from a personal perspective, but do you think you would have seen the value in it prior to that?

"Valerie" 9:54
No, not at all.

Scott Benner 9:56
How would it have struck you if if it came back that came across here? desk. It was 10 years ago except for example,

"Valerie" 10:03
you know, I think that we tend to think about things in that way as okay, like this isn't an inpatient issue or an outpatient issue. This is like an acute care setting or an ambulatory care setting. And it's like diabetes, other than if a person is newly diagnosed or in DKA is sort of like an ambulatory care disease state, like a chronic care, you know, something that you work with outpatient. And so that just has never been my thing that I've enjoyed. I've preferred working in a more acute care setting, inpatient setting. So that is primarily why I would have been like, Oh, this isn't, you know, this is more applicable to outpatient and even trying to recruit pharmacists to the position that is the responsible on IT people with like, Oh, this is really like an outpatient issue, even though we know we know, in our clinical care setting that having good glycemic management can improve outcomes for patients in the ICU and things like that. That's kind of the extent of it there, right? It's like, well, yeah, but we don't want to monitor all the like oral diabetes meds and that kind of stuff.

Scott Benner 11:10
But is it fair to say that even though we know outcomes are better if blood sugars are tightly managed in a hospital setting that that doesn't make it exactly a top of the line concern. I used to hate ordering my daughter's diabetes supplies, and never had a good experience. And it was frustrating. But it hasn't been that way for a while, actually for about three years now. Because that's how long we've been using us med us med.com/juice box or call 888721151 for us med is the number one distributor for FreeStyle Libre systems nationwide. They are the number one specialty distributor for Omni pod dash, the number one fastest growing tandem distributor nationwide, the number one rated distributor in Dexcom customer satisfaction surveys. They have served over 1 million people with diabetes since 1996. They always provide 90 days worth of supplies and fast and free shipping. US med carries everything from insulin pumps, and diabetes testing supplies to the latest CGM like the libre three and Dexcom G seven. They accept Medicare nationwide and over 800 private insurers find out why us med has an A plus rating with a better business bureau at us med.com/juice box or just call them at 888-721-1514 get started right now. And you'll be getting your supplies the same way we do.

"Valerie" 12:48
Right? Yeah, I mean, because it's it's not because it's not like an acute thing, right? I mean, hyperglycemia is, but if your sugar's sitting at 210 While you're in the hospital, but you're here because you just had a stroke, and you can't eat food anymore, because you have you know, aphasia and dysphasia. And you can't swallow, we're more worried about that right than the fact that your sugar's sitting at 210. Or that you just had a heart attack or you know, whatever it is that you're here for. That's always the priority. And then it's like, well, your blood sugar is a secondary kind of thing that we're looking at.

Scott Benner 13:25
Yeah, they focus on the thing that they think is going to kill you first. Correct? Yeah, by the way, because I only knew the word ambulatory from Grey's Anatomy, I actually looked it up, it actually means able to walk about and not bedridden. That's what it means.

"Valerie" 13:42
So yeah, I guess that is what the word at face value means. But then that makes sense why we call it like ambulatory care. So yeah, like ambulatory care setting is an outpatient setting. I think we kind of use those terms interchangeably in health care, outpatient ambulatory care. But yeah, inpatient doesn't necessarily mean that you can't get out of bed. But you are assigned to a hospital bed. So Oh, okay.

Scott Benner 14:06
That's interesting. That's such a word that you just hear all the time. And then when I looked at what it meant, I was like, that seems random. But, but, yeah,

"Valerie" 14:14
well, and then when you're talking about like patient care, like and the patient ambulating, like, can they walk around? It's used in that context, too. So

Scott Benner 14:20
earlier, you said we may or may not adjust the doses? It depends on the doctor. And then you giggled. Why did you why did you have that reaction? So

"Valerie" 14:31
yeah, I mean, in preparation for this, I listened to you know, I tried to get caught up on some of your podcasts more recently having to do with, you know, healthcare, healthcare system, health care providers. And I think so I think that people who don't work in hospitals sometimes forget that, like doctors are people too, and they come with their own personalities and their own like inclinations and their own ways that they were trained and Like, just like any other place that you work, you know, there's some co workers that you love and that you're easy to get along with and very collaborative. And then there's some co workers that are like not team players, and very much like, this is the way I do it. And I mean, their personalities come into play. So like, physicians, you know, pas, rnps, any everybody is that way, we're all people at the end of the day. So some are more receptive to interventions from pharmacy or from, you know, other specialties, and some are less receptive to that.

Scott Benner 15:36
So you're saying that it's possible that some doctors might have an ego that doesn't allow them to take direction from a pharmacist?

"Valerie" 15:42
That's possible.

Scott Benner 15:45
I like that it makes you giggle every time. Okay, so working where you work, knowing what you know, having had the experience for four years of taking care of a human being with type one diabetes, what is your comfort level, with your child going into a hospital system through the ER, zero,

"Valerie" 16:03
I am not at all comfortable with my child going. So I mean, so for example, when my son was diagnosed was during the height of COVID. He was diagnosed March 27 2020, we kind of realized that you knew he was sick from the pediatrician. And so our our pediatrician diagnosed him, which is different than a lot of people's stories, and it was a Friday afternoon. And most kids, he wasn't sick enough to be in full blown DKA. But his sugar was high on the meter, you know, over 500. And my first thought was like, he cannot go to the hospital because they weren't allowing parents to come in when their kids were admitted, like that had just happened that week, where it was like we parents, like we don't know, you know, and my pediatrician is part of the same health system. And that was what I was kind of saying to her was like, if he has to go in the hospital, like, I can't be there with him. So this is even before like, knowing anything about diabetes, it's just the hospital for someone who can't advocate for themselves can be a scary place. Yeah. And then when you add in a very specific disease state like diabetes, where it's very misunderstood, it's very different, like what diabetes means to one person can be vastly different. Even if you are a healthcare professional, that it's like, yeah, you need someone there to advocate for you. So actually, my son at diagnosis was never even admitted to the hospital. We managed him outpatient. The only time we have been in the hospital was where I work and the ER and it was because he was he was throwing up, I don't even check him for ketones at home, right? It's like, but if you if you're sick enough to where you can't keep fluids down, that's where I get worried. We need to go get you IV fluids. And they really weren't hearing me, like they were worried about he had a little congestion like, oh, let's get a chest X ray. And I'm like, you know, I could have done that other urgent care, like, I'm here because he's been throwing up and they're like, well, it's sugars only, you know, at the time, I think when they first stuck on when he came in, it's like, Oh, it's 130. And it's like, well, you glycemic decay as a thing. You know, I'm worried like, can we get Can we look at as bicarb? Like, can we look at it as the anion gap. And they just weren't receptive to hearing me even though I it's like, I work here, you know, in the meantime, you know, they have it's the children's er, so they have someone come in, and it's like, Oh, does he want a popsicle? And I'm like, Well, is it a sugar free popsicle? How many carbs are in it? They're like, I don't know. And it's like, what do you know that he's diabetic? Like, has anyone Wait, do you do this? Do you know, with all the patients, I'm starting to ask these questions that it's like, how much awareness is there among all of you about like, type one and what that means and like, you know, everyone keeps coming in and saying, Well, it's sugar is this, whatever it was when he was first admitted? It's like, well, we've been here for five hours, and we have a CGM. And like, I've been giving him insulin during this time as his sugar is gone up. Like, you know, you're not supposed to do that in the hospital. But that is what I'm gonna do with my son and Sarah because otherwise you're you're waiting. You're just sitting there and you can't do anything. Yeah,

Scott Benner 19:06
the process in the ER at this point takes forever so my daughter has had, she had some pain that we couldn't figure out at while she was away at college, and she spent 12 hours in an ER twice in three days. Then I'm going to ask you, Valerie, how many times was Arden's blood sugar checked by the hospital staff in a 24 hour stay over three over three days to different stays. We

"Valerie" 19:35
typically check blood sugar every six hours. So

Scott Benner 19:39
so if I told you Arden's blood sugar was never checked while she was in the ER would that surprise you? Know, if I told you she was 19 in there with a roommate from college, obviously scared in pain, put on morphine, and no one ever wants asked her what her blood sugar was, or check to see But it was it wouldn't surprise me that's not surprising to you. Okay? So aside from the idea of your, your child being diagnosed during COVID, you now have this experience of going in for vomiting. And even though you're in there saying I'm a pharmacist, by the way, a pretty well credentialed pharmacist, not just like, you didn't just get out and be like, I'm gonna go push pills, you really put your eggs into your education, if you don't mind me saying, Yeah, and you work there. So you're standing in front of somebody going Hi, I work here. I'm a pharmacist. I'm worried about my kids blood gases. I'm worried about this kind of stuff because I'm concerned about DKA. They don't even know that you could have DKA with a lower blood sugar. Today's episode is sponsored by ag one and I drink ag one every morning. I originally heard about ag one on a different podcasts. I had been using other drinks and not enjoying them. So I decided to try each one and loved it. I was using it every day when they approached me. And I was like, wait, you want to sponsor my podcast? I heard about this on another podcast. Alright, cool. So here we are. When you use my link, drink, ag one.com/juice box. Your first order will include a welcome kit. That's an ag one shaker scooping canister, the Ag one itself, five free travel packs, and a year supply of vitamin D. I drink ag one in the morning before I start my day, ag one makes me feel like I'm giving my body the nutrients that it needs to get through a hard day of podcasting. I'm just kidding. It's not that hard to podcast. But still, I feel great when I drink age one. Ag one is my foundational nutritional supplement. It helps me start my day, it helps me to support my immune system. And I think you're going to enjoy it. So if you want to take ownership of your health, it starts with ag one drink ag one and get a free one year supply of vitamin D and five free ag one travel packs with your first purchase. Go to my link drink ag one.com/juice box that's drink ag one.com/juicebox Check it out.

"Valerie" 22:08
No. And it's like, I'm not even gonna get into that argument with you right now. Just please, like, draw his blood. Because they're kind of like, you know, do we even want to get IV access? And it's like, yeah, yes. That's the whole reason why we're here right now. Like, I'm not no, don't send us for a chest X ray, like give him fluids first, and then you can do whatever else workup you want. Um, but yeah, I mean, me advocating for that it still took several hours and going to do the chest X ray first before anybody did what I was even there to do.

Scott Benner 22:39
Is there any validity to me saying with the complaints you came in the door with, they know they can do a chest X ray and Bill for an insurance won't be upset. So it's a thing they do to make money? Because you're there now. So

"Valerie" 22:53
no. So I think that a lot of people have that concept of it was interesting, because so let me answer your question. And then I'll say that the care is directed poor, you know, what can be billed for? That comes into play and in a lot larger scope than the individual, like health care providers standing in front of you. We don't care about that. Like as the clinician trying to help you as a patient, like, I am not ever thinking about billing, because that's I work for a large healthcare system. That's their job to figure that stuff out. Now, they might implement policies or things that I have to abide by that correlate back to billing, but it doesn't influence how I'm like directing my care right now with you as a patient. Okay,

Scott Benner 23:40
so the clinicians not thinking, hey, chi Ching, chest X ray, because they said this, but the policy could be set up so that even in the situation where you don't need a chest X ray, if you present a certain way, we're definitely going to do it anyway. Yes.

"Valerie" 23:54
And I would say even more so than billing. I think what drives maybe unnecessary testing is a concern about the liability if you didn't do it.

Scott Benner 24:05
Yeah, that's fascinating. Because Artem presented with initially she presented with appendicitis, it was pretty classic presentation. And they gave her a CAT scan. And then they came back hours later and said, your appendix is fine. But we see cysts all over your ovary. And we have to go do a another test now to see if they're twisted because they could require surgery like so this is what 19 year old Arden was told by herself in a hospital 700 miles away from my house with just a roommate sitting with her who by the way, had never had a medical issue and had literally never been in the hospital before. Try to imagine I'm managing Arden's blood sugar remotely through a roommate because Arden's high as on morphine, right, so we're doing all that. And you know, they said okay, we're taking you back For an ultrasound now she gets on the phone with me she's faced she's clearly scared. She's loaded on the morphine Arden's not a drinker or a drug user. So the morphine hit her really hard. And she's like, Dad, like, I have to go get a thing because if these cysts are twisted, then they might burst and I might need surgery. And I'm like, Okay, well go get the test, then call me when you get back from the test. So she calls me back a couple of hours later, the doctors here he's gonna give me the results from the ultrasound. And he literally gets on Arden's phone puts a smile on his face, because Hi, and I'm like, is she okay? She doesn't have any cyst on her ovary. And I went, what? You're the guy that four hours ago said that you took a CAT scan and saw cysts all over her ovary. And he goes, CAT scans, not a good way to tell if they're cysts on an ovary. I said, But you're the one who said that based on the CAT scan. She needed this other tests because this was a definite problem. It was clearly there. And now we just have to make sure that she's not in an emergent situation. And now you're telling me up, see. And he's like, yeah, good news. She doesn't have those tests. The good news, you're the only one who presented the bad news. I said, Okay, what's next? He goes, We're gonna send her home. I go Arden, are you still in pain? Yes, Mike, you're just gonna send her home? Well, she doesn't have an appendix. And I was like, could it be something else? He goes, Well, we're gonna have her follow up with her. OB. I said based on what? No answer. And then he treated her after 12 hours and let her go. So she spent the entire next day in a bad situation. And like not feeling well was not getting better. There's she had this low abdominal pain that had stabbing. The stabbing eventually went up into her. What would you call it? That kind of the center of your stomach your why is this basic word escaping me? Helped me a bottom my ribcage in the middle.

"Valerie" 26:56
I don't know what's in the anatomical word for that. Or even write about them. But for unknown, yes. Right away.

Scott Benner 27:03
Thank you right about there. And then the day goes on. She's able to eat and then she's like, you know, maybe it's gonna get better. And then all of a sudden around midnight. She's texting me dad the stabbings in my chest. It's going through the left side of my chest into my shoulder. Yeah, that's scary. Right. And so now you you do a little more looking at points. The gallbladder makes sense, right? They didn't check her gallbladder when she was there. Last time. I sent her back to the ER at two o'clock in the morning. And then I get on a plane and arrive where she is at 10am. When I get there at 10am They've done nothing for her except put her on more morphine. They have not checked her blood sugar in the now eight hours that she's been there. And as I walk in the door, there is a burly man standing over her in a raised voice demanding that she leave because she's been. He told her, we straight at you, you have to go. her roommates crying. Arden who does not cry about anything has puddles of tears in her clavicle. And she is telling him I am not leaving here until you tell me what's wrong with me. And you have to admit me. If you can't figure it out in the ER, that's the sentence I gave her before I got on the airplane. Yeah, if it wasn't for that sentence, he would have kicked her back out again without ever testing her gallbladder. Which by the way, it didn't end up being. But literally when I walked in, a jacked guy in his 50s was yelling at my 19 year old daughter to get up and leave the emergency room. And again, he had never touched her, checked her blood sugar, didn't check her for anything. She had had any testing. They ran some blood work, the same blood work. They ran 24 hours earlier. In that same room. There were four other sick people cordoned off into corners. And I often said that woman's been vomiting for six hours and no one has helped her. And then she pointed to the other lady and said, Wait, do you hear how they talked to her? And I stood there for a little bit. I was able to strong arm them into checking Arden's gallbladder within the proper test. And while I was there, I watched the doctor walk in to this woman who had Ms. And no no excuse me. Cystic fibrosis. And he walks in he goes Hey, so cystic fibrosis. Tough call. I was like what what just happened? Did he just look at her and go wow, cystic fibrosis tough roll the dice, honey, because that's what he did. I looked over and she had a look on her face like, ah, yeah, it's a terrible thing that has happened to me. Like this is your bedside manner right here. It was fascinating. Right? Yeah, I gotta go back and tell you Arden would have been better off laying in her bed and hoping it went away. Then what ended up happening to her that hospital? Fascinating. I'm sorry. Good night. No,

"Valerie" 30:00
I mean, that is a very so and that is a very nothing that you just said about that surprises me, unfortunately, I guess because I work in health. So it's hard for me to see them. So well, you know, I read a lot of this stuff on the on the juice box group and see and it's like, oh, yeah, I'm always, you know, people are rightfully so because they have a different expectation of what's going to happen when you show up to the ER, like, very offended and surprised. And I'm usually like, yeah, that doesn't surprise me. And some of it goes back to what I was saying as far as like inpatient versus outpatient, like, do you like to work in an acute care setting? Or do you like to work in an ambulatory care setting, so somebody with good bedside manner, who likes talking to their patients and is very sensitive, they are going to likely want to work in an insecure setting, like as a primary care provider or pediatrician, the type of people who, like the environment of an emergency room, are not the type of people that like, take your feelings as a patient into consideration. Because you can't because your career is dealing with traumas. And you know, the worst possible things that have happened to people, they roll into the ER. And that's what you don't see when you're in the ER waiting room, because you're seeing the people that physically got themselves there. You don't see the ambulance bay and all of the like five gunshot wounds and car accidents and everything coming into the back of the ER through the ambulance. And so you're thinking like, well, there's five people here, but it's like, no, they just brought 20 people and you know, what's the explanation

Scott Benner 31:42
for not doing a gallbladder test in eight hours with classic gallbladder symptoms? That I

"Valerie" 31:49
mean that that would be the only thing is that you triage, you triage your patient like ers work through a triage system. And it's like, every time someone more urgent comes in, you just bumped ahead of you. Yeah, so

Scott Benner 32:05
they weren't literally trying to make her leave. Without doing the test. I basically had to bring New Jersey to the, to where she was to the south, which straightened everybody up pretty quickly. And then got me a physician to speak to who assessed her and said, Yeah, it's very appropriate for us to test for gallbladder. I'm not sure why that hasn't happened. We'll do it right now, eight hours later. But the other guy, the other person was trying to kick her out

"Valerie" 32:29
someone telling her to leave when she's there for that. But that, unfortunately, I mean, that is whatever individual made that decision, right? That was like, I just need to clear out this, er, I'm tired of this person asking me and they're like, Oh, I'm gonna bully them into leaving, instead of like staying here and advocating for themselves. That's not necessarily a system thing. I mean, that's that, that individual deciding to deal with it that way. But

Scott Benner 32:58
I'm completely convinced that what happened was, is he needed to move somebody out of that building. And she was young, and he thought he could lean on her a little bit, and she just go, that's what I think. Except I, well, she's my kid. And I armed her with the right words before I got on the airplane. Yeah, yeah. So but who would know that? Like what regular? You know what it always always, here's what scares me. People on the Facebook group, you know, people get ketones, right? They get sick, they come on, they're like, I don't know what to do here. Hey, my ketones are really high as my blood sugar. I'm not sure what to do. And a flood of people go to the hospital, go to the ER, go to the ER and others. Pardon me? It's like, oh, I don't want to say something that puts you in a bad way. Like, you know, I mean, if you need an ER, you need an ER, but have you tried drinking a lot of water and giving yourself some more insulin? Like, is it maybe a bent cannula? Did you like you know, have you been sick? Do you think you can get this down on your own? Because you're gonna get to that er, and then all the stuff that we've talked about in the last half an hour is all going to exist? Maybe? And that's the thing I don't it's a coin flip? Like, am I going to show up and find a nurse who understands DKA? Or am I not? And then if I don't more than likely not? More than likely not. So. All right. But you also see people who are admitted, correct? Like, yes, yes,

"Valerie" 34:20
yes. So only I only we only looked at the patients that are admitted, right?

Scott Benner 34:24
So I'm gonna move away from this er idea and talk about somebody who's admitted for kind of like long term care, which could mean a couple of days to longer. I imagine. I'm in there with type two. They're feeding me. I've seen the type two diet at some pretty big hospitals. And it's fascinating how many carbs and crappy food are in it. Correct. It's not even it's not a type two diet. It's just you don't get to pick off as many portions of the menu. They only give you one dessert, but they'll still give you what we

"Valerie" 34:56
do with people on a carb controlled diet. Yeah, and there's a standard, and it's 45 grams for women, 60 grams for men.

Scott Benner 35:05
But on that list is grapefruit juice, apple juice, stuff like that stuff that's going to drive your blood sugar up in a split second. Right,

"Valerie" 35:13
the glycemic index of those foods is not taken into consideration at all. But we actually go back and forth about whether patients and even you know, we're kind of told to it's, you know, the nutrition services, it's a whole nother department kind of, of the hospital. And like whether or not patients are allowed to order more than their carb control, because it's like, okay, if I'm assuming this person is eating 60 grams of carbs with each meal when I'm dosing their insulin, but they're not, because maybe a relative is bringing them food, that's one thing, but they can actually order more than what their diet should be. And, you know, trying to like, figure that out and work with these other departments. And like, you know, we get information from one person versus another person has been a challenge that we that's one of the biggest challenges we found with our program, as it is currently is, is the diet. And then of course, as a type one parent, I'm like, oh, you know, and a lot of you I mean, you don't if you're insulin dependent, the type two diet is meaningless, kind of at that point. I mean, like, we're not trying to control you through your diet anymore. Like you need insulin, and we but but we do need to be able to dose that insulin with some concept of what you're eating at each meal. The diet is really, it's really tricky. No,

Scott Benner 36:35
I mean, that seems you just said something that didn't, it never occurred to me that people would just bring in outside food, of course, right. I'm not saying that the patients in certain settings and situations are not culpable in some of the problems that we're having. I'm certainly not saying that. I'm not saying that the people working in hospitals are ill intended. I don't think that either. I think that what you're describing is a system that is basically not set up to understand or control blood sugar. No, the understanding is just not there.

"Valerie" 37:07
The understanding 100% is not there. So the whole the whole thing about type one versus type two, I have tried very hard in this role to like get rid of those labels and just refer to patients as insulin dependent or non insulin dependent, that's a lot more useful way to describe someone's diabetes, if they are insulin dependent, they need Basal insulin every day, they've got to have some insulin on board. If they're diabetic, they may or may not need Basal insulin to avoid going into DKA. I mean, their sugars can be high and uncontrolled, but they're not going to become acidotic. You know, it's still a the terminology and talking to other like talking to the nurses is hard and other providers and using that terminology I find brings a lot of clarity to it. So if we could get rid of the type one, type two, that would be very helpful. Yeah. And then also just the idea of, of Yeah, like, what, what is this patient doing on their own, like the autonomy of the patient. So you have like this, some patients that are doing you know, all of like the podcast listeners, like doing their best to really like get a handle on their management. And then you have patients that just lie to you. And it's like, yeah, I take 80 units of love me or twice a day, and then we give them 80 units and their sugar's 20. And it's like, no, you don't. So but but they don't know, they think that they will be in trouble, I guess or like, you know, they say that they're doing it, which is what they've been saying to their doctor outpatient, which is why they're on that huge dose. But it's like, they don't understand the ramifications of saying that they're compliant, and then we give them that and it's like, no, we don't find out until we give it to you that you don't really take that out.

Scott Benner 38:56
Yeah. Is it possible that there are maybe two distinct, I don't know societies and diabetes, people who are steadfastly trying to understand trying to pull their education together and and to do a, you know, a better job, and that there are a group of people who have maybe just sort of, for whatever number of reasons bad direction bad, you know, education, intellect, not being desirous of caring, whatever, whatever. They're just not they have a onesies that are in the 10s elevens twelves. And that hospital employees see sick people more frequently than well people so they're accustomed to seeing diabetics who are higher a one sees higher variability don't have as much idea about how to handle themselves is and then you come in there with your kid, because he got a little stomach flu or whatever. And you actually know how to keep his a one to where she gets a one to 6.8 on our loss. Yeah. So you know how to keep it a one Seeing the sixth is you have a better understanding coupled with expectations. And that's why the hospital system looks roughshod to you and to me, but to most people, they probably don't even care or think about it when they're in there. Is that fair? Oh,

"Valerie" 40:18
100%. I mean, that's. So that's kind of the difficulty that I was listening to your podcast, like leading up to this, some of the more recent ones, you had one with Jenny, where you kind of went over, like the things that people were saying that like health care providers had ever said to them. That was very offensive. And they're like, there was one where the mom was like, Oh, the kids sugars 400. And they said to them, well, it's okay. As long as you get it down. There is a real, it's not like, Oh, that was stupid advice. Because, and that kind of the response, right? That's all the parents responses. Like, That's so dumb. It's not okay to be four, seven? Yes. And no, right? I mean, it is, it is what it is, you're 47. And you talked about that, like, you know, you just have to work with what you have get it down. So I think that they're coming from the perspective of like, it's okay, you don't have to freak out and go to the hospital, just because you hit four, seven, you can as long as it comes down, it will be okay. Right? That's a different conversation than like, is it okay to be for someone every day? Exactly. And so what we're looking at in an acute care setting is like, Yeah, are you going to immediately die from this, and most things diabetes related, as long as it's not hyperglycemia, no one's going to immediately die from it. Yeah. And so you have these different levels of education. I mean, you're taught as a health care provider, that everything should be communicated to patients at no higher than eighth grade literacy level, where I work at the large hospital on urban setting, the majority of our patients don't, they're indigent care, meaning they don't have private insurance, they don't have government insurance, they are not insured at all. They're typically, you know, homeless, a lot of mental health issues, substance abuse issues. So the idea that you could even provide education, or the patient's going to do anything that you you say they should do, I mean, they don't even have somewhere to sleep, much less like a way to get to the pharmacy to pick up their insulin. And so we have, you know, these frequent fliers where it's like, especially people who are type one, that are insulin dependent on that have all these psychosocial barriers to being able to manage their disease state. And that's the majority of the patients that we see. So it's a completely different perspective than, like the outpatient, Endo, who's seeing you know, you.

Scott Benner 42:43
So, yes. And so what you're telling me, I feel like this is what you're saying to me. You're saying, look, there are a lot of people who have a lot of things trying to kill them. And they come to a hospital. And their blood sugar is not nearly on the top of our list about what we need to do for them. Even when they're admitted. You're still trying to get them through this thing that's happening. And because that's overwhelming, Lee, what happens in a hospital setting that kind of, I don't know, rinses through the staff. And so when someone comes in there who's like, Hey, I've had type one diabetes for 40 years, my one sees five and a half. I know what I'm doing. That's completely foreign to people. No, that's

"Valerie" 43:28
where you get the comments like, Are you sure you have diabetes? Oh, wait, that's where that comes from. Because it's, you'd never see someone with diabetes, like you're taught, like, you have a very basic understanding of diabetes, and it's all taught from a diagnosis perspective, right? So like, your concept of diabetes is someone's a one sees higher than seven. And it's like, you come in with a 5.5. They're like, Are you sure you have diabetes? And it's like, you know, we know like, Yeah, I'm insulin dependent. Not like, but you know, if all you see is type two diabetics, then that that's not diabetic, you know,

Scott Benner 44:06
insane that somebody would even have anyone seen the fives and be using the word diabetes.

"Valerie" 44:11
Right? That's, that's foreign to Well, I mean, that's what people say, Oh, aren't you a nurse? Aren't you a nurse? And it's like, Yeah, but that this is a nurse that has been working for 20 years now in a huge hospital where all of her patients are type two. And so she doesn't see type ones unless she's maybe on like a med surg floor like saw someone after impact you or something or like the type one that said you have a onesie and the fives you're not going to decay all the time. So you're not in the hospital. Yeah,

Scott Benner 44:42
it feels like what you're saying. Seriously? Interesting, right? That it's commonly known that people who are law enforcement for over there's this scale that they go up as the longer they're in law enforcement. And by the time they get I think it's to a decade if I remember correctly. Their ability to trust people, even people that they're not intersecting at their work, it gets lower and lower and lower, because that's the experience they're having all day long, because they are seeing criminals, mostly. And then they run into a nice person. And they're like, I don't know, like, you know, are you going to shoot me? Are you going to like, flip out and bite me? And are you going to do this kind of thing? Because that's what gets. That's how they're colored. As as the time goes on, I was pulled over once. I want you to try to picture this. I'm a young man in my 20s, maybe in my late, mid to late 20s. I'm driving I think at the time, a Volkswagen Passat. I mean, it's a lady's car. I'm wearing a tie. And I'm going to my job. I get pulled over speeding to work because I'm late. And I watched the police officer in my I just want to be clear with you, lily white town where nothing happens ever come down my side of my car, one hand on the car, one hand on an unbuckled gun to come get my driver's license from me. And I'm looking in the rearview mirror going, what is happening here, and no lie when that person turns the corner. It's an older police officer, somebody who's been at it for 20 years, who doesn't want this day to be the day that they get. They get it. And meanwhile, nothing they're looking at indicates that I'm going to jump out with my GAC and start popping off. Do you see what I'm saying? And so like it, but I understood, I understood what they were doing, because I have a friend who's a cop. But if it was just me, I'd be like, wait on me. Like, I'm just going to work at a credit union right now. Like,

"Valerie" 46:42
I'm the least, that is that is so interesting, because that happened to me also when I was in undergrad. And I mean, my car was maybe a little more sketchy because I had a lot of stickers on it. You know, what a college student. But I'm still, you know, like a young, white female, I wouldn't think I would look like a threat. And I realized when he pulled me over, I had left my wallet and like the way back, I was like a Ford Explorer. So it was very bad. And so I just started to open the door once I realized, and he pulled his gun on me. Yeah. And I was like, Oh, my God, you know, like, and it's but yeah, it's like, Oh, you thought I was gonna like, do you know? Okay, I see that. But I was the one of course, like, scared. It's like, Oh, my God. And he's like, ma'am, stay in your vehicle, like, oh,

Scott Benner 47:28
yeah, the worst thing I've done is not told my parents where I was last night. But so taking that idea that you can be in a high pressure situation over and over again, where you see a specific scenario over and over again. And then suddenly someone comes into it, who doesn't fit it, you're not going to get the service that you expect in that hospital? And so the answer really has to be, you need to understand your diabetes care backwards and forwards, go in there and immediately begin to explain it in a way that lets the people listening know, I know this better than you do. Here's what we're going to do this is what's going to work for us. But you tried that and you couldn't even get them to listen. So what luck Am I gonna have, I'm not a pharmacist, but I don't work at the hospital.

"Valerie" 48:17
They did listen, eventually, it's just you know, don't be a Don't be surprised at how long it takes you to get your point across. Be Don't be surprised at how many people you have to keep repeating that too, because the healthcare is so specialized. And now you are going to have so many different people in and out and it's like, you know, the nurse assistant or the patient care technician, they don't necessarily need to understand your diabetes, but that's typically the person in the hospital who's doing the blood thing or, you know, if your checks your finger sticks, so if you have just drinking apple juice, and this is what we're assuming it's like a pre premium blood glucose, like you should probably tell that patient care technician I just drank an apple juice, but like, they don't necessarily know what that means. Is

Scott Benner 49:11
it my real goal to separate myself from what they normally see. Like to let them know if I am in fact a person who understands this on a greater level to like, get out in front of it and go look, I recognize what you normally see in this setting, but this isn't us. And and here are some examples of why that is like is it is just as easy as saying I have a glucose monitor and a pump and I know what I'm doing my one season the four in the fives, it's in the sixes like don't worry, we can help like, I'll help you with this. I know how to Bolus for food. Like we want to keep our pump on while we're here. Like that kind of

"Valerie" 49:42
stuff. And you and you need to lead with that. And that's like it was interesting because you had a conversation with that same Look Jimmy about the things and she was talking about her prescription for her test strip and the pharmacy technician saying like, Oh, why would you need like eight to 10 a day and I I did that. I did that as an intern when I was in pharmacy school, and I was an intern in a retail setting. And I had a woman come in who was newly diagnosed type two starting on insulin, and the inch, because so what we see is, oh, look, here's a prescription for 10 test strips a day. Medicare doesn't pay for that, I can tell you right now, it's not gonna go through your insurance. And it's gonna be a problem, because you're not gonna want to pay cash for it, where you need a prior authorization from your doctor. It's like a whole that sets off a whole chain of events. And it's like I said to her, you know, you shouldn't need to test your sugar this many times a day. And no, I didn't, I didn't say it in a rude way, like, Oh, this is a problem. I also did it, you know, she was also very nervous. And it's like, Oh, my God, like, it's overwhelming, right? Like, I've got to do this many fingers six in this many injections. And so part of it was me trying to say like, let's start with what insurance will cover. And if you find that you're needing to test more than that, then there's a process to get them to cover more. But it's not like an immediate thing that can happen. And part of it was kind of trying to reassure her that it's like, Hey, you're not going to have to be sticking yourself every two hours, indefinitely. Like you might feel like you need to do that now to get really tight control. And the reality is like, yeah, we aren't like my son's on Omnipod and Dexcom. And it's like, we still have a prescription that says eight to 10 times a day, but I'm not sticking a stinger eight to 10 times a day. But like everyone, I like to work supplies. And I mean, that that poses a bigger question of like, what what are the ramifications of that on the healthcare system at large? Like, you know, certain people aren't like, the idea is that, you know, there's someone at that insurance company whose job is for it to be profitable. And it's like, you know, giving, like, people getting more supplies than they need, is that somehow taking away from people that, aren't you? No, not really, because we don't have socialized medicine? But

Scott Benner 51:52
are you saying, Valerie that if I worked at that hospital, or somebody like me with the understanding that I have, at my level, my job would not allow me to take as good of care if somebody is I even would know how to do?

"Valerie" 52:03
In some ways. Yeah, there are constraints within the healthcare system that come down to billing like that with the insurance with the outpatient stuff, for example. I mean, everyone, that's the, like a diabetic or a parent of a diabetic kind of knows that with insurance, you're restricted to what's on your formulary, unless you go through a process to try to get her authorization. And so it's kind of that same concept. It's like, well, there's certain protocols and policies in place, like like with the nurse, and what the order says, say, you are type one, and you have your orders in the computer for you know, your insulin, and you get your meal tray. And it's like, okay, you know, that nurse has this order to give you four units, and you're like, why would normally take six units to cover this? She can't just give you six units, right? Like she has to give what's ordered, or she has to try to call and get that order changed, which is, there's policies in place to let them do I mean, there's not most hospitals, most health systems don't have that. So

Scott Benner 53:06
that's where you're stuck with like, go ask the doctor. And then even in your situation, I might have to go ask the pharmacist and then those people are busy with 1000 other things. And just getting to this like idea of like, changing my dose by two units, which seems so important to me, and is important to me. It's not important in the grand scheme of things in this ecosystem that I'm now in because I've gone to the hospital.

"Valerie" 53:27
Oh, yeah, not at all. I mean, there would be providers who would be annoyed that you would call them about that, and like really like, and they're just gonna say, no big try to teach you a lesson. I'm like, don't call me about stupid stuff like this anymore. Because if that person sugar goes up to 250, after this meal, when normally at home, they never get over 150. Like, it doesn't matter in the grand scheme of things. It matters to you as an individual. It matters to me as a parent of type one, but like, it doesn't matter as far as like the clinical outcome of that patient's hospital stay.

Scott Benner 54:00
So I only got art in the test for the gallbladder because I had the nerve to stand up to the male nurse, push him back, force him to the doctor force the doctor into the room, remake my concerns to the doctor. And I reached the doctor who was older and seemed more reasonable. And heard what I said and agreed with me. So the test happened. But if I don't do all of that, eventually we would have gotten kicked out of that hospital. If I just stood there waiting for somebody to help me. Somebody would have handed me paperwork and told me to leave. I think yeah,

"Valerie" 54:35
potentially or you would have been there like during shift change, and then someone new, a different attitude. But yeah, I mean, yeah, it sounds like you definitely my biggest lesson is you have to advocate for yourself. And I mean, that's in all aspects of health care, right? Like if you have a lump or you have a funny mole or whatever. Like, you can tell your primary care about it and then like Do you need to follow up with a dermatologist or you need to follow up with, you know, whatever specialist, you have to do that, like, no one's gonna call and make that appointment for you. But people I think don't realize that because you kind of think they're there to help me. It's like, they're there to do their job. And sometimes that's make a referral and whether you follow up on that referral or not, that's up to you. So it's kind of the same coming into the hospital. It's like, if you think, oh, everyone here is gonna now manage my diabetes. For me. It's like, well, they're gonna keep you alive. You know,

Scott Benner 55:33
they're gonna try not to make it worse. Yeah, hospital equals try not to let me die. Right? Yes. And, and even like, I had a surgery on my toe recently, it didn't even happen in a hospital. It happened in an office building. You know, like I was put under, in a place that could have been an insurance company. Seriously, you know, like you go into you go into an office building, and they have a surgical suite. And that's that. Yeah. Okay, I got it. But, and I think everybody listening gets it. I really appreciate you sharing your knowledge on this. Just for fun. Tell everybody where you're at right now doing this in the hospital? Are you at least on a break?

"Valerie" 56:10
Are you still in a conference room? Yes. I took my lunch break. Okay. And it's Friday, and it's a holiday. So you know, what happens in the hospital on days like today is that everyone's like getting discharged. Actually. They tried to discharge everyone yesterday. So that because it's a long weekend below for? Yeah.

Scott Benner 56:28
It's interesting. That's very interesting. Okay. I know we're calling you Valerie. So I'll say Valerie, thank you very much for doing this. I really do appreciate your time. Yes, I

"Valerie" 56:37
appreciate it. Thank you.

Scott Benner 56:44
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