#1259 Grand Rounds: Gas Passer

July 22, 2024Scott Benner

Diagnosed with type 1 diabetes at 41, Courtney, a nurse anesthetist, discusses the impact of her diagnosis and managing her condition alongside her career.

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Scott Benner 0:00
Hello friends and welcome to episode 1259 of the Juicebox Podcast

Courtney is a nurse anesthetist anesthetist enough for her boy, she's a gas passer. She's also, she also has type one diabetes, and she was diagnosed at 41 years old. She's now 46. She has Graves disease, and antibodies for Hashimotos and today we're going to find out what she sees that her job. 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. Don't forget, if you use my link drink ag one.com/juice box you'll get a free year supply of vitamin D and five free travel packs with your first order. And if you go to cozy earth.com and use the offer code juice box at checkout, you're gonna save 30% off of your entire order. Subscribing to the Juicebox Podcast newsletter is this easy. You type juicebox podcast.com into a browser. Scroll to the bottom put in your email address, click sign up. I was looking for a way that we could all get nice and tanned and meet each other and spend some time talking about diabetes. How are we going to do that on a juice cruise? Hang out at the end of this episode to learn more.

This episode of The Juicebox Podcast is sponsored by touched by type one. This is my favorite diabetes organization. And I'm just asking you to check them out at touch by type one.org on Facebook and Instagram. This episode of The Juicebox Podcast is sponsored by the Dexcom G seven, the same CGM that my daughter wears. Check it out now at dexcom.com/juicebox. Today's episode is sponsored by Medtronic diabetes, a company that's bringing together people who are redefining what it means to live with diabetes. Later in this episode, I'll be speaking with Mark, he was diagnosed with type one diabetes at 28. He's 47. Now he's going to tell you a little bit about his story. To hear more stories from the Medtronic champion community or to share your own story, visit Medtronic diabetes.com/juice box and check out the Medtronic champion hashtag on social media.

Courtney 2:26
I'm Courtney, I'm a nurse anesthetist, which is an anesthesia provider. And I was diagnosed with type one diabetes about 15 years into my career. And I think there's a lot patients can learn to advocate for themselves. And I think as health care providers, especially in the perioperative period, there's a lot of finesse to be learned as well. So that's why I'm here.

Scott Benner 2:52
Cool. So 100% This episode is going to be called gas pastor just so you know. And

Courtney 3:00
love it. Yeah, it's gotta wear it proudly. My coworker actually has a hat that says I have gas. Yes,

Scott Benner 3:06
Pastor, by the way, a phrase I know from the TV show mash. I love that show me where I know that that phrase. How old were you when you're diagnosed with type 141

Courtney 3:17
or 2912? Tightens I like this

Scott Benner 3:22
nice track. How old are you now

Courtney 3:24
46

Scott Benner 3:26
years ago, any type one or other autoimmune issues in your family line.

Courtney 3:31
I personally have both that I had Graves disease and the antibodies for Hashimotos as well. So me and I have a cousin with graves but nobody else with type one or other autoimmune that we know. No celiac. No celiac. Here's a weird one for you. Bipolar disorder. No, not that we not that I know of nothing. Anybody claims

Scott Benner 3:55
out loud out here. You know, okay, great. That's what I want to know. So

Courtney 3:59
And guys, both my kids have done the trial net, which is great and currently negative. And then I just got my sister and all my nieces and nephews to test as well.

Scott Benner 4:07
So oh, you're a bit of anomaly about that. Okay, I know so safe to say you were shocked.

Courtney 4:14
Absolutely blown away. So I graduated nursing school. So for those who don't know, a nurse anesthetist has to be a registered nurse first and then you do ICU experience for a few years and then you can apply to go back and get your Masters now it's current when I went to school is a master's it's a doctorate now. I was an ICU nurse for three years and then a recovery room nurse for a year before I went back to school. And I remember sitting in lecture about our endocrine lecture thinking back in, you know, 99 2000 thinking I really don't ever want type one diabetes like that would be really a nightmare. And granted the improvement is shocking compared to how we used to treat type one but it's Yes, I had had knee surgery and got the flu and went into the ER and was shocked to spend a few days in the ICU with a type one diagnosis. No idea.

Scott Benner 5:13
Wow, knee surgery brought on by an injury or degradation of your knee. Yeah,

Courtney 5:18
just trying to avoid a knee replacement. I've been really hard on my knees in my lifetime. And at the time when I went to the ER, my agency was 9.8. So I'd probably been limping towards that diagnosis for at least several months, I'd had a fasting sugar. I got diagnosed in March and October as part of my annual with a fasting sugar of like, 105. So not great, but obviously I wasn't severely impaired at that time. But at diagnosis in full blown DKA my blood sugar was only 262. So I think it was the flu just made me so insulin resistant, and I wasn't really eating, because it was on crutches like I was

Scott Benner 5:57
asked your question before we get too far past that. Are you some sort of a like, comic genius? No. Did you hear yourself say I limped towards diagnosis? I did now. Yeah, I've been You mean after telling me about your knee? And then I was like, Oh my God, she's so deadpan when she's doing this. She's either a genius or doesn't know. She just said that. Oh, my gosh, I would have stopped to congratulate myself for making that joke. If I would have said it. I would have been like, Hey, did everyone hear that? I'm so good at this. My god. I'm so good at this. Did anyone hear? No, no? Wow. Okay. So that diagnosis, are you. You're married at that point? I imagine. What two kids two kids already? What's your remembrance of the diagnosis time in the hospital stay.

Courtney 6:46
I mean, the first night was a blur. I was. I mean, everybody in DKA sick I was, you know, I was right along with everybody extremely sick. Ended up in the ICU for five days, I got pneumonia. I had pneumonia flew a and I was in this locked knee brace. I was pretty pathetic, like on the unit like jumping around. I actually missed my son's sixth birthday party because it happened. The second day, I was in the ICU. And I was like, I can't imagine rescheduling this with everything that is on my plate. So just the grandparents came down and ran the birthday party. But it's all it was all a complete blur. Yeah. And I was at the hospital that I work at. So people were coming and going because they were worried and I really appreciated the visits. But I can't say that I remember who.

Scott Benner 7:38
You know, there was a diabetes educator here once who told me they were diagnosed as a child, and had a big birthday party planned for themselves. And the parents didn't have the heart to cancel it because of all the other kids so he was the only one that didn't go to the birthday party. He felt it's a nice memory for him. He's like, I thought it was nice to my parents not to ruin it for everybody else. True, but my response was your recording. I was like, Oh, that's cold. Yeah, but apparently not. He doesn't remember it that way. Anyway. Okay, so people were in to visit with you. You don't have a lot of memory of it. Do you think it's a blur? A blender blur of the flu and the diagnosis at the same time?

Courtney 8:18
Yeah, I mean, I'm sure I got you know, the typical insulin resistance and needed more, you know, I'm sure I have some degree of plateau. Right. So that's just a slower onset of type one. So I'm sure I had some pancreatic function that was keeping me out of DKA until I got the flu, and then it just couldn't

Scott Benner 8:36
the rest of the game. Yeah. Well, I'm glad your kids don't have markers. That's, that's terrific news.

Courtney 8:40
Yes. And my sister was super my sister is a PCR nurse. And she's amazing. And I was calling her from the ER being like, I'm getting sicker. And I don't know what's happening. And so she drove down in the middle of the night and was kind of instrumental in in helping us through that. Since she sees a lot of DKA

Scott Benner 8:57
how many nurses did your parents make? Just to just 200%

Courtney 9:01
of their children, but to

Scott Benner 9:05
say helvar ratio? All right, so So you come out of the hospital. And you know, you're now I'm we're gonna jump around a little differently than we usually do in these episodes. Because of your background, we're going to talk a lot about what you see, you know, as a gas passer. So you learn about type one I heard you say like in school, I was like, I don't want that for sure. It's not weird that you chose that to like, say, I don't want that of all the things you were learning about. Right now we're going to hear from a member of the Medtronic champion community. This episode of The Juicebox Podcast is sponsored by Medtronic diabetes. And this is Mark.

David 9:40
I use injections for about six months. And then my endocrinologist at a navy recommended a pump.

Scott Benner 9:46
How long had you been in the Navy? Eight years up to that point? I've interviewed a number of people who have been diagnosed during service and most of the time they're discharged. What happened to you?

David 9:56
I was medically discharged. Yeah, six months after my diagnosis. Was it

Scott Benner 10:00
your goal to stay in the Navy for your whole life? Your career? It was, yeah,

David 10:03
yeah. In fact, I think a few months before my diagnosis, my wife and I had that discussion about, you know, staying in for the long term. And, you know, we made the decision despite all the hardships and time away from home, that was what we loved the most.

Scott Benner 10:17
Was the Navy, like a lifetime goal of yours. lifetime

David 10:21
goal. I mean, as my earliest childhood memories were flying, being a fighter pilot,

Scott Benner 10:26
how did your diagnosis impact your lifelong dream?

David 10:29
It was devastating. Everything I had done in life, everything I'd worked up to up to that point was just taken away in an instant. I was not

Scott Benner 10:37
prepared for that at all. What does your support system look like?

David 10:41
friends, your family caregivers, you know, for me to Medtronic, champions, community, you know, all those resources that are out there to help guide away but then help keep abreast on you know, the new things that are coming down the pike and to give you hope for eventually that we can find a cure, and you

Scott Benner 10:55
can hear more stories from Medtronic champions, and share your own story at Medtronic diabetes.com/juice box. You can manage diabetes confidently with the powerfully simple Dexcom G seven dexcom.com/juice. Box. The Dex Dexcom G seven is the CGM that my daughter is wearing. The G seven is a simple CGM system that delivers real time glucose numbers to your smartphone or smartwatch. The G seven is made for all types of diabetes, type one and type two, but also people experiencing gestational diabetes, the Dexcom G seven can help you spend more time and range which is proven to lower a one C, the more time you spend in range, the better and healthier you feel. And with the Dexcom clarity app, you can track your glucose trends. And the app will also provide you with a projected a one seen as little as two weeks. If you're looking for clarity around your diabetes, you're looking for Dexcom dexcom.com/juicebox. When you use my link, you're supporting the podcast dexcom.com/juicebox head over there now.

Courtney 12:07
Absolutely. I think about it a lot. Because sometimes I'll see like our ad on Craigslist, and I'm like, I don't want to do that. And it's the second it enters your mind. You're like, yep, that's going to be my case. So now in hindsight, I'm like, I should have never thought that I should have just embraced the knowledge,

Scott Benner 12:22
you should have just picked up the Daily News looked at the lottery winners and said, I don't want to be like that, I would have definitely I definitely would have been the way to go. If you were gonna Jinx yourself, I guess. But now you've got this different understanding right now you're five years into it? Um, well, let's figure out what your understanding is right now. Like, where's your agency?

Courtney 12:38
Since diagnosis, the highest agency I've had is 5.20.

Scott Benner 12:43
My goodness, are you eating low carb? Or are you just very good at diabetes? Yeah,

Courtney 12:46
I mean, I tend to eat lower carb when I'm at work, just because I have no time for Pre-Bolus. Like my break is when my break is. And so I tend to eat a little more low carb there just to try and maintain but no, we don't adhere to a low carb. Okay, I have just really tried to embrace what you teach on the podcast. And I actually have a friend who's, you know, likely going to get a diagnosis in the next few days. And he's started listening as well, I recommend that as I said, there's just so much they're not going to teach you in class, there's not time. But there's also just you have to teach to the very minimal, you know, the lowest, the person coming in with the least amount of knowledge, and you're starting with a much higher knowledge. So just embracing, trying to do better on your own.

Scott Benner 13:38
I didn't know this was going to be a story about how terrific I was or I would have gotten to it sooner. Yeah, no. How long? Have you been listening to the podcast?

Courtney 13:45
Somebody recommended it pretty quickly in to diagnosis, I would say within the first four months. And so I tend to focus more on the episodes of management versus storytelling, I guess. But I mean, nobody taught me about Pre-Bolus, or protein or any of those things in, in education, it was carb counting, and which is a great foundation, a great place to start.

Scott Benner 14:13
I'm thrilled I and listen, if you aren't the kind of person who likes to podcasts for the chatting, like I get that I support both sides of that coin with the other. I put all that like, I think great management content in there. Because everybody wants that, you know, on one level or another. But there are plenty of people who love the stories and they get a lot of community out of it and a lot of good feeling out of it. So I figure if we order, you know, offer a kind of a 5050 of that. You kind of make both sides of that coin happy. I love it. Yeah, so yeah, I'm thrilled about it. I mean, before we started recording, I mentioned something from another episode and you were like, Oh, I haven't heard that. But be honest. You wish you did, don't you?

Courtney 14:53
Oh, absolutely. I'm gonna go find it. Well, no, no,

Scott Benner 14:57
you're not allowed. You can only listen to the management stuff. I seriously didn't know that the podcast was valuable for you and had been. So that's fantastic. So Pro Tip series, that kind of stuff. real helpful. Yeah,

Courtney 15:08
exactly the bold beginnings. You know, the one episode that really rang true was just being that being diagnosed as an adult. And while there weren't tons of management tips that I went away with, I remember being like, it is my life was flipped, I felt seen. My life has been completely flipped upside down. And I remember just feeling part of it community and seen at that moment. Like, yeah, this is hard, and no one really understands it. Yeah,

Scott Benner 15:38
see, now I could call this episode Princess of Bel Air. I love gas pasture, though. It's gonna be hard to get away from it for me. Yeah, I'll take it. Yeah. So all this, this knowledge that you have about diabetes has informed your work. And that's why you're really here. I want to talk about that. So can you just kind of open up about that for me and fill me in?

Courtney 15:59
Sure, feel free to like, slow me down. If I get going too fast. I'm gonna touch quick, quickly back to like, when I talked about nursing school when I went to nursing school, which, you know, like I said, was late 90s. You know, the fast acting is the Nova log and humor log had just been patented, and they were not part of education at all, they weren't even rapidly adopted. So we were learning about mph and 7030 and regular insulin, and managing diabetes from a you take this insulin here, and you eat exactly four hours later, because that's the peak that we're talking about. Glargine was barely being adopted into practice. And so that's part of being like, Oh, you really had no freedom to eat, then because you were trying to match an insulin profile that had nowhere close to a carb uptake profile. So moving forward, a lot of people my age, which make up a huge chunk of medical providers, right, the the 40 crowd, you've graduated residency, or you've gotten your masters or you're a nurse at the bedside, but you haven't yet retired, or part of this group that went through education that didn't ever even learn about human laga Novolog as part of our basic education, let alone clergy. So now you come to today were upwards of 60, like so. And then 96, less than 1% of patients were using an insulin pump, we didn't I mean, we knew they existed, they were like the Zack Morris cell phone attached to your waistband, but people weren't using them, because what's the point and continuous infusion of regular insulin sub q. So now we fast forward to upwards of 60% of type one patients are using insulin pumps, and none of us ever learned about these devices, let alone that they only have rapid acting insulin. We don't We never talked about Basal Bolus insulin, because that wasn't really how insulin was given back. Back in the day, you had sort of insulin that you had to eat to protect the peak, so that you didn't bottom out. So when you come in with an insulin pump that someone's unfamiliar with their gut is sort of like I don't want to deal with that. What they're not recognizing is if you take an insulin pump from a tape, one patient, you have removed all basil or background insulin. And it's not the standard of care. But I think it's hard to re educate everyone on on the technology today. In one mass.

Scott Benner 18:36
I mean, I guess the basic problem is, is that people are where they were taught to these positions, like in med school got one level on one idea, then they moved out into the world, and the world changed, and nobody came along and told them. So they're just doing everything they do, right.

Courtney 18:53
And so specifically, like I don't want to like toot my own horn or my professions own horn. But if you think about any anesthesia provider in any sense, they have to be so knowledgeable on hundreds, if not 1000s of surgeries and what's going to happen during that time. They have to be knowledgeable on hundreds and 1000s of different medical problems and medical history and how anesthesia drugs affect them. And for instance, like the top drawer of my anesthesia machine has 25 different drugs just in it with that doesn't even talk about the you know machine that I can go get almost any drug I want out of in the hallway. So it's just the knowledge base is vast and trying to keep up on every knowledge. You know, every disease process is difficult. And then you talk about type one whose management has drastically changed in the last 30 years. Yeah, it's it's crazy. You

Scott Benner 19:52
have those drugs because there could be drug interactions that you have to counteract and that's what they're there for. Is that right?

Courtney 19:57
Yeah, so almost every anesthetic If drug is what's called a cardiac depressant, so your blood pressure drops, you're you may have those things that we have to have counteract or your heart rate may be fast, or it may be slow, or you may need pain medicine, or you may need pain medicines that not narcotic, or this particular surgical procedure, you know, causes less blood to come back to the heart. So we need to supplement that with a different type of IV fluid. It's, you know, it's just a complex thing. So then you have someone who for years came in with either this background of regular insulin or mph is their Basal, then we moved to Glar gene, which is beautiful for a MDI. Because it really does have almost 24 hours, so you didn't have to do anything, you were like, you took that check, okay, I don't need to give you insulin it's taken care of. And so now we have to come back to many hospital policies, say your insulin pump is not allowed in the O R. And while patients are advocating for themselves to take to their pump to the O R, it would be against policy. So then it becomes removed at some point in the beginning in the in the pre op area. But are we replacing that with? The big question is are we replacing your Basal insulin and we need to be that's the standard of care. So how do we do that in the perioperative period, there's really only two ways to do it. And that is to allow the insulin pump to run if it's within hospital policy, or you need to start an IV insulin infusion,

Scott Benner 21:30
why would they not want the pump to stay on? Well, a turns

Courtney 21:34
out anesthesia providers know nothing about an insulin pump. Like I could hand my insulin pump to my friend. And there's, it'd be difficult for them to figure out. Maybe not difficult, it would make them uncomfortable to try and Bolus from a pump. Also, during surgery, you tend to get steroids, there's a stress response, fasting in and of itself can make so the risk of hyperglycemia is actually higher during surgery than hypoglycemia. So to have to Bolus from that with a not be something in the wheelhouse of any anesthesia provider, they've probably never done it, it's not to say they can't learn I'm just the reality is it's unlikely that they've ever done that. And two, it's a very dynamic period, so your blood sugar could change rapidly up or down. More often than not, it's up. And when you Bolus from a pump, as we all know it takes time, right? So it's sort of behind and then you have a change in blood pressure and perfusion to your subdue tissue. If your blood pressure's low if you're cold if you're warm, so it's a lot less predictable to give sub q insulin in the perioperative period, versus IV insulin. If that makes sense. Though, we are starting to see studies come out with very good results for insulin pumps in especially like your smaller everyday run of the middle of surgeries versus your bigger surgeries that have high dose steroids or dramatic fluid shifts, the data doesn't exist. So adopting a pump to is like, I think it'll work fine. But there's very few controlled studies on insulin pumps, because we're not a very populous group of humans.

Scott Benner 23:19
So I get it, I understand how we get to where we are. What are people need to do to use them? Like what what can I do going into a surgery to say to someone look, this pump, I'll make sure that it's new, that it won't run out. But it's not so new that it's not working? I'll put it on 12 hours before the surgery, make sure it's nice and settled in and it's working? Well. I'll come in, show you where you can push the buttons if you have to shut it off. But in the end, I mean, it's just the insulin pump. Like if if it was really I mean, I don't know what they're concerned about. But if you weren't getting really low, they could just rip it off you. It's not like you don't I mean, it's not like not knowing how to push the buttons would stop you from stopping it if you needed to. It's just it's really, yeah, it couldn't it feels like there's a lot of not thinking that happens around stuff like this.

Courtney 24:05
Sometimes, and I you know, I feel strongly that we're missing an opportunity to embrace more insulin pump usage. And in fact, like the anesthesia Patient Safety Foundation, put out a piece a couple of years ago advocating for more use, and there's some interesting studies coming. There was a really fascinating one out of Switzerland that they put insulin pumps on a large group of type two patients that utilized insulin, and they had far better control with less hypoglycemia, shocking, they put it on in pre op and they were at their entire hospital stay so the data is starting to leak out. I guess my concern is, I think if an anesthesia provider feels good about the insulin pump, the surgical site is far from the insulin pump site. So if you're having an operation on your belly You really should probably have your insulin pump on your leg if you want to have any hope of it standing. Yeah,

Scott Benner 25:04
yeah, I mean, she's do people not think about stuff like that would

Courtney 25:08
be so surprised at the things sometimes you see. And I think that's the other reason you have somebody who comes in and rides their pump in a way that is probably, you know, they're a one sees still 11 And you're like, this really isn't doing a great job for you. And then you have someone like me and lots of your listeners who come in with super tight control and are very knowledgeable. But you don't know who you have in a 10 minute interaction, necessarily. I

Scott Benner 25:35
understand. Also, it wouldn't take that much more insulin to turn an 11 a one c into an eight, a one C and you still wouldn't be really tightly controlled, but it's you know, yeah. Well, that mean, listen, that goes to show, what it shines a light on is the vicious circle, there is just no reason in the world that a person should have an insulin pump, and an A one C of 11. That somebody's not understanding fundamentally how to use their insulin. And a doctor should be able to like step in and give them the information that they need. Yes, you know, it's not just it's not that hard. So then what it points to is either a person who doesn't understand or is unmotivated, or some, you know, somewhere in between that scale, having diabetes showing up in a hospital where another doctor looks and says, Oh, an 11 a one C, you don't even try, you don't even care. So then you kind of get written off at that point. You don't mean like, you shouldn't have to be you coming in going, I have a 5.2 I want to see and I really know what I'm doing. It's okay, if we take good care of me here. Yeah. You know, I'm saying like, take, why don't we take good care of everybody? Crazy thought, like, some people just aren't going to know, like, you've just explained why. You know, long time ago, there's not really that long ago, there weren't insulins that worked, as well as the ones to do today, the standard of care was much different. There are still people out in the space, who grew up with that. And there are people who are learning from those people. So that's why you can't get rid of it, if you would just think of a generation of doctors would just retire would be okay. But that's not so that's not the that's not going to work, you know, not completely. Yeah. So I don't know it's a it's hard to, it's hard to hear about. Yeah,

Courtney 27:10
I mean, I guess at the end of the day, I think if we want to provide safe care in the perioperative period, I want people to understand that Basal insulin is not an option. It is a requirement. And so for patients on MDI who took their long acting insulin, it's often simpler for us anesthesia people, Basal insulin requirements are met, right, we should be checking blood sugar every hour and treating hyperglycemia and hypoglycemia appropriately. If a patient comes in with an insulin pump, I think I have to say you need to work within your hospitals policy. My hospital allows patients to keep their insulin pumps for day surgeries. But those surgeries that are going to the ICU or bigger surgeries, they want their insulin pumps removed until the patient is awake and can restart them. And in those cases, our hospital dictates that you start an IV insulin infusion at the Basal rate that set in the pump. So we are meeting Basal insulin requirements. And then our life we have a glycemic team meets with the patient postoperatively. And some patients are NPO, or they're going to be on high dose steroids. And it's just easier to stay on an IV insulin infusion for a few days. And sometimes they move them right back to the pump and patient. Does

Scott Benner 28:27
the IV insulin give you like insane control.

Courtney 28:32
So the difference with IV insulin versus like a sub q, insulin is a is IV. So all IV insulin is regular insulin. So the same regular that people sometimes inject back in the day, but some of the low carb people, I think advocate for that still. But it is a completely different profile when you injected IV, so it's half life is seven minutes. So if you're running high, I can give you a Bolus of insulin and it is acting within seven to 15 minutes. And so then it's also completely gone. We say things about seven half lives, you can consider a drug kind of out of your system. So if you were hypoglycemic on an IV insulin infusion and I turned it off or cut it in half, it would be gone within an hour. So we're dealing with things that can we're dealing with a drug that can react or faster to the changing glycemic environment of surgery. So while I think we're missing opportunities to move forward with insulin pumps in multiple cases, I don't think every case can be done with an insulin pump. And I think we can safely use IV insulin. My big thing is we need to start IV insulin and so some patients unfortunately do get removed from their insulin pump and you hear horror stories. And then they gave me a Bolus of insulin through the IV because I got high Poor glycemic Well, no. Yeah, you had no basil. It'd be like a site going bad or whatever. And then they see your blood sugar at 200. So they give you a unit IV. Well, it works to drop you down to 180. But it's gone. Again, in less than, you know, it's affected this site, it was probably even less than that. So then they recheck and they're like, Oh, you're 200 again? And you're like, Well, yeah,

Scott Benner 30:25
I don't have any. And so my pancreas doesn't do anything. I mean, it does some stuff. It doesn't do insulin anymore. So

Courtney 30:31
the patient comes out, and it's like, what the hell? And I'm like, exactly. And so I've given a couple of lectures on this topic. And my girlfriend the other day was like, You should change it from type one diabetes in the perioperative period to its Basal baby. And like, that's just your mission. Does the patient have Basal insulin? Does the patient have Basal insulin? Like that should be what my hat says not gas passer. But does your patient have Basal insulin? But Courtney,

Scott Benner 30:57
is is the way you're talking about this right now, from a professional perspective? Is that only because you got type one diabetes five years ago? Like how would you have talked about this seven years ago?

Courtney 31:09
Totally different. So what there's about 5% of all patients with diabetes have type one. So I like to look at the flip side of that meaning 95% of patients with diabetes do not have type one. And so I think that's a common thing is people get diabetes, which I really want them to have two different names, but so that the confusion is less, but patients come in with type two, and we think about that different, right, they have insulin production, their risk of DKA and acidosis is far lower during the surgical period than somebody with type one. And I absolutely would like if an insulin pump came in, it gave me like a quiver in my gut. I'm like, I don't like I don't know what to do with that. And and every time it was like, Okay, I have to look it up. Do I keep it? What do I do? And so I think people, I really, really think many professionals don't realize that the insulin pump has only rapid acting insulin and that they're taking no Basal insulin. So that's where the mistake happens. I think I fell into that idea of like, oh, it's not regular insulin. Oh, that's weird. And then learning that, once I, I was just like, the second I was diagnosed, I'm like, I want to pump and I want to CGM. And they're like, well, your insurance is gonna make you wait for your pump, but you can get a CGM tomorrow. And I remember learning about my pump in the six months, I had to wait. And I was like, Oh, I like it's not. I get rid of clergy. I'm like, holy cow. Like, that was a moment for me. And it's sort of embarrassing to admit that I didn't even recognize that. And so I think that's a big part of why I'm here. Like, it's embarrassing. What I didn't know. And I also watch other people not know that, I

Scott Benner 33:01
think that it's the most disappointing thing I'm going to hear in the next four days. Honestly, just the idea that that a medical professional might not understand that basic idea about how an insulin pump functions. That's really like BS, you have to put yourself in a position of someone who's just going to the hospital to have their you know, I don't know, have their

Courtney 33:23
super Yeah, important conversation is that I do think that knowledge deficit exists. I'm unfortunately, and I think someone coming in to have surgery and has been told that their insulin pump needs to be removed, I want them to have the words to be like, That's my only Basal insulin. So what are you going to do to provide me Basal insulin while I'm in surgery? But don't

Scott Benner 33:49
you think that people have an X of reasonable expectation that that's not a thing they have to say? They should? Yeah, if you couldn't eat if you went to take your car to get four new tires on it? Do you think the last thing you should say to the guy at the counter when you hand them the keys is please tighten the lug nuts back up when you're done?

Courtney 34:07
I mean, yes, but I'm, I'm not. No, I

Scott Benner 34:11
know you're not. I'm not calling you. I'm just saying I'm just having a conversation with you. But like, I'm trying to put the conversation not you in the perspective of everyone else. Who has no reason in the world to expect that a medical professional wouldn't understand how an insulin pump work. You don't I mean, like I understand your description of why that's the case and I'm not even arguing with it. It makes complete sense to me I'm just saying that if you're just like I was gonna say Joe Blow do people say that anymore if you just the average guy on the street but his Joe Blow even mean we'll look into it later, Courtney, if you're just an average guy on the street, going in for a procedure a you're probably not thinking about it because you're probably worried about having your appendix out or something like that. But at the same time, like, I'm at the doctor building now, with all the doctor people in it. This is a medical thing. My device is a medical thing. They'll know like I don't even think it gets up Well, no, I don't think you even think about it. That's what I'm that's my point like, so I know people have to that's why it's important to talk about this. For people with diabetes, they need to go in there without acting like a lunatic or seeming strange and say, Hey, who do I talk to and explain this insulin pump? And then you know what happens when you say that somebody is going to want to reassure you? That's a famous thing in all professions. Oh, absolutely. Oh, no, we know what we're doing. Sure you do. I don't know. 10. Let me just say this. Now, I want to be clear. I don't know 10. People that know what they're doing. Okay. Like, forget about it. Forget about medicine in my life. I read I know, a few people who've got everything together. But I know way more people who would say, oh, no, don't worry, don't worry, don't worry, I got it. I got it. I got it. But what their brain is thinking is I don't know what I'm doing. So it's human nature. You don't I mean?

Courtney 35:52
No, I agree. But I also think I'm not. Yes, I think people come in and expect people to be knowledgeable, and I want them to be knowledgeable. And I believe that they should be how do we do that? Yes. I mean, I'm doing my best. I'm talking to you multiple times. And I, you know, I don't have a great answer.

Scott Benner 36:16
Is there not continuing education in the, in the facility? The like, all the, you know, do all the gas pastors not get together once a week for a 15 minute lecture on something? Or is there not an email that goes around and says, hey, don't forget, insulin pumps work like this? And then like, why is that not a thing? Would that be so simple? It

Courtney 36:37
is a thing? Oh, it is a thing? You told me that I work at a huge academic institution. Right. So we are very geared towards education. So I lecture at my own institution to our residents, once a year. So their first year, here's this, I give, I've given Grand Rounds, a full grand rounds where I just went through everything type one related including CGM and insulin pumps. And then I talked about insulin pumps, usually about for 15 minutes on what we call a CQ AI meeting, which is also Grand Rounds, but it we go through like, Hey, we're not doing this great. You need to do this every time. Here's our policy, this is what you need to be doing. So that exists in my institution. It does not exist throughout, you know, we have places that you know, are tiny, they're one anesthesia provider, and to try and stay up on every last detail in medicine is difficult, because anesthesia touches in every you know, high blood pressure stroke, blood clots, cancer, you know, and then the surgeries that go along with it. I'm not justifying not having the knowledge base but staying on top of every single change in medicine is is not I want

Scott Benner 37:56
to do an exercise with the coordinate Tell me Tell me again. What is your actual like job title?

Courtney 38:01
I must CRNA or a nurse anesthetist?

Scott Benner 38:04
Right? Spell anesthetists for me.

Courtney 38:08
My my Dexcom is going off. Did

Unknown Speaker 38:10
you hear it? Don't, sir.

Courtney 38:12
It's a n e t h i s t. Okay.

Scott Benner 38:20
Here's what I'm gonna do. Because I think the world's simpler than we make it. Okay, I'm gonna ask Chad GPT explain how an insulin pump works to an N S. Say that again. We How come it spelled like that? Why does nothing like me today, anesthetist? Or

Courtney 38:36
you could say anesthesiologist, it's all I have it. I have a different path to education, but we both provide the anesthesia.

Scott Benner 38:43
Let's do that. Because that I can spell include what they need to know about help about managing

Unknown Speaker 38:55
a person

Scott Benner 38:57
with type one diabetes, I've never done this before my wife. Okay. insulin pump is a medical device used to manage diabetes specifically type one diabetes, which is characterized by the body's inability to produce insulin. Insulin is a hormone almost second it is not stopping Insulin is a hormone that regulates blood sugar levels by allowing cells to absorb glucose for energy and type one diabetes the pancreas does not produce enough or any insulin requiring external insulin administration to maintain proper blood sugar levels. Here's how an insulin pump works and what an anesthesiologist should know about managing a person with type one diabetes, and the LIS function of the insulin pump continuous insulin delivery Bolus dosing adjustments during surgery and monitoring adjustments during surgery during surgery or any medical procedure requiring anesthesia. It is important for the anesthesiologist to communicate with the patient about their insulin pump. Depending on the duration and type of procedure adjustments may be may need to be made to the pump settings for instance, the Basal rate may need to be temporarily reduced or suspended prevent hypoglycemia, or low blood sugar. Okay, that's a browser window My computer coordinate, like, how come someone can't do that? And go, Oh, I'll be in charge of sending out the daily reminders to everybody. Like, I mean, did I just fix the whole world? You see no saying like, I love how everybody says, Oh, this is how it is, or here's how we got here, or it's so hard to fix. It's not that hard to fix. One focused person could fix this in every hospital. Do you really mean? Like, am I being pity? I don't know, if I am,

Courtney 40:28
you're not here today. What I'm gonna say is, I tend to be that person a little bit, you know, people

Scott Benner 40:35
know who you are, I have a document because we all got lucky and you got type one diabetes. But what I'm saying is,

Courtney 40:41
even as somebody who tirelessly advocates, I can't force someone to absorb that information.

Scott Benner 40:50
Let me say this to those people do your job there. Okay, you're getting paid. You know what I mean? Like, just do the thing you're doing, I don't know, it makes I get very upset very. So you're even keeled, which is lovely for the conversation. But this seems so basic to me. And the fact that it has to be rehashed over and over and over again. And that a person like yourself has to get type one diabetes, and take it upon themselves to educate other people in a professional setting. None of that makes any worldly sense. It feels like to me that people see problems and then go, oh, problems instead of going, Oh, that's a problem. Why don't we make an adjustment, so it doesn't happen again, like because this is not a new story. You can put a whiteboard up in a room and say to the anesthesiologists, which I can spell, you could say to them, there's a marker in there, every speed bump, we hit for a month, we're going to write it down. And then we're going to create a list of things that happen most frequently. And then we're gonna go ask Chad GPT, to explain it to us all, and then we're gonna put it out into an email, and it is part of your job to read the email. And that's that, like, I mean, honestly, this is 45 days worth of effort, fix everything. I don't know, that's the part that confuses me all the time. Why do smart people not do smart things?

Courtney 42:05
I mean, those things happen, right? Those happen all over the country that we talk about these things, but then how

Scott Benner 42:14
does it keep happening, then you're just saying it's a it's a failing of human beings?

Courtney 42:18
So if you think about, I mean, yes, it's a feel of human beings, right? We all forget things day in and day out. I mean, half the time I forget my anniversary, right? Which it's not that long. You know, like these are, that's part of my job as a wife, I'm not saying it's acceptable. I'm saying we're human. And our brains, I will tell you in healthcare are bombarded constantly with emails of how we can do better what we did wrong. And I would tell you that failing on an insulin pump would not show up on that whiteboard. Why? Because they're extremely rare, even though we deal in this community, where they seem like every day, things, the fact that that person makes it to surgery with their insulin pump is we, you know, so rare for you. Extremely rare. So maybe we see one insulin pump through my institution that staffs 50 plus operating rooms a day, and anesthetizing. Say maybe we see one, and we have 167 people providing anesthesia, or more, you may see an insulin pump on a patient once every two or three years. Yeah.

Scott Benner 43:33
Well, listen, coordinate between you and I. Some you motherfuckers wouldn't want to work for me. That's all I'm saying. I'd fire you. That's never been. It'd be no one left. I'd be like you're gone. Did you read the email? No. Goodbye. And lay good. I just didn't. Go ahead. How are you going to improve people? Can I say something about people? Yeah, I don't think they really want to work.

Courtney 43:57
Oh, I mean, right. Yeah. When Powerball I'm out.

Scott Benner 44:00
I think everybody wants to, like, get up around 11. You know, move into the day slowly, maybe hit their Bong, have a little lunch. And I mean, maybe watching Netflix, who knows? And then he's into the evening and you're on your way. Like, I get it like it sucks. It's, it's a lot. I don't mean to be flippant about. It's a lot of it's a lot to remember. You know, there's a scarcity of how many times it happens, which makes it I imagined even more difficult to remember. It still happens. It does. It feels to me like there's a hole in my backyard. I only walk in my hole in my backyard every few weeks. But somehow I fall in the goddamn hole every time I go out there. And no one goes, Hey, we should put a sign next to that hole or Let's get crazy and fill it in. That to me is what it feels like. I know it's not often I know it's kind of silly. I know it feels like a thing you should be able to remember and it doesn't need to be addressed. But I don't know how long we have to live and watch the same thing happen over and over again before someone says hey, you know what? Why'd this is a problem? Listen, I'll ask you. Let's take diabetes out of it for a second. Are there other topics specific to your profession that reoccur all the time that are an issue?

Courtney 45:11
Well, let me just clarify. I want to say that this does not happen every single time. But I do think it does happen. I hear about all the mistakes because people ask me how to fix them. I never hear Hey, everyone. Use your provider. Yeah, nailed it. I

Scott Benner 45:31
was the I was put under six months ago, it went perfectly I. But that's not. I mean, listen, that's not a thing we have to talk about. Like, we're all adults, we don't need to be celebrated for doing it. Right? I hope not. Right. But I take your point, we're not saying everybody is in this situation, it's not going to happen every time. It's not going to happen. Every institution. I'm not saying that either. But we're just drilling down on the problem. So Okay, Let's lighten this up for a second. Okay, we have like 10 minutes left, I have a real serious interest here. First, let me ask you, do you think we got through everything you wanted to talk about?

Courtney 46:03
I mean, I think if I had to say one thing to any health provider, like anesthesia provider listening, if they're listening, they already know this, but they have to have Basal. You know, I'm not going to tell you to go against your hospital policy and leave an insulin pump running. If that's not in your hospital policy, start an IV insulin infusion. There are plenty of journal articles that talk about and I'm happy to send you a link. Scott, if you want to put it in the notes to the one that I think is the most comprehensive, please do. Insulin pumps have not been well studied in the anesthesia literature, there are studies that say I think you can use them safely. There's not one study that says this is the end all be all, what the literature does say is you have to provide Basal insulin, it's about the Basal insulin. And I would encourage any patient going into surgery to a know their pump settings so that you can communicate clearly. And know that if your pump is being removed to advocate for Basal insulin, you may be falling on, you know, repeating what somebody already knows, but just say, you know, my understanding is if you remove my pump, I should be started on IV insulin at my Basal rate. Yeah. Is that your plan that I think oftentimes patients a don't think to have that conversation. But there's still something intimidating about medical providers. They're the knowledgeable ones, and we're not, but I think it is perfectly acceptable to advocate for yourself in any way, shape, or form, especially in a way that's open to conversation in the sense that you're not attacking someone just say, right, everything I've ever read is if you remove me from my insulin pump, I should be started on IV insulin before you remove it. So is that our plan? And I can give you a copy of this for you know, bring it in with you. Um, you know, just if you avoid one time where you have a hiccup,

Scott Benner 48:07
it's valuable, for sure. It's, yeah, and know what you're talking about. Don't just go in and say, Hey, fix this for me, you have to have some information about what is working well for you as well. You know, because the doctor is not good. I mean, in that situation, like somebody in coordinates position is not going to sit down and help you figure out that your Basal is too strong or too weak or something to that effect. Yeah,

Courtney 48:25
I mean, our recommendation if we remove the pump, we were starting to use a tool called endo tool, which is sort of like control IQ or Omni pi five, insulin decision algorithm that doesn't, it relies on the provider to input the data, and then into a computer program and it tells us at what rate to run insulin and how often to check the blood sugar to make adjustments where

Scott Benner 48:49
this stuff is headed, right, Courtney? Like eventually, you'll be a technician and a computer will decide what to do. Yeah,

Courtney 48:55
so it tells me it's best guess and then we are we're moving towards that an algorithm that helps learn the patient and make decisions based on the patient. Yeah, anybody being removed from an insulin pump should have Basal insulin in some form, and that in the perioperative period, the most recommended by far is IV insulin infusion at the patient's Basal rate in the pump. And so Omni pipe five, you're probably going to have to you know, it's not a set rate, right, so that we run into that problem, even people doing it right. They're like, I have to remove your pump for this reason, and the patient's like, I don't know what my basil is. So maybe take a little time on an algorithm and figure out what kind of your pump is running at basil wise you're gonna have to do some calculations or dig a little bit deeper but that will really help your anesthesia provider as well to be like, you're removing that this is where I would start. And then sometimes we recommend like an exercise mode if you are keeping your pump especially for a short surgery because we as anesthesia, people are death li definitely definitely afraid of hypoglycemia. It's rare during surgery,

Scott Benner 50:04
is it a bigger problem because I'm unconscious already.

Courtney 50:07
It's not a bigger problem. It is not more common but it unrecognized hypoglycemia. So you would say I feel like and we would do something we check your blood sugar but no one's there to say I feel like so it relies on an anesthesia provider checking your blood sugar at a regular rate at very minimum is once an hour, literally with a finger stick. Yes, yeah. So

Scott Benner 50:33
what we really want is people to wear a CGM during a surgery that would be really valuable. So

Courtney 50:38
CGM are not validated in the hospital, any patient of mine that so they got an FDA approval during COVID. And emergency FDA approval, which was really fascinating some of the literature that came out of that like how they were used, and I think there's going to be a data spill that probably comes out. By hospitals policy on CGM is the patient may wear their CGM, and I may use it as a trending device. But at minimum, I have to use a finger stick machine in surgery at least once an hour.

Scott Benner 51:08
Yeah, that's fair enough. Plus, you really want to charge them the 50 bucks for the test strip. So

Courtney 51:13
true, true story. So in other the data is signal loss is common on CGM. And if they're not in the surgical field, you should ground away from them. They've never again been well studied in the operating room. So the Bovie pad in the grounding is always a question mark. Because you're putting metal you have metal in the patient's skin. And you know, it's coated in plastic, but sitting on top for the Dexcom. But I think you could advocate to leave it on even if your anesthesia provider chooses not to use it. I never make somebody remove it because they're expensive. And I know that and I've tried to educate people on that, but advocate for

Scott Benner 51:48
yourself. I have a story about what I did for art. And once that I'm not going to add here because I think it'll take away from people believing in me in this conversation. But I, I remotely managed artisans on during an exploratory surgery once so, and they didn't know I was doing that. But you know, Wi Fi, it's all magical. Now, here's my question, right? Because how I want to finish up because I really appreciate you doing this. First, I want to thank you very much for lending your expertise and your knowledge in this blend of you having type one with your years and years of service. As an anesthesiologist that's really valuable. And thank you I'm actually going to make this episode part of my grand rounds series. So now I can't collect maybe I'll just call it grand rounds. gasp passer. Probably gonna say anesthesiology. You know, normal. But But here's my question. I've been out a number of times, right? I had had a colonoscopy, they'd make you sleepy for that. Had my knee scoped and cleaned out. I've had enough surgery and my toe. They give me what they call the Jackson juice. That's propofol, right? Is that what that is? Yep. I want to understand the mechanics of that. And I'm going to start by asking if you get a bed. Bed is not the right word. But if you get an anesthesiologist that doesn't know it burns like a mother, you're going in. And it's the last thing you remember before you're gone is Why does my arm burn? Oh my God, my chest burns, then you wake up and it's over. But I had another anesthesiologist I told him I said hey, the last time I got this it burned really bad. My chest and he goes, Oh, don't worry, I can fix that. And then I think he tourniquets my arm and hold it there for like, tell me all about that. Like first of all, how do you get it in without a burning? Okay,

Courtney 53:26
so there's no guarantee, but propofol is very alkaline and so then it causes a pH change and it makes your vein really angry and it burns like mother. Like you said, it really does. So most anesthesia providers, especially for a general anaesthetic, so in the operating room, numb up your vein with lidocaine, IV lidocaine, so numbing medicine. Oh, that

Scott Benner 53:48
was all he did, okay. And then but he holds it there for a minute, right? That's how he he like the Lidocaine goes into the tourniquet my arm, I'm trying to remember what happened. So we

Courtney 53:58
we say there's a lot of science and a lot of art and anesthesia. And so that is one of the art things some people believe if you put a tourniquet and put lidocaine in there, it has a chance to numb longer because that blood is not moving away from the site. Other people just believe the act of giving lidocaine before and kind of with the propofol is enough. I gotta tell you sometimes, despite everything we do, well, I always tell people it's spicy. I'm sorry, I'm doing my best to make it not. Yeah. But that is completely normal. And it's going to be gone when you wake up. Yeah. So

Scott Benner 54:34
then okay, so that well, first of all, I want people to know that in case they ever kept can ask for it. But my book, the rest of my question is, what is the mechanics of it? Like how is it shutting me off like that because it happens. In US, it's less than 10 seconds.

Courtney 54:49
Light works on a GABA receptor in your brain, which is a receptor that can cause this sort of sedation and then it hyper debating it makes you go to sleep. But don't ask me how anesthesia gas works because we don't we don't really know we have theories, but we've never, we don't. And so that's usually you go to sleep with propofol and mostly anesthetics, your cap asleep with anesthesia gas once the propofol works, propofol just worked so fast, that that's how we call what we call the induction of anesthesia. So

Scott Benner 55:21
you put me out with the pro ball, then you keep me out with something else, typically, then you back it off, and I wake up, but this is why I asked the question because I know this and I was well, I just wanted you to I wanted to I wanted to know if I was right or not from what I had heard, but medicine doesn't actually know why it works, right? We

Courtney 55:39
have a much better idea on propofol but the anesthesia gas we do not know that fantastic.

Scott Benner 55:44
Like we can shut people off and turn them back on. And we don't really know how it's exactly happening. That's

Courtney 55:52
insane dose. We know what's appropriate. But yeah, we don't think

Scott Benner 55:56
crazy gortney is it's crazy. It's like mad. It's like, I

Courtney 56:01
love love, love my job. Yeah, it is the coolest job. I get to practice medicine edit, like cellular level, like I'm giving this drug that I know which receptor it works on. And I know what should happen when I give that. But bio bio hacking to some degree history in front of me too. And humans are medicine is you can do everything right and things go wrong, and you can do everything wrong. And things go right. I have a really cool job, but it is definitely stressful at times.

Scott Benner 56:30
Hey, have you ever? Um, so if this is something you'd want to talk about or not, but have you ever put somebody out that didn't come back

Courtney 56:37
and work at a trauma center? So yeah, that does happen. Yeah. No. I mean, it is extremely, extremely rare for somebody to die on the operating room table. You have some of the most experienced emergency managers in the hospital there. And we have a lot of drugs on hand. It's extremely rare to die in the operating room. But it happens.

Scott Benner 56:57
I tried to remind myself the last time I just had my toe fix, right. And before I went under I said to myself, like when you wake up blurt out, not today, Jesus, right. But I didn't remember to

Courtney 57:10
like on the way home and you're like crap I forgot

Scott Benner 57:12
to do because it's a room wins again. There's a room full of nurses there. And they're all sitting around charting and everything. And I was like, How great would it be if I just burst awake? And I was like not today Jesus. But I you know, you're very out of it when you first start waking up. So but yeah, also fascinating how quickly you're not out of it afterwards.

Courtney 57:33
I love it. I love it when it's a sign of a good anaesthetic when I'm wheeling into the recovery room and the patient's like, Wait, we're done. Yeah. It happened. And I'm like, yeah, they're like, but I'm awake.

Scott Benner 57:45
to It really is I wake up very relaxed afterwards, like, Oh, my God, but rest of my day is gonna be fantastic. Anyway, I see what happened to Michael Jackson, I honestly see how we could get hooked on and if you had trouble sleeping and had access to a shady doctor, like I get it. You don't I mean, like, Jesus, I really appreciate you talking about this. I appreciate you going over that with I am. Like, I'm not much of a geek about stuff like this, usually. But this one really is fascinating. Like we are shutting people off in a medical situation that we do not actually know why it's working. Like that's fascinating. You know,

Courtney 58:18
it's sort of Yeah, it's like one of those things that like, probably wouldn't get FDA cleared today. They'd be like, figure it out, but it's been around and use safely for so long that you're like, all right. Yeah,

Scott Benner 58:30
they say peanut butter is one of those things. You know that? No, I don't think peanut butter could get through the FDA today.

Courtney 58:39
I mean, that would be a sad day.

Scott Benner 58:41
I don't want to freak anybody out. But don't google why

Courtney 58:46
we actually like in our break room just we have peanut butter for like it when you're just running behind and you need a quick snack and I eat a lot of peanut butter. But they switched over to the natural little cups and I was where's the sugar? Really? It's the oils on top and I'm like I'm trying to eat quick. My cracker doesn't dip

Scott Benner 59:07
its own natural. Great, great, why don't we try to help I tried to live so I'm 100 right Courtney the peanut butter can be a little sweet but the hell

Courtney 59:17
are mixed like at least anyways landed

Scott Benner 59:20
so that oils not floating on top of it because you know you look at it like this is like sucking on a peanut for a whole day and just squeezing it my teeth slowly.

Courtney 59:28
I know I'm sure my patients appreciate the oil spill down the front of my scrubs when I go

Scott Benner 59:32
professional. Everything's gonna be fine. Anyway, good luck to all of you. We're all we're all live by a wing and a prayer. Just all things being held together by spit and duct tape. Good luck. The seriously this was really wonderful. I appreciate your time and you and your good natured about it and I got upset in the middle and you you stay deep.

Courtney 59:51
I mean, I I want everyone to be experts at everything. But if at the end of the day, if you're not an expert Just know a type one patient needs basil if they you take their insulin pump off, and I think, you know, it's it's pretty rare that that things go wrong. But I think that understanding is really an important, important piece. I could nerd out all day on it.

Scott Benner 1:00:15
I agree. Yeah. And currently Listen, I'm not a I'm not a Pollyanna person, like, I've been making this cold wind series, which is healthcare providers are coming on anonymously and talking about their jobs. And now I'm getting notes all the time from people like, Were you just shocked when they said that? I'm like, No, wait.

Courtney 1:00:30
You're like, wait, I started it on for a reason. Yeah, I

Scott Benner 1:00:33
started because I knew what they were gonna say. Like, I'm just giving them a platform to say that I'm like, You're shocked that this is how the world works. I'm like, oh, that's fascinating, then I'm not shocked. Yeah. So I will

Courtney 1:00:44
say, the vast majority of people in medicine want to do right. And if they don't do right by you, it is not intentional, I believe not saying it's not their mistake to own. It's just, I think, unless you're really like in it, like the the amount that you get bombarded and like the burnout rate is high. Yeah. But we do need to own our mistakes and own our knowledge deficits. But I do think and I do think there are people out there making the same mistake over and over, but the need to learn, but the vast majority of people really are here for the right reason why

Scott Benner 1:01:21
Yeah. Oh, Courtney, I believe wholeheartedly in what you just said, and that people's good intentions and their desires and everything like that. And when I even when I say like limitations of human beings, I don't mean that pejoratively. I just it's a limitation. Like we just can't keep it all straight, where we are thinking about going home and watching Netflix, like we are like worried about a fight we had with our girlfriend, people are still people. I'm just saying if you're Yeah, what happens is that when you come in from the other angle, when you're the patient, you get lulled into this sense that like it's all going to be fine. Because the Magic Man in the white coats there, it's going to be alright, this lady went to school like I mean, she got a master's degree for this. You said, right. And now it's

Courtney 1:02:02
a seizure. Yeah. And now it's a master's degree in anesthesia. Right. I'm not an endocrinologist. And so oftentimes, a type one patient that comes in to me, obviously, I'm worried about their type one and in a certain way, but we've heard about the side effects of type one, right? So often people who had poor management at some point in their life have kidney disease, or they have coronary artery disease are perfect. Oftentimes, your hypertension or your kidney disease is more concerning to me than your type one. And because that will affect my anaesthetic in that moment, right? Or more than your type one, even if I'm not treating your type one. Yeah,

Scott Benner 1:02:39
see, now my perspective, though, Courtney is because I get to have all these conversations and see all these things come full circle is back to the vicious circle I brought up before, like someone's got to step up and put a stop to this, like the idea that people with type one are going to have these problems. Not everybody but more of them than we hope. And that begins at diagnosis. That's where my grand rounds series comes from. It begins with diagnosis and having a learned person explaining this to you from step one. And so that you don't end up a person in an ER 30 years from now that you look at and go I'm more worried about her hypertension than I am about her diabetes. You know what I mean? Absolutely,

Courtney 1:03:16
yeah. Thanks. I mean, we have the tools now that we shouldn't we shouldn't be a living with a one season the nines. Like

Scott Benner 1:03:27
we're gonna agree with each other. You and I are this is a society of people who are like, probably wish medicine

Courtney 1:03:32
paid for, like, you know, every few months, like go home with the basics of carb counting, and then you have another, you know, education appointment, like how are we going to do better? Where do you feel like you're lacking? I noticed this, but our healthcare system is not designed for that. Yeah. Which is where you come in? Apparently,

Scott Benner 1:03:51
it's why. Hey, listen, here's the truth of it. All you shoddy doctors. You set me up with a nice life here. You know what I mean? Like I got this podcast that helps a lot of people pays my bills. I should thank you for being so bad away. I'm just joking. Am I joking, Courtney? A little bit. All right. I'm gonna go Hold on one second.

The conversation you just heard was sponsored by Dexcom. And the Dexcom G seven. Learn more and get started today at dexcom.com/juicebox touched by type one sponsored this episode of The Juicebox Podcast. Check them out at touched by type one.org on Instagram and Facebook, give them a follow, go check out what they're doing. They are helping people with type one diabetes in ways you just can't imagine. Mark is an incredible example of what so many experience living with diabetes is show up for yourself and others every day, never letting diabetes define you. And that is what the Medtronic champion community is all about. Each of us is strong and together We're even stronger. To hear more stories from the Medtronic champion community or to share your own story. Visit Medtronic diabetes.com/juice box. I was looking for a way that we could all get nice and tanned and meet each other and spend some time talking about diabetes. How are we going to do that? On a juice cruise? Juice cruise 2025 departs Galveston, Texas on Monday, June 23 2025. It's a five night trip through the Western Caribbean visiting of course Galveston, Costa Maya and Cozumel. I'm going to be there. Eric is going to be there. And we're working on some other special guests. Now, why do we need to be there? Because during the days at sea, we're going to be holding conferences. You can get involved in these talks around type one diabetes, and they're going to be Q and A's. Plenty of time for everyone to get to talk, ask their questions and get their questions answered. So if you're looking for a nice adult or family vacation, you want to meet your favorite podcast host. But you can't figure out where Jason Bateman lives. So you'll settle for me. If you want to talk about diabetes, or you know what, maybe you want to meet some people living with type one, or just get a tan with a bunch of cool people. You can do that on juice cruise 2025 spaces limited. Head now to juicebox podcast.com and click on that banner, you can find out all about the different cabins that are available to you. and register today. Links the shownotes links at juicebox podcast.com. I hope to see you on board. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. If you're not already subscribed, or following the podcast in your favorite audio app, like Spotify or Apple podcasts, please do that. Now. Seriously, just to hit follow or subscribe will really help the show. If you go a little further and Apple podcasts and set it up so that it downloads all new episodes. I'll be your best friend. And if you leave a five star review, oh, I'll probably send you a Christmas card. Would you like a Christmas card? Hey, what's up everybody? If you've noticed that the podcast sounds better, and you're thinking like how does that happen? What you're hearing is Rob at wrong way recording doing his magic to these files. So if you want him to do his magic to you, wrong way recording.com You got a podcast you want somebody to edit it. You want Rob