Doctorly stuff

I crossed paths with medical professionals three times last week.

In chronological order:

Monday, June 11th

I had my six-month check-up with my ophthalmologist

How do you spell that?

I am almost certain I have misspelled that word several times in this blog. I'm usually pretty picky about things like this. But seriously, when did they put that "h" in there?

I've always pronounced it "Op-tho-mol-o-gist", which is probably hideously wrong. Could it really be pronounced "Of-thal-mol-o-gist"? Not sure. Anybody know?

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on Monday afternoon. The eyes are holding steady. It's been about a year since my laser surgery for my diabetic retinopathy. At my first six-month check-up, the doc noticed a new microaneurysm near the center of my eye (aka, my macula). He seemed concerned about this, but not too, too much. Basically, the microaneurysm is still there and holding steady. He said if it leaked, I could notice some blurry vision, at which point I should then come in to have some more laser treatment. This would be slightly different from the panretinal photocoagulation that I had before, and be specifically targeted at this microaneurysm. But since it's so close to the center of my field of vision, he wants to hold off on doing this because of the potential small loss of vision where the laser treatment is performed.

But it's also likely that this microaneurysm could either stay stable for many years or even go away without any need for further laser treatment (which is obviously what I'm and strongly hoping for).

Tuesday, June 12th

Thankfully, my saucer-like pupils returned to normal

Damn Insurance

They used to have drops to help speed up the pupils returning to normal, but they don't provide them at this office anymore because they're apparently too expensive, not necessary, and insurance won't cover the cost of them any longer.

Not necessary my ass. Try walking or driving on a sunny afternoon with your pupils maxed out. It's not fun.

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by the next morning so I could see the most recent pictures of... the babies!! (NB: two exclamation points).

They're doing great. Baby A is now head down, and Baby B is still in a breech position (we're not finding out the genders of the babies - but more on that later). We're at 24 weeks now. It's highly likely that they can flip and flop around into new positions in there for a little while longer (before they run out of space!). But positioning of the babies has EVERYTHING to do with whether the babies will be born vaginally or by C-section (if either one is breech, most docs these days won't even consider a vaginal delivery).

So, like I mentioned above, we don't want to find out the genders of the babies. But when I say "we", what I mean is: I don't want to know, and so Megan is not going to find out either. She wants to find out (very badly, in fact), but can't come up with a reason for wanting to know other than "just 'cause I want to!" and so she doesn't feel like this is a good enough reason to over-rule my not wanting to know. (And before anyone suggests it: she can't keep secrets very well, so her knowing and my not certainly wouldn't work).

Toward the end or our ultrasound session, Meg actually asked the sonographer:
"So, do you know the genders of the babies?"
"Oh, yeah, I know."
Honestly, I'm not sure how we got out of that room without finding out.

Baby A:


Baby B (sucking his/her thumb, even):

Wednesday, June 13th

A week or so ago, I went and had my blood work done for my A1c test. When I got into the office on Wednesday morning, there was a phone message from my endocrinologist congratulating me on my A1c reading: 6.9.

If you've read this blog for any amount of time, you might know that I've been struggling, and struggling, and struggling, and struggling, and struggling to get my A1c below 7.0 for the past year. Getting this reading was so anticlimactic it wasn't even funny. I felt almost no joy, which kinda sucks.

All I'm asking for is a little internal consistancy, is that so much?
For instance:
When one's meter averages go down, their A1c score should go down, no?
(Answer: mine stayed the same)
Or how 'bout this one:
When one's meter averages go up, one would expect their A1c score to go up, right?
(Answer: mine went down!)

IT JUST SIMPLY DOESN'T MAKE ANY SENSE. Urrrrrrgggggghhhhhh.
(see this previous post for a review of my stats to see what I mean).

I feel like the A1c test has become a meaningless benchmark (at least for me).
If there's no correlation between my A1c scores and the average readings I get out of my meter, how am I supposed to interpret the results? Do I just choose to judge how well I'm doing based on one versus the other?

Clinically, it's nice if there's a single quantifiable score that can be used to judge how well one is doing (kinda like the apgar score). But there's also the pitfall

Atari rules

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of such a score being an oversimplification of one's health status. Although I've been told there's mounting evidence (I realize I should support this claim with a reference, but unfortunately I don't have one, so caveat emptor) that blood pressure and lipid profile (not to mention microalbumin concentration) are more important than just an A1c score in gauging the overall well-being of a person with diabetes, the A1c is still the industry standard.

So anyway...stick that in your pipe and run it up a flag pole.
I've reached my goal. Whoop-dee-doo.

Testing, One, Two

I've figured it out.

I know what makes diabetes so difficult:

EATING.

Today I did a basal rate test.
And it clearly showed that I could acheive near normal blood sugars for a decently long time... if only I didn't eat anthing.

It's been about a year since I tested my basal rate settings. Before then, I had been on an insulin pump for almost 5 years and had practically the same 2 (TWO!) basal rates since the day I first started the pump. My endocrinologist at the time urged me to do some basal rate tests when I first started, but I always wimped out.

I tried, honest

After 20-some years of living with diabetes and having to eat each-and-every meal, often in exact time increments, and to be force-fed snacks in between meals, the whole concept of fasting was completely foriegn to me.

I tried a few times, but I would break out into sweats and get what I would describe as symptoms of hypoglycemia even though I was coasting in around 180 or something ridiculous like that.

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Before going on my pump, I was told how much better my control could be with it. But rather than improving my control, it actually got worse when I went on a pump (and I attribute at least part of that to the inaccurately set basal rates). I certainly liked not having to take 4-6 needles per day, but I was pretty non-plussed about the lack of improvement.

When I upgraded from my Minimed 508 to the 515, I was looking forward to taking advantage of the built-in bolus wizard. This meant that I REALLY needed to get all my basal rates figured out first. I knew that I needed to start with a solid foundation (i.e., a base) before I could even try to figure out my carb ratios. Without this base in place, even if I were to figure out some carb ratios, they wouldn't be exactly right because they would potentially (i.e., very likely) be incorporating some over- or under-coverage in my basal rates. Without this baseline of insulin coverage personally tailored, I don't think one can get nearly as much out of a pump as they should. This is the one piece of unsolicited advice that I dole out rather regularly when I meet (most likely via email) someone who is about to start on a pump. Getting your basal rates set can be tough, but it is very important to put in the effort and do 'em. It took me over 2 months to figure it all out. A lot of fasting and testing and retesting. I remember feeling frustrated when I would go low during a basal rate test because I knew that meant that I would have to start all over again in a few days. But there was also a bit of twisted relief because then I could eat!

Intellectually, I knew what I needed to do. But sometimes there is a significant gap between theory and implementation (and this just so happened to be one of those times). To help me bridge that gap, I decided to work with Gary Scheiner at Integrated Diabetes Services. In case you don't know Gary, he is great. He's a CDE and works remotely with clients to help them with their diabetes management. To be able to work with a fellow diabetic who was always an email or phone call away with assistance to help figure out my basal rate and carb ratio settings was remarkable. Really, I can't stress this enough. The current structure of meeting with an endocrinologist once every 3 months, for 20 minutes (max) is just ridiculous. That's not enough time. If you're feeling like you can't figure out something specific with your treatment plan, I highly recommend working with Gary to help out. It wasn't very cheap, and it wasn't covered by my insurance, but the benefits were huge, and it's hard to put a price on the long-term effects better control will have for me. While I still haven't gotten to my goal of an A1c reading below 7 (or 6.5), I do give him a lot of credit for helping me get as close as I have to that goal (one of these days I'll get there!).

After working with Gary for about 3 months, my 2 basal rates were replaced with 8(!).



Over the past few months, however, I've been noticing my blood sugars take a pretty significant drop on a semi-regular basis right before lunch. I knew that the first place to start in figuring out what is going on was to retest my basal rates (I've been putting this off for a while now).

But this morning, I woke up at 115 mg/dl (which was exactly where I was when I tested at 2:15am as well), and I decided at the spur-of-the-moment that I was going to do a basal rate test today. I biked into work so I didn't have to worry about trying to shower

Sleepy Logic

Upon waking up, I thought this was a good thing. What I didn't realize was that I wouldn't be able to pull off any sort of awkward shower at work, and so I would be kinda gross at work. And to make matters worse, I rode my bike home from work last night and didn't exactly shower before going to bed. I was, what Megan likes to call, a dirty bird today.

Oh well. I stayed in my office and didn't eat lunch with others (I was fasting, see?) so I shouldn't have offended too many people.

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while connected to my pump (you can't disconnect from the pump during a basal test).

My blood sugars stayed rock solid from 2:15am through 3:15pm. I was thinking I would hold out as long as I could without eating, but I finally broke down and had to eat something before biking home. The spike that came after eating was impressive. I under-bolused a little for what I ate because I knew I was going to be biking home while my insulin was peaking. Just as I planned, though that exercise knocked it down into range in no time. I'm pretty proud, actually. It's 9:30pm, after a rather unhealthy dinner of a PB&J, and I'm sitting here at 122 mg/dl. To quote Col. John "Hannibal" Smith: "I love it when a plan comes together."



If only we didn't have to eat... life would be so much easier.

Stats

Turns out I've been doing this blogging thing for a little over year now. Who knew? (answer: Blogger Dashboard, that's who). I believe this will be my 58th post, which (if I'm doing my math correctly) is a little over once a week (okay, I couldn't help myself: it's 1.115 times per week). This is about what I was expecting (hoping) when I started this little venture (despite the lengthy hiatus I've been on lately). So far so good, so I think I'm gonna try to keep it up!

Over the year, I've come to realize I use this blog for several reasons:

1. To connect with others who struggle with the day-to-day trials and tribulations of living with diabetes
2. To share some of my own trials and tribulations with folks (which hopefully contributes to an overall decrease in the sense of isolation "we" collectively might feel with this disease)
3. To vent some my frustrations (diabetic and otherwise)
4. To make stupid jokes, puns, and cultural (and statistical) references, and to let my inner geek run wild for a little while
5. But (it turns out) I also use this blog as a repository to keep stats about my blood sugars and A1c results

I keep this information in an Excel spreadsheet,

And you know

I love a good spreadsheet!

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too, mind you, but there's something about posting it here that I find necessary. I think it's about holding myself up for accountability -- public scrutiny. For a long while, whenever friends or family members inquired about my diabetes, my standard reply was: "Ehh, it's going alright." When, in fact, it was not (at least not to my standards and certainly not to the ADA's or the AACE's either). And that would be the end of it. Conversation over. And that was the extent of my sharing my diabetic life with others.

I find that I turn here when I've forgotten when my last A1c test was done or when my last eye doctor's appointment

Not yet

I have yet to make my opthalmologist appointment, but not for lack of trying, honest. I've been mentally telling myself to do this for the past couple of mornings on my way into work, but then I get to work and I get distracted by... well, by work. Next thing I know, I'm on my way home and I start cursing because I completely forgot to make my appointment. I'll get around to it before the week is out, I'm (almost) certain.

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was (February and December, respectively). After I posted last week, I got my butt in gear and went and had my blood drawn for my A1c the very next day (Thursday, May 31st). I was pretty vigilant about getting it pulled during the first week of every third month for a while, but that slipped, and now there's 4 months since my last test. Oh well.

Anyway, I've been posting my 7, 14, 30, 60, and 90 day averages and standard deviations from my glucometers (I use two) taken right before I go to have my blood work

Just curious

Is this a phrase that others use regularly?

"I have to go to the hospital and have some blood work done."

It always seemed a little strange to me. Sounds almost like taking your car in for a tune up or something. Or maybe the title of a bad B-movie. I dunno, maybe it's just me.

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done.

So without further ado:

May 2007: A1c = ?.?%

Meter Statistics
days	mg/dl	# tests	tests/day	S.D.
7	140	89	12.7	67
14	141	189	13.5	66
30	145	416	13.9	66
60	143	887	14.8	64
90	145	1,319	14.7	66

February 2007: A1c = 7.1%

Meter Statistics
days	mg/dl	# tests	tests/day	S.D.
7	136	88	12.6	57
14	132	202	14.4	56
30	130	436	14.5	51
60	139	859	14.3	61
90	137	1,335	14.8	60

November 2006: A1c = 7.1%

Meter Statistics
days	mg/dl	# tests	tests/day	S.D.
7	149	89	12.7	62
14	149	182	13.0	62
30	143	402	13.4	60
60	155	799	13.3	67
90	154	1,229	13.7	68

If I were a betting man (which I'm not much of, really), I'd put my money on another 7.1%. The November stats were generally higher than what I have right now, the February stats were generally lower than what I have right now, and they both yielded 7.1%, so there's no good reason to expect a change.

But I'd also be crazy to think that previous experience should be expected to inform future outcomes (I am so in the wrong line of business if this is something I actually believe, it's not even funny). Let's just say I've got a more than healthy level of skepticism about the validity of the A1c test.