I never like to use the word “perfect” when it comes to diabetes. Far less when it comes to being a “perfect” diabetic, although so many of us, including this recovering “perfectionist,” share this impossible desire.

So when I first saw this article,Seeking the Perfect Diabetic Day,” my face immediately turned into Munch’s painting “The Scream” and I was completely ready to condemn whatever the article said. 

Then I read the article and realized “the perfect diabetic day” is a measurement for hospital administrators to quickly see how well their institution is managing the glycemic control of patients. 

Seemingly a step in the right direction as we know hospitals tend to be monoliths with a hundred heads, silos that don’t cross, and filled with overworked providers and staff who need you to write on your body which arm should be operated on. And since practical wisdom says, “no one should be in a hospital without an advocate,” I’ll take all the help we can get.

According to Kalman Holdy, MD of Sharp Memorial Hospital in San Diego, the measure simply looks at the proportion of days during which every blood glucose measurement for every diabetic patient is within the recommended range for hospitalized patients — 70 to 180 mg/dL. 

In an informal poll of 51 nurses, doctors, and pharmacists, the vast majority (98%) said they preferred using perfect diabetic days over average blood glucose values as a performance metric. Personally, I’m all for doing what providers prefer provided it’s not life-threatening to me.

The benefit of using this measure Holdy says is that each hospital unit can improve their glycemic control. Tracking their performance, the percentage of perfect diabetic days increased overall from 33% in 2002 to 43.8% in 2010. 

That’s good, however this next statement seems irresponsible. In terms of a bottom threshold, says Holdy, values lower than 35% should require that some action is taken to improve the quality of institutional glycemic management. Well, that’s kind of scary – 36% glycemic control is considered good enough not to do anything?

I applaud any institution trying to make improvements and when I looked at Sharps a little more closely they do seem to stand out from the pack. They’re making lots of improvements to improve care: lowering noise to increase calm and redesigning the flow of the hospital for greater efficiencies. Not unlike an amazing hospital in Singapore I visited a few years ago.

That said, I do know one other way that better glycemic control can happen in the hospital setting. Let educated patients control their own blood sugar, provided they’re conscious and know their name. I’ve heard way too many stories of one’s insulin and syringes being taken away by a nurse who knows diddly about blood sugar management.

An engrossing and humane read by a doctor/patient

 

I’m reading a book I love – After the Diagnosis written by kidney specialist, MD Julian Seifter.

Doctor Seifter has diabetes himself, and so shares his own actions, or rather inactions, (he’s a notoriously bad patient the first several years) but it’s really in the background of this book. 

The book’s focus is the stories of his patients. Since all his patients live with kidney disease and generally face the unpleasant, yet only life-saving measure of dialysis, they each face life-altering decisions and are in different stages of their conditions. Seifter relates their stories, their journeys and how they prevail.

It is a fascinating look at the human spirit, and for me made all the more interesting told by a physician whose first orientation is clinical. Yet, he is deeply human and not afraid to share that side of himself with his patients; this often becomes the key for his patients to take the next step they might not otherwise. 

Here is a short bit from the book

Dr. Seifter meets Lyla, a young West Indian woman, who has end stage renal disease, diabetes and AIDs. Lyla went missing after her first dialysis appointment where she was prepped for future treatment. When Seifter next sees her he asks how her blood sugars are. She doesn’t know. They take out her meter and he helps her test, which she doesn’t know how to do. 183, “That’s not so bad,” he says. And then he realizes he has not put on gloves and this is probably the first time in years Lyla has had blood taken without someone wearing gloves. Seifter thinks of referring her to the dietitian, but does not when he thinks how culturally-insensitive she is. She will only hand Lyla the same standard diet she hands everyone. Instead he asks Lyla what she eats. When she tells him rice, beans and potato chips he asks her to match her carbohydrates with protein and make her portions a little smaller. He asks next how she’s feeling about dialysis, “I’ll try it,” she says.

Connecting with the patient, not the illness, is one of a physician’s greatest tool. Yet, it is not what’s emphasized in medical school In fact, I recently spoke with a physician who told me in a way humanity is trained out of  medical students. 

This book is written for patients and physicians alike. There are the stories and interwoven many of Dr. Seifter’s insights. For instance Seifter encourages doctors to help their patients be more imaginative and playful when considering treatment options. Doctors, he says, are instrumental in giving patients confidence, even permission, to keep going. If a doctor, for instance, doesn’t clearly encourage treatment a patient may hear, “Don’t do it!” 

If this is your cup of tea, as it is mine, you will take away a great deal fromAfter the Diagnosis. 

It doesn’t matter that it’s almost over, what matters is that you know something about kidney diseasebecause poorly controlled diabetes is a major contributor. 

Chronic kidney disease is a diabetes complication that usually takes 10 or more years to develop, and if your blood sugar and blood pressure are not well managed, you’re at risk.

The kidneys sit just under the rib cage in the middle of your back. Their jobis to filter waste and water from the blood, regulate blood pressure and maintain the proper balance of salt and minerals in the blood. When your kidneys are impaired wastes build up in the bloodstream making you feel sick and lead to high blood pressure, weak bones and nerve damage. 

Early kidney disease has no signs or symptoms so you should get a blood test every year that  indicates how well your kidneys are working. You should also have your urine tested to check for albumin, a protein that leaks into the kidneys when there is damage.

Symptoms you may begin to feel as kidney disease progresses, is more frequent urination,  particularly in the middle of the night, your urine may be foamy or bubbly, it may contain blood or you may feel pressure while urinating. Your may have swelling in your legs, feet, face or hands, feel fatigued, have a rash or severe itching, nauseaus or vomit, feel short of breath or more.

While you’re calling your doctor to make an appointment for your tests, you can take the National Kidney Foundation’s Kidney Quiz! right now to see if you’re at risk. 

Kidney disease is usually treated with an ACE inhibitor or ARB to slow damage. You may also need to cut down on eating protein. Of course, kidney dialysis is used when the disease is severe. Check here for more information.

Just looking into this, I realize the more you can do to avoid kidney disease, the more you should. Now I can’t wait to see what April is national month for…

I thought it was way cool while zoning out last night in front of prime time’s soap, “Grey’s Anatomy” to hear the words the “Ricordi chamber.” 

There I was wondering would Meredith make Mr. Dreamy realize she’s not just his wife but a fine resident? Would Calli ever stop screaming about her pregnancy? Would Mark ever tell Lexie about the baby he’s fathering? Then while Dr. Bailey’s performing surgery that Lexie’s twittering about in the background – much to the consternation of the Chief – someone either in the operating room or via twitter says they need a “Ricordi chamber.” The Chief looks doubtful but a twitterer (I think, because now I’m leaping over to my computer to send a fast email about this) helps them realize the viability and that there’s one down the road at a nearby hospital.

The Ricordi chamber is the creation of Dr. Camillo Ricordi, Scientific Director at the cure-focused premiere Diabetes Research Institute. The Ricordi chamber extracts healthy beta (insulin-producing) cells from a damaged pancreas that can be used for islet infusion. 

I interviewed Dr. Ricordi a few months ago on the Huffington Post, where he spoke about the Ricordi chamber, and much to his dismay having it named after him.

Dr. Ricordi: One night they were discarding a pancreas at the university. I waited for everybody to leave the lab and did a secret experiment. I thought if it doesn’t work I won’t tell anyone. If it does I’ll tell my boss. It worked, and within a few weeks all the engineers at the lab switched to this new procedure I’d tried. It’s based on a chamber.

Riva: This is the Ricordi Chamber?

Dr. Ricordi: Yes, but it was not my idea to call it that. I had called it the Automated Method.

Riva: How did you come up with it?

Dr. Ricordi: Truly, I was inspired watching a log burning in a fireplace. I thought you could develop a process where the pancreas would sit inside a chamber and like the slow, continuous process of disassembling a log in a fireplace, we could disassemble a pancreas and liberate insulin-producing islet cells. At the time it was very tough to break down an organ and get the islets out. They used a very heavy mechanical device not unlike a kitchen grinder. So my idea was quite radical. People laughed, “Sure you want to put a whole organ into a chamber and have things coming out the other side!” But it worked.

My leap to my computer was to email Tom Karlya, Vice President at DRI, whom I’d recently lunched with, and Lori Weintraub, VP of Marketing and Communications. Tom emailed right back, “Cool, huh?” Lori wrote back, “Thanks Riva!”

Yes, it’s ever so cool seeing a conversation about our lives coming out of the mouths of Dr. Bailey and her team over at Seattle Grace Hospital.

In January Eli Lilly, maker of Humalog rapid-acting insulin, began supplying hospitals with a smaller size vial– 3 ml instead of 5 ml. 

I got a flier about it because I’m a member of the Association of Diabetes Educators. My curiosity was peaked to know if there’s now a smaller size available for patients?

In truth, I don’t use Humalog anymore. I switched to Apidra about a year ago. I find Apidra works a little faster for me and this means I can also use a little less. Of course, since I eat a low-carb diet, I don’t use much mealtime insulin anyway. I use about three units to cover my morning oatmeal (my big carb meal) and then about 1 unit for lunch and 1 for dinner. My carbs in those meals being vegetables and beans.

This means at the end of every month, when I have to start a new bottle of rapid-acting insulin, I have to throw the one I’ve been using away – and it’s still 4/5 full. 

So I called Lilly and asked if a patient could buy the smaller size vial. I was told a patient could ask their pharmacist to check with his or her supplier whether they could get it. 

Not a wholly satisfying answer, but if you, like me, use very little mealtime insulin, and you use Humalog, you may want to check if you can get less.