The Thirsty Nurse

CDE exam eligibility is HERE! I am a nervous wreck and haven't submitted my application yet. I ordered some diabetes flash-cards and have been reading everything I can get my hands on, but I am still a TOTAL WRECK!

Fish!

I love the story behind the book Fish Tales. I’ve read every self help / self esteem book there is on the market to improve the makings of me, but Fish tales is about being alive and fully authentic  at work, which ultimately translates into everyday life. The concept sounds easy, but so few people put it into practice.  I find happy and successful people are a source of inspiration. That’s exactly what Fish! Is about. It’s not a ten steps to improve your life or a system on how to fake it until you make it. It’s about creating a positive environment and culture at work and in life. Fish! Is about making your life work for you. I think this philosophy definitely carries into the diabetes population and especially the medical profession. Here’s the basis of the Fish! Philosophy:

PLAY

MAKE THEIR DAY

BE THERE

CHOOSE YOUR ATTITUDE

I am going to create a scrapbook page for my work locker with the Fish! Philosophy in mind. Why not? School is over and I have to entertain myself.  It sounds much more pleasant than my usual thought for those who think the walls of work are a complaint tank:

“JUST SHUT UP AND DO YOUR FLIPPIN’ JOB. “

The Fish! Philosophy is much more professional. I am going to embrace it and run with it. I even like it as a lesson for my girls.  http://www.charthouse.com/content.aspx?name=home2

Diabetes Mystery Machine

One of my favorite things about diabetes is analyzing the blood glucose numbers and identifying the problem area(s). It’s like putting the pieces of a puzzle together. My preceptor in the endocrine office was great at throwing a chart my way and asking me to use my critical thinking skills to determine what I would change in a patient’s care plan. The best part of being a ‘student’ in this situation is if I royally screwed up it was completely irrelevant! There are definitely perks to being a student.

So here is what Gayle (APRN) would do:

 

IDENTIFY THE PROBLEM AND SUGGEST A SOLUTION

Type I diabetic on insulin pump

Breakfast	Lunch	Supper	Bedtime
254	175	235	190
172	223	214	180
278	197	195	176

 

PROBLEM:  Blood sugars are high across the entire day

 

SOLUTION:  Use basal insulin more aggressively

 

Yes, this is an easy one. There are lots of cases of interpretation and pattern management that threw me for a loop. It made me feel better now and again when a case would through Gayle for a loop as well and she would consult Dr. Lassman. Sometimes diabetes just doesn’t make sense. Numbers don’t always give the key to the solution, which is why patients see their providers consistently to discuss lifestyle, stressors, dietary intake, illness, etc. Diabetes reminds me of a mystery to be solved with new clues at every visit. I feel like Velma in Scooby Doo. If only I had a Mystery Machine!

 

Diabetes Texas Style

Interview with Mary, RN from Texas Children’s Hospital.

 I met Mary at the Core Concepts of Diabetes Course in Boston this past February. She was kind enough to be my blog interview guinea pig. I emailed her the questions and she kindly sent them back!  Thanks, Mary!

1.    How did you get involved with diabetes?

I was looking for a job that involved considerable education to tap into my desire to teach others. Nursing always includes educating others, but diabetes education is intense.

2.    How long did it take you to become a CDE (Certified Diabetes Educator)?

I worked in diabetes education for 9 months prior to attending the Core Concepts of Diabetes Education in Boston, MA in Feb. The course helped prepare me the CDE exam. I took it in May and I passed!

3.    What did you find the most challenging part of becoming a CDE?

Obtaining the experience necessary to qualify for the CDE exam. I applied a few times before finally being getting a job as a RN the hospital was willing to train. How do you create great educators if you don’t hire ‘green’ staff?

4.    What type of patient population do you work with?

 I spend a lot of time with type I and type II diabetics that are new onset.

5.    What are the most common questions and concerns you troubleshoot on a daily basis?

Parents are often concerned about their child being “different” or “labeled” and not having the same opportunities as other children because they have a chronic illness. The other common concerns are related to complications. They want a crystal ball predicting a happy and healthy diabetic future. It’s a difficult conversation to have.

6.    Where do you even begin with diabetes teaching for a child and their family?

 Families are fairly overwhelmed when they first come to see us. We start out with personalized questionnaires to assess their learning needs, their priorities, questions and fears. Our goal is to empower families to feel like they are in control in a situation where they often feel powerless and frustrated.

7.    So a doctor has prescribed an insulin management plan for the child. How do you determine if the plan is effective?

 Blood sugars are done an average of 5 times a day and more frequently in a newly diagnosed patient. We like to have at least a 24-48 hour log to work with in order to know whether the child is responding to the type and timing of the insulin. It’s a process that takes time and patience. 

8.    How do you talk specifically to the child about diabetes?

We explain to the child that they are not “sick” but that their pancreas has stopped working. Obviously, the education is age dependent and we make sure it is developmentally appropriate. We share great books about diabetes. We arrange meet and greets with other diabetic patients and families. We offer support groups. We encourage children to look at diabetes as something they need to manage rather than an illness that is making them sick.

9.    What is the most challenging aspect of diabetes education?

Many of the kids are fearful, but their ability to adjust to diabetes is incredible. They truly are a resilient breed. It’s the kids that keep coming back to us through the years that can be the most challenging. They get tired of having diabetes. They don’t want to check blood sugars, take insulin, and watch their food intake. A lot of times its normal child or adolescent behavior, but sometimes it’s tough to decipher between depression, acting out, frustration, etc. We are hypersensitive to their issues because their mental attitude has to be looked at from many different angles.

10.   How do you offer ongoing support to patients and their families?

We have extensive resources within the hospital and community contacts. We offer support groups and encourage contact with other families having children with diabetes. We offer reassurance that we are only a phone call away 24/7. We try to involve as much of the team as possible (child life, MD, RN, siblings, social work, etc.). Diabetes is an emotional roller coaster and we want them to know they don’t have to ride alone.

 

Thanks, Mary! I appreciate the time you took to answer all my questions. Hope to make it to Texas Children’s someday to visit and exchange knowledge over happy hour cocktails like we did in Boston.

The best part of nursing conferences……………making new friends with amazing knowledge and varied experiences. I bet you all thought I was going to claim ‘happy hour’ as the best part. LOL.

Political Affiliation: Diabetes?

What do diabetes and politics have in common? This is the question I asked myself during a clinical rotation one day when, much to my dismay, the conversation turned political. What do I know about politics? Bits and pieces of other people's conversations as well as some very non-specific data.

For starters, I am aware that all causes can benefit from political support and publicity. Awareness creates teachable moments. An informed public is key to innovation and funding $$$$! So even though the root of this post is actually old news I am writing about it for three reasons:

1.    During my clinical affiliation there was considerable talk one day about Sonia Sotomayor

2.    I avoid political discussion at all costs because it’s not something I am passionate about. Honestly, it bores me to tears!  

3.    I didn’t feel I could contribute to the conversation because I didn’t even know who Sonia Sotomayor was (yes, I am sheltered and forget to crawl out from my rock once in a while)

It wasn’t until the discussion turned to Sonia Sotomayor’s Type 1 diabetes as a potential handicap in her nomination for the Supreme Court that the political conversation caught my attention.

I chimed into the and asked some questions about Sonia. My colleagues laughed at my lack of knowledge regarding this major political media buzz. They suggested I turn on the TV once in a blue moon, but I flatly refuse. However, I did vow to start reading some political print now and then since June has arrived and I can put away my nursing books!!!  The cost of textbooks can be replaced with a subscription to the NY Times!

Anyway, the conversation alluded to the possibility of Sonia Sotomayor being discriminated against for being a Type 1 diabetic. My eloquent response (ha ha)…………….HUH? REALLY?  THAT’S SILLY. In this day and age, how is a medical illness considered a potential danger to someone working a desk job? She injects insulin, not illegal drugs!  Ugh!  Politics! I am going to crawl back under my rock (at least for today)!

 

Diabetes Pharmaceutical Representative!

Working in the endocrine office has given me the opportunity to see what the pharmaceutical sales reps do. I am married to a former pharma rep and often wondered how he spent his days at work. Of course, I know the basics of what my husband did everyday, but it’s totally different to see someone in action while in the midst of their career. What intrigues me even more than how a rep spends his or her days is how they interact with the staff and the patients. My husband used to tell me relationship building is key in the pharma world and now I can completely agree with him.

Last week I met a great rep from Novo Nordisk. Unfortunately, I didn’t grab his business card! He was impressionable, knowledgeable, patient, and very handsome I might add! Don't worry Morgan (husband).......you are still the love of my life! The Novo Nordisk rep impressed me because he was offering diabetes education rather than focusing on his bottom line. Of course, his job is to market Novo Nordisk products, but there is a balance between sales/marketing and relationship marketing. The Novo Nordisk rep made me feel like I was his customer and not just an end to a mean. He didn't need to speak with me, but he took the time to do so because we had similar interests:  DIABETES CARE!

It made me start thinking about my career path in diabetes education. Pharmaceutical Sales Rep? Why not!? I have a BSN now (actual date diploma will be in hand is June 24th) and I have the desire to fuel my career in an innovative path. Would I ever leave clinical nursing? No way! But I would love to utilize my motivation and passion in new and exciting ways. As a pharmaceutical rep I might actually have the funding necessary to work on community outreach projects!!!!  Awesome!  I would also be able to share my passion with others in the industry and help make a difference in the diabetes world. Wow!

So thank you, Mr. Handsome, kind, intelligent, and patient Novo Nordisk Pharmaceutical Rep. You have inspired a potentially new and exciting career path for me!

Check it out............Novo Nordisk is hiring. Perhaps it's meant to be! With my energy, passion for work, and awesome relationship building skills I guarantee my territory would thrive!

Resume submitted!!!

Potential Problem:  Dressing up everyday. Ugh!!!  I am so used to the luxury and comfort of scrubs. Control top nylons and Spanx undergarments..........here I come! I draw the line on high heels. As a diabetes care advocate it would be disrespectful to wear shoes that are

 not good for my feet!!!   

Diabetes Documentation Dinosaurs

 

 

 

One thing that has struck me during my diabetes clinical rotations at Saint Fran --- the staff endure documentation methods that went out with the dinosaurs!  Paper charts, old school documentation, MAR's, tape recorded dictation. OMG! I work on a unit that is dedicated to electronic medical records. I LOVE the rapid changes we are seeing in health related technology and everything it offers to the nursing world. I guess I have taken for granted the advanced technology I work with everyday. Since OB is a big money-maker for the hospital we get to be guinea pigs for all the latest and greatest stuff! EMR's (electronic medical records) offer device integration (systems that talk to each other) to reduce duplicate charting, systematic data collection, and smooth workflow allowing for providers to communicate with each other and work simultaneously on a single patient case. Are there drawbacks? Absolutely! A nursing shift can be deemed a disaster once you've adjusted to working solely in the cyber world. Troubleshooting computer issues is another non-nursing function to add to list of responsibilities above and beyond an already overloaded day. However, the troubleshooting time is well worth the effort. Watching the practitioners in the diabetes center work with paper charting seems so archaic and time consuming. It's exasperating! Their workflow could be improved tremendously with EMR's, bar-coding for medication administration, and laptops or COWS (computers on wheels)! It's time for the cyber dinosaurs to become extinct!

 

 

The CADE Chronicles

Connecticut Association of Diabetes Educators (CADE)

Sally Cooney, RN, CDE from the Saint Francis Hospital (my second home) was kind enough to bring me as an honorary guest to the Connecticut Association of Diabetes Educators meeting on Thursday, April 29, 2010, at Midstate Medical Center in Meriden.  I was very excited about the opportunity to network with the local entourage of diabetes educators after the positive and encouraging experience I had in Boston at the AADE Core Concepts course.

The CADE meeting appeared to be well attended including a lot of pharmaceutical reps who kindly provided a lovely meal (yum)! Part of me wanted to hand out my unemployed husband’s resume to all the pharma companies, but I restrained myself (lol).  

The meeting started off late (30 minutes) so there was time to navigate through and meet some new faces. The introduction process was a bit slow and I was quickly reminded I was surrounded by a bunch of New Englanders at heart. I am a native New Englander, which makes it acceptable for me to recognize there is an inherent attitude, ironic pessimism, and dry humor that comes with the territory. It’s not meant in a negative light, but it does not equate with super warm and fuzzy either.  It took me a minute to recall that the AADE conference in Boston was a myriad of travelers and the ones I had bonded with were from Texas, Tennessee and Kentucky --- the heart of warm and fuzzy.  So I continued on with my attempt at enthusiastically introducing myself and making connections until one woman said, “So you want to be an educator, huh? Are you African American? We need moreAfrican American educators?” I wasn’t sure how to respond. It didn’t appear to be a joke and my thoughts were confirmed when she said again, “Are you African American?”  My hair is super curly without my friendly straightening iron, and I have plenty of junk in the trunk (excuse the stereotypical reference), but other than that I am about as white girl as they come!  I politely said, “No,” and walked away.  I introduced myself to several people, but I have to admit feeling a general lack of interest from others. I was nervous to blog about the reality of my experience at CADE, but decided it is important to translate my perception into words since my perception is my reality. The CADE group reminded me a bit of a sorority where initiation is high priority and you are not ‘in’ the group until proven otherwise.  I never belonged to a sorority and have no desire to either.

 I will definitely not discount becoming a member of CADE once I am an educator.  I think it will be interesting to see if the analysis is different once I make the transition from guest to member.  It is not necessarily fair to judge the dynamics of a group when you are on the outside looking in. I realize it is a volunteer process requiring time above and beyond the traditional commitments of work and family. I appreciate the passion CADE members bring to the table and someday, I hope to be on the inside looking out. Perhaps I can head a welcoming committee!

Diabetes Vacation

I can imagine it is every parent and diabetic child’s dream to take a diabetes vacation. Imagine whisking your child away for a week without testing supplies, pump supplies, carb counting or emotional meltdowns. What made me think about this? Well, we spent a few days at the Cape last week during school vacation.  I took a hiatus from clinical work because I got to experience first-hand what it’s like to live with a child who has diabetes.

Meet Tess. Tess is a 6 year old, type I pumper.

She is a feisty little thing, hence the appropriate name of our JDRF walking team, “Don’t Mess with Tess!”  She is well adjusted to life with diabetes at this point. Does she like it? Hell no! But she handles it with grace most of the time. I think her parents (AKA: diabetes managers) endure considerable stress with Tess. Diabetes leaves a lot of unanswerable questions. For example, When Tess is acting out is it because she’s low or is it because she is being a typical 6 year old brat? How to you truly decipher between the two? Blood glucose fluctuates so quickly and Tess is too young to recognize and associate her emotions with her highs and lows. Diabetes is a tough battlefield and one that seems like it may never end. As a parent of a child with diabetes, how do you stop worrying? When do you loosen the control reigns and allow the child to start to manage their diabetes? How do you separate the child as a person from the child as a diabetic? The child rearing and the diabetes management must get enmeshed constantly, yet they are unique to themselves. Then there are sibling issues.  How do you stop the big sister from being the diabetes police? Then there’s a scary glimpse into the future……..Tess might be screaming for ice cream and potato chips now, but what about when she decides to experiment with alcohol or insulin manipulation related to body image issues, or wants to go to camp? OMG! That’s a lot of information to process. I guess you have to take diabetes in stride, one day at a time. Even if each day seems to focus around the contents of a diabetes kit (see picture of Tess with her Animas One Touch Ping Insulin Pump in her pocket and her diabetes testing/supplies kit below).

Our trip made me realize diabetes creates a unique dynamic within the family system. Tess has awesome parents and a caring big sis so the emotional rollercoaster appears to be a fairly steady ride, but it seems like the family will be on the coaster forever. Unfortunately, they can’t exit the ride and leave diabetes behind for the next passenger.  Until that day comes, we’ll keep walking and riding for a cure.

Tess and her family taught me a lot in the short time we were visiting.  I felt tremendous appreciation towards the freedom I have with food choices for my girls. Rather than being annoyed at the statement, “Mom, I’m soooo hungry,” I find myself thanking my lucky stars I don’t have to count their carbs, ration their chips, limit their ice cream, do “checks” (fingersticks), manage pump wizards, and wonder about numbers all day and night. We often take for granted the simple things in life!

Our next JDRF walk for a cure is October 2010, in Boston, MA. Last year, Tess thought her diabetes (diabeters, as she calls it) would go away if she finished the walk in 2009. Tessie is too cute! Tess, we would all walk across the country if it would cure your diabetes.

Join in the JDRF fun!  www.jdrf.org

Diabetes Gold Mine!

I feel like I hit the jackpot this month. After spending several days with Gayle Looby, APRN at Saint Francis Hospital Endocrinology Office, my craving for more hands-on diabetes related experience from a practitioner point of view is intense! I am already way over my required clinical hours for school, but I keep going back for more! I feel like Gayle is the pot of gold at the end of the rainbow. My whole journey has been brilliant so far, but Gayle is the jackpot. She is my ultimate role model in the nurse practitioner world. Her office days are crazy busy and I thrive in that environment! Each patient reminds me of a unique jigsaw puzzle….some need to be guided from start to finish while others only need a little tweaking. It’s a fascinating use of brain power, nursing skills, patient care, and relationship building.

 I don’t even know how to begin to summarize everything I have learned so here’s a brief synopsis of my favorite events:

Mr. R, 80 year old, Type I, HbA1C 6.7

A bit of a maverick, this man refuses to count carbs. However, he eats consistently, golfs consistently, and takes his insulin with a correction factor. He takes humulin 20 units in the AM and novolin 40 units before supper. He corrects 1 unit for every 10 points over 100. He has plenty of energy and enthusiasm and asked Gayle to prescribe him something to make him 40 years younger so he could ask me on a date. Lol!  All the old men seem to love me. I think it's because I am always smiling.

Mr.R's diabetes process seems a bit unconventional, but apparently it works?

Mr.RC, 45 year old,Type 1, Novolog Pump, HbA1C  7.4

This really through me for a loop. Mr. RC’s download was impeccable. Here were his daily totals:

Total Insulin   Average Blood Glucose

49 units 87

58 units 112

60.5 units   132

63 units 120

48.3 units   98

65 units 103

64.8 units   103

60.9 units  129

64.9 units   144

58.7 units  124

60.7 units       143

Here’s where diabetes must frustrate those living with it. Mr. RC’s numbers are great. Why is his HbA1C 7.4?

Does he need his basal rate adjusted? How would he know? Well, he needs to check his blood glucose before bed, but avoid giving insulin or taking in food unless the result is <70. Then Mr.RC needs to get up in the middle of the night and repeat the process. Upon awakening, Mr.RC needs to check his blood glucose again. Based on these unadjusted numbers he may be able to tell, in the absence of food, exercise and mealtime/bolus insulin, whether he needs to adjust his basal rate since the goal of basal insulin is to hold the blood sugar fairly steady. Wow. Sounds like fun, huh?

Next on the checklist for Mr.RC  if his HbA1C doesn’t improve at the 3 month follow up:  Dexcom!

 

Mr. C, 40 year old, Type I, Medtronic Pump (mini-med paradigm 722), CGM sensor x 14 days

Where do I even begin? Mr. C cracked me up. He shared his food journals with me, pulled off his pump and showed me all the ins and outs, and laughed when I asked him about the four cookies he listed at a total of 25 grams of carb for ALL FOUR scrumptious, homemade delights. Next time he promised to eat one and bring me the other three. Lol!  I learned lots about the perks and self proclaimed manipulation of the pump’s bolus wizard. Mr. C’s raw honesty was entertaining to say the least.

We had fun downloading all his stuff with help from the Medtronic rep and analysis by Gayle Looby, APRN. The Medtronic rep gave me my own insulin pump to play with and it was PINK! My FAV color. How awesome. At least if you have to attach yourself to something it may as well have flare, but Ido thank God I am not in need of that little pink accessory. Anyway, the boat load of information was impressive. Pie charts, graphs, adherence reports, snapshots, device settings….the list goes on. All in reference to two weeks of Mr.C’s data. What a phenomenal way to obtain accurate information for devising an optimal plan of care. Anything electronic medical record related is right up my alley. From the mass of information Gayle was able to determine Mr.C needed to change his carb ratios and insulin sensitivities. Amazing data!

Mr. J, 49 year old, Type I, alcoholic, morbidly obese

Here’s where primary care issues jump started my heart a little. Enter Mr. J, a morbidly obese gentleman recently discharged from the hospital. To make a long story short, he presented with complaints of leg pain. I asked him to remove his shoes and socks. Imagine my surprise when the picture below (taken from Google images, not actual patient photo) is almost identical to what I saw.

I kept my cool, gasped for air and called for Gayle’s assistance. This was way beyond my expertise, but what a learning experience. Mr. J went back inpatient. Both is legs looked like this from below the knee and touching them felt like fire.

Last, but not least, days with Gayle have taught me a lot about various disorders and the importance of treating osteoporosis. The majority of patients are on an oral bisphosphonate (Actonel, Fosamax, Boniva), but some take injections (Forteo), or intravenous (Reclast).  Considering my husband, Morgan worked for Procter and Gamble Pharmaceuticals for 8 years promoting osteoporosis drugs you would think I would have a strong working knowledge of all this information! Perhaps it is time I opened my ears and listened to what he has to share on a topic he spent hours and hours studying!  Then maybe I could carry on an eloquent debate about the pros and cons of them all.

Alright, this diabetes gold miner is worn down and ready for a nap!