by Ivy Fung, MS, OTR/L, CDE
My endocrinologist pleaded with me to switch to the insulin pump. I'd been taking four injections a day, and she called that "a crude method of managing diabetes." The thought of being attached to an object, 24 hours a day, did not appeal to me, but I trusted her with my well-being and finally took her advice. I have not regretted it since.
I'm an Occupational Therapist and Certified Diabetes Educator. I work at San Mateo County Medical Center, in San Mateo, California. I've worked here for six years now.
I was born in Hong Kong. I've had type 1 diabetes 29 years. I was 25 when I was diagnosed, two weeks after giving birth to my eldest daughter, Stephanie. I have a younger daughter, Jacquelyn.
When I was diagnosed with diabetes, I was not in the medical field, not a clinician, so I knew practically nothing about diabetes. I would not say that I had "gestational" diabetes, because it manifested after, not during, the pregnancy, and it left me insulin-dependent. (Editor's Note: Most gestational diabetes, if it worsens, proceeds into type 2 diabetes, not type 1.)
During the first week home from childbirth, I started manifesting the signs of diabetic ketoacidosis, DKA. My husband called the doctor, my GYN, and reported my symptoms. I was very weak, and had trouble breathing. My gynecologist prescribed Valium.
I took the Valium, and, since I couldn't keep any food down, I was on a liquid diet of orange juice and dark vinegar steeped in sugar. I did not eat the ritual Chinese "post-maternity cleansing" concoction: hard boiled eggs, ginger, and pig's knuckle.
My DKA was "DKA-ing," to a definite degree, shooting sky-high. My husband called the doctor back, and reported that my symptoms were getting worse, and finally, the GYN said to stop the Valium and take me to the Emergency Room. I remember passing out in the car, on the way; I was in such misery. Then I woke up in the ICU, where the attending physician immediately diagnosed type 1 diabetes.
Upon discharge from the hospital, I started going to a reportedly reputable endocrinologist who treated my type 1 diabetes with a single shot of NPH per day. I visited him every quarter; he did my fasting blood sugars, took my vitals. and did a gross visual check of my arms and legs. My A1c, lipid panels, et al, were never monitored. I remember being asked if I wanted to perform self-monitoring of blood glucose. I said "No," and the subject was dropped. I asked him about complications, and was given the impression they were inevitable: "We're all going to die someday."
In 1989, after 17 years with a major jeans maker, I was laid off from my job as a production/scheduling supervisor. I'd come to this country from Hong Kong as only a high school graduate. After going through an extensive career search, I started college at age 40, with the goal of becoming an occupational therapist.
It happened when I had to take a physical exam, for an occupational therapy aide job. The tests included a random blood glucose reading, and mine was "off the charts." My blood sugar was somewhere around 1000. I went back to the doctor, who called it a "fluke."
Through friends, I found a new endocrinologist, Dr. Sherna Madan. She put me on a whole different self-management regime. Then she took my A1c, and it was 11.1, very high. She put me in the hospital, so she could get my numbers down and get my diabetes back in control. She made a lot of changes.
She put me on four shots a day, where my earlier doctor had prescribed only one shot a day -- and she proposed I use the insulin pump. I've been going to her for 12 years now.
The insulin pump mimics the pancreas, in that it delivers insulin continuously to your body, 24 hours a day, seven days a week -- but it does not self-adjust, and it does not replace self-monitoring of blood glucose (SMBG). In fact, one essential requirement for a pump user is that she has to be willing to test herself a minimum of four times a day, every day: before each meal, and at bedtime. Also, it is very important to test before and after exercise.
The pump is a sophisticated little machine about the size of a pager, weighing as little as 3 ounces, and can be worn externally on a belt, or hidden under the clothing. Fast-acting insulin (Regular or Lispro/Humalog) is delivered to the body via a very fine infusion cannula, inserted subcutaneously into the abdomen. This infusion set has to be changed every three days, to minimize skin infection.
To cover a 24-hour day, the user can program several "basal" rates of continuous insulin delivery, set to fit different needs at specific blocks of time. I set mine to deliver 0.5 unit/hour during the early morning hours, to offset the rise in blood sugar known as the "Dawn Phenomenon." I reduce it to 0.3 during the day, because I am most active, at work, and I need less insulin. My current total basal rates add up to a total of 7.8 units a day, which can be adjusted at any time, as necessary.
In addition to basal rates, I also deliver "boluses," specific doses to cover a meal. I do carbohydrate counting, to compute the size of these boluses, and use them to cover meals, snacks, and to adjust high glucose readings (there is a ratio based on an individual's height and weight).
Pump users generally use less insulin than those who inject with syringe or pen. My daily dosage, for example, is about 22 units a day. As pump users run a higher risk of hypoglycemia than "injectors" do, it is critical to regularly self-monitor blood glucose. Also critical for pump users are cognitive skills, maturity, self-discipline, and dedication.
Insulin pumping is intricate, and many factors must be considered. But, for all the work, it does give type 1 diabetics very fine control, and a lot more flexibility in their daily activities. On rare occasions, a type 2 will be prescribed a pump, but only when a combination of oral medications and insulin injections proves insufficient.
In my work at the hospital, I often treat patients who have a "secondary diagnosis of diabetes." Occupational therapists like me teach people with disabilities to return to their maximum level of independence, in self-care and all other activities of daily living. This may, for example, include teaching a stroke patient in range of motion, strengthening, coordination, and functional use of the hemiplegic arm to do self-monitoring of blood glucose. It may involve instruction in foot care with the use of equipment, perhaps compensating for visual deficiencies or decrease of sensation. Activities of daily living may involve logging of meals, blood glucose readings, and stress management techniques, to name a few.
I am fortunate that my manager, Diane Prosser, supports my passion for diabetes education, and sees the relevance of incorporating it into my work as an occupational therapist, i.e., teaching people with disabilities to use their skills to reach their maximum level of function in self-care and activities of daily living.
I feel so strongly about empowering patients through education. To survive the demands of diabetes, diabetics need to strengthen both physically and emotionally. Learning, acquiring new self-management skills, and then using them, helps; but emotional coping is strengthened when patients take more responsibility for their own well-being -- and education helps that.
Diabetes care is a daily challenge. It takes a lot of discipline and self-motivation. There are some days when you feel like giving up, and there are some days when you're so happy to be healthy. But on the days you feel like chucking it in, on those days, give yourself some slack. I think the empowerment that comes from education is very important, and I think families play a big part in the health, support, and welfare of diabetics. It makes such a big difference.
It can be a struggle. Diabetics have told me they have days when "nothing works." There are days when I, too, feel like throwing in the towel. But I try not to be judgmental, or to use words like "cheat," for a departure from your meal plan. In fact, many of the old rigid rules are now obsolete. Diabetes educators are currently teaching people that it is allright to incorporate "sweets" into your daily diet, so long as they are accounted for in the meal plan.
Don't let diabetes control your life. Fear comes from not knowing. Knowledge is powerful. The more you learn, the more control you gain over your own well-being.