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Scott Benner 0:06
Welcome to the juice box podcast. I'm your host, Scott Benner. I first interviewed Jenny Smith, the CDE from integrated diabetes back in season one on episode 37. At that point, Jenny and I were just talking about different management ideas. But it was then that I realized how much we agreed about type one diabetes, and the management of the disease. I brought Jenny back on in Episode 105. And we really drilled down about a one sees what they were and what they weren't. After that second interview with Jenny, I decided that one day I would have her back on to discuss all of the diabetes management ideas that come up on the show, I wanted to break them down into small categories, something that was easily digestible, where we'd stay focused on just one idea, I wanted to create something that you could come back to, hopefully learn from, and if you found useful share with others simply. And so with that in mind, I give you the first in this 10 part series, diabetes pro tip for the newly diagnosed for those wanting to start over with Jenny Smith CD.

Please remember that nothing you hear on the juice box podcast should be considered advice, medical or otherwise. And always consult a physician before becoming bold with insulin or making any changes to your medical plan. If you're a newly diagnosed person with Type One Diabetes, or the parent of someone who's been newly diagnosed, what do you think the first things to understand our

Jennifer Smith, CDE 1:49
first things to understand beyond the glucose values are? What does insulin do? How does it work? I think that's it's a huge one that is it's under, it's under emphasized, I guess is the best way to put it. Many people, especially adults who are diagnosed are kind of given a this is your insulin, this is the dose to take and kind of go experiment at home. I feel like that's kind of the way that it is. And I think insulin is a first most important thing to really understand. How does it work? what's what's the purpose of it? How is it supposed to kind of finish working? And what is the effect for you?

Scott Benner 2:37
Okay, and so what are some, like bare bones ways to come up with those understanding. So I think, obviously, if you have a CGM, it becomes different, right? If you have a CGM, you can get yourself at a stable spot where you haven't had insulin or food for a while, and just give yourself an amount of insulin, see how it moves you? Let's talk for a second about like old school, do you still teach people that they need to do bazel testing?

Jennifer Smith, CDE 3:02
in a general way? Yes, I think especially for pumping is helpful in the beginning, because it does in that bazel only time period, it does give you a general idea of how things are being kept with the rate that that play, I do think that bazel testing needs to be more explained, let's say, when we are talking about pumping insulin, though, because there are as you know, a lot of variables that could be at play in that Barrett bazel testing time period, especially like from from a woman's standpoint, it could very much be that it's not the right time of the month to be bazel testing. Right? Right. Right. So all of these variants, or, or a kid or a teen who is a kid or a teen who is really athletic. Right, and there is a consistent effect of activity level. And it may be different on different days, but there could be overlap from a day ago that you had for our practice or a tournament. So bazel testing, as a general idea, yeah, it can be a really good place to start, especially if you think things are really off in a certain place of the day. But is it the end all be all of knowing where your insulin should be? Not 100% of the time and so

Scott Benner 4:28
so what I end up telling people when I speak with them, is that you know, if you're having an issue and that issue could be anything like you're spiking at a meal, or you're you know, drifting high all the time, or you're incredibly high all the time, you know, any of those things. You have to first look at your basal insulin. It's it's absolutely falling away. The first thing I have to apologize to ardens texting me and I believe she's trying to tell me, it's lunch. Okay, so lunch question mark. So Arden has been sick the last couple of days and probably already kind of resistant like to, to her insulin a little bit. But we are ahead of it now. So she's 106 and stable now. But to give you an idea, she woke up at 110. By the time she was getting dressed, she was one to one. He then was this diagonal up, I bolused a unit and doubled her bazel for an hour. And 30 minutes later had to bolus two more units to get her back to this 106. Now, she never got over about 150. But she sees that rise every morning like that, that little bit of a rise. But this morning, I used I'm going to save three units more than I would normally use. Yeah, it's just because she's not feeling quite well.

Jennifer Smith, CDE 5:40
Again, another reason that bazel testing things like this is not it's not purposeful. In fact, I think, you know, a lot of people try to overcome that morning time rise with a bazel adjustment. But what happens then when you wake up at a different time of the day, right? Or you have a variable schedule, so a lot of times I actually tell people, you know what, let's look at what the rise is. Don't correct it. Let's, let's watch the rise. Let's figure out how much of a rise Are you consistently having, you know what, we can offset it with a with a dose of it of bolus. Sometimes that actually hits the mark better than trying to incrementally adjust a bazel behind the scene that could actually change day to day.

Scott Benner 6:26
Right, right. Okay, so now this is um, this is really interesting. Do the 10 way to like tell you what just happened. So this is kind of hilarious, but my wife is here. I'm gonna have to walk away for a second. Yeah, back. Arden's pump only has 10 units left at it. And no and and just and her lunchtime bolus is going to be 12 units. So I just had to do a smaller bolus as a pre bolus still. And I'm going to send my wife over to like swap.

Unknown Speaker 6:56
I'll be Oh no, let me go ahead.

Scott Benner 7:01
The dexcom g six CGM is now FDA permitted for zero finger sticks. That's right, the continuous glucose monitor that Arden has been using forever, does not require calibration from a blood glucose meter any longer. But do you know what it does do? It allows you to see your blood sugar, speed and direction. Are you rising at two points a minute falling at three points a minute, the dexcom CGM will let you know with customizable alerts. And if you're the caregiver or someone who loves someone with type one diabetes, and you'd like to be able to see their blood sugar when they're not with you, that's possible too. Because dexcom has a share and follow feature that is available for Apple and Android. My daughter's in school right now. We just gave her insulin for her lunch, and I can see her blood sugar, her blood sugar started to creep up on us a little bit. So I got an alert and we added some insulin stopping arise. The dexcom g six features an applicator that is virtually painless. My daughter says she can't feel it at all. And it's completely automatic. One button push and the sensor bed has been applied. You snap in the transmitter and you're on your way. You can see your blood sugar's on your Apple watch or other smartwatches on your iPhone on your Android phone. You can share it with anyone in the world anywhere. I can tell you without hesitation that the dexcom continuous glucose monitor is without a doubt one of the main reasons why we've been able to keep my daughter's a one c between 5.2 and 6.2 for five continuous years. To find out more go to dexcom comm forward slash juice box with links in your podcast player show notes or a juice box podcast calm. It's going to be the best decision that you ever made.

Jennifer Smith, CDE 8:48
So all is okay.

Scott Benner 8:49
Yes. My wife sits across the street. Yeah, my wife's gonna run over. She's working from home today. And it really does just go to show. I guess the fluidity that you have to keep around diabetes because Okay, I'm lucky my wife's here today. If she wasn't, I would have to tell you, Hey, I gotta go. But in the end, there's no panic here. Arden's blood sugar's 107. I wanted I wanted to do a temp basal increase of 50% for an hour and a half. And an extended 12 unit bolus for lunch. But she only has 10 units. So instead, I had her set the temp bazel still and do an eight unit extended bolus. So she's still going to have four units. Going when my wife gets there, they're gonna swap that pump real quick. And then she's gonna head off to lunch and be okay.

Jennifer Smith, CDE 9:35
Right. It'll be fine to get early lunch.

Scott Benner 9:37
Yeah, on every other day. It's at 1030 and then on the austerity

Jennifer Smith, CDE 9:41
like what if you get up at five o'clock do breakfast?

Really that

Scott Benner 9:46
sheets 1030 every other day and the opposite day sheets at 1130 and she's out of school by two. Oh, wow. Okay, it's all kind of very quick. I don't know, learning anything but. So so I think Yeah, so anyway, what I wanted to say about bazel is that, I'm sure just like you, I meet people who are having trouble, right? They're either on the roller coaster and they're going to 400. And they're going to 60 and up and down, or, you know, somewhere in that problem, they're high constantly, they're always 180, you know, they can't really seem to do anything about it. And when they get to you, they have all of these theories about why their blood sugar is too high. Right? And I tell them, your blood sugar is too high, because you don't have enough insulin, and it's not timed correctly. And we're going to start with your basal. And they'll inevitably say, Well, what about my insulin to carb like, That doesn't matter. I'm like, you can have a perfect insulin to carb ratio. If your basal insulin is not right, none of this matters, right?

Jennifer Smith, CDE 10:44
That's right. That's why we call basal insulin, the foundation of your management, it really is we, we actually tell people, it's like the foundation of a house. If you have a sound structure that you're building on top of everything you put on top of it will work. Even if the influence of carbon, the correction factor and things are a little bit off. If the bezel is off, those are going to also look like they're not working well. And it becomes impossible to diagnose what's happening,

Scott Benner 11:14
right. And so what I end up saying is that you try to imagine we use round numbers for examples, but try to imagine your bazel is a unit an hour. That's what that's what it should be. But you have it at point five. And then you have you look at some food and you say, Oh, well that food is two units. So you and let's say you're right about that, let's say you're 100%, right, that the food takes two units, you put your two units in, all you've done is now replace the bazel that you needed, right you so you're resistant, you're high, now you're replacing your bazel it's possible those two units will only go towards impacting the problems your basal insulin has, right. And then your blood sugar shoots up and you go, I don't understand, I put in the right amount of insulin, I counted my carbs, right,

Unknown Speaker 12:01
I counted my carbs. I looked at the label and I did

Scott Benner 12:04
everything The doctor told me why didn't this work. And in the end, and you know, through this series that you and I are going to do together, I'm going to repeat a couple of things over and over that I've found to be incredibly helpful. But in the end, if your blood sugar is high or low, you've mis timed miscalculated, or a combination of those ideas. And that's pretty much it, you know that I find that to be the core of it. It's not the first step to me, not being afraid of insulin is the first step. But we're gonna talk about that in a different episode. But I think that it's it's timing and amount. And I think there's a million other things that can impact your life with diabetes. But that's the seed of the tree, right? And you could throw away all the leaves and all the branches and everything that comes off of that seed, if you have that seed timing and amount, you're well ahead of the game. Right?

Jennifer Smith, CDE 12:53
Right. Absolutely. And I would say the that those two pieces actually go very well together as far as not fearing insulin, you know, and not being afraid of using it because I I certainly work with many people who that is a major problem it is I just want to eat 200 because I'm afraid to give the amount my pump is telling me to give or the amount that the doctor told me to give, you know, and I think understanding insulin is the base of that, understanding it and understanding the timing, and the action of the insulin and how it also individually works for you, helps to dissipate that fear,

Scott Benner 13:37
right? I think that I think that if you can keep your blood sugar stable at 200, then you can keep it stable at 180. And if you can do it, you can do it at 140. And believe it or not, if you can do it at 120, then you can do it at 75. And you know and so because the the tools that you use to to achieve that stability aren't different depending on what level your blood sugar is at. It's all the same. It's all the same stuff. Okay, so that's that is that's excellent. So we'll talk about fear in an upcoming episode as well.

I'm newly diagnosed, I go into my doctor's office. Now you are uniquely qualified to tell me this. What do people get told a diagnosis and why do they only get told what is shared with them?

Jennifer Smith, CDE 14:37
I think it there's a wide range of what people are told. I certainly think that the younger the diagnosis, especially for type one, the younger the diagnosis, the more education there is, the more information is provided. adults that are diagnosed I think unfortunately, get the least amount of education again And it differs system to system and provider to provider. But in the beginning, you know, they're taught how to use a glucometer. They're taught how to give an injection. And they're taught that you're going to be taught essentially, the basics of that insulin action. And you're going to be taught carb counting, that is pretty much the gist of what you're going to be taught. And anyone who's been listening to this podcast for any amount of time will know that I call that do not die advice. That's the that's the advice you get so that you don't die. It doesn't keep you healthy. It doesn't help you understand anything, it just keeps you from going home and falling over. Well, and I think another piece of that, too, is it's very, very soon in that beginning is how to avoid hypoglycemia, how to avoid a low blood sugar because insulin causes low blood sugar. And unfortunately, that's where the fear starts.

Scott Benner 15:57
Exactly. And so that's where it's that's where the fear starts, but try to understand it from the clinicians point of view, you are frazzled, I say this all the time being diagnosed with a disease that you cannot cure. It feels like someone just walked up to you with a shovel and smack you square in the face with it and then started yelling, basal insulin, bolus glucometer. This is a test strip and you're like, wait, wait, why? And so the doctor sees that on your face, and can't in I guess in their minds, they don't want to overload you. But the unintended problem is just what you said that you start with fear, then everything starts with fear. It would be a simple sentence, it would be it would be Listen, we're going to teach this to you slowly. I know that seems counterproductive, but it's not. But there's no reason to be afraid. And that's what we're going to learn. Now. The question is, do doctors not teach that because they don't have the time? Or they don't have the knowledge? Like what like, because there are everyone's gonna walk into a different endos office, you're gonna get an 80 year old guy who's been doing this, since people have been boiling their urine, right? And he's just gonna think that if you count your carbs, and inject and go to 300, and come back to 100, that's amazing. And that's that, right? Right. And then you're going to get a guy who's in his 50s, who's just starting to hear about like, other CGM stuff and and and you're gonna get different advice from them, you're gonna get different advice from a, you know, a woman who's been out of medical school for three years and has diabetes. How do you as the patient know what advice you're getting? When you don't know anything about diabetes?

Jennifer Smith, CDE 17:36
That's a very good question. Absolutely. And I think, you know, with today's technology, honestly, I, personally, as people have come to, to work with me, or to work with us at integrated, you know, it's people come, because very soon, they realize they're not getting what they need. It's not quite, they're not sure what they're missing. But they know from researching and looking and googling it, that the information that they've gotten is so just literally the tip of the iceberg, that they're missing so much more beyond and that, you know, that their doctor is saying, well, you have to be in good control for a year to be able to start on a pump. And most parents or even adults are saying, that's not the case,

Scott Benner 18:23
right? Doesn't mean

Jennifer Smith, CDE 18:24
that that's not doesn't make sense. I want to know what I should be doing. I want to know, what is the best for my child or for myself? I want to know, and I think those are some of the things that as a as a newly diagnosed, asking more questions of your provider, even though you may not know exactly what you're asking, when you've googled it, and you've researched and done some of your own searching, and even asked, you know, some people I think more and more people are there kind of they have acquaintances or whatnot, who might have diabetes. And so they, they will ask them, they'll say, well, they're doing this, you know, maybe I should ask about this. And I tell all the people that I work with, you know, what, if your providers not able to meet you or can't answer, even those basic questions at the beginning, it's it's time unfortunately, to find a new provider. It really is.

Scott Benner 19:19
And based off of that idea, I want to say I want to say the same thing to two different segments. So if you're a clinician and you're listening to this, or if you're a person who has diabetes, or is trying to care for someone who does, there's a space that a lot of people get into, they're not given enough information up front. And they're, they're paying attention, right? They want to do well they're paying attention, and they see in consistencies with what's been taught to them in the doctor's office. But because you're the doctor, or because you're looking at a doctrine, you were raised to listen to a police officer, your teachers and a doctor, you're raised to believe that a person in a white coat is infinitely more intelligent than you are. There's no reason to question them. And so when they give you these concrete laws of diabetes, you go home, put these laws into practice, and they don't give you decent results. This is for the doctors, it puts people into such a psychological bad place. It just wrenches their gut, they feel like they're killing themselves or their children. And they don't understand why. And even when common sense things about their diabetes show up, they can't bring themselves to make the leap, because you've told them or not told them anything about that idea. And I will give you a great example. And it's a very simple example,

Jennifer Smith, CDE 20:36
or kind of before your example, you know, it's kind of a cut and dry too. As you know, kind of going with what the doctor said, The doctor said to do this, the doctor said I should take my, my insulin and eat right away. Well, if that's not working, and you don't, if you don't know that, and clinically, clinicians, I think, really do need more information about what really is the real life of diabetes, what's the real life use of insulin and mastering its action and all of that, because clinical book does not mean it meets what happens at home. And when your clients come to you and your patients with their people with diabetes come to you. And they say, this isn't working. I'm following all of your rules. It's not working. And instead of saying, well, you must be doing something wrong because that that happens often, whether as a clinician you want that expression to come out or not, it does you make them feel like they're not doing something right. And you don't give him a way to to help you don't explore with them and say, Okay, I hear what you're saying, I hear that you've tried everything I've thought would, excuse me would work, right? And it's not let's, let's see why it's not working, maybe something is variable for you.

Scott Benner 21:56
And let's have more of a conversation and explain what's happening. So that so the doctor can glean more from what's going on. I'm at the point now. And I'm sure you're there, too. I can look at a 24 hour graph, and make changes in five minutes that improve somebody's life and measurably in 24 hours. I don't know why a doctor can't do that.

Jennifer Smith, CDE 22:16
So I mean, I figured I can yes, some are, some are awesome, but some are not.

Scott Benner 22:21
well enough now to know that, you know, I'm not the brightest person in the world. And I can look at it and go Okay, this is this like this. My example of how powerful the doctors suggestion or non suggestion can be to people is that I was speaking with a woman in her 40s, who had had diabetes for 25 years. I looked at her graph, she was distraught. And I said, you just need more insulin? And she said, Well, no, no, because like I said, all these reasons why it that wasn't the case. And I said No, that doesn't make sense. And in a brief 32nd explanation, over a telephone call, I could literally hear the light bulb turned on in her head and she went, Oh, my God, I just need more insulin. And I was like, right, that's it? I mean, can we go an hour, you know, but But think about, think about that. A well intended, intelligent, educated person who goes to her doctor's visits, and in 20 years, can't figure out why their blood sugars are the way they are, and no one's ever helped her. So what I'm saying to people who are newly diagnosed, or people who have gotten to that point and want to start over, you have to sort of think different, you have to, you know, if you're, if you're in a situation where you're newly diagnosed, and you've gotten some real, like what I call like old timey information, you need to think differently. And if you've had diabetes for a long time, or have been caring for someone forever, and it's not going the way you want, that's the first thing you have to do you have to say to yourself, I must not be thinking like flip it upside down, look at it all the time, I have a friend who every decision they make is wrong. And I once said to them, how come when you have a reaction to something, you just don't wonder what's completely opposite of that, and then just do that. I was like, I was like, right, you're right, you're always wrong, you know, so like, right and, and that's what happens every day you get up, you do this thing with this insulin and this pump and all this stuff, and it always goes wrong, but yet there you are the next day,

Jennifer Smith, CDE 24:19
doing it over and over and over again, which is another reason that I you know, working especially with the women through pregnancy that I work with, that's a piece of the variability that I try to encourage them to sort of work on prior to pregnancy. Okay, you know, because if you can figure out it's why many people with diabetes, eat some of the same things over and over and over again, they have a standard breakfast. I know that it works. I know that I need this much insulin, I knew we need to use a temporary bazel for this much or for you know, whatever extended bolus and it works for me, it's that's the reason because once you figure it out, you're like great. I had Like little magic is magic piece right here and I'm not gonna screw

Scott Benner 25:05
it up. Now I should have this half a piece of wheat toast two eggs over easy and two tablespoons of avocado for the rest of my life. Right? Exactly. Every morning, if that's happening to you, if you're listening, and that's happening to you, I say this proudly, the there are some low carb people who will get upset and I want to tell them right now you can eat low carb your whole life, I don't care. I'm just saying that if you ended up there because you couldn't figure out insulin. You know, if you're if you're eating something you don't want to be eating, there might be a way to manage this. But I tell people very proudly, that at this point, my daughter is 14 years old when I'm recording this. She has had Type One Diabetes since she was two. And for the last five years, her eight one C has been between five two and six, two, with absolutely no diet restrictions whatsoever. Anything you can think of Arden eats and eats frequently.

Jennifer Smith, CDE 25:58
And I bet her more important within that I think we talked about this in the a one c discussion and podcasts. But more important than even the a one C is for standard deviation, the variability, which I would estimate without even seeing her information, I would estimate that her standard deviation is very nice, meaning she's got these little gentle rolls through the course of the day, rather than this major roller coaster because you could have anyone see a 5.4 Yes, but you could have a major, you know, standard deviation. And we will

Scott Benner 26:29
talk about that in coming episodes. You can't run around with your six a one c but be at 300 half the day and 50 the other half of the day that you've just trick the one c test

Jennifer Smith, CDE 26:39
right? On the doctor. Yeah, because again, that goes back to clinician. A one CS is certainly it's a starting place. It is not the end all be all there is more in depth that needs to be looked at with that a one seat. Yeah,

Scott Benner 26:52
we try very hard. Well, you know it. As you go on and listen to these episodes, you'll realize I'm not trying that hard anymore. I figured it out to the point where it doesn't really take that much involvement from us. But Arden's low alarm on her Dexcom is set at 70. On my follow app, it's 120 for the high alarm on hers, it's 130. And so we'll talk about like bumping and nudging later on, but that's my concept is that smaller amounts of insulin as you try to leave a tight range, get you back into that range more quickly. And cause far fewer lows later. Yeah. Give me one second here, we'll take a pause. Okay, um, I'm gonna text Arden, she's now wearing a new pump. I need to know how much insulin delivered from the last Bolus. And then because it's a new pump, and she's literally going to walk right into lunch. Excuse me, I'm going to double her bazel for I was only going to do 50%. Now I'm just going to double it for an hour and a half. And that way, if there's any slow start with that site absorbing and having action I'm just going to do, I'm going to do something that at some point during these, you'll hear me talk about what I call it over bolusing like I just I imagine not just what her needs are now, but the momentum and higher number that I know is coming. In 2008 we made the decision to get my then four year old daughter and insulin pump. It's a decision that I wish we would have made years sooner. After seeing everything that was available. We easily settled on the Omni pod that was back again in 2008. Today Arden is about to turn 15 years old and she has been wearing an ami pod every day since then, every day. And as I mentioned in the other ad Arden's a one she has been between 5.2 and 6.2 for five solid years. How do we do that? Well, we start by seeing an insulin pump is more than just a way to not have to take shots. The Omni pod gives you the ability to do temporary basal rates, that's increases or decreases in your background insulin, extended boluses which will help you spread out your insulin over the life of a meal, and so much more. The Omni pod has no tubing at all. The pod is self contained, you wear it on your body, and you control it with a wireless controller. So there's no tubes running through your clothing and no pump that you have to jam in your bra down your pants or wherever people have to put their palms that just doesn't exist with the Omni pod. What does exist is the ability to swim while you're getting your insulin bathed while you're getting your insulin and live life untethered. The Omni pod even features self insertion, just push a button. Now I want you to go to my omnipod.com forward slash juice box. And when you get there, you'll get a free no obligation demonstrator. pods sent directly to your house. Check it out and see what you think for yourself. I'm going to do something that at some point during these, you'll hear me talk about where I call it over bolusing. Like I, I imagine not just what her needs are now. But the momentum and higher number that I know is coming.

Jennifer Smith, CDE 30:20
Yep. So that's hot change was one thing that I

Unknown Speaker 30:26
was

Jennifer Smith, CDE 30:28
always in in. In the beginning, I was very thankful that I had noticed a difference with my Animas on change that I needed that site to just be like, just saturated with insulin to get absorption sooner. So and I was glad because when I started Omni pod in 2006, I started doing the same thing that I did with my other pump sites, you know, just Temp Basal going up by almost 100%. For about it was usually about an hour to two hours depending on kind of where I was at that point. And if it was, I was having to change that pod, especially if it was before a meal. And I was going to need insulin for that meal with the new pod. I actually, instead of doing it through the pod, I gave an injection, because I just found that a bolus with that new pod site, it never went well. Whereas if I did a Temp Basal increase, I took a bolus via injection for that food that I was going to eat and let the pod get settled in. I didn't have any blood sugar issues.

Okay. Yeah, yeah, it's everybody's strategy is different,

Scott Benner 31:39
right. But I'll tell you what it what it what that tells me is, and again, this is going to be another sentence you hear over and over again, you have to trust that what you know is going to happen is going to happen. Yeah. So if you make a pod change and your blood sugar's 90, you still need to do that. Right? Right. It's okay, hold on, at 5.6 units. So I'm gonna do a Temp Basal increase 95% for an hour, and Bolus seven units. All now go eat as soon as possible. So she's got 5.6 units in from 20 minutes ago or so she's still 102. And so I'm not scared of those seven units. She's going to be eating in five minutes. And look, the 5.6 units didn't do anything over the last 20 minutes. So I'm good. My goal here on this bolus is 75. Diagonal down while she's about halfway through her meal. Anyway, that's again, stuff we'll talk about later. Yeah. Okay. So,

Jennifer Smith, CDE 32:43
um, comfort level with what you know, will happen.

Scott Benner 32:47
Yeah. And because, and by the way, and just these, you have to, you have to have these experiences, like, I'm going to leave this in this episode, so that you know, that things have to happen that you don't expect, because it's data, right? It's, it's I did this and this happened next time, I'd like this to happen. So I'm going to do sooner or later, more or less, whatever it is, I'm going to do, but you can't know that unless something goes wrong. Right, right. And so and so here's a great tip for somebody starting over or who is newly diagnosed. There are no mistakes. There are only experiences that build on for next time. That's it when I see something happen. Instead, you can't get dramatic. You can't get upset, you can't cry, you can't go oh my god, I'm killing her. You can't do it. Right. You say to yourself, okay, bare bones, what just happened here, I put insulin in here. It went up to there. And then it came down and crashed. I bet you If I would have put that much insulin in sooner and spread it out a little bit like I could have created the resistance that that blood sugar needed. Right, right, right. But if you're busy running around, wringing your hands, and just you gave away an amazing opportunity, and I and I will use this as an example. This past weekend, I was helping a mother with a five year old four or five year old boy. And while I was talking to her, this kid's blood sugar went to 300 off of some Cheerios. And we talked for 20 years, that breakfast cereal. Oh my gosh, we're talking about 20 minutes or so. This poor kids blood sugar's at 300 it's not moving. And we're getting ready to get off the phone. She's like, he's hungry. I don't know what to do. And I was like, are you would you like to do something that's gonna sound insane. I'll help you. And she goes, I think I'm desperate enough to try something insane. I was like, great. How much insulin Do you think it'll take to bring a 302 90 and she says a unit? And I said How much do you think the lunch is gonna take? And she said a unit and a half. I was like cool. Bolus two and a half units right now. And she said, She's like, what's gonna happen? We're going to put him His blood sugar into a freefall. And then we're going to add the lunch at exactly the right time. And then with a little bit of fast acting carbs if we need to, we'll bring it in for a landing. I said, I'll never leave you will will text the whole time we'll talk again we have to, so she does it. We get diagonal down to 90 to 75 to 52 errors down to 50. She's texting. Oh my god. I'm like, No, no, perfect. Like, Oh, hold on. I actually texted her a picture of the guys from Star Wars. We're trying to blow up the Death Star, right? stay on target. Like just don't don't flinch. Like don't flinch to 52 down to 42 3200. I said, Okay. Now's the time to start getting the lunch together. And she laughs She goes, Oh, it's already it's just here on a plate. I was like I said when we get the one at given the food. So 182 down kid gets the food 10 minutes later. Now isn't this interesting? we're dropping 10 points every five minutes on the CGM. Then he eats. Then all of a sudden the dropping stops. The arrows are still there. But now it takes longer to get the 170 took even longer to get the 160 and she gets the watch this happen. 150 still two down 140 still two down. I said okay. It's not gonna catch the arrows. Do me a favor, give them a few ounces of juice. She says we don't have juice in the house. And I thought to myself, Oh, I just killed a kid over the phone. Goodbye, wrong number. So she said she says we treat Lowe's with jelly beans because they hit him so hard. I said, that's great. But do you have any liquid in the house that has carbs in it? That's not soda. And she said, we have lemonade. I said that's great. I want you to give him four ounces. Eliminate. So she gives them I said and don't go crazy measuring it. Just give them a little bit of lemonade, right? So she gives him the lemonade boom, goes to one arrow goes to diagonal down the cake comes in I swear to you 75 nice and stable. It's foods been in for a half an hour. And when it was over, she's like, wow, that was nerve racking. I said, Okay, I know that. Clear your head, and then go back and look at the boluses. Look at the time you put the food in and look at the CGM and figure out how that insulin works in him. Because you just had a Master's class how insulin impacts blood sugar and how food impacts insulin.

Jennifer Smith, CDE 37:26
Absolutely, absolutely. And that's, that's the place that as you know, clinicians, they don't have the time to do that. And it's unfortunate is it's unfortunate in the stance that with somebody something like diabetes, type one diabetes, specifically, if you need that hand holding in an instance like that, you need the ability to be with somebody who can say, You're okay, write it out, you're okay, he's gonna be fine. You've got jelly beans, you've got juice, you've got honey, you've got something in the house, you've got a mini glucagon that you could use if you need to, you're going to he's going to be okay, she's going to be you're going to be okay. It's, it'll be fine. But you do you have to use those learning pieces. I think it kind of goes along with a really good friend of mine. Who has had diabetes a bit longer than me, which is 30 plus years. And her her doctor actually gave her kind of a good little hint for numbers, you know, we we start to view numbers in diabetes as good and bad, right? And that comes with that feeling of frustration then, and oh my gosh, I'm like killing myself or I'm doing something bad or whatever. And he said, you know, the numbers are information to just like you said, it is okay, I'm here. Why am I here? You know, what can I learn from this? What can I do better next time? And maybe you analyze it, you know, three hours from now, maybe not in the instant, but it's information. And so he told her, you know, when the number is going to come up on the glucometer you put this test strip in you put your blood on the strip and you tell yourself, I am awesome. And here comes a number, right?

Scott Benner 39:11
Yeah, because they told me what to do next. It can't be a judgment. You can't feel judged by it. You can't let you can't you know, you can't look at it and say bad low you can say not what I wanted, not what I'm shooting for. Right? What makes me what gets me to what I'm shooting for. And you know, it's funny as you and I are pretty much wrapping up this first thought right? Um, I have so many people asking me when they're first diagnosed, what are the things I need to know? And I find around diabetes in general everyone's looking for an amount or a number from you just want to tell me how many minutes I should Pre-Bolus Please tell me how many units I should do if his budget is like this. And I tell them all the time. I don't know figure it out for yourself. And you will write like you have to but I can't give you no one can tell you that a 10 minute Pre-Bolus is going to be what's right for you, in any given situation, let alone all the time. I think it's insane that we think that just because we've set a basal rate of, you know, one and a half units at 2am, that we think that that's what our body is going to need every day at 2am. It's, it's insanity to think that it's just the best we have with the technology we have at the moment. Exactly. And so if you listen to this thinking, someone's going to tell me the rules about what I need to do. And I'm starting with diabetes, we did, we told you what to do, it just isn't what you expected. Right? Right. And so I get that, I understand that it's, it's not a pill disease, it's not take three of these a day, and you have to have food with them. Like, it's not that easy.