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Re: [IP] zero to DKA....

Listening to (I think I mean reading -- whoops) all the discussion about
doctors and CDEs reminds me of something that might help us as a group get
their reactions and maybe think of better strategies to deal with them.  So, a
bunch of long thoughts:

    I ended up with Kaiser insurance this year -- for one year -- and a decent
primary care physician who knows only a little about diabetes, nothing about
pumps, spends more time than she is supposed to with her patients and never
has a spare second.  Together we decided that the only Endo for Northern
California Kaiser (or at least the East side of the Bay) in Pleasanton (60
miles from where I live, 135 from where I work was not practical and unlikely
to do anything she couldn't -- with some research for me.  This was more my
idea than hers since I hadn't heard much encouraging about him.  There is a
CDE in Martinez, still a drive but in the direction I work in so I did go to
see her.  She is very nice, much more flexible about pumping than the
professionals I knew 10-15 years ago and herself a pumper.  She's a young mom,
clearly a bit overworked.
I think she is as resistant to young kids on the pump as many you've
described.  Nonetheless, she strikes me as a quite nice reasonable person.
    Pumping has been widely available for 15 or more years now.  But most of
the people I have met in doctor's offices who are either pumping or helping
patients with pumps have only been doing this for between 2-8 years (I can't
remember anyone at it for more than 8).  Like the CDE I know, they have
recently learned a dramatically new way of life.  While they seem to be
getting the YMMV bit (more than diabetes educators used to), like most people
who have recently converted to a major ideology, they are still pretty wed to
the theory and information they have.  In other words, they are not in the
"been there, tried that, now what else could you do with this thing" mode.
The CDE I met strikes me as someone genuinely concerned about putting kids out
of their depth.  And despite all the info she has at her finger tips, I
ocassionally realize that her answers are best on very short term knowledge.
For instance, I was trying to fix basal rates and asked her about including
different versions for varying dinner fat content.  Her answer was that bolus
should cover dinner.  I reminded her about gastroparesis, she said to take my
bolus after dinner.  She didn't believe me when I said that if I had lots of
fat at 7 PM than I would be high between 2 AM and 10 AM the next morning.  Is
she being difficult?  No, but there is nothing in her experience and book oif
instructions to show her that my experience is not common but quite logical
and not that uncommon either.  I think too that people who become diabetic
when they are adults may have a different relationship to what they are doing
than people who have grown up with this disease.
    Pumps were originally disseminated by new hot shot doctors who worked very
closely with their patients and did the then unusual thing of thinking about
food values as well as insulin and exercise.  They were then handed off to
CDEs along with blood sugar control.  As a result, few doctors (people like
John Walsch excluded) actually spend much time with the pump on a daily
basis.  Their opinions are based on an educated reading of a few materials.
CDEs are short on time and in the very ambiguous position of not being doctors
and not given adequate medical information to back up many of the situations
they encounter (hence so many of them still don't know what gastroparesis is
or the multiple strategies for dealing with hypo-unawareness).   Maybe if
these people were given more help encountering the experiences of the their
patients they would be more receptive to pump info for kids?

Michael wrote:

> >  I know she mentioned that she feels pumps are meant to allow
> > independece, and that kids under 12 would not be able to do all that is
> > necessary as far as counting carbs and then estimating the bolus.  I can
> > understand her point, but I figured we would just be involved with
> > helping her with this until she was old enough to do it on her own.
> >
> >
> Sorry, I disagree completely. The point is not whether or not the kid
> can be 100% reponsible for running the pump, it is whether or not the
> parent is willing to accept the responsibility until the kid is old
> enough.
> If a child can draw their own insulin and shoot it, they can program
> a bolus.  Carb counting is not the issue. Everyone should carb count.
> If a child must eat but can't carb count, then the food supplied by
> adults SHOULD ALREADY BE COUNTED and the bolus clearly defined before
> the food is given. That's pretty simple.
> The freedom of lifestyle that the pump provides FAR OUTWEIGHS any
> possible inconvienence to the person doing the food prep. Personally,
> I would much prefer to count carbs for my daughter so she can eat
> whatever she wants, sleep when she wants, etc... that put up with a 2
> or 3 shot a day standard diabetes regimen.
> But that's just my preference. Maybe I'm the one whose is missing
> their point??  I think not, they are just afraid and lazy.
> BTW, I'm in norcal also, Palo Alto to be exact. If you need an endo
> around here, there are a couple at least. Mine and Janet's.
> Michael
> email @ redacted
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