I am working with a Diabetes NP. She works with the NNMC Bethesda, for the Diabetes Institute. I am having trouble dealing with her ideas and need some feedback from you because what she is telling me doesn't make sense.
I was on a low carb diet, I feel best when my BGs are around 120 but I have lower than that BG all the time and feel good that way too. I do not feel good when my BG is high.
I have had these strange directions to follow until Tuesday. Lower my basal by 20 units, take 8 units when I eat of fast acting. Don't worry if your BGs are over 200 or even 300 for the next week. write everything down, don't make corrections and eat at least 30 carbohydrates with each meal.
Can't for the life of me figure out what the rationale is behind all this and I have felt awful this week with these high blood readings. I guess she is going to raise the short acting when I see her on Tuesday?
She has problems with the fact that my long acting and short acting is not 50/50. When I get ranges from her she likes my fasting to be 120-150! Just keeping things under 200! She keeps telling me that I have no complications and that I don't need tight control.
I don't care for eating all these carbohydrates, I feel bad with higher BGs and I plain and simple don't get it. I am not even hungry anymore.
My AIC was 6.4, I was low carbing and going for a lower one, now this. I am confused to say the least. Just tell me is this total craziness or what?
I'm sorry to hear about all these troubles. It can be really frustrating navigating the health system. At least you have a team and they are practicing "integrative medicine." It is all too common for doctors to not communicate well and fight over control of various aspects of our health. My suggest is that you focus on getting an agreement on your treatment goals with your endo, not your NP. Her job is not to make treatment decisions, but to work with you to properly implement your treatment plan. And the key elements, your blood sugar targets, etc are things that you can appropriately move from her decision sphere to your endos decision spehere (or other doctor). Their decision will trump whatever she wants.
But in the end, you will likely have to accept that there will be some mismatch. You may have to make some short term compromises in order to get through this. If your team concludes you are refusing to comply you can end up with your NP complaining that your low blood sugar and carb starved brain are causing all the problems. This will be a distraction that you just don't need right now. So be willing to agree to moving your lower range from 70 to 80 or 90 if requested. You can eat whatever you want, they won't know the difference, they will just think you do great bolus calculations. Just nod your head, say thanks for the advice and move on.
So think about my suggestions and don't fret yourself over the short term. The important thing is to figure out what is wrong, get it fixed and get on with your life. Once you get on with your life, you won't have some NP all over your back with whacko advice and you can return to normal.
She thinks either that you are, unfortunately, like most of the patients she sees,who do not do the things that you are doing to try to say in control, such carb counting, adjusting insulin dosages independently ,testing logging etc.(If she is their NP( CDE?),they probably have not been taught to do that. She may not have been educated to do that herself, and knows little else.
We on Tu d, with our knowledge base and skills, are a tiny minority of the diabetes population. She probably was not trained on anything else but sliding scale. She is useless to you. If you have to go there , just nod and smile and tell her that you KNOW how to stay away from hypoglycemia and will continue to do what works for you.
Another sad examople of how diabetes is treated at the level of these medical personnel thought processes:
"1.It is too complicated to present a more rigorous plan.
2.the patients will be overwhelmed with all that data, and not follow it: to say test then treat, No way...
3.It is too hard for us to manage all those individualized treatment plans: too many patients to see and be accountable for.
4.Tight control might cause a pass out from a low( and we might get sued)..
So just do enough to keep them alive, not well, but alive"
Such sad paradigms, but the nature of most diabetes education today.
Keep up with what you are doing and stay at peace.
Thanks Brunetta, I think the smile and nod is a good idea tomorrow.
I agree with Brunetta. My Mom (diabetic) told me once "Never eat to cover your insulin".....You should take insulin to cover what YOU want to eat. If what you have been doing was working, why change? I wish you well, and you got alot of great advice. xoxo
Following up on Tim's comments: It can make sense to rebalance basal and bolus insulin but it sounds like you're being asked to participate in a science fair project rather than a medical intervention. Fasting at 120-150 and post meal targets of under 200 are just too high. They might be appropriate targets for a brand new T1 trying to establish initial control but you've been doing this for 20+ years. I assume you carb count and therefore, don't understand instructions to take a fixed 8 units per meal. And telling you not to correct is simply cruel. Why should you feel sick so the NP can get nice little patterns.
I tend to be a compliant patient but I wouldn't go back.
Hi Maurie, you are right, I do feel like a guinea pig in a bad science experiment. I have to go back, but I think that I need to be clear that it is my body, some tweaking of the basal is fine with me and I am fine with that. I just can't tolerate a professional telling me that 200-300 is not of a concern and that data collection is more important right now. At this point I have abandoned the ship and I am correcting now. I do feel like I know what I am doing and I have not had a number lower than 145 yet, so I think it is a bad experiment. I stopped with all the higher carbs as well and I am eating what I consider healthy and nutritious food. Kind of nervous about a face off, I really like this NP and think she believes in giving good care but just don't agree with the methodology.
Given you're dealing with so many other medical issues, I'd say that having your blood sugar under YOUR good control and at levels YOU feel good at would be critical not to muddy the waters for everything else.
Playing with basal fine, but small changes and eat what works for you and what you've obviously expert at.
I would/could not follow her directions. A shot of 8 units for 30 carbs would have me lower than low..and I guess no one has informed her that damage begins to other body sytems when bg is >140? And if my BG is @ 25o I can start getting Keytones so..yeah, I would not do what she is asking.
The other question I'd have, more for you than her, is what were you seeing her for in the first place? Is it just "you should see the nurse?" sort of deal from the doc or did you have a goal in seeing her?
In your heart, you know the answers to all these questions. You just need the confidence to hold your ground. You know that raising your blood sugar for no good reason is just nonsense. You choose your blood sugar goals. Unless you are placing yourself at risk of hypos, there is no logical reason to raise your blood sugar.
And if you are eating low carb, you won't have a 50/50 basal/bolus ratio. When you restrict carbs, your daily total bolus drops. Your basal requirements remain the same, as do your ICR and ISF and it just makes sense, you just bolus less when you don't eat as many carbs. My ratio is actually higher than 80/20.
You need medical care, not medical mistreatment.
I agree completely with each and every reply, lotsofshots. You know more than this woman does, even though she has the letters after her name, she is woefully uneducated and just plain wrong. If you were going to her, because you are having some management problems you need help with, I would find a medical professional who you really think knows what they are talking about! I also wouldn't hesitate to ask questions on here. We may not be doctors but we have thousands of years of combined experience and knowledge. You may got various answers that you can sort through to see what applies, but you will get answers because someone on here has experienced the particular D issues that you have. It's worked for me so many times I should probably submit an insurance claim!
"Well you see, Anthem Blue Cross, they are the DOC so they really know their stuff!"
Yikes, that's the first time I noticed that DOC (Diabetes online community) spells "doc" as in "doctor"!
Hi BSC, Yes, I do know the answers. I am used to being in the background and not making waves, especially when so many doctors are involved. You are right, I just need the confidence, and I think that I need to stand up for what I know is right.
I think she is a good person and experienced but in this particular case she just doesn't agree or think the way that I do about how diabetes should be treated. She has been trained to do certain things a certain way I guess.
Sometimes I think with the diabetes part I am best to just smile and nod and have her mainly write my insulin and supply prescriptions. I get so frustrated when she takes my glucometer and puts up my readings on the computer and directly searches for anything below 80 as hypoglycemia, she will not trust me when I tell her that I have no hypoglycemic unawareness, I feel hypoglycemia and I don't even feel bad at 80 at all.