Oh it's been one of those days! I had an appointment at the hospital with my consultant this afternoon - I was dreading it as a recent week with a sensor attached had shown lots of high spikes and a handful of lows - lows mainly in the mid to high 3s with two in the high 2s; highs up to 16 but mostly 11 to 14. Overall, a tiny proportion of my time was spent below target maybe 2 or 3% but more than 25% of my time above target - mostly overnight. So, I wanted to discuss how we tackle the blippiness without compromising the HbA1c - basically how do we start trying to smooth out the profile. I knew that would be a challenging discussion and I expected the diabetes team to push me to increase my HbA1.
Anyway, almost as soon as I arrived I got called in by a young woman I'd never met. She introduced herself as the dietician and said she wanted to talk me through the results and her and her colleagues' observations. I can't say I was really happy to talk to a dietician, but I thought there could be no real harm in it. She wanted to discuss the 'hypos' - I explained I didn't see most of them as hypos as they were above 3.4mmol - she said 'even so' and continued on about the hypos. I said I wanted help addressing the spikes and would be happy to hear her and her colleagues' observations on the highs. I explained that we needed to sort out the basal as it clearly isn't working and then look at how to control the spikes. She said we needed to address the hypos. She said they had put together an action plan and that their views on the way forward differed from mine. She talked a bit about carb counting and I explained I low-carb. She said she'd noticed my carbs were very low and addressing this was part of the plan. I said 'Brilliant! I have been looking for some specialist help in matching insulin to a low-carb diet'. She said 'I'm just going to ask the consultant to join us'.
To cut a very long story short, the consultant started asking me about not recognising the signs of hypos - apparently the dietician and her colleagues had put in their report that I didn't recognise hypos. I hit the roof. How dare this person who has never met me and has no experience of diabetes make such a comment. I explained fully to the consultant when I correct 'hypos' and when I leave them; what I base my judgement on e.g. amount of active insulin and so on. Consultant then apologised for the dietician comments and said he was very happy with my hypo awareness and the way I deal with hypos and would put that on my notes in response to the dietician's comments. By then I was completely furious though, so I explained how frustrating I find it to deal with people who do not have diabetes and have only experience of diabetics with very high HbA1cs and that I have a right to expect help with flattening my profile within a good HbA1c. The consultant agreed!
The upshot of all of this is that I now have a third insulin - Insuman Basal - which I've used before. I'm going to use it as my evening basal for a few months to see if its peak can stop the overnight highs, but continue with Levemir as my morning basal and Apidra as my bolus. I think it will take a bit of trial and error, so I might be exasperated for a while, but at least we're trying something! If it doesn't work, I'll be back there insisting on Tressiba, but my case will have been strengthened by having tried everything reasonable. So a reasonable result in the end, but a flippin' nightmare to go through. Really stressful.
On the way out, I had a final sharp exchange with a nurse who told me that there isn't a half unit pen for Insuman so I'd have to have a full unit pen 'like everyone else' or she could give me Humalin I instead as it's 'exactly the same, just a different make'. I said 'you've never used insulin have you?' and don't worry about the half unit pen I'll get a JuniorStar direct from Sanoffi - that takes Insuman cartridges'.
I never did get to see the dietician's plan - the consultant told her he didn't think it would be suitable - and I'm sorting out my own pens with the supplier - so exactly what value did this team of DSNs and dieticians add? It felt like a very expensive job creation scheme. Thank goodness it's over!
Smidge
Anyway, almost as soon as I arrived I got called in by a young woman I'd never met. She introduced herself as the dietician and said she wanted to talk me through the results and her and her colleagues' observations. I can't say I was really happy to talk to a dietician, but I thought there could be no real harm in it. She wanted to discuss the 'hypos' - I explained I didn't see most of them as hypos as they were above 3.4mmol - she said 'even so' and continued on about the hypos. I said I wanted help addressing the spikes and would be happy to hear her and her colleagues' observations on the highs. I explained that we needed to sort out the basal as it clearly isn't working and then look at how to control the spikes. She said we needed to address the hypos. She said they had put together an action plan and that their views on the way forward differed from mine. She talked a bit about carb counting and I explained I low-carb. She said she'd noticed my carbs were very low and addressing this was part of the plan. I said 'Brilliant! I have been looking for some specialist help in matching insulin to a low-carb diet'. She said 'I'm just going to ask the consultant to join us'.
To cut a very long story short, the consultant started asking me about not recognising the signs of hypos - apparently the dietician and her colleagues had put in their report that I didn't recognise hypos. I hit the roof. How dare this person who has never met me and has no experience of diabetes make such a comment. I explained fully to the consultant when I correct 'hypos' and when I leave them; what I base my judgement on e.g. amount of active insulin and so on. Consultant then apologised for the dietician comments and said he was very happy with my hypo awareness and the way I deal with hypos and would put that on my notes in response to the dietician's comments. By then I was completely furious though, so I explained how frustrating I find it to deal with people who do not have diabetes and have only experience of diabetics with very high HbA1cs and that I have a right to expect help with flattening my profile within a good HbA1c. The consultant agreed!
The upshot of all of this is that I now have a third insulin - Insuman Basal - which I've used before. I'm going to use it as my evening basal for a few months to see if its peak can stop the overnight highs, but continue with Levemir as my morning basal and Apidra as my bolus. I think it will take a bit of trial and error, so I might be exasperated for a while, but at least we're trying something! If it doesn't work, I'll be back there insisting on Tressiba, but my case will have been strengthened by having tried everything reasonable. So a reasonable result in the end, but a flippin' nightmare to go through. Really stressful.
On the way out, I had a final sharp exchange with a nurse who told me that there isn't a half unit pen for Insuman so I'd have to have a full unit pen 'like everyone else' or she could give me Humalin I instead as it's 'exactly the same, just a different make'. I said 'you've never used insulin have you?' and don't worry about the half unit pen I'll get a JuniorStar direct from Sanoffi - that takes Insuman cartridges'.
I never did get to see the dietician's plan - the consultant told her he didn't think it would be suitable - and I'm sorting out my own pens with the supplier - so exactly what value did this team of DSNs and dieticians add? It felt like a very expensive job creation scheme. Thank goodness it's over!
Smidge
