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Guest Post: Handling Lows.

Today's guest post is from Leah, a person with type 1 diabetes, a nurse practitioner, and she's prepping for a 60 mile bike ride for the Tour de Cure. She writes today about dealing with lows in situations when you're expected to think on your feet ... like when you're dealing with patients.

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LeahAs a woman who's lived with diabetes for most of my childhood and all my adulthood, I'm well versed on how to be a good patient. I try not to be late to appointments, I bring my list of medications, I know all my doctor's addresses and phone numbers, and I always forgive healthcare providers who are running late (take a good book!).

I also happen to be a nurse practitioner, and I try to be good at that too. I try not to run late, I answer patient phone calls and emails promptly, and I listen with my eyes and ears. What I'm less sure about is how to be a healthcare provider whose life is sometimes interrupted by diabetes. I had a bad diabetes day recently, and it made me remember how frustrating diabetes can be.

I see patients in an office, and have patients booked every 30 minutes. Some days are full and I barely have time to eat, while others are slower and not every slot is filled. The problem comes when I have a bad low blood sugar that I don’t catch in time, which means that I feel completely gaaaah (that’s a medical term) and can barely remember my own name, much less what drug I should be prescribing for my patient.

These bad lows don’t happen very often because I can usually catch them before I feel gaaaah thanks to my Dex CGM. But when a bad low strikes, it means that I have to stop what I’m doing, eat enough to feel better (but not so much that I hate myself later), then wait. And wait and wait until my brain fog lifts and I’m ready to see patients again. I can usually do this eating and waiting between patients, but it make me late for the next patient, and the one after that, and so on.

And on the rare occasion when I have to stop mid-patient visit, I’m never quite sure what to say to the patient. It’s not that I don’t want them to know I’m diabetic—I wear my pump on my hip and I talk about living well with diabetes to anyone who will listen. But I don’t want my patients to see me as vulnerable or incompetent. I want to maintain a professional distance.

So here’s my question: How do you deal with lows in settings where you’re expected to think on your feet? Have you ever felt disrespected by someone who witnessed your low? Should we care what other (usually uninformed) people think?

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Leah is a 38 year old wife and mom who lives in Southeastern Massachusetts. She's a self-proclaimed Southerner at heart, having been raised in Nashville, Tennessee. She says, "I feel lucky to have a job I love that allows me to learn something new every day" This coming July, she's planning to ride 60 miles on her bike in the Tour de Cure. You can find Leah on Twitter: @photosinpink.


Leah, I totally understand and appreciate you sharing! I dont have as much experience because I was just diagnosed with type1 about 3 months ago, while pregnant. I am 27 and a nurse who teaches clinicals for our community college. I had a bad low a few weeks ago while in a patients room with my student. I remember feeling so hot and sweaty and feeling the fog in my brain... My student was giving an IV med and all I could think was "I wish she would hurry up so I can eat something!" It is hard being in the position of authority- other students needed me and I felt so embarrased having to tell them to wait until I ate and felt normal again. I dont know why I let myself feel that way- I guess as nurses we feel like we should be strong all the time because someone might need us. However, being on the side of the patient, I wouldn't consider you vulnerable in that situation. I would have more respect for you because you are taking care of your body!

I'm a first year medical student, so I've only had one or two of these experiences so far with patients. But I often feel the pressure of being in the midst of people who are in the health care profession. I set higher standards for myself when I'm around patients or my peers/educators at school-- I want to see good numbers so that I appear competent and ready to handle anything someone else could. But that's just not always the way the cookie crumbles, unfortunately. I think that as a patient, I would view a doctor who took care of herself when needed as a good thing... but I know that's not true for all patients and also challenging to remember on the other side of the equation. I wish diabetes would get out of our way so that we could get on with providing care-- but I also know that we're probably much better providers BECAUSE we deal with and understand this stupid disease on a personal level. Hopefully that knowledge can buoy us through the times when we have to pause and regroup.

I wish I had an answer to this question, but in eight years as a dentist, I've never found it. I too worry what patients will think, seeing me that vulnerable. I worry that they will somehow lose their trust and respect for me, or will no longer want me to treat them. So I'm ashamed to say I hide my diabetes from all my patients. I try to avoid lows in the first place, by checking and eating between patients. If needs be I make an excuse about an emergency case if I need to return a patient to the waiting room, or I'm running late for the next patient. I will lie as much as I have to - the only I will not do is pick up a handpiece, scalpel or even a mirror if I know that I'm low.

I can totally relate to the part about "eat enough to feel better (but not so much that I hate myself later)" -- I have had that feeling of regret later, where I've just stuffed whatever food I can find in my mouth, because I know I need to correct a low ... and then later I think "I really didn't need those cookies - should have given the glucose tabs a few extra minutes to work." Great post, though!

This has totally happened to me! I was with a patient and could feel a low coming on so I tried my best to finish their treatment as quickly as possible so I could get out of there and treat myself! Not happening. I had to give in and ask a colleague to continue for me. I felt awful but I had to do it, it wouldn't have been safe for me to carry on (I'm a podiatrist (almost) and using a scalpel whilst low is a BAD idea...).

I was teaching a discussion section of undergrad students once and was trying to explain a mathematical principle. I knew that I knew it, but couldn't figure it out. I realized I had low BG and told the students I would need a few minutes to come back up and told them why. They didn't seem bothered at all and as soon as my BG was normal, I could explain everything.

I think it is really tough, though, to be in a position where you are booked back to back like that... It sounds like you are handling it really well. Not sure how to improve it; but I think just explaining and maybe stepping out while you treat the low would be totally acceptable from a patient's point of view.

I think the hardest part is that we have no control over these numbers..and that is very hard for "regular" people to understand. We actually run into this as parents of a T1. People often assume we are doing something wrong as parents when our child goes low. I've seen this repeatedly when she participates in sports. People assume that because we are the adult in charge this shouldn't happen. I've learned to let it roll off my back, educating people when I can. You are in a prime position for role modeling that..as tough as it is..I know it is.

I got low in the middle of a PowerPoint presentation I was giving to about 20 people. They were training on a computer system and relying on me as the authority. But if I didn't stop, I wouldn't have finished the presentation. So I said "practice on your own for a minute, explore the program a bit," and then I walks to the back of the room and chugged one of the sodas in the back (that was there for the participants refreshment). Then I walked up to the front again and opened it up for a few questions - it was easier to handle those one offs rather than present material while I waited for the low fog to lift.

I think for you in your job as an NP, the only choice is to briefly excuse yourself and get some sugar -otherwise the visit will be cut short anyways right? I really feel your pain though, you don't want to be late for the next patient! It's tough but we sometimes are forced to just stop and take care of this high maintenance disease.

I'm an instructor like some mentioned here, but I haven't had to teach in person very often since my diagnosis. I think that students are likely to be understanding, especially since in my classroom I'm often asking them to make themselves vulnerable. If you have patients this might be true for you, too. They're vulnerable every time they come to see you. It might actually improve your relationship of trust if you reveal your own vulnerability, since it levels the playing field. However, it can also undermine trust if they think you should be in "perfect" control because you're a health professional. I think you can do a great deal to undermine that stereotype of the "perfect" patient by speaking openly about the impossibility of having perfect blood sugars all the time, or of your own understanding of how hard it can be to strive for a healthy life. I also think it is a way of bringing diabetes out of the dark, not hiding our suffering, not pretending we're normal, but asking the world to change for us a bit (rather than the other way around). However, it's a very brave thing to do, and I don't think it would be right to expect every professional to be that brave in all circumstances.

Good Question, Leah! I have a Health Degree, & I've been a Type I for 35+ years. A few years ago, I went back to school for my RN degree. I had two poor low diabetic days in row one week. I forgot how to spell, or even how to take notes when I had these two Low Blood Sugars. Thus, I went home and thought real hard about my future as a Diabetic RN. Yes, you have a high Responsibility to not have brain fog in these RN Nurse settings... and to be 110% Professional in this clinical Health Industry. It was obvious to me that I could not continue in this RN field. As a Type I diabetic- we must be highly aware of how variabilistic and fragile our Mind and Bodies are... in something that is not always predictable or an exact science! So, I realized this was not a field I could do properly or professionally. It has been about 5 years now, and I know I made the correct choice... Diabetes only gets worse as you age with this disease.

I am a physical therapist, and I work both inpatient and outpatient, so my schedule can be very hectic. I carry juice and glucose tabs in my pocket. If I'm going low and have a patient waiting for me, I just tell them that I'm a diabetic and that I need to get some sugar for my low blood sugar, and I'll be with them in 2 minutes. I've never had anybody make a negative comment, and a lot of times it seems to make me more approachable I think. Sometimes other co-workers may make comments about my control but then I just remind them that I'm doing the best I can without a vital organ!

Thanks so much for writing this and sharing, Leah. I have no comparison, except being in the news business and needing to be on the go constantly. I've had to take some breathers and ask for help, which really makes me feel like I'm not doing my job the way it should be. But I know that's not really the way anyone else sees it, just something in my mind. I actually have a CDE who's Type 1, and maintains that "professional distance" mentality. She doesn't share anything, and I totally respect that but do wish sometimes she might seem just a little more "real" and vulnerable. Anyhow, seems like a totally natural thing to feel and hope the situations don't arise often, if at all.

Thank you Leah, great post. I'm not in the medical field, but after 57 years with type 1, I have too often found myself
attempting to deal with a suddenly full blown low during gallery openings and meet the artist events. I just have to excuse myself, sit down and take a couple of gulps of soda. I do the best that I can. As my health provider, I would want you to do what you needed to do to treat your low.

I teach high school sconomics and the other week I had a low while teaching. A student was asking for help and I couldn't explain a very simple supply and demand problem. I am glad she asked for help because I didn't realize I was so low until I realized why I couldn't think. My students know about my diabetes and are very understanding. My students impress me with their compassion every day.

Great post! I'll an endocrine fellow so I know the pressure. When I have a high and show my Dexcom to a patient (many like to see how it works) I think it provides reassurance that "even my doctor has highs, nobody's perfect." However, a low seems like a much bigger failure bc the patient then wonders how long you've been low and then will try to discern whether you are again repeatedly with subsequent encounters. I get flaky and repetitive when low and I think the patients think I'm a but nutty before I slip out, mow chow a cookie or brownie, and return like nothing happened (usually with chunk of brownie adhere to my front tooth). In medical school I caring for a teen suicide attempt and discussin it with her father when my chronically low bs became even lower (pregnant) and I had to gracefully lie down on the floor of the examining room (protecting said bun in my oven). I was mortified. There's no return from that - the patient spends the rest of the time worried about you. A great bs corrector is the fruits acls for kids. Tiny package and perfect carb count for a low. Easy.

I go into a very slow deliberate mode when these things happen. One time I was testifying in front of our state committee for Human Services advocating for more funding. I started to feel the tingle and sweats come on. I stopped and apologized and said I needed to eat some glucose tabs. While I feel it was a horribly embarrassing moment in my life, the committee was very understanding and one of the senators had his aid run and get me juice. Of course I ate too much that time, but most of the time I find people care and understand.

It is tough to deal with, but people do understand.

Thank you so much for this post - both today and yesterday were so...."OMG - Me TOO!" and I am so grateful for this site, and Kerri, and guest posters like Leah who remind me that I am not the only one dealing with these situations. I am not one to "hide" my diabetes, but I hate it when it rears it's ugly head at inopportune moments, when I am around people who don't necessarily understand that I am really not all there until I treat the low. Wish I could find a foolproof way of dealing with it. maybe a color change seal, lol - when it turns back to pink Danielle is fully functional again...

I want to be a pediatric endocrinologist, and my fear has always been that I'll mess up a dose or write the wrong prescription because I'm low. On one hand, I would expect my patients with diabetes to understand what that feels like, but on the other, their parents might not be too thrilled about me not being under "control".

I have a teacher this semester who has Type 1. He admitted to me that there have been times he's had to leave a class because he was so low he couldn't teach. I could see it in his eyes that it hurt to even think about. From other people's point of view, there's something wrong with him. But I see it as the truth; he's doing the best he can, and that's all there is to it!

As a counselor working in a camp, there were times when I was low. Mostly, it was my JC who was good about it, because my campers were 8 year old boys who would purposely act up because I was incapacitated. But all the heads of the camp were wonderful about it, because they knew that I was doing my best.

Lows happen. They always will, no matter how "perfect" you are. But to give your patients 110%, you can't be low. Worst case scenario, you excuse yourself for a couple of minutes to go have some juice. Yes, your patients will be a little backed up, but I'd rather my patients see me as running late than as incompetent because I can't concentrate because I'm low.

I work at a small agency and all of my coworkers know I have diabetes and aren't at all phased when I enter a meeting still slurping on a juice box.

It is however a concern when I have client meetings, because my clients don't know (nor do they need to) that I have diabetes. I have yet to experience a low in one of these situations, but I feel that somehow it's unavoidable.

It's tricky - that balance of caring for your health and at the same time doing your job well and maintaining a level of professionalism. Of course, my doctors and loved ones always think I'm mad when I mention this conundrum - "what! You even considered not looking after yourself for the sake of appearances!?!?!" but no, it's more subtle.

I teach 4 x college classes a week. That's 4 x 5hr lecture/presentation/demonstrations, with questions, in front of groups averaging 15 people. So it's nice and intimate. If I go low, I have to catch it and fix it fast!

Generally I will just give my students a quick task so I can do a test, or if I'm feeling really crappy maybe call a 5 min break. Everyone loves a break so that's never a problem. But diabetes is definitely an interruption in my classes and I hate that I can't be on the ball all the time. But then I remember that non-diabetic people are never completely focused 100% of the time either, and I figure that I do a lot of good work. I get a lot of encouraging feedback from my students, so I must be doing something right. This is just the way I am. If I have to do a test, and drink juice, my students might look at me funny. Sometimes if I'm feeling up to it I will explain that I'm diabetic and what I'm doing. Most of the time I just think - hey they don't actually notice, and if they do it's their problem. I deal with it pretty well and try to minimize class disruption. It's a constant balancing act. :)

Thank you soooo much to everyone for the encouraging feedback. Since diabetes camp as a kid, I haven't had much interaction with other t1 peeps, especially professionals. Since I wrote this post I have tweaked my insulin doses, tried to pay more attention to my CGM, and haven't had another horrible low while with patients. It's a daily struggle, so I'm sure it will happen again, but now I'll feel all of you standing behind me as I say, "I need to step out, but I'll be back". Thank you.

I'm working as a teacher right now. Classes have usually about 30 children between 13 and 16 years with teir heads full of puperty nonsense, which means a lot of responsibility for me and need of attention and concentration by me. If you find a trick, please tell me. :-)

I had this happen just today, went low as I was working in my office. I had to go to a co-worker and ask her to go get me something to eat and drink, and fortunately I had briefed her beforehand to know where I kept things. She also knows about my Dex and pulled it out of my pocket to check it for me. She stayed with me until I pulled up into the 60s and she knew I'd be safe. She's a great "lifeguard" and I am very thankful for her.
Honestly, my worst enemy is myself, not wanting to admit that I'm low (as I read many others here admitting). I've been in the middle of a teaching situation and gone so low I didn't recognize my own notes, but slogged it out. When I told the group about it the next week, they all said "you should have told us - we would have completely understood!". OK, lesson learned (maybe).

I think you need to tell patients in advance when you meet them the first time that this could possibly happen. Then, if and when it does, they just think "oh yeah, she mentioned this." This is a sort of preemptive strike. A little different, but here is my example of how this works for me...I teach high school and sometimes my T1 daughter calls me for diabetes related reasons during the school day. I always warn my students at the beginning of the school year that this might happen and explain why I must always answer my cell phone during class. If I have a new student who doesn't know the deal, they will comment on it (Hey! How come you get to have your phone on during class?!) but those who know, just accept it as part of being in my class and we deal with it efficiently and move on. It works beautifully and nips hassles in advance.

I am so thankful for this post! I have been T1 for 17 years and I am the only PWD I know. I am also a police officer in southern california. Having a low while Im on my way to an emergency call is not an option. I solve that problem by carrying snacks in my pockets and a lunch box filled with goodies on the passenger seat of my car. I love my job and I am terrified to ever have to tell someone I am having a diabetic problem in fear of someone thinking I don't belong doing what I do. Just a couple of weeks ago, I was doing an interview with a theft victim and had to take out a bag of skittles from my pocket and jam a few in my mouth. He looked at me weird but kept on talking. His friend said, "Wow that's some serious addiction to candy". I had to tell him I have diabetes but I hated it. I was mad at myself for not eating before I got there. I did my best to get the victim's property back (which I did and a bad guy went to jail) but I was fearful that it was overshadowed by the thoughts of , "What's the deal with that cop and her skittles addiction?". Considering I helped the victim, I guess I shouldn't care at all, but it still bothered me. Thank you for your post. It made me feel normal! Its so amazing to know that what I can't share with anyone else I know, I can find comfort from the diabetes online community! What a great story!!

Being in front of a classroom is probably somewhere between working as a physician in an office and being a physician during somebody else's surgery in terms of how difficult it is to stop and deal with blood sugar that goes suddenly wrong.
I am a teacher. Both on and off the CGM, I aim for a higher blood sugar right before my classes- a blood sugar of 95 is great after school, but not while I'm teaching. I also carry small candies (soft mints worked well) and if I think I'm low, I take one. If I wasn't low, I'll be taking a correction after class (or between classes, or if I have a quiet lull). I don't take the time to check on my meter. If my CGM goes off, I respond to lows but not highs during class. Highs can wait.

My fifth grade teacher told us on the first day of classes that she had hypoglycemia, which she told us was "the opposite of diabetes" and that sometimes she would be eating during class. I don't know about how my classmates took that news, but I thought it was pretty cool and back then I didn't know jack about blood sugar.
My students need to know that I'm in control generally, but they are okay with the idea that I make mistakes or may be unavailable for short (really short) amounts of time. That I might need to eat is not going to faze them; if I were to take a break to sit and rock, it probably would. I have often taught through lows were I had a tremor and the students say "Mr. Jonah, your hands are shaking," and I say, "Yes, it's because my blood sugar is low. I ate a mint and the bood sugar is probably on its way up right now." Most of the kids are content with that explanation, although a few of the kids (mostly younger ones) will say something to the effect that even though they understand it, they don't like seeing it. That's okay by me.

I can generally continue to think on my feet through lows- I once played a simul with a blood sugar in the 40s and a full body tremor. If I'm having trouble with speech and trying to give a lesson, then the kids know the lesson isn't going well and are generally very willing to switch to whatever fall back activity I have planned, which allows me some time where I can focus on something smaller than the whole class, usually.

Sure I get disrespected by people when I'm low. As long as the people in question are not my students, I don't care. And if I had good control of a classroom before having a symptomatic low, the low is not a dealbreaker.

As the mom of a type 1 (age 12), I often feel disrespected, or like people are judging or think I’m an incompetent parent. People just don’t GET that diabetes isn’t something you can 100% plan for, and that Novalog is really a poor substitution for the body’s insulin. My daughter really doesn’t have that many lows, but when she does, there’s always someone around giving me the “you screwed up and put your kid in danger” look. It makes me nuts actually. I’ve even gotten this from diabetics a few times, usually those who are older and have it “all worked out” (which either means they’re fibbing or on a ridiculously strict diet and exercise regimen in my opinion). Yes, I totally know that if I give her a whole grain sandwich and a cheese stick for breakfast, lunch and dinner every day, I probably can keep her bg in a lot tighter control. But she’s 12, she likes sushi (including the rice), she likes pizza, she likes an occasional muffin. She likes to enjoy her life and be as normal as is possible for her.

I've been in the car business since 1984 and was diagnosed T2 in 1997. I went on insulin in 2001. I always stress to customers that I work strictly by appointment. I also have learned that since I am "just a salesperson", 90% ignore the appointment request. If a customer shows up unannounced and I have already injected my Humalog for a meal, I tell them I'm about to eat and they can wait, or I will have someone else assist theme. Then I explain why. Some actually will wait. Others seem put out. And I remind them, "this is why I work by appointment". Once, right after taking a shot, I went on what was supposed to be a 10 minute test drive. I was still in the learning curve. We got stuck on the freeway in traffic. By the time we got back to the store, I had gone through the 2-3 peppermints I always have in my pocket, and the customers wife had dumped her purse in the seat looking for anything that would be useful. I make sure my co-workers know I'm diabetic (an example of why: http://bit.ly/s6Damf) and now always have glucose tabs in my pocket (I miss my peppermints) and a can of apple juice in my desk drawer.

Great post and very eloquently expressed. There are Unexpected moments in every diabetic's life. I'm a Type 1 juvenile diabetic since the age of 8. I have realized that there is use worrying about what others say. There will be people whose talk may hurt you but they don't live your life, they have not gone through what you are going through. Dealing with patients is a job which has its emotional side which could result in low blood sugar. Take the break if you have to and may be always keep some glucose tablets which u can pop in without possibly having to take a break. You have done well. You are a brave woman.

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