The Saturday Share #2

Did you know that health topics are the number one internet search item, outstripping even porn? Uh… pardon the Freudian slip there...

Dr. Oz—yeah the Dr. Oz—recently stated that we are living in a “renaissance of medical knowledge.” He’s seen that patients have the desire to understand their illnesses and their bodies in a way like never before, and they’re turning to the internet for that knowledge. Dr. Oz was both thrilled and concerned; thrilled that patients have a new thirst for knowledge, but concerned that sometimes the information they find is just plain wrong.

So he created a unique one-stop shop for medical knowledge called Sharecare. Dr. Oz has assembled an awe-inspiring collection of world famous medical experts, who are tasked with answering a multitude of health and wellness questions posted by people who want to understand their health better. The quality of the content is controlled both by limiting who can create it, and by providing multiple points of view.

Are you sitting down? Among these Experts is… drum roll… me.

Yeah. I can hardly believe it myself, but three times a week, I troll the site reviewing diabetes questions, diabetes medication questions, and diabetes gear questions. When I find a question that needs my touch, I answer it. Sometimes I’m the first one to answer it, sometimes I’m only one of many Experts to chime in.

And every once in a while I find other types of questions that I know about. Access to care. Stuff about cholesterol. Health politics and policy.

I’m having a blast, and I’ve decided that every week I’m going to share one of my favorite questions with you here.


Sharecare Question: Can stress affect my blood glucose levels?


My “Expert” answer: It was easier back in the days when we were cave-people. Imagine that you are walking along, gathering nuts and berries when all of the sudden a saber tooth tiger jumps out of the bushes.

What would you do? Right. Scream and run like @#$%!

And that's what the little organs on top of your kidneys are for. They let you run faster (hopefully) than the hungry cat. They are called your adrenal glands and they pump a hormone called adrenaline into your blood giving you a momentary boost in energy, speed, and strength. It’s your body’s turbocharger for getting out of danger.

So stress, in this case fear, causes this boost of sugar-like hormone. Back in cave-people days when something caused a blast of adrenaline, you most likely used it up right away, so it did no harm to your body.

Now, the problem these days, is that we have no saber tooth cats to stress us out, arguably a mixed blessing. But today’s stressors are not things you can run away from. Dropped cell phone calls. Traffic jams. A letter from the I.R.S. Any of these things, and a great many more, will cause stress, and that will lead to an adrenaline release, which will raise your blood sugar so that you can run away. Except you can’t run away from these things, so often your blood sugar will stay high for long periods of time.

If you are really stressed out, your sugar may be elevated all of the time. So what can you do about it? Well, if moving to Aruba and living on the beach forever is not an option, any of the following may be: exercise is often a great stress reliever, and helps work off the adrenaline to boot. If you work in a stressful environment, give yourself some sort of personal ritual at the end of the day to leave the stress at the office. Depending on your diabetes medication, an increase may off-set the elevations in sugar caused by stress. You can discuss that with your doctor.

But, and this is important, stress affects more than just your blood sugar. It can raise your blood pressure. It can affect your muscles and bones. It can affect your friendships and loved ones. So high blood sugar is just one of the negative impacts of stress. Stress, like any other illness, needs to be treated before it makes you sick.


You can check out other Expert’s answers to this question, and my answers to many more questions by going here:

http://www.sharecare.com/user/william-lee-dubois

Then select the “Answers” tab near the top left.

Train wreck

I’m trying to think of something nice to say.

My patient is studying his hands, not wanting to make eye contact. He squirms in the side chair. My desk is flat against the wall, as not to come between me and whoever I’m working with. I always sit sideways, facing my patient, wireless keyboard on my lap. I’m blessed that I learned to “touch type” when I was young. I can make chart notes while keeping eye contact.

Of course I’m not typing at the moment.

On the corner of my desk is a wooden Lazy Susan, which holds my computer monitor. Right now it’s angled so we can both see the download from his Presto meter. We’re viewing the graphic Average/Spread report, an X/Y graph that records two week’s worth of fingersticks overlaid by time and level of blood sugar, and the view isn’t pretty.

Well, Victorio, this is pretty bad…

The lowest morning fasting number is 323 mg/dL. The highest is simply off the chart, denoted by a little triangle at 600 mg/dL. On average, his day starts around 350 and drifts up into the mid 400s. He’s dying right in front of me, and doesn’t know it.

“Worse than the time when you said I was a train wreck?” asks Victorio.

I laugh. Did I really say that? Wow. That’s harsh.

Victorio is one of those guys who gets his shit together, gets his diabetes under control, then starts drinking—and I mean really drinking—and spins out of control again. It’s a repeating cycle you can count on better than the ground hog. But this is the worst I’ve ever seen his blood sugar in four years.

He gives me a lopsided grin.

Yeah. Worse. A bigger train wreck, I suppose.

I drum my fingertips on the edge of my desk, bad habit of mine when trying to jump-start my brain. Apparently I do it frequently enough that my patient’s know it means I’m thinking. Trying to come up with a solution. Victorio maintains a respectful silence.

How are you feeling? I ask.

“Pretty good,” replies Victorio.

Any blurry vision?

“Well… yeah, actually.”

OK. Are you peeing a lot?

“Some, I guess.”

How many times per night do you get up to pee?

“Oh… a couple. Four maybe. Sometimes five.”

Uh huh. So, how’s your energy level?

“Well, to tell the truth, I’ve been feeling a little run down lately.”

My fingertips are drumming again.

The A1C machine let’s out it’s long beeeeeeeeeeeeep!

I crane my head around to see the glowing blue-green readout. An 11.5, much lower than I would have expected, given his meter readings. I pick up a circular cardboard slide rule from the ADA, spinning the top layer around to line up the little arrows with the A1C level. The ADA also has an online calculator and a pocket electronic one, but frankly, I find the old-fashioned conversion wheel to be the fastest. Victorio’s estimated average glucose, or eAG, appears in the little window. 283 mg/dL.

eAG is simply a way of converting A1C scores into meter-speak, which we all understand better. It’s hard to internalize that 11.5% of the surface area of your red blood cells are coated in glucose molecules. Doesn’t sound so bad… But when you know that an A1C of 11.5% means that your night and day average blood sugar is 283, well now, that is something we call all grasp. We get that. I’ve used eAGs since they very first came out a number of years ago, and I think it’s one of the better things the ADA has ever done for us. Which isn’t saying much, I guess.

But like I said, I was expecting a higher A1C for Victorio, so as soon as I saw the 283 in the eAG calcualtor’s window, and I knew in a flash what had happened to him.

Abruptly I ask, Did I ever tell you about the prairie dogs?

“Uh, prairie dogs? No. In don’t think so,” says Victorio, surprised.

OK, so picture a nice sunny day. It’s warm, with just a hint of a breeze. And all the prairie dogs are sitting up on top of their little mounds, like they do, you know?

“Sure. They sit up on their hind feet and hold their front paws like this,” says Victorio, holding his hands up in front of his chest, fingers down, in a very good imitation of a prairie dog.

Yeah. Exactly. But all the sudden a bald eagle flies over, casting his shadow across the prairie dog town. What’s going to happen?

“The prairie dogs are going to dive for cover. They’ll go back down into their holes.”

Exactly. Now your beta cells in your pancreas, the ones that make insulin, are prairie dogs. And your blood sugar levels are the hungry eagle…

Victorio is suffering from glucose toxicity. When the blood sugar gets high enough, the beta cells freak out and shut down, like prairie dogs ducking for cover. It’s almost like a temporary Type-1 diabetes, and it can get out of control pretty quickly. Think about it. Super high blood sugar with insulin, and all the sudden insulin production shuts down. Glucose toxicity is about the only circumstance in which a Type-2 diabetic can go into a coma, although it still takes a heck of a lot longer to happen.

The treatment is pretty simple. We’ll put him on insulin and titrate it up promptly. He’s not a tall guy, but he has a heck of a beer belly, so he’ll increase his insulin by two units per day until his sugar starts heading to normal levels. I don’t know how long it will take the prairie dogs to get over their scare and come back out of their holes. Once his average blood sugar is below 200, the beta cells will start working again. Sometimes they’re back on the job in a week or two, sometimes it takes a month or more.

Once his body is producing insulin again we can probably pull the plug on the shots and return him to his oral meds. And he’ll do fine.

For a while.

And then he’ll start drinking again, and the once and future train wreck will be back in my office, studying his hands, and not wanting to make eye contact.

The Saturday Share #1

Did you know that health topics are the number one internet search item, outstripping even porn? Uh… pardon the Freudian slip there...

Dr. Oz—yeah the Dr. Oz—recently stated that we are living in a “renaissance of medical knowledge.” He’s seen that patients have the desire to understand their illnesses and their bodies in a way like never before, and they’re turning to the internet for that knowledge. Dr. Oz was both thrilled and concerned; thrilled that patients have a new thirst for knowledge, but concerned that sometimes the information they find is just plain wrong.

So he created a unique one-stop shop for medical knowledge called Sharecare. Dr. Oz has assembled an awe-inspiring collection of world famous medical experts, who are tasked with answering a multitude of health and wellness questions posted by people who want to understand their health better. The quality of the content is controlled both by limiting who can create it, and by providing multiple points of view.

Are you sitting down? Among these Experts is… drum roll… me.

Yeah. I can hardly believe it myself, but three times a week, I troll the site reviewing diabetes questions, diabetes medication questions, and diabetes gear questions. When I find a question that needs my touch, I answer it. Sometimes I’m the first one to answer it, sometimes I’m only one of many Experts to chime in.

And every once in a while I find other types of questions that I know about. Access to care. Stuff about cholesterol. Health politics and policy.

I’m having a blast, and I’ve decided that every week I’m going to share one of my favorite questions with you here.


Sharecare Question: How can I manage my diabetes during the holidays?


My “Expert” answer: Yeah, it’s a tough time of year: temptations abound, there’s unique social pressures, and our schedules are a mess. The best way to manage is one day at a time, and accept that it may not go according to plan.

Starting with the social stuff, it’s your right to defend your health, and it’s not impolite to do so. You can simply say, “I’m sorry. I’m diabetic, I can’t eat that. But thank you so much for offering, I really appreciate the thought.”

Someone who didn’t know about your diabetes may feel bad momentarily, but at least they won’t give you a fruit cake again next year. Never sabotage your own health simply to try to avoid hurting other people’s feelings, or out of some sort of miss-placed notion of what’s socially acceptable. Nor should you be in anyway embarrassed to have diabetes. It’s not like you have a sexually transmitted disease, after all.

Another problem this time of year is that you’re exposed to things that tempt you, that might not normally be in your environment. One of your co-workers will bring in freshly baked brownies.

One option is to “taste” the goodies and stop there.

Me? I soooooooo can’t do that. One bite leads to two, which leads to three, and then my blood sugar shoots up and I’m high anyway so I might as well eat 14 brownies and…

Well, I guess it’s clear that I’m a better tour guide than role model. So if you, like me, have little self control, and no control over your environment, one coping option is to keep a supply of healthy snacks on hand. They break out the white chocolate chip macadamia nut cookies, you break out the beef jerky. Chewing sugar free gum throughout the holidays also works for some of us D-folk too.

So normally you hit you treadmill at 5 a.m., but now your mother-in-law is camping out in your home gym/guest bedroom? Exercise patterns are messy this time of year, and the risk is, if you get out of the habit, will you ever get back in the habit?

I think a little pre-planning can go a long way. Move your treadmill to your bedroom for a week or two. Or do sit-ups on the bathroom floor instead. Just get creative, but keep moving.

The most important thing, however, when it comes to the holidays, is remember that it’s OK to be human. If you eat things you didn’t want to, if you fall off the sugar-free wagon, don’t beat yourself up about it. No guilt. Dust that powdered sugar off your hands and start over.

Don’t look back for even one second.

You can check out other Expert’s answers to this question, and my answers to many more questions by going here:

http://www.sharecare.com/user/william-lee-dubois

Then select the “Answers” tab near the top left.

Teaching

The silence is deafening.

Even more so following the non-stop rush and crush of people over the past two hours, now all gone their hundred separate ways.

The small room remains hot from so many bodies packed in together. My shirt is sweat-soaked beneath my corduroy sport coat. In the center of the room are four long tables pushed together to form a larger rectangle. I survey the mess and sigh.

Time to clean up.

Strewn across the tables are pen needles, caps, needle sheaths, infusion set tubing, disposable inserters, and syringes. It looks like the refuse from a diabetes orgy.

Time to clean up.

I start sorting. No one bothered to bring a sharp’s container. I very carefully re-sheath naked needles and throw them into the center of one table. I’ll box them up when I’m done and take them to the clinic for disposal on Friday. Needle caps, paper debris, dead infusion sets go on another table, destined for the trash can. Stuff I can use again goes on a third table.

I undo the brown leather belt that holds my father’s briefcase closed. The right side latch is broken off and long lost, but it’s a still nice college-professor case. Deep reddish-brown leather. Smooth and soft to the touch.

There’s a brief burst of group laughter down the hall. From the pharmacology lab, oddly enough.

Yep, I’m in Albuquerque, at the University of New Mexico’s School of Medicine. And I just finished doing one of the things I enjoy most. Teaching.

Teaching runs in the blood. I grew up a “faculty brat,” both my father and grandfather were college professors. And as such I’m no stranger to college campuses. I’ve spent a lot of time on college and university campuses, both large and small. Some of my favorite memories of my father from my early 20’s was meeting him for lunch every Wednesday at the Faculty Club at the University of Northern Colorado, on the old campus.

The old campus and the new campus were literally side by side. Crossing a two-lane road took you from one to the other. The new campus was a place of wide open spaces and funky modern buildings. It would have been a great location for a sci-fi movie. The old campus was a place of tall, thick trees and solid stone buildings covered with climbing ivy. The type of place that would have been a great location for a movie about academicians.

The Faculty Club itself had an old-world quasi-Victorian feel to it. The food was good too, as I recall they made a killer Monte Cristo Sandwich.

But in my experience, the University of New Mexico campus, where I am today, stands in a league of its own.

It’s simply gargantuan.

The main campus encompasses 350 buildings sprawling over 769 acres of central Albuquerque. These buildings add up to almost 11 million square feet, the equivalent of 600 Wal-Mart Super Centers. The main campus’ libraries hold two and a half million volumes. Fourteen thousand people work here, and another fifty-four hundred man University Hospital.

Most of the work I do for the University—thank God—is via telemedicine, either from the comfort of my home library or my clinic office du jour (I’ve had three offices in six years, and rumor has it I’ll be moving again in the coming months).

About once a month or so, I actually do have to drive the two and a half hours to the University in person, but it’s often to the offices of Project ECHO, which sit in a building of their own just outside the main campus and just off the freeway—in, out, and on my way again. There’s an out-of-business car dealership right next door, so parking is never a problem.

But a couple or three times a year, I’m required to go to into the heart of the main campus itself, either to the School of Medicine or the University Hospital.

When I come here it is with a mix of dread and thrill. Remember that I live on 20 acres in the middle of nowhere. If I’m not working from home I’m working at a clinic in a town that has no stop lights. I’m not really a country bumpkin, but I might have been bumpkinified a little bit over the years. So coming to the heart of this mighty campus is both exciting and nerve wracking; a bit like riding roller coaster.

As I drive through swarms of traffic and fight for parking places I always swear I’ll never come again. But once I’m here, the rarified air is stimulating and I end up having a good time. Plus, there’s a Starbucks not too far away.

Today I was teaching diabetes technology: pens, pumps, and CGMs. It’s ultra quick intro time for student doctors finishing up their second year. They are young and smart and energetic. Pretty much everything I’m not. There are one hundred of them, in groups of 25, rotating every 20 minutes between my class room and three others.

Speed learning.

I’ve brought lots of hands-on goodies, and a super-quick Power Point. The School of Medicine loves, loves, loves Power Points. I, however, do not. I suffered near death by Power Point too many times. That said, used right, it has its place.

The students crowd in, a hush falling over them as they spy needles, strange devices, and tubing scattered across the tables. I introduce myself, then it is time for fun.

Like a ring master, standing in the spotlight of the laptop projector, I hold an insulin pen. I point it upwards and click-click-click-click-click-click-click-click the plunger home with my thumb, squirting a stream of expired insulin into the air, sparkling droplets glisten, liquid diamonds floating like butterflies, like rain descending through shafts of sunlight. We dive in.

Why do we tap the air bubbles out of our syringes?

“To avoid an embolism?” asks one boy.

You’re over thinking it. The shot goes in the subQ tissue, you can shoot as much air as you want with no risk. What problem can the bubble cause us?

“Could it displace the volume so you wouldn’t get the right amount of insulin?” asks another boy.

Bingo!

This is how you put the pen needle on. I throw the paper in one direction, the needle cap in another, and the sheath in a third direction. How often do you think patients are supposed to change the needle? How often do you think we actually do?

And then it’s time for the next group.

Why do we need a quick disconnect on our infusion sets?

The guesses flow in: in case you go too low; for taking a bath; in case you get your hose caught; in case…

What else?

“Sex?” asks an embarrassed female voice near the back of the room

We have a winner.

“Wow, I would have never thought of that,” says another girl near the front.

You study too much, I tell her. She blushes.

And then it’s time for the next group.

I snap an old CoZmo infusion set onto a red blood cell stress ball, then pull it off so they can see the cannula. I tell them insulin pumps are just fancy syringes, they don’t replace your brain. I show them a dismembered Omni Pod and explain how it is different from traditional pumps.

“All those circuit boards and batteries get thrown away every three days?” asks a student.

Yup. And do you think we D-folk care?

And then it’s time for the next group.

My CGM is passed around the room, complete with an embarrassing three hour trace, while I show them a projection of a sensor daily over lay report. What it can tell us and why they don’t have time to look at it during a 15 minute office visit.

You need to trust your educators.

And then, sadly, it’s over. Their excited voices echo down the hall as they head off to other classes.

And the silence is deafening.

Insulin pump follies

The CGM buzzed in my ear. Twice.

WTF?

The only light in the room is the glowing screen of the Dexcom.

Groan….

I fumble for the monitor, half-hidden beneath the bed sheets. Two buzzes means a high or a rise alarm. If you sleep though the buzzes, she’ll squawk at you.

I’m at 351 mg/dL and going up quickly. My mind tries to grasp the fact. How on earth? It’s 2am. I can’t think clearly. But I didn’t have any dinner…

I went to bed at 114 mg/dL…

My basal rate can’t be that far off…

Infusion set?

I turn on the bed side lamp and, squinting as my eyes adjust to the brightness, I check the site. Looks good. Nice and tight. No damp skin. No band-aid smell of insulin. I wiggle the hub to be sure. Then I disconnect and reconnect to be double sure.

Everything looks A-OK.

Well, it has been a stressful evening. I sent one of my little T-1s to the Emergency Room this evening. Her mother called around eight. The kiddo had been high all day, and didn’t respond to corrections as well as usual. Turns out her cannula on her OmniPod got dislodged. By the time I was on the case she’d been above 400 for six hours and was complaining she felt sick.

At first I dithered a bit. We know the problem. She didn’t have insulin for quite a while. The problem is resolved. The insulin will catch up. The blood sugar will come down. The mother checks for ketones, which show up dark pink on a urine stick. So between moderate and high. We don’t yet have a blood ketone meter for the child.

The insurance company does not want to pay for the strips.

The kiddo hasn’t thrown up. In fact she just asked for a slice of bologna. Good sign she’s not feeling nauseated. And she’s not panting, which would be a very bad sign. But she does have fruity breath.

All of this adds up to her being well on her way to Diabetic Ketoacidosis, or DKA for short. DKA happens, generally in T-1s, when the blood sugar is too high for too long and there is little or no insulin in the system. We pumpers are more at risk from DKA because we don’t use basal insulin, those specially formulated insulins that time-release over 24 hours. We get our basal needs covered by a constant drip of fast-acting insulin from the pump. Unless the pump fails or the cannula gets pulled out somehow. In which case you have no medicine for what ails you.

Everyone’s diabetes varies, but figure that six hours above 300 in the absence of insulin can get you into a world of hurt. What’s happening is that your cells are starving in a sea of plenty. Even though you are chock full to the gills with sugar, in the absence of insulin, none of the sugar can get to the hungry cells. They start eating their shoe leather and… no wait… that’s castaways. They start eating fat instead of sugar, and like the smoke from a camp fire, the burning of fat creates a toxic waste called ketones. Ketones shift the pH of the blood, making it more acid.

Bottom line, untreated, this will kill you.

Lucky for us the treatment is related to the cause. Just add insulin.

So back to our sick kiddo. I’m sure the blood sugar will resolve. The ketones will pass. That’s not the real issue. I’m worried about the “Kay” as we call it. Kay, actually spelled simply “K” is a resident of the periodic table of elements, located at number 19, known more formally as Potassium.

Potassium is one of the kitchen soup of elements that are part of parcel of our bodies. The reason we’re even talking about this is that when someone is DKA or DKAish, funky things happen to the potassium levels in their blood. Generally speaking, as you re-hydrate (remember that DKA will dry you out from increasing urination and vomiting and all of that), your potassium falls. Sometimes pretty damn quickly. And the reason that matters is that low potassium can affect your heart rhythm. Bad and scary stuff.

But she’s sort of borderline. Not quite DKA. Not quite OK. I weigh the various facts and figures for a full 90 seconds before I finally get my head out of my ass. Why am I even thinking about this? The patient is a child.

Take her to the ER, I tell the mother.

“Are you sure?’ she asks, shocked.

No. I’m not. So take her to the ER now. It may be a complete waste of time, but the alternative is unthinkable. Go now.

This is the second pump failure of the week. Two days ago, one of my middle aged T-1s ended up seriously DKA after her Med-T infusion set got pulled out. She got to the throwing up on her shoes stage before she came in for help.

It has been postulated that the genes that lead to T-1 are the same ones that govern self-reliance to the degree of stubbornness.

So back to my dark bedroom, I reel in the infusion set to find my CoZmo pump. As the set checks out, I’m thinking the best plan is to just go ahead and take a correction bolus. Maybe the stress of the evening just took its toll on my blood sugar.

I press a button to wake up the pump.

Nothing happens.

I press again.

The screen is blank. Dead. I stare at the eight thousand dollar paperweight, unable to process the facts through my sleep deprived hyperglycemic mind.

My pump is as dead as a door nail. Holy crap.

We all know that technology can fail, but it is supposed to happen to other people, not us. I must have sat staring at the blank screen for ten minutes. Not sure what to do next. Then the stomach cramps kicked in and my brain kick started.

Take a shot, take a shot, take a shot, take a shot, take…

I stumbled through the dark house to the kitchen, a.k.a. the insulin storage vault. About this time, I remembered that I had put a fresh battery in my pump before bedtime. Actually, it was about the time the phone rang, when I got the frantic call from my little patient’s mother.

Could I have put the battery in backwards and not noticed in all the confusion? After all, who looks at their pump unless you’re gonna use it, or it vibrates, beeps, or squawks at you? I fished my key chain out of the bucket were I throw my wallet, watch, day-meter and strips, medic alert, pen, box cutter, and pipe lighter when I come home from work. The key chain has one of the more useful gifts ever given to me on it. A “coin” the exact size of the slot on my pump’s battery lid. It a hole to slip it onto the key chain and has the graceful Animas logo on it.

I use the coin to unscrew the battery lid on my discontinued (but beloved) CoZmo. The battery is in right. Damn.

For the heck of it, I grab another battery out of the bucket and put it in the pump. Nothing. No shudder of a vibration followed by beep-beep-beep!

This doesn’t look good for the home team.

In a last ditch effort to jump start my pump, I go find my go-bag, hanging on its hook by the front door. Inside is the last AAA battery in my world (yeah, I know, it’s pathetic but money has been tight.)

I slide it into the battery chamber. Slip the lid on. Screw it down.

The pump shutters to life. YES!!

So, dumb ass (that would be me) somehow ended up with batteries that should have been thrown in the trash pitched instead into his spare-parts bin. I probably took them out of some device and left them on the table with intentions of throwing them away later. Serves me right. Later on, my wife must have thrown them in my bucket, assuming—sensibly enough—that if someone left them on the kitchen table (rather than putting them in the trash only three feet away) that they must be good.

The lesson here is that routine is a mind killer. Let’s look at our actors in this little play: middle aged diabetic who has been pumping for years, a child with a super-smart Type-3 mom at the helm, and a diabetes educator for Christ’s sake. Three people who you think would be paying better attention. Well, actually, it’s not that we weren’t paying attention, it’s that we are so blessed that things rarely go wrong that we get caught flat-footed when they sometimes do.

So my bottom line is this—next time you have a high that doesn’t go away do the following:

Check to make sure your infusion set is still attached to your hide.

Check to make sure your cannula is still poking through your epidermis.

Check to make sure you didn’t put dead batteries into your pump.

Don’t get too comfortable. Banana peels are equal opportunity.

The Gift

If you think giving away a stray cat is hard; try giving away a tiger.

Actually, I confess. Before I tried giving this particular beast away, I did try to sell it. You know, so I could buy something more useful. Like an elephant.

So let me tell you why I decided to give up on being a tiger tamer. Well, actually, to tell that story I guess I’d better tell you why I joined the circus in the first place.

Once upon a time… (the scene fades to black and white for that ol’ tyme look)…

Confession: while I’ve had a number of really funky jobs in my nearly five decades on the planet, working for the circus is actually not one of them. I was, however, the guy who cleaned the piranha tanks at a tropical fish shop, a security guard at a nuclear power plant.. and at a rodeo… and for one (horrible) day a laborer for Ready Man Labor. I was also a Colorado Licensed Fur Trapper for the Ft. Lewis College Psychology Department (we were trying to trap a coyote and put an radio telemetry collar on it for an animal behavior study); trust me on this, these critters live up to their reputation as wily. I also fed 100 head of cattle every morning before dawn in return for free rent, but the place literally had no insulation. I could see my breath in the morning while brushing my teeth. Besides, the only thing I really like about cattle is eating them.

Oh yeah. And I was a bouncer at a nudie bar. Actually, that job wasn’t so bad…

And why, you might wonder, would a stable, up-standing citizen like me have so many different jobs? Well, because the jobs were not what I did. They were how I kept from starving while I did what I really love to do: write.

CafePress has a coffee mug that sums it up perfectly, but I can’t afford it right now:

I also like the one that has the word “Author” warped to look like the Superman logo and the one that says “What came first? The writing or the drinking?” But that’s just me. They had one that reminded me of my sister, too. It says “Will write for chocolate.” She’s a professional playwright and has also had some interesting jobs in her life. But I digress.

Writing seems to come easily to my family. We don’t generally suffer writer’s block (although I frequently write my way into a corner); nor do we find it a torturous process. Quite the contrary, we find it joyful.

So it simply strikes me as natural that when I see a problem, I want to fix it by writing about it.

(The scene fades back into living color)…

Of course, all of that was before diabetes. As you know, diabetes changes everything. But for me at least, many of the changes were for the better. For instance it gave me better focus. Oh, and that whole small, but steady, paycheck thing.

That said, for the last five years I’ve been guilty of making a huge mistake in my life. I made the mistake of thinking of myself as a medical professional who also just happens to write.

That’s wrong. And nothing could be further from the truth. For lots of reasons. Yes, I work at a clinic. And yes, I’m a de-facto diabetes educator. But I’m not a doctor, or a physician’s assistant, or even a nurse. I have knowledge, and a hell of a lot of it, but I have no license. No certification. I’m just a lowly community health worker with about as much clout in medicine as the janitor.

In the medical world it really doesn’t matter how much you know. All that matters is what initials follow your name. Several of my better pedigreed colleagues readily admit that I know more about diabetes than they do, and are modest enough to seek out my council. But that doesn’t mean that they even for one microsecond think I’m part of the fraternity.

No way.

The problem is that men, including even testosterone-lite ones like me, define ourselves by what we do. It is both genetic and cultural. And believe me, even if it sounds silly to you females, it is powerful and impossible to escape. What we do is who we are.

Working for years in medicine, I forgot who I was. I, like Incurs, flew a bit too high and got my wings singed.

It serves me right in retrospect because I not a medical professional, and never will be. My name ends with the last letter of my last name. Nothing follows it. But who the fuck cares? The real truth, that I was slow to recognize, is that I’m a Writer who also just happens to work in medicine.

I let a certain lack of respect for my knowledge weigh more heavily on my soul than I should have, simply because I miss-defined myself. Now that I woke up and remembered who and what I am, the little shit doesn’t bother me anymore. I’m on a pretty shaky foundation when it comes to being a medical professional. But as an Author, I’m on a pillar that’s not so easily toppled.

So for those of you who were worried about my mental health. Worry no more. I remember who and what I am, I’m sleeping great at night, my back isn’t bothering me, and I’m not buying Pepto-Bismol in bulk anymore. And for those of you who’ve been with me for a while, know that the “human tumor” can’t touch me on the ground I’m standing on now.

Does all of this mean I’ve given up on helping my fellow d-folk in the arena of medicine? Hell no! I may not be a medical professional, but as a medical journalist I’m still in a heck of a good position to take the messages of doctors and make them understood by patients, and take the messages of patients and make them understood by doctors.

So I’m still an advocate. Maybe a better one for having gotten my head out of my ass.

And thus we get back to homeless tigers.

As a Writer who works in medicine, I’m a bit of a war correspondent. I’m stationed on, and reporting from, the front lines of the diabetes epidemic. More than 4,000 Americans are diagnosed with diabetes every day. And just last week, the CDC announced projections that by 2050 (which is much closer than it sounds), one in three Americans will have diabetes.

Oh. My. God. That’s 33% of the country. If this keeps up, we’ll be the majority. Can you imagine. An entire country of chronically ill?

Anyway, last summer, back in 2009, before the whole 1 in 3 thing, I could see that things were bad. Every week we were diagnosing someone with diabetes, generally Type-2. The emotional effect was devastating on the patients. They were terrified. Here in northern New Mexico they carry the family legacies of bad outcomes. They remember grandparents who lost their sight, their limbs, their kidneys, and their lives to diabetes.

They were also sick. Months and even years of hyperglycemia typically proceed an diagnosis of Type-2. It is a slow, creeping killer, wreaking havoc and damage before it reveals it’s face. The fast progression to the ER in Type-1 Diabetes is actually a blessing in comparison.

I was privileged and blessed to be on site at the moment of diagnosis to help these folks cope. To let them know it was not the end of the world. That they’d be OK.

But the math was bad. One of me and 4,000 a day of them. That would give me 21.6 seconds per patient, per day, if I never slept, ate, or drank. Not going to happen.

So I knew what I had to do.

I had to write.

About it. For it. For them.

And it had to be simple. Just the basics. Just what you need to know in the here-and-now. And it had to carry a positive message, because even though it doesn’t seem like it on the day it happens, a diagnosis is diabetes is probably not the worst thing that will ever happen to you.

In short, what these 4,000 people a day needed was a first year survival guide.

So I wrote one.

Now I’m not a complete idiot. A partial one, perhaps, but not a complete one. I knew that no one who was newly diagnosed was going to go to Amazon and buy a book. They just want to go home, go to bed, and pull the covers up over their heads. Forever.

I had innocently assumed that I could get some sort of grants to pay for books that could be given to doctors to give to patients at the time of diagnosis. The problem is that my publisher is not a non-profit. Well, they aren’t making any money whatsoever, but they are not technically a non-profit. Hope springs eternal. Anyway, most grants only go to official non-profits. Besides which, the grant wells have gone dry in this economy.

With great reluctance I turned to the deep pockets and questionable ethics of big Pharma. I contacted every company in the United States who sells diabetes drugs, meters and strips, or gear.

I started by offering them awesome discounts. No takers.

Then I offered books at cost. Still no takers.

Then I offered the high-res printing files for free. Still no takers.

By now I was getting… frustrated. Several hundred books were out in the world, mainly ones I paid for, and a small CDC grant to my clinic got the book translated into Spanish. To avoid conflict of interest no one made a penny, of course, but my publisher got to keep the rights. I think they have sold exactly one copy of the book in Spanish. Ever.

But what few copies were out in the world generated tremendous feedback. The little pocket book was really helping people through the diagnosis experience.

But not for enough people.

Finally, I had a light-bulb moment. If no one else will give it away, I will. Of course, as noted above, I have no money. But in this modern world of bits and bytes there is a way to give a book away without spending a penny.

An eBook can be a free book.

So that’s what I’ve done. I’ve created a low resolution PDF appropriate for reading on screen. Why low res? Well, because charity only goes so far. I put a lot of time into writing the book. Just because it is small does not mean it was fast or easy. In fact, writing concisely is often harder than going on, and on, and on.

Ummmmm…. Not quite sure what that says about my habit of writing very, very long blog posts…

But ignoring that for the time being (and probably forever), let us not forget that Red Blood Cell Books has put a lot of time and money into this too. To just let anyone print it doesn’t seem right. I also worry that various printed versions might be of low quality. That reflects on both my image and my publisher’s image.

So download it for fee. Read it for free. But if you want a physical copy, get out your damn wallet.

Which brings us back to the stray cat. The files are good to go. All the permissions are in place. Anyone can take them, download them, read them, post them. The rules of engagement are simple: make no money; charge no money.

There’s a link embedded in the black logo box at the top left of this column. It’ll take you to a page at the Red Blood Cell Books site that has the PDFs and the art work. Please help yourself. Or you can link to the page I just directed you to. It has been isolated from the rest of the Red Blood Cell Books web site to make it as un-commercial as possible.

Post it. Email it. Twitter and Tweet it. Facebook it. Please spread the word.

Because I need your help to get this little book to 4,000 people per day. Whether you are a patient, a medical professional, an advocate, a Writer like me, or if you are the other kind of writer (quoting now from another CafePress coffee cup):

“Writer. (ri-ter). Noun. Person who spends all day drinking coffee and posting on Facebook while pretending to write a novel.”

I need your help spreading the word. ‘Cause I hate marketing and I’m no good at it. Because:



PS: Special shout out to the following who are already helping spread the word: PS: Special shout out to the following who are already helping spread the word:

Ninjabetic
Diabetes Daily
tudiabetes
Hello Cupcake