I spent this morning at a local school, providing an in-service on insulin pumps with the RNs and staff. As we went through a review of type 1 diabetes, and the possible addition of insulin resistance through adolescents (both physiological and greater potential with added adiposity), I am reminded again how complicated type 1 diabetes really is. Then add to that the frequency of dysfunctional families, split families, and over the top busy families, and the scene of how to manage diabetes becomes even more complicated. One young lady has type 1 diabetes, Down’s Syndrome, heart failure and a split family. What a challenge for the family and care providers it can be.

When I returned to my desk, I received an email from a patient who skis in the backcountry. Reduction in basal rates while skiing is perfect, but often results in hyperglycemia post exercise and potentially hypoglycemia nocturnally. Adjustments are made with every trip, but each trip is really different in intensity and duration. So it is always checking, checking, checking and making adjustments on the fly, even when utilizing historical data on trends and patterns.

Last week, a patient with cystic fibrosis and type 1 diabetes was admitted to the hospital and developed a severe low about 4 a.m. Was it the insulin dosing? He was on a tube feeding during the night, and due to a violent reaction to his medication, his tube feeding was discontinued as he was wheeled to ICU; no one thinking of the consequences of the elevated basal dose of insulin to cover the overnight feeding.

This is the life of the patients we work with and the challenges of being part of their support system. It is so important to problem solve with patients, help them see the way, and be completely non judgmental on hyper and hypoglycemia. Even with those who manipulate insulin to gain attention or weight loss, getting back to reflecting on the results, the potential consequences and the possible solutions is a day to day challenge.

I bring these situations up, because I think it is important to always keep in mind that working with patients with type 1 diabetes is like trying to put a puzzle together. It is true for educators as well as for our patients. We can provide support every step of the way, and be a place they can come to and share their frustrations and be honest, without verbal abuse or accusations.

I hope I can always be a good listener, and focus on the problem solving in a non judgmental way. What challenges have you faced in your practice that remind you of the lack of a template for type 1 diabetes management? How do you help frustrated type 1 patients?