Atrium Health doctor Mark Vanderwel answers questions on the minds of many parents these days. We will be adding a transcription later today. Quick turn around on this episode! If you saw the original Facebook live, skip ahead 17 minutes – it dropped out after some audio issues but Stacey & Mark picked it back up again, off of FB.
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Stacey Simms 0:00
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This is diabetes connections with Stacey Sims.
Stacey Simms 0:24
Hey everybody, welcome to another episode of the show. So glad to have you here. I hope these episodes are helping. Today we are talking with a pediatric endocrinologist starting off by talking about Covid 19, of course, and things that people with diabetes specifically type one needs to keep in mind but then going down the line of listener questions things that my local Facebook group chimed in with things that the diabetes connections group chimed in with. Because if you’re not seeing your endocrinologist for longer than expected, which is the case for a lot of us kids and adults, what should you You’ll be doing and that’s a lot of what we talked about what to do in between how to make sure that you are taking care of what you need to take care of some things you might not have thought about. And just a great chat with Dr. Mark Vanderwel, this was originally done as a Facebook Live Alright, that’s only half the truth. This was originally done as a stream yard which is a an audio and video hosting system hosted Facebook Live, which crapped out halfway through and then mark and I jumped onto zoom and record it that way. So the whole video I kind of stitched it together. The whole video is up on YouTube, on diabetes connections there. It is also on our Facebook page. And here is the audio. That’s what we’re running is the audio of the initial Facebook Live and then everything that you didn’t hear. So if you watch the Facebook Live already, the new stuff is about 17 minutes in from the beginning of the interview. If you want to skip ahead, I’m not coming back at the end of the interview.
I do want to say, though, that I appreciate all of the messages I’m getting about, you know, putting out episodes. Look, we’re all looking for things to do at our homes. We’re all looking for good, reliable information. I am hoping to do more episodes like this more zoom Facebook stuff. So let me know what you’d like to hear. I’ve also been collecting audio from you from people in the audience. And I’m going to be releasing that episode and kind of figuring out how to use that great audio people just keep me posted on what’s happening in their homes and what’s on their minds. So I’m not really sticking to a schedule. And I guess what I’m trying to say is, I’m sorry, if you were expecting every episode on Tuesday, and sometimes on Thursdays like we normally do, but I don’t know about you. I’ve already lost all track of days of the week. So we’re just gonna put out episodes when they’re ready to go. And if you want to still listen on Tuesdays, that’s awesome. If you want to let me know that that is or isn’t working for you. That’s great, too. I just think we all need to be here for each other in these wild times. Thank you so much. All right, so here is my talk with atrium health Dr. Mark Vanderwel, welcome to everybody who is watching. I’m so glad to have you with me for this little bit of an unusual circumstances bear with us. This is the first time I’ve done something like this. I am Stacey Simms, the host of diabetes connections and with me is Dr. Mark Vanderwel, a pediatric endocrinologist here in the Charlotte, North Carolina area with atrium Health. Dr. Vanderwel. Thanks for joining me,
Dr. Mark Vanderwel 3:26
Stacey. It’s an honor as always,
Stacey Simms 3:29
well, we should say before we get going, we do have some disclaimers. But the very first thing in full disclosure that people need to know is that this is my son’s endocrinologist and I’ve known Dr. V, as I’ve called him many times on the show and in my book for more than 13 years now. So we’ve never done an interview.
Dr. Mark Vanderwel 3:48
Yeah. At least recorded interview for for diabetes connections. We did some back in your radio days. Oh, that’s right.
Stacey Simms 3:56
Yeah, I thought you were implying that I like interviewed you when I All right.
Dr. Mark Vanderwel 4:02
So it has been a long time since we’ve communicated it never on this platform.
Stacey Simms 4:05
Well, I really appreciate you jumping in because as you know, people have a lot of questions nervous times right now. So the The first thing we need to do is is do some disclaimers, obviously, while Dr. Vanderwel is our pediatric endocrinologist, he is not yours. So please, any comments questions that you may have addressed them to your own physician as well? Nothing I will put words in your mouth here, nothing that Dr. Vanderwel says today should be taken as your own personal medical advice. We’re here to get general answers to general questions. And that’s really about it. So I’m gonna put you on the spot a little bit, I think. But as you listen and watch at home, just you know, let’s use some common sense here.
Dr. Mark Vanderwel 4:43
Yes, I’m not speaking for the pediatric endocrinology community in general. I’m speaking for myself and different physicians have different perspectives on how they take care of kids with diabetes. Different physicians will have different perspectives on Covid 19. And what I am saying is my perspective And it will not even apply universally to all of the patients I take care of because we know you are all different. Similarly, I am not a pediatric infectious disease specialist. I’m not I am not an epidemiologist, and I’m not a fortune teller. And I think we’re all worried and we do not know what’s going to happen in the future. And a lot of what we’re talking about is just predictive, then we don’t know.
Stacey Simms 5:21
All right, so good things to keep in mind. Also, this is first being broadcast live on Facebook. If for some reason as you’re watching it, just bonks out or something crazy happens. We’re recording the audio, this will be rebroadcast as a podcast, it may be broadcast in video in some other forms. If you have questions or comments. We’re using technology called stream yard, and I can see your comments on Facebook, but we’re not actually on Facebook. So there’s a big delay, most likely, so bear with us. And I do have a lot of questions that I took in advance. So if we don’t get to your question today, I promise it may not be with Dr. Vanderwel schedules permitting, but we are going to be addressing Senior questions going forward. And you know, we’re just here to see what we can do. So we want to just jump right in. Sure. Let’s go. All right. So my first question is really just about what you’re hearing these days because I’m talking to you at home, you’re not in the office offices is closed, but are you still getting close? Okay, so what are people asking?
Dr. Mark Vanderwel 6:16
Yeah, so, you know, I think the the primary things are, will we still have appointments? And the answer is we will eventually have virtual appointments. Although a lot of people will also need to be rescheduled, we don’t only take care of kids with diabetes, and there are some conditions that we do need to see face to face. In general though, I think most of our kids with Type One Diabetes will be able to seen by a virtual visit, and we’ll talk a little bit about that in just a minute. We do still have nurses answering phone calls in our office, I’m not sure what other offices are doing. So we have nurses answering phone calls. We have a physician that’s on call 24 seven for hospital based medicine. And so we will we are creating a schedule. That’s why our office is closed. We’re working on developing virtual visits. And we’ve never done this before the platform that atrium uses was originally designed for perhaps five, six pediatricians to use to handle only general pediatric calls. And now this platform is being spread out to be used by pediatric specialists, as well as general pediatricians. And I think more than 100 physicians and, uh, and other providers are going to be on this platform. So we’re still learning how to do it. And that’s why we canceled appointments for a few weeks, but we will have virtual visits up and running hopefully, by next week, Tuesday,
Stacey Simms 7:34
because we’re going to be in that soup, right? Yeah.
Dr. Mark Vanderwel 7:38
Your name on my schedule when I was telling everyone that exactly.
Stacey Simms 7:43
Alright, well, I won’t call your office and ask what you’re doing with me. I will let them reach out to us. When you’re talking about virtual and again, this is kind of specific to your office. I don’t even know yet. Do we on the other side have to do anything yet or you’ll read? Yeah, we’ll watch. No,
Dr. Mark Vanderwel 7:58
we we Will for our type one diabetes patients will likely have a medical assistant call you first maybe on the day of the appointment maybe beforehand to review any changes in medications, any new allergies, the types of things they usually ask you while they were checking you back in. And then in preparation for the phone call with a physician, we are going to ask you to gather diabetes data for us whether it’s a pump, download a CGM, download a meter download, and that’ll be the main thing that we as physicians will review. So we’ll tell you more. We’ll try to talk through a little bit more about how to do that. Although hopefully you all know how to do that. The physician will also will hopefully again, this is all new. We’ll have all that information online.
Stacey Simms 8:42
If you’re watching, you kind of saw me roll my eyes there. Dr. Vanderwel knows this but it’s a little embarrassing to admit, I never upload anything in advance. I tell them please don’t be mad at me. I think the only time I ever logged into T Connect is to upgrade the pump. So
Dr. Mark Vanderwel 8:57
well you know, I think the thing is, we We’ll be able to get that data without, without advanced uploading, I don’t want to come that 100%. But I think if your data is there, we should be able to access it. But we’re gonna learn that over the next three to five days.
Stacey Simms 9:12
That’s what we’re all be learning it, I am sure. Um, in terms of questions that people have in between these appointments, you know, one that came to mind this morning was, you know, if I, if I need refills, if I’m worried about supplies, are you here? I know most people just call their physician pharmacies are open, but are you hearing anything about issues, shortages, that sort of thing with supplies
Dr. Mark Vanderwel 9:35
whatsoever, and I hope we don’t, um, you know, Covid 19 is going to affect people in every sector. And I hope we don’t get to a stage where there’s problems with pharmaceutical production at this point, there is no anticipated problem with production of insulin production of test strips production with any other diabetes related spies. And so No, I do not foresee that as a problem. I know there’s the temptation to stockpile And that’s one of the things that we’ve seen in the general public, obviously, with toilet paper, hand sanitizer, etc. And there’s that desire Should I stockpile my insulin? Well, we can’t commit insurance fraud. And so as physicians, I cannot write a prescription to your pharmacy saying suddenly that a child who used to use 20 units of insulin a day is all of a sudden requiring 200 units of insulin per day, so that your insurance will cover additional insulin, I can’t do that. That’s illegal. And so we will be honest with the pharmacies. I’m not sure how you can get extra insulin just in case that might be something better to work with your pharmacy in terms of what they will cover or what they will allow your insurance to cover. But I do not foresee a deficiency in any diabetes related supplies.
Stacey Simms 10:45
Let’s jump in and talk about Covid 19 best that we can. One of the questions that seems to be coming up over and over again is you know, we’ve all seen in the early days of this at least, the charts that came in from China and Italy saying they’re the comorbidities and diabetes Sure, can you do you know what that means? Because one of the questions was, is it all type two is it you know, work?
Dr. Mark Vanderwel 11:06
Right so earlier this morning I saw some data recently published in the New England Journal of Medicine related to the children 10 and under. And the only fatality in the Chinese data that was published was a 10 month old, who had had intussusception, which is basically when your intestines telescope on each other. And so the child was already previously ill because of that, and there were no other fatalities in that population under age 10. I do not have the data for other age groups stratified out but that was what I saw on the New England Journal of Medicine earlier today. When the word diabetes is used, obviously, that is a big word and often refers to both type one and type two diabetes. And so as far as I can tell from all the Chinese data, when it says diabetes is referring to the big group of both and everyone’s worried at greater risk, because I have type one diabetes, or let’s face it type two diabetes? And the answer is, we do not think that people with type one or type two diabetes are at any greater risk of contracting Covid 19 than the general population. So there’s no increased risk of picking up this virus as far as we know. Now data changes every day. That’s the caveat here. We are still learning but at this point, there’s no reason to think that people with diabetes type one or two are more likely to get Covid 19. Just like any virus, whether it’s the flu, whether it’s the cold, being sick, when you have diabetes makes taking care of diabetes more difficult, and we see that frequently during flu season, that when people are feeling sick, and they may not be eating or drinking quite as well, they have the predisposition to go into diabetic ketoacidosis. And so my answer to how do people with type one diabetes are people who have children who have type one diabetes, better take care of their children, either if They have been exposed to the virus or if they are already showing symptoms of a viral infection. And the answer is us you’re sick. And by Sick Day protocol, I mean check for ketones. Even if your child’s blood sugar is 124, you can still get ketones if they are not eating or drinking very well. So remember, ketones are what happened, or what happens when your muscles become desperate for energy. And usually with people with diabetes that happens when you don’t have enough insulin in your system to help your body take the sugar out of the bloodstream and get it into the muscle cell to be used for energy. But sometimes ketones can happen if you’re just not eating or drinking very well. And so ketones can happen even with a blood sugar 124 if your child has been sick, or if she is vomiting or if he is not eating very well because he feels sick. ketones also can be happening more often in the presence of fever. So although as far as we know right now, nausea and vomiting are not necessarily symptoms of Covid 19 like they are the flu. For example, fever is When you develop fever, that can also cause greater metabolic need, your muscles become more desperate for energy that can lead to the production of ketones and cause an increased risk of diabetic ketoacidosis. So my summary is related to kovat, 19 and diabetes, your child is not at greater risk, their immune system should still work just fine to fight off the virus However, they are at greater risk for developing diabetic ketoacidosis in the context of a viral illness.
Stacey Simms 14:29
A couple of follow up questions on that with keep checking for ketones. Do you recommend a keto blood meter? Are you comfortable with sticks and easily?
Dr. Mark Vanderwel 14:40
Yeah, I mean, most people check urine for ketones a blood ketone meter can give you more up to date information, for example, that tells you what’s in your blood sugar level. That’s what’s in your blood right now. Whereas your urine is often saying, well, we made this urine an hour ago and it’s been sitting in the bladder for an hour so it’s not as up to date as before. glucometer as a blood ketone meter is, but still I think you can get the information you need from, from urine, ketosis, I don’t feel you have to rush out and get a blood ketone checker just because of our current situation. I mean,
Stacey Simms 15:13
I’ll be honest with you, and I don’t know if this is true confessions time, we’ve never we’ve never purchased a blood ketones. This was the time I thought maybe, you know, the back of my head was like, should I get on Amazon? And then I got on Amazon, and there were so many and I thought, oh my god, I’m gonna buy a terrible one. So, um, stick with what we know maybe for me?
Dr. Mark Vanderwel 15:31
Yeah, I mean, there are many other things to worry about. And if you felt comfortable checking your child’s urine for ketones, there’s no need to suddenly change to use a blood glucose blood ketone meter.
Stacey Simms 15:42
Well, he’s 15. So maybe,
Dr. Mark Vanderwel 15:43
Stacey Simms 15:46
I’m sorry, this if you’re just joining us, we did have a bunch of disclaimers that this is not medical advice you should be taking personally, but this is my son’s pediatric endocrinologist. So I might sneak in some personal questions. We’ll see. But the follow up question. fever. And then I’m going to ask you that question about repro fantasy. Before I even get to that one, do you recommend? I’ve heard that sometimes it’s better to let the fever go, you know, not to 104 but to 101, things like that.
Dr. Mark Vanderwel 16:17
That is a great question Stacy and I am no longer a general I should say this. I am board certified in general pediatrics, but I have not practiced general pediatrics for 15 years. However, that all being said, fevers makes you uncomfortable. When your temperature is high, you don’t feel good, but many people are excessively afraid of fever as something that can hurt you, either in the short term or the long term and in general fever just makes you uncomfortable. So when we’re sick, and we have a fever, we often for other illnesses have taken an antibiotic whether it’s acetaminophen, whether it’s ibuprofen, and what some, some French suggested Scientists have suggested is that ibuprofen and other anti inflammatories may blunt your immune response as of right now that information what’s the exact word I had it pulled up is still up for debate. It is not necessarily something that is. That is a stocking answer that we say you must not use ibuprofen in the case of a fever related to Covid 19 unproven was the word I was looking for unproven so let’s let’s get the elephant out of the bag. What is killing people with Covid 19 is not fever. What is killing people with Covid 19 is respiratory distress is the inability to get breath in and children with diabetes are at no greater risk for developing that than children who don’t have diabetes when it comes terms in terms of managing fever. Yes, ibuprofen is a anti inflammatory, ibuprofen at this point. We don’t know if it’s safe or not. My recommendation, though, is is to say, you know, we want to make sure you’re drinking. We want to make sure you can keep fluids down. And if you are so uncomfortable that you can’t drink or keep fluids down because of the high fever, then yes, we probably should treat the fever and at first maybe you treat with IV or with acetaminophen. But if all you have is ibuprofen, and you’re you’re miserable, at this point, it’s still unproven that ibuprofen will make Covid 19 worse or prevent you to impair your ability to fight it off.
Stacey Simms 18:27
Well, and will continue to follow that obviously,
Dr. Mark Vanderwel 18:29
just new information.
Stacey Simms 18:31
It’s unproven, but I mean, I can’t lie. I still you know, I take ibuprofen here and there I immediately was like, No, because it’s it’s scary.
Dr. Mark Vanderwel 18:39
Stacey Simms 18:41
I went and checked everything in the house. How much acetaminophen do we have? What What else? Oh, because acetaminophen isn’t so many cold medicines, sir. Let me ask you that people with type one and type two people with diabetes. Let’s just say that who use CGM know that with Tylenol acetaminophen come warnings with death. calm. Now my understanding is Dexcom je six you can take 1000 milligrams of Tylenol safely by safely means it’s not going to burn out your sensor you can is nothing to do with them anything beyond the sensor we’re talking about here is that what you were understanding?
Dr. Mark Vanderwel 19:15
My understanding and just for clarification even in previous versions of Dexcom if you’re using g five if you’re using g four acetaminophen does not prevent it from working. It just may mean the readings it gives you are not as accurate as they might be without acetaminophen in your system. But that’s also my understanding for the for the Dexcom g six,
Dr. Mark Vanderwel 19:35
just think or stick. Agreed?
Dr. Mark Vanderwel 19:37
Yeah, if you feel your ducks comm isn’t accurate whether you have acetaminophen on board or whether you don’t have acetaminophen on board, poke your finger.
Stacey Simms 19:46
Right? Which means that a lot of people need to make sure that not only do we have a meter and test strips, but that we have the batteries or that our stuff is plugged in because um I know A lot of us are very reliant on CGM. Let’s just put it that way. And I’m looking at my phone, not to be rude, but to look at the next few questions. So as you’re watching,
Dr. Mark Vanderwel 20:10
I know you go Okay, fair enough.
Stacey Simms 20:15
That was more for these guys. But seriously, um, I’m curious too, with, with not knowing when many of us will see our children’s, endo next, or if we’re adults are watching. Are there things that we should be doing? To check in between? I mean, I know that I’ll give you an example. You always check penny for you know, scar tissue.
Dr. Mark Vanderwel 20:40
Right? Like lipohypertrophy. Exactly. Okay,
Stacey Simms 20:42
so go for it. Tell us what we do. Yeah,
Dr. Mark Vanderwel 20:43
so, so lipohypertrophy is when you will put your infusion side in the same place too often, or you give yourself insulin injections in the same place too often. And the downside of that is not only does it look funny, but it can prevent the insulin that you give yourself from getting into The bloodstream, and then it doesn’t get from the bloodstream to the eventual target tissues of liver and muscle. So if you are thinking you’re giving yourself a bolus, but you’re giving it giving it into an area of life or hypertrophy, then perhaps the insulin isn’t doing what it needs to do. And that can obviously be dangerous and increase your risk of decay. So, yes, I do think that parents should be checking your child for life or hypertrophy in the same way that their endocrinologist probably does regularly. And the thing that I would probably say is, the easiest way to do is just make sure it doesn’t feel like a tricep, you know, flex your tricep right here. And you can feel a little bit of muscle tissue right there. And light by hypertrophy feels a lot like that. It feels kind of clumpy. It doesn’t hurt the child, but it feels it like oh, it seems like there’s a big clump of subcutaneous tissue here. You can even see like oh hypertrophy a lot of times and I might wind up doing that when I’m doing virtual visits is just have the kid in the room and say, Show me where you Put your palm but just look to make sure it’s not looking clumpy now, I’m not going to do anything. Like make them show me their family or anything like that. But you know, their arms, their belly, that sort of stuff. Yeah, I might do that at the opposite.
Stacey Simms 22:13
That makes a lot of sense, though. You know. And another thing I was looking at my list of questions when we were talking about supplies, one of the interesting things is people seem to be posting quite a bit about not being able to get those little alcohol wipes. Yeah, we haven’t used those in a very
religiously for years. Sure, sure. Is that something people need to be concerned about? Should I be getting out the rubbing alcohol and checking to make sure as a pediatric
Dr. Mark Vanderwel 22:36
endocrinologist I should say the standard line Yes, the proper protocol for either giving an insulin injection or putting a new infusion site in or putting a new Dexcom in or poking a finger is to wipe that area with alcohol first. That being said, You are probably not the only family. I take care of Stacy where your child does not use rubbing out Color an alcohol swab every time. So yes, we want clean skin. We know that giving an injection or anything that punctures the skin. without alcohol, there is a slightly increased risk of getting an infected site. There’s bacteria everywhere. Obviously there are viruses everywhere. But when we’re thinking about using alcohol swabs, we’re thinking about killing the bacteria on the skin or removing the bacteria from the skin so that you can give a cleaner injection, or a cleaner infusion site or a cleaning Dexcom or cleaner Dexcom site etc. So if you can’t get alcohol swabs, you still need to give your child insulin and you still need to figure out what her blood sugar is. So all in all, what’s better to give a shot with alcohol to give a shot without alcohol swabs or to give no shot at all. They go in that order best is with second best is without third best is no insulin at all in that’s not best. That’s bad news. So
Stacey Simms 24:00
So, you know, another thing, that I have a whole bunch of questions here that I’m trying to get to the right order to go in,
when, when we’re talking about these in between visits for a long time, and again, I know that you may be limited as what you can say, because we are talking in official capacity. So some of this is on, you know, I don’t say on the record off the record, but you’ll understand. So there are a lot of people who are very comfortable adjusting pump settings. Sure. There are a lot of people who aren’t, you know, what’s your advice for a family? And this was a question that came up in our group. I’ll say, Michelle asked this, how do you advise or empower, newer diagnose parents on taking pump settings into their own hands? You know, are there ways to tell when something is a basal issue or a QRP? Sure.
Dr. Mark Vanderwel 24:46
Yeah, so first of all, I’m speaking for myself, I’m not speaking for every pediatric endocrinologist out there. I feel comfortable with my patients adjusting insulin settings without my permission, you do not need my permission to adjust your pump settings or your insulin dose. Is, however other pediatric endocrinologist may feel differently. I’m not speaking for all of us. In general, if your basal rate needs adjustment, that means that your child has been going a long time without eating. And her blood sugar either goes up, or her blood sugar goes down in the absence of all other factors. Best time is overnight. So if your kids waking up with a high blood sugar in the morning or higher than it was when he went to bed, that probably means he needs more basal. If he’s waking up with a lower blood sugar than it was when he went to bed in the absence of the correction dose at nighttime, then chances are he needs less basal insulin. And kind of the same thing goes for carb coverage, if you notice every time after a meal, and I’m not talking about just that postprandial spike on a Dexcom because that is related not to the insulin quantity but to the timing of the insulin absorption. But let’s say two hours, three hours, three and a half hours after every meal. If your kids blood sugar is going up that means That she needs a stronger carbohydrate factor. And remember, Stacy, I know you’ve written about this in your book, the factor is the denominator, right. So of insulin to carb ratio of one to 10 is stronger than insulin to carb ratio of one to 15. It’s the denominator of the fraction. Similarly, for the instant correction factor, if you’re giving a dose of insulin through the pump, or through the sliding scale that you’ve written down, and your child’s blood sugar doesn’t come far enough, universally, don’t make adjustments based on just one thing, let her wait for a pattern to develop. But if you’re noticing that you’re that your child’s blood sugar never comes down far enough after you give them a correction dose. That means let’s make the correction factor stronger. And by that I mean maybe change it from 60 to 50, or from 50 to 40 or from 40 to 35, etc. Vice versa, if you are scared to to give a correction dose because your child’s blood sugar because it doesn’t come in or comes down too far after for extra dose that make it a little weaker. And by doing that I’ve seen baby move it from 50 to 60 From 60 to 75, or 75 to 90, etc.
Stacey Simms 27:04
So if you’re watching this, and I covered my face and kind of made a joke, the reason is because in the book, I do talk about this, but I have definitely made the mistake of thinking that a smaller number meant less insulin.
Dr. Mark Vanderwel 27:18
So it is confusing. It is it, just think about it in terms of the denominator of the fraction, a half a pizza is bigger than a quarter of a pizza, even though two is smaller than four.
Stacey Simms 27:30
You know, and that brings, I know this, this interview is getting a little bit away from Covid 19. But we’ve got plenty of time to talk about that. The just a follow up on the calling your physician and you know, there are a lot of wonderful presenters like yourself, who will take a call every day for a month from a nervous mom of a newly diagnosed kid. But there are a lot of parents who worry that they’re bothering the doctor for things like that. Obviously, it never bothered me. But all kidding aside, can you assure people that if they’re calling for instance adjustments that
Dr. Mark Vanderwel 28:00
it’s okay. Yeah, it is absolutely. Okay. Like I said, I want you to feel empowered to do that on your own. But if you need help, we are there to help. And my office still has CDs answering the phone during daytime hours, you can take blood sugars and help make adjustments. The physician on call over the night or weekend can also do that, although it’s probably easier to do that during office hours while we have CDs answering the phone because they can pull up the child’s chart whereas if you call me on a Saturday afternoon, I’m not going to have your child’s chart at my fingertips to make those adjustments. So yes, but please don’t feel you are on your own. And please don’t feel you are bothering us. Yes, when we take call. We also are seeing patients in the hospital and we are usually seeing patients in the office although now we may be doing more virtual visits. We are doing other things. It’s not like all we do is just feel phone calls. We are doing other things and so we appreciate that one. If it’s not an emergency, if it can wait until morning. That’d be great to wait until more But there are emergencies. And we also understand that when people have a child with diabetes, they worry at three o’clock in the morning, and if they’re worried enough, please call us. Yes, that’s what we’re there for. But remember, we also are not general pediatricians. And so when it comes to Covid 19, if you are worried that potentially your child may have been 19, that is a better question for your primary care provider rather than us. We are not your general pediatricians. However, if you’re feeling like your child was getting sick, and you’re having trouble managing their blood sugar’s because they’re sick. That’s a question for us.
Stacey Simms 29:32
Well, and that was what I was just going to ask if someone says, Oh my gosh, I think my child has Covid 19 and they have type one diabetes, what would you advise them to do?
Dr. Mark Vanderwel 29:43
I think we’re still learning more and more, you know, testing is not really readily available and everything that I’ve heard about testing to this point, it’s been difficult to get a test now hopefully, that’ll change soon. Um, and However, our primary care providers are at the frontline of giving of getting people coded testing. figuring out who needs to be tested? So I would defer that question to your primary care office because they will have the most up to date answers about whether you should simply, well, we should all be quarantined ourselves, right, we should all be practicing social isolation, but especially if you have any suspicion that you or your child has Covid 19 you need to stay in your house. And you do not need to expose any other people to this. So in that situation, though, whether do you bring your kid for a Covid 19 test? Or do you just try to isolate them and pray that they get better and again, they should I mean, kids with type one diabetes are not at greater risk for developing Covid 19 or having the respiratory complications, it just makes them more likely to get ketones. So anyway, um, if your kids healthy enough to just stay at home and continue that quarantine. Right now, that’s probably what we’re recommending, although things may change anytime,
Stacey Simms 30:57
and I guess you’ve answered this, but I’m going to ask them Again, just in a different way, to be perfectly clear the evidence as we’re speaking right now, would say that if a child comes down with Covid 19 has type one diabetes, there is nothing different
Dr. Mark Vanderwel 31:11
to ground at home. Just Just differently from a diabetes management perspective perspective, make sure they’re hydrated check for ketones if they’re actually acting sick, even if their blood sugar seems fine. Um, follow your sick day protocol. But yes, nothing different compared to your other children who might not have type one diabetes.
Stacey Simms 31:32
Um, something else I wanted to ask. Gosh, I should have closed the blinds. Whoo. It’s getting hot in here. One of the things I meant to ask when you talked about the time in between visits because I had a lot of questions on this in our Facebook group. People are saying like me, Benny’s appointment was supposed to be in two weeks, we’ll do a virtual visit, but I assume we’re not going to get that a one. See that? We usually get quarterly.
Do you? Look we have a CGM so I can see what it probably is. But do you ever recommend a homemade one T tests.
Dr. Mark Vanderwel 32:01
Okay, you and I, about a one says yes, yes. So again, I’m not speaking for every pediatric endocrinologist out there, but people definitely overrate the importance of A1C, and so many people come into my office on pins and needles because they’re so nervous about what that number is going to be in. As we’ve said before, you’ve heard me say it. And I think that’s one of the reasons you and I get along so well is because we have a similar perspective, and everyone has different perspectives. But my perspective is, the ANC is just a number. And it’s right now the best number we can get in a six minute turnaround test, tell us to summarize blood sugars, but it’s just that it’s just a number. And as we have more CGM data available, I think we’re going to learn that time and range, maybe an even better predictor of avoidance of long term complications, because that’s what we’re talking about, right? We’re talking about not necessarily trying to get your kids A1C to be less than x. We We are talking about trying to help your child be as healthy as she can be when she is 85 or 90 years old, right? And so it’s not about the agency, there are plenty of kids I take care of where I’m worried. This kids having way too many low blood sugars, it’s affecting their lifestyle. And I’d be much happier if they’re a once you jumped up a half point or a full point if they had fewer low blood sugars. So my perspective on it once you may be different than many of my colleagues, I don’t think it’s worth it for you to check anyone see in the middle of between office visits, especially if you have the capability of looking at a continuous glucose monitoring system that can tell you time and rich.
Stacey Simms 33:38
Is it homey? Once the test even accurate? I’ve always wondered about
Dr. Mark Vanderwel 33:41
Yeah, I mean, I think so. I mean, I have not seen I’m sure there are studies out there comparing the home a woman c test to a serum drawn that means coming from your arm type of A1C test versus a finger poke A1C test, which we do in our office. Um, I honestly have not looked at those studies, so I can’t answer your question. But my guess is yes, it’s probably pretty close. Okay, so
Stacey Simms 34:04
I have another one. You know, all these people in my group know you very well. And the question, I’ve lost the question, Where did I put it? Ah, here it is. Okay. So it’s a two parter. The first part is all about technology. Have you mentioned time and range? You mentioned CGM advice for parents. This is a question who says, Are we overly reliant on technology? Or is that a thing? Does she need to worry about being isolated? If something doesn’t work?
Dr. Mark Vanderwel 34:35
Yeah, I mean, you use what you have. I mean, we didn’t have dex comes when Benny was first diagnosed. We didn’t have insulin pumps, when I was, you know, or there were they were out there, but they were not commonly used when I was a resident. Um, when my senior partner Dr. Parker was doing his medical school, they didn’t even have finger stick blood sugars, right. And so diabetes management is changing and we not relying on technology, but the technology has been good. And it’s helped make diabetes easier, not a cure, but a little easier unless you become a slave to that technology. And you can definitely overreact to the readings on a Dexcom. I know plenty of people who will not put their phone away because they always want to know what every second what their child’s blood sugar is. And that’s not healthy either.
Dr. Mark Vanderwel 35:22
I know what you’re talking about.
Stacey Simms 35:26
I’m only half kidding. But yeah, nothing really can be a problem. I think the bottom line for that too, is if as you’re listening, you think, gosh, I don’t even know where our meter is. Or do I have test strips? You know, that’s the kind of thing that you’ll definitely want
Dr. Mark Vanderwel 35:40
to check but you do need to have a beat. You need to have a meter even when your child wears a Dexcom or a Libra or Medtronic CGM. You will need a backup way to check blood sugar. So yes, please have a meter and strips and lancets that’s the finger poker available.
Stacey Simms 35:55
lancets we all have 5000 of those.
Dr. Mark Vanderwel 35:57
Dr. Mark Vanderwel 35:59
Last question was Do bow ties help you in your practice?
Stacey Simms 36:03
Dr. Mark Vanderwel 36:04
So, my grandfather always wear bow ties, you actually might be able to see him right over here at Grand Prix right over there over my shoulder. Always wear bow ties. Um, and so I got that from him. Um, and someone said, I looked smarter when I bought a bow tie. And I was like, you know, great. I like looking smart, even though I so, but to be honest, yes, um, especially in this age of viral transmission, you’re probably not going to see me wear a tie when we do a virtual visit. And you may not see me wear a tie as much in the office in the near future. The reason that many of the pediatricians through Boston Children’s Hospital other of the older pediatricians wear bow ties rather than long straight ties is because there’s less germs from this than there are from something dangling and so I will for virtual visits, I probably will not I almost certainly will not have a bow tie on and for the for visiting the office, I probably won’t either just to have one less thing on mice around me that can collect your
Dr. Mark Vanderwel 37:06
which is your grandfather in the medical field or, you
Dr. Mark Vanderwel 37:09
know, furniture industry.
Stacey Simms 37:13
All right. So before I let you go, because this is the first time I’ve ever had you on the podcast, hopefully not the last. But you know, it was in the interest of kind of feeling a little strange about, you know, that kind of relationship, my son’s endocrinologist and that sort of thing. But now, I this has been great.
I’m curious, you know, you’ve been in practice for us at 15 years. I finished
Dr. Mark Vanderwel 37:34
my fellowship in 2005. So this is this will be my 15th. year as of July one or the end of my 15th year.
Dr. Mark Vanderwel 37:42
Yeah, we caught you
Dr. Mark Vanderwel 37:44
right at the beginning. Right, exactly. You were one of my may not my very first but one of my first patients now, I shouldn’t say that. But yeah,
Stacey Simms 37:51
I mean, in the first couple of years,
Dr. Mark Vanderwel 37:52
right, exactly in the first few years. Exactly. So
Stacey Simms 37:54
I’m curious, you know, it’s hard to sum up in just a few minutes, but from then to now. already mentioned the technology have things. It’s kind of a pet question. I was gonna say, Have you seen things change, but I really want to know, like, how is it to be a pediatric endocrinologist from then to now? I mean, it’s got to be difficult with insurance things and all that sort of stuff. But are you still happy? This is a field you chose?
Dr. Mark Vanderwel 38:20
Yes. I love my job. I love taking care of kids with diabetes. I kids with diabetes are only about 30 to 35% of my patient volume. And so I take care of 60% of other kids that I also love taking care of. It’s the dream job. And yeah, I did not grow up thinking I wanted to be a pediatric endocrinology. I didn’t know I really wanted to be a doctor. When I was in high school. I mean, there are some people that say they knew it from age two for me, that was not the case. But every step along the way, I’ve kind of thought yeah, maybe I do want to be a doctor. And then I go to medical school and yeah, maybe I do want to be a pediatrician and then I do my pediatric rescue. See and yeah maybe I do want to become a pediatric specialist etc so each step has kind of led me along the way and it’s been a great choice I love taking care of your own as well as the all the other kids that I take care of. It’s a dream job except for the paperwork.
Stacey Simms 39:15
Alright, so I’ll check in with you again if I can during this time who knows how long we’re going to be at home you guys doing? Okay, you can have your own everybody
Dr. Mark Vanderwel 39:22
do everyone’s healthy. You know? I mean I I’m worried I mean, not about my kids not necessarily about my health I mean when one of those middle age brackets right but I’m worried about my parents, my grandparents who are still alive, you know, I’m, I am worried about I’m worried about the economy of not only our country, but the world I’m worried about, about the financial well being of my patients, even though I’m you can kind of get the sense I’m not really all that worried about the health of my patients with Covid 19 as long as they Following Sick Day protocols and but that doesn’t mean go out and get exposed because obviously we need to contain this virus. I am worried about our world. But I’m not necessarily worried about the children that I take care of related to cope with it and I just don’t want them spreading this terms to their grandparents.
Dr. Mark Vanderwel 40:17
I think you’re absolutely right on that. Well, we will leave it there. And hopefully we can check back in and I will see you for a virtual visit. I’m sure we’ll be hearing from
Dr. Mark Vanderwel 40:28
Stacey Simms 40:31
But I do appreciate it. Thank you so much.
Dr. Mark Vanderwel 40:33
Yes, thanks for getting the word out states you remember, wash your hands stay inside socially distinct yourselves.
Dr. Mark Vanderwel 40:41
But don’t forget to call your parents all the people you love.
Dr. Mark Vanderwel 40:50
Diabetes Connections is a production of Stacey Sims media. All Rights Reserved or wrongs avenged
Transcribed by https://otter.ai