"Z minus 10,000 meters"

“Z MINUS 10,000 METERS”

Nerd alert! This post contains some really old sci-fi references

This is one of my favorite diabetes teaching posts.

In the 1980’s Star Trek film “The Wrath of Khan”, the iconic Captain Kirk engages in a final “cat and mouse” battle with his nemesis Khan deep with a murky interstellar nebula. Midway through the action sequence, Mr. Spock makes an insightful comment to his Captain: “He (Khan) is intelligent, but not experienced...His pattern indicates TWO-dimensional thinking”. That observation ultimately seals Khan’s fate as Kirk moves the Enterprise along another axis (" z minus 10,000 meters) to launch a crippling photon torpedo and phaser attack on Khan’s starship.

I use this metaphor to make a point. In many (if not most) online posts from recently diagnosed families of children with diabetes (i.e., coming out of the “honeymoon” phase), I observe considerable “two-dimensional thinking” (at times even “one-dimensional”). Putting it another way, there is too much focus on the objective, static things (an insulin dose or pump settings) and less on the subjective (choices, timing, frequency and personal consistency) which are by their very nature more DYNAMIC. Of course, by definition the newly diagnosed are “not experienced”, regardless of their intelligence. But, they can be better prepared as I discuss below.

The human pancreas is constantly adapting its insulin output into the body, and not only with insulin. Other pancreatic hormones (glucagon) are produced as needed to boost sugar levels upward. Sugar Surfers understand that little in human biology is static. It might only appear that way from our limited points of view. Blood sugar levels in non-diabetic persons constantly drift up and down, but within a defined “normal range”. Straight line, or linear, thinking about how blood sugars move is another form of “two-dimensional” thought. So why should an insulin dosing regimen be static and not dynamic? Answer: a dynamic strategy better mimics nature. This forms my philosophical basis of Sugar Surfing.

Calculated insulin doses and preprogrammed insulin pump settings (at best) are estimates of what the user might require on a “typical” day. I’m still trying to wrap my own head around what “typical” really means. Most of us would probably better characterize each day as “typically atypical”.

In the 1990’s movie “Groundhog Day”, Bill Murray’s character relives the same day over and over again for years. Perhaps in such a reality, a two dimensional logic would apply since everything would be predictable well in advance. The Murray character was able to adapt to the constantly repeating day by taking advantage of his experience of having lived through them before. Ultimately, achieved his goal of escaping his time loop purgatory.

But in the non-repeating real world, each day is truly unique. Therefore we best need to be prepared for the dynamic nature of life on our diabetes control or diabetes in our kids. This belief forms one of the core underpinnings of my reactive-proactive philosophy of diabetes care: static versus the dynamic (aka Sugar Surfing”).

Going into and coming out of the honeymoon phase is (for most persons) our first encounter with the changing nature of type 1 diabetes. And there is nothing unusual about a honeymoon phase. After all, it’s part of the natural history of the condition in most type 1’s. Generally, it varies in duration (months to years). The younger you are, the briefer it may be; and the older you are the longer it may stay. There are other factors which come into play but too many right now to delve into. Therefore, there is little reason to judge a honeymoon for anything more than what it really is: a transitional period to be anticipated, managed and ultimately appreciated.

Unfortunately, many patients and families lose the opportunity to be better prepared for what comes next due to “fair weather thinking” at follow up visits during the honeymoon. It might go like this: at 6 months after diagnosis, your child’s A1C is 5.7%; blood sugars all look mostly in- range, no major problems (i.e., life is good), no physical complaints, and then…zoom!, you’re out the clinic door in under 10-15 minutes. I feel this is a missed opportunity.

Knowing that the honeymoon ends, might it be preferable to learn how to be prepared for that eventuality? Wouldn’t you prefer to learn in a more relaxed fashion compared to the shock and awe that followed diagnosis, perhaps further aggravated by the stress of DKA (~75% of new cases present this way) and the surprise of learning you or your child has a lifelong condition requiring frequent insulin injections to stay alive, check blood sugars often, and a seemingly endless string of new duties to comprehend?

Two dimensional thinking is certainly not limited to patients. I often see it in health care providers, just expressed differently. As I say all the time, I don’t dispense diabetes control from a bucket in my office. It’s something that’s created in the moment through frequent small (and large) choices and decisions made by the person or family. In my opinion, that’s “three dimensional thinking”. In fact, when time itself is taken into consideration and becomes a manageable variable, maybe it should be taken to the “fourth dimension”. But perhaps I’ve extended this metaphor a bit too far.

Don’t let the “honeymoon” phase become the “missed opportunity to learn” phase. Most of my posts are my effort to explain my multidimensional approaches to managing diabetes well. The book Sugar Surfing is the compilation of this accumulated wisdom.

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