Across the Exam Table: A Pet Owner’s Perspective on Diabetes

As veterinary professionals, we talk to clients all day – but in the thick of a busy day, it’s easy to forget what it’s like to be one of them. David Berlin and Alexandra Bronson, educators in the charter school system in Brooklyn, NY, join us to talk about their experience as “proud cat parents” of Audrey, who was diagnosed with diabetes mellitus in 2021.

Screen_Shot_2022-07-01_at_1.10.08_PM.jpgTwo Pet Owners Discuss How They Navigated a Difficult Diagnosis on Central Line: The AAHA Podcast

Most veterinary professionals know what it’s like to have a pet with a chronic illness—or two, or four. . . . But with a career’s worth of education, experience, and observation under our belts, it can be hard to remember what the view was like from across the exam table. Most clients have no medical knowledge to lean on when they’re facing down their pet’s chronic disease diagnosis. The emotional, financial, and logistical burdens a disease like diabetes mellitus places on the average pet owner can be as damaging as the illness itself.

In partnership with Boehringer Ingelheim Animal Health, host Katie Berlin, DVM, spoke with two dedicated pet owners: her brother, David Berlin, and sister-in-law, Alexandra Bronson, both educators in Brooklyn, New York. Their cat, Audrey, was diagnosed with diabetes in the fall of 2021. You can watch the full episode on YouTube here.

Audrey.jpgDavid Berlin: When [Audrey’s diabetes] diagnosis came, I wasn’t super surprised by it because it seemed like all the signs were there. I think we just were sort of struggling with how to navigate it. I was a little bit hard on myself at first because I felt like I should have seen the signs sooner.

Alexandra Bronson: I started getting really upset thinking about the discomfort that she would be in—thinking about, how long do we have with her and is this a death sentence? Does this mean months? And how do we ensure that she is as comfortable as possible for as long as we can?

Katie Berlin: [Audrey] is just the most loved cat, so I could only imagine what you must have been thinking then.

DB: Yeah, so I have to shout out [to our vet team] for just being awesome throughout the whole process. They gave me a multipage rundown of all the things to expect and think about, which was really helpful because you’re trying to take in all this information and some of the information you find is contrary to other information. So it was really helpful to have this resource that I could go back to.

And they were super patient with me as I had questions. I had some comfort giving her injections [from when] she had allergies and we were giving her medicine that way, but the thing I found most helpful was at the follow-up appointment, they had one of the technicians work with me on giving her injections of insulin and taking her blood sugar from her ears, and we just did it like 5 or 10 times, and just watching them and learning from them was extremely helpful and took a little bit of the anxiety away from doing that.

She also happens to be just a very pliable, agreeable cat, but the reps and the practice were super helpful for me.

KB: That’s pretty typical. Veterinarians talk a lot, and then the vet techs come in and do all the work.

DB: Honestly, he was like Mozart with that syringe. I have never seen anything like it. I had been doing the shots the wrong way, or I guess I never really learned. And I should say that I had done, I think, every single administration of the previous injections because Alex has a fear of needles. So then I had to teach her and she ended up being much better at it than I did.

AB: When I go in for my own shots, I apologize to the nurses ahead of time, telling them that the tears are inevitable no matter how good they are. When we learned that Audrey had diabetes and she needed to have injections twice a day, I think that if I were to give a hypothesis of what changed for me, [it’s that] this was what Audrey needed in order to continue living.

And as soon as I was able to administer the first shot and she didn’t even flinch, I think that it allowed me to just do this rhythmically moving forward.

KB: What was the learning curve like?

AB: For me, the nerves of actually administering the shot dissipated very quickly, and there were two things that created anxiety. It took a little while to figure out the rhythm of getting her blood for her glucose readings. The other thing that was difficult was navigating the dosage. Administering too much insulin is incredibly scary, and we worked really closely with our vet to understand, based on her glucose curves, how much insulin to give her. But that process was, I think, the most anxiety-producing point for us.

Audrey_snuggle.jpgDB: I was really scared to give her too much insulin. I’d read a lot about that. It was all over in the notes. It’s like if you’re not sure, don’t do it. And she had really high blood sugar so we kept increasing the dosage, and then we would check it and it would be super high still, or one day it would slingshot down to low. And we’re talking about such astronomically small units [of insulin]. That stuff I think was really way harder than the actual mechanics of doing it.

KB: I’ve given the diabetes talk so many times, and usually, I worry a lot about [the insulin administration and planning when to schedule the first glucose curve], but once we have that down, I don’t know that I have given that too much thought—that fear that if you give too much accidentally or we make the wrong judgment call, it could be catastrophic.

And that’s a little bit of an eye opener for me. It’s almost like the real work begins—and the real scary part begins—because you know how much responsibility we both have in making sure that we don’t do the wrong thing.

DB: Yeah, there was a point where we were giving, I think, one unit, and it did nothing, and so we bumped it up, and whether it was in my head or actual, she seemed really lethargic to me. I was like, oh my god, oh I messed it up, I’m done, what can we do, should we rub the honey in her gums or whatever or all the things, and in the end, she was fine. But you started looking for every little sign.

KB: Did you elect to do the blood sugar curves at home, or is that the only option that your vet gave you?

DB: They gave us the option of bringing her in and they would do it over 12 hours, but it seemed like something that we could do at home if we could figure it out. We would send them numbers via email, maybe every two weeks, three weeks, and adjust the dosage from there.

She developed pretty severe neuropathy in her back legs from the diabetes, so she was losing the ability to jump and she’d scrabble around when she was walking down the hallway. It got pretty serious. I don’t think we ever directly discussed it, but in my brain, I was thinking like if this is just going to get worse and worse, at what point are you like, well, this quality of life is not good anymore?

AB: It was clear that she was not only uncomfortable but she also wasn’t doing the things that she loved to do. She wasn’t as snuggly and cuddly with us as she previously was. In my mind, I was thinking, can we get her one of those wheelie situations that dogs have, or is she just going to live on a tuffet for the rest of her life?

DB: As the neuropathy got worse, [our vet team] were really responsive to that, and they referred us to specialists. We were having trouble getting the dosage right and her blood sugar, like I said—it boomeranged too high or too low, mostly too high.

And surprisingly in a city like Brooklyn, you think there would be more availability for that, but there really wasn’t. So Alex had to take her into Manhattan. They were helpful in parsing whether or not something was an emergency or not, and what to do about it, and what the signs were.

AB: I started writing down her glucose curves so that we could track them and look at them, and I’m a paper person, so I just picked up a journal and then started just writing all of the notes and changes that had happened. It was really helpful to have in one place. When we adjusted the doses, we could help tell the story to the vet and help understand as we were navigating this disease.

It was [also] really helpful for me to talk about my feelings, and I think for David as well, to process how I was feeling in navigating this so that I could make sure that I was monitoring myself and also giving the respect to what I was going through. I remember really clearly the day that David referenced earlier when we gave her insulin and then she was really lethargic afterward. Just kind of recognizing these human emotions was a really important part of the process for me.

KB: It’s not just about logistically getting you guys to give insulin. It’s about the feelings that come along with having a pet you love so much diagnosed with a chronic disease that has an uncertain future.

DB: I think the knowledge gap when you’re coming into it is really large, and so I would have loved to know what a great glucose curve looks like, you know? I understand you don’t want to give targets that aren’t going to be correct, but I would get the numbers and I really didn’t know what to do with them other than send them to the vet. And I was like, okay, it’s 275, which is better than it was before [when] it was 490, but that still seems high. What do I do?

We turned in a glucose curve once that we had done every two hours except we missed one of them, and they were like, “You need to do the whole thing again.” Which I understand, and I would never want to put a doctor in the position of having to judge with incomplete information and then hold them accountable if it wasn’t correct. But it was a little bit deflating because, oh my gosh, we just did this for 12 hours and drew blood and I think maybe sometimes just knowing a little bit more what to expect or when should you panic [would be helpful], I guess.

KB: Dave, first of all, same. I would like to know what normal looks like for diabetes management because it is so hard! Basically, the Diabetes Management Guidelines that we have is the closest thing we can come to how to treat diabetes, but the whole disease is a gray area. [Whether a number is too high or too low] depends on the number before it and the number after it, and the number in three hours, and how long they’ve been diabetic, and what did they eat that day. . . . It’s so tricky to make those judgment calls. But I think we could [always do] a better job of telling our clients what to expect and what to look for and ultimately what our goal was, even if not in numbers.

[One of] the updates that we made to the Diabetes Management Guidelines is about continuous glucose monitoring. It’s not something everybody is using, and I was wondering if that was something your vet team had ever talked to you about, or if you’ve ever heard about that other than talking to me since then.

DB: I can’t remember if they brought it up. I’m pretty sure I heard about it from you and not from them. I think if Audrey had been less compliant or if Alex hadn’t been so good at taking blood from ears, I think something like that would be really helpful. And I think anything you can do like that with cats would also be helpful in the sense that it does probably take a lot of the guesswork out of it. You could take their readings much more easily. I could see that being extremely helpful because I do think that the glucose curve is the hardest part.

KB: [Continuous glucose monitoring is] not perfect either, but it’s the vet team doing [the uncomfortable part] and not you, which is a key difference for a lot of people.

Do you feel like [it] would have helped you to have a once-a-day option [for insulin]?

AB: Yeah. Absolutely. Dave and I certainly couldn’t even think about doing a weekend away somewhere because we couldn’t be gone in the morning and the evening. And so having a once-a-day administration would definitely have made our lives easier.

KB: How’s Audrey doing now?

AB: She’s lounging on a chair in the sun. She’s, I would say, not even just back to normal, I think that she’s even sweeter now. It’s like she knows how much we have cared for her and how much we care about her, and her physicality is back to 100%, and she is just so sweet.

KB: And she’s in remission now, right? You’re not having to give insulin now?

AB: Yes.

DB: The vet declared her in remission at the end of March. I was really impressed that her neuropathy went away in a matter of weeks. She’s jumping all over the place and she’s the best.

KB: You’re the perfect situation. However, it still was really hard for you, and it’s still a matter of daily life that you think, “Is she going to need insulin again? We have to watch her all the time and make sure.” And you still had that guilt at the beginning, even though she’s had a wonderful life with you. I think her being the easiest case means in the best-case scenario, it’s still a really hard thing.

And Alex, I have this visual from a story Dave told me of you in a fetal position getting a vaccination, possibly sobbing. Props for being that person and also being this person who could make blood materialize out of a cat’s ear.

AB: I was on the ground with a stuffed animal that the nurse had given me while I heard her say to Dave, “Oh, you’re strong.”

KB: I wasn’t gonna let us get away with not telling that story.

AB: I appreciate you both. 

boehringer_CMYK.pngThis episode was made possible with generous support from Boehringer Ingelheim Animal Health. Boehringer Ingelheim Animal Health US, Inc, makers of ProZinc® (protamine zinc recombinant human insulin), is glad to sponsor AAHA in their discussion about diabetes care and encourage listeners to go to www.prozinc.us to learn more about once a day dosing for dogs. Boehringer Ingelheim Animal Health US, Inc, is not specifically responsible for the content of this podcast.

Find the latest update to AAHA’s Diabetes Management Guidelines at aaha.org/diabetes.

Catch a new episode of Central Line: The AAHA Podcast every Tuesday on all major podcast platforms, YouTube, and aaha.org.podcast. Send us feedback or questions anytime at podcast@aaha.org

Berlin_Katie_bio.jpg
Katie Berlin, DVM, is AAHA’s Veterinary Content Strategist.

Photo credits: Photos coutesy of David Berlin and Alexandra Bronson

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