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How T1D is Like Mission Control: Competence

Today is another installment in my series "How T1D is like mission control" - an in-depth look at how living a life with type 1 diabetes bakes in the same characteristics flight controllers practice as instructed by the "Foundations of Flight Operations". You can also read my takes on "Responsibility" and "Toughness". A recent diabetes experience got me thinking a lot about one of the more sterile flight controller qualities 'competence'. I say sterile because competence is black and white - you either have it or you don't - it's not "squishy" like 'teamwork' or 'toughness'. In the arena of human spaceflight, some of these qualities can wax and wane. For instance, on quiet weekend nights, I may never even have a technical conversation with a teammate because it just isn't necessary. In these instances, I need to be able to "turn on" teamwork, but the shift itself doesn't really require it.  Competence is different. It's critical, required, exercised.

And just as for human spaceflight, so too for a life with type 1 diabetes.
Size comparison: lego astronaut vs. Humalog vial. 

To set up this scenario I think its important to remember that insulin is a drug - a potent drug. The picture above is one of my vials of Humalog. It contains 1,000 units of insulin. For reference, the insulin cartridge that I fill for my insulin pump holds ~240 units to cover 3-4 days worth of basals (baseline insulin) and boluses (insulin to cover the carbohydrates I eat). So, I can usually get 4 cartridges out of 1 bottle of insulin. Oh, and astronaut lego man for size reference! It's small!

Ok, so we have the physical size and amount of insulin down - let's move on to the trends.

The last few nights I have woken up to the familiar "buzzz" from my insulin pump alerting me to a high blood sugar (remember, I have my limits set pretty tight, so "high" is something over 140 mg/dL). When I looked at the trend it was clear I needed to adjust my basal rates a pinch. And that's something I think a lot of people who don't live with this disease take for granted - it sounds so easy - take a blood reading, react to the number, count the carbs, dose the insulin - easy peasy. But diabetes isn't a 'set-it-and-forget-it' disease - it takes constant tweaking and trend watching, minute changes and constant self-reflection.

Competence.

In an effort to reduce the amount of my middle-of-the-night wakeups I increased my overnight basal rate settings by 0.1 unit/hour (yes, that's all). The left side of this picture is from Tuesday night (before basal rate change), and the right side is Wednesday night (after the change). On the left side you can see my blood sugar hanging out around 180 mg/dL all night with Control-IQ automatically increasing my basal rates several times and manual corrections by me (shown in the bolus section). After the 0.1 unit/hour change (right side graphs), my blood sugars were more around 140 mg/dL with no manual corrections and much less Control-IQ intervention. Remember, that tiny vial of Humalog has 1,000 (1,000!!!!!) units, so the total change overnight was less than 1/1000 of a vial (0.9 units from 9pm - 6am).

Basal rate comparison. Insanely gorgeous graphical display courtesy of Tidepool.  

Competence.

Flying the international space station absolutely requires "total preparation and complete dedication" - as flight controllers we are essentially trained to be paranoid. Am I seeing signs of a degrading sensor? Are those readings from the GPS units suspect? Where are those rates on the vehicle coming from? What is the next worse failure? This internal dialogue of constant questions and the training leading to their answers is "competence" - there is no substitute, as the description goes.

As a person living with type 1 diabetes, paranoia is not optional, not trained - at some level it's just omnipresent for "flight diabetes will not tolerate the careless or indifferent." You can't live with diabetes and be incompetent - the consequences are literally life and death. If you think I'm being dramatic - recall the quantity of insulin I carry around (up to 240 units) versus the quantity it takes to change my blood sugars (0.1 units/hr). A miscalculation can become extremely serious.

Competence.

Thankfully that natural drive for competence in managing my disease has spilled over into my role as a flight controller. And, in my experience, this is true for lots of T1Ds. The qualities this disease ingrains, while paralleling those specifically noted for flight controllers, are professional qualities that apply to any job and really, life in general. It takes competence to understand trends and have a potential solution ready to go. It's competence that leads to steady blood sugars and streamlined management. Competence is never letting your guard down, being paranoid (in a good way), constantly asking questions and seeking solutions, then repeating the process day after day, hour after hour for yourself or someone you take care of.

In my job as a flight controller I was lucky - I had six years of college plus two more years of training and simulations to build up my competency, but a type 1 diabetes diagnosis is not such a gentle ramp-up. Sure we have endocrinologists and nurses and health care providers to get us through those first few days, but at some point (and it always feels a bit raw), you are just expected to go home and not die competently-enough manage the situation in your body. You grab those previously-foreign objects like syringes and blood sugar meters, draw up an injection and give it - it's not optional. These are the moments that diabetes injects us with a quality - competence - that we never wanted to be forced to cultivate.

Personally, I'm incredibly grateful, not for the disease itself (hello, kinda sucks to have a bum pancreas), but for the characteristics and qualities it has infused - I'm a better flight controller and person because of them.

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