"Someone saved my life tonight": who invented injecting?

It’s been a while since I posted anything new on my blog.

For a start, I've had a very busy 2019 in various unrelated ways, and a summer spent outdoors working in my garden has left little time for keyboard musings.

But perhaps more sadly, I have felt somewhat disinclined to share too many thoughts online, when having in June attended an event* for people with diabetes from  across Europe, sponsored by a medical device company, I witnessed an outbreak of online criticism levelled against “bloggers” and “advocates” (neither are terms that I warm to or identify with - I’m just a person who enjoys writing and was encouraged by others to share my thoughts online)

It's easy to overstate the levels of antagonism, but it is nevertheless sad to find oneself attacked by strangers for taking opportunities in good faith, enjoying them and aspiring to use them for the greater good, or for just sharing thoughts that others might enjoy reading. It was equally sad in late June to see similar criticism levelled at a number of HCPs and people with diabetes who had been invited to a reception at 10 Downing Street, hosted by our T1D (former) Prime Minister. Again, there was discourtesy and insensitivity on display, but I was encouraged to see the supportive voices eventually outnumber critics in a big way.

So I have kept relatively quiet over the summer, leaving blog posts and GBDoc tweetchats to others, but thought it was perhaps time to share some thoughts that I was invited to deliver to a small group of people with diabetes (interestingly, many drawn from the Instagram diabetes community, which to an extent exists in a separate bubble from the Twitter and Facebook ones) at an event* organised by BD needles last Saturday, to assess their starter packs for people starting injection therapy.

So read on for a post adapted from my talk, as a committed MDI-er, on the continuing importance of injecting, together with a bit of history of this easily taken for granted therapy.

I have lived with my unwanted friend Type One diabetes for almost 22 years, as many readers will already know: I developed the condition at the end of 1997, shortly after my fortieth birthday, and have been fortunate enough to live well with diabetes throughout the subsequent years.

Among the reasons for this is the online diabetes community, which has brought me so many new friends and opportunities in recent years. Like many others, I have learned and shared more about diabetes in the past six years than I did through “official” channels in the first sixteen.

However, any online community can falsely magnify things, including the voices of those who choose to talk a lot. One of the things that the online diabetes world most magnifies and therefore exaggerates is the role and extent of technology in diabetes management. 

Perhaps because the community is mainly the province of younger people (I use that term very vaguely, meaning perhaps the under 40s), it can seem as if most people with Type One use an insulin pump and some form of continuous glucose monitoring system, and indeed that many of them are technophiles, busy working on DIY closed loop systems.

Through my online interaction with other Type 1s, I have seen and heard much about the benefits of pumps and DIY closed loop systems, and I warmly applaud those who have driven progress in this area. But it’s not for me. The fact remains that I, and 1000s like me, are highly unlikely to be offered an insulin pump on the NHS, and quite frankly, I remain unconvinced that the potential benefits are significant enough for me to bother pursuing the matter.

The reality is that the overwhelming majority of the UK’s 400 000 people with Type 1 (and a significant number of those with Type 2) are treated with multiple daily injections: the surprisingly vague national figures put the overall number using a pump in the UK at around 10%, with huge variations according to age group and geographical area.

Arguments rage about access or lack of it to this technology, but the fact remains that for the foreseeable future, injections will be the means of delivery of insulin for the vast majority of us. So some very rough mathematics suggests that every day in the UK something between 1.5 and 2 million insulin injections are administered, the vast majority of those done by the patients themselves - people with no medical qualification.

It’s mind-blowing when you stop and think about that: up to 2 million instances every single day of a life-saving, yet potentially dangerous and easily fatal substance being injected in homes, workplaces, shops, schools, parks, on trains, boats and planes, in cafés and restaurants, on barren mountain tops and on busy city streets, at all hours of the day and night. There’s a heck of a lot of injecting going on out there, much of it discreet and unseen.

So it’s pretty important that we get it right!

Injecting has a pretty bad name. For most people, it has associations with immunisations at school or with drug addicts in bus shelters. Anyone with diabetes has experienced ridiculous comments along the lines of:-

“Oh gosh, you are brave, I couldn’t stand injecting myself”

To which we wearily respond:

    “Erm, I think you would if the alternative was a slow and lingering death”

Like anyone, I wasn’t thrilled when back in January 1998 I discovered that I would be sticking a needle in myself several times a day for the rest of my life, but of course you get hardened to it, usually in no time. However, far from fearing injections, I soon came to value them, and have never really had any issue, physical or mental, with administering them. But what do we know about injecting insulin?

Well, whilst we rightly honour Sir Frederick Banting for his discovery of insulin therapy in 1924, perhaps we should also salute Irishman Francis Rynd, Frenchman Charles Pravaz and above all Scotsman Alexander Wood.

Francis Rynd

Charles Pravaz

Alexander Wood

Who? Well, whilst the concept of injecting (forcing liquids through a narrow tube) dates back thousands of years (there is evidence that the ancient Egyptians knew about it), it is these three scientists who collectively are responsible for the invention of the hypodermic syringe in the mid nineteenth century. This was less than 200 years ago, so we shouldn’t take that for granted any more than insulin itself. I hadn’t heard of them until I started doing a little research, and I bet few readers will have heard of them. Click on their names above and Wikipedia will tell you more.

Injections of various kinds are familiar to all of us, but of course familiarity breeds contempt, and like almost anything that we do repeatedly and continuously, we who inject multiple times a day become careless, take shortcuts and stray from what we were taught as the ideal way of doing things. I have written about this in a previous post.

At the risk of sounding like a repentant sinner at an American evangelical convention, I have to admit that I am less than assiduous in following all of the generally accepted guidelines, and occasionally neglectful of the entire lot. To my cost?

Well not exactly, but since learning more about lipos (thanks to my lovely HCP colleagues on the FIT Board), I have been carefully avoiding over-used sites, and guess what? My insulin sensitivity has improved and my requirement has fallen, both quite significantly!

I genuinely think that Lipohypertrophy is the Cinderella of diabetes issues. We PWD and those who care for us are all so bothered about avoiding hypos, dealing with the uncomfortable highs, pursuing elusive “flat lines”, over-reacting to the TMI that many of us now get from our Libres and CGMs, that we overlook the insidious damage that we are doing to our too-easy-to-reach tummies. And judging from my own experiences and what I hear from others, checking our injection sites and advising on injection technique are a frequently missing part of our consultations with HCPs in clinic.

Perhaps it’s time we all started to think rather more about injections. Whilst for those who don’t have to do it regularly, injections are a rare and somewhat intimidating experience, for those of us who do it multiple times daily, it seems almost too easy, taken too much for granted. Perhaps we should all pay more attention to to  technique, site rotation, size of needles etc. For example, I spent the first 20 of my 22 years with diabetes using the 8mm needles that were the norm back in 1998, blissfully unaware that current thinking among HCPs is that 4mm are best for everyone, regardless of their BMI. And whilst my eyes are screened annually, my feet jabbed at every visit, questions asked about my “control”, my highs and lows etc., nobody has ever asked about, let alone examined, my (frankly less than alluring) midriff.

So there you are: I stand before you a longstanding disciple of injecting and a born-again advocate of good injection technique. May I publicly thank my friends on the FIT Board for their wise guidance and friendship, and I hope that we will perhaps all resolve to move good technique just a little higher up the agenda.

And let's remember, “Someone saved my life tonight”. Well actually several someones have  helped save our lives: as well as Banting, let's hear it for Messrs Rynd, Pravaz and Wood - the unsung heroes of diabetes care?

There you go, there’s always a song title! Thank you for reading.

Disclosures: 
In June 2019 I was invited by Abbott Healthcare to DX Lisbon, a gathering of people with diabetes from across Europe. My travel, accommodation and subsistence was paid for by Abbott.

In September 2019 I was asked to speak at Shaping BD, an event in Birmingham to assess an education pack for people starting on insulin injections. My travel and subsistence was paid for by BD.