What is DKA? Breaking down the basics with Dr. Eden Miller

[00:00:00] Rob Howe: Hello, listeners. What you are about to hear is a series that I've been working on for quite some time, and I've taken great care in every aspect of it because it's centered around a very serious topic, diabetic ketoacidosis, or DKA. But we know that by openly discussing serious topics, we can take some of the fear away from them, learn about them, and hopefully improve the way that we deal with them. Name it to tame it. So this is a five-part series where we discuss diabetic ketoacidosis. It is sponsored by Abbott. The views expressed should not be used for medical diagnosis or treatment or as a substitute for professional medical advice. Individual symptoms, situations, and circumstances may vary. The series is in our podcast feed as well as on YouTube, Instagram, and TikTok. I hope you find it informative, entertaining, and I hope it helps you understand a little bit more about DKA, its causes, and what you can do to make sure you're ready in a DKA situation. Enjoy. Hello and welcome back to another episode of Diabetics Doing Things. We are telling the amazing stories of people with diabetes from all over the world. Very excited to introduce our special guest today, Dr. Miller, Dr. Eden Miller, is going to be with us for three episodes. We're going to be digging into diabetic ketoacidosis, answering down the basics, talking about what you need to know about terminology to navigate situations living with diabetes related to DKA. So Dr. Miller, welcome to the show. I'm excited that not only are you a clinician, but you are also a patient, a person living with diabetes. And I think that perspective is just going to help us today make a very challenging and somewhat scary topic accessible and approachable and informative for our audience.

[00:01:45] Dr. Eden Miller: Thanks so much, Rob. Always a pleasure to come and talk about diabetes and really dig in and

[00:01:50] Rob Howe: empower us. Well, let's talk a little bit about your background for those who may not be as familiar with you because you are also a diabetes podcaster. So let's talk a little bit about your life with diabetes and your practice, and then we'll get into the basics of diabetic ketoacidosis.

[00:02:05] Dr. Eden Miller: That's great. Well, diabetes has been living with me for almost 30 years now. I am a family medicine doctor by training, but I'm actually a specialist. I do diabetology and obesity medicine, which means I got a fellowship or did my diplomate status with it. So what I do is I do high level Diabetology type of intervention in Bend, Oregon with my physician husband at our clinic, Diabetes and Obesity Care. But all of it is wrapped in the loving arms of primary care. So you can see I have a unique perspective, both being a person living with type 1, trying to educate those, trying to make it my career path. So it's really been super fun, both on a personal and a professional level.

[00:02:43] Rob Howe: Well, I love the energy that you bring to the podcast. I'm so excited to talk about what we often have not covered as much on diabetics doing things and has been a focus of ours this year is to dig into more of the clinician and clinical elements of life with diabetes and answering difficult questions like related to diabetic ketoacidosis. So for this episode, we're going to break down the basics of DKA. So let's talk about it just at a high level. How do we think about diabetic ketoacidosis? What is it? Then let's break down the basics.

[00:03:13] Dr. Eden Miller: Yeah, it's great. When we think about diabetes, we're always trying to live in the zone, but we have the extremes of the zone, right? We all know hypoglycemia. We know about it. We got CGM. We're trying to prevent it. But there's also this outlier on the other side, and that's diabetic ketoacidosis. We often refer to it as DKA. It really is this unbridled wildfire of fat metabolism. It's this concept of like starvation on the cellular level, right? Because the cells need glucose and they're starving, but they can't get the glucose into the cell to burn for fuel. So all that sugar's building up into the circulation, can't get it in. And so as a result, the cell is still sending signals to the body. I'm starving. I'm dying. So guess what we start to do? We start to burn fat. And when we burn fat, we're like, we need more sugar. It's like, but we already have too much. Well, but the cell doesn't know. It's kind of smart and dumb, right? It still needs that fuel. So it sends all those signals. We start to burn fat and the byproduct through that crazy Krebs cycle. I promise I won't go back to biochem, right? That crazy Krebs cycle, what it does is in breaking down those fats, those free fatty acids, we throw off acid. We throw off beta-hydroxybutyrate. We throw off acetoacetate and acetone. And those one, those two, beta-hydroxybutyrate and acetoacetate, they rise the pH or make the pH actually go down. You know how pH is kind of funny, but they create acid. And when they create acid in our body, our body likes a very narrow pH to live in. And when that acid goes up, we start having problems.

[00:04:41] Rob Howe: What you're describing often, I think for our listeners, sounds like what happened to them at diagnosis, right? Like people living with type 1 diabetes or type 2 diabetes or really anyone on intensive insulin therapy needs to be aware that, you know, diabetic ketoacidosis is always something that's going to be sort of hanging in the background as a risk that we're going to be the risk that we could encounter.

[00:05:02] Dr. Eden Miller: Absolutely. And what a horrible way to get introduced to this chronic disease, right? Life-threatening in the hospital. I mean, that is what always the challenges are. That's where diabetes awareness, family history screening, that kind of thing is coming in. So we kind of want to make sure that our listeners know that this is something that they have to be aware of. You need to know those signs. You need to know the symptoms and you need to know the situation so that you can prevent it because we don't want to go back there again.

[00:05:29] Rob Howe: Yeah, I think when we talk about the signs of elevated ketones and DKA, right, they're a little bit similar to the signs that we see just related to diabetes in general. But there are also some extra signs that we need to be aware of when we're talking about DKA. And like you said, it can happen at any time. So what signs would indicate elevated ketones or indicate diabetic ketoacidosis for those who are listening?

[00:05:53] Dr. Eden Miller: For sure. I think the signs are those things, sometimes not specific. And I like how you said that. Those are those things where you're going to pause and look up. You know, we do talk about glucose, but glucose isn't the only metrics. It can be misleading. We also talk about what we call GI-related issues, right? Nausea, vomiting, confusion, peeing like a racehorse, doing all those different things, right? And so those are those concepts where you don't feel well. You may, if you have associated nausea and vomiting, if you have any of those things that kind of lends you to think that you're sick or something is abnormal. But also remember those key takeaways are those signs are for you to pause and consider to make sure and to check. And it may be that you don't have it, but so many times individuals don't even consider or check. How many times have you had in your life, myself included, oh, I just have the flu or I ate something bad, right? And so that's why we don't want to scare you because it's hard to manage what you don't monitor. And if we're not monitoring for ketones, how are we ever going to know until it's like you're already in, you know, circling the DKA drain?

[00:07:01] Rob Howe: Well, and I like what you said, that glucose is a part of it. Oftentimes, our glucose number is maybe an indicator in our process. Probably the first step that we take is to either check on our CGM or check on our glucometer where our glucose levels are. But that's not the entire story. And like you said, oh, it's really easy to explain away some of the signs of DKA, but also the signs of diabetes. And in a vacuum, they seem kind of innocuous. But when you notice multiple of them together, really important to take that first step. And it sounds like the first step is to check the ketones and grab your keto sticks from wherever you keep them. Make sure that because in my case, and as we were preparing for this, I had the ketone strips, but they're expired. So making sure that you have an up to date, you know, ketone strips ready to go and check for what those ketones look like. Does that sound right?

[00:07:49] Dr. Eden Miller: Exactly. And so let's talk a little bit about that because there's really only two available options right now. We talk about the ketone urine strips and very imperative that those aren't expired, kind of like our glucagon, right? We have to have that conversation all the time. And so we want to make sure that we have a meaningful conversation with our clinician to say, hey, I need those keto sticks. Also know you actually can get them on different platforms that are shopping without prescription. So don't let that be a barrier. Always involve your clinician, but don't let it be a barrier because they are readily available. There's a limitation of using urinary ketones because those are going to be acetoacetate. And although that is one of the byproducts of that fat metabolism and it does show up in the urine, it can be very behind. Imagine if we were doing urine test strips for glucose, right? There was- Right. Like we used to do. Right. And that was like, that was all we had back in the day, but that's so far behind. Now, I'm not saying that you don't use them, but just understand they're not going to be the gold standard. We know finger stick and CGM is becoming the gold standard. So at least at the very minimum, have those urine sticks. Be aware of it. Understand that you might already be well into it. Or in some cases, your expired ones, they show false negative. So any ones that are moisture type of thing, make sure you're putting in a Ziploc, keeping it sealed. Now, let's talk about the available finger stick or what we call the serum or capillary ketones. Those are beta-hydroxybutyrate. I promise you I won't have an organic chem review, but rather those are through the blood. And beta-hydroxybutyrate are actually a more indicator of ketosis. They happen in kind of a real time. That means you poke and you see. Pretty accurate those particular ketone meters are. Sometimes hard to come by, require a script, require ketone test strips, that kind of thing. But it would be a more superior way of doing it. But you can see we got a lot of inertia in whether we're doing urine or finger stick. And it really shows that in the future we're going to need a better way, just like we used to check urine. We used to do finger sticks. Now we do CGM. And so but at least we got to keep up with what we got right now.

[00:09:52] Rob Howe: I do want to pause and give you an award for organic chemistry mentions on the podcast. You're the first guest to mention beta hydroxybutyrate and the Krebs cycle in the first 15 minutes of an episode. So congratulations.

[00:10:03] Dr. Eden Miller: Thank you.

[00:10:04] Rob Howe: I do want to talk about a couple of things because you mentioned humidity can affect the urine strips. So we want to make sure that we're not storing those like in the bathroom or under the bathroom sink in a high humidity environment, because like you said, could indicate a false negative. When you're in a situation that's high stress, you need to be able to rely on that information and that data. So, you know, giving yourself the best chance to do that is really important. But I want to dig into the results really quick. We're in a situation where we've recognized that there are signs of DKA that we are indicating. We've gotten either our glucose or our finger prick, beta-hydroxybutyrate test strip, ketone tester, or our urine strips. What are the signs that would indicate levels of DKA when we look at those ketone results, and how should we interpret them, and what action should we take?

[00:10:54] Dr. Eden Miller: Yeah, that's a very, very good question, because I think it's also going to go back to the awareness that I'll be honest with you, a lot of clinicians don't know as well as those persons living with diabetes. So it could be an opportunity to have a very meaningful conversation with your provider as well. Traditionally, when we're doing the urine ketones, we kind of pee on the stick, we dip it, whatever kind of thing. We're making sure that they're not expired. They're in a Ziploc. They're away from direct sunlight or away from humidity. We know that they're accurate. If we start seeing moderate, now I go based on colors. They come in a kind of a pink to maroon to super, super dark kind of red. And so those are those indicator that you kind of should like, now you saw the signs, now you're seeing a symptom or an actual ketones. And so now you got to be like, okay, I'm going to be alerted. This is a great opportunity to have a conversation with your clinician ahead of time to say, when do you want me to call? What do you want me to do? What levels of a urine ketone strip do you want me to intervene with? What kind of follow-up? Now, when you're looking at those ketone meters, they're going to have a level associated with it and each manufacturer is different. There's one that called the Precision, everybody uses the most, but there is a lot out there because there are people doing nutritional ketosis things. So I don't wanna be presumptuous based on the level. And I will tell you, there's a lot of work being done right now of what level that we're gonna look up, maybe 1.5 or above. Definitely when you're above three, you're like, you're gonna need to make a phone call. You're gonna need to be doing some troubleshooting. because what it is is it's showing that there is acid byproduct or acid in your blood related to fat metabolism. Even if you don't have symptoms that you would think are notable, that you got to take a notice, just like hypoglycemia, right? Have you ever had your sensor go off and you were low, but you didn't feel low? You still alerted to it, right? So this is where that nuance comes in.

[00:12:45] Rob Howe: And I think it really does depend so much person to person, which is why I think it's really good, especially for me hearing this 20 years in now, living with diabetes. It's been a long time since I had a conversation with my endocrinologist about what level of ketone should I pick up the phone and call him or consider going to the emergency room or something similar. You mentioned something, though, that I think will be really a lot of guests, I think, encounter a lot online and the terminology can be a little bit confusing, especially early on. And that was what people or referred to as ketosis, so nutritional ketosis. So can you explain a little bit of the difference between the folks that we see online who are checking their ketones using some of the same methods and what that is compared to diabetic ketoacidosis?

[00:13:29] Dr. Eden Miller: Yeah, you know, the body is constantly monitoring and managing food. If we didn't, we would pass away, right? You know, if we didn't have enough glucose to the brain, it wouldn't last for very long. So it's a part of normal everyday activity that if you and I were, let's say we go to bed and we don't eat dinner, we wake up early in the morning and you and I compete on a little ketone strip, we might have a little bit of trace ketones. Why? Because we were burning fat in order to stay alive. And so that happens on a regular basis. Let's say you and I went for a big old two-hour throw-down basketball time. We might be also mobilizing glucose through that lipolysis or fat breakdown product. And so we're going to show a little bit of that, either from activity, fasting, or let's talk nutritional. So nutritional is where you and I change our diet where, right, we look at carbs. We're like, that's not carb worthy. I'm just going to eat low carb or I want to bulk up. I want to get some good muscle tone going on. So we're eating a lot of vegetables that are low carb or protein. So guess what? Those aren't glucose bearing foods. And so our body, brain's an obligate glucose burner, still needs fuel. So it will mobilize from fat and protein ketones. But it's not going to be what we call unbridled. Think of it as kind of like a nice campfire, right, where you're warm versus a wildfire. And that's why people like even Gandhi, who went on that hunger strike forever, why didn't he go into DKA? You know, he wasn't eating for days. He had no food. He was burning his fat and his muscle. And the reason is, is because his glucose production to insulin level was appropriate. Whereas you and I, we get mismatched with those different scenarios. So you and I will produce ketones, but they are not necessarily detrimental unless they're in a scenario that we see.

[00:15:16] Rob Howe: And let's talk about those scenarios. I think you did a really great job of explaining, you know, how the body works. And I think those scenarios here is a great way to think about kind of putting the bow on top of that explanation. And that really digs into like what causes DKA. And so we talked a little bit earlier about glucose not always being an indicator or hyperglycemia not always being an indicator. compared to lack of insulin. And so you're talking about Gandhi, right? Like his body not living with type 1 diabetes is able to regulate that itself. But with you and I, we would have a different scenario probably. So can you talk a little bit about what causes DKA relative to that?

[00:15:53] Dr. Eden Miller: Yeah, I think it's a great question because I think it really goes to the meat of it. So DKA is what we call a relative deficiency of insulin in regards to the current living environment. And you and I could have all of those different scenarios. Let's say we get a sweet little prednisone shot for our knee or something. Now we have this hormone that causes insulin resistance, which is crazy that we can still experience that. So now all of a sudden our insulin gas mileage and our amount of insulin are mismatched. We call that a relative deficient. Doesn't mean you don't have insulin on board. It means that your needs metabolically have gone up. Times of stress, right? You and I, we're burning the midnight oil. We're working the night shift, which is kind of crazy that that can do that. at any time of times of stress. Illness. Have you ever noticed some illnesses raise your blood sugars and some don't? Like, what is up with that, right? You have different scenarios, and that's cortisol and growth hormone and things like that. Then, of course, the traditional, my insulin next spot, summertime. Oh, my gosh. Summertime and heat, and the insulin gets a little bit less efficacious. Maybe you're in- Hydration. Right? Maybe, right, dehydration. You know, your fluid balance is off. Maybe you're injecting in the same spot over and over again because you forget you're supposed to rotate. Maybe because you have diabetes forever, you're putting your pump on and those occlusions occur. So you can see that I want our listeners to think about kind of running it through. I'm having some of those signs. I might have ketones. Let me troubleshoot. And this is what I, as a clinician, talk to them about sick day or what I call instead of sick day, I want to call it ketosis prone days. I want to call it that, not just sick day because you don't necessarily have to be sick. I want to call ketosis prone days. Do that little rundown in your head. Try to troubleshoot it. We're not saying for you to do it on your own, but it's sure going to help your clinician if you call them to say, you know what, here's what I've done, because it's all about identifying testing and then action.

[00:17:50] Rob Howe: Let's talk a little bit about those ketosis prone days. And a lot of what you talked about were when situations kind of put you off on a different schedule where the risk for DKA has increased. You mentioned the occluded site, which is, I think, always my number one DKA agonist in my life with diabetes. things like when schedules change, like if you're a shift worker and you have to work overnight quickly or you're traveling and you're jet lagged or you have to update your settings and your carb ratios are a little bit off or maybe you missed a meal or two or one thing or another. And then when your insulin needs change and you mentioned like if you took a steroid shot or you're having a sick day or you're in maybe a pregnancy and your insulin needs are changing very rapidly, like what are some of those other situations where we need to be more ketone aware?

[00:18:41] Dr. Eden Miller: I love how we're going to try to individualize this because this is that conversation I'm going to have with the person. Because some people are more ketosis prone than others. I won't go too in depth with that. We're going to find that out more later as we see more data. And it's really kind of like, what are your symptoms? What are the things that trigger you? Are you somebody who have a pump occlusion and two hours later you're in DKA? I can tell you, I got little kiddos that go to bed and wake up with it. Are you going to respond to a medication that's going to cause that insulin resistance? The thing was spot on because I get the opportunity to fly all over the world and the country. And when I'm going to different time zones, I'm like, oh my gosh, my circadian rhythm is like, no, it's the morning, your insulin resistance, but maybe it's the nighttime. So as much as I don't want them to be fearful, because it's not about being fearful, it's about being aware and being able to adapt to that. And so you go, oh yeah, that's right. This is what's different about me today. Whether it's I'm sick, I'm stressed out. you know, I got to change the site. The other thing too, and I'm going to mention it, and this is what tends to be the biggest barrier. So imagine you and I, you know, we look at our supplies, our CGM, our insulin vials, our pens, our infusion sets, and they're like gold to us. And we often don't change them because we don't get that additional emergency. That's why clinicians need to factor in that emergency in scripts because, you know, we all want to sit there, right? And be like, don't change the site. I don't have another one, you know, kind of thing. And yet that can be a facilitator, a DKA. And we really don't want more than about four hours to go by before you're like, you know what, I'm going to hit the reset button. I'm going to figure it out. And so I like the individual to have that discussion or what are your scenarios and situations that you have to be aware of possibility of ketosis prone times or events. I love that personalization aspect

[00:20:36] Rob Howe: with your provider. I think that's why, you know, even though we had to have that disclaimer at the top, it's really good advice to have that conversation. And like you said, working with your care team to have that plan, because the one thing we know about diabetes of all kinds is that, you know, you can plan all you want, but life's going to have another curveball to throw at you. it might come in the way of a doorknob pulling out your pump site or, you know, something just, you know, or a couple of insulin resistant days while you're traveling. And something that you brought up too, like whether it's lack of sleep or it's stress or hormones. And, you know, when you're a woman with diabetes, there's your menstrual cycle is part of that as well. Spoiler for all of us guys with diabetes, we don't have to deal with that. And it's a major life hack, but you know, you're, you're in this situation and you've got to be aware of it. But the thing I've learned more recently is that happens to people who don't have diabetes as well.

[00:21:25] Dr. Eden Miller: When you're stressed, when you have cortisol, when you have lack of sleep, we are just more aware of it because we're doing all the thinking of our pancreas and all the work that our pancreas would normally do. And so I don't think it's something to look at from a place of judgment, but it's good information to be able to run down that list and know where you are and to keep an eye out on those symptoms. It's kind of like what ignites our fire. We're just more prone to like spontaneously burst into flames, you know, and that could also be somebody who doesn't normally do that. but let's say a type 1 gets pregnant or even persons with type 2. You can get DKA and not be a person with type 1 diabetes. You can actually have other types of diabetes as well. And so I just think of it as what is different? What is different in your life and do I need to do anything differently about that? But no, we all have, we just, like you said, I love how you mentioned, we have to play pancreas on the outside. And when you do that, there's just a lot that goes into it. That's what kind of contributes to the fatigue. And so we want to make sure that we are purposeful. And if I could say it over and over again, never emotionalize your diabetes because it shouldn't be. We're just monitoring. It's not that you're good or bad or smart or dumb. It's just what it is. And you just go, I'm going to check. And then sometimes I say, good thing I checked, even when I have a high blood sugar, right? Good thing I know. Now I know what to do about it. But not to hold it as like they're these little badges, merit glucose badges. No, you just don't emotionalize it.

[00:22:48] Rob Howe: How do you as a patient and provider de-emotionalize or kind of separate your own? like, because it can be really hard. And I think I'm very lucky. I'm good at it. But occasionally, you know, when I have a sensor fails at 1130 at night and I want to go to bed, I don't want to wait for a warm up period or have to get out of bed and get uncomfortable and like do all my stuff. It's hard sometimes to fall into that trap of emotionalizing that diabetes. What advice do you

[00:23:12] Dr. Eden Miller: have or what steps do you take when you run into those types of issues? I think first is a gratefulness. I think sometimes when you're living in this time, we think, oh, it's so hard. You know, I had a guy that came to one of my lectures about continuous glucose monitoring, and he brought his mother's nursing book that had a chapter on tasting urine. And I was like, I am so glad we don't have to do that. So sometimes it's gratefulness, right? You know, you got to be looking at the positive. You want to go to sleep. You and I are both sitting there and our bed partner's like, go do it, right, kind of thing. I think some of it's gratefulness. Some of it's planning ahead. You know, you look and go, you know what? My sensor's going to fail at one o'clock in the morning. Why don't I change it ahead of time, which is hard. I think also understanding it doesn't define me. It's just a monitoring. It's just a metric. I use the analogy with people sometimes like, do you get upset when your gas gauge is half full? And sometimes they say they do. But no, I use a metric that it's like, we don't. You know, we don't. We shouldn't do it with our weight. We shouldn't do it with those things. And maybe here's the big one. And because I fall prey to this as well. So let's say you are having issues. Maybe you have had a decay episode. And because, you know, you go to your provider and they're like, you know, that's going to hurt you. And it's like, oh, that's really helpful. You know, but you have one of these complications or challenges. Let's not call it a complications or challenges. And so pause and say, what can I learn from this challenge? Because, you know, you and I, one of the things we fatally do with diabetes is we're pretty stubborn. And the reason we're stubborn is because we've kept ourselves alive. Right. We're only one cupcake away from a coma. And so we got to do a lot of things to keep ourselves there, right? And so sometimes it's just giving ourself a little slack. And it's also saying, like I just did this morning, you know, every time I drink my coffee, I don't take enough insulin. Why don't I try to take something different and see what happens? I think it's really trying to break out of the habit because we feel as though the habit is keeping ourselves alive, right? So maybe just kind of getting outside ourself a little bit, de-emotionalizing it, being a little grateful. And remember, you don't have to do it all in a day. It's a marathon. Let's keep going. Let's try the next mile. Let's learn from what we have. Don't look back. You get depressed.

[00:25:24] Rob Howe: Don't look forward. You get anxious. Stay in the present. I love it. I think so much of my life, even diabetes or otherwise, when I rooted in gratitude, everything else makes sense. You know, I'm not grateful because I'm happy. I'm happy because I'm grateful. And I think, you know, You know, that's something that I'm borrowing from someone else much smarter and wiser than me. But then also just that mindset of continuing to go forward and giving yourself a lot of credit. You are keeping yourself alive. And that is such an awesome thing to celebrate. And I think too often we fixate on the negative without also giving ourselves props on the positive. So just to close out this sort of 101 overview of what is DKA and breaking down some of the basics. What should, as a closer, what should someone do if they detect or suspect DKA? And obviously, we need to all individually talk to our care teams and our endocrinologists and our providers. But for you, maybe, if you detect or suspect DKA, what is on your to-do list?

[00:26:23] Dr. Eden Miller: So for my to-do list is both of a person and a professional. Make sure that you have the ability to detect. Have a very low threshold for checking. So what? You pee on a strip. You poke your finger. You get it. You check it out, right? Because if it is a cold, you get to binge watch, drink lots of fluids, eat chicken soup. If it's not, then what it's going to do is prioritize that to you. Troubleshoot. What might have happened? Did I miss an injection? Is my insulin old? Do I have, am I injecting in the same spot? Do I have an old pump site? Do I need to do something different? Am I ill? Did I have a new, you know, a surgery? Am I pregnant? You know, that kind of thing. Number three, contact your healthcare provider when it gets to a level that you guys have predetermined or that level I'm talking to you about, moderate, 1.5 or 3 on the thing. That's going to be a very specific conversation with you and your clinician because they want to make sure whether you have to message them, whether you have to call them after hours. If, if, if, if you have signs and symptoms that are very consistent with DKA, vomiting, confusion, high glucose. It doesn't have to be high. Those reasons for the DKA, don't hesitate. Even if you can't get your doctor, go in. Go into the emergency room. Go into that urgent care, whatever you can do. Because even if you aren't, great. Maybe you just need fluids. Maybe you just need a little bit of correcting. But have a low threshold. But always call your clinician because they want to know. They want to follow up with you as well.

[00:27:55] Rob Howe: I want to touch on that, right? One thing more before we close on this episode. So you touched on something. maybe they only give you fluids. You go to the emergency room, you follow the protocols, and you only get fluids. In the back of my mind, maybe I'm thinking, well, maybe I didn't need to go. And I think that's a weird mental space to be in because I think what we're saying is that DKA is very dangerous, even though it's not a scare tactic. It can change quickly, and it's really important to have all the resources at your disposal should you need them. So even if you only receive fluids and you go to the hospital, you did the right thing.

[00:28:29] Dr. Eden Miller: Well, hey, what about this? All I required was fluids to get out of it, right? Not an ICU admission, not, you know, an insulin drip. I mean, it's not like we're competing. Well, my DKA was worse than your DKA. I don't want to scare you, but rather let's go in and treat it when it's treatable. Let's not treat it when it's like everybody notices, right? And it's life threatening. I like to treat it when it's treatable, not when it's life threatening. So you get out of the hospital fluids. Awesome, right? Way to go. It's less of a burden and less of a bill. You know, the average admission cost is between about $5,000 and $30,000. Not that I'm putting a price on anybody because you guys are all priceless. But you go in and have fluids, great. Way to go. Way to prevent it. I'm all about it.

[00:29:13] Rob Howe: Yeah, I think it kind of follows up to that discussion about de-emotionalizing your diabetes and your treatment. You got the treatment that you needed. Let's learn from it and move forward versus, you know, looking back with judgment on what that treatment was. Well, Dr. Miller, this concludes part one of our sort of DKA 101, what is DKA and breaking down the basics. Stay tuned and subscribe for parts two and three with Dr. Miller, including some very special patient stories that we'll be sharing as part of this.