Meet Jack

Jack’s Story

• Born 1946 to Ojibwe parents in Northern Ontario
• Age 6 years, taken away to a Residential School
• Given the name ‘Jack’ by the priests
• Worked odd jobs, finally landing a job at a mine
• Met and married Mary
• Had two children, Phillip and Nancy

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Shingwauk Residential School – Sault Ste. Marie, ON

Owned & operated by The Anglican Church of Canada

Opened August 2^nd, 1875

New school opened October 3^rd, 1935 & housed 140 pupils

The school focused on teaching trades & agriculture

Jack was often subjected to:

• Harsh discipline
• Malnutrition
• Poor health
• Physical, emotional, and sexual abuse
• Deliberate suppression of his culture & language

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Daily Schedule

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Residential Schools & the Effects on Indigenous Health

Personal or familial residential school attendance is related to health in a multitude of ways

People who attended residential schools generally feel their health or quality of life has been negatively impacted

General health: poorer overall self-rated health, less likely to seek health care

Physical health: chronic health conditions and infectious diseases

Mental health & emotional well-being: mental distress, depression, addictive behaviour, substance misuse, stress, and suicidal behaviours

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Occupational Illness & Disease

Occupational health focused on the physical health – respiratory disease, the impact of noise, heat and vibration on the miners’ health.

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A significant number of miners are experiencing high levels of stress, anxiety, and depression (Centre for Research in Occupational Safety and Health).

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United Nations Photo

Jack’s Story Continues

• Jack felt he had nothing to offer his children

(Nancy & Phillip)

• He had lost his ancestral heritage
• He often took Nancy fishing & hunting
• He attended all his daughter’s sports events
• Did not spend much time with Phillip
• Worked hard to provide for his family

& maintain his home

• He loved his wife Mary, but often missed

the family & culture he grew up

with

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Jack’s Health

Jack was diagnosed with type II diabetes mellitus just before he turned 50 years of age.

Signs & Symptoms of type II DM often develop slowly.

You can live with type II DM for years and not know it.

When S&S are present, they include:

• Increased thirst
• Frequent urination
• Increased hunger
• Unintended weight loss
• Fatigue
• Blurred vision
• Slow-healing sores
• Frequent infections
• Numbness or tingling in hands or feet
• Areas of darkened skin, usually in the armpits & neck

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Causes

Type II DM is primarily the result of two interrelated problems:

• Cells in muscle, fat, and the liver become resilient to insulin.
• Because these cells don’t interact in a normal way with insulin,

they don’t take in enough sugar.

• The pancreas is unable to produce enough insulin to

manage blood sugar levels.

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How Insulin Works

Insulin is a hormone that comes from the pancreas

& regulates how the body uses sugar in the following ways:

• Sugar in the bloodstream triggers the pancreas to secrete insulin
• Insulin circulates in the bloodstream, enabling sugar to enter the cells
• The amount of sugar in the bloodstream drops
• In response to this drop, the pancreas releases less insulin

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The Role of Glucose

Glucose-a sugar-is a main source of energy for the cells that make up muscles & other tissue.

• The use & regulation of glucose includes the following:
• Glucose comes from 2 major sources: food & the liver
• Glucose is absorbed into the bloodstream, where it enters cells with the help of insulin
• Your liver stores & makes glucose
• When glucose levels are low, the liver breaks down stored glycogen into glucose

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In type II DM, this process does not work well. Sugar does not enter the cells, builds up in bloodstream. The beta cells in the pancreas release more insulin. Eventually these cells become impaired.

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In type I DM, the immune system mistakenly destroys the beta cells, leaving the body with little to no insulin.

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Risk Factors

Weight – being overweight or obese is a main risk

Fat distribution – storing fat mainly in the abdomen (men waist >40 inches, women waist >35 inches)

Inactivity – physical activity keeps weight done, and uses up glucose as energy, makes cells more sensitive to insulin

Family history – increases if parent or sibling has type II DM

Race & ethnicity – Black, Hispanic, Indigenous, Asian, Pacific Islanders

Blood lipid levels – increased risk associated with love levels of HDL cholesterol and high levels of triglycerides

Age – increases with age, especially after age 45

Prediabetes – blood sugars higher than normal, but not high enough to be classified as diabetes, if left untreated often progresses to type II DM

Pregnancy-related risks – increases if you develop gestational diabetes or if you give birth to a baby weighing > 9 pounds

Polycystic ovary syndrome – common condition characterized by irregular menstrual periods, excess hair growth and obesity-increases the risk of diabetes

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Complications & Frequent Comorbidities

Heart & blood vessel disease – increase risk of heart disease, stroke, hypertension, and atherosclerosis

Neuropathy in limbs – overtime nerves are destroyed, resulting in tingling, numbness, burning pain or eventual loss of feeling. Begins at tips of toes or fingers and gradually spreads

Other nerve damage – damage to heart nerves can contribute to irregular heart rhythms. Digestive nerve damage may lead to nausea, vomiting, diarrhea or constipation. Men, erectile dysfunction.

Kidney disease – may lead to irreversible end-stage kidney disease

Eye damage – cataracts and glaucoma, may damage the blood vessels in the retina

Skin conditions – more susceptible to bacterial and fungal infections

Slow healing – cuts and blisters can become seriously infected, severe damage might require amputation

Hearing impairment

Sleep apnea – obstructive sleep apnea is common, obesity may be the main contributing factor. Not clear if treating sleep apnea improves blood sugar control

Dementia – seems to increase risk of Alzheimer’s disease and other dementia disorders. Poor blood sugar control linked to more-rapid decline in memory and thinking skills

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Prevention

• Monitor and/or lower your blood pressure & cholesterol
• 30 minutes of activity per day five days per week helps lower risk of developing type II diabetes by 58%
• Eat a healthy diet, less fats, more fiber, whole grains, veggies, fruits, lean meats
• Manage your weight & BMI

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Table of Insulin Action

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Insulin Mixtures

For convenience, there are premixed rapid- and intermediate-acting insulin.

The insulin will start to work as quickly as the fastest-acting insulin in the combination.

It will peak when each type of insulin typically peaks, and it will last as long as the longest-acting insulin.

Examples include:

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• 30% regular and 70% NPH (Humulin 30/70, Novolin ge 30/70).
• 50% lispro and 50% lispro protamine (Humalog Mix 50).
• 25% lispro and 75% lispro protamine (Humalog Mix 25).
• 30% aspart and 70% aspart protamine (NovoMix 30).

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Jack’s Story Continues

• Jack is found by his daughter unkempt, SOB, limping slightly, and has a strange odor coming from him
• States he has not been eating or managing his blood sugars & insulin well
• Has not bathed since his wife went to hospital (unable to access the bathtub safely)
• Blood glucose level is 12.4 mmol/L
• Heart rate 130 BPM
• Daughter finds an open, oozing wound on Jack’s foot

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Diabetic Ulcer Symptoms & Diagnosis

Wagner Ulcer Classification System:

• 0: no open lesions, may have healed lesion
• 1: superficial ulcer without penetration to deeper layers
• 2: deeper ulcer, reaching tendon, bone, or joint capsule
• 3: deeper tissues involved, with abscess, osteomyelitis, or tendonitis
• 4: gangrene in a portion of forefoot or heel
• 5: extensive gangrenous involvement of the entire foot

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Causes of Diabetic Foot Ulcers

Poor circulation – blood does not flow to feet efficiently, also making ulcers more difficult to heal

Hyperglycemia – can slow healing process

Nerve damage – tingling and pain, decrease or loss of feeling

Irritated or wounded foot – reduced sensitivity results in painless wounds

Wearing inappropriate footwear - may be significant in wound progression

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Treatment for Diabetic Foot Ulcers

Treatment primarily depends on the stage of the ulcer

Essential to start treatment as soon as possible – helps prevent infection & provides better results sooner

• Antibiotics if applicable (C&S of wound site)
• Shoes designed for individuals with DM
• Debridement
• Foot baths
• Disinfecting the skin around the ulcer
• Keeping the ulcer dry with frequent dressing changes
• Dressings containing calcium alginates to inhibit bacterial growth
• Surgical procedures – shave bone or removing foot abnormalities (bunions or hammertoes)
• Other treatment options ineffective – amputation

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Preventing Diabetic Foot Ulcers

• Washing feet every day
• Keeping toenails adequately trimmed, but not too short
• Keeping your feet dry & moisturized
• Changing socks frequently
• Seeing a podiatrist for corn & callus removal
• Wearing proper-fitting shoes

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Jack’s Story Continues

• Jack is found by his daughter unkempt, SOB, limping slightly, and has a strange odor coming from him
• States it feels like his heart is racing and he can’t catch his breath
• Radial pulse 130 BPM (irregular)
• Jack is taken to the emergency department as per his family physician’s recommendation
• Jack is diagnosed with new onset of atrial fibrillation
• Admitted to hospital with a cardiologist and endocrinologist referral

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Atrial Fibrillation Overview

• Irregular & often rapid heart rate
• Can increase risk of stroke, heart failure, other heart-related complications
• The two atria beat chaotically & irregularly – out of coordination with the two ventricles
• Episodes may come & go, or does not go away requiring treatment
• Is not life-threatening but a serious medical condition that may require emergency treatment
• Major concern is the potential to develop blood clots in the atria
• These clots may circulate to other organs & lead to ischemia
• May weaken the heart and lead to heart failure

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In a normal heart rhythm, a tiny cluster of cells at the sinus (SA) node sends out an electrical signal. The signal then travels through the atria to the atrioventricular (AV) node and passes into the ventricles, causing them to contract and pump out blood. In atrial fibrillation, electrical signals fire from multiple locations in the atria (typically pulmonary veins), causing them to beat chaotically. Since the atrioventricular (AV) node doesn't prevent all of these chaotic signals from entering the ventricles, your heart will beat faster and more irregularly than normal.

Symptoms of Atrial Fibrillation

• Palpitations, sensations of a racing, uncomfortable, irregular heartbeat or a ‘flip-flopping’ in the chest
• Weakness
• Reduced ability to exercise
• Fatigue
• Lightheadedness
• Dizziness
• Shortness of breath
• Chest pain

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Atrial Fibrillation may be:

Occasional – paroxysmal A-fib comes and goes, usually lasting for a few minutes to hours. May last up to a week and happen repeatedly.

Persistent – heart rhythm does not go back to normal on its own. Will need treatment; medication or electrical shock to restore normal heart rhythm.

Long-standing persistent – continuous and lasts longer than 12 months.

Permanent – normal heart rhythm cannot be restored. Requires medication to control heart rate and to prevent clots.

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Possible Causes of Atrial Fibrillation

Abnormalities or damage to the heart’s structure are the most common cause of A-fib.

Possible causes of A-fib include:

• High blood pressure
• Heart attack
• Coronary artery disease
• Abnormal heart valves
• Heart defects (congenital)
• Overactive thyroid gland or other metabolic imbalance
• Exposure to stimulants – medications, caffeine,

tobacco, alcohol

• Sick sinus syndrome – improper functioning of

the heart’s natural pacemaker

• Lung diseases
• Previous heart surgery
• Viral infections
• Stress due to surgery, pneumonia or other illnesses
• Sleep apnea

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Treating Atrial Fibrillation with Medication

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Procedures for Rhythm Control

Electrical Cardioversion – delivering a shock to the heart, like defibrillation but a smaller amount of electricity. Cardioversion is a short-term solution. In most patients, the A-fib comes back.

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Catheter Ablation – inserting thin wires into the veins in your groin or neck. The tip of the wire is directed towards the area in your heart that is firing irregular impulses. Once in position, a small jolt of radiofrequency electrical current is delivered to burn out the tiny areas.

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