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Cynthia Pasquarello, B.S.N., R.N., C.D.E., Recognized for 40 Years at Joslin

Thursday, May 17, 2012

Cynthia Pasquarello, B.S.N., R.N., C.D.E., an educator in the Pediatric, Adolescent, and Young Adult Program, has seen a lot of diabetes history. She started at the Joslin Diabetes Center in 1972, surrounded by the pioneers of diabetes research and care—including Priscilla White and Alexander Marble. Today, she is being honored at Joslin’s Length of Service Ceremony for her 40 years of dedication to patients with diabetes.

So what was the path that brought you here to Joslin?

Long ago, well, 40+ years ago, I was working at Boston College in the student health infirmary when they did not have a year-round health infirmary. And so the nursing staff was all “laid off” during the summer. I needed a short-term summer job to cover three months’ worth of rent and bills.

So I went to Camp Joslin for summer number one, had an amazing time and loved the experience so went back for summer number two and met physicians who suggested, “Why don’t you apply for a full-time position working at the Joslin Clinic?”

So I applied for a position as a teaching nurse—providing education for all ages, youth to elders. It was a broad spectrum position; there were no pediatric educators because there was no pediatric department.

I was very fortunate in the sense that under Dr. Charles Graham, Dr. Donald Barnett, Dr. Donna Younger, and Dr. Priscilla White I got a pediatric education like you can’t believe. It was par excellence.

There were a few of us who attached ourselves to the pediatric patient and families experience consistently. The pediatric department evolved from a very tiny group to our current team of seven nurse practitioners, two diabetes nurse educators, two registered dieticians, two mental health specialists, nine M.D.s, two Child Life Specialists, and a phlebotomist.

What’s the biggest improvement you’ve seen in pediatric care after the creation of the creation of the pediatric unit?

The recognition that children are not small adults. That they are children who happen to have diabetes, and that the management of diabetes should not supersede the importance and relevance of being a child first.

And the importance of an interdisciplinary team—we have a mental health group specifically tuned in to kid needs, dieticians dedicated to helping families with healthy eating, a dedicated phlebotomist, and a Child Life department that makes coming to the Pediatric department something to be looked forward to rather than something to be feared. I think these are the important highlights of what help to make the Joslin Pediatric Department so unique.

And what about improvements in pediatric care in general?

Well certainly the evolution of newer insulins and newer delivery systems, and newer monitoring techniques making the management of diabetes less cumbersome than it was.

Families get discouraged with how slowly they think technology is moving forward. Insulin delivery systems of 40 years ago consisted of glass syringes sterilized by boiling on a stove. We used tricks to teach people how to boil the syringes in ways that the plunger would not bang up against the glass syringe and shatter the syringe.

You can’t appreciate how much work it is to boil syringes when you can go to your box of disposable syringes and you pull one out, you’re not assembling it, you’re not sterilizing it, you never have to worry about cloudiness of the syringe itself because of mineral deposits in the water. You don’t have to worry about the plunger falling out of the syringe because it’s slippery. You’re not sharpening steel needles on a pumice stone. You just take one out the package and you use it!

The only way families could monitor insulin dosing effect was by checking urine for sugar. They were using CliniTest Tablets—you would actually get urine in a cup. You would then, with a medicine dropper, take two drops of urine and put it in a test tube. You would then add 10 drops of water to that, then add one of these CliniTest tablets to it, being careful where you held the test tube because the tube got hot, easily burning fingers. The contents of the test tube would change color from blue, which was sugar-free, to orange, which signified a lot of sugar in the urine. And no way to interpret blood glucose values was available.

And how many times a day did you have to do that?

The recommendation was four times a day.

And at camp, urine was boiled using Benedict’s Solution on the stove.

And teaching nurses were the ones who taught a class called “Teaching Table.” We would put on plastic gloves and, with people who needed to learn how to identify portion sizes, we would sit at a table and cut meat off of bones and weigh it on a gram scale. So if you had 90g of meat for lunch, we would sit there and we would cut meat, take off fat and gristle, and weigh out 90g of meat.

So the teaching nurses we calculated the diets and wrote out menu cards with “one free tomato per day.”

A tomato was the freebie?

One free tomato per day.

Today families are taught that the emphasis is on healthy eating, not restricted by lists of “Foods Likely to Cause Problems,” the need to eat 1/5 of your calories at breakfast (not more or less) and 2/5 for lunch and 2/5 for dinner at consistent times of the day (no flexibility of timing allowed with that NPH or Lente insulin!). Diabetes management programs determined when and what you did during the day (no spontaneity allowed!)

How do you think pediatric care and diabetes care in general could be improved?

One of the things that every family is looking for is the ability to off-load decision making. The idea of having a closed-loop system, for example, using a medical device would check the blood sugar and make a decision about medication, a sort of artificial pancreas.

Families are bowed under by the amount of decision making that goes into successfully managing pediatric diabetes. There is no simple recipe or formula. 1+1 in diabetes often doesn’t equal 2. Families want things to be black or white. And often they are not.

Access to an interdisciplinary health care team should be made available to all children and families to allow for state of the art medical management education and support.