22 July, 2014

How many pieces of technology does it take to replace a pancreas?

In this case,
  • an iphone
  • a tablet
  • two continuous glucose monitors
  • one insulin pump
  • one wireless hotspot
  • a pump meter/remote

A couple weeks ago I got a call about participating in an Artificial Pancreas System trial at UVA, and being that the dates fit perfectly into my summer schedule and I've been wanting to participate in one since I first heard about the system, I of course signed right up.  After the checks to make sure I was alive and not pregnant, I was screened in to the trial.  This meant a week of data collection at home, and then two stays at UVA each lasting about 30 hours.

For 30 hours I got to watch as the devices I listed above worked collectively  as my pancreas.  I watched (somewhat in disbelief) as the system time after time corrected predicted highs and lows to keep me within range for the entire time I was there.  Through meals, sleep, and exercise, I maintained normal blood glucose levels.  While I get some good days here and there when that happens, it is usually because of very careful calculations on my part, or just plain luck.  At one point one of the nurses said "Who would have thought math could do something this great?"  In my head, I responded, "Me Lady!  Of course math can do this - math can do anything you ask it to do!" But I understood her point - after five years of treating my body like a science experiment, I was hooked up to a system that was making all the decisions for me - and making all the right ones.

While at UVA, I had zero high blood glucose values, and zero lows.  The following day at home, I experienced one high, and five lows (three of which were overnight).  Getting to see the system in action gave me hope - I can say with certainty that this will become a reality for home use in my lifetime and will make diabetes management so much more effective and less of a mental and emotional burden.  That is also what made it difficult to go back to "just" my cgm and pump.  It is hard knowing there is a system out there that is safer and more effective than the guessing game I do all day everyday, but also knowing I have to wait, and wait, and wait for it to become available.  If you know me, you know waiting isn't really my thing.

In addition to my rejuvenated hope and faith that this will get easier in my lifetime, I also walked away with a few pieces of information that I think will improve my current methods.

  1. My body seems to do well with an 80% bolus upfront for meals, with the other 20% given over a half hour, one hour, or two hours (depending on the fat content).  
  2. It had been way too long since I strictly carb counted any meals, which meant that my estimates were getting further from the truth.  
  3. While I cannot make a decision about my insulin needs every five minutes all day and all night like the Artificial Pancreas can, I can test more often in the two hours after meals to see what adjustments I need to make in response to my mealtime guess.  

Sorry for the blur - but this is what an entire day of in range glucose values looks like :) 

I head back on Thursday for another 30 hours of closed loop diabetes vacation!  It is nice not having to devote any brain power to diabetes management, but I honestly didn't really know what to do with free time where I couldn't run, bike, or kayak.  

13 April, 2014

Thoughts on NYT article

           It has taken me awhile to decide how I want to respond to the article "Even Small Medical Advances Can Mean Big Jumps in Bills"  published by the New York Times about a week ago.  The article as a whole addresses some important issues relating to the high cost (in the U.S.) of chronic medical conditions like type 1 diabetes. While the article addresses several underlying issues that contribute to the high costs (medical industry being business/profit oriented, high cost of research, pumps/meters having proprietary accessories, planned obsolescence), it still leaves the reader with an overall feeling that the patient is a contributing factor to driving up the costs - that patients are seeking out frivolous equipment that the entire country has to foot the bill for.
Here are a few items that I would have liked to see the article address that it did not.

1.  We are informed of what treatment options are likely best for us medically and based on our lifestyle.  From there, most of us make a choice based on what we think is likely to give us the best overall outcome with the fewest complications (that might lead to additional medical expenses, loss of work/income, eventual need for disability income).  Patients are usually not made aware of the total cost of a treatment up front.  They might be quoted an estimated amount that they will have to pay out of pocket, but likely won't see what was billed to insurance until receiving an Explanation of Benefits Statement after the treatment (or device) was already billed for.  This means that there isn't the same opportunity for comparison shopping that there is for other big purchases.  I don't chose to wear an insulin pump and cgm just because I can - or because my insurance covers it - I use them because they keep me alive - hardly frivolous.

2.  The "cost" of medical items is generally inflated with the understanding that insurance companies are only going to allow for a fraction of the billed amount.  This makes it impossible to determine what the true cost of a prescription drug or medial device is since the out of pocket cost is so significantly marked up (profit is clearly still gained from the much smaller amounts that insurance companies allow and cover).  This system seems to only the costs more difficult to cover for the uninsured, and also adds another layer of opaqueness to price transparency in the medical industry.  

3.  The article does not address at all the role that the FDA plays in complicating the medical device industry.  While planned obsolescence is a business practice that has been profitable for companies like Apple, and it may very well be a part of the business model for pump and meter manufacturers, the FDA also slows down the release of devices, to the point that by the time one model is finally released for sale in the U.S., the next model has already been developed.  In addition, there is no generic insulin because it is a biological drug, and until recently the FDA had not addressed regulation of biosimilar drugs.

And then there were a few items in the article that left me completely bothered.

1.  This quote: "People don’t need a meter that talks to them. There’s an incredible waste of money." DR. JOEL ZONSZEIN, director of the Clinical Diabetes Center at Montefiore Medical Center

Not everyone needs a wheel chair ramp, but we have them.  And guess what?  People who aren't in wheel chairs benefit from them.  Ever used one for a stroller or a bike?  That isn't why they are required to be there, but the ramps sure make it easier!  How exactly is someone who is blind or has low vision supposed to use a blood glucose meter effectively if it doesn't talk to them?  I'm not an expert (only someone who actually has the disease), but I'm pretty certain that vision complications can occur with diabetes.  Or, as the article stated, diabetics are living longer, and generally as people age, their vision declines.  Should people just stop testing once their vision goes?  This article shows a comparison of talking meters including cost https://nfb.org/images/nfb/publications/vod/vod_24_1/vodwin0910.htm So $16.79 is too high of a cost for it to be worth it for a diabetic with a vision problem to be able to monitor their blood sugar?  I can't imagine that it is more expensive than the cost of covering the complications and related expenses if the person's blood glucose levels are no longer well controlled due to not being able to monitor.

2.  And then this quote. "Most of the increase is attributable to Type 2 diabetes patients, whom manufacturers are encouraging to try insulin treatment and glucose monitoring, even though that is rarely medically required." 

Again, not claiming to be an expert here (I have t1, not t2, so what could I possibly know right?) but if by "glucose monitoring" they are referring to testing and monitoring blood glucose levels, this is absolutely medically necessary for people with t2.  Perhaps their doctor has not recommended that they test as often as I do (recommended by my doctor - not just for fun), but I am certain that testing is a part of their recommended treatment plan - whether it be multiple times a day, daily, or weekly.  If the author is actually meaning use of a continuous glucose monitor, then perhaps she should be more specific in her wording.  I was never contacted by a manufacturer prior to making my decision (along with my doctor) about use of a cgm.  Perhaps the mailing list and phone list for that sort of soliciting only has patients with type 2 diabetes, but despite all the junk mail and robo calls I get, none are trying to sell me additional diabetes bling to wear/use just for fun.  A cgm and insulin can't be obtained without a prescription, so perhaps if the manufacturers are influencing people to make decisions that are medially unnecessary, we need to address the doctors that are writing the prescriptions and what motivations they may have if they don't believe the meds/devices are needed.

My final bit of irritation came from a response to the DOC's reaction to the article.  I have no issues with points 1, 2, or 4.  But point 3 - the assumption that the strong opinions this article evoked were influenced by receiving mail from the JDRF I find ridiculous.  Despite having participated in events that benefit the JDRF, and being someone w/ t1d, I managed to not make it on to this mailing list either.  Unless of course this email was filtered to my junk mail, where it would have sat without me reading it anyway.  The idea that I could be swayed so easily be receiving an email telling me what to think about a particular article is frustrating.  Diabetes affects my pancreas, not my ability to read and develop an informed opinion on my own.

21 June, 2012

CGM studios presents....New Robot Parts!

I love tracking packages - it is one of my favorite things about Christmas time....I get to watch all the things I've ordered make their way around the country to my doorstep.  If you ever want to ship me something, send me the tracking information and it'll likely make me more excited than whatever is inside the box.  In this case I was pretty darn excited about what was inside too.

So a few weeks ago, I went to my endocrinologist and we discussed some new options in my diabetes management.  My A1c was 7.0, which was higher than every other time with the exception of my first appointment after my diagnosis.  For those of you who aren't lucky enough to get this test done every 3 months or so, it is a test of your average glucose levels over the past 2-3 months.  An A1c of 7 means that my average glucose levels over the past few months were around 154 according to the lovely wikipedia.  Fasting glucose levels for you normal humans should be under 110, and 2-hrs after a meal should be under 140.

There were many contributing factors to me losing some control over my diabetes management in the past few months.  My doctor attributes some of it to the "honeymoon" phase of my diabetes being over - meaning my body is likely not making any of its own insulin anymore, making it much harder to manage and much more unpredictable.  I was also under a lot of stress at work and in my personal life, and was having trouble not giving in to stress eating when I was surrounded by people who were.  Anyway - an option that we discussed for regaining control, especially since I've had a lot of difficulty lately maintaining normal levels during exercise, was a continuous glucose monitor.

It took a week or two to get all the insurance stuff sorted out - but finally I got what I wanted....A FedEx tracking number! (Seriously, you could get me just the tracking number for my birthday and I'd be happy).

I had a slight panic on the day that it was delivered because I  received a notice that it was delivered....and left on my doorstep.  The notation was that no signature was required.  This made me concerned for a number of reasons - quite a few dollars worth of medical devices/supplies were inside.  Packages are normally dropped off at the leasing office when nobody is home, not left on the doorstep.  To make maters worse, I had to drive to Rockville to get my fingerprints done for my new job and couldn't go straight home. Luckily, when I did finally arrive back at my place, this was waiting for me:

Opening it up felt a little like Christmas morning....the excitement of a new gadget.  So at this point I had received e-mails from a clinical specialist from the company that makes the continuous glucose monitor (CGM - aka my new frienemy) asking me what training options I would prefer.  I could do the self-training using the cd or the online tutorials, I could do training over the phone after viewing the tutorials, or I could wait and set up an appointment to do training at my doctor's office.  If you know me even a tiny bit, you know there was no way I was waiting to try this thing out.  If you know me, you also know that I watched every minute of every tutorial before I even decided that I wanted one.  If you REALLY know me, then you know that when I say I watched every minute, I actually mean I listened to it in the background and half paid attention while doing ten other things.  

So back to Christmas morning and opening the box (which soon became a Christmas present for the cats) - I hadn't even made it completely through the front door before I started pulling off the packing tape.  And inside was another box, and another box, and another box....it was like a set of nesting dolls, but in box form (ok, so maybe it wasn't that extreme.....).  Here is what was inside:

There were three of these boxes.  And inside each of these boxes were four sensors, and inside each sensor there were five golden rings.  There was also an additional box that had instruction books (mine is still in the plastic weeks later - to preserve its freshness of course), cables, power cords, the receiver, etc.  I pulled out all the parts that I needed and plopped myself down in front of my computer.  

Here I'm holding up the package with a new sensor and the device for inserting it.  In the background you can see the tutorial up.  Despite watching it and taking meticulous notes the first time (never would anybody refer to the notes I take as meticulous - and it would have been impossible to take notes while playing sudoku on my phone), I felt it would be best to play the tutorial again while I went through the steps of getting my CGM all hooked up for the first time.  

Here I've taken the backing off the tape on the sensor and applied it to my skin.  I paused before actually inserting it to take this picture - I mean come on, who doesn't want a photo album of their first days with their new robot parts?  So the next steps are to remove the safety thingamajig, push down on the plunger, pull up on the ring, and then you are one millionth of the way there (easy as 1, 2, 3.....).  

So here is where all those (1,000,000 - 3) other steps come in.  You remove the insertion device (this was the most difficult/awkward part for me the first time), snap in the grey transmitter, snap it in with the extra hangy tab thingy, and then remove that by twisting it away from your body.  So at this point I was pretty pumped - I got the damn thing in there.  Now came the worst part.....wait three hours before it actually does anything.  I have patience for a lot of things, but waiting to play with a new toy is not one of them.  

So here I am with everything attached - pump on the left side of the picture, and cgm and cgm receiver on the right.  After a day I decided I couldn't take the bulkiness of that carrying case for the receiver and ditched it.  

Here is the operation with just the two sites - pump on the left side of the picture and cgm on the right.  Cyborg status complete.  

So the first night I wore this, the alarms went off and woke me up 9 times - 3 overnight lows, with additional alarms because I was dropping quickly right before each.  This was a little scary because it had likely been happening for awhile and had been going unnoticed.  I made some changes to my insulin rates and things have been ok, but as I said above, this new little device is more of a frienemy than anything else.  I like having the extra security of knowing alarms will go off if I'm too high or too low, and I like that it tells me when my glucose levels are rising or falling quickly.  What I don't like is that I tend to overcorrect  - as soon as I see those dots heading for the top line I start giving myself insulin.  Which would be fine - except that when it doesn't come down right away I tend to get frustrated and give myself more.  And then more.  And then I end up low.  So sometimes I end up with this rollercoaster looking trend graphs.  I'm hoping this is just a newbie tendency and I'll grow out of it.  

Graphs like this are much happier - everything is between the lines, and the arrow shows that I'm holding pretty stable.  

So, every ten days I go through the steps above....lather, rinse, repeat.  I'm on my third sensor now and was able to put it in without watching the tutorial again, which was pretty sweet.  Almost like losing your training wheels.  

12 June, 2012

Thank you Bradley Airport TSA

One of my friends was just telling me about how she is stressed about upcoming travel.  Another friend told me the same thing last week.  I'm pretty sure this is a common occurrence.  Stress about what to pack, the cost of the trip, whether the dishwasher has been run, and the trash has been taken out.  Sure I stress about these things too, although I probably care a bit less than some of my neat freak friends about making sure every inch of my place has been vacuumed so that it will be clean while I'm gone.

......and here is where the post will probably end up getting me on a no fly list.....

My stress level shoots up a hundred times higher right before I go through airport security.  And here's why:

I took a weekend trip up to Connecticut with my family in May.  We drove up on Saturday (woohoo, five plus hours in the car with five adults - luckily we also had 5 smart phones to keep us from killing each other), attended graduation on Sunday, and my brother, sister-in-law, and I flew home Sunday evening.

Normally I don't start getting anxious until I approach the front of the line for security - especially at those airports where your order in line is going to make a difference between walking through the metal detector or walking through the giant zappy thing (technical term).

But for this particular trip, the anxiety began even earlier.  We had spent all morning sitting in an unbearably hot tent watching the entire college graduation first video streamed onto a screen from another larger tent, and then the smaller ceremony in the tent itself.  It was so hot that the red and white stripes on the tent started blurring together and I had to take breaks outside to not pass out.  We had lunch outside following the ceremony, and the food was great, but it was still hot out.  We were going straight from lunch to the airport, which meant no time to change out of the dress I wore to graduation.  I was hot, sweaty, cranky, and uncomfortable, and heading to the airport.

When we arrived, I couldn't find my confirmation number in my email on my new phone to print my boarding pass.  I ended up having to play around with the email settings to get it to load earlier emails, and then wait around for it to load a zillion of them.  At this point I was cursing at the new phone and wishing I had hit up an airport bathroom to change before bothering with the boarding pass.  I tell my brother and sister-in-law to  go ahead to security and the gate and I'd meet up with them.  I knew security was bound to be a pain, and I still wanted to change clothes.  They waited around instead for me to get my boarding pass situation worked out, which was very nice of them.

We all jump in line for security, and it is moving pretty quickly - I like this - lets just get it over with.  There are a few airports where I know what to expect - for example the one I fly out of most regularly at home has metal detectors that my pump doesn't set off.  There are a few other airports where I know when I walk through the metal detector my pump will set it off and I'll be in for a pat down.  I like to know which way it is going to go ahead of time - nobody likes a pat down surprise.  When I get to the front of the line they point me to the left.  I hadn't even had time to check out which lines had metal detectors and which ones had giant zappys.  I look up and notice that my line has a zappy.  Great - guaranteed pat down (it is recommended that my pump not be subjected to any x-rays).  I look over to the line my brother and sister-in-law are in and notice its a zappy line too, and so are all the others.  Good to know - Bradley is a guaranteed pat-down airport for me.  Not that its likely that I'll ever fly in or out of there again.

So it is almost my turn to go through - I approach the TSA guy directing traffic toward the zappy and inform him that I'm wearing an insulin pump and I can't go through.  He motions towards the grey bins and tells me I have to take my shoes off.  I explain that I know that and once again tell him that I can't go through.  He motions for someone else to come over, and I have to explain for a third time to her that I'm wearing an insulin pump and therefore can't go through her machine.  She states that they have never had anyone tell them that before and that their zappy machines wont cause any problems.  I look at her, look at the giant x-ray sticker on the side of the zappy, look back at her, and tell her I wont be going through.  Finally she calls for another tsa chick who drew the short straw and gets to pat me down.

So I explain to this girl for now I think the 5th or 6th time that I'm wearing an insulin pump, it is attached to the back of my arm and clipped to my dress, and I can't go through the machine.  So she does her pat down, which was particularly awkward given that I was still in a dress, meaning the leg feel up was much more invasive. So this chick finishes, but never pats down where the pump is, never asks to see it (its covered by my sweater) and goes over to the other lady and says she's done.  She gets sent back to do a "visual inspection" of my pump, and then has to test her hands and my hands for explosives.  All the while, my brother and sister-in-law are standing around waiting for me....again.

I'm finally deemed underwear bomb free and allowed to leave the cattle corral I've been kept in while this is all going on.  I am now determined to change into shorts and a t-shirt that I had longed to change into prior to our airport arrival.  We head to our gate and as soon as we get there, my brother asks if I'll watch their stuff for a bit.   I only had to wait five minutes, but after three hours in the tent, an hour outside at lunch, the new phone drama with the boarding pass, and the TSA feel up in a dress with an audience of the entire Bradley airport, it felt like forever!

I'm sure I looked like a little kid or a bum traveling with my brother and sister-in-law who were still all dressed up, but I was so past done with the dress-up clothes, the airport, and traveling in general.  I was so relieved to be going home.

tune in next time for news on my new CGM.  and other crap no one cares about.

05 April, 2012

That one time I went to a bridal show....

Anyone who knows me well....or has known me for a minute, knows that me at an indoor bridal show on a spring weekend when the weather is beautiful is an unlikely scenario. What you didn't know about me is I'll do just about anything for big money.

My current rate for offering my photography expertise (I have none), carrying gear in and out of the car, and handing fliers out to the enemy is a granola bar, half of a mushroom & olive pizza, and a bottle of water.

What I didn't realize is that I would also be provided with an incredibly entertaining day filled with voodoo witch photographers, boys afraid of spiders, and men who had no idea what they had been dragged to.

I have learned the following about bridal shows:
  • Always get a booth near the food (the reason is two-fold - make friends and get snacks all day, and if I had tracked the path of most clients, it would have shown a beeline from one food table to the next, with a glance at whatever happened to be on either side)
  • Get to know your neighbor - not only are you likely sharing a very tiny space, but they may provide necessary entertainment during the lulls in the crowd (at this particular show, our neighbors ran to the middle of the room w/ their laptops and bags when they noticed a bunch of spiders running around in their corner)
  • greatest.people.watching.ever. (this requires more detail than I feel comfortable putting in parentheses, so please read below)
(The following people attend bridal shows:

Type A personality bride: She arrives with her mother who appears to be dragging an entire mobile office. Her wedding is over a year away and she has planned every detail. If you don't believe her, you can look in her binder which is organized by product/vendor type and then alphabetically. Within each section, she has notes from the interviews she has conducted with prior clients. In fact, she is only at the show to second-guess all the decisions she has already made. She refuses to use your pen and brings her own.

The "Oh Shit, I'm getting married....I should probably plan something" bride: She brings 6 friends, who all agree on nothing. In fact, this group can't even go out to lunch together because they can never come to a consensus on where to eat. Her wedding is in 6 months, or something....she thinks. She has a location probably, maybe, picked out. It isn't until she gets to your photography booth that she realizes that maybe she should have one of those. She asks one of the contentious cronies she brought with her to write "photographer" down. They realize they brought nothing with them to write that on. You offer them a napkin from the mini crab cake you just got from the food vendor neighbor.

A man (yes, just one): He is dragged up the sidewalk by a woman, and has the same look on his face as someone who wakes up in a hospital after a coma. As they enter, receive a door prize, and a bunch of free stuff is shoved in his hands to carry, he asks, "where am I?". He then turns to the woman and says, "you said we were going to get lunch." She quickly ushers him to a food vendor, and says, "see, lunch." Every time he tries to ask another question about why he is there, the woman dragging him shoves another caprese skewer in his mouth. When they arrive at your table and you ask her when her wedding date is, he nearly chokes on the toothpick. She informs you that they haven't quite figured that out yet, and you take note of the lack of engagement ring on her finger.

The crazy: She arrives dragging a protesting teenage child. You are already confused, but thinking perhaps this is a second marriage, you ask when the woman is getting married. She gives you an even more confused look back. She informs you that she is here to plan a birthday party. How stupid could you be for not figuring that out? Confused, you walk over to the registration table to pick up a brochure, just to make sure you are, in fact, at a bridal show. While you step away to grab the brochure, mom flips through the albums you have out on the table. You arrive back at the table just in time for her to proclaim her irritation that all the photos are wedding photos, and for her to ask, "don't you have any of birthday parties?" Unsure of how to respond, you shake your head until she disappears.

The competition: They send ninjas to steal your advertising brochures to try to get a leg up on you. Always be on the lookout for ninjas. They have been known to use tactics as low as trying infiltrate your corner with robot spiders programmed to drag away your business cards.

The End)

31 January, 2012

Sometimes Life is Gross

So, it's been a little while....have to wipe the cobwebs off the blog...

Do you ever feel like your body responds physically to what you are feeling emotionally?

There have been a few times that I've been pretty run down mentally and emotionally, and it seems that my immune system picks that exact moment to run and hide in some deep dark corner somewhere, leaving me to muddle through a cold on my own. That worked out nicely when Karlyn and I were sick for three months last year.

Today I felt like I experienced a complete physical manifestation of how I've felt in recent weeks.

Things at work have becoming increasingly complicated and stressful, and with each new challenge I'm presented with, I feel like a little piece of me gets chipped away and I start to feel more numb each time. Each time a roadblock is put in front of me, I get over it or get through it, but with less and less feeling.

A few weeks ago, Cory and I were down in Cary, N.C. visiting some friends, and we played a game using the xbox kinect where we were in a glass tank and fish kept knocking holes in it, and we had to plug up the holes using our hands and feet and whatever parts of our body we could as fast as we could. The game gets progressively more challenging, finally requiring you to use your whole body at the end. I feel like this sums up how my work life has been the last few weeks - a problem arises, I block the hole, and at least for the time being, the problem is solved. Until the next thing crops up. And the next. And the next. And now it is at the point where I'm using everything I have to stop the water from pouring in, but I know any second a new hole will appear.

So how did this manifest physically? (yes, I know I rambled off topic with bad analogies for awhile...that's what I do best)

Today I sprung a leak. Literally.

So after picking up my 2nd borrowed car in a week (thanks to the deer that caused $3000 in damages) and running various other after-work errands, I was finally home and getting ready for bed (at 7pm). After washing my hands at the sink, I turned to dry my hands, but I got snagged on the cabinet door handle. For those other insulin pump wearers out there, this is more common than we'd like. So as is habit now, I quickly took a look at my pump site, just to make sure everything was still attached. The tiny bit of bruising I first noticed at the site yesterday had grown enormously. Knowing that my site likely wasn't working too well with all that bruising, I yanked it out.

Apparently that was the last thing holding me together.

I spent the next ten minutes holding a paper towel to my side trying to apply pressure, while simultaneously trying to insert another site on the other side of my body and fend off the cats who by now couldn't understand what could possibly be holding up their dinner. The bleeding finally stops long enough to throw a band-aid over that site and quickly insert one on the other side. The needle goes "thunk"...and when I pull it out, it is more bent than the back of my car after the bambi attack. Chances of bruising at the new site too? Pretty high.

I'm wrapping myself in bubble wrap and wearing my pfd and kayak helmet to work tomorrow. I feel like the extra protection can't hurt. I'm just juggling knives and spinning plates and chewing gum and plugging leaks and managing diabetes. No big thang.

11 September, 2011

Moving forward doesn't mean forgetting the past.

9/11 - 10 years later

Today, my facebook news feed was filled with statuses sharing what people remember from 10 years ago today. If I were to try to think back that far to any other Tuesday, I doubt I'd be able to remember a thing (who am I kidding, remembering what I did last Tuesday is hard). But just like most others my age, my memory starts much the same way - I was in my senior year of high school, and at the time I was in European History working on a group project. Mr. Ditman left the room for a minute to get something from the printer for one of the students in our class. When he returned, he told us that he knew there wasn't supposed to be a place for religion in public schools, but he knew what he needed to do it. He told us that a plane had hit the world trade center in New York, and that he would like us to gather together to pray for those inside. I personally am not very religious, but I stand by the choices Mr. Ditman made that day - we needed guidance from an adult, and he provided it in the form of his prayer. Right around 9:00 am, he turned on our classroom television, and we, like many others in the school, watched in silence as the rest unfolded on the news. When news broke of the Pentagon attack, many students began to panic, and many classroom teachers forwent the normal rules and allowed students to try to call home from the classrooms.

My reflections in the days and weeks that followed have remained largely the same when I think back on the events of that day. Ten years ago, my thoughts were about how unsafe it now felt to be in our country - and about how children in war zones must feel that all the time. I was in awe of the outpouring of pride in our country, in being an American, but also saddened by the hatred that was blanketed over a group of people simply because a few extremists happened share some commonalities. And I felt swells of emotion when I thought of all of the first responders that day, most of whom knew the tragedy that lay before them, but reported for duty anyway.

I recently visited the Faces of Ground Zero: 10 Years Later at the Time Warner Center in New York City, and while in New York, I caught my first in person glimpses of Ground Zero in person. Some of the very same emotions went through my grown-up mind now 10 years later, as those that traveled through my teenage brain in 2001. I feel mixed emotions about the wars our country has been fighting since that attack. I feel the same swell of emotion for those who have reported for duty, which I think can be summed up with a line from the Bixby letter that George W. Bush read today "and the solemn pride that must be yours to have laid so costly a sacrifice upon the altar of freedom". I feel a tremendous amount of indebtedness to those who serve or have served our country - they have signed up for a job that requires great courage, and they have gone forward with the knowledge that they may not return. When I think of the wars our country is fighting, I still can't help but think of how more innocent people continue to lose lives - a hurt that is so universal - a hurt that is not unlike what people felt when they lost loved ones on that day 10 years ago.

Ten years later, I continue to feel saddened that my fellow countrymen continue to show hatred or discrimination towards people simply because they are Muslim, or are of Middle Eastern decent. There are extremists in every religion, every sect. Nobody deserves to have to take the blame for something one person did just because they share the same hair color, or eye color, or overarching religion. Extremists can interpret ANY religion to justify ANY poor decision, and it shouldn't put the entire group under an umbrella of shame. I was relieved to hear today that there would be interfaith remembrance events, because this event didn't leave a single American untouched - and what makes me proud to be an American is that I can call myself that regardless of my race, religion, gender, or country my family originated from.

Sadness is not all I feel on this Patriot Day in 2011. I also feel hopeful. And this reason is two-fold. We have stuck by two sentiments that we heard countless times in the days and weeks that followed 9/11. We must move forward, and we must never forget. I observed both of these things many times over today. Moments of silence, memorial ceremonies, and sharing stories of that day occurred all over the country. But normal things happened too. Some of which were as normal as what may have been happening on September 10th, 2001. I laughed with friends. My dad watched football. My best friend boarded a flight to head home. Cory photographed a wedding. My day with friends was speckled with moments of reflection and remembrance. Football games all began with tributes, and players and coaches wore hats and ribbons to honor those lost. And while there was a heightened sense of uncertainty in airports and on airplanes, to have planes in the sky this evening, unlike this day 10 years ago, we are saying we cannot be brought down. And for the couple that got married, many would say why today? But really, what day better to share your love and devotion to one another? On this day 10 years ago, we were reminded to love - to feel it deeply, share it openly; this tragedy reminded us of the fragility of life.

My hope for the future is that we continue to live life with more purpose than before. That we face our differences with more compassion. That we appreciate our family and friends with the knowledge that we can't plan when we go, or when they might leave us. And, that we never forget the events of that day. We can't forgot those who we lost, we can't forget the feelings we had.

One last thought that I walk away from today with - sometimes the rules are meant to be broken; sometimes you have to just do what's right. A hero is someone that knows when to make those tough calls. For me, being so far removed from the tragedy, those heroes were the teachers that knew we needed to know, but knew we also needed their support in digesting this news. At ground zero and the pentagon, the heroes were the people that led others out of those towers even when people were told to stay put, and those who were told not to go back in who went searching anyway. The heroes are those on flight 93 who made the decision to fight back. The heroes are those who can pray alongside someone of another religion, fight alongside someone of another race, and combat fear with notions of peace.