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In their house, diabetes was as normal as a carton of orange juice in the fridge. "I think there was never really a time that I can remember that she didn't prick her fngers (to test her blood glucose)," says Meredith. "As a kid, it made perfect sense in my family that we would want to prick our fngers and check our blood sugars." But the reality of the danger of diabetes soon became clear. She and Neil were on their way to middle school when their mother lost consciousness while driving. "We were screaming at her, yelling at her to stop. We didn't know what else to do," Meredith says. Greenwell did manage to stop, but they could not rouse her to further action. Neil ran from house to house until he found help. Not long after, all the kids learned how to drive. "We went to the Holy Trinity parking lot," Meredith says. "She would be in the driver's seat and let go. We would hike our leg over and step on the brake. We learned to put it in park, and, if push came to shove, to sit on her In diabetes, the antibodies target specialized endocrine tissue in the pancreas (the hand-sized organ illustrated here) called the islets of Langerhans — speciÀcally, the islets' beta cells. It is the beta cells that pump insulin every time you eat. lap and drive" — an action they never had to take. Greenwell learned to check her blood sugar just before she got in the car. Even then, she could still run into trouble. "Our children had to learn things much earlier than any parent would ever want them to," she says. When Mike Greenwell begins talking about his wife's illness, he sounds exactly like the doctor he is, reviewing the medical facts of type 1 diabetes and its management. He has a hard time changing gears, discussing the personal side of things. "It's hard to separate sometimes," he says. "Dealing with someone with lots of stressors, sometimes I have to deal with it as a physician. "You do what you can to be a bufer. Tere were times when she was in a hospital setting, when I was scared as hell. I didn't impart that to the kids." Type 1 diabetes is an autoimmune disease, like multiple sclerosis or rheumatoid arthritis. In all of these diseases, something — probably an interplay of genetics and environment — triggers the immune system to make antibodies against its host. In MS, the antibodies attack the fatty sheath that insulates nerves. In rheumatoid arthritis, they go after other antibodies. In diabetes, the antibodies target specialized endocrine tissue in the pancreas called the islets of Langerhans — specifcally, the islets' beta cells. It is the beta cells that pump insulin every time you eat. Insulin signals your cells to take up glucose from your meal, where it powers cellular activity or is converted to fat and stored. When glucose can't get into the cells and builds up in the bloodstream, it can cause kidney, heart and nerve damage. If it gets too high, it can lead to death. S usan Greenwell was 37 years old when frst diagnosed with diabetes. She simply didn't feel well. Her energy was low, her heart rate seemed high, and she was having trouble reading street signs. Her doctor gave her a blood test. 38 LOUISVILLE MAGAZINE 2.13 "He called the next day. 'You can't leave. You can't be by yourself. Your blood sugar is 600 (mg/dL),'" she recalls. Tat's coma territory. Untreated, glucose levels this high can be lethal. For a while, she and her physician were able to control the disease, frst with oral medications, then with insulin injections, and always with careful monitoring of blood sugar, although she still was occasionally troubled by hypoglycemia. But everything fell apart in December of 2003 when she caught what she thought was a bout of the fu that kept getting worse. By the time she got in to see the doctor on Friday, the 19th, she was too sick to drive. Her husband's ofce manager drove her. She was admitted to the hospital with pneumonia caused by methicillin-resistant Staphylococcus aureus, MRSA. "I think I can get you out before Christmas," the doctor said. He was wrong. "I remember that night and part of the next day, and that's it," Greenwell says. She went into sepsis, an often-deadly immune response to infection. Her kidneys failed. Her lungs failed. She went on dialysis and twice went on a ventilator. She developed adult respiratory distress syndrome — lung damage caused by high ventilator settings. Her liver function was damaged. MRSA sepsis patients die half the time; patients with multiple organ failure seldom survive. Tat she got home at all was a miracle, even if it wasn't until Jan. 15 of the new year. "I spent a long time right on this couch (in her home), with somebody sitting with me," she says. "I'd been in renal failure. I'd been in respiratory failure. My liver function was not good, and my endocrine system didn't get skipped. My diabetes became very volatile after that. It was difcult and eventually impossible to control." Healthy bodies keep blood sugar in exquisite balance. Minute by minute the 1 million islet cells respond to changing glucose levels, regulating insulin levels according to how much and what you eat and how much you exercise. By comparison, insulin injections are a clumsy substitute, although for most diabetics, perfectly adequate. But not for Greenwell. Her case was further complicated by something called gastroparesis, Mokshagundam says. Just as diabetes and the resulting high blood sugar can erode a person's sensations in their hands and feet, nerve damage may also extend to such automatic functions as digestion. In normal digestion, strong muscular contractions push food through the stomach and intestines. In gastroparesis, the contractions fail, and the stomach doesn't empty properly and consistently. It becomes nearly impossible to calculate how much insulin will be needed because it's anyone's guess when nutrients will actually make it to the small intestine as glucose. And type 1 diabetics can be especially sensitive to insulin, so even a slight excess brings a dramatic problem. On the other hand, if the stomach empties suddenly, the insulin dose can be inadequate. "It makes it very difcult to estimate how much insulin to give," Mokshagundam says. "If blood sugars are ranging between 200 and 500, that's a serious problem, and that's where (Greenwell) was." On the other side of the equation were the hypoglycemic events. "I would go from sitting at the computer to being on the foor," Greenwell says. "Te kids would fnd me that way. Tey would have to give