August 13, 2025 • 53 mins
What happens when your body declares war on multiple organs? Julie Davis knows this reality all too well. Her medical journey began with a celiac disease diagnosis at 18, followed by ulcerative colitis in college, but it was the sudden onset of autoimmune pancreatitis in 2011 that turned her world upside down.
Julie's story is remarkable not just for the rare combination of conditions she manages, but for the extraordinary resilience she's shown throughout her journey. As a dietitian who became a physician's assistant while battling debilitating pancreatitis flares, Julie brings unique perspective from both sides of healthcare. She takes us through the harrowing experience of multiple hospitalizations, specialists puzzling over her case at Mayo Clinic, and ultimately, the life-altering decision to have her pancreas completely removed in 2023.
The procedure—called total pancreatectomy with islet cell autotransplantation—is so rare that Julie couldn't find a single podcast about it. Her pancreatic cells were extracted and transplanted into her liver, turning her into what she describes as "essentially a type 1 diabetic" overnight. Despite this dramatic medical intervention and the insulin pump she now relies on, Julie's perspective remains incredibly positive.
Perhaps most inspiring is how Julie has refused to let her health conditions define her limitations. She completed PA school despite having an endoscopy and nerve block the same morning as important exams. She had three children through IVF while managing multiple autoimmune conditions. And today, she's passing on her hard-won wisdom to her daughter, who has inherited celiac disease.
Julie's message to fellow chronic illness warriors rings clear: "It doesn't define you. You can still do things that you love." Her extraordinary journey demonstrates that even the most complex medical challenges can't stand in the way of a determined spirit pursuing a fulfilling career, family life, and future.
Links:
- The Juicebox Podcast
- Mission Cure: Nonprofit working in improve quality of life and bring more treatments to chronic pancreatitis
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hi, I'm Alicia and I'm Robin, and you're listening
to Bowel Moments, the podcastsharing real talk about the
realities of IBD Serve on therocks.
This week we talked to JulieDavis.
Julie is a physician'sassistant and dietician who
lives with inflammatory boweldisease, celiac disease, as well
(00:20):
as autoimmune pancreatitis.
We talked to her about managingher inflammatory bowel disease,
as well as her pancreatitisitisand all of the treatment that
she had to use for that.
We talked to her aboutnavigating PA school while also
dealing with very significantissues with her pancreatitis.
We talked to her about hercareer as a dietician and how
that helped her manage herceliac disease, as well as her
(00:41):
inflammatory bowel disease, andalso some of the complications
she had from her surgery for herpancreatitis.
And we talked to her about somuch more.
We know you're going to lovethis conversation just as much
as we love talking to JulieCheers.
Speaker 2 (00:56):
Hi everybody, Welcome to Bowel Moments.
This is Robin.
Speaker 1 (00:59):
Hello everyone.
This is Alicia and we arereally, really excited to be
joined by Julie Davis.
Julie, welcome to the show.
Thanks for having me.
I'm excited.
We are very excited for you totell your story because it is
involved.
But our first veryunprofessional question for you
is what are you drinking?
Speaker 3 (01:18):
You know I'm not really a tea drinker, but I have
hot tea tonight because mygirls gave me the crud and so
I've got a little sore throat.
Speaker 1 (01:25):
But we're powering through yeah oh gosh With three
little ones.
I would imagine this isprobably somewhat common in your
house it's real common.
Speaker 3 (01:35):
It's kind of on a cycle.
It's like one gets sick andthen it goes through the whole
family and then by the time thefirst one gets well, it's
starting over.
Speaker 1 (01:42):
So oh no, that's miserable Robin.
What about you?
Speaker 2 (01:48):
I am also drinking hot tea.
It is May when we are recordingthis, but it is 30 degrees
where I am, so it was a hundredhere today, so it snowed where I
am.
Speaker 1 (01:59):
Oh my gosh, what are you drinking, Alicia?
Tonight I got real excited.
I am drinking a strawberry andelderflower Collins tonight.
So, it's gin and elderflowertonic and strawberries, and a
little bit of lemon as well.
So look how pretty it is.
Speaker 3 (02:14):
Oh, that's lovely.
That looks way better than myhot tea.
Speaker 1 (02:17):
Sorry, guys, very pretty.
So anyway, Julie, it is aboutyou.
Tell us your IBD story.
What brings you into ourcommunity?
Speaker 3 (02:26):
Oh gosh, it's a long one and it's got a lot of twists
and turns.
So I didn't actually start outwith IBD.
I started out with celiacdisease, which was diagnosed
when I was 18.
After, gosh, probably five orsix years, I mean, I always had
stomach problems as a kid.
They kind of worked up stuffhere and there.
It was like the 90s so I'm surethe diagnostics weren't as
(02:51):
great back then.
But I was actually scoped whenI was 18 and was diagnosed with
celiac, went gluten free, didgreat for a while.
And then I started to have kindof some GI symptoms again during
college and I was like, oh,maybe I'm just not being as
careful, and you know, collegeand then had another scope and
that's when I was diagnosed withulcerative colitis, which
originally it was just kind ofproctitis.
(03:12):
It wasn't super bad.
They, you know, treated me kindof conservatively and kind of
managed it conservatively for awhile.
And then, 2011, I ended up withacute pancreatitis because I
was put on a medication to helpwith the IBD.
With the ulcerative colitis Iwas put on Imurian and ended up
(03:33):
within two weeks in the hospitalwith acute pancreatitis and so
they thought it was a reactionfrom the drug and stopped the
Imurian and I was having morelike UC symptoms by that point.
But I don't I can't rememberexactly the timeline.
I've had like a million scopesin my life, both, both ways, so
don't remember exactly thetimeline on scoping and all that
(03:54):
.
But long story short, I was inand out of the hospital for the
next like, so that was July of2011.
And then by February I think, Ihad been in and out of the
hospital like six times withacute pancreatitis and they
thought I had cancer at onepoint.
They were doing all these likeyou know, different scopes to
(04:17):
kind of see what was going on,because there was a mass on my
pancreas that they couldn'treally delineate and figure out.
That they couldn't reallydelineate and figure out and
ended up sending me up to MayoClinic in February of 2012,
where they did the full shebang.
I saw the pancreas specialist,I saw the IBD specialist, had a
bunch of imaging labs, scopesboth ways, diagnostic ultrasound
(04:37):
of my pancreas with biopsies,which when I came home, caused
another flare.
So that was fun.
But all that to say, all thatdiagnostic stuff revealed I had
pancolitis by that point andthen I had autoimmune
pancreatitis, which was very newat that point very unresearched
if that's a word minimallyresearched at that point, and
(05:00):
they were able to differentiateit to be type 2 autoimmune
pancreatitis, which is commonlyseen with ulcerative colitis.
So I had, in that fall where Iwas getting pancreatitis, I had
been started on Remicade for theUC and that was the only thing
that was helping the UC portionof it.
But then they stopped it becausethey didn't know if it was
causing more pancreatitis, andso when I went back to Mayo or
(05:25):
went up to Mayo, theyrecommended I restart the
Remicade, which is always risky.
I'm sure you guys know that ifyou stop it you could have a
reaction to it and thankfully itworked well for me.
I've been on that actuallysince then and I'm still on it
and there's we'll kind of get tothe later part of the story but
there's kind of talks aboutweaning it down, which is kind
(05:45):
of scary.
But they restarted me on that.
I had been on steroids andstuff for the pancreatitis and
that's the main gist of the UCpart of it.
There's a lot more to the story, though.
Speaker 1 (05:56):
Feel free to give us the full picture if you would
like, because certainly they allkind of play on each other and
work sometimes against eachother.
I would imagine yeah, yeah.
Speaker 2 (06:06):
But if you're going through it I mean somebody else
who's listening to the show ismaybe they're just starting to
have pancreatitis and they don'tunderstand what's going on.
So if you feel comfortablesharing, we'd love to.
Speaker 3 (06:16):
Yeah, absolutely so.
Let's see.
Mayo Clinic got me back onRemicade, pancreas stuff, kind
of calmed down with a very longcourse of steroids which, as you
know, are not fun.
I had to wean off those over,like I want to say it was
between three and six monthswith all the side effects, lost
a lot of my hair, which my hairhas always been like my feature,
(06:37):
you know, and that was kind ofdepressing and kind of got to, I
guess, a good place for thepancreas.
I was having nerve blocks sothey do an endoscopic ultrasound
and a celiac plexus block wherethey inject, like lidocaine and
bupivacaine, you know, and somesteroids and stuff to kind of
numb the area.
(06:57):
And those would work for me forabout, I would say, three to
six months on average.
I would hurt more for likethree or four days because they
always say in I'm a PA, by theway, but they always say in
medical school, pa school, don'tmess with the pancreas.
There's a reason, because it'svery fragile and very irritable.
So these nerve blocks wouldhurt for a few days and then,
(07:19):
once the medication would kickin, they would help and they
provided some relief to the painof the chronic pancreatitis.
By that point.
It was chronic because I had somany flares within such a short
period of time.
So I was doing that.
And then they put me ondigestive enzymes prescription
strength, because when yourpancreas gets damaged you lose
the ability to digest fats andproteins well, and so I needed
(07:42):
some help in that area.
And then let's see what elseKept going on.
The Remicade Ended up being ona double dose every six weeks,
so that's been kind of myregimen since 2012.
And thankfully that's put my UCin remission.
So I would say, within I don'tknow about a year of starting
(08:02):
the Remicade, after all theinitial hoopla of stopping it
and restarting it, I was inremission on scopes for my UC,
so that was wonderful.
But then you have this othercomponent where you've got a lot
of GI symptoms and so it's likewhat is flaring?
I had to kind of self-advocate.
(08:23):
So I'm a PA now, but I was adietician at the time when all
of this was happening and Iactually worked with cystic
fibrosis patients who havepancreatic insufficiency, and so
my worlds were kind ofcolliding because I was on the
enzymes that we also prescribemy patients, and so I kind of
told my doctor I was like I needmore enzymes.
(08:43):
You guys need to dose me higherbecause I'm still having all
these symptoms.
I was having a lot of urgencyand kind of like loose, greasy,
fatty stools, if you will.
So once I was able to get onthe right dose for that, I
regained the.
I think I lost like 30 pounds,which I don't really have 30
pounds to lose in that wholeprocess of the pancreatitis and
(09:06):
whatnot.
So I kind of regained my weight, regained my strength, got back
to doing life with my newregimen of nerve blocks every
four to six months and enzymesand all of that and Remicade.
And then let's see 2014,.
I decided to go PA school.
So I was a dietitian for, Ithink, three or four years
(09:26):
before I went to PA school andjust kind of was itching for
something a little bit more.
Unfortunately, as a dietitianyou don't make a lot of money.
I think it's gotten better, butit's still not great.
So I was like, hey, I can goback to school, I can, you know,
get smarter, you know, learnmore things and do more with
medicine.
(09:47):
And so I knew I wanted to goback into pediatrics, went back
to PA school.
That was about a three-yearprogram and I did relatively
well, considering all the stressthroughout PA school, I would
still get my nerve blocks everyfour to six weeks.
I even had a day where they'rereal strict in PA school.
I had a day where I had to goin the morning and get an
(10:07):
endoscopy and a nerve block andin the afternoon I had to do a
graded physical exam becausethey wouldn't let me schedule it
on a different day.
So post-anesthesia somehowpassed it and I was like this is
not right.
But if you know anyone who'sbeen through a kind of medical
school, pa school, anything likethat, they're pretty strict.
So unfortunately, towards theend of my PA school I did have a
(10:29):
flare up and I'm not reallysure whether it was pancreas or
UC or both.
It's kind of hard to tellsometimes.
I ended up in the hospital for,I think, close to a week and it
was during clinical rotations.
I was on my surgery rotationclose to a week and it was
during clinical rotations.
I was on my surgery rotation.
I actually went to scrub in ona case on a Saturday with the
(10:52):
surgeon and then like got out ofthe case and was like, um, I
need to go to the ER.
So I went home because I didn'twant to show up in the scrubs
at the same hospital that I wasworking at and went home, got a
bag packed and my now husbandwas very sweet, very new to the
relationship at this point.
But I was like, hey, you'regetting you know trial by fire
here, you're going to take me tothe ER and I think I'm going to
(11:14):
be admitted.
And I was admitted for about aweek and I had to repeat that
rotation because if you missmore than three days you have to
repeat it.
But I still graduated on timewith my class because there was
a little bit of wiggle room, Iguess, if you will.
And then graduated, got marriedtwo weeks later, moved to
Oklahoma two weeks after thatand did really well for the
(11:39):
majority of the rest of thattime.
We were in Oklahoma for fiveyears and I was not hospitalized
during that period of time,which was a miracle because all
my doctors were still.
I established care with a GI inOklahoma so they could write my
Remicade.
But I still came back to see myGI here because he's great and
(11:59):
he does all the pancreas stuffand I would come back for nerve
blocks and just kind of keptthat same routine throughout
that period of time we startedtrying to have kids, had trouble
with that, did IVF.
It's a long story but we havethree kids from IVF.
We have twins who turn fivetomorrow and then we have a two
(12:20):
and a half year old She'll bethree in August I guess more
than two and a half.
All girls.
They're very sweet and I didwell throughout pregnancy.
Some people flare, some peopledo okay and some people get
better.
I would say I did worse in thefirst trimester and then I did
better in the second and thirdtrimester for both pregnancies
(12:42):
and then did okay, likebreastfeeding and all of that.
So that was pretty cool that mybody was able to accomplish
that.
I was worried all those yearsthat like, oh, I won't be able
to have kids, and I rememberwhen I went to Mayo that they my
colon was so bad at that point.
They were talking about acolectomy and you know they they
talked about the scar tissueand if you have a colectomy then
(13:06):
they'd probably recommend anostomy until I'm done having
kids and then you could reverseit and all this and so all of
that was always in the back ofmy mind and thankfully Remicade
was my miracle drug.
I didn't end up having to havebowel surgery, but we moved back
to Texas in 2022.
My husband's a physician, so hefinished up his training in
(13:26):
Oklahoma and we moved back hereand I had my third child back
here in Texas in 2022, in August.
And then December of 23, or notDecember it was really more like
the fall my pancreas startedkind of acting up again and the
nerve blocks stopped working andI was like, okay, this is not
(13:50):
cool, because everything for 12years was going well.
I had my routine.
I was really religious aboutthe minute it felt like the
nerve block was wearing off.
I'd call my doc.
He'd get me in within like twoweeks.
He was wonderful and I wouldget a nerve block and then I'd
be on my way and I had one thatSeptember.
I was like I don't think itworked and the area that they
(14:14):
inject is very small and I'm asmall person, so it's very
difficult to get.
But he always seemed to get itand he even told me like this is
not easy, but like if it'sworking, we'll keep doing them.
Because they even told me likeinitially, oh, that probably
won't work and if it works, itmight only work a couple of
times and I'm like I've had 12years of success with those.
(14:40):
So I was like, don't break itif it's not broken, you know.
So we kept doing that and thenin September I was like this
didn't work and I was realnauseous all the time, hurting
it's like a band of kind ofepigastric pain, like right
underneath my rib cage justfeels like someone's kind of
stabbing, made it very difficultto eat, started losing weight,
just not good.
And so by December we weretrying all these different kinds
(15:03):
of medications to, you know,help with the pain without like
taking, you know, narcotics andthis, that and the other, which
all of those medications thatthey try have side effects.
They make you like super drowsy.
They tried me on variousdifferent like low dose
antidepressants that like causeterrible dry mouth, and I could
barely keep my eyes open on thevery smallest dose and I was
(15:25):
like I mean it helped a littlebit with the pain, but I can't
function.
I'm a PA, I have to think, Ihave to take care of three kids
and I was working full timethrough all of this.
And then, yeah, in December, Iwas like this isn't working and
so I started kind of looking atwhat the next steps were and
they weren't great.
So it's like, okay, well, wecould try another nerve block
(15:51):
which I ended up admitted inJanuary of 2024.
I was admitted for about fivedays because I just couldn't get
the pain under control.
And of course, what's reallyfrustrating is that, like CT
scans and things like that atthis point come back normal, and
so autoimmune pancreatitis canfrequently look like normal on a
(16:13):
CT scan.
Sometimes it can look normal ona specialized MRI.
It's an MRCP that they look atthe pancreas and the ducts and
everything, and really the onlything you can see it on is like
an endoscopic ultrasound whichvery I mean my GI does it,
obviously, but not allendoscopists I don't know how
(16:34):
you say that not all GI docs cando that specialized ultrasound,
and so they ended up doing anendoscopic ultrasound with a
repeat nerve block while I wasadmitted, just kind of a Hail
Mary, and it still showed, youknow, chronic pancreatitis.
I mean nothing new.
But then there was thisquestion mark Well, there might
(16:54):
be something different with oneof the ducts in the pancreas
which may be not draining, right.
But all that to say, like therewasn't really anything more.
They were like we could maybestent it, but sometimes that can
cause more problems and causemore pain.
And so I was kind of left with,okay, well, what do we do?
And my GI was like, well, maybe, let's you know, send you back
(17:17):
up to Mayo.
They probably have more optionsthan they did 12 years ago and
they're kind of the specialistin this than they did 12 years
ago and they're kind of thespecialist in this.
But being a PA and like havingthe medical knowledge, I started
just kind of researchingeverything and I was like, okay,
joined all these Facebookgroups and I was just like
what's next?
And the only thing that keptpopping up was removing my
pancreas and I was like that'sextreme.
(17:39):
So I kind of like looked intoit.
I was like what are theindications for this?
A lot of people who haveusually it's like a hereditary
form of pancreatitis wherethey've got like a gene mutation
that causes recurrent acutepancreatitis which leads to
chronic pancreatitis.
A lot of people who have thatend up with this surgery.
(17:59):
There's some mutations ofcystic fibrosis that don't
actually cause the lung diseasebut they cause problems with the
pancreas.
A lot of people with that endup with this surgery.
Otherwise, it's some peoplewith autoimmune pancreatitis,
but there's not that many of us,so there's not a lot of great
data out there, but usually it'speople who are.
(18:20):
They call it kind of likeminimal change pancreatitis, so
you don't see a lot of findingson scans.
But when you actually get inthere and take it out it's like
horribly scarred and atrophiedand just like a chunk of
terrible tissue is kind of whatI could gather.
And so I asked my GI.
I was like is this really likethe next step?
(18:43):
And he was kind of hedgybecause it's a big deal.
I mean, it's like a massivesurgery.
They take your pancreas, theytake your duodenum, which
connects to your small bowel.
They sometimes take your spleen.
They kept mine.
Spoiler alert.
I ended up having the surgery.
They kept my spleen.
But you I mean you reroute yourwhole GI tract because your
(19:04):
pancreas has a blood supplythat's the same as the duodenum
and so they can't take it outwithout compromising part of
your small bowel and reattachingit and all this.
So I saw that Baylor in Dallashad a program and they were one
of the bigger programs.
The surgery was pioneeredactually up in Minnesota, I
(19:24):
believe, not at Mayo, but at, Ithink, university of Minnesota.
Don't quote me on that.
But yes, they do the most.
But I was like I can't be awayfrom my family that long because
it's not only a 12-ish hoursurgery, it's like two plus
weeks hospital stay but then youhave to be close by for another
two or three weeks after youdischarge and all that.
(19:45):
So I looked into Baylor.
They got me in February 2nd, soI was admitted January 15th-ish
.
They got me in for anappointment February 2nd and
when I met with the surgeon hewas like it sounds like you need
the surgery.
So the indications for thesurgery are like loss of quality
(20:05):
of life, having to becomedependent on pain medication,
inability to maintain weight.
Restore quality of life, getoff narcotics.
Restore, you know, nutrition.
(20:30):
Restore ability to hopefully atleast get back to work, if not
full-time, part-time or schoolor whatever.
Because some kids have this.
There's kids who havehereditary pancreatitis that
have the surgery when they'relittle, like real little.
So that was heartbreaking butalso, I guess, reassuring,
because they don't do a lot ofstuff in kids unless they're
like sure that it's going to bemore benefit than harm.
(20:53):
So I met with them February 2nd, I went out of work on April
1st, I had the surgery on May1st and I'm just past a year
post-op.
So it's been a journey.
I had another surgery in Julybecause I had a suture granuloma
, which was basically like mybody trying to reject a suture
at the top of my incision.
(21:13):
And then I had a surgery inJanuary of this year for a
hernia that popped up on myoriginal incision.
So I've been back under threetimes, plus another scope, just
to kind of check things.
So it's been a year.
But I did go back to work inAugust, part-time.
I chose and my doctor was likeit's probably a good idea not to
go back full-time.
(21:33):
I chose to go back part-time,with their reassurance that that
was the right decision.
Because Alicia knows I'm kindof the if you don't put a
barrier or a, I guess, boundaryon me, I'm going to do too much.
So I went back part-time.
I'm, I would say, kind of backto normal.
(21:55):
Part of the surgery is they whenthey remove your pancreas, they
take your islet cells whichmake insulin and put them in
your liver, and so the goal isthat your liver takes over
making insulin.
About a third of patients don'tneed insulin after the first is
that your liver takes overmaking insulin About a third of
patients don't need insulinafter the first initial period
post-op.
About a third need insulinsmall amounts and a third need a
(22:15):
lot of insulin.
I'm in that middle part.
I'm now diabetic.
I'm on an insulin pump and aCGM, so a glucose monitor and
that's been probably the hardestpart is learning to be a
diabetic.
So shout out to anyone who hastype 1 diabetes, I have a
newfound respect for you.
It's a lot.
But as I was telling you guysbefore we started, that's kind
(22:37):
of how I found y'all's podcastis.
I was searching for pancreaspodcast.
I don't know like who writes apancreas podcast no one.
But there is a very populartype 1 diabetes podcast that had
one episode.
They might have had another onesince, but had one episode.
That was someone who had thesame surgery as me and so I
(22:58):
found that episode and I waslistening to her episode.
And then I've listened to thatpodcast a lot because I've
learned so much about how tomanage my diabetes because I'm
essentially a type 1.
It's just called type 3Cbecause my pancreas is gone.
It's not destroyed byautoimmune surprisingly, because
I have all the other autoimmune, but it's a surgical diabetes
or whatever.
(23:19):
But then I was like what otherpodcast can I find?
And I found you guys and I waslike, how did I not know this?
Because Alicia and I have knowneach other for years and it's
just been.
It's been a journey.
So that's kind of where we'reat present day.
The UC is still pretty wellcontrolled.
They talked about taking me offRemicade and I was like, yeah,
no, I'm not going to go for that.
So we're weaning it to everyeight weeks instead of every six
(23:42):
, and that's going to.
We're going to see how thatgoes for a bit.
Speaker 2 (23:45):
Yeah, that would scare me too.
Okay, I'm going to bring youall the way back to the
beginning, because I've thoughtabout this like three times.
So were you misdiagnosed withceliacs or do you have celiacs?
Speaker 3 (23:55):
I have celiac.
To my knowledge, however,because I am now a PA, I was a
dietician and my mom is a very,very, very good bookkeeper.
I went back through all of myrecords that she had, because
she saves everything, bless her.
And the celiac?
I do have the gene.
I have one gene of the two andone of my daughters has since
(24:19):
been diagnosed with celiac.
So I think I have celiac.
However, my biopsies were notlike home run celiac and
sometimes the biopsies can belike some of those findings can
be seen in Crohn's, and so I hadthis whole like have I had
Crohn's this whole time?
This whole like existentialcrisis yes, existential crisis.
(24:41):
I'm like you know what I'msaying when I was like have I
been misdiagnosed this wholetime?
And I don't think I.
I really do think I have celiacbecause I eat gluten and like I
don't purposely eat gluten butif I accidentally get served
gluten or you know, crosscontaminated or whatever, I get
symptoms.
But yeah, it's just, it's aninteresting kind of pathway to
go down, because I've never hadany other findings in my small
(25:03):
bowel.
So I don't think I wasmisdiagnosed and I don't think I
have Crohn's, but that questiondidn't pop up in my mind, yep.
Speaker 1 (25:10):
I am curious about pancreatitis, though.
Do you mind spending a littlebit of time here, cause maybe
this will become the episodepeople find when they're looking
for information aboutpancreatitis.
But so you mentioned likeautoimmune pancreatitis, can you
is?
Are there differences in howthey manifest, like is there a
way to tell that one isautoimmune versus the other, or
how does?
Speaker 3 (25:31):
that work Initially?
No, so my, my initial bout ofpancreatitis was very classic
presentation severe, epigastric,like right between your like
sternum, rib cage area,abdominal pain that felt like
someone was stabbing me, kind ofturning the knife.
That kind of radiated to myback.
(25:52):
Lots of vomiting couldn't getoff the I mean I had some UC
stuff going on too, but so itwas kind of both ends, but it
was mostly vomiting and likesevere, severe pain.
Like my mom found me.
I called her and I'm like mom,I'm not okay.
And she found me curled up in aball on the floor in the
bathroom because I was justhurting so bad.
(26:13):
And silly me, because I was likethey're going to think I'm like
you think pancreatitis, youthink alcoholic.
So I'm like they're going tothink I'm a drug-seeking
alcoholic.
So I refused pain meds, which Ithink back and I'm like why,
julie, why did you refuse painmeds?
The first admission.
But basically they admit you.
You go nothing to eat or drink,you're on IV fluids, pain meds
(26:35):
if you're smart and you takethem and nausea control.
So I think I was in for likethree days the first time and I
mean I was 25.
So I mean I drank, but itwasn't what brought it on.
So the delineation between, like, autoimmune versus not really
had to come by that specialbiopsy at Mayo, which I'm sure
(26:58):
that other places can do it now,but back in the day not to age
myself, but back in the day Ihad to go all the way up there
because they couldn't even dothat type of biopsy.
They did a biopsy here in FortWorth but they couldn't do that
type of biopsy.
So the diagnosis so there's twotypes of autoimmune
pancreatitis.
One is linked with what theynow call IgG4-related disease,
(27:24):
which has a whole I don't wantto even speak out of turn
because I couldn't tell youevery single thing but it's got
a whole slew of things that arenot just pancreas that it can
present as, and in that one youhave elevated IgG4 levels.
So they tested that on me andmine were normal and so that
kind of was like okay, is itautoimmune or not?
(27:44):
Because this type 2 was so newand so like I think they found
it in Japan or something, so itwasn't very well studied here in
the US.
But Mayo was kind of on theleading front of delineating
that and delineating the linkbetween ulcerative colitis and
type 2 autoimmune pancreatitis.
So when you have now, like whenI went to Baylor, you have
(28:09):
various different reasons Ithink I kind of talked through a
little bit of it where you canhave recurrent pancreatitis,
recurrent acute episodes ofpancreatitis, and the first
thing they said that appointmentwas we need to do genetic
testing on you, not because it'sgoing to change your outcome,
but because you have threelittle girls at home and if you
have hereditary pancreatitisthen you need to be on the
(28:31):
lookout for that in them.
And so thankfully I ended upgetting it covered by insurance.
But there was this whole bighoopla with the genetic testing
and insurance and we had tofight it.
Real bad because it was likenot cheap, but we got that done
and thankfully that was negative.
So I don't have these certainmutations that are seen with
this recurrent pancreatitis, butthere's not like a specific
(28:59):
gene that they've located forthe autoimmune pancreatitis.
So there's not really a greatway to know.
I mean most people I think youhave one episode of acute
pancreatitis.
It's just like, oh, you gotpancreatitis and you know, oh,
maybe you drank too much, maybeyou ate too much fatty food, you
know all the typical thingsthey say, but it's when you have
those recurrent episodes, thenthey're going to start
questioning why is thathappening, especially in someone
(29:22):
who doesn't drink or doesn'tdrink heavily, someone who
doesn't drink or doesn't drinkheavily and the pancreas looks
different on a pancreatitis withalcohol abuse and a
pancreatitis that's not analcoholic I won't get into all
the details, but it looksdifferent and the surgery that I
had really isn't indicated forpeople who have, like an
alcoholic pancreatitis because,one, the likelihood that they're
(29:45):
going to stay clean or you knowwhatever, doesn't bode well for
all of the post.
You know complications,diabetes and you know you've got
to protect your liver and allthis.
And two, I just don't thinkthat they have the same results
like the same relief results assomeone who has the kind of
recurrent acute pancreatitis,chronic pancreatitis picture.
Speaker 1 (30:06):
That makes sense, yeah, and it just it sounds so
painful, so, so, so painful.
Speaker 3 (30:12):
Yeah, I'm like why did I refuse pain meds that
first time?
I'm just like silly me Cause.
Speaker 1 (30:17):
How many times have you know you've been in a
medical situation where peoplesay that you know it's there's
maybe some medical gaslightingthat has happened that you've
witnessed in the past?
You know, like there's thatthese are the bags we carry with
us, right?
Speaker 3 (30:31):
You know so there's probably what's crazy is that,
like I've been very fortunate tohave had good experiences with
most of my doctors and I don'tfeel like I carry this burden of
having being gaslit a bunch oftimes which I feel for people
who are.
I feel like part of that isthat I'm able to advocate for
(30:52):
myself in a certain way becauseI have medical knowledge that
maybe someone who didn't havethat background just doesn't
know the right things to say orthe right things to ask or the
best way to advocate.
So I do feel thankful thatthat's been my journey, that I
have, you know, had really goodcare.
But I think that just thestigma of oh well, they see me,
(31:14):
I'm like a 25 year old, like youknow, single girl who like,
does like to have a drink hereand there and whatever, like I
think I had that in my mind thatthey were just going to pin me
as like she just wants pain meds.
Speaker 1 (31:31):
I don't know.
Yeah, I can understand thatvery much.
Yeah, there's definitely timeswhere I've kind of been like no,
no, I don't need that, it'sfine.
So I would imagine that havingthe background as a registered
dietitian has been incrediblyhelpful, as you've had to deal
with this pancreatitis and alsoyour celiac and also ulcerative
colitis and now diabetes and howyou're changing your diet.
All of these have dietary likekind of conundrums, I would
imagine.
So talk to us about how, likehow have you figured out your
(31:55):
diet now?
Speaker 3 (31:56):
Yeah, it's been an interesting journey because I
was ballerina, which I didn'tmention before.
I think you knew that, alicia.
But you know I grew up withkind of a hyper focus on
appearance and, you know, eatingand all this up with kind of a
hyper focus on appearance andeating and all this and so kind
of had some disordered eatingpatterns as a teenager and
decided to go be a dietitianbecause of some of that.
(32:16):
And then when I was diagnosedwith celiac, it was just kind of
like, oh well, maybe I can helppeople who have the same issues
that I do.
And so when I was diagnosedwith celiac, obviously that was
2004.
So it was before gluten-free wascool.
It was before there were anylike really good products,
before restaurants reallycatered to it.
There were like a handful ofrestaurants that you could go to
(32:39):
that had a gluten-free menu.
Aside from that, I sat in aChili's and cried when I was
like I think I was doing acollege tour or something and I
was like mom, I can't eatanything except chicken.
And, like you know, just had amoment and it's it's interesting
navigating it.
I know this is not what youasked and I'll get back to what
you asked, but navigating it asa mother with a child now that
(33:00):
who's four.
She was diagnosed when she wasthree and that was because I
pushed for early screening.
Just seeing moments in her thatI'm like it's appropriate for
her to sit there and cry andlike throw a tantrum because she
can't have something thatsomeone else can have, and I'm
like, why?
Like that's how I feel, but I'man adult and I can't do that
(33:22):
and so it's just interestingnavigating that and she's done
amazingly well, I will say, as ayou know three and four year
old to be able to tell people Ican't have gluten, is that
gluten free?
And I mean it's kind of ourlittle thing.
She's like me and mommy have toeat gluten free and you know
it's just very sweet.
But just seeing that in yourown child it kind of like makes
your heart break and be like, ohman, I just I want life to be
(33:47):
easier for her and so I'm hopingthat catching it early she
won't have this cascade ofmultiple autoimmune conditions,
cause that's you know, when Iwas researching stuff, that's
part of it is, you know, if youcatch it early, hopefully it
doesn't cause more damage andcause your body to attack more,
more things.
But back to what you asked.
It's been a challenge becauseceliac's gluten-free, obviously,
(34:11):
and then pancreatitis waslow-fat, and then I did the
low-fat thing and I was eatingmango sorbet for months because
I couldn't tolerate anythingelse and that's why I was losing
weight like crazy.
And I mean I look back and Iwas like Skeletor, just not a
good look for me.
It was like not great.
(34:34):
But then, getting on the rightenzyme doses, I was able to
incorporate more fat back intomy diet and eat more regularly
as long as I took my enzymes.
And then I did well with it foryears and I was able to, you
know, even have a drink here andthere without like causing a
flare up and just everything, inmoderation of course, have been
strict gluten free this wholetime.
And then really the nextchanges were actually when I was
(34:59):
breastfeeding my kids, becauseI had two out of three that were
dairy sensitive and so I cutdairy out when I was nursing
them and that actually Iprobably shouldn't eat dairy.
Let's just be real, because youknow most people don't tolerate
dairy well, and I do feelbetter, but I love cheese.
It's really good.
Speaker 2 (35:19):
So I went dairy.
I'm sorry, you can pry thecheese out of my cold dead hand,
Right, I'm like you know it'snot happening.
Speaker 3 (35:27):
I'm like, oh, we just got cheese back in our diet,
let's not take it back out again.
So it's been a journey withthat and I mean I've helped a
lot of friends who actually havegone through similar things.
I mean it has nothing to dowith IBD, but you know, nursing
their babies who had, like youknow, cow's milk protein
intolerance and be like, hey,these products are great, these
aren't, you know, try this.
(35:48):
And so just knowing where tolook for things and there's so
much out there now that it'sgotten so much easier for
gluten-free, dairy-free,egg-free, soy-free, like
everything you can findsomething.
And then once I had to add thediabetes into the picture, like
I didn't have to, I had to learn.
You know I still look up carbson certain things, but I didn't
have to learn the concept ofcounting carbs.
(36:10):
I'm on like a, an insulin pumpthat is very smart, but you
still have to put carbs in it.
So you know they do have someinsulin pumps out now that they
kind of the endocrinologist willset up and you know, you put in
a typical meal for me, a higherthan typical meal for me or a
lower than typical meal.
That's like someone who doesn'twant as neurotic control like I
(36:34):
do.
My endo told me that I need tojust kind of relax a little bit,
but my A1C is normal.
I'm living my best life overhere, counting my carbs and
eating a normal diet, though.
So, like, I take my enzymes andI take my insulin, and I do have
sugars that go too high and Ihave sugars that go too low, and
(36:57):
I'm still navigating that,because I have the weird part
about the surgery I had is Ihave the islet cells that are in
my liver that are doingwhatever the heck they want.
So some days they're like I'mgoing to pretend to be a
pancreas today, and some daysthey're like I'm lazy, and so my
insulin needs are very variable.
And so I actually got COVID acouple months ago and I needed
(37:21):
like three times as much insulin, and thankfully I knew that
that was a potential to happenand I just changed my settings
and rode through it.
But even since then it's been alittle higher than it was
before that.
And so illness, surgery,getting steroids as a pre-med
for Remicade all of those thingsaffect the amount of insulin I
(37:43):
have to give myself.
Steroids make your sugar gosuper high, and so I've got
different settings on the pumpand like I've learned all this
how to navigate this really withthe help of that podcast and
then just kind of doing it.
But being a dietician, I didn'thave to learn the concept of
like this is a carb and this isa fat and this is a protein.
(38:03):
So I don't know how people whodon't have that background
manage that on top of recoveringfrom surgery and they do it.
I'm in a group with a bunch ofpeople who have done it and they
do well with it.
But I feel blessed again thatlike I didn't have to navigate
that on top of everything else.
So God has a weird plan and Inever thought I really didn't
(38:26):
think that my pancreas wouldcome out.
I thought it would be my colon.
You know, like, when you thinkof what organ are you going to
have removed in your life,you're not like my pancreas.
I had my gallbladder out at onepoint in the whole process I
didn't even mention that.
But like who has their pancreasremoved?
Like you tell people that andthey're like you can't live
without a pancreas.
Well, apparently you can.
Speaker 2 (38:46):
I was told early on that I couldn't live.
I must be wrong.
I couldn't live without mycolon, and at that point I had
not had a colon for like 10years.
So like, oh, no, no no, youmust be wrong.
You must have misunderstoodyour doctor.
I'm like OK, yeah, yeah, you'relike check it.
Speaker 1 (39:03):
Yeah, all right, sir, stay in your lane.
Thank you, stay in your lane.
Speaker 3 (39:06):
The worst is seeing people talk about how they'll
get like CT scans after havingthis surgery that I had, and
sometimes the radiologist willeven comment on like the
pancreas looks normal andthey're like there's no pancreas
.
And then they're like, did theynot take it all?
And you know, I think thatsometimes we know not to throw
(39:34):
them under the bus, but you know, sometimes we rely on kind of
just like form.
You know, this is what Itypically say and like if you're
not aware that that was done,I'm like you gotta see that it's
not there, right?
Speaker 2 (39:38):
I don't know did.
Did you even look?
Did you even look?
Whenever anybody when I sayanybody, I mean a medical
professional, whenever I havetest runs now and they're like,
oh, that looks normal.
I'm like normal for who?
That's my first question Normalfor who?
Do you know what is normal forme?
Is this normal for the average50-year-old man that's 6'2 and
weighs 185 pounds, or is thisnormal for me?
Speaker 1 (39:59):
Julie, did you get to see your pancreas when they
were?
Speaker 3 (40:02):
done.
I have a picture of it.
I didn't get to like actuallysee it because so they take it.
The surgery is kind of in twostages.
So the first stage they'redissecting everything out very
carefully because it's all likeplastered from all the scar
tissue and all that Lots ofvasculature, arteries, veins.
(40:22):
You know they got to be realcareful, so that part took like
seven hours or something.
And then they hand it off tothe lab that actually takes it
and, like in layman's terms,blends it up and then puts it in
an IV bag.
And then they actually so theylike kept me on the table under
anesthesia but I was just kindof hanging out there for a while
while that process took.
(40:43):
And so they they extract theislet cells and then they bring
them back and then they put themin through your portal vein, so
your vein that goes into yourliver, and so it just uptakes
into your liver and they justkind of seed throughout your
liver and then they make theirself cozy and you know, there
they are.
Speaker 1 (41:01):
So it's like a smoothie for your liver, Like
wow.
Speaker 3 (41:06):
Yeah.
So I saw a picture of it and Imean it, it looked pretty like
scarred and he said it was verydifficult to get out.
So I mean, I guess it was likevalidation that I did the right
thing, because let me tell youit was a lot of pain, the
incisions from like the bottomof my sternum to my belly button
.
So I make jokes that I hadtwins and a third child without
(41:30):
a C-section, no scar.
And here I am getting a full,you know up and down vertical
scar, which it's fine, it'sfaded out, but you know it's a
battle wound that's hard torecover from, though that's a
big scar.
And then lifting restrictions.
I mean, we had, thankfully, alot of help from both my parents
(41:52):
and my husband's parents.
They kind of manned the fort onthis side of town with my kids
and my husband and then my momkind of manned me and my dad
came in helped out and my sistercame.
It was a joint effort to keepeverything afloat, because I was
in the hospital for two weeks,went home to my parents' house
for like five days and then gotreadmitted for another four days
because I had kind of just somepost-op complications.
(42:13):
And then I think I finally camehome about three weeks after
surgery to my family, but Icouldn't lift anybody which.
I have little kids and theyalways want to be picked up.
So we had to employ my in-lawsto kind of help out when I was
on duty because I couldn't pickup my at that point very young
two-year-old, you know, not eventwo at the point.
(42:34):
Yeah, so it was a it was ajoint effort.
Speaker 1 (42:38):
And it's not like two-year-olds are like super
reasonable either.
So it's not like you could belike no, I can't lift you up
because of this.
And she's like yeah, of course,gotcha.
Speaker 3 (42:45):
Thankfully the twins, I mean they could understand
and they still say you know?
The other day I went to myneurologist about my migraines
and my daughter was like is hegoing to cut your head open?
It's like no, every doctor Isee doesn't cut me open, honey,
it's okay.
Speaker 1 (43:04):
Last time I I checked .
That's not the treatment forthis, but yeah, yeah, I hope.
Speaker 3 (43:09):
I told him that and he laughed because of course
he's a neurologist, not aneurosurgeon.
He was like, yeah, no, I don'tdo that oh, that's, very funny,
yes that is I love itout of the mouths of babes, yep,
and they play doctor all thetime and they like lay down and
they're like okay, I'm gonna cutyou open to like most kids
don't have that like.
At least they're like okay, I'mgoing to cut you open, like
most kids don't have that Like.
At least they're workingthrough it right, like they're
(43:29):
kind of processing it.
Speaker 1 (43:31):
I mean, I think that's really sweet, that they
like they want to be part of itand it's nice for them to get to
that.
You probably are like you know,have tiny little doctors or PAs
on your hands yeah, probably.
Speaker 3 (43:42):
My daughter who has celiac.
She so invested my daughter whohas celiac.
She had to have another scopethe other day and she was a rock
star, like perfect.
You know she just she went inthere, she didn't get nervous,
like I kind of talked herthrough everything and the
nurses were all like wow, she'sdoing so good.
You know, they have child life,come in who kind of helps talk
through everything.
And she did great.
And you know she had a pH probeplaced and so she had to come
(44:08):
home with like a little pH probein her nose and she didn't
touch it and she kept it inuntil the next morning.
I was really proud, like I hatethat she has to go through it.
But you know I think that it'shelped kind of relay a sense of
calm with.
You know, medical professionalsI mean obviously I work as a PA
in pediatrics and so I see myfair share of kids who are
traumatized by us and who hateus, and so it's nice that at
(44:32):
least I've kind of relayed somecalm with them with going to the
doctor, remind me what youspecialize in.
Speaker 1 (44:39):
What part of pediatrics are you working in?
Speaker 3 (44:41):
I'm in pulmonology and so I work with lung
disorders.
I'm actually switching up.
It's kind of full circle.
So when I worked as a dieticianI worked with the cystic
fibrosis but I also worked onthe trachevent unit.
So kiddos who havetracheostomies and are on
breathing machines and I amactually in June switching back
up to exclusively be on thatfloor.
(45:02):
So still within pulmonology,but just a little bit more
specialized.
There've been a coupleopportunities to work in GI and
I've said no thanks, I haveenough of that on my own, like I
need to separate personal andprofessional.
Speaker 1 (45:16):
So yeah, we've talked to a few people now that work
within like the medical,different parts of medical
profession and yeah, they've hadto.
Some of them have had to stepaway and say like either they're
like I'm not at all interestedin that because, you're right,
it's such a big part of my life,or it was such a big part of my
life, and some of them are justlike, yeah, no, I think you
know I need to step away fromthis and do something else.
(45:37):
It makes sense.
Speaker 3 (45:47):
I mean, I think that I would be like the perfect fit
for that, being a dietitian anda PA, but I just I've kind of
always felt like I wouldprobably not have a very
objective viewpoint, and so Ithink that it's.
I mean, don't, don't get mewrong, I still deal with a lot
of GI with my patients.
You know, most of my kiddos,especially on the treatment unit
, have G-tubes and you know,there there's various different
congenital things that they'redealing with and whatnot.
So we kind of cross, crossovera lot, but it's just enough.
(46:09):
You know, I think it's good tohave that, that distance from it
professionally, kind of talkinginto the mental health aspect
of it, because I think thatthat's important to share too is
that in this last year, I mean,I've dealt with insomnia, I've
dealt with anxiety, I've dealtwith a lot of like I guess you
would call it like PTSD, likemedical PTSD, even though, like,
(46:30):
inherently, I'm a pretty likechill person.
And so I've had to go down theroute of like trying different
meds for anxiety and then, oh,guess what, these are all
causing diarrhea.
So that's real cool.
And so having to go through,like various different med
changes just to find somethingthat didn't cause GI problems
and I'm like I can't be in thebathroom when I'm already in the
(46:52):
bathroom all the time, and itwas like not to be TMI.
But it was like even worse thansome of my baseline and I was
like I asked my GI and he waslike I don't think it's the
medication.
And then, like lo and behold, Istopped it and it got better
and I was like it was themedication, you know.
So I think, just as a medicalprofessional too, like kind of
keeping that in mind, that likeeven if it's a rare side effect
that it does happen, you know,to certain people, and so I've
(47:15):
had to kind of go through thatroute.
Speaker 1 (47:17):
One of the things you talked about that I want to
kind of come back to is alsotalking about going to PA school
and not getting anaccommodation.
Speaker 3 (47:28):
Which an accommodation, which is
interesting because I hadaccommodations during PA.
Yes, that was completely absurd.
Like my time hop pulls up thepicture every year.
That was like endoscopy in themorning past Donosky in the
afternoon and I'm just like whydid that ever happen?
Speaker 1 (47:39):
Like I'm shocked.
Yeah, I'm really shocked.
Speaker 3 (47:42):
I don't know, I don't know how that happened, because
I did have accommodations.
I mean I had like special extratime, extra bathroom breaks,
you know, things like thatPretty standard.
But got to sit at the end ofthe row, you know, so I could
get out easily.
Speaker 1 (47:54):
That kind of stuff those are easy to accommodate
and something else is not, andso that's why I don't know.
It was a mess, but I gotthrough it.
Both patient and professionalhad on this one.
There are medications that arecoming out for celiac disease
and that are supposed to sort ofhelp in the off chance that you
get cross-contamination thingslike that.
Is that something you'veconsidered?
(48:16):
Or is it one of those where,like, you've hit a reasonable
homeostasis with the rest ofyour treatments and you manage
your diet really pretty well andyou're just like, if it's not
broke, don't fix it, you know?
Speaker 3 (48:26):
I see the trials and I have always been like cool,
I'd like to be part of that.
I get excluded because I haveIBD, so I've been interested in
it.
I think that I would probablylet other people try it a little
bit before me and see how itgoes, but I am excited for the
(48:48):
potential that maybe my daughtercould have a future where she
didn't have to limit her diet.
I don't know if it'll get tothat point, you know, in her
lifetime, but it's cool whatthey're doing with different
gene therapies and stuff.
When I started as a dietitianin CF, we had kids admitted all
the time into the hospital withrespiratory infections, flares,
(49:08):
poor weight gain, things likethat.
And they have come out withvarious different CF medications
now that actually alter thesodium channels that are
defective in CF and so we havehardly ever kids admitted now.
And it's literally been in the10 years that I was out of that
world.
When I lived in Tulsa I workedin brief, stint and cardiac
(49:32):
because my job kind of fizzledbut brief, stint and cardiac and
then I did pediatric ER for awhile and so I was out of the
pulmonary world and then when Icame back to DFW I went back, I
did urgent care for a year andthen came back to pulmonary and
I was like talking to the doctor, the medical director, and she
was like, yeah, we hardly everhave CF kids admitted anymore.
(49:53):
And I was like that is so cool.
And so that's literally been.
I left for school in 2014, cameback here in 2022, rejoined
pulmonary in 2023, 10 years andthey have made that much
progress.
And that's like I mean the CFFoundation like does a lot of
research and stuff, but it's nothuge.
There's probably not a lot ofmoney that anyone's giving them,
(50:14):
you know.
So that's just cool for that,obviously.
But like the thought that thatcould translate for IBD and for
celiac and for all thesedifferent disorders that are
genetically linked.
I mean we know that it's alittle harder to pinpoint with
IBD, celiacs more specific, butcool to think that, like in her
lifetime that could happen.
(50:35):
So I mean I'm so used to it nowthat it's like maybe you know
it'd be really nice to have areally nice piece of bread, but
I mean that's probably the worstthing still is the gluten-free
bread, but everything else ispretty reasonable.
I mean we eat mostlygluten-free at our house.
My husband tolerates it.
He doesn't really seem botheredby it, so he has his loaf of
(50:57):
bread and some tortillas, andaside from that it's mostly
gluten-free.
Speaker 2 (51:02):
Julie, thank you so, so much for coming on the show
and sharing your story.
I know that it is going to helpso many people, but
unfortunately, it is time for meto ask the last question, and
that is what is the one thingthat you want the community to
know?
Speaker 3 (51:15):
I think that kind of my, my standpoint is that, like
it doesn't define you, you canstill do things that you love.
And I mean I've been thrown, asyou heard, so many roadblocks
along the way and I stillmanaged to have a career and a
family and just don't let it, Iguess, get you down like in a
(51:35):
pit, because it's very easy todo that.
I mean, I had moments where Iwas like what, what is my life?
What am I doing?
Why?
You know why, why me?
You know you can get in that.
Why me my life?
What am I doing?
Why?
You know why, why me?
You know you can get in that.
Why me?
Moment, or very long moment,and you just got to kind of pull
yourself out of it, because ifyou sit there, everything else
becomes way way worse, includingyour, your symptoms, and so
(51:57):
just kind of keep moving forward.
It's all you can do.
Speaker 1 (52:00):
Yeah, I do think that's really easy, but I also
think that is that is the timewhen you do reach out for
community and you say you knowwhat.
I need to talk to somebody now.
I need to either get therapistspotentially to help with this
or I need to reach out tofriends that understand and, you
know, get some support at thattime, because sometimes it's
like it gets real dark and it'sreal tough to pull yourself out,
and so people can help you.
(52:20):
You can get a hand up.
I think, to help as well, forsure, absolutely.
I think to help as well, forsure, absolutely, julie.
One question that I forgot toask you, that I intended, is
what is the name of this podcastthat you were listening to the
Diabetes Podcast so that we canlink to it?
Speaker 3 (52:32):
The Juicebox Podcast.
It was started by a dad of achild who is now a young adult
who has type 1.
And so it is a massivecommunity.
They have a Facebook group anda podcast, and he churns them
out like almost every day.
It's insane.
That's like his full-time job,though, so he's not.
(52:54):
He's not doing other stuff, buthe has.
I'm actually going to recordwith him in the fall, so it
probably won't air until I don'tknow, next year or so, but yeah
, it's been very helpful, soit's awesome.
Speaker 1 (53:07):
Awesome.
Thank you for sharing that.
I will make sure I link to itdown in the show notes, so if
anybody is looking for this andthat sounds of interest to them,
please do look for that.
Julie, thank you so much forjoining us.
Thank you everybody else forlistening, and cheers, cheers,
cheers everybody.
Speaker 3 (53:23):
Hi, this is Julie.
If you hi, this is julie.
If you enjoyed this podcast,please rate, review and
subscribe and share it with yourfriends.
Hi, I'm Alicia and I'm Robin, and you're listening
to Bowel Moments, the podcastsharing real talk about the
realities of IBD Serve on therocks.
This week we talked to JulieDavis.
Julie is a physician'sassistant and dietician who
lives with inflammatory boweldisease, celiac disease, as well
(00:20):
as autoimmune pancreatitis.
We talked to her about managingher inflammatory bowel disease,
as well as her pancreatitisitisand all of the treatment that
she had to use for that.
We talked to her aboutnavigating PA school while also
dealing with very significantissues with her pancreatitis.
We talked to her about hercareer as a dietician and how
that helped her manage herceliac disease, as well as her
(00:41):
inflammatory bowel disease, andalso some of the complications
she had from her surgery for herpancreatitis.
And we talked to her about somuch more.
We know you're going to lovethis conversation just as much
as we love talking to JulieCheers.
Speaker 2 (00:56):
Hi everybody, Welcome to Bowel Moments.
This is Robin.
Speaker 1 (00:59):
Hello everyone.
This is Alicia and we arereally, really excited to be
joined by Julie Davis.
Julie, welcome to the show.
Thanks for having me.
I'm excited.
We are very excited for you totell your story because it is
involved.
But our first veryunprofessional question for you
is what are you drinking?
Speaker 3 (01:18):
You know I'm not really a tea drinker, but I have
hot tea tonight because mygirls gave me the crud and so
I've got a little sore throat.
Speaker 1 (01:25):
But we're powering through yeah oh gosh With three
little ones.
I would imagine this isprobably somewhat common in your
house it's real common.
Speaker 3 (01:35):
It's kind of on a cycle.
It's like one gets sick andthen it goes through the whole
family and then by the time thefirst one gets well, it's
starting over.
Speaker 1 (01:42):
So oh no, that's miserable Robin.
What about you?
Speaker 2 (01:48):
I am also drinking hot tea.
It is May when we are recordingthis, but it is 30 degrees
where I am, so it was a hundredhere today, so it snowed where I
am.
Speaker 1 (01:59):
Oh my gosh, what are you drinking, Alicia?
Tonight I got real excited.
I am drinking a strawberry andelderflower Collins tonight.
So, it's gin and elderflowertonic and strawberries, and a
little bit of lemon as well.
So look how pretty it is.
Speaker 3 (02:14):
Oh, that's lovely.
That looks way better than myhot tea.
Speaker 1 (02:17):
Sorry, guys, very pretty.
So anyway, Julie, it is aboutyou.
Tell us your IBD story.
What brings you into ourcommunity?
Speaker 3 (02:26):
Oh gosh, it's a long one and it's got a lot of twists
and turns.
So I didn't actually start outwith IBD.
I started out with celiacdisease, which was diagnosed
when I was 18.
After, gosh, probably five orsix years, I mean, I always had
stomach problems as a kid.
They kind of worked up stuffhere and there.
It was like the 90s so I'm surethe diagnostics weren't as
(02:51):
great back then.
But I was actually scoped whenI was 18 and was diagnosed with
celiac, went gluten free, didgreat for a while.
And then I started to have kindof some GI symptoms again during
college and I was like, oh,maybe I'm just not being as
careful, and you know, collegeand then had another scope and
that's when I was diagnosed withulcerative colitis, which
originally it was just kind ofproctitis.
(03:12):
It wasn't super bad.
They, you know, treated me kindof conservatively and kind of
managed it conservatively for awhile.
And then, 2011, I ended up withacute pancreatitis because I
was put on a medication to helpwith the IBD.
With the ulcerative colitis Iwas put on Imurian and ended up
(03:33):
within two weeks in the hospitalwith acute pancreatitis and so
they thought it was a reactionfrom the drug and stopped the
Imurian and I was having morelike UC symptoms by that point.
But I don't I can't rememberexactly the timeline.
I've had like a million scopesin my life, both, both ways, so
don't remember exactly thetimeline on scoping and all that
(03:54):
.
But long story short, I was inand out of the hospital for the
next like, so that was July of2011.
And then by February I think, Ihad been in and out of the
hospital like six times withacute pancreatitis and they
thought I had cancer at onepoint.
They were doing all these likeyou know, different scopes to
(04:17):
kind of see what was going on,because there was a mass on my
pancreas that they couldn'treally delineate and figure out.
That they couldn't reallydelineate and figure out and
ended up sending me up to MayoClinic in February of 2012,
where they did the full shebang.
I saw the pancreas specialist,I saw the IBD specialist, had a
bunch of imaging labs, scopesboth ways, diagnostic ultrasound
(04:37):
of my pancreas with biopsies,which when I came home, caused
another flare.
So that was fun.
But all that to say, all thatdiagnostic stuff revealed I had
pancolitis by that point andthen I had autoimmune
pancreatitis, which was very newat that point very unresearched
if that's a word minimallyresearched at that point, and
(05:00):
they were able to differentiateit to be type 2 autoimmune
pancreatitis, which is commonlyseen with ulcerative colitis.
So I had, in that fall where Iwas getting pancreatitis, I had
been started on Remicade for theUC and that was the only thing
that was helping the UC portionof it.
But then they stopped it becausethey didn't know if it was
causing more pancreatitis, andso when I went back to Mayo or
(05:25):
went up to Mayo, theyrecommended I restart the
Remicade, which is always risky.
I'm sure you guys know that ifyou stop it you could have a
reaction to it and thankfully itworked well for me.
I've been on that actuallysince then and I'm still on it
and there's we'll kind of get tothe later part of the story but
there's kind of talks aboutweaning it down, which is kind
(05:45):
of scary.
But they restarted me on that.
I had been on steroids andstuff for the pancreatitis and
that's the main gist of the UCpart of it.
There's a lot more to the story, though.
Speaker 1 (05:56):
Feel free to give us the full picture if you would
like, because certainly they allkind of play on each other and
work sometimes against eachother.
I would imagine yeah, yeah.
Speaker 2 (06:06):
But if you're going through it I mean somebody else
who's listening to the show ismaybe they're just starting to
have pancreatitis and they don'tunderstand what's going on.
So if you feel comfortablesharing, we'd love to.
Speaker 3 (06:16):
Yeah, absolutely so.
Let's see.
Mayo Clinic got me back onRemicade, pancreas stuff, kind
of calmed down with a very longcourse of steroids which, as you
know, are not fun.
I had to wean off those over,like I want to say it was
between three and six monthswith all the side effects, lost
a lot of my hair, which my hairhas always been like my feature,
(06:37):
you know, and that was kind ofdepressing and kind of got to, I
guess, a good place for thepancreas.
I was having nerve blocks sothey do an endoscopic ultrasound
and a celiac plexus block wherethey inject, like lidocaine and
bupivacaine, you know, and somesteroids and stuff to kind of
numb the area.
(06:57):
And those would work for me forabout, I would say, three to
six months on average.
I would hurt more for likethree or four days because they
always say in I'm a PA, by theway, but they always say in
medical school, pa school, don'tmess with the pancreas.
There's a reason, because it'svery fragile and very irritable.
So these nerve blocks wouldhurt for a few days and then,
(07:19):
once the medication would kickin, they would help and they
provided some relief to the painof the chronic pancreatitis.
By that point.
It was chronic because I had somany flares within such a short
period of time.
So I was doing that.
And then they put me ondigestive enzymes prescription
strength, because when yourpancreas gets damaged you lose
the ability to digest fats andproteins well, and so I needed
(07:42):
some help in that area.
And then let's see what elseKept going on.
The Remicade Ended up being ona double dose every six weeks,
so that's been kind of myregimen since 2012.
And thankfully that's put my UCin remission.
So I would say, within I don'tknow about a year of starting
(08:02):
the Remicade, after all theinitial hoopla of stopping it
and restarting it, I was inremission on scopes for my UC,
so that was wonderful.
But then you have this othercomponent where you've got a lot
of GI symptoms and so it's likewhat is flaring?
I had to kind of self-advocate.
(08:23):
So I'm a PA now, but I was adietician at the time when all
of this was happening and Iactually worked with cystic
fibrosis patients who havepancreatic insufficiency, and so
my worlds were kind ofcolliding because I was on the
enzymes that we also prescribemy patients, and so I kind of
told my doctor I was like I needmore enzymes.
(08:43):
You guys need to dose me higherbecause I'm still having all
these symptoms.
I was having a lot of urgencyand kind of like loose, greasy,
fatty stools, if you will.
So once I was able to get onthe right dose for that, I
regained the.
I think I lost like 30 pounds,which I don't really have 30
pounds to lose in that wholeprocess of the pancreatitis and
(09:06):
whatnot.
So I kind of regained my weight, regained my strength, got back
to doing life with my newregimen of nerve blocks every
four to six months and enzymesand all of that and Remicade.
And then let's see 2014,.
I decided to go PA school.
So I was a dietitian for, Ithink, three or four years
(09:26):
before I went to PA school andjust kind of was itching for
something a little bit more.
Unfortunately, as a dietitianyou don't make a lot of money.
I think it's gotten better, butit's still not great.
So I was like, hey, I can goback to school, I can, you know,
get smarter, you know, learnmore things and do more with
medicine.
(09:47):
And so I knew I wanted to goback into pediatrics, went back
to PA school.
That was about a three-yearprogram and I did relatively
well, considering all the stressthroughout PA school, I would
still get my nerve blocks everyfour to six weeks.
I even had a day where they'rereal strict in PA school.
I had a day where I had to goin the morning and get an
(10:07):
endoscopy and a nerve block andin the afternoon I had to do a
graded physical exam becausethey wouldn't let me schedule it
on a different day.
So post-anesthesia somehowpassed it and I was like this is
not right.
But if you know anyone who'sbeen through a kind of medical
school, pa school, anything likethat, they're pretty strict.
So unfortunately, towards theend of my PA school I did have a
(10:29):
flare up and I'm not reallysure whether it was pancreas or
UC or both.
It's kind of hard to tellsometimes.
I ended up in the hospital for,I think, close to a week and it
was during clinical rotations.
I was on my surgery rotationclose to a week and it was
during clinical rotations.
I was on my surgery rotation.
I actually went to scrub in ona case on a Saturday with the
(10:52):
surgeon and then like got out ofthe case and was like, um, I
need to go to the ER.
So I went home because I didn'twant to show up in the scrubs
at the same hospital that I wasworking at and went home, got a
bag packed and my now husbandwas very sweet, very new to the
relationship at this point.
But I was like, hey, you'regetting you know trial by fire
here, you're going to take me tothe ER and I think I'm going to
(11:14):
be admitted.
And I was admitted for about aweek and I had to repeat that
rotation because if you missmore than three days you have to
repeat it.
But I still graduated on timewith my class because there was
a little bit of wiggle room, Iguess, if you will.
And then graduated, got marriedtwo weeks later, moved to
Oklahoma two weeks after thatand did really well for the
(11:39):
majority of the rest of thattime.
We were in Oklahoma for fiveyears and I was not hospitalized
during that period of time,which was a miracle because all
my doctors were still.
I established care with a GI inOklahoma so they could write my
Remicade.
But I still came back to see myGI here because he's great and
(11:59):
he does all the pancreas stuffand I would come back for nerve
blocks and just kind of keptthat same routine throughout
that period of time we startedtrying to have kids, had trouble
with that, did IVF.
It's a long story but we havethree kids from IVF.
We have twins who turn fivetomorrow and then we have a two
(12:20):
and a half year old She'll bethree in August I guess more
than two and a half.
All girls.
They're very sweet and I didwell throughout pregnancy.
Some people flare, some peopledo okay and some people get
better.
I would say I did worse in thefirst trimester and then I did
better in the second and thirdtrimester for both pregnancies
(12:42):
and then did okay, likebreastfeeding and all of that.
So that was pretty cool that mybody was able to accomplish
that.
I was worried all those yearsthat like, oh, I won't be able
to have kids, and I rememberwhen I went to Mayo that they my
colon was so bad at that point.
They were talking about acolectomy and you know they they
talked about the scar tissueand if you have a colectomy then
(13:06):
they'd probably recommend anostomy until I'm done having
kids and then you could reverseit and all this and so all of
that was always in the back ofmy mind and thankfully Remicade
was my miracle drug.
I didn't end up having to havebowel surgery, but we moved back
to Texas in 2022.
My husband's a physician, so hefinished up his training in
(13:26):
Oklahoma and we moved back hereand I had my third child back
here in Texas in 2022, in August.
And then December of 23, or notDecember it was really more like
the fall my pancreas startedkind of acting up again and the
nerve blocks stopped working andI was like, okay, this is not
(13:50):
cool, because everything for 12years was going well.
I had my routine.
I was really religious aboutthe minute it felt like the
nerve block was wearing off.
I'd call my doc.
He'd get me in within like twoweeks.
He was wonderful and I wouldget a nerve block and then I'd
be on my way and I had one thatSeptember.
I was like I don't think itworked and the area that they
(14:14):
inject is very small and I'm asmall person, so it's very
difficult to get.
But he always seemed to get itand he even told me like this is
not easy, but like if it'sworking, we'll keep doing them.
Because they even told me likeinitially, oh, that probably
won't work and if it works, itmight only work a couple of
times and I'm like I've had 12years of success with those.
(14:40):
So I was like, don't break itif it's not broken, you know.
So we kept doing that and thenin September I was like this
didn't work and I was realnauseous all the time, hurting
it's like a band of kind ofepigastric pain, like right
underneath my rib cage justfeels like someone's kind of
stabbing, made it very difficultto eat, started losing weight,
just not good.
And so by December we weretrying all these different kinds
(15:03):
of medications to, you know,help with the pain without like
taking, you know, narcotics andthis, that and the other, which
all of those medications thatthey try have side effects.
They make you like super drowsy.
They tried me on variousdifferent like low dose
antidepressants that like causeterrible dry mouth, and I could
barely keep my eyes open on thevery smallest dose and I was
(15:25):
like I mean it helped a littlebit with the pain, but I can't
function.
I'm a PA, I have to think, Ihave to take care of three kids
and I was working full timethrough all of this.
And then, yeah, in December, Iwas like this isn't working and
so I started kind of looking atwhat the next steps were and
they weren't great.
So it's like, okay, well, wecould try another nerve block
(15:51):
which I ended up admitted inJanuary of 2024.
I was admitted for about fivedays because I just couldn't get
the pain under control.
And of course, what's reallyfrustrating is that, like CT
scans and things like that atthis point come back normal, and
so autoimmune pancreatitis canfrequently look like normal on a
(16:13):
CT scan.
Sometimes it can look normal ona specialized MRI.
It's an MRCP that they look atthe pancreas and the ducts and
everything, and really the onlything you can see it on is like
an endoscopic ultrasound whichvery I mean my GI does it,
obviously, but not allendoscopists I don't know how
(16:34):
you say that not all GI docs cando that specialized ultrasound,
and so they ended up doing anendoscopic ultrasound with a
repeat nerve block while I wasadmitted, just kind of a Hail
Mary, and it still showed, youknow, chronic pancreatitis.
I mean nothing new.
But then there was thisquestion mark Well, there might
(16:54):
be something different with oneof the ducts in the pancreas
which may be not draining, right.
But all that to say, like therewasn't really anything more.
They were like we could maybestent it, but sometimes that can
cause more problems and causemore pain.
And so I was kind of left with,okay, well, what do we do?
And my GI was like, well, maybe, let's you know, send you back
(17:17):
up to Mayo.
They probably have more optionsthan they did 12 years ago and
they're kind of the specialistin this than they did 12 years
ago and they're kind of thespecialist in this.
But being a PA and like havingthe medical knowledge, I started
just kind of researchingeverything and I was like, okay,
joined all these Facebookgroups and I was just like
what's next?
And the only thing that keptpopping up was removing my
pancreas and I was like that'sextreme.
(17:39):
So I kind of like looked intoit.
I was like what are theindications for this?
A lot of people who haveusually it's like a hereditary
form of pancreatitis wherethey've got like a gene mutation
that causes recurrent acutepancreatitis which leads to
chronic pancreatitis.
A lot of people who have thatend up with this surgery.
(17:59):
There's some mutations ofcystic fibrosis that don't
actually cause the lung diseasebut they cause problems with the
pancreas.
A lot of people with that endup with this surgery.
Otherwise, it's some peoplewith autoimmune pancreatitis,
but there's not that many of us,so there's not a lot of great
data out there, but usually it'speople who are.
(18:20):
They call it kind of likeminimal change pancreatitis, so
you don't see a lot of findingson scans.
But when you actually get inthere and take it out it's like
horribly scarred and atrophiedand just like a chunk of
terrible tissue is kind of whatI could gather.
And so I asked my GI.
I was like is this really likethe next step?
(18:43):
And he was kind of hedgybecause it's a big deal.
I mean, it's like a massivesurgery.
They take your pancreas, theytake your duodenum, which
connects to your small bowel.
They sometimes take your spleen.
They kept mine.
Spoiler alert.
I ended up having the surgery.
They kept my spleen.
But you I mean you reroute yourwhole GI tract because your
(19:04):
pancreas has a blood supplythat's the same as the duodenum
and so they can't take it outwithout compromising part of
your small bowel and reattachingit and all this.
So I saw that Baylor in Dallashad a program and they were one
of the bigger programs.
The surgery was pioneeredactually up in Minnesota, I
(19:24):
believe, not at Mayo, but at, Ithink, university of Minnesota.
Don't quote me on that.
But yes, they do the most.
But I was like I can't be awayfrom my family that long because
it's not only a 12-ish hoursurgery, it's like two plus
weeks hospital stay but then youhave to be close by for another
two or three weeks after youdischarge and all that.
(19:45):
So I looked into Baylor.
They got me in February 2nd, soI was admitted January 15th-ish
.
They got me in for anappointment February 2nd and
when I met with the surgeon hewas like it sounds like you need
the surgery.
So the indications for thesurgery are like loss of quality
(20:05):
of life, having to becomedependent on pain medication,
inability to maintain weight.
Restore quality of life, getoff narcotics.
Restore, you know, nutrition.
(20:30):
Restore ability to hopefully atleast get back to work, if not
full-time, part-time or schoolor whatever.
Because some kids have this.
There's kids who havehereditary pancreatitis that
have the surgery when they'relittle, like real little.
So that was heartbreaking butalso, I guess, reassuring,
because they don't do a lot ofstuff in kids unless they're
like sure that it's going to bemore benefit than harm.
(20:53):
So I met with them February 2nd, I went out of work on April
1st, I had the surgery on May1st and I'm just past a year
post-op.
So it's been a journey.
I had another surgery in Julybecause I had a suture granuloma
, which was basically like mybody trying to reject a suture
at the top of my incision.
(21:13):
And then I had a surgery inJanuary of this year for a
hernia that popped up on myoriginal incision.
So I've been back under threetimes, plus another scope, just
to kind of check things.
So it's been a year.
But I did go back to work inAugust, part-time.
I chose and my doctor was likeit's probably a good idea not to
go back full-time.
(21:33):
I chose to go back part-time,with their reassurance that that
was the right decision.
Because Alicia knows I'm kindof the if you don't put a
barrier or a, I guess, boundaryon me, I'm going to do too much.
So I went back part-time.
I'm, I would say, kind of backto normal.
(21:55):
Part of the surgery is they whenthey remove your pancreas, they
take your islet cells whichmake insulin and put them in
your liver, and so the goal isthat your liver takes over
making insulin.
About a third of patients don'tneed insulin after the first is
that your liver takes overmaking insulin About a third of
patients don't need insulinafter the first initial period
post-op.
About a third need insulinsmall amounts and a third need a
(22:15):
lot of insulin.
I'm in that middle part.
I'm now diabetic.
I'm on an insulin pump and aCGM, so a glucose monitor and
that's been probably the hardestpart is learning to be a
diabetic.
So shout out to anyone who hastype 1 diabetes, I have a
newfound respect for you.
It's a lot.
But as I was telling you guysbefore we started, that's kind
(22:37):
of how I found y'all's podcastis.
I was searching for pancreaspodcast.
I don't know like who writes apancreas podcast no one.
But there is a very populartype 1 diabetes podcast that had
one episode.
They might have had another onesince, but had one episode.
That was someone who had thesame surgery as me and so I
(22:58):
found that episode and I waslistening to her episode.
And then I've listened to thatpodcast a lot because I've
learned so much about how tomanage my diabetes because I'm
essentially a type 1.
It's just called type 3Cbecause my pancreas is gone.
It's not destroyed byautoimmune surprisingly, because
I have all the other autoimmune, but it's a surgical diabetes
or whatever.
(23:19):
But then I was like what otherpodcast can I find?
And I found you guys and I waslike, how did I not know this?
Because Alicia and I have knowneach other for years and it's
just been.
It's been a journey.
So that's kind of where we'reat present day.
The UC is still pretty wellcontrolled.
They talked about taking me offRemicade and I was like, yeah,
no, I'm not going to go for that.
So we're weaning it to everyeight weeks instead of every six
(23:42):
, and that's going to.
We're going to see how thatgoes for a bit.
Speaker 2 (23:45):
Yeah, that would scare me too.
Okay, I'm going to bring youall the way back to the
beginning, because I've thoughtabout this like three times.
So were you misdiagnosed withceliacs or do you have celiacs?
Speaker 3 (23:55):
I have celiac.
To my knowledge, however,because I am now a PA, I was a
dietician and my mom is a very,very, very good bookkeeper.
I went back through all of myrecords that she had, because
she saves everything, bless her.
And the celiac?
I do have the gene.
I have one gene of the two andone of my daughters has since
(24:19):
been diagnosed with celiac.
So I think I have celiac.
However, my biopsies were notlike home run celiac and
sometimes the biopsies can belike some of those findings can
be seen in Crohn's, and so I hadthis whole like have I had
Crohn's this whole time?
This whole like existentialcrisis yes, existential crisis.
(24:41):
I'm like you know what I'msaying when I was like have I
been misdiagnosed this wholetime?
And I don't think I.
I really do think I have celiacbecause I eat gluten and like I
don't purposely eat gluten butif I accidentally get served
gluten or you know, crosscontaminated or whatever, I get
symptoms.
But yeah, it's just, it's aninteresting kind of pathway to
go down, because I've never hadany other findings in my small
(25:03):
bowel.
So I don't think I wasmisdiagnosed and I don't think I
have Crohn's, but that questiondidn't pop up in my mind, yep.
Speaker 1 (25:10):
I am curious about pancreatitis, though.
Do you mind spending a littlebit of time here, cause maybe
this will become the episodepeople find when they're looking
for information aboutpancreatitis.
But so you mentioned likeautoimmune pancreatitis, can you
is?
Are there differences in howthey manifest, like is there a
way to tell that one isautoimmune versus the other, or
how does?
Speaker 3 (25:31):
that work Initially?
No, so my, my initial bout ofpancreatitis was very classic
presentation severe, epigastric,like right between your like
sternum, rib cage area,abdominal pain that felt like
someone was stabbing me, kind ofturning the knife.
That kind of radiated to myback.
(25:52):
Lots of vomiting couldn't getoff the I mean I had some UC
stuff going on too, but so itwas kind of both ends, but it
was mostly vomiting and likesevere, severe pain.
Like my mom found me.
I called her and I'm like mom,I'm not okay.
And she found me curled up in aball on the floor in the
bathroom because I was justhurting so bad.
(26:13):
And silly me, because I was likethey're going to think I'm like
you think pancreatitis, youthink alcoholic.
So I'm like they're going tothink I'm a drug-seeking
alcoholic.
So I refused pain meds, which Ithink back and I'm like why,
julie, why did you refuse painmeds?
The first admission.
But basically they admit you.
You go nothing to eat or drink,you're on IV fluids, pain meds
(26:35):
if you're smart and you takethem and nausea control.
So I think I was in for likethree days the first time and I
mean I was 25.
So I mean I drank, but itwasn't what brought it on.
So the delineation between, like, autoimmune versus not really
had to come by that specialbiopsy at Mayo, which I'm sure
(26:58):
that other places can do it now,but back in the day not to age
myself, but back in the day Ihad to go all the way up there
because they couldn't even dothat type of biopsy.
They did a biopsy here in FortWorth but they couldn't do that
type of biopsy.
So the diagnosis so there's twotypes of autoimmune
pancreatitis.
One is linked with what theynow call IgG4-related disease,
(27:24):
which has a whole I don't wantto even speak out of turn
because I couldn't tell youevery single thing but it's got
a whole slew of things that arenot just pancreas that it can
present as, and in that one youhave elevated IgG4 levels.
So they tested that on me andmine were normal and so that
kind of was like okay, is itautoimmune or not?
(27:44):
Because this type 2 was so newand so like I think they found
it in Japan or something, so itwasn't very well studied here in
the US.
But Mayo was kind of on theleading front of delineating
that and delineating the linkbetween ulcerative colitis and
type 2 autoimmune pancreatitis.
So when you have now, like whenI went to Baylor, you have
(28:09):
various different reasons Ithink I kind of talked through a
little bit of it where you canhave recurrent pancreatitis,
recurrent acute episodes ofpancreatitis, and the first
thing they said that appointmentwas we need to do genetic
testing on you, not because it'sgoing to change your outcome,
but because you have threelittle girls at home and if you
have hereditary pancreatitisthen you need to be on the
(28:31):
lookout for that in them.
And so thankfully I ended upgetting it covered by insurance.
But there was this whole bighoopla with the genetic testing
and insurance and we had tofight it.
Real bad because it was likenot cheap, but we got that done
and thankfully that was negative.
So I don't have these certainmutations that are seen with
this recurrent pancreatitis, butthere's not like a specific
(28:59):
gene that they've located forthe autoimmune pancreatitis.
So there's not really a greatway to know.
I mean most people I think youhave one episode of acute
pancreatitis.
It's just like, oh, you gotpancreatitis and you know, oh,
maybe you drank too much, maybeyou ate too much fatty food, you
know all the typical thingsthey say, but it's when you have
those recurrent episodes, thenthey're going to start
questioning why is thathappening, especially in someone
(29:22):
who doesn't drink or doesn'tdrink heavily, someone who
doesn't drink or doesn't drinkheavily and the pancreas looks
different on a pancreatitis withalcohol abuse and a
pancreatitis that's not analcoholic I won't get into all
the details, but it looksdifferent and the surgery that I
had really isn't indicated forpeople who have, like an
alcoholic pancreatitis because,one, the likelihood that they're
(29:45):
going to stay clean or you knowwhatever, doesn't bode well for
all of the post.
You know complications,diabetes and you know you've got
to protect your liver and allthis.
And two, I just don't thinkthat they have the same results
like the same relief results assomeone who has the kind of
recurrent acute pancreatitis,chronic pancreatitis picture.
Speaker 1 (30:06):
That makes sense, yeah, and it just it sounds so
painful, so, so, so painful.
Speaker 3 (30:12):
Yeah, I'm like why did I refuse pain meds that
first time?
I'm just like silly me Cause.
Speaker 1 (30:17):
How many times have you know you've been in a
medical situation where peoplesay that you know it's there's
maybe some medical gaslightingthat has happened that you've
witnessed in the past?
You know, like there's thatthese are the bags we carry with
us, right?
Speaker 3 (30:31):
You know so there's probably what's crazy is that,
like I've been very fortunate tohave had good experiences with
most of my doctors and I don'tfeel like I carry this burden of
having being gaslit a bunch oftimes which I feel for people
who are.
I feel like part of that isthat I'm able to advocate for
(30:52):
myself in a certain way becauseI have medical knowledge that
maybe someone who didn't havethat background just doesn't
know the right things to say orthe right things to ask or the
best way to advocate.
So I do feel thankful thatthat's been my journey, that I
have, you know, had really goodcare.
But I think that just thestigma of oh well, they see me,
(31:14):
I'm like a 25 year old, like youknow, single girl who like,
does like to have a drink hereand there and whatever, like I
think I had that in my mind thatthey were just going to pin me
as like she just wants pain meds.
Speaker 1 (31:31):
I don't know.
Yeah, I can understand thatvery much.
Yeah, there's definitely timeswhere I've kind of been like no,
no, I don't need that, it'sfine.
So I would imagine that havingthe background as a registered
dietitian has been incrediblyhelpful, as you've had to deal
with this pancreatitis and alsoyour celiac and also ulcerative
colitis and now diabetes and howyou're changing your diet.
All of these have dietary likekind of conundrums, I would
imagine.
So talk to us about how, likehow have you figured out your
(31:55):
diet now?
Speaker 3 (31:56):
Yeah, it's been an interesting journey because I
was ballerina, which I didn'tmention before.
I think you knew that, alicia.
But you know I grew up withkind of a hyper focus on
appearance and, you know, eatingand all this up with kind of a
hyper focus on appearance andeating and all this and so kind
of had some disordered eatingpatterns as a teenager and
decided to go be a dietitianbecause of some of that.
(32:16):
And then when I was diagnosedwith celiac, it was just kind of
like, oh well, maybe I can helppeople who have the same issues
that I do.
And so when I was diagnosedwith celiac, obviously that was
2004.
So it was before gluten-free wascool.
It was before there were anylike really good products,
before restaurants reallycatered to it.
There were like a handful ofrestaurants that you could go to
(32:39):
that had a gluten-free menu.
Aside from that, I sat in aChili's and cried when I was
like I think I was doing acollege tour or something and I
was like mom, I can't eatanything except chicken.
And, like you know, just had amoment and it's it's interesting
navigating it.
I know this is not what youasked and I'll get back to what
you asked, but navigating it asa mother with a child now that
(33:00):
who's four.
She was diagnosed when she wasthree and that was because I
pushed for early screening.
Just seeing moments in her thatI'm like it's appropriate for
her to sit there and cry andlike throw a tantrum because she
can't have something thatsomeone else can have, and I'm
like, why?
Like that's how I feel, but I'man adult and I can't do that
(33:22):
and so it's just interestingnavigating that and she's done
amazingly well, I will say, as ayou know three and four year
old to be able to tell people Ican't have gluten, is that
gluten free?
And I mean it's kind of ourlittle thing.
She's like me and mommy have toeat gluten free and you know
it's just very sweet.
But just seeing that in yourown child it kind of like makes
your heart break and be like, ohman, I just I want life to be
(33:47):
easier for her and so I'm hopingthat catching it early she
won't have this cascade ofmultiple autoimmune conditions,
cause that's you know, when Iwas researching stuff, that's
part of it is, you know, if youcatch it early, hopefully it
doesn't cause more damage andcause your body to attack more,
more things.
But back to what you asked.
It's been a challenge becauseceliac's gluten-free, obviously,
(34:11):
and then pancreatitis waslow-fat, and then I did the
low-fat thing and I was eatingmango sorbet for months because
I couldn't tolerate anythingelse and that's why I was losing
weight like crazy.
And I mean I look back and Iwas like Skeletor, just not a
good look for me.
It was like not great.
(34:34):
But then, getting on the rightenzyme doses, I was able to
incorporate more fat back intomy diet and eat more regularly
as long as I took my enzymes.
And then I did well with it foryears and I was able to, you
know, even have a drink here andthere without like causing a
flare up and just everything, inmoderation of course, have been
strict gluten free this wholetime.
And then really the nextchanges were actually when I was
(34:59):
breastfeeding my kids, becauseI had two out of three that were
dairy sensitive and so I cutdairy out when I was nursing
them and that actually Iprobably shouldn't eat dairy.
Let's just be real, because youknow most people don't tolerate
dairy well, and I do feelbetter, but I love cheese.
It's really good.
Speaker 2 (35:19):
So I went dairy.
I'm sorry, you can pry thecheese out of my cold dead hand,
Right, I'm like you know it'snot happening.
Speaker 3 (35:27):
I'm like, oh, we just got cheese back in our diet,
let's not take it back out again.
So it's been a journey withthat and I mean I've helped a
lot of friends who actually havegone through similar things.
I mean it has nothing to dowith IBD, but you know, nursing
their babies who had, like youknow, cow's milk protein
intolerance and be like, hey,these products are great, these
aren't, you know, try this.
(35:48):
And so just knowing where tolook for things and there's so
much out there now that it'sgotten so much easier for
gluten-free, dairy-free,egg-free, soy-free, like
everything you can findsomething.
And then once I had to add thediabetes into the picture, like
I didn't have to, I had to learn.
You know I still look up carbson certain things, but I didn't
have to learn the concept ofcounting carbs.
(36:10):
I'm on like a, an insulin pumpthat is very smart, but you
still have to put carbs in it.
So you know they do have someinsulin pumps out now that they
kind of the endocrinologist willset up and you know, you put in
a typical meal for me, a higherthan typical meal for me or a
lower than typical meal.
That's like someone who doesn'twant as neurotic control like I
(36:34):
do.
My endo told me that I need tojust kind of relax a little bit,
but my A1C is normal.
I'm living my best life overhere, counting my carbs and
eating a normal diet, though.
So, like, I take my enzymes andI take my insulin, and I do have
sugars that go too high and Ihave sugars that go too low, and
(36:57):
I'm still navigating that,because I have the weird part
about the surgery I had is Ihave the islet cells that are in
my liver that are doingwhatever the heck they want.
So some days they're like I'mgoing to pretend to be a
pancreas today, and some daysthey're like I'm lazy, and so my
insulin needs are very variable.
And so I actually got COVID acouple months ago and I needed
(37:21):
like three times as much insulin, and thankfully I knew that
that was a potential to happenand I just changed my settings
and rode through it.
But even since then it's been alittle higher than it was
before that.
And so illness, surgery,getting steroids as a pre-med
for Remicade all of those thingsaffect the amount of insulin I
(37:43):
have to give myself.
Steroids make your sugar gosuper high, and so I've got
different settings on the pumpand like I've learned all this
how to navigate this really withthe help of that podcast and
then just kind of doing it.
But being a dietician, I didn'thave to learn the concept of
like this is a carb and this isa fat and this is a protein.
(38:03):
So I don't know how people whodon't have that background
manage that on top of recoveringfrom surgery and they do it.
I'm in a group with a bunch ofpeople who have done it and they
do well with it.
But I feel blessed again thatlike I didn't have to navigate
that on top of everything else.
So God has a weird plan and Inever thought I really didn't
(38:26):
think that my pancreas wouldcome out.
I thought it would be my colon.
You know, like, when you thinkof what organ are you going to
have removed in your life,you're not like my pancreas.
I had my gallbladder out at onepoint in the whole process I
didn't even mention that.
But like who has their pancreasremoved?
Like you tell people that andthey're like you can't live
without a pancreas.
Well, apparently you can.
Speaker 2 (38:46):
I was told early on that I couldn't live.
I must be wrong.
I couldn't live without mycolon, and at that point I had
not had a colon for like 10years.
So like, oh, no, no no, youmust be wrong.
You must have misunderstoodyour doctor.
I'm like OK, yeah, yeah, you'relike check it.
Speaker 1 (39:03):
Yeah, all right, sir, stay in your lane.
Thank you, stay in your lane.
Speaker 3 (39:06):
The worst is seeing people talk about how they'll
get like CT scans after havingthis surgery that I had, and
sometimes the radiologist willeven comment on like the
pancreas looks normal andthey're like there's no pancreas
.
And then they're like, did theynot take it all?
And you know, I think thatsometimes we know not to throw
(39:34):
them under the bus, but you know, sometimes we rely on kind of
just like form.
You know, this is what Itypically say and like if you're
not aware that that was done,I'm like you gotta see that it's
not there, right?
Speaker 2 (39:38):
I don't know did.
Did you even look?
Did you even look?
Whenever anybody when I sayanybody, I mean a medical
professional, whenever I havetest runs now and they're like,
oh, that looks normal.
I'm like normal for who?
That's my first question Normalfor who?
Do you know what is normal forme?
Is this normal for the average50-year-old man that's 6'2 and
weighs 185 pounds, or is thisnormal for me?
Speaker 1 (39:59):
Julie, did you get to see your pancreas when they
were?
Speaker 3 (40:02):
done.
I have a picture of it.
I didn't get to like actuallysee it because so they take it.
The surgery is kind of in twostages.
So the first stage they'redissecting everything out very
carefully because it's all likeplastered from all the scar
tissue and all that Lots ofvasculature, arteries, veins.
(40:22):
You know they got to be realcareful, so that part took like
seven hours or something.
And then they hand it off tothe lab that actually takes it
and, like in layman's terms,blends it up and then puts it in
an IV bag.
And then they actually so theylike kept me on the table under
anesthesia but I was just kindof hanging out there for a while
while that process took.
(40:43):
And so they they extract theislet cells and then they bring
them back and then they put themin through your portal vein, so
your vein that goes into yourliver, and so it just uptakes
into your liver and they justkind of seed throughout your
liver and then they make theirself cozy and you know, there
they are.
Speaker 1 (41:01):
So it's like a smoothie for your liver, Like
wow.
Speaker 3 (41:06):
Yeah.
So I saw a picture of it and Imean it, it looked pretty like
scarred and he said it was verydifficult to get out.
So I mean, I guess it was likevalidation that I did the right
thing, because let me tell youit was a lot of pain, the
incisions from like the bottomof my sternum to my belly button
.
So I make jokes that I hadtwins and a third child without
(41:30):
a C-section, no scar.
And here I am getting a full,you know up and down vertical
scar, which it's fine, it'sfaded out, but you know it's a
battle wound that's hard torecover from, though that's a
big scar.
And then lifting restrictions.
I mean, we had, thankfully, alot of help from both my parents
(41:52):
and my husband's parents.
They kind of manned the fort onthis side of town with my kids
and my husband and then my momkind of manned me and my dad
came in helped out and my sistercame.
It was a joint effort to keepeverything afloat, because I was
in the hospital for two weeks,went home to my parents' house
for like five days and then gotreadmitted for another four days
because I had kind of just somepost-op complications.
(42:13):
And then I think I finally camehome about three weeks after
surgery to my family, but Icouldn't lift anybody which.
I have little kids and theyalways want to be picked up.
So we had to employ my in-lawsto kind of help out when I was
on duty because I couldn't pickup my at that point very young
two-year-old, you know, not eventwo at the point.
(42:34):
Yeah, so it was a it was ajoint effort.
Speaker 1 (42:38):
And it's not like two-year-olds are like super
reasonable either.
So it's not like you could belike no, I can't lift you up
because of this.
And she's like yeah, of course,gotcha.
Speaker 3 (42:45):
Thankfully the twins, I mean they could understand
and they still say you know?
The other day I went to myneurologist about my migraines
and my daughter was like is hegoing to cut your head open?
It's like no, every doctor Isee doesn't cut me open, honey,
it's okay.
Speaker 1 (43:04):
Last time I I checked .
That's not the treatment forthis, but yeah, yeah, I hope.
Speaker 3 (43:09):
I told him that and he laughed because of course
he's a neurologist, not aneurosurgeon.
He was like, yeah, no, I don'tdo that oh, that's, very funny,
yes that is I love itout of the mouths of babes, yep,
and they play doctor all thetime and they like lay down and
they're like okay, I'm gonna cutyou open to like most kids
don't have that like.
At least they're like okay, I'mgoing to cut you open, like
most kids don't have that Like.
At least they're workingthrough it right, like they're
(43:29):
kind of processing it.
Speaker 1 (43:31):
I mean, I think that's really sweet, that they
like they want to be part of itand it's nice for them to get to
that.
You probably are like you know,have tiny little doctors or PAs
on your hands yeah, probably.
Speaker 3 (43:42):
My daughter who has celiac.
She so invested my daughter whohas celiac.
She had to have another scopethe other day and she was a rock
star, like perfect.
You know she just she went inthere, she didn't get nervous,
like I kind of talked herthrough everything and the
nurses were all like wow, she'sdoing so good.
You know, they have child life,come in who kind of helps talk
through everything.
And she did great.
And you know she had a pH probeplaced and so she had to come
(44:08):
home with like a little pH probein her nose and she didn't
touch it and she kept it inuntil the next morning.
I was really proud, like I hatethat she has to go through it.
But you know I think that it'shelped kind of relay a sense of
calm with.
You know, medical professionalsI mean obviously I work as a PA
in pediatrics and so I see myfair share of kids who are
traumatized by us and who hateus, and so it's nice that at
(44:32):
least I've kind of relayed somecalm with them with going to the
doctor, remind me what youspecialize in.
Speaker 1 (44:39):
What part of pediatrics are you working in?
Speaker 3 (44:41):
I'm in pulmonology and so I work with lung
disorders.
I'm actually switching up.
It's kind of full circle.
So when I worked as a dieticianI worked with the cystic
fibrosis but I also worked onthe trachevent unit.
So kiddos who havetracheostomies and are on
breathing machines and I amactually in June switching back
up to exclusively be on thatfloor.
(45:02):
So still within pulmonology,but just a little bit more
specialized.
There've been a coupleopportunities to work in GI and
I've said no thanks, I haveenough of that on my own, like I
need to separate personal andprofessional.
Speaker 1 (45:16):
So yeah, we've talked to a few people now that work
within like the medical,different parts of medical
profession and yeah, they've hadto.
Some of them have had to stepaway and say like either they're
like I'm not at all interestedin that because, you're right,
it's such a big part of my life,or it was such a big part of my
life, and some of them are justlike, yeah, no, I think you
know I need to step away fromthis and do something else.
(45:37):
It makes sense.
Speaker 3 (45:47):
I mean, I think that I would be like the perfect fit
for that, being a dietitian anda PA, but I just I've kind of
always felt like I wouldprobably not have a very
objective viewpoint, and so Ithink that it's.
I mean, don't, don't get mewrong, I still deal with a lot
of GI with my patients.
You know, most of my kiddos,especially on the treatment unit
, have G-tubes and you know,there there's various different
congenital things that they'redealing with and whatnot.
So we kind of cross, crossovera lot, but it's just enough.
(46:09):
You know, I think it's good tohave that, that distance from it
professionally, kind of talkinginto the mental health aspect
of it, because I think thatthat's important to share too is
that in this last year, I mean,I've dealt with insomnia, I've
dealt with anxiety, I've dealtwith a lot of like I guess you
would call it like PTSD, likemedical PTSD, even though, like,
(46:30):
inherently, I'm a pretty likechill person.
And so I've had to go down theroute of like trying different
meds for anxiety and then, oh,guess what, these are all
causing diarrhea.
So that's real cool.
And so having to go through,like various different med
changes just to find somethingthat didn't cause GI problems
and I'm like I can't be in thebathroom when I'm already in the
(46:52):
bathroom all the time, and itwas like not to be TMI.
But it was like even worse thansome of my baseline and I was
like I asked my GI and he waslike I don't think it's the
medication.
And then, like lo and behold, Istopped it and it got better
and I was like it was themedication, you know.
So I think, just as a medicalprofessional too, like kind of
keeping that in mind, that likeeven if it's a rare side effect
that it does happen, you know,to certain people, and so I've
(47:15):
had to kind of go through thatroute.
Speaker 1 (47:17):
One of the things you talked about that I want to
kind of come back to is alsotalking about going to PA school
and not getting anaccommodation.
Speaker 3 (47:28):
Which an accommodation, which is
interesting because I hadaccommodations during PA.
Yes, that was completely absurd.
Like my time hop pulls up thepicture every year.
That was like endoscopy in themorning past Donosky in the
afternoon and I'm just like whydid that ever happen?
Speaker 1 (47:39):
Like I'm shocked.
Yeah, I'm really shocked.
Speaker 3 (47:42):
I don't know, I don't know how that happened, because
I did have accommodations.
I mean I had like special extratime, extra bathroom breaks,
you know, things like thatPretty standard.
But got to sit at the end ofthe row, you know, so I could
get out easily.
Speaker 1 (47:54):
That kind of stuff those are easy to accommodate
and something else is not, andso that's why I don't know.
It was a mess, but I gotthrough it.
Both patient and professionalhad on this one.
There are medications that arecoming out for celiac disease
and that are supposed to sort ofhelp in the off chance that you
get cross-contamination thingslike that.
Is that something you'veconsidered?
(48:16):
Or is it one of those where,like, you've hit a reasonable
homeostasis with the rest ofyour treatments and you manage
your diet really pretty well andyou're just like, if it's not
broke, don't fix it, you know?
Speaker 3 (48:26):
I see the trials and I have always been like cool,
I'd like to be part of that.
I get excluded because I haveIBD, so I've been interested in
it.
I think that I would probablylet other people try it a little
bit before me and see how itgoes, but I am excited for the
(48:48):
potential that maybe my daughtercould have a future where she
didn't have to limit her diet.
I don't know if it'll get tothat point, you know, in her
lifetime, but it's cool whatthey're doing with different
gene therapies and stuff.
When I started as a dietitianin CF, we had kids admitted all
the time into the hospital withrespiratory infections, flares,
(49:08):
poor weight gain, things likethat.
And they have come out withvarious different CF medications
now that actually alter thesodium channels that are
defective in CF and so we havehardly ever kids admitted now.
And it's literally been in the10 years that I was out of that
world.
When I lived in Tulsa I workedin brief, stint and cardiac
(49:32):
because my job kind of fizzledbut brief, stint and cardiac and
then I did pediatric ER for awhile and so I was out of the
pulmonary world and then when Icame back to DFW I went back, I
did urgent care for a year andthen came back to pulmonary and
I was like talking to the doctor, the medical director, and she
was like, yeah, we hardly everhave CF kids admitted anymore.
(49:53):
And I was like that is so cool.
And so that's literally been.
I left for school in 2014, cameback here in 2022, rejoined
pulmonary in 2023, 10 years andthey have made that much
progress.
And that's like I mean the CFFoundation like does a lot of
research and stuff, but it's nothuge.
There's probably not a lot ofmoney that anyone's giving them,
(50:14):
you know.
So that's just cool for that,obviously.
But like the thought that thatcould translate for IBD and for
celiac and for all thesedifferent disorders that are
genetically linked.
I mean we know that it's alittle harder to pinpoint with
IBD, celiacs more specific, butcool to think that, like in her
lifetime that could happen.
(50:35):
So I mean I'm so used to it nowthat it's like maybe you know
it'd be really nice to have areally nice piece of bread, but
I mean that's probably the worstthing still is the gluten-free
bread, but everything else ispretty reasonable.
I mean we eat mostlygluten-free at our house.
My husband tolerates it.
He doesn't really seem botheredby it, so he has his loaf of
(50:57):
bread and some tortillas, andaside from that it's mostly
gluten-free.
Speaker 2 (51:02):
Julie, thank you so, so much for coming on the show
and sharing your story.
I know that it is going to helpso many people, but
unfortunately, it is time for meto ask the last question, and
that is what is the one thingthat you want the community to
know?
Speaker 3 (51:15):
I think that kind of my, my standpoint is that, like
it doesn't define you, you canstill do things that you love.
And I mean I've been thrown, asyou heard, so many roadblocks
along the way and I stillmanaged to have a career and a
family and just don't let it, Iguess, get you down like in a
(51:35):
pit, because it's very easy todo that.
I mean, I had moments where Iwas like what, what is my life?
What am I doing?
Why?
You know why, why me?
You know you can get in that.
Why me my life?
What am I doing?
Why?
You know why, why me?
You know you can get in that.
Why me?
Moment, or very long moment,and you just got to kind of pull
yourself out of it, because ifyou sit there, everything else
becomes way way worse, includingyour, your symptoms, and so
(51:57):
just kind of keep moving forward.
It's all you can do.
Speaker 1 (52:00):
Yeah, I do think that's really easy, but I also
think that is that is the timewhen you do reach out for
community and you say you knowwhat.
I need to talk to somebody now.
I need to either get therapistspotentially to help with this
or I need to reach out tofriends that understand and, you
know, get some support at thattime, because sometimes it's
like it gets real dark and it'sreal tough to pull yourself out,
and so people can help you.
(52:20):
You can get a hand up.
I think, to help as well, forsure, absolutely.
I think to help as well, forsure, absolutely, julie.
One question that I forgot toask you, that I intended, is
what is the name of this podcastthat you were listening to the
Diabetes Podcast so that we canlink to it?
Speaker 3 (52:32):
The Juicebox Podcast.
It was started by a dad of achild who is now a young adult
who has type 1.
And so it is a massivecommunity.
They have a Facebook group anda podcast, and he churns them
out like almost every day.
It's insane.
That's like his full-time job,though, so he's not.
(52:54):
He's not doing other stuff, buthe has.
I'm actually going to recordwith him in the fall, so it
probably won't air until I don'tknow, next year or so, but yeah
, it's been very helpful, soit's awesome.
Speaker 1 (53:07):
Awesome.
Thank you for sharing that.
I will make sure I link to itdown in the show notes, so if
anybody is looking for this andthat sounds of interest to them,
please do look for that.
Julie, thank you so much forjoining us.
Thank you everybody else forlistening, and cheers, cheers,
cheers everybody.
Speaker 3 (53:23):
Hi, this is Julie.
If you hi, this is julie.
If you enjoyed this podcast,please rate, review and
subscribe and share it with yourfriends.
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