Diabetes Math

Here’s a little math problem for you. Your 13-year-old T1 has been sick with a nasty cold for a couple of days. At 2 AM you wake up to Dexcom alarm and see that your T1’s BG is 275 and trending up. You get up to give her a correction bolus. The pump says you should give 4 units of insulin for correction to bring BG to target of 100. You also notice that there are 17 units of insulin left in the pod. Your T1’s basal rate of insulin is 2 units per hour and you will not be able to change the pod until about 7:30 AM. You have ruled out a site failure, determining that it is working more or less OK. You are able to administer insulin correction via the pump and/or via a shot. How much insulin do you give her? How do you deliver it? For a bonus question, how long will it take you to fall back asleep after you are done?

If you quickly run the numbers in your head, it looks relatively simple. 17 units of insulin in the pod minus 11 units needed to last until 7:30 AM minus 4 units recommended for correction = 2 units left to spare. Administer a 4 unit correction via a pump. Fall back asleep within next 15 minutes.

Nice try. You get an F in diabetes math. If you administer a quick 4-unit correction, you could probably get back to sleep in 15 minutes. However, you will be woken up again very soon because the BG will continue to climb up, the alarms will continue to blare, and you will have to do this all over again. Diabetes math is far more complicated than what it seems.

The remarkable thing about our little math problem is that every bit of information I provided is relevant and changes the equation. So let’s do it together.

Age and sickness are important. Teenage hormones are not kind to T1D and can lead to heightened insulin needs, sometimes unpredictably. Illness also causes BG to go up. Both factors, combined with the fact that due to illness V was sedentary for a couple of days, lead to increased insulin resistance. The pump is not programmed to change its calculations based on these constantly moving targets. It recommends the amount of insulin needed based on preset ratios and estimated active insulin remaining (AKA IOB or Insulin Onboard). So when you see a BG of 275 and trending up, under these circumstances you should think about how much more insulin it’s likely going to take to bring V into a better range. This knowledge only comes with experience and trial and error.

I know from experience that in this scenario 4 units are completely insufficient. I also know from experience that when V’s BG is over 250, insulin resistance kicks in like there’s no tomorrow. And let’s not forget that her illness, hormones and lack of activity are also contributing to insulin resistance. This is time to dose aggressively. Not only will you need to give a much bigger correction, you should also increase basal insulin for a couple of hours. How much? Once again, informed by trial and error data, we need to jack it up to 200%. If you do the math again, you will quickly realize that 17 units left in pump are not enough.

Here is the answer. Give a correction of 7 units via a shot. Not only does it save you insulin in the pod, it delivers it more quickly and bypasses any potential absorption issues with pump site. The extra 3 units over the recommended 4 will account for insulin resistance and for the fact that by the time insulin starts working V’s BG will already be around 300. Then, increase temp basal rate by 100% (to 200% total) for 2.5 hours. ¬†Three hours would be ideal, but there is not enough insulin left in the pod. 4 units for 2.5 hrs, plus 2 units per remaining 3 hrs equals 16 units. V will make it to 7:30 AM with only 1 unit to spare.

Mind you that you do this math in your head at 2 AM because you can do this shit like a boss. Then you go downstairs to get insulin vial and syringe. You go back up and turn on the lights. You are fully awake now, and you better be fully awake because you have to draw the inulin and do the shot. You go back to bed hoping that your math is not off by too much. Experience tells you that in this particular scenario you may not have given enough insulin (believe me!). Forget target BG of 100. Due to illness you haven’t seen it for a few days. Your goal is that 1. BG will start trending down instead of up and 2. at 7 AM V will wake up with BG closer to 200 than 300. But it’s 2 fucking AM and you need to go back to sleep. Which, to answer the bonus question, takes you at least one hour.

When you wake up in the morning, while you may be feeling tired, foggy and grumpy, you are rewarded with an A in diabetes math.

BG peaked at 300 around 3 AM and went down to 182 by 6:45 PM. GOALS MET!

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Sometimes we nail it…

…and sometimes we don’t.

Thanksgiving yesterday was ok diabetes-wise, but definitely not on the “nail it” category. V was low around lunchtime. She ended up over-correcting and/or over bolusing. And we were too busy to pay any attention to her BG in the afternoon. So when we were about to sit down for dinner, we realized that her BG was less than optimal, in the 200’s. We made the best guess in carbs and she bolused. She continued to go up past 300, then began trending down. When it was time for dessert we gave her a shot. And we over-did it. She was dropping, dropping, dropping. And so she had some juice and a bite of pie and we suspended her insulin delivery. And…you guessed it… we over-did it again. We were up a couple of times at night dealing with Dexcom alarms and administering corrections for high BG.

Oh well. T1D is a jerk and doesn’t care about holidays. On the upside, because she was having fun with friends, the glucocoaster didn’t seem to affect her much. And she ate everything she wanted. So FU T1D.

Thanksgiving glucocoaster ride

SWAG brag

SWAG is a very important Diabetes term of endearment. It means Scientific Wild Ass Guess and it is used when there is no carb info available and you have to make your best guess.

So, when you take your T1 kiddo for some ice cream that was her promised reward for an outstanding swim meet performance, but then you realize that her BG is not optimal for ice cream…

…you take her anyway because a promise is a promise. And then she orders a milk shake, which is OK because a promise is a promise. So you SWAG the carbs at 100 g. (!) And she needs to give herself a shot because it’s a shit load of insulin and there’s not enough in the pump at the moment. Besides, a shot is more effective because she’s high already.

She does the shot without complaining and enjoys the hell out of her shake. But you still second-guess yourself and wonder if you should have given even more insulin.

Then a couple of hours later you ask her to check BG and BAM ūüí•

NAILED IT!

Highabetic Rectosis

Back a few months ago, V was dealing with a lot of stubborn highs. Now, highs are no fun. V feels crappy, and hangry, and rageful. One evening, after trying to weather another episode of her 300+ BG-induced hungry rage, when she really wanted to eat something but would keep rejecting any and every carb-free or low-carb options in the utmost tantrumy fashion, I turned to internet for help. I posed a request to one of the diabetes Facebook groups I belong to: please help me find a new diabetes term of endearment that describes someone who has high BG, is really angry, emotionally volatile and unreasonable as a result, and really hungry on top of it. The community responded with great enthusiasm and some outstanding suggestions. The clear winner was highabetic rectosis: high blood sugar and acting like an asshole. I do realize the hunger is not clearly reflected in the term, but I embrace it nonetheless. And I’ve made a conscious effort to make the term a part of our diabetes vernacular, as well as expand on its meaning.

For example, highabetic rectosis can also mean T1D being an asshole and causing high BG to not budge. Usually at the most inopportune time, and despite our best efforts to beat it down.

 

 

Highabetic rectosis can alternatively be defined as feeling like ass when BG is high.

 

 

Highabetic rectosis can also mean that all low-carb and zero-carb foods taste like ass when BG is really high, because all that is desired is ALL THE CARBS!

And in yet another definition, and perhaps my favorite, highabetic rectosis means becoming a total wise ass when discussing high BG. Like when your daughter screen caps your text convo and adds this astute wise-ass comment:

Sleepover: Behind The Scenes in 20 Screenshots

Sleepovers are the bane of my existence. It’s hard enough to manage T1D when V is sleeping a few feet away in her room. When she is elsewhere, we become the 24-hour on-call support and security center. Some nights are completely uneventful. Other nights we barely sleep. This is another invisible aspect of diabetes management, which most people are hardly aware of. I’m about to give you a little glimpse of what it takes to manage misbehaving BG when V is sleeping away from home.

V spent last night at her friend’s house. Before she got there, the daytime BG was fairly good. Trouble started brewing around dinner time.

So everything got back on track. Or so we thought, because at 9:52 PM…

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IOB = Insulin On Board, or amount of active insulin in her body.

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It pains me that I have to tell her to set the alarm to wake up in the middle of a night on a sleepover! What other kid has to do it? But it’s her life.
So at this point we have a plan and I am trying to get some sleep. When I open my eyes an hour later and check Dexcom, I do not like what I see, so I text V again:

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IMG_E5952.jpgI’m fighting to stay awake while doing complicated diabetes math. We need to override the pump and give more insulin because she is so high. But I don’t want to send her plummeting to a low either, especially because she is not at home!

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All that careful math, and still… She went from 400 to 225 with two arrows down in 45 minutes. And now she has a lot of active insulin in her body. Time for opposite action!

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So now it is about 1 AM. I have been sleeping poorly in 45 min increments, waking up to glance at Dexcom and make sure V is OK. I’m hoping that finally we can get things stabilized. I get to close my eyes for a couple of hrs. Then I wake up to Dexcom high alarm at 3:38 AM.

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Clearly something is not working with the pump. Absorption issue? Bubbles in the cannula? Who knows? It’s not completely useless, it’s obviously delivering some insulin, or else V’s BG would keep climbing even higher and higher. What we do know is that an injection of insulin can do wonders to bring BG into a better range. What we also do know, from the prior few hours, is that the same amount of insulin administered by the pump has been fairly useless. Understandably, V is not at all thrilled about my preferred course of action.

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V – if you are reading this, please realize that when this happens at home, I get up and give you a shot. And then I also change your pod. Usually you sleep through most of it. It sucks but it needs to be done.

I do not hesitate to put on my mean Mom hat. Also, by now we’ve been texting for nearly half an hour, it’s almost 4 fucking AM, and I have neither patience nor energy.

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I know V is really tired, mad at me, and in extra bad mood because her BG is so high. But for the record, what I really want to do is to launch into a tirade of how dare she does not appreciate how much I do for her. In all caps. But I know better because really, it is so, so hard on her. She may not believe me but I get it. So I suck it up and let her vent, try to keep my cool, and make sure everything is taken care of.

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At this point we both crash. When I wake up in the morning and check Dexcom, she’s OK. Not great, but somewhere around 200. Good enough.

By the way, the other bane of my existence is cropping and editing 20 screenshots. But if it helps you understand what we sometimes have to go through, it’s all worth it.

#makediabetesvisible 

 

Random, with a chance of foul language

No, not T1D, though it can definitely be that way…

My hubby asked me the other day if I was running out of ideas for this blog. Nope, plenty of ideas, but little time or energy to organize them. But then I thought, why not use this post as a giant dump of all some things T1D and gluten-free that have been occupying my head space for a while? So her we go, in no particular order.

Parental distress and T1D

In regards to the findings of this research study, which was the topic of another Insulin Nation article (not written by me): no shit Sherlock, T1D parents are stressed out. I think healthcare professionals forget about it so much that we need to have research from Yale to show them that it’s a real thing. But some parents were up in arms about the 33.5% average of people who reported distress. Only 33.5%?!

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An average can be rather useless. (Quick demo: you take a test and get a 10; I take same test and get a 90; our average is 50.) The researchers pulled and aggregated data from various studies that used widely different measurements of distress, from general parental distress to PTSD and clinical depression/anxiety. And the prevalence ranged from 10% to 74%. Most likely 74% reflects prevalence of more common and general distress, while the 10% is a figure more reflective of a clinical diagnosis. So the 33.5% means nothing, so let’s please not focus on it and instead focus on how to help T1D parents find the support they need, OK?

A recent gluten-free find that made me insanely happy:

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Refrigerated cookies ready to bake. Take them out, lay them on a cookie sheet, bake for 12-15 minutes. Perfect, easy, and so unbelievably good. Available at our local supermarket.

I made them for our fabulous New Year’s Eve celebration.

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I was going to take better pictures of these beauties but by the time I got around to it they were all gone. Eaten. Devoured. I got to inhale a few crumbs. Also, I’m too lazy to get off my chair now to look in the freezer, where we have a small stash, and look up the¬†carb count. It doesn’t matter anyway, they are carb-worthy.

(Speaking of things that are gone… Remember my love letter to Trader Joe’s meat sticks? They had issues with supplier and no longer carry them, and may never ever again carry them. Which makes me really sad. Good thing we have these wonderful cookies to cheer me up.)

When there is a real problem with the pump

Like, when you put more air than insulin in the pod, and the pod does not realize it, and it keeps thinking it’s delivering insulin whereas in reality it’s delivering insulin-flavored air, this happens:

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Fortunately we caught on quickly enough and rectified the problem within hours. It involved changing the pod AND doing an old-school injection to speed up insulin delivery.

Ted Cruz, you are an asshole

And an ignorant one, at it. Let me be more specific: I am referring to his promise to remove gluten-free food from military, because it is just PC or a social experiment. Of course gluten-free is just a fad and the US military is trying to keep up with the Joneses. Headdesk. Facepalm. OMGWTFBBQ.

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Diabetes Awareness Month, Day 28

Today I’m going to re-post something from last year. It popped up on my Facebook newsfeed. First, I laughed. Then I realized that I posted it exclusively on the Facebook page. So I’m actually going to transfer it here instead of simply linking to the Facebook post.

Diabetes Awareness Month, Day 28. I think yesterday we discovered the devil of Diabetes, aka the T1D equivalent of 666. But we were unintimidated and taught it a good lesson. Story in pictures below:

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Dexcom alerted us to a high. It does not read BG above 400, so this was bound to be interesting

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Behold the T1D equivalent of 666
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The logical course of action – exorcism! Exorcism here being defined as expelling diabetes devil via exercise.
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And it started working quickly…

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An hour and a half later exorcism was proclaimed to have been successful. See ya, devil. You are not a match for us!

I should add that of course some insulin was required to finish beating diabeetus into submission and bringing V into a healthy BG range, which was accomplished in no more than another hour. Without strenuous exercise it could have taken double that time to get BG under control.