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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What you won’t see

Not all lows are created equal. Sometimes the number is ridiculous but V barely feels it. Other times she’s in the 60s but scares the crap out of me when she wakes me up with this text in the middle of the night:

And then there is a video saved in my phone that may never see the light of day. We went to dinner with V’s swim teammates, parents and coaches. SWAGed the carbs and overestimated big time. On the way out of the restaurant V started to feel really low. We walked to the car to the soundtrack of blaring Dexcom alarms. I gave V some fast acting sugar and decided to wait it out until she was stable and feeling better. It was a long one and…interesting. If you didn’t know better, you’d think that I got my 13-year-old drunk. She was silly, giddy, giggly, goofy, and decidedly not her normal self. I’ve seen her act silly during a low before but this one was something else. So, after giving her some more fast acting sugar, I turned into that parent and started recording. She was acting like a happy drunk and at the same time she was feeling utterly crappy. We sat in the car for a while until her BG stabilized and went up, and she started to act more like herself.

I’m keeping the video for our own records. We talked about the importance of being very thoughtful about ever sharing it with anyone. There is a part of me that wishes I could share it, for the purpose of educating others about how easy it may be to mistake symptoms of hypoglycemia for intoxication. There is nothing inappropriate about it, but it feels really personal. So at least for now, it’s best to keep it for our eyes only.

The “before” picture

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

Another sleepover story in screencaps

Once upon a time, on a lovely September day, V went to her friend’s house for sleepover. We made sure to put a new Dexcom sensor on a few hrs prior so that it would be working well and give us a peace of mind. V went to a sleepover and everything was perfect and everyone slept soundly and lived happily ever after…

Hahahahahahaha. Right.

Mere couple of hours into the evening, and following some pool time, I get this text

Great. We didn’t pack an extra sensor because it was not supposed to just fall off. No Dexcom, no remote monitoring possible, no easy access to BG data and trends. OK, time for Plan B!

Then it was time to figure out night time strategy. If Dexcom was working, we could rely on it to alert to any issues at night. Alas, no such luxury.

Don’t you love it when you have to ask your 13-year old to wake up at 3 AM to check her BG? I felt that this occasion called for some serious sarcasm.

And back to business…

Seriously, whyyyyyy?

Promptly at 2 AM…

At least things were more or less on track. Luckily no more checks or wake-ups were needed.

When we finally spoke in the morning, it was alright…

The End

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 

 

Awareness, More Awareness…

Oh hi there! Come here often? I was totally shocked when I realized my last post was at the end of August. Has it really been that long? I guess I put a few things here and there on my FB page, but haven’t blogged in a while. November is Diabetes Awareness Month and in past years I’ve been blogging up a storm. This November I’ve stayed pretty quiet. I don’t have time or energy to post every day (or every month – HA!). I was not going to post anything today either but blogging material landed on my lap.

V’s diabeetus may have been feeling neglected, because just as World Diabetes Day got started on November 14th, diabeetus decided that we needed more awareness of it. To that end, Dexcom low alarm went off. And boom – one minute we are sleeping peacefully  and completely unaware, the other minute we are totally aware!

What a better way to mark Wold Diabetes Day than to battle lows in the middle of the night. (That was sarcasm.) Why was V’s BG so low? Diabeetus, that’s why.  According to all rules and logic it should not have happened. She went to bed at a solid 80 with no active insulin in her body and trend arrow holding nice and steady. She has walking pneumonia, which technically could have/should have raised her BG overnight, not lowered it. And in the past few days she’d been steadily going up overnight, even if she started with a good number before bed. We have not made any recent changes to her pump settings. We have not administered any insulin at bedtime. And yet, we had to pump her with four glucose tabs and suspend insulin delivery for an hour, and it took us about 3 hours to stabilize her BG and get it into a safe range.

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Over the course of 3 hrs alarms kept blaring. We kept getting up. V kept waking up. We poked her fingers multiple times. We could have given her more sugar right away but we did not want to over-treat and end up with an epic high, so we kept monitoring and doing it one step at a time. It was stressful and exhausting. Welcome to another night in our humble T1D adobe.

So why am I writing about this now, you may ask? Because I want to bring to light something that we don’t often talk about. What happened last night is great example of “shit happens, T1D edition.” People with diabetes have to face a lot of judgment. One reason for it is an assumption others often make that the person is doing something wrong: they are not eating well; not exercising enough or exercising too much; they are not following their doctor’s orders; they are not taking the correct amount of insulin. That surely there is a way to get BG under better control, to prevent most highs and lows, but the person is not making enough effort.*

Sure, there is always room for improvement and better glucose control. But what I want you to understand, really want you to understand, is that there are times when T1D makes absolutely no sense, follows no rules, and is completely unpredictable. Like last night, when it decided to act like a jerk, just because.

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The one thing I really want you to take away from this post on World Diabetes Day is that diabetes management has so many moving and unpredictable parts. Please don’t assume, never ever assume, that the person with diabetes or their caregiver are doing something wrong or not doing enough. And be prepared that if you ask me “why”, the only answer you may get is “diabeetus, that’s why.” Usually delivered with a shrug.

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*Disclaimer: People with Type 2 diabetes have it one hundred times worse when it comes to these types of judgments and assumptions. Sadly, sometimes it’s my fellow T1 peeps and parents who, in their defensive reactions of “I/my child did nothing to get T1D!”, throw fellow T2 brothers and sisters under the judgment bus. But that’s something to address in a separate post.

 

Diabetes Blog Week Tuesday: The Other Half of Diabetes

We think a lot about the physical component of diabetes, but the mental component is just as significant. How does diabetes affect you or your loved one mentally or emotionally? How have you learned to deal with the mental aspect of the condition? Any tips, positive phrases, mantras, or ideas to share on getting out of a diabetes funk? (If you are a caregiver to a person with diabetes, write about yourself or your loved one or both!)

Emotions. There are so many emotions surrounding diabetes. Her feelings. Our feelings. The feelings of everyone involved. Mental and emotional aspects of diabetes are tough, maybe even tougher than physical aspects. Because you get used to blood, and needles, and finger pokes, and bionic parts, and beeping. And, come to think of it, it’s more visible, more tangible, more straightforward. The emotional stuff is trickier, harder to notice, harder to understand.

Lots has been said about stress and burnout of T1D parents. I’ve written several posts about it before. When we are on our best behavior, we handle well. So much so that I wrote a column for Insulin Nation on tips and tricks on handling burnout.

But enough about us. Let’s talk about V. While she’s generally a rock star and takes it in stride with remarkable resiliency, humor and optimism, it’s not always easy. What makes it even more complicated is that in addition to managing emotions about diabetes, she has to manage emotions directly caused by diabetes.

I remember how several weeks leading up to V’s diagnosis we noticed that she became really emotionally volatile. There would be meltdowns seemingly out of the blue, over-blown reactions to minor things. She’d be sent to her room, raging and sobbing, acting and feeling completely out of control. My husband and I watched in bewilderment. What was going on? Was this a preview of what is to come in adolescence? But she’s only 8 years old, how can it be? But then I’d talk to some friends and they would share how their daughters sometimes acted the same way. So maybe it’s normal girl drama? But V was fairly even-keeled before. Something did not make sense.

We’d talk to her, trying to help her manage her feelings and behaviors. What is going on? We just want to understand so that we can help you. She could not explain. She’d be sobbing and telling us that she did not know why she was so upset or angry, and that she could not control it. It was especially bad around mealtimes. Suddenly hunger became intolerable, an almost certain trigger for an epic emotional meltdown.

T1D explained it all. V’s undiagnosed BG swings created tsunamis of mood swings. Highs translated into intense and uncontrollable rage with a generous side of strong upset. Lows brought out the whining, complaining and crying at the drop of a hat. But at least now we knew what was going on and we felt more empowered to handle it.

Not that it’s straightforward. How do you tell a difference between a “high angry” or “regular angry”? How do you know when the tears come from feeling beat and tired due to a stubborn high or low, or due to some unrelated upsetting event? How do you tell “hangry” from bad attitude? How do you know when to hug and comfort your child or when to discipline her for talking back or lashing out?

Helping a T1D child manage her emotions requires us to rely heavily on trained intuition. If something feels amiss we must first rule out BG as the culprit. “When in doubt, test BG” is our go-to motto. Another one we had to adapt quickly is “Don’t make decisions when you are high.” Closely related is “Don’t try to deal with a conflict when you are high.” And there’s always the good old “FOR CRYING OUT-LOUD DON’T JUST SIT THERE, TAKE A FAST ACTING SUGAR!!!” Wait, that’s not a strategy, it’s our own reaction. Because you know what, when you are a parent operating in an exhausted and sleep deprived mode, sometimes the last thing you want to do is be in tune with your child’s emotions. You just want your child to listen, comply and “act normally”. As you may have guessed, this does not work out well.

In some ways things have settled down a lot since diagnosis. Now that V’s BG is more tightly controlled, these meltdowns are far less frequent. Her emotional reactions are still very much affected by highs and lows but we all spot and understand them better. In other ways, things are getting more…well…interesting. Puberty is fast approaching and that emotional volatility is inching up regardless of what diabetes is doing. It’s for all of us to figure out. Even in V’s 504 there is a line addressing behavioral aspects of diabetes, and instructions to test BG if V’s behavior appears out of character before considering any disciplinary actions.

The roller-coaster continues. Strap yourselves in, it’s one hell of a ride.

The only roller-coasters I approve off.

The only roller-coasters I approve off.