Tuesday, April 8, 2014

Antibiotics

The sniffles and cough started last weekend.  "I feel fine, just stuffy," was the report.  We started the allergy medicine, assuming the start of spring was to blame. On Wednesday she woke with a disconcerting fever of 102.5.  The pediatrician did an exam and a strep test, and diagnosed a virus.  "Keep giving her Motrin and plenty of fluids."  I wasn't convinced, but we took that route for a couple of days. When she still had a cough and a fever of 102 on Saturday morning, I took her back to the doctor's office. To add insult to injury, her blood sugar had been hovering around the 250 mark for 3 days despite aggressive corrections and temp basals.  

The practice's other doctor had pulled the Saturday shift. I elaborated on the recorded chain of events, and emphasized my concern that nothing about her condition had changed in the past three days.  My stubborn skepticism about the virus idea led to a more careful look.  "Looks like she has a little ear infection. I'll put her on an antibiotic."  She thought for a while.  "I'm going to give her one that works on ear infections but which we also give for upper respiratory infections and mild pneumonia.  Her throat is very red and her lungs don't sound great either. This medicine should take care of anything that's going on."

Observing Saturday's Dexcom graph below, you'll see an ugly pattern in the first 18 hours.  This is indicative of the previous 3 days' patterns as well.  No tactic we attempted proved to be a match for the havoc this illness was wreaking on her blood sugar.  Her first dose of antibiotic was at noon.  We did nothing different that afternoon, diabetes-wise.


Exhibit A

She spent Sunday primarily below the (admittedly inflated because we couldn't stand the constant alarming) line.  Everything was not awesome all day long, but comparing the two is like looking at two different people's dexcom receivers. 



Exhibit B

The fever was gone by mid-day Sunday and so was the lethargy of illness.

I know the medical community is increasingly wary of prescribing antibiotics, recognizing that their overuse can cause problems on both individual and global levels.  These are important concerns.  But sometimes there's an actual infection and an antibiotic is needed. Had an antibiotic been started on Wednesday, we wouldn't have spent 3 days beating our heads against the wall fighting unfightable high blood sugars. And she wouldn't have spent so much time on the couch instead of at school, or out in the spring air.

But I suppose she wouldn't have been introduced to Gilligan's Island.

Tuesday, April 1, 2014

The Adrenaline Was A No-Show


Last year's school musical provided us a glimpse into how blood sugar can be influenced by adrenaline. Last year's performance excitement led to numbers in the 300's both nights of the show.  These highs, it turned out, needed very little insulin to correct them.  Having learned from our mistakes, we put together a game plan for this show. I was particularly concerned since this year's role involved first lines in the middle of the first act but a more significant part including solo singing during the second half.  If my daughter's blood sugar spiked in Act I, we needed to be very careful not to over-correct.

I was excited, in a nerdy science-y sort of way, to watch the Dexcom graph.  Would her blood sugar start to go up before the show as she started to think about being on stage, or not until she was the one in the spotlight?  Would it start to go down again as she relaxed during intermission, or would it stay up through the show?  How would our game plan to keep her from having a performance impacting high without causing a performance impacting low work out? How cool would it be to be able to use the Dexcom information from opening night to tweak our game plan for the next day?

We'll never know. We talk often about how everybody's experience with diabetes is different.  Activities and foods which may spike or tank one person's blood sugar may have no affect on another's.  What makes even less sense to me is that one person's own experience with diabetes can vary over time.

This year's blood sugar impact?  A gentle decrease throughout the show despite an intermission snack of three glucose tabs (yum) each day.  Mysterious, indeed.  While last year's show was her first, this year's role was significantly bigger, even involving running off stage for a stressful costume change in the middle of a solo song.  The spotlight was directly on her for several minutes at a time.  My adrenaline was pumping just watching her!

Whether you're a boy scout or not, today's diabetes lesson is this:  be prepared.  We did everything in our power to ensure a quality blood sugar number for the start of the show. She had her pump's meter remote backstage so she could gently correct the anticipated high blood sugar through her costume.  We arranged to text during intermission to decide a dose.  Fortunately, we'd planned for any eventuality. Her bag was also stocked with plenty of glucose tabs and juice boxes.  We were quickly able to switch gears to prevent an onstage low blood sugar.  Otherwise she'd have had to rely on Willy Wonka's pink candy boat, and Willy would have had to admonish her once again:

"Violet, please do NOT lick the boat.  You'll only make the ship sticky."

Monday, March 24, 2014

Dexi Sings Queen


Saturday night went a little like Queen's song, 'Bohemian Rhapsody.'

My daughter's Dexcom, 'Dexi,' buzzed around 1 a.m.

Caught in a landslide
No escape from reality
Open your eyes
Look up {to the skies} and see

I squinted at Dexi's message:

"LOW"  How low?  I clicked to see the estimate.  "67."

I shuffled off to my daugher's room.

Flashlight, meter, test strip, lancet.  "207."  Huh?

Is this the real life?
Is this just fantasy?

Back I went to grab Dexi from my bedside table so I could set her straight.  I informed her of the meter reading, and she asked for another.  Once I'd put that in, the graph showed a reasonable '193.'

As I started do doze off again, the buzzing resumed.  "HIGH"  "275."  Unconvinced, I checked anyway.  I informed Dexi both through her computer buttons and verbally with a few choice words, that "170" was the number she should be aware of.  An apology would have been nice.  Something like

Mama, ooo
Didn't mean to make you cry.

No apology was forthcoming, but she did get herself straightened out by morning, having overcome her night of ambivalence.

A little high, little low
Anyway the wind blows, doesn't really matter to me...to me.




Friday, March 21, 2014

Relentless


We're going through a stretch of very active diabetes management here, and it's exhausting.

Don't get me wrong.  We're always managing diabetes; all day, every day.  It's just that sometimes it fades into the background a little bit.  This isn't one of those times.

At February's appointment we were surprised by a creep up in my daughter's A1C.  Nothing dramatic, mind you, but worth working on.

Suggestions to address this problem were discussed at our appointment, and we implemented them right away.  Then she started eating.  Everything.  She's growing noticeably taller by the week.  At every appointment lately, the endocrinologist has reminded us that her total daily dose of insulin is likely to double in the next couple of years.  At this rate it'll double by the time we see him again in May.

Her basal rates and insulin to carb ratios are going up and up. With these changes come increased finger sticks and dexcom alarms, the return of the log sheets, and an extraordinary amount of thinking.

I'm trying to meal plan and grocery shop more carefully too.  Countable carbs and balanced meals are important so that we know if the insulin changes we're making are right.  The fewer variables in that equation the better.  I'm also trying to fill her up, so that she's not looking for a snack an hour after dinner. If she does want a snack, I want to have healthy, filling choices on hand.

I'm hearing from the nurse's office at least once a day for a high or a low.  Then she's at play practice until five or six o'clock most days after school, so we're managing snacks and dance induced lows via text all afternoon. Meanwhile we're spending time figuring out how to include her diabetes equipment in her play costume. But who doesn't love a challenge?

The sedentary lifestyle of winter is giving way to the activity of spring.  Yesterday was the first outdoor recess since November. She's walking home again when she doesn't have play practice.  Schedule changes and field trips are creeping back into the school days.  So are juice boxes.

Factor in what feels like more than our fair share of diabetes flukes like the other night's 2 a.m. site change, and it feels like it's all diabetes, all the time here.

Which it is.







Tuesday, March 18, 2014

Why We Look Tired Today


My daughter called from school mid-afternoon yesterday to report a blood sugar in the 300's.  "Correct it and we'll see what happens by the time you get home," I suggested.

"Why do you think I'm so high?  Do you think it's the site?  I can't see it too well."

"Maybe. You've been high lately in the afternoons anyway you know.  Not this high, but let's see what happens. You'll be home in less than 2 hours."  By the time she got home, she was 82.

I didn't think of it again, at least in terms of it being an urgent problem.  I recorded it on the log sheet and vowed to take some time this week to look at the after-lunch time frame.  Her dinner number was good, and after dinner wasn't terrible either.  By 10 she was creeping up to 200-ish, which I corrected.

At 1 a.m., the Dexcom was buzzing.  HIGH.  She was 310 and apparently I'd slept through it's first attempt to alert me.  I got up, confirmed the number, and corrected.

By the time I got back in bed, the wheels were turning.  Was it the site?  Why hadn't I looked at it when she got home?  What else could be going on?  She had some Irish Soda Bread after dinner for which I approximated a carb count, but I can't imagine I was that far off.  We've been changing basal rates overnight and things were starting to even out.  What was with this number?

For some sleep-muddled reason I chose to wait out the correction and see what would happen.

Forty-five minutes later, she was higher with a diagonal arrow up.  I un-snuggled her from her covers and unceremoniously peeled back her pajamas to take a look.

"Ick" is the G rated version of the mumbling which ensued.

I gathered the super-sized flashlight and the site change supplies.  I woke her (which is her preference...I know of people who simply proceed with site changes while their kids sleep).

"You're super-high, sweetie.  I need to put in a new site.  I'm sorry I had to wake you up."

"(Unintelligible mumbles) I'd rather get up and do it.  You can just turn on the light," she said in a disgusted yet somewhat understanding voice.

I got the new site in and operational as quickly as I could and tucked her back in with a kiss.

Now, how to do the "math" to lower the blood sugar?  I'd corrected this number once, but nothing had happened.  The pump now suggested only a small amount of correction because so much insulin was on board.  Some of that insulin had probably been delivered, but certainly not all.  She'd likely missed some basal insulin too from the gunky infusion set.  I looked at the suggested dose and compared it to the total dose the pump told me it would take to drop her back to her target blood sugar. I picked a number in between and pressed 'o.k.'

An hour later, I was still awake but happy to see her blood sugar slowly trending down.  At 3:30, Dexi roused me from my dozing.  "FALLING," she said.  The actual blood sugar was still in the low 200's, but insulin was infusing and doing it's job.  I finally fell asleep.

The story has a happy ending.  Her blood sugar at breakfast was 120.  Now for another cup of coffee.


Monday, March 17, 2014

Measuring The Rice


A household favorite weeknight dinner this a one-pot teriaki dish.  The recipe is on the back of the Minute Brown Rice box if you're interested.



I love the ease of making and cleaning up this meal, which is ready in 20 minutes and, true to its name, uses only one pot.  The odd yellow color is a feature of amateur photography, not of the dish itself.

The trouble with this dinner is with the serving of it.  Since the carbs are primarily in the rice, but in the end all of the ingredients are mixed together, serving my daughter's portion takes some time.


First, I find a half cup measuring cup since that's about how much rice she eats.



Then I push stuff around in the pot, attempting to separate enough rice from the other ingredients.


Finally, a half a cup.


Now to add the rest of the ingredients and toss it all back together so it looks like everyone else's.

Every day there are many weighty reasons I wish for a cure for diabetes.  But I must say I won't miss these little annoyances one bit.

Wednesday, March 12, 2014

Hello Ketones


She was awake early with stomach cramps, nausea and a low grade fever. She felt miserable. On the bright side her blood sugar was quite reasonable.  I relegated her to the 'sick corner' of the sofa with the remote and a cup of peppermint tea.  

I proceeded to make the requisite phone calls, and coffee.  Then, ironically, I had to go to the school anyway to drop off dessert for lunch with a visiting author. On the way home I stopped at the convenience store to pick up a low-carb sports drink.  

Arriving home, I had my daughter check her blood sugar again.  Then it occurred to me (belatedly, I know) to check for ketones too.  I dug the blood ketone meter out of the diabetes box.  A quick drop of blood and the result read out.  '1.2.'

"That seems pretty high," I said vaguely. We check ketones during illnesses, but it's been years since she's had any.  I did some quick research. 'Moderate' was the official term I was looking for.  We needed to take action quickly or things would go from bad to worse.  Meanwhile, her blood sugar was down to 120. She needed insulin to help clear the ketones, and therefore she'd need to take in some carbohydrates to balance it out. 

I calculated a generous insulin dose and she managed to get down 15 carbs of ginger ale.  I then provided her with a cheerful travel cup full of the diet sports drink. She sipped as best she could to start washing those ketones out of her system. The combination of insulin and hydration began to work their magic. We were soon out of the woods.

What struck me about this incident was how unprepared I felt for it.  My instinct, when I didn't know what that ketone reading meant, was to time travel back 11 years and dig out the booklet our children's hospital gave us when she was diagnosed. The chart was right where I pictured it, accompanied by lots of helpful advice which helped me deal with the problem.  Yet questions remain.

Should I be relying on 11 year old information or are there newer protocols?  Would it be worthwhile to review sick day plans at our next endo appointment?  Should plans for various emergencies be reviewed every couple of years as a rule?

Hopefully it will be another few years before I need this information again, but I don't plan to wait that long to refresh my memory.