A Long Night

It's 10 p.m. The teenager has been home for an hour from band practice. She has showered and is thinking about going to bed. She checks her blood sugar in order to calibrate the Dexcom.

"WHAT?!?!"

The parents watch warily from the couch while the teenager gets another test strip and rechecks her bg.

"WHAT IS GOING ON??? HOW IS THAT POSSIBLE??? HOW DID THAT HAPPEN???"

The teenager is distraught.

"Mom...can you help me do a site change so it goes faster? APPARENTLY I'M 485."

The mother rises wearily from the sofa, her plans for quiet time with her book followed by a good night's sleep dashed. She fetches a large glass of water for the daughter, in hopes of keeping ketones at bay.

"Yup. Drink this first. What happened do you think?"

"I DON'T KNOW!!!"

The teenager is grumpy, irrational and teary. Probably because of the blood sugar of 485. She gathers herself for a moment.

"I don't know... I was fine at dinner - 130 something. I don't remember Dexi alarming at band but it must have. It alarmed again a little while ago. But not that high. It's been iffy all day- it's like 10 days old - but I didn't know it was that far off and now I'm really high and I don't know WHY!"

The mother and teenager go off to the teenager's room to change the site. The chain of events leading up to the current situation is reviewed.

"I bolused dinner - I'm sure..." opens the pump's memory and double-checks "yup- and it wasn't a lot of carbs and you used the measuring cup. And then I just went UP! And I didn't eat anything at band- I just drank my water and I never had anything when I got home and now I'm SO HIGH FOR NO REASON."

When the site is removed the cannula is gunky, clearly clogged up. The mother thinks out loud.

"I don't think, in 13 years of pumping, you've had a pump site conk out that quickly. Usually they take a gradual turn for the worse, but this one seems to have suddenly and completely stopped working. That's the only logical explanation to go from 130 to almost 500 in 4 hours."

The teenager curls up on her bed, nursing her second pint of water. She is clearly miserable. She complains of a headache.

"... not just in one spot but like...my whole head...it just hurts...it's awful."

The mother initiates calming conversation … a friend's new puppy, a funny story someone posted on Facebook. Eventually, it's been 30 minutes since a correction dose of insulin was given. The teenager rechecks and is now just barely over 400. She gets up to brush her teeth and finish preparing for bed. The Dexcom alarms... FALLING! … and hope increases that the correction dose will work.

The teenager goes to bed. The mother gets to read her book, but for much longer than she'd intended, staying up until 12:30 a.m., when the blood sugar has dropped to 230-something.

The mother is awakened at 2 a.m. by the Dexcom alarm (which is now, incidentally, spot-on again) and gives the teenager some juice for a bg of 76.

The father gets up at 3:45 to give more juice for a bg of 68.

The family gets up in the morning. The teenager has a bg of 77. They are all tired. They are all grateful for the discovery of insulin. But moreso now for the discovery of caffeine. .

What Happened in Vegas

Last week's spring break adventure was a colossal road trip beginning and ending in Las Vegas.  As usual, we dragged diabetes along for the ride.  Between the restaurant food and the time change, there was an incredibly wide range of blood sugar numbers but thankfully no major disasters.  Until the last night of our trip.

My daughter's blood sugar was an amazing one-something-something after thoroughly enjoying the Golden Nugget buffet. We checked out the light show on Freemont Street and then walked back to our room leaving the remaining adults our party to enjoy the casino before bed.

No alarms were set.  We relied on the Dexcom to alert us of any problems.  At 4 a.m., it buzzed.  The first buzz is supposed to mean she's crested over 200, and that's what the graph showed.

I located the meter and the flashlight.  '505' read on the meter screen.  It was so far from what the Dexcom said, I thought there must be buffet residue on her fingers.  I wiped a different finger as clean as I could.  '485.'  So, in my less than awake state, I plugged that number into the meter remote and gave a bolus.  Then I thought about it.  Something must be wrong.

Indeed, a glance at the site confirmed it was done for: a bloody mess.  So, at 4 a.m. in a casino hotel room, I dug out a new set and woke her up.  She further confirmed she was very high by immediately chugging half a water bottle.  We inserted a new site by flashlight so we wouldn't fully awaken my husband. Why didn't we just do it in the bright light of the bathroom, you might ask?  We were half asleep, clearly, since the idea didn't occur to me until just now.

I then guessed at another correction dose, balanced by what might or might not have gone into the bad site a few minutes before.  She was in good shape by the morning, and in the end I'm grateful that it didn't happen earlier in the trip.  I wouldn't have wanted to be overtired here:

At Least We Got A Treat

My grandmother was clumsy.  My mother was clumsy.  I have inherited this gene.  And as I get older, the consequences become more dire.  Last Wednesday's incident leads me to consider living the remainder of my days in a hamster bubble.

I was leaving a meeting at my church and walking to my car with something in each hand when I tripped and found myself airborne and parallel to the sidewalk.  With my hands full, and not as much reaction time as the slow motion vision of the incident going on in my head would suggest, my chin was the first thing to hit the sidewalk.  As I started to try to get up, I realized my chin was bleeding heavily and that my mouth and jaw had several significant injuries.

Thankfully, someone I knew came along who had been at the meeting with me.  He walked me back into the building where a friend helped me clean up and then took me to urgent care.  No stitches were needed, and x-rays showed no broken bones.  Follow-up with the dentist on Thursday showed that a disk which cushions the bones around the intersection of the right side of my jaw was intensely swollen and inflamed, making it impossible to open my mouth more than a crack.  I am still unable to chew, and brushing my teeth is torture, but with rest and a variety of treatments the problem should continue to resolve over the coming weeks. Then the dentist will be able to fix the broken teeth. 

I'm guessing you're feeling badly for me but wondering what this has to do with diabetes.  Read on:

As I lay on my sofa Thursday morning, everything hurting, the phone rang.  It was my husband calling from work, who had conferenced in my daughter calling from the nurse's office.  In tears.  "I'm 385 and I was 300 an hour ago and corrected it and we're doing jump rope for heart today so I've been jumping rope and my blood sugar won't go down and I didn't want to bother you and I know you're not supposed to talk, but I don't know what to do and the site looks pretty yucky and .... what should I do???"  

I took a deep breath (one of us had to) and mumbled through clenched teeth, "Sounds like it's probably the site.  Do you think you can do it yourself?  I'll come down there if you really need me to but if you think you can do it, now's the time to try." 

"I think I can." 

"Are you sure?"

"Yeah."

"O.k.  Make sure the nurse sits with you and watches.  Call me if you need to.  It's o.k.  And if I need to come down there, I absolutely will. But I definitely think you can do it."

When she did her first site change a couple of weeks ago, I never would have seen this particular need coming.  I envisioned a site falling out on a day trip with another family, or a failure during a night with grandparents while her dad and I were off doing something fun.  But here we were, me looking like I'd been in a prize fight and in intense pain on the sofa, and my husband an hour's commute away at work.  

It took only 2 more phoned in questions to accomplish the task (I don't have to prime again, right? Can I leave the old site in until I get home in case it's a gusher?).  By lunch time she was in the 200's and by mid-afternoon, back under that 200 line.

As our little family reconvened around the dining room table that evening, and I sipped my pureed lentil soup through a straw, my husband decided the day needed a happy ending.  It was the warmest evening yet, with the hope of spring in the air, so I was loaded in the car and we headed to our favorite ice cream stand.  My daughter enjoyed her first italian ice of the season.  My milkshake was the most calories I'd consumed in 36 hours.  It was a well-deserved treat. 

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.

CSI Summer Cottage

Setting:  A vacation cottage in a quaint New England seashore village.  Specifically  a child's bedroom in which all surfaces are draped in white and cream colored fabric including but not limited to the bedspread, rug, doilies, armchair cover and child's shorts.

Scene 1:  Mother prepares items for site change.  She draws up fresh insulin, gathers supplies from a large plastic bin.  Daughter assumes a position for comfortable site insertion and happily finishes a chapter of this summer's Harry Potter book. 

Scene 2: Unisolve adhesive remover is applied to the old site for easy removal and IV prep to a new site area for infection-free insertion.  Mother and daughter chat about the day's seashore adventures while the wipes do their trick.

Scene 3: Mother peels off the old site.  Blood shoots out of it, reminiscent of a fountain.  Mother screams, prompting daughter to scream.  Mother lunges for tissue box across the room, hands covered in blood.  She grabs a wad of tissues and presses it on to the gushing area.  Daughter performs yoga moves to elevate the affected area above her heart.  The bleeding slowly subsides.

Scene 4:  Damage is assessed.  Spots of blood are located on the white-covered chair across the room, behind the child.  A pool of blood is located in the bed frame in front of the child.  Spots of blood are also found in several areas of the rug, bed skirt, child's shorts and sheets.  Mother wonders aloud what cottage owners would assume had happened here if the blood could not be cleaned up.

Scene 5: Mother secures paper towels and cold water.  Scrubbing commences.  Daughter remains in a yoga pose with fresh tissues firmly pressed to the offending area.  The white arm chair cover seems most important to clean.  Blood is removed with surprising ease, giving mother hope.  Rug blood is scrubbed to the point of being difficult to detect.  The bed frame wipes clean easily despite a surprising large puddle of blood. The bed skirt is the only remaining item not belonging to the child.  This proves more difficult to clean.  Mother gives up and returns her attention to the child who still needs a new site inserted.

Scene 6: A new site is inserted without incident.  The old one has stopped bleeding but is covered in a band aid just in case.  More cold water, then a bleach pen are applied to the bed skirt, with adequate results. Mother then repositions it so a remaining faint stain is less obvious.  The sheets have blood stains already from nightime fingersticks, so mother decides they are not worth washing 2 days before vacation's end.  Spattered clothing is pre-treated and put in the laundry.

Scene 7: Mother and daughter have showered and dressed in clean clothes.  The family sips cocktails (and iced tea) at a semi-fancy seafood restaurant.  Mother continues to wonder what a blood spatter expert would make of the scene she has just cleaned up, and how much DNA evidence she has left behind.

Another Site Change Twofer

As a rule, we have very few site change issues, and very few sites which conk out on us.  We had gone for many months with nary a hint of a problem.  Then we apparently entered the dark hole of terrible site issues.  Last week's glitch-ridden site change seemed like maybe it should fulfill our mishap quotient for a while?

Alas, somehow the diabetes gods did not get the memo.

Yesterday started as just a run-of-the-mill, because it was time, site change day.  The old site came out fine, and all of the pump-related tasks were uneventful.  Finding a new site is more challenging in swimming season since she really likes it to be under her bathing suit.  An acceptable spot was negotiated.  The 'o.k.' was given.  I squeezed the inserter, and it popped in.  Sort-of.

The tape bunched up into layers which I had to very carefully unstick before I could pull the inserter out again.  A closer look left me wondering.

"I think it's in."

"Whaddaya mean, you think it's in?"

Well, I can see a little more of the tubing than usual, but it's definitely in...does it feel in?"

"Yeah...I mean I think so?  Can you push it further in?"

"No...the tape's all stuck down.  And anyway...I'm not sure if that even could work?"

"I think it's o.k."

We finished the post-insertion details and headed upstairs.  Periodic questions about how the site felt were met with one word answers such as "fine" or "o.k."

Two hours later, just as I'm finishing  dinner, "I think we should change this site."

It was tempting to blurt out, "you're telling me this now???"  I'm certain my face said it, even though I held my tongue.  The rational side of my brain urged me to keep calm, to be proud of her for still thinking about it and recognizing the need to act.  Regardless of the timing, bolusing for a carb-heavy dinner with a questionable site seemed like a bad idea.  I did my best to put dinner prep into suspended animation and we headed back to site change central. 

The old one (from 2 hours before) was bloody and awful.  The new one went in better. While the tape bunched again (atmospheric conditions? any ideas?) the cannula was definitely all the way in and it felt 'great.'  High praise indeed.

I hope we've now fulfilled whatever diabetes karma debt we were up against.

Longest Site Change Ever

It started with a mid-morning, out of nowhere, super-high blood sugar.

"It's site change day, Mommy," my daughter said helpfully.

So off we went to our favorite site change spot in front of the basement t.v.  At which point I remembered I needed the new insulin from the fridge.  Upon my return, I saw that a suitably junky t.v. show had been chosen for the occasion.

I applied unisolve to loosen the old site, IV prep to sterilize the new.  I drew up the insulin into the cartridge.  Bubbles.  Tap, tap.  Bubbles.  Empty and refill.  Bubbles.  I whacked the cartridge against the book case a couple of times.  The bubbles disappeared.

I then pulled out the old site, opening a Hoover Dam of blood.  Yoga moves ensued, elevating the site above heart level.  Several tissues were put into action.  I desperately tried not to show how grossed out I was.  The blood finally stopped.  I retreated to wash my hands.

The first segment of her t.v. show was finished. It was time to replace the pump's insulin.  I removed the old cartridge, and pressed 'ok.'  "Full rewind required," flashed back at me from the screen.  Of course this had to be the day when the pump needed extra time to do a self-check. I eventually loaded cartridge and primed. Once I'd confirmed the bleeding had stopped for good, it was time to insert the new site.

The traditional three choices were offered, including one 'new' for a super-special prize.  She chose it.

Courage was hard to come by for her to allow me to pull the trigger.  After several minutes crouched on the floor, I was beginning to loose both patience and the feeling in my feet.

I threatened to revoke prize privileges if she took any longer. I heard a faint 'o.k.'  and squeezed the inserter.

"OW.  Ow ow ow ow ow.  OOOOOWWWWW."

This is not an ordinary reaction for my daughter.  Sometimes she'll utter a faint 'ouch,' but the pain subsides quickly.  This was clearly different.  We waited a minute.  I filled the cannula, and when she said she thought it was getting better, delivered the correction bolus for the high blood sugar which had begun this increasingly unfortunate chain of events.

"OOOWWWWWWWW!"

Something was certainly wrong with this site.  Or at least probably wrong with this site.  With a busy afternoon ahead, it seemed smarter to start over now than to wait and see. So I got more unisolve and i.v. prep. and noted that her t.v. show was now 2/3 over.  I took the new old site out. There was more yelling.

We then had to negotiate a spot for the next new site, not near the gusher spot and not near the painful spot. 

Hovering around the 25 minute mark, I got the 'o.k.' and popped the new new one in.  This time, there was nary an 'ouch.' 

I filled the cannula again and wondered whether the insulin I'd given to correct the high was doing its job or not.  I decided I had to assume at least some of it was, particularly with a softball game on the horizon.  I guessed correctly, and the afternoon was unremarkable diabetes-wise.

The morning, however, was remarkably awful. 
 

Location, Location, Location

Since my daughter started pumping insulin 8 years ago, we've used the same territory for her pump sites.  It was chosen when she was 3, because for her it was out of sight, and less tempting to mess with.  Now, to her, it's just where her site goes.  The endocrinologist agrees this general vicinity may be best, since she's on the thin side and some of the other possible spots (belly, arm) 'don't have much meat on them.'  Yet he's offered ideas for expansion.

Sites could be put lower or higher, over to the hip, or down to the thigh.  In the past this suggestion has been more theoretical. We weren't seeing blood sugar issues, or scar tissue, or infections.  It's something we'd try once in a blue moon when she was feeling very brave and I was feeling very patient.

I'm thinking we're now going to have to get more brave and more patient. Failed sites used to be scarce around here.  Yet recently, there have been a few stubborn highs which have quickly resolved themselves with a new site. Nobody here is going to be happy about the change. My daughter is familiar with how the sites feel going into her favorite spots, and how they feel under her clothes.  I've become confident inserting the sites in these locations too.  Those new angles and new topographies make me nervous.

So how do we move forward with this?

I started here, writing about it, to sell the idea to myself.  I need to be positive and convinced it's what we have to do.  Then I need to sell it to my daughter.  What route to choose?

There's the laying out the facts route:  You're having high blood sugars.  They're not healthy.  We need to try some new spots and see if that helps.  You know - the ones the doctor always suggests as alternatives? When he talks about scar tissue?  We need to start using them.

There's the buy-in route:  We have to chose some new spots.  I will allow you to choose what new spots.  I will make sure we have plenty of time for each site change so that you can take your time choosing, and so that there is no hurry to insert it before you feel ready.

Lastly, there's the reward route:   Currently, she gets a 'prize' for every 3 site changes without excessive drama.  Perhaps now there's something in it for her every site successfully inserted in a new spot.  Or maybe a bigger reward for a week or two of success.  Or both.

It will need to be a combination of all three, I'm sure.  She needs to know why: the facts part.  She needs to have some control over the situation.  Getting to choose which fresh spot gets the jab seems like the least I can offer.  Upping the ante on the reward part will hopefully be the bit that closes the deal.  I'll stock up on tic-tacs and hair accessories to be doled out for each success, and probably throw in a mother-daughter frozen yogurt outing if (when) we make it through 3 or 4 rounds of this.  I'll deserve a reward too, after all.

What Happened?

The call from the nurse's office at 2 p.m. started the mysterious chain of events:

My daughter's blood sugar was 70 after gym, having started at 208 with no insulin given for a correction.  I suggested eating her 15 g. snack and checking again before walking home.

At 3, it was up to 294...an extreme jump.  Uncertain of the cause of this high, and factoring in the coming walk home, I advised giving a little over half the correction.

After a 15 minute walk, she arrived home with a blood sugar of 358.

We made a site change the first order of business.  The cannula area appeared dark red and somewhat crusty.  I'd never seen one quite like it.  When I pulled it, it turned into a gusher.  It required a clever yoga move by my daughter to get her site area above her heart, but this basic first aid tactic did stop the bleeding and allow us to continue.

New site nicely inserted,  I determined that this grusome looking site had simply conked out, causing all of these blood sugar issues. I delivered a hearty correction for the 358 plus a few goldfish crackers. 

My daughter was able to move on to homework, but we lost a precious 20 minutes of our busy Thursday afternoon to diabetes troubleshooting.  Math homework was done in the car on the way to ballet.  Typing of the short story would have to be finished after ballet and dinner, in lieu of watching the baseball playoffs. Very sad.

About 40 minutes into the ballet class, she was next to me on the bench outside her studio.  "I need to check."  She was 49. 

"I guess the new site works," I muttered, shoving the straw into the juice box.  She sat and slurped.  She valiantly returned to her class and participated, resting on the window ledge between exercises.

What happened?  I wish I knew.  There are several possible scenarios:

The site was obviously shot, but maybe not as completely as it looked. Perhaps there was more insulin on board than I assumed when I gave the correction?

Maybe some of the high was from the bad site, but some was from another cause.  Perhaps she was lower than 70 sometime during gym and had a rebound reaction?  Gym or a math quiz might have prompted an adrenaline rush which spiked her blood sugar?  In either case, it would have been prudent to be more careful with the correction.

Maybe our correction factor is way off for that time of day?

Trying to complete a complicated math and logic problem with about half the possible information is nearly impossible.  If we're lucky, we guess the missing information correctly and solve it accurately.  Just as often, we'll guess wrong and have to hope that missing a little bit of ballet class is the worst outcome we'll see.