Another Opening, Another Low

It's been a couple of years, and we forgot. Performing in musicals makes my kid low.

Except for an occasional adrenaline-induced high, especially on opening night. For which insulin should be dosed sparingly, not aggressively.

Exercise is the most obvious cause. This year's show was particularly dance intensive. At two and a half hours long and involving at least five quick costume changes, every performance resembled a marathon. Saturday's double-header was made possible by a giant between-shows order of Thai pineapple fried rice.

Being in a show also puts her off schedule. Diabetes likes to eat, move, sit still and sleep within the confines of a predictable routine. Dinner at 4:30 on show nights, 8:30 on dress rehearsal nights? Both unusual. Dancing and performing in the evening instead of sedentary homework? Unusual. Diner pancakes or cast party food post-show? Her insulin to carb ratios are set pretty accurately for regular mealtimes, not so well for midnight. There was lots of overnight juice.

Exhaustion is another probable contributor to the show lows. The weeks leading up to opening night involved long rehearsal days followed by late homework nights. Schoolwork didn't stop. Regularly scheduled music rehearsals didn't stop. She burned more energy than usual just to keep up with the long hours.

It's absolutely true that kids with diabetes can do the same things others do. They can even make it look effortless. Waking a couple of times per night for juice, calculated intermission snacks to improve the odds of stable second act blood sugar, checking and double-checking the backstage bag of supplies, and maintaining an overall high level of diabetes vigilance are invisible tasks, even to most of her cast-mates.  To her all those tasks are totally worth it to be able to participate in her high school's musical.

Wouldn't it be nice, though, if she could just do the same things other kids did without all of the extra effort?

The Diabetes Card

I hate playing the 'diabetes card.'  Saying, 'but she has diabetes,' goes against my whole, 'diabetes can't stop you from doing anything' mantra. Also, invoking diabetes has the secondary problem of necessitating a longer, more complicated conversation than I ever want to have. We are often able to problem-solve diabetes stumbling blocks so that my daughter can participate fully in things without making a big deal about them. But sometimes that becomes impossible.

Before the weekend performances of the school musical I received an e-mail stating that all cell phones would be collected when the kids arrived at school an hour before curtain.  They would be kept 'in a safe place,' and made available 'in case of emergency.'  This was happening at dress rehearsals as well.  Sometimes my daughter turned hers in. Sometimes, like on days of crazy diabetes issues, she claimed she didn't have it but really kept it with her. The collection was kept in clear ziploc bags on an accessible table, so she knew she could reclaim hers and use it in an emergency, answering questions afterwards if needed. 

For the show, however, I had to say something.  We have a system of her texting me her numbers a few minutes before curtain time and at intermission.  We try even harder than usual on show days to intercept any problems early on, and to keep things on an even keel.  A fuzzy brained high could lead to forgotten lines.  A low on stage has all kinds of potential ramifications.  So we've got a system of checks and balances in place.

I contacted the director and plead my case through a (probably) over-explanatory e-mail. Not only did she need to keep her phone, I explained, she had to use it at least twice backstage.  I hoped that would not be a problem. The director's response?

"Of course she can keep it!"

Which is what I assumed the response would be from anyone with an ounce of decency and common sense.

But I still didn't like having to ask.  Playing the 'diabetes card' invariably puts a qualifier on 'diabetes can't stop you.'  It says that she needs some sort of special treatment to keep her safe.  Which is sometimes hard to ask for or to admit.  But sometimes it makes sense.

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."

Performing

My daughter's middle school musical was this past weekend.  She had a few lines and one phrase of song around the middle of the first act.  Throughout the show, she sang and danced as part of the 'chorus.'

It seems theater will require the honing of some new diabetes management skills. The first night, her pre-show blood sugar was in the high 100's: just fine for shortly after dinner.  At intermission, after her big part, she texted me from backstage.  Her blood sugar was 301: very high.  While in the back of my mind I was factoring in adrenaline while helping her tweak the pump's recommended correction, I had her dose a substantial amount of insulin.

I do know that adrenaline affects her blood sugar, and that depending on the circumstances, some or most of the resulting high will resolve itself on its own.   Revisiting my spelling bee post might have refreshed my memory, or reading this Diabetes Forecast interview with Crystal Bowersox.  Particularly the following:

Q. Does performing affect your blood glucose? It does affect it, actually. Right now my routine is: I’ll check my sugar one to two hours before hitting the stage. And then if it’s too high or too low, I can adjust accordingly. If it’s too high, I’ll take half the amount of insulin I’m supposed to take because adrenaline makes your blood sugar go up. But it also comes down on its own. You don’t have to correct for an adrenaline high, and if you do, you end up bottoming out after the show. It’s been a struggle to find that fine balance, but I feel like I’ve got it now.

It's hard to let a number like 301 ride, but I definitely overreacted.  I therefore found myself up all night chasing low blood sugars. The physiology is beyond me, but somehow that spike disappeared on its own, leaving a boatload of insulin to keep working well into the night.

Saturday saw a similar pattern, with a 308 at intermission.  This time, having learned something Friday, I had her give about a third of the suggested insulin.  Despite pizza, chips and a cookie an hour later at the cast party, then more pizza and a dessert buffet at a friend's after-party, she stayed in the 100's all night. 

She thoroughly enjoyed rehearsing for and performing the play, so I expect we'll have some more theater experiences ahead of us.  As with many other diabetes tricks of the trade we've picked up over the years, we'll figure this one out too.