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?

Back to School Year #13

My daughter went back to school this month- for the 13th time if we include the preschool years. It's still never easy.

Back to school is a challenge for most kids. There are difficult teachers, tough social situations, and strict schedules to keep.  But for my kid and many like her, fall's biggest stumbling block is diabetes.

The back-to-school diabetes problems are ever-present, but not always the same. Some years there's a new nurse who we have to meet and coordinate with. Some years there's a new activity which coincides with the start of school, adding another diabetes thing to think about. Some years the time of lunch has changed (like the 'year of brunch,' linked for you here though I'm going to choose not to reread and relive the horror). Some years gym proves to be a seemingly insurmountable obstacle (like last year, when at some points it was simultaneously terrifying and ridiculous). Some years there's a teacher who just doesn't quite get it. Or one who's extra nervous. This year we've added a daily walk to school, just a couple of blocks but most of it straight uphill.

There's one back-to-school diabetes challenge that's constant from year to year: the overall change in the daily schedule. August is lazy- featuring vacation, the backyard, books, friends and the pool. For the past couple of years August has also included sleeping late at least a few days a week, and alternate sedentary stretches of binge-watching Netflix and power-finishing summer homework. Going from a slow, sedentary start to 6:30 a.m. breakfast followed by a brisk walk to school would be a jolt to anyone's system. Adding diabetes requires an annual investment in juice boxes and a lot of dosage tweaking.

By the fourth day of school this year we'd already changed the breakfast bolus ratio and several basal rates. Twice.  And she was still eating glucose tabs every day half an hour before lunch. We've gotten that to the point where she's usually just barely 80 at lunchtime but then shooting way up into the high 200's late in the day- except when she has marching band in which case she's staying steady and then tanking overnight. We will not discuss what the weekend numbers look like with an ever-changing band/homework/fun/sleep schedule.

Every year kids face challenges going back to school, diabetes-related or otherwise. They come home and tell their parents, who provide any number of phrases to soothe them: This too shall pass. What doesn't kill you makes you stronger. Life's too short to worry about that. Just do your best. And so we'll continue to apply these same pithy phrases to our approach to managing the back-to-school diabetes adjustment. We'll do our best, making tweaks every couple of days, trying not to worry, knowing that we will get through this, stronger in the end, as we always do.

What Time is Gym?

Here's our latest challenge:

The high school has block scheduling.  This means that while kids take 8 classes, they only go to 6 per day.  There is a continuous rotation through A,B,C and D days.  Each day has 3 morning classes and 3 afternoon classes which always remain in their own day parts, but not at the same times. The first challenge is, of course, end up in the right classroom at the right time more often than not. 

Then, to up the degree of difficulty, add diabetes.

This schedule means that gym, like all of the other classes, only takes place 3 out of every 4 days. It's always in the morning, but rotates between 8 a.m. 8:58 a.m. or 9:54 a.m. depending on the day.

Yesterday was the first day the kids changed and had a full gym class. It was during the 8:58 time slot. It turns out, to provide an additional diabetes challenge, that one day per calendar week the class has a 'fitness activity.'  Yesterday's was running sprints outside, promptly followed by the first high school visit to the nurse's office due to low blood sugar.  Other days will be spent on traditional gym units like volleyball and badminton.  This fitness activity day will not occur predictably, so it is not as though we can know that every 'A' day will be different.

Every school year has required an adjustment in the basal insulin delivery rates on my daughter's pump. The summer schedule of waking, sleeping and activity is different from any school schedule.  Each year of elementary and middle school brought a different time for lunch and daily gym class. A couple of weeks into September we were able to see the new patterns and tweak insulin doses to prevent most post-gym or pre-lunch lows.  There were still variables like going outside on a gorgeous spring day to run the track instead of playing badminton; and half days threw everything off.  But generally there was some predictability to the daily schedule and its requisite insulin needs.

This year?  I really have no idea how to proceed.  I dropped the morning basal rates a bit last week after it became clear that being up and active at 6 a.m. was leading to a different pattern than the more civilized summer hours did.  Last night I further lowered, and changed the timing of, the morning basal rates as the first stab at addressing the gym issue.  But I fear that on no-gym days highs will creep in, and that the changes will be more effective on some days than on others due to the range of class times and activity levels. 

In a perfect world, my daughter would check her blood sugar an hour before gym class and then again when class was beginning.  She would know what the day's activity was and use all of the available information to decide whether to set a temporary basal rate or have a snack.  Or we'd have a few different basal patterns set up and change them based on the day's school schedule.  Maybe she would eat different breakfasts depending on when gym was scheduled in order to, theoretically, stabilize her blood sugar at the right times of morning. 

Life as a high school freshman is nothing akin to a perfect world..  At this point she's lucky to make it to the gym at the right time and to find the locker room. Arriving at school for 7 a.m. choir fed, bolused and with enough insulin left in the pump cartridge for the day (oh- and dressed, homework finished and carrying her backpack containing everything she needs for the day) is almost more than we can ask.  So for now at least, we'll play a little bit more with the basal rates to hope we can find a happy medium for the mornings.  And she'll keep the juice boxes close at hand.

What If...

My group of seventy-five jurors was called into a courtroom at 11:15 a.m.  We sat and were given the required lengthy speech about jury service.  The attorneys and defendants were introduced.  We were then handed the jury questionnaire.  By then it was noon.

The judge went through the first two pages of questions one at a time.  People who answered 'yes' to any question were asked to stand and give their names to the judge.  He made a note of each.  A dozen questions later, 40 people had stood up and it was 12:30.

Then he brought every person who had answered 'yes' to any question up to the bench one at a time to talk about their concerns.  It was nearly 2 p.m. when we were sent to lunch.

The second item on the questionnaire had to do with whether there were any medical, financial or personal problems which would prevent you from serving.  With that question came a sentence about the Americans With Disabilities Act under which many accommodations could be provided as needed. Nearly three hours of hungry boredom gave me plenty of time to consider possibilities.

If I had Type 1 diabetes and part of my personal management plan was to eat at approximately the same time every day, I would have needed an accommodation 45 minutes into what was turning into a nearly 3 hour affair.  What would I have done?  Stood up and asked to approach the bench? Tried to eat something without anyone noticing?  Sat there and hoped an emergency didn't develop?

What would happen if a person with diabetes experienced a significant low during testimony and needed a few minutes to regain the power of concentration?  What questions would be raised about someone repeatedly looking at electronic (diabetes) devices throughout the trial?  Would the beeping of devices and glucometers prove to be a distraction?

With a Supreme Court justice who must occasionally need to munch glucose tabs during a hearing, I'm certain diabetes isn't a barrier to jury service.  It's more of a question of when and how a potential juror would disclose the concern.  And of what specific information would need to be shared with the presiding judge.

All I can tell you is that if I were that person who'd been sitting there anxious about when or whether I'd get lunch before my blood sugar crashed, I would have been extra upset when we returned from lunch to learn that the morning's process had been all to find only one more person to fill an almost-complete jury.  Even I, being merely hungry and bored, was somewhat irritated that people were not dismissed more efficiently in this situation.

Playgroup

During my daughter's baby and toddler years, we attended a great playgroup in the community center gym. The local 'mothers club' had collected a plethora of toys and secured a closet in which to store them.  Every Friday, the toys were dragged out into the gym and children from birth to four were invited in to play.  A weekly donation of $2 got you two hours of playtime, a snack and juice, and even a cup of coffee for mom. 

My daughter and I, for the most part, enjoyed it.  She liked the 3 different play kitchens, the giant bouncy balls and the dress up clothes.  I liked meeting other mothers and having somewhere to go, particularly on frigid winter mornings.

This was one of the first places we brought diabetes out in public.  One or two other moms knew my daughter had diabetes, but I imagine many wondered about us; especially at snack time.

The kids would all sit on a couple of blankets laid out on the gym floor to eat their snacks.  Most mothers would then head for the coffee or sit on the bleachers and chat.  We'd head over to the side to check her blood sugar.  I'd then vet the snacks for carbs and determine whether she would eat the playgroup snack of the day or an alternative from my bag.  She was on NPH at the time, so very restricted at snack time. I would then awkwardly hover over the eating children.  I needed to be sure she ate her snack, and didn't eat anybody else's. What if she got her hands on somebody's juice? When snack time was over the children would be instructed to throw away their trash and go back to play.  More often than not, I'd have to drag my child over to the bleachers and make her finish her goldfish before she could go back out there. 

At home, diabetes was becoming part of our routine and its intervals were becoming second nature. The contrast of being somewhere diabetes wasn't part of the routine was challenging for both of us.  It was isolating to be the mom obsessively observing toddler snack time instead of sharing potty training tips over coffee.  My daughter desperately wanted to get back and play whether she'd finished her snack or not.  She wanted the playgroup snack whether it was goldfish (o.k.) or donuts(not o.k.).  She was really little, and any parent can therefore imagine her reaction to not being allowed to have her way.

In retrospect this was the beginning of a long series of moments when we brought diabetes along with us despite its challenges.  Yes, there were 2 or 3 days when I had to give up and bring her home because she melted down at snack time.  Most weeks, though, the fun far outweighed the challenge.  I wasn't going to let the possibility diabetes might throw us a curve ball stop us from enjoying a happy morning out.   A few years have passed, but that last bit remains just as true today.

Dinner?

Softball poses its own unique diabetes challenges.  For my daughter, game-related blood sugar fluctuations are predictable and we've learned how to manage those.  Her pump goes in a fanny pack and is nicely tucked under her uniform.  She's learned to find moments on the sidelines for quick blood sugar checks, and the roomy softball equipment bag has plenty of space for the meter, glucose tabs and a juice box.  At least one parent is always on the sidelines. We're cheering, but also ready to jump in should any diabetes needs arise.

The issue which seems unresolvable is the timing.  Weeknight games start at 5:30, which means warm-up begins by 5.  We're usually not home until 7:30 or 8.

I can only assume that every child plays better when fueled up.  Mine definitely needs something in her system before a 2-3 hour sporting event.  Ideally, she'll have a well-balanced combination of protein, and carbs with a healthy vegetable thrown in for good luck.  Ideally, we'll bolus this meal just right, leaving her a few carbs to burn off during the game until that nice bit of protein kicks in to sustain a lovely blood sugar through the 6th inning.  Ideally, this resulting steady blood sugar will provide her with the energy and focus she'll need to play well and have fun.

So, here's the question: does she eat dinner at 4:15 in the afternoon?

The answer has to be 'sometimes.'  Ideally, she'll eat dinner before the game, despite the early hour.  She feels better and plays better. Her blood sugar responds better throughout the game and into the evening.

Sometimes a pre-game dinner is just not possible. Today she has team pictures before the game, which would move dinner time to about 3:45.  Other days she has after school activities until game time, or homework which needs to be done before she's completely wiped out.  On these days she has to make do with a hearty snack such as yogurt and fruit or a quick pb&j in the car. 

Diabetes does not prefer 'sometimes.'  It prefers a set schedule.  Yet from time to time, we need to be flexible.  With a little planning we can be flexible and keep diabetes in its place at the same time.

The Delayed Opening

This mess caused a delayed opening of school today.

The delayed opening caused a bigger mess, blood-sugar-wise. 

Causes of said mess included:

• Neglecting to check blood sugar before finishing most of breakfast.  The excitement over extra pajama time distracted us terribly.
• Spending an ordinarily sedentary half-hour scraping ice off of our car and driveway.
• Lunch at the civilized but unusual hour of 11:14.
• Gym following lunch in a more rapid fashion than usual.

Soon I will drive her home in what is now just a wet mess, with ice turning to slush and fog.  Things will presumably begin to take a more ordinary course.  Homework, piano, then perhaps a few pages of her book before dinner.

Hopefully diabetes picks up quickly on this return to routine.