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."

What If?

 This is a story about something that happened last weekend.  It is not advice, medical or otherwise.  Except maybe to be extra-careful when walking on frozen lakes.

'Does your daughter have any medical conditions?'

I mumbled a little.  "Nothing that's relevant here."

'Too young to have much of a medical history, huh?'

'Mmm,' I said with a tight smile.

The EMT continued to treat the facial injury.

We were at a family resort for a girl scout troop overnight.  Our last outdoor stop of the day was to explore the frozen lake.  I saw it happen in super slow-mo from about 30 feet away.  My daughter was walking towards her friends when her feet went out from under her and her face hit the ice. We're unable to reconstruct where her arms went, but they were of no help to her mouth.

She bit deeply into her left outer lower lip. The left side of her mouth was swollen and riddled with abrasions and braces marks inside and out. There was a lot of blood. We took her inside, got ice, washed up her face and rinsed out her mouth.  The bleeding wouldn't subside.  We were told there was an EMT on site.  I decided, particularly being far from home, that it would be smart to have it looked at carefully so I wouldn't wonder later if more should have been done.

My daughter later described our time with the EMT eloquently.  "He had trouble finishing his sentences.  And he kept repeating himself."  He was perfectly kind, and gentle, and competent.  But 20 minutes into his work, he was still cleaning the cut.  He had reassured us that she didn't need stitches and that her teeth seemed fine. He was finally getting out antibiotic ointment and bandages.  Then he asked the question.  "Does your daughter have any medical conditions?"

I looked over at the rest of my daughter's girl scout troop, so patiently and lovingly gathered with the other parents, waiting for her.  I thought about bumper cars, and dinner, and the evening fun to come.

I ran through the diabetes-related possibilities in my head.  I knew I should be honest. But could anything either he or I would gain from the potential conversation be worth the 20 minutes it would take to have it?  I mumbled my answer.

It felt really weird.  As I denied the diabetes, her life flashed before my eyes: the traumatic events of diagnosis, the countless endocrinology visits, the pump and CGM stashed under her winter layers.  What if none of that had happened?  What if this lip injury was one of the most significant medical events of her young life?

Eventually we were walking towards the bumper cars with an adorable stuffed lion her friends chose for her from the gift shop (conveniently located adjacent to where we met up with the EMT) when my coat pocket vibrated and beeped. A glance confirmed the inevitable:  240, double arrows up.  The adrenaline was at work.  Diabetes was, indeed, relevant to this situation just as it is to just about every other one.

But I refuse to let it slow us down.

Adrenaline 2

My previous post described our experience with adrenaline when my daughter performed in the school musical last weekend.  The excitement and anxiety of performing resulted in a large spike in blood sugar.  The spelling bee, amusement park rides, and other big moments have resulted in similar spikes.  Yet there are circumstances in which we'd expect to see an adrenaline spike and do not, such as this weekend's other stressful event.

In the midst of her busy play weekend, I dropped my daughter and my husband at softball practice at 11 a.m. on Saturday morning.  I returned an hour later to find my daughter with an ice pack and a growing bruise near her eye.  She didn't catch the fly ball.

This scenario involved physical trauma, fear and embarrassment.  It seems to me that this would be a perfect trifecta of adrenaline production.  For her? Nothing. Her blood sugar was 81 after practice and didn't spike until her performance later that afternoon. 

There is a long list of areas in which people's experience with diabetes varies.  Foods which are disastrous for some pose no difficulty for others.  Exercise may cause a slow and steady drop, or it might cause a spike followed by a later crash.  Low and high blood sugar symptoms differ greatly from person to person.

It becomes a matter of tracking individual experiences and learning the patterns. We learn the basic science and execution of it all from our health care team.  We read and listen to the experiences of others with diabetes.  Yet diabetes management also involves a great deal of 'learning by doing.'

We hope not to have a repeat of the softball to the face incident, with its resulting black eye; particularly not hours before the school play.  Perhaps, though, we've learned something about the difference between physical and emotional trauma in their ramifications on my daughter's blood sugar.

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.