Number Thirty Seven

Have you ever heard that if you ask a person to name a number between one and one-hundred, the most common answer that people give is thirty-seven?

I don't know if that's something that can be proven mathematically but I have noticed it a lot over the years, that number just pops up all of the time.

Arden's All-Star softball team competed in their All-Star tournament last week. They played their first game on Thursday night and lost. Friday was rained out so they were scheduled to play two games on Saturday but they couldn't lose again or they would be out of the tournament - you can only lose two.

Thursday's game required a large bolus to battle Arden's adrenaline and the same was needed for the first game on Saturday. They won that first game Saturday and after a thirty minute break to recharge, they played again. During that second game her BG held steady until about the fourth inning. Arden's DexCom CGM was hung on the fence of the dugout during the games and I would check it every inning or so depending on how her BGs were acting. Arden ran out on the field when the forth inning began, as she did I walked into the dugout and looked at her CGM. Her BG was 120 with two arrows pointed down, she was falling fast but I knew that a juice box would handle it. I was actually waiting for this fall. Arden ran in to the dugout, drank a juice box in about ten seconds and ran right back to third base. Her BG balanced out as I expected and the girls won the game about an hour later. When Saturday ended, the team was 1 and 2, and scheduled to play again the next day at 1pm.

Arden's BGs were on the low side overnight, as I expected they may be and I handled them with a little juice and some temp basals. Nothing out of the ordinary after a day of activity.

Sunday brought high temperatures and a clear sunny sky, it was very hot. The girls warmed up at twelve-thirty, the game began at one and the adrenaline hit her about 45 minutes later. I bolused when her BG began to climb but I was too late, Arden's BG was on the move. I tried desperately to get it to come back down without going to low. Arden has trouble running when her BG gets above about 200 - she is normally very fast but above 200, her speed and dexterity become average, so my goal is always to keep her under that number when she plays. They won the first game and the next game was going to start in a half an hour. Arden's BG wasn't moving but I still only gave her a slight bolus (.20) for all of the food that she ate after game one. I thought that the .20 was a conservative approach to her game break snack as I was still leary of a fall from the earlier adrenaline bolus. 

We were now into the second game and my plan was to check her CGM after the third inning. The last time I looked at it was before the second inning began, it read 192 with an arrow diagonal down. Before I could get up after Arden made the last out of the third inning, she ran through the gate toward me holding her hands over her head and gesturing for me to come to her...

"I feel really dizzy!"

I didn't bother to test before I handed her a juice. She sucked it down as I tested her free hand...she was 37.

I said to Kelly, "Give her another one" as I ran to get the CGM from the fence. Arden's BG was dropping so fast that the CGM hadn't caught up yet, it read 101 but now both of it's arrows were pointed down. Arden's BG was falling way too fast, she drank two juices, ate a fast acting tablet and was now chewing on a handful of Mike and Ike's. I tested again, BG was 49 and she was still very dizzy.

Arden and I went into the dugout to get out of the sun, she alternated between sipping cool water and fuetly holding her head to try and stop the dizziness - seeing her press her hands into the side of her head broke my heart. I hugged her as she laid into me, I quietly told her that it would stop soon. We tested again, 69 but the arrows on the CGM were still pointed straight down. I decided to follow what the meter was indicating, I believed that her BG was climbing and stoped considering more carbs. It was then that Arden's place in the lineup came up... it was her turn to hit. "They can skip you for one inning", I told her.

"I can hit", Arden stood up squeezed her head between her hands one last time and put her helmet on, we tested again and her BG was 131 but she was still feeling the low. What came next was Arden's only strikeout of the tournament. She fouled off two pitches, running them both out before swinging and missing the last pitch of her at bat. I sat in the dugout staring at her, I was sure that I shouldn't have let her hit but I just couldn't find the parental wisdom in telling her that diabetes was going to make her miss that at bat. Secretly, I was so happy that she didn't get on base because I didn't want her to run but you can't imagine how proud I was of her for trying. She sat out the next half inning, opting to lay on the bench with her head on my lap so she could try to get her bearings. She only said two things to me during that time... "It's getting better" and " I can't believe two balls went to my position". She was annoyed that she missed the opportunity to make two plays.

When her team made the last out, she sat up, looked at me and said, "I'm okay, go back with mom".

Arden and her team went on to win that game and then they won the next one too. They never lost after losing the first game on Thursday and they won three in a row on that hot Sunday afternoon. I'm still not positive that I should have let her hit but, well, check this out...

 

That's Arden holding her trophy. Her team won the 2013 eight year old All-Star tournament last weekend! She played all but three outs in the field and never missed an at bat. Arden beat all comers, including diabetes - I think that if I was any prouder of her... my heart would burst.

Super Bolus, I Fear You No More

I just couldn't take it anymore. I'd count the carbs perfectly, pre-bolus at exactly the right time and still there are certain foods that require another bolus an hour later. On the surface you would think that I wasn't administering enough insulin but that couldn't be because every once and a while the bolus would work - but not usually.

Example: Movie theater

Arden is a nacho and popcorn lover at a movie, and we see our fair share of movies. Most times, I measure, count carbs and bolus only to watch her DexCom G4 point it's arrows to the sky before the second act is over. Then I spend the rest of the afternoon dropping random measurements of insulin on the number in an effort to get things back to a desired level without going too low. Sounds like a bad Price Is Right game, doesn't it?

Then it just hit me a few weeks ago, we have a CGM, why am I erring on the side of caution and chasing highs when I could be living on the edge of glory with Arden's DexCom G4. Suddenly, I felt stupid. All of this time I was playing scared when I know that's how you get hurt. Time to put my head down and run through a few wood be tacklers. (Sorry, my metaphors are all over the place today)

So I looked at that food on Arden's lap, counted carbs and then added every drop of extra insulin that I ended up given her at the last movie. My new thought, "What's the worst that could happen... she starts to get low, the DexCom catches it and we throw back a fast juice box and catch the fall".

That's exactly what happened

We watched Star Trek, Arden munched on her snacks and about an hour into the movie Arden's DexCom line had never wavered, her BG was 118 and steady. This was either going to be the perfect amount of insulin or too much. About fifteen minutes later, "Beep, Beep, Beep", 92 one arrow straight down. No big deal I thought - then I leaned over and said, "Here Arden, drink this juice". Twenty minutes later the CGM line was steady at 88, Arden was able to graze her remaining popcorn without worrying about bolusing and her BG never fluctuated, even hours after the movie had ended.

All of these fancy diabetes gadgets and I was using them to chase numbers instead of staving them off. I know that this sounds scary to many of you and I know that it takes time to find your comfort level, but please believe that on the day that you gain that level of comfort... this is all going to seem so much easier. Sadly, you can't rush that day to come, but it's so worth getting to and it makes me incredibly happy to know that you will all be there one day with me - kicking type I diabetes in it's annoying ass.

Sesame Chicken you Motherless $%&^@

It was a long Sunday and the nights hours were burning away quickly. We just wanted to have a fast and easy dinner when we made the call. It ended up being anything but.

I pre-bolused. I counted carbs. I over-estimated those carbs. I set temp basal rates. I did everything that I know how to do and two hours later, it appeared as though my foresight had won the battle. Arden's BG was 150 two hours after insulin and some ninety minutes after she finished eating. I was victorious!

That victory was however, short-lived - Chicken and rice... not so nice

The next few hours were a slugfest. I traded punches with diabetes all night. It hit me in the jaw, a countered with a bolus. It responded with a gut punch, I shot insulin with a needle. Uppercut, water bottle. Jab, Temp basal. We went back and forth like two prize fighters in a ten round fight. This exchange went on until four in the morning, I was staggered by the unrelenting nature of the attack. Defeated physically as well as spiritually.

We just wanted a number four with dumplings

It's so incredibly frustrating at times. The old diabetes adage really does stand true. You can do everything that you did the day before in the exact same situation and get completely different results. We don't make a habit out of Chinese take-out, but I was certain that I had developed a great system for combating those crazy carbs. Not on this night I guess, my best laid schemes failed me.

 

But little Mouse, you are not alone, In proving foresight may be vain:

The best laid schemes of mice and men

Go often awry

The most difficult part of staying up overnight in these situations isn't the loss of sleep, though that did eventually catch up to me. It's the stillness of the dark and how it allows you the time to reflect on what the high BG is doing to your child's body. The darkness makes me want to be better. Do better, make better decisions. I do a fair job of not beating myself up in these moments, I try to learn their lesson. Knowing that you are standing in the dark with me helps keep that attitude in the forefront of my mind. We are only alone in these moments if we forget that somewhere, there is another person just like us, having the same doubts, fighting the same fights. The DOC is always with you!

The Not So Great but VERY Powerful Bolus

Arden's CGM vibrated on my leg. Earlier during the previews I asked Arden to give me her G4 so that I could monitor her BGs while we watched 'Oz The Great and Powerful'. The vibrations that her CGM sent through me were too intense to ignore and moments later I was greeted rudely by the message on it's small glowing screen.

Arden's CGM indicated that her BG was 94 and the number's accompanying arrow was pointing straight down. You can see on the chart below that's not good news.

From the DexCom G4 Users Guide

Prior to the movie we stopped for a light meal, Arden had a salad and one baked potato skin. I pre-bolsed for twenty carbs, ten minutes prior to the waiter arriving with our food, she ate as I expected. A little over an hour later we settled into our theater seats (about thirty minutes before the movie was scheduled to begin). Arden was holding a box of Bunch-a-Crunch, a small popcorn and she was talking about sharing a few gummy candies with her friend who was joining us. I pre-bolused for forty carbs at this time. We donned our 3-D glassed and the movie began.

95, one arrow straight down

A CGM reading of 95 doesn't phase me, and one arrow down doesn't really cause me to become alarmed anymore, "Just missed with the bolus", I thought. Then I looked at the time on the OmniPod PDM and became a bit more concerned. This was all happening only one hour into the movie, I had more than "just missed" - I significantly over estimated how much Arden was going to eat. I shook the candy box, reached into the popcorn bag and discovered that she really hadn't eaten any of the treats that we initially believed she would. I reached into the gummy candies, put five in her hand and whispered, "Eat these please, your CGM says 95, one arrow down - I think I gave you too much insulin".

Arden ate the candy quickly but three more alarms were already shaking my leg

Now her CGM was reporting a BG of 84 with one arrow down, seconds later it was 76 and then the arrows doubled. 76, two arrows down. Arden's BG was running away from me. I had already opened the juice box by the time the double arrows hit, Arden knocked it back like a shot as I tested to autenticate the numbers on her CGM. Her BG was 56 on the meter and the arrows were staring back at me as if they were awaiting an answer to the question, "What are you going to do Scott?".

I recounted the carbs in my head based on what I now knew she had eaten and then added the new carbs that she just wolfed down to that total. I was okay, I knew that the numbers matched. I told myself, "Just wait, don't over treat" but no sooner than I was able to talk myself into that response...

BEEP, BEEP, BEEP, BEEP - "LOW, two arrows down"

I could feel my adrenaline surge when the beeps angrily blared out. I started looking around to see which way out of the aisle was less blocked, thought about where the snack stands were located and considered sending our son Cole for a cup of regular Coke. Then I looked at Arden, she was sitting next to her friend who came along with us for the movie and I just didn't want her to have to rush around like the world was coming to an end in front of her pal. So I quietly slipped Arden a glucose tab (We never use glucose tabs), I asked her to chew it up quickly and swish the powder around in her mouth.

She did so dutifully, then leaned over to me and whispered in my ear, "am I going to be okay?"

Those words broke my heart and brought a tear to my eye but I answered without hesitation, "absolutely, Daddy has it all under control, go back to watching the movie", but I wasn't sure. The CGM still said "Low", though now it was reporting only one arrow down - so I tested again and this time Arden was 68. I could breath again, she was going to be fine.

I asked Arden how she felt and she responded, "A little dizzy but I'm okay". I told her that we caught the fall and that she should go back to watching the movie. Her friend never saw a thing, I did however miss the flying baboons... I heard they were fierce though, Arden told me later in the car. She knew because she never had to take her eyes off of the screen, mission accomplished.

The DexCom CGM is an indispensable tool in our day with type I diabetes. I genuinely never imagined that Arden wouldn't eat the amount of food that we bolused for. This was a complete anomaly, movie theater food always needs a strong bolus, this never happens - until it did. CGM technology is the best. Who knows how this all goes with out the Dex, maybe Arden would have gotten dizzy and told me that she didn't feel well, maybe the movie would have held her attention to the point that she didn't notice. I'm thankful that we didn't have to find out.

I gave her way too much insulin, that happens. The DexCom CGM makes that eventuality feel less scary.

Update on Wednesday, March 20, 2013 at 11:25AM by Scott Benner

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Insulin to Carb Ratio

It doesn't matter if you infuse insulin with a pump or inject, you probably know how many units of insulin covers one carb. We use multiple Insulin to Carb Ratios (IC Ratio), in the morning Arden's IC is 1 to 16. One unit of insulin, for every sixteen carbs consumed. Her lunch, dinner and evening ratios are all slightly different. 

Two weeks ago Arden began experiencing unusual BG spikes after lunch, I'm happy that this happened, not because I want to see her BG high but because the anomaly caused me to draw a mental line between these new lunch spikes and a similar spike that I see too frequently after dinner. Post dinner spikes have been an ongoing issue for us this year. I was certain that they were happening due to bad carb counting but this new situation jarred something loose in my head and allowed me to see the problem from a different perspective.

I had become lulled into a false sense of calm by consistently good BGs from other times of day. Those triumphs clouded my ability to see simple issues that caused BG spikes, spikes that shouldn't have been difficult to diagnose. I made a mistake, focusing too much on the food in the equation and ignoring the insulin.

Diabetes: "Knock, Knock..."

Me: ("I'm just going to ignore that and see if he leaves")

I wonder now if I didn't subconsciously just need a break, maybe I didn't have enough energy to tackle another diabetes riddle. Whatever the reason, I figured it all out the other day... the answer ended up being so simple that I'm now annoying myself by retelling the story. 

Arden's insulin to carb ratios needed to be changed, one quick adjustment is all it took. I'm still fine tuning the dinner number and the breakfast ratio needs a little help from a temp basal but her BGs haven't been going above about 160 (CGM) after lunch or dinner since I made the adjustments. Everything has been so quiet around here for the last few days. No crazy highs, no panic inducing lows... it's almost too quiet, but I'll happily take that calm for as long as it lasts.

I'll be writing more this week about other simple adjustments that make a huge difference. Don't be afraid to make small changes, you can always put them back if they don't do what you expected. Please remember to record the old numbers before you make any changes in your pump.

Don't forget what the bottom of the site says... Always consult your doctor before making changes to your health care. I am not a doctor.