Basal the low away

It’s day two of Blog Week, today’s writing assignment is how to treat a low BG.

My wife and I sat in CHOP’s pump class listening to the trainers tout all the reasons why insulin pumping was the way to go and we were on board with all of them.  My daughter Arden had type I for about two years by this time, Arden was diagnosed just after her second birthday.  She is a tiny little thing, on the day of her diagnosis she weighed just seventeen pounds.  By the time we reached this pump class I had become a master of injecting dropsof insulin and I was adept at playing, what I refer to as, the scale game.  I think of diabetes management like the scales of justice but the scale trays have holes in the bottom in my version.  You put some food on one side and it takes the scale off balance, so you add some insulin to the other side.  Sometimes the food runs out before it should and then the scale gets too heavy on the other side and so the day goes like a teeter-totter, gaining and losing riders. All I have to do is stand next to it and add the needed ballast to the proper side.  Just that easy.

But back to that pump class.  The trainer came around and asked if we had any questions.  People had tons, about activity, swimming all the newbie questions that pop into your head. I only had one question, I wanted to make sure I was understanding basal rates correctly, I asked, “am I reading this right, can I shut off the basal rate?”

The nurse said, “yes” and with that I was sold.

To me dealing with a low as a MDI patient was particularly disturbing because of the slow acting insulin that is active in the body.  Anyone that has used Levemir or Lantus will tell you that it seems to “burn” faster at times for no real reason, making it wildly unpredictable.  The notion that I could just stop the background insulin was amazing to me.  I now do it all the time, sometimes to slow a fall, sometimes to keep a BG level and often I do it just to buy me more time.  I’ll give you some examples:

(Literally), our school nurse called just now, it is time for recess and Arden is 64, too low.  It’s been 2 hrs and 30 mins since her last bolus and she is eating lunch in 30 minutes. If she wasn’t going to recess a would shut her basal off and retest her before lunch. Her are my reasons; we are well past the peak of her last bolus, she isn’t going to get any lower without insulin.  I bet if I shut off her basal right now and sent her back to class (she has no symptoms) she would be 90 at her pre-lunch test.  But she is heading out to play so I gave her a small candy (13carbs) and turned her basal off for 30 minutes (the basal isn’t probably needed here but I’m gong to trade a slightly higher BG for the nurse’s sanity).  This will counteract the activity and address the low.  She’ll be back before lunch probably at 160.  If I’m still writing when they call back I’ll put the BG (here). UPDATE: Nurse just called, Arden is 165 before lunch and after recess.  I’ll leave this space empty to receive your applause {          }.

Last week Arden was trending very low all evening, she was in the 120s before bed and I expected the lows to continue, so I tested her at 1am.  At 1am she was lower then I had anticipated (64) so I shut her basal off for an 90 minutes and went back to bed.  When I tested her at 2:30 she was still in the 60s, a stubborn low.  This next bit is a great example of how you can use restricted basal rates to control BGs.  At 1am Arden hadn’t had a bolus in 5 hours, so there is no residual insulin from the 8pm bolus left.  She is falling because of her basal.  Now I know that you may think the basal is just too high but please trust me it isn’t, this is an isolated anomaly.  Now the last thing I (any of us) want to do is wake up a 5 year old with a low BG at 2:30 in the morning and ask her to eat or drink, so I didn’t.  Instead, I’m going to take what the previous BGs tell me and use it in conjunction with the upcoming ‘dawn phenomenon’ against the low.  I also lend some credence to the knowledge that our meters have a 20% window of accuracy and with Arden her “real” number is usually higher then the meter indicates by 10-15 points.  So I’m betting on a few things; her BG is probably more like 75, which is less scary, sometime after 3am her liver is going to start making glucose and there is absolutely no insulin left in her body.  So I shut her basal off for a further 3.5 hours and went back to sleep.  The next day I woke up early at 5:30am to check her BG and she was 125. I win!

I figured that there would be a barrel full of knowledge handed out today about foods that bring up BGs.  I have my favorites as well but to be honest, if your BG is falling fast you need a fast acting carb, if it’s stable but low you can use something a bit more slow acting that won’t cause such a severe spike.  None of this is brain surgery.  If you really want to jump to the next level of care... learn how to manipulate the basal rates to get you where you need to be.  For my money, the best feature of Arden’s OmniPod is being able to restrict or shut off the basal rate.  It’s the best way I know to control a low.  

Here’s where I tell you that I’m just an idiot with a computer, not a doctor and taking my advice may significantly shorten your or your child’s life. For the love of all that is holy do what my wife does... and don’t listen to me.  

Seriously, you should talk to your endo about this method but be warned that they may not be comfortable with it and therefor just dismiss it out of hand.  If I’ve learned anything, it’s that doctors don’t like to appear not to know, so do what you think is best after gathering as much information as you can.  

I do want to add for clarity that if you gave a bolus that ends up being too large and an hour later you are very low, shutting off the basal rate isn’t going to make a dent in your precipitous drop.  This method is to be used in a few very specific situations. Please be careful and test, test, test.

If you missed it, my day one addition, “A day in the life... with diabetes” to Blog Week is here.

**

The following are archived comments from this post. You can post new comments below.

Andrea S.

Great post! I think the pump is geat for kiddos. Oh yeah and I'm subscribing to your posts.

Tuesday, May 11, 2010 - 02:32 PM

Scott

Practiced what I preach early this morning. Arden's #BGnow was 64 at 6:30 am, shut her basal off for an hour and she woke up at 95.

Wednesday, May 12, 2010 - 10:41 AM

saucyredhead915

You've got it down! Good for you! Now, can you help me? :)

Wednesday, May 12, 2010 - 12:04 PM

Scott

I'd be happy to help everyone!

Thursday, May 13, 2010 - 07:55 AM

Karen

When I had my pump training, I was told not to correct a low by turning off my basal because it takes too long to work.  Which you also pointed out in your post.  But it never occurred to me that I could reduce my basal to fend off a low.  Brilliant!  I tried it just last night - before bed I was 71 with over 1 unit still active from a snack.  I didn't want to eat again because I had JUST brushed my teeth.  I know I've been staying fairly stable overnight - so I knocked my basal down to 70% for two hours.  Worked like a charm, because I didn't get a single low alarm from my CGM.  And when I woke at 4am (because the cat decided it was play time) my blood sugar was 82!!!  Thank you for the great tip!!

Friday, May 14, 2010 - 10:21 AM

Scott

Karen,

It makes me so happy that my tip worked for you - you don't know. Because I understanding what your life is like (on the level that I do), your comments literally made my eyes fill up with tears.  This comment alone made your Blog Week project worthwhile for me.

blog week - http://bittersweet-karen.blogspot.com/

Best,

Sunday, May 16, 2010 - 08:51 AM

Sarah Kelly

I also think that this must work more quickly for children.  I've utilized my two-year olds sons pump temporary basal setting to keep his BG stable or to come up over night quite often, mostly because he HATES to be asked to eat or drink anything once asleep (who could blame him).  I have however had a difficult time utilizing it for exercise as it seems that the effects of it being shut off are longer lasting than I'd like and often lead to more drastic highs later.  
But for us it's definitely the best way to treat nightime lows.

Sunday, May 23, 2010 - 06:38 PM

A day in the life

I some how deleted my post from Day one... This is it (reposted) word for word but I lost all of the nice comments you all left. Sorry!

This blog is an entry into blog week over at http://bittersweet-karen.blogspot.com Great thanks to Karen for this fantastic opportunity.  

This is version 2 of my ‘Day in the life... with diabetes’ blog week entry.  Version 1 is 85% complete and I don’t like it.  I was about to post it when I decided to walk away from it for a moment, so I took a shower.  I do my best thinking in the shower, as a matter of fact, if my iMac was water proof I think this blog would win a pulitzer.  Sadly, it seems that I lose like 25 intelligence points when the hot water stops running down my neck, so with that in mind, here is my blog, v2, sans hot water.

My first pass at this writing exercise was solid, lots of times and actions documented.  You know, “at 2am I test, she was...”.  It was informative and lent insight to what a day is like when you are the parent of a type I diabetic.  I just deleted it, deleted it because I realized that my audience likely falls into one of two camps; people that already know how much this all sucks and the people that can imagine how much this all sucks.  So forget all of that and let’s talk about what a day with diabetes is really like.

My day is long, sad, exhausting, stressful and frantic.  It is also, glorious, hopeful, enlightening and moving.

Some times when I walk from room to room and see my daughter Arden and I think, “Arden has diabetes” and that is just sad.  It’s sad that I didn’t think, “look how pretty she is” or “she’s doing so well in school... at softball... as a person”.  Don’t get me wrong, those things flood my mind most of the time but that I ever have that other thought makes me sad and it makes me angry and it dings my soul.  Some times I think of my soul, that part of me that holds my hope for the world, as being wrapped in armor.  I’m afraid that it can only take so many hits before it cracks open and my hope escapes.  Most days, my day has sadness in it, most days my soul takes a hit.

I haven’t slept soundly through the night in almost four years, even in those rare times that I am not with Arden when we sleep, I still think about her.  Last week my wife Kelly was out of town for business and the second she left I thought, “what if I don’t wake up tonight when I need to”... that was my first thought when she walked out the door.  What kind of a horrid existence makes that your first conscience thought, in that moment? A life with diabetes. My day is consumed with type I, it effects my every thought, feeling and action.

We all (parents of type I kids) have the same fears, stresses and worries.  Some of us, I believe, try very hard to keep the negative concerns out of our day to day thoughts.  But with all blunt honesty, we are all just trying to keep our kids alive for as long and as well as we can.  We are all beating back a tide of health concerns, both mental and physical.    Our community was rocked recently when a little boy with type I passed away.  He was by all accounts very well cared for, his death was an unthinkable tragedy and a stark reminder that it could have been any of us.  You want to know what my day is like?  Every night I tuck my daughter in bed and I think the same exact thing, “please don’t die”.  Will that happen, probably not but it still may and it’s not fair to have ponder that every day.  Like most other people’s, my day isn’t fair.

My every decision regarding Arden’s care is graded, her health hangs in the balance of my being able to properly understand and navigate a disease that is only partially predictable.  Before you think, “this guy needs to be more positive”, don’t bother, I’m the most positive guy you’ll likely meet.  However, there is a grand distinction to be made between being positive and being realistic.  Being ‘positive’ is important and it plays an monumental role in the mental side of living with type I but ‘realistic’ is going to keep Arden healthy and alive longer.  My mom use to say, “if wishes were horses, beggars would ride”.  What’s my day like? Vigilant. Why? Because the day will come when type I gets the better of our little girl and I want that day to be as far into her life as possible.  There is much that is out of my control but the things that I can effect, I will without fail, every minute of every day.  I’m not counting on wishes.

Okay, enough of that, let’s get to the good stuff.  No waiting in line at Disney.  Without a doubt not having to wait in line at Disney is the best part of type I diabetes.  I kid, well not completely, the no waiting in line at Disney perk really does rock... but there is more.

I may experience sad things in a day but I am not a sad person, nor do I think of my life or Arden’s as a sad existence.  Maybe better then the Disney thing, is the perspective that type I has given me.  I truly believe that you can’t fully appreciate the good when you don’t really understand just how awful the bad can be.  You want real perspective, all you need is a chronically sick child and then you’ll have it.  It trumps all other perspective.  Until you find yourself hoping for your child to be cured, you don’t know hope.  Until you see your child battle in a way that you never thought that a person, let alone a child could, you don’t know glory.  Arden is strong.  We probably all have the ability to be that strong but many of us never are.  Arden knows how strong she is because type I tests her and I am grateful that she has that knowledge.  I’m grateful to be able to just be near a person that is using that much of their capabilities.  It’s inspiring, my day inspires me.

Until you experience the warm embrace of a community so connected by the most important bond anyone can imagine... you’ve not been moved.  Diabetes parents have an energy about them, sometimes up and sometimes down but never alone.  We all know what a bad day is like and we know that a good day is on the way, so we lend support, so that today’s bloody and battered can make it to tomorrow.  Again, I am moved by the people that I’ve met since Arden’s diagnosis.  My day moves me.

Once I had goals, they were many and oft driven by my age and perspective.  I wanted money and success, luxury and relaxation.  Today, none of that is important.  My only concern is my family.  If we lived on the side of a hill in a shack and we were all healthy, I’d call that a win.  I don’t want or need any material thing that this world has to offer.  I only want my family to be happy and need type I diabetes to be cured.  If nothing else, my day with type I is enlightened.  

To conclude, my day is a fuc&i*g mess but it’s mine.  I own it and I’m making the absolute best of it that I can.  Plenty of people have plenty of problems, type I is just ours.  I don’t hide and I don’t quit, I believe that our children will gain the most normalcy through transparency and that openness is the best route to a cure.  This was about as open as I can be... this is what ‘a day in the life... with diabetes’ is like.... for me.

**

The following are archived comments from this post. You can post new comments below.

saucyredhead915

Wow! Thank God for Twitter and Diabetes Blog Week or I wouldn't have found this! I plan on coming back to read...often :)

Wednesday, May 12, 2010 - 11:58 AM

Barbara (Julia's Grandmother)

Cried as I read what you wrote since, unfortunately, I can relate to it all.
I worry all the time too  (especially at night) about my granddaughter, even though my daughter (Julia's mom) checks her blood sugars through the night (like you do).  It is always a constant worry because we love them so very much.

We too are positive and happy around Julia all the time.  Therefore, when I found out about the front of the line passes for type 1 diabetics at Disneyworld (as you spoke about in your write-up), I could not wait to let Julia know. She is so very excited about this. 

There is way too much sadness with this disease, therefore, when we find out about something wonderful, it does make our day.

Thanks again for your great web-site.

Wednesday, May 12, 2010 - 01:51 PM

Your loving mother

I knew if I waited long enough you would use one of my many oh mom! sayings-  

see I told you they were sayings you would remember and one day use.

Friday, May 14, 2010 - 04:03 AM