Does anyone else remember the scene in the early 90s movie, Reality Bites, where Winona Ryder’s character is on a job interview and someone asks her to define the word “irony”? And she’s in an elevator and she’s unable to get out anything coherent before the door closes, and so she doesn’t get the job? (And yet somehow ends up with Ethan Hawke, if memory serves.)
Being a bit obsessed with words, I think of that scene embarrassingly frequently. It’s a dorky daydream: I pretend that I am in the elevator instead of Winona, and as the door closes I blurt out, “It’s when the reality of a situation doesn’t match your expectations!” Then the door slides open and I get the job. Like I said, I have the fantasies of a nerd.
Anyway, I bring this up because last week I was subject to a severe case of diabetes irony, from which I’m still recovering. I was at the 2013 Joslin Diabetes Innovation Summit, an event presumably geared toward the cutting edge of diabetes technologies and care. Judging from the vendors present (Dexcom, Tandem, etc), I expected to come away psyched about the next generation of diabetes devices that will hopefully soon hit the market. And I did, mostly.
I say mostly because as I was rushing to get my train home from the conference, my insulin pump tucked into my bra (as is often the case when I actually dress nicely), I was reminded of the human variables that hold technology back. This was indicated, quite succinctly, by a disturbing vibration against my sternum. Not the single-buzz, “I just finished delivering a bolus” vibration, but the ten or so quick-in-succession vibrations that indicate there’s something wrong. I pulled it out, and saw one of my least favorite messages to see on my insulin pump late on a Friday afternoon while on Amtrak: “Button Error.”
I immediately knew that my pump was a goner — this is my third similar failure in approximately a year, one of which caused me to miss a close friend’s wedding ceremony. (Ladies, if you wear your pump in your bra, apparently it’s important that the buttons face out. Got that? Buttons out!)
Luckily this time there’s no wedding — but I was planning on eating dinner. So I get on the phone with my endocrinologist’s office and eventually am able to figure out how much Lantus to take. I also get my pump company to send me a replacement for the next day. I’m aware that going from my pump to shots is always rough, but at least it’ll be over in 24 hours when I get the new pump.
So it arrives, I fill it with insulin and go about my business, which that day involved building garden beds on an unseasonably warm day (note: not my normal Saturday activity). Have dinner, which involved a bit of bread, so I wasn’t immediately surprised when my glucose was high. But oddly, I couldn’t get it down. I was high Saturday night and all day Sunday, and then on Sunday night was woken up 4 times by my CGM.
Assuming there was something wrong with my infusion site, I switched it out Monday morning, took a correction bolus, didn’t eat breakfast, and walked a mile and a half to work — only to find my blood glucose even higher than when I’d woken up. And then it occurred to me: I’d had my insulin vial with me on that hot day in the garden. It must have denatured. I rushed home, got a new vial, took a shot, switched the insulin in my pump, and sure enough, I’d identified the problem. . . just in time for my Dexcom sensor to fail.
It was a very stressful couple days — definitely not what I’d expected the follow-up from the Innovation Summit to be — and it reminded me of a pesky fact that weighs down progress in diabetes care: just how human the disease can be.
For example, it might seem obvious in retrospect that my insulin had denatured — perhaps you’re asking yourself why I waited a day before even changing the infusion set. But that 20/20 hindsight doesn’t take into account all the other variables that could have contributed to the problem. Maybe my blood glucose was high because I’d spent two days at the conference sitting on my butt with no exercise. Maybe it was high because I’d had some of the delicious bread my husband made. Maybe it was high the next day because that bread had butter in it, and the fat could have slowed its absorption. Maybe I was pre-menstrual. Maybe I was getting sick. Maybe I was tired, and it was affecting my blood glucose. Also, my blood sugar never got higher than 240 mg/dl or so — so it wasn’t outrageously clear that there was a non-food-related problem. Only after working through all these possibilities did I go to the infusion set. And it was only after THAT failed that I thought about the insulin — which, frankly, surprised me, since in my 13 years of diabetic life, I’ve never had insulin denature. (And that includes seven months spent traipsing the world with inconsistent refrigeration.)
It makes me want to put together a flow chart-style quiz of possible diabetes failures (see Esquire Magazine’s Charlie Sheen example below). Questions would include things like, “Did you just eat a syrup-drenched waffle?” (If yes, go to “Uh, maybe you need insulin?!”), and “Did you just catch your pump on the silverware drawer?” (If yes, go to “You need to change your set — and your kitchen hardware.”) Anyone else got ideas? We’ll never be able to pin down all the variables in diabetes — and technologies, no matter how great, will never be foolproof — but we might as well at least try to establish a tool to determine which of the seemingly infinite variables of diabetes is responsible for screwing up our day.