Yesterday was a day to remember. Events began with an ungodly low blood glucose (BG) of 22, continued with a crazy high BG of 545, and ended with a tantrum over a lost movie. Hypoglycemia and hyperglycemia to the extreme. Some 18 hours later, however, all was well, as if the whole incident had never happened.
Part I: 4-5:40 pm
Our 19-year old caregiver, K, picked up our kids from school at 4 pm, as usual, and took them, and our 3-month old dog, to the park to play. K. is a great young woman: attentive, smart, and caring. She also has two younger sisters with Type 1, and has been around T1D for most of her life. She knows insulin pumps, basal rates, bolusing, and carb counting. And the kids love her.
K. had checked our five year old son, Sacha, just before starting to play. His BG was 190, just over his normal range. She gave him a snack, and under-bolused, knowing he was going to be running around.
The kids started to run around with Molly, our hyperactive puppy. They rolled down grassy hills, sprinted, threw the ball, chased and were chased. Good times.
Suddenly, about 15-20 minutes into the play session, Sacha lay down on the ground. He was hungry, he said, and couldn’t feel his legs.
K. quickly tested him – his BG was 22.
Sacha’s target, as a young kid, is 150, with a permissible range of 120-180. A BG of 22, in other words, is off-the-charts low. As the hospital nurse later said, she’s never heard of anyone going that low, and still remaining conscious.
K. picked Sacha up (she’s a strapping young woman – used to be an athlete), and sprinted to the car with his nine-year old sister, Tessa. She gave him three boxes of juice (15 carbs each) while driving home. Luckily, he was still conscious, and could hold the juice box in his hand. Again, the nurse couldn’t imagine someone being able to drink with a BG of 22.
By the time they were home and my wife got back to the house, Sacha’s BG was fine: he was 150.
Part II: 5:40-7:30 pm
I arrived home at 5:40. My wife and I conferred, and decided that Sacha was OK to go with his sister to their normal Friday evening activity, a math lesson at the local Kumon centre. We try not to let diabetes get in the way of his routine.
So the kids and I drove to Kumon. They were happy, laughing, and eager to get back home for their Friday evening pattern: hamburgers, french fries, and a movie.
Sacha began his class at 6:15, and was done by 7 pm. When he came out, I noticed he was pale. Before I could even pull out the test kit, Sacha told me his pump was beeping. I took off his belt, and saw a “pump occlusion” warning.
I tested him, and got my second shock of the day: his BG was now 545. It’s never been that high. In fact, I’ve never heard of anyone else being that high. I re-tested, and got a similar result. It wasn’t a mistake; he really was in the mid-500s. The combination of a failed pump, the three boxes of juice, and his counter-cyclical response – sugar released from the liver after the extreme low BG – were turning his blood into glucose-laden sludge.
I yanked his pump out of his body, and gave him two units of rapid acting insulin by syringe. We jumped into the car, and started driving home. I was so nervous, I couldn’t think straight. “How much will two units drop him?” I couldn’t remember the insulin impact factor we use (one unit should drop him by 160 BG points, but I only remembered that later). I didn’t know what to do; reinsert the pump once we arrived back home? How much basal? How much more bolus? What to do about dinner? My mind was racing, and suddenly, I was unable to add, subtract, or perform any higher order cognitive functions.
If I had been calmer, I would have realized that the two units of insulin I gave him by syringe would drop him by 320 BG points over two hours. That should have brought him down to about 220; still high, but better. We could have bolused him for dinner, put the pump back in at the regular basal rate, and then tested again a few hours later. As long as he wasn’t vomiting or losing consciousness from the super-high BG, he would have been fine. I would have checked his blood a few times for ketones, just to ensure that he hadn’t experienced a build-up that would require more insulin.
I should have known this; I’ve read the books, had the briefings, and held the conversations. I should have been able to think all this through.
Instead, I couldn’t think straight, and so called the children’s hospital, hoping to speak to the on-call endocrinologist.
In our old hospital in Canada, we could get right through to the on-call; one ring to the operator, and within 20-50 seconds, we were on the phone with a doctor. Here in Minneapolis, however, you have to go through two layers – a phone operator, and a nurse – before getting to the doctor. Each one is slowly accessed behind a wall of “press 2 for this, and press 3 for that,” and then asks you multiple questions before allowing you through (name, “spell that please,” insurance provider, date of birth, “sorry, can you repeat?…”). Seems like an eternity when you are anxious.
When I finally got through to the nurse – not the doctor – I must have gotten someone brand new. She asked me if Sacha was unconscious or vomiting, and I explained that despite the high BG of 545, he was now at home, playing with the dog, and ready for his dinner. She asked if he was thirsty. Of course he was, I replied; his BG was sky high.
She told me to go to the hospital.
Who was I to argue? I could barely think straight. My wife sensed this was a mistake; “Why not just stay here and let the insulin work,” she asked, but I was hell bent on doing what the nurse had told me. I needed reassurance from a professional, and if I had to go to the hospital to get that, I was willing to go.
Part III: 8-10:30 pm
We jumped into the car, and drove 10 miles to the children’s hospital in St. Paul. The nurse had advised that we should bypass the Minneapolis hospital, as the endocrinologists preferred to have T1D children in St. Paul.
We got through the preliminaries quickly; the intake nurse was astonished that Sacha had had a BG of 22, and had remained conscious throughout. We were rapidly shown to a room, and the emergency room doctor quickly arrived. She had no idea, of course, of what to advise – T1D pediatrics is such a speciality – but called the duty endocrine, probably the same person I’d wanted to speak with two hours ago.
I got on the phone, and within moments, the soothing voice of someone who’d seen this many times before walked me through the logic. Why had Sacha’s BG gone so low? Was it a pump problem? Had the occlusion led to a burst of insulin while he was playing at the park? Probably not, we concluded; the super-low BG was likely a result of the vigorous playing, and the occlusion probably came after, rather than before. We calculated what I’d given him by syringe, what I’d given him for dinner, what he’d eaten, and his impact factor.
The doctor quickly concluded that there was no need for me to be in hospital. Go home, she said, retest in a few hours, and start correcting with a bolus then.
We drove back home. We’d spent almost three hours going to and fro, and wasted lots of hospital time and money. My adrenalin had been sky high, and I was knackered.
Sacha’s main concern, however, was movie night – had he missed it? “Yes,” I said, “it’s now almost 10:30 pm. You have to go to sleep when we get home”
Sacha burst into tears for the first time today. “You’re the worst dad ever,” he howled. “I want to watch a movie! We always watch a movie on movie night!”
I was too exhausted to argue. He’d had a terrible afternoon, and had been through so much. I wanted to give him a movie, but knew that would be the wrong thing to do; a movie at 11 pm? Made no sense.
So we drove home in one-sided silence. I tried to mutter soothing words, and Sacha sobbed, stopping only to defiantly murmur that he was going to watch a movie, come hell or high water.
Things got worse when we arrived home, and his mother reinforced my message of going to bed. Now, Sacha wailed, it wasn’t fair; his sister, Tessa, had just racked up an extra hour of movie time. She’d watched while he was in the hospital, and then gone to bed. Even if Sacha watched the next morning, she’d be watching too, and then she’d have an extra hour of movie time in her movie watching history…..utterly and totally unfair, he said.
I couldn’t deal. I slumped into bed, and my wife took Sacha to sleep – usually that’s my job – but tonight, I just didn’t have the heart.
Sacha, of course, was asleep in seconds.
Part IV: 11pm -7 am
Not over yet.
His BG was in the 300s before he went to bed, but at midnight, he was up to 486 again. I was terrified that the pump wasn’t working again. What was going on? We’d switched insertion sites and insulin, but was the pump broken? Did his skin have too much scar tissue?
I tested again at 2 – BG now in the 300s, but dropping, thank goodness – and then again at 4 and 6, I think. I can’t really remember. He eventually came down to 205 by the morning; the pump was working. The night time high must have been the result of all that juice he drank earlier in the day, somehow mixed up with the protein from the hamburger at dinner, and the counter-cyclical sugar production from Sacha’ liver…..who knows.
The morning after, all was well. Kids were happy, dog was happy, Power Rangers were being gleefully watched, followed by swim class. I continued to watch him like a hawk all weekend, looking forward to Monday, when I could go to work and put Sacha’s BGs out of my mind for a few hours.
If it was exhausting for me, how must it have all felt for Sacha?
I’m guessing that his tears last night were only partly about the movie.