We are about to embark on the biggest transition since Bisi was diagnosed: she’s about to start on an insulin pump. When she was in the hospital, they told us that most people are ready for this transition about a year after diagnosis—that before you go on the pump, you need to understand the disease, understand how to do injections, understand how to count carbs, and understand the whole new routine of diabetes. We now know how to do all that, but still, I’m nervous and hesitant about the transition, and it probably wouldn’t be happening yet if Bisi hadn’t been pushing for it. More accurately, it’s because we know how to do all this with injections that I’m nervous about switching to another method. It’s leaving behind the known for the unknown. But she is beyond sick of getting shots, and it’s not fair for us to delay any longer than we have.
For those unfamiliar with the day-to-day routine of diabetes, there are some key differences between how injections work and how pumps work. With injections, the smallest amount of insulin you can give is ½ a unit. So there are often times—snacks, or meals where she’s not eating a lot of carbs, where Bisi doesn’t need to get insulin injections. For Bisi, anything below about 15 carbs is “free”—no insulin required. But the pump can give exact, tiny doses, so every time Bisi puts something with carbs in her mouth, we should test her blood sugar, calculate the number of carbs, and give her the insulin to match. This means that in theory you can achieve tighter blood glucose control on the pump along with less severe swings in blood sugar, because you’re able to give exactly the dose of insulin needed to cover the carbs you’re about to eat. But this change will be an adjustment, since I tend to use snacks to give her a “boost” in her blood sugar to keep her safe when she’s going to soccer practice, or to extended day, or over to a friend’s house. I feel nervous about giving that boost up.
Another big difference is how the basal, or baseline, dose of insulin is given. Right now, Bisi takes a shot of Lantus, long-acting insulin, once a day. This means that she always has some insulin working in her body—essential because even if Bisi were to eat nothing all day, her liver would still release glucose, which needs to be balanced by insulin. With the pump, rather than getting a Lantus shot, she’ll get a tiny drip of Humalog (short-acting insulin) throughout the day. If the pump malfunctions without our realizing it, she will have no baseline insulin in her system, and could go into diabetic ketoacidosis if we don’t discover and remedy the problem soon enough.
When the body can’t use glucose for fuel (insulin is the key that unlocks cells, letting glucose in), it burns fat cells instead. As the fat cells are broken down, they release ketones, which are toxic to the body. (In 2009, the most recent year for which stats are available, 140,000 people were hospitalized for DKA.) On the pump, this means that whenever Bisi’s blood sugar goes over 250 (a fairly frequent occurrence), we have to be much more aggressive than we have been about testing her for ketones. If the ketones are above a certain level, we are supposed to immediately give her an injection of insulin. Only then should we problem solve what’s going on with the pump.
Several kinds of pumps are on the market; together we chose the Omnipod, a little plastic case, about 2.5 inches by 1.5 inches, filled with insulin and stuck somewhere on Bisi’s torso or leg. The Omnipod, unlike all other pumps, is tubeless, meaning it’s stuck directly onto the skin, rather than separated from the body by plastic tubing. The other day we met with someone from Omnipod at our house, and she helped get us started by showing us how to put in all the necessary settings and how to install the pump. For the initial week, the pump is filled with saline, not insulin, so we can learn how to use it without consequences. It’s controlled by a separate, small computer, about the size of a double-thick iPhone, that also serves as a glucose meter, can calculate her carbs, and stores all of her dosage data.
At the end of the session, we stuck the pump on Bisi’s back. Controlled by the PDM (personal diabetes manager), a tiny needle inserts a little plastic tube from the pump into Bisi’s back. Her nurse had told us to sing happy birthday to distract her from the insertion, but Bisi chose Taylor Swift’s “22” instead. “It feels like a perfect night to dress up like hipsters [Bisi used to think Swift was saying hamsters instead of hipsters], make fun of our exes, uh huh…” POP. When the needle went in, Bisi’s eyes widened and she swallowed hard. It clearly startled her—she said it felt like a balloon popping inside her body. Starting next week, if all goes well, Bisi will be facing just one “balloon pop” every two or three days, rather than the 4-5 daily injections she now gets. She can’t wait to make the trade.
Katie Bacon writes the blog Eating With Bisi.