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Posts tagged ‘low blood sugar’

Looking Back: Lows in Public.

On the road this week, so I’m looking back at a post from June 2012 about experiencing hypoglycemia in a public place.  It’s never fun to be low, but I’m always grateful for the patience and compassion of others who help see me back to being in-range.

*   *   *

I heard the Dexcom BEEEEEEP!ing in that frantic, “you’re low” kind of tone and my brain was swimming with confusion, so I went to the bar at the dinner event and asked for an orange juice.

“Do you want vodka in that, as well?”

“No, definitely no thank you.  Just juice, please.”

The bartender filled up a small tumbler with orange juice and I downed the contents of the glass in one giant gulp.

“Thanks,” I said, and wandered off, fishing my meter from my bag to get a true assessment of how far down the rabbit hole I’d fallen.

There isn’t ever a convenient time for a low.  I suppose the ones that happen when I’m at home and are only in the 60 mg/dL range and can be treated with the logical and tempered rationing of glucose tabs are better than the ones that happen in public.  When you’re at a dinner event and you’re trying to meet people and make a favorable (or at the very least, coherent) impression, it’s not the most opportune time for a 38 mg/dL to make an appearance.

Once I saw the number on the meter, I became this strange, hypoglycemic bear, foraging for food and ready to growl at anyone in my way.  The very nice waiter who was bringing appetizers around to the attendees ended up with an empty plate after I had my way with him.  (Which sounds worse than it actually was; he only had three snacks left, but I snagged them and might have bared my teeth at him in the process.)  My low symptoms were peaking, with tears in my eyes and confusion on my tongue and every skin cell buzzing with panic and adrenaline.

I do not like being low in front of people.  I don’t like that momentary weakness and the vulnerability and that empty, lost look I’ve been told takes over my eyes.  I don’t like that lack of control.  I don’t like when my knees buckle while I trying to keep myself upright.  I don’t like the look of “Are you okay?” that comes over the faces of most people, because it’s one of the very few times I have to answer, “No, I’m not.”

Thankfully, I was at a diabetes-related event, surrounded by people who either had diabetes, cared for someone with diabetes, or worked to cure diabetes.  So when I casually mentioned to Jeff Hitchcock that my blood sugar was tanking and I didn’t know what was going on, I was ushered quickly and covertly to a seat at a nearby dinner table so I could make sense of things.

“I’m fine, you know.  I had juice.  I’ll be fine in just a few minutes,” I said, folding and refolding the napkin on the table while I waited for my blood sugar to respond to the juice.

“I know,” he said, his voice calm and reasoned.  “We’ll wait.”

As it always does, the panic subsided.  My blood sugar came back up into range (and went up just a bit more than it needed to, thanks to downing that whole glass of orange juice).  And I was able to rejoin the dinner conversation without needing a three-minute lapse between thoughts, thankful for people who “know.”

Hypo Unawareness.

There are times when I think that maybe my hypoglycemia unawareness is made up, or all in my mind, or that it’s overblown and exaggerated.  “Pfffft, you can go without a Dexcom for a few hours, because you’ll totally feel any lows that crop up,” is the mantra that runs through my head when I pull a sensor off and see scaly skin, knowing I should wait before even going near the skin with another sensor.  (The Dexcom adhesive/sensor rash isn’t entirely better, but mostly better. The Toughpad underneath the sensor holds it for at least seven days, and more often than not, I’m able to go approximately ten days per sensor.)

But the thing is, I shouldn’t let things go that long.  I should be pulling the sensors at the seven day mark, to avoid mangling my skin and forcing myself into brief CGM hiatuses.

I tend to wear my sensors in the same region of my body (outer thigh), where there is enough real estate to work with, but not enough to work with exclusively.  The time between sensor reapplications, whether it’s a week or more, isn’t enough time for my skin to fully heal.  Sometimes a skin reaction doesn’t occur and the skin that was trapped underneath the Toughpad for a week is still unmarked and supple, so I can stick another sensor in whenever I’m ready.  Usually, regardless of how the skin looks when I pull off a sensor, I rotate to the other thigh and try to pick a different insertion spot, just to keep things on the up and up.  And sometimes, even when the skin looks good after I pull a site, it sometimes turns red, prickly, bumpy, and scaly a day or two afterwards, and remains scaly for several days.  (I apply this Curel lotion to my scaly skin and it helps quite a bit.)


I have trouble – lots of it – pulling a sensor off simply because it’s hit the seven day mark.  If that sensor is stuck, and the results are good, I want to leave it on as long as possible.  I feel like the longer a sensor is on, the more accurate and precise it becomes.  Days 8, 9, and 10 are always spot-on and I feel confident in the results because they not only match up with my meter for spot-checks, but they consistently match up.  Seeing more than a 15 point spread between my Dexcom number and my blood sugar meter check is a rarity in those date ranges.

Frustrating, to say the least, to pull of a sensor that seems to be working just effing fine, thank you very much.

I need to take better care of my sites, because for every long sensor shelf (leg?) life, I’m paying for it on the other side with scaly, un-useable skin.  Which equals out to needing to let the sites breathe for even 18 hours or so every few weeks.

Which ends up resulting in moments like this today:  Sitting in the parking lot at the bank, chewing and swallowing glucose tabs as fast as I can because the blood sugar of 41 mg/dL came out of no where and the only reason I even tested my blood sugar before driving home was because Birdy asked me if she could have a snack and I wanted to have a snack, too.  I had no idea my blood sugar was tanking.  Even in retrospect, the only symptom I had was a clumsy fumble for my meter in my purse, but I initially blamed the fumbles on cold hands.

I chomped the hell out of those glucose tabs – not out of shaky, panicky hypoglycemic symptoms, but the lack thereof.

 

Looking Back: Telling Off the Paramedics.

A few things: 

This post is almost ten years old, which is unsettling on its own accord.

It also documents the only time in my 27 years with type 1 diabetes that paramedics needed to be brought in to assist, and mostly because my roommate needed help getting me to eat, not because I was unconscious.

I miss Abby and her magical, glucose-sniffing powers.

The day after this low blood sugar happened, I drove to the fire station and thanked the paramedics profusely for their help, and apologized just as profusely for my actions. They said they see it all the time. The fact that they see it all the time and continue to do what they do to help people makes me respect their profession, and all HCPs, even more.

Apologies for the language used. As you know, I wouldn’t swear unless I was low.

*   *   *

Abby. My cat.

She has never missed a low blood sugar. There have been times when I was so low that beads of sweat collected on my forehead, making my face clammy and my t-shirt damp with panic. Usually my body wakes itself up in time, leaving me just enough energy to stumble out to the kitchen and pour a glass of juice. But sometimes I don’t wake myself up.

That’s where Abby has never failed me.

She will sit on the pillow above my head, wailing like a banshee. “Meow!” She paws fiercely at my head and nudges my face with hers. I usually come around as she is pressing her nose fervently into my ear. “Me-ow!” More insistently now. She won’t stop wailing until I am trudging through the living room towards the kitchen. Siah hasn’t figured out this trick yet. But I’m sure she will in time. Or maybe Abby is just in tune with the way my body starts to panic.

Sometimes I feel waves. The ones that gently undulate and lap at the shores of my consciousness. I focus what is left of my resolve on remaining awake, waiting for the juice to take effect. Those are the worst ones. The ones where I am afraid I am going to pass out.

I’ve never passed out. In almost two decades of diabetes, I have never been unconscious. Of course it may happen. It could happen to any of us. But I have come close.

There have been some tricky lows, though.

There was one that I had in January of 2003, while I was living with my ex-boyfriend. The alarm clock went off in the morning, but I didn’t stir. He got up to turn it off. Usually I lean right over and grab my kit off the nightstand so I can test my blood sugar, but that morning I wasn’t moving at all. He had dated me for six years and he knew the signs of a serious hypoglycemic episode, so he immediately woke up and tested me himself. My bloodsugar clocked in at 44 mg/dl. He went downstairs and grabbed a glass of juice.

“Kerri, get up. Drink this. You’re low.”

Nothing from me.

“Hey. Drink this.”

Most often, I sit up, obligingly grab the glass, consume the contents with graceless gulping, and fall back upon the pillow until the tides of my sugar rise enough for me to sit up and say, “How low was I?” This time, I took the glass from his hand, told him to leave me alone, and proceeded to pour the juice all over the bed.

I’m known for being slightly combative when low.

He got another glass of juice. And the phone.

“Kerri, you need to drink this. If you don’t drink it, I am going to call the paramedics. “

After being told, repeatedly, to go fuck himself, [Note: I'm still embarrassed by this.] Roommate dialed 911. Three paramedics showed up, one slightly chubby. I am in bed, at a minimal level of functionality. I don’t remember what happened from here on in, but Roommate told me I was belligerent.

Roommate told them I rang in at 44 mg/dl. They grabbed the red and white tube of InstaGlucose from their med kit and advanced on me. In the throes of my low, I fought them off as best I could. They outnumbered me considerably; it took three paramedics to hold me down well enough for Roommate to administer the InstaGlucose in my fitful mouth. The paramedics let me loose. As the sugary substance absorbed into the inside of my cheeks, I turned to Roommate with a resounding “Fuck you!” I whirled to the most portly of the medics and growled, not unlike Linda Blair, “You too, fatty!”

I came around very slowly. I don’t remember much of how I ended up downstairs, but I am told that I wandered down the staircase and stood at the front door, clutching my blanket around my shoulders and murmuring, “I want my Daddy.” Because that’s not at all embarrassing.

Roommate told the medics that I would be fine in a few minutes, having just tested me and yielding a result of 68 mg/dl. “She’s on the upswing. She doesn’t need to go to the hospital.” To confirm my agreement, I had to sign a release form, stating that I refused to be brought to the hospital. I signed, half in a fog.

Fast forward to me in the shower, getting ready to go to work. The medics are gone. Roommate is sitting on the bathroom counter, monitoring me. I start to remember what happened. We talk about how everything is okay now, and how sometimes a low just sneaks up and destroys me.

I’m feeling much better. A little embarrassed that I was such trouble, but no harm, no foul, right? I smile sheepishly. Safe now. Abby was prowling about on the bathroom floor, making sure everything was okay now.

“Yes, Kerri. You did okay.”

And as the warm water washed away the traces of InstaGlucose from my arms and eased the tension in my muscles, I gasped in shock as I cried, “Oh my God! … I called them fat fucks, didn’t I?”

The laugh from the counter top confirmed.

On Sale.

The post-holiday discount aisle at CVS …

"In Case UR Low"  Or maybe "4 UR Hypo" ?

… is perfect for restocking low blood sugar supplies.

Endless Lows.

I do not know what makes them stick like this, the lows that creep in and stay creepy for hours at a time.

“Is this thing serious?” I asked.  Then I’d prick my finger to confirm that, indeed the Dexcom was serious, and I was in fact still low.

There are times when high blood sugars are stubborn and refuse to come down, even when I rage bolus and exercise.  But I can tolerate a sticky high because, even though it’s not comfortable, I can still function properly-ish.

The endless lows, though, work me over in a way that’s entirely different.  Last night, I came home from the gym with a downward drop in my Dexcom, and it lasted for two and a half hours.  Which meant that, for two and a half hours, I had a combination of numb lips/tongue, shaky hands, mental fogginess, and that urge to cry without reason.  I had to constantly tell my daughter, “I just need a few more minutes, because my blood sugar is low.”  I was thankful that Chris was home to help me negotiate parenting stuff/reminding me to eat something else.

What makes this happen?  How can I chomp down ten glucose tabs and a banana and some applesauce over the course of three hours and barely see a blood sugar budge?  It took over a 150 carbs to make a dent (And that dent peaked up to 200 and then promptly fell again.  What the eff?).

“What are you now?” Chris asked before bed.

“202.  And I’m fine with that,” I replied with finally-not-numb-lips-and-a-shirt-collar-dusted-with-glucose-tabs.

The Art of the Pre-Bolus.

"Fucking frost on my eggplants."  Batman tries to wait patiently for his bolus to kick in.“So it’s a Wednesday night … what’s the chance we might not be seated right away?”

“Are you talking to me?” Chris asked, pulling the car into a parking spot near the entrance of the restaurant.

“Yeah.  Sort of.  I’m trying to decide if I should bolus now, because I’m 200 and I don’t want to be high all night.  Or eat ice for dinner,” I responded.

The science of a pre-bolus makes sense to me.  Take your insulin before you eat so that it’s active in your system when the food hits.  Or, in smarty-pants terms:  “A bolus of rapid-acting insulin 20 min prior to a meal results in significantly better postprandial glucose control than when the meal insulin bolus is given just prior to the meal or 20 min after meal initiation,” states the conclusion of this study from 2010 examining the influence of timing pre-meal boluses on post-prandial blood sugars.

I put this theory into practical application during the second and third trimesters of my pregnancy, when insulin resistance was constantly on the climb, as were my actual insulin needs (thank you, hard-working placenta).  Around the 22 week mark, I needed to pre-bolus approximately 25 minutes before a meal.  Around the 30 week mark, I was upping that time frame to 45 minutes prior to eating.  And now, without a baby on board, I still try to bolus at least 20 minutes before I eat.

Making the decision to pre-bolus is a precarious one, because the success of that decision rests in the quiet of variables.  (What, too esoteric?  I wrote that sentence from a cloud.)  Pre-bolusing only works when nothing else gets in the way of eating.

Exhibit A:

Yesterday morning, I woke up to a shiny 218 mg/dL on my glucose meter, so I wanted to make sure I pre-bolused for breakfast, since morning highs tend to stick with me well into the early afternoon.  (Little jerkfaces.)  I took my correction bolus and my meal bolus in combination with one another for my meal (eggs, avocado, and a slice of toast do not judge me for eating toast), and set about playing with Birdzone until it was time for breakfast.  Only the best laid plans of this PWD were derailed by a phone call, a frantic search for Carrots (Birdy’s stuffed rabbit, who happened to be in the dryer, a la Knuffle Bunny), and falling down the email vortex for a spell.  End result?  I skipped the toast and ended up chugging some juice with my breakfast.

Exhibit B:

Before dinner out at a restaurant, I decided not to pre-bolus in the car, assuming it would be some time before we were seated.  But (of course), we were seated and eating within 20 minutes of arriving.  Even though my blood sugar was in range when I sat down, I had a post-meal spike that looked like a rocket ship taking off.

Timing is only part of the art of the pre-bolus.  For people dealing with gastroparesis, trying to predict the absorption of insulin and food is tricky.  For kids with diabetes, the art is more Pollock-y, because who knows what a kid will eat/won’t eat/might lick and then hide in a plant?  The blood sugar number you’re starting from makes a difference (or at least for me), too.  I’ve found that if I’m high, I need to wait until I see a downward slope on my Dexcom graph before I can start eating; otherwise, I start high and end up higher.  And the time of day matters for me, too.  A breakfast pre-bolus definitely needs more time to kick in than a dinner one.

Pre-bolusing, for all of its variables, is one of the most useful things I’ve done to help lower my A1C.  Keeping my post-prandials lower helps my overall control, and every time I see my endo, she nods in agreement when I mention pre-bolusing.  (She also warns me about lows every time, because she’s a doctor and also extremely smart and always has cool sneakers on /digression)

Do you pre-bolus? 

 

Long Term Lows.

Last night, just before bed, I did what I do every night before turning off the bedside lamp:  checked the IOB (insulin on board) on my pump and looked at the Dexcom graph.  IOB was okay (0.21u from a small snack bolus two and a half hours earlier), but the Dexcom was showing 146 mg/dL and heading in a southwesterly sort of way.

It was midnight-thirty, and I had to wake up at 5 am to catch a flight to California, so I knew I wasn’t going to be asleep long anyway.  Since my blood sugar was in the 140′s and not the 40′s, I decided to run a -90% basal rate for an hour and hoped that would stave off the low.

(This shit never happens on a night when I am able to sleep in and I don’t have any responsibilities the next day.  It ALWAYS happens when I’m scheduled to catch an early flight and have a full agenda for several days straight.)

Fifteen minutes later (close to 1 am), I saw double-down arrows and my meter confirmed me at 70 mg/dL.  A jar of glucose tabs on the bedside table showed I had four left in there, so I chomped them all down in an abundance of caution, pretty sure I’d end up in the 150′s when I woke up at 5 am.

Twenty minutes later (close to 1.30 am), I was 52 mg/dL.  And I stayed in the 50 mg/dL range for three hours.  THREE stupid hours.  For three hours, the Dexcom wailed, I checked my blood sugar, and steadily consumed carbs made out of dreams and air, apparently, because they didn’t touch the low.  This low wasn’t symptom-free, either; it was one that made my shirt damp between the shoulder blades, and had me flipping the pillow over repeatedly in search of something cold.  And once it was starting to taper off and the Dexcom arrows were pointing back up, the adrenaline from waiting out the low for hours had my muscles tense, like a cat who had been stalking the same dangling ribbons for hours.

Only instead of rolling over and taking a cat nap, I was wide, wide, wide awake.

“Are you awake?” I asked Chris at 4 am, who had been awake for part of the night, when the low dipped into a tough range.

“No.  Unless you need juice, and then yes.”

Just past 4 am, I fell asleep, and the alarm set to get me to the airport on time went off an hour later.  Pity party time?  No, but it will explain why most of this post is rambly and might smell like glucose tab dust.  So far, today has been a hazy, confusing shuffle of airplanes, connecting flights, and awkward naps on the shoulders of strangers (but we know each other better now, don’t we, Tom?).  And the low hangover is impressive, making me actually want to put on sunglasses and have a glass of that Naked Mighty Mango drink (which seems to cure every hangover I’ve ever had – shit is magical).

But I’m glad that today’s destination is somewhere warm (Los Angeles) and I’ll be seeing some of my favorite people from the diabetes community at the Medtronic diabetes forum taking place this weekend.  (Hashtag to follow is #MedtronicDAF, and by way of disclosure, Medtronic is covering my travel, lodging, and expenses, although my opinions and poorly-timed jokes remain, as always, mine.)  Other people posted that they were attending and asked for discussion points from the DOC, so I’m doing the same. If there’s anything you’d like me to be sure to bring up to the Medtronic team, please let me know.

… only I’ll be wearing my Animas Ping and my Dexcom G4 and a host of dark circles under my eyes and hopefully clutching a Mighty Mango drink.  We’ll see how that goes.

 

 

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