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Day 3 – Wednesday 30th October, “You look good considering you haven’t washed for 2 days!”

I slept well. The ward has had a turnover of patients and my current company seems a little more sleepy than my previous; Farty McFart is still here but other than that all-change!

I slept for an hour or so after my 5:00am hypo, feeling groggy and exhausted still. Yesterday was huge and I think all the hypoes and information ingestion left me drained. Breakfast came round at 7:00 and I was told to bolus 6 units. I am not arguing! Today, I went for the western breakfast… Cereal, croissant and salad… Much better (for me!!) than the rice and kimchi for yesterday’s breakfast…

After breakfast, Dr. Tae Nyun Kim came to visit again. He knew about my hypoes and we decided to drop my basal rates to:

·      0.8 units per hour from 00:00 to 06:00

·      0.7 units per hour from 06:00 to 18:00

·      0.8 u/hr from 18:00 to 00:00

I am feeling much more comfortable about this. I am aware that it is going to take a lot of work to get my hour by hour basal rates sorted, but I feel like lowering them is a step in the right direction. Without the correct basal rates my bolus calculations will not work properly either so if I am getting closer to the right ball-park, may ratios may work better. I have been given the go-ahead to experiment with my ratios and with the Bolus Wizard feature on the pump (more on that later!) Today, I am going to calculate my ratios manually, inputting my boluses. Depending on how this goes, I will then attempt the Wizard tomorrow…

I am now going to brush up on my pump knowledge with my Paradigm 712 user guide and read some more of Dr. Scheiner’s Think Like a Pancreas… 

I have passed the day people-watching, playing Scrabble, gossiping, reading and geeking out with Microsoft Excel. I have just discovered the ‘conditional formatting’ function. This allows me to format a cell to visually show whether the value in the cell is within a certain range; it’s like it was made for people with diabetes! I have now managed to format a worksheet with the exact ranges for my pre- and post- meal readings… I will see how it works out!

The pump is absolutely amazing. While I still have to test my blood and think about my levels, just the relief of not having to inject myself is beyond my wildest dreams. Every injection-time, especially before bed, I have a mild panic, “Oh god, I almost forgot to do my injection!” But then it dawns on me that I don’t have to.  Meal times are slightly different, I still have to bolus even if it is by pressing a button, so I guess that gives me my injection fix. But being able to go to bed without having to remember to do an injection? Blissful.

Today’s readings have been a mixed bag, especially when you add into the mix a significant discrepancy between my machine’s readings and the hospital’s.  Ever since this afternoon, my readings have been around 20 mg/dL lower than those of the hospital machine’s (56/71, 139/98) this confuses and worries me slightly as I have no idea which is correct!

In terms of today’s boluses, as agreed I was left alone to calculate my own. My level was tested around 11 am. PC and I wandered out for a coffee and when I came back lunch was being served. I called the nurse for a blood test as it was now around 12:40 and a lot can change in nearly 2 hours. The nurse had not been instructed to do a blood test at this time; for their purposes, ‘before lunch’ was 11:00, despite the fact lunch was not served for another hour and a half. I tried to explain why I wanted a blood test done: because I thought my bg level had dropped and because I wanted to accurately calculate my meal. I felt so sorry for the nurse, who didn’t understand. Eventually, after a call from the English-Korean liaison nurse and some help from a passing English-speaking doctor (who recognized me from my recent visit to the emergency room for a urine infection – and couldn’t help mentioning the fact!) I managed to explain and a blood tests was done. I’m glad too: I was 71.

After lunch, my level was 186, just outside of the acceptable peak of 180. Just after lunch I was whisked away to the dentist (my mouth has continued to be sore, partly due I thought to my wisdom teeth and a gum infection). After poking around in my gums with a metal stick and making me almost cry out from the pain, it turned out that my gum infection was more severe than I thought and the dentist wanted to anaesthetize me to treat it. He also wanted to take out my wisdom teeth, something I am truly petrified of (the dentist has always terrified me, and I’m sure it always will… Up until the age of 10, I refused to sit in the dentist’s chair…) Luckily (?!) he had to check with my admitting doctor before administering an anaesthetic and he was not available until the following week, so the procedure would not be done now. I did get some industrial strength mouthwash, which seems to be helping somewhat, and was told to keep brushing my teeth carefully, in spite of the bleeding; something I have been scared to do because of the bleeding.

Following the dentist visit, my bloods were 180: above the range for the time of day, but I am putting that down to the stress/ pain of the previous hour. I will see how it changes tomorrow.

For the rest of the day, my levels were fairly consistent, apart from the worrying differences between my readings and the nurses’. I think I am just going to stop testing myself, and put my faith in the hospital, as, I guess, I should!

After dinner, PC and I spent a good hour figuring out my insulin to carb ratios for my meals based on the couple of days’ data I had.  An ‘insulin to carb ratio’ is the amount of carbohydrate 1 unit of insulin counteracts. It is written as I:C where I is 1.

I started of with a table like this:

Date	12 am	breakfast	am	lunch	pm	dinner	bed
29/10/13	1:9	1:9	1:9	1:6	1:6	1:6	1:9
31/10/13	1:10	1:10	1:10	1:8	1:8	1:12	1:12

However, for the purposes of the pump, I need to think about them in terms of start times so I can programme them in; my table changed, to this:

Date	start time	ratio	start time	ratio	start time	ratio	start time	ratio	start time	ratio
29/10/13	0:00	9	11:00	6	21:00	9
31/10/13	0:00	10	11:00	8	17:00	12

Our conversations got quite confusing. Namely because I HATE ratios. They are the bane of my existence (now injections no longer occupy that title!) I get confused about lowering ratios and highering ratios and whether this means more insulin or less insulin. Eventually we agreed on a common language:  in my world, lowering a ratio means the number goes DOWN (e.g. 1:10 to 1:9) this in turn means MORE insulin is given per gram of carbohydrate so the insulin dose goes UP. So… If I were eating a meal with 60g of carbohydrate and my ratio was 1:10 I would cover the carbs with 6 units of insulin (60 ÷ 10), but if I LOWERED my ratio, from 1:10 to 1:9, this would mean a dose of 6.7 units (60 ÷ 9) to cover the carbs. Now, I know this is not rocket science, but jeez, it confuses me!

Given all this, we looked back at my readings and made the above changes. I decided to program them into the ‘Bolus Wizard’ on my pump: a function that does the calculating for me if I tell it my bg reading and the amount of carbohydrate I plan to eat. Although at this point I cannot be sure enough to fine-tune my boluses, my chief objective right now is to avoid extremes: highs make me feel shoddy, lows have an ongoing impact on my reading for the next few hours.  Today, my reading before lunch was fairly low, so we increased my ratio from 1:9 to 1:10. My previous ratio over lunch and dinner was quite low: 1:6. My readings have been showing lows over this time, so we decided to change them quite drastically for now: 1:8 over lunch time and 1:12 over dinner. This may well be too little, but I really want to avoid hypoes for now. And, it’s still a learning curve, a monumental learning curve!

Given all this, I was reading about fine-tuning basal and bolus doses on pumps courtesy of Dr. Scheiner: I am now fully aware that before I can work on my boluses I need to get my basal doses figured out. This will not be a short process: I can see it lasting weeks. It involves ‘basal testing’ which looks like this suggested schedule from Dr. Scheiner’s book:

Test	Eat and bolus no later than:	Check blood sugar at:	Okay to eat and bolus again at:
Overnight	7 pm	10 pm, 1 am, 3 am, 5 am, 7am	7 am
Morning	3 am	7 am, 9 am, 11 am, 12 pm	12 pm
Afternoon	8 am	12 pm, 2 pm, 4pm, 6 pm	6 pm
Evening	2 pm	6 pm, 8 pm, 10 pm, 11 pm	11 pm

In a nutshell, I will need to fast over a mealtime and test my levels regularly during this time. The purpose of basal insulin is to keep levels constant in the absence of food or exercise: the basal tst measures its ability to do this. On a pump, the basal insulin is delivered in tiny pulses throughout each hour, based on an hourly rate. Therefore, there is potential to fine tune it to the hour. According to Dr. Scheiner, most pump-users have a profile across the day which has around 5 different rates in a 24 hour period with a single peak (where the highest basal rate per hour is used) and a single valley (where the lowest basal rate per hour is used). Often (again, according to Dr. Scheiner’s research) in adults between 21 and 60 years old, the peak often occurs in the early hours of the morning when the liver is pumping glucose into the system, and the valley often in the afternoon/ early evening.

It is recommended to start with a test on the overnight basal. I am planning on trying this tonight.

All in all, to sum up my first full injection-free day, I have to say that all the stress and anticipation leading up to this week was worth it. There is a long way to go, and I am sure that when I start back at work next week, I will have to tweak all my doses all over again, but hopefully, my current settings can be saved as my ‘holiday’ profile! Just the fact that I am looking at my readings and seeing numbers within or near to the acceptable ranges is having the biggest impact on me. It makes me feel so much more positive and hopeful that maybe I really can get to a point where the holy grail of 70% of my readings really do fall within this range. Since Tuesday morning, I am on 55%...

Day 2: Tuesday 29th October, Hypo City!

As it turned out, yesterday’s shenanigans were not quite over when I wrote… First, a doctor appeared at me bed, speaking – as to be expected! – Korean. He had a wheeled machine with him and nattered away as he pulled my curtains around my bed. I think I mumble that I didn’t speak Korean and he said ‘Echocardiogram’ in English. I lay down on my back and he attached the electrodes to my ankles, wrists and chest, pressed a few buttons, the machine whirred and spat out a print-out of my heart rhythms. “Normal,” he reported. Phew.

Next, a young, nervous-looking nurse was given the job of escorting me down to radiology where I was to be given a chest X-ray. The lifts at the hospital seem to be the slowest lifts anywhere in the world for some reason; maybe just the sheer wait of demand on them! Getting from the 14^th floor to B1 seemed to take forever. We were joined by a doctor, wheeling another large machine and playing on his iPhone, and scowled at by a nurse on a lower floor in charge of an empty bed who couldn’t fit into our ride. In spite of the usual lift battle, the hospital was like a ghost town: the lights were off and the usually busy corridors were almost empty. The nurse seemed a little lost, but we found ourselves in the x-ray department before long, where a radiologist was sat, bored, behind the desk. They exchanged a few words in Korean, then aimed a single word at me: “Brassiere?” All ready for bed, I was just in my pyjamas, but I couldn’t help smiling. The radiologist took me into the X-ray room. First I had a couple of X-rays standing up, I was then asked to lie down on a bed, face-up, to have a couple more. In the UK, I’m sure they cover up other parts of the body that are not being photographed… Here, I felt very exposed! Standing in a room with X-rays floating around in the air…

The nurse and I made our way back up to the wards where I got into bed. It was still fairly early, but perhaps unsurprisingly I was ready for bed: the anticipation and illnesses of the past few days/ weeks/ months had caught up with me, I was finally at the point I had been waiting for and worrying about: in a Korean hospital about to get a pump. Needless to say the bed is reminiscent of concrete, the pillow is small and inflexible and the lime green blanket is heavy duty. All this aside, it’s not really so bad! Hard beds are good for your back, right? And I think I sleep with too many pillows anyway, so it’s probably doing my neck good!

Evenings in hospitals are always fraught with noise and disturbances and last night was no exception. I am sharing my room with 3 Korean ajumas… The lady to my left is fairly quiet, especially at night. The lady to my right I have (secretly, of course!) nicknamed Farty McFart as her wind is quite something to behold. However, she very kindly game me some satsumas yesterday and seems very nice other than the wind… The woman in the bed opposite is Snorey McSnore. She fell asleep at around 8pm and snored and snored and snored. This morning, I am re-evaluating these names… Farty McFart unfortunately also seems to suffer from insomnia… At various points in the night, I awoke to find her light on, or her shuffling around the bed, bashing and banging, or splashing about in the bathroom.  And Snorey McSnore has turned out to be Grumpy’s older sister…. All in all, my sleep was broken to say the least!

At around 2 am, I was woken to test my blood sugar, and at 6 am I woke to find a nurse, carrying a little tray with empty vials, poised with a needle to fill them with my blood; not the nicest wake-up call I’ve ever had! But at least it was over quickly, and I barely felt a thing because I was still half asleep.

This morning, the nurses have been mainly communicating with me via messages written on paper. Often old patient records with ID numbers, names, ages and medical details (such as “scrotal elevation”) on.  My temperature and blood pressure has been monitored twice so far, and all normal, my pulse has also been taken, something I forgot about!

At around 9:00 I had a couple of lovely visitors who were joined at my bedside by Dr. Tae Nyun Kim, who managed to somehow sense my excitement… And then, at around 10:15 it was time to make my way downstairs to the Endocrinology outpatients: P-Day had arrived!

My trusty sidekick, Pork Chop, and I were shunted into the ‘Diabetes Education’ room and sat down opposite a man in a suit. The table was littered with diabetic paraphernalia and on the table was a pump. The English liaison nurse joined us, as did one of the nurses from the department: 5 people, one table…

First, my CGM cannula was put in, on the right side of my belly. I have had a CGM before and I find them fairly uncomfortable. For some reason, the cannula remains sore and I am very aware of every movement around it. The sensor takes a while to activate, so we continued on with the pump lesson.

The next hour and a half are pretty much a blur! The training consisted of lots of talk in Korean, translated into English, a bit of back and forth in English before turning back to Korean for a little more back and forth. I have to say though that it was amazing. Every question was clarified and answered, the Medtronic rep explained and re-explained as necessary, flicking between pages of the manual in English and Korean. At the end of the session, it transpired that the poor guy had been really nervous about it all… Teaching in Korean is one thing, but teaching to a Wayguk in English, I can understand the nerves!

Using a practice pump, we went through how to set my basal rates, how to set a bolus, how to change the infusion set, how to draw up the insulin into the pump reservoir and how to insert the cannula, using a foam apple as our victim. A lot of it reminded me of the first time round, 18 years ago, when I was learning to draw up insulin into my syringe from tiny vials and practicing injecting a grapefruit.  Maybe that’s where my affinity to grapefruits comes from…

It was a LOT to take in.

For my starting basal rates we decided on:

·      1 unit per hour from 00:00 to 06:00

·      0.8 units per hour from 06:00 to 18:00

·      1 u/hr from 18:00 to 00:00

I was a little nervous about this. It was calculated from 80% of my total daily dose of basal insulin (24 units) which should have been a total amount of around 19 units altogether, actually, it turns out to be around 22.4 units.  When speaking to Lisa, she suggested I should start on around 0.6/ 0.7 units per hour. However, she also suggested listening to the doctors and going along with what they said! So, in spite of not being completely confident, we went ahead with the suggested doses.

The Medtronic rep programmed the date and time and then allowed me to set the basal rates for my very own, brand spanking new pump! It’s dark grey. A little disappointing as I had my fingers crossed for blue, but hey, beggars can’t be choosers! Setting the basal rate was easy, it involved pressing the up and down buttons and the ACT button a lot. I would consider myself fairly confident with technology/ gadgets which means 2 things: one, I like the pump simply because it’s a gadget; two, I find it pretty easy to navigate (so far!).

The next steps were harder… Mainly because they involved more than just a screen and pressing buttons.

Filling the pump’s “reservoir” was more complex than I was expecting.  The Novorapid (short-acting insulin) I am not taking is the same as the insulin in my pens. However, now it comes in a bottle. To fill the reservoir you need to draw up around 3 days’ worth of insulin plus a little spare: my approximate 3-day dose + extra is 200 units. The reservoir is just like a syringe. To draw up the insulin I had to draw back the plunger to 200 then push the 200 units’ worth of air into the insulin bottle. When I turned it upside down, the pressure then automatically filled the syringe with the same amount of insulin: genius! But, the tricky bit is the bubbles! I remember from before, how important it is to get rid of bubbles, but now it’s imperative. With a lot of flicking from the nurse and I, eventually all the bubbles had floated back into the bottle and the syringe was bubble-free. For now.  The next step was loading the reservoir into the pump. Easy. Or so you would think! TO do this, I had to remove the plunger from the syringe. Anyone with half a brain, would realize that simply pulling out the plunger would result in more air getting in! Not me… Seconds later there was a bubble-party in the syringe. Oops. A little problem-solving and the bubbles were back out where they belonged! I UNTWISTED the plunger from the reservoir and it slotted easily into the pump.

At some point, I had to push insulin through the tube which had been attached. But I can’t remember now if this was before or after it was put into the pump! Then, I have to insert the cannula. This was fiddly. And it didn’t help that both the nurse and I were trying to do it simultaneously. Our fingers kept clashing and I got a bit flustered: I kind of needed to make any mistakes I was going to make, even if it meant pulling it out and trying again. The device used to put the cannula in looks like a mini modern version of a medieval torture device; I’m not sure what its proper name is, but I’m going to call it the ‘shooter’. I loaded the infusion set into the shooter, forgetting to pull it back to set it ready to shoot. Then I set the two guiding arms onto the flesh of the left-side of my belly. It was an awkward position, but one I am sure I will get used to! It took me a few seconds to pluck up the courage to shoot, but when I did, I was surprised: there was a sting that lasted for a second or so, then nothing really. The next bit was the frustrating bit! I was sitting there, with the shooter sticking out from my belly; the nurse, the rep and I trying to fumble around with it. I needed to peel back the sticky bit to stick to my belly, unhook the shooter from the cannula, then remove the needle just leaving the miniscule plastic tubing under the skin to administer the insulin. Eventually, everything was where it should be, but I was not really any the wiser as to the order of these things!

Nevertheless… The pump was in, and there was just one more step: to prime the cannula ready for use by moving 0.7 units of insulin through the cannula attachment to ensue the first dose of insulin actually administered would be accurate. 

 Immediately, my pump was up and running. And it suddenly dawned on me that that was it: No more needles of any kind for 3 WHOLE DAYS.  I got goosebumps and I nearly started to cry… It was totally overwhelming, but absolutely amazing.

I left the room laden with stuff… A month’s worth of supplies, information pamphlets and my new best friend! Lunch was waiting for me back at the ward so my first independent challenge was setting my first bolus (insulin dose to cover my meal) I calculated my dose then pressed the Bolus button, entered the number and then pressed ACT. But I must have left too much time… Nothing happened! Now I didn’t know whether I had bolused or not… I didn’t think so but couldn’t be sure! So, I had to figure it our pretty quickly! I learned that to access the main menu, I need to press ACT from the homescreen. One of the menu options is bolus, and in here there is an option to see the 24 hour bolus history – a lifesaver for someone like me who is prone to forgetting whether or not an injection has been done… There were no boluses in my history, so I went through the steps again, more quickly, and this time the bolus registered. The screen counted up in 0.1 increments until 12.4 units were in. This is amazing to me… The accuracy I can get is phenomenal! I am used to injecting in whole-number lumps, rounding my calculations to the nearest unit, and even then the dose administered by injections is not always as accurate. 

After all this excitement I was pretty much exhausted! After I got back to the ward, a nurse came to fix up my CGM. Then, as I was dozing, another nurse came to get me for a ‘study’ appointment at 15:00. I had no idea where I was going or why! We ended up taking the elevator back down to the Endo outpatients where I had to undergo the diabetes complications tests: the part of the day I had been dreading (and thought I’d got away with!). I was weight (62.5 kg) measured (165.4cm) then asked to lay down on a bed for my ‘artery test’. I have never had this before… I had an inflatable band – like a blood pressure band – attached to each ankle and wrist and electrodes on my chest. The nurse punched a few buttons and the bands began to inflate. They inflated more and for longer than a blood pressure machine… It felt like my blood vessels were going to burst! Then, it was my retina test. I was taken to a dark room and had photographs of the back of my eyes taken. On my way back up to the ward, I asked if I would get the results of the tests and was told I could, if I wanted to. Why would anyone not want to?! I said I wanted to… But was not told when or how I would get the results!

When I got back Pork Chop and my lovely housemate, Vegetable, were waiting. V produced an amazing little ‘care package’ full of all the things you could possibly need when in hospital (and have just been told you can’t shower for 3 days because you are attached to a CGM!): mouthwash, hand and face wipes, chapstick, hand cream, lady wipes, Dentyne Fire gum, Coke Zero and Jalapeno flavor kettle chips. Yes! We settled back to watch this week’s Made in Chelsea and caught up on events.

The rest of the day was relaxed. As expected, my bolus rates resulted in a number of hypos over the course of the evening and night.

Week beginning:

Breakfast

am

Lunch

pm

Dinner

eve.

Night

before

after

before

after

before

after

bed

3am

T

TIME

1:50

5:30

6:20

9:00

10:00

5:00

Blood Sugar

212

128

62

168

95

84

49

CHO/ g

60

60

30

Total bolus

12.4

5

Physical activity

Time:

Intensity: Low / Moderate / High

Duration: Short / Moderate / Long

I had a hypo before dinner, which resulted in my bolus being cut down from 8 units to 5 (if I had calculated it based on my previous ratios, I would have given myself 7 units – I’m glad I didn’t!) Then, in the evening hours, my levels fell by 10 mg/dL in an hour… A dangerous state to go to bed in! PC and I snacked on some fruit given to me by Farty McFart and one of the packs of jalapeno crisps. In spite of this, I still woke at 5:00am with a reading of 49.