To pump or not to pump... That is the question.

On Tuesday morning, I had another appointment with Lisa, at Integrated Diabetes Services in Philadelphia. It began badly; I got the time wrong! My alarm went off at 6:00am and it was followed seconds later by a Skype call. I jumped out of bed, with my pillow still imprinted on my cheek, and called her back.

As usual, the appointment itself was a success. This time we talked about hypoes; quite an apt topic of conversation considering I seem to have been having quite a few recently. I learned that a hypo can affect you for around 6 hours afterwards. This is due to your body producing counter-regulatory hormones, like glucagon, which can load 300 calories’ worth of glycogen into your bloodstream as part of the body’s fight or flight mechanisms. I also learned, that you can feel the symptoms of a hypo when falling from say 300 to 200; this is called a relative hypo because you drop quickly, but not within the hypo range.

Lisa began talking to me about the best ways to treat a hypo. It turns out that I need to brush up on the glycemic index! When you treat a hypo, you should eat food with a high glycemic index, to prevent a low you should eat food with a low glycemic index; this should also take into account the insulin on board. So... If blood sugars are low after a meal, too soon after a meal, there will still be insulin working; hypo prevention will need to take this into account.

The best food to treat a hypo is dextrose-based food: some sweets, dextrose tablets, Lucozade. Unfortunately for me, both dextrose and Lucozade immediately transport me back to the early days following my diagnosis, where hypoes were frequent. Now, I can’t taste either without wanting to be sick! I usually try and drink apple juice; it’s sweet but not too sweet and liquid so is absorbed quickly. Lisa gave me a useful table with which to calculate how much carbohydrate is needed to figure out how much carbohydrate to use to treat hypoes in varying circumstance:

“Use this guide to help determine the amount carbohydrate needed:

Weight          1 gram of carb will increase BG by

60 lbs or less…………………… 6 pts

60-100 lbs……………………… 5 pts

100-160 lbs…………………….. 4 pts

160-220 lbs…………………….. 3 pts

greater than 220 lbs…………….. 2 pts

Weight (lbs)	BS of 70	BS of 60	BS of 50	BS of 40	BS < 40
< 60	8g	10g	12g	15g	18g
60-100	10g	12g	14g	16g	20g
100-160	12g	15g	18g	20g	25g
160-220	15g	20g	23g	25g	30g
> 200	20g	25g	30g	35g	40g

Mathematical calculation of carbs required:

(Target BS - Actual BS) /   BS Increase per gram of carb

Example:  Jim has a BS of 45 and wants to raise it to 120 (120-45=75).  1 gram of carb will raise him 4 pts, so Jim needs (120-45)/4, or 19g of carb.”

I have yet to experiment with this... Often, when I hypo I am not compus mentus enough to make a rational decision...

The second thing Lisa and I discussed was a particular brand of insulin pump, the Medtronic pump, which has a predictive alert if your blood sugar is on the rise or fall. This got me and Lisa onto the subject of pumps..

Now. As you will know if you have read my previous posts,  have been dreaming of getting an insulin pump for years. In England, the criteria for getting a pump is rigid; amongst other things, you have to have an HbA1c of consistently >8%; you need to have hypoes that you cannot treat yourself. I had been thinking of possibly trying to get a pump over the summer holidays. As I have described before, my doctor is not too keen on the idea. So as a precursor, I decided to email Scholars, my medical insurance provider to see whether they would cover my insulin pump. They emailed me back, almost immediately, with a list of criteria not dissimilar from the list I would be navigating in England! It said:

“Precertification of the services related to the insulin pump would be a 2 step process.  The first step is to determine whether you would meet the eligibility requirements for an insulin pump:

In order to complete this step, would you please obtain written documentation from your treating doctor that the following criteria have been satisfied?:

External insulin pumps (with or without wireless communication capability) are considered medically necessary for individuals with diabetes in any of the following groups:

1. Individuals with documented diabetes mellitus meeting all the following criteria 
   (a-e):
1. Completed a comprehensive diabetes education program within the past two years; and
2. Follows a program of multiple daily injections of insulin; and
3. Has frequent self-adjustments of insulin doses for the past 6 months; and
4. Has documented frequency of glucose self-testing an average of at least 4 times per day during the past month; and
5. Has documentation of any of the following while on a multiple daily injection regimen:
• Glycosylated hemoglobin level (HbAlc) greater than 7.0 percent; or
• "Brittle" diabetes mellitus with recurrent episodes of diabetic ketoacidosis, hypoglycemia or both, resulting in recurrent and/or prolonged hospitalization; or
• History of recurring hypoglycemia or severe glycemic excursions; or
• Wide fluctuations in blood glucose before mealtime; or
• "Dawn phenomenon" with fasting blood sugars frequently exceeding 200 mg/dl.
2. Pre-conception or pregnancy to reduce the incidence of fetal mortality or anomaly; or
3. Individuals with diabetes mellitus successfully using a continuous insulin infusion pump prior to enrollment, and have documented frequency of glucose self-testing on average of at least 4 times per day during the month prior to enrollment”

When I read this, my heart sank... I’m not sure my doctor here in Korea, sweet as he is, would actually know whether or not I fulfill criteria a-e (I do). It was only when Lisa mentioned the Medtronic pump that I wondered if she, or Gary, at IGS would be able to write my recommendation instead. Straight away, Lisa said she would be more than happy to vouch for me; the only potential problem was that neither she nor Gary are actually doctors; they are “diabetes educators”. So, I emailed Scholars back and, to my delight, they said that Lisa and Gary’s qualifications would be more than adequate. Yes! So... Lisa is writing my pump recommendation and I have my fingers and toes tightly crossed that step one of Operation “Finally Getting MJ a Pump” goes without a hitch... I will keep you posted...

The final diabetes-related area of interest from the last few weeks actually really has nothing to do with diabetes: I love writing. I have loved writing since I was a kid, but never really done anything about it. Earlier this year, I decided to bite the bullet and sign up for an online creative writing course. Week 1 was all about writing from ‘the self’; tapping into emotions and writing from experience. For our first exercise, we had to “Write about an incident that made you jealous, afraid, angry, joyful, miserable. Choose just one of these emotions for now. Try to find ways to show that emotion as we’ve discussed, rather than telling. For the purposes of this exercise you need to write at least a couple of good paragraphs and no more than around 300 words.” 

Perhaps unsurprisingly, I chose afraid, and I was immediately transported back to March 6th, 1995: the date of my diagnosis. I’d like to say that was the most afraid I’ve ever been, but I think my fear of dying on that day was later surpassed by the fear of living with it day in, day out. Luckily, I am learning, slowly, to leave that behind.

And here, to finish today’s post, is my first creative (somewhat dramatic) writing exercise.

The words he was saying morphed slowly into nonsensical sounds. My thoughts were heavy in my head. Too many of them. Weighing it down. My tongue ran over my cracked lips like sandpaper. My eyes flickered open; shapes blurred, lights blinded; it was all too white, too bright. I wanted to leap from between the crisp, clinical sheets in water; any water, as long as it was wet. I was desperate to feel moisture against my skin, in my mouth. But my body wouldn't move, and, even if it did, where would it go?

The voices continued to ebb and flow around me, my knuckles whitened as they made sense for a split second before falling away to somewhere just beyond my grasp. I knew they should make sense but they wouldn't and my heart quickened as I tried to move; still my body refused to obey.

I could feel the cloud enveloping me and I fought with what little strength I had to resist it. In my mind, my body was thrashing, fighting against the darkness. My heart continued to speed up, I felt a hand gripping mine as the panic rose up inside of me. Light dazed my eyes, sound swirled around me and my wasted muscles tensed as the darkness claimed me and the world went out.