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…
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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%...
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