Ninja Insulin #dblogcheck

You would think after close to 15 years on the pump I would know all the tricks of the trade, all the quirks of the pump, all of the sneakiness of insulin absorption…..but, nope.

I’ve come up with some blood sugar savers that really do work for me, though….like, when I change out an infusion set site, I used to ALWAYS have high blood sugars for hours afterwards. Thanks to a comment by Katy, I was encouraged to “ka-chunk” in a new site without removing the old one for a few hours, let it settle in & calm down, and then connect up the pump to the new site. Bells ringing, fireworks going off, and a ticker-tape parade later, I rarely have any post-site-change highs anymore, and when I do, they are due to other variables of life.

Sneaky, sneaky....

But lately, I’ve discovered a new brand of insulin….the Ninja Insulin. I swear, I take a bolus for a meal or correction, and go about my business, but my blood sugar remains slightly high. Then, I drink some water, or sometimes, even eat a couple grams of a carb, and whoa! Here comes that insulin out of nowhere, and suddenly I’m on a downward trend of blood sugar. It’s really weird. It’s like it’s been hanging out in the shadows of my bloodstream, just waiting for the right time to take effect. It’s a most puissant ninja.

Don’t forget to #dblogcheck today!!!!

Gastric Sleeve Surgery and Blood Sugars

I’ve had a handful of surgeries in the past 20 years since being diagnosed with Type 1 diabetes, and there are a few tips and tricks I’ve learned that have helped immensely:

  1. I want to be the FIRST surgery of the morning. Since you’re supposed to stop eating/drinking anything at midnight the night before, it’s much easier to manage blood sugars for a short amount of time in the morning before a surgery rather than attempt to manage sugars all day on an empty stomach, risk potential lows you might have to treat with food/drink, thus negating the whole not-eating-after-midnight thing.
  2. Better to risk running high than running low. The night before surgery, I usually cut back my basal rate to about half of what it normally is. I don’t do any corrections for high blood sugar unless it starts running over 200. Then, I very conservatively correct – again, give myself about half of what I normally would to correct it.
  3. FILL OUT PAPERWORK ahead of time that says YOU take responsibility as soon as possible after surgery for your own diabetes/insulin/blood sugar management. No nurse or doctor knows how to work my insulin pump and CGM better than I do, and I had no desire to go back to getting injections at the whim and on the time-frame of nurses who don’t understand MY diabetes.
  4. Take at least 1 brightly colored piece of paper with you that states you are type 1 and notes your management regimen. For example, mine said, “TYPE 1 DIABETIC, on Insulin Pump and Continuous Glucose Monitor (CGM.) Please NO acetaminophen – it disrupts my CGM.”  This worked very well for me during this stay – had several nurses comment that it was very helpful for them to see that in my chart and know it immediately when they were treating me. (It also led to several educational moments where nurses had never seen a CGM before, so of course, I showed them and explained the whole she-bang.)
  5. Ask if it’s OK for that surgery to keep on your insulin pump port-site, and/or your CGM sensor. For my c-section, my OB preferred I didn’t have anything foreign on my skin or body, but for this surgery (since it was obviously way higher up on my torso), every nurse, doctor, and anesthesiologist I talked to said I could keep them on.

Now, onto gastric sleeve surgery …..that morning of surgery, I kept my pump hooked up  – running on 1/2 my usual basal rate – and also kept my CGM sensor on and the receiver with me until the very last minute when they were going to wheel me back to the operating room. Then, I relinquished my pump and CGM receiver to my husband for safe-keeping.

IV, Pump, and CGM, oh my!

I was running in the 180s right before surgery, which was perfectly fine with everyone involved.
Immediately post-surgery in recovery, I have no idea what my blood sugars were there – I was just trying to get reoriented and awake from anesthesia, and make sure they gave me some more pain meds. Thankfully, they got enough pain meds into me fast enough so I wasn’t very uncomfortable for long. Waking up from a surgery – always surreal for me.

Once I was in my own room and my husband gave me back my CGM and pump, I fingerstick tested (just to calibrate the CGM for good measure), and I was somewhere around 270. I knew I wouldn’t be eating or drinking anything for the rest of the day, so I wanted to be very careful about correction bolusing. I gave myself about 1/2 of what I thought I needed to bring it down to 150. Waited a couple hours. I had a decently steady downward-heading arrow on the Dexcom, so I just kept doing little correction boluses until I got down to 150, then I stopped.

Amazingly, for the next 24 hours, I had steady and decent blood sugars. Of course, I consumed literally NOTHING on the day of surgery – not even a sip of water (thank goodness I was on IV fluids, but my mouth felt like a desert.) And the following day, I could start on clear liquids, but that meant broth, water, sugar-free lemonade, and the like that had zero carbs and minimal calories. You can see my Dexcom graphs below, but it doesn’t show what I was doing with my insulin and boluses. Short answer = I kept my basal rate at close to 1/2 of what it used to be (for me, that is 1 unit per hour), and made only teeny tiny correction boluses here and there (of like, 0.5 unit)  if my sugar started sneaking upwards.

Day of surgery graph

Day of surgery blood glucose graph, from 12 midnight to 12 midnight. NO food or drink.

Day after surgery graph

Day after surgery blood glucose graph – on clear liquids only.

Now, the 3rd day after surgery, I was allowed to start on “full” liquids again, which meant the nasty protein shakes, 1% milk, sugar-free Jello, chicken broth, sugar-free Popsicles, and all that sort of stuff.
That is when blood sugar management got….interesting. The second I had a protein shake that morning with milk in it, my blood sugar RACED up to the  mid-200s. Seriously, it was like dawn phenomenon, the breakfast spike, and who knows what else all came into play at once.  You know how many carbs were in that shake? Like, a measly 13g. And the spike happened after I’d taken only maybe 2 or 3 sips, so I’d be surprised if I had consumed 1g of carbs at that point.

Spikey spikey

On full liquids, “breakfast” spike and subsequent calm-down over the course of each day. My graphs looked like this for several days, until I let the Metformin kick in again AND started bolusing at least a little something well-before I started sipping on my breakfast.

  • Note: I had not returned to taking my Metformin, but decided to start back after a couple of days of these spikes. Realization? My insulin-resistance wouldn’t just suddenly disappear after surgery, it would take time to lose some weight and hopefully get it down that way.
  • Another note: On all liquids, whatever I intake now hits my system *almost immediately*, and I had gotten into the habit of bolusing right when I eat, using dual-wave boluses, etc. Nope, NOW I need to bolus well *ahead* of eating/drinking, so that the insulin has some time to get into my system before I consume something that takes zero time to digest.
  • Crap, one more note: I waited a couple days post-surgery before I reset my basals back to the rates they were before surgery. With the weird spikey spikey happening, I guessed (correctly) that I needed a higher basal rate back again, regardless.

I hope this is all making some sort of sense. Today, I’ve actually had a pretty decent blood sugar day, and my spike this morning was not nearly as bad! I am hoping I’ve turned a corner in understanding how fast my stomach is digesting things now, and can take insulin accordingly/ahead of time to help stave off that spike. BUT, I know things will be changing in the weeks to come as I introduce “regular” food back into my diet. For reference, here is the upcoming schedule of how I am working up to eating regular food again while my stomach heals from surgery:

Bariatric diet stages post-surgery

It’s going to be a wild ride on the roller coaster of blood sugars, I’m sure! 🙂

Even more notes: I am NOT a doctor or medical professional of any kind, and am just sharing my personal experience. Individual bodies are different, and just because this is how MY body is working as a Type 1 post-surgery for gastric sleeve, it doesn’t mean that everyone else’s will work this exact same way! Your Diabetes May Vary. 

 

3 Days In

In preparation for surgery (and the life I’ll have for several weeks after), I’ve survived 3 days of a mostly all-liquid diet. I am allowed to eat a couple of sugar-free Jello gelatin cups per day & sugar-free popsicles, and then the one true thing I can chew on is a special protein bar I can have 1 time per day, so I’ve been saving that as my “special treat” at night after my dinner shake. I thought it would be the best thing to do in order to help my sugars even out overnight, hopefully not allowing any weird crashes, and to also help stave off any possible over-the-top dawn phenomenon. The jury is still out on whether or not nighttime is the best time to have this so-called treat, that kind of tastes like flavored cardboard.

My Fitness Pal.

My Fitness Pal display of Nutrition for the day. Not too shabby.

A few notes and observations about this dramatic change in my eating habits:

  • I started using the My Fitness Pal app on my phone again to track what I’m eating, and assure I’m staying within the guidelines of calories, proteins, carbs, etc. I really like how it syncs up and works in tandem with my FitBit Flex. (Note: I am also taking a slew of special chewable bariatric vitamins – a multivitamin, Calcium, B12, a probiotic and iron. I will take these the rest of my life.)
  • In getting back into logging food and such, I realized I’ve gone from consuming between 100-150 carbs per day down to around 45-60 carbs per day these last 3 days. No wonder I could barely drag myself out of bed this morning.
  • I have not been exercising, and while I feel bad about that, I’d rather NOT exercise and NOT crash than to have to fall off the wagon and consume too much sugar trying to bring up a low blood sugar. The point of this liquid and reduced carb diet before surgery is to help my body go into ketosis (NOT ketoacidosis), and burn off some of the fat surrounding my liver so that laproscopic surgery on my stomach will be easier. Also, in preparation for having a similar low carb/higher protein diet post-surgery as well.
  • I miss coffee. I mean, I’ve been drinking some decaf here and there, but it’s just not the same. One day, in the far distant future, I’ll be able to drink it again, but only in small amounts. You don’t want caffeine to make you dehydrated, or interfere with vitamin/nutrient uptake.
  • Blood sugars have been…..weird. You’d think with the greatly reduced amount of carbs (and the ones I’m having aren’t the spikey ones) that I’d have perfectly straight Dexcom lines within range. NOT. After my morning shake breakfast, I will slowly creep up to the 150-180s, and stay there almost all day. When I eat lunch, and then dinner shakes, my sugars will briefly go down,
    FitBit Flex display

    The lack of exercise pains me, but check out the calories in versus out. I certainly should lose SOME weight before surgery, at this rate, assuming my body doesn’t go into starvation mode and shut down my metabolism.

    and might hang out in the 120s or 130s. Except for the 1st night on this diet (where I had a low in the 50s that I treated with 1 cup of 1% Lactaid milk. It barely kept me within the required amounts of sugar for the day), my overnight sugars have all been within range, 90-120 or so. Now, as this week wears on, maybe my body gets more “used” to it and will level things out? I’m afraid to change my basal rates on the pump, because I really think they are not the issue – I think it is my liver getting all riled up at not having as much sugar coming around, it thinks I’m starving (which, I do feel like that, occasionally), and it wants to spit out some to make itself feel better. Stupid liver.

While NOT getting to eat foods and things I’m used to eating is really, REALLY, tough sometimes (I almost swiped my daughter’s sausage out of her hand this morning. It smelled SO GOOD) I am OK. I just keep thinking of the end goal – losing weight, being healthier, and feeling better – and I can turn my head away, and go eat my sugar-free Jello gelatin in relative comfort. This is my new normal, at least for a few weeks. Once I am able to consume “normal” foods again post-surgery, I’m sure it will be a whole new ball game.

CGM – Now you can have it….but one day, you can’t.

I don’t know about you guys, but I live and breathe by my Dexcom CGM. Since acquiring it a few months before getting pregnant, I’ve learned (mostly) all it’s quirks, and rely heavily on the trends and readings when making decisions about what I eat, when to eat, when to take insulin, when to NOT take insulin, and when to participate in activities – like exercise, or even driving. I can’t tell you the number of times it’s stopped me from doing something stupid.

Prime example: Before my CGM, I would “assess” how I felt when getting in the car to drive. If I thought there was a chance I MIGHT be low, I would check my blood sugar on a finger-stick meter. It might tell me something great, like 100. So, I’d get in the car and drive. Imagine my surprise when, less than 10 minutes later, I’m feeling dizzy and woozy, and luckily have stopped in a parking lot, check my sugar, and it’s 55. IF I had only had a CGM at that time, it may have shown me that my sugar was 100, but with an arrow trending down. Or showing me double down arrows which means REALLY going down fast. In that case, I would have never gotten into the car and risked a crashing blood sugar while driving. Over the years, I’ve steadily lost some sensitivity to low-sugar awareness. Sometimes, I still “feel” it….but a LOT of times, I don’t. As I type now, imagining life without my CGM? Imagining being in a car with my daughter and a low sugar coming out of nowhere with no warning? Going to sleep one night thinking everything was fine, when it really wasn’t? Well, let’s just say, I don’t want to even think about it.

Sue from Test, Guess and Go is waging a war for her husband….trying desperately to get his CGM covered under Medicare insurance. Below is a guest post from her – please read, and act!! One day, it could be you or I without the CGM…..

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

Sue Berger from PennsylvaniaI am the wife of a diabetic. I’ve said and written these words so many times, that they seem to now define me. I sometimes feel as if I’m losing my own identity. This journey for me started around 1 ½ years ago. My husband, Marc, who has Type 1 diabetes and hypoglycemia and hyperglycemia unawareness, had been using a Continuous Glucose Monitor (CGM) for approximately five years and it had always been covered by the group insurance from my husband’s place of employment. In June of 2012 he turned 65 and had to go onto Medicare. A few months after that, the CGM he was wearing started to become very erratic. His doctor wrote a prescription for a new one but his supplemental insurance company, Highmark Freedom Blue, denied payment. We began the long process of Appeals.

Long, long story very short…. many phone calls ensued, doctors testified as to Marc’s need, tons of evidence was presented showing the medical need for the CGM….only to receive an UNFAVORABLE decision from a judge in February this year, basically saying no, his supplemental insurance would not pay for Marc’s CGM, and it was not covered under Medicare.

In December of 2013, Congresswoman Carol Shea-Porter (D-NH) introduced a bill into Congress. H.R. 3710 provides for coverage of a CGM by Medicare if recommended by a physician. I have been in touch with her Legal Assistant, Marjorie Connolly, and Representative Shea-Porter is doing a big push among her Colleagues asking for them to sign onto this bill.

If you go onto www.testguessandgo.com you will see my blog entitled “Join the Crusade”. At the bottom of the blog, you will see links to download a sample letter to write to your Congressperson asking him/her to support the bill. You will also see Congresswoman Shea-Porter’s letter to her Colleagues.

Why is this issue so important to me? The obvious reason is that I dearly love my Marc.

For the past year, Marc has been without a CGM and there isn’t a day that I’m not filled with anxiety. He’s had many close calls while driving and it’s only by the grace of God that he hasn’t injured himself or someone else. He’s a courier and spends a lot of time in the car and has had some pretty close calls. Our children both live in Atlanta (we live in Harrisburg, PA) and I used to be able to visit them regularly and now I have to make sure that he can take time off from work to go with me because there is no way that I would leave him alone all night. The worry is with me, and him also, 24/7.

During the time that I have been fighting for coverage of the CGM, I have encountered many other men and women who are in the same situation as Marc is in and need a CGM but can’t afford the out-of-pocket cost of the device and sensors. None of these people ever thought that after having a CGM covered for so many years by private insurance, that Medicare would not cover it. I have also met many men and women who will soon be entering the system, are presently covered by their private insurance and are worried that they will not be able to get a CGM or sensors once they go onto Medicare.

This issue is so important and the only way to change the Medicare guideline for the CGM is to put pressure on our Congresspeople asking them to vote YES to H.R. 3710.

Recently, a group has been formed on TuDiabetes called the CGM Reimbursement Advocacy Group. http://www.tudiabetes.org/group/cgm-advocacy. The purpose of this forum is a place to try to gather interest in CGM Advocacy; to share information about CGM efforts, craft common messages, link useful research and connect individual advocates.

Also, if you go onto https://www.popvox.com/bills/us/113/hr3710 you can click on Support, put in your name and email address and a notification will be sent to your Congressperson showing that you support H.R. 3710. There are comments from diabetics, wives, children and friends stating why they support the bill. I find them extremely interesting to read.

Won’t you please take the time to do these things? I can’t stress the importance of raising up our voices loud and clear and letting those in Congress know that for those who need a CGM, it’s a matter of life or death.

Thank you,

Sue Berger – writer/contributor at http://testguessandgo.com

Bubbly High Sugars…the REAL Culprit??

A few days ago, I was waxing poetic about how I had these really odd overnight highs that seemed to be for no good reason. I sort of (but not really) thought they could be connected to bubbles in my insulin pump cartridge reservoir. Or they could have been because of any number of extraneous causes. With blood sugars and diabetes, just when you think you’ve figured something out, something else comes out of left field and wrecks your theory.

Well, now I have a NEW theory….a couple of months ago (around the time the night-time highs started), I decided to give my hips and upper butt pump site areas a break, and went back to using my stomach. I really hadn’t used my stomach for infusion set sites much since I was pregnant – the past 3 years have FLOWN by! – but it always worked fine before, so I didn’t even think twice about it.

Now, remember: the crazy unexplained highs I was getting were mainly while I slept. I sleep *on my stomach.* After I wrote that post the other day, I did a site change-out and moved back to using ye olde trusty hip zone. Voila!! My first night in a long time where I had no crazy high readings. The next night, the same. And the next. Seriously folks, we are on a roll now!

So…..could that be it? Could the weight I put on an infusion site overnight (because I sleep on it on my stomach)  have caused all those high sugars? Or maybe, uptake of the insulin was somehow lessened because I was sleeping on my stomach, right on top of the infusion set site? How many licks does it take to get to the Tootsie Roll center of a Tootsie Pop? For all of these questions, and more,  the world may never know….

I wish EVERY overnight and morning looked like this!

Since I moved my infusion set back to my hip, here’s what my overnights and mornings have looked like, for the most part.
I WILL TAKE IT, HAPPILY, regardless of what the reason may be!!

 

 

The Devil is in the Bubbles?

I really must not have been paying attention when I filled this one. I’ve been fighting some really weird blood sugar highs recently – occurring at times when I normally see a level line on the CGM or am otherwise crashing (like 3am, all the freaking time) – and before my last pump site change, it was just getting ridiculous, so I took out the set early. And found this monstrous bubble (as seen above) in the reservoir.

Sitting here now with my new set for the past couple of days….the highs are still hanging around. (And that 1 bubble doesn’t explain the “bubble” I’ve seen in my blood sugar numbers being steadily higher for several months now.) The time I notice it most is the overnight sugars as seen on my Dexcom CGM. I’ll go to bed at a comfortable and steady 110 or so. Fall asleep. Rudely awakened by a blaring high in the 200s for several hours overnight. Wake up. Drink water. Take correction bolus. Sometimes eat a cheese stick if I think it’s dawn phenomenon-related. And most times, it goes down and I’m good by breakfast-time.

I keep wracking my brain….what am I doing differently from the past year+ that is making this happen??  It’s not *always* the last week of my cycle, I haven’t changed any medications or vitamins recently, I don’t think I’m sick (or getting sick), my exercise regimen is better than it’s been in years, I haven’t changed my basal rates (this will be the next thing I do to try to counteract it)….my checklist of “what it could be” goes on and on. MAYBE I’m not drinking enough water lately and I’m slightly dehydrated? I have been downing a lot of coffee over the past few weeks of cold-weather spells we’ve had. (But I’ve moved to half-caf and decaf, shouldn’t that be OK?) And sure, some nights the highs will happen after I’ve had a couple glasses of wine and some snacks with my girl friends, but even taking those out of the equation, it’s still a LOT of unexplained overnight highs for me. And it shows in my A1c – up 0.4 from my last A1c of 3 months ago (which was up 0.2 from the A1c before that.) It seems like a small enough gain, but feels really big. I’ve got to shut that sucker down, and stop the upwards “bubble” trend I keep seeing. Now, if I can just figure out how to do that…..

Diabetes Awareness Month Photo-a-Day 15, 16, 17- Alert, Blood, and DOC

Still recovering from last week’s stomach virus attack on my household, so these pics for prompts will be short and sweet.

DAMPAD15_Alert

Argh. These kinds of alerts, especially right after you brush your teeth or in the middle of the night, are ANNOYING.

DAMPAD_16Blood

Yep, that one’s a bleeder. To change or not to change? I rolled the dice, and this one ended up being just fine.

2013-11-17_DAMPAD17DOC

The DOC has provided so much support, and also lots of neat tips and tricks. My favorite one: cluing me in that wearing my Dexcom sensor for more than the recommended 1 week was perfectly fine, and teaching me about SkinTac and Opsite Flexi-fix that keeps these suckers on even through a nuclear holocaust.