A Missed Bolus
People who aren’t intimately involved with Type 1 will often assume that there’s a simple equation to lower and raise blood sugar depending on the amount of insulin or the amount of food that is consumed. If blood sugars are in range before eating, and the carb to insulin ratio is 15:1, then 2 units should be taken for a 30 gram carbohydrate meal. If a correction on an already high or low blood sugar is needed, there’s an equation to plug in for that too. It’s simple algebra, end of story.
But it’s not so simple. I was already well aware of diabetes when Walker was diagnosed, and even I approached her care in such simplistic, concrete thinking. Back then I had to though. I was going through such upheaval in things unknown that I HAD TO think there was some magic equation to care for this fragile little being. It didn’t take long before I realized that I had little control over any of this, and the plugging of numbers was just the beginning of things I had to relinquish to “what works today might not work tomorrow” philosophy.
What’s pretty amazing too, is how it’s different for each person (and really, each day for each person). What spikes Walker through the roof may have little affect on Ollie. They can eat the same meal and have very different reactions to the same food. This became glaringly evident during our first meal challenge for the pump study.
We never miss a mealtime bolus. Ok, I can remember one breakfast 3 weeks ago when Ollie forgot to dose for what he ate, but we caught it an hour later when we saw his CGM reading spike, and we dealt with it then. I’m sure it would be much more likely to forget to bolus if it were just one of us that had diabetes, but when there are three in the family, the odds of everyone forgetting is less likely. And the CGM helps alert us to these “after the fact” situations.
So you can imagine my anxiety when our first “meal challenge” was to intentionally NOT bolus for our meal. The purpose of skipping this bolus was to see what happens to blood sugars when the pump does nothing to adjust for rising blood sugars (a baseline for “worst scenario”). We were to take the kids off the “auto-mode” function of the pump, so it wasn’t able to adjust the the particular needs of the kids, 6 hours prior to eating. They were to have blood sugars less than 200 mg/dL before eating. We were then to eat a normal sized meal, calculate the amount of carbohydrates they ate, but NOT BOLUS FOR ANY OF IT. Then we were to test their blood sugars with blood 2 hours later, and dose a correction of insulin if needed, and then repeat that check/correct 2 hours after that again. At that point, 4 hours post meal, we could put their pumps back into auto-mode and the challenge was complete.
How the kids reacted to the uncovered food was quite interesting. Within an hour we could see on their CGMs that Walker’s blood sugar was spiking fast, whereas Ollie’s was rising gradually. If the kids were feeling crummy we could have given an early dose of insulin, but both were feeling ok (albeit “high”) so we decided to wait until the 2 hour mark. At 8 o’clock we were shocked to find that with a finger stick test Walker was above 500 mg/dL (her CGM was reading low 400s), but thankfully had not yet started developing ketones. We did a correction bolus and hoped the insulin would kick in quickly. Ollie’s finger stick was closer in line with his CGM, in the high 300s, and also at zero ketone count. He also had a correction bolus of insulin. At this point, the kids were heading to bed and planning to read for a while until I checked with blood again in 2 hours.
At 10 o’clock I was eager to see if the insulin had brought them down into a more comfortable range. Thankfully Walker had dropped down to 218 mg/dL and still had no ketones. Ollie, surprisingly, hadn’t dropped as much and had only come down by 50 points and was still in the 300s (but no ketones for him either). At least they were both heading in the right direction and I felt like I could safely head to bed. I put both their pumps back into the auto-mode function and set my alarm for 1am. By the time my normal middle-of-the-night-blood-sugar-check rolled around both kids were back into the 100s and sleeping soundly. The insulin had done its job.
Two kids eating the exact same meal with two VERY different outcomes. One shot like a bottle rocket and came careening back down, while the other cruised like a jetliner and stayed at altitude. We see this same trend throughout most days: Walker reacts quick and hard to food and insulin, and Ollie is slow and steady in either direction. Fascinatingly, this is true for their personalities as well.
Our next meal challenge will take place in a couple weeks. I’m eager to see what happens to both kids when the pump is able to play its part in regulating their blood sugars.
