Mix up
In many ways Type 1s tend to be creatures of habit. They’ll find foods they can accurately bolus for and they stick to them. They have go-to snacks they know will raise their blood sugar in a consistent way and they keep those low snacks in their bags and pantries. They know which workouts will lower blood sugars and which ones won’t. Routines help alleviate the unknown elements of Type 1 management.
Back in the day routine wasn’t just helpful it was crucial. When Marshall was diagnosed he had to eat at a certain time each day, go to sleep and wake up at a certain time, exercise in a consistent way, and eat the same foods (no sugar unless low). There was no carb counting, no math equations, and certainly no CGMs and closed loop systems. in 2001, when Marshall and I first started dating, he had just switched to a new kind of insulin: insulin lispro (Humalog). Humalog is a short-acting insulin and thus reacts faster in the system and consequently is used up quicker. This timing works more inline with how food interacts in the system as well. All in all this makes it easier to keep blood sugars in a safer range. On average Humalog remains active in the body for 3 hours and it peaks at 1 1/2 hours. This means that if you take a bolus shot of Humalog 20 minutes or so before you eat the insulin will be at peak performance just around the same time when the body is converting your food into energy. Perfect timing. NPH, the intermediate-acting insulin he was previously using, stays in the system for upwards of 12 hours, peaking at 4-6 hours after injecting. As you can imagine this change was huge for Marshall and all the other Type 1s out there trying to lead a normal life. Humalog only hit the market in 1996.
Marshall didn’t start counting the carbohydrates in the foods he was eating, and dosing accordingly, until shortly before he started using a pump in 2007. Up until then he was just taking “a shot” of Humalog at mealtimes and a shot of Lantus (his basal insulin) once in the morning. His “shot” of mealtime insulin was always 5 units of Humalog regardless of how much or how little he was eating. This was the standard practice nearly 20 years ago and it resulted in hard to control blood sugars. He did this for many years. He took a shot of Lantus every morning. As I’ve written before there are 2 “kinds” of insulin doses: bolus and basal. A bolus dose is one taken when you eat or when you need to correct for a higher blood sugar. This is done with a faster acting insulin (like Humalog). A basal dose is one that is taken once a day, or sometimes split up and taken twice a day. This basal shot is a slower acting insulin (when taking shots, this would be done with a different kind of insulin like Lantus, that stays active for 24 hours), and stays “in the background” to serve to provide energy transference for all bodily functions like breathing and heart-beating and survival stuff like that. You know, important stuff.
So like I said at the start of this post, routine helps save lives, even for a spontaneous and super active 27 year old who hates routine. A few months into dating, Marshall and I and a bunch of friends went camping in upstate New York. We were planning to climb Mt. Marcy. We caravanned the 3 hour drive after the last of us finished work and arrived at the trail head a little after midnight. A normal group of people would have just slept in their cars and headed out to find a campsite and start the hike early the next morning. We were far from a “normal” group of folks. We hiked in about 2 or 3 miles, finally pitching camp around 2am, and planned to wake at dawn to start the hike early.
The following morning we all started to wake, make coffee, and awkwardly get our first full day started. While I was filtering water at the stream Marshall was performing his morning routine in an all-but-routine setting: put in contacts with ice cold saline, talk to the game warden about a nearby bear sighting, take his basal shot of insulin, the normal every day morning prep. Once we were all ready to go (and all food was hung on the bear line to avoid unwanted party crashers) we started for the trail.
An hour or so into our hike Marshall was slowing down. We had fallen to the back of the pack and I could tell something wasn’t right. He definitely seemed distracted and worried about something. Once most of the group had charged ahead, and his dog was with my brother at the front of the pack, he let me in on what was on his mind. He told me that during the rush of the morning and blurry eyes he took Humalog instead of Lantus for his basal shot. 30 units of Humalog.
Oh. Shit.
We immediately turned around and took a slow walk (to conserve his energy) back to camp. Along the way he ate all the food he had brought in his day pack. Once we got back to camp he started eating anything sweet he could find. I kept asking him how worried I should be, to which he said, “I’ll be fine. I just need to eat.” and, “I don’t think I’ll need to, but there’s a chance we might need to hike out to the car.” I remember he kept apologizing, as if my summiting Mt. Marcy was the foremost worry in my mind.
There are so many things we would have done differently, had we had the knowledge then that we have now. I don’t think we even had a Glucagon shot with us. Stupid, I see that now, but in our defense 20 years ago things were very different. Glucagon wasn’t something Marshall typically carried with him. I think he had a dusty kit that lived somewhere in his medicine cabinet but it wasn’t something he would ever carry around. (Now, we have Glucagon or Baqsimi next to everyone’s bedside, in the car, in every one of my bags, etc). He also had just switched over to this new mode of insulin. Only a few months prior there was less chance of making this mistake and taking too much insulin, and the old style of insulin didn’t act as quickly on the body as this new method. That was how he had been doing things for nearly 10 years. And yet somehow, even with only “camp food” he downed enough carbs to counteract the 30u of Humalog. That was likely about 500g of carbs; the equivalent of a gallon of juice, 5 boxes of Mac&Cheese, or 18 Snickers bars. I’m still not quite sure how he managed it.
If that were to have happened now he would have instead administered a mini dose of Glucagon. A shot of 15u of Glucagon will raise the blood sugar about 100 points within 30 minutes. A full 30u dose of Glucagon is typically used as a life saving drug to pull someone up fast from a dangerously low blood sugar. With 30u of Humalog coursing through his body, Marshall was on track to seize within a couple hours had he not caught it and continued hiking. Taking a half dose of Glucagon would have acted like drinking many glasses of orange juice, and it would have saved him from having to ingest the crazy amount of carbs he did.
I don’t remember what the rest of that day was like, how his blood sugar graph must have looked, or how crappy he must have felt. This was all pre-CGM so he was going off feel for the most part. I don’t even know if anyone but us knew it had happened. I’m just so thankful he realized his mistake as soon as he did.
