Dominoes

Last week, M woke up with a pretty nice bg level: 125 mg/dl.

Then she ate a low carb breakfast of bacon, eggs, and half of a hamburger roll (Don't ask me about the hamburger roll. I was not part of that discussion, if there was one).

We arrived at church about an hour later. We were early. M reached toward the glove compartment, saying, "I feel low". She retrieved a handful of Smartees.

"Please check your blood sugar," I said.

It's 35.

We popped our seatbelts back on and cruised to the pharmacy, where I hurriedly plucked some glucose tabs off of the shelf in the back where there are about 58,000 bg meters on display. Then, knowing that M is often thirsty when her bg is especially high or low, I grabbed a water bottle.

I gratefully approached the customer-free counter, payed for the items, and jogged out to the car, where M started chomping down tabs.

I pulled out the calculator app on my phone and estimated that she should eat 3 glucose tabs (15 carbs) in addition to the two packs of Smartees (13 carbs total) that she has already eaten. Any more would start her on an upward spiral. At roughly 5 mg/dl increase per carb that M eats, she should have a nice bg level of 140, which would give us a little wiggle room.

We returned to the church, attended mass, and met M's boyfriend du jour and his mother in the parking lot afterwards. M had plans to spend time at their house that day. Since they live near the church, and not near our home, we decided to meet them there. I, at this point, am having my doubts about the wisdom of sending M to someone else's house, but I assume that her bg will be in a more comfortable range at this hour. We did the typical pre-departure bg check: 37mg/dl.

Panic ensues. I mean, she just ate a pile of pure sugar an hour ago. If anything, she should have a higher-than-ideal bg level. How could this have happened?

I had a quick conference with M. "How much did you bolus for this morning?"
Answer: "42 carbs"

I would like to pause here for a moment to point out that M handles these fact-finding inquiries much better now. A year and a half ago if I had asked any questions pertaining to figuring out "how this had happened" she would become angry, defensive, and startlingly teen-like.

But back to our story.

Let's revisit the aforementioned breakfast: bacon, eggs, half of a hamburger roll. Bacon: zero carbs. Eggs: zero carbs. A whole hamburger roll: 30 carbs so HALF should be 15 carbs. 15 carbs total for the meal. Not 42 carbs.

Insulin for 42 carbs is way more insulin than M needed this morning. We are lucky that she hasn't passed out yet. I ran into the church hall and grabbed her a coke. I ordered her to drink the whole thing: 39 carbs of fast-acting sugar. Times five is nearly 200. In theory, her bg should be 242 in a matter of minutes.

At this point I would like to point out that Boyfriend's mother is a nurse. As such, she insisted on having M over for the day despite the scary numbers we were reading in the parking lot. After all, she can handle it (which I know she can). I worriedly agreed, and asked that M promise to call me in one hour.

After two hours and no phone call, I called her. Boyfriend's mom tells me that M's bg is still low. It's about 48 - 50 mg/dl. She's having her hang around on the couch instead of helping paint the house as planned. She is forcing orange juice in 4 oz portions. She is making her check her bg every half hour.

Two more hours went by, and I called again. This time I spoke with M. She told me that her bg was now 325. After multiple attempts to bring up her bg, we have now overcompensated. She just bolused, sending insulin through her body to bring her bg back to normal. Boyfriend's mom tells M that she expected this. That we all expected this. Now we need to be careful and not overdo it again.

But no luck. When I picked up M two hours later, her bg was 53.

AAAAAUGH!

After 24 hours, we were back on course. But there is a valuable lesson to be learned here: really think about the number of carbs for which you are bolusing. Over-correction can be frustrating, time-consuming, exhausting, and dangerous.

And it can set off a chain-reaction for which we are unprepared.

It's amazing how life stops when these incidents happen. Our only focus is to get back to normal.

Well, diabetic normal.

Let's just say that rather than cleaning up after ourselves, it's easier not to start tipping that row of dominoes to begin with.

And let's thank God that that these incidents don't happen very often.

Good friends, Bad friends

Along the journey through teenhood, every child likely has to face some decision making regarding her friends. Do I still hang around with that guy who smokes? That girl who is so boy crazy that she'll probably end up pregnant before she's 16?

My reply has always been: If you find them to be valuable, and you are bringing them up, rather letting them bring you down, I will not interfere. After all, we have all made mistakes, and sometimes a good friend helps us to see the better path. Who am I to judge?

Well, now. Let's throw diabetes into the mix, and what constitutes a "good" friend and a "bad" friend changes. A good friend never makes his friend feel like diabetes is a burden to him when hanging out with him. He is curious about the disease and what to do if there is an emergency.

But as I peruse the assortment of friends that M and some of my students have asmassed, I realize that friends can have a strong influence on a teen's desire and ability to manage the disease.

M has a friend who is a lovely young lady. But every time M returns from an overnight excursion at this friend's house, her bg levels are out of whack: usually very high. M says that when she and this friend are together, they are "too busy" for her to check her bg levels or measure her food intake. So she routinely comes home with a bg of 330 or higher.

How does a parent handle a stituation like this? The friend is not encourging M to do anything illegal, immoral, or outwardly dangerous, like hitchhiking. But she is, consciously or not, discouraging her from doing something healthy. After all, not treating yourself for diabetes can be just as dangerous as using ilicit drugs, couldn't it?

So why would a friend of a diabetic NOT encourage her friend to take care of herself? There are, of course myriad reasons: 1) the friend forgets that her companion has diabetes 2) the friend does not know how dangerous diabetes is 3) the friend thinks that squeezing blood out of your finger at the dinner table is "icky" 4) the friend can't deal with the seriousness of the disease 5) the friend is always in a hurry to do the next thing, and the diabetic child does not want to "be a pain".

The fifth answer is a big one. M doesn't want to make a big deal about her diabetes. I believe that she thinks that a night of high bgs is worth a visit to her friend's house. Not good, but understandable.

But then she has other friends, just a few, who stay on top of it, and ask questions about the disease. These friends demystify the disease and are not afraid of it. When M is with these friends, her bg is much closer to her target level when she returns from a visit.

I can't blame the friends themselves. M, after all, is the one who needs to make sure that she is in control of her diabetes. I cannot put that kind of burden on other 15-year-old girls, who are mostly dreaming about the clueless boys in their biology class.

I can't help but wish for a special kind of friend for M: the kind of friend I like to call the diabetes hero friend. It seems to me, however, that it is mostly boys who have this type of friend.

The diabetes hero friend knows what a high blood sugar is, what a low blood sugar is, and frequently has exciting stories that go with that knowledge. I hear stories from these boys about climbing trees to get their delusional-super-high-blood-sugared companions down to the ground and to safety. They have injected their friends with both insulin and glucagon (at different times, obviously) They laugh about their diabetic friends going into diabetic rages while driving the car with a high blood sugar. And they tell the tale of how they took the wheel from their friend and got them to the side of the road without injury.

Diabetes hero friends know what to do in an emergency!

I once had a diabetes hero friend tell me that if our country ever really wants to win a war, it should put diabetics with high blood glucose levels on the front lines, because they are "crazy angry", and "don't feel pain."

When I tell someone that I have a child with type 1 diabetes, I have real respect for people who say, "I know what you mean, my best friend growing up had diabetes", because that usually means that they have a pretty intimate knowledge of the disease and its consequences. And some wild stories to go with it.

Of course, to have a diabetes hero friend with stories, one must have reasons to be rescued.

Fortunately for M, that has not yet happened.

So, I suppose I will settle for a few friends that ask M if she should eat that, or if she needs to check her bg. Even if she gets tired of hearing it, at least she'll know that they care.

And that they are trying to be good friends.

Good friends are worth their weight in insulin.

Instant gratification, the diabetic version

Still reading Think Like a Pancreas by Gary Scheiner and finding some useful tidbits. The author's style is much more friendly than I am accustomed to reading in the tomes through which I have usually slogged.

One chapter especially caught my eye, as I know that it can be hard for M to understand what the big freaking deal is about maintaining a consistent blood glucose level.

People often recommend that I introduce M to people who have lost feet or vision or kidney function due to diabetes.

The thing is, I know that M already knows the consequences. She knows that this disease, unmanaged, can kill her. But as a teen, it is just one of those other annoying things that can kill you, like walking across the street without looking both ways, or snorting bath salts, or swimming without a lifeguard present.

So how about another approach?

Think Like a Pancreas recommends pointing out what controlled blood sugars can do for you, instead of pointing out that poorly controlled bg can hurt you.

For my lovely M, this "instant gratification" alert might just work, especially because she is an athlete. Below is a list of short term benefits to controlling one's bg levels:

• Enhanced physical performance (better hand-eye coordination for stopping lacrosse balls)
• Enhanced intellectual performance (keep mom off your back about your grades!)
• Enhanced social/coping skills (deal with problems without embarrassing yourself in front of your classmates or the public in general)
• Better sleep (feel rested in the morning)
• Fewer infections (and colds!)
• Healthier skin (No acne or dry, flaky skin: includes dry scalp issues)

I can vouch for the veracity of the above list.

So can M.

Her bg-induced mood swings are notorious, and her ability to focus also varies with her bg levels. I also remember noticing that M's skin looked better immediately after her jaunt to the hospital, where we learned that dry skin is one of the many, many symptoms of diabetes.

I photocopied the page and stuck it to her mirror so she could see it in the mornings. She asked me about it, nodded, and put it in her room.

I can't say that she's been reading it, but her bg levels have been steadier than they had been in a while.

So here's to the power of positive thinking.

Ups, Downs, and Opinions

Shortly after M switched to Novolog, she also began lacrosse season, which usually requires a couple of weeks of adjustment.

I am pretty sure that the timing could not have been worse.

Having two major changes in lifestyle make the diabetic body, let's just say, unpredictable.

Her blood sugar was a mess. 32! 595! 31! 536! AHHHHHH!

This change and unpredictability sparked a lot of debate and discussion among those of us who were responsible for M's care.

First it was the DNE, who told me that "insulin is insulin", and that any change that was occurring must have to do with her renewed exercise levels. I disagreed, knowing that we have made this change before, and it was never quite this erratic. I did wonder if maybe M was eating food that I didn't know about, but she assured me that she was not.

Then the school nurse decided to chime in. "You need to get that insulin changed back! Ask the insurance company to change it! They will make an exception if there is a reaction that is detrimental to her health!"

The athletic trainer agreed. "It was not this bad before! It must be the insulin!"

I found these forceful declarations unfair.

I was exhausted. I was checking M's bg levels every two hours around the clock. I was stressed. I was tired. I actually became weepy a work. My coworker suggested that I take a mental health day after she asked me how M was doing, and I welled up at the thought of my daughter and her unpredictable results. I wondered daily which child I would be coming home to: the pasty gray-faced child, or the insane cranky child who felt defensive about her test results.

My diabetic students told me to hang in there; that I was doing the right thing. Monitoring bg levels regularly would give me the information that I needed.

M and I decided to give it a month. After two weeks of bi-hourly monitoring, we adjusted her basal rate rather aggressively, up in some places, down in others.

Happily, after about 4 weeks, we are back within our "normal" range.

But let me tell you, having everyone give me, a strung out parent, different advice just about sent me over the edge. I understood each point of view, and they all reflected my own guesses as to what was going on. I felt defensive any time someone felt that they could give me an absolute answer.

There are no absolute answers, no matter who thinks that just one thing will make a person's body go from insane to normal.

I knew in my gut that it had to be a combination of factors.

And while that reasoning and very careful monitoring paid off, I still feel that it would be inappropriate to tell people that they were only partially right.

Saying, "I am smarter than you are," just seems a little rude.

I may even be smarter than this car!

Glimmers of Maturity

M went to the Winter Weekend last week.

This program is especially for teens with diabetes. This year about 35 kids with diabetes spent the weekend in Vermont playing games, doing ropes courses, having a dance, and listening to adults with diabetes explain how they manage their disease.

There was a power lifter. There was a triathlete.

M reunited with some of her friends from summer camp, and also met some new ones.

Of course she had a good time. She's M. She loves people and new experiences.

Flash back to camp time: I pick up the flier about the Winter Weekend and ask M if she'd like to go. She shakes her head in distaste. "No, I am just not into that."

I signed her up anyway.

I am thinking that she seems to burn out on having diabetes every few months, and that this might be a chance for her to recharge her diabetic-management batteries.

Needless to say, I am smugly congratulating myself on being right about that one. She thanked me repeatedly on the way home.

At pick up time, there was a parent meeting, in which we heard about the kids' weekend as well as what resources are out there for parents and children with diabetes.

There was one program that caught my eye, but I didn't think that M would go for it. It is a program called STAR: Steps Toward Adult Responsibility. The program matches teens with mentors who are managing chronic illnesses in college. The illness does not have to be diabetes, but includes chron's disease, celiac, and other ailments that do not go away. As I listened to the college student in charge of the program, I thought I might talk to M about about checking it out in the car ride home.

The ride home was fun. M told me some stories, shared what the speakers were saying, and how it affected her. Then she mentioned the STAR program, and told me that she had signed up to be on their e-mail list, and can we start going to their monthly meetings?

I drove on, amazed as my daughter explained that she thinks that she needs support more than every six months, and that she thinks the program will really help her stay on track and keep a positive attitude.

Will wonders never cease?

But, just so you know that M is still M, she is begging us to buy her some girl scout cookies this year.

Because they are yummy.

Like brushing your teeth

I am feeling like a bad mother again. I sometimes feel like I can't do what I need to do to get M to independently follow her diabetes regimen. I mean, I have to get her to do this independently BEFORE she heads off to college in a few years, right? I can't be her helicopter mom for all eternity, can I? It goes against all of my Montessori training.

I am reading a book suggested by Jaqui, Think Like a Pancreas (God, how I miss reading fiction!). The author mentioned that to maintain tight bg control, one must test his bg at least four times per day.

Now I know this, and we ask M to do it, ask her what her bg levels were at breakfast, lunch, after school, etc. We think that she should test her bg at least 5 times per day, and we try to be sure that she does it.

But something about the way it was phrased in the book made me look over at the meter that M had left on the dining room table, and check her last 5 bg test results. I mean, she had already told me that her bg was 196 at breakfast and 209 at lunch. I had just had her check it at dinner, and it was 67, which I saw for myself.

Of course, any reader of this blog is unlikely to be surprised that I discovered that the 67 was the only time that M had checked her bg in the last 24 hours.

I shared my new found knowledge with Bill. He took off his glasses, sighed, and asked which one of us should talk to her about it. It was clear that neither of us did. When confronted with her own lack of discipline in this area, M tends to get ugly. High-pitched whining and angry spitting are common. Less common, but also to be anticipated, are the spinning head and the pea-soup vomit.

Rock smashed scissors and off I went to the lair of the diabetic beast.

Producing the meter, I asked M in a gentle voice why she thinks she should make up bg numbers (The voice really was gentle, I am not being sarcastic).

Her response: "I don't know. It's just easier."

Clearly my darling is a short-term thinker. Instant gratification is the name of the game, and if "I don't think about it now, it might just go away."

Except it doesn't.

I tell her that we try allowing her more independence, and try not bugging her about her diabetes all the time. We try to allow her to step up and take care of herself, but she hasn't once demonstrated the success level that would make us comfortable. I tell her that I really need her to be trained to care for herself properly, so that she will stay healthy when she goes off to college in the future. Then I ask her how we can do that.

Remembering how long it took her to brush her teeth on a regular basis, I asked if we would need to check her meter every night and sit on her for the next two years until it became a habit. I was half joking, but her answer surprised me.

"I don't know. Maybe."

Then she told me that she was really sorry that she was worrying us, and that she means to check her bg, but she just forgets. She really means it. And I know it.

I know that she is not doing this to upset us. I know that she just forgets.

I think that's what worries me the most.

So, for now, we will check her meter at 8:00 pm every night for the next two years. And hopefully testing her bg will go the way of brushing her teeth, and become a real habit.

After this, I will do everything in my power to control by bg levels!

Result 77

So, I checked my blood sugar the other day with one of M's old meters (not the one connected to her insulin pump).

I had never done it before.

Here is what I learned:

1) Those lancets sting like nobody's business, and the holes they make in your finger sting for a while after you think they should be over it by now. I've had bad paper cuts that have stopped hurting before these pricked holes did.

2) Squeezing out enough blood to satisfy your thirsty test strip takes talent. I had to make four, FOUR different holes in my finger and throw away two test strips before I could finally get a reading.

3) Even though the holes won't bleed enough to give you enough blood before the test strip times out, it won't stop bleeding for a couple of minutes. M simply licks her finger and wipes it on her jeans after a stabbing. I don't know what she does if it keeps bleeding, but I found myself sucking on my finger for a few minutes to both alleviate the sting and avoid having to put on a Band Aid.

4) The sides of your fingers are your preferred target for a lancing, because it won't interfere with the use of your finger pads. After all, we type, dial, text, and play instruments with those fingers. If they sting, it will make life a little less convenient. But the problem is that the pad is the easiest place from which to procure blood.

5) If your lancing hole isn't deep enough, no amount of squeezing and rolling your skin around will force out the appropriate amount of blood in time.

6) Get your big drop of blood out and sitting on your finger before inserting the test strip. Then there is not stress about timing.

7) I have a deeper respect for my daughter, who has clearly mastered this skill and endures the discomfort 5-7 times per day in order to better maintain her health. She almost never gets error messages on her meter! When she has trouble squeezing out blood, I will endeavor to be more patient, even if we are waiting for critical information from her meter.

I feel like a complete wimp.

Even so, like any parent of a child with diabetes, I would trade places with her if I could.

You look deceivingly small, but you don't fool me any more!

Not that, mom!

M has a problem with her pants (trousers for you Brits).

She likes to wear skinny jeans and pants with funky pockets on the side of the leg.

While this might not be a problem for most teens, neither of these styles is conducive to carrying an insulin pump.

But M tries anyway.

So about three times a week I hear that hissing "Ouch" that many of us use when we break our nails or stub our toes: the "ouch" that lets me know that the pump has fallen from a pocket and is now dangling from her infusion site. If I hear an accompanying "thud" then I know that the infusion set has been ripped out of her skin and is now delivering insulin to my floor.

Her clip broke, so she can't simply clip the pump to her pants. I recommended that she tuck it in her underwear, her bra, anything that might hold it securely into position.

She says it looks stupid and/or is uncomfortable.

So, instead of ordering a new clip like a normal mother, I take a look at tummietoes, which have been mentioned by multiple D-bloggers as great solutions for pump storage when exercising or going out in fancy clothes.

I mention tummietotes to M, and am immediately reminded of an episode of The Simpsons in which the whole family visits an IKEA-like store. In the episode, Marge offers to buy Lisa a new pencil holder called a Pupli (with two dots over the "u"). Lisa looks at her mother and says, "Mom! Not a Pupli! Even I make fun of the Pupli kids!"

M informs me that really only the dorky girls wear the tummietotes at D-camp.

I point out that if she wears it under her clothes, no one will even know that she is wearing it. And it is comfortable and convenient

M indicates that I just don't get it.

I look at the website again. And you know what, they do look dorky. But I don't care. They are available in black and white and other colors suitable for under the clothes. And they are supposed to be comfortable.

I make M look.

She relents.

"All right, Mom. If you want to spend your money on that, I will try it."

Victory!

Now if I can just scrape up the $25.....

The rule of small numbers

When M was diagnosed, her teacher gave her a very useful gift.

It is a book entitled Dr. Bernestein's Diabetes Solution, which was written by a doctor who is, himself, a diabetic. In the book are many interesting anecdotal stories regarding growing up as a diabetic over the years. Some of the stories involve boiling syringes, using daily urine tests, and general health inconveniences. The man became a doctor in order to learn more about managing diabetes well, and having the authority to teach people to manage their diabetes well. He claims that he has patients whose myopathy, retinopathy, etc, have actually REVERSED after learning to manage their diabetes using his methods.

One item that he brought up in his book is the "rule of small numbers". I am not sure if Dr. Bernstein is the first to call it such, but it seems to make sense, and it taught me a lot.

First of all, did you know that the FDA labels need to meet a certain accuracy level? I am sure you assumed that was the case. I know I did. What I didn't know, is that nutrition labels are permitted to be off by up to 20% and still meet FDA standards.

I really don't have that big a problem with this: food is a messy business. However, for people who rely on accurate nutritional information, labels can be disappointingly inaccurate.

Diabetics who are dependent on insulin use what they call a "carb ratio" to calculate how many units of insulin to give themselves when they eat. M's current carb ratio is 7. That means that for every 7 carbs M eats, she must give herself a unit of insulin. If M gives herself a unit of insulin without eating, it generally brings her bg down about 20 points (mg/dl).

The good doctor, therefore, recommends that diabetics stick to low carb food for accuracy purposes. Since the margin of error in food is 20%, a food whose label claims that it has 10 carbs in it may actually have somewhere between 8 to 12 carbs. The amount of insulin that covers 8 to 12 carbs does not vary that much; in M's case, it's about a half unit of insulin. If she gives herself 20% too much, her bg will be about 5 mg/dl less than the ideal. If doesn't give herself enough, her bg will be about 5 mg/dl higher than ideal. 5 mg/dl off is no big deal at all.

However, if a food claims to have 60 carbs in it, then the actual number of carbs in the food can range from 48 to 72 carbs, which can make a big difference in the amount of insulin you give yourself to cover it. Let's see: If she gives herself 20% too much insulin, her bg will be 40 mg/dl lower than ideal, which brings her into dangerous territory. If she gives herself 20% less than she needs her bg will be 40 mg/dl higher than ideal.

M's target bg - the one we shoot for every day- is 120.

In reality, we are very happy if it's between 85-145. Because she is a teen, and because some foods don't have labels, or portions are over estimated, underestimated, and because of other factors like exercise or lack thereof, most days it goes over 200 at least once. Nearly every day it drops below 70 at one point.

We notice that when M eats steak and salad, and minimizes bread, her bgs are much better under control. During the holidays, when the house is full of carb-loaded sugar-filled nutritionless crap, her bgs need to be monitored much more closely.

While many low-carb foods are delicious, sometimes a kid just wants a bagel, which we then pay for in extra test-strip usage and monitoring, or, alternately, higher bgs.

The argument in the DOC has been that, while "the rule of small numbers" seems to make logical sense, it doesn't always work.

I think it is true, but brittle diabetics and diabetics with other factors such as unrelated illness, medications, etc. might not be able to rely even on something as seemingly straightforward as the rule.

Currently, we use the rule as a guideline in determining a balance in food. For example, M is smart enough to realize that eating a large Blizzard from Dairy Queen  (at a labeled 160-190 carbs, depending on flavor) or a slice of cake is not only not worth it to her, but it can also be dangerous. But she knows that if she wants a big slice of Italian bread, she best eat it with a steak and salad so that her total meal is less than 70 carbs.

Verdict: I like the rule of small numbers, but while M is off at school, with high carb quick lunches and hot lunches, sticking to the rule can be a challenge. Let's hope she makes good food choices when she is out of sight.

Here's a small number. I'm pretty sure I can cover for that.

Just annoying

I feel, sometimes, like I must be a bad mother.

A good mother would never feel like her kid was just another thing she had to worry about before going to bed, would she?

We had a great dog for a long time. But sometimes, I would want to go right to bed after our family finished watching a movie. I wouldn't want to wash my face, or brush my teeth, or let out the dog.

But I knew that if I didn't let the dog out, I would have to clean a little puddle off of the floor, or that she would wake me two hours before I wanted to get up so that she could access the great outdoors to meet her needs.

So I would begrudgingly let the dog out before collapsing into bed. I would still skip the teeth and the face, just to mollify myself.

I will not say that I felt guilty about feeling resentful that the dog had to use the bathroom. I didn't. My dog loved me unconditionally, and she never sensed that I was feeling whiny about this particular chore.

Unfortunately, I occasionally have similar scenarios with my diabetic daughter. And I wonder if she picks up on my internal whine-o-meter.

Case in point: Around dinner time yesterday, M checked her bg.

It was 207 mg/dl: not outrageously high, but not in the range we are generally looking for.

After finishing dinner, doing our homework, and watching some television, we all went to bed.

I crawled under the covers with my beloved and warm husband. I snuggled my face into the pillow and began the quiet process of unwinding the day in my head.

That's when it hit me: I should have had M check her bg again before going to bed.

I lay there, without moving from my very comfortable position, wondering if I really had to get up. After all, I reasoned, a bg of 207 was unlikely to get outrageously high. There would be no immediate, serious consequences. Probably.

On the other hand, what if it did climb a lot higher? Then my daughter would feel crummy, she might not sleep, her day at school would be shot, and, worst of all, her long-term health would have another ding in it.

I lay there debating.

Whining internally.

I tried to pretend that I hadn't remembered that she needed to check her bg one more time.

It didn't work.

Sighing, I tossed the covers aside, and fumbled my way to the dining room. I grabbed M's purse, and brought it upstairs to her so that she could check her bg.

She seemed unsurprised to see me.

With absolutely no fanfare, she pricked her finger with the lancet, and squeezed a droplet of blood onto the test strip. 5... 4...3... 2... 1.

It was 274, so M ordered her pump to deliver the appropriate dose of insulin.

End of story.

Instead of being pleased that we prevented a potential night-time high, I had only one thought.

"Finally. 

Now I can get some sleep."

Bad mother.

Bad, bad, mother.

But it really is annoying!

Pizza

Fact: If you want teens to participate in any kind of extra effort, be it volunteering, doing an extra credit project, or whatever, it is easiest to get them to participate with the promise of food.

Fact: Teens are hungry, hungry people with seemingly bottomless stomachs.

Fact: Feeding more than one teen can get expensive.

Fact: Satisfying the tastes of several different teens can be a challenge.

Fact: Anticipating the serving size one must allot per teen can be tricky.

Solution: Order pizza!

It is cheap, comes divided into manageable portions, and has a flavor to match just about every taste!

But.

But, it is super high in carbs.

M has never been concerned with pizza in the same manner that she has been with cake, but it still takes a lot of skill and luck for her to keep her bg in range for several hours after consuming even one small piece (defined here as a one-inch wide slice of a 12 inch pizza).

The tricky part is that it doesn't seem to behave in a consistent manner. Cutting back the "dose" of pizza doesn't lessen the wacky impact it has. Adding more insulin seems to make no difference either.

So what is a mom to do? Neither M nor I find the option of making a stink about the lack of food choices to be a viable option.  Especially when the food is really only provided as a courtesy, not as a part of a culinary experience.

Additionally, people think we are crazy when M brings her own food, because pizza is so awesome.

Right now, even though she only has pizza maybe once every two weeks at events for church, school, or at the home of a friend, I still have this nagging feeling that we are playing a little Russian roulette with M's long term health.

So yes, folks. I will be sending food with M from time to time. After all, she doesn't even like the pizza provided at church. She eats it because she is hungry and there are no other options available.

And before you parents of non-diabetic children judge me by what an amazing killjoy I am, count your blessings that pizza is not on your list of worries.

I will offer up a prayer that it never will be.

Oh pizza, why must you be so cheap and easy?

Concussion

As I may have mentioned, M is the goalie for her field hockey team. Although she has never played before this season, her improvement has been marked.

Earlier this week, however, her team got a new kind of penalty that neither she nor I had heard of. A player fell on the ball, apparently covering it with her body.

I guess this was a serious one, because M was set up in the goal while the rest of her team was set up behind the midline. A girl on the other team was given a one-on-one shot at the goal.

The girl wound up and smacked the ball. It traveled in an upward fashion, hitting May on the front of her (helmeted) head.

It would have been a lot cooler if it had deflected right back into the field, but instead it went into the corner of the goal.

I wondered if it hurt. So when M returned for a time out, I asked her how she felt. She said, "I have a wicked headache!"

Somewhat alarmed, but not panicked, I asked if she wanted some Tylenol. She said she would be fine, and finished out the game.

It is three days later, and she still has the headache. She took "the concussion test", which she did not want to do ("It's so friggin' long!"), and it came back as "not a concussion" but with "22 symptoms."

While I wait to hear from the trainer about her recommendations regarding a doctor visit, I decide to look up information about diabetes and concussions.

To my dismay, I found something. It seems that diabetics do not "withstand impacts to the head" as well as non-diabetics. This is something I had never thought about, and is certainly not up there with the "diabetic feet" issues that are so frequently communicated to the diabetic community.

Why, you may ask, would having diabetes matter to your head with regard to impact?

Evidently, if brain cells contain high levels of glucose and magnesium, they are practically invincible. Unfortunately, since the diabetic body doesn't use glucose very efficiently, and depletion of magnesium nearly always predates insulin resistance (in Type 2),  we have the perfect cocktail of brain cells' natural defenses going down.

Not good.

In the meantime, I will wait for advice from the trainer and the school nurse.

And I will look up new and exciting things for me to worry about.

A call from the nurse

So M has been in high school for about 6 weeks.

As with most high-schoolers, there have been some bumps along the way, but for the most part her transition has been pretty smooth, especially considering that her previous school was so tiny. And Montessori.

In a small Montessori school, diabetes was pretty easy to manage.

M could eat when she was hungry. She could check her bg any time she felt like it. She could leave her work for a moment without losing valuable instruction time.

In traditional public school, these options are not typically available.

For example, students are not allowed to eat in class.

Oh sure, because she has a "disability", M is permitted to eat in class. But if no one else is permitted to eat in class, then M feels like she is making a big stinky deal out of being "special".

To check her bg, M either has to check it in class, which causes a distraction, or excuse herself to go to the bathroom (Ick! High school bathrooms!) or the nurse's office. Leaving the room excludes her from valuable instruction time.

Not to mention that racing from room to room, visiting her locker, carrying and organizing a bunch of stuff, etc. gives her plenty of opportunities to "forget" that she has to take care of herself.

Overall, she forgets less than she might.

However, while at work the other day, the phone in my classroom rings. I pick up the phone and our school secretary asks me to hold the line for M's school nurse.

I go into "I-am-calm-and-will-not-panic" mode.

I try to sound pleasant as the nurse asks how I am. I say something foolish like, "I don't know. You tell me!"

She explains that M has had a couple of lows that morning, and that it took her a few hours to shake them. She had to lie down in the office for a while and missed her Spanish class and thus valuable instruction time. She is fine now.

The nurse goes on to explain that M has not been eating breakfast in the mornings, which is news to me. The nurse suggests that perhaps M doesn't have time in the mornings to eat.

I stupidly begin to argue with the messenger, "She has an hour..." but I cut myself off. It is not the nurse that needs to realize that she has plenty of time. I have met M before. She does not like to eat in the mornings. She never has. In fact, when she was in preschool, her teacher once called to ask me if I fed M breakfast in the morning, because she was always starving at 9:00 am. My answer at the time was, "I try to, but she only eats about two bites before she says she's full."

M is still the same person she was at three years old. She is never hungry in the morning. In Montessori school, M ate when she was hungry. The problem is that traditional schools need to have designated lunch times or students will lose valuable instruction time.

I tell the nurse that I will buy M some Zone bars so that she can shove something into her face before heading to school. The nurse thinks that this is a good idea.

I ask the nurse to please have M come visit her before the end of the day to check her bg again. She had a field hockey game that afternoon, and I didn't want to burden her coaches with a sick, weak, or unstable kid at an away game. The nurse agrees and I hang up.

It was my prep period, so I only had one student in the classroom with me, looking for extra help.

"Is everything okay with M?" she asked. All of my students know about M's type 1.

"Yes," I sigh. "At least it will be."

Mmmm. Breakfast!

Killjoy

So the first thing I want to say before I tell this story is that diabetes is the killjoy here. Not Auntie Jeanne.

As a Spanish teacher, it is wise for me to periodically visit a Spanish-speaking country so that I can keep my knowledge fresh and up to date. This year, I went.

Which meant that, since Daddy has to work all day, M was to be left to her own devices for 11 days.

Auntie Jeanne saw the opportunity to spend some quality time with her goddaughter and seized it. The two of them chose to go zip-lining and generally hang out for a couple of days.

Now Auntie Jeanne is a medical professional, and has been asking me good questions about M's diabetes from the start. She files this information away for future use.

But then it comes back to haunt her.

Things that Auntie Jeanne remembers include:

1) M does not do as well managing her diabetes on the road as she does at home
2) M needs frequent snacks when doing physical activity
and for carb absorption:
3) Foods with fat and sugar in them are better than foods with just sugar in them

After a long day of swimming and running around, M informs Auntie Jeanne that she is hungry and would like a snack [2) M needs frequent snacks when doing physical activity]. She states that she would like some ice cream [3) Foods with fat and sugar in them are better than foods with just sugar in them]. Auntie Jeanne agrees and decides to take her to the local ice creamery for what she anticipates will be a small dish of ice cream.

When they arrive at the the ice creamery, M peruses the menu and decides that perhaps she would like a hot fudge sundae. "Uh-oh", Auntie Jeanne thinks, "3) Foods with fat and sugar in them are better than foods with just sugar in them."

But as M continues down the menu, she decides that she will have a milkshake. "Hmm," thinks Auntie Jeanne. "That's more ice cream than I'd like to see her have, but 3) Foods with fat and sugar in them are better than foods with just sugar in them."

As they continue to wait in line, M declares that she would like to have a malted milkshake.

Now up until this point, all of Auntie Jeanne's misgivings have gone unspoken. She is the fun Auntie. The one who lets M do stuff she doesn't always get to do at home. Sometimes "stuff she doesn't do at home" includes extravagant food choices, such as having shrimp for breakfast, lunch, and dinner.

But the word MALTED catches Auntie Jeanne's attention. She thinks, "What is malt, exactly? And why does M want it?"

So she breaks her silence and asks, "So what is malt?"

M says, "It's a thickener. It makes the shake taste really yummy."

Jeanne's brain processes this information. It seems to her that malt is some kind of grain, which means added carbs, which means that the rule of small numbers is likely to be broken, which means that M's bg could become pretty high, because 1) M does not do as well managing her diabetes on the road as she does at home.

Auntie Jeanne thinks about this to herself, and makes no comment to M. After all, M is supposed to be having fun. On the other hand, Auntie Jeanne is responsible for M's general health while M is in her care. On the other hand again, M is a surly teenager, and at times grows frustrated when others tell her how to manage her diabetes.

Auntie Jeanne hems and haws about whether to let M know about her concerns.

M interrupts Auntie Jeanne's thoughts. "Do you think I should get the malted milkshake, or just a regular milkshake?"

Auntie Jeanne, relieved, says, "Well, since you brought it up.... I think you should have the regular milkshake, because I think it will be lower in carbs."

M looks at Auntie Jeanne and sighs. "Yeaaahhh. I know." She sighs again.

Auntie Jeanne, feeling badly, says, "Sorry, but somebody has to be the killjoy ."

M says, "Yeah, I have a lot of those in my life."

No, M.

A lot of people have those in their lives. But you have a super-extra-annoying one, that most kids don't. While some girls your age forgo the malted milkshake to avoid packing on extra pounds, you have to do it to keep yourself from getting sick.

Good for you for recognizing the smart thing to do.

Good for you for asking Auntie Jeanne to verify what you already knew.

And good for you for making the better choice.

And nobody is sorrier that you had to make that choice than I am.

Except maybe Auntie Jeanne.

Diabetes: the ultimate killjoy.

A malted milkshake, hold the malt.

Flying solo

M made her first no-joke solo travel attempt this week. She had to fly from Indiana to our New England state all by her little lonesome.

Once her flight took off, I received a call from her grandmother.

"She's on her way!" she said, cheerily.

"How was security?" I asked. After all, not only was this M's first solo flight, it was also her first flight with a pump. I remember being behind someone with a dialysis machine at airport security right after 9/11. Needless to say the experience was less than pleasant for all involved.

"It seemed fine. We could have escorted her to the gate, but she said that she could do it herself, so we watched her go through security, and it seemed to go just fine."

Well, this sounded like good news. When M received her pump, she also received a medical device card that says, "I am wearing a required medical device prescribed by my physician" and includes general information about what to do if she acts peculiar.

Just what constitutes "not peculiar" for a teenaged girl, I would like to know.

After a few hours, I went our local airport to retrieve M. Aside from looking about a foot taller (a common side effect of gaining valuable life experience), she looked great.

I asked her about airport security.

She said it was fine.

She didn't have to remove the pump. She did have to go through the metal detector. Then she had to have her hands swabbed with a cotton ball. The cotton ball was then tested, presumably for explosives, and she was sent on her merry way.

She thought that whole thing with the cotton ball was weird, and nobody explained it to her until I gave her my theory at home.

But it sounds like the TSA gets the whole insulin pump thing, which made M's life easier and less stressful.

So, yea! My baby's home!

Who has an embarrassing mommy who loves her? You do! That's right, yes you do!

When she's away

M has been visiting her grandparents in Indiana this week.

I admire their can-do attitude. After all, living so far away from our New England home, they really aren't exposed to the daily inconvenience of living with Type 1. But they are unafraid. They enjoy M and her love for life. They know that she is capable, and they invited her to come visit them for the week. Just her and them.

I talked to her on the phone and it sounds like she is having a ball. And she claims that her bg levels are good.

I find this last piece of information believable, actually. I have to say that her bg levels have been pretty good lately, with very few highs over 200, and an average bg of about 140. We will Carelink her when she gets home, though, just to be sure.

She will be flying home solo. I can't wait to hear about her going through airport security on her own with her insulin pump.

In the meantime, it's been pretty quiet around here. (Not at work! That's been crazy!) At home, where there was some raucousness, there isn't any.

Here are some odd things that reminded me that, although my D-daughter was not here all week, I am clearly a D-parent.

• While sweeping the floor, I picked up purple needle covers from an insulin pen that M hasn't used in two months.
• I set aside the french fry bag at dinner the other night, so that M could calculate how many carbs she was going to consume. After about 20 minutes of it sitting there, I realized that no one was going to use that bag for anything.
• I made sugar free pudding, when there was perfectly good sugar filled pudding on the shelf.
• I kept picking up the insulin bottle on the kitchen counter to check how much was in it.
• I made too much bacon for Saturday breakfast. Bacon is M's favorite 0 carb food. Leftovers are usually non-existent.
• I picked up the sharps container to check how full it was. Twice.

They're these little things we never think about. I just do them because they are a constant part of life; like feeding the dog or shaving my legs.

The good news is that I won't feel so crazy doing any of these things once M gets home.

Now if only I would stop talking to the dog when I am alone....

I don't know what you're saying, but it had better involve bacon.

Travels with Daddy

M got to go to New York City last week for her 8th grade class field trip.

Gee, for my class trip we went to the coast of our own tiny state, and went deep sea fishing for a day.

The students and teacher planned out their destinations, and readied themselves to go. They would visit Ellis Island, the Statue of Liberty, the Empire State Building, the Museum of Modern Art, NBC Studios, and see a Broadway show. Bill and I decided that one of us should go, too. But not because we love spending time with hormonal young people.

M's tiny Montessori school has no nurse. It seemed only fair to the director of the trip for one of us to chaperone so that we could relieve her of the care and responsibility for M's type 1 diabetes. After all, she had plenty of other normal children with normal issues going on the trip. Her hands were already full.

After a heated round of rock, paper, scissors, it was decided that Bill would hang around with 8th graders for three days, and I would drive the 500 miles (one way) to pick up our son from college.

I am not sure who got the better deal.

Bill tells me that all went well. That M's bg was pretty steady. He also told me that he was surprised and dismayed by the number of carbs she ate, but he felt that he couldn't argue with success.

The secret was walking.

They walked everywhere.

And it seems that, as long as M is moving, she can eat nearly anything.

Nevertheless, I was not thrilled to find a foot long plastic pixie stick straw (empty) in her laundry pile at the end of the trip.

Bad diabetic, M. Bad, bad diabetic.

Ahhh, pixie stix. Just like I remember them!

Lacrosse and diabetes

So this has been interesting.

As I may have mentioned, M is an athlete. This season she is playing her favorite sport of all time, lacrosse.

Now, as you can likely imagine, running around is a big part of lacrosse, as is whacking sticks and scooping balls off of the ground. It can get a little rough.

So of course M loves it.

The first day of lacrosse practice this season, M opted to wear her pump as well as a purple hair extension that I had to comb into her ponytail, just so everyone could see. I think it was her way of announcing to her new teammates that M is here.

During practice, M learned how to manage having the pump clipped to her shorts or sweats, and experienced no problems. She did have lower bgs than normal, but we knew that was how her body worked after rigorous exercise.

M answered the obligatory questions about the pump from the other girls, and accepted compliments about her hair with grace. She began to get to know people.

After a month or so, along comes the first game. M is playing defense. She is running, blocking, stretching that stick so that nobody can get to the goal.

Then there is a moment of confusion on the field. A time out is called, and M comes running over to me holding the purple device in her hand, infusion set dangling from it.

She hands it to me, saying "I'll deal with this later," and runs back into the field.

I look at the device, decide that it is okay that she is not wearing it- considering her bg generally drops during athletic events- and watch the game.

Don't get me wrong. I am a little annoyed that it has pulled out of her body for the second time in a week. At the same time, I know we will have to figure this out: where to place it on her body, when to disconnect it, etc.

After a few minutes of watching the game, there is a startlingly loud vibrating sound on the bench next to me. It is the pump, much like a cell phone on vibrate, asking for attention.

I dutifully pick it up, look at it, and set it down. I am annoyed with the pump for taking my attention away from my amazing child as she races around the field. Looking at a purple box is not nearly as fun as watching your kid kick butt at a lacrosse game, is it? However, I am fascinated by this new noise.

Evidently, the pump is programmed to do this every fifteen minutes. It is one of those safety features that prevents people from not getting their insulin. It says, "Hey, dummy! I'm not pumping any insulin into you! You wanna do something about that?"

Fortunately, unlike baseball or horse shows, lacrosse is not a long game, so I only have to hear the angry buzz of the pump three more times.

After the game, we jump in the car, check the all-important bg (which is 85mg/dl) and decide to leave the pump off until M showers.

That was just easier.

From now on, the pump is disconnected during a game!

Knock the ball out! Woohoo!

Sick

Tap, tap, tap "I puked."

It was three in the morning, but M was outside my bedroom door, and I had to spring into action. The first thing I ask is, "What day is this, Sunday?" She tells me it's Tuesday. Now I know I have to call in for a substitute.

I remembered that nearly two years ago, when M was diagnosed with Type 1, we were told that vomiting is very serious business that could lead to hospitalization. This was the first time in those two years that we have had to face this problem.

I remembered nothing. Oddly enough, when M and I went down to Children's Hospital for her infusion set appointment, I went out of my way to grab a pamphlet on sick day management. But where was it? Where was all the information I was given two years ago?

Braaaack

Okay, now that's twice. I am glad this child knows how to get all the way to the toilet.

She wasn't feeling better after vomiting, which is not a good sign. I mean, I usually feel fantastic after throwing up. It must be that rush of adrenaline...

BRaaaack.

Three times in less than half an hour. This is going to be a long night.

Okay, so a loss of glucose from vomiting can mean a drop in blood glucose (bg). We had better monitor this. We pull out the monitor, and with a comforting beeDEEP, we are advised that M's bg is 161. I think that's good, because it leaves us a safety net of about 80 mg/dl.

She vomits again. We test again. 172.

Again. test again, 162.

M continues to vomit every 15 to 20 minutes. It is 4:00. At this point I have pulled an extra mattress into her room, written up sub plans for my Spanish class, brought M a glass of water, and brought up enough test strips to supply a battalion for a week.

I doze between vomits. So does M. After a while I realize that a) I must call the substitute coordinator, and b) testing M's bg every 15 minutes might be excessive. I decide we will test every other time she vomits. I have a sheet of scrap paper with a long list of times that M has vomited. Next to it is the bg level.

The sub coordinator at my school is an excellent human being. He knows that I am never sick. He knows that if I will be out, I will leave plans. He know that I feel guilty if I screw something up. He understands me, because he, too, suffers from Catholic Guilt. When I call him, he gives me no indication that this is a bad time (which, I soon discover, it really was). He just says, "Okay, thanks for calling."

Having handled the school situation as best I can, I devote some time between vomiting episodes to trying to find that information about sick day management. Being that my brain is addled and I am exhausted, this is no easy task.

Two years ago, my mother had put together a binder with M when she was first diagnosed. It helped both of them to organize the information that M had, and made them both feel better empowered and informed. I locate the binder, but there is no sick day management sheet.

I look in the car, hoping I had wedged the guidelines I had taken from our last appointment in between the front seats  on my way back from Children's.

Nope.

I go back to the binder. BRaaaaack.

M's bg is 126. I bring up a Coke and ask her to take two sips. M's target is 110. 126 feels a little too close for comfort. I want wiggle room, baby!

Okay, binder. Now, let's look through each individual sheet.

I look. The only information I get is from the test strip company, that says "When to contact your doctor". Vomiting is at the top of the list.

Fine. I vow to call the doctor once office hours begin.

At 9:00 am I call the DNE, who is not in today, would I like to speak to the endocrinologist? As I wait on hold, my anxiety increases. I felt like I was fine before now, but the haste with which the operator referred me to someone else makes me nervous.

I speak to M's doctor, who tells me to watch her Ketones. Damn! I forgot about those things! M hasn't has a high enough bg to warrant checking them in a while. If the Ketones are higher than 2, Dr advises us to go to the hospital.

Now where are those Ketone test strips? M says that she doesn't know, and I sure as hell don't. I find the urine strips, but not the nice blood strips for her monitor. Hopefully she will be hydrated enough to pee. I have been forcing her to drink two sips of water every time she vomits.

I run up to her room with the urine strip. She is asleep. Sound asleep. For the first time in 7 hours, she looks comfortable. I choose to leave her alone.

After two hours she awakens. I explain about the Ketones. She says she can pee. She does, but then she gets upset. The Ketone strip indicates a 5 or a trace amount. She says, "Should I pack for the hospital?"

I tell her to hold on, I will telephone the DNE on call for the day and ask. I think "trace" doesn't sound that bad....

Before I get downstairs, the phone rings. It is Dr. She asks about M. I tell her about the trace. She tells me, "Trace is fine. Stay home. Why don't you phone the DNE on call, and fill her in, just so we have a baseline in case something else develops."

M doesn't feel like vomiting any more. The final score: her bg ranged from 126 to 202. I feel like congratulating myself. When I talk to the DNE, she does. "Good job!" she says.

She then advises me to allow M to stay a little high in her bg range over the next day or two. Also, reduce her Lantus by about 20% for tonight. After all, she has no stores on which to draw. Keep pushing liquids. Maybe see if she will eat some broth or something.

Phew! We made it through our first test.

Now for the big question: Will sick day management be easier on the pump?

Boo on being sick. Double Boo on being sick with diabetes.

Gross

My daughter is strong. Determined. Beautiful. Awe-inspiring. And she has no idea how to maintain a life without carrying bio hazards around with her.

In other words, she is also kind of gross.

I understand that sometimes we just don't feel like getting off of our butts to throw away the needle that we just used to inject insulin into ourselves. I can even understand not moving it off the dinner table while we eat. I CANNOT understand how it can stay there for more than three days.

Ew. Just ew.

Signs of diabetic slobbery are evidenced all over our house. The syringe next to the computer. The sanitary covers from the pen needle caps on or under the dining room table. The used test strip on the bedroom floor.

Sometimes when M reaches into her kit to give herself a shot, she spends a lot of time digging around in there.

"What are you looking for?" I might ask.

"Nothing. I'll find it," might be the reply.

There is a distinctive sound that emanates from a fanny pack full of used pen needles, their foil protectors, and their safety caps as they are methodically shoved around and pawed as M searches for the one lonely unused item in the bag.

There is a shimmery appeal to the myriad foil wrappers containing used test strips as they cascade from the bg meter case to the floor. Sometimes there are up to thirty of them.

Again, ew.

There is a proper procedure for handling bio hazardous waste. We apply this method when it is brought to our attention that M hasn't been holding up this end of the diabetic bargain.

1)Remove all used needles, lancets, syringes from wherever they are being stored. These, in the medical field, are called "sharps".
2)Put the sharps in a designated "sharps" container. You may purchase official red bio hazard marked plastic containers for this purpose. With all of the perfectly intact plastic containers around, this seems a bit ridiculous. At my dump (no garbage collection in my little New England town), the dump guys tell us to use a sturdy plastic container.
3)Fill up the container, seal it with duct tape, and write "SHARPS" in big letters all over it. In Sharpie, please.

In fact, my dump guys like us to use the new plastic coffee cans with the handles on them. They like us to use them so much, that our dump guys set these canisters aside for us behind the cardboard crushing machine.

Talking to the dump guys is very educational. I learned that some of the residents in our little town just throw their needles in the dump without marking them. Once they had to pick syringes out of a clothing box on site.

While disturbing, I do know that M does a slightly better job than these folks. The sharps do eventually make it to the coffee can. The idea that other people might not be happy to see used medical supplies on their eating surfaces, however, may be forever lost to her. I equate it to the moment I was giving birth. I didn't care who was there, what was going on, or how messy it was, people were just going to have to deal with it.

I wonder if that is how M sees her diabetes. Maybe she figures that if she has to suffer, the rest of the world should have to suck it up and suffer right alongside her.

So yeah, ew.

But maybe also, "you go girl."

Maybe.