Diabetes has a sick sense of humor.

Following my hypoglycemia “incident,” I have been trying to get my medical ducks all lined up for a thorough inspection.  Making doubly sure to scrub behind my ears, floss between my teeth (ironically this broke my permanent retainer requiring an emergency trip to the orthodontist, but hey, it was in the name of hygiene), take my vitamins and do an extra plank or two before bedtime, I went into my May endocrinology appointment with the expectation that I was doing everything that could be done for optimal self-care.  Upon seeing that my HgA1C had dropped from 5.8 to 5.3 over the past three months, however, my doctor concluded that I’m probably doing too much to address my diabetes and that’s likely why I had the “incident” in the first place.

“You’re treating your diabetes like you’re still pregnant,” she says. “Your glucose control is too tight and you need to let your overall numbers rise or you’ll be facing more frequent occurrences of severe hypoglycemia.”

Stressing that my concept of the “ideal glucose range” (70 - 140 mg/dL) is only truly necessary for the conception and gestational development of a healthy fetus, my endocrinologist encouraged me to recalibrate my expectations and sight my blood sugar goals above 100 mg/dL so as to provide a buffer between me and, well, the pavement.  Attempting to introduce the concept of leniency into my daily regimen, she argued that my typically aggressive approach toward glucose management will only create more problems rather than solutions as time goes on.  Explaining that while it would logically follow that I become better at diabetes control the longer that I am a diabetic, she said the opposite is actually true because the disease becomes more erratic and more difficult to pin down the farther you go away from your honeymoon phase (which, if you remember, is the period of time following diagnosis where the dying beta cells in your pancreas still makes a small amount of insulin).

“But, what about the adverse consequences of letting my glucose numbers rise?”  I asked.  “Won’t slacking off on my self-care only result in organ damage down the line?”

Taking a deep breath, she responded with the thoroughly uninspired “maybe.”

Explaining that the technology for HgA1C measurements have only been around a short while and that there hasn’t been long term research done on the correlation of A1C management to complications or the lack there of, she said that doctors don’t really know what glucose range to recommend because there are life threatening consequences if you go too far toward either end of the spectrum.  On one side, tight regulation like I do creates frequent medical emergencies for diabetics due to the severe hypoglycemia it creates; whereas unconstrained hyperglycemia on the other end of the spectrum directly causes organ failure, neuropathy, blindness and a whole host of other issues one would rather avoid.  Thus framing my position (rock-me-hard place) as one requiring a very delicate balance, she indicated that she, at least, would be more comfortable with my HgA1C being between 5.8 and 6.0 by my next appointment in August.

Pulling another rendition of my all too familiar phrase of “yes, but” into the discussion I told her that “the perinatologist said that, were we to get pregnant again I should keep my A1C under 5.2 to prevent the complications we saw with this last pregnancy.”

“Well, that’s ridiculous,” she retorts.  “With an A1C that low, you’re more likely to have a hypo-fall and hurt any future babies than to protect them from macrosomia or polyhydramnios.”

Stating that such “minor” complications were (and likely will be in any future pregnancies) unavoidable due to my lengthening history with the disease, she explained that my “diabetic-age” essentially undermines the effects of tight regulation and probably caused the complications with FG’s pregnancy in spite of my stellar A1C throughout the ten months.  So although my A1C this go around ensured a perfectly formed heart, prevented the development of spina bifida and made all concerns about miscarriage or stillbirth a non-issue, it simply wasn’t enough to safe guard against all of the high-risk nuances of a diabetic pregnancy in the face of my crippled pancreas.  But, in light of the existential dangers more frequent hyperglycemia would cause for a growing baby, I think I can cope with the unpreventable complications of larger babies and excess amniotic fluid so long as my glucose management efforts to avoid the worst continue to pay off.  And, frankly, FG definitely counts as paying off!

So long story short, the rational side of me knows the only action plan from here is to set the longer term question about potential future pregnancies aside in favor of very real, here and now self-care concerns and choices.  The emotional side of me, however, is completely upset and frustrated by the “a’int nothin’ you can do about it” attitude I feel like my pancreas is giving me and no matter how I fight its sass-mouth, it still seems to find a way to breach my defenses and leave me vulnerable to its whim.   It’s completely unfair that my growing knowledge of and comfort with my body on artificial insulin doesn’t easily equate to a well balanced, healthy lifestyle.  In some sense, I am envious of those people who have Type 2 Diabetes as their positive effort to address their condition through diet and exercise directly impacts their overall outcome for the better… whereas I can go run a marathon, cut whole food groups to nurse, monitor my glucose numbers, drink water by the gallon and it won’t matter.  No matter what I do, I’ll still be a diabetic and no matter how much “expertise” this brings, I’ll perpetually be relegated to rookie status thanks to the sick humor of chronic illness. 

Hypoglycemia 202: the hard way.

I’ve been procrastinating this post for a while now.  I’ve had a couple opportunities to sit down and write it, but I’ve been practicing my avoidance.  I’ve started to draft it once or twice, but found the delete button highly effective.  I’ve even had a couple “just do it” moments that instigated nothing short of the my slamming the computer closed out of complete frustration.  It’s not that I can’t find the words to write about the walk I took last week, it’s just that I don’t want to write about the walk I took last week.  You see, if I write about it, then I have to think about it.  If I think about it, I have to address how I feel about it.  And if I have to address how I feel about it, well, the can of worms just opens and makes for one heck of a mess that I frankly don’t have the time, patience or emotional fuse to clean up. However, if I never get around to writing this post I'll never actually move on from it, so I might as well get it over with.

So, I went for a walk last week.  Not a particularly noteworthy thing to do as it was scheduled at a somewhat predictable time, in a fairly typical place and it was with a girlfriend I see more often than anyone else in town that I’m not directly related to.  It started out just as normally as our previous walks had with swapped inquiries and empathetic anecdotes, but instead of being a refreshing jaunt and enjoyable time it turned into an uncontrollable tailspin as my glucose brought me crashing to the ground.  Literally.   

But to explain the situation fully, I have to go back a few weeks to frame the disaster: 

Since the baby was born I have been struggling with my diabetes.  I don't know if it is because of the baby weight that I am just. not. loosing. (uggggg!!), the stress that we’ve been under, the restricted diet I’m following or what, but my blood sugars are all over the map.  Shooting high when I expect to have them in control and conversely bottoming out when I’m fully prepared to fight them down from the rafters, I feel like glucose predictability and regularity are two key factors that are currently missing from my diabetic self-care wheelhouse.  Finding that I can sit down to eat the exact same meal with the exact same insulin dose from one day to the next and have my resulting postprandial be anywhere from the mid 50’s to over 350 mg/dL with zero rhyme or reason, I've somewhat resigned myself to a terrible HgA1C at my next endocrinology appointment since my blood sugar just doesn't want to play nice and I simply don't have the wherewithal to fight it.   

Unfortunately, no matter how emotionally satisfying this apathy and slack may be, this unpredictability is complicating my life because I am experiencing new symptoms that may or may not be diabetes related and with my blood sugar so out of whack I cannot confidently rule it out as the source of these new problems.  Knowing full well that hypoglycemia can cause the loss of sensation in extremities - something I am quite familiar with in my hands and, oddly enough, my mouth - the worst sensation I’ve recently started to experience is wide spread tingling and numbness in my legs that I’ve never before felt.  And while it’s entirely possible that this could simply be a new expression of my maturing diabetes (just kidding, it’ll always be juvenile), the occurrences of this numb sensation do not necessarily correspond with the low readings on my continuous glucose monitor and make me think they could be something entirely else.  Maybe a result of my muscle atrophy from all those pregnant months of non-exercise? Who knows. But, not feeling a dire need to know what's up immediately and finding comfort with the knowledge that my doctor's undivided attention is just around the corner, I've conscientiously pushed my concern for the hot mess that is my diabetes down the list of daily priorities. 

So, bringing this all back to the infamous walk, I double checked my glucose before we left the parking lot and found my numbers to be at a safe walking-pace of 130 mg/dL (which I'd like to point out is notably and randomly less than the previous day's 320 mg/dL for the same breakfast scenario) so I suspended my pump's insulin delivery to be on the safe side.  But, about a mile into the three mile loop, I started to feel the initial inklings in my quads that my legs were loosing sensation and my friend noticed that my stride began to be audibly sloppy.  Unsure if this was because of my diabetes we took a break to look at my glucose monitor.  Finding that my sugars had dropped down to 65 mg/dL, a minor low and a number I've always been able to power through, I reassured my friend that I felt capable to finish the remaining mile and a half back to our cars. Not feeling any other familiar symptoms of a low, we passively discussed that there was food back at the car to correct my glucose and set out down the path at a slower, less coordinated pace.

Found this, and a few others like it,
on my phone two weeks after the
 incident happened. I don't
remember taking pictures and had
 no clue these were there. 

With every quarter mile we knocked out, I felt like my body became more alien.   Conscientious that this low might be getting more serious, I felt trapped within my own head as the unfamiliar symptoms overwhelmed my faculties and I sank into the confines of hypoglycemia:  my arms weren't my own and pushed the stroller too fast or in the wrong direction... my feet were independent from my body and, in both pace and basic function, impossible to coordinate… my fully formed, yet simple thoughts were too complicated to translate into articulate sentences… my cheeks were tingling and prevented my lips from forming intelligible words... 

Ultimately, the carbs in my car were too many blocks away to aid the rapidly deteriorating situation my friend found on her hands.  Already pushing a single stroller of her own, she took over pushing GV in my stroller as well with three quarters of a mile to go... with a half mile to go she helped me remove FG from my Ergobaby carrier and strapped him to her own torso... with the second to last road crossing in view, she asked me if she ought to call HB for help, to which I think I said "no" since, logically thinking, he was farther away from the situation than we were from the car.

What happened next is fuzzy.  All I can confidently recall are snapshot like memories: a happy looking man sitting alone at a picnic table; my hand touching a black metal fence railing; my friend's voice above me; the distant sound of sirens echoing through the seemingly empty halls of my head.  I remember sitting on the side of the path and mutely trying to figure out which of the three electronic gadgets in my lap was my glucose monitor (doesn't help that my pump, my glucose monitor and my cell phone are all the same shade of blue). I knew I needed to figure out what my blood sugar reading was and that insulin delivery had to be stopped (I'd forgotten by that point that I had placed my pump on suspend at the beginning of our walk), but how to go about doing those tasks was completely beyond me despite my efforts to the contrary. 

More snap shot memories followed:  a woman and a man, both dressed in blue, asking me and then my friend questions when silence was my only response; someone holding my palm out to test my blood sugar;  the number 33 mg/dL being said over a radio; a male voice saying something about rapid glucose as my mouth filled with a sweet tasting gel; my friend mentioning something about shade and walking away with my baby and little girl; a random woman using the phrase "poor dear" in passing... 

And just as if flipping on a light switch, the world became clear again. I knew where I was.  I knew what'd happened.  I recognized the blue-clad individuals to be paramedics.  I registered the oversized bandaid on my finger tip from where it'd been punctured.  I easily picked up my glucose monitor and read that my sugar was up to 55 mg/dL.   

"How you doing?" the male paramedic asked.  "Want to take a trip over to the hospital?" 

"Much better," I responded.  "I'll be fine now that I've had sugar." 

"Let's at least get you back to your car before making that call," the female paramedic said. 

Insisting on walking the remaining block to the car rather than receiving yet another ambulance ride (the two I have already done are enough, thank you very much), I let the paramedic escorting me ramble about the heat and her job and Lord knows what else as I silently focused on getting to the kids.  Don't get me wrong, I knew they were in good hands and that I was the one in danger rather than the other way around, but with my world so severely rocked by this hypoglycemic episode I needed them - at the very least - to be back within my comfort zone.  Upon getting back to the car and signing the paramedic's waiver that I was stable and had declined further medical intervention, my friend informed me that she'd called HB and that he'd given her strict instructions to not let me leave until he arrived at the park in about 15 minutes.  Insisting that he work from the house for the remainder of the afternoon, HB took us home and let me collapse from the exhaustion that thoroughly consumed my body.  

Having never suffered the consequences of a low this severe before, I am still reeling from the enormity of this experience.  Physically speaking, my head has felt foggy and my thoughts slow in the waking periods between the hours I've needed to sleep the shock away.  My legs were weary and fatigued for several days to follow, difficult to lift and tiring to move.  The cuts on my knees from where I must have fallen - something I have no memory whatsoever of - are still red, but the scabs have long since closed the open wounds.  

And while I expect these bodily symptoms to fully pass with time and rest, I am fearful that the emotional ramifications of this walk are lingering in a way that may prove to be permanent.  Bruising my pride and mettle, the fact that I have never before fallen out from under my own vigilance and become prey to a low has me unsure of my own abilities -- the symptoms were there, but they weren't what I'm used to and they progressed faster than I ever had hope to catch.  Unconfident in my hypoglycemic awareness and insecure in my capability to execute independent action, I feel like my lifetime's accomplishment of adult autonomy collapsed along side my body on that path and both shattered into an all too scary reality of helplessness.  I was fortunate this go around to be with a friend who is capable of action in the face of crisis, but the reality is that I am at the mercy of my blood sugar and, in the bleakest of moments, all I can do is pray that the circumstances I find myself - and potentially my children - in isn't life threatening and that someone capable of help is at hand.   

But where does that leave me?  Should I risk a solo-training run or wait for a pair of babysitters - one for the kids and one for myself?  Is another solo half marathon even remotely responsible?  Does that first alarm on my glucose monitor mean the heads-up it has historically or should the cavalry be called in to  forcefully drive my sugars back up from whence they'd come?  Must I broadcast my disease as my summary introduction or does my name still suffice?  Should I resign my aggressive glucose control for my nursing or potential future pregnancies and accept a higher HgA1c for the "safety" buffer it places between me and hypoglycemic oblivion?  What of the organ damage such a compromise would present -- do I risk dialysis, neuropathy and blindness to guard against seizure and unconsciousness? 

Half of me feels the answers to these questions are crystal clear and the other half is no longer sure.  I've worked so damn hard these past four years to have my sugars under tight control that the corresponding risk of increased hypoglycemia is logically increased, but at what point does one's good intentions cause right to become wrong?  I thought I knew, but now... I don't know. 

Do you know how to help someone suffering from hypoglycemia? 

Check out my post Hypoglycemia 101 for more information. 

3 Minutes. 9 Pounds. No tearing.

So I have someone simply wonderful and absolutely perfect to introduce to the word: FG!

Born on Wednesday, February 11 at 3:55 AM, he surprised everyone on the labor and delivery floor by coming hours earlier than we anticipated.  Starting the Cytotec, a cervix ripening drug, at 9:00 PM, the nurse briefed the treatment plan that I would receive another dose every three hours until 6:00 AM when I'd have the option of an epidural before starting Pitocin at roughly 7:00 in the morning. Not having decided if I wanted an epidural this go around or not, HB and I nodded in acknowledgment of the schedule as we followed the nurse out into the hall way to begin our ritual of walking the baby out.  

Getting a bit too crampy and too tired to continue our laps by 11:30, we went back to our room where the nurse began to encourage me to take a dose of Ambien and Tylonal so I'd be able to sleep comfortably after receiving my next dose of Cytotec.  Decline both of these medications, the nurse administered the second dose of Cytotec and reported that I was slowly progressing and only 1 cm dilated before turning out the lights and leaving HB and I to a) stew about my lack of progress and b)  sleep.  

A little after 1:30 in the morning, the contractions changed and I couldn't sleep through their frequent and rising intensity.  Thwacking HB with my pillow to get him to wake up (did he take my Ambien?), he helped me to the bathroom and gradually began to look at me with consternation as I went from "me" to "cranky" (his words, not mine).  Attempting to breath my way through the pain, I finally asked HB to go ask the nurse for that dose of Tylonal she'd offered... finding that she was on break, the back-up nurse assigned to my room, Debbie, came in with the small pills and immediately asked if I wanted to consider that epidural. 

Feeling like a complete wimp for not having made it remotely close to 6:00 before giving in on the pain and accepting the drugs, HB translated my non-comprehensible grimace and whimper as an articulate "yes, please" and the nurse called for the anesthesiologist at 2:45.  Gathering supplies and bouncing back and forth from the hallway - before double checking my dilation - it was 3:30 by the time the back-up nurse began to register the look of concern on my face and  helplessness on HB's. 

As the anesthesiologist began to prep by lumbar spine for the epidural placement, I was beyond my own abilities.  Unable move due to my own tension, HB and Debbie helped me sit up and breath calmly though the first series of needles. Looking at Debbie the whole time, I told her in no uncertain terms that "I feel like I need to push - I'm not - but I feel like I need to."  Having not checked my progress yet, she had no idea what we stage of labor we were actually looking at and could only respond by parroting that I not push.  Within a few seconds of the large gauge needle being inserted into my spine, however, I couldn't wait for the actual medication to be administered and I flat out said "I don't trust myself - I have to push NOW!" 

Helping my lie down, HB and Debbie found the baby fully crowning.  Sending the anesthesiologist into the hall for reinforcements, he returned a moment later with the closest thing he could find to my doctor: two random residents and my primary nurse.  With minor instructions and as much encouragement they could find amid the general shock of the unexpected, the baby's head, his shoulders and then his body along with ALL of my amniotic fluid were out within 3 minutes.  Without tearing. 

Unfortunately for the residents, it was only after my water broke following delivery that the nurse remembered to state: "Oh, yeah, she's poly."  

Collectively feeling like what just happened was completely surreal, the nurses quickly began working on the Baby - who didn't start crying immediately - as the residents cursed the late arriving polyhydramnios warning as they delivered the placenta and collected the pieces necessary for our cord blood kit.   

"Holy cow! He's nine pounds and sleeping!" laughed the nurses from the warming table.

Bringing him over to me, the nurse casually informed us of the NICU nurse lurking in the hallway due to FG's low blood sugar levels of 34 mg/dL.  Having talked with our nurse earlier in the evening about our intent to correct his hypoglycemia ourselves with nutramigen upon birth, she bought us some time as HB held our newborn skin-to-skin on his chest and dripped the formula drop by drop into the baby's mouth.

Requiring that FG's blood sugar above 50 mg/dL in order to prevent his admission to the Neonatal Intensive Care Unit, it was half an hour later that we anxiously watched the nurse prick his heel and apply his blood to the glucose strip.  Feeling like the resulting two seconds of processing was closer to two hours, there was a collective sigh of relief when the number 51 finally appeared upon the screen.  Happily dismissing the NICU nurse to return to her other charges, the labor and delivery team put our paperwork together and transferred our care to the maternity ward where we were generally left in peace by the staff given our "veteran" parent status.

Spending the following 24 hours going through the typical newborn routine, he received his first round of vaccinations, his hearing exam (which, unfortunately, he failed), bilirubin checks (slightly elevated) and his first pediatrician visit.  The pediatrician indicated some concern over his red color (likely a result of elevated hemoglobin levels) and his hips clicking (likely caused by his position while in utero), but indicated that the various abnormal results could be resolved with time or on an out-patient basis.  Otherwise granting a clean bill of health, the doctors found FG fit enough to  earn us a discharged ticket home.

Now that we're here... life with three kids will certainly take some time for us to get accustomed.  Upon walking in the door and introducing the baby to big brother GW and big sister GV, we found ourselves swimming in the deep end as FG promptly peed on the couch mid-diaper change as GV went into a full-on overtired two year old tantrum and GW raced about the house showing off his latest drawings and demonstrating his race car speed for his new brother (it was only on lap number three that he slipped on the hardwood in his socks and began to cry after careening into a cabinet).  I think things will be just fine when we develop our new rhythm, but for the mean time, I'm going to let the contentment of my post-delivery glow and a touch of mommy-brain carry me through.

Happy, happy, happy Mama!

Wait and see.

I apologize for the hiatus in posts over the past two weeks. Between my shear bewilderment over the Boston Marathon bombings and a horrific stomach pain that has had me sleeping since Monday I've been quite without comment.  But after having spent the majority of yesterday and this morning at the doctor's office running tests, it's about time I get back to it.

So Monday afternoon while driving with HB to get landscape rock for our yard my stomach and lower back began searing with pain.  Leaving him to load the 4 tons of river rock in to the truck, complete the landscaping and generally do everything that involves moving, I've been on the couch and barely eating ever since.  Finally opting to go see someone about it yesterday, the doc found my bilirubin levels to be high and ordered a complete blood panel and abdominal ultrasound that was completed this morning.

Thus far we haven't learned anything from the lab results and the ultrasound found nothing conclusive, but we have learned one thing: with an underlying, chronic condition general practitioners seem to automatically assume that diabetes is the cause of all of my problems.  Now, if my HgA1C was high and I truly had "poor diabetes management" as they accuse me of, then I'd nod my head in silent resignation that I've made myself worse with apathy. However, since my A1C is stellar and I test my sugar so often I have perpetual bruising from my lancets I refuse to sit passively by and take undo criticism of my self-care.  I mean at one point this morning the sonographer went so far as to ask if my stomach pain is because of "improper use of my infusion site" - perhaps a logical question if it wasn't in a completely different abdominal quadrant from where the pain is!

The thing is, while diabetes could be a problem and is regularly a bitter annoyance of mine, right now my diabetes is a reassurance that something beyond the norm is wrong and here's why: Before I began feeling ill on Monday, my blood sugar was completely stable, but especially over the last two days my bgs have been falling lower and lower without a relevant diabetes explanation...  Yesterday afternoon my glucose levels were low (63 mg/dL) so I corrected with a handful of saltine crackers.  But when I checked my blood sugar a few hours later at dinner and it was even lower (61 mg/dL), so I adjusted my basal to 70% of it's usual amount to account for being sick and I skipped a meal bolus for the minimal food that I ate.  Assuming this would set me up for stability via hyperglycemia over night since I had to fast for the ultrasound, I checked my post-dinner two hour postprandial, my bg was still low at 68 mg/dL... I grabbed a quick correction snack, adjusted my basal rate even lower to 50% and went to bed.

You'd think with half of my normal basal rate and a correction I'd have woken up this morning with my blood sugar well into the 100's - if not higher - but nope.  For the second day in a row, my blood sugar was down even farther to 41 mg/dL!  Since I couldn't even have water before this ultrasound I couldn't correct with either solid or liquid carbs, so at 7 AM I suspended my pump and removed it with the assumption that my sugars would naturally go up without my persistent basal dose.  Makes sense, right?
Well, yes, but it didn't work. Three hours later at 10 AM my blood sugar had merely gone up to 48 mg/dL... not awesome.

I've since had breakfast and found a temporary fix to my hypoglycemia, but that's beside the point.  The silver lining of my exhaustion, pain and zero appetite is that my diabetes is providing another quantifiable symptom to go from.  Typically when diabetics get sick the body releases extra hormones that cause a decrease in insulin efficiency and therefore causes unavoidable hyperglycemia,  but for whatever reason, something else is going on right now.  How obnoxious.

I guess we'll just have to wait and see what comes to pass.

Newborn GV

So in the last post I think I got the point across that despite all the concerns that labor and delivery itself went well and that as of 10:12 AM on November 27 HB and I have a daughter.  Yes? Okay then, moving on!

Once she was out, the nurses began their typical new born checks and double checks and successfully reported that GV scored highly on her APGAR and has ten fingers and ten toes (which after 21 sonograms was redundant, but still good news).  But seeing as I am not a normal mother, they had to run atypical checks on her as well to make sure she was healthy diabetes impact wise.  Course I knew that was coming and had worked hard to mitigate the worst case scenario with tight glucose regulation during labor (see my "Induction Begins Tonight" blog post for an explanation), but checking her blood sugar regardless of my control was just the responsible medical thing to do.

Pricking her little heel, the nurse applied the Accucheck test strip to the blood and reported a bg reading of 41 mg/dL for newborn GV.  While I would consider that number dangerously low for me, any number above 40 mg/dL is considered to be normal for newborn babies; in other words, she was borderline and verging on hypoglycemic despite my efforts to ensure her glucose would be in a safe range.  Hoping her sugars would go up on their own, the nurse handed her back to me for skin-to-skin time, immediate nursing and explained they'd need to check her sugars again in 30 minutes.

Holding that little baby and keeping her safe in my arms after so many months of worrying felt phenomenal... but in what felt like mere seconds after handing her to me the nurse was back to check GV's sugars again.   With HB supervising and being my emotional proxy, the nurse started the whole process again and pricked her heel.  The meter read 32 mg/dL.

Shit.  (Pardon my french).

Asking the pediatrician for a call on whether she needed to go directly to the NICU, the nurse reported back that GV's hypoglycemia wasn't "bad enough" to warrant a trip to the second floor but that we'd need to get her on formula right away.  Because a new mother's breast milk doesn't come in for two to three days after delivery and colostrum doesn't contain much in the way of glucose, we grabbed our Nutramigen formula and I tried to get at least an ounce into her before the next bg check in 45 minutes.  Warning that if her bg wasn't up by then we'd need to take "alternative measures" (aka the NICU), the nurse wished us luck and left us to it.

Fortunately, if there is one thing this kid does well, it's eat!  By the time the next check came around she'd gone up to 53 mg/dL!!  Unfortunately, they had to have a minimum of three readings over 70 mg/dL so even though her sugars were in the right range, the nurses on the "Family Centered Care" floor had to prick her several more times over the next 12 hours for record purposes -- all of which, thank the Lord, were in the perfect range.

But would that be the end of it?  Heck no -- that would be far too easy of an ending to an otherwise medically stressful pregnancy.

So we get up to the 7th floor recovery unit and we learn that GV's bilirubin levels are excessively high for a few hour old baby at 6.8.   The pediatrician initially said that they'd just keep an eye on it and see how she responded to simply being fed, but if the levels weren't better the following morning that they'd need to put her under the ultra violet lights for 24 or more hours.  I tried my darnedest to feed her  and combat the onset of jaundice (at 38 weeks, really?!), but the next morning her bilirubin levels had risen to 8.4 and the pediatrician made the call to get her under the lights.

I know even "normal mothers" have to put their babies in the grow box sometimes - heck even my husband had to go in it when he was born - but after everything this complication was simply one I hadn't emotionally prepared myself for.  I braced myself for all the plausible diabetes and abruption complications, but jaundice? It hadn't even crossed my mind.

Only able to take her out every three hours for a brief feeding, we sat up the entire night on Wednesday watching her tiny little chest rise and fall with each breath.  Feeling helpless to fix the problem, we waited for five o'clock Thursday evening to roll around and the defining bilirubin levels check to be completed.  If the labs showed that her levels were still high, I'd be discharged and sent home while she'd remain hospitalized in that incubator, but if her levels were low "enough" we'd be able to bring her home with us.  Needless to say we were praying and risking to hope for the second of those outcomes.

So with bated breath, we watched the clock until 6:00 PM on Thursday, November 29 when the nurse finally came in and gave us the verdict... GV could go home!!  Her bilirubin levels were still elevated higher than they ought to be, but not so high that at two days old she'd be in any risk by going home.

Thank God.

Absolutely Awful Apprehension of Apposite Amnio

Is it just me or is there unjust alliteration in the pairing of "anxiety" and "amniocentesis"?

With the way things have been going since Friday given the increased contractions and labor symptoms I'm having, I'm a bit surprised that Baby isn't here already and that I'm actually facing the needle tomorrow...  Which, obviously, I'm not thrilled about it.  I know that amnios are done regularly and, heck, my mother even had one with me, but given the number of times I see my blood each day and the normalcy of needles in my life I am not terribly ecstatic for yet another excuse to introduce a long sharp needle to my torso.

Perhaps I'm just being a big baby (please refrain from commenting in the affirmative here), but there's just something about the idea of a needle going through my abdominal wall and into my uterus that has me thoroughly freaked out.  It's my basic understanding that it's a generally uncomfortable procedure with very little risk to Baby given the simultaneous use of ultrasound, but I'm kind of done with additional pain and I truly want nothing to do with the stress of further testing.  What's more, I'm not entirely sure what the doctors are going to use the results for in the first place... Amniotic fluid testing during the third trimester of pregnancy is done to check on fetal lung development to ensure that they're mature enough to work properly outside of the uterus.  But with the way my blood sugars have been dropping so dangerously over the past couple weeks, the doctors are talking about taking her out (I don't know if this means induction or c-section at this point) this week and the amnio results they come up with are kind of irrelevant if they think the placenta is too unstable to sustain her until next Tuesday any way.

Don't get me wrong, I'm not scared of the needle or of the pain associated with it.  I've come to accept needles as a given - kind of like the reoccurrence of morning, the unavoidable existence of taxes or the simple fact that all dinosaurs poop (thank you for that insightful revelation Buddy and Tiny Pteranodon).  The part that freaks me out is that this is something I have no prior context to gauge it in and therefore no way to know what to expect, and, also, that the results will either reinforce the current concerns that she needs to be delivered sooner rather than later or that she's got a rough week ahead of her either fighting a failing placenta or struggling to breath on her own.   Bottom line, I'm finding it scary and overwhelming to be counting down the final eight days of pregnancy without even a hint of reprieve from complication... I'd hoped to end this pregnancy on a high, spontaneous labor note but at this point I'm too tired to expend the emotional capital of hoping for something I cannot within reasonable doubt expect.  She'll come out, but only after we've bared the difficulty of pregnancy right to the bitter end.

With my first pregnancy, I went into labor on my own at week 36 and five days -- which would have been yesterday in this pregnancy.  Seeing that this pregnancy is already longer than that with GW (not just by 24 hours, but also 12 weeks longer to be excessively literal), I'm feeling quite a bit frustrated that my water hasn't broken, that labor hasn't simply started and that the anxiety of bringing this baby into the world is dragging on...   Each morning I wake up feeling like another eternity awaits me over the coming 24 hours and given all the complications we've seen over the last nine months, each minute of those hours brings me closer to the end of my rope and a hopelessly emotional precipice.  Now that I know how wonderful being a mom is and how much my babies matter to me, the stakes are higher than ever and I just want to know she's healthy, she's safe and that we've made it across the finish line together, in tact.

I know that doing the amnio is the right thing to do as far as the Perinatal Associates of NOVA are concerned and, as such, I'm on board and will let you know what we come up with.  But for the sake of honesty, my nerves currently have the best of me and I'd definitely appreciate an extra prayer to be sent up for me in the morning if you've got one...  Saint Gerard Mejella please intercede for me!

Week 36, part two

For the third night in a row, I woke up in hell this morning with my blood sugar much lower than it ought to be.  Wednesday I was 34, Thursday I was 32 and today at 2:45 AM I was 43 -- what the heck?!  I mean I love the excuse to wantonly eat simple, quick acting carbohydrates like I am a care free non-diabetic child again, but within the context of the last few weeks of a class B diabetic pregnancy I'm not thrilled in the slightest to need to open my bed side table drawer and raid the stash of sweets HB and I have stock piled for moments like this.  It'd be nice to want a piece of candy for once!!

Any way, I've been going back and forth with my new endo via the phone practically every day this week and I lowered my basal rates by 0.05 each night in an attempt to curb my plummeting blood sugars. Heck, I've practically cut the rate from 12 AM to 3 AM in half over the past three days -- but unfortunately to no avail.  Needless to say my Friday appointments with the perinatologist and endocrinologist couldn't have been better timed this week...

Still gawd-awfully sick with this respiratory infection (I'm now on a new uffdah-uffdah prescription of antibiotics and still coughing like day one), we went back to the Antenatal Testing Center this morning for yet another round of non-stress tests and my 17th sonogram.   The NST was enough reactive to pass and the AFI was much higher than last time (19 on Tuesday, 24.6 today), which the sonographer and resident (ug) dismissed as "symptomatic of being a diabetic."  However, given the smorgasbord of health complications I've had this week - an optical migraine on Sunday, the coughing and vomiting of this infection and contractions - on top of my seriously unstable blood glucose, the resident kicked my case back to Doctor Bronsky who felt it was worth a cervix exam and blood panel to make sure I didn't necessitate immediate hospitalization for preeclampsia or placenta failure.  

Fortunately the blood panel came back showing normal liver function (thank God) so immediate hospitalization wasn't necessary, however Dr Bronsky placed orders for me to have an amnioenteses done on Tuesday (day one of week 37) to evaluate Baby's lung maturity so that he can move the delivery date up from November 27 to as soon as possible.  Soooo, essentially things with my blood sugar aren't stable enough for her to make it another 10 days in utero but the doctors cannot risk her coming out too soon since diabetic babies are notorious for having immature lungs (even at "full term") and you throw in my respiratory infection in on top of that and they've got a very delicate line to walk between letting her stay in and getting her out safely.

Furthermore, from talking with Dr. Bronsky about the possible use of additional steroids as a fail-safe to help her along, HB and I found out that subsequent injections of steroids to mature a premie baby's lungs for delivery is highly controversial after the first dose and there is mixed evidence regarding not only its efficacy, but the safety of it.  So while the doctors back at Stafford Hospital on Sept 25 made the right emergency choice to administer the steroids to me for a possible pre-term delivery, the reality at this point is that my docs aren't sure what they're going to do if a) I go into spontaneous labor sooner than induced or b) if the amnio shows her lungs to be less developed than ideal for a before Nov 27 delivery.

Generally we're feeling like deer in the headlights and overwhelmed by the delicacy of the entire situation.  Having lost the mucus plug and had some show already, I'm feeling like a passenger in a uncontrollable rail car with no clear, straight forward escape plan... thank God HB is the one who has to drive the truck to NOVA, thank God the Perinatal Associates are the best of the best high risk pregnancy docs Virginia has to offer and thank God that Fairfax INOVA has one of the top 5 NICU in the country!

After leaving the testing center, we went straight to my appointment with Dr Rogacz in Fairfax.   Taking a sharpened pencil to my chart, she slashed my basal and bolus rates with the finesse of a Michelin Star Chef at the cutting board.  She then brought up the ever present topic of "when labor begins" ... to which I must say, as a pregnant woman you're constantly thinking about what's this sensation and even as a second timer I find myself worrying about whether I'll know when my water breaks, but adding diabetes management to something I'm already stressed to the gills about is simply exhausting.  It's really no wonder I'm so sick.

Any way, she walked us through what she wants me to do with my pump settings for active labor.  Similar to an endurance athletic event, which let's face it, labor is, the whole physical process of pushing a baby out of your womb causes blood glucose to fall sharply in diabetics because of expended energy... That being said, she's asked me to cut my rates from what they are "normally" (ha, as if they are stable and normal now) to my lowest setting and keeping them at that low 0.2 unit setting until the baby is out.  Of course if my blood glucose continues to drop even at that low basal rate, we'll need to decrease it further and have me put on a glucose drip to make sure I don't go into hypoglycemic shock while in active labor.  Fun stuff.

So after Baby and the placenta are out, I'll need to reprogram my pump again since I'll be back to pre-pregnancy (actually probably lower) insulin needs because the placenta will no longer be present to create an insulin-resistant environment in my body.  For this Dr. Rogacz has instructed me to initially cut all of my basal rates in half, suspend use of the symlin injections and go from there.  Being naturally so hyper-sensitive to insulin will likely make the postpartum diabetes dance a difficult one, but I've been rightly warned that any non-diabetic symptoms I may display -- in other words maybe not even needing artificial insulin -- will be temporary as my body recovers and returns to a new normal.

I only have one word to describe all of this: over-frlcking-whelming.

I wish I was in the blissful period of enjoying the last few days of pregnancy with out a care and an extra foot rub or two, but the reality is that this pregnancy will be medically complicated start to finish.  I knew what I was signing myself up for, but conceptively rationalizing risk and tangibly feeling fear are completely different things.  Honestly, I'd like to just get this show on the road already so that I can know it how things turn out, but it's out of my hands.

Hallelujah for Hypoglycemia! Wait, what?

So at 1:50 AM last night I woke up with a start -- something, unfortunately, that isn't uncommon any more.  Between the trips to the bathroom to vomit, the horrendous coughing episodes that violently shake our bed and the occassional contraction that reminds me that no, seriously, labor really is just around the corner I've found myself spending many an early morning wide awake for one reason or another.  But last night, in an ironic sense, was a nice change from the ordinary -- I woke up sweating, over heating and shaking in another state of hypoglycemia.

I managed to get my light on, sit up and, granted I had to stab myself twice to get enough blood for the meter, I tested my blood sugar.   The meter read 34 mg/dL.  With difficulty I managed to wake HB up and he helped me get some orange juice into my system (I also took the excuse to grab 4 pieces of candy corn - life and death situation after all).  So I sit up waiting for my blood sugar to return to normal ranges for an hour or so and by 3 AM my meter finally read a solid over night number of 94 and I was able to go back to sleep.

The funny thing about all of this is that it felt wonderful to wake up without the other symptoms I've been experiencing the last couple nights.  My hypoglycemia was so bad that I couldn't feel my throat hurting or my chest aching, I didn't notice the congestion in my nose or lungs and I felt - ironically - normal again.  Course when I woke up this morning to HB's alarm clock it was with the same coughing, gagging and contracting as yesterday so the escapade back to "normal diabetes land" was short lived and fleeting in the night. 

I called my new endocrinologist to let her know about the low and - get this she calls you back personally - she said that unless I begin to have more hypoglycemic readings during the day that the baby is likely burning through too much of my glucose over night and that is causing the severe lows at that point.  However, she continued, if the lows continue during the day then we need to worry more about the integrity of the placenta - and given that she knows what she is talking about and my perinatologists trust that she knows what she is talking about, then those are the honest to God options for explanations.

So all morning I watched my bgs stay in normal ranges as I tried to decrease my body weight by at least one lung, but this afternoon has been a different story.  My blood sugar post nap #4 was 39 mg/dL... I had juice... I checked again and it was 38 mg/dL... I corrected again... I checked again and it was back up to 39 mg/dL... I waited... I checked again and it was down to 37 mg/dL... and as of about five minutes ago it finally got up to 47 mg/dL.  Needless to say, something is wrong and the grams upon grams upon grams of carbs I've ingested to correct this low aren't going very far.  I've left a message with Dr Rogacz and I'll fax her my logs tomorrow, but seriously this is ridiculous.

Just what I needed - to be excessively sick and having more diabetes complications. If I was a betting person I'd wager that my water breaks sometime soon... because, really, why wouldn't it?

Lows continued...

So after sending my blood sugar logs to both the endocrinologist and perinatologist on Monday, calling both yesterday and again early this morning to ask "what's up doc?" one of them (the perinatologist) finally got around to calling me back five minutes ago.  Yes, that is three business days later and one and a half hours after their offices officially close for the day...  so you can imagine how grumpy I've been as my blood glucose has continued to drop.

According to Dr Khoury there is either one of two things happening.  Given that I'm quite close to delivery (we're considering 32 weeks close? Wow... that's so not comforting), one possibility is that the baby is so busy swiping the nutrients from the food I eat to put on weight herself that my body isn't actually absorbing any of the carbohydrates that I am bolusing for.  Alternatively, the other option (as I've explained previously) is that the placenta is deteriorating and my increased insulin rates aren't necessary because the placenta isn't producing pregnancy hormones at the high rates that are appropriate for its gestational age.  Either way, my blood sugars are continuing to bottom out and Dr. Khoury agrees that hypoglycemia isn't a good position for me to be in at this stage in the pregnancy (this is mostly because of the risk of falling).

I guess it is a good thing that he didn't sound too concerned over the phone about getting me in to see them before my appointment next Tuesday. He did specifically request that I call the office in the morning to make sure that they have me scheduled for a few more tests that they otherwise would have waited to run until the following week.  He said to continue to decrease my bolus and basal rates in my insulin pump as necessary and to fight the lows as aggressively as I can "with the help of my endocrinologist" ... yeah, if she'd bother to call me back.  Hmph.

Well, considering my bg was 53 an hour ago and I "over corrected" with a piece of fudge and 8 pieces of candy corn and I'm still low (a lot of good those carbs did, I'm only up to 65) I think it's time for yet another dose of sugar.  You'd think I'd be thrilled to have the excuse to indulge my sweet tooth, but honestly, I'm pretty ticked off that I'm forcibly eating crap food to satisfy the sick needs of my bleeping pancreas.  I mean come on, if Baby is absconding with all of my nutrients then she shouldn't be gorging her tiny little self with the loads of simple carbs my body needs to balance out her well rounded diet!  And if, Heaven forbid, my placenta is breaking down then Baby needs for what little work it is bothering to put in to be quality rather than mere junk...

On Tuesday we should be able to know a bit more one way or the other by looking at the degree of calcification on the placenta and at Baby's weight.  If her weight is on track or higher than expected for week 33, then she's the cause of my hypoglycemia.  If her weight is below where it should be or if there are visible white patches of calcification, then the placenta is not only sending my blood sugar low but it may be adversely impacting her growth.  In either case they'll do a fetal non-stress test to see if she's okay and we'll go from there.  Obviously the ideal situation is for me to continue to be pregnant for an additional four weeks to make it to term, so we'll see what results those tests show and what options the doctors feel like they have.

I'm generally trying to remain calm and keep the contractions (yes, they're still happening and no, they're not much better) from being too frequent or too long, but I've got to admit that I'm feeling first timer stressed and overwhelmed right now.  I can't control anything when I'm constantly trying to play catch up with my sugars.  I can't plan for anything when the baby could arrive whenever (minus the hour of driving, of course).  I can't do anything or go any where without taking contractions or the physical exertion of simply standing into account.  Perhaps I'm just antsy from hanging out in bed so long or maybe the lows are really getting to my head, but I'm exhausted from anxiety and there is nothing about pregnancy right now that feels familiar.  All I can do is remind myself that there is a sweet little precious angel on the tail end of all this stress and that next time (yes, we still want more kids after this) it might be easier.

I don't think I should hold my breath though.  It'd probably cause hypoglycemia or some other something-or-other that I just don't want to deal with right now.

Again, hmph.

Grumpy, rainy, blah, low day.

HB and I recently started watching the show Once Upon A Time and, for those of you who don't watch it, oh my goodness is it addictive.  The plot is a witty, complex hybrid of fairy tales and (Hollywood) reality that has story book characters fighting for their memories and lives in the fictional small town of Storybrooke, Maine.  The reason I bring this up is that there is a scene in Season One where Snow White is talking with Grumpy and the other dwarves about her intention to take a potion that will cause her to forget all of her pain.  Grumpy, who Snow is specifically trying to convince of the brilliance of her plan, talks her out of her voluntary amnesia by explaining to her that "as wretched as it is, I need my pain.  It makes me who I am.  It makes me grumpy."

Now, if you can't find the humor in that brilliant script writing then I have no further explanation of anything in this post worth reading.  But, in the feeble attempt to throw a grain of salted humor on an otherwise open wound, I have to admit that Grumpy totally has a point: we are a walking, talking portrait of our histories and, to be true to ourselves, we must acknowledge who we are and where we've come from.  So starting as a pregnant diabetic and going from there, I have somehow managed to turn into a crotchety, bearded dwarf in the past couple days. 

Someone really ought to call the tabloids. 

It's a combination of the stress of the last three weeks, the overcast, crumby, dank weather outside and the constant hypoglycemic blood sugars I keep fighting that have caused the change.  If it wasn't for GW's incessant hugs and kisses I'd probably shrink a couple inches and be permanently attached to a pickaxe by now, but seriously, you try to be low all the time and not turn grumpy! It makes me shake, it makes me sweat, it makes me short tempered, it makes me physically and mentally weak, and it makes me worried.  The last of which is by far the worst symptom.

As I've explained previously, at this point in a diabetic pregnancy - regardless of what type of diabetes you're talking about - the mother should be experiencing increasing insulin resistance as a result of the placenta creating copious amounts of pregnancy hormones that cause the body to ineffectively absorb insulin.  In other words, there should be increased insulin requirements, more regular hyperglycemic readings and very few hypoglycemic episodes.  But over the last couple days, I have been struggling to keep my blood sugars out of the 50s and I've been decreasing my basal and bolus rates to fight off the low, grumpy, blah blues... 

I mean, I wake up and my blood sugar is in the mid 60s so I eat breakfast to correct this and it some how manages to drop lower when it ought to even out.  I correct for it again (home made fudge for GW's bday, so good and sooo very full of carbs) and remain low.  I repeat this a couple more times and remain low.  And finally I under bolus at dinner and manage to get up into the 90s-130s for a while - but even at that point, while that is a safe, healthy number it is lower than it typically ought to be for a postprandial with "insufficient insulin." 

HB faxed my logs to the endocrinologist and, when she eventually calls back, I expect her to basically confirm that I should decrease my basal and bolus rates (which I've already done) - but that doesn't explain why my rates are decreasing.  We also contacted the perinatologist to get their take on it and make sure that we're not looking at the issue we were warned about at my infamously "healthy" week 29 appointment of placenta deterioration (aka the old placenta).  Unfortunately, all of my diabetes and pregnancy books and web sources indicate that this is likely the case but until the perinatologist confirms this I'm just not ready to go there. 

Ideally the situation would be entirely my fault due to poor carb counting or manual errors in programming my pump, but I know my pump is dead nuts where the endocrinologist told me have it at my last appointment and Lord help anyone who thinks I can't do the basic arithmetic it takes to do accurate carbohydrate counting.  I'm hard enough on myself about being diabetic and doing things right the first time that slacking or miscalculation just doesn't happen at this consistent rate... not exactly uplifting.    

Hopefully the docs will get back to me shortly, but for the time being I'm going to hide in my bedcover-cave and grumble whenever I have to emerge for yet another quick carb.  Definitely not the lying in bed eating bon-bons situation I'd like to be in. 

Hmph. 

Hypoglycemia 101

Last week when my classes started, I informed my professors that I am a pregnant diabetic in the off chance something happens that will require medical attention.  Both profs being relatively concerned about what that means asked me to walk them through step-by-step what I would need them to do in the worst case scenario of hypoglycemia.  Seeing as neither of them have previous experience with this, I thought there might be a good possibility that readers here might not know what to do either... so I figured that this is a great opportunity to explain what hypoglycemia is in more detail, how to recognize it and what to do if I (or anyone for that fact) go into hypoglycemic shock around you.

What is hypoglycemia? 

Hypoglycemia is a condition that occurs primarily in diabetics (can occur in non-diabetics, but is relatively rare) when the blood glucose in their body drops into abnormal levels (below 70 mg/dl).  Caused by an excess amount of insulin, such abnormal bg levels require immediate corrective treatment or the person will suffer from neuroglucopenia which essentially means loss of consciousness, seizures, a coma, and ultimately death.

How to recognize it?

Hypoglycemia is divided into two phases which can be most simply described as the recognizable, moderately serious phase (adrenegeric) and the unrecognizable, potentially-fatal phase (neurooglucopenia).   I have experienced the first phase many times with bgs in the 50-69 mg/dl range and can correct the issue myself.  For me, it usually starts with a tingling sensation in my fingers and gradually becomes a full on shake or jitter.  On the occasions that my blood sugars have fallen below 50 mg/dl (lowest I've been is 34 mg/dl), I've noticed that my heart rate speeds, my temperature rises, I start to sweat profusely and my breathing becomes quite quick.

Unfortunately, sometimes symptoms don't occur in phase one or I am unable to recognize them for whatever reason.  This is when diabetics slip into neuroglucopenia and, in all likelihood, will require external help to correct the situation.  The symptoms you might notice are unexplained drowsiness, lack of coordination, slowed or slurred speech and disorientation (almost like someone inebriated).   If these symptoms are not corrected (see below), the loss of consciousness is inevitable and potentially life threatening.

Although this guy is a bit goofy, he does a good job of explaining hypoglycemia and how to recognize it:

How to treat it?

Treatment of hypoglycemia as soon as possible is extremely important, especially if phase two has kicked in.  If a diabetic seems disoriented and cannot respond rationally by checking their own blood sugar, it is crucial that the people around them provide them with fast acting glucose immediately.

Fast acting glucose includes carbohydrates like fruit juice, sugar packets, honey and straight sugar candy like starburst or jelly beans.  It is important to note here that I am suggesting there are better carbohydrate choices than others... chocolate for example isn't the best choice because the fat in chocolate slows sugar absorption into the blood; bread is another example of a carbohydrate that takes a longer amount of time (more than five to fifteen minutes) to affect blood glucose levels.  If you don't have access to fast acting glucose, any carb will do, but many diabetics carry sugar on them and that is worth checking into... I have starburst (administer at least 4) and sugar packets (administer as many as I have) in my purse at all times. 

If the diabetic looses consciousness, there are four life saving steps that must be made as soon as possible (seconds matter):

1) Make sure the diabetic is lying down on his/her side.

By ensuring the diabetic is prone and on his/her side will ensure that injury wont result if seizures begin and knock them down.  Also it will ensure that if the diabetic begins to vomit, which is probable, that they will not die of asphyxia (suffocation).

2) Administer an injection of glucagon.  

Glucagon is a hormone that the pancreas naturally produces to regulate blood sugar in non-diabetics. Just as diabetics need artificial insulin, they may require artificial glucagon to correct for excessive insulin.

Many diabetics will carry an emergency glucagon injection kit on them - check their purses, their backpacks, their briefcases, whatever they might put it in. The pictures here are of my kit, which fyi can be found in the middle zipper pocket of my purse. While there are pictorial instructions inside the cap, I'll spell them out for you here anyway:

a) Open the case.

b) Remove the cap from the syringe and also from the vial.  Inject the saline into the vial.  Pull the syringe back out and set aside (you will use it again).

c) The vial contains a powder form of glucagon.  Once the saline is in the vial, shake it until thoroughly mixed.

d)  Insert the (fully depressed) syringe needle back into the vial, turn it so the vial is upside down above the syringe.  Pull all of the glucagon solution out of the vial and disconnect the two.

e) If an alcohol swab is available (not crucial to save a life at this point), clean the injection site on the buttock, arm or thigh.  Inject the glucagon into the shallow loose tissue - not deep in the muscle - of the diabetic.

3)   If applicable, place their insulin pump on suspend or disconnect it entirely. 

It is really important if the person suffering from hypoglycemic shock that their insulin pump be suspended or disconnected so as to avoid additional administration of insulin.

I cannot speak to the programming or structure of all insulin pumps, but I can show you what to do with a Medtronic Minimed pump like I wear.

1) Pull out the pump.

2) The third button from the left, under the screen says the word "ACT" on it.  Press that button.

3) The main menu will pop up.  Using the down button on the far right, scroll down until the word "SUSPEND" is highlighted.  Press "ACT" again.

4) You will see the word "SUSPEND" begin to flash on the screen.  You need to press "ACT" once more to confirm your selection.  The pump is now stopped.

The other option is to find the infusion site - typically on a diabetic's abdomen, lower back, thighs or buttocks - and delicately disconnect the tubing from the site.  It works like a seat belt.

4) The final step (or the first step if you determine you don't have immediate access to an emergency  glucagon kit) is to dial 9-11.  

Tell the emergency operator the amount of time the diabetic has been unconscious, what you've been able to accomplish and where you are.  Ask them to send an ambulance immediately.  Keep an eye on the diabetic until the paramedics arrive... if they have been unconscious for more than 15 minutes (for this can be a point of no return) and help still hasn't arrived, call 9-11 again to update the situation.

....

And that is how you identify and correct hypoglycemic shock and save the life of a diabetic!  There are certain points where hypoglycemia is more likely to occur than others - like when exercising or pregnant - so it's smart to anticipate a possible issue with it and prepare yourself to know what to do.

Obviously questions are welcome and I'll happily walk you through this in person if you want me to - just ask :)

The Idoitic nature of diabetes and exercise.

One of the primary issues that I, personally, have with my diabetes is the fact that I lead an active lifestyle.  I expect that concept may be especially hard to wrap your head around for those of you who are more familiar with type 2 diabetes, however to those of us dealing with type 1 this irony is all the more frustrating.

Without the pregnancy factor, diabetes creates many issues for exercise because of the body's use of glucose for fuel.  When we exercise, our body burns whatever sugar is in our system to keep us moving and when it runs out of excess glucose it then turns to burning fat for fuel.  In a diabetic body, however, when the body runs out of glucose to burn and swaps to burning fat, the remaining active insulin in your system (which is working far more efficiently because of your exercise by the way) has nothing to counter-balance its effects. This means that you become hypoglycemic... I'm sure everyone has heard of someone or another passing out as a result of exercise, this is as a result of that imbalance of insulin to glucose-fuel.

That being said, prior to exercise a diabetic has to get their blood sugar up high enough (pre-pregnancy I'd ideally shoot for the 180s-190s) to counter balance this fuel usage and insulin efficiency.  I've found that if I get my sugars up high enough for a run that I can typically run about 2 miles before my sugars are back into the 70-80mg/dl range.  If I wish to run more than 2 miles (which I typically do), then I must ingest even more sugar.   When I ran my half marathon back in December I consumed four 12 oz water bottles of orange juice (12 oz of oj has roughly 57g carbs) - aka a ludicrous amount of sugar - in order to complete the 13.1 miles and my blood sugar still went low after the race was over (56 mg/dl).  Good thing they had food waiting for me, eh?

There is a huge community out there of type 1 athletes struggling with their blood sugar's impact on their individual sports.  Fortunately it is not a be-all, end-all problem and we each seem to come up with our own ways to balance insulin dependence and activity.  I've been quite inspired by several many of the endurance runners who blog about their experiences and the challenges they've faced... I'm hoping that I'll be able to step up and do a marathon at some point and join the ranks of the serious "insulin powered" runners.

Unfortunately, for the time being, I've been benched.  Exercise during pregnancy is already restricted to some extent (whether women listen to their OB's advice or not is another topic), but insulin dependence and pregnancy significantly restricts what exercise is safe.  There are two main factors I now must consider:

1. To start with, as I mentioned previously, I cannot let my blood sugars get too high during pregnancy without running the risk of causing damage to the baby.  So instead of letting my sugars get up to 180 like I did before, I have to keep them at or under 120 mg/dl which means that hypoglycemia as a result of exercise is far more likely to happen and far more quick to happen than previously.  
2. On top of that, I cannot let my heart rate go above 140 beats per minute or exercise for more than 30 minutes at any given time.  This is because the oxygen my heart and lungs require to function at higher heart rates would deprive the blood going to the baby of necessary oxygen which, worst case scenario, could a) deprive the baby of oxygen or b) cause the temperature of the womb to rise enough to cause the baby distress. 

Obviously, I feel that fetal distress and birth defects are worth skipping the extra mile of running or sit up, but that does come with a different set of knock on issues.  Like I said in my initial blog post, I've been struggling with the "fat girl" identity since high school and the concept of putting on weight (pregnancy-induced or not) is very uncomfortable for me.  According to my perinatologist,  I've put on an appropriate amount of weight so far, but with such an intense insulin usage I cannot control the excess weight gain as a result of my exercise restrictions... In order to get my sugars up high enough to work out, I typically must ingest about 130 calories of carbs (ie: 8 oz of milk or 5 starburst or 3 oz of soda, etc) and in the 30 minutes of approved exercise time I can typically burn only 160-200 calories due to the heart rate restrictions I must adhere to.  Anyone who can do basic math here can see that the number of calories ingested to number of calories burned don't tend to work out in favor of weight management.

HB argues with me that the action of exercise is worth the effort even if the purpose of exercise isn't achieved... I admittedly can see his point in terms of heart function and continued active lifestyle, however the frustration of balancing diabetes, pregnancy and exercise is enough to make any type 1 woman who is given a hard time about excess weight gain come to tears.  In any pregnancy - high risk or not - doctors recommend gaining between 25 and 35 lbs because that is all that is necessary for the baby, but more insulin means more glucose storage and more glucose storage means more fat and more fat means higher weight... not exactly an easy cycle to wrap one's head around.

I know that pregnancy is ephemeral and with the help of Sean T (by the way, I LOVE HIM) and a half marathon or two I'll be back in my original fighting shape after the baby is born.  Between now and then I'm not sure how I'm going to find a balance to the sick-cycle of insulin and weight gain, but I expect I'll have a few emotional break downs and extremely self-conscious moments about my weight.  I will need to keep reminding myself that "the baby comes first" (obviously) and that a more simple day of balancing "just" diabetes and exercise is at the end of the tunnel.