Insulin pump follies
The only light in the room is the glowing screen of the Dexcom.
I fumble for the monitor, half-hidden beneath the bed sheets. Two buzzes means a high or a rise alarm. If you sleep though the buzzes, she’ll squawk at you.
I’m at 351 mg/dL and going up quickly. My mind tries to grasp the fact. How on earth? It’s 2am. I can’t think clearly. But I didn’t have any dinner…
I went to bed at 114 mg/dL…
My basal rate can’t be that far off…
I turn on the bed side lamp and, squinting as my eyes adjust to the brightness, I check the site. Looks good. Nice and tight. No damp skin. No band-aid smell of insulin. I wiggle the hub to be sure. Then I disconnect and reconnect to be double sure.
Everything looks A-OK.
Well, it has been a stressful evening. I sent one of my little T-1s to the Emergency Room this evening. Her mother called around eight. The kiddo had been high all day, and didn’t respond to corrections as well as usual. Turns out her cannula on her OmniPod got dislodged. By the time I was on the case she’d been above 400 for six hours and was complaining she felt sick.
At first I dithered a bit. We know the problem. She didn’t have insulin for quite a while. The problem is resolved. The insulin will catch up. The blood sugar will come down. The mother checks for ketones, which show up dark pink on a urine stick. So between moderate and high. We don’t yet have a blood ketone meter for the child.
The insurance company does not want to pay for the strips.
The kiddo hasn’t thrown up. In fact she just asked for a slice of bologna. Good sign she’s not feeling nauseated. And she’s not panting, which would be a very bad sign. But she does have fruity breath.
All of this adds up to her being well on her way to Diabetic Ketoacidosis, or DKA for short. DKA happens, generally in T-1s, when the blood sugar is too high for too long and there is little or no insulin in the system. We pumpers are more at risk from DKA because we don’t use basal insulin, those specially formulated insulins that time-release over 24 hours. We get our basal needs covered by a constant drip of fast-acting insulin from the pump. Unless the pump fails or the cannula gets pulled out somehow. In which case you have no medicine for what ails you.
Everyone’s diabetes varies, but figure that six hours above 300 in the absence of insulin can get you into a world of hurt. What’s happening is that your cells are starving in a sea of plenty. Even though you are chock full to the gills with sugar, in the absence of insulin, none of the sugar can get to the hungry cells. They start eating their shoe leather and… no wait… that’s castaways. They start eating fat instead of sugar, and like the smoke from a camp fire, the burning of fat creates a toxic waste called ketones. Ketones shift the pH of the blood, making it more acid.
Bottom line, untreated, this will kill you.
Lucky for us the treatment is related to the cause. Just add insulin.
So back to our sick kiddo. I’m sure the blood sugar will resolve. The ketones will pass. That’s not the real issue. I’m worried about the “Kay” as we call it. Kay, actually spelled simply “K” is a resident of the periodic table of elements, located at number 19, known more formally as Potassium.
Potassium is one of the kitchen soup of elements that are part of parcel of our bodies. The reason we’re even talking about this is that when someone is DKA or DKAish, funky things happen to the potassium levels in their blood. Generally speaking, as you re-hydrate (remember that DKA will dry you out from increasing urination and vomiting and all of that), your potassium falls. Sometimes pretty damn quickly. And the reason that matters is that low potassium can affect your heart rhythm. Bad and scary stuff.
But she’s sort of borderline. Not quite DKA. Not quite OK. I weigh the various facts and figures for a full 90 seconds before I finally get my head out of my ass. Why am I even thinking about this? The patient is a child.
Take her to the ER, I tell the mother.
“Are you sure?’ she asks, shocked.
No. I’m not. So take her to the ER now. It may be a complete waste of time, but the alternative is unthinkable. Go now.
This is the second pump failure of the week. Two days ago, one of my middle aged T-1s ended up seriously DKA after her Med-T infusion set got pulled out. She got to the throwing up on her shoes stage before she came in for help.
It has been postulated that the genes that lead to T-1 are the same ones that govern self-reliance to the degree of stubbornness.
So back to my dark bedroom, I reel in the infusion set to find my CoZmo pump. As the set checks out, I’m thinking the best plan is to just go ahead and take a correction bolus. Maybe the stress of the evening just took its toll on my blood sugar.
I press a button to wake up the pump.
I press again.
The screen is blank. Dead. I stare at the eight thousand dollar paperweight, unable to process the facts through my sleep deprived hyperglycemic mind.
My pump is as dead as a door nail. Holy crap.
We all know that technology can fail, but it is supposed to happen to other people, not us. I must have sat staring at the blank screen for ten minutes. Not sure what to do next. Then the stomach cramps kicked in and my brain kick started.
Take a shot, take a shot, take a shot, take a shot, take…
I stumbled through the dark house to the kitchen, a.k.a. the insulin storage vault. About this time, I remembered that I had put a fresh battery in my pump before bedtime. Actually, it was about the time the phone rang, when I got the frantic call from my little patient’s mother.
Could I have put the battery in backwards and not noticed in all the confusion? After all, who looks at their pump unless you’re gonna use it, or it vibrates, beeps, or squawks at you? I fished my key chain out of the bucket were I throw my wallet, watch, day-meter and strips, medic alert, pen, box cutter, and pipe lighter when I come home from work. The key chain has one of the more useful gifts ever given to me on it. A “coin” the exact size of the slot on my pump’s battery lid. It a hole to slip it onto the key chain and has the graceful Animas logo on it.
I use the coin to unscrew the battery lid on my discontinued (but beloved) CoZmo. The battery is in right. Damn.
For the heck of it, I grab another battery out of the bucket and put it in the pump. Nothing. No shudder of a vibration followed by beep-beep-beep!
This doesn’t look good for the home team.
In a last ditch effort to jump start my pump, I go find my go-bag, hanging on its hook by the front door. Inside is the last AAA battery in my world (yeah, I know, it’s pathetic but money has been tight.)
I slide it into the battery chamber. Slip the lid on. Screw it down.
The pump shutters to life. YES!!
So, dumb ass (that would be me) somehow ended up with batteries that should have been thrown in the trash pitched instead into his spare-parts bin. I probably took them out of some device and left them on the table with intentions of throwing them away later. Serves me right. Later on, my wife must have thrown them in my bucket, assuming—sensibly enough—that if someone left them on the kitchen table (rather than putting them in the trash only three feet away) that they must be good.
The lesson here is that routine is a mind killer. Let’s look at our actors in this little play: middle aged diabetic who has been pumping for years, a child with a super-smart Type-3 mom at the helm, and a diabetes educator for Christ’s sake. Three people who you think would be paying better attention. Well, actually, it’s not that we weren’t paying attention, it’s that we are so blessed that things rarely go wrong that we get caught flat-footed when they sometimes do.
So my bottom line is this—next time you have a high that doesn’t go away do the following:
Check to make sure your infusion set is still attached to your hide.
Check to make sure your cannula is still poking through your epidermis.
Check to make sure you didn’t put dead batteries into your pump.
Don’t get too comfortable. Banana peels are equal opportunity.