Sunday, August 27, 2006

Telling people about diabetes

Last week, at the end of the final practice before the first game of the season, our coach called 4 of us together for a few words. He had just set the team for the match, and wanted to stress to us that given the fact that we were 4 forwards, we couldn’t expect to all be on the field at the same time, nor that we would only be given forward positions. Some of us might need to fill in a wing position for part of the game. Fair enough. The majority of the higher educations do not start until September 1, and thus quite a few of our team mates, especially defensive players, have not returned from holidays and/or working holidays yet, so of course we will have to take on alternative positions until all are back on the field again.

Our coach wanted to hear any objections we may have towards this before the match. There wasn’t many so we adjourned the meeting. As an aside, I just wanted to tell our coach that I would be playing with the pump for the first time, and therefore I would likely be a bit more focused on monitoring during the game (usually I only test before going out, not bothering to do it during the match), because I was at a loss about how to dose the insulin. One of my team mates overhead that, and asked me if I shouldn’t tell them a little about what to do “if you should collapse one day”. This girl has been my team mate in the club I played for before I transferred to my current club, so the reason she asked, I guess, is that she has known me for the last 5 years, some of which I have had great problems managing the D. Our coach quickly added that I had given both him and his assistant a piece of paper about that when I started, and that he carried it in his folder at practice and games. While I did that for obvious reasons, I haven’t really said much about it to my team mates. They know that I am diabetic and I don’t hide my remedies, but I usually don’t have any significant BG issues on the field.

Still, I couldn’t just dismiss the wish of my team mate, because maybe more of them had a need for just leaning a little more about diabetes, despite the fact that I myself haven’t considered it a big deal. My reasons for not having done something like what she felt missing is that when I meet new people, I evaluate the expected amount of time I will spend in their company before enrolling them in a long course about diabetes. For the soccer teams that I have attended, I have always told my team mates and let them know that of course I would be willing to answer any of their questions, and besides that I have made a hand-out for the coach, containing a few more details. To me this seems to be the wisest thing to do as the coach and/or assistant will always attend practice and games, whereas you will never see all of your team mates at once for these. E.g. my current team counts something like 25 different players, yet only 14 are allowed at each match, and for practice we will be anywhere from 7 to 20 players.

Another reason for being a bit hesitant about sharing more information about signs and treatments of low and/or high BG levels to my team mates is that in my experience you can tell people a lot, but it is not until the experience for instance a hypoglycaemic episode that they will really know what it looks like and how it may be treated. This experience primarily comes from my high school years.

The first year of high school we had a 4 days team-up-trip, and on the second year a week long study tour, both of which seemed obvious reasons to inform not only the participating teachers but also my class mates about what to do if something should happen. Nothing did happen during the first 2.5 high school years, or at the trips, and I felt confident that should I ever run into a bad low that required other people to help me, my class mates would be able to do so. That turned out not to be true. I experienced a bad low in the middle of my final high school year. It didn’t really give me any warning signs, I was just a bit tired, but did think too much about that as it was the second lesson of the morning and we were watching a movie. However, my teacher had noticed that I seemed incredibly tired, and I remember him asking if I was alright when we were dismissed. I think that I told him “yes”, but I really can’t remember any of what happened neither in the break nor at the next lesson, where finally one of my closest class mates, Morten, suspected that I might be approaching an insulin shock. My responses when accosted by my class mates or our Danish teacher was just too off compared to normal so Morten took action. At that time it had been approximately 60 minutes since I started showing the first signs, apparently not being aware of them myself. They tried to feed my juice and glucose tabs, but I was so low that they didn’t really saw any improvement and just awaited the arrival of an ambulance to bring me to the hospital. I have a blurry memory of the trip to the hospital, and remember that if my eyes could kill, Morten would have been dead, when he looked at me saying: “Now we are going to Disneyland”, as we arrived at the ER, so their initial treatment did have some effect ;-) I don’t blame any of my class mates or teachers, not at all. I just think that this episode is an excellent example on the above stating that if people do not experience you having problems, then they are not likely to react when you really need them to. Because they are in doubt or maybe just do not remember what they have been told.

At practice the other day I asked those attending whether they too felt a need for me to tell them a bit more about diabetes. The answer was: “Yeah, maybe, but maybe mostly whether any hypoglycaemic issues are recurrent, i.e., likely to happen in relation to soccer, so that we know how much attention to pay towards it. And you should probably do it a day, when most of us are here”. This answer kind of says it all, I think: 1) People do want to know, but most of all they would like to be reassured that any issues are not likely to require their involvement; and 2) They want to be sure that they are not the only ones having heard it, so that if one should forget something another will remember it.

I think that I should take a few minutes at practice, when appropriate, to say a few words to the crowd. At least to soothe the minds of the few worrying souls. But then again: You never know if it should actually come in handy at some point, or if it does, whether they will then remember it.

What do you guys do in this regard?

Saturday, August 26, 2006

This and that

It has been a while since my last post now. Work has kept me busy, and for most part the D has “behaved” nicely. Anyway, this post is going to be a lengthy one, with more about the issues on soccer playing with the pump, general management of the BG and my experience with the Guardian RT.

The last couple of weeks have been quite hectic. I have been awaiting a sports belt bag for the pump to use when I play soccer. It arrived a week ago on Friday, so Tuesday I wore the pump throughout practice for the first time. I had reduced my basal rate to 50 % for an hour before starting, but when I tested before going out I was only 3.7 (67), despite having eaten a banana without blousing for it 25 minutes earlier. Therefore I had 6 glucose tabs and set a temp basal of 50 % for the first hour of practice. I should probably have postponed the starting of practice a little, until the BG was back up in range, but as usual I was eager to get started so I just hit it. I did not feel too fit though, and had to quench a bottle of juice during the practice, still ending it at 3.3 (59).

After practice I had dinner with Jimmi, nothing out of the ordinary, but when testing before bed I had an unbelievable 17.4 (313)! I have no idea why I got that high, so I just corrected, 4 U, to get back in range. That was probably too much, or maybe I should just have reduced the basals throughout the night, although that just did not seem obvious considering the level of my BG when going to bed. Anyway, I woke up at 1:30 AM a bit confused, noticing that Jimmi was not in bed with me and the light was on in the kitchen/living room. At the same time my pump alarmed and I found that it had been suspended. Just as I resumed infusion, I could hear Jimmi showing two Falck-men (the Danish equivalent to paramedics) into our house. In a minute they were in the bedroom, much to my resentment. There wasn’t much for them to do, though. They tested my BG – 2.3 (41) – before watching me down a couple of glucose tabs, a piece of rye bread with cheese and a glass of milk, leaving me at 4.8 (86) afterwards. I tried to bolus for the carbs of the bread and milk, knowing that before the arrival of the Falck-men, Jimmi had loaded half a pack of glucose tabs (7-8 pieces) into me, and thus I anticipated a large rise in the BG. It came, and despite a 2.5 U bolus at 1:50 AM, I was 17.8 (320) at 6:00 AM :-(

The rest of Wednesday as well as Thursday my readings were mostly in range, though. To avoid starting practise on the low side Thursday, I reduced my basal to 50 % an hour before, ate a bit more without bolusing for it, and had a BG of 6.3 just before practise. That was perfect. For the first hour of practice I then ran a 75 % basal, feeling quite good. We played an interval game for the last half an hour, something that is quite strenuous though still a lot more fun and relevant to the games of the season than just running intervals between cones. Thus I was very sweaty at the end of practice, and when wanting to use the lower part of my t-shirt, a part not completely wet, to dry my face, I noticed that my site had come out. I guess the adhesive couldn’t cope with the excessive perspiration. It was up for a change anyway, but afterwards I couldn’t help wonder for how long it had actually been out. Not that the BG was that high afterwards, 7.9 (142), but within half an hour it had climbed to 9.9 (178), so I felt I better increase the bolus for my dinner just a bit to avoid the highs that I became familiar with following the matches of the spring season. That may have been a wrong decision though, as I was only 2.6 (47) when getting ready for bed. I ate a banana and some chocolate, figuring that would due the trick. Apparently not.

The next morning I could hardly wake up, and when I managed to test before Jimmi left for work, I rang in with a stunning and frightening 1.1 (20). I had an appointment with Alice, my diabetes nurse later that morning where some of the obvious topics were how to set the basals during and after practice/games, and keeping the site in place.

In spring I used to just disconnect during practice. This did not generate a need to reduce the basals during the following night, but I have also changed the night basals since then, and when not disconnecting during practice, I guess there is reason in running a slightly lower temporary basal on the nights following practice (the only problem in this is just to remember to do so, but I will get back to that later). Securing the site should be fairly easy with Tegaderm® or an equivalent adhesive. I got a stack of two different types to try. So far the winner is Tegaderm®, because it is much easier to apply, and also remove afterwards, than the other alternative.

Our first match of the tournament was coming up on Saturday, and when I expressed my frustration about having to figure out the insulin requirements for games in the dark, Alice offered me to wear one of their Guardian RT’s for a game day. She had one available so we agreed to just go ahead with that for the game of that weekend. When placing the transmitter on my stomach, she stated that the adhesive on it was very strong, so we wouldn’t need to secure that, just the part were the sensor entered would be sufficient. Again, not true!

For the game Saturday afternoon my newly acquired sports belt back came in handy. It is roomy enough to hold more than just the pump, something I appreciated when also having to carry the Guardian during the match. Both my pump and the Guardian fitted nicely into the back, and despite it being a bit bulky, it didn’t bother me during the game. I was to start as a substitute, but took part in the warm-up at equal intensity as the 11 starters. During this time my BG cruised nicely at 5-5.6 (90-100) with the pump going on 55 % basal. I kept it that way during first half, and having a 5.6 (100) just before entering the game at the start of the second half, I decided to play safe and keep the basal at 55 %. Just after the game the Guardian had me at 7.9 (142), but when I got out of the shower my meter told me 12.3 (221) in contrast to the 8.5 (153) of the Guardian. I didn’t have time to go through the records of Guardian at the time. Jimmi and I were to be at his mother’s at 6 PM, celebrating her birthday, and that meant a 6.5 km bike ride for me (depending on traffic that would be around 20 min). I was out of the locker room at 5:15 PM and needed to go home and secure the transmitter properly, as its adhesive had given in during the game, making it dangle from the Tegaderm®-secured sensor site. So much for the strong adhesive on its back :-)

I have had the opportunity to wear the predecessor of the Guardian sensor 3 or 4 times before, so I found it very advantageous that the Guardian is wireless and enables BG trace-tracking while wearing it. Still, with the 3 days I wore it this time, I wasn’t that impressed with the precision of the device. I am aware that there is a lack in time and therefore slightly different glucose levels in the blood and interstitial fluid is only to be expected, but it seemed that if one was to wear it more consistently, one would have to figure out this approximate lack in order to fully benefit from the low and high BG alarms that the system offers. I would usually test lower than Guardian would have me at when it alarmed for a low. I only had one high alarm (above 10 (180)), one that I did not test for because I expected it, but generally found that when I tested 8-12.5 (144-225), Guardian would show me a 7-9 mmol/l (126-162). The more levels entered into the system, the closer it seemed to get at my meter values, though.

I went to get a download of the Guardian data on Tuesday this week. In general I was pleased with the fact that – despite the differences between meter and Guardian-values – it seemed I was generally below 11.1 (200) during those days. What surprised me the most was the effect of the game. Despite being very consistent at 5-5.6 (90-100) before the game, during the warm-up and the first half that I saw from the touchline, the moment I entered the field, my BG started an ascent to more than twice these levels! Talk about an adrenaline surge! I honestly did not think it would be that pronounced. About 8 h after the game, the effect of the exercise seemed to turn in, lowering my BG to levels and making the Guardian alarm (I didn’t hear it, but Jimmi heard it and acted upon it). Thus, once again I had a low BG-start of the day, this being something that could have been avoided if I had been able to think constructively before going to bed at midnight the night before. Besides the soccer game, my Saturday had 36 km of bike riding on the exercise account, so I guess I ought to have foreseen up-coming hypoglycaemia, but apparently I was too tired to do so.

This week has been only work and practice. We have two games next week, Monday and Wednesday, so it is nice to relax a bit this week. Practice went well both Tuesday and Thursday this week, but Tuesday night I forgot to reduce the basals during the night, so I had a 2.3 (41) to start the day with on Wednesday. Thursday I remembered, and decided to try running a 90 % basal throughout the night. That gave me a 7.1 (128) Friday morning so that was pretty successful.

Tonight we are watching Jimmi’s younger brother, Steffen. Steffen is 11 years old and he recently started to show interest in cooking (much to my delight as he used to be a very picky eater), so he is going to cook for us tonight – he offered that himself, we are not forcing him to do it ;-) Last time we had him here for a sleep-over, he made homemade pita breads with a variety of vegetables and ham. This time the menu is a vegetable soup with homemade bread rolls, so right now he is busy in the kitchen. A thunderstorm is above our heads right now, so I guess our plans of playing soccer after dinner should be revised. Maybe we will just end up watching a good movie and enjoying the banana-cake that I made earlier today – we are allowed to spoil him a bit, when he is with us :-)

Friday, August 04, 2006

Wet, wet, wet

After my initial, and not very successful, try on wearing the pump during soccer practice - to get some experience with this before going to wear it during games - I debated with myself most of the afternoon yesterday, about weather or not to wear the pump during practice yesterday using other means to make stay put. Tuesday try with wearing the pump in my sports bra did not make me want to do that again. The pump moved too much around under my arm to be comfortable, and I ended up disconnecting after about an hour in which I had used every tiny break to move the pump back to the wanted position.

The following day I toured the Internet in the attempt to find other possible solutions for wearing the pump during soccer. I ended up deciding to go for the sports pack that integrated diabetes offers from their store. I will probably not receive it until next week, however, so yesterday I was considering trying the velco-strap pouch that I use for sleeping. As I use this pouch for sleeping, I came to the conclusion that I would probably not find it very comfortable to wear in bed that night if I had been soaking it in sweat during soccer practice a few hours before. Thus, I went for the disconnection. Finishing practice yesterday, I was very glad that I made that decision!

The weather yesterday was mostly cloudy, but it had been dry all day. Going home after work I noticed a very black cloud that was obviously pouring a lot of rain in another part of town. This cloud, I think, paid my area a visit just as we started practice yesterday, and it stuck around until we were done 90 minutes later! Let me tell you, it was not just raining, it was a regular cloudburst! After 5 min. or so we were all soaking wet, and every time our feet hit the grass you could hear a splash from the water lying on the field + all the water being contained in our socks and boots. Despite the weather we had a rather good practice, and when we finished, the sun broke out. Isn't that just typical? :-) With clothes several kilo grams heavier due to the excessive amount of water, I jumped on my bike to ride the 800 meters back home. When I got out onto the street, I saw that I would actually have been better of with a water bike, as little down the street a large "lake" had appeared: For 25-50 meter of the street, from one side to the other and across the pavement, about 15-20 cm of water were standing. Now, I was soaked anyway so I decided just to go right through it, but I barely made it as I had not expected the water to be that deep.

When I got home I wringed my close and stuffed my boots with an old newspaper, wondering if a neoprene pouch would have been able to keep the pump from being soaked as well in such a weather, and if not what that would have meant for the function of the pump afterwards.....

Tuesday, August 01, 2006

Soccer season

This spring I started playing for a new soccer club as I moved to far away from my old club, which by the way also ended last fall by totally closing their women’s department, so it was a good time to move! My new club, DSIO, is located just across the street where I live now, and I have had no problem settling down with my new team mates. Though we lost the two last games of the spring season, we stayed in the regional series of Funen (Fynsserien), bringing 2 points to our score in the fall tournament. This is actually quite an achievement, as I learned that the team just advanced to this series this year! Newly advanced teams usually have a hard time finding their feeds in the first season, but we managed to go through with only two lost games and three draws (out of 9 games in total), placing us in the top of the table until the last two games. We start the fall season as no. 4 of 6 teams, due to the transfer of points from the spring season, so we have to work to stay in the regional series. I should be possible though. We play each team twice, home and away, and the pool winner will advance to the national series (Danmarksserien), whereas no. 2 will go into two play-out games for possible promotion to this series as well. The number of teams that will advance to the national series depend on the number of teams from Funen that are relegated from this series, though. I don’t believe that our team is qualified to play in the national series anyway, so I think that that it would be fair for us to “just” aim for the 3rd or 4th place this fall.

Today practice starts for the soccer fall season. We have had the possibility to play a bit once a week during summer, but I haven’t gotten off to that, so I look forward to start again, although it was nice with the 1-month break :-)

In a previous post, I wrote about my discussion with my diabetes nurse about how to handle blood sugars during, and especially after, soccer games. We agreed that I should try wearing the pump during the games, mingling with the basals to see if that would solve the problems that I experienced in the spring season. Though I am still not that comfortable with wearing the pump during a game, I think that I ought to at least try it, and then if it doesn’t really work either, I will go back to shots at least on game days – that I know how to handle!

I am not all satisfied with the fact that I will have to figure out how to wear the pump and what the adjustments of the basals should be during games only. However, as I haven’t had the same issues during and after practice, I really have no choice but to try to figure the basal thing out during games. Where to wear the pump on the other hand I plan to experiment with during practices. This will probably also allow me to get an idea of the temporary basal level during at least the first part of a game (until adrenalin takes over and mess things up. My guess is that if I play a full game – 90 minutes – after approximately 30 minutes of warm-up, I will probably have to increase my basals slightly during the second half of the game, while the excitement and gearing up to hard work during warm-up and first part of the game will likely render a lower basal rate necessary). I plan on starting out with rather severe decreases of the basal rates (probably going down to at least 25-30 % of my normal rates) during the initial practices until I find the right level. In spring I went low several times during the last part of our 90-105 min. practices. This is quite annoying as the last half hour of our practices are usually devoted to games and shot practice, neither of which can be performed adequately when hypoglycaemic, but because I really want to be in those activities, I will usually end up just taking a 5 min break to swallow some glucose tabs before continuing. That is of course not ideal, I know, but I can’t help it, it is so hard to accept that diabetes should interrupt in this way and keep you out of the game for 15 minutes or more.

Finally, some question for those of you pumping and playing contact sports wearing the pump: 1) Where do you typically place your pump and tubing during games and practices? 2) How much to you decrease/increase your basals during and after games? 3) How long before and after a game or practice do you run on temp basals? I know that I will have to find my own answers for these questions myself, but it doesn’t hurt to listen to, and possibly learn from, other people’s experience :-)